Every finding on record at Complete Care at Grande Prairie

Based on interview and record review, the facility did not ensure it submitted accurate mandatory staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 79 residents residing in the facility.Staffing information for Quarter 1 (October 1 - December 31, 2025) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.Findings include:The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, documents: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: (quarter) 1 October 1-December 31, (quarter) 2 January 1-March 31, (quarter) 3 April 1-June 30, (quarter) 4 July 1-September 30.Surveyor reviewed the facility's PBJ Staffing Data Report, CASPER Report 1705D, for Fiscal year 2026 (run on 3/9/2026) which documented the facility had excessively low weekend staffing for the 1st Quarter (October 1 - December 31, 2025).Surveyor reviewed the facility's weekend schedules from October 2025 through December 2025. Surveyor noted licensed nurses and certified nursing assistants present on each shift, for each unit. Surveyor noted the facility's schedules indicated call ins, agency staff and which staff who picked up shifts. Surveyor noted there were numerous call-ins, however the shifts were filled by staff or agency. On 5/12/2026, at 10:04 AM, Surveyor interviewed Scheduler-H and asked to verify nursing staff per shift scheduled from October to December of 2025. Per Scheduler-H, the staffing totals are dependent on the resident census. On first shift and second shift, 8 to 9 Certified Nursing Assistants (CNAs) and 5 to 6 Nurses with at least 1 Registered Nurse (RN) are the minimum staffing requirements. On third shift, 5 to 6 CNAs and 2 Nurses with 1 RN is the minimum staffing requirement.Per Scheduler-H, the facility is transitioning over to a new staffing scheduling system where the facility staff can view their hours and shifts to pick up. Scheduler-H inputs the shifts not filled with agency staff and removes agency staff as facility staff pick up the shifts. Scheduler-H denies any low staffing on certain shifts or the weekends and stated more staff are scheduled than the minimum required amount to account for staff call ins.Surveyor noted the schedules documented many staff calling in and the openings being filled by other facility staff or agency staff. However, Surveyor noted that the facility did not have low staffing levels on the weekends as indicated in the facility's PBJ Staffing Data Report for the 1st Quarter (October 1 - December 31, 2025).On 4/29/2026, at 09:36 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the facility's low ratings for staffing on the Payroll-Based Journal. NHA-A stated someone from the facilities corporate is responsible for submitting the Payroll-based Journal. NHA-A denied any low staffing levels on weekends. On 5/12/2026, at 1:41 PM, Surveyor interviewed CNA-F regarding staffing. CNA-F has worked at the facility for 2 years and works a mix of first and second shifts and will pick up often. CNA- F denies the facility being low staffed and stated there is enough staff scheduled regularly to meet resident needs. On 5/14/2026, at 8:55 AM, Surveyor interviewed Licensed Practical Nurse (LPN)- G who has worked for the facility for about 2 years and picks up multiple shifts. LPN- G stated there is always plenty of nursing staff. LPN- G stated there is enough time to complete tasks and has no concerns with staffing levels.On 5/12/2026, at 2:35 PM, Surveyor informed NHA-A and DON-B of the concern with Payroll Based Journal reporting being inaccurate for the first quarter of the 2026 fiscal year.No additional information was provided as to why the facility did not accurately submit staffing information for Quarter 1 (October 1 through December 31, 2025) for the Payroll Based Journal (PBJ).

Based on observation, record review, and interview, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety (Wisconsin Food Code) in the main kitchen. This deficient practice has the potential to affect all 79 residents who receive food from the main kitchen. *Dietary Manager (DM)-C, Dietary Aide (DA)-D, and DA-E were observed in the main kitchen preparing and handling food without wearing hair restraints that covered facial hair. DA-E was observed wearing a hat that did not fully restrain hair. Findings include:The Wisconsin Food Code documents: Food employees shall wear hair restraints such as hair coverings or nets, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food.On 5/11/26 at 8:27 AM, Surveyor conducted an initial tour of the main kitchen with DM-C. Surveyor observed DM-C handling food in the main kitchen while not wearing a hair restraint for exposed facial hair. On 5/12/26 at 8:18 AM, Surveyor observed DM-C handling food in the main kitchen while not wearing a hair restraint for exposed facial hair. On 5/12/26 at 11:16 AM, Surveyor observed DM-C, DA-D, and DA-E preparing and handling food in the main kitchen without wearing a hair restraint for exposed facial hair. Surveyor observed DA-E wearing a hat that did not fully restrain hair. On 5/12/26 at 11:31 AM, DM-C confirmed the facility follows the Wisconsin Food Code standard of practice for food safety. On 5/12/26 at 11:42 AM, Surveyor observed DA-D and DA-E preparing and handling food in the main kitchen without wearing a hair restraint for exposed facial hair. Surveyor observed DA-E wearing a hat that did not fully restrain hair. On 5/12/26 at 1:50 PM, Surveyor shared concern with DM-C that Surveyor had several observations of DM-C, DA-D, and DA-E not wearing a hair restraint for exposed facial hair and DA-E wearing a hat that did not fully restrain hair. DM-C stated DM-C thought facial hair could be less than a quarter inch in length without wearing a beard restraint. DM-C stated DM-C would get the proper hair and beard restraints for kitchen staff right away. On 5/12/26 at 2:31 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the above findings. No additional information was provided as to why food was not prepared, distributed, and served in accordance with professional standards for food service safety.

Based on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles. *Surveyor observed 6 expired stock medications and 63 loose medication pills in 2 of 3 medication carts.This deficient practice has the potential to affect more than 3 residents residing on the units that utilize the medication carts for medication administration. Findings:The facility's policy, titled Medication Storage, with an implement date of 3/2026, does not document any policies regarding expired medications.On 05/12/2026, at 12:47 PM, Surveyor observed medication pass on the MESA unit with Licensed Practical Nurse (LPN)-N. Within the medication cart, Surveyor observed Vitamin B with an expiration date of 4/2026, Thiamin with an expiration date of 4/2026, Cetirizine unable to read expiration date with no open date, Non-aspirin no expiration date and Senna S- no expiration date. LPN-N asked the Unit Manager about the dates and the Unit Manager stated that LPN-N will toss the medications and get new ones. LPN-N indicated if a medication doesn't have an expiration date, LPN-N will put the open date and discard 30 days after.On 05/12/2026, at 1:10 PM, Surveyor observed the [NAME] short hall medication cart with Registered Nurse (RN)-O. While observing the drawers of the medication cart, Surveyor observed 58 loose medication pills. RN-O disposed of the loose medication pills in the drug buster container used to destroy medications. On 05/12/2026, at 2:41 PM, Surveyor observed the Garden unit medication cart with Unit Manager-L. Surveyor observed 5 loose medications and 1 bottle of liquid pain relief with an expiration date of 4/2026. On 05/12/2026, at 1:41 PM, Surveyor informed Director of Nursing (DON)-B of the above concerns. DON-B indicated nurses will usually go through the medications on the carts when residents discharge and will go through the medication cart monthly reviewing for expired medications. DON-B informed Surveyor that DON-B did not know what the expectation is for loose medication pills in the medication cart. On 5/14/2026, at 11:56 AM, Surveyor informed the facility of the above concerns, no additional information was provided.

Based on observation, interview and record review the facility did not ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, including risk for dehydration for 1 (R8) of 2 residents reviewed for enteral feeding.*R8 has an order for 12 hours continuous feed from 8PM to 8AM. Surveyor observed that on 5/11/2026, 5/12/2026 and 5/13/2026 that R8's tube feeding was not administered as ordered.Findings include:The facility policy, titled Enteral Tube Feeding via Continuous Pump, updated 12/14/2025, documents: Documentation The person performing this procedure should record the following information in the resident's medical record: . 2. Amount and type of enteral feeding. 7. If the resident refused the procedure, the reason(s) why and the intervention taken. Reporting . 3. Notify the supervisor if the resident refuses the procedure.R8 was admitted to the facility on [DATE] with diagnoses including gastrostomy (a surgical opening made through the skin of the abdomen directly into the stomach) and dysphasia (difficulty swallowing).R8's Annual Minimum Data Set, dated [DATE], documents that R8 was assessed to have a Brief Interview for Mental Status score of 6, indicating that R8 has severe cognitive impairment. The MDS also documents that R8 was assessed as having a feeding tube in place during the assessment period. On 05/11/2026, at 9:42 AM, Surveyor observed R8's tube feeding bottle and flush bag hanging on a pole in R8's room. Surveyor noted R8 was not in the room, the tube feeding bottle was dated 5/10/2026 with a start time of 8:30 PM. The tubing was labeled: Rate 69 milliliters (ml) per hour (hr), was not currently running and appeared to be about completely full.On 05/12/2026, at 9:58 AM, Surveyor observed R8's tube feeding bottle and flush bag hanging on a pole in R8's room. Surveyor noted R8 was not in the room. The tube feeding bottle was dated 5/11/2026 at 8PM at 69 ml/hr. Surveyor noted the tube feeding bottle was almost full.R8's physician order and noted the following, at bedtime, administer Osmolite 1.5CAL as a continuous feed via Pump at 69 ml per hour for 12 hours per day, 2000 - 0800 (nocturnal feed) 150ml flush every 4 hours.Surveyor noted R8 should receive 828ml of Osmolite total over 12 hours. Surveyor was unable to locate any documentation R8's electronic health record that R8 did not receive R8's total tube or why R8 was observed to have tube feeding solution almost full on 5/11/26 and 5/12/26. Surveyor noted R8 is on a puree diet with thickened liquids, with an overall intake of 25-50% at times with tube feeding to meet the lower end of energy needs, per Registered Dietician notes.On 05/13/2026, at 7:22 AM, Surveyor observed R8's tube feeding bottle and flush bag hanging on a pole in R8's room. Surveyor noted R8 not in the room, the tube feeding was not running and was dated 5/12/2026 at 8PM at 69 ml/hr and had 900 to 1000 ml remaining in the bottle.On 05/13/2026, at 7:39 AM, Surveyor asked Licensed Practical Nurse (LPN)-G about R8's tube feeding. LPN-G informed Surveyor that R8 was already off the tube feeding when LPN-G started at 6:45 AM. Third shift informed LPN-G that they got R8 up at 3 AM this morning because R8 was pulling at R8's tube feeding. Surveyor asked what the process is if R8 doesn't receive the full ordered nutrition via tube feeding. LPN-G indicated that R8 just doesn't get the tube feed because R8 was pulling on tube and no notifications made.Surveyor was unable to locate any documentation in R8's electronic health record that R8 was disconnected from R8's tube feed prior to 8 AM, that R8's physician was notified or any refusals by R8 to receive tube feedings from 5/11/2026 to 5/13/2026. On 05/13/2026, at 7:45 AM, Surveyor informed Unit Manager (UM)-L of Surveyors observations of R8's tube feedings being almost full since start of Survey and today had 900 out of 1000 remaining in R8's tube feeding bottle. Surveyor asked UM-L what the expectation is when R8 does not receive the full ordered tube feeding. Unit Manager-L informed Surveyor that the provider should be notified to let the physician know how much was missed and to see if they want to have the feeding administered. Unit Manager-L indicated that any missed or refused tube feedings should be documented in R8's electronic health record and if it is not documented in chart, there is also a platform used to contact providers but most of the time this is communicated via verbal communication while providers are in the facility. UM-L informed Surveyor UM-L would investigate it and get back to Surveyor with more information.R8's progress noted dated 5/13/2026, at 08:32 AM by UM-L documents: Nurse Practitioner (NP)-M was notified that R8 was disconnected from tube feed around 3 AM this morning due to refusing the tube feed and as result did not complete the tube feed until 8am as ordered. No new orders and NP-M is not concerned at this time since R8 does eat 3 meals throughout the day as well as snacks, Registered Dietician to be updated.Surveyor noted that if R8 was connected to tube feeding from 8PM to 3AM, R8 would have received approximately 483 mls per R8's order rate. Surveyor observed only 100 ml were administered from R8's tube feed. 05/13/2026 2:16 PM UM-L informed Surveyor that NP-M was notified of R8's missing tube feedings and what UM-L found through UM-L's investigation. UM-L spoke with staff and was told R8 was disconnected around 3 AM and only received 7 hours of tube feeding. UM-L indicated R8's tube feed is for supplemental nutrition since R8 does eat every meal. UM-L indicated UM-L needs to reach out to night shift staff to find out why R8 wasn't receiving the full tube feed, since there was no documentation in R8's electronic health record. UM-L indicated NP-M was updated that R8 only received 100 mls last night after seeing R8's tube feed bottle.On 05/13/2026, at 2:48 PM, Surveyor interviewed Director of Nursing (DON)-B regarding Surveyor's observations of R8's tube feedings. DON-B informed Surveyor that DON-B would expect the provider to be notified and updated of missed tube feeds and if a resident refuses tube feeds. DON-B informed Surveyor they are currently investigating the concern. On 05/14/2026, at 7:11 AM, Surveyor interviewed NP-M. UM-L informed NP-M of R8's missing tube feed yesterday morning. NP-M indicated R8 eats about 50% during the day with tube feed as a supplement. NP-M informed Surveyor that NP-M would expect to be notified of missed or refused tube feeds and that maybe adjustments need to be made. NP-M indicated the team would investigate why feeds were not being given as ordered and discuss R8 needsOn 5/14/2026, at 11:56 AM, Surveyor informed the facility of the above findings. No additional information was provided.

Based on interview and record review, the facility did not ensure 3 (R7, R12, & R91) of 3 residents reviewed for post-traumatic stress disorder (PTSD) received trauma informed care in accordance with professional stands of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. R7, R12, and R91 were admitted to the facility with a diagnosis of PTSD, and the facility did not develop a person-centered care plan identifying triggers, interventions, or monitoring for PTSD. Findings include: The facility policy titled Trauma Informed Care with implemented date March 2026 documents: The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident's care plan. The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understand if interventions must be modified. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. 1.). R7 was admitted to the facility 1/26/24 with diagnoses including post-traumatic stress disorder (a mental health condition in people who have experienced or witnessed a traumatic event), depression, and other schizoaffective disorders (a chronic mental health condition that is marked by a mix of hallucinations and delusions and mood disorder symptoms). R7 had an activated power of attorney (POA) to make healthcare decisions. R7's Minimum Data Set (MDS) assessment dated [DATE] documented that R7 had a brief interview for mental status (BIMS) score of 8, indicating moderate cognitive impairment, and R7 did not demonstrate any behaviors within the lookback period. R7's Care Area Assessment (CAA) for mood state dated 3/30/26 documented R7 has a diagnosis of depression and is on medication for depression and sees in-house psychiatric services, family visits and is supportive. Surveyor noted the CAA did not address R7's PTSD diagnosis. R7's admission Trauma Informed Care assessment dated [DATE] documented: Instructions: listed below are a number of difficult or stressful thing that sometimes happen to people. For each event choose one or more of the options to indicate that: (1) it happened to you personally; (2) you witnessed it happen to someone else; (3) you learned about it happening to a close family member or close friend; (4) you were exposed to it as part of your job (for example, paramedic, police, military, or other first responder); (5) you're not sure if it fits; (6) it does not apply to you . The assessment documents the following 17 scenarios:1. Natural disaster (for example, flood, hurricane, tornado, earthquake): answered does not apply2. Fire or explosion: answered does not apply3. Transportation accident (for example, car accident, boat accident, train wreck, plane crash): answered does not apply4. Serious accident at work, home, or recreational activity: answered does not apply5. Exposure to toxic substance (for example, dangerous chemicals or radiation): answered does not apply6. Physical assault (for example, being attached, hit, slapped, kicked, beaten up): answered does not apply7. Assault with a weapon (for example, being shot, stabbed, threatened with knife, gun, or bomb): answered does not apply8. Sexual assault (for example, rape, attempted rape, made to perform any sexual act through force or threat of harm): answered does not apply9. Other unwanted or uncomfortable sexual experience: answered does not apply10. Combat exposure to a warzone in the military or as a civilian: answered does not apply11. Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war): answered does not apply12. Life threatening illness or injury: answered does not apply13. Severe human suffering: answered does not apply14. Sudden violent death (for example, homicide or suicide): answered does not apply15. Sudden accidental death: answered does not apply16. Serious injury, harm, or death you caused to someone else: answered does not apply17. Any other very stressful event or experience: answered does not applyPart 2 of the assessment documents cannot think of any traumatic events that have happened. R7's Trauma Informed Care assessment dated [DATE] documented the same 17 scenarios as the admission Trauma Informed Care Assessment, all answered does not apply with the exception of the following:14. Sudden violent death (for example, homicide or suicide): answered as happened to me. Part 2 of the assessment documents girlfriend was killed long ago. R7's Social Service assessment dated [DATE] documented in section D: Psychosocial status/current life stressor/grief issues the following questions and responses:. 3. Have you ever been through anything life threatening or traumatic? Answered: No. 6. Are you aware of any particular triggers that may make this worse for you? Answered: No. Surveyor reviewed R7's care plan and was unable to locate a care plan specific to R7's PTSD diagnosis to include potential triggers for R7's trauma, individualized care plan interventions for R7's trauma, or specific interventions to decrease R7's exposure to triggers or ways to decrease the effect of the triggers. In an interview on 5/14/26 at 8:47 AM, Licensed Practical Nurse (LPN)-K stated the facility has not really talked to nursing staff about R7's PTSD or any triggers R7 may have related to R7's PTSD. In an interview on 5/14/26 at 9:34 AM, Social Services (SS)-I confirmed SS-I primarily completes trauma assessments for residents at the facility, and the assessments are completed on admission, annually, and if there is any sort of change in resident condition. SS-I stated if a resident has a diagnosis of PTSD, SS-I still performs the trauma assessment on admission and annually, unless there is a reason warranting a new assessment such as new resident behaviors or symptoms. SS-I stated if the resident answers that any of the scenarios occurred to them on the trauma assessment, SS-I asks more about the scenario, such as how long ago it occurred, if the resident is willing to share. SS-I stated if the traumatic event is recent, the resident's care plan would be updated, but if the traumatic event occurred in the past, the facility does not add it to the resident's care plan. SS-I stated the Social Services Assessment touches on resident triggers for PTSD, which are completed on a quarterly basis for all residents. SS-I stated if there are any relevant triggers on the Social Services Assessments, those would be added to the resident's care plan. SS-I confirmed R7 first mentioned his girlfriend was killed to SS-I on the Trauma Informed Care assessment dated [DATE]. SS-I stated the event occurred a long time ago to R7 and R7 did not seem upset by sharing the information, so SS-I did not add anything to R7's care plan. SS-I confirmed SS-I completed R7's Social Service assessment dated [DATE] and confirmed no was answered for the question have you ever been through anything life threatening or traumatic?. SS-I stated even though R7 disclosed the information about R7's girlfriend being killed to SS-I on 3/17/26, R7 gave the answer of no to any traumatic events on 3/26/26, so SS-I answered the question as no. In an interview on 5/14/26 at 10:37 AM, Director of Nursing (DON)-B stated social services completes assessments quarterly on all residents and completes a Trauma Informed Care Assessment annually and on an as needed basis. DON-B stated information from those assessments should be communicated to nursing staff so resident care cards and care plans can be updated accordingly. DON-B stated if there are specific interventions or monitoring needed for a resident based on those assessments, the resident care plan would be updated with those specific interventions. Surveyor shared concern with DON-B that R7 has a history of PTSD, and specific triggers, individualized interventions, and ways to decrease R7's exposure to triggers which may re-traumatize R7 were not identified or put into R7's care plan. No additional information was provided. In an interview on 5/14/26 at 10:56 AM, Director of Social Services (DSS)-J stated the facility completes a trauma assessment annually and if needed for a resident with PTSD. DSS-J stated a resident's care plan would only be updated if the resident currently shows symptoms or behaviors related to the resident's PTSD, and if the resident is not currently displaying symptoms or behaviors related to PTSD impacting their care, the facility does not add any interventions to the resident's care plan. DSS-J stated the facility does not really determine a resident's triggers and would involve psychiatric services to delve deeper into resident triggers for PTSD. Surveyor shared concern with DSS-J that R7 has a history of PTSD, and specific triggers, individualized interventions, and ways to decrease R7's exposure to triggers which may re-traumatize R7 were not identified or put into R7's care plan. No additional information was provided. 2.) R91 was admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder (PTSD). R91's Annual Minimum Data Set (MDS), dated [DATE], documents that R91 was assessed to have a Brief Interview for Mental Statue score of 14, indicating intact cognition. The MDS documents that R91 was assessed to have a traumatic brain injury, anxiety, psychotic disorder and Post Traumatic Stress Disorder. R91's Trauma Care Assessments, dated 6/16/25 documented: Flood and hurricane many years ago, was hit by a car and almost died, had abusive husband, assaulted with a weapon and knew many teenagers and adults that died of an overdose. Surveyor reviewed R91's Trauma Care Assessments, dated 10/20/25 documented: Experienced a tornado long ago, had a fire as a kid, hit by a car a couple years ago broke arm regularly as a kid, husbands were abusive, had a couple bad sicknesses and heart trouble a while ago, being homeless, knew some kids who over dosed and committed suicide years ago Surveyor reviewed R91's Care Plan and noted the following: Impaired neurological status related to: Traumatic brain injury causing hallucinations; Resident does have episodes of hallucinations, accusations, increased agitation d/t (due to) visions she sees or impaired thoughts. Interventions included: - Provide redirection to resident during episodes of hallucinations- Psychologist and psychiatrist to assess and follow resident as needed.-Encourage family to visit and bring in photos and momentous-Explain all procedures and reason before performing-Involve in activities that don't depend on patient's ability to communicate: music, parties, games-Listen to patient when verbalizing concerns over disease symptoms and address issues raised-Pleasant interaction which reassures patient when confused R91's anxiety care plan dated 6/20/25 documents: Resident has anxiety disorder; Interventions included: -encourage resident to express feelings-Monitor behaviors and update MD if symptoms occur more frequently or are unmanaged-Encourage resident to participate in activities-Encourage resident to walk or talk with fellow peers-Redirect resident as appropriate -The resident is verbally aggressive r/t (related to) Mental / Emotional illness4-3-25: threats towards staff, agitation, hallucinations.5/16/25: verbal altercation with family member. 5/16/25: removed resident from situation, monitoring resident mood/behavior. Date Initiated: 05/16/2025-Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document.-Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.-Assess resident's coping skills and support system.-Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation.-Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. -Psychiatric/Psychogeriatric consult as indicated. The resident has behavior problems related to allegations against peers. 10/20/25: No male caregivers/aides10/20/25: Updated psych provider on new allegations.-Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by.-If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.-Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.-Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.-Praise any indication of the resident's progress/improvement in behavior. -The resident has a behavior problem r/t allegations against peers.-Provide a program of activities that is of interest and accommodates residents status. Surveyor was unable to locate a Trauma Informed care plan relating to R91's Post-Traumatic Stress and triggers. On 05/13/2026, at 1:27 PM, Surveyor spoke with Social Services-I regarding R91's Trauma Assessments and care plans. Social Services-I informed Surveyor that R91 has a history of allegations/telling stories of things that would occur, which after following up did not have any validity. Social Services-I was not completing care plans at that time R91's Trauma Assessment was completed and believe it would have been placed by nursing. Social Services-I stated that R91 had a care plan created by nursing in October 2025 for behavior problems with allegation against peers. Social Services-I stated that trauma assessments are completed annually and as needed and every resident has one completed. Social Services-I indicated that If someone has diagnosis of PTSD they will still only do yearly assessments unless there is an incident. Social Services-I will ask about how long-ago incident occurred and if the trauma happened in the past, they do not care plan and is only there for our knowledge but will care plan if there is a recent event. On admission and quarterly, Social Services-I asks about triggers under the Social Services assessment, which is different than trauma assessment. Social Services-I stated that if the resident has a relevant trigger, it would be care planned if needed. On 05/14/2026, at 10:37 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated that trauma informed care assessments are done on an as needed basis and is not necessary annually. DON-B stated that Social Services does the assessments quarterly and that the expectation is that Social Services should be communicating those assessment findings to nursing staff so that they can update care plans and care cards. DON-B stated that if the resident needs something then it should be on the care plan but added that just because they have a diagnosis of PTSD, does not mean they have behaviors, if they have behaviors then staff are monitoring for that specific behavior. DON-B stated that if only if something was still triggering for that resident, then it would be added to the care plan. DON-B stated that if a behavior shows up on a resident's assessment, then DON-B would consider that to be a trigger. On 05/14/2026, at 11:09 AM, Surveyor informed Director of Social Services and the facility of the above concerns. No additional information was provided. 3.) R12 was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder and Depression. R12's Annual MDS, dated [DATE], indicates R12 has a Brief Interview for Mental Status score of 11, indicating intact cognition and has Post-Traumatic Stress Disorder. R12's trauma assessment dated [DATE] documents: and noted the following: Car accident 2 years ago where car was totaled, accident while working on car fell from jack onto resident 3 years ago, exposed to unknown toxic substances during desert storm, exposure to combat zone during desert storm, suicide in family. R12's trauma assessment dated [DATE] documents: Experienced Fire in Army, has been in many car accidents, 3 years ago hit by a plow and flipped car, exposed to substances in desert storm, was in a scuffle 5 years ago after car ran out of gas, family suicide years ago R12's trauma assessment dated [DATE] documents: Had many car accidents, served in desert storm, warzone and toxic substances, family suicide. R12's Depression care plan dated as revised 3/25/26 documents: -Administer medications as ordered. Monitor/document for side effects and effectiveness.-Arrange for psych consult, follow up as indicated.-Assist the resident in developing /provide the resident with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise,physical activity.-Discuss with the resident/family/caregivers any concerns, fears, issues regarding health or other subjects.-Monitor/document/report as needed adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidalthoughts, withdrawal; decline in activities of daily living ability .-Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving awaypossessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness.-Monitor/document/report as needed any signs/symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. -Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons Surveyor was unable to locate a Trauma Informed care plan relating to R12's Post-Traumatic Stress and triggers. On 05/13/2026, at 1:27 PM, Surveyor spoke with Social Services-I regarding R12's Trauma Assessments and care plans. Social Services-I stated that trauma assessments are completed annually and as needed and every resident has one completed. Social Services-I indicated that If someone has diagnosis of PTSD they will still only do yearly assessments unless there is an incident. Social Services-I will ask about how long-ago incident occurred and if the trauma happened in the past, they do not care plan and is only there for our knowledge but will care plan if there is a recent event. On admission and quarterly, Social Services-I asks about triggers under the Social Services assessment, which is different than trauma assessment. Social Services-I stated that if the resident has a relevant trigger, it would be care planned if needed. On 05/14/2026, at 10:37 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated that trauma informed care assessments are done on an as needed basis and is not necessary annually. DON-B stated that Social Services does the assessments quarterly and that the expectation is that Social Services should be communicating those assessment findings to nursing staff so that they can update care plans and care cards. DON-B stated that if the resident needs something then it should be on the care plan but added that just because they have a diagnosis of PTSD, does not mean they have behaviors, if they have behaviors then staff are monitoring for that specific behavior. DON-B stated that if only if something was still triggering for that resident, then it would be added to the care plan. DON-B stated that if a behavior shows up on a resident's assessment, then DON-B would consider that to be a trigger. On 05/14/2026, at 11:09 AM, Surveyor informed Director of Social Services and the facility of the above concerns. No additional information was provided.

Based on interview and record review, the facility did not thoroughly investigate 2 of 4 allegations of abuse involving residents (R) (R5 and R1) and did not take steps to prevent further potential abuse while an investigation was in progress. The facility was made aware of an incident involving allegations of abuse that occurred involving R5 and two staff members. The facility did not investigate the incident causing R5 to be fearful and cautious. R5 sought evaluation and treatment for left knee pain following the incident. The staff member alleged to have abused R5 was allowed to work approximately 46 shifts following the incident, resulting in R5 and other residents to not be safeguarded from additional potential abuse. The facility's failure to thoroughly investigate allegations of abuse allowed accused staff to continue working with residents following the incident resulting in the failure to safeguard residents from potential further abuse. These failures created a finding of Immediate Jeopardy that began on 01/13/2025 . Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the Immediate Jeopardy on 03/19/2025 at 12:16 PM. The Immediate Jeopardy was removed on 3/20/25, however the deficient practice continues at a scope/severity of D (potential for harm/isolated) due to the following example: *On 3/3/2025, the facility investigated allegations of sexual abuse for R1. The CNA was allowed to work 2 additional weeks at the facility while the investigation was in progress. These deficient practices has the potential to affect the residents on the unit which CNA-J was working on after the alleged incident. Findings include: The facility's policy titled Abuse, Neglect and Exploitation, dated as reviewed/revised on 10/2024, documents: Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others that has not yet been investigated and if verified, could be an indication of noncompliance with Federal requirements related to mistreatment, exploitation, neglect, or abuse . Mistreatment means inappropriate treatment or exploitation of a resident . Physical Abuse includes, but is not limited to hitting slapping punching biting and kicking. It also includes controlling behavior through corporal punishment. Serious bodily injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization , or physical rehabilitation; or an injury resulting from criminal sexual abuse . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; . The components of the facility abuse prohibition plan are discussed herein: . V. Investigation of alleged abuse, neglect and exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur VI. Protection of resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after an investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim in integrity of the investigation: . D. Room or staffing changes, if necessary, to protect the residents from the alleged perpetrator; E. Protection from retaliation by perpetrator. 1.) R5 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, unspecified dementia without disturbance, psychotic disturbance, mood disturbance and anxiety, pain in right knee, pain in left knee, anxiety disorder, peripheral vascular disease, pain in right wrist, pain in left shoulder, and rotator cuff tear or rupture of left shoulder. R5's Annual Minimum Data Set (MDS), dated [DATE], documents R5 is able to understand and be understood and a staff assessment for mental status was conducted which documented R5 has a memory problem but was able to recall current season, location of own room, staff names and faces, and he/she is in a nursing home/hospital swing bed. The MDS documents R5 has modified independence-some difficulty in new situations only, R5 has no behaviors/rejection of care exhibited, uses a walker, and is not on antipsychotic drug therapy. R5's Quarterly MDS dated [DATE], documents a staff assessment for mental status was conducted and that R5 has a memory problem but was able to recall current season, location of own room, staff names and faces, and he/she is in a nursing home/hospital swing bed. The MDS documents R5 has modified independence-some difficulty in new situations only, R5 has no behaviors/rejection of care exhibited, uses a walker, and is not on antipsychotic drug therapy. On 03/17/2025 at 08:50 AM, Surveyor interviewed R5. R5 informed Surveyor R5 was attacked in the doorway to kitchen by a named staff member, later identified as Certified Nursing Assistant (CNA)-J. Surveyor asked R5 what led up to the incident and R5 indicated being unsure and stated CNA-J is a belligerent and stupid person. R5 indicated that Adult Protective Services (APS) came to the facility and spoke with R5. R5 was unsure who notified APS and indicated there were many witnesses. R5 informed Surveyor CNA-J told R5 that Director of Nursing (DON)-B said R5 could not come in the kitchen. R5 indicated speaking with DON-B regarding the incident and was told it would be taken care of. R5 informed Surveyor R5 was hurt during the incident and had pain to left rib cage, left shoulder, and left foot. R5 stated R5 does not feel safe at the facility, the incident is not taken care of and stated, I was abused! R5 stated R5 is fearful and is very careful with what R5 says and does now in the facility. Surveyor reviewed staff roster for the last name of the staff member R5 identified. Surveyor noted 2 staff with that last name, so Surveyor interviewed one of the two staff members with the same last name and was able to determine that the individual alleged to have been in altercation with R5 was CNA-J. On 03/17/2025 at 10:42 AM, Surveyor spoke with Director of Dietary-N. Director of Dietary-N was not here the day of the incident but knows of incident involving R5. Director of Dietary-N was informed the following day by a DA-M who witnessed the incident between CNA-J and R5. On 03/17/2025 at 10:45 AM, Director of Dietary-N called DA-M via telephone. DA-M indicated on the day of the incident, dietary staff were getting ready to serve dinner, when R5 came to get ice. DA-M stated DA-M heard CNA-J saying, get away from there. DA-M then saw that CNA-J had the resident by the forearm area, then pushed the cart away aggressively trying to get the drink from R5's hand. DA-M stated CNA-J then pushed R5 and the cart, and R5 fell into the door. DA-M stepped in between resident and CNA-J. DA-M asked R5 if R5 was okay and DA-M stated R5 stated R5 was rattled. DA-M observed milk and coffee on the floor, DA-M walked resident back to R5's room. CNA-J kept yelling. DA-M spoke to DON-B and stated DON-B wasn't interested, and DON-B rolled DON-B's eyes. CNA-J proceeded to cause problems in the kitchen slamming doors and talking crap. The next day, Director of Dietary-N and DA-M went to talk to DON-B regarding CNA-J but again DON-B did not seem interested. On 03/17/2025 at 10:54 AM, Surveyor interviewed Lead Cook-P. Lead Cook-P indicated on the evening of the incident, Lead Cook-P heard commotion by the door to the dining room. Lead Cook-P indicated Lead Cook-P did not see what had occurred but indicated milk had fallen off the cart and onto the floor. On 03/17/2025 at 1:26 PM, Surveyor interviewed DON-B. Surveyor asked DON-B if an incident occurred in the dining room involving R5. DON-B indicated there was an incident possibly in December or January, involving two staff members yelling at each other and milk spilled on the floor. DON-B indicated R5 was there, CNA-J was telling R5 that R5 cannot grab milk from the cart due to infection control concerns and told resident DON-B said that. DON-B indicated DON-B spoke with both staff, and they never mentioned R5 being grabbed or pushed. DON-B indicated DON-B spoke to R5 at the time but only talked about not going into the pushcart due to infection control. [Note: R5 told surveyor that DON-B had told him the problem would be taken care of.) DON-B indicated the incident was not reported or investigated due to it being an incident between two staff members and DON-B had informed the staff members to separate. Surveyor reviewed R5's Electronic Medical Record (EMR) and noted an office visit with R5's Orthopedic Doctor on 01/13/2025 that documented, Seen for left knee pain, patient last seen for issue on 10.18.24 where he completed 3 injection series of Synvics injections. Patient was slammed into a door jam [sic] at Grande Prairie approximately 10 days ago which is when the pain began. Describes pain as sharp that radiates from the anterior of the left knee cap that radiates down the left leg. Patient rates the pain a 10/10, Patient states the pain does interfere with sleep. Patient states walking aggravates the pain. The patient does not endorse catching, popping, grinding, clicking. The patient does complain of leg buckling/giving way. Patient is not experiencing numbness/paresthesias, or gross motor weakness. The patient cannot walk for as long as they would like or exercise without pain. The symptoms aren't activity-related and don't improve with rest. The patient does have difficulty with Activities of Daily Living (ADLs) due to current symptoms. Patient denies any fever, chills, or issues with bowel/bladder functions .Assessment and Plan: Primary osteoarthritis of left knee Patient presents in office for an increase in left knee pain following an injury at his rehab facility. According the patient he was forcibly pressed into a wall in the left knee was twisted during the incident and his pain has been increased since. X-rays are negative for fracture; the knee is stable upon exam. Most likely this incident caused a flare in his arthritis for which a cortisone shot was given today .will follow up in our office as needed. On 03/18/2025 at 02:38 PM, Surveyor spoke with Registered Nurse (RN)-O from R5's Orthopedics office. RN-O indicated R5 was seen on 01/13/2025, and per R5's statement, R5 was suffering from left knee pain because of the incident involving CNA-J and R5. RN-O stated R5 called the doctor's office on 03/03/2025 complaining of still having pain in the left knee following the incident. RN-O encouraged R5 to be seen in urgent care and then RN-O then called in the complaint to APS. RN-O informed Surveyor R5 called the doctor's office again on 03/06/2025 with same complaints, and informed Surveyor RN-O called the facility to follow up which led R5 to be sent to emergency roiagnom on [DATE] for shortness of breath and edema. On 03/17/2025 at 3:22 PM, Surveyor left voice message for CNA-J requesting CNA-J call Surveyor. No return call was made. On 03/17/2025 at 3:04 PM, Surveyor asked DON-B and NHA-A about R5's Office visit note dated 01/13/2025. Surveyor asked if there was a separate incident or if this would be from the same incident in the kitchen area. DON-B indicated she would guess it is the same incident and indicated no other incidents occurred. DON-B stated the information from the visit was not brought to DON-B's attention. NHA-A stated a good guess of when the incident occurred between CNA-J and R5 would be around the time of the last annual survey. NHA-A indicated police have now been notified. On 03/18/2025 at 07:36 AM, DON-B updated Surveyor regarding the investigation into the incident involving R5 and CNA-J. DON-B stated DON-B thinks the incident occurred near the end of December and is trying to get in touch with CNA-J but has not got a call back. DON-B indicated she is attempting to pinpoint the exact date the incident occurred. Surveyor noted, DON-B stated she found a note dated 01/08/2025 by another CNA indicating kitchen staff was following CNA-J around on unit but DON-B did not follow up because DON-B is not in charge of kitchen staff, per DON-B. DON-B informed Surveyor CNA-J was upset because DON-B told CNA-J to stay out of the kitchen, but did not tell kitchen staff to stay off the unit where CNA-J was working. Surveyor noted CNA-J worked 12/21/24, 12/23/24, 12/25/24 in the dining room per the schedule, but was not scheduled for dining room after those dates. Surveyor noted CNA-J worked a total of 46 shifts from 01/01/2025 through 03/16/2025 and noted CNA-J was scheduled to work on 03/17/2025. On 03/17/2025 at 3:20 PM, DON-B informed Surveyor CNA-J was suspended as of today, pending investigation. On 03/18/2025 at 2:30 PM, Surveyor spoke with Adult Protective Services (APS)-K. APS-K informed Surveyor APS received a call through the elder abuse hotline from R5's doctor's office on 03/03/2025 regarding an abuse allegation. APS-K went to the facility on [DATE] and spoke with R5 whom indicated the incident happened near the kitchen door in the dining room. APS-K informed Surveyor R5 stated that CNA-J pushed R5 against the wall causing R5 foot pain. APS-K informed R5 APS-K would contact the Division of Quality Assurance (DQA). APS-K indicated APS-K did not speak to any staff at the facility because if a complaint is deemed credible, the complaint is sent to DQA. On 03/18/2025 at 2:54 PM, DON-B sent an email to Surveyor documenting R5 goes out for many appointments and does not give the facility the after-visit summaries for nursing to review. DON-B informed Surveyor the medical records person must then call the doctor's office to have the after-visit summaries faxed over. DON-B informed Surveyor the facility received R5's doctor office visit record from the 01/13/2025 visit with orthopedics over a month later, on 02/17/2025. DON-B informed Surveyor at the time, the document was uploaded but not given to a nurse to review. Surveyor noted that the facility did not follow up with R5's orthopedic office despite R5 being seen and reporting pain from the alleged incident on 1/13/25. The facility's failure to thoroughly investigate allegations of abuse allowed accused staff to continue working with residents following the incident resulting in the failure to safeguard residents from potential further abuse. These failures created a reasonable likelihood for serious harm thus leading to a finding of Immediate Jeopardy that began on 01/13/2025. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the Immediate Jeopardy on 03/19/2025 at 12:16 PM. The Immediate Jeopardy was removed on 3/20/25 when the facility completed the following: - R5 was interviewed by the Director of Social Services and Local Law Enforcement on 3/18/25 to verify any adverse outcomes were present. - The resident was interviewed and wants to remain at the facility and declines any referrals for other living arrangements. A thorough investigation was initiated by the Director of Nursing, Administrator, and Regional Nurse. All staff with knowledge of the incident were interviewed. - Residents that still reside at the facility who could have potentially witnessed the incident were interviewed by the Unit Manager. - An in-service education program on Investigations and Reporting will be conducted by the Regional Team Leaders. All Department Heads addressing circumstances that require reporting for timely investigations, and their responsibilities related to investigations. Abuse policies were reviewed to include all sources of abuse, investigations and reporting. - A random audit of five (5) residents/staff weekly for four (4) consecutive weeks was initiated. These residents/staff will be interviewed to ensure that any incidents are identified, properly investigated, and reported to the appropriate people. - Grievances were reviewed at the Clinical Stand-up meeting for any potential investigations, - Compliance will be monitored at the QAPI meeting until such time consistent substantial compliance has been met. The deficient practice continues at a scope/severity level of D (potential for harm/isolated) related to the following example: 50700 2.) R1 was admitted to facility on 7/10/2023 with diagnoses that include hemiplegia and hemiparesis following an unspecified cerebrovascular disease affecting R1's left dominant side, repeated falls, bipolar disorder, depression, dysphasia, cognitive communication deficit, and need for assistance with personal cares. R1's Quarterly Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating that R1's cognition was intact. Section B documented that R1 is understood and understands. Section E documents that R1 did not exhibit any behavioral symptoms. R1's Behavioral care plan, dated 7/17/2023, with a target date of 3/20/2025, documents under the intervention section: Rude, uncooperative behavior, refusals, risks versus benefits completed, caregivers to provide opportunity for positive interaction/attention. Psych services, explain all procedures to resident before starting to allow the resident time to adjust to changes, if reasonable, discuss the resident's behavior explain/reinforce why behaviors inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation intake to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Praise any indication of the resident's progress/improvement in behavior. Provide a program of activities that is of interest and accommodates resident's status. Refuse shower in skin check: a resident because of holiday, Staff encouraged to: use the buddy system, at all times, when going into resident's room. Surveyor noted that the facility documented in R1's MDS that no behaviors were exhibited but had mentions of R1's behaviors though out R1's behavioral care plan. On 3/17/2025 at 9:06 AM, Surveyor interviewed R1, who stated that Certified Nursing Assistant (CNA)-H, assisted with washing R1 up for cares. R1 stated that CNA-H washed R1's breast. R1 indicated that everyone at the facility knows R1 will do that independently. R1 stated that R1 told CNA-H, No, you don't wash me there. R1 stated CNA-H stated: Oh (R1's name). R1 indicated that CNA-H continued to wash R1's breast. R1 stated that she told CNA-H, Don't Oh (R1's name) me. R1 indicated telling CNA-H that R1 knows resident rights and that R1 will call the state to report the incident. R1 indicated this occurred on 2/27/2025 and again on 3/3/2025. R1 stated that R1 left a voicemail with the unit manager (UM)-E, and R1 indicated that the notification was left on UM-E's voicemail. R1 said, I will call the state. R1 indicated not hearing back from UM-E. On 3/17/2025 at 11:00 AM, Surveyor interviewed UM-E who indicated that UM-E will receive complaints via telephone or by voicemail. UM-E stated that R1 is one resident that will call her for complaints, but that UM-E did not get a complaint about someone inappropriately touching R1. UM-E indicated that if this was reported to UM-E, this would've been addressed right away. UM-E stated not writing down concerns, but that UM-E will address them verbally when received. UM-E stated not being part of an investigation with this matter but that Social Services (SS)-F indicated that R1 is now on the buddy system. On 3/17/2025 at 11:26 AM, Surveyor received a file from UM-E, which documented that an investigation relating to these allegations was started and that UM-E was unaware of this. Surveyor reviewed R1's electronic record, and reviewed progress notes from March 2025, but Surveyor could not locate any documentation relating to R1's behaviors and nursing staff. Surveyor reviewed behavioral charting from CNA's task list for March 2025 and noted that no behaviors were documented for R1. Surveyor reviewed the facility's investigation file, dated 3/6/2025. Both CNA-H and CNA-I had statements in the file that were similar. Surveyor noted statements from both CNAs indicated that R1 was updated on getting a bed bath and that R1 agreed. Both CNA statements documented, that R1 washed her face and neck area and that both CNA's grabbed washcloths and started to wash R1's arms and under R1's arms. Both CNA statements documented that before cleaning R1's breast, R1 stated nobody has permission to touch her breasts. It is documented on both CNA statements that R1 washed her own breasts. Surveyor reviewed statements from Social Service (SS) -F dated 3/6/2025. SS-F's statement documented that SS-F asked R1 if she had any concerns with staff, residents or cares. The statement from SS-F documented that R1 stated she has no concerns. On 3 /17/2025 at 11:46 AM, Surveyor was informed by the Nursing Home Administrator (NHA)-A, that CNA-H is now suspended. NHA-A indicated that the allegation wasn't reported before because R1 didn't say that R1 was inappropriately touched until today (3/17/25). Surveyor reviewed the complaint file that was dated 3/6/2025, and CNA-H was an active employee, working at the facility from 3/6/2025 until 3/17/2025. On 3/17/2025 at 12:39 PM, Surveyor interviewed SS-F, who indicated that R1's allegation wasn't SS-F's investigation, and that SS-F believes it was Director of nursing (DON)-B that was investigating it. SS-F indicated asking R1 if she had any concerns with cares or staff. SS-F indicated not asking R1 about being inappropriately touched, SS-F indicated only asking R1 about any care and staffing concerns. On 3/17/2025 at 12:49 PM, Surveyor interviewed Human Resources (HR)-G, who indicated CNA-H made concerned statements to HR-G. The above-mentioned statements were regarding CNA-H being worried about R1 reporting CNA-H to the state. HR-G indicated this occurred around 3/6/2025. HR-G indicated asking SS-F to go and speak with R1. HR-G stated that this was reported to Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. HR-G indicated that NHA-A asked HR-G to go retrieve some statements from staff, and HR-G collected statements and then was done with any more involvement with the investigation. On 3/17/2025, at 1:58 PM, Surveyor interviewed DON-B, who stated that all the investigation information was brought to NHA-A. DON-B indicated being informed there was conflicting statements, one CNA stated R1 washed herself and the other CNA something different. DON-B indicated not remembering what the other CNA stated and directed Surveyor to speak with NHA-A. DON-B stated that NHA-A would be the person to decide if the investigation needed to be reported. On 3/17/2025 at 2:09 PM, Surveyor interviewed NHA-A, who stated being the one that decides if something is to be reported to the state agency. NHA-A indicated that R1 denied the statements. Surveyor reviewed SS-F's statement collected from R1 on 3/6/2025 with NHA-A and there were no denied statements of allegation. Surveyor explained that SS-F was interviewed and stated SS-F did not ask R1 about being inappropriately touched. NHA-A indicated R1 wasn't directly asked about being inappropriately touched but R1 was asked about concerns with cares or staff. On 3/17/2025 at 3:09 PM, Surveyor informed NHA-A of having concerns that a thorough investigation into R1's allegation did not occur and was not reported to the state agency. NHA-A indicated NHA-A wouldn't lead someone into making a statement like that. NHA-A indicated the police are currently in the building for other residents and will also be seeing R1 for this reporting. On 3/18/2025 at 10:05 AM, Surveyor Interviewed R1, and asked R1 about feeling safe at the facility. R1 informed Surveyor that R1 is not currently scared and that R1 feels safe at the facility. R1 indicated, that the only reason R1 is not scared is because CNA-H does not work with R1 anymore. R1 stated that the facility had police talk with R1 about R1's allegation yesterday. On 3/18/2025 at 10:22 AM, Surveyor informed DON-B. of the concerns that the facility did not thoroughly investigate or report R1's allegation of potential abuse. Surveyor explained that reporting is for the allegation of abuse not that the abuse occurred. DON-B stated that NHA-A was out today, but that DON-B would pass on the information to NHA-A. No additional information was received regarding why a thorough investigation was not completed after a report from CNA-H and R1's allegation was received. No additional information received as to why CNA-H continued to work around residents and in care of residents at the facility from 3/6/2025 through 3/17/2025.

