Every finding on record at Complete Care at Christian Home LLC

Based on observation, interview, and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 3 of 5 residents (R5, R4, and R2) reviewed. R5 developed a blister to their right heel. The facility failed to complete diabetic foot checks, complete a full wound assessment, and update the physician timely. The facility failed to ensure proper skin assessment and wound measurements were completed at the time of admission for R2 R4 complained of not feeling well and had an emesis. Facility did not perform an assessment. R4 was hospitalized the following day due to noted change of condition and admitted with urinary tract infection. Evidenced by: The article Diabetic foot ulcer: A comprehensive review of pathophysiology and management modalities dated 3/16/23 states in part, .Diabetic foot ulcer (DFU) is a debilitating and severe manifestation of uncontrolled and prolonged diabetes that presents as ulceration, usually located on the plantar aspect of the foot. Approximately 15% of individuals with diabetes will eventually develop DFU, and 14%-24% of them will require amputation of the ulcerated foot due to bone infection or other ulcer-related complications. The pathologic mechanisms underlying DFU are comprise a triad: Neuropathy, vascular insufficiency, and secondary infection due to trauma of the foot. Preventative care: Due to diabetes being a risk factor for the development of underlying peripheral vascular disease, the majority of DFUs are asymptomatic until advanced enough to recognize more severe signs and symptoms. During the diagnosis of DFU, neuropathy may mask ischemia and vice versa. Therefore, the primary preventative strategy is regular diabetic foot screening to allow early identification of DFU, followed by initiation of treatment if appropriate. Ultimately, early detection and management work to avoid further complications such as gangrene and amputation. Diabetic foot ulcer: A comprehensive review of pathophysiology and management modalities - PMC The facility's policy titled Pressure Injury Prevention and Management dated 2/2025 states in part .c. Wound assessments will be documented in the medical record. Findings should include type of wound, wound measurements (measured upon discovery, and at least weekly thereafter), other wound characteristics (color, exudate, pain, tissue type in wound bed), and treatment and interventions implemented. Surveyor requested a policy for non-pressure wounds, and none was provided. Example 1 R5 was admitted to the facility on [DATE] with diagnoses that include posterior displaced type 2 Dens fracture (fracture is a break that occurs through a specific part of C2, the second bone in the neck), type 2 diabetes mellitus, and peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs). R5's most recent MDS (Minimum Data Set) dated 3/2/26 states that R5 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R5 is cognitively intact. R5's care plan dated 2/25/26 states in part: Focus: Skin Integrity: At risk /and/or potential for complications with impaired skin integrity including skin tears, bruising, and/or pressure r/t (related to) current medical/physical status. Has meds/dx (diagnosis) that can/may affect skin integrity. Stage 3 to sacrum, non-pressure to R (right) heel, unstageable to back of head, venous wound to right calf tx (treatment) per wound MD (Medical Doctor) order (Revision on 4/14/2026) .Interventions/Tasks: Assist/encourage pressure relief as needed/accepted. Follow community skin protocol. Observe skin with AM/PM (morning/evening) cares and with toileting for redness, rashes, open areas, pain, swelling and report them to team leader. Weekly skin check. Lotion to dry skin. Review skin concerns with MD. Of note, Surveyor reviewed R5's MD orders and there is no order for diabetic foot checks. Facility did not provide evidence to show nursing staff were checking R5's feet daily from admission on [DATE] through 3/15/26. On 3/15/26 at 8:49 PM R5's nurses note indicates: Resident has a 2cm (centimeter) x 5cm blister that peeled back to right outer heel. Cleansed and applied Mepilex to cover and protect until provider assesses and gives order. Note to provider put in folder. (of note: R5's provider was not updated timely with a new wound, treatment orders were not obtained and there is not a comprehensive assessment documented upon discovering R5's heel wound.) On 3/17/26 at 11:37 AM R5's nurses note indicates: [Nurse Practitioner's Initials] here and gave referral for the wound doctor to see resident's right heel, also gave resident referral to have a vascular consult if indicated. It is important to note that there is no documentation stating that wound care was provided between 3/16/26- 3/18/26. Diabetic foot checks still were not being implemented after discovering a wound on R5's heel. On 3/18/26 at 12:35 AM R5's nurses note indicates: Resident going to [Health Care Facility] for a doctor appointment with his son. Resident concerned about his circulation. On 3/18/26 at 4:25 PM R5's nurses note indicates: [MD (Medical Doctor) name] wound MD was here for rounds see documents for notes, measurements, and any new orders of this weeks visit.Resident went to [Health Care Facility] for wound that opened on R (right) heel and res (resident) forgot to give paperwork to MD so no paperwork came back. He refused to have wound MD look at the area d/t (due to) it being all dressed from the clinic. Writer tried to call [Health Care Facility] and it had already closed and will try in the morning for wound orders. On 3/18/26 at 1:30 PM R5 went to an outside provider for wound care. Wound care Nurse Practitioner's note states in part .Right foot wound: [R5's name] indicates he had been self-propelling his wheelchair at the [Facility's Name] with his right foot (despite knowing better). SNF (Skilled Nursing Facility) applied dressing/gauze overwrap 2 nights ago, has not been checked since then. Right foot is causing pain/burning at night; + (positive) serosang (serosanguinous (thin, watery fluid that contains a small amount of blood mixed with serum)) drainage, not malodorous.Physical exam: .Skin: R lateral heel: 4.4cm x3cm partially de-roofed bullae (the skin (roof) has either rubbed off or been removed). + serosanguinous drainage. Wound cleansed, Aquacel Ag and Allevyn dressing applied. It is important to note that the facility obtained this visit note on 4/15/26. The clinic notes R5's wound has not been attended to in the last 2 nights. On 3/19/26 at 10:47 AM, the facility received a faxed order from R5's visit on 3/18/26. The order states: Wound Care: Cleansed right lateral heel with anasept and gauze. Skin prep applied to peri wound. Cut aquacel AG to wound size and applied directly over wound bed, followed by bordered foam dressing. Additional supplies provided. May cleanse with soapy water and change every 2-3 days. (of note: this treatment order was received 4 days after the wound was discovered) Wound MD note on 3/25/26 states in part: .Non-Pressure Wound of the Right Heel Full Thickness: Etiology (quality): Neuropathy Further etiology detail: spinal disease, complicated by BLE (bilateral lower extremity) edema.Wound size (L (length) x W (width) x D (depth)): 7.7 x 7.3 x 0.2 cm (centimeters).Exudate: Heavy Serous (a clear or pale yellow, thin, watery fluid that naturally leaks from a wound )Thick adherent devitalized necrotic tissue: 10%. Granulation tissue: 90%. Additional Wound Detail: Ruptured blister of lateral right heel. Neuropathy from Spina Biffida occulta along with CHF (Congestive Heart Failure) edema and Charcot arthropathy of foot. Has been seeing [Health Care Facility name] wound clinic for this episodic issue up through last week. (of note: R5's heel wound is noted to be larger on 3/25/26, than it was on 3/18/26. The wound now has 10% necrotic tissue present) Wound MD note on 4/1/26 states in part: .Non-Pressure Wound of the Right Heel Full Thickness: Etiology (quality): Neuropathy Further etiology detail: spinal disease, complicated by BLE edema. Wound size (L x W x D): 7.7 x 7.4 x 0.2 cm .Periwound radius: maceration. Exudate: Heavy Serous. Thick adherent devitalized necrotic tissue: 30%. Slough: 10% Granulation tissue: 60% . Additional wound detail: Med team started on Doxycycline (antibiotic) when diuretic was doubled. Evidence now of moderate extensive RLE (right lower extremity) edema to just above knee and maceration but no purulence (pus) or erythema (redness of the skin) at this time.Surgical Excisional Debridement Procedure: Indication for procedure: Remove necrotic tissue and establish margins of viable tissue.Procedure note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 17.09 cm of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth on 0.2cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased for 40% to 10% . (of note: R5's wound had 40% necrotic tissue compared to 10% necrotic tissue on 3/25/26) Wound MD note on 4/8/26 states in part: .Non-Pressure Wound of the Right Heel Full Thickness: Etiology (quality): Neuropathy Further etiology detail: spinal disease, complicated by BLE (bilateral lower extremity) edema. Wound size (L x W x D): 4.8 x 6.5 x no measurable cm. Depth is unmeasurable due to presence of nonviable tissue and necrosis. Exudate: Moderate sero-sanguinous (pinkish yellow drainage). Thick adherent black necrotic tissue (eschar): 70% Thick adherent devitalized necrotic tissue: 10%. Granulation tissue: 20% . Additional wound detail: Reduces surface area but increased heel eschar.Sharp Selective Debridement Procedure: Indication for procedure: Removal of devitalized epidermis and/or dermis. Remove dried exudates or debris.Procedure note: The wound was cleansed with normal saline and anesthesia, though not required, was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to selectively remove devitalized epidermis and/or dermis, remove dried exudates or debris over the wound surface area of 31.2cm. On 4/14/26 at 9:56 AM, Surveyor observed wound care with RN H (Registered Nurse) and LPN I (Licensed Practical Nurse). Surveyor observed R5's right heel wound bed to be necrotic and appeared to look like a cap. The wound was approximately 2 x 3. R5 reported to Surveyor that they haven't been able to wear shoes for about 6 weeks due to them causing too much pain. It is important to know that Surveyor requested documentation of daily diabetic foot checks from 2/10/26 through 4/14/26, and none were provided. On 4/14/26 at 2:10 PM, Surveyor interviewed RN H. Surveyor asked RN H how often staff are completing diabetic foot checks, RN H reported that they are putting the order in to complete them daily. Surveyor asked RN H how often they were being completed prior to today, RN H stated they were being done weekly with their bath. Surveyor asked RN H where they chart weekly skin checks, RN H stated they are on the MAR/TAR (Medication Administration Record/ Treatment Administration Record) and that there is an assessment for weekly wound check/weekly skin check. Surveyor asked RN H if they complete the weekly skin check assessment weekly, RN H stated that they will be completing that from now on. On 4/14/26 at 2:21 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if the facility has a wound nurse, DON B stated it was LPN I. Surveyor asked DON B if LPN I was wound care certified, DON B stated no. Surveyor asked DON B what the expectation was for nursing staff and the completion of weekly skin checks, DON B stated they should be completed weekly on bath day. Surveyor asked DON B if they should be documented, DON B stated yes. Surveyor asked DON B how often diabetic foot checks should be completed, DON B stated daily. Surveyor asked if diabetic foot checks should be documented, DON B stated they should be documenting them on the TAR. DON B reviewed R5's TAR, and no order for diabetic foot checks was found on R5's TAR. DON B reported that staff are doing daily wound care and are looking at both of R5's feet at that time. Surveyor reported that during wound care observation, R5's right foot was the only foot exposed. On 4/15/26 at 1:35 PM, Surveyor interviewed LPN I. Surveyor asked LPN I if facility staff completed a wound assessment when R5's wound was first observed, LPN I stated that the nurse who found it measured the length and width. Surveyor asked LPN I if that was a complete assessment, LPN I stated no. Surveyor asked LPN I who is responsible for assessing wounds from the onset until the wound MD can see them, LPN I stated the nurses monitor the wounds. LPN I reported that if a resident has a pressure injury, they will look at the wound and determine a plan. Surveyor asked LPN I what the facility's policy is regarding wound assessments, LPN I stated that they look at the wound, measure it, update the MD, and put a plan in place. LPN I reported that R5 obtained their wound on a Sunday and they were not aware of the wound until Tuesday, and then R5 refused treatment by the wound MD on Wednesday due to seeing an outside provider. Surveyor asked LPN I if R5's wound was assessed on Monday, LPN I stated no and that R5 refused. Surveyor asked if R5's refusal was documented, LPN I stated no. Surveyor asked LPN I if nursing staff completed a complete assessment of R5's wound between Sunday and Wednesday, LPN I stated no. Surveyor asked LPN I if they would expect staff to call the on-call MD versus faxing or leaving a note in the MD's folder, LPN I stated yes. On 4/15/26 at 3:33 PM, Surveyor interviewed MD J (Medical Doctor). Surveyor asked MD J if they would expect staff to complete daily diabetic foot checks, MD J stated yes. Surveyor asked MD J about the etiology of R5's right heel wound and that documentation indicated that it started as a blister, MD J stated that the wound may be venous and that R5 lays on that side. R5 was at risk for skin concerns due to his diagnosis of diabetes, staff did not perform daily diabetic foot checks, resulting in R5 being found with a heel wound, that was not assessed upon discovery and deteriorated prior to being seen by the wound physician. Example 2: R2 was admitted to the facility on [DATE] with a diagnoses including diabetes, pulmonary disease, acute kidney failure, muscle wasting, chronic venous hypertension (high pressure in leg veins due to damaged or weak valves causing chronic leg swelling), heart failure, cellulitis of right lower limb, atrial fibrillation, and cardiac pacemaker. R2's skin assessment at time of admission states,.9/15/26, resident has blisters on RLE related to cellulitis. Treatment from hospital on admission placed already on RLE was oil emulsion to blisters, covered by abd pads, wrapped in kerlix. After supper, dressing saturated with drainage. Cleansed with saline and dressings reapplied. R2's Right big toe wound was not assessed, measured or documented on upon admission by facility staff. R2's hospital discharge paperwork indicated that R2 also had a wound on base of the big toe right side. it is important to note; there is no mention of R2's toe until 9/17/26 in the nursing progress notes. On 9/17/25 R2's Nurse Progress note written by an LPN (Licensed Practical Nurse) indicated, on wound round writer looked at right lower leg/foot from the medial aspect of mid calf and down to toes across top of foot it is very moist and loose skin from blisters that had popped. top of foot down by toes has some whitish very moist area where there was a blister that had popped. area was cleansed and new oil emulsion, abd (abdominal pad) and kerlix was applied. resident stated that it was a little tender. redness noted around all and up leg d/t (due to) cellulitis. R2 was hospitalized from [DATE]-[DATE]. On 4/15/26 at 11:36 AM, Director of Nursing B (DON) indicated all wounds should be documented in the initial skin assessments. DON B stated, Yes, definitely, all wounds should be on the skin assessments so proper measurements and treatments are provided. DON B indicated weekly measurements should also be documented. On 4/15/26 around 4:00 PM, Nursing Home Administrator A (NHA) indicated skin assessments should include all wounds and measurements. NHA A indicated understanding of the above concern. Example 3: The facility's Notification of Changes policy, dated 1/25, states, in part: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification.Circumstances requiring notification include: .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental, or psychosocial status. This may include: .b. Clinical complications. R4 admitted to the facility on [DATE] and has diagnoses that include acute respiratory failure with hypoxia (a condition where the lungs cannot transfer enough oxygen to the blood); muscle weakness; pressure ulcer of sacral region; atherosclerotic heart disease (a condition where plaque builds up in the heart's arteries, restricting blood flow and oxygen) R4's Progress Notes include: On 4/11/26 at 8:12 PM .resident ate in room seems a bit off/depressed or sad. Stated neck and shoulders hurt when asked what was wrong. On 4/11/26 at 10:15 PM Resident seems different ate in room.R4 stated, I'm not sure maybe just a combination of things. On 4/12/26 at 11:00 AM Resident tearful and worried about what is going on with her.Resident reported that she had one episode of gagging and showed writer basin. No vomit noted. Clear sputum was noted in basin. Resident took her medication one by one. No swallowing issues or gagging noted. On 4/12/26 at 2:53 PM Resident stating she did not feel well, started spitting in tooth basin after a few minutes had a medium emesis. Will continue to monitor. On 4/12/26 at 9:35 PM .Resident was spitting then gagging then had medium emesis. Was crying at times had another episode before bedtime. Refused HS (bedtime) medication and wanted a Norco (pain medication) to rest. Stated she had not slept well in 3 nights. On 4/13/26 at 3:29 PM Resident was being assisted to the bathroom by writer, using gait belt and walker, resident leaned against her recliner that was in a raised position due to resident needing to use the bathroom, resident stated her leg got weak and she sat on recliner but was sliding out, writer used gait belt and lowered resident to floor. On 4/13/26 at 4:27 PM Writer met with resident and discussed her recent change of condition. Writer inquired about the resident going to the hospital for further evaluation. R4's Weights and Vitals Summary for 4/1/26 through 4/30/26 show assessment of Blood Pressure, Oxygen Saturation, Pulse, Respiration, and Temperature on 4/6/26 and 4/13/26. Important to note there are no vital signs documented for 4/11/26 or 4/12/26. On 4/14/26 at 9:50 AM, Surveyor interviewed RN E (Registered Nurse) and asked about the procedure when a resident complains of not feeling well and/or is having emesis. RN E stated perform assessment with vital signs and bowel sounds. Document the vital signs and assessment in the progress notes; there is an additional section of the chart for vital signs as well as assessments. Tell the whole story, including who was updated. On 4/14/26 at 1:28 PM, Surveyor interviewed DON B (Director of Nursing) and asked about procedure when a resident complains of not feeling well and/or is having emesis. DON B stated assess vital signs, bowel sounds, pain, diet, medications. Keep the resident in their room until we know what is going on. Update the NP (Nurse Practitioner). Surveyor asked if there was an assessment or update to NP with R4's episodes of emesis on 4/12/26. DON B stated there should have been, yes. DON B reviewed R4's chart and stated there was no documentation of assessment or provider update. DON B stated the resident was hospitalized with urinary tract infection.

Based on observation, interview, and record review, the facility did not ensure that residents admitted without a pressure injury (PI) did not develop pressure injuries and did not ensure residents are provided cares and services consistent with professional standards of practice to prevent the development or worsening of PIs for 1 of 2 residents (R5) reviewed for pressure injuries.R5 was admitted to the facility with a cervical collar. The facility failed to complete skin assessments and R5 developed an unstageable pressure injury from his cervical collar. RN H (Registered Nurse) was observed not follow physician orders during treatment observation. Evidenced by: The American Medical Directors Association (AMDA) clinical practice guideline entitled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications. The National Pressure Injury Advisory Panel (NPIAP) at www.NPIAP.com defines PIs in the following categories:Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location.Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV.The facility's policy titled Pressure Injury Prevention and Management dated 2/2025 states in part .Definitions: Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with the resident needs, goals, and professional standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.c. Wound assessments will be documented in the medical record. Findings should include type of wound, wound measurements (measured upon discovery, and at least weekly thereafter), other wound characteristics (color, exudate, pain, tissue type in wound bed), and treatment and interventions implemented.R5 was admitted to the facility on [DATE] with diagnoses that include posterior displaced type 2 Dens fracture (fracture is a break that occurs through a specific part of C2, the second bone in the neck), type 2 diabetes mellitus, and peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs).Of note: R5 was admitted without a pressure injury to his neck/back of head area.R5's most recent Minimum Data Set (MDS) dated [DATE] states that R5 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R5 is cognitively intact.R5's care plan dated 2/25/26 states in part: Focus: Skin Integrity: At risk /and/or potential for complications with impaired skin integrity including skin tears, bruising, and/or pressure r/t (related to) current medical/physical status. Has meds/dx (medications/diagnosis) that can/may affect skin integrity. Stage 3 to sacrum, non-pressure to R (right) heel, unstageable to back of head, venous wound to right calf tx (treatment) per wound MD (Medical Doctor) order (Revision on 4/14/2026) .Interventions/Tasks: Assist/encourage pressure relief as needed/accepted. Follow community skin protocol. Observe skin with AM/PM (morning/evening) cares and with toileting for redness, rashes, open areas, pain, swelling and report them to team leader. Weekly skin check. Lotion to dry skin. Review skin concerns with MD.Of note, Surveyor reviewed R5's Physician orders and there is no order for staff to check the skin under or around R5's cervical collar. Additionally, there are no wound care orders entered to treat the PI on the back of R5's head.On 4/8/26, R5 had a visit with the Wound doctor. Documentation states in part .Focused Wound Exam (Site 5) Unstageable (due to necrosis) Head Full Thickness. Etiology: Pressure MDS 3.0 Stage: unstageable necrosis. Duration: > 7 days. Wound size (L (length) x W (width) x D (depth): 1.7 x 1.5 x not measurable cm (centimeters). Depth is unmeasurable due to presence of nonviable tissue and necrosis.Exudate: Moderate sero-sanguinous (thin, watery fluid that contains a small amount of blood mixed with serum). Thick adherent devitalized necrotic tissue: 80%. Granulation tissue: 20% .Additional Wound detail: Pressure wound from Rigid Cervical Collar at left/ middle occipital area. Dressing and treatment plan: Primary dressing: Alginate calcium apply once daily and as needed.Secondary dressing: Foam silicone border apply once daily and as needed.Peri wound treatment: skin prep apply once daily and as needed.On 4/14/26 at 9:56 AM, Surveyor observed R5's wound care with RN H (Registered Nurse) and LPN I (Licensed Practical Nurse). Surveyor observed RN H cleanse the wound to the back of R5's head, apply mepilex, and apply an ABD pad for comfort.It is important to note that RN H did not apply skin prep to the peri wound, nor is there an order for an ABD pad for comfort.Surveyor requested documentation of skin checks under R5's cervical collar, no documentation was provided.On 4/14/26 at 2:10 PM, Surveyor interviewed RN H. Surveyor asked RN H how often staff are completing skin checks under R5's cervical collar, RN H stated that they were doing them daily, Surveyor asked RN H if they documented the skin checks, RN H stated no. Surveyor asked RN H where they are documenting weekly skin checks, RN H stated that there is a weekly wound check/ weekly skin check under the assessments. Surveyor asked RN H if they are completing the assessments weekly, RN H stated no, but they will be from now on.On 4/14/26 at 2:21 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if the facility has a wound nurse, DON B stated it was LPN I. Surveyor asked if LPN I is wound care certified, DON B stated no. Surveyor asked DON B how often staff should be completing weekly skin checks, DON B stated they should be completed on bath day. Surveyor asked if they should be documented, DON B stated yes. Surveyor asked DON B how often they would expect staff to be checking under a device for skin breakdown, DON B stated at least every shift. Surveyor asked DON B if checking under R5's cervical collar is in the physician's orders, DON B reviewed R5's orders and DON B indicated there was no order found. Surveyor asked DON B if they would expect nursing staff to check the skin under R5's cervical collar, DON B stated yes.On 4/15/26 at 1:35 PM, Surveyor interviewed LPN I. Surveyor asked LPN I when they were made aware of the pressure injury to the back of R5's head, LPN I indicated that LPN I and the wound doctor found the PI during wound rounds on 4/8/26. Surveyor asked LPN I if there was any documentation on the wound prior to 4/8/26, LPN I stated no. Surveyor asked LPN I if the nurses enter the admission orders into the computer, LPN I stated that DON B puts the orders in. Surveyor asked if R5 should have had an order entered to check the skin under their cervical collar, LPN I stated if the resident had orders not to remove the cervical collar, they would not expect staff to check the skin. Surveyor asked LPN I if R5 had an order to not remove the cervical collar, LPN I stated that they would have to look and would get back to Surveyor.It is important to note that Surveyor was not provided with any documentation instructing staff not to remove R5's cervical collar or to not check the skin under the medical device.On 4/15/26 at 3:33 PM, Surveyor interviewed MD J (Medical Doctor). Surveyor asked MD J if they would expect staff to be checking the skin under R5's cervical collar, MD J stated yes.R5 developed a medical device related pressure injury that was found to be an unstageable pressure injury due to nursing staff not checking R5's skin under his cervical collar daily.

Based on interview and record review, the facility did not establish and maintain 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 infection. This has the potential to affect all 34 residents who reside at the facility.The facility had tests that were positive for Legionella. The facility did not have water heater temperatures adequate to kill Legionella, did not provide interventions for R22's room to mitigate risk of exposure for R22, and did not do additional testing to ensure effectiveness of control measures taken in the building.Evidenced by:Per the CDC (Center for Disease Control and Prevention) page entitled Controlling legionella in potable water systems, indicates the following: Operation, maintenance, and control limits . Guidance . Monitor temperature, disinfectant residuals, and pH frequently based on performance of WMP or Legionella performance indicators for control. Adjust measurement frequency according to the stability of performance indicator values. For example, increase the measurement frequency if there's a high degree of measurement variability. Hot water: Store hot water at temperatures above 140 F (60 C). Ensure hot water in circulation does not fall below 120 F (49 C). Recirculate hot water continuously, if possible.Cold water: Store and circulate cold water at temperatures below the favorable range for Legionella (77-113 F, 25-45 C). Legionella may grow at temperatures as low as 68 F (20 C).The facility's Infection Prevention and Control Program policy, dated 5/25, states, in part: This facility has established and maintains 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 as per accepted national standards and guidelines.17. Water Management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance Director serves as the leader of the water management program.The facility's, (Company Name) Water Management Plan, undated, states, in part: .Control Measure Conduct validation testing in domestic water systems and other drinking water.Monitoring Test for Legionella at least four times yearly initially and then more frequently if indicated by test results.Frequency of Control Measure Task every 90 days .Corrective Action Respond to any Legionella-positive sample (per the diagram in Training Note 4.101) If positivity or concentrations exceed the team's limits, initiate remediation within 2 days of receiving the test results, taking a step-by-step approach. 4.101 Responding to Legionella Environmental Test Results.1. Communicate the results and take immediate measures necessary to reduce risk or comply with laws.Take required and appropriate measures to comply with laws and reduce health risk based on the test results, occupant risk, and cases of disease. Measures may include but not be limited to:*Following regulations as well as specific orders and given by health officials or other authorities having jurisdiction (AHJ)*Reporting the test results to AHJs, if required*Following the Responding to Disease section of your WMP (Water Management Plan)*Getting help from qualified consultants as appropriate*Implementing domestic water restrictions or installing faucet and shower filters rated for < (less than) 0.2 micron and validated to block Legionella*Emergency disinfection of cooling towers*Emergency disinfection of domestic water (plumbing) systems .2. Review the sampling plan for adequacy, especially if Legionella was not found. In its Legionella Control Toolkit, the CDC (Center for Disease Control) warns that any of the following indicates poor control of potable water (drinking water): * (greater than or equal to) 1 CFU/mL (Colony-Forming Units per milliliter-the concentration of living bacteria in a liquid sample)*10-fold concentration increase from one sampling round to the next*two or more Legionella-positive locations within a system (e.g. faucets in a potable water system)*Legionella in a location that serves multiple areas On 4/14/26 at 1:04 PM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist) and MT C (Maintenance Technician) about water management. MT C stated about a year ago we looked at our water treatment system and felt that it wasn't needed. We contracted with a water management company and they suggested we get a baseline. 3 months after removing the water treatment system we tested and got some light positives.The facility's Legionella Summary Sheet, report date 9/22/25, indicates:* Date of Sampling: 9/10/25*Location [NAME] (Point of Entry) Cold Water Total Legionella (cfu/ml) ND (none detected)*Location Break Room Sink Total Legionella (cfu/ml) 14*Location [500 wing room number] Shower Total Legionella (cfu/ml) 23*Location Ice Machine 500 wing Total Legionella (cfu/ml) ND*Location [R22's room] Sink Total Legionella (cfu/ml) 26*Location Wing 400 Shower Room Total Legionella (cfu/ml) 20*Location [300 wing room number] Shower Total Legionella (cfu/ml) 15On 4/14/26, during continued interview with DON/IP B and MT C, MT C stated, we decided we needed to increase our flushing, then we tested again 2 weeks later.The facility's Legionella Summary Sheet, report date 10/8/25, indicates:*Date of Sampling: 9/30/25**Location Break Room Sink Total Legionella (cfu/ml) 3*Location [500 wing room number] Shower Total Legionella (cfu/ml) 3*Location [R22's room number] Sink Total Legionella (cfu/ml) 5*Location Wing 400 Shower Room Total Legionella (cfu/ml) ND*Location [300 wing room number] Shower Total Legionella (cfu/ml) 5On 4/14/26, during continued interview with DON/IP B and MT C, Surveyor asked what happened after the second round of testing. MT C stated we decided to go back to a chlorinated system, like we had, but now we will do a chlorine injection. We got bids on setting up a plan, and we started the chlorine injection last Thursday, 4/9/26, as there were issues with getting supplies from out of the country. MT C stated that the facility has continued the increased flushing; upped from 2 minutes to 5 minutes weekly. DON/IP B stated the facility has been monitoring residents for any signs of respiratory illness, staff were educated on what to look for and providers and the medical director were informed so that they'd be aware of a potential need to test residents. DON/IP B stated there have been no resident concerns. Surveyor asked if water temperatures are monitored. MT C stated yes, temperatures are monitored weekly at the water heater. Facility was at 111 degrees Fahrenheit (F) for scalding purposes; now set at 116 degrees F and resident rooms range from 111-114. Surveyor asked what temperature is needed to kill Legionella. MT C stated 117 or 123, don't recall for sure, but we can't keep our water heater temperature that high as we don't have anti-scald protection.On 4/14/26 at 4:10 PM, Surveyor interviewed R22 who stated that he/she washes up at the bathroom sink; (washing face and brushes teeth.)On 4/15/26 at 10:06 AM, Surveyor interviewed DON/IP B and MT C and asked about the water management plan's instructions following a positive test. DON/IP B, MT C and Surveyor reviewed the 4.101 notes. Surveyor asked if any of the interventions were implemented. MT C stated no, because we felt the numbers were low. Surveyor asked what a safe range for Legionella is, MT C stated he was unsure, but the consultant just advised on additional flushing. MT C stated, ultimately it was our decision how to proceed, the chlorination just took longer than we thought it would. Surveyor asked if there were any further interventions for R22's bathroom sink, water brought from another area / filter installed. MT C stated no, just additional flushing. DON/IP B stated residents don't generally drink from the sink in their room, water is distributed to them for drinking. Surveyor asked if water is consumed from the sink when brushing their teeth. DON/IP B stated yes. Surveyor asked if there is a potential for aspiration (inhaling fluid into lungs) when brushing their teeth. DON/IP B stated yes, of course. Yes, there is the potential for exposure to Legionella.On 4/15/26 at 2:20 PM, Surveyor reviewed concerns with NHA A (Nursing Home Administrator); positive tests with no further testing to determine if their water management plan has been effective, R22's continued possible exposure in their room, and water heater temperatures below 140 degrees which is not sufficient to kill Legionella. NHA A stated, I understand.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 25 opportunities that affected 2 out of 8 residents (R14 & R1) included in the medication administration task, which resulted in an error rate of 8%. Surveyor observed RN E (Registered Nurse) prepare to crush R14's Pantoprazole DR (delayed release; a medication used to reduce stomach acid) to administer it to R14 before Surveyor stopped her. Surveyor observed RN D (Registered Nurse) did not prime R1's insulin pen before administration and did not keep the needle in the skin after administration to ensure proper dosing. This is evidenced by: The facility policy, Administering Medications, updated 10/2022, states in part: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation:. 2. Medications must be administered in accordance with the orders, including any required time frame. 5. The individual administering the medication must check the label against the Physician's order to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Example 1: R14 was admitted to the facility on [DATE] with diagnoses that include gastro-esophageal reflux disease without esophagitis (GERD) (a digestive disorder with symptoms of chronic heartburn or acid reflux without visible damage to the esophagus) and a history of peptic ulcer disease (open sores in the stomach lining or top of the small intestine). R14's Physician Orders, dated 2/6/26, include, in part, the following medication: Pantoprazole Sodium Oral Tablet Delayed Release 20 mg – Give 1 tablet by mouth one time a day related to gastro-esophageal reflux disease without esophagitis. On 4/14/26 at 8:16 AM, Surveyors observed RN E prepare medications to administer to R14. RN E placed seven medication tablets into a plastic bag to crush for R14 to take with applesauce. One of the medications placed in the bag to crush was R14's Pantoprazole DR 20 mg tablet. It is important to note that delayed release medications are not to be crushed. According to MedlinePlus, pantoprazole DR is designed to pass through the stomach so it can be absorbed in the small intestine. Instructions for pantoprazole DR include: Swallow the tablets whole; do not split, chew, or crush them (https://medlineplus.gov/druginfo/meds/a601246.html). Crushing a delayed release medication hinders its therapeutic properties. On 4/14/26 at 8:19 AM, Surveyor stopped RN E right before she began crushing R14's medications in the plastic bag and asked if the pantoprazole should be crushed if it's a delayed release medication. RN E indicated she hadn't seen that the pantoprazole was delayed release. RN E pulled the medication card from the cart and looked at it with Surveyor. The card indicated that the pantoprazole was delayed release and instructions stated: Don't chew or crush. RN E removed the pantoprazole DR from the plastic bag and said it shouldn't be crushed because it's delayed release. On 4/15/26 at 2:33 PM, Surveyor interviewed DON B (Director of Nursing). DON B confirmed that pantoprazole DR should not be crushed and indicated she would reach out to R14's doctor to get this prescription adjusted, as R14 has a hard time swallowing pills. Example 2: The facility's Insulin Pen policy, dated 2/26, states, in part: It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing. 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir.11. Procedure: .g. Attach pen needle.h. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. i. Set the insulin dose. j. Injecting the insulin: .iii. Inject the needle straight at a 90-degree angle to the skin. iv. Fully depress the plunger until the dosing numbers count back to zero. v. While still pressing the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin. Manufacturer's instructions for use of the HUMALOG-insulin lispro injection, solution, from the manufacturer's website (https://uspl.lilly.com/humalog/humalog.html#ug1 ) states, in part: .Priming your pen Prime before each injection. Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.Step 11. Insert the Needle into your skin. Push the Dose Knob all the way in. Continue to hold the Dose Knob in and slowly count to 5 before removing the Needle. On 4/14/26 at 12:04 PM, Surveyor observed RN D prepare Insulin Lispro (Humalog) (fast acting insulin) at the medication cart for R1. RN D applied a needle to the insulin pen and dialed the pen to 14 units. RN D gathered gloves and an alcohol prep pad and began to walk to R1's room. Surveyor asked RN D if the insulin pen was ready for administration. RN D stated yes. Surveyor asked if anything else needed to be done to the pen prior to administration. RN D stated I verified the dosing of 14 units, checked the dates and resident identifier on the label. Surveyor asked if there was anything additional in relation to applying a new insulin needle. RN D stated no, I cleansed with alcohol before the application. Surveyor asked if there is a way to verify that the pen/needle are functioning properly. RN D stated you can prime, but that is only done with a new pen. Surveyor and RN D reviewed manufacturer's guidelines regarding priming the pen and RN D primed the pen with 2 units, then dialed the pen to 14 units for administration. In the resident's room, RN D inserted the needle into R1's skin, administered the dose, then removed the needle from the skin. No hold time was noted. After leaving R1's room, Surveyor asked if there was anything that needs to be done after the injection / after the plunger is depressed and count on the pen returns to zero. RN D stated let it sit for a second or two. Surveyor asked if there is any count. RN D stated no. On 4/14/26 at 1:02 PM, Surveyor interviewed DON B (Director of Nursing) who stated that insulin pens need to be primed prior to setting dose for administration and the needle must remain in place for at least 10 seconds after administration.

