Every finding on record at Complete Care at Germantown

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 53 residents residing in the facility. The facility did not cool food with an approved food cooling method. Findings include: On 3/3/25, Dietary Manager (DM)-E indicated the facility follows their own food safety policies and procedures. The facility's undated Cooling Procedures document indicates: Foods must be cooled as quickly as possible to prevent the growth of bacteria as the food drops through the danger zone. For hot food: Cool from 135 degrees Fahrenheit (F) to 70 degrees F in 2 hours or less and then from 70 degrees F to 41 degrees F in 4 hours or less. For food prepared at room temperature or using room temperature ingredients, cool from 70 degrees F to 41 degrees F in 4 hours or less. Cooling Methods: Refrigeration: Divide into smaller portions, use shallow 2 to 4 inch pans, do not cover until food reaches 41 degrees F, use containers that transfer heat (metal pans) .Ice Bath: Fill ice and water up to the level of food in the container, stir regularly .use ice paddle along with the refrigeration method or ice bath method . During an initial kitchen tour that began at 9:21 AM on 3/3/25, Surveyor and DM-E observed the following foods in the cooler: ~ Cooked ground beef dated 3/3 ~ Cooked turkey dated 3/1 ~ A bowl of spaghetti sauce, noodles, and ground beef labeled Tuesday and dated 3/3 ~ Ground sausage dated 2/28 ~ Beef casserole dated 3/2 ~ Shredded pork dated 3/1 DM-E indicated every Monday DM-E throws away food in the cooler that has been saved. DM-E indicated leftovers should not be saved for future meals. During a continuous kitchen observation that began at 10:00 AM on 3/4/25, Surveyor observed spaghetti being reheated in the oven for lunch. Surveyor requested the facility's food cooling log from DM-E who indicated the spaghetti was pre-cooked. On 3/4/25 at 11:44 AM, DM-E approached Surveyor and indicated DM-E could not find the cooling log. DM-E stated the foods observed in the cooler were thrown away. DM-E confirmed the spaghetti was not thrown away and was served to residents for lunch. DM-E thought the spaghetti was properly cooled after it was initially made but verified the cooling process was not documented. DM-E provided Surveyor with a copy of training provided to cooks on 3/4/25 that covered the cooling process and cooling logs and indicated the following: Food Cooling and Storage: Leftovers should be disposed of after each meal. Any pre-cooked food should be documented on the cooling log located on the clipboard in the cooking area. The clipboard and forms should not be removed or replaced. Any leftovers or foods not documented will be thrown out. On 3/4/25 at 12:15 PM, Surveyor observed residents in the main dining room eating spaghetti for lunch.

Based on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R3) of 3 sampled residents. R3 had a court-ordered Guardian and was admitted to the facility on [DATE]. The facility did not petition for protective placement when R3's stay exceeded 60 days. Findings include: Wisconsin State Statute 55.055(1)(b) indicates: The guardian of an individual who has been adjudicated incompetent may consent to the individual's admission to a nursing home or other facility not specified in par. (a) for which protective placement is otherwise required for a period not to exceed 60 days. In order to be admitted under this paragraph, the individual must be in need of recuperative care or be unable to provide for his or her own care or safety so as to create a serious risk of substantial harm to himself, herself, or others. Prior to providing that consent, the Guardian shall review the ward's right to the least restrictive residential environment and consent only to admission to a nursing home or other facility that implements that right. Following the 60 day period, the admission may be extended for an additional 60 days if a petition for protective placement under s. 55.075 has been brought, or, if no petition for protective placement under s. 55.075 has been brought, for an additional 30 days for the purpose of allowing the initiation of discharge planning for the individual. On 3/4/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including dementia without behavioral disturbance, stage 4 pressure injury, adult failure to thrive, dysphagia (difficulty swallowing), and osteomyelitis of vertebra (bone infection). R3's Minimum Data Set (MDS) assessment, dated 1/2/25, had a Brief Interview for Mental Status (BIMS) score of 99 which indicated R3 was not able to complete the assessment. R3 had a court-appointed Guardian since 6/10/19. R3's medical record did not contain an order for protective placement in the facility. On 3/4/25 at 11:24 AM, Surveyor interviewed Social Services Designee (SSD)-C who indicated when R3's Guardian decided to have R3 remain in the facility, SSD-C did not know there was anything more that needed to be done. SSD-C indicated SSD-C would check if protective paperwork was initiated for R3. On 3/5/25 at 10:55 AM, Surveyor interviewed SSD-C who indicated Director of Nursing (DON)-B was looking for protective placement paperwork for R3. On 3/5/25 at 10:57 AM, Surveyor interviewed DON-B who indicated DON-B contacted R3's case manager who indicated R3 did not have protective placement prior to being admitted to the facility. DON-B indicated R3's case manager stated they would request a legal consult to obtain a protective placement order for R3 to remain in the facility.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R46) of 2 sampled residents was screened through the Pre-Admission Screen and Resident Review (PASRR) Level II process to determine if nursing home placement was appropriate and if specialized services were required. The facility did not ensure completion of a Level II PASRR Screen for R46 or follow a Qualified Mental Health Professional's (QMHP) request to refile a Level II PASRR Screen if R46 remained in the facility. Findings include: On 3/4/25, Surveyor reviewed R46's medical record. R46 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, bipolar disorder, sleep terrors, panic disorder, post-traumatic stress disorder, and adjustment disorder with anxiety. R46's Minimum Data Set (MDS) assessment, dated 1/10/25, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R46 had intact cognition. On 3/4/25 at 10:37 AM, Surveyor reviewed a PASRR Level II determination document for R46 signed by a QMHP representative on 10/22/24. The document indicated the QMHP contacted the facility on 10/8/24, 10/11/24, and 10/16/24 to obtain additional information regarding the date of onset, symptoms, and previous treatment with no response from the facility. The QMHP canceled the PASRR Level II Screen due to an inability to reach the facility and not enough information to make a PASRR determination. The QMHP indicated if R46 still resided in the facility, the facility should re-submit another PASRR Level II for evaluation of R46's needs. On 3/4/25 at 11:32 AM, Surveyor interviewed Social Services Designee (SSD)-C who indicated the PASRR for R46 was not re-submitted because SSD-C was out of the office at the time and there was no coverage. SSD-C confirmed the PASRR should have been re-submitted.

Based on staff interview and record review, the facility did not notify the Ombudsman of hospital transfers for 3 residents (R) (R15, R39, and R4) of 3 residents reviewed for hospitalization. R15 was transferred to the hospital on 9/11/24. The facility did not notify the Ombudsmen of R15's hospital transfer. R39 was transferred to the hospital on [DATE], 12/23/24 and 1/16/25. The facility did not notify the Ombudsmen of R39's hospital transfers. R4 was transferred to the hospital on [DATE]. The facility did not notify the Ombudsmen of R4's hospital transfer. Findings include: The facility's Transfer and Discharge policy, revised 10/2024, indicates: .5. The facility will maintain evidence that the notice was sent to the Ombudsmen .10. Emergency Transfers to Acute Care: .h. The Social Services Director, or Designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents monthly if the list meets all requirements for content of such notices. 1. On 3/3/25, Surveyor reviewed R15's medical record and noted R15 was transferred to the hospital on 9/11/24 due to a fall with injury that resulted in a broken left hip. R15's medical record did not indicate the Ombudsman was notified of R15's hospital transfer. 2. On 3/3/25, Surveyor reviewed R39's medical record and noted R39 was transferred to the hospital on [DATE] due to aspiration pneumonia. R39 was also transferred to the hospital on [DATE] due to vomiting, atrial fibrillation, ulcerative esophagitis and weakness, and on 1/16/25 due to hematemesis and hypernatremia. R39's medical record did not indicate the Ombudsman was notified of R39's hospital transfers. 3. On 3/3/25, Surveyor reviewed R4's medical record. R4's medical record indicated R4 was transferred to the hospital on [DATE] due to suprapubic catheter insertion obstruction. R4's medical record did not indicate the Ombudsman was notified of R4's hospital transfer. On 3/3/25, Surveyor requested Ombudsman notification of transfer and discharges from Nursing Home Administrator (NHA)-A. On 3/4/25 at 1:00 PM, Surveyor reviewed monthly transfer and discharge reports sent to the Ombudsman and noted R15, R39 and R4 were not listed on the reports. On 3/5/25 at 8:20 AM, Surveyor interviewed Social Services Designee (SSD)-C who indicated residents on Medicaid Part A who are transferred to the hospital do not show up on the monthly reports that are sent to the Ombudsmen. SSD-C confirmed the Ombudsmen does not receive notification of those transfers or discharges. Business Office Manager (BOM)-D (who was in SSD-C's office at the time of the interview) showed SSD-C how to run a report that included Medicaid Part A residents. Surveyor noted R15, R39, and R4 were on the report. SSD-C was unsure why the residents did not show up on the initial report run by SSD-C.

Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate administration of drugs and biologicals for 5 residents (R) (R5, R20, R4, R7, and R9) of 20 sampled residents. On 1/30/25, medications were observed at R5, R20, R4, R7, and R9's bedsides. The residents did not have self-administration of medication assessments, physician orders to self-administer medication, or care plans that indicated they could safely and accurately self-administer medication. Findings include: The facility's Resident Self-Administration of Medication policy, revised 10/2024, indicates: 1. Eash resident is offered the opportunity to self-administer medication during the routine assessment by the facility's interdisciplinary team .14. The care plan must reflect resident self-administration and storage arrangements for such medications . On 1/30/25 at 10:37 AM, Surveyor interviewed R5 and observed dorzolamide ophthalmic eye drops, brimonidine ophthalmic eye drops, Biofreeze (topical pain reliever), Fast Freeze (topical pain reliever), and anti-fungal powder at R5's bedside. R5 indicated a nurse brings the eye drops at approximately 8:00 AM and comes back for them after 12:00 PM. R5 indicated R5 self-administers the eye drops in the morning at 12:00 PM. On 1/30/25 at 10:46 AM, Surveyor observed fluticasone propionate nasal spray and nystatin powder (anti-fungal) on R20's nightstand. On 1/30/25 at 10:50 AM, Surveyor observed anti-fungal powder and a bottle of acetic acid on R4's nightstand. On 1/30/25 at 11:07 AM, Surveyor was interviewing R7 when Licensed Practical Nurse (LPN)-C entered the room and gave R7 Orajel tooth care cream that had just arrived from pharmacy. On 1/30/25 at 11:30 AM, Surveyor interviewed R9 and observed a paper towel on R9's bed that contained a blue pill. Surveyor also observed a medication cup on R9's table. When Surveyor asked about the pill, R9 was unsure what the pill was. R9 indicated the blue pill dropped on the floor when R9 was taking pills the nurse dropped off that morning. R9 put the pill on the paper towel so the nurse could see it. R9 confirmed nurses drop off R9's medication and leave. R9 indicated R9 takes the medications when R9 is ready. On 1/30/25 at 1:35 PM, Surveyor interviewed LPN-C who indicated LPN-C was unsure if R7 was able to self-administer medication. When Surveyor asked about the pill in R9's room, LPN-C indicated LPN-C was unsure what the pill was. LPN-C indicated LPN-C thought the pill was finasteride (often used to treat an enlarged prostrate), but when LPN-C went back to the room, R9 had already taken the pill. On 1/30/25 at 2:42 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed a resident should have a self-administration of medication assessment completed prior to self-administering medication. NHA-A also indicated the resident's physician should be contacted for approval, the resident's care plan should be updated, and reassessment should be completed at certain intervals to ensure the resident is still able to safely and accurately self-administer medication. NHA-A confirmed R5, R20, R4, R7, and R9 did not have self-administration of medication assessments, physician orders to self-administer medication, or care plans that indicated they could self-administer medication.

Based on staff and resident interview and record review, the facility did not ensure allegations of abuse and misappropriation were thoroughly investigated for 3 residents (R) (R3, R4, and R9) of 11 sampled residents. Director of Nursing (DON)-B was informed of a resident-to-resident altercation between R3 and R4 on 6/17/24 in which R3 sustained a physical injury. The facility did not thoroughly investigate the allegation of abuse. R9 reported R9's wallet, debit card, and cash were missing. The facility did not thoroughly investigate the allegation of misappropriation. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated January 2023, indicates an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for the investigation include: 1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering with or destroying evidence; 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. 1. On 7/17/24, Surveyor reviewed an incident report, dated 6/17/24 and completed by DON-B, that indicated R3 swung a call light in R4's room and sustained lacerations on the left forehead and left eyebrow. R4 was not affected by the incident and R3 was removed from the room. R3's injuries were assessed and treated. An interview with Certified Nursing Assistant (CNA)-C indicated CNA-C heard yelling, entered R4's room, and saw R3 swing the call light next to R4's bed. CNA-C removed R3 from the room. The incident report did not include additional resident and staff interviews or a determination on possible resident-to-resident abuse. On 7/17/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] for a Hospice respite stay and had diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, anxiety disorder, and major depressive disorder. R3's Minimum Data Set (MDS) assessment, dated 6/22/24, had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R3 had severely impaired cognition. R3's medical record indicated R3 had an activated Power of Attorney for Healthcare (POAHC). A progress note, dated 6/17/24, indicated R3 was in R4's room and sustained lacerations on the left forehead and left eyebrow. The areas were cleaned with no signs or symptoms of pain. A message was left for the Nurse Practitioner at 3:30 PM. R3's emergency contact and DON-B were also notified. R3's medical record did not contain any additional documentation related to the incident. On 7/17/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity with mood disturbance, major depressive disorder, and generalized anxiety disorder. R4's MDS assessment, dated 5/22/24, had a BIMS score of 11 out of 15 which indicated R4 had moderately impaired cognition. R4's medical record indicated R4 had an activated POAHC. R4's medical record did not contain any documentation related to the incident. On 7/17/24 at 1:45 PM, Surveyor interviewed CNA-C who confirmed CNA-C worked with R3 on 6/17/24. CNA-C stated CNA-C answered R4's call light and observed R3 in R4's room. CNA-C removed R3 from R4's room and closed the door. CNA-C went to do something else and noticed R4's call light was on again. CNA-C answered the call light and again observed R3 in R4's room. R3 was holding the smaller end of the call light which had been pulled from the wall and R4 was holding the longer end of the call light and swinging it around (which was contradictory to what the incident report stated). CNA-C stated R3 was bleeding from the head. CNA-C stated R4 asked if R4 clocked R3 good and asked CNA-C to keep R3 out of R4's room. CNA-C removed R3 from the room. CNA-C stated CNA-C was not asked to provide a statement. CNA-C confirmed CNA-C did not witness how the injury occurred because R3 was already bleeding when CNA-C entered the room. On 7/17/24 at 2:59 PM, Surveyor reviewed the above information with Nursing Home Administrator (NHA)-A who confirmed DON-B was unavailable for interview. NHA-A did not deny the findings or that the facility did not complete a thorough investigation. 49563 2. On 7/17/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including biliary acute pancreatitis without necrosis, diabetes, and hypothyroidism. R9's MDS assessment, dated 7/13/24, had a BIMS score of 15 out of 15 which indicated R9 had intact cognition. R9's medical record indicated R9 was responsible for R9's healthcare decisions. On 7/17/24 at 12:40 PM, Surveyor interviewed R9 who stated approximately six to seven months ago a wallet that contained R9's debit card and $16.00 went missing and was not found. R9 reported the missing wallet. Four staff searched R9's room but were unable to find the wallet. On 7/17/24 at 1:40 PM, Surveyor interviewed NHA-A who stated NHA-A was not aware of R9's wallet missing and could not find a related grievance or investigation. On 7/17/24 at 2:25 PM, Surveyor interviewed CNA-D who stated R9 mentioned the missing wallet several months ago but CNA-D was not aware of any details. On 7/17/24 at 2:40 PM, Surveyor interviewed Social Services Assistant (SSA)-E who was not aware of R9's missing wallet. SSA-E reviewed grievance logs from September of 2023 to the present but could not find any documentation on the missing wallet. On 7/17/24 at 2:55 PM, Surveyor interviewed Regional Director (RD)-F who stated RD-F was informed about R9's missing wallet and was told there would be an investigation by the former NHA. RD-F verified a suspected misappropriation of resident property investigation was not completed.

Based on staff and resident interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when they did not ensure allegations of abuse and misappropriation were reported to the State Agency (SA) or local law enforcement for 3 residents (R) (R3, R4, and R9) of 11 sampled residents. Director of Nursing (DON)-B was informed of a resident-to-resident altercation between R3 and R4 on 6/17/24 in which R3 sustained a physical injury. The facility did not report the allegation of abuse to the SA or local law enforcement. The facility did not report an allegation of misappropriation of property for R9 to the SA or local law enforcement. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated January 2023, states it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .IV. Identification of Abuse, Neglect and Exploitation: A. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services .B. Possible indicators of abuse include, but are not limited to: .3. Physical injury of a resident of unknown source .VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. On 7/17/24, Surveyor reviewed an incident report, dated 6/17/24 and completed by DON-B, that indicated R3 swung a call light in R4's room and sustained a laceration on the left forehead and left eyebrow. R4 was not affected by the incident and R3 was removed from the room. R3's injuries were assessed and treated. An interview with Certified Nursing Assistant (CNA)-C indicated CNA-C heard yelling, entered R4's room, and saw R3 swing the call light next to R4's bed. CNA-C removed R3 from the room. An Interdisciplinary Team (IDT) review indicated R3 sustained two small lacerations on the face. During the struggle for the call light, R3 was hit. CNA-C was the only eyewitness to the event. Additional staff statements were not obtained because CNA-C was the only employee directly involved. On 7/17/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] for a Hospice respite stay and had diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, anxiety disorder, and major depressive disorder. R3's Minimum Data Set (MDS) assessment, dated 6/22/24, had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R3 had severely impaired cognition. R3's medical record indicated R3 had an activated Power of Attorney for Healthcare (POAHC). On 7/17/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity with mood disturbance, major depressive disorder, and generalized anxiety disorder. R4's MDS assessment, dated 5/22/24, had a BIMS score of 11 out of 15 which indicated R4 had moderately impaired cognition. R4's medical record indicated R4 had an activated POAHC. On 7/17/24 at 1:45 PM, Surveyor interviewed CNA-C who confirmed CNA-C worked with R3 on 6/17/24. CNA-C stated CNA-C answered R4's call light and observed R3 in R4's room. CNA-C removed R3 from R4's room and closed the door. CNA-C went to do something else and noticed R4's call light was on again. CNA-C answered the call light and again observed R3 in R4's room. R3 was holding the smaller end of the call light which had been pulled from the wall and R4 was holding the longer end of the call light and swinging it around (which was contradictory to what the incident report stated). CNA-C stated R3 was bleeding from the head. CNA-C stated R4 asked if R4 clocked R3 good and asked CNA-C to keep R3 out of R4's room. CNA-C removed R3 from the room. CNA-C stated CNA-C was not asked to provide a statement. CNA-C confirmed CNA-C did not witness how the injury occurred because R3 was already bleeding when CNA-C entered the room. On 7/17/24 at 2:59 PM, Surveyor reviewed the above information with Nursing Home Administrator (NHA)-A who indicated DON-B was unavailable for interview. NHA-A did not deny the findings or that the facility did not report the resident-to-resident altercation as required. 49563 2. On 7/17/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including biliary acute pancreatitis without necrosis, diabetes, and hypothyroidism. R9's MDS assessment, dated 7/13/24, had a BIMS score of 15 out of 15 which indicated R9 had intact cognition. R9's medical record indicated R9 was responsible for R9's healthcare decisions. On 7/17/24 at 12:40 PM, Surveyor interviewed R9 who stated approximately six to seven months ago a wallet that contained R9's debit card and $16.00 went missing and wasn't found. R9 reported the missing wallet. Four staff searched R9's room but were unable to find the wallet. On 7/17/24 at 1:40 PM, Surveyor interviewed NHA-A who stated NHA-A was not aware of R9's missing wallet and was unable to find a grievance or investigation for the missing wallet. On 7/17/24 at 2:25 PM, Surveyor interviewed CNA-D who confirmed R9 mentioned the missing wallet several months ago but CNA-D was not aware of any details. On 7/17/24 at 2:40 PM, Surveyor interviewed Social Services Assistant (SSA)-E who was not aware of R9's missing wallet. SSA-E reviewed grievance logs from September of 2023 to the present but was unable to find documentation regarding the missing wallet. On 7/17/24 at 2:55 PM, Surveyor interviewed Regional Director (RD)-F who stated RD-F recalled R9's missing wallet and was told there would be an investigation and report by the former NHA. RD-F verified reports to the SA and local law enforcement were not completed for the suspected misappropriation of resident property.

Based on staff interview and record review, the facility did not prevent further potential abuse during an investigation of sexual assault for 1 resident (R) (R2) of 7 sampled residents. R2 accused Licensed Practical Nurse (LPN)-F of sexual abuse on 4/8/24. The facility did not remove LPN-F from resident care pending the results of the investigation. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 11/22, indicates facility staff should respond immediately to protect residents, including but not limited to, staffing changes and increased supervision. On 5/8/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and anxiety. R2's Minimum Data Set (MDS) assessment, dated 4/26/24, stated R2's Brief Interview for Mental Status (BIMS) score was 6 out of 15 which indicated R2 had severely impaired cognition. R2 had an activated Power of Attorney for Healthcare (POAHC) at the time of admission. On 5/8/24, Surveyor reviewed a facility report that was submitted to the State Agency (SA) on 4/9/24 and indicated R2 alleged that a male nurse tried to touch R2's private parts. The investigation included interviews from staff including LPN-F, Registered Nurse (RN)-G, and Certified Nursing Assistant (CNA)-H. A progress note, dated 4/8/24 at 6:07 PM and written by LPN-F, indicated R2's daughter called the facility and said R2 stated a male nurse tried to rape R2. A statement by LPN-F, dated 4/9/24, indicated LPN-F spoke with R2 after the phone call and R2 denied all allegations of sexual abuse. A statement by RN-G, dated 4/9/24, indicated on 4/8/24, RN-G observed LPN-F attempt to assist R2 from the dining room after dinner when R2 began to yell and accuse LPN-F of rape. A statement by CNA-H, dated 4/10/24, indicated on 4/8/24, CNA-H assisted R2 down the hallway in R2's wheelchair. R2 pointed to LPN-F and told CNA-H that a man down the hall touched and hurt R2. On 5/8/24, Surveyor reviewed nursing schedules that indicated LPN-F worked on 4/10/24 4/12/24, 4/13/24, 4/14/24, and 4/15/24. On 5/8/24 at 1:14 PM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B was made aware of R2's allegation on the morning of 4/9/24. DON-B stated LPN-F was not removed from resident care pending the outcome of the investigation because LPN-F did not match R2's description of the alleged perpetrator provided to DON-B on 4/9/24. DON-B verified the five-day investigation was submitted to the SA on 4/16/24 and stated the allegation of abuse was not substantiated.

Based on staff interview and record review, the facility did not ensure an injury of unknown origin and allegation of sexual abuse were reported to the Nursing Home Administrator (NHA), the State Agency (SA) and/or local law enforcement in a timely manner for 2 residents (R) (R1 and R2) of 7 sampled residents. On 4/10/24, the facility discovered R1 had a fracture of unknown origin. Staff did not immediately report the injury of unknown origin to NHA-A which delayed the facility's report to the SA. On 4/8/24, R2 alleged R2 was raped by a male nurse. Staff did not immediately report the allegation of sexual abuse to NHA-A which delayed the facility's report to the SA and local law enforcement. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 11/22, indicates: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .IV. Identification of Abuse, Neglect and Exploitation: A. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services . B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse .3. Physical injury of a resident of unknown source .VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . 1. On 5/8/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive nervous system disorder that affects movement) and polyosteoarthritis (the repetitive use of joints that causes damage to joint tissue and results in pain and swelling). R1's Minimum Data Set (MDS) assessment, dated 4/12/24, stated R1's Brief Interview for Mental Status (BIMS) score was 12 out of 15 which indicated R1 had moderately impaired cognition. R1's medical record indicated R1's Power of Attorney for Healthcare (POAHC) was responsible for R1's healthcare decisions. On 5/8/24, Surveyor reviewed a facility investigation that indicated: On 4/11/24 (date should be 4/10/24), R1 complained of knee pain. R1 was sent to the hospital and diagnosed with a nondisplaced medial condyle fracture of the left femur. Upon investigation, it was discovered that a Certified Nursing Assistant (CNA) who cared for R1 transferred R1 via pivot transfer. After the transfer, R1 complained of pain. The CNA was suspended pending the investigation and was terminated from employment. The police department was contacted and spoke with R1. Conclusion: The improper transfer likely caused the fracture due to R1's inability to properly assist with the pivot transfer and R1's underlying medical conditions. The investigation indicated an initial report was submitted to the SA on 4/11/24 at 9:39 AM. R1's care plan (effective 4/7/23) indicated R1 required the assistance of two staff and a full mechanical lift for transfers. A progress note, dated 4/10/24 at 2:58 PM, indicated: Messages were left for R1's [NAME] of Attorney (POAs) regarding R1's request to go to the hospital due to left knee pain. One of R1's POAs called the facility at 2:41 PM and stated if R1 wanted to go to hospital, the facility should send R1. A progress note, dated 4/10/24 at 4:09 PM, indicated: Writer was called in for a skin check by CNA after R1's weekly shower. Writer noted skin tear on R1's left foot and R1 complained of left knee pain. R1 requested to be transferred to the hospital. R1's family was notified and in agreement. R1 was transferred to the hospital via ambulance. A progress note, dated 4/10/24 at 10:30 PM, indicated: R1 returned from the hospital on a stretcher and was placed in bed. R1 was diagnosed with a closed nondisplaced condyle fracture of the left femur and had an immobilizer on the left knee. R1 denied pain at that time. On 5/8/24 at 12:17 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B reviewed R1's paperwork on 4/11/24 and noticed the fracture diagnosis. DON-B indicated DON-B immediately notified NHA-A and started interviewing staff. DON-B indicated when CNA-C was initially interviewed, CNA-C stated CNA-C and a nurse transferred R1 with a full mechanical lift. DON-B stated CNA-C then admitted CNA-C transferred R1 into a wheelchair with the pivot technique without a second staff present because R1 wanted to go to Bingo. DON-B indicated R1 complained of pain following the incorrect transfer. DON-B stated DON-B found out R1 was transferred incorrectly at approximately 9:00 AM on 4/11/24 and immediately suspended CNA-C from resident care. DON-B stated CNA-C was terminated from employment the same day for being untruthful and not following R1's care plan. On 5/8/24 at 12:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D via phone. LPN-D verified LPN-D was on duty when R1 returned from the hospital on 4/10/24. LPN-D stated LPN-D learned R1 had a fracture when LPN-D read R1's hospital paperwork. LPN-D indicated R1 wore a knee immobilizer and denied pain. LPN-D stated LPN-D was educated to let administration know immediately of any fractures. On 5/8/24, Surveyor reviewed CNA-C's time card which indicated CNA-C worked on 4/10/24 from 5:59 AM to 2:02 PM and on 4/11/24 from 6:01 AM to 9:11 AM. On 5/8/24, Surveyor reviewed the facility's undated education regarding when to call the NHA/DON. The education instructed staff to call for injuries of unknown origin, including bruises, fractures, and suspected abuse. On 5/8/24 at 1:43 PM, Surveyor interviewed DON-B who indicated the facility provided staff education regarding when to call the NHA/DON related to a previous unrelated incident. DON-B indicated the staff education started on 4/9/24 and verified LPN-D's name was on the list of staff educated. DON-B verified the education indicated staff should call immediately for fractures. DON-B verified staff were aware of R1's fracture on 4/10/24, however, administration did not know about R1's fracture until 4/11/24. When Surveyor asked when LPN-D should have called NHA-A regarding R1's fracture, DON-B stated, Once (LPN-D) read the paperwork (from the hospital). 38793 2. R2 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and anxiety. R2's MDS assessment, dated 4/26/24, stated R2's BIMS score was 6 out of 15 which indicated R2 had severely impaired cognition. R2 had an activated POAHC at the time of admission. On 5/8/24, Surveyor reviewed a facility report submitted to the SA on 4/9/24 that stated R2 alleged that a male nurse tried to touch R2's private parts. A progress note, dated 4/8/24 at 6:07 PM, indicated R2's daughter called the facility and said R2 stated a male nurse tried to rape R2. On 5/8/24 at 1:14 PM, Surveyor interviewed DON-B who stated DON-B was made aware of the allegation of abuse on the morning of 4/9/24. DON-B verified Licensed Practical Nurse (LPN)-F should have told administration about R2's allegation on the evening of 4/8/24.

Based on staff and resident interview, and record review, the facility did not ensure scheduled showers were provided for 5 Residents (R) (R212, R22, R30, R38, R47) of 22 sampled residents. R212, R22, R30, R38, and R47 did not consistently receive scheduled showers. Findings include: 1. R212 was admitted to the facility on [DATE] and had diagnoses including difficulty in walking, and macular degeneration. R212's Minimum Data Set (MDS) assessment, dated 10/30/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R212 had intact cognition. The MDS indicated R212 required substantial or maximal assistance for showering and bathing. On 1/22/24 at 11:47 AM, Surveyor interviewed R212 who indicated R212 did not receive a weekly shower and received only a few showers since admission. R212 indicated R212 was fine with receiving a bed bath every other day, but indicated that did not always happen. On 1/23/24, Surveyor requested R212's shower documentation and shower schedule. On 1/24/24, Surveyor reviewed R212's medical record and noted R212's weekly shower was scheduled on Sunday. R212's medical record, including Point of Care (POC) documentation, progress notes, and shower sheets from 10/24/23 through 1/24/24, indicated R212 received 6 of 13 scheduled showers with one refusal. 2. R22 was admitted to the facility on [DATE] and had diagnoses including neurocognitive disorder with Lewy bodies, and macular degeneration. R22's MDS assessment, dated 11/23/23, contained a BIMS score of 15 out of 15 which indicated R22 had intact cognition. The MDS indicated R22 required supervision or touching assistance for showering and bathing. On 1/22/24 at 11:57 AM, Surveyor interviewed R22 who indicated R22 did not receive a weekly shower. R22 indicated R22 did not get nearly enough showers and preferred a shower every other day. On 1/23/24, Surveyor requested R22's shower documentation and shower schedule. On 1/24/24, Surveyor reviewed R22's medical record and noted R22's weekly shower was scheduled on Thursday. R22's medical record, including POC documentation, progress notes, and shower sheets from 10/24/23 through 1/24/24, indicated R22 received 2 of 13 scheduled showers. 3. R30 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (weakness on one side of the body) following cerebral infarction, mild cognitive impairment, and type 2 diabetes mellitus. R30's MDS assessment, dated 8/29/23, contained a BIMS score of 13 out of 15 which indicated R30 had intact cognition. The MDS indicated R30 required partial or moderate assistance for showering and bathing. On 1/22/24 at 1:51 PM, Surveyor interviewed R30 who indicated R30 did not receive a weekly shower. R30 estimated R30 received a shower every two weeks, but preferred to shower every day or at least twice weekly. On 1/23/24, Surveyor requested R30's shower documentation and shower schedule. On 1/24/24, Surveyor reviewed R30's medical record and noted R30's weekly shower was scheduled on Thursday. R30's medical record, including POC documentation, progress notes, and shower sheets from 10/24/23 through 1/24/24, indicated R30 received 4 of 13 scheduled showers. 4. R38 was admitted to the facility on [DATE] and had diagnoses including macular degeneration, morbid obesity, and type 2 diabetes mellitus. R38's MDS assessment, dated 5/30/23, contained a BIMS score of 15 out of 15 which indicated R38 had intact cognition. The MDS indicated R38 required substantial or maximal assistance for showering and bathing. On 1/22/24 at 2:18 PM, Surveyor interviewed R38 who indicated R38 did not receive twice weekly showers and went months without a shower after admission. On 1/23/24, Surveyor requested R38's shower documentation and shower schedule. On 1/24/24, Surveyor reviewed R38's medical record and noted R38's weekly showers were scheduled on Wednesday and Sunday. R38's medical record, including POC documentation, progress notes, and shower sheets from 10/24/23 through 1/24/24, indicated R38 received 4 of 27 scheduled showers and one bed bath. 5. R47 was admitted to the facility on [DATE] and had diagnoses including hemiplegia following cerebral infarction, and type 2 diabetes mellitus. R47's MDS assessment, dated 9/21/23, contained a BIMS score of 15 out of 15 which indicated R47 had intact cognition. The MDS indicated R47 required substantial or maximal assistance for showering and bathing. On 1/22/24 at 11:08 AM, Surveyor interviewed R47 who indicated R47 did not receive a weekly shower and went as long as a month without a shower during a COVID outbreak. R47 also stated R47 often went 10 to 14 days between showers. On 1/23/24, Surveyor requested R47's shower documentation and shower schedule. On 1/24/24, Surveyor reviewed R47's medical record and noted R47's weekly shower was scheduled on Monday. R47's medical record, including POC documentation, progress notes, and shower sheets from 10/24/23 through 1/24/24, indicated R47 received 7 of 13 scheduled showers. On 1/23/24 at 9:13 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who indicated shower sheets are completed for all residents after showers and placed in Director of Nursing (DON)-B's mailbox. On 1/24/24 at 9:50 AM, Nursing Home Administrator (NHA)-A provided Surveyor with shower sheets and indicated the shower sheets provided were all staff could find because some were thrown away. On 1/24/24 at 12:39 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C and DON-B. ADON-C stated CNAs document showers/bathing in residents' medical records. DON-B indicated residents should receive at least one shower per week if they choose.

Based on resident and staff interview, and record review, the facility did not make a prompt effort to resolve grievances for 3 Residents (R) (R32, R20, and R212) of 5 sampled residents. R32 and R32's Power of Attorney (POA) reported R32's wallet and phone were missing. There was no follow up by the facility. R20's POA filed a grievance related to missing clothing. There was no follow up by the facility. R212 and a family member filed a grievance related to call light wait times and customer service. The grievance was not fully addressed and there was no follow up by the facility. Findings include: The facility's Resident and Family Grievance Policy, dated 10/22, indicates: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination or reprisal .Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. 1. On 1/22/24 at 10:52 AM, Surveyor interviewed R32 who indicated R32 was missing a wallet with all of R32's identification and driver's license. R32 stated R32 told staff, but did not receive any follow up. On 1/24/24 at 10:46 AM, Surveyor interviewed R32's POA who indicated during the week of Christmas (12/25/23), R32 stated R32's wallet and phone were missing. R32's POA informed the facility and then went to the facility and asked staff if R32's wallet and phone were found. A staff member stated they told R32's nurse. R32's POA and the Director of Nursing (DON) were present and someone checked R32's room. R32's POA also stated they told Nursing Home Administrator (NHA)-A that R32's wallet and phone were missing, but there was no follow up. R32's POA stated they received a call from NHA-A that morning (1/24/24) because Surveyors were in the building. When Surveyor informed R32's POA that Surveyor spoke with R32 that morning and R32 showed Surveyor a phone, R32's POA indicated the phone was R32's second phone and the other phone was not found. On 1/24/24 at 11:37 AM, Surveyor interviewed NHA-A who verified NHA-A was informed of the missing wallet and phone by R32's POA around Christmas time, but NHA-A thought the wallet and phone were found. NHA-A verified a grievance should have been filed for the missing items and follow up should have been completed. NHA-A also verified the facility's policy instructs staff to file a grievance for missing items and follow up with an investigation. 43361 2. R20 was admitted to the facility on [DATE]. R20's Minimum Data Set (MDS) assessment, dated 1/4/24, contained a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R20 had severe cognitive impairment. R20 had an activated POA. On 1/24/24, Surveyor requested any grievances filed by or on behalf of R20. Social Worker (SW)-F provided a grievance, dated 10/24/24, that indicated R20's family had concerns related to missing clothing. The follow up section of the grievance indicated: will request list of missing items or pictures. On 1/24/24 at 11:20 AM, Surveyor interviewed SW-F who stated SW-F filled out the grievance form the last time the State Agency was in the building due to R20's family's concerns. SW-F indicated SW-F did not follow up yet or request a list or pictures of the missing items. 3. R212 was admitted to the facility on [DATE]. R212's MDS assessment, dated 10/30/23, contained a BIMS score of 14 out of 15 which indicated R212 had intact cognition. On 1/22/24 at 11:47 AM, Surveyor interviewed R212 who indicated Certified Nursing Assistant (CNA)-D and CNA-D's partner were rude to R212 related to R212 self-propelling to the dining room. R212 indicated the facility knew about the incident, but R212 didn't think anything was done. On 1/23/24 at 9:06 AM, Surveyor reviewed a grievance, dated 12/16/23, that indicated R212's family indicated R212 was not cleansed or changed in a week, had to wait over 3 hours for staff to answer R212's call light following a bowel movement, and was left in the cafeteria for hours after eating. R212's family also had concerns that a few unnamed CNAs were rude. The grievance indicated: Spoke with (R212) and confirmed concerns. Then spoke with staff and told them they need to answer calls quickly and not leave residents alone. Starting hourly rounds by the CNAs as well as management to ensure residents are getting their needs addressed. The grievance contained staff statements and an undated education sheet with staff signatures. Surveyor noted CNA-D's signature was not on the education page. On 1/23/24 at 8:57 AM, Surveyor interviewed NHA-A who indicated CNA-D's partner was CNA-E. Surveyor indicated the grievance follow up stated CNAs and management would complete hourly rounds, but the documentation was not included. Surveyor also indicated the grievance did not address the concern regarding rude staff. NHA-A indicated NHA-A thought the previous DON had a conversation with CNA-D and CNA-E and would check with Human Resources. NHA-A stated NHA-A would also look for documentation of hourly rounds. NHA-A did not provide confirmation that hourly rounds were completed. On 1/23/24 at 9:24 AM, NHA-A provided an education sheet with staff signatures and indicated customer service and call light education was completed on 12/14/23 (which was 2 days before the grievance was filed). NHA-A confirmed grievances should be properly addressed and follow up should be completed.

Based on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R31) of 1 resident was assessed for the use of bed rails. R31 had bilateral half rails on R31's bed. Staff did not assess R31 for the use of bed rails, and did not obtain informed consent or a physician's order when the bilateral half rails were implemented. Findings include: The facility's Proper Use of Bed Rails policy, implemented on 3/6/23, indicates: As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. Size and weight; c. Sleep habits; d. Medication(s); e. Acute medical or surgical interventions; f. Underlying medical conditions; g. Existence of delirium; h. Ability to toilet safely; i. Cognition; j. Communication; k. Mobility (in and out of bed); l. Risk of falling. 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. The resident assessment must also assess the resident's risk from using bed rails. 4. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. 5. The facility will assess to determine if the bed rail meets the definition of a restraint 6. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails .8. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnoses, condition, symptom, or functional reason for the use of the bed rail. R31 was admitted to the facility on [DATE] and had diagnoses including pain in the left shoulder. R31's Minimum Data Set (MDS) assessment, dated 10/23/23, contained a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R31 had moderate cognitive impairment. On 1/22/24 at 10:20 AM, Surveyor interviewed R31 and noted R31 had bilateral half rails installed on R31's bed. R31 indicated the bed rails were used to assist R31 with mobility. R31 indicated R31 had difficulty raising R31's arms due to shoulder pain. Between 1/22/24 and 1/24/24, Surveyor reviewed R31's medical record and noted the following: ~ A side rail order, initiated on 1/3/24, indicated: Device: Enabler bars: two 1/4 rails both to assist with independent mobility in bed. There were no directions specified. ~A care plan, initiated on 1/3/24, indicated: Risk for injury related to physical restraint due to: side rails. Approaches included: Complete appropriate restraint and/or side rail assessment per living center policy. ~R31 used an air mattress as a pressure relieving device. On 1/23/24, Surveyor requested an assessment for R31's bilateral half rail use. On 1/23/24 at 2:29 PM, the facility provided an assessment titled Quarterly/Annual/Significant Change Assessment, dated 1/23/24, that documented R31's side rail use and indicated R31 was appropriate for half side rails which were not a restraint. The assessment reviewed R31's entrapment risk and noted there were no gaps between R31's air mattress and the rails. The assessment indicated R31 was provided education regarding the use of half rails. Nursing Home Administrator (NHA)-A indicated the assessment was R31's quarterly evaluation. Surveyor requested to see prior evaluations for R31's half rail use. On 1/24/24 at 8:57 AM, NHA-A provided R31's Admit/Readmit assessment, dated 10/16/23. The assessment indicated R31 did not require any type of bed rail. On 1/24/24 at 8:57 AM, NHA-A confirmed an initial assessment should have been completed per the facility's policy when R31's bilateral half rails were implemented on 1/3/24. NHA-A also provided a Performance Improvement Project (PIP) that began on 12/20/23 to be completed on 1/26/24 related to side rail use for residents without proper assessments, orders, or consents. On 1/24/24 at 9:24 AM, Surveyor informed NHA-A that an order in R31's medical record indicated R31 should have quarter rails. NHA-A indicated the original completion date for the PIP was 1/12/24, but the facility chose to extend the date to 1/26/24 after they realized it wouldn't be completed. NHA-A confirmed physician orders for side rails should match what the resident has.

Based on staff interview and record review, the facility did not review and revise the care plan for 1 Resident (R) (R1) of 5 sampled residents. R1's plan of care indicated R1 had a passive range of motion (PROM) program; however, R1's care plan was not updated to include an intervention for active assistive range of motion (AAROM) on the right side. Findings include: On 11/7/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paraplegia and left femur fracture (5/2023). A care plan, dated 2/4/22, indicated R1 had PROM to the right leg and the left ankle due to a fracture in the left femur. The care plan contained a goal that indicated R1 would not have a decline in range of motion or any new contracture development through the three-month review period (revised on 9/18/23). Surveyor reviewed physical therapy notes, dated 9/22/23, that included an intervention for active assist side lying range of motion to R1's lower extremities except the left hip. Surveyor noted the intervention was not added to R1's care plan. On 11/7/23 at 10:00 AM, Surveyor interviewed Registered Nurse Manager (RNM)-E who verified R1 received PROM, but stated R1 often refused and education was provided. RNM-E verified the AAROM side lying intervention was not added to R1's care plan. On 11/7/23 at 10:36 AM, Surveyor interviewed Physical Therapist (PT)-F who verified R1's care plan should have included a new intervention for AAROM on 9/22/23. On 11/7/23 at 12:28 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who verified R1's care plan should have been updated.

