Every finding on record at Complete Care at Jefferson Meadows LLC

Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This has the potential to affect all 43 residents that reside in the facility.The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for three fiscal year quarters for excessively low weekend staffing and for one fiscal year quarter for one star staffing rating, and no Registered Nurse (RN) hours.Evidenced by:The facility's Payroll Based Journal policy, dated as revised 2/2026, states, in part: Policy: It is the policy of this facility to electronically submit timely 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. The facility will electronically submit timely to CMS complete and accurate direct care staffing information including the following: a. The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);.c. Information on direct care staff.on the hours of care provided by each category of staff per resident per day.Example 1:CMS's Payroll Based Journal (PBJ) Staffing Data Report Fiscal Year Quarter 2 2025 (January 1 - March 31) includes: This Staffing Data Report identifies areas of concern that will be triggered. One Star Staffing Rating: Triggered - Excessively Low Weekend Staffing: Triggered - No RN Hours: Triggered - Failed to have Licensed Nursing Coverage 24 Hours/Day. Infraction Dates: No RN Hours: 02/28 (FR); 03/01 (SA); 03/02 (SU); 03/03 (MO); 03/04 (TU); 03/05 (WE); 03/06 (TH); 03/07 (FR); 03/08 (SA); 03/09 (SU); 03/10 (MO); 03/11 (TU); 03/12 (WE); 03/13 (TH); 03/14 (FR); 03/15 (SA); 03/16 (SU); 03/17 (MO); 03/18 (TU); 03/19 (WE); 03/20 (TH); 03/21 (FR); 03/22 (SA); 03/23 (SU); O3/24 (MO); 03/25 (TU); 03/26 (WE); 03/27 (TH); 03/28 (FR); 03/29 (SA); 03/30 (SU); 03/31 (MO)Failed to have Licensed Nursing Coverage 24 Hours/Day: 02/28 (FR); 03/01 (SA); 03/02 (SU); 03/03 (MO); 03/04 (TU); 03/05 (WE); 03/06 (TH); 03/07 (FR); 03/08 (SA); 03/09 (SU); 03/10 (MO); 03/11 (TU); 03/12 (WE); 03/13 (TH); 03/14 (FR); 03/15 (SA); 03/16 (SU); 03/17 (MO); 03/18 (TU); 03/19 (WE); 03/20 (TH); 03/21 (FR); 03/22 (SA); 03/23 (SU); O3/24 (MO); 03/25 (TU); 03/26 (WE); 03/27 (TH); 03/28 (FR); 03/29 (SA); 03/30 (SU); 03/31 (MO)Surveyor requested the facility's submitted PBJ data.On 7/21/26 at 12:29 PM, NHA A (Nursing Home Administrator) stated there was no submission of PBJ data for March 2025 due to the facility change in ownership; they were supposed to submit but did not. NHA A stated I would expect there to be submission of the data.Surveyor reviewed schedules and verified the facility did have licensed nursing coverage.Example 2:CMS's PBJ Staffing Data Report Fiscal Year Quarter 1 2026 (October 1 - December 31) includes: This Staffing Data Report identifies areas of concern that will be triggered. Excessively Low Weekend Staffing: Triggered .Example 3:CMS's PBJ Staffing Data Report Fiscal Year Quarter 2 2026 (January 1 - March 31) includes: This Staffing Data Report identifies areas of concern that will be triggered. Excessively Low Weekend Staffing: Triggered .On 7/21/26 at 12:58 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding staffing and submission of PBJ data. NHA A stated I learned of the failure to report the March 2025 data when the facility's 5-star rating was updated to 1-star. You can't go back and resubmit anything, but now we do touch bases with the Labor Specialist to review the data before the information is submitted, and a verification report is sent to me. This started immediately after learning of the submission missed. Surveyor asked about the triggers for low weekend staffing for quarters 1 and 2 of 2026. NHA A stated I think there was an error in the reporting due to a change in the payroll systems. The new system did not have agency staff clocking in, so it did look like the agency hours may not have been accurately captured. There may have also been a challenge with the coding of staff present. We had management assisting and nurses working as CNAs, this could have led to coding issues with the reporting.NHA A provided a document titled, Ad Hoc QAPI Meeting/Four Point Plan of Correction Agenda and Summary, dated March 2025. The document states, in part: .Systemic Changes a. What changes will you make. The facility implemented multiple process improvements beginning in August 2025, including:*Quarterly PBJ review meetings between the Administrator and Corporate Labor Specialist to review labor hours prior to each PBJ submission.*The Administrator requested and participates in a detailed review of PBJ reports before submission.*Implementation of Simple PBJ software to analyze PBJ data, identify potential reporting errors, monitor CMS staffing triggers, and validate submission accuracy.*Identification and correction of common reporting gaps, including: -missing agency staff hours -incorrect coding of nurse managers working direct care shifts -incorrect coding of licensed nurses or managers covering CNA assignments*All agency personnel are now required to clock in and out using the facility's timekeeping system to ensure accurate capture of worked hours.*The Human Resources Director performs a pay-period review of employee job coding and labor allocations as a third level of verification before PBJ submission.How will you sustain compliance? The Administrator is responsible for oversight of PBJ compliance and will ensure:*Quarterly PBJ review meetings with the Corporate Labor Specialist continue.* PBJ reports are reviewed in detail prior to each CMS submission.*Human Resources audits labor coding every pay period*Agency time records are reconciled with payroll before submission.*Any discrepancies identified through Simple PBJ analytics are corrected before PBJ is finalized.*PBJ compliance and any identified trends will be reviewed during QAPI meetings to ensure sustained compliance and identity opportunities for continued improvement.On 7/21/26 at 1:59 PM, Surveyor asked if the analytics system identified the trigger for low weekend staffing for quarters 1 and 2 of 2026. NHA A stated the analytics system wasn't used until this quarter. Surveyor asked about the date of March 2025 on the QAPI plan. NHA A stated that the document was started after learning of the submission error for March 2025 and has been a fluid document since that time with no added dates for added intervention. Surveyor asked if concern with accuracy of reporting continued after the start of this document. NHA A stated yes.

Based on interview and record review, the facility did not ensure that the comprehensive care plan was reviewed by the interdisciplinary team and resident/resident representative after each assessment, including both the comprehensive and quarterly review assessments for 6 of 16 sampled residents (R2, R3, R35, R28, R7, & R41), reviewed for care conferences. R2 did not have quarterly care conference meetings. R3 did not have quarterly care conference meetings. R35 did not have quarterly care conference meetings. R28 did not have quarterly care conference meetings. R7 did not have quarterly care conference meetings. R41 did not have quarterly care conference meetings. Evidenced by: The facility policy entitled, Comprehensive Care Plans, dated 2/2026, states, in part: . Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: . 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS (Minimum Data Set) assessment. 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner designee involved in the resident's care. b. A registered nurse with responsibility for the resident. c. A nurse aide. d. A member of the food and nutrition services staff. e. The resident and the resident's representative. f. Other appropriate staff or professionals. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Example 1: R2 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, depression, and epilepsy. During record review noted R2 did not have quarterly care conferences documented in the record. Example 2: R3 was admitted to the facility on [DATE], and has diagnoses that include Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and Parkinsonism. On 7/15/26 at 1:16 PM, Surveyor interviewed R3 and asked if R3 has had care conferences with the staff and himself. R3 indicated no. R3 indicated during the first week of the month there is a facility group talk with residents and staff. Example 3: R35 was admitted to the facility on [DATE] and has diagnoses that include Parkinson's Disease, dementia and depression. On 7/20/26, Surveyor requested Care Conference documentation for R2, R3, and R35 from NHA A (Nursing Home Administrator). On 7/20/26 at 2:59 PM, NHA A (Nursing Home Administrator) indicated there was no documentation regarding care conferences for R2, R3, or R35. NHA A indicated the social worker was not documenting her conversations with the residents. NHA A indicated the staff is auditing care conferences and are in the process of scheduling care conferences. On 7/21/2026 at 10:04 AM, Surveyor interviewed DON B (Director of Nursing) and CNC C (Corporate Nurse Consultant) and asked how often care conferences are to be held. CNC C indicated on admission, then quarterly and with any significant change, or if therapy is ending due to the resident reaching goals. Surveyor asked who is included in the attendance at the care conferences. DON B indicated the DON, MD (Medical Director), NP (Nurse Practitioner), therapy, social services, the resident and the resident's POA (Power of Attorney). Surveyor asked if she would expect the care conferences to be documented. DON B indicated yes. Surveyor informed DON B and CNC C Surveyors had a concern with care conferences not being completed. On 7/21/26 at 2:10 PM, Surveyor informed NHA A that the Surveyors did have concern with care conferences not being completed quarterly. Example 4 R28 was admitted to the facility on [DATE] and has diagnoses that include mood disorder, mental disorder due to known physiological condition, and hereditary and idiopathic neuropathy. R28 is enrolled in hospice services. On 7/20/26, Surveyor requested care conference documentation for R28 from NHA A (Nursing Home Administrator). On 7/20/26 at 12:30 PM, NHA A (Nursing Home Administrator) indicated there was no documentation regarding care conferences for R28. NHA A indicated the facility's social worker would touch base with residents in the past, but moving forward, this will be documented, and more discipline areas will be included in the care conference. Example 5 R7 was admitted to the facility on [DATE] with diagnoses that include dementia, anxiety disorder, heart disease, age-related physical debility, and cerebrovascular disease. Surveyor reviewed R7's electronic health record and was unable to find documentation regarding care conferences. Example 6 R41 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, schizophrenia, and Post-Traumatic Stress Disorder. Surveyor reviewed R41's electronic health record and was unable to find documentation regarding care conferences. On 7/16/26 at 4:23 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A where the care conference documentation could be located, NHA A reported that SSD L (Social Services Director) does not put a note in and reported that they follow the MDS (Minimum Data Set) schedule, calls the family and goes over everything with them. On 7/20/26 at 3:49 PM, Surveyor interviewed SSD L (Social Services Director). Surveyor asked SSD L what the process was for care conferences, SSD L stated that they would talk to the resident and offer a care conference and if the resident was agreeable, they would set up the meeting and invite the department heads. If the resident is a long-term care resident, they would offer a care conference. If a resident had a representative, they would call and ask them if they had any concerns.

Based on interview and record review, the facility did not ensure written bed holds were completed for 1 of 2 residents (R3) reviewed for bed holds out of a sample of 16.R3 was transferred to the hospital on 2/17/26, 4/29/26, and 5/29/26. The facility did not provide written bed hold notice to R3 and/or R3's resident representative.Evidenced by:The facility policy entitled, Bed Hold Notice, dated 2/26, states, in part: . Policy: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave.Policy Explanation and Compliance Guidelines:1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic; leave, the facility will provide the resident and/or the resident representative with written information that specifies:a. The duration of the State bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;b. The reserve bed payment policy.c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed.2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours.3. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record.4. The facility will provide this written information to all facility residents, regardless of their payment source. R3 was admitted to the facility on [DATE] and has diagnoses that include cellulitis of left lower limb, diabetes mellitus type 2, and peripheral vascular disease.R3 was transferred to the hospital on 2/17/26, 4/29/26, and 5/29/26 requiring hospital stays. R3's medical record did not contain written bed hold notices for the hospital stays. On 7/21/26 at 11:15 AM, Surveyor spoke with NHA A (Nursing Home Administrator) and requested bed holds for R3 for 2/17/26, 4/29/26, and 5/29/26. NHA A returned to Surveyor and indicated the facility does not have bed holds for R3 due to R3 having Medicaid as a payment source.On 7/21/26 at 1:58 PM, Surveyor interviewed DOA D (Director of Admissions) and asked what the process is for obtaining bed holds. DOA D indicated that when the facility admits a resident, we do an electronic admission agreement that includes a bed hold. Surveyor asked DOA D how long the bed hold would be valid for. DOA D indicated for the length of the resident's stay at the facility. Surveyor asked if the facility would update it at any time. DOA D indicated no, it is valid for length of stay. DOA D indicated the facility changed to the electronic admission agreement with the bed hold captured within it around 2/2025. R3 admitted [DATE]. Surveyor asked for R3 would a written bed hold be expected to be obtained at time of transfers since R3 admitted to the facility prior to the change of admission agreements. DOA D indicated that a paper bed hold would need to be obtained for residents that admitted prior to the change to electronic admissions. The nurse sending the resident out to the hospital would be responsible for obtaining those written bed holds. Surveyor asked if all residents would receive a bed hold no matter what their payment source would be. DOA D indicated yes. DOA D indicated when the facility readmits residents the facility does not redo an admission agreement with bed hold but going forward the facility will. Surveyor asked DOA D would a resident on Medicaid receive a bed hold. DOA D indicated the facility does not always do bed holds for residents on Medicaid since the state pays for 15 days to hold the bed. Surveyor asked by chance if a resident requires a longer than a 15 day stay in the hospital what the process is. DOA D indicated seeing Surveyors point. On 7/21/26 at 2:10 PM, Surveyor interviewed NHA A and asked should bed holds be offered to all residents regardless of what payment source they have. NHA A indicated the facility does not do bed holds for residents receiving Medicaid due to the state pays for 15-day bed hold. Surveyor asked NHA A if the hospital stay extends past 15 days what is the process. NHA A indicated the facility would reach out to the resident when it gets close to the end of the 15-day hold. Surveyor informed NHA A that the federal regulation is to offer all residents bed holds regardless of payment source. Surveyor informed NHA A there was a concern with bed holds for R3.

Based on interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal, and oral hygiene for 1 of 4 Residents out of a sample of 16 Residents (R7).R7 reported to Surveyor that they did not receive a shower on their scheduled day last week.Evidenced by:The facility's policy titled Activities of Daily Living (ADLs) last reviewed on 2/2026 states in part .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.R7 was admitted to the facility on [DATE] with diagnoses that include dementia, anxiety disorder, heart disease, age-related physical debility, and cerebrovascular disease.R7's most recent Minimum Data Set (MDS) dated [DATE] states that R7 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R7 is cognitively intact. R7's MDS states that they require partial/moderate assistance for bathing.R7's care plan dated 11/16/23 states in part: .Focus: ADL: Actual/At risk and/or Potential for complications with deficits with ASDs r/t (related to) current medical/physical status. Has meds/dx (diagnoses) that can/may affect ADLs. Residual weakness from right leg fractures. Goal: Will have needs anticipated and met through next review date.Interventions/Tasks: . Bathing- Assist of 1.The facility's shower schedule states that R7 is to have a shower/whirlpool bath on Friday PM (evening) shift.R7's task documentation titled Shower/Bathing/Personal Care- Bath day- Friday PM shift states that over the last 30 days, R7 did not receive a shower/whirlpool bath on 7/10/26 and 7/17/26 and that the task is marked not applicable.On 7/15/26 at 10:01 AM, Surveyor interviewed R7. Surveyor asked R7 if they were getting showers when they were supposed to, R7 stated that they did not receive their shower last week because there wasn't enough staff.On 7/20/26 at 9:22 AM, Surveyor interviewed R7. Surveyor asked R7 if they had taken a shower on the prior Friday, R7 stated they did not get their bath, and no one came in and offered it another day.On 7/21/26 at 11:00 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if showers should be given as scheduled, DON B stated yes and that if a resident refuses, it needs to be rescheduled, and the resident should get a bath. Surveyor asked DON B what it means when staff marks not applicable on the shower task, DON B stated that should be used if the resident is in the hospital or out of the building.The facility did not ensure that residents were receiving their showers as scheduled.

Based on record review and interview, the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (R56) of 16 sampled residents reviewed for dialysis.R56 receives dialysis services and facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis access site, R56 did not have a complete care plan reflecting dialysis procedures, and the facility was not monitoring R56's dialysis port site/dressing. This is evidenced by:The facility's policy, titled Hemodialysis, implemented in 2/2025, states in part: Policy: The facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.Compliance Guidelines: .8. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. 16. Resident with external dialysis catheters will be assessed every shift to ensure that the catheter dressing is intact and not soiled. Change dressing to site only per the dialysis facility's direction.The policy does not include an emergency plan.According to the Clinical Journal of the American Society of Nephrology article titled Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies, dated February 2017, .Vascular Access Hemorrhage: Hemorrhage from an AV access is an uncommon but potentially fatal complication if it is not recognized promptly and acted on with an appropriate intervention. Most fatal vascular access hemorrhages occur outside of the dialysis facility, but occasionally, they rupture at the dialysis unit (120). Patients and their families should be educated about the recognition and emergent management of a bleeding AV access. In the event of bleeding from vascular access site, direct continuous pressure with a finger for 15-20 minutes is the most effective method of controlling the bleeding. In the event of rupture of a PSA or aneurysm away from dialysis unit or hospital, direct pressure with a finger at the site of bleeding is the best method of controlling bleeding. Patients should be advised to continue holding direct pressure until emergency medical help arrives and avoid applying a tourniquet, towel, or BP cuff to the extremity. https://journals.lww.com/cjasn/fulltext/2017/02000/diagnosis,_treatment,_and_prevention_of.20.aspxR56 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease and dependance on renal dialysis.R56 attends dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are unable to) on Mondays, Wednesday, and Fridays.R56 has a right subclavian dialysis port (a medical device inserted into the subclavian vein - underneath the collarbone - that is an access point to filter blood for dialysis). R56's care plan, dated 7/8/26, states in part: Focus: Resident has right subclavian dialysis port. Goal: Area will be free of bleeding. Interventions: Emergency dialysis kit to remain in resident's room and one to be sent along to dialysis in the even [sic] of bleeding at dialysis site.It is important to note that R56's care plan does not include any information regarding her dialysis treatments or an emergency plan for a resident bleeding from their dialysis access site. Additionally, R56's physician orders do not include monitoring of the dialysis site, nor instructions for staff regarding an emergency plan.On 7/20/26 at 10:25 AM, Surveyor interviewed RN F (Registered Nurse) regarding residents receiving dialysis at the facility. RN F discussed extra monitoring that she does for residents who are on dialysis - including checking the port site dressing for R56. RN F indicated the dialysis facility changes the dressing so nursing staff does not have to do that. RN F reviewed R56's MAR/TAR (Medication/Treatment Administration Record) and was unable to find an order instructing nursing staff to monitor the dialysis access site for R56. Surveyor asked RN F if she could find an order indicating that R56 goes to dialysis. RN F showed Surveyor an admission sheet for R56 that is kept on the medication cart for staff to reference. The admission sheet indicated that R56 attends dialysis appointments on Mondays, Wednesdays, and Fridays. RN F could not find an active order in the Orders tab that easily referenced this information in R56's chart. RN F indicated CNAs (Certified Nursing Assistants) know to have her ready for dialysis appointments because appointment times are posted daily on the wall by the nurses' station. On 7/20/26 at 1:53 PM, Surveyor interviewed CNA G (Certified Nursing Assistant) and asked what she would do if she noticed that a resident receiving dialysis was bleeding from their dialysis access site. CNA G indicated that she would contact the nurse right away. CNA I was sitting next to CNA G and indicated that she would immediately put pressure on the site and would then call the nurse.On 7/20/26 at 2:03 PM, Surveyor interviewed CNA H and asked what she would do if she noticed that a resident receiving dialysis was bleeding from their dialysis access site. CNA H indicated she would report this to the nurse right away and assist the best she could. On 7/20/26 at 3:35 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated different staff members work on different components of admitting a new resident (care plan, treatments, orders, etc.). Surveyor brought up missing dialysis information in R56's chart: assessing the dialysis port/dressing, having a complete care plan reflecting dialysis treatment, procedures and an emergency plan, and dialysis orders. DON B indicated that she would look into if assessing a resident's dialysis port should be on the MAR/TAR for nursing staff, whether or not R56 had a complete dialysis care plan, and if R56's dialysis orders should be in the Orders tab of her chart. DON B was able to pull up R56's hospital discharge paperwork, which indicated that she attends dialysis on Mondays, Wednesday, and Fridays.On 7/21/26 at 8:50 AM, Surveyor spoke with DON B about R56 again. DON B indicated R56's care plan had been updated to include relevant dialysis information and R56's electronic orders had been updated with dialysis information as well. Surveyor noted that R56's care plan now includes an emergency plan in case of bleeding. DON B indicated that she still did not see an order for nursing staff to monitor R56's dialysis port site, but said it would be a good idea for staff to assess the dressing that the dialysis facility puts over it, in case there would be any bleeding or drainage. DON B indicated she would have this order put in. Surveyor informed DON B about the concern with R56's missing dialysis care plan information, orders, and site assessment, and informed her that some CNAs who were interviewed did not know the correct emergency procedure in the event of bleeding from a dialysis access site. DON B indicated they should know to apply pressure immediately, since they recently had a training on this. DON B indicated she would readdress the training.

Based on record review and interview, the facility did not ensure 1 of 1 resident (R41) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident out of 16 sampled Residents. R41 has a diagnosis of Post-Traumatic Stress Disorder (PTSD) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions.Evidenced by:The facility's policy titled Trauma Informed Care last reviewed on 2/2026 states in part .2. 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, they history and physical, the social history/assessment, and others.6. 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 will re-traumatize the resident.7. Trauma- specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery.10. 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.R41 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, schizophrenia, and PTSD.R41's most recent Minimum Data Set (MDS) dated [DATE] states that R41 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R41 is cognitively intact.It is important to note that R41's MDS on admission dated 12/22/25 also indicates that R41 had a BIMS of 15 out of 15.R41's Trauma Informed Care Assessment dated 12/4/25 states in part .1. Natural Disaster.Does not apply. 2. Fore [sic] or explosion.Does not apply. 3. Transportation accident. Does not apply. 4. Serious accident at work, home, or recreational activity. Does not apply. 5. Exposure to toxic substance. Does not apply. 6. Physical assault. Does not apply. 7. Assault with a weapon. Does not apply. 8. Sexual assault. Does not apply. 9. Other unwanted or uncomfortable sexual experience. Does not apply. 10. Combat exposure to a warzone in the military or as a civilian. Does not apply. 11. Captivity. Does not apply. 12. Life threatening illness or injury. Does not apply. 13. Severe human suffering. Does not apply. 14. Sudden violent death. Does not apply. 15. Sudden accidental death. Does not apply. 16. Serios injury, harm, or death you caused to someone else. Does not apply. 17. Any other very stressful event or experience. Does not apply.It is important to note that the rest of the assessment was not completed.R41's admission assessment dated [DATE] states in part .LOC (Level of Consciousness)/Orientation/Cognition: Alert Yes Oriented to Person, Place, Time, Situation. Alert and oriented and able to make needs known.R41's care plan dated 6/9/26 states in part .Focus: Resident reports experience of trauma as evidenced by PTSD. Goal: Resident will be free from complications r/t (related to) PTSD through review date. Interventions: Approach resident in a calm manner. Attempt to calm if upset. Encourage resident to identify personal trauma and triggers and take steps to eliminate/minimize. Evaluate need/provide for Psych/Behavioral Health Consultation and make referral and needed or requested. Validate Feelings.On 7/15/26 at 10:10 AM, Surveyor interviewed R41. Surveyor asked R41 if they were comfortable talking about their trauma related to their diagnosis of PTSD, R41 stated yes and reported that they were a live-in caregiver and was raped and sexually assaulted by the patient's son on several occasions. Surveyor asked R41 if there was anything that triggers their PTSD, R41 stated that they have flashbacks and that they had one 3-4 weeks ago. Surveyor asked R41 if there were any interventions that helped with the triggers, R41 stated that they pray to God and asks God to protect them. On 7/16/26 at 9:28 AM, Surveyor interviewed RN J (Registered Nurse). Surveyor asked RN J if they were familiar with R41, RN J stated yes. Surveyor asked RN J if they knew what R41's trauma, triggers, and interventions were, RN J stated no, but they would find out.On 7/16/26 at 9:46 AM, RN J reported to Surveyor that the SSD L (Social Services Director) stated that when R41 was admitted , the resident and daughter couldn't say what R41's trauma was.On 7/16/26 at 9:42 AM, Surveyor interviewed CNA K (Certified Nursing Assistant). Surveyor asked CNA K if they were aware of R41's trauma, triggers, and interventions were, CNA K stated no. On 7/16/26 at 9:48 AM, Surveyor interviewed SSD L. Surveyor asked SSD L what they can tell about R41's PTSD and trauma, SSD L stated that they talked to R41 and their daughter on admission and the daughter thought the trauma was related to R41's childhood. SSD reported to Surveyor that R41 was confused on admission. Surveyor asked SSD L how often they complete Trauma Informed Care Assessments, SSD L stated they are done on admission and when they learn more information. Surveyor reviewed R41's Trauma Informed Care Assessment with SSD L and asked why the assessment does not indicate that R41 has PTSD, SSD L stated that they were not aware of the diagnosis. Surveyor reviewed R41's admission diagnoses with SSD L, SSD L stated that they did not see the diagnosis on admission. Surveyor reviewed with SSD L the information R41 shared about their trauma. Surveyor asked SSD L when the last time they met with R41 to discuss their trauma/PTSD, SSD L stated they met with R41 last week but did not talk about R41's trauma or PTSD. Surveyor asked SSD L if R41's care plan should be individualized to reflect their trauma, triggers, and interventions, SSD L stated they would like to do more, especially as they are learning more.On 7/20/26 at 3:44 PM, Surveyor interviewed SSD L. Surveyor asked SSD L if they had met with R41 after our last conversation, SSD L stated yes. Surveyor asked SSD L if they documented the visit, SSD L stated no. Surveyor asked SSD L if they completed a new Trauma Informed Care Assessment, SSD L stated they haven't gotten to formally documenting it yet.On 7/21/26 at 12:42 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if they would expect SSD to complete another Trauma Informed Care Assessment if they came upon new information regarding trauma/PTSD, NHA A stated yes. Surveyor asked NHA A if they would expect SSD to be documenting visits and interactions with residents, NHA A stated yes.

