Every finding on record at Complete Care at Kensington

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 and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered an alert for excessively low weekend staffing. This has the potential to affect all 70 residents residing in the facility. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate. Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: 1. October 1 - December 31, (quarter 1) 2. January 1 - March 31, (quarter 2) 3. April 1 - June 30, (quarter 3) 4. July 1 - September 30 (quarter 4) . PBJ Staffing Data Report, CASPER Report (Certification and Survey Provider Enhanced Reports) 1705D for Fiscal year Quarter 1 2026 (October 1 - December 31), run on 4/20/2026, indicates the following: Submitted Weekend Staffing data is excessively low. On 04/28/2026, Surveyor conducted a review of the schedules provided by the facility for the weekends during October- December 2025. It was noted there was a RN (Registered Nurse) or LPN (Licensed Practical nurse) on each shift as well as CNA (Certified Nursing Assistants) designated for each shift and units. If the facility had any unfulfilled hours, they would use agency although this was not frequently a concern. The schedules designated the charge nurse on each shift. Surveyor conducted a review of the Facility Assessment Tool, last reviewed/updated 1/27/26, which documents, Staffing: 7-10 RN providing direct care. 2 RNs with administrative duties. 12-16 LPNs providing direct care. 4-6 Medical Aides/Technicians. 32-38 CNAs. 1 Infection Preventionist. 1 MDS (Minimum Data Set). Direct care staff is calculated based upon acuity of resident needs and ADL (Activities of Daily Living) index scored; flexibility is allowed due to the nature of admissions and discharges for short term and long-term care resident needs reflected in the activities of daily living index reflected on the MDS. Staffing is adjusted based on resident clinical needs. On 04/22/2026 at 9:56 AM, Surveyor interviewed Scheduler-H who has been in this position for approximately 6 weeks. Scheduler-H stated she makes the schedule the same for the weekends as during the week. If there is a call-in, they will send out a message for staff to help. Scheduler-H stated the facility will also use agency staffing for call-ins. Scheduler-H stated she does not know why the staffing data report would indicate there is low weekend staffing and is not sure who submits the report. On 4/28/26, at 1:16 PM, Surveyor interviewed Director of Labor Management-I who stated they are aware of the staffing data report triggering for low weekend staffing and it is something they reviewed. Director of Labor Management-I stated she does not see why it would trigger but then stated facilities struggle with putting agency staff down, especially on the weekend. Director of Labor Management-I stated the office is closed and if the facility does not use good documentation, it is hard to reconcile punches and agency staff are not always counted. Director of Labor Management-I then stated it's a struggle to get the agency staff into the clock and capture those hours. Director of Labor Management-I stated she is new to the position and put a new process in place. As of the time of exit, the facility was not able to provide additional information regarding the inaccurate submission of staffing information, triggering excessively low weekends from October 1- December 31, 2025.

Based on observation, interview and record review the facility did not ensure residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 6 (R14 and R3) residents reviewed for pressure injuries. R14 did not have care plan interventions of a pillow under her legs while in chair implemented during survey. R3 had a delay of comprehensive assessment of her pressure injury upon return from an appointment. Findings include: The facility policy titled Pressure Injury Prevention and Management reviewed/revised 1/2026 documents (in part) . This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. 2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk a. Licenses nurses will conduct a pressure injury risk assessment, using the Braden risk assessment on all residents upon admission/readmission, weekly for 4 weeks, then quarterly or whenever the resident's condition changes significantly. c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. d. Assessments of pressure injuries will be performed by a licensed nurse. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. f. Interventions will be documented in the care plan and communicated to all relevant staff. R14's care plan documents: At risk for impaired skin integrity related to hx (history) of MASD (moisture associated skin damage) to sacrum, hx of DTI (deep tissue injury) to right foot and heel, Activity intolerance, cystitis, Alzheimer's, dementia, degenerative disease, anxiety, IBS (irritable bowel syndrome), age related cognitive disorder, reduced mobility, abnormal mobility, sinusitis, meds pain, incontinence, hallucinations , refusals of cares, refusals to turn/reposition, offload, refusals of meds, poor intake, weight loss, HX of sacral excoriation 3/23/26: R (right) calf and R post thigh- DTI 3/25/26: R medial & lateral foot, R first digit DTI - date Initiated 7/5/24, revision on 3/25/26. Interventions include: -Encourage and assist resident to reposition frequently. Encourage and assist to elevate heels off surface of bed. Pressure relieving cushion to wheelchair. Skin inspection: requires a skin inspection weekly and with cares. Observe for redness, open areas, scratches, blisters cuts, bruises – date initiated 7/5/24. -5/18/25 Encourage to off load buttocks when at rest in bed and on chair using wedge or pillow or rolled blanket, also replaced cushion to Broda chair. -Low air loss mattress to bed. Check function q (every) shift. Settings to resident weight or resident comfort - date Initiated 5/19/25. -Ensure she is positioned with BLEs (Bilateral Lower Extremities) away from table during meal to decrease risk of injury and promote skin integrity – date initiated 6/24/25. -8/11/25 encourage to wear boots at rest instead of shoes. -Gentle perineal care after each incontinence episode, application of barrier cream and frequent position changes – date initiated 12/26/25. -Pillow encouraged behind resident's legs while up in Broda chair to keep a barrier between legs and footrest to prevent further skin injury r/t (related to) friction - date initiated 3/24/26. -3/25/26: New heel boots, dietician review, and order for therapy to eval and treat for w/c (wheelchair) positioning. On 4/26/26 at 10:06 AM, Surveyor observed R14 sitting in the dining room in her Broda chair. R14 had grey heel protective boots on both feet extending to her knees. There was no pillow under her legs. On 4/27/26 at 10:05 AM, Surveyor observed R14 lying in her Broda chair, reclined all the way back with her legs elevated. She was wearing grey heel protective boots and there was no pillow under her legs. Surveyor observed R14 to be moving her legs around while in the chair. R14's April 2026 Treatment Administration Record documents: Wound care right lateral foot and heel cleanse with wound cleanser, pat dry, apply xeroform f/b (followed by) bordered gauze in the evening every Monday, Wednesday and Friday. Encourage pillow behind legs when up in Broda chair to prevent skin injury every shift – order date 3/24/26. Surveyor noted this was signed as completed every shift. On 4/28/26 at 7:32 AM, Surveyor observed R14 sitting in her Broda chair in the dining room. Her legs were elevated, and she was wearing grey boots on both feet, but there was no pillow under her legs. Surveyor noted her legs were in a bent position, turned toward the left side with the right knee on top of the left. 4/28/26 at 1:30 PM, Surveyor observed R14 sitting in her Broda chair in the dining room in the same position as previously observed and there was not a pillow under her legs. Surveyor asked the CNA if R14 lays down after meals. Surveyor was told R14 lays down after lunch. Surveyor observed the CNA transfer R14 to bed and visualized her skin. R14's buttocks had no open areas or signs/symptoms of skin breakdown. Surveyor observed a dressing to the lateral side of her right foot dated 4/27. On 4/29/26 at 8:37 AM, Surveyor observed R14 sitting in her Broda chair in the dining room. She was wearing her heel protective boots, but there was no pillow under her legs. 4/29/26 at 10:31 AM, Surveyor asked to view R14's pressure injury. Unit Manager (UM)-G brought R14 to her room. Surveyor observed a pillow under her legs. UM-G removed the dressing from her right foot revealing a small scab-like area to the right lateral foot. The area was dry, and surrounding skin was intact with no redness or signs of skin breakdown. Surveyor and UM-G discussed the evolution of wounds. UM-G reported when the areas were found, it was determined it was likely from squirming/moving around legs in the Broda chair and friction from the leg rest. UM-G reported R14 was provided new protective boots that extend to her knees with sheepskin inside and a pillow under her legs to prevent further rubbing. Surveyor advised UM-G of observations and concern that care plan interventions of a pillow under her legs has not been in place during survey. R14's wound physician note dated 4/22/26 documents: Right lateral foot 1.5 x 1.5 x 0.1 necrotic tissue 100 %. Improved evidenced by decreased surface area. On 4/29/26 at 9:30 AM, Surveyor advised Director of Nursing (DON)-B of concern regarding observations of R14's care plan interventions for pressure injury not in place during survey. No additional information was provided R3 was admitted to the facility on [DATE]. R3's diagnoses include left humerus fracture, hemiplegia, Type 2 Diabetes with polyneuropathy, fall, muscle wasting, lack of coordination and dementia. R3's Significant Change Minimum Data Set (MDS) completed on 2/23/26, documents R3 is dependent on staff for toileting, dressing, rolling left to right and transfers. R3 was documented as having a Brief Interview for Mental Status (BIMS) score of 9, indicating that R3 has moderate cognitive impairment. R3's Care Area Assessment (CAA) documents the following: Cognitive Loss/Dementia CAA: R3 displays some impairments in memory, judgement, safety awareness, and problem solving. A diagnosis of dementia appears to be directly contributing to R3's cognitive deficits. R3 has hearing impairment which affects R3's ability to hear and understand spoken words appropriately. No mood or behavioral issues were reported. Medical problems combined with a diagnosis of dementia may be contributing to cognitive deficits. Medical problems do not appear to be affecting cognitive functioning. R3 needs assistance with ADL's (Activities of Daily Living) due to both diminished cognitive and physical functioning. R3 has hearing impairment which affects R3's ability to hear and understand spoken words appropriately. Cognitive deficits affect R3's ability to safety care for R3's self and/or to appropriately direct R3's own care. Supervision and guidance are indicated. Visual Function CAA: R3 has a history of corneal erosion, brow ptosis, pseudophakia and retinal hemorrhage. R3 has impaired vision. Care Plan is in place to address visual impairment and complication risk. R3's care plan, documents the following: R3 has a self-care deficit related to activity intolerance, hemiplegia, type 2 diabetes, hyperlipidemia, hypertension, weakness, atrial fibrillation, low back pain, micturition, dementia, pain, medications and decrease in mobility (date initiated 12/20/24). Interventions include: -R3 requires 1 staff member for assistance with bathing/showering. R3 is able to wash R3's face, upper body, peri area and hands (date initiated 12/20/24). -R3 requires assistance of two staff members with Hoyer transfers (date initiated 5/22/25, last revised on 8/15/25). -R3 requires assistance of one staff member with dressing, undressing and bathing (date initiated 12/20/24). -R3 requires assistance of one staff member with toileting needs (date initiated 12/20/24). -R3 requires assistance of one staff member with wheelchair mobility (date initiated 12/20/24, last revised on 8/15/25). -R3 is to wear a brace to the left are at all times for two more weeks (date initiated 4/14/26). -R3 requires assistance of two staff members with bed mobility (date initiated 2/8/26). R3 has an alteration/potential for alteration in skin integrity with history of brief abrasion to the right buttocks, lower extremities, abscess to the left breast, and unstageable left posterior elbow post-surgery, related to activity intolerance, hemiplegia, type 2 diabetes, hyperlipidemia, hypertension, weakness, atrial fibrillation, low back pain, micturition, dementia, pain, medications and decrease in mobility (date initiated 12/20/24, last revised on 4/26/26). Interventions include: -R3 requested the air mattress been removed, risks and benefits discussed (date initiated 4/21/25). -Administer treatments as ordered and monitor effectiveness (date initiated 12/20/24). -Braden assessment on admission and per policy (date initiated 12/20/24). -Skin checks around soft cast to left upper extremity (date initiated 2/20/26). -Monitor/document/report to MD (Medical Doctor) as needed changes in skin status; appearance, color, wound healing, signs/symptoms of infection, wound size and stage (date initiated 12/20/24). -Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse (date initiated 12/20/24, last revised on 8/15/25). -Observe for redness, open areas, scratches, blisters, cuts and bruises. Report to nurse/MD (date initiated 12/20/24, last revised on 2/20/26). -Turn and reposition every 2-3 hours or as tolerated (date initiated 12/20/24). -Update MD for signs/symptoms of infection or deterioration of wound/skin (date initiated 12/20/24). Surveyor reviewed R3's EMR (Electronic Medical Record) which documents the following: R3 sustained a fall with injury on 2/8/26. R3 had ORIF (open reduction and internal fixation) (surgical repair) of the left humerus (left upper arm) on 2/11/26. R3 was sent back to the facility with a non-removeable splint placed for two weeks. R3 followed up with orthopedic surgery on 2/25/26 with orders to remove the left arm splint and work on passive ROM (range of motion). On 3/25/26, R3 followed up with orthopedic surgeon who placed a long arm fiberglass posterior slab splint, with orders for R3 to wear the splint 24/7 and do not remove. R3 was noted to have wrist drop due to radial nerve palsy which prompted the change for orthopedic surgery to place the non-removeable splint. On 4/1/26, R3 followed up with orthopedic surgeon with orders to continue the non-removable splint. On 4/13/26, R3 followed up with orthopedic surgeon with orders to continue the non-removable splint for 2 more weeks. On 4/27/26, R3 followed up with orthopedic surgeon. R3 was noted to have a healing ulceration of the left elbow, left wrist drop and flexion contracture (chronic joint condition where soft tissues become shortened and stiff, causing the joint to get stuck in a bent position that cannot be fully straightened). R3's non-removable splint was discontinued with recommendations to perform daily dressing changes using Xeroform 4 x 4 gauze and to place an ace wrap. Surveyor reviewed R3's TAR (Treatment Administration Record) which documents the following: -2/8/26 - immobilizer, splints, braces and casts. Skin check every shift. If there are positive findings, contact the MD. Keep left arm elevated every shift for broken left arm. -2/25/26 - Posterior elbow bandage change every day. -2/25/26 - Skin checks to be performed every shift. Splint to LUE (Left Upper Extremity). -3/10/26 - daily skin evaluation; monitor intact skin to identify any new or developing skin impairments, redness or breakdown every shift for skin monitoring. Notify the MD for any alteration in skin integrity. -4/8/26 - complete weekly skin check done by the nurse on bath day in the morning every Monday for shower day. On 4/29/26, at 8:30 AM, Surveyor reviewed R3's EMR which documents the facility performed wound care dressing change on 4/28/26. Surveyor notes R3 returned from Orthopedic Surgery with a non-removeable splint that was discontinued on 4/27/26, with orders to perform daily dressing changes to R3's left arm wound. On 4/29/26, Surveyor notes there is no comprehensive wound assessment performed for R3's left arm wound as of 4/29/26, at 8:30 AM. On 4/29/26, at 9:04 AM, Surveyor interviewed UM (Unit Manager)-L who stated R3 had a non-removable plaster cast that was placed by orthopedic surgery on 3/25/26, with orders explicitly stating, do not remove. UM-L stated R3 returned to the facility on 4/27/26, from an orthopedic surgery follow up appointment with the cast removed and an ace wrap and orders for wound care to be performed daily. UM-L stated she took off R3's ace wrap on 4/27/26 to evaluate R3's arm because the facility has not been able to see R3's arm since 3/25/26. UM-L stated the facility wound MD is not currently following R3 due to Orthopedic Surgery managing R3's left arm wound. Once Orthopedic Surgery has signed off, the facility wound MD will follow if appropriate. UM-L stated she will still see R3 weekly on Wednesdays during wound care rounds and perform a skin and wound assessment and will contact the Orthopedic Surgeon with any concerns or updates. Surveyor asked UM-L what the expectation is for a comprehensive wound assessment. UM-L stated normally the expectation is within 24 hours of discovery. UM-L stated she attempted to perform an evaluation on 4/27/26, and R3 declined. Surveyor asked UM-L if this was documented in R3's EMR and UM-L stated she does not think she documented it. Surveyor notified UM-L of concerns with R3 returning from the Orthopedic appointment on 4/27/26 with daily wound care orders with no comprehensive assessment documented as of 4/29/26 at 9:04 AM. On 4/29/26, at 9:21 AM, Surveyor observed wound care with Director of Nursing (DON)-B and UM-L. Surveyor observed DON-B and UM-L perform EBP (Enhanced Barrier Precautions) appropriately wearing a gown and gloves prior to entering R3's room with supplies already on R3's bedside table. R3 was observed laying supine in bed with the head of the bed approximately 45 degrees and R3's left arm elevated on a pillow. R3 was observed wearing a glove on R3's left hand. UM-L removed R3's old dressing dated 4/28. R3's wound was noted to be 100% granulation measuring 1 x 1 cm. UM-L and DON-B applied saline spray and applied Xeroform dressing. UM-L and DON-B then wrapped an ace wrap around R3's left arm and elbow, asking R3 if the ace wrapping was too tight and/or comfortable. Surveyor observed appropriate hand hygiene and EBP throughout the wound care observation. On 4/29/26, at 12:35 PM, Surveyor interviewed DON-B who stated the root cause for R3's wound was due to the medical device placed during surgery. DON-B stated R3's arm was slowly rubbing on the brace which caused the wound to develop. Surveyor asked DON-B what the wound looked like after R3 returned from the Orthopedic Surgeon's office on 4/27/26. DON-B stated a comprehensive assessment will be completed on Wednesday's during wound care rounds. Surveyor asked DON-B what the expectation is on when a comprehensive assessment should be completed now that the facility is able to remove R3's wrapping and noted the facility has not been able to view R3's arm since 3/25/26, when the non-removeable cast was placed. DON-B stated, I see what you're saying, and we completed a comprehensive assessment earlier today on 4/29/26. Surveyor notified DON-B of concerns with R3 returning from the Orthopedic appointment on 4/27/26, with a removeable ace wrap and orders to perform daily wound care dressing changes, with no comprehensive assessment completed until 4/29/26. DON-B acknowledged these concerns. On 4/29/26, at 12:56 PM, Consultant-C notified Surveyor, today (4/29/26) was the first day the facility completed wound care on R3. Surveyor notified Consultant-C that R3's EMR documents wound care being performed on 4/28/26 and Surveyor observed wound care earlier today (4/29/26), and noted the old dressing being dated 4/28/26.

Based on observation, interview and record review, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 (R76) residents observed during medication pass.R76's prescribed Lorazepam was not available at the facility, and the nurse was unable to remove it from the facility contingency supply because there was no handwritten prescription (script) provided by the physician for the medication. The handwritten script is provided to the pharmacy who in turn supplies the facility with a code which allows the facility to remove the medication from their contingency supply.Findings include:The facility policy titled Unavailable Medications reviewed/revised 1/2026 documents (in part) .This facility shall use uniform guidelines for unavailable medications.1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, PRN (as needed) and emergency medications.2. A STAT (immediate) supply of commonly used medications is maintained in-house for timely initiation of medications.3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications.4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable.a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility of pharmacy provider to obtain the medication.b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available.R76 admitted to the facility on [DATE] with diagnoses that include generalized anxiety disorder.Physician orders upon admission included: Lorazepam 0.5 mg (milligrams), give 1 tablet by mouth two times a day for anxiety and Lorazepam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety for 14 days. On 4/27/26 at 10:36 AM, Surveyor observed Licensed Practical Nurse (LPN)-E prepare medications for R76. While preparing R76's medications, LPN-E was unable to locate Lorazepam 0.5 mg (milligrams) in the medication cart. LPN-E stated, Maybe it's in the other med (medication) cart. LPN-E prepared the remaining medications, and they were given to R76 with water. LPN-E then walked to the other med cart to look for the Lorazepam; it was not in the med cart. Surveyor asked LPN-E what she would do in this situation. LPN-E reported she would remove the medication from contingency and call the pharmacy. On 4/27/26 at 10:57 AM, Surveyor observed LPN-E on the phone at the nurse's station. Surveyor heard LPN-E say, So it was never shipped out because you need a script for it. OK, I'll call the doctor. LPN-E told Surveyor R76's Lorazepam was never sent because they (pharmacy) didn't have a script. LPN-E stated, I'm going to call the doctor now.Surveyor reviewed R76's April 2026 Medication Administration Record (MAR) which documented: Lorazepam Oral Tablet 0.5 mg. Give 1 tablet by mouth two times a day for anxiety - order Date 4/24/26.The MAR documents 7 = other/see nurses notes on 4/25/26 AM and PM, 4/26 AM and PM and 4/27 AM which indicates 5 doses were not given. R76's EMAR (Electronic Administration Record) notes document:-4/25/26 at 10:48 AM, Lorazepam Oral Tablet 0.5 mg give 1 tablet by mouth two times a day for anxiety - not available.-4/25/26 at 9:28 PM, Lorazepam Oral Tablet 0.5 mg Give 1 tablet by mouth two times a day for anxiety med was not available, called pharm, they said they didn't have a script. HUCU (system for physician notification) the Dr (doctor), got a script. Resident stated she was tired and was going to sleep, if she was asleep when I got everything resolved to just leave it she doesn't want to be woken up.-4/26/26 at 10:26 AM, Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth two times a day for anxiety - not available.-4/26/26 at 8:05 PM, Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth two times a day for anxiety waiting on pharmacy on PM run.-4/27/26 at 11:47 AM, Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth two times a day for anxiety new script needed. Medication was never initiated. APNP (Advanced Practice Nurse Practitioner) put in for a psych consult.Facility progress notes document (in part) .On 4/27/26 at 2:45 PM, APNP initial visit: Patient had behavioral concerns overnight on 4/16/2026, including calling the police multiple times. Continue lorazepam 0.5 mg PO (by mouth) BID (twice daily) scheduled with 0.5 mg PO Q8H (every 8 hours) PRN (as needed) breakthrough anxiety.On 4/27/26 at 2:58 PM, F/U (follow up) Recent admit: Resident adjusting to facility well, able to make needs known. Appetite is good, usually asks for extra food with meals. Resident has been requesting Lorazepam 0.5mg tab, no script, NP made aware. Psych consult put in r/t (related to) anxiety/depression. No further concerns at this time.On 4/27/26 at 9:42 PM, F/U Recent admit: Resident adjusting to facility well, able to make needs known. Resident has been requesting Lorazepam 0.5mg tab, script received and given per order with HS (hour of sleep) meds.Surveyor noted R76's scheduled Lorazepam signed as given on 4/27/26 PM and thereafter. On 4/28/26 at 10:25 AM, Surveyor asked Director of Nursing (DON)-B what the procedure is for obtaining medication requiring a handwritten script upon admission. DON-B stated, We need a script, we can't take out anything from contingency until we get an authorization code from pharmacy and for that we need a script. Surveyor advised DON-B of concern R76 was admitted to the facility and missed at least 5 scheduled doses of Lorazepam because a script was not available. Consultant-C stated, There's charting every day about the script, they were calling pharmacy and the doctor to get it. Consultant-C provided Surveyor the HUCU communication between the facility and the Physician Assistant which documented:On 4/25/26, at 7:29 PM, hello I just called [pharmacy name] and they said they don't have a script for lorazepam 0.5 mg and would need it in order to give me a code for RX (perscription).7:40 AM (PA) what is the order.9:04 PM Lorazepam oral tab 0.5 mg, 1 tab po (by mouth) twice daily.9:05 PM (APNP) will send short tx (treatment).4/27/26 at 11:01 AM Lorazepam oral tab 0.5 mg 1 tab po twice daily needs script. Surveyor and Consultant-C reviewed the facility progress notes together. Surveyor advised documentation indicated the medication was not available or waiting on pharmacy run. Surveyor informed Consultant-D of the concern R76 was admitted to the facility on [DATE] with orders for scheduled Lorazepam twice daily and a script was not obtained until 4/27/26 after the facility was advised of Surveyors' concern during med pass. R76 missed at least 5 doses of scheduled Lorazepam.On 4/28/26 at 9:52 AM, Surveyor interviewed R76. Surveyor advised R76 after reviewing her medical record it was noted she has an order for Lorazepam. R76 stated, Yes, for my anxiety. Surveyor asked R76 if she was aware she had not received her Lorazepam for a few days after admission. R76 stated, Oh yes, I can tell. I kept asking for it and they kept telling me they don't have it. It was very frustrating, I figured if I was coming here, they would have all my medications in order. They did finally get it, I got one today and I'm so glad, because I'm having surgery today and I needed it for my anxiety.On 4/28/26 at 10:25 AM, the facility was informed of the above concerns regarding R76's missed doses of scheduled Lorazepam. No additional information was provided.