Based on observation, interview, and record review, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 12 residents (R3) reviewed for grooming.R3 verbalized wish to be clean shaven and was observed with facial hair for three consecutive days.Evidenced by:The facility's Grooming a Resident's Facial Hair policy, dated 2/26, states, in part: It is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. Important to note: the policy does not indicate how often shaving is to occur.On 4/13/26 at 10:25 AM, Surveyor interviewed R3 during initial screening. Surveyor observed facial hair over R3's cheeks, chin, and neck and asked if resident liked facial hair or a clean shave. R3 stated he prefers to be clean shaven, but that doesn't always happen. R3 admitted to the facility on [DATE] and has diagnoses that include Parkinson's Disease (a progressive disorder with symptoms including tremors, stiffness, slow movement and balance issues); weakness; lack of coordination; mild cognitive impairmentR3's Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview of Mental Status (BIMS) score of 13, indicating the resident is cognitively intact.R3's Care Plan Report includes:* Focus: with deficits with ADLs (activities of daily living) related to current medical/physical status. Has medications/diagnoses that can/may affect ADLs. Interventions/Tasks *Hygiene-1 minimal assist.*Focus: refuses cares. Goal-will have choices and able to make decisions through next review dateR3's Task Charting for Personal Hygiene: The ability to maintain personal hygiene, including combing hair, shaving. for 4/1/26 5:59 AM through 4/14/26 5:59 AM, shows documentation of a mix of dependent (helper does all), partial/moderate assist, and substantial/maximal assist. There is no documentation of resident refusal.On 4/14/26 at 9:40 AM, Surveyor observed R3 with facial hair and interviewed CNA F (Certified Nursing Assistant) about shaving. CNA F stated residents are shaved on bath days and if they request on other days. They can be shaven daily. Surveyor asked if R3 refuses cares/shaving. CNA F stated no, R3 asks about shaving and will do it himself with set up assist. CNA F stated, I'm not sure if it was offered today.On 4/15/26 at 8:15 AM, Surveyor observed R3 with facial hair and interviewed LPN G (Licensed Practical Nurse) about shaving. LPN G stated residents are usually shaved on bath day. LPN G stated R3's bath was Monday, 4/13/26. Surveyor asked if residents can be shaved more often than bath day if they wish to be clean shaven. LPN G stated yes. Surveyor asked if R3 was shaved. LPN G stated no.On 4/15/26 at 8:33 AM, Surveyor interviewed DON B (Director of Nursing) about shaving. DON B stated it should be offered daily.

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 3 residents (R2) reviewed.R2 had a noted change in condition by RN C (Registered Nurse). RN C failed to perform an assessment, check vital signs, and provide an accurate assessment to the physician. R2 continued to decline and was eventually sent to the ED (Emergency Department) where he received treatment for hypothermia and IV (intravenous) fluids.Evidenced by:Surveyor requested the facilities Change in Condition policy; no policy was provided. AMDA (American Medical Directors Association) guidelines, 2003, states, in part: In the long term care setting, a primary goal of identifying ACOCs (Acute Change of Conditions) is to enable staff to evaluate and manage a patient at the facility and avoid transfer to the hospital or emergency room .Examples of Staff Roles and Responsibilities in Monitoring Patients With ACOCs .Staff nurse *Recognize condition change early, *Assess the patient's symptoms and physical function and document detailed descriptions of observations and symptoms, *Update the charge nurse or supervisor if patient's condition deteriorates or patient fails to improve within expected time frame, *Report patient status to practitioner as appropriate . State of Wisconsin Nurse Practice Act states in part: . N 6.03 Standards of practice for registered nurses (1) General nursing procedures. An R.N. 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 or UAPs.(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 . R2 admitted to the facility on [DATE] with diagnoses that include Parkinson's disease (a progressive movement disorder of the nervous system; it causes nerve cells to weaken, become damaged, and die, leading to symptoms that include problems with movement, tremor, stiffness, and impaired balance), anemia, hypo-osmolality (a state of low blood solute concentration, causes hyponatremia (low sodium) symptoms by leading water into the cells, causing them to swell) and hyponatremia, chronic kidney disease stage 3b (moderate to severe loss of kidney function), congestive heart failure (the heart cannot pump blood well enough to give the body a normal supply), and hypertension (high blood pressure).R2's most recent MDS (Minimum Data Set) dated 9/12/25 states that R2 has a BIMS (Brief Interview for Mental Status) of 10 out of 15, indicating that R2 has moderate cognitive impairment. Nurse's notes state the following:10/6/25 at 8:30 AM: LATE ENTRYWhat is the resident exhibiting: Late note charting: Resident was not opening his eyes like he normally does and was shaking more than normal as well. Resident has Parkinson's, so these behaviors are exhibited, but resident was more symptomatic this morning than he had been the day before. Resident was also drooling more than normal for him. At lunch time, the resident was unable to take his Carbidopa medication as it kept falling out of his mouth and resident was unable to swallow any liquids or solid foods for lunch. Resident did have family present, and they were able to get him to open his eyes and talk a little with them. After lunch and visiting with his nieces, resident was taken back to his room. Describe current condition and your current assessment: Writer observed resident's condition and asked if he felt ok, to which he replied yes. Writer notified the DON (Director of Nursing) of resident's condition, and a little while later when the Provider was here, writer asked her to take a look at the resident [NAME][sic], after describing his condition.Provider and Family notification and responses: Provider ordered some lab work to be performed the next morning.New orders or interventions put into place: CBC (Complete Blood Count) with diff (differential), CMP (Complete Metabolic Panel) labs ordered.(It is important to note that this nurse's note was written on 10/7/25 at 2:57 PM, there is no comprehensive RN assessment, vital signs or documentation of what was communicated to the Physician, there is no physician note regarding this interaction.) 10/6/25 at 4:42 PM Vital signs are documented as: BP (Blood Pressure) 152/74, Temperature 98.4, Pulse 53, Respirations 18, Oxygen level 75 % on room air.10/6/25 at 4:48 PM: Day shift nurse reported that resident has been drooling, not swallowing and change of alertness during day shift. He would not swallow meds, or open eyes or respond per normal. Writer did assessment and POA (Power of Attorney) here, concerned, expresses concerns to writer. Resident with minimal responsiveness, unable to follow commands and will not open eyes. Leaning to right side while in wheelchair. POA would like resident sent out.(Of note: the PM shift nurse indicates the Nurse on day shift was aware of the change in condition for R2 and did not follow standards of practice during a noted change in condition.) 10/6/25 at 5:00 PM: Resident's oxygen saturation originally 75% on room air. Oxygen placed on 2-4 lpm (liters per minute) back to 90s.10/6/25 at 5:14 PM: [Ambulance Company Name] here, gave resident history and todays findings. Hospital called with report.10/6/25 at 8:34 PM: Update from [Hospital Name], resident being admitted for comfort care.Emergency Department (ED) notes dated 10/6/25 at 5:29 PM state the following: .Visit final diagnostic impression: 1. Unresponsive 2. Altered mental status, unspecified mental status type 3. Hypothermia, initial encounter 4. Dehydration 5. Hypermagnesemia 6. Chronic renal impairment, unspecified CKD (chronic kidney disease) 7. Chronic anemia.History of present illness: [AGE] year-old gentleman brought in by ambulance from [Nursing Home Name] as patient was noted unresponsive with low pulse ox (oxygen) this morning between 8 and 12 noon today. But when patient came his pulse ox was 99% on room air and initially, he was able to follow commands open his eyes and left [sic] his arms but soon after when I went to evaluate he was unresponsive and was only responsive to painful stimuli. He has noted hypothermic (low body temperature) with temperature of 96.2 initially which soon dropped to 92.5 Fahrenheit has had and not improved. Patient remains unresponsive.Review of Systems (ROS): Unable to perform ROS: Critical illness.Physical Exam: Constitutional: Appearance: He is ill-appearing. Comments: Deeply unresponsive. HENT (Head, Eyes, Nose, Throat): .Mouth: Mucous membranes are dry.Neurological: Comments: Patient is unresponsive and now not responding even to painful stimuli.ED Course 10/6/25 at 7:26 PM: Patient remains unresponsive in ED. He is noted very hypothermic, so Bair Hugger (a continuous temperature monitoring system) and warm bladder irrigation and other measures started in ED to increase his core body temperature.He seems dehydrated so started on IV (Intravenous) fluids.R2's abnormal lab values include the following:RBC (Red Blood Cells) 2.71 (L) (low)- reference range 4.30- 5.70 X(10)6/uLHemoglobin 8.6 (L)- reference range 13.8- 17.3 g/dLHematocrit 26.2 (L)- reference range 39.5- 51.0 %Potassium 5.1 (H) (High)- reference range 3.5- 4.9 mEq/LBUN (Blood urea Nitrogen) 46 (H)- reference range 6-21 mg/dLCreatinine 1.62 (H)- reference range 0.64- 1.27 mg/dLBUN/ Creatinine ration 28 (H)- reference range 12- 20BNP (B. Natriuretic Peptide) 398 (H)- reference range <=100 pg/mLMagnesium 3.1 (H)- reference range 1.8- 2.4 mg/dLR2's Temperature readings in the ED include:5:29 PM 96.26:00 PM 92.46:18 PM 91.96:41 PM 92.16:56 PM 92.37:15 PM 92.57:30 PM 92.77:45 PM 92.87:54 PM 93.0During R2's ED visit, he received 1000ml (milliliters) of NaCl (Sodium Chloride) IV Bolus at 6:20 PM and 7:49 PM, totaling 2000ml received.R2 was admitted to the hospital overnight, placed on comfort care, and returned to the nursing home on hospice services. R2 passed away on 10/12/25.On 10/13/25 at 1:00 PM, Surveyor interviewed CNA D (Certified Nursing Assistant). Surveyor asked CNA D to explain the events regarding R2 on 10/6/25. CNA D stated that when she got R2 up for the day, he wouldn't open his eyes and was very confused, and that at breakfast staff had to feed him. Surveyor asked if R2 requires assistance with eating normally; CNA D stated no. CNA D stated that she reported R2's condition to the nurse and RN C stated that he was having a bad Parkinson's day. CNA D reported that at lunch, R2 was holding food in his mouth, not swallowing, and was not responding. CNA D then told Surveyor that when the second shift came on duty, she reported R2's change of condition to her and she did an assessment and sent R2 to the hospital. CNA D also reported that typically R2 is a pivot assist to transfer, and on this day, they were having to use an EZ stand (mechanical lift) to transfer him.On 10/13/25 at 2:30 PM, Surveyor interviewed LPN E (Licensed Practical Nurse). Surveyor asked LPN E about the events of 10/6/25 and R2. LPN E stated that she worked 2nd shift that day and that during report, RN C stated that R2 had altered mental status and wasn't acting like himself. LPN E reported that she asked RN C if she assessed R2, took vital signs, or updated the doctor, and RN C stated no, he's fine. LPN E stated that the CNA wasn't comfortable transferring R2 and asked her for assistance. LPN E went to R2's room and noted that he did not look right and proceeded to check vital signs and complete an assessment. LPN E also reported to Surveyor that CNA D stated that R2 was having a change of condition over the weekend as well.On 10/14/25 at 9:34 AM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C to explain R2's change in condition on 10/6/25. RN C stated that R2 wasn't opening his eyes, was not giving verbal responses, and had increased shaking. RN C stated that the CNA reported R2's condition to her and that R2's wife was concerned. RN C stated that she asked R2 how he was, and he said ok, and asked him if he was cold, and he said no. RN C stated that R2 took his morning medications, but he was unable to swallow his noon medications, and that she tried ten times to give it to him. RN C reported that R2's head was tipped down and he was unable to get his lips to go around the spoon. RN C reported that after she checked on R2 at breakfast, she reported R2's condition to DON B. Surveyor asked RN C what directives were given by DON B. RN C stated that she was told that R2 was probably having a Parkinson's flare up. RN C stated that she asked the physician to look at R2 because he was not looking good and was having increased shaking. Surveyor asked RN C if the physician assessed R2. RN C stated that she was unsure, and that the physician ordered labs. Surveyor asked RN C if she completed any kind of assessment on R2. RN C stated that she just talked to him and that she could have obtained R2's vital signs, but she didn't. Surveyor asked RN C if documentation should be completed timely, RN C stated yes.On 10/14/25 at 1:04 PM, Surveyor interviewed MD H (Medical Doctor). Surveyor asked MD H if RN C reported R2's change of condition to her while she was in the building on 10/6/25, MD H stated no. MD H stated that the CNA came up to her and said that the nurse wanted her to look at R2 and reported that he was weaker. MD H stated that she saw R2 earlier in the morning when she was visiting his wife and that he seemed ok. Surveyor asked MD H if she would have expected RN C to complete an assessment, obtain vital signs, and report them to you, MD H stated yes.On 10/14/25 at 1:25 PM, Surveyor interviewed DON B. Surveyor asked DON B when she was made aware of R2's change of condition? DON B stated that RN C had reported that R2 had increased shaking, and I told her to let the physician know. Surveyor asked DON B what the expectation is for nurses when a resident is noted to have a change of condition? DON B stated that they should assess the resident, check vital signs, and contact the physician. Surveyor asked DON B if RN C should have completed an assessment on R2 and reported the findings to the physician, DON B stated yes. Cross reference F692