Based on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 5 residents (R41) reviewed for unnecessary medications.R41 was admitted to the facility with an order for apixaban 2.5mg (milligrams) BID (twice a day), the dose was increased to 5mg BID, and the facility decreased the dose to 2.5mg BID without a physician's order.Evidenced by:The facility's policy titled Medication Errors last reviewed 2/2026 states in part . Significant Medication Error means one which causes the resident discomfort or jeopardizes his/her health and safety.1. The facility shall ensure medications will be administered as follows: a. According to physician's orders.The facility's policy titled Notification of Changes last reviewed 2/2026 states in part . Circumstances requiring notification include: .3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences.According to Drugs.com article titled Apixaban dated 12/10/25 Apixaban is used to lower the risk of stroke and blood clots in adults with a heart rhythm disorder called atrial fibrillation not caused by a heart valve problem . Apixaban can cause you to bleed more easily. Apixaban Uses, Side Effects & WarningsR41 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes, and atrial fibrillation.R41's most recent Minimum Data Set (MDS) dated [DATE] states that R41 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R41 is cognitively intact.R41's admission orders dated 12/3/25 state in part: .Apixaban oral tablet 2.5mg. Give 1 tablet by mouth two times a day for blood clot prevention.On 12/11/25, MD (Medical Doctor) notes states .Plan: Please increase her Eliquis to 5mg BID. This order was transcribed into R41's electronic health record.It is important to note that Eliquis is the brand name for apixaban.This order was noted by facility staff on 12/11/25, per signature.On 12/15/25 at 11:10 AM, LPN M (Licensed Practical Nurse) entered an order for Apixaban 5mg tablet. Give 0.5 tablet by mouth two times a day for blood clot prevention.On 7/20/26 at 2:27 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B who reviews orders when they come in, DON B stated the unit clerk reviews the orders and the nurse confirms the order. Surveyor asked DON B to review R41's apixaban order, DON B confirmed that R41's order was for 2.5mg BID on 12/3/26, 5mg BID on 12/11/25, and changed to 2.5mg BID on 12/15/25. Surveyor asked DON B where the order was for the change on 12/15/25. DON B stated they would look and get back to Surveyor.It is important to note that Surveyor and DON B reviewed R41's Electronic Health Record (EHR) through the clinic and its order states Apixaban 5mg BID.On 7/20/26 at 4:50 PM, NHA A (Nursing Home Administrator) reported to Surveyor that on 12/15/25 the pharmacist changed the order due to drug interactions and the R41's doctor signs off on the orders every month. Surveyor asked NHA A if the MD (Medical Doctor) was notified of the change, NHA A stated they would check. Surveyor asked NHA A how long it was from the time the pharmacist was changing the orders to when the MD reviewed the monthly orders, NHA A stated that the MD reviewed R41's orders on 1/14/26.On 7/21/26 at 10:08 AM, Surveyor interviewed LPN M. Surveyor asked LPN M where they got the order to change R41's apixaban, LPN M stated that they were looking at it yesterday and they are unsure where it came from, but it looked like the pharmacy revised the order.On 7/21/26 at 10:32 AM, Surveyor interviewed Pharmacist P. Surveyor and Pharmacist P reviewed R41's apixaban medication changes. Pharmacist P reported that they received orders on 12/3/25 and 12/11/25 directly from the MD and the order on 12/15/25 came from the facility's EHR system. Surveyor asked Pharmacist P if the pharmacy typically changes orders, Pharmacist P stated they wouldn't change orders, but they would print out recommendations and send the recommendations to the facility or send a message to the facility via their secure portal.On 7/21/26 at 11:10 AM, Surveyor interviewed DON B. Surveyor asked DON B if they would expect nurses to have a physician's order before changing an order in the computer, DON B stated yes.On 7/21/26 at 12:22 PM, Surveyor interviewed MD N (Medical Doctor). Surveyor asked MD N if they were aware of R41's apixaban order change on 12/15/25, MD N stated no, and that they don't see any order changes regarding the apixaban after 12/11/25. MD N stated they must have missed the change on the monthly orders and was going to call the facility to change the orders. Surveyor asked MD N if they would expect to be notified of a medication change, MD N stated yes, especially if they didn't order it.On 7/21/26 at 12:31 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if they would expect the MD to be notified of a medication change, NHA A stated yes. Surveyor asked NHA A if staff should be changing orders without an MD order, NHA A stated no.On 7/21/26 at 12:31 PM, Surveyor interviewed MD O. MD O reported that they spoke with MD N and they have no idea where the order came from and it was not MD N's intention to change the order.

Based on interview and record review, the facility did not ensure staff postings were accurate, which has the potential to affect 43 of the 43 residents residing at the facility.Review of staffing schedules and required staff postings revealed discrepancies between the documents. This resulted in inaccuracies with the total number and the actual hours worked for licensed and non-licensed staff directly responsible for resident care each shift.This is evidenced by:The facility's Nurse Staffing Posting Information policy, date reviewed/revised 2/26, states, in part: .A copy of the schedule will be available to all supervisors to ensure the information posted is up-to-date and current. A. The information shall reflect staff absences on that shift due to call-outs and illness. After the start of each shift, actual hours will be updated to reflect such.Surveyor reviewed the schedules and staff postings from 7/1/26-7/15/26 and noted the following inaccuracies:On 7/4/26, the Staff Posting indicates for PM Shift: 1 RN (Registered Nurse), 1 LPN (Licensed Practical Nurse), and 6 CNA (Certified Nursing Assistants)-48 hours. The schedule indicates 1 RN, 1 LPN, and 5 CNAs, plus 1 CNA partial shift (6 hours) worked.On 7/5/26, the Staff Posting indicates for PM Shift: 1 RN, 1 LPN-8 hours, 5 CNA. The schedule indicates 1 RN, 1 LPN-6 hours, and 6 CNAs worked.Surveyor reviewed the schedule and staff posting for 10/17/25 and noted the Staff Posting indicates for the AM Shift: 5 RN. The schedule indicates 4 RNs worked. On 7/20/26 at 1:52 PM, Surveyor interviewed SC E (Scheduling Coordinator) and asked about staff postings. SC E stated it is created the morning of and adjustments are made for call-ins by the nursing supervisor on the shift. Surveyor asked SC E about the noted inaccuracies. SC E stated 7/4/26 was my error, one CNA was not a full shift. 7/5/26 was done before I left for the weekend and should have been updated to show the correct hours and numbers. At the time of 10/17/25, I was doing the posting the day prior and it wasn't updated when the call-in happened.On 7/21/26 at 12:58 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who stated that postings are to be kept up to date.

Based on interview, record review, document review, and policy review, the facility did not ensure to prevent a resident elopement for one of four residents (Resident (R) 2) reviewed for wandering risks out of a total sample of eight residents. R2 exited the alarmed facility door, while unsupervised. Findings include: Review of the facility's policy titled, Elopements and Wandering Residents last revised June 2026 indicated, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.The facility is equipped with door locks/alarms to help avoid elopements.Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team.Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff.Adequate supervision will be provided to help prevent accidents or elopements.Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly.Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. Review of R2's admission Record located under the Profile tab of the electronic medical record (EMR) revealed that R2 was admitted to the facility on [DATE] with a diagnoses of dementia and chronic obstructive pulmonary disease. Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/26 indicated a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R2 was severely cognitively impaired. The MDS documented that R2 had wandering behavior on one to three days of the assessment period. R2 required supervision/touching assistance for walking 150 feet. Review of R2's Admit/Readmit assessment dated [DATE] indicated, resident is confused and ambulatory. Expressed desire to be at home with wife. Resident on wander list and a wander guard has been placed on his wrist. Review of R2's Care Plan initiated on 06/10/26 in the EMR under the Care Plan tab indicated, The resident is an elopement risk/wanderer r/t [related to] dementia with desire to be at home with wife.Interventions:.WANDER ALERT: (wander bracelet) right wrist.Distract resident from wandering.Provide structured activities. Care plan was revised on 06/12/26 to include new intervention, CNAs [Certified Nursing Assistants] to provide 1:1 [one on one] monitoring with resident. Review of R2's Physician Order located under the Order tab of the EMR dated 06/10/26 indicated, Check wander guard placement and function every shift. Facility provided documentation of the elopement investigation and timeline revealed R2 was observed on 06/12/26 at 6:25 PM seated in a chair outside the facility's chapel. Additional observations on 06/12/26 at approximately 6:30 PM during routine rounding revealed R2 was unable to be located in his room. Elopement procedures were implemented, including contact with the local Police Department. On 06/12/26 at 6:33 PM the facility camera system revealed R2 had exited the facility's front door. On 06/12/26 at 7:02 PM, R2 was located 0.275 miles (1450 feet) from the facility seated on a curb with a local Police Department Officer and was assisted to the facility by the Administrator. Review of R2's Head-to-Toe Assessment located under the Assmnt tab of the EMR dated 06/10/26 and completed upon the resident's return revealed that the Police Officer had observed the resident trip while away from the facility. A small abrasion was noted to the left hand. No other injuries were identified. Review of R2's Physician Order dated 06/12/26 indicated a new intervention CNAs to provide 1:1 [one-to-one] monitoring with resident while awake. Facility provided documentation of the investigation revealed, Additional testing was completed on Wander Guard devices utilized by other residents, with no concerns identified. During testing, the resident's device was observed to function inconsistently. The device carried an expiration date of June 2027 and had been tested for proper function prior to placement on the resident without concerns. Additionally, earlier that day, the alarm activated appropriately when the resident exited the facility's front door with family. During a concurrent interview on 06/30/26 at 4:30 PM, the Administrator and Director of Nursing (DON) stated that the facility investigated the incident and found that all appropriate interventions were in place and monitoring of the Wander guard system was in place prior to the elopement. They stated that they retested the facility's exits and the Wander guard system, as well as other residents wearing bracelets, and had found no failures. Upon review of R2's bracelet it was determined that it was not working consistently, although it had scanned as functioning prior to the elopement. R2's equipment was replaced, and the resident was placed on 1:1 monitoring indefinitely. The Administrator confirmed that the facility had brought in a company to assess the facility's Wander guard system and had found the facility's front door was functioning properly. During an interview on 07/01/26 at 11:18 AM, the Maintenance Tech (MT) stated that the equipment, including the doors and alarms, was tested every month, to ensure the equipment was active and functioning when placed at the nurse station for resident placement. He stated that there had been no prior concerns with the system. The MT said that the Wander guard R2 had used upon admission was from a newer device purchase and had functioned prior to the elopement. During an interview on 07/01/26 at 11:54 AM, the Admitting Registered Nurse (ARN) stated that R2 was assessed to be a wandering risk upon admission, and a Wander guard was determined to be appropriate at that time. She stated that the resident was care planned for the use of the device and it was placed upon R2's wrist. She said that the devices were always tested prior to placement, and again each shift for functioning and placement. ARN said that just prior to putting it on the resident, the device had tested as functioning properly, and had even set off a door, when going to the resident's room. During an additional interview on 07/01/26 at 4:45 PM, the DON stated that R2 was determined to be a wanderer upon admission, and ARN had tested the Wander guard device with the testing wand upon placement. She said they also checked the facility's doors. The facility was aware R2 wanted to go home and that he had made comments. The DON said that she had received a call on 06/12/26 that R2 had eloped the facility and that she called the Administrator, who later found R2 on the street, standing with a police officer. She said that they tested all of the equipment when R2 was brought back to the facility. She confirmed that the resident's Wander guard device did not go off when retested. The DON stated that the facility had just removed the device from a new packet and had no idea why it was faulty. The staff were interviewed, and R2 had been seen sitting near the chapel just prior to the elopement. The facility cameras had confirmed the resident had left through the front door.

Based on observation, interview and record review, the facility failed to ensure residents received adequate nutrition and fluid intake for 3 (R25, R26, R42) of 4 Residents reviewed for nutrition. R25 is being cited at severity level 3 (actual harm). R26 and R42 are being cited at severity level 2 (potential for more than minimal harm). R25 was admitted to the hospital on 12/16/24 for weakness, anorexia, and severe hypernatremia (a high concentration of sodium in the blood often caused by dehydration). R25's sodium was 169. The facility failed to ensure R25 received adequate fluid intakes to maintain acceptable parameters of hydration by failing to total and assess daily fluid intake, accurately assess and complete on-going assessments for signs and symptoms of dehydration (e.g., sunken eyes, cool/clammy skin, dry tongue, dark colored urine, and sticky saliva), and failed to update interventions to encourage hydration as necessary. R25 returned to facility on 12/17/24, the facility failed to update R25's nutritional assessments. R26 experienced weight loss. The facility did not update the MD/NP (Medical Doctor/ Nurse Practitioner) appropriately, started R26 on a nutritional supplement without a physician's order, and did not monitor the amount of the supplement R26 was drinking. The facility failed to monitor R42's fluid intake, notify the physician of severe weight loss of 10% over 2 weeks, add R42's favorite beverage to her care plan per facility policy, and conduct a complete nutrition assessment by the Registered Dietician. R42's fluid intake was also not consistently documented and R42 was not consistently offered snacks. Evidenced by: The facility policy, Hydration, dated 2/25, states, in part; .The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health .Compliance Guidelines: 1. The facility will utilize a systematic approach to optimize the resident's hydration status: a. Identifying and assessing each resident's hydration status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revisiting them as necessary. 2. Nursing staff shall assess hydration status upon admission and throughout the resident's stay in accordance with assessment protocols. b. The dietary manager or designee shall obtain the resident's beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay. c. The dietitian will assess hydration as part of the comprehensive nutritional assessment within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessment will be completed as needed .3. Evaluation/analysis: a. The assessment shall clarify the resident's current hydration status and individual risk factors for dehydration or fluid imbalance. b. The dietitian shall use data gathered from the nutritional assessment to the resident's fluid needs and whether intake is adequate to meet those needs .4. Care plan implementation: a. The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care .f. The resident will be monitored for complications associated with interventions. g. The care plan will be updated as needed, such as when a resident's condition changes, goals are met or the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of hydration-related problems are identified .6. Documentation: a. Record observations pertinent to the resident's hydration status in the nurses' notes. b. Record beverage intake in designated locations (meal intake records, MAR (medication administration record) as indicated). c. Record output in designated locations (MAR or output record). d. Record fluid intake via tube or IV on MAR or designated intake record. e. Document physician/family notifications and any responses. f. Document assessments in designated locations (RAI, dietary notes, or nurses' notes) . Per Mayo clinic dehydration occurs when the body uses or loses more fluids than it takes in. Not replacing lost fluids leads to dehydration. Anyone can become dehydrated, but the condition is more serious for older adults .Drinking more fluids usually fixes mild to moderate dehydration, but severe dehydration needs medical treatment right away. Thirst isn't always a good way to tell if the body needs water. Many people, mainly older adults, don't feel thirsty until they're dehydrated .The symptoms of dehydration can differ by age.adults, extreme thirst; urinating less; dark-colored urine; tiredness; dizziness; being confused; skin that doesn't flatten back right away after being pinched, sunken eyes or cheeks. Dehydration can lead to serious complications such as heat injury, urinary and kidney problems, seizures, low blood volume shock. Example 1: R25 was admitted to the facility on [DATE] with a diagnoses including dementia and abnormalities of gait and mobility. R25's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 3/24/25, indicates R25 has a BIMS (Brief Interview for Mental Status) score of 99 indicating R25 is severely cognitively impaired. R25 has an activated power of attorney. R25's Comprehensive Care Plan, states, in part; .ADL: .EATING: assist of 1; supervise. 11/16/23 .NUTRITION/HYDRATION: Actual/At risk/and/or potential for complications with nutrition/hydration d/t severe dementia, mechanically altered diet and staff dependence to eat. 11/16/23 revision on 4/24/25 .Encourage fluids at and between meals initiated 4/22/25, Diet type: General/standard diet, soft bite sized, ground meat, may have toast, thin liquids .11/16/23, revision 4/22/25, meds/labs/treatments as ordered 11/16/23, record weights a minimum of monthly or per MD/RDN (Registered Dietitian Nutritionist) 11/16/23, set up meal per resident direction and assist with eating as/if needed. Honor food requests as able 2/7/24, Adaptive equipment: provide inner lip dish at all meals. Cups with lids, Partial assistance 2/7/24 . It is important to note, R25's care plan was not updated after being hospitalized on [DATE] for weakness, anorexia (eating disorder, characterized by food restriction), and severe hypernatremia (high sodium) to include interventions to promote hydration. R25's current Kardex, states, in part; .As of 5/13/25 .Eating/Nutrition: Encourage fluids at and between meals .EATING: assist of 1; Supervise .Dining/Eating/Nutrition: Cups with lids, partial assistance . R25's DIET Nutritional Risk Tool, states, in part; .4/25/24 .G. Dining ability: Assistance/cueing needed/slow .meeting needs, skin intact and weight is stable .2. Hydration needs ABW. Adjusted weight yes. Weight adjusted for obesity. Hydration needed: 1325-1590 .Recommendations: BLANK. Meeting needs, skin is intact, and weight is stable. Will continue to monitor and update as needed . It is important to note the facility did not update R25's Nutritional Risk Tool after R25 experienced significant change in condition and was admitted to the hospital on 12/16/24 for weakness, anorexia, and severe hypernatremia. R25's Mini Nutritional Assessment, states, in part; .Effective Date: 10/25/24 .Score 8 .At risk for malnutrition .screening A. Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? No decrease in food intake. B. Weight loss during the last 3 months: No weight loss. C. Mobility: Bed or chair bound. D. Has suffered psychological stress or acute disease in the past 3 months? Yes. E. Neuropsychological problems: Severe dementia or depression . R25's Dehydration Risk Screening Tool, states, in part; .10/25/24 .mobility: ambulate with 2 assist .fluid intake/eating: extensive physical assist .weight: no weight loss .continence: on bladder management program .risk factor: no risk factor .predisposing factors: 1-2 present .Based on the results of this assessment and your clinical judgment, is this resident at risk for dehydration? .No .Takes adequate fluids at meals and is given fresh water at bedside 3 times per day . R25's fluid intake, states, in part; December 2024 .1st 720ml, 2nd 680ml, 3rd 1200ml, 4th 600ml, 5th 960ml, 6th 720ml, 7th 720ml, 8th 1200ml, 9th 720ml, 10th 720ml, 11th 960ml, 12th 1200ml, 13th 1,020ml, 14th 480ml, and 15th 1200ml . It is important to note, the only documentation the facility provided showing R25's hydration needs was from R25's Nutritional Risk Tool dated 4/25/24, that indicated ,1325-1590ml of fluid daily. R25 does not meet this and there is no documentation of interventions attempted or discussed, no updates to R25's care plan and/or nutritional assessments, and no discussion with the Registered Dietician. On December 14th it is also noted R25 drank significantly less than other days, and there is no documentation of other interventions attempted. R25's NP routine visit note, states, in part; .12/11/24 .Pertinent History: major neurocognitive disorder .Today, R25 is in her room when I see her. She is pleasant and confused. She looks to be comfortable. She does not respond verbally to any of my questions but does nod/shake her head appropriately. She is dependent for most ADL's but is able to feed herself independently. Her weight is stable. She has had no falls since her admission to the facility .labs monitored in 12/2023 and are stable .lips and gums pink, moist .Patient Goal: maintain comfort and restore previous level of functioning . R25's Progress notes from December 2024, states, in part; .12/16/24 .9:01 .resident slid out wheelchair went [sic] attempting to propel wheelchair. No injury noted.12/16/24 .14:23 .we have attempted to place I.V. (intravenous catheter that goes into a vein to provide fluid) for hydration as POA (power of attorney) agreed. We were unsuccessful. Update MD (Medical Doctor). She was going to call family to see wished.[sic] 12/16/24 .14:24 .Talked with family also updated. 12/16/24 .14:26 .Just spoke with GNP (Geriatric Nurse Practitioner) family would [sic] resident sent to ER (emergency room ). 12/17/24 .10:11 .In hospital. 12/17/24 .12:01 .Resident is coming back to us from hospital on hospice . NP note from 12/16/24, states, in part; .Regarding hypernatremia found today on routine labs, coupled with resident's recent in past few days of weakness, eating/drinking less, foul smelling urine, it has been discussed earlier with daughter/proxy that she'd favor trying some IV fluids vs heading straight for comfort care (in context of her advanced age/dementia, general decline .) IV 1 L LR (1 liter lactated ringers (sterile IV solution to replace fluids and electrolytes) ordered in SNF (skilled nursing facility). RN (Registered Nurse) tried x 4 to access vein but were unable. Writer then called proxy to discuss options, possible causes/outcomes .it's possible she has an underlying acuity that could be treatable, that further testing may reveal. She talked to her brother and they are favoring trying to treat something if it's there before making peace with an ed of life process. Order given to SNF to send to ED for weakness, hypernatremia, fluid hydration . ED (Emergency Department) note, states, in part; .12/16/24 3:13PM .CHIEF COMPLAINT: Altered mental status (mental decline over the last few days, decreased level of consciousness at the facility. Normally ambulates with a walker. Had blood work done and showed hypernatremia .HISTORY OF PRESENT ILLNESS: R25 history of dementia presents by EMS (emergency medical services) from nursing care facility with decreased mentation and oral intake. She does have a history of dementia. I did review medical packet from the nursing care facility. She is DNR (do not resuscitate) with limited aggressive treatment. Medical history as detailed below .notably she had a sodium of 169 as well as chloride level of 137. [NAME] blood cell count was borderline at 10.8 . Additional documentation provided on 5/23/25 by NHA A related to 12/16/25 hospital visit states in part: .12/17/24 visit . long-standing Alzheimer'sdementia currently hospitalized with dehydration and severe hypernatremia. Her sodium was up to 169, chloride 137 and BUN 51. She was given some free water with modest improvement in values of sodium 163 and chloride 131. Additionally her hemoglobin is 10 (down from recent baseline of 12) despite the fact she is severely dehydrated, meaning if her dehydration was reversed her hemoglobin would be much much lower .She has required feeding assistance recently. She has been having increasing difficulty holding herself upright in her wheelchair and 2 days ago she had a sliding to ground event out of her wheelchair. Patient has had unintended weight loss. Over the past year she has lost 19 lbs which is nearly a 15%weight loss going from 148 to 129 lbs. The patient is dependent in all ADLs .electronically signed by the MD on 12/17/2024 11:51 AM.Final Diagnoses: .1.hypernatremia from dehydration. 2 Advanced dementai. 3. AMS (altered mental status). 4.Hypokalemia 5. Anemia .Presenting history .worsening dementia, and now dehydration and severe hypernatremia .we did discuss that in a SNF this problem is usually the result of the elder declining food and drink due to loss of appetite and thirst due to terminal dementia. And that trying to force-feed people in this condition does not work due to then they aspirate and get pneumonia in addition to the discomfort of it. And that IV fluids will temporarily improve this life-threatening problem but will not change the underlying problem. the risks of treatment are mostly pain from IV starts and q4h lab draws. But the problem will happen again off IV's. the alternative is good comfort care without IVF (intravenous fluids) while offering but not forcing food/fluids . R25's Dehydration Risk Screening Tool, states, in part; .12/17/24 .mobility: bed bound .fluid intake/eating: extensive physical assist .weight: 3lbs weight loss in one month .risk factor: history of refusing liquids .predisposing factors: 1-2 present .Based on the results of this assessment and your clinical judgment, is this resident at risk for dehydration? .Yes .high risk but is hospice . It is important to note, R25's care plan was not updated to include interventions to promote hydration even though R25's dehydration screening tool indicates R25 is at high risk for dehydration. Transition note from NP on 12/18/24, states, in part; .R25 is readmitted .on 12/17/24 for continued care with change to comfort focus and additional hospice support in context of advancing dementia with new onset weakness, anorexia, and hypernatremia. HOSPITAL COURSE: 12/16/24-12/17/24 presented to ED with weakness, anorexia, and severe hypernatremia. She was in her usual baseline state a few days prior, eating well, self-propelling her wheelchair all around the nursing home, largely nonvocal. Then she had a fall and she was noted to be eating and drinking a lot less. On routine lab work her sodium was noted to be 169 .Response to treatment: .On admission she was placed on IV dextrose fluids and electrolytes were checked q (every) 4 hours, her sodium did slowly improve (from 169-163), this AM when I saw her she wasn't responsive voice, won't open eyes, appeared comfortable, vitals were stable .Review of Systems .urine was noted to be foul smelling before hospitalization , likely in setting of dehydration . It is important to note the facility did not update R25's Mini Nutritional Assessment after R25 experienced a significant change in condition and was admitted to the hospital on 12/16/24 for weakness, anorexia, and severe hypernatremia. R25's dietary progress note after 12/16/24 hospital admission, states, in part; .1/2/25 .Resident is on a pureed diet with small portions and intakes average 50-80%. CBW (current body weight) is 130 which is stable. Skin is intact. Receives inner lip dish, beverages in cups with lids and straws at all meals. Did flag for at risk for malnutrition d.t. (due to) dementia. Will continue to monitor and update as needed . It is important to note this is the only dietary progress note after being hospitalized on [DATE] for weakness, anorexia, and severe hypernatremia. R25's Mini Nutritional Assessment, states, in part; .Effective Date: 1/2/25 .Score 8 .At risk for malnutrition .screening A. Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? No decrease in food intake. B. Weight loss during the last 3 months: No weight loss. C. Mobility: Bed or chair bound. D. Has suffered psychological stress or acute disease in the past 3 months? Yes. E. Neuropsychological problems: Severe dementia or depression . R25's Mini Nutritional Assessment, states, in part; .Effective Date: 3/17/25 .Score 9 .At risk for malnutrition .screening A. Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? No decrease in food intake. B. Weight loss during the last 3 months: No weight loss. C. Mobility: able to get out of bed/chair but does not go out. D. Has suffered psychological stress or acute disease in the past 3 months? Yes. E. Neuropsychological problems: Severe dementia or depression . R25's Dehydration Risk Screening Tool, states, in part; .3/17/25 .fluid intake/eating: limited physical assist .weight: no weight loss .risk factor: no risk factor .Based on the results of this assessment and your clinical judgment, is this resident at risk for dehydration? .No .Takes adequate fluids at meals and is given fresh water at bedside 3 times per day . It is important to note, R25 has history of dehydration, has a diagnosis of dehydration, and through interview and observation R25 would be unable to adequately meet hydration needs without staff assistance. On 5/7/25 at 11:52 AM, Surveyor observed R25 receive total assistance from staff for all fluids and food. On 5/7/25 at 3:13 PM, Power of Attorney U (POA) indicated R25 had declined in December and had been admitted to the hospital. POA U indicated she felt like the facility didn't catch that R25 was losing the ability to eat and drink on her own and that led to being hospitalized . POA U indicated R25 came back to facility on hospice. POA U indicated R25 is no longer on hospice. On 5/13/25 at 10:18 AM, Registered Nurse O (RN) indicated if a resident is at risk for dehydration there should be an order stating to encourage fluids and the specific amount of fluids should also be on the MAR/TAR. RN O indicated the nurse on the floor should remind the Certified Nursing Assistants (CNA's) to encourage the residents that need extra fluids and reminders. RN O indicated that R25 needs encouragement and reminders to eat and drink. RN O indicated there are times that R25 will eat and drink around mealtimes and not always during the actual mealtime. On 5/13/25 at 10:25 AM, Certified Nursing Assistant P (CNA) indicated for the residents that need reminders and are at risk for dehydration CNA P will offer water every time she walks into the resident bedroom when she is assisting them with freshening, changing, and ADL's. CNA P indicated if someone is at risk for dehydration she will push more fluids. CNA P indicated they don't document the fluids but do document fluids during meals. CNA P indicated R25 needs encouragement and assistance to eat and drink. On 5/13/25 at 11:45 AM, CNA Q indicated if a resident is at risk for dehydration he would offer more fluids. CNA Q indicated he would offer fluids during meals and when going into the resident room. CNA Q indicated R25 very seldom will drink on her own and that she has always needed encouragement and assistance to eat and drink. CNA Q indicated R25 is no longer on hospice and CNA Q remembers in December when R25 had a decline in health. CNA Q indicated R25 always wheels herself up and down the hallways and some time in December she wasn't doing that. CNA Q indicated that was a change for R25 and then she was admitted to the hospital. On 5/13/25 at 1:28 PM, Registered Dietician R (RD) indicated the nutritional assessments should be completed quarterly and/or if a resident has a significant change. Surveyor asked RD R how staff would know R25's specific hydration goal and where is it documented? RD R indicated RD R could put in a specific order stating the exact amount. RD R indicated R25 has an order to encourage fluids with meals and in between meals 3 times a day and this order was started after hospitalization . RD R indicated RD R has recently started with the company and that RD R has been doing a lot of nutritional assessments. RD R indicated she was employed at the facility in December, but she was working remotely. Surveyor asked RD R if there are any additional interventions offered if a resident is at risk for dehydration? RD R stated, The people at risk of dehydration are reviewed when I'm doing their assessment. Surveyor asked RD R if she could provide any insight on R25's hospitalization on [DATE]. RD R indicated It's hard to speak on something I wasn't in the loop for. On 5/13/25 at 1:50 PM, CNA S indicated CNA S offers residents fluids when she is in resident rooms, assisting with cares, and during meals. CNA S indicated she assisted R25 with lunch today. CNA S indicated from her experience R25 needs staff physical assistance for meals and all fluids. On 5/13/25 at 2:06 PM, Nurse Practitioner T (NP) indicated she would expect the facility to encourage and provide interventions to promote hydration if the resident was not able to remember to eat and drink on their own. NP T indicated she would also expect the Registered Dietician to be actively involved as well. NP T indicated R25 is at risk for dehydration due to dementia. On 5/13/25 at 4:25 PM, Director of Nursing B (DON) indicated the facility attempted IV fluid for R25 because labs came back showing sodium level was at 169 and diagnosed with hypernatremia. DON B indicated she vaguely remembers the labs and the incident. DON B indicated the daughter wanted R25 to be sent out to ER. DON B indicated R25 came back on hospice because they were anticipating R25 was going to pass away. DON B indicated one of the interventions that was put in place when R25 came back was ensuring staff were offering her extra sips of water and drinks. DON B indicated in R25's state of dementia she doesn't know to take a drink. Surveyor asked if extra sips and drinks were provided before R25 was hospitalized . DON B stated, I can't say for sure, but probably not. Nurse Supervisor C (NS) indicated she does not recall any changes in R25 prior to 12/16/25. NS C indicated on 12/16/24 R25 slid out of her wheelchair and that was the first change. NS C indicated R25 usually wheels herself around the hallways and she was not doing that. NS C indicated they observed these changes and that is what triggered them to realize something more was going on. NS C indicated the labs were ordered because R25 slid out of her wheelchair, and this was unusual. NS C indicated the labs showing hypernatremia, foul urine, and weakness were all signs they observed on 12/16/24. NS C indicated they tried to start IV fluid at the facility. NS C stated, We couldn't get her IV in because she was so dehydrated. The facility failed to ensure there was a system in place to total and assess daily fluid intake, accurately assess and complete on-going assessments, and failed to update interventions to encourage hydration and nutrition for R25. Additional information was received and reviewed. 42038 Example 2 The facility policy titled Weight Monitoring dated 2/2025 states in part .1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/ analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary .4. Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status .6. Weight Analysis: The newly recorded resident weight should be compared to the previous weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) c. 10% change in 6 months (180 days) .7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. b. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss . The facility policy titled Nutritional and Dietary Supplements dated 2/2025 states in part . 9. Supplements may be provided by dietician recommendation as allowed by physician standing order. 10. The care plan will be updated with the new or modified nutritional interventions. R26 was admitted to the facility on [DATE] with diagnoses that include history of a stroke, dementia, and polyosteoarthritis (arthritis occurring in 5 or more joints simultaneously). R26's most recent MDS (Minimum Data Set) dated 3/11/25 states R26 has a BIMS (Brief Interview of Mental Status) of 3 out of 15, indicating that R26 is severely cognitively impaired. The MDS also states in Section K: K0300. Weight Loss: Loss of 5% or more in the last month or loss of 10% or more in last 6 months: 2. Yes, not on physician- prescribed weight- loss regimen. R26's care plan revised on 2/21/24 states in part: . Focus: NUTRITION/HYDRATION: Potential for Complications with Nutrition / hydration d/t (due to) Dementia, GERD. Goal: Will eat / drink as desired / accepted / tolerated through next review date. Interventions/ Tasks: Diet: Heart Healthy pureed. Set up meal per resident direction and assist with eating as/if needed. Honor food requests as able. Allow to eat / drink as desired / accepted / tolerated. Adaptive Equipment: All food in small silicone mugs. Two handled spouted cups. Offer fluids between meals . R26 most recent RD Nutritional Risk Tool dated 1/11/24 states in part . 1f. Calories needed 1258- 1363 .2f. ml (milliliters) hydration needed 1500- 1680 . 3g. gms (grams) protein needed 56- 67 . It is important to note that the facility did not have a completed comprehensive dietary assessment for R26 since 1/11/24 that calculates R26's calorie, protein, and hydration needs. R26's weights are as follows: 12/8/24: 152.3 1/8/25: 154 2/8/25: 149 3/8/25: 149.8 4/8/25: 153 5/8/25: 142 From 4/8/25 to 5/8/25 R26 had a weight loss of 7.19 pounds. There is no documentation indicating that the Physician or Nurse Practitioner was updated. Physician's orders: 1/31/25: Mirtazapine Oral Tablet 15 mg (milligram) Give 0.5 tablet by mouth one time a day for BPSD (Behavioral and Psychological Symptoms of Dementia) x 7 days, then 15mg daily. Dietary/ Nutrition Notes state the following: 3/7/2025 3:02 PM Note Text: Weight remains decreased over the past six month and stable over the past month. Current diet is cardiac pureed, Intakes fluctuate does a large breakfast with smaller lunch and supper. Does have special bowls where she can hold and self [sic] as well as cups with spout and two handles. Does take mirtazapine which is also an appetite stimulant. Skin is intact. Will continue to monitor and update as needed. 3/11/2025 11:57 AM Note Text: Resident is here long term. Current diet is cardiac pureed, and intakes fluctuate. Eats . large breakfast and smaller lunch and supper. All food is served in small silicone mugs where she can hold on to and 2 handles spouted cups. CBW (Current Body Weight) is 150# stable over month and decreased over the past six months however BMI (Body Mass Index) remains increased at 29.3. Does take mirtazapine which is also an appetite stimulant. Skin is intact. Will continue to monitor and update as needed. 3/20/2025 10:23 AM Note Text: Weekly weight note: Weight remains decreased over the past six months by 17.2#/10.3. This was related to downgrade in diet and nausea. Is stable over month. Intakes are good. Receives food in small silicone mugs where she can hold and self-feed as well as 2 handled cups with a spout. Does take cups with lids and straws when she is hunched over at meals and cannot use the other cup. Skin is intact. Will continue to monitor and update as needed. 4/10/2025 2:23 PM Weight Change Note: Weight has decreased over the past month by 10#/6.3%. Current diet is pureed, and food is served in cups she can hold and drinks in cups with 2 handles. Takes mirtazapine, which is also an appetite stimulant. Current intakes are 50% which at times is 25% and others 75%. Starting ensure BID. Skin is intact. Will continue to monitor and update as needed. It is important to note that R26 does not have a physician's order for Ensure. Nurse's note with effective date of 1/31/25 and a created date of 4/16/25 states: resident was started on mirtazapine for weight loss. GNP (Gerontologic Nurse Practitioner) in house and updated regarding weight loss. (of note, this note was put in approximately 75 days later.) On 5/7/25 at 9:37 AM, Surveyor interviewed R26. Surveyor asked R26 how she likes the food, R26 stated that she didn't like the food, it's mush. Surveyor asked R26 if she receives any snacks, R26 stated no. On 5/12/25 at 9:34 AM, Surveyor interviewed CNA X (Certified Nursing Assistant). Surveyor asked CNA X how staff knows if a resident is to receive a snack, CNA X reported that it would show up when they are completing documentation. CNA X reported that there is a snack list for PM shift (evening), and a snack cart that is prepared by the dietary staff. Surveyor asked if snacks are provided during the day shift, CNA X stated no, but the kitchen is open, and residents can come in and ask for a snack. Surveyor asked CNA X how staff knows if a resident is to receive Ensure, CNA X stated that it is on the meal ticket and dietary staff gives it during meals. On 5/12/25 at 9:59 AM, Surveyor interviewed DA AA (Dietary Aide). Surveyor asked DA AA how often they are offering R26 Ensure, DA AA stated they offer it every day and that R26 doesn't eat much food. DA AA reported that this morning R26 refused the Ensure. DA AA stated that the thicker Ensure is hard for R26 to drink when she is not feeling well, but she likes the clear, juice like one. Surveyor asked DA AA if the refusals are reported, DA AA stated that they (refusals) are reported to the nurse. On 5/12/25 at 10:15 AM, Surveyor interviewed DM W (Dietary Manager). Surveyor asked DM W if R26 is being seen by the RD (Registered Dietician), DM W stated that the RD only comes in once a week and if a resident has weight changes, they would be referred to the RD. Surveyor asked DM W why the RD hasn't seen R26 for weight loss, DM W stated that she did not know. Surveyor asked DM W how she would know if the RD was seeing a resident, DM W stated that she wouldn't know. Surveyor asked DM W how they would know what a resident's calorie, protein, and hydration needs are, DM W stated that she would calculate that, and it goes into the MDS quarterly and annual assessments. Surveyor asked if it would be documented in a note, DM W stated that she puts in a note about percents eaten. Surveyor asked DM W if she is able to initiate a nutritional supplement without a physician's order, DM W stated yes. Surveyor asked DM W who tracks if R26 is drinking the Ensure, DM W stated that dietary staff writ [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure food was prepared and served in a safe and sanitary manner. This practice has the potential to affect all 48 residents who reside at the facility. Surveyor observed dietary staff directly touching food with bare hands. Surveyor observed staff enter kitchen area while food service was taking place, not wearing a hair restraint. Evidenced by: The facility policy, Food Safety Requirements, dated 2/25, states, in part; .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas .d. Dietary staff must wear hair restraints to prevent hair from contacting food . On 5/12/25 at 7:26AM, Surveyor observed a dietary staff directly touching sausage with their bare hands. Surveyor observed dietary staff touching inside lip of fruit cups directly touching the food. Dietary staff was not wearing any gloves at the time. No hand hygiene was observed. Surveyor observed staff enter the kitchen area while food service was taking place and was not wearing a hair restraint. On 5/13/25 at 9:46AM, Dietary Aide V (DA) indicated it is never acceptable to touch food with bare hands. DA V indicated tongs should be used or wear gloves. DA V indicated hairnets must be worn any time in the kitchen and service area. On 5/13/25 at 10:00AM, Dietary Manager W (DM) indicated staff should never directly touch food with bare hands. DM W indicated staff should wear gloves. DM W indicated all staff should wear hairnets when in the kitchen and food service area. The facility did not ensure food was prepared and served in a safe and sanitary manner.