Based on interviews and record review, the facility failed to protect the residents' right to be free from verbal and or physical abuse by Certified Nursing Assistant (CNA)-J. *R5 reported that R5 was attacked in the doorway of the kitchen, in the dining room, at the facility resulting in R5 to be fearful and cautious in the facility. R5 reported left shoulder, left rib and left knee pain following the incident. R5 sought evaluation and treatment for R5's left knee pain on 01/13/2025 resulting in R5 requiring an invasive injection into R5's left knee. Findings: Findings include: The facility's policy, titled Abuse, Neglect and Exploitation, dated as reviewed/revised on 10/2024, documents: Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others nut has not yet been investigated and if verified, could be indication of noncompliance with Federal requirements related to mistreatment, exploitation, neglect, or abuse . Mistreatment means inappropriate treatment or exploitation of a resident . Physical Abuse includes, but is not limited to hitting slapping punching biting and kicking. It also includes controlling behavior through corporal punishment. Serious bodily injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization , or physical rehabilitation; or an injury resulting from criminal sexual abuse . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations . The components of the facility abuse prohibition plan are discussed herein: V. Investigation of alleged abuse, neglect and exploitation A. On immediate investigation is warranted when suspicion of abuse, neglect or expectation, or reports of abuse, neglect or exploitation occur VI. Protection of resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after an investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim in integrity of the investigation: . D. Room or staffing changes, if necessary, to protect the residents from the alleged perpetrator; E. Protection from retaliation by: . VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, Adult Protective Services and to all required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the event that caused delegation involves abuse or result in serious bodily injury, or b. Not later than 24 hours of the event that caused the allegation do not involve abuse and do not result in serious bodily injury. 1.) R5 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, unspecified dementia without disturbance psychotic disturbance mood disturbance and anxiety, pain in right knee, pain in left knee, anxiety disorder, peripheral vascular disease, pain in right wrist, pain in left shoulder and rotator cuff tear or rupture of left shoulder. R5's Annual Minimum Data Set (MDS), dated [DATE], documents that R5 is able to understand and be understood and that a staff assessment for mental status was conducted that documented R5 has a memory problem and was able to recall current season, location of own room, staff names and faces, and that he/she is in a nursing home/hospital swing bed. The MDS documents that R5 has modified independence- some difficulty in new situations only, that R5 has no behaviors/rejection of care exhibited, uses a walker, and is not on antipsychotic drug therapy. R5's Quarterly MDS, dated [DATE], documents a staff assessment for mental status was conducted and that R5 has a memory problem and was able to recall current season, location of own room, staff names and faces, and that he/she is in a nursing home/hospital swing bed. The MDS documents that R5 has modified independence- some difficulty in new situations only, that R5 has no behaviors/rejection of care exhibited, uses a walker, and is not on antipsychotic drug therapy. On 03/17/2025, at 08:50 AM, Surveyor interviewed R5. R5 informed Surveyor that R5 was attacked in the doorway to kitchen by a named staff member, later identified as Certified Nursing Assistant (CNA)-J. Surveyor asked R5 about what led up to the incident and R5 indicated being unsure and stated CNA-J is a belligerent and stupid person. R5 indicated that Adult Protective Services (APS) came to the Facility and spoke with R5. R5 unsure who notified APS and indicated there were many witnesses. R5 informed Surveyor that CNA-J told R5 that Director of Nursing (DON)-B said that R5 could not come in the kitchen. R5 indicated speaking with DON-B regarding the incident and was told it would be taken care of. R5 informed Surveyor that R5 was hurt during the incident and had pain to left rib cage, left shoulder, and left foot. R5 stated that R5 does not feel safe at the facility, that the incident is not taken care of and stated, I was abused!. R5 stated that R5 is fearful and is very careful with what R5 says and does now in the facility. Surveyor reviewed staff roster for the last name of the staff member R5 identified. Surveyor noted 2 staff with that last name, so Surveyor interviewed one of the two staff members with the same last name and was able to determine that the individual alleged to have been in altercation with R5 was CNA-J. On 03/17/2025, at 9:37 AM, Surveyor left a voice message with Adult Protective Services (APS)-K. On 03/17/2025, at 10:37 AM, Surveyor spoke with Dietary Aide (DA)-L. DA-L stated that DA-L heard about the incident involving R5, and indicated R5 will usually come to the kitchen door to get juice/milk/ice etc. at mealtimes. DA-L indicated DA-L was not working that day of incident. On 03/17/2025, at 10:42 AM, Surveyor spoke with Director of Dietary-N. Director of Dietary-N was not here the day of the incident but knows of incident involving R5. Director of Dietary-N was informed the following day by a DA-M who witnessed the incident between CNA-J and R5. Director of Dietary-N indicated DA-M is not working today but stated Director of Dietary-N could call DA-M via phone. Director of Dietary-N stated that DA-M and Director of Dietary-N spoke with DON-B together the following day. On 03/17/2025, at 10:45 AM, Director of Dietary-N called DA-M via telephone who witnessed the incident between CNA-J and R5. DA-M indicated on the day of the incident, dietary staff were getting ready to serve dinner, when R5 came to get ice. DA-M stated that DA-M heard CNA-J saying, get away from there. DA-M then saw that CNA-J had the resident by the forearm area, then pushed the cart away aggressively trying to get the drink from R5's hand. DA-M stated that CNA-J then pushed R5 and the cart, and R5 fell into the door. DA-M stepped in between resident and CNA-J. DA-M asked R5 if R5 was okay and DA-M stated R5 stated that R5 was rattled. DA-M observed milk and coffee on the floor, DA-M walked resident back to R5's room. CNA-J kept yelling. DA-M spoke to DON-B and stated DON-B wasn't interested, and DON-B rolled DON-B's eyes. CNA-J proceeded to cause problems in the kitchen slamming doors and talking crap. The next day Director of Dietary-N and DA-M went to talk to DON-B regarding CNA-J but again DON-B did not seem interested. On 03/17/2025, at 10:54 AM, Surveyor interviewed Lead Cook-P. Lead Cook-P indicated on the evening of the incident, Lead Cook-P heard commotion by the door to the dining room. Lead Cook-P indicated Lead Cook-P did not see what had occurred but indicated milk had fallen off the cart and onto the floor. On 03/17/2025, at 1:26 PM, Surveyor interviewed DON-B. Surveyor asked DON-B if an incident occurred in the dining room involving R5. DON-B indicated there was an incident possibly in December or January, involving two staff members yelling at each other and milk spilled on the floor. DON-B indicated R5 was there, that CNA-J was telling R5 that R5 cannot grab milk from the cart due to infection control concerns and told resident that DON-B said that. DON-B indicated that DON-B spoke with both staff, and they never mentioned R5 being grabbed or pushed. DON-B indicated DON-B spoke to R5 at the time but only talked about not going into the pushcart due to infection control. DON-B indicated the incident was not reported or investigated due to it being an incident between two staff members and DON-B had informed the staff members to separate. Surveyor reviewed R5's Electronic Medical Record (EMR) and noted an office visit with R5's Orthopedic Doctor on 01/13/2025 that documented, Seen for left knee pain, patient last seen for issue on 10.18.24 where he completed 3 injection series of Synvics injections. Patient was slammed into a door jam at Grand Prairie approximately 10 days ago which is when the pain began. Describes pain as sharp that radiates from the anterior of the left knee cap that radiates down the left leg. Patient rates the pain a 10/10, Patient states the pain does interfere with sleep. Patient states walking aggravates the pain. The patient does not endorse catching, popping, grinding, clicking. The patient does complain of leg buckling/giving way. Patient is not experiencing numbness/paresthesias, or gross motor weakness. The patient cannot walk for as long as they would like or exercise without pain. The symptoms aren't activity-related and don't improve with rest. The patient does have difficulty with Activities of Daily Living (ADLs) due to current symptoms. Patient denies any fever, chills, or issues with bowel/bladder functions .Assessment and Plan: Primary osteoarthritis of left knee Patient presents in office for an increase in left knee pain following an injury at his rehab facility. Corded the patient he was forcibly pressed into a wall in the left knee was twisted during the incident and his pain has been increased since. X-rays are negative for fracture; the knee is stable upon exam. Most likely this incident caused a flare in his arthritis for which a cortisone shot was given today .will follow up in our office as needed. On 03/17/2025, at 3:20 PM, DON-B informed Surveyor that CNA-J was suspended as of today, pending investigation. On 03/17/2025, at 3:22 PM, Surveyor left voice message for CNA-J requesting CNA-J call Surveyor. On 03/17/2025, at 3:04 PM, Surveyor asked DON-B and NHA-A about R5's Office visit note dated 01/13/2025. Surveyor asked if there was a separate incident or if this would be from the same incident in the kitchen area. DON-B indicated that she would guess it is the same incident and indicated no other incidents occurred. DON-B stated that the information from the visit was not brought to DON-B's attention. NHA-A stated that a good guess of when the incident occurred between CNA-J and R5 would be around the time of the last annual survey. NHA-A indicated police have now been notified. On 03/18/2025, at 07:36 AM, DON-B updated Surveyor regarding the investigation into the incident involving R5 and CNA-J. DON-B stated that DON-B thinks the incident occurred near the end of December and is trying to get in touch with CNA-J but has not got a call back. DON-B indicated she is attempting to pin point exact date the incident occurred. Surveyor noted, DON-B stated she found a note dated 01/08/2025 by another CNA indicating kitchen staff was following CNA-J around on unit but DON-B did not follow up because DON-B is not in charge of kitchen staff, per DON-B. DON-B informed Surveyor that CNA-J was upset because DON-B told CNA-J to stay out of the kitchen, but did not tell kitchen staff to stay off the unit where CNA-J was working. On 03/18/2025, at 08:37 AM, Surveyor interviewed Social Services Director (SS)-F. Social Services Director-F indicated R5's last care conference was 12/18/2025, R5 is his own person, R5 refuses Brief Interview for Mental Status (BIMS), declines psychiatric services and stated that no referrals to be seen for psych services have been made for R5. SS-F stated that R5 has no activated Power of Attorney (POA) and stated that SS-F is not aware of any situation involving allegations of abuse with R5 but would expect to be notified if there were any. Surveyor noted CNA-J worked 12/21/24, 12/23/24, 12/25/24 in the dining room per the schedule, but was not scheduled for dining room after those dates. Surveyor noted CNA-J worked a total of 46 shifts from 01/01/2025 through 03/16/2025 and noted CNA-J was scheduled to work on 03/17/2025. On 03/18/2025, at 2:30 PM, Surveyor spoke with Adult Protective Services (APS)-K. APS-K informed Surveyor that APS received a call through the elder abuse hotline from R5's doctor's office on 03/03/2025 regarding an abuse allegation. APS-K went to the facility on [DATE] and spoke with R5 whom indicated the incident happened near the kitchen door in the dining room. APS-K informed Surveyor that R5 stated that CNA-J pushed R5 against the wall causing R5 foot pain. APS-K informed R5 that APS-K would contact the Division of Quality Assurance (DQA). APS-K indicated APS-K did not speak to any staff at the facility because if a complaint is deemed credible, the complaint is sent to DQA. On 03/18/2025, at 02:38 PM, Surveyor spoke with Registered Nurse (RN)-O from R5's Orthopedics' office. RN-O indicated R5 was seen on 01/13/2025, and that per R5's statement, R5 was suffering from left kneed pain because of the incident involving CNA-J and R5. RN-O stated that R5 called the doctor's office on 03/03/2025 complaining of still having pain in the left knee following the incident. RN-O encouraged R5 to be seen in urgent care and then RN-O then called in the complaint to APS. RN-O informed Surveyor that R5 called the doctor's office again on 03/06/2025 with same complaints, and informed Surveyor that RN-O called the facility to follow up which led R5 to be sent to emergency roiagnom on [DATE] for shortness of breath and edema. On 03/18/2025, at 2:54 PM, DON-B sent an email to Surveyor documenting that R5 goes out for many appointments and does not give the facility the after-visit summaries for nursing to review. DON-B informed Surveyor that the medical records person must then call the doctor's office to have the after-visit summaries faxed over. DON-B informed Surveyor that the Facility received R5's doctor office visit record from the 01/13/2025 visit with orthopedics over a month later, on 02/17/2025. DON-B informed Surveyor that at the time, the document was uploaded but not given to a nurse to review. On 03/19/2025, at 09:43 AM, Surveyor received email from DON-B containing resident witness statements conducted on 03/19/2025, regarding the incident between CNA-J and R5. Surveyor noted the following questions lead the resident's statements, Did you witness an altercation in the dining room around Christmas time between a resident and staff member? If so, did you see the staff member push a resident into the wall? Did you see a staff member touch a resident in the dining room? If so, who was the resident and who was the staff. Describe. Surveyor noted that a resident witness statement, dated 03/19/2025, documents yes CNA-J started yelling (talking) loudly toward R5, did not see CNA-J - hit or push R5, CNA-J backed R5 down by talking to R5. Another resident statement, dated 03/19/2025, documents yes I did CNA-J was in the right and was looking out for everyone, denies R5 was pushed into the wall and indicated if R5 said that then R5 is lying, CNA-J told R5 if R5 wanted something to ask for it and moved the cart away which upset R5 because R5 does not like to be told no and indicated the kitchen staff thought they could put their two cents in. Another resident statement, dated 03/19/2025, documents the resident heard about the incident but did not witness it. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistive devices to prevent accidents for 1 (R6) of 2 residents reviewed for falls. R6 was assessed as needing bilateral enabler bars on the bed to assist with positioning and bed mobility. An enabler bar was placed on the left side of the bed. No enabler bar was placed on the right side of the bed. R6's care plan had the intervention of bilateral enabler bars until 1/7/2025 when the care plan was revised to reflect what was actually in place, the left enabler bar only. On 3/10/2025, Certified Nursing Assistant (CNA)-C was providing cares to R6 and rolled R6 away from CNA-C. R6 continued to roll to the right and fell out of bed sustaining a right hip fracture requiring surgical intervention. The post-fall intervention was to place an enabler bar to the right side of the bed, which should have been in place per the admission assessment for siderail use. Findings include: The facility's policy and procedure titled Incidents and Accidents dated 7/2024 documents: The propose of incident reporting can include: -Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. -Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences. -Alert risk management and/or administration of occurrences that could result in claims or further reporting requirements. The facility's policy and procedure titled Turing and Repositioning dated 10/2024 documents: 5. Use the appropriate number of staff to perform the tasks safely. The facility's policy and procedure titled Proper Use of Side Rails dated 10/2019 documents: General Guidelines: . 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. 6. Less restrictive interventions that will be incorporated in care planning include: a. Providing restorative care to enhance abilities to stand safely and to walk; b. Providing a trapeze to increase bed mobility; c. Placing the bed lower to the floor and surrounding the bed with a soft mat; . 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 8. The risks and benefits of side rails will be considered for each resident. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 1.) R6 was admitted to the facility on [DATE] with diagnoses of repeated falls, diabetes, cognitive communication deficit, schizophrenia, and depression. R6's Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating that R6 has moderate cognitive impairment. The MDS documented that R6 was always incontinent of bowel and bladder with total dependence for toileting hygiene and moderate assistance with bed mobility. R6's Falls Care Area Assessment (CAA) dated 10/29/2024 documented the CAA was triggered due to R6 requiring assistance for all transfers which placed R6 at an increased risk for further falls with a history of falling in the past. R6's Admit/Readmit Assessment form dated 10/23/2024 and completed by a Licensed Practical Nurse (LPN) documents under Section M: Mobility/Safety/Fall Risk/Recliner/Side rail, based on the evaluation, R6 needed a half side rail to the right and left side of the bed to promote independence with bed mobility and a consent was received for bilateral side rails. No alternatives were documented as being attempted before the side rails were installed. The LPN documented R6 could be at risk for falls due to weakness. On 10/23/2024, R6's POA signed the Informed Consent: Side Rail(s)/Mobility Bar(s) form. The form documented: An assessment was conducted to determine the appropriateness and need for side rail(s)/mobility bar(s). Side rails/mobility bars are metal or plastic bars that are attached to either on, or both sides of the bed frame, depending on the resident's needs. In some instances, side rails/mobility bars may present an inherent safety risk. In order to implement side rails/mobility bars, it must be determined that the benefits of the use of side rails/mobility bars outweighs the risk and therefore side rails/mobility bars are not a restraint for the resident. Potential benefits of side rails/mobility bars include: -The ability to aid in turning and positioning in bed. -Provides a hand hold for the resident to utilize when transferring in or out of bed. -Assist the resident to attain/maintain their highest practicable level. I understand that side rails/mobility bars are to be used only as mobility aids, and not as a physical restraint, or a way to prevent falls. I understand that the facility will continue to evaluate the need for the side rails/mobility bars in the future. If the side rails/mobility bars are no longer able to be used for their intended purpose of improving bed mobility, or as a supportive device during transfers to and from bed, then the side rails/mobility bars will be removed so they are not un unintended physical restraint. By signing below, I acknowledge that I have been provided with education regarding the risks and benefits of side rails/mobility bars. I understand the placement and use of side rails/mobility bars creates a potential for serious injury up to and including death. Despite being aware and understanding the risks, I consent to the placement of side rails/mobility bars. Surveyor noted the form did not indicate if the consent was for one or two side rails/mobility bars. R6's Activities of Daily Living (ADL) Care Plan was initiated on 10/23/2024 with the intervention right and left enabler bars to increase independent bed mobility added on 10/25/2024. This care plan and intervention was initiated by LPN Unit Manager (UM)-E. R6's At Risk for Falls Care Plan was initiated on 10/23/2025 with interventions: -Anticipate and meet R6's needs. -Be sure the call light is within reach and encourage R6 to use it for assistance as needed; R6 needs prompt response to all requests for assistance. -Ensure R6 is wearing appropriate footwear when ambulating or mobilizing in the wheelchair. -Follow facility fall protocol. -R6 needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, slide fails as ordered, handrails on walls, and personal items within reach. R6's ADL Care Plan was revised on 1/7/2025 with the intervention left enabler bar to increase independent bed mobility. This intervention was revised by LPNUM-E. Surveyor noted the right enabler bar was removed from R6's care plan. On 3/10/2025 at 9:48 AM on the SBAR (Situation, Background, Assessment, Request) form, Registered Nurse (RN)-D documented R6 had a witnessed fall. R6 had rolled out of bed and had complaints of right hip pain. R6 was unable to extend the right leg and R6 was sent to the hospital for evaluation and treatment. RN-D documented things that make the conditions or symptoms better are assist of two for bed mobility. R6's fall/incident investigation documents under the nursing description of the fall section: R6 was in bed with the bed elevated as the CNA was standing behind R6 providing incontinence cares. R6 was on the side already while cares were being performed when R6 attempted to grab the side of the bed and turn themselves more. R6 was already in an appropriate position for the CNA, but R6 attempted to roll further. R6 rolled over too far, causing R6 to fall. The interdisciplinary team (IDT) determined a long-term intervention to prevent future falls was to place a right side enabler bar as R6 was able to assist with rolling but had nothing to hold onto. R6's ADL Care Plan was revised on 3/10/2025 with the intervention left enabler bar to increase independent bed mobility - add right enabler bar. This intervention was revised by LPNUM-E. R6's At Risk for Falls Care Plan was revised on 3/10/2025 with the intervention place right side enabler bar. R6's hospital record dated 3/10/2025 documented R6 presented to the emergency department to be evaluated after a fall. R6 had a witnessed fall out of bed landing on the right side while staff was changing R6. The x-ray results showed an acute fracture of the right femoral neck. R6 underwent a right hip hemiarthroplasty to stabilize the bone and improve mobility. On 3/13/2025, R6 was readmitted to the facility. On 3/13/2025 on the Admit/Readmit Assessment form, an LPN documented in Section M: Mobility/Safety/Fall Risk/Recliner/Side rail, based on the evaluation, R6 did not need a full side rail, a half side rail, a quarter side rail, a bed bar, or an enabler on the bed. The LPN documented R6 was a low risk for falls. On 3/13/2025, R6's POA signed a second Informed Consent: Side Rail(s)/Mobility Bar(s) form. Surveyor noted the form did not indicate if the consent was for one or two side rails/mobility bars. On 3/17/2025 at 10:21 AM, Surveyor observed R6 in bed. Enabler bars were on both sides of the bed. Surveyor asked R6 how R6 was feeling. R6 stated R6 had pain in the right leg. Surveyor asked R6 if R6 was taking any pain medication and did it help. R6 stated, yes, R6 was getting medicine but it did not help very much. Surveyor asked R6 what happened that caused R6 to have pain. R6 stated the staff rolled R6 in bed and R6 fell on to the floor. Surveyor asked R6 how many staff were helping R6 when R6 fell . R6 stated one staff member was in the room. R6 stated the staff member was behind R6 cleaning R6 up. Surveyor asked R6 if the facility staff put an enabler bar on the right side of the bed. R6 said yes, they put it on the bed after R6 fell . In an interview on 3/17/2025 at 10:33 AM, Surveyor asked CNA-C if CNA-C knew who was caring for R6 on 3/10/2025 when R6 fell to the floor from bed. CNA-C stated CNA-C was doing cares with R6 when R6 fell . CNA-C stated the bed had been raised so CNA-C could do cares. CNA-C stated CNA-C rolled R6 away from CNA-C onto the side and was trying to wipe R6 when CNA-C could feel R6 rolling further away from CNA-C. CNA-C stated CNA-C told R6 to not move but R6 rolled off the bed. CNA-C thought R6 was trying to help CNA-C by turning over further. CNA-C stated CNA-C immediately got the nurse and R6 stayed on the floor until rescue personnel arrived. Surveyor clarified with CNA-C that CNA-C initially rolled R6 away from CNA-C. CNA-C stated yes. At 1:48 PM, Surveyor interviewed CNA-C regarding any education that had been provided to CNA-C after R6 fell from the bed. CNA-C stated CNA-C was educated on turning residents toward CNA-C and CNA-C stated CNA-C signed the education. In an interview on 3/17/2025 at 12:37 PM, Surveyor asked RN-D if RN-D was involved in the fall R6 had on 3/10/2025. RN-D stated RN-D was walking down the hall when CNA-C said CNA-C needed a nurse. RN-D stated CNA-C had been doing cares when CNA-C rolled R6 and R6 slid off the bed. RN-D stated R6 told RN-D R6 fell out of bed and had bumped the head. RN-D stated RN-D did a neurological check which was fine, but the hips did not feel symmetrical and R6 could not extend the right leg without grimacing. RN-D stated R6 stayed on the floor, and they called Emergency Medical Technicians (EMTs). Surveyor asked RN-D what the proper technique was for rolling a resident in bed. RN-D stated you should pull the resident towards you, and if you are on the other side of the bed, you move around the bed and pull towards you. In an interview on 3/17/2025 at 12:50 PM, Surveyor asked LPNUM-E if LPNUM-E had knowledge about R6's fall on 3/10/2025. LPNUM-E stated RN-D told LPNUM-E about the fall. LPNUM-E stated CNA-C was performing cares on R6 when R6 fell out of bed. Surveyor asked LPNUM-E how a CNA should roll a resident in bed. LPNUM-E stated CNA should pull the resident toward them. Surveyor asked LPNUM-E how the fall was reviewed. LPNUM-E stated the IDT meets and looks at the immediate intervention that was put in place and then determine a long-term intervention. LPNUM-E stated R6 only needed the enabler to the left side when R6 was admitted and they determined R6 would benefit from having an enabler on the right side as well. LPNUM-E stated an assessment for the enabler is usually done on admission. LPNUM-E stated R6's POA agreed to the second enabler. Surveyor asked LPNUM-E how often assessments are completed for enablers or side rails. LPNUM-E stated assessments are done quarterly by nursing staff. At 1:20 PM, LPNUM-E provided a Side Rail Consent form dated 3/10/2025 and a Half Side Rail/Bed Bar/Enabler Assessment form dated 3/13/2025 that had been printed from the computer charting system with hand-written answers completing the form. The assessment documented bilateral half siderail, bed bar, or enabler is not a restraint and will be utilized to enable R6 to attain to maintain their highest practicable level. The form was not in R6's medical record with no way to verify when it had been completed. In an interview on 3/17/2025 at 3:00 PM, Surveyor asked Director of Nursing (DON)-B about the hand-written assessment and consent forms LPNUM-E had provided. DON-B stated sometimes nurses handwrite the consent and wait for a signature before putting them in the record. Surveyor shared with DON-B R6 has a signed consent for the bed rails dated 3/13/2025 that was signed by R6's POA the day R6 readmitted to the facility in R6's medical record. DON-B did not know about the consent. DON-B stated R6 had only one enabler on the bed and now has two, so the second consent was needed. On 3/17/2025 at 4:35 PM, Surveyor shared with DON-B the concerns with R6's fall from bed. R6 fell from bed when CNA-C was performing cares behind R6 after rolling R6 away from CNA-C. R6's admission assessment for siderails documented bilateral enablers were needed and that was put in R6's ADL Care Plan. R6's ADL Care Plan was revised on 1/7/2025 to have a left enabler bar only with no assessment at that time to determine the need for enabler. The intervention after the fall was to put an enabler on the right side of the bed when that should have been in place with the initial admission assessment. When R6 was readmitted to the facility, the assessment for siderails documented no enablers were needed yet R6 had bilateral enablers placed on the bed. R6's fall resulted in a fractured right hip requiring surgical intervention. In an interview on 3/18/2025 at 8:56 AM, Surveyor shared with LPNUM-E the observation of LPNUM-E initiating R6's ADL Care Plan on admission with the intervention of bilateral enabler bars to R6's bed and then LPNUM-E revised R6's ADL Care Plan on 1/7/2025 to have only the left enabler bar to R6's bed. LPNUM-E stated the original assessment for siderails indicated bilateral enablers so that was why LPNUM-E put that in R6's care plan. LPNUM-E stated when LPNUM-E did a sweep of the unit to see what was actually in place on the bed, R6 only had an enabler bar on the left side so LPNUM-E revised R6's care plan to reflect what was in place. Surveyor clarified with LPNUM-E that R6 only had the left enabler bar in place since admission and LPNUM-E did not observe R6's bed until 1/7/2025, over two months after R6 was admitted . LPNUM-E stated LPNUM-E had observed R6's bed prior to that time but was not comparing the observations with R6's care plan. Surveyor noted the care plan revision was made to reflect what in place rather than the care plan driving what the assessment indicated should be in place. No additional information was provided as to why the facility did not ensure that R6 had assistive devices in place to prevent accidents for R6.

Based on interview and record review, the facility did not report 3 (R5, R1, R3 and R4) of 4 reportable incidents to the State survey agency and/or Law Enforcement within the required timeframe. The facility was made aware of an incident involving allegations of abuse that occurred involving R5 and two staff members. The facility did not report to law enforcement the allegation of potential abuse. R5 sought evaluation and treatment for R5's left knee pain following the incident. The staff member alleged to have abused R5 was allowed to work approximately 46 shifts following the incident, resulting in R5 and other residents to not be safeguarded from additional potential abuse. * On 3/3/2025, the facility investigated allegations of sexual abuse for R1 and did not update the police or state agency within the 2-hour time frame. Suspension of the accused CNA did not occur until 3/17/2025. * On 1/24/25, R3 and R4 had a resident-to-resident altercation. During the investigation, the facility did not call the police. Findings include: The facility's policy titled Abuse, Neglect and Exploitation, dated as reviewed/revised on 10/2024, documents: Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others that has not yet been investigated and if verified, could be indication of noncompliance with Federal requirements related to mistreatment, exploitation, neglect, or abuse . Mistreatment means inappropriate treatment or exploitation of a resident . Physical Abuse includes, but is not limited to hitting slapping punching biting and kicking. It also includes controlling behavior through corporal punishment. Serious bodily injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization , or physical rehabilitation; or an injury resulting from criminal sexual abuse . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; . The components of the facility abuse prohibition plan are discussed herein: . VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, Adult Protective Services and to all required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the event that caused delegation involves abuse or results in serious bodily injury, or b. Not later than 24 hours of the event that caused the allegation do not involve abuse and do not result in serious bodily injury. 1.) R5 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, unspecified dementia without disturbance, psychotic disturbance mood disturbance and anxiety, pain in right knee, pain in left knee, anxiety disorder, peripheral vascular disease, pain in right wrist, pain in left shoulder, and rotator cuff tear or rupture of left shoulder. R5's Annual Minimum Data Set (MDS), dated [DATE], documents that R5 is able to understand and be understood and that a staff assessment for mental status was conducted that documented R5 has a memory problem but was able to recall current season, location of own room, staff names and faces, and that he/she is in a nursing home/hospital swing bed. The MDS documents R5 has modified independence-some difficulty in new situations only, R5 has no behaviors/rejection of care exhibited, uses a walker, and is not on antipsychotic drug therapy. R5's Quarterly MDS, dated [DATE], documents a staff assessment for mental status was conducted and R5 has a memory problem but was able to recall current season, location of own room, staff names and faces, and that he/she is in a nursing home/hospital swing bed. The MDS documents R5 has modified independence-some difficulty in new situations only, R5 has no behaviors/rejection of care exhibited, uses a walker, and is not on antipsychotic drug therapy. On 03/17/2025 at 08:50 AM, Surveyor interviewed R5. R5 informed Surveyor R5 was attacked in the doorway to kitchen by a named staff member, later identified as Certified Nursing Assistant (CNA)-J. Surveyor asked R5 what led up to the incident and R5 indicated being unsure and stated CNA-J is a, belligerent and stupid person. R5 indicated Adult Protective Services (APS) came to the facility and spoke with R5. R5 was unsure who notified APS and indicated there were many witnesses. R5 informed Surveyor CNA-J told R5 that Director of Nursing (DON)-B said R5 could not come in the kitchen. R5 indicated speaking with DON-B regarding the incident and was told it would be taken care of. R5 informed Surveyor R5 was hurt during the incident and had pain to left rib cage, left shoulder, and left foot. R5 stated R5 does not feel safe at the facility, the incident is not taken care of, and stated, I was abused! R5 stated R5 is fearful and is very careful with what R5 says and does now in the facility. Surveyor reviewed the staff roster for the last name of the staff member R5 identified. Surveyor noted 2 staff with that last name, so Surveyor interviewed one of the two staff members with the same last name and was able to determine that the individual alleged to have been in an altercation with R5 was CNA-J. On 03/17/2025 at 9:37 AM, Surveyor left a voice message with Adult Protective Services (APS)-K. On 03/17/2025 at 10:45 AM, Director of Dietary-N called DA-M via telephone. DA-M indicated on the day of the incident, dietary staff were getting ready to serve dinner, when R5 came to get ice. DA-M stated DA-M heard CNA-J saying, get away from there. DA-M then saw that CNA-J had the resident by the forearm area, then pushed the cart away aggressively trying to get the drink from R5's hand. DA-M stated CNA-J then pushed R5 and the cart, and R5 fell into the door. DA-M stepped in between resident and CNA-J. DA-M asked R5 if R5 was okay and DA-M stated R5 stated R5 was rattled. DA-M observed milk and coffee on the floor; DA-M walked resident back to R5's room. CNA-J kept yelling. DA-M spoke to DON-B and stated DON-B wasn't interested, and DON-B rolled DON-B's eyes. CNA-J proceeded to cause problems in the kitchen slamming doors and talking crap. The next day Director of Dietary-N and DA-M went to talk to DON-B regarding CNA-J but again DON-B did not seem interested. On 03/17/2025 at 10:54 AM, Surveyor interviewed Lead Cook-P. Lead Cook-P indicated on the evening of the incident, Lead Cook-P heard commotion by the door to the dining room. Lead Cook-P indicated Lead Cook-P did not see what had occurred but indicated milk had fallen off the cart and onto the floor. On 03/17/2025 at 1:26 PM, Surveyor interviewed DON-B. Surveyor asked DON-B if an incident occurred in the dining room involving R5. DON-B indicated there was an incident possibly in December or January, involving two staff members yelling at each other and milk spilled on the floor. DON-B indicated R5 was there, CNA-J was telling R5 that R5 cannot grab milk from the cart due to infection control concerns and told resident DON-B said that. DON-B indicated DON-B spoke with both staff, and they never mentioned R5 being grabbed or pushed. DON-B indicated DON-B spoke to R5 at the time but only talked about not going into the pushcart due to infection control. DON-B indicated the incident was not reported or investigated due to it being an incident between two staff members and DON-B had informed the staff members to separate. Surveyor reviewed R5's Electronic Medical Record (EMR) and noted an office visit with R5's Orthopedic Doctor on 01/13/2025 that documented, Seen for left knee pain, patient last seen for issue on 10.18.24 where he completed 3 injection series of Synvics injections. Patient was slammed into a door jam [sic] at Grand Prairie approximately 10 days ago which is when the pain began. Describes pain as sharp that radiates from the anterior of the left knee cap that radiates down the left leg. Patient rates the pain a 10/10, Patient states the pain does interfere with sleep. Patient states walking aggravates the pain. The patient does not endorse catching, popping, grinding, clicking. The patient does complain of leg buckling/giving way. Patient is not experiencing numbness/paresthesias, or gross motor weakness. The patient cannot walk for as long as they would like or exercise without pain. The symptoms aren't activity-related and don't improve with rest. The patient does have difficulty with Activities of Daily Living (ADLs) due to current symptoms. Patient denies any fever, chills, or issues with bowel/bladder functions .Assessment and Plan: Primary osteoarthritis of left knee Patient presents in office for an increase in left knee pain following an injury at his rehab facility. According to the patient he was forcibly pressed into a wall in the left knee was twisted during the incident and his pain has been increased since. X-rays are negative for fracture; the knee is stable upon exam. Most likely this incident caused a flare in his arthritis for which a cortisone shot was given today .will follow up in our office as needed. On 03/17/2025 at 3:04 PM, Surveyor asked DON-B and NHA-A about R5's Office visit note dated 01/13/2025. Surveyor asked if there was a separate incident or if this would be from the same incident in the kitchen area. DON-B indicated she would guess it is the same incident and indicated no other incidents occurred. DON-B stated the information from the visit was not brought to DON-B's attention. NHA-A stated a good guess of when the incident occurred between CNA-J and R5 would be around the time of the last annual survey. NHA-A indicated police have now been notified. On 03/18/2025 at 07:36 AM, DON-B updated Surveyor regarding the investigation into the incident involving R5 and CNA-J. DON-B stated DON-B thinks the incident occurred near the end of December and is trying to get in touch with CNA-J but has not received a call back. DON-B indicated she is attempting to pinpoint the exact date the incident occurred. Surveyor noted, DON-B stated she found a note dated 01/08/2025 by another CNA indicating kitchen staff was following CNA-J around on unit but DON-B did not follow up because DON-B is not in charge of kitchen staff, per DON-B. DON-B informed Surveyor that CNA-J was upset because DON-B told CNA-J to stay out of the kitchen, but did not tell kitchen staff to stay off the unit where CNA-J was working. On 03/18/2025 at 08:37 AM, Surveyor interviewed Social Services Director (SS)-F. Social Services Director-F indicated R5's last care conference was 12/18/2024, R5 is his own person, R5 refuses Brief Interview for Mental Status (BIMS), declines psychiatric services and stated no referrals to be seen for psych services have been made for R5. SS-F stated R5 has no activated Power of Attorney (POA) and stated SS-F is not aware of any situation involving allegations of abuse with R5 but would expect to be notified if there were any. Surveyor noted CNA-J worked 12/21/24, 12/23/24, and 12/25/24 in the dining room per the schedule, but was not scheduled for dining room after those dates. Surveyor noted CNA-J worked a total of 46 shifts from 01/01/2025 through 03/16/2025 and noted CNA-J was scheduled to work on 03/17/2025. On 03/18/2025 at 2:30 PM, Surveyor spoke with Adult Protective Services (APS)-K. APS-K informed Surveyor APS received a call through the elder abuse hotline from R5's doctor's office on 03/03/2025 regarding an abuse allegation. APS-K went to the facility on [DATE] and spoke with R5 whom indicated the incident happened near the kitchen door in the dining room. APS-K informed Surveyor R5 stated that CNA-J pushed R5 against the wall causing R5 foot pain. APS-K informed R5 that APS-K would contact the Division of Quality Assurance (DQA). APS-K indicated APS-K did not speak to any staff at the facility because if a complaint is deemed credible, the complaint is sent to DQA. On 03/18/2025 at 02:38 PM, Surveyor spoke with Registered Nurse (RN)-O from R5's Orthopedics office. RN-O indicated R5 was seen on 01/13/2025, and per R5's statement, R5 was suffering from left knee pain because of the incident involving CNA-J and R5. RN-O stated R5 called the doctor's office on 03/03/2025 complaining of still having pain in the left knee following the incident. RN-O encouraged R5 to be seen in urgent care and RN-O then called in the complaint to APS. RN-O informed Surveyor R5 called the doctor's office again on 03/06/2025 with same complaints, and informed Surveyor RN-O called the facility to follow up which led R5 to be sent to emergency roiagnom on [DATE] for shortness of breath and edema. On 03/18/2025 at 2:54 PM, DON-B sent an email to Surveyor documenting that R5 goes out for many appointments and does not give the facility the after-visit summaries for nursing to review. DON-B informed Surveyor that the medical records person must then call the doctor's office to have the after-visit summaries faxed over. DON-B informed Surveyor the facility received R5's doctor office visit record from the 01/13/2025 visit with orthopedics over a month later, on 02/17/2025. DON-B informed Surveyor at the time, the document was uploaded but not given to a nurse to review. Surveyor noted that the facility did not follow up with R5's orthopedic office despite R5 being seen and reporting pain from the alleged incident on 1/13/25. Surveyor noted that the facility did not follow up or notify law enforcement, the administrator or the state agency of the above allegations on 1/13/25. On 03/19/2025 at 09:43 AM, Surveyor received email from DON-B containing resident witness statements conducted on 03/19/2025 regarding the incident between CNA-J and R5. Surveyor noted the following questions led the resident's statements, Did you witness an altercation in the dining room around Christmas time between a resident and staff member? If so, did you see the staff member push a resident into the wall? Did you see a staff member touch a resident in the dining room? If so, who was the resident and who was the staff. Describe. Surveyor noted that a resident witness statement, dated 03/19/2025, documents yes CNA-J started yelling (talking) loudly toward R5, did not see CNA-J hit or push R5, CNA-J backed R5 down by talking to R5. Another resident statement, dated 03/19/2025, documents yes I did CNA-J was in the right and was looking out for everyone, denies R5 was pushed into the wall and indicated if R5 said that then R5 is lying, CNA-J told R5 if R5 wanted something to ask for it and moved the cart away which upset R5 because R5 does not like to be told no and indicated the kitchen staff thought they could put their two cents in. Another resident statement, dated 03/19/2025, documents the resident heard about the incident but did not witness it. No additional information was provided. 20025 2.) Surveyor reviewed a facility investigation regarding a resident to resident physical altercation between R3 and R4. This incident was reported to the state agency. R3 was admitted to the facility on [DATE] with diagnoses of quadriplegia, type 2 diabetes, and anxiety. R3's annual MDS (minimum data set) dated 2/8/25 indicates R3 is cognitively intact and is dependent for ADLs (activities of daily living). R4 was admitted to the facility on [DATE] with diagnoses of ESRD (end stage renal disease), type 2 diabetes, and PTSD (post traumatic stress disorder). R4's quarterly MDS dated [DATE] documents that R4 is cognitively intact and independent for ADLs. The facility investigation dated 1/24/25 documents that R3 was in bed and thought R4 was trying to climb in bed with him. R3 then threw water at R4 and R4 retaliated by throwing a fan at R3 hitting R3 in the shin. The investigation reveal R4 denied trying to get in bed with R3. R4's statement indicated the room was dark and he was walking and touched R3's bed on his way to his own bed. The facility investigation indicates both residents were separated and R4 slept in a different room. Interviews were conducted with R3 and R4 and staff involved. R3 and R4 are no longer are roommates and no further incidents have occurred. The investigation does not indicate whether the police were notified of this resident to resident altercation. On 3/17/25 at 3:10 p.m., Surveyor interviewed NHA (Nursing Home Administrator)-A. Surveyor asked NHA-A if the police were notified of R3 and R4's physical altercation. NHA-A stated he thought they were called but it's obvious they weren't called because it's not documented. No additional information was provided as to why R3 and R4's resident to resident physical altercation was not reported to law enforcement. 50700 3.) R1 was admitted to facility on 7/10/2023 with diagnoses that include hemiplegia and hemiparesis following an unspecified cerebrovascular disease affecting R1's left dominant side, repeated falls, bipolar disorder, depression, dysphasia, cognitive communication deficit, and need for assistance with personal cares. R1's Quarterly Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating that R1's cognition was intact. Section B documented that R1 is understood and understands. Section E documents that R1 did not exhibit any behavioral symptoms. R1's Behavioral care plan, dated 7/17/2023, with a target date of 3/20/2025, documents under the intervention section: Rude, uncooperative behavior, refusals, risks versus benefits completed, caregivers to provide opportunity for positive interaction/attention. Psych services, explain all procedures to resident before starting to allow the resident time to adjust to changes, if reasonable, discuss the resident's behavior explain/reinforce why behaviors inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation intake to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Praise any indication of the resident's progress/improvement in behavior. Provide a program of activities that is of interest and accommodates resident's status. Refuse shower in skin check: a resident because of holiday, Staff encouraged to: use the buddy system, at all times, when going into resident's room. Surveyor noted that the facility documented in R1's MDS that no behaviors were exhibited but had mentions of R1's behaviors thoughout R1's behavioral care plan. On 3/17/2025 at 9:06 AM, Surveyor interviewed R1 who stated that Certified Nursing Assistant (CNA)-H assisted with washing R1 up during cares. R1 stated that CNA-H washed R1's breast. R1 indicated that everyone at the facility knows R1 will do that independently. R1 stated that R1 told CNA-H, No, you don't wash me there. R1 stated, CNA-H stated: Oh (R1's name). R1 indicated that CNA-H continued to wash R1's breast. R1 stated that she told CNA-H, Don't Oh (R1's name) me. R1 indicated telling CNA-H that R1 knows resident rights and that R1 will call the state to report the incident. R1 indicated this occurred on 2/27/2025 and again on 3/3/2025. R1 stated that R1 left a voicemail with the Unit Manager (UM)-E and R1 indicated that the notification was left on UM-E's voicemail. R1 said, I will call the state. R1 indicated not hearing back from UM-E. On 3/17/2025 at 11:00 AM, Surveyor interviewed UM-E who indicated that UM-E will receive complaints via telephone or by voicemail. UM-E stated that R1 is one resident that will call her for complaints, but that UM-E did not get a complaint about someone inappropriately touching R1. UM-E indicated that if this was reported to UM-E, this would've been addressed right away. UM-E stated not writing down concerns, but that UM-E will address them verbally when received. UM-E stated not being part of an investigation with this matter but that Social Services (SS)-F indicated that R1 is now on the buddy system. On 3/17/2025 at 11:26 AM, Surveyor received a file from UM-E, which documented that an investigation relating to these allegations was started and that UM-E was unaware of this. Surveyor reviewed R1's electronic record, and reviewed progress notes from March 2025, but Surveyor could not locate any documentation relating to R1's behaviors and nursing staff. Surveyor reviewed behavioral charting from CNAs' task list for March 2025 and noted that no behaviors were documented for R1. Surveyor reviewed the facility's investigation file, dated 3/6/2025. Both CNA-H and CNA-I had statements in the file that were similar. Surveyor noted statements from both CNAs indicated that R1 was updated on getting a bed bath and that R1 agreed. Both CNA statements documented that R1 washed her face and neck area and that both CNAs grabbed washcloths and started to wash R1's arms and under R1's arms. Both CNA statements documented that before cleaning R1's breast, R1 stated nobody has permission to touch her breasts. It is documented on both CNA statements that R1 washed her own breasts. Surveyor reviewed statements from Social Service (SS)-F dated 3/6/2025. SS-F's statement documented that SS-F asked R1 if she had any concerns with staff, residents, or cares. The statement from SS-F documented that R1 stated she has no concerns. On 3/17/2025 at 11:46 AM, Surveyor was informed by the Nursing Home Administrator (NHA)-A that CNA-H is now suspended. NHA-A indicated that the allegation wasn't reported before because R1 didn't say that R1 was inappropriately touched until today (3/17/25). Surveyor reviewed the complaint file that was dated 3/6/2025 and CNA-H was an active employee, working at the facility from 3/6/2025 until 3/17/2025. On 3/17/2025, at 12:39 PM, Surveyor interviewed SS-F, who indicated that R1's allegation wasn't SS-F's investigation, and that SS-F believes it was Director of Nursing (DON)-B that was investigating it. SS-F indicated asking R1 if she had any concerns with cares or staff. SS-F indicated not asking R1 about being inappropriately touched; SS-F indicated only asking R1 about any care and staffing concerns. On 3/17/2025 at 12:49 PM, Surveyor interviewed Human Resources (HR)-G, who indicated CNA-H made concerned statements to HR-G. The above-mentioned statements were regarding CNA-H being worried about R1 reporting CNA-H to the state. HR-G indicated this occurred around 3/6/2025. HR-G indicated asking SS-F to go and speak with R1. HR-G stated that this was reported to Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. HR-G indicated that NHA-A asked HR-G to go retrieve some statements from staff, and HR-G collected statements and then was done with any more involvement with the investigation. On 3/17/2025 at 1:58 PM, Surveyor interviewed DON-B, who stated that all the investigation information was brought to NHA-A. DON-B indicated being informed there were conflicting statements; one CNA stated R1 washed herself and the other CNA stated something different. DON-B indicated not remembering what the other CNA stated and directed Surveyor to speak with NHA-A. DON-B stated that NHA-A would be the person to decide if the investigation needed to be reported. On 3/17/2025 at 2:09 PM, Surveyor interviewed NHA-A, who stated being the one that decides if something is to be reported to the state agency. NHA-A indicated that R1 denied the statements. Surveyor reviewed SS-F's statement collected from R1 on 3/6/2025 with NHA-A and there were no denied statements of allegation. Surveyor explained that SS-F was interviewed and stated SS-F did not ask R1 about being inappropriately touched. NHA-A indicated R1 wasn't directly asked about being inappropriately touched but R1 was asked about concerns with cares or staff. On 3/17/2025 at 3:09 PM, Surveyor informed NHA-A of having concerns that a thorough investigation into R1's allegation did not occur and the allegation was not reported to the state agency. NHA-A indicated NHA-A wouldn't lead someone into making a statement like that. NHA-A indicated the police are currently in the building for other residents and will also be seeing R1 for this reporting. On 3/18/2025 at 10:05 AM, Surveyor Interviewed R1, and asked R1 about feeling safe at the facility. R1 informed Surveyor that R1 is not currently scared and that R1 feels safe at the facility. R1 indicated that the only reason R1 is not scared is because CNA-H does not work with R1 anymore. R1 stated that the facility had police talk with R1 about R1's allegation yesterday. On 3/18/2025 at 10:22 AM, Surveyor informed DON-B of the concerns that the facility did not thoroughly investigate or report R1's allegation of potential abuse. Surveyor explained that reporting is for the allegation of abuse not that the abuse occurred. DON-B stated that NHA-A was out today, but that DON-B would pass on the information to NHA-A. No additional information was received regarding why a thorough investigation was not completed after a report from CNA-H and R1's allegation were received. No additional information received as to why CNA-H continued to work around residents and in care of residents at the facility from 3/6/2025 through 3/17/2025.

Based on observations, interviews, and policy review, the facility failed to ensure two of two Licensed Practical Nurses (Licensed Practical Nurses (LPN) 3 and LPN 5) followed Enhanced Barrier Precautions (EBP) during medication administration for two of two residents (Resident (R) 68 and R231). Findings include: Review of the facility's revised October 2024 Enhanced Barrier Precautions policy revealed EBP would have been followed when providing high-contact resident care activities including feeding tubes and PICC (peripheral inserted central catheter) lines. During an observation on 11/13/24 at 8:50 AM of LPN3 during medication administration through a gastrostomy tube (tube inserted into the stomach) for R231 revealed she did not put on a barrier gown prior to accessing his gastrostomy tube. There was an EBP sign on R231's door and supplies beside the door. During an interview on 11/13/24 at 2:52 PM with LPN3 revealed she did not put a barrier gown on as she did not feel there was no risk of any type of infectious transmission. She agreed she should have used the barrier gown according to the policy as it was a high contact procedure. During an observation on 11/13/24 at 10:15 AM of LPN5 during medication administration through a PICC line for R68 revealed she did not put on a barrier gown prior to accessing his PICC line. During an interview on 11/13/24 at 2:30 PM with LPN5 revealed she had not worn a barrier gown as she had not thought it was necessary due to just the PICC line being accessed and not his wounds. She agreed she should have followed the policy as it was a high-risk activity. During an interview on 11/13/24 at 3:00 p.m. with the Director of Nursing confirmed LPN's 3 and 5 should have worn a barrier gown prior to the medication administration through the gastrostomy tube and PICC line. The policy for EBP had indicated both of those were high-risk activities.