Based on interview and record review, the facility did not ensure that each resident receives adequate supervision to prevent accidents for 2 of 3 residents (R1 and R3) reviewed for falls. R1 had 7 unwitnessed falls while self-transferring. The facility failed to complete adequate assessments, conduct root cause analyses, and implement interventions to address the unsafe self-transferring. R1 was found to have a subdural hematoma (a collection of blood that accumulates between the brain and the inner layer of the skull). R3 was admitted to the facility on [DATE] and identified at risk for falls. R3 has had 8 falls since the time of admission to current. The facility failed to identify root causes of the falls, identify trends, and update care plan. This is evidenced by: The facility policy Fall Prevention Program, dated 2/28/25, includes: 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. The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: i. A clear pathway to the bathroom and bedroom doors. ii. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. iv. Adequate lighting. v. Wheelchairs and assistive devices are in good repair. b. Implement routine rounding. c. Monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. d. Encourage residents to wear shoes or slippers with non-slip soles when ambulating. e. Ensure eye glasses, if applicable, are clean and the resident wears them when ambulating. f. Monitor vital signs in accordance with facility policy. g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. b. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter, if indicated iv. Medication regimen review v. Low bed vi. Alternate call system access vii. Scheduled ambulation or toileting assistance viii. Family/caregiver or resident education ix. Therapy services referral. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. The facility policy Fall Risk Assessment, dated 9/25, includes: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents. The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified. The risk assessment will contain the following components: a. Identify environmental hazards and individual risks, including the need for supervision b. Evaluate and analyze hazards and risks. An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. Monitor the effectiveness of the care plan interventions, and modify the intervention as necessary, in accordance with current standards of practice. The facility policy Head Injury, dated 2/28/25, includes: It is the policy of this facility to report head injuries to the physician and implement interventions to prevent further injury. Assess resident following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum: a. Vital signs. b. General condition and appearance. c. Neurological evaluation for changes in: i. Physical functioning ii. Behavior iii. Cognition iv. Level of consciousness v. Dizziness vi. Nausea vii. Irritability viii. Slurred speech or slow to answer questions d. Evaluation of head, eyes, ears, and nose for significant changes in vision, hearing, smell, or bleeding. e. Any injuries to head, neck, eyes, or face, including lacerations, abrasions, or bruising. f. Pain assessment. Perform neuro checks (Neurological assessment) as indicated or as specified by the physician. Continue monitoring for 72 hours following the incident or until the resident is asymptomatic for a period of time specified by the physician. Notify family and document all assessments, actions, and notifications. The facility policy Comprehensive Care Plans, dated 2/28/25, includes: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. f. Resident specific interventions that reflect the resident's needs. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. On 10/14/25 at 12:33 PM, Surveyor interviewed DON B (Director of Nursing) regarding the facility's neurological assessment sheets. DON B indicated the facility uses a form titled Vital Signs and Neuro Checks. DON B indicated the timing of vital signs and neuro checks are listed on the sheet. DON B indicated vital signs and neuro checks are completed as follows: every 15 minutes four times, every 30 minutes twice, every hour twice, every shift eight times for a total of 72 hours post fall. Example 1: R1 admitted to the facility on [DATE] with diagnoses including lymphedema (a condition in which excess lymph fluid accumulates in the tissues causing swelling), atrial fibrillation (a heart rhythm disorder where the upper chambers of the heart beat irregularly and rapidly, out of sync with the lower chambers), repeated falls, difficulty in walking, and cognitive communication deficit. R1's Brief Interview for Mental Status, dated 9/26/25, had a score of 9, indicating R1 is moderately cognitively impaired. R1's physician orders active as of 10/6/25, include: Warfarin Sodium Oral Tablet 2 MG (anticoagulant, a medication that prevents blood clots from forming, also known as blood thinners) by mouth one time a day every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for A-fib (Atrial Fibrillation). OT (Occupational Therapy) Evaluation and treatment 3-5x week (3-5 times a week) for 41 days order date 9/10/25. Resident to have lymphedema treatments from PT/OT (Physical Therapy/Occupational Therapy) order date 9/2/25. R1's comprehensive care plan, printed on 10/14/25, includes:Focus: ADL (date initiated 8/13/25)Goal: Will be more independent in bathing, dressing, grooming, bed mobility, transfers and ambulation/locomotion by discharge date . Interventions/Tasks: Ambulation – Independent with 2 wheeled walker. Locomotion – Independent with 2 wheeled walker. Transfers – Independent with 2 wheel walker. Focus: The resident is at risk for falls r/t (Related To) BLE (Bilateral Lower Extremity) edema (Swelling), and weakness (date initiated 3/24/25)Goal: The resident will be free of falls through the review date.Interventions/Tasks: Anticipate and meet the resident's needs (date initiated 3/24/25). 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 (date initiated 3/24/25). Follow facility fall protocol (date initiated 4/17/25). On 10/14/25 at 12:33 PM, Surveyor interviewed DON B (Director of Nursing) regarding falls. DON B indicated if a resident has an unwitnessed fall, the staff should treat that fall as if the resident received a head injury. DON B indicated staff should immediately complete a thorough assessment of the resident to include, but not limited to, vital signs, neurological assessment (pupil size and reaction to light), hand grasps, facial symmetry, speech, pain, range of motion to extremities, full skin check, anything that might be a change from the resident's baseline status and to ask the resident what they were doing or how they fell. DON B indicate the assessment should be documented in the resident's medical record. DON B indicated the staff are responsible to complete an incident report, make proper notifications to family and providers, to document the complete assessment, start the vital signs and neuro checks sheet, and complete the post fall assessments. DON B indicated a resident who has fallen will be monitored, evaluated, and documented on every shift for 72 hours. DON B indicated the interdisciplinary team (IDT) reviews all falls and will make a note in the resident's medical record regarding that meeting. DON B indicated the following disciplines are in the fall meetings: therapy, MDS (Minimum Data Set) nurse, dietary, social services, DON B, and NHA A (Nursing Home Administrator). DON B indicated new interventions to prevent falls would be added to the resident's comprehensive care plan. DON B indicated LPN J (Licensed Practical Nurse) is responsible for updating the care plans with new interventions. DON B indicated the interventions on the comprehensive care plan flows into the CNAs' (Certified Nursing Assistants) Kardex so all staff would be aware of the resident's fall prevention interventions. DON B indicated the comprehensive care plan is updated with fall prevention interventions immediately or as soon as possible after a resident has a fall. Event 1R1's fall incident report dated 6/23/25 at 7:15 AM, includes: Incident Description: Nursing Description: cna (Certified Nursing Assistant) had found resident kneeling by the doorway of his room. Resident Description: slipped on his grippy socks and fell. Was this incident witnessed: N (No)Immediate Action Taken: Description: no first aid was needed. assisted back into his recliner using the hoyer lift. Injuries Observed at Time of Incident: No injuries observed at time of incident.Mental Status: Oriented to Person, Oriented to Place, Oriented to Situation, Oriented to TimePredisposing Environmental Factors: NonePredisposing Physiological Factors: ConfusedPredisposing Physiological Factors: Vision ImpairmentPredisposing Situation Factors: None R1's Vital Signs and Neuro Checks sheet dated 6/23/25, includes: Blank sections for Day 2 Shift #2 and Day 3 Shift #2. On 10/14/25 at 12:33 PM, Surveyor interviewed DON B regarding R1's 6/23/25 fall. DON B indicated R1 did not have a full assessment immediately following his fall. DON B indicated R1's comprehensive care plan was not reviewed and was not updated with a new intervention to prevent further falls. DON B indicated the facility did not complete a post fall assessment for R1. DON B indicated the post fall vital signs and neuro checks was not completed fully. Event 2 R1's fall incident report dated 7/27/25 at 6:00 AM, includes: Incident Description: Nursing Description: Writer noticed first thing this morning that resident had skin tears and bruising on LUE (Left Upper extremity) and bruising on RUE (Right Upper Extremity) and asked resident what happened. Resident stated that he fell during the night. Writer asked if resident reported the fall to the Nurse, and he stated No. Writer then asked why not, and resident replied: I was mad that someone was knocking on my door stating 'Help me, help me', so I got up and fell while trying to get to my walker. Was this incident witnessed: N (No)Immediate Action Taken Description: Writer took vital signs and assessed the wound right away and asked if resident had any other injuries or had pain and resident stated No.Mental Status: Orientation to Person, Orientation to Place, Orientation to Situation. Notes: resident has been getting more confused and forgetful lately. As well as having temper outbursts. Injuries: Abrasion Forearm left, Abrasion Forearm RightPredisposing Environmental Factors: NonePredisposing Physiological Factors: Confused, Impaired Memory. Predisposing Situation Factors: NoneOther Info: Resident was hearing things and was confused and got up to get to his walker, and fell before he got to it. Resident failed to report fall to staff right away due to being angry per his statement to writer. R1's Vital Signs and Neuro Checks sheet, dated 7/27/25, includes: Blank section for Day 2 shift #2. R1's Post Fall assessment dated [DATE] includes: Date and time fall occurred: 7/27/25Location where fall occurred: resident's bathroomWhat was the resident doing prior to the fall, if known? Stated he fell during the night and did not report to amWhere was the resident? resident's roomWas the resident incontinent? YesWhen was the last time the resident was toileted/changed? Resident toileted self duing the nightWas the call light within reach? YesWas the call light activated? NoDescribe environment/surroundings (was w/c (wheelchair) nearby, bedside table etc): bedside table by reclinerDid the resident sustain an injury? If yes, describe: yes bruising and a skin tearDate and time family notified: 7/27/25 10:00 AMFall interventions currently in use (prior to fall): call light in reach and grippy socks on; resident was not using walkerFall history: 3 or more falls in last 6 monthsUnderlying Diseases or Conditions: Psychiatric or cognitive conditions, Cardiac diagnosis or pacemaker, Orthopedic/joint/arthritisMedications: Choose any of the following that predisposes the member to falling: (The following are checked) Psychotropics, Diuretics, Antihypertensives, Functional Status: Observe mobility, standing and sitting balance. Any problems noted? Yes. Does the resident use any assistive devices/adaptive equipment? Yes. Is the resident continent of bladder? No. Describe any variances from above questions: resident frequently does not ask for assistance; is supposed to use walker but forgets frequently; therapy evaluation for increased edemaReview of Post Fall Findings1. Summarize the post-fall findings: resident continues to have poor safety awareness2. Describe new fall prevention interventions to be implemented as a result of the assessment: staff continue to ask resident if he needs assistance and checks on resident frequently3. List suggestions of referrals to be made as a result of the fall: Blank4. Root Cause: Blank Of note, the post fall assessment was completed on 8/15/25 for the fall that occurred on 7/27/25. That is 19 days after R1's fall. Of note, the post fall assessment dated [DATE] for the fall that occurred on 7/27/25 mentions therapy evaluation for increased edema. The first orders after R1's 7/27/25 fall are dated 9/2/25 for R1 to have lymphedema treatments from PT/OT (Physical Therapy/Occupational Therapy). This is 37 days after R1's fall. On 10/14/25 at 12:33 PM, Surveyor interviewed DON B regarding R1's 7/27/25 fall. DON B indicated R1 did not have a full assessment immediately following staff notification of R1's fall. DON B indicated R1's comprehensive care plan was not reviewed and was not updated with a new intervention to prevent further falls. DON B indicated the facility did not complete a post fall assessment for R1 timely. DON B indicated the post fall vital signs and neuro checks was not completed fully. DON B indicated an IDT review was not completed. DON B indicated R1's walker not being near R1 was the root cause for this fall. DON B indicated the root cause of this fall was reviewed by the interdisciplinary team on 8/20/25. (Of note, this is 24 days after the fall.) Event 3 R1's Risk for Falls assessment, dated 8/3/25, includes:Score: 6Category: Low RiskReason for Assessment: Recent fallsLOC (Level of Consciousness)/Mental Status: Alert –(oriented x3)Falls: 1-2 falls in past 3 monthsAmbulation/Elimination Status: Ambulatory/ContinentGait Balance: Gait/Balance normal. Requires use of assistive devices (i.e., cane, w/c (wheelchair) walker, furniture) Summary of findings Narrative Summary: Res (R1) is at high risk for falls. Res has had 2 falls this past week, poor safety awareness, and resistant to staff assistance. R1's fall incident report, dated 8/3/25 at 11:20 AM, includes:Incident Description: Nursing Description: Res (R1) was yelling help. Writer entered res room and found res sitting on the floor in the doorway of his bathroom. Res was sitting up with legs straight out facing his bed. Resident Description: Res states, I was walking out of the bathroom and lost my balance. I guess I should keep my w/c (wheelchair) by my recliner instead of across the room.Was this incident witnessed: N (No)Immediate Action Taken Description: Writer assessed res and assisted CNA (Certified Nursing assistant) with using hoyer lift to transfer res off floor and into hi [sic] recliner. Mental Status: Oriented to Person, Oriented to Place, Oriented to TimeNotes: Res does have periods of confusion at times. No confusion noted at this time. Predisposing Environmental Factors: BlankPredisposing Physiological Factors: BlankPredisposing Situation Factors: BlankOther info: Res was ambulating without his walker. On 10/14/25 at 12:33 PM, Surveyor interviewed DON B regarding R1's 8/3/25 fall. Surveyor asked DON B what the nurse meant when she documented Writer assessed res? DON B indicated she did not know what type of assessment or what was included in the nurse's assessment. DON B indicated R1 did not have a full assessment immediately after falling. DON B indicated R1's comprehensive care plan was not reviewed and was not updated with a new intervention to prevent further falls. DON B indicated the facility did not complete a post fall assessment for R1. DON B indicated an IDT review was not completed. DON B indicated R1's walker not being near R1 was the root cause for this fall. DON B indicated the root cause of this fall was reviewed by the interdisciplinary team on 8/20/25. (Of note, this is 17 days after the fall.) DON B indicated the root cause of the 8/3/25 and 7/27/25 falls were the same. Surveyor asked DON B, if an IDT review, intervention, and care plan update after R1's 7/27/25 fall could have prevented the fall on 8/3/25 since they both had the same root cause. DON B did not provide a response. Event 4 R1's fall incident reported, dated 8/14/25 at 16:30 (4:30PM), includes: Incident Description: Nursing Description: this incident was not witnessed resident was yelling loudly help. I went into residents room to find him sitting on the floor half into the shower legs straight out in front of him. Hes [sic] yelling to get him up he is not hurt. Hoyer and 2 staff members used to get him up. I can see he was trying to remove the elevated toilet chair as he is refusing to use it. It was half way pulled out from the toilet. Resident Description: lost his footing and fell. Reports he is not hurt.Was this incident witnessed: N (No)Immediate Action Taken Description: Resident gotten up off the floor with 2 assist and hoyer. Skin check done with no open areas or bruising at this time. ROM (Range of Motion) within residents normal. As soon as I finished skin check and vitals resident was off walking in the hallway. DON (Director of Nursing) and daughter [name] called. Mental Status: Oriented to Person, Oriented to Place, Orientated to Situation, Orientated to TimeNotes: called his daughter as soon as we got him up off the floorPredisposing Environmental Factors: Medical EquipmentPredisposing Physiological Factors: Gait ImbalancePredisposing Situation Factors: Ambulating without Assistance, Improper FootwearOther Info: resident reminded to use call light for assistance R1's Vital Signs and Neuro Checks sheet, dated 8/14/25, includes: Blank section for 1 hour #2. On 10/14/25 at 12:33 PM, Surveyor interviewed DON B regarding R1's 8/14/25 fall. DON B indicated R1's comprehensive care plan was not reviewed and was not updated with a new intervention to prevent further falls. DON B indicated the facility did not complete a post fall assessment for R1. DON B indicated the post fall vital signs and neuro checks were not completed fully. DON B indicated an IDT review was not done for this fall. R1's Risk for Falls assessment, dated 8/15/25, includes:Score: 21Category: High RiskReason for Assessment: Recent fallsLOC (Level of Consciousness)/Mental Status: Intermittent ConfusionFalls: 3 or more falls in past 3 monthsAmbulation/Elimination Status: Ambulatory/IncontinentGait Balance: Balance problem while standing. Balance problem while walking. Lower extremity weakness. Summary of findings Narrative Summary: resident at risk for falls; has had numerous falls in the past 2 months Event 5 R1's fall incident report, dated 9/17/25 at 11:40 AM, includes:Incident Description: Nursing Description: Writer had just walked past resident's room and saw him standing in the middle of the room with his walker. Writer walked down a few rooms with the med cart (Medication Cart), and heard a crash noise and resident was calling out for help. Writer ran to resident's room and found him on the floor. Writer asked other staff for help in getting resident up. Resident was gotten up off the floor with a hoyer sling and put into his wheelchair. Vitals were taken and resident was assessed for injuries, which he had none. Resident denied any pain as well. Resident Description: Resident stated he lost his balance and fell. Was this incident witnessed: N (No)Immediate Action Taken Description: resident up [sic] picked up off the floor with a hoyer sling and lift. Vitals were taken and resident was assessed for injuries, which he had none. Resident denies having any pain either. Mobility: Ambulating without assistanceMental Status: Oriented to Person, Oriented to PlaceNotes: resident is alert and oriented x2, forgetful and confused at timesPredisposing Environmental Factors: NonePredisposing Physiological Factors: Impaired MemoryPredisposing Situation Factors: Wanderer, Using Wheeled Walker On 10/14/25 at 12:33 PM, Surveyor interviewed DON B regarding R1's 9/17/25 fall. Surveyor requested R1's Vital Signs and Neuro Checks sheet for the fall on 9/17/25. The facility was unable to provide the document. DON B indicated the post fall vital signs and neuro check were not completed for this fall. Surveyor asked DON B what the nurse assessed for when the nurse documented resident was assessed for injuries? DON B indicated she is unable to determine what the nurse assessed. DON B indicated R1 did not have a full assessment immediately following R1's fall. DON B indicated R1's comprehensive care plan was not reviewed and was not updated with a new intervention to prevent further falls. DON B indicated the facility did not complete a post fall assessment for R1. DON B indicated an IDT review was not completed. DON B indicated a root cause analysis was not completed. Event 6 R1's fall incident report, dated 9/28/25 at 6:15 PM, includes:Incident Description: Nursing Description: Staff in dining room heard someone yelling help. Staff immediately scattered to find where voice was coming from. Writer found resident sitting on buttocks in bathroom, alert, breathing and conscious. Resident Description: I went to the toilet, wiped and fell onto my butt. I'm fine, really. Was this incident witnessed: N (No)Immediate Action Taken Description: Checked for injuries, used hoyer lift per facility protocol, obtained vitals and back to chair. Mental Status: Oriented to Person, Oriented to Place, Oriented to Situation, Oriented to TimeNotes: softball sized bruise noted to right upper thigh proximal to buttocks. Predisposing Environmental Factors: NonePredisposing Physiological Factors: NonePredisposing Situation Factors: Using Walker On 10/14/25 at 12:33 PM, Surveyor interviewed DON B regarding R1's 9/28/25 fall. Surveyor asked DON B what the nurse assessed for when the nurse documented checked for injuries? DON B indicated she is unable to determine what the nurse assessed. DON B indicated R1 did not have a full assessment immediately following R1's fall. DON B indicated R1's comprehensive care plan was not reviewed and was not updated with a new intervention to prevent further falls. DON B indicated the facility did not complete a post fall assessment for R1. DON B indicated an IDT review was not completed. DON B indicated a root cause analysis was not completed. Event 7 R1's fall incident report, dated 9/29/25 at 3:15 PM, includes:Incident Description: Nursing Description: Staff overheard resident yelling loudly for help. Staff immediately went to room and found him on the floor. Resident laying under sink with feet pointing towards wall. Denies LOC (Loss of Consciousness), denies hitting head, stated he was using the circular towel holder to get up. [NAME] in bathroom, unknown which way it was facing. Resident has been on the toilet several times. Resident description: I was using this handle to get up. Was this incident witnessed: N (No)Immediate Action Taken Description: checked for injuries and got off floor with hoyer lift per facility protocol. Mental Status: Oriented to PersonPredisposing Environmental Factors: NonePredisposing Physiological Factors: ConfusedPredisposing Situation Factors: Using WalkerOther Info: Resident has been on toilet several times since the beginning of second shift. On 10/14/25 at 12:33 PM, Surveyor interviewed DON B regarding R1's 9/28/25 fall. Surveyor asked DON B what the nurse assessed for when the nurse documented checked for injuries? DON B indicated she is unable to determine what the nurse assessed. DON B indicated R1 did not have a full assessment immediately following R1's fall. DON B indicated R1's comprehensive care plan was not reviewed and was not updated with a new intervention to prevent further falls. DON B indicated the facility did not complete a post fall assessment for R1. DON B indicated an IDT review was completed on 10/4/25. DON B indicated a root cause analysis was not completed. R1's nurse progress notes, dated 9/29/25 at 4:21 PM, includes: Resident unable to void for specimen, did bladder scan of over 1000 ml in bladder. Attempted to cath (catheterize) him sterile technique to get him to void, unable to see penis through foreskin even with manipulation. Another nurse also tried, unsuccessful. Writer also talked with NP (Nurse Practitioner) [name] with above. Resident continues with confusion and urgency. Talked to Daughter [name] with update to send out to ER (Emergency Room). R1's emergency room notes, dated 9/29/25 at 5:13 PM, include: Chief Complaint: Altered mental status. He also has urinary retention and on arrival bladder scan is showing 554 ml in the bladder. Patient denies any symptoms. No.abdominal pain except suprapubic pressure reported by patient. Physical Exam: General: He is not in acute distress. Has baseline dementia. He is awake and alert and answers simple questions. 9/30/25 at 11:07 AM, Patient CT (Medical imaging that create a detailed image of the body) head showed subacute subdural hematoma. On 10/13/25 at 1:30 PM, Surveyor interviewed CNA D (Certified Nursing Assistant) regarding fall interventions. Surveyor asked CNA D what interventions were in place for R1 related to falls. CNA D stated, We didn't do much, he was very independent, but maybe if he had used the call light he would not have fallen as much. On 10/14/25 at 9:07 AM, Surveyor interviewed CNA F regarding fall interventions. CNA F indicated if a resident is at risk for falls it would be on their Kardex. CNA F indicated fall interventions are also on the Kardex. On 10/14/25 at 7:48 AM, Surveyor interviewed LPN G regarding falls. LPN G indicated she looks at the CNAs' Kardex to see the residents at risk for falls and their interventions because the CNA Kardex is more focused and the information comes from the care plan. LPN G indicates the CNA Kardex gives a quick overview of the resident. LPN G indicated if a resident falls the nurse has to complete an overall head to toe assessment with vitals. LPN G indicated the nurse is looking for a change in condition, physical anomalies, internal/external rotation of legs, bleeding, neuro assessment including pupils, and range of motion. LPN G stated her entire assessment gets documented in the resident's medical record. LPN G indicated she would try to find a root cause of the resident's fall if she could and she would make recommendations to the DON about any interventions that may help prevent another fall. On 10/14/25 at 10:14 AM, Surveyor interviewed RN I (Registered Nurse) regarding falls. RN I indicated fall interventions are on the care plan. RN I indicated if a resident falls, a full assessment needs to be completed to include things such as pain, range of motion, skin checks, hand grasps, pupils, and cognition. RN I indicated an incident report has to be completed. RN I stated there are a couple of assessments that are triggered when an incident report is completed including the Post Fall Assessment. RN I indicated the incident report helps to identify the root cause and interventions should be put in place after a resident falls. RN I indicated the resident needs documented follow up every shift for 72 hours after a fall. On 10/14/25 at 1:46 PM, Surveyor interviewed LPN J regarding care plans. LPN J stated she is responsible for updating resident care plans when she completes the MDS (Minimum Data Set) assessment. LPN J indicated she also updates the care plans after the IDT meetings in the morning. LPN J indicated she does update care plans with fall interventions that were discussed in the morning IDT meeting. LPN J indicated the care plans should be updated as soon as possible with new information. Surveyor and LPN J reviewed R1's care plan together. LPN J indicated R1's care plan had not been updated related to any of his 7 documented falls. LPN J indicated if she does not attend the IDT meeting in the morning or is not made aware of new interventions she would not know the care plan needed to be updated. Surveyor asked what the process was for updating the care plans when LP

Based on interview and record review, the facility did not complete a thorough investigation in response to a potential allegation of abuse for 1 of 3 Residents (R1) reviewed for abuse.On 10/1/25, the facility became aware of an alleged injury of unknown origin due to R1's subdural hematoma (a collection of blood that accumulates between the brain and the inner layer of the skull). The facility did not complete a thorough investigation.Evidenced by:The facility's Injuries of Unknown Source policy, dated 2/2025, states, in part: All unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated.7. An injury of unknown source shall be investigated even if the resident is discharged from the facility as a result of an injury, or an injury of unknown source is identified after discharge.R1 admitted to the facility on [DATE] with diagnoses including cognitive communication deficit (a difficulty with communication caused by problems with the brain's thinking ability); repeated falls; difficulty in walking; muscle wasting and atrophy (a condition where muscles lose mass and strength).R1's Brief Interview for Mental Status, dated 9/26/25, had a score of 9, indicating R1 is moderately cognitively impaired.A facility self-report indicates on 10/1/25 the facility learned that R1 was found to have a subdural hematoma.On 10/14/25 at 7:49 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about the self-report for R1. NHA A stated the facility looked at the situation as an injury of unknown origin as they did not know how the subdural hematoma occurred. NHA A stated that DON B started getting statements from staff. Surveyor requested the statements from staff. No staff statements were provided. Surveyor asked NHA A if staff statements are expected. NHA A stated, yes, statements are a part of a thorough investigation. NHA A stated that staff education was started on falls prevention as part of a process improvement project (PIP) initiated following this incident. Pre/Post Tests from the education were provided to surveyor for 21 staff members. Surveyor asked if there was training provided for the other 19 staff members who have worked between starting the training to the present. NHA A stated no, there was no additional documentation of training yet. NHA A stated that the facility was planning for additional training as they worked through their PIP, but it had not yet occurred. Surveyor asked if all staff should have the training. NHA A stated yes.On 10/14/25 at 12:32 PM, Surveyor interviewed DON B who stated that staff were talked to about the subdural hematoma, but no written statements were obtained. The facility failed to complete a thorough investigation for an injury of unknown origin.

Based on interview and record review, the facility did not ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible, or resident preferences indicate otherwise for 1 of 3 residents (R2) reviewed for hydration. R2's fluid intakes were not monitored to ensure he was meeting his estimated daily fluid needs, resulting in R2 being hospitalized for dehydration. Evidenced by:The facility's policy titled Nutritional Management dated 2/2025 states in part .3. Evaluation/ analysis: a. The assessment shall clarify the resident's current nutritional status and individual risk factors for altered nutrition/ hydration. b. The dietician shall use the data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs.5. Monitoring. Revision: a. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. According to the National Library of Medicine article titled Adult Dehydration dated 3/5/25 states in part .Dehydration in adults is a clinically significant condition caused by an imbalance between fluid intake and loss, often leading to disturbances in the balance of total body electrolytes. Dehydration is often precipitated by low fluid intake, increased fluid loss, or a combination of both of these factors. This is further influenced by factors such as age-related changes, chronic illness, and medication use.[2] The pathophysiological mechanisms include activation of the renin-angiotensin-aldosterone system, increased release of antidiuretic hormone (ADH), and stimulation of the sympathetic nervous system, all of which work to retain fluids and stabilize circulation. Clinically, dehydration presents with symptoms ranging from mild thirst and fatigue to severe complications such as confusion, hypotension, and multiple organ dysfunction.[3] Dehydration is a common cause of hospital admissions, contributing to significant morbidity and mortality while often complicating a range of medical conditions.[2] Dehydration is primarily diagnosed clinically, with laboratory investigations, including serum electrolytes, serum osmolality, and renal function tests, providing supportive information. Treatment focuses on correcting fluid and electrolyte imbalances through oral or intravenous (IV) rehydration while closely monitoring serum electrolytes and renal function.[4] Early symptoms may include increased thirst, dry mouth, weakness, and decreased urine output. As dehydration worsens, additional symptoms such as dizziness, muscle weakness, palpitations, confusion, and irritability may emerge. In severe cases, lethargy, seizures, and hypovolemic shock can occur. Laboratory testing is crucial in diagnosing dehydration and assessing electrolyte imbalances. Common findings include an elevated blood urea nitrogen (BUN) to creatinine ratio greater than 20:1, suggesting prerenal azotemia due to reduced renal perfusion. Adult Dehydration - StatPearls - NCBI BookshelfR2 admitted to the facility on [DATE] with diagnoses that include Parkinson's disease (a progressive movement disorder of the nervous system; it causes nerve cells to weaken, become damaged, and die, leading to symptoms that include problems with movement, tremor, stiffness, and impaired balance), anemia, hypo- osmolality ( a state of low blood solute concentration, causes hyponatremia (low sodium) symptoms by leading water into the cells, causing them to swell) and hyponatremia, chronic kidney disease stage 3b (moderate to severe loss of kidney function), congestive heart failure (the heart cannot pump blood well enough to give the body a normal supply), and hypertension (high blood pressure).R2's most recent MDS (Minimum Data Set) dated 9/12/25 states that R2 has a BIMS (Brief Interview of Mental Status) of 10 out of 15, indicating that R2 has moderate cognitive impairment.R2's Medical Nutrition Therapy Assessment date 9/10/25 states in part .D. Risk Factors.4. Dehydration Risk: j. Laxatives.POC (Plan of Care) needs are determined by above Risk Factors- Risk Factors are addressed in POC. 6. Proceed with POC: a. Yes.9. Fluid Needs: cc (cubic centimeter)/ day.2350 cc fluids.R2's care plan dated 9/10/25 states in part . Focus: I have a dx (diagnosis) of CKD (chronic kidney disease): at risk for lab abnormalities and alteration in nutrition.Goal: Stabilize and/ or improve my bloodwork within an acceptable range. My meal intake will be >50% .Interventions/ Tasks: .Monitor my PO (oral) intake PRN (as needed) .Provide me with food/ beverage preferences as available.It is important to note that R2's care plan does not address R2's risk for dehydration.R2's fluid intake documentation is as follows:9/14/25: 820 cc9/15/25: 1020 cc9/16/25: 820 cc9/17/25: 690 cc9/18/25: 840 cc9/19/25: 840 cc9/20/25: 840 cc9/21/25:980 cc 9/22/25: 990 cc9/23/25: 1110 cc9/24/25: 1050 cc9/25/25: 1560 cc9/26/25: documentation indicates that resident not available and resident refused9/27/25: 1570 cc9/28/25: 2030 cc9/29/25: 1400 cc9/30/25: 980 cc10/1/25: 1810 cc10/2/25: 1850 cc10/3/25: 2430 cc (of note, this is the first day R2 has hit his daily estimated fluid needs)10/4/25: 1810 cc10/5/25: 1915 cc10/6/25: 600 cc, resident refusedOf note, R2 did not hit his estimated daily fluid needs of 2,350cc/day during any of the dates indicated above except for 10/3/25. There is no evidence of a dehydration assessment or comprehensive RN assessment being completed for R2. No evidence R2's provider was notified. No evidence the dietary manager/registered dietitian was notified when R2 did not meet his fluids needs multiple days in a row. On 10/6/25, R2 was noted to have a change of condition that included altered mental status, lethargy, increased confusion, increased shaking, and increased weakness and was sent to the hospital.Emergency Department (ED) notes dated 10/6/25 at 5:29 PM state the following: .Visit final diagnostic impression: 1. Unresponsive 2. Altered mental status, unspecified mental status type 3. Hypothermia, initial encounter 4. Dehydration 5. Hypermagnesemia 6. Chronic renal impairment, unspecified CKD (chronic kidney disease) 7. Chronic anemia.History of present illness: [AGE] year-old gentleman brought in by ambulance from [Nursing Home Name] as patient was noted unresponsive with low pulse ox this morning between 8 and 12 noon today. But when patient came his pulse ox was 99% on room air and initially, he was able to follow commands open his eyes and left [sic] his arms but soon after when I went to evaluate he was unresponsive and was only responsive to painful stimuli. He has noted hypothermic (low body temperature) with temperature of 96.2 initially which soon dropped to 92.5 Fahrenheit has had and not improved. Patient remains unresponsive.Review of Systems (ROS): Unable to perform ROS: Critical illness.Physical Exam: Constitutional: Appearance: He is ill- appearing. Comments: Deeply unresponsive. HENT (Head, Eyes, Nose, Throat): .Mouth: Mucous membranes are dry.Neurological: Comments: Patient is unresponsive and now not responding even to painful stimuli.ED Course 10/6/25 at 7:26 PM: Patient remains unresponsive in ED. He is noted very hypothermic, so Bair Hugger (a continuous temperature monitoring system) and warm bladder irrigation and other measures started in ED to increase his core body temperature.He seems dehydrated so started on IV (Intravenous) fluids.R2's abnormal lab values include follows:RBC (Red Blood Cells) 2.71 (L) (low)- reference range 4.30- 5.70 X(10)6/uLHemoglobin 8.6 (L)- reference range 13.8- 17.3 g/dLHematocrit 26.2 (L)- reference range 39.5- 51.0 %Potassium 5.1 (H) (High)- reference range 3.5- 4.9 mEq/LBUN (Blood urea Nitrogen) 46 (H)- reference range 6-21 mg/dLCreatinine 1.62 (H)- reference range 0.64- 1.27 mg/dLBUN/ Creatinine ration 28 (H)- reference range 12- 20BNP (B. Natriuretic Peptide) 398 (H)- reference range <=100 pg/mLMagnesium 3.1 (H)- reference range 1.8- 2.4 mg/dLDuring R2's ED visit, he received 1000ml (milliliters) of NaCl (Sodium Chloride) IV Bolus at 6:20 PM and 7:49 PM, totaling 2000ml received.R2 was admitted to the hospital overnight, placed on comfort care and returned to the nursing home on hospice services. R2 passed away on 10/12/25.R2's fluid intake documentation is as follows:10/7/25: Res. not available10/8/25: 200cc, not applicable, and Res. refused10/9/25 300cc, not applicable and res. refused10/10/25 200cc, not applicable 10/11/25: 50 cc, not applicable10/12/25: 0cc, not applicableOn 10/14/25 at 9:34 AM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C who is responsible for monitoring resident's fluid intakes, RN C stated that they only monitor fluid intakes if the resident is on a fluid restriction, otherwise no one is monitoring fluid intakes. Surveyor asked RN C how staff knows if a resident is at risk for dehydration, RN C stated that if a resident is not drinking, then they are at risk. Surveyor asked RN C if residents' care plans or Kardex's indicate if they are at risk for dehydration, RN C stated that she did not know.On 10/14/25 at 1:25 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how staff know if a resident is at risk for dehydration, DON B stated that all residents are at risk for dehydration. Surveyor asked DON B who is responsible for ensuring that residents are receiving adequate fluids, DON B stated that the dietician is responsible for monitoring the fluid intakes, but they will look at it if they notice a change in the resident's intake or urine. Surveyor asked DON B if the dietician recommends a resident receive 2350 cc of fluids per day, who is ensuring that the resident is meeting their goal, DON B was not sure.R2's fluid intakes were not monitored to ensure he was meeting his estimated daily fluid needs, resulting in R2 being hospitalized for dehydration.Cross reference F684.

Based on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a significant change in condition. This occurred for 1 of 3 residents (R17) reviewed for change in condition. R17 had a significant weight loss that was not reported to R17's provider timely. R17 had a change in condition on 11/24/24 that was not reported to R17's provider timely. This is evidenced by: The facility's Notification of Change policy, dated 1/2025, states, in part: The community will consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative or an interested family member when there is: .acute illness or a significant change in the resident's physical, mental, or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). The facility's Weights of Residents policy, dated 1/2019, states, in part: .3. Resident should be reweighed if there is a weight variance of over 3 pounds or more. (important to note: the policy does not indicate when the physician should be notified of weight variance.) The facility's Nurse/CNA (certified nursing assistant) / RA (resident assistant) Meeting Agenda, dated [DATE] and 31, 2024, states, in part: .11. Weights .d. Once you look at the weight on the clipboard, if you notice a change in weight of 3 pound either way, please reweigh resident to verify weight. e. If there is a change, notify nurse immediately. Nurse will update provider of weight change and enter a nurse progress note in the chart. R17 was admitted to the facility on [DATE], and has diagnoses that include vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain; depression; and dysphagia (difficulty swallowing). R17's Minimum Data Set (MDS) dated [DATE] shows R17 has a Brief Interview of Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Example 1 R17's physician's orders state, in part: Weight Management: Weights-daily x3 (3 times), and then weekly. Start date 11/20/24. R17's care plan states, in part: Focus: Nutrition/Hydration: Potential for Complications with Nutritions/Hydration d/t (due to) appetite, meal intake, medication side effects, past medical history. Date initiated: 11/25/24. R17's Weights and Vitals Summary indicates the following weights: *11/19/24 222 Lbs (pounds) *11/20/24 222.2 Lbs *11/21/24 221.6 Lbs *11/25/24 224.2 Lbs *11/27/24 222.4 Lbs *12/18/24 196.8 Lbs *12/25/24 198.8 Lbs *12/25/24 198.8 Lbs *1/1/25 196.9 Lbs *1/1/25 196.4 Lbs *1/8/25 194.4 Lbs *1/15/25 189 Lbs *1/22/25 187 Lbs On 1/29/25 at 9:36 AM, Surveyor interviewed RN C (Registered Nurse) and asked how often residents are weighted. RN C stated that residents are weighed at least weekly, some as often as daily. Surveyor asked if weights are monitored. RN C stated that the standard is for physician to be notified of a 3 pound change in 1 day or a 5 pound change in 1 week. Surveyor asked where physician notification is documented. RN C stated in the resident's chart under progress notes. Surveyor asked if R17 has had any change in her weight. RN C reviewed the chart and stated R17 has had weight loss. RN C stated she could see a 10 pound weight loss in an alert screen. RN C stated that weight loss would be significant and would need physician notification. On 1/29/25 at 1:45 PM, Surveyor interviewed DON B (Director of Nursing) and asked if resident weights are monitored. DON B stated weights are reviewed by the nurses and the dietician. Surveyor asked when physicians are updated on changed in weight. DON B stated physician is updated with weight change of 3-5 pounds and that notification is documented in the progress notes. Surveyor asked about R17's weights. DON B stated that R17 was on isolation in December and was not weighed during that time. DON B stated following isolation R17's weight was down. Surveyor asked if DON B would expect the facility to notify the physician of a change from 222.4 pounds to 196.8 pounds (a 25.6 pound / 11.5% loss between 11/27/24 and 12/18/24). DON B stated yes. Surveyor asked for documentation of physician notification. No documentation was provided. On 1/30/25 at 1:18 PM, Surveyor interviewed NP D (Nurse Practitioner) and asked if NP D would expect to be notified of a resident's weight loss. NP D stated yes. Surveyor asked if facility had notified of R17's weight loss from 11/19/24 to 12/18/24. NP D stated no, not that I am aware of. Surveyor asked if NP D would expect to be notified of this weight loss. NP D stated yes. Example 2: R17's Progress Note, dated 11/24/24 at 3:20 PM, states: Res (resident) has one large incontinent BM (bowel movement) this morning with moderate to large amount of blood noted. Denies any rectal pain and no hemorrhoids noted. B/P (blood pressure) 108/54. On 1/29/25 at 9:47am, Surveyor interviewed RN C (Registered Nurse) and asked what would be done if bleeding were noted from a resident. RN C stated the resident would be assessed and the physician would be notified. On 1/29/25 at 2:45 PM, Surveyor interviewed DON B (Director of Nursing) and asked if a physician should be updated of a resident having moderate to large amount of blood following a bowel incontinence. DON B stated yes. DON B stated that the resident was sent to the hospital for evaluation at approximately 5:30 PM and returned to the facility at approximately 9:00 PM. Surveyor asked if the facility notified the physician in the morning when the bleeding was noted. DON B stated no. Surveyor asked if facility would be expected to notify the physician at the time of the bleeding. DON B stated yes. On 1/30/25 at 1:18 PM, Surveyor interviewed NP D (Nurse Practitioner) and asked if NP D would expect the facility to notify the provider of a resident having an episode of bowel incontinence with moderate to large amount of blood noted. NP D stated yes. Surveyor asked when NP D would expect notification of a bleeding episode noted in the morning. NP D stated right away in the morning.