Based on staff interview and record review, the facility did not record, thoroughly investigate, and provide follow up or resolution of a grievance for 1 Resident (R) (R2) of 3 residents reviewed. A grievance, dated 10/24/23, was filed on behalf of R2 related to hygiene. The facility did not thoroughly investigate or provide follow-up and resolution for the grievance. Findings include: The facility's Resident and Family Grievances policy, dated 1/2023, indicated: Prompt efforts to resolve include acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. On 11/7/23, Surveyor reviewed R2's medical record. R2 had diagnoses including kidney failure, heart failure, and diabetes. R2's Minimum Data Set (MDS) assessment, dated 8/11/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. The MDS also indicated R2 required staff assistance with activities of daily living (ADLs). R2 had an activated Power of Attorney for Healthcare (APOAHC). A grievance form, dated 10/24/23, indicated a concern related to hygiene was forwarded to Social Worker (SW)-D via email on 10/20/23. SW-D saw the email when SW-D returned to work on 10/23/23, filled out a grievance form on 10/24/23, and gave the form to Assistant Director of Nursing (ADON)-C for review. The grievance form, dated 10/24/23, contained a grievance official follow-up statement that indicated bath sheets were reviewed and R2 was receiving baths. The investigation did not contain resident or staff interviews, including an interview with R2, or follow up with the complainant. On 11/7/23, Surveyor interviewed SW-D who indicated SW-D gave the grievance to ADON-C who completed the investigation. On 11/7/23 at 1:34 PM, Surveyor interviewed ADON-C who indicated ADON-C reviewed the bath sheets and documentation indicated R2 was receiving baths. ADON-C did not recall a conversation with R2 regarding bathing and verified there was no follow up with the complainant. ADON-C verified grievances should be thoroughly investigated and follow up with the complainant should be completed.

Based on staff and provider interview, and record review, the facility did not notify the provider of an elevated blood sugar level for 1 Resident (R9) of 28 residents reviewed. R9 had a documented blood sugar level of 495 mg (milligrams)/dL (deciliter) on 2/25/23. R9's provider was not notified. Findings include: According to the American Diabetes Association, hyperglycemia is the technical term for high blood glucose (blood sugar). High blood glucose happens when the body has too little insulin or when the body can't use insulin properly .Hyperglycemia can be a serious problem if you don't treat it, so it's important to treat as soon as you detect it. If you fail to treat hyperglycemia, a condition called ketoacidosis (diabetic coma) could occur .Ketoacidosis is life-threatening and needs immediate treatment. The American Diabetes Association suggests the following targets for most non-pregnant adults with diabetes: 1. Before a meal: 80-130 mg/dL 2. 1-2 hours after beginning of the meal: Less than 180 mg/dL R9 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complications, and acute osteomyelitis (bone inflammation caused by infection). On 10/25/23 at 9:49 AM, Surveyor interviewed Registered Nurse (RN)-D who indicated RN-D thought the facility followed the standard blood sugar notification to providers of under 70 mg/dL and above 350 mg/dL. Between 10/23/23 and 10/25/23, Surveyor reviewed R9's medical record. Surveyor noted on 2/25/23 at 4:00 PM, R1 had a documented blood sugar of 495 mg/dL. R1's medical record did not indicate R1's provider was notified. The facility provided a physician order (contained in R9's admission orders) to notify the physician in 1 week regarding R9's blood sugars. The facility also provided a provider note from Advanced Practice Nurse Prescriber (APNP)-E, dated 2/27/23, that indicated: Type 2 diabetes mellitus without complications. Home regimen included glipizide, metformin, and Lantus daily (medications used to control blood sugar). Currently only on glipizide. Blood glucose ranges in 200-400s. Continues on prednisone (a steroid medication). Restart metformin 2/27/23. If continues to be hyperglycemic, restart Lantus later this week. Monitor. On 10/25/23 at 10:34 AM, Surveyor interviewed APNP-E who indicated APNP-E's parameters for notification of blood sugar levels were over 400 mg/dL and less than 70 mg/dL. APNP-E confirmed the facility did not notify APNP-E or the physician of R9's blood sugar level of 495 mg/dL on 2/25/23. APNP-E indicated if APNP-E was notified, APNP-E likely would not have added or changed anything at that time because R9 was on prednisone and had osteomyelitis, both of which can temporarily cause high blood sugar levels. APNP-E indicated APNP-E would have instructed staff to continue to monitor R9's blood sugar levels.

Based on staff interview and record review, the facility did not thoroughly investigate a fall to ensure the environment was as free of accident hazards as possible for 1 Resident (R) (R4) of 2 residents reviewed for falls. R4 had a fall with injury on 8/18/23. The facility did not complete a thorough investigation to determine a root cause analysis or complete staff education to minimize the likelihood of future falls. Findings include: The facility's Falls Prevention Program Policy dated 10/2023, indicates: 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. On 10/24/23, Surveyor reviewed R4's medical record. R4 was readmitted to the facility on [DATE] with diagnoses including encephalopathy, acute kidney injury, and acute renal failure, and received Hospice services. R4's Minimum Data Set (MDS) assessment, dated 5/25/23, contained a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R4 had severely impaired cognition. The MDS also indicated R4 had one fall without injury since admission/prior assessment, and required staff assistance for dressing and other activities of daily living (ADLs). R4's fall care plan, dated 8/14/23, contained the following fall interventions: call light in reach, anticipate needs, appropriate footwear, environment safe and free of clutter, side rails and encourage activities. R4's medical record indicated R4 fell on [DATE]. The investigation indicated R4 was in the activity room in a wheelchair with R4's head in hand and resting on R4's wheelchair arm. Activity Assistant (AA)-I was moving residents back to their rooms and moved the table in front of R4 to allow other residents through. AA-I's back was to R4 when R4 fell forward out of the wheelchair and onto the floor. R4 incurred a forehead laceration and an eye injury. AA-I's witness statement indicated AA-I was finishing with a birthday party, getting residents back to their rooms, doing nails, and providing water to those in the room. AA-I indicated R4 was asleep on R4's hand when AA-I moved R4 to get another resident to their room. AA-I indicated in the middle of that, R4 fell forward. A witness statement from Certified Nursing Assistant (CNA)-N, dated 8/18/23, indicated CNA-N witnessed R4's head on the table prior to the incident. Surveyor noted the witness statements were vague and did not provide a clear picture of the events prior to the fall. Following the fall, R4 was sent to the ER (emergency room ) and did not return to the facility. The facility reviewed and investigated R4's fall, did a head-to-toe assessment of R4, and obtained witness statements; however, the facility did not follow-up with a root cause analysis of the fall, obtain a clear indication of what occurred prior to the fall, or provide staff education to prevent future falls. Surveyor was unable to interview AA-I (who no longer worked at the facility) during the course of the investigation. On 10/25/23 at 12:02 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A did not educate staff on R4's fall. NHA-A indicated there should have been education completed following R4's fall.

Based on staff interview and record review, the facility did not implement their abuse prevention policy and procedure for 2 (Certified Nursing Assistant (CNA)-F and CNA-G) of 8 staff reviewed during the caregiver program compliance check. The facility did not complete a current Background Information Disclosure (BID) form, Department of Justice (DOJ) letter, or Integrated Background Information System (IBIS) letter for CNA-F. The facility did not complete an out-of-state background check for CNA-G. Findings include: The facility's Abuse, Neglect and Exploitation policy and procedure, with an implementation date of 6/1/22, indicates the facility's abuse prevention plan includes a screening process in which potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that the facility will maintain documentation of proof that the screenings occurred. On 10/24/23, Surveyor completed a caregiver program compliance check for eight sampled staff employed by the facility. 1. CNA-F was hired by the facility's corporate company on 7/29/21. Surveyor noted CNA-F's BID form was completed on 11/19/19, and CNA-F's DOJ and IBIS letters contained dates of 12/3/19. On 10/25/23 at 4:05 PM, Surveyor interviewed Human Resource Director (HRD)-H who confirmed CNA-F was hired on 7/29/21, but stated CNA-F was originally hired in 2017. HRD-H could not provide documentation to verify that CNA-F was continuously employed at the facility from the time CNA-F's background checks were completed in 2019 to CNA-F's documented hire date on 7/29/21. 2. CNA-G was hired on 9/26/23. CNA-G's BID form was completed on 9/21/23, and CNA-G's DOJ and IBIS letters were completed on 9/26/23. On the BID form, CNA-G answered Yes to living out of state, and indicated CNA-G lived in Alabama in 2022. On 10/25/23 at 11:19 AM, Surveyor interviewed HRD-H who confirmed the facility did not complete an out-of-state background check for CNA-G.

Based on staff interview and record review, the facility did not record, thoroughly investigate, or provide resolution of a grievance for 1 Resident (R) (R10) of 28 residents reviewed. R10's dentures were reported missing on either 5/12/23 or 5/13/23. The facility did not fill out a grievance form, thoroughly investigate, or provide follow-up and resolution of the grievance. R10 expressed care concerns to R10's physician on 5/22/23. The facility did not fill out a grievance form, thoroughly investigate, or provide follow-up and resolution of the grievance. R10's family expressed concerns about a transfer with injury that occurred on 5/27/23. The facility did not fill out a grievance form, thoroughly investigate, or provide follow-up and resolution of the grievance. Findings include: The facility's Resident and Family Grievances policy, with an implementation date of 10/2022, indicated the following: 1. Director of Social Services has been designated as the Grievance Official. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility .issuing written grievance decisions to the resident .4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (long-term care) facility stay. 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. b. Written complaint to a staff member or Grievance Official. c. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings. R10 was admitted to the facility on [DATE] with diagnoses that included heart failure, peripheral vascular disease (PVD), need of assistance with personal cares, dysphagia (difficulty swallowing), and reduced mobility. On 5/12/23, R10's Minimum Data Set (MDS) assessment, dated 5/12/23, contained a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R1 had moderately impaired cognition. R10 had an Activated Power of Attorney for Healthcare (APOAHC). 1. Between 10/23/23 and 10/25/23, Surveyor reviewed R10's medical record and noted a care plan, dated 5/19/23, that indicated: At risk for dental problems related to dentures, full - resident states is missing bottom dentures. On 10/24/23 at 1:30 PM, Surveyor interviewed Social Worker (SW)-C who stated R10's dentures went missing on R10's first or second night at the facility. SW-C stated SW-C was notified in the morning that R10's dentures were missing a day or two after R10 was admitted , but could not recall the exact date. SW-C indicated staff believed R10 put the dentures on R10's dinner tray and the dentures were accidentally thrown away. The dentures were reported missing the next morning when staff couldn't find them prior to breakfast. SW-C recalled a discussion about someone searching the dumpster for the dentures, but was unsure if that occurred. SW-C indicated SW-C did not fill out a grievance form and could not provide Surveyor with documentation of an investigation or follow up. SW-C also indicated SW-C did not make an appointment for R10 because SW-C was not sure if R10 or R10's family wanted the dentures replaced. SW-C indicated the facility would make an appointment if R10 or R10's family requested one. On 10/24/23 at 3:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed a grievance form should have been completed. 2. Between 10/23/23 and 10/25/23, Surveyor reviewed R10's medical record and noted a physician progress note, written by R10's Advanced Practice Nurse Prescriber (APNP) on 5/22/23, that indicated: (R10) seen today resting in wheelchair. (R10) is tearful, feels was not helped by nursing staff yesterday. On 10/25/23, Surveyor reviewed a Witness Statement form signed by Registered Nurse (RN)-D. The statement did not contain an incident date, interview date, or a date next to RN-D's signature. The statement was not attached to a grievance form and did not contain an investigation. The statement indicated: Spoke with (R10) after being told by Nurse Practitioner that (R10) had nursing concerns. (R10) was requesting (RN-D) have a Certified Nursing Assistant (CNA) assigned only to (R10's) room so (R10) doesn't have to wait for staff to answer call light. (RN-D) explained to (R10) that we can not assign an aide to do one-to-one. On 10/25/23 at 9:56 AM, Surveyor interviewed NHA-A who confirmed a grievance form should have been filled out with further investigation into R10's concerns. 3. Between 10/23/23 and 10/25/23, Surveyor reviewed R10's medical record and noted a change of condition note, dated 5/27/23 at 4:35 PM, that indicated: (R10) has laceration to left calf, caused during transfer into wheelchair, pressure was held to control bleeding, Steri-Strips applied followed by Xeroform, gauze, 4 x 4 Kerlix. A call was placed for transfer to ER for evaluation. (R10) sent via (ambulance company). On 10/24/23 at 1:30 PM, Surveyor interviewed SW-C who recalled the above incident and recalled hearing that R10's family had concerns that the staff who completed the transfer were incompetent. SW-C indicated SW-C did not look into the concern because the concern was more of a nursing issue. The facility was not able to provide a grievance form and investigation related to the above care concern. The facility provided Surveyor with a skin injury incident report that contained a statement of what occurred from the CNA who completed the transfer and the nurse who responded. The information also included a note that indicated R10's wheelchair was reassessed for size and fit, and skin and pain assessments were completed. The information did not include a grievance form or investigation into the concern expressed by R10's family. On 10/24/23 at 1:30 PM, SW-C indicated the grievances process is as follows: If there is a grievance and SW-C is aware, the grievance is given to NHA-A who distributes the grievance to the appropriate department. On 10/25/23 at 9:56 AM, Surveyor interviewed NHA-A who indicated grievance forms are available for anyone (family, residents, or staff) to fill out. NHA-A stated grievance forms are given to SW-C who distributes them to the departments that are required to follow up. NHA-A also indicated grievances are discussed at morning meetings, and stated if staff are made aware of a concern, a grievance form should be completed.

Based on observation and resident and staff interview the facility did not provide the necessary services to ensure a clean and sanitary environment for 8 Residents (R) (R2, R3, R4, R9, R14, R16, R17, R18) of 8 residents. A garbage can in R2 and R9's shared bathroom contained dried feces. The toilet, floor and wall in R3's room contained dried urine and feces. The toilet, floor and wall in R14's room contained dried urine and feces. The wall in R4 and R16's shared bathroom contained dried feces. The wall and garbage can in R17 and R18's shared bathroom contained dried feces. Findings include: On 1/18/23 at 9:28 AM, Surveyor interviewed R2 and R9 who were roommates and shared a bathroom. Surveyor observed a garbage can next to the bathroom door that did not contain a garbage bag and had streaks of dried feces inside of the can. On 1/18/23 at 9:47 AM, Surveyor observed perineal care for R3 who stood in front of the toilet in R3's bathroom. Certified Nursing Assistant (CNA)-J used a washcloth to clean feces off R3's backside and threw the washcloth toward a garbage can next to the door of the bathroom. R3 was assisted out of the bathroom and Surveyor observed dried feces on the outside of the toilet bowl along the rim and urine streaks from the rim down to the floor. On the wall above the garbage can, Surveyor noted a half dollar-size amount of dried feces and a larger amount of smeared dried feces underneath that appeared to have run down the wall. Surveyor also noted the floor was sticky and the bathroom had an odor of urine. Surveyor asked to speak with CNA-J after CNA-J returned from assisting R3 to the lobby. In the meantime, Surveyor entered R14's room and bathroom. Surveyor noted a large puddle of dried urine that spread across the bathroom to the wall and noted the wall near the garbage was splattered with dried feces. R14's bathroom contained a strong odor and the floor was also sticky. When CNA-J returned, Surveyor confirmed with CNA-J the substances on the floors and walls were urine and feces. On 1/18/23 at 10:12 AM, Surveyor interviewed Housekeeping Supervisor (HSK)-I who stated resident rooms and bathrooms were cleaned daily. HSK-I and Surveyor observed R3 and R14's bathroom. HSK-I verified the walls, toilet, and floors in the bathrooms contained urine and dried feces. HSK-I and Surveyor went to another wing to observe additional resident rooms and bathrooms since staff were done cleaning that wing for the day. HSK-I and Surveyor observed dried feces on the back of R4 and R16's bathroom wall. HSK-I and Surveyor also observed dried feces on the wall above the garbage can and inside the garbage can in R17 and R18's shared bathroom. HSK-I confirmed the rooms were cleaned that morning. Surveyor also reported to HSK-I the observation of dried feces in R2 and R9's garbage can. On 1/18/23 at 11:18 AM, Surveyor and Nursing Home Administrator (NHA)-A observed the above mentioned rooms which were cleaned by housekeeping staff; however, still contained urine and dried feces. NHA-A stated the current contracted housekeeping service was provided a termination notice because they were not meeting the expectations of their contract. NHA-A verified the observations and concerns with urine and feces on the floors, walls, and in the garbage cans.

Based on interview, observation and record review, the facility did not ensure on-going communication and collaboration with the dialysis center for 1 Resident (R) (R1) of 1 resident reviewed for dialysis services. R1's received dialysis three times weekly. R1's dialysis binder and communication forms contained incomplete information from the facility despite multiple requests from the dialysis center for the necessary information. Findings include: From 1/17/23 through 1/18/23, Surveyor reviewed R1's medical record which indicated R1 admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD) requiring hemodialysis three times weekly, diabetes mellitus, acute on chronic anemia and dementia. R1's most recent Minimum Data Set contained a Brief Interview for Mental Status (BIMS) score of 6 which indicated R1 was severely cognitively impaired. The facility's Hemodialysis policy, dated 10/20/22, stated, The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; b. Physician/treatment orders, laboratory values, and vital signs; c. Advance Directives and code status; specific directives about treatment choices, and any changes or need for further discussion with the resident representative, and practitioners . On 1/17/23 at 11:55 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated residents who received dialysis took a communication binder with a new communication form to each dialysis session. Facility staff completed the top portion of the form with resident specific information and the dialysis center completed the bottom portion of the form prior to the resident leaving the dialysis center to return to the facility. On 1/17/23, Surveyor reviewed R1's dialysis communication binder. The binder contained seventeen communication record forms, dated 10/28/22 through 12/21/22; however, the binder should have contained twenty-four communication forms for the same time period. Surveyor reviewed the communication forms and noted the top and middle portions were not completed. Four of the documents did not include R1's name or any information from the facility. None of the documents included resident specific pre-dialysis information. On 1/17/23 at 12:30 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who stated staff were expected to complete the middle portion of the communication form for a resident who was going to dialysis. The middle portion of the form contained resident specific pre-dialysis information to be completed by facility staff prior to the resident's dialysis appointment. ADON-C stated the top portion of the form was repetitive information, including the resident's name, etc. On 1/17/23 at 12:50 PM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should complete the top half of the form and send the communication binder with the resident to all dialysis appointments. On 1/17/23 at 2:35 PM, Surveyor received seven dialysis communication forms for R1 for January 2023. All seven forms were incomplete and were missing resident specific pre-dialysis information. On 1/18/23 at 11:57 AM, Surveyor interviewed dialysis Registered Nurse (RN)-G. RN-G indicated the dialysis center was not getting communication sheets from the nursing facility and stated R1 at times brought the wrong type of binder or another resident's binder. RN-G stated when R1's communication binder came with R1, the communication forms were incomplete or blank. RN-G stated a representative from the dialysis center called and talked to an unidentified staff at the facility about the incomplete forms. RN-G stated RN-G wrote notes on some of the communication forms and requested R1's information be filled out prior to R1's dialysis sessions. R1's dialysis communication sheet, dated 12/19/22, stated, Please fill out pre-dialysis form before sending patient to dialysis. R1's dialysis communication sheet, dated 12/21/22, stated, Must fill out top portion. RN-G stated the facility continued to not complete the pre-dialysis information for R1.

Based on observation, interview, and record review, the facility did not ensure 2 (R8, R10) of 3 residents reviewed who are at risk for falls received the necessary services and supervision to prevent an injury from a fall or conduct through fall investigations. *The facility did not thoroughly investigate to determine a root cause analysis of R8's falls on 4/14/22, 4/21/22, 5/7/22, and 7/7/22. On 5/7/22, R8 fell while attempting to toilet themselves, sustaining a left femur fracture which required hospitalization with surgical intervention. *R10 sustained falls on 5/4/22 and 5/8/22 that were not thoroughly investigated by the facility to determine a root cause analysis. Findings include, Surveyor reviewed the Fall Management policy and procedure revised 2012 and notes the following: .Newly admitted Residents 1. Facilities will take a proactive approach for new Residents and will consider new admissions at risk for falls until the Resident is reviewed by the Interdisciplinary Team (IDT). 4. New Admissions will be placed on the Falling Star Program until reviewed by the IDT. 5. The IDT will review all Resident falls within 24-72 hours at the morning IDT meeting to evaluate circumstances and probable cause for the fall 1. R8 was admitted to the facility on [DATE] with diagnoses of subarachnoid hemorrhage, [CONDITION(S)] and [CONDITION(S)]. 1. R8's Admission MDS (Minimum Data Set) dated 4/18/22 documents R8's BIMS (Brief Interview for Mental Status) score of 03, indicating R8 is severely cognitive impaired for daily decision making. R8's Admission MDS documents that R8 requires extensive assistance of 2 staff for bed mobility and transfers. R8 requires extensive assistance of 1 staff for toileting. R8 had a urinary catheter in place upon admission to the facility for a diagnosis or [CONDITION(S)]. R8 is at high risk for falls. Surveyor reviewed R8's medical record including physician's orders, progress notes and comprehensive care plans. R8's fall care plan with an initiation date of 4/15/22 and a revision date of 7/8/22 reads, R8 is high risk for falls related to gait/balance problems. Unaware of safety needs. On 4/15/22, R8's fall care plan included the following interventions: Anticipate and meet the resident's needs. 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. Fall 4/14/22 x 2: bring to common area when awake. On 4/14/22 at 11:34 AM, the facility documents R8 sustained a fall from their bed while trying to put on pants independently. Staff assisted R8 off of the floor with a Hoyer lift into their wheelchair. Staff initiated neurological checks for R8's unwitnessed fall. On 4/14/22 at 12:00 PM, R8 was observed on the floor next to their wheelchair after attempting to get back to bed. The facility continued neurological checks for R8's second unwitnessed fall. Facility staff assisted R8 into their wheelchair at this time and took R8 to a common area for closer monitoring. No injuries were sustained related to R8's two falls on 4/14/22. On 7/19/22 at 2:30 PM, Surveyor requested fall investigations for R8 from 4/14/22 to present date. The Facility did not provide a fall investigation to determine the root cause analysis for R8's two falls for 4/14/22. Surveyor noted there was no facility fall investigation for R8's two falls on 4/14/22 to determine when R8 was last seen, what R8 was doing last, when R8 was last toileted, whether R8 was continent or incontinent when found. The facility did not conduct a root cause analysis of R8's two falls on 4/14/22. On 4/15/22, a care plan intervention was added reading Fall 4/14/22 x 2: bring to common area when awake. On 4/21/22 at 2:27 PM, the facility documents R8 was observed sitting on floor after attempting to self-transfer to the toilet. R8 was found to be incontinent of stool at the time of observation. There was no facility fall investigation provided for R8's 4/21/22 fall to determine when R8 was last seen, what R8 was doing at that time, when R8 was last toileted. There is no indication as to why R8 was found alone in their room when the care planned interventions of 4/14/22 was to bring R8 to the common area when awake. The facility did not conduct a root cause analysis of R8's 4/21/22 fall. On 4/26/22, a care plan intervention was added reading 4/21/22 fall: do not leave alone in room while awake or bathroom, bring to common area. On 5/7/22 at 7:30 AM, the facility documents R8 was found on floor in their room at about 5:30 AM, lying on their left side. R8 stated they had wanted to use the bathroom. Staff reminded R8 that they have a Foley catheter in place. R8 was assisted to their wheelchair, complaining of left hip pain. Facility staff updated the on call physician who gave orders for R8 to be evaluated at the emergency room due to left hip pain. R8 was discharged to the hospital on 5/7/22. R8 was admitted to the hospital on 5/7/22 with a diagnosis of left femur fracture which required surgical intervention. R8 was hospitalized from 5/7/22 to 5/11/22, returning to the facility on [DATE]. On 7/20/22 at 9:00 AM, Surveyor reviewed R8's incident report for 5/7/22 fall. The incident description reads that R8 was found laying on left side between bed and bathroom door and told staff they were trying to use the bathroom. R8 was sent out the emergency room for evaluation. Surveyor noted that the facility did not provide a through investigation of R8's 5/7/22 fall with no staff statements regarding the circumstances surrounding the fall provided to Surveyor. The facility's investigation does not identify when R8 was last seen and when last toileted. The facility did not conduct a root cause analysis of R8's 5/7/22 fall. On 7/20/22 at 11:35 AM, Surveyor conducted an interview with LPN (Licensed Practical Nurse)-F. Surveyor asked LPN-F if they recalled R8's fall on 5/7/22. LPN-F told Surveyor they remembered staff had decided to send R8 to the emergency room because they could not bear weight on their left lower extremity. Surveyor asked LPN-F if the facility has a specific protocol for residents who sustain unwitnessed falls. LPN-F told Surveyor there is a fall checklist they would follow and they would update the resident's family and doctor if there were any falls. Surveyor asked LPN-F why R8's incident report for their 5/7/22 fall did not have a complete investigation, including statements from staff. LPN-F responded they are not sure why there were no staff statements obtained related to R8's 5/7/22 fall. On 5/10/22, a care plan intervention was added reading: 5/7/22 fall-sent out to ER-educate staff to toilet on rounds/prn (as needed) if resident expresses need for bathroom even if urine or for bowel movement- do not leave alone in bathroom. On 5/12/22, a care plan intervention was added reading: New toileting plan to take to bathroom/incontinence care upon rising, before or after meals, at hour of sleep, and on rounds at NOC, as needed. On 5/11/22, R8 returned to the facility with a urinary catheter in place. On 6/6/22, a voiding trial was initiated after removal of the Foley catheter per urology orders. R8 continued to receive scheduled toileting by staff at this time. R8's Significant Change MDS dated [DATE] documents R8's BIMS score of 05, indicating R8 is severely impaired for daily decision making skills. R8's MDS also documents that R8 requires extensive assistance of 2 staff for transfers and toileting. On 7/18/22 at 2:10 PM, Surveyor made observations of R8 at the facility. R8 was attending facility's afternoon activity group. R8 was sitting in their wheelchair wearing non-skid footwear. On 7/19/22 at 9:15 AM, Surveyor made observations of R8 at the facility. R8 was receiving assistance from staff members to use the bathroom at this time. On 7/7/22 at 10:00 AM, the facility documents that R8 sustained a fall from their wheelchair while attempting to toilet self in another resident's room. (R8 had been in a common area however was noted to enter into another resident's room to toilet self.) Surveyor noted the facility's fall investigation included staff statements for the 7/7/22 fall. Staff statements indicate R8 had been toileted after breakfast at 9:00 AM in accordance with R8's fall care plan. R8 was noted with urinary incontinence at the time of fall. On 7/8/22, R8's fall care plan was updated reading 7/7/22-bowel and bladder patterning. Surveyor noted documentation of bowel and bladder patterning initiated by facility on 7/7/22. The facility's fall investigation does not address the amount of supervision R8 requires and why R8 was not being supervised while up in the common area in accordance with fall care plan intervention previously initiated on 4/14/22 and 4/21/22. On 7/10/22 at 7:30 PM, facility documents that R8 was observed on the floor after sliding out of their wheelchair. Surveyor noted a fall investigation with staff statements for 7/10/22. R8 was not incontinent at the time of this fall. R8 was in a common area at the time of this fall. On 7/11/22, a care plan intervention was added reading 7/10/22 fall-Therapy to assess wheelchair. Surveyor reviewed an Occupational therapy screening form for R8 dated 7/11/22. Occupational therapy screening form indicates recommendations for R8 to receive occupational, physical and speech therapy at this time in addition to assessment of wheelchair. Surveyor reviewed R8's current therapy documentation. On 7/20/22 at 3:15 PM, Surveyor shared concerns with NHA (Nursing Home Administrator)-A related to R8's unwitnessed falls on 4/14/22, 4/21/22, 5/7/22, and 7/7/22 including lack of thorough fall investigation with staff statements to determine the root cause analysis of falls. No additional information was provided to Surveyor at this time. 2. R10 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of Bladder, Alcoholic [CONDITION(S)] of Liver with Ascites, Type 2 Diabetes Mellitus, [CONDITION(S)], Stage 3, Chronic Obstructive Pulmonary Disease, and Obesity. R10 has an unactivated Health Care Power of Attorney (HCPOA). R10 discharged from the facility on 5/12/22. R10's Admission Minimum Data Set (MDS) dated [DATE] documented R10's Brief Interview for Mental Status (BIMS) score to be a 15, indicating R10 is cognitively intact. R10 required limited assistance with 2 for bed mobility, transfers, and hygiene. R10 required extensive assistance of 2 for toileting. R10's activities of daily living (ADL) and fall care area assessment (CAA) dated 5/11/22 document R10 is a short term rehabilitation patient. R10 has bladder cancer and became weak from nausea and vomiting. R10 is participating in therapy. R10 is alert and able to make needs known. R10 did have 2 falls while on the unit. R10's Kardex provided to Surveyor on 7/19/22 documents no falls since admission or prior assessment. The Kardex documents R10 is not steady moving from seated to standing and moving on and off toilet. Surveyor reviewed R10's care plan and notes the following: R10 has an activities of daily living (ADL) self-care performance deficit due to weakness initiated on 5/3/22 with an intervention dated 5/3/22 that R10's transfer status was moderate assistance x1, stand pivot transfer with 2 wheeled walker and gait belt. R10 is at risk for falls due to weakness initiated 5/3/22 with an intervention dated 5/3/22 to make sure R10's call light is within reach and encourage R10 to use it for assistance as needed. R10 needs prompt response to all requests for assistance. On 5/4/22 the intervention of educating R10 to not self transfer was initiated. On 5/8/22, the immediate intervention was to send to hospital and continue in therapy. On 5/4/22 at 4:00 AM, R10 was found on the floor of R10's room. R10's Interdisciplinary Post Fall Review signed 5/6/22 documents R10's fall to be unwitnessed due to an unassisted transfer from wheelchair to bed. R10's nursing progress notes indicate on 5/4/22 at 5:53 AM, neuro-checks were initiated. On 5/4/22 at 10:55 AM, R10 is complaining of severe pain (9/10) to R10's left hip and x-rays are ordered. On 5/5/22 at 10:10 AM, it is documented there is no fracture of the left hip. Surveyor reviewed all documentation in regard to R10's unwitnessed fall on 5/4/22 provided by the facility. Surveyor notes there is only 1 'staff fall investigations' form completed by Certified Nursing Assistant (CNA-G) who was assigned to R10. CNA-G checked no to the question: 'Did you observe this Resident during your shift?' The shift is scheduled 10:00PM-6:00AM. The form is incomplete with 8 questions not answered. 8 questions are answered with no or not applicable (N/A). Surveyor notes there are no other documented written statements or details related to the fall from any other staff working at the time of R10's fall. Surveyor notes there is no documentation of what R10 was wearing at the time, what position found in, why was R10 attempting to self transfer, when was R10 last assisted with ADLs, etc R10's care plan indicates the intervention put into place was to re-educate R10 to not self transfer. Surveyor notes an updated fall risk assessment was not completed in regards to R10's unwitnessed fall on 5/4/22. Surveyor notes R10 had a second fall on 5/8/22. R10's nursing progress notes document that R10's knees buckled as R10 was being transferred back into bed and was lowered to the floor by a CNA with gait belt in use. Surveyor notes there is no documented written statements from the CNA who was transferring R10 on 5/8/22. Surveyor notes there is no documentation of what R10 was wearing at the time, what position was R10 in when lowered to the ground, etc. R10's Situation Background Assessment Recommendation (SBAR) Communication Form and Progress note dated 5/16/22 documents R10 reports feeling pain in left leg and left knee. Also reports pain to left ankle and knee. Resident was lowered to the floor during a transfer back into bed after toileting. Per R10's Admission MDS, R10 required extensive assistance of 2 for toileting. It is unclear if R10 was transferred off the toilet with 2 CNAs. Per R10's care plan the intervention put into place was to send R10 to the hospital. However, per R10's nursing progress notes, R10 was sent to the hospital per R10 and family request due to R10 having nausea and vomiting. On 5/8/22, a Fall Risk Assessment was completed and documents R10 is high risk for falls. On 7/20/22 at 10:32 AM, LPN-F stated to Surveyor that the expectation is that all statements should be obtained from all staff on the unit at the time of a fall, whether it is witnessed or unwitnessed. On 7/20/22 at 2:30 PM, Surveyor shared with Administrator (NHA-A) the concern that with both of R10's falls on 5/4/22 and 5/8/22 that a full investigation was not completed including obtaining written statements to facilitate a root cause analysis. NHA-A understands the concern and no further information was provided by the facility at this time.

Based on interviews and record review the facility did not ensure that each resident received adequate supervision and assistance to prevent accidents for 1 of 2 (R1) residents reviewed for accidents. R1 had 16 falls while residing in the facility. The facility did not complete a root cause analysis to determine the cause of R1's repeated falls or implement interventions based on a root cause analysis to prevent future falls. On 12/2/21, R1 subsequently fell and sustained a [CONDITION(S)] which required surgical repair. Findings include: The facility policy titled Fall Management, revised January 2022, documented (in part) . The center assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Care Plan is developed and implemented, based on this evaluation, with ongoing review. When a resident is found on the floor, the center is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring. The IDT reviews all resident falls within 24-72 hours at the IDT meeting to evaluate circumstances and probable cause for the fall. R1 was admitted to the facility on [DATE] and had diagnoses that included right [CONDITION(S)], idiopathic aseptic necrosis of right femur, dementia, Major Depressive Disorder and anxiety. R1's fall risk assessment, dated 9/8/21, documented a score of 18, indicating R1 was at high risk for falls. R1's Admission Minimum Data Set assessment with an Assessment Reference Date of 9/14/21, Care Area Assessment documented: Recent right [CONDITION(S)] status post hemiarthroplasty. Potential for falls - difficulty maintaining sitting balance, impaired balance during transitions R1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 11/3/21, documents a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment; a Patient Health Questionnaire (PHQ-9) score of 5, indicating mild depressive symptoms; requires extensive assist of 1 staff for bed mobility, transfers, walking, dressing, toilet use and personal hygiene; not steady and only able to stabilize with human assist for moving from seated to standing position, turning around to face opposite direction while walking, moving on and off the toilet and surface to surface transfers; one sided, lower extremely range of motion impairment; frequently incontinent of bladder and occasionally incontinent of bowel with no toileting program. R1's Bowel and Bladder evaluation, dated 9/14/21, documented: Incontinent of bowel and bladder. Alert to person only, confused at all times. Short term and long term memory loss. Requires extensive to total physical assist with toileting. Overall plan for bowel/bladder management: Check and change upon rising, before/after meals, HS (hour of sleep), PRN (as needed) and NOC (night) rounds. R1's Care Plan Focus area dated 9/9/21 documented: High risk for falls r/t (related to) cognitive impairment, incontinence, impaired mobility, not aware of safety needs. Interventions included: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated 9/9/21; Do not leave alone in room when up in wheelchair d/t (due to) not aware of safety needs at all times, will attempt to self transfer, initiated 9/10/21; Ensure that the resident is wearing appropriate footwear when transferring or mobilizing in wheelchair, initiated 9/10/21; Ask resident if she would like to sit up in lounge chair if insisting on returning to room, initiated 9/23/21; Fall mat at bedside, initiated 10/2/21; Keep pressure relieving boots off couple days, use pillow to offload heels, monitor heels for breakdown. Check skin 2 times shift for 3 days. initiated 10/6/21; Fall-given hand bell to use when needing assist (does not use call bell or touch pad), initiated 10/14/21; Immediate intervention brought to lounge area for close supervision, initiated 10/14/21; Requested TELS order for auto lock brakes to be applied, initiated 10/15/21; DC (discontinue) offloading boots d/t (due to) improved mobility and able to reposition, continue floating heels while in bed, initiated 10/15/21; Requesting NP (Nurse Practitioner)/MD (Medical Doctor) to eval (evaluate) with possible medical workup and medication review, initiated 10/19/21; UA (Urinalysis) received and sent to lab, initiated 10/20/21; Education to family to notify staff if they are leaving so staff can provide close supervision of resident as resident feels she must leave and follow her family, initiated 10/20/21; Moved to long term care unit where activities are more available, initiated 10/22/21; Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: (specify), initiated 10/23/21; The resident needs activities that minimize the potential for falls while providing diversion and distraction, initiated 10/23/21; If resident is up standing in MPR (multipurpose room), ambulate to the bathroom and then back to MPR if tolerated to exercise/reposition and meet possible toileting need, initiated 11/19/21; Continue with current interventions with the goal of preventing injury, initiated 11/19/21; Toilet resident after breakfast see toileting plan icon care plan, initiated 1/22/22; Fall-intervention apply [NAME] to w/c under cushion - initiated 1/27/22. R1's Fall investigations documented: Fall # 1 On 9/8/21, at 1:15 PM - Found on floor in room, in wheelchair prior, wearing socks. IDT intervention: Do not leave in wheelchair (w/c) in room. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation as to when R1 was last seen, when R1 was last toileted, if R1 was incontinent, or in need of toileting assistance. Fall # 2 On 9/23/21, at 2:00 PM - Found sitting on leg rests of w/c. Unable to explain what she was doing. Continent, denied need to toilet, gripper socks on. Things that made condition worse: Left in room in w/c unassisted. IDT - resident left alone in room pending 2 person transfer to bed, slid out of w/c. Will get lounge chair if wants to sit up in room. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation as to when R1 was last toileted or repositioned. There is no documentation as to why R1 was left in her room when the intervention to R1's fall on 9/10/21 was to not leave R1 alone in her room due to R1 not being aware of safety needs and will attempt to self transfer. The intervention of getting a lounge chair if R1 wants to sit in room does contradict the intervention from Fall #1 of not leaving R1 alone in her room due to not being aware of safety needs and attempts to self transfer. Fall # 3 On 10/2/21, at 4:40 PM - Found sitting on floor in room, wearing pressure relief boots. Noted 5 minutes earlier by nurse in bed, eyes closed. After fall, assisted to BR (bathroom) - had large BM (bowel movement). IDT - multiple falls due to poor safety awareness and inability to make needs known. Will place floor mat at bedside to potentially prevent injury. Surveyor noted there was no investigation to determine the root cause of the fall. R1 was assisted to the BR after the fall and had a large BM. There was no documentation when R1 was last toileted prior to the fall. There is no documentation as to how long R1 had been in bed that afternoon. The intervention put into place to prevent future falls does not address the reason for R1's fall. Fall # 4 On 10/6/21, 6:50 PM, - Found lying on floor on mat next to bed, pressure relief boots on, in bed prior. IDT - trial D/C (discontinue) boots and use pillows to offload heels. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation as to when R1 was last seen, when R1 was last toileted, if R1 was incontinent or in need of toileting. There is no documentation as to when R1 was assisted to bed and what R1's preferred bed time was. The intervention put into place to prevent future falls does not address the reason for R1's fall. Fall # 5 On 10/13/21, at 5:30 PM, - Found kneeling on mat on floor next to bed, in bed prior, socks on. IDT - unable to remember to call for assist, will give bell hand held in attempt to get resident to ring for assist. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation as to when R1 was last seen, when R1 was last toileted, if R1 was incontinent or in need of toileting and if prior care plan interventions were in place at the time of the fall. There is no documentation as to why R1 was in bed at 5:30 PM. The new intervention put into place to prevent future falls does not address the reason for R1's fall. R1 was also assessed to have a BIMS score or 3, indicating severe cognitive impairment and there is no assessment completed to determine if R1 has the cognitive capacity to ring a hand bell for staff assistance. Fall # 6 On 10/14/21 at 4:30 PM - found on floor at foot of bed, in bed prior, socks on. IDT - will add autolock w/c brakes as resident will use w/c to ambulate for stability. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation as to when R1 was last seen, when R1 was last toileted, if R1 was incontinent or in need of toileting and if prior care plan interventions were in place at the time of the fall. There is no documentation as to why R1 was in bed at 4:30 PM. R1 had a fall from bed on 10/2/21 at 4:40 PM; a fall from bed on 10/6/21 at 6:50 PM; and a fall from bed on 10/13/22 at 5:30 PM. This is R1's 4th fall from bed in the late afternoon, early evening with no explanation as to why R1 is in bed at these times. The intervention put into place to prevent future falls does not address the reason for R1's fall. Fall # 7 and Fall #8 On 10/19/21, at 4:00 and 4:10 PM - found on floor mat, assisted to bed. Stated did not need to use BR (bathroom). Found on floor again 10 minutes later. Brought to nurses' station for supervision. Wearing socks. IDT - resident has become more restless and wanting to go home. To obtain UA (urinalysis) to see if [CONDITION(S)] (urinary tract infection) could be causing changes in behavior. Surveyor noted there was no investigation to determine the root cause of the fall. R1 denied need to use the BR, however, R1 has severe cognitive impairment. There was no documentation as to when R1 was last assisted with toileting needs, checked for incontinence, or if prior care plan interventions were in place at the time of the fall. This is R1's 5th fall from bed in the late afternoon, early evening time with no explanation as to why R1 is in bed at these times. There is no documentation as to why R1 was put back into bed at 4:00 PM after R1's initial fall on this day. The intervention put into place does not address the reason for R1's fall. Fall # 9 On 10/19/21, at 6:30 PM - Found on floor in dining room (DR). Wearing socks. Denied need for BR. In w/c prior to fall. IDT - to obtain UA. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation as to when R1 was last seen, when R1 was last toileted, if R1 was incontinent/in need of toileting or if prior care plan interventions were in place at the time of the fall. This is R1's third fall on this day. The intervention put into place to prevent future falls does not address the reason for the fall. Fall # 10 On 10/20/21, at 12:30 PM - witnessed fall in DR. Seated at table eating lunch prior to fall. Stood up and fell on her right side. IDT - remind family to tell staff when leaving so can provide increased supervision. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation as to when R1 was last toileted, if R1 was incontinent or in need of toileting assistance, or if prior care plan interventions were in place at the time of the fall. This is R1's 4th fall in 2 days. The intervention put into place to prevent future falls does not address the reason for R1's fall. Fall #11 On 10/21/21, at 8:00 PM - Witness fall in hall. Started to scoot forward in w/c after being instructed to sit back. Resident complied and shortly after slid out of chair. Socks on. Last toileted at 6:00 PM. IDT - continue present fall interventions, auto lock brakes, staying in common areas, having 1:1 supervision by staff. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation if the resident was incontinent, in need of toileting or if prior care plan interventions were in place. There is no documentation as to when staff implemented 1:1 supervision of R1 and if 1:1 supervision was in place at the time of R1's fall. This is R1's 5th fall in 3 days. Fall #12 On 11/16/21, at 2:15 PM - Found on floor mat. In bed prior. No footwear. IDT - no new interventions. Continue current with goal to prevent injury. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation as to when R1 was last seen, when R1 was last toileted, if R1 was incontinent/in need of toileting assistance or if prior care plan interventions were in place at the time of the fall. There is no documentation as to why R1 was in bed at the time of the fall. Fall #13 On 11/17/21, at 4:00 PM - witnessed fall in multipurpose room (MPR). fell backward in DR attempting to self transfer. Socks on. Did not want to wait in multipurpose room after visiting with her family outside. Requesting to return to her room. IDT - if resident is up standing in MPR, ambulate to the bathroom and then back to MPR if tolerated to exercise/reposition and meet possible toileting needs. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation if the resident was incontinent, in need of toileting, if autolock breaks were applied to R1's wheelchair as recommended after 10/21/21 fall or if prior care plan interventions were in place at the time of the fall. Fall #14 On 11/21/21, at 10:00 AM - witness fall. Landed on floor on right side. IDT - observed attempting to get up and walk to BR. Last toileted upon rising. Intervention - toilet after breakfast. Surveyor noted R1's Bowel and Bladder evaluation dated 9/14/21 documented R1 was to be checked and changed before and after meals - which was not implemented on the care plan. Surveyor noted there was no documentation as to when the R1 got up that morning and was last toileted, or if prior care plan interventions were in place at the time of the fall. Fall #15- fall with injury On 12/2/21, at 1:04 PM - found on floor in DR lying on left side complaining of pain to left hip. In DR prior to fall. Gripper socks on. IDT - will continue with current plan of care and interventions as resident has profound dementia and no safety awareness. The impulsive behavior is caused for multiple reasons and all have been addressed. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation as to when R1 was last seen, when she was last toileted, if she was incontinent/in need of toileting assistance or if prior care plan interventions were in place. This fall resulted in a left [CONDITION(S)] which required surgery. No new interventions were put into place to prevent future falls. Fall #16 On 1/26/22, at 3:30 PM - found on floor in dining area. IDT determined RCA (root cause analysis) of fall was that resident slid down. Intervention is to insert Dycem under w/c cushion. Surveyor noted there was no investigation to determine the root cause of the fall. There was no documentation as to when R1 was last seen, when R1 was last toileted, if R1 was incontinent/in need of toileting, or if prior care plan interventions were in place. In addition, Surveyor noted R1 had sustained 5 previous unwitnessed falls from the w/c and Dycem was not implemented until after this last fall. On 5/3/22, at 1:50 PM, Surveyor advised Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A of the concern the facility did not complete a root cause analysis of R1's falls which resulted in R1 sustaining a fall with a [CONDITION(S)] requiring surgery. No additional information was provided.