Based on observations, interviews, record review, and facility policy review, the facility failed to assess two of 18 sampled residents (Resident (R) 11 and R45) for self-administration of medications. This failure led to medications being left at the bedside where they could be accessed by other residents. Findings include: Review of a facility policy titled Resident Self-Administration of Medication dated 2024 indicated .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.Residents are offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team.When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should be at a minimum consider the following.The medications appropriate and safe for self-administration.The resident's ability to ensure that medication is stored safely and securely. 14. The care plan must reflect resident self-administration and storage arrangements for such medications and CGM [Continuous Glucose Monitors] devices . 16. A re-assessment for safety at a minimum should be considered by the interdisciplinary team for the following: a. Significant change in resident's status . 1. Review of R11's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R11's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which revealed the resident was cognitively intact. Review of R11's EMR titled Care Plan located under the Care Plan tab failed to contain evidence the resident was assessed for the safe administration of medications. Review of R11's EMR failed to contain evidence that the resident was assessed for the safe administration of medications. During an interview conducted on 11/12/24 at 3:10 PM, R11 was observed with a plastic cup of several medications. The resident stated she arrived back from dialysis and needed to eat so the staff left the medications for her to take after. During an interview conducted on 11/12/24 at 3:15 PM, Licensed Practical Nurse (LPN) 2 stated medications were not to be left at the bedside and then entered R11's room. During this observation the resident told LPN2 that the medications were left by staff so she could eat her meal first. LPN2 then left the resident's room without taking the medications with him. During an interview on 11/13/24 at 10:51 AM, LPN1 stated there was no safety assessment for R11's self-administration of medications. LPN1 stated the medications were inadvertently left at the bedside by an agency nurse. During an interview on 11/13/24 at 11:22 AM, the Director of Nursing (DON) confirmed there was no safety assessment for R11 and the self-administration of medications. 2. Review of R45's annual MDS with an ARD of 07/28/24 located in the MDS tab of the EMR revealed an admitted [DATE], had a BIMS score of 15 out of 15, which indicated R45 had intact cognition and had diagnoses of unspecified asthma, uncomplicated, other specified cataract, and arthritis. Review of R45's Care Plan, revised 10/31/24, located in the EMR under the Care Plan tab revealed R45 indicated functional decline, decreased movement of BLE [bilateral extremities], increased edema. An intervention included May leave meds at bedside. Review of R45's Orders located in the EMR under the Order tab revealed Fluticasone Propionate HFA [Hydrofluoroalkane] Aerosol 110 MCG[MicroGram]/ACT 2 puff inhale orally in the morning for Wheezing, dated 04/29/22 and Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril two times a day for Allergies, dated 09/23/22. Review of R45's Self Administration of Medications, dated 12/15/22, located in the EMR under the Assessment tab revealed Resident will administer medication to self only once nurse has collected meds [medications] and provided them. Review of R45's November 2024 Medication Administration Record (MAR) located in the EMR under the Order tab revealed May leave meds at bedside., May leave meds at bedside: - Fluticasone Propionate (inhaler) - Fluticasone Propionate Suspension (nasal spray). Review of R45's Quarterly/Annual/Significant Change Assessments, dated 08/28/23, 10/30/23, 01/26/24, 02/27/24, 04/27/24, 05/07/24, 07/26/24, and 10/28/24 located in the EMR under the Assessment tab revealed a section titled Self Administration of medications included a. Does the resident desire to self administer his/her own medications? 2. No Observation on 11/11/24 at 8:51 AM, R45 was in her wheelchair in her room eating breakfast. Medications were observed on R45's overbed table. The medications included an inhaler and a bottle of nasal spray. R45 was asked if the medications were hers and R45 responded very slowly, Yes. Observation on 11/12/24 at 10:16 AM, R45 was sitting in her wheelchair in her room watching television and eating puffed chips. R45 was again observed with an inhaler on her overbed table. R45 was asked if the medication was hers and did the nurse leave it for her to use. R45 responded very slowly, Yes. On 11/12/24 at 10:22 AM, Certified Nurse Aide (CNA)2 was in R45's room. CNA2 was asked if the nurse left R45's inhaler with her every day and CNA2 stated, Yes. During an interview on 11/13/24 at 9:13 AM, LPN4 was asked if R45 can have inhaler and nasal spray medications at bedside. LPN4 stated, Yes and she's watched her before. LPN stated R45 can self-administer her medications and (R45) likes to do her puffer from her inhaler herself and the nasal spray. LPN4 was asked if there was an order for self-administration. LPN4 reviewed the EMR and stated, No order and no specifics. LPN4 was asked what the facility policy included. LPN4 stated she wasn't sure but confirmed it wasn't care planned with details such as to what medications could be left at bedside and for how long. LPN4 went on to say assessments for self-administration should be quarterly and are flagged in the EMR when they are due. During an interview on 11/13/24 at 11:02 AM, Director of Nursing (DON) was asked if she was aware R45's inhaler and nasal spray were being left with R45 in her room. The DON stated she wasn't aware. The DON was asked what her expectation was for medications left with R45 in her room. The DON stated she couldn't answer that until she looked into it. During a follow-up interview on 11/13/24 at 11:20 AM, the DON was asked how often R45's self-administration assessments were conducted as the last one was dated 12/15/22. The DON stated the Quarterly/Annual/Significant Change Assessment included the self-administration medication and confirmed the last quarterly assessment was missed but hadn't gone through all the assessments. The DON reviewed the EMR and pointed to the section that read Self Administration of medications a. Does the resident desire to self administer his/her own medications? DON stated the medications are listed on the original assessment. The DON was also asked about R45's care plan not including details about R45's self-administration. The DON confirmed the care plan only included an intervention that medications could be left at bedside but lacked what kind of medication these could be. 12679

Based on observation, interview, record review, and policy review, the facility failed to ensure leftovers were cooled properly, over easy eggs were pasteurized or cooked thoroughly for one (Resident (R)55) of one resident, and the ice machine was routinely cleaned in one of one kitchen reviewed for food handling practices. This deficient practice had the potential to cause food-borne illness and affect 32 of 33 residents who received meals prepared in the facility's only kitchen. Findings include: Review of the facility policy titled Ice Machine, revised 06/12/24, revealed Frequency: Monthly- Remove ice, Wash inside machine, Use sanitizing solution and clean cloth, Allow to air dry, Refill with ice. Review of the facility policy titled Cooling Monitor for Hazardous Foods, dated 05/01/19, revealed Food handling rules for cooling hazardous foods will be used by Dietary employees. Hazardous foods will be defined as: . eggs . Procedure: Transfer cooked product to a container(s) with a depth no greater than two inches, . Leave container uncovered or loosely covered during the cooling process, .If temperature doesn't reach 70 degrees in 2 hours, reheat to 165 degrees and try cooling process again. Review of the facility policy titled Egg Cookery and Shortage, revised 05/01/22, revealed To serve eggs free of salmonella and acceptable to the patient/patient Procedures: .Individually prepared eggs shall be cooked to heat all parts to 145 degrees F [Fahrenheit] or above. The following cooking times are recommended: . A soft egg shall not be served unless the temperature is at least 140 degrees F for 3 minutes or 145 degrees F for 15 seconds. Generally, at these temperatures, the whites are completely set, and the yolks have congealed. Pasteurized eggs in the shell may be cooked and served individually per resident's preference. 1. On 11/12/24 at 1:59 PM, the ice machine located in the kitchen was observed filled with ice and the interior contained a mold-like substance that included a collection of dark spots and light-yellow shinny substance alone the walls, door, and top. The Dietary Manager (DM) acknowledged the mold-like substances and started to wipe the inside lid. The DM was asked when the last time the ice machine was cleaned. The DM stated an outside company cleans it every six months. The DM confirmed the dietary department had not cleaned the interior since he had started his employment one and a half years ago. During an interview on 11/12/24 at 4:10 PM, the Administrator was asked if he was aware of the ice machine not cleaned routinely and a mold-like substance was present. The Administrator stated he was made aware, and then stated, it's clean now. The Administrator was asked for evidence of the last time the ice machine was cleaned by the outside company and manufacture's requirements. The Administrator provided an invoice, dated 08/03/22, from an outside company who cleaned the ice machine last. 2. On 11/12/24 at 2:09 PM, the DM was asked if there were any leftovers from breakfast or lunch. The DM stated, Yes, then pointed to a metal pan (four-inch deep stainless steel) filled with scrambled eggs in the walk-in refrigerator. The DM stated the leftover eggs were from the 11/12/24 breakfast and were taken directly from the steam table at 8:00 AM or 8:30 AM. The DM removed the pan and measured the scrambled eggs at 46 degrees F. The DM stated the eggs were prepared from pasteurized liquid eggs. The DM was asked what method the staff used to quickly cool down leftovers and if he was aware of the rule to cool food down to 41 degrees F within six hours. The DM stated, No, they usually didn't have leftovers. The DM then immediately disposed of the eggs in the trash can. 3. On 11/13/24 at 7:56 AM, during the observation of meal service in the kitchen, two shelled eggs were noted to be sitting out on the counter at room temperature. Dietary Aide (DA)1 and the DM were asked about the eggs. DA1 stated they had a resident who sometimes wanted over easy but that morning he changed to scrambled eggs. DA1 then asked if they had other residents who requested over easy fried eggs. DA1 Will stated, Yes, R55 was getting two over easy eggs, and the DA1 lifted a lid from a plate that was sitting on the steam table and showed the two fried eggs he had prepared for him. Review of R55's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/24 revealed an admitted [DATE], had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated he had intact cognition and had diagnoses type 2 diabetes mellitus, other spondylosis with radiculopathy, lumbar region, and hypertension. On 11/13/24 at 8:47 AM, R55's breakfast was delivered to his room. R55 was served two fried eggs, two slices of toast, coffee, and a sausage patty. R55 place one fried egg between two slices of toast making it into a sandwich and ate it. The second fried egg was still on the plate and a liquid yolk was present. R55 was asked if his egg yolk was runny and R55 confirmed his fried eggs were runny. During an interview on 11/13/24 at 8:53 AM, the DM was asked what eggs were used for the over easy eggs served that morning, 11/13/24. The DM went into the walk-in refrigerator and removed the box of fresh shelled eggs, placing it on to the kitchen counter. The box was noted to have a Best by 10/30 date on it and only a few eggs remained. The label on the box did not indicate the eggs were pasteurized. The DM was asked if he was aware of the requirement to use pasteurized shelled eggs for over easy fried eggs. The DM stated, No. During an interview on 11/13/24 at 1:41 PM, the Registered Dietitian (RD) was asked if she was aware of the mold-like substance observed inside the ice machine on 11/13/24 and RD stated she just heard. The RD asked if she was aware of a pan of left-over scrambled eggs not cooled down properly and RD stated, No. The RD was asked if she was aware of unpasteurized eggs being used for over easy eggs at breakfast 11/13/24 and RD stated, Yes, she heard about it 11/13/24. The RD went on to say she had only been working at the facility for about two weeks as a replacement to the full-time RD who recently left her employment with the facility. The RD was asked what her expectation was for the above sanitation issues. The RD stated to follow the cleaning schedule and regulation. The RD was asked for any past kitchen RD audits. None were provided. During an interview on 11/14/24 at 9:34 AM, the Regional Staff (RS) confirmed the box of unpasteurized eggs was discarded and pasteurized eggs were purchased.

Based on observation, interview and record review the facility did not provide adequate supervision and interventions to prevent accidents for 2 (R4 and R6) of 3 sampled Residents identified by the facility to be at risk for falls. *On 11/10/23, R4 had a fall from the toilet resulting in a skin tear to the left elbow. The facility did not complete a thorough investigation and determine a root cause analysis for R4's fall. *On 1/4/24, R6 was not transferred per plan of care (including the care sheet), which indicates the use of 2 staff assist and the use of a sit to stand. Findings Include: On 1/4/24, the facility provided Surveyors with the Incidents and Accidents policy and procedure implemented 7/23/23. Surveyor reviewed the policy and procedure and notes the following applicable: .Policy: It is the policy of this facility for staff to utilize risk management/fall packet to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a Resident. Policy Explanation: The purpose of incident reporting can include: >Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of Resident care. >Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences. >Alert risk management and/or administration of occurrences that could result in claims or further reporting requirements. >Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines: 2. Licensed staff will utilize risk management and fall packet to report incidents/accidents and assist with completion of any investigative information to identify root causes. 6. In the event of an incident or accident, immediate assistance will be provided or securement of the area will be initiated unless it places one at risk. 7. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. 8. The supervisor or other designee will be notified of the incident/accident. 9. The nurse will contact Resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital. 10. In the event of an unwitnessed fall or blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. 11. The Resident's family or representative will be notified of the incident/accident and any orders obtained or if the Resident is to be transported to the hospital. 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 15. If the incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator. 1. R4 was admitted to the facility on [DATE] with diagnoses of Unspecified Fracture of Sternum, Subsequent Encounter For Fracture, Wedge Compression Fracture of Third Thoracic Vertebra, Wedge Compression Fracture of T5-T6 Vertebra, Syncope and Collapse, Chronic Kidney Disease, Stage 3, Heart Failure, Cognitive Communication Deficit, and Need for Assistance with Personal Care. R4 had an unactivated Health Care Power of Attorney (HCPOA). R4 discharged from the facility on 11/11/23. Surveyor reviewed R4's Admission Minimum Data Set (MDS) dated [DATE] which documents R4's Brief Interview for Mental Status (BIMS) score to be an 8, indicating R4 demonstrated moderately impaired skills for daily decision making. R4's MDS also documents that R4 had range of motion impairment on both sides of upper extremities. R4's MDS also documents that R4 requires partial/moderate assistance for bed mobility, and partial/moderate assistance for toilet transfer. R4's fall care area assessment dated [DATE] documents the following: [R4] requires assistance for all transfers which places [R4] at increased risk for further falls. [R4] is at risk for falls S/P hospitalization due to syncope resulting to a fall sustaining multiple fractures to sternum, T3 and T6 including left rib fracture with pneumothorax causing generalized weakness and a decline in his functional status. [R4] is working with physical and occupational therapy for strengthening and in improving [R4's] mobility/ambulation status. [R4] requires redirection which [R4] scored an 8 on [R4's] BIMS indicating moderately impaired cognition. [R4] is able to verbalize [R4's] needs and wants when asked. Needs anticipated to maintain safety. Safety awareness will be reinforced especially to all transfers and use of call light encouraged. R4's care card indicates that R4 requires partial assist of 1 staff to move between surfaces as necessary. Be sure R4's call light is within reach and encourage R4 to use it for assistance as needed. R4 needs prompt response to all requests for assistance. Ensure that R4 is wearing appropriate footwear when ambulating or mobilizing in wheelchair. On 11/10/23 the following was added to R4's care card: do not leave unattended while in bathroom. R4 had the following applicable care plans initiated 10/20/23: R4 is at risk for falls S/P hospitalization due to syncope resulting to a fall sustaining multiple fractures to sternum, T3 and T6 including left rib fracture with pneumothorax causing generalized weakness and a decline in his functional status. Interventions include: -10/20/23 anticipate and meet R4's needs -10/20/23 be sure R4's call light is within reach and encourage R4 to use it for assistance as needed. R4 needs prompt response to all requests for assistance -10/20/23 educate R4/family/caregivers about safety reminders and what to do if a fall occurs -10/20/23 encourage R4 to participate in activities that promote exercise, physical activity for strengthening and improved mobility -10/20/23 ensure that R4 is wearing appropriate footwear when ambulating or mobilizing in wheelchair -10/20/23 R4 needs a safe environment -11/10/23 do not leave unattended while in bathroom R4 has has an Activities of Daily Living (ADLS) self-care performance deficit due to weakness and decreased mobility post hospitalization due to syncope resulting to a fall sustaining multiple fractures to sternum, T3 and T6 including left rib fracture with pneumothorax causing generalized weakness and a decline in his functional status. TOILET USE: R4 requires limited assistance by 1 staff for toileting-Initiated 10/20/23 R4's Admit/Readmit assessment dated [DATE] indicates R4 is high risk for falls. Surveyor reviewed R4's physical (PT) and occupational (OT) treatment notes from admission (10/20/23) to discharge (11/11/23). On 11/9/23 it was documented in the PT discharge summary that R4 requires supervision or touching assistance for toilet transfers. The OT discharge summary dated 11/8/23 documents R4 was provided skilled treatment interventions included instructing and training R4 in compensatory strategies. ADL retraining, toilet transfers training, facilitation of increased dynamic sitting and standing tolerance/balance, sit to stand training with verbal and tactile cues for hand and foot placement, instruction in upper body strengthening exercises, use of assistive devices and safety precautions in order to increase ADL and functional transfers independence to discharge home safely. On 11/10/23 at 6:33 AM, R4 had a fall off the toilet. Both representative and physician were notified. Neuro Checks were completed for R4. R4 sustained a small skin tear to R4's left elbow. Per family request, R4 was not to be left alone on the toilet. R4's care card and care plan were updated. On 1/3/24, Surveyor was provided the fall packet for R4's fall. Surveyor notes that the 'Post Incident Questionnaire' for R4's fall was not complete with documentation to all questions. Surveyor had to request additional information, specifically witness statements. The facility was only able to provide Certified Nursing Assistant (CNA-C) statement which documented that CNA-C had just come on shift and found R4 on the floor of the bathroom. Per CNA-C statement, R4 was last seen by the night CNA. The facility was unable to provide any other statements, specifically the CNA who may have assisted R4 to the toilet. The facility was unable to provide any documentation on what time R4 was placed on the toilet to determine how long R4 had been on the toilet. The facility did not complete a root cause analysis of R4's fall. On 1/3/24 at 1:21 PM, Surveyor interviewed CNA-C who recalled R4's call light was on when CNA-C arrived at 6:30 AM for CNA-C's shift. CNA-C reported CNA-C usually arrives before the shift to get report. CNA-C stated the night shift CNA did not indicate that R4 was on the toilet. CNA-C stated had R4 self-transferred, R4 would have fallen prior to getting on the toilet. CNA-C stated R4's wheelchair was in the bathroom. CNA-C answered R4's call light and found R4 on the floor of the bathroom. R4 had indicated R4 had slipped off the toilet. CNA-C stated R4 knew R4 was supposed to get help before attempting to get off the toilet by R4's self. On 1/4/24 at 1:54 PM, Surveyor shared the concern with Director of Nursing (DON-B) that a full thorough fall investigation was not completed including a root cause analysis of R4's fall. Statements from all involved staff were not obtained. DON-B provided no further information at this time. 20483 The Safe Resident Handling/Transfers policy last revised 10/23 under compliance guidelines includes 11. Resident lifting and transferring will be performed according to the resident's individual plan of care. 2. R6's diagnoses includes Alzheimer's Disease, dementia, hypertension, muscle weakness, and anxiety. The ADL (activities daily living) self-care performance deficit r/t (related to) Alzheimer's dementia care plan initiated 7/3/22 and revised 1/17/23 includes an intervention initiated 7/3/22 & revised 10/17/22 of *TRANSFER: I require extensive assistance by 2 staffs to move between surfaces every 2-3 hours and as necessary. The quarterly MDS (Minimum Data Set) with an assessment reference date of 9/30/23 has a BIMS (Brief Interview Mental Status) score of 1 which indicates severe impairment. R6 is assessed as requiring extensive assistance with two plus person physical assist for bed mobility & transfer, extensive assistance assistance with one person physical assist for toilet use, and does not ambulate. R6 is assessed as always incontinent of bowel and bladder. The Visual/Bedside Kardex Report as of 1/4/24 under the transferring section documents *TRANSFER: I require extensive assistance by 2 staffs to move between surfaces every 2-3 hours and as necessary. On 1/4/24 at 7:33 a.m. Surveyor observed CNA (Certified Nursing Assistant)-E in R6's room. Surveyor asked CNA-E what he was going to do. CNA-E informed Surveyor he was going to get R6 dressed and up. CNA-E placed gloves on raised the height of R6's bed and informed R6 he was going to get her ready. CNA-E unfastened the incontinence product, removed stool from R6's rectal area using a wipe, removed the incontinence product and placed a new incontinence product under R6. Surveyor noted R6 would not allow CNA-E to wipe the frontal perineal area. CNA-E fastened the incontinence product, placed pants on R6, and removed a shirt from the closet. CNA-E removed the pajama top and placed a shirt on R6. CNA-E placed the wheelchair along R6's bed, lowered the bed down and stated to R6 Ok [R6's first name] are you ready to get into the chair. At 7:48 a.m. CNA-E sat R6 on the edge of the bed telling R6 he has her and transferred R6 from the bed into the wheelchair by placing his hands under R6's axillary (armpit) and lifting R6 off the bed & into the wheelchair. Surveyor observed CNA-E did not use a gait belt or any mechanical lift. CNA-E placed slippers & sweater on R6, brushed R6's hair, washed R6's face and then wheeled R6 into the dining room. On 1/4/24 at 7:55 a.m. Surveyor asked CNA-E how he knows how to transfer a Resident. CNA-E informed Surveyor they have care sheets at the nurses station. Surveyor asked CNA-E if a Resident is transferred by a sit to stand how many staff are required. CNA-E informed Surveyor normally two people. Surveyor asked if they use gait belts at the Facility. CNA-E replied yes. Surveyor asked CNA-E why he transferred R6 by himself without a gait belt or any other transfer device. CNA-E informed Surveyor he spoke with therapy and since R6's knees are contracted they can transfer R6 with one or two assist if able. Surveyor asked CNA-E to show Surveyor the care sheets he was referring to. Surveyor then accompanied CNA-E to the nurses station where CNA-E provided Surveyor with the care sheet dated 1/3/23. This care sheet includes R6. Under the transfer section documents sit to stand x (times) 2. On 1/4/24 at 9:18 a.m. Surveyor asked Director of Rehab/PT (Physical Therapy)-D if therapy has recommended how R6 is to be transferred. Director of Rehab/Pt-D informed Surveyor R6 has not been on therapy since March 2023. On 1/4/24 at 10:57 a.m. Surveyor asked LPN (Licensed Practical Nurse)/UM (Unit Manager)-G how R6 should be transferred. LPN/UM-G informed Surveyor with a sit to stand times two (two staff). Surveyor informed LPN/UM-G of this morning's observation of CNA-E transferring R6 by himself and not using a sit to stand lift. On 1/4/24 at 1:55 p.m. Surveyor informed DON (Director of Nursing)-B of the above.

Based on interview and record review, the Facility did not ensure the medical record contained advanced directives for 1 (R5) of 5 residents. On 10/2/23 SW (Social Worker)-F received physician's statement of incapacity form from Physician-H for R5. As of 1/4/24 there has been no follow up from the Facility for a 2nd physician signature to activate R5's healthcare power of attorney. Findings include: The Residents' Rights Regarding Treatment and Advanced Directives policy last revised 10/23 under Policy Explanation and Compliance Guidelines includes 4. The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. R5's diagnoses includes dementia, hypertension, anxiety, and chronic kidney disease. The quarterly MDS (Minimum Data Set) with an assessment reference date of 11/28/23 has a BIMS (Brief Interview Mental Status) score of 12 which indicates moderate cognitive impairment. The social service note dated 9/28/23 written by SW (Social Worker)-F documents Writer introduced self and completed BIMS assessment with resident. Writer called [Physician-H's] office and faxed over HCPOA (healthcare power of attorney) to be activated. Social Services to visit as needed. The social service note dated 10/2/23 written by SW-F documents, Writer received Physician's statement of incapacity form from [Physician-H]. Writer will have second doctor sign form to complete activation of HCPOA. Social Services to visit as needed. The social service note dated 10/18/23 written by SW-F documents, Writer has not received second doctors signature to activate HCPOA. Social Services to visit as needed. Surveyor did not note any documentation after 10/18/23 regarding a second signature to activate R5's power of attorney for healthcare. On 1/3/24 at 10:00 a.m. Surveyor noted under the profile tab there is no documentation R5's power of attorney was activated. R5 is listed as the responsible party and R5's daughter is listed as emergency contact #1. On 1/3/24 at 2:13 p.m. Surveyor asked SW-F what the process is if a Resident's power of attorney needs to be activated. SW-F informed Surveyor they need to make sure the power of attorney papers have been filled out or if the Resident is able to fill out the papers. The next step is to fax over the incapacity form to their doctor or the house doctor and then get a 2nd physician signature. Surveyor asked who is responsible to ensure the 2nd signature is obtained. SW-F informed Surveyor it is the social worker. SW-F informed Surveyor they usually have the PA (physician assistant), [Name of medical group], or their own physician. SW-F informed Surveyor it may take a couple days but she will follow up. Surveyor asked SW-F if R5 has an activated power of attorney for healthcare. SW-F informed Surveyor the family wanted to possibly get the power of attorney activated. SW-F informed Surveyor she thinks the doctor didn't think it was in R5's best interest to activate her power of attorney. Surveyor asked SW-F where this documentation is as Surveyor noted there was a social service note that indicated [Physician-H] signed the activation form and then there is another social service note dated 10/18/23 that the second signature has not been received. Surveyor informed SW-F Surveyor didn't see anything after 10/18/23. Surveyor asked SW-F to look into this and get back to Surveyor. On 1/4/24 at 8:21 a.m. Surveyor spoke with SW-F regarding R5. SW-F informed Surveyor she did get Physician-H's signature and PA (Physician Assistant)-J told her & SSD (Social Services Director)-I she did not feel comfortable being the 2nd signature and PA-J was going to document that but as we can see that didn't happen. SW-F informed Surveyor she was going to have their in house psych, Psychologist-K be the 2nd signature. Surveyor asked if Psychologist-K saw R5. SW-F replied she did but her note is confusing. SW-F explained her note says she was evaluating R5 for POA activation but the note doesn't state whether R5's power of attorney should be activated or she's of sound mind and shouldn't be activated. Surveyor asked SW-F if she followed up with Psychologist-K. SW-F replied I did not. SW-F informed Surveyor Psychologist-K went out on leave and another psychologist, Psychologist-L came to the Facility so yes guess there was miscommunication. Psychologist-L's note dated 12/7/23 does not address R5's assessment for power of attorney activation & whether power of attorney should be activated or not. On 1/4/24 at 1:55 p.m. Surveyor informed DON (Director of Nursing)-B of the above.

Based on observation, interview, and record review the Facility did not obtain and provide medications to meet the needs of each resident for 2 (R5 & R1) of 3 Residents reviewed for medications. * R5's scheduled twice daily Hydrocodone-Actaminophen 5-325 mg (milligram) tablet was not available for multiple days from 10/28/23 to 11/1/23. * R1 did not receive Ertapenem Sodium (antibiotic) injection solution reconstituted 1 gram intravenously on 10/29/23 at 1:00 p.m. Findings include: 1. R5's diagnoses include dementia, low back pain, other chronic pain, and anxiety disorder. R5's physician orders include an order dated 5/5/23 of Hydrocodone-Acetaminophen oral tablet 5-325 mg (Hydrocodone-Acetaminophen) controlled drug. Give 1 tablet by mouth every morning and at bed time for chronic pain. The nurses note dated 10/31/23 at 15:26 (3:26 p.m.) documents Called [Pharmacy name] about Hydrocodone and when it will be delivered. Stated it will be delivered tonight. The nurses note dated 10/31/23 at 22:47 (10:47 p.m.) documents, Hydrocodone did not arrive with the pharmacy drop tonight. Called [Pharmacy name] 2 more times and spoke to [Name] two times to get state Hydrocodone for tonight. Both codes did not work in contingency. Resident sleeping at this time. The nurses note dated 11/1/23 at 21:59 (9:59 p.m.) documents called pharmacy, spoke to [Name]. Hydrocodone needs a new script. Called [Physician-H] and was told to call again during open hours tomorrow. Wrote note to pass it on to AM (morning) nurse tomorrow. Surveyor reviewed R5's October MAR (medication administration record) and noted R5 did not receive the scheduled Hydrocodone-Acetaminophen 5-325 mg on 10/28/23 at 8:00 a.m., 10/29/23 at 8:00 a.m., 10/30/23 at 8:00 a.m. & 8:00 p.m., and 10/31/23 at 8:00 a.m. & 8:00 p.m. According to R5's October MAR R5's pain level at 6:30 a.m. on 10/28/23 was 9, 10/29/23 was 7, 10/30/23 was 9 & on 10/31/23 was 10. Surveyor reviewed R5's November MAR and noted R5 did not receive the scheduled Hydrocodone-Acetaminophen 5-325 mg on 11/1/23 at 8:00 a.m. According to R5's November MAR R5's pain level at 6:30 a.m. was 10. On 1/3/24 at 10:14 a.m. Surveyor spoke with R5. During this conversation R5 did not voice any pain concerns to Surveyor. On 1/4/23 at 9:47 a.m. Surveyor asked LPN (Licensed Practical Nurse)-M the process for reordering narcotic medication for Residents. LPN-M explained if there is a valid script the medication can be ordered on the computer and if there isn't a valid script have to get a hold of [medical group] or the physician who prescribed the medication. Surveyor inquired if there is a certain number of pills in the blister pack that would prompt a nurse to reorder the narcotic medication. LPN-M informed Surveyor usually it's your judgement as you don't want the resident to run out of medication. On 1/4/24 at 10:44 a.m. Surveyor asked LPN (Licensed Practical Nurse)/UM (Unit Manager)-G the process for reordering narcotic medication for Residents. LPN/UM-G informed Surveyor the medication can be reordered on the computer. If the medication is not received, they call the pharmacy and ask where the medication is. LPN/UM-G informed Surveyor if a new script is required the pharmacy will let them know when they call. Surveyor asked if there is a certain number of pills in the blister pack that would prompt the nurse to reorder a Resident's medication. LPN/UM-G replied typically 5 and explained it would depend on how often the medication is given but 2 to 5 days in advance. Surveyor informed LPN/UM-G of R5 not receiving Hydrocodone-Acetaminophen 5-325 mg on 10/28/23 to 11/1/23. LPN/UM-G informed Surveyor she didn't know why it wasn't ordered. LPN/UM-G explained the nurses on the medication carts are responsible for ordering medication. LPN/UM-G informed Surveyor if a Resident requires a new script they are at the mercy of the doctor if they don't send the script. On 1/4/24 at 1:55 p.m. Surveyor informed DON (Director of Nursing)-B of the above. 2. R1 was admitted to the facility on [DATE] & discharged on [DATE]. Diagnoses include encephalopathy, urinary tract infection, infection and inflammatory reaction due to indwelling urethral catheter, morbid obesity, diabetes mellitus, neuromuscular dysfunction of bladder, chronic kidney disease, and hypertension. The hospital after visit summary printed on 10/27/23 under summary of your discharge medications includes Sodium chloride 0.9% Solution 100 mL (milliliters) with Ertapenem 1 g (gram) recon (reconstituted) Soln (Solution) 1 g. with directions to Inject 1 g into the vein daily for 10 days. Next dose due: Tomorrow 10/28/23. The nurses note dated 10/27/23 documents Resident admitted to facility. Resident signed consent forms herself. Alert and orientated X3 (times three). suprapubic cath (catheter) in place. Resident DNR (do not resuscitate) status - fax to [medical group name] for DR (doctor) signature. Right arm midline intact. NKA (no known allergies). The baseline care plan dated 10/27/23 is checked for I.V. therapy & I.V. orders. There is a handwritten notation which documents Ertapenem 1 g (gram) daily x (times) 18 day. The emar (electronic medication administration note) dated 10/29/23 at 13:05 (1:05 p.m.) documents Ertapenem Sodium Solution Reconstituted 1 gm (gram) Use 1 gram intravenously one time a day related to infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter (T83.511D) for 18 days. Pharmacy has not delivered medication yet and I cannot get a hold of pharmacy to see when it will be delivered. The nurses note dated 10/29/23 at 22:13 (10:13 p.m.) documents Resident is on the 24-hour board as a new admit. Resident is currently receiving IV (intravenous) antibiotic which is awaiting from pharmacy. Spoke with [name of medical group] on call [Name] who will be sending script to pharmacy start date is for 10/30 once daily for 10 days ending on 11/8/23. Will continue to monitor on 24-hour board. The PA (physician assistant) note dated 10/30/23 under history of present illness includes documentation of The patient was recently admitted to the hospital for altered mental status suspected to be due to acute UTI (urinary tract infection). She follows with a urologist secondary to history of neurogenic bladder and recurrent UTIs and was found to have MDRO (multi drug resistant organism) bacterial UTI. She was admitted with ID (infectious disease) and urology consult and stated on ertapenem Nursing staff reports that she missed several days of her IV antibiotics due to pharmacy not sending her medication. They deny noting any fever, chills, hematuria or other concerns. Discharge summary, admission records, EMR (electronic medical record) reviewed. patient discussed with staff. The nurses note dated 10/30/23 at 12:40 documents Writer called pharmacy regarding resident's IV abt (antibiotic). Pharmacy stated they did not have order for medication and writer informed them that resident was admitted on Friday 10/27/23 and order was sent then. Order was found by pharmacy tech. Writer asked that medication be stated out to facility. Writer spoke with PA (physician assistant) and medication to be start today and run for 18 days. Writer obtained a vial from backup and administered to resident for 1pm dose today. Will continue with plan of care at this time. This note was written by LPN/UM (Licensed Practical Nurse/Unit Manager)-G. Review of R1's October MAR (medication administration record) revealed R1 did not receive the 1300 (1:00 p.m.) dose of Ertapenem Sodium injection solution reconstituted 1 gram on 10/29/23. On 1/3/24 at 1:50 p.m. Surveyor asked LPN/UM-G how medications are ordered for a new admission. LPN/UM-G informed Surveyor once they review the medication they input the medication into the system which goes directly to the pharmacy. Certain medications like IV medications have to be faxed from the AVS (after visit summary) to the pharmacy. Surveyor inquired who follows up to ensure the medications are delivered. LPN/UM-G informed Surveyor typically herself or the nurse on the floor will call and see where the medications are if they haven't been delivered. LPN/UM-G informed Surveyor she will reach out to the pharmacy if they don't receive medications and if they don't receive a Resident's medication they will discuss this in morning report. LPN/UM-G informed Surveyor she will also update the Administrator and Corporate nurse. Surveyor asked LPN/UM-G why R1's IV antibiotic was not delivered. LPN/UM-G replied I personally don't know what happened. LPN/UM-G explained R1 came in on Friday or over the weekend and when she came in on Monday, she was told R1 didn't have the antibiotic and they had been calling the pharmacy. LPN/UM-G informed Surveyor she reached out to the pharmacy and told them she didn't the IV antibiotic stat. LPN/UM-G informed Surveyor R1 hadn't gotten a prescription from the hospital and she also reached out to the doctor regarding the missing doses. Surveyor asked LPN/UM-G if Ertapenem Sodium is in contingency. LPN/UM-G informed Surveyor they only had 1 vial. Surveyor inquired if this was the vial she pulled from contingency. LPN/UM-G replied yes. Surveyor informed LPN/UM-G of the concern of R1 not receiving Ertapenem Sodium injection 1 gram according to the AVS and orders.

Based on interview and record review the Facility did not investigate an allegation of neglect for 1 (R1) of 2 Residents reviewed for abuse. On 11/4/23, R1 alleged not being changed all morning. R1's allegation of neglect was not investigated. Findings include: The Facility's abuse, neglect and exploitation policy and procedure last revised 11/23 section V Investigation of alleged Abuse, Neglect and Exploitation documents: A. An immediate investigation is warranted when suspicion of abuse, neglect for exploitation or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g. not tampering, or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. R1's diagnoses include encephalopathy, urinary tract infection, infection and inflammatory reaction due to indwelling urethral catheter, morbid obesity, diabetes mellitus, neuromuscular dysfunction of bladder, chronic kidney disease, and hypertension. The admission MDS (Minimum Data Set) with an assessment reference date of 11/12/23 has a BIMS (Brief Interview Mental Status) score of 12 which indicates moderately impaired. R1 is assessed as being independent for eating, requiring substantial/maximal assistance for toilet hygiene & dressing, partial/moderate assistance for mobility roll left to right, and dependent for transfer. R1 has an indwelling catheter and is always incontinent of bowel. The nurses note dated 11/4/23 at 18:24 (6:24 p.m.) documents, Resident complaining about not being changed at all during the morning. Aid just changed all her sheets and blankets and got her cleaned up. No additional complaints at this time. This note was written by RN (Registered Nurse)-N. On 1/3/24 at 2:08 p.m. Surveyor asked SW (Social Worker)-F if she was ever made aware of R1 voicing a concern that she had not been changed. SW-F replied no. On 1/4/24 at 10:32 a.m. Surveyor showed LPN/UM (Licensed Practical Nurse)-G R1's 11/4/23 nurses note at 18:24 (6:24 p.m.) and asked if anyone reported to her R1 complained of not receiving cares. LPN/UM-G informed Surveyor she doesn't remember anyone reporting this. Surveyor asked if this is something which should have been reported to her. LPN/UM-G replied yes and explained staff should report if a resident is not being changed or properly taken care of and then she would have reported it to the DON (Director of Nursing)/Administrator. On 1/4/24 at 1:05 p.m. Surveyor spoke with RN (Registered Nurse)-N on the telephone. Surveyor read RN-N her nurses note on 11/4/23 at 18:24 (6:24 p.m.) RN-N informed Surveyor she wrote just what R1 said. Surveyor asked RN-N if she reported what R1 said to anyone. RN-N replied no I did not report it to management or anyone. Surveyor asked RN-N why she didn't report this. RN-N informed Surveyor she just spoke with her aides. Surveyor asked RN-N if R1 had voiced concerns prior to this about not receiving cares. RN-N replied no never heard any complaints. RN-N informed Surveyor she knows R1 was upset and had staff change her. Surveyor again asked RN-N why she didn't report this. RN-N replied I'm thinking, it's because, I just don't remember. On 1/4/24 at 1:55 p.m. Surveyor informed DON-B of R1's 11/4/23 nurses note which documented R1 complained of not being changed at all during the morning, which is an allegation of neglect, and asked if there was any documentation which would show cares were provided during the morning of 11/4/23 and if not why this wasn't investigated. On 1/4/24 at approximately 3:00 p.m. Surveyor was provided with a nurses note dated 11/4/23 at 13:28 (1:28 p.m.) which documents Resident PICC (peripherally inserted central catheter) line remains, able to make needs know, no complaint of pain, VSS (vital signs stable). On 1/4/24 at 3:21 p.m. Surveyor asked DON-B if she has any information which would show R1 received cares on 11/4/23. DON-B informed Surveyor just the note she provided to Surveyor. Surveyor informed DON-B the note she provided Surveyor did not document cares were provided to R1. Surveyor informed DON-B RN-N should have report the allegation of possible neglect and the Facility should have conducted an investigation. R1's allegation of neglect was not investigated. On 1/8/24 at 12:07 p.m. Administrator-A emailed a statement from CNA (Certified Nursing Assistant)-E dated 1/8/24 which documents, I do not remember 11/4/23 exactly; however, every day I am here, I do cares for all of my residents and assist the other CNAs when they need help. This allegation of neglect was not thoroughly investigated by the facility.

Based on interview and record review the Facility staff did not report to the Administrator & the Facility did not self report to the State agency an allegation of neglect for 1 (R1) of 2 Residents. R1's allegation of not receiving cares during the morning of 11/4/23 was not reported to the Administrator or State agency. Findings include: The Facility's abuse, neglect and exploitation policy and procedure last revised 11/23 section VII Reporting/Response documents: A. The facility will have written procedures that include: 1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. R1's diagnoses include encephalopathy, urinary tract infection, infection and inflammatory reaction due to indwelling urethral catheter, morbid obesity, diabetes mellitus, neuromuscular dysfunction of bladder, chronic kidney disease, and hypertension. The admission MDS (Minimum Data Set) with an assessment reference date of 11/12/23 has a BIMS (Brief Interview Mental Status) score of 12 which indicates moderately impaired. R1 is assessed as being independent for eating, requiring substantial/maximal assistance for toilet hygiene & dressing, partial/moderate assistance for mobility roll left to right, and dependent for transfer. R1 has an indwelling catheter and is always incontinent of bowel. The nurses note dated 11/4/23 at 18:24 (6:24 p.m.) documents Resident complaining about not being changed at all during the morning. Aid just changed all her sheets and blankets and got her cleaned up. No additional complaints at this time. This note was written by RN (Registered Nurse)-N. On 1/3/24 at 2:08 p.m. Surveyor asked SW (Social Worker)-F if she was ever made aware of R1 voicing a concern that she had not been changed. SW-F replied no. On 1/4/24 at 10:32 a.m. Surveyor showed LPN/UM (Licensed Practical Nurse)-G R1's 11/4/23 nurses note at 18:24 (6:24 p.m.) and asked if anyone reported to her R1 complained of not receiving cares. LPN/UM-G informed Surveyor she doesn't remember anyone reporting this. Surveyor asked if this is something which should have been reported to her. LPN/UM-G replied yes and explained staff should report if a resident is not being changed or properly taken care of and then she would have reported it to the DON (Director of Nursing)/Administrator. On 1/4/24 at 1:05 p.m. Surveyor spoke with RN (Registered Nurse)-N on the telephone. Surveyor read RN-N her nurses note on 11/4/23 at 18:24 (6:24 p.m.) RN-N informed Surveyor she wrote just what R1 said. Surveyor asked RN-N if she reported what R1 said to anyone. RN-N replied no I did not report it to management or anyone. Surveyor asked RN-N why she didn't report this. RN-N informed Surveyor she just spoke with her aides. Surveyor asked RN-N if R1 had voiced concerns prior to this about not receiving cares. RN-N replied no never heard any complaints. RN-N informed Surveyor she knows R1 was upset and had staff change her. Surveyor again asked RN-N why she didn't report this. RN-N replied I'm thinking, it's because, I just don't remember. On 1/4/24 at 1:55 p.m. Surveyor informed DON-B of R1's 11/4/23 nurses note which documented R1 complained of not being changed at all during the morning, which is an allegation of neglect, and asked if there was any documentation which would show cares were provided during the morning of 11/4/23 and if not why this wasn't reported to the Administrator and State Agency. On 1/4/24 at approximately 3:00 p.m. Surveyor was provided with a nurses note dated 11/4/23 at 13:28 (1:28 p.m.) which documents Resident PICC (peripherally inserted central catheter) line remains, able to make needs know, no complaint of pain, VSS (vital signs stable). On 1/4/24 at 3:21 p.m. Surveyor asked DON-B if she has any information which would show R1 received cares on 11/4/23. DON-B informed Surveyor just the note she provided to Surveyor. Surveyor informed DON-B the note she provided Surveyor did not document cares were provided to R1. Surveyor informed DON-B RN-N should have reported the allegation of possible neglect and the Facility should have conducted an investigation. R1's allegation of neglect was not report to the Administrator or State agency. On 1/8/24 at 12:07 p.m. Administrator-A emailed a statement from CNA (Certified Nursing Assistant)-E dated 1/8/24 which documents I do not remember 11/4/23 exactly; however, every day I am here, I do cares for all of my residents and assist the other CNAs when they need help. Surveyor noted RN-N should have reported this allegation to the administrator. The facility should have reported this allegation to the State Agency.

Based on observation and interview the facility did not ensure residents the right to a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect 2 of 3 units where residents were observed eating in the dining room on Garden Hall and [NAME] Hall lounge on 9/7/23 and on 9/11/23. Ten residents were served and ate their meals on delivery trays and staff was observed assisting with feeding while standing next to the resident which was not homelike. Findings include: The facility policy, entitles Serving a Meal, dated 10/01/2022, states: Residents should be encouraged to eat in the dining room . 4. Arrange the dishes and silverware so the resident can reach them easily. It is often helpful to take dishes off the tray . On 09/07/23, at 12:26 PM, Surveyor observed lunch on Garden Hall. There were 10 residents sitting in the dining room. All 10 residents had their lunch meal served on a delivery tray. All 10 residents ate their meal off of the delivery tray. The meal was not served in a homelike fashion. R4 was observed being fed by Certified Nursing Assistant (CNA)-L who was standing next to R4 while assisting with feeding. R4 was not fed by staff in a dignified/homelike manner. On 09/07/23, at 12:35 PM, Surveyor observed CNA-L wash hands and then go to another resident and start to feed the resident while standing. This resident was not fed by staff in a dignified/homelike manner. On 09/07/23, at 12:42 PM, Surveyor interviewed CNA-L who informed Surveyor that the residents do typically eat their meals off the delivery tray. Surveyor asked why the residents eat their meals off the tray and CNA-L stated that it just depends on where the resident is. CNA-L stated that if residents are in their room they eat off of the tray. Surveyor asked if residents should be eating off of a tray in the dining room and she stated, I guess not. Surveyor asked CNA-L if it was customary to stand next to a resident while assisting with feeding and she stated, I guess not. On 09/07/23, at 12:49 PM, Surveyor observed two residents eating lunch in [NAME] Hall lounge. Both residents were observed eating their meal off of a delivery tray. These meals were not served in a homelike fashion. On 09/11/23, at 08:36 AM, Surveyor observed three residents eating breakfast in [NAME] Hall lounge. These three residents were served their breakfast on a delivery tray. All three residents ate their meal off of the delivery tray. On 09/11/23, at 08:39 AM, Surveyor observed the dining room on Garden Hall. Eight residents were observed in the dining room. All residents were observed eating breakfast off of delivery trays. On 09/11/23, at 01:44 PM, Surveyor interviewed the Director of Nursing (DON)-B who informed Surveyor that residents eating in Garden dining room, main dining room and lounge spaces should not be eating their meals on delivery trays. DON-B confirmed that staff assisting a resident with feeding should be seated and comfy with the resident and not standing. Surveyor informed DON-B of observations during survey. On 09/11/23, at 03:09 PM, at the end of the meeting with Nursing Home Administrator-A and DON-B, Surveyor informed them of the multiple observations of residents eating their meals off a delivery tray and staff standing while feeding residents. The Facility did provide a copy of their policy. No additional information provided.

Based on observation, interview, and record review, the facility did not ensure that self-administration of medications was determined to be clinically appropriate for 3 (R68, R7, and R66) of 3 residents reviewed for self- administration of medications out of a total sample of 18. * R68 had Voltaren gel and Clobetasol located in room but did not have an assessment or doctors order to determine if R68 was safe to self-administer medications. * R7 had Voltaren gel located in room but did not have an assessment or doctors order to determine if R7 was safe to self- administer medications. * R66 had glucose tablets on the dresser but did not have an assessment or doctors order to determine if R66 was safe to self-administer medications. Findings include: The facility policy, entitled Resident Self-Administration of Medication, dated 10/1/2022, states: 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 safely. Policy Explanation and Compliance Guidelines: . 3. When determining if self- administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and sale for self-administration. b. The resident's physical capacity to swallow without difficulty, open medication bottles, administer injections, etc. c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for. d. The resident's capability to follow directions and tell time to know when medications need to be taken. e. The resident's comprehension of instructions for the medications they are taking, including the does, timing, and signs of side effects, and when to report to the facility. f. The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs. g. The resident's ability to ensure that medication is stored safely and securely. 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self- administration when necessary. 13. The care plan must reflect residents' self-administration and storage arrangements for such medications. 1.) R68 was admitted to the facility on [DATE] with diagnoses that include hemiplegia (right dominant side), myocardial infarction, type 2 diabetes mellitus, aphasia, and anxiety disorder. On 9/7/2023 at 7:27 AM Surveyor observed registered nurse (RN)-K during medication pass. RN-K was unable to locate R68's Voltaren gel in the medication cart. R68 stated R68 had it the room and applied the Voltaren gel themselves. RN-K was not aware R68 could apply the Voltaren gel and observed R68 put on the Voltaren gel. RN-K finished medication pass for R68 and walked out of the room leaving the Voltaren gel in R68's room. Surveyor asked RN-K how RN-K would find out if it was ok if the medication stayed in R68's room. RN-K stated RN-K was not sure and would talk with the unit manager. R68 came out of R68's room and showed RN-K that R68 also has Clobetasol cream in the room that R68 applies themselves as well. Surveyor did not observe an assessment, care plan or a physician order for R68 to self-administer R68's own medications. 2.) R7 was admitted to the facility on [DATE] with diagnoses that include osteoarthritis, blindness of the right eye, muscle wasting and atrophy, left hip replacement, and reduced mobility. On 9/7/2023 at 7:57 AM Surveyor observed RN-K during medication pass. RN-K was unable to locate R7's Voltaren gel. When RN-K was administering medications, R7 stated the Voltaren gel was in a drawer in R7's dresser. R7 stated it is kept there so when R7 has pain it can be applied. Surveyor asked R7 if R7 applies the Voltaren gel themselves. R7 stated that R7 asks other people to do it. Surveyor asked R7 what other people apply the Voltaren gel. R7 replied that staff and sometimes family. RN-K was not aware if R7 could have Voltaren gel left in R7's room. RN-K finished medication pass for R7 and left the Voltaren gel in R7's room. RN-K stated RN-K will notify the unit manager. Surveyor did not observe an assessment, care plan or a physician order for R68 to self-administer R7's own medications or to keep medications in R7's room. On 9/7/2023 at 10:34 AM Surveyor interviewed licensed practical nurse, unit manager (LPNUM)-J who stated self-administration of medications should be care planned and the resident is educated on where the medications need to be kept in the bedroom and demonstrate how to take the medication and when. Surveyor asked LPNUM-J if R68 or R7 were ever assessed to keep ointments in R68 and R7's rooms, LPNUM-J replied R7 was never assessed and felt R68 had an assessment prior but would have to investigate it more. On 9/7/2023 at 11:10 AM Surveyor interviewed director of nursing (DON)-B who stated R68 and R7 should not have had the ointments in their room because they did not have assessments completed. DON-B stated self-administration of medications should be care planned but not always put on the MAR. Surveyor asked DON-B if staff is unaware if a resident is able to self-administer, what should happen to the medication. DON-B stated the nursing staff should remove the medication from the resident's room and bring it to the attention of the unit manager or DON to further investigate. On 9/7/2023 at 3:01 PM Surveyor told DON-B and nursing home administrator (NHA)-A of above concerns regarding R68 and R7 having medications in room without being assessed to self-administer the medications. No further information was provided at this time. 40533 3.) R66 was admitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes Mellitus, Chronic Diastolic (Congestive) Heart Failure, Lymphedema, Peripheral Vascular Disease, and Cellulitis. R66's admission MDS (Minimum Data Set) dated 07/24/23, documents a BIMS (Brief Interview of Mental Status) score of 15, indicating that R66 is cognitively intact for daily decision making. On 09/06/23, at 10:01 AM, Surveyor observed a bottle of glucose tablets on the bedside dresser of R66's room. Surveyor noted the bottle of tablets and asked R66 about them. R66 confirmed that R66 would self-administer the glucose tablets when needed. On 09/07/23, Surveyor reviewed the EHR (Electronic Health Record) for R66 and noted there was no self-administration of medication assessment conducted by the IDT (Interdisciplinary Team) related to the observed glucose tablets. Surveyor also noted R66 did not have a physician's order for the glucose tablets. On 09/11/23, at 08:34 AM, Surveyor observed R66 in their room sitting up in a wheelchair, eating their breakfast meal. Surveyor noted the bottle of glucose tablets remained on the bedside dresser. On 09/11/23, at 08:43 AM, Surveyor interviewed Director of Nursing (DON) - B to ask for documentation related to R66 being assessed for self-administration of medication. DON-B stated she would check. On 09/11/23, Surveyor reviewed R66's medical record and noted a self-administration of medication assessment was completed earlier that morning on 09/11/23 at 9:17 AM by RN (Registered Nurse) - G that was only related to Latanoprost Eye Drops, not for Glucose Tablets. On 09/11/23 at 12:32 PM, Surveyor interviewed R66 who stated that staff put my tablets in the drawer because I'm not supposed to have them. Surveyor observed R66's dresser had a top drawer that contained a key lock, but the second drawer was open and pulled out. Surveyor observed that the glucose tablets were clearly visible within the drawer due to it being propped open. R66 told Surveyor staff gave them a direction to use the call light prior to taking the glucose tablets. R66 explained that when they feel blood sugar dropping, it is easier to take the tablets. R66 confirmed that the bottle of tablets had been in the room since arrival to the facility. On 09/11/23, at 12:58 PM, Surveyor interviewed Registered Nurse (RN) Unit Manager - F, to ask about R66's self-administering medications. RN Unit Manager - F informed Surveyor that R66 has not been assessed to self-administer. We have taken some meds (medications) out of the room. They're in the med fridge right now. R66 has family that brings things in. We told R66 the rules that we are supposed to supply the medications and everything else. On 09/11/23, at 1:24 PM, Surveyor interviewed DON-B regarding R66. Surveyor asked if there was an assessment for self-administration of medications for R66. DON-B explained they did not see a self admin for R66. RN-G spoke to R66 today. Before that we did not have anything. RN-G went in and assessed R66 today because prior to, we had the issue with the Voltaren gels. They did a whole house sweep of anything that would be in R66's room. They went in today and saw R66's eye drops. RN-G went in and spoke with R66 about it and went over the eye drops. R66 was not assessed for the glucose tablets. What was discussed with R66 per RN-G, R66 was not assessed for that, so those were removed. We have no orders for those glucose tablets. Surveyor explained to DON-B the concern that after the sweep of the resident rooms this Surveyor observed glucose tablets in R66's dresser drawer that was propped open. DON-B stated that she was wondering if R66's family is bringing those in. DON-B stated R66 was educated today that they should not take the glucose tablets when they do not know what their blood sugar is. Surveyor informed DON-B of the multiple observations of the glucose tablets in R66's room without a physician's order and without an assessment to evaluate if R66 is safe to self-administer such medication. On 09/11/23, Surveyor was provided documentation from facility that RN-G noted resident is not to keep OTC (over the counter) glucose tablets at bedside. OTC glucose tablets removed from resident's room and given to nursing staff.