Based on observation, interview and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficient practice had the potential to affect 4 (R3, R18, R24 and R56) of 4 residents residing on the unit that require blood sugar testing.The glucometer that is shared between residents was not cleaned between resident use.Findings include:The facility policy titled Glucometer Disinfection reviewed/revised 1/2026 documents (in part) .The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms except bacterial spores on inanimate objects.The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The glucometers will be disinfected with a wipe pre-saturated with an EPA (environmental protection agency) registered healthcare disinfectant that is effective against HIV (Human Immunodeficiency Virus), Hepatitis C (HVC) and Hepatitis B (HVB) virus. Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Procedure:Retrieve (2) disinfectant wipes from container. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. All the glucometer to air dry. On 4/28/26 at 7:50 AM, Surveyor asked Licensed Practical Nurse (LPN)-F if she had any blood sugar reading to do. LPN-F stated, Yes. LPN-F gathered supplies of a glucometer, lancet and alcohol wipes in a cup, and entered R24's room. LPN-F washed her hands, applied gloves and obtained R24's blood sugar. LPN-F then wiped the glucometer with an alcohol wipe for approximately 5 seconds. LPN-F then entered R56's room, washed her hands, applied gloves and obtained R56's blood sugar using the same glucometer. After obtaining R56's blood sugar, she wiped the glucometer with an alcohol wipe for approximately 5 seconds, before placing it on the mediation cart. Surveyor asked what is used to clean the glucometer. LPN-F stated, I use an alcohol wipe, but I know there's also bleach wipes in the med cart. Surveyor removed a container labeled Micro kill bleach germicidal bleach wipe from the medication cart. The label on the container documents (in part) .3-minute C diff (Clostridium Difficile) spore kill time. Kills HIV-1, HBV and HCV on precleaned environmental surfaces/objects previously soiled with blood/body fluids. Contact time: Allow surface(s) to remain visibly wet for 30 seconds to kill the bacteria and viruses on the label except a 1-minute contact time is required to kill Candida Albicans and Trichophyton Interdigitale, a 2-minute contact time is required to kill Candida Auris and a 3- minute contact time is required to kill clostridium difficile spores.On 4/28/26 at 8:10 AM, Surveyor advised Director of Nursing (DON)-B of concern the glucometer that is shared and used between residents was not cleaned between resident use. DON-B advised Surveyor the expectation is to use bleach wipes to clean the glucometer and provided Surveyor with a list of residents on the unit that require blood sugar testing and the policy and procedure for glucometer cleaning. Surveyor verified there were no residents on the unit that require blood sugar testing with bloodborne pathogens. No additional information was provided.

Based on observations, interviews and record review, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect 33 residents. * Garbage was observed in the personal protective equipment (PPE) storage. * Dirty linen and used tissues were observed in the basket for the vital signs machine, the machine was brought into R2's room and used on R2. The machine is shared on the unit with potential to affect 33 residents. * R3 was on Enhanced Barrier Precautions (EBP), proper Personal Protective Equipment (PPE) was not worn during cares. * R1, R2, and R4 were observed to not have appropriate hand hygiene during personal care observations. * The mechanical lift was not disinfected after being used for R1, R3, R4, R5, R7, and R8. Findings include: The Handwashing policy and procedure last revised 1/2026 documented: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by washing with soap and water or the use of an antiseptic hand rub, also known as alcohol based hand rub (ABHR). . Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. .Hand Hygiene Table Either soap and water or alcohol based hand rub (ABHR is preferred). between resident contacts before applying an after removing PPE, including gloves before and after handling clean or soiled dressings, linens, etc. before performing resident care procedures before and after providing care to residents in isolation after handling items potentially contaminated with blood, body fluids, secretions, or excretions when, during resident care, moving from a contaminated body site to a clean body site after assistance with personal body functions (eg., elimination, hair grooming, smoking). The Cleaning and Disinfection of Resident Care Equipment policy and procedure, last revised 1/2026 documented: Resident care equipment can be a source of indirect transmission of pathogens. Reusable resident care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. Reusable multiple resident items are items that may be used multiple times for multiple residents. Examples include lifts, stethoscopes, blood pressure cuffs, feeding tubes, rolling vital sign monitor, and oxygen concentrators. . Each user is responsible for routine cleaning and disinfection of multi resonant items after each use, particularly before use for another resident. .Multiple resident use equipment shall be cleaned and disinfected after each use. The Enhanced Barrier Precautions policy and procedure, last revised 1/2026, documented: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms. Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug- resistant organisms that employs targeted gown and gloves use during high contact resident care activities. . In order for enhanced barrier precautions will be obtained for residents with any of the following: -.wounds. . PPE for enhanced barrier precautions is only necessary when performing high contact care activities. . High contact resident care activities include: dressing bathing transferring providing hygiene changing linens changing briefs or assisting with toileting device care. wound care. 1. On 2/23/26, at 9:08 AM, Surveyor observed multiple articles of garbage in the Personal Protective Equipment (PPE) carts outside multiple residents' rooms. multiple carts contained balled up paper from used straws in the top drawers. One cart contained packing from cookies in the bottom drawer with clean gowns. These carts hold clean PPE to be donned before going into a resident's room. On 2/23/26, at 10:07 AM, Surveyor observed another PPE cart to have balled up paper from used straws with the clean PPE in the top drawer of the cart. 2. On 2/23/26, at 9:23 AM, Surveyor observed dirty linen and tissues with a dried red substance on them in the basket of the rolling vital signs monitor. The blood pressure cuff, thermometer, and pulse oximeter were sitting on top of the dirty linen and tissues with dried red substance. On 2/23/26, at 10:48 AM, Surveyor observed Licensed Practical Nurse (LPN)-K bring the rolling vital signs monitor with dirty linen and used tissues into the room with R2. LPN-K then applied the blood pressure cuff on R2's arm. Surveyor did not observe LPN-K wipe down the blood pressure cuff prior to applying it to R2's arm. LPN-K then left R2's room and grabbed a manual blood pressure cuff from the nurse's cart, applied it to R2's arm, then returned the manual blood pressure cuff to the cart. LPN-K did not wipe down the manual blood pressure cuff before storing it in the nurse's station. On 2/23/26, at 11:36 AM, Surveyor interviewed LPN-K. LPN-K stated the rolling vital signs monitor is shared on the unit between 33 residents. LPN-K stated the rolling vital signs machine was used on some residents. Surveyor asked LPN-K what was in the basket of the rolling vital signs machine, LPN-K stated dirty linens and used tissues. LPN-K stated the dirty linen and tissues were not supposed to be there, and LPN-K did not notice the dirty linens or tissues on the rolling vital signs machine when it was used that morning. 3. R3 was admitted on [DATE] with diagnoses that include aftercare following Joint Replacement Surgery, Infection and Inflammatory Reaction Due To Internal Left Knee Prosthesis (The material used to replace the knee joint was infected), Type 2 Diabetes (the body cannot use insulin correctly, causing sugar in the blood to accumulate and cause death if not treated), Primary Hypertension (chronic high blood pressure), vitamin D deficiency (decreased immune response), and Stage 3 Chronic Kidney Disease (moderate damage to kidneys causing waste to build in the body). R3's admission Minimum Data Set (MDS) dated [DATE], which is in progress, documented R3's Brief Interview for Mental Status (BIMS) of 14, which indicated R3 is cognitively intact. The MDS documented R2 required set up assistance for personal hygiene and eating, partial assistance for upper body dressing, substantial assistance with oral hygiene, showering, and lower body dressing, and staff dependent on toileting hygiene and applying and removing footwear. R3's current Physician orders: Isolation: Enhanced Barrier Precautions; Resident is currently on Enhanced Barrier Precautions, follow isolation guidelines; wound every shift for isolation precautions. Start date 2/18/26 R3's care plan documented: The resident is on prophylactic abx (antibiotics) post knee surgery. Initiated 2/19/26. Maintain universal precautions when providing resident care. Initiated 2/19/26 R3's Kardex which indicated to CNA staff how to care for R3, does not have Enhanced Barrier Precautions or any precautions listed for R3. On 2/23/26, at 9:31 AM, Surveyor observed no EBP signs or PPE storage outside of R3's room. Surveyor observed Infection Preventionist (IP) – E and Certified Nursing Assistant (CNA)- I exit R3's room. There was no discarded PPE in the room or carried out of the room. On 2/23/26, at 9:36 AM, Surveyor observed IP-E applied a EBP sign and PPE storage cart outside of R3's room. On 2/23/26, at 11:15 AM, Surveyor observed CNA-I and CNA-J go into R3's room with a mechanical lift and did not apply PPE. CNA-J returned the mechanical lift to the utility room and did not sanitize after use. On 2/23/26, at 11:20 AM, Surveyor Interviewed CNA-J. CNA-J stated they helped CNA-I transfer R3 with a mechanical lift. CNA-J stated R3 is a newer resident and is not sure if R3 is on any precautions. CNA-J did not see any sign or PPE storage outside of R3's room to indicate R3 required precautions. CNA-J stated they did not wear any PPE as CNA-J and CNA-I were only transferring R3. CNA-J stated transferring residents is not included in the list of high contact care activities requiring the use of PPE. Surveyor asked CNA-J if there was a list readily available to reference what care activities are included in the precautions list, CNA-J stated they were not sure where to look for that list. Surveyor noted on the EBP sign included the list of high care activities that would require the usage of PPE, and transferring residents was on the list. On 2/23/26, at 11:27 AM, Surveyor Interviewed CNA-I. CNA-I confirmed CNA-J assisted to transfer R3 with a mechanical lift. CNA-I Informed Surveyor that CNA-I was unaware that R3 required EBP. CNA-I confirmed that CNA-I did not wear PPE to transfer R3. CNA-I went to view the room and noted the EBP sign and PPE storage outside of R3's room. CNA-I stated they did not see the sign or storage bin before entering the room. CNA-I showed Surveyor the list of high care activities on the EBP sign and pointed to surveyor that transferring is included in high care activities that require PPE. On 2/23/26, at 10:12 AM, Surveyor observed cares for R2. CNA-I came and got Surveyor to observe R2's care. CNA-I had gloves on. CNA-I returned to the room with the same gloves and began providing care. CNA-I moved the wheelchair, moved the Sit to stand lift, used gloved hand to lean on the wall, assisted to remove R2's brief, assisted to put new clothes on R2, assisted putting R2 into the bathroom with the sit to stand, then left the room, and went to the linen closet in the hallway with the same gloves. CNA-I came out of the linen room with no gloves and completed hand hygiene. CNA-I went back into R2's room and put on new gloves. CNA-I assisted with R2's peri care, removed the sit to stand from the bathroom, assisted putting on a brief on R2, CNA-I then turned on the faucet and placed the clean linen into the sink and pumped the pump part of the soap dispenser, then spread the soap onto the clean linen. R2 then washed R2's face with the contaminated linen. CNA-I then removed the gloves and washed hands. On 2/23/26, at 10:48 AM, Surveyor observed CNA-I come out of R1's room with gloves on, retrieve clean linens from the linen cart, and return to R1's room. On 2/23/26, at 11:13 AM, Surveyor interviewed CNA-I. CNA-I admits they do not normally wear gloves outside of the room and is supposed to remove gloves and do hand hygiene before exiting. CNA-I stated before providing care, the expectation is to perform hand hygiene then apply gloves. CNA-I stated the expectation is to remove gloves and do hand hygiene in between cares going from clean to dirty. On 2/23/26, at 9:48 AM, Surveyor observed CNA-J and CNA-I transferring R8 into a wheelchair using a mechanical lift. After the transfer was complete, CNA-J returned the mechanical lift to the lift storage room, CNA-J did not sanitize the mechanical lift. On 2/23/26, at 10:12 AM, Surveyor observed CNA-J and CNA-I Transfer R7 into a wheelchair using the mechanical lift. After the transfer was complete, CNA-J returned the mechanical lift to the lift storage room and did not sanitize the lift. On 2/23/26, at 11:15 AM, Surveyor observed CNA-J and CNA-I go into R3's room with a mechanical lift to transfer R3. After the transfer was complete, CNA-J returned the mechanical lift to the lift storage room and did not sanitize the lift. On 2/23/26, at 11:20 AM, Surveyor interviewed CNA-J. CNA-J stated lift machines only get wiped down after exiting a room with precautions. CNA-J stated they have not needed to wipe any lifts down yet. On 2/23/26, at 11:27AM, Surveyor interviewed CNA-I. CNA -I stated lift machines are washed at night. CNA-I was asked how often lifts should be sanitized. CNA-I stated after each use. On 2/23/26, at 2:20 PM, Surveyor interviewed IP-E. IP-E admitted to assisting CNA-I with cares for R3 but does not recall if IP-E wore PPE. IP-E admitted to not knowing at the time of R3's care that R3 was on EBP. IP-E admitted R3 did not have EBP signage or PPE storage cart outside of R3's room. When IP-E became aware of R3's precautions, IP-E placed the cart and sign in front of R3's room. IP-E stated all staff are oriented on the different precaution types and have to take a test on it. IP-E also stated, there are signs in front of the residents' rooms to indicate what type of precautions the resident is on, what PPE to wear, and what types of cares require PPE. IP-E expected gloves need to be removed and hand hygiene performed in between care types and going from clean to dirty. IP-E expected gloves to be changed, and hand hygiene performed before and after perineal care. IP-E expected gloves to be removed before exiting a resident's room and hand hygiene preformed. IP-E expected staff to dispose of dirty linen in the dirty linen carts or down the chute to laundry and dispose of garbage in the garbage cans. IP-E stated it was not standard of practice to store dirty linen or garbage in the basket of the rolling vital signs machine or the PPE containers. IP-E expected staff to sanitize the lift machines after every use. On 2/23/26, at 3:03 PM, Surveyor shared infection control concerns of garbage in the PPE storage, dirty linen and used tissues in the basket for the vital signs machine -the machine was used on R2, R3 was on EBP - no PPE was worn during cares for R3; R1, R2, and R4 were observed to not have appropriate hand hygiene during personal care observations; Mechanical lifts were not disinfected after being used for R1, R3, R7, and R8 with Director of Nursing (DON)-B. No additional information was provided regarding the infection control concerns at this time. 4. R4's diagnoses includes multiple sclerosis (disease in which the immune system eats away the protective covering of nerves resulting in disruption in communication between the brain & body), diabetes mellitus (high blood sugar), morbid obesity (high risk health condition defined by a body mass index of 40 or higher), and hypertension (high blood pressure). R4's quarterly MDS (minimum data set) with an assessment reference date of 12/15/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R54 is assessed as being dependent on chair/bed to chair transfer and is always incontinent of urine & bowel. On 2/23/26, at 9:25 a.m., Surveyor observed Certified Nursing Assistant (CNA)-F & CNA-G in R4's room. CNA-F was asking R4 what she would like to wear. CNA-G washed her hands, filled wash basins and placed gloves on. CNA-F washed her hands and placed gloves on. CNA-G uncovered R4 and placed pants on R4. R4 removed her gown and then threw the gown at CNA-F. CNA-G washed R4's upper body, placed the towels in the garbage can next to R4's bed and pulled down R4's incontinence product. Surveyor observed R4's incontinent product contains urine and noted a urine odor. At 9:33 a.m., CNA-G asked CNA-F to get additional towels. CNA-F removed her gloves, did not perform hand hygiene and left R4's room. CNA-G placed a shirt on R4 and a pad inside R4's incontinence product per R4's request. At 9:34 a.m., CNA-F reentered R4's room with towels, washed her hands, and placed gloves on. CNA-G washed under R4's abdominal fold, inner thighs and frontal perineal area. At 9:36 a.m., R4 was positioned on the left side, and the soiled incontinence product was removed. CNA-G washed R4's upper thighs and buttocks. CNA-G did not remove her gloves and perform hand hygiene. CNA-G placed the incontinence product with a pad under R4 and applied barrier cream on R4's buttocks. R4 was positioned on her back, CNA-G pulled the incontinence product up between R4's legs and fastened the right side. CNA-G positioned R4 on the side and CNA-F pulled the product out from under R4's left side and fastened the incontinence product. CNA-F & CNA-G positioned R4 from side to side to pull up R4's pants and place a Hoyer sling under R4. At 9:39 a.m., CNA-G removed towels from the garbage can placing them in a bag and placed the bag next to the door. CNA-G removed her gloves, did not perform hand hygiene, and went in the hallway returning with the Hoyer lift. CNA-F removed her gloves, washed her hands, and placed gloves on. CNA-G placed the Hoyer lift on the left side of R4's bed, emptied the wash basins, washed her hands, and placed gloves on. At 9:42 a.m., CNA-F attached the sling to the Hoyer lift, CNA-F asked R4 if she was ready, R4 was raised off the bed and transferred into a wheelchair. CNA-F placed R4's feet on the footrests and gloves on R4 while CNA-G removed sheet from R4's bed. CNA-F & CNA-G removed their gloves and washed their hands. The Hoyer lift was moved into the hall and CNA-G then removed the soiled linen bags, walked down the hallway to the soiled linen room which is located opposite room [ROOM NUMBER]. Surveyor noted the Hoyer lift used to transfer R4 was not sanitized. On 2/23/26, at 10:03 a.m. Surveyor observed the Hoyer lift continues to be in the hallway and has not been sanitized. On 2/23/26, at 10:23 a.m., Surveyor observed CNA-G wheel the Hoyer lift used to transfer R4 down the hallway into the bath/shower room, and then immediately leave this room. Surveyor observed the Hoyer lift was not sanitized. On 2/23/26, at 12:52 p.m., Surveyor asked CNA-H when lifts are sanitized. CNA-H informed Surveyor they should be sanitized after each use. On 2/23/26, at 1:03 p.m., Surveyor asked CNA-G when lifts are sanitized. CNA-G informed Surveyor the lifts are taken to the shower room and wiped down after each resident with a bleach wipe. Surveyor informed CNA-G after transferring R4 into the wheelchair, the Hoyer lift was placed in the hall. Surveyor has observations of her wheeling the Hoyer lift down the hallway into the shower room, but the Hoyer lift was not sanitized. On 2/23/26, at 2:30 p.m., Surveyor asked Infection Preventionist (IP)-E if staff should perform hand hygiene after removing their gloves and after performing incontinence cares. IP-E replied yes. Surveyor asked IP-E when lifts are sanitized. IP-E informed Surveyor they should be sanitized after every use. On 2/23/26, at 3:06 p.m., Surveyor asked Director of Nursing (DON)-B when lifts should be sanitized. DON-B informed Surveyor they are supposed to be sanitized when they leave the room. Surveyor informed DON-B of hand hygiene concerns and Hoyer lift not being sanitized after R4's transfer. On 2/23/26, at 3:25 p.m., Nursing Home Administrator (NHA)-A, DON-B, Regional Nurse Consultant-C and Chief Compliance Officer-D were informed of the above. No additional information was provided to Surveyor as to hand hygiene concerns and why the Hoyer lift was not sanitized. 5. R5's diagnoses include diabetes mellitus (high blood sugar), atrial fibrillation (irregular and rapid heartbeat), and hypertensive heart disease with heart failure (prolonged high blood pressure that leads to the heart's inability to pump blood effectively). R5's quarterly MDS (minimum data set) with an assessment reference date of 11/26/25 has a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. R5 is assessed as being dependent on chair/bed to chair transfer. On 2/23/26, at 11:31 a.m., Surveyor observed Certified Nursing Assistant (CNA)-F and CNA-H wearing gloves in R5's room. Surveyor observed that R5 is dressed for the day in bed with a Hoyer sling under R5. CNA-H left R5' room, returning with a Hoyer lift. CNA-H attached the sling to the Hoyer lift, lowered the bed, raised the head of the bed, and stated to R5 going up. R5 was raised off the bed and transferred into the wheelchair. CNA-F asked R5 if he needed a boost with R5 responding a little bit. CNA-F & CNA-H repositioned R5 in the wheelchair and then unhooked the sling from the Hoyer lift. At 11:34 a.m. CNA-H removed his gloves and washed his hands. CNA-F wheeled the lift out of R5's room placing the lift in the hallway. CNA-F reentered R5's room, removed her gloves and washed her hands. On 2/23/26, at 11:38 a.m., Surveyor observed CNA-F wheeling the Hoyer lift which was used to transfer R5 from outside R5's room into the bath/shower room and leave the room. Surveyor observed the Hoyer lift was not sanitized. On 2/23/26, at 12:52 p.m., Surveyor asked CNA-H when lifts are sanitized. CNA-H informed Surveyor they should be sanitized after each use. On 2/23/26, at 1:03 p.m., Surveyor asked CNA-G when lifts are sanitized. CNA-G informed Surveyor the lifts are taken to the shower room and wiped down after each resident with a bleach wipe. On 2/23/26, at 2:30 p.m., Surveyor asked Infection Preventionist (IP)-E when lifts are sanitized. IP-E informed Surveyor they should be sanitized after every use. On 2/23/26, at 3:06 p.m., Surveyor asked Director of Nursing (DON)-B when lifts should be sanitized. DON-B informed Surveyor they are supposed to be sanitized when they leave the room. Surveyor informed DON-B of the Hoyer lift not being sanitized after R5 was transferred. On 2/23/26, at 3:25 p.m., Nursing Home Administrator (NHA)-A, DON-B, Regional Nurse Consultant-C and Chief Compliance Officer-D were informed of the above. No additional information was provided to Surveyor as to why the Hoyer lift was not sanitized.