Based on observation, interview and record review the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure injuries an do not develop pressure injuries unless the individuals's clinical condition demonstrates that they were unavoidable for 2 of 2 (R2 and R4) residents reviewed for pressure injuries. R2 developed facility acquired Suspected Deep Tissue Injury (SDTI) on both heels. R2 was identified to be at risk for pressure injuries and preventative measures were not implemented until after pressure injuries developed. R4 was assessed to be at high risk for the development of pressure injuries. On 4/4/22 the Nurse Practitioner documented being told of the development 2 shearing areas to the right and left buttock. On 4/4/22, neither wounds were assessed, measured, and treatment was not immediately implemented until 4/8/22. Findings include: The facility policy titled: Skin Management revised January, 2022 documents (in part) . .1. Upon admission or readmission, residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing the Braden Scale for Predicting Pressure Sore Risk User Defined Assessment (UDA) in conjunction with the Nursing Admission Data Collection Set. 2. Following admission, the Braden Scale for Predicting Pressure Sore Risk (UDA) will be completed weekly for 3 additional weeks (for a total of 4 weeks, including admission), quarterly, annually, and with a significant change of status to determine the risk for development of pressure injuries. 3. Appropriate preventative surfaces (e.g., beds, wheelchairs, etc.) will be implemented for residents identified at risk. Interventions are documented on the Care Plan. 6. If a new pressure injury is identified, either upon admission, readmission, or during the resident's stay, the wound is assessed and documented on the Weekly Pressure Ulcer Record. 7. The licensed nurse will document daily monitoring of pressure injuries on the Treatment Administration Record (TAR). 8. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. R2 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Braden Scale for Predicting Pressure Sore Risk, dated 2/10/22, documented a score of 13 indicating moderate risk for pressure injury. R2's Admission Minimum Data Set with an Assessment Reference Date of 2/10/22, documented R2 requires extensive 2 person physical assist for bed mobility, is at risk of developing pressure ulcers/injuries, no pressure injuries present on admission. The Care Area Assessment documented: Triggering conditions: Bed mobility: Self performance - extensive assist. No pressure areas noted. Immobility, Diabetes, Dementia, chronic or end-stage renal, liver or [CONDITION(S)]. R2's Care Plan Focus area, initiated 2/4/22, documented: (R2) has potential/actual impairment to skin integrity. Interventions include: The resident needs pressure relieving/reducing mattress, cushion, pillows, to protect the skin while in bed and chair, initiated 2/4/22; Encourage good nutrition and hydration in order to promote healthier skin, initiated 2/4/22; Air mattress - monitor every shift for correct inflation. Boots to feet at all times, may remove for cares/skin inspection. Float heels in bed if choosing not to use boots. Frequent repositioning. Up for meals only, initiated 3/10/22; House supplement as ordered, initiated 3/11/22. Prostat ordered 3/14/22. Juice supplement 3/17/22; Diabetic foot checks every HS (hour of sleep), initiated 3/12/22; R2's Care Plan Focus area initiated 3/11/22, documented: (R2) has Diabetes Mellitus. Interventions include: Inspect feet daily for open areas, sores, pressure areas, blisters, [CONDITION(S)] or redness, initiated 3/11/22. R2's Head to Toe skin check sheet dated 3/3/22, documented: Intact skin. R2's Head to Toe skin check sheet dated 3/10/22, documented: Skin tear right hand and abrasion to gluteal fold. There was no documentation of pressure injuries to heels. R2's Skin Weekly Pressure Ulcer Record dated 3/10/22, documented: Right heel - pressure - SDTI. 7 cm (centimeters) x 7 cm. Wound presents as a 100% intact purple area with no drainage or s/s (signs/symptoms) of infection. Date of onset 3/10/22. Left heel - pressure - SDTI. 6 cm x 9.5 cm. Wound presents as a 100% intact purple area with no drainage or s/s infection. Date of onset 3/10/22. The wound Nurse Practitioner (NP) began following the resident on 3/10/22. Appropriate treatment, Care Plan interventions and supplements were implemented. Surveyor noted R2's Head to Toe skin check sheets, dated 3/24/22 and 4/1/22 did not document pressure injuries on R2's heels, despite the fact SDTI's were identified on 3/10/22. Surveyor noted R2's TAR (Treatment Administration Record) did not document Diabetic foot checks were implemented upon admission or completed. Surveyor noted R2's March TAR indicated Diabetic foot checks every HS (every evening shift) to promote skin integrity was implemented on 3/12/22 (after the bilateral heal pressure injuries were identified). Review of the facility wound documentation and the NP wound notes revealed appropriate treatment and interventions implemented. NP notes dated 3/31/22 documented the left and right heel pressure injuries as unstageable, dry eschar. NP notes on 4/29/22 document: Unstageable pressure injury left heel. 75% dry black eschar, 25% granular tissue measuring 5.3 x 4.3 cm with lifting edges. Small serosanguinous drainage. Positive pedal pulse. No s/s of infection. Softening eschar peeled easily from edges of wound. Status: Improved. Unstageable pressure injury right heel. 100% dry eschar measuring 4.5 x 5.4 cm. Lifting edges. Scant serosanguinous drainage. Positive pedal pulse. No s/s of infection. Softening eschar peeled easily from edges of wound. Status: Improved. On 5/3/22, at 9:20 AM, Surveyor observed R2 sitting in a Broda chair in the dining room. R2 was wearing soft protective boots on both feet and his heels were wrapped in gauze. On 5/3/22, at 10:35 AM, Surveyor spoke with Wound Registered Nurse (WRN)-E. WRN-E reported on 3/10/22 during wound rounds, WRN-E completed a head to toe assessment on R2 and identified the SDTI's on both heels. WRN-E reported all residents are provided pressure relieving mattress and cushion upon admission. Surveyor advised WRN-E that R2 did not have Diabetic foot checks implemented upon admission and the Care Plan did not include turning and repositioning or floating of heels despite the fact R2 was identified to be at risk for pressure injuries and required 2 person physical assist with bed mobility. WRN-E stated: I don't know why turning and repositioning, floating heels or boots were not on the care plan, it should have been, especially since he is diabetic and immobile. The facility did not complete daily Diabetic foot checks on R2 despite the fact he was at risk for pressure injuries, was immobile, and required 2 person physical assist for bed mobility. Preventative measures such as turning and repositioning, floating heels or pressure relieving boots were not implemented until after SDTI's developed. On 3/3/22, at 3:00 PM, this Surveyor advised Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the above concerns. No additional information was provided. 2. The facility's policy titled, Skin Management, with revision date of January 2022 documents under, Ongoing Skin Assessments: 3. The nurse will initiate treatments, interventions, Care Plan, and the appropriate skin documentation records in a timely manner according to Practice Guidelines. R4 was admitted to the facility on [DATE], with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MDS (Minimum Data Set) with assessment,t reference date of 4/6/22 documents, A Brief Interview of Mental Status score of 15, indicating R4 is cognitively intact; PHQ-9 (Patient Health Questionnaire) assessment score of 12, indicating moderate depressive symptoms; R4 is assessed to be at risk for the development of pressure injuries with no unhealed pressure injuries upon admission; R4's surgical wound was identified; R4 requires extensive two + person physical assist for bed mobility, transfers, personal hygiene and toileting needs; unstable and only able to stabilize with human assist when moving from seated to standing position and transferring from surface to surface; lower extremity, one sided limited range of motion and uses a wheelchair for mobility; occasionally incontinent of bladder and frequently incontinent of bowel and not on a bladder or bowel toileting program. R4's Orthopaedic Surgery Discharge Summary, dated 3/30/22 documents, R4 was admitted to the hospital 3/22/22 after a ground level fall and left femur fracture and had a left total hip arthroplasty' (surgical reconstruction or replacement of a joint) on 3/25/22. R4's Braden Scale for Predicting Pressure Sore Risk score dated 3/30/22, documents a score of 11, indicating R4 is at a High Risk for the development of pressure injuries. R4's baseline care plan titled, Interim Resident Kardex with admitted [DATE] has check boxes under section Skin Intact, Skin Impairment, and Preventative Care: .Repositioning Freq: (frequency) , which are blank. R4's baseline care plan does not address R4's assessed high risk for the development of pressure injuries and does not include interventions to prevent pressure injury development. (Cross Reference F655) R4's Nursing Daily Skilled Charting, note dated 4/4/22, signed by Registered Nurse (RN) H, documents, . G. Skin/Wound: 1. Is skin intact? No, is checked. Under 1a. Skin Integrity Issue(s) .e. Pressure Ulcer and f. Non-Pressure Ulcer, are not checked, and g. Surgical Incision, is checked. Under, 1b. Document for each skin integrity issue if it was previously identified, location and status, it's left blank. R4's, SNF (Skilled Nursing Facility) Progress Note, dated 4/4/22, signed by Advanced Practice Nurse Practitioner (APNP)-I documents, Subjective: Today patient resting in bed .Limited range of motion to left leg .Wound nurse observed skin shear to buttocks. Skin precautions initiated: new air mattress, prevalon boots, and wound care following. This Surveyor is unable to locate documentation of wound assessments, measurements or wound treatment in R4's medical record until 4/8/22 (4 days after the area to the buttock was identified). R4's care plan was not updated to address the identified shearing to R4's buttocks and the new interventions of an air mattress, prevalon boots and wound care to follow were not added to R4's care plan. On 5/3/22, at 3:35 PM, this Surveyor interviewed Wound Registered Nurse (WRN) E. WRN-E stated that WRN-E does not recall being notified of R4's skin shearing to the buttock identified on 4/4/22. On 5/3/22, at 4:00 PM, this Surveyor interviewed APNP-I via telephone. APNP-I stated APNP-I does not remember the 4/4/22 encounter with the facility Wound RN and being informed of R4's skin shear to the buttocks documented in her progress note. APNP-I further stated that, The wound nurse (referred to in APNP-I's progress note) would be WRN-E, and that, If I wrote it, then it happened. APNP-I also stated the facility Contracted Wound NP (CNP)-F isn't at the facility on Mondays, (4/4/22 was a Monday), and CNP-F comes to the facility later in the week. APNP-I stated she must have been informed of R4's skin shear to the buttock by facility wound nurse, WRN-E, if that's what was documented in R4's medical record. On 5/3/22, at 4:20 PM, WRN-E informed Surveyor he did not find any notes regarding the 4/4/22 encounter with APNP-I, and further stated he was not working at this facility on 4/4/22 and WRN-E was working at one of their other facilities on 4/4/22. WRN-E stated he doesn't know which wound nurse APNP-I would be referring to in her progress note. R4's Wound Care Assessment progress note, dated 4/8/22, electronically signed by Contracted Wound NP (CWNP)-F documents, Assessment: .Unspecified open wound to right buttock, initial encounter, and .Unspecified open wound of left buttock, initial encounter. Physical Examination: Right buttock - shearing: Partial thickness wound, pink wound bed, measures 1.7 x 0.7 cm (centimeters) x 0.1 cm. Peri wound area is peeling. Scant amount of serosanguinous (mixture of blood and the liquid part of blood - serum), drainage. No s/sx (sign or symptoms) of infection Plan - Cleanse with NSW (Normal Saline Water), apply Xeroform (a kind of dressing that keeps air out), and cover with bordered foam (a foam dressing with a waterproof adhesive backing), three times a week. Physical Examination: Left buttock - shearing: Partial thickness wound, pink, friable wound bed, measures 3.7 x 4.0 x 0.1 cm. Peri wound with blanchable [CONDITION(S)] and peeling skin. Wound with moderate amount of serosanguinous drainage. No s/sx of infection Plan - Cleanse with NSW, apply Xeroform and cover bordered foam three times a week. R4's Skin -Weekly Non-Pressure Condition Record note, dated 4/8/22, signed by WRN-E reads documents, 1a. Site for this assessment: 32) Right Buttock .1b. Date of Onset: 04/08/2022: 1c. Is this a new or existing Non-Pressure Skin Condition? b. New, is checked. 1d. Was resident admitted with this Non-Pressure Ulcer or was it acquired while in facility? b. Acquired at Facility, is checked. The document reads the Right Buttock wound is shearing and measures, 1.7 in length x 0.7 in width. No depth measurement is found. It further reads, Wound bed is 100% smooth pink with rolled flap of skin noted at distal portion, a scant amount of serosanguineous drainage is noted and no s/s (signs or symptoms) infection are noted. R4's Skin -Weekly Non-Pressure Condition Record note dated 4/8/22, signed by WRN E reads under, 1a. Site for this assessment: 32) Left Buttock .1b. Date of Onset: 04/08/2022: 1c. Is this a new or existing Non-Pressure Skin Condition? b. New, is checked. 1d. Was resident admitted with this Non-Pressure Ulcer or was it acquired while in facility? b. Acquired at Facility, is checked. The document reads the Left Buttock wound is shearing and measures 3.7 in length x 4 in width. No depth measurement is found. It further reads, Wound bed is 100% smooth pink with rolled skin flap at edges, there is a moderate amount of serosanguineous drainage noted and no s/s infection observed. On 5/4/22, at 8:10 AM, WRN-E stated that R4 discharged to another facility an hour after her wounds were assessed on 4/8/22. On 5/4/22, at 8:29 AM, DON-B stated that DON-B has no idea who APNP-I could be referring to (in APNP-I's progress note dated 4/4/22), because WRN-E is the only wound nurse at the facility. Surveyor asked DON-B what caused the delay in assessment, measurement and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . DON-B confirmed the date of 4/8/22 as the initial assessment, measurement and treatment order for the wounds to R4's buttocks. DON-B assumes R4's buttock wound assessments, measurements and treatment orders had slipped through the cracks. On 5/4/22, Nursing Home Administrator-A and Director of Nursing-B were informed of the concern R4 developed shearing to her buttocks, preventative measures where not put into place prior to the development of the areas, the areas were identified on 4/4/22 and not assessed, measured, and a treatment ordered until 4/8/22. No further information was provided.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19. This created a reasonable likelihood for serious harm to all 67 residents residing within the facility at the time of the outbreak on 12/23/21. At the time of survey, this outbreak has affected 8 residents and 18 staff. The facility did not: *Recognize when an outbreak had occurred and did not implement appropriate precautions to prevent the further spread of infection. * Screen all residents for signs and symptoms of COVID-19 daily and increase screening to every shift once the outbreak was identified. *Implement use of Full PPE (Personal Protective Equipment). *Stop communal activities. *Map the COVID positive infections to ascertain outbreak tracing and source. *Place dedicated staff on Long Term Care Unit One where the outbreak was in progress. *Retrain all staff on appropriate use of PPE: observations and interviews confirmed that staff did not always wear full PPE. The above failures created a finding of immediate jeopardy that began on 12/23/21. The NHA-A (Nursing Home Administrator), DON-B (Director of Nursing), CC-C (Corporate Consultant) were notified of the immediate jeopardy on 1/5/21 at 3:30 PM. The immediate jeopardy was removed on 1/07/22, however the deficient practice continues at a scope/severity of F (potential for more than minimal harm, widespread) as the facility continues to implement its removal plan. Findings include: The facility policy titled, Caring for a Resident with suspected/confirmed COVID-19, dated March 18. 2021, indicated: In the event that a resident is SUSPECTED of COVID-19 should be moved to a single room on the observation cohort, if possible, pending results. While awaiting results of testing, staff should wear an N95 respirator (or facemask if respirator is not available), eye protection (i.e. goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Initiate droplet and contact transmission-based precautions and post appropriate signage. If the suspected COVID-19 resident has a roommate, leave the roommate in their current bed while awaiting additional information on the suspected resident. While awaiting test results, monitor the roommate closely for COVID-19 symptoms. Initiate COVID-19 Enhanced Screening (Electronic Medical Record order template) for all residents to document every shift temperature check, oxygen saturation checks, and symptom monitoring. Dedicate staff to care for residents with suspected COVID-19 to reduce the potential for the spread of infection to other areas of the center. Consider using Contact Tracing Tools (staff and resident). Track symptomatic residents on a center room map. Continue to update the map with symptomatic and COVID-19 positive cases, as needed. On 1/3/22, at 9:00 AM, the Survey Team filled out paper screening forms, self -temperature taken, and placed the form into a bin. On 1/3/22, at 9:48AM, Surveyor interviewed R2 regarding care in R2's semi-private room while observing that roommate R5, without a mask, was self-propelling in and out of the room into the hallway, talking to staff, and asking the nurse questions about medications. R2 and R5's room was located in the unit designated by the facility as Long Term Care Unit One. On 1/3/22, at 11:40 AM, Surveyor was made aware by R2's family member that R2's roommate R5 was positive for COVID-19. On 1/3/22, at 12:15 PM, the Survey Team observed communal food service in the dining room with residents. On 1/3/222, at 12:36 PM, Surveyor observed R2's room had an isolation cart outside the room with 1 yellow disposable gown and a new typed white sign on the door regarding the need for PPE. Surveyor observed RCS-G (Resident Care Specialist) and RCS-H providing meal trays to R2 without gowns or eye protection. RCS-G stated we enter and exit in 2 seconds and there is limited amounts of PPE (Personal Protective Equipment) and no gowns. On 1/3/22, at 12:39 PM, Surveyor interviewed DON-B (Director of Nursing) regarding testing, isolation, and COVID-19 in the facility. DON-B stated 3 residents (R7, R8, and R9) were positive for COVID-19. DON-B stated the IP-D (Infection Preventionist) was unavailable due to a respiratory infection and that all residents and staff had been tested via PCR testing on Friday 12/31/21. DON-B stated some residents were symptomatic with cough and fever and should be in isolation. DON-B stated that the facility had no shortage of gowns or goggles and the staff had been trained. DON-B stated the facility was accepting admissions but she did not know the policy as IP-D was not available. DON-B stated R5 was symptomatic with cough and fever even though rapid test was negative, R5 should have been moved and monitored. DON-B stated she did not know about roommates of symptomatic residents. DON-B stated all policies regarding COVID-19 would have to wait for the IP-D or NHA-A (Nursing Home Administrator) to come to the facility. On 1/3/22, at 12:50 PM, Surveyor interviewed LPN-E (Licensed Practical Nurse) who was the designated Long Term Care Unit One manager. LPN-E stated we are waiting for a key so we can get into the supply room because DON-B told us to get PPE from the subacute unit and they are out of PPE supplies. Surveyor observed an empty isolation PPE cart outside R2's room. LPN-E stated she did not know why R5 was not moved to the COVID-19 unit. LPN-E stated she did not know the COVID-19 policy and Surveyor should ask DON-B. On 1/3/22, at 12:55 PM, Surveyor shared concerns with DON-B regarding lack of follow through on a symptomatic resident (R5), no available PPE, and staff not following the isolation signs on R5's door with high risk of spread to roommate R2. DON-B stated the staff is pulling your leg that there is no PPE. On 1/3/22, at 1:40 PM, Surveyor shared COVID-19 concerns with NHA-A upon his arrival to the facility who stated he will get information to the team that might be missing. NHA-A stated there are 4 positive COVID-19 residents (R5, R9, R10, and R11) in the facility this am which makes a total of 7 positive residents. On 1/3/22, at 2:40 PM, Surveyor wore full PPE to re-interview R2 and noted the isolation sign had been removed from the door and the isolation cart had been taken away despite R2's days of being exposed to positive roommate R5 and being potentially infected/infectious to others. On 1/3/22 at 2:50 PM, Surveyor interviewed LPN-E who stated yes, the isolation cart and sign were removed from R2's doorway as R5 was moved to the COVID-19 unit and isolation is not needed for R2. On 1/3/22, at 2:55 PM, Surveyor interviewed DON-B who stated R5 was moved to the COVID unit and they are trying to move the other positive residents but the facility is running out of rooms and housekeeping is behind with cleaning the rooms. Surveyor questioned DON-B regarding R2 who is still in the double room and not isolated but with significant exposure. DON-B stated R2 had a negative PCR test on 12/31/21 but we could test her again. Surveyor requested policy and DON-B stated she did not know as IP-D was out the building. DON-B stated she did not know if R2 should be in isolation but not now as there is no place to go. On 1/3/22, at 3:25 PM, NHA-A stated he would obtain COVID-19 policies from CC-C (Corporate Consultant). On 1/4/22, at 7:30 AM, the Survey Team filled out paper screening forms, self -temperature taken, and placed the form into a bin. NHA-A stated the facility held an ad hoc meeting early this am and all policies are 100% updated as of this am. NHA-A stated IP-D came to the facility for the meeting and both hallways on Long Term Care Unit One where the COVID positive residents were residing and exposed others are now in isolation with Enhanced Barrier precautions and Droplet Isolation. Surveyor questioned if that should have been done previously or even yesterday. NHA-A chose not to respond I don't want to say yes. Surveyor noted nursing staff continued to wear surgical masks, not N95s and requested policies, line lists, 1st positive identified and plan of action, staffing for the last 2 weeks. On 1/4/22, at 8:00 AM, Surveyor asked NHA-A about the plan of action as no isolation signs are up and no PPE was observed in Long Term Care Unit One as observed by Survey Team. NHA-A stated the Director of Housekeeping is now pulling all the boxes of PPE and there is a plan to put the isolation signs up. NHA-A stated all the staff need to be wearing N95s because of suspected exposure in the hallways. NHA-A stated DON-B was educated on COVID-19 and policies. On 1/4/22, at 8:40 AM, the Survey Team noted staff dropping off several new plastic 3 drawer bins into the front lobby. Surveyor interviewed IP-D in a front conference room as she had a respiratory infection. IP-D shook the bag with her rapid COVID negative test to prove her negative status in front of the Surveyor who was wearing an N95 and googles. IP-D stated she was the IP and staff development for 2 years. IP-D stated a staff member was positive on 12/23/21 and she started outbreak testing. Another staff was positive on 12/24/21 and a resident on 12/25/21. IP-D stated the contract tracing shows the outbreak on Long Term Care Unit One but it was not placed into exposure precautions. IP-D stated some of the RCS (Resident Care-Nursing Assistants) and nurses worked across units and split assignments. IP-D stated that now looking back in hindsight the Long Term Care Unit One should have been in isolation as all the residents that tested positive were from that unit. IP-D stated she told the facility to place signs for R2 and R5 but the residents are moved to the COVID-19 unit now, R5 who was COVID-19 positive and R2 due to the extended exposure. DON-B stated testing happened on 12/25/21, 12/31/21, and 1/3/22 due to the outbreak. DON-B stated the facility will catch up with testing any staff who were not in the facility on 1/3/22. DON-B stated as more people were becoming positive, she realized all were from Long Term Care Unit One and if symptomatic, residents should be moved to COVID-19 unit with private rooms as staff in the specialized unit are more used to caring for COVID-19 residents and would decrease the workload in the long term units. DON-B stated COVID-19 protocol states residents are monitored daily with respiratory assessments but a month ago we were doing it every shift. DON-B stated all families were contacted and Long Term Care Unit One should have been in isolation yesterday. Surveyor requested any COVID/PPE education that had been provided to the staff. DON-B provided a copy of her handwritten notes from her stenographic notebook which listed the names of positive residents and staff. On 1/4/22, at 9:10 AM, Surveyor observed R2 in the resident room on the Long Term Care Unit One despite IP-D stating she had been moved due to R2's exposure. NHA-A provided schedules and Surveyor shared concerns over R2's move or not move, exposures and the hallways that should have been in isolation and/or exposure precautions. NHA-A stated right, that is what we discussed this am, and education is being done. NHA-A stated he would go over the policy again with IP-D re R2's not being moved. On 1/4/22, at 10:35 AM, Surveyor interviewed DM-K (Dietary Manager) regarding the dining room. DM-K stated communal dining room will be closed due to the outbreak today and all residents will receive room trays. DM-K stated the COVID-19 unit will receive their food on foam and paper. On 1/4/22, at 11:00 AM, IP-D brought Immunization records to the Surveyor conference which was accessible by walking through the Long Term Care Unit One hallways. IP-D did not have an N95 mask, wore a surgical mask below her nose, and had a cough. On 1/4/22, at 1:05 PM, Surveyor was talking with NHA-A outside R1's room in the Long Term Care Unit One hallway. Surveyor and NHA-A observed RCS-L walking in and out of rooms delivering food trays without gowns or gloves despite signs on the door with RCS-I assisting with the food cart. Surveyor questioned RCS-L if she needed a gown to enter the room to deliver and set up food trays and RCS-L stated no, only if they are COVID positive. NHA-A stated to RCS-I and RCS-L that they needed to wear gowns to go in the rooms and follow the signs on the door. On 1/4/221, at 3:00 PM, Surveyor met with NHA-A to request the outstanding need for any COVID-19 education as IP-D provided only education related to the recertification 9/2021 survey and POC (Plan of Correction). Surveyor conveyed an expectation of an organized line listing related to the outbreak including mapping and recognition of the issue. NHA-A stated yes that is the expectation to recognize when to shut down, isolate, PPE changes, and Quality review. COVID mapping was completed by the Surveyor from IP-D's notes and Surveyor shared the map of several COVID positive residents on Long Term Care Unit One with NHA-A. On 1/4/22, at 3:53 PM, IP-D entered the Survey Team conference room with an N95 under nose and mouth with COVID-19 education dated 3/16/20 to 6/25/20. On 1/4/22, at 4:15 PM, the Survey Team conducted a daily exit with NHA-A and DON-B sharing concerns. Surveyor questioned about R7 positive COVID-19 12-31-21 results as R7 was discharged on [DATE] with home health and there is no documentation in the chart of R7 being notified. NHA-A stated he is trying to follow up with R7. Survey team met separately with NHA-A to share observations of IP-D not wearing a surgical mask or an N95 appropriately over mouth and nose. On 1/5/22, at 7:30 AM, the Survey Team filled out paper screening forms, self- temperature taken, and placed the form into a bin. Surveyor observed NHA-A with surgical mask and goggles and DON-B with surgical mask and no eye protection walking down the Long Term Care Unit One hallway. On 1/5/22, at 7:38 AM, Surveyor questioned NHA-A regarding eye protection required on Long term Care Unit One and he stated goggles or shield in hallway to protect face and he will talk to DON-B who is a role model. On 1/5/22, at 8:00 AM, NHA-A stated the vaccination rate for the residents was 90% and 60% for the staff. NHA-A provided COVID-19 education that was initiated on 1/3/2022 but no other education has been done or available since 6/25/20. Surveyor reviewed the typed white paper signage that had been posted on all the resident doors which stated: Droplet and Contact Precautions Required PPE: Gown Gloves Mask Make sure you are washing hands with soap and water frequently throughout your shift. Make sure you wash your hands before leaving the isolation room. Surveyor questioned the NHA-A what is missing from the facility isolation signs on the residents' doors and NHA-A pointed to his goggles (indicating eye protection). The signage does not indicate the type of mask required. NHA-A stated the facility now has another resident, R14 who tested positive for Covid-19. On 1/5/22, at 8:25 AM, DON-B provided paperwork to the Survey Team and was observed to now being wearing goggles. On 1/5/22, at 9:00 AM, Surveyor observed RCS-I wearing PPE including a washable yellow gown, going from room to room delivering breakfast trays, setting them up without changing her gown. On 1/5/22 at 9:05 am, Surveyor observed AM-O (Activity Manager) on Long Term Care Unit One putting things up on the bulletin board. AM-O had a surgical mask on and no face shield/or goggles. Surveyor asked if the facility was having activities and AM-O stated not located on Long Term Care Unit One but she was having in-person activities on Long Term Care Unit 2 because they didn't have any COVID positive residents. AM-O stated she may take Long Term Care Unit One residents that are not COVID positive to Long Term Care Unit 2 to participate in activities. On 1/5/22, at 9:20 AM, Surveyor interviewed IP-D with CC-C at her side. IP-D stated all staff need to be wearing N95s and eye protection. IP-D stated she was told this am that the door signage was missing eye protection and she plans to put up new signs. On 1/5/22, at 10:44 AM, Surveyor interviewed IP-D who stated the definition of fully vaccinated was 2 shots but now it is a booster. IP-D stated she offered a booster clinic on 12/30/21, thinks she has offered other booster clinics but is unable to find the paperwork. IP-D stated she completed the infection screening for all the positive residents but not for all the exposed residents because it is all the residents in the whole building. IP-D stated she tries to look at the visitor and staff screening forms, every day she checks the previous evening and night, checks when she goes up front 2-3 times/day. IP-D stated she is trying to figure out the electronic system printout for screening as it does not match the log. IP-D stated the facility initiated an outbreak on 1/4/22 and testing of all staff and residents. IP-D reviewed the log of test results with Surveyor and noted R13 is positive and R1-room [ROOM NUMBER] is positive but several more residents are still pending. IP-D stated more staff are testing positive including RCS-I who was observed caring for residents without appropriate PPE. Surveyor noted RCS-I was currently working in the facility and had been observed breaking infection control practices by not following PPE guidelines in removing a contaminated gown from room to room. IP-D stated more tests were sent on 1/4/22 as staff were coming in to work. The results were logged as of 8:48 AM but not reviewed until Surveyor request at 10:44 AM. This facility had 67 residents at the start of survey on Monday 1/3/22. 90% of residents have been vaccinated for COVID-19 and 60% of staff have been vaccinated. The facility has had at least one clinic for booster shots, but it was not well attended and not widely advertised. IP-D thought she had held others besides the one on 12/30/21 but did not have documentation of any other booster clinics. On 1/5/22, at 11:00 AM, Surveyor observed NHA-A and CC-C begin placing orange facility enhanced droplet-contact precautions signs, dated March 20, 2020, on residents' doorways. Sign indicated: Perform Hand Hygiene N95 or surgical face mask when entering room Eye protection when entering room Gown when entering room Gloves when entering room Private room and keep door closed. Families and Visitors: Do not enter the room. Report to the nurses' station with questions. Eight of 67 residents (9%) were ill by the conclusion of the survey. At least one of these residents, R5 (the roommate of R2), was symptomatic with a cough and fever. On 1/6/22, at 12:23 PM, NHA-A sent a line listing with positive resident and staff stating Please see the attached. I've consolidated IP-D's line list notes. Long Term Care Unit One COVID positive residents: R07 PCR+ 12/25/21-Results on 12/28/21 R08 PCR+ 12/30/21- Results on 12/30/21 R05 PCR+ 12/31/21- Results on 1/3/22 R09 PCR+ 12/31/21- Results on 1/3/22 R10 PCR+ 12/31/21- Results on 1/3/22 R11 PCR+ 12/31/21- Results on 1/3/22 R01 PCR+ 01/03/22- Results on 1/5/22 R13 PCR+ 01/03/22- Results on 1/5/22 Staff Identified as working on Long Term Care Unit One and COVID positive: RCS-P Results 12/25/21 LPN-Q Results 12/24/21 RCS-R Results 12/28/21 RCS-S Results 12/28/21 RCS-T Results 12/27/21 RCS-U Results 12/28/21 RCS-V Results 12/27/21 RCS-W Results 12/27/21 Diet-X Results 12/29/21 Laund-Y Results 12/30/21 RCS-Z Results 12/29/21 RCS-BB Results 1/1/22 FT-CC Results 12/30/21 RCS-DD Results 12/31/21 RCS-L Results 1/6/22 AM-O Results 1/6/22 Diet-EE Results 1/5/22 RCS-I Results 1/5/22 The facility failure to: Recognize when an outbreak had occurred and to implement appropriate precautions to prevent the further spread of infection; Routinely screen all residents for signs and symptoms of COVID-19 daily and increase screening to every shift once the outbreak was identified; Implement use of Full PPE (Personal Protective Equipment); Stop communal activities; Map the COVID positive infections to ascertain outbreak tracing and source; Place dedicated staff on Long Term Care Unit One where the outbreak was in progress; and Retrain all staff on appropriate use of PPE where observations and interviews confirmed that staff did not always wear full PPE created reasonable likelihood that serious harm to all residents could occur, resulting in a finding of Immediate Jeopardy. The facility removed the jeopardy on 1/7/22, when it had completed the following: 1. Notified Medical Director on 1/5/22. 2. Completed a Root Cause Analysis and held an Adhoc QAPI (Quality Assurance Performance Improvement) on 1/4/22 3. Reevaluated COVID outbreak status and possible exposed residents determining all current residents met criteria of COVID exposure and were placed in enhanced droplet precautions on 1/5/22. 4. Conducted Inventory of all PPE in facility on 1/4/22 5. Implemented facility wide assessment order set to monitor respiratory status and signs/symptoms of COVID every shift for all current residents on 1/5/22. 6. Contacted Washington County Health Department to seek guidance on COVID outbreak at facility on 1/4/22. Suggested facility cease accepting new admissions as of 1/4/22. 7. Staff Education on: Outbreak Status-Occurrence, Enhanced Droplet Isolation, Hand Hygiene, Infection Control Signage, Doffing and Donning PPE, Proper Location and use of PPE, Proper Handling of Linen, Infectious Waste Procedure, Ongoing Staff Screening (Tracing/Line Listing-IP-D primary, DON-B backup) Ongoing cleaning and disinfection, Room moves to facilitate specific status, Visitation, Dining, Rehab, Activities, Appointments and Resident outings, Staffing including positivity rate, testing, and symptom based outbreak strategies. 8. Facility will review all new staff/resident positive COVID results to trend staff work locations and possible resident exposure. 9. Quality Assessment and Assurance to ensure ongoing compliance-random observations of resident care by focusing on hand hygiene and PPE.