Based on observation, interview and record review, the facility did not ensure 1 (R20) of 19 sampled residents were free of from accident hazards and were provided supervision and assistive devices to prevent avoidable accidents. R20's call light was observed laying on the floor and not within reach and their bed was not at the lowest level as identified as a fall prevention intervention in R20's care plan. Findings Include: R20 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction, Type 2 Diabetes, Aphasia Following Infarction, Dysphasia, and Cognitive Communication Deficit. R20's Quarterly Minimum Data Set (MDS) dated [DATE] indicates that a BIMS (Brief Interview for Mental Status) could not be performed for R20 due to cognitive deficits. The MDS further documents R20 requires extensive assistance of two+ person physical assistance for bed mobility, and total dependence of two+ person physical assistance for transferring. R20's care plan, dated 05/10/23, with a target date of 11/14/23, documents interventions for falls that include in part: -Fall mat to bedside while resident is in bed, bed in lowest position. Date Initiated 07/20/23; -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 05/10/2023 On 09/06/23, at 12:58 PM, Surveyor observed R20 in bed with the television on. R20 pointed at the floor and patted the mattress. R20 looked at surveyor but did not speak. Surveyor observed that R20 had a fall mat in place beside the bed. Surveyor observed R20's call light was on the floor and not within reach. On 09/06/23, at 03:32 PM, Surveyor observed R20 in bed watching television that is placed to the right of R20. Surveyor observed R20's call light on the floor, on the left side of the bed, and not within reach. Surveyor noted that R20's bed was raised to surveyor's waist level, approximately the height of a bedside table and not in the lowest position as indicated on the care plan. On 09/07/23, at 07:42 AM, Surveyor observed of R20 in their room. R20's call light was attached to the left side of the bed, wrapped around the left rail and within resident's reach. The bed was observed to be at waist level of surveyor and not in he lowest position per the care plan. On 09/11/23, at 08:42 AM, Surveyor observed R20 in bed. R20's call light was clipped to R20's night gown. Surveyor noted that the bed was not in the lowest position, but at surveyor's waist level. On 09/11/23, at 10:18 AM, Surveyor observed R20 lying in bed with the call light clipped to their hospital gown. Bed is noted at surveyor's waist level and not at the lowest position as care planned. Fall mat in place at right side of bed. On 09/11/23, at 10:22 AM, Surveyor spoke with Certified Nursing Assistant (CNA)- H, in the hallway just outside of R20's room, to ask about R20's needs with call lights and fall interventions. CNA-H explained that staff keep R20's call light close to R20's body. Aides reposition R20 every 2 hours. When R20 is in the room, we clip the call light to R20's gown. The only problem is, we can only converse with yes or no questions. I have not seen R20 try to remove it (call light). R20 only wants it in a specific area. CNA-H and Surveyor observed R20's current bed height. CNA-H stated R20's bed should be at the lowest level when in bed and it currently was not in the lowest position. CNA-H tells surveyor that after R20's cares were done, it (bed) may not have been moved back to the lowest position. CNA-H informs surveyor that R20 did have 1 fall because R20 tried to get up. On 09/11/23, at 1:22 PM, Surveyor spoke with Director of Nursing (DON)-B and informed her of the observations of R20's bed being at waist level during multiple observations and their call light laying on the floor out of the resident's reach. DON-B informed Surveyor that R20's bed is to be at the lowest level. Surveyor described observations and concerns regarding the level of the bed and call light. On 09/11/23, at 03:37 PM, Surveyor observed R20 to be in bed. Surveyor observed R20's bed had been lowered, flat to the ground. Resident waved to Surveyor.

Based on interview and record review, the facility did not ensure residents received treatment and care based on a comprehensive assessment in accordance with professional standards of practice for residents experiencing changes in condition and failed to assess non-pressure wounds weekly for 2 of 7 residents (R1 and R3) reviewed for changes in condition. *R1 was observed on the floor mat next to their bed covered with emesis on [DATE]. R1 was assisted back to bed. A Registered Nurse did not perform an assessment at the time of R1's fall. R1 was found several hours later in bed with severe facial bruising and lethargy. A Registered Nurse did not conduct an assessment of R1 at this time. R1 was later found pulseless and not breathing. R1 expired at the facility on [DATE]. The facility's failure to have a licensed professional (RN) comprehensively assess residents (R1) who were having a change in condition, the failure of the facility to have licensed professional staff monitoring residents with changes in condition, the failure to closely monitor R1's neurological status after falling out of bed, and failure to update a physician after R1's fall on [DATE] created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on [DATE] at 3:35 PM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement and monitor the effectiveness of their removal plan and as evidenced by; *R3 fell on [DATE] and on [DATE]. The facility did not conduct neuro checks after the falls. In addition, R3 had multiple non pressure wounds to the left hip, bilateral lower extremities (left shin, right leg, left leg,) and right upper extremity where non pressure wound assessments were not completed. Findings include: R1 was admitted to the facility on [DATE] with diagnoses of left hip dislocation, lymphedema, and malnutrition. R1's MDS (Minimum Data Set) Admission Assessment with an assessment reference date of [DATE] documents a BIMS (brief interview mental status) score of 6 which indicates R1 has severe cognitive impairment with daily decision making skills. R1 required extensive assistance with a one person physical assist for bed mobility, transfers, & toilet use, and was non-ambulatory. Surveyor reviewed R1's progress notes. On [DATE], R1 was noted to not have had a bowel movement in approximately 2.5 days. A bisacodyl suppository was administered by LPN (Licensed Practical Nurse)-M. On [DATE] at 4:15 AM, CNA (Certified Nursing Assistant)-N noted R1 on a floor mat next to their bed covered with emesis. CNA-N and LPN-M assisted resident back to bed at this time and cleaned R1's body and face. On [DATE] at 6:36 AM, LPN-M documented, Emesis x2 this shift. PRN (as needed)suppository given w (with) no results. NP updated. Enema x1 given as instructed. No results at this time. Resident positioned on side. HOB (head of bed) elevated. Bed in low position. LPN-M did not notify the on-call NP about resident R1 being observed on the floor mat. LPN-M did not report observations of resident on the floor to oncoming day shift nursing staff. LPN-M is no longer employed by the facility and was not available for interview at the time of this survey. On [DATE] at 11:45 AM, Surveyor conducted an interview with CNA-N. CNA-N told Surveyor R1 had been restless throughout the night shift on [DATE] and they had been checking on R1 approximately every 15 minutes that night to make sure R1 was ok. CNA-N went to take a scheduled break and notified LPN-M that they would be off of the Garden unit where R1 resides. When CNA-N returned from their break at approximately 4:15 AM, they went to check on R1, who was discovered on a floor mat next to their bed covered with emesis. CNA-N notified LPN-M immediately to come to R1's room. CNA-N told Surveyor the night shift LPN-M conducted vital signs and did check resident's neurological status when they were discovered on the floor mat. CNA-N did not note any obvious injuries to R1 at the time of the fall. Surveyor asked CNA-N if they had been asked to complete any sort of witness statement or documentation regarding R1 being observed on the floor? CNA-N told Surveyor they were not asked to write up any statements related to observations of resident on the floor or to participate in a fall investigation. On [DATE] at 12:35 PM, Surveyor conducted an interview with CNA-O. CNA-O had arrived at the facility on [DATE] at approximately 6:40 AM. CNA-O told Surveyor they had asked LPN-M if there was anything new going on with residents on the unit since when CNA-O worked on [DATE] LPN-M did not report anything new to CNA-O. CNA-O recalled arriving to R1's room at approximately 7:45 AM to provide care. CNA-O noted a raised lump and discolorations to the left side of R1's face and R1's lower lip with dried blood. CNA-O told Surveyor that R1 did not look right at all and was very sleepy. CNA-O reported to RN-I immediately about R1's change of condition. RN-I went to R1's room at this time and observed R1's condition including facial injuries. CNA-O saw that RN-I reported R1's status to LPN Unit Manager-D at this time. LPN Unit Manager-D did not go to R1's room at this time but told RN-I they would let DON-B know about R1 at the facility's morning meeting. Surveyor asked CNA-O if RN-I had taken R1's vital signs or conducted an assessment of R1 or any neurological exam? CNA-O told Surveyor they did not witness anyone going to take vital signs or perform any type of assessment until approximately 9:00 AM when LPN-F came to R1's room with a vitals cart. On [DATE] at 1:30 PM, Surveyor conducted interview with LPN-F. LPN-F told Surveyor that they had been assigned to work between 2 units on [DATE]. LPN-F was assigned to work on the [NAME] unit and take a portion of the Garden unit also. R1 was residing on the Garden unit on [DATE]. LPN-F had been working on the [NAME] unit at the beginning of their shift to obtain blood sugar readings and administer insulin to their diabetic patients before breakfast. On [DATE] at approximately 9:00 AM, LPN-F was told by RN-I to go to R1's room and take R1's vital signs. LPN-F noted R1 with extensive facial discolorations and lethargy, and a Blood Pressure reading was taken at this time which showed ,d+[DATE]. Writer left to speak with LPN Unit Manager-D to report their serious concerns. At approximately 9:15 AM, LPN-F was directed by LPN Unit Manager-D to reach out to R1's power of attorney for further direction and update R1's doctor to see how to further proceed. LPN-F went back to check on R1 to retake vital signs at approximately 10 AM. At this time, LPN-F noted no chest rise when entering and checked for pulse which was absent. LPN-D knew that R1 had a Do Not Resuscitate order in place and did not attempt life saving measures at this time. LPN-F notified R1's doctor and power of attorney at 11:00 AM about resident expiration. R1's remains were released to the funeral home approximately 30 minutes later. Surveyor asked LPN-F if they knew why RN-I had not assessed R1 prior to LPN-F coming into R1's room when CNA-O reported R1's serious change of condition at approximately 7:45 AM? LPN-F told Surveyor that they are not sure why an assessment wasn't conducted when RN-I became aware of R1's change of condition and injuries. LPN-F told Surveyor that as an LPN, they would not be allowed to assess residents as it is out of their scope of practice as an LPN. On [DATE] at 2:30 PM, Surveyor interviewed RN-I. Surveyor asked RN-I if they had conducted any assessment for R1 on [DATE] when CNA-O came with serious concerns related to R1's physical and neurological status? RN-I told Surveyor No. Surveyor asked if a resident is noted with a change of condition whether or not an RN should assess the resident? RN-I told Surveyor that they had not been assigned to R1 that day so when they reported to LPN Unit Manager-D, they figured that LPN Unit Manager-D would take care of the next steps to help R1. Surveyor asked why RN-I wouldn't have decided to assess R1 at this time as LPNs or LPN Unit Manager-D would not be able to assess R1 as they function as LPNs? RN-I told Surveyor that it did not occur to RN-I to conduct an assessment of R1 including vital signs, full body assessment, and neurological checks. Surveyor noted approximately a 1 hour and 15 minutes gap before vital signs were obtained by assigned LPN-F which showed a low blood pressure reading of ,d+[DATE]. Surveyor reviewed a police report related to R1's expiration at facility on [DATE]. On [DATE], per police report, an Anonymous staff member went to the police department and reported R1's death seemed suspicious and they were concerned about the injuries to R1's face. An investigation was initiated at the facility by the police department. The county medical examiner performed an exam of R1's corpse. The facility confirmed LPN-M did not initiate a fall investigation for R1's fall, failure to perform neurological checks, and did not report the observation of R1 on the floor to oncoming nursing staff. On [DATE] at 12:25 PM, Surveyor conducted interview with DON (Director of Nursing)-B. Surveyor asked DON-B if they had conducted any assessment of R1 on [DATE]? DON-B told Surveyor that they had worked with R1 on the evening of [DATE] and did not note any injuries or any abnormalities in R1's behavior that evening. DON-B did not conduct an assessment of R1 on [DATE]. Surveyor asked if a resident experiences a change of condition or an unwitnessed fall from bed if they should have an assessment conducted by an RN, including neurological checks? DON-B responded that they had not been aware of R1's fall from bed on [DATE] until conducting further investigation into R1's death and that LPN-M did not conduct a fall investigation. Surveyor shared concerns that RN-I did not respond accordingly to R1's unexplained facial discolorations and altered mental status when CNA-O reported concerns on [DATE]. Surveyor shared concerns that no vital signs were obtained for R1 until approximately 1 hour and 15 minutes after change of condition was reported to RN-I. DON-B did not have any additional information at this time. On [DATE] at 12:45 PM, Surveyor made NHA (Nursing Home Administrator)-A aware of concerns related to R1's unwitnessed fall on [DATE] with no RN assessment, no ongoing neurological checks, and the facility's failure to respond to R1's change of condition on [DATE] in accordance with standards of practice. No additional information was provided. The facility's failure to conduct ongoing neurological checks after R1 fell , the failure to notify the MD/NP of resident being found on the floor mat, the failure of the LPN to notify the oncoming first shift of R1's fall, and the failure to complete an RN assessment of R1 when a change in condition was noted created a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when: * The Director of Nursing (DON)/Designee provided education to all nursing staff on recognizing a change in condition. This education includes what is considered a change in condition, reporting and assessment by RN with MD notification. * The Medical Director reviewed the deficient practice and reviewed the facility's policy with recommendation of changes. The Medical Director reviewed the staff education provided. All nursing staff was educated on the facility policy and procedure regarding notification of changes. The training included Nursing staff to complete the SBAR (Situation, Background, Assessment, Recommendation) and notification of change training handouts with competency and any change in condition will be clearly identified in the medical record with plan of action. All changes in conditions will be placed on the 24 hour board for shift to shift communication with follow up with nursing management team. * The DON/Designee provided education to LPNs/RNs on understanding the scope of practice. The LPNs will work under general supervision with delegation of tasks from an RN. RNs are to be consulted for any assessments needed. This will include onsite/phone triage. * The DON/Designee provided education to all licensed nursing staff on falls and management of such. This education included defining details of falls, steps in the procedures, and documentation requirements. Staff completed Relias training on About Falls which included handouts with competency. Education was provided on the policy and procedures including assessing falls and their causes, interventions, notifications, and documentation requirements. * On [DATE], the facility reviewed policies on Changes in Condition, Falls, MD notification, and prompt RN assessments. Policies and systems were reviewed and updated with the Medical Director to ensure they meet the current standards of practice. * Audits have been developed. Change in condition audits consist of the SBAR, prompt RN assessment, MD family/representative notification, orders and follow up. DON/Designee will complete audits daily for two weeks, three times a week for four weeks, and then weekly x three months. * All change in condition/audits will be reviewed at morning meeting and afternoon clinical. Any policy deviations will be immediately corrected. * Audits will be reviewed by the QAPI (Quality Assessment Performance Improvement) committee until such time compliance is achieved as determined by the committee. * The facility assessments/policies will be updated and reviewed as needed with partnership of the Medical Director. The deficient practice continues at a scope and severity level of E (potential for harm/pattern) as evidenced by: 20483 2. R3 was admitted to the facility on [DATE], was hospitalized from [DATE] to [DATE], and expired in the facility on [DATE]. R3 was reviewed as a closed record review. R3's diagnoses included heart failure, atrial fibrillation, depressive disorder, anxiety disorder, diabetes mellitus, hypertension, and fracture of left femur. R3 was receiving IV (intravenous) Vancomycin and oral antibiotics for left hip infection upon admission. The impaired tissue integrity care plan initiated [DATE] has the following interventions: * Assess site of impaired tissue integrity and its condition. Initiated [DATE]. * Monitor site of impaired tissue integrity w (with) tx (treatment) and weekly shower for color changes, redness, swelling, warmth, pain, or other signs of infection. Initiated [DATE]. * Provide skin tissue care as needed. Initiated [DATE]. * Treatments as ordered. Initiated [DATE]. The admission MDS (Minimum Data Set) with an assessment reference date of [DATE] documents a BIMS (Brief Interview Mental Status) score of 14 which indicates resident is cognitively intact. R3 requires extensive assistance with one person physical assist for bed mobility, transfers, & toilet use and does not ambulate. R3 is coded yes for fracture related to fall in 6 months prior to admission and has not fallen since admission. R3 is coded as having 0 venous or arterial ulcers. Neuro checks The nurses note dated [DATE] at 10:16 p.m. documents: Writer called to residents room, reported fall. Resident found sitting on the floor on her buttocks with her back against the edge of the bed and legs outward in front of her. Resident stated she was self transferring from the wheelchair to bed and fell , landing on her left hip. Neuro check WNL (within normal limit). Denies hitting her head. ROM (range of motion) to bilateral upper extremities WNL, hand grasps equal. ROM to bilateral lower extremities not attempted, resident yelling out in pain stating pain in her left hip. Foot presses equal. Left hip is residents surgical hip, S/P (status post) non-union of left intertrochanteric femur fracture and removal of hardware on [DATE]. Resident to be sent to [Hospital name] E.R. (emergency room ) for evaluation. Husband [name] notified. Call placed to Dr. [name], MD (medical doctor) paged. Awaiting call back. The nurse's note dated [DATE] at 3:52 a.m. documents: Resident back from [Hospital name] ER, VS (vital signs) stable BP (blood pressure) ,d+[DATE], P (pulse) 75, Temp (temperature) 97.3, O2 (oxygen) 98%, BS (blood sugar) check 128. Res (Resident) c/o (complained of) pain to L (left) knee at a pain level 8 in a scale from ,d+[DATE], PRN (as needed) med (medication) admin (administered). ER imaging showed no fx (fracture). ER Dx (diagnosis) Hypoglycemia, Acute pain to L knee. Res c/o SOB (shortness of breath), R (respirations) 18, PRN breathing tx (treatment) admin. Surveyor reviewed R3's medical record and was unable to locate neuro checks for R3. On [DATE] at 9:55 a.m., Surveyor asked RN (Registered Nurse)/UM (Unit Manager)-E when neuro checks are completed after a resident's fall? RN/UM-E explained if the fall is witnessed and the resident hits their head neuro checks are completed. If a fall is unwitnessed whether they hit their head or not neuro checks are completed. Surveyor inquired how often neuro checks are completed? RN/UM-E replied per the packet. Surveyor inquired what this means? RN/UM-E informed Surveyor every 30 minutes times four, every hour times four, every four hours for twenty four hours and every eight hours for the remainder of the 72 hours. Surveyor inquired if a Resident goes to the emergency room following a fall and returns does the facility do neuro checks upon their return? RN/UM-E informed Surveyor they would complete neuro checks until 72 hours post fall. On [DATE] at 10:15 a.m., Surveyor reviewed R3's fall investigation for the fall on [DATE] which consisted of an incident report, post fall assessment, and pain evaluation all dated [DATE]. Surveyor did not note any neuro checks in this fall investigation packet. The nurse's note dated [DATE] at 5:10 p.m. documents: Writer was called over to Mesa unit in regards to resident fall. Upon entering room the resident was laying on the floor on her right side with her feet next to the bed and body outwards away from the bed. Resident alert. Large hematoma noted to left forehead, ice applied. No other head injury noted. Multiple small skin tears noted on residents right forearm and hand, bleeding stopped. Writer informed staff not to move the resident until paramedics arrived, resident made comfortable. Resident is alert and oriented. Resident demanding a glass of water, instructed resident that no PO (by mouth) intake could be given related to her head injury. Paramedics arrived. Resident demanding they give her a glass of water, demanding her blue cup I'm not going anywhere until I get my blue glass of water. The assigned nurse told resident she would give the blue glass to her husband when he came. Resident transported to [name] E.D. (emergency department) for evaluation and treatment. The nurse's note dated [DATE] at 9:37 p.m. includes documentation of: I placed signs in [R3's first name] room, to use call button, and not get up alone. [R3's first name] returned from the ER. As the EMTs (emergency medical technicians) wheeled her into the facility, she asked me as she passed the nurse station Is it time for my pain pill yet?? The EMTs put her in bed and came to give me report Surveyor reviewed R3's medical record and was unable to locate neuro checks for R3. On [DATE] at 10:15 a.m., Surveyor reviewed R3's fall investigation for the fall on [DATE] which consisted of an incident report, post fall assessment, pain evaluation, risk for falls, SBAR (situation, background, assessment, request,) all dated [DATE] and follow up 72 hours post fall dated [DATE]. Surveyor did not note any neuro checks in this fall investigation packet. On [DATE] at 12:16 p.m., Surveyor asked RN (Registered Nurse)/UM (Unit Manager)-E where Surveyor would be able to locate neuro checks. RN/UM-E informed Surveyor they are in the falls packet. Surveyor informed RN/UM-E Surveyor was unable to locate neuro checks following R3's falls on [DATE] & [DATE]. Surveyor then provided RN/UM-E the fall investigation packet Surveyor had been provided with. RN/UM-E reviewed the fall packets and informed Surveyor he doesn't see the neuro checks. Neuro checks were not completed after R3's falls on [DATE] & [DATE]. Non Pressure Wounds The nurse's note dated [DATE] documents: Resident arrived via ambulance. She was able to pivot transfer off the gurney and she took a few steps to get into bed. She has a dressing to her left hip with a drain. The drain has dark red colored drainage. No edema to her lowers. Her bilateral lowers are discolored and cool to the touch and per resident they are always like that. She has a central line to her right upper arm single lumen. She has upper and lower dentures and does not have them with her. No hearing aides and hearing is adequate. Her abdomen is bruised across the whole lower abdomen. She is alert and oriented and call light within reach. She is able to maneuver the bed with her controls. Family is present. The nurse's note dated [DATE] documents: Resident obtained a skin tear to her left anterior shin area. She self transfers into her wheelchair and during the transfer at approx (approximately) 0730 (7:30 a.m.) she obtained a 1 cm (centimeter) x (times) 1 cm skin tear in a v shape. The area has some bleeding. It was cleaned and dressing applied. The nurse's note dated [DATE] documents: Dressing changed to left hip. Moderate amount of sero-sanguineous drainage to old dressing. There are approximately 41 staples intact to incision. There is no redness, swelling or warmth to incision. The incision is approximated but the proximal area is slightly opened between the staples. Resident denies any pain to the area. Resident skin tear to her left anterior shin area has no active bleeding. Dressing changed and she has some clear drainage from the area. It remains approximately 1 cm x 2 cm in a V shape. No s/sx (signs/symptoms) of infection-no redness, warmth or pain to the area. Order received from Dr. [name] for dressing changes as he is covering for Dr. [name]. The nurse's note dated [DATE] documents: IV ABT (intravenous antibiotic) infused without difficulty. BLE (bilateral lower extremity) dressings chgd (changed). Refused legs to be wrapped. states can't stand them on! Yells out @ (at) x's (times). The nurse's note dated [DATE] includes documentation of .She continues to remove her dressings several times on each shift. Writer just had the staff put bath blankets on her bed to absorb the fluid, as she took her dressings off twice this shift. Staff will continue to monitor as needed. The nurse's note dated [DATE] documents: Writer changed resident L hip dressing. Moderate amt (amount) sero-sanguineous drng (drainage) noted on old dressing. Noted entire incision line slightly reddened. Has 1 area that has dehisced. Packed area with cling, noted area to be deep. receiving IV ABT (antibiotics) for L hip infection. Resident has an appt. (appointment) with [name] wound care [DATE]. The nurse's note dated [DATE] documents: This Pt. (patient) has an open area to her left hip incision, where the area has dehisced. The Pt. state's that this has been open for awhile. Writer will check with the wound nurse to see if she is aware of this wound. The area does not look infected, however, it does has a small amount of yellowish drainage. The nurse's note dated [DATE] documents: This Pt. dressings are intact to her lower legs. She had no complaints of wet dressings this shift. She stayed in bed most of his shift. Only calling out two to three different times. Staff will continue to monitor her weeping legs. The nurse's note dated [DATE] documents: Patient has been sleeping off and on all shift. Patient removed dressings to right shin and is screaming to get her 6 rolls of gauze to her. patient has called writer names all night. Patient is insisting that writer redo dressing because doctor told her that was the new orders. The nurse's note dated [DATE] documents: BLE (bilateral lower extremity) & L (left) hip open areas tx's (treatments) done as ordered. No behavior issues noted. The nurse's note dated [DATE] documents: Patient has been awake most of shift, leg wounds were redressed at beginning of shift. Patient has tried to take off dressings to have writer redo dressings a second time. Patient will not get into bed when asked. Patient also took supplies for leg wounds and wrapped right arm up with gauze and tape by self. The nurse's note dated [DATE] documents: Resident has a pressure dressing to her left foot. She verbalized her desire to remove the dressing as she wanted to see what it looked like. I educated her on the importance of keeping the pressure dressing in place. It is secure. I updated her husband [name] and also spoke with [name] RN from Dr. [name] office. There are no new concerns and she stated she would let doctor know and get back to me if there were new orders. The nurse's note dated [DATE] documents: Resident had a lot of crying out until HS (hour sleep). Husband asked her what she was doing, stated yelling out, that's what I do. Tx to BLE done. Medicated for pain x 1. R3 was hospitalized [DATE] to [DATE]. The hospital discharge summary dated [DATE] under physical examination for skin documents multiple wounds over bil (bilateral) lower extremities. Non-healing left hip wound. Buttock wounds/excoriation. Wounds have improved since admission. The skilled nurses note dated [DATE] documents under skin/wound: No new changes to skin integrity noted. Has wounds Resident has treatable wounds. Dressing changed as per treatment orders. Multiple leg wounds, wound to buttocks, surgical wound to L hip. R3 expired in the Facility on [DATE]. Left trochanter (hip) The weekly non pressure condition record dated [DATE] under site for this assessment is other, for describe other documents Left Hip. Date of onset [DATE]. Measurements are length 20, width 0.5, and depth 0.0. Under description of site documents S/P (status post) hip surgery incision edges are approximated with staples, moderate amt. (amount) of serous drainage, no odor, peri wound slight red in color and warm to touch, no s/s (signs/symptoms) of infection Surveyor was unable to locate an assessment during the week of [DATE] to [DATE]. The Orthapaedics NP (nurse practitioner) note dated [DATE] under physical exam includes documentation of Examination of her left posterolateral incision reveals staples that are present. She has two areas of dehiscence about the most proximal aspect of her incision that measures 2 cm (centimeter) most proximally and 1 cm in length distally about her incision. The remainder of her incision is well approximated without signs of infection. There is no erythema, no active or intermittent drainage. The weekly non pressure condition record dated [DATE] documents date of onset [DATE] type is surgical incision. Measurements are length 3.0, width 2.2, and depth 2.5. Under description of site documents S/P (status post) surgical incision to left trochanter of hip, incision line meas (measures) approximately 25 cm (centimeter) in length after staples were removed hip incision dehisced, incision line has attached edges, moderate amt. (amount) serous drainage, no odor, no s/s of infection. Surveyor was unable to locate assessments during the week of [DATE] to [DATE] & [DATE] to [DATE]. The outpatient wound care progress note dated [DATE] Under history of present illness documents Pt. (patient) had left hip replacement on [DATE] by [physician's name], has partial area of incision that is a dehisced wound. Under wound assessment documents Left hip with dehiscence of incision, has granulation, fibrin, has edema, no induration, no purulence, sero sananguineous drainage. Surveyor noted there are no measurements. The weekly non pressure condition report dated [DATE] documents for measurements length 3, width 2, depth 2. Under description of site documents Surgical dehiscence of incision: wound bed has granulation, with fibrin, peri-wound has slight edema, no induration, no drainage, no odor, no s/s of infection. Surveyor was unable to locate an assessment during the week of [DATE] to [DATE]. The outpatient wound care progress note dated [DATE] under wound assessment documents Left hip with dehiscence of incision, has granulation, fibrin, tunneling does not probe to bone. The wound hip/trochanter measurements are length 1.5 cm (centimeters), width 0.2 cm and depth 2.5 cm. Surveyor was unable to locate assessments during the week of [DATE] to [DATE] & [DATE] to [DATE]. The weekly wound evaluation flow sheet dated [DATE] for left hip under type documents surgical incision. Length 1.05 cm, width 0.05 cm and depth 1.00 cm. The outpatient wound care progress note dated [DATE] under wound assessment documents Left hip with dehiscence of incision, has granulation, fibrin, tunneling does not probe to bone. No peri wound induration, erythema, or warmth. The wound hip/trochanter left incision measures length 2.4 cm, width 0.6 cm. & depth 1.5 cm. The wound hip/trochanter left measure length 16.8 cm, width 12 cm, depth 0.2 cm. R3 was hospitalized from [DATE] to [DATE]. The hospital discharge summary dated [DATE] documents under other diagnoses Nonhealing surgical wound, subsequent encounter. The weekly wound evaluation flow sheet for wound evaluation week 2 dated [DATE] documents length .9 cm, width .1 cm, and depth .7 cm. Under additional notes documents area improving per last assessment. Under other documents patient just returned from hospital. The weekly wound evaluation flow sheet for wound evaluation week 3 dated [DATE] documents length .9 cm, width .1 cm, and depth .6 cm. Wound bed is 75% granulation and 25% slough. Under current wound status/additional comments documents area stable. R3 expired in the facility on [DATE]. Surveyor noted the facility's non pressure assessments were completed by Traveling Wound RN-L who is no longer at the facility. Bilateral Lower Extremities (BLE) The weekly non pressure condition record for site is other. For describe other documents left leg shin. Date of onset is [DATE]. Existing is checked. Under type documents skin tear. Length 0.5 cm, width 1 cm. Description of site documents Skin tear edges are approximated, small amt. (amount) of serous drainage, no s/s of infection, no odor, peri-wound slight edematous. There are no assessments of R3's BLE until [DATE]. The outpatient wound care progress note dated [DATE] under history of present illness documents Pt. (patient) was previously recommended ,d+[DATE] mmHg compression but did not have any on for visit today. Pt . Reports BLE with weeping and scattered wounds. Under wound assessment documents BLE with edema, hemosiderin staining (appearance of brownish patches above the ankles), weeping, scattered partial and full thickness wounds, has slough, fibrin, nonviable tissue. Surveyor noted there are no measurements of R3's bilateral lower extremities wounds. Surveyor was unable to locate assessments during the week of [DATE] to [DATE] & [DATE] to [DATE]. The outpatient wound care progress note dated [DATE] under history of present illness includes documentation of: Pt was previously recommended ,d+[DATE] mmHg compression but did not have any on for visit today. Under wound assessment documents BLE with edema, hemosiderin staining, weeping, scattered partial and full thickness wounds, has slough, fibrin, nonviable tissue. The wound right leg documents length 4 cm (centimeters), width 4 cm, and depth 0.2 cm. The wound left leg documents length 5 cm,

Based on observation, interview, and record review, the facility did not ensure that residents with pressure injuries or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R3 & R14) of 6 Residents reviewed for pressure injuries. * R3's weekly head to toe skin check dated [DATE] documents small open area on buttocks. There was not a comprehensive assessment of R3's left buttocks until [DATE] which documents a left buttocks Stage 3 pressure injury. There are no further assessments of R3's left buttocks, there was no treatment initiated, and the care plan was not revised. R3 expired on [DATE]. * R14 was observed without a dressing on her back pressure injury for an extended period of time and R14's heels were not being offloaded. Findings include: 1) R3 was admitted to the facility on [DATE], was hospitalized from [DATE] to [DATE], and expired in the Facility on [DATE]. R3's diagnoses included heart failure, atrial fibrillation, depressive disorder, anxiety disorder, diabetes mellitus, hypertension, and fracture of left femur. The nurses note dated [DATE], documents Resident arrived via ambulance. She was able to pivot transfer off the gurney and she took a few steps to get into bed. She has a dressing to her left hip with a drain. The drain has dark red colored drainage. No edema to her lowers. Her bilateral lowers are discolored and cool to the touch and per resident they are always like that. She has a central line to her right upper arm single lumen. She has upper and lower dentures and does not have them with her. No hearing aides and hearing is adequate. Her abdomen is bruised across the whole lower abdomen. She is alert and oriented and call light within reach. She is able to maneuver the bed with her controls. Family is present. The potential for pressure ulcer development care plan initiated [DATE] has the following interventions: * The resident requires the bed as flat as possible to reduce sheer. Initiated [DATE]. * Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated [DATE]. * Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x (times) width x depth), stage. Initiated [DATE]. * Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated. Initiated [DATE]. * Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Initiated [DATE]. * The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Initiated [DATE]. * The resident requires pressure reducing device on bed/chair. Initiated [DATE]. * Treat pain as per orders prior to treatment/turning etc to ensure the resident's comfort. Initiated [DATE]. The admission MDS (minimum data set) with an assessment reference date of [DATE], documents a BIMS (brief interview of mental status) score of 14 which indicates R3 is cognitively intact. R3 requires extensive assistance with one person physical assist for bed mobility, transfers, & toilet use and does not ambulate. R3 is coded as being continent of urine and occasionally incontinent of bowel. R3 is at risk for pressure injuries and is coded as not having any pressure injuries. The head to toe skin check dated [DATE] under further description of skin issues documents, Buttocks has redness on both sides. Small open area on left buttock. This skin check was completed by LPN (Licensed Practical Nurse)-G. The outpatient wound care progress note dated [DATE] under wound assessment includes documentation of Buttock, superficial wound, full thickness, minimal drainage, mainly granular. Under local wound care documents buttock - barrier cream daily and prn (as needed) stooling by [name of Facility] RN (Registered Nurse). Surveyor noted there are no measurements documented. The weekly pressure ulcer record dated [DATE] documents site for this assessment 32) Left buttocks. Under date of onset documents [DATE]. For the question is this a new or existing pressure ulcer new is checked. Under Site documents 32) left buttocks, type is Pressure, length 0.5, width 0.5, & depth is 0.10. Stage is documented as III (3). Under description of site documents attached edges, wound bed superficial mainly granular tissue, no drainage, no odor, no s/s (signs/symptoms) infection. R3's physician and responsible party were notified on [DATE]. This assessment was completed by Traveling Wound RN (Registered Nurse)-L. Surveyor reviewed R3's physician orders and was unable to locate a treatment for R3's stage 3 left buttocks pressure injury. Surveyor reviewed R3's progress notes from [DATE] to [DATE] when R3 was transferred to the hospital. Surveyor was unable to locate any documentation in the progress notes regarding R3's left buttocks pressure injury. Surveyor reviewed R3's assessments under the assessment tab and was unable to locate any weekly pressure ulcer assessment after [DATE]. On [DATE] at 9:37 a.m., Surveyor met with RN (Registered Nurse)/UM (Unit Manager)-E to discuss R3. Surveyor informed RN/UM-E Surveyor had noted a weekly skin to toe check dated [DATE] which documented a small open area on R3's left buttocks which was completed by a LPN. Surveyor noted a comprehensive assessment was not completed until [DATE] and was unable to locate any further assessment or treatment. Surveyor asked RN/UM-E to look into this and get back to Surveyor. On [DATE] at 10:44 a.m., RN/UM-E informed Surveyor he spoke with DON (Director of Nursing)-B and they are still working on it. RN/UM-E informed Surveyor during this time they had a traveling wound nurse who was helping them. On [DATE] at 12:14 p.m., RN/UM-E informed Surveyor they are still looking for the weekly measurements and they have a call out to the traveling wound nurse. On [DATE] at 1:26 p.m., RN/UM-E informed Surveyor he doesn't know where the assessments are for R3's left buttocks pressure injury. RN/UM-E informed Surveyor they had a contracted wound nurse who may have been helping the staff nurse, may have seen the pressure injury and put the assessment in herself. Surveyor informed RN/UM-E there are no comprehensive assessments, treatments, or change in R3's care plan for R3's left buttocks Stage 3 pressure injury. RN/UM-E replied, I see that. On [DATE], at 1:58 p.m. Administrator-A and DON-B were informed of the above. 2.) R14's diagnoses includes diabetes mellitus, peripheral vascular disease, and dementia. R14 has been receiving hospice services since [DATE]. The pressure ulcer care plan initiated [DATE] & revised on [DATE] has the following interventions: * New APM (Alternating Pressure Mattress) to be provided by facility as hospice does not have this available. Initiated [DATE]. * New APM placed. Initiated [DATE]. * Administer medications as ordered. Observe/document for side effects and effectiveness. Initiated [DATE]. * Administer treatments as ordered and observe for effectiveness. See the emars (electronic medication administration record) in pcc (pointclickcare) for specific details on pressure ulcer/skin area tx's (treatments). Initiated [DATE] & revised [DATE]. * Complete a full body check weekly and document. Initiated [DATE]. * Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Initiated [DATE]. * Enc (encourage) turn and reposition every ,d+[DATE] hrs (hours). Initiated [DATE] & revised [DATE]. * Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiated [DATE]. * If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Initiated [DATE]. * Inform the resident/family/caregivers of any new area of skin breakdown. Initiated [DATE]. * [R14's first name] has a low air loss mattress to aid in pressure reduction. Initiated [DATE] & revised [DATE]. * [R14's first name] will have heel boots on as much as she can tolerate and allow. Initiated [DATE] & revised [DATE]. * Observe nutritional status. Serve diet as ordered, observe intake and record. Initiated [DATE]. * Observe/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x (times) width x depth), stage. Initiated [DATE]. * Obtain and observe lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Initiated [DATE]. * Provide incontinence care after each incontinence episode, or per established toileting plan. Initiate [DATE]. * The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Initiated [DATE]. * The resident requires pressure relieving/reducing device on bed/chair. Initiated [DATE] & revised [DATE]. * Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Initiated [DATE]. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Initiated [DATE]. The quarterly MDS (minimum data set) with an assessment reference date of [DATE] documents a BIMS (brief interview of mental status) score of 9 which indicates moderately impaired cognition. R14 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfers, and does not ambulate. R14 is at risk for developing pressure injuries and is coded as having one Stage 3 pressure injury. Wound NP (Nurse Practitioner)-K's note dated [DATE], under interventions in place documents LAL (low air loss) air mattress and boots for offloading, house barrier cream as needed, pressure relieving cushion for when out of bed, assist with every 2 hours turns while in bed as needed. Physical examination documents Stage III (3) pressure injury to the mid back partial thickness wound 0.4 cm (centimeters) x (times) 0.5 cm x 0.1 cm. The base is pink and there is a small amount of serosanguineous drainage. Peri wound with moist tissue. No signs or symptoms of infection. Status: Reopened. Plan: Silver alginate bordered foam change weekly. The Braden assessment dated [DATE] has a score of 14 which indicates moderate risk for the development of pressure injuries. Wound NP-K's note dated [DATE] under interventions in place documents, LAL air mattress and boots for offloading, house barrier cream as needed, pressure relieving cushion for when out of bed, assist with every 2 hours turns while in bed as needed. Physical examination documents Stage III (3) pressure injury to the mid back-proximal. Partial thickness wound 0.7 cm (centimeters) x (times) 0.9 cm x 0.1 cm. The base is red and there is a small amount of serosanguineous drainage. Peri wound with moist tissue. No signs or symptoms of infection. Status: Reopened. Plan: Silver alginate bordered foam change weekly. Stage 2 PI (pressure injury) spine distal. Partial thickness wound measuring 0.9 cm x 0.9 cm x 0.1 cm. The base is red and there is a small amount of serosanguineous drainage. Peri-wound with blanchable erythema. No s/s of infection. Status: New. Plan: Silver alginate and border foam change weekly. The physician orders with a start date of [DATE] documents wound care mid back 2 areas: cleanse with soap and water, pat dry, silver alginate to wound bed and cover with border foam every day shift every Friday for wound care and start date of [DATE] wound care mid back 2 areas: cleanse with soap and water, pat dry, silver alginate to wound bed and cover with border foam every 24 hours as needed for if soiled. On [DATE], at 8:38 a.m., Surveyor observed R14 in bed on her back with the head of the bed elevated in a high position. Surveyor observed R14's right heel is resting directly on a pillow and the left heel is on the mattress. R14's heels are not being offloaded and R14 is not wearing pressure relieving boots. On [DATE], from 9:27 a.m. to 10:10 a.m., Surveyor observed morning and incontinence cares for R14 with CNA-C. During this observation at 9:46 a.m. Surveyor asked CNA-C if R14 has any skin concerns. CNA-C informed Surveyor R14 has a wound on her back. Surveyor asked CNA-C if Surveyor can see the date on the dressing. CNA-C informed Surveyor the dressing came off when she was rolling R14. CNA-C showed Surveyor the dressing which was dated ,d+[DATE]. CNA-C informed Surveyor the nurse is going to do the dressing when she changes the catheter. Surveyor observed after CNA-C washed R14's upper body, CNA-C placed a shirt on R14. Surveyor noted there is not a dressing over R14's back pressure injuries. On [DATE], at 10:14 a.m., LPN/UM-D and LPN-F entered R14's room with supplies to change R14's Foley catheter. LPN-UM-D informed R14 she was going to change her urinary catheter. Surveyor observed LPN/UM-D remove R14's catheter, attach the urinary collection bag to the new catheter and inserted the Foley catheter. At 10: 18 a.m. LPN-F placed the collection bag in a privacy bag and placed the bag on R14's bed frame. LPN/UM-D informed R14 they need to put a brief on her. At this time LPN-F left R14's room for an incontinence brief. LPN-F returned with an incontinence brief. LPN/UM-D asked R14 if she wanted to get up or stay in bed. R14 informed LPN/UM-D & LPN-F she wanted to get up. LPN/UM-D and LPN-F placed an incontinence brief & pants on R14 and a hoyer sling was placed under R14. LPN-F informed R14 they would be back in about 10 minutes as staff are using the hoyer lift & left R14's room. LPN/UM-D placed socks on R14, covered R14 with a blanket, raised the head of the bed and lowered the bed down. LPN/UM-D placed the call light within reach and cleaned & placed glasses on R14. LPN/UM-D placed a pillow under R14's lower legs, removed her gloves, performed hand hygiene, and left R14's room. Surveyor observed R14's heels are resting directly on the pillow and are not being offloaded. Surveyor noted neither LPN/UM-D or LPN-F did the treatment to R14's back pressure injuries and there is no dressing over the pressure injuries. On [DATE], at 1:17 p.m., Surveyor observed R14 on her right side. Surveyor observed R14's heels are not being offloaded and R14 is not wearing pressure relieving boots. On [DATE], at 1:48 p.m., Surveyor accompanied LPN-F to R14's room. Surveyor asked LPN-F if there should be a dressing on R14's back. LPN-F informed Surveyor there should be because she changed it yesterday. LPN-F placed gloves on, lowered the head of R14's bed, removed the pillow from R14's left side and rolled R14 onto her right side. LPN-F lifted up the back of R14's shirt stating should be right here, nope it's not there. Surveyor noted CNA-C entered R14's room. LPN-F asked CNA-C if she removed R14's patch. CNA-C indicated the dressing had come off during her bed bath. LPN-F stated did you tell me. CNA-C replied I forgot. On [DATE], at 1:57 p.m., Surveyor observed LPN/UM-D and LPN-F enter R14's room. LPN/UM-D applied a Foley catheter tubing device to R14's upper left thigh, removed her gloves, washed her hands, and placed gloves on. LPN/UM-D informed R14 going to do your back now. R14 was positioned on her right side and LPN/UM-D completed R14's pressure injury treatment according to physician's orders. After completing the treatment LPN/UM-D asked R14 if she wanted to lay on her back or left side. R14 was placed on her back, LPN/UM-D and LPN-F repositioned R14 up in bed and a pillow was placed under R14's knees. Surveyor observed R14's heels are resting directly on the mattress. LPN/UM-D raised the head of the bed, lowered the height of the bed, removed her gloves, performed hand hygiene and LPN/UM-D & LPN-F left R14's room. On [DATE], at 10:28 a.m., Surveyor observed R14 in bed on her right side. Surveyor observed R14's heels are not being offloaded and R14 is not wearing pressure relieving boots. On [DATE], at 1:20 p.m., Surveyor observed R14 in bed on her back with her lunch tray on an over bed table in front of R14. Surveyor observed R14's heels are not being offloaded and R14 is not wearing pressure relieving boots. On [DATE], at 3:33 p.m., Surveyor observed R14 in bed on her back. R14's heels are not being offloaded and R14 is not wearing pressure relieving boots. On [DATE], at 10:29 a.m., Surveyor observed R14 in bed on her back with hospice staff in R14's room. Surveyor observed R14 heels are not being offloaded and R14 is not wearing pressure relieving boots. On [DATE], at 10:32 a.m., Surveyor met with LPN/UM-D to discuss R14. Surveyor asked LPN/UM-D if a Resident's pressure injury dressing is off what should the CNA do. LPN/UM-D informed Surveyor the CNA should let the nurse know right away. Surveyor informed LPN/UM-D Surveyor had noted Wound NP-K's notes documents under interventions boots for offloading. LPN/UM-D informed Surveyor R14 uses pillows to float her heels and this was more of a recommendation from the NP. LPN/UM-D informed Surveyor Wound NP-K and the wound nurse has been informed R14 prefers not to have boots and just use pillows for floating R14's heels. Surveyor informed LPN/UM-D Surveyor has observed a pillow under R14's legs but R14's heels are not being offloaded. Surveyor informed LPN/UM-D Surveyor has multiple observations where R14's heels are not being offloaded. On [DATE], at 10:40 a.m., Surveyor informed DON (Director of Nursing)-B of the above.