Based on interview and record review, the facility failed to ensure the medication regimen was free from unnecessary medications for 1 of 5 residents (R23) reviewed for unnecessary medications. R23 receives an antidepressant for sleep without an appropriate diagnosis. R23 did not have a sleep assessment conducted prior to medication administration. This is evidenced by: The facility policy entitled, Psychotropic Medication dated 5/2020, states, in part: .1. The indication for any psychotropic medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and identification of behavioral symptom(s) being treated. The medical record must show documentation of adequate indication and diagnosed condition . 2. A Psychotropic Drug Assessment will be completed on admission, quarterly, a new medication or renewal order, an irregularly identified in the pharmacist's medication regimen review and with changes of condition . The assessment will be reviewed by the IDT (Interdisciplinary Team) helps to identify resident's needs, goals, comorbid conditions, and prognosis to determine factors (including medications and new or worsening medical conditions) that are affecting signs, symptoms, and test results. This evaluation process is important when selecting initial medications and/or non-pharmacological approaches and when deciding whether to modify or discontinue a current medication. Attempt to identify underly cause for behavioral symptom(s) .4. Based upon individualized assessment, determine non-pharmacological approaches that can be implemented prior to the use of psychotropic medications . R23 was admitted to the facility on [DATE] with diagnoses that include, in part: fatty liver, pulmonary embolism (blood clot in the lungs), dementia, Wernicke's encephalopathy (memory disorder most often caused by alcohol), alcohol dependence, and panlobular emphysema (disorder causing damage to all lobes of the lung making it difficult to breathe). R23's Physician Orders, dated 1/17/25, include, in part: Trazadone (antidepressant medication often used for sleep) 50 MG, Give by mouth one time daily for sleep. Take 50 MG daily at bedtime. Start date: 10/7/24. Order status: Active. (Of note: Patient does not have a diagnosis of insomnia and there is no diagnosis associated with this medication) Surveyor requested the sleep assessment for R23 that was conducted prior to ordering and administering the Trazadone. Surveyor was provided a document titled, SNF-ADMIT/READMIT TOOL, dated 10/1/24 at 7:04 AM. In the section titled, Sleep, questions were asked regarding R23's sleep patterns are marked trouble staying asleep, wakes in night. The usual bedtime is indicated to be between 8:00 PM and 8:30 PM. The usual hours of sleep states, depends 4 to 5. The usual waking time is indicated to be between 5:00 AM and 6:00 AM. The preference for AM and PM naps are both marked, not really. (Of note: The facility reports this is the only sleep assessment conducted for R23) A Physician Notification, dated, 10/1/24, states, Resident having difficulty sleeping, and pain in BLE (bilateral lower extremities). No PRNs (as needed medications) available if there is anything we can get? Thanks! A reply was made to this notification that was signed on 10/3/24, which provided the order for 50 MG of Trazadone by mouth at bedtime. A progress note, indicated to be effective on 10/5/24 at 5:00 AM, indicates R23 was restless and had difficulty sleeping. R23 had to be assisted back to her room and settled into her recliner. (Of note: In the SNF-ADMIT/READMIT TOOL, conducted on 10/1/24, R23 indicated she usually wakes up between 5:00 AM and 6:00 AM) On 10/7/24 at 1:13 PM, a progress note is written that states, Resident received new orders for trazadone at bedtime. (Of note, no other progress notes are written describing the patient's sleep patterns or habits during this time period.) On the Behavior Monitoring and Interventions Report from admission on 9/30/24 through 10/8/24, Insomnia is marked as a behavior only once on 10/7/24 at 5:25 AM. On 1/30/25 at 2:20 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how the facility assesses a resident's sleep upon admission. DON B indicates, they initiated behavior monitoring if they are on psychotropics, but states, I really don't have a process. DON B indicates if a resident is having trouble sleeping, staff should be notifying the doctor. DON B also indicates melatonin, or other medications should be attempted prior to starting hypnotics. DON B also states R23 did have an assessment upon admission and did not sleep well prior to admission. Surveyor asked DON B how the facility monitors residents' sleep. DON B indicates they track sleep on the Behavior Monitoring and Interventions section of the EMR (electronic medical record), and staff are expected to document insomnia, but there is no actual sleep hours tracking. Surveyor asked DON B if the facility uses sleep diaries. DON B states, no. Surveyor asked DON B how R23's sleep was on admission. DON B indicates her sleep was not good, she was very restless and had a couple falls. Surveyor asked DON B if the facility was tracking R23's sleep. DON B indicates staff were tracking her sleep by marking insomnia in the Behavior Monitoring and Interventions section of the EMR. Surveyor asked DON B if there should be documentation if a resident is experiencing insomnia. DON B states, there should be a progress note or physician notification. DON B also indicates the facility was aware the hospital was using Seroquel (antipsychotic medication) for sleep and did not think melatonin would be effective. Surveyor asked DON B if a sleep assessment should be conducted prior to starting trazadone for sleep. DON B states, probably, and indicates she would leave that up to the provider.

Based on staff and resident interview, and record review, the facility did not ensure a grievance was documented, thoroughly investigated, and resolved for 1 Resident (R) (R11) of 15 sampled residents. The facility did not document, investigate and resolve R11's grievance regarding a pair of missing pants. Findings include: The facility's Grievance Policy and Procedure, with a revised date of January 2020, indicated: Residents have a right to voice grievances to the facility .Such grievances include those regarding care and treatment which has been furnished, as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay .A grievance form will be completed either by the person filing the grievance or the staff member of the facility that received the complaint .The grievance officer and additional support staff will investigate the formal grievance, write a summary statement of the grievance, include the steps taken to investigate the grievance, a summary of the findings or conclusions regarding the grievance, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued .The grievance should be resolved, on average, within 7 days or less .Following the conclusion of the grievance, a summary will be provided to the resident of any findings by the grievance officer or designee. The facility will respond in writing, by phone, or one on one with the results of the investigation. R11 was admitted to the facility on [DATE] with diagnoses including diabetes, major depressive disorder, and displaced simple supracondylar fracture without intercondylar fracture of the left humerus (an injury to the upper arm bone, at its narrowest point, just above the elbow). R11's Minimum Data Set (MDS) assessment, dated 10/25/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 had intact cognition. On 11/20/23 at 9:17 AM, Surveyor interviewed R11 and asked R11 if R11 had any missing personal items. R11 indicated R11 was missing a pair of burgundy pants that matched one of R11's tops. R11 indicated laundry staff was aware of the missing pants. On 11/22/23 at 12:21, Surveyor again interviewed R11 who indicated R11's pants were missing since the second week of September. R11 expressed concern the facility would not resolve the issue without Surveyor inquiring about R11's pants. R11 indicated R11 would like the pants back since they were new and part of a matching outfit. R11 indicated R11 informed Laundry Lead (LL)-C and Laundry Aide (LA)-D about the missing pants. Per R11, LL-C informed R11 a grievance would be filed if the pants were not found after 6 weeks. On 11/20/23, Surveyor reviewed the facility's grievance log which did not contain a grievance regarding R11's missing pants. On 11/21/23 at 12:10 PM, Surveyor interviewed LL-C who confirmed LL-C was aware of R11's missing pants for approximately 4-6 weeks. LL-C indicated LL-C did not file a grievance because LL-C waited to see if R11's pants were returned from the facility's outside laundry service. On 11/22/23 at 10:04 AM, Surveyor interviewed LA-D who confirmed LA-D was aware of R11's missing pants. LA-D could not recall the date R11 informed LA-D that R11's pants were missing, but confirmed if a grievance form was filled out, LA-D would know the exact date R11 reported the missing pants. On 10/22/23 at 11:00 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A was not aware R11's pants were missing for approximately 4-6 weeks and stated NHA-A thought R11's pants were only missing for a few weeks. NHA-A indicated a grievance should have been filed and investigated when R11 first reported R11's pants were missing.

Based on staff interview and record review, the facility did not implement their written policies and procedures that prohibit abuse of residents (including misappropriation of property), provide abuse training to employees at orientation and provide on-going education for 1 (Social Worker (SW)-C) of 2 staff interviewed regarding abuse training. SW-C was not trained on abuse to include misappropriation of property. Findings include: The facility's undated Resident Abuse-Employee Training policy contained the following information: It is the policy of the facility to train employees, through orientation and on-going education, on issues related to abuse to include misappropriation of property. Annual mandatory education will be provided to train staff on the prevention of abuse. This information will also be included in the orientation of new employees. On 2/28/23 at 12:40 PM, Surveyor interviewed SW-C regarding R1's allegation of abuse/misappropriation of property. SW-C stated R1 did not make an allegation of abuse as misappropriation of property was not abuse. Additionally, SW-C stated SW-C was not provided abuse training during orientation and was not provided on-going education related to abuse to include misappropriation of property. On 2/28/23 at 3:36 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding abuse training for employees. NHA-A verified all staff need abuse training (including misappropriation of property) at orientation, through ongoing annual education, and as needed. NHA-A verified SW-C was not trained on abuse related to nursing home regulations at orientation and was not provided ongoing education related to abuse, including misappropriation of property. The only abuse training SW-C received at hire was geared toward hospital fraud.

Based on record review, and resident and staff interview, the facility did not ensure all allegations of misappropriation of property and injuries of unknown origin were reported timely to the State Agency (SA) and law enforcement for 2 Residents (R) (R1 and R2) of 5 sampled residents. R1 reported an allegation of misappropriation of property to staff who reported the allegation to administration. Administration did not report the allegation of misappropriation to the SA within 24 hours on a form identified by the SA and did not report the results of the investigation to the SA within 5 working days. In addition, the facility did not report the allegation of misappropriation to law enforcement. R2 had an injury of unknown origin which resulted in a left hip fracture. Administration did not report the injury of unknown origin to the SA within 24 hours on a form identified by the SA and did not report the results of the investigation to the SA within 5 working days on a form identified by the SA. Findings include: The facility's Resident Abuse-Investigation policy, updated on 6/2/21, contained the following information: It is the policy of the facility to send an initial report (F-62617) of an allegation of abuse to include misappropriation of property to the Division of Quality Assurance (DQA) immediately. The local police department will be contacted for assistance if it appears that a crime has been committed. The results of the investigation must be documented on the appropriate state Caregiver Misconduct Incident Report DQA form F-62447 and provided to DQA within 5 working days. 1. On 2/28/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility with diagnoses to include chronic obstructive pulmonary disease and diabetes mellitus. R1's annual Minimum Data Set (MDS) assessment dated [DATE], documented R1's cognition was 15 out of 15 (the higher the score, the more cognizant). On 2/28/23, Surveyor reviewed a complaint form with an occurrence date of 11/3/22 and a reported date of 11/4/22 at 3:30 PM completed by Caring Partner (CP)-E. On 2/28/23 at 11:53 AM, Surveyor interviewed R1. R1 stated R1 reported two missing rings to CP-E. R1 did not know if the rings were misplaced or stolen. R1 paid $189 for one ring and $50 for the other ring. R1 was not asked if R1 wanted the police contacted and was not interviewed by a police officer. On 2/28/23 at 12:09 PM, Surveyor interviewed CP-E regarding R1's allegation of misappropriation of property. CP-E stated the allegation of misappropriation was reported to the prior Nursing Home Administrator (NHA) the same date (11/4/22) R1 reported the allegation to CP-E. CP-E verified CP-E did not call the police. On 2/28/23 at 12:25 PM, Surveyor interviewed NHA-A regarding R1's allegation of misappropriation. NHA-A verified the initial 24 hour report indicated it was submitted to the SA on a Microsoft Word document rather than on form F-62627 on 11/7/22, and the 5 day report was submitted to the SA late on 11/22/22. Additionally, NHA-A verified the police should have been contacted regarding the allegation of misappropriation. On 2/28/23 at 12:40 PM, Surveyor interviewed Social Worker (SW)-C regarding R1's allegation of misappropriation. SW-C stated SW-C did not call the police when R1 alleged misappropriation of property and was not aware the police needed to be notified by the facility when an allegation of abuse, including misappropriation of property, was reported to the facility. The facility did not submit the initial allegation of misappropriation of property on the form identified by the SA, the results of the investigation of the allegation of missing property were not reported to the SA within 5 working days as required, and the facility did not contact the police when R1 reported the allegation of missing or stolen rings. 45942 2. On 2/28/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include terminal dementia, recent pneumonia, generalized weakness, disorientation and confusion, poor balance and gait difficulty. R2 was discharged to the hospital on 1/1/23. A progress note, dated 1/1/23 at 5:00 AM, contained the following information: (R2) slept well through the night. During repositioning, appeared (R2) had pain and with assessment noted left lower extremity to be rotated out and shorter than right. (R2) did grab left hip and grimace with movement of left lower extremity. (R2) had a fall on 12/28/22 and has been non-ambulatory since the fall. (R2) appears to favor leaning to the right in bed. (R2) remains confused and difficult to assess. Will contact (Director of Nursing) regarding findings. On 1/1/23, R2 was sent to the emergency room for evaluation of the left hip for a possible hip fracture. On 2/28/23 at 9:45 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R2's fall. DON-B stated R2 was discharged from the facility's assisted living unit and was used to walking independently. Per DON-B, R2 was at the facility for approximately 10 minutes when R2 was wheeled into R2's assigned room. DON-B stated R2 must have then wheeled R2's self into another resident's room; however, there were no witnesses. Per DON-B, R2 was able to independently wheel R2's self in the wheelchair; however, there were foot pedals on the wheelchair which R2 was not used to. DON-B spoke with R2 after the unwitnessed fall while R2 was still on the floor. R2 denied pain and displayed no signs or symptoms of pain. On 2/28/23, Surveyor reviewed the facility-reported incident (FRI). Surveyor noted the facility's initial report was not submitted on SA identified initial reporting document (F-62617), instead the initial report was sent on SA identified document Misconduct Incident Report (F-62447) which is used to report the results of the facility's investigation. The facility reported the result of R2's injury of unknown origin on a word document titled Final Reportable, instead of the appropriate SA identified document (F-62447).

Based on record review, and resident and staff interview, the facility did not make a prompt effort to resolve a grievance for 1 Resident (R) (R3) of 5 sampled residents. In addition, the grievance was not contained in the facility's grievance file. R3 reported to staff that R3 was missing a large tube of toothpaste. The facility did not follow up with R3 or resolve the grievance in a timely manner. Findings include: The facility's Grievance Policy and Procedure, last revised in January 20202, contained the following information: Policy Statement: Residents have a right to voice grievances to the facility or other agency or entity that hears grievances without fear of discrimination or reprisal. Such grievances include those regarding care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents and other concerns regarding their stay. Procedure: 1. If a resident or family member has a concern, complaint or suspects resident neglect, abuse, exploitation or misappropriation of property and would like to file a formal grievance, it is to be reported to the charge nurse on duty or the department supervisor. 3. A grievance form will be completed either by the person filing the grievance or the staff member of the facility that received the complaint. Note: Any sort of misconduct will be reported to the Division of Quality Assurance in accordance with the facility's current abuse policies and the current regulatory requirements regarding the specified time frames. 6. The grievance should be resolved on average, within 7 days or less, unless the grievance is complex in nature and/or requires additional time for further investigation and response . On 2/28/23, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses to include heart failure and diabetes. R3's Minimum Data Set assessment, dated 2/27/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R3 had intact cognition. On 2/28/23 at 11:59 AM, Surveyor interviewed R3 who stated R3 was missing a large tube of toothpaste R3 won playing Bingo at the facility. R3 stated, I let the nurses and aides know about 2 weeks ago about my large toothpaste in the drawer was gone. R3 also stated, Sometimes you feel like somebody doesn't believe you. R3 stated no one followed up with R3 regarding the toothpaste. R3 stated the toothpaste is not worth a lot; however, the thought of missing items doesn't feel right. On 2/28/23 at 12:38 PM, Surveyor interviewed Certified Nursing Aide (CNA)-D who confirmed R3 informed CNA-D about the missing toothpaste 2 weeks ago. CNA-D stated CNA-D told R3 to check in the closet. CNA-D stated, I looked for (the toothpaste) and passed the information to the nurse. When Surveyor asked CNA-D which nurse CNA-D informed, CNA-D stated, I don't remember who it was. CNA-D verified CNA-D did not know where the facility's grievances forms were located. CNA-D also confirmed CNA-D did not follow up with R3 regarding the missing toothpaste. On 2/28/23 at 12:55 PM, Surveyor interviewed Social Worker (SW)-C who had no knowledge of R3's missing toothpaste. SW-C stated SW-C's expectation is for staff to report resident grievances promptly to SW-C. On 2/28/23 at 2:29 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who also had no knowledge of R3's missing toothpaste. NHA-A stated if a resident reported a missing item to staff, staff should inform NHA-A promptly.

Based on record review and staff interview, the facility did not ensure all injuries of unknown origin and allegations of misappropriation of property were thoroughly investigated for 2 Residents (R) (R2 and R1) of 5 residents. R2 was admitted to a local hospital following left leg pain on 1/1/23 and diagnosed with a left hip fracture. The facility did not conduct a thorough investigation to determine the cause of the injury and/or rule out potential abuse/neglect. R1 reported to staff that R1 was missing two rings. The facility did not conduct a thorough investigation to rule out misappropriation of property. Findings include: The facility's undated Resident Abuse-Investigation Including Unexplained Injury policy contained the following information: Policy Statement: It is the policy of this facility to thoroughly investigate reports of abuse, neglect, injury of unknown origin . Procedure: 14. Injury of Unknown Source: a. CMS requires that nursing homes report all injuries to a resident of unknown source. The federal interpretative guidelines for 42. C.R.R. 484.13 (c) (2) and (4) define injuries of unknown source to mean an injury that: 2. Is suspicious because of the extent of the injury or the location of the injury, or the number of injuries observed at one particular point in time or the incidence of injuries over time. b. An injury of unknown origin or suspicious injury must be immediately investigated to rule out abuse .An injury is suspicious based on the extent of the injury, for example, the size or severity of the injury, such as a large bruise, a skin tear or a broken bone. 15. Interviewing/investigation: As appropriate, the investigation should consist of: b. Who was present at the time of the incident? (Victim, perpetrator, witnesses). f. Interview other residents to determine if they have had a similar experience or if they have been abused or mistreated. 23. Additional items are included/considered based on the type of misconduct and is helpful to send these investigative documents .to (Division) of Quality Assurance (DQA). f. Injury of Unknown Source: 5. Interviews with staff, residents, visitors, and family members who visit/live/work in the affected resident's unit as appropriate. The facility is responsible to prohibit and prevent abuse including misappropriation of resident property. Interview other residents to determine if they have had a similar experience. 1. On 2/28/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses to include terminal dementia, recent pneumonia, generalized weakness, disorientation and confusion, poor balance and gait difficulty. R2 was discharged to the hospital on 1/1/23 due to left hip pain and was diagnosed with a left hip fracture. Surveyor reviewed R2's fall investigation which was not thorough and did not contain resident interviews or staff education post incident. A progress note, dated 1/1/23 at 5:00 AM, contained the following information: (R2) slept well through the night. During repositioning, appeared (R2) had pain and with assessment noted left lower extremity to be rotated out and shorter than right. (R2) did grab left hip and grimace with movement of left lower extremity. (R2) had a fall on 12/28/22 and has been non-ambulatory since the fall. (R2) appears to favor leaning to the right in bed. (R2) remains confused and difficult to assess. Will contact (Director of Nursing) regarding findings. On 1/1/23, R2 was sent to the emergency room for evaluation of the left hip for a possible hip fracture. On 2/28/23 at 9:45 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R2's fall. DON-B stated R2 was discharged from the facility's assisted living unit and was used to walking independently. Per DON-B, R2 was at the facility for approximately 10 minutes when R2 was wheeled into R2's assigned room. DON-B stated R2 must have then wheeled R2's self into another resident's room; however, there were no witnesses. Per DON-B, R2 was able to independently wheel R2's self in the wheelchair; however, there were foot pedals on the wheelchair which R2 was not used to. DON-B spoke with R2 after the unwitnessed fall while R2 was still on the floor. R2 denied pain and displayed no signs or symptoms of pain. On 2/28/23 at 11:59 AM, Surveyor interviewed R3 regarding R2's fall. R3 stated R3 witnessed R2 enter R3's room and fall against the wall by the room entrance. R3 confirmed R3 was not interviewed by the facility regarding R2's fall. On 2/28/23 at 1:52 PM, Surveyor interviewed DON-B regarding R2's fall investigation. DON-B stated R2 tripped on the foot pedals of the wheelchair. DON-B confirmed residents were not interviewed, including R3 (who resides in the room where the fall occurred). Surveyor questioned DON-B if R3 and other residents should have been interviewed to rule out abuse/neglect. DON-B confirmed R3 should have been interviewed and stated, I would not have thought to ask the residents. If the injury is unknown, then yes, interview residents. Per DON-B staff education was not completed, only a questionnaire in regard to R2's pain. 18815 2. On 2/28/23, Surveyor reviewed a facility-reported incident (FRI). The FRI indicated R1 reported an allegation of misappropriation of property that was discovered on 11/7/22. The FRI stated R1 reported two missing rings. One ring was valued at $189 and the other ring was valued at $50. The FRI indicated no other residents on R1's unit stated they were missing valuable items. The FRI did not include documentation that the allegation of misappropriation was thoroughly investigated as the facility did not document interviews with other residents regarding misappropriation of property to determine if other residents were missing jewelry or other items. On 2/28/23 at 12:25 PM, Surveyor interviewed NHA-A who verified other residents should have been interviewed to determine if other residents were missing jewelry or other items. NHA-A also verified the interviews should have been documented and included in the investigation.

Based on interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments accurately reflected the residents status for 4 Residents (R) (R19, R13, R23, R30) of 13 residents reviewed. R19 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's MDS did not accurately reflect this. R13 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's MDS did not accurately reflect this. R23 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's MDS and PASRR Level 1 did not accurately reflect this. R30 was discharged to the community. R30's MDS did not accurately reflect this. Findings Include: 1. R19 was admitted to the facility on [DATE] and had related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, R19 has physician prescribed [CONDITION(S)] medications; [MEDICATION(S)] (an antidepressant,) related to [CONDITION(S)] and other specified depressive episodes and antipsychotic medication [MEDICATION(S)], related to disorganized [CONDITION(S)]. Between 10/17/22 and 10/19/22, Surveyor reviewed R19's medical record which showed R19 had a PASRR Level 2 completed on 2/7/18 due to a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Between 10/17/22 and 10/19/22, Surveyor reviewed R19's last full MDS assessment dated [DATE], which was related to a Significant Change of Condition. In Section A1500 (Preadmission Screening and Resident Review (PASRR)), the question asks: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This section was answered: No. 2. R13 was admitted to the facility on [DATE] with related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally R13's physician prescribed [CONDITION(S)] medication, [MEDICATION(S)] (an antianxiety,) as needed to treat anxiety disorder and panic disorder. Between 10/17/22 and 10/19/22, Surveyor reviewed R13's medical record which showed R13 had a PASRR Level 2 completed on 4/5/22 due to a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Between 10/17/22 and 10/19/22, Surveyor reviewed R13's MDS assessment dated [DATE]. In Section A1500 (Preadmission Screening and Resident Review (PASRR)), the question asks: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This section was answered: No. On 10/19/22 at 10:14 AM, Surveyor and Minimum Data Set Registered Nurse (MDSRN)-D reviewed R13's MDS assessment dated on 8/31/22 together. MDSRN-D confirmed incorrect coding of Section A1500. MDSRN-D verbalized the error will be corrected. 3. R23 was admitted to the facility on [DATE] and had related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Between 10/17/22 and 10/19/22, Surveyor reviewed R23's medical record which showed R23 had a PASRR Level 1 completed on 9/19/22: Under the question: Check one of the boxes below based on the responses to the questions in Section A of this form. Resident is not suspected of having a serious mental illness or a developmental disability was checked. Between 10/17/22 and 10/19/22, Surveyor reviewed R23's admission MDS assessment dated [DATE]. In Section A1500 (Preadmission Screening and Resident Review (PASRR)), the question asks: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This section was answered: No. On 10/18/22 at 3:03 PM, Surveyor interviewed Social Worker (SW)-F who confirmed R23's PASRR Level 1 dated 9/19/22 and the MDS dated [DATE] were coded incorrectly. SW-F verbalized her expectation is to code MDS correctly and would correct R23's PASRR Level 1. On 10/19/22 at 10:14 AM, Surveyor interviewed MDSRN-D who confirmed PASRR Level 1 and MDS assessment dated on 9/21/22 was incorrectly coded. MDSRN-D verbalized the error will be corrected. 4. R30 was admitted to the facility on [DATE] and discharged to an assisted living facility on 8/23/22. Between 10/17/22 and 10/19/22, Surveyor reviewed R30's discharge MDS assessment dated [DATE]. In Section A2100 (Discharge Status), this section was coded 03 which indicated R30 was discharged to an acute hospital. On 10/19/22 at 10:00 AM, Surveyor interviewed MDSRN-D who confirmed an error was made on R30's discharge MDS assessment dated [DATE] in section A2100 (Discharge Status). MDSRN-D confirmed resident discharged to assisted living and will correct error. MDSRN-D verbalized expectation is to code MDS assessment correctly.

Based on interview and record review, the facility did not ensure post-fall neurological observations (neuro checks) were completed consistently and/or timely for 3 Residents (R) (R17, R13, R18) of 4 residents reviewed for falls. R17 did not have neuro checks completed consistently and/or timely for 5 out of 6 unwitnessed falls reviewed. R18 did not have neuro checks completed consistently and/or timely for 1 unwitnessed fall reviewed. R13 did not have neuro checks completed consistently and/or timely for 4 unwitnessed falls reviewed. Findings include: Facility policy titled, Neurological Observations, with a revision date of May 2020, indicated: Checks are to be performed at 15-minute intervals for a minimum of 1 hour. Thereafter, they are to be done every 30 minutes for one hour, then every hour for two hours; then once a shift for 72 hours or as ordered by the attending physician or per facility standard. This totals 17 neurological checks to be completed after each unwitnessed fall. 1. R17 was admitted to the facility on [DATE] and had a Brief Interview of Mental Status (BIMS) score of 4/15, which indicated that R17 had severe cognitive impairment. R17 had diagnoses that included: [CONDITION(S)] with behavioral disturbance (a disorder characterized by changes in the brain that cause changes to memory, thinking, behavior, impulsivity); generalized anxiety disorder; and psychotic disorder with delusions. R17 had a Falls care plan in place with multiple falls interventions. Between 10/17/22 and 10/19/22, Surveyor reviewed R17's medical record for falls. Surveyor reviewed 6 unwitnessed falls R17 had between 5/1/22 and 10/19/22. Surveyor noted that 5/6 of R17's falls reviewed did not have neuro checks completed according to facility policy/protocol. ~On 9/29/22, R17 had an unwitnessed fall. Surveyor noted 5 out of 17 Neuro checks were completed. ~On 8/2/22, R17 had an unwitnessed fall. Surveyor noted 7 out of 17 neuro checks were completed. ~On 7/29/22, R17 had an unwitnessed fall. Surveyor noted 0 out of 17 neuro checks were completed. ~On 7/26/22, R17 had an unwitnessed fall. Surveyor noted 10 out of 17 neuro checks were completed. ~On 6/28/22, R17 had an unwitnessed fall. Surveyor noted 12 out of 17 neuro checks were completed. On 10/19/22 at 10:37 AM, Surveyor interviewed Director of Nursing (DON-B) who confirmed the expectation that neuro checks should be completed per the new management companies policy (listed above) for unwitnessed falls. DON-B indicated the facility has been in transition with changing policies due to a new management company taking over as well as a new electronic health records system being implemented on 8/1/22. At this same time, Consultant Nurse (CN-C) also confirmed this expectation. 2. R18 was admitted to the facility with diagnoses to include [CONDITION(S)] (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and a history of falling. R18 had a BIMS score of 3 out of 15 indicating a severe cognitive deficit. The Surveyor reviewed R18's medical record and noted R18 sustained a fall on 10/1/22 at 12:15 pm. Nursing progress notes stated: ~resident heard yelling help and writer entered room and resident was laying on [her] left side in front of wheelchair .called and spoke with the on call MD (Medical Doctor) .she stated to follow protocol. The Surveyor noted neurological checks were initiated for the unwitnessed fall with 8 of 17 neurological checks being completed. See staff interview following example #1. 3. R13 was admitted to the facility on [DATE] and had a BIMS score of 1/15 which indicated that R13 had severe cognitive impairment. R13 had diagnoses that included: trsoke with right side of body paralysis, anxiety disorder, panic disorder, chronic kidney disease, dognitive deficits and weakness. R13 had a Falls care plan in place with multiple falls interventions. Between 10/17/22 and 10/19/22, Surveyor reviewed R13's Medical Record for falls. Surveyor reviewed 4 unwitnessed falls R13 had between 6/1/22 and 10/19/22. Surveyor noted that 4/4 of R13's falls reviewed did not have neuro checks completed according to facility policy / protocol. ~On 10/11//22, R13 had an unwitnessed fall. Surveyor noted 6 out of 17 Neuro checks were completed. ~On 9/20/22, R13 had an unwitnessed fall. Surveyor noted 5 out of 17 neuro checks were completed. ~On 8/4/22, R13 had an unwitnessed fall. Surveyor noted 8 out of 17 neuro checks were completed. ~On 6/15/22, R13 had an unwitnessed fall. Surveyor noted 8 out of 17 neuro checks were completed. ~On 6/6/22, R13 had an unwitnessed fall, Surveyor noted 14 out of 17 neuro checks were completed. On 10/18/22 at 12:27 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated neuro checks for unwitnessed falls were as follow: Every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for two hours and lastly every shift for 72 hours. This is in accordance with facility neuro check policy. On 10/19/22 at 10:15 AM, Surveyor interviewed Minimum Data Set Registered Nurse (MDSRN)-D who confirmed there were no documented neuro checks in resident's medical record and that all neuro checks should be in resident's electronic health records. MDSRN-D confirmed if neuro checks were not there then they weren't completed. MDSRN-D reviewed R13's neuro checks for the above unwitnessed falls with surveyor and verified missing neuro checks. See staff interview following example #1.

