Every finding on record at Complete Care at Glendale West

Based on interview and record, the facility did not ensure 1(R1) of 1 resident was assessed by the interdisciplinary team to determine it was clinically appropriate to self-administer medication.*On 11/11/25 Surveyor observed a medication cup marked with R1's first name & noon with two white tablets.Findings include:The facility's policy titled, Resident Self-Administration of Medication and dated 4/25 under policy documents It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safety. Under Policy Explanation and Compliance Guidelines documents 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record.R1's diagnoses includes hypertension, radiculopathy (1 or more nerve roots in spinal column become compressed or irritated) lumbar region, bilateral primary osteoarthritis of knee benign prostatic hyperplasia (enlarged prostate, obstructive & reflux uropathy (urine flows backward from bladder into ureters) and anxiety disorder (group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). R1's quarterly MDS (minimum data set) with an assessment reference date of 9/8/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact.On 11/11/25, at 12:52 p.m., Surveyor observed R1 in bed on his back. Surveyor observed on the overbed table is a medication cup marked with R1's first name & noon with two white tablets. R1 informed Surveyor they said they are going to transfer him around 1:00 p.m. R1 informed Surveyor, Surveyor can watch the transfer but doesn't want Surveyor watching the shower. Surveyor informed R1 this is his right, and Surveyor will only observe his transfer. Surveyor then asked R1 about the two pills in the medication cup on the overbed table. R1 stated those are my Tylenol. R1 explained his lower half is frozen and stated sometimes I take the medication. I might take it after I get out of the shower.On 11/11/25 at 1:04 p.m. Surveyor observed Physical Therapy Assistant (PTA)-J transfer R1 from the bed into a shower chair using a gait belt. Surveyor observed Certified Nursing Assistant (CNA)-F was in R1's room at this time and at 1:08 p.m. CNA-G entered R1's room. PTA-J informed CNA-F & CNA-G he will be back when they are done. CNA-F wheeled R1 into the bathroom which contains a shower. As Surveyor was leaving R1's room, at 1:10 p.m., Surveyor observed the medication cup with 2 Tylenol tablets continues to be on R1's overbed table.On 11/11/25, at 1:16 p.m., Surveyor reviewed R1's November MAR (medication administration record) and noted an order date 9/2/25 which documents Acetaminophen 500 mg (milligrams). Give 1000 mg by mouth three times a day for back pain. Surveyor reviewed R1's medical record and was unable to locate a self-administration assessment for R1.On 11/11/25, at 1:41 p.m., Surveyor observed R1 sitting in a shower chair covered with a towel in R1's room. R1 informed Surveyor he is waiting to get back in bed. Surveyor observed on the overbed table the medication cup is tipped on the side and still contains two Tylenol tablets.On 11/11/25, at 1:44 p.m., Surveyor asked Licensed Practical Nurse (LPN)-I if she usually leaves R1's medication. LPN-I replied he can self-administer his medication. Surveyor asked LPN-I if she knew where Surveyor would be able to locate R1's self-administration medication assessment. LPN-I informed Surveyor she did not.On 11/11/25, at 1:47 p.m., Surveyor asked Director of Nursing (DON)-B where Surveyor would be able to locate self-administration medication assessments. Regional Registered Nurse (R)-M, who was in DON-B's office, informed Surveyor it's under the assessment section quarterly/annual assessment.R1's WI (Wisconsin) Admit/Readmit assessment dated [DATE] under the self-administration section for the question Does the resident desire to self-administer his/her own medications, no is answered.R1's WI (Wisconsin) Admit/Readmit assessment dated [DATE] under the self-administration section for the question Does the resident desire to self-administer his/her own medications, no is answered.Surveyor was unable to locate a self-administration for medication assessment for R1.On 11/11/25, at 2:12 p.m., Surveyor asked LPN-I how she knew R1 could self-administer his medication. LPN-I replied he can't I was wrong, sorry.On 11/11/25, at 3:05 p.m., during the end of the day meeting Surveyor informed Nursing Home Administrator (NHA)-A, DON-B, and Regional RN-M, of the observation of R1's Tylenol being left on the overbed table without a self-administration medication assessment.No additional information was proved to Surveyor as to why R1's medication was left on the overbed table.

Based on Interview and record review, the facility did not ensure showers were provided for 3 out of 3 residents (R1, R2, and R3) dependent on staff for Activities of Daily Living (ADLs). Findings Include: The facility policy, entitled Activities of Daily Living (ADLs), dated 12/24, stated: The facility will comma based on the residence comprehensive assessment and consistent with the residents' needs and choices comma ensure a residence abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: - Bathing, dressing, grooming, and oral care. Policy Explanation and compliance Guidelines: - A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition grooming and personal and oral hygiene. - The facility will maintain individual objectives of the care plan and periodic review and evaluation. The facility policy, entitled Resident Showers, dated 6/25, stated: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice Equipment and Supplies: - gloves - two washcloths - several towels - shower cap (if needed) - shower chair - bath blanket (if available) - resident's clothing Policy Explanation and Compliance Guidelines: - Residents will be provided showers as per request or as per facility scheduled protocols and based upon resident safety partial baths may be given between regular shower schedules as per facility policy. - Help the residents sit on the shower chair. Use safety straps if necessary and available. The Facility Assessment for Glendale Care and Rehab, dated 10/17/25, documented: Purpose Statement: o The purpose of this assessment is to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. Scope: o This assessment addresses the following elements: The facility's resident population. The facility's resources, including but not limited to: equipment (medical and non medical). Information about how we ensure adequate supplies and upkeep. o physical equipment each department manager, or designer, follows procedures for maintaining inventory, assessing the condition of all equipment and determining what equipment is needed. Preventive maintenance and/more cleaning schedules are in place according to manufacture recommendations. When equipment is needed, whether new or replacements, each department head follows procedures for obtaining purchase orders or capital expenditure authorizations for obtaining the needed equipment. 1.) R3 was admitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis after intracerebral hemorrhage (Paralysis and weakness on one side of the body after a stroke that causes blood vessels in the brain to rupture and bleed into the brain tissue), epileptic seizures (repeated seizures), and Dementia (cognitive decline that severely impacts ADLs). R3's Quarterly Minimum Data Set (MDS) dated [DATE], indicated that R3 had Long-term and short-term memory problems, and severely impaired cognitive skills for daily decision making. R3 is completely dependent for all cares: transferring, bed mobility, eating, dressing, hygiene/showers, and transportation in a wheelchair. R3's annual MDS dated [DATE] indicated staff answered for R3's preferences for customary routines including bathing due to R3 not responding to questions related to R3's cognition. Staff answered for R3 to prefer a bath or sponge bath for bathing. Surveyor noted historically, R3's MDS including R3's 5 day admission MDS dated [DATE], section F which documented R3's preferences, Indicated that it was very important to R3 that R3 received and decided between Shower, tub bath, bed bath, or a sponge bath historically. R3's comprehensive care plan documented: - R3 has an ADL self care performance deficit r/t (related to) impaired mobility, weakness. Initiated 7/1/25 o BATHING/SHOWERING R3 is totally dependent on one staff to provide bathing/showering 2X/week and as necessary. Initiated 5/4/23, revised 7/1/25 Surveyor notes R3 has 2 care plans for falls, neither mention R3 as not being able to receive showers due to safety. - R3 is at risk for falls related to poor trunk control and total assistance with transfers. Initiated 7/1/25. - Potential/actual for falls, R3 is at risk for injury from falls WEAKNESS, unsteady gait, history of fall. Initiated 2/21/2020, revised 5/24/2022 R3's Physician orders documented: - Shower days: chart refusal and body check Every evening shift every Wednesday and Sunday for showers. Make sure hair is washed at least weekly. Every evening shift every Wednesday, Sunday. Start date 4/2/2025. R3's Care Card dated 11/6/25, indicates to Certified Nursing Assistants (CNAs) how to care for residents, documented: - R3 shower is on Sunday and Wednesday - Assist of 1, dependent for upper and lower body dressing/hygiene, wash hair at least weekly on shower days. - For transfers use Hoyer lift and Broda chair On 11/10/25, at 3:20 PM, Surveyor interviewed CNA-O regarding cares for R3. CNA-O stated CNA-O provides all cares to R3, including baths, washing up, oral care, lotion, check and changes for incontinence, and catheter care. CNA-O stated R3 only gets bed baths and it has been like that for a while now. CNA-O stated R3 has poor trunk control and cannot sit up in the shower chair, so for safety R3 gets bed baths only. CNA-O denied if any alternatives were provided for R3 in place of bed baths. On 11/11/25, at 10:45 AM, Surveyor interviewed Registered Nurse Unit Manager (RN UM)-N regarding R3 only getting bed baths. RN UM-N stated R3 only gets bed baths due to safety as R3 cannot sit up and has poor trunk control, and it has been like that since RN UM-N has worked at the facility. RN UM-N denied if any alternatives were provided for R3 in place of bed baths. On 11/11/25, at 11:01 AM, Surveyor interviewed Director Of Nursing (DON)-B regarding R3 only getting bed baths. DON-B stated R3 cannot sit up and for safety only bed baths are provided. DON-B stated there are multiple residents throughout the building who cannot get showers and only get bed baths for the same reason. DON-B stated the facility does not have shower cots and if they did the shower rooms are not big enough to accommodate the shower cot and the staff member assisting the shower. DON-B stated the facility had been planning on extending one of the shower rooms in the facility to make it big enough to accommodate the shower cot and staff. DON-B does not have a timeframe for which the shower room remodeling will occur. Surveyor asked DON-B if any bathing alternatives were provided for R3, DON-B stated no, only bed baths. Surveyor asked DON-B how CNAs would know that R3 can only have a bed bath, DON-B stated that on each resident's care card, under the shower section, it notes if the resident can have a shower or bed bath. DON-B stated DON-B would provide surveyor a copy, surveyor did not receive a copy of R3's care card that indicated that R3 only can get bed baths. Surveyor noted that the care card Surveyor obtained on the unit, did not indicate if R3 can gets a shower or bed bath. It only notes to bathe Wednesday and Sunday and wash hair at least weekly. Surveyor reviewed R3's bathing records from 5/22/25 – present, that indicated: - 5/22/25 – 5/31/25 R3 did not receive 1 of the scheduled bathings: o on Sunday 5/25/25. - June 2025, R3 did not receive 5 of the scheduled bathings: o 6/8/25 Sunday o 6/11/25 Wednesday o 6/18/25 Wednesday o 6/22/25 Sunday o 6/25/25 Wednesday o R3 went 7 days straight without bathing twice in the month of June. - July 2025, R3 did not receive 2 of the scheduled bathings: o 7/23/25 Wednesday o 7/27/25 Sunday o R3 went 9 days straight without bathing in the month of July - August 2025, R3 did not receive 3 of the scheduled bathings: o 8/3/25 Sunday o 8/6/25 Wednesday o 8/20/25 Wednesday o R3 went 10 days straight without bathing in the month of August - September 2025, R3 did not receive 1 of the bathings: o 9/3/25 Wednesday o R3 went 7 days straight without bathing in the month of September. 8/29/25-9/4/25 - October 2025, R3 did not receive 4 of the scheduled bathings: o 10/8/15 Wednesday o 10/19/25 Sunday o 10/22/25 Wednesday o 10/26/25 Sunday o R3 went 8 days straight without bathing in the month of October. - November 2025, R3 received all bathings thus far. Surveyor noted that all documentation of bathing is recorded as bed baths. On 11/12/25, at 9:30 AM, DON-B provided additional information regarding dates R3 received bathing. The sheets provided are titled, CNA walking shift reporting, documented: - 6/25/25, 2nd shift a y (indicating yes) is written at the top of the shower category and a line going straight down through each resident section. It is not documented what type of shower/bed bath/sponge bath was given. o The charting in the electronic medical recorded (EMR) for 6/25/25 on 2nd shift is recorded as N/A (not applicable) for bathing on this day for R3. - 6/20/25, 2nd shift a yes is written at the top of the shower category and a line going straight down through each resident section. It is not documented what type of shower/bed bath/sponge bath was given. o The charting in the EMR for 6/20/25 on 2nd shift is recorded as N/A for bathing on this day for R3. - 9/19/25, 2nd shift a Y (indicting yes) is written in R3's shower category. It is not documented what type of shower/bed bath/sponge bath was given. o The charting in the EMR for 6/19/25 on 2nd shift is recorded as N/A for bathing on this day for R3. - 9/18/25, 2nd shift a Y (indicting yes) is written in R3's shower category. It is not documented what type of shower/bed bath/sponge bath was given. o There is no documentation for showering in EMR on this day. On 11/11/25, at 3:20 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A, DON-B, and Regional RN -N that R3 is only getting bed baths and has missing bathing days. No further information has been provided at this time by the facility for R3's missing scheduled shower dates, alternative shower/bath methods for R3, or when the remodeling of the shower room to accommodate a shower cot for R3 and other residents like R3. 2.) R1's diagnoses includes hypertension, radiculopathy (1 or more nerve roots in spinal column become compressed or irritated) lumbar region, bilateral primary osteoarthritis of knee, benign prostatic hyperplasia (enlarged prostate, obstructive & reflux uropathy (urine flows backward from bladder into ureters) and anxiety disorder (group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). R1's ADL (activities daily living) self-care performance deficit care plan initiated 6/26/25 & revised 7/17/25 includes an intervention *BATHING/SHOWERING: The resident requires max (maximum) assist x1 (times one) staff to provide (shower) (twice weekly) and as necessary. Initiated 6/26/25 & revised on 9/2/25. R1's admission MDS (minimum data set) with an assessment reference date of 7/2/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. For the question how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath #1 very important is answered. R1's quarterly MDS with an assessment reference date of 9/8/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R1 is assessed as requiring substantial/maximal assistance for shower/bathe self. The Certified Nursing Assistant (CNA) Care Card for Unit: [Name} under section room/shower for R1 documents [Room #] Tues/Sat (Tuesday/Saturday) AM (morning) shift. Surveyor reviewed under the task tab of R1's electronic medical record, showers/bathing/personal care for the past 30 days. Surveyor noted there is only documentation of no data found. On 11/10/25, at 11:43 a.m., Surveyor asked Certified Nursing Assistant (CNA)-H if R1 receives showers. CNA-H informed Surveyor R1 is very nervous, anxious and makes the caregivers nervous. On 11/10/25, at 1:07 p.m., Surveyor asked CNA-G if R1 takes showers. CNA-G replied yes if PT (physical therapy) can get him up otherwise bed baths. On 11/10/25, at 1:24 p.m., Surveyor asked Director of Nursing (DON)-B where Surveyor would be able to locate when a resident received a shower. DON-B informed Surveyor it's under the task section. On 11/11/25, at 7:46 a.m., Surveyor asked DON-B how often Residents receive a shower. DON-B informed Surveyor residents are offered two times a week. Surveyor informed DON-B Surveyor does not have evidence R1 was provided with showers two times a week. DON-B replied let me see what I can pull. On 11/11/25, at 8:47 a.m., Surveyor observed R1 in bed on his back with the head of the bed up high and R1's breakfast tray on the overbed table in front of R1. Surveyor asked R1 permission to observe morning cares today. R1 informed Surveyor today is his shower day, and they said they were going to give him a shower this morning after breakfast. Surveyor asked permission to observe which resident gave. On 11/11/25, at 9:27 a.m., CNA-F informed Surveyor CNA-G is with another resident but she's going to get started. CNA-F placed gown & gloves on and entered R1's room. CNA-F informed R1 she was going to change him, and CNA-G is going to meet them. CNA-F filled a washbasin and placed the washbasin & towels on the overbed table and a clear garbage bag on the floor. R1 washed his own face, CNA-F placed Dove body soap on a washcloth and R1 washed under his neck and under his underarms. CNA-F rewashed under R1's neck & underarms and then handed R1 deodorant. CNA-F lowered the head of the bed, removed bedding and washed R1's inner thighs. At 9:41 a.m. CNA-G entered R1's room with the appropriate PPE (personal protective equipment) and CNA-F cleaned the tubing of the catheter and R1's frontal perineal area. CNA-G positioned R1 on the side, CNA-F wiped R1's rectal area with the incontinence product, folded the draw blanket under R1 and washed R1's rectal area & buttock, and applied remedy cream on R1's buttocks. A draw blanket and incontinence product were placed under R1 and R1 was positioned onto his back. R1's urinary collection bag was attached to the right side of the bed frame and R1 was positioned on the right side to remove the soiled product & draw sheet and straightened out the draw blanket & incontinence product. CNA-F sprayed cologne on R1 per his request, R1 was covered with bedding, and the bed was lowered. Surveyor noted R1 received a bed bath and did not receive a shower during this observation. On 11/11/25 at 9:56 a.m., Surveyor asked CNA-F how she knows which residents are to receive a shower. CNA-F explained she looks at the assignment sheet as they are listed for AM (morning) and PM (evening) or the care plan will let them know. Surveyor asked CNA-F if there is any paper, they are required to fill out. CNA-F informed Surveyor there are shower sheet, she fills out her part, hands it to the nurse and the nurse signs them. Surveyor asked CNA-F why she didn't give R1 a shower. CNA-F replied there is still time for him to get a shower, probably will be a bed bath because it's too much strain on my body and name of R1. Surveyor asked what the difference will be from what Surveyor observed this morning. CNA-F explained his arms, legs, all of that. Surveyor asked CNA-F when she will do this. CNA-F replied probably before I get him dressed. On 11/11/25, at 10:58 a.m., Surveyor asked R1 what time he was getting up. R1 informed Surveyor he doesn't know, and they said they were going to get me in the shower. R1 stated I don't know they say one thing. They said they were waiting for therapy. Surveyor asked R1 if he ever refuses showers. R1 replied no, suppose to be two times a week, therapy not here on Saturday. Surveyor asked R1 if he receives his showers on Tuesday. R1 replied yes. Surveyor asked about Saturday showers. R1 replied that's the one they are scared to give me, they say they don't want to do it. Surveyor asked R1 so Tuesday is not a problem, but Saturday is because they are scared to do it. R1 replied yes. On 11/11/25, at 11:08 a.m. Surveyor reviewed R1's Saturday shower sheets from July 22, 2025 to November 2025 and noted the following: Week of 7/20 to 7/26/25 Surveyor was not provided with a shower sheet for 7/26/25 (Saturday) R1 received a bed bath on 7/24/25. Week of 7/27 to 8/2/25 Surveyor was not provided with a shower sheet for 8/2/25 (Saturday) R1 received a shower on 7/31/25. Week of 8/3 to 8/9/25 Surveyor was not provided with a shower sheet for 8/9/25 (Saturday). Week of 8/10 to 8/16/25 Surveyor was not provided with a shower sheet for 8/16/26 (Saturday) R1 received a shower on 8/14/25. Week of 8/17 to 8/23/25 R1 received a bed bath on 8/23/25 (Saturday). Week of 8/24 to 8/30/25 Surveyor was not provided with a shower sheet for 8/30/25 (Saturday). Week of 8/31 to 9/6/25 R1 received a bed bath on 9/6/25 (Saturday). Week of 9/7 to 9/13/25 R1 received a bed bath on 9/13/25 (Saturday). Week of 9/14 to 9/20/25 R1 received a shower on 9/20/25 (Saturday). Week of 9/21 to 9/27/25 Surveyor was not provided a shower sheet for Saturday 9/27/25. R1 received a bed bath on 9/26/25. Week of 9/28 to 10/4/25 Surveyor was not provided with a shower sheet for Saturday 10/4/25. Week of 10/5 to 10/11/25 R1 received a bed bath on 10/11/25 (Saturday). Week of 10/12 to 10/18/25 R1 received a bed bath on 10/18/25 (Saturday). Week of 10/19 to 10/25/25 R1 received a bed bath on 10/25/25 (Saturday). Week of 10/26 to 11/1/25 R1 received a shower on 11/1/25 (Saturday). Week of 11/2 to 11/8/25 R1 received a bed bath on 11/8/25 (Saturday). On 11/11/25, at 12:56 p.m., Surveyor asked Physical Therapy Assistant (PTA)-J if he assists staff with R1's showers. PTA-J informed Surveyor he is not involved with R1's showers but he assists with getting him in the shower chair and back. Surveyor asked PTA-J if he's not here to help what do staff do. PTA-J informed Surveyor they use a Hoyer lift or sit to stand. Surveyor asked PTA-J if he works on Saturday. PTA-J informed Surveyor he is usually not here on Saturday unless he missed a day during the week and then may work Saturday. Surveyor asked PTA-J if he's not here on Saturday what does R1 receive. PTA-J informed Surveyor he's guessing a bed bath. On 11/11/25, at 3:05 p.m., during the end of the day meeting Nursing Home Administrator (NHA)-A, DON-B, and Regional RN-M were informed of the above. No additional information was provided to Surveyor as to why R1 was not provided showers on Saturdays. 3.) R2 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease (progressive damage and loss of function in the kidneys), Chronic Obstructive Pulmonary Disease (lung disease that block airflow and make it difficult to breathe), Type 2 Diabetes Mellitus (adult onset of trouble controlling blood sugar), Anemia (lack of blood), Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Metabolic Encephalopathy (brain dysfunction resulting from underlying condition that disrupts the metabolic processes), Rheumatoid Arthritis (autoimmune disease that causes chronic inflammation in the joints and can affect other parts of the body), Obesity, Lupus Anticoagulant Syndrome (autoimmune disorder where body produces antibodies that mistakenly attack phospholipids, and Osteomyelitis (bone infection that can be caused by bacteria, fungi, or other germs spreading through the bloodstream or from nearby tissues). R2 is currently her own person. R2's Quarterly Minimum Data Set (MDS) completed 9/24/25 documents R2's Brief Interview for Mental Status (BIMS) score to be 12, indicating R2 demonstrates moderately impaired skills for daily decision making. R2's MDS documents R2 has range of motion (ROM) impairment on both sides of both upper and lower extremities. R2 requires set-up for eating. R2 requires partial/moderate assistance for showers, upper dressing, mobility, and transfers. R2 requires substantial/maximum assistance for lower dressing. R2 has an indwelling catheter due to neurogenic bladder and is frequently incontinent of bowel. R2 has no mood or behavior symptoms. R2's admission MDS completed 2/2/25 documents it is somewhat important for R2 to choose between tub bath, shower, bed bath, or sponge bath. R2's current weight documented on 11/6/25 is 216.5. R2's current physician orders document R2's shower days are on Wednesday and Saturday. R2's Activities of Daily Living (ADL) self-care performance deficit due to disease process, wounds to feet, impaired mobility initiated 1/29/25 and revised on 6/20/25. Showering: R2 is able to assist with upper body task, shower 2x weekly Initiated 1/30/25 Revised 6/20/25 R2's Certified Nursing Assistant (CNA) Care Card instructs R2 is to receive a shower on Wednesday and Saturday AM and to use a shower chair. Surveyor reviewed R2's electronic medical record (EMR) for documentation R2 has been receiving showers on Wednesday and Saturday. On 11/10/25, at 11:17 AM, Surveyor interviewed R2 in regard to receiving showers. R2 stated R2 was informed by the facility at admission that R2 could not receive showers because of R2's feet. R2 stated that R2 has never received a shower since admission and has only received bed baths. R2 stated that no one from the facility has washed R2's hair. R2 explained that R2 has paid someone to wash R2's hair. R2 informed Surveyor that R2 would love a shower. On 11/11/25, at 7:47 AM, Director of Nursing (DON)-B informed Surveyor that residents are offered a shower two times a week and the expectation is that skin checks should be done on shower days and documented On 11/11/25, at 8:11 AM, Director of Nursing (DON)-B informed Surveyor that showers should be documented in the residents' EMR. The CNAs chart the showers, and a skin check form should be completed. The CNA should get the nurse to verify the skin issues and then both the CNA and the nurse sign off. DON-B stated the facility has boxes of completed shower sheets and will need to look for R2's completed shower sheets. On 11/11/25, at 8:40 AM, Certified Nursing Assistant (CNA)-R informed Surveyor that the nurse gets the shower sheets ready for the day for the residents that are scheduled to get a shower that day. CNA-R stated that the shower given to each resident should be documented in the residents' EMR. CNA-R stated the expectation is to complete the shower sheets with every shower, and then the nurse signs off on the residents' shower sheet. On 11/11/25, at 9:07 AM, Surveyor reviewed the provided shower documentation(Body Audit Form) by the facility of R2's showers from May-November. Based on the calendar the following shower days are not documented as being completed: May 5/10/25, 5/13/25, 5/24/25, 5/31/25-no shower documented as being provided 5/21/25-R2's Body Audit Form does not document if R2 has had a tub bath or shower 5/28/25-R2's Body Audit Form does not document if R2 has had a tub bath or shower June 6/7/25, 6/21/25-no shower documented as being provided 6/4/25-Body Audit Form is not signed by the nurse as having completed the skin check 6/11/25- Body Audit Form does not document if R2 has had a tub bath or shower 6/14/25- Body Audit Form does not document if R2 has had a tub bath or shower July 7/2/25-Body Audit Form is not signed by the CNA who provided the shower 7/5/25- Body Audit Form does not document if R2 has had a tub bath or shower 7/16/25-R2 received a bed bath 7/19/25- Body Audit Form is not signed by the nurse as having completed the skin check August 8/20/25-no shower documented as being provided 8/9/25-Body Audit Form is not signed by the CNA providing the shower and the nurse as having completed the skin check 8/23/25-Body Audit Form is not signed by the CNA who provided the shower 8/27/25-R2 provided a bed bath and is not signed by the CNA and nurse 8/30/25- Body Audit Form does not document if R2 has had a tub bath or shower September 9/3/25- Body Audit Form does not document if R2 has had a tub bath or shower October 10/8/25, 10/18/25, 10/29/25, 10/31/25- no shower documented as being provided November 11/1/25- Body Audit Form is not signed by the CNA who provided the shower On 11/11/25, at 10:46 AM, Surveyor interviewed Unit Manager (UM)-N explained that if a resident refuses showers, the nurse should be informed and it should be documented in the resident's EMR. UM-N does not recall if R2's feet was a barrier to receiving showers. On 11/11/25, at 12:13 PM, Surveyor interviewed CNA-Q. Surveyor had noted that CNA-Q had signed a majority of R2's Body Audit Forms. CNA-Q states that CNA-Q has never given R2 a shower, only a bed bath. CNA-Q stated R2's hair is not washed with the bed bath. CNA-Q states that the facility does not have a shower chair that fits R2 due to R2's weight. CNA-Q specifically stated that R2's hips are too big for the shower chair. CNA-Q states that none of the staff give R2 a shower because everyone is afraid R2 will slide off the small shower chair and get injured. CNA-Q states its too unsafe to use the current available chair for R2. CNA-Q repeated that R2 will slide out or fall off. Surveyor asked CNA-Q why CNA-Q signed the Body Audit Forms documenting R2 has received showers. CNA-Q explained that CNA-Q has never given R2 a shower, just documented on paper as a shower. CNA-Q stated CNA-Q does not know of anyone who gives R2 a shower. On 11/11/25, at 12:34 PM, Social Worker (SW)-S informed Surveyor that SW-S is not aware of R2 refusing showers. On 11/11/25, at 3:04 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, DON-B and Regional Registered Nurse (RN)-M of R2 not receiving scheduled showers on Wednesday and Saturday on a consistent basis. Surveyor shared staff have never given R2 a shower because the shower chair does not fit R2 and it would not be safe to provide a shower to R2. Surveyor was informed by staff that the facility does not have appropriate equipment to give residents showers including appropriate sized shower chairs and shower cots. No further information has been provided by the facility at this time as to why R2 did not receive scheduled showers on a consistent basis.

Based on interview and record review the facility did not ensure residents received assessment, treatment and care in accordance with professional standards of practice for 1 (R1) of 2 residents reviewed for a change in condition.*On 8/26/25 R1 received Oxycodone 5 mg during the night shift & rated his pain level at 8. This was the first time R1 received Oxycodone during the night shift & at this pain level. There was no assessment of what was causing R1's pain and other vitals. R1's physician ordered vital signs taken every day due to hypertension. The last vital sign documented in August is on 8/13/25. Interviews with CNA's revealed on 8/25/25 & 8/26/26 R1 was not feeling good, didn't look good and on the morning of 8/26/25 interviews revealed there was no urine in R1's urinary collection bag. R1 informed Surveyor he told the nurse his urine was loud and was informed this was due to his medication and he was going out for an appointment with the doctor. R1 was transferred from the doctor's office to the emergency room and admitted to the ICU (intensive care unit). R1's admitting diagnoses included Sepsis with acute renal failure and septic shock due to unspecified organism, unspecified acute renal failure.Findings include:According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider .(b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient .(e) Perform the following other acts when applicable:1. Assist with the collection of data.2. Assist with the development and revision of a nursing care plan.3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction.4. Participate with other health team members in meeting basic patient needs.The facility's policy titled, Acute Condition Changes - Clinical Protocol Med Pass Inc. (Revised March 2018) Updated 10/2019 under Assessment and Recognition documents 2. In addition, the nurse shall assess and document/report the following baseline information: a. vital signs; b. Neurological status; c. Current level of pain, and any recent changes in pain level; d. Level of consciousness; e. Cognitive and emotional status; f. Resident's age and sex; g. Onset, duration, severity; h. Recent labs; i. History of psychiatric disturbances, mental illness, depression etc.; j. All active diagnoses; and k. All current medications.3. Direct care staff, including nursing assistants will be trained in recognizing subtle, but significant changes in the resident (for example, a decreased in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse.*R1 was admitted to the facility on [DATE] with diagnoses which includes hypertension, radiculopathy (1 or more nerve roots in spinal column become compressed or irritated) lumbar region, lumbago with sciatica (lower back pain & pain that travels down the leg along the path of the sciatic nerve), benign prostatic hyperplasia (enlarged prostate, obstructive & reflux uropathy (urine flows backward from bladder into ureters), neuromuscular dysfunction of bladder, and anxiety disorder (group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). R1's admission MDS (minimum data set) with an assessment reference date of 7/2/25 has a BIMS (brief interview mental status) score of 15 which indicates R1 is cognitively intact. R1 is assessed as not having any behavior. R1 is assessed as requiring set up for eating, supervision/touching assistance for roll left and right, substantial/maximal assistance for chair/bed to chair transfer and toilet transfer. R1 is assessed as having an indwelling urinary catheter and is frequently incontinent of bowel.R1's urinary CAA (care area assessment) dated 7/8/25 under analysis of findings for nature of the problem condition documents Resident is noted with an indwelling foley - admit with. Under care plan considerations for describe impact of this problem/need on the resident and your rationale for care plan decision documents Resident was admitted with an indwelling foley and a care plan will be in place to reduce risk factors (at risk for falls, skin concerns, infections, decreased anxiety), and continue to monitor.R1's physician order includes an order dated 6/26/25 Oxycodone HCI Oral Tablet 5 mg (milligrams) (Oxycodone HCI) Give 1 tablet by mouth every 8 hours as needed for chronic pain.R1's physician orders include an order dated 6/26/25 Pain flow sheet **Document with each PRN (as needed) pain medication administration Characteristics 20= (equals) Aching, 21=Burning, 22=Crampy, 23=Numbness, 24=Pins/needles, 25=Sharp, 26=Stabbing, 27=Throbbing, 30=Other. Frequency- 40=Rarely, 41=Occasionally, 42=Frequently, 43=Almost constantly, 44=Unable to answer. Non-Med Intervention 0=Heat. 1=Cold, 2=Position, 3=Message, 4=Meditation, 5=Music, 6=Gentle ROM (range of motion), 7=TENS, 8=Support Group 10=Other. As needed **When addressing follow up address any side effects.Surveyor noted the facility was not following R1's physician order dated 6/26/25 related to the pain flow sheet to document with each PRN pain medication administration to document the characteristics, frequency, and non-med (medication) intervention. R1's August 2025 MAR is blank for this order. Surveyor reviewed R1's August MAR (medication administration record) and noted R1 receive PRN (as needed) Oxycodone 5 mg on 8/2/25 at 8:52 a.m. with pain level of 5, 8/3/25 at 8:02 a.m. with a pain level of 4, 8/4/25 at 7:56 a.m. with a pain level of 5, 8/7/25 at 8:47 a.m. with a pain level of 4, 8/8/25 at 8:30 a.m., with a pain level of 5, 8/9/25 at 5:49 p.m. with a pain level of 6, 8/10/25 at 8:48 p.m. with a pain level of 5, 8/11/25 at 8:40 a.m. with a pain level of 5, 8/18/25 at 8:59 a.m. with a pain level of 5, 8/19/25 at 9:28 a.m. with a pain level of 5, 8/22/25 at 8:17 a.m. with a pain level of 5, 8/25/25 at 9:03 a.m. with a pain level of 4, 8/26/25 at 12:03 a.m. with a pain level of 8, and 8/26/25 at 8:09 a.m. with a pain level of 4. Surveyor noted R1 received Oxycodone 5 mg only one time during the night shift & only had one recorded pain level of 8 which occurred at this time.On 11/12/25, at 12:29 p.m., Surveyor interviewed Registered Nurse (RN)-C on the telephone. Surveyor informed RN-C during the night shift prior to R1 going to a doctor's appointment and then emergency room, she administered Oxycodone 5mg. Surveyor informed RN-C this is the only time R1 received this prn (as needed) pain medication during the night shift and R1 rated his pain level at an eight. Surveyor asked RN-C if she assessed R1's pain. RN-C informed Surveyor she always asks where the pain is, and pain level stating want to say achy all over. Surveyor asked RN-C if she completed an assessment. RN-C informed Surveyor she checked R1's urine, body, asked where it hurt. Surveyor asked RN-C where Surveyor would be able to locate her assessment. RN-C informed Surveyor she asked where R1's pain was & he said all over, quickly glanced at urine and did a quick head to toe assessment. Surveyor informed RN-C Surveyor was unable to locate an assessment and asked RN-C if she documented an assessment. RN-C replied not that I recall. Surveyor asked RN-C if she should document her pain assessment. RN-C replied yes and explained she would do it in a note. Surveyor inquired what note. RN-C replied in nurses note.R1's physician orders include an order dated 7/2/25 Foley (urinary) Catheter: 16f (French) size, 10cc (cubic centimeter) balloon size r/t (related to) urinary retention.R1's physician orders include an order dated 7/25/25 Check VS (vital signs) daily for HTN (hypertension) monitoring one time a day related to essential (primary) hypertension.Surveyor reviewed R1's August 2025 TAR (treatment administration record) and noted vital signs are not recorded on the TAR. Surveyor noted on 8/5/25 5 is documented. According to the chart code 5 equals leave of absence. 8/9, 8/12, & 8/19 are blank and there are checks for the other days on the TAR indicating this was completed, without any indication as to what the vital signs are, until 8/27/25.On 11/11/25, at 9:13 a.m., Surveyor informed LPN-I R1's physician ordered daily vital signs for R1 and inquired where would Surveyor be able to locate the vital signs. LPN-I replied to you would find that in his chart. Surveyor asked LPN-I where in the charting. LPN-I replied to it would be in his TAR. Surveyor informed LPN-I Surveyor only noted checks and asked if the vital signs aren't on the TAR where would Surveyor be able to locate them. LPN-I informed Surveyor under the weight & vital sign section.Surveyor reviewed the weight/vital sign section of the electronic record and noted the last record vital signs for blood pressure, respirations, temperature, & pulse are dated 8/13/25.On 11/11/25, at 10:54 a.m., Surveyor asked Regional Registered Nurse (RN)-M if she could provide Surveyor with R1's vital signs from 7/25/25 to 8/26/25. Surveyor reviewed the vital sign information provided by Regional RN-M and noted R1's blood pressure was taken on 7/25/25, 7/28/25, 8/1/25, & 8/13/25. R1's oxygen saturations were obtained on 7/28/25, 8/1/25, & 8/13/25. R1's pulse was obtained on 7/25/25, 7/28/25, 8/1/25, & 8/13/25. R1's respiratory rate was obtained on 7/25/25, 7/28/25, 8/1/25, & 8/13/25. R1's temperature was obtained on 7/25/25, 7/28/25, 8/1/25, & 8/13/25.Surveyor noted the facility did not obtain R1's vital signs according to physician orders and did not have recorded vital signs 8/26/25 when R1 experienced a change in condition.R1's nurses note dated 8/22/25 at 13:38 (1:38 p.m.) written by LPN-K documents Resident stable, no c/o (complaint of) pain or discomfort, LOA (leave of absence) to Dr. (doctor) appointment via wheelchair van services.PTA (Physical Therapy Assistant)-J's physical therapy note dated 8/25/25 for response to treatment documents Response to Session Interventions: Patient tolerated therapy fair with decreased strength, balance, and activity tolerance noted.Review of R1's nutrition: amount eaten on 8/26/25 at 0800 (8:00 a.m.) breakfast was not completed & is blank. According to transportation log R1 was picked up at 9:19 a.m. for R1's appointment. Under task tab for CNA (Certified Nursing Assistant) documentation prior to R1 leaving for R1's appointment on 8/26/25 at 06:26 (6:26 a.m.) for GG Sit to Stand, Toilet Transfer, Roll Left and Right, Sit to Lying, Lower Body Dressing, & Chair/Bed-to-Chair Transfer are all assessed as not applicable. On 8/26/25 at 06:27 (6:27 a.m.) Upper Body Dressing and Toileting Hygiene are assessed as not applicable. Surveyor noted there is no assessments during the day shift for these ADLs (activities daily living) prior to R1 leaving for the appointment.R1's August MAR (medication administration record) for urinary output on 8/25/25 day shift documents 450 cc (cubic centimeters), evening shift 450 cc and night shift documents 450 cc. On 8/26/25 the urinary output for the day shift is blank.R1's next nurses nurse is dated 8/26/25 at 13:45 (1:45 p.m.) written by LPN-K documents This writer received call from [Name] Hospital ER (emergency room) Physician stating resident was diverted to ER department from Physician appointment off campus related COC (change of condition) in baseline cognition and response with noted drooling. Physician stated resident will be admitted for further evaluation.R1's WI - SBAR (Wisconsin - Situation, Background, Assessment, Request) dated 8/26/25 under section Situation for 1. The change in condition, symptoms, or signs I am calling about is/are documents change of condition at hospital appointment. 2. This started on documents 8/25/25. 3. Since this started it has gotten documents stayed the same. This SBAR was signed on 9/13/25.R1's Hospital Encounter Summary for ED (emergency department) notes dated 8/26/25 under physical examination for genitourinary documents for comments Foley catheter with scant output to bag. For abdominal: Palpations: Abdomen is soft. Tenderness: There is no guarding. Comments: Suprapubic tenderness and distention. Under medical decision making includes documentation of patient presented with near syncope secondary to hypotension suspected sepsis on arrival. Started on protocol with IV fluids. Patient with significant improvement in blood pressure with fluids but did require Levophed following completion. Considered multiple sources but most concerned about urinary source. Patient with significant urinary retention of presentation. Foley was replaced in the ED with large output. U/A (urinalysis) suggestive of infection. Patient had relief of abdominal pain following foley placement. CT with hydronephrosis and hydroureter which I suspect was due to earlier postrenal obstruction from clogged foley. Labs significant for leukocytosis with bandemia (immature neutrophils). Patient also with lactic acidosis & AKI (acute kidney injury). Started on empiric Zosyn for covered of UTI (urinary tract infection) as well as possible concurrent PNA (pneumonia). Patient with productive cough in the ED. Did required 2L (two liters) O2 (oxygen) via NC (nasal cannula). CXR (chest x-ray) with opacity in the left lower lobe. Patient initial drowsiness significantly improved in the ED with improvement in his blood pressure. Does not appear meningeal. Answering questions appropriately. No focal deficits on exam. Plan for admission to ICU (intensive care unit). Summary of ED sepsis-related care. Under admitting diagnoses documents Sepsis with acute renal failure and septic shock due to unspecified organism, unspecified acute renal failure.R1's hospital Discharge summary dated [DATE] under history of present illness documents Pt (patient) is a 69 y.o. (year old) gentleman with a PMH (past medical history) of COPD (chronic obstructive pulmonary disease), HTN (hypertension), unilateral nephrectomy and cervical myelopathy presented to the ED (emergency department) with change in condition. Patient initially seen early in the day at family medicine clinic from nursing home for pre-op clearance. He was scheduled for a C4-C5, C5-C6 Anterior Cervical Decompression with Fusion on 8/28. Patient reported feeling dizzy. He did not have urine output for unclear period of time. Patient has a chronic foley. Per ED report, once his catheter was replaced, there was immediate outflow of urine noted. He reports that for the past 2 days prior to admission, he was experiencing lower abdominal pain due to bladder distention.Discharge diagnoses documents #Sepsis 2/2 (secondary to) UTI (urinary tract infection) caused by obstruction- resolved. #Distributive shock 2/2 Sepsis- resolved. #AKI (acute kidney injury) 2/2/ urinary obstruction caused by clogged catheter- resolved. #Acute Hypoxic Respiratory Failure 2/2 pneumonia- resolved. #Cervical myelopathy. #Lumbar stenosis. #Chronic left foot drop.R1's nurses note dated 9/2/25, at 17:13 (5:13 p.m.) written by Nursing-T documents Resident readmitted to room [number] approx. (approximate) time via stretcher, Resident a/o x 4 (alert orientated times four), resident c/o (complained of) lower back pain, pain level 8/10 verbalized, resident sated it feels achy, prn (as needed) pain med (medication) given upon request, repositioned implemented ted no results noted with pain subsiding, foley cath (catheter) intact and patent with clear yellow urine, call light and fluids noted at reach.R1's nurses note dated 9/4/25, at 16:21 (4:21 p.m.) written by LPN-K documents Resident alert and orientated, adjusting well to readmission S/P (status post) Sepsis UTI and Sepsis Distributive shock, VSS (vital signs stable), indwelling foley cath remains patent without pain from urination with amber yellow output into cath bag, resident remains compliant with skilled and nursing services, resident resting in bed, call light in reach, will continue to monitor and follow POC (plan of care) as ordered.On 11/10/25, at 11:43 a.m., Surveyor asked Certified Nursing Assistant (CNA)-H if on R1 informed her he didn't feel good, stomach hurt or wanted to go to the hospital. CNA-H replied believe he wanted to go to the hospital. Surveyor asked why. CNA-H informed Surveyor thinks there was a concern with R1's foley. Surveyor asked CNA-H if she told the nurse R1 wanted to go to the hospital. CNA-H replied probably then informed Surveyor can't recall if R1 wanted to go to the hospital, sounds familiar, doesn't want to make a mistake.On 11/10/25, at 12:29 p.m., Surveyor if he could talk with Surveyor about 8/25/25 & 8/26/25 when he went to the doctor's office and was then transferred to the emergency room. R1informed Surveyor he repeatedly told somebody; it was [first name of LPN-K] the nurse. R1 informed Surveyor he told the CNA this is not like me, my stomach was hard, my urine smelled loud. The nurse [first name of LPN-K] said it was the pills, and he was going to see the doctor anyway. R1 explained that morning (morning R1 was going to the doctor's appointment) he was so weak, couldn't pick up a cup or nothing, could hardly eat his breakfast, one of the aides wheeled me to the front, [first name of CNA-F] she's here now. Surveyor asked R1 if he told staff he wasn't feeling good. R1 replied yes but they weren't doing anything. R1's lunch then arrived, and Surveyor left R1's room.On 11/10/25, at 12:35 p.m., Surveyor asked CNA-F if she remembers on 8/25/25 & 8/26/25, when R1 went out to a doctor's appointment and then went to the hospital. CNA-F informed Surveyor R1 didn't feel good and R1 was not looking good. Surveyor asked CNA-F what she meant by R1 not looking good. CNA-F replied you know how you can tell something is wrong, looked a little out of it, didn't seem right. CNA-F informed Surveyor when they got him up into the wheelchair, she told R1 you don't look good. R1 stated he didn't feel right. Surveyor asked CNA-F if she reported this. CNA-F replied yes, the nurse at the time. Surveyor asked CNA-F if the nurse was LPN-K. CNA-F replied yes, [the first name of LPN-K]. Surveyor asked if LPN-K did anything. CNA-F replied not that I can remember. CNA-F informed Surveyor LPN-K was in the room and they kind of talked about it, that R1 didn't look good. Surveyor asked CNA-F how R1 was transferred into the wheelchair. CNA-F informed Surveyor LPN-K helped transfer R1 into the wheelchair as R1 is a two assist with pivot. On 11/10/25, at 1:01 p.m., Surveyor telephone LPN-K and left a message requesting a return call.On 11/10/25, at 1:07 p.m., Surveyor asked CNA-G about 8/26/25, when R1 was going to the doctor's appointment and was then transferred to the hospital. CNA-G informed Surveyor R1 informed LPN-K he was not feeling good and LPN-K told R1 well you have a MD (medical doctor) appointment so you should feel better after that. CNA-G informed Surveyor R1 wasn't peeing, no urine in catheter bag. Surveyor asked if LPN-K knew there wasn't any urine in the catheter bag. CNA-G replied honestly don't know but he was there. Surveyor asked CNA-G how she knew there wasn't any urine in the catheter bag. CNA-G replied because I seen it. Surveyor asked CNA-G if R1 knew there wasn't any urine in his catheter bag. CNA-G informed Surveyor when she told him, R1 started freaking out stating this is why not feeling good. Surveyor asked CNA-G if the other CNA may have possibly emptied the catheter bag. CNA-G replied I don't know who I was working with, but I was there. On 11/10/25, at 1:13 p.m., Surveyor asked CNA-F if there was urine in R1's collection bag the morning R1 went to his doctor's appointment. CNA-F informed Surveyor she can't remember.On 11/10/25, at 1:57 p.m., Surveyor asked R1 who he told he didn't feel good on 8/25/25 & 8/26/25 prior to going to the doctor's appointment. R1 informed Surveyor he talked with the CNA, [CNA-F's first name]. Surveyor asked R1 if he remember what he told CNA-F. R1 replied I told her I feel funny, event told her to feel his stomach as it was hard, real hard. R1 stated kept telling them my urine smells loud. Surveyor asked R1 on 8/26/25 who helped with the transfer. R1 replied the first name of LPN-K, he told me to get up. Surveyor asked R1 if he told LPN-K he wasn't feeling good. R1 replied ya, I told [LPN-K's first name], he knew I wasn't feeling good. R1 informed Surveyor LPN-K told him you're in rehab your suppose to be able to get up, told him wasn't feeling good. R1 informed Surveyor he told LPN-K let me try to eat something. R1 stated he couldn't lift the coffee cup or fork up. Surveyor asked R1 if he told LPN-K. R1 replied no, he was right there looking. R1 told CNA-F. Surveyor asked R1 who wheeled him to the front for his appointment. R1 replied [CNA-F's first name]. Surveyor asked R1 if he knew if there was any urine in his collection bag. R1 informed Surveyor he didn't know. R1 informed Surveyor when he got to the doctors office, he told the staff he wasn't feeling good and asked if they could hurry up. R1 informed Surveyor the doctor came out about 10 minutes later, looked at me & catheter bag, and told them to take me to the ER. R1 informed Surveyor they took him to the ER, he was really weak, could hardly talk, they looked at foley bag and said it needed to be changed. They stuck an IV in my neck and started working on me, felt like I'm in bad shape, like I'm about to bust. R1 informed Surveyor he was kind of mad at LPN-K as he really didn't do anything, my stomach was hard and I wasn't feeling good. On 11/10/25, at 3:23 p.m., Surveyor asked CNA-E about R1 on 8/25/25. CNA-E informed Surveyor R1 said his stomach was hurting and not feeling right. CNA-E informed Surveyor she told the nurse more than one time, and she told the nurse they should go in and speak with R1. Surveyor asked who the nurse was. CNA-E informed Surveyor might have been [Name of LPN-K], the male nurse.On 11/11/25, at 7:02 a.m., Surveyor asked RN-C about R1. RN-C informed Surveyor R1 usually sleep through the night. Surveyor asked during the night of 8/25/25 did anyone say anything to her about R1. RN-C informed Surveyor she doesn't recall R1 or anyone saying anything about R1. Surveyor asked RN-C if there is anything during the night she must do for R1. RN-C replied just record output of catheter that's what we do for all catheters.On 11/11/25, at 10:02 a.m., Surveyor telephoned CNA-U, who worked the night shift on 8/25/25. Surveyor received a voice message request cannot be processed.On 11/11/25, at 10:08 a.m., Surveyor spoke with LPN-L on the telephone regarding R1 during the evening shift on 8/25/25. Surveyor asked LPN-L if there were any concerns brought to her attention on this date. LPN-L replied not that I'm aware of and explained she usually makes notes or updates 24-hour board. LPN-L informed Surveyor nothing stands out and she doesn't recall staff coming to her. LPN-L informed Surveyor she administered R1 his medication and he didn't say anything. On 11/11/25, at 10:44 a.m., Surveyor asked Registered Nurse (RN) Nurse Unit Manager-N if any concerns were brought to her attention on either 8/25/25 or 8/26/25. RN Nurse Unit Manager-N replied no, it was a surprise when he went to the ED (emergency department).On 11/11/25 at 12:17 p.m. Director of Nursing (DON)-B informed Surveyor they had a quarterly QAPI (quality assurance performance improvement) meeting, and they talk about rehospitalization for long term and short-term residents. DON-B informed Surveyor they have an increase in number of residents especially long-term residents being sent to the hospital and a resident who went to the doctor's office and was sent to hospital for change of condition. DON-B informed Surveyor she is having the managers assist in assessing residents prior to their appointment. On 11/11/25, at 3:05 p.m., during the end of the day meeting Nursing Home Administrator (NHA)-A, DON-B, and Regional RN-M were informed of the above. On 11/11/25, at 3:40 p.m., Surveyor spoke with Physician Office NP (Nurse Practitioner)-V regarding R1's physician visit on 8/26/25. Physician Office NP-V informed Surveyor when he saw R1 in the room his lungs were trashed, there were crackles & R1 had phlegm which R1 said was abnormal for him. Physician Office NP-V informed Surveyor trashed wasn't the correct word, there were rhonchi & rales but no wheezing in R1's lungs. Physician Office NP-V informed Surveyor R1 said in the morning he had some dizziness. Physician Office NP-V informed Surveyor he looked at R1's urinary collection bag and it was empty. He asked R1 if they drained the bag which R1 indicated they did not. Physician Office NP-V informed Surveyor the tubing was not kinked as far as he could see as he traced the tubing from the bag to R1's penis. Physician Office NP-V stated to Surveyor A. R1 was not providing urine or B. there something internally. Physician Office NP-V stated no matter what R1 was an ER visit. Physician Office NP-V informed Surveyor he made a phone call to the ER at 10:15 a.m. and R1 was admitted to the hospital with sepsis & acute kidney injury. Physician Office NP-V informed Surveyor it's a good thing R1 came in as sepsis doesn't go away.On 11/12/25, at 8:14 a.m., Surveyor telephone LPN-K for the second time and left message asking for a return call.On 11/12/25, at 8:57 a.m., Nursing Home Administrator (NHA)-A and DON-B met with Surveyor. DON-B informed Surveyor R1's family member saw R1 on 8/24 and didn't complain and there was no information given to the nurse. R1 was seen by therapy on 8/25/25 and he did therapy and was fine. DON-B informed Surveyor LPN-K assessed R1 for opioid side effects. R1 was picked up at 9:19 a.m. and prior to being picked up he had a conversation with the receptionist, which the receptionist is writing a statement. DON-B informed Surveyor R1 was seen by the wound NP with the wound nurse on 8/21/25 and they don't just look at the wound. DON-B was asking if there was any documented full assessment. Surveyor did not receive any assessment. DON-B informed Surveyor the day prior R1 ate 50% to 100% of meals which showed good appetite. DON-B informed Surveyor if something is going on with a resident the care givers can complete a stop and watch which the CNA's did not. DON-B indicated there are dynamics between the CNA & nurse. DON-B was asked after they received the call from the hospital ED was there any investigation. DON-B stated no one came to her until you guys showed up (referring to the survey team). DON-B indicated she spoke with R1's family there was nothing negative, did education on UTI and management team is going to check residents prior to their appointment for any issues. On 11/12/25, at 9:28 a.m., LPN-K telephoned Surveyor. Surveyor asked LPN-K about R1 on 8/25/25 & 8/26/25 and inquired if R1 told him he wasn't feeling good. LPN-K informed Surveyor R1 did not say anything. R1 asked if he could have a pain pill, and he took his vital signs. LPN-K informed Surveyor they don't have anywhere to record the vital signs as whoever did the order did the order incorrectly. Surveyor asked LPN-K if he mentioned there is no place to document the vital signs. LPN-K replied no explaining there are a number of residents with the same order. Surveyor asked LPN-K who helped transfer R1 into the wheelchair on 8/26/25. LPN-K informed Surveyor he did it himself with a slide board. Surveyor asked LPN-K before R1 left for the doctor's appointment did he check R1's urinary collection bag. LPN-K informed Surveyor he couldn't recall. Surveyor asked LPN-K if R1 complained of pain on 8/26/25. LPN-K informed Surveyor he complained of pain that morning. Surveyor asked LPN-K if he spoke to anyone. LPN-K informed Surveyor APNP (advance practice nurse prescriber)-P is at the facility, and he speaks to APNP-P about R1 and every resident on the unit every other day. Surveyor asked LPN-K who brought R1 to the front for transportation. LPN-K informed Surveyor he did.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R1) of 1 Residents.* Appropriate hand hygiene was not observed during incontinence cares for R1, R1's urinary collection bag was observed on the floor and Licensed Practical Nurse (LPN)-I was not wearing a gown while removing the urinary collection bag off the floor and removing R1's pants who is on EBP (enhanced barrier precautions).Findings include:The facility's policy titled, Hand Hygiene and dated 6/25 under Policy documents All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Under Policy Explanation and Compliance Guidelines documents 1. Staff will perform hand hygiene when indicated, using proper technique consistent with acceptable standards of practice.The facility's policy titled, Enhanced Barrier Precautions and dated 9/25 under Policy documents It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Under Policy Explanation and Compliance Guidelines documents 2. Initiated of Enhanced Barrier Precautions documents b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC (peripherally inserted central catheter) lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO (multi drug resistant organism). (Peripheral IV's (intravenous), continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP). 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE (personal protective equipment) for enhanced barrier precaution is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: a. Dressing. b. Bathing. c. Transferring. d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters. h. Wound care: any skin opening requiring a dressing.CDC (Centers for Disease Control and Prevention) Summary of Recommendations, Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) under section III. Proper Techniques for Urinary Catheter Maintenance includes documentation of Keep the collection bag below the level of the bladder at all times. Do not rest the bag on the floor.R1's diagnoses includes hypertension, radiculopathy (1 or more nerve roots in spinal column become compressed or irritated) lumbar region, bilateral primary osteoarthritis of knee benign prostatic hyperplasia (enlarged prostate, obstructive & reflux uropathy (urine flows backward from bladder into ureters) and anxiety disorder (group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). R1's quarterly MDS (minimum data set) with an assessment reference date of 9/8/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R1 is assessed as requiring substantial/maximal assistance for toileting hygiene and partial/moderate assistance for roll left and right. R1 is assessed as having an indwelling urinary catheter and is always incontinent of bowel.R1's physician orders include an order dated 10/9/25 which documents Isolation: Enhanced Barrier Precautions; Resident is currently on Enhanced Barrier Precautions, follow isolation guidelines.R1's requires enhanced barrier precautions care plan initiated 10/9/25 includes an intervention of Gown and gloves to be worn by staff during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Includes: dressing, bathing/showering, transferring, provide hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. Initiated 10/9/25.On 11/10/25, at 8:49 a.m., Surveyor observed a plaque/sign on R1's door indicating enhanced barrier precautions.On 11/10/25, at 1:52 p.m., Surveyor observed Licensed Practical Nurse (LPN)-I in R1's room. Surveyor observed LPN-I did not have the appropriate PPE (personal protective equipment) on for R1 who is on enhanced barrier precautions. LPN-I was only wearing gloves and did not have a gown on. LPN-I informed Surveyor R1 likes to be nude and stated urinary bag is under, showing Surveyor R1's collection bag is under the portion of R1's bed frame which stabilizes the bed. Surveyor observed R1's urinary collection bag is laying directly on the floor and the round stabilizing section is on top of a portion of R1's urinary collection bag. Surveyor observed LPN-I raised the height of the bed, but the stabilizing portion continued to be on top of R1's urinary collection bag & did not raise up. LPN-I was able to pick up R1's bed slight to remove the collection bag from under this round stabilizing section. LPN-I placed the urinary collection bag in the blue privacy bag, placed the bag through the right leg of R1's pants, removed R1's pants and attached the urinary collection bag to the right side of R1's bed frame. LPN-I asked R1's about the incontinence product which R1 informed LPN-I to leave it open. LPN-I covered R1 with a sheet and placed the over bed near R1's bed. LPN-I then removed her gloves and left R1's room. Surveyor observed LPN-I did not perform any hand hygiene prior to leaving R1's room. On 11/11/25, at 9:27 a.m., CNA-F informed Surveyor CNA-G is with another resident but she's going to get started. CNA-F placed gown & gloves on and entered R1's room. CNA-F informed R1 she was going to change him, and CNA-G is going to meet them. CNA-F filled a washbasin and placed the washbasin & towels on the overbed table and a clear garbage bag on the floor. R1 washed his own face, CNA-F placed Dove body soap on a washcloth and R1 washed under his neck and under his underarms. CNA-F rewashed under R1's neck & underarms and then handed R1 deodorant. While R1 was putting on deodorant, CNA-F went in the bathroom and blew her nose. CNA-F did not remove her gloves and perform hand hygiene after blowing her nose. CNA-F lowered the head of the bed, removed bedding and washed R1's inner thighs. At 9:41 a.m. CNA-G entered R1's room with the appropriate PPE and CNA-F washed the tubing of the catheter and R1's frontal perineal area. CNA-G positioned R1 on the side, CNA-F wiped R1's rectal area with the incontinence product, folded the draw blanket under R1 and washed R1's rectal area & buttock. Surveyor observed there is stool on the washcloth. CNA-F did not remove her gloves and perform hand hygiene. CNA-F applied remedy cream on R1's buttocks, a draw blanket and incontinence product were placed under R1 and R1 was positioned onto his back. R1's urinary collection bag was attached to the right side of the bed frame and R1 was positioned on the right side to remove the soiled product & draw sheet and straightened out the draw blanket & incontinence product. CNA-F sprayed cologne on R1 per his request, R1 was covered with bedding, and the bed was lowered. CNA-F & CNA-G removed their PPE, removed the soiled linen & garbage from R1's room and washed their hands.On 11/11/25, at 11:18 a.m., Surveyor asked Assistant Director of Nursing (ADON)-D, who is the facility's infection preventionist, when a resident is on enhanced barrier precaution what is the expectation for staff. ADON-D informed Surveyor when staff are doing any cares with direct contact outside sitting a meal tray on the table, they should wear a gown & gloves. Surveyor asked if the urinary collection bag should be on the floor. ADON-D replied no. Surveyor informed ADON-D of the observation of LPN-F not wearing the appropriate PPE with R1 and R1's urinary collection bag lying directly on the floor.On 11/11/25, at 3:00 p.m. Surveyor asked ADON-D what the expectation regarding hand hygiene is. ADON-D explained with all her training and years of work the expectation is if change gloves wash hands in between. Change gloves when visibly soiled or if providing peri care. Surveyor asked during cares after cleaning a resident who had a bowel movement should they remove their gloves & perform hand hygiene before doing the next task. ADON-D replied yes and explained dealing with an area with fecal matter. Surveyor informed ADON-D of hand hygiene concerns observed.On 11/11/25, at 3:05 p.m., during the end of the day meeting Nursing Home Administrator (NHA)-A, DON-B, and Regional RN-M were informed of the above.