Based on observation, interview, and record review, the facility did not assure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable in 1 of 1 medication room. Surveyors observed the following: -6 stock antibiotic ointments were expired, found in the medication room: -3 antibiotic ointments (bacitracin zinc) expired on ,d+[DATE], ,d+[DATE], and ,d+[DATE] -1 triple antibiotic ointment (bacitracin zinc / neomycin sulfate / polymyxin B sulfate) expired on ,d+[DATE] and 2 expired on ,d+[DATE] Evidenced by: The facility policy, Medication Storage, dated ,d+[DATE], states in part: Policy: It is the policy of this facility to ensure all medications house on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations .8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. On [DATE] at 2:21 PM, Surveyors observed the medication storage room with DON B (Director of Nursing). Surveyors found six expired stock antibiotic ointment cream: three antibiotic ointments expired in ,d+[DATE], ,d+[DATE], and ,d+[DATE], one triple antibiotic ointment cream expired in ,d+[DATE], and two triple antibiotic creams expired in ,d+[DATE]. On [DATE] at 2:30 PM, Surveyors interviewed DON B. DON B verified all six antibiotic ointment creams were expired. DON B indicated, the creams should not be in circulation since they are expired. DON B pulled the antibiotic ointment creams for disposal.

Based on interview and record review, the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized in accordance with accepted professional standards and practices in 13 of 13 residents reviewed (R26, R3, R41, R21, R19, R31, R13, R42, R36, R25, R20, R5, & R15). The facility did not have readily accessible MD/NP visit notes for R26, R3, R41, R21, R19, R31, R13, R42, R36, R25, R20, R5, and R15. Evidenced by: The facility policy titled Physician Visits and Physician Delegation dated 2/2025 states in part .1. The Licensed Nurse should: a. Track due dates of physician visits .f. Remind the physician to date and sign all order and write a progress note .3. The Director of Nursing or Designee should: a. Conduct monthly audits for timeliness of physician visits . The facility's policy titled Documentation in Medical Record dated 2/2025 states in part Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy . On 5/8/25, Surveyors discovered that residents in the Resident sample chosen did not have visit notes from their MD/ NP in their EHR or in their paper charts. Surveyors requested visit notes since May 2025 to current; all noted were printed off of [EHR] during this survey. Example 1 R26 was admitted to the facility on [DATE]. R26 did not have any documentation in the facility's EHR (Electronic Health Record) or paper chart regarding any routine or acute MD/ NP (Medical Doctor/ Nurse Practitioner) visits. Example 2 R19 was admitted to the facility on [DATE]. R19 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/ NP visits. Example 3 R31 was admitted to the facility on [DATE]. R31 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/ NP visits. Example 4 R13 admitted to the facility on [DATE]. R13 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/ NP visits. Example 5 R36 admitted to the facility on [DATE]. R36 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/ NP visits. Example 6 R15 was admitted to the facility on [DATE]. R15 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/ NP visits. 49434 Example 7 R41 was admitted to the facility on [DATE]. R41 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/ NP visits. Example 8 R21 was admitted to the facility on [DATE]. R21 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/ NP visits. Example 9 R42 was admitted to the facility on [DATE]. R42 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/ NP visits. Example 10 R20 was admitted to the facility on [DATE]. R20 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/ NP visits. 44552 Example 11: R3 was admitted to the facility on [DATE]. R3 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/NP visits. Example 12: R25 was admitted to the facility on [DATE]. R25 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/NP visits. Example 13: R5 was admitted to the facility on [DATE]. R5 did not have any documentation in the facility's EHR or paper chart regarding any routine or acute MD/NP visits. On 5/8/25 at 2:29 PM, Surveyor interviewed NS C (Nursing Supervisor). Surveyor asked NS C who is responsible for monitoring the frequency of MD/ NP visits, NS C stated that the clinic monitors the timing of visits. Surveyor asked NS C how the facility would know if a visit was missed, NS C stated that they wouldn't know. Surveyor asked NS C how the facility gets the visit notes and documentation from the visit, NS C stated that she would have to go into the clinic's [EHR]. Surveyor asked NS C if she is doing that, NS C stated that she is not doing it regularly. On 5/12/25 at 7:14 AM, Surveyor interviewed RN J (Registered Nurse). Surveyor asked RN J what the process is for reviewing MD/ NP visit notes, RN J reported that she has access to [EHR], but not everyone does. RN J stated that does not go into the [EHR] every day, but she could if she wanted to. RN J stated that they rely on the supervisors to tell them what they need to know. On 5/12/25 at 7:19 AM, Surveyor interviewed RN O. Surveyor asked RN O how staff can review MD/ NP visit notes, RN O reported that she would ask NS C. Surveyor asked RN O if she had access to [EHR], RN O stated no. On 5/12/25 at 8:03 AM, Surveyor interviewed LPN Y (Licensed Practical Nurse). Surveyor asked LPN Y how staff can review MD/ NP visit notes, LPN Y stated that she does not have access to [EHR] and that she would have to ask NS C or DON B (Director of Nursing). On 5/13/25 at 11:130 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A who is responsible for obtaining the notes from MD/ NP visits, NHA A stated that the Nursing Supervisor, DON, or Unit Clerk should be getting the documentation. Surveyor asked NHA A who is responsible for tracking MD/ NP visits, NHA A stated that Medical Records tracks the visits. On 5/13/25 at 1:09 PM, Surveyor interviewed MR Z (Medical Records). Surveyor asked MR Z if she is responsible for tracking MD/ NP visits, MR Z stated that in 2024, the facility did a whole house sweep and that a couple of weeks ago they discussed doing it again. MR Z stated that she is currently working on 2025. Surveyor asked MR Z who is responsible for obtaining visit noted from MD/ NP visits, MR Z stated that she will be and that she used to be but hasn't been. The facility did not have readily accessible MD/NP visit notes for R26, R3, R41, R21, R19, R31, R13, R42, R36, R25, R20, R5, and R15 in their health records.

Based on interview and record review the facility failed to ensure they followed standards of practice for an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 17 sampled residents (R42) and 3 of 4 supplemental residents (R300, R16 and R11) reviewed for antibiotic stewardship. R300 had documented urinary symptoms. The facility did not verify that infection criteria was met or monitor symptoms and effectiveness of treatment following the start of an antibiotic. R42 started an antibiotic for urinary tract infection (UTI). The facility did not verify that infection criteria were met, monitor symptoms through time of order for antibiotic treatment, or monitor symptoms and effectiveness of treatment following start of antibiotic. R16 started an antibiotic for UTI. The facility did not verify that infection criteria were met, monitor symptoms through time of order for antibiotic treatment, or monitor symptoms and effectiveness of treatment following start of antibiotic. R11 had change in respiratory status and was started on an antibiotic for pneumonia. The facility did not verify that infection criteria were met or monitor symptoms and effectiveness of treatment following start of antibiotic. Evidenced by: The facility's Antibiotic Stewardship Program policy, dated 4/2025, states, in part: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control Program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: Nursing staff shall assess residents who are suspected to have an infection . b. Monitoring antibiotic use: Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made. Antibiotic orders obtained upon admission, whether new admission or readmission to the facility shall be reviewed for appropriateness. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness . 5. Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 of antibiotic therapy to monitor response to the antibiotic and review laboratory findings and will consult with the practitioner to determine if the antibiotic is to continue or if adjustmens need to be made based on findings .11. Documentation related to the program is maintained by the IP, including, but not limited to: .Assessment forms .data collection forms for antibiotic use, process, and outcome measures . McGeer revised criteria indicates the following: . Urinary tract infection (UTI) surveillance definitions . UTI without indwelling catheter. Must fulfill both 1 AND 2. 1. At least one of the following signs or symptoms. - Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate. - Fever or leukocytosis, and greater than or equal to 1 of the following: - Acute costovertebral angle pain or tenderness; suprapubic pain; gross hematuria; new or marked increase in incontinence; new of marked increase in urgency; new or marked increase in frequency. - If no fever or leukocytosis, then greater than or equal to 2 of the following: - Suprapubic pain; gross hematuria; new or marked increase in incontinence; new of marked increase in urgency; new or marked increase in frequency. 2. At least one of the following microbiological criteria. - Greater than 10^5 cfu/ml (colony forming unit per milliliter) of no more than 2 species of organisms in a voided urine sample. - Greater than or equal to 10^2 cfu/ml of any organism(s) in a specimen collected by an in-and-out catheter. Pneumonia MUST fulfill 1, 2, AND 3 1. Chest radiograph as demonstrating pneumonia or presence of a new infiltrate 2. At least 1 of the following: 2. At least 1 of the following: - new or increased cough - New or increased sputum production. - O2 saturation <94% on room air or a reduction in O2 saturation of >3% from baseline. - New or changed lung examination abnormalities - Pleuritic chest pain - Respiratory rate >25 breaths/min 3. at least 1 of the constitutional criteria - fever - leukocytosis - Acute change in mental status from baseline - Acute functional decline. Example 1 R300 admitted to the facility on [DATE] and has diagnoses that include: cystitis (an inflammation of the bladder); chronic kidney disease, stage 4 (moderate to severe kidney damage); gross hematuria (visible blood in the urine). P300's Progress Notes include: 4/8/25 9:32 AM Situation: Resident has hematuria, extreme burning with urination, flank pain.May we check a UA and/or labs? P300's Hospital Emergency Provider Note, date of service 4/8/25 6:12 PM, states, in part: R300 has been having dysuria (painful urination) over the past approximate 24 hours .dysuria is really the only symptom at this time .it is reasonable to send her home with outpatient p.o. (by mouth) antibiotics .Temperature 97.5 P300's April 2025 Medication Administration Record (MAR) includes: Cefdinir (antibiotic) oral capsule 300 mg (milligrams) by mouth every 12 hours two for UTI (urinary tract infection) for 6 days until finished. Order date 4/9/25 Surveyor requested progress notes regarding whether or not there are any further urinary symptoms or regarding antibiotic effectiveness through the end of this course of treatment. No progress notes were provided. Progress note was provided regarding a new episode of urinary symptoms beginning 4/25/25. R300's Progress Notes include: *4/25/25: Resident with complaints I have a bladder infection. Reports burning with urination before and after urination. Also c/o nausea before R300 urinates. Reports some frequency and only going in spurts. States s/s (signs and symptoms) for 3-4 days. Denies lower abdominal pain, denies hematuria. Afebrile (without fever). Fluids encouraged. MD to visit this afternoon. *4/28/25: Resident had a UA (urine test) sent off Friday night and resident has burning, blood in urine also. Could we get her started on some treatment? Important to note: there are no progress notes regarding urinary symptoms between 4/25/25 and 4/28/25. R300's April 2025 MAR includes: Cefprozil (antibiotic) Tablet 250 mg Give 1 tablet by mouth every 12 hours for infection for 7 days. Order date: 4/29/25 Surveyor requested facility documentation of infection meeting criteria, documentation regarding urinary symptoms for the time frame of 4/25 and 4/28/25 and documentation of and whether or not there were any further symptoms after start of and through completion of antibiotic treatment. No documentation was provided. On 5/13/25 at 10:10 AM, Surveyor interviewed MDS/IP D (Minimum Data Set / Infection Preventionist) and asked if there was monitoring of R300's urinary symptoms between 4/25/25 and 4/28/25. MDS/IP D stated there is no documentation of this. Surveyor asked how the facility determines infection. MDS/IP D stated McGeer's Criteria. Surveyor asked if this was reviewed for meeting McGeer's. MDS/IP D stated McGeer's was not checked due to the resident being seen at the hospital. MDS/IP D stated if a resident admits on antibiotic or has antibiotic prescribed in the emergency room that McGeer's is not verified by the facility. Surveyor asked if there was monitoring of the resident's symptoms and antibiotic effectiveness following start of antibiotic. MDS/IP D stated no documentation was noted. Example 2 R42 admitted to the facility on [DATE] and has diagnoses that include encephalopathy ( a dysfunction or disease of the brain that alters its function or structure); adult failure to thrive (a state of decline in older adults that manifests as a downward spiral of health and activity); need for assist with personal care. R42's April 2025 MAR includes: Cefdinir oral capsule 300 mg Give 1 capsule by mouth two times a day for uti until 4/12/25. Order date 4/4/25. R42's Provider Telephone Encounter, dated 4/4/25, states, in part: nitrofurantoin (antibiotic) is generally not recommended for complex or complicated UTIs [for example fever, somnolence (drowsiness)], given its poor tissue penetration. I will order cefdinir.fever has improved and R42 became less somnolent with acetaminophen (medication used to reduce fever). So will monitor closely. Surveyor requested facility documentation of infection meeting criteria and documentation related to resident assessment of symptoms of UTI and whether or not there were any further symptoms after starting antibiotic and through completion of antibiotic treatment. No documentation was provided. On 5/13/25 at 10:10 AM, Surveyor interviewed MDS/IP D (Minimum Data Set / Infection Preventionist) and asked if R42 met McGeer's Criteria. MDS/IP D stated that it had been reviewed at time of antibiotic order, but there was no documentation of the review. Surveyor asked if there was monitoring of the resident's symptoms and antibiotic effectiveness following the start of the antibiotic. MDS/IP D stated no documentation was noted. Example 3 R16 admitted to the facility on [DATE] and has diagnoses that include: multiple sclerosis (a chronic, neurological disease, affecting communication between the brain and body, leading to a wide range of symptoms that may include bladder dysfunction), overactive bladder (a condition where the bladder squeezes urine out involuntarily at the wrong time, leading to sudden and strong urge to urinate), urge incontinence (a condition where there is a sudden, strong urge to urinate which is difficult to control, often resulting in leakage). R16's Provider Progress Note dated 3/27/25, states, in part: .noted to be more confused by nursing home staff. R16 denies urinary changes but has been noted to have frequency, incontinence, and foul-smelling urine per staff observation, history of sepsis (a life-threatening condition caused by the body's extreme response to an infection) secondary to UTI in the past. UA with culture reflex (laboratory test that identifies microorganisms, like bacteria, in a urine sample) has been ordered . R16's Provider Telephone Encounter Note dated 3/28/25, states, in part: .urinalysis concerning for UTI. Since afebrile and no systemic symptoms to suggest complicated cystitis, recommend Macrobid 100 mg twice daily for 5 days. R16's Progress Note dated 3/28/25 3:09 PM, states, in part: Situation: with results of lab and urine will start resident on Macrobid (antibiotic) for UTI . R16's March 2025 MAR includes: *Macrobid oral capsule 100 mg give one capsule by mouth two times a day for UTI for 5 days. Order date 3/28/25. D/C (Discontinue) date 3/31/25 *Macrobid oral capsule 100 mg give one capsule by mouth two times a day for UTI until 4/7/25 11:59 PM Take with morning and evening meal. Order date 3/31/25. Surveyor requested facility documentation of infection meeting criteria and documentation related to resident assessment of symptoms of UTI and whether or not there were any further symptoms after the start of and through completion of the antibiotic treatment. No documentation was provided. On 5/13/25 at 10:10 AM, Surveyor interviewed MDS/IP D (Minimum Data Set / Infection Preventionist) and asked if R16 met McGeer's Criteria. MDS/IP D stated that it had been reviewed at time of antibiotic order, but there was no documentation of the review. Surveyor asked if there was facility documentation of symptoms prior to the provider assessment. MDS/IP D stated no documentation was noted. Surveyor asked if there was monitoring of the resident's symptoms and antibiotic effectiveness following the start of the antibiotic. MDS/IP D stated no documentation was noted. Example 4 R11 admitted to the facility on [DATE] and has diagnoses that include chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs); paroxysmal atrial fibrillation (an irregular heart rhythm which can cause fluttering or pounding in the chest and shortness of breath); dependence on supplemental oxygen. R11's Progress Notes include: *2/11/25 9:26 AM .residents vital signs taken. Oxygen saturation was 99% on 2.5L (liter flow of oxygen); however, her respirations were 38. Lung sounds diminished with some coarse crackles heard in the right base, very shallow breathing. Resident denied SOB (shortness of breath) sitting in her chair at the time. Supervisor updated. *2/11/25 7:30 PM .spoke with daughter regarding chest xray which showed pneumonia and that R11 was started on an antibiotic . R11's Provider Telephone Encounter note, dated 2/11/25, states, in part: .Mobile chest xray completed due to new basilar crackles (abnormal lung sounds) and tachypnea (abnormally rapid breathing), vital signs, no hypoxia, patient denies shortness of breath. Concerning for L (left) pneumonia, recommend treating empirically due to frailty .Levofloxacin (antibiotic) 750 mg po (by mouth) every 48 hours x (for)4 doses . R11's February 2025 MAR (Medication Administration Record) includes: Levofloxacin oral tablet 750 mg give 1 tablet by mouth every 48 hours for pneumonia for 4 administrations. Order date 2/11/25. Surveyor requested facility documentation related to resident assessment of symptoms of pneumonia after starting the antibiotic and through completion of antibiotic treatment. No documentation was provided. On 5/13/25 at 10:10 AM, Surveyor interviewed MDS/IP D (Minimum Data Set / Infection Preventionist) and asked if R11 met McGeer's Criteria. MDS/IP D stated that it had been reviewed at time of antibiotic order, but there was no documentation of the review. Surveyor asked if there was monitoring of the resident's symptoms and antibiotic effectiveness following start of antibiotic. MDS/IP D stated no documentation was noted. On 5/13/25 at 1:16 PM, Surveyor interviewed DON B (Director of Nursing) and asked about facility protocol for resident's with new symptoms. DON B stated staff is expected to monitor for at least 72 hours or through course of antibiotic/wellness. Surveyor asked if this monitoring is documented. DON B stated yes. Surveyor asked how infections are determined. DON B stated through McGeer's Criteria. Surveyor asked if McGeer's Criteria is expected to be documented. DON B stated yes.