Based on observation, Resident (R) interview, staff interviews, and record review, the facility did not ensure a call light touch pad was within reach for 1 (R2) of 4 sampled residents observed during investigation. Staff did not ensure R2, who was dependent on staff for transfers, positioning, and mobility, had a call light touch pad within reach. Findings include: On 5/24/22, Surveyor reviewed R2's medical record which documented R2 had decreased range of motion and difficulty moving. R2 was dependent on staff for care, transfers, positioning, meals, and toileting needs. R2 had a [CONDITION(S)] (stroke) which affected mobility, especially R2's left side. R2's care plan documented R2 utilized a touch pad (large button call light generally requiring less force to activate and not requiring fine motor skills to activate) to call for assistance. R2's Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) assessment score was 10 (moderate cognitive impairment). R2's Power of Attorney (POA) for healthcare was activated and R2 was not responsible for medical decisions at the time of investigation. On 5/24/22 at 10:51 AM, Surveyor entered R2's resident room and observed R2's call light touch pad was on R2's bed. R2 was seated approximately six feet away from call light touch pad. R2 confirmed R2 was not able to access call light touch pad. R2 explained R2 was dependent on staff for almost everything because R2 had a dead hand. R2 motioned to left hand as dead hand. At 11:02 AM, Surveyor activated R2's call light with R2's permission. Certified Nursing Assistant (CNA)-F and CNA-G responded. CNA-F verified R2's call light was not in reach. CNA-F indicated CNA-F was last in R2's room approximately 10:00 AM and R2's call light was in reach at the time. CNA-F disclosed that activities staff were in R2's room between 10:00 AM and time of interview. On 5/24/22 at 1:32 PM, Surveyor interviewed Registered Nurse (RN)-E, who was responsible for R2's care at the time of interview. RN-E explained that activities staff were with R2 at about 10:20 when activities staff activated R2's call light because R2's wound vacuum was alarming. RN-E was not able to resolve R2's wound vacuum alarm so RN-E left to get assistance. RN-E could not recall the location of R2's light at the time RN-E went to get assistance but verified R2 was not able to move around room independently, all staff are trained to keep call light buttons in reach, and call light touch pad should always be kept in R2's reach.

Based on observation, Resident (R) interviews, staff interviews, and record review, the facility did not ensure assistance with oral hygiene was provided for 2 Residents (R) (R1 and R2) of 5 sampled residents. R1 reported that staff had not been providing the assistance R1 required to complete daily oral care. Staff did not assist R2 with morning oral care on 5/24/22 or in accordance with R2's desire for oral assistance three times per day. Between 4/1/22 and 5/23/22, oral care was never provided three times per day and was not provided at all 32 days out of the 53 days reviewed. (60.37% days with no oral care.) Findings Include: 1. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's most recent Minimum Data Set (MDS) assessment, dated 2/25/22, indicated R1's cognition to be intact and that R1 required 1 staff assistance with personal hygiene. R1's care plan, revised 5/6/22, states that R1 is to clean teeth/gums if you (staff) set out what I need. On 5/24/22, the Surveyor interviewed R1 regarding staff assistance with oral hygiene. R1 reported that staff did not provide assistance with setting up the supplies for R1 to complete oral cares while R1 was a resident at the facility. R1 stated that R1 asked staff to set up oral care supplies but that staff were too busy to help. On 5/24/22, the Surveyor reviewed R1's medical record to include oral hygiene documentation. According to the nursing documentation, R1 received assistance with oral cares on 43 of 89 (about 48% of the time). On 5/24/22, the Surveyor reviewed a grievance form dated 2/27/22 and completed on R1's behalf regarding the lack of assistance with oral care. The grievance indicated that staff were re-educated by the Director of Nursing (DON) - B to offer oral hygiene and that R1 was encouraged to ask for assistance when needed. The grievance form indicated a resolution date of 3/9/22. 2. On 5/24/22, Surveyor reviewed R2's medical record which documented R2 was dependent on staff for care, transfers, positioning, meals, and toileting needs. R2 had a [CONDITION(S)] (stroke) which affected mobility, especially with R2's left side. R2's care plan documented had loss of teeth and poor dental hygiene and required assistance and provision of oral hygiene. Between 4/1/22 and 5/23/22, R2's oral care was never provided three times per day, was provided twice on 5/3/22, was provided once on 20 dates (4/3/22, 4/5/22, 4/14/22, 4/15/22, 4/17/22, 4/19/22, 4/20/22, 4/23/22, 4/29/22, 5/1/22, 5/2/22, 5/4/22, 5/7/22, 5/9/22, 5/10/22, 5/11/22, 5/15/22, 5/16/22, 5/19/22, and 5/20/22), and not provided oral care at all 32 days out of the 53 days reviewed. Surveyor noted 60.37% of days and 86.16% of opportunities (based on three times per day) no oral care happened. On 5/24/22 at 10:51 AM, Surveyor interviewed R2 who explained staff had to assist R2 with brushing teeth because R2 had a dead hand. R2 motioned to left hand as dead hand. R2 complained that while R2 required staff assistance for oral care, staff hardly ever brushed R2's teeth. R2 complained R2 felt food in R2's teeth from the previous day (5/23/22) at the time of interview. R2 verbalized that R2's dentist communicated to R2 that R2 needed to have Certified Nursing Assistance (CNA) help with brushing and R2 should ask for assistance. R2 explained R2 usually asked staff to assist with oral care after staff get R2 up and ready for breakfast. Staff respond that oral care will be provided after breakfast but R2 said it never happens. On 5/24/22 at 11:04 AM, Surveyor interviewed Registered Nurse (RN)-C about R2's oral care needs. RN-C indicated R2 had a care plan for CNAs to assist with oral care. On 5/24/22 at 11:09 AM, Surveyor interviewed CNA-F. CNA-F verified assisting R2 out of bed for day. CNA-F confirmed R2's oral care was not yet offered or completed at the time of interview. CNA-F explained R2 required set-up to full assistance. CNA-F indicated R2's oral care typically happened mid-morning which CNA-F defined as 10:00 AM to 11:00 AM. CNA-F confirmed the time of interview was beyond that timeframe. On 5/24/22 at 2:31 PM, Surveyor interviewed RN-E about nursing treatment documentation for R2 Make sure (R2) has been helped to brush (R2's) teeth which was initialed by a nurse twice per day. RN-E confirmed RN-E and other nurses do not provide oral care assistance to R2; CNAs provided oral care. Marking the treatment record as done meant RN-E touched base with CNAs about R2's care. On 5/24/22 at 3:07 PM, CNA-H demonstrated to Nursing Home Administrator (NHA)-A and Surveyor the CNA electronic documentation system for oral care entries. On 5/24/22 at 3:26 PM, Surveyor interviewed RN-D, who served as Assistant Director of Nursing (ADON) for the facility. RN-D expressed an expectation that CNAs offer oral care to R2 three times a day per R2's request. RN-D explained that R2 request for oral care three times per day was because sometimes R2 experienced pocketing of R2's crushed medications and the feeling of medication residue was bothersome to R2.

Based on record review and interview, the facility did not ensure all allegations of abuse/mistreatment were thoroughly investigated for 1 Resident (R) (R1) of 4 residents and that measures were put in place to prevent further potential abuse/mistreatment while an investigation was in progress. Multiple staff witnessed and reported FLPN (Former Licensed Practical Nurse)-L used one finger, multiple fingers or an entire hand to remove stool from R1's rectum. Staff reported R1 expressed discomfort with the procedure and asked FLPN-L to stop. Staff also reported R1 became increasingly anxious prior to care, during care and when getting into bed as a result of FLPN-L's actions. The allegations of abuse/mistreatment were reported to the Nursing Home Administrator and Director of Nursing and were not thoroughly investigated. Measures were not put in place to prevent further potential abuse/mistreatment, which allowed the actions of FLPN-L to continue. Findings include: The facility's Abuse-Investigation Including Unexplained Injury policy, revised August 2020, states: It is the policy of this facility to thoroughly investigate reports of abuse .and efficiently maintain an environment free of abuse. The goal of all investigations is to prevent further occurrences. Investigations will gather the facts necessary to form a reasoned conclusion as to what happened .All investigations and the reason for the conclusions will be documented by the facility. Procedure: 1. In short synopsis a. An event occurs. b. Protect the resident, as applicable. g. Thorough investigation. 3. The Administrator or Designee (usually DON (Director of Nursing or SW (Social Worker) is responsible for investigating reports of abuse . 4. While this investigation is conducted, the accused individual, employed by the facility is to be denied access to the resident. 7. The abuse investigation should be a timely, professional inquiry, a systematic examination, an objective fact-finding mission, with unbiased decision making and using impartial judgement. 10. Abuse/Neglect by any individual: c. Regardless of whether the incident is reportable, the facility should fully assess the situation and identify measures to keep residents safe. 14. Interviewing/Investigation: As appropriate, the investigation should consist of: a. What is the specific allegation? This is the basis of the investigation. d. Include all persons who are connected in any way with the incident under investigation. f. Interview other residents to determine if they have had a similar experience or if they have been abused or mistreated. g. Interview other staff who might know or have information about the behaviors of .the staff person in question. 15. Resident (victim) and staff member(s) are interviewed for their account of the information. 16. It is recommended that the staff member writes down in their own words the events that led up to the incident, and how they handled it. 18. A resident's behavior/actions should be charted to monitor for any changes from their usual .for 3 days minimum. 28. All investigation reports, including witness statements, resident statements, etc. are to be maintained on file .by the Administrator/DON/Designee in a confidential manner. The Surveyor reviewed R1's medical record. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's most recent Quarterly MDS (Minimum Data Set), dated 3/15/21, indicated R1 was cognitively intact, but had an onset of mental status change. The MDS also indicated R1 was dependent on staff for most ADLs (activities of daily living), had ROM (range of motion) impairments to both upper and lower extremities, had an indwelling catheter and was incontinent of bowel. R1 was transferred to a local hospital on 5/15/21 following increased confusion and an abnormal potassium level. R1 was tentatively scheduled to return to the facility on [DATE]. R1's plan of care indicated R1 had increased confusion, cognitive changes and disorientation. R1's plan of care did not indicate R1 had a bowel program or experienced signs and symptoms of constipation. On 5/19/21 at 2:30 PM, the Surveyor interviewed CNA-E who witnessed FLPN-L digitally remove stool from R1's rectum multiple times over a period of one month. CNA-E stated, 'Every time I went in there and (R1) showed signs of constipation, (FLPN-L) would dig (R1) out. CNA-E stated FLPN-L didn't encourage or ask R1 to push and went right in. CNA-E stated in one instance, CNA-E retrieved supplies for cares and stood directly next to FLPN-L while R1 was rolled on R1's side. CNA-E stated CNA-E encouraged R1 to push (to have a bowel movement), but FLPN-L stuck a straight hand in R1's rectum and pulled out stool. CNA-E stated R1 screamed and asked FLPN-L to stop. CNA-E stated, I said we shouldn't do that, but (FLPN-L) just kept going. CNA-E stated CNA-E reported the incident to DON-B, ADON-C and asked other nurses to watch for bleeding or anything concerning. CNA-E stated, It got so bad to the point (R1) refused to lay down. When we'd roll (R1), (R1) would say, 'Don't let the nurse come in here and do that to me' . CNA-E stated CNA-E wrote a three page statement on 4/08/21 and gave the statement to ADON-C. CNA-E stated CNA-E attempted to address the concerns with management prior to 4/08/21, but was not asked to write a statement prior to 4/08/21. CNA-E stated CNA-E did not believe the concerns were addressed because DON-B was best friends with FLPN-L. CNA-E stated CNA-E and CNA-F met with NHA-A on 4/06/21 and gave NHA-A a two page statement with multiple concerns regarding FLPN-L. CNA-E stated CNA-E felt the digital removal of stool was abuse because R1 and CNA-E asked FLPN-L to stop. Following the incidents, CNA-E stated CNA-E tried to go in R1's room prior to FLPN-L so CNA-E could encourage R1 to push before (FLPN-L) got in there. CNA-E provided the Surveyor with half of CNA-E's written statement and stated CNA-E was unable to locate the rest of the statement. Amongst other concerns, the statement indicated on 3/27/21, FLPN-L dug (R1's) bowel out while R1 yelled No please stop. The statement indicated CNA-E told FLPN-L to stop, but FLPN-L did not stop. The statement also stated on 3/28/21, FLPN-L dug (R1) out with a whole hand while R1 yelled, Ouch, please stop. The statement indicated on 3/29/21, CNA-E reported the concerns to ADON-C who laughed and said, (FLPN-L) needs to knock it off. The statement further indicated in March of 2021, when R1's showed signs of having a BM during wound care, FLPN-L put two or more fingers inside of R1 to pull the BM out as R1 asked FLPN-L to stop and yelled, Please don't hurt me. The statement concluded with, It has gotten to a point where every time we lay (R1) down (R1) asks if that nurse has to come in. It has also gotten to a point where (R1's) refusing to lay down because of this said issue. On 5/19/21 at 11:37 AM, the Surveyor interviewed DON-B regarding the allegations of abuse/mistreatment. DON-B stated DON-B did not have an investigation regarding the allegations. DON-B stated a quality of care concern involving R1 was reported in early April; however, R1 had no concerns except discomfort with catheter changes. DON-B stated FLPN-L was able to explain the proper protocol for someone with a large amount of stool and stated, (Staff) thought (FLPN-L) was digging (R1) out. Some said they were in the room, but they weren't on the same side (as FLPN-L during cares) . DON-B stated, Staff gave statements, but they weren't written down. (A concern) was brought to (WCRN-D's) attention. We had a brief discussion in morning meeting (on 4/08/21). DON-B stated FLPN-L was scheduled to work the 4/08/21 PM shift; however, DON-B suspended FLPN-L when FLPN-L arrived for work. DON-B said FLPN-L was not asked to write a statement and stated, (R1) stated (the allegation) didn't happen. When asked if DON-B asked R1 a direct question regarding whether or not the allegation occurred, DON-B stated, No. DON-B stated it was not appropriate for FLPN-L to digitally remove stool from R1's rectum; however, the action was not considered abuse. DON-B could not recall which staff were interviewed during the investigation and stated, I'd have to look at the schedule to see who was on. On 5/19/21 at 12:00 PM, the Surveyor interviewed NHA (Nursing Home Administrator)-A regarding the allegations of abuse/mistreatment. NHA-A stated, I understand there was a care concern about peri-care .A staff member said there was a concern in how (FLPN-L) was dealing with the BM (bowel movement) .That (FLPN-L) was extracting the BM manually with a finger. NHA-A could not recall the date of the conversation or name of the staff who reported the concern. NHA-A stated NHA-A forwarded the concern to DON-B. NHA-A stated, I didn't take it as an allegation of mistreatment .Just the appropriateness of which (FLPN-L) was providing care. (The staff who reported the concern) didn't think it was the proper technique to be used in that situation. NHA-A stated, My understanding is that (DON-B) spoke with (FLPN-L) .(FLPN-L) denied doing it. On 5/19/21 at 12:15 PM, DON-B approached the Surveyor and stated DON-B forgot DON-B conducted an investigation related to the allegations. DON-B stated facility-wide abuse education was completed on 4/10/21 following an unrelated and unsubstantiated allegation of abuse reported by another resident; however, the facility did not conduct staff education regarding digital stool removal or the facility's bowel protocol. The Surveyor reviewed the four statements contained in the investigation provided by DON-B. A statement by CNA-R (who DON-B indicated was FLPN-L's fiance) contained no concerns. A statement by CNA-V stated CNA-V had not worked with R1 in the last month on the PM shift (when the alleged abuse occurred). A statement written by CNA-W stated CNA-W worked with R1 for four hours on 4/05/21; however, prior to 4/05/21, CNA-W had not worked with R1 in four months. None of the staff interviewed during the investigation stated they witnessed FLPN-L digitally remove stool from R1's rectum. An interview conducted by SW-Q on 4/07/21 indicated R1 was asked if R1 felt safe and comfortable with staff, if staff were inappropriate and if there were any concerns SW-Q could assist with. The statement did not indicate R1 was asked a direct question regarding the allegation of abuse. On 5/19/21 at 11:26 AM, the Surveyor interviewed Social Worker (SW)-Q regarding the allegations of abuse/mistreatment. SW-Q stated SW-Q spoke with R1 to see if R1 had any concerns and if the reported concern was an allegation of abuse. SW-Q stated, I asked if (R1) had any concerns about care, if (R1) felt safe, if any caregivers treated (R1) differently than others. SW-Q also stated, I asked (R1) if anyone was hurting (R1) or being inappropriate with (R1) or if (R1) wanted anything done differently. (R1) said everything is fine. SW-Q stated SW-Q did not write a progress note since nothing was serious. SW-Q stated there was a staff member who brought up a question about (R1's) care. SW-Q stated SW-Q couldn't recall the name of the staff or the exact question and stated, It was just about (R1's) care. SW-Q stated the incident was not viewed as abuse because (R1) was okay with everything. On 5/19/21 at 1:55 PM, the Surveyor again interviewed DON-B regarding the investigation. When asked if CNAs who assisted FLPN-L with cares and wound treatments on the PM shift were interviewed, DON-B stated DON-B talked to as many staff as possible on 4/09/21 before DON-B had to unexpectedly leave the facility for a medical emergency. On 5/19/21 at 11:12 AM, the Surveyor interviewed ADON-C regarding the allegations of abuse. ADON-C stated ADON-C did not receive any direct reports from staff; however, ADON-C asked three staff to write statements for an investigation conducted by DON-B. ADON-C stated ADON-C could not recall the staffs' names and did not keep copies of their statements. ADON-C stated staff were reeducated regarding digital removal of stool and encouraged to follow the facility's bowel protocol. On 5/19/21 at 9:55 AM, the Surveyor interviewed CNA (Certified Nursing Assistant)-M regarding allegations of abuse involving R1. CNA-M stated CNA-M was aware of an allegation involving the digital removal of stool from R1's rectum by FLPN-L, but did not witness the incident. CNA-M stated R1 made comments during peri-care such as, They're going to hurt me now .Don't let them hurt me again .They're going to put that in there again . CNA-M also stated, (R1) has been having more confusion lately . CNA-M stated CNA-M was not interviewed or asked to write a statement regarding the allegation of abuse/mistreatment. On 5/19/21 at 10:05 AM, the Surveyor interviewed CNA-K regarding the allegations of abuse. CNA-K stated CNA-K was also aware of an allegation, but did not witness the incident. CNA-K stated CNA-K heard FLPN-L took three fingers and tried to dig (stool) out (of R1) when R1 was backed up due to a fecal impaction. CNA-K stated CNA-K was not interviewed or asked to write a statement regarding the allegation of abuse/mistreatment. On 5/19/21 at 10:15 AM, the Surveyor interviewed LPN (Licensed Practical Nurse)-N regarding the allegations of abuse. LPN-N stated LPN-N heard FLPN-L stuck her fingers into (R1's) rectum and tried to remove stool. LPN-N stated R1 commented during cares, Please don't stick anything up me. LPN-N stated LPN-N was not interviewed or asked to write a statement regarding the allegation of abuse/mistreatment. On 5/19/21 at 10:22 AM, the Surveyor interviewed RN (Registered Nurse)-O regarding the allegations of abuse/mistreatment. RN-O stated RN-O heard FLPN-L was rough and used multiple fingers when FLPN-L removed stool from R1's rectum. RN-O stated RN-O did not witness the incident, but reported the allegation of abuse to WCRN (Wound Care Registered Nurse)-D. RN-O stated RN-O was not interviewed or asked to write a statement regarding the allegation of abuse/mistreatment. On 5/19/21 at 10:40 AM, the Surveyor interviewed CNA-P regarding the allegations of abuse/mistreatment. CNA-P stated CNA-P was aware of an allegation of abuse, but did not witness the incident. CNA-P stated CNA-P heard coworkers talk about the incident and stated multiple coworkers were asked to write statements. In addition, CNA-P stated CNA-P was not interviewed or asked to write a statement regarding the allegations. On 5/19/21 at 11:05 AM, the Surveyor interviewed WCRN-D regarding the allegations of abuse/mistreatment. WCRN-D stated WCRN-D did not receive any reported allegations of abuse involving R1. WCRN-D said, Nobody directly came to me, but I heard about the event. WCRN-D then recalled a conversation with an unnamed CNA and stated, (The CNA) may have said something to me. They said something to me after the investigation something about a whole fist up the rectum. I believe they witnessed it. WCRN-D stated DON-B and ADON (Assistant Director of Nursing)-C conducted an investigation; however, WCRN-D did not participate in the investigation. On 5/19/21 at 3:00 PM, the Surveyor interviewed CNA-G who witnessed FLPN-L digitally remove stool from R1's rectum on multiple occasions. CNA-G stated CNA-G provided dates of the observations to ADON-C and SC (Scheduling Coordinator)-S. CNA-G stated during one instance of peri-care when R1 stated R1 had to pass gas, FLPN-L just went in there and started scraping stool out stool with two fingers. CNA-G stated CNA-G felt the action was abusive because R1 was able to pass stool without intervention if given the time and encouragement. CNA-G stated CNA-G witnessed a similar incident approximately one month later. CNA-G stated CNA-G wrote a statement on 4/08/21 and gave the statement to ADON-C. CNA-G's statement was not included in the investigation provided by DON-B. On 5/19/21 at 3:15 PM, the Surveyor interviewed CNA-H who witnessed FLPN-L digitally remove stool from R1's rectum approximately two weeks prior to 4/08/21. CNA-H stated FLPN-L digitally removed stool prior to wound care after R1 stated R1 was uncomfortable and had a stomach ache. CNA-H stated R1 did not request to have stool removed nor did FLPN-L ask if R1 wanted stool removed. CNA-H stated, (FLPN-L) was scooping (stool) out with (FLPN-L's) hand. CNA-H stated CNA-H was uncomfortable when FLPN-L stated FLPN-L lost a hair tie from FLPN-L's wrist the last time FLPN-L digitally removed R1's stool. CNA-D stated CNA-D wrote a statement in ADON-C's office on 4/08/21. CNA-D's statement was not included in the investigation provided by DON-B. On 5/19/21 at 3:40 PM, the Surveyor again interviewed DON-B and asked if DON-B had any additional staff statements. DON-B stated DON-B did not have statements written by CNA-E, CNA-G or CNA-H and denied knowledge of their contents. On 5/19/21 at 11:00 PM, the Surveyor interviewed CNA-T who did not witness FLPN-L digitally remove stool from R1's rectum, but heard about an incident from coworkers. CNA-T stated CNA-T gave a statement to DON-B on 4/08/21. CNA-T stated DON-B wanted to know if CNA-T witnessed the digital removal of stool. CNA-T stated, I said I heard about it, but (DON-B) said (DON-B) didn't want hearsay. CNA-T stated DON-B did not ask any further questions. A statement contained in the investigation provided by DON-B stated CNA-T did not witness anyone physically removed BM from (R1). On 5/20/21 at 10:53 AM, the Surveyor interviewed FCNA (Former Certified Nursing Assistant)-I who witnessed FLPN-L digitally remove stool from R1's rectum. FCNA-I stated FCNA-I was in R1's room during cares with CNA-J and FLPN-L. FCNA-I stated when FCNA-I wiped R1, there was no stool and R1's rectum was closed. FCNA-I stated, (FLPN-L) was there to do (R1's wound treatment). (FLPN-L) asked (R1) if (R1) had to poop and began thrusting (FLPN-L's) fingers back and forth in (R1's) rectum. FCNA-I stated FLPN-L started with one finger, then two fingers and then three fingers. FCNA-I stated FCNA-I knew R1 was uncomfortable, but did not think R1 yelled or said stop. FCNA-I stated FCNA-I was asked to write a statement on 4/08/21. FCNA-I's statement was not included in the investigation provided by DON-B. On 5/20/21 at 12:01 PM, the Surveyor interviewed CNA-F who witnessed FLPN-L digitally remove stool from R1's rectum. CNA-F stated, I witnessed (FLPN-L) multiple times stick three or more fingers and clear (stool) out. I know (R1) was uncomfortable. CNA-F stated R1 did not express care concerns or fear of being hurt prior to the incident with FLPN-L, but did so afterward. CNA-F stated R1 cried sometimes when FLPN-L's fingers were in R1's rectum and stated, I can't do this when you're going against me. CNA-F provided the Surveyor with the two page written statement that was given to and discussed in person with NHA-A on 4/06/21. Amongst other concerns, the statement said, On multiple occasions, (FLPN-L) digs into (R1's) rectal area whenever (FLPN-L) does (R1's) wound care to dig out excess stool. Sometimes the stool isn't ready to come, yet (FLPN-L) digs it out anyway. (R1) now gets worked up when we have to roll (R1) and do (R1's) treatments saying Don't let them hurt me again. On 5/20/21 at 12:25 PM, the Surveyor interviewed CNA-J who witnessed FLPN-L digitally remove stool from R1's rectum. CNA-J stated as CNA-J held R1 on R1's side, another CNA was about to clean up R1's bowel movement when FLPN-L stuck multiple fingers in R1's rectum. CNA-J stated, (R1) was screaming. It was obvious it was causing (R1) pain. CNA-J stated following the incident, R1 was leery about us putting (R1) in bed. CNA-J stated CNA-J was asked to write a statement on 4/08/21 and gave the statement to DON-B and ADON-C. CNA-J stated DON-B read the statement, asked CNA-J for a few clarifications and that was it. CNA-J's statement was not included in the investigation provided by DON-B. During an exit conference with DON-B, ADON-C, SNHA (Sister Nursing Home Administrator)-X and the Surveyor on 5/20/21 at 3:00 PM, DON-B and ADON-C again denied they received any reports or statements from staff that contained actual or potential allegations of abuse involving R1.