Based on observation and interviews, the facility did not ensure each Resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 4 (R65, R68, R173, and R174) of 10 Residents reviewed for dignity. *R65 was observed to be in a gown during 3 days of the survey process and prefers to be dressed. *R68 was observed to be in the hallway by the nurse's station in a gown during the survey process. *R173 was observed to be in the dining room eating lunch in a gown. *R174 was observed walking down the hallway with therapy in a gown. Findings Include: The facility's Accommodation of Needs policy implemented 2/25 documents: .The facility will treat each Resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a Resident, except when the health and safety of the individual or other Residents would be endangered. Policy Explanation and Compliance Guidelines: 3. Facility staff shall make efforts to reasonably accommodate the needs and preferences of the Resident as they make sue of their physical environment. 4. Based on individual needs and preferences, the facility will assist the Resident in maintaining and/or achieving independent functioning, dignity, and well being to the extent possible. 1.) R65 was admitted to the facility on [DATE] and is their own decision maker. R65's admission Minimum Data Set (MDS) completed 4/16/25 documents R65's Brief Interview for Mental Status(BIMS) score to be 12, indicating R65 demonstrates moderately impaired skills for daily decision making. R65's MDS documents R65 has no mood or behavior symptoms. R65 has range of motion(ROM) impairment on 1 side of both upper and lower extremity, R65 requires substantial/maximum assistance for showers, upper and lower dressing and transfers. R65's MDS documents that it is somewhat important for R65 to choose clothes to wear. On 5/19/25, at 9:59 AM, R65 is observed wearing a gown. R65 informed Surveyor that R65 does not think R65 has any clothes in the closet. On 5/19/25, at 1:21 PM, R65 is still in a gown. On 5/19/25, at 3:37 PM, R65 is sitting in R65's wheelchair in a gown. On 5/20/25, at 10:26 AM, R65 is in bed, with a gown on. On 5/21/25, at 11:42 AM, Surveyor observed R65 sitting in R65's wheelchair with a gown on. Surveyor interviewed R65 who stated that at home R65 always got dressed. R65 stated R65 wants to be in clothes, and prefers to be in clothes. R65 stated that R65 has been telling facility staff since R65 got here that R65 wants to be dressed. Surveyor notes R65 engages in conversation, but appears with a flat affect, disheveled hair, with full growth beard. On 5/22/25, at 10:06 AM, Surveyor observed R65 wearing a black sweatshirt and blue pants. R65 started singing to Surveyor and expressed how happy R65 was to be wearing clothes and was excited. Surveyor also observed R65 had a significant haircut and received a shave. R65 stated R65's son came in and brought clothes, gave a haircut and a shave. Surveyor observed R65 had a big smile when talking about being dressed and gave Surveyor a high five in thanks for obtaining clothes. 2.) R68 was admitted to the facility on [DATE] and is their own decision maker. R68's admission Minimum Data Set (MDS) completed 5/3/25 documents R68's Brief Interview for Mental Status(BIMS) score to be 12 indicating R68 demonstrates moderately impaired skills for daily decision making. There are no documented mood or behavior symptoms for R68. R68 requires partial/moderate assistance for showers, supervision for upper dressing, substantial/maximum assistance for lower dressing and mobility and is dependent for transfers. R68 stated it is very important to choose what clothes to wear. On 5/21/25, at 11:50 AM, Surveyor observed R68 sitting at the nurse's station in just a gown. On 5/21/25, at 1:07 PM, Surveyor interviewed R68 who stated R68 would prefer to be dressed and is usually cold in the gown. On 5/22/25, at 10:14 AM, Surveyor observed R68 in bed with clothes on. 3.) R173 was admitted to the facility on [DATE]. R173's admission Minimum Data Set (MDS) completed 5/6/25 documents R173's Brief Interview for Mental Status(BIMS) score to be 3 indicating R173 demonstrates severely impaired skills for daily decision making. There are no documented mood or behavior symptoms for R173. R173 has range of motion (ROM) impairment on both upper and lower extremities on both sides. R173 requires partial/moderate assistance for upper and lower dressing, and substantial/maximum assistance for mobility and transfers. R173 stated it is somewhat important to choose what clothes to wear. On 5/21/25, at 11:50 AM, Surveyor observed R173 in a gown with red gripper socks in a wheelchair located in the hallway by the nurse's station. Surveyor observed Certified Nursing Assistant (CNA)-I take R173 to the main dining room. On 5/21/25, at 12:34 PM, Surveyor observed R173 in the dining room with a gown on. On 5/21/25, at 12:43 PM, CNA-I confirmed to Surveyor that R173 was in the main dining room eating lunch and CNA-I brought R173 back by the nurse's station and placed in the hallway with just a gown on. On 5/22/25, at 10:21 AM, Surveyor observed R173 in bed sleeping and has clothes on. 4.) R174 was admitted to the facility on [DATE]. R174's admission Minimum Data Set (MDS) completed 5/16/25 documents R174's Brief Interview for Mental Status (BIMS) score to be 11 indicating R174 demonstrates moderately impaired skills for daily decision making. There are no documented mood or behavior symptoms for R174. R174 requires substantial/maximum assistance for upper and lower dressing, showers, and partial/moderate assistance for mobility and transfers. R174 stated it is very important to choose what clothes to wear. On 5/21/25, at 11:50 AM, Surveyor observed R174 walking down the hallway with the assistance of therapy wearing a gown and black shoes. R174 had a gait belt around R174's waist. On 5/21/25, at 12:35 PM, Surveyor interviewed R174, who is wearing a gown, and R174 stated R174 prefers to be dressed. That's why I am always cold and why I like my room really warm. On 5/22/25, at 10:17 AM, Surveyor observed R174 in bed with a gown. R174 informed Surveyor that R174 prefers to wear a gown only at night. On 5/21/25, at 12:32 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who stated that several Residents come in with no clothes, if they have clothes, we will put them on, otherwise we put gowns on. On 5/21/25, at 12:41 PM, Surveyor interviewed Social Worker (SW)-F regarding clothes for Residents. SW-F confirmed there are donated clothes down in laundry. SW-F informed Surveyor that sometimes staff will go down to laundry themselves and obtain clothes for Residents. If staff were to inform SW-F a Resident needs clothes, SW-F would call the family and have them bring in clothing items. On 5/21/25, at 3:03 PM, Surveyor shared the dignity concern that R65, R68, R173, and R175 have been in gowns during the survey process and at times Surveyor has observed R68, R173, and R174 in common areas of the facility with gowns on with Nursing Home Administrator (NHA)-A, Director of Nursing (DON-B), and Director of Quality Compliance (DQC)-C. The facility provided no further information at this time. On 5/22/25, at 9:58 AM, Surveyor interviewed Physical Therapist (PT)-J. PT-J stated that occupational therapy is limited in working on dressing with a Resident if a Resident has no clothes as well as therapy would be limited in working with a Resident on walking if a Resident has no shoes. PT-J stated they would need to double gown a Resident if the Resident has no clothes. On 5/22/25, at 10:18 AM, Surveyor interviewed Maintenance Director (MD)-N who confirmed MD-N is the supervisor of laundry. MD-N explained MD-N prefers staff approach a laundry staff member for donated clothing items which MD-N stated the facility has. MD-N stated there are different sized clothing items and a variety for both men and woman. MD-N stated if laundry staff notice a closet is empty, they will bring up donated clothing items. MD-N stated usually the social worker or admissions will let the laundry department know if a Resident needs donated clothing items. Surveyor notes that R65, R68, and R173 were dressed on 5/22/25, the last day of the survey process.

Based on interview and record review, the facility did not ensure 4 Residents (R172, R23, R13 and R65) of 18 sampled residents were fully informed of, but not limited to; resident rights, required financial information and options, and consent to treat prior to or upon admission. *R172 was admitted to the facility on [DATE] and did not sign the admission agreement within a reasonable timeframe which includes facility information regarding: consent for treatment, financial agreement, and resident rights and responsibilities. R172 was discharged from the facility on 3/28/25, and did not acknowledge receipt of the admission agreement before discharge from the facility. On 3/22/25 R172 alleged $1800 was missing from the resident. Review of whether R172 was aware of the facility options/restrictions available to safeguard R172's belongings was reviewed. R172 was never provided or disclosed this information, to be included in the facility admission policy, as the admission agreement was not presented or signed By R172 during their admission time in the facility. *R13 was admitted to the facility on [DATE] and and did not sign the admission agreement within a reasonable timeframe which includes facility information regarding: consent for treatment, financial agreement, and resident rights and responsibilities. R13 was discharged from the facility on 4/1/25, and did not acknowledge receipt of the admission agreement before discharge from the facility. R13 was admitted to the facility a second time on 4/30/25. R13 did not acknowledge receipt of the admission agreement until 5/16/25. *R23 was admitted to the facility on [DATE] and did not sign the admission agreement within a reasonable timeframe which includes facility information regarding: consent for treatment, financial agreement, and resident rights and responsibilities. R23 did not acknowledge receipt of the admission agreement until 3/26/25. *R65 was admitted to the facility on [DATE] and did not sign the admission agreement within a reasonable timeframe which includes facility information regarding: consent for treatment, financial agreement, and resident rights and responsibilities. R65 was discharged from the facility on 3/14/25, and did not acknowledge receipt of the admission agreement before discharge from the facility. R65 was admitted to the facility a second time on 4/9/25. R65 did not acknowledge receipt of the admission agreement until 4/29/25. Findings Include: The facility's admission policy implemented 1/25 documents: .The facility will maintain an admissions policy governing admissions to the facility to ensure fair and impartial admission practices. 5.A nursing facility must disclose and provide a Resident or potential Resident, prior to time of admission, notice of special characteristics or service limitations of the facility that guides its practices and routines which must be communicated to any potential Resident. The facility's admission of a Resident implemented 1/25 documents: .The admission process is intended to obtain all possible information regarding the Resident for the development of the comprehensive plan of care, and to assist the Resident in becoming comfortable in the facility. Policy Explanation and Compliance Guidelines: The admission process has several phases: a. The facility designated staff member(S) may meet with prospective Residents/families while they are first touring the facility. Information about facility services should be provided. B. Once the Resident/family has selected the facility, pre-admission information should be gathered. ac. A Resident Handbook and/or Facility orientation material should be provided to the Resident/family prior to or upon admission, so they understand what to bring to the facility. On 5/21/25, at 12:26 PM, Surveyor interviewed Admissions staff (Admit)-G regarding the process of reviewing the admission agreement with Residents. Admit-G stated that Admit-G attempts to review the admissions agreement with Residents as soon as Admit-G can. Admit-G stated reviewing the admission agreement is usually completed the next day, the 2nd day after a Resident admits to the facility. Admit-G is not aware of a specific time-line to review the admissions agreement. Admit-G stated the admission process with a Resident includes, but not limited to: financial information, resident rights and rules, services provided, permission for photograph. Admit-G is aware that Admit-G has not always reviewed the information included in the admission process in a timely manner with Residents. 1.) R172 was admitted to the facility on [DATE]. R172 was her own person while at the facility. R172 discharged from the facility on 3/28/25. R172's admission Minimum Data Set (MD'S) completed 3/19/25 documents 172's Brief Interview for Mental Status (BIMS) score to be 15 indicating R 172 was cognitively intact for daily decision making. R172 admitted to the facility on [DATE]. R172 discharged to the hospital on 3/28/25 and did not return to the facility. On 3/31/25, the facility documents that the facility's admission agreement was not completed due to R172 being discharged to the hospital. The facility initiated an investigation on 3/22/25, due to R172's allegation that R172 was missing $1,800.00. Surveyor notes there is no documentation that the facility reviewed how the facility could facilitate safeguarding R172's personal possessions including the possible loss or theft of the $1,800.00 as the admission agreement was not signed. 2.) R13 was admitted to the facility on [DATE]. R13 is currently her own person. R13's admission Minimum Data Set (MDS) completed 5/6/25 documents R13's Brief Interview for Mental Status(BIMS) score to be 8, indicating R13 demonstrates moderately impaired skills for daily decision making. R13's first admission to the facility was on 3/10/25. R13 discharged from the facility on 4/1/25. The facility did not review the admission agreement including but not limited to: consent for treatment, financial agreement, and resident rights and responsibilities. R13's second admission to the facility was on 4/30/25. Documentation provided by the facility states that R13 did not acknowledge review and receipt of the admission agreement until 5/16/25. 3.) R23 was admitted to the facility on [DATE]. R23 is her own person. R23's admission Minimum Data Set (MDS) completed 3/17/25 documents R23's Brief Interview for Mental Status(BIMS) score to be 15, indicating R23 is cognitively intact for daily decision making. R23 was admitted to the facility on [DATE] and did not acknowledge review and receipt of the admission agreement until 3/26/25. 4.) R65 was admitted to the facility on [DATE]. R65 is currently is his own person. R65's admission Minimum Data Set (MDS) completed 4/16/25 documents R65's Brief Interview for Mental Status(BIMS) score to be 12, indicating R65 demonstrates moderately impaired skills for daily decision making. R65 was admitted to the facility on [DATE] and the facility documents R65 did not review the admission agreement due to being discharged on 3/14/25. R65 was admitted to the facility a second time on 4/9/25. R65 did not acknowledge the review and receipt of the admission agreement until 4/29/25. On 5/21/25, at 3:03 PM, Surveyor shared the admission concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Director of Quality Compliance (DQC)-C that R172, R13, R23, and R65 did not review or receive the admission agreement explaining areas to include: resident rights and responsibilities, financial agreement, services provided, while a Resident in the facility or up to 7-20 days after admission to the facility. Surveyor shared that neither R172, R13, R23, and R65 received the required financial information and options, the abuse policy and procedure and resident rights. The Residents either never gave consent to treat until after a considerable amount of time after admission to the facility. The Residents would not have been provided the disclosure of facility characteristics within a timely manner. On 5/28/25, at 1:09 PM, Surveyor reviewed additional information provided by the facility. The concern remains that the either the Residents never gave consent for treatment, resident rights including being free from abuse or neglect, how to contact the ombudsman and/or state agency, financial information and options or was not obtained until at a minimum of 7 days later.

2.) R13 was originally admitted to the facility on [DATE] and was readmitted again on 4/30/25. R13's original admission to the facility was on 3/10/25. Review of R13's baseline care plan indicates Registered Nurse (RN)-D signed R13's first baseline care plan on 3/26/25. Surveyor noted R13's baseline care plan has no documentation that R13 reviewed R13's plan of care. There is no documentation that R13 was provided a copy of the baseline care plan. R13 had a care plan meeting on 3/18/25 and there is no documentation that R13's plan of care was reviewed with R13. R13's 2nd admission was on 4/30/25. Licensed Practical Nurse (LPN)-O signed R13's baseline care plan on 5/7/25. There is no documentation that R13 was provided a copy of this baseline care plan. R13 had a care plan meeting on 5/8/25 and there is no documentation that R13's plan of care was reviewed with R13. 2.) R23 was admitted to the facility on [DATE]. R23 is her own person. On 5/19/25, at 9:07 AM, R23 informed Surveyor that R23 has not received anything like a plan of care, they never have, and they have been admitted to the facility several times. Review of R23's admissions indicates Registered Nurse (RN)-D signed R23's baseline care plan on 3/12/25. Surveyor notes that R23's baseline care plan has no documentation that R23 reviewed R23's plan of care. There is no documentation that R23 was provided a copy of the baseline care plan. R23 had a care plan meeting on 3/17/25 and there is no documentation that R23's plan of care was reviewed with R23. 3.) R65 was admitted to the facility on [DATE]. R65 is currently is his own person. On 5/19/25, at 10:04 AM, R65 informed Surveyor that R65 does not recall receiving a plan of care, I don't have any papers in my room. R65 was admitted to the facility on [DATE] and a baseline care plan was not completed. R65 went out to the hospital on 4/16/25 and was re-admitted to the facility on [DATE]. Registered Nurse (RN)-D signed R65's baseline care plan on 2/19/25, which was R65's first admission. Surveyor notes that R65's baseline care plan has no documentation that R65 reviewed R65's plan of care. There is no documentation that R65 was provided a copy of the baseline care plan. R65 has had no care plan meeting to review the plan of care. 4.) R172 was admitted to the facility on [DATE]. R172 discharged from the facility on 3/28/25. Review of R172's baseline care plans indicates Registered Nurse (RN)-D signed R172's baseline care plan on 3/26/25. Surveyor notes that R172's baseline care plan has no documentation that R172 reviewed R172's plan of care. There is no documentation that R172 was provided a copy of the baseline care plan. R172 had a care plan meeting on 3/27/25, however, there is no documentation that R172's plan of care was reviewed. On 5/21/25, at 3:03 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Director of Quality Compliance (DQC)-C that R13, R23, R65, and R172 did not have baseline care plans completed and there is no documentation the plan of care was reviewed with R13, R23, R65, and R172 with 48 hours No further information has been provided by the facility at this time. Based on interview and record review, the facility did not ensure a baseline care plan was developed and implemented within 48 hours of a resident's admission for 5 (R13, R23, R65, R173, R322) of 18 Residents. *R13, R23, R65, and R173's baseline care plans were not completed within the required 48-hour timeframe. The facility did not provide evidence that the baseline care plan was reviewed with the resident or the resident's representative. *R322 was admitted to the facility on [DATE]. R322's baseline care plan was signed by facility staff as being complete on 12/24/24, which is not within the required 48-hour timeframe. R322's baseline care plan was not signed by R322. Findings include: The facility policy dated 8/24, titled Baseline Care Plan, documents, in part: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care . The baseline care plan will: Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident . A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. B. A summary of the resident's medications and dietary instructions. C. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. A supervising nurse or [Minimum Data Set (MDS)] nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative. This will be provided by completion of the comprehensive care plan . 1.) R322 was admitted to the facility on [DATE] with diagnosis that include Congestive heart failure, Type 2 Diabetes, and End stage renal disease. R322's admission Minimum Data Set (MDS) assessment dated [DATE] documents R322's cognition is moderately impaired. R322 is responsible for self. R322's Baseline care plan dated 12/19/24 was completed by Unit Manager Registered Nurse (RN)-D. Surveyor noted that the base line care plan was signed as complete on 12/24/24 by RN-D, which is not within the 48-hour timeframe. Surveyor noted that the baseline care plan was not signed by R322. On 5/20/25 at 9:10 AM, Surveyor interviewed R322's Spouse-E. Spouse-E informed Surveyor that R322 is unavailable for interview. Spouse-E stated that R322 was not provided with a copy of R322's baseline care plan. Surveyor noted in R322's Electronic Medical Record (EMR) at the facility, Spouse-E is listed as R322's spouse and is listed as Emergency contact #1. Surveyor reviewed R322's electronic medical record and did not find evidence that the baseline care plan summary was signed by R322 or provided to R322. On 5/21/25 at 10:19, Surveyor interviewed Unit Manager, RN-D. Surveyor asked who is tasked with completing the baseline care plan. RN-D stated that RN-D or another nurse manager is responsible for completing the baseline care plan. RN-D stated that RN-D will open the baseline care plan assessment within 24 hours of admission and get it started. RN-D stated that RN-D leaves it open for therapy to do their evaluation. Surveyor asked if the baseline care plan is signed and reviewed by the resident. RN-D stated that the base line care plan is reviewed and signed with the resident or resident representative at the first care conference which is usually in the first week. RN-D stated that R322's baseline care plan was started on the day R322 was admitted to the facility. On 5/21/25 at 10:39 AM, Surveyor interviewed Director of Nursing (DON)-B about baseline care plans. Surveyor asked who is responsible for completing the baseline care plan. DON-B stated that a nursing manager will complete the baseline care plan. RN-D does the bulk of the baselines care plans, but it is a team effort. Surveyor asked what the expectation is for completing the baseline care plan. DON-B stated that it should be started on admission. DON-B stated that DON-B is not sure of the policy but knows it is started on admission. DON-B stated that DON-B would get back to surveyor. DON-B did not provide further information about baseline care plans. On 5/21/25 at 1:00 PM, Surveyor interviewed Social Worker (SW)-F about baseline care plans. SW-F stated that nursing is responsible for starting the baseline care plan. SW-F is given the baseline care plan by nursing staff. SW-F stated that the baseline care plan is then reviewed with the resident at the first care conference, which is typically within the first week. Surveyor asked if the baseline care plan is reviewed with the resident prior to that. SW-F stated that it is not reviewed prior to that. On 5/22/25 at 12:09 PM Surveyor asked SW-F what is given to the resident at the first care conference. SW-F stated that baseline care plan and medication list is given to the resident or resident representative at that time. Surveyor asked where that is documented. SW-F stated that it should be in the care conference note, but SW-F sometimes forgets. Surveyor asked if the resident or resident representative signs anything at the care conference. SW-F stated that in the past, they don't typically sign anything but that will be changing. SW-F stated that SW-F just found out that the resident or representative needs to sign the baseline care plan. After signing the baseline care plan, it will be scanned into the EMR. SW-F stated that the new process will begin now. On 5/21/25 at 3:16 PM, Surveyor informed Nursing Home Administrator (NHA)-A, and DON-B of the concern that R322 was admitted on [DATE]. R322's baseline care plan was not signed by facility staff as completed until 12/24/24. There is no evidence that R322 was provided a written summary of R322's baseline care plan and no evidence that R322 signed R322's baseline care plan.

Based on record review and interview, the facility did not ensure a resident receiving an antidepressant medication was comprehensively assessed for use. This was observed with 1 (R40) of 5 resident medication reviews. * R40 was admitted to the facility on an antidepressant medication. There is not a comprehensive assessment for use of the medication, including indicators for use and non-pharmacological interventions. Findings include: The facility's policy and procedure titled Use of Psychotropic Medication dated 2/25. The definition for adequate indications for use states: refers to the identified, documented clinical rationale for administering medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. R40 was admitted to the facility on [DATE] with a diagnoses including Depression and Stroke. The Hospital Discharge summary, dated [DATE], includes orders for Prozac 20 milligram (mg), 3 capsules daily. The facility physician admission orders documents Prozac 20 mg, 3 capsules every day for Depression. The 3/4/25 admission Minimum Data Set (MDS) assessment documents daily use of an antidepressant medication. The Care Area Assessment (CAA) for Psychotropic Drug Use, completed by MDS Registered Nurse (RN) -C on 3/10/25, documents Prozac (antidepressant) for depression. This CAA does not include symptoms of depression R40 experiences, along with non-pharmacological interventions. A Significant Change in Status MDS assessment completed on 4/22/25 documents daily use of an antidepressant medication. The Care Area Assessment (CAA) for Psychotropic Drug Use, completed by MDS RN -C on 4/30/25, documents Prozac (antidepressant) for depression. This CAA does not include symptoms of depression R40 experiences, along with non-pharmacological interventions. R40's plans of care were reviewed. R40 has a care plan, initiated on 2/26/25, titled The resident uses antidepressant medication Prozac. There is NOT documentation of indicators for use of the antidepressant. The interventions listed indicates the side effects of the medication to be monitored. R40's medical record contained Behavior Management/ Medication Review forms dated 2/27/25, 3/28/25 and 4/25/25. These forms document R40 is on Prozac 60 milligrams (mg) every day for Depression. There are no indicators for use. There is no documentation to support the use of the antidepressant. There is no documentation of non-pharmacological interventions or depression symptoms specific to R40's use of the antidepressant. On 5/21/25, at 1:30 PM, Surveyor interviewed Unit Manager (UM) -D. UM-D stated They will look for indicators for use of the antidepressant medication. UM-D did not have any additional information. UM-D did not complete a comprehensive assessment on R40's antidepressant use. On 5/21/25, at 2:02 PM, Surveyor interviewed Social Worker (SW) -F. SW-F stated They just look at the medication itself and do not ask about symptoms for use. SW-F does not complete a comprehensive assessment for psychotropic medication for R40. On 5/21/25, at 3:03 PM, at the facility exit meeting with Nursing Home Administrator (NHA)-A and Director of Nurses (DON) -B, Surveyor shared the concerns with R40's antidepressant medication. There is no a comprehensive assessment for use, including care plan, non-pharmacological interventions and specific symptoms for treatment. Following exit from the survey, the facility provided additional documentation to review for R40 indicating R40 refused to meet with the facility behavioral/psychological services provider and two medication reviewed had been completed. Review of the medication reviews dated 2/27/25 and 3/27/25 do not include documentation of behaviors and their frequency to support monitoring of R40 for indicators for use of the medication. They also do not include any non pharmacological interventions for the resident when depressed other than to self direct activities at their own leisure. On 4/30/25 R40 declined formal psychological services, there is no indication the facility established a plan of care to address and monitor indications for use and interventions related to R40's receipt of antidepressants.

Based on record review and interview, the facility did not conduct a comprehensive assessment of depression/mood with the admission Minimum Data Set (MDS), and Significant Change in Status (SCS) MDS, for 1 (R40's) of 18 sampled residents. * R40 was admitted to the facility with orders to receive Prozac (an antidepressant) daily. R40's admission MDS dated [DATE] and SCS MDS dated [DATE] do not fully assess R40's depression/mood symptoms to lead to a Care Area Assessment (CAA) and development of a comprehensive plan of care for R40 that addresses indicators for use, individual symptoms for R40 and intervention to include nonpharmacological interventions (Cross-reference F605). Findings include: R40 was admitted to the facility on [DATE] with diagnoses including Depression and Stroke. The Hospital Discharge summary, dated [DATE], includes orders for Prozac 20 milligram (mg), 3 capsules daily. The facility physician admission orders document Prozac 20 mg, 3 capsules every day for Depression. R40's admission Minimum Data Set (MDS) assessment was completed on 3/4/25. This assessment documents daily use of an antidepressant medication. The assessment for mood indicates 0 for the presence of and frequency of experiencing little interest or pleasure ion things or feeling down, depressed and hopeless. Additional assessment of depression/mood including questions C-I are not assessed giving an inaccurate severity score/an incomplete assessment. The Care Area Assessment (CAA) for Psychotropic Drug Use, completed by MDS Registered Nurse (RN)- C on 3/10/25, documents Prozac (antidepressant) for depression. This CAA does not include symptoms of depression R40 experiences, along with non-pharmacological interventions. R40's Significant Change in Status MDS assessment was completed on 4/22/25. This assessment documents daily use of an antidepressant medication. The assessment for presence of and frequency of experiencing little pleasure are assessed as 0. The assessment for feeling down, depressed, or hopeless to include the presence of and frequency are assessed as 1's. This indicates presence of these symptoms 2-6 days of the assessment period. Additional questions C-I to assess the presence and frequency of additional symptoms of depression/mood are not assessed on the MDS. This gives an inaccurate severity score of 01. The Care Area Assessment (CAA) for Psychotropic Drug Use, completed by MDS RN-C on 4/30/25, documents Prozac (antidepressant) for depression. This CAA does not include symptoms of depression R40 experiences, along with non-pharmacological interventions. On 5/21/25, at 1:40 PM, Surveyor interviewed MDS RN-C. MDS RN-C stated they just code the medication and the medication goes to the behavior management team. They just monitor symptoms on the Medication Administration Record (MAR) and does not know where that information comes from. MDS RN-C did not conduct a comprehensive assessment related to R40 antidepressant use. On 5/21/25, at 2:02 PM, Surveyor interviewed Social Worker (SW)-F. SW-F stated they just look at the medication itself and does not ask about symptoms for use. SW-F does not complete a comprehensive assessment for psych medication for R40. On 5/21/25, at 3:03 PM, at the facility exit meeting with Nursing Home Administrator (NHA)-A and Director of Nurses (DON)-B, Surveyor shared the concerns with R40's antidepressant medication. There is not a comprehensive assessment for use, including a care plan, non-pharmacological interventions and specific symptoms for treatment. Following exit from the facility additional information was submitted from the facility to include medication reviews for R40, and a care conference progress note. Surveyor noted the medication reviews do not include clear Review of the medication reviews dated 2/27/25 and 3/27/25 do not include documentation of behaviors and their frequency to support monitoring of R40 for indicators for use of the medication. They also do not include any non pharmacological interventions for the resident when depressed other than to self direct activities at their own leisure. The care conference note dated 4/30/25 indicates R40 declined formal psychological services, there is no indication the facility established a plan of care to address and monitor indications for use and interventions related to R40's receipt of antidepressants. This progress note references presence of depression for R40. Also included is a late entry PHQ 9 (Personal Health Questionnaire) with an effective date of 4/8/25. There is no indication this assessment contributed to the completion of accurate MDS assessments or creating plans of care to address R40's use of an antidepressant.

Based on interview and record review, the facility did not ensure residents are accurately screened for a mental disorder prior to admission or prior to the expiration of a 30-day exemption for 2 (R41 and R13) of 4 residents reviewed for the PASARR (Preadmission Screening and Resident Review). *R41 did not have a PASARR level 1 screen resubmitted prior to the expiration of the 30-day exemption documented on the original PASARR level 1. *R13 did not have a serious mental illness documented on the PASARR level 1 which would have triggered the PASARR level 2 to be initiated. Findings include: The facility policy and procedure titled Resident Assessment - Coordination with PASARR Program dated 8/2024 documents: Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends that PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. 3. Exceptions to the preadmission screening program, dependent upon the State requirements, include those individuals who: a. Are readmitted directly from a hospital. b. Are admitted directly from a hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. 4. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID, or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. 1.) R41 was admitted to the facility on [DATE] with diagnoses of dementia and unspecified psychosis. R41 had physician orders on admission for Seroquel, an antipsychotic, 50 mg twice daily for psychosis and Ativan, an antianxiety medication, 0.5 mg every two hours as needed for anxiety for fourteen days. A PASARR level 1 was submitted on 2/26/2025 documenting R41 had a hospital discharge exemption of a 30 day maximum. A level 2 screen was not required at that time due to the exemption documented on the level 1 screen. On 5/19/2025 during the survey process, Surveyor was not able to locate a PASARR level 1 for R41 prior to 3/28/2025, 30 days after R41 was admitted since R41 was still a resident of the facility. Surveyor requested from Nursing Home Administrator (NHA)-A for a copy of R41's PASARR level 1 and level 2 screens. On 5/21/2025 at 9:17 AM, NHA-A provided a copy of R41's PASARR level 1 submitted 2/26/2025 with the 30 day exemption. Surveyor asked NHA-A what facility member completes the PASARRs prior to a resident being admitted to the facility. NHA-A stated NHA-A completes all the PASARRs for the facility. Surveyor asked NHA-A if R41 had a revised PASARR level 1 submitted prior to the expiration of the 30 day exemption. NHA-A stated NHA-A completed the PASARR level 1 screen prior to R41's admission on [DATE] and saw that the agency did not require a level 2. Surveyor shared with NHA-A that NHA-A had entered yes for the question of R41 having a 30 day hospital exemption and therefore a level 2 would not be required. Surveyor shared with NHA-A that a resident who stays at the facility beyond the 30 days, a follow up PASARR level 1 needs to be submitted. NHA-A stated since R41 was taking psychotropic medications with diagnoses and was on hospice, NHA-A thought the agency would not complete a level 2. Surveyor shared with NHA-A that R41 has been a resident of the facility for over two months without an accurate PASARR level 1 and one should have been submitted prior to the expiration of the 30 days. NHA-A agreed a follow up PASARR was not completed and would resubmit a new PASARR level 1. 2.) R13 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and unspecified psychosis (disorder with symptoms including incoherent or nonsense speech or behavior inappropriate for the situation). R13 is currently her own person. R13's admission Minimum Data Set (MDS) completed 5/6/25 documents R13's Brief Interview for Mental Status(BIMS) score to be 8, indicating R13 demonstrates moderately impaired skills for daily decision making. R13's MDS documents that R13 is not currently considered by the state level 2 Preadmission Screen and Resident Review(PASARR) process to have serious mental illness and/or intellectual disability or a related condition. R13's MDS documents R13 has no mood or behavior symptoms. On 5/19/25, Surveyor reviewed R13's level 1 PASARR summary. Surveyor noted the facility answered NO to the question: .Does the person have a major mental disorder? . The National Institute of Mental Health-https://www.nimh.nih.gov documents: . psychosis, including unspecified psychosis, is considered a serious mental illness. It involves a disruption in thinking and perception, leading individuals to lose touch with reality. This can manifest as delusions, hallucinations, disorganized thinking, or disorganized behavior, causing significant distress and impairment in daily functioning. While unspecified psychosis is a diagnosis of exclusion, meaning it's used when a person experiences psychotic symptoms but doesn't fit into a specific psychotic disorder category, it is still a serious condition that requires prompt attention and appropriate treatment. What is psychosis? Psychosis refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality. During an episode of psychosis, a person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not. People with psychosis typically experience delusions (false beliefs, for example, that people on television are sending them special messages or that others are trying to hurt them) and hallucinations (seeing or hearing things that others do not, such as hearing voices telling them to do something or criticizing them). Other symptoms can include incoherent or nonsense speech and behavior that is inappropriate for the situation. Psychiatrists use The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) to help them decide if a patient has psychosis. Psychosis is when a person has abnormalities in thoughts and perceptions. https://hcpc.[NAME].edu documents: .anxiety disorders are considered serious mental illnesses. They are characterized by excessive worry, fear, and nervousness that can significantly interfere with daily life, work, and relationships. Sometimes anxiety disorders can cause fear so intense it totally disables its victims. Anxiety disorders are the most common of all mental illnesses, and they are also the most treatable. Anxiety Disorder, Unspecified in the DSM-5 is a diagnosis used when an individual experiences significant anxiety and/or panic, but their symptoms don't fully meet the criteria for a specific anxiety disorder, such as Generalized Anxiety Disorder (GAD), Panic Disorder, or a specific phobia. It's essentially a catch-all category for individuals who experience anxiety-related distress or impairment that doesn't fit neatly into other, more defined anxiety disorder diagnosis. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), both Unspecified Psychosis and Unspecified Anxiety Disorder meet the definition of a major mental disorder. Surveyor noted R13 is currently not receiving psychotropic medications to treat symptoms of a major mental illness. R13's diagnosis of Unspecified Psychosis is most likely suggesting that R13 has symptoms that may indicate the presence of a major mental illness. On 5/20/25, at 3:17 PM, Nursing Home Administrator (NHA)-A confirmed that NHA-A completes the PASARR on each Resident admitted to the facility. NHA-A informed Surveyor that NHA-A documented NO to R13 having a major mental disorder because R13 does not have a diagnosis to substantiate a YES. On 5/21/25, at 3:03 PM, Surveyor shared the concern with NHA-A, Director of Nursing (DON)-B, and Director of Quality Compliance (DQC)-C that R13 has 2 major mental disorders under the DSM-5 and R13's PASARR was completed incorrectly stating R13 has no major mental disorder. No further information was provided by the facility at this time.

Based on record review and interview, the facility did not develop a comprehensive plan of care for residents on antidepressant medication. This was observed with 3 (R40, R6, & R71) of 18 residents reviewed for plans of care. * R40 and R6 were admitted to the facility on antidepressant medication and did not have a plan of care for their depression. * R71 did not have bowel or bladder care that included goals and interventions. Findings include: 1.) R40 was admitted to the facility on [DATE] with diagnoses including Depression and Stroke. The Hospital Discharge summary, dated [DATE], includes Prozac 20 milligram (mg), 3 capsules daily. The facility admission physician orders document Prozac 20 mg, 3 capsules every day for Depression. R40's admission Minimum Data Set (MDS) assessment was completed on 3/4/25. This assessment documents daily use of an antidepressant medication. The Care Area Assessment (CAA) for Psychotropic Drug Use, completed by MDS Registered Nurse (RN) -C on 3/10/25, documents Prozac (antidepressant) for depression. This CAA does not include the symptoms of depression R40 experiences, along with non-pharmacological interventions. R40's Significant Change in Status MDS assessment was completed on 4/22/25. This assessment documents daily use of an antidepressant medication. The Care Area Assessment (CAA) for Psychotropic Drug Use, completed by MDS RN -C on 4/30/25, documents Prozac (antidepressant) for depression. This CAA does not include symptoms of depression R40 experiences, along with non-pharmacological interventions. R40's plans of care were reviewed. R40 has a care plan, initiated on 2/26/25, titled The resident uses antidepressant medication Prozac. There is no documentation of indicators for use of the antidepressant. The interventions listed indicate the side effects of the medication to be monitored. R40 does not have a plan of care for depression symptoms and treatment to include specific symptoms along with non-pharmacological interventions. On 5/21/25, at 1:30 PM, Surveyor interviewed Unit Manager (UM) -D. UM-D stated They will look for indicators for use of the antidepressant medication. UM-D did not have any additional information. UM-D did not develop a comprehensive plan of care for R40's depression. On 5/21/25, at 2:02 PM, Surveyor interviewed Social Worker (SW)-F. SW-F stated They just look at the medication itself and do not ask about symptoms for use. SW-F did not develop a comprehensive plan of care for R40's depression. On 5/21/25, at 3:03 PM at the facility exit meeting, with Nursing Home Administrator (NHA)-A and Director of Nurses (DON) -B, Surveyor shared the concerns with R40's antidepressant medication. There is not a comprehensive assessment or use, including care plan, non-pharmacological interventions and specific symptoms for treatment2.) R6 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dementia, psychotic disturbance, mood disturbance, anxiety and depression. R6's Annual Minimum Data Set (MDS) assessment, dated 5/6/2025, documented a Brief Interview Mental Status (BIMS) score of 11, indicating that R6's cognation is intact. Section B, documents that R6 is understood and understands. Surveyor reviewed R6's care plan and could not locate a care plan for R6's depression. Surveyor reviewed the care plan for depression medication but that had only interventions related to the medication itself and nothing with interventions for the depression diagnosis. On 5/22/2025, at 8:16 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-K who indicated to be one of the people responsible for going over care plans and making sure they are correct and current. ADON-K indicated that the depression care plan should show up in Point Click Care (PCC). PCC is a program used for R6's health information while at the facility. Surveyor informed ADON-K that it was not observed in PCC. ADON-K stated to Surveyor that a depression care plan will be put in for R6 right away. Surveyor also explained that there was a care plan for R6's depression medication, which had the following two interventions: Monitoring/document/report PRN (as indicated) adverse reactions to antidepressant therapy; Administer antidepressant medications as ordered. Surveyor reviewed the treatment record for R6. It is documented that on April 18th, 19th and 20th of 2025 that side effects were observed for depression medication. There was no documentation that the adverse effects of R6's medication were reported to a physician on April 18th, 19th or 20th. On 5/22/2025, at 11:19 AM, Surveyor informed Nursing Home Administrator (NHA)-A, of the above findings. Surveyor explained that there is no care plan for depression and the care plan found for depression medication intervention was not followed. No additional information received for R6 not having a depression care plan with interventions and goals. No information received as to why the interventions for depression medication were not followed on the above dates of April 2025. 3.) R71 was admitted to the facility on [DATE] with diagnoses that include heart failure, generalized anxiety disorder, depression, osteoarthritis. R71's admission Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) of 11, indicating R71 is cognitively intact. The MDS documents mobility as needs some help, as helper does some of the effort, and R71 does some of the activity. Under the bowel and bladder section, it is documented that R71 is occasionally incontinent of bladder and never incontinent of bowel. Surveyor reviewed the care plan for R71 and there was not a bladder care plan initiated for R71, despite the MDS documenting that R71 is occasionally incontinent of bladder. On 5/22/2025, at 8:06 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-K who indicated that she was one of the individuals responsible for going over care plans and making sure they are correct and current. Surveyor informed ADON-K of the above findings and R71's lack of a bladder care plan. ADON-K indicated not remembering much relating to R71 and would review R71's care plan and let Surveyor know. On 5/22/2025, at 11:19 AM, Surveyor informed Nursing Home Administrator (NHA)-A, of concerns with R71's care plan, and no start for a bladder care plan for R71. No additional information was provided as to why R71 had no care plan for bladder incontinence despite it being documented in R71's admission MDS dated [DATE].

Based on observation, interviews, and record review, the facility did not ensure residents with vision impairment received proper treatment and assistive devices including arrangements for an optometrist (eye doctor) visit for 1 (R21) of 1 resident's reviewed for vision. R21 has not been seen by an optometrist since 8/20/21 and R21's last missed vision appointment on 11/18/22 was never rescheduled to evaluate R21's advancing vision issues with an active request and signed consent to receive vision care. Findings include: R21 was admitted on [DATE] which includes a diagnosis of legal blindness and other optic atrophy. R21's comprehensive Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, indicating R21 has intact cognition. R21 has highly impaired vision with no corrective lenses, glasses or contacts. R21's active Physician Order, dated 10/5/23, documents, May be seen by Optometrist No directions specified for order. R21's Care Plan, date Initiated, 10/06/2023, documents, Focus: The resident has impaired visual function r/t (related to) can see and ID (Identify) objects. Goal: The resident will maintain optimal quality of life within limitation imposed by visual function (SPECIFY how) through the review date. Date Initiated: 05/25/2022 Revision on: 04/17/2025. The resident will maintain optimal quality of life within limitation imposed by visual function (SPECIFY how) through the review date. Date Initiated: 05/25/2022 Revision on: 04/15/2025 Interventions: The resident will have no indications of acute eye problems through the review date. Date Initiated: 05/25/2022 Revision on: 04/17/2025. Arrange consultation with eye care practitioner as required. Date Initiated: 05/25/2022. Keep my personal items in the same place so I can find them. Date Initiated: 05/25/2022. Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of acute eye problems: Change in ability to perform ADLs, (Assistance with Daily Living) Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Date Initiated: 05/25/2022. Offer me a consult with optometrist/ophthalmologist, as needed. Date Initiated: 05/25/2022. Tell the resident where you are placing their items. Be consistent. Date Initiated: 05/25/2022 R21's HealthDrive Request for services form completed on 12/30/19, documents R21 requests to be seen for eye care and consents to services requested. R21's HealthDrive's Eye Care Group form on 8/20/21 documents, R21's visit assessment concludes optic atrophy; both eyes, macular degeneration, dry, both eyes; intermediate dry stage, cataract mixed; worse; both eyes; mild to moderate, exotropia, constant; no change; L (left) eye, legal blindness, as defined in USA. R21's plan documents, monitor; follow up comprehensive 8/20/22, patient education and advise staff of any changes, monitor, cataract surgery not recommended due to poor prognosis, monitor, staff education-patient will require assistance with ADL's (assistance with daily living). R21's action required by nursing home staff, glasses required, no. Eyelid care required, no. Recommend new orders, no. R21's HealthDrive's Eye Care Group form on 11/18/22, documents, Patient was scheduled to be treated today but was not treated. Reason: Patient was unavailable-in bed. On 05/19/25 at 10:01 AM, R21 stated her vision is very bad. She had glasses but they did not work well. She believes she has talked to someone about this. On 05/20/25 at 11:03 AM, Surveyor interviewed Social Worker (SW)-F who stated the process for residents to receive vision appointments starts with the resident's requesting services and signing a consent. Once this is established, residents are on the list for HealthDrive to come to the facility quarterly for vision appointments. Surveyor asked SW-F why R21 stopped receiving vision care with her last scheduled visit on 11/18/22 which was missed and SW-F stated, she does not know but will find out. On 05/21/25 at 08:33 AM, Surveyor interviewed SW-F, who received information from HealthDrive. SW-F stated R21's last visit was scheduled for 11/18/22 but R21 was in bed. HealthDrive does not know why R21 was no longer on their list following last attempted visit, but HealthDrive has re-added R21 to list and she will be seen 6/2/25. On 05/22/25 at 10:41 AM, Surveyor interviewed SW-F, who stated, HealthDrive sends a summary for each visit but if resident is no longer going to be seen, she does not know because it has not happened since she has been here in a year. Surveyor asked, SW-F if HealthDrive stops seeing a resident, whose responsibility is it to find out why and SW-F stated, That is a good question and did not provide answer. Surveyor asked SW-F if there is a tracking mechanism in place to know if a resident was missed for any reason and SW-F stated she doesn't keep one, but HealthDrive should have one. She will reach out to HealthDrive and see if they have any system. On 05/22/25 at 10:54 AM, Surveyor spoke with R21 who stated she has told someone a few weeks ago that she wanted a visit for vision because her right eye becomes blurry as the day goes on, but she has not heard anything. Surveyor told R21 that a visit has been set up for 6/2/25. R21 stated she had not been informed of upcoming visit and stated she did not know why she had not been seen since 8/20/21 or why her last scheduled visit on 11/18/22 was not rescheduled. Surveyor notes, the facility does not have a system in place for monitoring HealthDrive visits, to include if visits occurred, when visits are missed or canceled or if residents decide to longer have services provided. On 05/22/25 at 3:15 PM, Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concerns regarding R21 not being seen by optometry to continue to evaluate the care plan and decline of R21's vision. Following exit from the survey, the facility submitted additional information regarding R21 to include the statement Resident (R21) has macular degeneration, cataracts in both eyes and is legally blind. The residents (sic) care plan since 2022 (attached for Surveyor review) states to arrange consultation with eye care practitioner as needed. Resident s followed by (name of replacement plan group), during each visit with the NP (nurse practitioner) resident has not expressed any concerns. The order from (name of replacement plan group) for resident (attached for Surveyor to review) states opthalmology consult as needed and they have not recommended a consult. (Name of replacement plan group) also documented that resident refuses to get out of bed and an eye examination cannot be done with resident in bed. Surveyor noted the additional information does not address R21's discussion with staff expressing concern with changes in her right eye and a request for a vision appointment. The documents submitted from the replacement plan provider are noted to be date 9/11/24 and 12/12/24. The 12/12/24 form documents a generic statement of: Continue with Routine labs and in house services per facility policy: Podiatry; Opthalmology; Dental; Audiology; and Psychiatric Consults PRN (as needed). The 9/11/24 does not reference a review of vision or services related to vision as provided to surveyor for review.