2.) R32 was admitted to the facility on [DATE] with diagnoses which includes fracture of T11-T12 vertebra, chronic kidney disease (characterized by progressive damage and loss of kidney function), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), morbid obesity, anxiety disorder and depression. R32's hospital Discharge summary dated [DATE] includes under discharge diagnoses pressure injury. Under hospital course pressure injury wound care consulted. R32's nurses note dated 4/18/25 at 15:18 (3:18 p.m.) and written by Licensed Practical Nurse (LPN)-W documents New admit head to toe: Resident was brought into facility from [hospital's initials] for rehabilitation around 1230. Resident was in care of [Name] ambulance and transferred from cot to bed and positioned to comfort. Vitals were obtained BP (blood pressure) 129/62, HR (heart rate) 59, spo2 (peripheral oxygen saturation) 94, temp (temperature) 97.4, RR (respiratory rate) 18. Resident had complaints of pain in her upper and lower back from compressions and fractures, no other pain noted at this time. scalp was dry with no signs of bruises or abrasions, ears appeared clear and able to hear and understand directions. Eyes were tracking however, resident stated that she is legal blind which per her definition she cannot see straight ahead but that she can see outlines and fuzzy shapes. face is free from cuts or bruises, neck is able to freely move in all direction with no pain. Resident has bruise on left arm purple and yellow of color ROM (range of motion) present in both arms. chest raises and fall evenly with inhalation and exhalation, lungs sound are clear bilateral, no apparent bruises or abrasions noted. abdomen is soft, bowel sounds normoactive in all 4 quadrants. left left side has multiple bruise location, (1)left side of buttocks, (2) left lateral thigh (3) left side calf. all are a bluish/yellow color. ROM is present bilateral legs but stiff no pain. Back had a lidocaine patch on upper midline, no abrasions or bruising noted under or around the patch. back is clear of all bruising and abrasions. abrasion on left buttock roughly 10 cm long by 1cm wide with no active bleeding at this time. abrasion on right buttock roughly 5cm long by 1cm wide with no active bleeding at this time. resident remained in bed and left in a comfortable position with call light and bed controls within reach. R32's admission/readmission assessment dated [DATE] completed by LPN-W for the skin section under details/comments documents (1) left buttock abrasion 10cm (centimeter) by 1cm. (2) right buttock abrasion 5cm by 1cm. (3) left upper arm bruising. (4) left hip bruising. (5) left thigh bruising. (6) left lower calf bruising. Surveyor noted there is no Registered Nurse (RN) assessment of R32's buttocks until 4/23/25, 5 days after admission. R32's Braden assessment dated [DATE] has a score of 14 which indicates moderate risk. R32's potential for impairment to skin integrity care plan initiated 4/18/25 & revised 5/15/25 documents the following interventions: Low air loss mattress to bed. Check function q (every) shift. Settings to resident weight or resident comfort. Initiated 4/24/25 & revised 5/15/25. Encourage good nutrition and hydration in order to promote healthier skin. Initiated 4/18/25. Encourage me to elevate my heels. Initiated 4/28/25. Encourage me to offload my heels. Initiated 4/28/25. Encourage/assist me with reposition as needed. Initiated 4/24/25. Keep my linen dry, clean, and free of wrinkles. Initiated 4/28/25. My skin will be assessed on a weekly basis on my scheduled bath day and document findings on a weekly skin assessment. Initiated 4/24/25. Report any skin redness/impaired integrity areas to my nurse. Initiated 4/24/25. Use draw sheet or lifting device to move resident. Initiated 4/28/25. Use barrier cream to prevent skin impairment issues, as needed. Initiated 4/28/25. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Initiated 4/28/25. R32's modification of admission MDS (minimum data set) with an assessment reference date of 4/20/25 has a BIMS (brief interview mental status) score of 6 which indicate severe impairment. R32 is assessed as not having any behavior including refusal of cares. R32 is assessed as requiring partial/moderate assistance for toileting hygiene, supervision/touching assistance for roll left & right, and dependent for chair/bed to chair transfer. R32 is assessed as always incontinent of urine and bowel. R32 is at risk for pressure injury development and has two unstageable slough and/or eschar pressure injuries which were present on admission. R32's pressure injury CAA (care area assessment) dated 4/28/25 under analysis of findings for nature of problem/condition documents Resident has 2 unstageable due to necrosis pressure injuries. Resident has a pressure relieving mattress and cushion to her manual wheelchair. Under care plan considerations documents Resident's pressure ulcers will improve with treatments. Advanced Practice Nurse Prescriber (APNP)-BB initial visit dated 4/22/25 does not address R32's pressure injuries. On 4/23/25 R32 was seen during wound rounds by Wound Nurse/Registered Nurse (WN/RN)-J and Wound Doctor (WD)-CC. This assessment is 5 days after R32 was admitted to the facility. WD-CC initial wound evaluation dated 4/23/25 documents for the left buttock etiology as pressure, Stage is Unstageable Necrosis, wound size for length is 8 cm (centimeters), width 9 cm, and depth is 0.1 cm. Thick adherent devitalized necrotic tissue is 40 % and intact normal color skin is 60%. The right buttock etiology is pressure and stage is unstageable necrosis. Wound size for length is 8 cm, width is 2 cm and depth is 0.1 cm. Thick adherent devitalized necrotic tissue is 30% and granulation tissue is 70%. Surveyor noted weekly assessments of R32's right and left buttock. R32's right buttock pressure injury resolved on 5/7/25 and the left buttock pressure injury resolved on 5/14/25. R32's weight on 5/18/25 was 220.5 pounds, on 5/19/25 221.5 pounds, and on 5/20/25 224.3 pounds. On 5/18/25, at 11:18 a.m., Surveyor observed R32's air mattress is set at 340 pounds. On 5/19/25, at 6:59 a.m., Surveyor observed R32 in bed on the right side. R32 has a comforter covering her head down to her feet. R32's air mattress is set at 340 pounds. On 5/19/25, 1:58 p.m., Surveyor observed Certified Nursing Assistant (CNA)-X provide incontinence cares to R32 who was incontinent of bowel. Surveyor observed the air mattress is set at 340 pounds. After CNA-X was finished with providing incontinence cares, a new incontinence product was placed on R32 and R32 was covered with bedding. The head of R32's bed was elevated, the call light was placed in reach and R32's bed was lowered. Surveyor observed R32's heels are resting directly on the mattress and are not being off loaded nor did CNA-X speak with R32 about offloading her heels. On 5/20/25, at 6:52 a.m., Surveyor observed R32 in bed on her back with the head of the bed elevated. R32 is wearing black gripper socks and R32's heels are resting directly on the mattress. R32's air mattress is set at 340 pounds. On 5/20/25, at 8:32 a.m., Surveyor observed R32 asleep in bed on the right side. R32 is now covered with an additional white blanket and R32's heels are not being offloaded. On 5/21/25, at 7:06 a.m., Surveyor observed R32 awake in bed on her back. Surveyor observed R32's heels are not being offloaded and the air mattress is set at 340 pounds. On 5/21/25 at 7:09 a.m. Surveyor asked R32 if staff has spoken to her about keeping her heels off the mattress. R32 replied no. On 5/21/25, at 12:29 p.m., Surveyor asked Wound Nurse/Registered Nurse (WN/RN)-J when a resident is admitted who assesses the residents skin. WN/RN-J informed Surveyor the admitting nurse. Surveyor asked WN/RN-J when would she or another RN assess the skin. WN/RN-J informed Surveyor she could be a second set of eyes if the nurse requests and then they do their weekly wound rounds with the doctor on Wednesday. Surveyor asked WN/RN-J if a resident comes in with a pressure injury on Saturday when would she assess the area. WN/RN-J informed Surveyor if the nurse wanted her to see it she would see it. Surveyor asked WN/RN-J when would she do an assessment. WN/RN-J replied Wednesday. Surveyor informed WN/RN-J of the concern that R32 pressure injuries were not assessed until 5 days later. WN/RN-J replied that's not how her role is. On 5/21/25, at 12:35 p.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-E how the air mattress should be set. LPN/UM-E informed Surveyor by the residents weight. Surveyor then asked LPN/UM-E to accompany Surveyor to R32's room where Surveyor showed LPN/UM-E R32's air mattress was set at 340 pounds and on May 20th R32 weight was 224.3 pounds. LPN/UM-E informed Surveyor it can be set for the resident's comfort. Surveyor informed LPN/UM-E of the observations of R32's heels not being offloaded or asking R32 to offload her heels. 3.) R64's diagnoses includes dementia, mild protein calorie malnutrition, spinal stenosis (space inside the bones of spine get too small putting pressure on the spinal cord), hypertension (high blood pressure) and anxiety disorder. R64 receives hospice services. R64's alteration in skin integrity care plan initiated 11/28/24 & revised 5/15/25 documents the following interventions: 1/18/25 assessed brief size and tightness noted to be tight - sized up one size. Encourage resident to communicate any discomfort related to brief tightness & sizing. Initiated 1/30/25. Apply an alternating pressure mattress to the bed, check function every shift for proper inflation. Initiated & revised 12/26/24. Offered offloading boots, but declines. Initiated 12/26/24. Will continue to encourage all cares, treatments and interventions. Initiated 5/9/25. Administer treatments as ordered and monitor for effectiveness. Initiated 11/28/24. Apply barrier cream after incontinence. Initiated 11/28/24. Braden assessment on admission and per policy. Initiated 11/28/24. Encourage adequate hydration. Initiated 11/28/24. Encourage to float heels when in bed. Initiated 11/28/24. Monitor/document/report to MD (medical doctor) PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size, stage initiated 11/28/24. Notify MD for new orders, administer treatments as ordered, inform family initiated 11/28/24. Skin inspection: requires a skin inspection weekly and with cares. Observe for redness, open areas, scratches, blisters, cuts, bruises. Report to nurse/MD initiated 11/28/24. Update MD s/sx of infection or deterioration of wound/skin initiated 11/28/24. R64's pressure injury CAA (care area assessment) dated 1/9/25 under analysis of findings for nature of problem documents Resident has skin prep applied to left ankle scab. The quarterly MDS (minimum data set) with an assessment reference date of 4/1/25 has BIMS (brief interview mental status) score of 5 which indicates severe cognitive impairment. R64 is dependent for toileting hygiene, roll left & right, and chair/chair to bed transfer. R64 is assessed as always incontinent of bowel and bladder. R64 is at risk for pressure injury development and does not have any pressure injuries. Hospice care is marked yes. R64's hospice aide visit note dated 4/30/25 documents There is an open area to her right buttocks. The only cream available was some anti fungal cream. Nurse [Name] was aware. She stated she will call the [hospice name] nurse. I informed her I will also send her a message. Surveyor noted there is no assessment of R64's right buttocks open area until 5/7/25. R64's weight on 5/2/25 was 93.7 pounds. R64's Braden assessment dated [DATE] has a score of 12 which indicates high risk. The physician orders dated 5/7/25 documents Wound Care: right buttocks - Cleanse with wound cleanser and pat dry. Apply xeroform f/b (followed by) bordered foam daily and as needed. In the evening for wound care and as needed for wound care. The nurses note dated 5/9/25, at 10:44 a.m., documents IDT (interdisciplinary team) met and discussed: 5-7-25 1000 (10:00 a.m.). Resident was assessed on wound rounds by wound MD due to a report of an open area to resident's bottom. A 1cm (centimeter) x (times) 1 cm red and open area was noted to resident's right buttocks. The area is blanchable with light serious drainage. There is no pain at the site, but resident has generalized pain being controlled by comfort meds due to being on hospice. Wound MD gave treatment orders. Husband was in the room and updated on POC (plan of care). Hospice aware. NP (nurse practitioner) updated via Hucu (health communication platform) also. Daughter also aware. Resident has an air mattress. Intake is poor to fair and been generally declining (hospice). All prior interventions are in place. Encouraging intake and to turn and reposition, due to chronic pain and frail state resident is resistive and does not like to be bothered but with accept cares. She does cry out often, pain managed. MASD (moisture-associated skin damage) to buttock due incontinence, enc (encourage) to be check and changed as tolerated. Treatment as ordered to optimize wound healing but due to state of resident it maybe unavoidable as resident declines. Will continue to encourage all cares, treatments and interventions. All parties aware. On 5/18/25, at 1:09 p.m. Surveyor observed R64 in bed on her back with her eyes closed and the head of the bed elevated. There is a pillow under R64's right and left upper side and under R64's left arm. R64's heels are not being offloaded. The nurses note dated 5/19/25, at 21:26 (9:26 p.m.) and written by LPN-DD documents Resident area on right buttock is purple in color and skin intact. TX (treatment) was changed, no issues noted, continue monitoring. Surveyor did not note any change in treatment in R64's physician orders or on the May 2025 treatment administration record. There is no RN assessment of this area. The Braden assessment dated [DATE] has a score of 12 which indicates high risk. On 5/20/25, at 6:58 a.m., Surveyor observed R64 asleep in bed on her back. Surveyor observed R64's heels are not being offloaded. On 5/20/25, at 9:15 a.m., Surveyor observed Certified Nursing Assistant (CNA)-Z and CNA-AA in R64's room with gloves on. CNA-Z asked R64 if she could change her top. CNA-Z removed the pillow under R64's left upper arm. CNA-Z informed she would be gentle & removed R64's top, placed deodorant on and placed an undershirt and sweater on R64. CNA-AA informed R64 they were going to lay her head back and lowered the head of the bed. CNA-Z informed R64 they were going to check her brief and they would be fast. R64's incontinence product was unfastened. CNA-Z stated it's dry in the front and washed R64's frontal perineal area. CNA-Z then stated to R64 they were going to turn her towards CNA-AA and R64 was placed on her side. Surveyor observed there is a dressing on R64's sacrum dated 5/19/24 but there is no dressing on R64's right buttocks according to physician orders. CNA-Z washed R64's buttocks, placed an incontinence product under R64 & applied barrier cream on R64's buttocks. CNA-Z removed her gloves, washed her hand and left R64's room. CNA-Z returned with a draw sheet and R64 was positioned side to side to remove the incontinence product, straighten & fasten the new incontinence product and straighten the draw sheet. CNA-Z and CNA-AA positioned R64 up in bed and CNA-Z placed a pillow under R64's lower leg. Surveyor observed although CNA-Z placed a pillow under R64's lower legs, R64's heels were resting directly on the pillow and were not being offloaded. R64 was covered with bedding and CNA-Z & CNA-AA removed their gloves and washed their hands. On 5/20/25, at 10:26 a.m. Surveyor observed R64 continues to be in bed on her back with the head of the bed elevated. R64's heels are not being offloaded. On 5/20/25, at 12:55 p.m., Surveyor observed Licensed Practical Nurse (LPN)-W and CNA-Z enter R64's room. Surveyor observed R64 is in bed with the head of the bed elevated & a pillow under R64's left shoulder. LPN-W informed R64 they were going to roll her on the side, it's going to hurt a little bit but that's why they have her the medication. LPN-W washed his hands and placed gloves on. CNA-Z wearing gloves removed the bedding and the pillow under R64's lower legs. Surveyor observed R64's heels had been resting directly on the pillow. CNA-Z unfastened R64's incontinence product and washed R64's frontal perineal area. CNA-Z & LPN-W positioned R64 on the right side. LPN-W removed the incontinence product and the dressing from R64's sacrum area. After removing the dressing, LPN-W removed his gloves, washed his hands, and placed gloves on. LPN-W cleaned the sacrum area with wound cleaner, removed his gloves, washed his hands and placed gloves on. Surveyor observed a deep tissue injury on R64's sacrum area the approximate size of a dime. At 1:06 p.m. Infection Control/Registered Nurse (IC/RN)-T entered R64's room, washed her hands, and placed gloves on. IC/RN-T stated she's looking to see if its chronic. IC/RN-T removed her gloves, washed her hands and left R64's room. At 1:09 p.m., Surveyor asked LPN-W if he had seen R64's open area prior. LPN-W replied it's been a minute since he was on the unit. At 1:10 p.m., LPN-W placed xeroform over the deep tissue injury and covered the deep tissue injury with a foam dressing. Surveyor noted there is no dressing on R64's right buttock. LPN-W washed R64's buttocks, LPN-W & CNA-Z positioned R64 on the left side and LPN-W stated he was going to get [first name of Wound Nurse/Registered Nurse (WN/RN)-J. LPN-W removed his gloves & cleansed his hands and CNA-Z removed her gloves & washed her hands. On 5/20/25, at 1:28 p.m., LPN-W informed Surveyor at the moment there are 2 wounds on R64's bottom. The coccyx one on the right buttocks and other on center coccyx. LPN-W informed Surveyor he can't explain the center one on coccyx. LPN-W informed Surveyor the only thing he can think of they saw that (referring to Deep Tissue Injury) and though that the was the area. LPN-W informed Surveyor he knows people mislabel right & left but that's speculation. Surveyor stated to LPN-W there are no order for the deep tissue injury. LPN-W replied correct for that one. On 5/20/25, at 1:32 p.m. LPN-W removed the dressing from his pocket, opened treatment supplies and then left R64's room for gauze. On 5/20/25, at 1:37 p.m. LPN-W returned to R64's room with gauze, opened the gauze, moved the garbage can closer, washed his hands & placed gloves on. At 1:38 p.m. CNA-Z entered R64's room placed gloves on and informed R64 they were going to turn her to change the bandage on her bottom. On 5/20/25, at 1:39 p.m. WN/RN-J entered R64's room stating she's here to do a televisit. Surveyor noted Wound Doctor-CC was on the televisit. R64 was positioned on the left side, LPN-W removed the dressing and Wound Doctor-CC indicating coccyx more sacrum 1.5 by 1 DTI (deep tissue injury) and right buttocks doesn't look open any more, continue with barrier cream. On 5/20/25, at 1:44 p.m., CNA-Z who was wearing gloves positioned R64 on the side. LPN-W wash his hands, placed gloves on and sprayed wound cleanser on gauze and cleansed the deep tissue injury. LPN-W removed his gloves, washed his hands, and placed gloves on. LPN-W applied zinc oxide on R64's deep tissue injury & buttocks and R64 was positioned on her back. LPN-W removed his gloves and washed his hands. CNA-Z fastened the incontinence product, covered R64 with a blanket, removed her gloves and placed a pillow under R64's left arm. CNA-Z washed her hands, placed the over bed table across R64 and offered R64 a sip of water then left R64's room. At 1:54 p.m. CNA-Z returned to R64's room with a pillow case, placed the pillow in the pillow case and informed R64 she was going to lift her legs a little bit. CNA-Z placed the pillow under R64's lower legs. Surveyor observed R64's right heel is resting directly on the mattress and the left heel is on the pillow. R64's heels are not being offloaded. R64's nurses note dated 5/20/25 at 13:58 (1:58 p.m.) and written by WN/RN-J documents Nurse, [Name], reported to Writer that resident had a new wound to her sacral area. Writer assisted with completing a telemedicine visit with wound MD and resident. Wound MD was able to assess a 1.5cm x 1cm DTI to the sacrum and gave orders for barrier cream q (every) shift and as needed. Writer explained to husband who was in the room at time of assessment. Resident will be seen in person by wound MD on wound rounds. Wound MD also noted during assessment that the area to resident's right buttock is resolved. On 5/20/25, at 2:01 p.m. Surveyor informed WN/RN-J Surveyor has a concern R64's had a dressing over the deep tissue injury dated 5/19/25 and there is no documentation in R64's medical record regarding this pressure injury on the sacrum. Surveyor informed WN/RN-J R64 was suppose to have a dressing on the right buttocks but there was none. Surveyor asked WN/RN-J if there is any information regarding this. WN/RN-J informed Surveyor LPN-W came and said hey she (referring to R64) has a new area that had a dressing. WN/RN-J informed Surveyor Wound Doctor-CC will be here tomorrow. Surveyor asked WN/RN-J how the deep tissue injury developed. WN/RN-J replied just her end of life not wanting to move as much. R64's nurses note dated 5/20/25, at 15:22 (3:22 p.m.) and written by LPN-W documents Entered residents room to perform wound care on residents right buttocks. resident was informed of what was happening, rolled to residents left side dressing removed, washed and dried per order and while performing wound cares writer noted a new wound located about the sacrum/coccyx area. Wound care nurse, [Name], was notified who messaged wound care provider. left voice mail for [hospice name] RN, contacted daughter who has no concerns. management inform and added to the 24 hour board new vitals: 102/78, 97.5, 74HR (heart rate), 18 RR (respiratory rate) , 94% RA (room air). Change of condition added and resident will continue to be monitored. R64's nurses note dated 5/20/25 at 17:45 (5:45 p.m.) and written by Director of Nursing (DON)-B documents Discussed risks vs benefits with resident and POA r/t (related to) to refusing to turn/reposition, refusing cares, refusing wound treatment, refusing showers, poor intake r/t skin prevention and wound healing. Surveyor did not note a refusal care plan. On 5/21/25, at 7:12 a.m. Surveyor observed R64 awake in bed on her back with the head of the bed elevated. There is a pillow under R64's left shoulder and Surveyor observed R64's heels are not being offloaded. On 5/21/24, at 9:40 a.m., Surveyor observed R64 in bed awake on her back with the head of the bed elevated. Surveyor observed there are two pillows under R64's knees but R64's heels are resting directly on the mattress and are not being offloaded. R50 informed Surveyor hospice just left R64. On 5/21/25, at 9:46 a.m., Surveyor informed CNA-Z Surveyor noted R64 refused to wear pressure relieving boots but wondered if R64 allows her heels to be offloaded. CNA-Z replied yes, like yesterday I put a pillow. On 5/21/25, at 10:15 a.m. Surveyor informed WN/RN-J Surveyor had noted a hospice aide note dated 4/30/25 which documented an open area on the right buttocks and the nurse was aware. WN/RN-J informed Surveyor she was not aware of the right buttocks until 5/7/25. Surveyor asked what should have happened. WN/RN-J informed Surveyor our nurse should of done a skin check list on it. Surveyor informed WN/RN-J Surveyor was not able to locate this on 4/30/25. Surveyor also informed WN/RN-J of R64's heels not being offloaded. 4.) R49 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with diabetic chronic kidney disease and polyneuropathy, chronic diastolic heart failure, end stage renal disease, pressure ulcer of the sacral region, and dependence on renal dialyses. R49's admission minimum data set (MDS) dated [DATE] indicated R49 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 and the facility assessed R49 needing minimal assistance with hygiene and repositioning. R49 did not have upper or lower extremity impairment and was occasionally incontinent of bowel and bladder. R49 was admitted to the facility with a stage 4 sacral wound, in the admission MDS the facility documented 1 unstageable pressure injury on the sacrum due to presence of slough or eschar. The facility assessed R49 on 1/10/2025 to be a low risk for pressure injury development with a Braden score of 18. On 1/10/2025, at 14:43 (2:43 PM) in the progress notes nursing documented (R49) admitted to the facility Admitting diagnoses of sacral wound and treatment in place. Surveyor reviewed R49's admission skin assessment documented on 1/10/2025 with the following: -Sacral wound is 4.5cm X 2.0cm X 1.0cm (length X width X depth) 1.0cm tunneling at 6 o'clock. Surveyor noted that there was not a comprehensive assessment completed to describe what R49's sacral wound looked like if there was drainage, or description of the wound bed or surrounding tissue. On 1/15/2025 the wound doctor completed an initial visit with R49 and documented the following: - Unstageable (due to necrosis) coccyx, full thickness . - 2.5cm X 2.5cm X 1cm, moderate serous (clear, thin, watery fluid) drainage, 30% slough, 70% granulation tissue. - debridement procedure to remove necrotic tissue and establish margins and viable tissue performed. R49's continues to get weekly wound assessments with the wound doctor with the most recent assessement documents: - Stage 4 pressure injury coccyx, full thickness . - 2.5cm X 2.5cm X 0.8cm, moderate serous drainage, 10% slough, 90% granulation tissue . On 5/20/2025, at 1:50 PM, Surveyor interviewed wound nurse (WN)-J who stated a head to toe assessment is required within at least 24 hours of admission. WN-J stated that nursing staff should do a full comprehensive assessment of any areas of concern which includes, wound measurements, staging, description of the wound bed and surrounding skin. Surveyor shared concern that a comprehensive assessment for R49's sacral pressure injury could not be located. WN-J looked through R49's medical record and agreed that a comprehensive assessment could not be located when R49 admitted into the facility on 1/10/2025. WN-J stated that nursing documented R49's sacral wound measurements but did not include a comprehensive assessment that detailed R49's sacral wound to include wound staging, or description of the wound bed/ surrounding skin. WN-J agreed that a comprehensive assessment for R49's sacral wound was not documented until R49 saw the wound doctor on 1/15/2025. On 5/20/2025, at 2:23 PM, Surveyor interviewed licensed practical nurse unit manager (LPNUM)-F who stated if an area of concern for a resident was noted on admission nursing would do a comprehensive assessment that included measurements, describe what the area looked like, surrounding area, describe the length, width, depth, stage if applicable, etc. Surveyor shared concern that 49 did not have a comprehensive assessment for R49's sacral pressure injury when admitted to the facility on [DATE] until the wound doctor's initial visit on 1/15/2025. LPNUM-F stated there should have been more description of what R49's sacral wound looked like on 1/10/2025 when R49 was admitted to the facility. On 5/20/2025, at 3:19 PM, Surveyor interviewed nursing home administrator (NHA)-A, director of nursing (DON)-B, and regional consultant (RC)- I. Surveyor asked what the expectations of staff are when a resident is admitted to the facility with an area of concerns such as a pressure injury. DON-B stated that nursing staff are expected to document a skin and body assessment that includes a head to toe assessment, if an area of concern is identified nursing staff is to measure and describe the area. Surveyor shared concern that R49 did not have a comprehensive assessment documented for R49's sacral pressure injury. Surveyor shared that staff did not describe what the pressure injury looked like, surrounding tissue, or if drainage was present until R49's initial visit with the wound doctor on 1/15/2025. DON-B stated a description should have been completed on admission. No additional information was provided. Based on observation, interview, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 4 (R9, R32, R64, R49) of 8 residents reviewed for pressure injuries. * R9's unstageable pressure injury to the left posterior thigh reopened on 2/24/25. The facility states it is due to noncompliance with repositioning and offloading. Four Minimum Data Set (MDS) assessments were completed in 2025 and none document rejection of care or refusals by R9. R9 has an air mattress and no documentation for inflation setting guidance was found. The day after the pressure injury was discovered an intervention was added to the care plan related to refusals. The cushion in R9's wheelchair is not on the care plan or correct for R9's weight and type of pressure injury. 5/8/25 is the first documentation of a discussion with R9 regarding the risk and benefits of R9's noncompliance with wound care and interventions. After the weekly wound assessment on 2/26/25 was completed, two weeks are missed before the next comprehensive wound assessment. On all facility assessments the wound bed tissue type is selected but not the percentage of coverage over the wound. The wound has continued to increase to almost double the size from the time of discovery with no pertinent, new interventions attempted. * R32's hospital records state R32 admitted back to facility with 2 (unstageable) pressure ulcers. A Licensed Practical Nurse did the readmission assessment and noted abrasions with treatment of barrier cream. The wound was not comprehensively assessed until 5 days later. Surveyor made observations of R32's heels not being offloaded and the mattress setting was incorrect. * R64 has orders for a dressing to right buttocks due to MASD (Moisture Associated Skin Damage). Surveyor observed R64 had a dressing to sacrum area. Surveyor observed a nurse put dressing on a different area. When the dressing was removed, Surveyor observed a Deep Tissue Injury. Surveyor made observations of R64's heels not being offloaded. * R49 did not have a comprehensive assessment upon admission on [DATE] for a sacral wound until 1/15/25. Findings include: The facility's policy titled Pressure Injury Prevention and Management revised 2/2025, documents (in part): Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries . Policy Explanation and Compliance Guidelines .: 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk assessment on all residents upon admission/readmission, weekly x (times) four weeks, then quarterly or whenever the condition changes significantly . c. Licensed nurses will conduct a full body skin