Based on interview and record review, the facility failed to ensure that 3 (R11, R4, and R181) of 23 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, that will meet each resident's physical, mental, and psychosocial needs. ~ R181 was admitted [DATE] from the hospital following surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not do a follow up to the R181's low potassium level, did not follow up and schedule appointments within a week to general surgery and cardiology, did not get treatment orders for the abdominal incision (including ABD pads and abdominal binder), did not routinely monitor and assess the abdominal incision or the JP drain, did not monitor blood pressure even after low readings, and did not question the nurse practitioner's repeated comments that the resident was stable. The resident was hospitalized due to complications from the JP drain 10 days after admission. The resident was readmitted and again was not monitored for lab values, low BP, GI assessments, surgical incision, dehydration due to nausea, vomiting and loose stools. On [DATE] R181's granddaughter asked that she be sent out because she was in severe pain. The resident was transferred to the emergency room about 2:52 PM. She was hospitalized with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Blood pressure was ,d+[DATE]. Her right leg was twice the size of her left leg. She was hemodynamically unstable and not a surgical candidate. The resident died on [DATE] at 8:17 PM. The facility's failure to properly care for R181's surgical incision, JP drain, to assess low BPs, GI and incision, to obtain ordered labs, to schedule ordered MD appointments and to monitor and follow up on dehydration created a finding of Immediate Jeopardy beginning on [DATE]. Nursing Home Administrator (NHA)-A was informed of the Immediate Jeopardy on [DATE] at 2:36 PM. The Immediate Jeopardy was removed on [DATE] when the facility implemented an action plan related to standards of practice, MD orders and quality of care for residents. This deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan and as evidenced by the following: ~ R11 developed trauma wounds to the left first, second, third, and fourth toes that were discovered on [DATE]. No comprehensive assessment was made of the wounds, no documentation the physician was notified, no treatment was obtained, and no revision of the care plan was made to prevent further trauma to the areas when discovered. ~ R4 was admitted to the facility on [DATE] with a chronic vascular wound to the left lower leg. No documentation was found of a weekly assessment from [DATE] through [DATE]. R4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Surveyor reviewed facility's Admission to the Center policy with a revision date of [DATE]. Documented was: .Admission-Nursing 1. If not already initiated, the licensed nurse creates the resident's Electronic Health Record (EHR). 2. The licensed nurse obtains and verifies the physician's admitting orders. 3. Orders for medications and/or care are entered into the Electronic Health Record (EHR) . 5. The licensed nurse notifies the attending physician of the resident's admission and completes an initial assessment of the resident using the Nursing Admission Data Collection (UDA). 6. The nursing staff develops and initiates the Baseline Care Plan (UDA) within 48 hours of admission . Surveyor reviewed facility's Skin Management policy with a revision date of [DATE]. Documented was: .NON-PRESSURE WOUNDS . 5. Wounds will be assessed weekly and status/progress documented on the Weekly Non-Pressure Skin Condition Record (UDA). 6. The resident is assessed for pain, and appropriate interventions are implemented and care planned . 8. The resident is added to the 24-Hour Report via Progress Note. Care Plan interventions are implemented and discussed during shift report with members of the care team. 9. The nurse will monitor the area closely during treatment to evaluate appropriateness of treatment regimen . 11. Consult with rehabilitation services for evaluation and options for treatment intervention, such as [CONDITION(S)] management. 12. Consultation with a certified wound care nurse, wound consultant, or surgeon may be appropriate. [CONDITION(S)] REDUCTION 1. Consult with the attending physician for treatment plan. 2. Consult with rehabilitation services for treatment interventions for [CONDITION(S)] management . Surveyor reviewed facility's Diagnostic Services Management policy with a revision date of [DATE]. Documented was: POLICY Residents requiring laboratory, radiology or other diagnostic services will receive accurate and timely testing services from certified diagnostic facilities in accordance with Federal regulations to support diagnosis, treatment, prevention, and assessment. The facility is responsible for quality and timely services whether or not services are provided by the facility or an outside agency. Medically necessary diagnostic services may be ordered by the resident's physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with State law and scope of practice laws. Diagnostic testing results are promptly reported to the ordering physician/licensed practitioner or in accordance with the physician's/licensed practitioner's orders. Abnormal or results showing critical values are reported immediately to the ordering physician/licensed practitioner. The resident and/or resident representative will be notified of abnormal findings promptly. Diagnostic reports are maintained in the resident's medical record . Surveyor reviewed facility's Change in Resident's Condition policy with a revision date of February 2017. Documented was: The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Communication with the Interdisciplinary Team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. GUIDELINES: 1. For life-threatening events, call 911 if initial assessment indicates that such action is necessary. 2. Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's attending physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatment significantly. 3. If the attending physician cannot be reached, nursing attempts to contact the following providers in this order until a physician has been contacted: the physician on call, the facility Medical Director, the Division Medical Director and emergency services. 4. The SBAR Communication Form and the Progress Note are used to: a. Assess and document changes in condition in an efficient and effective manner; b. Provide assessment information to the physician, and c. Provide clear comprehensive documentation. [5.] Changes in condition are communicated from shift to shift through the 24 Hour Report. [6.] Changes in the resident status that affect the problem(s)/goal(s) or approach(es) on his or her care plan are documented as revisions and communicated to the interdisciplinary caregivers. Surveyor reviewed facility's Assessment, General Survey policy with a date of February 18, 2022. Documented was: Introduction The goal of an assessment is to determine the care, treatment, and services that will meet the patient's initial and continuing needs. The purpose of a general survey assessment is to provide an overall review of the patient's wellness. The general survey assessment begins with the first encounter with the patient and continues throughout the assessment process. Nonverbal cues enable you to use more targeted questions to obtain additional relevant information. The general survey assessment typically includes the patient's general appearance, apparent state of health, demeanor, facial expression or affect, grooming, posture, and gait. The depth and frequency of a more detailed assessment depends on several factors, including the patient's needs and the care, treatment, and services the patient received. Information you obtain at the patient's first contact may indicate a need for more data or a more intensive assessment . Documentation Document significant normal and abnormal findings in an objective, organized manner and according to the order of information you collected. Record the date, time, name of the practitioner you notified of any abnormal results, prescribed interventions, and the patient's response to those interventions (as indicated). Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching . R181 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R181's MDS (Minimum Data Set) Admission Assessment with an assessment reference date of [DATE]. Documented under Cognition was a BIMS (brief interview mental status) score of 15 which indicated cognitively intact. Prior to admission, R181 had been hospitalized from [DATE] to [DATE]. Discharge Summary from hospital documented: .Subacute care follow up - monitor bowel regimen . Hospital Course: [AGE] year old female with [past medical PM] including polymyalgia rheumatica, T2DM, hypertension, [CONDITION(S)], PE on [MEDICATION(S)] who presents today from [subacute rehab (SAR)] with [complaints of (c/o)] increasing abdominal pain and [nausea and vomiting (N/V)]. The patient was recently discharged from this facility on [DATE] for AFib with VR and findings of saddle PE with heart strain. She was taken urgently for thrombectomy. Post procedure she developed hemoptysis and increased [oxygen (02)] requirements. Her 02 requirements gradually improved. She then developed [CONDITION(S)] while on [MEDICATION(S)] [drip (gtt)] for PE. She was noted to have melena stools and required 1 [unit (U)] [packed red blood cells (PRBC)] with stabilization of [hemoglobin (hgb)]. She was eventually transitioned to [oral (po)] [MEDICATION(S)] at discharge. She was also hospitalized on [DATE] for acute hypoxic [CONDITION(S)] covid-19 pneumonia, [CONDITION(S)] with VR, and subsegmental pulmonary embolism treated initially with [MEDICATION(S)] infusion and transitioned to PO [MEDICATION(S)]. During that hospital stay she did develop left flank pain and worsening hydronephrosis for which she underwent retrograde pyelogram and stent placement. Patient was planning on [CONDITION(S)] stent removal just prior to her hospitalization last month and therefore had been off [MEDICATION(S)] when she developed saddle [CONDITION(S)]. Patient stated she has been off [MEDICATION(S)] for about 2 weeks in anticipation of procedure. Patient has since had stent removed by urology on [DATE] with recommended [follow up (f/u)] in 6 weeks. This admission patient with finding of incarcerated hernia. [CT scan] was obtained showing bowel perforation in area of the incarceration. Gen surgery was consulted and patient taken to OR from ED. She had small section of colon removed in the area of the incarceration and [abdominal (abd)] wash out. Blood and urine cultures are growing [CONDITION(S)] [pneumoniae (PNA)], [extended spectrum beta-lactamase [ESBL)] infection. She was treated with [MEDICATION(S)] and [MEDICATION(S)]. [MEDICATION(S)] restarted . Significant Diagnostic Studies/Procedures: .[DATE] SODIUM 140 . Latest reference range and units: 136 - 145 mmol/L . POTASSIUM (K+) 4.2 . Latest reference range and units: 3.5 - 5.1 mmol/L . [blood urea nitrogen (BUN)] 11 Latest reference range and units: 7 - 26 mg/dL . [CREATININE (Cr)] 0.84 Latest reference range and units: 0.55 - 1.11 mg/dL . Surveyor reviewed facility's report sheet for incoming admission for R181. Documented was .Hernia Repair, [abdominal (Abd)] pads over incision then abd binder . [Jackson Pratt (JP)] drain on right side, empty [every (Q)] shift, Abd incision . Surveyor reviewed Admission Data Collection assessment with a date of [DATE]. There was no assessment documented of the abdominal incision. There was no assessment documented of the JP drain. Surveyor reviewed Baseline and Comprehensive Care Plan for R181. There was no care plan in place for the abdominal incision or JP drain care, management or monitoring. Surveyor reviewed Admission MD Orders for R181. There were no MD orders in place for the abdominal incision or JP drain care, management or monitoring per report sheet by taken by facility. On [DATE] Nurse Practitioner (NP)-CC visited R181. Visit note documented .Physical Exam: abdomen with surgical staples, protrusion of abdomen, tender to palpation . ASSESSMENT/PLAN: 1. [CONDITION(S)], stable monitoring labs. 2. ESBL, stable on antibiotics, follows infectious disease. 3. Hernia, stable general surgery follow up. 4. Perforation of intestine, stable post surgical repair, bed rails for mobility . There was no comprehensive assessment of the abdominal incision and no mention of the JP drain. On [DATE] NP-CC wrote an order in for [complete blood count (CBC)] and [comprehensive metabolic panel (CMP)] . Surveyor reviewed R181's labs. These labs were not completed for R181. There were no orders written to address the abdominal incision or JP drain care, management or monitoring per report sheet taken by facility. Surveyor reviewed R181's Electronic Medical Record (EMR). There was no documentation of the abdominal incision or JP drain care, management or monitoring on [DATE]. Surveyor reviewed Skin - Weekly Non-Pressure Condition Record assessment with a date of [DATE]. Documented was .Site: 14) Abdomen; Type: Surgical Incision; Length: 9 cm; Width: 0.1 cm; Depth: [blank]; Stage: N/A; Description of the site: area scabbed over. No drainage noted . There is no comprehensive assessment of the abdominal incision or JP drain. On [DATE] NP-CC visited R181 again. Visit note documented .Physical Exam: abdomen with surgical staples, protrusion of abdomen, tender to palpation . ASSESSMENT/PLAN: 1. [CONDITION(S)], stable monitoring labs. 2. ESBL, stable on antibiotics, follows infectious disease. 3. Hernia, stable general surgery follow up. 4. Perforation of intestine, stable post surgical repair, bed rails for mobility-awaiting installation . There was no comprehensive assessment of the abdominal incision and no mention of the JP drain. Surveyor reviewed R181's Electronic Medical Record (EMR). There was no documentation of the abdominal incision or JP drain care, management or monitoring on [DATE] and [DATE]. Surveyor reviewed Physical Therapy note from [DATE]. Documented was per [nursing (nsg)] reports [patient (pt)] not eating well and updated and discussed. [With (w/)] improved intake and fluids to improve task participation and healing to improve quicker, pt agreeable though reports of they need to wake me up to eat. Pt approached this date at lunch and stated I'm done w/ 2 bites only consumed off of plate. pt reports [symptoms (sx's)] in abdomen. pt reports of spinning w/ [weight bearing] trial and seated. BP 85/? diff to hear assessment and advised pt to cont to drink fluids. updated to nsg regarding concerns W/ BP's. Surveyor reviewed R181's Progress Notes from [DATE], [DATE] and [DATE]. There was no documentation of decreased appetite. There was no documentation of concern with low BP's. There was no documentation of the abdominal incision or JP drain care, management or monitoring. On [DATE] at 12:03 PM, a dose of Loperamide HCl Capsule 2 MG: Give 1 capsule by mouth as needed for diarrhea, up to twice daily was administered. There was no other documentation of loose stools or assessment of R181. On [DATE] orders were entered for R181 documenting Stool sample for [Clostridioides difficile (c diff)] and Stool sample for diarrhea. Surveyor reviewed R181's labs. There was no stool sample collected for R181. On [DATE] NP-CC visited R181 again. Visit note documented .[History of Present Illness (HPI)]: [AGE] year old female seen today for nausea and loose stool. Patient reports symptoms 3 days in duration. Patient is stable in no acute distress . Physical Exam: abdomen with surgical staples, protrusion of abdomen, tender to palpation . ASSESSMENT/PLAN: 1. Nausea - stable [MEDICATION(S)] and bland diet encouraged. 2. Loose stools - stable stool sample ordered. There was no comprehensive assessment of the abdominal incision and no mention of the JP drain. The stool sample was yet to be collected. Surveyor reviewed R181's Skin - Head to Toe Skin Checks with an assessment date of [DATE]. Documented was .JP drain to right pelvic area . There was no comprehensive assessment of the abdominal incision and no other charting of care, management or monitoring of either. Surveyor reviewed R181's labs. There was a CMP and CBC drawn on [DATE] at 8:37 PM. Lab results were faxed to the facility at 10:41 PM on [DATE]. The labs were not reviewed by NP-CC until [DATE]. Results included: SODIUM 135 (L) Range: 136 - 145 mmol/L . POTASSIUM 3.1 (L) Range: 3.4 - 5.1 mmol/L . BUN 29 (H) Range: 7 - 26 mg/dL . CREATININE 1.30 (H) Range: 0.50 - 1.10 mg/dL . NP-CC signed and dated the top of the CMP and CBC and wrote repeat in 1 week on the CBC lab. On [DATE] NP-CC visited R181 again. Visit note documented .HPI: [AGE] year old female seen today for nausea and loose stool. Recent labs reviewed. Patient is in no acute distress . Physical Exam: abdomen with surgical staples, protrusion of abdomen, tender to palpation, poor skin turgor, 24 gauge IV in left forearm placed, blood return noted . ASSESSMENT/PLAN: 1. Nausea - stable [MEDICATION(S)] changed to scheduled q 8 hours and bland diet encouraged. 2. Loose stools - stable awaiting stool sample results. 3. [CONDITION(S)] - stable repeat CBC in one week. 4. Dehydration - stable BUN 29, creat 1.30, potassium 3.1, creatinine 1.30, [MEDICATION(S)] 2.3, calcium 7.9, repeat labs in 2 days. 5% dextrose 50 ml/hr X 3 days ordered. Peripheral IV 24 gauge placed in left forearm by writer using sterile technique, clear dressing applied, blood return noted, IV fluids running. There was no comprehensive assessment of the abdominal incision and no mention of the JP drain. The stool sample was yet to be collected. NP-CC did not address the low Potassium level of 3.1. NP-CC did address the low Sodium, high BUN and high Creatinine with fluids for dehydration. Surveyor reviewed R181's Progress Notes. Documented under Administration Note on [DATE] at 11:22 AM was Dextrose Solution 5% Use 50 ml/hr intravenously every 24 hours for dehydration for 3 Days: on order. The IV fluids for dehydration were not administered. Surveyor reviewed Skin - Weekly Non-Pressure Condition Record assessments with a date of [DATE]. There is no assessment of the abdominal incision or JP drain. Surveyor reviewed R181's Progress Notes. Documented under Administration Note on [DATE] at 12:36 PM was Dextrose Solution 5% Use 50 ml/hr intravenously every 24 hours for dehydration for 3 Days: Medication not available. Pharmacy has been called and medication has been ordered STAT. [NP-CC] notified, [NP-CC] said to hang [normal saline (NS)] until dextrose arrives. This order was not put into the EMR and no IV fluids for dehydration were administered. Surveyor reviewed Occupational Therapy note from [DATE]. Documented was Pt feeling sick, vomiting and diarrhea. On [DATE] NP-CC visited R181 again. Visit note documented .HPI: [AGE] year old female seen today for follow up for nausea, loose stool, [CONDITION(S)], and dehydration. Patient reports slight improvement to symptoms. Patient is in no acute distress . Physical Exam: abdomen with surgical staples, protrusion of abdomen, decreased tender to palpation . ASSESSMENT/PLAN: 1. Nausea - stable [MEDICATION(S)] changed to scheduled q 8 hours and bland diet encouraged. 2. Loose stools - stable awaiting stool sample results. 3. [CONDITION(S)] - stable repeat CBC in one week. 4. Dehydration - stable BUN 29, creat 1.30, potassium 3.1, creatinine 1.30, [MEDICATION(S)] 2.3, calcium 7.9, repeat labs in 2 days. 5% dextrose 50 ml/hr X 3 days, may substitute [MEDICATION(S)] or normal saline if no dextrose available. There was no comprehensive assessment of the abdominal incision and no mention of the JP drain. NP-CC did not address the low Potassium level of 3.1. NP-CC did address the low Sodium, high BUN and high Creatinine with fluids for dehydration, but the IV fluids were not administered. Surveyor reviewed R181's Progress Notes. Documented on [DATE] at 6:04 AM was pt had blood in brief during the noc. will leave report for dayshift nurse to follow up. Documented on [DATE] at 10:30 AM was Resident has had two episodes of bloody stool. She is stating she is having pain near her rectum, and is nauseous. BP ,d+[DATE] but is in the normal range for resident. NP has been notified as of [DATE] 0800. R181 was sent to the hospital and admitted from [DATE] through [DATE]. Hospital admission note documented: Assessment and Plan: Gl bleed C/o loose dark maroon stools × 3 days Just hospitalized in Jan w/ Gl bleed; received 1 unit PRBC, had NM bleeding scan Recent colon resection [DATE]; this could be [secondary] to surgery Hgb 9.1 (prior ,d+[DATE] range); BUN 21 Type and screen done Started on [MEDICATION(S)] 40mg [twice daily (BID)] IV; Held home [MEDICATION(S)] PO, IV fluids 100cc/hr Gen surgery already on for pneumoperitoneum; await further advice [hemoglobin and hemtocrit (H&H)] q6 hrs; monitor [Telemetry] . Pneumoperitoneum Confirmed on CT imaging Recent surgery at Ascension for incarcerated hernia and bowel perforation, had colon resection [DATE]- still has surgical drain in place ED provider contacted [Surgeon-AA] at Ascension; no beds available [MD of general surgery] consulted; no urgent need for surgery at this time; await further advice [nothing by mouth (NPO)] C diff infx C/o diarrhea x 3 days tested + 2 days ago; wasn't on [treatment (tx)]; per ED provider [facility] couldn't get hold of a doc to get tx Was started in ED on oral [MEDICATION(S)]; will continue . Mild acute kidney injury Creatinine 1.06 (typically under 1) Given 600ml IV fluids in ED; continue at 100 cc/hr Likely [secondary] to dehydration and/or meds Avoid nephrotoxins today Am labs ordered, monitor [CONDITION(S)] K+ 2.8 Supplemented 20 meq in ED; will order another 40 meq Likely [secondary] to home medication/diarrhea AM labs ordered; monitor . Patient Discharge Summary with a date of [DATE] documented: .admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Secondary Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Hospital Course: [R181] is a(n) 75 Y female who presents with bloody diarrhea for 3 days prior to admission. Patient also complained of 10 out of 10 generalized abdominal pain with associated nausea and vomiting. Patient was noted to have recently been hospitalized in [DATE] with Gl bleed receiving 1 unit packed red blood cells. She also has a history of saddle PE with right heart strain status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient still had a JP drain in place at the time of her presentation to our facility. CT imaging showed concern for pneumoperitoneum however after review by [MD] and clinical evaluation he suspected the pneumoperitoneum was secondary to the JP drain so this was removed. She was also seen in consultation by Gl who determined the patient's hematochezia and diarrhea was from C. difficile infection. For this the patient was started on oral [MEDICATION(S)] for 14 days total. Patient's stools were formed and infrequent prior to her discharge. Additionally patient had no further Gl blood loss prior to her discharge. She was seen by [cardiology] who indicated patient did not need to continue her [MEDICATION(S)] given her recurrent GI bleeding and the presence of an IVC filter placed. Patient has been advised to follow- up with [Cardiologist-BB] to discuss continued use of her [MEDICATION(S)]. Around the time of discharge it was noted the patient had some superficial necrosis of the incision area therefore the top of 8 staples were removed by [MD] and the other staples are to be left in place for at least another week. Patient has been advised to follow-up with [Surgeon-AA] who performed the surgery at Ascension for further instruction. Patient has been cleared by all consultants for discharge today and follow-up as indicated. Patient is agreeable and eager anticipating her discharge today . Lab values: POTASSIUM 4.0 Range: 3.4 - 5.1 mmol/L . BUN 8 Range: 7 - 26 mg/dL . CREATININE 0.79 Range: 0.50 - 1.10 mg/dL . After Visit Summary with a date of [DATE] documented: What's Next: -Schedule an appointment with [Primary MD] as soon as possible for a visit in 1 week(s) -Schedule an appointment with [Cardiologist-BB] as soon as possible for a visit in 1 week(s) -Schedule an appointment with Ascension physicians' general surgery [Surgeon-AA] as soon as possible for a visit in 1 week(s) . Surveyor reviewed R181's stool sample and Urine Culture collected [DATE] at the facility. Surveyor noted labs were sent to the facility [DATE] and [DATE] but not reviewed or followed up on until [DATE] when resident had already been hospitalized for 4 days. Surveyor reviewed Admission Data Collection and Skin - Head to Toe Skin Checks assessment with a date of [DATE]. Documented was .Site: 14) Abdomen; Type: Surgical Incision . There was no comprehensive assessment documented of the abdominal incision. Surveyor reviewed Readmission MD Orders for R181. There were no MD orders in place for the abdominal incision treatment, management or monitoring. Surveyor reviewed Comprehensive Care Plan for R181. There was no care plan added for the abdominal incision care, management or monitoring. Surveyor reviewed R181's EMR. There was no documentation that follow up appointments were made with Surgeon-AA or Cardiologist-BB. Surveyor reviewed Comprehensive Care Plan for R181. There was no care plan in place for the abdominal incision or GI assessments, management or monitoring. Surveyor reviewed R181's vital signs. On [DATE] the resident's blood pressure was ,d+[DATE], pulse 77. This was the last set of vital signs taken until [DATE]. On [DATE] NP-CC visited R181 again. Visit note documented .HPI: [AGE] year old female seen today for re H&P for C-diff, perforation of intestine, saddle [CONDITION(S)]. Patient and writer discuss plan of care. Patient is in no acute distress . Physical Exam: abdomen with surgical staples, protrusion of abdomen decreased tender to palpation . ASSESSMENT/PLAN: 1. C-diff, stable on vanco. 2. Perforation of intestine, stable follow up with surgeon encouraged. 3. Saddle [CONDITION(S)]- stable blood thinner stopped in hospital, IV filter in place. There was no comprehensive assessment of the abdominal incision. There is no instruction or orders for monitoring of R181's GI system, BP or documentation of nursing to schedule follow up appointment. Surveyor reviewed MD Orders for R181 placed by NP-CC on [DATE]. Documented was: [MEDICATION(S)] Tablet 20 MG: Give 1 tablet by mouth one time a day for diuretic. [MEDICATION(S)] HCl Tablet 4 MG: Give 1 tablet by mouth with meals for nausea. Admission Labs. Surveyor noted there was no order for a potassium supplement with the diuretic order per standard practice. According to American Family Physician, [CONDITION(S)] and [CONDITION(S)] are common electrolyte disorders caused by changes in potassium intake, altered excretion, or transcellular shifts. Diuretic use and gastrointestinal losses are common causes of [CONDITION(S)], whereas kidney disease, [CONDITION(S)], and medication use are common causes of [CONDITION(S)]. When severe, potassium disorders can lead to life-threatening cardiac conduction disturbances and neuromuscular dysfunction. Therefore, a first priority is determining the need for urgent treatment through a combination of history, physical examination, laboratory, and electrocardiography findings. Indications for urgent treatment include severe or symptomatic [CONDITION(S)] or [CONDITION(S)]; abrupt changes in potassium levels; electrocardiography changes; or the presence of certain comorbid conditions. [CONDITION(S)] is treated with oral or intravenous potassium. To prevent cardiac conduction disturbances, intravenous calcium is administered to patients with hyperkalemic electrocardiography changes . Causes: GI losses are another common cause of [CONDITION(S)], particularly among hospitalized patients.9 The mechanism by which upper GI losses induce [CONDITION(S)] is indirect and stems from the kidney's response to the associated alkalosis. As a portion of daily potassium is excreted in the colon, lower GI losses in the form of persistent diarrhea can also result in [CONDITION(S)] and may be accompanied by hyperchloremic acidosis. https://www.aafp.org/afp/,d+[DATE]/p487.html#:~:text=[CONDITION(S)]%20is%20treated%20with%20oral,patients%20with%20hyperkalemic%20electrocardiography%20changes Surveyor reviewed R181's labs faxed to the facility at 4:09 PM on [DATE]. Results included: POTASSIUM 3.0 (L) Range: 3.4 - 5.1 mmol/L . Noted on the top was sent to NP-CC. NP-CC did not address the low potassium or schedule a potassium supplement that should have been added to [MEDICATION(S)] the loss of the potassium from the diuretic. NP-CC increased the [MEDICATION(S)] from as needed to scheduled and as needed with no other instructions or reasoning. Surveyor reviewed MD orders. Documented on [DATE] with a start date of [DATE] was Klor-Con 10 Tablet Extended Release 10 MEQ (Potassium Chloride ER), Give 1 tablet by mouth one time a day for low potassium. There were no repeat labs ordered to check the level of the low potassium from [DATE]. From [DATE] through [DATE] there were no assessments, no treatments, no vital signs, and no gastrointestinal assessments. Surveyor reviewed Administration Note for R181 from [DATE] at 10:11 AM which documented wrap lower extremities in kerlix then ace wrap. everyday shift for [CONDITION(S)]; no [CONDITION(S)] this shift. There was no assessments of the [CONDITION(S)] and no other assessments of R181. Surveyor reviewed Progress Notes for R181. Documented on [DATE] at 8:10 PM was Distal abdominal incision noted

Based on observation, interview, and record review, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent the development of pressure injuries for 1 (R11) of 4 residents reviewed for pressure injuries. R11 was admitted to the facility on [DATE] with a Stage 4 pressure injury to the sacrum that was not comprehensively assessed until 2/25/2022 and a treatment not in place until 2/22/2022. There was no documentation the physician was notified of the new skin impairment. R11 was determined to be at high risk for the development of pressure injuries, but did not have any interventions in place to float the heels or have heel boots until R11 developed a stage 3 pressure injury to the right foot and an unstagable pressure injury to the left foot. On 4/25/2022, R11 was discovered to have developed a stage 3 pressure injury to the right outer plantar aspect of the right foot. On 4/26/2022, R11 was discovered to have an unstagable pressure injury to the outer plantar aspect of the left foot. R11 was observed to have both feet pressed against the footboard of the bed on 4/25/2022 and 4/26/2022. A comprehensive assessment was not completed when the pressure injuries were discovered on 4/25 and 4/26/2022, and the care plan (addressing the removal of R11's foot board) was not revised to prevent further damage, until 4/27/2022. Findings include: The facility policy and procedure entitled Skin Management dated 7/2017 states: 4. Residents admitted with skin impairments will have: a. Interventions implemented to promote healing; b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] c. Wound location and characteristics documented in the Nursing Admission Data Collection Set (UDA); . e. Notification of the presence of skin Impairment to the resident's representative and attending physician and documentation in the Nursing Admission Data Collection Set (UDA) or Progress Notes; f. Completion of the Weekly Pressure Condition Record for pressure ulcers . 5. A Care Plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. 7. If a new pressure ulcer is identified, either upon admission, readmission, or during the resident's stay, the wound is, assessed and documented on the Weekly Pressure Ulcer Record (UDA). 8. The licensed nurse will document daily monitoring of pressure ulcers on the Treatment Administration Record (TAR). 9. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ONGOING SKIN ASSESSMENTS: 1. A 'Weekly Skin Check' will be completed in the resident's record using the Head to Toes Skin Check (UDA) (User-Defined Assessment). Note: Alterations or change(s) in skin integrity, breaks in the resident's skin including skin tear, bruises, abrasions, ulcers, rash, surgical wounds etc., are recorded on the Head to Toe Skin Check UDA. 2. An SBAR Communication Form and Progress Note (UDA) is completed and a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The nurse will initiate treatments, interventions, Care Plan, and the appropriate skin documentation records in a timely manner according to Practice Guidelines. 4. Pressure ulcers are measured and staged in accordance with the Practice Guidelines. R11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's hospital Discharge Summary dated 2/17/2022 indicated an active problem list included a Stage 3 pressure injury to the left buttock noted on 9/21/2021 and a Stage 4 pressure injury to the sacral region noted on 12/12/2019. Review of the hospital paperwork did not show any active treatment or assessments of any pressure injuries to the left buttock or sacral region. No treatment orders were sent from the hospital on discharge. On 2/17/2022 on the Admission Data Collection form, nursing documented in the Skin Integrity section R11 had a perineal cyst to the sacrum. The wound had no measurements or descriptive characteristics. R11's Pressure Ulcer to Sacrum Stage IV Care Plan initiated on 2/18/2022 had the following interventions: -Administer treatments as ordered and observe for effectiveness. -Assist to reposition and/or turn at frequent intervals to provide pressure relief. -Evaluate and treat by the wound doctor as needed. -Observe dressing to ensure it is intact and adhering; report loose dressing to Treatment nurse. -Provide incontinence care after each incontinence episode, or per established toileting plan. -Pressure relieving mattress. -When up in wheelchair, ensure a cushion is in chair. R11's Potential Risk for Impairment to Skin Integrity Care Plan initiated on 2/18/2022 had the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Identify/document potential causative factors and eliminate/resolve where possible. -Keep skin clean and dry; use lotion on dry skin. -Monitor dressing to ensure it is intact and adhering. -Provide treatment as ordered. -Use a draw sheet or lifting device to move resident. -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. There was no documentation the MD was notified on admission of the pressure injury to the sacrum on 2/17/22. On 2/21/2022, a treatment order was received to cleanse the left lateral buttock wound with soap and water and apply a foam bordered gauze daily. On 2/23/2022, the treatment order was changed to cleanse the left lateral buttock with normal saline, apply skin prep to the surrounding area, pack the wound with [MEDICATION(S)], and cover with border gauze daily. On 2/24/2022, R11's Braden assessment had a score of 12 indicating R11 was at high risk for pressure injury. R11's Admission Minimum Data Set (MDS) assessment dated [DATE] indicated R11 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 00 and needed extensive assistance with all activities of daily living including bed mobility, eating, toilet use, and hygiene. The Care Area Assessment for Pressure Injuries state: Resident has impaired mobility requiring assistance for (R11's) mobility & repositioning which places (R11) at increased risk for further pressure ulcer development. (R11) also has incontinence issue which is another contributing issue due to exposure of skin to moisture. (R11) is S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] & debridement of soft tissue resulting to generalized weakness and a decline in (R11's) functional status. (R11) is WBAT (weight bearing as tolerated) to LLE with surgical shoe at present. (R11) uses broda chair for (R11's) general mobility and working with PT/OT for strengthening and in improving (R11's) mobility status. (R11) is a hoyer lift for all transfers. (R11) is also working with ST (speech therapy) due to cognition & swallowing issue which (R11) is on mechanical soft diet. (R11) has chronic dementia which is another complicating issue in addition t [sic] [CONDITION(S)] with hypoventilation, CKD (chronic kidney disease) & asthma. Needs anticipated per staffs at all times due to severe cognitive impairment R/T (related to) dementia. On 2/25/2022 on the Weekly Pressure Ulcer Record, Director of Nursing (DON)-B charted the sacrum Stage 4 pressure injury was present on admission and measured 0.7 cm x 0.6 cm x 2.0 cm with the wound bed unable to be seen due to the area being tunneled. DON-B charted the wound physician described the wound as having early/partial granulation with a small amount of serous drainage. DON-B noted this was the first wound round assessment of the pressure injury. R11 had been admitted on [DATE] and the first comprehensive assessment was on 2/25/2022, eight days after admission. The Stage 4 sacral pressure injury was comprehensively assessed and documented on weekly after 2/25/2022. R11's Pressure Ulcer to Sacrum Stage IV Care Plan was revised on 2/25/2022 with the following interventions: -Administer medications as ordered; observe/document for side effects and effectiveness. -Assess/record/observe wound healing; measure length, width and depth where possible; assess and document status of wound, perimeter, wound bed and healing progress; report improvements and declines to the physician. -Complete a full body check weekly and document. -Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. On 3/3/2022, R11's Braden assessment score was 13 indicating R11 was at moderate risk for developing a pressure injury. On 3/10/2022, R11's Braden assessment score was 11 indicating R11 was at high risk for developing a pressure injury. R11's Pressure Ulcer to Sacrum Stage IV Care Plan was revised on 3/11/2022 with the following interventions: -Assist to reposition and/or turn at least every 2 hours to provide pressure relief. -Observe dressing during ADL care/incontinent care to ensure it is intact and adhering; report loose dressing to charge nurse. -Low air loss mattress. On 4/25/2022 at 9:26 AM, Surveyor observed R11 lying in bed in a hospital gown and a sheet covering the left side of the body with the right leg unclothed and uncovered. R11 had slid down in bed so the bottom of both feet were up against the foot board. On 4/25/2022, R11 was seen by Nurse Practitioner (NP)-CC. NP-CC documented in the NP notes nursing staff reported no new changes; R11 was alert and oriented times two, the right side of the neck was stiff, no pitting [CONDITION(S)] present in the upper extremities, and obese. On 4/26/2022 at 10:57 AM, Surveyor observed R11 lying in bed with a gown on and no sheet covering R11's feet. R11 had slid down in bed so both feet were up against the foot board. R11 did not have any heel boots on, any pillows under the calves to lift the heels off the bed, or any dressings to the feet. Surveyor observed two heel boots on R11's Broda chair in the room. R11's feet were very dry with excessive dry skin build-up on the toes of both feet. R11 stated the right foot hurt. Surveyor asked R11 if R11 could raise the right foot up. R11 complied. Surveyor observed the bottom of the right foot on the outer aspect of the ball of the foot to have an open area approximately 1.5 cm x 1.5 cm with a red wound base and callous-type skin surrounding the wound. Surveyor asked R11 if R11 could raise the left foot up. R11 complied. Surveyor observed the bottom of the left foot on the outer aspect of the ball of the foot to have a wound measuring approximately 3 cm x 2 cm with necrotic tissue. The lateral aspect of the left foot had an area that measured 1 cm x 1 cm with eschar. Surveyor reviewed R11's chart after the observation of R11's feet on 4/26/2022. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Referral to the wound physician for wound care for foot ulcers. -Heel boots on while in bed in the evening for wounds on feet. -Right sole of foot-[MEDICATION(S)] and foam border dressing daily one time a day for wound care to start on 4/27/2022. No documentation of a comprehensive assessment of the left foot wounds was found. No change in R11's Care Plan was found. No documentation of the physician being notified of the new skin alteration was found. On 4/26/2022 at 1:42 PM, Surveyor observed R11 sitting in a Broda chair in the TV community area. R11 had bare feet; no heel boots or dressings were observed. In an interview on 4/26/2022 at 1:55 PM, Surveyor asked Certified Nursing Assistant (CNA)-P what staff member was caring for R11 that day. CNA-P stated CNA-P was caring for R11 and is a total care resident. Surveyor asked CNA-P if any wounds were noticed that morning when doing morning cares with R11. CNA-P stated R11 got a bed bath that morning and CNA-P did not notice any wounds when cleaning R11 up. CNA-P stated R11 had a dressing on the backside but was told that is changed on second shift. In an interview on 4/26/2022 at 1:58 PM, Surveyor asked RN-J about the wound care orders RN-J had entered into R11's medical record that morning. RN-J stated the wound to R11's feet was reported to RN-J at change of shift that morning by the night shift nurse and NP-CC was going to look at the wounds today. RN-J stated the second shift nurse yesterday, 4/25/2022, called NP-CC about the wounds. RN-J stated RN-J transcribed the orders into the computer after NP-CC looked at R11's feet. Surveyor asked RN-J if RN-J had looked at R11's feet. RN-J stated RN-J looked at R11's feet with NP-CC and NP-CC ordered [MEDICATION(S)] to the right foot wound, but that is not in stock. RN-J stated the wound on the right foot was dry and calloused and the wound on the left foot was had been there before. Surveyor asked RN-J if any measurements were taken of the areas. RN-J stated no, RN-J just looked at the feet. On 4/26/2022 at 2:13 PM in the progress notes, RN-J charted NP-CC was notified by the facility nurse that R11 had a wound to the right foot. RN-J observed the wound with NP-CC. The wound was dry at that time. There was also a dry callous type wound to the outer left foot. Both areas were dry and open to the air. R11 appeared to have no non-verbal signs of pain or discomfort to the feet. Boots were applied to bilateral feet for comfort. On 4/26/2022 at 2:35 PM in the progress notes, RN-J charted RN-J was updated regarding areas noted on the feet. RN-J assessed R11's feet to update Wound Physician-K. R11 was noted to have a small 0.5 cm x 0.7 cm open area to the plantar aspect of the foot at the base of the fifth toe; the area is open and dry. RN-J charted to leave open to air and update the physician. RN-J charted the area that was noted to the left lateral foot was dried calloused scar tissue from a resolved wound with no signs or symptoms of infection; the physician will be updated. On 4/26/2022 at 2:46 PM in the progress notes, RN-J charted Wound Physician-K had been updated regarding the noted areas. RN-J charted Wound Physician-K said to leave both feet open to the air and will be evaluated during rounds on 4/27/2022. No documentation was found of a comprehensive assessment of the right and left feet pressure injuries and the Care Plan was not revised to prevent further damage. On 4/26/2022 at 9:33 PM in the progress notes, nursing charted: Writer went to do this Pt. dressing to (R11's) coccyx wound, when we noticed blood on this Pt. right foot and the foot board of (R11's) bed. writer looked at (R11's) right foot and noted on the sole of (R11's) foot, just below (R11's) fifth digit there was an open area, about the size of a dime. and about 1/8 inch in depth. There had been a callous over that area. Pt. was so low in the bed (R11's) foot had been rubbing against the footboard and writer believes that's what opened up the callous. Writer cleaned the area with normal saline, and applied a border gauze to the area. Writer then called the NP and told her about the wound, and asked her to please see it in the AM. Then staff pulled (R11) up in the bed so (R11's) feet weren't touching the foot of the bed. No documentation of an assessment to R11's left toes were found. On 4/27/2022 at 9:16 AM, Surveyor observed R11 sleeping in bed. R11 had heel boots on. In an interview on 4/27/2022 at 9:33 AM, NP-CC stated the facility has an in-house wound doctor that does all the wounds. NP-CC stated NP-CC saw R11 yesterday, 4/26/2022, and saw R11's feet; one foot had a dry-looking ulcer and the right foot had wound orders because it was open. NP- stated the toes needed help, too. NP-CC stated the night nurse texted NP-CC on Monday night, 4/25/2022 at 9:33 PM, to look at R11's feet in the morning. NP-CC stated the nurse texted NP-CC about a small open area to the sole of the right foot just under the small toe; that was the only area that was reported. NP-CC stated the nurse cleaned it up and put a bandage on it. NP-CC stated no treatment orders were given at that time. NP-CC stated heel booties were ordered after NP-CC saw R11's feet on 4/26/2022. NP-CC stated nothing was actively bleeding at that time and put in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked NP-CC if a progress note had been written after the visit as it was not in R11's medical record. NP-CC stated yes, a note was written and NP-CC sends it in to medical records where it is scanned into the chart. NP-CC read from the NP note that the right foot ulcer was open and the left foot ulcer was dry. NP-CC stated wound care, heel boots and a referral were also in the note as orders. Surveyor asked NP-CC who does a comprehensive assessment of the wound. NP-CC stated the nurse is expected to do the measurements. Surveyor asked NP-CC what the expectation for documentation was. NP-CC stated NP-CC would expect an assessment by the nurse that found the wounds with notification of the NP and the fact that the nurse dressed the wounds documented. Surveyor reviewed NP-CC NP note dated 4/26/2022. The chief complaint was follow-up on the right plantar ulcer, left plantar ulcer, and muscle weakness. The note states: R11 was seen today for reports from nursing of wound to bottom of right foot. Patient is stable in no acute distress. The physical exam states: right foot ulcer underneath 5th toe, open, reddened wound bed, left foot dry ulcer to lateral side of foot, flaking and thickened skin to bilateral feet. No measurements of the wound were documented. On 4/27/2022 at 2:17 PM, Surveyor observed wound care with Wound Physician-K, Registered Nurse (RN)-L, and Certified Nursing Assistant (CNA)-M. R11 was rolled onto the left side with heel boots on. The sacral wound dressing was removed, and the packing was removed. Wound Physician-K measured the depth of the sacral wound: 0.8 cm deep. RN-L packed the wound with [MEDICATION(S)] gauze and covered with a bordered dressing. Wound Physician-K assessed the right lateral foot wound; the wound was a Stage 3 pressure injury. RN-L stated R11 used to have a callous over that area at one point. Wound Physician-K assessed the left lateral foot wound; the wound was an Unstageable pressure injury. RN-L stated the area is close to where R11 had the surgery to the fifth toe. Surveyor shared with Wound Physician-K and RN-L the observations on 4/25/2022 and 4/26/2022 of R11 having both feet pressed up against the foot board. Wound Physician-K stated the foot board needed to be removed from the bed to prevent further damage and RN-L removed the foot board at that time. RN-L stated R11 had no wounds on the feet last week. Surveyor asked RN-L what the process was when a new skin issue is found. RN-L stated DON-B is told about a wound and then passes that information on to RN-L and the resident is assessed on wound rounds with RN-L and Wound Physician-K. RN-L stated RN-L was told verbally yesterday to look at R11's feet. Surveyor told RN-L no assessment was completed by the nurse that found the wounds. Surveyor asked RN-L what the expectation was for the nurses in the facility when a new area is found. RN-L stated the resident gets a head-to-toe skin check done once a week by the nurses and they would document any new areas there and then an SBAR (Situation, Background, Assessment, Recommendation) should be completed with a progress note of the new area. Surveyor reviewed Wound Physician-K's documented assessment on 4/27/2022. Wound Physician-K charted the left distal/lateral foot had an Unstageable pressure injury that measured 1.97 cm x 1.55 cm x 0.1 cm with eschar. The right lateral foot had a Stage 3 pressure injury that measured 1.54 cm x 1.34 cm x 0.1 cm with 51-75% granulation and 1-25% slough. Treatments were ordered for each wound. On 4/27/2022 on the Weekly Pressure Ulcer Record, RN-L charted the left distal/lateral foot had an Unstageable pressure injury that measured 1.97 cm x 1.55 cm x 0.1 cm with 100% eschar. The treatment note stated [MEDICATION(S)] followed by ABD and Kerlix. The wound notes stated: Wound care right posterior calf blister: cleanse with normal saline, pat dry, place silver alginate over wound and cover with border foam dressing. This was not the correct location or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/27/2022 on the Weekly Pressure Ulcer Record, RN-L charted the right plantar foot had a Stage 3 pressure injury that measured 1.54 cm x 1.34 cm x 0.1 cm with 25% slough and 75% granulation. The treatment note stated half-strength Dakin's wash, skin prep peri-wound, and Santyl to the wound bed followed by border gauze. The wound notes stated: reviewed risks and benefits of repositioning, floating heels while in bed, and good nutritional intake up to and including death. On 4/28/2022 at 3:31 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concerns regarding R11's pressure injuries. On admission, R11's sacral Stage 4 pressure injury was not comprehensively assessed for eight days with no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's right foot pressure injury was discovered on 2/25/2022 by the second shift nurse; no comprehensive assessment or documentation of the wound was completed and there was no documentation the physician or NP were notified. The left foot pressure injury was discovered on 4/26/2022 by NP-CC when NP-CC assessed the right foot. No comprehensive assessment was completed by NP-CC or RN-J when following up on the notification made by the nurse the day before in a text message to NP-CC. The pressure injuries were not comprehensively assessed until 4/27/2022 when R11 was seen by the wound physician and the cause of the pressure injuries, the foot board of the bed, was not addressed until Surveyor brought the observation of R11 with feet pressed up against the foot board to Wound Physician-K. No further information was provided at that time.

