Every finding on record at Complete Care at Care Age

Based on observation, interview, and record review, the facility did not ensure food was served in accordance with professional standards for food service safety potentially affecting 45 of 67 residents who eat their meals in their room. Observations were made of staff delivering meal trays to residents in their room with uncovered dessert items and beverages.Findings include:The facility policy and procedure that is undated and titled Dining: Maintain Nutritive Values documents: 4. Food Service . b. Prepared food will be transported to other areas in covered containers.On 12/2/2025 at 12:15 PM, Surveyor was in R1's room when staff brought in R1's lunch tray. The tray had a bowl with chocolate cake that had not been covered and coffee that did not have a lid on. Staff had prepared R1's meal tray at the nurses' station down the hallway and carried the uncovered items through the hall to present to R1.On 12/3/2025 at 8:02 AM, Surveyor observed the breakfast service on the rehab (rehabilitation) unit. Trays were brought to the unit by the kitchen staff in an insulated cart. Certified Nursing Assistant (CNA)-D, Registered Nurse (RN)-E, CNA-F, CNA-G, Central Supply/Unit Secretary (CS/US)-H, Director of Nursing (DON)-B, and Assistant DON (ADON)-C were observed passing trays to residents in their rooms. Orange juice that was in an individual serving containers were opened at the nurses' station, poured into a glass, and placed on the meal trays. Coffee was poured from a carafe into cups and placed on the meal trays. Milk was poured from a gallon jug and placed on the meal trays. None of the beverages that were poured into glasses or cups were covered and were brought down the hallway to resident rooms.In an interview on 12/3/2025 at 11:00 AM, Surveyor asked District Dietary Manager (DDM)-I how many residents ate in the dining room compared to eating in their room. DDM-I stated about 35 percent of the residents eat in the dining room with the rest eating in their rooms. Surveyor asked DDM-I what the expectation was of staff serving residents in their room regarding covering the food and beverages on the tray. DDM-I stated individual juices containers and milk cartons are on the beverage cart on each unit as well as a carafe of coffee. DDM-I stated the individual beverage cartons should be opened in the resident room and put in a glass at that time and coffee is poured as needed. DDM-I stated the coffee cups have lids that should be used when going down the hallway. DDM-I stated the milk in gallon containers are used only in the dining room. DDM-I stated anything going from the cart down the hall should be covered. Surveyor shared with DDM-I the observation on 12/2/2025 of a resident receiving a room tray with their chocolate cake and coffee not covered and the observations of multiple staff on the rehab unit on 12/3/2025 pouring beverages into glasses or cups and bringing them to resident rooms without any lids on. DDM-I stated all the beverages and food items should be covered.On 12/3/2025 at 12:55 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, DON-B, Regional Consultant (RC)-J, and RC-K the observations made on 12/2/2025 and 12/3/2025 of uncovered food and beverages on the hall trays. NHA-A requested clarification of where the observations were made and when. Surveyor clarified the dates and units the observations were made. No additional information was provided.

Based on interview and record review, the facility did not ensure each resident receives the necessary care and services in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) after experiencing a change of condition for 1 of 11 residents reviewed (R20). R20 had an unintended sudden change of plane while being transferred by a sit to stand lift by a lone Certified Nursing Assistant (CNA). While in the lift sling, the lift's battery died, and resident ended up in a squatting position with her buttocks touching the foot pads of the lift. This sudden change of plane resulted in a hip fracture. Staff did not follow R20's plan of care which included using 2 staff for transfers with a sit to stand lift, and staff moved resident twice without a Registered Nurse (RN) assessment after the change of plane. The facility failed to report R20 having a change of plane to the oncoming shift, failed to give details regarding R20's incident to R20's provider delaying medical treatment, failed to complete a thorough assessment including vital signs at the time of the incident, failed to provide continued monitoring with change in condition including completion of a thorough RN assessment when R20 reported 8 out of 10 pain and 9 out of 10 pain, failed to complete an RN assessment when CNA K reported changes to the appearance of R20's leg and that something was wrong, and failed to document known changes in condition in R20's medical record, including internal rotation of lower right extremity. The facility's failure to ensure each resident received the necessary care and services in accordance with professional standards of practice after experiencing a change of condition led to a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on [DATE] at 11:35 AM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a severity/scope of D (potential for no more than minimal harm/isolated) as the facility continues to implement its action plan. Evidenced by: Facility policy, titled Notification of Changes, implemented [DATE], includes: The purpose of this policy is to ensure the facility promptly informs resident, consults with the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Definitions . Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction), or commence a new form of treatment to deal with a problem; for example the use of any medical procedure, or therapy that has not been used on that resident before . Clinical complications: examples- development of stage 2 pressure injury, recurrent episodes of delirium, recurrent UTIs or onset of depression . Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Accidents- Resulting in injury. Potential to require physician intervention. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration. This may include: Life threatening conditions, or Clinical complications. Circumstances that require a need to alter treatment. This may include: New treatment. Discontinuation of current treatment due to: adverse consequences, acute condition, exacerbation of a chronic condition . An article from the Nation Library of Medicine, titled, Risk Factors for Preoperative Deep Venous Thrombosis in hip fracture patients: a meta-analysis, by J Orthop Traumatol. 2022, includes: . Hip fracture (HF), including intertrochanteric fracture, femur neck fracture, and subtrochanteric fracture, as one of the most geriatric fractures associated with osteoporosis, is expected to affect about 6 million people by the year 2050 worldwide. Previous studies have demonstrated a close relationship between geriatric hip fractures and perioperative morbidity and mortality at 1 year. The treatment of geriatric hip fracture patients is a great challenge due to multiple medical comorbidities and serious perioperative complications. Obtaining stable reduction and fixation to permit early mobilization is critical to decreasing the development of perioperative complications. Early surgery is thought to be the best option for HF patients to reduce the risk of perioperative complications and death . Preoperative DVT, which affects 8-34.9% of hip fracture patients and may be as high as 62% in those with delayed operations, plays a critical role in HF patients' preoperative waiting time. [NAME] reported that delayed surgery, hypoproteinemia, three or more comorbidities, and a d-dimer level?>?1.59 mg/l were predictors of preoperative DVT . Preoperative DVT is one of the most common complications after hip fractures because of immobilization and medical problems of patients. Early prevention of preoperative DVT was beneficial in shortening the time from injury to surgery and lowering the incidence of postoperative complications. Medical problems and prolonged time from injury to admission have recently been linked to an increased risk of preoperative DVT . Patients over the age of 90 had a significantly higher rate of preoperative DVT than any other age group, which was linked to a prothrombotic state and decreased vascular function due to aging . In the present study, the mean time from injury to admission and surgery was significantly longer in the DVT group than in the non-DVT group. Three possible reasons may explain this. First, prolonged immobilization could result in venous congestion; second, vascular injury caused by fracture activated the coagulation system; third, the fracture was frequently coupled with dominant and hidden blood loss, especially hidden blood loss for intertrochanteric fractures. Therefore, earlier admission was necessary for intertrochanteric fractures . According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. R20 admitted to the facility on [DATE]. Her diagnoses include rheumatoid arthritis, atrial fibrillation, atherosclerotic heart disease, joint disorder, history of falling, weakness, hypertension, sensorineural hearing loss bilaterally, pulmonary hypertension, and age-related osteoporosis. R20's Minimum Data Set (MDS), with Assessment Reference Date (ARD) of [DATE], indicates R20 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. R20's Comprehensive Care Plan, initiated on [DATE], indicates R20 required assistance of 1 for the following: dressing, bathing, bed mobility, and assist of 2 with sit to stand lift for transfers and needs one staff member to propel her in the wheelchair for long distances. R20's Comprehensive Care Plan indicates R20's medications are administered by the nurse. Facility Self Report, dated [DATE], includes: Investigation Summary: . On [DATE], R20 put on her call light because she wanted to be toileted. The assigned CNA (Certified Nursing Assistant) . was in the lunchroom, and CNA L was covering the floor. CNA L transferred R20 with sit to stand lift and took her to the toilet. Shortly thereafter, R20 put on the call light to get off the toilet and go back to bed. CNA L once again used the sit to stand lift without assistance of another staff member and upon raising her up the battery died. R20 was complaining that under her arms (where sling was) was hurting her, so CNA L used the emergency button to lower the lift arm. Apparently, that did not lower initially so CNA L tried to start pushing lift toward R20's bed and after going from the tile bathroom floor to the carpeted bedroom, the lift started to lower with resident still in sling. As the lift arm lowered the resident ended up in a squatting position with her buttocks touching the foot pad of the lift. CNA L decided to try to help the resident by pushing her buttocks and got her high enough to sit in her wheelchair. Shortly after that, CNA M arrived at the unit. CNA L told her she needed help with the transfer from the wheelchair to the bed. After the resident was settled, CNA L told the nurse that the resident was complaining of pain in her leg and that during the transfer with the sit to stand the battery died. She did not mention that this transfer was completed by only herself. LPN G (Licensed Practical Nurse) asked CNA L to write a statement and then she was going to see the resident. CNA L wrote an initial statement on [DATE] that was left for the nurse and not read until after end of day shift. CNA L statement left at nurse station, includes: [DATE] While transfer with the sit to stand. The sit to stand went dead in mid-air. She complained about her arms hurts [sic] so did the force thing to force the sit stand while that was going. [sic] It end sitting her down on the floor. I held her back with my legs so she wouldn't fall back. With her help I was able to get her back in her chair. Then a new sit to stand was used to get her in bed. Nurse was told. Statement was wrote [sic]. UM/RN Q (Unit Manager/Registered Nurse) statement, dated [DATE], includes: R20 had complained of right knee pain after being in the sit to stand. Resident was assessed in bed. Pain to right knee was stated at a 4 out of 10. Floor nurse gave scheduled Tylenol for pain. Resident's right knee was parallel to left knee. Right leg did not have internal rotation when assessed. CNA L second statement, dated [DATE], includes: I answered R20's call light. She was in the bathroom, [sic] as I am lift her up with sit to stand, she complains of pain in her arm pits as I go to lower her the machine died in mid-air, so I press the release button so it can be lower. [sic] wasn't aware that it was going so I tried to get her to her bed as quick as possible but on the way, she had been lower to the ground, so I made sure she didn't hit head and made sure she was sitting upright. With her help, I was able to get her off the floor into her wheelchair, then I use a charged sit to stand to put her in her bed. (Handwritten on the interview is a statement that states per interview did a squat on lift and was able to push up enough to get into wheelchair.) DON B (Director of Nursing) statement, dated [DATE], includes: On [DATE] at around 2:30 PM LPN G reported to me that R20 said she had an issue with an earlier transfer in the sit to stand lift and that her leg was sore. I instructed her to get Unit Manager/RN Q and look at R20 and prepare an incident report. LPN G did complete incident report as other incident. On [DATE] R20 was seen by Nurse Practitioner (NP O and NP P) and she noted there was a leg discrepancy and ordered an x-ray. R20 also had denied any fall at that time and told NP O that she thought it was from being up in the sit to stand too long. I was made aware of the possible change just around 9:00 AM. CNA L was in the facility with a resident . completing one-on-one observation. Around 10:30 AM, I interviewed CNA L and had her complete a new written statement. During that interview I found out that the sit to stand transfer was not completed per policy initially and that only CNA L was in the room. CNA L witnessed the issue with the lift and resident. I felt at that point that the potential injury could be the result of a witnessed fall due to change of plane for the resident. I then went into risk management and changed the reason for the incident report from other to witnessed fall and completed the corresponding assessments for the incident. At about 1:00 PM, the X-ray did reveal a fracture of the right hip, and the resident was being transferred to the emergency room for evaluation. The incident was then reported to the state as an injury of unknown origin because I could not definitively determine cause and investigation was initiated. Facility 24 Hour Communication Board, dated [DATE], includes: R20- Day shift- right knee pain, up long in sit to stand, complained of right knee/leg pain . PM shift- extra strength Tylenol as needed given for 9 out of 10 pain, new order for Flexeril 10mg (milligrams) 1 dose . (It is important to note there is no mention of R20 sitting down on the floor during a sit to stand transfer.) R20 Nurse Notes, Medication Administration Record (MAR), and text messages exchanges with R20's provider include: Nurse Note, Late entry added on [DATE] for [DATE] at 2:00 PM . Writer was notified by LPN G that resident had complaints of pain to her right knee after being in the sit to stand too long. Writer assessed the resident. Right knee appeared equal to left knee. No rotation, redness, or swelling noted. Resident stated she has arthritis in that knee and has pain from time to time. Had pain 4 out of 10 at that time. (It is important to note this is the documentation in R20's medical record of an assessment being completed, but this note was not added to R20's medical record until [DATE], 9 days later. It is also important to note there is no evidence in R20's medical record of vital signs being gathered, including heart rate, blood pressure, or respirations per minute.) Text message, date and time unknown, from facility to provider, includes: resident complained of knee and leg pain after being in sit to stand too long. No injury noted. Will continue to monitor for pain and update with any changes. (It is important to note the facility did not report R20's change of plane, fall, or sudden drop from lift to R20's medical doctor.) Text message dated [DATE] at 2:59 PM, from provider to facility, includes: noted no new orders. Thank you. MAR Note dated [DATE] at 7:33 PM Tylenol Extra Strength Tablet 500 MG. Give 1000 mg by mouth as needed for pain every evening. Text message dated [DATE] at 8:04 PM, from facility to provider, included: R20 is now complaining of 9 out of 10 pain with movement. I did give her as needed Tylenol. Nurse Note, [DATE] at 8:06 PM: Resident is rating hip pain a 9 out of 10, no swelling or discoloration to hip, Pain is with movement. Message sent . to on call Nurse Practitioner. As needed Tylenol given to resident. Will monitor. (It is important to note there is no evidence in R20's medical record of an RN assessment being completed with this new onset of 9 out of 10 pain.) Text message, dated [DATE] at 8:07 PM, from provider to facility, includes: Is there any visible change? (It is important to note R20's medical provider still is unaware of R20's change of plane or that a transfer ended sitting her on the floor.) Text message dated [DATE] at 8:09 PM, from facility to provider, includes: No swelling or skin discoloration but she said it hurt during cares with movement. (It is important to note R20's medical record did not contain evidence of a thorough RN assessment being performed. The above data of no swelling and no discoloration was gathered by an LPN.) Text message, dated [DATE] at 8:10 PM, from provider to facility, includes: It was just from being in the sit to stand? Text message, dated [DATE] at 8:13 PM, from facility to provider, includes: Are you able to see the incident report in point click care? Text message dated [DATE] at 8:16 PM, from facility to provider, includes: Apparently she was in the sit to stand for a while according to her and now is having the right hip pain. She says it feels like she pulled a muscle. MAR Note dated [DATE] at 8:30 PM, includes: Tylenol Extra Strength Tablet 500 MG. Give 1000 mg by mouth as needed for pain every evening. Administration was ineffective . Follow up pain scale: 8. Text message, dated [DATE] at 8:35 PM, from facility to provider, includes: any new orders? Text message dated [DATE] at 8:41 PM, from facility to provider, includes: She now rates the hip pain 8 out of 10, this is one hour after taking the extra strength Tylenol. Text message dated [DATE] at 8:49 PM, from provider to facility, includes: We can try a one time dose of Flexeril 10 milligrams to see if it helps. Text message dated [DATE] at 9:15 PM, from facility to provider, includes: Thank you. Noted. Will continue to monitor for pain and update with any changes. Nurse Note dated [DATE] at 9:29 PM, includes: Physician Assistant from . aware and new order for one time dose of Flexeril 10mg muscle relaxer. Resident aware. Will monitor. Nurse Note, [DATE] at 10:13 PM, includes: One time dose of Flexeril given and effective. Resident reports less pain to right hip, 2 out of 10. Facility 24 Hour Communication Board, dated [DATE], includes: Night Shift- R20- complained of pain to right knee/leg . Day Shift- New order stat x-ray related to right hip, right knee, Flexeril 5mg as needed three times a day for pain . Advanced Practice Nurse Practitioner (APNP) Note, dated [DATE] at 10:30 AM, includes: Chief complaint- right knee and leg pain . Patient was an acute add on today presenting today with right knee and leg pain after being transferred via sit to stand overnight last night per RN report . vital signs- [DATE]: blood pressure- 122/64, oxygen saturation- 96%, pain- 0, temperature- 97.6 degrees, respirations-18, heart rate 74, weight 140 . vitals [DATE] blood pressure- 110/62, oxygen saturation- 95%, pain-0, temperature 97.3 degrees, respirations-17, heart rate- 65 . vitals [DATE] pain 8 . vitals [DATE] pain-0 .Muscoskeletal- no joint tenderness or deformity. Right lower extremity with minimal range of motion. Unable to flex, extend, abduct, adduct, or externally rotate hip without extreme pain. Right lower extremity internally rotated while resting in bed and unable to straighten. Pedal pulses plus 2 bilaterally, warm to touch, and sensation intact. No bruising or swelling noted. (It is important to note the incident took place on [DATE] between 1:00 PM and 2:30 PM according to the resident's statement, CNA L's statement, CNA M's statement, LPN G's statement, and UM/RN Q's statement and this APNP's note reflects the most recent vitals recorded in R20's medical record. These vitals are from [DATE] and [DATE]. The facility did not record R20's blood pressure, heart rate, respiratory rate, or temperature on [DATE] or after the change in condition was noted.) R20's Radiology Report, dated [DATE] at 12:25 PM, includes: . Hip . Right . Results: Intertrochanteric right femoral fracture with mild angulation. Mild soft tissue swelling . Conclusion: Acute Intertrochanteric right femoral fracture as noted . Knee . Right . No acute fracture or dislocation. The osseous structures appear intact. Modest joint space narrowing. Soft tissues are unremarkable. Conclusion: No acute osseous findings. Recommend a repeat multi-view imaging in 1 week or sooner if clinically warranted especially if symptoms continue or persist or progress. R20's SBAR Communication Form, dated [DATE], includes: this started on [DATE] . Since it started it has stayed the same. The condition, symptom, sign has occurred before: No . Medication Changes in the last week: Flexeril . Vital Signs: 139/79, Pulse: 81, Respirations: 18, Temperature: 97.8 . Functional Status: No changes observed. Skin Evaluation: not clinically applicable to the change in condition being reported . Pain: New Intensity of pain: 9 . Appearance- Summarize your observations and evaluations: (blank) . Review and Notify: Primary Care Clinician Notified: Yes- date and time: [DATE] at 1:00 PM. Recommendations of Primary Clinicians: Send to emergency room for evaluation and treatment of right hip fracture. Check all that apply: X-ray . Nursing Note for additional information on change in condition: (blank) . Signed by RN/UM Q . R20's Emergency Department Note, dated [DATE], includes: X-ray today shows a broken hip. Given that you are not ambulatory, there is no clear indication for surgery and based on your wishes and discussion with family, it is safe to go back to your facility. You will need care with movement to try to avoid significant displacement of the right leg especially. You should at least take Tylenol, up to 1 gram, every 6 hours, as needed; if you have stronger pain, it is reasonable to try hydrocodone. The medication prescribed for pain today will make you sleepy; . X-ray pelvis AP and hip right final results: Impression: Impacted and displaced intertrochanteric right femur fracture . Reason for exam: fall, deformity . additional relevant history: fall, deformity . Findings: The osseous structures appear demineralized. There is a mildly impacted and displaced fracture of the proximal right femur involving the base of the femoral neck extending into the intertrochanteric region. Increased varus angulation. The femoral head remains normally aligned with the acetabulum. The pelvic ring appears intact. Left hip alignment is normal . On [DATE] at 10:42 AM during a phone interview, CNA M indicated when she entered the room R20 was in her wheelchair and CNA L told her the sit to stand lift malfunctioned and R20 was on the floor. CNA M indicated she did not report this change of plane to the nurse on the floor or to the oncoming shift, because she figured CNA L would report it. CNA M indicated when a resident has a change of plane, is on the floor, or has a sudden fall from a lift she goes to get the nurse immediately and does not move the resident until the nurse is done with an assessment and tells her it is ok to move the resident. CNA M indicated 2 staff are to be present when staff use any mechanical lift per facility policy. On [DATE] at 11:24 AM during interview, LPN G stated, Originally I was told by CNA L that R20 was complaining of pain to her leg and there was an issue with the sit to stand. I had asked her to write a statement. I ended up finding the statement later on. It was very unclear, and I was looking for clarification. LPN G indicated she did not see any changes in R20 when she looked but asked UM/RN Q to assess her. LPN G indicated she did not remember gathering a set of vitals on R20. LPN G stated, I would like to have had more accurate information and more information by the CNA L. She should not have picked R20 up off of the floor. She should have grabbed a nurse. LPN G indicated education was given after the incident to be sure staff are using sit to stand lifts with two staff. LPN G indicated education that was given did not include what to do post fall or reporting accurate information. On [DATE] at 11:47 AM during a phone interview, CNA K indicated he came in on [DATE] at 2:30 PM and in report they said there was an incident with R20 and the sit to stand lift. CNA K stated, During first rounds, I could tell something was wrong with R20. I said to LPN N I think you need to get an x-ray, her leg does not look quite right. The position of her leg was not right. She was laying in the bed. Didn't look normal. CNA K indicated if a resident has a fall, he is to report the fall immediately and he does not move resident until after an RN has completed an assessment. CNA K indicated staff are to have two staff present when running any mechanical lifts in house per facility policy and he received education on this. CNA K indicated the typed summary of his interview in the Facility Self Report does not reflect what he reported to the facility. On [DATE] at 1:54 PM during interview, DON B indicated CNA L reported to LPN G that the lift battery died during transfer and now R20 is complaining of pain. Then CNA L slipped a written statement containing more information on the nurses' desk before exiting the building for the day. LPN G found the statement around 2:30 PM and brought it to DON B. DON B told LPN G to start an incident report, grab UM/RN Q for an assessment, and to report incident and findings to R20's provider. DON B and Surveyor reviewed CNA L's first statement. DON B and Surveyor reviewed contact with R20's provider. DON B indicated the provider was not made aware R20 was sitting on the ground. DON B stated, I was going to get a second statement from her to make sure there was a fall. DON B indicated CNAs are to report falls immediately to the floor nurse and give as many details as possible. Surveyor asked DON B what the process is for witnessed falls and unwitnessed falls. DON B indicated the process is for an RN to complete an assessment and notify the resident's provider. DON B indicated a thorough assessment contains a full set of vitals, a description of the affected area including any deformities, any discoloration, any changes in temperature, any shortening, or any rotation. DON B indicated she does not see any vitals recorded for [DATE] in R20's medical record. DON B indicated a fall is an unintended change of plane. DON B indicated staff are to have two staff present for all mechanical lift transfers per facility policy and CNA L transferred R20 two times alone, once to the toilet and once out of the bathroom. DON B indicated LPN N called her on [DATE] around 8:15 PM to let her know R20 was experiencing 9 out of 10 pain. DON B indicated she planned to assess R20 when she came in on [DATE] in the morning. Surveyor asked DON B if she would be willing to do an enactment of a staff member using the mechanical lift. DON B indicated she and Corporate Consultant EE would volunteer to demonstrate how to activate the emergency button so Surveyor could see how long it takes to lower a resident completely using the emergency button. (It is important to note R20's medical record does not contain a thorough assessment by DON B.) On [DATE] at 2:18 PM, Surveyor observed DON B and CNA FF maneuvering the lift while Corporate Consultant EE was seated with the sling in place around her. DON B, CNA FF, and Corporate Consultant EE could not get the emergency button to engage and lower the lift all at once. Surveyor observed a turn button on the hydraulic boom of the shift and when DON B turned that button it would only go one turn at a time. When the button made one full turn, the lift would lower a little bit and stop. Then DON B or CNA FF would turn button another full turn and lift would lower a small amount and stop. Surveyor observed staff were unable to drop the lift in one smooth motion using the red emergency buttons. DON B indicated she did not perform any re-enactments with CNA L or other staff after the incident, but she wished she would have. On [DATE] at 3:36 PM during interview, LPN N stated, When I got here for second shift, I was told R20 was on the sit -to - stand lift too long and now her knee hurts. R20 told me she pulled a muscle. I did look at her before dinner time and gave her a Tylenol at 8:30 PM. She said the pain was in her knee. Her leg goes in a little at baseline. I didn't think too much about it. CNA K thought it was an issue. I wasn't so sure. I had R20 move her leg, and it was her knee that she reported hurt. LPN N indicated R20 reported her pain was 9 out of 10 at one point, but she thought it was a strained muscle. LPN N indicated after Tylenol, R20 rated pain 8 out of 10 so she sent another message to R20's provider and eventually she was given a new order for a muscle relaxer. LPN N indicated she did not report R20 had a change of plane, a sudden drop from the lift, a witnessed fall, or ended up sitting on the ground during a transfer to R20's medical provider. LPN N stated, I was not given correct information in report. I would have monitored her differently through my shift if I knew she fell. CNA K and I looked at her leg and it was turned in a little. I thought that was normal. LPN N indicated her and CNA K thought an x-ray would have been ordered. LPN N indicated she did not remember gathering vitals and did not record information about R20's leg being internally rotated in R20's medical record. LPN N indicated she called DON B to report the resident's pain levels 9 out of 10 and 8 out of 10 and DON B indicated she would be in to look at her in the morning. On [DATE] at 3:46 PM, CNA K was interviewed in person this time and stated, I noticed before I did any cares on her (R20) that something was wrong. Her foot did not sit correctly. It was rotated in. I thought there was swelling above her knee. CNA K demonstrated for Surveyor by pointing the toes of his right foot towards his left foot. CNA K stated, I told the nurse. She contacted the doctor, and I was surprised she (the doctor) did not order an x-ray. I reported the pain and the leg to LPN N. I don't know what LPN N reported to the doctor. Surveyor and CNA K reviewed the facility's summary of CNA K's interview of the incident. CNA K indicated the typed statement from the Facility Self Report does not reflect the interview he gave to the facility. CNA K indicated again he knew something was wrong before he performed any cares with R20 and he was unsure if he should even move R20. On [DATE] at 4:33 PM, NP P (Nurse Practitioner) and Surveyor reviewed communication between the facility and the clinic. NP P indicated the clinic was not made aware that R20 had a change of plane, ended up sitting on the ground during a transfer with a mechanical lift, or was dropped suddenly from the lift. NP P stated, If I knew there was a fall I would have probably ordered x-ray then and there, on [DATE] at 8:04 PM. NP P indicated she was present in the facility on [DATE] in the morning and she did the exam in R20's appointment with NP O. NP P stated, R20 had severe bony tenderness and her foot looked like it had inward rotation. I could barely touch her. She was unable to flex, extend, abduct, or adduct. We did not know of a fall. X-ray was ordered stat because when I saw her it was internally rotated, and she was in so much pain. On [DATE] at 7:46 AM during interview, RN/UM Q (Registered Nurse/Unit Manager) indicated she never saw CNA L's first written statement and what she was told was the lift's battery died and the lift dropped her suddenly. RN/UM Q stated CNA L did not know how to activate the emergency button. CNA L pushed it and it didn't work. Then it did. CNA L tried to move R20 in the lift quickly so she wouldn't be on the floor. I did not see the note. I was told about it. Surveyor asked what the definition of fall is. RN/OM Q indicated a fall is a change of plane. Surveyor asked if dropped her suddenly was a fall? RN/UM stated, I don't know if it was a fall. RN/UM Q indicated she does not remember taking a set of vitals on R20 and if she did it would be recorded in R20's medical record. UM/RN Q indicated she did not report R20 had a fall to R20's provider. Surveyor asked, Are aides observed using lifts before they are using them with residents and does the facility perform competency checks? RN/UM Q stated, No they are not part of a skills checklist before they start. That is a good idea. UM/RN Q stated, She (CNA L)

Example 2 R35 was admitted to the facility 4/24/23 with diagnoses including, but not limited to, the following: Dementia (a group of thinking and social symptoms that interferes with daily functioning), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar), abnormal gait (walking different than normal), chronic kidney disease (disease of the kidneys that will eventually lead to kidney failure), and hypertension (high blood pressure). On 4/24/23, the facility's Treatment Administration Record (TAR) documents the following: Monitor feet to ensure skin is intact and free from s/sx (signs/symptoms) of developing skin alterations. Notify MD (Medical Doctor) with any change in skin integrity. Every evening shift for prevention of skin impairment. R35's Braden's are as follows: 4/24/24: 19 (Not At Risk) 7/24/24: 20 (Not at Risk) 10/25/24: 18 (Mild Risk) 11/8/24: 15 (Mild Risk) 1/21/25: 14 (Moderate Risk) 2/13/25: 11 (High Risk) 5/3/25: 16 (Mild Risk) On 7/5/24, the facility's Skin and Wound Evaluation documents R35 developed an In-house acquired Stage II PI (Partial-thickness skin loss with exposed dermis) to her right heel that resolved on 8/20/24. The document notes, area resolved will continue prevalon boot x7 days. On 2/12/25, R35 enrolled in hospice services. R35's Significant Change Minimum Data Set (MDS) dated [DATE] indicates R35 has a Brief Interview of Mental Status (BIMS) of 2 out of 15, indicating she is severely cognitively impaired. Section M (Skin Conditions) indicates R35 is at risk of PI's. R35 has an Activated Power of Attorney for Health Care (APOAHC). R35's comprehensive care plan documents, in part, as follows: (Date Initiated: 5/5/25) The resident has pressure ulcer (injury) right heel r/t (related to) tight shoes, DM (diabetes mellitus), and generalized weakness, on hospice care; also history of similar wound in 7/2024; Goal: Wound will heal within the limits of the disease process. (Target Date: 8/7/25); *Interventions: (Date Initiated: 5/5/25) Bilateral heel boots at all times; (Date Initiated: 5/5/25) *The resident needs monitoring/reminding/assistance to turn/reposition at least every 2-3 hours, more often as needed or requested. R35's comprehensive care plan for Restorative Program, documents, in part, as follows: (Date Initiated 1/20/25; Date Resolved: 5/13/25) Roll left and right: The resident requires supervision or touching assistance to complete task. (Date Initiated: 5/13/25) The resident requires partial/moderate assistance on [sic] 1 staff to complete task R35's Certified Nursing Assistant (CNA) Kardex, dated 5/27/25, documents, in part, as follows: *Prevalon boot on right foot AAT (at all times) except for transfers; no shoes; and Alternate Device(s): Offloading boots on bilateral feet when in bed. It is important to note, the comprehensive care plan indicates Bilateral heel boots at all times. On 4/29/25, R35's Physician visit documents, in part, as follows: 30 day compliance visit SKIN- no masses, no rashes, no lesion on exposed skin Unspecified protein-calorie malnutrition: Patient continues on Boost (supplement). Ongoing weight loss noted and not unexpected due to terminal disease. Weight has decreased by 3 pounds in the last week. On 5/3/25 at 11:33 AM, R35's Progress Notes documents as follows: Body check completed after shower. Resident c/o (complained of) pain to right heel when touched. Noted dark purple area to right heel. Skin is intact. Wound care nurse notified and new orders received. Hospice updated, family updated and provider updated. Will continue to monitor. On 5/4/25 at 10:49 AM, R35's Progress Note documents as follows: Heel boot on while in bed. Pressure injury remains to right heel. Skin remains intact. Area dark purple in color. No c/o (complaints of) pain noted at this time. Betadine applied as ordered. Will continue to monitor. On 5/6/25, NP C (Nurse Practitioner) assessed R35 indicating, in part, as follows: Diagnosis that could affect wound healing: diabetes, dementia, history of falls, abnormal gait, Vitamin D deficiency, CKD, HTN Interventions in Place: Offloading measures per facility protocol, nutrition support, topical wound care Physical Examination Right posterior heel (unstageable pressure ulcer) *100% adherent eschar measuring 1 x 1 x UTD (Unstageable Tissue Depth) cm. No fluctuance or drainage noted. Peri wound is intact, no signs of infection. *Status: reoccurrence Plan: Apply betadine daily, leave open to air. Continue use of Prevalon boot whenever in bed Assessment *Unstageable pressure ulcer of right heel Discussed with nurse Medical records reviewed Wound care re-evaluation in 1 week On 5/13/25 at 8:30 AM, NP C documented the following note: Type: Wound Care Follow Up Chief Complaint: wound to right heel Subjective: Patient seen today sitting up in her wheelchair. Subjective is limited due to dementia however appears comfortable. Per staff no recent fever, chills, nausea or vomiting. Diagnosis that could affect wound healing: diabetes, dementia, history of falls, abnormal gait, Vitamin D deficiency, CKD, HTN Interventions in Place: Offloading measures per facility protocol, nutrition support, topical wound care Physical Examination: Right posterior heel (unstageable pressure ulcer) 100% adherent eschar measuring 1 x 1 x UTD (Unstageable Tissue Depth) cm. No fluctuance or drainage noted. Peri wound is intact, no signs of infection. Status: stable Plan: Apply betadine daily, leave open to air. Continue use of Prevalon boot whenever in bed Assessment: *Unstageable pressure ulcer of right heel Discussed with nurse Medical records reviewed Wound care re-evaluation in 1 week On 5/19/25 at 10:05 AM, a Nutrition Note documents as follows: Most recent weight of 98.8# on 5/17 triggered for a significant weight loss 7.5% x 30d. Resident refused breakfast this morning & per nsg spit out meds. Continued weight loss anticipated as overall status declines. Will continue to offer foods as tolerated and follow hospice plan of care. R35 remains on hospice services, gradual weight loss is expected. Resident is triggering for 8# over 30 days. Resident intake varies and receives Boost supplement 3x (three times) daily. Will continue current POC (Plan of Care) . On 5/20/25 at 8:30 AM, NP C documented the following note: Type: Wound Care Follow Up Chief Complaint: wound to right heel Subjective: Patient seen today sitting up in her Broda chair. Subjective is limited due to dementia however appears comfortable. Per staff no recent fever, chills, nausea or vomiting. Diagnosis that could affect wound healing: diabetes, dementia, history of falls, abnormal gait, Vitamin D deficiency, CKD, HTN Interventions in Place: Offloading measures per facility protocol, nutrition support, topical wound care Physical Examination: Right posterior heel (unstageable pressure ulcer) 100% adherent eschar measuring 1 x 1 x UTD (Unstageable Tissue Depth) cm. No fluctuance or drainage noted. Peri wound is intact, no signs of infection. Status: stable Plan: Apply betadine daily, leave open to air. Continue use of Prevalon boot whenever in bed Assessment: *Unstageable pressure ulcer of right heel Discussed with nurse Medical records reviewed Wound care re-evaluation in 1 week 5/27/25 at 8:15 AM, NP C documented the following note: Type: Wound Care Follow Up Chief Complain: wound to right heel Subjective: Patient seen today sitting on the side of bed getting dressed. Subjective is limited due to dementia however appears comfortable. Per staff no recent fever, chills, nausea or vomiting. Diagnosis that could affect wound healing: diabetes, dementia, history of falls, abnormal gait, Vitamin D deficiency, CKD, HTN Interventions in Place: Offloading measures per facility protocol, nutrition support, topical wound care Physical Examination: Right posterior heel (unstageable pressure ulcer) 100% adherent eschar measuring 1 x 1 x UTD (Unstageable Tissue Depth) cm. No fluctuance or drainage noted. Peri wound is intact, no signs of infection. Status: stable Plan: Apply betadine daily, leave open to air. Continue use of Prevalon boot whenever in bed Assessment: *Unstageable pressure ulcer of right heel Discussed with nurse Medical records reviewed Wound care re-evaluation in 1 week On 5/27/25 at 11:39 AM, the facility documents the following note: Skin/Wound Note: Seen by wound team today. Wound on right heel measuring 1.0 x 1.0 x UNS (Unstageable); wound is now a hard eschar cap that the orders read skin prep and offloading; care plan reviewed and remains appropriate On 5/28/25 the facility changed ownership. On 6/1/25 the facility added the following documentation: Turned and repositioned for each shift (AM: 6:30 AM-2:30 PM, PM: 2:30 PM-10:30 PM, NOC: 10:30 PM-6:30 AM) It is important to note, turning and repositioning is not documented for the following dates/shifts: 6/1 AM 6/3 AM and NOC 6/5 NOC 6/6 PM, NOC 6/7 NOC 6/10 NOC 6/11 AM On 6/3/25 at 4:02 PM, the facility documents the following note: Skin/Wound Note: Seen by wound team today for wound on the right heel which is a UNS (Unstageable) pressure injury. The wound measures: 1.0x1.0xUTD (Unstageable Tissue Depth) (Unstageable Tissue Depth) (Unstageable Tissue Depth). The wound base has full eschar with no drainage. The current order is Iodine and OTA (open to air) twice daily with offloading boots on. All orders approved by NP C (Nurse Practitioner). Care plan in place and remains appropriate. On 6/10/25 at 7:45 AM, Surveyor observed R35 up in her broda chair in the dining room wearing gripper socks. Surveyor observed R35 was not wearing prevalon boots. On 6/10/25 at 8:10 AM, Surveyor spoke with LPN Y (Licensed Practical Nurse). Surveyor asked LPN Y, should R35 be wearing Prevalon boots. Surveyor showed LPN Y R35's care plan. LPN Y stated, R35 should have a prevalon boot on her right foot and is not wearing a prevalon boot. LPN Y stated, she will notify CNA HH (Certified Nursing Assistant). On 6/10/25 at 8:20 AM, Surveyor observed NP C measure and assess R35's PI to her right heel. DON B (Director of Nursing) and Unit Manager/RN Q (Unit Manager/Registered Nurse) were also present in R35's room. NP C stated, the PI measures 1.0 cm x 1.0 cm and is the same and stable. Surveyor observed NP C apply betadine to R35's right heel PI. DON B voiced the start date of the PI as 5/3/25. On 6/10/25 at 8:26 AM, Surveyor spoke with NP C (Nurse Practitioner). Surveyor asked NP C, what caused the PI to R35's right heel. NP C stated, not walking at all, has boots on her, previous PI to the same area, and overall health declining. NP C stated, the PI is unavoidable, she's at risk, she sits in broda or bed; NP C stated, I feel it's going to heal but going to be slow. NP C added, she does feel it's absorbing. NP C stated, it's important for R35 to have boots on. NP C added, R35 does not refuse the prevalon boots. NP C stated, she will always recommend prevalon boots first and if a resident refuses prevalon boots she will try a HeelzUp (an offloading device for heels/feet). NP C stated, R35 has not needed a HeelzUp as she is agreeable to wearing the prevalon boots and does not refuse them. Surveyor shared observation of R35 up in the broda chair in the dining room with no prevalon boots on. Surveyor asked NP C, would you expect R35 to be wearing bilateral prevalon boots per her care plan. NP stated, yes, this is important to offload pressure so the PI can heal. 6/10/25 at 12:15 PM, NP C (Nurse Practitioner) documented the following note: Type: Wound Care Follow Up Chief Complain: wound to right heel Diagnosis that could affect wound healing: diabetes, dementia, history of falls, abnormal gait, Vitamin D deficiency, CKD, HTN Interventions in Place: Offloading measures per facility protocol, nutrition support, topical wound care Physical Examination: Right posterior heel (unstageable pressure ulcer) 100% adherent eschar measuring 1 x 1 x UTD (Unstageable Tissue Depth) cm. No fluctuance or drainage noted. Peri wound is intact, no signs of infection. Status: stable Plan: Apply betadine daily, leave open to air. Continue use of Prevalon boot whenever in bed and in Broda chair Assessment: *Unstageable pressure ulcer of right heel Discussed with nurse General wound care instructions: Keep the wound clean and dry, Monitor for signs of infection (increased redness, warmth, swelling, drainage, odor, or pain), Elevate affected extremity when possible. Wound care re-evaluation in 1 week On 6/10/25 at approximately 9:30 AM, Surveyor spoke to DON B (Director of Nursing) Surveyor asked DON B, if the facility has documentation from R35's provider indicating if the PI is avoidable or unavoidable. DON B stated, the facility does not have this documentation and has requested it from NP C (Nurse Practitioner). On 6/10/25 at 8:52 PM, NP C (Nurse Practitioner) appended the 6/10/25 note to include the following: The following unavoidable statement should be included: Patient with multiple comorbidities and multiple risk factors for developing and worsening of pressure injuries. Interventions consistent with individual needs, goals and standards of care have been implemented. Revisions to intervention were made as appropriate. Wound is considered unavoidable and patient is at risk for further worsening or development of additional areas. On 6/10/25 at 1:45 PM, Surveyor spoke with CNA HH (Certified Nursing Assistant). Surveyor asked CNA HH, how long she has worked at the facility. CNA HH stated, she has worked at the facility since January. Surveyor asked CNA HH, how do you know how to care for R35 and other residents. CNA HH stated, there's a CNA Kardex in each resident's bathroom. Surveyor asked CNA HH, what are R35's skin interventions. CNA HH stated, R35 is supposed to have heel boots in bed. Surveyor and CNA HH walked to R35's room and reviewed the CNA Kardex, dated 5/27/25, in R35's bathroom. Surveyor asked CNA HH, should you have put the prevalon boots on R35's bilateral feet when you got her up, dressed, and in her broda chair. CNA HH stated, Yes. Surveyor asked CNA HH, does R35 refuse the prevalon boot. CNA HH stated, No. Surveyor asked CNA HH, how does R35 transfer. CNA HH stated, she used to transfer with the stand lift but she is declining and now uses a Hoyer (full body) lift. On 6/12/25 at 8:25 AM and 11:00 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B to tell me about R35's current and previous PI to her right heel. DON B stated, R35 has diabetes, wears shoes and was wearing shoes after the PI healed the first time (in August 2024). DON B stated, R35's family member got what he believed were diabetic shoes. R35 with her dementia preferred the clunky shoes. DON B stated, she believes the clunky shoes were the cause of the previous PI to R35's right heel. DON B stated, R35 was walking at that time and still mobile. DON B stated, R35 has dementia, diabetes, peripheral vascular disease and started to decline. DON B stated, R35 was enrolled in hospice services in February 2025 before the PI re-developed. Surveyor asked DON B, what is the cause of R35's current PI to her right heel. DON B stated, digging her heels into the bed (note, care plan documents it was her same shoes that caused her first PI to her right heel), not on an air mattress, a lot of back pain, she lays on her back in bed with her arms crossed over her chest. Surveyor asked DON B, is R35 on an air mattress. DON B stated, she believes so. DON B stated, she asked hospice to get her an air mattress as the facility's standard mattress is pressure redistribution. DON B provided documentation that the facility's standard mattress is the Medline Advantage Select SE. R35's mattress is a the Medline Advantage Select SE which is indicated up to a Stage III PI (pressure injury). DON B added, sometimes she is at the mercy of hospice. DON B stated, she has paid for air mattresses in the past before the company changed ownership on 5/28/25. Surveyor asked DON B, how soon should a PI be measured and assessed when it's initially discovered. DON B stated, it should be completed upon discovery. Surveyor asked DON B, is it acceptable for the PI to not be measured and assessed for three (3) days. DON B stated, no. DON B stated, she has residents that have healed PI's that are on air mattresses because they need it. Surveyor requested documentation of DON B's request for an air mattress and hospice correspondence. Of note, no further information was provided to Surveyor. Surveyor asked DON B, was R35 on a turning and repositioning schedule prior to the Unstageable PI developing for the second time to R35's right heel. DON B stated, the facility did not document turning and repositioning prior to the development of the PI. DON B stated, the new company does have staff documenting turning and reposition every 2 hours for the shift. Of note, currently staff are not documenting that turning is repositioning is being done every 2 hours, per standard of practice. DON B stated, unfortunately prior to discovery of R35's PI, the facility's was turning and repositioning residents every 2-3 hours. DON B stated, going forward the facility will be turning and repositioning R35 (and other residents) every 1-2 hours. DON B stated, she learned turning and repositioning a resident a resident with a PI should be occurring every 1-2 hours. DON B added, initially NP C (Nurse Practitioner) instructed staff that R35 is to have prevalon boots on while in bed. DON B added, we did change it to at all times. Based on interview and record review, the facility did not ensure each resident receives necessary treatment and services, consistent with professional standards of practice, to prevent pressure injuries (PIs) from developing and/or worsening and promote healing of PIs for 3 of 5 residents (R35, R34, R28) reviewed for PIs out of a sample of 16 residents. R28 and R35 are being cited at Actual Harm/Isolated; R34 is being cited at Potential for Harm/Isolated. R28 admitted with a pressure injury on his coccyx and was identified to be at risk for pressure injury development. R28 had an intervention in place to wear Prevalon boots at all times except for when in therapy. R28 developed an unstageable pressure injury on his left heel. Surveyor observed R28 to be without his Prevalon boots on, was wearing black shoes, and had his heels directly on the mattress. R28's Medication Administration Record/Treatment Administration Record (MAR/TAR) did not contain an order for Prevalon boots. R28's Kardex did not have an intervention for Prevalon boots. Staff interviewed were not aware R28 had orders for Prevalon boots to be worn at all times and did know that he was care planned to have Prevalon boots on at all times except for when working with therapy for standing/walking. R35 had a previous history of a PI to her right heel. On 5/3/25 the facility discovered a Deep Tissue Injury (DTI) to R35's right heel. The facility did not measure or assess the DTI prior to NP C (Nurse Practitioner) assessing the PI on 5/6/25. On 5/6/25, NP C classified the PI as Unstageable measuring 1.0 x 1.0 cm (centimeter) with 100% eschar. The facility did not notify NP C of any changes to the PI. The facility was turning and repositioning R35 every 2-3 hours versus every 1-2 hours. In addition, the facility is not documenting that turning and repositioning is being completed. R35's care plan documents a PI intervention of Bilateral heel boots at all times. Surveyor observed R35 up in her broda chair without bilateral heel boots with R35's heel in direct contact with the broda chair. R34 did not have an assessment of her pressure injury until 5 days after discovering the wound. Evidenced by: The facility policy, Pressure Injury Prevention Guidelines, dated 5/28/25, documents, in part, as follows: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Support surfaces do not eliminate the need for turning and repositioning. The standard mattress for all facility beds are pressure redistribution mattresses (i.e. high specification reactive foam). Provide alternative support surfaces as needed. Considerations for utilizing specialized support surfaces: .Stage 3,4, unstageable, or deep tissue injury on trunk (lower body) The facility does not have a policy for turning and repositioning. The National Pressure Injury Advisory Panel (NPIAP) classifies a PI as follows: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Unstageable: Obscured full-thickness skin and tissue loss full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. The facility policy, Completing an Accurate Assessment Regarding Pressure Injuries, dated 5/28/25, includes: The purpose of this policy is to assure that all residents receive an accurate assessment of pressure injuries, including risk, presence, appearance, and change of pressure injuries. 1. Accurate assessments addressing each resident's skin status will be conducted by qualified staff and correctly documented in the medical record. 3. A qualified health professional will document the presence, number, stage, and pertinent characteristics of any pressure injury on the wound documentation form in the medical record. The facility policy, Documentation of Wound Treatments, dated 5/28/25, includes: 2. The following elements are documented as part of a complete wound assessment: a. Type of wound (pressure injury, surgical, etc.) and anatomical location b. Stage of the wound, if pressure injury (stage 1, 2, 3, 4, deep tissue pressure injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness) c. Measurements: height, width, depth, undermining, tunneling d. Description of wound characteristics: i. Color of the wound bed ii. Type of tissue in the wound bed . iii. Condition of the peri-wound skin . iv. Presence, amount, and characteristics of wound drainage/exudate v. Presence or absence of odor vi. Presence or absence of pain. Example 1 R28 admitted to the facility on [DATE] with the following diagnoses: hemiplegia and hemiparesis, chronic atrial fibrillation, type 2 diabetes mellitus, cognitive communication deficit, abnormal gait and mobility, arthropathy, cerebral infarction, and need for assistance with personal cares. R28 admitted with a pressure injury on his coccyx area. R28's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/18/25, indicates R28's cognition is moderately impaired with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. R28's Comprehensive Care Plan, initiated Includes: The resident has pressure ulcer left heel, and sacrum- closed 5/27/25- related to immobility, prolonged hospitalization, some ascites and lymphedema with history of PVD, revision 6/2/25 . Goal: the resident's pressure ulcer will show signs of healing and remain free from infection through review date of 8/25/25 . Interventions: Heel lift boots on at all times except when working with therapy for standing/walking, revision date 2/26/25 . heel lift boots on at all times except when working with therapy for standing/walking date, initiated 3/11/25, revision 5/29/25 . the resident needs monitoring/reminding/assisting to turn/reposition at least every 2 to 3 hours, more often as needed or requested, initiated 3/11/25, revision 5/29/25 . R28's Braden Scale for Predicting Pressure Injuries, dated 3/4/25, indicates R28 is at risk for pressure injury development with a score of 15. R28's Nurse Note, dated 3/10/25, includes: Writer called to room by assigned CNA (Certified Nursing Assistant) concerning open area to left heel. Upon entering room resident had bilateral heel boots in place. Small amount of dried blood was seen on bed sheets near foot of bed. Open area observed to left heel and purple discoloration also observed to left heel. Open area to left heel measures 3.0 cm (centimeters) x 1.5 cm x 0.0 cm. Area cleansed and foam dressing applied to area. Heel boot in place. As needed Tylenol given for pain. Skin prep applied to purple discoloration on heel. (It is important to note R28 has a new open area to his left heel.) R28's Wound Care Initial Evaluation, dated 3/11/25, includes: Left posterior heel DTI (deep tissue injury) . Full thickness wound with mix of granular tissue and purple devitalized tissue at the base. Wound measuring 2.0cm x 2.0cm x unable to determine. Moderate serous drainage noted, no purulence or odor noted. Peri wound without redness or warmth to indicate infection . Plan: Cleanse with normal saline or wound cleanser then apply Silver Alginate to the wound base and cover with ABD pad, secure with kerlix. Change 3 times a week and as needed . Pressure ulcer of unspecified site, unstageable . Pressure-induced deep tissue damage of left heel . Discussed with wound care team . Continue aggressive offloading measures . R28's Nurse Practitioner Note, dated 3/12/25, includes: Pressure-induced deep tissue damage of left heel . Deep tissue injury to left posterior heel with mix of granular tissue and purple devitalized tissue at the base, measuring 2.0cm x 2.0cm x unable to determine. Moderate serous drainage noted, no purulence odor. Peri wound without redness or warmth. Evaluated by wound care team yesterday. Continue current wound care protocol and offloading measures. R28's Nurse Note , dated 3/17/25, includes: Pt (patient) has Left heel DTI, boot in place at all times. R28's Wound Care Follow Up Note, date: 3/18/2025, includes: Left posterior heel (deep tissue injury) . Full thickness wound with 80% Eschar and 20% granular tissue at the base. Wound measuring 2.0cm x 2.0cm x unable to determine . Small amount of serous drainage noted, no purulence or odor noted. Peri wound without redness or warmth to indicate infection. Status: improving . Plan: Cleanse with normal saline or wound cleanser, then apply Silver Alginate to the wound base, and cover with ABD pad, secure with kerlix. Change 3 times a week and as needed . Assessment .Pressure ulcer of unspecified site, unstageable . Pressure-induced deep tissue damage of left heel . Deep tissue injury to left posterior heel with mix of granular tissue and purple devitalized tissue at the base, measuring 2.0cm x 2.0cm x unable to determine . Moderate serous drainage noted, no purulence or odor. Peri wound without redness or warmth. Evaluated by wound care team yesterday. Continue current wound care protocol and offloading measures. Discussed with wound care team . Continue aggressive offloading measures . R28's Wound Care Follow Up, dated 3/25/25, includes: . Left posterior heel (deep tissue injury) . Full thickness wound with 100% Eschar, measuring 2.0cm x 2.2cm x unable to determine. No drainage noted, no purulence or odor noted. Peri wound without redness or warmth to indicate infection . Plan: apply betadine daily, leave open to air . Pressure ulcer of unspecified site, unstageable . Pressure-induced deep tissue damage of left heel . Deep tissue injury to left posterior heel with mix of granular tissue and purple devitalized tissue at the base, measuring 2.0 x 2.0 x unable to determine. Moderate serous drainage noted, no purulence or odor. Peri wound without redness or warmth. Evaluated by wound care team yesterday. Continue current wound care protocol and offloading measures . Discussed with wound care team . Continue aggressive offloading measures . Medical records reviewed . Wound care re-evaluation in 1 week . R28's Wound Care Follow Up, dated 4/1/2025, includes: . Left posterior heel (deep tissue injury) Full thickness wound with 100% Eschar, measuring 2.0cm x 2.0cm x unable to determine. No fluctuance or drainage noted, no purulence or odor noted. Peri wound without redness or warmth to indicate infection . Plan: apply betadine daily, leave open to air . Pressure ulcer of unspecified site, unstageable . Pressure-induced deep tissue damage of left heel . Deep tissue injury to left posterior heel with mix of granular tissue and purple devitalized tissue at the base, measuring 2.0 x 2.0 x unable to determine. Moderate serous drainage noted, no purulence or odor. Peri wound without redness or warmth. Evaluated by wound care team yesterday. Continue current wound care protocol and offloading measures . Discussed with wound care team . Continue aggressive offloading measures . R28's Wound Care Follow Up, dated 4/8/2025, includes: . Left posterior heel (deep tissue injury) . Full thickness wound with 100% Eschar, measuring 2.0cm x 2.0cm x unable to determine. No fluctuance or drainage noted, no purulence or odor noted. Peri wound without redness or warmth to indicate infection . Plan: apply betadine daily, leave open to air . Pressure ulcer of unspecified site, unstageable . Pressure-induced deep tissue damage of left heel . Deep tissue injury to left posterior heel with mix of granular tissue and purple devitalized tissue at the base, measuring 2.0cm x 2.0cm x unable to determine. Moderate serous drainage noted, no purulence or odor. Peri wound without redness or warmth. Evaluated by wound care team yesterday. Continue current wound care protocol and offloading measures . Discussed with wound care team . Continue aggressive offloading measures . R28's Wound Care Follow Up, dated 4/15/25, includes: Left posterior heel (deep tissue injury) Full thickness wound with 100% Eschar, measuring 1.5cm x 1.5cm x unable to determine. No fluctuance or drainage noted, no purulence or odor noted. Peri wound without redness [TRUNCATED]

Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents in 1 of 2 residents (R20) reviewed for falls resulting in actual harm, 1 of 1 resident (R31) reviewed for motorized wheelchair charging, and 2 of 4 units reviewed for lithium battery charging. R20 is being cited at Actual Harm/Isolated. R31 and 2 of 4 units is being cited at Potential for Harm/Isolated. R20 was care planned to be a two person assist with a sit to stand transfer. CNA L transferred R20 alone when the lift lost battery power. R20 ended up sitting on the ground, had a sudden drop from the lift, and a change of plane/fall. CNA L assisted R20 off the floor and did not report R20 ended up sitting on the ground, had a sudden drop from a lift, and a change of plane/fall immediately to the floor nurse or to the oncoming shift. CNA L reported that R20 was on the ground to CNA M. CNA M did not report R20 had a fall to the floor nurse. R20 was found to have an intertrochanteric right femoral fracture. R31's motorized wheelchair is charged in her room. The facility charges electric patient lifts in the hallways. This is evidenced by: Facility policy, titled Hoyer Lift and Sit to Stand, undated, states in part; it is important to use all lifts safely . All CNAs should have the proper training before using the lift . Each lift has a safety feature in case of battery malfunction, please be aware how to utilize that feature and potential obstacles that could happen . Per facility policy, all lifts require 2 staff members in the room for transfers for the resident's safety. It is NOT OPTIONAL. (It is important to note in this policy there are no further instructions on how to identify or activate the lifts safety feature.) Facility policy, titled Fall Prevention Program, reviewed and revised on [DATE], states in part; each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not because of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . When any resident experiences a fall, the facility will assess the resident, complete post fall assessment, complete an incident report, notify physician and family, review resident's care plan and update as indicated, document all assessments and actions, obtain witness statements in case of injury. Manufacturer's recommendations for use of battery-operated patient lift, states in part; the emergency lowering device is intended for use during lift failure. This device will allow lowering of patients only . Turn clockwise to lower. Emergency Lowering Mechanism: In case of lift failure, please follow the procedures below to safely lower the user. The emergency lowering device is located at the top of the actuator shaft. It is intended for use if the actuator fail to operate while a patient is suspended. The device consisting of a plastic collar ring that should be turned clockwise continually until the patient has been lowered. The facility's policy titled Motorized Wheelchairs, dated [DATE], includes: 4. Charging of a motorized wheelchair will take place in an approved area, which is ventilated. At no time is a motorized wheelchair to be charged in a resident room. The facility's policy titled Safe Resident Handling/Transfers, dated [DATE], includes: it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. R20 admitted to the facility on [DATE]. Her diagnoses include rheumatoid arthritis, atrial fibrillation, atherosclerotic heart disease, joint disorder, history of falling, weakness, hypertension, sensorineural hearing loss bilaterally, pulmonary hypertension, and age-related osteoporosis. R20's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE], indicates R20 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. R20's Comprehensive Care Plan, initiated on [DATE], indicates R1 requires assistance of 1 for the following: dressing, bathing, bed mobility, and assist of 2 with sit to stand lift for transfers and needs one staff member to propel her in the wheelchair for long distances. R20's Comprehensive Care Plan indicates R1's medications are administered by the nurse. Facility Self Report, dated [DATE], includes the following: Date and time occurred-[DATE] at 1:35 PM . Date discovered-[DATE] . Date and time reported-[DATE] 12:46 PM Initial Report-Summary of incident: Patient had reported increased pain in her hip related to a transfer from bathroom to wheelchair where the sit to stand lost power and started to lower while resident was up in lift. The resident ended up in a squatting position with her buttocks touching bottom of the lift and staff were able with the resident's help to get her in an upright seated position and into her wheelchair. A new lift was used to transfer to the resident's bed. Resident is complaining of increased pain since incident and X-rays were ordered by primary nurse practitioner which indicates possible dislocation of right hip and resident will be transferred to hospital for further evaluation and treatment. An investigation initiated. CNA (Certified Nursing Assistant) who completed the transfers was suspended today. Investigation to follow . Follow-up Report and Investigation-Investigation Summary: . On [DATE], R20 put on her call light because she wanted to be toileted. The assigned CNA (Certified Nursing Assistant) . was in the lunchroom, and CNA L was covering the floor. CNA L transferred R20 with sit to stand lift and took her to the toilet. Shortly thereafter, R20 put on the call light to get off the toilet and go back to bed. CNA L once again used the sit to stand lift without assistance of another staff member and upon raising her up the battery died. R20 was complaining that under her arms (where sling was) was hurting her, so CNA L used the emergency button to lower the lift arm. Apparently, that did not lower initially so CNA L tried to start pushing lift toward R20's bed and after going from the tile bathroom floor to the carpeted bedroom, the lift started to lower with resident still in sling. As the lift arm lowered the resident ended up in a squatting position with her buttocks touching the foot pad of the lift. CNA L decided to try to help the resident by pushing her buttocks and got her high enough to sit in her wheelchair. Shortly after that, CNA M arrived at the unit. CNA L told her she needed help with the transfer from the wheelchair to the bed. After the resident was settled, CNA L told the nurse that the resident was complaining of pain in her leg and that during the transfer with the sit to stand the battery died. She did not mention that this transfer was completed by only herself. LPN G (Licensed Practical Nurse) asked CNA L to write a statement and then she was going to see the resident. CNA L wrote an initial statement on [DATE] that was left for the nurse and not read until after end of day shift. CNA L statement left at nurse station, includes [DATE] While transfer with the sit to stand. The sit to stand went dead in mid-air. She complained about her arms hurts [sic] so did the force thing to force the sit stand while that was going. [sic] It end sitting her down on the floor. I held her back with my legs so she wouldn't fall back. With her help I was able to get her back in her chair. Then a new sit to stand was used to get her in bed. Nurse was told. Statement was written. (It is important to note R20's Care Plan indicates she requires the assistance of 2 staff members and a mechanical lift to meet her transfer needs and CNA L indicates in her interview that she used a sit to stand lift to transfer resident without another staff member present. It is also important to note CNA L indicates R20 ended up sitting on the floor experiencing a change in plane. Also important to note CNA L assisted R20 off of the floor and into her wheelchair without an RN assessing R20 per facility policy and current standards of practice for post fall care.) R20 statement, dated [DATE], includes I wanted to go get on the machine because I wanted to go to the bathroom, like I always do after lunch. It was around 1:00 PM and I put my call light on. It took a little time and then someone came in to take care of me. I had CNA M that day, but she was busy, so this other one came to help. I don't remember her name. She put me on the sit to stand. Then I went to the bathroom and then I was brought back by my bed. Then CNA M came in. She came to help this girl. They put me in bed. I don't think I fell or anything. I don't remember my butt hitting the ground. CNA M statement, dated [DATE], includes I wasn't present when the incident happened yesterday. I only came when I seen [sic] her on the chair and the aide together. The aide told me that R20 was on the floor and that the sit to stand wasn't working, but R20 stated she was never on the floor but that her legs started hurting after being up on the machine for a while. I then helped the CNA L put R20 on the bed. (It is important to note CNA M stated she was aware R20 was on the floor.) LPN G statement, dated [DATE], includes as the day shift was ending on [DATE], CNA L told me there was an issue with the sit to stand lift during the transfer prior to the end of shift and that R20 had said her leg hurt. I told CNA L to write a statement before she left about the transfer. I noticed a statement by my computer about R20 from CNA L. The statement was unclear, and I did not see it until after 2:30 PM. I went looking for CNA L off the unit and found out she had already left the building. I notified DON B (Director of Nursing) why I was looking for the CNA and she directed me to put in an incident report and notify NP O (Nurse Practitioner). I notified Unit Manager/Registered Nurse Q about the statement, and we went in to look at R20 and try to identify what had happened earlier to her. R20 reported she was hurting on her right side from being up in the sit to stand lift for too long and maybe she had pulled a muscle. The statement stated that R20 was on the floor at some point and R20 vehemently denied that. R20 was able to lift her knee and leg on the right side while lying in bed and LPN G had not noticed any change in her pain levels at that time or any leg discrepancy in length. R20 rated her pain as a six on a scale of one to ten. LPN G then completed a risk management report of other incident and passed on in report to LPN N what she knew of the incident. LPN G also did report to NP O (Nurse Practitioner) . of the incident . No new orders given at this time. (It is important to note LPN G did not follow facility fall protocol for a witnessed fall, a reported fall, or presumed fall.) DON B (Director of Nursing) statement, dated [DATE], includes on [DATE] at around 2:30 PM LPN G reported to me that R20 said she had an issue with an earlier transfer in the sit to stand lift and that her leg was sore. I instructed her to get Unit Manager/RN Q and look at R20 and prepare an incident report. LPN G did complete incident report as other incident. On [DATE] R20 was seen by Nurse Practitioner (NP O and NP P) and she noted there was a leg discrepancy and ordered an x-ray. R20 also had denied any fall at that time and told NP O that she thought it was from being up in the sit to stand too long. I was made aware of the possible change just around 9:00 AM. CNA L was in the facility with a resident . completing one-on-one observation. Around 10:30 AM, I interviewed CNA L and had her complete a new written statement. During that interview I found out that the sit to stand transfer was not completed per policy initially and that only CNA L was in the room. CNA L witnessed the issue with the lift and resident. I felt at that point that the potential injury could be the result of a witnessed fall due to change of plane for the resident. I then went into risk management and changed the reason for the incident report from other to witnessed fall and completed the corresponding assessments for the incident. At about 1:00 PM, the X-ray did reveal a fracture of the right hip, and the resident was being transferred to the emergency room for evaluation. The incident was then reported to the State as an injury of unknown origin because I could not definitively determine cause and investigation was initiated. CNA L second statement, dated [DATE], includes I answered R20's call light. She was in the bathroom, [sic] as I am lift her up with sit to stand, she complains of pain in her arm pits as I go to lower her the machine died in mid-air, so I press the release button so it can be lower. [sic] wasn't aware that it was going so I tried to get her to her bed as quick as possible but on the way, she had been lower to the ground, so I made sure she didn't hit head and made sure she was sitting upright. With her help, I was able to get her off the floor into her wheelchair, then I use a charged sit to stand to put her in her bed. Handwritten on the interview is a statement that states per interview did a squat on lift and was able to push up enough to get into wheelchair. (It is important to note CNA L reports a second time that R20 was on the ground and had a change of plane. It is also important to note CNA L reports she assisted R20 off the floor and transferred her 2 times without an RN assessing R20.) UM/RN Q (Unit Manager/Registered Nurse) statement, dated [DATE], includes R20 had complained of right knee pain after being in the sit to stand. Resident was assessed in bed. Pain to right knee was stated at a 4 out of 10. Floor nurse gave scheduled Tylenol for pain. Resident's right knee was parallel to left knee. Right leg did not have internal rotation when assessed. UM/RN Q second statement, dated [DATE], includes as we further investigated events from [DATE], I was made aware by CNA L, that only one person was used to transfer the resident with the sit to stand lift. I had previously been under the impression that 2 staff were used for the transfer as this is facility policy. R20's Nurse Note, dated [DATE], includes late entry for [DATE] at 2:00 PM: Writer was notified by LPN G that resident had complaints of pain to her right knee after being in the sit to stand too long. Writer assessed the resident. Right knee appeared equal to left knee. No rotation, redness, or swelling noted. Resident stated she has arthritis in that knee and has pain from time to time. Had pain 4 out of 10 at that time. (It is important to note UM/RN Q did not treat R20 as if she just had a fall, a change of plane, a sudden drop from a lift, and she did not record an RN assessment in R20's medical record until [DATE] when she added a late entry.) Advanced Practice Nurse Practitioner (APNP) Note, dated [DATE] at 10:30 AM, includes chief complaint- right knee and leg pain . Patient was an acute add on today presenting today with right knee and leg pain after being transferred via sit to stand overnight last night per RN report . vital signs- [DATE]: blood pressure- 122/64, oxygen saturation- 96%, pain- 0, temperature- 97.6 degrees, respirations-18, heart rate 74, weight 140 . vitals [DATE] blood pressure- 110/62, oxygen saturation- 95%, pain-0, temperature 97.3 degrees, respirations-17, heart rate- 65 . vitals [DATE] pain 8 . vitals [DATE] pain-0 .Muscoskeletal- no joint tenderness or deformity. Right lower extremity with minimal range of motion. Unable to flex, extend, abduct, adduct, or externally rotate hip without extreme pain. Right lower extremity internally rotated while resting in bed and unable to straighten. Pedal pulses plus 2 bilaterally, warm to touch, and sensation intact. No bruising or swelling noted. R20's Radiology Report, dated [DATE] at 12:25 PM, includes . Hip . Right . Results: Intertrochanteric right femoral fracture with mild angulation. Mild soft tissue swelling . Conclusion: Acute Intertrochanteric right femoral fracture as noted . Knee . Right . No acute fracture or dislocation. The osseous structures appear intact. Modest joint space narrowing. Soft tissues are unremarkable. Conclusion: No acute osseous findings. Recommend a repeat multi-view imaging in 1 week or sooner if clinically warranted especially if symptoms continue or persist or progress. R20's Emergency Department Note, dated [DATE], includes x-ray today shows a broken hip. Given that you are not ambulatory, there is no clear indication for surgery and based on your wishes and discussion with family, it is safe to go back to your facility. You will need care with movement to try to avoid significant displacement of the right leg especially. You should at least take Tylenol, up to 1 gram, every 6 hours, as needed; if you have stronger pain, it is reasonable to try hydrocodone. The medication prescribed for pain today will make you sleepy; . X-ray pelvis AP and hip right final results: Impression: Impacted and displaced intertrochanteric right femur fracture . Reason for exam: fall, deformity . additional relevant history: fall, deformity . Findings: The osseous structures appear demineralized. There is a mildly impacted and displaced fracture of the proximal right femur involving the base of the femoral neck extending into the intertrochanteric region. Increased varus angulation. The femoral head remains normally aligned with the acetabulum. The pelvic ring appears intact. Left hip alignment is normal . On [DATE] at 10:42 AM, during a phone interview, CNA M indicated when she entered the room R20 was in her wheelchair and CNA L told her the sit to stand lift malfunctioned and R20 was on the floor. CNA M indicated she did not report this change of plane to the nurse on the floor or the oncoming shift, because she figured CNA L would report it. CNA M indicated when a resident has a change of plane, is on the floor, or had a sudden fall from a lift she goes to get the nurse immediately and does not move the resident until the nurse is done with an assessment and tells her it is ok to move the resident. CNA M indicated 2 staff are to be present when staff use any mechanical lift per facility policy. (It is important to note CNA M was aware R20 was on the floor and did not report this to the floor nurse.) On [DATE] at 11:24 AM, LPN G stated, Originally, I was told by CNA L that R20 was complaining of pain to her leg and there was an issue with the sit to stand. I had asked her to write a statement. I ended up finding the statement later. It was very unclear, and I was looking for clarification. LPN G indicated she did not see any changes in R20 when she looked but asked UM/RN Q to assess her. LPN G stated, I would like to have had more accurate information and more information by the CNA L. She should not have picked R20 up off of the floor. She should have grabbed a nurse. LPN G indicated education was given after the incident to be sure staff are using sit to stand with two staff. Surveyor asked if education was provided regarding the fall and post fall policy and protocol. LPN G indicated she was unsure. On [DATE] at 1:54 PM, DON B (Director of Nursing) indicated CNA L reported to LPN G that the lift battery died during transfer and now R20 is complaining of pain. Then CNA L slipped a written statement containing more information on the nurse' desk before exiting the building for the day. LPN G found the statement around 2:30 PM and brought it to DON B. DON B told LPN G to start an incident report, grab UM/RN Q for an assessment, and to report incident and findings to R20's provider. DON B and Surveyor reviewed CNA L's first statement. DON B and Surveyor reviewed contact with R20's provider. DON B indicated the provider was not made aware R20 was sitting on the ground. DON B stated, I was going to get a second statement from her to make sure there was a fall. DON B indicated the facility did not follow the Fall policy and procedure for witnessed falls, reported falls, or presumed falls. DON B indicated CNAs are to report falls immediately to the floor nurse and give as many details as possible. DON B indicated a fall is an unintended change of plane. DON B indicated staff are to have two staff present for all mechanical lift transfers per facility policy and CNA L transferred R20 two times alone, once to the toilet and once out of the bathroom. Surveyor asked DON B if she would be willing to do an enactment of a staff member using the mechanical lift. DON B indicated she and Corporate Consultant EE would volunteer to demonstrate how to activate the emergency button so Surveyor could see how long it takes to lower a resident completely using the emergency button. DON B indicated staff education was provided regarding always using 2 staff with mechanical lifts. DON B indicated education was not provided on the facility fall policy and post fall protocol. On [DATE] at 2:18 PM, Surveyor observed DON B and CNA FF maneuvering the lift while Corporate Consultant EE was seated with the sling in place around her. DON B, CNA FF, and Corporate Consultant EE could not get the emergency button to engage and lower the lift all at once. Surveyor observed a turn button on the hydraulic boom of the shift and when DON B turned that button it would only go one turn at a time. When the button made one full turn, the lift would lower a little bit and stop. Then DON B or CNA FF would turn button another full turn and lift would lower a small amount and stop. Surveyor observed staff were unable to drop the lift in one smooth motion using the red emergency buttons. DON B indicated she did not perform any re-enactments with CNA L or other staff after the incident, but she wished she would have. It should be noted there is a second emergency button that lowers the lift in one motion. On [DATE] at 7:46 AM Surveyor asked RN/UM Q,Are aides observed using lifts before they are using them with residents, does the facility perform competency checks? RN/UM Q stated, No they are not part of a skills checklist before they start. That is a good idea. UM/RN Q stated, She (CNA L) should have come and got LPN G right away. She shouldn't have led us to believe there was a second CNA in the room. Example 2 On [DATE] at 10:14 AM, Surveyor observed R31's motorized wheelchair in R31's room along with the charging cords for the motorized wheelchair. On [DATE] at 3:14 PM, Surveyor interviewed R31 regarding charging of her motorized wheelchair. R31 stated staff charge her wheelchair in her room. On [DATE] at 3:27 PM, Surveyor interviewed CNA CC (Certified Nursing Assistant) regarding charging R31's motorized wheelchair. CNA CC indicated staff charge R31's motorized wheelchair in her room. On [DATE] at 3:31 PM, Surveyor interviewed DON B (Director of Nursing) regarding the charging of R31's motorized wheelchair. DON B indicated staff charge R31's motorized wheelchair in her room. DON B stated she was not certain of the facility's policy on charging motorized wheelchairs. VPOC DD (Vice President of Clinical Operations) was present during the interview with DON B. VPOC DD informed Surveyor and DON B that motorized wheelchairs are not allowed to be charged in a resident's room. Example 3 The facility utilizes Medline electric patient lifts. The battery used in these lifts are sealed lead acid batteries. The Safety Data Sheet (SDS) for sealed lead acid batteries, dated 6/23, includes: Battery posts, terminals, and related accessories contain lead and lead compounds, chemicals known to cause cancer and reproductive harm, and during charging, strong inorganic acid mists containing sulfuric acid are evolved. Use adequate ventilation. The acid mist and vapors generated by heat or fire are corrosive. Store batteries in cool, dry, well-ventilated areas. Avoid overcharging and smoking, or sparks near battery. On [DATE] at 10:15 AM, Surveyor observed a Hoyer (electric patient lift) plugged into the wall and charging on the 400-hallway. On [DATE] at 10:16 AM, Surveyor observed a stand lift (electronic patient lift) plugged into the wall and charging on the 300-hallway. On [DATE] at 10:16 AM, Surveyor interviewed CNA FF (Certified Nursing Assistant) regarding the charging of electronic patient lifts. CNA FF indicated staff charge the electronic patient lifts in the hallway. On [DATE] at 10:18 AM, Surveyor interviewed CNA GG regarding the charging of electronic patient lifts. CNA GG indicated staff charge the electronic patient lifts in the hallway. On [DATE] at 10:52 AM, Surveyor interviewed CNA M regarding the charging of electronic patient lifts. CNA M indicated staff charge the electronic patient lifts in the hallway. On [DATE] at 10:03 AM, Surveyor interviewed NC EE (Nurse Consultant) regarding the charging of electronic patient lifts. NC EE indicated typically electronic patient lifts are not charged in the hallways but the facility does not use wall battery charging stations, so they plug them into the wall on the hallways to charge. On [DATE] at 8:18 AM, Surveyor interviewed DON B (Director of Nursing) regarding where staff charge the electric patient lifts. DON B indicated the lifts are charged in the hallways. DON B indicated they have always charged the lifts in the hallway and the facility has no concerns regarding safety with the batteries charging in the hallways.

Based on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 57 residents who reside in the facility. The facility did not have a system in place for manually monitoring the internal concentration of the chemical dishwasher. Surveyor observed staff prepping food and in food preparation areas without hair restraints. Surveyor observed food in circulation to be opened and undated or pass the expiration date. Evidenced by: Example 1 Facility's policy, titled Recording Dish Machine Temperatures, undated, includes: Dishwashing staff will monitor and record dishwasher machine temperatures to assure proper sanitizing of dishes. The food service manager will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. Staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal. The food service manager will spot check this log to assure temperatures are appropriate and staff is actually monitoring dish machine temperatures. Dishwashing staff will be trained to report any problem with the dish machine to the food service manager as soon as they occur. The food service manager will promptly assess any dish machine problems and take action immediately to assure sanitation of dishes. (It is important to note the facility has a dishwasher set up to be a chemical sanitizing dishwasher and the facility would need a policy related to manually monitoring the concentration of the dishwasher, not the temperature.) On 6/9/25 at 10:16 AM, DA T (Dietary Aide) indicated he was unsure if the facility used anything for monitoring the internal temperature or the parts per million of the dishwasher. DA T indicated there is a log for recording dishwasher temperatures. DA T indicated there are test strips that they could use too. Surveyor observed the test strips to have expired on 10/1/21. Surveyor observed the dishes pass through the dishwasher and the dishwasher stayed at a constant temperature of about 120 degrees Fahrenheit. DA T indicated the dishwasher should be at 150 for wash and 180 for rinse. DA T indicated the nursing staff used all of the hot water for resident showers and that is why the dishwasher is not reaching temperature. Surveyor observed DA T continue to pass dishes through dish washer. On 6/9/25 at 10:31 AM, District Dietary Manager T indicated the dishwasher should reach 150 degrees Fahrenheit for wash and 180 degrees Fahrenheit for rinse. District Dietary Manager T and Surveyor observed the dishwasher noting the temperature is staying right around 120 degrees Fahrentheit. District Dietary Manager T indicated someone else was on the way and they would know the dishwasher better than her. District Dietary Manager T and Surveyor reviewed the Dish Machine Temperature Log together. Dish Machine Temperature Log Diary dated 1/1/25-6/9/25, include: Temperature must be recorded once during each meal period daily. If dishwasher does not reach minimum temperature for wash and rinse, contact manager on duty. AM- Wash 150 . Rinse 180 . PM- Wash 150 . Rinse 180 . All boxes have check marks . On 6/10/25 at 11:48 AM, District Dietary Manager U indicated the facility does not have a system for monitoring of internal temps or concentration of dishwasher, but he called Ecolab, and he will get a system going. On 6/10/25 at 1:43 PM, NHA A (Nursing Home Administrator) and District Dietary Manager U indicated the facility should be monitoring the dishwasher's concentration with test strips and not monitoring the temperature, because the dishwasher is set up to be a chemical sanitizing machine. District Dietary Manager U indicated he received some test strips from Ecolab that were not expired and he threw the expired ones out. NHA A indicated the facility has a new log now that they will be using to record the test strip results daily. Example 2 Facility policy, titled Hair Restraints, undated, includes: Policy- to ensure that proper sanitation standards are being followed in all dining department kitchens. Procedure- all staff entering a kitchen will wear a hairnet/hair restraint, ensuring that all hair is completely covered by the hair net. Hairnets/hair restraints will be available to all staff near the entrance to each kitchen. Signs will be posted on each kitchen door to alert staff to wear a hair net/hair restraint before entering. On 6/10/25 at 10:52 AM, Surveyor observed District Dietary Manager U to have very short hair and beard and to be in the food preparation area with no beard net or hair restraint. On 6/10/25 at 10:52 AM, Surveyor observed [NAME] W to be using the 3-compartment sink with no beard net. [NAME] W indicated he was washing cookie sheets. On 6/10/25 at 11:35 AM, Surveyor observed [NAME] V to have an uncovered mustache while scooping coleslaw and putting it into small bowls. [NAME] V indicated he forgot to put on a beard net, and he would get one right away. On 6/10/25 at 11:48 AM, District Dietary Manager U indicated he thinks hair over 1/2 inch needs to be covered by a hair restraint . On 6/10/25 at 1:43 PM, NHA A and District Dietary Manager U indicated all hair should be restrained when in the kitchen and especially when working with clean dishes and open food. Example 3 Facility policy, titled Dining Department Storage, undated, includes: Food should be dated as it is placed on the shelves . Date marking to indicate the date or day by which a ready to eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high risk food . Leftover food . is clearly labeled and dated before being refrigerated . All food should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded . On 6/9/25 at 9:54 AM, Surveyor observed honey wheat bread that had been opened with no open date. Surveyor observed opened breaded fish in the freezer with no open date, opened breaded chicken patties in the freezer with no open date, opened turkey brats with no open date, and opened chicken breasts in the freezer with no open date and no expiration date. In the facility's walk-in refrigerator, Surveyor observed sliced ham to be dated 5/10/25, applesauce to be removed from original container with no label/ no open date/no expiration date, and Surveyor observed potato salad that had been opened with no open date. During an interview [NAME] W indicated all food that is opened should have an opened date, the ham should have been tossed out, and any food removed from the original container should also have a label on it of what it is. On 6/10/25 at 1:43 PM, NHA A and District Dietary Manager U indicated all opened food should be labeled and dated and food pass the use by date or expiration date should be discarded.

Based on observation, interview, and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 4 of 4 sampled residents (R56, R23, R37, R29) reviewed for food palatability and 4 of 4 supplemental residents (R2, R8, R14, and R5). R56, R23, R37, R29, R2, R8, R14, and R5 voiced concerns with their food not being palatable. Surveyors conducted 2 test trays and both test trays were not palatable. Evidenced by: Facility policy, titled Record Food Temperatures, implemented 5/28/25, includes: . Hot foods will be held at 135 degrees Fahrenheit or greater . Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. Example 1 R29 admitted to the facility on [DATE]. His most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 4/9/25, indicates his cognition is moderately impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. It also indicates he understands others and is understood by others. On 6/9/25 at 12:26 PM, R29 indicated their meat was too tough to chew. Surveyor observed R29's plate to have beef cut in bite size pieces pushed to the side. Example 2 R8 admitted to the facility on [DATE]. His most recent MDS with ARD of 3/8/25, indicates R8 is cognitively intact with a BIMS score of 13 out of 15. On 6/9/25 at 12:26 PM, R8 indicated the meat was too tough to chew. Surveyor observed R8's plate to have beef cut in bite size pieces pushed to the side. R8 demonstrated trying to pass a fork through the meat and was unsuccessful. Example 3 On 6/9/25 at 12:29 PM, Surveyor ordered a test tray. On 6/9/25 at 12:30 PM, Surveyor observed DA S (Dietary Aide) walking down the hallway with a room tray. The room tray had a plate of hot food on it and over the top of the food was the bottom of a heat holding cambrio. DA S indicated the cambrio should have a top that goes over the plate and a bottom that goes under the plate to keep the hot food hot, but the facility often runs out of cambrio bottoms and tops because there are more residents than cambrios in the facility. On 6/9/25 at 12:33 PM, Surveyor conducted a test tray in the facility's main dining room. The mixed vegetables temperature was 122 degrees Fahrenheit. The beef with gravy over rice was 130 degrees Fahrenheit. Surveyor tried to pass a fork in a piece of beef. With some pressure, Surveyor was able to pick up the meat with the fork. Surveyor was not able to chew the meat down enough to swallow as the meat was tough and difficult to chew. This test tray was not palatable. On 6/10/25 at 10:52 AM, [NAME] W indicated he partially cooked the beef the day prior to serving it and then finished it yesterday when it was served. [NAME] W indicated he knew the meat was tough, dry, and he thought he cooked it too long. [NAME] W indicated the recipe did not say to cook the meat two separate times. [NAME] W indicated the temperature of the food should be about 160 when it is plated. Example 4 R5 admitted to the facility on [DATE]. His most recent MDS with ARD of 4/4/25 Indicates R5 usually understands others and is usually understood by others. On 6/9/25 at 2:10 PM, R5 indicated the meat was terrible and tough in his noon time meal. R5 also indicated he eats most meals in his room and his hot food comes cold at times. Example 5 R14 admitted to the facility on [DATE]. Her most recent MDS with ARD of 4/4/25 indicates R14's cognition is intact with a BIMS score of 14 out of 15. On 6/9/25 at 2:15 PM, R14 indicated her meat was chewy at her noon lunch meal. R14 stated, I eat in my room, but the meal is cold a lot of the time. I have people bring me in food. I can't eat a lot of the food here it is terrible. At lunch, I couldn't swallow the meat, chewed and chewed and chewed. Example 6 On 6/10/25 at 11:06 AM, during the Resident Council Group Task, R23, R2, R8, and R37 voiced concerns related to their hot foods being served to cold and at an undesired temperature. On 6/10/25 at 1:43 PM, District Dietary Manager U and NHA A (Nursing Home Administrator) indicated hot foods should be served hot and cold foods should be served cold. Example 7 R56 admitted to the facility on [DATE] and has diagnoses that include mild protein-calorie malnutrition and fracture of right femur. R56's admission Minimum Data Set (MDS) Assessment, dated 3/28/25, shows R56 has a Brief Interview of Mental Status (BIMS) score of 9 indicating R56 has moderate cognitive impairment. On 6/9/25, at 10:52AM, R56 indicated to Surveyor that the food and coffee is always lukewarm to cold. Example 8 R23 admitted to facility on 4/28/25 and has diagnoses that include moderate protein-calorie malnutrition, unspecified dementia (a diagnosis of dementia where the specific type of dementia cannot be clearly determined) and need for assistance with personal care. R23's admission MDS Assessment, dated 5/2/25, shows R23 has a BIMS score of 11 indicating moderate cognitive impairment. On 6/9/25, at 11:48AM, R23 indicated to Surveyor that the beef that was served for lunch he could not chew and food is not always hot. Example 9 On 6/9/25 at 11:05 AM, Surveyor interviewed R2 regarding the meals she eats at the facility. R2 indicated the meat they are served is tough to chew. R2 indicated when eating in her room, the food is always cold. R2 was eating in the dining room on 6/9/25 for lunch and stated the food is warmer when it is in the dining room. Example 10 On 6/12/25 at 12:03 PM, Surveyor observed meal delivery on the 300 and 400 hallways. The meal trays were on an open metal rack. The last tray was delivered at 12:17 PM. On 6/12/25 at 12:17 PM, Surveyor took the temperatures of the food on the test tray. Manicotti was 167 degrees Breadstick was 133.3 degrees Milk was 52.1 degrees Cranberry juice was 51 degrees The milk and Cranberry juice were not at a palatable temperature.

Based on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 19 sampled residents (R49, R23, and R41) and 1 of 1 supplemental residents (R19) observed for hand hygiene. Staff did not perform proper hand hygiene per standards of practice during wound care on R49 and R23. A nurse had a breach in infection control during medication adminstration observation for R19 when a nurse did not perform hand hygiene following a blood glucose test. A nurse had a breach in infection control during wound care for R41. Evidenced by: The facility policy entitled Hand Hygiene, dated 5/28/25, states, in part: . Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: . 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . 5. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Hand Hygiene Table: . Before applying and after removing personal protective equipment (PPE), including gloves . Before and after handling clean or soiled dressings, linens, etc. After handling items potentially contaminated with blood, body fluids, secretions, or excretions. When, during resident care, moving from a contaminated body site to a clean body site . The facility's Hand Hygiene policy, dated 5/28/25, states, in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.2. Hand hygien is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.Hand Hygiene Table includes: *after handling contaminated objects *before and after handling clean or soiled dressings, linens, etc *after handling items potentially contaminated with blood, bodily fluids, secretions, or excretions . The facility's Clean Dressing Change policy, dated 5/28/25, states, in part: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination.9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered . Example 1 R49 admitted to the facility on [DATE] and has diagnoses that include pressure ulcer of sacral region, unstageable and Type 2 diabetes mellitus with diabetic chronic kidney disease (a long-term condition in which the body has trouble controlling blood sugar and using it for energy and develops kidney disease). R49's Quarterly Minimum Data Set (MDS) Assessment, dated 5/21/25 shows R49 has a Brief Interview of Mental Status (BIMS) score of 13 indicating R49 is cognitively intact. R49's Care Plan dated 5/22/25, states, in part: . Focus: The resident has pressure ulcer coccyx and right ischium related to immobility, ulcers present upon admission and prior admit to facility. Date Initiated: 5/22/25. Revision on: 5/22/25 . Interventions: . Administer treatments as ordered and monitor for effectiveness. Date Initiated: 5/22/25 . R49's June Medication Administration Record (MAR) shows order: Dakin's wash to right ischial wound followed by culiform packing to fill open space of wound and cover with 4 x 4 bordered gauze every day and evening shift for wound care. Order Date: 6/3/25 . On 6/10/25 at 7:24 AM, Surveyor observed NP C (Nurse Practitioner) perform wound care on R49's coccyx and right ischium. Surveyor observed NP C remove the dressing and packing from the ischium wound and measure the wound. NP C removed gloves and applied new gloves without hand hygiene. NP C applied treatment and dressing to the ischium wound then removed gloves. NP C applied new gloves without hand hygiene. NP C measured the coccyx wound and applied treatment and dressing. NP C removed gloves and applied new gloves without hand hygiene. On 6/10/25 at 8:05 AM, Surveyor interviewed NP C and asked when hand hygiene should be performed during wound care. NP C indicated you would remove gloves every time when it's dirty. NP C indicated she washes hands when she leaves the residents' rooms. NP C indicated that is the policy she follows. Surveyor asked if hand hygiene should be performed after doffing and donning gloves and NP C indicated she removes the dirty with the glove. On 6/11/25 at 8:20 AM, Surveyor interviewed DON B (Director of Nursing) and asked when hand hygiene should be performed during wound cares and peri/catheter cares. DON B indicated you would perform hand hygiene and change gloves in between cleansing the area and rinsing the area. Surveyor informed DON B of observation of NP C removing gloves and applying new gloves without hand hygiene. DON B indicated hand hygiene should be performed after doffing and donning gloves. Example 2 R23 admitted to facility on 4/28/25 and has diagnoses that include moderate protein-calorie malnutrition, unspecified dementia (a diagnosis of dementia where the specific type of dementia cannot be clearly determined) and need for assistance with personal care. R23's admission MDS assessment dated [DATE] shows R23 has a BIMS score of 11 indicating moderate cognitive impairment. R23's Care Plan dated 4/29/25, states, in part: . Focus: The resident has multiple pressure ulcers relate to immobility, deconditioning and refusals to reposition at times. Date Initiated: 4/29/25. Revision on: 4/29/25 . Interventions: . *Administer treatments as ordered and monitor for effectiveness. Date Initiated: 4/29/25 . R23's June MAR shows: Bilateral Buttock Wounds: Cleanse with saline, pat dry. Skin prep peri-wound. Apply calcium alginate to wound base, cover with bordered gauze dressing every day shift for wound care. Order Date: 6/5/25. Discontinue Date: 6/10/25 . Normal Saline Wash to left plantar foot wound followed by skin prep to peri wound followed by Purachol to wound bed followed by bordered gauze every day shift every Tuesday, Thursday, Saturday for wound care. Order Date: 5/20/25 Discontinue Date: 6/10/25 . Normal Saline Wash to left front iliac crest wound followed by skin prep to peri wound followed by Purachol and foam dressing every day shift every Tuesday, Thursday, Saturday for wound care. Order Date: 5/20/25 . On 6/10/25 at 7:41 AM, Surveyor observed NP C perform wound care on R23. NP C removed dressing from left foot, measured the wound and removed her right glove with gloved left hand and applied new right glove without hand hygiene. NP C measured left iliac wound and applied alginate and bordered gauze. NP C removed gloves and applied new gloves without hand hygiene. NP C removed dressings to right lower leg, cleansed wound and applied treatment and dressing. NP C removed right glove with gloved left hand and applied new glove without hand hygiene. NP C measured moisture associated dermatitis wound on R23's bottom, cleansed wound and applied treatment. NP C removed both gloves and applied new gloves without hand hygiene. NP C measured right and left buttock wounds and applied treatment and dressings. NP C removed gloves and applied new gloves without hand hygiene. On 6/10/25 at 8:05AM, Surveyor interviewed NP C and asked when hand hygiene should be performed during wound care. NP C indicated you would remove gloves every time when it's dirty. NP C indicated she washes hands when she leaves the residents' rooms. NP C indicated that is the policy she follows. Surveyor asked if hand hygiene should be performed after doffing and donning gloves and NP C indicated she removes the dirty with the gloves. On 6/11/25 at 8:20 AM, Surveyor interviewed DON B (Director of Nursing) and asked when hand hygiene should be performed during wound cares and peri/catheter cares. DON B indicated you would perform hand hygiene and change gloves in between cleansing the area and rinsing the area. Surveyor informed DON B of observation of NP C removing gloves and applying new gloves without hand hygiene. DON B indicated hand hygiene should be performed after doffing and donning gloves. Example 3 On 6/11/25 at 11:51 AM, Surveyor observed LPN J (Licensed Practical Nurse) during Medication Administration observation. LPN J performed a blood glucose test for R19 in R19's room. LPN J took the supplies to the medication cart in the hall, opened the medication cart drawer and accessed disinfectant wipes to wipe off the testing meter. LPN J did not remove gloves or perform hand hygiene after the test, prior to touching the medication cart. Surveyor interviewed LPN J and asked about hand hygiene. LPN J stated that hand hygiene is needed before resident cares, when coming out of a resident room, and before and after any procedures. Surveyor asked about hand hygiene following R19's blood glucose test. LPN J stated that gloves should have been removed and hand hygiene should have been performed prior to touching the medication cart. On 6/12/25 at 9:06 AM, Surveyor interviewed DON B (Director of Nursing) and asked about hand hygiene when performing a blood sugar. DON B indicated that gloves are contaminated following blood glucose testing. DON B stated that gloves should be removed after the test and hands cleansed prior to touching the medication cart. Example On 6/11/25 at 11:10 AM, Surveyor observed LPN G (Licensed Practical Nurse) perform wound care for R41. LPN G removed R41's wound dressing, disposed of the dressing, then began to cleanse the wound. LPN G did not remove gloves and cleanse hands prior to cleansing the wound. Following the dressing change, LPN G removed gloves, then with bare hands, grabbed the outside front of the gown and pulled the gown away to remove it. Upon leaving R41's room, Surveyor asked LPN G when hand hygiene is needed during wound care. LPN G stated before starting, anytime you go from dirty to clean, and after complete. Surveyor asked if a wound dressing is considered dirty. LPN G stated yes, gloves should have been removed and hand hygiene performed after removal of the dressing. Surveyor asked about procedure for removal of PPE. LPN G stated gloves are removed first, then gown. Surveyor asked if the outside of the gown should be touched with bare hands. LPN G stated, no, the gown should be touched inside when removing. Surveyor asked if LPN G had touched the outside of the gown. LPN G stated yes. On 6/12/25 at 9:06 AM, Surveyor interviewed DON B (Director of Nursing) and asked about hand hygiene with wound care. DON B stated that there should be removal of gloves and hand hygiene after removal of a wound dressing, prior to cleansing the wound. Surveyor asked DON B about technique for removal of PPE. DON B stated that the outside of the gown is contaminated and should not be touched with bare hands.

Based on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 2 of 2 sampled residents (R36, 31) and 1 of 1 supplemental resident's (R24) reviewed for self- administration of medications. R36 was observed to have a cup of medications left on his bedside table for him to take independently. R36 does not have an assessment for self-administration of medications indicating that he is safe to administer medications independently. R31 had containers of medication at bedside and had scheduled medications left on her bedside table for longer than 1 hour. R31's self-administration assessment only allows Lactaid at bedside and requires nurses to follow up with R31 after 1 hour. R24 had an inhaler at his bedside. R24 does not have an assessment for self-administration of medications indicating that he is safe to administer medications independently. Evidenced by: The facility's policy titled Resident Self- Administration of Medication dated 5/28/25 states in part, .3. When determining if self- administration is clinically appropriate for a resident, the interdisciplinary team should, at a minimum consider the following: a. The medications appropriate and safe for self- administration; b. The resident's physical capacity to open medication bottles, administer injections. c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for. d. The resident's capability to follow directions and tell time to know when medications need to be taken. e. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff . Example 1 R36 was admitted to the facility on [DATE] with diagnoses that include generalized anxiety disorder, polyosteoarthritis (a diagnosis that indicates that arthritis is present in 5 or more joints simultaneously), and congestive heart failure (the heart cannot pump enough blood to meet the body's needs). R36's most recent Minimum Data Set (MDS) dated [DATE] states that R36 has a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating that R36 is cognitively intact. On 6/9/25 at 10:45 AM, Surveyor interviewed R36. Surveyor noted that there was a medication cup with medications in it, sitting on R36's bedside table. Surveyor asked R36 if those were his morning medications, R36 stated yes, and reported to Surveyor that he always takes them. Surveyor reviewed R36's physician's orders. There was no order for R36 to self- administer medications. Surveyor reviewed R36's care plan. There was no care plan for self- administration of medications. Surveyor reviewed R36's assessments. There was no assessment completed indicating that R36 was safe to self- administer medications. On 6/10/25 at 2:29 PM, Surveyor interviewed LPN F (Licensed Practical Nurse). Surveyor asked LPN F if she had administered R36's morning medications on 6/9/25, LPN F stated yes. Surveyor asked LPN F if R36 is able to take medications independently, LPN F stated yes. Surveyor asked LPN F if R36 has an order to self- administer medications, LPN F stated no. Surveyor asked LPN F if R36 has a completed self- administration assessment, LPN F stated that she was not sure. On 6/11/25 at 11:23 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the facility's process is for determining that a resident is safe to self- administer medications, DON B reported that they would complete an assessment and based on the results of the assessment, they would get an order for the resident to self- administer medications. Surveyor asked DON B if R36 has an assessment to self- administer medication, DON B stated that R36 has never indicated that he was interested in self- administration, so there is not an assessment. Surveyor shared observation with DON B. Surveyor asked DON B if R36 should have an assessment and a physician's order to self- administer medications if the nurses are going to leave the medications in the room, DON B stated yes. Example 2 R31's self-administration assessment dated [DATE] includes the following: Lactaid at bedside with resident. All other meds must be administered by nurse but may be left at bedside for up to 1 hour. 1. The resident can correctly read label and/or identify each medication. Requires assistance. 2. The resident can correctly state what each medication is for. Requires assistance. 3. The resident can correctly state the time/frequency medications are to be taken. Requires assistance. 4. The resident can correctly state the correct dosage/quantity for each administration. Requires assistance. 6. The resident can appropriately document self-administration of the medications listed. Requires assistance. 7. The resident can demonstrate secure storage of medications kept in room. Requires assistance. 11. The resident can correctly administer eye drops or eye ointments correctly. Not Applicable. C. Approvals IDTC (Interdisciplinary Team) 1a. IDTC Review Summary: Medications will be administered by Nurse but may be left at bedside for up to 1 hour. 1b. IDTC fees resident is safe to self-administer listed medications? No. R31's physician orders, printed 6/11/25, include: NURSE to administer all meds to resident - can leave at bedside for up to 1 hour after dispensing but must follow up and document. On 6/9/25 at 3:00 PM, Surveyor observed containers of Lactaid, artificial tears, Imodium and Tums in a basket on R31's bedside table. On 6/10/25 at 11:51 AM, Surveyor entered R31's room. CNA Z (Certified Nursing Assistant) was finishing getting R31 up for the day. Prior to CNA Z leaving the room, CNA Z reminded R31 to take her medications. Surveyor observed 3 pills on R31's bedside table and a pill on R31's floor. On 6/10/25 at 12:10 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) regarding R31's medications. LPN F indicated she had given R31 her morning medication between 9:45 - 10:00 AM. LPN F indicated R31 had taken all her medication at that time. LPN F indicated R31 may have medications at bedside for up to 1 hour. LPN F picked up the pill off the floor and removed the pills from R31's bedside table. LPN F indicated those medications were left from the evening shift yesterday. LPN F removed the Imodium and Tums from R31's room and informed R31 that DON B (Director of Nursing) would come talk with R31 regarding the medications. On 6/10/25 at 12:10 PM, Surveyor interviewed R31 regarding her medications. R31 indicated the medications were from last night. R31 indicated she was too tired and forgot to take them. On 6/11/25 at 1:47 PM, Surveyor was walking past R31's room. R31's door was open. Surveyor observed R31 was not in her room. Surveyor observed 8 pills in a medication cup on R31's lunch tray. On 6/11/25 at 1:52 PM, Surveyor interviewed LPN J regarding noon medication pass. LPN J indicated the noon medication pass takes about 30 minutes. LPN J indicated she completed her noon medication pass before 1:00 PM. LPN J indicated R31 is allowed to have her medications at bedside after administration for up to 1 hour then the nurse must ensure R31 took her medications. On 6/11/25 at 2:06 PM, Surveyor observed R31 coming down the hallway. R31 indicated she had been in the rehabilitation room to meet with visitors. R31 indicated she left her room at 1:00 PM. On 6/11/25 at 2:36 PM, Surveyor observed R31 had taken her noon medications. On 6/11/25 at 8:44 AM, Surveyor interviewed DON B (Director of Nursing) regarding R31's medications. DON B indicated R31 was assessed to have medications left at bedside for up to 1 hour and the nurses must follow up with R31 to ensure the medications were taken. DON B indicated the artificial tears, Imodium, and Tums should not be at R31's bedside and the nurse should have followed up within an hour to ensure R31 took her medications but did not. Example 3 On 6/9/25 at 10:30 AM, Surveyor observed R24's room. R24 had a Combivent inhaler on his bedside table. On 6/11/25 at 2:17 PM, Surveyor observed R24's room. R24 had a Combivent inhaler on the stand next to his bed. On 6/11/25 at 1:52 PM, Surveyor interviewed LPN J regarding self-administration of medications. LPN J indicated R24 was not assessed to safely self-administer medications. On 6/10/25 at 2:47 PM, Surveyor interviewed DON B (Director of Nursing) regarding R24's self-administration of medication assessment. DON B indicated R24 does not have a self-administration of medication assessment. DON B indicated medications should not be left at their bedside if a resident is not assessed to be safe to take medications independently.