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent an accident from occurring for 1 of 1 Resident (R65) reviewed for accidents. *R65's physician orders instructed 1:1 (one on one) supervision with all meals. Surveyor had observations during the survey process of R65 not receiving supervision with meals. Findings Include: The facility's Accidents and Supervision policy implemented 11/24 documents: .Policy: The Resident environment will remain as free of accident hazards as is possible. Each Resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s) 2. Evaluating and analyzing(s) and risk(s) 3. Implementing interventions to reduce hazard(s) and risk(s) 4. Monitoring for effectiveness and modifying interventions when necessary Policy Explanation and Compliance Guidelines: 1. Identification of Hazards and Risks 2. Evaluation and Analysis 3. Implementation and Interventions 4. Monitoring and Modification 5 Supervision-is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency b. Based on the individual Resident's assessed needs and identified hazards in the Resident environment R65 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction (complete paralysis on one side of body and partial/incomplete weakness on one side following stroke), Dysphagia (difficulty swallowing foods), Metabolic Encephalopathy(brain dysfunction resulting from underlying condition that disrupts the metabolic processes), Chronic Kidney Disease (progressive damage and loss of function in the kidneys), Anemia (low red blood cells and hemoglobin), and Essential Hypertension (chronic condition of persistently high blood pressure). R65 is currently is his own person. R65's admission Minimum Data Set (MDS) completed 4/16/25 documents R65's Brief Interview for Mental Status(BIMS) score to be 12, indicating R65 demonstrates moderately impaired skills for daily decision making. R65's MDS documents R65 has no mood or behavior symptoms. R65 has range of motion (ROM) impairment on 1 side of both upper and lower extremity, set-up for eating, requires substantial/maximum assistance for showers, upper and lower dressing and transfers. R65 requires partial to moderate assistance for mobility. R65's MDS also documents that R65 is holding food in mouth/cheeks or residual food in mouth after meals and has complaints of difficulty or pain when swallowing. R65's nutrition care area assessment completed 4/16/25 (CAA) documents: Mechanical soft NAS diet R65 will maintain adequate nutritional status as evidenced by maintaining weight within 5% of 160 lbs, no signs/symptoms of malnutrition, and consuming at least 50% of at least 3 meals daily through review date. R65's initial nutrition assessment completed 4/11/25 by Dietitian (RD)-Q documents R65 is setup help only and on a mechanical soft texture thin liquid diet at time of admission. R65's current physician orders documents: -No added salt (NAS) diet mechanical soft texture, regular (thin) consistency, 1:1 supervision for meals-start date 4/9/25 -1:1 supervision for all meals, hold meals if increased coughing, three times a day-start date of 4/18/25 Surveyor reviewed R65's Treatment Administration Record (TARS) for April and May and notes that nursing staff was monitoring for 1:1 supervision for all meals, three times a day. R65's initial nutrition assessment is inconsistent with R65's physician orders of 1:1 supervision with all 3 meals. R65's care card instructing certified nursing assistants (CNAs) as of 5/19/25 documents R65 is on a mechanical soft diet, thin liquids, and feeds self with set up. R65's comprehensive care plan documents: R65 has a swallowing problem due to (Surveyor notes this has not been completed) Initiated 4/22/25 Interventions: -All staff to be informed of R65's special dietary and safety needs -Diet to be followed as prescribed -Instruct R65 to eat in an upright position, to eat slowly, and to chew each bite thoroughly -Monitor for shortness of breath, choking, labored respirations, lung congestion · The resident will have clear lungs, no signs and symptoms of aspiration through the review date. · The resident will have no choking episodes when eating through the review date. · The resident will maintain weight and nutritional balance through the review date. · The resident will not have injury related to aspiration through the review date. All initiated 4/29/25 Surveyor notes R65's care card and comprehensive care plan were not updated with R65's physician order of 1:1 supervision with all 3 meals. On 4/10/25, Speech/Language Pathologist (SLP)-P's SLP screen documents R65 is on a mechanically altered diet, holds food in mouth/cheeks or residual food in mouth after meals, and complaints of difficulty or pain when swallowing. Recommendations are for SLP Evaluation for swallow. SLP-P in the summary, documents that a problem has been identified and SLP evaluation indicated. SLP-P's documentation completed 4/10/25 located in SLP-P's evaluation and plan of treatment includes the following applicable goals: -R65 will increase ability to safely swallow mechanical soft/ground consistencies to within functional limits in order to meet primary nutrition/hydration needs. -R65 will safely and efficiently swallow mechanical soft/ground textures 90% of the time without compensatory strategies and/or maneuvers as evidenced by minimal to absent signs/symptoms of oral/pharyngeal dysphagia. On 4/16/25, R65 is discharged to the hospital from the facility. R65's hospital discharge summary completed 4/22/25 includes SLP notes from the hospital. SLP's progress notes completed 4/18/25 documents: Swallow Recommendations: 3. Constant supervision/tray setup-ensure slow rate, small bites, liquid wash as appropriate 4. Discontinue feeding if increased coughing, throat clears, increased breathing 5. Monitor mentation, hold by mouth intake as appropriate, may need total assist as needed due to cognition/mentation Recommendations documented by the SLP from the hospital: -Liquid-thin and IDDSI (International Dysphagia Diet Standardization Initiative) 7 Easy-to-Chew -Feeding Guidelines: *Tray set-up, constant supervision by staff, slow rate of intake, small bites, alternate liquids and solids, stay upright after meals, small single sips, and check mouth for leftover food The overall short term goal is that R65 will tolerate a least restrictive diet without overt signs/symptoms of dysphagia/aspiration R65's nutrition assessment completed by RD-Q after R65's return from the hospital dated 4/25/25 documents R65 now requires one person physical assistance. SLP-R, a different speech/language therapist completed a SLP screen on 4/27/25 indicating R65 has a swallow disorder as evidenced by holding food in mouth or cheeks or residual food in mouth after meals and complaints of difficulty or pain when swallowing. On 4/27/25, SLP-R documented: .Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, R65 is at risk for: decreased ability to return to prior level of supervision/assistance. R65 presents with mild oral dysphagia which necessitates skilled SLP services for dysphagia to analyze oral function, assess/evaluate for safest level of oral intake and design and implement strategies in order to improve ability to safely consume highest level of oral intake. R65's completed MDS 5 day dated 4/28/25 documents R65 continues to hold food in mouth/cheeks or residual food in mouth after meals and complaints of difficulty or pain when swallowing. On 4/28/25, SLP-R documented providing .R65 with verbal education regarding safe swallow strategies with rationale and explanations for implementation On 5/1/25, SLP-P documented .Mildly discoordinated oral movements and mastication noted. On 5/19/25, SLP-P documents .R65 with mildly wet vocal quality post swallow of fruit, but cleared with secondary swallow On 5/19/25, at 12:38 PM, Surveyor observed Admissions (Admit)-G deliver R65's lunch tray and bring in a cup of juice, and set the tray on R65's overbed table. R65 is up in wheelchair. On 5/19/25, at 12:44 PM, Surveyor observed R65 drinking juice. On 5/19/25,at 12:59 PM, Surveyor observed Certified Nursing Assistant (CNA)-S lower R65's overbed table, take the cover off the fruit, and moved the plate closer to R65. On 5/19/25, at 1:04 PM, Surveyor observed R65 eating lunch with no supervision. On 5/19/25, at 1:12 PM, Surveyor observed R65 continuing to eat lunch with no supervision. On 5/20/25, at 8:05 AM, Surveyor observed CNA-I bring R65's breakfast tray, opened up everything, raised R65's head of bed, and left the room. On 5/20/25, at 8:11 AM, Surveyor observed R65 eating breakfast in bed, unsupervised, head of bed is slightly elevated. On 5/20/25, at 8:40 AM, Surveyor observed that R65 ate all of breakfast, and no staff was in the room to supervise. On 5/20/25, at 12:26 PM, Surveyor observed R65 sitting in wheelchair, eating lunch with staff supervising R65. On 5/20/25, at 12:52 PM, Surveyor observed that R65 ate all of R65's lunch, finishing up cup of juice. Surveyor observed R65 did not receive any supervision from staff. On 5/21/25, at 8:49 AM, Surveyor interviewed SLP-P in regards to R65. Surveyor asked SLP-P to define what 1:1 supervision is defined as. SLP-P stated it would be assistance of 1 and watching R65 throughout the meal. SLP-P is not aware of the physician's order for 1:1 supervision for R65. SLP-P stated R65 has few teeth, and has a history of swallowing difficulty. On 5/21/25, at 8:49 AM, Surveyor observed R65's breakfast tray in front of R65, cover still on, and R65 is laying in bed. R65's head of bed is slightly elevated but not enough to eat comfortably. R65 has not started to eat yet. On 5/21/25, at 8:57 AM, Surveyor observed CNA-H go into R65's room and set up R65 for breakfast, elevated bed completely in a better position. On 5/21/25, at 8:59 AM, Surveyor observed CNA-I go into R65's room and shut the door. On 5/21/25, at 9:19 AM, Surveyor asked CNA-H what CNA-I was doing in R65's room and CNA-H stated CNA-I was watching R65 eat. CNA-H stated CNA-H cut up the pancakes but R65 needs monitoring. On 5/21/25, at 12:41 PM, Surveyor observed R65 eating lunch, with no staff supervision. On 5/21/25, at 3:03 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Director of Quality Compliance (DQC)-C that R65's physician orders document R65 is to have 1:1 supervision with all meals, and Surveyor has observations of 3 meals that R65 did not receive supervision, R65's hospital record indicates the need for physical supervision, R65's most recent nutritional assessment completed 4/25/25 indicated that R65 now requires 1 person physical assistance, and that SLP-P was not aware that R65 had a physician order for 1:1 supervision. No further information was provided by the facility at this time. On 5/22/25, at 8:36 AM, Surveyor interviewed RD-Q. Surveyor asked RD-Q if RD-Q reviewed re-admission hospital paperwork in regards to R65. RD-Q can not remember if RD-Q did. Surveyor asked RD-Q if RD-Q reviewed R65's physician orders upon return from the hospital. RD-Q can not remember. Surveyor asked RD-Q if RD-Q was aware that R65's physician orders documented 1:1 supervision for all meals. RD-Q stated that RD-Q has R65 needing 1:1 supervision in the 'tray system'. Surveyor asked RD-Q what total assistance is defined as. RD-Q stated the expectation would be that a staff member should sit with R65 and feed R65. RD-Q does not know why R65 was downgraded from regular to mechanical soft. I'm assuming he has a tooth issue due to the diet change. RD-Q does not know anything about R65's teeth. On 5/22/25, at 11:20 AM, DON-B submitted additional information of SLP progress notes, and hospital paperwork. Surveyor explained to DON-B that Surveyor had all identified documentation but would review it again. DON-B stated DON-B was told to bring Surveyor the additional information. Surveyor shared the concern that between the facility, SLP, and Dietitian, that there is confusion to exactly what level of supervision R65 requires for meals. Surveyor explained what SLP-P and RD-Q had communicated to Surveyor in previous interviews. DON-B understands the confusion and the concern regarding R65. On 5/22/25, at 11:33 AM, Surveyor interviewed Unit Manager Registered Nurse (RN)-D who does not remember why a diet change was needed for R65. RN-D would make a recommendation if there was difficulty swallowing and sent to speech therapy for follow-up. On 5/28/25, at 1:35 PM, Surveyor reviewed the additional information the facility provided. The concern remains that R65 had current physician orders for 1:1 supervision for all 3 meals and during the survey process the facility was not following the physician orders. The TARS document nursing staff were acknowledging and signing off they were monitoring that R65 was receiving 1:1 supervision at all 3 meals. SLP-P who Surveyor interviewed was not aware that R65 had physician orders for 1:1 supervision so a complete assessment of R65 was not completed by SLP-P in that SLP-P did not complete a record review of R65's medical record. RD-Q confirmed R65 was in the tray system in the facility as needing 1:1 supervision. Additional review of records provided by the facility indicate the physician order for 1:1 supervision was discontinued on 5/20/25, during the survey.

Based on interview and record review, the facility did not ensure the residents were free of significant medication errors for 1 (R122) of 1 resident reviewed for medication transcriptions. R122 had a hospital discharge order for Apixaban, an anticoagulant, 5 mg once in the morning and once at bedtime. The order was transcribed by the facility as Apixaban 5 mg once daily. R122 was a resident of the facility for 34 days and received the wrong dose of Apixaban on those days. Findings include: R122 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure, chronic obstructive pulmonary disease, diabetes, dysphagia requiring a gastrostomy tube for nutrition and medication administration, and atrial fibrillation (a fluttering of the atria in the heart potentially causing blood clots to form and creating an increased risk for a stroke). R122 had an activated Power of Attorney (POA). R122 discharged from the facility on 1/6/2025 and was not a resident at the time of survey. Apixaban, or Eliquis, is an anticoagulant prescribed to reduce the risk of blood clots from forming. R122's hospital discharge orders dated 12/2/2024 included Apixaban 5 mg tablet commonly known as Eliquis: take 1 tablet (5 mg) by mouth or tube in the morning and 1 tablet (5 mg) before bedtime for atrial fibrillation. On 12/3/2024, Assistant Director of Nursing (ADON)-K transcribed the order from the hospital discharge medication list to R122's Medication Administration Record (MAR). The order was entered onto the MAR as: Apixaban Oral Tablet 5 mg - give 1 tablet via PEG-Tube (Percutaneous Endoscopic Gastrostomy tube) one time a day related to paroxysmal atrial fibrillation. Surveyor noted the hospital order for Apixaban was twice daily and the facility entered the order as Apixaban once daily, halving the dose R122 was to be taking. R122's facility physician signed the order as transcribed by ADON-K for 5 mg of Apixaban daily. No documentation was found indicating the physician was aware R122 had been on twice the dosage in the hospital and wanted the medication decreased. No documentation was found indicating R122's POA had been notified of the change in dose of Apixaban. In an interview on 5/21/2025 at 1:48 PM, Unit Manager Registered Nurse (UMRN)-D stated the unit nurse would complete the physical head to toe assessment on a newly admitted resident and either UMRN-D, ADON-K, or DON-B would put in the standing orders and hospital discharge orders into the computer. UMRN-D stated the orders would then be double checked by one of the other administrative nurses. Surveyor shared with UMRN-D Surveyor could see who entered the order into the medical record. Surveyor asked UMRN-D if there was documentation in the medical record to indicate who double checked the order. UMRN-D stated no, there was no place in the electronic medical record to show the order had been double checked. Surveyor asked UMRN-D if UMRN-D could recall any conversations with R122's POA regarding medications. UMRN-D stated R122's POA came in and was concerned R122 did not get any medications, but the medications were given via the PEG tube because the discharge summary stated to administer the medications that way. RNUM-D stated R122 could take the medications orally and Speech Therapy cleared R122 to take medications orally, so the orders were changed at that time. In an interview on 5/22/2025 at 10:48 AM, Surveyor asked ADON-K where do the nurses that enter orders for a newly admitted resident get the orders from. ADON-K stated the resident comes with an order summary from the hospital and that is reviewed and compared with other medication lists in the hospital documentation to make sure there were not any changes made to the medications. ADON-K stated sometimes they will get an oral report for orders. ADON-K stated the medications are reviewed the next day to make sure there is not an error. Surveyor showed ADON-K R122's discharge medication list from the hospital dated 12/3/2024 and asked ADON-K how that order would be entered into the residents MAR. ADON-K read the order and stated ADON-K would enter the order as Apixaban 5 mg twice a day. Surveyor showed ADON-K R122's facility admission orders. ADON-K stated the Apixaban was not entered into the MAR as it was ordered; it should have been twice a day instead of once a day. Surveyor noted ADON-K is the nurse that entered R122's Apixaban order on 12/3/2024. On 5/22/2025 at 11:20 AM, DON-B provided Surveyor with a physician progress note dated 12/3/2024, the date of admission. DON-B stated the progress note documented the order for Apixaban one time daily was collaborated by the physician with the pharmacy on the scheduled prescriptions. Surveyor reviewed the physician progress note. Surveyor noted the physician progress note was a late entry for 12/3/2024 and the medication list was pulled from the facility MAR with pharmacy notation from 12/4/2024. Surveyor shared with DON-B the concern the medication list that was reviewed by the physician per the progress note was comprised of the orders that had been entered into R122's MAR by ADON-K on 12/3/2024 which was not entered correctly for the Apixaban from the hospital discharge summary medication list. Surveyor shared the concern there was no documentation of a conversation indicating the physician was aware the hospital order was for Apixaban twice daily and wanted to decrease the dose to once daily. Surveyor shared the concern with DON-B that R122 received half the dose of Apixaban that should have been administered for the 34 days R122 was in the facility potentially increasing the risk of blood clot formation and stroke. In an interview on 5/22/2025 at 1:11 PM, ADON-K stated the physician was in the facility on 12/3/2024 when R122 was admitted . ADON-K stated the physician reviewed R122's medications and approved Apixaban once daily. Surveyor shared with ADON-K the concern no documentation was found of the Apixaban 5 mg twice daily entered into R122's MAR as ordered from the hospital and then the dose being decreased by the physician at the facility or any documentation to show the physician was aware of the Apixaban being decreased. On 5/28/2025 at 6:17 AM, Nursing Home Administrator (NHA)-A sent an email with additional information regarding R122's medication transcription error. Surveyor reviewed the information attached to the email. A physician visit on 12/9/2024 documents: All medications including all prescriptions, over-the-counter, herbals, and nutritional supplements with each medication's name, dosage, frequency, and administered route have been documented, updated, reviewed, and reconciled on the date of the visit within the Nursing Home's EMR (electronic medical record) system. Specialty-pertinent medications are documented and reconciled within the practice EMR system on the date of the visit. Surveyor noted the medication list reviewed by the physician was what was entered into the MAR by facility staff and does not indicate the medications were compared to the hospital discharge medications.

Based on observation, interview, and record review, the facility did not ensure the medical record for 1 (R33) of 18 residents reviewed was complete accurately documented and readily accessible. *During the survey investigation, it was determined R33 was admitted to the facility on [DATE] with multiple pressure injuries that were not comprehensively assessed until 11/25/2024, three days after admission, and treatments were not documented as being completed from 11/22/2024 to 11/25/2024. On 5/28/25, after completion of the survey, the facility submitted hand written documents that were not part of the medical record that indicated details of wound assessments alleged to be completed on 11/22/24. The hand written forms did not include who completed the documentation and were not included as part of the formal medical record until concerns were raised by the surveyor. Findings include: The facility policy and procedure titled Pressure Injury Prevention and Management dated 10/2024 documents: 3. c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. d. Assessment of pressure injuries will be performed by a licensed nurse. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS (Minimum Data Set). The facility policy and procedure titled Wound Treatment Management dated 12/2024 documents: 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. R33 was admitted to the facility on [DATE] with diagnoses of encephalopathy (a brain disorder), diabetes, dementia, and rheumatoid arthritis. R33's admission MDS dated [DATE] documented R33 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and had one Stage 4 pressure injury on admission, three Unstageable pressure injuries on admission, and two Deep Tissue Injury pressure injuries on admission. On 11/21/2024 on hospital discharge paperwork, the hospital documented R33 had a Stage 4 pressure injury to the coccyx that measured 6.5 cm x 10.5 cm x 1.5 cm with undermining from 12 o'clock to 4 o'clock with the deepest area at 3 o'clock measuring 2.2 cm, a wound to the right lateral leg from friction/shearing that measured 4 cm x 1.5 cm x 0.3 cm, a wound to the right ischial tuberosity (lower buttock) that measured 6.7 cm x 1.4 cm x 0.1 cm, a wound to the right hip/trochanter that measured 5 cm x 3.5 cm x 0.1 cm, a wound to the right great toe and wounds to the left foot and multiple toes. On 11/22/2024 on the Admit/Readmit Assessment form, a Registered Nurse (RN) documented R33 had skin issues to the coccyx, the right buttock, the right heel, the left heel, the right toe(s), and the left toe(s). Surveyor noted the documentation of the wounds did not include measurements, staging if caused by pressure, an etiology, or a description of the tissue type in the wound beds; the right toes and left toes were not individualized as to what type of wounds, how many wounds, and where the wounds were located. R33 had the following wound treatment orders on admission [DATE]: -Dakins one quarter strength: apply to wounds topically one time a day for wound care, apply to clean dry gauze. -Wound care to right lower extremity: cleanse area with normal saline, pat dry, apply calcium alginate to wound bed, skin prep to peri wound, cover with ABD pad, wrap with Kerlix to secure, change every other day. Surveyor noted this order was not signed out on the Treatment Administration Record (TAR) as being completed on 11/23/2024. -Wound care to Stage 4 pressure injury to coccyx and Unstageable pressure injury to the right hip: cleanse area with saline, apply quarter strength Dakins to clean gauze, apply to wound bed, skin prep to peri wound, cover with foam border dressing daily. Surveyor noted this order was not signed out on the TAR 11/23/2024 and 11/24/2024. -Wound care to left foot and toes: apply skin prep to foot/heels and toes twice daily. Surveyor noted this order was not signed out as completed on the TAR 11/22/2024, 11/23/2024, and 11/24/2024. R33's Potential/Actual Impairment to Skin Integrity Care Plan was initiated on 11/22/2024 with interventions: -Encourage to elevate heels. -Encourage/assist with repositioning as needed. -Ensure pressure relieving cushion is used in dialysis chair when R33 is in the chair for dialysis sessions; document if R33 refuses to use the cushion. -Weekly skin assessment with scheduled bath day and document findings on a weekly skin assessment. -Report any skin redness/impaired skin integrity areas to the nurse. -Use barrier cream to prevent skin impairment issues as needed. On 11/25/2024 at 12:33 PM in the progress notes, an RN documented R33 had a Deep Tissue Injury (DTI) to the left tip of the great toe and left heel, a Stage 4 pressure injury to the coccyx, and Unstageable pressure injuries to the right hip, right ischium, and right lateral ankle. Dressings were applied to all wounds. R33 had a low air loss mattress with bilateral offloading boots, and R33 would be repositioned every 2-3 hours and per R33's request. On 11/25/2024 on the Wound Rounds form, an RN documented the Stage 4 pressure injury to the coccyx measured 9 cm x 7 cm x 2.4 cm with 100% beefy red tissue and the Unstageable pressure injury to the right lateral upper ankle measured 5 cm x 0.8 cm x 0.4 cm with 80% pink or red non-granulating tissue and 20% slough. Surveyor was not provided with the Wound Round forms for the other noted pressure areas and was unable to access the record to see initial measurements of the wounds. The Wound Round forms in R33's record documented the left heel DTI healed on 1/8/2025, the left great toe tip DTI healed on 2/19/2025, the right hip Unstageable pressure injury healed on 1/8/2025, and the right ischium Unstageable pressure injury healed on 1/1/2025. Surveyor noted R33's pressure injuries were not comprehensively assessed until 11/25/2024, three days after admission. R33's Potential/Actual Impairment to Skin Integrity Care Plan was revised on 11/25/2024 with interventions: -Low air loss mattress. -Off loading boots bilateral when in bed. -Reposition every 2-3 hours and as needed per R33's request. -Treatment per physician orders. R33's Stage 4 pressure injury to the coccyx was comprehensively assessed weekly. R33's Unstageable right lateral upper ankle pressure injury was determined to be an arterial wound on 2/26/2025 and was comprehensively assessed weekly and healed on 5/7/2025. On 5/19/2025 at 10:00 AM, Surveyor observed R33 sleeping in bed. R33 had an air mattress in place and heel boots on. On 5/22/2025 at 7:49 AM, Surveyor observed Director of Nursing (DON)-B complete R33's wound care. R33 was in bed on the air mattress and bilateral heel boots were in place. DON-B stated the wound Nurse Practitioner comes weekly and would be assessing R33's wounds later that day. In an interview on 5/22/2025 at 10:54 AM, Assistant DON (ADON)-K stated a newly admitted resident should be assessed for skin impairment as soon as possible with measurements and descriptions of the wound or wounds. ADON-K stated if a Licensed Practical Nurse (LPN) does the initial intake, they would document where the wounds were located but then an RN would look at the resident that day, or if they came in after 8:00 PM, an RN would assess the wound in the morning. On 5/22/2025 at 11:19 AM, Surveyor shared with DON-B the concerns R33 did not have a comprehensive assessment of the pressure injuries that were present on admission on [DATE] until 11/25/2024, three days later, and the wound treatment orders were not signed out as being completed on the TAR on those days. DON-B stated DON-B would look to see if there was any more information. On 5/22/2025 at 1:14 PM, ADON-K provided Surveyor with a wound log showing R33's wounds when R33 was admitted on [DATE]. The log was handwritten and documented the following: -Coccyx pressure injury Stage 4, granulation tissue, friable, serosanguineous drainage, measured 8 cm x 6 cm x 1.7 cm. -Left heel pressure injury DTI, intact blood filled blister, measured 3.2 cm x 2.4 cm. -Right hip pressure injury Unstageable, 25% epithelial, slough, measured 4.7 cm x 2.9 cm. -Right ischium pressure injury Unstageable, pink 80%, ne 20%(unknown documentation), measured 1 cm x 0.8 cm. -right ankle pressure injury Unstageable, friable, serosanguineous drainage, measured 5 cm x 0.8 cm. Surveyor noted the wound log did not have any signature of who documented the information, no date was written other than the wounds were discovered on 11/22/2024, and the descriptions and measurements were not complete. The wound log was not part of R33's medical record.

Based on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (R45) of 11 residents observed. *R45 was placed in Enhanced Barrier Precautions (EBP) and facility staff did not don a gown on when assisting R45 with cares. Finding Include: The Facilities Policy titled, Enhanced Barrier Precautions revised 11/2024, documents: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug, resistant organisms. Policy explanation and compliance guidelines: . 4. High-contact resident care activities include: . G. Device care or use: central line, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, pick lines, midline catheters. R45 was admitted to the facility on [DATE] with diagnosis that include Cerebral Aneurysm, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, dysarthria (slurred speech) and anarthria (loss of speech), dysphasia, neuromuscular dysfunctional bladder. R45's Quarterly Minimum Data Set (MDS) assessment, dated 5/1/2025, documented a Brief Interview Mental Status (BIMS) score of 3, indicating poor cognitive awareness. Section B, documents that R45 is usually understood and understands. R45's infection control care plan (requires enhanced barrier precautions), dated 7/28/2024, with a target date of 8/15/2025, documents: Gown and gloves to be worn by staff during high contact resident care activities that provide opportunities for transfer of Multidrug-Resistant Organism's (MDRO)'s to staff hands and clothing. Includes: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. Surveyor observed a plaque on R45's door indicating a need for enhanced barrier precautions with cares. On 5/21/2025, at 9:34 AM, Surveyor observed Licensed Practical Nurse (LPN)-L changing R45's tube feeding from one container over to a new one and LPN-L did not have on a gown. On 5/21/2025, at 9:41 AM, Surveyor observed Certified Nursing Assistant (CNA)-M, who was moving R45's catheter bag off the floor and replaced the privacy cover that was on the catheter without a gown. On 5/22/2025, at 8:16 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-K, regarding staff not using proper Personal Protective Equipment (PPE) during cares of R45's tube-feeding and catheter cares. ADON indicated being present during observation of no PPE on 5/21/2025. ADON-K stated that she already educated both LPN-L and CNA-M of the fact that gowns should have been in place during those activities. On 5/22/2025, at 11:22 AM, Surveyor informed Nursing Home Administrator (NHA)-A, of the concern that proper PPE was not observed during R45's contact cares on 5/21/2025. Surveyor also informed NHA-A that ADON-K was present during observations and educated staff on PPE use. No additional information was given as to why proper PPE was not utilized for R45 during contact cares.

Based on observation, interview, and record review, the facility did not ensure the medication rate was below 5 percent in 1 (R422) of 3 residents observed receiving medications. The facility medication error rate was 16.67 percent. *R422 had medications that were not administered in the right dose or were omitted from the medications administered. R422 had insulin ordered and the wrong dose was drawn up in the syringe. Findings include: The facility policy and procedure titled Administering Medications dated 12/28/2024 documents: 4. Medications are administered in accordance with prescriber orders, including any required time frame. On 5/20/2025 at 7:56 AM, Surveyor observed Licensed Practical Nurse (LPN)-L obtain R422's blood sugar. The result was 216. At 8:15 AM, Surveyor observed LPN-L prepare R422's morning medications and documented the medications as they were placed into the medication cup: -Allopurinol 100 mg -Aspirin 81 mg -Vitamin D 25 mcg -Docusate 100 mg -Furosemide 40 mg -Midodrine 5 mg -Acetaminophen 1000 mg LPN-L drew up 3 units of 70/30 insulin from the vial and when showing Surveyor the dosage, noticed that the needle was bent. LPN-L discarded the syringe and took out a new syringe. LPN-L drew up the 70/30 insulin and showed Surveyor the dose drawn up. LPN-L had drawn up 5 units. Surveyor asked LPN-L how many units were ordered. LPN-L stated 3 units and then recognized that 5 units were drawn up in the syringe. LPN-L corrected the dose to 3 units before administering to R422. Surveyor reviewed R422's physician orders. R422 had an order for Vitamin D 25 mcg 2 capsules and Docusate 100 mg 2 capsules to be given. Surveyor noted R422 had orders for Pantoprazole Sodium 40 mg and Thiamine 100 mg to be given at 8:00 AM that were not administered during the morning medication pass. On 5/20/2025 at 9:05 AM, Surveyor asked LPN-L if R422 received one or two capsules of Vitamin D and Docusate. LPN-L stated LPN-L administered one of each of the medications and should have given two of each. Surveyor asked LPN-L if R422 received Pantoprazole or Thiamine. LPN-L stated LPN-L did not give either of those two medications and should have. LPN-L stated LPN-L was flustered because R422 was sitting at the medication cart waiting to go to dialysis and it threw LPN-L off. LPN-L stated LPN-L would have caught that R422 did not get the Pantoprazole when LPN-L looked at the medication card because the pills are punched out by date and would have seen that the #20 punch was not done for that medication. LPN-L stated LPN-L would bring the four medications to dialysis for R422. On 5/21/2025 at 3:03 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the medication pass task had been completed and the medication error rate was 16.67 percent with five errors out of 30 opportunities. Surveyor shared the observation of LPN-L on 5/21/2025 giving one Vitamin D and Docusate instead of the ordered two capsules, not giving Pantoprazole or Thiamine, and LPN-L drawing up 5 units of 70/30 insulin when the order was 3 units and Surveyor intervening to ensure R422 received the correct dose of insulin.

Based on observation, interview, and record review, the facility did not ensure that foods were prepared in a way that prevented the risk of foodborne illness for 5 of 10 sampled residents (R2, R5, R7, R8, R10). Interview with residents foud that juices from the chicken served on 11/16/24 was red and touched all other foods on their plates. There was no investgation to determine what may have happened/how the food could have been under cooked, the number of residents who may have been affected, or to determine what steps need to be taken in order to avoid potential food borne illness. Findings include: ~During an interview on 11/26/24 at 8:53 AM, R2 stated on 11/16/24 (weekend) she and other residents in the dining room were served undercooked chicken pieces. R2 stated the blood from the chicken contaminated the noodles, vegetables, and everything else on the plate. R2 was admitted on [DATE]. The Minimum Data Set (MDS) dated [DATE] indicated R2 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. ~During an interview on 11/26/24 at 12:40 PM, R7 and R10 stated they were served uncooked chicken recently for lunch. R7 stated there was, .blood coming onto the noodles .bright red blood . R10 stated, There was no way I could eat it. R7 and R10 stated there was nothing else available to eat. R10 stated her family was very upset about it. R7 and R10 verified the DM was not in the facility when it occurred. R7 was admitted to the facility on [DATE]. The MDS dated [DATE] indicated R7 had a BIMS score of 15 out of 15 indicating she was intact in cognition. R10 was admitted to the facility on [DATE]. The MDS dated ,d+[DATE] indicted R10 had a BIMS of 15. ~During the resident group interview on 11/26/25 at 1:45 PM with R2, R5, R7, and R8, the residents complained about undercooked, inedible, chicken, the lack of an alternate, and that they went hungry due to not being able to eat their meals and no other food being available, which occurred on 11/16/24. R5 was admitted to the facility on [DATE]. The MDS dated [DATE] indicated R5 was cognitively intact with a BIMS of 14. R8 was admitted to the facility on [DATE]. The MDS dated [DATE] indicated R5 was cognitively intact with a BIMS of 15. Review of the Week at a Glance for General Week 4 menu revealed on 11/16/24 the supper (evening) meal consisted of baked chicken, herbed noodles, seasoned corn, and frosted cake. The alternate meal was meatballs with gravy. During an interview on 11/26/24 at 8:10 AM, DM C (Dietary Manager) stated R2 had complained to him recently about undercooked chicken. The DM stated he was not working the day it was served, but the next day he worked he talked to [NAME] D and looked at the leftover pieces in the walk-in refrigerator. The DM stated the bigger pieces were a little pink but did not look bloody. DM C stated the cook denied the chicken was undercooked. During an interview on 11/26/24 at 2:57 PM, DM C stated the report of undercooked chicken occurred on 11/16/24 when [NAME] D was on duty. DM C stated [NAME] D reported to him one person complained about undercooked chicken and a CNA (Certified Nursing Assistant) brought the resident's tray back. The chicken pieces served were legs and thighs, The DM stated he checked the temperature log for the chicken and the temperature for the chicken was satisfactory. The DM stated he did not interview any additional residents or staff related to the concern of undercooked chicken. During an interview on 11/26/25 at 3:44 PM, RD E (Registered Dietitian) stated she had not heard about undercooked chicken. RD E stated undercooked chicken could result in an outbreak of food borne illness and it would be important to investigate what the menu item was, how it was cooked, and what changes might need to be made in the future. During an interview on 11/26/24 at 5:03 PM, DON B (Director of Nursing) stated a CNA had informed her that the chicken served on 11/16/24 was not cooked and the food was returned to the kitchen. DON B stated she contacted NHA A (Nursing Home Administrator) and informed her of what the CNA reported to her. During an interview on 11/26/24 at 5:56 PM, NHA A stated she had received a message from DON B that the chicken served on 11/16/24 was red in the center. NHA A stated she went to the facility the next day (Sunday 11/17/24) and met with [NAME] D. NHA A stated [NAME] D informed her there was no issue. NHA A stated she talked to a few residents who denied there was a concern. NHA A stated the incident was handled informally and did not go through the grievance process. NHA A verified she had not interviewed any of the CNAs who served the chicken meal to the residents on 11/16/24. NHA A stated she concluded that only R2 had a concern with the chicken.

Based on interview, record review, and policy review, the facility failed to identify resident concerns as grievances and failed to provide a written response/resolution after receiving a grievance for 2 of 10 sampled residents (R2 and R3). Findings include: Review of the facility's policy titled, Resident and Family Grievances, dated 01/2024 and provided by the facility revealed, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal . Social Services has been designated as the Grievance Official . Grievance may be voiced in the following forums . a verbal complaint to a staff member or Grievance Official . The staff member receiving the grievance will record the nature and specifics of the grievance . forward the grievance form to the Grievance Official as soon as practicable . In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation . 1. R2 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) dated 09/03/24 indicated R2 was cognitively intact. During an interview on 11/26/24 at 8:53 AM, R2 stated on 11/16/24 (weekend) she and other residents in the dining room were served undercooked, bloody, and inedible chicken pieces. R2 stated she was not able to get anything else to eat and was hungry following the meal. R2 stated she reported the incident about undercooked chicken and the lack of alternates being available to DM C (Dietary Manager). R2 stated it was a formal complaint and there had been no follow up since it was reported. During an interview on 11/26/24 at 8:10 AM, DM C stated R2 had complained to him recently about undercooked chicken. DM C stated he was not working the day it was served but the next day he worked, he talked to [NAME] D and looked at the leftover pieces in the walk-in refrigerator. DM C stated the bigger pieces were a little pink but did not look bloody. During an interview on 11/26/24 at 2:57 PM, the DM stated the report of undercooked chicken occurred on 11/16/24 when [NAME] D was on duty. DM C stated [NAME] D reported to him one person complained about undercooked chicken and a CNA (Certified Nursing Assistant) brought the resident's tray back. DM C stated he checked the temperature log for the chicken and it was satisfactory. DM C stated he did not interview any additional residents or staff and verified he did not initiate a grievance form for R2. During an interview on 11/26/24 at 4:23 PM, SS F (Social Services) verified she was the Grievance Official. SS F stated grievances could come to her in numerous ways such as from a nurse, CNA, or resident coming to her with a concern. SS F stated it was important that grievances were logged to ensure they were handled in accordance with the facility's process and to ensure satisfactory resolution. SS F stated she was not aware of the report of undercooked chicken as a grievance had not been initiated. SS F stated the DM C should have initiated the grievance form or should have let social services know and she or her counterpart would have initiated one. During an interview on 11/26/24 at 5:56 PM, NHA A (Nursing Home Administrator) stated she had received a message from DON B (Director of Nursing) that the chicken served on 11/16/24 was red in the center. NHA A stated she went to the facility the next day on Sunday and met with [NAME] D. NHA A stated [NAME] D informed her there was no issue. NHA A stated she talked to a few residents who denied there was a concern. NHA A verified she had not interviewed any of the staff who served the chicken meal to the residents on 11/16/24. NHA A stated the incident was handled informally and did not go through the grievance process. NHA A stated that she concluded only R2 was affected. 2. R3 was admitted to the facility on [DATE] with a diagnosis of dementia. During an interview on 11/25/24 at 9:52 AM, R3's Family Member stated she had concerns with how the facility handled R3's laundry, with missing clothing, and with a meal tray being left in R3's room with gnats swarming around it. Family Member stated she was not satisfied with the outcome of some of the grievances and stated she had not received a written response from the facility for any of the grievances she had filed: ~06/12/24 R3's Family Member had concerns with missing clothing, ripped clothing, R3 being put to bed with pillows that did not have pillowcases, mixing up outfits, and that R3's laundry was going to the facility's laundry when she preferred to do the laundry. The form indicated the issues were addressed, the grievance was resolved on 06/13/24, and the concerned party was satisfied. ~07/18/24 R3's Family Member had concerns with another resident's food tray being left in R3's room and had gnats flying around it. The form indicated the issue was addressed and the grievance was resolved on 07/18/24. The form did not indicate that the concerned party had been notified of the result or whether she was satisfied. ~09/27/24 R3's Family Member had concerns with a missing outfit and two denim skirts. The investigation revealed the missing clothing was not listed on the inventory sheets. Family Member was educated on the importance of inventorying and labeling clothing. The request for reimbursement was denied because the items were not listed on the inventory sheets and the facility did not launder R3's laundry. Family Member was contacted on 10/01/24 and was not satisfied with the resolution. ~10/01/24 R3's Family Member had a concern regarding R3's dirty laundry. Family Member was offered for R3's clothing to be laundered by the facility which Family Member refused. Family Member was contacted on 10/01/24 with the resolution which she was not satisfied. ~10/02/24 R3's Family Member had a concern regarding a missing shirt and bottoms for R3. The investigation revealed the shirt had been replaced at a previous clothing drive and there were no inventory sheets with the shirt or bottoms noted. The family did R3's laundry. Family Member was notified on 10/03/24 and was not satisfied with the resolution. During an interview on 11/26/24 at 4:23 PM, SS F (Social Service) stated she was not R3's social worker and R3's social worker was out. SS F stated R3's Family Member had filed several grievances. SS F stated the facility reimbursed families/residents for missing clothing if the clothing was documented on an inventory sheet and the item could not be found. SS F stated families/residents were notified of the results of the grievance verbally; however, nothing was provided in writing. During an interview on 11/26/24 at 5:34 PM, NHA A (Nursing Home Administrator) stated she was aware of all of R3's Family Member's grievances and signed off on the grievance forms. NHA A stated Family member made complaints about missing clothing that the facility did not have logged on inventory sheets and the facility would not reimburse the Family Member for those items. NHA A stated the results of grievances were provided verbally, typically by a phone call; however, not in writing.

Based on observation, interview, and policy review, the facility failed to serve food that was palatable, at the appropriate temperature, for two of seven residents (Residents (R) 12 and R13) who were asked about food palatability out of 11 sample residents. This failure had the potential to affect resident meal intakes. Findings include: Review of the facility's policy titled, Record of Food Temperatures, dated 10/23 revealed, .It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled .Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy . Review of the Food and Drug Administration (FDA) Food Code, Chapter 3.5 Assessing Holding Time and Temperatures and Date Marking, dated 2022 revealed, .Use of an infrared thermometer for verifying holding temperatures is not consistent with Food Code requirements since verifying only the surface temperature of the food may not alert to problems that exist under the food's surface . Review of R12's quarterly Minimum Data Set (MDS) located in the MDS tab of the Electronic Medical Record (EMR) with an Assessment Reference Date (ARD) of 08/08/24 revealed R12 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact. Review of R13's quarterly MDS located in the MDS tab of the EMR with an ARD of 08/20/24 revealed a BIMS score of 15 out of 15 which indicated R13 was cognitively intact. During an observation and interview on 09/25/24 at 12:29 PM, R12 and R13 were observed seated at a dining table right by the entrance to the kitchen area. R12 was asked if the BBQ rib patty was hot and if it was palatable. R12 stated, The meat could have been warmer, it wasn't very hot. R12 was asked if the BBQ rib patty was palatable. She stated, I ate it, but it just wasn't hot. R13 was asked if she thought the BBQ rib patty was hot and palatable. R13 stated, The meat wasn't very hot, but it tasted ok, not like the Chili last night which was very hot and delicious. Review of the Week at a Glance, Week 3, menu provided by the Dietary Manager (DM) revealed the lunch meal for 09/25/24 was the following: .BBQ Rib Patty, Macaroni and Cheese, [NAME] Beans, Mix Fruit and Pita Bread . During an observation and interview on 09/25/24 at 12:22 PM, a test tray was provided by the DM. The DM stated that the food for the test tray was obtained off the steam table just prior to taste test. The BBQ rib patty was lukewarm when tasted. The macaroni and cheese and green beans were very hot and palatable. The DM tasted the BBQ rib patty and confirmed that it tasted lukewarm. The DM further confirmed the plate on which the food was served was cold. The DM stated that the hall trays had a pellet warmer under the plate however, since the dining room residents were served directly from the kitchen, there were no warming pellets under the dish. The DM was asked to temp the BBQ rib patty. He obtained an infrared laser thermometer, instead of a probe thermometer, which read 125 degrees. He stated that the serving temperature should have been 135 degrees. The DM was asked to provide the holding temps while the BBQ rib patty was on the steam table. The temp read 186. During an interview on 09/26/24 at 8:40 AM, Maintenance Director (MD) stated, I tempted the steam table wells, last night with a laser and all the wells were greater than 140 degrees however, there was one well that came in at 120 degrees. I called the technician who came out and stated that there was a switch on the circuit board that was bad. The MD confirmed that the facility was unaware of the broken switch until this issue came up.

Based on record review and interview, the facility did not ensure 1 of 4 sampled residents (R13) reviewed for falls failed to provide adequate assistance during a transfer. R13 was to be transferred with the assist of 2 staff and per a therapy recommendation, those staff were to use a gait belt and pivot transfer. On 8/12/23, staff transferred R13 with a sit to stand lift without assistance. R13 fainted and fell out of the sit to stand lift resulting in a laceration to the head requiring sutures. Findings include: R13 was admitted to the facility on [DATE] with diagnoses that included syncope (fainting) and collapse. R13's significant change Minimum Data Set (MDS), dated [DATE] indicated R13 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R13 was cognitively intact. the MDS also indicated R13 required extensive assistance of two staff for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. R13's care plan includes a problem area of .ADL self-care deficit related to impaired mobility, dated 3/3/23. An intervention for this problem area includes, The resident is totally dependent on two staff for transferring, which was implemented on 3/3/23. On 8/4/23, a Physical Therapy (PT) note stated, Pt (patient) was upgraded on unit to 2 person assist transfers bed<>chair and to toilet with pivot transfer and a gait belt. On 8/10/23, PT noted R13 was dizzy during therapy that day. On 8/11/23, Occupational Therapy (OT) documented that R13 reported a dizzy episode during therapy. On 8/12/23, a progress note indicated R13 was given Meclizine HCL (used for dizziness) at 1:50 a.m. for complaints of dizziness. A nursing note on 8/12/23 at 7:50 p.m., states R13 fell on floor in bathroom and had bleeding from the back of his head, complaints of headache, and numbness to both legs. It was recorded R13 was transferred to the hospital. R13 returned from the hospital with 3 sutures to the back of the head. The incident report, completed by LPN C (Licensed Practical Nurse) revealed LPN C heard a loud noise and ran in the direction the noise and entered R13's room. LPN C documented the resident was laying in the supine position on the bathroom floor, with his caregiver present. LPN C recorded that blood was noted coming from the back of R13's head and that R13 had complaints of headache and discomfort and stated he had fainted. The incident/accident report contained a written statement from CNA D (Certified Nursing Assistant). CNA D wrote R13 needed to have a bowel movement and wanted to go to the toilet. CNA D wrote R13 asked him if he would use the sit-to-stand lift instead of the gait belt transfer. CNA D wrote he hooked R13 up to the sit-to-stand and began moving him to the bathroom, when R13 just went down, hitting his head. CNA D wrote he called the resident's name, and the resident did not say anything for a minute or two. CNA D wrote R13 told him he fainted. On 11/28/23 at 8:08 AM, R13 was interviewed. R13 stated a CNA was taking him to the bathroom using the sit-to-stand lift and he fainted, fell back, and hit his head on the floor. He stated he could not remember the details of the fall. On 11/28/23 at 4:34 PM, LPN C was interviewed via telephone. She stated at the time R13 fell , CNA D was transferring R13 to the bathroom using the sit-to-stand lift. LPN C stated CNA D did not have a second staff present during the transfer and the resident slipped out of the sling and fell back and hit his head on the floor and had a laceration. LPN C stated at the time of the fall, R13 was a 2 person transfer and a second staff should have been present and assisting. On 11/29/23 at 12:05 PM, surveyor interviewed PT E (Physical Therapist) who was seeing R13 at the time of the fall. PT E stated his recommendation was for R13 to be a 2 person transfer using a gait belt and a stand and pivot from the bed to the chair and from the wheelchair to the toilet. He stated he did not recommend the use of the sit-to-stand lift for R13. Review of the Direct Supply Atlas Sit-to-Stand Lift Owner's Manual revealed on Page 14 of the manual under the operation section, .Caution: More than one assistant is recommended for all resident transfer activities; however, one assistant may be used based on proper evaluation by a medical professional . R13's medical record was reviewed in its' entirety, and there was no documentation of an evaluation from a medical professional indicating that R13 was safe to have only 1 staff assist with the use of the sit-to-stand. There was also no order for R13 to use a sit to stand lift. On 11/29/23 at 1:00 PM, DON B (Director of Nursing) verified there was no evaluation available for the sit-to-stand lift to be used for transferring R13. On 12/8/23 the facility submitted additional information including a summary time-line to review regarding the identified concerns regarding R13. Surveyor noted in reviewing the additional information the therapy details from OT vs PT differed, however PT had specified R13 was an assist of 2 for transfers, which should have been in place at the time of the fall. Review of the information indicates R13 was not assessed to safely use a sit to stand lift prior to the fall occurring. The facility indicated their policy regarding safe resident handling/transfers implemented and revised 11/23 allows under the facility explanation allows staff to determine the use of a mechanical lift as a safer alternative. Surveyor noted this is not a determination a CNA should be making and that for R13, if staff were to use a mechanical lift, R13 had been assessed to use a Hoyer lift as an alternative. Review of staff competencies indicate they were not completed prior to the fall.