Based on observation, interview, and record review the facility did not ensure that 2 (R1, R6) of 2 residents with pressure injuries received assessments in accordance with facility's policy and procedure, that care plan interventions were put into place to prevent pressure injuries from developing to to prevent current pressure injuries from worsening. *R1 was admitted to the facility on [DATE] and was at risk for pressure injuries. On 1/24/22, R1 was noted with a pressure injury to the sacrum which was not assessed by an RN (Registered Nurse) from 1/24/22-2/2/22. There was no revision to the care plan or monitoring to ensure consistent turning. On 2/2/22, R1 was seen by the facility's wound physician who staged R1's sacrum as an unstageable pressure injury. The facility did not have an RN conduct a comprehensive assessment of R1's pressure injuries, including staging and wound characteristics until 2/2/22. The facility did not implement the intervention of an alternating air mattress until 2/3/22 per facility documentation. The facility did not revise R1's skin integrity care plan to address R1's unstageable pressure injury until 2/8/22. The Facility failure to have an RN perform an assessment or accurate staging for R1's pressure injury and implement appropriate care measures for 9 days when the area was identified on 1/24/22, to not identify the area as an unstageable pressure injury until 2/2/22, which is later identified by a physician as a stage 4 pressure injury, created a finding of Immediate Jeopardy (IJ) which began on 2/2/22. Administrator-A and Director of Nursing B was notified of the Immediate Jeopardy on 3/8/22 at 3:55 P.M. The Immediate Jeopardy was removed on 3/14/22. The deficient practice continues at a scope and severity level of a G (harm/isolated) as the facility continues to implement its action plan and as evidenced by: *R6 was identified to have an unstageable pressure injury to the right heel which was not properly assessed by facility staff. Findings include: 1. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's significant change Minimum Data Set (MDS) assessment dated [DATE] indicates R1 has a BIMS (Brief Interview of Mental Status) score of 00, indicating R1 is unable to participate in daily decision making. R1's significant change MDS dated [DATE] indicates R1 requires extensive assistance of 1 staff with bed mobility, limited assistance of 1 staff with transfers and extensive assistance of 1 staff with dressing, personal hygiene, toileting and total dependence of 1 staff for bathing. R1 has impairment to the right lower extremity due to right femur fracture. Significant change MDS dated [DATE] indicates R1 was at risk for pressure injuries due to immobility. Significant change MDS dated [DATE] indicates that R1 did not currently have a pressure injury. On 1/12/22, A Braden Scale assessment was conducted for R1. A score of 18 was noted, indicating R1 was at risk for pressure injuries. Surveyor conducted a review of R1's EMR (Electronic Medical Record), including physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress notes indicate that an open area was identified on 1/24/22 by LPN (Licensed Practical Nurse)-C. A head to toe skin check document dated 1/24/22 documents the following: coccyx: 1 cm x 0.5 cm x 0.1 cm, stage: 1. Surveyor did not find any wound characteristics in the documentation including a description of the wound bed and presence of or amount of drainage. On 1/24/22 an order was put into place to cleanse with normal saline, pat dry, apply [MEDICATION(S)] and cover with foam dressing daily for wound care. There was no RN assessment of the wound, which could not be a stage 1 because the wound had depth. Surveyor could not locate an assessment of R1's pressure injury until 2/2/22 when R1 was seen by facility's wound physician. On 2/2/22, the facility's wound physician documents the following: Location: sacrum, etiology: pressure injury, unstageable, 2.45 cm x 2.48 cm x 1.0 cm, Wound bed assessment: 75% slough tissue, 25% granulation tissue. A new treatment order was ordered by Wound MD-I on 2/2/22. Treatment was ordered for sacrum ---- cleanse with Dakin's solution to wound bed with a wet to dry gauze dressing and cover with a secure dressing, change twice daily. On 2/9/22, the facility's wound physician documents the following: Location: sacrum, etiology: pressure ulcer-stage 4, 3.58 cm x 3.62 cm x 2.0 cm, Wound bed assessment: 75% slough tissue, 25% granulation tissue. Drainage amount: small, serous. Undermining: 5.2 cm. The treatment continued for Dakin's solution with a wet to dry dressing to be changed daily at this time. On 2/16/22, the facility's wound physician documents the following: Location: sacrum, etiology: pressure ulcer-stage 4, 3.17 cm x 4.7 cm x 1.3 cm, Wound bed assessment: 25% slough tissue, 75% granulation tissue. Drainage amount: moderate, serous. Undermining: 6.0 cm. A new treatment order was ordered by Wound MD-I on 2/16/22 to cleanse wound with silver alginate, cover and change 2 times daily. This order was implemented by facility on 2/21/22. Surveyor reviewed R1's MAR for January and February 2022. Surveyor identified treatments in place for R1's sacral pressure injury from 1/24/22 to 2/23/22. Surveyor reviewed R1's skin integrity care plan with an initiation date of 12/8/21 and revision dates of 2/21/22 which includes interventions of monitoring wounds and conducting wound assessments including measurements and weekly assessments, treatment as indicated and frequent repositioning, and floating heels when in bed. On 2/8/22, a new skin integrity care plan was initiated, which reads that R1 has an unstageable pressure area to the coccyx-facility acquired. New intervention initiated 2/8/22 reads I have special ointments/and or bandages prescribed by my doctor and I need those to be applied as directed. No initial care plan revision was noted on 1/24/22 when R1's facility acquired pressure injury was first noted or on 2/2/21 when the wound MD noted that the wound had deteriorated to a stage 3. On 2/21/22 at 11:30 am, Surveyor observed R1 in bed, positioned on the right side with a pillow between legs. An alternating air mattress is in place. R1's heels were observed directly on the mattress at this time. On 2/21/22 at 1:45 pm, Surveyor observed R1 in bed, positioned on the right side with a pillow between the legs. An alternating air mattress is in place. R1's heels were observed directly on the mattress at this time. On 2/21/22 at 3:50 pm, Surveyor observed R1 in bed, positioned on the right side with a pillow between the legs. An alternating air mattress is in place. R1's heels were observed directly on the mattress at this time. On 2/22/22 at 12:45 pm, Surveyor observed R1 in bed, positioned on the right side with a pillow between the legs. An alternating air mattress is in place. R1's heels were observed directly on the mattress at this time. On 2/22/22 at 3:05 pm, Surveyor observed R1 in bed, positioned on the right side with a pillow between the legs. An alternating air mattress is in place. R1's heels were observed directly on the mattress at this time. On 2/23/22 at 8:20 am, Surveyor observed R1 in bed, positioned on the right side with a pillow between the legs. An alternating air mattress is in place. R1's heels were observed directly on the mattress at this time. 2/23/22 Surveyor reviewed R1's CNA documentation for the previous 30 days. Surveyor noted frequent missing documentation of R1 being repositioned. No documented refusals by R1 were noted for repositioning. On 2/22/22 at 3:20 pm, Surveyor conducted an interview with LPN-C. Surveyor asked what measures nursing staff would take if they identified a wound. LPN-C told Surveyor that they would measure the wound and make the facility's wound nurse and DON (Director of Nursing)-B aware of the wound. Surveyor asked LPN-C if an RN would be required to conduct an assessment of pressure injuries including wound measurements and characteristics of the wound. LPN-C responded that they are not sure when an RN would do a wound assessment and that LPNs are not allowed to stage wounds. LPN-C added that they remembered letting NP-H know about R1's sacral wound and that they put a treatment order in place. Surveyor asked LPN-C if wounds should be assessed weekly. LPN-C told Surveyor wounds should be assessed at least on a weekly basis. Surveyor asked LPN-C if a resident with pressure injuries or at risk for pressure injuries should have their heels floated while in bed. LPN-C responded Definitely. Surveyor asked LPN-C how often residents with pressure injuries should be repositioned. LPN-C told Surveyor that residents with pressure injuries should be repositioned at least every 2 hours, if not more often. On 2/23/22 at 8:25 am, Surveyor conducted an interview with LPN-E via phone. Surveyor asked what measures nursing staff would take if they identified a pressure injury. LPN-E told Surveyor that they would first determine what the root cause of the resident's pressure injury was from and then would measure wound and document the description of the wound. LPN-E added that they would notify NP-H to obtain wound treatment orders then notify the resident's family of the development of a wound. LPN-E would let the facility's wound nurse and DON know about any wounds. Surveyor asked LPN-E if an RN would be required to conduct an assessment of pressure injuries including wound measurements and characteristics of the wound on a weekly basis. LPN-E responded that wounds or pressure injuries should be measured and assessed by an RN weekly. Surveyor asked LPN-E if a resident with pressure injuries or at risk for pressure injuries should have their heels floated while in bed. LPN-E told Surveyor that anyone who is at risk for pressure injuries should have their heels floated while in bed. Surveyor asked LPN-E how often residents with pressure injuries should be repositioned. LPN-E told Surveyor that residents with pressure injuries should be repositioned at least every 2 hours. On 2/23/22 at 9:30 am, Surveyor conducted interview with MDS Coordinator-G. Surveyor asked what measures nursing staff should take if they identified a pressure injury. MDS Coordinator-G told Surveyor that they would not be in charge of pressure injuries for residents. MDS Coordinator-G added that the facility's wound nurse who is currently on leave from facility was in charge of wounds and that DON-B is responsible for wounds during wound nurse's absence. MDS Coordinator-G told Surveyor that R1's pressure injury was found by LPN-C. Surveyor asked MDS Coordinator-G if an RN would be expected to conduct an assessment of pressure injuries including wound measurements and characteristics of the wound on a weekly basis. MDS Coordinator-G responded that they think wounds should be documented weekly and staged by an RN weekly. Surveyor asked MDS Coordinator-G if a resident with pressure injuries or at risk for pressure injuries should have their heels floated while in bed. MDS Coordinator-G Yes, they should have their heels floated while in bed. Surveyor asked MDS Coordinator-G how often residents with pressure injuries should be repositioned. MDS Coordinator-G told Surveyor that residents with pressure injuries should be repositioned every 2 hours. On 2/23/22 at 11:10 am, Surveyor conducted an interview with RN Manager-F. Surveyor asked RN Manager-F what measures nursing staff should take if they identified a pressure injury. RN Manager-F told Surveyor that they would not be in charge of pressure injuries for residents and that the facility's wound nurse had been in charge of pressure injuries, including R1's pressure injuries. RN Manager-F added that the facility's wound nurse who is currently on leave from facility was in charge of wounds and that DON-B is currently responsible for wounds during wound nurse's absence and that RN Manager-F was out of the facility on leave in January 2022. Surveyor asked RN Manager-F if an RN would be expected to conduct an assessment of pressure injuries including wound measurements and characteristics of the wound on a weekly basis. RN Manager-F responded that wounds should be documented weekly and staged by an RN weekly. RN Manager-F told Surveyor that they don't know what happened with the assessment of R1's pressure injury and that the documentation seems poor. Surveyor asked RN Manager-F if a resident with pressure injuries or at risk for pressure injuries should have their heels floated while in bed. RN Manager-F responded Heels should always be floated when residents are in bed. Surveyor asked RN Manager-F how often residents with pressure injuries should be repositioned. RN Manager-F told Surveyor that residents with pressure injuries should be repositioned every 2 hours, if not more often. On 2/23/22 at 12:50 pm, Surveyor conducted an interview with RN-D. Surveyor asked RN-D what measures nursing staff should take if they identify a pressure injury. RN-D told Surveyor that they would measure wound and document the description of the wound. RN-D added that they would notify NP-H to obtain wound treatment orders then notify the resident's family of the development of a wound and would let the facility's wound nurse and DON know about wounds. Surveyor asked RN-D if an RN would be required to conduct an assessment of pressure injuries including wound measurements and characteristics of the wound on a weekly basis. RN-D responded that wounds or pressure injuries are to be measured and assessed by an RN weekly. Surveyor asked RN-D if a resident with pressure injuries or at risk for pressure injuries should have their heels floated while in bed. RN-D told Surveyor that anyone who is at risk for pressure injuries should have their heels floated while in bed. Surveyor asked RN-D how often residents with pressure injuries should be repositioned. RN-D told Surveyor that residents with pressure injuries should be repositioned at least every 2 hours. RN-D told Surveyor that R1 is being followed by the facility's wound doctor every week and that they perform R1's wound treatment when they work on the unit. On 2/23/22 at 1:24 pm, Surveyor conducted a phone interview with NP-H. NP-H told Surveyor that they had been made aware of R1's pressure injury by the facility on 1/24/22. NP-H recalled giving facility staff an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked NP-H if they would expect an RN to conduct a weekly assessments of pressure injuries including wound measurements and characteristics of the wound. NP-H responded, I think that should be done at least weekly. Surveyor asked NP-H if a resident with pressure injuries or at risk for pressure injuries should have their heels floated while in bed. NP-H responded Yes. Surveyor asked NP-H how often residents with pressure injuries should be repositioned. NP-H told Surveyor that they would expect residents with pressure injuries to have an air mattress and be repositioned at least every 2 hours. On 2/23/22 at 11:30 am, DON-B notified Surveyor that they are continuing to try to locate the facility wound nurse's wound rounds binder. DON-B indicated that they may have additional information related to R1's pressure injury. DON-B added that they wish they had more information on R1's pressure injury but that DON-B had been out of the facility on leave when R1's pressure injury was first identified and hadn't assessed the wound initially. DON-B confirmed that R1 had a alternating air mattress applied to their bed on 2/3/22. On 2/23/22 at 2:40 pm, Surveyor shared concerns with NHA-A and DON-B regarding multiple observations of R1's heels not being floated or consistently repositioned when in bed from 2/21/22-2/23/22. Surveyor shared additional concerns related to lack of pressure injury assessments from 1/24/22-2/2/22 for R1's sacral pressure injury. The facility did not provide additional information at this time related to R1's missing pressure injury assessments and the development of R1's pressure injury acquired at the facility. On 3/8/22 at 12:47 pm, Surveyor conducted an interview with Wound MD-I. Wound MD-I confirmed that they did not mechanically debride R1's pressure injury with a scalpel due to tissue not being thick enough. Wound MD-I confirmed that they had recommended the wet to dry dressing changes with Dakin's solution to manage the slough tissue for R1's sacral pressure injury. Wound MD-I confirmed that DON-B had notified them that Wound MD-I's treatment order for silver alginate was not initiated on 2/16/22 until 2/21/22. Wound MD-I confirmed that facility has immediate access to his wound documentation and that the order should have been implemented on 2/16/22. Wound MD-I could not confirm that the order for silver alginate not being implemented had caused deterioration to the wound as the granulation tissue remained intact. Wound MD-I told Surveyor that they had observations of resident with soiled wound dressings and often found incontinent of bowel and bladder when on wound rounds. The facility's failure to ensure R1, who was at risk for pressure injury development and who required extensive assistance with bed mobility, received appropriate care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The immediate jeopardy was removed on 3/14/22, when the facility implemented the following action plan: * Nursing Home Administrator contacted the Medical Director and advised of the deficiency. * The Interdisciplinary team (IDT) reviewed care plans for current at risk for pressure injury and current residents with pressure injury to ensure interventions/preventions measures are in place by 3/14/22. * Nurse Managers completed a skin sweep of current residents to identify any skin abnormalities and documented of these findings on the weekly Pressure worksheet. * All licensed nursing staff were educated by the Nurse Manager on ensuring resident's skin is assessed/measured upon admission/readmission and included wound staging and documentation. change in condition. * An RN will conduct assessments of a resident's pressure injury upon admission, readmission, and change in condition. * Education was completed on the IDT (Nursing) will review the hospital discharge recommendations/orders, physician orders, including wound physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] * All licensed nursing was educated by the Nurse Manager to ensure care plans were/are developed, implemented and revised based on individual assessments and needs. * All RCS/CNA were educated by the Nurse Manager on the identified equipment/interventions that are part of resident individual care plan. * The Director of Nursing (DON) or Nurse Manager will audit 3 residents from skin report to ensure accurate, timely, and thorough assessments 3 times a week for 2 weeks, then weekly thereafter until QA committee deems appropriate. * The DON or Nurse Manager will review Point Click Care (PCC), dashboard, 24-hour board, for new admissions skin assessment daily for 2 weeks, than 3 times a week for 2 weeks, then weekly thereafter until QA committee deems appropriate. * MDS/Designee will audit 3 resident care plans from skin report for appropriate intervention based on skin risk 3 times a week for 2 weeks then weekly thereafter until QA committee deems appropriate. * DON/Designee will audit/interview a random RCS weekly to ensure he or she knows equipment/interventions for residents individual care plans. * DON/Designee will make random audits of Treatment Administration Records comparing wound physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The deficient practice continues at a scope and severity of a G (actual harm/isolated) based upon the example regarding R6. 2. R6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Annual MDS (Minimum Data Set) dated 11/15/21 documents a BIMS (Brief Interview for Mental Status) score of 5, indicating that R6 is severely cognitively impaired. Section G (Functional Status) documents that R6 requires extensive assistance and one person physical assist for his bed mobility and transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents that R6 has no impairment to either side of both his upper and lower extremities. Section M (Skin Conditions) documents that R6 is at risk for the development of pressure ulcers/injuries and that at the time of the assessment, R6 had no open areas or pressure injuries present. R6's Skin Integrity care plan dated as initiated on 9/23/21 documents under the Focus section, Resident has Actual Skin Issues related to left coccyx - stage 2 noted on readmit from hospital - now healed; remains at increased risk for further pressure ulcer development due to DM (diabetes mellitus) and history of healed ulcer to right heel. Under the Interventions/Tasks section it documents, Skin checks weekly per facility protocol, document findings; while I am in bed encourage me to float my heels I frequently refuse to lay down and float my heel. R6's nursing note dated 9/23/21 documents, Skin/Wound Note Text: Resident admitted to facility with indwelling Foley, bruising to bil. (bilateral) forearm r/t (related to) IV (intravenous) placement in hospital, scabbing 1 cm x 0.5 cm to right heel, heels floated with pillows for pressure wound prevention, stage 2 pressure wound to L coccyx, no bleeding noted, hydrogel applied, covered with comfort foam drsg (dressing), tx (treatment) orders obtained, care plan updated, writer will add resident to rounds with wound MD (physician). Surveyor was unable to locate an initial assessment of R6's right heel pressure injury that included measurements, staging and description of the wound bed. Surveyor noted that the facility had care plan interventions prior to 9/23/21 to relieve and prevent pressure injuries for R6 that included: offloading heels, heel boot use, turn and reposition and skin checks. Surveyor noted that the facility had treatments for R6's heel in place from 9/23/21 to 2/23/22. Surveyor noted that R6's MAR (Medication Administration Record) documented that facility staff provided R6 with treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor was unable to locate weekly wound assessments for R6's right heel from 9/23/21 to 10/13/21. R6's Tissue Analytics dated 10/13/21 documents, Location: Right Heel; Length: 1.89 cm (centimeters); Width: 1.86 cm; Depth 0.10 cm; Etiology: Pressure Ulcer-Unstageable; Woundbed Assessment: Slough 76-100%. R6's Tissue Analytics dated 10/20/21 documents, Location: Right Heel; Length: 1.73 cm (centimeters); Width: 1.49 cm; Depth 0.10 cm; Etiology: Pressure Ulcer-Unstageable; Woundbed Assessment: Eschar. R6's Skin Weekly Pressure Ulcer Record dated 10/23/21 documents, Right Heel; Date of Onset: 1/21/20; Existing Pressure Ulcer; Site: Right Heel, Type: Pressure: Length: 0 cm, Width: 0 cm, Depth: 0 cm; Stage: N/A, Description of Site: Right Heel healed. Surveyor noted that despite R6's Weekly Pressure Ulcer Record dated 10/23/21 documenting that R6's right heel was healed, R6 continued to receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R6's Tissue Analytics dated 10/27/21 documents, Location: Right Heel; Length: 1.43 cm (centimeters); Width: 1.51 cm; Depth 0.10 cm; Etiology: Pressure Ulcer-Unstageable; Woundbed Assessment: Eschar. R6's Skin Weekly Pressure Ulcer Record dated 10/30/21 documents, Right Heel; Date of Onset: 1/21/20; Existing Pressure Ulcer; Site: Right Heel, Type: Pressure: Length: 0 cm, Width: 0 cm, Depth: 0 cm; Stage: N/A, Description of Site: Right Heel healed. Surveyor noted that despite R6's Weekly Pressure Ulcer Record dated 10/30/21 documenting that R6's right heel was healed, R6 continued to receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor was unable to locate any weekly wound assessments for R6's right heel from 10/30/21 to 11/16/21. R6's Pressure Ulcer/Injury CAA (Care Area Assessment) dated 11/15/21 documents under Analysis of Findings section, (R6) has decreased mobility requiring assistance for his mobility & repositioning which places him at risk for pressure ulcer development. He also has incontinence issue of B&B (bowel and bladder) which is another contributing issue due to exposure of skin to moisture in addition to history of healed pressure ulcer to right heel & coccyx . He is able to verbalize his needs and wants when asked. Under the Care Plan Considerations section it documents, (R6) has decreased mobility requiring assistance for his mobility & repositioning which places him at risk for pressure ulcer development . He is able to verbalize his needs and wants when asked. Heels off bed, incontinence care and skin checks will be maintained per facility's protocol. Will follow POC (plan of care) to prevent skin breakdown. R6's Tissue Analytics dated 11/17/21 documents, Location: Right Heel; Length: 0.98 cm (centimeters); Width: 1.39 cm; Depth 0.10 cm; Etiology: Pressure Ulcer-Unstageable; Woundbed Assessment: Granulation 51-75%, Slough 1-25%. Surveyor was unable to locate any weekly wound assessments for R6's right heel from 11/18/21 to 12/14/21. R6's Tissue Analytics dated 12/15/21 documents, Location: Right Heel; Length: 0.49 cm (centimeters); Width: 0.86 cm; Depth 0.20 cm; Etiology: Pressure Ulcer-Unstageable; Woundbed Assessment: Other. Surveyor was unable to locate any weekly wound assessments for R6's right heel from 12/16/21 to 1/14/22. R6's Skin Weekly Pressure Ulcer Record dated 1/15/22 documents, Right Heel; Date of Onset: 1/21/20; Existing Pressure Ulcer; Site: Right Heel, Type: Pressure: Length: 0 cm, Width: 0 cm, Depth: 0 cm; Stage: N/A, Description of Site: Right Heel healed. Surveyor noted that despite R6's Weekly Pressure Ulcer Record dated 1/15/22 documenting that R6's right heel was healed, R6 continued to receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R6's Tissue Analytics dated 1/19/22 documents, Location: Right Heel; Length: 0.79 cm (centimeters); Width: 0.75 cm; Depth 0.10 cm; Etiology: Pressure Ulcer-Unstageable; Woundbed Assessment: Other. R6's Tissue Analytics dated 2/2/22 documents, Location: Right Heel; Length: 0.60 cm (centimeters); Width: 0.91 cm; Depth 0.10 cm; Etiology: Pressure Ulcer-Unstageable; Woundbed Assessment: Other. Surveyor noted that the facility began completing weekly skin assessments from 1/20/22 to 2/18/22. R6's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 18, indicating that R6 is at risk for the development of pressure ulcers/injuries. R6's Skin Weekly Pressure Ulcer Record dated 2/18/22 documents, Right Heel; Date of Onset: 9/23/21; Existing Pressure Ulcer; Site: Right Heel, Type: Pressure: Length: 0 cm, Width: 0 cm, Depth: 0 cm; Stage: N/A, Description of Site: Healed. On 2/22/22 at 2:58 p.m., during the daily exit, Surveyor informed DON (Director of Nursing)-B and NHA (Nursing Home Administrator)- A of the above findings. Surveyor asked DON-B if R6 had any weekly wound assessments for his right heel completed from 9/23/21 to 10/13/21, from 10/30/21 to 11/16/21, from 11/18/21 to 12/14/21 and from 12/16/21 to 1/14/22, as Surveyor was unable to locate any in R6's medical record. DON-B informed Surveyor that the facility was unable to locate the wound binder where the weekly assessments were located but that she would continue searching and let Surveyor know. Surveyor asked DON-B if R6's above Skin Weekly Pressure Ulcer Record assessments were accurate, as they documented R6's right heel was healed but R6's Tissue Analytics assessments, completed by R6's wound physician, did not. DON-B informed Surveyor that she believed that nursing probably made errors in the documentation of R6's right heel assessments and informed Surveyor that R6's Tissue Analytics assessments were accurate as they were completed by R6's wound physician. On 2/23/22 at 10:33 a.m., Surveyor requested to see R6's right heel. DON-B and Surveyor observed R6's right heel together and Surveyor observed R6's right heel to not be healed. Surveyor observed R6's right heel to have Eschar over the wound measuring approximately 0.3 cm x 0.6 cm. Surveyor asked DON-B if R6's right heel was still unstageable and not healed. DON-B confirmed the above findings and informed Surveyor that she would reassesses R6's right heel and let R6's physician know of the open area. R6's Skin Weekly Pressure Ulcer Record dated 2/23/22 documents, Right Heel; Date of Onset: 9/23/21; Existing Pressure Ulcer; Site: Right Heel, Type: Pressure: Length: 0.3 cm, Width: 0.6 cm, Depth: 0 cm; Stage: Unstageable, Description of Site: Hard Yellow Scab. On 2/23/22 at 1:46 p.m., DON-B informed Surveyor that she was unable to locate any additional weekly wound assessments for R6's right heel. No information was provided as to why the facility did not ensure that R6 received care, consistent with professional standards of practice, to prevent the development of pressure injuries.

Based on record review and interview, the facility did not ensure that a resident who enters the facility without a Pressure Injury (PI) does not develop a PI and a resident with a PI receives appropriate care, treatment, and preventative interventions to promote healing for 2 of 4 residents reviewed (R9 and R5) for PI's. The facility did not implement an aggressive care plan on admission for R9 who had previously been independent but now needed extensive assist with bed mobility, repositioning and transferring. When a pressure injury developed on 4/17/20, the facility incorrectly called it a non-pressure wound and did not implement aggressive measures at this time to keep it from worsening. The facility did not update the physician until 3 days later on 4/20/20, did not begin treatment until the next day on 4/21/20, and did not update the care plan until 4/24/20. Subsequently, when the wound became bigger, the facility did not immediately notify the physician, revise treatment or change the care plan. The facility never implemented a care plan with a specific turning schedule until the MD gave orders on 5/6/20 to turn every two hours. R9 was sent to the hospital on [DATE] for Altered Mental Status (AMS) and increased pain and admitted . R9's PI was identified as a stage 4 pressure injury [MEDICAL CONDITION] was found at the hospital and R9 needed surgical debridement for the wound. During surgery, osteo[DIAGNOSES REDACTED] was found that led to the removal of her coccyx. She returned to the facility on [DATE] and was placed on hospice care. R9 passed away 6/4/20. The facility's failure to take immediate action to ensure care planned interventions are specific to the resident to prevent the development and the deterioration of a pressure injury, the failure to properly identify and to notify the physician of the development and deterioration of a pressure injury and to implement treatment created a finding of Immediate Jeopardy (IJ) that began on 4/17/20. Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Corporate Consulting Nurse (Corporate RN)-C of the IJ on 9/17/20 at 9:32 AM. The IJ was removed on 9/17/20, however; the deficient practice continues at a scope/severity level of G (Actual Harm/Isolated) as evidenced by: R5 resided in the facility from [DATE] to 6/12/20. Per admission assessment performed 4/6/20, R5 was admitted with a stage 2 PI. R5's PI was not consistently monitored during their stay at the facility and worsened from a stage 2 to an unstageable PI. After review of R5's closed medical record and interviews with staff, it was determined that the facility did not accurately monitor, stage and document R5's pressure injury in accordance with the facility's policy and procedure related to skin care management. Findings include: The AMDA (American Medical Directors Association) clinical practice guideline entitled 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear. Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management. Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications. Step 2. Examine the patient's skin thoroughly to identify existing pressure ulcers. Examine the patient's skin upon admission or readmission. Step 3. Assess the patient's overall physical and psychosocial health and characterize the pressure ulcers. A pressure ulcer should be assessed along with the patient's overall clinical, functional, and cognitive status weekly reassessment and documentation of ulcer characteristics is recommended. More frequent assessment may be necessary for ulcers that are not responding to treatment or are worsening despite treatment. Step 4. Identify factors that can influence ulcer treatment and healing.functional status. Functional factors, including impaired mobility, a self-care deficit, and incontinence (especially fecal incontinence), may influence the severity, duration, and healing of a pressure ulcer. Step 5.Documentation should cover all pertinent characteristics of existing pressure ulcers, including location; size; depth; maceration; color of the ulcer and surrounding tissues; a description of any drainage, eschar, necrosis, odor, tunneling, or undermining; tissue types covering the wound bed; .and a description of the peri-wound skin .including type and amount of drainage. Step 6. Identifying priorities in managing the ulcer and the patient .Pain control related to the ulcer and any comorbid conditions.The same factors that increase a patient's susceptibility to developing pressure ulcers .may also impair the healing of an existing pressure ulcer . Surveyor reviewed facility's SaveSeniorCare Quick Reference for Wound Care with a copyright date of 2018. Documented was NPUAP (National Pressure Ulcer Advisory Panel) Pressure Injury Staging Definitions April 2016: IAD: Incontinence Associated [MEDICAL CONDITION] -OR- MASD: Moisture Associated Skin Damage -OR- Denuded skin on buttocks. Cleanse: with perineal cleanser. Pat skin dry gently. Protect: Apply Skin Protectant and gently rub in (don't leave excess product visible on the skin.) Repeat cleanse and protect after every incontinence episode. Stage 1 Pressure Injury Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Area exposed to incontinence: Cleanse with perineal cleanser. Pat skin dry gently. Apply Skin Protectant and gently rub in (don't leave excess product visible on the skin.) Repeat cleanse and protect after every incontinence episode. Area exposed to friction: Apply Skin Prep daily/allow to dry -OR- Apply Transparent Film. Change every 5 days/ (as needed (PRN.)) Stage 2 Pressure Injury Partial thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Drainage: none to minimal Apply Transparent Film dressing -OR-Apply [MEDICATION NAME] dressing Change every 3 to 5 days/PRN. Deep Tissue Injury (DTI) Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darker pigmented skin. Apply Skin Prep protectant daily and allow to dry *If suspected DTI opens, select dressing according to wound characteristics observed: o Depth o Drainage o Wound bed appearance o Level of bioburden Stage 3 Pressure Injury Full thickness loss of skin, in which adipose (fat) is visible in the ulcer and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of the tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone not exposed. Stage 4 Pressure Injury Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone to the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occurs. Depth varies by anatomical location. Shallow pressure ulcer Stage 3 or Stage 4 No or Minimal Drainage o Apply Hydrogel dressing o Secure with cover dressing o Change daily & PRN Moderate to Heavy Drainage o Apply Composite, CMC Dressing or Foam dressing o Change every 1-3 days/PRN Deep pressure ulcer Stage 3 or Stage 4 No or Minimal Drainage o Lightly fill cavity with Hydrogel gauze dressing o Secure with cover dressing o Change daily & PRN Moderate to Heavy Drainage o Apply CMC Dressing, Superabsorbent or Alginate - lightly fill cavity o Secure with cover dressing o Change every 1 to 3 days and PRN Stalled pressure ulcer Stage 3 or Stage 4 o Moisten Collagen Matrix dressing per package instructions before applying o Secure with cover dressing o Change daily & PRN Moderate to Heavy Drainage o Apply Collagen Matrix Dressing o Secure with cover dressing o Change daily & PRN Unstageable Pressure Injury Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar, if slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Note: once slough or eschar has been removed, re-evaluate the plan for topical treatment. No or Minimal Drainage o Apply Hydrogel dressing o Secure with cover dressing o Change daily & PRN -OR- o Apply Transparent Film dressing or [MEDICATION NAME] dressing o Change every 3 to 5 days & PRN Moderate to Heavy Drainage o Apply Alginate, CMC or Super Absorbent dressing o Cover with Bordered Gauze or Composite o Change every 1 to 3 days & PRN . Surveyor reviewed facility's Skin Management System policy with a copyright date of 2017. Documented under Practice Guidelines was: .5. A Care Plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The Care Plan should address, but is not limited to the following: a. Hydration; b. Nutrition; c. Preventative devices; d. Physical activity; e. Pain management; f. Positioning requirements; g. Proper body alignment; and h. Psychosocial adjustment to skin impairment. 7. If a new pressure ulcer is identified, either upon admission, readmission, or during the resident's stay, the wound is, assessed and documented on the Weekly Pressure Ulcer Record (UDA.) 8. The licensed nurse will document daily monitoring of pressure ulcers on the Treatment Administration Record (TAR.) 9. A physician's orders [REDACTED]. a. The licensed nurse will record observations and initial . d. If any abnormalities are observed, a descriptive note of findings and the licensed nurse's response are documented in the Progress Notes section of the resident's medical record . Ongoing Skin Assessments 1. A Weekly Skin Check will be completed in the resident's record using the Head to Toe Skin Check (UDA.) 2. An SBAR Communication Form and Progress Note (UDA) is completed and a new physician's orders [REDACTED]. 3. The nurse will initiate treatments, interventions, Care Plan, and the appropriate skin documentation records in a timely manner according to Practice Guidelines. 4. Pressure ulcers are measured and staged in accordance with the Practice Guidelines . Stage 3 Pressure Ulcer Suggested Interventions Care Interventions 1. The resident, resident's representative and the attending physician are notified of development of a Stage 3 pressure ulcer. 2. Avoid pressure over the wound as much as possible, especially during position changes. Thirty-degree oblique positioning (rolled partially to the side and supported by pillows or wedge) of the resident may be effective to help relieve pressure, if tolerated. 3. The Care Plan and Care Kardex are updated to reflect the wound status and interventions. 4. Licensed nurse should assess weekly and document progress. 5. Resident is added to the 24-Hour Report via Progress Notes. 6. Care Plan interventions are implemented and discussed during shift report. 7. Assess the resident for pain related to a pressure ulcer(s) during turning, positioning, dressing changes, and debridement. Provide [MEDICATION NAME] as needed. 8. Use a turn/draw sheet for repositioning. This will help prevent shearing. 9. Consult with rehabilitation services for evaluation and options for treatment interventions, if indicated. 10. Consultation with CWOCN nurse consultant, wound consultant, or surgeon as appropriate. Pressure Reduction/Relief 1. Evaluate for pressure reduction/relief support surfaces, as indicated. 2. The IDT may make a referral to rehabilitation services for positioning recommendations and appropriate seating surface, if the resident is able to be out of bed. 3. Implement an individualized schedule for turning and positioning. 4. Residents with a wound(s) to the lower trunk should limit time up in a chair, unless using specialized support surface appropriate to the wound of the activity is not contraindicated. Surveyor reviewed facility's Change in Resident Condition policy with a copyright date of 2017. Documented under Guidelines was: .2. Prompt notification is required when there is an accident involving the resident which results in injury or has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatment significantly. Surveyor reviewed R9's medical record which indicated R9 was admitted to the facility on [DATE]. R9's [DIAGNOSES REDACTED]. Resident was her own person with no Activated Healthcare Power of Attorney. Surveyor reviewed R9's 2/14/20 Admission Data Collection assessment. Documented under 7. Physical Examination: Skin Integrity was 2. Does the resident have pressure ulcer(s)? b. No. Documented under 8. Braden Scale for Predicting Pressure Sore Risk was score of 12.0 which indicated High Risk for development of pressure ulcers/injuries. Surveyor reviewed R9's 2/15/20 Skin - Head to Toe Skin Checks assessment. Documented was 1. Skin Integrity: 1a. Skin Intact. Surveyor reviewed R9's admission MDS (Minimum Data Set) with an assessment reference date of 2/20/20. Documented under Cognition was a BIMS (brief interview mental status) score of 12 which indicated mildly impaired. Documented under Functional Status for Bed Mobility and Transfer Status was 3/3 which indicated Extensive Assistance - resident involved in activity, staff provide weight-bearing support; Two plus persons physical assist. Documented under Skin Conditions was Risk of Pressure Ulcer/Injuries was Is this resident at risk of developing pressure ulcers/injuries? 1. Yes. Documented under Unhealed Pressure Ulcers/Injuries was Does this resident have one or more unhealed pressure ulcers/injuries? 0. No. Surveyor reviewed R9's Care Area Assessment (CAA) for 16. Pressure Ulcer/Injury with an assessment reference date of 2/20/20. Documented under Analysis of Findings was Triggered this CAA (due to) needing more extensive assist with bed mobility/repositioning. She also was frequently incontinent of bladder this (Assessment Reference Date (ARD)) period. She has had a recent hospitalization after falling in her bathroom (lives at a (Assisted Living Facility)) and (fractured) her left proximal humerus. No surgery required, is healing on its own. She has had her arm in a sling, (non-weight bearing left upper extremity) for this assessment period. She is here for rehab to improve her (activity of daily living (ADL)) skills. See the ADL CAA under nature of problem for more details on her ADL skills which impact this CAA. Head to Toe Skin Assessment in (Point Click Care (PCC)) dated 2/15/20, no noted pressure ulcers for this ARD period. Surveyor reviewed R9's Comprehensive Care Plan with a problem start date of 2/28/20. Documented was I will have intact skin, free of redness, blisters or discoloration by/through review date. Documented interventions dated 2/28/20 were Assist me to reposition and / or turn at frequent intervals in my (wheelchair) and my bed to provide pressure relief on my skin to prevent skin breakdown. Complete a full body check weekly and document Educate me/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Observe nutritional status. Serve diet as ordered, observe intake and record. Provide incontinence care after each incontinence episode, make sure skin is clean & dry. Apply barrier ointment on skin for protection. Apply protective brief. (There is no specific time interval specified for repositioning.) Surveyor reviewed R9's 2/22/20, 2/29/20, 3/7/20, 3/14/20, 3/21/20, 3/28/20, 4/4/20 and 4/10/20 Skin - Head to Toe Skin Checks assessments. There was no documentation of any PI's or open areas to R9's buttocks when reviewing these assessments. Surveyor reviewed R9's Office Visit Note for visit with Primary Care Physician (PCP)-I with a date of 4/17/20. Documented under Subjective was [AGE] year old had fallen at the nursing home. She is here today for suture removal. She met with orthopedics yesterday regarding her elbow fracture. He changed some of the splinting. But does not feel surgery is required. PCP-I does not document any PI for R9. Surveyor reviewed R9's 4/17/20 Skin - Head to Toe Skin Checks assessment. Documented was 1. Skin Integrity: Existing Bruises, New Non-Pressure Ulcer, Existing Non-Pressure Ulcer, New Pressure Ulcer . 3. For any areas identified above further document the site and a description of the site and a description including progress as appropriate. Only use the Stage column for pressure ulcers or use NA for all other skin issues. Documented for R9's buttocks was Site: Other (specify) right gluteal cleft. Type: Other (specify) moisture. Length: 4 (cm). Width: 4.5 (cm). Depth: Blank. Stage: Blank. Documented under 4. Further description of skin issues was .Gluteal cleft wound is gyrate in shape, there is 50% loose slough and 50% granulation tissue present, small amount of serous drainage, no pain, odor, infection. Assessment was E-signed by Former Director of Nursing (DON)-K on 4/20/20. Surveyor reviewed SaveSeniorCare Quick Reference for Wound Care and NPUAP Pressure Injury Staging Definitions. Surveyor noted, based on standards of practice, R9's buttocks wound would not be MASD or Stage I due to skin being broken. Surveyor noted R9's wound would not be Stage II having presence of granulation tissue and slough. Surveyor noted R9's buttocks wound should have been classified as at least Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The wound was inaccurately assessed as a non-pressure wound instead of PI. Surveyor reviewed all of R9's Electronic Medical Record including Progress Notes, Care Plan, MD orders, TAR and SBAR (Situation, Background, Assessment Recommendation) entries for 4/17/20, 4/18/20 and 4/19/20. There is no documentation on 4/17/20, 4/18/20, and 4/19/20 of R9's PCP being updated on the wound, of wound treatment being put in place or performed or any updates to R9's Care Plan on new facility acquired PI. Surveyor reviewed R9's SBAR note from 4/20/20 completed by Licensed Practical Nurse (LPN)-D. Documented was (PCP-I) was contacted in regards to having our in-house wound care nurse determine treatment plan for the patients wound. MD stated that was fine. On 9/15/20 at 1:28 PM, Surveyor interviewed LPN-D. Surveyor asked where the wound was located that she called PCP-I about on 4/20/20. LPN-D stated it was on her coccyx area. Surveyor asked why she called the MD. LPN-D stated Former DON-K asked her to call the MD and update him that the wound team would see R9. LPN-D stated she did not inform PCP-I of the wound description or receive any treatment orders. Surveyor reviewed the MD orders and TAR for April 2020. Documented with an order date of 4/20/20 and discontinue date of 5/1/20 was Wound care gluteal cleft: clean with saline, apply [MEDICATION NAME] to wound bed, cover with border foam dressing, every shift for wound care. Wound care was not completed on 4/20/20. On 9/17/20 at 9:08 AM Surveyor interviewed PCP-I. Surveyor asked when he was updated on the wound. PCP-I stated he spoke to a nurse at the facility on 4/20/20. The nurse informed him that R9 had some moisture damage. PCP-I stated facilities call him for stage 1 or MASD to handle in house and he is fine with that. PCP-I stated if the wound is a stage 2 or higher I want to be informed and I want to see it. Surveyor asked PCP-I if he was aware of 50% slough and 50% granulation when he was updated on 4/20/20. PCP-I stated no, he was not aware; if he would have been aware he would have asked to see her. PCP-I stated he should have been informed of the extent of the wound. Surveyor asked if he gave treatment orders for R9 on 4/20/20. PCP-I stated no, only that the wound team would assess the wound because he did not know it was at least a Stage III. Surveyor reviewed R9's 4/24/20 Skin - Head to Toe Skin Checks assessment. Documented was Skin Integrity: Existing Other Issue. Describe new or existing other issues: See weekly wound nurse notes. There was no other documentation on the Head to Toe assessment. Surveyor reviewed R9's Skin - Weekly Non-Pressure Condition Record with an effective date of 4/24/20. Documented under Site Details was Site: Other (specify) gluteal cleft. Type: Other (specify) moisture. Length: 4.6 (cm). Width: 5.0 (cm). Depth: 0.2 (cm). Stage: Blank. Documented under Description of Site was is wound is gyrate in shape, there is 50% loose slough and 50% granulation tissue, small amount of serous drainage noted on the dressing. There is no pain, odor, or (signs or symptoms (s/s)) of infection. Documented under Characteristics was Characteristics of area (use stage above for ulcers): c. Full Thickness. Documented under Response to Treatment was Describe resident's response to current treatment: c. Deteriorated. Notes: slightly larger in size. Documented under Notifications was Physician Notified: 4/24/20. Name of person contacted: (PCP-I.) Assessment was E-signed by Former DON-K on 5/8/20. On 9/16/20 at 9:54 AM Surveyor interviewed PCP's Registered Nurse (RN)-J. Surveyor asked if the MD's clinic had been contacted on 4/20/20 for new treatment orders or on 4/24/20 for deterioration of the wound. RN-J stated there was a call from the facility on 4/20/20 that stated the wound team at facility will address MASD. RN-J stated there was a call from the facility on 4/24/20. RN-J stated the call was in regards to a Urinalysis (UA) order, but no mention of the wound. Surveyor asked how calls from the facilities are tracked. RN-J stated all calls that come to the clinic are timestamped in the computer for follow-up. RN-J stated the next update/call from the facility after 4/24/20 was on 5/5/20 to update PCP-I on pain to her buttocks due to an ulcer. Surveyor reviewed R9's Comprehensive Care Plan with a revision date of 4/24/20. Documented was Administer treatments as ordered and observe for effectiveness. Assess/record/observe wound healing (of (right) gluteal cleft& left heel) Measure length, width and depth where possible. Assess and document status of wound, wound bed and healing progress. Report improvements and declines to the MD. Off load heels when in bed to keep pressure off of her heels. Prostat recommended by dietician for wound healing. See MD orders/ (Medication Administration Record) for details. The wound Care Plan was not updated again until 5/29/20. Surveyor reviewed R9's Skin - Weekly Non-Pressure Condition Record with an effective date of 5/1/20. Documented under Site Details was Site: Other (specify) gluteal cleft. Type: Other (specify) moisture. Length: 5.5 (cm). Width: 5.0 (cm). Depth: 0.5 (cm). Stage: Blank. Documented under Description of Site was wound is gyrate in shape, there is 95% slough and 5% granulation tissue present in the wound bed, there is a moderate amount of serous drainage noted on the dressing. There is no pain, odor, or (s/s) of infection. Documented under Characteristics was Characteristics of area (use stage above for ulcers): c. Full Thickness. Documented under Response to Treatment was Describe resident's response to current treatment: c. Deteriorated. Notes: more slough this week. Documented under Notifications was Physician Notified: 5/1/20. Name of person contacted: (PCP-I.) Assessment was E-signed by Former DON-K on 5/8/20. During Surveyor's interview with RN-J on 9/16/20 at 9:54 AM, RN-J stated there is no record of facility calling PCP-I on 5/1/20. Surveyor reviewed MD orders and TAR for May 2020. Documented with an order date of 5/1/20 and discontinue date of 5/4/20 was Santyl Ointment 250 unit/gram ([MEDICATION NAME]) Apply to right gluteal cleft topically every day shift for wound care. Clean with saline, apply nickel thick layer of Santyl, cover with border foam dressing Wound care was not completed on 5/1/20. Documented with an order date of 5/4/20 and discontinue date of 5/6/20 was Wound care to the right gluteal cleft: Clean with saline, apply [MEDICATION NAME] to wound bed, cover with border foam dressing, every day shift for wound care. During Surveyor's interview with RN-J, she stated there is no record of facility calling PCP-I on 5/1/20 or 5/4/20. There is no documentation at PCP-I's clinic giving the order for Santyl or [MEDICATION NAME]. PCP-I stated he did not give any orders between 4/20/20 and 5/6/20 when he assessed R9 in his office. Surveyor reviewed PCP-I's visit note for R9 with a date of 5/6/20. Documented was Assessment and Plan: 1. Pressure Injury of left buttock, stage 4 (*): 9 cm in diameter and 4 to 5 cm in depth. Base of ulcer looks fairly healthy. No drainage. No surrounding redness. It appeared someone had put some Iodosorb powder in the wound. I have referred her immediately to wound care who can see her at this time. And her orders for return she needs to alternate laying on her left and right side every 2 hours . Subjective: This [AGE] year-old female is a resident of Grande Prairie nursing home. We received a call yesterday that she was complaining of a lot of pain stemming from an ulcer on her buttocks. I asked that she be brought in. There was no active treatment for [REDACTED]. The wound appears to go down to the sacrum. It is very tender. There is no surrounding redness. No drainage. There is some brownish powder which appears to be [MEDICATION NAME] powder in the wound . Surveyor asked PCP-I during 9/17/20 interview when he first assessed the wound. PCP-I stated 5/6/20 when she (R9) visited his office. PCP-I stated the facility had called the day before and updated him that R9 was having pain to her buttocks because of an ulcer. PCP-I stated he had them make an appointment for 5/6/20. Surveyor asked what he assessed the wound as. PCP-I stated he originally staged it as a stage III and about 9 cm in length and 4 cm in depth. PCP-I stated he was shocked when he saw it and that it had not been reported to him earlier. PCP-I stated it had a foul odor and needed debridement. PCP-I stated he immediately called the wound clinic who saw her right after his visit with R9. Surveyor asked what should have been done for R9. PCP-I stated he should have been contacted earlier and wound treatment started sooner. Surveyor reviewed Wound Clinic's visit note for R9 with a date of 5/6/20. Documented was Assessment and Plan: Pressure ulcer of unspecified buttock, stage 4 (*): The patient was sent from (PCP-I's) office with what appears to be a stage IV buttock ulcer. That was debrided. It has been going on for one week. Patient was afebrile here, the vital signs were stable. I discussed the case with (PCP-I,) what we are going to do is order heel protection boots, bottom turning every 2 hours . pack the sacral wound with [MEDICATION NAME] Ag and cover with [MEDICATION NAME] change every other day. (PCP-I) is going to order a surgical consult with (wound surgeon) for possible surgical management, air mattress for off-loading, return to wound clinic in 1 week, we can switch to every 2 week visits when the wound is more stable. Documented under Assessments was Site: Necrotic; Painful; Red . Wound Length: 6 cm. Wound Width: 6 cm. Wound Depth: 2 cm . Wound Bed Granulation: 50%. Wound Bed Slough: 50%. Undermining: 2 cm. Undermining Clock Position: 11 o'clock. Wound was debrided and documented after was Wound Bed Granulation: 70%. Wound Bed Slough: 30%. Documented under History of Present Illness was (PCP-I saw the patient at his office and was alarmed when he saw the large decubitus ulcer . Surveyor reviewed R9's Skin - Weekly Non-Pressure Condition Record with an effective date of 5/7/20. Documented under Site Details was Site: Other (specify) gluteal cleft. Type: Other (specify) moisture. Length: 6.5 (cm). Width: 5.0 (cm). Depth: 2.5 (cm). Stage: Blank. Surveyor noted the facility did not amend the type of documentation to PI Assessment; documentation continues as Non-Pressure. Documented under Notifications was Physician Notified: 5/7/20. Name of person contacted: (PCP-I.) Assessment was E-signed by Former DON-K on 5/8/20. During Surveyor's interview with RN-J, she stated there is no record of facility calling PCP-I on 5/7/20. Surveyor reviewed the Wound Clinic's visit note for R9 with a date of 5/12/20. Documented was Assessment and Plan: Pressure ulcer of unspecified buttock, stage 4 (*): The patient's wound looks worse today. There is a foul odor. There is a flap of necrotic tissue over the top of the wound, that was debrided, also debrided the rest of the wound. (Appointment) is being scheduled as I feel that the patient should see a general surgeon in case she needs further debridement. (Appointment) was made with (wound surgeon.) I already wrote for a bottom turning every 2 hours when I saw the patient in the hospital. We will continue that . For sacral wound we are going to treat with Santyl, pack with [MEDICATION NAME], then cover with [MEDICATION NAME]. Continue to offload. Surgical referral. Return to clinic in 1 week. Documented under Assessments was Wound Length: 9 cm. Wound Width: 4.5 cm. Wound Depth: 2.8 cm .Wound Bed Granulation: 90%. Wound Bed Slough: 10%. Surveyor reviewed R9's Skin - Weekly Non-Pressure Condition Record with an effective date of 5/15/20. Documented under Site Details was Site: Other (specify) gluteal cleft. Type: Other (specify) moisture. Length: 9.5 (cm). Width: 4.0 (cm). Depth: 1.5 (cm). Stage: Blank. Surveyor noted t (TRUNCATED)

Based on interview and record review the facility did not contact the physician with a critical lab for 1(R4) of 1 resident reviewed with a critical lab. * R4 was having symptoms of dizziness, nausea and chest pressure. R4's physician ordered immediate labs. R4's hemoglobin and hematocrit came back as critical. R4's physician was called and did not call back, further steps to get ahold of a physician for additional orders were not made until almost 6 hours later when R4 was sent immediately to the hospital and required 4 units of blood. The Facility failure to take additional action when R4's physician did not call back on a critical lab, created a finding of immediate jeopardy that began on 1/8/20. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on [DATE] at 2:00 PM. The immediate jeopardy was removed on 1/15/19. However, the deficient practice continues at a scope/severity level of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan and is able to show sustained compliance. Findings include: R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4 was admitted to the facility on the blood thinner [MED] and remained on it until discharge on [DATE]. On [DATE] R4's progress notes were reviewed and read: * 1/7/20 at 2:52 PM: R4 had a scant amount of blood mixed with urine and stool. No other complaint issues. R4 returned from Medical Doctor appointment where her Foley was removed and the doctor states there will be a small amount of blood in the urine. During physical therapy in early afternoon upon standing R4's blood pressure dropped to [AGE]/57, another tarry stool. R4 is pale in color, no other complaints. Doctor's physician assistant informed of the above information. Physician's Assistant ordered a Complete Blood Count STAT (immediately). * 1/7/20 at 10:56 PM: Vital Signs blood pressure 135/65, Pulse Ox 94%. * 1/7/20 at 11:45 PM (written by Registered Nurse (RN)-D: R4 has been complaining of not feeling well all shift, complains of abdominal pain, feeling dizzy, and of feeling nauseous. It was reported to writer by unit manager that she had some coffee ground stool at approximately 3:30 PM. R4 complains of ear pain and chest heaviness especially when she gets up to the bathroom. Writer has called doctor 2 times due to her complaints. He stated we are to get the Complete Blood Count and to monitor her vital signs. If her systolic (blood pressure top number) goes below 100 or her labs are extremely abnormal we can call him, otherwise he will be in tomorrow to follow up with her. Her last vital signs were blood pressure 112/58, pulse ox 98% on room air, Temperature 98.3, pulse 81, respirations 18. * 1/8/20 at 2:30 AM (written by Licensed Practical Nurse (LPN)-E: R4 had some discomfort in her chest starting from her right ear radiating down to her neck. Writer previously called the doctor in regards to her critical labs and we are currently still waiting for call back. R4 is alert and agreed to be called if symptoms worsen or change. * 1/8/20 at 6:33 AM (written by LPN-E): Writer received call from lab with critical lab reports. Writer call doctor's office around 1:00 AM in regards to critical hemoglobin (4.3) and critical hematocrit (14). On call nurse paged doctor and doctor never returned page. Currently awaiting orders. * 1/8/20 at 8:20 AM (written by LPN-F): Writer came in for shift change. Night nurse (LPN-E) informed me of critical lab. Contacted Director of Nurses (DON)-B at 6:50 AM as the doctor did not call back from the page at 1:00 AM. Call placed to Medical Director (MD)-G by DON-B at 6:55 AM. Send R4 to emergency room . Ambulance arrived at 7:15 AM and left at 7:20 AM. On [DATE] R4's Complete Blood Count results collected on 1/7/20 at 8:30 PM were reviewed and read: Hemoglobin 4.3 (reference range 11.3-15.1) critical. This critical value reported to LPN-E 1/8/20 at 1:16 AM Hematocrit 14 (reference range 34-45) critical. This critical value reported to LPN-E 1/8/20 at 1:16 AM. On [DATE] R4's emergency room report dated /8/20 was reviewed and read: R4 is hemodynamically normal. [MEDICATION NAME] bolus and drip were started. Plan will be for admission, blood transfusion continuation of [MEDICATION NAME] and a Gastric consultation. Time of arrival 7:27 AM. Alert, pale appearing, no acute distress. Hemoccult positive stool. Blood pressure 129/58, heart rate [AGE] and regular, temperature 98.3 Labs in the emergency room read: 1/8/20 7:35AM hemoglobin 4.6, hematocrit 14.7. On [DATE] R4's hospital record was reviewed and indicated R4 received 4 units of blood between 1/8/20 and 1/9/20. That R4 was diagnosed with [REDACTED]. On [DATE] R4's physician consultaion note dated 1/9/20 was reviewed and read: R4 started having black bowel movements, progressively weaker as well. Blood work demonstrated [MEDICAL CONDITION] and she was brought to the emergency room . No gross red bleeding. Past medical history: [MEDICAL CONDITION] post recent colectomy, [MEDICAL CONDITION] Fibrillation. Assessment and plan: upper [MEDICAL CONDITION], has been repleated with blood feeling much better. Hemoglobin has been stable. On [DATE] at 10:30 AM LPN-E was interviewed and indicated she received in report that R4's doctor said to monitor her. LPN-E indicated she spoke with R4 at midnight and she said she was feeling the same and would wait to see the doctor in the morning. LPN-E indicated R4 woke up about 3 times and she checked in on her hourly and R4 remained the same. LPN-E indicated she took R4's vitals at 5 am (weren't charted till 6:10 AM) and they were normal. LPN-E indicated she only took R4's vitals once during the night. LPN-E indicated she called R4's doctor at about 1am regarding the critical labs and was told they would page the doctor but she received no call back. And she did not attempt to call the doctor again. LPN- E indicated she did not know she should call the medical director if the primary doctor does not call back and she did not talk to the other 2 nurses on the shift about it, LPN-E indicated she did not tell R4 of the critical labs. LPN-E indicated when day shift nurse came on she said we need to get R4 to the hospital and called DON-B who called medical director. On 2/12/20 at 3:00PM LPN F was interviewed and indicated she was getting report from LPN-E who told her about R4's critical labs. LPN-F indicated she thought R4's labs were beyond critical. LPN-F indicated she then called DON-B who said get R4 out of here now. LPN-F indicated MD-B gave the order to send R4 to the hospital immediately. 0n [DATE] at 10:00 AM RN-D was interviewed and indicated she called R4's doctor twice on 1/7/20, once about 6:00PM and once about 8:00PM regarding R4's symptoms. RN-D indicated R4's symptoms started about 5:00PM. RN-D indicated R4's doctor told her to call him with lab results, monitor her and he would see her in the morning. RN-D indicated R4 did not complain about chest pain but pressure. RN-D indicated R4 said twice she didn't want to go to the hospital and would wait to see the doctor in the morning. RN-D indicated R4 was light headed when she was walking to the bathroom and appeared pale. RN-D indicated she took vitals x3 and were all normal. On 12/12/20 at 11:45 AM DON-B was interviewed and indicated they notified me first R4's critical labs on 1/8/20 at 6:50 AM. DON-B indicated she called MD-G, who gave the order to send R4 to the hospital. DON-B indicated LPN-E should have called the medical director when R4's primary doctor didn't call back. DON-B indicated that when LPN-E was hired the training of what to do if a doctor doesn't call back wasn't covered but because of this incident the training has been added to new employee orientation. On [DATE] at 12:05 PM MD-G was interviewed and indicated it is a no brainer have to get someone out to get blood with a hemoglobin as low as R4's was on 1/8/20. MD-G indicated a hemoglobin under 7 needs an immediate trip to the hospital. MD-G indicated it is a very serious situation as blood carries oxygen and no oxygen to the brain and could kill somebody. On [DATE] the facilities policy titled Diagnostic Services Management dated 7/17 was reviewed and read: Make a decision for immediate or non-immediate notification. If the results are abnormal or show critical values the attending physician/licensed practitioner will be notified immediately. If a resident's attending physician/licensed practioner (or their on-call designee) cannot be reached to report a critical or abnormal value, the facilities Medical Director/ designee and the DON/designee will be contacted with the results. The above findings were shared with the Administrator and DON on [DATE] at 2:00PM. The facilities failure to inform R4's physician of critical laboratory values created a finding of immediate jeopardy. The facility removed the jeopardy on 1/15/20 when: 1. Education for all Licensed Nurses was completed. No licensed nurse was allowed to work until education had been completed on the following. The education was also now included in the nurse orientation training. Notification of the physician and what to do is there is no response. 2. Developed a Performance Improvement Project which identified the problem, cause, and goal. Root cause was determined to be lack of ongoing education of the nurses. 3. Medical Director to be involved in determining why a doctor doesn't return calls. 4. Audits completed on residents receiving labs daily to see if their physician were notified timely of abnormal/critical laboratory values.