3.) R62 was transferred to the hospital on 2/7/25 after experiencing a change of condition. R62 was discharged from the hospital and returned to the facility on 2/18/25. Surveyor conducted a review of R62's medical record and could not locate any evidence that R62 or their representative were given the required bed hold notice information in writing to identify the reserve bed payment rate for all payer sources for R62's bed hold after 15 days. The Ombudsmen was not notified of 62's transfer and discharge on [DATE]. No additional information was provided. Based on interview and record review, the facility did not ensure 10 (R16, R50, R62, R23, R33, R9, R12, R40, R58, & R72) of 10 residents reviewed were notified of the reason for transfer/discharge in writing to the resident & their representative. Residents were not notified of the rate to reserve the residents bed because it was not documented in the transfer & discharge notice and the ombudsman was not notified of the transfer/discharge. Findings include: The facility's policy titled, Bed Hold Notice and date reviewed/revised 2/2025 under Policy documents It is the policy of this facility to provide written information to the resident and/or the residents representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. The facility's policy titled, Transfer and Discharge (including AMA (against medical advice)) and date reviewed/revised 2/2025 under Policy Explanation and Compliance Guidelines documents 5. The facility will maintain evidence that the notice was sent to the Ombudsman. Under section 10 Emergency Transfers to Acute Care g. documents Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated. h.The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. On 5/19/25, at 1:24 p.m., Surveyor asked Social Service Director (SSD)-P who notifies the Ombudsman of residents who have been transferred or discharged . SSD-P informed Surveyor Medical Records Director (MRD)-Q. Surveyor asked SSD-P if she is involved when a resident is transferred or discharged to the hospital. SSD-P informed Surveyor she might assist with printing paperwork or opening the door for the ambulance. Surveyor asked SSD-P if she has any involvement with transfer/discharge notices or bed hold forms. SSD-P replied no. On 5/19/25, at 1:30 p.m., Surveyor asked MRD-Q if she is responsible for notifying the Ombudsman of resident transfers/discharges. MRD-Q replied not any more. MRD-Q explained it was changed to the MDS (minimum data set) nurse but she doesn't think they taught the MDS nurse to do it. Surveyor asked when the notification was changed to the MDS nurse. MRD-Q informed Surveyor three years ago. MRD-Q informed Surveyor she used to send it once a month. MRD-Q explained PCC (pointclickcare) came up with a report, MDS would print and send the report. MRD-Q informed Surveyor when the MDS nurse left she asked her when she sent the reports and she told her she wasn't doing it. Surveyor asked MRD-Q who is the MDS nurse now.MRD-Q replied there isn't one, she just moved on, she's been gone for two weeks. Surveyor asked MRD-Q if she is involved with transfer/discharge notices or bed hold when a resident goes to the hospital. MRD-Q replied no. MRD-Q informed Surveyor there is a transfer notice. Surveyor then accompanied MRD-Q to the one central nurses station. MRD-Q looked for the transfer/discharge notice form but wasn't able to find one and asked Licensed Practical Nurse (LPN)-R where they keep the transfer/discharge notice form. LPN-R informed MRD-Q she thought it was in the computer. MRD-Q then called Unit Secretary (US)-N asking where the new transfer/discharge notice forms are. US-N indicated they were in her office. On 5/19/25, at 1:45 p.m., Surveyor asked US-N who completes the transfer/discharge notice form. US-N informed Surveyor she does and if she's not here then the nurse will do it. Surveyor asked where these forms are kept. US-N informed Surveyor in the business office. US-N explained if the resident has a POA (power of attorney) she will get a verbal consent. If the resident is their own person and is able to sign she will have them sign. If the resident can't sign then she will get a verbal consent. On 5/20/25, at 8:45 a.m., Nursing Home Administrator (NHA)-A informed Surveyor the MDS (minimum data set) nurse was the one who sent the transfer/discharge list to the ombudsman. NHA-A stated that when the MDS nurse left and they hired a new MDS person but that the transfer/discharge duties were not transferred to the new MDS nurse. Surveyor asked when the MDS nurse left. NHA-A replied about a year ago. NHA-A stated to Surveyor we did a PIP (performance improvement plan), transferred the responsibility to medical records and sent a list to [name of] Ombudsman for residents who have been discharged during the last three months. Surveyor informed NHA-H since the MDS nurse left a year ago until yesterday there has been no notification to the Ombudsman for transfers/discharges. NHA-A replied correct, we've talked to her about other things. Surveyor was provided with the PIP not dated and an email to the ombudsman dated 5/19/25. On 5/20/25, at 9:40 a.m., Surveyor showed US-N the transfer/discharge notice. US-N informed Surveyor she does these forms if she is here but she's not here on the weekends. US-N informed Surveyor she will get a verbal consent and will send the form if the POA requests it. US-N explained some of the POA's live out of state. Surveyor asked US-N if she is the one who sends the form if requested. US-N replied no me personally I would have the receptionist type the envelope. Surveyor asked US-N if Surveyor was a POA for a resident how would Surveyor know what the cost of the room is to hold the bed. US-N informed Surveyor the business office helps out with all that. If the resident is title 19 the room is automatically saved, if they are private pay that's when we have to tell them the rate. Surveyor asked US-N if she tells the POA what the room rate is or does the business office. US-N informed Surveyor she doesn't have the rates for that. US-N informed Surveyor the nurses will call the POA and let them know why they are sending the resident out. US-N informed Surveyor the white copy of the transfer/discharge notice goes to the hospital and they keep the yellow copy. US-N informed Surveyor sometimes if the nurses are doing the transfer/discharge notice they send the yellow to the hospital and keep the white copy. Surveyor stated to US-N the white copy goes to the hospital, facility keeps the yellow copy, and a copy is sent to the POA if they request it. US-N replied correct. On 5/20/25, at 10:12 a.m. Surveyor asked Business Office Manager (BOM)-O if she is involved with residents being transferred/discharged to the hospital. BOM-O informed Surveyor the only time she gets involved is when she gets the transfer/discharge notices, other than that no. Surveyor asked what she does with these transfer/discharge notices. BOM-O explained the first thing she does is check to see if the nurse or unit secretary has filled them out correctly & if they marked bed hold or no bed hold. BOM-O explained if they are private pay in their computer and don't have a secondary insurance she always calls the POA to see if they want to pay for the bed hold. Surveyor asked if this is documented anywhere. BOM-O replied just on the bed hold sheets. Surveyor asked if a resident is medicaid would she contact the resident representative. BOM-O replied no. Surveyor asked if the transfer/discharge notice are mailed out. BOM-O informed Surveyor the white one goes to the hospital and the yellow one gets mailed to the family. Surveyor asked BOM-O if she documents the bed hold rates and reason for transfer are documented anywhere. BOM-O replied no. 1.) R16's diagnoses includes seizures (sudden burst of electrical activity in brain which can cause changes in behavior, movement, & level of consciousness), neurogenic bowel (loss of normal bowel function caused by a nerve problem), and hemiplegia (paralysis on one side of the body) & hemiparesis (weakness on one side of the body) following cerebral infarction (type of stroke) affecting right dominate side. R16's power of attorney for healthcare was activated on 12/8/21. R16's nurses note dated 2/21/25, at 04:01 (4:01 a.m.) written by Licensed Practical Nurse (LPN)-K documents Resident was sent out via 911 ambulance at 0300 (3:00 a.m.). Writer was notified by floor CNA (Certified Nursing Assistant) that Res (Resident) was not doing well when she went in to do his cares. Writer immediately went to residents room and he was sitting up in bed visibly working hard to breath and writer could hear crackles in his chest standing at bedside. Writer listened to residents chest with stethoscope and heard loud lung crackles. Resident was diaphoretic, jaundice in his face/eyes, his whole right arm was purple, his torso and lower extremities were gray, his feet and ankles were more swollen than normal. BP (blood pressure): 79/56, HR (heart rate): 95, T (temperature):97.3, O2 (oxygen): 70% and dropping. A second and third attempt at a BP was unsuccessful. Writer immediately called 911(0255) (2:55 a.m.), ambulance arrived at 0300 (3:00 a.m.) and departed at 0303 (3:03 a.m.). Writer called [hospital initials] ER (emergency room) [Name] to give report; On call nurse notified at 0300; Residents POA (power of attorney) notified at 0318 (3:18 a.m.). Writer sent a notification in HUCU (healthcare communication platform) to providers to update them on the situation at 0346 (3:46 p.m.). R16 was readmitted to the facility on [DATE]. R16's nurses note dated 3/4/25 at 21:48 (9:48 p.m.) documents Writer noticed pt (patient) having a hard time breathing, respirations were increasing, O2 71% on room air. Messaged HUCU with no response. Placed resident on 2L (liter), resident stating at 81%. Placed pt on 3L, pt stating at 85%. Pt is now diaphoretic and only responding to person. Writer called [Name] Medical and left a message with receptionist who was unable to get a hold of provider, have not received call back at this time. Sent pt to ER (emergency room) Called in report to [Name] Memorial Hospital. Called POA (power of attorney) sister and left voicemail to contact facility for update. Called Case worker and left voicemail to contact facility for update. R16 was readmitted to the facility on [DATE]. Surveyor reviewed R16's medical record and was unable to locate a bed hold policy and reason for transfer was provided to R16 and R16's representative in writing for R16' discharge on [DATE] & 3/4/25. On 5/19/25, at 3:09 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Consultant-I Surveyor informed staff Surveyor was unable to locate the bed hold policy and reason for transfer was provided to R16 & R16's representative when R16 was discharged to the hospital on 2/24/25 & 3/4/25. On 5/20/25 Surveyor was provided with the white & yellow copy of the transfer and discharge notice for R16's discharge on [DATE]. Surveyor noted Title 19 Bedhold Policy is circled. The Title 19 Bedhold policy documents Medical Assistance (T19) will pay to hold the bed while you are in a general hospital for up to 15 days per hospital stay. If the hospital stay is longer than 15 days, you may choose to continue the bedhold by paying privately for duration of hospital stay. If the leave extends beyond the paid bedhold, the bed will not be held. However, if you wish to be readmitted to the facility following hospital stay, readmission could occur upon the first availability of an appropriate semi-private room. Surveyor noted there is not a bed hold rate documented on this form. Surveyor also noted there was verbal consent but there is no evidence written notification was provide to R16's representative. On 5/20/25 Surveyor was provided with a yellow copy of the transfer and discharge notice for R16's discharge on [DATE]. Surveyor noted there is not a bed hold rate documented on this form. Surveyor also noted there was verbal consent from R16's POA but there is no evidence written notification was provided to R16's representative. 2.) R50's diagnosis includes diabetes mellitus (high blood sugar), urinary retention, metabolic encephalopathy (metabolic disturbances affecting how the brain functions), malignant neoplasm (cancer) of lateral wall of bladder, hypertension (high blood pressure) and depression. R50's nurses note dated 12/30/24 at 14:37 (2:37 p.m.) documents Writer reassessed pt (patient) after previous shift replaced Foley for hematuria. Writer pulled 800 cc (cubic centimeters) of dark, blood urine out of Foley. APNP (Advanced Practice Nurse Prescriber) was contacted and patient is being sent out to ER (Emergency Room) for further evaluation. Writer contacted [Name] ambulance for a ride to [Name] Memorial Hospital. [Hospital's initials] was called with report. Vitals are within normal limits at this time. R50 was readmitted to the facility on [DATE]. The nurses note dated 3/29/25 at 19:30 (7:30 p.m.) documents Called to residents room by CNA (Certified Nursing Assistant). Residents daughter was concerned about possible decline since surgery for super pubic placement on 3/26/2025. Daughter was stating that she noticed more weakness, confusion, and is hallucinating. Notified NP (Nurse Practitioner) via HUCU (healthcare communication platform) and was informed that resident was seen by a NP yesterday and there was not a indication to send to ER (emergency room) for eval. (evaluation). NP wanted to monitor resident here, push fluids and have resident rest. Daughter was not happy with this information and insisted that resident be sent anyway [hospital initials] for eval. Updated NP and DON (Director of Nursing). Order received to send resident to hospital for eval. Will continue to monitor. R50 was readmitted to the facility on [DATE]. Surveyor reviewed R50's medical record and was unable to locate a bed hold policy and reason for transfer was provided to R50 and R50's representative in writing for R50's discharge on [DATE] & 3/29/25. On 5/19/25, at 3:09 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Consultant-I Surveyor informed staff Surveyor was unable to locate the bed hold policy and reason for transfer was provided to R50 & R50's representative when R50 was discharged to the hospital on [DATE] & 3/29/25. On 5/20/25 Surveyor was provided with the yellow copy of the transfer and discharge notice for R16's discharge on [DATE]. Surveyor noted there is a star next to Title 19 Bedhold Policy. The Title 19 Bedhold policy documents Medical Assistance (T19) will pay to hold the bed while you are in a general hospital for up to 15 days per hospital stay. If the hospital stay is longer than 15 days, you may choose to continue the bedhold by paying privately for duration of hospital stay. If the leave extends beyond the paid bedhold, the bed will not be held. However, if you wish to be readmitted to the facility following hospital stay, readmission could occur upon the first availability of an appropriate semi-private room. Surveyor noted there is not a bed hold rate documented on this form. Surveyor also noted there was verbal consent but there is no evidence written notification was provide to R50's representative. On 5/20/25 Surveyor was provided with a yellow copy of the transfer and discharge notice for R50's discharge on [DATE]. Surveyor noted there is not a bed hold rate documented on this form. Surveyor also noted there was verbal consent from R50's representative but there is no evidence written notification was provided to R50's representative. 4.) R23 was admitted to the facility on [DATE] and has diagnoses that include chronic systolic and diastolic congestive heart failure, type 2 diabetes with circulatory complications, muscle wasting and atrophy, major depressive disorder, peripheral vascular disease, chronic kidney disease stage 3, and anxiety disorder. R23 power of attorney (POA) was activated. On 4/25/2025 R23 was admitted to the hospital for an upper respiratory infection/ Bronchitis and readmitted to the facility on [DATE]. Surveyor reviewed R23's medical and was unable to locate a bed hold or transfer notice that was provided to R23's and R23's POA in writing for R23's discharge on [DATE]. On 5/19/25, at 3:09 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Consultant-I Surveyor informed staff Surveyor was unable to locate the bed hold policy and reason for transfer was provided to R23 & R23's representative when R23 was discharged to the hospital on 4/25/2025. On 5/20/25 Surveyor was provided with the white & yellow copy of the transfer and discharge notice for R23's discharge on [DATE]. Surveyor noted Title 19 Bed hold Policy is circled. The Title 19 Bed hold policy documents Medical Assistance (T19) will pay to hold the bed while you are in a general hospital for up to 15 days per hospital stay. If the hospital stay is longer than 15 days, you may choose to continue the bed hold by paying privately for duration of hospital stay. If the leave extends beyond the paid bed hold, the bed will not be held. However, if you wish to be readmitted to the facility following hospital stay, readmission could occur upon the first availability of an appropriate semi-private room. Surveyor noted there is not a bed hold rate documented on this form. Surveyor also noted there was verbal consent but there is no evidence written notification was provide to R23's representative. On 5/20/25 Surveyor was provided with a yellow copy of the transfer and discharge notice for R23's discharge on [DATE]. Surveyor noted there is not a bed hold rate documented on this form. Surveyor also noted there was verbal consent from R23's POA but there is no evidence written notification was provided to R23's representative. 5.) R33 was admitted to the facility on [DATE] and has diagnoses that include metabolic encephalopathy, type 2 diabetes with neuropathy, schizoaffective disorder, pneumonia, cognitive communicative deficit, and history of cerebral infarction affecting the right dominant side. R33's power of attorney (POA) is activated. On 1/24/2025 R33 was admitted to the hospital with a diagnosis on Pneumonia and readmitted to the facility on [DATE]. On 3/12/2025 R33 was admitted to the hospital with a change of condition and readmitted to the facility on [DATE]. Surveyor reviewed R23's medical and was unable to locate a bed hold or transfer notice that was provided to R23's and R23's POA in writing for R23's discharge on [DATE]. On 5/19/25, at 3:09 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Consultant-I Surveyor informed staff Surveyor was unable to locate the bed hold policy and reason for transfer was provided to R33 & R33's representative when R33 was discharged to the hospital on 1/24/2025 and 3/12/2025. On 5/20/25 Surveyor was provided with the white & yellow copy of the transfer and discharge notice for R33's discharge on [DATE] and 3/12/2025. Surveyor noted Title 19 Bed hold Policy is circled. The Title 19 Bed hold policy documents Medical Assistance (T19) will pay to hold the bed while you are in a general hospital for up to 15 days per hospital stay. If the hospital stay is longer than 15 days, you may choose to continue the bed hold by paying privately for duration of hospital stay. If the leave extends beyond the paid bed hold, the bed will not be held. However, if you wish to be readmitted to the facility following hospital stay, readmission could occur upon the first availability of an appropriate semi-private room. Surveyor noted there is not a bed hold rate documented on this form. Surveyor also noted there was verbal consent but there is no evidence written notification was provide to R33's representative. On 5/20/25 Surveyor was provided with a yellow copy of the transfer and discharge notice for R33's discharge on [DATE] and 3/12/2025. Surveyor noted there is not a bed hold rate documented on this form. Surveyor also noted there was verbal consent from R33's POA but there is no evidence written notification was provided to R33's representative. No additional information was provided. 6.) R9 was admitted to the facility on [DATE] with pertinent diagnoses that include unstageable pressure ulcer of sacral region (a severe pressure sore that's difficult to stage because the base of the wound is obscured by slough or eschar, making it impossible to determine the true depth of tissue damage. The sacral region is located at the base of the spine), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), morbid obesity (body mass index (BMI) of 40 or higher), and chronic pain syndrome (a condition characterized by persistent pain that lasts for more than three months). R9's Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/10/25, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R9 is cognitively intact. R9's patient depression questionnaire (PHQ-9) score was 00 which means that R9 showed no depressive symptoms. R9 was coded to have adequate hearing, understands others and makes self understood. R9 is responsible for self. Surveyor reviewed R9's electronic medical record which indicated R9 was transferred to Waukesha Memorial Hospital for a scheduled ostomy surgery on 1/7/2025, R9 returned to the facility on 1/10/25. R9 was transferred to Waukesha Memorial hospital on 1/15/25 for ostomy pain, R9 returned to the facility on 1/29/25. R9 was transferred to Waukesha Memorial hospital on 3/4/25 for bleeding under the colostomy bag due to cellulitis, R9 returned to the facility on 3/6/25. Surveyor requested evidence from the Facility that a bed hold notice information to identify the reserve bed payment rate for all payor sources for R9's bed hold after 15 days was provided to R9 or their representative. Surveyor was given a form Kensington Care and Rehabilitation Transfer and Discharge Notice that had verbal Consent written in each signature area on the form for each of the three transfers. Surveyor noted that the bed hold notice did not identify the rate for all payor sources for the bed hold after 15 days. Surveyor noted no evidence that the paperwork was provided in written form to R9 or R9's representative. On 5/20/25, at 03:19 PM, during the end of day meeting with Director of Nursing-B and Nursing Home Administrator-A Surveyor let know of concern that no payment information was included on the bed hold form and that it was not provided in a written form. No additional information was provided regarding bed hold payment information and forms being provided in writing. 7.) R12 was admitted to the facility on [DATE] with diagnoses that included Urinary Retention and Ileostomy. R12's Transfer and Discharge notice dated 12/03/24 documents that R12 was transferred and admitted to the hospital on [DATE]. R12's electronic medical record documents R12 was admitted for renal calculi (formation of mineral stones in the urinary tract). R12's Transfer and Discharge notice dated 04/19/25 documents R12 was transferred and admitted to the hospital on [DATE]. R12's electronic medical record documents R12 was admitted for small bowel obstruction (partial or complete blockage of the bowel). R12's Transfer and Discharge notice dated 04/24/25 documents R12 was transferred to the emergency room on [DATE]. R12's electronic medical record documents R12 was transferred for concerns with R12's Ileostomy (small abdominal opening to allow waste discharge from the small bowel). On 05/20/25, at 03:18 PM, Surveyor informed Director of Nursing (DON)-B, Consultant-I, and Nursing Home Administrator (NHA)-A of Surveyor's concerns that the Ombudsman has not been notified at least monthly for the past year for any resident transfers or discharges and the bed hold notice provided for R12 did not identify the facilities reserve bed payment rate for all payor sources for bed hold after 15 days. NHA-A informed Surveyors the facility needs to update the form for the bed hold reserve bed payment rates and was unable to find Emails or documentation that the Ombudsman was notified of any resident transfers or discharges in the past year. 8.) R40 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease and Emphysema. R40's Transfer and Discharge notice dated 03/17/25 documents that R40 was transferred and admitted to the hospital on [DATE]. R40's electronic medical record documents R40 was admitted for chest heaviness and shortness of breath. R40's Transfer and Discharge notice dated 05/19/25 documents R40 was transferred and admitted to the hospital on [DATE]. R40's electronic medical record documents R40 was admitted for exacerbation of Chronic Obstructive Pulmonary Disease On 05/20/25, at 03:18 PM, Surveyor informed Director of Nursing (DON)-B, Consultant-I, and Nursing Home Administrator (NHA)-A of Surveyor's concerns that the Ombudsman has not been notified at least monthly for the past year for any resident transfers or discharges and the bed hold notice provided for R40 did not identify the facilities reserve bed payment rate for all payor sources for bed hold after 15 days. NHA-A informed Surveyors the facility needs to update the form for the bed hold reserve bed payment rates and was unable to find Emails or documentation that the Ombudsman was notified of any resident transfers or discharges in the past year. 9.) R58 was admitted to the facility on [DATE] and 02/11/25 with diagnoses that included Unspecified Systolic (congestive) Heart Failure. R58's Transfer and Discharge notice dated 11/27/24 documents that R58 was transferred and admitted to the hospital on [DATE]. R58's electronic medical record documents R58 was admitted for chest pain. R58's Transfer and Discharge notice dated 01/2/25 documents R58 was transferred and admitted to the hospital on [DATE]. R58's electronic medical record documents R58 was admitted for Hypotension (low blood pressure). R58's Transfer and Discharge notice dated 04/7/25 documents R58 was transferred to the hospital on [DATE]. R58's electronic medical record documents R58 was treated for a nosebleed. On 05/20/25, at 03:18 PM, Surveyor informed Director of Nursing (DON)-B, Consultant-I, and Nursing Home Administrator (NHA)-A of Surveyor's concerns that the Ombudsman has not been notified at least monthly for the past year for any resident transfers or discharges and the bed hold notice provided for R58 did not identify the facilities reserve bed payment rate for all payor sources for bed hold after 15 days. NHA-A informed Surveyors the facility needs to update the form for the bed hold reserve bed payment rates and was unable to find emails or documentation that the ombudsman was notified of any resident transfers or discharges in the past year. 10.) R72 was admitted to the facility on [DATE] with diagnoses that included Contusion (bruising) of the left hip. R72's Transfer and Discharge notice dated 02/20/25 documents that R72 was discharged home because R72's health improved and no longer needed the facility's services. R72's Medical Doctor's Discharge summary dated [DATE], at 12:45 PM, documents that R72 was discharged home with home health services. On 05/21/25, at 12:50 PM, Surveyor informed Nursing Home Administrator (NHA)-A that the Surveyor found no documentation that R72's discharge was reported to the Ombudsmen and the bed hold notice provided for R72 did not identify the facilities reserve bed payment rate for all payor sources for bed hold after 15 days. No additional information was provided.