Based on interview, observation and record review, the facility failed to prevent dehydration for 1 (R31) of 3 residents reviewed on enteral feeding. R31 had a Percutaneous endoscopic gastrostomy (PEG) tube placed 3/26/21. The facility failed to give R31 enough fluids which resulted in multiple hospitalization s for [CONDITION(S)]. The facility did not follow specific orders given to the facility to prevent [CONDITION(S)] and did not monitor or order electrolyte labs that showed high and critical levels of Na+ (sodium). R31 was readmitted to the hospital 3 times for [CONDITION(S)] and Acute Kidney Injury due to dehydration. The facility's failure to properly monitor, assess and correctly follow physician (MD) orders and treatments for nutrition and dehydration created a finding of Immediate Jeopardy (IJ) that began on 5/25/21. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Clinical Services (DCS)-E of the IJ on 8/24/21 at 1:34 PM. The IJ was removed on 08/27/21 however; the deficient practice continues at a scope/severity level of D (Potential for Harm/Isolated) as the facility continues to implement their action plan. Findings include: According to the Merck Manual on [CONDITION(S)] published by Brookwood Baptist Health and Saint Vincent's Ascension Health, Birmingham with a revision date of April 2020, [CONDITION(S)] is a serum sodium concentration > 145 mEq/L (> 145 mmol/L). It implies a deficit of total body water relative to total body sodium caused by water intake being less than water losses. A major symptom is thirst; other clinical manifestations are primarily neurologic (due to an osmotic shift of water out of brain cells), including confusion, neuromuscular excitability, seizures, and coma. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment is usually controlled water replacement . According to Best Practices for Managing Tube Feeding A Nurse's Pocket Manual by Abbott Nutrition under Selecting Tube-Feeding Formula and Volume documented, Tube-feeding formula and volume should meet nutritional needs based on a comprehensive initial and ongoing patient assessment. Interventions 1. Assess and document the patient's nutrition and hydration needs on admission, routinely, and when condition changes in the medical record. A. Estimating initial nutritional requirements: a. Energy: 20-35 Calories (Cal)/kilogram (kg) body weight/day b. Protein: 0.8-1.2 grams (g) protein/kg body weight/day1-3 c. Estimate water needs using a variety of methods, such as: o Approximately 2.5 liters (L) /day for women and 3 L /day for men o At least 2 L /day to replace obligatory water losses o 30-35 milliliters (mL) water/kg body weight/day or 1 mL water/Cal fed/day B. Increase water intake during conditions that elevate water needs: a. Replace gastrointestinal (GI) fluid losses (eg, vomiting, diarrhea, and ostomy drainage) with a rehydration solution that contains appropriate amounts of water and electrolytes b. Document therapy and patient's response in the medical record . 4. Each day check for factors that can affect hydration needs. Document the following conditions in the medical record, and notify the health care team regarding the need for additional fluids. A. Potential for water deficit: a. Increased water needs (eg, increased room temperature, low room humidity, fever (every degree of fever increases water needs by 10%), unhumidified oxygen therapy, air-fluidized bed therapy, and diuretics B. Potential for water and electrolyte deficit secondary to GI fluid losses (eg, vomiting, diarrhea, and wound and/or ostomy drainage) . Surveyor reviewed the facility's Enteral Nutrition policy with a date of 2017. Documented was .Each resident is provided with sufficient fluid intake to maintain proper hydration and health . A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. GUIDELINES .11. Nursing and dietary routinely monitor the following factors for evaluation of therapeutic efficacy, adverse effects, and clinical changes . b. Hydration - signs/symptoms of dehydration or overload, e.g., [CONDITION(S)] and cardiopulmonary or vital sign changes, are continuously evaluated . d. Laboratory values (indices of nutritional and hydration status) - monitored monthly or as ordered by the physician. Minimally, serum electrolytes, serum sodium (Na+), serum potassium, serum [MEDICATION(S)], glucose, blood urea [MEDICATION(S)] (BUN), serum creatinine, hemoglobin and hematocrit should be monitored . R31 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R31's admission MDS (Minimum Data Set) dated 3/15/21 documented a (BIMS) Brief Interview Mental Status score of 00 which indicated severe impairment. R31 was hospitalized [DATE] through 3/26/21 and a PEG tube was placed for nutrition and hydration after a pre-admission weight loss of 26 pounds (20.5%) in 5 months. Surveyor reviewed R31's Comprehensive Care Plan with an initiation date of 3/18/21 and a revision date of 4/6/21. Documented was, Focus: [R31] has potential for dehydration recent infections, feeding tube. Goal: o [R31] will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions: o Administer medications as ordered. Observe/document for side effects and effectiveness. o Ensure the resident has access to ordered food/fluids whenever o Lab work: BUN (blood urea [MEDICATION(S)]), creatinine as ordered o Observe vital signs as ordered/per protocol and record. Notify MD of significant abnormalities o Observe/document/report [as needed (PRN)] any [signs and symptoms (s/sx)] of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. o Obtain and Observe lab/diagnostic work as ordered. Report results to MD and follow up as indicated. o Provide liquids at consistency ordered by physician. Surveyor reviewed R31's Comprehensive Care Plan with an initiation date of 3/29/21 and a revision date of 4/28/21. Documented was, Focus: [R31] requires tube feeding ([MEDICATION(S)] 1.5) [related to (r/t)] Dysphagia, [history (hx)] of Weight Loss, [nothing by mouth (NPO)] status, impaired skin integrity Goals: o [R31] will be free of aspiration through the review date. o [R31] will remain free of side effects or complications related to tube feeding through review date. o [R31's] insertion site will be free of s/sx of infection through the review date. Interventions: o Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater than 250cc aspirate. o Elevate head of bed 30-45 degrees (semi-fowler's position) during feedings and at least 1 hour after feeding to prevent aspiration/pneumonia. o Observe/document/report PRN any s/sx of: Aspiration- fever, [shortness of breath (SOB)], Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. o Obtain and observe lab/diagnostic work as ordered. Report results to MD and follow up as indicated. o Provide local care to G-Tube site as ordered and Observe for s/sx of infection. o [Registered Dietician (RD)] to evaluate quarterly and PRN. Observe caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. o [Speech Therapy (ST)] evaluation and treatment as ordered. o The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Surveyor reviewed R31's MD orders with a start date of 3/26/2021. Documented was [MEDICATION(S)] 1.5 400 ml bolus via peg tube [three times a day (TID)] for supplement, water flushes of 100 ml before and after each feeding . House 2.0 Supplement give 4oz. [two times a day (BID)] for supplement. House 2.0 Supplement was increased 3/27/2021 to Med Pass 4oz Supplement three times a day. [MEDICATION(S)] was changed 3/27/21 to three times a day for supplement [MEDICATION(S)] 1.5 400 ml bolus via peg tube TID, water flushes of 100 ml before and after each feeding three times a day for supplement TF provides 1800kcal, 77g PRO, 1512ml fluid. Surveyor reviewed Former RD-Q's Progress Note with a date of 3/29/2021. Documented was Resident readmitted s/p PEG placement on 3/24/21. Diet is puree with NTL (nectar thick liquids). He is eating ~50% of meals. [Tube feeding (TF)] is ordered to supplement [oral (PO)] intake to help assist meeting estimated nutritional needs. TF provides 1800kcal, 77g [protein (PRO)], 1512ml total fluid with water flushes. His estimated nutritional needs are 1609-1876kcal (30-35kcal/kg IBW), 80-107g PRO (1.5-2g/kg IBW), 1609-1876ml (30-35ml/kg IBW). He needs total assist with meals. Writer recommends to change TF bolus times to b/w meals to help po intake at meal times. Awaiting nursing approval to change times. Will follow. The total fluid amount R31 was receiving was not adequate to his nutritional needs. On 4/15/21 labs were drawn. Results were sent to the facility and then faxed to the MD with no new orders. Documented results were [MEDICATION(S)] 3.0 [Low (L)], Protein total: 6.1 (normal), Prealbumin 18 (L), and Na+ 144 (normal). Surveyor reviewed Former RD-Q's Progress Note with a date of 5/3/21. Documented was Nutrition review: Diet is Puree NTL - po intake ~25% of meals. Receives Med Pass 4oz TID via po. TF ordered to supplement po intake - [MEDICATION(S)] 1.5 400ml bolus TID. Prostat 30ml BID ordered via PEG [related to (r/t)] stage 3 [pressure injury (PI)] to [left] hip and unstageable [PI] area to [right (R)] buttock. Total provided with TF, Prostat, Med Pass is ~2722kcal, 141g PRO and over 1500ml fluid/day - this excess his estimated nutritional needs. Weight is up to 111# from 105.8# 1 month ago -planned and desired weight gain. BMI=20.3. Resident is tolerating TF as ordered. Will con't po diet, TF and supplements to help promote weight gain and promote intact skin integrity. Will follow. The total fluid amount R31 was receiving was not adequate to his nutritional needs noted in the 3/29/21 assessment. R31 was hospitalized [DATE] through 4/23/21 and again 4/24/21 through 4/27/21. Surveyor reviewed Hospital Nutrition Services Assessment with a date of 4/20/21. Documented was [R31] is a [AGE] year old male who presents 4/20/21 with: [urinary tract infection ([CONDITION(S)])], [CONDITION(S)]/dehydration . Intervention . Monitor Na+: current H2O flush of 200 mL TID + IVFs running - fluids per primary team, pt admitted with [CONDITION(S)] . Surveyor reviewed Hospital Discharge Summary with a date of 4/27/21. Documented under Discharge Instructions was [MEDICATION(S)] 1.5 400 ml bolus TID, flush 200 ml TID (100 ml before/after each bolus) . Recommended Future Labs: Repeat electrolytes and renal function panel. 5-7 days per discretion of primary care physician . Surveyor reviewed R31's MD orders with a start date of 4/27/21. Documented was [MEDICATION(S)] 1.5 400 ml bolus via peg tube TID, three times a day for supplement, water flushes of 100 ml before and after each feeding . TF provides 1800kcal, 77g PRO, 1512ml fluid. On 5/7/21 labs were drawn. Results were sent to the facility and then faxed to the MD with no new orders. Documented results were 5/7/21 [MEDICATION(S)] 2.9L, Protein total: 5.9L, Prealbumin 17L Na 147 [High (H)]. Sodium level of 147 is high and suggests [CONDITION(S)] (reference range: 136 - 145 is normal.) Surveyor reviewed Former RD-Q's Nutrition RD Assessment with a date of 5/11/21. Documented was Nutrient Estimated Needs . 3. Fluid: 1609 - 1876 ml (30-35 ml/kg IBW). The total fluid amount R31 was receiving of 1512ml was not adequate to prevent dehydration. On 5/19/21 labs were drawn. Results were sent to the facility. R31 had a Critical Na+ level of 161. R31 was hospitalized [DATE] through 5/25/21 for [CONDITION(S)] and Aspiration Pneumonia and an [Acute Kidney Injury (AKI)] with [CONDITION(S)]. Documented was Prerenal in the setting of severe dehydration with active infection. Patient had numerous IV fluid boluses as well as LR infusion on admission. Electrolytes stabilized over course of hospitalization . Kidney function returned back to baseline. Patient Hospital Discharge Instructions with a date of 5/25/21 were: Nutrition Intervention: Enteral Nutrition: Type of Delivery: Intermittent Type of Enteral Formula: [MEDICATION(S)] 1.5 Delivery Mode: PEG Goal volume per feeding (ml): 400 ml Goal delivery rate (ml/hr): 200 ml Number of times per day: 3 Feedings/Suggested Schedule: 0800 (400 ml), 1300 (400 ml), 1800 (400 ml) Goal volume per day will provide ~1200 ml formula, 1800 kcals, 77 g protein, and 912 ml free water Enteral Nutrition Supplements: Continue 2 packets ProSource/day. Continue Banatrol TID as pt continues to have loose stools Total Nutrition: EN (1200 ml) + ProSource (2x/day) + Banatrol (TID) = 2000 kcals and 99 g protein Free Water Flushes: Continue 350 ml [every (Q)] 4 hours per MD order (5/23). Na+ elevated today (147) but trending down since increase in flushes Total Fluid: EN (912 ml) + free water flushes (2100 ml) = 3012 ml per day. Surveyor reviewed R31's MD orders with a start date of 5/25/21. Documented was [MEDICATION(S)] 1.5 400 ml bolus via peg tube TID for supplement, water flushes of 100 ml before and after each feeding. TF provides 1800kcal, 77g PRO, 1512ml fluid and May have small sips of thin liquids. No directions specified for order. The MD order does not follow the specific fluid intake orders on the hospital discharge summary. The fluid intake is 1500 ml less than the order given from the hospital. On 5/28/21 labs were drawn. Results were sent to the facility and Na+ level was 146 (High). Handwritten on the bottom of the lab sheet by Licensed Practical Nurse (LPN)-F was Resident [with (c)] new order for 400cc flush per recommendation from hospital. To be started with your approval. He currently gets 200cc flush. Handwritten underneath by MD-G with a date of 5/31/21 was Agree. Repeat [Basic Metabolic Panel (BMP)] 6/3/2021. Surveyor reviewed Former RD-Q's Nutrition Status Review with a date of 6/1/21. Documented was Diet is NPO. Resident receives tube feeding to provide 100% of his nutritional needs. TF provides 1800kcal, 77g PRO and 1512ml + med flushes for total fluid. Prostat 30ml TID is added via PEG for 303kcal, 51g PRO for wound healing. Resident has pressure injuries to L hip, R buttock and L lateral ankle - wound team is following. TF and Prostat provide a total of 2103kcal, 128g PRO. BMI=19.3- acceptable. Con't to monitor weight, TF tolerance and skin. Will follow. Resident estimated nutritional needs are: 1609-1876kcal (30-35kcal/kg IBW) 80-107g (1.5-2g/kg IBW) 1609-1876ml (30-35ml/kg IBW). The fluid intake and assessment does not follow the hospital specific guidelines for fluid intake. The Prostat was increased to 3 times daily but that still does not meet the fluid needs of 3012 ml recommended by the hospital. On 6/4/21 labs were redrawn per MD-G's orders. Results were sent to the facility and Na+ level was 151 (High). Handwritten on the bottom of the lab sheet by MD-G with a date of 6/4/21 was Na+ up a bit. Check BMP in 2 weeks. On 6/7/2021 an MD order was added to increase the amount of fluids given. Documented was [MEDICATION(S)] 1.5 400 ml bolus via peg tube TID, three times a day for supplement, water flushes of 200 ml before and after each feeding, TF provides 1200 kcal, 77g PRO, 1200 ml water flush. The flushes were increased but the free water flushes were still not put in place to meet the hospital recommended fluid intake of 3012 ml per day. On 6/18/21 labs were drawn. Results were not received at the facility and were not followed up on. Surveyor requested results during survey on 8/19/21. R31 had a high Na+ level of 154. The facility was unaware of the high Na+ level until requested during survey. R31 was hospitalized again 6/24/21 through 7/1/21 for [CONDITION(S)], Aspiration Pneumonia and a wound infection. R31's Na+ was high at 157 on admission to the hospital 6/24/21. Documented in the Discharge Summary with a date of 7/1/21 was Failure to Thrive/[CONDITION(S)] . TF via PEG, [MEDICATION(S)] 1.5 continuous, 100 cc/hr over 12 hours from 2000 - 0800 . for full hydration: 150 Q 4 H (~900 ml) - however if Na+ remains elevated may want to consider increasing to 200-250 Q4H pending Na trend . R31 was readmitted to the facility and the following MD orders were put in place to reflect the Hospital Discharge Summary: 7/1/2021 [MEDICATION(S)] 1.5 at 100 ml/hour via pump continuously from 2000-0800 - every shift for supplement TF provides 1200 kcal, 77g PRO, 1200 ml water flush. 7/1/2021 NPO (Nothing by Mouth) diet, NPO (Nothing by Mouth) texture, Regular consistency for may have sips of thin liquid for pleasure. 7/2/2021 Protein Liquid three times a day give Prostat 30ml via PEG. 7/2/2021 150ml water every 4 hours via g-tube, every 4 hours for hydration. Surveyor reviewed Former RD-Q's Quarterly Nutrition Status Review with a date of 7/5/21. Documented was Diet is NPO. Resident receives tube feeding to provide 100% of his nutritional needs. TF provides 1800kcal, 77g PRO and 1812ml + med flushes for total fluid. Prostat 30ml TID is added via PEG for 303kcal, 51g PRO for wound healing. Resident has pressure injuries to L hip, R hip, R buttock and coccyx - wound team is following. TF and Prostat provide a total of 2103kcal, 128g PRO. BMI=15.8- underweight. Con't to monitor weight, TF tolerance and skin. Will follow. Resident estimated nutritional needs are: 1609-1876kcal (30-35kcal/kg IBW) 80-107g (1.5-2g/kg IBW) 1609-1876ml (30-35ml/kg IBW). The RD's assessment did not include the free water flushes. The RD did not assess any lab values or electrolytes including Na+. On 7/22/21 R31 had labs drawn. There was no BMP which would have included Na+ drawn. The hospital specific instructions of if Na+ remains elevated may want to consider increasing to 200-250 Q4H pending Na trend could not be followed if there was no Na+ lab draw. There were no other labs drawn from 7/22/21 through 7/28/21. R31 was hospitalized again 7/28/21 through 8/3/21 for [CONDITION(S)] and Acute Metabolic [CONDITION(S)]. R31's Na+ was Critical at 165 on admission to the hospital on 7/28/21. Documented in the Discharge Summary with a date of 8/3/21 was [CONDITION(S)]: Assessment: Likely due to inadequate free water intake. Improved with IV fluids given in the ICU, which were stopped with increase of his water flushes. Plan: Na 143 on d/c repeat in 3-4 days. Surveyor entered the facility for survey on 8/17/21 and reviewed lab draws for R31 on 8/19/21 and 8/23/21. There was no Na+ draw as of 8/23/21. The facility and MD were updated by Surveyor on 8/23/21. On 8/23/21 at 1:36 PM Surveyor interviewed LPN-H. Surveyor asked who is in charge of making sure labs are followed up on. LPN-H stated the nurses on the floor and unit managers. Surveyor noted the 6/18/21 lab that was drawn and never arrived at the facility. LPN-H stated labs get lost all the time because the lab doesn't send them, they go to the wrong unit or the resident gets discharged . Surveyor asked where lab results are kept. LPN-H stated they should be downloaded into the chart. On 8/23/21 at 2:07 PM Surveyor interviewed Director of Clinical Services (DCS)-E and DON-B. Surveyor asked who is responsible to make sure labs are completed and followed up on. DON-B stated the unit managers. Surveyor asked what do the unit managers do when they get the results. DON-B stated they contact MD and follow up on any orders given. Surveyor noted the labs were not followed up on 6/18/21 and there has been no lab draw BMP per hospital directions 8/3/21. DON-B stated there should have been. On 8/23/21 at 1:08 Surveyor interviewed MD-G. Surveyor asked if he reviews readmission paperwork. MD-G stated yes, if I need to. Surveyor asked if the Nutrition orders are reviewed on readmission. MD-G stated he usually defers them to the RD. Surveyor noted the trending Na+ up: increase water flushes order and no labs drawn. Surveyor noted the repeat BMP in 3 to 4 days order from 8/3/21 discharge orders. MD-G stated he was not aware of either and would have ordered labs. MD-G stated I agree with your assessment - that is missing documentation. On 8/24/21 9:29 AM Surveyor interviewed RD-I. Surveyor asked how often a resident is being assessed for nutrition. RD-I stated monthly if on tube feeding. Surveyor asked if she assesses patients on readmission. RD-I stated yes. RD-I stated she reviews the hospital paperwork, reevaluates the orders they came in on and alerts nursing if changes are made. Surveyor asked if she reviews lab trends. RD-I stated yes. RD-I stated she watches Hemoglobin and Hematocrit, [MEDICATION(S)], BUN, Creatinine, Na+, Potassium and Chloride. Surveyor asked if these labs should be monitored often for R31. RD-I stated absolutely for a tube fed resident. Surveyor asked what she would do if she saw labs such as Na+, BUN, and Creatinine trending up? RD-I stated contact MD and possibly give orders to nursing to increase fluids as they may be dehydrated. The facility's failure to ensure R31 received care and treatment to prevent dehydration created a situation of immediate jeopardy that was removed when the facility implemented the following action plan. The deficient practice continues at a D (potential for harm/isolated). 1. Medical Director was contacted by the NHA and advised of deficiency. 2. Dietitian assessed all current residents with gastrostomy tube for risk of dehydration and recommendations as needed. 3. The facility secured a permanent Dietician on 8-16-21 who will assess residents with gastrostomy tubes upon admission, quarterly and change of condition and make recommendations as required. DON/ Nurse Manager will notify the Physician of these recommendations and obtain orders as required. 4. IDT (Nursing/Dietitian) will review hospital discharge recommendations/orders for follow through. 5. All licensed nursing staff was educated by the Nurse Manager on the center's process for obtaining labs as ordered by the physician, monitoring for return of results and reporting of results to the physician with plans to train remaining staff prior to assuming next shifts. 6. DON/Designee will audit 3 residents with new lab orders daily for 2 weeks, then 3 times a week for 2 weeks, then weekly thereafter until QA committee deems appropriate. 7. DON or Nurse Manager will review new admissions with gastrostomy tubes to ensure the Dietician has completed an assessment with recommendations daily for 2 weeks, then 3 times a week for 2 weeks, then weekly thereafter until QA committee deems appropriate.

Based on interview, observation and record review, the facility failed to ensure 4 (R31, R55, R14, and R21) of 4 residents reviewed for pressure injuries (PI) received care consistent with professional standards of practice, to prevent pressure injuries and residents with pressure injuries receive necessary treatment and services, to promote healing, prevent infection and prevent new injuries from developing. R31 was admitted to the facility with no wounds and with a high risk for skin breakdown. R31 had no care plan in place to prevent skin breakdown. R31 developed multiple pressure injuries including a Stage 4 and unstageable pressure injury to the buttocks area, right and left hips, heels, and feet. The wounds were not assessed timely or by a licensed nurse resulting in wounds deteriorating and developing additional areas. The facility's failure to identify prevent and address R31's pressure injuries based upon current standards of practice once developed created a situation of of immediate jeopardy that started on 4/27/21. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Clinical Services (DCS)-E of the immediate jeopardy on 8/24/21 at 1:34 PM. The immediate jeopardy was removed on 08/27/21, however; the deficient practice continues at a scope/severity level of G (No Actual Harm/Isolated) based upon the additional examples regarding R14. Examples involving R21 and R55 are being cited at the scope and severity of a D (potential for harm/isolated). R14 had a below the knee amputation and was at high risk for breakdown. R14's right stump and left heel were not adequately assessed or cared for resulting in deterioration of both areas and formation of pressure injuries. R21 was admitted with stage 4 pressure injury to the sacrum and stage 3 pressure injuries to the bilateral heels. The facility did not assess the wounds on admission and no assessment of the wounds was completed until 3 days after admission. R55 was admitted with a stage 2 pressure injury to the sacrum. The pressure injury was not assessed again after initial identification. Findings include: Infected Pressure Injuries in Elderly Individuals notes, Pressure ulcers have important consequences both for patients and for the health care system. They can lead to severe or intolerable pain, are prone to infection, and are associated with high mortality rates. They also inflict a considerable economical burden on the health care system. https://academic.oup.com/cid/article/35/11/1390/ 7 Advancing Excellence notes that Pressure ulcers can be dangerous and painful for a resident, in part because broken skin can allow infection into the body. If untreated, pressure ulcers can deepen and even expose the bone. Deeper ulcers may be hard to heal or may not heal at all. Sometimes, pressure ulcers can lead to death. The presence of pressure ulcers limits the quality of life for a resident as evidenced by: ~Decrease in bowel and bladder function ~More incontinence ~Decrease in ability to move without help ~Decrease in mental capacity ~Increase in pain ~Increased risk for infection ~Less participation in activities (http://www.nhqualitycampaign.org/files/factsheets/Staff%20Fact%20Sheet%20-%20Reducing%20Pressure%20Ulcers.pdf Mayo Clinic's website describes the complications of pressure injuries, including: ~[CONDITION(S)]. [CONDITION(S)] occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It's a rapidly progressing, life-threatening condition that can cause organ failure. ~[CONDITION(S)]. [CONDITION(S)] is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. [CONDITION(S)] can lead to life-threatening complications. ~Bone and joint infections. An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections ([CONDITION(S)]) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications. http://www.mayoclinic.org/diseases-conditions/bedsores/basics/risk-factors/con- 848 Review of the facility's Skin Management System: Policy, Practice Guidelines, Resources & References, and Skin Management System Algorithm with a revision date of July 2017. Documented was: POLICY Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provide treatment to prevent healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes . Staging as pressure injuries heal: When a pressure ulcer is staged appropriately as described above as a Stage 1, 2, 3 or 4 wound, the staging of the wound does not change as the wound heals and tissue fills any defects. Healing pressure ulcers are not backstaged. Backstaged refers to changing the staging as a wound heals . It is important to remember that an area that has a healed Stage 3 or 4 pressure ulcer remains vulnerable to pressure and shear forces, and that preventative measures, such as turning and repositioning, specialty mattresses and wheelchair cushions, should be considered to keep in place after the wound heals to prevent recurrence. PRACTICE GUIDELINES 1. Upon admission or readmission, residents are assessed for skin integrity by completing a head to toe physical assessment of skin conditions and completing the Braden Scale For Predicting Pressure Sore Risk User Defined Assessment (UDA) in conjunction with the Nursing Admission Data Collection Set (UDA) . 4. Residents admitted with skin impairments will have: a. Interventions implemented to promote healing; b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] c. Wound location and characteristics documented in the Nursing Admission Data Collection Set (UDA) . f. Completion of the Weekly Pressure Ulcer Record for pressure ulcers . 5. A Care Plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, and the interventions implemented to promote healing and prevent further breakdown . 9. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ONGOING SKIN ASSESSMENTS 1. A Weekly Skin Check will be completed in the resident's record using the Head to Toe Skin Check (UDA). Note: Alterations or change(s) in skin integrity, breaks in the resident's skin including skin tear, bruises, abrasions, ulcers, rash, surgical wounds, etc., are recorded on the Head to Toe Skin Check (UDA). 2. An SBAR Communication Form and Progress Note (UDA) is completed and a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The nurse will initiate treatments, interventions, Care Plan, and the appropriate skin documentation records in a timely manner according to Practice Guidelines. 4. Pressure ulcers are measured and staged in accordance with the Practice Guidelines . 1.) R31 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R31's Admission Data Collection with a date of 2/27/21. Documented under Skin Conditions was 1. Is resident's skin intact? A. Yes. Surveyor reviewed R31's Skin - Head to Toe Skin Checks form with a date of 2/27/21. Documented was 1. Skin Integrity: 1o. Existing Other Issues. 1p. Describe new or existing other issues: He has a 3 [inch] incision on Right hip and a dressing is on. R31 was hospitalized [DATE] through 3/8/21. Surveyor reviewed R31's Admission Data Collection with a date of 3/8/21. Documented under Skin Conditions was 1. Is resident's skin intact? A. No. 2. Does the resident have pressure ulcers? b. No. Surveyor reviewed R31's Skin - Head to Toe Skin Checks form with a date of 3/8/21. Documented was 1. Skin Integrity: 1o. Existing Other Issues. 1p. Describe new or existing other issues: surgical incision right hip with staples. R31's Braden Scale for Predicting Pressure Sore Risk with an assessment date of 3/15/21 documented score of 10 which indicated high risk. R31's admission MDS (Minimum Data Set) dated 3/15/21 documented a (BIMS) Brief Interview Mental Status score of 00 which indicated severe impairment. Documented under Functional Status for bed mobility was 3/2 which indicated R31 required extensive assistance with one person physical assist. Documented under Skin Conditions was Is this resident at risk of developing pressure ulcers/injuries? 1. Yes and Does this resident have one or more unhealed pressure ulcers/injuries? 0. Yes. Number of Stage 2 pressure ulcers: 2. Surveyor reviewed R31's Care Area Assessment (CAA) related to Pressure Ulcer/Injury with an assessment date of 3/15/21. Documented under Nature of the Problem/Condition was .Two Stage 2 pressure injuries, [treatment (tx)] in place, to be seen by Wound [Nurse Practitioner (NP)] . Surveyor reviewed R31's Skin - Head to Toe Skin Checks form with a date of 3/15/21. Documented was 1. Skin Integrity: 1l. New Pressure Ulcer . 3. Site: Coccyx. Type: Pressure. Length: 1cm. Width: 1cm. Depth: blank. Stage: blank . Site: Coccyx. Type: Pressure. Length: 2.5cm. Width: 2cm. Depth: blank. Stage: blank . 4. Further description of skin issues: Two open areas were noted on [right (R)] coccyx area. First area that is located superior to the other is 1 cm by 1 cm. It is red and pink in the middle. The edges are not approximated. The second [open area (OA)] that is inferior is 2.5 cm by 2 cm. It is red and pink in the middle. The edges are not approximated. There was no Stage noted in the assessment of the areas. Surveyor reviewed MD Orders for 3/15/21 through 3/18/21. There was no treatment order put in place for the pressure injuries identified on R31's coccyx. Progress Notes stated there was a dressing in place but there was no documentation of what the treatment was, if the dressing was changed and any staging or assessment of the areas. There was no Care Plan in place either to prevent skin breakdown and help heal the areas. Surveyor reviewed R31's Skin - Weekly Pressure Ulcer Record form with a date of 3/18/21 completed by Licensed Practical Nurse (LPN)-F. Documented was Date of Onset: 3/15/21 . Site: Right buttocks. Type: Pressure. Length: 7.0 cm. Width: 2.5 cm. Depth: 0.1 cm. Stage: Unstageable. Additional Description of Site documented large area of deflated flat blister with (2) wounds within area. Wounds are 50% viable red tissue and 50% whitish yellow nonviable tissue . The wound deteriorated to an unstageable pressure injury and grew in size. Surveyor reviewed Wound Care Assessment documented by Former NP-J with a date of 4/8/21. Documented was Pressure ulcer of right buttocks, stage 3: Scattered full thickness wounds within the dimension of 7.0 cm x 2.5 cm x 0.2 cm. The base is 50% granular 50% yellow slough covered. There is blistering noted at the proximal aspect of wound. Periwound is intact. No signs or symptoms of infection. Status: New - facility acquired 3/18 border foam 3 times a week, air mattress. Surveyor reviewed R1's Comprehensive Care Plan with an initiation date of 3/18/21. There was no preventative care plan in place prior to 3/18/21. Documented was: Focus: [R31] has Potential and Actual Skin Issues related to: incontinence, impaired mobility, [CONDITION(S)], malnutrition, poor [oral (po)] intake. Goal: [R31's] skin will not show any new signs of breakdown by next review. Interventions: o Notify MD of changes in wound or emerging wounds. o Observe wound healing. o Provide wound care / preventative skin care per order. o Skin checks weekly per facility protocol, document findings o Turn and reposition frequently to decrease pressure. R31 was hospitalized [DATE] through 3/26/21. Surveyor reviewed R31's Admission Data Collection with a date of 3/26/21. Documented under Skin Conditions was 1. Is resident's skin intact? A. No. 2. Does the resident have pressure ulcers? b. Yes . Site: Right buttock. Type: Pressure. Length: 1.8 cm. Width: 0.9 cm. Depth: blank. Stage: blank. Site: Right buttock. Type: Pressure. Length: 2.0 cm. Width: 0.8 cm. Depth: blank. Stage: blank. Site: Right buttock. Type: Pressure. Length: 4.3 cm. Width: 2.4 cm. Depth: blank. Stage: blank. There were no Stages noted and no assessment of the wound bed for the three areas. Surveyor reviewed R31's Skin - Head to Toe Skin Checks form with a date of 3/30/21. Documented was 1. Skin Integrity: 1m. Existing Pressure Ulcer. There was no further documentation of site, type, measurements, stage or assessment of wound. Surveyor reviewed R31's Skin - Weekly Pressure Ulcer Record form with a date of 4/1/21 completed by Licensed Practical Nurse (LPN)-F. Documented was Date of Onset: 3/18/21 . Site: Right buttocks. Type: Pressure. Length: 1.5 cm. Width: 1.3 cm. Depth: 0.1 cm. Stage: Unstageable. Additional Description of Site documented area has greatly improved with only one remaining wound. Wound is smaller but with nonviable base. Wound edges are attached. No [signs and symptoms (s/s)] of infection . 3a. Describe the wound bed appearance: c. Yellow. Former NP-J also assessed R31 on this day and documented the same measurements and assessments. During review, it is noted there is only one area referenced versus the 3 areas referenced on 3/26/21. Surveyor reviewed R31's Comprehensive Care Plan with a revision date of 4/1/21. Documented interventions that were added were off load heels in bed with pillows/boots and air mattress with small bolsters. Surveyor noted that air mattress was ordered by NP on 3/18/21. There were no other updated interventions to the care plan after 4/1/21. Surveyor reviewed R31's Skin - Head to Toe Skin Checks form with a date of 4/6/21. Documented was 1. Skin Integrity: 1m. Existing Pressure Ulcer . Site: Coccyx. Type: Pressure. Measurements and staging were left blank. Surveyor reviewed R31's Skin - Weekly Pressure Ulcer Record form with a date of 4/8/21 completed by Licensed Practical Nurse (LPN)-F. Documented was Date of Onset: 3/15/21 . Site: Right buttocks. Type: Pressure. Length: 6.0 cm. Width: 0.5 cm. Depth: 0.1 cm. Stage: Unstageable. Additional Description of Site documented wound base 80% viable granulation tissue and 20% yellow slough. Area is larger as an area that was previously closed has reopened and now has 2 wounds within measurements. Wound deteriorated since assessment on 4/1/21. During review, it is noted there is only one area referenced versus the 3 areas referenced on 3/26/21. Surveyor reviewed Wound Care Assessment with a date of 4/8/21 documented by Former NP-J. Documented was Pressure ulcer of right buttocks, stage 3: 2 full thickness wounds measuring 6.0 cm x 2.0 cm x 0.1 cm. The base is 50% yellow slough covered and 50% granular and there is a small amount of serosanguineous drainage. Periwound with scar tissue. No s/s of infection. Status: stable - measurement is larger due to previous wound that appears to be healed last week draining today . Surveyor noted there has only been one wound documented on by NP during assessments of right buttocks. There is no documentation of additional wounds (3 areas) as referenced on 3/26/21. Surveyor reviewed R31's Skin - Weekly Pressure Ulcer Record form with a date of 4/15/21 completed by Licensed Practical Nurse (LPN)-F. Documented was Date of Onset: 3/15/21 . Site: Right buttocks. Type: Pressure. Length: 1.5 cm. Width: 1.3 cm. Depth: 0.1 cm. Stage: Unstageable. Additional Description of Site documented wound base 80% viable granulation tissue and 20% yellow slough. One wound has resolved with area measuring much smaller. Surveyor noted there has only been one wound documented on by facility during assessments of right buttocks. There is no documentation of a second or third wound to the right buttocks as initially assessed on 3/26/21. Surveyor reviewed Wound Care Assessment with a date of 4/15/21 documented by Former NP-J. Documented was Pressure ulcer of right buttocks, unstageable: full thickness wound measuring 1.5 cm x 1.3 cm x 1.0 cm. The base is 100% yellow slough covered and there is a small amount of serosanguineous drainage. Periwound with scar tissue. No s/s of infection. Status: improved . Surveyor noted the NP assessment of right buttocks notes 100% slough which deteriorated from last assessment. The documentation contradicts the facility assessment of 80% viable granulation tissue and 20% yellow slough. During review, it is noted there is only one area referenced versus the 3 areas referenced on 3/26/21. R31 was hospitalized [DATE] through 4/23/21. Surveyor reviewed Hospital Admission Notes which documented .coccyx wound, wrist abrasion, and skin tear to left hip - all present on admission . Surveyor reviewed R31's Admission Data Collection with a date of 4/23/21. Documented under Skin Conditions was 1. Is resident's skin intact? A. No. 2. Does the resident have pressure ulcers? b. Yes . Site: Right buttock. Type: Pressure. Length: blank. Width: blank. Depth: blank. Stage: blank . There was no Stage noted and no assessment of the wound bed of the pressure injury. A comprehensive assessment was not completed on readmission. Surveyor reviewed R31's Skin - Head to Toe Skin Checks form with a date of 4/23/21. Documented was 1. Skin Integrity: 1m. Existing Pressure Ulcer . Site: Right Buttocks. Type: Pressure. Measurements and staging were left blank. R31 was hospitalized [DATE] through 4/27/21. Surveyor reviewed Hospital Wound/Skin Nurse Specialist Consultation with a date of 4/26/21. Documented was .seen today for consultation at the request of [MD] for multiple wounds . * Pressure Injury Sacrum Midline . Present on Hospital Admission: Yes .Site Assessment: Yellow; white; sloughing; moist; fibrin; pink. Peri-Wound Assessment: Intact; scarred. Wound Length (cm): 3.2 cm. Wound Width (cm): 2.1 cm . Wound Depth: 0.2 cm . Wound Bed Slough (%): 90% . Pressure Injury Stage: [Unstageable (U)] . * Pressure Injury Hip Left . Present on Hospital Admission: Yes .Site Assessment: moist; red (dark red areas throughout wound bed). Peri-Wound Assessment: Dry; Intact. Wound Length (cm): 2.5 cm. Wound Width (cm): 3.2 cm . Wound Depth: 0.2 cm . Pressure Injury Stage: [Deep Tissue Injury (DTPI) (DTI)] (DTI opening to stage 3) . * Pressure Injury Right Heel . Present on Hospital Admission: Yes .Site Assessment: red; purple; non-blanchable [CONDITION(S)]. Peri-Wound Assessment: Dry; Intact. Wound Length (cm): 2 cm. Wound Width (cm): 2 cm . Wound Depth: 0 cm . Pressure Injury Stage: DTPI (resolving) . * Pressure Injury Ankle Left . Present on Hospital Admission: Yes .Site Assessment: purple; red; intact (loose epidermis). Peri-Wound Assessment: Dry; Intact. Wound Length (cm): 1.2 cm. Wound Width (cm): 1.2 cm . Wound Depth: 0 cm . Pressure Injury Stage: DTPI . Impression: [Present on Admission (POA)] multiple scabs POA stage 1 to right lateral foot POA unstageable pressure injury to sacrum POA DTI to right heel POA right medial foot stage 1 POA left lateral ankle DTI POA right medial foot with DTI and stage 1 Associated Factors for Wound/Skin Impairment: Incontinent of bowel and bladder Inability to reposition self Pressure Goals of Treatment: Promote wound healing Manage incontinence Debridement of necrotic/non-viable tissue Debridement: Autolytic RECOMMENDATIONS/PLAN OF CARE: .Wound Care Treatment to Sacrum: 1. Cleanse wound with Puracyn Plus. Let soak for 5 minutes. 2. Pat dry with gauze. 3. Apply 3M [MEDICATION(S)] barrier to peri-wound skin. 4. Apply a medium acrylic [MEDICATION(S)] over wounds. 5. RN to assess wound dressing [every shift (QS)] and change dressing every other day. Mark dressings with date applied. Wound Care Treatment to Left lateral ankle and Left Hip: 1. Cleanse wound with Puracyn Plus. Let soak for 5 minutes. 2. Pat dry with gauze. 3. Apply 3M [MEDICATION(S)] barrier to peri-wound skin. 4. Apply a foam border dressing. 5. RN to assess wound dressing [every shift (QS)] and change dressing every other day. Mark dressings with date applied. Wound Care Treatment to Right lateral foot, right medial foot and right heel: 1. Cleanse wound with Puracyn Plus. Let soak for 5 minutes. 2. Pat dry with gauze. 3. Apply 3M [MEDICATION(S)] barrier to peri-wound skin. 4. RN to assess wound dressing [every shift (QS)] and change dressing every other day. Mark dressings with date applied. Preventative Measures: RN to review PIP Bundle (SKIN Tool) Q shift and implement interventions according to identified needs based on low Braden Scale sub-scores of 1-2. ~ TURN - Turn patient every 2 hours, utilizing [right and left (R&L)] turning surfaces if possible. Supine for one hour max three times a day. ~ Pad bony prominences. ~ ELEVATE HEELS - float heels off bed with heel lift boots. ~ [Head of bed (HOB)] <30 - Keep head of bed <30 degrees whenever possible, unless contraindicated. ~ NO BRIEFS - Do not use incontinence briefs in bed as they hold moisture on the skin and may hasten skin breakdown. May be used during activity and while out of department for testing. Single layer of moisture wicking underpads to be used for incontinence management in bed. ~ WAFFLE CUSHION - Utilize waffle cushion when in chair. ~ SPECIALTY MATTRESS - Patient to be placed on low air loss mattress. ~ Use Partan sheet to avoid sheering and skin dragging. ~ Moisture skin with: [MEDICATION(S)]. Discharge Planning: - Utilize above wound care instructions in nursing home environment. - Patient to follow up with wound care instructions in nursing home environment. - Patient to follow up with wound care services at Virginia Highlands. If needing additional services from the [wound clinic] a referral will need to be placed . Surveyor reviewed R31's Admission Data Collection with a date of 4/27/21. Documented under Skin Conditions was 1. Is resident's skin intact? A. No. 2. Does the resident have pressure ulcers? b. Yes . Site: Left trochanter (hip). Type: Pressure. Length: blank. Width: blank. Depth: blank. Stage: blank .Site: Right buttock. Type: Scar. Length: blank. Width: blank. Depth: blank. Stage: blank. Site: Right toe(s). Type: Other (specify): scab. Length: blank. Width: blank. Depth: blank. Stage: blank . Site: Sacrum. Type: Pressure. Length: blank. Width: blank. Depth: blank. Stage: blank . There was no Stage noted, no measurements and no assessment of the wound bed of the pressure injuries. A comprehensive assessment was not completed on readmission. This assessment was completed by LPN-F. Surveyor noted there is no indication the specific discharge recommendations from the hospital were implemented into the plan of care. Surveyor reviewed R31's Skin - Weekly Pressure Ulcer Record form with a date of 4/29/21 completed by LPN-F. Documented was Date of Onset: 3/15/21 . Site: Right buttocks. Type: Pressure. Length: 3.5 cm. Width: 1.8 cm. Depth: 0.1 cm. Stage: Unstageable. Additional Description of Site documented wound base non-viable yellow slough. Area smaller with thinning slough. The assessment was completed 2 days after the resident was readmitted . Surveyor reviewed R31's Skin - Weekly Pressure Ulcer Record form with a date of 4/29/21 completed by LPN-F. Documented was Site: Left trochanter. Type: Pressure. Length: 2.1cm. Width: 3 cm. Depth: 0.1 cm. Stage: III (3). Additional Description of Site documented wound base 100% viable granulation tissue. No s/s of infection. The assessment was completed 2 days after the resident was readmitted . Surveyor reviewed Wound Care Assessment with a date of 4/29/21 documented by Former NP-J. Documented was Pressure ulcer of right buttocks, unstageable: full thickness wound measuring 3.5 cm x 1.8 cm x 0.1 cm. The base is 100% yellow slough covered and there is a small amount of serosanguineous drainage. Periwound with scar tissue. No s/s of infection. Status: decline . Pressure ulcer of left hip, stage 3: full thickness wound measuring 2.1 cm x 3.0 cm x 0.1 cm. The base is 90% slough covered and 10% granular. There is a moderate amount of serosanguineous drainage. Periwound with blanchable [CONDITION(S)]. No s/s of infection. Status: POA . Patient has darker areas on his ankles and feet. They are intact. Do not appear to be deep tissue injuries . Surveyor noted the NP assessment of left hip noted 100% slough which contradicts the facility assessment of 100% viable granulation tissue. The assessment does not address all the areas identified in the hospital report. The facility assessment states left hip was present on admission but there was no comprehensive skin assessment completed at the facility on readmission 4/27/21. The hospital identified the left hip pressure injury on admission to the hospital. The hospital specific wound recommendations were not put in place. The hospital's wound treatment plan was not put in place. There was no update to the Care Plan to reflect the specific preventative recommendations. Surveyor reviewed R31's Skin - Head to Toe Skin Checks form with a date of 5/2/21. Documented was 1. Skin Integrity: 1m. Existing Pressure Ulcer . Site: Right Buttocks. Type: Pressure . Measurements and staging were left blank. There was no assessments of the left trochanter or other pressure injuries identified in hospital records from 4/26/21. Surveyor reviewed R31's Skin - Weekly Pressure Ulcer Record form with a date of 5/6/21 completed by LPN-F. Documented was Date of Onset: 3/15/21 . Site: Right buttocks. Type: Pressure. Length: 1.5 cm. Width: 1.0 cm. Depth: 0.1 cm. Stage: III. Additional Description of Site documented wound base 100% viable granulation tissue. No s/s of infection noted. There was no assessments of the left trochanter or other pressure injuries identified on hospital records dated 4/26/21. This assessment was also completed by LPN-F There was no NP or RN assessment of the wounds with this week's assessment. Surveyor reviewed R31's Skin - Head to Toe Skin Checks form with a date of 5/9/21. Documented was 1. Skin Integrity: 1m. Existing Pressure Ulcer . Site: Right Buttocks. Type: Pressure. Site: Left trochanter (hip). Type: Pressure . Measurements and staging were left blank. There was no assessments of the other PI's identified on hospital records dated 4/26/21. Surveyor reviewed R31's Skin - Weekly Pressure Ulcer Record form with a date of 5/13/21. Documented was Date of Onset: 3/15/21 . Site: Right buttocks. Type: Pressure. Length: 2.0 cm. Width: 1.5 cm. Depth: blank. Stage: Unstageable. Additional Description of Site documented wound base 100% viable granulation tissue. No s/s of infection noted. Surveyor reviewed R31's Skin - Weekly Pressure Ulcer Record form with a date of 5/13/21 completed by LPN-F. Documented was Site: Left trochanter. Type: Pressure. Length: 1.9 cm. Width: 2.6 cm. Depth: blank cm. Stage: III. Additional Description of Site documented wound base 100% viable granulation tissue. No s/s of infection. Surveyor reviewed Wound Care Assessment with a date of 5/13/21 documented by Former NP-J. Documented was Pressure ulcer of right buttocks, unstageable: full thickness wound measuring 2.0 cm x 1.0 cm x 0.1 cm. The base is 100% yellow slough covered and there is a small amount of serosanguineous drainage. Periwound with scar tissue. No s/s of infection. Status: improved . Pressure ulcer of left hip, stage 3: now unstageable. Full thickness wound measuring 1.9 cm x 2.6 cm x 0.1 cm. The base is 100% slough covered. There is a moderate amount of serosanguineous drainage. Periwound with blanchable [CONDITION(S)]. No s/s of infection. Status: decline . Surveyor noted the NP assessment of right buttocks and left hip noted 100% slough which contradicts the facility assessment of 100% viable granulation tissue. The stage of the left hip was also incorrect on the facility assessment. R31 was hospitalized [DATE] through 5/25/21. Surveyor reviewed Hospital Wound/Skin Nurse Specialist Consultation with a date of 4/26/21. Documented was .seen today for consultation at the request of [MD] for multiple pressure injuries . * Pressure Injury Hip Left. Date First Assessed/Time First Assessed: 4/26/21 [11:40 AM]. Present on Hospital Admission: Yes .Site Assessment: moist; sloughing; pink. Peri-Wound Assessment: Blanchable [CONDITION(S)]; hyperpigmented. Wound Length (cm): 2.0 cm. Wound Width (cm): 3.0 cm . Wound Depth: 0.5 cm . Pressure Injury Stage: U . * Pressure Injury Coccyx Midline; Proximal . Date First Assessed/Time First Assessed: 4/26/21 [11:37 AM]. Present on Hospital Admission: Yes .Site Assessment: Yellow; friable; fibrin; moist; pink. Peri-Wound Assessment: Hyperpigmented; scarred. Wound Length (cm): 1.5 cm. Wound Width (cm): 1.0 cm . Wound Depth: 0.2 cm . Wound Bed Slough (%): 50% . Pressure Injury Stage: 3 . * Pressure Injury Ankle Left; Lateral . Date First Assessed/Time First Assessed: 4/26/21 [12:15 PM]. Present on Hospital Admission: Yes .Site Assessment: Non-blanchable [CONDITION(S)]. Peri-Wound Assessment: Blanchable [CONDITION(S)]; Scarred. Wound Length (cm): 0.3 cm. Wound Width (cm): 0.2 cm . Wound Depth: 0 cm . Pressure Injury Stage: 1 . * Wound Hip Anterior; proximal; right; superior. Date First Assessed/Time First Assessed: 5/20/21. Present on Hospital Admission: Yes .Site Assessment: Intact; Non-blanchable [CONDITION(S)]; hyperpigmentation; blister; blood filled. Peri-Wound Assessment: Blanchable [CONDITION(S)]. Wound Length (cm): 1.5 cm. Wound Width (cm): 3.0 cm . Wound Depth: 0 cm . Pressure Injury Stage: DTPI . * Pressure Injury Coccyx Distal; Midline . Date First Assessed/Time First Assessed: 4/26/21 [12:00 PM]. Present on Hospital Admission: Yes .Site Assessment: Granulation; friable. Peri-Wound Assessment: Hyperpigmented. Wound Length (cm): 2.0 cm. Wound Width (cm): 1.5 cm . Wound Depth: 0.1 cm . Pressure Injury Stage: 3 . * Pressure Injury Sacrum Right. Date First Assessed/Time First Assessed: 5/19/21 [2:00 PM]. Present on Hospital Admission: Yes .Site Assessment: Hyperpigmentation. Peri-Wound Assessment: Blanchable [CONDITION(S)]. Wound Length (cm): 2.0 cm. Wound Width (cm): 1.5 cm . Wound Depth: 0 cm . Pressure Injury Stage: DTPI . Impression: POA stage 1 to L lateral ankle POA DTI pressure injury to R sacrum POA unstageable L hip POA Stage 3 proximal and distal coccyx Associated Factors for Wound/Skin Impairment: Incontinent of bowel and bladder Inability to reposition self Pressure Goals of Treatment: Promote moist wound healing Manage incontinence Debridement of necrotic/non-viable tissue Debridement: Autolytic, enzymatic RECOMMENDATIONS/PLAN OF CARE: .Wound Care Treatment R Sacrum: 1. Leave [open to air (OTA)] 2. Off load at all times Wound Care Treatment to Left lateral ankle: 1. Cleanse wound with Puracyn Plus. Let soak for 5 minutes. 2. Pat dry with gauze. 3. Apply 3M [MEDICATION(S)] barrier to peri-wound skin. 4. Apply a foam border dressing. 5. RN to assess wound dressing [every shift (QS)] and change dressing every other day. Mark dressings with date applied. Wound Care Treatment to L hip: 1. Cleanse wound with Puracyn Plus. Let soak for 5 minutes. 2. Pat dry with gauze. 3. Apply 3M [MEDICATION(S)] barrier to peri-wound skin.<B