Based on record review and interview, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 1 Resident (R) (R1) of 4 residents. Multiple staff witnessed and reported that FLPN (Former Licensed Practical Nurse)-L digitally removed stool from R1's rectum. Staff reported the digital removal of stool occurred when R1 had already defecated and/or was not showing signs and symptoms of constipation. Staff reported R1 expressed discomfort with the procedure and asked FLPN-L to stop. Staff also reported R1 became increasingly anxious prior to care, during care and when getting into bed as a result of FLPN-L's actions. Findings include: The facility's Bowel Assessment Protocol, dated November 2013, states: Residents will maintain adequate elimination. The purpose is to avoid constipation with individual residents whenever possible. Procedure: 2. A list will be made of all residents that have gone two and three days without a BM (bowel movement). 3. Any resident on the BM list for two days should be offered prune juice with the PM med pass. 4. Encourage the resident to increase fluid and food intake. 5. If no results from prune juice on day two, offer MOM (Milk of Magnesia) (a [MEDICATION(S)] used to treat constipation) on the PM shift as ordered by the physician. 6. If no results from MOM on day three, offer suppository and/or Fleets enema (a saline [MEDICATION(S)] that causes a bowel movement by increasing fluid in the small intestine) as ordered by the physician. 7. Check bowel sounds and perform rectal check if no BM for three days. Notify physician if current bowel program is ineffective. The Surveyor reviewed R1's medical record. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's most recent Quarterly MDS (Minimum Data Set), dated 3/15/21, indicated R1 was cognitively intact, but had an onset of mental status change. The MDS also indicated R1 was dependent on staff for most ADLs (activities of daily living), had ROM (range of motion) impairments to both upper and lower extremities, had an indwelling catheter and was incontinent of bowel. R1 was transferred to a local hospital on 5/15/21 following increased confusion and an abnormal potassium level. R1 was tentatively scheduled to return to the facility on [DATE]. R1's plan of care indicated R1 had increased confusion and may think staff are lying due to confusion, cognitive changes and disorientation. R1's plan of care did not indicate R1 had a bowel program or experienced signs and symptoms of constipation. R1 had orders for 625 mg (milligrams) of [MEDICATION(S)] (a [MEDICATION(S)]) daily for abnormal stools and 17 grams of [MEDICATION(S)] (a [MEDICATION(S)]) daily for constipation. R1 had daily PRN (as needed) orders for a 10 mg [MEDICATION(S)] suppository, 30 ml (milliliters) of Milk of Magnesia, 100 mg of [MEDICATION(S)] (a stool softener) and 1 dose of prune juice for constipation. A progress note on 3/12/21 stated R1 was tearful during ADLs; however, R1's mood improved when R1 was out of bed. A progress note on 3/17/21 stated R1 was confused and thought R1 was one of the daughters on a television show. A progress note on 5/01/21 stated R1 was tearful and praying to God during ADLs and wound care. The note stated R1's mood improved when cares were completed and R1 was out of bed. On 5/19/21 at 2:30 PM, the Surveyor interviewed CNA-E who witnessed FLPN-L digitally remove stool from R1's rectum multiple times. CNA-E stated, 'Every time I went in there and (R1) showed signs of constipation, (FLPN-L) would dig (R1) out. CNA-E stated FLPN-L didn't encourage or ask R1 to push and went right in. CNA-E stated in one instance, CNA-E retrieved supplies for cares and stood directly next to FLPN-L while R1 was rolled on R1's side. CNA-E stated CNA-E encouraged R1 to push (to have a bowel movement), but FLPN-L stuck a straight hand in R1's rectum and pulled out stool. CNA-E stated R1 screamed and asked FLPN-L to stop. CNA-E stated, I said we shouldn't do that, but (FLPN-L) just kept going. CNA-E stated CNA-E reported the incident to DON-B, ADON-C and asked other unnamed nurses to watch for bleeding or anything concerning. CNA-E stated, It got so bad to the point (R1) refused to lay down. When we'd roll (R1), (R1) would say, 'Don't let the nurse come in here and do that to me .Don't pull my poop out. I can do it'. Following the incidents, CNA-E stated CNA-E tried to go in R1's room prior to FLPN-L so CNA-E could encourage R1 to push before (FLPN-L) got in there. CNA-E provided the Surveyor with half of a written statement provided to DON-B on 4/08/21. The statement indicated on 3/28/21, FLPN-L dug (R1's) bowel out while R1 yelled, No, please stop. CNA-E stated despite CNA-E and R1's requests to stop, FLPN-L did not stop. The statement also indicated on 3/28/21, FLPN-L dug (R1) out with a whole hand while R1 yelled, Ouch, please stop. The statement further indicated when R1 showed signs of having a BM during wound care in March of 2021, FLPN-L put two or more fingers inside of R1 to pull the BM out as R1 asked FLPN-L to stop and yelled, Please, don't hurt me. The statement further indicated R1 refused to lay down because of this said issue and asks if that nurse has to come in. On 5/19/21 at 3:00 PM, the Surveyor interviewed CNA-G who witnessed FLPN-L digitally remove stool from R1's rectum on two occasions. CNA-G stated during one instance of peri-care when R1 stated R1 had to pass gas, FLPN-L just went in there and starting scraping stool out stool with two fingers. CNA-G stated R1 did not did not express pain or tell FLPN-L to stop. CNA-G stated R1 was able to pass stool if given the time and encouragement to push. CNA-G stated CNA-G witnessed a similar incident approximately one month later. CNA-G again stated R1 did not complain of pain or ask FLPN-L to stop. On 5/19/21 at 3:15 PM, the Surveyor interviewed CNA-H who witnessed FLPN-L digitally remove stool from R1's rectum approximately two weeks prior to 4/08/21. CNA-H stated FLPN-L digitally removed stool prior to wound care after R1 stated R1 was uncomfortable and had a stomach ache. CNA-H stated R1 did not request to have stool removed nor did FLPN-L ask if R1 wanted stool removed. CNA-H stated, (FLPN-L) was scooping (stool) out with (FLPN-L's) hand. CNA-H did not recall if R1 asked FLPN-L to stop, but heard FLPN-L say, It's okay. I'm just trying to help. On 5/20/21 at 10:53 AM, the Surveyor interviewed FCNA-I who witnessed FLPN-L digitally remove stool from R1's rectum. FCNA-I stated FCNA-I was in R1's room with CNA-J and FLPN-L. FCNA-I stated when FCNA-I wiped R1, there was no stool and R1's rectum was closed. FCNA-I stated, (FLPN-L) was there to do (R1's wound treatment). (FLPN-L) asked (R1) if (R1) had to poop and began thrusting (FLPN-L's) fingers back and forth in (R1's) rectum. FCNA-I stated FLPN-L started with one finger, then two fingers and then three fingers. FCNA-I indicated R1 moaned and groaned a little. FCNA-I stated FCNA-I knew R1 was uncomfortable, but did not think R1 yelled or said stop. FCNA-I stated R1 took stool softeners and could defecate on R1's own. On 5/20/21 at 12:01 PM, the Surveyor interviewed CNA-F who stated CNA-F witnessed FLPN-L manually remove stool from R1's rectum. CNA-F stated, I witnessed (FLPN-L) multiple times stick three or more fingers and clear (stool) out. I know (R1) was uncomfortable. CNA-F- stated R1 did not express care concerns or fear of being hurt prior to the incidents with FLPN-L. CNA-F indicated staff encouraged R1 to lay down to relieve pressure on R1's sacral wound and stated, The moment you roll (R1) or change (R1's) brief, (R1) would say. 'Please don't hurt me. I don't want to do this any more. CNA-F stated R1 did not make those statements before FLPN-L began digitally removing stool from R1. CNA-F stated if staff saw a small amount of stool in R1's brief, staff asked R1 if R1 could defecate more. CNA-F stated, As (R1) would start pooping, (FLPN-L) would stick (FLPN-L's) fingers in there. CNA-F stated R1 stated, I can't poop if you're pushing against me. CNA-F stated R1 cried sometimes when FLPN-L's fingers were in R1's rectum and stated, I can't do this when you're going against me. CNA-F stated CNA-F asked NHA-A if that was appropriate treatment. CNA-F stated NHA-A indicated that was not appropriate. CNA-F provided the Surveyor with the two page written statement that was provided to NHA-A on 4/06/21. Amongst other concerns, the statement said, On multiple occasions, (FLPN-L) digs into (R1's) rectal area whenever (FLPN-L) does (R1's) wound care to dig out excess stool. Sometimes the stool isn't ready to come, yet (FLPN-L) digs it out anyway. (R1) now gets worked up when we have to roll (R1) and do (R1's) treatments saying Don't let them hurt me again. On 5/20/21 at 12:25 PM, the Surveyor interviewed CNA-J who stated CNA-J witnessed FLPN-L manually remove stool from R1's rectum. CNA-J stated as CNA-J held R1 on R1's side, another CNA was about to clean up R1's bowel movement when FLPN-L stuck multiple fingers in R1's rectum. CNA-J stated, (R1) was screaming. It was obvious it was causing (R1) pain. CNA-J stated R1 said, Oh Lord help me. Oh Lord, help me. You must think this is funny. You must get enjoyment out of this. CNA-J stated FLPN-L stated, I'm trying to help you. CNA-J stated following the incident, R1 was leery about us putting (R1) in bed. On 5/20/21 at 8:45 AM, the Surveyor interviewed a nurse (who declined to provide a last name and requested anonymity) at a local hospital regarding R1's status. The nurse stated R1 was scheduled to return to the facility later that day pending physician rounds. The nurse stated R1 was alert and oriented to self and expressed confusion prior to the Surveyor's visit. The nurse stated R1 had to be oriented to R1's whereabouts as R1 thought R1 was in the nursing home. On 5/20/21 at 8:50 AM, the Surveyor interviewed R1 regarding the allegation of abuse. R1 indicated R1 did not recall the incidents reported and stated, I don't think that's exactly how it happened. R1 stated R1 did not remember FLPN-L, was not afraid to go to bed and was not afraid of staff at the facility. R1's medical record did not indicate R1's physician was contacted by FLPN-L regarding signs and symptoms of constipation or R1's inability to pass stool. R1's medical record also did not indicate R1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility did not ensure residents were free from mental abuse for 1 of 9 sampled residents (R1). R1 expressed an allegation of sexual abuse in previous months and again on 8/10/19. R1 indicated she is fearful to be left alone with others and became tearful when conversing about the incident. The facility did not immediately protect R1 or other residents and continued to allow the accused staff, certified nursing assistant (CNA) J, to work with or in the vicinity of R1. R1 was observed by staff to have catastrophic reactions when CNA J was present. Additionally, facility staff intimidated R1 when LPN (Licensed Practical Nurse) M brought staff into R1's room and told R1 to identify who had hurt her. This is evidenced by: Facility Policy entitled Resident Abuse- Protection, dated 8/17, states, in part: Each resident has the right to be free from abuse, corporal punishment, mental abuse, humiliation, and involuntary seclusion. Residents must not be subjected to abuse from anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.It is the policy of this facility to protect residents from further incidents while investigations of allegations of abuse are being conducted. R1 was admitted on [DATE] with [DIAGNOSES REDACTED]. R1's Annual MDS (Minimum Data Set), dated 8/19/19, indicates under Section B, R1 is able to make self understood and usually understands others. R1's BIMS (Brief Interview of Mental Status) is 4 out of 15, indicating severe cognitive impairment. R1 requires extensive 1 person assist with bed mobility, transfers and toileting. R1 has impairment on one side of her lower and upper extremities. R1 is frequently incontinent of urine and always continent of bowel. No behaviors are indicated for R1. R1 first accused staff of raping her in late (MONTH) or early (MONTH) 2019. CNA J's written statement, on 8/13/19, states in part; in (MONTH) on N[NAME] (evening) shift I (name) was working down 300 hallway as well as 400 and 500 with (name) since we were the only 2 CNA's we did our call lights and check and changes together. I don't remember what time exactly but it was around 3:-4:30 it was time to check and change (R1). I was on the window side of the bed and (name) was on the other side. We rolled (R1) my way for (name) to change her. (LPN M) (Licensed Practical Nurse) the nurse had to give (R1) a supository (sic). (R1) was still facing my way when (LPN M) gave (R1) the supository (sic). (R1) didn't say anything about it. We closed her breif (sic), boosted her up in the bed, and tucked her in, put the touchpad (sic) in the right spot and left. The next shift which was morning shift (Name) was on and (R1) told her I raped her and (R1) told (Name) the story of how it happened. On 8/28/19 at 4:15 PM, Surveyor interviewed CNA J regarding R1. CNA J indicated that he reported R1's accusation about a month and a half ago, before (MONTH) 10th. CNA J indicated he reported R1's accusation at the beginning of (MONTH) or the end of (MONTH) to IDON B. CNA J indicated he was working 3rd shift with another CNA and LPN M. CNA J indicated that they checked and changed R1 together and LPN M gave R1 a suppository. CNA J then gave report to 1st shift and then came back for his next scheduled shift and was told by the day CNA that R1 said a male raped her. CNA J indicated that he reported this to IDON B at that time. CNA G's written statement, on 8/15/19, states, in part: I want to say maybe 2 months ago was the first time I had heard about (R1's) discomfort with (CNA J). This wasn't directly from (R1) herself but during report when (CNA J) and (name) were talking about how (R1) had stated (CNA J) raped her one of the nights prior. From my understanding (CNA J) had went into (R1's) room during N[NAME] shift with (LPN M) and (CNA Q) so (LPN M) could give (R1) a suppository. (CNA J) and (name) had figured (R1) was confused about what happened and eventually would get the idea of him raping her out of her head. I hadn't worked with (CNA J) much recently because of him working a majority of N[NAME] shifts but I would hear that (R1) absolutely hates him and would refuse any cares given by him. I know when he would be the only CNA down 300 during his shifts he would have someone go into (R1's) room with him when she needed cares to make her feel more comfortable and to prevent anything further being said about how he cares for her. On 8/22/19 at 3:20 PM, Surveyor interviewed CNA G. Surveyor asked CNA G what she could tell me about R1 and when she found out about the most recent accusations made toward CNA J. CNA G stated, I am guessing I heard first around the beginning of July. An AM (Morning) CNA had stated through report that R1 had stated that CNA J had raped her. CNA G when on to state to Surveyor, When in the room with R1 and CNA J I try to get her to trust me and that I would not bring someone into her room that would hurt her. Surveyor then asked CNA G when she first heard of any accusations made against CNA J by R1. CNA G stated, I first heard about it a couple of months ago from another CNA. Surveyor asked if this was reported at that time. CNA G stated, I don't know if it was reported at that time. I didn't but CNA J had stated that they had let IDON (Interim Director of Nursing) know. Even when previous DON was here she knew about it, that is how long it has been. On 8/22/19 from 4:20 PM to 4:45 PM, Surveyor interviewed NHA A, IDON B and NHA P regarding R1 and alleged incident. IDON B and NHA A indicated they never heard that R1 was uncomfortable prior to 8/15/19 statement from CNA G. NHA A indicated while they completed the initial investigation they found out about other situations. Despite R1's accusations against CNA J, staff did not report to the administrator. There was no investigation and no changes to R1's care plan to protect her from further potential abuse. CNA J was allowed to continue working with R1, although statements and interviews indicate that CNA J did not work alone with R1 after these accusations were made. On 8/10/19 R1 again accused CNA J of raping her again. DA O's (Dietary Aide) written statement, on 8/14/19, states: Saturday the 10th right before supper at about 5:20 PM, (LPN N) the nurse on duty on 300 hallway flagged me down say (sic) Hey boss lady can you come here a moment, as she was standing next to an upset (R1) in her wheelchair. (R1) was shaking as she grabbed my hand and asked if she can speak with me privately. (LPN N), (R1) and I went into the 300 hallway away from the dining hall. (R1) then told me she was scared. She told me how she had no family left to protect her from (CNA J) (male nurse). She continued to tell me how (CNA J) had raped her twice a while ago. She said she didn't feel safe alone in her room. She also mentioned that he (CNA J) would hurt her when everyone was busy. I reassured (R1) we are always there to protect her and said, let's try to get dinner and then we can enjoy the evening. She seemed content after talking about it with me. (CNA J) then told me he was a part of a roll to help a nurse give a medication that no mistreatment happened. (LPN N) was present during all of the conversation with (R1). I asked if she reported the situation and she said she felt no need. DON knew. I alerted the DON of what had happened. On 8/22/19 at 12:21 PM, Surveyor interviewed DA O regarding the incident with R1. DA O indicated, on 8/10/19, she was in the long-term care dining room. DA O indicated, at approximately 5:30 PM, LPN N was talking to R1 and R1 grabbed DA O's hand and seemed concerned. DA O indicated she and LPN N took R1 to the hall and that R1 was shaky and upset. DA O indicated R1 indicated she had no family left, no siblings to protect her from the boy over there. DA O indicated R1 was pointing to CNA J. DA O indicated R1 stated, He hurts me and I feel unsafe. DA O indicated LPN N was there and stated, Yeah, yeah I'm going to, when DA O told her to tell someone. DA O indicated R1 stated, He's hurt me twice; he's raped me twice, but didn't go into depth about it. DA O indicated she talked to the DON (IDON B) after hours and was told to write out a statement which I didn't do right away. DA O indicated she called the DON on the 10th and the call was brief and DA O indicated LPN N was there during the whole conversation with R1. DA O indicated she is a newer staff member and didn't know how to process the information. DA O indicated she realized now that the on-call nurse should have been notified. (Please note although staff were aware that R1 alleged being raped by CNA J on 8/10/19 the facility did not protect R1 or other residents. CNA J continued to work in the facility after the allegation on 8/10/19. CNA J worked on 8/10/19 and 8/11/19). CNA J's Time Clock punches indicate he worked on 8/10/19 from 1:38 PM until 2:13 AM on 8/11/19. CNA J also worked on 8/11/19 from 1:39 PM until 6:08 AM on 8/12/19. (Please note that CNA J was not removed in order to protect the residents residing within the facility when the allegation was reported on 8/10/19. Additionally staff report that R1 has alleged CNA J raped her over the past several months. Facility employees were aware of these allegations and failed to report the incident thus protect R1 and other residents.) CNA-G's written statement on 8/15/19 indicates: This past weekend (which would be 8/10 and 8/11/19) was my first time working down 300 with (CNA J) in a while and I actually witnessed the way she (R1) treats him. She screams at him to get out if he even comes near her room or tells him don't look at me. I don't want anything to do with you. This also occurs when she sees him in the hallways and at the supper table. (R1) has said to me that she feels bad for me and that I need to be careful of that man because he's raped her twice. I never want to tell her she's wrong because I know she's confused, but I always let her know that he's my coworker and treats me well. On Sunday night I stayed with (CNA J) down 300 until 2 AM to try out N[NAME] shift. We had went into (R1's) room after her light went off because she was trying to crawl out of bed and decided we would change her brief because she was wet. (LPN M) was in the room too and when we had laid her down she began to hit and kick (CNA J) and shout to get away from her and for him not to touch her. I grabbed her hand and told her she could trust me and that I wouldn't bring anyone into her room to harm her. This calmed her down but she still kept a close eye on (CNA J) while we proceeded to change her. CNA-J's written statement on 8/13/19 states, in part: Last Saturday the (10th). I was assigned 300 hall w/ (with) (CNA G) on my way to nurses station I saw (R1) in the hallway wandering. I said ' hey how is your day going,' she yelled back not to look at her, talk to her, and that she didn't want to see me. I don't talk to her anymore or since. Starting in March/April I have not put (R1) to bed. Also haven't gone in her room alone in a long time because I don't want to be accused of doing things. At supper I don't bring food over to her table. She stares at me until she gets her food at supper. When I did assist others change her at night shift, we always roll her my way so the other person changes her. (R1) has hit me many times while we change her. (Signed by CNA J on 8/13/19) Note: This statement indicates the facility was still allowing CNA-J to work with R1 despite R1's fear of him.) During interview on 8/28/19 at 4:15 PM, CNA J indicated that around 8/10/19 he saw R1 in the hallway and asked her how her day went and that R1 told CNA J not to talk to her and to go away. CNA J indicated he did not talk to R1 again or work with R1 the next day. CNA J indicated that CNA G took care of R1 the rest of the shift on 8/10/19. CNA J indicated that IDON B did not talk to him until 8/13/19 when he was suspended. CNA J indicated that he always checked and changed R1 with another staff member and that he did not check and change her by himself. Surveyor asked CNA J if R1 had acted this way towards CNA J prior to the incident indicated, CNA J indicated he was not comfortable answering that question. LPN N's written statement, on 8/15/19, states: On Saturday 8-10-19 around (5:30 PM) (CNA J) came to me and told me, (R1) is accusing me of raping her again. He was working on the unit and she had seen him walk past her room. She doesn't allow him in her room and hasn't as long as we have been in this building. He has offered assistance when her light is on but she refuses. I asked him what he means by again, he said she has been accusing him of things like stalking and even rape since he has been working here. He said he had talked to (previous DON's name) about it. I told him to not go by her for the rest of the night. I was then going into the dining room and (R1) had a kitchen staff member pulled into the hall and was telling her about being raped. I told her I was aware of it. During supper she was upset so the aide left the dining room. He did not go by her the rest of the shift. (R1) was quiet after that and allowed the other aide to take care of her. I updated the next shift on this but do admit I made no other calls or charted. CNA G's written statement on 8/15/19 also noted: I can't remember what day it was (either Sat (Saturday) or Mon (Monday)) but one of the nights (R1) was telling her table partner (resident name) about how (CNA J) raped her. I didn't hear it but nurse (LPN N) did and confronted (R1) about it. I'm not sure what she said to (R1) but when I put her to bed that night she brought up how the lady with the brown hair had yelled at her at supper time. On Wednesday (R1) had made a comment to me while I was toileting her that a man she had never seen came to her room the day before and shoved something that looked like a Christmas present in her vaginal opening. I really wasn't sure how to respond to that so I just let my nurse know. On 8/22/19 at 5:06 AM, Nurses Note states, in part: Mood patterns: Resident put light on at 04:25 (4:25 AM) and reported to staff that she had just been (sic) raped. Writer went into room with staff members that completed cares and asked which one did the rapping (sic). Resident stated not them but someone did. Writer explained they we (sic) are the only caretakers here now so I needed to know which one did it. Resident could not point to any staff member. Writer asked what happened and what body part did they hurt. They touched between my legs. I explained that she had been incontinent of urine and they were doing cares to make sure she was clean and dry. No bruising noted to groin area; remains red in groin, notified Assistant Director of Nursing (ADON) at 04:45 (4:45 AM) and she stated just to document. (Please note that the ADON is IDON B (Interim Director of Nursing). IDON B was aware LPN M took staff into R1's room and stated which caretaker raped her. R1 was already expressing fear and having catastrophic reactions regarding CNA J. LPN M actions resulted in mental abuse by intimidating R1.) On 8/26/19 at 1:58 PM, Surveyor interviewed LPN M regarding previous situation with R1. LPN M indicated that CNA G and CNA J and she went into change R1 as she was wet. R1 had been sitting on the side of the bed and CNA G approached R1 and laid her down while CNA J helped lift her up in bed. CNA G did the changing of R1, and R1 did not mention anything. Surveyor asked LPN M about her 8/22/19 Nurses Note. LPN M indicated the two CNA's had changed her and that R1 told one of the CNA's that someone raped her again. LPN M indicated that she took staff in and asked R1 which one did it, because she needs to do a report. On 8/22/19 from 4:20 PM to 4:45 PM, Surveyor interviewed NHA A, IDON B and NHA P regarding R1 and alleged incident. NHA P indicated. when asked about 8/22/19 Nurses Note, that it's not appropriate to take staff in, as it's unfair and not sensitive to the resident. On 8/22/19 at 3:20 PM, Surveyor interviewed CNA G. Surveyor asked CNA G if she ever reported any of the accusations R1 made. CNA G stated, R1 reported CNA J raped her twice and I reported that to RN K on Saturday (8/10/19) then I went and told IDON B on Monday (8/12/19), that was two weeks ago when I was working with CNA J. Then on Monday (8/12/19) R1 reported that someone put a present up in her private area. I reported that to LPN L right away. CNA G also stated that on either Saturday (8/10/19) or Monday (8/12/19) R1 was telling her table mate in the dining room that CNA J had raped her. After supper R1 told me RN K yelled at her about saying CNA J raped her. Surveyor asked CNA G if she reported to anyone that RN K yelled at R1. CNA G stated, I didn't report it but looking back I should have. Surveyor asked CNA G if she had ever heard R1 make accusations against any other staff in the facility. CNA G stated, R1 is uncomfortable with CNA F but has never made any accusations against him. Surveyor asked CNA G if CNA J is still able to care for R1. CNA G stated, CNA J has been unable to go into R1's room since (MONTH) 11th, prior to that CNA J would take another CNA with him. Despite accusations in late June/early (MONTH) and again on 8/10/19, the facility did not update R1's care plan until 8/13/19. Care Plans, dated 8/13/19, indicate, in part . I HAVE: The potential to feel sad, anxious, confused or forgetful. R1 is noted to be more anxious around male staff and has a history of being uneasy around male resident who may be in her visual area. I need my nurses to --- Identify patterns of behavior, assess understanding; evaluate effectiveness and adverse effects of medication. Review documentation of medical necessity for drug; offer me distractions and relaxation techniques. Assess resident for mood and behavior changes, be aware of situational triggers such as male interactions. Reassure resident that she is safe and provide 1:1(one-to-one) to resident. I need my aides to --- Record my behaviors. Report to nurse any changes in mood or behavior. Be aware of situational triggers that involve male gender. I need everyone to --- Understand resident's situational triggers related to male gender. Updated nurse and social services of any concerns or need for 1:1 and reassurance. MY GOAL IS TO: Feel safe and secure, feel rested, use coping/relaxation tools. Decreased episodes of anxiety. I HAVE: Uneasy feelings around male residents who may be in her visual area. I need my aides to --- Report to nurse any changes in mood or behavior. Be aware of situational triggers that involve male gender. I need everyone to ---Understand resident's situational triggers related to male gender. Updated nurse and social services of any concerns or need for 1:1 and reassurance. On 8/13/19 at 7:15 AM, Nurses Note entitled 'Mood Patterns' states, in part: .Unreal fears: expressed unrealistic fear regarding his/her environment today. Afraid to be left with others.unpleasant morning mood. Care Plan, dated 8/15/19, indicates, in part . I HAVE: The potential to feel anxious or scared when I am around male caregivers. I have experienced [MEDICAL CONDITION] which causes me to be confused or forgetful. I need my nurses to --- Make sure that male caregivers are not assigned to me. To make sure that staff providing care that I have these preferences. I need everyone to --- Monitor for triggers and stressors. On 8/22/19 at 3:40 PM, Surveyor spoke with R1 regarding the incident on 8/10 and 8/22/19. R1 indicated someone came in and wanted to take her to church and indicated she needed to wash up. R1 indicated the individual was quiet next to her and touched between her legs in her room. R1 stated she felt horrible, and she didn't talk to anyone until the next day. R1 denied anything prior to this event. R1 indicated they checked her skin and she had not seen the person who did it before. R1 indicated the male staff assists her and she isn't okay with it. (Please note R1 was observed to become tearful when speaking with Surveyor regarding the situation. Surveyor stopped the interview at this time as R1 was visibly upset.) On 8/22/19 from 4:20 PM to 4:45 PM, Surveyor interviewed NHA A, IDON B and NHA P regarding R1 and alleged incident. NHA A indicated she followed up with R1 today related to the officer and the situation. NHA A indicated R1 indicated they (male caregiver) came in while R1 was sleeping and they did their thing. R1 indicated she could hear them come in, a long time ago, didn't see the person today. R1 indicated they dug a hole and stuffed a box in it, R1 indicated it hurt just by the stuffing and there was blood. NHA A indicated R1 was tearful when talking about it, because people at church might be judging her. (Please note that R1 is again tearful and fears she will be judged by others.) The facility failed to immediately protect R1 and other residents when R1 alleged she had been raped by CNA J. Failure to protect R1 caused R1 mental anquish as evidenced by R1's catastrophic reactions when CNA J was in her vicinity. Facility staff members where aware R1 had made allegation of rape against R1 yet failed to protect R1, report the incident or investigate her allegations. Furthermore, R1 was subjected to additional mental anguish and intimidation when LPN M brought staff members into R1's room and asked her to identify the person she had been raped by. R1 was already displaying fear and tearfulness regarding this alleged rape.