Based on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan included a sleep assessment and sleep tracking for 3 of 5 residents (R6, R18, and R43) reviewed for unnecessary medications. R6 is prescribed melatonin and does not have a sleep assessment or sleep tracking. R18 is prescribed melatonin and does not have a sleep assessment or sleep tracking. R43 is prescribed melatonin and does not have a sleep assessment or sleep tracking. This is evidenced by: The facility's policy titled Use of Psychotropic Medication(s), dated 5/28/25, includes: Adequate indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. 5. The indications for initiating, maintaining, or discontinuing medications(s), [sic] as well as the use of non-pharmacological approaches, will be determined by evaluating the resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. 7. The resident's medical record shall include documentation of this evaluation and the rationale for chosen treatment options. 15. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the residence medical record. Example 1 R6's physician orders, printed on 6/12/25, include melatonin 3 mg at bedtime for difficulty sleeping. R6 does not have a sleep assessment completed. R6 does not have sleep monitoring documented. Example 2 R18's physician orders, printed on 6/12/25, include melatonin 3 mg at bedtime for sleep hygiene. R18 does not have a sleep assessment completed. R18 does not have sleep monitoring documented. Example 3 R43's physician orders, printed on 6/12/25, include melatonin 3 mg at bedtime for insomnia. R43 does not have a sleep assessment completed. R43 does not have sleep monitoring documented. On 6/11/25 at 4:27 PM, Surveyor interviewed DON B (Director of Nursing) regarding sleep assessment and sleep monitoring for residents taking a sleep aid. DON B indicated the facility does not complete sleep assessments and sleep monitoring as part of their routine practice for sleep aids. DON B indicated R6, R18, and R43 do not have sleep assessments or sleep monitoring.

Example 2 R28 admitted to the facility on [DATE] with diagnoses including urinary tract infection (2/25/25) , urine retention, and neuromuscular dysfunction of bladder. On 6/10/25 at 10:56 AM Surveyor observed R28 being pushed in his wheelchair down the hallway. Surveyor heard something rubbing as R28 passed. Surveyor observed R28's catheter bag dragging on the floor. On 6/10/25 at 10:59 AM LPN Y (Licensed Practical Nurse) indicated R28's catheter bag should not be in contact with the floor. LPN Y stated, I will fix this. On 6/10/25 12:03 PM NHA A (Nursing Home Administrator) indicated residents' catheters should not be touching the floor. On 6/10/25 at 1:53 PM DON B (Director of Nursing) indicated R28's catheter should not be in contact with floor. On 6/11/25 at 1:26 PM during wound care observation, Surveyor observed R28's catheter bag to be resting in contact with the floor. On 6/11/25 at 1:27 PM LPN G indicated R28's catheter bag should not be in direct contact with the facility's floor. Based on observation, interview and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI) for 2 of 2 residents (R49 & R28) reviewed for catheters. *Certified Nursing Assistant (CNA) did not perform proper hand hygiene during catheter/peri care on R49. *R28's catheter bag was dragging on the floor under wheelchair. Evidenced by: The facility policy, dated 5/28/25, states, in part: . Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 1. Catheter care will be performed every shift and as needed by nursing personnel . Compliance Guidelines: . 7. Perform hand hygiene . The facility policy entitled Hand Hygiene, dated 5/28/25, states, in part: . Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: . 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . 5. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Hand Hygiene Table: . Before applying and after removing personal protective equipment (PPE), including gloves . Before and after handling clean or soiled dressings, linens, etc. After handling items potentially contaminated with blood, body fluids, secretions, or excretions. When, during resident care, moving from a contaminated body site to a clean body site . Example 1 R49 admitted to the facility on [DATE] and has diagnoses that include pressure ulcer of sacral region, unstageable and Type 2 diabetes mellitus with diabetic chronic kidney disease (a long-term condition in which the body has trouble controlling blood sugar and using it for energy and develops kidney disease). R49's Quarterly Minimum Data Set (MDS) Assessment, dated 5/21/25 shows R49 has a Brief Interview of Mental Status (BIMS) score of 13 indicating R49 is cognitively intact. R49's Care Plan dated 5/22/25, states, in part: . Focus: The resident has a urinary catheter. Date Initiated: 5/20/25. Revision on: 5/05/25 . Interventions: *Catheter: care and treatment per current MD (Medical Doctor) orders. Date Initiated: 5/20/25. Revision on: 5/20/25 . R49's Physician Orders as of 6/11/25, states, in part: . Catheter care every shift for catheter hygiene . On 6/11/25 at 7:37AM, Surveyor observed CNA D (Certified Nursing Assistant) perform catheter care on R49. CNA D gathered supplies to include two garbage bags, one with 4 soapy washcloths in and the other garbage bag with rinse washcloths in. CNA D set both bags onto bed. CNA D grabbed a soapy washcloth and performed catheter care and then put soiled wash cloth back into the garbage bag with the clean soapy wash clothes. CNA D then reached into the garbage bag with the rinse washcloths in and retrieved a rinse washcloth and rinsed R49's peri area and catheter and put the used rinse washcloth back into garbage bag with the clean rinse wash clothes. CNA D then dried the peri area with a clean towel. CNA D removed gloves and performed hand hygiene with soap and water and applied new gloves. CNA D rolled R49 onto right side and reached into the garbage bag with soapy washcloths and grabbed the used washcloth with a spot of blood on it from previous catheter care. CNA D put the washcloth back into the garbage bag and retrieved a new washcloth and proceeded to perform cares on R49's bottom. CNA D placed used washcloths back into the garbage bag and grabbed a rinse washcloth out of the other garbage bag with the rinse washcloths in. CNA D rinsed and dried R49's bottom and then removed gloves and applied new gloves without hand hygiene. On 6/11/25 at 7:57AM, Surveyor interviewed CNA D and asked when hand hygiene should be performed during catheter/peri care. CNA D indicated before and after and if gloves become soiled. Surveyor asked if hand hygiene should be performed between removing gloves and applying new gloves. CNA D indicated yes. Surveyor asked CNA D if hand hygiene should have been completed after care was provided on R49's bottom, new gloves were applied, and a new brief placed under R49. CNA D indicated yes, I should have washed my hands. Surveyor asked if soiled washcloths should be in same garbage bag as the clean washcloths and CNA D indicated she keeps the dirty and clean separated in the garbage bags by keeping the dirty ones in one corner and clean ones in another corner. Surveyor asked CNA D if that could be a risk of cross contamination and CNA D indicated yes. On 6/11/25 at 8:20 AM, Surveyor interviewed DON B (Director of Nursing) and asked when hand hygiene should be performed during wound care and peri/catheter care. DON B indicated you would perform hand hygiene and change gloves in between cleansing the areas and rinsing the areas. DON B indicated hand hygiene should be performed after doffing and donning gloves. Surveyor informed DON B of observation of CNA D placing soiled washcloths and clean washcloths in the same garbage bags during catheter care. DON B indicated she would have expected separate garbage bags for the clean and dirty washcloths to avoid a risk of cross contamination.

Based on interview and record review, the facility did not ensure residents are free of any significant medication errors for 2 of 2 residents (R31 and R41) reviewed for medications. The facility did not ensure R31 took her evening medications as prescribed. R41 did not receive one dose of the intravenous (IV) antibiotic ordered for wound infection. This is evidenced by: The facility's policy titled Medication Errors, dated 5/28/25, includes: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. The facility shall ensure medications will be administered as follows: a. According to physician's orders. b. Per manufacturer's specifications regarding the preparation, and administration of the drug or biological. c. In accordance with accepted standards and principles which apply to professionals providing services. 3. Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: a. Resident's condition: If the resident's condition requires rigid control . 4. The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: . Medication omission; The facility's Medication Administration policy, dated 5/28/25, states, in part: .20. Sign MAR (medication administration record) after administered. According to the National Institutes of Health National Library of Medicine (www.nih.gov), patients with Parkinson's disease require strict adherence to an individualized, timed medication regimen . Dosing intervals are specific to each individual patient because of the complexity of the disease. When medications are not administered on time and according to the patient's unique schedule, patients may experience an immediate increase in symptoms. Delaying medications by more than one hour, for example, can cause patients with Parkinson's disease to experience worsening tremors, increased rigidity, loss of balance, confusion, agitation, and difficulty communicating. Example 1 R31 admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors). R31's physician orders, printed 6/11/25, include Carbidopa-Levodopa 25-100 mg tablet give 2.5 tablets by mouth six times a day for Parkinson's Disease 5:30 AM, 9:30 AM, 1:30 PM, 5:30 PM, 8:30 PM and 11:30 PM. On 6/10/25 at 11:51 AM, Surveyor entered R31's room. CNA Z (Certified Nursing Assistant) was finishing getting R31 up for the day. Prior to CNA Z leaving the room, CNA Z reminded R31 to take her medications. Surveyor observed medications on R31's bedside table and on R31's floor under R31's electric wheelchair. On 6/10/25 at 12:10 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) regarding R31's medications. LPN F indicated she had given R31 her morning medication between 9:45 - 10:00 AM. LPN F indicated R31 had taken all her medication at that time. LPN F picked up the pill off the floor and removed the pills from R31's bedside table. LPN F identified the medications as Carbidopa-Levodopa. LPN F indicated the medications on the bedside table were left from the evening shift yesterday. LPN F cannot account for the time when the Carbidopa-Levodopa found under R31's electric wheelchair should have been administered. On 6/10/25 at 12:10 PM, Surveyor interviewed R31 regarding her medications. R31 indicated the medications were left from last night. R31 indicated she was too tired and forgot to take them. On 6/11/25 at 7:43 AM, Surveyor interviewed LPN J regarding medication errors. LPN J indicated an omitted medication is a medication error. On 6/10/25 at 2:47 PM, Surveyor interviewed DON B (Director of Nursing) regarding R31's medications. DON B indicated R31 had previously been able to self-administer her medications, but it became unsafe due to her tremors. DON B indicated in December 2024, R31 was assessed to not be able to self-administer her medications. DON B indicated staff were finding medications under R31 when she would take her medications in bed and on the floor also. Surveyor shared the observation of medications on R31's bedside table from the previous day and medication being found on the floor. DON B indicated omitted medications were a medication error. Example 2 R41 admitted to the facility on [DATE] and has a diagnosis of encounter for surgical aftercare following surgery on the digestive system. R41's Progress notes include: *5/27/25 1:28 PM received call from lab that wound culture contained klebsiella (a bacteria that can cause infection) . *5/27/25 3:46 PM .new orders for meropenem (antibiotic used to treat serious bacterial infections) . R41's Physician's Orders include: Meropenem Intravenous Solution Reconstituted 500 mg (milligrams) every 8 hours for incision infection. Start date: 5/28/25. End date: 6/4/25. R41's June 2025 Medication Administration Record (MAR) shows a blank for the 6/1/25 10:00 PM dose of Meropenem Intravenous Solution. On 6/12/25 at 8:22 AM, Surveyor interviewed LPN H (Licensed Practical Nurse) and asked if documentation is needed when administering medications. LPN H stated that the medication needs to be signed out on the MAR. Surveyor asked what a blank on the MAR means. LPN H stated it wasn't given. On 6/12/25 at 8:30 AM, Surveyor interviewed ADON I (Assistant Director of Nursing) and asked about a blank on the MAR. ADON I stated it means it was not given. On 6/12/25 at 9:24 AM, Surveyor interviewed DON B (Director of Nursing) and asked if documentation is needed when administering medications. DON B stated the medication needs to be signed out on the MAR. Surveyor asked what a blank on the MAR means. DON B stated no one signed it out. Surveyor asked if a medication has been given if the MAR is blank. DON B stated no, if it is not documented, it was not done.

Based on observation, interview, and record review, the facility did not provide food that accommodates resident preferences; appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for 3 of 17 sampled resident's (R23, R31, & R37). R23 was being served foods that were listed on his meal ticket as disliked food. R23's food preferences were not being honored. R31 was being served gravy that was listed on her meal ticket as disliked food. R31's food preferences were not being honored. R37's received foods that are on the R37 has indicated she should not have. Evidenced by: The facility policy entitled Resident Food Preferences, dated 5/28/25, states, in part: . Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Policy Interpretation and Implementation: 1. Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the dietician or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan . The facility's policy entitled Resident Rights, dated 5/8/25, states, in part: . Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay at the facility . 5 Self- Determination. The resident has the right to, and the facility must promote and facilitate the resident self-determination through support of resident choice . Example 1 R23 admitted to facility on 4/28/25 and has diagnoses that include moderate protein-calorie malnutrition, unspecified dementia (a diagnosis of dementia where the specific type of dementia cannot be clearly determined), and need for assistance with personal care. R23's admission Minimum Data Set (MDS) assessment dated [DATE] shows R23 has a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. R23's Care Plan, dated 4/29/25, states, in part: . Focus: The resident is at risk for inadequate intake related to does not wear dentures, history of dysphagia. Increased nutritional needs related to skin breakdown. Date Initiated: 4/29/25. Revision on: 4/29/25 . Interventions: . *Monitor/record/report to MD (medical doctor) PRN (as needed) s/sx (signs and symptoms) of malnutrition . *Provide, serve diet as ordered . R23's meal ticket shows: . Diet: Regular- regular consistency. Liquid: Thin. Allergies: NKA (no known allergies) Likes: Bananas, toast with jelly, pancakes, French toast, waffles, peanut butter & jelly sandwiches, soups, mashed potatoes. Dislikes: all vegetables, salads . On 6/9/25 at 11:48 AM, Surveyor observed R23's lunch tray being served to him in his room. Surveyor observed vegetables (carrots, yellow carrots, and green beans), rice and cubed beef on plate. R23 told the CNA (Certified Nursing Assistant) to take the tray back because the beef is too tough to chew, and he does not like vegetables. While this Surveyor was talking with R23, RD E (Registered Dietician) came into room and offered R23 alternatives. R23 indicated wanting a peanut butter and jelly sandwich and mashed potatoes with gravy if they have it. R23 told RD E, I told you last week I don't like vegetables. RD E indicated she was aware, and the staff must get better about not serving disliked foods. Surveyor asked RD E to see the meal ticket she brought into R23's room. Surveyor pointed out the disliked foods R23 has listed, and vegetables were one. RD E indicated they must get better about this, and she was going to talk with the kitchen staff about this. On 6/9/25 at 11:48 AM, Surveyor interviewed R23 who indicated he was losing weight, and he has no teeth. R23 indicated he does not like vegetables or oatmeal, and he has told the staff this and he keeps getting served vegetables and oatmeal and items he can't chew. R23 indicated he voiced this concern to the dietician just last week. On 6/11/25 at 8:01 AM, Surveyor interviewed RD E and asked if residents should be served foods they have listed as disliked foods and RD E indicated no. Surveyor asked if preferences should be respected, and RD E indicated yes. RD E indicated R23 should not have been served vegetables as it was a dislike of his. RD E indicated she was going to educate the kitchen staff regarding this issue. Example 2 R37 was admitted to the facility on [DATE] with diagnoses that include vascular dementia, Crohn's disease (a chronic inflammatory bowel disease that causes inflammation and swelling in the digestive tract), and history of strokes. R37's most recent Minimum Data Set (MDS) dated [DATE] states that R37 has a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating that R37 is cognitively intact. R37's care plan dated 3/18/24 states in part: .Focus: The resident has an alteration in gastro- intestinal status r/t (related to) GERD (Gastroesophageal reflux disease ( a chronic digestive disorder that occurs when stomach contents flow back into the esophagus, causing irritation), Crohn's .Interventions: Avoid snacks that aggravate the condition. Give medications as ordered. Monitor/document side effects and effectiveness. Obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow up as indicated . It is important to note that R37's care plan does not indicate what foods to avoid or what safe alternatives would be. R37's dietary meal ticket states in part .Instructions: Low Residue diet. No fresh vegetables, no oatmeal, no beans, no salad- or may have if resident requests . On 6/9/25 at 11:25 PM, Surveyor interviewed R37. R37 reported that she has Crohn's Disease and that sometimes the dietary staff gives her food items that are not compatible with her disease. On 6/9/25 at 12:27 PM, Surveyor observed R37's meal in the dining room. R37 was served mixed vegetables that included green beans. R37 reported to Surveyor that staff gave her mixed vegetables that she can't eat, despite it being on her meal ticket. On 6/9/25 at 12:33 PM, Surveyor interviewed RD E (Registered Dietician). Surveyor asked RD E if a resident's meal ticket says no beans, should the resident be served beans, RD E stated no. Surveyor reviewed R37's meal ticked with RD E. RD E stated that R37 should have not been served beans. Example 3 R31's meal ticket, printed 6/11/25, includes: Dislikes: Gravy Breakfast: . Cherrios [sic] . On 6/10/25 at 2:13 PM, Surveyor interviewed R31 regarding her meals. R31 stated she dislikes gravy, and it is on her meal ticket. R31 stated I think they think it says I like gravy because they always give me extra. R31 expressed frustration with receiving gravy at mealtimes because she has told them she dislikes it and it is on her meal ticket yet she continues to receive gravy. R31 indicated she frequently has to ask staff to bring her Cheerios at breakfast even though it is listed on her meal ticket that she wants to receive Cheerios at breakfast.

Based on observations, interviews and record reviews, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 5 (R3, R5, R6, R7 and R8) of 7 residents reviewed for medications. *R3, R5, R6, R7 and R8 had MD orders for narcotic pain medication. Facility staff did not consistently document the administration time of the pain medication directly after administering the pain medication as outlined in the facility policy. The late documentation could result in duplication of pain medication administration. *R5 had duplicate Medical Doctor (MD) orders for Oxycodone (a narcotic pain medication). Facility staff were using both MD orders for documenting the administration of Oxycodone. Findings include: The Wisconsin State Regulation entitled, DHS 132.60(5)(d)2. documents, in part: . Responsibility for administration. Policies and procedures designed to provide safe and accurate acquisition, receipt, dispensing and administration of medications shall be developed by the facility and shall be followed by personnel assigned to prepare and administer medications and to record their administration. The same person shall prepare, administer, and immediately record in the resident's clinical record the administration of medications. The facility policy dated May 2018, titled, Preparation and General Guidelines. Medication Administration-General Guidelines documents, in part: Medications are administered as prescribed in accordance with good nursing principles and practices . Documentation (including electronic) . The individual who administers the medication dose records the administration on the resident's MAR/eMAR [Medication Administration Record/electronic Medication Administration Record] directly after the medication is given . On 1/16/25, Director of Nursing supplied the above Medication Administration Policy to Surveyor. Surveyor asked if the Medication Administration policy had been changed recently. DON-B stated No. 1.) R3 was admitted to the facility on [DATE] with diagnosis that includes dementia, and recent hospitalization for sepsis and right lower extremity fractures. R3's Admission Minimum Data Set (MDS) assessment dated [DATE] documents R3 is severely cognitively impaired. R3 has pain almost constantly and the pain will occasionally affect R3's sleep. R3's Medical Doctor (MD) order, dated 9/18/24, documents: Oxycodone HCL Tablet 5 milligrams (MG). Give 5MG by mouth every 6 hours as needed for pain. Surveyor reviewed R3's Medication Administration Record (MAR) and R3's Orders administration note within the electronic medical record. Surveyor noted that the time entered on R3's MAR as the administration time was not documented directly after medication administration. Surveyor noted 12 times that R3's medication administration was documented later in the day. Examples include: -On 9/20/24, Licensed Practical Nurse (LPN)-H documented Oxycodone 5MG was administered at 9PM. This administration note was created at 10:58 PM, which is 1 hour and 58 minutes later. -On 9/27 24, LPN-I documented Oxycodone 5MG was administered at 10:36 AM. This administration note was created at 1:37 PM, which is 3 hours and 1 minute later. -On 9/28/24, LPN-I documented Oxycodone 5MG was administered at 8:35 AM. This administration note was created at 9:05 AM, which is 40 minutes later. -On 9/29/24, LPN-I documented Oxycodone 5MG was administered at 8:21 AM. This administration note was created at 1:22 PM, which is 5 hours and 1 minute later. -On 10/6/24, LPN-H documented Oxycodone 5MG was administered at 3:02 PM. This administration note was created at 10:03 PM, which is 7 hours and 1 minute later. -On 10/6/24, LPN-H documented Oxycodone 5MG was administered at 9:20 PM. This administration note was created at 10:04 PM, which is 44 minutes later. -On 10/12/24, LPN-I documented Oxycodone 5MG was administered at 9:28 AM. This administration note was created at 11:29 PM, which is 2 hours and 1 minute later. -On 10/17/24, LPN-I documented Oxycodone 5MG was administered at 7:05 AM. This administration note was created at 4:15 PM, which is 9 hours and 10 minutes later. -On 10/22/24, LPN-I documented Oxycodone 5MG was administered at 7:15 AM. This administration note was created at 12:39 PM, which is 5 hours and 24 minutes later. -On 10/25/24, LPN-H documented Oxycodone 5MG was administered at 9:30 PM. This administration note was created at 10:51 PM, which is 1 hour and 21 minutes later. -On 10/26/24, LPN-I documented Oxycodone 5MG was administered at 8:08 AM. This administration note was created at 2:26 PM, which is 6 hours and 18 minutes later. -On 10/26/24, LPN-H documented Oxycodone 5MG was administered at 4:15 PM. This administration note was created at 5:35 PM, which is 1 hour and 20 minutes later. Surveyor noted these 12 examples include late documentation up to 9 hours and 10 minutes later than the medication was administered. Surveyor noted in these 12 examples, staff did not follow facility policy or Wisconsin State Regulation that indicate staff should immediately record in the resident's clinical record the administration of medications. Surveyor noted during the time the medication was given but not documented, another facility staff could have come along and saw the medication was not given and administer the medication again. This could potentially cause a medication error. 2.) Surveyor reviewed R5's MAR and R5's Orders administration note within R5's electronic medical record. Surveyor noted that the time entered on R5's MAR as the administration time was not documented directly after medication administration. Surveyor noted 11 times that R5's medication administration was documented later in the day. Examples include: -On 10/25/24, Licensed Practical Nurse (LPN)-H documented Oxycodone 5MG was administered at 8:34 PM. This administration note was created at 10:54 PM, which is 2 hours and 20 minutes later. -On 10/29/24, LPN-I documented Oxycodone 5MG was administered at 12:04 PM. This administration note was created at 2:04 PM, which is 2 hours later. -On 10/29/24, Registered Nurse (RN)-K documented Oxycodone 10MG was administered at 2:45 PM. This administration note was created at 3:46 PM, which is 1 hour and 1 minute later. -On 10/30/24, LPN-I documented Oxycodone 10MG was administered at 8:02 AM. This administration note was created at 8:22PM, which is 20 minutes later. -On 10/30/24, LPN-H documented Oxycodone 10MG was administered at 3:30 PM. This administration note was created at 6:28 PM, which is 2 hours and 58 minutes later. -On 10/30/24, LPN-H documented Oxycodone 10MG was administered at 8 PM. This administration note was created on 10/31/24 at 00:21 AM, which is 4 hours and 21 minutes later. -On 10/31/24, LPN-I documented Oxycodone 10 MG was administered at 7:30 AM. This administration note was created at 8:13 AM, which is 43 minutes later. -On 11/5/24, LPN-I documented Oxycodone 10 MG was administered at 7 AM. This administration note was created at 7:45 AM, which is 45 minutes later. -On 11/7/24, LPN-I documented Oxycodone 10 MG was administered at 7 AM. This administration note was created at 7:32 AM, which is 32 minutes later. -On 11/9/24, LPN-I documented Oxycodone 10 MG was administered at 7:15 AM. This administration note was created at 9:05 AM, which is 1 hour and 50 minutes later. -On 11/13/24, LPN-I documented Oxycodone 10 MG was administered at 8:02 AM. This administration note was created at 11:51 AM, which is 3 hours and 49 minutes later. Surveyor noted these 11 examples include late documentation up to 4 hours and 21 minutes later than the medication was administered. Surveyor noted in these 11 examples, staff did not follow facility policy or Wisconsin State Regulation that documents staff should immediately record in the resident's clinical record the administration of medications. Surveyor noted that during the time the medication was given but not documented, another facility staff could have come along and saw that the medication was not given and administer the medication again. This could potentially cause a medication error. 3.) R6 was admitted to the facility on [DATE] with diagnosis that include Wedge compression fracture of T11-T12 Vertebra, Subsequent encounter for fracture with delayed healing, and Low back pain. R6's Admission Minimum Data Set (MDS) assessment dated [DATE] documents R6 is cognitively intact. R6 has pain almost constantly. R6's pain occasionally affects R's sleep and almost constantly interferes with day-to-day activity. R6's MD order dated 10/24/24 and discontinued on 10/30/24 documents, Hydrocodone-Acetaminophen tablet 5-325 milligrams (MG). Give 1 tablet by mouth every 4 hours for pain. R6's MD order dated 10/30/24 and discontinued on 11/4/24 documents, Oxycodone HCL oral tablet 5MG. Give 1 tablet by mouth every 6 hours as needed for pain. R6's MD order dated 11/4/24 and discontinued 11/15/24 documents, Oxycodone HCL oral tablet 5MG. Give 1 tablet by mouth every 6 hours as needed for pain. Surveyor reviewed R6's Medication Administration Record (MAR) and R6's Orders administration note within R6's electronic medical record. Surveyor noted that the time entered on R6's MAR as the administration time was not documented directly after medication administration. Surveyor noted 11 times R6's medication administration was documented later in the day. Examples include: -On 10/25/24, Licensed Practical Nurse (LPN)-H documented Hydrocodone-Acetaminophen 5-325MG was administered at 8:10 PM. This administration note was created at 10:49 PM, which is 2 hours and 39 minutes later. -On 10/26/24, LPN-I documented Hydrocodone-Acetaminophen 5-325MG was administered at 1:01 PM. This administration note was created at 2:21 PM, which is 1 hour and 20 minutes later. -On 10/26/24, LPN-H documented Hydrocodone-Acetaminophen 5-325MG was administered at 9PM. This administration note was created at 00:55 AM, which is 3 hours and 55 minutes later. -On 10/27/24, LPN-I documented Hydrocodone-Acetaminophen 5-325MG was administered at 1:29 PM. This administration note was created at 2:29 PM, which is 1 hour later. -On 10/28/24, RN-K documented Hydrocodone-Acetaminophen 5-325MG was administered at 4:45 PM. This administration note was created at 6:22 PM, which is 1 hour and 37 minutes later. -On 10/30/24, LPN-I documented Oxycodone 5MG was administered at 10:32 AM. This administration note was created at 12:56 PM, which is 2 hours and 24 minutes later. -On 10/30/24, LPN-H documented Oxycodone 5MG was administered 4:30PM. This administration note was created at 5:24 PM, which is 54 minutes later. -On 10/30/24, LPN-H documented Oxycodone 5MG was administered at 10:30 PM. This administration note was created on 10/31/24 at 00:19, which is 1 hour and 49 minutes later. -On 11/7/24, LPN-I documented Oxycodone 5MG was administered at 8:30 AM. This administration note was created at 11:13 AM, which is 2 hours and 43 minutes later. -On 11/9/24, LPN-I documented Oxycodone 5MG was administered at 8:16 AM. This administration note was created at 1:16 PM, which is 5 hours later. -On 11/13/24, LPN-I documented Oxycodone 5MG was administered at 7:16 AM. This administration note was created at 11:44 AM, which is 4 hours and 28 minutes later. Surveyor noted that these 11 examples include late documentation up to 5 hours later than the medication was administered. Surveyor noted that in these 11 examples, staff did not follow facility policy or Wisconsin State Regulation that documents staff should immediately record in the resident's clinical record the administration of medications. Surveyor noted that during the time the medication was given but not documented, another facility staff could have come along and saw that the medication was not given and administer the medication again. This could potentially cause a medication error. 4.) R7 was admitted to the facility on [DATE] with diagnosis that include Aftercare following joint replacement surgery, Fibromyalgia and Chronic pain Syndrome. R7's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documents that R7 is cognitively intact. R7 had pain almost constantly. R7's pain frequently affects R7's sleep. R7's MD order with a start date of 10/23/24 documents Oxycodone HCL tablet 5 milligrams (MG). Give 2 tablets by mouth every 6 hours as needed for pain. Surveyor reviewed R7's Medication Administration Record (MAR) and R7's Orders administration note within R7's electronic medical record. Surveyor noted that the time entered on R7's MAR as the administration time was not documented directly after medication administration. Surveyor noted 2 times that R7's medication administration was documented later in the day. Examples include: -On 10/24/24, Licensed Practical Nurse (LPN)-H documented Oxycodone 10MG was administered at 4PM. This administration note was created at 4:17 PM, which is 17 minutes later. -On 10/28/24, LPN-H documented Oxycodone 10MG was administered at 10:10 PM. This administration note was created at 11:15 PM, which is 1 hour and 5 minutes later. Surveyor noted that these 2 examples include late documentation up to 1 hour and 5 minutes later than the medication was administered. Surveyor noted that in these 2 examples, staff did not follow facility policy or Wisconsin State Regulation that documents staff should immediately record in the resident's clinical record the administration of medications. Surveyor noted that during the time the medication was given but not documented, another facility staff could have come along and saw that the medication was not given and administer the medication again. This could potentially cause a medication error. 5.) R8 was admitted to the facility on [DATE] with diagnosis that include Cellulitis of left lower limb, Osteoarthritis, and chronic pain syndrome. R8's Admission Minimum Data Set (MDS) assessment dated [DATE] documents R8 is cognitively intact. R8 has pain frequently. R8's pain frequently affects R8's sleep. R8's MD order with a start date of 10/2/24 documents Oxycodone HCL tablet 5 milligrams (MG). Give 1 tablet by mouth every 6 hours as needed for pain. R8's MD order with a start date of 10/2/24 documents Oxycodone HCL tablet 5MG. Give 2 tablets by mouth every 6 hours as needed for pain. Surveyor reviewed R8's Medication Administration Record (MAR) and R8's Orders administration note within R8's electronic medical record. Surveyor noted that the time entered on R8's MAR as the administration time was not documented directly after medication administration. Surveyor noted 8 times that R8's medication administration was documented later in the day. Examples include: -On 10/3/24, Licensed Practical Nurse (LPN)-H documented Oxycodone 10MG was administered at 4PM. This administration note was created at 7:50PM, which is 3 hours and 50 minutes later. -On 10/6/24, LPN-H documented Oxycodone 10MG was administered at 2:30 PM. This administration note was created at 2:54PM, which is 24 minutes later. -On 10/10/24, LPN-I documented Oxycodone 10MG was administered at 10:30 AM. This administration note was created at 10:57 AM, which is 27 minutes later. -On 10/12/24, LPN-I documented Oxycodone 10MG was administered at 10:20 AM. This administration note was created at 4:21 PM, which is 5 hours and 1 minute later. -On 10/13/24, LPN-I documented Oxycodone 10MG was administered at 11 AM. This administration note was created at 11:49 AM, which is 49 minutes later. -On 10/15/24, LPN-I documented Oxycodone 10MG was administered at 7:08 AM. This administration note was created at 3:08 PM, which is 8 hours later. -On 10/17/24, LPN-I documented Oxycodone 5MG was administered at 6:45 AM. This administration note was created at 8:20 AM, which is 1 hour and 35 minutes later. -On 10/23/24, RN-K documented Oxycodone 10MG was administered at 9:50 PM. This administration note was created at 11:07 PM, which is 1 hour and 17 minutes later. Surveyor noted that these 8 examples include late documentation up to 8 hours later than the medication was administered. Surveyor noted that in these 8 examples, staff did not follow facility policy or Wisconsin State Regulation that documents staff should immediately record in the resident's clinical record the administration of medications. Surveyor noted that during the time the medication was given but not documented, another facility staff could have come along and saw that the medication was not given and administer the medication again. This could potentially cause a medication error. On 1/15/25, at 2:10 PM, Surveyor interviewed Registered Nurse (RN)-J. Surveyor asked when a medication administration time should be documented. RN-J stated that RN-J will always document the administration of a medication as soon as the medication is administered. On 1/15/25, at 2:20 PM, Surveyor interviewed RN-K. Surveyor asked when a medication administration time should be documented. RN-K stated it should be documented at the same time as the medication was administered. Surveyor asked if a medication would ever be documented hours after the medication administration. RN-K stated it shouldn't be documented like that, but in a rare circumstance like being pulled away to do something else or deal with something urgent, it may be documented later. RN-K indicated that best practice would be to document at the time of administration. On 1/16/25 at 8:35 AM, Surveyor observed LPN-I administering medications. Licensed Practical Nurse (LPN)-I documented the administration of medications immediately after administering the medications. On 1/16/25, at 8:45 AM, Surveyor interviewed LPN-I. Surveyor asked how long LPN-I had been working in the facility. LPN-I stated LPN-I had worked [AGE] years in the facility. Surveyor asked if in the past, LPN-I had documented the administration of medications later than immediately after the administration. LPN-I stated over the years, yes. LPN-I continued and indicated that after a recent incident regarding diverging of medication involving a different nurse, LPN-I did not document the administration late anymore. LPN-I stated that LPN-I would sometimes forget to put the documentation into the electronic medical record and sign out the narcotic pain medication until later in the day. LPN-I indicated there were times that LPN-I was at home when LPN-I remembered that documentation was not completed. On 1/16/25, at 11:25 AM, Surveyor interviewed RN Manager-F. Surveyor asked if facility staff can document a medication administration hours after it was given. RN-F stated that facility staff can back time a medication administration, if needed. Surveyor asked when documentation of a medication administration should occur. RN-F stated that after a medication if given, it should immediately be documented as given. Surveyor informed RN-F of facility staff documenting the administration of medications sometimes hours after the administration. Surveyor asked if RN-F was concerned about the late documentation. RN-F stated yes, it is not best practice. On 1/16/25, at 12:55 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked when a medication administration should be documented. DON-B stated the minute that the medication is given. DON-B stated that through an investigation relating to diverting medication that occurred on 10/30/24, DON-B noted that staff were not always signing out a medication administration on the MAR. Surveyor informed DON-B and NHA-A that facility staff were not always documenting the medication administration time on the MAR immediately after the medication was given. Surveyor gave examples of documentation being completed up to 9 hours after the medication administration. Surveyor asked if DON-B would be concerned about documenting medication administration that long after giving a medication. DON-B stated that 9 hours is ridiculous, especially since staff have 8-hour shifts. DON-B stated that DON-B would be concerned. On 1/16/25, at 3:32 PM, DON-B stated that DON-B reviewed medication administration times on a few facility staff members for the last month. DON-B stated that LPN-I did not have any long gaps in between medication administration and documentation of the administration. DON-B stated that RN-K did have one instance of about an hour difference in documentation. DON-B stated that DON-B will complete education and will audit. On 1/17/25 at 1:17 PM, NHA-A sent Surveyor additional information for review. Surveyor reviewed the additional information however Surveyor notes current noncompliance was identified at this regulation. 6.) R5 was admitted to the facility on [DATE] with diagnosis that include: Infection and inflammatory reaction due to internal right knee prosthesis. R5's Admission Minimum Data Set (MDS) assessment dated [DATE] documents R5 has intact cognition. R5 has pain almost constantly which frequently affects R5's sleep. R5's Medical Doctor (MD) order dated 10/24/24 with a discontinue date of 11/16/24 documents: Oxycodone HCL oral tablet 5 milligrams (MG). Give 1 tablet by mouth every 4 hours as needed for Pain Management. R5's Progress note dated 10/25/24, at 4:36 PM, documents in part, New Order Received to increase As Needed Oxycodone to 1 or 2 tabs every 4 hours as needed . R5's MD order dated 10/25/24 with a discontinue date of 10/28/24 documents: Oxycodone HCL oral tablet 5 MG. Give 2 tablet by mouth every 4 hours as needed for Pain. Give 1-2 tablets by mouth every 4 hours as needed for Pain Management. R5's MD order dated 10/28/24 with a discontinue date of 11/16/24 documents: Oxycodone HCL oral tablet 5 MG. Give 1 tablet by mouth every 4 hours as needed for Pain. R5's MD order dated 10/28/24 with a discontinue date of 11/16/24 documents: Oxycodone HCL Oral Tablet 5 MG. Give 2 tablets by mouth every 4 hours as needed for pain. Surveyor noted that from 10/28/24 through 11/16/24, R5 had a duplicate order of one tablet of Oxycodone. Surveyor reviewed R5's Medication Administration Record (MAR) and noted that facility staff would document the administration of one 5MG tablet in either the order started on 10/24/25 or the order started on 10/28/24. Surveyor noted this could cause confusion and the possibility of giving more medication because the documentation was split between the two orders on the MAR. On 1/16/25, at 12:55 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor informed NHA-A and DON-B that R5 had duplicate orders of Oxycodone 5MG. DON-B indicated that R5's dose was increased to 1 to 2 tabs every four hours as needed on 10/25/24. Surveyor informed DON-B and NHA-A of the concern that when the new order was received the previous order was not discontinued thus leaving a duplicate order for facility staff to document administrations on in the MAR. No further information was provided regarding the duplicate one tab of 5MG Oxycodone order. .

Based on interview and record review the facility did not report 1 (R2) of 2 incidents to the State Survey Agency and/or Nursing Home Administrator during the required timeframe. On 12/7/24 NHA (Nursing Home Administrator) was informed of a skin tear on R2's left wrist which CNA (Certified Nursing Assistant)-G reported to LPN (Licensed Practical Nurse)-E as occurring when taking off R2's sweat shirt. NHA-A was not informed on 12/7/24 of R2's allegation the skin tear occurred when CNA-G grabbed her arm. The allegation of CNA-G grabbing R2's arm was reported to DON (Director of Nursing)-B on 12/7/24 but DON-B did not report this to the State agency. The allegation of physical abuse was not reported to NHA-A or the State agency until 12/9/24. Findings include: The facility's policy titled, Abuse, Neglect and Exploitation and last reviewed/revised 9/22/23 under policy documents: It is the policy of [name of facility] to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under the section VII. Reporting/Response documents A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. R2's diagnoses includes osteoarthritis, anxiety disorder, hypertension, essential tremor, and depressive disorder. R2's annual MDS (minimum data set) with an assessment reference date of 11/27/24 has a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R2 requires substantial/maximal assistance for toileting hygiene, rolling left & right, lying to sitting on the edge of the bed , chair/bed to chair transfers and toilet transfers. Walk 10 feet and walk 50 feet with two turns is assessed as partial/moderate assistance. R2 is assessed as frequently incontinent of urine and occasionally incontinent of bowel. The cognitive loss/dementia CAA (care area assessment) was not triggered. The Functional Abilities (Self-Care and Mobility) CAA dated 12/10/24 under Care Plan Considerations documents Is a long term resident. Needs assist with ambulation, locomotion, dressing, hygiene, toileting, bathing, bed mobility, and transfers. BIMS 13. Diagnosis includes arthritis, PAF (Paroxysmal Atrial Fibrillation), and venous insufficiency. Proceed to care plan functional abilitities. R2's nurses note dated 12/7/24, at 20:41 (8:41 p.m.) documents CNA (Certified Nursing Assistant) reported when she took off residents sweat shirt resident said I'm bleeding and CNA came to get the nurse. Noted 4.5 cm (centimeter) x (times) 4 cm skin tear to left wrist. Skin tear cleansed with NS (normal saline) approximated and steri stripped. [Medical Group Name] [Name] PA (Physician Assistant) updated on call RN (Registered Nurse) Manager updated. This nurses note was written by LPN (Licensed Practical Nurse)-E. On 1/15/25, at 11:48 a.m., Surveyor reviewed the Facility Reported Incident involving R2 with date of occurrence documented 12/7/24, date discovered is documented as 12/9/24, and date reported is 12/9/24. On 1/15/25, at 2:42 p.m., Surveyor interviewed LPN-E regarding her nurses note dated 12/7/24. LPN-E informed Surveyor CNA-G told her when she was taking off R2's sweatshirt she got a skin tear. LPN-E informed Surveyor she asked CNA-G how R2 received the skin tear as it was a large skin tear. LPN-E informed Surveyor R2 said she just knows after the CNA took off her shirt she was bleeding when the CNA was in the room. LPN-E informed Surveyor she called the nurse manager right away regarding R2's skin tear. LPN-E informed when she went back to R2's room and CNA-G was not in the room, R2 told her the CNA grabbed to arm to put her in bed. Surveyor asked LPN-E after R2 told you the CNA grabbed her arm did you notify the RN Manager know. LPN-E replied yes and then they did an investigation. Surveyor asked LPN-E who the nurse manager was. LPN-E replied [name of] RN Manager-F. On 1/16/25, at 8:15 a.m., Surveyor interviewed RN Manager-F regarding R2's skin tear which occurred on 12/7/24. Surveyor asked RN Manager-F if she was in the building. RN Manager-F informed Surveyor she was on call and not in the facility. Surveyor asked RN Manager-F how she became aware of R2's skin tear. RN Manager-F replied the floor nurse and thought it was name of LPN-E. Surveyor asked RN Manager-F if she remembers what LPN-E said to her. RN Manager-F stated R2 got a skin tear and thinks she received the skin tear when the CNA was getting her ready for bed. The CNA wasn't exactly sure how it happened and notified her (LPN-E) of the skin tear. RN Manager-F informed Surveyor she called NHA (Nursing Home Administrator)-A to let her know of the skin tear as R2 had said wait until her son hears. RN Manager-F explained a lot of times the son will skip over everyone and goes to NHA-A. Surveyor asked RN Manager-F after LPN-E's initial call to her did LPN-E call her back. RN Manager-F replied she text me later. Surveyor asked what did LPN-E text her. RN Manager-F informed Surveyor R2 was upset and R2 said she received the skin tear when the CNA grabbed her arm. RN Manager-F informed Surveyor not to down play but R2 can be very particular on how she wants her cares, R2 will tell you what she wants and can get persnickety. Surveyor asked RN Manager-F if she called NHA-A back after she was informed R2 had said the CNA grabbed her arm. RN Manager-F replied I did not because she was in Chicago, figured I'd call [first name of] DON (Director of Nursing)-B. Surveyor asked RN Manager-F what she told DON-B. RN Manger-F replied the CNA grabbed her arm. Surveyor asked RN Manager-F if she was given any instructions from DON-B. RN Manager-F informed Surveyor the CNA wasn't staying for the whole shift, not working the next day (Sunday) and they were going to look at it on Monday. On 1/16/25, at 8:49 a.m., Surveyor asked DON-B when she became aware of R2's skin tear which occurred on 12/7/24. DON-B replied think they called me that night. I had [first name of CNA-G] sent home after her statement. DON-B informed Surveyor she wants to say LPN-E called her that they have an issue with [name of resident]'s skin. Surveyor asked if RN Manager-F called her. DON-B informed Surveyor RN Manager-F called her to report what was going on with R2 and CNA-G was sent home after her statement. Surveyor asked DON-B if she was made aware R2's allegation of CNA-G grabbing her arm. DON-B informed Surveyor that's what R2 told LPN-E. Surveyor asked DON-B if she notified the State on 12/7/24. DON-B replied no I did not. Surveyor asked DON-B why she didn't report the allegation to the State agency. DON-B replied I was still investigating. DON-B informed Surveyor R2 has a history of accusing staff that's why she wanted to look into it more before going forward with anything else. Surveyor asked DON-B when the last time R2 made an accusation about staff. DON-B replied I don't know, I really have to look, don't know the answer off the top of my head. Surveyor asked DON-B to look into when R2 last made an accusation and get back to Surveyor. On 1/16/25, at 9:39 a.m., DON-B informed Surveyor September was the last time R2 accused a CNA or staff of doing something that wasn't intentional. On 1/16/25, at 11:01 a.m., Surveyor asked NHA-A why R2's allegation of CNA-G grabbing her arm which resulted in a skin tear on 12/7/24 wasn't reported until 12/9/24. NHA-A informed Surveyor when she was initially called the initial report didn't say anything about the CNA grabbing R2's arm. NHA-A informed the skin tear was written up as a grievance. NHA-A informed Surveyor when she came in Monday (12/9/24), R2's son called her and at some point she went to speak to R2. When she spoke with R2 it was different than what she was told and so she did a self report. Surveyor informed NHA-A Surveyor spoke with RN Manager-F who informed Surveyor she had called her (NHA-A) about R2's skin tear but didn't call NHA-A back as she didn't want to bother NHA-A as she was in Chicago. RN Manager-F informed Surveyor she called DON-B. Surveyor asked DON-B if she reported the allegation of CNA-G grabbing R2's arm on 12/7/24 and Surveyor was informed by DON-B she didn't. Surveyor informed NHA-A R2's allegation should have been reported on 12/7/24. No additional information was provided to Surveyor as to why the facility did not report R2's allegation until 12/9/24.