Based on interview and record review, the facility failed to protect a residents right to be free from verbal abuse by a visitor for 1 of 13 residents (R3) reviewed for abuse. R3 was verbally abused on multiple occasions while at the facility by R3's Activated Power of Attorney (POA). The facility failed to ensure measures were in place to prevent verbal abuse from reoccurring. It was reported that R3's POA was yelling at R3 in December 2024. The facility completed an investigation regarding a possible verbal abuse by R3's POA on 3/27/25 and 4/21/25. The facility did not add appropriate interventions to ensure R3 was free from abuse, did not update R3's care plan with interventions, and staff were not aware of the need for extra support and/or monitoring when R3's POA was in the facility. Evidenced by: The facility policy, Abuse, Neglect and Exploitation, dated 4/8/25, states, in part; .Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .IV. Identification of Abuse, Neglect and Exploitation .5. Verbal abuse of a resident overheard .7. Psychological abuse of a resident . The facility Visitation Policy Summary, states, in part; .Visitation may be restricted or denied under the following circumstances: .If the visitor's behavior is disruptive, aggressive, threatening, or emotionally harmful . R3 was admitted to the facility on [DATE] with a diagnoses including unspecified dementia, abnormalities of gait and mobility, major depressive disorder, chronic pain, unspecified mood, and other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence. R3's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/18/25, indicates R3 has a Brief Interview for Mental Status (BIMS) score of 11 indicating R3 is moderately cognitively impaired. R3 has an activated power of attorney. R3's Comprehensive Care Plan, states, in part; .Abuse Prevention: At risk and/or potential for abuse vulnerability- areas of vulnerability include: limited family involvement, cognitive impairment .Observe and provide safe environment. It is important to note R3's care plan and Kardex do not include interventions or increased monitoring for R3 or R3's POA. Facility self report, states, in part; .3/27/25 .staff member reported it sounded like R3's granddaughter was talking loudly to R3. Staff first checked on resident and then reported. NHA went to room for further investigation and ensure resident safety. POA exited the room and was leaving the facility .additional residents were interviewed, and staff statements were collected. Facility completed the following: NHA (Nursing Home Administrator) called the POA on 3/30/25 regarding this incident with the DON present. NHA informed POA that loud talking, yelling, and/or swearing in the facility would not be tolerated. 2. DSS G (Director of Social Services) is working with APS on potential guardianship. 3. A memo was placed at the nurses station to contact the NHA immediately if the POA exhibits any unprofessional conduct during future visits . It is important to note that in the 3/27/25 self report there was a statement, that states in part: . In December of 2024 staff notified writer that POA was by the front doors yelling at R3. By the time I was able to get to the doors, R3 had already left with POA. When R3 returned I asked her about interaction R3 told me that her POA was upset R3 stated that this interaction was not distressing to her . Facility self report, states, in part; .4/21/25 .On 4/21/25, around 8:30AM, Nurse and CNA called the DON to R3's room due to loud yelling and profanity, DON notified Administrator. DON and Administrator immediately entered R3's room. POA was yelling at resident and using profanity saying things such as: You don't know what I am f**king going through, because I don't tell you. I am busting my f**king ass to care for you just like I busted my f**king ass to care for my dad. When Administrator and DON entered room, POA's behavior immediately de-escalated with a visible change in demeanor. She welcomed DON into the room. Administrator followed. POA stated they were talking about R3's shingles. POA was then acting like she was comforting R3 by holding her hand and then hugging her Describe the effect .R3 was crying when the DON and Administrator entered the room. However, she reported she is okay and that is how the POA is. R3 confirmed that she wants to continue having visits with her POA and feels safe around her .Explain what steps the entity took .The incident took place in R3's room, with the door shut. There were no additional residents around. Additional residents were interviewed . Facility incident report, states, in part; .4/21/25 .RN O (Registered Nurse) statement .at approx. 9am POA approached writer at my cart and stated, Were you the one that complained that we were being too loud? Writer replied no I was not the one that set that in motion. POA then asked who was because I want to yell at them because I am so sick of this place. Writer replied, I don't feel comfortable telling you this. POA states, Oh that's okay. I will find out. And walked away. Her demeanor was intimidating .Root cause analysis: Based on thorough investigation and statements obtained, staff reported the observations/hearing loud talking and profanity to administration immediately. It is reasonable to believe that this incident is part of R3 and POA's relationship. R3 has reported that this is just how POA is and that she feels safe with POA. Action taken: Police were notified of this incident. In order to prevent escalation of the incident, the police officer has decided to not talk with POA regarding this situation, however, future situations law enforcement will be notified immediately and will come to the facility to intervene. Facility leadership is consulting with the Ombudsmen as well as sending POA a warning letter that future incidents may result in supervised visits going forward. POA [sic] is being closely monitored by nursing and social services for any negative effects from this interaction CNA GG (Certified Nursing Assistant) written statement, states, in part; .On 4/21/25 I overheard yelling coming from R3's room. Her POA was in there with her. I heard POA yell I don't f**king care. I also heard her loudly say I'm not letting you change the f**king subject. I reported this to the nurse right away and she reported to DON right away . (Of note, based on CNA GG's statement, CNA GG did not intervene or protect R3 from verbal abuse.) On 5/8/25 at 8:50 AM, CNA S indicated she is not aware of any interventions in place or any concerns between R3 and POA. CNA S indicated if she witnessed abuse or possible abuse she would report concerns immediately and intervene. On 5/8/25 at 8:58 AM, CNA I indicated she is not aware of any interventions in place or any concerns between R3 and POA. CNA I indicated if she heard verbal abuse she would intervene and immediately report. On 5/8/25 at 9:00 AM, RN E indicated she would immediately report any allegations of abuse. RN E indicated she is not aware of any interventions in place or anything to be mindful of between R3 and R3's POA. RN E indicated there has been a lot of education on abuse recently. On 5/8/25 at 9:05 AM, RN BB indicated she is not aware of any interventions or anything in place for R3 and POA. RN BB indicated if she witnessed possible abuse she would intervene and report to the DON (Director of Nursing). RN BB indicated if she observed abuse between a POA and resident she would ask the POA to leave. RN BB indicated there has been a lot of education regarding abuse the last couple of months and that she can't remember if it was specific to R3. On 5/8/25 at 9:10 AM, S CC (Scheduler) indicated she has heard R3's POA yelling and swearing at R3 before. S CC indicated this was quite awhile ago and a lot more has been done recently to support R3. Surveyor asked S CC how R3's demeanor seems after POA has been yelling and swearing at her. S CC stated, R3 handles it well for as much as she gets yelled at. Sometimes she's upset, most of the time she just brushes it off. S CC indicated there is a posting at the nurse's station and S CC pointed at a note. S CC indicated if staff hear any yelling by POA they need to report it immediately. Surveyor asked if there are new staff or agency staff how does this get relayed to them? S CC indicated staff should communicate this to any new staff. Surveyor asked if this was care planned and S CC indicated it wouldn't hurt to have it on the care plan. On 5/8/25 at 9:15 AM, AA DD (Administrator Assistant) indicated she has not seen any negative interactions between R3 and POA. AA DD indicated if she witnessed possible abuse she would ensure resident is safe and immediately notify administration. AA DD indicated even if the resident said they were fine she would still react the same way. AA DD indicated she has recently received abuse education. Surveyor inquired about a questionnaire that AA DD completed during 1st self report- it stated that AA DD heard POA raise voice to R3. AA DD indicated this was a long time ago and R3 was going for a ride with POA. POA's dad was very sick and AA DD indicated everyone in the family had been stressed. AA DD indicated R3 indicated she was fine and that R3 and POA left the facility together. On 5/8/25 at 9:51 AM, Housekeeper FF indicated she has heard R3's POA yell at R3. Housekeeper FF indicated this had been reported and the nurse talked with R3. Housekeeper FF indicated she would report abuse concerns immediately and she has recently received abuse education. On 5/8/25 at 10:26 AM, DSS G indicated there has been a couple times where R3's POA has yelled at R3. DSS G indicated she has followed up with R3 regarding her POA. DSS G indicated every time a verbal incident occurs DSS G follows up with R3. DSS G indicated R3 always says that is just how POA is and that's how she talks. Surveyor asked DSS G what is in place now to keep R3 safe? DSS G indicated NHA (Nursing Home Administrator) has sent R3's POA a letter, if staff hear POA yelling they are to immediately call the police, R3 has routine behavior health visits, APS and Ombudsman have been notified, and there is a note posted at the nurse's station. Surveyor asked how do the staff know these interventions? DSS G indicated, I believe this is in her care plan, but I am not certain and would have to look. DSS G indicated staff are to check on R3 and make sure she is safe, but not engage with POA because historically POA can get aggressive. DSS G indicated then staff call the police. It is important to note, through staff interview most were not aware of these interventions in place. The interventions are not in R3's care plan or on R3's Kardex. On 5/8/25 at 1:37 PM, CNA GG indicated she was the CNA that heard R3's POA yelling at R3 on 4/21/25. CNA GG indicated it was a couple weeks ago. CNA GG indicated R3's bedroom door was closed, and CNA GG could hear R3's POA yelling, and she was being very loud. CNA GG indicated she was in the middle of doing multiple things, assisting a co-worker, a call light went off, and going into another resident's bedroom so she asked the nurse to go do something. CNA GG indicated the nurse went and got the DON. CNA GG indicated she could hear some swear words and R3's POA kept interrupting R3. CNA GG indicated there has been a lot of education on abuse recently and CNA GG indicated she would report any possible abuse concerns to administration immediately. CNA GG indicated she didn't see R3 right after the incident, but during lunch she seemed fine. On 5/8/25 at 4:12 PM, RN O indicated she was the nurse on the floor when the incident occurred on 4/21/25. RN O indicated R3's POA is known to have anger issues and a short fuse. RN O indicated this is R3's POA and R3's unusual dynamic. RN O indicated CNA GG reported to RN O she thought she heard yelling coming from R3's bedroom. RN O indicated RN O was by med cart and went down to R3's bedroom. The door was closed, RN O listened to see if she could hear any yelling, RN O did not hear anything and walked back to med cart. RN O indicated RN O was at med cart and saw DON (Director of Nursing) and NHA (Nursing Home Administrator) walking towards R3's bedroom. RN O indicated shortly after R3's POA came up to RN O asking if RN O was the person that reported her. RN O indicated R3's POA is very intimidating and had that look in her eye. RN O indicated that she has known R3 since R3 was admitted to facility and R3 has never said she is afraid of her POA. RN O indicated this is the way it's always been between these two. She (POA) can get very inappropriate with her words .she's always been this way. Surveyor asked if RN O has ever observed R3 yelling and screaming at POA? RN O stated, No, I have not. Surveyor asked RN O is verbal abuse considered a form of abuse? RN O indicated Yes, absolutely. On 5/12/25 at 8:40 AM, NHA A (Nursing Home Administrator) indicated the first self report investigation occurred on 3/27/25. A staff overheard loud voices coming from R3's bedroom. Staff couldn't make out exactly what was being said. Staff peeked head in bedroom and didn't see anything alarming and then reported to NHA A immediately. DON B and NHA A went down to R3's bedroom and POA was leaving facility. DON B and NHA A asked R3 if she felt safe and had any concerns with POA. R3 indicated she is not scared and values the relationship between the two. DON B and NHA A called POA the next day, interviewed residents and staff. NHA A indicated POA was not pleased with the phone call and NHA A told POA that the police will be notified if further incidents occur. NHA A indicated they reviewed the incident and plan of action in QAPI and felt they handled incident correctly. NHA A indicated DSS G notified APS and all staff were educated on abuse. NHA A indicated it is a fine line promoting R3 and POA's relationship and keeping resident safe. NHA A indicated they made the decision to not put anything in the Kardex and care plan because they didn't want the POA to see that and cause any issues. NHA A indicated staff are educated on the abuse policy and there is a memo at the nurses station for all staff to notify NHA if they hear POA yelling at R3. The memo is in a central location so all staff should know to be on alert when POA is in facility. NHA A indicated second self report investigation occurred 4/21/25. Staff heard yelling coming from R3's bedroom. CNA GG reported the concern to RN O. NHA A and DON B (Director of Nursing) went to R3's bedroom. NHA A indicated they watched POA exit the facility. NHA A indicated facility contacted the police, contacted Ombudsman, sent POA a letter and resources on guardianship, and provided resources to R3 on Ombudsman information, interviewed staff, interviewed residents, and monitored R3. NHA A indicated they did not put interventions on Kardex or care plan because POA sees these documents. NHA A indicated all staff are educated and must follow abuse policy. NHA A indicated all staff are to follow if you see a crime you call law enforcement. NHA A indicated R3 is very adamant that this is their relationship and that it's always been this way. NHA A indicated it is not appropriate. NHA A indicated she does not view the incidents as verbal abuse because R3 does not view it that way. NHA A indicated it would be different if she was upset by it or if it was more physical in nature, since R3 doesn't view it as verbal abuse NHA A does not view it that way. Surveyor asked NHA A if she is aware of R3's past trauma? NHA A indicated she does not know specifics of R3's trauma, but that DSS G would be able to speak more on that. On 5/12/25 at 3:39 PM, DSS G indicated APS was visiting R3 tomorrow. DSS G indicated R3 has shared with her that she was abused by her father as a child. DSS G indicated R3 didn't elaborate or share any more information other than that. Surveyor asked is verbal abuse is considered abuse? DSS G shrugged shoulders and nodded yes. Based on interview and record review, the facility failed to protect R3's right to be free from verbal abuse by a visitor.

Based on interview and record review, the facility failed to immediately intervene when alleged verbal abuse was observed for 1 of 3 Residents (R3) involved in a facility reported incident. Staff heard an alleged verbal abuse altercation and failed to immediately ensure R3's safety. Evidenced by: The facility policy, Abuse, Neglect and Exploitation, dated 4/8/25, states, in part; .VI. Protection of Resident .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the residents from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse . R3 was admitted to the facility on [DATE] with a diagnoses including unspecified dementia, abnormalities of gait and mobility, major depressive disorder, chronic pain, unspecified mood, and other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence. R3's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 3/18/25, indicates R3 has a BIMS (Brief Interview for Mental Status) score of 11 indicating R3 is moderately cognitively impaired. R3 has an activated power of attorney. R3's Comprehensive Care Plan, states, in part; .Abuse Prevention: At risk and/or potential for abuse vulnerability- areas of vulnerability include: limited family involvement, cognitive impairment .Observe and provide safe environment. Facility self report, states, in part; .4/21/25 .On 4/21/25, around 8:30AM, Nurse and CNA called the DON to R3's room due to loud yelling and profanity, DON notified Administrator. DON and Administrator immediately entered R3's room. POA was yelling at resident and using profanity saying things such as: You don't know what I am f**king going through, because I don't tell you. I am busting my f**king ass to care for you just like I busted my f**king ass to care for my dad. When Administrator and DON entered room, POA's behavior immediately de-escalated with a visible change in demeanor. She welcomed DON into the room. Administrator followed. POA stated they were talking about R3's shingles. POA was then acting like she was comforting R3 by holding her hand and then hugging her Describe the effect .R3 was crying when the DON and Administrator entered the room. However, she reported she is okay and that is how the POA is. R3 confirmed that she wants to continue having visits with her POA and feels safe around her .Explain what steps the entity took .The incident took place in R3's room, with the door shut. There were no additional residents around. Additional residents were interviewed . Facility incident report, states, in part; .4/21/25 .Registered Nurse O (RN) statement .at approx. 9am POA approached writer at my cart and stated, Were you the one that complained that we were being too loud? Writer replied no I was not the one that set that in motion. POA then asked who was because I want to yell at them because I am so sick of this place. Writer replied, I don't feel comfortable telling you this. POA states, Oh that's okay. I will find out. And walked away. Her demeanor was intimidating .Root cause analysis: Based on thorough investigation and statements obtained, staff reported the observations/hearing loud talking and profanity to administration immediately. It is reasonable to believe that this incident is part of R3 and POA's relationship. R3 has reported that this is just how POA is and that she feels safe with POA. Action taken: Police were notified of this incident. In order to prevent escalation of the incident, the police officer has decided to not talk with POA regarding this situation, however, future situations law enforcement will be notified immediately and will come to the facility to intervene. Facility leadership is consulting with the Ombudsmen as well as sending POA a warning letter that future incidents may result in supervised visits going forward. POA is being closely monitored by nursing and social services for any negative effects from this interaction Certified Nursing Assistant GG (CNA) written statement, states, in part; .On 4/21/25 I overheard yelling coming from R3's room. Her POA was in there with her. I heard POA yell I don't f**king care. I also heard her loudly say I'm not letting you change the f**king subject. I reported this to the nurse right away and she reported to DON right away . (of note, CNA GG's statement indicates CNA GG did not intervene and protect R3 when hearing yelling coming from R3's room.) On 5/8/25 at 10:26 AM, Director of Social Services G (DSS) indicated there has been a couple times where POA (Power of Attorney) has yelled at R3. DSS G indicated she has followed up with R3 regarding POA. DSS G indicated every time a verbal incident occurs DSS G follows up with R3. DSS G indicated R3 always says that is just how POA is and that's how she talks. Surveyor asked DSS G what is in place now to keep R3 safe? DSS G indicated NHA (Nursing Home Administrator) has sent POA a letter, if staff hear POA yelling they are to immediately call the police, R3 has routine behavior health visits, APS and Ombudsman has been notified, and there is a note posted at the nurse's station. Surveyor asked how do the staff know these interventions? DSS G indicated, I believe this is in her care plan, but I am not certain and would have to look. DSS G indicated staff are to check on R3 and make sure she is safe, but not engage with POA because historically POA can get aggressive. DSS G indicated then staff call the police. On 5/8/25 at 1:37 PM, CNA GG indicated she was the CNA that heard POA yelling at R3 on 4/21/25. CNA GG indicated it was a couple weeks ago. CNA GG indicated R3's bedroom door was closed, and CNA could hear POA yelling, and she was being very loud. CNA GG indicated she was in the middle of doing multiple things, assisting a co-worker, a call light went off, and going into another resident's bedroom so she asked the nurse to go do something. CNA GG indicated the nurse went and got the DON. CNA GG indicated she could hear some swear words and POA kept interrupting R3. CNA GG indicated there has been a lot of education on abuse recently and CNA GG indicated she would report any possible abuse concerns to administration immediately. CNA GG indicated she didn't see R3 right after the incident, but during lunch she seemed fine. On 5/8/25 at 4:12 PM, RN O indicated she was the nurse on the floor when the incident occurred on 4/21/25. RN O indicated POA is known to have anger issues and a short fuse. RN O indicated this is POA and R3's unusual dynamic. RN O indicated CNA GG reported to RN O she thought she heard yelling coming from R3's bedroom. RN O indicated RN O was by med cart and went down to R3's bedroom. The door was closed, RN O listened to see if she could hear any yelling, RN O did not hear anything and walked back to med cart. RN O indicated RN O was at med cart and saw DON (Director of Nursing) and NHA (Nursing Home Administrator) walking towards R3's bedroom. RN O indicated shortly after POA came up to RN O asking if RN O was the person that reported her. RN O indicated POA is very intimidating and had that look in her eye. RN O indicated that she has known R3 since R3 was admitted to facility and R3 has never said she is afraid of POA. RN O indicated this is the way it's always been between these two. She (POA) can get very inappropriate with her words .she's always been this way. Surveyor asked if RN O has ever observed R3 yelling and screaming at POA? RN O stated, No, I have not. Surveyor asked RN O is verbal abuse considered a form of abuse? RN O indicated Yes, absolutely. It is important to note staff did not immediately intervene when they heard alleged verbal abuse. On 5/12/25 at 8:40 AM, Nursing Home Administrator A (NHA) indicated the self report investigation occurred 4/21/25. Staff heard yelling coming from R3's bedroom. Certified Nursing Assistant GG (CNA) reported the concern to Registered Nurse O (RN). NHA A and Director of Nursing B (DON) went to R3's bedroom. NHA A indicated they watched POA exit the facility. NHA A indicated facility contacted the police, contacted Ombudsman, sent POA letter and resources on guardianship, and provided resources to R3 on Ombudsman information, interviewed staff, interviewed residents, and monitored R3. NHA A indicated they did not put interventions in Kardex or care plan because POA sees these documents. NHA A indicated all staff are educated and must follow abuse policy. NHA A indicated all staff are to follow if you see a crime you call law enforcement. NHA A indicated staff should immediately intervene if they observe alleged abuse and immediately report. NHA A indicated during investigation it was not discovered the delay in intervening. Based on interview and record review, the facility failed to immediately intervene when alleged abuse was observed for R3.

Based on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASSR) process for 2 of 5 residents (R23 and R20) reviewed for PASSR screening. R23 did not have a PASSR level I (1) completed. R20 did not have a PASSR level II (2) completed. This is evidenced by: The facility's Resident Assessment-Coordination with PASRR Program, dated 2/2025, states, in part: This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder (MD), intellectual disability (ID), or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. A. PASRR Level I-initial pre-screening that is completed prior to admission. i. Negative Level I Screen-permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen-necessitates a PASRR Level II evaluation prior to admission. B. PASRR Level II-a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs.3. A record of the pre-screening shall be maintained in the resident's medical record.6. The Social Services Director shall be responsible for keeping track of each resident's PASRR screening status, and referring to the appropriate authority. Example 1 R23 was admitted the facility on 7/26/21 with diagnoses that include dementia, depression, and mood disorder. Surveyor requested PASSR documentation. No PASSR documentation was provided. On 5/13/25 at 2:49 PM, Surveyor interviewed SW G (Social Worker) and asked if R23 had a PASSR completed. SW G stated SW G could not find any documentation of a PASSR being completed. SW G stated that PASSR should have been completed for R23. 49434 Example 2: R41 was admitted to the facility on [DATE] with diagnoses that include: delusional disorders, and restlessness and agitation. On 5/15/24, R41's PASRR level I was submitted with a documented 30-day exemption. On 5/13/25, Surveyor requested R41's PASRR level II. SW G (Social Worker) was unable to locate the document or provide documentation that a PASRR level II was completed. On 5/13/25 at 3:19 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she would expect PASRRs to be completed timely. DON B indicated, yes. Surveyor asked DON B if she would expect PASRRs to be kept within the resident's medical record. DON B indicates, yes. Surveyor asked DON B if R41 should have had a PASRR II completed. DON B indicates, yes.

Based on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This affected 1 of 5 residents (R25) reviewed for activities. Surveyor observed R25 on 5/7/25 and 5/8/25 sitting in the hallway with no meaningful activities. Surveyor observed R25 on 5/7/25 at 9:41 am positioned staring at a wall. Surveyor observed R25 again at 10:46am, 11:20am sitting in same position. R25's daily activity documentation showed R25 napped and roamed the halls most days from January 2025-May 2025. Evidenced by: The facility policy, Activities, dated, 2/25, states, in part; .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community 1. Each resident's interest and needs will be assessed on a routine basis. The assessment shall include, but is not limited to: a. RAI (resident assessment instrument) process: MDS (minimum data set)/CAA(care area assessment)/Care Plan. b. Activity assessment to include resident's interest, preferences and needed adaptations. c. Social History. d. Discharge information, when applicable. 2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Create opportunities for each resident to have a meaningful life. c. Promote or enhance physical activity. d. Promote or enhance cognition. e. Promote or enhance emotional health. f. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence. g. Reflect resident's interests and age. h. Reflect cultural and religious interests of the residents. i. Reflect choices of the residents . R25 was admitted to the facility on [DATE] with a diagnoses including dementia and abnormalities of gait and mobility. R25's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 3/24/25, indicates R25 has a BIMS (Brief Interview of Mental Status) score of 99 indicating R25 is severely cognitively impaired. R25 has an activated power of attorney. R25's care plan, states, in part; .Activities/Life Enrichment: Need for therapeutic recreation for comfort and interaction 11/16/23 .revision 2/15/24. Will actively participate in 2 activities weekly as well as weekly 1:1 visit with an activity facilitator to increase interaction with others, as evidenced by a relaxed demeanor and positive facial expressions or comments at each event .Inform pet volunteers that they can stop by residents room .Offer supplies for independent activities: offer a doll for comfort, she also has some of her own. Offer magazines and picture books. Assist outdoors as weather permits. Assist as needed. Encourage participation in group activities such as social events, happy hour (is motivated by food), music, sensory programming, pet visits, outdoor events, St. John's Lutheran services, games, and cooking/baking events. Provide with baby dolls for comfort (also has her own). Encourage participation in nail painting. Provide with weekly 1:1 visit with an activity facilitator R25's 2025 Activity Participation record, states, in part; .January: 21x (times) naps, 25x roaming hallway, 3x family visit, 1x hobbies, 3x people watching, and 1x cookies. February: 19x roaming hallways, 24x naps, 1x 1:1 visit, 5x people watching, 2x beauty shop, 2x family visits, 1x animal therapy, and 1x group. March: 23x roaming the halls, 22x naps, 6x people watching, 4x family visits, and 2x animal therapy. April: 23x roaming hallways, 18x naps, 3x family visits, 1x musical entertainment, 1x cookie cafe, and 8x people watching. May: 7x roaming halls, 9x naps, 1x nails, 4x people watching, and 1x children visit . Surveyor observed R25 sitting in wheelchair in the hallway on 5/7/25 and 5/8/25 with no meaningful activities offered. On 5/7/25 Surveyor observed R25 positioned so she was sitting staring at wall. On 5/12/25 at 3:51 PM, Activity Assistant EE (AA) indicated that R25 is not able to structure her own leisure time and needs staff support and encouragement to attend activities. AA EE indicated the documentation does not document how long the activity lasted, participation level, and enjoyment. AA EE indicated some residents are more vocal on their enjoyment on an activity. AA EE indicated if R25 is napping during an activity there isn't another option for an activity for R25. On 5/13/25 at 8:57 AM, Activity Director II (AD) indicated R25 is most happy when she can move freely, she enjoys looking out the window, sunshine, baby dolls, outside, her daughter, dog visits, and loves music. AD II indicated R25 enjoys sensory activities. AD II indicated they are working on updating their activity participation documentation and that they see there is room for improvement. AD II indicated R25 needs staff to assist her to activities and to the activity room. The facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being for R25.