Based on observation, interview and record review, the facility did not ensure residents receive care consistent with professional standards of practice to prevent development of pressure injuries (PI) unless clinically contradicted and residents with pressure injuries receive treatment and services consistent with professional standards of practice for 2 of 2 residents with pressure injuries, out of a total sample of 20 residents (R30 & R9). R30 developed an unstageable PI to the right heel, the physician was not notified of the unstageable right heel PI, the care plan for skin was not followed, and an incorrect [DIAGNOSES REDACTED]. The facility did not ensure R9 received the correct wound dressing to R9's pressure injury areas. The facility's policy Guidelines for skin/wound management, updated 11/16, documents: Notify MD (Medical Doctor) of any changes. The physician will be notified of significant changes in the resident's condition in relation to the development of a pressure injury, or change in the progression of healing of an existing pressure injury. Discus consequences, risks, benefits, etc. and document the discussion. Create a turning and positioning schedule based on the resident's individual risk factors, support surface in use .; Position the resident to minimize pressure over boney prominences and shearing forces over the heels .; Use appropriate off loading or pressure - redistribution devices. Ensure heels are free from the bed. Use a heel suspension device as it offers prevention of foot drop and protects the Achilles.; It is also helpful to include on the care plan the resident's degree of cooperation .; Educate resident and family about risks of PI and document this education as applicable; Staff will complete charting also using the Pressure Ulcer Scale for Healing (PUSH) tool that will monitor the changing status of the pressure injury as it progresses through the healing process. Example 1 R30 was admitted to the facility on [DATE]. R30 was admitted with the following Diagnoses: [REDACTED]. R30 is [AGE] years old. R30's admission Minimum Data Set (MDS), dated [DATE], documents: Brief Interview for Mental Status (BIMS) as 11-mildly cognitively impaired; Hard of Hearing; Required extensive assistance with bed mobility; At no risk for PIs. R30's care plan for skin, dated 11/13/18, included: I have [MEDICAL CONDITION]; Reduce pressure between myself and the bed; Elevate my heels when lying in bed; Help me reposition every 1-2 hours when I'm in bed. Review of R30's [DIAGNOSES REDACTED]. The facility provides a separate care card for the nurse aides. The nurse aides use the information on the care card to provide the customized care the individual resident requires. R30's care card, undated, includes: Limited assistance for bed mobility; Incontinent of bladder. (It is important to note R30's care card used by the nurse aides does not include repositioning every 1-2 hours while in bed or to float heels.) R30's Braden Scale (a scale used to predict risk for PIs), dated 11/3/18, scores 16, which places R30 at risk for PI. At risk interventions included a heels up cushion to protect heels and turning schedule. Surveyor requested manufacturer's information on the type of mattress R30 has. Documentation provided by the facility indicated R30's mattress was a Panacea that had a heel slope that improves pressure redistribution. The mattress information contained no information about if it was indicated for use for a resident with an unstageable PI. On 12/11/18 at 11:03 AM, Surveyor observed R30 lying in bed on back. No heels up cushion was in place and heels lay on the bed, touching the mattress. On 12/12/18 at 7:12 AM, Surveyor observed R30 lying in bed on back. No heels up cushion was in place and heels lay on the bed, touching the mattress. Surveyor examined R30's room and a heels up cushion was not found. Review of R30's Physician Orders, Telephone Physician order [REDACTED].>DON B (Director of Nursing) is the wound certified nurse. DON B's wound care documentation includes: Review of the PUSH tool dated: 11/30/18 right lateral heel -no measures or staging; 12/3/18 right lateral heel-Red and Black ½ and ½ -2 CM (centimeter) by 1.6 CM; 12/9/18 right lateral heel-1.5 CM by 1.5 CM-dark brown/black-firm. The PUSH tool contained handwritten wound measurements with no PUSH scoring completed on the tool. Review of wound documentation: 12/3/18- Right lateral heel this week is more defined and easier to see-this week is half black and half darker red coloring, firm and is 2.0 CM by 1.6 C. Wearing thick gripper socks. Resident has heels up but pushes out of the way. Last week 11/29/18 the area was found and had a softer border of 3CM by 3C. This week the area has darkened. Left OTA (open to air) and use of the heels up or heel suspension boots as he will allow. This heel is currently unstageable PI; 12/9/18-Right lateral heel this week has gotten smaller, firmer and no surrounding redness. This week is dark brown/black of 1.5CM by 1.5CM. Has been having heels up pillow under blankets, will push away other products. (It is important to note when Surveyor examined R30's room on 12/11, 12/12, 12/17, and 12/18/18 no heels up cushion or heel pressure relieving boots were in room.) On 12/12/18 at 3:01 PM, Surveyor spoke with CNA D (Certified Nursing Assistant). Surveyor asked CNA D what the procedure is for putting R30 to bed. CNA D lays R30 down after toileting-smooth bed linens to make sure no wrinkles in sheets, asks R30 how many blankets R30 wants. Surveyor asked CNA D if the care card for how to take care of the resident is followed. CNA D said yes, that is our instructions for resident care. On 12/17/18 at 10:47 AM, Surveyor spoke with CNA E. CNA E said we use the care cards to see how to care for the residents. On 12/17/18 at 10:55 AM, Surveyor spoke with DON B. DON B said R30 doesn't have a heels up cushion in R30's room because R30 keeps pushing it out. I don't think we tried the boots. Surveyor asked DON B if R30's mattress had been assessed for indication of PI use for an unstageable PI. DON B said the mattress had the heel slope on it. Surveyor asked DON B if any education was provided to R30 or the Activated Power of Attorney on risks and benefits of repositioning, using the heels up cushion or pressure relief boots. DON B said no education has been provided to R30 or the Power of Attorney on risks and benefits. Example 2 R9 was admitted to the facility on with Diagnoses: [REDACTED]. R9 has a indwelling catheter in place for [MEDICAL CONDITION] and [MEDICAL CONDITION]. R9's Annual MDS (Minimum Data Set) Assessment on 10/6/18, Section M notes that R9 is at risk for pressure injuries. R9's Braden Score Assessment (indicating risk for pressure injury development) on 7/7/18 was 15 indicating high risk, on 9/30/18 was 16 indicating medium risk. R9's CNA (Certified Nursing Assistant) care plan dated 12/11/18, includes in part: Bed Mobility: Total assist 2-3 .Transfers: Hoyer 2 assist with split leg sling . Skin-Aqual gel cushion in g/c (gerichair). Encourage to rest in bed after meals . R9's Comprehensive Care Plan dated 12/10/18, includes in part: I have the potential to have a skin injury because I have diabetes . can't move well on my own, am incontinent of bowel, have high potential to shear with movement due to needing full assist, has recurrent issues due to moisture . Goal: keep (R9's) skin healthy and intact . Approaches: . reduce pressure and friction between myself and my bed or chair . check my skin weekly . apply treatments as ordered/needed, Help keep me clean and dry .use pillows for supporting me, help me get up by using a mechanical lift . (It is important to note that R9's Comprehensive Care Plan does not specifically address R9's current open areas to his buttocks) R9's Physician order [REDACTED]. 11/30/18 Skin Treatment: Apply [MEDICATION NAME] twice a day AM PM to buttock areas that are crusty hold Barrier cream. 12/10/18: Skin Treatment: Cover buttocks (after cream used) with foam dressing without border to cover open areas so they don't stick to brief. Replace when soiled as needed. (It is important to note that R9's Skin Treatment order is not specific, it does not indicate: what specific wounds (number and location) are being treated; what type of foam dressing to use; the correct size of the dressing; how to clean R9's wound before applying the dressing or how often to apply or check the dressing to ensure it is not soiled.) R9's most recent Skin Assessment notes includes in part: 12/3/18- Coccyx this week continues to be pink, small amount of bleeding . thick spit down when separated and cleansed . 3.5 x 0.6 CM (centimeters), not tender. Last week . 2.1 CM x 1 CM pink wound . Staff to use [MEDICATION NAME] cream to buttocks . and hold other creams . -Left buttock has patch of 6 x 5 CM and has abraised surface . -Right buttock . purple/pink patch 6 x 3 CM . within this has an opening that has thick pink ridge going down the medial aspect, has white skin that will slough off near this . 12/11/18-Coccyx is smaller . 2.5 x .5 CM . -Left buttock . opening of pink wound of upper lateral of 1.3 x. 8 CM and .red open wound of 3.5 x 2.0 CM -Right buttock .one area of 2 x 2.5 CM red wound with darkness on the medial border . Have suggested to staff to use the foam dressings without border which will adhere the cream on but not stick as snuggly to his skin. (It is important to note that R9's skin assessments do not clearly identify if areas observed area open, or what type of wounds R9 has.) The facility provided copies of PUSH (Pressure Ulcer Scale for Healing) tools for R9's open areas on his buttocks from 10/1/18-12/17/18 which had hand written notes of measurements of R9's wounds, at the top of the tool. The PUSH tools were not completed and did not include PUSH scores, Length x Width of wounds, exudates (drainage) or tissue type, which would provide an indication of the improvement or deterioration in pressure injury healing. On 12/12/18 at 10:01 AM Surveyor observed open areas on R9's buttocks with LPN C (Licensed Practical Nurse). Surveyor observed a 4 inch X 4 inch foam dressing rested against R9's buttocks, not covering 3 of 5 open areas observed. Surveyor observed open slit on coccyx, 2 open areas left buttock, 2 open areas on right buttock. Open areas were superficial, red and scant amount of blood was noted on R9's brief from wounds not covered by the foam dressing. Surveyor interviewed LPN C about R9's treatment, LPN C stated that she had completed the treatment early in the morning and that R9's skin looked worse now. LPN C stated that she would have DON B (Director of Nursing) look at R9's wounds, as she was the wound nurse. On 12/12/18 at 2:50 PM Surveyor and DON B observed R9's open wounds on his buttocks, DON B stated that the wrong size dressing was placed and that some of the areas looked worse. DON B stated that a larger foam dressing should have been used and was not. Surveyor interviewed DON B who stated that she identified R9's wounds as moisture associated open areas, in October. R9 had been treated for [REDACTED]. DON stated that in the past the use of Lortrisone would help to heal this breakdown. Surveyor asked if pressure, friction and shear would contribute to R9's open areas, DON B stated that yes, pressure was a component of these open areas and had not identified the open areas as pressure injuries but would now. On 12/17/18 at 10:16 AM, Surveyor observed dressing to R9's buttocks noting that larger foam dressing was placed and cream was applied covering all open areas. Surveyor interviewed LPN C, who stated that she had not been using the right dressing for R9's treatment. 12/17/18 at 1:43 PM, Surveyor interviewed DON B asking if DON B had updated the doctor about R9's skin changes, DON B stated that some of R9's wounds looked a little better, DON B stated that she should have updated the doctor last week but would be notifying him today.

Based on observation, interview and record review the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 2 of 5 residents (Resident 1 and 12). Resident 1 fell from her Broda chair. There was noted swelling in her knee and an increase in pain. There was no assessment for this pain. It was later discovered Resident 1 had 3 fractures in her bilateral lower extremities. Hospice care was not coordinated between the family and the facility and Hospice to provide Resident 1 with appropriate pain relief and assessments of her extremities after a significant fall from her Broda chair. Resident 12 was admitted to the facility after a surgical procedure and had a [DIAGNOSES REDACTED]. This is evidenced by the following: Example 1 Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 has been on hospice since 4/28/15. Resident 1's most recent Minimum Data Set assessment, reference date 5/2/15, indicates the following: Long term and short term memory impairment, sometimes makes self-understood, sometimes understands others, has scheduled pain medications and no 'as needed' pain medications or non-pharmacological interventions for pain were used during the reference period. The MDS also indicates that Resident 1 transfers with a mechanical lift for transfers and totally dependent with 2 staff assist and extensive assistance of 2 personas for bed mobility. Resident 1's physician orders include: -[MEDICATION NAME] 10/325 mg four times a day for pain. ([MEDICATION NAME] is a medication that is a combination of [MEDICATION NAME] and [MEDICATION NAME].) -[MEDICATION NAME] 325/10 mg every four hours as needed (PRN) for pain. On 7/6/15, Resident 1 sustained a fall. The fall report, completed by Licensed Practical Nurse (LPN) I, indicates Resident 1 was found lying face down on the floor with her right arm underneath her body and her knees touching the floor. Prior to the fall Resident 1 was sitting up in her Broda chair in her room. The fall occurred at 4:45 PM. Resident 1 was noted with the following injuries: abrasion middle of forehead, 1.5 cm laceration on bridge of nose and laceration inside upper lip, right knee swollen with a dimple like area. Hospice and family were notified. Ice applied to forehead and nose. Complains of right knee pain only when moved. Resident 1's progress notes include: -7/6/15 at 5:38 PM, Writer walking past room and heard Resident 1 calling help which she normally does at times. Resident 1 found lying face first on floor. Right knee appears swollen with dimple like dent above knee, which was not there before. Resident 1 continues to call out as usual but denies any pain. Hospice nurse on call will be coming to evaluate Resident 1. -7/6/15 at 6:29 PM, call placed to hospice and answering service stated that they would give the on call another call and facility still waiting for Resident 1 to be assessed by hospice. -7/6/15 at 7:00 PM, Continues to call out frequently. Hospice nurse here to assess Resident 1. States to just observe and if pain increases in knee, will get order for X-ray. Hospice note 7/6/15, Resident 1 had unwitnessed fall. Laceration noted to inside of upper lip and bridge of nose. Bruising and swelling of nose also noted. Right knee is beginning to bruise and is mildly swollen. Abrasion noted to forehead. Bruise to right hand between thumb and forefinger. (Please note that there is no documentation of any range of motion of her knees even though she has swelling and bruising starting.) Note: There is no indication of comprehensive assessment of Resident 1 following the fall including checking for range of motion in extremities or a pain assessment. There is also no assessment with continued significant pain in her leg. On 7/15/15, at 3:00 PM, Surveyor interviewed LPN I. LPN I confirmed she was working on 7/6/15 and was the one who found Resident 1 on the floor. LPN I stated she called hospice around 5:00 PM that night and Hospice Nurse J came around 6:30 PM to assess Resident 1. LPN I stated she did not speak with Hospice Nurse J until about 7:30 PM via phone to report what she thought (please note the Hospice Nurse did not talk to LPN I when she was in the building after seeing Resident 1). LPN I asked Hospice Nurse J about an X-ray for Resident 1's knee and Hospice Nurse J stated she did not feel it was necessary tonight and just to watch her and she will come again in the morning. Hospice Nurse J reported she felt Resident 1's nose might be broken but LPN I stated LPN I was more worried about her knee as it looked swollen, had a dimple and Resident 1 complained of pain with movement. Hospice Nurse J told LPN I that Resident 1's knee popped when she moved it but just watch it. LPN I confirmed no new treatment orders were obtained for pain that night. LPN I did place ice to the head and nose immediately after the fall. Resident 1's progress notes: -7/6/15 at 9:05 PM, Does complain of pain in right knee when turned. Pain medication given. -7/6/15 at 9:10 PM, Daughter/Guardian updated on condition. Would like X-ray on right knee. Will notify hospice in morning and ask for order. -7/7/15 at 1:15 AM, PRN [MEDICATION NAME] 325 mg-10 mg given for comfort. -7/7/15 at 5:47 AM, Visible discomfort right knee when checked. Knee is slightly red and somewhat swollen. Cool cloth placed on forehead. Temperature at 5:10 AM 100.1 degrees Fahrenheit. (Note there is no indication hospice or the physician was notified of the increase temperature or redness to knee). -7/7/15 at 8:26 AM, PRN [MEDICATION NAME] 0.25 mg given for Resident 1 appeared to be in pain/anxious related to fall on 7/6/15. -7/7/15 at 9:36 AM, Called hospice service regarding concerns about Resident 1's pain, requesting something other than [MEDICATION NAME] for as needed pain because of the amount of [MEDICATION NAME] Resident 1 already receives with her scheduled doses of [MEDICATION NAME]. Informed hospice would be visiting Resident 1 today and concerns would be addressed then. Resident 1's hospice note 7/7/15: Called Resident 1's guardian and left message regarding status and expressed concern. Reported that she has minor cut on nose that is healing and that the abrasion to forehead is resolving. Also commented that bruise to right hand looks ok. Said that we are so glad that there were no more serious injuries. Discussed Resident 1's current status with DON B. Discussed possibility of obtaining another pain medication for Resident 1 as concerns regarding routine [MEDICATION NAME] four times a day thus unable to use PRN [MEDICATION NAME] during the daytime and have only been able to give it at bedtime for PRN dose. Will contact physician with request. Discussed with Nurse Practitioner and [MEDICATION NAME] PRN can be given in addition to the scheduled [MEDICATION NAME]. Resident 1's hospice note 7/7/15, Focus today is recent fall. Facial abrasion mid forehead improving. Cut to nose well approximated, dry scab. Bruising right posterior hand is less. Small purple bruises noted left forearm. Note: There is no mention of the right knee pain or any assessment of lower extremities even though there continued to be complaints of pain and swelling. On 7/7/15 at 11:00 AM, the facility sent a fax to Resident 1's physician for review informing him that Resident 1 fell on [DATE] from the chair. The fax states hospice aware and made visit last night. Neurological checks ok. Bruises to hand, small cut to bridge of nose, abrasion to forehead. Daughter requested to have physician notified. Hospice orders are to treat pain and continue to monitor. Note: There is no information regarding Resident 1's swollen knee or the level of pain she is having. On 7/7/15 at 1:25 PM, Surveyor observed Certified Nursing Assistant (CNA) C and D assist Resident 1 with cares. Resident 1 was transferred from the Broda chair to bed with a full body mechanical lift. Resident 1 began calling out during the cares. CNA C and CNA D rolled Resident 1 side to side to remove the lift sling and her brief. When Resident 1 was rolled onto her left side her right leg slid over her left leg and fell off the bed. Resident 1 was calling out throughout the entire observation. Surveyor noted Resident 1 was in pain at this time. Following the observation Surveyor interviewed CNA C who stated Resident 1 had fallen yesterday and had pain in her right knee. CNA C stated she tries to be careful when moving her leg. CNA C then went to the nurse and reported the concern of pain with cares. Resident 1's progress notes: -7/7/15 at 1:57 PM, PRN [MEDICATION NAME] 325 mg-10 mg given for Resident was yelling in pain when CNA's did cares; pain related to fall. -7/8/15 at 2:49 AM, Resident 1 has been resting most of shift, stated ouch when writer touched bilateral feet for warmth. Did not reply when asked if she was in pain. -7/8/15 at 6:40 AM, PRN [MEDICATION NAME] 325 mg-10 mg given for Resident 1 showed nonverbal signs and symptoms of pain. On 7/8/15, at 9:06 AM, Surveyor observed CNA C and CNA E transfer Resident 1 from bed into the Broda chair. Again staff used the full body mechanical lift. Resident 1 was calling out during the transfer. Surveyor observed Resident 1 to be in pain during the transfer. Following the transfer CNA E reported to the nurse that Resident 1 was having pain. Resident 1 then received her scheduled dose of [MEDICATION NAME]. On 7/8/15, at 10:09 AM Surveyor interviewed Director of Nursing (DON) B. DON B stated it is the facility process if family request laboratory testing or X-rays done the facility will contact the physician for a response and it would be documented in the nursing progress notes. If the resident is on hospice they would contact the physician and hospice to make the decision. DON B stated that hospice was asked about an X-ray but did not feel it was necessary. DON B stated this should be documented in the progress notes. DON B stated she would contact the physician and follow up regarding Resident 1's pain and the request for an X-ray. Following the interview DON B sent a fax to Resident 1's physician indicating Resident 1 has discomfort to right knee with turning and cares. Is on hospice and nurse felt no X-ray was needed. Due to continued pain, could we do an X-ray of right knee? Daughter/guardian also in favor of this. Resident 1's progress notes: -7/8/15 at 10:56 AM, hospice nurse spoke with writer yesterday and stated she did not think that Resident 1 needed an X-ray and that she was ok. Physician sent fax to update that staff has noted pain with movement in the area of this right knee when turned and with cares. Updated that prior hospice did not think that X-ray was needed. Due to continued pain, writer asked physician to consider an X-ray and daughter had been in favor of this. (Documented by DON B after interview with Surveyor ) On 7/8/15 at 12:15 PM, Surveyor interviewed Family Member F (Resident 1's guardian). Family Member F stated she was called on the night Resident 1 fell . Family Member F also stated she requested an X-ray of Resident 1's knee due to the pain and swelling but no one followed up with her regarding this request. Family Member F also stated she was told the facility was going to follow up with the physician regarding the pain in her knee. -7/8/15 at 2:17 PM, PRN [MEDICATION NAME] 325 mg-10 mg given for Resident 1 showing nonverbal signs/symptoms of pain; screaming out during cares. -7/8/15 at 2:17 PM, Writer called Resident 1's hospice service and spoke with office nurse to seek clarification order for [MEDICATION NAME]. Nurse told writer when giving PRN [MEDICATION NAME] to go by the PRN time and to ignore her scheduled dose. (Note: there is no physician order for [REDACTED].>On 7/8/15 at 4:00 PM, DON B informed Surveyor that she had not heard back from Resident 1's physician and she will send the fax again. Resident 1's progress notes: -7/8/15 at 9:03 PM for 7:00 PM, Resident 1 does cry out when right leg moved. Hands very puffy. Middle of right knee appears red. Hospice nurse notified of temperature and blood sugars. States will be coming in the morning. -7/8/15 at 9:06 PM for 7:30 PM, Resident 1's daughter (not guardian) her to see Resident 1 asking questions and moving her leg around causing Resident 1 to cry out. Daughter called guardian and discussing that Resident 1 should be in the hospital. Hospice was called and stated she will call Mobile X-ray to see if they can come tonight, otherwise guardian wants to take off hospice and sent to hospital. -7/8/15 at 9:35 PM, Hospice returned call and unable to get a hold of Mobile X-ray and guardian wants Resident 1 taken off hospice and sent to hospital. Physician called and gave order to send to emergency room for evaluation. Note: On 7/7/15 and 7/8/15 Resident 1 was also having trouble with her blood sugar levels. The physician was contacted multiple times for new insulin orders but Resident 1's pain was not discussed. Resident 1's plan of care or medications was never revised to assess the new increase in pain following the fall. Resident 1's hospice note 7/9/15 at 1:37 AM (for 7/8/15 at 8:00 PM). Resident 1's guardian called as was told by another family member that Resident 1 was having pain in her knee after her fall on Monday and wanted her to be sent to the hospital for evaluation. Writer stated that she would be responsible for costs incurred as hospice does not cover this. Writer also informed guardian that she had the right to revoke hospice services if she felt that Resident 1 needed to be sent out to the hospital for treatment. Guardian stated that is what she wanted to do. Revocation form emailed and signed. Facility notified of revocation of hospice. Resident 1 was sent to the emergency roiagnom on [DATE] and admitted to the Intensive Care Unit. Resident 1's Hospital History and Physical report, dated 7/9/15 indicates Resident 1 had a left knee impacted comminuted distal femoral fracture. Resident 1's right knee has distal femoral and proximal tibia fractures. Additional [DIAGNOSES REDACTED]. Resident 1 was discharged back to the facility on comfort cares. Basically will get [MEDICATION NAME]. She has [MEDICATION NAME] but also has [MEDICATION NAME] ordered now. On 7/9/15, at approximately 10:30 AM, Surveyor interviewed DON B. DON B stated last evening a family member was visiting and manipulated Resident 1's leg. Resident 1 ' s leg was red and warm and requested the facility to send Resident 1 out. On 7/9/15, at 3:30 PM, Surveyor interviewed Hospice Nurse G and Hospice Supervisor H. Hospice Nurse G stated Resident 1 was assessed by Hospice Nurse J after the fall and there were lacerations on her face but no significant injuries were noted per the notes. Hospice Supervisor H stated he spoke with hospice staff and there was not any talk of wanting an X-ray initially or the next day. On 7/9/15, at 4:23 PM, Surveyor interviewed Family Member F again. Family Member F stated Resident 1 is no longer on hospice. Family Member F stated Resident 1's other daughter was visiting her last night (7/8/15) and called Family Member F stating Resident 1 was in excruciating pain and her blood sugar was above 500. This daughter also stated that Resident 1's legs felt hot. Family Member F then called Hospice Nurse J and told her what had been transpiring and that the injury is from the fall. Family Member F stated she informed Hospice Nurse J at that time that she wanted Resident 1 sent to the hospital for an X-ray. Hospice Nurse J stated that was not possible because it was not covered. Hospice Nurse J told Family Member F she needed to make some calls and get back to her. Hospice Nurse J then called back and stated they cannot send Resident 1 to the hospital while on hospice but Family Member F can revoke hospice then have her sent to the hospital. Family Member F stated she wanted to revoke hospice and Hospice Nurse J stated we can do that in the morning, Family Member F stated no I want it done now. Family Member F stated Resident 1 was removed from hospice and sent to the emergency room and has fractures in both legs and has splints on both legs now. Family Member F stated the doctor told her they were not positive of the source of [MEDICAL CONDITION] but felt it was from the injuries to her legs. Family Member F stated they could not do surgery but they are now controlling her pain with different medications. The facility did not ensure that Hospice services were coordinated so that Resident 1 received the highest practicable services that could be obtained as it relates to pain and assessments of her continued pain symptoms to provide a reasonable treatment plan to lessen her pain. Resident 1 had both legs broken from a fall on 7/6/15 and was not diagnosed until 7/8/15 after the family insisted she be transferred to the hospital due to her continued complaints of significant pain. Example 2 Resident 12 was admitted to the facility for rehabilitation after a surgery on 4/14/15 with [DIAGNOSES REDACTED]. According to her Brief Interview for Mental Status score of 15 on her Minimum Data Set completed 4/21/15 she was cognitively intact. Resident 12's initial care plan dated 4/14/15 Problem: Potential/alteration in Comfort/Pain states, Resident (12) will rate pain level less than 3 on a scale of 0 - 10. It includes the interventions: Use pain scale 0-10 to express pain intensity; Use faces for pain scale if unable to rate the pain. Offer pain medication; Assess pain: characteristics, location, intensity, duration, aggravating and alleviating circumstances; Offer heat; Offer cold; Offer massage; Encourage relaxation; Update MD (physician) PRN (as needed) if pain not controlled or if experiencing side effects of pain meds or if pain consistently scored at 5 or greater; All staff may update Nurse if resident is noted to have pain. Resident 12 had the following physician's orders for pain medication signed 4/26/15: [MEDICATION NAME] 325 mg Tab, 650 mg oral every 4 hours as needed [MEDICATION NAME] 650 mg Suppository, 1 rectal every 4 hours as needed [MEDICATION NAME] 15 mg tab, give 1 tab oral every 4 hours as needed [MEDICATION NAME] 325 mg - 5 mg Tab ([MEDICATION NAME]/[MEDICATION NAME]) 1 tab every 4 - 6 hours oral as needed [MEDICATION NAME] 325 mg - 5 mg Tab ([MEDICATION NAME]/[MEDICATION NAME]) 2 tabs every 4 - 6 hours oral as needed [MEDICATION NAME] 30 mg TER/ 12 hour tablet, 1 tab three times daily [MEDICATION NAME] 300 mg cap ([MEDICATION NAME]) 2 tabs every AM, 3 tabs at noon, 4 tabs at hour of sleep. Resident 12's initial Pain assessment on 4/14/15 at 2:46 PM states she rated her pain at an 8 with moderate intensity and a goal of 3. Resident 12 indicated she has used positioning to help relieve pain symptoms in the past. Resident 12's electronic Medication Administration Record [REDACTED] 4/18/15 at 9:58 AM Resident 12 complained of pain in her left leg. (There is no documentation of her rating her pain.) She received [MEDICATION NAME] 325 mg - 5 mg 2 tabs. At 12:01 her documentation states Not effective. There is no documentation that anything else was done to attempt to relive her pain. 4/19/15 at 12:16 AM Resident 12 complained if [MEDICAL CONDITION] pain in her left foot rated 8 and left abdominal (incision) pain rated 6. She received [MEDICATION NAME] 325 mg - 5 mg 2 tabs. At 1:52 AM Resident 12 reported pain in her left foot was not much better rated 7/10 and her pain in her abdomen rated 4/10. There is no follow up documentation to know if the medication was effective or not. 4/22/15 at 10:17 AM Resident complained of pain to her left leg/ankle at 9-10/10. She received [MEDICATION NAME] 325 mg - 5 mg 2 tabs. There is no follow up documentation to know if the medication was effective or not. 4/22/15 at 4:22 PM Resident 12 rated pain 6/10 to her left foot and received [MEDICATION NAME] 15 mg. There is no follow up documentation to know if the medication was effective or not. 4/23/15 at 1:02 AM Resident 12 complained of pain in her left foot rated 8/10. She received [MEDICATION NAME] 325 mg - 5 mg 2 tabs. There is no follow up documentation to know if the medication was effective or not. On 7/9/15 at 1:03 PM Surveyor interviewed Director of Nursing (DON) B who stated that if a pain medication is not effective she would expect nursing to offer interventions such as positioning or topical medication. DON B agreed that nursing staff should have the resident rate the pain prior to and after receiving pain medication to access for effectiveness.

Based on interview and record review, the facility did not ensure that a resident maintained acceptable parameters of nutritional status to maintain body weight unless the resident's clinical condition demonstrated that it was not possible for 1 out of 6 residents (Resident 7). Resident 7 experienced a weight loss of 11 pounds in a month which is a significant weight loss of 7.5%. The facility did not put in place interventions to prevent the weight loss. The facility did not consult with the physician regarding Resident 7's weight loss. This is evidenced by: The facility's policy for Weighing Residents, updated on 5/08 indicates the purpose is to use weights for assessment of resident's changes in health and fluid/food impact. The procedure is as follows: 5. Report changes in weight to the unit nurse and/or restorative coordinator and dietary. Any weight change of +/- 5# should be reweighed before weight taken as fact. 6. Consult with dietary manager if a resident has loss or gain in weight. 7. Notify MD (Medical Doctor) of any significant weight loss or gain. Staff to look at possible causes of weight changes-change in health, change in diuretic medication, [MEDICAL CONDITION], etc. 8. Supplement weight loss according to supplementation protocol. 10. A resident may show small weight changes over a week but it could be significant if the weight is compared from one month to the other. This is then viewed by the physician on rounds to see what is their usual weight. Example 1 Resident 7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 7's weight on 12/10/11 was 144. Resident 7's meal intake on 12/9/11 was 58.3%, on 12/10-66.7%, 12/11-91.7%, 12/12-91.7%, 12/13 83.3%. Resident 7 weighed 139.5 pounds on 12/13/11. She lost 4.5 pounds in 5 days. Her meal intake on 12/14 was 75% and 12/15-66.7%. This is an average of 76.2% of meal intake over her first week at the facility and she has lost about 4.3% of her weight in her first week. She was not reweighed at any time. Resident 7's IPN (Interdisciplinary Progress Notes) indicated her initial nutritional assessment was completed on 12/15/11. The assessment note indicated her diet consists of no concentrated sweets and no added salt. Her appetite and intake have been good with her eating 75-100% of meals. Resident 7 thinks that her usual weight is between 140 - 150 pounds. She is at lower end of her usual weight. Resident 7 is receiving adequate calories to meet estimated needs at this time. Goal is for her weight to maintain with glucose in acceptable range. (Resident 7 was not on a weight reduction plan. Since her admission on 12/9/11, she has lost 4.5 pounds.) Resident 7's Nutritional Care Plan, dated 12/21/11 indicates she is on a therapeutic diet. She is to maintain her weight, continue to eat 75% of most meals. Resident 7 and her family have requested small portions for all meals. Nursing and dietary to continue to assess for changes and to notify MD of any changes. Resident 7's average meal intake on 12/16-83.3%, 12/17-66.7%, 12/18-66.7%, 12/19-75%, 12/20-58.3%, 12/21-58.3%, 12/22-58.3%, 12/23-50%, 12/24-33.3%, 12/25-41.7%, 12/26-50%. For the last 11 days she had an average meal intake of 58.32%. On 12/27 Resident 7 weighed 135 pounds. She was down 9 pounds, a 6.2% weight loss, in 19 days after she was admitted to the facility. The MD was not notified of her significant weight loss and the facility did not implement interventions to maintain her weight. Additionally, there was no evidence that dietary was notified of the significant weight loss as the policy indicates. The dietary note on 12/22/11 indicated Resident 7's weight is stable. The Care Pan Summaries indicated the family and resident feels she gets a lot to eat and would like smaller portions for all meals but it is not noted that the facility informed the family and resident that she was losing weight. Additionally, the MD was not notified that the resident and family wanted a change in her diet when she was losing weight. Resident 7's average meal intake on 12/27-66.7%, 12/28-83.3%, 12/29-75%, 12/30-58.3%, 12/31-58.3%, 1/1/12-66.7%, 1/2-75%, 1/3-66.7%, 1/4-50%, 1/5-66.7%, 1/6-75%, 1/7-25%, 1/8-83.3%, 1/9-75%, 1/10-91.7%. Her average meal intake for these days was 67.8%. On 1/10/12 Resident weighed 133 pounds, a loss of 11 pounds. This is a 7.5% weight loss in 1 month. The MD, family, and RD were not notified of the significant weight loss. Additionally, interventions to maintain her weight were not implemented as the policy indicates. A dietary note on 1/17/12 a late entry for 1/16/12 indicates Resident 7 is having a weight loss of 5% since admission on 12/9/11. The note indicated she had [MEDICAL CONDITION] and has been more active. The facility did not implement additional interventions to maintain her weight. Additionally, they did not notify the MD of the weight loss. (There is no evidence from nursing notes that the resident ever had any [MEDICAL CONDITION].) Resident 7's diet continued to be without any new interventions to stop or maintain weight loss. On 1/11 her intake was 75%, 1/12-83.3%, 1/13-91.7%, 1/14-91.7%, 1/15-100%, 1/16-66.7%, 1/17-83.3%, 1/18-58.3%, 1/19-83.3%, 1/20-75%, 1/21-66.7%, 1/22-75%, 1/23-91.7%, 1/24-83.3%. The resident's average intake was 80% but Resident 7's portions were smaller. On 1/24/12 Resident 7's weight was 132.5 indicating an additional 1.5 pound weight loss. Resident 7's record did not indicate the MD, RD, and family were notified of her weight loss. Additionally, new interventions were not started to maintain her weight. No other weights were noted in her record. A dietary note on 1/23/12 indicated Resident 7 has had a 5% weight loss since admission on 12/9/12. Resident has less [MEDICAL CONDITION] and is more active and walks more. Once again, the facility did not notify the MD of her weight loss. Additionally, they did not change her diet or add additional supplements to maintain her weight. (There is no evidence that the resident ever had [MEDICAL CONDITION].) A physician's dictated note from 1/29/12 did not indicate that he was made aware of Resident 7's weight loss. On 1/31/12, at 1:30 pm a dietary note indicated Resident 7 as having a 5% weight loss in a month. Resident has less [MEDICAL CONDITION] since admission. She is more active and walking. Will refer to nursing and RD (Registered Dietitian). (There is no evidence that the resident ever had [MEDICAL CONDITION].) On 1/31/12, at 9:05 am Surveyor asked DM (Dietary Manager) D what her protocol was for weight loss. DM D said she notifies nursing, they talk about a supplement, lots of times the MD is notified and the RD is notified. DM D said she has not notified nursing and will notify the RD of the weight loss this week. DM D said Resident 7 has lost weight because she has been more active with movement and is in PT (Physical Therapy).