The facility's policy titled, Enhanced Barrier Precautions date as reviewed/revised 2/2025 documents under the Policy section: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Under the Policy Explanation and Compliance Guidelines section it documents: 2. Initiation of Enhanced Barrier Precautions documents a. The facility will have the discretion in using EBP (enhanced barrier precautions) for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO (multidrug resistant organism) that is not currently targeted by CDC (Centers for Disease Control) but may be considered epidemiologically important. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC (peripherally inserted central catheter) lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.) ii. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. 4. High-contact resident care activities include: a. Dressing. b. Bathing. c. Transferring. d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters. h. Wound care: any skin opening requiring a dressing. 3.) R32's modification of admission MDS (minimum data set) with an assessment reference date of 4/20/25 has a BIMS (brief interview mental status) score of 6 which indicates severe cognitive impairment. R32 is assessed as requiring partial/moderate assistance for toileting hygiene and is always incontinent of urine and bladder. On 5/19/25, at 1:49 p.m., Surveyor observed Certified Nursing Assistant (CNA)-X in R32's room. R32 is sitting in a wheelchair and informed CNA-X that R32 made a mess. CNA-X placed a bath blanket on R32's bed, informed R32 she was going to get help and left R32's room. On 5/19/25, at 1:52 p.m., CNA-X & CNA-M entered R32's room and put gloves on. CNA-X and CNA-M assisted R32 to bed. R32 took a couple steps, then CNA-X & CNA-M lowered R32's pants and R32 sat on the edge of the bed. CNA-M removed the gait belt, moved the wheelchair away from R32's bed and swung R32's legs so R32 was laying flat in bed. At 1:58 p.m, CNA-X unfastened R32's incontinence product & lowered the product between R32's legs. Surveyor noted a strong odor of BM (bowel movement). CNA-X washed under R32's abdominal fold to remove BM, squeezed water from the wash cloth onto R32's frontal perineal area and washed the frontal perineal area from front to back. CNA-X stated oh boy at least you are in bed and rewashed the frontal perineal area. CNA-X asked R32 if she could roll towards the wall and assisted R32 with rolling onto her side. CNA-X washed R32's rectal area to remove BM, removed the soiled incontinence product & placed this product in the garbage can. CNA-X folded the bath blanket over the BM to cover the BM. CNA-X rewashed R32's rectal area, squeezed water onto R32's buttocks and washed R32's buttocks and rectal area. After CNA-X finished washing R32's buttocks & rectal area, CNA-X did not remove her gloves. CNA-X removed silicone cream from the dresser, applied the cream on R32's buttocks, folded the bath blanket, moved R32's comforter and stated I know I had a brief. CNA-X placed an incontinence product under R32, R32 was assisted on her back and CNA-X rewashed R32's frontal perineal area. CNA-X applied silicone cream on R32's inner thighs, removed her gloves and washed her hands. Surveyor observed this is the first observation of CNA-X performing hand hygiene. CNA-X placed gloves on, assisted R32 with positioning on her side, and removed the bath blanket. R32 was positioned on her back, the incontinence product was fastened and R32 was covered with bedding. The head of R32's bed was elevated, the call light was placed in reach and R32's bed was lowered. At 2:09 p.m. CNA-X removed her gloves and washed her hands. On 5/21/25, at 10:32 a.m., Surveyor asked Infection Control/Registered Nurse (IC/RN)-T when staff are doing incontinence cares for resident who is incontinent of bowel, after they have finished washing the resident, before placing a new incontinence product on the resident should they remove their gloves and perform hand hygiene. IC/RN-T replied yes. Surveyor informed IC/RN-T of the observation with R32 & CNA-X. No additional information was provided. 4.) R50's significant change MDS (minimum data set) with an assessment reference date of 4/10/25 assesses R50 as being dependent for toileting hygiene & chair/bed to chair transfer. R50 is assessed as having a urinary indwelling catheter. On 5/19/25, at 10:54 a.m., Licensed Practical Nurse (LPN)-W entered R50's room wearing a gown that was not tied at the neck. LPN-W placed gloves on, removed a graduate from the bathroom and placed the graduate directly on the floor. LPN-W did not place a barrier on the floor. LPN-W asked R50 if he was having any pain in his stomach or bladder, which R50 indicated he wasn't. LPN-W informed R50 he was having the sediments & urine go down to the collection bag informing R50 the urine is looking really clear. At 10:59 a.m., LPN-W unclipped the spicket from the collection bag and drained the urine into the graduate. Surveyor observed there is still not a barrier on the floor. R50's representative moved LPN-W's gown towards the back as the gown was slipping off LPN-W's shoulders, placed the spicket back in the collection bag and placed the collection bag in the blue privacy bag. LPN-W informed Surveyor he removed 550 cc (cubic centimeters) of urine. At 11:01 a.m. LPN-W removed his gloves and placed gloves on. Surveyor observed LPN-W did not perform hand hygiene prior to placing gloves on. LPN-W removed syringe kit from R50's dresser, placed a towel under R50's upper leg, poured sodium chloride 0.9% into the container & withdrew 60 cc. LPN-W unclamped the tubing and flushed R50's urinary catheter. At 11:06 a.m. LPN-W collected the garbage, removed his gloves & gown and washed his hands. On 5/20/25, at 7:29 a.m., Surveyor observed Med Tech-Y and Certified Nursing Assistant (CNA)-Z entered R50's room and placed gloves on. Surveyor observed neither Med Tech-Y or CNA-Z were wearing a gown. Surveyor observed R50 is sitting on the edge of the bed. The height of R50's bed was raised, a sling was placed around R50 & connected to the hoyer lift. R50 was raised off the bed, R50's pants were pulled up and R50 was lowered into the bed. Med Tech-Y unhooked the sling from the lift & removed the sling from R50. CNA-Z removed the draw sheet from R50's bed and informed R50 she was going to help change his shirt. Med Tech-Y removed her gloves, washed her hands, and left R50's room. CNA-Z stated to R50 she was going to help you pull your shirt over your head and removed R50's shirt. CNA-Z handed R50 deodorant which R50 applied. CNA-Z placed a shirt & sweater on R50, informed R50 she is going to wash his glasses & she needs a weight. CNA-Z then washed R50 glasses. After washing R50's glasses, CNA-Z removed her gloves and washed her hands. At 7:45 a.m. Surveyor observed CNA-Z enter R50's room with a flat sheet. Surveyor observed CNA-Z is not wearing any PPE (personal protective equipment). CNA-Z placed the flat sheet on R50's bed and made R50's bed. On 5/21/25, at 7:14 a.m. Surveyor noted the EBP sign located on the right side of R50's doorframe, which has been on the doorframe since the beginning of the survey on 5/18/25, documents Providers and staff must also wear gloves and gowns for high contact resident care activities, dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assist with with toileting device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care any skin opening requiring a dressing. On 5/21/25, at 10:32 a.m., Surveyor asked Infection Control/Registered Nurse (IC/RN)-T when emptying an urinary collection bag should the graduate be placed directly on the floor. IC/RN-T replied no. Surveyor asked when staff removes their gloves should they perform hand hygiene before placing new gloves on. IC/RN-T replied yes. Surveyor asked how does staff know a resident is on enhanced barrier precautions. IC/RN-T informed Surveyor there is signage on the door, they are informed by their nurse and upon hire they are educated. Surveyor asked IC/RN-T when staff are transferring a resident or making their bed & the resident is on enhanced barrier precautions should they wear a gown. IC/RN-T replied yes they should be wearing a gown based on the EBP sign. Surveyor informed IC/RN-T of the observations with R50.5.) R9 was admitted to the facility on [DATE] with pertinent diagnoses that include unstageable pressure ulcer of sacral region (a severe pressure sore that's difficult to stage because the base of the wound is obscured by slough or eschar, making it impossible to determine the true depth of tissue damage. The sacral region is located at the base of the spine), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), morbid obesity (body mass index (BMI) of 40 or higher), and chronic pain syndrome (a condition characterized by persistent pain that lasts for more than three months). On 05/20/25, at 01:24 PM, Surveyor observed Licensed Practical Nurse (LPN)-L perform wound care on R9's left posterior thigh pressure injury. LPN-L put on a face mask, gown, washed hands and applied gloves. Surveyor observed LPN-L take the existing wound cover off R9's wound. LPN-L cleaned the wound with gauze and normal saline. Next LPN-L applied the Silver sulfadiazine with a cotton tip applicator. LPN-L then folded an abdominal pad into thirds, dated and initialed it and applied it over the Silver sulfadiazine and wound with tape. Surveyor observed LPN-L then remove gloves and wash hands. Surveyor noted that LPN-L did not change gloves change after taking the existing wound cover off, cleaning the wound or touching and applying the new wound cover. According to the Pennsylvania Department of Health gloves should be changed after the old dressing is removed and discarded immediately, dirty gloves removed and discarded. Hand hygiene should be performed properly before accessing clean supplies. Clean gloves donned. Then wound cleaned using aseptic non-touch technique. Wound treatment completed using aseptic non-touch technique. Dirty supplies discarded in trash receptacle. Gloves removed and hand hygiene performed properly after dressing change is complete. On 05/20/25, at 03:19 PM, during the end of day exit meeting with the facility, Surveyor shared concern that while watching wound care, LPN-L did not perform handwashing and a glove change between dirty and clean tasks. No additional information was provided regarding handwashing and glove changes. Based on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during 5 (R12, R44, R32, R50 & R9) of 8 resident care and treatment observations. * Surveyor observed a staff member empty R12's ileostomy bag (small abdominal opening to allow waste discharge from the small bowel). After empting the ileostomy bag, Surveyor observed the staff member not remove their gloves and did not wash their hands prior to turning on R12's radio. * Surveyor observed a staff member walk into R44's enhanced barrier precaution room and leave R44's enhanced barrier precaution room without performing hand hygiene as required for posted enhanced barrier precaution rooms. * Surveyor observed a staff member not remove their gloves or wash their hands after providing incontinence care to R32. * Staff was observed not wearing a gown when caring for R50 whom was on enhanced barrier precautions. * During Surveyor's observation of R9's wound care, Licensed Practical Nurse-L was observed not washing hands and changing gloves between dirty and clean procedures. Findings include: The facility's Enhanced Barrier Precaution signs on the resident's door frames document: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high contact resident care activities. dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assist with toileting device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care any skin opening requiring a dressing. The facility's policy dated as revised 2/2025 and titled, Hand Hygiene documents: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol-based hand rub with 60 to 95 % alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are viably dirty, before eating, and after using the restroom 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. b. Bar soap is approved for a resident's personal use only. Keep bar soap clean and dry in protective containers (i.e. plastic case or bag). c. Liquid soap reservoirs must be discarded when empty. If refillable, dispensers must be emptied and cleaned, rinsed and dried according to manufacturer instructions Findings include: 1.) R12 was admitted to the facility on [DATE] with diagnoses that included Urinary Retention and Ileostomy. On 05/20/25, at 09:56 AM, Surveyor observed R12's ileostomy bag being emptied of fecal material by CNA-G during R12's cares. Surveyor noted that R12 is in enhanced barrier precautions with an enhanced barrier precaution sign located outside of R12's room. Surveyor observed CNA-G wash hands and don gloves and gown prior to CNA-G performing cares on R12. Surveyor observed CNA-G empty R12's Ileostomy bag and then place contents from R12's ileostomy bag into a closed bag and then double bag the fecal contents of the bag. Surveyor observed R12 then request that CNA-G turn on R12's stereo. Surveyor observed CNA-G walk over to R12's radio while still wearing the gown and gloves used during the emptying of R12's ileostomy bag and turn on R12's radio. Surveyor observed CNA-G then remove CNA-G's gown and gloves and wash CNA-G's hands and leave R12's room. On 05/21/25, at 12:50 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B Surveyor's concerns of CNA-G touching R12's radio without removing CNA-G's contaminated gloves and performing hand hygiene after emptying R12's ostomy bag of fecal material. No additional information was provided. 2.) R44 was admitted to the facility on [DATE] with diagnoses that included Urinary Incontinence with an Indwelling Catheter and Cancer. On 5/19/25, at 08:05 AM, Surveyor observed Certified Nursing Assistant (CNA)-H walk from a meal cart down the hall into a room occupied by R44. Surveyor observed CNA-H place a mask on and bring a meal tray into R44's room and set it down in front of R44. Surveyor watched CNA-H pick up the meal tray and not perform hand hygiene when CNA-H left R44's enhanced barrier precaution room. Surveyor watched CNA-H walk back to meal cart and pick up another tray and return to R44's enhanced barrier precaution room and set the new tray down in front of R44. Surveyor watched CNA-H only perform hand hygiene when leaving R44's enhanced barrier precaution room after the second tray was delivered. Surveyor was positioned outside of R44's room and could see in the room because the door to R44's room was left open. On 05/21/25, at 12:50 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B Surveyor's concerns during the 5/19/25 incident when CNA-H did not perform hand hygiene when leaving R44's enhanced barrier precaution room. No additional information was provided.

Based on interview and record review, the facility did not ensure 1 (R50) of 1 injury of unknown origin that was reviewed was submitted to the State survey agency. On 4/22/25, R50's daughter informed the facility of a bruise on R50's left eyelid of R50's left eye. The facility did not report this injury of unknown source to the State survey agency. Findings include: The facility's policy dated November 2024 and titled, Abuse, Neglect and Exploitation documents under the policy section: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under section IV Identification of Abuse, Neglect and Exploitation includes documentation of B. Possible indicators of abuse include, but are not limited to: 3. Physical injury of a resident, of unknown source. Under section VII. Reporting/Response documents A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1.) R50's diagnosis includes diabetes mellitus (high blood sugar), urinary retention, metabolic encephalopathy (metabolic disturbances affecting how the brain functions), malignant neoplasm (cancer) of lateral wall of bladder, hypertension (high blood pressure) and depression. R50's significant change MDS (minimum data set) with an assessment reference date of 4/10/25 documents a BIMS (brief interview mental status) score of 15 which indicates that R50 is cognitively intact. Surveyor reviewed R50's nurses notes from 4/12/25 to 4/21/25 and did not note any documentation of R50 having trouble putting his glasses on and/or hitting his face with his glasses. R50's nurses note dated 4/22/25 at 18:21 (6:21 p.m.) written by Licensed Practical Nurse/Unit Manager (LPN/UM)-E documents: Daughter brought to staff's attention a bruise to resident's left eye lid that she noticed on Sunday. Bruise was not reported to staff, and staff just noticed it today. Writer assessed resident, bruise is covering almost the entire eyelid, resident reports no pain. Resident is a hoyer. Daughter shared she noticed that resident rests the left side of his face against the hoyer sling during transfers, and she had to apply a towel to secure resident's head straight. Hoyer education will be provided for staff. CNAs (Certified Nursing Assistant) reported to writer that resident has a hard time trying to put on his glasses and keeps on hitting different spots on his face before getting behind his ears. Resident wants to be independent but refuses assistance. Writer spoke with resident and asked him to allow staff to assist to avoid injuries. R50's head to toe skin check dated 4/22/25 under the skin integrity section is checked for new bruises. Under the describe new or existing other issues it states: Bruise to left eyelid. Under the site section it documents: 4) Face, type is Bruising, length in centimeters is 4 and width in centimeters is 2.5. Under the further description of skin issues section it documents: Bruise covering left eyelid. R50's nurses note dated 4/23/25 at 06:42 (6:42 a.m.) and written by Registered Nurse (RN)-S documents: Res. (Resident) has flat bruise to lateral left upper lid and to skin lateral of eye. Bruise is purple. Res. states he was not injured in any way that he is aware of. Slept well in intervals with no c/o's (complaint of) pain. R50's nurses note dated 4/23/25 at 10:46 a.m. and written by Director of Nursing (DON)-B documents: IDT (interdisciplinary team) met and discussed: 4-22-25 1450 (2:50 p.m.) Daughter brought to staff (unit manager) attention a bruise to resident's left eyelid, that she shared she noticed it on Sunday but did not say anything then. Very tiny on Sunday she thought maybe because he was resting his face on sling in hoyer. I have no idea how it happened. I did not hit or bump my eye I do not think. Nobody hurt me. Nurse assessed resident, bruise is covering almost the entire eyelid, resident reports no pain. Resident is a hoyer. Daughter shared she noticed that resident rests the left side of his face against the hoyer sling during transfers, and she had to apply a towel to secure resident's head straight. Hoyer education will be provided for staff. CNAs reported to writer that resident has a hard time trying to put on his glasses and keeps on hitting different spots on his face before getting behind his ears. Resident wants to be independent but refuses assistance. Nurse spoke with resident and asked him to allow staff to assist to avoid injuries with glasses and/or other tasks. Denies any pain. NP (Nurse Practitioner) updated. New interventions: offer wash cloth against cheek to keep head straight in hoyer sling, hoyer education with staff, offer A1 (assist one) with glasses. R50's nurses note dated 4/23/25 at 21:51 (9:51 p.m.) and written by Licensed Practical Nurse (LPN)-U documents: Resident has ecchymosed sic (ecchymosis) area to left eye. Skin remains intact, no c/o pain or discomfort. Resident denied any trauma and was unable to recall incident. Denied double or blurred vision, no s/sx (signs/symptoms) of trauma to sclera. R50's nurses note dated 4/24/25 at 14:51 (3:51 p.m.) and written by Infection Control (IC)/RN-T documents: Resident continues to be monitored for 2000FR (fluid restriction). FR maintained this shift. Resident continues with bruise to L (left) eye remains dark Burgundy in color, no c/o (complaint of) pain or discomfort noted. On 5/19/25, at 11:10 a.m., Surveyor informed R50 last month he had a bruise on his left eye and asked R50 if he remembers what caused the bruise. R50 replied no. R50's representative, who was also in the room, informed Surveyor she saw the bruise on Sunday and was bigger on Monday & Tuesday. R50's representative thought it was from the hoyer lift and after the bruise occurred, staff started to put a towel on the hoyer. On 5/20/25, at 12:02 p.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-E if R50's injury of unknown source to R50's left eye lid was reported to the State Agency. LPN/UM-E replied that's a question for [first name of Nursing Home Administrator (NHA)-A]. On 5/20/25, at 12:39 p.m., Surveyor asked NHA-A if R50's bruise on left eye identified on 4/22/25 was reported to the State agency. NHA-A replied no. Surveyor asked NHA-A why this wasn't reported. NHA-A replied we didn't feel it was of unknown origin. Surveyor asked NHA-A how this was determined. NHA-A informed Surveyor R50 hits himself with his glasses. Surveyor asked NHA-A if there was any concerns with the hoyer lift. NHA-A replied I don't recall I'll have to look back. Surveyor informed NHA-A R50's bruise to the left eye lid should have been reported as the eye isn't an area which generally bruises. NHA-A informed Surveyor the eye is an area does get bruised often. On 5/20/25, at 1:59 p.m., NHA-A informed Surveyor the eye is not an area that is suspicious if you wear glasses and informed Surveyor she gathered information regarding R50's bruise. Surveyor asked NHA-A for any information regarding R50's injury of unknown source. On 5/20/25, at approximately 3:45 p.m., Surveyor reviewed information provided by NHA-A during regarding R50's injury of unknown source. Surveyor noted included in this information is Division of Quality Assurance's Injury of Unknown Source Flowchart. Surveyor noted this flowchart was not completed to show on the Facility determined this injury of unknown source did not need to be reported to the State agency. A statement from Med Tech-V that wad not dated indicated R50 had difficulty putting on glasses & often jabbed the nose piece or the arms of the glasses into his face and education to staff regarding hoyer education as R50's representative thought the hoyer lift could have caused the injury. On 5/21/25, at 10:20 a.m., Surveyor informed NHA-A that Surveyor had reviewed the facility's Abuse, Neglect and Exploitation policy and asked if there is any other policy that address injury of unknown source. NHA-A informed Surveyor she will have to look. Surveyor informed NHA-A R50's bruise to the left eye should have been reported as the injury was not observed by anyone, a CNA thought it was due to his glasses but R50's representative thought the hoyer lift, R50 did not know how he sustained the bruise, and the bruise is in a location not generally vulnerable to trauma, R50's left eye with measurements of 4 by 2.5 cm (centimeters). NHA-A stated it was little, referring to the size of R50's bruise. NHA-A informed Surveyor she read the regulations and did not consider the eye suspicious because R50 wears glasses and stated to Surveyor we have a difference of opinion. No additional information was provided as to why the facility did not report R50's injury of unknown source to the State Agency.