Based on interview and record review the facility did not ensure 1 (R2) of 4 residents care plans were revised. R2's care plan was not revised after an allegation on 12/7/24 of a CNA grabbing R2's wrist causing a skin tear. Findings include: The facility's policy titled, Care Plan Revisions Upon Status Change and implemented 10/21/24 under Policy documents The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Under Policy Explanation and Compliance Guidelines documents 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. R2's diagnoses includes osteoarthritis, anxiety disorder, hypertension, essential tremor, and depressive disorder. The ADL (Activities Daily Living) Functional Potential/Rehabilitation and/or Limited Mobility care plan initiated 9/29/23 documents the following interventions: *Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated. Initiated 9/29/23. *Bathing/Showering: Resident prefers showers. Initiated 9/29/23 & revised 10/3/24. *Bathing/Showering: The resident is dependent on (1) staff to provide bath/shower. Initiated & revised 9/29/23. *Do not disturb resident between Midnight and 0800 (8:00 a.m.) unless call light is on. Initiated 11/13/23. *Dressing-Resident will have the option to wear gown or other item of choice for sleeping. Initiated 4/24/24. *Eating: The resident needs setup or clean up assistance to eat. Initiated 9/29/23. *Lower Body dressing: The resident is dependent on (1) staff for dressing. Initiated & revised 9/29/23. *Lying to sitting on the side of the bed: The resident requires substantial/maximum assistance by (1) staff to complete task. Initiated & revised 9/29/23. Mobility: The resident uses manual wheelchair. Initiated 9/29/23. *Oral Care: The resident needs moderate/clean up assistance with oral care assist with brushing and flossing twice daily am/eve (morning/evening) and antibacterial rinse to follow. Initiated 9/29/23 & revised 3/21/24. *Personal Hygiene: The resident is dependent on (1) staff for personal hygiene. Initiated & revised 9/29/23. *Putting on or taking off shoes: The resident is dependent on staff to complete. Initiated 9/29/23. *Roll left and right: The resident requires substantial/maximum assistance on (1) staff to complete. Initiated & revised 11/24/24. *The resident has no weight bearing restrictions. Initiated: 9/29/23. *Toileting Transferring: The resident needs substantial/maximum (1) staff assistance to complete task. Initiated & revised 11/24/24. *Toileting Transferring: The resident needs partial/moderate assistance of 1 staff assistance to complete task. Initiated 9/29/23. *Transfer: The resident needs partial/moderate assistance of 1 staff for transferring. Initiated 9/29/23. *Upper Body Dressing: The resident is dependent on (1) staff for dressing. Initiated 9/29/23 & revised 8/23/24. *Walk 10 FT (feet): The resident requires substantial/maximum assistance on 1 staff to complete task. Initiated 9/29/23. *Walk 10 FT: The resident uses a [2 wheeled walker] [standard walker] for walking. Initiated & revised 9/29/23. R2's annual MDS (minimum data set) with an assessment reference date of 11/27/24 has a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R2 requires substantial/maximal assistance for toileting hygiene, rolling left & right, lying to sitting on the edge of the bed , chair/bed to chair transfers and toilet transfers. Walk 10 feet and walk 50 feet with two turns is assessed as partial/moderate assistance. R2 is assessed as frequently incontinent of urine and occasionally incontinent of bowel. The Visual/Bedside Kardex Report located in R2's bathroom dated 12/9/24 under the section Resident Care documents * DRESSING-Resident will have the option to wear gown or other item of choice for sleeping. Under the section Mobility documents * MOBILITY: The resident needs substantial/maximum assistance for 1 staff for mobility. * MOBILITY: The resident uses manual wheelchair. *WALK 10 FT (feet): The resident requires substantial/maximum assistance on 1 staff to complete task. *WALK 10 FT: The resident uses a [2 wheeled walker] [standard walker] for walking. On 1/15/25, at 10:32 a.m., Surveyor observed CNA (Certified Nursing Assistant)-C enter R2's room and ask R2 if she was ready to get up. CNA-C removed the bedding, removed gripper socks, and placed tubi grips & gripper socks on R2. CNA-C opened R2's closet and gave R2 choices of what to wear. CNA-C placed gloves on and asked R2 if she wanted the door open or closed. R2 stated open and CNA-C explained to Surveyor R2 is claustrophobic. CNA-C stated to R2 you do your thing. R2 grabbed onto the left transfer bar stating I try to get out of bed by myself. Resident then asked CNA-C to swing her legs so she was sitting on the edge of the bed. CNA-C placed the walker next to R2, raised the head of the bed up high and then R2 stated I don't have to tell her, she knows what to do. CNA-C placed a towel on top of the cushion in the wheelchair and then raised the height of the bed up telling R2 let me know when. R2's bed was raised up until R2 slid with her feet on the floor while R2 held onto the walker & wheelchair. After R2 was standing up, R2 sat in the wheelchair. CNA-C wheeled R2 into the bathroom. CNA-C explained in the evening R2 likes to be wheeled into the bathroom and walk back to bed with a walker. CNA-C then placed powder on the toilet seat. R2 explained to Surveyor she sticks to the toilet seat. R2 held onto the grab bar, stood up, took a couple steps to turn and sat on the toilet. CNA-C removed her gloves, washed her hands, and placed gloves on. R2 washed her face, CNA-C removed R2's gown, washed R2's upper body & placed a sweatshirt on R2. CNA-C placed an incontinence product and pants on R2, moved the wheelchair closer and then R2 grabbed onto the grab bar and stood up. CNA-C washed R2's frontal perineal area & buttocks, applied barrier cream and pulled up incontinence product & pants. R2 sat in wheelchair. On 1/15/25, at 2:11 p.m., Surveyor asked CNA-C if she heard any concerns regarding CNA-G. CNA-C replied just from first name of R2. CNA-C explained CNA-G did a double and didn't do what R2 wanted her to do going to bed, grabbed her wrist that's how she got her skin tear. On 1/16/25, at 10:20 a.m., Surveyor spoke with CNA-D on the telephone regarding R2 on 12/7/24. CNA-D explained R2 was already in bed with a sweater. CNA-D informed Surveyor R2 never is in bed with a sweater as she takes it off before going to bed. CNA-D informed Surveyor the CNA was confused on how to put R2 to bed. CNA-D explained R2 walks back from the bathroom to the bed with a walker. On 1/16/25, at 11:01 a.m., Surveyor met with NHA (Nursing Home Administrator)-A regarding R2's allegation on 12/7/24 when CNA-G grabbed R2's arm which resulted in a skin tear. Surveyor reviewed this facility reported incident. Surveyor asked NHA-A if there was any change in R2's plan of care after this incident to prevent a further occurrence. Surveyor informed NHA-A Surveyor observed morning cares on 1/15/25. Surveyor explained to NHA-A how R2 has a certain routine of how to gets out of bed and was informed in the evening R2 is wheeled into the bathroom and then she walks back to bed with a walker. Surveyor also informed NHA-A R2 likes to have the room door open as she is claustrophobic. Surveyor informed NHA-A none of R2's interventions address what R2 likes and asked how would a CNA who hasn't taken care of R2 prior know this. NHA-A informed Surveyor she doesn't recall and will have to ask. On 1/16/25, at 12:25 p.m. NHA-A provided Surveyor with R2's Visual/Bedside Kardex Report dated 1/16/25. Surveyor noted the Resident Care section has been updated with the following: *Prefers to keep her door open even while cares are being performed per her preference and *Toileting in the evening: Will ambulate from BR (bathroom) to bed with wheeled walker but will not ambulate from bed to BR per her choice. Do not rush her. On 1/16/25, at 1:27 p.m., Surveyor met with NHA-A and DON-B. Surveyor asked if the interventions on the Kardex come from the care plan. DON-B replied yes. Surveyor asked why the care plan was not revised prior to Surveyor asking. DON-B informed Surveyor she doesn't want to throw anyone under the bus and stated she delegated it and didn't follow up to make sure it was done. Surveyor asked for a copy of R2's revised care plans. On 1/16/25, at 1:56 p.m., Surveyor was provided with R2's care plans. The ADL Functional Potential/Rehabilitation and/or Limited Mobility care plan initiated 9/29/23 was revised with the following interventions: *Prefers to keep her door open even while cares are being performed per her preference. Initiated 1/16/25. *Toileting in the evening: Will ambulate from BR to bed with wheeled walker but will not ambulate from bed to BR per her choice. Do not rush her. Initiated 1/16/25. No additional information was provided as to why R2's care plans were not revised prior to Surveyor inquiring on 1/16/25.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. This had the potential to effect 19 of 19 residents on the 400 hallway. On 4/2/24 while providing cares, R1 accused Certified Nursing Assistant (CNA)-D of slapping her. CNA-D reported this to Licensed Practical Nurse (LPN)-C. LPN-C did not immediately report the allegation of abuse to administration resulting in CNA-D not being removed from the resident care area immediately pending investigation and was allowed to work the rest of the shift. Findings include: Surveyor reviewed facility's Abuse, Neglect and Exploitation policy with a revised date of 09/22/2023. Documented was: Policy: It is the policy of [this facility] to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the residents) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse . R1 was admitted to the facility 2/1/23 with diagnoses that included COPD (Chronic Obstructive Pulmonary Disease), Dementia, Restlessness and Agitation and History of Falls. Surveyor reviewed R1's MDS (Minimum Data Set) Assessment with an assessment reference date of 2/7/24. Documented under Cognition was a BIMS (brief interview mental status) score of 05 which indicated severe cognitive impairment. Surveyor reviewed Misconduct Incident Report with a Report Submitted Date of 4/5/2024. Documented under Summary of Incident was Date occurred 04/02/2024. Time occurred 03:35 AM . Briefly Describe the incident . On 4/2/24, it was reported to the Administrator that the resident stated that she was slapped in the face. An investigation was immediately initiated. Resident had been immediately evaluated and found to have no injury. [CNA-D] was identified as accused caregiver. She was contacted, statement obtained and she was notified of investigation and that she was being suspended pending the results of the investigation. Surveyor reviewed Investigation Summary prepared by Nursing Home Administrator (NHA)-A. Documented was: 4/2/24 at [6:25 AM] in person interview with [Director of Nursing (DON)-B] Met with [LPN-C] to discuss allegations of [R1] for possible physical abuse from earlier in the shift. Discussed that it there is abuse alleged, the staff member needs to be removed from providing care to that resident and all others . Surveyor reviewed witness statement documented by Director of Nursing (DON)-B. Documented was: 4/2/24 at [6:35 AM] in person interview to discuss events and written statements provided. [CNA-D] [CNA-D] told writer You know how [R1] is. I said I was aware of her history of behaviors and bowel obsession. Asked questions about the initial interaction with [R1] that night and [CNA-D] verbalized her written statement to me. Asked why she went to get the [LPN-C], [CNA-D] stated because [R1] kept saying I hit her when I did not. So, I told [LPN-C] because I was not going back in that room again and that [R1] would most likely need help again around 5am. Asked if [R1] may have struck the wall during provision of cares and [CNA-D] responded no. Asked if anything could have fallen on [R1] while completing bed change and brief change, [CNA-D] said no. Informed [CNA-D] . I would contact her after investigation has been completed. On 4/11/24 at 12:27 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B. Surveyor asked when CNA-D was removed from the resident care area pending investigation. DON-B stated the morning of 4/2 after the interview. Surveyor noted incident time of 3:45 AM and interview time of 6:35 AM. Surveyor stated the CNA was not immediately removed from the resident care area then. DON-B stated no. DON-B stated LPN-C should have called and reported the incident and CNA-C would have been removed from the resident care area at that time. DON-B stated LPN-C had individualized abuse training that day.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported immediately to the administrator of the facility and to the State Survey Agency in accordance with State law through established procedures. The staff did not report the incident to the administration immediately after the incident and did not contact law enforcement to report this reasonable suspicion of a crime for 1 (R1) of 3 residents reviewed for abuse and neglect. On 4/2/24 while providing cares, R1 accused Certified Nursing Assistant (CNA)-D of slapping her. CNA-D reported this to Licensed Practical Nurse (LPN)-C. LPN-C did not immediately report the allegation of abuse to administration. Law enforcement was not called to report this reasonable suspicion of a crime. Findings include: Surveyor reviewed facility's Abuse, Neglect and Exploitation policy with a revised date of 09/22/2023. Documented was: Policy: It is the policy of [this facility] to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. .VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes . 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provisions will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. The expected date for implementation; and Identification of staff responsible for monitoring the implementation of the plan. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies . R1 was admitted to the facility 2/1/23 with diagnoses that included COPD (Chronic Obstructive Pulmonary Disease), Dementia, Restlessness and Agitation and History of Falls. Surveyor reviewed R1's MDS (Minimum Data Set) Assessment with an assessment reference date of 2/7/24. Documented under Cognition was a BIMS (brief interview of mental status) score of 05 which indicated severe cognitive impairment. Surveyor reviewed Misconduct Incident Report with a Report Submitted Date of 4/5/2024. Documented under Summary of Incident was Date occurred 04/02/2024. Time occurred 03:35 AM . Briefly Describe the incident . On 4/2/24, it was reported to the Administrator that the resident stated that she was slapped in the face. An investigation was immediately initiated. Resident had been immediately evaluated and found to have no injury. [CNA-D] was identified as accused caregiver. She was contacted, statement obtained and she was notified of investigation . Surveyor reviewed Investigation Summary prepared by Nursing Home Administrator (NHA)-A. Documented was: 4/2/24 at [6:25 AM] in person interview with [Director of Nursing (DON)-B] Met with [LPN-C] to discuss allegations of [R1] for possible physical abuse from earlier in the shift. Discussed that if there is abuse alleged, the staff member needs to be removed from providing care to that resident and all others and that notification should be immediate and a phone call to myself or the Administrator. Verbalized understood and told me [CNA-D] no longer cared for that resident and [LPN-C] completed all the necessary cares the rest of the evening. [LPN-C] did tell the writer that residents often have similar behaviors especially during the night including delusional type episodes and resisting care for at least the last year here in facility. [R1] is often startled easily and often paints her walls with feces and tears off her briefs. [LPN-C] does not think that anything happened to [R1] but that she was having some behaviors and upset due to her-dementia. [LPN-C] herself went into room and provided incontinence care around 5am and saw no injury to [R1's] face but [R1] did continue to say that someone hit her. Surveyor noted that Administration was not immediately informed of the abuse allegation and it was not reported until the morning. Surveyor reviewed Misconduct Incident Report with a Report Submitted Date of 4/5/2024. Documented under Summary of Incident was Date discovered 04/02/2024. Documented under Law Enforcement Involvement was Was law enforcement contacted or involved? No. Surveyor noted law enforcement should have been contacted due to suspicion of physical abuse as a crime. On 4/11/24 at 12:27 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B. Surveyor asked if the incident was reported to the police. NHA-A stated no, I didn't think it was a crime. Surveyor asked why LPN-C did not report the incident immediately upon being made aware of the allegation. DON-B stated she was not sure. DON-B stated she had just arrived at the facility and got a text message while she was still in the parking lot at 5:42 AM. DON-B stated she went directly to the nurse's station to investigate. Surveyor asked if LPN-C should know to call administration immediately with an allegation of abuse. DON-B stated yes. DON-B also noted with a phone call, not a text. DON-B stated LPN-C had individualized abuse training that day.

The facility did not ensure grievances and recommendations discussed during resident group meetings (Resident Council) were acted upon promptly and with feedback provided by the Facility. R2, R4, R20, and R51, expressed concern the Facility did not resolve grievances or provide feedback of steps taken to resolve grievances discussed at Resident Council Meetings. The grievance documents generated from Resident Council Meetings do not identify how the grievances were investigated, if interviews with staff/residents were completed, or the outcome of the investigation. Resident Council Minutes did not include actions taken regarding the concerns voiced by residents. Findings Include: Surveyor reviewed the facility's Resident Council Meetings policy and procedure implemented 2/20/23 and notes the following: . Policy: This facility supports the rights of Residents to organize and participate in Resident groups, including a Resident Council. This policy provides guidance to promoting structure, order, and productivity in these group meetings. Policy Explanation and Compliance Guidelines: 6. The group may appoint a Resident to take notes/maintain meeting minutes or may elect the Life Enrichment Director/designated liaison to take notes/maintain minutes. Meeting minutes may include, but are not limited to: a. Names of Residents in attendance b. Follow up from previous meetings c. Issues discussed d. Recommendations from the group to facility staff e. Names of staff members, speakers, and other guests present in the meeting 7. The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. On 3/18/24 at 2:09 PM, Surveyor reviewed the Facility documented minutes from the Resident Council meetings. Documented was: -On 9/27/23: One Resident expressed concern their toilet is not clean. -One Resident stated they are missing pants. Surveyor notes the Facility does not have documented grievance forms completed addressing the expressed concerns and resolution. Surveyor notes the 10/30/23 meeting minutes do not have documentation addressing the follow up of the grievances from the 9/27/23 meeting or if the grievances were resolved. On 11/20/23 the meeting minutes document: -One Resident expressed a concern related to the outside lab technician not explaining what they were doing to her. -One Resident stated they have to ask to get their room cleaned. Surveyor notes the Facility does not have documented grievance forms completed addressing the expressed concerns and resolution. On 12/28/23 the meeting minutes document: - Concern expressed that Dietary staff are not wearing hair nets. - Call lights not answered on 3rd shift. -Resident with toilet troubles and dusting. -Door not shutting right. Surveyor notes the meeting minutes do not have documentation the grievances from the 11/20/23 meeting were resolved and the Facility does not have documented grievance forms completed addressing the expressed concerns and resolution from the 12/28/23 meeting. Surveyor notes the facility did not have hold a Resident Council Meeting in January 2024 due to a RSV here was no meeting in January 2024 due to RSV (respiratory Syncytial Virus) outbreak. On 2/13/24 the meeting minutes document: -Food could be warmer, the past weekend was bad and very slow. Surveyor notes the meeting minutes do not have documentation the grievances from the 12/28/23 meeting were resolved or follow up provided and the Facility does not have documented grievance forms completed addressing the expressed concern and resolution from the 2/13/24 meeting. On 3/14/24 the meeting minutes document: -Activities-more activities on Saturday. -Laundry concerns. -Food is always cold, meat tough and terrible, raw broccoli in the cheese soup. Food delivery in dining room takes way too long, Not served by table. Surveyor notes there are grievance forms written up for the concerns and it is documented the designated staff have until 3/29/24 to resolve the concerns. On 3/19/24 at 10:30 AM, Surveyor conducted the Resident Council Interview task. The following Residents attended and Surveyor notes their Brief Interview for Mental Status (BIMS) score. -R50-BIMS of 7 as documented on the 5 day Minimum Data Set (MDS) dated [DATE]. The score of 7 indicates R50 is severely impaired for daily decision making. -R2-BIMS of 4 as documented on the quarterly MDS dated [DATE]. The score of 4 indicates R2 is severely impaired for daily decision making. -R4-BIMS of 15 as documented on the quarterly MDS dated [DATE]. The score of 15 indicates R4 is cognitively intact for daily decision making. -R20-BIMS of 15 as documented on the quarterly MDS date 1/25/24. The score of 15 indicates R20 is cognitively intact for daily decision making. -R51-BIMS of 15 as documented on the admission MDS dated [DATE]. The score of 15 indicates R51 is cognitively intact for daily decision making. Surveyor discussed the topic of resolution to concerns and follow up with concerns discussed in the Facilely Resident Council Meetings with all Residents present at the meeting. All Residents expressed concern the Facility staff do not address concerns discussed at the Resident Council meetings and follow up to concerns is not discussed or addressed. On 3/19/24 at 12:28 PM, Surveyor interviewed Activity Director (AD)-V. AD-V stated AD-V has only been in the position for 3 months and sometimes takes minutes. AD-V indicated Activity Assistant (AA)-W was taking minutes prior to AD-V. AD-V stated the facility just started this month with a new procedure for addressing concerns and getting resolution. AD-V confirmed that Resident Rights are not reviewed at the Resident Council meetings, does not review who the facility ombudsman is or how to contact the State Survey Agency with concerns. AD-V stated AD-V does not even know where that information is located in the facility for Residents to view. AD-V informed Surveyor the following: Why would I remind Residents where the survey results are if they don't ask? On 3/19/24 at 2:12 PM, Surveyor interviewed the Nursing Home Administrator (NHA)-A. Per NHA-A a review of outstanding concerns is done and the facility goes department by department to obtain any general concerns. NHA-A has started a new process with the Activity Director (AD)-O. Surveyor shared the concern that during the Resident Council meeting, Residents expressed that Resident Rights are reviewed, the Residents did not know who or what the ombudsman is, where the state survey results are kept for review, and the Residents do not know where the information is kept informing them how to contact the State Agency to express concerns. Surveyor also shared the concern there is no documented resolution to concerns from previous months in the Resident Council meeting notes. No further information was provided at this time. On 3/19/24 at 2:42 PM, NHA-A confirmed they can not locate written documentation concerns discussed in Resident Council for September, November, December 2023, and February 2024 were addressed and resolved. NHA-A also confirmed the facility does not review Resident Rights, location of State Agency complaint information, ombudsman, or location of State Survey results at the Resident Council Meetings. On 3/20/24 at 8:21 AM, Surveyor was notified by NHA-A that an inservice was completed with staff and an impromptu Resident Council Meeting will be held today to review topics discussed yesterday.

Based on interview and record review the Facility did not thoroughly investigate a possible misappropriation of property for Residents receiving liquid morphine. This has the potential to affect 7 hospice residents who received liquid morphine on the 300 & 400 units in October 2023. Findings include: The Abuse, Neglect and Exploitation policy last reviewed/revised 9/22/23 documents alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Section V. Investigation of alleged abuse, neglect and exploitation documents A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect, or exploitation occur. B. Written procedures for investigation include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and; 6. Providing complete and thorough documentation of the investigation. 7. Provide resident/representative a summary of conclusion of investigation using the Investigation Resolution Form. The Discrepancies, Loss and/or Diversion of Medications policy & procedure with an effective date of May 2018 under policy documents All discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed. Under procedures documents: A. Immediately upon the discovery or suspicion of a discrepancy, suspected loss of diversion, the Administrator, Director of Nursing (DON) and Consultant Pharmacist are notified and an investigation conducted. The Director of Nursing leads the investigation. 1.) The information is not to be discussed with other individuals. 2.) During the process, the Consultant Pharmacist will verify suspected loss. On 3/18/24 at 2:06 p.m. Surveyor asked LPN (Licensed Practical Nurse)-K if she was aware of any morphine or other narcotics missing. LPN-K informed Surveyor she heard about it but didn't know any details. LPN-K informed Surveyor because of the potential narcotics missing they changed the way they log all received narcotics. LPN-K explained when medication comes in they have to sign for the card and when the card is finished or the resident is discharged on the log two people have to sign. On 3/18/24 at 3:52 p.m. Surveyor asked LPN-M if she was aware of Resident's morphine being missing. LPN-M informed Surveyor she heard about it in report. Surveyor inquired when this was. LPN-M informed Surveyor about four months ago roughly but she's bad with time. LPN-M informed Surveyor they went from liquid to tablet form of morphine. Surveyor asked if LPN-M if she knew the name of the Resident who was missing their morphine. LPN-M informed Surveyor it was mostly hospice patients. On 3/18/24 at 2:32 p.m. during the end of the day meeting NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B, Surveyor asked DON-B if there are any concerns regarding missing narcotics. DON-B informed Surveyor they don't have any concerns regarding missing narcotics and thought the nurses were lackadaisical in counting. Surveyor asked DON-B why she thought this. DON-B informed Surveyor there were not a lot of signature on the shift to shift but things were matching up. DON-B informed Surveyor they changed their system on how they track narcotics in and out. DON-B explained it is not by Resident's name each card gets a number. DON-B informed Surveyor if a resident is discharged or the medication is used up it has to be signed by two nurses. DON-B stated we had rumors, there was agency in the building there were random rumors. Easy to divert that's why we worked on a plan. DON-B stated there was no missing narcotics. On 3/19/24 at 9:47 a.m. Surveyor asked LPN-N if she was aware of any Residents missing their morphine. LPN-N informed Surveyor she heard rumbling of something but doesn't know specific details. Surveyor asked LPN-N if she remembered anything. LPN-N informed Surveyor something with morphine, there was juice in the bottle instead of morphine then they switched the liquid morphine to a pill form. Surveyor asked LPN-N when this was. LPN-N replied honestly don't know, within the last year. LPN-N informed Surveyor there was a resident who's morphine was ineffective, the nurse found out it was juice not morphine and the liquid morphine was switched immediately to pill form for all residents. LPN-N was unable to provide Surveyor with the name of the Resident. On 3/19/24 at 2:41 p.m. Surveyor asked LPN-J if she was aware of any Resident's morphine or narcotics missing. LPN-J informed Surveyor they used to have liquid morphine. Her manager told her something was wrong with it and they started using pills. Surveyor asked who the manager is. LPN-J informed Surveyor name of LPN/UM (Licensed Practical Nurse/Unit Manager)-Q but she doesn't think she is here today. On 3/19/24 at 2:46 p.m. Surveyor asked LPN-R if she heard of Resident's morphine being missing. LPN-R replied I have. LPN-R explained there was an issue with morphine liquid and then converted everything to tablets. Surveyor asked LPN-R what the issue was. LPN-R explained there was a Resident down the 300 unit that they couldn't get their pain symptoms under control. The unit manager said enough of this, she popped off the morphine top and said it smelled like mouthwash. The Manager then got a sealed morphine out of the contingency machine on south. Surveyor asked who the Resident was on the 300 unit. LPN-R informed Surveyor she doesn't know the name as she doesn't take care of residents on 300. Surveyor asked who the manager was. LPN-R stated the first name of LPN/UM-Q. LPN-R informed Surveyor they also changed the system of how they count narcotics. On 3/19/24 at 4:04 p.m. Surveyor spoke with Pharmacist-S on the telephone and asked if he was able to tell Surveyor in the last six months has there been any liquid morphine removed from the contingency machine at [Name of] Facility and when the Facility switched from liquid morphine to tablets. Pharmacist-S informed Surveyor, Surveyor probably needs to speak with FM (Facility Manager)-T. At 4:07 p.m. Surveyor spoke with FM-T on the telephone. Surveyor asked FM-T when [Name of] Facility switched from liquid morphine to tablets and if they have any records of when liquid morphine was removed from contingency. FM-T informed Surveyor they switched to tablets in the beginning of October and had discussions of doing this with the DON. Surveyor asked FM-T if he knew why the Facility switched from liquid to tablets. FM-T informed Surveyor he would have to go back and do more research but would get back to Surveyor. On 3/19/24 at 5:20 p.m. FM-T left Surveyor a voice message asking Surveyor to return his call. On 3/19/24 at 5:49 p.m. Surveyor telephoned FM-T back and left a message requesting a return call. On 3/20/24 at 9:32 a.m. Surveyor telephoned FM-T and left a message requesting a return call. FM-T did not return Surveyor's call. On 3/20/24 at 8:21 a.m. Surveyor asked LPN-U if she knew why the Facility changed from liquid morphine to tablets. LPN-U replied I'll have to get back to you on that one. LPN-U went into an office, returned and informed Surveyor they all did an in-service and it was visually hard to read the bottles. Surveyor asked LPN-U if she was aware of a Resident's morphine not being in the bottle. LPN-U replied no and informed Surveyor she just knows there was a situation with the count doesn't know officially as it was on the other side of the building. LPN-U informed Surveyor she just knows the count was off. On 3/20/24 at 12:50 p.m. Surveyor asked DON-B why liquid morphine was switched to tablets. DON-B replied I already told you because of the counting issues and the spilling issues. Morphine comes with an eye dropper. Consistently that bottle leaks. DON-B informed Surveyor before they switched to tablets the pharmacy provided them with stoppers so the nurses were not just pulling from the bottles but they were spilling into the carts. DON-B informed Surveyor the bottles were hard to read and it's not a guessing game when it comes to narcotics for end of life. DON-B informed Surveyor the official change was 10/13/23. DON-B stated to Surveyor she knew Surveyor was going to come back to her and 10/16/23 was when they started in-servicing. DON-B showed Surveyor the new log with card number, resident name, medication name, date received, date removed, reason and signatures. Surveyor then informed DON-B what Surveyor was being told by nursing staff of a Resident's pain not being managed and the Resident was on liquid morphine. LPN/UM-Q checked the morphine and there wasn't morphine in the bottle. Surveyor was told by one nurse it was juice and by another nurse it was mouthwash. LPN/UM-Q went to contingency for a new bottle of liquid morphine and after morphine from the new bottle was given to this resident, the resident's pain was being managed. Surveyor informed DON-B Surveyor was unable to interview LPN/UM-Q as she is on vacation out of the state. DON-B informed Surveyor there was that rumor going around and heard that too but didn't witness it herself. Surveyor asked DON-B if she spoke with LPN/UM-Q when she thought there was something else other than morphine in the morphine bottle. DON-B informed Surveyor there was no way to confirm whether it was or wasn't. Surveyor asked DON-B if she did an investigation into the possible misappropriation of resident property/drug diversion. DON-B replied no I did not. Surveyor asked DON-B why she didn't do an investigation. DON-B replied I was in the process of changing the way narcotics were being handled before this happened. I was already working on it. DON-B explained she ordered a control substance log book. Surveyor informed DON-B Surveyor doesn't understand why she wouldn't have investigated this. DON-B informed Surveyor she didn't feel it was necessary at that point because she didn't think there was a diversion. DON-B stated my unit manager (LPN/UM-Q) is a little jagged from where she worked before when it was happening. I told her she was being overly paranoid. Surveyor asked DON-B if there is anything else she'd like to tell Surveyor. DON-B replied no. On 3/20/24 at 1:13 p.m. Surveyor asked NHA (Nursing Home Administrator)-A if she was aware of why Resident's liquid morphine being switched to pill form. NHA-A informed Surveyor they were switching due to concerns of the amounts identified. Surveyor asked NHA-A if she was informed liquid in a Resident's morphine bottle may not have been morphine. NHA-A replied no. Surveyor asked if she had been made aware of this would an investigation been initiated. NHA-A replied I would look into it. Surveyor asked NHA-A who makes the decision if there is going to be an investigation. NHA-A informed Surveyor generally it would go to [name of] DON-B and then she would bring it to her. NHA-A informed Surveyor there was a concern of liquid morphine checks on the narcotics log and they decided to get rid of the liquid morphine. Surveyor inquired if there was any investigation. NHA-A replied no. On 3/20/24 at 1:26 p.m. Surveyor asked DON-B if LPN/UM-Q informed her of the Resident's name who she thought liquid morphine had been removed and replaced with something else. DON-B replied no. Surveyor asked DON-B if she asked LPN/UM-Q the Resident's name. DON-B replied I don't remember to be honest. DON-B informed Surveyor she thinks it was a Resident on the 400 hall. Surveyor asked why she thought this. DON-B that's where most of the hospice residents were.

Based on interview and record review the Facility did not report 2 of 2 incidents to the State Survey Agency and/or Nursing Home Administrator. * A possible diversion of liquid morphine was not reported to the Nursing Home Administrator and State Agency. * R25's ankle fracture was not reported to the State Agency as an injury of unknown origin. Findings include: The Abuse, Neglect and Exploitation policy last reviewed/revised 9/22/23 documents alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Under VII Reporting/Response documents: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1.) On 3/18/24 at 2:06 p.m. Surveyor asked LPN (Licensed Practical Nurse)-K if she was aware of any morphine or other narcotics missing. LPN-K informed Surveyor she heard about it but didn't know any details. LPN-K informed Surveyor because of the potential narcotics missing they changed the way they log all received narcotics. LPN-K explained when medication comes in they have to sign for the card and when the card is finished or the resident is discharged on the log two people have to sign. On 3/18/24 at 3:52 p.m. Surveyor asked LPN-M if she was aware of Resident's morphine being missing. LPN-M informed Surveyor she heard about it in report. Surveyor inquired when this was. LPN-M informed Surveyor about four months ago roughly but she's bad with time. LPN-M informed Surveyor they went from liquid to tablet form of morphine. Surveyor asked if LPN-M knew the name of the Resident who was missing their morphine. LPN-M informed Surveyor it was mostly hospice patients. On 3/18/24 at 2:32 p.m. during the end of the day meeting NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B, Surveyor asked DON-B if there are any concerns regarding missing narcotics. DON-B informed Surveyor they don't have any concerns regarding missing narcotics and thought the nurses were lackadaisical in counting. Surveyor asked DON-B why she thought this. DON-B informed Surveyor there were not a lot of signatures on the shift to shift but things were matching up. DON-B informed Surveyor they changed their system on how they track narcotics in and out. DON-B explained it is not by Resident's name each card gets a number. DON-B informed Surveyor if a resident is discharged or the medication is used up it has to be signed by two nurses. DON-B stated we had rumors, there was agency in the building there were random rumors. Easy to divert that's why we worked on a plan. DON-B stated there was no missing narcotics. On 3/19/24 at 9:47 a.m. Surveyor asked LPN-N if she was aware of any Residents missing their morphine. LPN-N informed Surveyor she heard rumbling of something but doesn't know specific details. Surveyor asked LPN-N if she remembered anything. LPN-N informed Surveyor something with morphine, there was juice in the bottle instead of morphine then they switched the liquid morphine to a pill form. Surveyor asked LPN-N when this was. LPN-N replied honestly don't know, within the last year. LPN-N informed Surveyor there was a resident who's morphine was ineffective, the nurse found out it was juice not morphine and the liquid morphine was switched immediately to pill form for all residents. LPN-N was unable to provide Surveyor with the name of the Resident. On 3/19/24 at 2:41 p.m. Surveyor asked LPN-J if she was aware of any Resident's morphine or narcotics missing. LPN-J informed Surveyor they used to have liquid morphine. Her manager told her something was wrong with it and they started using pills. Surveyor asked who the manager is. LPN-J informed Surveyor name of LPN/UM (Licensed Practical Nurse/Unit Manager)-Q but she doesn't think she is here today. On 3/19/24 at 2:46 p.m. Surveyor asked LPN-R if she heard of Resident's morphine being missing. LPN-R replied I have. LPN-R explained there was an issue with morphine liquid and then converted everything to tablets. Surveyor asked LPN-R what the issue was. LPN-R explained there was a Resident down the 300 unit that they couldn't get their pain symptoms under control. The unit manager said enough of this, she popped off the morphine top and said it smelled like mouthwash. The Manager then got a sealed morphine out of the contingency machine on south. Surveyor asked who the Resident was on the 300 unit. LPN-R informed Surveyor she doesn't know the name as she doesn't take care of residents on 300. Surveyor asked who the manager was. LPN-R stated the first name of LPN/UM-Q. LPN-R informed Surveyor they also changed the system of how they count narcotics. On 3/19/24 at 4:04 p.m. Surveyor spoke with Pharmacist-S on the telephone and asked if he was able to tell Surveyor in the last six months has there been any liquid morphine removed from the contingency machine at [Name of] Facility and when the Facility switched from liquid morphine to tablets. Pharmacist-S informed Surveyor, Surveyor probably needs to speak with FM (Facility Manager)-T. At 4:07 p.m. Surveyor spoke with FM-T on the telephone. Surveyor asked FM-T when [Name of] Facility switched from liquid morphine to tablets and if they have any records of when liquid morphine was removed from contingency. FM-T informed Surveyor they switched to tablets in the beginning of October and had discussions of doing this with the DON. Surveyor asked FM-T if he knew why the Facility switched from liquid to tablets. FM-T informed Surveyor he would have to go back and do more research but would get back to Surveyor. On 3/19/24 at 5:20 p.m. FM-T left Surveyor a voice message asking Surveyor to return his call. On 3/19/24 at 5:49 p.m. Surveyor telephoned FM-T back and left a message requesting a return call. On 3/20/24 at 9:32 a.m. Surveyor telephoned FM-T and left a message requesting a return call. FM-T did not return Surveyor's call. On 3/20/24 at 8:21 a.m. Surveyor asked LPN-U if she knew why the Facility changed from liquid morphine to tablets. LPN-U replied I'll have to get back to you on that one. LPN-U went into an office, returned and informed Surveyor they all did an in-service and it was visually hard to read the bottles. Surveyor asked LPN-U if she was aware of a Resident's morphine not being in the bottle. LPN-U replied no and informed Surveyor she just knows there was a situation with the count doesn't know officially as it was on the other side of the building. LPN-U informed Surveyor she just knows the count was off. On 3/20/24 at 12:50 p.m. Surveyor asked DON-B why liquid morphine was switched to tablets. DON-B replied I already told you because of the counting issues and the spilling issues. Morphine comes with an eye dropper. Consistently the bottle leaks. DON-B informed Surveyor before they switched to tablets the pharmacy provided them with stoppers so the nurses were not just pulling from the bottles but they were spilling into the carts. DON-B informed Surveyor the bottles were hard to read and it's not a guessing game when it comes to narcotics for end of life. DON-B informed Surveyor the official change was 10/13/23. DON-B stated to Surveyor she knew Surveyor was going to come back to her and 10/16/23 was when they started in-servicing. DON-B showed Surveyor the new log with card number, resident name, medication name, date received, date removed, reason and signatures. Surveyor then informed DON-B what Surveyor was being told by nursing staff of a Resident's pain not being managed and the Resident was on liquid morphine. LPN/UM-Q checked the morphine and there wasn't morphine in the bottle. Surveyor was told by one nurse it was juice and by another nurse it was mouthwash. LPN/UM-Q went to contingency for a new bottle of liquid morphine and after morphine from the new bottle was given to this resident, the resident's pain was being managed. Surveyor informed DON-B Surveyor was unable to interview LPN/UM-Q as she is on vacation out of the state. DON-B informed Surveyor there was that rumor going around and heard that too but didn't witness it herself. Surveyor asked DON-B if she spoke with LPN/UM-Q when she thought there was something else other than morphine in the morphine bottle. DON-B informed Surveyor there was no way to confirm whether it was or wasn't. Surveyor asked DON-B if she did an investigation into the possible misappropriation of resident property/drug diversion. DON-B replied no I did not. Surveyor asked DON-B why she didn't do an investigation. DON-B replied I was in the process of changing the way narcotics were being handled before this happened. I was already working on it. DON-B explained she ordered a control substance log book. Surveyor informed DON-B Surveyor doesn't understand why she wouldn't have investigated this. DON-B informed Surveyor she didn't feel it was necessary at that point because she didn't think there was a diversion. DON-B stated my unit manager (LPN/UM-Q) is a little jagged from where she worked before when it was happening. I told her she was being overly paranoid. Surveyor asked DON-B if there is anything else she'd like to tell Surveyor. DON-B replied no. On 3/20/24 at 1:13 p.m. Surveyor asked NHA (Nursing Home Administrator)-A if she was aware of why Resident's liquid morphine being switched to pill form. NHA-A informed Surveyor they were switching due to concerns of the amounts identified. Surveyor asked NHA-A if she was informed liquid in a Resident's morphine bottle may not have been morphine. NHA-A replied no. Surveyor asked if she had been made aware of this would an investigation been initiated. NHA-A replied I would look into it. Surveyor asked NHA-A who makes the decision if there is going to be an investigation. NHA-A informed Surveyor generally it would go to [name of] DON-B and then she would bring it to her. NHA-A informed Surveyor there was a concern of liquid morphine checks on the narcotics log and they decided to get rid of the liquid morphine. Surveyor inquired if there was any investigation. NHA-A replied no. On 3/20/24 at 1:26 p.m. Surveyor asked DON-B if LPN/UM-Q informed her of the Resident's name who she thought liquid morphine had been removed and replaced with something else. DON-B replied no. Surveyor asked DON-B if she asked LPN/UM-Q the Resident's name. DON-B replied I don't remember to be honest. DON-B informed Surveyor she thinks it was a Resident on the 400 hall. Surveyor asked why she thought this. DON-B that's where most of the hospice residents were. DON-B did not report the possible misappropriation of resident property/medication diversion to NHA-A. This allegation not report this to the State agency. 38253 2.) R25 was admitted to the facility on [DATE] with diagnoses of a fractured patella, coronary artery disease, muscular dystrophy, anxiety, depression, and dementia. R25's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R25 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 11 and was assessed as being dependent on staff for toileting with moderate to substantial assist with other activities of daily living. R25 had a knee immobilizer to the left leg due to the left patella fracture and had a transfer status of Hoyer lift. R25 had an activated Power of Attorney (POA). R25's hospital Discharge Summary dated 11/6/2023 documented R25 presented to the emergency roiagnom on [DATE] with complaints of left knee pain but did not recall falling. The hospital spoke to R25's POA via phone who informed them R25 had a colonoscopy the day before and was more weak than usual, fell twice, and had left knee pain. R25 ambulated with a walker. The x-ray report from 10/31/2023 impression stated increased swelling/thickening of the patellar tendon suspicious for injury with avulsion fracture of the inferior patella. The ankle appeared normally aligned on nondedicated imaging with degenerative changes in the partially imaged foot; minimal spurring at the plantar and posterior calcaneus. On 12/5/2023 at 1:17 PM, in the progress notes, Nurse Practitioner (NP)-F charted R25 was seen on 12/4/2023 and R25 denied pain. The extremity exam indicated a left knee immobilizer was in place and there was no edema, clubbing, or cyanosis. On 12/9/2023 at 6:41 AM, in the progress notes, Licensed Practical Nurse (LPN)-E charted R25 was found sitting on the edge of the bed and had the call light pulled out of the wall. R25 stated they were looking for the remote for the TV. LPN-E charted R25 was assisted back into bed and explained that the TV was off. The bed was placed in low position. On 12/10/2023 at 7:17 PM, in the progress notes, the physician charted R25 was seen on 12/8/2023 and R25 denied pain. The extremity exam indicated a left knee immobilizer was in place and there was no edema, clubbing, or cyanosis. On 12/21/2023 at 6:30 AM, in the progress notes, NP-F charted R25 was seen on 12/21/2023 and R25 denied pain. The extremity exam indicated a left knee immobilizer was in place and there was no edema, clubbing, or cyanosis. On 12/26/2023 at 6:00 AM, in the progress notes, NP-F charted R25 was seen on 12/26/2023 and R25 denied pain. The extremity exam indicated a left knee immobilizer was in place and there was no edema, clubbing, or cyanosis. On 1/2/2024 at 1:03 PM, in the progress notes, LPN-E charted R25 was noted to have increased edema to bilateral extremities with 1-2 plus pitting edema. R25 did not have any complaints of shortness of breath or difficulty breathing. A recent weight was obtained and R25 had a ten-pound weight gain. The NP was notified, and new orders were obtained for tubigrips to bilateral lower extremities and labs to be drawn in the morning. On 1/3/2024 at 11:30 AM in the progress notes, LPN-E charted edema continued to R25's bilateral lower extremities with 1-2 plus pitting edema. Tubigrips were on, lung sounds were clear, and R25 did not have any complaints of shortness of breath or difficulty breathing. R25 complained of pain to the left ankle when moved or touched. R25 was given acetaminophen and the NP was notified. New orders were obtained to ice ankle as needed and to get an x-ray of the left ankle. Acetaminophen was scheduled. R25's POA was contacted, and a message was left to call back for the change in condition. On 1/3/2024, R25 was seen by NP-F and documented NP-F had been alerted the day before of R25 complaining of left ankle pain increased with movement. R25 had not had any falls in the last 30 days. R25 had been non-weight bearing to the left lower extremity since hospitalization due to patellar deformities. (Surveyor noted R25 had been weight bearing as tolerated.) R25 had been wearing an immobilizer. R25 is forgetful of current weightbearing status and has attempted to self-transfer in the past. R25 reported pain 8/10 with movement, 3/10 at rest. Swelling was noted to the left ankle. An x-ray was ordered due to significantly limited range of motion. NP-F documented R25 had a possible ankle fracture from fall prior to hospitalization with new onset of pain related to improved edema and resolved pain in the knee. (Surveyor noted previous documentation by NP-F indicated there was no swelling or edema to R25's lower extremities and nursing charted edema on 1/2/2024.) On 1/4/2024 at 2:25 AM, in the progress notes, nursing charted the x-ray results came back indicating a fracture to the left fibula shaft at level of syndesmosis with no displacement. The NP was notified, and orders were obtained to splint the left ankle, non-weight bearing to left lower extremity, and schedule an appointment with ortho. Surveyor reviewed Facility Reported Incidents that had been submitted to the State Agency. No report was found for R25's left ankle fracture as an injury of unknown origin. On 3/19/2024 at 2:02 PM, Surveyor requested from Nursing Home Administrator (NHA)-A any information regarding R25's fractured left ankle. On 3/20/2024 at 8:54 AM, NHA-A provided an investigation into R25's left ankle fracture. Staff statements were obtained on 1/4/2024, the day after the x-ray confirmed a fracture. No report was filed with the State Agency. In an interview on 3/20/2024 at 9:52 AM, Surveyor asked Social Worker (SW)-G what the facility process was when a resident was found with an injury of unknown origin. SW-G stated Director of Nursing (DON)-B will follow up with the incident to determine what is reportable and what is not reportable. Surveyor asked SW-G if NHA-A is involved in the reporting process. SW-G was not sure if NHA-A was involved in determining what is reported to the State Agency, but thought NHA-A would have some say in the process. In an interview on 3/20/2024 at 10:11 AM, Surveyor asked NHA-A why R25's fractured ankle was not reported to the State Agency. NHA-A stated they thought the fracture was due to the original fall and NP-F was very involved in determining the cause. NHA-A stated nursing would know better than NHA-A about the circumstances of the fracture. In an interview on 3/20/2024 at 10:23 AM, Surveyor met with NP-F and NHA-A. Surveyor asked NP-F how it was determined what caused R25's fractured ankle. NP-F stated documentation was reviewed and R25 had not had any recent falls, had an immobilizer on the left leg, and R25 complained of left ankle pain. NP-F stated NP-F assessed R25 and ordered an x-ray at that time. Surveyor shared with NP-F and NHA-A R25 did not have any swelling to the ankle prior to 1/2/2024 and the original fall occurred two months prior to the discovery of the left ankle fracture. NP-F stated R25 had immense pain to the left knee with swelling and when that subsided, the ankle injury could have been more pronounced. NP-F stated with R25's cognition, R25 did not always remember R25 was not supposed to bear weight to the left leg. NP-F stated R25 was frail and geriatric so cannot say if the ankle fracture would have healed within the two months since the fall. Surveyor shared with NHA-A the concern R25's ankle fracture was not reported to the State Agency as an injury of unknown origin. NHA-A agreed the incident should have been reported. No further information was provided at that time.