Based on record review and staff interview, the facility did not ensure a resident received supervision to prevent accidents for 1 Resident (R) (R1) of 1 residents reviewed for supervision and interventions to prevent accidents. R1 was severely cognitively impaired, at risk for falls and required assistance of staff for mobility. R1 had difficulty making needs known and was taking three prescribed blood-thinning medications. R1 had an unwitnessed fall on [DATE] and the facility did not conduct an investigation to determine the circumstances surrounding the fall and how to prevent a similar occurrence in the future. R1 had another unwitnessed fall from the wheelchair on [DATE] with injuries to face, and the facility did not implement interventions timely. R1 fell out of the wheelchair again on [DATE] and sustained a head injury that required emergency transport to the hospital. R1 expired at the hospital on [DATE]. Facility failure to provide effective fall assessments and implement timely fall interventions for R1 created a finding of Immediate Jeopardy (IJ) that began on [DATE]. Surveyor notified the Nursing Home Administrator (NHA)-A of the IJ on [DATE] at 3:00 PM. The IJ was removed on [DATE]. However, the deficient practice continues at a severity/scope of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: On [DATE], the Surveyor reviewed R1's medical record. R1 was admitted to the new admissions unit of the facility on [DATE] for COVID 19 rehabilitation following hospitalization for a stroke. R1 had additional diagnoses of [CONDITION(S)], muscle weakness, need for assistance with personal care, difficulty walking, and unspecified lack of coordination. R1's Admission MDS (Minimum Data Set) documented R1 was severely cognitively impaired (scored 2 of 15 on Brief Interview for Mental Status) and required assistance of staff for mobility, transfers, and ADLs (activities of daily living). R1's Medication Administration Record (MAR) documented R1 received Aspirin 81 milligram (MG) (anti-coagulant for stroke prevention), [MEDICATION(S)] 75MG (blood thinner for stroke prevention), and [MEDICATION(S)] 5 MG (blood thinner for stroke prevention) daily. The facility did not do a fall risk assessment on admission. The care plan for fall prevention was generic and included approaches such as keeping call light in reach, low bed, and anticipate needs. R1 fell on [DATE]. There was no documentation in R1's medical record regarding this fall until [DATE] when an IDT (Inter-Disciplinary Team) note created by DON (Director of Nursing)-B documented that R1 was, noted to be on the floor next to .bed. No injuries noted. ROM (range of motion) adequate Neuro (neurological) checks initiated. MD/RP (doctor and resident primary contact) aware. (R1) encouraged to use call light for assist. Further investigation revealed one nurse note was made on the 24 hour alert board on [DATE] that stated UWF (unwitnessed fall). Review of records documented no further nurse charting, fall assessments, or neurological checks were completed for R1 related to the [DATE] fall. There was no fall risk assessment. The fall care plan was not updated and fall interventions were not implemented. No further explanation or details were provided on how to effectively implement the recommendation for R1 to be encouraged to use the call light for assist given R1's severe cognitive impairment. On [DATE] a note was made on the 24 hour alert board for R1 that noted, UWF bleeding from mouth VSS (vital signs stable). RN (Registered Nurse)-H nurse progress note on [DATE] stated, (R1) was found on floor in front of wheelchair .Blood was seen in .mouth. No broken teeth or other injuries noted in .mouth . An IDT note created by DON-B on [DATE] stated, (R1) noted to be on the floor face down in front of her wheelchair. Blood noted coming from her mouth. No broken teeth noted Hematoma (an injury that causes blood to collect and pool under the skin) noted to (L) orbital area . R1's medical records documented fall interventions were not implemented to prevent future falls and neurological checks were not initiated to monitor for changes related to this fall. R1's MAR documented R1 received Aspirin 81 MG, [MEDICATION(S)] 75 MG, and [MEDICATION(S)] 5 MG daily along with other medications at the time of the fall. Fall assessment completed [DATE] after R1's second fall documented R1 as a, High Risk for falls due to intermittent confusion, dependence with ambulation/elimination, altered balance/gait, anti-[CONDITION(S)] medication, and seizures. On [DATE] R1 was transferred from the admission unit to the long term care area of the facility. No additional documentation was noted regarding communication to staff on the new receiving unit regarding R1's high risk of falls, fall history, or fall interventions. A physical therapy note on [DATE] documented, (Physical therapist) unable to obtain O2 (oxygen) reading as pt (patient) hands were very cold. Pt on 2L O2 (2 liters oxygen) per nc (nasal cannula). Nurse progress notes did not document further assessment was completed related to physical therapist concern. On [DATE] medical records documented nursing staff was alerted by R1's roommate that R1 was found on the floor. The roommate indicated, The fall was heard but not witnessed. Records further noted R1's, (Vital signs) erratic. Unable to follow directions . Dr.(doctor) order to send to ER (emergency room ) for evaluation . 911 called. A large hematoma was noted to R1's forehead at the time of the fall. R1's MAR documented R1 received scheduled medications that day, including the three anti-coagulant medications noted above. Hospital records documented R1 was in acute respiratory failure with [CONDITION(S)] (the absence of enough oxygen in the tissues to sustain bodily functions) at the time of admission on [DATE] after arriving via ambulance from the facility. Emergency Medical Technicians responding to the facility to transport R1 to the ER reported R1, was found to have a pulse ox (oximetry) (test that measures your oxygen saturation levels in the blood; ,d+[DATE] considered normal) in the 80's at the facility. EMS (Emergency Medical Service) placed 15 liters supplemental oxygen and pulse (oximetry)was then noted to be in the 90's. R1's care plan was updated on [DATE] related to falls. At the time of the [DATE] update, R1 was in the hospital and no longer in the facility. On [DATE] at 11:00 AM, the Surveyor interviewed Washington County Deputy Coroner (DC-E) who reported R1 passed away at the hospital on [DATE] at 4:53 AM. DC-E noted an autopsy would be completed due to undetermined cause of death. On [DATE] at 2:30 PM, Surveyor interviewed DON-B. DON-B stated no interventions were added for fall prevention of R1 after the fall on [DATE]. DON-B stated R1 was placed on 15 minute checks after fall on [DATE]. DON-B was not able to provide Surveyor with documentation to show the 15 minute checks were effectively implemented or completed. On [DATE] at 2:47 PM, DON-B confirmed again in interview that no fall interventions were implemented after falls on [DATE] and [DATE]. DON-B stated checks were increased from every 30 minutes to every 15 minutes after the fall on [DATE] and neurological checks were completed by nursing staff. DON-B was not able to provide documentation that either checks or monitoring had occurred. DON-B stated, I even looked through shred bin. We don't have them (documentation of 15 minute checks and neurological checks.) On [DATE] at 2:00 PM, Surveyor spoke with CNA (Certified Nursing Assistant)-F who assisted R1 on [DATE] after R1's fall on that date. CNA-F stated R1 was not on 15 minute safety checks or fall precautions at the time of the fall. CNA-F stated 15 minute fall checks are completed by the CNAs but they were not being done on R1. On [DATE] at 8:20 AM, Surveyor spoke with RN-H who assessed R1 after the [DATE] fall. RN-H told Surveyor RN-H was instructed by DON-B to add a more detailed note to R1's electronic health record on [DATE] after Surveyor had questioned DON-B about R1's falls. RN-H stated the facility policy is to perform neurological checks after an unwitnessed fall. RN-H was unable to recall if the checks were completed and did not recall personally performing any of the neurological checks on R1. RN-H explained the neurological check results were recorded on paper, but did not know where the recordings were for R1. RN-H further stated R1 was placed on 15 minute safety checks after the fall but did not recall who did the checks and stated the checks were not recorded. Review of R1's medical record documented a late entry was added by RN-H related to the [DATE] fall that provided additional details related to R1's injuries. On [DATE] at 8:30 AM, Surveyor spoke with LPN (Licensed Practical Nurse)-I who was unaware R1 was had fallen on [DATE] and [DATE] while on the admissions unit. LPN-I explained R1 was transferred to the long term care unit on [DATE] and the staff on that unit was not informed of any previous falls. R1 was not on any fall precautions; post fall neurological checks and 15 minute safety checks were not being completed upon R1's transfer to the new unit at the facility. The failure to provide effective fall assessments and implement timely fall interventions for R1 created a finding of Immediate Jeopardy (IJ). The facility removed the jeopardy on [DATE], when it completed the following: 1. Medical Director contacted and advised of deficiency 2. All residents residing in facility will have updated fall risk assessments completed. 3. Care plans and Kardex's for those residents found to be at high risk for falls will be reviewed to ensure appropriate interventions are in place. 4. All residents with a fall in the past 30 days also reviewed and compared with care plan to ensure all recommended interventions are in place. 5. An incident checklist form was initiated to ensure the proper post fall procedure is appropriately conducted. 6. All nursing staff educated on post fall procedure including SBAR, Incident Reports, pain UDA, fall risk assessments, skin checks, neurological checks (if warranted) and IDT post fall review. 7. NHA or designee will review all falls in risk management dashboard to ensure post fall process has been completed.

Based on interview and record review, the facility did not ensure that 1 of 6 (R3) residents reviewed remained free of accident hazards as is possible during a Hoyer lift transfer of R3. * Facility staff did not attach the sling strap correctly to the Hoyer lift and did not wait for a second staff member to assist with R3's transfer. As a result of these actions, R3 fell from the Hoyer sling and sustained a laceration to her face requiring stitches and fractures to both her legs. R3 died that evening. * Additionally, and more systemically, at the time of R3's fall, the facility was using universal straps not designed specifically for the Hoyer lift, had not numbered the slings per facility policy, and was not routinely inspecting the slings to ensure appropriate and safe use for residents. This deficient practice was determined to affect 18 residents who used the sling and mechanical lift for their transfer needs. The failure to use the correct sling, to use an additional person while transferring R3, and the failure to routinely inspect slings and to use straps designed specifically for the Hoyer lift created a finding of Immediate Jeopardy that began on [DATE]. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on [DATE] at 12:25 p.m. The immediate jeopardy was determined to be past non-compliance and was found to be removed and corrected on [DATE]. Findings include: The facility's policy with no listed date and titled, Sava SeniorCare Quicklist: Transfer with a Mechanical Lift documents, Review the patient's medical record for conditions that may affect mechanical lift use and ensure the patient's weight doesn't exceed the mechanical lift's weight limitation; Introduce yourself and state the purpose of your visit; Ask about recent changes in the patient's health status; Explain the procedure; Determine the patients ability to cooperate and follow directions; Survey the patient care environment ; Inspect the mechanical lift and test the lift controls; Inspect the sling and the straps ; Ensure that both the bed and the chair or wheelchair are stable: if any of the wheels are present ensure they are locked; Position the patient supine and then roll the patient onto the side away from you; Place the center of the sling under the patient spine and fanfold the material of the far side of the sling; Roll the patient onto the back so that the patient is centered on the sling; Position the mechanical lift so that its arm is perpendicular to the bed, directly over the patient. Ensure the arm doesn't hit the patient; Attach the straps on the sling to the hooks on the arm of the mechanical lift according to the manufacturer's instructions. Face the hooks away from the patient. Ensure the straps are securely attached to the hooks and aren't twisted ; Instruct the patient to keep the arms inside the sling straps during transfer; If the patient has an IV line or urinary drainage bag, move it first; Tell the patient when you are going to the activate the mechanical lift. R3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's Quarterly MDS (Minimum Data Set) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 14, indicating that R3 was cognitively intact. Section G (Functional Status) documents that R3 had total dependence on facility staff and required a two person physical assist for her transfer needs. R3's ADL (Activities of Daily Living) care plan dated as revised on [DATE] documents under the Interventions section, TRANSFER: Full body lift with 2. On [DATE], the Southeastern Regional Office received a facility self-report that documented R3 had fallen from a Hoyer lift and sustained injuries. R3's nursing note dated [DATE] at 7:30 a.m. documents, SBAR (Situation, Background, Assessment, Recommendation) Summary: Vital Signs: BP (Blood Pressure) ,[DATE], P (Pulse) 85, R (Respirations) 20, T (Temperature) 97.6 (degrees Fahrenheit) .LPN (Licensed Practical Nurse) Appearance of resident - What I think is going on with the resident is: Resident fell from Hoyer lift when transferred to wheelchair per 2 RC's (CNAs- Certified Nursing Assistants). Writer was down the hall passing medications when called to the room to assist with patient. Legs bent at the knee's laying position. Resident was alert and able to answer questions. Pressure and ice pack applied to left side of forehead. Called DON (Director of Nursing) who was on call at the time and updated. 911 called and arrived to resident's room. Additional Nursing Notes as applicable: Family/Health Care Agent Notified: [DATE] 7:55 AM. Primary Care Clinician Notified: [DATE] 7:50 AM. R3's Fall Incident Report dated [DATE] documents, Incident Description: Nursing Description- Resident fell out of Hoyer when transferring from bed to wheelchair; Resident Description- I was up in the air in the thing and I fell . Under the Immediate Action Taken section it documents, Writer ran to resident's room when CNAs (Certified Nursing Assistants) called out to staff. Seen resident laying on the floor under the hoyer. Cold pack and pressure to left side of head. Legs bent at the knee. Call to RN (Registered Nurse) on call and updated. 911 called and updated. Came to resident's room for transport. Under the Mental Status section it documents, Resident had abrasion to left side of face, temple area. Cold pack and pressure applied. Resident had pain when ambulance tech's (technicians) tried to position. Medicated by ambulance techs (technicians). R3's Hospital Admission documentation dated [DATE] at 3:16 PM documents, ER (emergency room ) Joint Care Attestation: Patient presented after a fall from Hoyer lift and extensive work for traumatic injuries revealed right femur fracture and left tib-fib (tibia-fibula) fracture. She has what almost appeared to be incidental [MEDICATION NAME] by CT (Computerized Tomography) belly which was really done for trauma and while in the ED (emergency department) has transient and very labile blood pressures with intermittent [MEDICAL CONDITION] and I did reexamine her thigh multiple times and do not see large hematoma to suggest she is in hemorrhagic shock and blood pressure rebounds quickly. Independent of her blood pressure fluctuations she also developed some [MEDICAL CONDITION] or waxing and waning mental status in the ED .Case was discussed with the intensivist who evaluated the patient at the bedside and agrees to admit her to ICU (Intensive Care Unit). Case was also discussed with multiple specialists including surgery, IR ([MEDICATION NAME] Radiology) and orthopedic surgery. Procedures: Wound Repair The 0.5 cm (centimeter) long puncture wound with necrotic edges on the left face was anesthetized with 2 cc (cubic centimeter) of 1% [MEDICATION NAME] .and closed using a single layer closure with #2 ,[DATE] [MEDICATION NAME] simple interrupted sutures. Impression and Plan: R3 is an 80 y female who presented to the ED (Emergency Department) with fall. Multiple [DIAGNOSES REDACTED].were considered in the care and evaluation of this patient. Patient was seen immediately upon arrival and examined. Past medical history, medications and allergies [REDACTED]. She was placed on nasal cannula. I called my supervising physician who came and evaluated patient. Her initial blood pressure was also 77 systolic. She was mentating. Able to answer questions. She had no chest wall tenderness or tracheal deviation to suggest tension pneumothorax, chest x-ray was immediately ordered and imaging was called. As fall was less than ground level, I discussed with my supervising physician regarding as a trauma alert and it was determined that this was not a trauma alert level .Patient remained hypotensive throughout her stay in the ER (emergency room ) with occasional episodes of normotensive. She was found to have a right femur fracture and left tib-fib (tibia-fibula) fractures. Her CT (Computerized Tomography) of the chest abdomen pelvis revealed acute [MEDICATION NAME], worsening pancreatic mass. I spoke with orthopedics who recommended knee immobilizer on the right, long leg posterior splint from mid-thigh to ankle on the left. Given the fact that she is a quadriplegic, this is likely inoperable . Patient was given IV (Intravenous) fluid bolus here in the ER (emergency room ). She had minimal improvement with her blood pressure. I discussed with the hospitalist who initially accepted patient for admission however with the persistent [MEDICAL CONDITION], I discussed at length with the intensivist who accepted patient for admission. Diagnosis: [REDACTED]. Death Summary: R3 was pronounced dead at 2156, [DATE]; Hospital Course: Brief Narrative: R3 is a(n) 80 yo female with incomplete [MEDICAL CONDITION] secondary to cervical tumor .She presented to ER (emergency room ) today after falling from the hoyer lift at her care facility. She landed with her legs underneath her and hit her head. She did not lose LOC (level of consciousness). EMS (Emergency Medical Services) called . Upon arrival, she reported right leg pain and had hypertension. Trauma work up showed bilateral leg fractures .Seen in ER (emergency room ) for intermittent [MEDICAL CONDITION]. She had already been given 1 liters NS (normal saline). Additional 2 liter given over an hour. Exam difficult due to [MEDICAL CONDITION]. ER (emergency room ) RN (Registered Nurse) report bowel incontinence on arrival and foley. Foley was replaced. Admit to ICU. At 1500 (3PM), BP (blood pressure) noted to be ,[DATE]. 1 liter of LR ([MEDICATION NAME] Ringers) bolus given with good response but then BP (blood pressure) dropped to ,[DATE]. Additional liter of LR ([MEDICATION NAME] Ringer) given. In total including ED (emergency department), 4 liters fluid given .Decision made to not escalate therapies including, central line and pressors. Over the course of several hours patient became lethargic and then obtunded. EICU (electronic intensive care unit) discussed transition to full comfort care with family, and orders placed. She converted to asystole at 2156; Complications in the hospital: Cardiogenic shock; Body disposition: Body released to the morgue. The facility's self-report and investigation regarding R3's fall on [DATE] documents, On [DATE] at approx. (approximately) 7:10 a.m. R3 was assisted by CNA (Certified Nursing Assistant)-H with morning ADL's (activities of daily living). The CNA placed a mechanical lift sling under resident, brought in Hoyer lift and hooked resident up to lift. CNA-H went into the hallway to get a second CNA to assist with the lift. The second CNA (CNA-I) entered room and was putting on gloves and getting into position as CNA-H lifted resident from bed, pulled lift back, and began to pivot resident over to her power wheelchair. During the turn a snapping noise was heard and the resident slid out of the sling and landed on the floor at the base of the Hoyer lift. The second CNA (CNA-I) yelled for help and a nurse responded to room immediately and assessed the situation. Emergency response personnel were called and resident was sent to the hospital for evaluation. DON (Director of Nursing) obtained statement from the second CNA, CNA-I. This CNA reported she was asked to come to room to assist with the mechanical transfer. She stated she was still getting her gloves on as the transfer started and did not actually see what happened. She stated she did hear a snap sound just prior to the resident falling from the lift. Statement obtained from CNA-H. CNA-H reported she got the resident ready, placed the sling under resident, hooked the resident to the lift, and got a second CNA. She reported hearing a snap sound just prior to resident falling. At approx. (approximately) 8:45 AM Administrator-A went to the resident's room and obtained the sling used for the transfer. Upon inspection the lower left sling strap appeared to be broken. Outside of the broken strap, the sling appeared to be in good working condition with fraying or holes. The assistant housekeeping manager was interviewed about the laundering process. Proper laundering instructions were clearing posted in laundry room and inspection log was verified to be in use when sling are laundered. Approx. (approximately) 10 AM both CNA's involved in the incident were re-educated on proper lifting procedures. The lift used in the transfer was inspected by maintenance director. All safety devices on lift were present and functioning properly. Approx. (approximately) 2 PM CNA-J stated while the resident was on the ground waiting for the ambulance to arrive she knelt on ground to comfort the resident while they waited. She stated at the time she did this the sling was still hanging on the lift which the resident was under. She reported she looked at the sling strap hanging down and noted it was not broken. She further stated she told CNA-H You must not have had this hooked up right. This was witnessed by CNA-K who was orientating with CNA-J. DON (Director of Nursing) called CNA-H and informed her she was suspended pending the outcome of the investigation. The DON requested CNA-H return to the facility so she could be questioned about this new information. CNA-H stated she couldn't today, but would come in on Tuesday morning. On Tuesday [DATE] Administrator-A called CNA-H to find out when she was coming in. CNA-H reported she couldn't come in today, but would come in tomorrow at 8:30 AM to give her statement. Around 15 minutes after this conversation CNA-H sent a text message to the facility's scheduler and stated she would not be coming in and would instead be terminating her employment to save herself the embarrassment of being fired. Administrator-A called her again and left a voicemail with no call back. Administrator-A attempted to contact again on ,[DATE] with no response. CNA-H has been a nursing assistant for nearly [AGE] years. She began orientation at this facility on [DATE]. CNA-L verified she did orient CNA-H to the proper Hoyer lift process. On [DATE] a conference call was held with Administrator-A, DON-B, corporate Operational Safety Director and division regional team. Pictures of the sling and lift were shared to debrief this incident. It was the opinion of the Operational Safety Director that the break in the sling strap was not a failure in the equipment but most likely cut. This opinion was based on the fact the break was clean with no fraying. The lift was further examined. There is a spring loaded washer which keeps the sling straps in place. When the straps are removed, the washer slaps against the mental of the spreader bar and causes a snapping noise. Interventions put into place: Training was conducted with administrator and nurse management staff by Hoyer representative. Training was also conducted with all CNAs and nurses on proper transfers with mechanical lifts. Root Cause Summary: The root cause of the fall was the use of an incorrect sling that was not completely hooked into all 4 of the clips of the lift. As the lift was executed the lower strap became dislodged which caused the washer to make the snapping noise, and caused the resident to fall to the ground. The facility is able to come to a reasonable conclusion that an isolated incident involving a staff member no longer employed at Virginia Highlands using a mechanical lift and sling improperly resulted in the resident fall. Correcting action has been taken and ongoing. Surveyor noted that staff statements included in the investigation and self-report from CNA-H & CNA-I verified the above findings. Surveyor noted that per the facility's investigation and staff statements, CNA-H did not attach the sling strap correctly to the Hoyer lift and did not wait for a second staff member to assist with R3's transfer per R3's plan of care. On [DATE] at 11:39 a.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B to confirm that the facility's self-report and fall investigation for R3's fall on [DATE] as documented above was accurate. DON-B informed Surveyor that the facility's self-report and fall investigation for R3's fall on [DATE] as documented above was accurate. Surveyor asked DON-B if CNA-H should have ensured that the strap for the sling was correctly attached prior to transferring R3 with the Hoyer and if CNA-H should have waited for a second staff member to be in position to assist with R3's transfer per R3's plan of care. DON-B informed Surveyor that CNA-H should have ensured that the strap for the sling was correctly attached prior to transferring R3 with the Hoyer. DON-B also informed Surveyor that CNA-H should have waited for a second staff member to be in position to assist with R3's transfer per R3's plan of care. On [DATE] at 11:35 a.m., Administrator-A provided Surveyor with the sling that CNA-H used on R3 when R3 fell on [DATE]. Surveyor observed the sling to be torn, as if it was cut by a sharp edge, and not frayed or worn condition. Surveyor noted that the sling did not have a manufacturer name and was not numbered. Surveyor was unable to find any documentation that the facility was inspecting the conditions of the sling being used at the time when R3 fell on [DATE]. Surveyor asked Administrator-A what type of lift was used by CNA-H when R3 fell on [DATE] and if he (Administrator-A) could provide Surveyor with the manufacturer recommendations for the lifts used by the facility. Administrator-A informed Surveyor that all the lifts at the facility were manufactured by Hoyer and that he would provide the manufacturer recommendations for the lifts used by the facility. On [DATE] at 11:20 a.m., Administrator-A provided Surveyor with the manufacturer recommendations for the Hoyer lifts used by the facility. The manufacturer recommendations titled Hoyer Full Back Sling documents, HOYER RECOMMENDS THE USE OF [MEDICATION NAME] HOYER PARTS. Hoyer slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver. For the safety of the patient and carer; before using a sling a full risk assessment must be conducted to ensure that the correct sling choice, method of positioning in the sling and procedure for transfer has been determined for the patient. Check sling and stitching before each use. Using bleached, torn, cut, frayed or broken sling is unsafe and could result in serious injury or death to the patient. Destroy and discard worn slings. Do not-alter slings. Never leave a patient unattended. Surveyor noted that per the facility's investigation and the lift's manufacturer's recommendations, CNA-H was using universal sling that was not designed specifically for the Hoyer lift when R3 fell on [DATE]. Surveyor also noted that at the time of R3's fall, the slings being used by CNAs for resident transfers were not routinely inspected by the facility to ensure their condition and safety of each sling used by residents. On [DATE] at 11:22 a.m., Surveyor informed Administrator-A of the above findings. Surveyor asked if at the time of R3's fall on [DATE], the facility had a system in place to routinely inspect the lift slings to ensure their condition and safety. Administrator-A informed Surveyor that at the time of R3's fall on [DATE], the facility was not routinely inspecting the lift slings. Administrator-A informed Surveyor that the previous system of sling inspection was to have all the lift slings numbered and inspected when washed. Administrator-A informed Surveyor that at the time of R3's fall on [DATE], not all the lift slings were numbered and that at the time, not all lift sling were being routinely inspected. Administrator-A informed Surveyor that in addition to not having all the lift slings numbered, the lift slings that were in use at the time of R3's fall were not all made for use with a Hoyer lift and that some lift slings, like the one that was used on R3 when R3 fell , were considered to be universal fit lift slings. Administrator-A informed Surveyor that after R3's fall, all the slings were inspected and replaced with Hoyer brand slings to ensure proper fit with the Hoyer lifts. On [DATE] at 12:25 p.m., Surveyor informed Administrator-A and DON-B of the above findings. The failure to use the correct sling and an additional person for the transfer and the failure to ensure slings were routinely inspected and were designed specifically for the Hoyer lift, created a finding of Immediate Jeopardy because of the serious outcome that can occur when an older person falls. According to For Elderly, Even Short Falls Can Be Deadly: Adults 70-Plus Three Times as Likely to Die Following Low-Level Falls (Science Daily [DATE]), .ground level falls, essentially falls from a standing position, with feet touching the ground prior to the fall, have traditionally been considered minor injuries. But, the new study found elderly adults - [AGE] years of older - who experience ground-level falls are much more likely to be severely injured and less likely to survive their injuries compared to adults younger than [AGE] years. Elderly patients are three times as likely to die following a ground-level fall compared to their under-70 counterparts .approximately 4.5 percent of elderly patients ([AGE] years and above) died following a ground-level fall, compared to 1.5 percent of non-elderly patients. Elderly patients remained in the hospital and the intensive care unit longer and only 22 percent were able to function on their own after they left the hospital, compared to 41 percent of non-elderly patients. The facility removed the jeopardy on [DATE], when it had completed the following: - Education was provided to all nursing staff (RN, LPN and CNA) regarding the proper transfer techniques with Hoyer lifts which was completed on [DATE]. - All lift slings were replaced with Hoyer branded slings per the Hoyer lift manufacturer recommendations. All the lift slings are now numbered and are color coded by patient weight to ensure proper fit and use. - The facility conducted lift audits and a QAPI (Quality Assurance and Performance Improvement) plan has been put in place for ongoing review regarding the proper use of lift slings.

Based on interview and record review the facility did not ensure 1 (R1) of 3 residents reviewed was free from significant medication errors. R1 was hospitalized from [DATE]-4/19/19 and was diagnosed with [REDACTED]. R1 returned to the facility with new medications orders related to the treatment and management of R1's new [MEDICAL CONDITION] as well as other chronic disorders. Upon return to the facility, between 4/19/19 and 4/20/19, R1 missed; 2 doses of [MEDICATION NAME], 1 dose of [MEDICATION NAME], 1 dose of [MEDICATION NAME], 2 doses of [MEDICATION NAME], 1 dose of [MEDICATION NAME], 1 dose of [MEDICATION NAME], 1 dose of [MEDICATION NAME], and 2 scheduled [MEDICATION NAME] treatments. R1 was re-hospitalized [DATE]-4/26/19 due to her [MEDICAL CONDITION] which the hospital documents was due to patient not receiving any of her rate control or antiarrhythmic medications at her facility. R1 was re-hospitalized [DATE]-4/29/19 due to [MEDICAL CONDITION]. On 4/29/19, R1 missed 1 dose of [MEDICATION NAME] and 1 dose of [MEDICATION NAME]. R1 was then sent to the hospital during the early morning of 4/30/19. Findings include: R1 has [DIAGNOSES REDACTED]. Progress notes on 4/5/19 document, Resident noted to be in respiratory distress upon coming into shift, pm shift nurse assessed resident, contacted M.D. and family, ambulance company contacted. R.N. night shift supervisor .made aware by writer, Lifestar ambulance company arrived to transport resident. Night shift Nurse supervisor, pm shift nurse and writer present in the room, all assisted Lifestar staff with transfer of resident onto gurnee (sic), resident left facility in stable condition with Life star at approximately 2354 (11:45 pm). Per night shift supervisor contacted CMH (hospital) to receive update/report resident admitted to hospital. R1 was hospitalized from [DATE]-4/19/19 with discharge [DIAGNOSES REDACTED]. Hospital discharge paperwork documents, New medications, [MEDICATION NAME] for respiratory alkalosis, [MEDICATION NAME] and [MEDICATION NAME] for A. fib rate control, [MEDICATION NAME] for vitamin B12 deficiency, [MEDICATION NAME] for A. fib. Medications discontinued: Aspirin since the patient is on [MEDICATION NAME] and [MEDICATION NAME] to make room for [MEDICATION NAME]. A late entry progress note with an effective date of 4/19/19 at 3:28 am documents, DRR (drug regimen review): Medication reviewed by floor nurse on admission with MD with recently signed Hospital discharge summary and H & P. No significant issues noted. Orders verified by physician on 4/20/19. A RESIDENT INFORMATION NOTICE form documents R1 was readmitted on [DATE] at 1 pm. On 4/19/19 at 1:48 pm, RN (Registered Nurse) -C documents, (R1) arrived via LifeStar wheelchair van. (R1) was happy to be back. Concentrator set up for continuous O2 (oxygen) at 4L (liters). (R1) is more weak then before her hospitalization , requiring more assistance with transfers. SMS Respatory (sic) here to set up [MEDICAL CONDITION] machine. Hospital discharge medication instructions for R1 upon her return to the facility on [DATE] included to start taking: [MEDICATION NAME] ([MEDICATION NAME]) 125mg two time a day, [MEDICATION NAME] HCL ([MEDICATION NAME] CD, used to slow heart rate in patients with [MEDICAL CONDITION]) 240mg extended release daily, [MEDICATION NAME] HCL ([MEDICATION NAME] SR, used to prevent and treat [MEDICAL CONDITION]) 225mg extended release two times daily, [MEDICATION NAME] ([MEDICATION NAME], used to reduce blood clotting in patients with [MEDICAL CONDITION]) 1 mg daily. The hospital discharge medication instructions included to continue taking: Atorvastatin ([MEDICATION NAME], a medication used to treat high cholesterol) 20mg nightly, [MEDICATION NAME] ([MEDICATION NAME], a nerve pain medication) 400mg three times daily, [MEDICATION NAME] 0.5-2.5 (3)MG/3ML nebulizer solution 4 times daily (a combination of medications used to help treat and prevent symptoms of [MEDICAL CONDITION]), and [MEDICATION NAME] ([MEDICATION NAME], a medication used for the treatment of [REDACTED]. These orders were documented as being followed as ordered from the hospital by the facility. Hospital discharge records document R1's next dose of [MEDICATION NAME] was due the night of 4/19/19. R1's Medication Administration Record [REDACTED]. Hospital discharge records document R1's next dose of [MEDICATION NAME] ([MEDICATION NAME]) was due 4/20/19. R1's MAR indicated [REDACTED] Hospital records document R1's next dose of [MEDICATION NAME] was due the night of 4/19/19. R1 is not documented as receiving the [MEDICATION NAME] as ordered the night of 4/19/19. Hospital discharge records document R1's next dose of [MEDICATION NAME] was due the night of 4/19/19. R1's MAR indicated [REDACTED]. Hospital records document R1's next [MEDICATION NAME] dose was due the night of 4/19/19. R1 is not documented as receiving [MEDICATION NAME] on the night of 4/19/19. Hospital record document R1's next dose of [MEDICATION NAME] due the night of 4/19/19. R1 is not documented as receiving the [MEDICATION NAME] the night of 4/19/19. Hospital records document R1's next dose of [MEDICATION NAME] due the night of 4/19/19. R1 is not documented as receiving the [MEDICATION NAME] the night of 4/19/19. R1's was ordered to receive [MEDICATION NAME] neubilzer treatment four times a day. R1 is not documented as receiving her 4pm dose or 8 pm dose as ordered on [DATE]. On 6/12/19 at 10:09 am, the surveyor interviewed RN-C. The surveyor asked RN-C about the admission process when a resident returns from the hospital. RN-C stated they go through the medications with the doctor, get the orders into the computer, get therapy orders if needed, do assessments, and admission data collections. The surveyor asked RN-C what if medications are not available. RN-C stated would let the doctor know, if needed STAT we have available through CVS if a resident has to have a medication, otherwise the medication is STAT'ed out from Omnicare which is 4-6 hrs. RN-C informed the surveyor he clarified with the scheduler and believes on 4/19/19 he helped R1 when they first arrived to the facility as LPN-D was not there yet. RN-C stated he did not recall being asked to help with getting the orders put in. RN-C stated he recalled giving Licensed Practical Nurse (LPN)-D report and getting R1 settled into her room. On 6/13/19 at 2:41 pm, the surveyor interviewed LPN-D. LPN-D did not recall R1. LPN-D informed the surveyor when a resident returns from the hospital as soon as the person comes in she talks with the doctors to verify orders and put them into the computer. LPN-D stated there was no specific time frame just as soon as possible. The surveyor asked LPN-D how she ensures a new admission receives their next dose of medication. LPN-D stated usually for the next dose pharmacy won't have delivered it yet so will get what can from contingency and if not available, pharmacy will STAT it out, depends on pharmacy, may be up to 5 hours. The surveyor asked LPN-D what she would do if a medication is unavailable. LPN-D stated she would call the doctor to see what he would want to do, if wants it held or give something else. The surveyor asked LPN-D if she would document that. LPN-D stated yes, she would write the doctor was notified and what action the doctor wanted taken. On 6/11/19 at 12:30 pm, the surveyor interviewed DON-B. DON-B confirmed to the surveyor on 4/19/19 the nurse did not put the orders in timely There is no documentation a physician was notified R1 did not receive her ordered medications. Progress notes on 4/20/19 at 5:08 pm document, Nurse observed resident lethargic and unable to follow commands. RN notified. RN notified Doc. Resident sent to CMH for evaluation and treatment. VS (vital signs) BP (blood pressure) 89/58 P (pulse) 58 R (respirations) 16 o2 SAT (oxygen saturation) 91% Denies pan and SOB (shortness of breath). Family and on call notified. Progress notes on 4/21/19 at 6 am document, LPN notified writer that patient was lethargic and pale. Writer assessed patient-upon auscultation patient appeared to be in active afib ([MEDICAL CONDITION]), apical HR (heart rate) ranging from 40s-50s, pt (patient) lethargic and pale, manual BP 8-s/50s. Patient transported to CMH by EMS (emergency medical services). Progress notes on 4/21/19 at 1:56 pm document, (R1) was admitted to CMH with [DIAGNOSES REDACTED]. R1 was hosptalized on [DATE] at 5:22 pm from 4/20/19-4/26/19. The hospital documents the reason for hospitalization as [MEDICAL CONDITION] with rapid ventricular rate. The (4/26/19) hospital discharge summary documents, Patient is a [AGE] year-old female with history of [MEDICAL CONDITION] presented to the emergency room from her nursing facility when staff checked her vital signs that time her rate was between 140-160. She was asymptomatic. Even uncontrolled heart rate she was sent over to the emergency for further management. At the time of admission, she reported no symptoms and denies chest pain, shortness of breath or lightheadedness Patient reported that she was not being given her rate control medicines at the facility as they have not received her prescriptions. In the emergency room , work-up revealed essentially unremarkable except for mildly elevated BNP at 1760. Chest x-ray showed interstitial [MEDICAL CONDITION] with right-sided moderate pleural effusion. EKG done showed A- fib with RVR with a rate of 140. She received [MEDICATION NAME] 1-mg IV once and placed on a [MEDICATION NAME] drip with improvement in rates but her blood pressure dropped. She was then given [MEDICATION NAME] 250 mcg IV once and was admitted to the ICU (intensive care unit) for further management .[MEDICAL CONDITION] with rapid ventricular response. This was thought to be due to patient not receiving any of her rate control or antiarrhythmic medications at her facility. Hospital notes also document, #[MEDICAL CONDITION] with rapid ventricular response, Onset last admission -2/2 patient not receiving any of her rate control and antiarrythmic medications at facility. She didn't receive [MEDICATION NAME] and [MEDICATION NAME]. A RESIDENT INFORMATION NOTICE form documents R1 was re-admitted to the facility on [DATE] at 2pm. Progress notes on 4/26/19 at 3:50 pm document, SSA (Social Services) and UM (unit manager) met with resident for re-admission on this date. Discussed past concern regarding medication; and new plan in place. Discussed LTC (long term care) at this facility still goal of resident; resident stated, 'I don't want to move/(discharge) anymore now being back here'. Resident in good spirits and thankful for updates. SSA provided psychosocial support. IDT (interdisciplinary team) will continue to monitor for re-admission. Progress notes on 4/27/19 at 12:15 am document, Resident C/O (complaint of ) SOB (shortness of breath). O2 46%, P 147, (blood pressure) 118/82, R 24. Notified RN supervisor. Resident to be sent to ER for eval and treatment. Family notified. Doc notified. R1 was readmitted to the hospital on [DATE] at 6:49 pm from 4/26/19-4/29/19 for [MEDICAL CONDITION] with rapid ventricular rate and pleural effusion. Hospital discharge paperwork (4/29/19) documents, Major medication changes and reasons, '[MEDICATION NAME] increased to 90mg q6H (every 6 hours)' and to 'continue [MEDICATION NAME] ([MEDICATION NAME]).' The hospital documents, At the time of discharge, she reported she was feeling well she was on baseline oxygen with heart rate and blood pressure Patient is currently on increased dose of [MEDICATION NAME] at 360mg a day/90mg every 6 (hours). This is to be continued at discharge Continuing [MEDICATION NAME] at 25 mg twice daily. Heart rate seems to be well controlled on the above regimen .Patient is a very high risk of readmissions to the hospital as evident from her most recent admission with the shortest discharge from the hospital for lower or 6 hours (sic). The biggest limiting factor to her overall health is her chronic persistent [MEDICAL CONDITION], decondition and his obstructive [MEDICAL CONDITION] mass which is likely causing increased respiratory distress which further worsens the rapid ventricular rate. Per electrophysiology, patient is not a candidate for rhythm control at this time. They recommended only rate control. A RESIDENT INFORMATION NOTICE form documents R1 was readmitted to the facility on [DATE] at 4:30 pm. The hospital documents the current discharge medication list to include to start taking; [MEDICATION NAME] ([MEDICATION NAME]) 90mg every 6 hours and Continue taking [MEDICATION NAME] ([MEDICATION NAME]) 125mg two times a day, Atorvastatin ([MEDICATION NAME]) 20 mg nightly, [MEDICATION NAME] (Vitamin B-12) 1000 mcg daily, [MEDICATION NAME] ([MEDICATION NAME]) 20mg two times a day, [MEDICATION NAME] ([MEDICATION NAME]) 400mg three times a day, [MEDICATION NAME] nebulizer treatment 4 times a day, [MEDICATION NAME] ([MEDICATION NAME]) 25mg every 12 hours, [MEDICATION NAME] ([MEDICATION NAME]) 5mg three times a day, and [MEDICATION NAME] ([MEDICATION NAME]) 1.5mg daily. Hospital discharge paperwork indicates R1's next dose of [MEDICATION NAME] was due the night of 4/29/19. R1's MAR indicated [REDACTED]. Hospital discharge paperwork indicates R1's next dose of [MEDICATION NAME] was due the night of 4/29/19. R1's MAR indicated [REDACTED]. There is no documentation a physician was notified of R1's medications not being administered. Progress notes on 4/30/19 at 1:52 am document, RN Assessment/LPN Appearance of resident- What I think is going on with the resident is: Resident's Afib continues to change resident's O2 demands, lowering pulse ox into 60-77%. Causing resident to be weak and not able to participate in own cares as she has been in the past. This frustrates the resident and she tries harder to be self sufficient, which only frustrates her more and increases her O2 demand. Resident is pale but does not display and (sic) SOB. RR 20-22. Additional Nursing Notes as applicable: (physician) given update and approved of transfer. (emergency room ) called and report given to (hospital RN). 911 called and picked up the resident . R1 was admitted to the hospital and did not return to the facility. On 6/11/19 at 11:18 am, NHA-A informed the surveyor R1 was very sick and had multiple diagnoses. NHA-A stated at the time the facility was having trouble with pharmacy and getting some of her [MEDICAL CONDITION] medications. NHA-A stated after the first time we had pharmacy come and get her medications in contingency. On 6/12/19 at 12:30 pm, the surveyor interviewed DON-B. DON-B informed the surveyor the facility had not been doing the best practice related to informing the MD if medications were not given, especially if medications were not available in contingency. DON-B did inform the surveyor the facility had developed a new tool to assist and audit new admission, including ensuring orders are completed, entered (into the electronic health record), and medications available.