Based on observation, record review, and interview, the facility did not ensure residents received care consistent with professional standards of practice to prevent pressure injuries, promote healing of pressure injuries, and prevent infection of pressure injuries for 4 (R274, R57, R63, and R55) of 6 residents reviewed for pressure injuries. *R274 developed a Moisture Associated Skin Damage (MASD) area to the sacrum on 9/8/2022 and the Care Plan was not revised with interventions to prevent further damage. The MASD progressed into an Unstageable pressure injury on 10/3/2022. The Unstageable pressure injury required hospitalization on [DATE] due to infection and [CONDITION(S)] requiring intravenous antibiotics where it was determined to be a Stage 4 pressure injury. The Facility failure to identify the causative factors for the MASD and revise the care plan based on the skin assessment to prevent a Stage 4 pressure injury created a finding of immediate jeopardy that began on 9/8/2022. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on 10/20/2022 at 11:49 AM. The immediate jeopardy was removed on 10/21/2022 however; the deficient practice continues at a scope/severity of G as evidenced by the following examples. *Upon admission to the facility R57 was assessed to be at moderate risk for the development of pressure injuries. R57's Admission Minimum Data Set (MDS) assessment documents R57 did not have any pressure injures upon admission to the facility. R57 developed an unstageable pressure injury to the left trochanter that became infected. R57's care plan did not address the preventative interventions of turning and repositioning. R57 then developed unstageable left heel and left outer ankle pressure injuries. R57's care plan did not address preventative interventions of off loading the heels or wearing off loading heel boots until after the pressure injuries developed. *R63 was admitted with a Stage 4 pressure injury. On 10/19/22, Surveyor observed a cushion in R63's Broda chair wrapped with a blanket and sheet. The cushion was identified as a Medline's gel foam cushion. Manufacturer instructions indicated the cushion was for comfort and pressure redistribution. The manufacturer instructions did not include information as to whether this cushion was appropriate for a Stage 4 pressure injury. * R55 was identified to be at moderate risk for skin impairment with a history of a stage 3 pressure injury to the coccyx which according to the last assessment healed on 10/3/22. On 10/18/22 Surveyor noted the facility power outage on 10/18/22 at 7:22 am. On 10/18/22 at 7:45 A.M., R55 was observed to be in bed with an alternating pressure mattress that was off during a power outage. Surveyor observed R55's air mattress remained off until 8:01 A.M. when the air mattress was plugged into a red outlet. Findings include: The facility policy and procedure entitled Clinical Protocol: Pressure Injuries/Skin Breakdown dated 7/22/2022 states: Assessment and Recognition: 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. 4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. 5. The physician will help identify and define any complications related to pressure ulcers. Cause Identification: 1. The physician will help identify factors contributing or predisposing residents to skin breakdown 2. The physician will clarify the status of relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, and the impact of comorbid conditions on healing an existing wound. Treatment/Management: 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. a. Although poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional interventions clearly prevent or heal pressure ulcer. b. Beyond trying to maintain a stable weight and providing approximately 1.2-1.5 gm/kg protein daily there are no routine pressure ulcer-specific nutritional measures for those with or at risk for developing a pressure ulcer. c. Any nutritional supplementation should be based on realistic appraisal of an individual's current nutritional status and minimizing any medications and conditions that may be affecting appetite and weight. 3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors 4. As needed, the physician will help identify medical and ethical issues influencing wound healing; for example, the impact of end-stage [CONDITION(S)] or because the resident or family declines artificial nutrition and hydration. a. Advance directives may limit the scope, intensity, duration, and selection of various wound-related or adjunctive treatments such as a choice to forego artificial nutrition and hydration. Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. b. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker. 1. R274 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R274's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R274 had severe cognitive impairment with a Brief Interview for Mental Status score of 7 and needed extensive assistance with bed mobility, transfers, toilet use, and hygiene. R274 was coded as being frequently incontinent of bladder and always incontinent of bowel. R274 was admitted with a deep tissue injury to the right heel. The Care Area Assessment (CAA) for Pressure Ulcer stated R274 was at risk for pressure ulcers due to currently impaired skin, incontinence, and decreased mobility; a Care Plan was implemented to have pressure reducing devices in place. On admission, R274 weighed 119 pounds. R274 did not have an activated Power of Attorney and was a full code. R274 went to [CONDITION(S)] every Monday, Wednesday, and Friday at the [CONDITION(S)] center located in the facility. R274's Potential Impairment to Skin Integrity Care Plan was initiated on 3/3/2022 with the following interventions: -Encourage good nutrition and hydration. -Assess skin on a weekly basis on scheduled bath day and document findings on a weekly skin assessment. -Report any skin redness/impaired integrity areas to the nurse. -Use barrier cream to prevent skin impairment issues as needed. On 3/17/2022, R274's Functional Bladder Incontinence Care Plan was initiated with the following interventions: -Check frequently and as required for incontinence; wash, rinse, and dry perineum; change clothing as needed after incontinence episodes. -Monitor/document for signs/symptoms of urinary tract infection. On 3/17/2022, R274's Potential Impairment to Skin Integrity Care Plan included the Deep Tissue Injury to the right heal and was revised with the following interventions: -R274 needs a pressure reducing cushion to protect the skin while up in chair. -R274 needs a pressure reducing mattress to protect the skin while in bed. On 4/1/2022, R274 developed Moisture Associated Skin Damage (MASD) to the buttocks that measured 7.0 cm x 8.0 cm x 0.1 cm with 50% intact skin and 50% pink or red non-granulating tissue. Wound Registered Nurse (RN)-J documented scattered areas denuded across bilateral buttocks; R274 has had obvious weight loss due to loose, extra skin folds throughout body and has poor intake. Supplements and off-loading mattress and cushion in place. R274 had a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/1/2022, a treatment to the buttocks was obtained: wash with normal saline, apply silver alginate followed by a bordered gauze dressing every Monday, Wednesday, and Friday. Surveyor noted silver alginate is contraindicated for individuals with severe renal disease. R274's MASD to the buttocks was comprehensively assessed weekly from 4/1/2022 until 5/16/2022 when the wound healed. On 4/18/2022, 17 days after the discovery of the MASD to the buttocks, R274's Altered Skin Integrity Care Plan for non-pressure rash was initiated with the following interventions: -Conduct weekly skin inspection. -Monitor for signs/symptoms of infection such as swelling, redness, warmth, discharge, odor; notify physician of significant findings. -Provide pressure-reducing wheelchair cushion. -Provide thorough skin care after incontinent episodes and apply barrier cream. -Treatments as ordered. -Weekly Wound assessment. On 5/4/2022, R274's Potential Impairment to Skin Integrity Care Plan was resolved. On 5/4/2022, R274's Bowel Incontinence Care Plan was initiated with the following interventions: -Apply barrier cream every shift as needed or after every incontinent episode. -Check R274 every two hours and assist with toileting as needed. -Provide loose fitting, easy to remove clothing. -Provide pericare after each incontinent episode. On 5/16/2022, the treatment to the MASD to the buttocks was discontinued. On 5/16/2022, R274's Altered Skin Integrity Care Plan for non-pressure rash was resolved. On 5/17/2022, Ensure Plus 240 cc daily with breakfast was ordered for additional calories and protein. On 6/1/2022, R274's Potential Impairment to Skin Integrity Care Plan was reinstated with the following interventions: -Assist and encourage to keep nails short/trimmed. -Avoid scratching and keep hands and body parts from excessive moisture. -Monitor/document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician. -Use draw sheet or lifting device to move R274. -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. On 6/3/2022, R274 was positive for COVID-19 and recovered. On 8/24/2022, Magic Cup 120 cc daily was ordered. On 9/5/2022, R274's Braden scale score was 16 indicating at risk for pressure injuries. On R274's quarterly MDS assessment dated [DATE], R274 was coded as having moderate cognitive impairment with a BIMS score of 12 and needed extensive assistance with bed mobility, transfers, toilet use, and hygiene. R274 was frequently incontinent of bladder and always incontinent of bowel. No skin impairments were identified. R274 weighed 118 pounds on 8/25/2022 which was the weight used on the MDS assessment. On 9/8/2022 at 3:24 PM in the progress notes, Licensed Practical Nurse (LPN)-I charted an open area to the coccyx and an open area to the left buttock were discovered during cares for R274. A dressing was applied, Wound RN-J was notified, DON-B was notified, and Medical Director (MD)-K was updated. On 9/8/2022 on the Head to Toe Skin Check form, LPN-I documented a new skin integrity issue with open areas to the coccyx and left buttock. LPN-I documented the coccyx was a pressure injury and the left buttock was a skin tear. LPN-I charted in the area for further description of skin issues: R274 has very dry and flaky skin. No measurements or characteristics of the wounds were documented. On 9/8/2022, R274's Braden Scale score was 14 indicating moderate risk for pressure injuries, a change from 9/5/2022 where R274 was at risk for pressure injuries. No revisions were made to the Care Plan to address the increase in risk for pressure injury based on the Braden Scale score. On 9/9/2022 on the Wound Assessment Details form, Wound RN-J documented R274 had MASD caused by incontinence that was facility acquired on 9/9/2022 to the coccyx that measured 1.5 cm x 1.5 cm x 0.1 cm with 100% pink or red non-granulating tissue. Wound RN-J documented: Area with skin has been removed to the maceration area has virtually no drainage but resident does report some paying (sic) their resident has no Adipost tissue in the region? Surveyor noted the MASD started on 9/8/2022, not on 9/9/2022 as documented by Wound RN-J. The Wound Assessment Details form included a colored picture of the area and Surveyor noted the right half of the wound to have shiny pink tissue and the left half of the wound to have what appeared to be yellow slough-like tissue; the wound did not appear to be MASD but pressure due to the presentation of the tissue types. Surveyor noted RN-J's wound assessment does not accurately describe the picture of the coccyx wound, as there is no referencing that the wound having slough-like tissue. On 9/9/2022 on the Weekly Skin Review form, Wound RN-J documented R274 had a new area of MASD to the coccyx and buttocks. Surveyor noted the documentation on 9/8/2022 and the Weekly Skin Review form on 9/9/2022 indicated two skin impairment areas: the coccyx and the (left) buttock. Only the coccyx was documented on, and no clarification was documented regarding the total number of areas present. On 9/9/2022, an order to cleanse the coccyx wound with normal saline, apply skin prep to the surrounding area, apply xeroform to the wound bed and cover with a bordered gauze dressing every evening shift was entered onto the Treatment Administration Record (TAR). Surveyor noted the packaging for Xeroform dressing indicated it is an occlusive dressing that keeps air out, which can help to protect the area while also promoting a moist environment for healing. Surveyor noted a Xeroform dressing to an area of skin breakdown caused by moisture would keep the skin moist and potentially increase the damage to the skin. On 9/9/2022, an order to monitor the skin alteration to the coccyx for any signs or symptoms of infection (warmth to wound site or surrounding area, increased pain, odor, bleeding, [CONDITION(S)], or change in the amount or the color of the wound drainage) and notify the physician if any signs or symptoms of infection were noted every shift was entered onto the TAR. No interventions to the Care Plan were added to address increased incontinence care, turning, or prevention of further damage to the skin. On 9/10/2022 at 3:10 PM in the progress notes, LPN-I charted the dressing change was done that morning and remained clean and intact to the coccyx/buttocks. On 9/11/2022 at 6:38 AM in the progress notes, nursing charted R274 slept through the night with no complaints of any pain. Nursing will continue to monitor the open area to the coccyx. On 9/11/2022 at 9:56 PM in the progress notes, nursing charted the dressing was intact to the coccyx; R274 was encouraged to reposition self from side to side while in bed. On 9/12/2022 at 3:56 AM in the progress notes, nursing charted R274 had no complaints of pain from the open area to the coccyx. On 9/12/2022 on the Wound Assessment Details form, Wound RN-J documented R274 had MASD caused by incontinence that was facility acquired on 9/9/2022 to the coccyx that measured 2.0 cm x 1.0 cm x 0.1 cm with 100% pink or red non-granulating tissue. Wound RN-J documented: area with skin has been removed to the maceration area has virtually no drainage but resident does report some paying (sic) their resident has no Adipose tissue in the region overall skin condition very dry and flaking. Surveyor noted the MASD started on 9/8/2022, not on 9/9/2022 as documented by Wound RN-J. The Wound Assessment Details form included a colored picture of the area and Surveyor noted two areas present. Surveyor noted RN-J's wound assessment does not describe the picture of the coccyx wound which shows 2 areas. On 9/12/2022 at 10:14 PM in the progress notes, Medical Director (MD)-K documented a physician visit was done due to staff and family concerns. The progress note states no complaints from R274, and nursing concerns are R274 was sleepier than before, difficult to be aroused on occasion, and more confused than at baseline. The Assessment and Plan section of the note stated R274 was a demented patient with increasing sleepiness and some failure to thrive; fluctuating consciousness may suggest [CONDITION(S)] and acute process. Labs for CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), and ammonia level will be checked; R274 was non-focal on exam and in interview. Surveyor noted MD-K did not address or document any skin concerns that had been brought to MD-K's attention on 9/8/2022. On 9/13/2022, R274 weighed 107.8 pounds, a weight loss of 10.6 pounds in 19 days or 9%. On 9/14/2022 at 10:43 AM in the progress notes, DON-B charted R274 had a weight loss. DON-B charted R274 was alert and responsive and denied any stomach discomfort stating R274 did not have an appetite. MD-K was updated, and labs were ordered. On 9/14/2022 at 2:24 PM in the progress notes, nursing charted R274 complained of headache and left eye pain. R274 was alert and oriented, no swelling was noted to the left eye, R274 had decreased food and fluid intake and complained of diminished vision to the left eye. MD-K was updated, and an order was received to send R274 to the hospital for evaluation and treatment. On 9/14/2022 at 5:32 PM in the progress notes, nursing charted a call was received from the hospital and all labs, vital signs, and the CT of the head were negative and R274 would be coming back to the facility. On 9/14/2022 at 10:15 PM in the progress notes, MD-K documented a physician visit due to patient request for services. MD-K documented R274 complained of a headache which R274 could provide no details of except that it was the worst headache of R274's life; R274 was unable to recall a trigger, duration, recurrent, aggravating or mitigating factors surrounding the headache but says there is something wrong with the eye and then was unable to finish the thought. MD-K documented nursing had concerns R274 was sleepier than before, difficult to arouse on occasion, and more confused than at baseline. MD-K documented nursing stated R274 had complained to two different nurses about the left hand and then the right eye. The Assessment and Plan section of the progress note indicated R274 would be sent for imaging to rule out any active bleeding and if negative, add [MEDICATION(S)] to the medication regimen to address the headache. Surveyor noted MD-K did not address or document any skin concerns that had been brought to MD-K's attention on 9/8/2022. On 9/16/2022 on the Weekly Skin Review form, LPN-I documented R274 had an open area to the coccyx and the right buttock. No further description of the areas was documented. On 9/16/2022 at 3:58 PM in the progress notes, the Registered Dietician (RD) documented R274's significant weight loss of 12.2 pounds (11%) in the last month, a loss of 9 pound (8.3%) in the last three months, and an under significant loss of 6.2 pounds (5.8%) in the last six months. Oral intake over the last four weeks averaged 36-52% of the meals. Some weight fluctuations were anticipated due to [CONDITION(S)], but R274 appeared to have wrinkled skin from notable weight decrease. Labs were reviewed and with decreased intake and weight loss, Ensure was increased to three times daily. On 9/16/2022, Ensure Plus 240 cc three times daily was ordered, increasing the Ensure Plus from once daily to three times daily and Magic Cup was discontinued. On 9/18/2022 at 10:15 AM in the progress notes, MD-K documented a physician visit due to staff concerns. MD-K documented nursing had concerns with R274 losing weight and having a poor appetite occasionally refusing meals stating R274 did not like the food. The Assessment and Plan section of the progress note indicated R274 had progressive weight loss without significant fluid overload to begin with and could not account for the weight loss. R274 had severe protein malnutrition and was running out of option and not responding to current therapies. MD-K offered R274 a PEG (percutaneous endoscopic gastrostomy) feeding tube which R274 could not understand and would have to discuss with R274's family which had been declining the PEG tube lately. On 9/19/2022 on the Wound Assessment Details form, Wound RN-J documented R274 had MASD caused by incontinence that was facility acquired on 9/9/2022 to the coccyx that measured 5.0 cm x 6.0 cm x 0.1 cm with 50% intact skin and 50% pink or red non-granulating tissue. Wound RN-J documented: area with skin has been removed Now in a minute with other small areas that the maceration has removed the top layer of dermis doesn't (sic) resident does report area being tender resident appetite is poor returned from [CONDITION(S)] and just wanted to sleep? Surveyor noted the MASD started on 9/8/2022, not on 9/9/2022 as documented by Wound RN-J. The Wound Assessment Details form included a colored picture of the area and Surveyor noted multiple areas present. Surveyor noted RN-J's wound assessment details does not include a description of the multiple areas as shown on the coccyx wound picture. Surveyor noted the area increased in size with more open areas; no change in treatment or revision of R274's Potential Impairment to Skin Integrity Care Plan was implemented to prevent further damage. No documentation was found that the physician was notified of the change in the wound. On 9/20/2022 at 10:16 AM in the progress notes, MD-K documented a physician visit due to patient request for services. MD-K documented R274 complained of low back pain but was unable to state how long the pain had been present, if there were any triggers, associated symptoms, or modifying factors to the pain; R274 only stated that it hurts. MD-K documented nursing had no concerns. The Assessment and Plan section of the progress note indicated R274 was a demented cachectic [CONDITION(S)] patient with low back pain in advanced age with possible osteoporotic fracture and an x-ray would be ordered to rule out a fracture; R274 did not have any neurological deficits to suggest spinal cord compromise or fever to suggest an [MEDICATION(S)] abscess. No documentation was found that MD-K was informed of R274's increase in MASD to the coccyx or participation in developing interventions to address the MASD. On 9/21/2022 at 4:06 PM in the progress notes, DON-B charted DON-B spoke to R274 regarding the weight loss and R274 stated R274 does not have an appetite. DON-B charted MD-K was updated and recommended a gastrostomy tube (G tube). DON-B charted DON-B discussed the G tube with R274 and R274 stated, I don't want a tube, I will try to eat what I can. DON-B also discussed the recommendation of a colonoscopy by the gastrointestinal clinic and after much encouragement and reassurance, R274 agreed to have a colonoscopy scheduled. On 9/22/2022 at 10:18 AM in the progress notes, MD-K documented a physician visit due to a preoperative cardiopulmonary risk assessment requested in preparation for a colonoscopy for a patient on anticoagulant and multiple cardiovascular risk factors. MD-K documented R274 had no complaints. MD-K documented nursing had no concerns. The Assessment and Plan section of the progress note indicated R274 denied chest pain and there were no signs or symptoms of heart failure; routine labs and EKG before the procedure were acceptable. The anticoagulant medication would be discontinued. On 9/23/2022 at 6:57 PM in the progress notes, the RD documented R274 continued to trend down in weight with current weight of 102.6 pounds on 9/23/2022. The RD documented R274 eats 25-50% of meals which was similar to the last RD review; tube feeding had been discussed with R274 and R274 had declined tube feeding. Oral intake was encouraged and R274 accepts approximately 1.5 cans of Ensure per day of the three cans that are offered. On 9/23/2022 on the Weekly Skin Review form, nursing documented R274 had open areas on both buttocks with a treatment in place. No further description of the areas was documented. On 9/26/2022 on the Wound Assessment Details form, Wound RN-J documented R274 had MASD caused by incontinence that was facility acquired on 9/9/2022 to the coccyx that measured 6.0 cm x 2.0 cm x 0.1 cm with 50% intact skin and 50% pink or red non-granulating tissue. Wound RN-J documented: area has contracted and filled with scar tissue now displays as 4 areas separated by scar tissue resident does report area being tender resident appetite is poor returned from [CONDITION(S)] and just wanted to sleep. Surveyor noted the MASD started on 9/8/2022, not on 9/9/2022 as documented by Wound RN-J. Surveyor noted scar tissue is not a typical tissue type for MASD; no change in treatment or revision of R274's Potential Impairment to Skin Integrity Care Plan was implemented to prevent further damage. No documentation was found that the physician was notified of the change in the wound. On 9/26/2022 at 8:46 AM in the progress notes, MD-K documented a physician visit due to weight loss. MD-K documented R274 had no complaints. MD-K documented nursing had a concern with continued weight loss, decreased oral intake, and several weeks of R274 losing as much as 2 pounds per week. The Assessment and Plan section of the progress note indicated R274 was failure to thrive with multiple medical issues and unresolved gastrointestinal problems requiring an EGD (esophagogastroduodenoscopy), colonoscopy, and likely a PEG tube as interventions against weight loss. MD-K documented R274 had failed appetite stimulants and had lost 20 pounds over the last fifteen months to get to the current weight of 102 pounds. MD-K documented R274 was unable to carry out conversation regarding management of the weight loss due to dementia and cannot discuss directives, issues, and cannot give informed consent; R274's family was not returning phone calls. No documentation was found that MD-K was informed of R274's change in MASD to the coccyx or participation in developing interventions to address the MASD. On 9/27/2022 at 8:29 AM in the progress notes, DON-B charted R274 continued to have poor food and fluid intake and DON-B spoke to R274 regarding the consequences of malnutrition like continued skin breakdown, fatigue, and decline in overall health and discussed R274's declination of artificial feeding. DON-B charted R274 stated R274 never said R274 did not want artificial feeding and R274 did not seem to recall conversations about artificial feeding. MD-K was updated. On 9/28/2022 at 12:16 PM in the progress notes, MD-K documented a physician visit due to staff concerns. MD-K documented R274 had no complaints. MD-K documented nursing had a concern R274 was unable to participate in making decisions regarding decisions with healthcare. The Assessment and Plan section of the progress note indicated R274 was assessed for mental capacity and met the statutory definition of incapacity, and the Power of Attorney (POA) for Health Care would be activated. On 9/30/2022 on the Weekly Skin Review, LPN-I documented R274 had open areas to the coccyx and right buttock. No further description of the areas was documented. On 9/30/2022 at 10:30 AM in the progress notes, the RD documented the RD visited R274 due to continued weight loss. The RD documented R274 was hallucinating and pointed to snacks that did not exist when asked what food sounded good to R274. The RD documented R274 visualized a lady in the room and perseverated on that vision and could not focus on the RD when encouraging R274 to drink Ensure. The RD documented R274's behavior was discussed with the nursing staff and nursing staff reported R274 did better with drinking the Ensure at breakfast; nursing staff was monitoring intake and encouraging R274 to eat and drink. The RD documented nursing and the interdisciplinary team was working on a GI consult, interventions for weight loss, and POA activation. The RD recommended staff offer R274 food and fluids between meals. On 9/30/2022, give snacks at 10:00 AM, 2:00 PM, and 10:00 PM was ordered to help gain weight, and to notify physician if R274 was not eating. On 9/30/2022 at 12:02 PM in the progress notes, MD-K documented a physician visit due to confusion and polypharmacy. MD-K documented R274 had no complaints. MD-K documented nursing had a concern R274 was progressively more confused than before. The Assessment and Plan section of the progress note indicated R274's medications were reviewed with some being discontinued, and labs would be drawn to rule out reversible causes of confusion. From 9/30/2022 through 10/2/2022, nursing monitored and charted on R274's appetite and intake. On 10/2/2022 at 10:37 AM in the progress notes, MD-K documented a physician visit due to self-care deficits. MD-K documented R274 had no complaints. MD-K documented nursing had no concerns. The Assessment and Plan section of the progress note did not have any information documented. On 10/3/2022 on the Wound Assessment Details form, Wound RN-J documented R274 had MASD caused by incontinence that was facility acquired on 9/9/2022 to the coccyx that measured 6.0 cm x 2.0 cm x unknown depth with 100% necrotic tissue. Wound RN-J documented the wound had degraded and was now an Unstageable pressure injury; tissue was necrotic with no drainage. Wound RN-J documented supplements were added, and an off-loading mattress was ordered. Surveyor noted the MASD started on 9/8/2022, not on 9/9/2022 as documented by Wound RN-J. The Wound Assessment Details form included a colored picture of the area and Surveyor noted the wound appeared drastically different from any of the previous pictures and assessments. Surveyor reviewed the TAR from 9/9/2022-10/3/2022; the order to notify the physician if there were any signs or symptoms of infection to the coccyx wound was marked n or 0 indicating no signs or symptoms of infection were noted by the nursing staff for each shift. No documentation was found that MD-K, administrative staff, or Wound RN-J had been notified by nursing staff of the deterioration of the wound from 9/26/2022 through 10/3/2022. On 10/3/2022 on the Head to Toe Skin Check form, Wound RN-J documented R274 had a new Unstageable pressure injury to the sacrum measuring 3.5 cm x 9.0 cm x unable to determine depth. Further description of the skin section of the form stated the area had declined rapidly. Surveyor noted the measurements of the Unstageable pressure i [TRUNCATED]

Based on observation, interview, and record review the facility did not provide care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . -R48 was at risk for the development of pressure injuries. The facility did not put interventions in place to offload pressure to R48's heels prior to R48 developing a pressure injury that developed necrotic tissue. -R62 was at risk for the development of pressure injuries. The facility did not put interventions in place to offload pressure to R62's heels following R62 having a fracture to their left femur. R62 developed an unstageable pressure injury to the left heel. The facility stated R62 refused offloading measures to his heel, but did not develop a plan of to address R62's refusals. -R66 has an unstageable pressure injury. R66 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R66's care plan of care did not include offloading interventions. -R64 is at risk for the development of pressure injuries. R64 was observed with their heels not offloaded. -R8 was admitted to the facility with pressure injuries and was observed not being turned and repositioned per their plan of care. The examples involving R48 and R62 are being cited at the scope and severity of a G (actual harm/isolated). Findings include: 1.) R48 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Braden Assessment on 5/1/21 scores R48 as 14 indicating R48 at being moderate risk for the development of pressure injury. The assessment documents R48's mobility as being slightly limited, chairfast, and nutrition as very poor. R48's quarterly MDS (minimum data set assessment), with an assessment reference date of 6/30/21 documents R48 requiring extensive assistance of 1 person's physical assist for bed mobility and rejection of care behavior was not exhibited during the assessment reference period. The assessment documents R48 having a brief interview for mental status score of 0 indicating 48 is severely cognitively impaired. The assessment documents R48 as being at risk for the development of pressure injuries. R48's plan of care includes a focus area for At moderate risk for skin integrity Score on Braden assessment for pressure Ulcers, [CONDITION(S)] [[CONDITION(S)]], Diabetes, Mellitus, Incontinence (B/B) [bowel/bladder], Weakness. Initiated on 10/28/2019 and revised on 4/29/20. The care plan includes interventions for Skin checks weekly when changing clothes, bathing, showering revised on 6/30/21 from previously being skin checks 2x week when changing clothes, bathing, showering and positions self revised on 6/11/20. Progress notes on 7/6/2021 at 6:18 am document resident bilateral heels is [sic] purplish in color and mushy, left message for [granddaughter] and [case manager] to returned [sic] call. A Wound Assessment on 7/6/2021 at 7:49 am documents a 5 cm x 6 cm deep tissue pressure injury to R48's right heel. A wound assessment note on 7/6/2021 at 9:05 am by Wound RN (registered nurse)-C documents .found on resident cares DTI [deep tissue injury] to right heel area is soft when palpated sero purulent drainage expressed slight depression where callused had been present peri wound dry and flaking: Medical history: [CONDITION(S)] diabetes [CONDITION(S)] MS [[CONDITION(S)]], depression, [CONDITION(S)] [hypertension], resident has been declining in health; supplements in place off loading boots in place. MD and POA [power of attorney] updated. Progress notes on 7/6/2021 at 8:42 am document [Contact] updated on wounds, goals of care discussed, air mattress ordered, heel boots worn at this time. On 7/6/2021 R48's plan of care was updated to include a focus area for The resident has pressure injury left heel for potential for pressure ulcer development r/t [related to] disease process, Immobility. The care plan was revised on 7/7/2021 to The resident has pressure injury right heel or potential for pressure ulcer development r/t disease process, Immobility. Interventions include off loading boots at all times, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate initiated on 7/6/2021 and air mattress initiated on 7/7/2021. The surveyor noted prior to 7/6/2021 R48's plan of care did not include interventions to offload R48's heels and that R48 required extensive assistance for bed mobility. On 7/12/2021 a wound assessment documents R48's wound as being a deep tissue pressure injury 60% necrotic hard firm adherent tissue and 40% blood filled blister. A wound assessment note by Wound RN-C documents .area is forming hard eschar. Further area of the wound bed still appears discolored and boggy Medical history: [CONDITION(S)] diabetes [CONDITION(S)] MS depression [CONDITION(S)], resident has been declining in health; supplements in place off loading boots in place. On 7/13/2021 at 7:54 AM the surveyor observed Wound RN-C perform wound care on R48. The surveyor observed R48 in a wheelchair and Wound RN-C lifted her foot, removed R48's offloading boot, and applied [MEDICATION(S)]. The surveyor observed Wound RN-C lift R48's foot and noted R48 did not help hold up her own foot. The surveyor observed R48's right heel to be black in color (eschar). On 7/13/2021 at 11:09 AM the surveyor interviewed Wound RN-C. The surveyor asked who developed care plans. Wound RN-C stated the MDS nurse makes a blanket one, and she was putting into that care plan when someone was admitted , or when they developed an area so if at risk interventions are in place such as given on their bed mobility if someone needs an air mattress or immobile need heels boated or boots on. The surveyor asked how it is determined in someone needs boots or heels offloaded to offload pressure from their heels. Wound RN-C stated based on their braden or bed mobility. The surveyor informed Wound RN-C of being unable to find interventions to offload pressure from R48's heels prior to her developing a pressure injury to her right heel. Wound RN-C stated she knew for R48 it wasn't put into place prior to the area developing. Wound RN-C stated it was one of those things, she just all of a sudden had this big blister. Wound RN-C stated R48 was still able to move and wearing shoes which now looking back probably wasn't the best thing. Wound RN-C stated she wasn't notified of discoloration prior to the big blister. The surveyor informed Wound RN-C of R48's care plan indicating she positions self, and R48's MDS indicating R48 required extensive assistance for bed mobility and requiring assistance with positioning during the survey. Wound RN-C informed the surveyor she did not develop R48's at risk pressure injury care plan. Wound RN-C stated during the last 3 and a half/ 4 months R48 has slowed down, some days she is better, and that today when she went to look at the heel it was difficult, she has had up days and down, hasn't had a steady decline, and that she believed it was a progression of R48's MS. The surveyor asked when care plans are reviewed. Wound RN-C stated quarterly and after she sees a residents' wounds. Wound RN-C stated she R48 did not have any issues until recently, R48 wasn't having any skin issues, wasn't eating much but was getting supplements, and was doing increased skin assessments. Wound RN-C stated R48 went to not having issues to having a big blister on her foot. On 7/13/2021 at 1:01 PM the surveyor informed NHA (nursing home administrator)-A and DON-B of concern related to R48 being at risk for the development of pressure injuries with no interventions in place to offload her heels prior to the development of a pressure injury with necrotic tissue. NHA-A stated R48 used to be up and walk and has had a recent decline. On 7/13/2021 at 2:17 PM NHA-A provided the surveyor with a doppler report completed on 7/8/21 indicating R48 has mild to moderate peripheral vascular disease changes. 2.) R62 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R62's Braden Risk assessment for predicting pressure ulcer risk on 4/1/21 documents R62 at being at risk for the development of pressure injuries scoring 18 R62's Braden Risk assessment for predicting pressure ulcer risk on 6/28/21 documents R62 at being at increased risk with an increased score of 16 indicating R62 is chairfast, and his mobility as slightly limited. R62's quarterly MDS (Minimum Data Set) Assessment, with an assessment reference date of 6/18/21 documents rejection of care behavior occurred 1 to 3 days during the 7 day look back period, R62 required extensive assistance of one person's physical assistance with bed mobility, was at risk for the development of pressure injuries, and does not indicate a turning/repositioning program was in place. R62's plan of care includes a focus area for At moderate risk for skin integrity Score on Braden Assessment for Pressure Ulcers, Decrease in cognition, Incontinence (B/B) [bowel/bladder], Weakness, [CONDITION(S)] initiated on 11/12/19 and most recently revised 6/22/21. The surveyor noted R62's plan of care did not include interventions to offload his heels of pressure or how and when staff should assist R62 with repositioning. R62's plan of care includes a focus area for [R62] is resistive to care r/t [related to] Not wanting to turn down music, refusing to use assistive device i.e. Walker or wheelchair. [R62] will barricade door to room. Resident will remove foley drainage bag and connect to leg bag, and pull strap tight, will refuse to have staff help initiated on 5/5/21 and most recently revised 5/11/21. The surveyor noted the plan of care does not indicate R62 has refusals to offloading measure of his heels or repositioning. R62's plan of care also includes a focus area for Alteration in skin integrity- resident has a venous stasis ulcer with partial/with swelling and dark discoloration of outer aspect of left lower leg 6/16/2021: intact, clear, fluid filled blister left heel initiated on 10/19/20 and most recently revised 6/22/21. Interventions include Elevate extremity initiated 10/19/20. R62's CNA (certified nursing assistant) Care Card, dated 7/12/21, documents Does not use call light or always make needs known, staff to anticipate needs and left heel wound, no shoe to left foot, gripper sock only. The Care Care does not instruct staff for offloading measures heels or to use a pressure relieving boot. On 5/21/21 R62 was seen by Wound Physician-L for venous ulcers to his bilateral lower extremities. Under Orders for Pressure Relief/Offloading the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/11/21 R62 was readmitted to the facility following a hospitalization for a left femur fracture. Progress notes on 6/16/21 document While doing ordered wound treatment to left leg writer noted a clear, fluid filled intact blister to left heel. Area difficult to measure due to resident asking writer to stop several times. Education provided to resident not to ambulate without assist and elevate lower extremities . On 6/17/21 a wound assessment note documents a 7 cm x 5.5 cm blood filled blister to R62's left heel. Wounds notes on 6/17/21 by Wound RN (registered nurse)-C documents . large fluid filled DTI [deep tissue injury] painful to the touch resident leg still edematous post fracture and was wearing shoes causing increase pressure . Resident educated he will be unable to wear shoes until swelling goes down and area heals Medical History: intellectual disabilities acute kidney failure, A FIB [[CONDITION(S)]] [CONDITION(S)] [hypertension] chronic Foley d/t [due to][CONDITION(S)] , PVD[peripheral vascular disease], [CONDITION(S)] ascites stasis [CONDITION(S)] supplements in place On 6/18/21 R62 was seen by Wound Physician-L who documents R62 as having a 5.29 cm x 5.59 cm suspected deep tissue injury to the left heel. Under orders for Pressure Relief/Offloading states Offload heels per Facility Policy/Protocol. On 6/22/21 the wound is documented as being 7 cm x 5.5 cm 100% deep maroon. On 6/25/21 R62 was seen by Wound Physician-L Who documents R62' s wound as being unstageable. Under orders for Pressure Relief/Offloading states Offload heels per Facility Policy/Protocol. On 6/28/21 the wound is documented as being unstageable 3.5 cm x 3.5 cm with 100% soft-adherent necrotic tissue. On 7/5/21 the wound is documented as being unstageable 3.5 cm x 3.5 cm with 100% soft necrotic tissue. On 7/9/21 Wound physician L documents R62's wound as being unstageable. Under orders for Pressure Relief/Offloading states Offload heels per Facility Policy/Protocol. On 7/12/21 the wound is documented as being 3 cm x 3.5 cm 20% bright pink or red tissue and 80% soft adherent necrotic tissue. On 7/7/21 at 12:10 PM the surveyor observed R62 in the hallway in his wheelchair with grey gripper socks on both feet, with his feet resting on the wheelchair foot pedals. On 7/7/21 at 1:22 PM the surveyor observed R62 in his wheelchair with grey gripper socks on both feet, with his feet resting on the wheelchair [NAME] pedals. On 7/7/21 at 8:37 AM the surveyor observed R62 in bed on his back, with his heels resting on the mattress, not offloaded or pressure. The surveyor asked R62 if he ever wears boots or puts a pillow under his feet to relieve pressure. R62 stated sometimes. On 7/12/21 at 9:27 AM the surveyor observed R62 in his wheelchair with gripper socks on both feet. On 7/12/21 at 10:26 AM, 12:14 PM, and 3:42 PM the surveyor observed R62 in his wheelchair with a boot on his left foot and a shoe on his right foot. On 7/13/21 at 9:03 AM the surveyor observed R62 sitting at the edge of his bed with gauze wrapper around both feet and with no boots on. On 7/13/21 at 12:37 PM the surveyor interviewed CNA (certified nursing assistant)-K. The surveyor asked if R62 wears boots. CNA-K stated she thought R62 only wore his boots in his bed, and that she was not aware of him refusing his boots. On 7/13/2021 at 11:09 AM the surveyor interviewed Wound RN-C. The surveyor asked who developed care plans. Wound RN-C stated the MDS nurse makes a blanket one, and she was putting into that care plan when someone was admitted , or when they developed an area so if at risk interventions are in place such as given on their bed mobility if someone needs an air mattress or immobile need heels boated or boots on. The surveyor asked how it is determined in someone needs boots or heels offloaded to offload pressure from their heels. Wound RN-C stated based on their Braden or bed mobility. The surveyor asked if R62 was supposed to have pressure relieving boots on. Wound RN-C stated no, R62 refuses. Wound RN-C stated R62 had wanted to wear shoes despite having [CONDITION(S)], and has an intellection disability delay, and can get upset if he fixates on something. Wound RN-C stated he had been agreeable to having a pillow in bed and occasionally will agree to a boot. Wound RN-C states some days he will agree and other days gets angry about it and it is not worth upsetting him. On 7/13/21 at 12:57 PM the surveyor interviewed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B. The surveyor informed NHA-A and DON-B of the concern related to R62 being at risk for the development of pressure injuries with no interventions in place to offload his heels following a fracture to his left leg and developing an unstageable pressure injury, and no care plan to address his refusals for offloading measures to his heels. DON-B stated the biggest thing for R62 was his continuing to want to wear shoes and updating his care card not to wear shoes and finally able to get him to do that. DON-B stated R62 moves around on his own, for example to the edge of the bed, without calling for staff assistance so also for him worries about boots being unsafe for him. DOB-B stated R62 refuses boots and offloading measures. The surveyor informed NHA-A and DON-B of the observation of R62 in bed and his wheelchair without offloading of pressure to heel occurring and of R62 being observed with a boot on to his lower extremity. 3.) R66 was readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R66's Annual MDS (Minimum Data Set) dated 6/16/21, documents a BIMS (Brief Interview for Mental Status) score of 13, indicating that R66 is cognitively intact. Section G (Functional Status) documents that R66 requires extensive assistance and a two person physical assist for his bed mobility and transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents that R66 has impairment to both sides of his upper and lower extremities. Section M (Skin Conditions) documents that R66 was admitted to the facility with 2 unstageable pressure injuries. Section M also documents that R66 is at risk for the development of pressure injuries. R66's Pressure Ulcer/Injury CAA (Care Area Assessment) dated 6/16/21 documents under the Analysis of Findings section, Alteration in skin integrity-Resident has a ulcer with partial/ full thickness with swelling and dark discoloration of greater aspect of left lower leg. R66's Braden Scale for Predicting Pressure Sore/Injury assessment dated [DATE] documents a score of 14, indicating that R66 is at moderate risk for the development of pressure injuries. R66's most recent Right Heel Wound Summary assessment dated [DATE] documents, Status: Active; Clinical Stage: Unstageable; Tissue Types: Necrotic Hard, Firm, Adherent-100%; Infection Present: Unable to determine; Exudate: None; Length: 6.00 cm (centimeters); Width: 9.00 cm; Depth: Unknown. R66's most recent Left Heel Wound Summary assessment dated [DATE] documents, Status: Active; Clinical Stage: Unstageable; Tissue Types: Necrotic Hard, Firm, Adherent-100%; Infection Present: Unable to determine; Exudate: None; Length: 6.50 cm (centimeters); Width: 8.00 cm; Depth: Unknown. Surveyor noted that R66's unstageable heel pressure injuries were improving since admission to the facility. Surveyor noted a decrease in the size of the wounds, weekly assessments with measurements and wound bed descriptions, physician notification and following of the wounds by a wound physician. R66's Tissue Analytics Wound Evaluation dated 6/18/21 documents, Location: Left Heel; Measurements: Length-1.98 cm (centimeters), Width: 5.62 cm, Depth: 0.20 cm; Etiology: Pressure Ulcer-Unstageable; Margin Detail: Attached Edges; Woundbed Assessment: Eschar; Drain Amount/Description: Small, Serous; Notes: Rx (Prescription): Cleanse with [MEDICATION(S)] QD (Daily) and PRN (as needed); apply lodosorb to open areas at the edges; secure with ABD (Army Battle Dressing) and Kerlix QD and PRN. Surveyor was unable to locate the second part of the order for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor noted that R66 was only receiving [MEDICATION(S)] to the left heel and missing the following part of the treatment order: Apply lodosorb to open areas at the edges; secure with ABD (Army Battle Dressing) and Kerlix QD and PRN. Surveyor noted that despite missing the second part of the treatment order, R66's left heel pressure injury was healing and improving since being admitted to the facility. R66's Skin Integrity plan of care dated as initiated on 7/8/19 documents under the Focus section, At moderate risk for skin integrity Score on Braden Assessment for Pressure Ulcers .Diabetes Mellitus, Weakness. Surveyor was unable to locate any offloading interventions for R66's heels in R66's Skin Integrity plan of care. On 7/7/21 at 10:07 a.m., Surveyor interviewed R66 regarding the pressure injuries to his heels. Surveyor asked R66 if facility staff offered to offload his heels to prevent further injury and promote healing. R66 informed Surveyor that facility staff offered to float his heels from time to time and that he did not mind having his heels offloaded. On 7/8/21 at 3:35 p.m., Surveyor observed R66 laying supine in bed with both heels resting directly on the mattress and not offloaded to prevent further injury and promote healing of R66's heel unstageable pressure injuries. On 7/12/21 at 8:04 a.m., Surveyor observed R66 laying supine in bed with both heels resting directly on the mattress and not offloaded to prevent further injury and promote healing of R66's heel unstageable pressure injuries. On 7/12/21 at 12:17 p.m., Surveyor informed Wound RN (Registered Nurse)-C of the above findings. Surveyor asked Wound RN-C if R66 should have his heels offloaded to prevent further injury and promote healing of R66's pressure injuries. Wound RN-C informed Surveyor that R66 should have his heels offloaded to prevent further injury and promote healing of R66's pressure injuries. Surveyor asked Wound RN-C why R66 did not have offloading interventions for his heels in his plan of care. Wound RN-C informed Surveyor that R66 should have had offloading interventions for his heels in his plan of care , but that due to the change in the EHR (Electronic Health Record) systems the facility recently went through, R66's offloading heel interventions were not added to his new plan of care. Surveyor asked Wound RN-C why R66's wound treatment order dated 6/18/21 was not included in R66's current wound treatment orders. Wound RN-C reviewed the order and informed Surveyor that she would add the second part of the wound order to R66's current wound order treatment. On 7/13/21 at 11:54 a.m., Surveyor informed DON (Director of Nursing)-B of the above findings. No additional information was provided. 4.) R64 was readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R64's Quarterly MDS (Minimum Data Set) dated 6/14/21 documents that R64 has short and long term memory problems. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R64 has severely impaired cognitive skills for daily decision making. Due to R64's mental status at the time of the survey, Surveyor was unable to interview R64. Section G (Functional Status) documents that R64 requires extensive staff assistance and a two person physical assist for her bed mobility and transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents that R64 has impairment to one side of her upper and lower extremities. Section M (Skin Condition) documents that R64 is at risk for the development of pressure injuries. R64's Pressure Ulcer/Injury CAA (Care Area Assessment) dated 4/7/21 documents under the Analysis of Findings section, Resident at risk for developing pressure ulcers as indicated by: Comorbidities. R64's Braden Scale for Predicting Pressure Sore/Injury assessment dated [DATE] documents a score of 13, indicating that R64 is at moderate risk for the development of pressure injuries. R64's most recent Left Lateral Wound Summary assessment dated [DATE] documents, Status: Active; Clinical Stage: Stage 3; Tissue Types: Necrotic Hard, Firm, Adherent-100%; Infection Present: Unable to determine; Exudate: Moderate; Length: 0.70 (centimeters); Width: 1.00 cm ; Depth: 0.60 cm. Surveyor noted that R64's unstageable left lateral pressure injury was improving since. Surveyor noted a decrease in the size of the wound, weekly assessments with measurements and wound bed descriptions, physician notification and following of the wound by a wound physician. R64's Skin Integrity plan of care dated as initiated on 7/27/20 documents under the Focus section, At risk for impaired skin integrity: Score on the Braden Scale Assessment for Pressure Ulcers; History of Pressure Ulcers; Cognitive impairment, Contractures of BILATERAL LOWER EXTREMITIES. Under the Interventions section it documents, Date Initiated: 04/27/2021: Bilateral heel boots on at all times except for cares. On 7/8/21 at 3:37 p.m., Surveyor observed R64 laying supine in bed with both heels resting directly on the mattress and not wearing heel boots per her plan of care. On 7/12/21 at 8:05 a.m., Surveyor observed R64 laying supine in bed with both heels resting directly on the mattress and not wearing heel boots per her plan of care. On 7/12/21 at 11:48 a.m., Surveyor observed R64 laying supine in bed with both heels resting directly on the mattress and not wearing heel boots per her plan of care. On 7/12/21 at 1:12 p.m., Surveyor observed R64 laying supine in bed with both heels resting directly on the mattress and not wearing heel boots per her plan of care. On 7/12/21 at 3:23 p.m., Surveyor observed R64 laying supine in bed with both heels resting directly on the mattress and not wearing heel boots per her plan of care. On 7/12/21 at 12:17 p.m., Surveyor informed Wound RN (Registered Nurse)-C of the above findings. Surveyor asked Wound RN-C if R64 should have her heels offloaded to prevent further injury and promote healing of R64's pressure injury. Wound RN-C informed Surveyor that R64 should have his heels offloaded to prevent further injury and promote healing of R64's pressure injury. On 7/13/21 at 11:54 a.m., Surveyor informed DON (Director of Nursing)-B of the above findings. No additional information was provided. 5.) R8 was admitted to facility on 3/5/21, and has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Minimum Data Set (MDS) assessment, dated 6/10/21, indicated R8 has a Brief Interview for Mental Status (BIMS) score of 6, which indicates R8 is severely impaired for daily decision making skills. R8 is on a repositioning program, extensive assist of one with bed mobility, extensive assist of 2 with transfers, incontinent of bowels and catheter for urine. R8's Care Plan, dated 3/11/21, revised on 7/06/21, with a target date of 9/20/21, states: . R8's is at risk for skin integrity, score on [NAME] Assessment for pressure ulcers, incontinence, weakness, actual stage IV pressure ulcer to sacral region. Interventions: *positioning wedge to be utilized and place at lower back. *Reposition at frequent intervals and PRN (as needed). *Wedge cushion may be used for repositioning as needed. R8's Braden Skin Assessment score on 6/24/21 was 14, indicating R8's is at a moderate risk for pressure injury. On 7/07/21, at 09:11 AM, Surveyor observed R8 lying in bed on his back with head of the bed elevated about 30 degrees. R8's heels were resting on air mattress, one heel boot on the floor and blue wedge cushion for positioning, lying on the floor under his bed at the foot of his bed. On 07/07/21, at 10:21 AM, Surveyor observed R8 lying in bed on his back slouched down, head of the bed up about 30 degrees. R8's legs slightly bent and leaning to his left side with green pressure reducing boots on both feet resting on the bed. R8 was unable to straighten legs on his own. On 07/07/21, at 11:58 AM, Surveyor observed R8 in bed continues to lay on his back. R8 has one green pressure reducing heel boot on and one laying on the floor. On 07/08/21, at 07:52 AM, Surveyor observed R8 sleeping in bed lying on his back. R8 had pressure relieving boots on bilateral feet resting on the bed. On 07/08/21, at 10:45 AM, Surveyor observed R8 lying in bed on his back and slouched down. R8's head of the bed was raised to 45 degrees. R8 was removing his clothes and his blanket was on the floor with no fall mat in place. On 07/08/21, at 11:12 AM, Surveyor observed Certified Nursing Assistant (CNA)-F go into R8's room, covered him up and put fall mat in place. CNA-F returned a five minutes later to provide cares. On 7/08/21, at 11:17 AM, Surveyor spoke with CNA-F about how often R8 should be repositioned. CNA-F informed surveyor R8 should be repositioned every 2 hours. R8 currently has a stage 4 pressure injury to sacral region. The facility staff did not implement the interventions on R8's care plan for repositioning frequently or use the wedge cushion for positioning.

Base on interview and record review the facility did not ensure 1 (R6) of 3 residents reviewed maintained acceptable parameters of nutritional status. R6 was noted to have a significant weight loss of 5.4 lbs. (pounds) within the first month of admission to the facility. R6's physician and family were not notified and interventions were not put into place to prevent further weight loss. R6 continued to lose weight and the physician and family were not notified timely, lab tests were ordered but not obtained timely and speech therapy recommendations were not identified on the care plan. R6 became unresponsive at the facility and was sent to the hospital via 911, where R6 weighed 77 lbs (a 30 lb. weight loss in 5.5 months). R6 passed away 18 days later. The facility's failures include: ~ Failure to complete a dietary assessment that included resident preferences ~ Not obtaining weekly weights per registered dietitian recommendations (there was a gap of 54 days in October/November 2020) ~ Lack of identification of the discrepancies in the amount of supplements ordered ~ Lack of intervention to encourage increased oral intake in the resident ~ Not having speech therapy recommendations included in the care plan ~ No family involvement until 1/19/21 and no physician involvement until 2/11/21 ~ Delay of ensuring ordered labs were completed and followed up on These failures created a finding of immediate jeopardy that began on 10/2/20. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of immediate jeopardy on 3/25/21 at 12:28 PM. The immediate jeopardy was removed on 3/26/21 when the facility implemented an action plan. The deficient practice continues at a scope and severity of an E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan for residents at risk for weight loss. Findings include: The facility policy entitled Weight dated 7/08, revised 7/14, states: . 1. All residents will be weighed on admission, readmission, weekly for the first 4 weeks and then at least monthly; 2. Weekly weights will also be done with significant change of condition, food intake decline that has persisted for more than one week, or with a physician order.; 4. The DON (Director of Nursing) or designee to determine a list of reweighs will review all weights, upon completion; 5. Once reweights have occurred any resident with an unexplained significant or insidious weight loss will have a weight loss investigation; 6. Dietary recommendations will be forwarded to the Health Care Provider. The facility policy, entitled Weight Change Investigation, dated 7/08, revised 7/14, states: to provide a policy for the investigation of significant or insidious weight changes. Guideline: 1 Weight change investigation will be initiated with the following: a. A significant weight change of 5% or more in 1 month, 7.5% or more in three months and/or 10% or more in 6 months; b. An insidious weight change of 5 pounds or more in 2 consecutive months; c. Any weight loss in a resident with a BMI (Body Mass Index) of < (less than) 20; 2. Once the weight change investigation is completed, the dietician and Health Care Provider will be contacted for interventions; 3. Interventions will be updated in the resident chart and if appropriate the resident or resident representative will be notified of the interventions; 4. If the resident or resident representative refuse any of the interventions, education regarding the rational for the interventions will be given. If they continue to refuse, documentation of the refusal will occur in the resident [NAME] and the Health Care Provider will be notified; 5. The weight change investigation will occur each month until the weight has stabilized, if based on the resident's condition, weight stability is the most appropriate goal; 6. If the weight loss is unavoidable based on resident condition, and stabilization is unlikely, a physician should document to why weight loss is medically unavoidable. R6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 9/9/20, documents: Staff Assessment of Mental Status, long and short term memory loss, rarely or never makes decisions; PHQ-9OV- Staff Assessment of Mood score of 3, indicating minimal depressive symptoms; requires extensive assist of 2 staff for bed mobility and transfers, requires extensive assist of 1 staff for dressing, eating, toilet use and hygiene; swallow disorder, holding food in mouth or cheeks, or residual food in mouth after meals; height 63 inches and weight 107 pounds; weight loss-no or unknown weight loss of 5% loss in 1 month or 10% in 6 months. R6's Care Plan, dated 9/4/20, documents: [R6] has potential nutritional problem r/t (related to) AFTT (Adult Failure to Thrive), Alzheimer's dementia, malnutrition as evidenced by MNA (Mini Nutritional Assessment) score of 0, CAD (Coronary Artery Disease), GERD (Gastroesophageal Reflux), [CONDITION(S)], weakness with unsteady gait and debility, h/o (history of) MI (Myocardial Infarction), need for mechanically altered diet. Per sister [R6] would limit intake in past stating she didn't want to get fat. 12/2020: MNA score is 2, indicating malnutrition. 1/2021 MNA score is 2 indicating, malnutrition. Interventions: Administer medications as ordered. Monitor/documents for side effects and effectiveness, date initiated: 9/4/20, revisions on: 9/4/20; Monitor, Document/report to MD (Medical Doctor) PRN (as needed) for s/sx (signs/symptoms) of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals; Date initiated: 9/4/20, revision on: 9/4/20; Monitor/record/report to MD PRN s/sx of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: 3 lbs. (pounds) in 1 week, > (greater than) 5% in 1 month, > 7.5 % in 3 months, > 10% in 6 months, date initiated: 9/4/20, revision on: 9/4/20; Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated, date initiated: 9/4/20, revision on: 9/4/20; Obtain and monitor weight report for any significant change, date initiated: 9/4/20, revision on: 9/4/20; OT (Occupational Therapy) to screen and provide adaptive equipment or feeding as needed, date initiated: 9/4/20, revision on 9/4/20; Provide and serve supplements as ordered: 2 Cal HN 120 cc (cubic centimeter) TID (three times per day), Magic cup at lunch, date initiated: 12/8/20, revision on: 12/8/20; Provide and serve diet as ordered. General diet with Mech (Mechanical) Soft texture. Observe intake and record q (every) meal, date initiated: 9/4/20, revision on: 12/8/20; RD (Registered Dietitian) to evaluate and make diet change recommendations PRN, date initiated: 9/4/20. R6's Care Plan, dated 9/4/20, documents: [R6] has potential fluid deficit r/t (related to) poor intake, dementia, history of UTI (Urinary Tract Infection), adult failure to thrive, mechanically altered diet, dated initiated 9/4/20, revision date: 9/4/20. Interventions include: Administer medications as ordered. Monitor/document for side effects and effectiveness, date initiated: 9/4/20; Monitor and document intake and output as per facility policy; date initiated: 9/4/20; Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities, date initiated: 9/4/20; Monitor/document bowel sounds and frequency of BM (bowel movement); provide mediation per order, date initiated: 9/4/20; Monitor/document/report to MD PRN 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, dated initiated: 9/4/20; Notify Physician if: Persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours; persistent output exceeding intake past 48 hours; abnormal labs, date initiated: 9/4/20; Obtain and monitor lab/diagnostic work as ordered. Report results to MD ad follow up as indicated, date initiated: 9/4/20. R6's Care Plan, dated 9/4/20, documents: [R6] has an ADL (Activities of Daily Living) self-care performance deficit r/t Alzheimer's, impaired balance, adult failure to thrive, weakness, dated initiated: 9/4/20, Interventions: . Eating: Assist with feeding with meals, instruct to hold head up with eating, date initiated: 9/4/20, revision on 10/20/20. On 9/4/20, R6's MNA (Mimi Nutrition Assessment), documents: A severe decrease in food intake over the past 3 months, due to loss of appetite, digestive problems, chewing or swallowing difficulties; Weight loss greater than 3 kg (kilograms) in the last 3 months; Bed or chair bound; Has suffered psychological stress or acute disease in the last three months; Severe dementia or depression; BMI less than 19. R6' Score on the MNA is documented as N/A (not applicable). The MNA scores indicated: 0-7: malnutrition; 8-11: at risk for malnutrition; 12-14: normal nutritional status. These is no indication for a score of n/a. On 9/4/20, R6's medical record documents a Dietary Profile, which notes: An admission assessment, Height: 63, weight 106.8 lbs.; BMI: 18.9; General diet with puree texture and regular liquids; no current nutritional supplements, appetite fair; estimated calorie needs 1699, estimated protein needs 45-58; estimated fluid needs 1699; no likes or dislikes documented, this area of the assessment is left blank; is alert; has dentures; has a swallowing problem; uses regular utensils and drinks from a cup; nutritional risk factors: BMI is 20.9 or less, malnutrition or MNA score of 0-7, failure to thrive; during the past three months has been eating less than usual amount, has lost weight, has limited mobility, is wheel chair or bed bound. Resident observations: [R6] is assisted with all meals, ate about 50% of lunch today; skin intact, Meds (medications) reviewed. MNA score is 0, indicating malnutrition, per hospital records, appetite and intake were poor prior to admission. Current weight-106.8, currently at 92% IBW (ideal body weight) with BMI of 18.9. appears underweight. Would recommend starting 2 cal 60 cc TID (three times per day) as supplement due to malnutrition. Will also refer to RD for same. Will continue to monitor and follow up as needed. R6's September Medical Administration Record (MAR) documents: on 9/5/20 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 120 cc. This is different from the recommendation of 2 cal HN TID 60 cc. On 9/8/20, R6's medical record documents: Registered Dietitian (RD)-D's progress note: Advanced dementia with MNA score of 0, indicating malnourished status. Puree diet, thin liquids, 60 cc 2 cal HN TID. Needs to be fed by staff; . has dentures. Eating in room per Covid protocol. Meal intake ranging 50%-100% until 9/7, when it ranged 25%-50%. Staff encourages adequate fluid intake to promote desired hydration status. 9/3 wt (weight)=106.8# (pounds). BMI-18.9, indicating underweight status. Stable weight or weight gain desired. Hosp (hospital) wt= 106.5#. No recent wt change noted. Hosp labs reviewed; no nutritionally significant labs noted.Nutritional problem: inadequate oral intake related to adult FTT (failure to thrive), as evidenced by variable meal intake, low BMI, need to be fed by staff. Unable to visit due to Covid protocol. Plan to continue diet and supps (supplements) to meet nutritional needs. Monitor prn, including weekly weights. R6's score on the 9/4/20 MNA screen is documented as N/A, not 0; the actual amount of 2 cal HN supplement R6 is receiving is 120 cc not 60 cc as documented by RD-D. R6's weights were not recorded weekly as requested by RD-D. R6's weights are documented as: 9/3/20: 106.8 lbs.; 9/14/20: 11 days after R6's initial weight, 105.5 lbs.; 9/21/20: 7 days after last weight, 105.0 lbs.; 10/2/20: 11 days after last weight, 101.4 lbs. R6's weight loss from admission 9/3/20: 106.8 lbs. and one month later 10/2/20: 101.4 lbs. documents a significant weight loss in one month of 5.4 lbs., greater than 5% loss in one month. No new interventions were put into place and surveyor is unable to locate documentation R6's physician and family were notified of the significant weight loss. Surveyor unable to locate documentation a Weight Change Investigation was completed per facility policy. On 10/6/20, R6's medical record documents, Interdisciplinary Team (IDT)/WWF (Wounds, Weight Loss and Falls) meeting, which documents: Case discussed at today's WWF meeting for weight status: 10/2 wt=101.4 #. BMI-18.0, indicating underweight status, consistent with thin appearance. 9/21=105.0#. 9/3/106.8#. Note significant weight loss in past month >.5% loss), most likely r/t inadequate oral intake. On MS (mechanical soft diet), thin liquids, 60 cc 2 cal HN TID. Diet upgraded to MS from puree (sic) as of 9/23. Needs to be fed by staff, eats at slow pace. Meal intake records show variable intake at 25-75 %. Staff encourages adequate fluid intake; shows no s/s (signs/symptoms) of dehydration with good skin turgor, moist lips. Skin intact. Nutritional problem: Weight loss r/t adult failure to thrive and inadequate oral intake, AEB (As Evidenced By) significant weight loss > 5% in past month, variable meal intake, low BMI, need to be fed by staff, slow rate of eating, supps. New nutritional interventions: increase 2 cal HN to 120 cc TID for additional calories to compensate for variable meal intake. Plan to continue to have staff assist resident in feeding. Monitor prn, including weekly weight. R6's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No new interventions were put into place when R6 was identified as having a significant weight loss since admission and R6's physician and family were not notified of the significant weight loss and R6's care plan was not updated and weekly weights were not obtained per RD-D's recommendation. On 10/7/20, R6's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Magic Cup, Ice Crm (cream)] in the afternoon for additional calories, serve Magic Cup with lunch. On 11/25/20, R6's medical record documents: a weight of 94.6 lbs. R6 is down 12.2 lbs., 11.4% since admission. No new interventions are put into place to address the weight loss, R6's care plan was not updated to address the severe weight loss. Surveyor is unable to locate documentation R6's physician and family were notified of the weight loss and R6's November 25th weight was 54 days from R6's last weight, when RD-D recommended weekly weights on 10/6/20. On 12/2/20, R6's medical record documents: Quarterly review; MNA with a score of 2, indicating malnutrition. No decrease in food intake in the last 3 months; weight loss greater than 6.6 lbs. in 3 months; bed or wheelchair bound; psychological stress or acute disease in last 3 months; severe dementia; BMI of less than 19. On 12/8/20, R6's medial record documents RD-D's progress note, which notes: Quarterly nutrition review . MNA score of 2 indicting malnutrition. On MS diet, thin liquids, 120 cc 2 cl HN TID, magic cup every L (lunch), diet upgraded to MS from pureed as of 9/23. Needs to be fed by staff, eats at slow pace.Meal intake records show variable intake at 25-75 %. Consuming 100% magic cup (except for once in last 8 days) and 100% 2 cal HN, yet still showed weight loss.Case discussed at today's IDT/WWF meeting; decision to check [CONDITION(S)] labs and to refer to SLP (Speech Language Pathology). Plan to continue diet and supps per orders as they meet nutritional needs. Monitor prn. R6's medical record documents a TSH ([CONDITION(S)] Stimulating Hormone) lab was ordered on 12/8/20 and not drawn until 1/7/21. On 1/7/21, R6's medical record documents a TSH level of 10.300, indicating a high TSH level. R6's [CONDITION(S)] medication was adjusted at this time. R6's medical record documents Speech Therapy services did not start until 12/16/20. On 3/25/21 at 8:38 AM, surveyor interviewed Therapy Director (TD)-K, who stated the facility was waiting for R6's Case Manager to provide prior authorization for the therapy services and it did take some time for the Case Manager to provide the authorization. TD-K stated therapy services cannot begin until the Case Manager provides the insurance authorization for the service, thus causing the delay in Speech Therapy services. R6's care plan was updated on 12/8/20 with interventions of: provide supplements as ordered: 2 cal HN 120 cc TID, Magic Cup at lunch; provide, serve diet as ordered. General diet with Mech soft texture. Observe intake and record q (each) meal. The intervention of 120 cc 2 cal HN TID has been in place since 9/5/20, the magic cup at lunch was ordered on 10/7/20 and R6's diet was upgraded to mechanical soft on 9/23/20. No new interventions were added to R6's care plan. On 12/11/20, R6's medical record documents a weight of 93.6 lbs. R6 is down 13.2 lbs. since admission, 12.4% in 3 months. No new interventions were documented to prevent further weight loss. R6's care plan was not updated and surveyor was unable to locate documentation R's physician or family were notified of the significant weight loss. On 12/15/20, R6's medical record documents: Case discussed at today's IDT/WWF meeting re: weight status. 12/11 wt=93.6 lbs. confirming a significant weight loss in November but the rate has slowed to 1# in past 3 weeks. Resident continues to eat slowly, so many benefit from SLP tx. (Speech Therapy treatment). IDT discussed and agreed to continue to refer to SLP and check TSH level. R6 was documented to have severe weight loss in November. No new interventions were implemented as the IDT/WWF team recommended the same interventions recommended at the 12/8/20 IDT/WWF meeting that had yet to be implemented. R6's care plan was not updated with new interventions to prevent weight loss, the physician and family were not informed of the significant weight loss. On 12/16/20 R6's medical record documented Speech Therapy services began related to the recommendation from the IDT/WWF meetings on 12/8/20 and 12/15/20. On 3/24/21, at 1:50 PM, surveyor interviewed Speech Therapist (ST)-H, who stated positioning was an issue for R6. ST-H stated R6's neck muscles could not hold her head up. ST-H stated she would do Myofascial Release on the back of R6's neck to help loosen and release the neck muscles to allow R6 to hold her head up better for eating. ST-H stated she created swallowing guidelines for R6. ST-H stated she created the swallowing guidelines to help the staff assist R6 with meals. ST-H stated R6's swallowing guidelines documented staff should: tilt back R6's high back wheelchair slightly to help R6 hold her head up and not tucked into her chest. ST-H stated R6 had very slow intake and it would take 45 minutes to assist her with a meal. ST-H stated she did not observe any signs or symptoms of overt aspiration but R6 did demonstrate excessive mastication and would require cues to swallow. ST-H stated R6 would require small bites, ½ to a full teaspoon size. ST-H stated she gave R6's swallow guidelines to the Director of Nursing, Assistant Director of Nursing, the Unit Manager, MDS nurse and the nurse on the unit. ST-H stated the nursing staff would put the swallow guidelines in a notebook for staff to read. ST-H stated she would expect to see R6's swallow guidelines added to R6's care plan and care card. ST-H stated she does not see R6's care cards to confirm the guidelines have been added. ST-H stated 2 weeks to 10 days before she would end therapy she would have regular unit staff observe her assisting R6 so the staff could understand the assistance R6 needed. ST-H stated she did have concerns for staff's ability to have the time needed to assist R6 since it would take 45 minutes per meal. ST-H stated when she assisted R6 with meals she would eat well. ST-H stated R6 would become full fast but if the staff took the time to feed, position and cue R6 she would eat enough and eat well. On 12/22/20, R6's medical record documents: Case discussed at IDT/WWF meeting. SLP tx. Started for IDT referral. RD visited resident during meal rounds with SLP fed resident. Resident tends to masticate her food for a longer than needed even though edentulous. Responds to verbal cues to lift up head during eating, but needs total feeding assistance to eat. Meal intake records show pattern of breakfast being the best meal with lower intakes with lunch and lowest intakes at supper. Usually consumes 100% of magic cup at lunch usually consumes 100% of 2 cal HN. Staff encourages adequate fluid intake, shows no s/s of dehydration with good skin turgor and moist lips. Plan to continue MS diet, thin liquids, Magic Cup at every L (lunch), 120 cc cal HN TID as they meet nutritional needs. On 1/4/21, R6's medical record documents speech therapy swallow guidelines, which document: Diet: Mech Soft/Thin [liquids]; Level of Supervision: Must be fed; Position: tilt chair slightly back; remain upright for 30 minutes after meals; small bites; liquids by cup; cue patient to clear mouth/swallow before taking additional bites. Watch for swallow; verbally cue to hold head up and provide tactile cues as needed for head up. Surveyor unable to locate documentation of R6's swallow guidelines in R6's care plan. On 3/24/21, at 2:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)- A, who stated the facility does not keep a copy of a resident's care card when they discharge from the facility. On 1/5/21, R6's medical record documents a weight of 90.8 lbs. R6 is down 16 lbs. since admission a 15% weight loss. In the last three months R6 has experienced a 10.6 lbs. weight loss, a 10.5% loss. No new interventions were documented to prevent further weight loss. Surveyor unable to locate documentation R6's physician or family were notified of the weight loss. On 1/8/21, R6's medical record documents a MNA with a score of 2, indicating R6 is malnourished. No new interventions were documented to prevent further weight loss. Surveyor unable to locate documentation R6's physician or family were notified of the weight loss. On 1/19/21, R6's medical record documents: a review of the case by the IDT/WWF meeting and care plan conference; nursing team discussed further goals of care such as TF (tube feeding) and GI (Gastrointestinal) consult; awaiting decision. [R6] remains on a mechanical soft diet with thin liquids, 120 cc of 2 ca HN TID, Magic Cup at every lunch. [R6] needs to be fed by the staff, eats at a slow pace. Meal intake records show variable intake, usually 25%-50%. Consuming 100% of Magic Cup and 100% 2 cal HN/ Speech therapy treatment is done for 4 weeks ending last week; note slow mastication and need for 45 minutes to complete full meal. Staff encourages adequate fluid intake for desired hydration. Note insidious wt. loss in past 2 months, following significant weight loss in past 4 months. Wt. loss is unintentional and r/t (related to) inadequate oral intake. Plan to continue diet and supps per orders as they meet nutritional needs with adequate intake. On 1/19/21, R6's medical record documents: care conference via phone. Family participated with DSS (Director of Social Services), DON (Director of Nursing), [R6]'s case manager was called but never answered. Nursing discussed different options like tube feeding or GI consult. POA (Power of Attorney) would like to think about it and follow up. This is the first documentation of R6's family being made aware of the weight loss. Surveyor is still unable to locate documentation R6's physician was made aware of the weight loss. On 2/3/21, R6's medical record documents a weight of 82.4 lbs. This is a 24.4lbs. weight loss since admission, 22.8% loss. This is an 8.4 lbs. loss, 5% loss in the last month. No new interventions were documented to prevent further weight loss. Surveyor unable to locate documentation R6's physician or family were notified of the severe weight loss. On 2/9/21, R6's medical record documents a weight of 78.8 lbs. This is a 28.0 lbs. weight loss, 26.2 % loss since admission. No new interventions were documented to prevent further weight loss. Surveyor unable to locate documentation R6's physician or family were notified of the weight loss. On 2/9/21, R6's medical record documents: Case discussed at today's IDT/WWF meeting for weight status. Today's weight=78.8 lbs.; 2/3=82.4 #;1/5 wt. 90.8#; 12/11=93.6#; 11/25 wt.=94.6#; 10/2= 101.4#; 9/21=105.0#; 9/3=106.8#. BMI=14.0, indicating underweight status, consistent with thin appearance. Note significant weight loss in month (>5% loss) and past 3 months (>10% loss). Wt loss is unintentional and r/t inadequate oral intake. Meal intake records show variable and poor intake, usually 25%-50%. CNA (Certified Nursing Assistant) reported that resident sometimes spits food back out. Consuming 100% magic cup and 100% 2 cal HN. Note: slow mastication and need for 45 minutes to complete full meal. Staff encourages adequate fluid intake for desired hydration. Nutrition problem: Moderate PCM (Protein Calorie Malnutrition) r/t MNA score of 2 and adult FFT (Failure to Thrive) AEB (As Evidence By) progressive weight loss in past month, inadequate intake, low BMI, need to be fed by staff, slow rate of eating, supps. 1/19 care plan conference indicated that TF (tube feeding) was discussed but no decision made. Case referred to DON for further goals of care. Plan to continue diet and supps. per orders as they meet nutritional needs with adequate intake. No new interventions were documented to prevent further weight loss. Surveyor unable to locate documentation R6's physician or family were notified of the continued weight loss. On 2/9/21, R6's medical record documents: a reweight of 81.0 lbs. On 2/11/21, R6's Medical Record documents: R6's diet was downgraded to puree. Surveyor unable to locate documentation as to why R6's diet was downgraded. On 3/25/21, NHA-A and DON-B informed surveyor R6's diet was downgraded following a recommendation by speech therapy. On 2/11/21, R6's medical record documents: a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of systems negative X13. diet per dietitian and speech language therapist. Assessment and plan: 2/11/21 weight loss, etiology unclear: CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), TSH ([CONDITION(S)] Stimulating Hormone) and trial of [MEDICATION(S)] ([MEDICATION(S)]) 400 mg (milligrams) twice a day. R6's care plan was updated with new interventions. This is the first documentation R6's physician was made aware of R6's continuous weight loss. R6's medical record documents: [MEDICATION(S)] was started on 2/12/21 and the lab work was not ordered until 2/15/21. The lab attempted to draw the ordered labs on 2/16/21 but were unsuccessful. Surveyor was unable to locate documentation R6's physician was informed the labs ordered on 2/11/21, were not ordered until 2/15/21 and not attempted to be drawn until 2/16/21 and the lab draw was unsuccessful. On 2/16/21, R6's medical record documents: Case discussed at today IDT/WWF meeting for weight status and poor intake. Meal intake records show poor intake < 25% intake. [MEDICATION(S)] stated on 2/12/21 as appetite stimulant. New nutritional interventions: increase 2 cal HN to 120 cc QID (four times per day) for additional calories. Plan is to monitor effectiveness of [MEDICATION(S)]. On 2/17/21, R6's medical record documents: [R6] became unresponsive, difficulty obtaining SPO2 (oxygen saturation level) sat (saturation), oxygen started via mask with rebreather, titrated 1-15 liters of O2 (oxygen), SPO2 74% at 15 liters, respirations shallow, called 911. [R6] sent to the hospital POA (Power of Attorney) aware. R6 was admitted to the hospital on 2/17/21. The hospital History and Physical, dated 2/17/21 documents: . On EMS (Emergency Medical Services) arrival patient hypoxic and placed on supplemental oxygen, blood sugar noted to be in the 40's.On 2/17: admitted to the ICU (Intensive Care Unit) with [CONDITION(S)] and altered mental status. Impression and plan: Hypovolemic [CONDITION(S)]- subacute vs. chronic; dehydration; acute metabolic [CONDITION(S)] d/t (due to) above (dehydration); severe protein-calorie malnutrition; [CONDITION(S)], hypertension, dementia. Likely [patient] has refeeding syndrome given her severe malnutrition. Given overall comorbidities, hospice might be appropriate. On 2/18/21, hospital paperwork documents: [POA] was surprised to hear that [R6] weighed about 77 pounds. [POA] agreed to discuss hospice. Discussed that feeding tube and IV hydration would not be used but [R6] would be allowed to eat for comfort. On 2/26/21, hospital paperwork documents: family meeting on 2/26/21, plan to proceed with outpt (outpatient) hospice. Severe Protein Calorie Malnutrition; remains NPO (Nothing Per Oral) NG (Nasogastric) tube in place, on TF (tube feeding); continue on [MEDICATION(S)]; dietitian consulted; Would not recommend PEG (Percutaneous Endoscopic Gastrostomy) tube placement given advanced dementia. Family decided to start comfort care and transition to hospice. R6 passed away on 3/6/21. On 3/23/21, at 3:19 PM, surveyor interviewed Registered Dietitian (RD)-D, who stated every Tuesday the Interdisciplinary Team (IDT) meets to discuss concerns with any resident in the area of weights, wounds and falls. The meeting is called the IDT/WWF meeting. RD-D stated the interventions with R6 began right away in September of 2020 when R6 was admitted with a puree diet and 2 cal HN 60 cc was added three times a day. RD-D stated R6 continued to lose weight and the supplement of 2 cal HN was increased to 120 cc on 10/6/20. RD-C stated the IDT/WWF team meet on 12/8/20 and recommended a referral to speech therapy for interventions because R6 needed to be fed by the staff and was eating at a slow rate. RD-D stated she wasn't aware of the outcome of the speech therapy treatment. RD-D stated on 12/15/20 the IDT/WWF recommended R6 continue with speech therapy and to check R6's TSH level. RD-D stated she is not aware of the outcome of the TSH level check. RD-D stated R6 continued to lose weight and on 12/22/20 a magic cup supplement was added to increase R6's caloric intake. RD-D stated on 1/19/21 the nursing team had a care conference with R6's family and discussed further goals of care including the possibility of tube feeding. RD-D stated on 2/9/21 she can see from her progress notes that R6's family was spoken to on 1/19/21 about the possibility of tube feeding but not decision had been made at this point. RD-D stated on 2/16/21 [MEDICATION(S)] was started on 2/12/21 as an appetite stimulant and on 2/16/21 RD-D recommended increasing R6's 2 cal HN to four times a day. RD-D stated the nursing team is responsible for updating and speaking to R6's physician about weight loss. RD-D stated she did observe R6 and she could not feed herself without help from the staff and needed encouragement. RD-D stated she did not speak with R6's family about her weight loss and that type of conversation would be nursing's responsibility. RD-D stated the Director of Nursing, Assistant Director of Nursing or the Floor Manager would have discussed concerns about R6's weight with the family. RD-D stated she would make recommendations in PCC (Point Click Care/ Electronic Medical Record) at the end of the day for nursing to address and inform the physician as needed. RD-D stated she would expect to see residents weighed at least 1 time per month and if we cannot identify the weight loss trend then the