Based on observations, record review and staff interviews, the facility did not always ensure that 3 out of 4 residents ( R37, R2, R360) reviewed for pressure ulcers received the necessary care and treatment to promote healing of existing pressure ulcers and to avoid the development of new pressure ulcers. R37 developed a Stage #3 pressure ulcer to his middle finger of the right hand. R37's range of motion to the right hand had deteriorated and a contracture developed. R37 was not provided with pressure relief for the contracture to the right hand and developed the stage #3 pressure ulcer. R2 had a history of resolved pressure ulcers to the right ankle and left buttocks. On [DATE] R2 developed a new pressure ulcer to the right buttocks (stage 2) and an order was given to obtain an alternating air mattress to provide additional pressure relief. The facility acknowledged that R2 should have had this type of mattress on his bed prior to the development of the new pressure ulcer to the right buttock and also that the mattress was ordered [DATE] and was not placed on the bed until [DATE]. R360 was admitted on [DATE] with a left heel pressure injury which was not comprehensively assessed on admission. In addition, R360 was admitted with a general skin issue of buttocks red and blanchable which was not assessed on admission on [DATE]. The first skin and wound evaluation of these areas was on [DATE] where the facility identified the left heel as a stage 3 and incorrectly identified the buttock as a stage 2. A review of the treatment administration record (TMAR) noted that the medi-honey treatment ordered on [DATE] for the left heel was not been signed out as administered from [DATE] through [DATE] (7 days). Findings include: Policy review: Wound Care, revised October, 2010 Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Documentation: The following information should be recorded in the resident's medical record: (includes) 1. Type of wound care given 6. All assessment data (i.e., wound bed color, size, drainage, etc.) 8. Any problems or complaints made by the resident related to the procedure. 1. R37 was admitted to the facility on [DATE] with diagnoses that include Malignant Neoplasm of Colon, Unspecified; Nondisplaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Right Humerus Fracture, Encounter for Palliative Care, Other Unspecified Arthritis, Unspecified Shoulder; and Polyneuropathy, Unspecified. R37 was admitted with the supportive services of hospice care and remained on hospice care through the survey exit date of [DATE]. R37's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated R37 is at risk of developing pressure injuries; there are no pressure injuries documented during the assessment reference period. The MDS documented R37 did not have a functional limitation of range of motion impairment on one side (upper and lower extremities) of R37's body; R37 required the total assistance of two (2) staff for showering/bathing, one (1) staff assistance in the form of supervision, cueing, or encouragement, for eating; and one (1) staff extensive assistance for personal hygiene, dressing, and oral care tasks. R37 has an indwelling catheter and is always incontinent of bowel. R37's Quarterly MDS assessment, dated [DATE], indicated R37 Brief Interview for Mental Status (BIMS) score is 7, indicating R37's cognition is severely impaired. R37 is at risk of developing pressure injuries, and R37 has an unhealed Stage 3 pressure injury at time of assessment. The MDS indicates R37's has a pressure relieving device for chair, pressure relieving device for bed, turning/repositioning program, pressure injury care, application of non-surgical dressing and ointment treatment applied, other than feet. R37 has a functional limitation of range of motion impairment on one side (upper extremity) of R37's body. R37 requires total assistance of two (2) staff for showering/bathing, one (1) staff assistance in the form of supervision, cueing, or encouragement, for eating; and one (1) staff extensive assistance for personal hygiene, dressing, and oral care tasks. R37 has an indwelling catheter and is always incontinent of bowel. R37's Care Plan, dated [DATE], documents [R37] has an Activities of Daily Living (ADL) self-care performance deficit. Interventions include: -[R37] is totally dependent on two (2) staff assistance due to total dependence on staff for showering/bathing, date initiated: [DATE] -[R37] requires the extensive assistance by one (1) staff to eat, date initiated: [DATE]. On [DATE], this intervention was revised to include: EATS IN CARE GROUP TWO. -[R37] is totally dependent on two (2) staff for dressing, date initiated: [DATE]. -[R37 is totally dependent on one (1) staff total dependence with personal hygiene and oral care, date initiated: [DATE]. R37's Care Plan, dated [DATE], documents R37 has limited physical mobility, with a goal to remain free of complications related to immobility, including contractures . Interventions include: -[R37] does not walk, date initiated: [DATE] -[R37] is totally dependent on one (1) staff for locomotion, date initiated: [DATE] -[R37] has NO WEIGHT BEARING RESTRICTIONS; date initiated: [DATE]. R37's Care plan, date initiated [DATE], documents [R37] has the potential/actual impairment to skin integrity. Interventions include: -Elevate heels off the bed, date initiated: [DATE] -Encourage good nutrition and hydration in order to promote healthier skin, date initiated: [DATE]. -Monitor plan and administer pain medications/treatments as ordered and/or per pain problem, date initiated: [DATE]. -[R37] needs pressure relieving/reducing cushion to protect the skin while up in chair, date initiated: [DATE]. -[R37] needs pressure relieving/reducing cushion to protect the skin while in bed, date initiated: [DATE]. The facility completed a Quarterly Braden skin assessment on [DATE]. The score was 14, indicating R37 is a moderate risk for developing a pressure injury Surveyor reviewed R37's medical record and notes the following: On [DATE], Hospice Client Coordination Note Report documents [R37] voiced concern over the contraction of R37's left (sic) right hand and nails digging into R37's hand. Hospice will supply R37 with a palm guard. On [DATE], Hospice Recert Summary Report documents [R37's] right hand is severely contracted, and R37 can no longer open hand. On [DATE], Health Status Note documents [R37] noted to have redness to tip of right middle finger with swelling and puss like drainage to nailbed. R37 received an order for Doxycycline Monohydrate mg PO (by mouth) BID (twice daily) x 7days, Iodine to nailbed and tip of right middle finger BID. On [DATE], Health Status Note documents [R37] continues ABT (antibiotic)/Cellulitis to Right Middle Finger, Doxycycline 100mg BID x7 Days, and tolerating with no adverse reactions noted. Affected area contracted, reddened, edematous, painful to touch. Tx (treatment) ordered to affected area daily and (Licensed Practical Nurse M) unable to complete (treatment) d/t (due to) contracture and pain (at) this time. Surveyor noted there is no documentation R37's physician was consulted when the treatment to R37's right middle finger could not be completed as ordered. On [DATE], Skin and Wound Evaluation documents [R37] is a new patient and has a left (sic) middle finger with Stage 3 pressure injury due to contracture. New treatment documented: Gentamicin then Alginate, change daily. Place washcloth in palm to prevent further pressure. Wound measurements include: Length: 0.30 cm (centimeters) Width: 0.59 cm On [DATE], the Physician Orders Note documents [R37] was prescribed Cyclobenzaprine HCL Tablet 10 MG every morning for contracture management, and as needed (PRN) every 12 hours for contracture care. Surveyor notes R37 was prescribed Cyclobenzaprine (a muscle relaxant) six (6) days after staff was unable to complete the treatment to R37's right contracted hand due to pain, and this is the same day R37 was identified as having a Stage 3 pressure injury to the middle finger of the contracted hand. On [DATE], Health Status Note documents [R37] required premedication with morphine prior to wound treatment due to R37 having increased pain even prior to wound treatment. R37 had pain, but appeared to tolerate treatment better. On [DATE], Health Status Note documents a rolled washcloth was applied (to R37's right hand). Surveyor notes this is the first documentation of this intervention being implemented although it is listed on Skin and Wound Evaluation form dated [DATE]. This intervention is not documented on R37's care plan. On [DATE], Skin and Wound Evaluation documents. Wound measurements include: Length: 0.19 cm Width: 0.20 cm On [DATE], the Physician's Orders Note documents: Wash right hand and middle finger with Dakin's 0.25% f/b (followed by) Anasept to tip of middle finger and nail bed f/b calcium alginate and rolled wash cloth or carrot every day shift for wound care. On [DATE], Health Status Note documents [R37's] affected area (right hand) is contracted and painful to touch. R37 continues on Cyclobenzaprine 10mg Q (every) AM for contractures with minor improvement noted. Pain managed with scheduled Tramadol & (and) APAP (Acetaminophen), and PRN (as needed) Morphine with dressing changes. On [DATE], Hospice Visit Note Report documents [R37] experienced pain when R37's hand was opened to add a barrier to (right) palm. On [DATE], Nutrition/Dietary Note documents [R37] triggered for a wound on (R37's) finger, new. (R37) remains on hospice, with variable intakes from ,d+[DATE]%. Diet Rx (prescription): regular. Weights have fluctuated substantially. Trial house supplement 120 ml BID (twice daily) for wound healing and overall nutrition support, comfort care. Will f/u (follow up) prn (as needed). On [DATE], Skin and Wound Evaluation documents: Wound measurements include: Length: 0.93 cm Width: 0.72 cm Treatment Administration Record documents: Wash right hand and middle finger with Dakin's 0.25% f/b calcium alginate and rolled wash cloth or carrot every day shift for wound care. Start Date: [DATE] On [DATE], Skin and Wound Evaluation documents [R37's] carrot is to be placed (in right hand) to help reduce pressure. (R37) often throws (carrot); will continue to place and to use Alginate to help decease moisture. Wound measurements include: Length: 0.51 cm Width: 0.68 cm On [DATE], Skin and Wound Evaluation documents [R37's] pressure ulcer is essentially closed and staff to continue Alginate and carrot to assist with moisture control and reduce pressure. Wound team will monitor x3 weeks as follow up; continue contracture management and treat as ordered. Wound measurements include: Length: 0.68 cm Width: 1.07 cm Surveyor reviewed the Weekly Skin Shower Observation forms for R37 from [DATE]-[DATE] ([DATE] was not received). Surveyor notes the following: On [DATE], R37's Weekly Skin Shower Observation form indicates R37's skin is intact, free from alterations/impairments. On [DATE], R37's Weekly Skin Shower Observation form indicates R37's skin has alteration(s), list all areas observed. Surveyor notes there are no areas documented. On [DATE], R37's Weekly Skin Shower Observation form indicates R37's skin has alteration(s), list all areas observed. Surveyor notes there are no areas documented. On [DATE], R37's Weekly Skin Shower Observation form indicates R37's skin has alteration(s), list all areas observed. Surveyor notes there are no areas documented. On [DATE], R37's Weekly Skin Shower Observation form indicates R37's skin has alteration(s), list all areas observed. Surveyor notes there are no areas documented. On [DATE], R37's Weekly Skin Shower Observation form indicates R37's skin has alteration(s), list all areas observed. Surveyor notes there are no areas documented. Surveyor notes there are no identified areas documented (right hand contracture and right middle finger pressure ulcer) on reviewed Weekly Skin Shower Observation forms. On [DATE], at 09:50 AM, Surveyor observed Licensed Practical Nurse (LPN) J perform a wound treatment to R37's right middle finger. Surveyor observed R37's right hand was contracted and there was no dressing, nor carrot, in R37's right hand. LPN J verbalized (R37) usually takes it off throughout the day. LPN J verbalized R37's right hand looks tight today. LPN J had difficulty opening R37's right hand, and required one (1) person staff assistance to open R37's right hand minimally to get to wound area in order to perform ordered wound treatment. LPN J verbalized having more difficulty opening R37's hand and placing the carrot to reduce pressure. On [DATE], at 10:00 AM, Surveyor interviewed Licensed Practical (LPN) J, who stated R37's carrot is to always remain in R37's right hand. LPN J verbalized R37 pulls out the carrot frequently. On [DATE], at 1:02 PM, Surveyor interviewed Director of Rehabilitation Services N, who indicated the rehabilitation department has never provided services to R37. Director of Rehabilitation Services N verbalized the rehabilitation department provided the carrot for R37 after finding out the carrot hospice ordered is on backorder. Director of Rehabilitation Services is unaware of date when carrot was provided to R37. On [DATE], at 1:45 PM, Surveyor interviewed Certified Nursing Assistant (CNA) O, who verbalized any special instructions for resident personal cares are written on care cards located in each resident bathroom, or in an electronic record. CNA O showed Surveyor the care card for R37; Surveyor noted no instructions were listed in regard to R37 receiving Range of Motion (ROM) exercises, nor identification or use of any appropriate devices (palm guard, washcloth, carrot) for contracture and wound management in order to relieve pressure. CNA O stated R37 had nothing in R37's right hand this morning when CNA O arrived to perform morning personal cares. CNA O saw the carrot and verbalized not knowing what to do with it. CNA O did not place carrot in R37's hand, but believes the rehabilitation department assisted in placing R37's carrot in right palm today. On [DATE], at 09:57 AM, Surveyor interviewed Registered Nurse (RN) Manager P, who verbalized on [DATE], [R37] had been participating in a Life Enrichment activity (manicure) with R37's daughter. RN Manager P stated R37's daughter brought R37 back to the unit and was concerned as R37's finger was red. RN Manager P verbalized there was nothing (palm guard) in R37's hand at the time, and RN Manager P opened up (R37's right hand) by pulling (R37's) finger back the best I could. It was hard, but I did the best I could. I saw definitely an infection around the nailbed. RN P verbalized for contractures; it is RN Manager P's understanding to routinely monitor the contracture. RN Manager P verbalized treatments (on R37's right middle finger) can be difficult because it is so tight and (R37) winces. On [DATE], at 10:08 AM, Surveyor interviewed Licensed Practical Nurse (LPN) M, who stated it is an expectation that nurses will perform full body checks for each resident upon admission, and at every weekly shower day. During weekly shower body checks, nurses look for skin breakdown, rashes, including anything out of the norm for each resident. LPN M verbalized it is the expectation that contractures and anything related to feet, hands, and skin are observed; all wounds are documented as such. Nurses record findings on a Weekly Skin Shower Observation form. LPN M verbalized R37 is premedicated before R37's daily wound treatment to alleviate the pain associated with opening up R37's hand, verbalizing R37 receives morphine before the treatment. LPN M made a fist with LPN M's hand to demonstrate R37's contracture. LPN M flexed fingers and touched the palm of LPN M's hand, he goes like this and (R37's) fingers dig in. LPN M verbalized R37's contracture is severe, and it is a constant battle keeping (R37's) palm guard in place. LPN M verbalized R37's contracture is a very tight contracture so lots of pressure in there (LPN M pointed to palm area of own hand). On [DATE], at 10:20 AM, Surveyor entered R37's bedroom with Licensed Practical Nurse (LPN) M. Surveyor observed R37 sitting in R37's Broda chair with eyes closed. LPN M touched R37's right hand. Surveyor observed R37's mouth open, and R37 scrunched R37's eyes together. LPN M verbalized R37 makes that face when R37 is in pain. Surveyor noted carrot was in place in R37's right hand. On [DATE], at 11:49 AM, Surveyor interviewed Director of Nursing (DON) B. When Surveyor asked how R37 developed a contracture, DON B replied, I don't have an answer for that. A hospice aide was coming in ,d+[DATE] times per week. I assumed they were providing routine CNA care to do Range of Motion. DON B verbalized finding out about R37's pressure injury from a note left by Registered Nurse (RN) Manager P. DON B verbalized due to being on hospice care, R37 wouldn't normally be seen by wound care team, but as the wound was in a trickier spot, DON B included R37 on facility wound care rounds. DON B verbalized as R37 was on antibiotics for Cellulitis since [DATE], R37 wouldn't have been seen by wound team right away. R37 was seen seven (7) days later, on [DATE]. DON B verbalized R37 will be receiving restorative services (Passive Range of Motion (PROM) and carrot program), beginning [DATE]. DON B verbalized no interventions were implemented for R37 for contracture before the washcloth and carrot placement. DON B verbalized the carrot was first used as an intervention for R37 on [DATE]. On [DATE], at 3:05 PM, Surveyor informed Nursing Home Administrator (NHA) A of the concern with R37 not being provided with pressure relief due to right hand deterioration and subsequent contracture, resulting in a Stage 3 pressure injury to R37's right middle finger. 2. Resident #2 was originally admitted to the facility on [DATE] with diagnosis that included Vascular Dementia, Type 2 Diabetes, Major Depressive Disorder and Hypertension. R2 was started on hospice care on [DATE] and remained under hospice care through the survey exit date on [DATE]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicates that R2 is severely cognitively impaired and needs total and extensive 2-person physical assistance with activities of daily living. R2 is noted to always be incontinent of bladder and frequently incontinent of bowel. R2 has experienced weight loss that is not physician prescribed and is at risk for pressure ulcer development. The MDS indicates that during the assessment reference period, R2 does not currently have any unhealed pressure ulcers. It is noted there is a pressure reducing device for the bed and chair. The facility completed a quarterly Braden skin assessment on [DATE]. The score was 11, indicating R2 is at high risk for developing a pressure ulcer. A review of R2's individual plan of care states that R2 has potential for the skin impairment due to fragile skin. Revised [DATE]. Interventions included: o Heel lift boots on when in bed- often refuses but continue to try o The resident needs pressure relieving/reducing cushion to protect the skin while up IN CHAIR. o The resident needs pressure relieving/reducing mattress to protect the skin while IN BED. R2's plan of care also indicated that R2 has pressure ulcer left buttocks and history of small sacral PI (Pressure injury) r/t Immobility, refusals to reposition on sides; Date Initiated: [DATE] Revision on: [DATE]. Interventions include: o Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: [DATE] o If the resident refuses treatment, confer with the resident, IDT (Interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: [DATE] o Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated: [DATE] o Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Date Initiated: [DATE] o Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Date Initiated: [DATE] o Wound MD consult as indicated Date Initiated: [DATE] Nutrition progress note dated [DATE]; R2 triggers for a wound, though it is now essentially closed. Diet Rx: consistent CHO. Supplement RX: 120 ml 1x/d House supplement. PO ranges from ,d+[DATE]%. R2 remains on hospice. Will f/u prn. Surveyor conducted further review of R2's medical record and noted that R2 had a previously healed area to the left buttock. The pressure ulcer was noted to be first observed on [DATE], stage #3 and healed [DATE]. During treatment of this area, an air pump mattress was in use. R2 has also had previous pressure ulcer to the right outer ankle. Skin and wound evaluation, dated [DATE]; pressure ulcer stage #2 - 1 day old, location right buttocks area 0.65 cm, length 1.92 cm, width 0.52 cm. Notes- new PI (pressure injury) noted, resident (R2) no longer has air mattress- hospice updated to get a new one due to PI development; area is clean NOR (New Order Received) for skin prep and barrier cream 3 x week, hospice re-ordering mattress. Physician order dated [DATE]: MONITOR PRESSURE INJURY FOR S/SX OF INFECTION, OR WORSENING OF WOUND. NOTIFY MD IF S/SX OF INFECTION ARE OBSERVED OR WOUND HAS WORSENED every shift for monitor skin integrity Physician order dated [DATE]: SWW (soap, water, to right buttock PI f/b skin prep and small foam dressing every day shift every Tue, Thu, Sat for wound care. Surveyor made an observation of R2 on [DATE] at 10:23am. R2 was lying in bed on his back. HOB (head of bed) elevated. Side rail up with call light. Has regular mattress. Has a new mattress, wrapped in plastic wrap, in entry of room and placed on side of wall. Skin and wound evaluation dated [DATE]; pressure ulcer stage #2 right buttock status 8 days old. Acquired in - house. Area: 0.68 cm, length 1.68 cm, width 0.62 cm. Notes: area has improved and is more consistent with MASD (moisture associated skin damage) as opposed to pressure injury. Will discontinue foam now that air mattress in place. Barrier cream each shift and offload if R2 allows. [DATE] at 03:30 PM, Surveyor conducted an interview with DON- B regarding R2's development of the Stage #2 pressure ulcer to right buttock. DON- B stated she doesn't understand why hospice took away the air mattress and they were trying to get it back in place. DON- B stated new mattress got delivered yesterday ([DATE]) and was placed on bed yesterday. DON- B was not able to provide additional information as to why it was recommended that R2 have the air mattress in place on [DATE] and it was not until [DATE] that the mattress was in place on R2's bed. On [DATE], DON- B provided Surveyor with a copy of an invoice showing that on [DATE], the medical equipment company had come to the facility to take back an alternating pressure mattress. It was noted this was the date that R2 started on hospice. DON- B stated that he had the air mattress recently, but Hospice again discontinued it. On [DATE] 03:38 PM observation was made with Administrator- A that the air mattress is in place on bed for R2. As of the time of exit on [DATE], the facility was not able to provide additional information as to why R2 was not provided with an alternating air- mattress, as per the plan of care, to assist in the prevention of developing a pressure ulcer to the right buttocks. 3. R360 was admitted to the facility on [DATE] with diagnosis that included Hypertension, Cerebral Infraction, Epilepsy, Aphasia, Hemiplegia and Hemiparesis, moderate protein- calorie malnutrition and Dehydration. An Admission Evaluation dated [DATE] reflects in Section J: Skin: Are there any skin issues present- yes. General skin issues: buttocks red and blanchable. Is there a pressure injury- left heel pressure (no further description given such as size and stage). Care Plan: skin- educate resident/ family of causative factors and measures to prevent skin injury. Elevate heels off bed. Pressure relieving/ reducing cushion for chair and bed to protect skin. A physician order, written [DATE] documents: Heel Boots to be worn when in bed every shift. A physician order was written on [DATE] for the left heel to be cleansed with NSW and then to apply medi- honey to open areas every day shift every Tuesday, Thursday, Saturday for wound care. Medicare Charting dated [DATE]; New Admit [DATE] with PMH: Recurrent CVA, Seizure Disorder, Afib s/p PPM, HTN, Dyslipidemia, Expressive Aphasia, R-Sided Weakness. AAOx,d+[DATE], pleasant & cooperative @ times, expressive aphasia with picture board or white board, and hand gestures. Res Total Dependent for Transfer x2 assist via Hoyer Lift, and Extensive Assist x1 for ADLs. Res NPO (nothing by mouth) with continuous tube feed 60 ML for 1300 cc, w/ 45 ml water flushed Q 1 hr and tolerating, G-tube intact & patent, placement confirmed, No residual this AM & 10mL @ Noon. Skin PWD with Pressure Ulcer to Left Heel, Tx completed this AM as ordered with dressing c/d/i, off-loading boots in bed. BLEs with no edema noted. VSS. Non-verbal indicators of pain/discomfort upon movement only, managed with scheduled & PRN APAP @ this time. Participates in PT/OT/ST as ordered. R360 refused to get out of bed this AM and refused PT/OT. R360 accepted PT/OT later upon second approach. Continue to monitor accordingly. Medicare Charting dated [DATE] left heel - wound care. (No mention of Right buttock). Nursing note dated [DATE] at 03:11 a.m., F/U admit, Alert easily aroused, difficult with speech uses communication board. has continuous tube feeding tolerating well 0200 residual 15ml. sleeping well no c/o pain or disc. Medicare Charting dated [DATE] indicated wound care to Left heel and buttocks. Medicare Charting dated [DATE]- wound care to left heel. Narrative: Resident (R360) with history of stroke, a-fib, seizure disorder and HTN. Recently arrived from . to be close to family. Recent stroke with right sided weakness and aphasic and difficulty swallowing. Recent PEG tube placement and receiving tube feeding for 20 hours a day. Resident receives Osmolite 1.5 at 65cc/hr, resident tolerating without difficulty. Resident is aphasic, can talk but speech can be garbled at times. Resident easily communicates with yes and no questions and has a communication board available at bedside. Staff anticipates most of resident's needs. Resident can be forgetful at times. Resident does not appear to be in any pain except with movement, resident will moan and groan with any movement. Resident requires assist of 2 with mechanical lift for all transfers. Resident is incontinent of bowel and bladder. All meds via PEG tube. Resident does occasionally get up into w/c but usually no more than 2 hours, as he cannot tolerate being up for extended amount of times. Resident does have a pressure wound to left heel. Resident wears protective heel boots at all times, and treatment is done as ordered. Resident participates in therapies. Surveyor conducted a review of the admission MDS (Minimum Data Set) dated [DATE]. The assessment indicates that R360 has moderately impaired cognitive skills. R360 needs extensive 2-person physical assist with activities of daily living. R360 is always incontinent of bowel and bladder. R360 is at risk for developing a pressure ulcer and currently has an unhealed pressure ulcer. R360 is said to have 1- Stage 2 present on admission and 1 Stage #3 present on admission. R360 has a pressure relieving device for the chair and bed. The CAA (care area assessment) for skin states: R360 admitted to facility from a SNF in (name of state). Needs assist with bed mobility, transfers, toileting, eating, locomotion, dressing, hygiene, and bathing. Attends therapy per POC (plan of care) . BIMS (Brief Interview for Mental Status) 0. Diagnosis includes hemiplegia, aphasia, and malnutrition. Incontinent of bowel and bladder. admitted with skin concerns. Braden scale 12. Proceed to care plan skin integrity. R360's individual plan of care, initiated [DATE] states that R360 has pressure ulcer left heel and right buttock r/t Immobility, hemiparesis, prefers to lay on back, HOB (Head of Bed) has to be elevated for tube feeding. Interventions included: *Administer treatments as ordered and monitor for effectiveness. Date Initiated: [DATE]. *Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: [DATE]. *R360 needs assistance to turn/reposition at least every ,d+[DATE] hours, more often as needed or requested. Date Initiated: [DATE]. *R360 requires Pressure relieving/reducing device on bed/chair. Date Initiated: [DATE]. A Skin and Wound evaluation, dated [DATE], indicates R360 has a Stage #3 pressure ulcer to the left heel that was present on admission. Exact date [DATE]. Wound measurements: area- 2.1 cm, length 3.2 cm, Width 1.1 cm no depth or undermining or tunneling. Moderate exudate. Slow to heal; wound healing is slow or stalled but stable, little/ no deterioration. Notes: admitted with Stage #3 to heel was treated with Medihoney and foam; will change to Iodosorb and foam since slough diminished. MD and POA aware. The facility had not conduct a previous assessment of this Stage 3 left heel pressure injury on [DATE] in order to determine the progression or deterioration of the wound. The facility completed no assessment to include staging, measurements or other wound characteristics on admission. A physician order was written on [DATE] for the left heel to be cleansed with NSW and then to apply medi- honey to open areas every day shift every Tuesday, Thursday, Saturday for wound care. Further review of the treatment administration record (TMAR) noted that the medi-honey treatment had not been signed out as administered from [DATE] through [DATE]. A Skin and Wound evaluation dated [DATE] indicates R360 has a Stage #2 pressure ulcer to right buttock that was present on admission ([DATE]). Exact date: [DATE]. Area: 0.2 cm, Length 0.7 cm, Width 0.5cm, no depth, undermining or tunneling. Epithelial- 60% of wound covered. 40% granulation. Light amount of exudates. Notes: admitted with MASD (moisture associated skin damage) which has now evolved into Stage 2 pressure injury in this location. Will discontinue barrier cream and start skin prep and foam dressing 3 times a week. Surveyor noted according to the European Pressure Ulcer Advisory [NAME], the National Pressure Injury Advisory Panel (NPIAP) and Pan Pacific Pressure Injury Alliance, Prevention and Treatment of Pressure ulcers/injuries: Quick Reference Guide, 2019 granulation tissue is not present in a stage 2 pressure injury. Granulation tissue is noted in a stage 3 pressure injury. Surveyor noted the facility's skin and wound evaluation dated [DATE] incorrectly staged the right buttock as a stage 2 and not a stage 3. There was no comprehensive assessment of R360's right buttocks pressure ulcer that was said to be present on admission on [DATE]. There were no treatment orders obtained. The facility did

Based on interview, observation, and record review, the facility did not ensure a Resident with limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion for 1 (R37) of 1 Residents reviewed for limited range of motion. On 5/25/22, R37 was transferred from the hospital to the facility. R37 had been hospitalized following a fall which resulted in a right hip fracture and right humerus fracture. There was no surgical repair of the right humerus and R37 was advised to keep the right arm in a sling. R37 was admitted to the facility with the supportive services of hospice care. The facility did not document the interventions to address R37's limited arm Range of Motion (ROM), or identity interventions to prevent further decline in the right arm ROM until after R37's right hand became contracted. Findings include: The Facility policy, entitled Prevention of Decline in Range of Motion, dated 10/1/22 documents Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Policy Explanation and Compliance Guidelines: 1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant, shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care. 2. Assessment for Range of Motion a. Licensed nurses will assess a resident's range of motion (such as current extent of movement of his/her joints and the identification of limitations) on admission/readmission, quarterly, and upon a significant change. b. Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion. c. Nursing assistants will report any significant changes in range of motion, as noted during daily care activities, to the resident's nurse when any changes are noted. d. The assessment should include identified risks which could impact resident's range of motion including, but not limited to: i. Immobilization . iii. Any condition where movement may result in pain, spasms, or loss of movement. iv. Clinical conditions such as immobilized limbs or digits because of injury, fractures . 3. Appropriate Care Planning a. Based on comprehensive assessment, the facility will provide interventions, exercises, and/or therapy to maintain or improve range of motion. b. The facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to i. Appropriate services (specialized rehabilitation, restorative, maintenance). ii. Appropriate equipment (braces or splints) . d. Interventions will be documented on the resident's person centered plan. Documentation should include, but not limited to: i. Type of treatments; ii. Frequency and duration of treatments; iii. Measurable objectives . f. Modifications to the plan of care will be made as needed. 4. Preventative Care a. Staff will be educated on the risk factors for a decline in range of motion. These include, but are not limited to: i. Limbs or digits immobilized because of injury . iv. Pain, spasms, and immobility associated with arthritis . b. Staff will be educated on basic, restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight . v. Assisting residents with range of motion exercises, performing passive range of motion for residents unable to actively participate. R37 was admitted to the facility on [DATE] with diagnoses that include Humerus Fracture, Nondisplaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Encounter for Palliative Care, Malignant Neoplasm of Colon, Unspecified; Other Unspecified Arthritis, Unspecified Shoulder; and Polyneuropathy, Unspecified. R37's Admission Minimum Data Set (MDS) assessment, dated 5/31/22, indicated R37 has a functional limitation in range of motion impairment on one side (upper and lower extremities) of R37's body; R37 required total assistance of two (2) staff for showering/bathing, and the extensive assistance of one (1) staff for eating, personal hygiene, dressing, and oral care tasks. R37's quarterly MDS assessment, dated 8/31/22, indicated there is no longer a functional limitation of range of motion impairment on one side (upper and lower extremities) of R37's body; R37 required the total assistance of two (2) staff for showering/bathing, one (1) staff assistance in the form of supervision, cueing, or encouragement, for eating; and one (1) staff extensive assistance for personal hygiene, dressing, and oral care tasks. R37's Quarterly MDS assessment, dated 12/1/22, indicates R37 has a functional limitation of range of motion impairment on one side (upper extremity) of R37's body. R37 requires the total assistance of two (2) staff for showering/bathing, one (1) staff assistance in the form of supervision, cueing, or encouragement, for eating; and the extensive assistance of one (1) staff for personal hygiene, dressing, and oral care tasks. On 01/05/23, at 1:40 PM, Surveyor interviewed Minimum Data Set (MDS) Coordinator I, who verbalized completing R37's Admission MDS assessment, dated 5/31/22 as having a functional limitation in range of motion impairment on one side (upper and lower extremities) of R37's body due to fractures. MDS Coordinator I stated if a contracture was present, MDS Coordinator I would have written a progress note citing that. MDS Coordinator I verbalized R37's quarterly MDS assessment, dated 8/31/22, lists no impairment noted, which means R37 had no issues with performance of either active or passive Range of Motion (ROM). R37's Quarterly MDS Assessment, dated 12/1/22, documents R37 has a functional limitation of range of motion impairment on one side (upper extremity) of R37's body, which MDS Coordinator I verbalized documenting this due to R37's right hand contracture. Surveyor reviewed MDS Coordinator I progress notes and found no documentation noting R37 had a contracture during initial Admission MDS assessment. Surveyor notes there is no documentation R37 was admitted to the facility with a contracted right hand. R37's right hand became contracted while residing at the facility. R37's Care Plan, dated 5/25/22, documents [R37] has an Activities of Daily Living (ADL) self-care performance deficit. Interventions include: -[R37] is totally dependent on two (2) staff assistance due to total dependence on staff for showering/bathing, date initiated: 5/25/22 -[R37] requires the extensive assistance by one (1) staff to eat, date initiated: 5/25/22. On 9/6/22, this intervention was revised to include: EATS IN CARE GROUP TWO. -[R37] is totally dependent on two (2) staff for dressing, date initiated: 5/25/22. -[R37 is totally dependent on one (1) staff total dependence with personal hygiene and oral care, date initiated: 5/25/22. R37's Care Plan, dated 5/25/22, documents R37 has limited physical mobility, with a goal to remain free of complications related to immobility, including contractures . Interventions include: -[R37] does not walk, date initiated: 5/25/22 -[R37] is totally dependent on one (1) staff for locomotion, date initiated: 5/25/22 -[R37]has NO WEIGHT BEARING RESTRICTIONS; date initiated: 5/26/22. Surveyor noted no initial or revised interventions pertaining to R37's limited Range of Motion (ROM) and subsequent contracture, to include participation in a Range of Motion (passive or active) program, nor the use of any ordered appropriate devices (palm guard, washcloth, or carrot). Interventions of a palm guard, washcloth, and carrot were implemented after the right-hand contracture was first documented on 9/20/22 in Hospice Recert Summary Report. Surveyor reviewed R37's medical record and notes the following: On 5/25/22, Health Status Note documents [R37] was wearing a sling for a right humerus fracture. Surveyor noted there is no sling mentioned as an intervention anywhere on R37's care plan. On 9/20/22, Hospice Recert Summary Report documents [R37's] right side is contracted, so vitals were checked on R37's left side. On 10/17/22, Hospice Client Coordination Note Report documents [R37] voiced concern over the contraction of R37's left (sic) hand and nails digging into R37's hand. Hospice will supply (R37) with a palm guard. On 10/25/22, Hospice Recert Summary Report documents [R37] complained of right-hand arm/hand pain, but mostly R37's hand. R37 indicated pain at all times but hurts more when R37 tries to move R37's right hand or arm. The only intervention recorded/provided was R37 receiving as needed (PRN) pain medication. Surveyor notes there is no documentation of a palm guard being in place or used as an intervention. On 11/9/22, Hospice Recert Summary Report documents [R37] was not wearing a palm guard. R37 noted hand hurts a little without palm guard. R37 indicated someone was going to come fix the palm guard, but this hadn't occurred yet. Surveyor noted this is the first time there is documentation of R37 having the palm guard. On 11/26/22, Hospice Recert Summary Report documents [R37's] right hand severely contracted, and R37 no longer can open hand. On 11/30/22, Health Status Note documents [R37's] affected area (right hand) is contracted, reddened, edematous, painful to touch. Licensed Practical Nurse (LPN) M was unable to complete an ordered treatment for R37 due to contracture and pain. On 01/05/23, at 10:08 AM, Surveyor interviewed Licensed Practical Nurse (LPN) M, who verbalized not remembering whether LPN M returned to try to re-attempt (R37's) treatment. LPN M verbalized that if this had occurred, LPN M would have written it in a progress (Health Status) note. On 12/6/22, Physician Orders Note documents [R37] was prescribed Cyclobenzaprine HCL Tablet 10 MG (micrograms) every morning for contracture management, and as needed (PRN) every 12 hours for contracture care. On 12/11/22, Health Status Note documents a rolled washcloth was applied (to R37's right hand). Surveyor notes this intervention is not documented on R37's care plan. On 12/13/22, Physician's Orders Note documents [R37] to use a rolled washcloth or carrot every day shift in conjunction with treatment. On 12/13/22, Health Status Note documents [R37's] affected area (right hand) is contracted and painful to touch. R37 continues on Cyclobenzaprine 10mg Q (every) AM for contractures with minor improvement noted. Pain managed with scheduled Tramadol & (and) APAP (Acetaminophen), and PRN Morphine with dressing changes. On 12/15/22, Hospice Visit Note Report documents [R37] experienced pain when R37's hand was opened to add a barrier to (right) palm. On 12/21/22, Hospice Recert Summary Report documents [R37] has increased contracture to right hand, and tenderness to affected area. On 12/29/22, Hospice Recert Summary Report documents [R37] receives pain medication to relieve discomfort when contracted hand is cleaned. On 12/30/22, Hospice Visit Note Report (Type: Aide Hospice Visit) documents hospice aide services performed with/for R37. This report identifies categories (Activities of Daily Living, Intake/Output, and Other Services) and subsequent services a hospice aide provides to R37 during each visit. Surveyor noted there is no category, nor service, of Range of Motion (active or passive) indicated/performed for R37 during this visit. Surveyor reviewed the Weekly Skin Shower Observation forms for R37 from 11/21/22-01/02/23 (11/28/22 was not received). Surveyor notes the following: On 11/21/22, R37's Weekly Skin Shower Observation form indicates R37's skin is intact, free from alterations/impairments. On 12/05/22, R37's Weekly Skin Shower Observation form indicates R37's skin has alteration(s), list all areas observed. Surveyor notes there are no areas documented. On 12/12/22, R37's Weekly Skin Shower Observation form indicates R37's skin has alteration(s), list all areas observed. Surveyor notes there are no areas documented. On 12/19/22, R37's Weekly Skin Shower Observation form indicates R37's skin has alteration(s), list all areas observed. Surveyor notes there are no areas documented. On 12/26/22, R37's Weekly Skin Shower Observation form indicates R37's skin has alteration(s), list all areas observed. Surveyor notes there are no areas documented. On 01/02/23, R37's Weekly Skin Shower Observation form indicates R37's skin has alteration(s), list all areas observed. Surveyor notes there are no areas documented. On 1/04/23, at 09:50 AM, Surveyor observed Licensed Practical Nurse (LPN) J perform a wound treatment to R37's right middle finger. Surveyor observed R37's right hand was contracted and there was no dressing, nor carrot, on R37's right hand. LPN J verbalized (R37) usually takes it off throughout the day. LPN J verbalized R37's right hand looks tight today. LPN J had difficulty opening R37's right hand and required one (1) person staff assistance to open R37's right hand minimally to get to wound area in order to perform ordered wound treatment. LPN J verbalized having more difficulty opening R37's hand and placing the carrot to reduce pressure. On 01/04/23, at 10:00 AM, Surveyor interviewed Licensed Practical (LPN) J, who stated R37's carrot is to remain in his right hand at all times. LPN J verbalized R37 pulls out the carrot frequently. On 01/04/23, at 1:02 PM, Surveyor interviewed, Director of Rehabilitation Services N, who indicated the rehabilitation department has never provided services to R37. Director of Rehabilitation Services N verbalized the rehabilitation department provided the carrot for R37 after finding out the carrot hospice ordered is on backorder. Director of Rehabilitation Services is unaware of date when carrot was provided to R37. On 01/04/23, at 01:17 PM, Surveyor interviewed Licensed Practical Nurse (LPN) J, who verbalized R37 was not on any Range of Motion (ROM), nor restorative program, since R37's admission to the facility. LPN J indicates R37's carrot is on backorder from hospice, so facility provided one approximately 1-2 weeks ago. Before this, LPN J states facility was using a washcloth for (R37's) right hand. Surveyor notes there is no documentation of placing a washcloth in R37's right hand related to the contracted hand on R37's care plan. On 01/04/23, at 1:45 PM, Surveyor interviewed Certified Nursing Assistant (CNA) O, who verbalized providing cares for R37 routinely in the Summer of 2022 and stated no special attention was required for R37's right hand/arm. CNA O recalled having no issues opening R37's right hand to provide daily personal cares. CNA O stated any special instructions for cares would be written on care cards located in each resident bathroom, or in an electronic record. CNA O showed Surveyor the care card for R37; Surveyor noted no instructions were listed in regard to R37 receiving Range of Motion (ROM) exercises, nor identification or use of any appropriate devices (palm guard, washcloth, carrot). CNA O verbalized never performing Range of Motion exercises to R37 when assigned to his care for the day. CNA O stated R37 had nothing in R37's right hand this morning when CNA O arrived to perform am personal cares. CNA O saw the carrot and verbalized not knowing what to do with it. CNA O did not place the carrot in R37's hand but believes the rehabilitation department assisted in placing R37's carrot in right palm today. On 01/05/23, at 09:57 AM, Surveyor interviewed Registered Nurse (RN) Manager P, who verbalized [R37] had been participating in a Life Enrichment activity (manicure) with R37's daughter. RN Manager P stated R37's daughter brought R37 back to the unit and was concerned as R37's finger was red. RN Manager P verbalized there was nothing (palm guard) in R37's hand at the time, and RN Manager P opened up (R37's right hand) by pulling (R37's) finger back the best I could. It was hard, but I did the best I could. I saw definitely an infection around the nailbed. RN P verbalized for contractures; it is RN Manager P's understanding to routinely monitor the contracture. RN Manager P verbalized treatments (on R37's right middle finger) can be difficult because it is so tight and (R37) winces. On 01/05/23, at 10:08 AM, Surveyor interviewed LPN M, who stated it is an expectation that nurses will perform full body checks for each resident upon admission, and on every weekly shower day. LPN M verbalized all contractures are noted upon admission and monitored. During weekly shower body checks, nurses look for skin breakdown, including anything out of the norm for each resident. LPN M verbalized it is the expectation that contractures and anything related to feet, hands, and skin are observed. Nurses record findings on a Weekly Skin Shower Observation form. LPN M stated R37 has a palm guard and that R37 typically takes it off. LPN M verbalized R37 is premedicated before R37's daily treatment to alleviate the pain associated with opening up R37's hand, verbalizing R37 receives morphine before the treatment. LPN M made a fist with LPN M's hand to demonstrate R37's contracture. LPN M flexed fingers and touched the palm of LPN M's hand, he goes like this and (R37's) fingers dig in. LPN M verbalized R37's contracture is severe, and it is a constant battle donning his palm guard. LPN M verbalized R37's contracture is a very tight contracture so lots of pressure in there (palm area of right hand). On 1/5/23, at 10:20 AM, Surveyor entered R37's bedroom with Licensed Practical Nurse (LPN) M. Surveyor observed R37 sitting in R37's Broda chair with eyes closed. LPN M touched R37's right hand. Surveyor observed R37's mouth open, and R37 scrunched R37's eyes together. LPN M verbalized R37 makes that face when R37 is in pain. Surveyor noted carrot was in place in R37's right hand at this time. On 01/05/23, at 11:49 AM, Surveyor interviewed Director of Nursing (DON) B. When Surveyor asked how R37 developed a contracture, DON B replied, I don't have an answer for that. A hospice aide was coming in 2-3 times per week. I assumed they were providing routine CNA (Certified Nursing Assistant) care to do Range of Motion. DON B verbalized R37 will be receiving Passive Range of Motion and carrot program, restorative services, beginning 1/9/23. DON B verbalized no interventions were implemented for R37 for the contracture before the washcloth and carrot placement. DON B verbalized the carrot was first used as an intervention for R37 on 12/20/22. Surveyor notes there is no documentation of the use of a washcloth or carrot as an intervention in R37's care plan. On 01/05/23, at 3:05 PM, Surveyor informed Nursing Home Administrator (NHA) of the concern of R37 not having documented interventions to address R37's limited arm Range of Motion (ROM) or have identified interventions to monitor to prevent the decline of Range of Motion in the right arm until R37's hand became contracted.

Based on interviews and record reviews, the facility did not ensure 1 of 3 residents reviewed (R1) was free of significant medication errors. On 3/5/21 Licensed Practical Nurse (LPN)-C was completing medication pass in front of R1's room when she was distracted by therapy staff requesting pain medications for a resident prior to treatment. LPN-C stepped aside to administer the pain medications. Upon return to the medication pass the cart was outside R1's room; however, the medication electronic medical record (EMR) on the screen was for R5. LPN-C proceeded to prepare R5's medications and presented them to R1 who took the medications. LPN-C did not carry out the rights of medication administration including right person and right medication when the facility failed to have a picture of R5 in the EMR for LPN-C to refer to during administration and when LPN-C failed to check R1 for an identification bracelet. R1 receiving R5's medications which included a beta blocker that affects the heart and circulation, a potent diuretic with warnings for individuals with severe kidney disease to use with caution, an additional diuretic with warnings to use with caution if you have kidney problems, [MEDICATION(S)] ER (Extended release) which relaxes the muscles of the heart and blood vessels, to be used with caution in patients with kidney disease; an injectable blood thinner and a [MEDICATION(S)]. Following the administration of R5's medications to R1, R1 complained of feeling some lightheadedness and difficulty focusing her eyes and R1 was transferred to the hospital. Review of the hospital record documents R1 had: Accidental drug ingestion, adverse effect of beta blocker, symptomatic [CONDITION(S)], chronic kidney disease stage 4. Intravenous line established, fluid resuscitated, she will be given 0.5 mg of [MEDICATION(S)] (used to treat heart rhythm problems), and she also received [MEDICATION(S)]. R1 remained bradycardic in the low 40's with adequate blood pressure. R1 presented in critical condition at imminent risk of disability or death. The Facility's failure to ensure nursing staff followed the 6 rights of medication administration (right person, right medication, right dose, right time, right route and documentation), created a finding of immediate jeopardy that began on 3/5/21. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on 5/19/21 at approximately 10:45 am. The facility removed the immediate jeopardy on 5/21/21 and the deficient practice continues at a scope and severity of an F (potential for harm/widespread) as the facility continues to implement its action plan. Findings include: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was admitted to the facility after being hospitalized with Hypertension, Lower Extremity Weakness and Shingles. R1 received therapy while at the facility for strengthening and gait improvement with plans to discharge home after meeting her goals. R1's Admission Minimum Data Set, dated dated dated [DATE] indicated R1 scored an 8 on her Brief Interview for Mental Status indicating moderate memory impairment. On 5/18/21 the facility's incident report dated 3/5/21 indicated R1 received R5's medication on 3/5/21 in error. Surveyor interviewed Licensed Practical Nurse (LPN)-C on 5/18/21 at 10:21 AM. LPN-C indicated that on 3/5/21 she was passing medication and therapy staff came by and asked her to give another resident a pain pill so they could do therapy. LPN-C indicated she parked and locked her medication cart outside of R1's room and when she came back to continue her medication pass R5's medication record pulled up on the screen. LPN-C indicated she thought she was outside of R5's room and R5 did not have her picture in the computer because she was a new admission (R5 was admitted to the facility on [DATE]). LPN-C then indicated she went into R1's room and said R5's name and asked was she ready for her medication and R1 responded yes and LPN-C gave R1 the medication. LPN-C then indicated when she went back to the medication cart to sign out the medications she realized she made a mistake and immediately went to tell the supervisor who got the Nurse Practitioner, who was in house, who came down to assess her. The Nurse Practitioner decided to send R1 to the hospital immediately so her heart could be monitored. LPN-C indicated it was no longer than 30 minutes from when she noticed the error to when the ambulance arrived to transport R1 to the hospital. LPN-C indicated R1 had an identification bracelet on and she should have checked or asked the resident her name and birth date before giving her the medication and she didn't. Review of the medications indicates R1 received the following medications that were intended for R5: * [MEDICATION(S)] 120 mg (milligrams): a beta blocker that affects the heart and circulation. Common side effect is [CONDITION(S)] (slow heart rate). * [MEDICATION(S)] 1 mg: potent diuretic. Kidney disease severe use with caution. The effects may be increased because of the slower removal of the medicine from the body. Potential side effect includes weak pulse. * [MEDICATION(S)] 25 mg: diuretic. Use with caution if you have kidney problems. Potential side effect includes fast or irregular heartbeat. * [MEDICATION(S)] ER (Extended release) 60 mg: Relaxes the muscles of the heart and blood vessels. Use caution in patients with kidney disease. Potential side effects include pounding heartbeat. * [MEDICATION(S)] 90 mg injection: Blood thinner (R1 did not have any signs of bleeding per the hospital record.) * Acidophilis 1 capsule: [MEDICATION(S)]. Potential Side effects include mild gastric symptoms. The above drug information was taken from the website drugs.com on 5/19/21. On 5/18/21 R1's Situation Background Assessment and Recommendation (SBAR) charting for 3/5/21 at 11:30 AM indicated R1's heart rate was 53 but all other vital signs were within normal limits. R1's records for her heart rate measurements were reviewed from Admission on 2/24/21 to discharge on 3/5/21. R1's heart rate was taken twice a day with a low of 54 on 3/3/21 and a high of 67 on 2/26/21. Most rates were in the 60's (normal is 60-100). On 5/18/21 R1's hospital record dated 3/5/21 was reviewed and indicated: (R1) presents from care facility with reported administration of the wrong medications. (R1) complains of feeling some light headedness and difficulty focusing her eyes. Accidental drug ingestion, adverse effect of beta blocker, symptomatic [CONDITION(S)], chronic kidney disease stage 4. Intravenous line established, fluid resuscitated, she will be given 0.5 mg of [MEDICATION(S)] (used to treat heart rhythm problems), and she also received [MEDICATION(S)]. (R1) remained bradycardic in the low 40's with adequate blood pressure. (R1) presented in critical condition at imminent risk of disability or death. Hospital records indicated (R1's) creatinine (assesses level of kidney function) was 1.94 (normal is 0.64 to 1.21) at admission and went up to 2.27 on 3/8/21. On 5/18/21 R1's facility medical record was reviewed and indicated R1's last creatinine before the 3/5/21 hospital admission and medication error was on 2/15/21 with a value of 1.28 and at that time she was diagnosed with stage 3 kidney disease (compared to stage 4 kidney disease during her 3/5/21 to 3/11/21 hospital stay). Review of an additional hospitalization with a record dated 4/18/21 indicated her creatinine was 2.1 and she was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/18/21 at 9:30 AM R1's Power of Attorney for Healthcare (POAHC)-D was interviewed and indicated R1 was at home with hospice and R1's cognition was getting better but she is stuck in bed because she is unable to walk. On 5/18/21 the facility's policy titled Obtaining Resident's Photograph on admitted d 3/12/20 was reviewed and indicated: upon admission or by morning of the next business day to the facility, each resident will have their picture taken using Point Click Care online chart picture. Nursing staff will use arm bands to identify those patients that request other means of identification. R5 was on day 3 at the facility on 3/5/21 and no picture was in the chart for her. On 5/19/21 at 8:10 AM Administrator-A was interviewed and indicated that the facility did not identify the concern with R5's picture not being in the medication record system until yesterday when the surveyor brought it to their attention. Administrator-A indicated the activity director is responsible for taking the pictures but could not remember why there was a delay in taking R5's picture. Administrator-A indicated they are working on a plan to make sure all residents are identifiable but have not finalized anything yet. On 5/18/21 the facility's policy titled Administering Medication dated 4/19 indicated: the individual administering medication verifies the resident's identity before giving medications. Methods include checking identification band, checking photograph attached to the medical record and if necessary verifying resident identification with other facility personnel. None of these were done for R1 before she received R5's medication on 3/5/21. The above findings were shared with the Administrator and DON on 5/19/21 at 11:30 AM. Additional information was requested if available. None was provided. The facility's failure to ensure nursing staff carried out the rights of medication administration and systems were in place to allow verification to be completed created a situation of immediacy that started on 3/5/21. The facility removed the immediacy on 5/21/21 when the implemented the following: The facility developed a plan to educate all Nurses/ Med Techs on proper medication administration including six rights of medication administration and guidance / completion of medication error reports when appropriate. This education will include identification of residents with use of pictures and /or name band. This education will be completed before the staff member can pass medications until all Nurses / Med Techs are completed. As needed staff will also be contacted by phone and educated. All staff members will be educated on how to avoid disruptions to the Nurse / Med Tech during medication administration unless there is an emergency or immediate issue that requires the Nurses' attention. Admissions team / Nursing staff will be educated on location of name bands as needed for residents with no pictures in place for any unforeseen reason. All resident records were reviewed to assure all pictures are in place and policy is followed by NHA-A. The facility conducted an AdHoc QAPI including the Medical Director to review the policy and procedures on obtaining resident photos and to determine the assignment of task. The policy will be revised if necessary. The facility conducted an AdHoc QAPI including the Medical Director to review the policy and procedures on Medication Administration and Reporting of Medication Errors. A retrospective review of all medication errors in last 6 months was completed by DON-B and findings were presented in the meeting. Medication pass direct observation/ audit to establish competency will be conducted for each Nurse/ Med Tech and any findings will be reviewed and discussed by QAPI team. DON/ Designee will provide a summary of the competency /audits to the QAPI committee monthly x 3 months for analysis and development of action plan if indicated. The facility assessment will be reviewed and any additional information will be updated by QAPI team and Medical Director. Audits on identification of residents will be completed daily x 7 days and weekly x 3 months to ensure process is working as intended and reviewed with QAPI team for analysis and development of a plan if indicated.