Based on the interview and record review the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 (R1) of 5 residents reviewed. * R1 was found to have unprescribed medications on 11/17/19 and the facility did not take steps to identify and or contact the proper authorities to confiscate the unprescribed medications to ensure R1's safety. R1 was found to have an altered level of consciousness and depressed respirations as a result of an overdose on 11/18/19 at 4:00 a.m. The RN gave [MEDICATION NAME], but did assess R1, did not call the physician and did not monitor R1 or the effectiveness of the [MEDICATION NAME] for the next 35-60 minutes The facility's failure to contact the appropriate authorities to confiscate unprescribed medications first discovered on 11/17/19 and the failure by nursing staff to assess R1 or contact the physician when R1 was found to have an altered level of consciousness and depressed respirations as a result of overdose on 11/18/19 created a finding of immediate jeopardy that began on 11/17/19. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on 12/10/19 at 2:00 p.m. The immediate jeopardy was removed on 12/12/19. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy with a revised date of (MONTH) 2012 and titled Medication Management documents under the Guidelines section, 3. Medications brought in by a resident may not be used unless medications are properly identified, packaged and correctly labeled .Medications from non-contract pharmacies must: (a.) Comply with State and Federal regulations for packaging and labeling (b.) Arrive in non-tamperproof packaging and should be verified by the pharmacist. The facility's policy with a revised date of 11/18/19 and titled Self-Administration Policy documents, Addendum: If residents are observed with medication in their room and they are not a self-medicator or they do not have a prescription for the medication, the medication is removed immediately. If a resident does not comply with turning over the medication, the police will be notified. Notify the Administrator and Director of Nursing. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Annual MDS (Minimum Data Set) dated 9/30/19 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating that R1 is cognitively intact. Section G (Functional Status) documents that R1 required extensive assistance and a two person physical assist for his bed mobility needs. Section G also documents that R1 had total dependence on staff and required a two person physical assist for his transfer needs. Section G (Functional Limitation in Range in Motion) documents that R1 has impairment to both sides of his upper and lower extremities. Section J (Health conditions) documents R1 was on a scheduled pain medication in past five days of the assessment period in addition to receiving a PRN (as needed) pain medication. The assessment indicates there are no non-medication intervention for pain and R1 rates his pain on a scale of 1-10 as 09 with almost constant pain. R1's Pain CAA (Care Area Assessment) dated 9/30/19 documents under the Care Plan Considerations section, Resident triggered this CAA review for pain due to reports of pain all over due to chronic pain complicated by [MEDICAL CONDITION] from cervical injury & previous left tibia fracture. He has pain pump in place to manage his pain in addition to scheduled [MEDICATION NAME] & [MEDICATION NAME]. He is a long term resident requiring significant assistance for most of his ADL's due to [MEDICAL CONDITION] effected by injury to cervical spine causing limitation. He uses Hoyer lift for all transfers and uses motorized wheelchair for his general mobility He is able to verbalize his needs and wants .Staff to administer the pain medications as ordered and monitor for any side effects or any increased pain that is not easily altered and report to MD (medical doctor) as needed. Will follow plan of care. R1's Pain care plan dated as initiated on 11/3/16 documents under the Interventions section,R1's pain is alleviated/relieved by: [MEDICATION NAME], and prn [MEDICATION NAME]; direct staff will Administer pain medication prior to treatments and per my request if indicated. R1's Self-Administration of Medications assessment dated [DATE] documents that R1 was safe and eligible to self-administer medication. R1's physician orders [REDACTED]. -[MEDICATION NAME] Patch 72 hours 25 MCG (microgram)/HR (hour), Apply 1 patch [MEDICATION NAME] every 72 hours for pain. Last use: 11/17/19 at 5:25 PM -[MEDICATION NAME] Tablet 15 MG (milligrams), Give 1 tablet by mouth every 4 hours as needed for Pain. Last use: 11/17/19 at 5:00 AM. In addition to taking the above prescribed pain medications, R1 was noted to be followed by a pain clinic and was last seen on 11/14/19. R1's Pain Management Consult notes dated 11/14/19 documents, Advance Pain Management- Pt (patient) was seen at office for follow up. He reports no improvement with last IT ([MEDICATION NAME]) Pain (Pump) dose increase. IT Pump was reprogrammed today to increase dose by 50%. R1's Pain IT Pain Pump Report dated 12/8/19 documents that R1 was receiving up to 1,000 mg (milligrams) of [MEDICATION NAME] and up to 100 mcg (micrograms) of [MEDICATION NAME] per day via his pain pump. R1's physician order, as a result of R1 having an IT Pain Pump, dated 5/1/19 documents, [MEDICATION NAME] Liquid 4 MG/0.1ML ([MEDICATION NAME] HCl); 0.1 ml Alternating nostrils every 3 minutes as needed for Pain pump use Repeat dose every 2-3 minutes as needed alternating nostrils with each dose. R1's Psychiatric Consults dated 9/30/19 and 10/25/19 documented that R1 was anxious but had no [MEDICAL CONDITION] and or suicidal type behaviors. Per R1's medical record, the facility was monitoring R1 for depression like symptoms that included self-isolation and crying. On 12/9/19, a complaint was filed with the Southeastern Regional office stating that on 11/18/19, R1 was found unresponsive and had overdosed. R1's nursing note dated 11/17/19 at 6:23 p.m., as written by LPN (Licensed Practical Nurse)- D, documents, Patient asked to speak in confidence, patient stated that 'I have been self-medicating with [MEDICATION NAME] 1mg (milligram) a day as well as taking oral THC (Tetrahydrocannabinol)' MD (medical doctor) notified on how to proceed. DON (Director of Nursing) notified as well. (THC is the main psychoactive compound found in marijuna.) R1's nursing note dated 11/17/19 at 6:28 p.m., as written by LPN- D, documents, When asked to confiscate medications, patient refused and stated I paid good money for those currently waiting for MD (medical doctor) to notify, message left on voicemail. R1's nursing note dated 11/17/19 at 6:30 p.m., as written by LPN-D, documents, Spoke to patient in patients (sic) room, regarding the [MEDICATION NAME], and advised patient to not take any non-prescribed medications like [MEDICATION NAME], or oral THC, asked patient whether he was sad, agitated, or had any suicidal ideation when prompted about being nervous for his pain management appt. and taking [MEDICATION NAME], patient said he was fine and had no intentions, just anxious. Informed patient that I was legally obligated to contact his MD and DON and he said he understood. Patient was alert, and mellow when being put to bed. Surveyor noted there was no additional documentation of follow up until 11/18/19. R1's nursing note dated 11/18/19, as written by RN-C, documents, Note Text: Resident observed at 0400 extremely lethargic. Output down. Having difficulty breathing. O2 started at 3-4 l per N/C. Given 4mg [MEDICATION NAME] no improvement. Given another 4mg of [MEDICATION NAME] at 0500 and 911 called. Resident continued to be extremely lethargic and had rattling in the throat. There is no documentation that RN-C monitored R1 or assessed the effectiveness of the [MEDICATION NAME] for the next 35-60 minutes. There is no documentation that RN-C consulted with a physician. R1's SBAR (Situation, Background, Assessment, Recommendation) dated 11/18/19 documents, SBAR Summary: Vitals Signs: BP (blood pressure) 151/112 - 11/18/2019 05:00 AM Position: Lying (left) L/arm , P (pulse) 77 - 11/18/2019 07:34, R 12 - 11/18/2019 07:35, T 97.5 - 11/11/2019 19:11 Route: Tympanic .O2 (oxygen concentration) 94.0 % - 11/11/2019 19:11 Method: Room Air 3-4 L (liters); RN Assessment - What I think is going on with the resident is: Possible drug overdose or pneumonia; Additional Nursing Notes: 911 called and resident sent to ER (emergency room ). Surveyor was unable to locate any documentation in R1's medical record or any physician orders [REDACTED]. Surveyor was unable to locate any assessment of R1's mental status, vital signs and or respiratory status when RN-C found R1 at approximately 4 AM and or after [MEDICATION NAME] was first administered as documented in R1's nursing note dated 11/18/19. R1's nursing note dated 11/18/19 documents, Note Text: Spoke with RN (Registered Nurse) from[NAME]Hospital regarding update on resident. RN stated that resident is currently admitted to the hospital for medication overdose and is in the ICU (intensive care unit) at this time intubated. R1's Hospital Admission documentation dated 11/18/19 documents, 41 y/o (year old) male here from nursing home with altered mental status. He was found by nursing home staff unresponsive. He is a quadriplegic who apparently is usually alert and can move his arms; he is on a lot of pain medicines including a pain pump. Staff administered 2 doses of intranasal [MEDICATION NAME] with partial improvement paramedics arrived and assessed his respiratory status to be in adequate and he was not verbalizing they performed rapid sequence intubation and transported to the emergency department .Per paramedics report on (sic) marked pill bottles were found in the patient's room and there were looked up by total number and were found to be [MEDICATION NAME], he has a history of taking extra medication apparently. R1's Hospital Admission documentation dated 11/18/19 documents under the Assessment/Plan section, [AGE] year old male admitted to the ICU (Intensive Care Unit) after being found unresponsive with empty unlabeled pill bottle next to him, intubated in the field .Plan: Found unresponsive with empty unlabeled pill bottle. Though to have taken [MEDICATION NAME] (no prescription). Pt (patient) does have a hx (history) of taking too much of his prescribed meds (medications) (on [MEDICATION NAME] outpatient). Urine tox (toxicology) screen positive for THC (Tetrahydrocannabinol), Opiates, Benzos (Benzodiazepines). R1's Hospital Admission documentation dated 12/4/19 documents, History of Present Illness: On 11/18/19 via EMS (emergency medical services) with a chief complaint of altered mental status and acute [MEDICAL CONDITION]. EMS stated and empty, unmarked bottle of pills was found next to the patient, later determined to be [MEDICATION NAME] .Patient arrived to be (sic) ED (emergency department) after being intubated by EMS and urine tox (toxicology) screen returned positive for THC (Tetrahydrocannabinol), Benzos (Benzodiazepines) and opiates .The patient was admitted due to his intubation. On 11/19/19, the patient was extubated .On 11/26/19, the patient requested [MEDICAL CONDITION] placement. The patient was deemed to have maintained mental status which was determined to be improved from baseline. [MEDICAL CONDITION] and PEG (Percutaneous Endoscopic Gastrostomy) placement were performed on 12/2/19. R1's police report dated 11/18/19 and completed by PO (Police Officer)-E documents, On Monday 11/18/2019 at approximately 0525 (5:25 AM), I responded to Grande Prairie Health and Rehabilitation for a [AGE] year old male who was unconscious with gargled breathing .I arrived on scene at the same time as the rescue squad. I entered the room where I observed (RN (Registered Nurse)-C) checking the patient later identified as (R1) for responsiveness. RN-C informed me that he had administered two doses of 4 mg (milligram) of [MEDICATION NAME] to (R1) and it began to cause a positive reaction. (R1) could not talk but was breathing on his own. (R1) is a morbidly obese patient with a spinal cord injury. (R1) is paraplegic with limited mobility in his arms as well. While rescue was rendering aid to (R1), I asked (RN-C) what kind of medications (R1) was on. (RN-C) stated he (R1) is currently on a pain pump delivering meds (medications) through his back. (RN-C) stated he also takes [MEDICATION NAME] and was recently informed that (R1) has been self-medicating himself with [MEDICATION NAME] .I found (RN-C) and asked him if I could get specifics about the incident and (R1's) medications/schedule. (RN-C) informed me the last time he checked on (R1) before the incident was around midnight. (RN-C) stated (R1) appeared to be in a deep sleep and did not want to wake him. (RN-C) stated that around 0425 (4:25 AM), (RN-C) asked CNAs (Certified Nursing Assistants) to check on (R1), because it is unusual for him to go this long without asking for his [MEDICATION NAME]. (RN-C) sated that he went into the room and (R1) was found unresponsive and having issues breathing. (RN-C) stated he forested (sic) administered the first dose of [MEDICATION NAME] and returned around 0500 (5:00 AM) hours and administered a second dose of [MEDICATION NAME] before calling 911 .Myself and SGT (Sergeant-F) conducted a search of the room for anything that could have cause this medical emergency. During the search, (SGT-F) located a small snow man themed metal lunch box style container sitting on his bedside tray. Inside the box were prescription pill bottles without labels. There was approximately 20-30 pills in each pill bottle, but each bottle contained a different pill. One bottle contained yellow small yellow rectangular pills with serrations grooved in them. The pills were labeled R039. I know through my training and experience these pills had a high probability of being [MEDICATION NAME] ([MEDICATION NAME]). The other bottle contained small blue oval shaped pills labeled B706. I was not sure what the pills were, however due to the nature of the call and there being no label on them, the bottle was confiscated I returned to the police department and began processing the evidence .One pill bottle contained 30 blue pills identified as 1 mg (milligram) [MEDICATION NAME] using https://pillbox.nlm.nih.gov. The other pill bottle contained 21 ¾ pills identified as 2 mg [MEDICATION NAME] using the same source. Inside the lunch box were 7 disposable bill cups stacked together. Several cups were labeled 49 believed to indicate they were for R1's room. Stacked in between two of the cups were another four 1 mg pills and three and half 2 mg pills. There were also two additional 1 mg pills located in the bottom of the lunch box with some business cards. All evidence was photographed and entered into evidence. Charges are being submitted to the Kenosha District Attorney's Office for Possession of a Restricted Controlled Substance. On 12/9/19 at 1:49 p.m., Surveyor interviewed LPN (Licensed Practical Nurse)-D regarding R1's incident dated 11/17/19. LPN-D informed Surveyor that on 11/17/19, R1 had requested to speak with her (LPN-D) in private. When LPN-D spoke with R1, R1 informed her (LPN-D) that he (R1) was nervous about going to the pain clinic on 11/18/19 because he had been self-administering medication believed to be [MEDICATION NAME], to which he (R1) did not have a prescription for. R1 then proceeded to show LPN-D unknown medication pills which he had in a metal tin/container. LPN-D then informed R1 that she (LPN-D) had an obligation to tell DON (Director of Nursing)-B and R1's physician regarding R1's self-administration of unknown medication pills. LPN-D informed Surveyor that she then stepped out of R1's room and called R1's physician who directed LPN-D to inform DON-B. Per LPN-D, she then called and informed DON-B of the above findings, to which DON-B informed LPN-D to attempt to confiscate R1's unknown medication pills. LPN-D then returned to R1's room and attempted to confiscate R1's unknown medication pills, to which R1 refused and informed LPN-D that he had paid good money for these (referring to the unknown medication pills). LPN-D informed Surveyor that she then provided R1 with education regarding not taking unprescribed medications and confirmed that R1 did not have any [MEDICAL CONDITION]. Surveyor asked LPN-D if she had received any physician orders [REDACTED]. LPN-D informed Surveyor that she (LPN-D) did not receive any physician orders [REDACTED]. LPN-D informed Surveyor that she did inform the oncoming nurse, RN (Registered Nurse)-C, that R1 had in his possession unknown medication/pills and that R1 was self-administering the unknown medication/pills. On 12/10/19 at 6:27 a.m., Surveyor interviewed RN-C regarding R1's overdose on 11/18/19. Surveyor asked RN-C to summarize what had occurred on 11/18/19, as documented in R1's medical record. RN-C informed Surveyor that on 11/17/19, LPN-D had informed him that R1 had in his possession unknown medication/pills and that R1 was self-administering the unknown medication pills. RN-C informed Surveyor that around 12:00 a.m. on 11/18/19, RN-C saw R1 sleeping in bed with no issues. RN-C informed Surveyor that he (RN-C) was worried about R1's decreased output and that around 4 AM on 11/18/19, he went into R1's room as R1 had not yet asked him (RN-C) for his pain medication, which was unusual for R1. RN-C informed Surveyor that when he went into R1's room at approximately 4 AM, he (RN-C) found R1 to have an altered level of consciousness and respiratory depression. RN-C informed Surveyor that because of what LPN-D had informed him of earlier (regarding R1's possession unknown medication pills), RN-C suspected R1 to have a drug overdose and so RN-C administered 4 mg of [MEDICATION NAME] to R1 and placed R1 on oxygen. Surveyor asked RN-C if he (RN-C) contacted R1's physician after administering R1 [MEDICATION NAME] at approximately 4 AM. RN-C informed Surveyor that he did not contact R1's physician after administering R1 [MEDICATION NAME] at approximately 4 AM. RN-C informed Surveyor that he then went back onto the floor as he was busy working and that he returned approximately 35 to 45 minutes later to check on R1. RN-C informed Surveyor that at this time, he found R1 to continue to have respiratory depression and found R1's vitals were shot so R1 administered an additional 4 mg of [MEDICATION NAME] and called 911 for R1. Surveyor was unable to locate any documentation in R1's medical record of any physician orders [REDACTED]. Surveyor was unable to locate any assessment of R1's mental status, vital signs and or respiratory status when RN-C found R1 at approximately 4 AM and or after [MEDICATION NAME] was first administered as documented in R1's nursing note dated 11/18/19. On 12/10/19 at 10:54 a.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B if LPN-D should have attempted to identify R1's unknown medication pills and or to monitor R1 after R1 showed LPN-D the unknown medication pills. DON-B informed Surveyor that LPN-D should have attempted to identify R1's unknown medication pills and or to monitor R1 after R1 showed LPN-D the unknown medication pills. DON-B informed Surveyor that facility staff should have contacted the police after R1 did not want to give LPN-D the unknown medication pills. Surveyor asked DON-B if RN-C should have contacted R1's physician after administering R1 [MEDICATION NAME] at approximately 4 AM. DON-B informed Surveyor that RN-C should have contacted R1's physician after administering R1 [MEDICATION NAME] at approximately 4 AM. Surveyor asked DON-B if RN-C should have assessed R1's mental status, vital signs and or respiratory status when RN-C found R1 at approximately 4 AM and or after [MEDICATION NAME] was first administered as documented in R1's nursing note dated 11/18/19. DON-B informed Surveyor that RN-C should have assessed R1's mental status, vital signs and or respiratory status when RN-C found R1 at approximately 4 AM and or after [MEDICATION NAME] was first administered as documented in R1's nursing note dated 11/18/19. DON-B informed Surveyor that RN-C should have called 911 after he found R1 at approximately 4 AM and not delay for another 35 to 45 minutes as RN-C informed Surveyor. No additional information was provided by DON-B. The facility's failure to contact the appropriate authorities to confiscate unprescribed medications first discovered on 11/17/19 and the failure by nursing staff to assess R1 or contact the physician when R1 was found to have an altered level of consciousness and depressed respirations as a result of overdose on 11/18/19, created a finding of immediate jeopardy that began on 11/17/19. The facility removed the immediate jeopardy on 12/12/19, when it had completed the following: -All resident rooms checked and verified to have no medication present. -All nursing staff: educated on policy and procedures related to residents brining medication in from outsider sources, change in condition for residents with a pain pump, assessments and physician notification according to standards of practice. -Director of Nursing or designee will audit 5 randomly sample resident rooms on each unit for presence of outside medication daily for 2 weeks, then 3 times a week for 2 weeks, then weekly thereafter until QA committee deems appropriate. -Director of Nursing or designee will audit 24 hour board and progress notes for all residents with change in condition to ensure assessment and physician notification compliance daily for 2 weeks, then 3 times a week for 2 weeks, then weekly thereafter until QA committee deems appropriate.

Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation), for 1 of 2 residents (R1) reviewed, in accordance with the resident's directives. A total of 49 residents in the facility were to be Full Code at the time of survey. R1's Physician order [REDACTED]. stopped beating or R1 would stop breathing. On [DATE], staff found R1 without blood pressure or pulse and not breathing. Nursing staff did not initiate CPR despite R1's Physician order [REDACTED]. The facility failure to ensure R1 received basic life support, including CPR, in accordance with R1's wishes, per signed Physician order [REDACTED]. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ finding on [DATE] at 4:45 PM. It was determined the immediacy was removed, on [DATE], but not yet corrected. The deficiency continues at a scope/severity level E (potential for harm/pattern), as the facility continues to fully implement, educate and evaluate the effectiveness of its action plan. Evidenced by: R1's Facesheet, updated [DATE], includes, in part, the following: Advance Directive: Full Code. R1's Physician order [REDACTED]. R1's Care Plan Focus I choose to have CPR. Date Initiated: [DATE]. Interventions/Task: Please provide CPR. R1's Progress Notes include, in part, the following entry: [DATE], 22:03 (10:03 PM): Nursing Note: Note Text: Called to resident room by CNA (Certified Nursing Assistant) and resident noted with no B/P (blood pressure), no respirations, no pulse, and SPO (amount of oxygen in the blood) @ (at) 0%. Resident expired. RNs (Registered Nurses) called over to Unit to verify assessment. Call placed to (R1's physician) and physician pronounced death over the phone. Call placed to (R1's Guardian) and was made aware of death. Call placed to Coroner and was made aware. (Funeral Home) call to pick up deceased . (DON B) called and made aware. (Funeral Home) here to pick up decease. There is no contemporaneous documentation indicating that rigor mortis or lividity was present. The facility's Misconduct Incident Report, dated [DATE], includes, in part, the following: Date Occurred: [DATE]. Time Occurred: 8:00 PM. Date Discovered: [DATE]. Briefly Describe the Incident: On the evening of [DATE], an aide went into (R1's) room and found her unresponsive. (Aide) left the room and got the LPN (Licensed Practical Nurse) (LPN Q) who told the aide LPN Q had to go get the other nurses and left the room. The aide went back into the room and stayed with the resident. The other nurses arrived and saw that (LPN Q) was calling the MD (Medical Doctor) to pronounce, and assumed that (R1) was a DNR (Do Not Resuscitate). The NHA received a call from the (Local Police Department) letting him know that they were aware of (R1's) death and that there was no call made for services. The (Local Police Department) has been involved in another allegation regarding (R1). When the NHA went into resident's EMR (Electronic Medical Record) he became aware that she was a full code. The DON was called and (LPN Q) was suspended and investigation was initiated. Surveyor was unable to interview the nurse who was working with R1, on [DATE], when R1 was found without pulse or breathing. On [DATE], Surveyor interviewed DON B. DON B stated staff should have reviewed R1's medical record to see what R1's code status was, called 911, and initiated CPR immediately. Surveyor and DON B reviewed the education given to staff. It was found that CNA F and CNA P each worked a shift without being provided education. The facility's failure to administer CPR to R1 when R1 was found without pulse or breathing created a situation of IJ, which was removed, on [DATE], when the facility implemented the following action plan: Corrective Action: Resident no longer resides at the facility; however, staff did a root cause analysis to identify areas of improvement for recognizing code status. The results of the root cause analysis was that one LPN failed to follow the policy regarding checking code status when a resident was found to be unresponsive. Identification of Others: All residents' charts were reviewed to ensure accuracy of code status both in the hard chart and in the EMR. Any changes to the code status were updated on the residents' records. Systemic Changes: Complete education with licensed staff regarding the importance of checking and updating code status on a routine basis, but in no case longer than on a quarterly basis. Changes in code status will be discussed in the morning meeting. Unit managers will update licensed status in the event of change of code status after the morning meeting. Care plans and code status documentation will be updated on residents' records. Licensed staff has been educated on code status, the process for identifying code status in the event of a code, and updated policy on Medical Emergency Management. Facility will review and update Medical Emergency Management Policy with addendum related to The American Heart Association (AHA) recommendations for No CPR for Full Code residents, with compliance date of [DATE]. Monitoring: DON/designee has and will continue to conduct mock codes at least twice a months for 3 months to ensure all staff are knowledgeable of the proper procedures for responding to codes. At the end of each mock code, the IDT (Interdisciplinary Team) will review the results and determine if further education is warranted. The results of the mock codes will be discussed as part of the Quality Assurance Performance Improvement Committee monthly or ad hoc meetings as necessary. The Administrator is the individual responsible for compliance with this action plan.

Based on interview and record review, the facility failed to prevent sexual abuse affecting 1 resident of a total 89 residents in the facility (R1). POA I (Power of Attorney) was observed sexually touching R1 without a brief on by CNA F (Certified Nursing Assistant). CNA F had previously reported finding scratches in R1's vaginal area. The facility's failure to keep residents free from sexual abuse created a finding of Immediate Jeopardy (IJ) beginning on 2/5/19. On 4/10/19 at 4:45 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ. The IJ was removed on 2/6/19. The deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Evidenced by: The facility's Abuse and Neglect Policy policy, dated (MONTH) (YEAR), includes, in part, the following: Procedure: Prevention: 3. Facility supervisors will immediately investigate and correct reported and identified situations in which abuse, neglect, injuries of unknown origin, or misappropriate of resident property is at risk for occurring. R1's [DIAGNOSES REDACTED]. R1 had an AHCPOA (Activated Health Care Power of Attorney) activated on 11/7/16. POA I was R1's AHCPOA until 2/6/19. R1's primary language is Japanese with limited understanding of the English language, and is essentially non-verbal. R1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/24/19 indicates R1 has severe cognitive impairment, can make self sometimes understood and usually understands others. In addition, R1 needs extensive assist of 2 people for bed mobility, is totally dependent on 2 people to transfer, needs extensive assistance of 2 people for personal hygiene and is always incontinent of bowel and bladder. R1's ADL (Activities of Daily Living) Care Plan, initiated 10/30/16, includes, in part, the following: I am a total full mech (mechanical) lift for transfers with 2 assist. I need assist with toileting, bed mobility, bathing skills, and personal hygiene of extensive to total assist of 1 - 2 (depends on resistance to cares/and uncooperativeness). The handwritten note, written and signed by CNA F, dated 2/5/19, includes the following: I walked into room (R1's room number) and witnessed the POA sexually touching the client without a brief on. I reported it to my nurse right away. The facility's Misconduct Incident Report, dated 2/5/19, included, in part, the following: Date Occurred: 2/5/19. Time Occurred: 7:30 PM. Date Discovered: 2/5/19. Briefly describe the incident: On the evening of 2/5/19 an aide went to (R1's) room to provide cares. When (aide) entered (aide) witnessed (R1's) POA (POA I) standing next to the bed with hands under the sheet and it appeared (POA I) was inappropriately touching (R1). (POA I) stopped and (aide) exited the room to alert supervisor, (POA I) followed (aide) out of the room. The POA then left the facility. The NHA and DON were notified. The facility called the (Local) Police Department and officers were dispatched. The following morning a detective from the (Local) PD (Police Department), along with a representative from Adult Protective Services, arrived at the facility to conduct an investigation. The resident was seen by a SANs (Sexual Assault Nurse) to identify any possible injuries and to obtain possible evidence. The POA was interviewed by the detective and was informed to have no contact with the resident while this is being investigated. Resident interview/summary of finding or allegation: Resident is not interviewable due to dementia and being non-verbal. Did interview staff who were present and informed of the allegation. Accused is (POA I), (R1's) POA. Summary of factual investigative findings: Per witness, there was alleged abuse. The facility called the (Local) Police Department and officers were dispatched. The following morning a detective from the (Local) PD along with the representative from Adult Protective Services arrived at the facility to conduct an investigation. The resident was seen by SANs nurse to identify any possible injuries and to obtain possible evidence. The POA was interviewed by the detective and was informed to have no contact with the resident while this is being investigated. Inappropriate behavior toward the resident by the POA. On examinations there were scratches found in the vaginal area of the resident. This is currently under investigation by the (Local) Police Department. An undated (Local) Police Department Witness Statement, written by CNA F, includes the following: On 2/5/19 at or about 7 - 7:30 PM, I heard or saw the following: It was about 7 or 7:30 and there were probably 4 or 5 call lights on and when I came around the nurse's station to see what light was on I saw (POA I) walk out of (R1's room) with a used brief and he caught me to ask if I could finish (R1). I said, Ok I will right after this light. As I walked in she was just under a top sheet with her legs open which is not normal and (POA I's) hand was under the sheet towards her vaginal area. I did not look him in the eye but instead I said Oh we're out of gloves let me go grab some. I left the room to report it to (RN G (Registered Nurse)) when (POA I) came out quickly asking for water for (R1). I got it for him after I changed her when I went to change her she had no brief only a top and no pants. I shut the privacy curtain so he would not watch and I wiped her so I could examine her really well. At the time I did not see anything out of the blue wrong with her physically or mentally. After that occurred, it kind of clicked to me that the scratches could possibly be from him. Because while she was on the another unit I was changing her once and he had come in and starting kissing her neck and shoulder and cheeks in the middle of me changing her, which I could not stop what I was doing. (Local) Police Department Supplementary Report, dated 2/6/19, includes, in part, the following: (CNA F) has observed scratches on (R1) in between her clitoris, her outer labia and inner labia. (CNA F) said sometimes the scratches bleed, sometimes they do not. Sometimes the scratches are fresh, sometimes they are scabbed over, sometimes they are reopened. (CNA F) said on many occasions the cuts seem to be irritated. (CNA F) estimates about 35% of the days (CNA F) cared for (R1), (CNA F) observed scratches, cuts, wounds and or abrasions on (R1's) vaginal area. (CNA F) has not observed scratches anywhere else on (R1's) body. (CNA F) has shown the scratches to other CNAs and has reported it to the nurse on duty. On 4/9/19 at 11:12 AM, Surveyor interviewed CNA F via telephone. CNA F stated, on 2/5/19 between 7:00 PM and 7:30 PM, POA I came out of R1's room carrying a used brief asking CNA F to throw it away for POA I. CNA F took the brief. CNA F stated POA I had never removed R1's brief before to CNA F's knowledge. CNA F stated after answering a couple of lights, CNA F walked into R1's room to find POA I sitting next to R1's bed, R1 was lying down, did not have pants or a brief on and was covered by a thin sheet. R1's legs were opened, which was unusual because of contractures. POA I's hand was under the sheet, near R1's vaginal area moving around. CNA F could see POA I's hand as the sheet was thin. CNA F told POA I CNA F had to get gloves and left the room. POA I followed CNA F out of the room, asking CNA F for ice. CNA F went directly to RN G and informed RN G what CNA F saw. RN G told CNA F to write a statement and slide it under DON B's (Director of Nursing) door as DON B was going to be in the facility later that evening. CNA F stated POA I waited in the hall while CNA F finished with R1's cares. POA I came into the room, left the glass of ice in R1's room and left. CNA F did not see POA I again that shift. CNA F stated RN G helped to write the statement and was aware of what it said prior to putting it under DON B's door. Surveyor asked if CNA F had seen anything unusual with R1. CNA F stated CNA F washed R1's peri area, looking for any signs of scratching or trauma. CNA F had seen scratches in the past in R1's vaginal area, had reported them to other CNAs and the nurse, but nothing ever came of the information. On 4/9/19 at 9:10 AM, Surveyor interviewed RN G via telephone. RN G stated, on 2/5/19 between 7:00 PM and 7:30 PM, CNA F informed RN G that CNA F had walked into R1's room and observed POA I's hand under the sheet, near R1's vaginal area. RN G asked CNA F to write a statement and slide it under DON B's door. Surveyor asked if RN G called DON B or NHA A. RN G stated no, because in the past, when staff would find scratches in R1's vaginal area or blood found in brief, nothing was done or investigated. RN G would inform the Unit Manager and DON B, but nothing would ever go any further. RN G stated many staff thought POA I was doing something, but nothing was ever witnessed. RN G stated nothing ever was followed up with when R1 would return from outings with POA I with scratches or bleeding. These incidents were reported prior to this incident, so RN G did not think anything would be done with this incident either. The facility failed to protect R1 from sexual assault. Staff reported scratches in the vaginal area and blood in R1's brief, but nothing was investigated or followed up on. R1 was sexually assaulted on 2/5/19. The facility's failure to protect R1 from sexual assault created a situation of IJ, which was removed on 2/6/19 when the facility implemented the following action plan: Corrective Actions: The resident was assessed and no apparent injuries were noted. The police were called to conduct an investigation and the resident was sent out for rape kit. Upon return, the resident's room was changed in order to assure safety. The Healthcare POA was not allowed in the facility to contact resident again post allegation. Identification of Others: Residents at risk, due to vulnerabilities, such as inability to call out or cognitive impairment, are at risk as a result of this allegation. The records of these residents were reviewed and they were assessed, and where appropriate, interviewed to assure no other concerns were identified. Systemic Changes: Facility staff was educated again regarding the abuse prevention policy and the importance of reporting allegations of abuse to their immediate supervisor, the DON or the Administrator immediately. Interviews will be conducted with residents in house to assure that no further concerns are identified. Any new allegations will be immediately investigated in accordance with facility policy. Monitor: Administrator/designee reviews resident concerns and conducts random interviews with a sample of residents weekly for three months to determine whether there are other concerns identified. The Administrator or designee will also conduct a sample of family members weekly for three months to identify any additional concerns. The results of these interview audits will be brought to monthly QAPI (Quality Assurance Process Improvement) Committee, or ad hoc committee if necessary, for review. Any recommendations will be discussed and implemented as appropriate. The Administrator is the individual responsible for compliance with this action plan.

Based on interview and record review, the facility did not thoroughly investigate and take steps to prevent further potential abuse while an investigation was in progress for 1 resident (R1) of 89 residents in the facility, thus allowing further abuse to occur. On 2/5/19, between 7:00 PM and 7:30 PM, POA I (Power of Attorney) was observed sexually touching R1 without a brief on by CNA F (Certified Nursing Assistant). CNA F had previously reported (on unknown dates) finding scratches in R1's vaginal area when R1 had been on outings with POA I. The facility failed to investigate scratches in R1's vaginal area previously reported and failed to put measures in place to prevent further possible abuse. The failure of the facility to fully investigate previous scratches and to put measures in place to prevent further potential abuse, led to the finding of Immediate Jeopardy (IJ), which started on an unknown date. The facility was notified of the IJ on 4/10/19 at 4:45 PM. It was determined the immediacy was removed on 4/10/19, but not yet corrected. The deficiency continues at a scope/severity level D (potential for harm/isolated), as the facility continues to fully implement, educate and evaluate the effectiveness of its action plan. Evidenced by: The facility's Abuse and Neglect Prohibition policy, dated July, (YEAR), includes, in part, the following: Prevention: 3. Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. Investigation: 1. The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property in accordance with state law. R1 was first admitted [DATE]. R1's native tongue was not English and had limited command of English. R1 had dementia and was essentially non-verbal. R1 also had a past [MEDICAL CONDITIONS] that resulted in [MEDICAL CONDITION]. R1 was unable to use one arm and had limited mobility of the other due to contractions. R1 had an activated health care agent (POA I) who was a friend. POA I visited three times a day, seven days a week and took the resident out on day passes on a regular basis. R1's ADL (Activities of Daily Living) Care Plan, initiated 10/30/16, includes, in part, the following: I am a total full mech (mechanical) lift for transfers with 2 assist. I need assist with toileting, bed mobility, bathing skills, and personal hygiene of extensive to total assist of 1 - 2 (depends on resistance to cares/and uncooperativeness). (Local) Police Department Witness Statement, undated, written by CNA F, includes the following: On 2/5/19, at or about 7 - 7:30 PM, I heard or saw the following: It was about 7 or 7:30 and there were probably 4 or 5 call lights on and when I came around the nurse's station to see what light was on I saw (POA I) walk out of (R1's room) with a used brief and he caught me to ask if I could finish (R1). I said, Ok I will right after this light. As I walked in, (R1) was just under a top sheet with her legs open, which is not normal and (POA I's) hand was under the sheet towards her vaginal area. I did not look him in the eye, but instead I said, Oh, we're out of gloves, let me go grab some. I left the room to report it to (RN G (Registered Nurse)) when (POA I) came out quickly asking for water for (R1). I got it for him, after I changed her, when I went to change her, she had no brief, only a top and no pants. I shut the privacy curtain so he would not watch and I wiped her, so I could examine her really well. At the time, I did not see anything out of the blue wrong with her physically or mentally. After that occurred, it kind of clicked to me that the scratches could possibly be from him. Because, while she was on the Garden Unit I was changing her once and he had come in and starting kissing her neck and shoulder and cheeks in the middle of me changing her, which I could not stop what I was doing. (Local) Police Department Supplementary Report, dated 2/6/19, includes, in part, the following: (CNA F) has observed scratches on (R1) in between her clitoris, her outer labia and inner labia. (CNA F) said sometimes the scratches bleed, sometimes they do not. Sometimes the scratches are fresh, sometimes they are scabbed over, sometimes they are reopened. (CNA F) said on many occasions the cuts seem to be irritated. (CNA F) estimates about 35% of the days (CNA F) cared for (R1), (CNA F) observed scratches, cuts, wounds and or abrasions on (R1's) vaginal area. (CNA F) has not observed scratches anywhere else on (R1's) body. (CNA F) has shown the scratches to other CNAs and has reported it to the nurse on duty. On 4/9/19 at 11:12 AM, Surveyor interviewed CNA F via telephone. CNA F described observation, on 2/5/19, as reported to the police. Surveyor asked if CNA F had seen anything unusual with R1. CNA F washed R1's peri (perineal) area, looking for any signs of scratching or trauma. CNA F had, in the past, seen scratches in R1's vaginal area, had reported them to other CNA's and the nurse, but nothing ever came of the information. Surveyor asked CNA F if R1 could touch self in perineal area. CNA F stated, due to R1's contractures, R1 could not touch self in perineal area. On 4/9/19 at 9:10 AM, Surveyor interviewed RN G via telephone. RN G stated, on 2/5/19, between 7:00 PM and 7:30 PM, CNA F informed RN G that CNA F had walked into R1's room and observed POA I's hand under the sheet, near R1's vaginal area. RN G asked CNA F to write a statement and slide it under DON B's door. Surveyor asked if RN G called DON B or NHA A. RN G stated no, because in the pas when staff would find scratches in R1's vaginal area or blood found in R1's brie nothing was done or investigated. RN G would inform the Unit Manager and DON B, but nothing would ever go any further. RN G stated many staff thought POA I was doing something, but nothing was ever witnessed. RN G stated nothing ever was followed up with when R1 would return from outings with POA I with scratches or bleeding - these incidents were reported prior to this incident, so RN G did not think anything would be done with this incident either. Surveyor asked NHA A and DON B if they had been informed of scratches or bleeding in the peri area. DON B stated a nurse saw scratches in R1's vaginal area and had informed DON B R1 had scratched herself. DON B stated that incident was not formally investigated. DON B stated, after the incident, staff monitored R1 for scratches in her vaginal area, review of the documentation showed there were no scratches noted. The failure to fully investigate allegations of abuse and to prevent further potential abuse while an investigation was in progress created a finding of IJ. The facility removed the immediacy, on 4/10/19, when it began implementing the following: Corrective Action: The facility will conduct a timely investigation of allegations of abuse by residents' family members or others. Investigations of abuse will commence immediately following notification to the abuse coordinator or on shift supervisor regarding allegations of abuse. Any individual suspected of abuse will immediately be suspended pending the outcome of the investigation. Identification of Others: Residents with cognitive impairment or residents who are vulnerable due to cognition or mental status could be at risk for abuse. Residents at the facility, who are at risk due to these factors, were reviewed to determine whether there were any concerns regarding abusive behavior by staff or others. Systemic Changes: In the event of an allegation of abuse, the facility management team will immediately conduct a thorough investigation in accordance with the facility's general investigation policy. The policy includes the following steps: Interviewing the resident Interviewing the person reporting the incident Interviewing any witnesses to the incident Interview staff members who cared for the resident on the shift when the allegation was made or any other time period based on the results of the resident interview or the interview of the person bringing forward the allegation Interviewing family members or others familiar with the resident Interviewing visitors, if applicable Interviewing any other individuals who are pertinent to the case Interviewing others who might have knowledge of the allegations, which should include other residents and staff Once the investigation is completed, the person(s) conducting the investigation will summarize the results and meet with the ITD (Interdisciplinary Team) to discuss the results and interventions that should be implemented as a result of the findings. Educations will be completed with the appropriate staff members (staff members involved in the resident's care and/or the care of residents similarly situated) regarding the interventions implemented and generally regarding the results of the investigation Monitoring: The Administrator and/or Director of Nursing will conduct routine interviews with staff regarding their knowledge of the abuse prevention policy, the general investigation policy, and the facility code of conduct and review and update Care Plans. This will continue for three months and then monthly for three months. The results of the interviews will be brought to QAPI (Quality Assurance Process Improvement) monthly meeting, or ad hoc meeting, as necessary. Any recommendations that are brought forward as a result of the meetings will be discussed and implemented, as appropriate. The Administrator is the individual responsible for compliance with this action plan.