Based on record reviews and interviews, the facility did not ensure that 2 (R7 and R16) of 3 residents reviewed for unplanned weight loss, maintained acceptable parameters of body weight, unless the resident's clinical condition demonstrates that this is not possible. * R7 experienced a weight loss of 29 pounds from 6/20/18 to 9/12/18. According to the facility Weight Management policy, the facility documents weights in the Weights and Vitals Summary section of the computerized record. The facility dietitian reviews weights from the computerized record. R7 had a physician's order for weekly weights that were being documented in the Medication Administration Record (MAR). The weekly weights were not being entered into the Weights and Vitals Summary section of the computerized record. There were weight discrepancies between weights taken on the same days. On 8/29/18, R7's weight in the Weights and Vitals Summary was 110.6 pounds, and on the (MONTH) MAR for 8/29/18, a weight of 94.6 pounds was documented. On 9/12/18, the Weights and Vitals Summary indicated R7's weight was 109.6, and the (MONTH) MAR for 9/12/18, indicated R7's weight was 88.2 pounds. The dietitian evaluated R7's nutritional status on 9/17/18, based on a weight of 109.6 pounds. The dietitian was evaluating R7 on 9/13/18, for a reported new pressure area. (R7 did not have a new wound on 9/13/18, however a new open area was noted upon observation on 9/17/18.) R7 was re-weighed on 9/17/18, and weighed 86.4 pounds. The dietitian was not aware of the extent of R7's weight loss until informed by the surveyor on 9/17/18. The dietitian does not monitor weights that are recorded on the MAR. * R16 experienced a weight loss of 8.1 pounds from an admission weight on 8/27/18 (98 pounds) until a weekly weight taken on 9/5/18 (89.9 pounds). The dietitian discussed the weight loss with the resident, who declined any supplements. R16 had weekly weights ordered. As of 9/18/18, there were no further weights taken. The surveyor asked the facility to weigh R16 on 9/18/18. R16's weight was 88.8 pounds. The facility did not monitor R16's weight weekly as ordered. Findings include: A review of the facility policy Weight Management, with a revision date of (MONTH) (YEAR) includes the following instructions for staff: -Weigh all residents upon admission and readmission; weigh weekly for an additional 3 weeks, then monthly or as indicated by physician orders. -As residents are weighed, staff can compare current weight to previous weight. Residents with weight variance are re-weighed within 48 hours. Weight variances include: Weight change of 5 pounds or weight change of 3 pounds if weight less than 100 pounds. -Enter final, validated weight data in the Weights and Vitals section of the electronic health record for each resident. -Weekly At Risk Review Meetings will be conducted on each resident with a weight loss until the Interdisciplinary Team determines weight has stabilized and can discontinue from weekly review. 1.) R7 was admitted to the facility in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. R7's admission weight on 3/9/18, was 124 pounds. R7's advanced directives on 3/9/18, revealed R7 and family do not wish tube feedings. A nutrition note on 3/13/18, mentions decreased oral intake at meals, approximately 25-50%. Med Pass 4 ounces twice daily started. On 4/17/18, R7 weighed 116.6 pounds. A Weight Warning note dated 4/19/18, acknowledges weight change and recommendations made to increase Med Pass to 4 ounces three times daily. MD to be updated. A nutrition note date 4/23/18, indicates MD was notified and agreed to increased MedPass. There is no monthly weight for (MONTH) (YEAR). On 6/20/18, R7's weight is 117.2 pounds. Weekly weights on the (MONTH) (YEAR) MAR were 115 - 117 pounds. Only the 6/20/18 was on the Weights and Vitals Summary. Weekly weights on the (MONTH) (YEAR) MAR indicated the 7/4/18, weight was not taken, the 7/11/18 weight was 116.1 pounds, the 7/18/18 weight was 116.6 pounds, and the 7/25/18 weight was 107.6 pounds. The Weights and Vitals Summary had two weights recorded in (MONTH) (YEAR). On 7/23/18, a weight of 106.4 pounds is recorded and on 7/26/18, a weight of 110 pounds is recorded. A Weight Warning note dated 7/26/18, indicates a reweigh was done to verify weight loss. Will update MD on weight change. Continue regular diet with MedPass 4 ounces three times daily. Will offer chocolate milk with meals, and add PRO powder to milk to increase calories and protein. New Stage 2 to left hip noted. On 8/1/18, R7's MAR has a recorded weight of 105.4 pounds, and the Weight and Vitals Summary has a weight of 111.2 pounds. Subsequent weights on R7's (MONTH) MAR were: 8/8-105 pounds, 8/15-110.8 pounds, and 8/22-100.2 pounds. On 8/29/18, the Weights and Vitals Summary has a recorded weight of 110.6 pounds, and the (MONTH) MAR for 8/29/18 has a recorded weight of 94.6 pounds. Nutrition notes in (MONTH) included a reference to a family care conference with daughter on 8/13/18. Daughter was updated on weight loss and poor intake. Encouraged daughter to bring in favorite foods/shakes etc. Will continue with supplements as ordered. A Nutrition Note on 8/21/18, recommends Prostat 30ml twice daily for added calories and protein for wound healing related to poor intake. A Weight Warning note on 8/30/18, indicates the weight is 110.6 pounds when the MAR weight is 94.6 pounds. The note indicates the weight is noted and continue current interventions in place. When reviewed on 9/17/18, R7's (MONTH) (YEAR) MAR had a weight on 9/5 of 97.4 pounds, and a weight on 9/12 of 88.2 pounds. The weights and Vitals Summary had one weight recorded on 9/12/18 of 109.6 pounds. There is a Weight Warning dated 9/13/18, which indicates R7's weight is 109.6 pounds which is more than a 10% change over 180 days. The plan was to continue with current plan of care. A Nutrition Status Review dated 9/13/18, notes the continued poor appetite, eating only 25-50% of meals. Weight down 11.6% in 6 months from 124 pounds to 109.6 pounds. Left hip has an unstageable area. New pressure area to right hip reported today. Will increase Prostat to three times daily and MedPass to four times daily for added calories and protein. Resident drinks supplements well. Continue to monitor weight, skin and intake. On 9/17/18 at 10:25am, the surveyor observed wound care for R7. Director of Nurses (DON)-E assisted Licensed Practical Nurse (LPN)-G with R7's wound care. A new open area below the right ischium was noted. DON-E stated the area was new and she would call and get a treatment order. R7 was observed to be very thin, with all bony prominence's visible. On 9/17/18 at 1:00pm, the surveyor spoke with Registered dietitian (RD)-F. RD-F stated the most recent weight was 109.6 pounds as mentioned in the weight variance report. RD-F stated she was told on 9/13/18, that R7 had a new pressure injury, and based on that report increased R7's supplements. The surveyor showed RD-F the weekly weights recorded in the MAR's for R7, and RD-F stated she was not aware of those weights. RD-F stated the weights that she reviews are those recorded in the electronic record. Nurses don't usually notify her of weight losses, she gets a report from the electronic record that identifies weight variances. RD-F stated that she does not review weights that may be recorded on the MAR's. RD-F stated she would have R7 re-weighed today and make any recommendations. R7 was re-weighed on 9/17/18 and weighed 86.2 pounds. On 9/17/18, RD-F stated there was a care conference scheduled for 9/18/18 to discuss options (possibly hospice) with the family. A Weight Warning note on 9/18/18, indicated the family had chosen hospice services for comfort. The MD has been updated on weight loss. From mid (MONTH) (YEAR) until mid (MONTH) (YEAR), R7 lost 28.4 pounds. Because nurses were not ensuring weekly weights were documented in the electronic record, the RD was unaware that R7's weight when evaluated on 9/13/18 was 88.2 pounds and not 109.6 pounds as recorded in the electronic record. 2.) R16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. There was a physician's order written 8/29/18, for weekly weights to be done on Wednesdays. R16's admission weight on 8/27/18 was 98 pounds. R16 was weighed again on 9/5/18, at which time R16's weight was 89.9 pounds (an 8.1 pound weight loss). RD-F's note indicated; The resident and family state usual body weight is around 90 pounds. Resident chooses to direct own care and does not want any nutritional supplements at this time. She feels appetite is good and does not need them. She is eating 50-100%. Will follow. A review of the (MONTH) (YEAR) MAR and the Weights and Vitals Summary reveals R16's weight was not taken on Wednesday 9/12/18. On 9/18/18 at 10:50am, the surveyor confirmed with Nurse Manager (NM)-C that R16 did not have a weekly weight taken on 9/12/18 as ordered. The surveyor requested that R16's weight be taken. R16's weight on 9/18/18 was 88.8 pounds. NM-C told the surveyor that RD-F was notified of the 9/18/18 weight. The facility did not complete weekly weights for R16 as ordered. This put R16 at risk of the facility failing to identify continued weight loss.

Based upon observation, interview and record review, the facility did not ensure the highest practicable well-being was met for 3 of 17 supplemental sampled residents (R23, R17 and R28) along with 2 of 19 sampled residents (R17 and R3). ~ R23 was admitted to the facility in February of 2017, for rehabilitation, following a hospitalization for a stroke. According to staff interview, R23 had made great progress in increasing her communication and activities of daily living skills where she was potentially going home and no longer in need of therapy services. On 3/11/17 the facility was notified of a critical lab value related to R23's PT/INR ([MEDICATION NAME] Time/International Normalized Ratio - a blood test to measure blood clotting time when taking [MEDICATION NAME]) indication R23's PT was > (greater than) 100 and her INR was >10. R23's [MEDICATION NAME] and [MEDICATION NAME] were both discontinued at this time. On 3/13/17 multiple staff indicate R23 was not herself right away in the morning. R23 presented with garbled speech, confusion, and an inability to sequence. R23 was observed by Licensed Practical Nurse (LPN)-R. R23 was observed again at lunch by LPN-R who now noted R23 was unable to sequence and could not coordinate to feed herself and needed hand over hand assistance to try to eat. This was a change from R23's baseline. LPN-R faxed the physician and called in to the physician's office to tell them the fax was coming. In the fax, LPN-R indicated R23 had increased confusion, garbled speech, inability to sequence, needs hand over hand contact to initiate tasks. Hx (history) of cerebral infarction frontal lobe, A-fib ([MEDICAL CONDITION]). The fax also indicated R23's blood pressure was low and her blood pressure medications were held in the morning, they were encouraging fluids, R23 had urine output as she was incontinent twice (which was also a change from her baseline). LPN-R asked the physician may we have orders to straight cath or send out to the ER (emergency room )? The physician responded with agree with ER eval (evaluation) - [MEDICAL CONDITION], confusion, please update the family. There is no indication LPN-R asked for a comprehensive assessment from a registered nurse (RN) and neurological assessments were not completed. LPN-R contacted a private ambulance company to transport R23 to the hospital and did not call 911. The private ambulance transport was delayed in arriving to the facility for over two hours due to weather and traffic conditions. At no time was an alternate source of transportation to the hospital sought by the facility despite the change of condition potentially being a stroke or intracranial bleed. Upon arrival to the facility, the documentation by the paramedics indicates it was communicated to them R23 was confused and possibly had dehydration. There was no indication that R23's change in condition and the possibly of a stroke was presented to the paramedics. R23 was transported to the closest hospital due to the weather, without lights and sirens. Upon arrival to the hospital, diagnostic tests indicate R23 was in likely [MEDICAL CONDITION] with rapid ventricular response. R23's PT/INR was 44.9/4.0 despite not receiving [MEDICATION NAME] since the evening of 3/10/17 and a CT (computerized tomography) scan showed a large left sided subdural hematoma with a 4 mm (millimeter) right midline shift . The facility's failure to properly assess and respond to R23's change in condition created a situation of immediate jeopardy that started on 3/13/17. The facility administration was made aware of the immediate jeopardy on 5/10/17 at approximately 3:19 pm. The facility removed the immediate jeopardy on 5/11/17. The scope and severity (s/s) of the deficient practice continues at a G related to the example involving R17. ~ On 2/26/17, R17 sustained a skin tear to the right foot by the area that would be part of the metatarsal right great toe amputation site. The wound declined and developed a dark discoloration over what would be part of the metatarsal, measuring 1.7 cm by 2 by 1 cm. The facility did not develop a plan of care for R17's wound on the tip of the right foot. On 5/05/17, R17 was observed sitting in a wheelchair. the tip of the R17's right foot (where the great toe was amputated), that currently has a wound, was positioned directly on the hard metal surface of the wheelchair's footrest. The condition of R17's wound declined from 5/03/17 through 5/05/17. ~ R28 did not have a wound vac applied according to physician's orders [REDACTED]. R28's wounds were not properly assessed. ~ R3 did not have a proper assessment of a wound to go along with an ordered skin treatment. Findings include: 1.) The FAST guideline by the American Heart Association and the American Stroke Association directs individuals to call 911 immediately if someone shows any of these symptoms, even if the symptoms go away .to help get the person to the hospital immediately. Time is important! Don't delay . The S in FAST represents SPEECH - Ask the person to repeat a simple phrase. Is their speech slurred or strange? http://www.strokeassociation.org/STROKEORG/WarningSigns/Stroke-Warning-Signs-and-Symptoms_UCM_ 8_SubHomePage.jsp R23 was admitted to the facility on [DATE] following hospitalization for A-fibrillation and frontal lobe cerebral infarction. R23/s admission to the facility was for rehabilitation with plans to return home following the rehabilitation. R23's Admission Minimum Data Set (MDS) indicates R23 was cognitively intact with a brief interview of mental status (BIM) score of a 15. R23 was able to make herself understood and understand others. R23 required extensive assistance of two-plus staff for bed mobility, transfer, dressing, toilet use and personal hygiene. R23 was able to feed herself with supervision and set up assistance. Section GG0130 indicates for safety and quality of performance R23's admission performance for eating was independent with a discharge goal of continuing to be independent with eating. The MDS indicates R23 is occasionally incontinent of bladder and always continent of bowel. R23's care plan related to activities of daily living (ADL's) initiated 2/17/17 indicates R23 is independent eating with set up. R23's care plan for incontinence initiated on 2/23/17 indicates R23 has occasional bladder incontinence related to assistance needed with toileting and inability to get to toilet in time. Prompt toilet upon rising, before meals, HS (at night) and q (each) round at NOC (overnight), encourage fluids throughout the day to promote prompted voiding responses . Review of R23's speech and language pathology (SLP) indicates R23 was being seen to facilitate safety with oral intake (goal met 3/9/17), articulate a complex conversation with 100% intelligibility (goal met 3/11/17), improve labial strength (goal met 3/9/17), safely and efficiently manage medications (goal met 3/11/17), increase functional problem solving skills (goal met 3/11/17). R23's Medication Administration Record [REDACTED]. Diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, SOB (shortness in breath) or nose bleeds. Document y if free from side effects and N if not free from side effects. Surveyor noted no side effects are indicated by staff for the month of March. Review of R23's medical record indicates an order was given on 2/28/17 for R23 to have a follow up PT/INR lab drawn on 3/7/17. There is no indication this lab was carried out as ordered. (Cross-reference F329.) On Friday 3/10/17 at approximately 20:31 (8:31 pm) R23 had a PT/INR lab drawn. Review of the report indicates R23's [MEDICATION NAME] was greater than 100 and the INR was greater than 10 indicating a critical lab value. The facility nursing staff was notified and R23's morning [MEDICATION NAME] dose was held and R23 was later assessed by physician (MD)-GG who held R23's [MEDICATION NAME] and discontinued the [MEDICATION NAME] she was receiving. MD-GG ordered follow up PT/INR labs for 3/12/17 and 3/13/17. Review of R23's progress notes indicates an entry dated 3/11/17 at 5:40 am referencing the critical PT/INR lab result and orders to hold R23's [MEDICATION NAME] as of 3/11/17. On 5/10/17 Surveyor reviewed the 24-hour reports for 3/11/17, which indicates for R23: date of COC (change of condition) 3/11/17, the COC is PT >10. Documentation for NOC (3rd shift) indicates: Asymptomatic (Name of dr.) on call for (name of attending physician) Hold [MEDICATION NAME] Sat + Sun, Re (check) Mon. Days documents: c/o (complaint of) diarrhea x2 wanted [MEDICATION NAME]. (no) order for it, told her we wanted to it to get out of system, she said fine. Surveyor noted diarrhea is one of the symptoms staff is to monitor for on the MAR/TAR related to receiving anticoagulants. Surveyor noted the MAR/TAR does not indicate any symptoms were observed on day shift for 3/11/17. Surveyor also noted there is no documentation on the 24 hour report for pm shift. A speech therapist documented on 3/11/17 that the resident reported not feeling well today; it is referenced that the therapist reported R23's statement about not feeling well to nursing staff. Surveyor noted there was no documentation in R23's progress notes to indicate nursing staff responded to the therapist and R23's report of not feeling well. The 3/12/17 24-hour report indicates for 3rd shift: Re(check) Mon. No s/s bleeding. Day shift documents: PT/INR (decreased) 6.2 [MEDICATION NAME] on hold c/o loose stools. Not watery. PT/INR in AM. Surveyor noted again on day shift R23 experienced loose stools which is one symptom to monitor for according to the MAR/TAR related to R23 receiving anticoagulants. This is not reflected on the MAR/TAR. There is no indication R23's physician was notified R23 was experiencing loose stools for a second day. Surveyor also noted PM shift was blank. Surveyor noted the only documentation in the progress notes for 3/12/17 is for medication administration entries. On 5/10/17 at approximately 10:45 am Surveyor interviewed RCS-II regarding R23. RCS-II told Surveyor she remembered R23 because she would always be talking about her cat. RCS-II indicated she had worked with R23 the weekend before R23 went out (3/11 and 3/12/17) and reported to nursing staff that something was not right with R23. RCS-II indicated R23 did not want to eat and she was having accidents; where she wouldn't even realize that she had completely wet herself. RCs-II indicated R23 could sometimes have accidents because of not getting to the bathroom on time but she never just wet herself and not realize it. RCS-II told Surveyor R23 even needed to start wearing a brief because she was having so many accidents. RCS-II indicated R23 would typically sleep in and when she'd wake up in the morning she'd request black coffee and her breakfast. RCS-II indicated R23 couldn't do that on 3/13/17 and she let the nurse know. Surveyor asked RCS-II if she recalls filling out a stop and watch form to give to the nurse. RCS-II asked Surveyor what that form was and when explained that it was a small form that could be filled out if they notice something is not right RCS-II told Surveyor that would be a great thing but she never knew about it or filled one out. On 5/10/17 at approximately 11:30 am Surveyor interviewed RCS-JJ about R23. RCS-JJ indicated R23 was not her normal self on 3/13/17 and even on Sunday (3/12/17) R23 was not right. RCS-JJ told Surveyor R23 wasn't really eating, was having more accidents, and she seemed sleepy. Surveyor asked RCS-JJ if she recalls sharing this with nursing staff. RCS-JJ indicated she told nursing staff but does not know what they did. RCS-JJ told Surveyor on 3/13/17 at the start of RCS-JJ's shift R23 already was not making sense when she would speak and she was really confused. On 5/9/17 at approximately 1:16 pm Surveyor interviewed LPN-R regarding R23. Surveyor asked LPN-R if she recalled working with R23 and what happened on 3/13/17. LPN-R indicated R23 was a resident that liked to sleep in and would give the RCS (Resident Care Staff (CNA) an order for [REDACTED]. LPN-R indicated shortly after waking up she interacted with R23 and noticed the confusion and garbled speech. LPN-R indicated she noticed it was definitely different for R23 so much so that she asked the RCS staff to see if R23 had been able to give her breakfast order. Surveyor asked LPN-R what she did once she realized the change in R23. LPN-R indicated that she decided to continue to monitor R23 and mentioned therapy worked with R23 and also noticed changes in her. Surveyor asked LPN-R to explain the changes. LPN-R indicated R23 could answer questions and state what she wanted and follow a sequence of steps given to her. LPN-R indicated when lunch time came around R23 could not figure out how to pick up her utensils to feed herself or sort out what to do with the tray and the items on it. LPN-R indicated she became more worried at that point. Surveyor shared the fax with LPN-R that had been sent to R23's attending physician. This fax noted: S: (increased) confusion, garbled speech, unable to sequence, needs hand over hand contact to initiate tasks. B: hx (history) of cerebral infarction frontal lobe, A Fib. A: BP (blood pressure) (decreased) [MEDICATION NAME], Losartan held this morning, encouraging fluids. Urine output - incontinent x (times) 2. Lungs clear, vitals stable with exception of BP. No facial droop or weakness noted. May we have orders to straight cath or send out to ER? Today's INR included. The documented new orders on the fax indicate: Agree with ER eval - [MEDICAL CONDITION], confusion, please update family signed 3/13/17 at 14:30 (2:30 pm). Surveyor asked LPN-R if she recalled actually calling the physician and consulting with them. LPN-R indicated she thinks she called but was not sure; typically they call the office to notify them an SBAR is coming to them by fax. Surveyor asked LPN-R if she recalled whether she discussed with R23's attending physician the changes in medication or discussed the previous critical PT/INR from a few days earlier. LPN-R indicated she did not recall. Surveyor asked LPN-R about the decision to have R23 sent to the hospital. LPN-R indicated R23's family wanted her to go to Froedtert so that's what the ambulance company was told. Surveyor asked LPN-R about the length of time between first noticing R23's changes in mental status and what appears to be the time R23's physician was contacted and when she actually was transported to the hospital. LPN-R indicated she thought maybe R23 was dehydrated or had a UTI. Surveyor asked LPN-R if there had been any consideration to call 911 as R23's symptoms changed and since transport appeared to be taking a long time. LPN-R told Surveyor that she knew R23's daughter wanted to go with to the hospital. Surveyor asked LPN-R if an RN ever assessed R23 though out the day on 3/13/17. LPN-R indicated she thought RN-M was the RN for the building besides the Director of Nursing (DON)-B. LPN-R indicated she thought RN-M looked into the room but knew nothing was charted about an RN so she is not really sure. Surveyor asked LPN-R if she had given consideration to R23 possibly experiencing stroke symptoms that day. LPN-R looked at the fax sheet and indicated R23 was alert with no facial drooping and thought she was able to grasp . LPN-R then asked Surveyor if Surveyor knew if R23 had experienced a stroke. Review of R23's record includes an SBAR (Situation, Background, Assessment, Request) form dated 3/13/17 indicating the following information: Situation: the change in condition, symptoms or signs I am calling about is/are: Increased confusion, garbled speech, unable to sequence, needs hand over hand guidance to initiate task. This started on 3/13/17 and has stayed the same since it has started, things that make it worse or better: n/a (not applicable). This condition/symptom has not occurred before. Other relevant information includes: cerebral infarction, frontal lobe. Background: Changes in the last week includes [MEDICATION NAME] held as of 3/10 for elevated INR; Resident is on [MEDICATION NAME]/[MEDICATION NAME]: yes; results of last PT/INR PT: 42.7 INR 4.5: 3/13/17. Vital signs indicate: at 13:43 (1:43 pm): Blood pressure: 82/62, pulse 106, Temperature: 98.8, Respirations as of 8:37 am were 18. Most recent O2 (oxygen) sats (saturation) is 98% on room air as of 13:44 (1:44 pm), oxygen at 2 liters/minute/nasal cannula. Mental status changes: increased confusion with symptoms described as garbled speech, unable to sequence. Functional status changes: needs more assistance with ADLs, slurred speech with symptoms described as garbled speech, needs hand over hand to initiate tasks. Respiratory, GI/Abdomen, GU/Urine changes all indicate not applicable. The section for recent lab results indicates to see INR above, last INR on 3/12 PT 59.2/INR 6.2. Resident is full code. Assessment (for RN) or Appearance (LPN) indicates: I am a LPN: the resident appears: nursing and therapy noted increased confusion, garbled speech. I suggest or request section (check all that apply) has no checks indicated, transfer to the hospital and other new orders is blank. Nursing notes indicates: [MEDICATION NAME] discontinued, [MEDICATION NAME] held as of 3/10. Date and time notified 3/13/17 13:45. Signed LPN-R. Progress notes dated 3/13/17 at 14:42 (2:42 pm) indicate: Dr (name of) ordered resident to ER for eval of [MEDICAL CONDITION] & confusion. Daughter (name of) will be coming to VHHRC (Virginia Highlands Rehabilitation Center) to accompany resident to Froedtert via ambulance. Signed: LPN-R The next progress note date 3/13/17 at 15:29 (3:29 pm) indicates: Resident's daughter requests that resident be sent to CMH (Community Memorial Hospital) as roads are backed up d/t (due to) weather. Lifestar ambulance called to reroute and report given to CMH. Signed: LPN-R. Progress note dated 3/13/17 at 16:45 (4:45 pm) indicates: Lifestar here to transport resident. Daughter present and to follow to the hospital. Signed: LPN-R. On 5/9/17 at approximately 10:50 am Surveyor received and reviewed the transport documentation from Lifestar. Details on the report indicate Lifestar received the call from the facility at 14:46 (2:46 pm) with indication it was not a lights/sirens call. Non-emergent is documented for the priority scene. The report further indicates Lifestar was en-route at 14:49 (2:49 pm) but did not respond on scene until 16:41 (4:41 pm) and was not at the patient's bedside until 15:50 (4:50 pm). The ambulance departed the facility at 17:05 (5:05 pm) and was at the hospital at 17:24 (5:24 pm). Surveyor noted this was over 3 hours and 45 minutes since LPN-R initiated contacting R23's physician. The report indicates the primary impression was dehydration with chief complaint being increased confusion; the protocol was the [MEDICAL CONDITION]/shock protocol. Review of the report indicates R23's blood pressures varied from 91/55 to 87/54 and 97/50. The ECG readings indicate R23 had [MEDICAL CONDITION] flutter for a rhythm and R23 was administered normal saline and then glucose with no improvement in status. The narrative in the report indicates: Lifestar (number) was dispatched to (name of facility) for a PT (patient) who was not feeling well. Has had increased confusion and wished to be transported to Froedtert Memorial Hospital in Milwaukee. Lifestar went en-route to (the name of facility) and were severely delayed by weather and traffic. US 41 was closed due to a multiple vehicle accident so alternatively HWY 164 was used however, an accident on Holy Hill road delayed (number of team) for nearly 2 hours. (Number of team) was contacted by dispatch via cell phone with an update on PT destination. Due to the weather PT's family thought transport to Community Memorial Hospital in Menomonee Falls would be more feasible. Lifestar (Team number) arrived on scene without further incident or delay and EMS received report from RN staff. The PT, an 80 Y/O (year old) female has been acting more confused as of late with a marked increase over the last day. Pt has also been hypotensive throughout the day. RN thought the PT was just dehydrated and could use some fluids however, PT's family with for transport to and evaluation by the hospital. EMS found the PT lying supine in her bed being visited by family. Family understood the reason behind the delay and accepted it, not looking forward to the drive to CMH (community Memorial Hospital) themselves. The PT was alert, oriented to event and confused, was breathing adequately on her own, warm, dry skin, a palpable radial pulse and did not appear to be in distress. The Pt was moved over to the ambulance cot .the PT was borderline [MEDICAL CONDITION] and borderline hypotensive with all other values within normal limit. Once inside venous access was gained in the right forearm and a 250 mL bolus of normal saline was administered. 12 lead EKG was performed with a rhythm of A-flutter 1:1. A blood glucose analysis was done with a result of 79, a tube of 15G oral glucose was opened and was administered slowly at the PT's pace. Lifestar (number of team) was en-route to CMH. Pt rested comfortably for the duration of the transport without significant changes to condition or complaint. The Pt conversed with EMS for the entirety of the time and had transient orientation without ever regaining her full faculty. The Pt's blood pressure failed to respond to the initial bolus of normal saline so a second was administered en route. Blood glucose rose to 92 with the oral glucose . On 5/10/17 at approximately 9:05 am Surveyor interviewed RN-M via telephone. Surveyor asked RN-M if she recalled R23 and her change in condition on 3/17/17. RN-M indicated she recalled R23 and what occurred. Surveyor asked RN-M if she recalls assessing R23 on 3/13/17. RN-M indicated she tries to eyeball the residents but did not assess R23 on 3/13/17. On 5/9/17 at approximately 4:30 pm Surveyor interviewed RN-FF regarding R23 and asked whether RN-FF recalled assessing R23 on 3/13/17. RN-FF indicated when she came on her shift (2nd shift) that day she believed that any change in condition for R23 had already taken place during the day. RN-FF indicated she thought R23 had been sleeping and that she thought she was told that R23 was stable and there weren't any unusual findings. Surveyor read the details from the 3/13/17 SBAR to RN-FF and asked her if she was aware of any of the details from that day. RN-FF indicated no and that it sounded like R23 was having a stroke. RN-FF indicated to Surveyor something must not have been communicated because she had no idea all of that had been taking place with R23. On 5/10/17 at approximately 10:25 am Surveyor interviewed SLP-HH regarding R23's communication status and [DIAGNOSES REDACTED]. SLP-HH indicated R23 had met her speech therapy goals and had shown great improvement in her skills. SLP-HH indicated to Surveyor that R23's speech was not garbled or confused until 3/13/17 and R23 was able to follow directions and had made great progress in her memory recall. SLP-HH indicated to Surveyor that R23 was just about ready to return home. SLP-HH indicated the change R23 demonstrated on 3/13/17 was a sudden and definite change from R23's previous status. Review of the hospital records dated 3/13/17 indicates R23 was in likely [MEDICAL CONDITION] with rapid ventricular response. R23's PT/INR was 44.9/4.0 despite nor receiving [MEDICATION NAME] since the evening of 3/10/17 and a CT scan showed a large left sided subdural hematoma with a 4 mm (millimeter) right midline shift .R23 was eventually transferred to Froedtert Hospital due to the critical brain bleed where R23 subsequently passed away. R23 was reviewed as part of a complaint received by the coroner's office. No additional information was provided to Surveyor to review regarding R23's change of condition following exit from the facility. The facility's failure to appropriately assess R23's change in condition and respond quickly to having R23 receive emergency medical care resulted in R23 being hospitalized in critical condition with a subdural hematoma that required transfer to a critical care hospital for advanced treatment. The facility removed the immediate jeopardy on 5/11/17 when the implemented the following action plan: 1. All licensed staff received education on recognizing, assessing, documenting and responding to acute change in condition, physician notification, RN assessment, and emergency response. 2. All unlicensed staff received education on notifying nurse of changes in resident condition and utilization of INTERACT communication form Stop and Watch. 3. The facility established a system where the Director of Nursing (DON)/Nursing Home Administrator (NHA) will review 24 hour report, clinical alerts, and Point Click Care Dashboard to ensure any Acute Change in Condition documentation incorporates RN assessment. 4. Licensed staff will notify RN on call for any acute changes in condition 5. The NHA/designee will audit 24 hour report, clinical alerts, and Point Click Care Dashboard daily for 30 days, then 3 x a week for 30 days and then monthly thereafter. Audits will be brought to the QA committee monthly until committee determines substantial maintenance of compliance. 6. The District Director of Clinical Services to review results of audit weekly for 30 days then Bi-weekly for 30 days. Audits will be brought to the QA committee monthly until committee determines substantial maintenance of compliance. The deficient practice continues at a scope and severity of a G (actual harm/isolated) related to example 2, involving R17. 2.) On 5/05/17 Surveyor reviewed R17's medical record. The [DIAGNOSES REDACTED]. The significant change Minimal Data Set (MDS), dated [DATE], indicates R17 has a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive impairment), uses a wheelchair for mobility, and does not ambulate. The Nursing Note, dated 2/26/17 at 9:12 p.m., and the Incident/Accident Report, dated 2/26/17, indicate R17 was noted to have an open area measuring 1.8 cm to the tip of the foot (where great toe was amputated). The record review indicates no plan of care was developed for the wound to R17's right foot by the area that would be part of the metatarsal right great toe amputation site. The Nursing Note dated 2/28/17 at 10:50 am. Indicates the wound was assessed and noted to be an area with the appearance of old lifting keratinized tissue with fluid trapped beneath causing maceration to surrounding tissue. The Skin-Weekly Non-Pressure Condition Record dated 3/14/17 indicates R17's wound on the tip of the right foot (where the great toe was amputated) measured 1.6 centimeters (cm) by 1.2 cm by 0.1 cm in depth. The record review indicates the facility assessed R17's non-pressure wound weekly from 3/14/17 through 5/03/17. The record review indicates that on 5/03/17, R17's wound to the tip of the right toe was evaluated by (name of group) Wound Physicians. The Wound Care Specialist Initial Evaluation, dated 5/03/17, indicates R17 has a 1.7 cm by 2.0 cm by 0.1 cm wound to the right toe that started as a skin tear, has dark discoloration over what would be part of the metatarsal. The note indicates R17 does transfer with foot and may be putting pressure on it. The evaluation includes a recommendation to offload the wound. On 5/05/17 at 8:25 a.m. and 8:40 a.m., the Surveyor observed R17 sitting in a wheelchair in the dining room. R17 had a gauze dressing and gripper sock on the right foot. R17's right foot was elevated with the wheelchair leg rest. The tip of the R17's right foot, where the great toe was amputated & currently has a wound, was positioned directly on the hard, metal surface of the wheelchair's footrest. On 5/05/17 at 9:45 a.m. the Surveyor observed R17 sitting in a wheelchair in the day area. R17 had a gauze dressing and gripper sock on the right foot. R17's right foot was elevated with the wheelchair leg rest. The tip of the R17's right foot, where the great toe was amputated and currently has a wound, was positioned directly on the hard metal surface of the wheelchair's footrest. On 5/05/17 at 9:45 a.m. the Surveyor and Director of Nursing (DON)-B observed R17's right foot positioning. DON-B verified that the tip of the R17's right foot (where the great toe was amputated and currently has a wound), was positioned directly on the hard metal surface of the wheelchair's footrest. DON-B indicated the facility would evaluate R17 for proper positioning of the right foot, when R17 is positioned in the wheelchair, to ensure off-loading to the right foot wound. On 5/05/17 at 11:15 a.m. the Surveyor, DON-B and District Clinical Services Registered Nurse-C observed the tip of the R17's right foot (where the great toe was amputated and currently has a wound). The wound had bloody drainage and was measured to be 2.1 cm by 2.4 cm. DON-B indicated she observed the wound on 5/03/17 and the wound condition has deteriorated since that assessment date (the date of the evaluation that was completed by the (name of group) Wound Physicians). The facility did not develop a plan of care for R17's wound on the tip of the right foot. On 5/05/17 the facility did not provide R17 with off-loading of pressure to the wound on the tip of the right foot when the resident was positioned in the wheelchair. R17's wound increased in size and developed bloody drainage. 3.) R3's medical record was reviewed by Surveyor due to a complaint intake concerns. R3 was reviewed as a closed record during the survey. R3 was admitted for rehabilitation services on 7/14/16 and was discharged on [DATE] to the hospital with no return back to the facility. R3's Admission MDS assessment, completed on 7/20/16, indicates they are at risk for pressure injuries. The Treatment Administration Record for August 2016, indicates on 8/6/16 to apply Hydraguard house barrier cream protection for gluteal wound every day and evening shift until healed. This was administered 8/7/16 through to discharge on 8/12/16. The Physician/Nurse Practitioner Progress Note dated 8/5/16 indicates 2 stage 2 decubitus ulcers in the sacral area approximately 1 centimeter in diameter. The treatment pal is House Barrier for protection and to monitor closely. R3's medical record does not contain any additional information, nor a comprehensive assessment, regarding these skin areas. On 5/3/17 at 1:46 p.m. Surveyor spoke with DON-B (Director of Nurses). DON-B indicated they were not at the facility during this time and would look for any additional information. On 5/3/17 at 2:23 p.m. Surveyor spoke with R3's NP-O (Nurse Practitioner) who followed R3 at the facility. NP-O and Surveyor, reviewed the Physician/ Nurse Practitioner Notes together. NP-O does not recall any actual pressure injuries/wounds. NP-O indicated R3 was not eating and declining in their disease process. Surveyor reviewed R3's hospital record upon discharge form the facility on 8/12/16. The Wound Assessment Notes, dated 8/12/16, indicated R3 was referred for assessment due to having a possible pressure injury on the sacral area. The skin assessment could not be completed due to R3 having incontinence of stool. R3 passed way a few hours later, so a skin assessment was not conducted from the hospital. On 5/10/17 at 7:38 a.m. Surveyor shared R3's skin assessment concerns with DON-B and Administrator-A. No further information was provided. 4.) The facility's Skin Management policy with a revision date of August 2012, under practice guidelines states: NEWLY admitted RESIDENTS .4. Residents admitted with skin impairments will have a. Appropriate interventions implemented to promote healing; b A physician's orders [REDACTED].