Based on observation, interview, and record review the Facility did not ensure 3 (R1, R2, R3) of 3 Residents reviewed for PI (pressure injuries) received the necessary treatment and services to promote healing and prevent new PIs from developing. * R1 was admitted after a right femur fracture repair. R1 did not have a care plan for repositioning, no repositioning program, or offloading heels despite requiring extensive assistance for bed mobility and being at risk for skin breakdown. R1 developed avoidable bilateral heel PIs. On 1/8/21, the podiatrist assessed the bilateral PIs to the heels as Left heel unstageable heel ulcerated due to blistering, filled with serous and hemorrhaging, measuring 8 x 5 cm. The Right heel Stage 2 heel ulcer, blister deroofed previously 8.5 cm x 5.5 cm. * R2 was admitted on [DATE] after a left femur repair. R2 was identified to be at risk for the development of Pressure injuries. R2's care plan did not address the use of heel boots until 12/27/20 and did not have a care plan for offloading heels until 12/30/20, after R2 had developed an avoidable facility acquired Left heel PI. The Left heel PI deteriorated to a Stage 3 despite requiring extensive assistance for bed mobility and at risk for skin breakdown. * R3's heels were not floated (elevated off the bed) according to R3's care plan for being at risk for skin breakdown. Findings include: *Pressure Ulcers in the Elderly, as a Public Health Problem notes, Lying in bed or sitting in a chair without movement induces pressure on the skin and sub-cutaneous tissues, and are predisposing factors for PU [pressure ulcer] .The pressure on the skin and subcutaneous tissue during prolonged lying on a bone prominence, as well as immobility without repositioning compresses the blood perfusion and induces oxygen deprivation. https://www.omicsonline.org/open-access/pressure-ulcers-in-the-elderly-as-a-public-health-problem-2329-9126XXX 74.php?aid= The Facility Skin Integrity policy and guidelines dated 4/20/20, indicated . The Facility promotes integrity of skin for all residents. Residents having wounds will receive appropriate treatment and services to promote healing, prevent infection, and prevent the development of additional wounds as disease process and aging allow. If a new skin change is observed, the team leader will contact the nurse for initiation of a complete skin/wound assessment. Full care planning for a new or existing wound is the responsibility of the nurse manager/designee. Care planning needs to include prevention of further wounds, plus management plans for the existing wound. Measurable goals should be part of the care plan. Any resident with a pressure wound will have the area looked at daily. The directive to look at the area daily will be located in the electronic TAR (Treatment Administration Record). Reference: 1. NPUAP/EPUAP Guideline for Clinical Practice. Example #1: R1 was admitted to the facility on [DATE] after a right femur fracture repair for therapy. R1 was transferred to another skilled facility on 1/8/21. R1 is no longer residing in the facility. Surveyor reviewed the closed record. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 5 day Admission MDS (Minimum Data Set), dated 1/4/21, indicated a BIMS (Brief Interview of Mental Status) score of 14 which is cognitively intact, no behavior or rejection of care. R1 requires extensive assist with bed mobility and transfers and the assistance of 2 staff. R1's MDS Section M for skin indicated R1 was at risk for skin breakdown, admitted without PI (Pressure Injuries), and no repositioning program. R1's 1/4/21 MDS CAA (Care Area Assessment) stated admitted to facility following hospitalization for R hip fx. Needs assist with bed mobility, transfers, toileting, locomotion, dressing, hygiene, and bathing. Attends therapy per POC (Plan of Care). BIMS 14. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Braden scale 18. Proceed to care plan skin integrity risk. R1's Care Plan, dated 12/29/20, indicated a Focus: R1 has potential/actual impairment to skin integrity r/t immobility, recent surgical procedure, decreased circulation. R1's goal indicated maintain or develop clean and intact skin by the review date (3/29/21). Interventions, dated 12/29/20, include: Encourage good nutrition and hydration in order to promote healthier skin, Monitor for S & S (Signs & Symptoms) of infection, Monitor pain and administer pain medications/treatments as ordered and/or per pain problem. R1 needs pressure relieving/reducing cushion to protect the skin while up in chair, R1 needs pressure relieving/reducing mattress to protect the skin while in bed. The Facility implemented a generic care plan for skin care. The Facility was unable to provide a CNA (Certified Nursing Assistant) Care Card. R1's Admission Evaluation, dated 12/29/20, stated R1 had no PIs. R1's Braden score, dated 1/5/21, at 10:05 pm, stated a score of 21 which indicated R2 was not at risk for PI. Review of R1's multiple progress notes indicated: On 1/6/21, at 3:32 pm, an intact fluid filled blister to the left outer heel extending to the back of the heel measuring 6 cm x 9.5 cm was noted. Treatment order to skin prep and leave OTA (Open to Air). On 1/6/21, at 9:39 pm, blisters to R1's bilateral heels was noted. Left heel measures 4.5 x 4.5 cm. On 1/7/21, at 4:42 am, R1's Right heel blister had busted open and non-adherent greasy gauze was used and site covered with kerlix. On 1/7/21, at 10:30 am, RN-K (Registered Nurse) .Discussed R1's wound care with NP (Nurse Practitioner), Treatment order for intact Left heel blister 2 times/day. [MEDICATION(S)] and foam dressing to Right heel open blister. NP's note on 1/7/21 indicated a popped blister on right heel, unable to approximate edges, scant bloody drainage, no foul odors, no surrouding [CONDITION(S)]. R1's Skin and Wound Evaluation, dated 1/7/21, at 10:57 am completed by DON-B (Director of Nursing), indicated R1's Left heel was pressure Stage 1, in-house acquired (onset date 1/7/21), measuring 3.3 cm x 4.2 cm intact serum filled blister, surrounding tissue dark-reddish brown. R1's evaluation form stated the area is new, R1 had recent surgery, some of the blister may have been a result of blood pooling; R1 often lay on back with heel on bed; air mattress ordered, skin prep and prevalon boot on when in bed. Surveyor noted the 1/7/21 Skin and Wound Evaluation made no reference or assessment of the right heel blister which had opened and with a new order from the NP dated 1/7/21 for [MEDICATION(S)] and foam dressing. On 1/7/21, R1 went to the orthopedic surgeon and the report indicated the need for a podiatrist to evaluate and treat bilateral heel wounds, keep weight off Right foot until evaluated and gives further recommendations. On 1/8/21, R1 went to the podiatrist and the report indicated: Left heel unstageable heel ulcerated due to blistering, filled with serous and hemorrhaging, measuring 8 x 5 cm. Right heel Stage 2 heel ulcer, blister deroofed previously 8.5 cm x 5.5 cm. Recommendations: Offload heels at all times with pillow or offloading device, bilateral heel dressing at all times, Change dressing daily, non-adherent to all wounds, Recommend wound care consultation at facility. On 1/8/21, at 4:14 pm, R1 was transferred to another facility at the request of R2 and family. Interviews: On 1/27/21, at 8:14 am, Surveyor interviewed DON-B who is the facility wound nurse and stated certified as WCC (Wound Care Certified). She stated she does wound rounds on Tuesdays. DON-B stated R1 was not here long enough to be placed on the facility wound log. DON-B provided current facility wound log. On 1/27/21, at 1:30 pm, Surveyor interviewed DON-B who stated R1 had a regular pressure reducing mattress and an air mattress was ordered on 1/6/21. DON-B stated R1 had nothing on the Right heel, no breakdown, staff possibly charting on the wrong resident. Surveyor reviewed R1's 1/6 & 1/7/21 progress notes with DON-B who stated obviously I did not see it (Right heel), R1 did not tell me. DON-B stated the staff try to float heels all the time for all residents and the Facility protocol was to reposition every 2 hours unless customized. DON-B stated R1 was mobile in the bed, had lots of comorbidities for breakdown including Diabetes and PVD. DON-B stated she did not know about R1's Right heel so it was not assessed or treatment ordered by her on the 1/7/21 Wound Evaluation form. *The NPIAP (National Pressure Injury Advisory Panel) 2019 Guideline defines PIs as localized damage to the skin and underlying soft tissue as a result of intense pressure, prolonged pressure or pressure in combination with shear: A Stage 1 PI is non-blanchable [CONDITION(S)] in a localized area of intact skin. A Stage 2 PI is partial thickness skin loss with exposed dermis. No fat or deeper tissues are visualized. A Stage 3 PI is full thickness skin loss with fat tissue visible. Muscles, bone, and tendons are not visualized. Slough or eschar (black necrotic tissue) could be present. A Stage 4 PI is full thickness skin and tissue loss with exposed or directly palpable muscle, bone, or tendon. An Unstageable PI is obscured full thickness skin and tissue loss in which the extent of damage cannot be determined. A DTI (Deep Tissue Injury) is persistent non-blanchable deep red, maroon, or purple discoloration from intense and/or prolonged pressure. Surveyor noted R1's wound evaluation completed on 1/7/21 staged the Left heel incorrectly as a Stage 1 instead of the accurate Stage 2 serum filled blister. DON-B stated she would gather information on why NP ordered treatment on 1/7/21 for Right heel but it was not documented in the TAR or progress notes as being done. On 1/27/21, at 2:30 pm, Surveyor interviewed RN-K (Registered Nurse) over the phone regarding R1's bilateral heel wounds. RN-K stated she saw R1's Right heel was open and got the NP for a treatment order on 1/7/21 but I don't remember if I measured it. RN-K stated she did the Right heel treatment right away but did not document in the TAR or progress notes that the treatment was done. RN-K stated she imagined she did talk to DON-B because as a general rule RN-K updates her. RN-K stated she offered R1 repositioning but R1 did not like to be anywhere but on R1's back. RN-K stated the facility planned to start offloading heels and started with boots but R1 wanted a heels up cushion instead of boots. Surveyor observed that RN-K did not document an assessment of R1's Right heel PI or the Right heel treatment ordered on 1/7/21 in R1's medical record. R1 and R1's family verbalized a grievance to DON-B (Director of Nursing) indicating R1 was left lying in the bed and no one came to assist R1 to turn and reposition from 1/2/21 to 1/4/21. The Facility did not initiate an investigation into R1's grievance or determine the severity of the allegation and potential outcome to R1. On 1/27/21, at 1:50 pm, Surveyor interviewed DON-B who stated she did know about the call regarding a grievance for lack of turning and repositioning for R1. DON-B stated no formal grievance was written or followed up. The Facility did not document how frequently staff was turning R1. R1 did not have a care plan for repositioning, no repositioning program, or offloading heels despite requiring extensive assistance for bed mobility and being at risk for skin breakdown. R1 developed avoidable bilateral heel PIs. Example #2: R2 was admitted to the facility on [DATE] after a left femur repair for therapy. R2 is currently residing in the facility. R2's 5 day Admission MDS, dated [DATE], indicated a BIMS score of 15 (cognitively intact). R2 requires extensive assist with bed mobility and transfers and the assistance of 2 staff. R2's MDS Section M for skin indicated R2 was at risk for skin breakdown, admitted without PI (Pressure Injuries), and no repositioning program. R2's Braden scale score, dated 12/17/20, was 18 indicating R2 was at risk for skin breakdown. R2's care plan, dated 12/17/20, indicated R2 has a Focus: R2 has potential/actual impairment to skin integrity: 12/29/20 left heel blister, revision 12/30/20. R2's goal indicated maintain or develop clean and intact skin by the review date (3/17/21). Interventions included in part . Encourage offloading heel boots on at all times (12/27/20). Elevate heels off the bed (12/30/20). R2's care plan, dated 1/5/21, indicated R2 has a Focus: R2 has a pressure ulcer left heel related to immobility, Diabetes, weakness and need for ADL; complicated by Diabetes/[CONDITION(S)], revision date 1/12/21. R2's goal indicated R2's pressure ulcer will show signs of healing and remain free from infection through review date, initiated 1/5/21, review date 3/17/21. Interventions included in part . Educate R2/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, initiated 1/5/21. Prevalon boots on bilateral feet when in bed and up in wheelchair; may remove for transfers and use heel surgical foot, initiated 1/5/21. R2's CNA care card, dated 1/27/21, indicated for resident care to encourage offloading heel boots on at all times; and for bed mobility a limited assist of 1. R2's Interact documentation, dated 12/29/20, indicated R2 had a new left heel blister intact with clear fluid with a dark central area, measuring 3.2 cm x 3.5 cm. Treatment ordered, dated 12/30/20, stated left heel: skin prep to blister and cover with foam dressing to protect on evening shift every other day. R2's wound assessment, dated 1/5/21, indicated R2 had a left heel PI stage 3 measuring 2.2 x 1.9 cm as the blister had evolved. Treatment ordered, dated 1/6/21, Apply Santyl to left heel topically every day for wound care, Normal Saline Wash followed by skin prep to periwound, Apply nickel thick Santyl to wound bed and cover with dry dressing and secure with tape. R2's Wound Physician evaluation form, dated 1/19/21, indicated left heel unstageable PI measuring 1.73 cm x 1.86 cm x 0.10 cm. Treatment ordered: Cleanse with ½ strength Dakin's solution, protect periwound with skin prep, apply Santyl to wound bed, cover wound with bordered gauze, change daily change prn for soiling and/or saturation. R2's skin & wound evaluation, dated 1/26/21, indicated R2's left heel as full thickness, facility acquired on 12/24/20. R2's left heel measured 1.3 cm x 1.6 cm, had 90% eschar, and was crosshatched last week by J-MD (Wound Physician) to increase penetration of Santyl; was not effective in decreasing size; will change up treatment this week and monitor for results. Treatment ordered, dated /1/26/21, stated Normal Saline Wash to left heel followed by skin prep to periwound followed by [MEDICATION(S)] followed by [MEDICATION(S)] cushion followed by kerlix daily. Surveyor noted that although R2's left heel wound measurements decreased in size but the stage of the PI worsened from Stage 2 to a Stage 3. On 1/27/21, at 9:00 am, Surveyor conducted observations and noted R2 up in the wheelchair with therapy assisting R2 and bilateral blue soft protective boots on feet. On 1/27/21, at 1:30 pm, Surveyor interviewed DON-B who stated R2 had an intact serum blister that was a DTI (Deep Tissue Injury) but treated as a PI. R2's left heel had a purple area underneath, left heel was the surgically repaired left femur fracture, and only one heel broke down. R2 did not have a care plan for repositioning, no repositioning program, or offloading heels until after R2 had developed an avoidable facility acquired Left heel PI which worsened to a Stage 3 despite requiring extensive assistance for bed mobility and at risk for skin breakdown. Surveyor requested information regarding R2's wound and clinical information and any other assessments regarding R2's wound. DON-B stated she did not have access to J-MD (Wound Physician) notes at this time. Example #3: R3 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS, dated [DATE], indicated R3 required extensive assistance with 2 staff for bed mobility and transfer. R3's MDS indicated R3 was at risk for skin breakdown and was not on a repositioning program. On 1/27/21, at 9:00 am, Surveyor conducted observations and noted R3 was in bed in R3's room and heels were not floated or elevated off the bed. R3's care plan, dated 1/5/21, indicated a Focus: R3 has potential/actual impairment to skin integrity with a Goal that R3 will maintain or develop clean and intact skin by the review date (4/5/21). R3's Interventions included Elevate heels off the bed (initiated 1/5/21). R3's CNA care card, dated 1/27/21, indicated for bed mobility that R3 requires limited assistance by 1 staff to turn and reposition in bed. R3's care card does not indicate Elevate heels off the bed. R3's heels were not floated (elevated off the bed) according to R3's care plan for being at risk for skin breakdown. On 1/27/21, at 2:37 pm, DON-B provided updated facility wound log with the addition of a resident with facility acquired left heel DTI. DON-B stated she forgot to update as she only uses an IPAD for rounds and the wound log is only for Surveyors. Surveyor discussed PIs with DON-B. DON-B stated there should be another resident added to the log for sacral PI. *Advancing Excellence notes that Pressure ulcers can be dangerous and painful for a resident, in part because broken skin can allow infection into the body. If untreated, pressure ulcers can deepen and even expose the bone. Deeper ulcers may be hard to heal or may not heal at all. Sometimes, pressure ulcers can lead to death. The presence of pressure ulcers limits the quality of life for a resident as evidenced by: o Decrease in bowel and bladder function o More incontinence o Decrease in ability to move without help o Decrease in mental capacity o Increase in pain o Increased risk for infection o Less participation in activities (http://www.nhqualitycampaign.org/files/factsheets/Staff%20Fact%20Sheet%20-%20Reducing%20Pressure%20Ulcers.pdf On 1/28/21, at 8:35 am, Surveyor conducted a phone exit with NHA-A. Surveyor shared PI concerns regarding accurate assessments, prevention, and treatments including inaccurate Facility PI lists and DON-B not having access to J-MD's notes during the onsite visit.

Based on observation, interview, and record review the Facility did not ensure 2 (R6 & R7) of 3 Residents reviewed for pressure injuries received the necessary treatment and services to promote healing and prevent new pressure injuries from developing. * R6 was admitted on [DATE] without any pressure injuries. On 12/25/19 R6 was identified as having pressure injuries on her right and left gluteal fold. These pressure injuries were assessed on 12/26/19 with measurements but only one wound bed description. There was no revisions in R6's skin care plan. The wound assessment identified a coccyx pressure injury without R6's care plan being revised. This assessment also documented a stage 2 on the left gluteal fold and stage 3 on right gluteal fold. The left gluteal is assessed as having 15% eschar and [AGE]% slough. The right gluteal is [AGE]% necrosis and 20% slough. These should have been staged as unstageable. The pressure injuries continued to be incorrectly staged until 1/21/20. On 1/11/20 R6 was identified as having pressure injury on her left heel. There is no further assessment including measurement after this date. R6 was observed not to be repositioned for multiple hours on 1/21/20, her heels were not offloaded and the pressure injury treatments were not completed according to physician orders. * R7 was identified to be at risk for the development of pressure injuries and did not have adequate interventions to prevent the development of a stage 2 pressure injury. Findings include: The prevention of pressure ulcers/injuries from 2001 Med-Pass, Inc. (Revised July 2017) under the prevention section for mobility/repositioning documents 1. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. 2. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. 3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. 4. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort. 5. Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change position. Under monitoring documents 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. The pressure ulcer/injury risk assessment from 2001 Med-Pass, Inc. (Revised July 2017) steps in the procedure document 1. Gather assessment tools and documentation and conduct the assessment in the manner most appropriate to the resident's condition and willingness to participate. 2. If necessary, allow the resident to take rest periods during the assessment. 3. Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool. 4. Conduct a comprehensive skin assessment with every assessment. a. When conducting a skin assessment, provide for the resident's privacy. b. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration of skin. 5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of practice. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. 1.) R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R6 is receiving hospice services. The comprehensive admission/readmission evaluation with an effective date of 12/12/19 under section J. Skin for the question are there any skin issues present no is answered. The Braden scale assessment dated [DATE] has score of 14 which is moderate risk. The potential/actual impairment to skin integrity care plan created on 12/12/19 and changed to actual impairment to skin integrity right and left buttocks stage 3 open area on 1/14/20 documents the following interventions: Elevate heels off the bed. initiated 12/12/19. Encourage good nutrition and hydration in order to promote healthier skin. initiated 1/7/20. Involve/educate resident and/or family designee. initiated 12/12/19. MNT (medical nutrition therapy) provided for wound healing. initiated 1/7/20. Monitor for s/s (signs/symptoms) of infection. initiated 12/12/19. Monitor pain and administer pain medications/treatments as ordered and/or per pain problem. initiated 12/12/19. Offer to lay down after lunch for offloading. initiated 1/15/20. The resident needs pressure relieving/reducing cushion to protect the skin while up in chair. initiated 12/12/19 and revised 12/22/19. The resident needs pressure relieving/reducing mattress to protect the skin while in bed. initiated 12/12/19 & revised on 12/22/19. Assist resident with elevating heels off surface of bed using (pillows). initiated & revised 12/12/19. The weekly skin shower observation dated 12/12/19 documents skin intact. The admission MDS (minimum data set) with an assessment reference date of [DATE] has a BI[CONDITION] (brief interview mental status) score of 11 which indicates moderately impaired. R6 requires extensive assistance with one person physical assist for bed mobility, is dependent with two plus persons physical assist, does not ambulate and is dependent with one person physical assist for toilet use. R6 is occasionally incontinent of urine and continent of bowel. R6 is at risk of developing pressure injuries and is coded as not having any pressure injuries. The weekly skin shower observation dated 1[DATE] documents no new changes to skin integrity noted. The pressure injury CAA (care area assessment) dated 12/22/19 under care plan considerations documents The falls CAA (care area assessment) dated 12/22/19 under care plan considerations documents admitted to facility following hospitalization for acute [MEDICAL CONDITION]. Needs assist with bed mobility, transfers, toileting, locomotion, dressing, hygiene, and bathing. Attends therapy per POC (plan of care). BI[CONDITION] 11. [DIAGNOSES REDACTED]. Braden scale 14. Proceed to care plan skin integrity risk. The nurses note dated 12/25/19 documents During am (morning) cares 2 open areas found one to left gluteal fold and one to right gluteal fold. Son updated and DON (Director of Nursing) updated and will call MD (medical doctor) for treatment. The nurses note dated 12/25/19 documents Call out to on call MD to update on open areas. The wound team: Pressure injury evaluation with an effective date of 12/26/19 documents for site left gluteal fold, type is pressure, length 1.8 cm (centimeters), width is 1.6 cm, depth is 0.1 and Stage II (2). Under site documents right gluteal fold, type is pressure, length 5.5 cm, width 2.2 cm, depth 0.1 and Stage III (3). Under wound bed [MEDICATION NAME] is checked and for percentage of [MEDICATION NAME] 90% of wound covered is checked. Slough is also checked and for percentage of slough 10% of wound filled is checked. Under interventions in place air mattress to bed and equagel cushion to wheelchair are checked. Surveyor noted there are two pressure injuries identified but only one wound bed is described and there are no care plan revisions. The nurses note dated 12/30/19 documents Dressing changed to right and left gluteal fold. Right side red with some necrotic tissue. Wound manager aware. Tx (treatment) is cleanse area f/b (followed by) [MEDICATION NAME] f/b allevyn. Left open area has red wound base. Tx cleanse area f/b [MEDICATION NAME] f/b allevyn. Small open area to coccyx and cleanse area f/b allevyn. This note was written by a LPN (Licensed Practical Nurse). The nurses note dated 12/31/19 documents Resident dressings changed to bilateral buttocks/gluteal folds and coccyx due to urinary incontinence compromising dressings. Areas cleansed and new dressings applied. Eschar and slough noted in each buttock wound, no s/s of infection noted to any of the three wounds. The wound team: pressure injury evaluation with an effective date of 12/31/19 documents for site coccyx, type pressure, length 1 cm, width 0.3 cm, depth 0.1 cm and stage II (2). For site left gluteal fold, type pressure, length 5.4 cm, width 4.2, depth 0.1 cm and stage II (2). For site right gluteal fold, type pressure, length 5.5 cm, width 5.2 cm, depth 0.6 cm and stage III (3). Under interventions in place air mattress to bed and equagel cushion to wheelchair are checked. Under summary of wound assessment documents L (left) buttocks-15% eschar, [AGE]% slough, 5% [MEDICATION NAME] 2 edges/margin, small beefy area 2 4 o'clock, area @ (at) 6 o'clock soft, slough R (right) buttocks [AGE]% Necrosis, 20% slough, 5% granulation Coccyx 95% [MEDICATION NAME] with remaining wound base pale. Surveyor noted there are now three pressure injuries with the right & left gluteal fold increasing in size and no revision in R6's plan of care. In addition the pressure injuries for the right and left gluteal fold have been incorrectly staged. According to the pressure injury evaluation wound description documents for Stage II (2) Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. For Stage III (3) documents Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present on some parts of the wound bed. Often include undermining and tunneling. For unstageable documents Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Surveyor noted the left buttocks is assessed as having 15% eschar & [AGE]% slough. The left buttocks should have been assessed as unstageable. The right buttocks is [AGE]% necrosis and 20% slough. The right buttocks should have also been assessed as unstageable. The nurses note dated 1/7/20 documents Res (resident) complaining of discomfort to buttocks and the areas that are being treated, wound team assessed this today and will implement a larger bandage with treatment changes and skin prep periwounds. did administer [MED] prn (as needed) and states that she wishes she could have this more often, is forgetful and will not ask all of the time per staff, call placed to Physician-R team and scheduled [MED] bid (twice daily) for res comfort. The wound team: pressure injury evaluation with an effective date of 1/7/20 documents for site coccyx, type pressure, length 0 cm, width 0 cm, depth 0.1 cm and stage II (2). For site left gluteal fold, type pressure, length 5.0 cm, width 5.0, depth 0.1 cm and stage II (2). For site right gluteal fold, type pressure, length 6.0 cm, width 6.5 cm, depth 0.6 cm and stage III (3). Under interventions in place air mattress to bed and equagel cushion to wheelchair are checked. Under summary of wound assessment documents L (left) buttocks-15% eschar, [AGE]% slough, 5% [MEDICATION NAME] 2 edges/margin, small beefy area 2 4 o'clock, area @ (at) 6 o'clock soft, slough R (right) buttocks 90% Necrosis, 5% slough, 5% granulation Coccyx resolved. Surveyor noted R6's right and left gluteal fold pressure injuries continue to be incorrectly staged. The Facility added medical nutrition therapy but there were no further revisions in R6's care plan The nurses note dated 1/9/20 documents Dressing changed to Bilateral gluteal folds. Foul smell and narcotic tissue remains to both area. Surveyor noted this is the first documentation of foul smelling drainage and was unable to locate a RN assessment as this note was written by a LPN. The nurses note dated [DATE] documents Dressings changed to Bilateral gluteal folds. Both had moderate amount of foul smelling drainage. Areas both have narcotic tissue. Tx (treatment) cleanse f/b [MEDICATION NAME] f/b allevyn. The nurses note dated 1/11/20 documents Resident has couple areas to Lt (left) and Rt (right) heel. Rt. heel appears to be a dry blister scabbed 1.2 x (times) 1 cm in size Lt heel area callous eschar 1 cm x 1 cm in size, heel lift boots will be placed treat with iodine prep bid (twice daily). The nurses note dated 1/11/20 documents [MEDICATION NAME] ordered to bilateral heels. Heel lift boots in place. Dressings to bilateral buttocks changed per orders. Large amount of drainage noted. Repositioned PPOC (per plan of care). Res denies pain. The physician orders [REDACTED]. (bilaterally) while in bed. The nurses note dated 1/12/20 documents Res continues to be monitored for OA (open area) to bilateral buttock and scabbed areas to bilateral heels. Dressings changed to buttock. Mod (moderate) amount of foul smelling drainage noted. Res is repositioned PPOC and does c/o (complain of) pain when up in w/c (wheelchair). She does receive scheduled [MEDICATION NAME] which appear to be effective. [MEDICATION NAME] applied to bilateral heels and has orders for heel lift boots. The nurses note dated 1/13/20 documents Mod amount of odiferous drainage on dressings to open areas on buttocks. Dressings changed per orders. Res denies pain during tx. The wound team: pressure injury evaluation with an effective date of 1/14/20 documents for site left gluteal fold, type pressure, length 5.5 cm, width 5.5, depth 0.4 cm and stage III (3). For site right gluteal fold, type pressure, length 8.5 cm, width 7.5 cm, depth 0.6 cm and stage III (3). Under interventions in place air mattress to bed, equagel cushion to wheelchair, and nutritional supplements are checked. Under summary of wound assessment documents L (left) buttocks-50% eschar, 40% slough, 10% [MEDICATION NAME] 2 edges/margin, small beefy area 2 4 o'clock, area @ (at) 6 o'clock soft, slough R (right) buttocks 90% Necrosis, 5% slough, 5% granulation. Surveyor noted R6's right and left gluteal fold pressure injuries continue to be incorrectly staged. On 1/15/20 R6's care plan was revised with offer to lay down after lunch for offloading. There was no further revision to R6's care plan. The nurses note dated 1/15/20 documents Dressing changed to right and left gluteal folds. Necrcotic areas appear to be loosening from wound bed. Tx is cleanse wound/f/b [MED] f/b allevyn. On 1/16/20 at 2:43 p.m. Surveyor observed R6 in bed on her left side. Surveyor observed there is one pressure relieving boot at the foot of the bed. Surveyor observed R6's foot is not in the boot and both heels are not being offloaded. On 1/16/20 at 4:20 p.m. Surveyor observed R6 continues to be in bed on her left side. Surveyor observed there is still one pressure relieving boot at the foot of the bed. Surveyor observed R6's foot is not in the boot and both heels are not being offloaded. The nurses note dated 1/17/20 documents dressings changed foul odor with pain is present with dark drainage. This note was written by a LPN and there was no RN assessment. The nurses note dated 1/19/20 documents Dressings changed to open areas right and left gluteal folds. Necrotic areas remain. Foul smell. Painful when touched. This note was written by a LPN and there was no RN assessment. The nurses note dated 1/20/20 documents res is tired and appetite is poor, takes fluids with much encouragement and given supplements, would not eat eggs this am (morning) and states she dislikes these intensely, given yogurt and milk, and oatmeal and assisted with meal. wound cares administered and son here, expressed concerns that doesn't believe she has capacity to improve, talked with on call Physician-R group and ok to add protein supplement for healing and wound soaks with dakins prior to applying new bandages and continue the [MED] bid and prn, res tolerates this well, there is necrotic tissue, soft and malodorous with slough present as well, with significant depth, encouraged to lie down after meals for offloading and does have air mattress in place, son is involved and supportive. This note was written by a LPN. The physician order [REDACTED]. and Coccyx blanchable redness - skin prep followed by foam dressing once a day & prn for protection. The wound team: pressure injury evaluation with an effective date of 1/21/20 documents for site left gluteal fold, type pressure, length 5.6 cm, width 6.2, depth 2.4cm and unstageable. For site right gluteal fold, type pressure, length 9.6 cm, width 6.5 cm, depth 4.5 cm and stage unstageable. Under interventions in place air mattress to bedand equagel cushion to wheelchairare checked. Under summary of wound assessment documents Hospice and family are aware of wound status and expected changes. Wound size changes may be relative to enzymatic debridement. Right buttock area of depths are 4.5 cm at 9-10 o'clock and 2.5cm at 6 o'clock. [AGE]% slough and 20% granulation. Left buttock areas of depth are both 2.4cm at 5 and 7 o'clock. 90% slough and 10% granulation. Surveyor noted R6's right and left gluteal fold pressure injuries are now correctly staged. There is no assessment of R6's right and left heels. The last assessment is dated 1/11/20. On 1/21/20 at 7:19 a.m. Surveyor observed CNA (Certified Nursing Assistant)-E in R6's room. CNA-E informed R6 she was going to get her washed up and dressed. CNA-E placed gloves on, filled a wash basin, and asked R6 what she wanted to wear. After picking out R6's clothing, CNA-E removed the mat from the right side of R6's bed, lowered the head and raised the height of the bed. CNA-E removed the bedding and removed a pillow from between R6's knees. Surveyor observed R6's heels are resting directly on the mattress and R6 did not have a pressure relieving boots on. CNA-E handed R6 a wash cloth, R6 washed her own face, CNA-E removed R6's shirt and covered R6 with a sheet. CNA-E washed R6's upper body and placed a shirt on R6. At 7:27 a.m. LPN (Licensed Practical Nurse)-D entered R6's room with treatment supplies. LPN-D washed her hands, placed gloves on and unfastened R6's incontinence product. R6 was placed on her right side, LPN-D poured dakins on four by four gauze and placed the gauze on the necrotic pressure injury. LPN-D removed her gloves, washed her hands, placed gloves on and informed CNA-E they have to leave the dakins on for a few seconds. Surveyor asked LPN-D why there wasn't a dressing over R6's pressure injury. LPN-D informed Surveyor Former DON (Director of Nursing)-C just measured the pressure injuries. LPN-D placed collanase [MED] on a foam dressing, asked CNA-E to remove the dakins soaked gauze from R6's left pressure injury and then LPN-D placed the foam dressing over R6's left gluteal fold pressure injury. Surveyor noted LPN-D did not apply skin prep around the perimeter of R6's left gluteal pressure injury according to physician's orders [REDACTED]. At 7:33 a.m. Surveyor asked LPN-D how R6 obtained the pressure injury. LPN-D informed Surveyor R6 has another one on the other side and R6 came in with the pressure injuries. LPN-D removed her gloves, washed her hands and placed gloves on. At 7:34 a.m. CNA-E positioned R6 on her right side, LPN-D poured dakins on four by four gauze and placed the gauze over the right gluteal fold necrotic pressure injury. LPN-D removed her gloves, washed her hands and informed CNA-E she was going to get R6's bandage ready. LPN-D placed gloves on, placed collanase [MED] on a foam dressing, removed the gauze, and applied the foam dressing with collanase [MED] over the right gluteal pressure injury. At 7:38 a.m. LPN-D and CNA-E removed their gloves and washed their hands. LPN-D then left R6's room. Surveyor observed LPN-D did not apply skin prep around the peri wound of the right gluteal fold and did not apply a foam dressing over R6's coccyx area according to physician's orders [REDACTED]. At 7:39 a.m. CNA-E placed gloves on, informed R6 she was going to clean up her bottom and put on a clean brief. CNA-E washed R6's frontal perineal area, positioned R6 onto there left side, washed R6's buttocks and rectal area and placed an incontinence product under R6. CNA-E positioned R6 onto her right side to straighten out the product, then positioned on her back, and fastened R6's incontinence product. Surveyor noted no barrier cream was applied to R6's buttocks. CNA-E removed her gloves, washed her hands, and placed gloves on. At 7:45 a.m. Surveyor observed on R6's right heel was a small brown callous area and on the left heel is a black necrotic area the approximate size of a dime. CNA-E placed pants on R6, covered R6 with a sheet informing R6 she will be back with the machine and help to get her up. At 7:48 a.m. Surveyor checked R6's wheelchair cushion. Surveyor observed there is an Equagel cushion in R6's wheelchair that has been placed in the wheelchair backwards. The side of the Equagel cushion is a label with front and an arrow indicting the front of the cushion and back with an arrow indicating the back of the cushion. Surveyor observed the front arrow is pointing towards the back and the back arrow is pointing towards the front. At 7:57 a.m. CNA-E re-entered R6's room, wheeled R6's wheelchair out of the bathroom, wheeled a sit to stand lift into the room and indicated someone is coming to help her. CNA-E washed her hands. At 7:58 a.m. CNA-H entered R6's room. CNA-E placed soft black shoes on R6, R6 was positioned so she was sitting on the edge of the bed, and staff placed a sling around R6. CNA-H brought the sit to stand over in front of R6, the leg straps were attached, the sling attached to the lift and R6 was transferred into her wheelchair. Staff unhooked the sling from the lift and the sling was removed from R6. CNA-H removed the lift from R6's room, CNA-E placed footrest on the wheelchair, brushed R6's hair, washed her hands and at 8:05 a.m. wheeled R6 out of her room into the cafe. On 1/21/20 at 9:25 a.m. Surveyor observed sitting at a table in the cafe with her breakfast in front of her. On 1/21/20 at 9:46 a.m. R6 was wheeled out of the cafe by Medical Record Coordinator-J, into her room and placed on the roommate's side of the room. On 1/21/20 at 9:48 a.m. R6's son entered R6's room asking R6 why she was on the other side. Medical Records Coordinator-J indicated she placed her on the wrong side and wheeled R6 over to R6's side placing her along the bed. On 1/21/20 at 11:22 a.m. Surveyor observe R6 sitting in the wheelchair in the front lobby with her son next to her. On 1/21/20 at 11:56 a.m. Surveyor asked CNA-E if R6 lays down or does she like to stay up. CNA-E informed Surveyor she would have laid R6 down after breakfast but she was busy with another resident and then her son came to visit. CNA-E informed Surveyor R6's son left about 15 or 20 minutes ago and will be laying R6 down after lunch. Surveyor inquired what time lunch was. CNA-E informed Surveyor 12:30 to 1:00 p.m. On 1/21/20 at 12:48 p.m. Surveyor observed R6 sitting at a dining room table in the cafe. On 1/21/20 at 1:25 p.m. Surveyor observed R6 continues to be sitting at a table in the cafe. LPN-D is assisting R6 with eating her lunch. On 1/21/20 at 1:50 p.m. Surveyor observed LPN-D wheel R6 out of the cafe and place R6 in her room along side her bed. On 1/21/20 at 1:57 p.m. Surveyor observed CNA-E place gloves on and inform R6 she was going to get her into bed. On 1/21/20 at 1:58 p.m. Surveyor asked CNA-E if she did anything for R6 after Surveyor had observed her this morning. CNA-E replied no and explained like she told Surveyor earlier she was busy and then her son was with her. On 1/21/20 at 1:59 p.m. CNA-H entered R6's room with a sit to stand lift. A sling was placed around R6, the leg strap was connected and CNA-E asked R6 if she had to use the bathroom. R6 shook her head no and R6 was transferred onto the bed. R6 was unhooked from the sit to stand lift, staff layed R6 onto her back, and removed her shoes. Surveyor observed the back of R6's pants were wet. CNA-H then left R6's room. CNA-E lowered R6's pants, unfastened the incontinence product and washed R6's frontal perineal area. Surveyor observed serosanguineous drainage on R6's incontinence product from the right gluteal pressure injury. After washing R6, CNA-E placed an incontinence product under R6, fastened the product, R6 was positioned on her left side, and CNA-E removed her gloves. CNA-E placed a pressure relieving boot only on R6's left foot. Surveyor observed R6's right heel is resting directly on the mattress. CNA-E covered R6 with bedding, lowered the bed, placed a mat along the right side of R6's bed, and washed her hands. At 2:10 p.m. Surveyor checked the cushion in R6's wheelchair and observed the cushion continues to be in backwards. On 1/21/20 at 2:11 p.m. Surveyor asked CNA-E if she knew how R6 obtained the pressure injuries. CNA-E informed Surveyor she came from the south unit of the building and didn't know how she got them. Surveyor asked CNA-E how often R6 is repositioned. CNA-E replied every two hours. Surveyor asked if this is in the bed or chair. CNA-E replied in bed. Surveyor asked if CNA-E has to reposition R6 in her wheelchair. CNA-E replied no not really. Surveyor noted R6 was not repositioned from approximately 8:00 a.m. until 1:59 p.m. On 1/21/20 at 2:14 p.m. Surveyor asked CNA-H if she did anything for R6 other than assisting CNA-E transfer R6. CNA-H replied no. On 1/21/20 at 2:18 p.m. Surveyor asked CNA-T if she did anything for R6 today. CNA-T replied I didn't do anything for R6 today. On 1/21/20 at 3:50 p.m. Surveyor observed R6 in bed on her left side. R6 continues to be wearing a pressure relieving boot on her left foot and her right foot is resting directly on the mattress. On [DATE] at 7:15 a.m. Surveyor checked R6's wheelchair cushion and observed the cushion continues to be in backwards. On [DATE] at 7:45 a.m. Surveyor asked CNA-F if Surveyor could look at R6's feet. Surveyor observed the pressure relieving boot is near the footboard and R6's heels are resting directly on the mattress. CNA-F did not place the pressure relieving boot on R6's foot. On [DATE] at 7:46 a.m. Surveyor asked CNA-F who checks Resident's wheelchair cushion. CNA-F explained usually the person who is assisting with the transfer or she also does. Surveyor informed CNA-F R6's Equagel wheelchair cushion is in backwards. On [DATE] at 8:28 a.m. Surveyor observed R6 continues to be in bed on her left side. R6 is not wearing pressure relieving boots and her heels are not being offloaded. On [DATE] at 9:08 a.m. Surveyor observed R6 continues to be in bed on her left side. R6 is not wearing pressure relieving boots and her heels are not being offloaded. On [DATE] at 10:48 a.m. Surveyor observed R6 sitting in a wheelchair at a table in the cafe dining room. On [DATE] at 12:40 p.m. Surveyor asked Former DON-C about R6's heels. Former DON-C informed Surveyor when she did wound rounds on Tuesday she saw scabs. On [DATE] at 12:46 p.m. Surveyor spoke with Former DON-C about R6's pressure injuries. Surveyor informed Former DON-C Surveyor noted R6's pressure injuries were incorrectly staged. Former DON-C informed Surveyor the wound nurse who staged the pressure injuries is out of the country. Surveyor informed Former DON-C the pressure injuries were staged as either Stage 2 or Stage 3 when the wound bed is described as having 95% slough or necrotic tissue. These pressure injuries should have been staged as unstageable. Former DON-C informed Surveyor she wasn't sure why they were staged this way. Surveyor informed Former DON-C Surveyor didn't understand how the pressure injuries weren't identified until there was slough. Surveyor informed Former DON-C R6's care plan was not revised when the pressure injuries were first identified, when they declined, when a coccyx pressure injury was identified on 12/31/19 and when the areas on her heels identified on 1/11/20. Surveyor informed Former DON-C Surveyor was unable to locate any assessment including measurements after 1/11/20. Surveyor informed Former DON-C R6 was not repositioned for multiple hours on 1/21/20 when R6 was in the wheelchair. During the pressure injury treatment LPN-D did not apply skin prep around R6's pressure injury and did not apply a foam dressing over her coccyx according to physician orders. On [DATE] at 1:04 p.m. Surveyor asked Former DON-C to accompany Surveyor to R6's room to look at R6's heels. Surveyor showed Former DON-C R6's heels were not being offloaded and there was one pressure injury boot on the bed. R6's physician's orders [REDACTED]. Surveyor then looked at R6's left heel and showed Former DON-C the necrotic area which Surveyor had observed two days prior. Former DON-C placed the pressure relieving boot on R6's left foot and informed Surveyor she will get another boot for R6. 2.) R7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R7's Annual MDS (Minimum Data Set) dated 11/9/19 documents a BI[CONDITION] (Brief Interview for Mental Status) score of 3, indicating that R7 is severely cognitively impaired. Section G (Functional Status) documents that R7 requires extensive assistance and a two person physical assist for her bed mobility needs. Section G also documents that R7 has total dependence on staff and requires a two person physical assist for her transfer needs. Section M (Skin) documents that R7 is at risk for the development of pressure injuries. R7's Pressure Ulcer/Injury CAA (Care Area Assessment) dated 11/9/19 documents under the Care Plan Considerations section, Is a long term resident. On hospice services. Needs assist with bed mobility, transfers, toileting, eating, locomotion, dressing, hygiene, and bathing. [DIAGNOSES REDACTED]. Is incontinent of bowel and bladder. Has skin integrity impairment. Proceed to care plan skin integrity. R7's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 13, indicating that R7 is at moderate risk for the development of pressure injuries. R7's nursing note dated 10/19/19 documents, Health Status Note: Closed slit to sacral bone is reopened. Approx (approximate).5 cm (centimeters) long. No drainage noted. No s/s (signs and symptoms) of pain. N/S (normal saline) rinse f/b (followed by) [MED] foam dressing applied. Dr (doctor) aware. Surveyor noted that R7 did not have any documented interventions in place for the prevention of pressure injuries prior to 10/19/19, even though the facility assessed R7 to be at risk for the development of pressure injuries on 8/9/19. R7's Sacrum Stage 2 Pressure Injury care plan dated as initiated on 10/28/19 documents under the Focus section, The resident has a stage 2 open area on sacrum. Under the I

Based on observation, record review and interview, the facility did not ensure that 5 (R4, R3, R2, R6, R8) of 6 residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents and falls. * R2 was left unattended sitting on the edge of the bed and fell . Staff found R2 lying facedown on the floor. R2 was hospitalized with significant facial injuries. * R8 fractured his hip after falling on [DATE]. The facility did not investigate to determine the root cause of the fall and if fall prevention interventions were in place as care planned. * R6 was observed to not have fall interventions in place per the plan of care. The facility did not thoroughly investigate falls that had occurred on 1/5/20 and 1/6/20. The facility did not collect statements from staff or determine if fall-prevention measures were in place. * R4 fell on [DATE] and suffered a fractured arm. The facility did not do a thorough investigation after the fall, including gathering staff statements, to determine the root cause of the fall and to determine if fall prevention measures were in place as care planned. * R3 was admitted [DATE] following a right hip replacement. R3 fell on [DATE]. The facility did not have any documented fall interventions in his plan of care until after R3 was discharged from the facility following this fall. Findings include: 1.) R2 was admitted [DATE] and discharged from the facility on 11/25/19. [DIAGNOSES REDACTED]. The ADL (activities daily living) self-care performance deficit care plan initiated [DATE] includes an intervention also dated [DATE] of TRANSFER: The resident requires mechanical lift with (2) staff assistance for transfers with stand up lift. The visual/bedside kardex report provided to Surveyor on 1/21/2020 under the transfer section documents TRANSFER: The resident requires Mechanical Lift with (2) staff assistance for transfers with stand up lift. and under the bed mobility section documents BED MOBILITY: The resident requires extensive assistance by (2) staff to turn and reposition in bed. The Morse fall scale dated 11/25/19 has a score of [AGE] which indicates a high risk for falling. The nurses note dated 11/25/19 documents Writer received a stat call to resident room. Upon arrival noted resident lying face-down at the foot of the bed with head turned to the left and left arm behind her with palm of hand facing upward. Resident assist to her back and head placed of (on) a pillow. R2 stated, I was trying to push myself back and just slid off the bed. She complained of increase pain to left wrist/hand also noted to have swollen closed left eye. Ice pack applied to eye. Bell ambulance called. Son-O made aware requested mom be sent to Froedtert verses Elmbrook. Report called over to ER (emergency room ). Physician-N made aware. Will continue to monitor per plan of care. The verification of investigation dated 11/25/19 documents CNA (Certified Nursing Assistant)-P was interviewed by writer. CNA-P stated she had left R2 sitting at the edge of the bed, leaving her alone in her room, to get assistance to transfer R2 from the bed to her wheelchair. When CNA-P was asked why she had left the resident alone at the edge of the bed, she stated I needed to get another person to help with the transfer. CNA-P stated she had not worked with R2 before and was unsure of how to care of her. When asked if she had been given report, she stated someone told me how some people transfer. CNA-P was asked if she was aware of the Kardex in each resident's room. She replied I knew they were in a folder in everyone's bathroom. When CNA-P was asked if she felt the resident was safe alone in her room at the edge of the bed, she replied, yes. CNA-P stated she needed to physically assist R2 to sit up at the edge of the bed. R2's therapy notes were reviewed. R2 was dependent to max assist for supine to sit. Therapy notes also indicated lack of core strength upon assessment. R2 was also deemed a 2-assist for transfers with the sit to stand to transfer from bed to chair. R2's Kardex reflected that she was a 2-assist for transfers. Under summary and outcome of investigative findings documents CNA-P was found not [MEDICATION NAME] to facility standards of care by leaving R2 (a resident in need of significant assistance for mobility) alone in her room in an unsafe position, which resulted in a fall with significant injury and hospital admission. The nurses note dated 11/25/19 documents Resident admitted to Froedtert hospital with DX (diagnosis): weakness. Will continue to monitor per plan of care. Surveyor was unable to interview CNA-P as she does no longer works at the Facility. On [DATE]20 at 1:48 p.m. Covering Administrator-A and DON (Director of Nursing)-B were informed of the above. 2.) R8's [DIAGNOSES REDACTED]. R8 is receiving hospice services. The at risk for falls care plan initiated 4/22/19 documents the following interventions: Anticipate and meet the resident's needs. initiated 4/22/19. Ask for help sign. initiated 10/29/19. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. initiated 4/22/19. Bed to be placed in lowest position when occupied. initiated 11/6/19. Bilateral fall mats at bedside while bed is occupied. initiated [DATE]. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. initiated 4/22/19. Encourage res (resident) to wear bilateral heel boots. initiated 4/22/19 & revised 10/2/19. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. initiated & revised on 4/22/19. Follow facility fall protocol. initiated 4/22/19. Pt (physical therapy) evaluate and treat as ordered or PRN (as needed). initiated 4/22/19. The nurses note dated 10/29/19 documents resident had a fall, at 0200 (2:00 a.m.) observed resident lying on floor/matt next to bed on his rt (right) side his head was laying against head board causing indentation to head. has been resolving no redness or bruising noted. no further injuries noted. ROM (range of motion) as before no c/o (complaint of) pain or disc. (discomfort) cran (cranial) checks neg (negative) placed on 24 hr (24 hour) report will continues to monitor. The Morse fall scale dated 10/29/19 has a score of [AGE] which indicates high risk. Surveyor reviewed R8's fall investigation for the fall on 10/29/19. Under notes documents IDT (interdisciplinary team) review: Therapy has screened. Resident is on hospice, but requesting therapy. Therapy did not pick up, as family wants to keep resident on hospice services. Intervention: Bed to be placed in lowest position while occupied. Surveyor noted there are no statements from staff as to who last saw R8, when was he last check and changed, etc. The fall investigation does not address whether prior care plan interventions were in place at the time of the fall and what was the root cause for the fall. The nurses note dated [DATE] documents This writer was called to resident room noted him to be lying on the floor on right side by the window. Large hematoma to right forehead, skin tear to right elbow. Resident complained of increase pain to right hip. Forehead iced x (times) 20 min (minutes) per staff nurse. R8 stated When I woke I felt myself rolling. Bell ambulance called due to increase complaints of pain. Physician-N, wife and St. Croix nurse made aware of above. Report given to WMH (Waukesha Memorial Hospital) ER (emergency room ) nurse. Bell here to transport resident to ER for eval (evaluation). The nurses note dated 12/11/19 documents Pt (patient) being monitored r/t (related to) post fall [DATE], distended abd (abdomen), and open areas to skin. Pt A+Ox2 (alert and oriented times two); nonverbal cues of discomfort noted. Repositioned and PRN (as needed) [CONDITION]O4 ([MEDICATION NAME]) helpful with pain management. Bruising to both eyes and [MEDICAL CONDITION] to face noted. Left arm and left leg swelling remains. Radial and pedial pulses present and strong. X-ray ray results from hospital show left hip fx (fracture). Ultrasound abd results shows gallstones. Physician-N updated. NNO (no new orders). Hospice RN (registered nurse) to update family on above. RN Manager updated. Abd remains distended; BS+4 (bowel sounds positive times four); no tenderness with palpation. Inc. (incontinent) small mushy BM (bowel movement). Accepted 50% clear liquid diet. VSS (vital signs stable). MD (medical doctor) and hospice RN to be in facility this afternoon to see pt (patient). The Morse fall scale dated [DATE] has a score of [AGE] which indicates high risk. Surveyor reviewed R8's fall investigation for the fall on [DATE]. Under notes dated [DATE] documents IDT review: No therapy indicated for hospice resident. Bilateral floor mats put in place and hospice to order bed can be lowered to floor level. resident sustained [REDACTED]. Surveyor noted there are no statements from staff as to who last saw R8, when was he last check and changed, etc. The fall investigation does not address whether prior care plan interventions were in place at the time of the fall and what was the root cause for the fall. The nurses note dated [DATE] documents Patient was found hanging out of the bed from the left side of bed, patient is immobile and requires two people assistance with cares, mattress is slippery, used an pillow to support resident from falling out of bed, was re positioned in bed. Hospice called for update. Matt (sic) at the bedside, low bed. Vitals taken and recorded. The nurses note dated [DATE] documents F/u (follow up) fall. Has a small lump to forehead and small red abrasion to forehead. Stayed in bed all am (morning) shift. Denies pain at this time. Surveyor reviewed R8's fall investigation for the fall on [DATE]. Under immediate action taken documents Patient assisted back to bed with three staff members, repositioned in bed and a body pillow placed to the resident ; resident from sliding out again. Ice pack placed to the forehead and Hospice called for update. Surveyor noted under notes documents no notes found. The fall investigation does not address whether prior care plan interventions were in place at the time of the fall and what was the root cause for the fall. On [DATE] at 11:05 a.m. Surveyor met with DON (Director of Nursing)-B to discuss R8's falls on 10/29/19, [DATE] and [DATE]. Surveyor informed DON-B Surveyor had reviewed the Facility's fall investigation for each fall but the investigations did not include staff statements as to when R8 was last seen, when was he last check and changed, whether prior care plan interventions were in place and what the was the root cause of the falls. DON-B informed Surveyor they don't do that here and indicated they will be. 3.) R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (minimum data set) with an assessment reference date of [DATE] has a BI[CONDITION] (brief interview mental status) score of 11 which indicates moderately impaired. R6 requires extensive assistance with one person physical assist for bed mobility, is dependent with two plus persons physical assist, and does not ambulate. R6 is coded as not having any falls. The falls CAA (care area assessment) dated 12/22/19 under care plan considerations documents admitted to facility following hospitalization for acute [MEDICAL CONDITION]. Needs assist with bed mobility, transfers, toileting, locomotion, dressing, hygiene, and bathing. Attends therapy per POC (plan of care). BI[CONDITION] 11. [DIAGNOSES REDACTED]. Fall score 65. Proceed to care plan fall risk. The at risk for falls care plan initiated and revised on 12/22/19 document the following interventions: Anticipate and meet the resident's needs. initiated 12/22/19. Physical therapy to evaluate and treat as ordered or PRN (as needed). initiated 12/22/19. Resident to be an early NOC (night) shift get up to prevent from getting inpatient and re-positioning herself to prevent from rolling off bed. The nurses note dated 1/5/20 documents Resident rolled out of bed on right side. Found on floor on right side. Assessed for injuries. Has a skin tear to right elbow. Area was steri stripped and allevyn applied. Son updated on fall and Former DON (Director of Nursing) RN (Registered Nurse)-C updated call out to MD (medical doctor). Surveyor reviewed R6's fall investigation for the fall on 1/5/20. Under notes documents no notes found. Surveyor noted there are no statements from staff as to who last saw R6, when was she last check and changed, etc. The fall investigation does not address whether prior care plan interventions were in place at the time of the fall and what was the root cause for the fall. The Morris fall scale dated 1/6/20 has a score of 65 which indicates high risk. The nurses note dated 1/6/20 documents CNA (Certified Nursing Assistant) called writer into residents room. Resident was found on floor next to bed. Resident wrapped in blanket, states that she turned over to her right side and rolled off. Resident is alert and verbal, equal bilateral hand grasps, speech clear and appropriate, no noted injuries or skin tears. ROM (range of motion) WNL (within normal limit). Resident c/o (complained of) being sore all over PRN (as needed) [MED] administered. NP (nurse practitioner)-Q on call for Physician-R aware. Son/POA (power of attorney)-S was also called and notified. Will continue to monitor. Surveyor reviewed R6's fall investigation for the fall on 1/6/20. Under notes documents no notes found. Surveyor noted there are no statements from staff as to who last saw R6, when was she last check and changed, etc. The fall investigation does not address whether prior care plan interventions were in place at the time of the fall and what was the root cause for the fall. The nurses note dated 1/7/20 documents res now to have mats by bedside when in bed secondary to fall recently, no further injuries noted and is pleasant and indicates needs, although is very forgetful, has full rom (range of motion), sit to stand transfer and tolerates well. The visual/bedside kardex report as of 1/15/20 under bed mobility documents BED MOBILITY: The resident requires extensive assistance by (1) staff to turn and reposition in bed. Use floor mats on each side of the bed. On 1/16/20 at 2:43 p.m. Surveyor observed R6 in bed on her left side. Surveyor observed there is a mat on the right side of the bed and the bed is down low. Surveyor did not observe a mat on the left side of R6's bed. On 1/16/20 at 4:20 p.m. Surveyor observed R6 continues to be in bed on her left side. Surveyor observed there is a mat on the right side of the bed and the bed is down low. Surveyor did not observe a mat on the left side of R6's bed. On 1/21/20 at 7:11 a.m. Surveyor observed R6 in bed on her right side. Surveyor observed the bed is in the low position and there is a mat on the right side of R6's bed. Surveyor did not observe a mat on the left side of R6's bed. On 1/21/20 at 1:59 p.m. Surveyor observed CNA (Certified Nursing Assistant)-E and CNA-H transfer R6 from the wheelchair into bed using a sit to stand lift. After R6 was transferred CNA-H left R6's room. Surveyor then observed CNA-E provide incontinence care to R6 until 2:09 p.m. Surveyor observed there is a mat on R6's right side of the bed but not on the left side. On 1/21/20 at 3:50 p.m. Surveyor observed R6 continues to be in bed on the left side. Surveyor observed the bed is low and there is a mat on the right side of R6's bed. Surveyor did not observe a mat on the left side of R6's bed. On [DATE] at 7:16 a.m. Surveyor observed R6 in bed on her left side. The bed is down low with a mat on the right side. Surveyor did not observe a mat on the left side. On [DATE] at 9:09 a.m. Surveyor observed R6 continues to be in bed on her left side. The bed is down low with a mat on the right side. Surveyor did not observe a mat on the left side. On [DATE] at approximately 11:10 a.m. Surveyor informed DON-B Surveyor is having the same concern with R6's fall investigations as R6's fall investigation where there are no statements from staff as to who last saw R6, when was she last check and changed, etc. The fall investigation does not address whether prior care plan interventions were in place at the time of the fall and what was the root cause for the fall. Surveyor also informed DON-B of the observations R6 not having a mat on the left side according to her kardex. On [DATE] at 1:48 p.m. Covering Administrator-A and DON-B were informed of the above. 5.) R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4's Admission MDS (Minimum Data Set) dated 10/3/19 documents a BI[CONDITION] (Brief Interview for Mental Status) score of 10, indicating that R4 is moderately cognitively impaired. Section G (Functional Status) documents that R4 requires extensive staff assistance and a one person physical assist for her bed mobility and walking in room needs. R4's Falls CAA (Care Area Assessment) dated 10/3/19 documents under the Care Plan Considerations section, At facility following hospitalization for pneumonia. Needs assist with bed mobility, transfers, toileting, ambulation, dressing, hygiene, and bathing . Had a fall prior to admission. Morse fall score [AGE]. Proceed to care plan fall risk. R4's Morse Fall Scale assessment dated [DATE] documents a falls risk score of [AGE], indicating that R4 is at high risk for falls. R4's Falls plan of care dated as initiated on 10/8/19 documents under the Interventions section, Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; ensure that the resident is wearing appropriate footwear shoes or non-skid socks when ambulating or mobilizing in w/c (wheelchair). R4's nursing note dated 10/11/19 documents, Note Text: Res (resident) found on floor after called out for help at 0625 (6:25 AM)-states she suspects she broke her arm, hurts and cannot get up, vitals stable and blood sugar wnl (within normal limit), called MD (medical doctor) and orders received to send to ER (emergency room ) at WMH (Waukesha Memorial Hospital) for eval (evaluation) and treat, called APOA (Activated Power of Attorney) and updated on change in plane and reports of pain and would like bed hold to take place. Manager on call updated. R4's nursing note dated 10/11/19 documents, Health Status Note: Res (resident) picked up by bell ambulance for transfer to ER (emergency room ) for eval (evaluation) and treat for pain to left arm after falling. Report and paperwork given, res is complaining of left arm pain. R4's nursing note dated 10/11/19 documents, Note Text: Res (resident) returned from WMH (Waukesha Memorial Hospital) with confirmed fracture of humerus, administer [MEDICATION NAME] as ordered prn and set up appointment with ortho (orthopedics), [MEDICATION NAME] administered as ordered res in bed, continues to be seen by therapy, is pleasantly responsive and appropriate, appetite good fed self in bed and takes fluids well. R4's After Visit Hospital Summary dated 10/11/19 documents, Reason for Visit: Fall; Diagnosis: [REDACTED]. R4's Unwitnessed Fall Investigation dated 10/11/19 documents, Per phone conversation with the night nurse, the resident was heard calling out for help .Resident found her on the floor with her head toward the bathroom and feet toward the window; Resident was assessed. Noted guarding and reports of significant pain to left upper arm and shoulder. Surveyor noted that R4's fall investigation dated 10/11/19 did not include any staff statements, a root cause analysis of R4's fall and did not provide information such as when R4 was last seen or if R4's fall interventions were in place prior to R4's fall. Surveyor was unable to locate any documentation or evidence in R4's medical record that R4's falls interventions were in place prior to R4 falling on 10/11/19. Surveyor was unable to locate any documentation or evidence that a thorough investigation that included a root cause analysis, staff statements and other pertinent information such as when R4 was last seen or toileted was completed after R4's fall on 10/11/19. On [DATE] at 9:38 a.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B if there was any documentation or evidence that R4's fall interventions were in place prior to R4's fall on 10/11/19, as Surveyor was unable to locate any evidence or documentation in R4's medical record. DON-B informed Surveyor that she would review R4's medical record and let Surveyor know. On [DATE] at 10:26 a.m., DON-B informed Surveyor that she could not locate any additional information or evidence that R4's fall interventions were in place prior to R4's fall on 10/11/19. DON-B informed Surveyor that she (DON-B) had provided Surveyor with all the information the facility had on R4's 10/11/19 fall. DON-B informed Surveyor that she was not at the facility and could not provide any additional information. No additional information was provided as to why R4 did not have adequate interventions in place to prevent falls in accidents prior to R4's fall on 10/11/19. 6.) R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's Admission MDS (Minimum Data Set) dated 10/17/19 documents a BI[CONDITION] (Brief Interview for Mental Status) score of 6, indicating that R3 is severely cognitively impaired. Section G (Functional Status) documents that R3 requires extensive assistance and a one person physical assist for his transfer and walking in the room needs. R3's Falls CAA (Care Area Assessment) dated 10/17/19 documents under the Care Plan Considerations section, Caa triggered Falls risk r/t (related to) R3 has balance problems with transfers. Not steady only able to stabilize with staff assist. He is s/p (post after) total R (right) hip replacement. He is here for rehab with goal to return home .Proper foot wear maintained and environment is kept hazard free .Proceed to poc (plan of care) and assist and monitor. R3's Morse Fall Scale assessment dated [DATE] documents a score of [AGE], indicating that R3 is at high risk for falling. R3 discharged from the facility on 10/21/19, when R3 was transferred to the hospital. R3 did not return to the facility. R3's nursing note dated 10/21/19 documents, Note Text: Resident alert, confused, was found on the floor laying next to bed by CNA (Certified Nursing Assistant). Resident had call light attached to him, bed was in lowest position, floor mats placed on both sides of bed. Skin tear to right hand measuring 4cm (centimeters) X 1.5cm skin tear to right elbow measuring 3cm X 2.5cm, cleaned with NS (normal saline), steri strips applied, dressings applied to both sites . No c/o (complains of) pain or discomfort. Dressing to Right hip in place C/D/I (clean/dry/intact). ROM (Range of Motion) unchanged. Neuro status unchanged. R3's nursing note dated 10/21/19 documents, Note Text: resident had an un-witnessed fall, bed was in lowest position, call light in place, floor mats in place, Right hip seen externally rotated, daughter was contacted and informed he is being sent to Waukesha memorial hospital, awaiting Dr. (doctor) returning phone call. Surveyor was unable to locate the above interventions (low bed, call light in reach, floor mats to both side of the bed) documented in R3's Falls plan of care until 10/22/19, one day after R3 had discharged the facility. On 1/21/20 at 10:34 a.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B why R3 did not have documented fall interventions in his plan of care until 10/22/19, one day after R3 was discharged from the facility on 10/21/19. DON-B informed Surveyor that she (DON-B) was not at the facility at the time and did not have any additional information and directed Surveyor to speak with RN (Registered Nurse) Manager-G. On 1/21/120 at 10:52 a.m., Surveyor informed RN Manager-G of the above findings. Surveyor asked RN Manager-G why R3 did not have documented fall interventions in his plan of care until 10/22/19, one day after R3 was discharged from the facility on 10/21/19. RN Manager-G informed Surveyor that she did not know why R3 did not have documented fall interventions in his plan of care until 10/22/19, one day after R3 was discharged from the facility. No additional information was provided.