Based on interview and record review, the facility did not have evidence that an injury of unknown source was thoroughly investigated for 1 (R50) of 1 residents. On 4/22/25, R50 was observed to have a bruise to the left eye. This injury of unknown source was not thoroughly investigated. Findings include: The facility's policy titled, Abuse, Neglect and Exploitation and reviewed/revised 11/24 under Policy documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under section V. Investigation of Alleged Abuse, Neglect and Exploitation documents A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigation include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of all the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. 1.) R50's diagnosis includes diabetes mellitus (high blood sugar), urinary retention, metabolic encephalopathy (metabolic disturbances affecting how the brain functions), malignant neoplasm (cancer) of lateral wall of bladder, hypertension (high blood pressure) and depression. R50's significant change MDS (minimum data set) with an assessment reference date of 4/10/25 documents a BIMS (brief interview mental status) score of 15, which indicates R50 is cognitively intact. Surveyor reviewed R50's nurses notes from 4/12/25 to 4/21/25 and did not note any documentation of R50 having trouble putting his glasses on and/or hitting his face with his glasses. R50's nurses note dated 4/22/25 at 18:21 (6:21 p.m.) written by Licensed Practical Nurse/Unit Manager (LPN/UM)-E documents Daughter brought to staff's attention a bruise to resident's left eye lid that she noticed on Sunday. Bruise was not reported to staff, and staff just noticed it today. Writer assessed resident, bruise is covering almost the entire eyelid, resident reports no pain. Resident is a hoyer. Daughter shared she noticed that resident rests the left side of his face against the hoyer sling during transfers, and she had to apply a towel to secure resident's head straight. Hoyer education will be provided for staff. CNAs (Certified Nursing Assistant) reported to writer that resident has a hard time trying to put on his glasses and keeps on hitting different spots on his face before getting behind his ears. Resident wants to be independent but refuses assistance. Writer spoke with resident and asked him to allow staff to assist to avoid injuries. R50's head to toe skin check dated 4/22/25 documents under the skin integrity section: new bruises. Under the describe new or existing other issues section it documents Bruise to left eyelid. Under the site section it documents 4) Face, type is Bruising, length in centimeters is 4 and width in centimeters is 2.5. Under the further description of skin issues section it documents: Bruise covering left eyelid. R50's nurses note dated 4/23/25 at 06:42 (6:42 a.m.) and written by Registered Nurse (RN)-S documents Res. (Resident) has flat bruise to lateral left upper lid and to skin lateral of eye. Bruise is purple. Res. states he was not injured in any way that he is aware of. Slept well in intervals with no c/o's (complaint of) pain. R50's nurses note dated 4/23/25 at 10:46 a.m. and written by Director of Nursing (DON)-B documents IDT (interdisciplinary team) met and discussed: 4-22-25 1450 (2:50 p.m.) Daughter brought to staff (unit manager) attention a bruise to resident's left eyelid, that she shared she noticed it on Sunday but did not say anything then. Very tiny on Sunday she thought maybe because he was resting his face on sling in hoyer. I have no idea how it happened. I did not hit or bump my eye I do not think. Nobody hurt me. Nurse assessed resident, bruise is covering almost the entire eyelid, resident reports no pain. Resident is a hoyer. Daughter shared she noticed that resident rests the left side of his face against the hoyer sling during transfers, and she had to apply a towel to secure resident's head straight. Hoyer education will be provided for staff. CNAs reported to writer that resident has a hard time trying to put on his glasses and keeps on hitting different spots on his face before getting behind his ears. Resident wants to be independent but refuses assistance. Nurse spoke with resident and asked him to allow staff to assist to avoid injuries with glasses and/or other tasks. Denies any pain. NP (Nurse Practitioner) updated. New interventions: offer wash cloth against cheek to keep head straight in hoyer sling, hoyer education with staff, offer A1 (assist one) with glasses. R50's nurses note dated 4/23/25 at 21:51 (9:51 p.m.) and written by Licensed Practical Nurse (LPN)-U documents Resident has ecchymosed sic (ecchymosis) area to left eye. Skin remains intact, no c/o pain or discomfort. Resident denied any trauma and was unable to recall incident. Denied double or blurred vision, no s/sx (signs/symptoms) of trauma to sclera. R50's nurses note dated 4/24/25 at 14:51 (3:51 p.m.) and written by Infection Control (IC)/RN-T documents Resident continues to be monitored for 2000FR (fluid restriction). FR maintained this shift. Resident continues with bruise to L (left) eye remains dark Burgundy in color, no c/o (complaint of) pain or discomfort noted. On 5/19/25, at 11:10 a.m., Surveyor informed R50 last month he had a bruise on his left eye and asked R50 if he remembers what caused the bruise. R50 replied no. R50's representative who was also in the room informed Surveyor she saw it on Sunday and was bigger on Monday & Tuesday. R50's representative thought it was from the hoyer lift and after the bruise staff started to put a towel on the hoyer. On 5/20/25, at 12:02 p.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-E if there was an investigation for R50's left eye bruise identified on 4/22/25. LPN/UM-E replied yes we investigated and explained R50's representative kind of assisted them. LPN/UM-E explained R50 was a hoyer lift at that time, every time R50 was brought up R50 would turn his face so a towel was folded on the side. LPN/UM-E informed Surveyor she asked the CNA right after. LPN/UM-E informed Surveyor after R50 came back from the hospital R50 really declined, R50 used to be a stand pivot and after hospitalization R50 was a hoyer. LPN/UM-E informed Surveyor R50 was hallucinating, changed the Gabapentin and the way R50 was trying to put on his glasses was going everywhere on R50's face. LPN/UM-E informed Surveyor R50 tries to be independent and wasn't realizing he needed help. Surveyor asked LPN/UM-E the CNA who she spoke with did she write down what the CNA said or did the CNA write down a statement. LPN/UM-E replied no he did not. Surveyor asked LPN/UM-E who she spoke with during the investigation. LPN/UM-E replied the daughter, first name of Med Tech-V, obviously first name of DON-B and first name of NHA-A because they didn't know how the bruise happened so they had to figure it out. Surveyor asked LPN/UM-E if any other staff were interviewed. LPN/UM-E replied I can't remember, know we were having a conversation with first name of Med Tech-V. LPN/UM-E informed Surveyor R50 was confused, he had declined and R50 said he had no idea how it happened. LPN/UM-E informed Surveyor she implemented an intervention of putting a towel so R50 wasn't against the sling. On 5/20/25, at 1:59 p.m., NHA-A informed Surveyor she gathered information regarding R50's bruise. Surveyor asked NHA-A for any information regarding R50's left eye bruise. On 5/20/25, at approximately 3:45 p.m., Surveyor reviewed information provided by NHA-A during the end of the day meeting regarding R50's injury of unknown source. Surveyor noted included in this information is Division of Quality Assurance's Injury of Unknown Source Flowchart. A statement from Med Tech-V not dated which documents [R50's name] had difficulty putting on glasses, often jabbed the nose pieces or the arms of the glasses into his face. Most likely cause of the bruising documented 4/22/25. A statement from LPN/UM-E dated 5/20/25 which documents On 4/22/25, I [LPN/UM-E's name] received a verbal statement from CNA (Certified Nursing Assistant)[Med Tech-V's name] that he observed resident hitting his eye several times with his glasses while attempting to put them on. A note NP (Nurse Practitioner) 4/23, 4/25, & 4/30 had no concerns. R50's head to toe skin check dated 4/22/25 under the skin integrity section is checked for new bruises. Under the describe new or existing other issues section it documents Bruise to left eyelid. Under the site section it documents 4) Face, type is Bruising, length in centimeters is 4 and width in centimeters is 2.5. Under the further description of skin issues section it documents Bruise covering left eyelid. A handwritten note which documents completed hoyer education as a precautionary, since the R50's family member felt it may have come from leaning on the hoyer with education material & in-service sign in sheets. Surveyor noted there is was no evidence other staff who provided cares to R50 on 4/20/25, the day R50's representative stated she first observed the bruise, 4/21/25, or 4/22/25 other than Med Tech-V were interviewed regarding R50's left eye bruise. On 5/21/25, at 10:20 a.m., Surveyor informed NHA-A R50's there is not evidence R50's left eye bruise was thoroughly investigated. No additional information was provided.

Based on observation, interview, and record review the facility did not ensure residents received proper treatment and care to maintain mobility and good foot health for 2 (R50 & R64) of 2 residents. * R50 & R64's toenails were very long and in need of trimming. Findings include: The facility's policy titled, Podiatry Services with date reviewed/revised 5/2025 under Policy documents It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. Under Policy Explanation and Compliance Guidelines documents 1. Foot care that is provided in the facility, such as toe nail clipping for resident without complicating disease processes, should be provided by staff who have received education and training to provide this service. 2. Residents requiring foot care who have complicating disease processes will be referred to qualified professionals such as Podiatrist, Doctor of Medicine, and/or Doctor of Osteopathy. 3. Foot disorders which require treatment include, but are not limited to: corns, neuromas (noncancerous growth of nerve tissue), calluses, hallux valgus (bunions), ,digiti flexus (hammertoe), heel spurs, and nail disorders. 4. Employees should refer any identified need for foot care to the social worker or designee. 5. The social worker or designee will assist residents in making appointments and arranging transportation to obtain needed services. 1.) R50 was admitted to the facility on [DATE] with diagnosis which includes diabetes mellitus (high blood sugar). On 5/18/25, at 3:33 p.m., Surveyor observed R50 in bed on his back with bare feet. Surveyor observed R50's toe nails on both feet are observed the toenails to be long and in need of trimming. On 5/19/25, at 11:19 a.m., R50's representative stated to Surveyor they, referring to R50 & R64, need to have their toe nails cut and trimmed and stated that the residents (R50 & R64) had not been seen by a podiatrist since they've been at the facility. Surveyor reviewed R50's medical record and was able to locate a podiatry consent form dated 11/24, but was unable to locate any documentation that R50 received podiatry services. On 5/19/25, at 1:11 p.m., Surveyor asked Unit Secretary (US)-N if the facility has a podiatrist who comes into the facility to provide foot care. US-N informed Surveyor that the facility has a podiatrist, eye, & dentist that comes in the building. Surveyor asked US-N how a resident gets on the list to be seen by the podiatrist. US-N explained she has consent forms from the company. After the resident or POA (power of attorney) signs the consent, US-N will send the consent along with their face sheet and then they are on their list. Surveyor asked US-N when the podiatrist saw R50. US-N informed Surveyor R50 was skipped over on April 8th when the podiatrist came. Surveyor asked US-N what she meant by R50 being skipped over. US-N explained R50 wasn't on the list and she didn't realize R50 wasn't on the list. US-N informed Surveyor R50's representative said something to her about the podiatrist and asked her to make sure R50 was on the list when the podiatrist comes in. Surveyor asked US-N since R50 was admitted in November 2024 has R50 been seen by the podiatrist. US-N stated to Surveyor let me take a peek when they signed because they don't always sign the consent right away. US-N checked R50's consent form and informed Surveyor the consent was signed on 11/29/24. Surveyor asked if the podiatry group make up the list of residents to be seen. US-N replied yes and explained she gets a list of who is to be seen. Surveyor asked US-N if she knows why the podiatrist didn't see R50. US-N informed Surveyor she has said something to them and they said he will be on the list. US-N informed Surveyor she has changed when the podiatrist comes in explaining they can't come in early as there was a problem with the podiatrist skipping people. US-N informed Surveyor the podiatrist can't come in until she gets here which is about 7:00 a.m. Surveyor asked US-N what time was the podiatrist coming in. US-N informed Surveyor he was coming in sometime on 3rd shift around 5:00 a.m. or 6:00 a.m. US-N informed Surveyor the podiatrist would say he saw residents and the residents would tell her they weren't seen. US-N stated she was in a pickle as she wasn't there and didn't know. On 5/20/25, at 12:07 p.m., Surveyor informed Licensed Practical Nurse/Unit Manager (LPN/UM)-E of the observation of R50's toe nails being very long and in need of trimming and that R50 hasn't been seen by the podiatrist since R50 was admitted in November 2024. No additional information was provided. 2.) R64 was admitted to the facility on [DATE] and has diagnosis which includes dementia. On 5/19/25, at 11:19 a.m., R64's representative stated to Surveyor that R50 & R64 need to have their toe nails trimmed and that R50 & R64 have not been seen by a podiatrist since they've been here. Surveyor reviewed R64's medical record and was able to locate a podiatry consent form dated 11/24 but was unable to locate when R50 was provided with podiatry services. On 5/20/25 from 9:15 a.m. to 9:31 a.m. Surveyor observed morning cares for R64 with CNA-AA & CNA-Z. During this observation, Surveyor observed that R64's toe nails are very long on both feet and in need of trimming. On 5/20/25, at 9:37 a.m. Surveyor asked Unit Secretary (US)-N if there is a signed podiatry consent for R64. US-N replied yes. Surveyor asked US-N if R64 has been seen by the podiatrist as Surveyor observed R64's feet today & R64's toe nails are very long. US-N stated to Surveyor that after Surveyor left yesterday, US-N realized that R64 wasn't not seen by the podiatrist. US-N informed Surveyor she has sent several emails to the podiatry group. US-N stated that yesterday they answered her telling her the person she sent the emails is gone and that the podiatrist did not receive her emails. US-N informed Surveyor she went back to her email dated 11/29/24 and forwarded the email informing them it was sent on 11/29/24 at 11:43 a.m. for both R50 & R64. The nurses note dated 5/20/24 at 17:02 (5:02 p.m.) and written by Infection Control/Registered Nurse (IC/RN)-T documents: This nurse assessed resident toenails, it was noted that the resident's toenails are excessively thick and difficult to trim safely. Due to the risk of injury, toenails trimming was not performed. A podiatry appointment has been scheduled to address this issue appropriately. The resident and POA (power of attorney) have been informed and is agreeable to the plan. No additional information was provided.