Based on interview and record review the facility did not ensure 1 (R3) of 1 residents reviewed had an environment that remained free from accident hazards and received adequate supervision and assistive devices to prevent accidents. *Since 3/5/20, R3 has had 4 falls occurring on 3/5/20, 3/7/20, 4/16/20, 6/19/20. The fall on 3/7/20 resulted in sutures to the head. The facility did not identify safety risks related to the falls, did not establish and implement fall precautionary interventions and did not provide adequate supervision to prevent further accidents. Findings include: The facility policy, entitled Falls, dated 8/13, revised 7/14 and reviewed 8/14, states: This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed and the resident's existing plan of care shall be evaluated and modified as needed. Facility Guidelines following a fall incident 1 Evaluate the resident for any injury and alert the Health Care Provider and Emergency Contact. 2. Complete fall event. This event included the circumstances surrounding the fall, devices in use, full body observation for injury, pain, range of motion, and neuro (neurological) checks. 3. Fall Risk is completed by the Nurse and reviews by the Fall Nurse. R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/16/20, documents: Long and short term memory problems, severely impaired cognitive status; experiences delusion; requires extensive assistance of one staff for bed mobility, dressing, toilet use and personal hygiene, requires limited assistance of one staff for transfers, walking and eating; unsteady and only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around, moving on and off the toilet and surface to surface transfers; requires a wheelchair and walker for mobility; is occasionally incontinent of bowel and bladder; 3 falls total with 2 with injuries; and daily use of bed and chair alarm. On 2/3/20, R3 was assessed to be at High Risk for falls. On 3/5/20, R3 was assessed to be at High Risk for falls. On 3/7/20, R3 was assessed to be at High Risk for falls. On 4/16/20, R3 was assessed to be at Moderate Risk for falls. On 6/19/20, R3 was assessed to be at Moderate Risk for falls. R3's Care Plan, dated 11/21/18, revised 3/10/20, documents: Falls: Potential for falls, fall on 11/21/18, fall 12/5/18, 12/6/18, 3/7/20. Interventions include: Resident receives education related to potential fall risk and preventative measures. Initiated: 11/21/18, created 11/21/18; 12/5/18, 12/6/18: labs, x-rays, low bed, non-skid socks, and staff to be sure floor around resident is free of clutter. Initiated: 12/6/18, created on: 12/6/18; Labs done 12/6/18, x-rays, low bed when sleeping, medication review, meeting with family, toilet during noc (night) between 3-4 am. Initiated: 12/6/18, created: 12/6/18; Fall, keep in common/activities area when not sleeping in room. Initiated: 3/7/20, created: 3/10/20 . R3's Care plan, dated 11/26/18, documents: Skilled/ADL (Activities of Daily Living): Self-care deficit, requires assist with adls, debility, FX (fracture), left rib and left clavicle. Interventions include: . Bed and chair alarm. Initiated on: 1/7/19, created: 1/7/19; Confused needs assist with all adls. Initiated: 1/7/19, created: 1/7/19; . Fall risk 15 min (minute) checks. Initiated: 1/7/19, created 1/7/19; Low bed. Initiated: 1/7/20, created 1/7/19; Non-skid socks. Initiated: 1/7/19, created: 1/7/19; . Nursing Rehab (rehabilitation): walking program: ambulation 250 ft. (feet). Initiated on: 1/7/19, created 1/7/19; Offer toilet upon rising, after meals, and at bedtime and between 3-4 am on night shift. Initiated 1/7/19, created 1/7/19; . Transfer with 1 assist. Initiated: 1/7/19, created 1/7/19; . R3's Care Plan, dated 11/26/18, revised on 6/22/20, documents: Potential/actual for falls, resident at risk for injury from falls, weakness, unsteady gait, psychoactive drugs use, and history of falls with fracture. Fall 12/5/18, fall 12/6/18, fall 12/27/18, fall 1/21/19, fall 3/15/19, fall 8/23/19 laceration, 10/22/19 fall, 3/5/20 fall, 4/16/20 fall 6/19/20 fall. Interventions include: . Get to know resident's habits to anticipate resident's needs. Initiated on: 11/26/18, created 11/26/18; . Check on resident frequently and place resident in visible view of staff when up in chair as resident will allow. Initiated on: 11/26/18, created 11/26/18; Encourage and assist as needed to wear non-slip footwear. Initiated on: 11/26/18, created on 11/26/18; PT (Physical Therapy)/OT (Occupational Therapy) evaluation per MD (Medical Doctor). Initiated on: 11/26/18, crated 11/26/18; Toilet resident in a timely manner. Initiated on: 11/26/18, created: 11/26/18; Keep resident's immediate environment clutter free. Initiated on: 11/26/18, created 11/26/18; Have commonly used items within reach. Initiated on: 11/26/18, created 11/26/18; Call light within resident's reach when in room. Initiated on: 11/26/18, created on 11/26/18 12/6/18 bed and chair alarm. Initiated: 12/10/18, created 12/11/18, revision 12/18/18; Fall toileting self, staff to anticipate toileting needs, offer and assist on noc rounds, 12 am, 2 am, 5 am. Initiated on: 1/21/19, created on 2/12/19; Staff to approach at 8pm for bedtime. Initiated on: 3/15/19, created 3/26/19; Room rearrangement. Initiated on: 8/23/19, created 8/26/19; WC next to bed. Initiated on: 10/22/19, created: 10/23/19; Labs obtained. Initiated on: 3/5/20, created on 3/8/20; Do not leave resident while in w.c. (wheelchair) in room or bathroom unattended. Initiated: 3/5/20, created 3/26/20; Fall 4/16/20 attempting to ambulate, continue redirect, give reassurance, and provide activities of resident choice. Initiated: 4/16/20, created: 4/24/20; Fall seen by NP (Nurse Practitioner), labs ordered. Initiated on: 6/19/20, created: 6/22/20; Fall 1 On 3/5/20, R3's Medial Record documents, SBAR (Situation, Background, Assessment and Recommendation) Report, effective 3/5/20 at 23:10 (11:10 PM) documents: R3 was wandering with her w/c (wheelchair) on the unit; has dementia and is a fall risk; likes to disable her bed alarm and get up to the toilet; there has been an acute change in condition; the resident is more confused. No suggestions or requests from the physician were documented and no injuries were documented. On 3/5/20, R3's Medical Record documents, Fall Event, effective 3 /5/20 at 23:29 (11:29 PM), R3 has a fall in the resident's room. Just prior to the fall R3 was noted to be sitting and propelling self all over the unit. Going in and out of the unit. R3 was last seen at 16:30 (4:30 PM), last assisted to the toilet at 12:00 pm. R3 was noted to be wearing gripper socks, physician and responsible party were notified and an intervention of: put resident to bed b/w (between) 8pm and 9pm was documented. On 3/5/20, R3's Medial Record documents, Fall report, dated 3/5/20 at 23:53 (11:53PM,) R3 was found sitting down in someone's room; alarm present not sounding; noncompliant with safety guidelines, impaired memory, weakness/fainted; wanders and uses a wheelchair. On 3/5/20 R3 was found on the floor in another resident room. According to staff, R3 seems a bit agitated, which is unusual. IDT (Interdisciplinary Team) recommends labs to be performed (treatment plan if any irregularities are determined) therapy to screen and ongoing monitoring for changes in mood and behavior. Staff witness statement, reported by NHA (Nursing Home Administrator)-A, to have been obtained on 9/1/20 due to the facility's inability to locate original statement documents: 3/5/20 at 16:30 (4:30 PM), R3 found sitting on the floor of room [ROOM NUMBER]-2 facing another resident. No sign of pain or discomfort noted. When writer asked resident what doing in the room, she unable to explain. Staff's last contact with R3: 16:00 (4:00 PM), safety devices were in place and functioning at that time; interventions put in place at the time of the fall: R3 was brought up to the nursing station within staff eye sight, a book was given to R3 to read; not incontinent; last toileted at 12:00 noon; went to bed at 8 pm, slept from 8pm until staff left for the shift at 10:30 pm; call light within reach; alarms sounding, gripper shoes on. Surveyor could not locate the exact time of the fall, facility documentation has conflicting information related to R3's chair alarm being on and not functioning or if it was on and sounding, if R3 got out of bed independently or was assisted out of bed and wandering about the unit. Surveyor could not locate documentation indicating if fall interventions of 15 minute checks, checking on resident frequently, placing resident in visible view of staff when up, offer toileting upon rising, after meals, and at bedtime and toilet timely were implemented to prevent this fall. R3's Care Plan is updated on 3/5/20, with fall interventions of: Do not leave resident while in w.c. in room or bathroom unattended, labs obtained. These fall interventions do not address the reason for the fall. Fall 2 On 3/7/20, R3's Medical Record documents: SBAR report, effective date: 3/7/20 at 9:39 AM; fall with head Lac (laceration) at 9:15 AM; Lt (left) arm bruise, Laceration to forehead and above rt (right) eye; there is an acute change in condition; transfer to the hospital. R3 received sutures to the forehead. On 3/7/20, R3's Medial Record documents: Fall Event form, effective date: 3/7/20 at 15:24 (5:24 PM), R3 fell in resident room, was seen sitting just prior to the fall; was last observed at 9:10 am; last toileted 9:12 am; R3 complained of a headache; pain level-hurts a whole lot; given [MEDICATION NAME]; physician and responsible party notified. On 3/7/20, R3's Medical Record Documents: Fall report, dated 3/7/20 at 15:31 (3:31 PM), Found resident laying on her rt (right) side by the closet of her room bleeding from forehead; ROM (Range of Motion) WNL (Within Normal Limits) for her. Assisted to feet, then wc (wheelchair). Laceration noted above RT forehead. Pressure dressing area cleansed stri-strips applied then pressure dressing. Orders to send to ED (Emergency Department) for sutures; bed in lowest position; seen in the last 2 hours; toileted in last 2 hours; call light in reach; ambulating without assistance; takes alarms off so staff cannot hear them, Will hide them under her pillows; no witness; R3 found on the floor next to her wardrobe bleeding from a visible laceration. Prior to finding resident on the floor, nurse observed resident walking in hallway unassisted was taken to the BR (bathroom) and assisted back to wheelchair. LPN (Licensed Practical Nurse) on duty went to check on resident not even 5 min (minutes) later and was found on floor. Educated staff during non-sleeping hours resident needs to be in community areas or activities for frequent monitoring. Staff witness statement, reported by NHA (Nursing Home Administrator)-A, to have been obtained on 9/1/20 due to the facility's inability to locate original statement documents: 3/7/20 LPN-C assisted R3 to the toilet, while R3 was sitting on the toilet LPN-C walked outside of the room and locked her med cart, returned to R3's room and observed R3 outside of bathroom on the floor by the closet; all safety devises were in place and functioning; prior to the fall R3 was sitting quietly on the toilet; call light was in reach; the alarms were not sounding; R3 was wearing well fitted shoes. A second staff witness statement, dated 3/7/20, documents: found R3 on the floor in the bathroom and she had a gash on her head. R3 was last seen at 2:00 PM; the safety device were in place and functioning; last toileted at 2:00 PM; call light within reach and R3 was wearing gripper socks. The witness statements provided document conflicting information as to the events of the fall related to time R3 was last seen, what R3 was doing just prior to the fall and where and what time the fall took place. Surveyor could not locate documentation indicating whether care planned interventions of: do not leave resident while in wheelchair in room or bathroom unattended (intervention dated 3/5/20) and check on resident frequently and place resident in visible view of staff when up (intervention dated 11/26/18) were implemented at the time of R3's fall on 3/7/20. The new intervention of: during non-sleeping hours R3 need to be in community areas or activities for frequent monitoring does not address the reason for the fall. Fall 3 On 4/16/20, R3's Medical Record documents: Fall report, dated 4/16/20 11:45 AM; R3 got up from wheelchair and proceeded to start walking forward. Staff proceeded towards R3 to assist her back into her chair when R3 lost her balance and fell on her buttocks. R3 was sitting upright on the floor. R3 did not hit her head. R3 did hit her elbow on wheelchair. Area is slightly reddened, skin is intact; denies pain; ROM WNL for R3; alert, mentation per usual. R3 stated, she was trying to follow him, as she pointed at another resident; vital signs are stable; alarm present and sounding; fall witnessed; R3 was self-ambulating, staff attempted to assist but R3 lost balance before staff could get to her, alarm sounding at time of self-transfer; in spite of her continued self-transferring, number of falls have decreased dramatically; facility will continue to provide redirection, monitoring and reassurance to minimize self-transferring. On 4/16/20, R3's Medical Record documents: Fall form with effective date: 4/16/20 at 11:45 AM; R3 fell in the hallway; R3 stood up from wheelchair and proceeded to walk; last observed 11:45 AM; last toileted 11:30 AM; no pain noted; redness to the right elbow; physician and responsible party notified. On 4/16/20, R3's Medical Record documents: SBAR Report, effective date: 4/16/20 at 13:46 (1:46 PM), R3 fell at 11:45 AM; has dementia; not sure what the problem is but there has been an acute change in condition; request to monitor vital signs and observe. Surveyor could not locate any witness statements; R3's care plan was updated with the intervention of: attempting to ambulate, continue redirect, give reassurance and provide activities of resident choice. This intervention does not address the reason for the fall. Surveyor could not locate documentation indicating that the documented care plan interventions of a walking program, ambulation of 250 ft (feet), get to know resident's habits to anticipate resident's needs, during non-sleeping hours R3 need to be in community areas or activities for frequent monitoring were implemented. Fall 4 On 6/19/20, R3's Medical Record documents: Fall Event form, effective date: 6/19/20, at 8:00AM, R3 fell in the hallway; was last observed at 7:57 AM asleep in the wheelchair; last toileted 7:20 AM; reports a little bit of pain; soft tissue, such as muscle pain; no injures noted and physician and responsible party were informed. On 6/19/20, R3's Medical Record documents: Fall form, dated 6/19/20 at 8:40 AM; observed R3 laying on left side on the floor to the left of her wheelchair; unwitnessed fall from wheelchair; incontinent. R3 with complaints of mild left shoulder and left knee pain; full body check completed; no lengthening, shortening, eternal or internal rotation of extremities observed; no deformities noted; no bumps, bruises or abrasions observed on resident body at this time; R3 assisted back into wheelchair with gait belt and assist of two; attempted to put ice pack to R3's left shoulder and knee, R3 pushed it away and stated it wasn't needed; given scheduled [MEDICATION NAME] for complaints of pain to left shoulder and left knee; R3 was incontinent at the time of the fall. The form was left blank indicating if the chair alarm was on and sounding; R3 was sitting in wc (wheelchair) at nursing station, poor safety awareness r/t (related to) dementia, propels self in/out room; R3 stated she turned and fell ; NP (Nurse Practitioner) in facility, labs ordered; R3 has long history of falling; however fall interventions have been effective; IDT met to discuss fall and plan of care. After recreating the incident, the fall was determined to be an isolated incident. R3 was repositioning self in wheelchair, and was too close to the edge. Staff will remind and assist R3 with proper seating and positioning while in wheelchair. On 6/19/20, R3's Medial Record documents: SBAR Report, effective date: 6/19/20 at 15:40 (3:40 PM), fall with complaints of mild pain to left shoulder and left knee; 6/19/20 at 0803 (8:03 AM), right after R3 observed laying on left side on the floor next to wheelchair; took scheduled [MEDICATION NAME] for pain and ate 100% of breakfast and 100% fluids; has dementia; new orders for UA (Urinary Analysis) with C&S (Culture and Sensitivity) if indicated and CBC (Complete Blood Count); suggestions and requests: provider visit, lab work, x-rays and monitor vital signs and observe; continue with neurological monitoring; await results of x-rays, labs and UA. Witness statements document: 6/19/20 at 0800 (8:00 AM), heard the chair alarm while in another room, came out and the nurse had made it to her before; last had contact with R3 5 mins (minutes) before went into room; fall occurred in another room; last saw R3 sleeping in her chair, interventions in place at the time of the fall: chair alarm and placed in front of the nursing station; last toileted an hour before the fall; and R3 had shoes on. R3's Care Plan was updated with fall intervention of: fall, seen by NP, labs ordered. This intervention does not address the reason for the fall. On 9/1/20, at 1:12 PM, Surveyor interviewed LPN-C, who stated: R3 would frequently take off the chair alarm and hide it under her pillows and R3 was very quick. LPN-C stated, R3 would often wear a sweater and the chair alarm would be pinned to her sweater and R3 would take off her sweater to assure the alarm would not go off when she tried to stand or toilet herself. LPN-C stated, you would hear R3's alarms sound and R3 could tell the staff she needed to use the bathroom. LPN-C stated she did not assess if the bed alarm was an appropriate intervention, such decisions were for the management team to determine. LPN-C did not recall the interventions that had been put into place following R3's falls. LPN-C stated, all falls are reviewed by the Risk Management Team, then the team does an assessment after the fall to see if the fall prevention interventions are appropriate and work or if new interventions needed to be added. On 9/1/20, at 2:02 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A, who stated: She is responsible for the fall investigations. NHA-A stated, nurses complete the Risk Management following each fall. The nursing staff will put simple interventions into place following each fall and Risk Management will review. The nursing team and therapy will review the plan of care after a fall and will make changes if needed and will even recreate the fall and check the environment for factors that could have caused the fall. NHA-A stated, in R3's case, she had multiple falls and was using a chair alarm and was very creative, and could remove the chair alarm. NHA-A stated, the team made changes to R3's room and moved furniture to make a better space. NHA-A stated the team would review all falls and put interventions into place to address the falls and this could be found on the SBAR and Fall Event forms. Surveyor informed NHA-A, Surveyor was unable to locate complete documentation for all of R3 falls. NHA-A stated she would email Surveyor with the information when it is found as the facility is unable to locate the falls binder where all of the information is kept. On 9/2/20, at 10:59 AM, Surveyor spoke with NHA-A and informed her of concerns, after reviewing additional fall information provided to Surveyor on this day, R3's fall investigations do not provide clear picture of the fall, the staff statements that were newly created due to the facility's inability to find their Falls Binder provide conflicting details of the falls and fall interventions do not address the reason for R3's falls. No further information was provided. On 9/2/20, at 1:37 PM, Surveyor informed NHA-A of the above concerns.

Based on observation, record review and interview, the facility did not ensure that 5 (R15, R31, R52, R1 & R70) of 11 residents reviewed and at risk for developing pressure injuries received consistent measures to prevent the development of pressure injuries. * R15 developed an avoidable stage 4 pressure injury that was not identified, assessed or treated upon its initial discovery. R15 was also observed not to have her heels offloaded and or have pressure reducing devices in place per R15's plan of care. The facility's failure to identify, assess, document, update the care plan and treat R15's pressure injury created a finding of Immediate Jeopardy that began on 3/7/19. Nursing Home Administrator-A and Director of Nursing-B were notified of the immediate jeopardy on 5/22/19 at 2:35 p.m. The immediate jeopardy was removed on 5/23/19, however the deficient practice continues at a scope/severity level of [NAME] (potential for harm/pattern) related to the following examples: * R31 did not have her skin integrity care plan updated to reflect a pressure injury and received the incorrect pressure injury treatment to her sacrum and to the back of her head. * R52 was observed to not have pressure reducing boots on to prevent pressure injuries per R52's plan of care. * R1 did not have a her stage 4 pressure injury assessed by an Registered Nurse upon development. * R70 was observed to not have pressure reducing interventions in place per R70's plan of care. Findings include: A. Stage IV Pressure Injury Development 1.) R15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R15's Quarterly MDS (Minimum Data Set) dated 3/1/19 documents that R15 has short and long term memory problems. Section G (Functional Status) documents that R15 requires extensive assistance and one person physical assist for her bed mobility needs. Section G also documents that R15 requires extensive assistance and two person physical assist for her transfer needs. Section M (Skin Conditions) documents that R15 has a pressure injury/ulcer, however no unhealed pressure injuries are listed and no pressure injury care is documented as being administered. Section M also documents that R15 is at risk for the development of pressure injuries. R15's Skin Integrity plan of care with an initiated date of 7/17/17 documents under the Focus section, At moderate risk for skin integrity for Pressure Ulcers, Incontinence (B/B) (Bowel & Bladder), Weakness. R15's Pressure Injuries/Ulcers CAA (Care Area Assessment) dated 7/13/18 documents under the Analysis of Findings section, Resident is at risk for pressure ulcers due to require (sic) extensive assistance with bed mobility and is at risk for pressure ulcers per Braden score. R15's Braden Scale for Predicting Pressure Sores/Injuries assessment dated [DATE] documents a score of 13, indicating that R15 is at moderate risk for the development of pressure ulcers/injuries. R15's Skin Event documentation dated 2/4/19 documents no open skin areas for R15. R15's nursing note dated 2/7/19 at 7:30 p.m. documents, SBAR (Situation, Background, Assessment, Recommendations) Note Text: REASON FOR REPORT: Open area to rt (right) buttock and coccyx NEW ORDERS: Surveyor was unable to locate any documentation in R15's medical record of any physician orders for the open right area as documented in R15's nursing note dated 2/7/19. R15's nursing note dated 2/7/19 at 11:30 p.m. documents, Health Status/Progress Note Text: CNA (Certified Nursing Assistant) reported open area to rt (right) buttock and coccyx. Observe in rt (right) lateral position. Perineum area slightly moist. Rt (right) buttock 20 x 10 cm (centimeters). Coccyx 0.3 x 0.3 cm. House cream applied x2 (twice). Positioned to lt (left) and rt (right) lateral with pillows. Left message for poa (power of attorney) to call facility. R15's SBAR dated 2/7/19 documents, SBAR- Request monitor vitals and signs and observe- documents, Open areas to rt buttock and coccyx. R15's Skin Event documentation dated 2/7/19 documents, Rt (right) buttock superficial, pink open area. No drainage. Coccyx area superficial, pink open area. Surveyor noted that the above nursing notes, Skin Event documentation and R15's SBAR all dated 2/7/19 were completed by RN (Registered Nurse)-MM. Although the above documentation was completed by RN-MM, Surveyor was unable to locate in R15's medical record any documentation that included measurements, staging or assessments of R15's open areas as described on 2/7/19. Surveyor was also unable to locate any documentation that R15 received treatment for [REDACTED]. Surveyor noted that R15's plan of care was also not updated to reflect R15's new open skin areas as documented on 2/7/19. Surveyor noted that R15's Skin Integrity plan of care prior to 2/7/19 included the following interventions: offloading cushion- even at [MEDICAL TREATMENT]- reposition every 2 hours, offload heels with pillows- observe resident heels- barrier cream after each incontinence episode. Surveyor could not locate any documentation that facility staff assessed, identified a stage or updated R15's care plan to reflect open areas as documented on 2/7/19. Surveyor noted that R15's (MONTH) 2019 TAR (Treatment Administration Record) did not document any treatment to R15's open areas as documented on 2/7/19. R15's nursing noted dated 2/9/19 at 1:19 a.m. documents, Health Status/Progress Note Text: Follow up for not eating/coughing with food/liquids/open areas to right buttock and coccyx. Resident resting quietly in low bed. Zero s/sx (signs and symptoms) of distress/discomfort exhibited. Cream applied to affected areas. Repositioned every two and as needed. Will continue to monitor. R15's nursing note dated 2/9/19 at 2:57 p.m. documents, Health Status/Progress Note Text: OA (open areas)'s clean zinc applied and turned .No pain noted. Surveyor could not locate any documentation that facility staff assessed, identified a stage or updated R15's care plan to reflect open areas as documented on 2/9/19. Surveyor noted that R15's (MONTH) 2019 TAR (Treatment Administration Record) did not document a specific treatment of [REDACTED]. R15's Physician Consult notes dated 2/12/10 documents under the Physical Examination section, Warm and dry, normal color and texture. Surveyor noted that R15's Physician Consult noted did not document any findings of open areas on R15 as previously documented. R15's Skin Integrity care plan documents under the Goals section, 2/13/19 Actual skin impairment: abrasion to left buttock. Under the Interventions section it documents, Alternating pressure mattress added. R15's Braden Scale for Predicting Pressure Sores/Injuries assessment dated [DATE] documents a score of 10, indicating that R15 was now at high risk for the development of pressure ulcers/injuries. R15's Wound Notes dated 2/14/19 includes a picture of R15's right buttock and coccyx that demonstrate that on 2/14/19, when the picture was taken, R15's skin on her right buttock and coccyx was intact. However R15's nursing note dated 2/15/19 at 1:49 a.m. documents, Health Status/Progress Note Text: Follow up for not eating/coughing with food/liquids/open areas to right buttock and coccyx. Surveyor could not locate any documentation that facility staff assessed, identified a stage or updated R15's care plan to reflect open areas as documented on 2/15/19. R15's nursing note dated 2/16/19 at 3:49 p.m. documents, Skilled Look Back Late Entry: Note Text: remains stable, appetite fair, OA (open areas)'s healing to buttocks/coccyx. R15's nursing note dated 2/16/19 at 9:04 p.m. documents, Health Status/Progress Note Text: F/U (follow up) coughing with food/liquids/not eating/open area rt (right) buttock and coccyx .Open area to rt buttock and coccyx/barrier cream applied. Surveyor could not locate any documentation that facility staff assessed, identified a stage or updated R15's care plan to reflect open areas as documented on 2/16/19. Surveyor noted that R15's (MONTH) 2019 TAR (Treatment Administration Record) did not document a specific treatment of [REDACTED]. R15's nursing note dated 2/19/19 at 6:24 a.m. documents, Health Status/Progress Note Text: Follow up from 2/6/19: Coughing with food & liquids, refusing meals, OA (open area) to R Buttock & Coccyx. Resident resting in bed through the night. No changes in condition. Open area cleansed, pat to dry, protection cream applied. Resident repositioned Q2hr. No c/o of pain or discomfort. Will continue to monitor. Surveyor could not locate any documentation that facility staff assessed, identified a stage or updated R15's care plan to reflect open areas as documented on 2/19/19. Surveyor noted that R15's (MONTH) 2019 TAR (Treatment Administration Record) did not document a specific treatment of [REDACTED]. R15's Dietary Assessment note dated 2/19/19 documents, Dietary Note Text: Monthly TF MNT review and coordination of care with [MEDICAL TREATMENT] . Skin status: closed areas to R butt and coccyx. Surveyor could not locate any documentation that facility staff assessed and verified that R15's open areas as documented on 2/7/19 had closed as documented on 2/19/19. Additionally, Surveyor was unable to locate any documentation that documented that the facility updated R15's care plan to reflect R15's closed areas as documented on 2/19/19. Surveyor was unable to locate any nursing documentation that verified that R15's open areas as first documented on 2/7/19 had closed as documented on 2/19/19. R15's nursing note dated 3/7/19 at 11:23 p.m. documents, Health Status/Progress Note Text: CNA (Certified Nursing Assistant) reported 3 more open areas to left buttock. 0.4 x 0.3 cm (centimeters) (2) (areas). Another open area irregular shape close to coccyx. All 3 superficial with no drainage. CNA applied house barrier and lateral positioning with pillows. Attempted to call son /received answering service/ left message to call facility Medical Director-X. R15's nursing note dated 3/7/19 at 11:29 p.m. documents, SBAR Note Text: REASON FOR REPORT: Has 3 new open area to left buttock. 2 open areas 0.4 x 0.3 cm (centimeters). Another one irregular shape close to coccyx. All are superficial with no drainage. R15's SBAR dated 3/7/19 documents, SBAR- open area to coccyx has small reddish drainage. Under the What do you think is going on with the resident? section it documents, Open areas need evaluation and treatment other than barrier. Surveyor was unable to locate any Skin Event documentation dated 3/7/19 in R15's medical record. Surveyor noted that the above nursing notes and R15's SBAR all dated 3/7/19 were completed by RN-MM. Although the above documentation was completed by RN-MM, Surveyor was unable to locate in R15's medical record any documentation that included measurements, staging or assessments of R15's open areas as documented on 3/7/19. Surveyor noted that R15's plan of care was also not updated to reflect R15's new open skin areas as documented on 3/7/19. A review of R15's (MONTH) 2019 TAR (Treatment Administration Record) documents that no physician orders were obtained to treat R15's open areas as documented on 3/7/19. R15's nursing note dated 3/8/19 at 1:56 a.m. documents, Health Status/Progress Note Text: Follow up for three open areas to left buttocks. Resident resting quietly in low bed. Reposition every two hours and as needed. Barrier cream applied to buttocks. Area kept clean/dry. Assistance with cares provided x1. Will continue to monitor affected areas until resolved. R15's physician order dated 3/8/19 documents the following treatment, Apply Zinc cream to open areas on left buttock and coccyx Q (every) shift until healed. Monitor for S/S of infection every shift for To Promote Wound Healing. R15's nursing noted dated 3/8/19 at 10:11 a.m. documents, Health Status/Progress Note Text: Follow up open areas to coccyx and left buttock. No sign or symptom of infection noted. Zinc cream applied per MD order. No pain or discomfort noted. Will continue to monitor. Surveyor was unable to locate any assessment that included staging, measurements or a description of the open area as documented on 3/8/19. Surveyor noted that R15's plan of care continued to be not updated to reflect R15's new open skin areas as initially documented on 3/7/19. R15's nursing note dated 3/9/19 at 3:50 a.m. documents, Health Status/Progress Note Text: Follow up for three open areas to left buttocks. Resident resting quietly in low bed. Reposition every two hours and as needed. Zinc oxide cream applied to buttocks. Area kept clean/dry. Assistance with cares provided x1. Will continue to monitor affected areas until resolved. Surveyor noted that R15's plan of care continued to be not updated to reflect R15's new open skin areas as documented on 3/7/19. Surveyor was unable to locate any assessment that included staging, measurements or a description of the open areas as documented on 3/7/19. R15's nursing note dated 3/11/19 at 3:48 p.m. documents, Health Status/Progress Note Text: Dressing intact to left buttock. R15's nursing note dated 3/11/19 at 11:00 p.m. documents, Health Status/Progress Note Text: F/U 3 open area to left buttock. Dressing CDI (clean/dry/intact ) to left buttock. No s/s of any pain. Surveyor noted that R15's plan of care continued to be not updated to reflect R15's new open skin areas as initially documented on 3/7/19. Surveyor was unable to locate any assessment that included staging, measurements or a description of the open areas as documented on 3/11/19. A review of R15's (MONTH) 2019 TAR (Treatment Administration Record) documents no physician orders for any dressing to be applied to R15's open areas as documented on 3/11/19. R15's nursing note dated 3/16/19 at 1:18 p.m. documents, Health Status/Progress Note Text: Monitoring of OA (open area) to left buttock continues, area cleansed and treatment applied per order. Surveyor noted that R15's plan of care continued to be not updated to reflect R15's new open skin areas as initially documented on 3/7/19. Surveyor was unable to locate any assessment that included staging, measurements or a description of the open areas as documented on 3/16/19. R15's nursing note dated 3/17/19 at 2:58 p.m. documents, Wound Care Notes Late Entry: Note Text: No open area noted to left buttock. Surveyor noted that R15's nursing note dated 3/17/19 was completed by Wound Care RN (Registered Nurse)-C. Surveyor was unable to locate any documentation prior to 3/17/19 that documented R15's open area to the Left buttock had healed and there was no documentation that the open area on R15's coccyx had been assessed. Surveyor noted that per R15's medical record, R15's coccyx pressure injury was first assessed by an RN on 3/17/19. Prior to 3/17/19, Surveyor was unable to find any documentation of assessments that included wound staging, a wound description and wound measurements for the various open areas documented for R15 since 2/7/19. Furthermore, Surveyor noted that R15's open areas as documented since 2/7/19 were not reflected on R15's plan of care. R15's initial wound assessment that included staging and measurements was completed by Wound Care RN-C on 3/17/19. R15's Wound Rounds assessment dated [DATE] documents, Wound Summary- Site: Coccyx; Type: Pressure; Source: Facility-acquired; Date Identified: 3/17/19; Identified by Wound Care RN-C; Clinical Stage: Stage 3; Tissue Types: Pale pink non granulating 75% slough loosely adherent 25%; Exudate: moderate- serosanguineous; Length: 2.30 cm (centimeters); Width: 1.80 cm; Depth: 0.10 cm. Surveyor noted that while R15's Wound assessment dated [DATE] documented R15's pressure injury as identified on 3/17/19; this wound was documented in R15's medical record as present and discovered on 3/7/19. Surveyor noted that on 3/17/19, when R15's stage 3 pressure injury to her coccyx was first assessed, no physician orders or treatments were put in place until 3/18/19. Surveyor noted that R15's care plan was not updated to reflect the stage 3 pressure injury to her coccyx on 3/17/19. R15's physician orders dated 3/18/19 documents, Normal Saline wash to to wound, f/b (followed by) skin prep periwound, f/b santyl f/b dressing daily every day shift for coccyx wound. R15's physician order dated 3/18/19 documents, Wound care to coccyx: cleanse with Dakins half strength solution, followed by normal saline, pat dry with gauze, apply skin prep to peri-wound, apply Santyl ointment ( nickel thick ) to wound bed , cover with bordered gauze. Change every day and prn every day shift for To Promote Wound Healing. R15's care plan was first updated to reflect the stage 3 pressure injury to her coccyx on 3/20/19 and not on 3/7/19 when R15's coccyx wound was first documented. Per R15's nursing notes, R15 was sent to the hospital on [DATE] and returned to the facility on [DATE]. Upon return, no assessment by facility staff that included staging and or measurements of R15's coccyx pressure injury were located in R15's medical record. R15's Physician Consult notes dated 3/19/19 documents a stage 3 pressure injury to R15's coccyx. However the Physician Consult notes do not include staging and or any measurements of R15's coccyx pressure injury. Per R15's nursing notes, R15 was sent out to the hospital on [DATE] and did not return to the facility until 3/21/19. R15's Discharge Summary from the hospital dated 3/21/19 documents, Stage 3 Sacral Pressure Ulcer . at risk for skin breakdown due to comorbidities, decreased mobility, friction, shear, moisture, nutrition and pressure. R15's nursing note dated 3/21/19 documents, Health Status/Progress Note Text: readmitted . Returned to facility per Medacare ambulance via 2 attendants. Coccyx open area 30.3cm x 30 cm/ small reddish drainage/ dressing changed. No s/s of any discomfort or pain. R15's Braden Scale for Predicting Pressure Sores/Injuries assessment dated [DATE]/19 documents a score of 12, indicating that R15 continued to be at high risk for the development of pressure ulcers/injuries. R15's Wound Rounds assessment dated [DATE] documents, Wound Summary- Site: Coccyx; Type: Pressure; Source: Facility-acquired; Date Identified: 3/17/19; Identified by Wound Care RN-C; Clinical Stage: Stage 3; Tissue Types: Pale pink non granulating 75% slough loosely adherent 25%; Exudate: moderate- serosanguineous; Length: 2.50 cm (centimeters); Width: 2.40 cm; Depth: 0.10 cm. Per R15's (MONTH) 2019 TAR (Treatment Administration Record), R15's coccyx wound treatment remained the same as ordered on [DATE]. Surveyor noted that while R15's coccyx pressure injury increased in size as documented on 3/22/19, there was no documentation from Wound Care RN-C that documented any changes in R15's coccyx pressure injury treatment or new interventions to attempt to improve wound healing on 3/22/19. R15's Wound Rounds Treatment Plan Annotations dated 3/26/19 documents, Resident is alert with a [DIAGNOSES REDACTED]. She has a history of failure to thrive .POA (power of attorney) and PCP (Personal Care Physician) has been updated on wound status, she is to see wound MD (medical doctor) on 3/29/19. Management continues. Surveyor noted that while R15's Wound Rounds Treatment Plan comments dated 3/26/19 document a summary of R15's comorbidities, they did not document any changes in R15's coccyx pressure injury treatment or new interventions to attempt to improve wound healing on 3/26/19. Per R15's nursing notes, R15 was sent out to the hospital on [DATE] and did not return to the facility until 3/29/19. R15's Hospital Discharge Summary dated 3/29/19 did not document any information regarding R15's skin or pressure injury conditions. R15's Wound Rounds assessment dated [DATE] documents, Wound Summary- Site: Coccyx; Type: Pressure; Source: Facility-acquired; Date Identified: 3/17/19; Identified by Wound Care RN-C; Clinical Stage: Unstageable; Tissue Types: Loosely adherent 100%; Exudate: moderate- serosanguineous; Length: 3.20 cm (centimeters); Width: 2.60 cm; Depth: unknown. Surveyor noted that R15's plan of care was not updated on 3/29/19 to reflect the change in R15's coccyx pressure injury from a stage 3 to unstageable. Surveyor was unable to find any documentation that documented R15 saw the wound physician on 3/29/19 as documented in R15's Wound Rounds Treatment Plan Annotations dated 3/26/19. Per R15's (MONTH) 2019 TAR (Treatment Administration Record), R15's coccyx wound treatment remained the same as ordered on [DATE]. R15's Wound Rounds assessment dated [DATE] documents, Wound Summary- Site: Coccyx; Type: Pressure; Source: Facility-acquired; Date Identified: 3/17/19; Identified by Wound Care RN-C; Clinical Stage: Stage 3; Tissue Types: Pale pink non granulating 75% slough loosely adherent 25%; Exudate: moderate- serosanguineous; Length: 1.70 cm (centimeters); Width: 1.80 cm; Depth: 0.20 cm. Per R15's (MONTH) 2019 TAR (Treatment Administration Record), R15's coccyx wound treatment remained the same as ordered on [DATE]. R15's Wound Rounds assessment dated [DATE] documents, Wound Summary- Site: Coccyx; Type: Pressure; Source: Facility-acquired; Date Identified: 3/17/19; Identified by Wound Care RN-C; Clinical Stage: Stage 4 (emphasis added); Tissue Types: Necrotic Soft, Adherent =100%; Exudate: moderate- serosanguineous; Length: 2.80 cm (centimeters); Width: 2.00 cm; Depth: 1.80 cm. Surveyor noted that R15's Wound Rounds assessment dated [DATE] did not include any annotation notes regarding the change in R15's coccyx wound staging from a stage 3 to a stage 4. Surveyor was unable to locate any additional information regarding the progression of R15's coccyx pressure injury from a stage 3 to a stage 4. R15's physician order dated 4/12/19 documents a new treatment plan for R15 as follows: Wound care to coccyx: cleanse with Dakins half strength solution, followed by normal saline, pat dry with gauze, apply skin prep to peri-wound, apply wet to dry gauze in ½ strength Dakins' to wound bed , cover with ABD pad . Secure with dressing retention tape. Change twice a day and prn every day and evening shift for To Promote Wound Healing . Surveyor noted that R15's plan of care was not updated on 4/12/19 to reflect the change in R15's coccyx pressure injury from a stage 3 to stage 4. R15's nursing note dated 4/12/19 at 1:07 p.m. documents, Wound Care Notes Text: Son was updated on worsening wound to coccyx. He was notified that a wound culture was taken and that resident will be receiving IV (intravenous) antibiotics. Interventions explained, he verbalized understanding. Per R15's nursing notes, R15 was sent out to the hospital on [DATE] due to a G (gastrointestinal)-tube dislodgement and R15 returned to the facility on [DATE]. R15's Wound Culture Results dated 4/13/19 documents the following bacteria present in R15's coccyx pressure injury: -+ 4 bacteria (Klesbiella, [MEDICATION NAME], Corynebacterium, Proteus Mirabilis) R15's Hospital Discharge Summary dated 4/23/19 documents, Went in for PEG tube placement with debridement of coccyx wound on 4/17/19 by Acute Care Surgery. Notable pocket of pus was reported during debridement of the coccyx wound. Reasonable to assume it to be the source of her fevers. Seen by ID during this admission and treated for [REDACTED]. It was decided there was no utility in treating the chronic osteo[DIAGNOSES REDACTED]. Surveyor noted that R15's discharge [DIAGNOSES REDACTED]. R15's nursing note dated 4/23/19 at 8:30 p.m. documents, Health Status/Progress Note Text: Resident returned to facility accompanied via two ambulance personnel via stretcher .resident received ABT treatment for [REDACTED]. ABT treatment was completed today. Surveyor was unable to find any documentation that R15's stage 4 coccyx pressure was assessed by an RN when R15 returned from the hospital on [DATE]. Surveyor noted that R15's plan of care was not updated to reflect R15's stage 4 coccyx pressure injury until 4/24/19. R15's Wound Rounds assessment dated [DATE] documents, Wound Summary- Site: Coccyx; Type: Pressure; Source: Facility-acquired; Date Identified: 3/17/19; Identified by Wound Care RN-C; Clinical Stage: Stage 4; Tissue Types: Pale Pink Non-granulating= 75%, Slough Loosely Adherent: 25%; Exudate: moderate- serosanguineous; Length: 4.50 cm (centimeters); Width: 4.90 cm; Depth: 1.80 cm. Surveyor noted that while R15's coccyx pressure injury increased in size as documented on 4/25/19, there was no documentation from Wound Care RN-C that documented any changes in R15's coccyx pressure injury treatment or interventions to attempt to improve wound healing on 4/25/19. Per R15's (MONTH) 2019 TAR (Treatment Administration Record), R15's coccyx wound treatment remained the same as ordered on [DATE]. Surveyor noted that on 4/25/19, as R15's coccyx pressure injury increased in size, no Wound Rounds annotations were located that documented any change in R15's plan of care. R15's physician order dated 4/27/19 documents a change in R15's coccyx pressure injury as follows: Wound care to coccyx : cleanse with 1/4 strength Dakins solution, pat dry with gauze, apply skin prep to peri-wound, apply silver alginate to wound bed, cover with bordered gauze. Change daily and prn for soiling and or saturation every day shift for coccyx wound. Surveyor noted that R15's physician order for [REDACTED]. R15's Wound Rounds assessment dated [DATE] documents, Wound Summary- Site: Coccyx; Type: Pressure; Source: Facility-acquired; Date Identified: 3/17/19; Identified by Wound Care RN-C; Clinical Stage: Stage 4; Tissue Types: Pale Pink Non-granulating= 90%, Slough Loosely Adherent: 10%; Exudate: moderate- serosanguineous; Length: 5.0 cm (centimeters); Width: 4.50 cm; Depth: 1.80 cm. Surveyor noted that while R15's coccyx pressure injury increased in size as documented on 5/2/19, there was no documentation from Wound Care RN-C that documented any changes in R15's coccyx pressure injury treatment or interventions to attempt to improve wound healing on 5/2/19. Per R15's (MONTH) 2019 TAR (Treatment Administration Record), R15's coccyx wound treatment remained the same as ordered on [DATE]. R15's physician order dated 5/4/19 documents a change in R15's coccyx pressure injury as follows: Wound care to coccyx : cleanse with normal saline, pat dry with gauze, apply skin prep to peri-wound, apply silver alginate to wound bed, cover with bordered gauze. Change daily and prn for soiling and or saturation every day shift for coccyx wound. Surveyor noted that R15's physician order for [REDACTED]. R15's Wound Rounds assessment dated [DATE] documents, Wound Summary- Site: Coccyx; Type: Pressure; Source: Facility-acquired; Date Identified: 3/17/19; Identified by Wound Care RN-C; Clinical Stage: Stage 4; Tissue Types: Pale Pink Non-granulating= 90%, Slough Loosely Adherent: 10%; Exudate: moderate- serosanguineous; Length: 4.0 cm (centimeters); Width: 4.0 cm; Depth: 2.30 cm. Per R15's (MONTH) 2019 TAR (Treatment Administration Record), R15's coccyx wound treatment remained the same as ordered on [DATE]. R15's physician order dated 5/10/19 documents a change in R15's coccyx pressure injury as follows: Wound care to coccyx : cleanse with 1/4 strength Dakins solution, pat dry with gauze, apply skin prep to peri-wound, apply silver alginate to wound bed, cover with bordered gauze . Change daily and prn for soiling and or saturation every day shift for coccyx wound. Surveyor noted that R15's physician order for [REDACTED]. R15's Wound Rounds assessment dated [DATE] documents, Wound Summary- Site: Coccyx; Type: Pressure; Source: Facility-acquired; Date Identified: 3/17/19; Identified by Wound Care RN-C; Clinical Stage: Stage 4; Tissue Types: Intact Skin=50%, Pale Pink Non-granulating: 50%; Exudate: moderate- serosanguineous; Length: 4.7 cm (centimeters); Width: 4.9 cm; Depth: 2.30 cm. On 5/21/19 at 2:23 p.m., Surveyor observed R15's coccyx pressure injury wound treatment performed by Wound Care RN-C, along with Medical Director-X. During the observation, Surveyor observed R15's coccyx pressure injury dressing not to be in place. Wound Care RN-C confirmed to Surveyor that there was no dressing observed on R15's coccyx pressure injury prior to the wound treatment observed by Surveyor. On 5/21/19 at 3:55 p.m., Surveyor informed DON (Director of Nursing)-B and Wound Care RN-C of the above findings. Surveyor reviewed the above timeline and expressed the following concerns to DON-B and Wound Care RN-C: - The lack of an assessment, treatment and documentation of R15's open areas as first documented on 2/7/19 and later on 3/7/19. - The lack of documentation and nursing assessments documenting the closure of R15's open area's first documented on 2/7/19. - The documentation that R15's care plan was not updated on 2/7/19 and 3/7/19 to reflect the open areas as documented above. - The discrepancies in documentation regarding open areas on the right side of R15's buttocks and then later documented as left buttocks as documented above. - The lack of updates to R15's care plan as R15's coccyx injury progressed from a stage 3 to unstageable and then to a stage 4. - The lack of wound documentation documenting changes in R15's plan of care that included new pressure injury interventions and treatments as R15's wound progressed. - The lack of documentation documenting why R15 did not see the wound physician on 3/29/19. - The delay in R15's wound treatments after assessments by Wound Care RN-C on the dates listed above. - The lack of documentation of any infection signs and symptoms prior to 4/12/19. - The observation regarding R15 not having a dressing on her wound on 5/21/19. Surveyor requested additional information regarding the identification, assessment, treatment and documentation of R15's open areas and coccyx pressure injury. DON-B and Wound Care RN-C informed Surveyor that they did not have any additional information but that they would review R15's medical record for additional information. On 5/22/19 at 11:52 p.m., Surveyor informed Administrator-A of the above findings. No additional information was provided. On 5/22/19 at 12:39 p.m., Surveyor asked Wound Care RN-C what prompted the change in stage of R15's coccyx pressure injury on 4/12/19. Wound Care RN-C informed Surveyor that the stage of R15's coccyx pressure injury on 4/12/19 from a stage 3 to a stage 4 was due to her (Wound Care RN-C) being able to palpate bone while doing R15's wound treatment. Surveyor asked Wound Care RN-C why the facility had cultured R15's coccyx pressure injury on 4/1