Based upon interview and record review, The facility did not consult with the resident's physician when 1 of 1 residents (R2) had a significant change in his medical condition or provide all pertinent information to the physician when contacted. On [DATE] R2 was diagnosed with [REDACTED]. R2 was started on 60 mg of [MEDICATION NAME] twice daily, 5 mg of [MEDICATION NAME] at bedtime related to the [MEDICAL CONDITION]. R2 was already receiving 81 mg of Aspirin each morning. Review of R2's medical record and review of the facility timeline provided to surveyor indicate R2 may have missed taking a 5mg dose of [MEDICATION NAME] on [DATE] and a 60 mg dose of [MEDICATION NAME] on [DATE]. There is no indication this was communicated with R2's physician. On [DATE] R2 had his initial PT/INR ([MEDICATION NAME]/international normalized ratio - blood test to monitor anticoagulation) completed which resulted in a sub-therapeutic INR rate at 1.6. R2's physician increased R2's [MEDICATION NAME] to 6mg at bedtime at this time. On [DATE] R2 also started to develop nose bleeds. There is no indication the facility monitored R2's nosebleed activity to allow for accurate consultation with R2's physician providing details such as color of blood, frequency and duration of nose bleeds along with treatments attempted to control the nose bleeds. On [DATE] R2 requested to go to the hospital emergency department (ED) instead of [MEDICAL TREATMENT] to have the nose bleeds looked at and to possibly receive cauterization to stop the bleeding. There is no indication R2's physician was consulted with the address R2 not receiving [MEDICAL TREATMENT]. Upon return from the ED a PT/INR was drawn in the facility with a result that was greater than the PT/INR drawn at the hospital. Facility nursing staff contacted Physician-H - who was neither R2's attending physician or part of the attending's medical group nor the facility medical director - who ordered to hold the [MEDICATION NAME] and continue with [MEDICATION NAME]. On [DATE] R2's attending physician, Physician-C, was interviewed who expressed concern with the facility contacting the wrong physician and expressed concern with the treatment decision Physician-H ordered. On [DATE] at approximately 2:52 am progress notes indicate R2 continued to have nose bleeds, had to rinse blood from his mouth and R2 now had a bloodshot eye indicating a second area of bleeding. There is no indication the facility nursing staff consulted with R2's physician at this time. On [DATE] at approximately 10:20 am Physician-C indicated to Surveyor that she would have expected a call with that change so she could have decided what to do for R2. On [DATE] at 11:38 am a facility progress note indicates R2 was to be sent to the hospital noting R2 continued to have nose bleeds, bloody drainage down the back of the throat making it difficult for R2 to eat or drink and R2 has bilateral bloodshot eyes. Facility progress note dated [DATE] at 12:58 indicates: Call received from [NAME] ambulance that resident was diverted to EMH (Elmbrook Memorial Hospital) d/t increased bleeding, starting from the eyes in the ambulance. Review of the hospital record dated [DATE] indicates all of R2's labs were abnormal while at the hospital. R2's PT/INR was INR: 6.8/PT: 84.3/INR: 6.8. The Physical exam indicates: Bleeding from right nare, bright red blood also pours out from right ear duct when nose is clamped. Posterior pharynx reveals blood dripping down back of throat. R2 was treated at the emergency room . Just prior to moving patient to inpatient, he suddenly became diaphoretic, tachypneic, [MEDICAL CONDITION], cyanotic. Despite efforts to treat, Patient remained apneic He suffered cardiorespiratory arrest and was pronounced dead at 3:06 pm. The facility's failure to consult with R2's physician when R2 demonstrated a significant change in condition and to provide all pertinent information when contacted resulted in a situation of immediate jeopardy that started on [DATE] when the facility became aware R2's INR levels were elevated. The facility's administration, including Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-D, were notified of the immediate jeopardy on [DATE] at approximately 1:20 pm. The facility removed the immediate jeopardy on [DATE] when the facility implemented an action plan. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: R2 was long term resident of facility originally admitted on [DATE]. R2's [DIAGNOSES REDACTED]. On [DATE] at approximately 10:20 am Physician-C told Surveyor R2 was a long standing individual with [MEDICAL CONDITION] having received [MEDICAL TREATMENT] for longer than the average 5 years. Review of R2's quarterly Minimum Data Set ((MDS) dated [DATE] and R2's 14 day PPS (prospective payment system) MDS dated [DATE] indicates R2 has a Brief Interview for Mental Status (BIM) score indicating R2 is cognitively intact. The MDS's indicate R2 receives [MEDICAL TREATMENT] and rejection of care was not demonstrated. R2's medical record indicates on [DATE] a telephone order was written for R2 to have a Doppler study to rule out possible [MEDICAL CONDITION] of the left arm. Results of the Doppler study dated [DATE] indicates: Left upper extremity + (positive) for focal [MEDICAL CONDITION] involving mid to distal ulnar veins. Progress notes dated [DATE] at 17:15 indicate: Venous Doppler LUE (left upper extremity) positive for focal [MEDICAL CONDITION] involving mid to distal ulnar veins. Results discussed with (Physician-C) with NOR (new order) to begin [MEDICATION NAME] 60 mg SQ (subcutaneously) bid (twice daily) starting tonight and [MEDICATION NAME] 5 mg po (by mouth) to start [DATE]; INR routine q (every) M/Th (Monday/Thursday) for monitoring. Surveyor noted R2's progress notes indicate the facility's electronic health record flagged order notes indicating the orders being entered for [MEDICATION NAME] and [MEDICATION NAME] triggered drug protocol alerts/warning of potential drug to drug interactions, with an increased risk for bleeding related to R2 having orders for Aspirin 81 mg q am. Review of R2's [DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The [DATE] MAR for evening administration indicates: [MEDICATION NAME] 60 mg administered on pm shift. Review of the [MEDICATION NAME] indicates the MAR indicated [REDACTED]. On [DATE] the facility provided Surveyor with the order progress notes for the [DATE] medication administration. The [DATE] 21:41 order-administration note just restates the order for the [MEDICATION NAME]: [MEDICATION NAME] tablet 5mg give 5 mg by mouth at bedtime for LUE [MEDICAL CONDITION]. Surveyor noted this does not clearly indicate if R2 received this dose of [MEDICATION NAME] as ordered or not. On [DATE] the facility provided Surveyor with a timeline related to R2's care. On this timeline the facility indicates: [DATE] - aspirin not given, [MEDICATION NAME] not given, [MEDICATION NAME] given AM and HS. Surveyor noted this would indicate R2 missed the first scheduled dose of [MEDICATION NAME]. There is no indication R2's physician was consulted with regarding this missed dose. R2's MAR for administration of the evening medication on [DATE] indicates R2 received the first documented dose of [MEDICATION NAME] 5 mg at hs. Surveyor noted the MAR indicated [REDACTED]. Review of the facility order progress notes for [DATE] do not include any documentation regarding R2's hs [MEDICATION NAME] medication administration. Review of the facility provided timeline for R2 on [DATE] has the facility indicating R2 received all anticoagulant medications on that date for all shifts despite no documentation R2 received the pm dose of [MEDICATION NAME]. Surveyor noted there is no documentation to indicate R2's physician was consulted regarding a possible second missed dose in two days of R2's anticoagulant therapy. A progress note on [DATE] at 10:15 am indicates: Resident noted to have epistaxis (nose bleed) - moderate amount bright red blood. Receives ASA (Aspirin) 81 mg, [MEDICATION NAME] and [MEDICATION NAME] due to [MEDICAL CONDITION] upper left extremity. Had received ASA and [MEDICATION NAME] this am prior to nosebleed. Area clamped with nose clamp and applied ice. Lab has drawn PT/INR earlier this am and awaiting results. (Physician-C) paged and awaiting call back. The [DATE] progress note at 11:35 am indicates: Resident had nose bleed. Nose clamp applied and ice. Finally stopped after 15 minutes. (Physician-C) updated. Resident is on [MEDICATION NAME] injections and [MEDICATION NAME] and PT/INR drawn today. (Physician-C) no new orders but wanted to know when PT/INR is drawn and drawn today (sic). Surveyor noted it is unclear if this is a repeat episode of a bloody nose or references an additional episode. Review of the progress notes dated [DATE] at 13:40 include a communication with physician (SBAR - Situation/Background/Assessment-Appearance/Recommendation form). The note indicates: Situation: PT/INR. Surveyor noted the sections for Background and Appearance for SBAR are blank. Recommendations: increase [MEDICATION NAME] to 6 mg daily and recheck INR on Friday. Surveyor noted the SBAR does not include reference to the bloody nose and whether it was isolated or multiple episodes. The SBAR also does not include information regarding possibility R2 did not get anticoagulants on [DATE] and [DATE] prior to the initial PT/INR lab being completed. This could have impacted the decision to increase the resident's [MEDICATION NAME]. Review of R2's medical record indicates a PT/INR lab was drawn at 5:34 am. Results of the lab indicate: [MEDICATION NAME] (PT): 15.0 H (high) reference range (9XXX,[DATE].2). INR: 1.6 The lab indicates INR therapeutic range is 2XXX,[DATE].0 for [MEDICAL CONDITION], PE (pulmonary embolism) and [MEDICAL CONDITION]. Hand written with no date or indication of who made the notation is: (up arrow) increase 6mg recheck referring to R2's [MEDICATION NAME]. On [DATE] at approximately 10:20 am Surveyor interviewed Physician-C who indicated she was aware of R2 having a bloody nose after PT/INR was drawn. When asked about increasing [MEDICATION NAME] despite R2 having the bleeding Physician-C indicated R2 was sub-therapeutic with PT/INR so the [MEDICATION NAME] was increased to achieve therapeutic goal. A [DATE] progress note at 17:06 indicates: Spoke with Physician-C regarding [MEDICATION NAME] . (Physician-C) also updated on increasing episodes of nose bleeds. Orders to have res (resident) seen by (Name of) ENT (Ear Nose and Throat) at EMH (name of hospital) for possible cauterization r/t nose bleeds. Will update POA/HC (power of attorney/health care). Order left for unit secretary to follow up on apt. Surveyor's review of R2's record indicates the ENT appointment was scheduled for [DATE] at 10am. Review of R2's [DATE] MAR/TAR indicates Aspirin in am was refused, the increased dose of [MEDICATION NAME] at 6 mg was administered at HS, [MEDICATION NAME] was administered in am, Surveyor noted the pm dose is coded 9 meaning other/see progress notes. Surveyor noted the order administration progress note dated [DATE] at 20:52 states: [MEDICATION NAME] Solution 60 mg/0.6ML inject 60 mg subcutaneously every morning and at bedtime for LUE [MEDICAL CONDITION]. Surveyor noted this progress note does not clearly indicate if R2 received the [MEDICATION NAME] as ordered or not. The facility provided timeline on [DATE] states: [DATE] [MEDICATION NAME] given, [MEDICATION NAME] given in am and pm, there is no reference to the aspirin. Review of the 24 hour report indicates for [DATE]: N[NAME] shift: no c/o pain /discomfort Monitor LUE for [MEDICAL CONDITION] (no vitals). Day shift: Had some nose bleed no c/o pain, denies pain from [MEDICAL CONDITION] (vitals BP: ,[DATE]). PM shift: INR 1.6 [MEDICATION NAME] increased 6mg (check) INR [DATE]. Continues to have epistaxis episodes - (Physician-C) aware consult with (name of Dr) ENT for poss b/c cauterization. An Interact SNF/NF to Hospital transfer form dated [DATE] and signed by LPN-F at 8:00 am indicates: (R2) has risk alerts of anticoagulation medication, [MEDICAL CONDITION] Left arm and on kidney [MEDICAL TREATMENT]. Surveyor noted despite the reference to R2 being on kidney [MEDICAL TREATMENT] there is no indication on form that this would be the day R2 should receive [MEDICAL TREATMENT] on the transfer form. Upon review of the [DATE] SBAR Surveyor noted that much of the form is missing relevant information. The section for Situation indicates: bleeding off and on x (times) 1 day. Started on [DATE] (Surveyor noted there is no documentation of nose bleeds on [DATE] in record). The section to indicate if worse, same, or better . is blank. Things that make it worse, better etc. is blank. treatment for [REDACTED]. The SBAR includes R2's diagnoses. Medication alerts indicate: [MEDICATION NAME] 6mg daily [MEDICATION NAME] 0.6 BID. Resident is on [MEDICATION NAME]/[MEDICATION NAME] Result of last INR 1.6 on [DATE]. (Surveyor noted this is not an accurate date for this INR result. This was the result of the INR on [DATE]). The SBAR indicates R2 is on hypoglycemic meds, allergies [REDACTED]. Resident/Patient evaluations for mental status and functional status are marked as unchanged. The evaluations for behavior, respiratory, cardiovascular, abdominal/GI, GY/Urine, skin, pain and neurologic are all marked as not clinically applicable. Code status indicates: DNR-No CPR. The section for Appearance/assessment details on the [DATE] SBAR is blank as is the sections for Review and Notify is blank. Sections for Additional nursing notes and testing are blank as is notification to family/healthcare agent. Review of the Emergency Department (ED) notes dated [DATE] at 8:46 am indicates: Chief complaint Epistaxis. HPI: Patient is pleasant [AGE] year old gentleman with a history of [MEDICAL CONDITION] infarction/coronary disease, type 2 diabetes, end stage [MEDICAL CONDITION] on [MEDICAL TREATMENT], hypertension, and [MEDICAL CONDITION] on [MEDICATION NAME]. Here for evaluation of epistaxis x 3 days. Patient states intermittent right-sided nose bleed for 3 days. This resolved with pressure but is persistent and intermittent. He is here by EMS for further evaluate. He denies dizziness or lightheadedness. Vital signs are stable on arrival. On arrival he is noted to be actively bleeding from the right naris. Labs: RBC 3.86, Hgb 12.2, Hct 37.8, RDW 15.3, platelets 148. PT/INR: 43XXX,[DATE].5. and are flagged as abnormal. Medical decision making: Here with nose bleed, differential to epistaxis secondary to excessive anticoagulation on [MEDICATION NAME], also on aspirin consider anterior versus posterior nosebleed. On exam there is evidence for active bleeding from the anterior septum. Clots were evacuation, add, Neo-Sunephrine was used for vaso [MEDICATION NAME], patient did have cauterization of his right anterior septum. Will check basic labs to assess for [MEDICAL CONDITION], excessive anticoagulation, consider packing of the nasal passages if persistent bleeding. ED course 9:00 am Hemoglobin of 12.2 appears to be a chronic [MEDICAL CONDITION] baseline is 11.1. INR is slightly elevated at 3.5 and slightly supratherapeutic. Final Diagnosis: [REDACTED]. The records provided to Surveyor during the survey regarding the [DATE] hospital information do not include details regarding any recommended treatments, medication orders or monitoring post discharge from the emergency department (ED). On [DATE] and [DATE] Surveyor asked DON-B and ADON-D repeatedly for information regarding R2's trip to the ED on [DATE]. On [DATE] at approximately 1:26 pm DON-B indicated R2 went to the ED at his request instead of [MEDICAL TREATMENT] because he wanted to get his nose cauterized. DON-B indicated the facility followed up on orders from the ED because it was the ED who recommended the ENT. Surveyor had to clarify that the ENT was ordered prior to ED. Surveyor noted upon further review of R2's medical record R2 had orders [MEDICATION NAME] spray to start [DATE], 2 sprays every 1 hour for nosebleed and Vaseline BID for bleeding. When asked, facility staff could not explain where these treatments originated or if there was any indicated monitoring recommended by the hospital post ED visit with cauterization. Review of R2's medical record indicates there is no documentation in the progress notes to indicate when R2 returned to the facility from the ED, what his condition was or recommendations made. Surveyor noted there is no indication a physician was communicated with regarding R2 missing [MEDICAL TREATMENT] on this date. R2's labs indicate a PT/INR was drawn at the facility at 14:00 on [DATE]. Results of PT/INR were PT: 41.8/INR: 4.8. Surveyor noted PT is flagged as high with reference range of (9XXX,[DATE].2). Handwritten on lab slip is ,[DATE], update (Physician-H) New Order - Hold [MEDICATION NAME] over the weekend check INR M (Monday) Continue to give [MEDICATION NAME]. Surveyor noted there is no reference whether to continue or discontinue R2's aspirin order. Surveyor noted R2's INR drawn earlier in morning at the ED was flagged as elevated at 3.5. R2 had a second lab completed at 14:00 (potentially shortly after R2 returned to the facility) indicating it had increased in value since the earlier hospital visit. Review of a progress note dated [DATE] at 21:11 indicates: updated (Physician-H) New order received. Hold [MEDICATION NAME] over the weekend (Sat & Sun) Re check INR M (Monday) Continue to give [MEDICATION NAME]. On [DATE] at approximately 10:20 am Surveyor interviewed Physician-C about R2 going to the ED. Physician-C indicated she learned later that R2 wanted to go there (to the ED) instead of [MEDICAL TREATMENT]. During the interview, Physician-C reviewed R2's labs in his record and noted the increase in INR from the ED to the facility. Surveyor asked about contact with Physician-H and the decision to continue [MEDICATION NAME] and hold [MEDICATION NAME] with the lab result. At this question, Physician-C shared she was very upset about this. She indicated Physician-H is not a physician within her medical group and not the facility medical director so he (Physician-H) should not have been contacted or giving orders on her patient (R2). Physician-C indicated she would not have maintained the [MEDICATION NAME] as Physician-H did. Physician-C indicated at this point she would have held both the [MEDICATION NAME] and the [MEDICATION NAME] and with the INR at 4.8 she would have considered giving vitamin K especially if R2 was continuing to have nose bleeds. Review of the progress note dated [DATE] at 21:12 indicates: Nose bleed on/off throughout PM shift. Applied Cotton balls, ice, nose clip, Vaseline. Review of R2's MAR/TAR for [DATE] indicates a code of 9 (other-see progress notes) for the aspirin. Surveyor noted there is no progress order note regarding the aspirin. R2's [MEDICATION NAME] is documented as held on [DATE]. [MEDICATION NAME] is marked as 9 (other-see progress notes) for am. Review of the order-administration progress notes include a note dated [DATE] at 7:47 indicates: sent to ER for nose bleed. Surveyor noted there is no note explaining the administration of the [MEDICATION NAME] on the pm shift and the coding of 2 which would indicate the drug was refused on PM shift. Surveyor noted there is no indication R2's physician was contacted to let them know R2 refused the [MEDICATION NAME] despite having a [MEDICAL CONDITION]. A progress noted dated [DATE] at 2:52 am indicates: On 24 hour report d/t [MEDICAL CONDITION] to left arm currently [MEDICATION NAME] in (sic) hold over weekend. INR results 4.8 resident has had a nose bleed was out to hospital in am nose started bleeding on pm shift has stopped bleeding after nose clamp applied for a while. Some blood in mouth, was rinsed out, left eye appears blood shot. PRN [MEDICATION NAME] given for [MEDICAL CONDITION]. Surveyor noted there is no indication the facility contacted R2's physician for consultation with the bleeding to now include a blood shot eye in addition to the continued nose bleeds. On [DATE] at 3:35 pm Surveyor interviewed Registered Nurse (RN)-G regarding R2. RN-G indicated R2 was having bloody noses; that they seemed to stop when R2 would be lying down but as soon as he got up or if they removed the clip or ice or anything they were using to stop the bloody nose, it would start back up. RN-G indicated R2 was just exhausted and the bleeding kept happening and she did not know what to do for him. RN-G indicated they would think the bleeding had stopped and wonder should we or shouldn't we remove the clip? They would remove the clip and it would start right back up again. Surveyor asked about the blood shot eye and if RN-G had considered contacting the physician with the added bleeding from a second location. RN-G indicated no, she did not call the doctor. RN-G indicated she wasn't sure if that was change or if she heard he came back from the ED with the blood shot eye. Surveyor noted there is no documentation regarding R2's condition upon return from ED. RN-G repeated R2 was just exhausted; the blood was getting in his mouth, he was anxious. RN-G indicated she told R2 he had a medication for sleep ([MEDICATION NAME]) that might help him relax to sleep so she gave him the [MEDICATION NAME]. Surveyor noted R2 does not have a care plan for sleep and there is no additional documentation on 3rd shift regarding R2 and his status the rest of the night. Review of the 24 hour report for the N[NAME] shift [DATE] indicates: Nose bleeding at beginning of shift appears to have stopped 0200 [MEDICATION NAME] given d/t [MEDICAL CONDITION] on hold this weekend. On [DATE] at approximately 10:20 am Surveyor interviewed Physician-C regarding R2's change in condition with the [MEDICAL CONDITION], anticoagulants and nose bleeds. Surveyor asked if she would have expected to be consulted with on the evening of ,[DATE]-[DATE] when R2 continued to have nose bleeds and R2 was now saying blood was in his throat and his eye was bloodshot. Physician-C indicated yes, that he (R2) would have been sent out or given vitamin K or something. R2's record indicates the next progress note is at 10:26 am indicating: Call to resident room at 10 am re: nose bleed. Resident has constant nasal (blood) drip noted cool compress applied x 10 minutes, attempted to place nose clip on resident refused stated I can feel the blood and (sic) the back of my throat. Ice applied at this time. Left eye is blood shot red. Denies pain or discomfort. Call placed to (Physician-I) on call for (Physician-C). The next progress noted dated [DATE] at 11:38 am is a transfer to the hospital summary indicating: TL (team leader) updated. (Physician-I) on call for Physician-C at 11:15 that resident nose continuously bleeding (sic) causing much drainage down the back of throat making him unable to eat and drink this am. Blood vessels burst to bilateral eyes this AM. NOR to send to WMH (Waukesha Memorial Hospital). TL updated resident that he is going via ambulance as well as dtr (name of daughter) at 11:30. Ambulance en route. Resident refused AM [MEDICATION NAME] and AS[NAME] [MEDICATION NAME] remains on hold. Resident also refused to wear clamp or pack it. Applying pressure with tissue and ice applied x1. Progress note dated [DATE] 12:58 indicates: Call received from [NAME] ambulance that resident was diverted to EMH (Elmbrook Memorial Hospital) d/t increased bleeding, starting from the eyes in the ambulance. TL called to EMH and report given. Voice message also left for dtr (name of) updating on change of change in hospital. Review of the hospital ED record dated [DATE] indicates visit started at 12:08 am. (Surveyor noted this is approximately 2 hours after LPN-J was first called to R2's room.) Chief complaint: Patient presents to the emergency department for evaluation of nose bleed. He was seen yesterday in the emergency department for same symptoms. At that time ER (emergency room ) physician used silver [MEDICATION NAME] to cauterize the bleed and that the SNF does not want him back until all bleeding has stopped. Apparently the patient was on [MEDICATION NAME] but that was supposed to have stopped on Thursday due to supratherapeutic INRs. He has been receiving [MEDICATION NAME]. The MAR from Care Age SNF was not sent to the emergency department to verify whether he was receiving [MEDICATION NAME] or not. No recent fall or injury reported. Patient reports that he is also swallowing blood. Physical exam: Bleeding from right nare, bright red blood also pours out from right ear duct when nose is clamped. Posterior pharynx reveals blood dripping down back of throat. The [DATE] emergency record indicates Labs results of: INR: 6.8/PT: 84.3. RBC: 3.10, Hgb: 9.8, Hct: 30.0, RDW 15.6, Platelets 146, Segs 79.1, Lymphocytes 10.3, Lymphocytes absolute 0.6, potassium 5.2, chloride: 99, BUN 132, Creatinine 6.25, Glucose 132. Alkaline [MEDICATION NAME] 181, Anion Gap 24, BUN/Creatinine Ratio 21. All lab results were flagged as abnormal. ED Course indicates: Patient thoroughly examined. Medical records, nursing notes, vs reviewed. IV, labs, ekg ordered. Neosynephrine sprayed in nares. Rhino rocket 5.5 cm soaked in saline, coated in lube and slid gently in right nare by me. Balloon inflated with air and secured with mustache dressing. Patient tolerated well. Labs show elevated INR 6.8 drop in Hb to 9.8 down from 12 on ,[DATE]. Platelets low at 148. Patient low at 148. Patient treated with vit K 5mg IV. Type and cross for FFP, 2 units ordered. D/w (discussed with) hospitalist and (name of) ENT (surveyor noted this is the ENT resident was to see on [DATE]). Recheck shows patient stable, tolerating rhinorocket. Just prior to moving patient to inpatient, he suddenly became diaphoretic, tachypneic, [MEDICAL CONDITION], cyanotic. I went to bedside to suction patient's mouth, assist respirations, rhinorocket removed and suctioning to airway and nose. New larger rhinorocket placed by me, 7.5. Patient continued to have respiratory distress, with tachypnea, cyanosis, [MEDICAL CONDITION] There is dnr order on chart respirations assisted for comfort to alleviate distress. Oropharynx suctioned by me, patient became apneic, I was concerned about aspiration of blood clot and therefore I performed direct laryngoscopy and suctioned airway and looked for clot or other fb (foreign body). No clot or fb seen. Vocal cords visible and clear no movement. Patient remained apneic He suffered cardiorespiratory arrest and was pronounced dead at 3:06 pm. Facility progress note dated [DATE] at 18:44 indicates: RN from EMH-ER called at approx. 1700 and updated writer that resident has passed away. No dx (diagnosis) given. Did state family was updated. RN supervisor updated on above. Cross reference F757. The facility's failure to consult with R2's physician when a significant change in medical condition occurred while receiving anticoagulation medications and side effects developed and its failure to provide all pertinent information when contact was made created a situation of immediate jeopardy that started on [DATE]. The facility removed the immediate jeopardy on [DATE] when the facility implemented the following action plan: ~ Residents receiving anticoagulants were reassessed by nursing staff for potential adverse effects of the medications or changes in condition. ~ Labs for each resident on anticoagulants were drawn and reviewed with attending physicians to ensure proper dosage and monitoring. ~ The pharmacy consultant completed record and medication reviews for residents on anticoagulants and any concerns were presented to the attending physicians. ~ The policies for managing medication order alerts, unnecessary medications, identifying and monitoring resident change in condition and physician notification were reviewed and revised. ~ Care plans for residents on anticoagulant medications were reviewed and updated as appropriate. ~ The facility engaged in hiring an outside consultant to assist with process improvement. ~ Education was provided to licensed staff on managing medication alerts, drug interactions, change in condition and physician notification. ~ The facility developed a QAPI process to monitor and ensure ongoing compliance.

Based on interview and record review, facility staff did not ensure 4 of 4 Residents (R10, R9, R1 and R4) who entered the facility without a pressure injury did not develop a pressure injury; nor did staff provide care and services in accordance with accepted standards of practice once a pressure injury was identified. * R10 currently has 3 stage 4 pressure injuries. On 9/28/18 R10 developed a wound on the RLE (right lower extremity) that was first assessed as arterial, then re-assessed as pressure related. There are not consistent, accurate or weekly assessments of the wound, nor did the facility develop a comprehensive plan of care for this wound. On 10/31/18 R10 developed an unstageable pressure injury on the sacrum. There are not consistent, accurate or weekly assessments, and the facility did not develop a comprehensive plan of care for this wound. On 12/7/18 developed a wound to the LLL(left lateral leg) that was first assessed as arterial, then re-assessed as pressure related. There are not consistent, accurate and weekly assessments, and a comprehensive plan of care was not developed for this wound. R10's medical record did not contain supporting evidence that the development of the lower leg wounds were arterial in etiology. The facility's failure to accurately and consistently assess R10's wounds, and develop a comprehensive plan of care with their development, created a finding of immediate jeopardy that began 3/22/19. This was when the leg wounds were accurately documented and assessed as stage 4 pressure injuries. On 7/1/19 at 4:03 PM Surveyor notified Administrator-A, DON-B (Director of Nurses) and ADON-D (Assistant Director of Nurses) of the immediate jeopardy with R10's pressure injuries assessments and plan of care. The immediate jeopardy was removed on 7/3/19. The deficient practice continues at a scope and severity level of G (actual harm/isolated) based upon the additional examples regarding R9 and R1. * R9 had an unstageable pressure injury on the right heel that resolved on 2/15/19. On 4/7/19 the right heel developed an unstageable pressure injury. There are no consistent/weekly assessments of this pressure injury. There wasn't a comprehensive plan of care developed with the first onset and the re-development of the pressure injury. * Staff identified open areas on R1's natal cleft/buttock 1/31/19, but the first assessment and measurement of the areas was not until 3/8/19, when one of the pressure injuries had 70% slough, though they did obtain some orders in February. A care plan was not developed for pressure injuries until 4/5/19. The care plan developed 4/5/19 indicated the pressure injuries were partially due to frequent incontinence of bowel, yet there was no assessment of the bowel incontinence nor care plan developed for the incontinence that was determined to be a causal factor of R1's pressure injuries. When the wound doctor first saw R1 on 3/22/19, R1 had an unstageable pressure injury to right and left buttocks, the left measuring 4.5 x 5.0 cm. 100% covered with thick black eschar. * The facility did not develop a care plan to address R4's risk for the development of pressure injuries despite being assessed as being at risk. On 6/9/19 facility staff observed reddened areas on R4's feet. The areas were not assessed until 2 days later by the facility wound physician. A plan of care was not developed to address R4's risk for developing pressure injuries from tight fitting shoes. Findings include: Facility Policies and Procedures: Pressure Injury Overview- Clinical Protocol (revised (MONTH) (YEAR)). Assessment and Recognition 1. Nursing staff and/or practitioner will assess and document an individual's significant risk factors for developing pressure ulcers . 2. In addition, the nurse shall describe and document/report the following: a. Wound appearance and status b. Pain assessment c. Resident's mobility status d. Current treatments, including support surfaces and e. All active diagnoses. 3. The staff and practitioner will examine the skin of newly admitted residents . 4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. 5. The physician will help identify and define any complications related to pressure ulcers. Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown . 2. The physician will clarify the status of relevant medical issues . Treatment/Management 1. The physician will order pertinent wound treatments . 2. The physician will help identify medical interventions related to wound management . 3. The physician will help staff characterize the likelihood of wound healing based on a review of pertinent factors . 4. As needed, the physician will help identify the medical and ethical issues influencing wound healing . Monitoring 1. During physician visits, the physician will evaluate and document the progress of wound healing . 2. The physician will guide the care plan as appropriate . Prevention of Pressure Ulcer/Injuries (Revised July, (YEAR)) . Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. 1.) R10's medical record was reviewed by Surveyor. R10 has resided in the facility since 5/12/17. R10 is totally dependent on staff for activity of daily living. R10 DOES NOT have [DIAGNOSES REDACTED]. On 6/26/19 at 9:26 AM Surveyor observed R10 in their bed. The head of the bed was elevated and R10's upper torso was turned to the left and slouched over. R10's legs were straight out with the heels resting on the mattress. The balls of the feet were against the edge of the foot board. The air mattress was on and functioning. On 6/26/19 at 11:06 AM Surveyor observed R10's pressure injury treatments to their legs and sacrum. R10 has stage 4 pressure injuries to these areas. LPN-U (Licensed Practical Nurse)performed the treatment. R10 did not express any pain during the dressing changes. The lower leg wounds look like a mirror image of each other. The surrounding skin around all 3 wounds appeared uneventful. R10 did not have any discoloration on their legs or feet. The wound beds appeared as currently documented on 6/26/19 by the Wound team. The right lateral calf : measures 17.0 cm (centimeter) x 3.0 cm x 0.1 cm. no pain with procedure. There is 10% slough, 90% granulation and moderate amount of serous drainage. The left calf: measures 15 cm x 2 cm x 0.1 cm. There is 10% slough and 90% granulation. There is a moderate amount of serous drainage. The sacrum: measures 8 cm x 7.5 cm x 0,8 cm with undermining 1 cm at 10' clock. There is 100% granulation with moderate amount of serous drainage. These are identified as stage 4 pressure injuries. There were no wounds identified on the heels or soles of the feet during this observation. MDS (minimum data set) ASSESSMENTS R10's MDS assessments were reviewed by Surveyor * The Quarterly MDS assessments completed on 6/15/18 and 9/13/18 indicate no pressure injuries or vascular ulcers. The assessments indicate R10 is at risk for pressure injuries. * The Annual MDS assessment completed on 12/4/18 indicate 1 stage 4 pressure injury and 1 vascular ulcer. Per Skin/Wound note on 9/28/19 there is a arterial wound on the lateral right lower leg. The wound measures 4.1 cm x 2.0 cm. The wound bed has 100% granulation tissue. No pain or symptoms of infection. There is no other assessment information documented to support the [DIAGNOSES REDACTED]. * The Quarterly MDS assessment completed on 2/22/19 indicates 1 stage 4 pressure injury and no vascular ulcers. Per Skin/Wound note on 2/22/19 there are 3 wounds. The sacrum has a stage 4 pressure injury measuring 7.5 cm x 5.6 cm with undermining 9-2 o'clock x 2.5 cm. The RLE ( documented as a arterial ulcer) measures 11.5 cm x 3.9 cm with no signs of pain or infection. The LLE ( documented as a arterial ulcer) measures 11.3 cm x 4.3 cm with no signs of pain or infection. Per Skin/Wound note on 5/8/19 there is 3 stage 4 pressure injuries. These are the same wounds that were initially assessed with [REDACTED]. The sacrum measures 8 cm x 7.5 cm x 1.0 cm with undermining 1.5 cm at 11 O' clock. The RLE measures 15 cm x 2.5 cm x 0.5 cm. The LLE measures 12.5 cm x 3 cm x 0.5 cm. There is no documented pain with these wounds. * The Quarterly MDS assessment completed on 5/10/19 indicates 4 stage 4 pressure injuries and no vascular ulcers. According to the Vascular Center of Wichita Falls, which is an accredited facility for vascular testing, copyright 2019. Arterial ulcers: Characteristics: usually on the toes and feet; frequently painful; associated with cold, bluish shiny feet; may have a gray colored wound base; Doppler arterial testing. Primary treatment: the goal is to increase circulation to the area either surgically or medically. On 6/26/19 at 8:45 AM Surveyor spoke with DON-B (Director of Nurses) regarding R10's pressure injuries. DON-B indicated they took over the role as DON around 6 months ago. When they took over the DON role they heard R10's leg wounds were caused by a heel lift device. DON-B could not confirm that. DON-B indicated they thought they were pressure related and not arterial. They felt the wound physician during this time period was not assessing resident correctly. The facility did terminate that wound physician contract. The new wound physician started 3/22/19 and assessed R10's wounds as pressure related. The current wound physician assessed R10 as pressure related. DON-B indicated the previous MDS Nurse and the Nurse Manager for that unit have been terminated. On 6/26/19 at 2:13 PM Surveyor spoke with RN-N (registered Nurses), who is the Manager and WCC (Wound Care Certified). RN-N took over the wounds on the unit in (MONTH) (YEAR). R10 already had the wounds. RN-N indicated the previous wound physician assessed the lower legs as arterial. The new wound physician took over 3//22/19 and is assessing the wounds as stage 4 pressure injuries. RN-N completed the MDS Quarterly assessment on 5/10/19 as pressure injury, however the number of wounds was not coded correctly. RN-N does know the history of the wounds. RN-N in their professional assessment indicated they appear as pressure injuries. CARE PLAN The Plan of Care includes the resident has stage 4 pressure ulcer sacrum and bilateral posterior legs related to immobility and terminal illness. This has an initiated date of 10/17/18, however this does not correlate with wound development. The revision date is 4/22/19. The interventions have initiated dates of 4/2/19 with a few revision dates of 6/26/19. The plan of care does not include revisions with the onset of new wounds, nor intervention prevention with revisions. The goal date is 8/10/19 and the interventions include: * administer medications and treatments as ordered. It does not include what they are administering. * Assess/ monitor/ record wound healing * educate resident and family on causes of skin breakdown * if resident refuses treatment involve IDT (interdisciplinary team) to develop alternatives * instruct to shift weight in wheelchair every 15 minutes * monitor dressing * monitor/document/report changes * monitor lab/diagnostic work as ordered * teach resident/family importance of positioning changes for prevention of pressure ulcers. encourage small and frequent position changes The above interventions have dates of 4/2/19. There is not evidence of identified wounds with onset and interventions. On 6/27/19 at 1:43 PM Surveyor requested R10's comprehensive plan of care information from DON-B and ADON-D. As of 7/1/19 at 1:45 PM there was no addition information found related to R10's plan of cares. PRIMARY PHYSICIAN/ NURSE PRACTITIONER NOTES * Progress note dated 10/11/18. Indicates R10 is followed by the wound physician. The handwritten notes include an unstageable sacral ulcer and RLE arterial wound per wound Physician. Has chronic bilateral extremity weakness and foot drop. The A/P(action/plan) include: pressure ulcer to RLE and sacral continue current treatment. * Progress note dated 11/2/18. Indicates R10 is followed by a wound physician and has a sacral pressure ulcer and a RLE arterial wound. * Progress note dated 4/2/19. Indicates R10 has a sacrum stage 4 pressure injury. The new wound physician assesses the lower leg ulcers as stage 4 pressure ulcers. The A/P includes stage 4 pressure ulcers to sacral and bilateral lower legs. SKIN/WOUND ASSESSMENTS RIGHT LOWER EXTREMITY * 9/28/18 arterial wound measuring 4.1. cm x 2.0 cm No documented assessment until 10/17/18. A gap in consistent assessment of the wound. * 10/17/18 arterial wound measuring 2.3 cm x 0.9 cm. Next documented assessment is 10 days later on 10/26/18. * 10/26/18 arterial wound measuring 3.2. cm x 1.4 cm x 0.4 cm. Next documented assessment is 6 days later on 11/2/18 * 11/2/18 arterial wound measuring 2.62 cm x 1.56 cm x 0.4 cm Next documented assessment is 14 days later on 11/16/18 * 11/16/19 arterial wound measuring 2.12 cm x 1.18 cm x 0.4 cm Next documented assessment is 22 days later on 12/7/18 * 12/7/18 arterial wound measuring 7.17 cm x 2.12 cm x 0 cm * 12/14/18 arterial wound measuring 7 cm x 2.2 cm Next documented assessment is 15 days later on 12/28/18. * 12/28/18 arterial wound measuring 8.2 cm x 2.5 cm Next documented assessment is 43 days later on 2/8/19 * 2/8/19 arterial wound measuring 9.45 cm x 3.5 cm * 2/15/19 arterial wound has been assessed weekly up to this survey On 3/22/19 with the start of a new wound physician the area is now considered a stage 4 pressure injury. *3/22/19 stage 4 pressure injury measuring 13 cm x 3.5 cm x 1 cm. this is assessed weekly with the most recent assessment being 6/26/19 * 6/26/19 stage 4 pressure injury measuring 17 cm x 3 cm x 0.1 cm SKIN/WOUND ASSESSMENTS LLE (left lower extremity) * 12/7/18 arterial wound measuring 6.89 cm x 2.3 cm x 0.1 cm * 12/14/18 arterial wound measuring 6.4 cm x 2.2 cm x 0.2 cm Next documented assessment is 15 days later on 12/28/19 * 12/28/19 arterial wound measuring 2.5 cm x 2.0 cm Next documented assessment is 43 days later on 2/8/19 * 2/8/19 arterial wound measuring 4.52 cm x 1.48 cm. * 2/15/19 arterial wound measuring 7.2 cm x 2.2. cm. This wound has weekly assessments up to the time of survey. On 3/22/19 a new wound physician started and assessed this as a stage 4 pressure injury. * 3/22/19 stage 4 pressure injury measuring 15 cm x 4 cm x 1 cm This has been assessed weekly with the most current assessment being 6/26/19 * 6/26/19 stage 4 pressure injury measuring 15 cm x 2 cm x 0.1 cm SKIN/WOUND ASSESSMENTS SACRUM * 10/26/18 US (unstageable) PI (pressure injury) measuring 5.35 cm x 4.03 cm x 0.10 cm The next documented assessment indicates 2 separate assessments of the sacrum. The wound pictures appear to have 2 areas, however the documentation does not indicate this. *11/2/18 US PI measuring 2.4 cm x 2.6 cm x 1.2 cm * 11/2/18 US PI measuring 3.0 cm x 2.8 cm x 1.0 cm Next documented assessment is 14 days later on 11/16/19 and there is just one sacrum assessment. The documentation does not indicate what occurred. * 11/16/18 Stage 4 PI measuring 2.6 cm x 3.0 cm x 1.2 cm with 2.5 cm undermining Next documented assessment is 22 days later on 12/7/18 * 12/7/18 Stage 4 PI measuring 2.79 cm x 4.8 cm x 1.2 cm with 2.0 cm undermining. * 12/14/18 Stage 4 PI measuring 2.8 cm x 4.6 cm x 1.3 cm with 1.9 cm undermining. Next documented assessment is 15 days later on 12/28/18 * 12/28/18 Stage 4 PI measuring 3.8 cm x 3.9 cm x 1.8 cm with 1.9 cm undermining Next documented assessment is 43 days later on 2/8/19 * 2/8/19 stage 4 PI measuring 4.17 cm x 3.28 cm x 1.9 cm with 1.8 cm undermining This has been assessed weekly with the most current assessment on 6/26/19 * 6/26/19 Stage 4 PI measuring 8 cm x 7.5 cm x 0.8 cm On 6/26/19 at 2:13 PM Surveyor spoke with RN-N who has been documenting R10's wounds since 12/2018. RN-N indicated they took over the position in (MONTH) and goes with the wound physician on rounds. RN-N was on vacation in 1/2019 and does not know who took over the wound assessments, nor why there are none documented. On 6/26/19 at 3:55 PM DON-B indicated that the previous wound physician would not send their dictation timely. DON-B will look for any additional wound assessments. DON-B indicated that at the time the wound was observed the orders for treatment would change when the dictation came back several days later. R10's Skin/wound assessment on 11/16/18 indicates to use a wound vac. The Treatment Administration Record indicates this was not provided until 5 days later. The wound vac was discontinued on 12/7/18. On 6/27/19 at 1:43 PM DON-B indicated they were still attempting to locate any missing wound assessments. On 7/1/19 at 1:05 PM DON-B and ADON-D spoke with Surveyor. DON-B indicated they spoke with the current wound physician to review the wound assessments and determine if Doppler studies are needed. DON-B did not provide any additional care plan information. DON-B did not provide any additional wound assessments. DON-B provided a Doppler exam conducted on the right lower extremity on 10/19/17. This diagnostic test indicates generally mild [MEDICAL CONDITION] vascular disease. DON-B indicated the lower legs are a mixed etiology of arterial and pressure. There is not a plan of care identifying the onset of these wounds with interventions. There is not a comprehensive management of the progression of the wounds. On 7/1/19 at 4:03 PM Surveyor told Administrator-A and DON-B of the immediate jeopardy with R10's wounds starting on 3/22/19 with the assessment of stage 4 pressure injuries. The facility's failure to provide proper pressure injury prevention and care based upon standards of practice created a situation of immediate jeopardy. The facility implemented the following action plan: ~ Resident 10's plan of care for skin integrity was reviewed and updated on 7/2/19. ~ Resident 10 had a full body check completed for identification of all skin alterations. Current skin alterations were assessed and have associated documentation. ~ Facility skin sweeps was completed on 7/2/2019. All resident's had full skin assessment to identify any skin alterations. Identified areas were documented appropriately. Result of skin sweeps will be reported to QAPI committee. ~ Residents with current pressure injuries will have skin assessments daily to note any skin changes immediately. ~ Upon admission, a Braden Scale will be conducted to identify resident's at risk for pressure injuries. Appropriate interventions will be put in place and documented in the resident's plan of care based on the resident's identified level of risk. ~ DON/designee will review care plan and interventions to prevent wound development and ensure comprehensive skin prevention care plan is in place for at risk residents weekly x 3 months. ~ Residents with skin alterations will be assessed and documented weekly by RN Unit Manager/designee. ~ Resident's with actual skin impairments will have a plan of care to promote healing completed upon identification of skin impairment ~ Weekly audit will be conducted to ensure weekly documentation of skin alterations and associated plan of care is in place by DON/designee. Results of audit will be reported monthly to QAPI committee x 3 months. ~ Education with licensed nurses was completed on 6/25 for documentation of skin alterations. ~ Education was completed with RN Managers regarding weekly wound documentation expectations, completing a comprehensive plan of care for resident's at risk for skin alterations and resident's with current skin alterations. The immediate jeopardy was removed on 7/2/19 however the deficient practice continues at a scope and severity of a G (actual harm/isolated) based upon the additional examples regarding R9 and R1. 2.) R9's medical record was reviewed by Surveyor. R9's Admission MDS (minimum data set) assessment completed on 9/11/18 indicates an unstageable PI (pressure injury) measuring 3 cm x 3 cm. The CAA (care area assessment ) dated 9/13/18 for Pressure Injury does not indicate vascular ulcers and an unstageable right medial heel. SKIN/WOUND ASSESSMENTS RIGHT MEDIAL HEEL * 9/12/18 first assessment of the right heel by the wound physician. A US (unstageable) PI (pressure injury) measuring 2.63 cm x 3.37 cm x 0.10 cm Next documented assessment is 14 days later on 9/26/18. * 9/26/18 US PI measuring 2.5 cm x 3.5 cm The wound is assessed weekly up to 10/17/18 * 10/17/18 US PI measuring 2.17 cm x 2.56 cm eschar covered Next documented assessment is 17 days later on 11/2/18 * 11/2/18 US PI measuring 2.01 cm x 3.06 cm x 0.8 cm. There is 2 separate wound assessments for the same area. There is not documentation indicating why this occurred. * 11/2/18 US PI measuring 2.01 cm x 2.72 cm Next documented assessment is 36 days later on 12/7/18. *12/7/18 US PI measuring 1.5 cm x 1.4 cm x 0.3 cm Next documented assessment was 15 days later on 12/21/18 * 12/21/18 US PI measuring 1.5 cm x 2.0 cm x 0.1 cm * 12/28/18 US PI measuring 1.1 cm x 1.0 cm x 0.1 cm * 1/4/19 US PI measuring 1.7 cm x 1.5 cm x 0.1 cm On 1/28/19 there is a Progress Note that indicates 2 intact blisters to the right heel. No additional measurements or characteristics. On 2/15/19 there is a Progress Note that the right heel is resolved. There is no documented assessment from 1/4/19 through 2/15/19. The Progress Note on 4/7/19 indicates there is a open area on the right heel where the callous fell off. There is a measurement of 3 cm x 1 cm and no depth. The Progress Note on 4/20/19 indicates the open are to the right heel appears larger with foul smelling drainage. On 4/23/19 is the first comprehensive assessment of the right heel. This was by the wound physician. * 4/23/19 US PI measuring 5.5 cm x 5.5 cm x 0.1 cm This is assessed weekly with the most recent assessment date of 6/25/19 * 6/25/19 US PI right heel measuring 6 cm x 4 cm x 0.1 cm CARE PLAN R9 has a plan of care identifying an unstageable pressure injury to the right heel. This has an initiated date of 4/22/19 and revision date of 6/25/19. There is not evidence there was a plan of care initiated with the onset of the right heel PI developing on 4/7/19. The interventions are initiated on 4/22/19. The care plan does not include interventions to prevent the development of the ulcer, nor after it was discovered. On 6/26/19 at 7:08 AM Surveyor observed R9 in their bed. R9 had pressure relief boots. On 6/26/19 at 8:45 AM Surveyor spoke with DON-B (Director of Nurses). DON-B indicated they had a different wound physician before they took over as the DON 6 months ago. The new wound physician took over in (MONTH) of this year. DON-B did not have any additional information regarding the plan of care. On 7/3/19 at 9:30 AM at the facility exit meeting with Administrator-A and DON-B Surveyor shared the concerns with R9's pressure injury treatment and services. No additional information was provided. 3). R1, age 93, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Surveyor reviewed R1's medical record in response to a complaint concerning a pressure injury, among other things. On 6/11/19 and 6/12/19 Surveyor reviewed R1's medical record which reveals: MINIMUM DATA SET/CARE AREA ASSESSMENTS R1's Admission MDS (Minimum Data Set) dated 7/31/18 indicates R1 had moderately impaired cognition, and required extensive assistance of one person for bed mobility, transfers, ambulation, dressing, toilet use, and bathing. R1 had a urinary catheter and was occasionally incontinent of bowel. (R1's Quarterly MDS's dated 1/11/19 indicates he was always continent of bowel; the 4/5/19 Quarterly MDS indicates R1 was then frequently incontinent of bowel.) R1 was noted to be at risk for pressure injuries and have Moisture Associated Skin Damage on the (MONTH) Admission MDS. On the (MONTH) 2019 Quarterly MDS, R1 had no skin impairments or pressure injuries but was noted to be at risk for developing pressure injuries. The (MONTH) 2019 Quarterly MDS shows R1 had 2 unstageable pressure injuries due to slough or eschar. BRADEN ASSESSMENTS Surveyor asked for all of R1's Braden assessments due to the change-over in EHR systems. Surveyor was provided with two Braden Assessments, one dated 1/10/19 scoring 20, (not at risk); the other dated 4/4/19 scoring 12, high risk. The changes in the Braden score were a result of R1 changing from no impairment to very limited sensory impairment; rarely moist to very moist skin; from walks occasionally to chairfast; no limitation in mobility to very limited; and friction and shear went from a potential problem to a problem. PROGRESS NOTES AND PHYSICIAN ORDERS 1/26/19 8:57 p.m. Blister to right upper leg is resolved. Tx dc'd. (Treatment discontinued.) Surveyor note- this blister was caused by the Resident's catheter tubing. This is the last note pertaining to R1's skin until the eINTERACT SBAR (change of condition communication form) dated 1/31/19 at 1:13 p.m. stating: Situation: The change in condition reported on the CIC (change in condition) evaluation is: Skin wound or ulcer . Outcomes of Physical Assessment: . Skin Status Evaluation: Pressure ulcer/injury Pain Status Evaluation: Does the Resident have pain? Yes Nursing observations, evaluation, and recommendations are: Resident has difficulty cleaning self and needs more assistance. Resident also stated he does not change his underwear every day and should be done so. Primary Care Provider Feedback: [NAME] Recommendations: None to report. Writer applied NS (normal saline) fb (followed by) sp (skin prep) and finally foam to the area. B. New Testing Orders: other C. New Intervention Orders: Other; Changed underwear. This eINTERACT SBAR was completed by LPN (Licensed Practical Nurse)-P but there is no documentation regarding what physician she contacted, and there are no orders for the above until 2/10/19. The above information simply indicates what LPN-P did; an order would include the provider's name, how often the treatment should be performed, etc. No description of where this pressure injury was located, measurements, color, odor, exudate, or condition of surrounding tissue was documented on this SBAR form or in the progress notes (Health Status Notes, Skin Wound notes, etc.) LPN-P no longer works for the facility. The next notes pertaining to R1's pressure injury are: 2/1/19 3:44 a.m. Dressing intact to gluteal cleft o/a (open area) no c/o (complaint of) pain or discomfort at this time. (This note was signed by RN-G.) 2/1/19 at 7:46 p.m. Dressing to natal cleft/buttock is intact. Resident denies pain documented by LPN-E. Surveyor note: The natal cleft and gluteal cleft refer to the same area, defined as the deep groove which runs between the two buttocks from just below the sacrum to the perineum. However, the natal or gluteal cleft is a different location from the buttocks, which is a different location from the sacrum, which is a different location from the coccyx - the coccyx being below the sacrum. Other than a note dated 2/9/19 indicating an order was obtained for antifungal powder to be applied to R1's groin, abdominal folds, and under right axilla, the next note regarding skin integrity is dated 2/10/19 at 7:49 p.m., ten days after LPN-P documented R1 had a pressure injury, documented by LPN-E, stating: Resident c/o discomfort to buttock. Observed a fluid-filled intact blister to right natal cleft, redness surrounding skin, 5 small what appear to be blood blisters (intact) to right gluteal crease close to the fluid-filled blister on the right natal cleft. Protective dressing placed after cleansing the areas with NS (normal saline). Resident encouraged to reposition off area while in bed. Will have manager follow. The next Skin/Wound Note is on 2/11/19 at 1:50 a.m. stating: Has blister intact to right butt/right natal cleft, dressing intact, no c/o pain or discomfort. On 2/10/19 staff obtained new treatment orders for R1: Normal saline rinse followed by protective foam dressing to right gluteal cleft and right buttock. Change every evening and prn (as needed), at bedtime for fluid filled blisters to right buttock and right natal cleft. A Health Status Note dated 2/11/19 at 2:10 p.m. states One blister still intact. Two open areas to buttock. RN Manager did assess today. Treatment changed. (Surveyor Note: There is no documentation of an assessment of R1's pressure injury in his medical record until 3/8/19.) On 2/11/19 staff obtained another new treatment order stating Open area left and right buttock, cleanse wound with NS (normal saline). Apply wound gel to wound bed and skin prep peri- wound change daily and prn every day shift for open area. (Wound gel creates a moist wound environment.) Surveyor note: the order on 2/10 was for right gluteal cleft and right buttock. The order on 2/11 is now for open area left and right buttock - this is different than the right gluteal cleft and right buttock. Neither the nursing notes nor the physician's orders [REDACTED]. A Skin/Wound Note on 2/11/19 at 10:01 p.m. states Dressing to natal cleft and buttock in place. Denies pain. Staff obtained a new order for R1 on 2/12/19 for Skin prep intact blood blister to left buttock every day shift for blister left buttock. It is unclear if R1 has an intact blood blister as noted on the 2/12 order, and an open area as noted on the previous 2/11 order on R1's left buttock, and some type of open area on R1's right buttock (2/10 and 2/11 orders) and fluid-filled blisters on R1's right gluteal cleft requiring a treatment (2/10 order). A Weekly Skin Shower Observation Note dated 2/20/19 states Resident has had open areas on buttock and right natal cleft. Natal cleft appears to be getting larger. Scabbing appears dark in color. No drainage. Dressing changed. The next documentation in the Progress Notes regarding R1's skin impairments is dated 2/22/19 at 11:13 a.m., again, ten days later, stating Health Status Note: Resident has a new treatment to buttock . Air mattress put on bed. And on 2/22/19 at 1:46 p.m. NP (nurse practitioner) updated on open area to buttocks and new treatment ordered. Both notes were documented by LPN-F. The notes do not indicate which buttock the treatment is for; there is still no documented assessment of the pressure injury(ies), including location(s), stage(s) of pressure injury, color, tissue type, exudate, and measurements. Orders obtained for R1 on 2/22/19 were: Cleanse right buttocks open area with NS and skin prep peri-wound, apply Iodosorb to wound bed followed by border gauze daily and prn. (Surveyor note: When applied to a wound, Iodosorb cleans it by absorbing fluids, removing exudate, slough and debris and forming a gel over the wound surface. As the gel absorbs exudate, iodine is released, killing bacteria and changing