Based on observation, interview, and record review, the facility did not ensure residents who receiving nutrition and medication by G-tube (Gastrostomy tube, a thin flexible tube inserted through a small incision in the abdomen and into the stomach, used to provide nutrition and fluids) receive the appropriate treatment and services. This affects 1 of 1 residents (R42) reviewed for tube feedings. The facility did not properly check placement of R42's G-tube prior to administering tube feeding. This is evidenced by: The facility's policy entitled, Care and Treatment of Feeding Tubes, dated 4/2/25, states, in part: Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . 1. Feeding tubes will be utilized according to physician orders . 4. The facility will utilize the Registered Dietitian in estimating and calculating a resident's daily nutritional and hydration needs . 6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location . a. Tube placement will be verified before beginning a feeding and before administering medications by auscultation and aspiration (use of a syringe to pull out or check content) of stomach contents . R42 was admitted to the facility on [DATE] with diagnoses that include, in part: encephalopathy (disease or disorder that affects the brain's structure or function), unspecified severe protein-calorie malnutrition, adult failure to thrive, and abnormal weight loss. R42's Admission Minimum Data Set with Assessment Reference Date of 3/18/25 indicates R42 has a Brief Interview for Mental Status (BIMS) score of 99, indicating that the interview could not be completed. Section C indicates R42 has short term and long-term memory problems and has severely impaired decision-making skills regarding tasks of daily life. Section K indicates R42 has a feeding tube. R42's Physician Orders indicate: Enteral Feed Order four times a day for nutrition. Flush feeding tube with 100 cc (cubic centimeters) of H2O (water) four times a day and 60 cc of water before and after each feeding. Start date: 4/9/25. Order status: Active. R42's Comprehensive Care Plan indicates, in part: Focus: Feeding Tube: Actual/At Risk/ and/or Potential for complications with tube feeding. Date Initiated: 3/13/25. Interventions/Tasks: Check for tube placement & gastric contents/residual volume per facility protocol and record. Hold feeding if more than 200 cc (cubic centimeters) aspirated. Date Initiated: 3/13/25. On 5/12/25 at 9:06 AM, Surveyor observed RN J (Registered Nurse) start a feeding through R42's G-tube. Surveyor observed RN J check the G-tube placement with air, but not by aspiration of stomach contents. (Of note: Facility policy and R42's Comprehensive Care Plan indicate R42 is to have gastric contents aspirated when checking for tube placement and prior to providing feeding.) On 5/12/25 at 10:48 AM, Surveyor interviewed RN J. Surveyor asked RN J if the facility required resident's gastric contents to be aspirated prior to starting a tube feeding. RN J indicated she has tried in the past but that she usually doesn't aspirate any gastric contents. Surveyor asked RN J if she should have aspirated R42's gastric contents prior to starting her tube feeding. RN J indicated yes, but she usually just uses air to test placement. On 5/13/25 at 3:13 PM, Surveyor interviewed NS C (Nursing Supervisor). Surveyor asked NS C what her expectation is for staff when checking for proper G-tube placement. NS C indicates she would expect staff to listen for air flow into the tube and aspirate gastric contents. Surveyor asked NS C if R42 should have had gastric contents aspirated prior to her tube feeding. NS C indicates, yes. On 5/13/25 at 3:19 PM, Surveyor interviewed DON B (Director of Nursing) . Surveyor asked DON B what her expectation is for staff when checking for proper G-tube placement. DON B indicates she would expect staff to flush water and aspirate gastric contents. Surveyor asked DON B if R42 should have had gastric contents aspirated prior to her tube feeding. DON B indicates, yes. On 5/16/25, NHA A (Nursing Home Administrator) provided additional information that included Chapter 17 enteral tube management- Nursing skills, that states in part: REDUCING RISK OF ASPIRATION .Measurement of gastric residual volume (GRV) is performed by using a 60-mL syringe to aspirate stomach contents through the tube. It has traditionally been used to assess aspiration risk with associated interventions such as slowing or stopping the enteral feeding. GRVs in the range of 200-500 mL cause interventions such as slowing or stopping the feeding to reduce risk of aspiration.

Based on observation, interview and record review, the facility did not comprehensively assess or develop a person-centered comprehensive care plan to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (R3) reviewed for behavior management. R3's son passed away and R3 experiences on going grief and sadness. R3 receives behavioral health services, but interventions and recommendations have not been care planned. R3 shared she has past trauma, and this has not been care planned to ensure all staff are aware and offer appropriate interventions and support. Evidenced by: R3 was admitted to the facility on [DATE] with a diagnoses including unspecified dementia, abnormalities of gait and mobility, major depressive disorder, chronic pain, unspecified mood, and other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence. R3's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 3/18/25, indicates R3 has a BIMS (Brief Interview for Mental Status) score of 11 indicating R3 is moderately cognitively impaired. R3 has an activated power of attorney. R3's Trauma Screening Assessment, dated 3/28/25, states, in part; . E. Before age 18, were you ever physically punished or beaten by a parent, caretaker, or teacher so that: you were frightened; or you thought you would be injured; or you received bruises, cuts, welts, lumps or other injuries? 1. YES .G. Has anyone ever made you or pressured you into having some type of unwanted sexual contact? 1. YES .F. Physical assault (for example, being attacked, hit, slapped, kicked, beaten up) a. Happened to me .G. Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, bomb) a. Happened to me .H. Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm) a. Happened to me .I. Other unwanted or uncomfortable sexual experience a. Happened to me .L. Life-threatening illness or injury a. Happened to me .M. Severe human suffering a. Happened to me .O. Sudden, unexpected death of someone close to you a. Happened to me . R3's Psychology appointment, dated 12/30/24, states, in part; .Necessity for referral: .Client is exhibiting maladaptive behavioral symptoms that affect functioning, client is experiencing emotional symptoms that affect functioning .Staff report R3 has been socially withdrawn, sleeping a lot more than typical, and has been tearful since the recent passing of her son .Excessive guilt endorsed. Example including feeling as though putting her son's picture in a spot where she does not see him so frequently (Trigger to distress and tearfulness) would be like me forgetting about him.Treatment Recommendations: .2. Writer will focus also on identifying ways to increase positive emotion over time using positive psychological interventions and behavioral modification .4. Writer will integrate faith-based concepts as it relates to comping [sic] and grief/loss whenever appropriate given resident's strong faith. 5. Consider having staff open her blinds daily, especially on sunny days. 6. Continue to encourage and invite resident to attend activities to serve as distraction and to reduce oversleeping during the day. 7. Consider having a roommate for R3 if possible to help increase social contact and reduce isolation. 8. She may benefit from increased spiritual service support whenever available. 9. Recommend staff respond to tearfulness and clear displays of sadness (grief) with Of course you feel this way. It is ok to feel the way you do. With the goal of providing validation and a situation where R3 may feel less inclined to withdraw into her room. 10. Given the recent loss of her son and the closeness of their relationship, R3 will need time to feel less distressed. Writer will coordinate with her PCP (primary care physician) and NP (nurse practitioner) team if her depressive symptoms persist beyond what would be expected or if depressive symptoms intensify further . R3's Comprehensive Care Plan, states, in part; .MOOD/BEHAVIOR: Actual and/or potential for complications with mood/behavior .Encourage/assist to activities of choice. Encourage resident to be out of room . R3's Kardex, states, in part; .Behavior/Mood: Observational Behavior Monitoring . It is important to note R3's care plan does not have recommended interventions from her psychology appointment to support her with her grief from losing her son. On 5/7/25 at 1:10 PM, Surveyor observed R3 laying in bed. R3 indicated her son passed away and he was the only son that lived in Wisconsin. R3 was teary eyed when she talked about her son. R3 indicated she talks to a few nurses about how she is feeling and that has helped. R3 indicated she receives services from behavior health. On 5/12/25 at 8:40 AM, Surveyor interviewed Nursing Home Administrator A (NHA) Surveyor asked NHA A if she is aware of R3's past trauma? NHA A indicated she does not know specifics of R3's trauma, but that DSS G (Director of Social Services) would be able to speak more on that. NHA A indicated R3 receives services with behavior health, and she would expect interventions to be care planned. On 5/12/25 at 3:39 PM, Director of Social Services G (DSS) indicated R3 has shared with her that she was abused by her father as a child. DSS G indicated R3 didn't elaborate or share any more information other than that. DSS G indicated recommendations and interventions made by behavior health should be care planned. DSS G indicated nursing or social services would be responsible for making sure it's care planned. The facility did not comprehensively assess or develop a person-centered comprehensive care plan for R3 to attain or maintain the highest practicable mental and psychosocial well-being regarding her past trauma or the loss of her son.

Based on observation, interview, and record review, the facility failed to ensure other alternatives were tried prior to installing/utilizing side rails. The facility failed to identify and recognize that the use of side rails with an air mattress increases the risk for entrapment for 12 of 12 residents in the facility (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12) who use a side rail and an air mattress. On [DATE], the facility implemented the use of a side rail for R1. The facility failed to ensure other alternatives were tried prior to installing/utilizing side rails/enabler device for R1. On [DATE], the facility changed R1's mattress to a Panacea Convertible Mattress with powered alternating-pressure therapy (a pump); the facility failed to complete an assessment for entrapment at this time. On [DATE], R1 became entrapped in the siderail resulting in the following three (3) fractures: 1. Left proximal humerus fracture (broken arm), 2. Right periprosthetic distal femur fracture (a break in the thigh bone just above the knee) and 3. Left prosthetic distal femur fracture (a break in the thigh bone just above the knee). R1 expired the next day. The facility currently has 11 residents (R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12) utilizing a Panacea Convertible Mattress with powered alternating-pressure therapy (a pump) together with side rails/enabler devices. The facility did not evaluate alternatives prior to installing the side rails The facility did not provide new risks and benefits to R2, R4, R5, R8, and R12 or their Health Care Power of Attorney when the facility changed their mattress and added an alternating air mattress to their bed with side rails. The facility's Bed System Measurement Device for measuring gaps caused by the use of bed rails is not recommended to be used with alternating air mattresses for R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12 and these forms did not specify a date, a bed identification, or a resident name on them. Director of Maintenance F did not complete quarterly bed/side rail measurement tests per facility policy and procedure. The facility failed to ensure other alternatives were tried prior to installing/utilizing side rails/enabler device. The facility failed to identify that the use of side rails with an air mattress increases the risk of entrapment and failed to ensure a risk and benefit is discussed with the resident or their responsible party when risks/benefits change such as adding an air mattress. The facility failed to properly assess the gaps created by the combination of an air mattress with a side rail. These failures created a finding of immediate jeopardy that began on [DATE]. Surveyor notified the facility of the finding of immediate jeopardy on [DATE] at 2:30 PM. The Immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a severity/scope of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. This is evidenced by The Center for Devices and Radiological Health Guidance for Industry and FDA (Food and Drug Administration) Staff, Hospital Bed System Dimensional and Assessment to Reduce Entrapment, dated [DATE], documents, in part, as follows: Pressure Reduction Therapeutic Products Framed flotation therapy beds, powered air mattress replacements, and similar pressure reduction products that have therapeutic benefits such as reducing pressure on skin are easily compressed by the weight of a patient and may pose an additional risk of entrapment when used with conventional hospital bed systems. When these types of mattresses compress, the space between the mattress and the bedrail may increase and pose an additional risk of entrapment. While entrapments have occurred with the use of framed flotation therapy beds (specialty air beds built into a hospital bed frame) and air mattress replacements, these products are excluded from the dimensional limit recommendations, except for those spaces within the perimeter of the rail. This partial exemption is due to the highly compressible nature of these mattresses, which poses technical difficulties with measuring certain dimensional gaps in these types of products. We will continue to work with the IEC (The International Electrotechnical Commission issues standards for the safety and performance of medical electrical equipment including air mattresses) to develop and refine test methods to address the risk of entrapment in bed systems using these products. Additional caution should be taken when using these products to ensure a tight fit of the mattress to the bed system. If a powered air mattress is replacing a mattress on a bed system that meets the recommendations in the guidance with the original mattress, the resulting bed system with the new air mattress may still pose a risk of entrapment. When these products are used, we recommend that steps are taken to ensure that the therapeutic benefit outweighs the risk of entrapment. NOTE: FDA continues to recommend the dimensional limits in this guidance for bed systems using mattress overlays. We recommend that steps be taken to assess the therapeutic benefit to the patient when applying a mattress overlay to a bed system that does not meet the recommended dimensional limits. The clinical benefit should outweigh the risk of entrapment presented by use of such a system. Potential Zones of Entrapment This guidance describes seven zones in the hospital bed system where there is a potential for patient entrapment. Entrapment may occur in flat or articulated bed positions, with the rails fully raised or in intermediate positions. The seven areas in the bed system where there is a potential for entrapment are . Zone 1: Within the Rail Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support Zone 3: Between the Rail and the Mattress Zone 4: Under the Rail, at the Ends of the Rail Zone 5: Between Split bedrails Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board Zone 7: Between the Head or Foot Board and the Mattress End Entrapment at the Bed Deck or Frame Many of the entrapment event reports FDA received involved entrapment between the rail and the bed ' s frame. It is unclear from the event descriptions whether this refers to the mattress deck, the bed frame, or even the hardware attaching the bedrail to the bed system. While this guidance does not recommend dimensional limits on the space at the deck or frame locations, FDA believes that meeting the other recommended dimensional limits would reduce the possibility of entrapment at the deck or frame locations. The manufacturer guidelines for the Panacea Convertible Mattress with powered alternating-pressure therapy, documents, in part, the following: Alternating-Pressure cycle - provides 10-minute loading and unloading cycles designed to relieve peak interface pressures. Warnings: Failure to comply with all directions and warnings may result in injury or death; use only as directed. Note - This product is designed to assist in the prevention and treatment of pressure ulcers and may require other equipment. This may include but is not limited to bedrails for repositioning and fall prevention. Note - This product is only one element of care in the prevention and treatment of pressure ulcers by medical professionals and skilled caregivers to assist in the treatment and prevention of up to Stage IV (4) decubitus ulcers (pressure injuries) for residents under their care. This product is not designed to and cannot replace good care giving practices and treatment, including but not limited to: .Adequate training for a precaution by staff personnel for bed entrapment. The facility policy, Devices and Device Assessment, reviewed ,d+[DATE], documents, in part, as follows: Due to risk of injury related to the use of physical devices, such devices will only be used after an assessment has been completed to determine the risks and benefits of this use. The resident/responsible party will be educated regarding the risk and benefits of physical devices. Physical devices will be reviewed for safety and used according to manufacturer's recommendations. Continued use of physical devices will be assessed at least every 90 days or with significant change to determine if the device is still needed to enhance the resident's safety and/or bed mobility. Devices will be installed as appropriate for the type of bed: For hospital beds: Device will be installed per FDA (Food and Drug Administration) guidelines. For non-hospital beds: Devices will be installed according to the device manufacturer's instructions. Documentation will be entered in the resident's record to include Results of the assessment; Discussion with resident/responsible party regarding risks and benefits and alternatives considered/recommended; Decision made/outcome of discussion. Information from FDA Regarding Side Rails: In 2006 the Food and Drug Administration (FDA) released its recommendations for reducing entrapments. The FDA identified seven zones of entrapment and recommended maximum dimensions for four of the zones. Zone 1: Within the Rail (4.75); Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support (4.75); Zone 3: Between the Rail and the Mattress (4.75) 1.R1 was admitted to the facility on [DATE] with diagnoses including, dementia-severe without behavioral disturbance (an advanced stage of cognitive decline where significant impairment in memory, language, reasoning and daily functioning occurs), reduced mobility (reduced ability to move), osteoporosis (a condition in which bones become weak and brittle), cerebrovascular disease (a condition that impacts the brain's blood vessels and blood supply). R1 was incapacitated on [DATE]. R1's has an APOAHC (Activated Power of Attorney). On [DATE] R1's initial APOAHC signed Half Side Rail/Bed Bar Informed Consent that document as follows: An assessment was conducted to determine the appropriateness and need of either a half side rail or bed bar for you. A half side rail or bed bar is a metal or plastic bar that is attached to the side of the bed. A half side rail is approximately one quarter of the length of the bed and a bed bar is approximately one eighth of the length of the bed. Potential benefits of a half side rail or bed bar includes Facilitates turning and repositioning within the bed; Facilitates access to bed controls and personal care items. In some instances, half side rails or bed bars present an inherent safety risk. Potential risk include: *Strangulation, suffocation, entrapment or death when a resident or part of his/her body is caught between the bedrail or between the bedrails and the mattress and the opening of the rails *Serious bodily injury from falls if a resident climbs over the half side rail or bed bar; *Bruising, abrasions, contusions, skin tears; and *Negative psychological effects and altered resident self-esteem There was no evaluation of alternatives to the use of a side rail at this time. R1's Minimum Data Set with an ARD (Assessment Reference Date) of [DATE], documents a BIMS (Brief Interview of Mental Status) score of 3, indicating R1 is severely cognitively impaired. R1 is totally dependent on staff for ambulation, transferring, bathing, dressing, and toileting. Section P, Restraints, documents R1 does not use a bedrail. R1's comprehensive care plan, dated [DATE], documents the following: Focus: Devices - Safety/Mobility: At risk for injuries/complications R/T (related to) use of ,d+[DATE] Side Enabler Bar on Top; Both sides; to help promote independence with bed mobility and to aid in holding sitting position at side of bed. (Date Initiated: [DATE]; Date Revised: [DATE]) Goal: Will be free of serious injuries/complications r/t device use through next review. (Date Initiated: [DATE]; Revised [DATE]) Intervention: Device Assessment upon application/admission, quarterly, SCC (Significant Change) and/or PRN (as needed); Monitor/Observe/Document application of device, device use, behavior r/t (related to) device and review observations/concerns with MD (Medical Doctor).; IDT (Interdisciplinary Team) review of Device placement for continued appropriateness per facility protocol. (Date Initiated [DATE]). The facility has a Resolved Care Plan entry: Uses upper ,d+[DATE] rail to enable bed mobility. (Date Initiated: [DATE]; Revision on: [DATE]; Resolved Date: [DATE]). Note, it is unknown why the facility discontinued the comprehensive care plan entry of ,d+[DATE] siderails to R1's bed on [DATE] when the side rails were still in place at the time of the entrapment. R1's comprehensive care plan, dated [DATE], documents as follows: Actual/At Risk/and/or Potential for Complications with OR fall R/T (related to) current medical/physical status. Has med's/[NAME] (medications/diagnosis) that can/may affect fall risk. Resident transfers with EZ lift (Note, staff confirmed EZ Lift is total body lift) (Date Initiated: [DATE]; Goal: Will be free of falls, but if does, will be free of serious injuries r/t falls through next review date. (Date Initiated: [DATE], Target Date: [DATE]); Interventions: Bed in low position; Call light positioned for easy access; Check for unmet needs: pain, toileting, hunger, thirst, temperature; Ensure environment is free of clutter On [DATE] the facility put a Panacea Convertible Mattress with an optional alternating-pressure pump in use for R1. It is important to note, this is the same air mattress and pump the facility puts in place for all residents that require an air mattress. The facility failed to identify that the use of side rails with an air mattress increases the risk of entrapment; subsequently, the facility did not complete a new assessment at the time a powered alternating-pressure air mattress was utilized for R1. The side rail in use since R1's admission is Invacare Model IHCSRLAS. This side rail has three (3) vertical bars and two (2) horizontal bars. On [DATE], facility staff (this staff member has since retired) completed Bionix Safety Technologies (Food and Drug Administration Approved) for R1's air mattress and bedrail in use together. On [DATE] the inspection documents the air mattress with a pump together with a bedrail Passed safety inspection. It should be noted based on the FDA Staff, Hospital Bed System Dimensional and Assessment to Reduce Entrapment, Pressure Reduction Therapeutic Products Framed flotation therapy beds, powered air mattress replacements, and similar pressure reduction products that have therapeutic benefits such as reducing pressure on skin are easily compressed by the weight of a patient and may pose an additional risk of entrapment when used with conventional hospital bed systems. When these types of mattresses compress, the space between the mattress and the bedrail may increase and pose an additional risk of entrapment. While entrapments have occurred with the use of framed flotation therapy beds (specialty air beds built into a hospital bed frame) and air mattress replacements, these products are excluded from the dimensional limit recommendations, except for those spaces within the perimeter of the rail. This partial exemption is due to the highly compressible nature of these mattresses, which poses technical difficulties with measuring certain dimensional gaps in these types of products. On [DATE] R1's Fall Risk Screening documents: R1 is at Slight risk due to intermittent confusion On [DATE] R1's Enabler/Safety Device Use Tool documents the following: Reason for review: Quarterly Type of Device: Rails Reason for use: Safety Status -Cognitive Status: Confusion -Behavioral Status: Other -Additional Information: No behaviors -IDT (Interdisciplinary Team) Potential Benefits: Increased feeling of safety Potential Risks: Increased-Falls Device Use - Is the device considered a restraint: No *Device Use - Considered beneficial to individual: No IDT (Interdisciplinary Team) Discussion: Uses the side rail for bed mobility Of note, R1's most recent fall prior to the entrapment (below) was in [DATE]. No injuries. On [DATE] around 4:07 AM, R1's Progress Notes document the following: CNA C (Certified Nursing Assistant) heard yelling from R1's room. R1 was yelling as she was on the ground. Her roommate was yelling because she heard R1 yelling. Upon entering their room, CNA C found R1 on the floor on her fall mat. R1 was facing the wall. Her right arm was holding onto the assist bar, while her left arm was between the mattress and the assist bar. (Note, R1's left arm that was entrapped sustained a left proximal humerus fracture.) Her legs were under her on the mat. R1 had her foam boots on. Her blankets were on the floor and her arm protectors were off. It was also noted there was blood on the floor near her nightstand. CNA C immediately called for the nurse on duty. LPN D (Licensed Practical Nurse) assessed R1 and noted, that R1 had a large mole on her right upper arm that was ,d+[DATE] off and bleeding. It was also noted that there was bruising on the top of her left hand. LPN D then called for an ambulance to send R1 to the emergency room for further evaluation. R1's family member (name) and NP (Nurse Practitioner name) were notified. X-rays were completed at the hospital indicating a nondisplaced proximal left humerus fracture, a slightly displaced fracture of the right distal femoral metaphysis and a significantly displaced fracture of the left distal femoral metaphysis. R1 reported, I was trying to get up. I've been laying in this bed since 10:00 PM and I want to go home. Immediate Action Taken: Call placed to family member. Resident sent to ER (emergency room ) for further evaluation and treatment. Resident taken to hospital: Y (Yes) Injuries Observed at Time of Incident Fracture Right thigh (front) Fracture Left thigh (front) Fracture Left Upper Arm Hematoma Left hand (palm) Skin Tear (Right Upper Arm Level of Pain: 1 Level of Consciousness: Alert Mobility: Wheelchair bound Mental Status: Baseline for Individual emergency room Visit/hospitalization Notes: Has a large mole on her right outer arm that is ,d+[DATE] off and is bleeding. Bruising on the top of her left hand. Resident is unable to tell pain. Injuries Reported Post Incident: Other: Right antecubital Level of Pain: Blank (R1 is unable to voice) Level of Consciousness: Alert Mobility: Wheelchair bound Mental Status: Oriented to Place, Oriented to person Predisposing Environmental Factors: None Predisposing Physiological Factors: Confused, Gait imbalance, Impaired Memory Predisposing Situation Factors: Ambulating with Assist; Side Rails up Other Info: Staff are unaware of why or how she got out of bed as she has not self-ambulated in multiple years. Agencies/People Notified: Family Member and Nurse Practitioner R1's hospital ED (Emergency Department) report documents, in part, as follows: R1 arrived to the hospital at 4:51 AM. Skilled nursing facility resident who sustained an unwitnessed fall at her skilled nursing facility. The patient was found to have rolled out of bed, and she was propped between the bed and her nightstand. (Note, NHA A, stated, per staff interviews, this information is incorrect.) The patient was brought to the ED for evaluation. Imaging studies were obtained, which indicated a right periprosthetic distal femur fracture, a left periprosthetic distal femur fracture (a break in the thigh bone just above the knee), and a left proximal humerus fracture (broken arm). Orthopedic Surgery was consulted for further evaluation and treatment of the patient. The patient is currently noncommunicative due to neurocognitive disorder. No other problems are reported. Assessment: 1. Left proximal humerus fracture 2. Right periprosthetic distal femur fracture 3. Left prosthetic distal femur fracture Plan: R1 is a skilled nursing facility resident who sustained an unwitnessed fall with resultant bilateral periprosthetic distal femur fractures and a nondisplaced left proximal humerus fracture. Per report, the patient is relatively bedbound. In addition, the patient has very significant neurocognitive disability. After discussion with the patient's family member, who is also the patient's power of attorney, the family wishes to pursue nonoperative intervention for the patient's lower extremity fractures and provide comfort measures only. Given the patient's overall medical condition, this is completely acceptable. Both lower extremities will remain in knee immobilizers, and left upper extremity will remain in a sling. Comfort measures will be provided. On [DATE] at 11:35 AM, R1 was discharged back to the facility. On [DATE] (after the incident), the facility completed Bionix Safety Technologies testing for R1's air mattress and bedrail in use together. On [DATE] the inspection documents the air mattress with a pump together with a bedrail Passed safety inspection. However, the facility made the decision to remove the side rail from R1's bed upon her return from the hospital ED. On [DATE] at 6:00 AM, LPN D (Licensed Practical Nurse) documented the following Progress Note: CNA had turned her at 4:20 AM. Night CNA asked day to help turn her and they walked in her room. They called nursing to her room as she had no pulse, no BP (blood pressure). On [DATE] at 6:30 AM, LPN D (Licensed Practical Nurse) documented the following Progress Note: Situation: Found with no BP or pulse Background: Had a fall 24 hours ago and came back comfort care On [DATE] at 6:10 AM, LPN D (Licensed Practical Nurse) documented the following Progress Note: R1's family members were called and told about her passing away. The daughter wants us to hold off calling funeral home until she processes all of this. On [DATE], Physician/Medical Director E documented the following information to NHA A (Nursing Home Administrator) via email: Case Review 2025.01 Sources: Epic; references; PCC (Point Click Care/Electronic Health Record) chart inaccessible- *The fracture was pathologic (significantly due to osteoporosis) *The fracture was traumatic (significantly due to a fall from bed height) *The fracture had other causes (there were no signs the resident asked for help) *The fracture was a cause of death (were it not for the fracture .) *The fracture was not the only cause of death (were it not for the dementia and frailty .) *The alarm, mats, and side rail did not clearly contribute to the fracture. *Opinions expressed are to a reasonable degree of medical certainty and subject to revision if additional information becomes available. On [DATE] at 11:15 AM, Surveyor spoke with CNA C (Certified Nursing Assistant). CNA C stated she was completing rounds at approximately 4:,d+[DATE]:20 AM when she heard R1 hollering, and she immediately went to check on R1. CNA C stated, she observed R1 on the red floor mat next to her bed with her legs under her. CNA C added, R1 was facing the wall (in front of her) with one arm stuck (entrapped) in the railing and the other arm was holding onto the railing. CNA C stated, she cannot recall which arm was tangled (entrapped). CNA C stated, she hollered for LPN D (Licensed Practical Nurse). CNA C stated, LPN D came to R1's room right away. CNA C stated, we got a pillow and laid R1 down on the mat. CNA C stated, R1 was crying in pain, stated she was hungry wanted to get up out of bed because she has been in bed since 10:00 PM. CNA C stated, the facility put the fall mat intervention in place in ,d+[DATE] when R1 last fell . Surveyor asked CNA C, is R1 able to make movement on her own. CNA C stated, no, not for a long time since she last fell on ,d+[DATE], and we put the fall mat in place as an intervention. Surveyor asked CNA C if she had noticed R1 acting differently recently over the past week or so. CNA C stated, no. CNA C stated, R1 would use siderails when staff would check and change her. On [DATE] at 1:15 PM, Surveyor spoke with LPN D (Licensed Practical Nurse). Surveyor asked LPN D to describe what happened when R1 was found on the floor on [DATE]. LPN D stated, CNA C (Certified Nursing Assistant) had just finished rounds on 1 wing when LPN D and CNA C both heard R1 start calling out. LPN D stated, CNA C immediately responded to R1 calling out. LPN D stated, it is not uncommon for R1 to yell out that she wants to go home or to go see her mother. LPN D stated, CNA C found R1 on the floor mat on her knees and called out for LPN D. LPN D stated, R1's left arm was stuck down about 1 inch in between the siderail and the mattress with her right arm in front of her holding onto the side rail. LPN D stated the side rail was in the up and correct position. LPN D stated, she needed to move the bed up (as it was in the lowest position) in order to disengage the side rail. Emphasis Intended. LPN D stated, she was then able to get R1's arm out from being entrapped in between the mattress and side rail. LPN D stated, when she asked R1 if she has any pain. R1 pointed to her left shoulder. LPN D stated, R1 looked like she had a little pain. LPN D stated, she and CNA C laid R1 down on the mat to assess. LPN D stated, a different nurse contacted R1's APOAHC (Activated Power of Attorney for Health Care) while she stayed with R1. LPN D stated, R1 was then immediately sent to the hospital ED (emergency department). LPN D stated, she heard R1 yell when the EMT's (Emergency Medical Technicians) put her on the stretcher. LPN D stated, all of R1's care plan interventions were in place at the time of this accident. LPN D stated, she observed R1 to be sleeping when she passed water just a short time before the fall. LPN D was also working at the time R1 passed away on [DATE], 24 hours after the entrapment and fall with fractures. LPN D stated, on [DATE] R1 was found pulseless and not breathing. LPN D stated, this experience has been very traumatic for her as well. On [DATE] at 4:45 PM and 5:00 PM, Surveyor spoke with NHA A (Nursing Home Administrator) and DON B (Director of Nursing). Surveyor asked NHA A, what date was R1's side rails put in place. NHA A stated, R1's side rails were likely in place since admission to the facility. NHA A added, the facility previously did not remove side rails when residents discharged . Therefore, any newly admitted residents automatically have a side rail(s) that was in place for the previous resident. The facility identified this as a deficient practice and is addressing it in QAPI (Quality Assurance Process Improvement). Surveyor asked NHA A and DON B, what alternatives were attempted prior to utilizing a bedrail. NHA A stated, the facility has no prior alternatives documented. NHA A stated, alternatives attempted should have been documented and the facility is working to correct this for other residents via the Therapy Department. NHA A stated the Therapy Department is about ,d+[DATE]rds of the way through screening all 48 residents. Surveyor asked NHA A and DON B, when the air mattress was put in place on [DATE], should an assessment have been completed at that time. (Note, the assessment was not completed until [DATE].) NHA A stated, yes. 2. R2 admitted to the facility on [DATE] with the following diagnoses: malignant neoplasm of the prostate, encounter for palliative care, age related osteoporosis, and polyneuropathy. R2's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of [DATE] indicates R2's cognition is moderately impaired with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. R2's MDS also indicates he is dependent on staff to meet his needs in toileting, rolling from left to right, going from lying to sitting, going from sitting to lying, and transfer bed to chair or chair to bed. R2's informed consent for bed rails, signed [DATE], includes potential benefits of a half side rail . in some instances half side rails or bed bars present an inherent safety risk. Potential risks include strangulation, suffocation, entrapment, or death when a resident or part of his or her body is caught between the bed rail or between the bed rails and the mattress and the opening of the rails . serious bodily injury from falls if a resident climbs over the half side rail or bed bar . Bruising, abrasions, contusions, skin tears, and negative psychological effects . and altered resident self-esteem . (It is important to note the facility did not provide evidence of alternative interventions being tried prior to the installation of the bed rails.) R2's Comprehensive Care Plan, includes revision date [DATE] bed mobility- independent, assist of 1 to 2 if weak . R2's Medical Record indicated an alternating air mattress was added to R2's bed on [DATE]. (It is important to note adding an alternating air mattress to a bed with side rails changes the risks and a new informed consent form describing the new risks and benefits of using the side rails with the alternating air mattress was not given to R2 or his activated Health Care Power of Attorney.) R2's Bed System Measurement Device Test Results Worksheet, undated, includes Bed ID: (blank) . Bed make- (blank) . Model-(blank) . Barcode- (blank) . Mattress make- (blank) . Mattress Model- (blank) . Left zone 4- pass, zone 2 pass, zone 4 pass . Right zone 4 pass, zone 2 pass, zone 4 pass . (It is important to note there is no resident name, no bed identification and no date on this form. It is also important to note this system of testing is not recommended to be used with alternating mattresses as the air in the cells shifts when weight is applied.) On [DATE] at 8:43 AM Surveyor observed R2's room including his bed. R2's bed had an alternating air mattress and bedrails that reached ,d+[DATE] of the way down his bed. 3. R3 admitted to the facility on [DATE] with the following diagnoses: unspecified dementia, abnormality of gait, open wound . R3's informed consent for bed rails, signed [DATE], includes potential benefits of a half side rail . in some instances half side rails or bed bars present an inherent safety risk. Potential risks include strangulation, suffocation, entrapment, or death when a resident or part of his or her body is caught between the bed rail or between the bed rails and the mattress and the opening of the rails . serious bodily injury from falls if a resident climbs over the half side rail or bed bar . Bruising, abrasions, contusions, skin tears, and negative psychological effects . and altered resident self-esteem . (It is important to note the facility did not provide evidence of alternative interventions being tried prior to the installation of the bed rails.) R3's Medical Record indicates an alternating air mattress was added to her bed on [DATE] (on admission). Bed System Measurement Device Test Results Worksheet, undated, includes Bed ID: 251 . Bed make- (blank) . Model-(blank) . Barcode- (blank) . Mattress make- (blank) . Mattress Model- (blank) . Left zone 4- pass, zone 2 pass, zone 4 pass . Right zone 4 pass, zone 2 pass, zone 4 pass . (It is important to note there is no resident name and no date on this form. It is also important to note this system of testing is not recommended to be used with alternating mattresses as the air in the cells shifts when weight is applied.) R3's most recent MDS with ARD of [DATE] indicates R3's cognition is severely impaired with a BIMS score of 7 out of 15. On [DATE] at 8:48 AM Surveyor observed R3's room including her bed. R3's bed had an alternating air mattress and bedrails that reached ,d+[DATE] of the way down her bed. 4. R4 admitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus and unspecified mental disorder. R4's most recent MDS with ARD [DATE] indicates R4's cognition is severely impaired, and he never or rarely makes decisions. R4's informed consent for bed rails, signed [DATE], includes potential benefits

Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident did not develop a pressure injury (PI) and that the resident received necessary treatment and services to promote healing and prevent infection of the pressure injury for 2 of 4 residents sampled for pressure injuries (R2 and R9). R2 had a history of pressure injuries and was at risk for PI development. The facility failed to implement aggressive measures upon admission, failed to update R2's MD timely when a new pressure injury developed, failed to re-evaluate interventions that were not working, failed to update the care plan timely, failed to complete diabetic foot checks per current standards of practice, and failed to use R2's offloading boots per manufacturer's guidelines. The facility did not consider changing course of action when 3 of R2's Medical Doctors noted the wound to be caused by pressure. R2 developed an infected stage IV PI. It should be noted thoroughout R2's medical record there is conflicting documentation regarding the causative factor of R2's wounds. R2 had a diagnosis of diabetes and some providers called the heel ulcers diabetic ulcers where others called it pressure ulcers. Interviews suggest there is likely a component of both. Obesrvations and interviews during the survey support a pressure related causative factor thus determining citation under 686. The failure of the facility to prevent the development of a PI for an at-risk resident, failure to conduct diabetic foot checks per current standards of practice, failure to implement R2's offloading boots per manufacturer's guidelines, failure to re-evaluate the use of pillows for offloading when they were not working, failure to update R2's care plan timely, and failure to update R2's MD with a new open wound resulted in R2 developing a Stage 4 PI, which became infected requiring antibiotic therapy and surgical intervention. This created a situation of Immediate Jeopardy which began on 1/3/23 when R2's stage 4 PI became infected. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were formally notified on 2/22/23 at 4:25 PM that an Immediate Jeopardy situation existed. The immediate jeopardy was removed on 2/21/23. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. Evidenced by: The facility policy titled Wound Care Guidelines, dated 2/05, includes, in part: .Each resident will be assessed on admission and will have a personalized skin care plan to address skin care needs including preventative care. Weekly assessments and documentation of all wounds will include: the specific location of the ulcer the stage of the ulcer the presence of exudate or drainage or odor, the length width and depth of wound in centimeters, the frequency of dressing changes and what products are being used to treat the wound, the progress, deterioration, or the development of new problems . for heels: apply topical agent to toughen the skin . goal is to keep skin dry . offload heels with foam boots or pillows under ankles . Stage 2 pressure ulcer / partial thickness / skin tear / blister: loss of skin involving the epidermis and possibly the dermis, May see blistering: protect area from undue stress and or pressure, keep the surrounding skin dry, soft, and supple. For ankle or foot wounds: prompt attending physician for Podiatry consult . If necrotic or covered with 20% or greater slough . stage 3 pressure ulcer/full thickness: tissue loss involving subcutaneous tissue but not muscle or bone . stage 4 pressure ulcer/full thickness: deep tissue destruction involving muscle, bone, and fascia. May see draining and necrosis . . (It is important to note the outdated information found in this policy, including slough under the definition of stage 2 as in current standards slough in wound bed indicates stage 3 wound.) Genesis 111 Mattress Manufacturer's Information, undated, includes: 5 inch-Pressure reducing support surfaces are a type of medical equipment used for the care of pressure sores, also known as pressure ulcers or injuries. Pressure ulcers are lesions caused by constant pressure on areas in contact with the mattress, resulting in damage of skin and deep tissues. Some pressure reducing mattresses are powered by electricity (known as powered pressure-reducing air mattresses) and others are not. They replace a standard hospital or home mattress and are either integrated to or placed on a hospital bed frame. Powered pressure reducing mattresses have a surface designed to reduce friction and shear through technologies know as alternating pressure, low air loss, or powered flotation without low air loss. They have a pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress. They are indicated for persons with deeper pressure ulcers (stage II, III or IV) or after surgery, for persons who received a flap or skin graft to cover a wound. Weight Capacity: 350 Pounds Heel Lift Classic Suspension Boot Manufacturer's Information, undated, includes: . suspends the heel to prevent pressure injuries with superior customizability . Application Instructions - Place the foot inside of boot with the heel resting above the opening . Thread straps through the D-rings and secure straps back together . Test the fit under heel opening. Ensure no straps touch the skin . Heel Lift Classic Suspension Boot Customization Instructions Video includes: .Make sure the heel is positioned directly above the opening . To avoid Achilles tendon irritation: cut a v shape into the fixed pad . Carefully place foot in boot making sure the heel is properly centered above the heel opening. The National Pressure Ulcer Advisory Panel's Pressure Ulcer Prevention Points, updated 2007, include: Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed. Place heel suspension boots for long-term use . Use a written repositioning schedule .Perform a head-to-toe skin assessment at least daily, especially checking pressure points such as sacrum, ischium, trochanters, heels, elbows, and the back of the head . Implement pressure ulcer prevention educational programs that are structured, organized, comprehensive, and directed at all levels of health care providers, patients, family, and caregivers. Include information on use of support surfaces . Ensure that the heels are free from the bed . R2 was admitted to the facility on [DATE] following a 10-day hospital stay that included surgical repair of a displaced spiral fracture of the shaft of R2's left femur. R2's medical diagnoses included Type 2 Diabetes Mellitus with diabetic polyneuropathy and nephropathy, reduced mobility, abnormality of gait and mobility, postprocedural complications and disorders of the circulatory system, and age-related osteoporosis. R2's Hospital Discharge Worksheets, dated 10/19/22, include, in part: R2 lives at home with his wife . uses a walker . He tripped, fell at home, and suffered left distal femur displaced periprosthetic fracture. On 10/11/22 an open reduction and internal fixation of left periprosthetic fracture was performed. Elevate surgical leg while resting . post-operative medical devices to be removed daily for head-to-toe skin assessments . if alterations in skin integrity is found, notify R2's MD, document, clean, and dress per standing wound orders . Offload pressure always. He tolerated procedure well . Gluteal cleft wound . Coccyx has sore dark area, un-blanchable 12cm x 9cm with 1cm x 2cm open area . R2 was found to be medically and orthopedically stable but inappropriate to return home independently, therefore, is being transferred to nursing home for short term care and therapy. R2's Norton Plus Skin Risk Assessment Scale includes, in part, the following: Key - 10 or below is high risk 10/19/22 - R2's Norton score 5 - at high risk for skin breakdown R2's Closet Care Plan, dated 10/19/22, includes Offload heels with boots or pillows under ankles . Document refusals . Turn/Reposition Schedule: Turn and reposition on night rounds . Naps as needed . float heels . elevate left lower extremity but do not place pillow directly under knee . CNAs Check heels/feet AM and PM . (It is important to note the facility did not provide evidence of diabetic foot checks being completed.) R2's Initial Skin Assessment, dated 10/21/22, includes Skilled Nursing observation completed for entire body with focus over bony prominences. The following skin problems noted: open areas by coccyx, surgical incisions, bruising abdomen, needs panacea mattress in the morning. R2's MD Progress Note, dated 10/25/22, includes, in part: . seen today for follow up for coccyx wound and anal pain . continue offloading and daily wound care until healed . likely pain from pressure on coccyx wounds while seated. Reposition and is using a foam cushion on chair. R2's Norton Plus Skin Risk Assessment Scale includes, in part, the following: Key - 10 or below is high risk 10/26/22 - R2's Norton score 5 - at high risk for skin breakdown R2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/22 states R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R2's MDS also indicates R2 requires the extensive physical assistance of two or more staff to meet his needs in bed mobility, toileting, dressing, and personal hygiene. R2's MDS indicates he is totally dependent on two or more staff to meet his needs in transfer. In addition, the MDS indicates R2 is frequently incontinent of urine, always incontinent of stool, and is at risk for pressure injury development. R2's MDS indicates he did not have any unhealed pressure injuries, venous, or arterial injuries and needs a pressure reducing device for chair and bed and a turning/repositioning program. (It is important to note the stage 2 pressure injury of the coccyx that R2 admitted with is not captured on this MDS.) R2's Nurse Note, dated 10/27/22, include large clear fluid filled blister . right heel . Blue boot applied. The heels have been floated on the PM shift when nurse checked over the past few days. On 2/20/23 at 2:01 PM, Surveyor interviewed RN L (Registered Nurse) regarding R2's pressure injuries (PI.) RN L stated, R2 had pillows to float heels until 10/27/22, but I put a blue boot on the right heel when I was made aware of the first blister. He was on pressure relieving foam mattress on 10/21/22 and I worked late so I left a note for morning shift and housekeeping to replace it with a low air loss mattress. I did not update R2's Care Plan. I should have. (Of note, RN L only placed the heel lift boot on the right heel. Approximately 2 weeks later R2 developed a PI on the left heel.) On 2/21/23 at 10:19 AM, Surveyor interviewed CNA Q (Certified Nursing Assistant) regarding R2's pressure injuries to the heels. CNA Q stated, We were using pillows at the beginning, but his feet were sliding off onto the mattress and he got heel ulcers. Now we use boots. Surveyor asked CNA Q if he notified anyone the pillows were not effective in offloading the heels. CNA Q stated he was sure nursing staff were aware the pillows were not keeping R2's heels off the mattress. R2's Norton Plus Skin Risk Assessment Scale includes, in part, the following: Key - 10 or below is high risk 11/2/22 - R2's Norton score 7 - at high risk for skin breakdown R2's Nurses Notes, dated 11/8/22, include fluid filled blister on left heel R2's Nurses Notes, dated 11/9/22, include left heel 2.5cm (centimeters) x 3.0cm, intact serous filled blister on left heel . right heel blister is now fully absorbed. Resident has been wearing boots in bed - unsure of cause of blister . Calvon applied. Boots remain in place at all times . Will monitor . R2's Nurses Notes, dated 11/14/22, include left heel blister 4.7cm x 5.5cm x superficial . roof of blister came off . small amount of serous exudate . MD (Medical Doctor) updated. (It is important to note this is the first time R2's MD is updated regarding new open areas on heels.) R2's MD Progress Note, dated 11/22/22, includes Active problems - gluteal cleft wound present on admission, blister on right heel (R2) has had edema to both lower extremities. (It is important to note, R2's MD does not mention R2's open wound to his left heel in this note.) R2's Nurses Note dated 11/22/22, includes left heel blister 4.3cm x 4.6cm continue same treatment . right heel blister - 4.0cm x 4.9cm, blister is resolving . foam boots to offload heels . (It is important to note the wounds are measured but there is no other description of the wounds.) R2's MD Progress Note dated 11/25/22-11/28/22, includes, in part: .was recently hospitalized [DATE]-[DATE] for a left distal displaced periprosthetic fracture which required surgical intervention. Unfortunately, during his stay, he was found to have an acute on chronic congestive heart failure exacerbation with elevated tropin levels and acute post procedural atrial fibrillation . final diagnosis - . wound on left and right heel, wound on left leg, recent femur fracture with surgical repair . Blister of left and right heel: evidence of delayed healing, with likely component of pressure injury and edema skin break down. No surrounding erythema or evidence of infection. Leg eschar loosened 11/27/22. Wound emphasis . included offloading the area, and keeping it clean and covered with mepilex . R2's MD Progress Note, dated 11/29/22, includes Blister of left and right heel: evidence of delayed healing, with likely component of pressure injury and edema skin breakdown. No surrounding erythema or evidence of infection. Leg eschar loosened on 11/27/22. Wound care emphasis . included offloading the area and keeping it clean and covered with mepilex . Left heel ulcer - not hurting unless handled. He is wearing his offloading boots . Bilateral heel ulcer per wound team Left - 6cm x 4cm dry blister with 2cm x 2cm dark central small bleeding . Right - 2 cm x 2cm blister opened with small bleeding. Wounds dressed with Aquacel Ag and Mepilex and offloaded. Assessment/Plan - blister of left heel subsequent encounter: continue offloading and daily wound care . R2's Nurses Notes, dated 11/29/22, include has dark spot within left heel blister 1.8cm x 1.8cm. R2's Closet Care Plan, dated 12/12/22, includes Offload heels with boots or pillows under ankles . Document refusals . Turn/Reposition Schedule: Turn and reposition on night rounds . Naps as needed . float heels . elevate left lower extremity but do not place pillow directly under knee . Foam boots bilateral when in bed . Foam boots on for protection except with transfers . CNAs Check heels/feet AM and PM . (It is important to note this is the first time R2's boots show up on his Care Plans (12/12/22). Also, important to note the facility did not provide evidence of diabetic foot checks being completed.) Nurses Note dated 12/13/22, includes: .left heel peripheral neuropathic wound . DON B (Director of Nursing), ADON C (Assistant Director of Nursing) and Dietician all present. Left heel 2.6 cm x 3.5 cm, eschar plate 95% . left heel again 3.0cm x 3.5cm eschar plate measures 2.5 cm x 2.0 cm . Updated NP (Nurse Practitioner) R2's MD Progress Note dated 12/14/22, includes: .alert and oriented x 4 . alert, cooperative, and pleasant . open wound of left heel (primary encounter diagnosis) . the eschar plate was about 95% covering the wound. Necrotic odor was noted . I debrided the wound . No pain during procedure and very minimal bleeding was observed. The majority of the plate was removed, and the remaining residual was scored . Change wound orders to apply Santyl, cover with Aquacel, followed by Mepilex. Change wound dressing daily . R2's Nurses Notes dated 12/19/22, include: 4.0cm x 4.8cm eschar necrotic odor noted . Updated NP . R2's MD Progress Note, dated 12/23/22, includes: .seen today for follow up for nonhealing left heel ulcer, for possible debridement and wound culture as reported by staff. Skin: left heel ulcer is approximately 5cm in diameter, is completely covered by dry eschar, surrounded by scale . Procedure: Removal of dry eschar revealed more than 1/4 inch of slimy brown slough/necrotic foul-smelling tissue. A 1/4-inch layer was removed, but there remains further depth of this tissue across wound bed. Raw wound is reached at the 2 o'clock position, with scant bleeding. Wound culture is obtained there. Procedure: Secondary confirmation of the site was identified by patient and staff. Verbal consent was obtained by patient. Size 5 cm . Description: necrotic eschar covered ulcer located on left heel . the lesion was anesthetized . Sharp excision was performed of the dry eschar plate and 1/4 inch depth of the underlying soft slough/necrotic tissue. Bleeding was largely absent, stopped gauze pressure. Wound was dressed with Santyl, Aquacel, and gauze wrap . Continue offloading, daily wound care . Treat infection if presence noted on culture. Podiatry consultation. R2's Nurses Notes, dated 12/24/22, include: .still necrotic with darker gray area surrounding wound . R2's Nurses Notes, dated12/27/22, include left heel wound: 3.3cm x 4.0cm, eschar plate measuring 2.4cm x 2.9cm . strong odor . Updated MD R2's Nurse Notes, dated12/28/22, include MD added oral antibiotics R2's MD Progress Note, dated 12/28/22, includes: . staff report again that eschar plate has re-covered, and ulcer has had persistent foul odor. No surrounding erythema, no purulent drainage. He agrees to further debridement and wound culture if possible. He is reminded of upcoming evaluation with MRA and podiatry. He denies pain unless deeply handled . Has maintained offloading. Skin: 5-6 cm left heel ulcer, eschar covered, has extended laterally now 2-3 cm open area with slough covering. Foul smelling, slimy brown necrotic tissue remains below eschar plate. 1/4 inch depth is excised again, with more attention to wound borders. Minimal tunneling is noted, approximately 2 mm (millimeters) around wound edge, worst superiorly . Secondary confirmation of the site was identified by patient and staff. Verbal consent was obtained by patient. Size 5 cm to 6cm . Description: necrotic eschar covered ulcer located on left heel . the lesion was anesthetized . Sharp excision was performed of the dry eschar plate and 1/4 inch depth of the underlying soft slough/necrotic tissue. Bleeding was largely absent, stopped gauze pressure. Wound was washed with Dakins 50%, rinsed, and dressed with Santyl, packed 1/4 depth and 2mm surrounding tunnels with Santyl saturated packing gauze, and covered with gauze pad and gauze wrap. Debridement has been conservative in setting of pending vascular imaging. Deeper debridement of necrotic tissue is needed to access healthy tissue and stage wound . Eschar plate will likely continue to re-cover. Imaging for osteomyelitis assessment pushing out 6 weeks from wound opening . Antibiotic therapy is initiated in setting of likely diabetic ulcer, necrotic foul-smelling tissue, and positive culture. Wash with Dakin's and rinse. Continue Santyl gauze for packing and covering. If worsens . he may need escalation to inpatient services with parental antibiotics. Follow up . routinely or sooner if worsening/not improving . R2's Closet Care Plan, dated 1/1/23, includes Offload heels with boots or pillows under ankles . Document refusals . Turn/Reposition Schedule: Turn and reposition on night rounds . Prevalon boots bilateral when in bed. Left femur fracture near knee, elevate left lower extremity but avoid pillow directly under knee. Float heels . foam boots on for protection except with transfers. CNAs check feet . R2's Podiatry Visit Note, dated 1/3/23, includes Examination of his feet reveals nonpalpable dorsalis pedis and posterior tibial pulses bilaterally. Feet are warm to touch. Hair growth is absent. Skin is thinning. Epicritic sensations grossly diminished bilaterally. No [NAME] or clonus present. No paresthesia anesthesia, dysesthesias could be elicited. He has necrotic, full thickness through subcutaneous ulceration to the plantar/posterior left heel measuring approximately 35 mm x 30 mm in dimension with 2-3 cm of periwound erythema to follow odor. There is no purulence. There is an intact, noninfected blister to the plantar/posterior right heel . The ulcer appears infected and likely deep, possibly down to the bone. Concerns for osteomyelitis. Does not appear improved from a few days ago. Recommend admission for IV antibiotics, debridement, and further testing . podiatry consultation: resulting in pressure ulcer left heel, blister of right heel . measurements full thickness to calcaneus 4 cm x 3 cm x 1 cm with anullar base . pressure ulcer left heel stage 4 . osteomyelitis left heel . R2's Closet Care Plan, dated 1/11/23, includes Offload heels with boots or pillows under ankles . Document refusals . Turn/Reposition Schedule: Turn and reposition on night rounds . float heels with foam boots on both feet for protection at all times . left heel wound vac . CNAs check heels/feet am and pm . (It is important to note the facility did not provide evidence of diabetic foot checks being completed.) R2's Nurses Note, dated 1/11/23, includes: . left heel surgical wound 2.3cm x 3.1cm R2's Nurses Note, dated 1/13/23, includes: . left heel wound has exposed tendon . R2's Hospital Note, dated 1/13/23, includes Patient presented for direct admission from Podiatry clinic due to worsening left heel ulcer in setting of type 2 diabetes . It started as a blister on the posterior left heel 4-6 weeks ago and progressively worsened . blister also on the right heel at this time. Exam consistent with suspected necrotic ulcer approximately 3 by 3 cm in size with full thickness penetration and fat layer exposed with surrounding erythema and tender to palpation, nonpalpable dorsal pedal and posterior tibial pulses. Concern for cellulitis with possible osteomyelitis by evaluation by Podiatry, recommended imaging including MRI (a test to view muscle and bone), ABI (a test to check lower extremity circulation), and x ray of left foot. X ray left foot shows subtle cortical irregularity suspicious for possible osteomyelitis. MRI also showed changes consistent with osteomyelitis. Patient previously had wound culture on 12/23/23 that showed =light MRSA, light Citrobacter, freundii, started on oral antibiotic Augmentin and Bactrim. IV antibiotics started on admission. On 1/4/23 had surgical debridement of the wound by Podiatry. Initial culture positive for MRSA. Discussed options going forward with patient, who wants to try antibiotic treatment to save his foot. ABI's completed on 1/6/23 were within normal limits. Infectious Disease saw the patient on 1/5/23 in person, recommended blood cultures and changing antibiotics to Cefepime, Vancomycin, and Metronidazole. PICC placement 1/9/23 . Nutrition consulted given multiple wounds and recommendations were given. Today, he is up in his wheelchair, heels offloaded, wound vac to left heel. He states he is doing ok. He wants to know when he can go home. We discussed how difficult this would be since he currently cannot stand on his feet, and his wife could not transfer him. He verbalized understanding. He says Tramadol is helping his heel pain . Left heel ulcer with wound vac, status post-surgical debridement, right heel blister . He is non weight bearing to left foot . Left heel is bandaged with wound vac . 2.5cm x 3.0 cm intact, reducing/drying blister to right heel without surrounding erythema . acute osteomyelitis of left calcaneus . R2's Nurses Note, dated 1/16/23, includes new wound right inner buttock 1.0cm x 0.5cm . left heel surgical site 2.0cm x 3.0cm . R2's most recent MDS with an ARD of 1/17/23 states R2 is cognitively intact with a BIMS score of 15 out of 15. R2's MDS also indicates R2 requires the extensive physical assistance of two or more staff to meet his needs in bed mobility and R2 requires the extensive physical assistance of one staff to meet his needs in transfer, toilet use, dressing, and personal hygiene. In addition, the MDS indicates R2 is frequently incontinent of urine, always incontinent of stool, and is at risk for pressure injury development. R2's MDS indicates he did not have any unhealed pressure injuries, venous, or arterial injuries and needs a pressure reducing device for chair and bed and a turning/repositioning program. (It is important to note R2's MDS does not capture the heel wounds at all, under any category.) R2's Infectious Disease MD Progress Note, dated 1/19/23, includes asked to see patient for infected left heel . after fracture . he had decreased mobility . developed bilateral heel blisters. These got progressively worse. Was following with wound care, left blister developed necrosis, cultures 12/23/22 MRSA and Citrobacter freundii . underwent debridement on 1/4/23 . Podiatrist felt necrosis was all the way to the periosteum. My exam there was only a small area that was very close to the bone . started on a combination of antibiotics . MRI calcaneal osteomyelitis . antibiotics changed on 1/5/23 . wound vac was placed 1/6/23 . 1/11/23 Patient was discharged to nursing home . Exam done via video, with assistance of nursing staff on patient's bedside, with limitations of not examining patient in person . left heel status post debridement of necrotic heel, reported by nursing staff as significant improvement, no reported exposed bone limited visualization on video, wound vac was removed for exam . right foot poorly visualized, blister reported as superficial by nursing staff . Radiology: MRI left foot 1/4/23- large soft tissue ulcer at the posterior medial aspect of the calcaneus with abnormal marrow edema, marrow replacement, and marrow enhancement of the adjacent posteromedial calcaneus with an overall diameter of about 2.5 cm. Findings are highly suspicious of osteomyelitis. Decreased enhancement of the soft tissue around the ulcer suggesting devitalized soft tissue. Longitudinal splitting of the tibialis posterior tendon as well as the proneus brevis tendon. No drainable soft tissue abscess is evident. Assessment: Pressure Injury to left heel led to necrosis, and underlying osteomyelitis, status post debridement 1/4/23 . Pressure injury to right heel appears superficial. Cultures from left heel MRSA and Citrobacter freundii . intraoperative cultures MRSA and E faecalis. R2 developed a pressure injury to left heel, after being immobile from the left side femoral fracture in October. He also has a pressure injury that appears to be superficial on the right heel . Unfortunately, calcaneal ulcers are very difficult to heal, and the success rate is rather low. We are trying to treat underlying osteomyelitis with antibiotics, along with wound vac. Hopefully wound will eventually granulate . will granulate over. With limited exam on video, it appears wound is improving. Will leave antibiotics open ended minimum of 6 weeks . R2's Podiatry Visit Note, dated 1/20/23, includes: . approximately 2 weeks ago R2 underwent a debridement of the severe diabetic/pressure ulcer to the posterior/plantar left heel. He has been recuperating at hospital. He has been receiving IV antibiotics. They have been changing wound vac. He is accompanied today by his wife and son. Physical exam: . resolving blister to the plantar/posterior right heel without sign of infection. The dressing to the left foot is intact and upon removal the wound measures approximately 30 mm x 25 mm x 5mm in depth. It does appear to be down to the calcaneal periosteum. There is increased granulation tissue. There is no purulence. There is no periwound erythema. There is no odor. Neurovascularly he's unchanged. R2's Nurse Notes, dated 1/23/23, include left heel 1.8cm x 3.0cm R2's Infectious Disease MD Progress Note, dated 1/25/23, includes admitted to skilled nursing facility after hospital stay on 1/11/23 for acute osteomyelitis complicating the previously identified left heel ulcer, with multiple comorbidities. Antibiotics and a negative pressure wound treatment were prescribed with some skepticism the infection could be healed . impaired mobility and activities of daily living due proximately to acute left heel osteomyelitis complicating the facility acquired left heel wound .right heel wound reportedly just a blister, under observation with pressure relief . Visit diagnoses: Pressure wound of left heel 11/22, Pressure Wound of right heel 1/23 . (It is important to note this is the third MD to call these heel wounds pressure injuries. R2's primary MD, R2's Podiatrist, and R2's Infectious Disease MD have diagnosed R2 with heel pressure injuries.) R2's MD Progress Note, dated 1/30/23, includes Patient slid out of bed on 1/28/23 with no injury . a bit more confused than last care . He is transferred to bed via Hoyer for wound team management of heel ulcers, left with wound vac, right stage 1 since this hospitalization . He denies feeling ill or otherwise confused. He is oriented today . frail but alert . left heel ulcer measures 2 cm x 3 cm with 1-2 cm depth, with clean edges and granulation tissue, slough center . Right heel ulcer with 3cm blanchable stage 1 wound, skin is intact but appears fragile. Pressure wound left heel 11/22: continue offloading, wound vac, change 3 times a week and antibiotics course per Infectious Disease. Pressure wound of right heel 1/23: continue protective topical and offloading, close monitoring to prevent breakdown . Visit diagnoses: Pressure wound of left heel 11/22, Pressure Wound of right heel 1/23 . R2's Nurse Note, dated 1/31/23, includes coccyx- slough noted in center of wound . 2.5cm x 1.0cm . R2's Nurse Notes, dated 2/1/23, include left heel1.9 cm x 2.9 cm. R2's Infectious Disease MD Progress Note, dated 2/2/23, includes exam done via video with assistance of nursing staff on patient's bedside, with limitations of not examining the patient in person. Left heel status post debridement of necrotic heel, reported by nursing staff as continues to improve, no reported exposed bone limited visualization on video, wound vac was removed for exam, right heel appears superficial. Right foot, poorly visualized, blister reported as superficial by nursing staff . Radiology: MRI left foot 1/4/23- large soft tissue ulcer at the posterior medial aspect of the calcaneus with abnormal marrow edema, marrow replacement, and marrow enhancement of the adjacent posteromedial calcaneus with an overall diameter of about 2.5 cm. Findings are highly suspicious of osteomyelitis. Decreased enhancement of the soft tissue around the ulcer suggesting devitalized soft tissue. Longitudinal splitting of the tibialis posterior tendon as well as the proneus brevis tendon. No drainable soft tissue abscess is evident. Assessment: Pressure Injury to left heel led to necrosis, and underlying osteomyelitis, status post debridement 1/4/23 . Pressure injury to right heel appears superficial. Cultures from left heel MRSA and Citrobacter freundii . intraoperative cultures MRSA and E faecalis. R2 developed a pressure injury to left heel, after being immobile from the left side femoral fracture in October. He also has a pressure injury that appears to be superficial on the right heel . Unfortunately, calcaneal ulcers are very difficult to heal, and the success rate is rather low. We are trying to treat underlying osteomyelitis with antibiotics, along with wound vac. Hopefully wound will eventually granulate . will granulate over. With limited [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents in 2 of 23 residents (R63 and R30) reviewed for falls. R63 sustained a nasal fracture with nasal laceration requiring sutures. R63 had multiple previous self-transfer attempts and the root cause was not always identified, staff did not follow safe transfer procedures and appropriate interventions were not put in place to prevent further falls. R30 eloped from the building on two separate occasions. R30 was identified as being at risk for elopement on admission. The facility did not update the care plan after the initial incident, which could have prevented the second occurrence. The facility also did not implement a new intervention after the second elopement in which the resident had gotten outside into the driveway. Evidenced by: The facility's Fall Management Program policy, dated 12/15, includes, in part, the following: Policy: The resident's environment will remain as free of accident hazards as possible and restraint alternatives will be implemented as needed to reduce fall risks and reduce chance of injury. An individualized plan will be followed for residents identified at high risk or in the event of a fall. All residents will be reviewed at least on a quarterly basis . III. Procedure for fall and fall related incident evaluation. 2. Following the fall, the nurse will call a huddle with the staff on the unit to identify what happened and why it happened. The huddled team will review the interventions in place at the time of the fall, the factors contributing to the fall, possible causes, and possible preventative measures. The Post-Fall Huddle Worksheet will be used during the huddle as a tool to identify root causes. This completed tool will be routed to the DON (Director of Nursing) or designee to be used by the Fall Management Team and for QA (quality assurance) purposes. 3. Following the huddle, the team will identify a new approach to implement to try to prevent future falls. This new approach will be documented on the closet care plan with a dated and/or highlighted entry and will be recorded with fall information in the medical record. The new approach will be added into the self-care deficit care plan. 4. The next working day, the Fall Management Team will review the fall, the Post-Fall Huddle Worksheet, and will complete a new fall risk assessment. The Fall Management Team will review interventions and evaluate its effectiveness and make further recommendations as appropriate. Example 1 R63's [DIAGNOSES REDACTED]. R63 has an AHCPOA (Activated Healthcare Power of Attorney) and is not his own decision maker. R63's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 7/17/19, indicates R63 has a BIMS (Brief Interview of Mental Status) score of 4, indicating R63 has severe cognitive impairment, has no physical or verbal behaviors, does exhibit wandering behaviors and delusions. Transfers with extensive assistance of one person and ambulates with extensive assistance of one person. Uses toilet with extensive assistance of one person and is frequently incontinent of bladder and is continent of bowel. R63's Care Plan Problem, Loss of Independent Mobility, dated 7/24/19, includes, in part, the following approaches: Nurses --- Observe, record, and report all unsafe conditions and situations. Encourage to ask for assistance. Evaluate Fall Assessments Quarterly and prn (as needed). Update Closet Care Plan as needed. Make sure alternative devices are in place. Nurse Aide --- Follow Closet Care Plan with ongoing changes and approaches. Goal: Alternative devices will alert staff to help prevent falls. R63's Closet Care Plan, dated 8/18/19, includes, in part, the following approaches: Behavior: Short-tempered/easily annoyed, trouble with sleep, elopement, combative behaviors including: kicking, hitting with fist or hand, grabbing, due to delusions of persecution. Safety Devices: Alarm mat on exit side of bed, self-release wheelchair alarm belt, automatic locking brakes on wheelchair, WanderGuard, alarm on bathroom door, grippy socks, grippy tape across alarm mat, bolster mattress, bolstered bed frame, sensor pad alarm in wheelchair, red tumble mat on exit side of bed, sensor pad alarm in bed, front tippers in wheelchair. Ambulation: Gait belt with wheelchair to follow, ambulate to tolerance two times a day. R63's Incident Reports are as follows: 1. Date: 6/22/19, Time: 21:40 (9:40 PM), Incident Type: Fall/found on floor. Description of the incident: Resident found by CNA (Certified Nursing Assistant) in the bathroom on hands and knees. Knees are red, no other injuries noted. Resident states, I'm okay. Possible Cause: Found down. New Intervention: Remind to call for assist. Use alarm mat and make sure alarm mat and bathroom alarm is on. (Note: Facility did not identify the root cause of the fall. An intervention was included to remind to call for assistance. R63 has [DIAGNOSES REDACTED] with a BIMS of 4. Intervention indicates that R63's alarms were not turned on and functioning at the time of this fall.) 2. Date: 7/24/19, Time: 06:24 (6:24 AM), Incident Type: Fall/found on floor. Description of incident: Report does not give description of fall. Possible Cause: Found down. New Intervention: Red tumble mat. (Note: Root cause of fall, on 7/24/19, is not indicated on fall investigation. Facility did not identify the root cause of the fall.) 3. Date: 8/10/19, Time: 22:42 (10:42 PM), Incident Type: Fall/slide from bed. Description of incident: Resident was found kneeling next to his bed. No injuries noted. Possible Cause: Slid from bed. New Intervention: Sensor pad alarm for bed. IDT (Interdisciplinary Team) changed intervention following fall to place bed against wall. (Note: This is the 2nd fall occurring between 9:40 PM and 10:40 PM in the last 6 weeks.) 4. Date: 8/14/19, Time: 06:22 (6:22 AM), Incident Type: Fall/slide from bed. Description of incident: Resident was found on the floor on his hands and knees on his tumble mat next to his bed. No injuries noted. Possible cause: Slid from bed. New Intervention: Sensor pad alarm for bed. (Note: Root cause not identified. This is the 2nd fall occurring between 6:24 AM and 6:22 AM in the last 3 weeks. A sensor pad alarm should already have been in place.) 5. Date: 8/15/19, Time: 14:25 (2:25 PM), Incident Type: Fall from wheelchair - nose dive as resident stood up. Possible Cause: Stood up unassisted, belt not in place, staff not present. Witnesses: CNA present. New Intervention: Keep belt in place. On 8/28/19 at 4:41 PM, Surveyor interviewed CNA C. Surveyor asked if CNA C could recount what happened, on 8/15/19, when R63 fell . CNA C stated, I was across the hall in another resident's room and heard R63's alarm going off. I went in R63's room to assist two others CNAs who entered the room prior to me. R63 was half out of the bed, was being belligerent, so the 3 of us pivot transferred R63 into his wheelchair. Surveyor asked CNA C if a gait belt was used when transferring R63. CNA C stated, No, he was half in and half out of bed and we just grabbed him and put him in the chair. Surveyor asked CNA C what happened after they had gotten R63 into his wheelchair. CNA C stated, The 2 other CNAs left the room. I stayed to take R63 to the bathroom. I lifted the handles of R63's wheelchair to pick the back wheels up off the ground so I was able to turn him around. As I was turning the wheelchair, with the wheels lifted, R63 fell out of the wheelchair, face first, onto the floor. There was no gait belt on R63 at that time either. Surveyor asked where the incident happened in R63's room. CNA C stated, By dresser, not by the bed, I was turning the wheelchair and he just fell out. I think he was having an episode, which he had been experiencing prior to the fall, appeared to be similar to a vasovagal response. On 8/15/19, following the fall, physician was notified and R63 was sent to the ER (emergency room ) for evaluation. R63 was diagnosed with [REDACTED]. R63 returned to the facility with instructions for suture care and when to return if further complications. Nurses Note, dated 8/15/19 at 9:16 AM, states: It came through report that resident is having 'episodes' almost daily where he is blank and does not respond. Episodes last a very short time then he seems to be back to his usual. Last one reported to you on 8/7/19, which lasted a couple of minutes. On 8/28/19 at 5:08 PM, Surveyor attempted to call LPN D (Licensed Practical Nurse). Message was left for LPN D. Surveyor never received a call back. On 8/28/19 at 1:49 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B about interventions put into place for R63's falls. DON B states the facility is leery of putting specific interventions in place, such as, a toileting plan, in case the resident would fall again at that time and the intervention did not work. Surveyor asked DON B about R63's fall from 8/15/19. DON B stated R63 was attempting to self-transfer and fell face first and was believed to be having another episode. Surveyor asked DON B if staff noted a similarity in the time of the falls. DON B reviewed times and stated, I can see a pattern now. On 8/28/19 at 3:16 PM, Surveyor interviewed DON B again regarding fall from 8/15/19. DON B stated, I looked through all the information on R63's falls and none of the statements match. Surveyor asked DON B if any more information regarding the fall was available. DON B stated, I don't think so. I guess we don't know what happened. R63 was known to be at high risk for falls and was taking [MEDICATION NAME] (blood thinner). R63 has dementia and is impulsive and had multiple falls while attempting to self-transfer; the facility did not identify the root cause of the falls. The fall, on 8/15/19, was a direct result of a staff member lifting the back wheelchair wheels off the floor in an attempt to turn the wheelchair around; this action caused R63 to fall face first out of the wheelchair, resulting in a nasal fracture and facial laceration. Example 2 R30 was admitted to the facility on [DATE]. R30 was assessed for wandering, on 12/21/18, and found to be at risk for elopement, scoring 10 points on the assessment. A score of 10 or greater indicates a risk for elopement. R30's Care Plan Problem for Alteration in Thought, Communication, and Potential for Ineffective Individual Coping was dated 12/31/18. This care plan is documented as related to Loss of independence, new environment, cognitive disorder with BPSD (Behavioral and Psychological Symptoms of Dementia.), HCPOA activated. It is manifested by Potential for ineffective sleep pattern, agitation, cannot meet own needs, started on antidepressant, difficulty with problem solving, safety, impaired direction following, mildly HOH (hard of hearing), feeling down, depressed, wandering, rejection of care. None of the interventions in the care plan address wandering, resident's WanderGuard, or facility wandering plan. On 3/8/19 at 5:35 PM, R30 successfully eloped from the building and was found outside. There is no documentation of any follow up assessment of the resident related to the elopement and the care plan was not updated. There is no indication in the Nurses Notes or any follow up documentation stating whether R30's WanderGuard was on or if it was functioning. On 4/21/19 at 1:30 PM, R30 was able to get out of the front door and was propelling in her wheelchair up the driveway, before being recovered by a staff member. The Incident Note indicates the front door alarm did sound, but R30 is fast and was still able to make it outside and into the driveway. No follow up assessments are documented related to this specific incident and the care plan was not updated. On 6/18/19, an Elopement Assessment was completed for R30. R30 scored 24 on this assessment, indicating an elopement risk. No changes were made to R30's care plan related to wandering after this assessment. On 8/27/19 at 4:48 PM, Surveyor discussed wandering with CNA Q (Certified Nursing Assistant) and asked if there was a book or communication form that lists residents at risk for wandering. CNA Q indicated she was not aware of something that listed everyone. Surveyor asked CNA Q if she knew how many residents were identified as wandering, and she indicated that she did not know how many there were, but that she knows who they are by names and faces. On 8/28/19 at 8:16 AM, Surveyor spoke to DON B who indicated the facility does not have a wandering book, but they have a protocol that if there is a missing resident, they would look at the picture listed in their electronic charting system and then locate all of the residents with WanderGuards placed. Surveyor asked if there was any other place to locate follow up assessments or documentation regarding R30's two elopements, but she stated anything they had been done should be in the charting. DON B did provide Surveyor with the facility WanderGuard Alarm System Policy/Procedure. On 8/28/19, the facility created a new care plan problem for R60 documented as, Potential for Identified wanderer, Related to: dementia, manifested by: wanders in hallways. Approaches for this new care plan include for nurses to follow wandering plan prn to locate residents who have left facility, notify MD (medical doctor) prn, have photo taken for identification, on MAR (Medical Assessment Record). Nurse Aide approaches include, Be able to identify resident, know whereabouts, determine pattern to wandering, maintain WanderGuard per policy. Other interventions listed are to involve family if needed, inform resident of activities, and assist to activities. On 8/28/19 at 3:57 PM, Surveyor interviewed DON B and ADON M (Assistant Director of Nursing) regarding R30's elopements. ADON M stated, Residents are assessed on admission. ADON M also indicated that R30's WanderGuard was initiated on admission. Surveyor asked what was done or changed after R30's first elopement from the building to prevent it from happening again. DON B stated, We didn't do a new intervention. The WanderGuard system is our approach. The front door locks as they approach, but if someone is coming in from the outside, the door opens. DON B indicates that in the last four months the facility has added cameras to the front doors that can be viewed on alarm at the nurses' station. This wasn't in response to her, but it has been very helpful, said DON B. R30 was identified as an elopement risk on admission, but the facility did not ensure adequate supervision to prevent elopement and did not reassess resident or update care plan after two successful elopements by this resident.