Based on observation, record review and interview, the facility did not ensure 7 (R10, R5, R1, R6, R7, R17 & R19) of 19 sampled residents and 1 (R27) supplemental resident at risk for the development of pressure ulcers, received consistent measures to prevent the development of pressure ulcers. *R10 did not receive adequate treatment, assessment and monitoring for a stage 3 pressure ulcer that deteriorated. *R7 did not receive adequate treatment, assessment and monitoring for his pressure injuries. R7 developed a facility acquired stage 4 pressure injury with ostemylitis and a facility acquired stage 3 pressure injury. *R5 was observed to not to have pressure relief boots on per his plan of care. R5 did not have a plan of care that documented and managed R5's refusals to wear pressure relief boots. *R1 was observed to not to have a pressure relief cushion in his wheelchair per his plan of care. *R6 was observed to not have her heels floated to relieve pressure per her plan of care. *R17's wheelchair was observed to not have foot pedals on and the bottom of R17's right foot was observed to be dragging on the floor. R17's feet were not floated to relieve pressure per her plan of care. *R19 developed a pressure injury due to a wheelchair footrest that was bent. The facility did not identify the root cause of the pressure injury and did not prevent pressure to the right foot. The facility did not develop a plan of care with goals and interventions to promote healing of the pressure injury. *R27 developed a scabbed area to his heel that was not assessed or monitored per his plan of care. Findings include: 1.) Surveyor reviewed R10's medical record from 5/1/17 to 5/9/17. R10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R10's quarterly MDS (Minimum Data Set) dated 1/26/17 documents a BIMS (brief interview for mental status) score of 10, indicating that R10 is moderately cognitively impaired. Section G (Functional Status) documents that R10 requires extensive assist and a one person physical assist for his bed mobility and transferring needs. Section G0400 documents that R10 has impairment to one side of his lower extremities. Section M (Skin Conditions) documents that R10 is at risk for the development of pressure ulcers and was admitted to the facility with a stage 2 pressure ulcer. R10's Pressure Ulcer CAA (Care Area Assessment) with a reference date of 4/25/17 documents under the Analysis of Findings section, Resident admitted with stage 2 pressure ulcer coccyx. Resident has potential for more pressure ulcers development r/t (related to) incontinence, decline in recent ADLs (activities of daily living), nutrition risks, friction/shear issues and co morbid conditions such as DM (Diabetes Mellitus), [MEDICAL CONDITIONS], Dementia, CKD ([MEDICAL CONDITION]). See Braden scale 4/24, nursing progress notes and weekly wound sheets. Now has sinus/fissure and vascular and surgical wounds. Under the Care Plan Considerations section it documents, Resident admitted with stage 2 pressure ulcer to coccyx. Resident has potential for more pressure ulcers development r/t (related to) incontinence, decline in recent ADLs (activities of daily living), nutrition/hydration risks, friction/shear issues and co morbid conditions such as DM (Diabetes Mellitus), [MEDICAL CONDITIONS], Dementia, CKD ([MEDICAL CONDITION]). Will follow interventions noted in the pressure ulcer care plan. Now has sinus/fissure on sacrum, vascular wound on left hell and surgical incision right foot. R10's Pressure Ulcer plan of care with an initiated date of 11/1/16 documents under the Focus section, Resident has potential for pressure ulcers development r/t (related to) incontinence, decline in recent ADLs (activities of daily living), nutrition risks, friction/shear issues and co morbid conditions such as DM (Diabetes Mellitus), [MEDICAL CONDITIONS], Dementia, CKD ([MEDICAL CONDITION]). R10's Braden Scale for Predicting Pressure Sore Risk on 10/20/16 documented a score of 18, indicating that R10 is at risk for the development of pressure ulcers. Under the Interventions section, Administer treatments as ordered and observe for effectiveness. R10's admission Nursing assessment dated [DATE] documents under the Skin section, Coccyx Pressure Sore, Length: 2, Width: 1.5 (centimeters). Surveyor notes that R10's admission Nursing Assessment does not stage R10's pressure injury to his Coccyx. Surveyor notes that the stage for R10's admission Nursing Assessment is documented in R10's admission MDS with a reference date of 10/28/16. Section M (Skin Conditions) documents that R10 is at risk for the development of pressure ulcers and was admitted to the facility with a stage 2 pressure ulcer. Surveyor reviewed R10's admission orders [REDACTED]. R10's Physician Consult notes dated 10/21/16 has no documentation of a pressure injury to R10's coccyx. Surveyor was unable to locate any treatment orders, measurement or staging of R10's pressure injury in R10's Physician Consult notes dated 10/21/16. R10's Physician Consult notes dated 10/21/16 does document under the Impression and Plan section, #6 Wounds: Wound care as ordered. R10's Nursing Daily Skilled Charting dated 10/27/16 documents under the Skin section, Sacrum: Vascular. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present, had healed or no was longer staged as pressure. Surveyor was unable to locate any documentation that R10 had developed a vascular area to his sacrum as documented on R10's Nursing Daily Skilled Charting dated 10/27/16. Surveyor noted that the documentation did not include any measurements or description of the open area to R10's sacrum. R10's Braden Scale for Predicting Pressure Sore Risk on 10/27/16 documented a score of 11, indicating that R10 is at high risk for the development of pressure ulcers. R10's Nursing Note dated 10/26/16 documents, IDT (Interdisciplinary Team) met related to clinical rounds .admitted with Sacral Ulcer 0.3 x 0.3 x 0.1 stage 2 healing well. Dressing Intact. [DIAGNOSES REDACTED] to peri wound satellite [MEDICAL CONDITION] at edges of peri wound consistent with fungal skin rash. Resident reports no pain. R10's Nursing Daily Skilled Charting dated 11/01/16 documents under the Skin section, Sacrum: Pressure. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's pressure injury to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present, had healed or was no longer considered vascular as documented on 10/27/16. R10's Nursing Daily Skilled Charting dated 11/05/16 documents under the Skin section, Sacrum: Pressure. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's pressure injury to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present, had healed or was no longer considered vascular as documented on 10/27/16. R10's Nursing Daily Skilled Charting dated 11/08/16 documents under the Skin section, Sacrum: Pressure. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's pressure injury to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present, had healed or was no longer considered vascular as documented on 10/27/16. R10's Nursing Daily Skilled Charting dated 11/09/16 documents under the Skin section, Sacrum: Pressure. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's pressure injury to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present, had healed or was no longer considered vascular as documented on 10/27/16. R10's Skin-Head to Toe Skin Checks dated 11/9/16 documents under the Skin Integrity section, Sacrum: Type-Other: Abrasion: 17 centimeters in length, 4 centimeters wide. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present, had healed or was no longer considered vascular as documented on 10/27/16. R10's Braden Scale for Predicting Pressure Sore Risk on 11/10/16 documented a score of 11, indicating that R10 is at high risk for the development of pressure ulcers. R10's Nursing Daily Skilled Charting dated 11/11/16 documents under the Skin section, Sacrum: Pressure. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's pressure injury to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present, had healed or was no longer considered vascular as documented on 10/27/16. R10's Nursing Daily Skilled Charting dated 11/12/16 documents under the Skin section, Sacrum: Pressure. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's pressure injury to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present, had healed or was no longer considered vascular as documented on 10/27/16. R10's Nursing Daily Skilled Charting dated 11/14/16 documents under the Skin section, Sacrum: Pressure. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's pressure injury to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present, had healed or was no longer considered vascular as documented on 10/27/16. R10's Nursing Daily Skilled Charting dated 11/15/16 documents under the Skin section, Sacrum: Pressure. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's pressure injury to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present, had healed or was no longer considered vascular as documented on 10/27/16. R10's Primacy Care Office/Clinic Note by the physician dated 11/16/17 documents under the History of Present Illness section, I'm seeing R10 for a rash. The rash is present on his sacral area and buttocks and has been present for many months. It is red and painful. He is not currently using any treatment for [REDACTED]. There is no itching. Surveyor noted that R10's Primary Care Office/Clinic Note by the physician dated 11/16/16 does not document any pressure injury to R10's coccyx as described in R10's Nursing Daily Skilled Charting on 11/15/16. There is no documentation of any open area to R10's coccyx per R10's Primary Care Office/Clinic Note by the physician dated 11/16/16. R10's Nursing Daily Skilled Charting dated 11/16/16 documents under the Skin section, Sacrum: Pressure. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's pressure injury to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed. R10's physician order [REDACTED]. Apply to affected areas of sacrum and buttocks three times daily for 7-14 days. Contact MD (medical doctor) if not improving. Surveyor noted that the above treatment was the first treatment to R10's sacrum, as Surveyor could not locate any documentation or treatment orders to R10's sacrum since R10 was admitted on [DATE]. R10's Primacy Care Office/Clinic Note by the physician dated 11/23/16 documents under the History of Present Illness section, I'm seeing R10 for 1 week follow-up of a sacral/gluteal rash. This rash was painful. The pain is improving. I do speak with the staff and they're unsure whether it is improving or not. The rash started several months after per his report. Under the Physical Examination-Integumentary section it documents, In the sacral/gluteal area there is a very mild [DIAGNOSES REDACTED]tous rash. There are satellite [MEDICAL CONDITION]. The rash is smaller and much less [DIAGNOSES REDACTED]tous than last week. There is a 3 mm (millimeter)defect in the skin at the superior portion of the gluteal cleft. Surveyor noted that R10's Primary Care Office/Clinic Note by the physician dated 11/23/16 does not document any pressure injury to R10's coccyx as described in R10's Nursing Daily Skilled Charting on 11/16/16. There is no documentation of any open area to R10's coccyx per R10's Primary Care Office/Clinic Note by the physician dated 11/23/16. R10's Nursing Daily Skilled Charting dated 11/29/16 documents under the Skin section, Sacrum: Vascular. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed . Surveyor did not locate any documentation with a [DIAGNOSES REDACTED]. Daily Skilled Charting dated 11/16/17. R10's Primacy Care Office/Clinic Note by the physician dated 11/30/16 documents under the History of Present Illness section, I'm seeing R10 for 1 month follow up of his chronic medical problems .I saw him on 2 occasions recently due to a rash in the sacral and gluteal area. This appeared to be candidal and so he was started on [MEDICATION NAME]. The follow-up visit showed significantly improved rash. Surveyor noted that R10's Primary Care Office/Clinic Note by the physician dated 11/20/16 does not document any pressure injury to R10's coccyx as described in R10's Nursing Daily Skilled Charting on 11/16/16. There is no documentation of any open area to R10's coccyx per R10's Primary Care Office/Clinic Note by the physician dated 11/30/16. R10's Nursing Daily Skilled Charting dated 12/02/16 documents under the Skin section, Sacrum: Vascular. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed. Surveyor did not locate any documentation with a [DIAGNOSES REDACTED]. Daily Skilled Charting dated 11/16/17. R10's Nursing Daily Skilled Charting dated 12/03/16 documents under the Skin section, Sacrum: Incontinent Derm ([MEDICAL CONDITION]). Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed. R10's Nursing Daily Skilled Charting dated 12/04/16 documents under the Skin section, Sacrum: Incontinent Derm ([MEDICAL CONDITION]). Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed. R10's Nursing Daily Skilled Charting dated 12/05/16 documents under the Skin section, Sacrum: Incontinent Derm ([MEDICAL CONDITION]). Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the sacrum. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed. R10's Care Plan Note dated 12/8/16 documents, IDT met related to risk for non pressure wounds. Per wound nurse wounds are showing signs of healing. Will continue with treatments as ordered. Surveyor noted that the above note did not document any open areas to R10's coccyx. Surveyor was unable to locate any treatment for [REDACTED]. Daily Skilled Charting dated 11/16/17. R10's SBAR (Situation, Background, Assessment, Recommendation) dated 12/28/16 documents under the Situation section, O/A (open area to coccyx. This started on 12/28/16. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. R10's SBAR fax dated 12/28/16 and sent to Medical Director-GG documents under the Question for Physician section, O/A to coccyx. Will consult with wound nurse for type of treatment. Under the Assessment section it documents, O/A (open area) noted to coccyx 0.7 cm (centimeters) x 0.5 cm. Surveyor noted that the documentation did not include any description or staging of R10's open area to his coccyx. Under the Physician Recommendation section it documents, Agreed and thank you. Surveyor notes that Medical Director-GG signed and returned the fax to the facility on [DATE]. R10's nursing note dated 12/28/16 documents, Area cont (continues) to coccyx. Tx (treatment) applied per order. Denies pain. Surveyor was unable to locate any physician orders, treatment orders or any documentation of a treatment to R10's open area to his coccyx as described on R10's SBAR dated 12/28/16. Surveyor was unable to locate a treatment plan or orders for R10's open area to his coccyx that documented treatments were provided and the area was monitored in R10's medical record. Surveyor did not locate any treatment orders that documented completion of any treatment to R10's open area t his coccyx on R10's December MAR and TAR. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. R10's nursing note dated 12/29/16 documents, Area continue to coccyx, barrier applied per order. No c/o (complaints of) pain or discomfort noted. Surveyor did not locate any treatment orders that documented completion of any treatment to R10's open area t his coccyx on R10's December MAR and TAR. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. R10's nursing note dated 12/30/16 documents, Area continues to coccyx, tx (treatment) applied per order. No injury noted r/t (related to) to previous fall. Surveyor did not locate any treatment orders that documented completion of any treatment to R10's open area t his coccyx on R10's December MAR and TAR. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. R10's nursing note dated 12/31/16 documents, Area continues to coccyx , tx applied per order. Surveyor did not locate any treatment orders that documented completion of any treatment to R10's open area t his coccyx on R10's December MAR and TAR. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. R10's nursing note dated 12/31/16 documents, O/A (open area) remains to coccyx. Resident denied pain discomfort. Surveyor did not locate any treatment orders that documented completion of any treatment to R10's open area t his coccyx on R10's December MAR and TAR. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. R10's nursing note dated 1/1/17 documents, Resident in bed sleeping, alert and responsive drsg (dressing) intact to coccyx and heel. Surveyor did not locate any treatment orders that documented completion of any treatment to R10's open area t his coccyx on R10's January MAR and TAR on the above date. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. R10's Primacy Care Office/Clinic Note by the physician dated 1/18/17 documents under the Impression and Plan [DIAGNOSES REDACTED]. Surveyor noted that R10's Primary Care Office/Clinic Note by the physician dated 1/18/17 does not document any pressure injury to R10's coccyx as described in R10's SBAR dated 12/28/16. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor noted that the documentation did not include any treatment orders for R10's open area to his coccyx as described on R10's SBAR dated 12/28/16. R10's Wound Clinic Follow up note dated 2/6/16 documents under the History of Present Illness section, R10 seen today for follow up of left heel wound, coccyx, and right 3rd toe. This has most recently been treated with santyl for heel and has been gradually improving. The coccyx and toe are new to me. Under the Wound exam it documents, Location/Measurement: Coccyx: 0.7 cm x 0.3 cm x 0.5 cm good granulation. Surveyor noted that R10's Wound Clinic Follow note dated 2/6/16 did not include a stage for the open area to R10's coccyx. R10's Report of Consultation Wound clinic report dated 2/6/17 documents under the findings section, Coccyx: Hydrogera blue rope [MEDICATION NAME] sacrum, change every 2 days or if soiled. Follow up in 2 weeks with MD. Surveyor noted that R10 did not have a treatment order for the open area to his coccyx as described on R10's SBAR on 12/28/16 prior to 2/6/17. Surveyor was unable to locate any documentation of treatment or monitoring for R10's open area to his coccyx as described on R10's SBAR from 12/28/16 to 2/6/17. R10 was sent to the hospital on [DATE] and readmitted to the facility on [DATE]. R10's Nursing Admission Data Collection form dated 2/20/17 documents under the Skin section, Coccyx: Other: Cyst. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx as described on R10's SBAR dated 12/28/16. Surveyor noted that R10 was receiving the following treatment upon readmission to the facility on [DATE]: Coccyx: [MEDICATION NAME] blue follow be mapliex. Change every 2 days for coccyx wound. R10's readmission Braden Scale for Predicting Pressure Sore Risk dated 2/20/17 documents a score of 14, indicating that R10 is a moderate risk of developing a pressure ulcer. R10's Nursing Daily Skilled Charting dated 2/20/17 documents under the Skin section, Coccyx. Other: Cyst. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Wound Clinic Follow up note dated 2/6/16. R10's Skin-Head to Toe Skin Checks dated 3/13/17 documents under the Skin Integrity section, Left heel and coccyx area remain. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Wound Clinic Follow up note dated 2/6/16. R10's Skin-Head to Toe Skin Checks dated 3/20/17 documents under the Skin Integrity section, Left heel and coccyx area remain. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Wound Clinic Follow up note dated 2/6/16. R10's Skin-Head to Toe Skin Checks dated 3/23/17 documents under the Skin Integrity section, Sacrum: Other: Sinus/Fissure Area. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Wound Clinic Follow up note dated 2/6/16. R10's Skin-Head to Toe Skin Checks dated 3/27/17 documents under the Skin Integrity section, Resident refused body check. Writer aware left heel and coccyx area remain. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Wound Clinic Follow up note dated 2/6/16. R10's Wound Clinic Report of Consultation report dated 4/3/17 documents under the [DIAGNOSES REDACTED]. Under the Findings section it documents, Coccyx 1.0 x 0.6 x 0.6 cm (centimeters) undermining 12:00-6:00 and 0.5 depth. Under the recommendation section it documents, Pt (patient) sent to the ER (emergency room ) for evaluation and probable admission. Abscess right foot. Wound covered with gauze. R10 was sent to the hospital on [DATE] and readmitted to the facility on [DATE]. R10's Discharge Summary dated 4/8/17 documents under the Discharge [DIAGNOSES REDACTED]. R10's Skin- Head to Toe Skin Checks dated 4/8/17 documents under the Skin Integrity section, Coccyx: Other: Fissure: 1.0 cm length by 1.0 cm width. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Discharge Summary dated 4/8/17. R10's Skin- Head to Toe Skin Checks dated 4/9/17 documents under the Skin Integrity section, Coccyx: Other: Fissure: 1.0 cm length by 1.0 cm width. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Discharge Summary dated 4/8/17. R10's Skin-Weekly Non-Pressure Condition Record dated 4/11/17 documents under the Location/Description section, Sacrum: Other: Sinus Fissure 1.0 cm length by 1.0 cm width. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Discharge Summary dated 4/8/17. R10's Nursing Daily Skilled Charting dated 4/14/17 documents under the Skin section, Coccyx. Pressure. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Discharge Summary dated 4/8/17. R10's Nursing Daily Skilled Charting dated 4/14/17 documents under the Skin section, Coccyx. Pressure. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Discharge Summary dated 4/8/17. R10's Skin-Weekly Non-Pressure Condition Record dated 4/19/17 documents under the Location/Description section, Sacrum: Other: Sinus Fissure 0.5 cm length by 0.5 cm width by 0.1 cm depth. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Discharge Summary dated 4/8/17. R10's Skin-Weekly Non-Pressure Condition Record dated 4/25/17 documents under the Location/Description section, Sacrum: Other: Sinus Fissure 0.5 cm length by 0.5 cm width by 0.1 cm depth. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Discharge Summary dated 4/8/17. R10's nursing note dated 4/27/17 completed by DON (Director of Nursing)-B documents, Treatment continues to sinus on coccyx. Surveyor noted that the documentation did not include any measurements, description or staging of the R10's open area to the coccyx. Surveyor was unable to locate any documentation that R10's pressure ulcer to his coccyx was no longer present or had healed as described by R10's Discharge Summary dated 4/8/17. On 5/3/17 at 1:30 p.m., Surveyor informed DON-B of the above findings. Surveyor asked DON-B if R10's coccyx injury was considered a pressure injury as described on R10's Discharge Summary dated 4/8/17. DON-B informed Surveyor that based on R10's previous history obtained from the wife, the area to his coccyx was considered to be a sinus fissure and not a pressure ulcer. DON-B informed Surveyor that the wound doctor would see R10 and provide a diagnosis. Surveyor asked DON-B if the facility had obtained a [DIAGNOSES REDACTED]. area to his coccyx as pressure related, vascular, an abrasion and a sinus fissure. DON-B informed Surveyor that the facility had not obtained a [DIAGNOSES REDACTED]. was a sinus fissure. DON-B informed Surveyor that she would review R10's medical record and let Surveyor know. Surveyor asked DON-B if she could confirm whether or not R10 received treatment and monitoring for his coccyx open area from when he was admitted on [DATE] to 11/16/16, as Surveyor could not find any treatment orders, measurements or descriptions of R10's open coccyx area in R10's medical record. DON-B informed Surveyor that she would review R10's medical record and let Surveyor know. Surveyor asked DON-B if she could confirm whether or not R10 received treatment and monitoring for his coccyx open area described on R10's SBAR dated 12/28/16 to 2/6/17, as Surveyor could not find any treatment orders, measurements or descriptions of R10's open coccyx area in R10's medical record. DON-B informed Surveyor that she would review R10's medical record and let Surveyor know. On 5/3/17 at 3:35 p.m., Surveyor observed R10's coccyx wound treatment. Surveyor observed an area on the coccyx with two open areas with healthy skin between both open areas. Surveyor did n(TRUNCATED)

Based on observation, interview, and record review the Facility did not comprehensively assess 1 of 3 Residents (Resident #3 & Resident #2) who had a decline in their bowel continence in order to provide the necessary care and services to attain or maintain the highest practicable physical well being. * On 10/2/13, Resident #3's MDS reflects Resident #3 had a decline in bowel continence from continent to frequently incontinent. Findings include: 1. Surveyor # reviewed Resident #3's medical record on 11/4/13 & 11/5/13. The unit Kardex for Resident #3 dated 2/4/13 documents under the section bowel and bladder "bladder incontinence, yellow brief." Although this Kardex is dated 2/4/13 on 11/4/13 at 9:39 a.m. LPN (Licensed Practical Nurse)-E informed Surveyor # that she had updated this Kardex this morning. The bowel elimination problem care plan dated 4/1/13 and last reviewed on 10/1/13 includes approaches of "Assess and record bowel movement status, Report to the physician significant changes in bowel status, Ask/encourage resident to use call system and report need to bathroom, Administer/monitor effectiveness/side effects of medications used for bowel elimination, Provide and monitor intake, diet, and fluids." and "If no BM (bowel movement) follow facility protocol." The admission MDS (minimum data set) signed as completed on 4/8/13 documents that Resident #3 is continent of bowel and requires extensive assistance with one person physical assist for toileting. The quarterly MDS signed as completed on 10/2/13 documents that Resident #3 is frequently incontinent of bowel and requires extensive assistance with two plus persons physical assist for toileting. The evaluation for bowel and bladder training dated 10/8/13 for present bowel status is checked "yes" with a handwritten notation of "@ x's (at times)" for incontinence. The rest of the bowel section is blank. Under plan for management documents "will toilet upon rising, post lunch, post dinner & @ (at) H.S. (hour of sleep) - also per request. Will toilet between 1-2 a.m. & 4-5 a.m. d/t (due to) hx (history of) fall d/t toileting needs @ NOC." There is a 3 day bladder data collection dated 10/9/13, 10/10/13, 10/11/13 which documents for Resident #3 on an hourly basis whether she was wet or dry. This 3 day bladder data collection does not address bowels. On 11/4/13 at 1:16 p.m. Surveyor # observed CNA (Certified Nursing Assistant)-L and CNA-K transfer Resident #3 from the wheelchair into bed using a Hoyer lift. After the sling was removed from under Resident #3, staff unfastened the incontinence product. CNA-L washed Resident #3's frontal perineal area. CNA-L asked Resident #3 if she was ok and then informed Resident #3 "think you had another BM (bowel movement)." Resident #3 was positioned on her left side. Surveyor # observed that Resident #3 had been incontinent of bowel. Surveyor # was unable to locate a bowel patterning and assessment after Resident #3 had a decline in her bowel continence. On 11/6/13 at 1:48 p.m. Surveyor # informed LPN Manager-E that the Surveyor reviewed Resident's #3 medical record and noted Resident had a decline in her bowel continence that was identified on the quarterly MDS on 10/2/13. Surveyor # informed LPN Manager-E that Surveyor was unable to locate an assessment or patterning when the decline was identified. LPN Manager-E informed Surveyor # she would get back to Surveyor # regarding the decline. On 11/6/13 at 3:10 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. On 11/7/13 at 11:41 a.m. the Survey team met with the Administrator, Director of Nursing, and LPN Manager-E. During this meeting the Director of Nursing informed Surveyor # that the CNA's document in the Kiosk when a Resident has a bowel movement. The Director of Nursing indicated that the CNA's should go right after a Resident has a bowel movement and input this information into the Kiosk. Surveyor # was provided with the bowel and bladder detail report for Resident #3. Surveyor # noted on 10/9/13 at 2:18 a.m. Resident #3 was incontinent of bowel, at 9:50 a.m. 10:01 p.m., & 10:02 p.m. Resident #3 did not have a bowel movement. On 10/10/13 at 2:42 a.m. & 10:05 a.m. Resident #3 was incontinent of bowel, and at 9:50 p.m. Resident #3 did not have a bowel movement. On 10/11/13 at 2:53 a.m. Resident #3 did not have a bowel movement, at 1:28 p.m. Resident #3 was continent of bowel, and at 9:42 p.m. Resident #3 was incontinent of bowel. Surveyor # noted that the CNA's were documenting on average once a shift. In order to help restore bowel continence a regular schedule for bowel elimination needs to be based on previous patterns of bowel elimination. As of the time of the exit, Surveyor # was not provided with a comprehensive assessment for Resident #3's decline in bowel continence. On 11/15/13 the facility provided Surveyor # with additional information to review with regard to Resident #3's bowel continence status. Within this information, the facility indicates that Resident #3's change in continence status is related to changes in pain, lethargy, and her [DIAGNOSES REDACTED].# expressing concerns related to Resident #3's bowel continence status, comprehensively assessed and reviewed all factors that contributed to Resident #3's change in status and develop a comprehensive plan of care based upon the results of the assessment; including review of a three day pattern related to bowel continence status. This is the information that the facility needed to utilize to be able to work to restore Resident #3's continence status back to being continent of bowel. Review of documents indicates that Resident #3 went from being continent of bowel to frequently incontinent of bowel in the time span of July 2013 to October 2013 without being comprehensively assessed by the facility to determine contributing factors.

Based on interview and record review the facility did not ensure that each resident's drug regimen was be free from unnecessary drugs for 1 resident out of 7 reviewed (Resident 1). An unnecessary drug is any drug when used without adequate monitoring or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Resident 1 was on [MEDICATION NAME] therapy. On [DATE] a PT ([MEDICATION NAME] time) and INR (International Normalized Ratio) was drawn. The INR was 3.5 which is elevated. The facility does not have any evidence that the elevated INR was called to the physician to consult with him and for obtaining follow up orders for [MEDICATION NAME] monitoring. Resident 1 received an order for [REDACTED]. [MEDICATION NAME] is a drug that has a probable reaction of increasing the anticoagulation effects of [MEDICATION NAME]. The facility did not notify an MD to report this potential drug interaction and did not monitor for increased signs and symptoms of bleeding. When bruising developed (a sign of a potential overdose), the facility did not monitor Resident 1 for increased bleeding. On [DATE] a PT/INR was done and the results were over 100 and over 10 respectively (Normal PT is 9XXX,[DATE].6 and INR is 2XXX,[DATE].0). The physician stopped the [MEDICATION NAME] and ordered another PT/INR to be done in 4 days. The nurse did not question the physican as to why no treatment was ordered and did not ensure that Resident 1's family was consulted about treatment options. The facility did not monitor or assess Resident 1's condition when they were made aware of a critical INR of over 10 and new extensive bruising. On [DATE] Resident 1 had a change of condition and was sent to the emergency room where she was found with her INR still over 10 with bilateral subdural hematomas. Resident 1 was treated with Vitamin K and fresh frozen plasma. Resident 1 expired at the hospital from the subdural hematomas as a result of chronic anticoagulation and hypercoaguable state. This situation created a findings of Immediate Jeopardy, which began on [DATE]. The facility was informed of the finding of Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE], but continues at a severity/scope level of E (potential for harm that is not immediate Jeopardy/isolated) until all inservices are completed and the revised system is completely implemented. On [DATE] the facility had 15 residents that were on [MEDICATION NAME] therapy. Findings include: Division of Quality Assurance Memo ,[DATE], [DATE] indicates a standard of practice for [MEDICATION NAME] monitoring. The standard of practice includes the following: A test called International Normalization Ratio (INR) is the lab test that is routinely performed to monitor [MEDICATION NAME] levels. Most individual if stable, safe INR level will be between 2 and 3.5, depending on the reason for the medication. When a [MEDICATION NAME] regime is started, a baseline INR is typically obtained. The initial INR should be performed within two to three days. After the initial INR, Follow-up INR's may be done every three to five days. INR's are then continued every three to five days until two consecutive stable therapeutic INR readings are established, usually a level between 2 and 3.5. After the two consecutive INR reading are obtained that are between 2 and 3.5, guidelines support INR's to be drawn weekly for 4 weeks. When a resident is stable after the weekly INR's, then an INR will be performed every four weeks as long as [MEDICATION NAME] is being used. NOTE: The above standards are clinically supported and published by the American College of Chest Physicians. However, as with all standards, physicians or others who are monitoring [MEDICATION NAME] may order INRs to be conducted sooner or later to meet specific or unique resident needs. As a nurse, nurse assistant or caregiver, when you see that the accepted standard is not being followed, you should ascertain if there is a legitimate reason for the deviation. You have a responsibility to make sure there is an adequate reason for providing care that is contrary to the accepted standards of practice. Oftentimes, a resident may be stable while on [MEDICATION NAME]; however, other factors may cause the [MEDICATION NAME] to become toxic or in some cases ineffective. Facility staff needs to be aware of those circumstances that may compromise [MEDICATION NAME]'s effect so that they can inform the resident, the resident's family, physician, or pharmacist. Monitoring and additional interventions can than be taken in order to avoid clotting or bleeding. Facility staff needs to include the following in their [MEDICATION NAME] monitoring procedures DRUG INTERACTIONS-There are many medications that interact with [MEDICATION NAME]. Some medications increase the effect of [MEDICATION NAME], while other medications decrease its effect. In most cases, if a medication is added that interacts with [MEDICATION NAME], an INR should be checked within one week. Subsequent INR readings will be dependent on those initial readings and the length of time that the medication interacting with [MEDICATION NAME] will be used. Generally, INR readings will be done as often as every two to four days while a resident is on the offending medication and continued until there is evidence that the medication interaction is stable. If; however, a medication that interacts with [MEDICATION NAME] is used short term, and if the INR is within the normal range, or even slightly elevated at the first check, then it is likely that the effects of the [MEDICATION NAME] will not be altered. NUTRITION-Nutrition can play a significant role in the response to [MEDICATION NAME]. When residents stop eating, have nausea and vomiting, or start IV therapy, this may significantly affect the response to [MEDICATION NAME]. When patients stop eating, change diet, or add supplements; it is important to notify the physician, pharmacist and others who are monitoring the [MEDICATION NAME] about this change in the resident's routine. In the event of such changes, the INR should be checked within one week and monitored just like a medication interaction. Subsequent INR readings will be dependent on the resident's condition and INR readings... MONITORING-Besides monitoring for INR, facility staff can monitor for signs and symptoms of bleeding. Those symptoms include bruising, bleeding from the gums during teeth brushing, blood in the stool, sudden onset confusion that may indicate bleeding in the brain, or recent changes in breathing patterns or sounds that may indicate bleeding in the lungs. These symptoms need to be reported to the physician and addressed quickly as they may be an indication that [MEDICATION NAME] has become toxic. The facility's policy and procedure for Laboratory Management..[MEDICATION NAME] Guidelines state, "Don't Mix other Medicines with [MEDICATION NAME]" the chief precaution with this drug revolves around interactions with other drugs. Some medications magnify the [MEDICATION NAME] effect and some act as a relative antidote...Be advised that starting or stopping any medication could potentially affect your [MEDICATION NAME] control. It is important to recheck [MEDICATION NAME] whenever starting or stopping any other medicine...The policy indicates that Fluconazole ([MEDICATION NAME]) has a high probability of increasing [MEDICATION NAME]'s effect, and a probable increase when given with [MEDICATION NAME] ([MEDICATION NAME])...FOLLOW A SCHEDULE-Give [MEDICATION NAME] at the same time every day it is easier to adjust the dose if given in the evening...BLOOD TESTING-Dosing of [MEDICATION NAME] is individualized to each patient. There are different ranges of target values in different situations. It is important to know what target range the doctor is using to treat the residents condition, and continue to have blood draws as directed by the physician.. After each blood draw call the doctor with results and follow through with any changes in orders, immediately after results are received. WHAT TO LOOK FOR- The following symptoms could be a sign of excessive [MEDICATION NAME] dosage if any of the symptoms occur notify the physician: Nose bleeding, bleeding gums, red or brown urine, black or red stools, bruises that enlarge, headaches or abdominal pain, faintness, dizziness or unusual weakness. Resident 1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident 1 was hospitalized from [DATE] to [DATE]. Resident 1's Hospital Discharge Summary dated [DATE] indicates that her discharge [DIAGNOSES REDACTED]. Resident 1's discharge summary states that her INR prior to discharge was 2.8. Resident 1's Advanced Directives indicated that she did not want CPR or artificial nutrition. Resident 1 did want to be hospitalized , palliative care: Oxygen, Antibiotics, IV therapy. Resident 1's POA (Power of Attorney signed the form on [DATE]. Resident 1's care plan for increased risk for bleeding related to [MEDICATION NAME] use and [MEDICAL CONDITION] right lower extremity, dated [DATE] indicates that interventions listed are to monitor labs as ordered, notify MD of abnormal labs for further direction and treatment determination and observe for bleeding or increased bruising frequently... Resident 1's readmission orders [REDACTED]. A Physician's Telephone order dated [DATE] states, "[MEDICATION NAME] 4 mg (milligrams) Monday through Friday and 5 mg on Saturday and Sunday. PT/INR [DATE]." An Anticoagulant Therapy Flow Sheet initiated [DATE] (Resident 1's hospital return) indicates that her [MEDICATION NAME] was 27.2 and INR was 2.6 and is on [MEDICATION NAME] 4 mg M-F and 5 mg S-S and to recheck PT/INR on [DATE]. A physician's telephone order dated [DATE] states to do a urinalysis and culture and sensitivity if indicated, CMP, and CBC for increased lethargy and confusion. A physician's telephone order dated [DATE] states to start [MEDICATION NAME] 150 mg once daily for 7 days for yeast in her UA. This order was received from an on-call physician, not the primary physician. Please note that [MEDICATION NAME] is a medication that increases [MEDICATION NAME] effects. A nursing note on [DATE] indicates that MD was aware of UA report and results. A nursing note on [DATE] indicates that a call was placed to MD office to clarify culture results and orders. Awaiting return call. No further information documented about updating the primary MD that the resident had been started on [MEDICATION NAME]. No change in care plan for increased monitoring for side effects and no order obtained for increased INR/[MEDICATION NAME] monitoring. Resident 1 had a fall on [DATE] out of her bed when she was reaching for the remote control, no injuries noted at the time of the fall. A "Change of Condition" form filled on on [DATE] indicates that Resident 1 was found with 3 by 3 cm (centimeter) bruise on her upper right back that is new and she is also on [MEDICATION NAME] therapy. Despite the potential significance that bruising can have for a person on [MEDICATION NAME], the facility did not immediately consult with the physician about a potential adverse reaction to [MEDICATION NAME]. Instead, the facility faxed the MD on [DATE] at 8:30 PM (outside of office hours). On [DATE] Resident 1's primary physician responded to the fax from [DATE] and the fax indicates to "observe" with the newly found bruises . A Physician's Telephone order dated [DATE] states, "PT/INR on [DATE] for Dx of [MEDICAL CONDITION] RLE ([MEDICAL CONDITION] to right lower extremity). There is no nursing notes or any documentation as to why the order was received for this lab to be done on this day. On [DATE], no time noted, a note indicates there had been a Rehab Medicine consult. The consult includes the following information..."Bruises back of chest wall..." A nursing note on [DATE] at 9:20 PM states, "Spoke with (primary physician name) Partial clarification order, update ordering MD in AM for clarification." Resident 1's medical record reveals that Resident 1's weights were 129.7 pounds on [DATE], 118.6 pounds on [DATE], and 112.9 on [DATE]. This is a 16.8 pound weight loss in 17 days. Although Resident 1's physician knew of her weight loss, there is no documentation in Resident 1's medical record that he was made aware that she lost 5.3 more pounds on [DATE]. This weight loss could also affect Resident 1's INR levels. The lab called and notified the facility of critical lab values on [DATE] at 12:06 PM from a draw that had occurred at 4 AM. Lab test results were PT-over 100 seconds and INR-over 10. Handwritten on the form states, "Addressed with MD orders to D/C [MEDICATION NAME] and recheck PT/INR on [DATE]." A nursing note on [DATE], no time noted, states that the on call MD was called and stated the x-rays were ordered to related to fall with bruising to rule out fracture of ribs...updated on bruising to right lateral back/sides, right lateral breast, critical [MEDICATION NAME] level this AM. Was on [MEDICATION NAME] for 7 days...Med review done with primary physician . [MEDICATION NAME] discontinued and repeat PT/INR on [DATE]..XXX[DATE] on PM's the x-rays were negative for any new fractures. The orders did not include any treatment to reverse the [MEDICATION NAME] side effects. There is no documentation of any conversations with any family members or the resident in the choice of not treating Resident 1's high [MEDICATION NAME] level. There is no documentation in Resident 1's nursing notes of any monitoring of the extensive bruising to Resident 1's front and back of her chest areas. No monitoring for any other types of bleeding, no vital signs taken and no neuro checks done to rule out any further bleeding for Resident 1. A "Change of Condition" form dated [DATE] at 9:30 AM indicated that Resident 1 had a temp of 99.8, heart rate of 100, slurred speech, mental status changes, diaphoretic, sluggish pupil response. A nursing note on [DATE] at 3:45 AM states, "Temp 99.6, O2 sat 95% room air apical pulse regular at 100 bpm......There is no evidence of any documentation of an assessment for Resident 1's critical INR level, such as bleeding progressing, level of consciousness, neuro checks and a complete set of vital signs. A "Change of Condition" form dated [DATE] at 9:30 AM indicated that Resident 1 had a temp of 99.8, heart rate of 100, slurred speech, mental status changes, diaphoretic, sluggish pupil response, flaccid and bruising generalized with a INR over 10 yesterday. A note at 9:40 AM states, "Spoke with son/POA re:COC as above son states he will wait for (primary physician) about whether or not to send resident out to hospital for eval and treatment. Awaiting call from (primary physician name). At 9:45 AM a note from MD was documented to send to ER they will need to do a CT of her head." The hospital emergency room report includes the following: History of present illness-Brought to the ER this morning with altered mental status since 8:00 AM. Earlier this week an elevated INR of 10. Patient arrives here quietly moaning. Resident could not give history spoke with SON and states not eating or drinking well at nursing home. Physical Exam-Moaning..arousable to voice..She had a blood pressure initially of 58 systolic and a pulse of 122, temp 99.4 with a pulse ox of 88%..there is a bruise to her chin. Bruising to her right lateral chest wall with tenderness on palpation, bruising to her tight breast with some firmness in the breast as well. Black colored stool, that is guiac positive...Bruising to her left shoulder. ER course: Placement of 2 IV's and was given fluid [MEDICATION NAME] for hypertension and her blood pressure improved with this. A CT scan of the head was done and showed bilateral acute appearing subdural hematomas with only minimal right-sided mass effect..INR was elevated greater than 10 She was given fresh frozen plasma and Vit K. Lab showed a white count of 22,500. Aggressive treatment was discussed such as central line for her [MEDICAL CONDITION] and elevated lactic acid as well a surgical intervention for subdural hematoma...He is in agreement with IV fluids, antibiotics as well as fresh frozen plasma and vitamin K. Resident 1 was transferred to ICU with [DIAGNOSES REDACTED]. Assessment and plan-INR >10 due to [MEDICATION NAME], will reverse with 6 units of fresh frozen plasma. Resident 1 is critically ill with neurologic failure and [MEDICAL CONDITION] and requires high complexity decision making for assessment and support including volume resuscitation and neurological monitoring and treatment. Resident 1 expired at hospital from bilateral subdural hematomas non-survivable, chronic anticoagulation and hypercoaguable state. On [DATE] Surveyor asked the facility if they had a lab result for the [DATE] PT/INR level that was ordered [DATE]. On [DATE], at 1:00 PM the facility had called the lab and found out that they did to the PT/INR for Resident 1. The PT was 35 and the INR was 3.5 (INR therapeutic range 2XXX,[DATE].0 for [MEDICAL CONDITION], PE and [MEDICAL CONDITION]). There is still no evidence that this abnormal lab was called to the physician or that physician consulted with the facility on the elevated INR and the plan of care regarding follow up orders for the next INR and [MEDICATION NAME] dose. On [DATE] at 10:00 AM Surveyor interviewed DON B regarding Resident 1's medical record. Surveyor asked if she had any concerns in Resident 1's medical record. DON B stated that she had no concerns and that they do a summary of each discharge/hospital record and take it to QA. When the summary is done they look for any areas that need improvement and follow up and discuss at QA. This record had not been taken to QA yet. On [DATE] at 2:45 PM Surveyor interviewed DON B and RN C regarding Resident 1's elevated INR level. RN C stated that she thought that she had called Resident 1's MD regarding the INR level on [DATE], but does not know why no follow up lab was ordered; either he didn't call back or he just didn't order one. RN C agrees that the [DATE] lab does not have any documentation on the lab from the facility staff that the physician was updated. DON B stated that they use an Anticoagulant Therapy Flow Sheet. The flow sheet is on the MAR and it also is used by the managers to keep track of the [MEDICATION NAME] monitoring. DON B stated that she agreed that the [MEDICATION NAME] monitoring flow sheet was not followed per protocol. Surveyor asked for the policy and procedure for the Anticoagulant Flow sheet. The facility did not have a specific policy on the flow sheet. Surveyor asked if the facility received an indicator for the potential drug interaction with [MEDICATION NAME] and [MEDICATION NAME] and the DON B stated that she does not recall receiving one from the pharmacy. On [DATE] at 3:00 PM Surveyor interviewed Nurse R regarding [MEDICATION NAME] and medications. Nurse R states that the pharmacy sends indications to alert us to check on meds that can have interactions. When an indicator comes for a medication we call the doctor. Some antibiotics affect [MEDICATION NAME] and when they start the antibiotic we are to call the MD to see if we need to draw an INR. On [DATE] at 3:10 PM Surveyor interviewed RN C regarding Resident 1 and her elevated INR on [DATE]. RN C stated that she called the physician after she received the critically high INR on Resident 1. RN C stated that the MD stated to stop the [MEDICATION NAME] and recheck the INR on [DATE]. RN C stated that the MD just gave those orders nothing else. Surveyor asked RN C if she asked the MD about treatment and she said, "No he is the physician." Surveyor asked RN C what her expectation would be for monitoring when a resident had a critical INR level. RN C stated that she would expect the nursing staff to to vitals every 4 hours, monitor for confusion and increased bleeding. On [DATE] at 10:30 AM Surveyor interviewed via phone Resident 1's Primary Physician (Physician P) regarding Resident 1's elevated INR level. Surveyor asked Physician P if he was aware of the [DATE] INR level that was 3.5. Physician P stated that he had seen the lab result and that Resident 1's level was elevated a little but with Resident 1's [DIAGNOSES REDACTED]. Physician P stated that he did see the lab and does not know why there was no follow up INR ordered, he could not remember if he talked to a nurse about the lab or not. Surveyor asked Physician P if he was aware of her current condition. Physician P stated that he was in to see her (on [DATE]) and knew she was not eating, had weight loss and difficulty swallowing. Physician P said that he and the facility had a plan of care to adjust Resident 1's medications, have a rehab MD see her for her pain, get therapy involved especially speech, and see if she improves. Surveyor asked Physician P if he was aware of the extensive bruising found on Resident 1 and Physician P stated that he was aware of the bruising. Surveyor asked Physician P what the standard of practice is for treating someone with a INR of over 10, and if Resident 1 had been on [MEDICATION NAME] (which elevates the INR levels), was found with increased bruising, was lethargic, and had a over 10 INR why he didn't address the treatment of [REDACTED]. Physician P stated, "We didn't want a knee jerk reaction. The hardest thing to do is nothing. In her (Resident 1's) case I did not believe that the INR level was over 10; it couldn't be right and that is why I stopped the [MEDICATION NAME] and ordered another test. (Please note that another INR test was not ordered until 4 days later). It would not have made a difference if I treated her or not as she had active bleeding. I did fear that she had a subdural hematoma if (treating her) would have prolonged her agony." Surveyor asked Physician P if he had any conversation with family about treating or not treating Resident 1. Physician P responded that due to her being ill recently he had many conversations daily with Resident 1's family, but did not have any conversation about risks and benefits regarding treating with Vitamin K or sending Resident 1 to the ER for evaluation. Surveyor asked Physician P what his expectation would be for the staff for monitoring Resident 1 after she was found with a over 10 INR. Physician P stated that he would expect the nursing staff to monitor for at least the next 12 hours for increased bleeding, bleeding stool or urine, change in mentation and vital signs to assess if she has any changes or if the bleeding gets worse. On [DATE] at 12:43 PM Surveyor interviewed Family Member O regarding Resident 1 and her elevated [MEDICATION NAME] level. Family member O stated that on [DATE]th they came into the building and were informed of Resident 1's high INR level. RN C told us that her level was high and went from 2 to 10 overnight and the doctor stopped the [MEDICATION NAME]. RN C stated that she couldn't talk right now as she had a meeting to go to. The nurse did not explain that she was bleeding internally nor that there was a treatment for [REDACTED]. (Primary Physician name) stated many times that he was frustrated and he writes orders and cannot understand why the nurses do not follow them. Physician P said that our mother received an overdose of [MEDICATION NAME] and he stopped the medication and will get another test to see if the [MEDICATION NAME] levels go down." Surveyor asked Family Member O if Resident 1's primary physician reviewed or discussed treatment option or what the plan of action was going to be for her elevated [MEDICATION NAME] level. Family Member O stated, "No, he did not offer us any treatment options we didn't know that there was any. We thought that was the treatment to stop the medication." Surveyor interviewed via phone Medical Director Q regarding standard of practice and treatment for [REDACTED]. Medical Director Q stated that the standard of practice for treating depended on the residents big picture and what conversations that the physician has with the family and/or resident when they find out that the INR was over 10 with obvious bleeding. Medical Director Q stated that he would treat the resident with Vitamin K, hold the [MEDICATION NAME], and recheck the lab that eve or the very next morning to see if the bleeding was decreasing. If the INR is that high a lot of things may be going on and an evaluation in the ER should be done also. The facility should be monitoring her vital signs, cognitive level of mentation, neuro checks etc. The physician/facility should be contacting the family and explaining the seriousness of the issue and developing of plan of action. Due to he facility not providing proper [MEDICATION NAME] management, this led to the resident developing signs and symptoms of bleeding, a critical lab value and ultimately hospitalization . The Immediate Jeopardy was determined to begin on [DATE]. The facility removed the Immediate Jeopardy on [DATE] when the facility initiated the following: Inservice initiated immediately for all licensed nurses on [DATE] on lab policy related to [MEDICATION NAME]. Inservice training will continue until all nurses completed before the start of their shift. Inservices will also include the following: -Accurate follow up on all [MEDICATION NAME] tests -Consultant pharmacist has been advised of the importance of notifying DON and nursing staff of potential drug interactions, so that nursing staff can advise the physicians of possible drug interactions. -Following physician orders, if not clear or certain orders given, contact Medical Director. -Clarification of orders if unclear -Follow up with documentation of signs and symptoms of possible signs of excessive [MEDICATION NAME] dosage. If any symptoms occur, notify the physician with any signs of bleeding, nose bleeds, bleeding gums, red or brown stools, red or black stools, cuts that don't stop bleeding, bruises that enlarge, headaches abdominal pain, faintness, dizziness, or unusual weakness. -A review of residents receiving [MEDICATION NAME] will be initiated on [DATE] and completed on [DATE]. Labs have been reviewed and followed up according to policy. Residents on [MEDICATION NAME] therapy are being reviewed by pharmacists for possible drug interactions that could potentially interact with [MEDICATION NAME]. Attending physician will be notified of any drug interactions. -Nursing staff check labs daily. Lab results are faxed to the physicians and critical labs are faxed and phoned to the physician immediately. Nursing staff complete [MEDICATION NAME] monitoring flow sheet for al PT/INR labs. Nurse manager audit daily to ensure accuracy of [MEDICATION NAME] orders. Quality Assurance plans to monitor facility performance. As part of the ongoing Quality Assurance Program the DON will review all lab variances monthly with Quality Assurance Advisory Committee. Identified lab issues with be tracked and trended and brought to the Quality Assurance Committee for recommendations/action plan.

Based on record review and interview in 1 of 7 total residents reviewed (Resident 7), the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Resident 7 was transferred with the use of a mechanical lift. Contrary to Resident 7's care plan, only 1 person provided this transfer. Resident 1 fell and sustained a head laceration and hematoma. This is evidenced by the following: Resident 7's [DIAGNOSES REDACTED]. Resident 7's "Resident Transfer Evaluation / Annual" dated 8/27/12 states Resident 7 is "Dependent x 2 (with) Hoyer" and is assessed as a "Category 4 (score 15 or greater): Caregiver performs 100% of the task. Equipment: Mechanical Lift (total body / sling lift). Resident 7's "Care Plan - Activities of Daily Living" identifies a problem, dated 3/16/12, which states Resident 7 "requires staff assistance and intervention for completion of ADL (Activities of Daily Living) needs. Requires extensive assistance, total care, utilizing 1 staff member / 2 staff members." Interventions to this care plan problem include: "Hoyer transfer (with) 2." The facility's "Lift, Transfer, and Repositioning Policy" states "*NOTE: Facility policy requires two staff members to assist when lifting with mechanical lifting devices." (Emphasis in original document.) Resident 7's record contains the following documentation: 10/29/12 Change of Condition SBAR (Situation Background Assessment Request): "... fall with injury... Staff nurse called to room. Res (resident) observed lying on floor on back. Hoyer lift over top (of) res straddling her. Hoyer sling observed hanging in Hoyer. Staff nurse noticed head bleeding to back of head. C/O (complained of) chest pain, neck pain. Called 911 for transport. Resident left for (Hospital) for eval (evaluation) and tx (treatment)". 10/29/12 Nurse's Notes: "2330 (11:30 pm) (Hospital) called facility to inform Nursg (Nursing) staff that resident was admitted to ICU (Intensive Care Unit) unit due to an intracranial bleed that they found. Daughter (Name) called et (and) informed of above by (Facility) Nursg staff..." Resident 7's hospital "Trauma and Emergency Surgery Discharge Note" documentation includes: Admit Diagnosis: [REDACTED]. Procedures performed: Laceration closure History of Present Illness: (Resident 7)... status [REDACTED]. Brought by EMS (Emergency Medical Service) to ED (Emergency Department) and underwent CTOH (Computed Tomography of Head)... Initial CTOH noted possible small ICH (Intracranial Hemorrhage). Hospital Course:... Repeat CTOH confirmed absence of ICH. Resolving scalp hematoma. Underwent lac (laceration) closure (absorbable suture, no removal necessary)..." The facility's Investigation into Resident 7's fall on 10/29/12 documents: "Interview with Resident Care Specialist revealed the resident was asking her to please put her to bed. Resident Care Specialist indicated that she wanted to accommodate the resident wanting to go to bed right away. The Hoyer lift was used and the resident began moving in the sling and then slid from the sling. On 11/7/12 at 12:40 pm Surveyor spoke with NHA (Nursing Home Administrator) I regarding Resident 7's fall on 10/29/12. NHA I stated there was just 1 CNA (Certified Nursing Assistant) providing the transfer at the time of the fall and confirmed Resident 7's care plan was not followed.