Based on observation, record review, and interview, the facility did not ensure residents received care in order to prevent pressure injuries in 6 (R4, R3, R1, R2, R54, and R45) of 8 residents reviewed who are at risk for developing pressure injuries. * R4 developed an unstageable pressure injury to the sacrum without a complete assessment or notification to the physician for four days. On 4/19/18, nurse documentation indicated the coccyx-sacral wound dressing was replaced and the area worsened in appearance with a foul odor noted. This area was not assessed by the wound nurse until 4/22/18 where it documented as going from a red wound base on 4/19/18 to a wound base with slough on 4/22/18. The physician was not notified until 4/23/18. * The 4/26/18 Minimum Data Set (MDS), R3 was assessed to be at risk for pressure ulcers. On 4/30/18, R3 developed a Stage 2 blister to the right heel that progressed to a deep tissue injury. The Plan of Care was not updated until 5/3/18 to include offloading heel boots with pillow between the knees or heel lift boots to be implemented at all times when in bed and up for meals and therapy only. These interventions were not signed out by staff on PM shift 5/5/18 - 5/8/18 and on night shift on 5/5/18. On 5/6/18 the Wound nurse documented R3's pressure ulceration is now staged as a deep tissue injury to the right heel, after R3 saw the wound physician on 5/5/18. * R1, R2, and R54 were observed in bed with heels not being floated per plan of care. * R45 was observed out of bed without wearing offloading boots per plan of care. Example 1 rises to a scope and severity level of G (harm/isolated.) Findings: The facility Policy and Procedure entitled Skin Care Prevention dated 11/2003 with a revision date of 10/2016 and a review date of 5/2017 states: GENERAL: All residents will receive appropriate care to decrease the risk of skin breakdown. RESPONSIBLE PARTY: All nursing Staff. GUIDELINE: 1. The Wound Care Coordinator will review all new admissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. 2. All residents will be evaluated daily for changes in their skin condition. 3. Dependent residents will be assessed during care for any changes in skin condition including redness (non-blanching [DIAGNOSES REDACTED]) and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider and the wound care coordinator. 4. If the resident is independent in their care, they will be instructed to alert the nurse if they notice any areas of redness or open areas. The nurse will report this information to the Health Care Provider. 5. Residents unable to reposition themselves will be repositioned at least every two hours. Residents able to reposition themselves will be encouraged to reposition every two hours. 6. Unless contraindicated, elevate heels off bed surface and avoid skin-to-skin contact. 7. Maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions. 8. Treat dry skin with moisturizers as needed. 9. Clean skin at time of soiling and at routine intervals. 10. If incontinent, use a moisture barrier. 11. DO NOT massage reddened areas or bony prominences. 12. Provide patient and family information regarding pressure ulcer prevention and treatment as appropriate. 13. For residents who are bed or chair bound consider using a pressure-reducing device. 1. R4 was admitted to the facility on [DATE]. R4 has [DIAGNOSES REDACTED]. On 1/21/2015, R4's plan of care for Braden score of 13 with a history of coccyx wound and left heel deep tissue injury was initiated. Interventions include: examine skin during bathing for signs and symptoms of skin irritation and report any changes to the nurse immediately, pressure reducing device on the bed and chair, provide good pericare after each incontinent episode, and apply barrier cream or ointment every shift and after each incontinent episode. Revisions were made on 6/21/2016 to include treatment as ordered until healed, 6/27/2016 to include a roho cushion to the wheelchair, 7/7/2016 to include pressure relief boots. On 10/12/2017, R4's plan of care for moderate risk for skin breakdown was initiated with interventions: cleanse with peri-wash or wash with mild soap and warm water, rinse and pat dry, observe meal and fluid intake, reposition left, right, and back every two hours and as needed, skilled therapy as ordered, skin checks twice weekly when changing clothes, bathing, or showering, and toilet R4 per toileting pattern or scheduled toileting program. On 9/22/2017, R4 had an order for [REDACTED]. Apply [MEDICATION NAME] dressing every 3 days and prn (as needed). Monitor for signs of skin breakdown/infection. for Skin: Prevention. On 4/19/2018 at 2:39 PM in the Progress Notes, nursing charted the coccyx-sacral wound dressing was replaced after the caregiver reported the dressing was off. The area of concern has worsened in appearance, approximately 1.5 cm x 0.5 cm red base and red edges of wound. No exudate was noted. A foul odor was exuding from the site. The facility wound nurse was alerted and the unit nurse requested an assessment of the area. On 4/22/2018 at 8:42 AM in the Wound Assessment Details Report, nursing charted R4 has a facility-acquired pressure ulceration that is unstageable with 50% slough covering the wound base. The area measures 3.5 cm x 0.5 cm. R4's Braden score was 12 showing high risk for skin impairment. The Current Plan and Comments section was completed on 4/23/2018 at 11:40 PM stating R4 has reoccurring wounds to the coccyx/sacrum area and requires assistance with all activities of daily living, including being fed by staff. The physician was notified and new orders were received. R4 continues on an alternating pressure mattress, turning schedule and offloading wheelchair cushion. R4 is to be up for meals only. Family was notified. On 4/23/2018, new orders were placed in the TAR: wound care to sacrum - cleanse with normal saline, pat dry with gauze, apply skin prep to peri-wound followed by honey wound gel to wound bed, followed by bordered gauze to be changed every other day and as needed. On 4/23/2018, R4's plan of care for Braden score of 13 with a history of coccyx wound and left heel deep tissue injury was revised to include R4 to be up for meals one hour three times a day. On 4/24/2018 at 6:48 PM in the Progress Notes, dietary charted R4 was reviewed due to pressure area to sacrum and recommendations were made to increase protein intake to promote wound healing. On 4/26/2018, R4's wound treatment was changed from honey wound gel to Santyl ointment and the dressing was to be changed every day and as needed. R4's quarterly MDS (Minimum Data Set) assessment dated [DATE] coded R4 as needing extensive assistance with bed mobility, toileting, and is always incontinent of both bowel and bladder. The Brief Interview for Mental Status (BIMS) score was 00 showing severe cognitive deficit. On 5/9/2018 at 8:10 AM, Surveyor observed R4 sleeping in bed positioned on the left side with low air loss scoop mattress in place. A sheet was covering R4. Surveyor was unable to determine how R4 was positioned due to the amount of pillows under the sheet. At 1:50 PM, CNA-G accompanied Surveyor into R4's room. R4 was sleeping on the left side. CNA-G lifted the sheet off of R4 to reveal a pillow behind R4's right side propping R4 on the left, multiple pillows were under R4's left knee with no pillow between the legs, and off-loading boots were on each foot. CNA-G adjusted R4's legs by placing the pillow between the knees. CNA-G stated R4 has boots on her feet all the time. On 5/10/2018 at 1:05 PM, Surveyor met with DON-B and Wound RN-C to discuss R4's pressure injury to the sacrum. Wound RN-C stated R4 has recurrent pressure injuries so there was already a plan of care in place with a roho cushion, nutritional supplements and a wedge to help with positioning. There was a treatment in place for prevention of a pressure injury. Surveyor read the progress note that was charted on 4/19/2018 to DON-B and Wound RN-C. Wound RN-C stated she didn't know about the foul odor that was documented. Wound RN-C stated she did the initial assessment on 4/22/2018 and notified the physician on 4/23/2018 which is when the new orders were received. Wound RN-C stated she was not aware of the pressure injury on 4/19/2018. Surveyor shared the concern that the wound wasn't assessed or treated from 4/19/2018 until 4/23/2018 with no physician notification. The wound progressed from a red wound base on 4/19/2018 to a wound base with slough on 4/22/2018. DON-B and Wound RN-C had no further information at that time. On 5/10/2018 at 3:00 PM, Surveyor met with Nursing Home Administrator (NHA)-A and DON-B and shared the concerns for R4's pressure injury that developed in the facility on 4/19/2018 but was not assessed until 4/22/2018 with physician notification on 4/23/2018 and for R3's pressure injury that developed in the facility and progressed to a deep tissue injury. 2. R3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. R3's admission Minimum Data Set (MDS) assessment dated [DATE] coded R3 as needing extensive assistance with bed mobility, occasionally incontinent of both bowel and bladder, and is at risk for pressure ulcers. Section M: Skin Conditions coded R3 as not having any skin or ulcer treatments in place: such as pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, nutrition or hydration interventions. R3's Brief Interview of Mental Status (BIMS) score on 4/26/2018 was 11 showing moderate cognitive impairment. On 4/19/2018 at 10:15 PM in the Progress Notes, nursing charted R3 has reddened area to the groin, buttock, and bilateral breasts. R3's plan of care for potential alteration in skin integrity created on 4/20/2018 states the intervention will be educating R3 on the potential for alteration in skin integrity as well as preventative measures. R3's plan of care for moderate risk for skin breakdown was created and initiated on 4/20/2018. Interventions initiated on 4/20/2018 are: cleanse with peri-wash or wash with mild soap and warm water, rinse and pat dry, observe meal and fluid intake, reposition on left, right, and back every two hours and as needed, skilled therapy as needed, skin checks twice a week when changing clothes, bathing and showering, and toilet R3 per toileting pattern or scheduled toileting program. On 4/30/2018 at 12:46 AM in the Progress Notes, nursing charted R3 has an intact blister to the right heel. Skin prep was applied and the family was notified. The Wound Assessment Details Report states the blister was facility-acquired measuring 4.0 cm x 2.0 cm. On 4/30/2018, an order for [REDACTED]. On 4/30/2018 at 3:13 PM in the Progress Notes, dietary charted their initial assessment including the newly formed blister to the right heel. No recommendations were made by the dietitian. On 5/3/2018, R3's plan of care for moderate risk for skin breakdown was revised to include: applying barrier cream to buttocks three times per day and with each incontinent episode, Doppler study of bilateral lower extremities as ordered by the physician with a [DIAGNOSES REDACTED]. R3's plan of care for a blister to the right heel was created on 5/3/2018 with interventions: nutritional supplements as recommended by registered dietitian, R3 is not to wear tennis shoes to help prevent pressure to [MEDICAL CONDITION] feet, R3 to be up for meals and therapy only, R3 is to have skin checks daily including diabetic foot checks, and R3 is to utilize offloading heel boots with pillows between the knees or heel lift pillow at all times when in bed. The interventions of the heel lift pillow and heel lift boots to be implemented at all times when in bed and up for meals and therapy only were added to the TAR on 5/3/2018. These interventions were not signed out by staff on the PM shift 5/5/2018-5/8/2018 and the night shift 5/5/2018. On 5/6/2018 at 9:49 PM in the Wound Assessment Details Report, nursing charted R3 has a pressure ulceration staged as a deep tissue pressure injury to the right heel measuring 5.0 cm x 3.5 cm. The Current Plan and Comments section was completed on 5/7/2018 at 11:34 PM stating the wound has developed into a deep tissue injury. R3 saw the wound physician on 5/5/2018. The wound treatment was continued but no bordered foam to be applied. The physician recommended R3 to continue not to wear tennis shoes or slippers and to wear offloading boots when in the chair and the heel lift pillow at all times when in bed. No further assessment or recommendations were documented by dietary. On 5/7/2018, R3's plan of care for moderate risk for skin breakdown was revised to include: protect elbows and heels if exposed to friction, off load heels when in bed when indicated, apply protective barrier cream after every incontinence care and as necessary, keep skin clean and dry, may use lotion to moisturize skin after every shower and as needed, and daily and weekly skin checks. On 5/8/2018, R3's plan of care for the blister to right heel was revised to include: heel lift pillow when in bed. On 5/10/2018 at 7:50 AM, Surveyor observed R3 in bed with gripper socks on and the heels up cushion on the floor next to the bed. R3 stated there is a blister on the right heel and the staff doesn't want her to walk on it. When asked about the heels up cushion, R3 stated they use that every night on the bed, but they took it off this morning when they were getting her dressed. R3 couldn't recall how long ago the staff was in assisting her, but thought it had been about half an hour. Registered Nurse (RN) Unit Manager-D was outside R3's room passing medications to other residents. When asked how long ago the Certified Nursing Assistants (CNAs) had been in R3's room helping with morning cares, RN Unit Manager-D stated it was about ten minutes ago since the CNAs had left the room to get the lift. CNA-E and CNA-F returned to R3's room with the lift as surveyor was talking to RN Unit Manager-D and confirmed they had left R3's room about ten minutes ago. On 5/10/2018 at 1:15 PM, Surveyor met with Director of Nursing (DON)-B and Wound Registered Nurse (RN)-C to discuss R3's right heel pressure area. R3 developed a blister to the right heel while at the facility on 4/30/2018. The plan of care and treatment weren't updated until 5/3/2018 and the blister worsened into a deep tissue injury on 5/5/2018 per wound clinic notes. The heel lift pillow was not implemented until 5/3/2018. 3. R1 was admitted to the facility on [DATE]. R1 is currently receiving hospice services due to Alzheimer's dementia and has a history of pressure injury to the coccyx. On 2/20/2018, R1's Braden score was 11. (A score of 10-12 is high risk for skin breakdown.) R1 needs assistance with bed mobility per plan of care. R1's plan of care for skin integrity dated 11/23/2015 states to float the heels on a pillow while in bed. On 5/9/2018 at 8:40 AM, R1 was observed in bed with covers in place. Surveyor interviewed Certified Nursing Assistant (CNA)-D regarding R1's positioning in bed. CNA-D entered R1's room and lifted off the covers to visualize R1's positioning. R1 had a pillow under the legs, but R1's heels were resting on the mattress. 4. R2 was admitted to the facility on [DATE] after a cerebral infarction resulting in right-sided paralysis. On 5/7/2018, R2's Braden score was 12 showing a high risk for skin breakdown. R2's Minimum Data Set (MDS) assessment dated [DATE] coded R2 as needing extensive assistance with bed mobility. R2's plan of care for skin integrity dated 5/9/2018 states R2 is to wear offloading boots to heels when in bed. On 5/9/2018 at 8:00 AM, R2 was observed in bed, lying on his back. The head of the bed was slightly elevated and the foot of the bed was slightly elevated. R2's heels were resting on the mattress. No boots were present on R2's heels. 5. R54 was admitted to the facility on [DATE] following a [MEDICAL CONDITION] infarction. R54 is currently receiving hospice services. On 4/12/2018, R54's Braden score was 14 showing a moderate risk for skin breakdown. R54's plan of care for skin integrity 3/25/2018 states R54 is to utilize pillows to offload heels when in bed. On 5/9/2018 at 2:10 PM, R54 was observed in bed, sleeping on top of the covers. R54's heels were resting on the mattress with no pillows under the legs. 6. R45 was admitted to the facility on [DATE] with a readmission date of [DATE]. On 5/6/2018, R45's Braden score was 13 showing moderate risk for skin breakdown. R45's MDS assessment dated [DATE] coded R45 as needing extensive assistance with bed mobility. R45's plan of care for history of pressure ulcers dated 4/27/2018 states R45 is to wear an offloading boot when out of bed and up in a chair. On 5/9/2018 at 2:00 PM, R45 was observed sitting in a wheelchair in resident's room. Gripper socks were on both feet. No offloading boot was present to either foot. On 5/10/2018 at 1:35 PM, Surveyor interviewed Director of Nursing (DON)-B and Wound Registered Nurse (RN)-C regarding the intervention for R45's skin. Wound RN-C stated R45 should wear a boot on the right foot when out of bed for prevention. R45 had a pressure injury to the right heel that recently healed. Surveyor asked why not both heels since R45 had a history of [REDACTED]. Wound RN-C stated R45 uses the left foot to self-propel in the wheelchair. Surveyor informed DON-B and Wound RN-C of the observation of R45 up in the wheelchair with no offloading boot on. No further information was provided at that time. On 5/10/2018 at 3:00 PM, Surveyor met with Nursing Home Administrator -A and DON-B to review the above observations.

Based on observation, record review and staff interview, the facility did not ensure 1 (R32) of 4 residents reviewed for pressure injuries had interventions in place to prevent the development of a pressure injury. R32 developed 2 unstageable and avoidable pressure injuries to their heels. This resulted in actual harm to R32. Findings include: 1.) On 10/18/17 the facility completed a Braden Scale assessment for R32 indicating a risk score of of 18 indicating R32 was at risk for pressure injuries. Review of R32's Progress Notes indicate: 10/22/2017 04:41 (4:41 am) Health Status/Progress Note Text: F/U (follow up) ADMIT: S/P (status [REDACTED].@ (at) home. R32's Admission MDS (minimum data set) assessment completed on 10/25/17 indicates a pressure injury risk. , There were no pressure injuries upon admission to the facility. The MDS indicates R32 requires one staff assist with bed mobility and R32 does not move independently in bed or reposition self. Despite the fact that R32 did not move independently in bed or position self, the facility did not implement a care plan that addressed this risk. The MDS does not indicate pressure relief was implemented for the bed or chair. The 12/13/2017 20:04 (8:04 pm) Wound Care Notes Note Text: NP (Nurse Practitioner) notified via phone regarding DTIs (deep tissue injuries) on bilateral heels. New order received for iodosorb wound gel. Surveyor noted there was no assessment completed at this time that included measurements or characteristics of the wound. The facility did not put a plan in place to offload the resident's heels. The 12/16/17 Wound assessment indicates: right heel is unstageable and measures 2.7 cm (centimeter) by 6.7 cm; the left heel is unstageable and measures 2.5 cm by 3.5 cm. The facility did not put a plan in place to offload the resident's heels. On 1/17/18, one month after R32 had developed unstageable pressure injuries to both heels, the plan of care for Alteration in skin integrity was updated to include: utilize heel lift pillows. On 2/22/18 the care plan was updated to indicate R32 is to be non-weight bearing to heels and to use Hoyer lift for transfers. On 3/22/18 the care plan was updated to include wearing an offloading boot to left heel when up in chair. Surveyor noted all offloading interventions were implemented after R32 developed bilateral, unstageable pressure injuries to both heels. On 03/26/18 at 02:00 PM Surveyor spoke with, and observed, RN-H (Registered Nurses), the facility wound nurse for the past 11 months. Surveyor observed and RN-H confirmed R32's deep tissue injury to the left heel is closing up and the right heel is healed. RN-H indicated both heel areas are improving. RN-H shared with Surveyor that the suspected etiology of development for the areas is R32's lack of movement. RN-H indicated R32 stayed in bed a lot and was not walking at that time. RN-H indicated R32 does use boots now and has an air mattress. On 03/27/18 at 03:09 PM Surveyor spoke with RN-H about the development of R32's heel pressure injuries. RN-H indicated there was no specific intervention for heel prevention prior to development of the pressure injuries. RN-H indicated they were surprised the pressure injuries developed, however RN-H did not elaborate. RN-H indicated she developed a plan of care for the pressure injuries on the heel on 1/17/18, (even though the heel areas were discovered on 12/13/17 and even though the facility identified that R32 was at risk on admission). RN-H indicated she added on 1/17/18 for Resident to utilize heel lift pillow at all times when in bed for offloading. On 03/28/18 02:40 PM at the facility exit meeting with Administrator-A and DON-B (Director of Nurses). Surveyor shared the concerns with R32 pressure injuries no additional information was provided.

Based upon interview, record review and observation, the facility did not ensure 1 of 1 supplemental Residents (R26) reviewed for monitoring of their blood pressure received care and treatment to meet the highest practicable well-being. The facility also did not ensure 1 of 2 sampled Residents (R3) with a fluid restriction was monitored to ensure proper fluid intake. ~ R26 had a history of [REDACTED]. In May/June 2016 R26's blood pressure readings began to show increased hypertension and R26 was started on a new hypertension medication. During the month of August 3 different blood pressure parameters were listed on R26's orders that were not clarified by the facility to determine which parameter should be followed and there is no indication the facility nursing staff followed the parameters and contacted the physician with systolic blood pressures greater than 160, 180 or 190. On 8/28/16, when R26's morning blood pressure was recorded as being 185/74, there is no indication the Licensed Practical Nurse (LPN) that collected the blood pressure contacted the physician per ordered parameter nor is there indication this blood pressure was shared with an RN to ensure a thorough assessment. At approximately 7:45 pm R26 was found with signs and symptoms of a stroke including facial drooping and slurred speech. R26 was transferred to the hospital where an intracranial bleed was diagnosed . R26 was placed on hospice and subsequently passed away. ~ R3 was placed on a fluid restriction 1500mL/24 hours related to [DIAGNOSES REDACTED]. During the survey R3 was observed freely drinking water from pitchers on the dining tables without staff taking note of the amount of fluid R3 was drinking above staff provided fluids. Findings include: 1.) R26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nurse Practitioner-L progress note dated 6/9/16 indicates R26 was seen at the request of nursing staff. R26 is seen in follow up of elevated BP (blood pressure) as well as BLE (bilateral lower extremity) [MEDICAL CONDITION]. She was placed on [MEDICATION NAME] for 10 days. She reports that her voiding has not changed much since being on the medication. Weight has been stable. BP has been running high. She was previously on [MEDICATION NAME] for [MEDICAL CONDITION](hypertension). However, this was stopped 2/2 (secondary to) episodes of [MEDICAL CONDITION] and dizziness. She denies any HA (headache) or dizziness at this time Physical exam: .CARDIOVASCULAR: regular rate and rhythm. BLE with 1-2+ [MEDICAL CONDITION]. IMPRESSION/PLAN: 1. [MEDICAL CONDITION]. Continue with TEDS. Complete [MEDICATION NAME] course. Labs requested for follow up. Weekly weight. 2. HTN. Start [MEDICATION NAME] 25 mg PO (by mouth) daily. 3. Constipation. Increase Senna-S to 2 tabs daily at bed time. A physician progress notes [REDACTED].Impression: [AGE] year old female with deconditioning, generalized weakness, orthostatic [MEDICAL CONDITION] resolved by dc (discontinuation) aldomet ([MEDICATION NAME]), [MEDICATION NAME] . Surveyor noted the progress note does not reference R26's redeveloping hypertension and start of [MEDICATION NAME]. Review of R26's physician orders [REDACTED].>160 or < 90 Syst call and update MD. This order was also in place in July 2016 and August 2016. Review of R26's Medication Administration Records (MARs) indicate nursing staff placed a check mark that this order was completed each day, each month, however, Surveyor noted the actual blood pressure rate taken is not listed with this MAR indicated [REDACTED] Review of R26's physician orders [REDACTED]. Nurse Practitioner-L's progress note dated 6/27/16 indicates R26 was seen for follow up of ongoing BLE [MEDICAL CONDITION] as well as elevated BP. Her SBP (systolic blood pressure) has been running anywhere from 14-'s-170's (sic). She denies any pain or discomfort. No chest pain or shortness of breath. She does spend most of the day in a wheelchair. Voiding without any problems. No dizziness or headaches. Currently she is on [MEDICATION NAME] 25 mg daily. Weight has been stable. Eating and drinking well. (R26) does have a h/o (history of)[MEDICAL CONDITION] has been on medications for this for several years. She was taken off of them a few months ago 2/2 [MEDICAL CONDITION] IMPRESSION/PLAN: 1. [MEDICAL CONDITION]. Continue to monitor. Labs have been requested to monitor. 2. HTN. Increase [MEDICATION NAME] to 37.5 mg daily. Review of R26's blood pressure vitals summary for June 2016 indicates R26's blood pressure rate was not recorded for the dates of 6/15/16-6/18/16, 6/20/16-6/24/16, 6/26/16-6/27/16 and 6/30/16. Review of the recorded rates indicates R26's blood pressure rate exceeded >160 systolic on 6/25/16: at 162/86. There is no indication the nurse practitioner or physician was contacted with this specific blood pressure rate. A 7/17/16 physician visit progress note indicates R26 is doing well.Impression: [AGE] year old female with deconditioning, generalized weakness, orthostatic [MEDICAL CONDITION] resolved by dc (discontinuation) aldomet ([MEDICATION NAME]), [MEDICATION NAME] . Surveyor noted the progress note does not reference R26's ongoing hypertension and adjustments of [MEDICATION NAME] by NP-L. A 7/28/16 note by NP-L indicates: (R26) is seen today for follow up of elevated BP as well as LE (lower [MEDICAL CONDITION]). The [MEDICAL CONDITION] in her legs has greatly improved. She denies any chest pain or shortness of breath. Blood pressure however, has been elevated recently. She denies any HA's, dizziness or blurred vision. Currently, she is on [MEDICATION NAME] 37.5 mg daily for HTN. Weight has remained stable .IMPRESSION/PLAN: 1. HTN. Increase [MEDICATION NAME] to 25 mg PO BID (twice a day). Continue to monitor BP. 2. [MEDICAL CONDITION]. Stable at this time. Review of R26's blood pressure vitals summary for July 2016 indicates on 7/4/16 R26's blood pressure was 177/91, 7/10/16: 168/42, 7/17/16: 169/95, 7/19/16: 180/74, 7/23/16: 176/80; 7/28/16: 185/84, 7/29/16: 176/80, and 7/31/16: 175/87. Surveyor noted that there is no indication that the facility nursing staff updated the physician or nurse practitioner with each blood pressure greater than 160 as ordered. Review of R26's blood pressure's indicate there are no documented blood pressure results recorded for 7/5/16-7/6/16, 7/9/16, 7/11/16-7/16/16, 7/18/16, 7/20/16-7/22/16, 7/24/16-7/27-16, 7/30/16. Review of R26's 8/1/16 physician orders [REDACTED].>160 or <90 Syst call and update MD. A progress note written by NP-L dated 8/4/16 indicates (R26) is seen today in follow up of HTN. This continues to be elevated despite the increase of [MEDICATION NAME] to 25mg BID. She denies any HA, pain or discomfort, no chest pain or shortness of breath. Also, [MEDICATION NAME] was recently decreased from 1mg to 0.5 mg QHS (at bedtime) for anxiety. Staff has not noted any change in behavior. Sleep remain fair, 2/2 roommate issues that she has been having. She declines offer of being moved to another room. Overall she reports that she is doing well .IMPRESSION/PLAN: 1. HTN. Increase [MEDICATION NAME] to 50 mg BID and to continue to monitor and make adjustments as needed. 2. Anxiety. Stable at this time, even with recent dose decrease of [MEDICATION NAME]. Continue to observe behavior. Review of R26's blood pressure vitals summary indicates there is no documented blood pressure reading for R26 for the dates of 8/1/16-8/5/16 and 8/8/16-8/10/16. On 8/11/16 NP-L documented (R26) is seen today for follow up [MEDICAL CONDITION] well as for medical review. She reports she is doing quite well. She denies HA, dizziness or lightheadedness. She is eating and sleeping well, no concerns with her B&B (bowel & bladder) .At one point she did have some issues with her roommate and not sleeping well at night. However, this has been resolved. She does have a dx (diagnosis) of HTN. However, several months ago she was having hypotensive episodes. At that time she was on [MEDICATION NAME] as well as [MEDICATION NAME] for BLE [MEDICAL CONDITION]. Both were stopped. Over the last few weeks, her BP has been elevated again. She was the started on [MEDICATION NAME] and slowly the dose is being titrated. This morning, before her medication, BP was 194/81. Current dose is 50 mg BID .she denies any chest pain or shortness of breath. Recently her anxiety medication was decreased. She was previously on [MEDICATION NAME] 1 mg at bedtime. This was decreased to 0.5 mg at bedtime. She is doing quite well with the decrease ASSESSMENT: 1. HTN. 2. LE weakness and gait instability. 3. Anxiety disorder. 4. [MEDICAL CONDITION] of multiple joints PLAN: Previous labs and medications reviewed. Continue with current activities and diet. Restorative therapy to begin working with resident for LE strengthening. Increase [MEDICATION NAME] to 75 mg BID and continue to closely monitor BP. Continue with all other medications. Review of R26's electronic medication orders and MAR for August 2016 indicated on 8/11/16 with the increase in [MEDICATION NAME] a second blood pressure monitoring parameter was added to R26's MAR. The order for [MEDICATION NAME] indicates: [MEDICATION NAME] Tablet 75 mg by mouth two times a day related to essential (primary) hypertension (I10) call MD if SBP (systolic blood pressure) is <90 or >180. Start date: 8/11/16. Surveyor noted there were now two blood pressure parameters ordered for R26 one indicating to contact the physician if >160 and one now giving a parameter of >180. The facility did not clarify these orders. Review of R26's blood pressure vitals summary indicates the following: 8/12/16: 162/74 & 168/72, 8/13/16: 166/70 & 158/75, 8/14/16: 152/71 & 171/72, 8/15/16: 175/90 & 160/72, 8/16/16: 183/62 & 177/72, 8/17/16: 160/72 & 178/70. Review of R26's progress notes indicate there was no progress note documentation in R26's medical record from 8/12/16 to 8/18/16. There is no indication in R26's record that nursing staff had updated the physician or nurse practitioner, each time, for any blood pressure result that exceeded 160 based upon the parameter started on 6/15/16 or the second parameter started on 8/11/16 for a systolic result greater than 180. On 8/18/16 NP-L documented (R26) is seen today for follow up of elevated BP. [MEDICATION NAME] was increased at the time of the last visit to 75 mg BID. BP continues to be elevated. (R26) reports overall she is doing well. Denies any HA, chest pain or shortness of breath. She continues to have some roommate issues and feels that may be responsible for the elevated BP . IMPRESSION/PLAN: (R26) continue (sic) with elevated BP despite recent adjustment to the [MEDICATION NAME]. Will add [MEDICATION NAME] 0.1 mg PO BID and monitor result over the next few weeks. SW (Social Worker) has approached her to offer a different room but she has declined. Review of R26's MEDICATION ORDERS FOR [REDACTED]<90 or >190. Surveyor noted this is the third blood pressure parameter running consecutively for R26. There were orders to call with SBP <90 and >160, >180 and >190. Review of R26's progress notes indicates NP-L wrote a progress note on 8/23/16 however, this note is specific to R26 having complaints of heartburn; the review does not include review of R26's hypertension status. R26's documented blood pressure vital summary indicated the following: 8/18/16: 197/78 & 194/75, 8/19/16: 192/75 & 156/89, 8/20/16: 192/71 & 140/87, 8/21/16: 191/80 & 156/85, 8/22/16: 187/76 & 180/75, 8/23/16: 172/72 & 169/75, 8/24/16: 168/70 & 170/65, 8/25/16: 188/79 & 181/79, 8/26/16: 176/74 & 172/73. 8/27/16: 178/76 & 173/60, 8/27/16: 178/76 & 173/60, 8/28/16: 185/74 & 173/72. Surveyor noted there is no indication that nursing staff updated/contacted the physician or nurse practitioner with each blood pressure that exceeded an existing parameter. On 2/8/17 at approximately 1:55 pm Surveyor interviewed LPN-FF regarding R26's parameters and documentation on the MAR indicated [REDACTED]. LPN-FF indicated looking at the MAR indicated [REDACTED]. Surveyor asked LPN-FF if she recalled contacting R26's physician or nurse practitioner anytime her blood pressure exceeded a parameter. LPN-FF indicated she could not specifically recall but indicated if a physician was contacted, it should be documented. LPN-FF indicated that NP-L is in the building Monday through Friday so there may be times that a nurse may have mentioned a blood pressure reading in passing to NP-L but that should be documented if they did. LPN-FF reviewed R26's MARs for August 2016 and noted the parameter indicating to update the physician for a blood pressure <90 and >160. LPN-FF told Surveyor she did not recall implementing that parameter and wasn't sure what the check mark in a box exactly meant. As LPN-FF reviewed the MARs she noted that there was also a third parameter in August attached to the order for [MEDICATION NAME]. LPN-FF indicated someone should have caught that because it is unclear what the expectation was. On 2/8/17 at approximately 10:50 am Surveyor interviewed NP-L about R26's hypertension. NP-L indicated that despite hating the term, they were playing with R26's blood pressure medications and that it is NP-L's philosophy to start a low dose and adjust because you do not know how an elderly person may respond to the medication. NP-L confirmed to Surveyor that R26 had a history of [REDACTED]. NP-L indicated she thought the reduction went well until the blood pressures started to go back up. Surveyor asked NP-L if she recalled being contacted with each blood pressure result that exceeded a written parameter. NP-L indicated she was not contacted with each one, NP-L indicated she is in the building Monday through Friday and nurses may stop her and mention something but then they should chart that contact. Surveyor asked NP-L if she knew whether Physician-N had been contacted with each blood pressure exceeding a parameter and she indicated that he was not to her knowledge; indicating they would recall if they had received that many phone calls. Surveyor asked NP-L at what point, with the adjustments to R26's anti-hypertension medications and continued high blood pressures, would she consult with Physician-N. NP-L indicated if there had been a persistent condition or if a resident is not responding to a medication. Surveyor asked NP-L if she recalled consulting with Physician-N about R26, given her high blood pressures and need to frequently increase her medications. NP-L indicated she did not recall specifically consulting with Physician-N about R26. Surveyor shared with NP-L that Physician-N's last two progress notes (one in June & one in July) did not reference R26 having hypertension and the need for medications and adjustments but rather the history of [MEDICAL CONDITION] and discontinuing previous hypertension medications. NP-L indicated she was not aware of that. On 2/9/17 at approximately 7:21 am Surveyor interviewed Physician-N about R26 and her elevated blood pressures and conflicting parameters. Physician-N indicated he remembered R26 and her [MEDICAL CONDITION] and [MEDICAL CONDITION]. Surveyor asked Physician-N when he would expect to be contacted with an elevated blood pressure. Physician-N indicated he would expect to be notified if greater than 180 or sometimes 190. Surveyor showed Physician-N the three conflicting parameters ordered for R26. Physician-N indicated that it didn't make sense to have three conflicting parameters and it appeared that a parameter was gotten for each medication with no one paying attention that there may have already been one in place. Physician-N indicated when a new parameter is put into place the old one does not fall off, it has to be discontinued. Physician-N indicated he was not sure and could not remember who had ordered the individual parameters. When asked about consultation with NP-L regarding R26 Physician-N indicated that was a long time ago and could not specifically recall. When asked if he would expect a phone call from a nurse with a systolic blood pressure greater than 180 Physician-N indicated yes. R26's medical record indicated in the progress notes dated 8/28/16 at 20:40 (8:40 pm): Resident has been transported to St. Mary's Columbia per ambulance. (Physician-K) called and made aware of condition change and (name of family member) also notified. A progress note dated 8/28/16 at 22:02 (10:02 pm) indicated: Reason for report: confusion, restlessness, lt (left) facial droop and slurred speech. New orders. A progress noted dated 8/28/16 at 22:46 (10:46 pm) indicated: has been admitted to ICU. R26's medical record included an SBAR (Situation, Background, Assessment and Recommendation) dated 8/28/16 at 22:02 (10:02) indicating: Situation: This is (LPN-EE) calling about (R26). The symptom/sign/change I am calling about is: confusion, restlessness, lt (left) facial droop and slurred speech. This started: Noted at 7:45 pm. This has gotten___ since it started? Worse, Things that make condition worse are: BP=215/132, p (pulse) =137, R (respirations) =18, pO% (pulse ox) =78. Things that make condition better are & other things that have occurred with this change are: blank. Background: Primary [DIAGNOSES REDACTED]. Pertinent history: none recent. BP have been an issue and medication adjustments have taken place. Most recent blood pressure: 173/72 8/28/2016 17:42 (5:42 pm) sitting r (right)/arm. Most recent temperature: 97.6 on 8/11/16 (sic) 13:03 (1pm). Most recent pulse: 59 8/21/2016 (sic) 10:00. Most recent respiration: 18 8/7/2016 (sic) 11:42. Blood glucose 111.0 mg/dL 8/22/2016 (sic) 9:23. Most recent O2 sats: 96% 5/28/2016 17:00 (5 pm) (sic). Most recent height: 64 1/5/2016 (sic) 19:41 (7:41 pm). Most recent weight: 138.6 8/16/2016 (sic) 12:18. Change in function or mobility: blank. Medication changes or new orders in the last two weeks: addition of [MEDICATION NAME]. Mental status changes (e.g. confusion/agitation/lethargy): blank. GI/GU changes: blank. Pain level/location: no hurt. Location of pain: blank. Change in intake/hydration, change in skin or wound status labs: all blank. Advanced directives: Full code. Assessment (RN): What do you think is going on with this resident? Checked is mental status change. Appearance (LPN): checked is more confused. Request: I suggest: transfer to hospital is checked. Surveyor noted there is no documentation to show an RN assessed R26 at any point on 8/28/16 nor is there any documentation or assessment to show what R26's status was throughout the day or whether R26 was demonstrating any hypertension emergency symptoms following an earlier blood pressure result of 185/74; which exceeded one of her established parameters. There is also no indication with the earlier elevated blood pressure a physician had been contacted with the result. On 2/9/17 at approximately 2:09 pm Surveyor interviewed LPN-EE via telephone regarding R26 and the monitoring of her blood pressure and change in condition. LPN-EE indicated she remembered the night of 8/18/16 and R26. LPN-EE indicated that R26's blood pressure was constantly high. When asked about the parameters for R26 LPN-EE indicated she thought if the initial blood pressure was high, it would more than likely come down after the administration of her medications. LPN-EE indicated she did not go back after a short period to double check whether it came down or not; LPN-EE collected blood pressures with medication administration. LPN-EE was asked if she recalled ever contacting the physician or nurse practitioner with an elevated blood pressure and LPN-EE indicated she did not recall calling anyone if it was elevated. LPN-EE indicated that she would periodically have contact with NP-L but did not recall ever documenting a specific conversation or referral to NP-L about a specific blood pressure result. LPN-EE was asked about 8/28/16 and R26's blood pressure results and change in condition. LPN-EE indicated she was the nurse on the unit and had worked a double shift that day. When asked whether she contacted a physician or requested an RN assessment when R26 had a blood pressure result of 185/74 in the morning of 8/28/16 LPN-EE indicated she probably should have. LPN-EE indicated at no point throughout the day did an RN assess or check on R26. Surveyor asked LPN-EE if she recalled asking R26 if she had any symptoms of a headache or dizziness etc. LPN-EE indicated she did not specifically ask. LPN-EE indicated she thought R26 was ok throughout the day and had eaten. Surveyor asked LPN-EE for details of what time and who was the person who found R26 with the stroke like change in condition symptoms because no details were documented. LPN-EE indicated she thinks a CNA (certified nursing assistant) went in to help R26's roommate and noticed R26 did not appear to be herself that R26 was agitated and the CNA got LPN-EE. LPN-EE told Surveyor she thought R26 had eaten her dinner and had been ok. Surveyor reviewed R26's charting of the percentage of meal eaten for 8/28/16 and noted the charting for 8/28/16 includes charting at 1:40 pm indicating 76-100% of a meal eaten and another entry dated 8/28/18 at 1:41 pm also indicating R26 ate 76-100% of a meal. Surveyor noted the report does not indicate what meal the intake is being recorded for so it is not clear if this was a double entry or if it was for breakfast and lunch and breakfast was being charted much later in the day. Surveyor also noted that despite LPN-EE indicating R26 had eaten dinner and she thought she was ok there is no charting to indicate R26 ate dinner or what R26's status was throughout the day until she was seen by LPN-EE with signs and symptoms of a stroke. Review of the emergency department medical record dated 8/28/16 indicates for a review of systems R26 had neurologic symptoms of a headache, slurred speech, facial droop and ROS (review of systems) limited secondary to AMS (altered mental state). Vital sign measurement indicates blood pressure of 228/102 at 20:30 (8:30 pm). The CT scan without intravenous contrast indicated: large intraparenchymal hematoma identified right temporal and parietal lobes with some minimal surrounding [MEDICAL CONDITION] and mild mass effect. Areas of subarachnoid bleeding identified adjacent to the large hematoma. The intraparenchymal hematoma maximally measures 4.1 cm in diameter. There may be a small amount of subdural blood adjacent to the intraparenchymal hematoma The hospital discharge summary dated 9/10/16 indicates: R26 passed away on 9/10/16 at 17:30 (5:30 pm) [DIAGNOSES REDACTED]. On 2/8/17 at approximately 3:26 pm, at the facility daily meeting, Surveyor shared concerns regarding the facility's monitoring of R26's blood pressures based upon ordered parameters by the nursing staff. Surveyor asked Director of Nursing (DON)-B what is the facility's policy and procedure regarding blood pressure monitoring and changes in condition. DON-B indicated she did not know what standard the policies and procedures are based upon and that surveyors would need to ask the corporate consultant given the policies are corporate policies. On 2/9/17 at approximately 10:35 am, Surveyor and Surveyor interviewed NP-L about R26 and the three different blood pressure monitoring parameters and expectations for being contacted. NP-L indicated the outcome to R26 was unfortunate and that NP-L had not been in the facility in the week or so leading up to R26's hospitalization due to being on vacation. NP-L indicated that she was not aware of the three different parameters and specifically was not sure who originally ordered the parameter to call if blood pressure is greater than 160 knowing that it went back almost to R26's admission. NP-L wondered if the facility's electronic software populates parameters or if the greater than 180 parameter was facility protocol. NP-L was unsure. NP-L indicated she would expect to be contacted based upon parameters and specifically if greater than 180. NP-L indicated if she had been contacted with each elevated blood pressure she would have expected a nurse's assessment to determine the situation surrounding the elevated blood pressure to make an informed decision of what is needed, if anything, to be done. Surveyor asked NP-L if LPN-EE had contacted a physician or NP-L on 8/28/16 about R26's blood pressure of 185/74 could it have made a difference in R26's outcome. NP-L indicated that if a nurse had contacted a physician or the nurse practitioner questions would have been asked to look at the overall situation surrounding R26 and it would have required an assessment that may have caught any changes with R26 earlier, it also may have led to increased monitoring and assessment throughout the day. On 2/9/17 at approximately 10:53 am Nursing Home Administrator (NHA)-A shared with Surveyor that the facility's policy related to blood pressure monitoring and hypertension/[MEDICAL CONDITION] is based upon the American Heart Association as conveyed to NHA-A by the facility's corporate Nurse Consultant. According to The American Heart Association (AHA) high blood pressure (hypertension) stage 1 includes systolic mm Hg (upper #) 140-159. High blood pressure (hypertension) stage 2 is a measure result of 160 or higher. The American Heart Association defines a Hypertensive Crisis (Emergency care is needed) for a blood pressure higher than 180. The definition of a Hypertensive Crisis is when blood pressure rises quickly and severely. There are two types of hypertensive crises - both require immediate medical attention. Hypertensive Urgency: If you get a blood pressure reading of 180/110 or greater, wait about 5 minutes and try again. If the second reading is just as high, seek immediate medical help . Hypertensive Emergencies generally occur at blood pressure levels exceeding 180 systolic or 120 diastolic .The consequences of uncontrolled blood pressure in this range can be severe and include: stroke, loss of consciousness, memory loss, [MEDICAL CONDITION], damage to eyes and kidneys, loss of kidney function, aortic dissection, [MEDICAL CONDITION], [MEDICAL CONDITIONS] and[DIAGNOSES REDACTED]. AHA recommendation: If you get a blood pressure reading of 180 or higher on top or 110 or higher on the bottom AND are experiencing signs of possible organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision, difficulty speaking do not wait to see if your pressure comes down on its own call 911. The above information was shared with DON-B and Nursing Home Administrator (NHA)-A on 2/10/17 at approximately 9:30 am. DON-B mentioned the facility had completed a QAPI (Quality Assurance Improvement Program) process regarding care plans and assessments and asked Surveyor if this could be taken into consideration regarding R26. Surveyor asked DON-B to provide any additional information for review and consideration; no additional information was provided to Surveyor following exit from the facility regarding the facility's work on care planning and assessment with regard to R26. 2.) R3 has [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. R3's care plan with a goal to tolerate diet as ordered includes the intervention created on 1/19/17 to Explain and reinforce to the resident the importance of maintaining the diet ordered + fluid restriction. Encourage the resident to comply. The care plan also includes an intervention created on 1/19/17 to Monitor for non-compliance with fluid restriction. Watch for use of bubbler. R3's most recent Minimum Data Set Assessment with an assessment reference date of 12/9/16 documents that R3 has a brief interview for mental status score of 6 indicating R3 is severely cognitively impaired. The facility's FLUID RESTRICTION POLICY with a review date of 7/14 states Residents on fluid restriction will be placed on intake monitoring. This will be completed every shift. On 2/2/17 at 11:30 a.m. Surveyor reviewed R3's lunch meal card. Surveyor noted that the slip documented a 1500cc fluid restriction. On 2/2/17 at 12:09 p.m. Surveyor observed R3 drinking a 120 mL glass of water. At 12:15 p.m. Surveyor observed R3 finish the glass and pour himself another glass of 120 mL of water. Surveyor observed that no staff was monitoring R3's fluid consumption at this time. On 2/2/17 at 12:16 p.m. Surveyor observed Dietary Aide-Y pour R3 a 240mL glass of coffee. At 12:23 p.m. Surveyor observed R3 continue to drink his coffee and refill his 120cc water glass. Surveyor observed that no staff were monitoring R3 as he filled his water glass. Surveyor observed R3 finish his glass of coffee. And at 12:34 p.m. Surveyor observed R3 refill his water glass with all the water that remained in the water pitcher, which filled R3's cup halfway and noted to be approximately 60 mL of water. Surveyor noted that no staff was monitoring R3's fluid consumption at this time. Review of R3's fluid intake for 1st shift on 2/2/17 documents that R3 only had 600mL. Surveyor noted that during lunch alone R3 was observed to have at least 660mL of fluids, and that the first shift documentation would have also included breakfast. Review of R3's fluid intake for 2/3/17 had no documented fluid intake. Review of R3's fluid intake for 2/5/17 had no documented fluid intake. Review of R3's fluid intake for 2/7/17 had no documented fluid intake. On 2/9/17 at 8 a.m. Surveyor interviewed Registered Dietitian-D. Surveyor asked if Registered Dietitian-D had been made aware of R3 having increased fluid consumption for lunch on 2/2/17. Registered Dietitian-D stated that she had been made aware in the past, and that R3 has been educate, but had not been made aware on Thursday (2/2/17). Surveyor asked how fluid consumption at meals is monitored for R3. Registered Dietitian-D stated that it is a team effort and that R3 has been educated and chooses not to always follow the restriction. Surveyor informed Registered Dietitian-D that she was concerned with how R3's fluid consumption is monitored. Registered Dietitian-D stated that she understood the concern.