Based upon interview and record review, the facility administered a medication that thins the blood without adequate monitoring and in the presence of active bleeding and adverse side effects to 1 (R2) of 2 residents reviewed who received anticoagulant medications. On [DATE] Resident 2's (R2) physician suspected R2 had a [MEDICAL CONDITIONS] in their left arm which is the arm R2 has a fistula in to allow R2 to receive [MEDICAL TREATMENT]. R2's physician ordered a Doppler which was completed on [DATE] and confirmed the presence of a [MEDICAL CONDITION] in R2's left arm. R2's physician ordered [MEDICATION NAME] 60 mg at am and pm to start on [DATE], [MEDICATION NAME] 5 mg at bedtime to start on [DATE] with an order to draw a PT/INR ([MEDICATION NAME] time/international normalized ratio test - this is a blood test to evaluate the coagulation of blood) on [DATE]. At this time, R2 was already receiving Aspirin at 81 mg in the am and there were no additional orders regarding the Aspirin. On [DATE] R2 started to experience nose bleeds. R2's physician was notified of the nosebleed and was awaiting the results of R2's PT/INR lab results which had been drawn earlier on [DATE]. The results of R2's PT/INR on [DATE] were PT: 15.0 (reference range: 9XXX,[DATE].2)/INR 1.6. R2's attending physician was contacted with the results of the PT/INR and new orders were received to increase R2's [MEDICATION NAME] to 6 mg q (each) hs (at bedtime) despite R2 showing signs of active bleeding. Review of R2's record indicates prior to the PT/INR lab draw on [DATE] R2 may have not received the actual ordered doses of anticoagulant medications including not receiving 5 mg of [MEDICATION NAME] on [DATE] as ordered and [MEDICATION NAME] on [DATE] at bedtime. There is no indication this was communicated to the physician to assist in making an informed decision regarding increasing R2's [MEDICATION NAME] in the presence of a low INR with active bleeding occurring. Review of R2's medical record indicates R2 continued to experience nosebleeds throughout the day/night on [DATE] however, the facility did not specifically monitor R2's nosebleeds to show a record of frequency, duration or characteristic of R2's bleeding to assist in consulting with R2's physician. On [DATE] R2's physician ordered for R2 to be seen by an ear nose and throat specialist to review for possible cauterization and this was scheduled for [DATE] at 10 am. On [DATE] R2 communicated to facility staff a preference to not attend [MEDICAL TREATMENT] and instead to go to the hospital emergency department (ED) to get the nosebleeds looked at and to potentially have his nostrils cauterized to stop the bleeding. Review of the ED documents indicate R2 showed active signs of bleeding while at the ED and cauterization was completed on R2's right nare. PT/INR results at the ED indicate a level of 43XXX,[DATE].5 and were flagged as abnormal values. R2 returned to the facility on [DATE], there is no documentation to indicate what the discharge instructions were for R2 from the ED or what R2's condition was upon return to the facility. Upon return to the facility a PT/INR was drawn on R2 which had a result of 41XXX,[DATE].8, which is higher than the earlier drawn results at the ED. Review of R2's medical record indicates a physician, not familiar with R2 or associated with R2's attending physician, was contacted regarding R2's PT/INR results. This physician gave orders to hold R2's [MEDICATION NAME] over the weekend and recheck on Monday and to continue with the [MEDICATION NAME] twice daily. Interviews with Physician-C indicate concern that she was not consulted with regarding the results of this lab and would have issued different medication orders including discontinuation of the [MEDICATION NAME] and [MEDICATION NAME] and consider possible administration of Vitamin K as a result of R2 actively bleeding with an elevated INR. On [DATE] facility nursing staff indicate R2 is on the 24 hour report d/t (due to) [MEDICAL CONDITION] to left arm currently [MEDICATION NAME] on hold over weekend. INR results 4.8, resident has had a nose bleed, was out to hospital in am nose started bleeding on pm shift has stopped bleeding after nose clamp applied for a while. Some blood in mouth was rinsed out, left eye appears blood shot. PRN [MEDICATION NAME] given for [MEDICAL CONDITION]. There is no indication R2's physician was consulted with when R2 continued to demonstrate active bleeding despite having elevated PT/INR lab results earlier in the day and R2's nare had been cauterized in the ED to control bleeding. There is no assessment to show if the blood was coming from the nare that had just been cauterized or now also the other side. There is no indication R2's physician was consulted with at the time (approximately 2:52 am) when R2 was determined to now have a blood shot eye indicating bleeding was occurring in areas other than the nose. It was not until 10 am on [DATE] where facility nursing staff indicate they contacted the physician on call for Physician-C to discuss R2 continues to have nose bleeds that are affecting R2's ability to eat or drink because R2 can feel it in the back of their throat and R2 has a bloodshot eye. At this time R2 was sent to the ED. Review of R2's medical record indicates R2's ambulance had to be diverted to a different hospital due to increased bleeding, starting from the eyes in the ambulance. The hospital ED record dated [DATE] indicates patient presents to the emergency department for evaluation of nose bleed. Physical exam: Bleeding from right nare, bright red blood also pours out from right ear duct when nose is clamped. Posterior pharynx reveals blood dripping down back of throat. Review of the ED record indicates R2's INR was 6.8. The ED record indicates: Just prior to moving patient to inpatient R2 suddenly became diaphoretic, tachypneic, [MEDICAL CONDITION], cyanotic. Despite efforts to save him, R2 was pronounced dead at 3:06 pm. The final [DIAGNOSES REDACTED]. The facility's actions of continuing to administer a medication that thins the blood without adequate monitoring and in the presence of active bleeding and adverse side effects created a situation of immediate jeopardy that started on [DATE]. The facility's administration, including Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-D, were notified of the immediate jeopardy on [DATE] at approximately 1:20 pm. The facility removed the immediate jeopardy on [DATE] when the facility implemented an action plan. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: R2 was long term resident of facility originally admitted on [DATE]. R2's [DIAGNOSES REDACTED]. On [DATE] at approximately 10:20 am Physician-C told Surveyor R2 was a long standing individual with [MEDICAL CONDITION] having received [MEDICAL TREATMENT] for longer than the average 5 years. Review of R2's quarterly Minimum Data Set ((MDS) dated [DATE] and R2's 14 day PPS (prospective payment system) MDS dated [DATE] indicates R2 has a Brief Interview for Mental Status (BIM) score indicating R2 is cognitively intact. The MDS's indicate R2 receives [MEDICAL TREATMENT] and rejection of care was not demonstrated. Review of R2's medical record indicates on [DATE] a telephone order was written for R2 to have a Doppler study to rule out possible [MEDICAL CONDITION] of the left arm. Surveyor noted there is no facility documentation to indicate how the order originated or what the signs & symptoms were that R2 was experiencing. On [DATE] at approximately 10:20 am Surveyor interviewed Physician-C who indicated the lack of documentation regarding R2's need for a Doppler is her fault. Physician-C indicated she was in the facility and R2 complained of his left (L) arm being swollen and painful and Physician-C suspected a [MEDICAL CONDITION] and ordered the Doppler. Physician-C apologized for not charting indicating she had just been passing through the facility and didn't chart. Surveyor noted there is no indication facility staff documented monitoring of R2's left arm on [DATE] despite R2 having a suspected [MEDICAL CONDITION]. [DATE]: Review of R2's record on [DATE] indicates R2 went to [MEDICAL TREATMENT] on this date Results of the Doppler study dated [DATE] indicates: Left upper extremity + (positive) for focal [MEDICAL CONDITION] involving mid to distal ulnar veins. Progress notes dated [DATE] at 17:15 indicate: Venous Doppler LUE (left upper extremity) positive for focal [MEDICAL CONDITION] involving mid to distal ulnar veins. Results discussed with (Physician-C) with NOR (new order) to begin [MEDICATION NAME] 60 mg SQ (subcutaneously) bid (twice daily) starting tonight and [MEDICATION NAME] 5 mg po (by mouth) to start [DATE]; INR routine q (every) M/Th (Monday/Thursday) for monitoring. Surveyor noted review of R2's progress notes indicate the facility's electronic health record flagged order notes indicating the orders being entered for [MEDICATION NAME] and [MEDICATION NAME] triggered drug protocol alerts/warning of potential drug to drug interactions, with an increased risk for bleeding related to R2 having orders for Aspirin 81 mg q am. Surveyor reviewed R2's care plans and noted despite R2 being diagnosed with [REDACTED]. Review of R2's [DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the facility 24 hour report for [DATE] indicates R2 was on the 24 hour board. Documentation indicates: day shift: left UE Doppler scheduled; PM shift: clot to upper LA (left arm) [MEDICATION NAME] 5 mg q hs, [MEDICATION NAME] 0.6 mL BID, INR M/Thur. [DATE]: Progress notes dated [DATE] at 2:41 am indicate: [MEDICAL CONDITION] left arm started on [MEDICATION NAME] inj (injection) BID [MEDICATION NAME] 5 mg q hs no c/o pain or discomfort at this time. Surveyor noted there is no indication in R2's record to explain what R2's arm with the [MEDICAL CONDITION] looks like. The [DATE] progress note at 14:43 indicates: no pain or c/o's (complaints of) to LUE. Continues on [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] to left arm. Resident refused aspirin this am, remains on 24 hour report. Review of R2's MAR for the morning on [DATE] indicates R2 received aspirin in the morning despite the progress note indicating R2 refused the Aspirin. On [DATE] at 17:13 a progress note indicates: resident monitored for [MEDICAL CONDITION] LUE denies pain continue on [MEDICATION NAME] BID & [MEDICATION NAME] no bleeding s/s (signs/symptoms) of pain T (temperature) 97.7 orally .BP (blood pressure) ,[DATE]. The [DATE] MAR for evening administration indicates: [MEDICATION NAME] 60 mg administered on pm shift. Review of the [MEDICATION NAME] indicates the MAR indicated [REDACTED]. On [DATE] the facility provided Surveyor with the order progress notes for the [DATE] medication administration. The [DATE] 21:41 order-administration note just restates the order for the [MEDICATION NAME]: [MEDICATION NAME] tablet 5mg give 5 mg by mouth at bedtime for LUE [MEDICAL CONDITION]. Surveyor noted this does not clearly indicate if R2 received this dose of [MEDICATION NAME] as ordered or not. On [DATE] the facility provided Surveyor with a timeline related to R2's care. On this timeline the facility indicates: [DATE] - aspirin not given, [MEDICATION NAME] not given, [MEDICATION NAME] given AM and HS. Surveyor noted this would indicate R2 missed the first scheduled dose of [MEDICATION NAME]. There is no indication R2's physician was consulted regarding this missed dose. On [DATE] at approximately 2:50 pm Surveyor interviewed Licensed Practical Nurse (LPN)-E about the administration of R2's medications and notations in R2's general nursing progress notes regarding ordered medications. LPN-E indicated she could not remember if R2 had received the [MEDICATION NAME] or not or why there isn't clear documentation regarding the medication. Review of the facility 24 hour report for [DATE] indicates for N[NAME] (night shift): [MEDICAL CONDITION] left arm started [MEDICATION NAME] injection BID, [MEDICATION NAME] 5mg hs, no complaints discomfort; Day shift: denies pain, [MEDICATION NAME] injection + (plus) [MEDICATION NAME] cont'd; and PM shift [MEDICAL CONDITION] left upper arm no c/o pain [MEDICATION NAME] & [MEDICATION NAME] BID. There is no notation on the 24 hour board to indicate R2 may have not received scheduled anticoagulants during the day. [DATE]: R2's progress notes dated [DATE] at 3:36 am indicate: resident being monitored for LUE [MEDICAL CONDITION] no c/o pain or discomfort. Vitals: Bp ,[DATE] (Surveyor noted upon review of R2's vitals summary that this blood pressure was taken while R2 was lying down and on the left arm which is the arm R2 has the [MEDICAL CONDITION] and [MEDICAL TREATMENT] fistula in). Continue with plan of care on [MEDICATION NAME] BID and [MEDICATION NAME]. No bleeding. Surveyor noted at the time of this note, there is no care plan for R2 receiving the [MEDICATION NAME] or [MEDICATION NAME]. Surveyor noted the only potential plan would be for the ordered PT/INR scheduled for [DATE]. R2's MAR for the morning medications indicate R2 was administered and took aspirin in the am and received the [MEDICATION NAME] injection. A progress note dated [DATE] at 13:37 indicates: monitored for [MEDICAL CONDITION] no c/o pain at this time continues on [MEDICATION NAME] & [MEDICATION NAME] therapy back from [MEDICAL TREATMENT] now. Surveyor noted there is no documentation or indication nursing staff assessed or documented on R2's fistula site or condition of arm regarding [MEDICAL CONDITION] post [MEDICAL TREATMENT] except a notation regarding pain or discomfort. A progress note on [DATE] at 17:14 indicates: resident monitored for [MEDICAL CONDITION] Left upper arm. Denies pain or discomfort received [MEDICATION NAME] and [MEDICATION NAME] tolerating well no bleeding vitals: BP ,[DATE]. Review of R2's MAR for administration of the evening medication on [DATE] indicates R2 received the first documented dose of [MEDICATION NAME] 5 mg at hs. Surveyor noted the MAR indicated [REDACTED]. Review of the facility order progress notes for [DATE] do not include any documentation regarding R2's hs [MEDICATION NAME] medication administration. Review of the facility provided timeline for R2 on [DATE] has the facility indicating R2 received all anticoagulant medications on that date for all shifts despite no documentation R2 received the pm dose of [MEDICATION NAME]. Surveyor noted there is no documentation to indicate R2's physician was consulted regarding a possible second missed dose in two days of R2's anticoagulant therapy. The facility 24 hour report for [DATE] indicates: N[NAME] shift: monitor LUE for [MEDICAL CONDITION] no c/o pain or discomfort continue with plan of care [MEDICATION NAME] & [MEDICATION NAME]; Day shift: monitored for [MEDICAL CONDITION] denies pain at this time on [MEDICATION NAME] & [MEDICATION NAME]; and PM shift: [MEDICAL CONDITION] LUE no c/o pain/disc (discomfort). Review of R2's care plans indicate on [DATE] a care plan was initiated with an identified need of: The resident is on anticoagulant therapy ([MEDICATION NAME] and [MEDICATION NAME]) r/t (related to) [MEDICAL CONDITION] left arm. Goals include: The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date of [DATE]. Interventions include: Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness q (each) shift. Daily skin inspection. Report abnormalities to the nurse. Labs as ordered. Report abnormal lab to the MD. Monitor/document/report PRN (as needed) adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs) . A care plan for Resident having impaired circulation r/t [MEDICAL CONDITION] left arm was also initiated on [DATE]. The Goal includes: the resident will be free from s/sx (signs/symptoms) of complications of poor circulation through the review date. Interventions dated [DATE] include: assess fingers and toes for warmth and redness q shift and prn, encourage routine physical exercises (ie: walking to the bathroom, dining room, exercise programs). Ensure proper fitting footwear. Inspect feet q shift with cares, for areas of rubbing or injury. On [DATE] at approximately 12:45 pm Surveyor interviewed RN Nurse Manager-L about R2's care plans. Surveyor asked RN-L why R2 did not have care plans for the [MEDICAL CONDITION] or anticoagulant medications until [DATE], 2 days after R2 was diagnosed with [REDACTED]. RN-L indicated she was going through R2's record and noticed R2 did not have a care plan for each issue so she created one at that time. Surveyor asked RN-L if R2 should have had a care plans for each issue sooner. RN-L indicated she believed so, but no one had created one. [DATE]: R2's progress notes dated [DATE] at 3:46 am indicate: continue to monitor resident for [MEDICAL CONDITION] in LUE, no c/o pain or discomfort. Plan of care with [MEDICATION NAME] and [MEDICATION NAME] continued. Surveyor review of R2's vitals summary indicates R2's blood pressure was collected at 01:42 while R2 was lying down. The result was ,[DATE]. Surveyor noted this entry indicates R2's blood pressure rate was collected from R2's left arm which is the arm R2 has the [MEDICAL CONDITION] in and fistula for [MEDICAL TREATMENT]. A progress note on [DATE] at 10:15 am indicates: Resident noted to have epistasis (nose bleed) - moderate amount bright red blood. Receives ASA (Aspirin) 81 mg, [MEDICATION NAME] and [MEDICATION NAME] due to [MEDICAL CONDITION] upper left extremity. Had received ASA and [MEDICATION NAME] this am prior to nosebleed. Area clamped with nose clamp and applied ice. Lab has drawn PT/INR earlier this am and awaiting results. (Physician-C) paged and awaiting call back. The [DATE] progress note at 11:35 am indicates: Resident had nose bleed. Nose clamp applied and ice. Finally stopped after 15 minutes. (Physician-C) updated. Resident is on [MEDICATION NAME] injections and [MEDICATION NAME] and PT/INR drawn today. (Physician-C) no new orders but wanted to know when PT/INR is drawn and drawn today (sic). Surveyor noted it is unclear if this is a repeat episode of a bloody nose or references an additional episode. Review of the progress notes dated [DATE] at 13:40 include a communication with physician (SBAR - Situation/Background/Assessment-Appearance/Recommendation form). The note indicates: Situation: PT/INR. Surveyor noted the sections for Background and Appearance for SBAR are blank. Recommendations: increase [MEDICATION NAME] to 6 mg daily and recheck INR on Friday. Surveyor noted the SBAR does not include reference to the bloody nose and whether it was isolated or multiple episodes. The SBAR also does not include information regarding possibility R2 did not get anticoagulants on [DATE] and [DATE] prior to the initial PT/INR lab being completed. R2's medical record indicates a PT/INR lab was drawn at 5:34 am. Results of the lab indicate: [MEDICATION NAME] (PT): 15.0 H (high) reference range (9XXX,[DATE].2). INR: 1.6 The lab indicates INR therapeutic range is 2XXX,[DATE].0 for [MEDICAL CONDITION], PE (pulmonary embolism) and [MEDICAL CONDITION]. Hand written with no date or indication of who made the notation is: (up arrow) increase 6mg recheck referring to R2's [MEDICATION NAME]. On [DATE] at approximately 10:20 am Surveyor interviewed Physician-C who indicated she was aware of R2 having a bloody nose after PT/INR was drawn. When asked about increasing [MEDICATION NAME] despite R2 having the bleeding Physician-C indicated R2 was sub-therapeutic with PT/INR so the [MEDICATION NAME] was increased to achieve therapeutic goal. A [DATE] progress note at 17:06 indicates: Spoke with Physician-C regarding [MEDICATION NAME] . (Physician-C) also updated on increasing episodes of nose bleeds. Orders to have res (resident) seen by (Name of) ENT (Ear Nose and Throat) at EMH (name of hospital) for possible cauterization r/t nose bleeds. Will update POA/HC (power of attorney/health care). Order left for unit secretary to follow up on apt. Surveyor's review of R2's record indicates the ENT appointment was scheduled for [DATE] at 10am. Review of R2's [DATE] MAR/TAR indicates Aspirin in am was refused, the increased dose of [MEDICATION NAME] at 6 mg was administered at HS, [MEDICATION NAME] was administered in am, Surveyor noted the pm dose is coded 9 meaning other/see progress notes. Surveyor noted the order administration progress note dated [DATE] at 20:52 states: [MEDICATION NAME] Solution 60 mg/0.6ML inject 60 mg subcutaneously every morning and at bedtime for LUE [MEDICAL CONDITION]. Surveyor noted this progress note does not clearly indicate if R2 received the [MEDICATION NAME] as ordered or not. The facility provided timeline on [DATE] states: [DATE] [MEDICATION NAME] given, [MEDICATION NAME] given in am and pm, there is no reference to the aspirin. Review of the 24 hour report indicates for [DATE]: N[NAME] shift: no c/o pain /discomfort Monitor LUE for [MEDICAL CONDITION] (no vitals). Day shift: Had some nose bleed no c/o pain, denies pain from [MEDICAL CONDITION] (vitals BP: ,[DATE]). PM shift: INR 1.6 [MEDICATION NAME] increased 6mg (check) INR [DATE]. Continues to have epistaxis episodes - (Physician-C) aware consult with (name of Dr) ENT for poss b/c cauterization. R2's plan of care indicates the facility did not develop a care plan for R2 having possible complication from anticoagulant therapy in the form of nose bleeds. On [DATE] at approximately 9:15 am Surveyor interviewed RN-L regarding R2's care plans. Surveyor asked RN-L if a separate plan of care should have been developed when R2 started to demonstrate complications from receiving anticoagulation medications. RN-L reviewed R2's care plan and told Surveyor R2 should have had a care plan regarding the nose bleeds R2 was experiencing and one was not developed. At this time Surveyor asked RN-L as the nurse manager, what are the expectations for staff regarding the monitoring R2's [MEDICAL CONDITION] and nose bleeds. RN-L indicated she would have expected monitoring and assessment details that included whether R2's arm was swollen, painful, showing signs or symptoms of infection. When asked about the nose bleeding RN-L indicated staff should have kept track of details including the color of the blood, frequency, duration, and treatments tried so the physician could know exactly how often the bloody noses were occurring and what were the characteristics of the bleeding. [DATE]: A progress noted dated [DATE] at 3:14 am indicates: [MEDICAL CONDITION] to Lt. (left) arm, no c/o pain or discomfort. Nose bleed started up tonight. Cool wash cloth applied to bridge of nose, bleeding stop (sic). Will continue to monitor. Review of R2's vitals summary report indicates R2's blood pressure was taken at 01:25: ,[DATE], while R2 was lying down. The entry indicates R2's blood pressure was taken in his left arm which is the arm R@ has the [MEDICAL CONDITION] in and also his fistula for [MEDICAL TREATMENT]. Review of R2's medical record does not indicate a follow up PT/INR was drawn on the morning of [DATE]. An Interact SNF/NF to Hospital transfer form dated [DATE] and signed by LPN-F at 8:00 am indicates: (R2) has risk alerts of anticoagulation medication, [MEDICAL CONDITION] Left arm and on kidney [MEDICAL TREATMENT]. Surveyor noted despite the reference to R2 being on kidney [MEDICAL TREATMENT] there is no indication on form that this would be the day R2 should receive [MEDICAL TREATMENT] on the transfer form. Upon review of the [DATE] SBAR Surveyor noted that much of the form is missing relevant information. The section for Situation indicates: bleeding off and on x (times) 1 day. Started on [DATE] (Surveyor noted there is no documentation of nose bleeds on [DATE] in record). The section to indicate if worse, same, or better . is blank. Things that make it worse, better etc. is blank. treatment for [REDACTED]. The SBAR includes R2's diagnoses. Medication alerts indicate: [MEDICATION NAME] 6mg daily [MEDICATION NAME] 0.6 BID. Resident is on [MEDICATION NAME]/[MEDICATION NAME] Result of last INR 1.6 on [DATE]. (Surveyor noted this is not an accurate date for this INR result. This was the result of the INR on [DATE]). The SBAR indicates R2 is on hypoglycemic meds, allergies [REDACTED]. Resident/Patient evaluations for mental status and functional status are marked as unchanged. The evaluations for behavior, respiratory, cardiovascular, abdominal/GI, GY/Urine, skin, pain and neurologic are all marked as not clinically applicable. Code status indicates: DNR-No CPR. The section for Appearance/assessment details on the [DATE] SBAR is blank as is the sections for Review and Notify is blank. Sections for Additional nursing notes and testing are blank as is notification to family/healthcare agent. Review of the Emergency Department (ED) notes dated [DATE] at 8:46 am indicates: Chief complaint Epistasis. HPI: Patient is pleasant [AGE] year old gentleman with a history of [MEDICAL CONDITION] infarction/coronary disease, type 2 diabetes, end stage [MEDICAL CONDITION] on [MEDICAL TREATMENT], hypertension, and [MEDICAL CONDITION] on [MEDICATION NAME]. Here for evaluation of epistaxis x 3 days. Patient states intermittent right-sided nose bleed for 3 days. This resolved with pressure but is persistent and intermittent. He is here by EMS for further evaluate. He denies dizziness or lightheadedness. Vital signs are stable on arrival. On arrival he is noted to be actively bleeding from the right naris. Labs: RBC 3.86, Hgb 12.2, Hct 37.8, RDW 15.3, platelets 148. PT/INR: 43XXX,[DATE].5. and are flagged as abnormal. Medical decision making: Here with nose bleed, differential to epistaxis secondary to excessive anticoagulation on [MEDICATION NAME], also on aspirin consider anterior versus posterior nosebleed. On exam there is evidence for active bleeding from the anterior septum. Clots were evacuation, add, Neo-Sunephrine was used for vaso [MEDICATION NAME], patient did have cauterization of his right anterior septum. Will check basic labs to assess for [MEDICAL CONDITION], excessive anticoagulation, consider packing of the nasal passages if persistent bleeding. ED course 9:00 am Hemoglobin of 12.2 appears to be a chronic [MEDICAL CONDITION] baseline is 11.1. INR is slightly elevated at 3.5 and slightly supratherapeutic. Final Diagnosis: [REDACTED]. The records provided to Surveyor during the survey regarding the [DATE] hospital information do not include details regarding any recommended treatments, medication orders or monitoring post discharge from the emergency department (ED). On [DATE] and [DATE] Surveyor asked DON-B and ADON-D repeatedly for information regarding R2's trip to the ED on [DATE]. On [DATE] at approximately 1:26 pm DON-B indicated R2 went to the ED at his request instead of [MEDICAL TREATMENT] because he wanted to get his nose cauterized. DON-B indicated the facility followed up on orders from the ED because it was the ED who recommended the ENT. Surveyor had to clarify that the ENT was ordered prior to ED. Surveyor noted upon further review of R2's medical record R2 had orders [MEDICATION NAME] spray to start [DATE], 2 sprays every 1 hour for nosebleed and Vaseline BID for bleeding. When asked, facility staff could not explain where these treatments originated or if there was any indicated monitoring recommended by the hospital post ED visit with cauterization. R2's medical record indicates there is no documentation in the progress notes to indicate when R2 returned to the facility from the ED, what his condition was or recommendations made. Surveyor noted there is no indication a physician was communicated with regarding R2 missing [MEDICAL TREATMENT] on this date. Review of R2's labs indicates a PT/INR was drawn at the facility at 14:00. Results of PT/INR were PT: 41.8/INR: 4.8. Surveyor noted PT is flagged as high with reference range of (9XXX,[DATE].2). Handwritten on lab slip is ,[DATE], update (Physician-H) New Order - Hold [MEDICATION NAME] over the weekend check INR M (Monday) Continue to give [MEDICATION NAME]. Surveyor noted there is no reference whether to continue or discontinue R2's aspirin order. Surveyor noted R2's INR drawn earlier in morning at the ED was flagged as elevated at 3.5. R2 had a second lab completed at 14:00 (potentially shortly after R2 returned to the facility) indicating it had increased in value since the earlier hospital visit. Review of a progress note dated [DATE] at 21:11 indicates: updated (Physician-H) New order received. Hold [MEDICATION NAME] over the weekend (Sat & Sun) Re check INR M (Monday) Continue to give [MEDICATION NAME]. On [DATE] at approximately 10:20 am Surveyor interviewed Physician-C about R2 going to the ED. Physician-C indicated she learned later that R2 wanted to go there (to the ED) instead of [MEDICAL TREATMENT]. During the interview, Physician-C reviewed R2's labs in his record and noted the increase in INR from the ED to the facility. Surveyor asked about contact with Physician-H and the decision to continue [MEDICATION NAME] and hold [MEDICATION NAME] with the lab result. At this question, Physician-C shared she was very upset about this. Indicating Physician-H is not a physician within her medical group and not the facility medical director so he (Physician-H) should not have been contacted or giving orders on her patient (R2). Physician-C indicated she would not have maintained the [MEDICATION NAME] as Physician-H did. Physician-C indicated at this point she would have held both the [MEDICATION NAME] and the [MEDICATION NAME] and with the INR at 4.8 she would have considered giving vitamin K especially if R2 was continuing to have nose bleeds. Review of the progress note dated [DATE] at 21:12 indicates: Nose bleed on/off throughout PM shift. Applied Cotton balls, ice, nose clip, Vaseline. The facility 24 hour report for [DATE] indicates: N[NAME] shift: (No) c/o pain to left arm ([MEDICAL CONDITION]) nose bleed tonight; Day shift: to ER at 7:15 for nosebleed (Elmbrook) return with new orders. Surveyor again notes the facility could not share what those order are. PM shift: nose bleed off and on applied Vaseline. Review of R2's MAR/TAR for [DATE] indicates a code of 9 (other-see progress notes) for the aspirin. Surveyor noted there is no progress order note regarding the aspirin. R2's [MEDICATION NAME] is documented as held on [DATE]. [MEDICATION NAME] is marked as 9 (other-see progress notes) for am. Review of the order-administration progress notes include a note dated [DATE] at 7:47 indicates: sent to ER for nose bleed. Surveyor noted there is no note explaining the administration of the [MEDICATION NAME] on the pm shift and the coding of 2 which would indicate the drug was refused on PM shift. Surveyor noted there is no indication R2's physician was contacted to let them know R2 refused the [MEDICATION NAME] despite having a [MEDICAL CONDITION]. [DATE]: A progress noted dated [DATE] at 2:52 am indicates: On 24 hour report d/t [MEDICAL CONDITION] to left arm currently [MEDICATION NAME] in (sic) hold over weekend. INR results 4.8 resident has had a nose bleed was out to hospital in am nose started bleeding on pm shift has stopped bleeding after nose clamp applied for a while. Some blood in mouth, was rinsed out, left eye appears blood shot. PRN [MEDICATION NAME] given for [MEDICAL CONDITION]. Surveyor noted there is no indication the facility contacted R2's physician for consultation with the bleeding to now include a blood shot eye in addition to the continued nose bleeds. On [DATE] at 3:35 pm Surveyor interviewed Registered Nurse (RN)-G regarding R2.

Based on record review and interview, staff did not provide necessary services to try to restore as much normal bowel function as possible for 1 of 1 residents incontinent of bowel (R1). R1 declined from always continent of bowel to frequently incontinent of bowel but no further assessments, care planning or interventions were conducted regarding R1's bowel incontinence. Bowel incontinence was noted in R1's 4/5/19 care plan as a causative factor for R1's pressure injuries. Cross reference F686. Findings include: R1, age 93, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Surveyor reviewed R1's medical record in response to a complaint concerning a pressure injury, among other things. On 6/11/19 and 6/12/19 Surveyor reviewed R1's medical record which reveals: MINIMUM DATA SET/CARE AREA ASSESSMENTS R1's Admission MDS (Minimum Data Set) dated 7/31/18 indicates R1 had moderately impaired cognition, and required extensive assistance of one person for bed mobility, transfers, ambulation, dressing, toilet use, and bathing. R1 had a urinary catheter and was occasionally incontinent of bowel. R1's CAA (Care Area Assessment) completed with the Admission MDS for Cognitive Loss states I use the bathroom with the help of one person. I need help wiping. I need help adjusting my clothes. R1's CAA for Urinary Incontinence/Catheter states Description of Problem: Has an indwelling urinary catheter . is occasionally incontinent of bowel and is not on a toileting program . I need to be clean and dry. I need my nurses to prompt me to use the bathroom. I need my aides to let my nurses know if I am incontinent more frequently . R1's Quarterly MDS's dated 1/11/19 indicates he was always continent of bowel; the 4/5/19 Quarterly MDS indicates R1 was then frequently incontinent of bowel. Surveyor reviewed R1's Bowel and Bladder Continence Evaluation dated 1/10/19 which asks: Are you or have you ever been incontinent of bowel or bladder? Neither. (Surveyor note- R1 was occasionally incontinent of bowel on the 7/31/18 Admission MDS.) The evaluation continues indicating R1 has a bowel movement daily, does not frequently have hard or difficult bowel movements, and does not use laxatives/suppositories or enemas for regulation. R1 is noted to be taking a diuretic. Since R1 is noted to be continent of bowel, questions pertaining to bowel incontinence are not answered. [DIAGNOSES REDACTED]. R1 is noted to ambulate with a walker, needs one person assist to get in and out of bed/chair, is able to find the toile, understands reminders or prompts, can ask for assistance, can remove clothing to toilet, is motivated to be continent, socially aware of appropriate place to pass urine, is able to use toiler, commode and bed pan. Contributing factors are mobility. R1 is noted to be continent of bowel, and has a urinary catheter, but the treatment option selected is Incontinence product. R1's 4/4/19 Bowel and Bladder Continence Evaluation now indicates R1 has or has been incontinent of both bowel and bladder. Bowel incontinence onset is checked unknown even though R1 has been a resident of the facility continuously since his 1/10/19 Bowel and Bladder Continence Evaluation. The Evaluation notes R1's bowel incontinence symptoms have improved over the last six months, and the duration of bowel incontinence is less than six months. R1 continues to have bowel movements daily. Under Medication Review, R1 is noted to be taking diuretics and antidepressants. [DIAGNOSES REDACTED]. Mobility is noted to be Sits unsupported in chair or wheel chair but cannot propel self without help, needs assist of one person getting in and out of bed/chair. Is not aware of urge to void, is able to find the toilet, understands reminders or prompts, can ask for assistance, can remove clothing, can sit on the toilet, is motivated to be continent, is socially aware of appropriate place to urinate, has Foley catheter. Can use toilet, commode, not bedpan. Contributing factors- mobility. Under Type of Incontinence Bladder is marked none due to the Foley catheter, but Bowel is not checked for incontinence either. Treatment options is left blank. Surveyor reviewed R1's Care Plan for Pressure Injuries which states: The Resident has potential/actual impairment to skin integrity of the bilateral buttocks r/t fragile skin secondary to bowel incontinence and resident refusal of cares/repositioning, at times. Date initiated: 4/10/19 Created by: RN-L Goals: The Resident's (skin) will have no complications r/t pressure areas of the bilateral buttocks through the review date. Target date: 7/10/19. Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate Resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration . Follow facility protocols for treatment of [REDACTED]. Identify/document potential causative factors and eliminate/resolve where possible. Keep skin clean and dry. Use lotion on skin. Do not apply to coccyx wounds. Monitor/document location, size and treatment of [REDACTED]. to MD. Obtain blood work such as CDC with Diff (complete blood count with differential), Cultures and sensitivities of any open wounds as ordered by physician. The Resident needs pressure reducing mattress to protect the skin while in bed. The Resident needs pressure relieving/reducing cushion to protect the skin while up in chair. Use draw shift or lifting device to move resident. Use caution during transfers . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Despite the care plan stating R1's pressure injuries are secondary to bowel incontinence, none of the interventions address bowel incontinence. A care plan for R1's indwelling Foley urinary catheter, which he had since admission, was added 1/10/19 by the previous RN manager, and revised 4/17/19 by RN-L, but it does not address bowel. Surveyor could not locate a care plan addressing R1's bowel incontinence, even though he has pressure injuries on both buttocks. R1's Behavior care plan dated 9/20/18 and revised 4/12/19 notes Resident has the potential to refuse cares but does not specifically address R1 refusing to use the toilet, commode or bed pan to have a bowel movement. R1 has a care plan for ADL self-care performance deficit related to impaired balance initiated 12/19/18 and revised 1/23/19, states Toilet Use: The resident requires assistance of 1 staff for toileting. That is the only mention of anything related to toileting. On 6/11/19 at 8:58 a.m., Surveyor interviewed CNA-R asking about R1. CNA-R stated R1 would wheel self around building until he got sick (R1 had pneumonia in (MONTH) 2019). He got more depressed when his roommate passed away. Would go to the bathroom in his bed. Wanted to be left alone when you tried to convince him to get out of bed. Surveyor interviewed RN Manager-L on 6/12/19 at 9:10 a.m. asking why R1 did not have a care plan for bowel incontinence prior to his discharge 4/24/19 even though bowel incontinence is listed as a causal factor for pressure injuries. RN-L said she only started at the facility in March, a month or so before R1 was discharged . RN-L created the pressure injury care plan when she completed R1's Quarterly MDS 4/5/19 and must have missed the bowel incontinence care plan, but agreed it should have been done. Surveyor asked if any further assessment of R1's now frequent bowel incontinence (according to the 4/5/19 MDS) was conducted, including patterning/when R1 was incontinent of bowel, what were the circumstances regarding the episodes: were staff not available, resident refusing to toilet, urge comes on suddenly, medications, changes in diet, or any other possible factors causing the decline in continence. Depending on the reasons for the decline in continence, that would guide staff interventions. RN-L stated no further assessment of R1's decline in bowel continence was completed.