Based on interviews and record reviews, facility staff did not provide 1 of 3 residents who experienced [MEDICAL CONDITION] with appropriate and timely care. Resident #1 suffered a three-minute [MEDICAL CONDITION] on [DATE] at approximately 9:15 p.m., followed by a second [MEDICAL CONDITION] at about 9:22 p.m.; Resident #1 never fully came out of the second [MEDICAL CONDITION]. Resident #1 was at the nurses' station at the time of the [MEDICAL CONDITION] and fell to the floor, hitting his head. Despite the fact that the resident had hit his head, staff did not consistently monitor the resident's neurological functioning. Facility staff called the physician at 9:25 p.m. When they did not receive an immediate return call from the physician, staff did not call 911. The physician did return the call at 9:41 p.m. and agreed to send Resident #1 to the emergency room . Despite the fact that literature considers a [MEDICAL CONDITION] longer than 15 minutes a medical emergency, facility staff called a private ambulance company at 9:51 p.m. instead of calling 911, which would have been a quicker response time. Resident #1 had been in his second [MEDICAL CONDITION] for a half hour at that time. The private ambulance company was not informed Resident #1 had been seizing for over a half-hour, nor were they informed that Resident #1 had struck his head when he fell . The private ambulance arrived at the facility at 10:10 p.m., noted Resident #1 had snoring respirations, was actively seizing on the ground, had swelling on the back of his head, and a coma scale of 3 (8 or less indicates a coma). They indicated Resident #1 would need ALS (Advanced Life Support) and called 911 at 10:20 p.m. and inserted a nasal airway. The first responder arrived at 10:23 with the full crew arriving at 10:27 p.m., over an hour after Resident #1 started the second and on-going [MEDICAL CONDITION]. Resident #1 was transported to the hospital where he was diagnosed with [REDACTED]. He passed away on [DATE]. Autopsy results include 1. [MEDICATION NAME] trauma of head: a. subdural hematoma, subarachnoid hemorrhage, left temporal bone fracture, and left orbital plate fracture Resident #1 had a physician's orders [REDACTED]. The failure to provide prompt and appropriate care in response to Resident #1's changed condition resulted in the finding of immediate jeopardy beginning on [DATE]. The Nursing Home Administrator and Director of Nursing were notified of the immediate jeopardy and substandard care on [DATE] at 4:30 p.m. and removed the immediate jeopardy on [DATE] The deficient practice continues at a scope and severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan and assess care process for the 10 Residents (Resident's #2, #3, #4, #5, #6, #7, #8, #9, #10, #12) identified to be at risk for [MEDICAL CONDITION] activity. Findings include: 1.) Resident #1 was [AGE] years old, admitted to the facility [DATE] with major [DIAGNOSES REDACTED]. Surveyor # reviewed an updated Advance Directive from Resident #1 dated [DATE] which states "No" to artificial nutrition and CPR (cardiopulmonary resuscitation), and "Yes" to hospitalization s, Palliative Care including oxygen, antibiotics, and IV therapy. This directive also includes a hand-written addendum stating "Please treat [MEDICAL CONDITION] and hospitalize at FMLH (Froedtert Memorial Lutheran Hospital) if necessary." This is signed by Resident #1 on [DATE], and signed and initialed by RN-M on [DATE]. Resident #1's Initial MDS (Minimum Data Set) dated [DATE] and his Annual MDS dated [DATE] indicates he is alert and oriented to person, place and time. On [DATE], Surveyor # reviewed Resident #1's medical record. Nurses' Notes indicate Resident #1 suffered a single [MEDICAL CONDITION] on [DATE] at 5:10 p.m., on [DATE] at 2:30 p.m., on [DATE], and [DATE]. [MEDICAL CONDITION] History: Orders [DATE]: Nurses' notes on [DATE] and [DATE] indicate Resident #1 had consumed alcohol, had fallen several times, was verbally abusive to staff and indicated he wanted to leave the facility. On [DATE] when staff updated Resident #1's physician, (MD-K), she did not want to discharge Resident #1 due to the risk of alcoholic [MEDICAL CONDITION]. Physician MD-K gave the following new orders "Monitor for [MEDICAL CONDITION]. Give 0.5 mg. - 1.0 mg. [MEDICATION NAME] PO (by mouth) if seizing and call 911." Staff talked with Resident #1 who decided against leaving AMA (Against Medical Advice) and chose to stay at the facility. [MEDICAL CONDITION] [DATE]; New Orders- Do Not Call 911 unless [MEDICAL CONDITION] sustained or resident hypoxic: [DATE] 5:10 p.m. Nurses' Notes indicate: Resident #1 was sitting in the dining room, his eyes fixed and dilated to 0.6 cm. (centimeters), no tremoring but oral drooling present. Not at all responsive to verbal stimuli; he was moving his mouth and chewing but no food was present in his mouth. [MEDICAL CONDITION] lasted about 6 minutes. VS (vital signs) BP (blood pressure) ,[DATE], T (temperature) 98.5, P (pulse) 68, R (respirations) 20, SPO2 (saturation of oxygen in blood) 98% on room air. The next note is dated [DATE] at 6:00 p.m. stating the physician was updated, new order received to administer [MEDICATION NAME], (a benzodiazepine with anticonvulsant effects). The facility received a telephone order dated [DATE], stating: "D/C (discontinue) call 911 for [MEDICAL CONDITION] unless [MEDICAL CONDITION] is sustained or patient hypoxic." (Note: When transcribing this order, staff wrote "Facility does need to call 911 when resident has had a [MEDICAL CONDITION] unless sustained or hypoxic." This incorrect transcription was repeated on Resident #1's monthly physician's orders [REDACTED]. Note: The facility did not clarify or define what "sustained" or "hypoxic" meant. The Care Plan dated [DATE], with most recent review date of [DATE], does not define a "sustained" [MEDICAL CONDITION] (how long?), or set parameters for "hypoxic." When interviewed on [DATE] at 1:50 PM, MD-F told Surveyor # that he thought "sustained" would mean ,[DATE] minutes and that "hypoxic" meant anything under 88%. [MEDICAL CONDITION] [DATE] [DATE] Nurses' Notes indicate at 2:30 p.m. Resident #1's family member summoned staff to Resident #1's room. Resident #1 was laying across his bed, not responding to his name. Resident #1's eyes were fixed and dilated to 0.6 cm., tremoring and jerking movement throughout his body. No drooling or spitting. Lasted approximately 4 minutes, then patient started spitting out as [MEDICAL CONDITION] was resolving. VS BP ,[DATE], P112, R24, T100.0, SPO2 98% at 6 L (liters) oxygen per NRM (non-rebreather mask). Skin clammy and flushed. On-call Physician was called who ordered [MEDICATION NAME] 2 mg. (milligrams) IM (intramuscular) given in right deltoid (shoulder). 911 called and patient transferred to Froedtert Hospital as per MD orders. Family and hospital updated... [MEDICAL CONDITION] [DATE]: Surveyor # reviewed the sequential January Nurses' Notes. Nursing Daily Skilled Summary documentation dated [DATE] was noted which indicates Resident #1 had a [MEDICAL CONDITION] at 6:10 a.m. [MEDICATION NAME] approximately 15 minutes. At 6:11 a.m., 0.5 mg. of [MEDICATION NAME] was given, at 6:13 a.m. an additional 0.5 mg. [MEDICATION NAME] was given. At 6:20 a.m., 5 mg. [MEDICATION NAME] was given per verbal MD order. Pupils dilated, reactive to light... A "Change of Condition" fax was sent to MD-L (Resident #1 had requested changing physicians from MD-K to MD-L) on [DATE] stating: 8:10 a.m. T100.2, P86, R20, BP ,[DATE]. (Resident #1) at 6:10 a.m. -[MEDICAL CONDITION]- clonic phase [MEDICATION NAME] approximately 15 minutes. Spoke with MD-F, order for 1 mg. [MEDICATION NAME] PO times one (give one time). [MEDICATION NAME] 5 mg. PO, may repeat times one PRN (as needed). Tylenol given for elevated temp. Rechecked temp 99.5 cool compress applied to forehead. Pt. (patient) resting in bed. A/O (alert and oriented) times 3 (to person, place and time). Able to make needs known. New orders were received for 1 mg. [MEDICATION NAME] to be given by mouth as need for [MEDICAL CONDITION], may repeat once; [MEDICATION NAME] 0.5 mg. 1 tablet daily at midnight; and Trazadone 100 mg. daily at midnight. On [DATE], [MEDICATION NAME] 0.5 mg. PO TID (three times a day) PRN was added to Resident #1's orders per his request. [MEDICAL CONDITION] [DATE]: Nurses' notes indicate on [DATE] at 8:16 p.m. Resident #1 was standing at the medication cart with his crutches, had a [MEDICAL CONDITION], went straight down and landed on his left side and shoulder; he did not hit his head. [MEDICAL CONDITION] lasted 4 minutes. VS T97.2, P80, R18, BP ,[DATE], SPO2 94% on room air. Pupils highly dilated, foamed at mouth, unresponsive for 4 minutes. MD informed, no new orders. In June and [DATE], Resident #1's psychiatrist recommended medication changes that were confirmed and approved by Resident #1's primary care physician, MD-L, including gradually starting [MEDICATION NAME] [DATE] at 0.5 mg. nightly for 4 nights. On [DATE], start [MEDICATION NAME] 1 mg. nightly and discontinue Resident #1's scheduled [MEDICATION NAME]. On [DATE], the psychiatrist recommended discontinuing [MEDICATION NAME] 0.25 mg. PRN. On [DATE] staff received orders for and clarified with MD-L orders to increase the [MEDICATION NAME] to 1.5 mg. every night and discontinue [MEDICATION NAME] 1 mg. PO PRN for [MEDICAL CONDITION]. On [DATE], Resident #1 was seen by his neurologist. The consult states Resident #1 reported some dizziness in the evenings; also had [MEDICATION NAME] started by psychiatrist for anxiety; and no [MEDICAL CONDITION] since [MEDICATION NAME] started in March. The neurologist ordered: 1.) [MEDICATION NAME] ([MEDICATION NAME]) to be tapered over the next three weeks. 2.) No other med changes. 3.) Advise to call in case of [MEDICAL CONDITION]. [MEDICAL CONDITION]/Fall [DATE]: Nurses' Notes Notes dated [DATE] at 9:15 p.m. by LPN (Licensed Practical Nurse)-E states "Resident was talking to staff at nurses' station, suddenly stopped talking and fell backwards. Resident hit head and back on floor, was unresponsive/ started having [MEDICAL CONDITION] (approximately 3 minutes). Resident then started to become responsive for about 4 minutes, after that was non-responsive and seizing on and off. MD updated, approved to send resident out to Community Memorial. Family updated." This is followed by a note [DATE] at 9:15 p.m. by RN (Registered Nurse)-C, who documented "Writer sitting by desk /nurses' station, resident standing by nurses' station talking to RCS (Resident Care Services/ Certified Nursing Assistants). Writer heard a "bang," observed resident lying on his back in hall with [MEDICAL CONDITION] activity BP ,[DATE], BP at 9:30 p.m. ,[DATE], P103, R22, SPO2 94% RA (room air). Blood pressure at 9:40 p.m. was ,[DATE], SPO2 94% RA. Resident very diaphoretic with tremors- observed resident to be alert for 4 minutes from 9:20 - 9:24 p.m., resident observed to have [MEDICAL CONDITION] active, non-responsive to verbal command- writer called on-call (MD-F), told writer to send out to ER to evaluate and treat- writer called POA and updated her-verbalized understanding. Called Paratech, called CMH (Community Memorial Hospital). " Nurses' Notes state: [DATE] at 10:10 p.m. "Paratech present at facility." That is the last nurses' note in Resident #1's medical record. Incident/ Accident Report: Surveyor # reviewed a facility Incident/ Accident Report dated [DATE] indicating at 9:15 p.m. Resident #1 sustained a fall. "Resident standing by nurses station, fell to floor landing on back in hallway, actively seizing. Vitals taken, pillow placed under head, continued to seize with upper and lower body tremors, resident was not in respiratory distress, not diaphoretic, making eye contact, [MEDICAL CONDITION] approximately 3 minutes, no apparent injuries to back of head, no bruises noted. Resident was alert and able to communicate for the next 4 minutes. Looked for [MEDICATION NAME] to give resident, no order available to give resident. Resident then started to seize again. Paged (MD-F) at 9:25 p.m. LPN (Licensed Practical Nurse) sitting with resident at this time to ensure safety. BP ,[DATE], R20, P103, SPO2 97% RA. (Note: Written statements obtained by the facility from LPN-C and LPN-E on [DATE] and from LPN-D on [DATE] confirm these events. In addition, written statements from CNA (Certified Nursing Assistant)-H dated [DATE] and from CNA-I dated [DATE] both indicate that Resident #1 was on the floor and "snoring.") 9:30 p.m. - Vitals re-assessed BP ,[DATE], P103, R22, SPO2 94% RA (on room air). (Note: This blood pressure reading is significantly higher than blood pressure readings during previous [MEDICAL CONDITION]: [DATE] BP ,[DATE]; [DATE] BP ,[DATE]; [DATE] BP ,[DATE]; and February 26, 2011 BP ,[DATE].) 9:40 p.m.- (MD-F) returned page. LPN talked with (MD-F), reviewed BP ,[DATE], SPO2 94% RA, resident diaphoretic, reviewed advanced directives with (MD-F)- Resident no code. (MD-F) gave order for [MEDICATION NAME] suppository 5 mg., not available, writer wanted to send resident to ER- new order received. (In a written statement given to the facility on [DATE], LPN-E indicates MD-F called back around 9:45 or 9:50 p.m., adding "I think we may have paged him multiple times. He finally called back and I talked to him. He asked if (Resident #1) was a full code, I told him no, but he was "yes" to hospitalization if necessary. I reported the high blood pressure and the [MEDICAL CONDITION]. He wanted to give him the [MEDICATION NAME] suppository. We did not have any. He questioned what the hospital could do that we couldn't do here at VH (Virginia Highlands). (RN-C) then took the phone and told (MD-F) that we didn't have the suppository and that we were going to send him to the ER. Then (RN-C) called Paratech for transport ...Paratech arrived around 10:15 p.m." In her written statement, LPN-D wrote on [DATE], "MD-F gave the order to send Resident (#1) out. The Resident was still having shaking of the lower extremities and buttock, he was on his side and his airway was clear. His pulse oximetry dropped down to 84%, oxygen was applied at 3 L and it came back up. (RN-C) called Paratech." On [DATE] at approximately 1:50 p.m. Surveyors # and # interviewed MD (Medical Director)-F, who was on call [DATE]. MD-F stated since Resident #1 was a DNR (Do Not Resuscitate) he would not expect an ambulance to respond with red lights and siren, so a private ambulance would be an acceptable choice. If he specifically wanted 911 to be called for a resident, he would say so. Otherwise, staff could choose. Surveyors noted at that point, Resident #1 had a pulse and was breathing on his own, but had a prolonged [MEDICAL CONDITION] and hit his head. (Resident #1 was not in need of CPR, and his Advanced Directives stated he did want hospitalization .) 9:40 p.m. Called Paratech for transport, told them resident's vital signs, was on the floor having [MEDICAL CONDITION] and the physician wanted him sent out to ER. (Note: On [DATE] at 12:25 p.m., Surveyor # spoke with Paratech Director of Operations-O (Dir. Ops-O) who played a recording of the call from RN-C to the Paratech dispatcher on [DATE]. The recording notes that the call came in at 9:51 p.m. The recording shows RN-C calmly stating one of the residents needs to be sent out to the hospital. The dispatcher asks the resident's name. RN-C states she has to get the face sheet for the correct spelling, then spells the resident's name. The Dispatcher asks for the resident's room number. RN-C states "He's actually laying in the hallway. He had a [MEDICAL CONDITION]." Dispatcher says they're on their way. RN-C states "come to sub-acute- those doors are open. Then come to the long-term care unit. He's laying in the hallway." The recording shows RN-C never informed the Paratech dispatcher Resident #1 was a half-hour into his second [MEDICAL CONDITION], that he had hit his head, or that his blood pressure was ,[DATE].) The Incident/Accident report concludes with the following: 10:00 p.m. Resident was foaming at the mouth and was rolled onto his side by writer and LPN. BP ,[DATE], SPO2 ,[DATE]% RA- oxygen applied 2L (liters) NC (nasal canula) and SPO2 was 92%. (In a statement given to the facility on [DATE], LPN-C wrote that at 10:00 p.m. she again "palpated the back of his head and did not see anything...") 10:10 p.m. Paratech arrived. A copy of Paratech's report had been faxed to Surveyors on [DATE]. Surveyor # reviewed the Comprehensive Report, dated [DATE], noting the call was received at 2151 (9:51 p.m.), unit dispatched at 2153, on scene at 2110, at patient at 2111. A diagram on page 4 of the report indicates an injury on the left side of the back of Resident #1's head. The narrative section states "Arrived on scene to find an older gentleman in his 50's unresponsive with snoring respirations who is actively seizing on the ground. Dispatch was called and an ALS unit was requested for seizing and hypertensive. Patient placed on 15 LPM (liters per minute) on NRM (non-rebreather mask) with a nasal airway in the left nostril. Patient is lying on his left lateral side with a nurse sitting behind him keeping him on his side. Facility placed a nasal canula at 3 LPM prior to our arrival. Nurse states that the patient has been actively seizing approximately one hour prior to our arrival. They state the patient had just arrived back at the facility after going out with friends. He came up to the nurses' station and fell back striking his head on the vinyl floor. When the nurses went to help patient he was unresponsive and actively seizing....Record BP ,[DATE]. Patient had swelling on the back of his head and a GCS (Glasgow Coma Scale) of 3....Vital taken and recorded. Vitals were hypertensive. Nasal airway did alleviate the snoring respirations. Pupils were fully dilated and non-reactive. At that time Germantown Fire arrived on scene along with Germantown Police. Care was transferred to Germantown Fire..." Fire Department/ EMS -On [DATE] at 11:00 a.m., Surveyors # and # obtained an Out Of Hospital Care Report dated [DATE] from the Germantown Fire Department. The report indicates they received the call for assistance at 2220 (10:20 p.m.) and the ambulance arrived on the scene at 2227, arrived at patient 2228. They were en route to the hospital at 2247, and arrived at the hospital at 2255. The Narrative section includes: Upon their arrival Paratech ambulance was on the scene, dispatched for a male patient having a [MEDICAL CONDITION]. Patient was found lying supine on the floor unresponsive. Patient had snoring respirations. Patient's whole body was shaking...Prior to our arrival Paratech had placed a nasal airway and had the patient on oxygen at 15 liters per minute via non-rebreather mask...Due to patient falling, manual C-spine stabilization taken and c-collar was placed on the patient. Patient was rolled on to a long board and secured. When rolling the patient onto his (side) noticed a contusion to his posterior head. Once rolled patient's airway was suctioned...Patient was moved to the cot and placed in the ambulance...Patient had snoring respirations throughout the transport...Patient had equal chest rise and fall throughout transport. On [DATE] at 11:15 a.m., Surveyors # and # interviewed Fire/ EMS Captain-P at the fire station. FD-P stated a 17 minute response time from the private ambulance is not unusual, but in an emergency, the Fire Dept. is only a few minutes away. FD-P stated he was the First Responder on the scene and arrived at 2223. FD-P stated he observed a large hematoma on the back of the patient's head, he shined a flashlight on it to be sure, it was readily seen. FD-P stated Paratech only has two crew members, the patient needed to be immobilized, and they needed an extra pair of hands. FD-P stated two police officers arrived on the scene, one was possibly in training. The RN on duty was very upset, she didn't seem to understand the situation. FD-P stated he was frustrated she didn't comprehend the gravity of the situation. Staff were complacent, they kept saying "that is the resident's norm, he has [MEDICAL CONDITION]." They didn't identify the urgency of the situation. Police Report -On [DATE], Surveyor # reviewed a report from the Germantown Police Department dated [DATE]. The report states the officers arrived at the facility on [DATE] at 10:26 p.m.. (RN-C) stated to the police (Resident #1) "was standing approximately 10 feet from the nurses station when he fell backwards, landing on his back and head. (RN-C) stated that (Resident #1) had a bruise on the back of his head from striking the floor and began having [MEDICAL CONDITION] immediately." Hospital Record -On [DATE] at 12:00 noon Surveyors # and # reviewed Resident #1's hospital medical record. Resident #1 arrived at the Emergency Department at 10:59 p.m. The record notes he has been seizing since approximately 9:00 p.m.., he had been actively seizing in the ambulance transport. Seizing now going on 2 hours. BP ,[DATE], heart rate 105, respirations 11, pulse ox 93% on 15 liters oxygen. Patient is unresponsive. He has a focal [MEDICAL CONDITION] with left leg twitching. He is clearly not protecting his airway and is obtunded. He has essentially a GCS (Glasgow Coma Scale) of 3....He does come with paper work that he wishes no cardiopulmonary resuscitation, but this is more of an airway issue and breathing issue at the moment ...Family gave consent to electively intubate patient...Given 6 mg. of [MEDICATION NAME] in 2 mg. increments...given 20 mg./kg. [MEDICATION NAME] which actually resolved his [MEDICAL CONDITION] is not having any return of neurological baseline, though he did stop seizing...Admitting Diagnoses: [REDACTED]. A CT scan on [DATE] reveals a large left-sided subdural hematoma with significant associated subarachnoid hemorrhage. Further tests indicated brain death and Resident #1 passed away on [DATE]. Autopsy -Surveyors # and # reviewed documentation from the Washington County Medical Examiner's Office which states an autopsy was conducted. Results include: 1. [MEDICATION NAME] trauma to head a. subdural hematoma (85 mL), predominately on left side and basilar, b. subarachnoid hemorrhage c. left temporal bone fracture, d. left orbital plate fracture, e. left parietal subscalp hemorrhage. On [DATE] at 1:52 p.m., Surveyor # interviewed RN-C. Surveyor # and LPN-G were also present. RN-C stated on [DATE], she was the float nurse between Long Term Care and Memory Lane. She was documenting on the 24 hour board when she heard a bang, but did not see Resident #1 fall. RN-C stated she grabbed her bag of equipment, ran around the desk to Resident #1's right side. Resident #1 was on his back, having a [MEDICAL CONDITION]; he couldn't communicate, tremors, shaking of his lower extremities. It lasted about 3 minutes. Then he started to come around. RN-C stated she kept calling his name, saying "Are you OK?" Resident #1 said his own name softly. After about 4 minutes, the seizing started again, tremoring/ shaking lower body. RN-C stated he had "variable [MEDICAL CONDITION] activity"- he would mumble, come out of the [MEDICAL CONDITION] a little, start seizing again. Surveyor # asked if Resident #1 ever fully came out of the [MEDICAL CONDITION] activity after the first 4 minute span after the first [MEDICAL CONDITION]. RN-C stated "Not that I recall." RN-C stated Resident #1's eyes were open, pupils equal in size, but does not remember if his pupils were dilated or constricted or reactive to light. RN-C stated she couldn't check Resident #1's pupil reaction to light due to the ongoing [MEDICAL CONDITION] activity. RN-C stated Resident #1 kept turning his head to his left. RN-C stated she has a systematic way of assessing a resident, and she palpated his head, which was turned toward the left, and no trauma was noted, only one small pimple on the top of his head was noted. RN-C stated she works her way down the body and no visual injuries were noted. Surveyor # noted there was no documentation of a neurologic assessment conducted, or other assessment besides blood pressure and pulse oximetry. RN-C stated she reviewed her documentation when DON-B asked her yesterday what assessments she did, and they compiled additional documentation (Summary of Evaluation) on [DATE] from DON-B helping RN-C walk through what happen three weeks earlier, on [DATE]. RN-C stated that while talking with DON-B, she remembered when she used the pulse oximetry device, Resident #1 had a good hand grasp with his right hand, he held on tight. RN-C stated he also had his teeth clenched. This was during the 4 minutes he seemed to be coming out of the first [MEDICAL CONDITION]. Surveyor # noted testing motor responses during a neurologic exam assesses the resident's ability to follow commands, purposeful movement, response-if any-to pain, if they flex or extend extremities abnormally, or if flaccid. Surveyor # asked if Resident #1's hand grasp was purposeful movement or if it was due to the seizing. RN-C did not reply. Surveyor # asked if she subsequently conducted any motor response assessment. RN-C stated she did a sternal rub during this time and he turned his head and mumbled. RN-C stated she did not document the hand grasp, sternal rub or clenched teeth. RN-C stated after Resident #1 started seizing again, LPN-D came over and stayed with the Resident for safety reasons and she went behind the desk and paged MD-F. Then LPN-D went behind the desk to get the paperwork ready, and RN-C stayed with Resident #1. Surveyor # noted the times of the blood pressures and pulse ox at 2130 and 2140 and asked if those times are approximate or if she documented the time she actually took the vitals. RN-C stated those times are accurate. She wears a watch and was "babysitting the watch" waiting for the next set of vitals to be taken. Surveyor # asked if she assessed pulse, respirations and temperature along with the blood pressure and pulse ox readings. RN-C stated she thought she did them, but they are not documented. RN-C stated she was with Resident #1 when MD-F called the facility. He first spoke with one of the LPN's, then LPN-D came over to stay with Resident #1 and she took the phone. RN-C stated she informed MD-F Resident #1 was seizing and she reported his elevated blood pressure readings. MD-F ordered [MEDICATION NAME] suppository (referring to the [MEDICATION NAME]). RN-C told MD-F they did not have that available. RN-C stated she informed MD-F she was sending Resident #1 out to the hospital. RN-C does not recall if she told MD-F Resident #1 hit his head, or if he was in his second [MEDICAL CONDITION] that had been going on for 20 minutes at that time. Surveyor # asked RN-C if there is any policy and procedure to direct the nurses regarding who to call to make a transport to the hospital. RN-C did not respond. Surveyor # then asked, when you got off the phone with MD-F, what were your options to transport Resident #1 to the hospital. RN-C stated Paratech or LifeStar. Surveyor # asked RN-C when she would call 911. RN-C did not answer. Surveyor # asked if calling 911 was an option on [DATE]. RN-C did not answer. Surveyor # asked again if calling 911 was and is an option when sending a resident to the hospital. RN-C did not answer, she just continued to look straight ahead. RN-C then said "my first priority is to focus on my resident and his safety. I wanted him sent out ASAP. I opened the emergency book, Paratech's number was on top, I called it." Surveyor # asked if there was any consideration given or discussion regarding calling 911. RN-C stated no, she did not consider calling 911 since she thought Resident #1 was stable. Surveyor # asked what evidence supported her assessment that Resident #1 was stable. RN-C stated Resident #1's vital signs were coming down (BP down to ,[DATE] from ,[DATE]). Surveyor # stated if you wanted Resident #1 out ASAP, wouldn't it be faster to call 911. RN-C did not reply. (Note: On [DATE], Surveyor # reviewed a report from the Germantown Police Department dated [DATE], which states, " (RN-C) stated she did not call 911 immediately because they have another patient who routinely has [MEDICAL CONDITION] and they do not contact 911 for that patient.") Surveyor # asked RN-C if she was aware of Resident #1's physician's orders [REDACTED]. RN-C was unaware of the order. Surveyor # asked RN-C to describe Resident #1's variable seizing. RN-C stated he would seize for ,[DATE] minutes, mumble incoherently, and tremor and seize again. Surveyor # asked what information she gave the Paratech dispatcher. RN-C stated she gave them Resident #1's name, and that had a [MEDICAL CONDITION], vital signs. Paratech asked what room he was in and RN-C stated he was in the hall. RN-C does not recall if she told them about a possible head injury, that Resident #1 hit his head on the floor. Surveyor # asked RN-C if she was familiar with Resident #1's [MEDICAL CONDITION] patterns, what his typical [MEDICAL CONDITION] was. RN-C stated no, she did not know what Resident #1's usual [MEDICAL CONDITION] pattern was. She would have to look at the chart. Surveyor # asked where in the chart she would find that information. RN-C stated she would have to read through thee nurses' notes, which could be difficult since they thin the records every three months. RN-C stated she was not aware Resident #1's previous [MEDICAL CONDITION] usually lasted ,[DATE] minutes, with one [MEDICATION NAME] 15, but there is no documentation Resident #1 ever had a second [MEDICAL CONDITION] following the first. Surveyor # asked RN-C, at any time that night, did she think they needed to switch to a different plan of action- that it was taking too long for Paratech to arrive? RN-C stated no, she thought Resident #1 was stable. RN-C stated they have had additional training and she now knows 911 will get here in under 6 minutes. RN-C told Surveyor # that once the Paratech crew came down the hall, they were given the paperwork and vital signs, and she went behind the desk and began working on paperwork. RN-C stated the Paratech crew was quiet and the next thing she knew the fire department was here. RN-C stated she did not speak to the Paratech crew or the Fire Department staff. RN-C stated she did not recall anyone voicing a concern that 911 should have been called sooner. RN-C stated she palpated Resident #1's head again at 10:00 p.m. and saw no sign of trauma. Surveyor # asked RN-C if anyone followed up with MD-F, letting him know that Resident #1 was still seizing in the facility almost an hour after it first started, and the ambulance had not arrived. RN-C stated she did not have any further contact with MD-F, and was not aware that anyone else called him. Surveyor # asked if RN-C documented anything further in Resident #1's chart after "10:10 p.m. Paratech present at facility." RN-C stated no, this was her last documentation. Based on the above information contained in the report, the nurses did not call MD-F until Resident #1 started seizing for the second time (9:25 p.m.) - which was at least 10 minutes after the start of his [MEDICAL CONDITION], and waited for another 15 minutes for him to return the call (9:40 p.m.) - then 25 minutes after the seizing started, without calling 911. Also, according to the report, it took Paratech 30 minutes to arrive at the facility (9:40 - 10:10 p.m.), while Resident #1 continued to seize. The occurrence of the second [MEDICAL CONDITION], the duration of the second [MEDICAL CONDITION] and the significantly elevated blood pressure should have been

Based on interview and record review, the facility did not ensure services provided by a Registered Nurse (RN) met professional standards of quality for 1 of 3 records reviewed. Resident #1 fell and had a [MEDICAL CONDITION] on [DATE]. RN-C did not thoroughly assess Resident #1 in accordance with accepted standards of practice. RN-C did not identify a large hematoma on Resident #1's head, nor did she identify Resident #1's neurological condition was serious and required immediate attention. Resident #1 did not get to the hospital until an hour and a half after his second [MEDICAL CONDITION] started, an hour and 45 minutes after the first [MEDICAL CONDITION] started, without any medical intervention to stop the [MEDICAL CONDITION]. Once at the hospital and the [MEDICAL CONDITION] were stopped, it was noted the subdural hematoma was severe and Resident #1 never regained consciousness, and died several days later. The lack of thorough assessment and timely action failed to meet professional standards of quality, creating a finding of immediate jeopardy beginning [DATE]. The Nursing Home Administrator and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 4:30 p.m. The Immediate Jeopardy was removed on [DATE]. However, the deficient practice continued at a scope and severity of E, potential for more than minimal harm, pattern as the facility continues to train licensed nursing staff on proper completion of assessments and how to handle a medical emergency particularly for the 10 additional Residents ( Resident's #2, #3, #4, #5, #6, #7, #8, #9, #10, #12) identified to be at risk for [MEDICAL CONDITION] activity. Findings include: According to the State of Wisconsin Chapter N6: Standard of Practice for Registered and Licensed Practical 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 less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. On [DATE], Surveyor # reviewed Resident #1's medical record, which revealed on [DATE] at approximately 9:15 p.m., Resident #1 was standing at the nurses' station when he both had a [MEDICAL CONDITION] and fell to the floor. RN-C assessed Resident #1's blood pressure and pulse oximetry at 9:15 p.m., 9:30 p.m., 10:00 p.m. However, at 9:40 p.m., RN-C only documented blood pressure (,[DATE]). The only pulse and respiration recorded was at 9:30 p.m., no temperature was recorded. RN-C did not identify Resident #1's snoring respirations, though two CNA's (Certified Nursing Assistants) and both ambulance crews did note the snoring respirations. Changing vital signs can provide important information regarding a resident's physical status. RN-C did not perform and document neurological assessments recommended for individuals with both [MEDICAL CONDITION] and head injuries, that provide critical information regarding the severity of the resident's neurological status. Eye, motor and verbal responses are to be scored on the Glasgow Coma Scale (GCS) to indicate an individuals level of neurological response. When the private ambulance arrived, they scored Resident #1's GCS as 3, which is the lowest score, and usually fatal. 8 or less indicates coma. While Resident #1 was in a coma, RN-C did not identify the seriousness of his condition, thinking he was stable since he had had [MEDICAL CONDITION] in the past. RN-C did not follow Resident #1's physician's orders [REDACTED]. RN-C did not call the private ambulance until 9:51 p.m., after MD (Medical Director)-F called back at 9:41 p.m.. Resident #1 had been seizing for about a half hour at that point, qualifying as a sustained [MEDICAL CONDITION] which would require calling 911. The EMS /Fire Dept. response time is within 6 minutes of the facility, with the first responder arriving in minutes. The average response time for the private ambulance is 2 to 3 times that. RN-C did not provide crucial information to the Paratech dispatcher when she did call for the private ambulance. She did not mention Resident #1 had a second, ongoing [MEDICAL CONDITION] that had lasted a half hour at the time, that he hit his head when he fell , and that his blood pressure was elevated, ,[DATE]. Sharing that information helps the ambulance company send the proper response. When the private ambulance arrived, they quickly identified a large subdural hematoma on Resident #1's left posterior head, that RN-C did not identify despite palpating Resident #1's head just prior to their arrival. Along with the elevated blood pressure, GCS of 3, the private ambulance crew felt the Resident required ALS (Advanced Life Support) and called 911, creating a further delay in Resident #1 getting to the hospital. RN-C did not conduct a thorough, comprehensive assessment which would have identified the graveness of Resident #1's clinical condition, which should have prompted a more urgent response. Professional guidelines (cross reference F309) state 911 should be called when an individual starts having a second [MEDICAL CONDITION]. That would have been 9:22- 9:25 p.m. Resident #1 could have been at the hospital when RN-C was first talking with Medical Doctor (MD)-F. RN-C ended her documentation on [DATE] at 10:10 p.m. when the Paratech ambulance arrived. Besides the medical record not reflecting pertinent physical findings, RN-C did not document the presence of the hematoma, the arrival of the Fire Department EMS ambulance, and that he was ultimately transported by the Fire Department. On [DATE] at 1:52 p.m., Surveyor # interviewed RN-C. Surveyor # and LPN-G were also present. RN-C stated on [DATE], she was the float nurse between Long Term Care and Memory Lane. She was documenting on the 24 hour board when she heard a bang, but did not see Resident #1 fall. RN-C stated she grabbed her bag of equipment, ran around the desk to Resident #1's right side. Resident #1 was on his back, having a [MEDICAL CONDITION]; he couldn't communicate, tremors, shaking of his lower extremities. It lasted about 3 minutes. Then he started to come around. RN-C stated she kept calling his name, saying "Are you OK?" Resident #1 said his own name softly. After about 4 minutes, the seizing started again, tremoring/ shaking lower body. RN-C stated he had "variable [MEDICAL CONDITION] activity"- he would mumble, come out of the [MEDICAL CONDITION] a little, start seizing again. Surveyor # asked if Resident #1 ever fully came out of the [MEDICAL CONDITION] activity after the first 4 minute span after the first [MEDICAL CONDITION]. RN-C stated "Not that I recall." RN-C stated Resident #1's eyes were open, pupils equal in size, but does not remember if his pupils were dilated or constricted or reactive to light. RN-C stated she couldn't check Resident #1's pupil reaction to light due to the ongoing [MEDICAL CONDITION] activity. RN-C stated Resident #1 kept turning his head to his left. RN-C stated she has a systematic way of assessing a resident, and she palpated his head, which was turned toward the left, and no trauma was noted, only one small pimple on the top of his head was noted. RN-C stated she works her way down the body and no visual injuries were noted. Surveyor # noted there was no documentation of a neurologic assessment conducted, or other assessment besides blood pressure and pulse oximetry. RN-C stated she reviewed her documentation when DON-B asked her yesterday what assessments she did, and they compiled additional documentation (Summary of Evaluation) on [DATE] from DON-B helping RN-C walk through what happen three weeks earlier, on [DATE]. RN-C stated that while talking with DON-B, she remembered when she used the pulse oximetry device, Resident #1 had a good hand grasp with his right hand, he held on tight. RN-C stated he also had his teeth clenched. This was during the 4 minutes he seemed to be coming out of the first [MEDICAL CONDITION]. Surveyor # noted testing motor responses during a neurologic exam assesses the resident's ability to follow commands, purposeful movement, response-if any-to pain, if they flex or extend extremities abnormally, or if flaccid. Surveyor # asked if Resident #1's hand grasp was purposeful movement or if it was due to the seizing. RN-C did not reply. Surveyor # asked if she subsequently conducted any motor response assessment. RN-C stated she did a sternal rub during this time and he turned his head and mumbled. RN-C stated she did not document the hand grasp, sternal rub or clenched teeth. Surveyor # asked if she assessed pulse, respirations and temperature along with the blood pressure and pulse ox readings. RN-C stated she thought she did them, but they are not documented. RN-C stated she was with Resident #1 when MD-F called the facility. He first spoke with one of the LPN's, then LPN-D came over to stay with Resident #1 and she took the phone. RN-C stated she informed MD-F Resident #1 was seizing and she reported his elevated blood pressure readings. MD-F ordered [MEDICATION NAME] suppository (referring to the [MEDICATION NAME]). RN-C told MD-F they did not have that available. RN-C stated she informed MD-F she was sending Resident #1 out to the hospital. RN-C does not recall if she told MD-F Resident #1 hit his head, or if he was in his second [MEDICAL CONDITION] that had been going on for 20 minutes at that time. Surveyor # asked RN-C if there is any policy and procedure to direct the nurses regarding who to call to make a transport to the hospital. RN-C did not respond. Surveyor # then asked, when you got off the phone with MD-F, what were your options to transport Resident #1 to the hospital. RN-C stated Paratech or LifeStar. Surveyor # asked RN-C when she would call 911. RN-C did not answer. Surveyor # asked if calling 911 was an option on [DATE]. RN-C did not answer. Surveyor # asked again if calling 911 was and is an option when sending a resident to the hospital. RN-C did not answer, she just continued to look straight ahead. RN-C then said "my first priority is to focus on my resident and his safety. I wanted him sent out ASAP. I opened the emergency book, Paratech's number was on top, I called it." Surveyor # asked if there was any consideration given or discussion regarding calling 911. RN-C stated no, she did not consider calling 911 since she thought Resident #1 was stable. Surveyor # asked what evidence supported her assessment that Resident #1 was stable. RN-C stated Resident #1's vital signs were coming down (BP down to ,[DATE] from ,[DATE]). Surveyor # stated if you wanted Resident #1 out ASAP, wouldn't it be faster to call 911? RN-C did not reply. (Note: On [DATE], Surveyor # reviewed a report from the Germantown Police Department dated [DATE], which states, " (RN-C) stated she did not call 911 immediately because they have another patient who routinely has [MEDICAL CONDITION] and they do not contact 911 for that patient. " ) Surveyor # asked RN-C if she was aware of Resident #1's physician's orders [REDACTED]. RN-C was unaware of the order. Surveyor # asked what information she gave the Paratech dispatcher. RN-C stated she gave them Resident #1's name, and that had a [MEDICAL CONDITION], vital signs. Paratech asked what room he was in and RN-C stated he was in the hall. RN-C does not recall if she told them about a possible head injury, that Resident #1 hit his head on the floor. (Note: On [DATE] at 12:25 p.m., Surveyor # spoke with Paratech Director of Operations-O (Dir. Ops-O) who played a recording of the call from RN-C to the Paratech dispatcher on [DATE]. The recording shows RN-C never informed the Paratech dispatcher Resident #1 was a half-hour into his second [MEDICAL CONDITION], that he had hit his head, or that his blood pressure was ,[DATE].) Surveyor # asked RN-C if she was familiar with Resident #1's [MEDICAL CONDITION] patterns, what his typical [MEDICAL CONDITION] was. RN-C stated no, she did not know what Resident #1's usual [MEDICAL CONDITION] pattern was. RN-C stated she was not aware Resident #1's previous [MEDICAL CONDITION] usually lasted ,[DATE] minutes, with one [MEDICATION NAME] 15, or that Resident #1 had never had a second [MEDICAL CONDITION] following the first. Surveyor # asked RN-C, at any time that night, did she think they needed to switch to a different plan of action- that it was taking too long for Paratech to arrive? RN-C stated no, she thought Resident #1 was stable. RN-C stated she did not speak to the Paratech crew or the Fire Department staff after they arrived. RN-C stated she did not recall anyone voicing a concern that 911 should have been called sooner. RN-C stated she palpated Resident #1's head again at 10:00 p.m. and saw no sign of trauma. Surveyor # asked RN-C if anyone followed up with MD-F, letting him know that Resident #1 was still seizing in the facility almost an hour after it first started, and the ambulance had not arrived. RN-C stated she did not have any further contact with MD-F, and was not aware that anyone else called him. Surveyor # asked if RN-C documented anything further in Resident #1's chart after "10:10 p.m. Paratech present at facility." RN-C stated no, this was her last documentation. Surveyor # shared the above concerns at the exit meeting on [DATE] that the facility did not ensure services provided by the facility nurse RN-C met professional standards of quality. RN-C did not meet professional standards of the Wisconsin Nurse Practice Act N6 since she did not provide appropriate assessment, planning, intervention and evaluation of Resident #1's response to the intervention. Cross reference F309. On [DATE] at approximately 4:30 pm, the Administrator and Director of Nursing were notified that a finding of Immediate Jeopardy at a scope/severity of J (immediate jeopardy/isolated) existed at F281 regarding professional standards of practice. The facility removed the finding of Immediate Jeopardy on [DATE] by which time the facility had completed the following: * The facility provided increased communication materials at each nurse's station regarding the handling of emergencies including use of the overhead paging system, calling 911, calling the MD and tips to use critical thinking. * The facility initiated staff development training regarding the use of the Interact tool that the facility utilizes. * The facility developed a plan and initiated training nursing staff regarding [MEDICAL CONDITION] management, differentiating [MEDICAL CONDITION] types and medical emergencies. * The facility developed a plan & initiated training nursing staff on the completion of neurological assessments. * The facility met with the local fire department and developed a plan for when to call 911 versus private ambulance services during a medical emergency. *The facility reviewed their existing policies and procedures regarding falls and neurological assessments and revised the frequency of the checks to make them consistent. On [DATE], NHA (Nursing Home Administrator)-A informed Surveyors that RN-C has not acted as supervisor since [DATE] and will receive additional 1 on 1 training before she resumes providing nursing care.