Based on observation, interview, and record review, the facility did not ensure that based on the comprehensive assessment of a resident, a resident who enters the facility without pressure ulcers does not develop pressures ulcers unless the individual's clinical condition demonstrates that they were unavoidable, and that a resident having pressure ulcers receives the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 5 of 8 residents reviewed for pressure sores (Residents 6, 4, 13, 2 and 8). Resident 6 was noted to have a necrotic area to the left outer ankle. The facility did not consult with Resident 6's physician until 5 days after the area on the ankle was discovered. Resident 6's heel was not floated on the heels up device when in bed, as indicated by her plan of care. Resident 6's left ankle wound increased in size and the facility did not consult with Resident 6's physician to discuss alternative treatments. Resident 13 was determined by the facility to be at moderate risk for pressure ulcers and was admitted with a pressure ulcer on the left heel; the area was not measured or monitored on a weekly basis. Resident 13 was observed with heels resting directly onto a foot rest of the reclining chair. In addition, Resident 13's care plan was not updated or new interventions added to prevent reoccurrence of this open area. Resident 4 had a open area that was not assessed as to the type of wound, origin of the wound, was not measured, and was not monitored on a weekly basis. In addition, Resident 4's care plan was not updated or new interventions added to prevent the re-occurrence of this open area to assess if the wound was a pressure area on her left inner buttock. Resident 2 developed a pressure ulcer after admission to the facility. The resident was immobile due to a [MEDICAL CONDITION]. Resident 8 had re-admitted to the facility on [DATE] with orders for a Thin site dressing to the buttocks, to be changed every three days, and as needed. The treatment was stopped on 9/24/10 with no physician notification, and no changes in physician orders. Resident 8's pressure ulcers were not measured weekly by an RN (Registered Nurse) per the facility policy. This is evidence by the following: The facility policy titled "Guidelines for skin/wound management and skin care guidelines," dated 2/10 states the following; Purpose to provide ongoing prevention, assessment, evaluation and treatment of [REDACTED]. condition demonstrates that they were unavoidable. a resident having pressure ulcers will receive necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing... Policy also indicates general skin guidelines... 3. Residents should have a head to toe examine on admit, preferably within the first 8 hours of admission and no later than 24 hours. Within the first 24 hours, the resident should have a comprehensive risk evaluation and should have the following assessed; heels for elevation, dietary and therapy referrals, supportive surfaces in bed and in the wheel chair, turning and repositioning, incontinence care and keeping the skin clean and dry..... 6. A skin assessment for open areas will also be completed on each resident upon admission, re-admission, change of condition and quarterly with the MDS (Minimum data set)... 8. Licensed Nurses will document wound description with the dressing changes and to chart any changes between the weekly skin wounds rounds. It is recommended to do daily charting on the condition of the wound... 12. The nurse is to notify the MD (medical doctor) of any changes. The physician will be notified of any significant changes in the resident condition or failure of the treatment plan to prevent or heal a pressure ulcer... 27. The resident will be monitored for condition changes that might increase the risk of skin breakdown and intervene with preventative measures - during fever, mobility changes where a resident is spending more time in bed, and with an acute illness... The facility policy titled "Skin Care Team, Assessment, Documentation, and Rounds." dated 2/10 states the following; Skin care team rounds will be conducted by an RN (Registered Nurse) / wound nurse of the Skin Care team weekly or as deemed necessary. Skin care team member will receive and/or review the charting weekly... The skin care team policy guidelines further indicate the following.... 2. The skin team weekly wound assessment of all open skin areas will include the following; assessed for size, depth, odor, wound bed, wound edges, surrounding skin tissue, drainage and tunneling... 3. The team will review skin care team forms at least weekly so that all the pressure ulcers within the facility will be placed on a list to examine. Also the nurse that is doing the skin rounds will review the nurse's notes regarding the skin from the previous week. 4. Skin care team rounds will be made at a convenient time...Skin care rounds will be done by an RN. The documentation will be done by the same RN after the rounds are completed. On 12/9/10 at 12:40 PM Surveyor received a single paper titled "Pressure ulcer report log" from Assistant Director Of Nursing (ADON) C. Surveyor spoke with ADON C regarding the area titled Measurements and a dash (-) mark was in the columns for length, width and depth. ADON C stated the dash marks indicate the measurements were not completed for that week on the pressure ulcer. ADON C also indicated that ADON C does not assess the pressure ulcer or measure the pressure ulcer weekly, ADON C indicated the report is filled out by using the weekly skin problem nursing notes that the floor nurses write. In addition, ADON C indicated the Licensed Practical Nurse's (LPN's) and RN's working the day, that the assessments and measurements are to be completed are responsible for the documentation. ADON C indicated the expectation is for the LPN's working the day of assessment and measurements are expected to complete the pressure ulcer assessment. No further information was provided to Surveyor . On 12/14/10 at 8:25 AM Surveyor spoke with Director of Nursing (DON) B regarding pressure ulcer measuring and facility current standard of practice for pressure ulcer care. DON B stated pressure ulcers are to be measured weekly by the wound team to include the ADON. DON B also stated the pressure ulcer assessment and weekly measuring are to be done by an RN according to policy. DON B continued to state when a new pressure ulcer is found the nurse is to measure the pressure ulcer and call the physician, if an LPN is the one finding the new pressure ulcer the expectation is for ADON C or another RN to complete the assessment of the new pressure ulcer. In addition, DON B stated the expectation is that all pressure ulcers are to be measured weekly and all worsening or non healing pressure ulcers are to be called to the physician as a change in condition. No further information was provided to Surveyor . On 12/14/10 at 9:35 AM Surveyor spoke with LPN F regarding pressure ulcer assessments and documentation, LPN F stated the nurse on the floor is to measure the pressure ulcer weekly and document the measurements in the nursing notes. LPN F also indicated the LPN's decide what stage, the treatment to ask for, and when a pressure ulcer is healed, without the observation of an RN. LPN F also stated she was unaware of a wound team or that an RN has been present during pressure ulcer rounds. Example 1 Resident 6 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 6's MDS (Minimum Data Set), dated 10/14/10, indicates Resident 6 has impaired short and long term memory problems and is not her own decision maker. Resident 6's MDS also indicates no pressure ulcers were present during the assessment period. The MDS indicates Resident 6 is at risk for developing pressure ulcers. Resident 6's MDS also indicates Resident 6 needs extensive assistance of 1 person for bed mobility and transfers, extensive assistance of 1 for personal hygiene and is occasionally incontinent of urine. Resident 6's care plan originally dated 7/13/10 states that Resident 6 has potential for decreased skin integrity impairment of skin integrity. The care plan also indicates Resident 6's Braden scale score indicates high risk. The interventions related to the skin problem that were on place on 7/13/10 are to assist with hygiene, reposition every 2 hours, and assist with bed mobility. In addition, Resident 6's care plan indicates Resident 6's peripheral pulses were present and strong. Resident 6's goal was no skin breakdown. Resident 6's care plan updated on 10/19/10 states that Resident 6 care plan was reviewed and the Braden scale was reviewed at the care plan conference. No changes noted. The care plan also indicated Resident 6 has no skin breakdown. No further changes were identified on Resident 6's care plan for the problem or the goal sections. Resident 6's left ankle unstageable pressure ulcer was not identified on Resident 6's current care plan. The care plan intervention updated on 11/19/10 indicates Resident 6 has [MEDICAL CONDITION] controlled by bilateral tubular compression bandages, which are placed on Resident 6 in the morning and removed at bed time. The care plan updated 11/19/10 indicated Resident 6 is to wear derma saver boots on both feet when in bed. Resident 6's Braden scale, ulcers dated 7/18/10, indicates Resident 6 is a 13 which places Resident 6 at risk for pressure ulcers. Resident 6's nurses notes dated 10/19/10 at 12:24 PM indicate the Braden scale was reviewed at the care plan conference and indicated there are no changes to the Braden scale. It should be noted a new Braden scale was not completed at this time when a new pressure ulcer was identified. A Health Drive Podiatry group consultation report dated 7/26/10 states Resident 6's dorsal pedal pulses and posterior pulses were absent in both feet. The consultation also indicates Resident 6 has 2 plus [MEDICAL CONDITION] (fluid accumulation demonstrated by applying pressure to the swollen area causing a depression in the skin), and the skin was pale in color and cool to touch. A health drive consultation dated 11/29/10 states Resident 6's condition remains unchanged. Resident 6's nursing notes, dated 10/18/10 at 5:35 AM indicated Resident 6's left ankle bone is very reddened about 2-3 cm (centimeters) in diameter and there is a soft spot in the middle of the red area. There are no changes to the care plan and the physician was not notified of the changes to the left ankle on 10/18/10 as would be required by the policy and procedure. Resident 6's nursing notes, dated 10/19/10, at 5:33 AM indicate Resident 6 does not have a pressure ulcer. However, the nursing notes dated 10/19/10 at 9:12 PM indicate Resident 6 has an open area on the left outer ankle area that measures 0.5 cm by 0.6 cm. The note indicates there is some redness noted to the area. The nursing note also indicates a fax was made out to be sent to the physician on Wednesday (10/20/10) morning and the nurse left a message with the ADON (Assistant Director of Nursing). On 10/20/10, a fax regarding Resident 6's left outer ankle indicating Resident 6 has an open area to the left ankle with some redness to the wound it self, and the open area is left open to air at this time was sent to the physician. There was a place on the form indicating "Any treatment recommended." The physician response documented on the returned fax indicates to monitor the wound area. It is important to note that no changes to the care plan for pressure relief to the area are implemented. Resident 6's nursing notes, dated 10/25/10, at 9:40 PM indicates Resident 6 has an open area on the left outer ankle that measurers 0.7 CM by 0.9 cm and is unmeasurable in depth. The open area has a layer of black hard tissue that is covering the open area. The surrounding skin tissue is bright red and warm to touch. The red area is tender to touch. The nursing notes also indicated a fax was written describing the open area and was left for the morning (10/26/10) nurse to send to the physician. The fax written to be sent on 10/26/10 indicated the open area has gotten larger since the area was first noticed on 10/19/10. Resident 6's nursing notes, dated 10/26/10, at 4:33 AM indicates Resident 6 has a reddened area covering the entire outer ankle bone. Resident 6 has a black necrotic tissue in the middle of the reddened area approximately 3 times bigger the necrotic are was on 10/19/10. On 10/26/10 at 3:23 PM the fax was returned to the facility indicating the physician's new orders. The new orders are as follows Keflex 500 mg 1 tablet for 10 days. The fax also indicated the facility was to implement soft boots and padding the wheel chair pedal. It is important to note a pressure sore treatment was not obtained for the necrotic area. Resident 6's nursing notes, dated 11/1/10, at 4:59 PM indicates Resident 6' open area to the left outer ankle continues to be black in color. Will continue to monitor. It is important to note that no wound measurements were taken on 11/1/10. Resident 6's nursing notes, dated 11/3/10, at 10:37 PM indicate Resident 6's left ankle bone open area has redness around and the black center and the area has gotten a little bigger since last seen. It is important to note that no wound measurements were taken on 11/3/10.. Resident 6's nursing notes, dated 11/6/10 indicate Resident 6's skin is intact. Resident 6's nursing notes, dated 11/12/10 indicates Resident 6 continues to have the black necrotic area to the left outer ankle that appears to be larger in size. Resident 6 has facial grimacing when left ankle area is touched and the surrounding skin is red. The nursing notes also indicate a fax was written to be sent to the physician on Monday 11/15/10. On 11/15/10, no time indicated, a fax for Resident 6 was sent to the physician indicating Resident 6's left outer ankle bone has a necrotic center that has gotten bigger and there is currently no treatment in place for this pressure ulcer. On 11/16/10 at 10:49 PM a physician order [REDACTED]. Resident 6's nursing notes, dated 11/21/10 indicate Resident 6's left outer ankle has a small amount of yellow drainage on the dressing. It is important to note that no wound measurements were taken on 11/21/10. On 12/9/10 at 9:35 AM Surveyor observed LPN G provide wound care to Resident 6's left outer ankle. LPN G cleansed the left outer ankle pressure ulcer area with normal saline. LPN G continued to provide the pressure ulcer treatment to Resident 6 by applying [MEDICATION NAME] ointment to the black necrotic center and to the surrounding red tissue. Resident 6's left ankle necrotic pressure ulcer measured approximately 0.6 by 0.6 cm diameter with 2 cm surrounding red tissue. A physician order [REDACTED]. The Treatment Administration Record (TAR) for the month of December 2010 indicates Resident 6's current treatment to the left outer ankle as [MEDICATION NAME] ointment to the left eschar area and cover with light dressing and change daily On 12/9/10 at 12:40 PM Surveyor spoke with ADON (Assistant Director of Nursing) C regarding Resident 6's wound care. ADON C stated Resident 6's current treatment order is for [MEDICATION NAME] to the left outer ankle pressure area. ADON C also indicated the nurses working the floor are to measure all pressure ulcers weekly and chart the results in the chart. ADON C provided Surveyor with a pressure ulcer report log for Resident 6. ADON C indicated the area on Resident 6's left outer ankle is a pressure ulcer and should be measured weekly. On 12/9/10 at 12:40 PM Surveyor received a single paper titled "Pressure ulcer report log" from ADON C. Surveyor spoke with ADON C regarding Resident 6's pressure ulcer report log and the column titled stage. ADON C stated the wound to the left outer ankle bone was found on Resident 6 as unstageable on 10/18/10. ADON C also stated she has not seen Resident 6's pressure area on Resident 6's left outer ankle bone. A summary of Resident 6's Pressure ulcer report log, measurement column indicates that Resident 6's left outer ankle bone was measured on 10/18/10, the day of initial observation of the unstageable wound, as approximately 2 cm (centimeters) by 3 cm, and on 10/25/10 the area measured 0.7 cm by 0.9 cm of black tissue and the surrounding "bright red" tissue was not identified in the measurements. In addition, the pressure ulcer report log for the unstageable left outer ankle bone indicates a dash (-) in the measurement column of the form for the following dates; 11/1/10, 11/12/10, 11/21/10, 11/25/10, 11/30/10, and 12/5/10. On 12/9/10 at 1:00 PM Surveyor observed Certified Nursing Assistant (CNA) E assist Resident 6 from the wheel chair to the bed. CNA E removed Resident 6's slippers and lifted Resident 6's legs on to the bed. Resident 6 has compression stockings in place on both legs. Resident 6's ankle was placed directly on the mattress and CNA E covered Resident 6 with a blanket. CNA E removed her gloves, and then CNA E washed her hands and exited the room. Surveyor observed Resident 6's heelzup (a cushion used to keep the heels off the bed) device and a derma heel protector lying on the foot of the bed on top of Resident 6's covers. CNA E did not place the heelzup device under Resident 6's legs or apply the derma heel protectors prior to leaving Resident 6's room. On 12/9/10 at 1:30 PM Surveyor again observed Resident 6 lying in the bed with the heelzup device and the derma soft heel protector lying on top of Resident 6's covers. Resident 6's ankles continued to lie directly on the mattress. On 12/9/10 at 1:50 PM Surveyor observed Resident 6 lying in the bed with the heelzup device and the derma soft heel protector lying on top of Resident 6's covers. Resident 6's ankles continued to lie directly on the mattress. On 12/13/10 at 2:40 PM Surveyor spoke with ADON C regarding the facility pressure ulcer policy and MD notification with skin change of condition. ADON C stated the expectation is the pressure ulcers are to be measured and documented weekly on the resident. ADON C also stated the expectation is weekly measurements are to be compared and if there is a change in the pressure ulcer or the treatment is not effect the physician is to be notified the day the change of condition is noticed. In addition ADON C stated the expectation is the physician is to return the fax or call the same day the fax was sent or the call was placed, and if the fax or call is not returned the nurse must call the physician prior to the close of office hours. On 12/13/10 at 2:40 PM Surveyor spoke with ADON C regarding the plan of care for Resident 6. ADON C stated Resident 6 is at risk for skin breakdown and currently Resident 6 has a pressure ulcer on left outer ankle and the heelzup device and the derma heel protector are to be in place when Resident 6 is in bed. Example 2 Resident 13 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 13's MDS dated [DATE] indicates Resident 13 has impaired short and long term memory problems and is not her own decision maker. Resident 13's MDS also indicates a stage 2 pressure ulcer was present during the assessment period. The MDS indicates Resident 13 is at risk for developing pressure ulcers. Resident 13's MDS also indicates Resident 13 needs extensive assistance of 2 persons for bed mobility and transfers, extensive assistance of 2 for personal hygiene and is frequently incontinent of urine. Resident 13's Resident Assessment Protocol (RAP) documentation dated 9/13/10 indicates Resident 13 was admitted to the facility with a dark purple pressure area to the left heel. The RAP assessment summary also indicates Resident 13 has impaired cognition, sits in his recliner most of the day for more then 8 hours a day, and that Resident 13 had a potential for shearing and Resident 13 does not adjust his own repositioning. The interventions for the pressure area identified on the RAP summary for Resident 13 are pressure relieving cushion for the chair and a pressure relieving mattress for the bed, and to prevent pressure to the feet. The RAP summary also indicates Resident 13 is a high risk for skin breakdown. Resident 13's care plan dated 9/15/10 states that Resident 13 has potential for decreased skin integrity and impairment of skin integrity. The care plan also indicates Resident 13's Braden scale is noted at high risk, and Resident 13 has a pressure ulcer present the left heel has a dark mushy area. The interventions related to the skin problem that were on place on 9/15/10 are assist with hygiene, minimize pressure on bony prominences, and use pillows, heel and elbow protector for positioning. Resident 13's goal was no skin breakdown and regain skin integrity to the left heel area. Resident 13's care plan, dated 11/03/10 indicates to try a heelzup (a cushion device to keep the heel off the bed) devices to keep Resident 13's heel off the mattress or place a pillow under Resident 13's calves area to alleviate the pressure. Resident 13's Braden scale to determine risk of pressure ulcers dated 11/18/10 indicates Resident 13 at a 12 or less, which places Resident 13 at high risk for pressure ulcers. A Health Drive Podiatry group consultation report dated 8/27/10 states Resident 13's dorsal pedal pulses are one fourth present and, posterior pulses were absent in both feet. The consultation also indicates there is increased cooling the distal part of both feet. A health drive consultation dated 10/28/10 states Resident 13's condition remains unchanged. On 12/13/10 at 2:55 PM Surveyor spoke with ADON C regarding the pressure area to Resident 13's left heel. ADON C stated according to the pressure ulcer report log Resident 13's left heel area was healed on 12/7/10. ADON C also indicated the left heel was assessed to be healed by an LPN and ADON C has not seen the heel to verify the LPN observations. On 12/13/10 at 2:57 PM Surveyor and ADON C observed the left heel of Resident 13. The left heel observation indicated Resident 13 Left heel was bright red in color non blanchable with an approximately 2 cm (centimeter) round light tan hard area in the center of the dark red area. Resident 13 was sitting in his recliner with slippers on and both heels resting directly on the foot rest of the reclining chair. On 12/13/10 at 3:05 PM Surveyor spoke with ADON C regarding Resident 13's left heel. ADON C stated Resident 13's left heel was not healed and continued to have a non blanchable left heel and a tan in color hard area remained to left heel. ADON C also indicated no pressure relieving or reducing devices are used when Resident 13 was observed in his reclining chair. ADON C provided Surveyor with Resident 13's pressure ulcer report log. A summary of Resident 13's Pressure ulcer report log measurement column indicates that Resident 13's left heel was originally measured on 9/3/10; the day of admission, noting an unstageable left heel area the area was identified with a dash (-) in the measurement column on the report form. On 11/4/10 the first documented measurement was 2.4 cm by 1.5 cm. The pressure ulcer report log for the unstageable area also indicated the left heel area with a dash (-) in the measurement column of the form for the following dates; 9/3/10, 9/9/10, 9/17/10, 9/18/10, 9/24/10, 10/1/10, 10/18/10, 10/19/10, 10/20/10, 10/22/10, 10/30/10, 11/14/10, and 11/29/10. In addition, the pressure ulcer report log indicates on 12/7/10 that the left heel area was healed and a callous are was noted to the left heal. No further information was provided to Surveyor . On 12/14/10 at 7:15 AM Surveyor again observed Resident 13 in his wheel chair with left heel directly placed on the floor and no change in foot wear from 12/13/10. On 12/14/10 at 1:50 PM Surveyor with DON B observed Resident 13 sitting in the reclining chair in Resident 13's room with slipper on left heel and left heel resting directly on the foot rest of the reclining chair. Surveyor review Resident 13's care plan dated 9/15/10 no changes to the care plan was identified on Resident 13's care plan. No further information was provided to Surveyor Example 3 Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 4 was readmitted to the facility from the hospital on [DATE] after an acute episode of congested heart failure and an acute change in mental status. Resident 4's MDS dated [DATE] indicates Resident 4 has impaired short and long term memory problems. Resident 4's MDS also indicates no pressure ulcers were present during the assessment period. The MDS indicates Resident 4 is at risk for developing pressure ulcers. Resident 4's MDS also indicates Resident 4 needs extensive assistance of 1 person for bed mobility and 2 persons for transfers, extensive assistance of 1 for personal hygiene and is continent of bowel and bladder. Resident 4's care plan originally dated 10/1/10 states that Resident 4 has potential for decreased skin integrity impairment of skin integrity. The care plan also indicates Resident 4's Braden scale score notes moderate risk. The interventions related to the skin problem that were in place on 10/1/10 are assist with hygiene, use a pillow for positioning, and lift body when moving. In addition, Resident 4's care plan indicates Resident 4 just returned from the hospital where Resident 4 was treated for [REDACTED]. The care plan was updated on 11/8/10 to indicate Resident 4 has been sick so needs to sleep in later in the morning, no other updates were indicated on Resident 4's care plan. Resident 4's skin care plan updated 11/23/10 indicates Resident 4 needs to be repositioned from side to side when in bed, and provide frequent change in position. Resident 4's care plan also indicates Resident 4 currently transfers with the use of a mechanical Hoyer lift. Residents 4's care plan did not identify any information on Resident 4's pressure ulcer size or location. Resident 4's Braden scale to determine risk of pressure ulcers dated 7/18/10 indicates Resident 4 at a 15 which places Resident 4 at risk for pressure ulcers. On 12/13/10 at 2:55 PM Surveyor spoke with ADON C regarding the pressure area to Resident 4's right inner buttock. ADON C stated according to the pressure ulcer report log Resident 4's right inner buttocks area is not healed, and a treatment should be provided to the right inner buttock. ADON C also indicated that ADON C has never seen Resident 4's pressure ulcer and ADON C only goes by the nursing notes in the chart. ADON C provided Surveyor Resident 4's pressure ulcer report log. A summary of Resident 4's pressure ulcer report log measurement column indicates that Resident 4's right inner buttocks was measured on 11/8/10, the day of initial observation, as a stage 2 pressure ulcer and was measured at 1.5 cm (centimeters) by 1 cm. In addition, the pressure ulcer report log for the stage 2 right inner buttocks pressure ulcer indicates a dash (-) in the measurement column of the form for the following dates; 11/14/10, 11/21/10, and 12/6/10. A physician order [REDACTED]. The physician order [REDACTED]. Resident 4's TAR dated November 2010 indicates Resident 4's treatment is to apply a Thin site ([MEDICATION NAME]) to right inner buttock and the Thin site can be left in place for 7 days. The November TAR also indicates a nurse's signature daily from 11/8/10 to 11/30/10. It is important to note that the TAR does not indicate the pressure area was healed or the treatment was discontinued as of 11/30/10. Resident 4's TAR for December 2010 indicates [MEDICATION NAME] may be used for the treatment of [REDACTED]. The TAR also indicates the treatment under the hours column is PRN (as needed) and the daily nurse signature area is blank. In addition, the TAR indicates Resident 4's right inner buttock pressure ulcer measurement as 1.5 cm by 1 cm barrier cream applied monitor until healed. The TAR does indicate the wound healed as of 12/14/10 no time of assessment was identified. It is important to note the Thin site order was not written on the December 2010 TAR. On 12/14/10 at 9:35 AM Surveyor and LPN F observed Resident 4's right inner buttocks area. Resident 4's right inner buttocks area is pink in color. Resident 4 did not have a Thin site [MEDICATION NAME] in place at the time of the observation. On 12/4/10 at 9:35 AM Surveyor spoke with LPN F and LPN F stated there was not a treatment in place and Resident 4 should have had a dressing on and LPN F would have to check if the treatment was discontinued for Resident 4. LPN F also stated the nurse working the shift that discovers a pressure sore healed will discontinue the treatment. LPN F indicated LPN F has discontinued treatment when LPN F assessed a pressure ulcer to be healed. LPN F also indicated LPN F does not inform the RN when a pressure ulcer is identified or when a pressure ulcer is healed. No further information was provided to Surveyor . Example 4 Resident 2's [DIAGNOSES REDACTED]. Resident 2 came to the facility with a [MEDICAL CONDITION]. The resident's Medicare 14 day MDS (Minimum Data Set) dated 12/6/10 indicates the resident's bed mobility is total assistance. Resident 2's nurses' notes on 11/15/10 indicate her skin was intact. Her Braden scale (a tool used to measure the risk of skin breakdown) placed her at high risk for skin breakdown due to her immobility but the resident was not placed on preventive measures until after she developed a pressure ulcer. On 11/16/10 the nurses' notes indicate Resident 2 had a white intact blister on her right heel. A heel boots and a heel riser were added after the blister developed. The blister was not measured when found by the nurse. On 11/19/10, the pressure ulcer was described as small dark area on right heel. On 11/21/10, the pressure ulcer report log indicates the blister is ? cm (centimeter) x ? cm. This was the only measurement done since the pressure ulcer was found. Resident 2's care plan, potential for decreased skin integrity, dated 11/24/10 did not indicate the resident had a pressure ulcer. Additionally, the CNA (Certified Nursing Assistant) care plan did not indicate to use the heel riser or heel boot on her right foot. On 12/13/10, at 2:50 pm Surveyor observed Resident 2's pressure ulcer on her heel with LPN I. The blister area was dark and hard and large. The pressure ulcer was not measured since 11/21/10. The facility would not know if the condition of the pressure ulcer changed in size without measuring and documenting the area. On 12/14/10, at 1:40 pm Surveyor asked DON (Director of Nursing) B what her expectation was when a resident is admitted with a [MEDICAL CONDITION]. DON B said there should have been preventions in place when the resident was admitted . Example 5 Resident 8 was re-admitted to the facility on [DATE] with the diagno