Based on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 11 residents reviewed (Resident 12). On 10/27/14 Resident 12 fell in her room while self-transferring from the bed to the wheelchair. Resident 12's wheelchair brakes were not locked. Resident 12 received a laceration to her left forearm. No new interventions were added for Resident 12. On 12/25/14 Resident 12 fell in her room while self-transferring from the bed to the wheelchair. Resident 12's wheelchair brakes were not locked. Resident 12 broke her left hip. Evidenced by: The facility's "Fall Management Program," dated 4/2014, includes the following: II. Procedure for Assessment: 2. If the fall risk assessment score is 10 or more, appropriate fall prevention interventions/approaches will be initiated. III. Procedure for Fall and Fall Related Incident Evaluation: 3. ... the team will identify a new approach to implement to try to prevent future falls. This new approach will be documented on the closet care plan with a dated and/or highlighted entry and will be recorded with fall information in the medical record. The new approach will be added into the self-care deficit care plan. Resident 12 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Resident 12's annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/29/14 indicates Resident 12 is cognitively intact, uses a walker and wheelchair, transfers with supervision of one person and toilet use with extensive assist of one. This assessment also indicated Resident 12 had one fall with injury. Resident 12's CAA (Care Area Assessment), Falls, dated 11/3/14, included the following information: (Resident 12) has had one fall on 10/27/14 when she slipped and fell to floor when she turned to sit in her w/c (wheelchair). She is at high risk for falls due to her independence, incontinence, recent falls and unsteady gait. Skin and fall preventative measures are in place. See closet care plan for ongoing approaches and interventions. Resident 12's Fall Risk Assessment, dated 10/29/14, indicates Resident 12 is at high risk for falls. See current closet care plan for ongoing preventative measures. Resident 12's closet care plan, dated 10/29/14, includes the following: Bed Mobility: Independent. Elimination: Independent: Bladder continent, Bowel continent. Transfers: Independent in room with 4 wheeled walker or w/c, will call for assist prn (as needed). Wheelchair: Independent: will call assist of 1, prn, standard wheelchair, seat cushion. Safety Devices: none. It is important to know the there are no dates on the closet care plan to indicate when the interventions were put into place. Resident 12's nursing notes included the following entries: 10/27/14, 10:42 PM, Incident type: fall/slide from wheelchair. Time of Incident: 8:30 PM. Description of event: Resident states that she was standing near her bed, turned to sit back in wheelchair, she slipped and fell to the floor hitting her left arm on footboard of bed. Resident was not wearing her grippy sock, had regular socks on. She was able to get herself up to wheelchair and then put call light on for help. 10/28/14, 9:04 AM, Fall Management Committee: Review of Incident of 10/27/14 PM shift. Interventions: What is used prior to fall: bed against wall so she has more room to move about in room. Posey grip over w/c cushion independent with all transfers and mobility. What is recommended: lock w/c brakes when performing l/e (lower extremity) cares in evening. May wear grippy socks if wishes. She doesn't feel this will happen again. (It is important to know that the interventions were not on the closet care plan.) 12/25/14, 2:28 AM, Incident Type: fall/found on floor. Time of Incident: 1:15 AM. Description of event: Per Resident she was going to go to the bathroom, placed grippy socks on and was ready to transfer to wheelchair. When transferring did not make sure wheelchair was locked and wheelchair moved, resident fell to floor. Found down on right side. Complaining of pain to left hip/femur area. Skin tear noted to right elbow area. 12/25/14, 4:59 AM, Resident Transferred: Time of transfer: 1:47 AM, Transferred to: ER (emergency room )/Acute care hospital, (name of hospital) for evaluation. 12/26/14, 10:28 AM, Fall Risk Assessment: Total Score: 11, Resident is at risk of falling, Score of 10 or highest may indicate high risk. Interventions: What was used prior to fall: no devices. Resident was independent with transfers. 12/31/14, 1:47 AM, Nursing Admission Assessment: ... Resident admitted to Medicare A bed following hospitalization for acute: fall with left femoral fracture and left hip hemiarthroplasty (surgical repair of fracture). On 2/24/15 at 8:20 AM Surveyor interviewed Resident 12 regarding her fall on 12/25/14. Resident 12 stated she transferred herself to bed the evening of 12/24/14, leaving her wheelchair next to the bed with the brakes locked. Sometime during the evening staff came and removed the wheelchair to wash it. The wheelchair was returned, however it was not replaced in the same exact same place and the brakes were not locked when staff did return it. Resident 12 stated why should I think it was not locked when it was locked when I went to bed? On 2/24/15 at 3:40 PM Surveyor interviewed Certified Nursing Assistant (CNA) G. CNA G stated that she works on Resident 12's unit. CNA G stated that prior to Resident 12's fall on 12/25/14 if she moved Resident 12's wheelchair from beside the bed that she would have returned it and locked the brakes as that is the way Resident 12 would leave it when she went to bed. On 2/24/15 at 3:45 PM Surveyor interviewed Certified Nursing Assistant (CNA) H. CNA H stated that she works on Resident 12's unit. CNA H stated that Resident 12 always locked the wheels on her wheelchair and left the wheelchair next to the bed. CNA H stated if someone moved the wheelchair they should have returned it and locked the brakes. O 2/24/15 at 3:50 PM Surveyor interviewed Certified Nursing Assistant (CNA) I. CNA I stated she floats down Resident 12's unit when she is needed. CNA I stated that Resident 12 always kept her wheelchair next to her bed with the brakes locked. CNA I stated she would lock the brakes if she moved the chair and returned it to the position next to the bed as she found it. On 2/24/15 at 3:55 PM Surveyor interviewed Director of Nursing (DON) B. DON B stated Resident 12 was independent prior to her fall on 12/25/14. DON B stated Resident 12 forgot to lock her brakes on the wheelchair or check them prior to transferring to the wheelchair on the morning of 12/25/14. Resident 12 had a fall on 10/27/14 when she was transferring from her bed to her wheelchair, due to not locking her wheelchair brakes, receiving a laceration. Resident 12 was deemed high risk for falls following this fall, no new interventions were put into place to prevent further falls, although the Fall Management Committee did recommend locking the wheelchair brakes when completing l/e cares in the evening. On 12/24/14 during the evening shift Resident 12's wheelchair was removed from the room to wash. The wheelchair was returned, however the brakes were not locked. On 12/25/14 Resident 12 fell again when transferring from her bed to her wheelchair due to not locking her wheelchair brakes. Resident 12 sustained a hip fracture and was hospitalized and had a surgical repair of her hip fracture.