Based on observation, interview, and record review the facility did not ensure that 3 (R14, R11, and R7) of 7 sampled residents at risk for the development of pressure injuries received the necessary care and services to prevent the development of avoidable pressure injuries. R14 developed 3 avoidable unstageable pressure injuries after no interventions were put into place to prevent the development of pressure injuries or to reposition despite being at risk for the development of pressure injuries and requiring total dependence on staff for bed mobility. R11, who has a history of pressure injuries, developed an avoidable pressure injury to her right heel after the facility had no interventions in place to prevent pressure injuries to R11's heel. R7, who is at risk for the development of pressure injuries, was observed to not be offered, encouraged, or attempted to have her heels offloaded of pressure as indicated per her plan of care. R14 is being cited at severity level 3 (actual harm). Findings include: According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance's Prevention and treatment of [REDACTED].), Cambridge Media: Perth Australia; 2014 the section REPOSITIONG TO PREVENT AND TREAT HEEL PRESSURE ULCERS states The reduction of pressure and shear at the heel is an important point of interest in clinical practice. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. It continues to state under the section Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that the heels are free of the surface of the bed The facility's Skin Care Prevention Policy with a revision date of 10/16 states 5. Residents unable to reposition themselves will be repositioned at least every two hours. Residents able to reposition themselves will be encouraged to reposition every two hours. 6. Unless contraindicated, elevate heels off bed surface and avoid skin-to-skin contact. 1.) R14 has [DIAGNOSES REDACTED]. A Braden Risk assessment score on 8/29/16 scores R14 as moderate risk for the development of pressure injuries. R 14's Pressure Ulcer Care Area Analysis signed as completed 7/8/16 documents Resident does not have a pressure ulcer but is at risk of developing one. She is frequently incontinent of her bowels and bladder. Also, she needs extensive assistance from the staff with her bed mobility. Skilled/Look Back Documentation notes on 10/1/16-10/4/16 document that R14 required total dependence of two plus persons physical assist for bed mobility and transfers. On 10/5/16 R14 was documented to have developed two unstageable pressure injuries to her bilateral heels. Wound notes documented that the areas were first identified on 10/5/16. The left heel was documented as a 6cm x 6cm unstageable pressure injury. The predominant tissue type is documented to be 100% necrotic soft and adherent. The right heel was documented as a 4cm x 4cm unstageble pressure injury. The predominant tissue type is documented to be 100% necrotic soft and adherent. Surveyor noted that the pressure injuries were not identified until necrotic tissue had developed. A physician notification note was completed on 10/6/16, but does not include a documented physician recommendation related to R14's pressure injury to her heels. The pressure injury to R14's right heel was documented as healed on 10/21/16. The pressure injury to R14's left heel was last measured on 11/14/16 and documented to be unstageable measuring 5cm x 4cm, with the prominent tissue type documented to be 100% necrotic soft and adherent. R14 passed away on 11/19/16. Surveyor reviewed R14's October 2016 treatment administration record and was unable to find documentation of a treatment being completed on R14's heels until 10/22/16. Review of R14's care plan included a potential for skin integrity care plan initiated on 6/8/16 that included interventions initiated on 6/8/16 to observe skin during routine care and report alterations to the nurse and to provide peri-care and barrier after incontinent episodes. Surveyor noted that R14's care plan did not include interventions to off-load R14's heels of pressure prior to the development of R14 developing bilateral unstageable pressure injuries to her heels. Review of R14's Care Plan has no documented changes regarding the management or prevention of pressure injuries until 10/13/16 despite R14 developing 2 unstageable pressure injuries on 10/5/16. On 2/9/17 at 8:40 a.m. Surveyor interviewed CNA-BB. Surveyor asked CNA-BB how she would know if a resident needs to have their heels floated. CNA-BB stated by the resident's care plan. On 2/9/17 at 11:35 a.m. Surveyor interviewed DON (Director of Nursing)-B regarding R14's pressure injuries. Surveyor asked for any additional information regarding no documented treatment until 10/22/16. R14 informed Surveyor that she would look into it. No further information was provided. Surveyor asked if a resident required total dependence on staff for bed mobility if staff would be expected to float the resident's heels. DON-B stated that it would depend. Surveyor asked if R14's heels should have been offloaded of pressure. DON-B stated that she would look into it. No further information was provided. Surveyor informed DON-B that CNA-BB had stated that she would look at the care plan for instruction on repositioning residents and floating their heels. DON-B informed Surveyor that the CNA's do not have access to the care plans, that they use care cards. Surveyor asked if the information the CNA care cards would be reflected on the care plan. DON-B stated that it should be. On 10/13/16 R 14 developed a stage 2 pressure injury to her coccyx measuring 4cm x 2.5 cm x 0.2cm with 100% [MEDICATION NAME] tissue. On 10/26/16 the area worsened with the predominant tissue type 100% non-adherent slough. Measurements remained the same. The area is documented as a healing stage 3, despite the new presence of slough, and the slough documented as 100%. The pressure injury to R14's coccyx was last documented as measured on 11/14/16 measuring 3.5cm x 2.5cm x 0.5cm with the predominant tissue type documented to be 100% non-adherent slough. The area is documented as a healing stage 3 despite an increased depth from 0.2cm on 11/8/16 to 0.5cm on 11/14/16 and despite the present of 100% non-adherent slough. R 14 passed away on 11/19/16. The facility's Skin Management: Pressure ulcer, lower extremity ulcer evaluation and documentation with a revision date of 7/14 defines an unstageable pressure injury as Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) in the wound bed. Further Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore staging cannot be determined . Surveyor noted that per the facility's policy R 14's pressure injury should have been staged as unstageable. Review of R14's care plan included a potential for skin integrity care plan initiated on 6/8/16 that included interventions initiated on 6/8/16 to observe skin during routine care and report alterations to the nurse and to provide peri-care and barrier after incontinent episodes. Surveyor noted that R14's care plan did not include interventions to reposition R14 prior to the development of her pressure injuries. On 2/9/17 at 8:40 a.m. Surveyor interviewed CNA-BB. Surveyor asked CNA-BB how she would know if a resident needs to be repositioned. CNA-BB stated by the resident's care plan. On 2/9/17 Surveyor was provided with a follow up question report that asks Was Resident turned and or repositioned every 2 hours and as needed during shift? for September and October. Surveyor noted that this question was not documented as being completed by all 3 shifts on 9/5/16, 9/11/16, 9/15/16, 9/17/16, 9/26/16,9/27/16, 9/28/16, 9/29/16, 10/1/16, 10/2/16, 10/3/16, and 10/4/16. On 2/9/17 at 11:35 a.m. Surveyor interviewed DON-B and informed her that CNA-BB had stated that she would look at the care plan for instruction on repositioning residents and floating their heels. DON-B informed Surveyor that the CNA's do not have access to the care plans, that they use care cards. Surveyor asked if the information the CNA care cards would be reflected on the care plan. DON-B stated that it would. Surveyor asked why the wound was changed as a healing stage 3 despite the documented presence of 100% slough. DON-B stated that it depends on the periwound how everything is looking. Surveyor noted that this was not in accordance with the facility's policy. 2.) Surveyor reviewed R7's medical record on 2/2/17 to 2/8/17. R7 has a [DIAGNOSES REDACTED]. The potential for altercation of skin integrity initiated on 6/9/14 and revised on 1/4/17 includes an intervention dated 11/23/15 of float heels on pillow when R7 is in bed. The annual MDS (minimum data set) with an assessment reference date of 8/10/16 and signed as complete on 8/18/16 documents that R7 has short & long term memory problems and is severely cognitively impaired. R7 requires extensive assistance with one person physical assist for bed mobility, transfers, & toileting and is always incontinent of bowel and bladder. R7 is at risk for developing pressure injuries and does not have any pressure injuries. The Pressure Ulcer CAA (care area assessment) dated 8/16/16 under analysis of findings documents Resident does not have a pressure ulcer but is at risk of developing one. She is incontinent of both her bowels and bladder. Also, she needs the staff's extensive assistance when it comes to her bed mobility. The quarterly MDS with an assessment reference date of 11/10/16 and signed as complete on 11/30/16 documents that R7 has short & long term memory problems and is severely cognitively impaired. R7 requires extensive assistance with one person physical assist for bed mobility, transfers, & toileting and is always incontinent of bowel and bladder. R7 is at risk for developing pressure injuries and does not have any pressure injuries. The CNA (certified nursing assistant care card) dated 2/1/17 and provided to Surveyor on 2/2/17 at 9:12 a.m. documents Float heels on pillow in bed as she allows. On 2/2/17 at 10:09 a.m. Surveyor observed CNA-P and CNA-U place gloves on and transfer R7 from the wheelchair into bed using a gait belt. CNA-P checked R7's incontinence product and stated that R7 was wet. CNA-U wet a wash cloth, R7's pants were lowered, CNA-U unfastened R7's incontinence product and washed R7's frontal perineal area. R7 was assisted to roll on her left side and CNA-U washed R7's buttocks, removed the soiled incontinence product and placed a clean product under R7. R7 was positioned from side to side to fasten the incontinence product and pull up R7's pants. CNA-U placed a body pillow along the right side of the bed, covered R7 with bedding, removed her gloves and washed her hands. CNA-P raised the head of the bed slightly, lowered the bed down, informed R7 that she could take a nap and placed a mattress on the floor next to R7's bed. CNA-P removed her gloves and washed her hands. Surveyor observed that R7's heels were resting directly on the mattress and were not being offloaded. Surveyor also noted that neither CNA-P or CNA-U offered to place a pillow under R7's legs to off load her heels. On 2/2/17 at 10:58 a.m. Surveyor observed R7 in bed on her back. Surveyor observed R7's heels were resting directly on the mattress and were not being offloaded. On 2/2/17 at 11:59 a.m. Surveyor observed CNA-U wheeling R7 out of her room and down the hallway towards the back dining area of the unit. On 2/2/17 at 1:37 p.m. Surveyor observed R7 in bed on her back with her heels resting directly on the mattress. R7's heels were not being offloaded. On 2/2/17 at 3:35 p.m. Surveyor observed R7 continues to be in bed on her back. Surveyor observed R7's heels continue not to be offloaded. On 2/6/17 at 7:20 a.m. Surveyor observed R7 in bed on her left side. Surveyor observed R7's bare feet are resting directly on the mattress and are not being offloaded. On 2/6/17 at 10:34 a.m. Surveyor observed CNA-U wheel R7 into her room, inform R7 she was going to lay down for a nap and place gloves on. CNA-V entered R7's room, washed her hands and placed gloves on. CNA-V placed a gait belt around R7 and staff transferred R7 from the wheelchair into bed. CNA-U removed the gait belt and informed R7 that she was going to check her. CNA-V removed her gloves, washed her hands, and left R7's room. CNA-U lowered R7's pants, unfastened the incontinence product, and washed R7's frontal perineal area. CNA-U positioned R7 on her left side, removed the incontinence product, washed R7's buttocks and placed a clean incontinence product under R7. CNA-U fastened the incontinence product, positioned R7 from side to side to pull up her pants and CNA-U positioned R7 on her left side. Surveyor observed R7's heels were resting directly on the mattress. CNA-U placed a body pillow along the right side, lowered the bed down, and placed a mattress on the floor. CNA-U then removed her gloves, washed her hands and left R7's room. Surveyor noted that CNA-U did not offer to place a pillow under R7's legs to off load her heels. On 2/6/17 at 11:36 a.m. Surveyor observed R7 continues to be on her left side with her heels resting directly on the mattress and are not being offloaded. On 2/6/17 at 3:00 p.m. Surveyor observed R7 in bed on her left side. Surveyor observed R7's bed was in the lowest position, a body pillow was along the right side, and a mattress on the floor. Surveyor observed that R7's heels were resting directly on the mattress and were not being offloaded. On 2/7/16 at 1:35 p.m. Surveyor met with RN (Registered Nurse) Manager-M to discuss R7. Surveyor showed RN Manger-M the CNA care cards and asked if this is what the CNA's are expected to follow. RN Manager-M replied yes. Surveyor informed RN Manager-M of the observations of R7's heels not being floated according to her care plan and CNA care cards. On 2/7/16 at 3:06 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above. 3.) Surveyor reviewed R11's medical record on 2/6/17 to 2/9/17 R11's [DIAGNOSES REDACTED]. On 1/24/17 R11 a recurrent Stage 2 pressure injury developed on her coccyx. On 2/1/17 R11 developed an avoidable Stage 2 pressure injury on her left heel. The potential for alteration in skin integrity care plan initiated on 3/18/16 and revised on 2/3/17 has interventions of Resident will receive education related to potential for altercation in skin integrity as well as preventative measures dated 3/18/16 and canceled on 1/24/17, air mattress dated 1/24/17, check and change every 2 hours at night to prevent maceration to buttock area dated 1/24/17, reposition when in bed to relieve pressure to coccyx area dated 1/24/17, Rt (right) buttock coccyx wound cover with Exuderm LP 3X/Wk (three times per week) dated 1/24/17, 2/3/17 bruise top of Lt (left) foot = (equals) pressure relieving boot changed from black to blue boot with softer straps dated 2/3/17 and 2/5/17 Fall: Medication review had recent medication changes. dated 2/8/17. The quarterly MDS (minimum data set) with an assessment reference date of 1/4/17 and signed as complete on 1/11/17 has a BIMS (brief interview mental status) score of 3 which is severe impairment. R11 requires extensive assistance with one person physical assist for bed mobility, requires limited assistance with one person physical assist for transfer, extensive assistance with two plus person physical assist for toileting, and is frequently incontinent of bowel & bladder. R11 is at risk for development of a pressure injury and does not have any pressure injuries. For skin and ulcer treatment pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program and nutrition or hydration interventions to manage skin problems are checked. The Braden assessment dated [DATE] has a total score of 17 which is at risk. The wound assessment progress report dated 2/1/17 documents a fluid filled blister was 5 cm (centimeters) in length and 6 cm in width. The nurses note dated 2/1/17 documents reason for report: 5 cm (centimeter) circular blister to LT (left) heel. New orders: skin prep, monitor and elevate. The nurses note dated 2/2/17 documents f/u (follow up) behavior/blister to left heel: slept all NOC (night) with no bx (behavior) noted, skin prep to left elevated heel, skin is intact, surrounding areas have no s/s (signs/symptoms) of infection. resident has no (complaint of). Will continue to monitor. The late entry nurses note dated 2/2/17 documents Late Entry: 2/2/17 @ (at) 1400 (2:00 p.m.) Lt (left) heel examined, blister noted fluid filled, fluid has slight purple tinge, area pained with [MEDICATION NAME], foam dressing applied then kerlix wrap and black pressure relieving boot. The CNA (certified nursing assistant) care cards provided to Surveyor on 2/2/17 at 9:12 a.m. and are dated 2/1/17 has sections which include B & B (bowel and bladder), bath, sensory, transfer, support device, fall precautions/safety, diet, cues, and an un-named section. Under the un-named section documents R11 likes to go to bed between 8-8:30 p.m. Barrier cream to coccyx peri area BID (twice daily) and PRN (as needed) after incontinent episodes. R11 wears pajamas not a gown. Elevate legs when in bed. R11 likes to spend time in her room. Tubi grips on am (morning) off PM (evening) As pt (patient) tolerates. Prompt to use call light. Likes to have glass of water at bedside. No male caregivers please! Please do not wash hair per family. Reposition every 2 hours Please make sure her hearing aides are removed at noc (night) and placed in ears in am (morning) Gait belt with transfers. Must check all pockets for hearing aides when removing clothes at night. On 2/7/17 at 7:51 a.m. Surveyor observed CNA (Certified Nursing Assistant)-P enter R11's room and inform R11 that she was going to get her dressed for breakfast. CNA-P removed the covers off R11. Surveyor observed R11 was wearing a blue prevelon boot on her left foot and there was a gripper sock on R11's right foot. Surveyor observed that R11's right foot was resting directly on the mattress. On 2/8/17 at 7:17 a.m. Surveyor observed CNA-P enter R11's room, wash her hands and place gloves on. CNA-P informed R11 that they were going to get started for the day. CNA-P removed the covers off R11. Surveyor observed R11 has a blue prevlon boot on her left foot and her right foot which has a gripper sock on is resting directly on the mattress. CNA-P sat R11 up in bed, placed a gait belt around R11 and transferred R11 into the wheelchair. On 2/8/17 at 1:40 p.m. Surveyor met with RN (Registered Nurse) Manager-M to discuss R11's Stage 2 pressure injury on her left heel. Surveyor informed RN Manager-M that during R11's record review Surveyor did not note interventions that were in place to prevent R11 from developing the pressure injury. Surveyor informed RN Manager-M that Surveyor did observe R11 with the left boot on in bed but her right heel was resting directly on the mattress. Surveyor asked RN Manager-M how she thought R11 developed the pressure injury. RN Manger-M informed Surveyor that she was thinking that R11's shoes may have been rubbing on her heel. RN Manager-M informed Surveyor that R11's daughter said that R11 was wearing gripper socks, socks, and shoes but she didn't witness this herself. RN Manger-M indicated that R11 didn't have new shoes but does have three different pairs of shoes. RN Manger-M informed Surveyor that she would look into R11's pressure injury and get back to Surveyor . On 2/8/17 at 3:26 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above. On 2/9/17 at 9:54 a.m. Surveyor met with RN Manager-M. Surveyor asked RN Manager-M if the interventions that were in place to prevent R11 from a pressure injury on her left heel was diabetic foot checks, weekly skin checks, mattress, and tubi grips. RN Manger-M indicated that they were. Surveyor informed RN Manager-M that R11's left heel pressure ulcer was avoidable and R11's care plan does not address offloading for R11's heels.

Based on record review and interview, the facility did not not provide adequate supervision and assistive devices to prevent accidents for 4 of 10 sampled residents (R13, R12, R7, R6) reviewed for falls. Facility staff did not consistently implement care-planned approaches for preventing falls. R13 suffered a closed fracture of her left radius due to a fall in which interventions to prevent accidents and falls (gripper socks) were not in place. R12 suffered a hip fracture due to a fall in which interventions to prevent accidents and falls (checking the alarm) were not in place. R13 and R12 are being cited at severity level 3 (actual harm). R7 was observed to have her bed alarm disconnected and not wearing gripper socks per her fall prevention plan of care. R6 was observed to not have her chair alarm attached for approximately two hours per his fall prevention plan of care. Findings include: 1.) Surveyor reviewed 13's medical record from [DATE] to [DATE]. R13 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R13 expired at the facility on [DATE]. R13's quarterly MDS (Minimum Data Set) dated [DATE] documents short and long term memory problems and severely impaired cognitive skills for daily decision making for R13. Section G (Functional Status) documents that R13 requires supervision and a one person physical assist for transferring and bed mobility. Section G0400 (Functional Limitation in Range of Motion) documents that R13 has no impairment to her upper or lower extremities. R13's Falls CAA (Care Area Assessment) dated [DATE] documents under the Care Plan Considerations section At risk for falls, due to balance issues, wandering behavior and antidepressant use, Resident with history of actual falls. R13's Falls care plan with an initiated date of [DATE] documents under the Interventions section Encourage and assist as needed to wear non-slip footwear. R13's Fall Risk Screen with an effective date of [DATE] documents a score of 13, indicating that R13 was at moderate risk for falls. R13's physician orders [REDACTED]. Surveyor was unable to locate a CNA (Certified Nursing Assistant) Care Card for R13, as R13 had expired on [DATE]. R13's nursing progress note dated [DATE] at 6:30 a.m. documents Writer heard someone calling out and upon entering the room found R13 sitting on the bathroom floor next to the door. Had blood coming for Lt (left) Nare .C/O (complains of) pain LT arm, wrist. Lt wrist swollen and in much pain when trying to move it .Splinted wrist and order rec (received) to send to emergency room . R13's nursing progress note dated [DATE] at 10:43 a.m. documents Writer called Hospital to see how R13 was doing. They are going to admit with a Fx (fracture) L (left) wrist. R13's hospital discharge summary dated [DATE] documents, R13 presented after she fell unwitnessed at nursing facility. Xrays showed a distal radial/ulnar fracture. She was splinted in the ED (emergency room ) and admitted . She was seen by MD who performed a closed reduction after a nerve block. A hard cast was applied. R13's Investigation Form signed by LPN (Licensed Practical Nurse)-O for R13's fall on [DATE] documents What was on the resident's feet? Socks. The investigation form also documents, What could we do differently to prevent this from happening again? Try to keep gripper socks on at all times. R13's Investigation Form signed by CNA-DD for R13's fall on [DATE] documents, What was on the resident's feet? Socks. R13's RiskWatch Post Fall investigation as completed by LPN-O for R13's fall on [DATE] documents under the Footwear section that R13 was wearing Socks only. R13's Fall Event for R13's fall on [DATE] documents, What footwear did the resident have on at the time of the fall? 4. Socks-Regular. R13's fall investigation for R13's fall on [DATE] includes a statement signed from the previous Administrator, Administrator-CC that documents, Writer spoke with CNA-DD the aide who had R13 at the time of the fall. CNA-DD stated he had seen R13 about an hour before she was found on the floor. CNA-DD stated he had taken her (R13) to the bathroom at the time and settled her back into bed and she appeared to go back to sleep. CNA-DD stated he believes she had the gripper socks on at that point but can't be 100% sure. The next time he (CNA-DD ) saw her (R13) she was on the floor .He did state that at times she does remove the gripper socks and puts on other socks. Writer (Administrator-CC) re-educated CNA-DD regarding the need to make sure all fall interventions are in place and if the resident refuses management needs to be made aware. R13's Fall Summation for R13's fall on [DATE] completed by Administrator-CC documents, R13 didn't have her gripper socks on at the time of the fall, however CNA-DD believes they were on when he toileted her an hour earlier. CNA-DD stated that at times she had changed her socks or clothing during the night. Writer did re-educate CNA-DD on the need to ensure all fall interventions are in place and to let his nurse and management know if someone is non-compliant. Education was provided to nursing staff regarding the need to make sure all fall interventions are in place per plan of care and if non-compliant to make sure that the nurse and management know. Resident is a moderate risk for falls. Surveyor was unable to locate any documentation in R13's medical record that documented any non-compliance from R13 in regards to removing or refusing to wear gripper socks per physician orders. On [DATE] at 10:28 a.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B if R13 was supposed to have on gripper socks when she fell on [DATE]. DON-B informed Surveyor that she was not working at the facility at the time of R13's fall on [DATE] and that per R13's falls care plan, R13 was supposed to have appropriate footwear to prevent falls. DON-B informed Surveyor that R13 was supposed to be encouraged to wear gripper socks per R13's fall care plan. On [DATE] at 10:55 a.m., Surveyor interviewed LPN-O regarding R13's fall on [DATE]. Surveyor asked LPN-O if R13 was supposed to have gripper socks when she fell on [DATE]. LPN-O informed Surveyor that R13 would take off her gripper socks and keep her regular socks on during the night time as she did not like to keep on both pairs of socks. LPN-O informed Surveyor that she observed R13 sleeping in bed approximately 30 minutes prior to R13's fall. Surveyor asked LPN-O if R13 was wearing gripper socks at the time. LPN-O informed Surveyor that she was unable to visualize R13's feet as she was under the covers when she observed R13 sleeping in bed prior to R13's fall. Surveyor asked LPN-O if the wearing of gripper socks was an active fall intervention for R13 when R13's fell on [DATE]. LPN-O informed Surveyor that the wearing of gripper socks was an active fall intervention when R13 fell on [DATE]. On [DATE] at 3:10 p.m., Surveyor informed Administrator-A and DON-B of the above findings. No further information was provided as to why the facility did not ensure R13's falls interventions of gripper socks were in place to prevent R13's closed fracture of her left radius as a result of her fall on [DATE]. 2.) R12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS (minimum data set) dated [DATE] indicates R12 has moderate cognitive impairment and needs extensive assistance with transfers, dressing and hygiene. It also indicates R12 needs limited assistance with ambulation. The care plan for potential for falls dated [DATE] indicates when R12 is in bed, the bed alarm is to be checked two times a shift for function and position. The care plan also indicates when R12 is sitting in a chair, the chair alarm is to be checked two times a shift for function and position. The care plan also indicates R12 had falls on [DATE], [DATE], and [DATE]. The medical record indicates on [DATE] R12 sustained a fall. The fall event dated [DATE] indicates R12 was lying in bed prior to the fall and R12 did not know what happened. It also indicates a bed alarm was in use at the time. The fall event indicates R12 complained of hip pain and two lacerations were observed the right ear and a scrape to the scalp. The facility conducted an investigation and self-reported the incident to the State agency. The self-report dated [DATE] indicates R12 sustained a fall and the NP (nurse practitioner) was contacted. An order to send R12 to the hospital for an evaluation was given. The investigation indicates, on [DATE], the facility was notified R12 sustained a hip fracture. The facility self-report indicates CNA G was interviewed. CNA G was responsible for R12 on [DATE], when R12 sustained the fall. CNA G stated R12 was in bed at the start of her shift and R12 was not feeling well. CNA G stated she continued to check on R12 and brought in the dinner tray. CNA G statement indicates around 6:00p.m. she left the unit and made the other staff on the unit aware of this. CNA G states when she came back to the unit, she was made aware R12 sustained a fall. CNA G statement indicates she did not check the function of the bed alarm and assumed it was working properly. CNA G stated she should have checked the function of the bed alarm. The facility self-report indicates CNA H was interviewed. CNA H indicates she was walking down the hall and saw R12 in her room leaning over the front of the chair. CNA H stated she assisted R12 to sit down in the chair and then called for help. CNA H stated R12 had blood coming from her forehead. CNA H stated the bed alarm was not sounding. The facility verification of investigation indicates R12 had unwitnessed fall in her room and sustained a laceration to the head and a left femoral neck fracture. The recommendations and interventions post incident indicates the facility will use wireless bed alarm to prevent the wires from being pinched, the facility continues to work with staff and providing education on checking alarms at the start of shift. The summary of the investigation indicates the facility was able to determine that the bed alarm was plugged in, but was pinched at some time while the patient was in bed. The CNA (G) failed to check function of the alarm at the beginning of her shift. If the CNA (G) had checked the function of the alarm we may have noted the alarm wired was pinched. The alarms may not have prevented the fall still from occurring however the alarm would only have notified staff that R12 was attempting to self-transfer. Since the CNA (G) did not follow the instructions of checking the alarm for function the facility decided to terminate employment of the CNA (G). R12 did return to the facility on [DATE] and a new wireless bed alarm will be the new intervention. The nurses note dated [DATE] at 6:40 p.m. indicates RN I was called to R12 room. RN I indicates she noticed R12 was sitting in the chair in her room and there was blood on the right side of R12 head. RN I indicates she noticed blood drops were in front of the television stand. RN I assessment indicated R12 vital signs were stable, and R12 yelled ouch and place a hand on her right hip. RN I assessment also indicated R12 had two lacerations on the right side of her head, one measuring 1 cm (centimeters) and the other ½ cm. There also was a 2 cm scrape and 2 cm bruise noted to the right eyelid. RN I also made a note indicating the observation of the R12 room post incident, which indicated R12 was sitting upright in a chair facing her bed, blood on the right side of the bed and on the floor in front of her television stand. The note also indicates the bed alarm was not sounding, it was noted to be unplugged. The hospital history and physical dated [DATE] indicates R12 had a laceration at the temporal scalp which was repaired with staples and x rays show a right hip fracture. On [DATE] at 10:58 a.m. Surveyor # interviewed DON B. DON B stated CNA G admitted she did not check the function of the bed alarm prior at the start of her shift. DON B stated the investigation revealed the alarm was pinched and was not sure when it became pinched. DON B stated the facility conducted staff education regarding checking for the function of bed and chair alarms at the beginning of the shift. Surveyor # explained to DON B the concern that the survey team has current concerns with alarms not functioning during the survey and because of the current concerns R12 incident cannot be considered past non-compliant. DON B indicated she understood the concern. On [DATE] at 3:30 p.m. during the exit conference, DON B indicates the investigation was inconclusive as to if the alarm was sounding. Surveyor # explained the facility self-report indicates the conclusion to the investigation was the bed alarm was not functioning when R12 was observed to have sustained a fall and CNA G was terminated and staff was reeducated because of the results of investigation. DON B did not provide any additional information. 3.) Surveyor reviewed R6's medical record on [DATE] to [DATE]. R6 has a [DIAGNOSES REDACTED]. The quarterly MDS (minimum data set) with an assessment reference date of [DATE] and signed as complete on [DATE] has a total BIMS (brief interview mental status) score of 9 which indicates moderately impaired. R6 requires extensive assistance with two plus person physical assist for bed mobility & transfers and does not ambulate. R6 has not had any falls since prior assessment. The Fall risk screen dated [DATE] has a score of 15 which indicates moderate risk. The CNA (certified nursing assistant care card) dated [DATE] and provided to Surveyor on [DATE] at 9:12 a.m. under the fall precautions/safety section documents Fall Risk: High, Chair alarm, Bed alarm, Body pillow in bed, Matt to floor when in bed, low bed. On [DATE] at 7:19 a.m. Surveyor observed R6 sitting in the wheelchair in the hallway outside the small front dining room. Surveyor observed R6 is dressed for the day and has an alarm box hooked on the back right side of R6's wheelchair. Surveyor observed the clip is not attached to R6 and the string with the clip is hanging down on the back right side. On [DATE] at 8:00 a.m. Surveyor observed R6 sitting in the wheelchair in the dining room. Surveyor observed that the alarm clip is still not attached to R6 and is hanging down in the back on the right side. On [DATE] at 8:19 a.m. Surveyor observed R6 is propelling himself in his wheelchair in the dining room. Surveyor observed that the alarm clip is still not attached to R6 and is hanging down in the back on the right side. On [DATE] at 8:46 a.m. Surveyor observed R6 sitting the wheelchair in the dining room. Surveyor observed that the alarm clip is still not attached to R6 and is hanging down in the back on the right side. On [DATE] at 8:52 a.m. Surveyor observed LPN (Licensed Practical Nurse)-O wheel R6 to his table in the dining room. Surveyor observed that LPN-O did not attach the alarm clip to R6 and the string with the clip is still hanging down in the back of the wheelchair on the right side. On [DATE] at 9:26 a.m. Surveyor observed CNA-V wheel R6 out of the dining room. R6 then started to propel his wheelchair down the hallway. Surveyor observed that CNA-V did not attach the alarm clip to R6 and the string with the clip is still hanging down in the back of the wheelchair on the right side. On [DATE] at 9:34 a.m. Surveyor observed that R6 continues to be propelling his wheelchair down the hallway. Surveyor observed that the alarm clip is still not attached to R6. On [DATE] at 9:37 a.m. Surveyor observed RN (Registered Nurse) Manager-M attach the clip of the alarm string to the back of R6's shirt on his right side. On [DATE] at 1:40 p.m. Surveyor informed RN Manager-M of the observation of Surveyor observing her attach R6's alarm to his shirt on [DATE]. Surveyor informed RN Manager-M that Surveyor has multiple observations for two hours of the alarm not being attached prior to her attaching the alarm. RN Manager-M replied that's not good at all. On [DATE] at 3:06 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above. * Surveyor reviewed R7's medical record on [DATE] to [DATE]. R7 has a [DIAGNOSES REDACTED]. The potential for falls care plan initiated on [DATE] and revised on [DATE] includes an intervention of Bed alarm when in bed - safety, check 2 x every shift for placement and function revised [DATE]. The annual MDS (minimum data set) with an assessment reference date of [DATE] and signed as complete on [DATE] documents that R7 has short & long term memory problems and is severely cognitively impaired. R7 requires extensive assistance with one person physical assist for bed mobility, transfers, & toileting. R7 is coded as having a fall since the prior assessment with no injury. The falls CAA (care area assessment) dated [DATE] under analysis of findings documents Resident had a fall recently that resulted in no injures. She has balance problems and needs the staff's assistance stabilizing when it comes to moving from a seated to standing position, walking turning directions, moving on and off the toilet and with transferring. The quarterly MDS with an assessment reference date of [DATE] and signed as complete on [DATE] documents that R7 has short & long term memory problems and is severely cognitively impaired. R7 requires extensive assistance with one person physical assist for bed mobility, transfers, & toileting and extensive assistance with two plus person physical assist for ambulation. R7 has not had any falls since the prior assessment period. The fall risk screen dated [DATE] has a score of 15 which is moderate risk. The CNA (certified nursing assistant care card) dated [DATE] and provided to Surveyor on [DATE] at 9:12 a.m. under the fall precautions/safety section documents Fall risk; High Low bed, scoop mattress, body pillow, mattress at bed side, Bed & chair alarms. The CNA care card also documents griper socks at HS (hour sleep). The February 2017 TAR (treatment administration record) documents bed alarm when in bed-safety check 2 x (times) every shift for placement and function every 4 hours for safety. Surveyor noted that the safety check on [DATE] at 0400 (4:00 a.m.) is not initialed as being completed. On [DATE] at 10:17 a.m. while CNA-U was providing cares to R7, CNA-U informed Surveyor that there's not a call light in R7's room as the daughter is afraid her mother will do something with the cord. On [DATE] at 7:20 a.m. Surveyor observed R7 in bed on her left side. Surveyor observed R7's feet were bare and was not wearing gripper socks. On [DATE] at 8:00 a.m. Surveyor observed CNA-U in R7's room. Surveyor asked CNA-U what she was going to do for R7. CNA-U informed Surveyor that she was going to change her. Surveyor observed R7 was dressed with undershirt and pants lowered down. At 8:02 a.m. Surveyor asked CNA-U if R7 had gripper socks on this morning. CNA-U replied no, she didn't have anything on her feet. CNA-U provided incontinence care, placed a clean incontinence product on R7 and pulled up R7's pants. At 8:06 a.m. CNA-U lowered the bed and mattress on the floor next to the bed, removed her gloves and cleansed her hands. CNA-U then left R7's room. At 8:14 a.m. CNA-U and CNA-P entered R7's room. CNA-U removed the mattress from the floor and staff swung R7's legs so she was sitting on the edge of the bed. CNA-P placed a gait belt around R7, a shirt was placed on R7, and then CNA-U & CNA-P transferred R7 from the bed into the wheelchair. At 8:16 a.m. Surveyor asked CNA-U why R7's bed alarm did not sound. CNA-U replied I don't know and then moved R7's bed away from the wall. CNA-U showed Surveyor the alarm cord with the clip at the end of the cord was not connect to the alarm box. On [DATE] at 11:39 a.m. Surveyor asked CNA-U if R7 doesn't have a call light how does staff know that R7 needs something. CNA-U informed Surveyor that R7 usually moves in her bed which makes the bed alarm and the call light then goes off. On [DATE] at 1:42 p.m. Surveyor met with RN (Registered Nurse) Manager-M to discuss R7. Surveyor informed RN Manager-M of the observation of R7 not wearing gripper socks according to the CNA care card and the observation of R7 bed alarm not attached. Surveyor informed RN Manager-M that Surveyor was informed the bed alarm activates the call light and this is how they know if R7 requires attention. On [DATE] at 3:06 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above.

Based on observation, interview and record review the facility did not ensure that the physician or physician extender and/or resident's POA (power of attorney) were notified after a change of condition for 2 of 18 residents (Residents #4 and 19) plus 1 supplemental resident. Resident #4 was started on an antibiotic with physician orders [REDACTED]. On 7/25/14 and 7/27/14 nursing staff document the presence of Hematuria for Resident #4 and there is no indication that the physician was consulted with. On 7/30/14 Resident #4 was noted to have an elevated temperature of 100.2 degrees while actively taking an antibiotic for a urinary tract infection; Resident #4's physician was not consulted with regarding this temperature. On 8/1/14 Resident #4 was discovered to have a rash all over her body and an elevated temperature with altered vitals. Resident #4 was admitted to the hospital with [REDACTED].#4 was placed on hospice. Resident #19 sustained a blood blister/hematoma to the right shin and the physician or resident's POA were not notified immediately. Findings include: 1.) Surveyor # reviewed Resident #4's medical record from 8/5/14-8/6/14. Resident #4 was a long term Resident of the facility and had [DIAGNOSES REDACTED]. Review of Resident #4's medical record indicates in the nurse's notes dated 7/23/14 at 05:50: noted blood with clots in incontinent product. Notified (Medical Doctor (MD)-N). New order received for cbc (complete blood count) with diff. (differential) and UA (urinalysis) with c&s (culture and sensitivity) if indicated. Urine obtained straight cath using aseptic technique. Noted urine to be brick in color and with clots. Notified (family) of above and family wants to be updated with lab results. On 7/23/14 at 22:46 the next Nurse's note entry indicates: Resident started on antibiotic [MEDICATION NAME] 800-160 mg. Called Family with test results. Review of the lab report dated 7/23/14 indicates that Resident #4's urine was slightly cloudy, amber in color with blood present. 7/23/14 05:35:00 Urinalysis Reflex Comment indicates: Specimen positive for leukocyte esterase and or [MEDICATION NAME]. Urine Culture has been ordered. Pending orders: urine culture ordered. On this lab report is a written order stating check urine C&S. Start [MEDICATION NAME] DS bid (twice a day) x (times) 7 days. Call if any further blood noted. Faxed 1426 (2:26 pm). Review of the facility Definition of infection (Infection Verification Report) dated 7/23/14 indicates that this is a healthcare associated urinary tract infection in a resident without a catheter. The firm indicates that the Resident must have at least 1 of the following & listed is: acute dysuria (painful urination), Fever or Leukocytosis (abnormally high white blood cell count) and at least 1 of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross Hematuria, new or marked increase in incontinence, frequency and/or urgency or in the absence of fever 2 or more of the following: acute costovertebral angle pain or tenderness suprapubic pain, gross Hematuria, new or marked increase in incontinence, new or marked increase in frequency, new or marked increase in urgency AND must have at least 1 of the following: at least 103 cfu/mL of no more than 2 species microorganisms in a voided urine sample or at least 103 cfu/mL of any number of organisms in a specimen collected by in-and-out. Checked is gross Hematuria and new or marked increase in incontinence. Surveyor # noted that the second criteria regarding culture and sensitivity is blank. The report indicates that labs were completed with e-coli greater than 100,000 order listed is [MEDICATION NAME] DS 800/160 mg bid x 7 days. [MEDICATION NAME] must be checked. On 7/24/14 at 04:50 Nurse's notes indicate: F/U (follow up) T(temperature) 97.9, ABT (antibiotic) continues, no adverse reactions noted, had mod (moderate) amt (amount) Hematuria noted in diaper during incontinent care, resident shown no s/s (signs/symptoms) of distress or pain, skin W/D (warm/dry) res (respirations) non labored. Surveyor # noted that there is no indication that Resident #4's physician was contacted to discuss the observation of Hematuria in Resident #4's incontinent product despite orders from the physician to contact if further blood. On 7/25/14 at 00:26 the Nurse's note indicates: Follow up abt for uti (urinary tract infection), Hematuria. Temp 97.8. No noted s/s of adverse reaction to abt noted. NO noted clots with incontinent cares. Urine dark amber. The 7/25/14 13:19 (1:19 pm) Nurse's note indicates: still up on board for ABT for UTI, no Hematuria noted in the urine. T-97.2. Continue to monitor. The nurse's note dated 7/25/14 at 18:28 (6:28 pm) indicates: (name) D/C (discontinue) [MEDICATION NAME] and prescribed [MEDICATION NAME] 100 mg PO (by mouth) Q (every) 12 hrs (hours). Review of the laboratory reports for Resident #4 indicates: Culture urine, Collected 7/23/14 started 7/23/14, verified 7/25/14 11:41. Final report > (greater than) 100,00 cfu/mL (colony forming unit per milliliter) Escherichia coli. Susceptibility results list: [MEDICATION NAME]-S (susceptible), [MEDICATION NAME]/Clavulanate-R (resistant), [MEDICATION NAME]-R, [MEDICATION NAME]-R, [MEDICATION NAME]-S, [MEDICATION NAME]-S, Cephalothin-R, [MEDICATION NAME]-R, [MEDICATION NAME]-S, Imipenem-S, [MEDICATION NAME]-R, Merepenem-S, [MEDICATION NAME]-S, [MEDICATION NAME]/Tazobactam-S, [MEDICATION NAME]/Sulfa-R, [MEDICATION NAME]-S. Surveyor # noted that [MEDICATION NAME] was not one of the antibiotics listed that the bacteria would be susceptible to based upon the results of the culture and sensitivity. This laboratory report includes a notation to D/C [MEDICATION NAME] start [MEDICATION NAME]. Physician telephone orders dated 7/25/14 indicate: 1. D/C [MEDICATION NAME] - resistant. 2. Start [MEDICATION NAME] 100 mg ER (extended release) po q 12 hrs for 7 days ... Review of the 24 hour report for Resident #4 dated 7/26/14 indicates for the night (NOC) shift: ABT continues. Denies burning. Hematuria noted. 97.8. Nurse's notes dated 7/27/14 at 01:40 indicates: Continues on ABT for UTI. Temp=97.8. Denies burning. Hematuria noted. Surveyor # noted that there is no indication that Resident #4's physician was contacted with the noted Hematuria despite orders from 7/23/14 to contact with any further blood noted. Nurse's note 7/28/14 at 03:33 indicates: Continues on ABT for UTI. No adverse reactions noted. Afeb (afebrile) (97.1), no dysuria. Nurse's note dated 7/28/14 at 18:37 (6:37 pm) indicates: Temp 96.1. Antibiotic therapy continues for UTI. Extra fluids offered and taken well. No adverse reactions noted. Nurse's note dated 7/28/14 at 22:18 (10:18 pm) indicates: No adverse reaction noted from ABT therapy for UTI. Temp 97.6. Nurse's note 7/29/14 at 01:09 indicates: Follow up abt for UTI. Temp 97.2 No noted s/s of adverse reaction to abt noted. Nurse's note dated 7/29/14 at 21:35 (9:35 pm) indicates: T (temperature)=97.9 No adverse reaction to antibiotic therapy noted. Tolerating as ordered. Fluids offered and accepted prn (as needed). Nurse's note dated 7/30/14 at 01:25 indicates: Follow up UTI. Temp 97.7. No noted s/s of adverse reaction. The Nurse's note entry dated 7/30/14 at 22:37 indicates: abt uti 100.2, prn Tylenol given. Surveyor # noted that there is no indication that Resident #4's physician was contacted to consult on the elevated temperature that Resident #4 was experiencing while actively receiving an antibiotic for a UTI. Surveyor # noted that this would be the sixth day post starting the [MEDICATION NAME]. Review of the 24 hour report for Resident #4 dated 7/30/14 indicates for pm shift: 100.2/Tylenol given. There is no indication that the nurse contacted the physician to discuss the elevated temperature of Resident #4 prior to administering Tylenol, particularly given that Resident #4 was actively receiving an antibiotic for an infection at the time of this temperature. Surveyor # noted that there is no documentation in Resident #4's record or the facility's 24 hour report to indicate that an assessment was completed on Resident #4 with this change in status. Review of Resident #4's July 2014 physician orders [REDACTED]. According to the American Medical Directors Association (AMDA) Common Infections in the Long Term Care Setting resource dated 2011: "Many facilities have standing orders for [MEDICATION NAME] (Tylenol) to be given for fever or pain, and many routinely give [MEDICATION NAME] for fevers in older adults without notifying the practitioner. Because this may delay the [DIAGNOSES REDACTED]." The next Nurse's note dated 7/31/14 at 01:45 indicates: Follow up abt for UTI. Temp 97.1. No noted s/s of adverse reaction noted. Surveyor # noted that the next Nurse's note for Resident #4 was dated 7/31/14 at 23:26 (11:26 pm) stating abt/uti: abt discontinued (to be given for 7 days only) temp 98.0, extra fluids given po. The next Nurse's note dated 8/1/14 at 01:46 indicates: Follow up for abt for uti. No noted s/s of adverse reaction to abt noted. The nurse's note on 8/1/14 at 13:57 (1:57 pm) indicates: Follow up ABT for UTI. T-97.6 no adverse reaction noted at this time. The nurse's note dated 8/1/14 at 16:30 (4:30 pm) indicates: Resident has rash all over the front and back of her torso, buttocks and legs. Resident had a temperature of 100.2 gave scheduled Tylenol and [MEDICATION NAME]. Resident BP (blood pressure of 160/80. Pulse ox was 74 gave oxygen pulse ox came back up to 98. Pulse was changing between 120-179. Resident torso was warm to the touch and lower extremities were cool to touch. The nurse's note dated 8/1/14 at 17:35 (5:35 pm) indicates: Summoned to resident's bedside to evaluate rash. Upon assessment noted scattered reddened raised rash/bump all over trunk of her body, buttocks, and thighs. Resident alert with agitation and confusion. Face flushed with flaring nares. Skin pink, very warm and dry with cool extremities. Temp 100.2. Lungs course bilaterally no cough noted. POX (pulse ox) 70% on RA (room air). Resident repositioned with HOB (head of bed) at 90 degree angle to facilitate breathing. Resp 24 and rapid. Oxygen therapy initiated at 4 Liter via NC (nasal cannula) Very [MEDICAL CONDITION] with Hr (heart rate) of 177-150 and erratic. Noted cardiac pacer to upper left chest. No [MEDICAL CONDITION] noted. Abdomen soft, flat and non-tender nor distended with active BS (bowel sounds). Tylenol 650 mg plus 0.5 mg [MEDICATION NAME] administered by unit RN to fever and agitation. Call placed to (Physician -N) to update on Resident's COC (change of condition) and order received to send to St. Mary's Milwaukee ER dept. for eval and treatment. Family - (name) was notified of COC and same was in agreement to send to hospital for eval. Bell ambulance called for pick up and report given to charge nurse (name) at St. Mary's. Was transferred at 17:45 (5:45 pm) to hospital. On 8/6/14 Surveyor # reviewed the hospital records for Resident #4. The records indicated that Resident #4 presented at the ER with a temperature of 103 degrees and a rash. Staff noticed today that she was warm when they took her temperature this evening. She has a h/o (history of) severe dementia and does not speak. Nursing home denies any fever or vomiting. She has been coughing, no diarrhea. Limited ROS (report of status) was available from nursing home. Patient unable to give any history. Review of symptoms indicates: Respiratory symptoms: cough. Physical examination: Temperature 103.4. General: Alert, very thin, frail and agitated, awake, nonverbal. Skin: hot, dry, diffuse fine rash some of which was petechial (according to www.Mayoclinic.org <http://www.Mayoclinic.org> : pinpoint, round spots that appear on the skin as a result of bleeding under the skin. The bleeding causes the petechiae to appear red, brown or purple. Petechiae commonly appear in clusters and may look like a rash. Usually flat to the touch, petechiae don't lose color when you press on them. Some types of infectious diseases can cause petechiae on the skin [MEDICAL CONDITION].) and some of angioma. Ears, nose, throat: mucous membranes dry, Respiratory: wet cough, scattered rhonchi and rales, tachypenic, 1+ retraction ....Admit to intensive care unit. Pharmacy note dated 8/1/14 indicates that the Resident admitted tonight to IMC (intensive medical care) [MEDICAL CONDITION] from (nursing facility). She presented with a fever (103.4 oral) in the ED (emergency department) - and a rash. Her u/a cath was " dirty " ... The [MEDICAL CONDITION] tool dated 8/1/14 from the hospital indicates: infection: pneumonia, empyema (Empyema is a collection of pus in the space between the lung and the inner surface of the chest wall (pleural space), urinary tract infection. SIRS criteria (systemic [MEDICAL CONDITION] response syndrome): Hyperthermia > 38.3 deg C (Celsius) (101 degrees F), [MEDICAL CONDITION]>90 bpm, Tachypnea >20 bpm ....meets criteria for [MEDICAL CONDITION]. On 8/6/14 at approximately 12:25 Surveyor # interviewed RN - O regarding Resident #4 first presenting with a Hematuria on 7/23/14. Surveyor # asked RN-O if she was the nurse who noted the Hematuria and contacted the physician. RN-O indicated that she did. RN-O indicated that the certified nursing assistant showed her the Resident's Depends which had blood in it. RN-O indicated that the symptom presented itself early on 1st shift on 7/23/14 so she was to call the doctor and get orders for lab work. RN-O indicated that the lab staff was still in the building so she was able to get the lab drawn and the urinalysis started. Surveyor # asked RN-O if she assessed Resident #4. RN-O indicated that she believes that she took vitals and assessed the Resident. RN-O indicated that she did not notice any pain in the Resident and that the Resident's speech was garbled related to her dementia but that she "tapped" a lot and she was doing that per normal. Surveyor # asked RN-O where would she have documented the details of this assessment. RN-O indicated that she would have documented it in either the nurse's notes or the vitals tab of the Resident electronic medical record. Surveyor # indicated that she was unable to locate the vitals in either record. RN-O indicated that she remembers taking them (cross reference F514). On 8/6/14 at approximately 12:35 pm Surveyor # interviewed RN-M via telephone. Surveyor # asked RN-O about her entry in Resident #4's medical record on 7/30/14 at 22:37 (10:37 pm) that documents that Resident #4 had a temperature of 100.2 and that prn Tylenol was given. Surveyor # asked RN-M about her entry. RN-M indicated that she recalls that it was the end of her shift and that she quickly caught the temperature. Surveyor # asked RN-M if she recalled what manner she used to get the temperature. RN-M indicated that it was a temporal probe temperature. Surveyor # asked RN-M what her understanding of why temperatures are taken & RN-M indicated that she knew Resident #4 was on an antibiotic and that they are always supposed to get temperatures when someone is on an antibiotic. RN-M indicated that they are checking to make sure that body is not "overworked" trying to fight the infection. RN-M indicated that it was late, the end of her shift so she gave the Resident a couple of Tylenol's and reported off. Surveyor # asked RN-M if she contacted the physician and she indicated that the next nurse would do that. RN-M indicated that she would think that the next nurse would have gone back in a half hour to recheck the Resident and if the temperature was not resolved then they would call the physician. RN-M indicated that she did not take any additional temperatures or collect any other vitals on Resident #4. RN-M indicated that it seemed like any other day with Resident #4 being up in her Merry Walker. Surveyor # asked if she gave any consideration that Resident #4 may have been experiencing a change of condition and she repeated that it seemed like a normal day. Surveyor # asked RN-M if she was aware of any facility policies specifically directing frequency of temperatures, assessment and when to contact the physician. RN-M indicated that she was not aware of any such policies specifically. On 8/6/14 Surveyor # requested facility policies related to change of condition and monitoring of Resident temperatures. Surveyor # was provided with a copy of an undated change in Resident's Condition Policy which simply states: General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and residents responsible party of a change in condition. Responsible party: RN, LPN (licensed practical nurse), social services. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident's physician, mental or emotional status. c. There is a pattern of refusing treatment or medication. d. The resident wants to be discharged or leaves AMA (against medical advice). e. It is deemed necessary or appropriate in the best interest of the resident. 2. Once the physician has been notified and a plan developed, the nursing or social; service staff will let the resident and family of the issue and physician orders. 3. The communication with the resident and their responsible party as well as the physician will be documented in the Resident's record. On 8/6/14 Surveyor # reviewed an undated facility policy and procedure titled antibiotic use. This policy indicates: It is the policy of (facility name) to be judicious in the use of antibiotics to help prevent the development and spread of Multiple Drug Resistant Organisms (MDROs), avert adverse drug effects for the residents, and to decrease unnecessary drug costs. This is achieved through infection prevention; surveillance of infection, use of established criteria to identify signs and symptoms of infection, and education of staff. Once an infection has been identified, antibiotic therapy will be prescribed, in collaboration with the physician, pharmacy, and lab to ensure appropriate selection, dose route and duration of antimicrobial therapy. Criteria for identifying infection: McGreer's Criteria will be used to assist with identification of infection; however, the final decision to treat with an antibiotic is determined by the MD. Change of Condition: 2. Upon change in condition, the nurse will perform a thorough systems assessment and document information. Other causes of illness will be evaluated such as: med changes, adverse drug effects, and change in appetite or fluid intake, hypo/[MEDICAL CONDITION], pain, new or worsening depression/anxiety, constipation, or neurologic event. 3. The nurse is to refer to McGreer's Criteria to determine if signs and symptoms reflect a possible infectious process. 4. The physician and family will be notified of the change in condition. 5. If the resident has signs or symptoms that an infection is present, a CBC and a culture and sensitivity should be obtained (of wound or urine as appropriate). A CXR (chest x-ray) should be considered if pneumonia is suspected. A urine culture and sensitivity should not be performed unless the resident has evidence of a UTI. Physicians and nurses should be aware of a negative urinalysis is effective in ruling out a UTI, but positive results are not indicative of a UTI without substantiating signs and symptoms. It is recommended the physician postpone ordering an antibiotic until results of diagnostic tests are received unless the physician thinks the resident's condition requires immediate treatment. 6. The nurse will place the resident with a change of condition on the 24 hour report board. The resident will be evaluated every shift and information will be documented until the resident is stable and any pending diagnostic test results have been received. 7. When diagnostic test results are received the nurse will re-evaluate the resident for further signs and symptoms of infection. If the resident no longer demonstrated signs or symptoms of infection, the nurse will notify the physician when reporting culture and sensitivity results. It is recommended that physician not initiate an antibiotic if the resident is no longer demonstrating signs or symptoms of an infection, however the final decision rests with the physician. If the resident has diagnostic results indicating infection and the resident remains symptomatic, antibiotic therapy should be considered as appropriate. 9. After 48 hours, the nurse is to re-evaluate the resident. If signs and symptoms have resolved, no further action is needed. If signs and symptoms have not resolved, the nurse should notify the physician and family and implement interventions as ordered by the physician. 10. Once antibiotic therapy has been initiated, the nurse will continue to monitor the resident for signs and symptoms of illness and adverse effects related to antibiotic use until antibiotic is completed and signs and symptoms of infection are resolved. On 8/6/14 at approximately 1:00 pm Surveyor # interviewed RN-Nurse Manager (RN NM)-G regarding the facility's policy for monitoring a resident on an antibiotic for a change in condition and to clarify the policy referenced above regarding monitoring and re-evaluating the resident. RN NM-G indicated that when a resident has an infection or is started on an antibiotic that the resident is supposed to go on the 24 hour board. RN NM-G indicated that staff is supposed to be monitoring if there are adverse reactions to the antibiotic or changes in condition and it is her understanding and expectation that nurses are not only collecting temperatures but that they should also be gathering vitals when they are monitoring. RN NM-G indicated without vitals how does a nurse really know when an adverse reaction or change is occurring. RN-NM-G was asked about documentation of this information and she indicated that it should all be documented in the resident's record and that they are just now starting to use the vitals tab in the medical record. Surveyor # asked RN NM-G about the expectations if a resident on an antibiotic develops a temperature while taking the antibiotic. RN NM-G indicated that it is her knowledge that the physician should be contacted and consulted with. Surveyor # shared that on 6/30/14 Resident #4 developed a temperature of 100.2 while taking [MEDICATION NAME] for a UTI and there is no indication through interview or documentation that the physician was contacted regarding this change in temperature. RN NM-G indicated that the physician should have been contacted with that temperature. Surveyor # asked RN NM-G about the facility's equipment to take temperatures and whether staff should be documenting the route that temperatures are obtained. RN NM-G indicated that the facility policy is temperatures are to be taken either orally or axillary and the route should be documented. Surveyor # shared that RN-M indicated that she had taken temperatures using a temporal probe. RN NM-G indicated that sometimes nurses will bring in their own equipment including thermometers and blood pressure wrist cuffs and that they are not supposed to do that. RN NM-G indicated that if she sees that practice she immediately corrects the situation however, she does not know what RN-M may have used. On 8/6/14 at the facility daily meeting, Surveyor # shared with Nursing Home Administrator (NHA)-A and Corporate Consultant-C concerns regarding Resident #4 being started on an antibiotic prior to the receipt of cultures and sensitivities without a clear documented indication for the antibiotic at the time. Additionally, the antibiotic had to be changed to a different antibiotic that Resident #4's infection was sensitive to once the results came in from the culture and sensitivity labs. Additionally, nursing staff failed to contact and consult with the physician when Resident #4 experienced an elevated temperature despite being on an antibiotic for an infection and when nursing staff documented the ongoing presence of Hematuria despite orders to contact the physician. Additionally, facility nursing staff did not fully assess Resident #4 when these changes occurred. Facility staff also did not clearly document the details of their care for Resident #4 specifically details of reported assessments, the route which temperatures were received and the pertinent details of Resident #4's care/condition leading up to her hospital transport on 8/1/14 on the transfer form that accompanied Resident #4 to the hospital. Surveyor # requested a copy of any facility policy that specifically speaks to the collection of temperatures and expectations of staff. At the time of exit from the facility, no additional information or clarification was provided. 2.) On 8/5/14 at 8:30 a.m. Resident #19 daughter spoke with the survey team regarding concerns she had with Resident #19 unexplained bruises. Resident #19's daughter stated the resident was at facility for rehab following a fall at the assisted living. The Daughter stated Resident #19 was being discharged back to the assisted living on this date. The Daughter stated she was not notified of Resident #19's bruises and wasn't given an explanation as to how Resident #19 sustained her bruises. On 8/5/14 Surveyor # reviewed Resident #19's medical record. The admission MDS(minimum data set) with ARD (assessment reference date) date of 6/19/14 indicates Resident #19 has some cognitive impairment and it also indicates the resident has displayed no behavior issues such as physical or verbal behaviors towards others and has not refused any cares. It indicates Resident #19 needs extensive assistance with 2 staff for transfers and extensive assistance with 1 staff for dressing, propelling self around in the wheelchair, dressing and hygiene. The progress note dated 7/4/14 indicates late entry for 7/2/14 written by Licensed Practical Nurse (LPN) K, "resident has blood filled blister noted" to the resident's right shin. The note indicates LPN K showed the nurse manager the area and reported it off to 2nd shift nurse. The progress note does not indicate the size of the blood blister or any assessment done by the RN manager D or any RN. The progress note also does not indicate the physician was notified of the area or Resident #19's POA. The progress note dated 7/4/14 indicates Resident #19's daughter showed RN M that the resident had a "blood filled blister" on her right shin. It states the area was cleansed and [MEDICATION NAME] dressing was applied. Again the progress note does not indicate the physician was notified of the area. Also there wasn't an assessment of the blood blister noted in the medical record. The progress note dated 7/7/14 indicates NP (nurse practitioner) L was asked to see Resident #19's right shin area. NP L states the hematoma to the right shin area measures 1 inch by 3/4 inch wide and the area is covered by a absorbent dressing and [MEDICATION NAME]. NP L states the resident is not on blood thinners. The progress note dated 7/16/14 indicates a body check was done and multiple bruises were observed. Bruises to top of left had, left elbow, left upper arm, right upper outer arm, left hand near thumb and left inner thigh. The progress note does not indicate Resident #19's POA was notified of the various bruise. The admission body check dated 6/12/14 indicates Resident #19 had surgical wound to right outer leg and multiple bruises to lower extremities and bruising to inner arms. On 8/5/14 at 10:00 a.m. Surveyor # asked NHA for investigations into the hematoma on the right shin and any other injuries of unknown origin related to Resident #19. Surveyor # received incident reports for the hematoma that was found on 7/2/14. The incident report was dated 7/7/14 provided no other additional information as to how the hematoma occurred. There were no statements from staff and no statement explaining the hematoma. The incident report dated 7/13/14 for the left hand bruise has no additional information except on 7/14/14 the incident report indicates LPN K noted resident's left hand on the side of the wheelchair pressing up against the metal bar of the rail on the wheelchair. As far as the other bruises noted from the 7/16/14 body check there weren't any incident reports documented or any investigation into those unknown bruises. On 8/5/14 1 p.m. Surveyor # spoke with NHA A regarding Resident #19's bruises. NHA A states the hematoma to the right shin was not investigated because it was concluded the sit to stand cause the injury. Surveyor # asked for any documentation that would corroborate that conclusion. NHA A stated she didn't have any documentation to support that conclusion. NHA A also present Surveyor # with a typed up statement not dated regarding the "July 4th 2014 incident" NHA A's statement indicates the blood blister was noted on the right shin on 7/3/14,( which is not correct according to the progress note). It also indicates 8 staff (first names only and not job title) were interviewed by NHA A who stated to her they saw no injury to the right shin. It also indicates Resident #19 is transferred by sit to stand and the location of the hematoma is indicative of the use of the stand. Again Surveyor # asked NHA A for documentation that interviews with the 8 staff had taken place and the assessment of the sit to stand which was guessed to have caused the injury was done. NHA A did not provide Surveyor # with that information. NHA A also provided Surveyor # with a wound documentation dated 7/10/14 which shows a picture of the hematoma to the shin with measurement of 4.10 cm by 2.2 cm. Surveyor # was unable to speak with DON B on 8/5/14 or 8/6/14 because NHA A stated DON B left to a "resort". On 8/6/14 at 1:30 p.m. Surveyor # spoke with RN manager D. RN manager D stated she was made aware of the injury on 7/2/14 and stated it looked like a blood blister. RN Manager D states the protocol is to fill out the incident report. RN Manager D did state she did not document her assessment or report the injury to the physician, POA or DON B. RN Manager D states it was a mistake on her part. RN manager D states that on 7/7/14 DON B stated she would "take care of it" RN Manager D stated she took that to mean DON B would investigate the injury. On 8/5/14 at 2:30 p.m. during the daily exit meeting with NHA A, Surveyor # expressed the concern the physician and the POA were not notified of the hematoma when it was discovered. As of 8/6/14 at 3:30 p.m. facility did not provide any additional information. On 8/9/14 the facility submitted additional information to review regarding Resident #19 written by Physician-N indicating that Physician-N was asked to review Resident #19's medical records. Physician-N indicates that he initially saw Resident #19 on 6/12/14 after the Resident transferred to the facility from the hospital after treatment for [REDACTED]. Physician-N indicates that the point in question is the development of a lesion to the right anterior calf. Physician-N indicates that he did not specifically see Resident #19 for this injury however he was able to review chronological pictures of how the injury apparently occurred and believes that the injury occurred on July 4th. At that time, she presented with a 4 x 2 cm raised hemorrhagic lesion to the right anterior calf. In reviewing the pictures, it appears to be a blood blister as opposed to a hematoma. Physician-N indicates he is suggesting this because is that the initial picture and subsequent pictures their appears to be no [DIAGNOSES REDACTED] or discoloration that normally would be seen from a hematoma...The letter goes on to further note why this is possibly a blood blister versus a hematoma. Physician-N indicates that in periodically seeing Resident #19 during her stay at the facility this was a Resident who was a very active lady, agitated and frequently moving and fidgeting while in a wheelchair which could explain why this could have been self-imposed pinchi