Based on observation, interview, and record review, the Facility did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries resulting in deterioration for 4 of 8 sampled Residents (Residents R5, R1, R13 and R9). R5 developed an avoidable, blackened fluid filled pressure injury to R5's left heel. The Facility did not implement measures to offload the left heel after development of the pressure injury. On 9/3/16 when R5 was readmitted the Facility did not assess R5's foot, did not treat the pressure injury from 9/3/16 to 9/6/16 and did not consult with the physician when the facility first identified an odor on 9/10/16. R5 was hospitalized and surgery was perform which resulted in a left [MEDICAL CONDITION]. The Facility's failure to provide the necessary care and services to R5 created a finding of Immediate Jeopardy beginning on 9/3/16. Administrator-A and RN (Registered Nurse) Regional Consultant-B were informed of the Immediate Jeopardy on 11/8/16 at 3:35 p.m. The Immediate Jeopardy was removed on 11/9/16 when the Facility implemented an action plan related to proper pressure injury care. The deficient practice continues at scope/severity of G (harm/isolated) for the example related to R1. R1 was admitted to the facility on [DATE] with a stage 2 pressure injury to the left ischium. On 8/10/16 the facility assessed the pressure injury as a shear. On 8/17/16 the facility assessed the pressure injury as a 1.0 centimeter (cm) by 1.0 cm shear with no odor and no drainage. On 8/31/16 the facility assessed the pressure injury as a 1.0 centimeter (cm) by 1.0 cm by less than 0.4 cm shear with no drainage. The facility did not monitor the pressure injury's progression towards healing and did not monitor for potential complications of the pressure injury from 8/31/16 through 9/16/16. On 9/16/16 the pressure injury was assessed to be a shear measuring 4 cm by 2.5 cm by less than 0.4 cm. (deterioration of wound condition). The plan of care for the left ischium pressure injury was not updated/revised when the pressure injury was noted to have deteriorated on 9/16/16. On 9/21/16 the pressure injury was assessed and noted to have deteriorated to an unstageable 3.8 cm by 2.9 cm by 1.9 cm pressure injury with 100% black/tan slough to the base of the wound with moderate drainage and a pungent odor. The plan of care for the left ischium pressure injury was not updated/revised when the pressure injury further deteriorated on 9/21/16. The pressure ulcer is currently progressing towards healing. R1 developed a facility acquired unstageable pressure injury to the left heel on 8/29/16. R1's plan of care to prevent the development of pressure injuries and promote healing of the left heel pressure injury was not always followed. On 11/01/16 R1 was observed lying in bed without interventions in place to offload pressure from the heels. The condition of the pressure ulcer did not deteriorate. R1's medical record indicates that the Resident has a physician's orders [REDACTED]. The facility did not provide the barrier cream to the coccyx on the day shift from 11/01/16 through 11/05/16, from 11/07/16 through 11/09/16 and from 11/11/16 through 11/13/16. Additional examples of deficient practice identified, but at severity level 2 (potential for harm that is not immediate jeopardy) include: R13 did not have physician order [REDACTED]. R9's plan of care specified pressure relieving equipment for both his bed/mattress and wheelchair cushion. R9 was observed during the survey to not have this specific equipment in place for pressure relief. Findings include: The Facility's Skin Management policy and procedure with a revision date of August 2012 under the section Staging Classification documents, The following Staging Classification is consistent with the National Pressure Ulcer Advisory Panel (NPUAP). Stage I An observable pressure related to alteration of intact skin whose indicators as compared to an adjacent or opposite areas on the body may include changes in one or more of the following: Skin temperature, tissue consistence and/or sensation; the ulcer appears as a defined area of persistent redness in lightly pigmented skin whereas, in darker skin tones, the ulcer may appear with persistent red, blue or purple hues. Stage II Partial thickness of skin loss involving epidermis and/or dermis; the ulcer is superficial and presents clinically as abrasion, blister, or shallow crater. Note: Slough is not found on Stage II ulcers. In addition, a Stage II blister may be intact or open serum filled. A blood blister is considered to be a suspected Deep Tissue Injury (DTI). Stage III Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; the ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Note: A Stage III may include tunneling or undermining. Ulcers to the bridge of the nose, ear, occiput and malleolus may be a Stage II but may appear shallow due to lack of large amounts of adipose tissue. Stage IV Full thickness loss of skin with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon joint capsule, etc.). Unstageable When eschar is present, accurate staging is not possible until the eschar has sloughed or the wound has been debrided. Identify/documents as eschar covered area, unable to determine depth and stage, etc. Eschar in the wound bed may be tan, brown, or black in color. Unstageable wounds may be covered by yellow, tan, gray, green, or brown slough. Note: Tunneling and sinus tracts may also be associated with Stage IV pressure ulcers. Suspected Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage to underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is firm, mushy, boggy, or warmer or cooler as compared to adjacent tissue. May open and deteriorate rapidly even with optimal treatment. The Facility's staging classifications are not the current pressure ulcer classifications. The current International NPUAP/EPUAP Pressure Ulcer Classification system are as follows: Category/Stage I: Nonblanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding areas. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage II: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.* This Category/Stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates suspected deep tissue injury. Category/Stage III: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, malleolus do not have subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. During survey, it was noted by the survey team that the facility's policy and procedure for pressure injuries was not based upon the most current, revised standards put forward by the NPUAP in 2014. 1.) Surveyor reviewed R5's medical record on 11/1/16 to 11/7/16. R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R5 was admitted to the Facility without any pressure injuries and receives [MEDICAL TREATMENT] three times a week. The nursing admission data collection dated 7/12/16 documents for main reason for admission per admission paperwork left [MEDICAL CONDITION]. Under the skin section, for the question does the resident have skin issues yes is documented. Documented under the site is Right antecubital & for Type documents, other (specify) [MEDICAL TREATMENT] port Under site also documents, left trochanter (hip) and under type documents, Surgical Incision. There are no pressure injuries documented under the skin section for R5. The Braden assessment dated [DATE] has a score of 17, which indicates R5 is at risk for developing pressure injuries. Surveyor noted that although R5 was at risk for developing pressure injuries the Facility did not develop an initial plan of care and did not develop a potential for skin integrity plan of care. The in house communicator from OT (occupational therapy) dated 7/16/16 documents, Heel floater issued for use @ (at) all times in bed. (B) (bilateral) LE (lower extremity) boots for use in bed and when up in w/c (wheelchair). There isnurses note regarding the use of the heel floater and nothing was added to the plan of care. The SBAR (Situation, Background, Assessment Recommendation) communication form and progress note dated 7/19/16 documents for the statement the change in condition, symptom, or signs I am calling about is/are pressure ulcer left heel. excoriation to buttocks. The SBAR summary documents, RN (Registered Nurse) Assessment/LPN (Licensed Practical Nurse) Appearance of resident - What I think is going on with the resident: to have an excoriation and sheering to sacral area. pt (patient) also has 4x4 (four times four) pressure sore to left heel. noted black in color and fluid filled at top of sore. Additional nursing notes as applicable: to have an excoriation and sheering to sacral area. pt also has 4x4 cm (centimeter) pressure sore to left heel. noted black in color and fluid filled at top of sore. Physician-JJ was notified on 7/19/16. The Facility did not develop a pressure injury care plan after R5 developed the pressure injury on his left heel. The nurses note dated 7/19/16 documents, Resident in bed, awake and alert, left heel ulcer noted, applied [MEDICATION NAME] to site, feet offloading, heel boots in place, applied calazyme to buttocks area, repositioned to left side, gave PRN (as needed) pain medication as indicated. The nurses note dated 7/21/16 documents, resident went to ER (emergency room ) for blood clots around 0215 (2:15 a.m.) this morning. R5 was hospitalized from [DATE] to 8/5/16. The nursing admission data collection with an effective date of 8/5/16 under the skin section, for the question does the resident have skin issues yes is documented. There are two pressure injuries documented. Under site documents, 2nd toe left foot For type documents, pressure, for length documents, 0.8, for width 0.2 and stage documents, Suspected Deep Tissue Injury. For site documents, left heel, for type documents, pressure, for length 5 cm (centimeters), for width 4.5 cm and for stage documents, II (2). There is an open area documented for site inner right foot, for type other, for length 1 cm for width 1.3 cm and for stage n/a (non applicable). The nursing initial plan of care with an effective date of 8/5/16 for the care plan Resident has potential/actual skin issues related to potential breakdown and pressure ulcer related to mobility has the following interventions checked provide wound care/preventative skin care per order, observe wound healing, skin checks weekly per facility protocol, document findings, notify MD of changes in wound or emerging wounds, and turn and reposition frequently to decrease pressure. This care plan does not address offloading R5's heels. The Braden assessment dated [DATE] has a score of 18, which indicates R5 is at risk for developing pressure injuries. The skin head to toe skin check with an effective date of 8/11/16 documents, stage 2 pressure to left heel. Under site documents, left heel, type pressure, length 5, width 5, and stage II (2). Under further description of skin issues documents, no necrotic tissue, no slough. There is no documentation regarding the left second toe or right inner foot. The admission MDS (minimum data set) with an assessment reference date of 8/12/16 and signed as complete on 8/16/16 documents a BIMS (brief interview mental status) score of 15, which indicates cognitively intact. R5 requires extensive assistance with two plus persons physical assist for bed mobility and transfers, and extensive assistance with one person physical assist for toilet use. R5 is coded as being continent of bowel and bladder. R5 is at risk of developing pressure injuries and is coded as having one Stage 2 pressure injury and one unstageable pressure injury. The most severe tissue type is coded as eschar. Pressure reducing device for chair, pressure reducing device for bed, pressure ulcer care, and application of ointments/medications other than to feet are checked under skin and ulcer treatments. The nurses note dated 8/13/16 documents, Dressing changed to left heel. Serosanguineous drainage noted to old dressing. No odor present. Left second toe black area-[MEDICATION NAME] applied PRN (as needed) [MEDICATION NAME] 5 mg (milligrams) 2 tabs (tablet) given this HS (hour sleep) for c/o (complaint of) pain. Will continue to monitor. The pressure ulcer care plan has interventions dated 8/16/16 of Administer medications as ordered. Observe/document for side effects and effectiveness., Administer treatment as ordered and observe for effectiveness., Assess/record/observe wound healing with nrsg (nursing) assessment and weekly per unit manager. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress, Report improvements and declines to the MD, Complete a full body check weekly and document., Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning., Follow facility polices/protocols for the prevention/treatment of [REDACTED]. Serve diet as ordered, observe intake and recordb, and Reposition in chair/W/C (wheelchair) frequently for comfort and pressure reduction. Provide resident/family education as needed. The pressure ulcer care plan does not address offloading of R5's heels. Surveyor noted there were no further revisions in R5's pressure ulcer care plan after the interventions dated 8/16/16. The pain care plan has an intervention initiated on 8/16/16 of The resident's pain is aggravated by putting pressure on his heels; make sure pressure relieving boots on his feet when in bed. The weekly pressure ulcer log dated 8/18/16 documents for site (L) (left) toe 2nd, size 0.6 x 0.2 cm <(less than) 0.1, treatment [MEDICATION NAME] and site (L) heel, size 4.9 x 4.3 < 0.1, and treatment hydrogel. There is no description of the wound bed other than the measurements on this pressure ulcer log. The pressure ulcer CAA (care area assessment) dated 8/16/16 under analysis of findings documents, Triggered this caa d/t (due to) having a pressure ulcer on his left heel on admit stage 2 and also noted to have small black area on left toe, see tx (treatment) order 8/12/2016 for [MEDICATION NAME] to the toe, this was noted to be on admissions assessment by floor nurse, tx. obtained to tx toe, Toe was noted to be unstageable pressure (small area). he has protective boots on both feet to help with healing of area and also to prevent further skin issues. he is [MEDICAL TREATMENT] resident 3x (three times) per week and diabetic on insulin. he has other other issues medically. see dc (discharge) summary, H*P (history physical) and Physician-JJ noted dated 8/10/2016. he has areas on lower legs that receive tx, had some open areas on his feet on admit. see skin assessment on nrsg (nursing) admission assessment dated [DATE], also see skin assessment dated [DATE]. staff will be assessing skin with cares, nrsg assesses areas every shift & prn (as needed). treatment to the areas by nrsg as ordered, staff to frequently reposition him when he is in bed or in his w/c (wheelchair). The weekly pressure ulcer log dated for w/o (week of) 8/28-9/2 for R5 documents for site (L) heel stage uns (unstageable), treatment [MEDICATION NAME] with a handwritten notation of surgery 8/30. and site (L) toe) and stage II (2) is checked. There are no measurements or assessments/descriptions of R5's pressure injuries on this weekly pressure ulcer log. The nurses note dated 8/30/16 documents, Dressing changed to left heel and left toe [MEDICATION NAME] applied. Continues to have serosang (serosanguineous) drainage to left heel. PRN [MEDICATION NAME] 2 tabs and [MEDICATION NAME] given this HS. Resident aware of order for AM (morning) with surgery. Will continue to monitor. R5 was hospitalized from [DATE] to 9/3/16. Surveyor noted the last measurements of R5's pressure injuries are dated 8/18/16 and the last assessment is dated 8/11/16. There were no further assessments or measurements of R5 pressure injuries in August. The nursing admission data collection with an effective date of 9/3/16 under main reason for admission per admission paperwork documents, left hip revision. For the question does resident have skin issues yes is coded. Under site documents, coccyx type Pressure, stage I (1), and for notes redness. covered with dressing. Under site left trochanter (hip) type surgical incision and notes dressing intact. No drainage noted. 31 staples. Under site documents, Left heel, Type Pressure and notes necrotic tissue. Open to air. Under site documents, left toe(s), type blister and notes [MEDICATION NAME] and OTA (open to air). Under site documents, left thumb, type blister and notes left thumb blister [MEDICATION NAME] and OTA. There is no measurement of R5's left heel or a description of the wound when R5 was admitted on [DATE]. The Braden assessment dated [DATE] has score of 16 which indicates R5 is at risk for developing pressure injuries. The nurses note dated 9/4/16 documents, Resident in bed, medicated with Tylenol for post surgical hip pain which afforded relief, L (left) hip immobilizer in place, will continue to monitor. The nurses note dated 9/6/16 documents, Dressing changed to left hip. Serosang drainage noted with some bleeding. Heel dressing intact. Will continue to monitor. The physician order [REDACTED]. Surveyor noted upon admission on 9/3/16 there was not a treatment for [REDACTED]. The physician progress notes [REDACTED]. The weekly pressure ulcer record with an effective date of 9/8/16 documents for site left heel, type pressure, Length 8, Width 8, Depth 0, Stage unstageable. Under description of site documents, L heel worsened since hospitalization . Was stage II (2) when left for surgery on 8/30/16. Resident states that no one looked at my L heel or did any treatment while I was in the hospital. Under description of wound bed black is coded, for drainage none is coded and for odor not present is coded. This weekly pressure ulcer record is the first measurements and assessment of R5's left heel pressure injury since R5 was admitted 5 days prior. The weekly pressure ulcer record with an effective date of 9/8/16 for site documents, left toe(s), type pressure, Length 0.5, width 0.5, depth 0 and Stage II (2)' Under description of site documents, L 2nd toe with intact blister. These weekly pressure ulcer record do not address R5's Stage 2 buttocks pressure injuries The nurses note dated 9/8/16 documents, Pt. (patient) reported to writer that the hospital, St. Cats did not look or dress the left heel during hospital stay with left hip surgery. Pt's heel was healing well before surgery. Buttock was clear prior to surgery/hospital stay. Reported to DON (Director of Nursing) and Physician-JJ office. Call out to Physician-JJ office for wound clinic referral and drsg. (dressing) change to santyl. Also requesting [MEDICATION NAME] for buttocks bid (twice daily). The nurses note dated 9/10/16 documents, Dressing changed to left heel. Serosang drainage and foul odor noted to wound. PRN (as needed) [MEDICATION NAME] 2 tabs given prior to dressing. Will continue to monitor. There was no consultation with R5's physician. The nurses note dated 9/12/16 documents, Dressing changed and intact to left heel. Serosan drainage and odor noted to wound. PRN [MEDICATION NAME] 5 mg 2 tabs and [MEDICATION NAME] given this HS (hour sleep) Refused [MEDICATION NAME] this hs due to accucheck of 78. Resident has snacks in room at this time. Will continue to monitor. There is no consultation with R5's physician despite R5's the odor for the pressure injury. The weekly pressure ulcer record dated 9/14/16 for left heel documents size as 8.5 x 8 cm, depth 0, Stage unstageable and under notes documents, (L) heel cont. (continue) with necrotic tissue wound clinic consult made. For response to treatment deteriorated is checked. R5's plan of care was not revised. The wound care note dated 9/15/16 documents, (L) heel unstable black necrotic tissue malodorous. needs debridment with general surgery small stable wounds to lateral and medial foot and 2nd toe continue [MEDICATION NAME]. Buttocks Stage II pressure ulcers small open areas recommend protective buttocks cream. There is not measurement or assessment of the wound bed for R5's buttocks stage 2 pressure injury. The nurses note dated 9/15/16 documents, returned from wound clinic. needs debridment of left heel with general surgery need to call to make apt. (appointment) with Physician-LL drsg. (dressing) changed to antimicrobial foam/silver daily to cont (continue) [MEDICATION NAME] to 2nd toe and medial foot. pt. wears off loading boot at all time. heel riser is in use. The nurses note dated 9/15/16 documents, Called Physician-LL office to make appt for today. Able to get pt. (patient) into office today 9/15/16 at 3-330 for consult of left heel. scheduled appt. The nurses note dated 9/15/16 documents, Dressing intact to left heel from Physician-LL appointment. PRN [MEDICATION NAME] 5 mg 2 tabs given this HS along with [MEDICATION NAME]. No s/s (signs/symptoms) [DIAGNOSES REDACTED] noted. Will continue to monitor. The actual skin issues stage 2 pressure ulcer to coccyx care plan initiated 9/15/16 has interventions also dated 9/15/16 of Notify MD (medical doctor) of changes in wound or emerging wounds., Observe wound healing., Provide wound care/preventative skin care per order., R5 is non complaint with taking insulin and turning and repositioning to offload pressure to heels and buttocks. R5 will refuse to take scheduled insulin., Skin checks weekly per facility protocol, document findings, and Turn and reposition frequently to decrease pressure. The weekly pressure ulcer record with an effective date of 9/21/16 documents for site left heel, type pressure, length 8.3, width 12, depth UTD (unable to determine), and stage unstageable. Under description of site documents, Resident noted 100% black/tan necrotic slough with purulent fluid expressing from softening eschar cap, heavy [MEDICAL CONDITION] drainage and pungent odor. Under specialty interventions w/c (wheelchair) cushion and positioning devices are coded. For types of positioning devices ez boots is documented and other interventions documents, change to prevalon boots. Under response to treatment deteriorated is coded and under note documents, Wound appears to be infected. Resident followed by wound clinic and wound clinic refused to follow recommendation made by wound team. Resident is scheduled for debridment. Under notifications date notified documents, 9/21/16 and under name of person notified documents, wound clinic. Surveyor was unable to interview the nurse who completed the weekly pressure ulcer record as to why the physician was not consulted, who she spoke with at the wound clinic and if there were any recommendations as the nurse is no longer employed at the Facility. The nurses note dated 9/21/16 documents, Treatment done to left heel. Noted necrotic tissue with slough. Foul odor. Pt. has surgical debridment Tuesday. Call out to wound clinic to request santyl. The nurses note dated 9/22/16 documents, Treatment to left heel done. Foul smell. Serosang drainage. Dakins wet to dry applied. Loosened boot to left foot to relieve pressure to sides of foot. Noted black area to outer side of left foot. [MEDICATION NAME] applied to sides of left foot. Received labs faxed to Physician-LL and Physician-JJ. The nurses note dated 9/27/16 documents, Returned from surgical debridment. Foot wrapped in gauze and ace bandage. Prevalon boot on. Foot elevated. New order for wet to dry drsg. changes daily. Follow up with Physician-LL in one week. The wound dimensions 15 cm (centimeter) long, 7cm wide 1 cm deep. The hospital operative report dated 9/27/16 documents under postoperative diagnoses/[DIAGNOSES REDACTED]. Under description of the procedures documents, I went ahead and debrided all the necrotic tissue including the skin and subcutaneous tissue, the fat, as well as tendon and muscle. The calcaneus bone was already needed to be debrided as well. So most likely has osteo[DIAGNOSES REDACTED] as well. The wound created is 15 centimeters long, 7 centimeters wide, and 1 centimeter deep. After I cleaned all that area packed it up and dressing applied to the wound. The patient was transferred to recovery room in satisfactory condition. He is going to require amputation in the future. The weekly pressure ulcer dated 9/28/16 documents for site left heel, type pressure, length 17, width 8.3, depth UTD (unable to determine), and stage unstageable. Under description of site documents, wound noted to be necrotic, calcaneus bone exposed s/p (status [REDACTED]. No undermining or tunneling noted but due to uncertainty of wound bed difficult to assess. Under notes wound appears to have a large decline from previous assessment Under physician notification, date notified is documented as 9/28/16 and name of person notified documents, -----. Surveyor was unable to interview the nurse who completed this weekly pressure ulcer record as the nurse no longer works at the Facility. The nurses note dated 9/30/16 documents, Spoke with [MEDICAL TREATMENT] staff-NN at [MEDICAL TREATMENT] about what the plan is for pt. reported low BP's (blood pressure) pale pallor, increased weakness, low voice tone. Reported pt was sent out to ER (emergency room ) and sent back the same night. with orders to hold [MEDICATION NAME] if BP < (less than) 105. [MEDICAL TREATMENT] followed up with Physician-MM, Physician-JJ, and Physician-LL. Pt. will be admitted to St. Cats for eval (evaluation). Noted pt had boots on at [MEDICAL TREATMENT] for pressure relief. The hospital discharge summary dated 10/24/16 under discharge [DIAGNOSES REDACTED]. artery disease) who presents to the hospital due to worsening LE (lower extremity) wounds. Patient had recent [MEDICAL CONDITION] in July of this year post ORIF (open reduction internal fixation). He was residing in NH (nursing home) and developed BLE (bilateral lower extremity) wounds. He was hospitalized at St. Catherine's hospital due to declining status of wounds. He was transferred to SLMC (St. Luke's Medical Center) for further management. Per wound care, they noted on exam that patient is with calcaneus widely exposes to left foot. Arterial US (ultrasound) notes extensive PAD (peripheral artery disease). Wound care, surgery, and plastic surgery were consulted. Consensus was that limb was not salvageable due to extensive nature of wound. He was initially resistant to amputation, but eventually consented. Cardiology followed and vascular intervention performed. He had PTA with stent to anterior tibial lesion. He was subsequently taken to surgery and BKA (below knee amputation) performed. R5 was readmitted to the facility on [DATE] with left below knee amputation. The potential/actual skin issue care plan initiated 10/26/16 has interventions dated 10/26/16 of Notify MD of changes in wound or emerging wounds., Observe wound healing, Provide wound care/preventative skin care per orders, Skin checks weekly per facility protocol, document findings, and turn and reposition frequently to decrease pressure. This care plan does not address offloading R5's right heel or preventing pressure on t

Based on observations, record reviews and interviews, the facility did not ensure that 1 (Resident #8) of 14 sampled residents received medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident #8 was admitted with a [DIAGNOSES REDACTED]. Over the next 6 weeks, Resident #8 lost 31.3 pounds, due to refusals to eat, and experienced increased frequency of depressive symptoms. Nursing staff did not alert facility social service staff to the weight loss or increased depressive symptomatology. Although the facility was aware of the refusals to eat and and increased frequency of symptoms related to depression, appropriate medically-related social services were not provided to assure Resident #8's health and safety were maintained. Findings include: According to a geriatric psychiatrist, Depression in these vulnerable seniors (nursing home residents) has a profound negative impact on both their quality of life and physical health. Family members, unable to relieve the despair, suffer along with the resident; and nursing home staff and administrators struggle to meet the needs of these residents who find little comfort or pleasure. <https://www.chausa.org/publications/health-progress/article/November-December-2014/a-doctor's-view-depression-in-long-term-care-residents> Further, the Illinois Council on Long-Term Care notes that depression also affects one's physical health. Depression not only affects a person's mental health, but often impacts on a person's physical health. In a one year study by psychiatrists at Johns Hopkins University, nursing home residents with depressive disorder were 59% more likely to die than residents who were not depressed. The researchers attributed this result due to some of the common symptoms of the disease: nutritional deficits due to lack of appetite, insufficient rest due to insomnia, and immobility due to despondency. <http://www.nursinghome.org/fam/fam_005.html> Surveyor # reviewed Resident #8's record on 8/24-8/27/15. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident #8's admission physician's orders [REDACTED]. On 6/22/15, nurses' note documentation indicates nursing received an early warning tool from occupational therapy stating patient said I wish I would die. The note further indicated Resident #8 has a history of depression and the physician was notified. A Depression/Anxiety/Sad Mood care plan was initiated on 6/19/15. Sad, pained, worried facial expressions were checked and the [DIAGNOSES REDACTED]. The goal was to have indicators of depression decreased by 9/19/15. The Admission Minimum Data Set (MDS) completed 6/30/15, reveals a score of 6 for Mood, indicating mild depression. An Initial Social Services Assessment and History was completed by Social Services Assistant (SSA)-F on 6/23/15. The social services summary section indicated Resident #8 would like to complete therapy goals and return home. The Mood State section of the assessment was marked NA (non-applicable) and included verbal expression of distress, which was not checked. There was no acknowledgement of the verbal expression on 6/22/15, of I wish I would die. Social Progress Notes indicate an initial staffing was held on 6/24/15. This note acknowledges Resident #8 is currently taking Celexa for depression and social services are available as needed. Social Progress Notes on 6/25/15, indicate the BIMS (Brief Interview for Mental Status) were completed and Social Services are available as needed. Social Progress Notes on 7/6/15, indicated the Mood and Cognitive assessment were completed with Resident #8, and Social Services are available as needed. Social Progress Notes on 7/8/15, indicated Resident #8's son was applying for Title 19 for the resident to be LTC (long term care) at the facility, and Social Services are available as needed. All progress notes were written by SSA-F. There were no further progress notes written after 7/8/15. The facility initiated behavior monitoring related to the use of the Celexa for depression when Resident #8 was admitted . The target behaviors were listed as self-isolation and sadness/flat affect. A review of the June 2015 Anti-Depressant Medication Monitoring Form indicates numerous shifts of self-isolation, and 5 all shift expressions of sadness on the dayshift, and 2 all shift expressions of sadness on the afternoon shift between 6/19 - 6/30/15. A review of the July 2015 Anti-Depressant Medication Monitoring Form indicates no observations of sad affect, and 4 all shift observations on the afternoon shift of self-isolation. A review of the August 2015 Anti-Depressant Medication Monitoring Form indicates no observations of sad affect until 8/7/15, when dayshift noted a sad affect all day. By 8/8/15, staff is documenting a sad affect for all awake hours until Resident #8 was sent to the hospital from a physician's visit on 8/25/15. Self-isolative behaviors were exhibited 8/7 through 8/14, and again on 8/22 through 8/24/15. Resident #8 was seen by her primary physician on 6/24 and 7/8/15. A review of documentation on Nursing Daily Skilled Summary forms reveals: Multiple entries regarding poor appetite between admission and late July. On 7/25/15, Resident #8 had a visit from an out of town son. Nursing describes an improvement of mood for several days after the visit. By 8/2/15, nursing is documenting almost daily refusals to get out of bed, poor appetite and refusals to drink supplements. On 8/7/15, Resident #8 is described as listless and depressed. On 8/14/15, staff weighed Resident #8 and noted she had experienced a 31.3 pound weight loss since admission. The physician was notified of the weight loss. Resident #8 was found to have a urinary tract infection and was started on an antibiotic. On 8/17/15, Resident #8 is described with a flat affect and responds late. Resident #8 was sent to the emergency roiagnom on [DATE], and her antibiotic was changed. Resident #8's antibiotic was changed again on 8/19/15, when a urine culture revealed MRSA (Methicillin Resistant Staphylococcus Aureus). Continued poor appetite is documented in progress notes and appetite monitoring done in the CareTracker system. Surveyor # spoke with Resident #8 on 8/24 and 8/25/15. Resident #8 presented with a flat affect and had delayed responses to verbal interaction. On 8/25/15, Resident #8 was sent to a routine visit with her primary physician. Resident #8 was admitted to the hospital from the physician's office. On 8/27/15, Surveyor # reviewed chart material obtained from the hospital. On 8/26/15, in the Interval History under the heading of Depression it states, Feels more depressed since being in SNF (Skilled Nursing Facility). Feels mood improved with citalopram. Admits to not wanting to eat, get out of bed, leave room or participate in any activities at the SNF. On 8/25/15 at 8:10am, RN-H told Surveyor # that Resident #8 had changed after the visit from her son in July. Resident #8 seemed to have lost the will to live. RN-H stated she had spoken with Resident #8's son/POA (Power of Attorney) when informing about starting a new medication on 8/14/15, and the son had mentioned he had seen a decline in his mother after his brother had visited. On 8/26/15 at 9:35am, Surveyor # spoke with SSA-F regarding Resident #8. SSA-F stated she was unaware of the early warning tool communication from occupational therapy regarding Resident #8's comment that she wanted to die. SSA-F stated she had not been informed of Resident #8's weight loss or increased symptoms of depression. SSA-F stated she has not increased the frequency of visits with Resident #8 and the documentation in the Social Progress Notes accurately represents the interactions she has had with Resident #8. SSA-F stated nursing staff may have informed Social Service Manager (SSM)-L. On 8/26/15, Surveyor # spoke with SSM-L regarding Resident #8. SSM-L stated she was not aware of the weight loss, comments from son or increased depressive symptomotology. SSM-L stated the facility has a psychiatrist who comes to the building monthly, and a psychologist who comes as necessary. SSM-L stated if she had been aware of the concerns she could have arranged for psychiatric services for Resident #8.

Based on record review and interviews, the facility did not ensure that 1 (Resident #8) of 14 sampled residents maintained acceptable parameters of nutritional status such as body weight, unless the resident's clinical condition demonstrates that this is not possible. Resident #8 experienced a 31 pound unplanned weight loss between 6/20 - 8/14/15. Although nutritional supplements were ordered, Resident #8 was refusing to drink the supplements from mid July through 8/25/15. Resident #8 had a poor appetite. Facility protocol is to weigh residents weekly for 4 weeks after admission. Resident #8 had an admission weight taken on 6/20/15, and a second weight taken on 7/1/15. No further weights were taken until 8/14/15. The facility was without the services of a Registered Dietician from late June through 8/26/15. Resident #8 was not adequately monitored for weight loss and assessed for appropriateness of nutritional interventions. Findings include: Sudden, unintended weight loss can also lead to serious negative effects. According to a medical director, Grace Brooke Huffman, The consequences of sudden weight loss include increased mortality rates. there is a strong correlation between the quality of life and quick, unintentional weight loss. Muscle wasting takes place when the elderly lose weight too quickly. Their immune systems can become severely compromised, making them more at risk for developing infections. <http://www.livestrong.com/article/ 9-what-are-the-dangers-of-sudden-weight-loss-in-the-elderly/> Surveyor # reviewed Resident #8's record on 8/24-8/27/15. Resident #8 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Upon admission 6/19/15, there is a physician's orders [REDACTED]. The Nutritional Status Care Area Assessment (CAA) completed 6/30/15, indicates Resident #8 has an MD (physician) order for a general diet and added House supplement to provide protein and calories needed for heeling. Resident fluid intake is lower at nursing home with a history of a lower [MEDICATION NAME] at the hospital. A potential weight loss/nutritional risk care plan was developed on 6/19/15. The plan indicated the need to monitor for poor food/fluid intake. House supplement 3-4 ounces twice daily was included on the plan. One of the approaches was for a referral to a registered dietician as needed. A Medical Nutritional Therapy Review was completed by Registered Dietician (RD)-Z on 6/25/15. The review referenced a hospital admission weight of 200 pounds and a facility admission weight of 195.2 pounds on 6/20/15. RD-Z documents that a general diet to provide adequate nutrition if consumed. Overall oral intake at 34% is poor. Add House supplement 3-4 ounces twice daily. According to Administrator-A, RD-Z has been on medical leave since late June 2015. A review of the Treatment Administration Record (TAR) for June 2015, reveals instructions for Admit Weight, then daily x 3. There was an admission weight, but no further weights in the 3 days. The June 2015 TAR also indicated weight weekly x 4 weeks; if stable then monthly. No dates were programmed for the weights to be taken weekly and there were no weights on the TAR. A review of the July TAR reveals no mention of the need for weekly weights. Weekly weights should have been included on the TAR through 7/21/15. On 8/27/15 at 8:40am, Director of Nursing-B told Surveyor # that the facility will do weekly weights for 4 weeks after admission, then monthly if stable. According to the monthly vital signs record, Resident #8 had a weight of 191.6 pounds on 7/1/15. A review of documentation of administration of the House Supplement reveals Resident #8 consumed the supplement in June with a few refusals through July 14, 2015. After July 14, 2015 Resident #8 refused most or all supplements for the remainder of July and all of August. A review of nursing documentation on the Nursing Daily Skilled Summary reveals numerous days on which nursing mentions Resident #8's poor appetite. Resident #8 was also exhibiting symptoms of depression which may have been affecting her appetite. The facility documents the percentage of meals consumed in CareTracker (a computer program for data entry from Certified Nursing Assistants (CNA). This documentation was reviewed for June, July and August 2015. Resident #8 rarely ate anything for supper. The data shows that in late July, the percentage of breakfast and lunch meals consumed significantly decreased. On 8/14/15, Resident #8's weight was 163.8 pounds, a 31.6 pound weight loss since admission. The physician was notified and Resident #8 was started on [MEDICATION NAME] to stimulate her appetite, a calorie count was initiated and a urinalysis was ordered. On 8/25/15 at 10:15am, Surveyor # spoke with Assistant Director of Nursing (ADON)-D, who was also the nurse manager for Resident #8's living unit. Surveyor # asked if Resident #8 had any weights taken that were not documented in the clinical record. ADON-D checked the weight book on the living unit and discovered Resident #8 had not been added to the list of residents needing weekly weights. ADON-D stated in the absence of a RD, ADON-D has been completing admission nutritional assessments, but no one has been calculating any weight variances. ADON-D stated that under usual circumstances, the RD would monitor the weekly weights and figure out weight variances with the information. There is no evidence that Resident #8 was monitored for weight loss, despite poor appetite and refusals of supplements.

Based on staff interview and record review, the facility did not ensure that 1 of 4 residents at risk for falls received adequate supervision to prevent falls. On 10-5-11, Resident #4 fractured her right leg when CNA - E transferred her without assistance from another staff person, as directed per Resident #4's care plan (not dated). Findings include: Surveyor # reviewed Resident #4's medical record at the facility from 11/1 - 11/3/11. Resident #4 is [AGE] years old and has a [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] with Generalized Weakness related to a UTI (Urinary Tract Infection). Resident #4 planned to discharge home after receiving rehab for strengthening. Resident #4's initial Minimum Data Set ((MDS) dated [DATE] indicates Resident #4 requires extensive assistance with two person physical assistance for transfers. The 9-9-11 CAAS (Care Area Assessment Summary) for Resident #4 noted that she was at risk for falls related to her MS and Right Sided Weakness. On 10-18-11, the state agency received a complaint regarding Resident #4's fractured right leg. According to the facility's "Post Fall Review", CNA - E transferred Resident #4 from her bed to her wheelchair on 10-5-11 at 6:20 a.m. Resident #4 said that her knees buckled. CNA - E lowered Resident #4 to the floor. Resident #4 sustained a fracture of the right femur (leg). On 11-2-11, Surveyor # reviewed the Hospital discharge information located in Resident #4's medical record. The Hospital discharge information dated 10-12-11 indicates Resident was admitted into the hospital on 10-5-11 after sustaining a fracture of the right femur from a fall at the nursing home. Surgical repair of the right lower extremity was completed and Resident #4 was readmitted back into the facility on [DATE]. On 11-2-11, Surveyor # asked the Director of Nursing (DON) for a copy of the CNA care plan that would have been in effect for Resident #4 on 10-5-11. The DON provided Surveyor # with a CNA Assignment Sheet that was not dated. This CNA Assignment Sheet/care plan noted that Resident #4 was to be transferred with the assistance of 2 staff persons and a slide board. On 11-3-11 at 1:45 p.m., Surveyor # met with the Administrator and DON. The Administrator and DON acknowledged that Resident #4's care plan had not been followed when she was transferred on 10-5-11; as there should have been two staff persons assisting with the transfer. The Administrator and DON further stated that CNA - E had transferred the resident by herself, because of a very specific bowel regime that Resident #4 followed. Resident #4 lived at home prior to her admission to the facility, and had plans to discharge home. The resident's Gastroenterologist (physician specializing in the gastro-intestinal tract) had developed a very specific bowel regime for the resident, which the facility was attempting to follow. The regime involved getting Resident #4 to the toilet immediately upon her request; otherwise, she was unable to evacuate her bowels and was at risk for impaction. The CNA said that she was responding to the resident's request to follow her bowel regime by immediately assisting her to the toilet. The Administrator noted that at the time of the incident, Resident #4 was alert and oriented and able to make her own decisions.

Uncorrected on Verification Visit See Survey Event ID # NCWK11; Plan of Correction completion date was 12/13/10. Based on observation, interview and record review, the facility did not always ensure that 1 out of 7 Residents (Resident #1) reviewed with pressure ulcers, received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Resident #1 was observed with a Stage 3 pressure ulcer to the sacrum/coccyx region that has increased in size. Resident #1 was found to be without proper treatment, that included a dressing to protect the wound from contamination, on 12/14/10 and on 12/28/10 at the wound clinic, and also on 1/6/11 during observation of care provision. On 1/6/11, Resident #1 was without proper treatment to her Stage 3 pressure ulcer that included a protective dressing for 2 or more hours in an area that was prone to fecal contamination. Findings include: Resident #1 was admitted to the facility on [DATE] for care of venous stasis ulcers of her legs and other medical problems. Resident #1's care plan dated 10/20/10 addresses problems that include decreased muscle coordination, Cardio Vascular Accident ([MEDICAL CONDITION]-stroke), [MEDICAL CONDITION], history [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus), history of skin ulcers, Bowel incontinence, history of significant weight decline and history of [MEDICAL CONDITION] (swelling of the legs), urosepsis, anxiety and history of [MEDICAL CONDITION]. The plan of care addresses resident having a short and long term memory problem and moderately impaired decision making ability. Resident #1's plan of care also indicates resident having [MEDICAL CONDITION] as reflected on lab tests 12/30/10 of low Serum [MEDICATION NAME] of 2.7, with normal ranges being 2.5 - 5.7. Resident also has a problem of venous stasis ulcers and [MEDICAL CONDITION] which is currently being followed by the Wound Clinic at the local hospital. Resident #1 developed a Stage 3 pressure ulcer in the facility to the coccyx (tailbone) region on 8/29/10. Wound clinic documentation from Resident #1's medical record indicates the following: " 11/9/10 - Coccyx wound stable. [MEDICATION NAME] stage 3 ulceration ..." " 12/7/10 - Coccyx with Stage 3 pressure ulcer, viable base, no purulence, stable periwound with maceration. No pressure changes ...re-check 2 weeks." " 12/14/10 - ...no dressing on sacrum ...sacrum with superficial [MEDICATION NAME] Allevyn to sacrum, change 3 times per week." ([MEDICATION NAME] and Allevyn are names of dressings used in wound care.) " 12/28/10 - Wound care, follow up multiple pressure ulcers. No dressing on sacrum, No packing into leg wounds ...sacrum is advancing pressure changes, wound is larger, positive granulation. No signs/symptoms of infection ...Sacral wound has deteriorated, call out to (DON) Director of Nurses to discuss treatment. No dressing on wound again ... [MEDICATION NAME] to sacrum, change daily after cleanzing with 1/8 strength Dakins. " On 1/6/11 at 8:30 AM, Surveyor # observed care provision for Resident #1 by Certified Nursing Assistant (CNA)- D and CNA - E. During care provision, Resident #1 was first turned to her left side to provide incontinence care. Surveyor # observed a coccyx ulceration that had no dressing over it for protection. Resident #1 was also found to be having a stool present in the rectal area. CNA's D and E told the surveyor during care provision that they received no report from the previous shift that resident's dressing had come off and that resident was without a dressing. CNA's D and E said that they started their work shifts on 1/6/11 at 6:30 AM and that at this time (8:30 AM), was their first opportunity to care for Resident #1 and the first time that Resident #1's buttocks were checked. On 1/6/11, Licensed Practical Nurse (LPN)-F entered the room at 9:22 AM to complete care provision by doing wound care to the coccyx of Resident #1. LPN-F was questioned at this time about the wound being without a protective dressing. LPN-F told Surveyor that she received no report from the previous shift that the dressing had come off, and if she had, she would have immediately, at the beginning of her shift, attended to the wound dressing. LPN-F told the surveyor the difficulty staff were having in keeping a dressing to adhere in this area of Resident #1's body, and speculated that the dressing likely came off during previous incontinence care given, however, the dressing removal had not been reported. On 1/6/11, RN (Registered Nurse)-C was interviewed following this treatment provision for Resident #1. RN-C re-iterated that staff were having difficulty in dressing this wound. RN-C said that previous wound care notations of resident coming to Wound Clinic with no dressings had been looked into, and it was found that the nursing assistants had removed the dressing during incontinence cares before sending resident to wound clinic on previous occasions. RN-C said she would personally see that dressing was intact before transport to wound clinic in the future. Wound rounds were completed on 1/5/11 by RN-C. The assessment of the coccyx/sacral wound was noted to be a size of Stage 3, 3cm (centimeter) X 3cm. X 0.2 cm, with pink wound bed ...area moist all the time and frequently incontinent of stool. Wound rounds were completed on 12/29/10 by RN-C. The assessment of the coccyx/sacral wound was noted to be a size of Stage 3, 1.5 cm X 2cm X 0.2 cm with no odor and no drainage. On 1/6/11, RN-C telephoned the wound clinic and documented a new order for use of a sacral shaped [MEDICATION NAME] dressing to protect the wound.

Based on observation, record review, and staff interviews, the facility did not ensure 2 of 11 Residents with pressure ulcers (Residents #21 and #25) received necessary treatment and services to promote healing and prevent infections. * Resident #21 was admitted to the facility with three pressure ulcers; while at the facility, Resident #21's pressure ulcers deteriorated and Resident #21 was subsequently hospitalized [MEDICAL CONDITION] from the pressure ulcers and a urinary tract infection. The pressure ulcer required debridement to the bone. The facility's failure to monitor the changing conditions of Resident #21's pressure ulcers that would require the implementation of new interventions and to contact the physician for consultation when Resident #21's pressure ulcer increased in size led to Resident #21's development [MEDICAL CONDITION] and needed debridement of the pressure ulcer to the bone created a situation of immediate jeopardy, which began on 9/22/10. The facility was notified of the immediate jeopardy on 11/23/10. The immediate jeopardy was removed on 11/23/10. Following the removal of the immediate jeopardy, the deficient practice continues at a scope and severity of a D (No Actual harm with potential for more than minimal harm that is not immediate jeopardy/isolated) because the facility needs to continue implementing their pressure ulcer policies, assessment, and training to evaluate its effectiveness and compliance through review at the Quality Assessment and Assurance Committee weekly for one month and on a monthly basis there after. Additionally, noncompliance for pressure ulcers was identified in 1 additional resident who is risk for the pressure ulcers and who is currently residing in the facility, Resident #25. * Resident #25 developed a Stage 2 facility acquired pressure ulcer on the left buttock on 11/18/10 and a physician's order was not obtained for treatment until 11/23/10. Findings include: 1. Surveyor # reviewed the closed medical record of Resident #21 on 11/11/10. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission pressure ulcer sheet dated 08/18/10. Resident #21 was admitted with three pressure ulcers, two at stage 2 and one at stage 3 on the coccyx. A readmission Minimum Data Set ((MDS) dated [DATE] indicates Resident #21's cognition is severely impaired-never/rarely made decisions. The (MDS) also indicates Resident #21 has a Gastrotomy tube for nutrition and is totally dependent on staff for activities of daily living. Resident #21 is incontinent of bowel and has a catheter in place. The (MDS) also indicates Resident #21 has limitations on both side of the body with voluntary movement as full loss and partial loss. The facility plan of care dated 08/17/10 indicates Resident #21 has pressure ulcers on the coccyx which measure 1 x 3 x .3 and the right buttock 0.3 x 0.1 x 0.1. Goal: Pressure ulcer will show signs of healing. Approach: Apply pressure reduction mattress to bed. Apply pressure reduction cushion to chair or wheel chair. Reposition in chair every 1-2 hours. Turn and reposition every 1-2 hours. Complete a full body check weekly. Thursday. IDT (interdisciplinary team) referral, Physical therapist, and Pressure ulcer treatment as ordered. On 08/18/10 the facility wound sheets indicates the right buttock wound healed. The upper sacral coccyx area measured 1 cm X 3 cm X 0.3 cm. and it was staged at a 3 and Santyl was the treatment. No odor and serous exudate was documented. The third pressure ulcer was staged at a 3 and measured 3 X 2 X .1 depth. with purulent exudate and no odor and the treatment is Santyl. On 11/11/10 at 1:25 p.m., Surveyor # spoke with Assistant Director of Nursing (ADON)-D regarding the pressure ulcers for Resident #21. ADON-D indicated Resident #21 had a Stage 4 mattress until 08/25/10, when Resident #21 fell out of bed. The Stage 4 mattress was replaced with a scoop mattress from 08/25/10 until 09/23/10, when the Stage 4 mattress was put back in place because pressure ulcer was getting worse. Resident #21 was hosptalized on [DATE] for unresponsiveness and altered mental status and readmitted to the facility on [DATE]. According to the hospital discharge notes dated 08/31/10, Resident #21 had a stage 3 decubitus wound and the wound care nurse was involved at the hospital. The treatment was a DuoDerm patch. Upon readmission on 08/31/10, the wound sheets indicate the coccyx measures 2.8 cm X 2.2 cm X 0.3 cm depth (centimeter). Staged at a 3 and DuoDerm is the treatment. On 09/01/10, the two pressure ulcers on the coccyx area deteriorated and merged into one, measuring 6 cm. X 2 cm. X 0 cm depth, with a slightly yellow center and staged at a 2 and the physician was not informed. The facility Care Plan for Enteral Nutrition dated 09/01/10 indicates impaired swallowing, urinary tract disease, [MEDICAL CONDITIONS]. Goal: Resident to tolerate tube feeding and maintain healing. Approaches: Tube feedings as ordered, flush as ordered ... On 09/02/10, the primary care physician ordered Santyl twice a day for the wound which according to the wound sheets was already in use as a treatment. The facility did not consult with the physician as to why the physician was continuing with the Santyl, which initially had been ordered on [DATE], but with no subsequent improvement of the pressure ulcer. On 09/08/10, the facility wound sheets indicated the pressure ulcer measured 3 X 1 X .2 Serosanguineous exudate, no odor and improved. Stage 2. The note states no yellow, no necrosis, continue hydrogel and opt foam dressing. Date Notified Physician 08/31/10. The Resident Assessment Protocol Summary (RAPS) for pressure ulcer dated 09/11/10 states, Resident "admitted from the hospital with 2 stage 2 pressure ulcers on her coccyx area...Resident has decrease mobility due to her [DIAGNOSES REDACTED].. Resident repositioned by staff....Resident has a feeding tube for her nutritional needs....Resident also has Foley Catheter until pressure ulcers are healed...Resident has air mattress." "Will proceed to care plan." The (RAPS) dated 09/11/10 for nutrition states, "Resident has a [DIAGNOSES REDACTED]..Resident is totally dependent on staffs with her nutritional needs...Resident is receiving Glucerna 70 ML (milliliters) continuous...Will monitor for any intolerance with feeding and will monitor blood sugars." " Will proceed care plan." According the facility Nursing Daily Skilled Summary sheet on 09/12/10 Resident #21 had a low grade temperature of 99.1-96-20 and no Tylenol was given. On 09/15/10, the facility wound sheets indicate the pressure ulcer on the coccyx measures 5 cm X 3 cm X 0 depth. Stage 2 Serosanguineous exudate scant amount. odor? Note states, coccyx large in size 5 x 3 stage 2 continue hydrogel with opt. foam dressing. The facility had Santyl as the treatment at this time. The facility used Hydrogel on this date even though Resident #21's wound did not improve and the physician was not notified. On 09/22/10, the facility wound sheets indicate the pressure ulcer on the coccyx was larger, measureing 7 cm X 3 cm X .1 depth. Purulent exudate-scant amount, wound bed red and yellow. No change. Note states coccyx 7 x 3 x. 1 no necrosis will add stage 4 mattress treatment Santyl and dressing. No apparent pain. Resident #21's pressure ulcer increased in size and the physician was not contacted regarding the lack of improvement of the pressure ulcer. Santyl was continued as the treatment even though there was no improvement. On 11/11/10 at 1:25 p.m., Surveyor # spoke with Assistant Director of Nursing (ADON)-D regarding the pressure ulcers for Resident #21. ADON-D indicated Resident #21 went back to a Stage 4 mattress on 09/23/10 because the pressure ulcer was getting worse. On 09/29/10, the facility wound sheets indicate the pressure ulcer on the coccyx measures 7 cm X 3 cm X .1 cm depth. Stage 2. Serosanguineous exudate scant amount no odor. No change. Date notified physician 08/31/10. Note states coccyx 7 X 3 X .1 with yellow slough wound bed cleansed, Santyl with dressing. Continue interventions nutrition via GT. with tube feeding. Resident #21's pressure ulcer continued to deteriorate and the facility continued with the same treatment. On 11/22/10 at 1:10 p.m. Surveyor # spoke with Registered Nurse (RN)-C via telephone regarding the physician order on 09/29/10 for Santyl. RN-C indicated she was on the phone with the primary care doctor for Resident #21 and ADON-D told her to get an order for [REDACTED].#21 already had an order for [REDACTED]. On 10/06/10 the facility wound sheets indicates the pressure ulcer on the coccyx measured 7 X 3 X 0 depth. Stage 2. Serosanguineous, no odor, would bed yellow and black, no change. Note states, coccyx 7 x 3 with 50% yellow slough wound bed. cleansed. Continue Santyl with opt. Foam dressing. Bed past week except for therapy with no improvement wound. No pain. According to the facility Nursing Daily Skilled Summary at 9:30 a.m. dated 10/02/10 Resident #21 had a low grade temperature 99.6 and Tylenol was given. On 10/13/10, the facility wound sheets indicate the pressure ulcer on the coccyx measures 7 X 3 X .1 depth, Stage 2, Serosanguineous exudate small amount. No odor, wound bed yellow, no change. Note states, coccyx 7 x 3 x. 1 wound bed with yellow slough treatment Santyl covered with opt Foam. Bedrest except for therapy sessions. No pain. Resident #21's pressure ulcer depth increased in size and the facility did not inform the physician and the facility continued to use Santyl as the treatment. On 10/20/10, the facility wound sheets indicated the pressure ulcer on the coccyx measured 7 X 3 X .1 depth, Stage 2. Serosanguineous exudate, wound bed yellow, no odor. No change. Note states coccyx 7 x 3 x .1 with yellow center. Granulation outer edges. Treatment: Santyl with dressing twice a day. Date notified physician 08/31/10. The pressure ulcer on the coccyx continued to deteriorate and the physician was not notified and the facility continued with Santyl as the treatment. On 10/21/10, the facility Nursing daily Skilled summary sheet indicates Resident #21 had a low grade temperature of 99, no Tylenol was given. On 10/22/10 at 4:00 p.m. according to the family and facility staff, Resident #21 was not responding to family members or staff. The medical record indicates Resident #21's respirations were rapid with lung sounds with audible wheezing. BP 96/54 99.6 axillary-108-20. SpO2 90%. Extremities limp, several family members here. 911 to local hospital. Resident #21 was admitted [MEDICAL CONDITION]. The hospital admission profile dated 10/22/10 states: Stage 3 sacral wound: dressing changed and packed in ER. Foul odor. Treated with [MEDICATION NAME]. The hospital Assessment and Cares indicates pressure ulcer on coccyx stage 3. Approximately 5 cm X 3 cm, size large Stage 3 decubitus ulcer located to the coccyx. The ED Report states, "There is a large sacral decubitus ulcer with foul smelling purulent sanguinous exudate that was cultured. As mentioned above her sacral ulcer was cultured. The white blood cell count is elevated at 22.6. She is anemic. Her hemoglobin is 7.9. She has a left shift in the differential. Her chemistries show a potassium that is slightly elevated at 4.9 glucose elevated at 366. Her BUN and creatinine are elevated at 67 and 1.39, consistent with dehydration. Her liver enzymes show the transaminases, bilirubin, and alkaline [MEDICATION NAME] are elevated, which were normal just a couple of months ago. Her lactic acid is elevated at 4.1 consistent [MEDICAL CONDITION] but she is not acidotic at this point. Clinical Impression: 1. Altered mental status. 2. Decubitus sacral ulcer, probably infected 3.[MEDICAL CONDITION] The patient was also hypotensive and also for dehydration was given a liter of intravenous fluids." Hospital Consult dated 11/08/10 states: She (Resident #21) was subsequently admitted and found to be septic from urinary tract infection and possible wound infection as well. The consult also indicates necrotic sacral decubitus ulcer full thickness in need for debridement. The patient's current septic episode is likely related to this as well. May have a urinary etiology as well. On 10/22/10, wound cultures from the sacral decubitus ulcer indicates many gram positive rods and many negative coccobacilli. The blood cultures were also positive for gram negative rods and Escherichia Coli. Operative Report for hospital indicates a necrotic sacral decubitus ulcer. Details of the procedure: There was large necrotic tissue which was completely excised revealing necrotic tissue beneath. As much of the necrotic tissue as was possible was debrided back. There were still a few little regions bilaterally that had good bleeding edges throughout. It was all the way down to the coccyx tip and this was exposed. The final wound length was 13.0 x 13.0 X 5 cm at its deepest portion. After debridement the wound was a stage 4." On 11/22/10 1:55 p.m., Surveyor # spoke with Dietitian-G. Dietitian-G indicated a full assessment is done on each new admission and on Resident #21's admission on 08/17/10 the fluid calculation was not correct from the hospital and it was recalculated according to Resident #21's weight. On 08/18/10, Resident #21's tube feeding was changed from [MEDICATION NAME] 1.2 to Glucerna 1.2 70 cc/hour for 24 hours and 150 cc flush every four hours. Dietitian-G notes she was aware of the sacral wound and Resident #21's need for increased protein for wound healing. On 09/28/10, Dietary notes indicate increased calories and increased protein would promote healing stage 2 from stage 3. The measurements indicate the pressure ulcer is getting worse. On 11/22/10 at 1:40 p.m., Surveyors # and # spoke with the ADON-D. ADON-D was ask why santyl was ordered on [DATE] and reordered on [DATE]. The ADON-D indicated she did not know why this was done. ADON-D indicated the use of Santyl was appropriate for a Stage 2 and a Stage 3 wound that was dry and leathery. ADON-D indicated there was always some depth to the pressure ulcer on the coccyx and sometimes the exudate was purulent and sometimes it was sero-sanguineous. ADON-D stated the interior of the wound was yellow leather and dry and it should have been staged as unstageable because they didn't know what was underneath. ADON-D stated, that Santyl is not a good [MEDICATION NAME] agent. On 10/06/10 when the wound had some black in the center and it was 75% yellow, she did not think nurses were putting enough Santyl on the wound. A representative came out to do an inservice for nurses. ADON-D indicated the wound measurements were faxed to the primary care physician every week. ADON-D stated that she was hoping the wound would get better with the Santyl and she did not call the physician; that they thought about the wound clinic but Resident #21 was not sent to wound clinic. ADON-D indicated that Licensed Practical Nurse (LPN)-F did tell her the pressure ulcer looked a little worse. ADON-D indicated she offered to look at it again and it did not look like the Santyl started to break down the leathery tissue, "I was hoping it would work." On 11/22/10 at 10:15 a.m., Surveyor # spoke with LPN-F. LPN-F indicated the dressing to Resident #21 was changed on Mondays, Tuesdays, and Thursdays. LPN-F indicated her concerns of the pressure ulcer not healing and getting worse were brought to the attention of the ADON-D and nothing was done about it. On 11/24/10 at 2:25 p.m., Surveyor # spoke with Medical Doctor (MD)-H. MD-H indicated the facility did not inform her when (Resident #21's) pressure ulcer started to deteriorate with purulent exudate and increase in size. MD-H also indicated the facility did not fax weekly wound measurement sheets when (Resident #21) resided at the facility. Resident #21 had office visits with MD-H on 09/17/10 and 10/13/10 however, Resident #21 came to the office in a wheel chair and MD-H indicated she was unable to examine (Resident #21's) pressure ulcer. MD-H indicated she informed the nurse that Resident #21 needed to come to office via gurney or stretcher. According the undated facility "Signs and Symptoms Interact" pressure ulcer protocol: new onset grade 2 or higher pressure sore or progress of pressure sore despite interventions is Non-Immediate. Notify the attending or on-call MD, NP, or PA no later than the next work day. This was not implemented by the facility when the pressure started to deteriorate. The failure to ensure that Resident #21 received the necessary treatment and services of pressure ulcers created an immediate jeopardy situation. The immediate jeopardy was removed on 11/23/10 when the facility completed the following: * As of 11/23/10, the facility completed a full skin sweep of all in-house residents, reviewing all pressure ulcers identified by previous assessments to verify that staging is correct and treatments in place. Pressure ulcers that have not improved will have consultation with the attending physician for treatment changes or wound clinic consultation. * As of 11/23/10, the facility leadership team has reviewed the facility's policy regarding pressure ulcer identification and assessment and has determined the policies are sufficient. * All residents are assessed head to toe on admission for skin integrity. * Identified pressure ulcers will have intervention implemented to promote healing, based on physician orders. * Licensed nurse will document daily the condition of each identified pressure ulcer. Alteration in appearance will be referred to the wound team within 24 hours. Coverage for weekend and Holidays will be consultation with Director of Nursing or Designee. * Pressure ulcers will be measured and staged weekly by the wound team, which will consist of 2 nurses recognizing changes in size, drainage, and odor. Education to ensure nurses completing measuring and staging will be accomplished through the local wound clinic to be completed within 1 to 2 weeks. * Weekly reports will be documented on a pressure ulcer record. * Weekly physician notification of wound assessments will be faxed with confirmation of fax attached. Documentation of such will be entered on the wound sheet. The Director of Nursing or Designee will follow up with phone consultation if condition warrants. * Weekly family notification will be by phone or in person. Documentation of such will be entered on the wound sheet. * Change in condition of pressure ulcer or no improvement in 2 weeks, or based on resident's co-morbid conditions, will require direct consultation with physician for treatment change or referral to wound clinic for intervention. * New onset of 101 F temperatures with Stage II or higher ulcer will require immediate physician consultation. * New onset of Stage II or higher pressure ulcer will require physician consultation. * Repeat nutritional evaluation will be requested for pressure ulcer change of condition. * The 24 hour report is the communication tool used during shift change to discuss physician consultation and direction related to pressure ulcer identification and management. * The Director of Nursing or Designee is responsible for monitoring the 24 hour report to assure that the physician consultation and nursing assessments are completed timely. * The Medical Director will be consulted if the physician response is not timely. * Care plans and RCS assignment sheets will be initiated or updated based on interventions necessary for pressure ulcer reduction and/or elimination. * On November 23, 2010, the Quality Assessment and Assurance Committee met to review and approved of this plan. The facility's Medical Director also approved of this plan. * The Quality Assessment and Assurance Committee will meet weekly for one month to assure that the facility remains compliant with this plan. Thereafter, the Committee will review on a monthly basis to monitor compliance. * The Director of Nursing will report findings and track and trend any notable patterns. Summaries of any noted patterns will be submitted to the Quality Assessment and Assurance Committee for review and further recommendation during the scheduled meetings. The Committee also will make recommendations for further education as warranted. * The Regional Vice President of Operations and the Regional Directors will review the Quality Assessment and Assurance on a monthly basis to make recommendations. The deficient practice continues at a scope/severity of D (No Actual harm with potential for more than minimal harm that is not immediate jeopardy) as evidenced by: 2. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/23/10 at 1:30 p.m., Surveyor # observed Resident #25's buttocks with Licensed Practical Nurse (LPN)-E. Resident #25 was observed to have an abraded looking area to the left buttock. A white cream was observed to be on the pressure ulcer. LPN-E stated that barrier cream was used as a treatment to the pressure ulcer. Surveyor # reviewed the initial documentation of the pressure ulcer on Resident #25's left buttock dated 11/18/10. The documentation on the document titled, "Weekly Pressure Ulcer Record" read: date of onset 11/18/10, stage 2, 2.3 centimeter (cm) by 2.5 cm and superficial depth. Surveyor # reviewed the nurses note for Resident #25 dated 11/19/10 which read: Call to doctor regarding area to left buttock. Barrier cream applied. Updating doctor and seeing if different treatment is preferred. Surveyor # reviewed the rest of Resident #25's medical record on 11/23/10 and could find no physician's order regarding the treatment of [REDACTED]. Surveyor # interviewed Administrator-A on 11/23/10 at 3:30 p.m. who stated that no follow up was made after the initial call to the doctor regarding Resident #25's pressure ulcer was made and that the facility was in the process of getting an order.