Based on interview and record review, the facility did not ensure that each resident receives and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 8 residents reviewed (Resident 3). Resident 3 was noted to have increased difficulty with chewing and swallowing food. The facility decided to involve the speech therapy, to determine if additional services were needed. Speech therapy did not follow through with Resident 3's assessment and other interventions to protect Resident 3's highest level of well-being were not placed. Resident 3 had a change of condition, was hospitalized and diagnosed with [REDACTED]. This is evidenced by: According to <http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm>, "Aspiration pneumonia is inflammation of the lungs and airways to the lungs ([MEDICATION NAME] tubes) from breathing in foreign material. Aspiration pneumonia occurs when foreign materials (usually food, liquids, vomit, or fluids from the mouth) are breathed into the lungs or airways leading to the lungs." Resident 3 has the following diagnoses, according to [DIAGNOSES REDACTED]. "Speech Therapy Weekly Note" dated 4/26/12 states, "Purple sheet received from nursing stated 'Resident noted with increased congested cough-CXR (chest x-ray) did show [MEDICAL CONDITION] (congested heart failure) but family concerned that maybe he is aspirating liquids again. Should we go to thickened liquids? DO a swallow study?' No change in nursing report of frequency of coughing. The resident does persist with impulsivity and reduced awareness of swallowing safety, occasionally stuffing his mouth very full of food or drinking liquids too rapidly. During these times, resident observed with cough...Caregivers and family will be updated on resident current condition and recommendations for continued verbal cues and supervision for swallowing safety. At this time, it is not warranted to trial thickened liquids or repeat swallow study. If there is a change in condition, formal swallow evaluation should be conducted..." Signed by SLP (Speech Language Pathologist) F. Resident 3's "Guidelines for Daily Care" indicate that Resident 3 was on "aspiration precautions" from at least July, 2012 forward. Aspiration precautions are defined on the guideline as "upright when eating, decreased rate, small bites, small sips." Nurse's Notes dated 10/31/12 state, "Describe change of condition: Resident is coughing and not chewing food and choking when eating and drinking. When did the change of condition to be addressed begin? 10/31/12. What have you done to correct the change of condition? Advised to chew food. Have all changes been documented in ECS? Yes. Direct to: ST (speech therapy). Oral problems-chewing problem, not chewing food, coughing and choking when both eating and drinking." St. Clare Meadows Daily Report dated 11/1/12 states, "...(Resident 3)-speech screen..." Nurse's Notes dated 11/2/12 state, "Weekly Summary Charting: Week 1: Changes noted this past week: 10/31/12 resident noted not chewing food and coughing while eating and drinking, evaluation by OT (occupational therapy)..." Resident 3's medical record does not indicate that this change of condition was addressed and that Resident 3 received care in order to address this change. There was no evidence that speech therapy addressed this change in Resident 3. Nurse's Notes dated 11/23/12 state, "Blood Pressure: 122/60, Pulse: 63, Temperature: 97.2, Respiratory Rate: 20, Condition Noted: audible crackles and resident someone despondent, O2 (oxygen) saturation: 85% on room air, applied O@ 2L(liters)/NC (nasal cannula)...sent to ER...Call placed to: (doctor), Regarding: Resident short of breath, oxymetry in the low 80s, was placed on 2L/min oxygen and oxymetry still 85%. Oxygen turned up to 4L/min and went up to 90%. Resident had 2 episodes of unresponsiveness and color is pale/gray." "Physician Discharge Summary" for Resident 3's hospitalization [DATE] to 11/27/12 states, "Discharge Diagnosis: [REDACTED]. 1. Aspiration pneumonia (principal) Patient has had residual difficult swallowing and frequent aspirations because of a previous stroke. Initially hypoxic and hypotensive, so admitted to ICU from ER, and started on [MEDICATION NAME] and [MEDICATION NAME] and received ICU care. Remained hemodynamically stable. Transferred to the floor, swallow eval recommended slow feeding, solids ok. Was getting ready to be discharged yesterday, however he aspirated on the last bite. Frequent suctioning was performed. Although he remained stable, kept him for another day to assure stability. Patient also had a sodium of 150 and BUN of 40 at some point during this admission that were corrected at discharge. The most important aspect of his care at the SNF (skilled nursing facility), would be cautious, very slow feeding to prevent aspiration. Recommend puree diet for time being. Discussed the need for feeding tube to prevent frequent aspiration with his wife..." The facility updated Resident 3's "Guidelines for Daily Care" after his readmission to the facility to state the following "11/27/12: Pureed diet, Aspiration precautions, upright when eating, decreased rate, small bites, small sips, feed slowly per MD, good oral care after meals. Check for pocketing after meals, no straws." Speech Therapy notes dated 11/28/12 state, "Resident recently hospitalized at SCH for aspiration pneumonia. According to medical records, on 11/23/12 the resident was found in his room and was unresponsive and hypoxic. He was sent to ED. At the ED, he was found to have significant food caked (old and new) caked on his dentures. CXR reported RLL (right lower lobe) pneumonia. During hospitalization , he was seen for bedside swallow evaluation, revealing ongoing oral pharyngeal dysphagia secondary to previous R (right)[MEDICAL CONDITION]([MEDICAL CONDITION]-stroke). Resident switched to pureed in order to promote swallowing safety..." A fax from the facility's therapy department dated 12/7/12 states, "...Request diet upgrade to include one mechanical soft item per tray, rest of tray pureed items and continue thin liquids. Continue to follow the following safe swallowing guidelines: 1. Direct supervision during all PO (by mouth) intake. 2. 90 degrees upright during all intake. 3. Remain 90 degrees upright following PO intake. 4. Slow pace. 5. Small bites/sips. 6. Dentures in place for PO intake. 7. Oral cares immediately following oral intake, including removal of/cleaning/replacement of dentures. 8. No straws. 9. Monitor for pocketing, particularly on the left. 10. Verbal and physical cues as necessary to ensure safe swallowing. 11. Encourage frequent throat clearing and re-swallow throughout meal." This fax is signed and states "agree." Resident 3's current "Guidelines for Daily Care" dated 1/18/13 state, "Dentures; oral hygiene before and immediately following all oral intake...Diet: General/regular Pureed with one mechanical soft item thin liquids (Aspiration precautions: upright when." Resident 3's care plan interventions do not address the specific recommendations related to eating (slow rate, small bites etc.). These interventions were not placed on Resident 3's plan of care when a new care plan was printed on 1/18/12. Surveyor spoke with Occupational Therapist (OTR) I at 12:34 PM on 1/17/13. OTR I stated that Resident 3 was picked up for OT on 12/11/12 after he came back from the hospital. OTR I stated that if someone was having chewing or swallowing problems this work would typically be done by speech therapy. Surveyor asked OTR I to review Resident 3's therapy records. OTR I stated that she did not see a screen done for Resident 3 after the 10/31/12 message (Nurse's Note) was sent. Surveyor asked OTR I about the process for communication between departments and acquiring services for residents. OTR I stated that if a message is sent from nursing a screen would be done and this would prompt orders. OTR I stated that the therapy department gets messages from nursing via the computer. OTR I stated that she does not remember getting anything on that and that she will check with Speech Therapy. Surveyor spoke with SLP F on 1/17/13 at 12:37 PM. SLP F stated that Resident 3 was picked up after his hospitalization at the end of November. Surveyor asked SLP F if a screen was completed in regard to the 10/31/12 note. SLP F stated that she did a screen in September and this was all she had documented. Surveyor requested anything information regarding SLP F's response to the 10/31/12 message sent from the nursing department. Surveyor again spoke with OTR I on 1/22/13 at 9:17 AM. OTR I stated that she did not find anything for Resident 3 related to an evaluation on or around 10/31/12. Surveyor spoke with Licensed Practical Nurse (LPN) J on 1/22/13 at 12:02 PM. LPN J stated that she did write the 10/31/12 note to therapy, requesting speech services. LPN J stated that the communication between nursing and therapy is done by the computer and that she knew that she filled out a message for therapy for Resident 3 at least one time. Surveyor spoke with OTR I on 1/22/13 at 12:15 PM. Surveyor asked OTR I if she could show her the message history in the computer. OTR I stated that she could not find the message regarding Resident 3 in the log, but they do delete these. OTR I stated that both she and SLP F went in and did not find additional information. OTR I stated that she was not sure if it just was not documented of if there was no follow up completed. ORT I stated that the department used to get a purple paper referral form that nursing would bring to therapy. OTR I stated that now they get red boxes on the computer which are messages. ORT I stated that the message is part of the actual Nurse's Notes as well. OTR I agreed with Surveyor 's concern about Resident 3 not receiving care and the resultant aspiration pneumonia. OTR I stated that she would follow up with the new speech therapist to make sure messages are coming in. Surveyor spoke with Certified Nursing Assistant (CNA) G and CNA H on 1/22/13 at 2:15 PM. CNA G and CNA H both indicated that currently and have in the past worked with Resident 3. CNA G stated that in November, she remembers Resident 3 coughing a lot and she would have to remind him to take small bites, as he does "shovel" in his food. CNA H stated that Resident 3 seems to be better now, but still needs supervision or he will eat fast. Surveyor asked CNA G and CNA H how they know how to care for Resident 3. CNA G and CNA H retrieved Resident 3's care plan from his room and indicated that theses interventions were not on the care plan. CNA G stated that maybe they were just told about it and that you "can tell when someone needs extra help." Surveyor spoke with Director of Nursing (DON) B on 1/22/13 at 3:11 PM. DON B stated that when a decline is suspected and there is a need for therapy, a request for a screen is made. DON B stated that the facility used to use a purple sheet, but that was changed (before this incident) to be hard-wired into the computer and is automatically sent to therapy. DON B stated that she is aware of the concern regarding Resident 3 not receiving speech services. Surveyor asked DON B what was done to address Resident 3's change in condition. DON B stated that the nurse who wrote the message to therapy said that we were going to remind him to chew and that Resident 3 was already on aspiration precautions. DON B stated that she supposed the missing piece was that the screen was not done when it should have been. DON B agreed that this was concerning for Resident 3. Surveyor reviewed with DON B the inconsistencies in Resident 3's care plans.

Based on observation, interview and record review, the facility failed to ensure that each resident receives appropriate supervision and assistive devices to prevent accidents for 3 of 10 residents reviewed for falls (Residents 6, 19 and 12 and 8 of 11 residents reviewed for WanderGuard? device placement (Residents 6, 19, 22, 23, 24, 25, 26, and 27). Resident 12 had a history of [REDACTED]. Resident 12 sustained another fall on 10/19/11 when she was noted to have "possibly transferred herself" and the alarms were not sounding and sustained fractures to her ribs. The facility's fall policy indicates the resident's environment will remain as free of accident hazards as possible. An individualized plan will be followed for residents identified as high risk or in the event of a fall. Resident 19 was to have an alarm over a mat for fall prevention. Resident 19 sustained a fall and the alarm was not in place. The facility did not investigate to determine why the alarm was not in place. No corrective action was documented related to the failure. Resident 6 was to have "posey grip" under his wheelchair cushion. Surveyor observed this intervention not in place. Resident 6 was to have a WanderGuard security device on the wheelchair and on his wrist. Resident 6 did not have the WanderGuard device on the wrist. The facility signed the Medication Administration Record, signifying that Resident 6's WanderGuard was checked for placement on the wrist and wheelchair on 12/7/11. However, Resident 6 was observed on 12/7/11 without the WanderGuard in place on the wrist. Residents 19, 22, 23, 24, 25, 26, and 27 had WanderGuard security devices attached to or resting on metal portions of their wheelchair frames against manufacturer guidelines. This is evidenced by the following: I. Policy: The Fall Management Program, dated 1/01 indicates the resident's environment will remain as free of accident hazards a possible. An individualized plan will be followed for residents identified as high risk or in the event of a fall. II. Procedure for Assessment: 3. If the assessment score is 10 or more, the assessor will initiate appropriate fall prevention interventions/approaches. (The fall risk assessment the facility follows only indicates if the resident is a fall risk, not if the resident is a low or high risk). 6. Fall prevention interventions will be communicated to all staff by appropriate means. (The staff were confused on what interventions were in place when the mat was not placed in front of the residents recliner). III. Procedure for Fall and Fall Related Incident Evaluation 4. The Fall Management Team will review current intervention and evaluate its effectiveness and make further recommendations as appropriate. 5. The Fall Management Team will update and monitor intervention programs. (Resident 12's mat was observed as not placed in front of the resident in her recliner when her care plan indicated the mat was to be placed in front of the recliner when she is sitting in it). Example 1 Resident 12's [DIAGNOSES REDACTED]. Resident 12 had a fall 7/3/11 and 7/9/11; both falls were documented indicating that Resident 12 had pushed her alarm mat under her bed. On 7/11/11 a fall risk assessment was completed for Resident 12 due to the fall on 7/9/11 indicating Resident 12 to be at risk for falls. At this time the facility implemented new interventions. The interventions recommended include assistance for all transfers, an alarm on the bathroom door to alert staff when she was entering the bathroom, a personal alarm in her wheel chair and alarmed mat taped to the floor at her bedside. The nurses' note indicated she needed assistance for all transfers. It is noted that she unclipped her personal alarm that was used to summon the staff to help her. (It should be noted that this risk assessment does not indicate what additional fall prevention strategies the facility would implement given the assessed concerns with Resident 12 unclipping her alarm.) Resident 12's Care plans for Trauma-Falls, dated 8/10/11 indicated to follow the closet care plan (Guidelines for Daily Care) with ongoing changes and approaches. Place mat at bedside and by recliner chair and personal alarm in wheel chair. (Again, this care plan does not provide staff with strategies to prevent Resident 12 from disarming her alarm or moving the mat.) A fall incident report dated 9/12/11 indicated Resident 12 had a fall when she tried to transfer herself to her reclining chair when she lost her balance. The fall incident report indicated she had removed her personal wheel chair alarm. The report indicated the facility placed the alarm mat in front of her recliner to alert the staff she was transferring herself. (Again, the facility is on notice that Resident 12 removes her alarm and does not indicate any change in interventions to ensure Resident 12's safety.) Resident 12's fall risk assessment, dated 9/13/11, was 15, noting a fall risk. The fall risk assessment indicated she and her roommate disarm the alarms and muffle the sound of the alarms. A wheel chair cushion alarm was added. The nurses' note indicated this alarm could not be shut off but the resident and roommate may figure out how to disconnect the wiring. (Again, although the facility indicates that Resident 12 and her roommate may figure out a way to "disconnect the wiring" there are no other interventions to ensure the safety of Resident 12.) Nursing notes indicate that on 10/19/11, at 4:15 pm Resident 12 had a fall when she attempted to transfer herself from her recliner to her wheel chair. The resident's alarm mat was not sounding when staff found her on the floor. The resident's nurse's note indicated she possibly transferred herself from the wheelchair to the recliner earlier in the afternoon and the alarm mat was not turned on. She complained of right back and side and right shoulder pain. She told staff she bumped her back on the table near her dresser. (There is no indication that the facility determined the root cause of this fall, only that she may have transferred herself "earlier in the afternoon" and there is no indication what further interventions the facility would implement in view of Resident 12's continued falls and that the alarm did not sound.) On 10/20/11 Resident 12 had an x-ray of her back. The x-ray report indicated Resident 12 had right posterior 6th and 7th rib fractures. The nurse's note indicated Resident 12 continues to disarm the alarms. The alarms and the mat alarm in front of the recliner were discontinued. (It should again be noted that the facility was aware of Resident 12's continued unassisted transfers and that Resident 12 was turning the alarms off and there was no changes to the care plan except the removal of the alarms.) A fall assessment, dated 10/20/11, indicated Resident 12's personal alarm in Resident 12's wheel chair and mat alarm in front of the recliner are discontinued as these alarms agitate the resident. However, the alarm mat and personal alarm on her wheel chair were reinstated on 10/21/11. Additionally, the facility reinstated the alarms on the CNA's (Certified Nursing Assistant) Guidelines for Daily Care. A wireless alarm mat replaced the previous alarm mat as Resident 12 was known to disarm the previous mat. (Although the facility reinstated the alarms there are no additional strategies to ensure Resident 12's continued safety.) The closet care plan (Guidelines for Daily Care), dated 12/3/11, indicated Resident 12's transfer changed from non weight bearing to a pivot transfer with one assistant on 10/27/11 and indicated her wheel chair is to be next to her recliner for resident to self transfer. Her care guidelines indicated Resident 12 was a pivot transfer with the assist of 1. (These care guidelines appear to be incongruent with Resident 12's assessed fall risk.) On 12/711, at 12:35 pm Surveyor observed Resident 12 sitting in her recoiner. The alarmed mat was not placed in front of the recliner as care planned but was behind her half way under the bed. (If Resident 12 transferred herself the staff would not be aware of her transfer to prevent a fall). On 12/7/11, at 12:45 pm Surveyor asked CNA N if the alarmed mat should be in front of Resident 12 while she is in the recliner. She said yes it should be in front of her when in her recliner but she will transfer her self no matter what. On 12/7/11, at 12:47 pm Surveyor asked CNA O if the alarm mat should be placed in front of Resident 12. CNA O said Resident 12 did not use an alarm on her wheel chair or the alarm pad in front of her recliner because she has antilock brakes on her wheel chair. It should be noted that the Guidelines for Daily Care indicates Resident 12 is to have the alarmed mat in front of her chair and the personal alarm on her chair. The above interviews indicate staff confusion as to what is needed to prevent Resident 12 from falls and injury. On 12/8/11, at 7:45 am Surveyor observed RN (Registered Nurse) C transfer Resident 12 with a gait belt and pivot transfer to the recliner. RN C placed the alarm mat in front of the recliner after the resident was transferred. It should be noted that the wheel chair is to be place next to Resident 12, not in front of her, to keep her safe from falling if she transfers herself. However, the wheel chair was placed in front of the mat placed in front of the recliner and had Resident 12 attempted transfer without assistance she would have had to walk on the mat to get to the wheel chair presenting a potential hazard to Resident 12. Additionally, the closet care plan (Guidelines for Daily Care) indicate to keep wheel chair next to her recliner. On 12/8/11, at 10:30 am Surveyor asked DON (Director of Nursing) B if she expected the alarm mat to be in front of Resident 12's recliner. She said the care plan was very confusing when she read it and the mat should be down. She said they put the wheel chair by her to help prevent falls. Example 2 Resident 19 has the following diagnoses, according to [DIAGNOSES REDACTED]. The facility completed a fall assessment for Resident 19 on 9/14/11. This assessment states that Resident 19 scored 16 points, indicating that Resident 19 is at great risk for falls. Resident 19's "Guidelines for Daily Care," dated 10/24/11 (in place at the time of the 10/29/11 fall), state that Resident 19 is to have the following safety devices "Alarm Mat, wanderguard, auto-lock brakes on w/ch (wheelchair), tumble mat, low bed in lowest position." According to an Incident Report dated 10/29/11, Resident 19 sustained a fall in her room at 1400 (2:00 PM) on 10/29/11. "Resident was in bed and was trying to get out and slid onto her tumble mat along with a pillow. No injuries. No alarm on tumble mat. Landed on bottom." Surveyor spoke with Director of Nursing (DON) B on 12/8/11 at 9:48 AM. DON B stated that the facility screens for fall risk before admission, upon admission, and with each fall. DON B stated that the facility utilizes a falls team to determine the root cause of falls and to determine a new intervention to prevent future falls. DON B stated that she and the nursing staff monitor direct care staff to determine if they are following the resident's care plan. DON B stated that she could see what Surveyor meant when asked about why the alarm mat was not in place at the time of Resident 19's fall on 10/29/11. DON B stated that she does not have additional information related to why the alarm mat was not in place. Example 3 Resident 6 has the following Diagnoses: [REDACTED]. The facility completed a "Fall Assessment" on 11/21/11 in which Resident 6 scored 12 points, indicating that Resident 6 is at high risk for falls. Resident 6's "Guidelines for Daily Care" dated 12/1/11 indicate that Resident 6 is to have Posey grip under all cushions. Posey Grip is a non-slip matting material. On 12/6/11 at 7:16 AM, Surveyor observed Resident 6's wheelchair in his room. Surveyor noted that the cushion placed in the wheelchair did not have a Posey grip material under the cushion. On 12/7/11 at 7:25 AM, Surveyor observed Certified Nursing Assistant (CNA) D provide cares for Resident 6. Surveyor noted that cushion placed in Resident 6's wheelchair did not have the Posey grip material under the cushion. Surveyor observed CNA D transfer Resident 6 from the bed to the wheelchair. CNA D did not check under the cushion for the Posey grip. Example 4 The facility uses a WanderGuard? system to prevent elopements out of the facility. Manufacturer's Instructions state the following: "Wheelchair Placement: Facilities often ask about attaching the signaling device to a wheelchair. If attempts to use wrist or ankle placement have failed, mount the signaling device away from the metal frame of the wheelchair at a height of approximately 3' (feet) from the floor (in the center of the back of the wheelchair) ..." Resident 6 has a Physician Order, signed 11/18/11 that states the following: "Check security system bracelet on wrist and on w/c (wheelchair) foot rest two times per day, am shift pm shift." On 12/7/11 at 9:15 AM, Surveyor noted that Resident 6 did not have a WanderGuard security device on his wrist, but did have one attached to the metal frame of the wheelchair. Surveyor asked Certified Nursing Assistant (CNA) L to check Resident 6's body for a WanderGuard device. CNA L stated that Resident 6 did not have a device on his body. On 12/7/11 at 4:10 PM, Surveyor asked Registered Nurse (RN) M to check Resident 6's body for a WanderGuard device. RN M checked Resident 6's body (wrists and ankles) for the device and noted that Resident 6 was not wearing a WanderGuard security device. RN M stated that Resident 6's care plan states just "Wanderguard." RN M verified in her computer that Resident 6 did have an active physician's orders [REDACTED]. On 12/7/11 at 4:15 PM, Surveyor asked Director of Nursing (DON) B to check Resident 6 for placement of the WanderGuard device on Resident 6's body. DON B checked Resident 6's body and verified that Resident 6 did not have a WanderGuard device on his body. On 12/7/11, Surveyor reviewed Resident 6's Medication Administration Record (MAR). Resident 6's MAR states the following: "Check security system bracelet is on wrist and w/c foot rest two times per day." This treatment is signed out as complete for the AM shift of 12/7/11. Example 5 Resident 26's WanderGuard security device was noted to be connected to the front metal frame of her wheelchair on 12/8/11 at 11:17 AM. Example 6 Resident 19's WanderGuard security device was noted to be connected to the metal frame of the wheelchair on 12/8/11 at 11:15 AM. Example 7 Resident 27's WanderGuard security device was noted to be connected to the metal frame of the wheelchair on 12/8/11 at 11:16 AM. Example 8 Resident 23's WanderGuard security device was noted to be resting on the left arm of her wheelchair, resting on a metal part of the wheelchair on 12/8/11 at 11:20 AM. Example 9 Resident 25's WanderGuard security device was noted to be on the left side of the wheelchair, and observed to be touching the metal portion of the wheelchair arm on 12/8/11 at 11:20 AM. Example 10 Resident 24's WanderGuard security device was noted to be on her wheelchair and touching a metal portion of the wheelchair frame on 12/8/11 at 11:20 AM. Surveyor spoke with Registered Nurse (RN) Manager C on 12/8/11 at 12:28 PM. RN C stated that everyone in the nursing department is in charge of ensuring that the WanderGuard devices are placed appropriately. Surveyor asked if the instruction manual is referenced before applying a WanderGuard device. RN C stated that everyone is responsible for appropriately placing the devices. Example 11 On 12/8/11 at 11:07 AM Surveyor observed Resident 22 with a wanderguard attached to her right metal bar of the back of her wheelchair. The wanderguard was between the edge of the back of Resident 22's wheelchair against the metal bar.

Based on observation, record review and interview the facility did not ensure 1 of 12 residents (Resident 10) received adequate supervision and assistance devices to prevent accidents. Resident 10 was left unattended without the proper fall interventions in place. Resident 10 was found on the floor by a Certified Nursing Assistant. The nurse was not summoned for assessment of injury, nor did the Certified Nursing Assistant properly report the incident to the nurse on duty. Resident 10 experienced falls in the facility and no new interventions were put into place to prevent additional falls. This is evidenced by the following: The facility's policy "Fall Management Program," effective 1/01, includes the following: II. Procedure for Assessment 6. Fall prevention interventions will be communicated to all staff by appropriate means. 7. The Fall Management Team will evaluate residents on an ongoing basis and as needed. III. Procedure for Fall and Fall Related Incident Evaluation 1. Following a fall, the nurse assesses the resident and notifies the physician and family. 2. The nurse documents the fall and any contributing factors. The nurse will initiate a trail of restraint alternatives or other interventions. 3. The Fall Management Team will review the fall and fall related incidents... 4. The Fall Management Team will review current intervention and evaluate its effectiveness and make further recommendations as appropriate. Example 1 Resident 10's [DIAGNOSES REDACTED]. Resident 10's care plan, printed 1/30/12, identifies the problem area of "Potential for Trauma-Falls" with interventions that include follow closet care plan, bed in low position, and make sure alternative devices are in place. Resident 10's closet care plan identifies the following safety devices for Resident 10: Low bed in low position, alarm mat, tumble mat and hip protectors. On 2/8/12, at 12:47 PM, Surveyor observed Certified Nursing Assistant (CNA) P and CNA N provide cares for Resident 10. CNA P and CNA N assisted Resident 10 into the restroom. Surveyor asked if Resident 10 was wearing hip protectors. CNA P stated no she does not wear them. CNA P and CNA N both stated Resident 10 has not worn hip protectors for a very long time. Then CNA P looked at Resident 10's closet care plan and indicated that it must not have been updated because Resident 10 does not have them. CNA P and CNA N then transferred Resident 10 into bed and CNA N left the room. At 1:14 PM, Resident 10's roommate began asking for assistance. CNA P left Resident 10 to assist the other resident. Resident 10 was in bed at the time and the bed was not in the low position, the tumble mat was not in place, the alarming mat was not in place and the hip protectors were not on. CNA P assisted the other resident into the bathroom and was in the bathroom with the door slightly cracked but was approximately 10 feet away from Resident 10's bed. CNA P finished assisting the other resident and returned to Resident 10's bedside at 1:22 PM and put the fall precautions into place including the hip protectors that were on Resident 10's dresser. On 2/8/12, at 1:35 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated CNA P should not have walked way from Resident 10 without putting the bed in the low position and putting the fall mats in place. DON B also confirmed that Resident 10 should have the hip protectors on during the day time and removed at night. DON B continued to state the CNAs should be reviewing the closet care plan each time they work with a resident to know what new interventions have been put into place. Example 2 Resident 10's closet care plan, updated 1/30/12, indicates Resident 10 is to be transferred with an EZ Lift. Resident 10's safety precautions include a low bed, tumble mat and alarm mat on the floor. On 2/8/12, at 12:47 PM, Surveyor was observing Certified Nursing Assistant (CNA) P provide cares for Resident 10. CNA P informed Surveyor that Resident 10 had fallen out of bed that morning. CNA P stated he saw Resident 10 on the red mat by her bed. Surveyor reviewed Resident 10's charting for 2/8/12 following the above conversation and noted no documentation or mention of a fall for Resident 10 that day. At 1:35 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated she was not made aware that Resident 10 had fallen out of bed. DON B called Licensed Practical Nurse (LPN) J on the phone. LPN J stated that CNA N stated that Resident 10's feet were swung out of the bed but she got to Resident 10 before she fell . LPN J did not assess Resident 10. Neither DON B nor LPN J were aware of an incident with Resident 10 falling out of bed. On 2/8/12, at 3:10 PM, Surveyor interviewed CNA N via phone with Registered Nurse (RN) C present. CNA N stated that in the morning she found Resident 10 with her legs out of the bed at the head of the bed. CNA N stated Resident 10's knees were on the floor between the red mat and the wall at the head of the bed. CNA N stated Resident 10's upper body was still laying on the bed face down. CNA N swung her legs back up into bed. CNA N stated she checked Resident 10's knees and she did not see anything then she proceeded to get Resident 10 up for the day. CNA N stated she reported the fall to LPN J on the way to breakfast. Following the call Surveyor interviewed RN C. RN C stated she would have LPN J complete a late entry into Resident 10's record about the fall. RN C stated it was okay for CNA N to swing Resident 10's legs back into bed but then should have gotten LPN J or a nurse to assess Resident 10. Example 3 Resident 10 had a fall assessment completed following a fall out of bed on 1/16/12. The fall assessment identified Resident 10's fall risk score to be 18 which indicates Resident 10 is a fall risk. Resident 10 has had multiple falls out of bed at the facility. The facility is in the process of activating Resident 10's Power of Attorney for health care, they and are awaiting the second signature. Resident 10's closet care plan, updated 1/24/12, includes the following fall interventions: Low bed in low position, alarm mat, tumble mat. Resident 10's nursing notes indicate: -1/27/12 fall on floor at 10:15 AM. Activity-transferring unassisted. -1/27/12 fall/slide from bed at 2:45 PM. Resident stated she didn't push her call light. Resident reminded to use call light with any and all needs and to wait for staff to assist her. -1/28/12 Fall. Resident was found on tumble mat beside bed by staff. Resident attempting to self transfer out of bed. Will be adding hip protectors and a personal alarm in bed. There is no evidence that a fall assessment or a new intervention was put into place following either fall on 1/27/12. On 2/8/12, at 1:35 PM, Surveyor interviewed Director of Nursing (DON) B about Resident 10's falls. DON B stated following the fall on 1/27/12 at 10:15 AM staff were "paying more attention" to Resident 10 and following the 2:45 PM fall staff were going to toilet her at change of shift. Surveyor asked for documentation that this was implemented and/or communicated to staff; DON B stated there was not any documentation available. DON B stated the new interventions should have been on the closet care plan. There was no definitive indication what "paying more attention" means.