Based on interview, record review, and observation, facility staff did not ensure one of four Resident's environment remained as free from hazards as possible. Resident #2 had 5 falls that were not thoroughly evaluated to determine the root cause of the falls in order to develop appropriate interventions to prevent future falls. Since the fall analyses were not completed, Resident #2's care plan was not updated and Resident #2 fell a 6th time, fracturing a finger. Findings include: On 8/8/13 and 8/12/13, Surveyor # reviewed Resident #2's medical record. Resident #2's [DIAGNOSES REDACTED]. Resident #2 takes three medications for hypertension, receives two eye drops for glaucoma, and receives Namenda for multi-infarct dementia, Remeron for depression and Buspar for anxiety. Resident #2 has lived at the facility for several years and has multiple Fall Risk Assessments including 2/7/13, 5/9/13, 7/25/13, and 8/4/13 that indicate she is at risk for falls due to decreased safety awareness, poor recall, judgement, safety awareness, impaired mobility, needs assistance with toileting, balance problem while standing and walking, decreased muscle coordination, poor vision, history of falls, medications including antihypertensives, diuretics, and psychotropics, dementia and arthritis, and use of assistive devices. Surveyor # 's review of quarterly Minimum Data Set ((MDS) dated [DATE], 2/25/13, 5/14/13 and a review of the annual MDS dated [DATE], score Resident #2's Brief Interview for Mental Status for cognitive patterns at a 06, 05, 05, and 03, respectively, indicating Resident #2 has severe cognitive impairment. Surveyor # reviewed Resident #2's current Care Plan dated 7/26/13 for Actual Fall 7/25/13, Potential for Falls and Potential for Trauma- Falls related to dementia, falls history, gait/balance, ambulatory elimination status, mental status; manifested by Fall Risk Assessment Score: 20 (at risk), impaired sense of balance, gait/balance, fall or near fall in past 180 days, use of psychotropics. The Goal is No Falls for two months. On 8/6/13, staff added the following to the Falls Care Plan: Problem-Actual Fall 8/4/13 with trauma, related to dementia, fall history, mental status, ambulatory elimination status; manifested by Poor safety awareness, Fall Risk Assessment Score=21 (at risk), fall or near fall in past 180 days, impaired sense of balance. Goal- No falls, minimize injury from falls for three months. Interventions: Sensor alarm-bed; proactively promote comfort; toilet per bowel/bladder plan, Transfer with one assist and gait belt, restorative nursing program- walking twice a day; use wheel chair, walker; increase use of reminders and cues regarding resident need for assist; include teaching regarding the possible serious consequences of fall. Instruct to call for help. Keep personal items in reach. Nonskid footwear. Call light within reach, answer call light promptly. Encourage use of glasses. Monitor for behavior changes; monitor for drug side effects. Assure adequate pain management. Assure regular exercise. Do not leave unattended when toileting. Anticipate needs. Toilet resident before and after meals. Sensor alarm: bed and chair. Bed in lower, locked position. Locate near staff when out of bed. A Care Plan for Potential for Falls dated 10/31/12 and discontinued 8/6/13 had essentially the same interventions, but it states "sensor alarm-bed" (bed alarm on care plan at least since March 2011; does not mention wheelchair alarm), and the intervention "Increase assistance and surveillance" was discontinued 8/6/13 and not included in the current care plan. Older, discontinued care plans indicate on 5/6/12, interventions included "check wheelchair alarm"; 7/29/12 "fall- disengaged wheelchair alarm", "did not use call light for assistance", "reinforce that resident cannot disengage wheelchair alarm." That is the last reference to a chair alarm until on 8/12/13, staff added "Sensor alarm: trialing d/c (discontinuing) bed and chair alarm due to agitation. Bed in lower, locked position,...non-skid footwear..." Other interventions repeated at least since 2011-2012 (but are not effective) include: instruct resident to call for help, remind to use call light for assistance, teach about possible serious consequences of fall. Surveyor # reviewed a 3-Day Bladder/ Bowel Wheel dated 5/15/13- 5/18/13, and a Bladder and Bowel 3-day Patterning Flowsheet completed for Resident #2 5/7/13-5/9/13. The Patterning Flowsheet showed Resident #2 incontinent of urine just once on 5/8 and 5/9 (11:00 p.m. and 2:00 a.m., and twice on 5/7 (9:00 p.m. and 2:00 a.m.). The "Wheel" showed similar results- wet at 3:00 a.m. and 7:00 a.m. on 5/15/13, at 3:00 a.m. on 5/16/13, and not incontinent on 5/17/13. Both tools showed Resident #2 continent day and evening shift at least until 9:00 p.m., with several hours in between toileting. Surveyor # observed a Care Plan dated 8/8/12 and renewed every three months for Resident #2 for: Functional Incontinence related to neurogenic bladder, mobility deficit, and cognitive deficit. Interventions include: Offer to toilet every two hours and PRN (as needed) during the day but check and change at night as resident does not want her sleep to be disturbed by awakening to toilet. Resident has frequency of urination and would request toileting every 30-45 minutes per staff due to diuretic medications, stress, and is on Enablex for neurogenic bladder. Encourage use of bed pan PRN, facilitate medication review for contributing factors, encourage fluid intake, assess for absorbent product, assist with toileting needs. Refuses to use bed pan. Perform incontinent care after toileting /each incontinent episode and apply barrier cream. On 10/31/12, staff added: Frequent urine incontinence; incontinent while sleeping as resident does not want to be awakened at night to toilet. Goal- no increase in incontinence, no urinary complication, no skin breakdown due to incontinence. Surveyor # reviewed Resident #2's Significant Change in Status MDS (Minimum Data Set) dated 10/23/12 indicating Resident #2 had two or more falls with no injury since the previous MDS, and was frequently incontinent of urine. Resident #2's Quarterly MDS dated [DATE] MDS shows Resident #2 had 1 fall with no injury, and remained frequently incontinent of urine. Surveyor # reviewed documentation regarding Resident #2's falls: * 3/29/13 10:25 a.m. A hand-written "Fall Investigation Form" states on page 1 Resident #2 had an unwitnessed fall from bed; she reached over to get the phone and slid off the bed. The Form indicates a bed alarm was in use at the time. Resident #2 was last seen and last toileted at 9:30 a.m. Page 2 of the Fall Investigation Form asks "What new intervention will be implemented prior to fall team review?" Staff answered "Resident needs a grip mesh in chair/under cushion." On the first page, it states Resident #2 fell from bed, but the intervention addresses wheelchair use. The "Investigation Questions" state Resident #2's bed alarm went off, the nurse was called to Resident #2's room by the aide; patient leaned over to answer the phone and slid to the floor. No new interventions address Resident #2 sliding out of bed, such as use of body pillows, mattress with lipped edges or "wings, etc. Documentation in the Nurses' Notes states: ...No apparent injury, patient states she tried to answer phone and slipped onto the floor landing on buttocks. Patient found laying on right side with phone in right hand on the floor by the bed. Notes from the Fall Committee dated 4/4/13 at the end of the Report state "Isolated incident. Previous falls have all been self-transfers. Meds are under review as well." But staff did not review or consider factors such as where were staff at the time of the fall, what were staff doing when resident fell , what staff were on the unit, etc. Answers to those questions are needed to develop appropriate interventions to help prevent Resident #2 from having further falls, but none of this information is gathered. * 5/19/13 1:00 p.m. Nurses' Notes state Resident #2 was observed on the floor in her bathroom; she was transferring without assistance; no apparent injury. MD and family notified. Continue to re-enforce the need to call for assistance when needing to use the bathroom. (This intervention has been on Resident #2's care plan since at least 2011 and is not been shown to be effective.) The computerized Occurrence Report dated 5/19/13 at 1:00 p.m. indicates Resident #2 "was found sitting on bathroom floor between the toilet and her wheelchair...Denied pain. Resident statement of what happened "I had to use the bathroom and couldn't wait." The second page of the report, the "Falls Details Report" asks about "Care Prior to Fall." When asked the last time Resident #2 was "visually observed, toileted; repositioned, given fluids, medicated for pain and/or anxiety, staff answered all with "N/A", even though Resident #2 said she self-transferred since she could not wait for help, she needed to use the bathroom. Under "Preventative Measures at time of fall" staff wrote "none" for "alarms", and "wheelchair in use." The "Conclusion" states "Assess toilet for toilet frame; if not present, therapy to apply." A section titled "Staff Interviews" states "No staff interviews available." Without interviewing staff, they do not know if Resident #2 was toileted 10 minutes earlier or many hours earlier, or if she asked staff to assist her with toileting but they were not able to respond timely. They do not know if Resident #2 put on her call light and waited for a period of time before she decided to self-transfer, or if she did not activate her call light. Without interviews, staff do not know when someone last saw Resident #2, what she was doing (calm, agitated, sleepy, trying to get out of chair, etc.) They do not know where staff were and what they were doing leading up to and at the time of Resident #2's fall. Knowing this information is critical to developing appropriate interventions to try to prevent further falls. * 6/20/13 8:30 p.m. A computerized Occurrence Report states: Type- Fall; Location-Other; Activity-Transferring; Witnesses- none. Neuro checks initiated; resident redirected; MD and family notified; head-to-toe body check done. Nurses' statement of what happened and Resident's statement of what happened are both marked "N/A." On the second page- the Falls Detail Report- staff are asked "Care Prior to Fall- Visually observed/ Toileted/ Given Fluids/ Repositioned/ Medicated for pain/ Medicated for Anxiety" but staff answered "N/A" (not applicable) to each question. In the section: "Preventative measures at time of fall"; when asked about alarms staff entered "None"; and for "Wheelchair or Geri Chair" - staff answered "In Use." The "Conclusion" states "Resident with recent room change. Getting acclimated to new unit/room." Nurses' notes dated 6/20/13 state Resident #2 was found down on her buttocks in another resident's room, next to the bed, transferring herself from the wheelchair. No apparent injury. * 6/21/13 6:00 p.m. Nurses' Notes state Resident #2 was found on the floor in her bathroom after trying to self-transfer to the toilet. No apparent injury. MD and family notified. A hand-written Fall Investigation Form dated 6/21/13 at 6:00 p.m. states there were no witnesses; Resident #2's statement was "she wanted to go to the bathroom." "Resident was lying on back on floor in bathroom with underwear/pants pulled down. Alarm in place. She refused to use/ask for assist." The Form indicates Resident #2 was last seen and toileted at 5:00 p.m. The Form asks "What new intervention will be implemented prior to fall team review?" Staff wrote "Instruct resident to use call light to request assist." Surveyor # reviewed documentation from the Falls Committee dated 6/21/13 stating "Current interventions remain appropriate. Resident had room change, is getting acclimated to new surroundings." (Resident #2 changed to a new room on a new unit 6/18/13). However, the fall investigation notes "alarm in place", but does not say if the alarm was sounding, if it malfunctioned, if there were batteries in it, etc. The committee would need to know these specifics to best direct staff with interventions to prevent additional falls. Nurses' Notes dated 6/22/13 at 10:27 p.m. state: "Resident alert and oriented per usual self this shift. Making several attempts to go to the bathroom on her own unassisted but staff was able to toilet her at those times... Chair alarm on chair this shift." * 7/5/13 10:00 a.m. Nurses' Notes state Resident #2 was observed on the floor in the bathroom of another resident's room; she was apparently trying to toilet self and fell self-transferring from wheelchair. No apparent injury. MD and family notified. Resident #2 was calling out and a CNA (Certified Nursing Assistant) heard her. "Resident was reminded to ask for assist when needing the bathroom", (though this intervention has not been successful in several years). A computerized Occurrence Report dated 7/5/13 at 10:00 a.m. indicates a nurse was called to Resident #2's room by a CNA who heard Resident calling out. The CNA found the resident sitting on the floor in front of her wheelchair. Resident's statement of what happened "I was going to the bathroom." Immediate Actions Taken: Neuro checks initiated, alarm applied, placed in bed, applied alarming motion detector, notified supervisor, MD, family... The second page- the Falls Details Report- staff are asked about "Care prior to fall." Resident #2 was last seen, repositioned (does not indicate if she was in bed or wheelchair) and given medication for anxiety at 9:30 a.m., but when asked when Resident #2 was last toileted, staff entered "N/A", although Resident #2 said she was trying to go to the bathroom so that would be important to know. Staff also indicate Resident #2's "Alarm was not sounding" and she was using her wheelchair. (Staff do not probe further as to why Resident #2's alarm was not sounding- dead batteries, resident removed it, malfunction...). The Report also stated "No staff interviews available." Surveyor # reviewed Falls Committee notes dated 7/12/13, after they reviewed Resident #2's fall on 7/5/13. The notes state "Team recommendation: Current interventions remain appropriate, recent room change." * 7/25/13 7:42 p.m. Nurses' Notes state Resident #2 was found on the floor in her room, apparently trying to self-transfer herself from her wheelchair to the toilet. No apparent injuries. MD and family informed. The computerized Occurrence Report indicates staff entered Resident #2's room with her roommate and found Resident #2 sitting on the floor beside the toilet. Resident stated that she slipped off the toilet. Immediate Actions Taken include: assisting Resident to bed, alarm applied, body check, bed lowered, supervisor informed, gripper socks... Page 2- the Falls Detail Report- says Resident #2 was visually observed at 5:00 p.m., almost three hours earlier; last time toileted "N/A" (even though she was found on the floor at the side of the toilet and Resident #2 said she slipped off the toilet.) "Alarm- not sounding"; wheelchair in use; call light off. The conclusion is dated 8/6/13 (staff reviewed this 7/25/13 fall with the 8/4/13 fall), and states "Resident fell during self-transfer, will trial discontinuance of chair alarm." "No staff interviews available." Again, staff do not follow up on why the alarm did not sound, when was Resident #2 last toileted, and was a confused resident with dementia and multiple recent falls really not seen for almost three hours- if so, where were staff, what were they doing, who was on duty, etc. * 8/4/13 8:00 a.m. Nurses' Notes indicate Resident #2 was found on the floor in her room, attempting self-transfer from bed. Resident took alarm off bed. Complained of pain left hand slight swelling on top of hand, unable to move fingers, refused ice. Slipped off bed. MD informed, ordered mobile x-ray. The x-ray results dated 8/4/13 state "There is a fracture of the third metacarpal bone (finger). Demineralization is seen." Staff updated the on-call MD with the results. The on-call MD instructed staff to update Resident #2's physician on 8/5/13 (Monday). The computerized Occurrence Report dated 8/4/13 at 8:00 a.m. indicates Resident #2 fell in her room while transferring. Swelling noted to left hand, resident with decreased mobility of digits on left hand. MD and family informed. X-ray ordered. Page 2- the Fall Details Report states "Care Prior to Fall" and staff entered "N/A" for the last time Resident #2 was visually observed, toileted, given fluids, repositioned, or medicated for pain or anxiety. All the "Footwear" options are marked "N/A", even though staff could select "Slipper-socks, well-fitting shoes, poorly fitting shoes, barefoot, socks only, nylon hose, TED hose, or slippers; so staff do not know if Resident #2 had gripper socks on (or non-skid footwear) as the care plan directs. For "Preventative measure at time of fall" it is noted Resident #2's call light was off. The Conclusion documented on 8/8/13 at 2:20 p.m. (after Surveyor # was in the building on 8/8/13) states "Resident slid out of bed while attempting to self-transfer. Had removed the bed alarm so no alarm was sounding. Root cause- due to resident action or internal risk factors." "Recommendations: Will attempt a trial of discontinuing bed and chair alarm. Agitation due to alarm sounding may be a contributing factor to her fall. Will monitor and determine if less agitated with absence of alarms." (Surveyor noted- on this fall, as on several others, the alarm did not sound.) Nurses' Notes indicate on 8/6/13, Resident #2 was seen by an orthopedic physician, who splinted Resident #2's left hand. Surveyor # reviewed physician progress notes [REDACTED]. On multiple observations on 8/8/13 and 8/12/13, Surveyor # observed Resident #2 both in her bed and wheelchair. Resident #2's fingers and thumb on her left hand and the top of her left hand what was visible sticking out of the splint, were bruised- yellow, brown, purple and green. Resident #2 told Surveyor # her hand did not hurt now, but did at first. Surveyor # interviewed DON (Director of Nursing)-B regarding Resident #2's falls, noting in all of the follow-up investigations, most if not all the important information needed to determine a possible root cause of the fall was missing. Even though Resident #2 repeatedly states she was trying to go to the bathroom, staff enter "N/A" when asked when was the last time toileted. Multiple investigations stated staff interviews are not available, yet without those staff interviews, how does the facility know what may have contributed to Resident #2's falls. Did staff not toilet Resident #2 when the should have, do they need to toilet her more often, are there enough staff, where were they and what were they doing, why did staff not see Resident #2 for almost 3 hours before one fall, what was Resident #2 doing before the falls, why the alarm didn't sound, etc. Surveyor # noted Resident #2's care plan (prior to 8/12/13) does not mention "chair alarm" since July 2012, but staff note on some fall reports and nurses' notes that a chair alarm is in use. The 8/12/13 care plan refers to a trial without the chair alarm. DON-B stated Resident #2 has had a chair alarm in place and it was expected to be used until 8/8/13. DON-B did not know why some of the fall reports say no chair alarm was in use (none or N/A) or while other reports say 'alarm not sounding." DON-B agreed that needs to be looked at - to see if staff were using the alarm, if it malfunctioned, etc. Surveyor # also noted Resident #2's Physician Notes refer to urinary frequency, and she receives hydrochlorothiazide, a diuretic, and the Urinary Incontinence care plan states Resident #2 will request toileting every 30-45 minutes, and most if not all Resident #2's falls involved her trying to get to the toilet, but the care plan states to offer toileting every two hours. Surveyor # asked how often staff conduct Bladder Patterning and incontinence assessments. DON-B stated they are usually done quarterly; Resident #2's was completed mid-May and will be repeated in mid August as part of the quarterly MDS. Surveyor # noted staff needed to re-assess Resident #2's incontinence and toileting times seeing as Resident #2's fall all involve her trying to get to the toilet, and the last assessment was completed right before Resident #2 started falling more often- they need to assess for changes in Resident #2's urinary status to know if changes are needed to her care plan in an effort to reduce or prevent future falls. Surveyor # also asked how the Falls Committee deems the care plan interventions are appropriate if staff do not gather the necessary information to make that determination (last time seen, what was she doing, last time toileted, was alarm on, if so, why didn't it sound, etc.). Surveyor # asked DON-B if there was any additional information regarding Resident #2's falls and what investigation staff did to determine the root cause, and what care plan interventions were instituted, modified, etc. based on the root cause analysis. DON-B did not provide a response to these questions posed. Later on 8/12/13, DON-B informed Surveyor # that LPN (Licensed Practical Nurse)-C told her she was on duty 8/4/13 when Resident #2 fell and she did obtain a statement from CNA-D, and put it in the manager's mail box. DON-B stated they could not find CNA-D's statement, so they just called her at home and obtained her statement over the phone. In addition, DON-B had LPN-C write a statement on 8/12/13 regarding Resident #2's fall on 8/4/13. DON-B provided Surveyor # with those statements. LPN-C's statement says: "Approximately 10 minutes prior to the fall, I had walked past the room (Resident #2's room) on my way to another room and saw (Resident #2) sleeping; no calling out heard." Surveyor # asked DON-B if it would have been more useful to get LPN-C's statement prior to the Fall committee meeting as Surveyor noted the facility did not obtain a statement from LPN C until 8 days after resident's fall and after Surveyor # 's inquiry into this fall. DON-B did not provide a response to this question posed. CNA-D's statement says: "It was about 7:30 a.m. I was walking past (Resident #2)'s room to go to (Resident #4)'s room as I had just given her a shower when I heard (Resident #2) yelling out- can someone help me. When I got to (Resident #2)'s room I saw her sitting by the side of bed. She was last changed by night (shift) CNA." DON-B stated day shift CNAs start at 6:30 a.m. and night shift CNAs go off duty at 7:00 a.m. Surveyor # asked if they interviewed other day shift CNAs (or other staff) to see if they saw Resident #2 that morning, if so, what was she doing; or did they interview night shift CNAs to determine when Resident #2 was last toileted. DON-B stated they did not interview any other staff. DON-B provided Surveyor # with a copy of their Falls Investigation Policy in place up to 8/12/13, but with unknown start date. The Policy states, in addition to treating any injury, informing supervisor, MD, and family, staff should complete documentation in ECS (Nurses' Notes) and the fall report in Risk Watch (computerized Occurrence Reports). Initiate cranial checks for unwitnessed falls or when resident strikes head. Notify therapy. Complete Fall Assessment in ECS. Address and implement interventions and note on care plan and care card. Educate staff as needed. Place resident on 24 hour board for monitoring and assessment each shift for no less than 72 hours. Complete report in Risk Watch and submit to DON for review. DON-B provided Surveyor # with an updated policy, dated 8/12/13, including the above plus adding "Obtain statements from all staff on the unit or in the area of the fall. Determine if those staff saw the resident, interacted with the resident, toileted the resident. Document on investigation statement form. No further information was provided regarding Resident #2's falls.

Based on record review, observation, and resident and staff interview the facility did not always deliver appropriate treatment and services to restore as much normal bladder function as possible. The lack of an accurate and thorough comprehensive assessment, care planning, and measures to ensure that appropriate toileting techniques were delivered affected 5 of 14 incontinent residents sampled. Residents #9 and #7 had a decline in their bladder continence status and were not accurately and thoroughly reassessed to determine if they were able to participate in a program to restore continence or in a scheduled toileting program. Resident #6, #1 and #5 were assessed by the facility as incontinent of bladder. The facility did not complete an accurate and thorough bladder assessment and did not develop an individualized toileting plan of care for these Resident's urinary incontinence based upon an accurate assessment. Resident #6, #1 and #5 did not have a decline in their bladder continence status. * The facility did not provide treatment and services to Resident #9 to restore as much normal bladder function as possible after the the MDS (Minimum Data Set) indicated Resident #9 had declined in her bladder function. The MDS's indicate Resident #9 went from being "occasionally" to "always incontinent" of urine. The facility did not provide treatment and services including an accurate assessment to determine the reason for the decline and to establish a plan of care with objectives, interventions and goals to improve or maintain bladder functioning. * On 8/29/11, Resident #7 was assessed by the facility as occasionally incontinent of bladder (less than 7 episodes of incontinence). On 11/22/11 and 2/03/12, Resident #7 was assessed by the facility as frequently incontinent of bladder (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). The facility did not complete an accurate and thorough bladder assessment for Resident #7 and when she developed a decline in her bladder continence status. There was no evidence that the facility completed an accurate and thorough incontinence assessment and used the results of the assessment to develop a plan of care for Resident #7's incontinence. * On 11/28/11 and 2/03/12, Resident #6 was assessed by the facility as frequently incontinent of bladder (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). There was no evidence that the facility completed an accurate and thorough incontinence assessment and used the results of the assessment to develop, review and/or revise Resident #6's incontinence plan of care. * Resident #1 was assessed by the facility on 12/28/12 to be frequently incontinent of bladder (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). There was no evidence that the facility completed an accurate and thorough incontinence assessment and use the results of the assessment to develop, review and/or revise Resident #1's incontinence plan of care. * Resident #5 was assessed by the facility on 12/28/12 to be frequently incontinent of bladder (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). There was no evidence that the facility completed an accurate and thorough incontinence assessment and use the results of the assessment to develop, review and/or revise Resident #5's incontinence plan of care. Findings include: On 4/10/12, Surveyor's # , # , , and # reviewed the facility's procedure for "Bowel and Bladder Assessment" (undated). The procedure states each resident will be assessed for 72 hours for bowel and bladder voiding patterns on admission, quarterly and with a significant change in elimination patterns with evaluation for feasibility in retraining for bowel and bladder control. The procedure indicates the licensed nurse will gather information from the chart, the resident's family/representative, staff members, from resident observations, and from review and analysis of the 72 hour voiding patterns. The procedure indicates the information will be used to complete the bowel and bladder assessment. The procedure indicates the resident's plan of care will be developed to address the issue, goals and appropriate interventions for elimination program. On 4/10/12, the facility also provided an updated/revised "Bowel and Bladder Assessment" policy and procedure dated 4/10/12, that included the procedure that each resident will be assessed for 72 hours for bowel and bladder voiding patterns utilizing the Bowel and Bladder Wheel, observation, staff and resident/family input when appropriate, and past medical history. The 3 day Bladder/Bowel Wheel procedure was reviewed. The procedure indicates that after three days of data have been obtained, the nurse reviewer will review for patterns of elimination. The updated/revised procedure indicates that in conjunction with the 72 hour Bowel and Bladder Wheel, a comprehensive Bowel and Bladder Assessment will be completed in the Electronic Charting System (ECS). The updated/revised procedure indicates a plan of care for residents with an alteration in elimination will be developed to address the issue, goals and appropriate interventions for elimination program. On 4/09/12 at 3:30 P.M., and on 4/10/12 at 3:00 P.M., Surveyor's # , # , # , and # spoke with the Administrator and the Director of Nursing (DON) regarding the facility's incontinence program. The Director of Nursing indicated a resident's bladder assessment is completed upon admission, quarterly, and with changes of condition. The DON indicated the assessment should include a 7 day Bladder Wheel, followed by a review of the Bladder Wheel diary data and the resident's assessments in the ECS. The DON indicated, after nursing staff reviews the bladder diary and the ECS assessment information, the facility identifies the type of incontinence and develops an incontinence plan of care. 1. Resident #9 had been residing in the facility since 2008. Per clinical record review conducted on 04/05/12, Resident #9 was noted to be alert with short term memory problems and required staff assistance with activities of daily living. The review of the annual MDS (Minimum Data Set) with a completion date of 01/02/12 indicates Resident #9's incontinence status to be that of "occasionally incontinent" of urine and " always continent" of bowel. A bladder assessment identified in the nurses notes and dated 12/29/11 indicates "incontinent of stools 1x/day..... never aware of toileting needs...voices no complaints related to incontinence....resident never voids correctly without incontinence...amount is small, spots clothes/bed, but doesn't need changing, stress overflow incontinent present." The resident's care plan dated 01/05/12 identified the resident's problem as being that of Functional Incontinence related to mobility deficit manifested by occasional urinary incontinence, small amounts. The identified goals for the resident indicated, "no urinary complications, skin integrity maintained." The established goal time identified is three months. The approaches for achieving those goals also dated 01/05/12 directed staff to "encourage fluid intake, use absorbent products, wear incontinence briefs, change PRN (as needed), toilet upon request, offer toileting regularly, transfer to toilet with EZ stand and two assist, observe void pattern, report changes in voiding pattern or appearance of urine to the nurse, cleanse peri-area and apply barrier cream to after incontinent episodes and PRN, monitor skin and report changes to nurse." The quarterly MDS completed and dated 03/23/12 now indicates Resident #9 was "always incontinent" of urine" and "occasionally incontinent of bowel." The Bowel and Bladder assessment dated [DATE] documents that the resident has a history of UTI's (urinary tract infections), rarely aware of toileting needs, [DIAGNOSES REDACTED]." During interviews conducted on 04/10/12 with the Director of Nursing (DON) and RN-C (Registered Nurse), Surveyor # inquired as to the decline in Resident #9's urinary status from the annual MDS to the quarterly MDS. The resident declined in both her urinary status and bowel status and there was no evidence in the clinical record to indicate the reason for the decline. RN-C was questioned as to if she noted the decline in the residents urinary status and if so what was done with the information? RN-C was questioned as to whether there was any determination as to the reason for the decline and what interventions were put into place to improve or restore bladder function? RN-C stated that the unit managers and nurses on the unit "know about the declines and changes." RN-C provided no evidence that the decline in Resident #9's bladder function was recognized and that treatment and services were provided to restore normal bladder functioning. There was no evidence of additional assessments to identify any cognitive or mobility changes, no evidence of interviews with direct care staff of nurses or nurse aides and no interview with the resident to determine or identify the decline and if the decline was avoidable or unavoidable. The clinical record noted that the last urinalysis conducted for the resident was on 02/27/12 and was positive for bacteria, however; there was no evidence that a urinalysis had been conducted since the noted decline. The facility also did not ensure that the appropriate interventions were established for the resident after the 03/20/12 Bladder Assessment and 03/23/12 MDS. It was noted that the Resident's care plan was not updated with the new identified urinary status and different approaches and goals to maintain the residents continence. On 04/10/12 at 8:55 a.m., the DON provided a copy of the care plan with approaches dated 04/09/12 in which the "nurses are to encourage fluid intake, assess for absorbent products, observe voiding patterns, check and change incontinent product arising before and after meals, during noc. rounds and PRN.....toilet AM/PM shift and PRN to promote bowel elimination." It was noted by surveyor that direct care staff awareness of the resident's needs were not identified by the care plan and documented by RN-C. On 04/10/12 at 9:50 a.m., Surveyor # interviewed LPN-J (Licensed Practical Nurse) who stated that Resident #9 "tells us when she has to go." When asked how often, LPN-J stated, "about every three...two to three hours, she tells us if she is uncomfortable and other needs." Interviews by Surveyor were also conducted with CNA-I (Certified Nurse Aide) on 04/10/12 at 1:15 p.m. CNA-I stated, that (Resident #9) "she tells when she has to go especially for bowel movements." When questioned regarding if the resident asks to be toileted, CNA-I stated, "sometimes she does, sometimes she doesn't." When questioned when she is taken, CNA-I stated, "before breakfast, before and after lunch, you know like that." Additional interview with LPN-J on 04/10/12 at 1:20 p.m. in which LPN-J stated when asked if Resident #9 is wet when taken to the toilet, "sometimes but not soaked, but damp." Per interview with CNA-K also on 04/10/12 at 1:25 p.m., CNA-K stated when asked if Resident #9 is able to tell you if she needs toileting, "no you have to ask her....she is total care, we sit her on the toilet, you know before meals." Per interview conducted with Resident #9 by Surveyor on 04/10/12 at 1:30 p.m., when asked if she was able to tell staff when she needs to go to the bathroom, Resident #9 stated clearly "yes.....#2 is kind of hard, they help me with that." The resident was noted to be alert with no evidence of confusion, spoke to surveyor about having gotten her hair done today and just relaxing." Surveyor interviewed CNA-I again at 1:45 p.m. and asked if Resident #9 would be toileted before the end of her shift (which ended at 3:00 p.m.). CNA-I stated, "if she asks to be taken." On 04/11/12 at 11:00 a.m., Surveyor interviewed the DON and RN-C after RN-C provided a modified MDS dated [DATE] to the Surveyor that identified the resident's bladder status as "Frequently incontinent" and bowel status as "Occasionally incontinent." Surveyor questioned RN-C as to her determination as to the reason for the resident's decline and she stated, "No." 2. On 4/09/12 and 4/10/12, Surveyor # reviewed Resident #7's medical record. The record indicates Resident #7 is [AGE] years old, was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], indicates Resident #7 has moderately impaired cognitive skills (decisions poor; cues/supervision required), is independent with transfers, requires limited assistance of one staff for toilet use, and is occasionally incontinent of bladder (less than 7 episodes of incontinence). The Care Area Assessment (CAA) dated 8/29/11, indicates Resident #7 is occasionally incontinent of bladder and wears adult incontinence products. The CAA indicates the facility will proceed to an incontinence plan of care. There was no record of resident #7's bladder patterns that should have been used to monitor and assess the resident's incontinence. There was no evidence that the facility completed a comprehensive bladder assessment and used the results of the assessment to develop an incontinence plan of care The quarterly MDS', dated 11/22/11 and 2/03/12, indicate Resident #7 has moderately impaired cognitive skills (decisions poor; cues/supervision required), requires extensive assistance of one staff for toilet use, and is frequently incontinent of bladder (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). The Bladder assessment dated [DATE], indicates Resident #7 has a large amount of incontinence and requires changing. There was no record of Resident #7's bladder patterns that should have been used to monitor and assess the resident's incontinence. There was no evidence that the facility completed a comprehensive bladder assessment and used the results of the assessment to develop an incontinence plan of care when Resident #7 experienced a decline in her continence status. The Certified Nursing Assistant (CNA) Assignment Sheet, (undated but currently being used by CNA staff), indicates Resident #7 is to be offered toileting every 2 hours, and before and after meals, to offer, check and toilet every 2 hours and as necessary. On 4/09/12, at 1:00 P.M., Surveyor # spoke with Licensed Practical Nurse (LPN)-D who indicated Resident #7 is incontinent, uses an incontinence product, and is toileted upon rising and before and after meals. LPN-D indicated Resident #7 will also independently use the toilet. On 4/10/12 at 9:25 a.m., Surveyor # spoke with CNA-F who indicated Resident #7 is incontinent, uses an incontinence product and is offered assistance with toileting every 2 hours. CNA-F indicated Resident #7 will also let staff know when she needs assistance with toileting or will at times take herself to the bathroom to use the toilet. On 4/10/12 at 10:15 a.m., Surveyor # observed CNA-F offering and providing Resident #7 assistance with toileting. Resident #7 was not incontinent and voided in the toilet. On 4/10/12 at 3:00 P.M., Surveyor # spoke with the Administrator and the Director of Nursing regarding Resident #7's incontinence assessment and plan of care. The DON indicated Resident #7 should have had a bladder assessment completed quarterly and with a decline in her bladder status. The DON indicated the bladder assessment should include an evaluation of her voiding patterns using a " Bladder Wheel." The DON indicated Resident #7 should have an incontinence plan of care. There was no documentation that the facility completed accurate and complete bladder assessments for Resident #7 on a quarterly basis and when Resident #7 experienced a decline in her continence status on 11/24/11, including the evaluation of her voiding patterns using a " Bladder Wheel." There was no documentation that the facility used the results of a comprehensive bladder assessment to develop a plan of care for Resident #7's incontinence. 3. On 4/09/12 and 4/10/12, Surveyor # reviewed Resident #6's medical record. The record indicates Resident #6 is [AGE] years old, was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], and the quarterly MDS, dated [DATE], indicates Resident #6 has severely impaired cognitive skills (never/rarely made decisions), requires extensive assistance of one staff for toilet use, and is frequently incontinent of bladder (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). The Care Area Assessment (CAA) dated 11/28/11, indicates Resident #6 wears briefs and is checked at least every 2 hours. The CAA indicates the facility will proceed to an incontinence plan of care. There was no record of Resident #6's bladder patterns that should have been used to monitor and assess the resident's incontinence. There was no evidence that the facility completed a comprehensive bladder assessment and used the results of the assessment when completing the incontinence plan of care. The incontinence plan of care, dated 11/28/11, includes the approach to check for incontinence and toilet every 2 hours. The Certified Nursing Assistant (CNA) Assignment Sheet, (undated but currently being used by CNA staff), indicates Resident #6 is a check and change before and after meals. On 4/09/12, at 1:00 P.M., Surveyor # spoke with Licensed Practical Nurse (LPN)-D who indicated Resident #6 is usually continent and will request assistance with toileting. On 4/09/12, at 1:15 P.M., Surveyor # observed LPN-D offering and providing Resident #6 assistance with toileting. Resident #6 was not incontinent and voided in the toilet. On 4/10/12 at 3:00 P.M., Surveyor # spoke with the Administrator and the DON regarding Resident #6's incontinence assessment and plan of care. The DON indicated Resident #6 should have a completed a bladder assessment, including the evaluation of her voiding patterns using a " Bladder Wheel," and the facility should have used the results of a comprehensive bladder assessment when developing Resident #6's incontinence plan of care. There was no documentation that the facility completed a bladder assessment for Resident #6, including the evaluation of her voiding patterns using a " Bladder Wheel." There was no documentation that the facility used the results of a comprehensive bladder assessment when developing Resident #6's incontinence plan of care. 4. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/9/12, Surveyor # reviewed Resident #1's Minimum Data Set (MDS) coded as a Significant Change of Status Assessment, dated complete 12/28/11. Resident #1 had a Brief Interview for Mental Status and scored a 14 out of a possible 15 points. Resident #1 is coded as frequently incontinent on this assessment. The Care Area Assessment (CAA) for this MDS dated [DATE] indicates Resident #1 needs assistance with toileting and is frequently incontinent of urine. The CAA also indicates Resident #1 is functionally incontinent and the goal is to decrease urinary incontinence. No evidence could be found that this assessment was based off a bladder tracking tool or what the plan is to help try to maintain as much continence as possible. On 4/10/12 at 10: 00 a.m., Surveyor # interviewed Resident #1 who stated she is always incontinent of urine in her brief and can only feel if she is going to have a bowel movement. Resident #1 stated she has been incontinent since admission to the facility and she will let staff know if she needs to be changed. On 4/10/12 at 8:55 a.m., Surveyor # interviewed Director of Nursing (DON)-B who stated she could not find a comprehensive assessment or bladder patterning for Resident #1 since admission and one was started yesterday. On 4/10/12 at 12:45 p.m., Surveyor # interviewed MDS Coordinator-C who stated that she did not interview Resident #1 on her incontinence pattern and relied on nurse's notes and interviews from the staff to determine her incontinence status. MDS Coordinator-C stated residents do not always give reliable information and may be embarrassed to talk about there incontinence. On 4/11/12, Surveyor # reviewed Resident #1's Bowel and Bladder assessment dated [DATE] which read: resident is sometimes aware of toileting needs, amount of incontinence is large, gets outer clothing wet. No evidence could be found that this assessment was based off a bladder tracking tool or what the plan is to help try to maintain as much continence as possible. On 4/10/12, Surveyor # reviewed Resident #1's care plan dated 1/2/12 which read: functional incontinence, frequently incontinent of urine scheduled toileting every 2 hours and as needed, observe voiding patterns, goal is to decrease urinary continence to occasional during the day while awake. No evidence could be found that the care plan was based off of a comprehensive assessment to determine that the toileting schedule of every 2 hours would be the most effective for Resident #1. On 4/10/12 Surveyor # reviewed Resident #1's Certified Nursing Assistant (CNA) assignment sheet which read: Check/ change before and after meals. Brief / Toilet. No other information is given for toileting for Resident #1 on the CNA assignment sheet. The above findings were shared with the Administrator and DON on 4/10/12 at 3:00 p.m. at the daily exit meeting. Additional information was requested if available and on 4/11/12 the DON provided a Bladder Assessment for Resident #1 but it was not comprehensive and could not be proven to be based off a period of bladder patterning. 5. Resident #5 was admitted to the facility on [DATE]. Resident #5 has [DIAGNOSES REDACTED]. On 4/5/12 at 1:00 p.m., Surveyor #3328 was reviewing Resident #5's medical record. Surveyor # reviewed the most recent Minimum Data Set ((MDS) dated [DATE] for Resident #5. The MDS indicates Resident #5 was continent of bowel and bladder. Surveyor #3328 reviewed the last annual MDS dated [DATE] and it indicated Resident #5 was frequently incontinent. Surveyor #3328 reviewed the Care Area Assessment (CAA) for Urinary Incontinence for the annual MDS dated [DATE]. The CAA indicates Resident #5 is frequently incontinent and is rarely aware of the need to toilet self. It indicates Resident #5 wears incontinence briefs at all times and receives a shower daily to keep clean and prevent skin breakdown. On 4/9/12 at 8:30 a.m., Surveyor #3328 spoke with Nursing Assistant-G regarding Resident #5's urinary incontinence. Nursing Assistant-G indicated Resident #5 is not continent of bladder. He needs to be checked and/or changed every 2 hours. Nursing Assistant-G indicated that depending on Resident #5's mood, he will allow your to toilet him. If not in a good mood Nursing Assistant-G indicated that we just change Resident #5. Surveyor reviewed the Incontinence assessment dated [DATE]. It indicates that Resident #5 voids correctly, has functional incontinence and should be checked/changes every 2 hours. On 4/9/12 at 3:00 p.m., Surveyor #3328 spoke with the Director of Nursing regarding Resident #5's incontinence. Surveyor inquired if a voiding pattern was completed for Resident #5 to determine if there was a pattern to his incontinence. On 4/10/12 at 8:30 a.m., the Director of Nursing indicated that the facility did not have a voiding pattern completed for Resident #5. On 4/10/12 at 1:40 p.m., Surveyor #3328 observed Nursing Assistant-H take Resident #5 to his room for incontinence care. Surveyor spoke with Nursing Assistant-H and she indicated that sometimes Resident #5 will allow you to toilet him and sometimes not. Nursing Assistant-H was able to toilet Resident #5 who had been incontinent and did void on the toilet at this time. The facility policy indicates that in order to complete a comprehensive bladder assessment, the resident should have a 72 hour voiding pattern completed. Resident #5 did not have a 72 hour voiding pattern completed and did not have an accurate bladder incontinence assessment completed.

Based on staff interview and record review the Facility did not provide food that was appropriately modified to a pureed consistency to meet the individual need of 1 of 7 Residents (Resident #2) reviewed requiring a pureed diet. On 11/13/11 Resident #2 was not provided with meat that was altered to a proper pureed consistency (food that has no course textures or lumps of any sort). Dietary Aides were instructed to serve meat that was modified to a mechanical soft consistency and were instructed to pour extra gravy over it. (Mechanical-soft foods are moist, soft-textured, and easily formed into a [MEDICATION NAME]. Meats are ground or are minced no larger than one-quarter-inch pieces; they are still moist, with some cohesion). Facility staff noted that the meat was not pureed once the plate was at the table but proceeded to feed Resident #2. Resident #2 choked, turned blue and staff had to perform the [MEDICATION NAME] maneuver and complete a mouth sweep to remove the food. The Facility's failure to provide puree consistency food to Resident #2 created a finding of Immediate Jeopardy that began on 11/13/11. The Administrator and Director of Nursing were informed of the immediate jeopardy on 12/2/11 at 11:17 a.m. by Surveyor # . The immediate jeopardy was removed on 12/2/11. The deficient practice continues at a scope/severity of a "E" (potential for harm that is not immediate jeopardy/pattern) as not all staff have been in-serviced. This deficient practice has the potential to affect the 6 Residents currently receiving a pureed diet in the Facility (Residents #3, 4, 7, 8, 9, 10). Findings include: On 11/30/11 & 12/1/11 Surveyor # reviewed Resident #2's closed medical record as a result of an anonymous complaint called into the State agency that Resident #2 was served the incorrect diet and choked. Resident #2 expired at the Facility on 11/16/11. Resident #2 was a [AGE] year old female who was admitted on [DATE]. [DIAGNOSES REDACTED]. Resident # 2's power of attorney was activated on 2/23/09 and Resident #2 was admitted to hospice on 1/20/11. She had some teeth (no dentures) and had experienced coughing when fed during a speech therapy screen. The monthly physician orders [REDACTED]. FLUIDS: Nectar liquids." On 12/1/11 at 2:56 p.m. Surveyor # met with Certified Nursing Assistant (CNA)-I and asked CNA-I to explain to Surveyor # what happened the night Resident #2 choked (11/13/11). CNA-I informed Surveyor # that she was in the other dining room and went to the Tudor dining room to help. Resident #2 was sitting at the table and had not eaten. CNA-I informed Surveyor # that CNA-K brought Resident #2 's dinner over and CNA-I asked CNA-K "like what the hell is this?" CNA-I informed Surveyor # that there was mashed potatoes, vegetable and some meat that was totally covered with gravy. CNA-I stated that she asked CNA-K "what's this, isn't she (Resident #2) puree." CNA-I stated that CNA-K checked with dietary then told her that was the pureed food and they were to put a lot of gravy on it. CNA-I stated that she told CNA-K "I'm not going to give this[***] this is not pureed meat." CNA-I stated that she gave Resident #2 a little bit of gravy and mashed potatoes that may have had a few pieces of meat. CNA-I informed Surveyor # that she gave her a tiny bit because Resident #2 was not opening her mouth and only gave her three teaspoons. CNA-I stated that Resident #2 started "gurgling" LPN (Licensed Practical Nurse)-L walked in the dining room and CNA-I stated that she told LPN-L that she didn't think Resident #2 needs to be eating this. LPN-L told her to stop and that Resident #2 was choking. CNA-I informed Surveyor # that LPN-L did a mouth sweep and the [MEDICATION NAME]. Surveyor # asked CNA-I what the meat that Resident #2 received looked like. CNA-I replied that it looked mechanical, more sandy, little bigger than sand grains. Surveyor # asked if the meat looked pureed. CNA-I replied "no, that's why I questioned CNA-K." On 12/1/11 at 4:11 p.m. Surveyor # interviewed CNA-K via the telephone to inquire what happened the night Resident #2 choked. CNA-K informed Surveyor # that at dinner the Residents were served mock chicken general and mechanical. CNA-I was feeding Resident #2 and she started to choke and they took Resident #2 out of the dining room. RN-F informed them to stop everyone else from eating the mechanical food. Surveyor # asked CNA-K if the meat looked any different. CNA-K replied that it was all ground up. CNA-K informed Surveyor # that she asked dietary about the pureed food and the young lady said they didn't have pureed and was told to give extra gravy as they only had mechanical meat and general. CNA-K stated that she didn't know why there wasn't any pureed she assumed that it wasn't made or it didn't come up. Surveyor # asked CNA-K if she spoke to a nurse about the pureed. CNA-K replied "no" and that the young lady told her use mechanical soft with extra gravy for people that were suppose to have pureed. The nurse's note dated 11/13/11 documented by LPN (Licensed Practical Nurse)-L indicates "Resident was choking during mealtime. Writer able to assist resident out of dining room, resident started turning blue in the face. Writer and CNA (Certified Nursing Assistant quickly assisted resident to the floor on unit and writer performed the [MEDICATION NAME] Maneuver and mouth sweeps and was able to get the food out of her mouth. Resident's started to cough and skin color turned back pink. Staff assisted resident back into chair and assisted to bed. Vitals were obtained T (temperature) 98.8 ax (axillary), P (pulse) 97, R (respirations) 22, Pox (pulse oximeter) was 83%. Unable to obtain B/P (blood pressure). LS (lung sounds) were coarse bilaterally. Oxygen was applied via mask at 2 liters per min. (minute). HOB (head of bed) elevated. Rechecked vitals on resident T 98.8 ax, P87, R16, Pox 96% on oxygen. Resident's skin pink and dry. Resting in bed comfortably. Hospice nurse called and updated on Resident's change in condition and she stated to monitor resident for any signs of aspiration. Son also updated on resident's change of condition." The nurse's note dated 11/13/11 documented by RN (Registered Nurse)-F documents "Writer called to unit during supper meal. Resident in broda chair turning blue. Resident immediately removed from chair and the [MEDICATION NAME] maneuver was preformed by the unit nurse at which time airway cleared and resident starting coughing. At present time resident is resting quietly in bed. Is alert and oriented per usual. Skin pink warm and dry. No adventitious lung sounds heard. O2 (oxygen) on at 2L (liter)/min (per minute) per nasal cannula. Writer spoke with Physician-M and made her aware of incident." The nurse's note dated 11/14/11 documents "No choking/problems eating this shift assisted with meal by CNA, took medications without problems." The nurses note dated 11/15/11 documents "Resident resting quietly. Arouses slowly. Skin pink warm and dry. Pulse Ox 79% on room air. Wheeze heard through out both lungs. O2 started at 2L/min per nasal cannula. Pulse Ox up to 89%." The nurses noted dated 11/16/11 documents "Not alert enough to drink or eat." "Checked Resident #2 at 0730 (7:30 a.m.), no response to verbal to painful stimuli turned at this time, supervisor in about 0800 (8:00 a.m.), no change, Family at bedside, at 0910 (9:10) a.m. No pulse or resp (respirations) noted at that time." On 12/1/11 at 11:45 a.m. Surveyor # interviewed DD (Dietary Director)-C to inquire how and when he became aware of Resident #2's choking on 11/13/11. DD-C informed Surveyor # that he was informed the night of the choking at 6:10 p.m. by the Administrator who asked him "don't we have pureed meats." DD-C stated that after he spoke with the Administrator he called the Facility and spoke with DA (Dietary Aide)-H, who was the cook that evening. DA-H assured him that the food was pureed. DD-C stated that he had numerous phone calls with the Administrator and RN (Registered Nurse)-F. During one of the phone calls, RN-F informed DD-C that another nurse was pretty convinced that the food Resident #2 was served was mechanical soft. DD-C stated that he called and spoke with the DA-J and DA-G who also assured him that night that pureed food was served. DD-C informed Surveyor # that there were also two CNAs (Certified Nursing Assistants), CNA-I and CNA-K, involved. DD-C informed Surveyor # that it was his understanding that CNA-K looked over the serving area and informed DA-G that the food was not pureed and DA-G informed CNA-K that was all they had that evening. DD-C informed Surveyor # that the next morning he spoke with DA-G and DA-J and told them that they had to come clean. DD-C stated that DA-G and DA-J came clean and told him that they were told it was mechanical soft and were instructed to put extra gravy on it. Surveyor # inquired how many Residents were to receive pureed food. DD-C informed Surveyor # there are six Residents. DD-C informed Surveyor # that DA-H has been cooking for years and that the mock chicken was not a new food item. Surveyor # asked DD-C if the dietary staff were in-serviced. DD-C replied not formally but that he informed all his staff what happened and told them they needed to provide both a mechanical soft and pureed meal. On 12/1/11 at 12:08 p.m. Surveyor # interviewed the DON (Director of Nursing) to inquire how she became aware of Resident #2's choking. The DON informed Surveyor # that she was made aware during their morning meeting the next day. The DON informed Surveyor # that she interviewed CNA-I, who fed Resident #2 the night she choked, and also set up an in-service with the speech therapist. Surveyor # inquired who attended the in-service. The DON informed Surveyor # that it was mandatory for CNA-I and the dietary staff who worked on 11/13/11 and encouraged other staff to attend. The DON provided Surveyor # with a list of staff who attended the dysphasia in-service provided by the speech therapist. Surveyor # noted 25 nursing and dietary staff members attended and there are approximately 86 staff in the two departments. Surveyor # also noted that DA-H did not attend the in-service. On 12/1/11 at 12:17 p.m. Surveyor # interviewed the Administrator regarding Resident #2's choking episode. The Administrator informed Surveyor # that she had received a telephone call from RN-F that staff had to perform the [MEDICATION NAME] on Resident #2 because she was choking, chunks of food were removed and they didn't know if Resident #2 received a pureed diet. The Administrator stated that after she spoke with RN-F she called DD-C and asked him to find out what they served. The Administrator stated that she also spoke with CNA-I and CNA-K. CNA-K informed her that DA-J said that DA-H said to add extra gravy. The Administrator stated that RN-F checked the other Residents who received the pureed diet and they were fine. On 12/1/11 at 1:56 p.m. Surveyor # interviewed DA-J via the telephone to inquire about the night that Resident #2 choked. DA-J informed Surveyor # that DD-C had spoken to her about that night. DA-J informed Surveyor # that she did not serve Resident #2 that night. Surveyor # asked DA-J if DA-H said anything to her about the pureed food that night. DA-J replied that the cook (DA-H) told her to use mechanical soft and add the gravy to it. On 12/1/11 at 3:13 p.m. Surveyor # interviewed DA-G via the telephone to inquire about the night that Resident #2 choked. DA-G informed Surveyor # that DA-H gave her meat to use for pureed and said to put a lot of gravy on it. Surveyor # asked DA-G if the meat was pureed. DA-G replied from what DA-H told her it was but everyone else said it was mechanical soft. Surveyor # asked if the meat had any pieces in it. DA-G replied "kind of, it was chunkier than we usually use." Surveyor # asked if any of the CNA's asked her about the pureed meat. DA-G replied that a CNA said it wasn't pureed so she went and asked the cook (DA-H). DA-G stated that DA-H told her to use it. DA-G informed Surveyor # that the CNA told her it was too chunky to be pureed. On 12/2/11 at 7:42 a.m. Surveyor # asked DD-C if DA-H cooked after the night Resident #2 choked. DD-C informed Surveyor # that she was not allowed to cook anymore. Surveyor # inquired how often DA-H cooked. DD-C replied that DA-H every Sunday night and would fill in when needed. DD-C informed Surveyor # that he never got the feeling that the food was pureed that night and that RN-F had told him that it was not pureed. DD-C stated that DA-G was kind of new and overlooked it. Surveyor # asked who would have put the food in the wells. DD-C indicated that the cook would and then would direct the dietary aides on what to do. DD-C informed Surveyor # that "there was a failure in every step." DD-C stated that it was his perception that DA-H got lazy. DD-C informed Surveyor # that he even spoke with the daughter of another Resident who was supposed to receive a pureed diet that night (Resident #4). Resident #4's daughter had fed her mother that night (11/13/11). DD-C informed Surveyor # that Resident #4's daughter informed him that she had tried the meat and it was mechanical soft. Resident #4's daughter informed him that she knew it was mechanical soft because her mother used to be on it. DD-C explained to Surveyor # that Resident #4 was a general diet then downgraded to mechanical soft and is now on a pureed diet. Review of the facility's 11/15/11 administrative investigation into Resident #2's choking incident documents "After numerous calls back and forth between Dietary Director-C, RN-F, CNA-I and CNA-K it appears that the cook did not make the food, instructed the servers to add extra gravy to the mech soft meat and continue." On 11/13/11 the proper pureed meat was not served to Resident #2 on 11/13/11. " Based upon the facility's failure to ensure that Resident #2 received the proper pureed consistency diet as ordered lead to Resident #2 having a choking episode that caused her to turn blue and required there [MEDICATION NAME] Maneuver to clear her airway in-turn leading to the determination that the facility had a situation of immediate jeopardy. On 12/2/11 at 11:17 am the facility's administration was made aware of the immediate jeopardy determination. On 12/2/11 the facility was able to remove the level of immediate jeopardy and the scope and severity continues at a level of "E" (no more than potential for minimal harm/pattern) as the facility continues to implement the system changes for the 6 facility residents identified to receive a pureed diet (Residents #3, 4, 7, 8, 9, 10). The facility initiated the following changes as part of the immediate jeopardy removal process: 1. The facility reviewed and revised the policy and procedure for the Dining Process. 2. Policies and procedures for various consistency diet preparation has been developed and staff have been inserviced. 3. Nursing, dietary and all other employees involved in the meal delivery processed have been trained. 4. The facility developed a process where nursing staff observe all plates of food with a modified texture to ensure that it is the proper consistency prior to delivery to the resident. 5. Diet orders have been added to all resident medication administration records. 6. The facility developed a system for monitoring the delivery process and involved the Quality Assurance and Assessment committee.