Based on observation, record review and staff interviews, the facility did not ensure that 2 (R16 & R6) out of 3 residents reviewed for bowel and bladder incontinence received the appropriate treatment and services to restore continence to the extent possible. * R16 did not have a documented bowel movement for 6 days in February, 2025. The facility did not provide interventions to assist with proper bowel function nor did they notify R16's physician of R16's constipation. R16 was sent out to the hospital for an unrelated change of condition and was found to have a small bowel obstruction. * R6 had a decline in incontinence status without a comprehensive assessment completed to help maintain or restore bladder / bowel functioning. Findings include: The facility's policy dated as revised 2/2025 and titled, Incontince documents: Based on resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Policy Explanation and Compliance Guidelines: (includes) 1. The facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. 2. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. 1.) R6 was admitted to the facility on [DATE] with diagnosis that included dementia, bilateral hearing loss, urge incontinence, anxiety disorder, insomnia, hypertension and type 2 diabetes. R6's annual MDS ( Minimum Data Set) dated 1/20/25 documents a BIMS ( brief interview for mental status) score of 7, indicating that R6 is severely cognitively imparied. The MDS documents that R6 is occasionally incontinent of bowel and bladder. The MDS asked if a trial of a toileting program ( e.g., scheduled toileting, prompted voiding, or bladder training) has been attempted on admission/ entry or reentry or since urinary incontinence was noted in this facility. The facility answered No. The MDS also asked is a toileting program currently used to manage the resident's bowel continence. The facility answered No. R6's CAA ( care area assessment) for Urinary Incontinence and Indwelling Catheter documents that R6 is occasionally incontinent of bladder and requires partial assistance for toileting. Under the care plan considerations sectionit documents that staff are to offer toileting assistance and assist resident with his toileting hygiene and transfers as indicated on the care card. R6's individual plan of care documents that R6 has bladder incontinence/potential for incontinence r/t (related to)cognitive impairment dated as initiated on 08/23/2022 documents: Interventions include: o Check and change upon rising, before and after meals, HS (evening) and PRN (as needed). Date Initiated: 01/09/2024. o three-day bladder diary and assessment to be completed on admission, quarterly, annually, with significant change and as needed. Date Initiated: 08/23/2022. o Utilizes a bedpan, urinal, commode to void. Date Initiated: 08/23/2022. o wears a brief. Date Initiated: 08/23/2022. R6's alteration in the gastrointestinal tract care plan related to bowel incontinence and is at risk for constipation due to pain, meds, decrease in mobilit dated as revised on 12/27/2024 documents: Interventions include: *Check and change upon rising, before and after meals, HS and PRN. Date Initiated: 09/25/2023. * Describe and document any loose stools. Date Initiated: 08/23/2022. o monitor and document BM every shift. Date Initiated: 08/23/2022. o peri cares to be provided after any incontinence .Date Initiated: 08/23/2022 *Three-day bowel and bladder assessment on admission and per policy .Date Initiated: 08/23/2022 On 4/11/25, the facility conducted the quarterly MDS for R6. The assessment documented that R6 has a BIMS ( brief interview for mental status) score of 7 - severe cognitive impairment. The MDS also documents that R6 is frequently incontinent of bowel and bladder. This would be a decline in both bowel and bladder incontinence since 1/10/25 when R6 was assessed to be only occasionally incontinent of bowel and bladder. Surveyor requested to review the most current bladder and bowel assessment. The facility provided a quarterly/annual/significant change assessment dated 4/11/25 that documents: Section J: Bladder/ Bowel How long has the resident been incontinent or has a catheter? A: incontinent longer than 1 year. How often is the resident wet? A: once or more per shift. Resident is wet during: A: Day and nighttime Amount of urine? A: Small Medications affecting continence: A: Antipsychotics Bowels: continent of stool? A: yes Bowel pattern: normal formed stool, rarely/never depends on a laxative. This assessment was completed by Director of Nursing -B. Surveyor conducted a review of the CNA care card and noted that R6 is to be checked and changed upon rising, before bed and after meals, HS and PRN. R6 is incontinent of bowel and bladder at times. R6 is to wear pull ups- size large. On 05/20/25 at 1:42 PM, Surveyor observed R6 seated in his wheelchair in room. R6 was observed from the hallway, to have taken off his jeans and then removed the brief. The brief appeared soiled and R6 placed it in the waste basket. R6 was then observed attempting to put pants back on. Surveyor noted that R6 had not activated the call light for staff assistance. R6 stands up from wheelchair, without locking the breaks, pulls on pants and connects belt. R6 sits back into wheelchair and then wheels over to closet. R6 then removes the jeans he had just put on, throws then on the floor and takes out another pair of jeans from his closet. R6 is able to put the new pair of jeans on, stands again without locking the brakes on the wheelchair and connects belt. On 05/21/25 at 11:06 AM , Surveyor interviewed LPN Unit Manager- E regarding R6's decline in incontinence. LPN Unit Manager- E stated that R6 is for sure incontinent of urine. R6 will decline cares at times, he likes his independence. R6 can stand and pivot to toilet , so he likes to use the toilet for his bowels. R6 is stubborn and will take himself to the bathroom LPN Unit Manager-E confirmed that R6 is at high risk for falls and will often not lock his wheelchair brakes when standing. LPN Unit Manager- E also stated that R6 is not good at alerting staff his needs, staff must anticipate them. Surveyor asked if the staff follow a toileting schedule for R6 to help anticipate his toileting needs. LPN Unit Manager- E stated that there is not a set schedule other than asking/ checking when R6 gets up in the morning, before meals, before bedtime and as needed. Surveyor asked LPN Unit Manager- E if she was aware the MDS has identified R6 as having a decline in his incontinence from 1/10/25 to 4/11/25. LPN Unit Manager - E stated that she does not have access to the MDS. LPN Unit Manager- E stated that she is not sure how accurate the assessment might be because R6 might or might not always tell staff when he needs to be changed or toileted and he will sometimes do it himself. He might tell or might not. LPN Unit Manager- E stated that education to R6 won't work, he is confused and often will not remember. As of the time of exit, the facility was not able to provide evidence that they had comprehensively assessed R6's decline in bowel and bladder continence. The facility did not conduct any type of voiding pattern to develop an individualized toileting plan for R6 to help restore or maintain his bowel and bladder continence. 2.) R16's diagnoses includes seizures (sudden burst of electrical activity in brain which can cause changes in behavior, movement, & level of consciousness), neurogenic bowel (loss of normal bowel function caused by a nerve problem), and hemiplegia (paralysis on one side of the body) & hemiparesis (weakness on one side of the body) following cerebral infarction (type of stroke) affecting right dominate side. R16 incontinent of bowel at times and is at risk for constipation care plan initiated 1/28/23 & revised 3/10/25 documents the following interventions: Administer medications as ordered, initiated 1/18/23. Assess and document bowel sounds, pain, abdominal distention, appetite, initiated 1/18/23. Assist with toileting, initiated 1/18/23. Complete hydration assessment, if at risk notify dietician, initiated 1/18/23. Describe and document any loose stools, initiated 1/18/23. Follow facility protocol for no BM (bowel movement) for three days, initiated 1/18/23. Incont (incontinent) of bowel/bladder at check/change upon rising, before/after meals and HS (hour sleep) and PRN (as needed), initiated 1/9/24. Monitor and document BM every shift, initiated 1/18/23. Offer additional fluids, initiated 1/18/23. Peri cares to be provided after incontinence, initiated 1/18/23, and three day bowel & bladder assessment on admission and per policy, initiated 1/18/23. R16's quarterly MDS (minimum data set) with an assessment reference date of 1/26/25 has a BIMS (brief interview mental status) score of 7 which indicates severe impairment. R16 is assessed as being dependent for toileting hygiene and is always incontinent of urine & bowel. Surveyor reviewed R16's bowel documentation located under the task tab and noted the following: On 2/11/25 during the day shift (6:30 a.m. to 1430 (2:30 p.m.)) R16 was incontinent, BM (bowel movement) size is medium and consistency of BM is loose/diarrhea. The PM (1430 (2:30)-2230 (10:30)) shift and night shift (2230 (10:30 p.m.)-630 (6:30 a.m.)) are blank. On 2/12/25 day shift is blank, PM shift documents 2 no bowel movement, and night shift is blank. On 2/13/25 day shift documents 2 no bowel movement, PM shift documents 2 no bowel movement and night shift is blank. On 2/14/25 day shift, PM shift, and night shift are all blank. On 2/15/25 day shift is blank, PM shift documents 2 no bowel movement, and night shift is blank. On 2/16/25 day shift documents 2 no bowel movement, PM shift and night shift are blank. On 2/17/25 day shift is blank, PM shift documents 2 no bowel movement, and night shift is blank. On 2/18/25 day shift documents incontinent, BM size is large and consistency of BM is putty like, PM shift documents 2 no bowel movement and night shift documents 97 not applicable. On 2/19/25 day shift is incontinent, BM size is small, consistency of BM is formed/normal, PM shift & night shift document 2 no bowel movement. On 2/20/25 day, PM and night shift are blank. On 2/21/25 day shift document 2 no bowel movement and PM shift & night shift are blank. On 2/22/25 day shift, PM shift, and night shift are blank. On 2/23/25 day shift, PM shift, and night shift are blank. On 2/24/25 day shift & PM shift are blank and night shift documents 99 resident not available. R16's February 2025 MAR (medication administration record) reveals there are no scheduled bowel medications and the following PRN (as needed) bowel medications: order date 1/16/23 Bisacodyl Rectal Suppository 10 mg (milligrams) with directions to insert 1 suppository rectally as needed for PRN QD (as needed every day) for constipation. Order date of 1/16/23 Magnesium Hydroxide Oral Suspension 400 mg (milligrams)/5 ml (milliliter) with directions to give 30 ml by mouth as needed PRN QD for constipation. Surveyor noted during February 2025 R16 did not receive any PRN (as needed) bowel medications. R16's nurses note dated 2/24/25, at 04:01 (4:01 a.m.) written by Licensed Practical Nurse (LPN)-K documents Resident was sent out via 911 ambulance at 0300 (3:00 a.m.). Writer was notified by floor CNA (Certified Nursing Assistant) that Res (Resident) was not doing well when she went in to do his cares. Writer immediately went to residents room and he was sitting up in bed visibly working hard to breath and writer could hear crackles in his chest standing at bedside. Writer listened to residents chest with stethoscope and heard loud lung crackles. Resident was diaphoretic, jaundice in his face/eyes, his whole right arm was purple, his torso and lower extremities were gray, his feet and ankles were more swollen than normal. BP (blood pressure): 79/56, HR (heart rate): 95, T (temperature):97.3, O2 (oxygen): 70% and dropping. A second and third attempt at a BP was unsuccessful. Writer immediately called 911(0255) (2:55 a.m.), ambulance arrived at 0300 (3:00 a.m.) and departed at 0303 (3:03 a.m.). Writer called [hospital initials] ER (emergency room) [Name] to give report; On call nurse notified at 0300; Residents POA (power of attorney) notified at 0318 (3:18 a.m.). Writer sent a notification in HUCU (healthcare communication platform) to providers to update them on the situation at 0346 (3:46 p.m.). R16's hospital Discharge summary dated [DATE] under discharge diagnoses includes Small bowel obstruction. Under hospital course includes documentation of Small bowel obstruction: general surgery followed. Conservative mngmt (management) recommended at this time due to soft abdomen on exam. Concern for ischemic injury as a potential source of elevated lactate. Diet advanced and tolerating. R16's readmission note dated 3/3/25 at 2:00 p.m. and written by Licensed Practical Nurse/Unit Manager (LPN/UM)-F documents admitted from, transferred by, accompanied by: [Hospital's initials], Ambulance, no family present. admitted From: [Hospital's initials]. Admitting dx (diagnoses):: sepsis and small bowel obstruction. Transported by (family or ambulance company name): ambulance Assessment overview:: Resident was lethargic, was able to respond, and looked comfortable. Ambulatory/WC (wheelchair)/Gurney: gurney. Family Member(s) Present: General Mood/Affect Upon Arrival: R16's nurses note dated 3/3/25 at 14:48 (2:48 p.m.) and written by LPN-L documents Pt (patient) arrived via stretcher. Pt seems lethargic, responds to name only, does not respond to other questions. readmitted post hospital stay for sepsis and a small bowel obstruction. Head to toe skin check revealed scabbing to left side of patient's neck. BUE (bilateral upper extremity) and BLE (bilateral lower extremity) +3 pitting edema. Tubi grips have been applied to BLE. Pt remains incontinent, dependent with all cares, hoyer for all transfers. Last BM (bowel movement) was 3/2/25. Pt has completed ABT (antibiotic) for sepsis. Bowel sounds present. New order for skin prep to scabs on neck daily. No other issues or concerns. R16's quarterly MDS with an assessment reference date of 4/28/25 documents a BIMS score of 7 which indicates severe impairment. R16 is assessed as dependent for toileting hygiene and is always incontinent of urine and bowel. On 5/20/25, at 10:02 a.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-F if there is a bowel protocol at the facility. LPN/UM-F replied yes we do and explained the CNA's chart bowel movements. LPN/UM-F explained if a Resident hasn't had a bowel movement in three days they will give MOM (milk of magnesia) unless it's contraindicated. If it's been four days then they give a Bisacodyl suppository and if the resident still does not have a bowel movement they contact the physician for further guidance. LPN/UM-F informed Surveyor when they give PRN MOM it will pop up to reassess and asks if the medication is effective or ineffective. On 5/20/25, at 11:54 a.m., Surveyor asked LPN/UM-E if there is a bowel protocol at the facility. LPN/UM-E explained if a resident is incontinent the CNA can tell how many times the resident has had a bowel movement and if the resident is independent they will ask the resident if they have had a bowel movement. LPN/UM-E informed Surveyor this is documented and when the nurses open PCC (pointclickcare) will show if a resident hasn't had a BM for 72 hours. Three days with no BM they will do an intervention. Surveyor asked what the intervention would be. LPN/UM-E informed Surveyor contact the NP (nurse practitioner) for increase in Senna or extra dose of Miralax or suppository depending on the situation. LPN/UM-E informed Surveyor the first thing she'll ask is if the resident is taking any stool softner. Surveyor asked if this would be documented in the residents medical record. LPN/UM-E replied yes and explained if there is a new order or anything happening with the resident should be documented. Surveyor informed LPN/UM-E Surveyor had reviewed R16's bowel documentation and noted R16 did not have a bowel movement from 2/12/25 until day shift on 2/18/25. Surveyor did not note any PRN bowel medication administered during this time. R16 was transferred to the hospital for change of condition on 2/21/25 and hospital discharge summary documents small bowel obstruction. Surveyor asked for any information regarding monitoring of R16's bowels. On 5/20/25 Surveyor was provided with a pink post it note which documented R16 had BM's on the dates that Surveyor provided. On 5/20/25, at 3:32 p.m., during the end of the day meeting with Nursing Home Administrator-A, Director of Nursing (DON)-B and Consultant-I Surveyor informed staff Surveyor had reviewed R16's bowel records which indicated R16 did not have a bowel movement from 2/12/25 until the day shift on 2/18/25, small bowel movement on the day shift on 2/19/25, no BM on 2/21/25, 2/22/25, &2/23/25, and discharged to the hospital on 2/24/25. R16 returned on 3/4/25 with a diagnosis of small bowel obstruction. Surveyor informed staff Surveyor was provided with a pink post it note from LPN/UM-E which indicated R16 had bowel movements during this time. Surveyor asked DON-B when staff document 2 with their initials and time what does 2 mean. On 5/21/25, at 6:57 a.m., DON-B provided Surveyor with a piece of paper which documented 2 could indicate small BM, incontinent, loose stool, etc .unable to determine which is which on this report. On 5/21/25, at 7:00 a.m., Surveyor asked Certified Nursing Assistant (CNA)-M if a resident doesn't have a bowel movement during his shift what does he document and could he show Surveyor how this is documented. CNA-M went over to the computer and showed Surveyor there is a tile which has no bowel movement. CNA-M showed Surveyor if no BM is clicked on the tiles for size of BM and consistency go away. Surveyor noted if the resident has a BM then these two options continue to be on the computer screen. On 5/21/25, at 9:48 a.m., Surveyor asked LPN/UM-E if she can go into the CNA charting. LPN/UM-E replied yes and stated she never has charted but can try. Surveyor explained to LPN/UM-E Surveyor would like to confirm on the CNA documentation for bowel movement when there is a 2 with initials & time the 2 means no bowel movement. LPN/UM-E was unable to chart in the bowel documentation. Surveyor then asked LPN/UM-E if Surveyor could ask one of the CNA's chart no bowel movement for today and then have the bowel documentation report printed out. On 5/21/25, at 9:58 a.m., Surveyor with LPN/UM-E spoke with CNA-M. Surveyor asked CNA-M to document in the CNA charting for R16 no bowel movement for today during the day shift. CNA-M then entered no bowel movement and saved this documentation. Surveyor showed LPN/UM-E the bowel movement report Surveyor had been provided and asked if she could print out this report for today. LPN/UM-E was unable to print this report and contacted DON-B to print this report. On 5/21/25, at 10:11 a.m., Surveyor accompanied LPN/UM-E to DON-B office. Surveyor showed DON-B the bowel documentation report Surveyor would like printed out as Surveyor had asked CNA-M to document R16 did not have a bowel movement on today's day shift. DON-B printed out this report which documented for 5/21/25 on the day shift 2 with CNA-M's initials and the time. Surveyor showed DON-B and Consultant-I this report for today (5/21/25) documents code 2 which means no bowel movement. Surveyor informed LPN/UM-E, DON-B & Consultant-I R16 went 6 days (2/12/25 to 2/17/25) and 5 days (2/20/25 to 2/24/25) without a bowel movement & without any interventions provided. No additional information was provided.

Based on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 3 medication errors in 28 opportunities which resulted in a medication error rate of 10.71%. Medication errors were identified for R54 & R47. * R54 did not receive Glimepiride 4 mg before breakfast according to physician orders and received the incorrect eye drop medication. * R47 received the incorrect eye drop medication. Findings include: On 5/20/25, at 9:56 a.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-F if there are certain times when Resident's medication should be administered. LPN/UM-F explained they have scheduled times like 8:00 a.m. & 9:00 a.m., some are AM (morning) medications which are administered between 7:00 a.m. & 10:30 a.m., and noon medications which LPN/UM-F believes are between 12:00 p.m. to 2:30 p.m Surveyor asked LPN/UM-F if it's the expectation nurses follow physician orders. LPN/UM-F replied yes. Surveyor asked LPN/UM-F if a medication ordered by a physician to be given before a meal should the medication be given before the resident eats. LPN/UM-F replied yes. 1.) On 5/18/25, at 8:36 a.m. Surveyor observed Registered Nurse (RN)-C obtain R54's blood pressure of 117/83 and then wheel R54 into R54's room. Surveyor asked RN-C if R54 has eaten breakfast already. RN-C replied yup, R54 has eaten already. On 5/18/25, at 8:38 a.m., Surveyor observed RN-C cleanse her hands and then prepare R54's medication which consisted of Aspirin EC (enteric coated) 81 mg (milligrams) one tablet, Folic Acid 1 mg one tablet, Senna 8.6 mg one tablet, Glimepiride 4 mg one tablet, Losartan Potassium 50 mg one tablet and Miralax 17 grams. On 5/18/25 at 8:42 a.m., RN-C who was looking through the medication cart, informed Surveyor R54 gets eye drops and then stated RN-C will have to go downstairs to get them as RN-C doesn't see them in the cart. Surveyor then verified with RN-C there are 5 tablets in the medication cup. On 5/18/25, at 8:46 a.m., RN-C administered R54's medication whole with Miralax. On 5/18/25, at 8:53 a.m. RN-C dated artificial tears lubricant eye drops informing Surveyor R54 will be getting two drops in the right eye. On 5/18/25, at 8:55 a.m., RN-C placed gloves on, handed R54 a tissue, opened R54's right eye and administered two drops in R54's right eye. RN-C removed her gloves, wheeled R54 out of the room into the dining room and cleansed her hands. On 5/19/25, at 2:54 p.m., Surveyor reviewed R54's physician orders. Surveyor noted there is a physician orders dated 7/18/23 which documents Systane Ophthalmic Solution 0.4-0.3% (Polyethylene Glycol-Propylene Glycol (Opth) Instill 2 drops in right eye two times a day for eye redness. R54 received artificial tears lubricant eye drops and not Systane Ophthalmic Solution. R54's physician orders dated 7/21/22 documents Glimepiride Tablet 4 mg. Give 1 tablet by mouth in the morning for DM (Diabetes Mellitus) (high blood sugar) before breakfast. R54 did not receive Glimepiride 4 mg before breakfast according to physician order. This observation resulted in two medication errors for R54. On 5/20/25, at 11:47 a.m., Surveyor asked LPN/UM-E if nurses should be following physician orders. LPN/UM-E replied absolutely. Surveyor informed LPN/UM-E of R54 not receiving Glimepiride 4 mg before breakfast and receiving the incorrect eye drop medication. 2.) On 5/18/25, at 9:07 a.m., Surveyor observed Med Tech-D prepare R47's medication which consisted of Acetaminophen 325 mg (milligrams) two tablets, Vitamin C 500 mg one tablet, Aspirin 81 mg one tablet, Multi Vitamin one tablet, Allopurinol 100 mg one tablet, Visine dry eye relief lubricant, Furosemide 20 mg one tablet, and Spironolactone 100 mg two tablets. On 5/18/25, at 9:14 a.m., Surveyor verified there are 9 tablets in the medication cup with Med Tech-D and Med Tech-D then placed gloves on. On 5/18/25, at 9:15 a.m., Med Tech-D administered one drop of Visine dry eye relief lubricant in R47's right & left eye and administered R47's medication whole with water. On 5/19/25, at 3:22 p.m., Surveyor reviewed R47's physician orders and noted a physician order dated 8/18/22 Artificial Tears Solution 1.4% (Polyvinyl Alcohol). Instill 1 drop in both eyes two times a day for eye redness. The active ingredients in Visine Dry Eye Relief Lubricant eye drops is polyethylene glycol 400 1%. This observation resulted in one medication error for R47. On 5/20/25, at 10:01 a.m., Surveyor informed LPN/UM-F of R47 receiving the incorrect eye drop on 5/18/25. No additional information was provided.

Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). Staffing information for Quarter 1 (October 1 - December 31) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS. This deficient practice has the potential to affect all 69 residents residing in the facility. Findings include: The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, documents: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: (quarter) 1 October 1-December 31, (quarter) 2 January 1-March 31, (quarter) 3 April 1-June 30, (quarter) 4 July 1-September 30. 1.) Surveyor reviewed the PBJ Staffing Data Report, CASPER Report 1705D, for Fiscal year 2025 (run on 5/12/25) documents that the Facility had excessively low weekend staffing and a one star staffing rating for the 1st Quarter (October 1-December 31). Surveyor reviewed the Facility's weekend schedules from October 2024 to December 2024. Surveyor noted licensed nurses and certified nursing assistants present on each shift and for each unit. Surveyor noted these schedules included call ins and showed that agency staff and staff who picked up the shifts. Surveyor noted there did not appear to be excessive call-ins. Surveyor reviewed the facility's assessment and noted staffing ratios and compared them to the provided schedules. No discrepancies were found. On 05/19/25, at 11:10 AM, Surveyor interviewed Scheduler-J who stated that minimum staffing levels of 4/4/2 is the set algorithm used but that more staff can be added. Scheduler-J stated that the facility will take census into account and resident acuity. Surveyor verified what the italicized names meant on the schedule and was told that person picked up the shift. If the name is handwritten it was a change after the schedule was printed. If there is a line through the name, it indicates the person was not there either due to call in or no show. On 05/19/25, at 12:10 PM, Surveyor interviewed Scheduler-J regarding who reports the scheduled working hours to CMS. Per Scheduler-J, the hours are pulled from the timekeeping system directly. Surveyor asked if Scheduler-J was aware that October through December was flagged for One Star Staffing and Excessively Low Weekend Staffing. Scheduler-J stated that corporate had talked to them and Nursing Home Administrator (NHA)-A had to give a report with a spreadsheet to them. On 05/19/25, at 12:11 PM, Surveyor interviewed NHA-A who stated corporate had flagged low and high days of staffing. NHA-A had to go through and see what was not being captured. NHA-A stated that when census is 75 or over the unit manager or Director of Nursing (DON)-B will help nursing staff. On 05/19/25, at 03:16 PM, Surveyor interviewed NHA-A and was told the staffing ratio on the Facility Assessment was wrong, NOC shift should actually be 1:20 (1 aide for 20 residents). NHA-A stated that corporate flagged nurses for low staffing, DON-B was a floating supervisor and the unit managers filled in. On 5/20/25, at 03:19 PM, during the end of day meeting with Director of Nursing-B and Nursing Home Administrator-A Surveyor stated need to figure out what was sent to CMS for data to determine why they triggered for low weekend staffing. On 05/21/25, at 09:47 AM, NHA-A followed up with Surveyor that they just got off phone with corporate was told that in the month of October no agency staff hours were transmitted, corporate fixed the error and has not triggered since. Surveyor informed NHA-A of concern related to improper reporting and NHA-A stated understanding.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not maintain a system of surveillance, tracking and trending of infections and identifying possible communicable diseases or infections before they can spread to other persons in the facility potentially affecting 75 of 75 residents. ~ The facility had an Infection Control Program that did not accurately track, trend or analyze the infection rate and data to help decrease the rates, numbers and spread of infections in the facility. No maps were completed to identify monthly infections on units. Graphs that were created grouped all infections together as Healthcare Associated Infections (HAI's) and was not being analyzed. ~ The facility had 3 outbreaks of Covid 19 in 2023. There were no summaries, timelines, contact tracing or documentation of the outbreaks explaining the course of the outbreak and the steps the facility took to mitigate the outbreak. ~ R29, R24 and R43 had signs and symptoms of infections and Transmission Based Precautions were not put in place immediately to potentially prevent further spread of the potential infections to other residents. ~Maintenance Technician-S was observed entering and exiting R12 and R46's shared room without washing their hands or donning a gown and gloves. The shared room had singe on the door for Enhanced Barrier Precautions and Contact Precaution were necessary. ~R46 is an immunocompromised resident and was placed in a room with R12 who had a history of MRSA (Methicillin-Resistant Staphyloccous Aures) in August 2023 against CDC (Centers for Disease Control) guidance and facility policy. In October 2023 R46 tested positive for MRSA. ~ On R46 and R12's sink there were bins of unlabeled wound care products that were being used on both residents possibly cross contaminating and spreading infection. ~ During Medication Pass, observations of staff not performing hand hygiene before preparing medications, before administering medications, before administering eye drops and after touching resident to take vital signs was observed. Staff did not don gloves to administer eye drops and touched residents' bare skin on face. ~Staff used multi-use equipment to take blood pressures and did not clean the equipment in between residents. Staff used a glucometer that is used for multiple residents on a resident and then did not clean it with an EPA (Environmental Protection Agency) registered healthcare disinfectant. Staff used an alcohol wipe that does not prevent the transmission of bloodborne pathogens. ~Surveyor had observations of R177's Foley catheter on floor during survey. Findings included: Surveyor reviewed facility's Infection Prevention and Control Program policy with a revision date of 05/2023. Documented was: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Definitions: Staff includes all facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2. All staff are responsible for following all policies and procedures related to the program. 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. The Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) participate in surveillance through assessment of residents and reporting changes in condition to the residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. a. All staff shall assume that all residents are potentially infected or colonized with an that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices, a described in relevant facility policies. e. Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility, and are to report problem: outside of their scope to the appropriate department. 5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. b. Residents on transmission-based precautions should be placed into a private/single room if available/appropriate, or are cohorted with residents with the same pathogen, or share a room with a roommate with limited risk factors, in accordance with national standards. c. Residents will be placed on the least restrictive transmission-based precaution for the shortest duration possible under the circumstances. d. When a resident on transmission-based precautions must leave the resident care unit/area, the charge nurse on that unit/area shall communicate to all involved departments the nature of the isolation and shall prepare the resident for transport in accordance with current transmission-based precaution guidelines. e. Residents with tuberculosis are placed on airborne precautions and placed in a special room that is equipped with special air handling and ventilation capacity. If no such room is available, the residents will be discharged to a facility with such capabilities. f. Immunocompromised and myelosuppressed residents shall be placed in a private room if possible and shall not be placed with any resident having an infection or communicable disease . 10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. b. Single-use disposable equipment is an alternative to sterilizing reusable medical instruments. Single-use devices must be discarded after use and are never used for more than one resident. c. Reusable items potentially contaminated with infectious materials shall be placed in an impervious clear plastic bag. Label bag as CONTAMINATED and place in the soiled utility room for pickup and processing. d. The central supply clerk will decontaminate equipment with a germicidal detergent prior to storing for reuse . Surveyor reviewed facility's Glucometer Disinfection policy with an implementation date of 10/23. Documented was: Policy: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. Definitions: Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected then the meter will not be used for multiple residents. 3. The glucometers will be disinfected with a wipe pre-saturated with an EPA A registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. 4. Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 5. Procedure: a. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, sin lancet, blood glucose testing strips, disinfecting wipes. b. Wash hands. c. Explain the procedure to the resident. d. Provide privacy. e. Put on gloves. f. Obtain capillary blood glucose sampling according to facility policy. g. Remove and discard gloves, perform hand hygiene prior to exiting room. h. Reapply gloves if there is visible contamination of the device or if the resident is HIV or Hepatitis B or C positive. i. Retrieve (2) disinfectant wipes from container. j. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. l. Discard disinfectant wipes in waste receptacle. m. Perform hand hygiene. A. Infection Surveillance Surveyor reviewed Facility's Infection Surveillance policy with a revision date of 1/24. Documented was: Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. Definitions: Infection surveillance refers to an ongoing systematic collection, analysis, interpretation, and dissemination of infection-related data. Outcome measure is a mechanism for evaluating outcomes or results, such as tracking specific infection events. Process measure is a mechanism for evaluating specific steps in a process that lead, either positive negatively, to a particular outcome metric. Also known as performance monitoring, a process measure is used to evaluate whether infection prevention and control practices are being followed. Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation incidents, findings, and any corrective actions made by the facility and reports surveillance finding, the facility's Quality Assessment and Assurance Committee, and public health authorities when required 2. The RNs and LPNs participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and management staff, per protocol for notification of change and in-house reporting of communicable diseases and infections. Examples of notification trigger include, but are not limited to: a. Resident develops signs and symptoms of infection. b. A resident is started on an antibiotic. c. A microbiology test is ordered. d. A resident is placed on isolation precautions, whether empirically or by physician order. e. Microbiology test results show drug resistance. 3. An annual infection control risk assessment will be used to prioritize surveillance efforts, as documented in the facility's Infection Surveillance Action Plan. In turn, surveillance data will provide information for subsequent infection control risk assessments. 4. The CDC's National Healthcare Safety Network (NHSN) Long Term Care Criteria, updated McGeer criteria or other nationally-recognized surveillance criteria will be used to define infections. For MDS purposes, specific guidance in the RAI manual will be followed when coding for infections (i.e. UTI). 5. Surveillance activities will be monitored facility-wide, and may be broken down by department or unit, depending on the measure being observed. A combination of process and outcome measures will be utilized. 6. The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: a. Data to be collected, including how often and the type of data to be documented, including: i. The infection site, pathogen (if available), signs and symptoms, and resident location, including summary and analysis of the number of residents (and staff, if applicable) who developed infections: ii. Observations of staff including the identification of ineffective practices, if any; and iii. The identification of unusual or unexpected outcomes, infection trends and patterns. b. How the data will be used and shared and with appropriate individuals (e.g, staff, medical director, director of nursing, QAA committee) when applicable, to ensure that staff minimize spread of the infection or disease. 7. The facility will communicate via (specify how, e.g., written reports, staff meetings, etc.) to staff and/or prescribing practitioners information related to infection rates and outcomes in order to revise interventions/approaches and/or re-evaluate medical interventions as indicated. 8. Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. 9. All resident and infections will be tracked. Separate, site-specific measures may be tracked as prioritized from the infection control risk assessment. Outbreaks will be investigated. 10. Employee, volunteer, and contract employee infections will be tracked, as appropriate, such as influenza or gastrointestinal infection outbreaks. 11. The facility will conduct testing of staff and residents for communicable diseases (e.g., COVID-19) in accordance with national standards. 12. The facility will conduct specimen collection and testing in a manner consistent with standards of practice. a. 24 hour shift reports b. Lab reports c. Antibiograms obtained from lab d. Antibiotic use reports from pharmacy e. Medication regimen review reports f. Skills validations for hand hygiene, PPE, and/or high risk procedures g. Rounding observation data h. Resident and employee immunization data i. Documentation of signs and symptoms in clinical record j. Transfer/discharge summaries for new or readmitted residents for infections k. Staff reports of signs and symptoms and other relevant documentation, if indicated. 14. Formulas used in calculating infection rates will remain constant for a minimum of one calendar year, and will require discussion in QAA meetings before changes in the formulas are made. 1. On 2/22/24 Surveyor requested Facility Infection Surveillance tracking and trending from July 2023 through December 2023. Surveyor was provided with Infection Surveillance Monthly Reports from July 2023 through December 2023. The Report documented: Total Infections, Community Acquired Infections, Healthcare Acquired Infections, Healthcare Acquired Infections Rate, Multi Drug Resistant Organisms. Healthcare Acquired Infections 12-Month Trend (Graph over 12 months) Summary By Infection Category (Broke down into: Infection Category, Total, Healthcare Acquired Infections, Healthcare Acquired Infections Rate) On 2/22/24 at 1:00 PM Surveyor interviewed Infection Preventionist (IP)-J. Surveyor asked how IP-J knows the trends of the HAI (Healthcare Acquired Infections) for each infection if it is not broken down into individual infections. IP-J stated she can look at the daily log of infections. IP-J provided Infection By Unit for August 1-31, 2023, which broke down infections by resident. Surveyor asked how the data is analyzed, tracked, and trended to determine infections increasing and decreasing. IP-J stated when I see that data then I can kinda look at maybe if they have the same aide. Surveyor asked if there was a summary or other data analysis of what she determined are the trends in infections for the facility. Surveyor stated as an example, based on the unit list there were thirteen yeast infections in the month of August. Surveyor asked did she analyze that infection or any of the others as a trend. IP-J stated no, I do not do that. Surveyor asked for mapping of infections. IP-J handed Surveyor a blank map and explained she would indicate infections on each unit and location of each different infection designated in assorted colors. Surveyor asked for the Facility maps for July 2023 through December 2023. IP-J stated she has not been doing them. IP-J stated she is doing Infection Prevention part-time, 2 days a week and cannot get everything done since it is not a full time position anymore. 2. On 2/19/24 Surveyor requested a list of outbreaks in the facility that occurred in 2023 or 2024. Surveyor received a list that documented Outbreaks [DATE] to current: Covid 2/10/23, Covid 6/29/23, Covid 9/24/23. Surveyor received line lists for each outbreak. On 2/22/24 at 2:02 PM, Surveyor interviewed IP-J. Surveyor asked if there was a summary of the Covid outbreaks and what happened or a timeline. IP-J stated she had emails to the health department updating them on the progress of the outbreak but nothing else. Surveyor asked if they did mapping or contract tracing for the outbreak. IP-J stated they had done broad base Covid testing. Surveyor asked about the analysis of finding the source of the outbreak. IP-J stated no. IP-J stated there is no way to contract trace on the dementia unit. B. Transmission Based Precautions Surveyor reviewed facility's Transmission-Based (Isolation) Precautions policy with a revision date of 2/24. Documented was: . Policy Explanation and Compliance Guidelines: 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. The facility will use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. (A table that depicts the types of PPE to use is attached to this policy.) When implementing transmission-based precautions, the facility will consider the following: a. The identification of resident risk factors that increase the likelihood of transmission (such as uncontained secretions or excretions, non-compliance, cognition deficits, incontinence, etc.); b. The provision of a private room as available/appropriate; c. Cohorting residents with the same pathogen; and d. Sharing a room with a roommate with limited risk factors (e.g., without indwelling or invasive devices, without open wounds, and not immunocompromised) as appropriate based on the pathogen and method of transmission . Surveyor reviewed facility's (Multi Drug Resistant Organism) MDRO Infection policy with a revision date of 2/24. Documented was: .Policy Explanation and Compliance Guidelines: 1. Infection, as opposed to colonization, with an MDRO will be determined by a physician in accordance with current CDC diagnostic and testing guidelines for the specific organism. 2. Information related to a resident who is known to be infected with an MDRO will be communicated as follows: a. Staff will use contact precautions in addition to standard precautions when caring for a resident with MDRO infection. b. Signage at entry of the resident's room shall indicate Contact Precautions, and the type of personal protective equipment is required upon entry into the room. i. Instructions for visitors shall be identified. ii. The specific indications for precautions or personal health information shall not be included in the sign. c. Contact precautions will be modified for a resident with MDRO infection on a case-by-case basis. d. The precautions shall be the least restrictive possible for the resident under the circumstances, for the least amount of time. e. Increased measures may be employed in certain situations, including, but not limited to: i. Evidence of ongoing transmission of the organism in the facility. ii. Challenges with containing sites of infection (i.e. infected secretions, body fluids, or drainage cannot be contained). iii. Resident requires more intensive care (i.e. totally dependent, ventilator). iv. Presence of a rare, highly resistant organism. f. Contact precautions will be discontinued when the physician and Infection Preventionist review the situation and determine the resident is no longer infectious, or is colonized, and is at low risk of transmitting the organism to others . 5. Resident placement: a. When private rooms are available, assign priority for these rooms to residents with known MDRO infection or colonization. b. Give highest priority to those residents who have conditions that may facilitate transmission, e.g., uncontained secretions or excretions. c. When private rooms are not available, cohort residents with the same MDRO in the same room. d. When cohorting residents with the same MDRO is not possible, place MDRO residents who are at low risk for acquisitions of MDRO's and associated adverse outcomes (residents without open wounds, invasive devices, or who are not immunocompromised) from infection and/or are likely to have short lengths of stay. e. Minimize transmission in shared rooms by maintaining 3 feet separation between residents, pulling privacy curtains, dedicating equipment to the resident with MDRO infection, and increase 7. One or more intensified MDRO control efforts may be implemented at a time. Additional efforts may be implemented as needed, after additional surveillance. Examples include: a. Obtaining expert consultation from persons experienced in infection control and epidemiology of MDROS. b. Evaluating facility systems, such as staffing, training, available resources, and performance monitoring, that may be contributing to the problem. c. Providing additional individual or departmental education. d. Reviewing susceptibility patterns and antibiotic prescribing practices. e. Obtaining active surveillance cultures from roommates, residents who have significant contact with MDRO-infected residents or staff (if staff are suspected to be a source of transmission). f. Increasing the frequency or intensity of surveillance activities. g. Implementing contact precautions routinely for all residents colonized or infected with a target MDRO. h. Suspend admissions to units with a high prevalence of MDRO infections. i. Assign dedicated staff to residents with the target MDRO infection. j. Obtain environmental cultures. Vacate rooms for intensive cleaning when the environment is implicated in transmission. k. Consulting with experts on the appropriate use of decolonization therapy for residents or staff . 11. Care considerations related to Methicillin-resistant Staphylococcus aureus (MRSA): a. MRSA is a drug-resistant strain of a bacterium found on people's skin. b. It is usually spread by contact with infected wounds or from direct contact with contaminated objects. c. Implement strategies to reduce device and procedure related healthcare associated infections (i.e. central lines, urinary catheter, surgical sites, hemodialysis, and ventilator). d. Follow local, state, regional, or national recommendations for treatment and precautions . Surveyor reviewed facility's Infection Outbreak and Response policy with a revision date of 12/23. Documented was: .Policy Explanation and Compliance Guidelines: 1. Prompt recognition of outbreak: a. Changes in condition and/or signs and symptoms of infection will be reported according to procedures for infection reporting. b. The following triggers shall prompt an investigation as to whether an outbreak exists: i. An increase over baseline infection rate (i.e. ten percent or more increase). ii. A sudden cluster of infections on a unit or during a short period of time (i.e. three or more cases). iii. A single case of a rare or serious infection i.e. invasive group A Strep, foodborne pathogens, active TB, acute hepatitis, Legionella, chicken pox, measles, COVID-19). c. An outbreak will be defined according to the characteristics of a given organism. Current definitions used by local and state health departments will help guide the determination. d. An outbreak will be reported to the local and/or state health department in accordance with the state's reportable diseases website. 2. Implementation of the infection control measures: a. Symptomatic residents will be considered potentially infected, assessed for immediate needs, and placed on empiric precautions while awaiting physician orders. b. Symptomatic employees will be screened by the Infection Preventionist, or designee, and referred to appropriate medical provider. c. Standard precautions will be emphasized. Transmission-based precautions will be implemented as indicated for the particular organism. d. Staff will be educated on the mode of transmission of the organism, symptoms of infection, and isolation or other special procedures. This includes special environmental infection control measures that are warranted based on the organism and current CDC guidelines. e. Surveillance activities will increase to daily for the duration of the outbreak. 3. Outbreak Investigation: a. When the existence of an outbreak has been established, an investigation will begin. b. The Infection Preventionist will be responsible for coordinating all investigation activities. (Note: the health department may assume decision making and coordination activities. In this case, the Infection Preventionist will be the liaison between the health department and the facility.) c. A case definition will be developed in order to identify other staff and residents who may be affected. Criteria for developing a case definition include: i. Person - key characteristics the patients share in common ii. Place - the location associated with the outbreak iii. Time - period of time associated with illness onset for the cases under investigation iv. Clinical features - objective signs and symptoms, such as sudden onset of fever and cough d. A line list about each person affected by the outbreak will be maintained. e. The incubation period, period of contagiousness, and date of most recent case will be making the determination that the outbreak is resolved. f. A summary of the investigation will be documented and reported to QAA committee health department, if indicated. 3.) R29 was admitted to the facility 8/31/21 with diagnoses that included Heart Failure, Diabetes Mellitus 2 and Chronic Kidney Disease. R29 had an Unstageable Pressure Ulcer to the Right Heel identified 6/16/23. Surveyor reviewed R29's MD orders. Documented with a start date of 12/15/23 was Monitor skin alteration to R (right) heel, right great toe for any s/sx signs/symptoms of infection (warmth to wound site or surrounding area, increased pain, odor, bleeding, edema, change in the amount or the color of the wound drainage. Notify MD if any s/sx (signs/symptoms) of infection are noted; every shift for Wound monitoring Notify MD of any s/sx of infection are noted. Surveyor reviewed Progress Notes for R29. Documented on 1/17/24 at 2:47 PM was [Wound MD-L] gave orders for a wound culture to the right heel in relation to increased drainage and pain. Results pending. Case manager updated. Resident denied family update at this time. Documented in R29's MD orders with a start date of 1/17/24 was Wound culture to the right heel one time only for Wound culture to the right heel. Documented in R29's Progress Notes on 1/19/24 at 12:20 AM was Wound culture still pending. Dressing to right foot changed, previous dressing was saturated with yellow drainage. Odor also noted. C/O (complaint of) pain, 9/10 in right foot . Documented in R29's Progress Notes on 1/22/24 at 4:25 PM was Resident has MRSA to wound and would not like to move rooms, and roommate does not want to move. Risks vs benefits discussed with resident and it is explained she will need to be in enhanced barrier precautions after the MRSA is resolved, resident understands. Documented in R29's MD orders with a start date of 1/21/24 and end date of 1/22/24 was Single room isolation due to active infection, highly transmissible via contact, Full PPE all services brought to room; every shift for right heel. Surveyor noted R29 was not on any precautions prior to 1/21/24. Surveyor noted the wound was identified 6/16/23 and TBP (Transmission Based Precautions) were in place and the wound infection was suspected 1/17/24 and no TBP were put in place until 1/21/24. On 2/22/24 at 1:45 PM, Surveyor interviewed Infection Preventionist (IP)-J. Surveyor asked when residents are put on Transmission Based Precautions. IP-J stated when they have an airborne or contact infection. Surveyor asked if a resident has signs and symptoms of an infection are they placed on precautions. IP-J stated yes, we put them on precautions when we are monitoring their symptoms such as coughing when we think it is pneumonia. Surveyor asked would a resident be put in precautions if a wound infection was suspected. IP-J stated yes, we would put them in contact isolation. Surveyor asked about R29. Surveyor noted the culture was ordered due to signs and symptoms on 1/17 and there was an increase in symptoms on 1/19 including odor and drainage. Surveyor asked why was R29 not in precautions. IP-J stated She would be just be under universal precautions because [the wound] was covered. Surveyor noted that was not what the facility policy noted as basis for precautions. Surveyor asked if she should have been in Enhanced Barrier due to the wound and then Contact Precautions on 1/17 due to the suspected infection. IP-J stated yes. 4.) R24 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Epilepsy, Muscle Weakness, Difficulty in Walking, and Cutaneous Abscess of Buttocks. Documented in R24's MD orders with a start date of 1/31/24 was Wound culture and send to lab; No directions specified for order. Documented with a start date of 2/1/24 was Monitor skin alteration to L (left) buttock abscess for any s/sx of infection (warmth to wound site or surrounding area, increased pain, odor, bleeding, edema, change in the amount or the color of the wound drainage. Notify MD if any s/sx of infection are noted; every shift for Wound monitoring Notify MD of any s/sx of infection are noted. Documented in R24's Progress Notes on 2/2/24 at 10:34 AM, was Residents wound culture came back positive for MRSA. Resident will stop amoxicillin and start on clindamycin 300 mg Q6 (every 6 hours) x (for) 10 days per NP (Nurse Practitioner). She will

Based on observation, interview, and record review, the facility did not ensure residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice for 4 (R20, R29, R5, and R72) of 10 residents reviewed for pressure injuries. *R20 developed a Stage 4 pressure injury to the left lateral ankle. The wound was not comprehensively assessed weekly. *R29 was admitted to the facility with a chronic right heel Unstageable pressure injury that was not comprehensively assessed on admission and readmission, a wound treatment was not ordered for three days after readmission, and the wound was not comprehensively assessed weekly. *R5 was admitted to the facility with a right buttock Stage 3 pressure injury that was not comprehensively assessed on admission, a wound treatment was not ordered for three days after admission, and the wound was not comprehensively assessed weekly. *R72 was observed not wearing heel boots as per care plan. Findings include: The facility policy and procedure entitled Pressure Injury Prevention and Management dated 10/2023 states: Policy Explanation and Compliance Guidelines: . 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. d. Assessment of pressure injuries will be performed by a licensed nurse. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS (Minimum Date Set) . 4. c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) . 4. d. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. ii. Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection, wound bed, wound edge and surrounding tissue characteristics. In an interview on 2/22/2024, at 10:39 AM, Surveyor asked Registered Nurse (RN) Unit Manager (UM)-F what the facility process and expectation was for newly admitted residents and skin assessments. RN UM-F stated from RN UM-F's understanding they do not have a strict policy who does or does not do the admission skin assessment. RN UM-F stated the RN should assess any wound, IV sites, and that sort of thing and if there is no RN in the building when a new admission comes in, then the Licensed Practical Nurse (LPN) will do the assessment in their scope of practice which is to collect data and then the RN will delegate and guide the LPN as to what to do. Surveyor asked RN UM-F what an assessment of a wound would entail. RN UM-F stated the wound would be measured getting the length, width, and depth if possible. RN UM-F stated if the wound is open, there may be no depth to that wound. RN UM-F stated the description of depth depends on the individual nurse. RN UM-F stated the LPN cannot stage a wound. RN UM-F stated the new admission wound description gets followed up with an admission audit to stage the wound and if the facility nurses do not know what the stage of the wound is, they ask Wound Physician-L. Surveyor asked RN UM-F if any nurses on staff were wound care certified. RN UM-F did not think so. Surveyor asked RN UM-F what staff members do weekly wound rounds. RN UM-F stated RN UM-F, RN UM-E, and Director of Nursing (DON)-B go with Wound Physician-L to do wound rounds. Surveyor asked RN UM-F who assesses a resident's wounds if they are not available when Wound Physician-L is doing wound rounds. RN UM-F stated the UM will assess the wound or they will delegate it to the nurse that is doing the treatment to get the measurements and assessment and document it in the Progress Notes. RN UM-F stated RN UM-F is not in the building on Fridays, so RN UM-F does not assess a resident until the following Monday if they came in on Friday or over the weekend. RN UM-F stated when the nurse gets a report from the hospital, they should be getting wound treatment notes and if there are not any, they should be calling the physician to get a treatment. 1) R20 was admitted to the facility on [DATE] with diagnoses of dementia, osteoarthritis, moderate protein-calorie malnutrition, autoimmune hepatitis, atherosclerosis to bilateral legs, depression, spinal stenosis, and a history of methicillin resistant staphylococcus aureus (MRSA). R20's Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated R20 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5 and the facility assessed R20 as being dependent for repositioning, transfers, hygiene, and dressing. R20 was admitted to Hospice on 1/18/2023 due to dementia and declining health. R20 had an activated Health Care Power of Attorney. R20's Skin Integrity Care Plan was initiated on 2/19/2020. R20 had a history of pressure injuries to the right and left shin, right lateral distal foot, and right buttock. R20 had the following interventions in place on 1/11/2023: -R20 will be encouraged to offload and reposition more frequently; on 10/18/2023 the wound doctor discontinued the heel boots based on the risk vs benefits of the heel boots. -Alternating pressure mattress; check function every shift. -Encourage R20 to offload heels. On 11/1/2023, R20 was assessed by Wound Physician-L for an Unstageable pressure injury to the right medial foot, a Deep Tissue Injury to the right medial distal foot, an Unstageable pressure injury to the left buttock, and an Unstageable pressure injury to the right shin. During that visit, Wound Physician-L discovered an Unstageable pressure injury to the left lateral ankle that measured 0.3 cm x 0.5 cm x 0.1 cm with 100% necrotic tissue to the wound bed. A treatment of xeroform gauze to the wound three times per week was ordered. Wound Physician-L documented the pressure injury was unavoidable secondary to general decline and contraction. R20's Skin Integrity Care Plan was revised on 11/7/2023 with the intervention to offload left lateral ankle with pillows and encourage frequent offloading that started on 11/1/2023. On 11/8/2023, R20's left lateral ankle Unstageable pressure injury was comprehensively assessed by Wound Physician-L. R20's Skin Integrity Care Plan was revised on 11/9/2023 with the intervention to put a sign in R20's room to not place heel boots that started on 11/8/2023. On 11/15/2023 on the Skin and Wound Evaluation form, RN UM-F documented the left lateral ankle Unstageable pressure injury measured 0.3 cm x 0.4 cm with no depth documented with eschar to the wound bed. No percentage of tissue type was documented. On 11/22/2023 on the Skin and Wound Evaluation form, nursing documented the left lateral ankle Unstageable pressure injury measured 2.3 cm x 2.2 cm with no depth documented with 10% slough to the wound bed. 90% of the wound did not have a tissue type documented. On 11/29/2023 on the Skin and Wound Evaluation form, nursing documented the left lateral ankle Unstageable pressure injury measured 2 cm x 2.2 cm with no depth documented with 90% eschar. 10% of the wound did not have a tissue type defined. On 12/6/2023, R20's left lateral ankle Unstageable pressure injury was comprehensively assessed by Wound Physician-L. The wound measured 0.3 cm x 0.3 cm x 0.1 cm with 100% slough. On 12/13/2023, R20's left lateral ankle Unstageable pressure injury was comprehensively assessed by Wound Physician-L. On 12/20/2023 on the Skin and Wound Evaluation form, RN UM-F documented the left lateral ankle Unstageable pressure injury measured 0.3 cm x 0.2 cm with no depth documented with 100% slough. R20's Skin Integrity Care Plan was revised on 12/26/2023 with the intervention to use bilateral body pillows for offloading that started on 12/23/2023. On 12/27/2023 on the Skin and Wound Evaluation form, RN UM-F documented the left lateral ankle Unstageable pressure injury measured 0.2 cm x 0.2 cm with no depth documented. No documentation was found describing the wound bed. No documentation was found of a wound assessment of the left lateral ankle from 12/27/2023 until 1/10/2024. On 1/10/2024, R20's left lateral ankle Unstageable pressure injury was comprehensively assessed by Wound Physician-L and the pressure injury was staged at a Stage 4. The wound measured 1.5 cm x 1.5 cm x 0.1 cm with 100% slough. Wound Physician-L documented the post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a Stage 4 pressure injury. This is not a wound deterioration. Wound Physician-L comprehensively assessed the left lateral ankle Stage 4 pressure injury weekly on 1/17/2024 and 1/24/2024. On 1/31/2024 on the Skin and Wound Evaluation form, RN UM-F documented the left lateral ankle Stage 4 pressure injury measured 1 cm x 1.3 cm with no depth documented with granulation and slough. No documentation was found describing the percentages of tissue type in the wound bed. On 2/7/2024, R20's left lateral ankle Stage 4 pressure injury was comprehensively assessed by Wound Physician-L. The wound measured 2 cm x 2.5 cm x 0.1 cm with 50% slough and 50% granulation tissue. Wound Physician-L documented the wound had exacerbated due to generalized decline of R20. On 2/14/2024 on the Skin and Wound Evaluation form, RN UM-F documented the left lateral ankle Stage 4 pressure injury measured 1.8 cm x 2.2 cm with no depth documented. No documentation was found describing the wound bed. On 2/21/2024 at 2:12 PM, Surveyor observed R20 sitting in a Broda chair with socks on and no heel boots on. A sign was observed on the wall to read no heel boots. Wound Physician-L, RN UM-F, and RN UM-E came into the room to do R20's weekly comprehensive assessment of the left lateral ankle Stage 4 pressure injury. The ankle wound was on the bony prominence where there was no subcutaneous tissue leading to a quickly developing Stage 4 pressure injury. The dressing was removed from the outer ankle with serous drainage on the dressing. The wound bed was 90% healthy pink tissue and 10% slough. Wound Physician-L stated R20 was a hospice patient and was declining with poor nutritional intake. Wound Physician-L stated R20's left foot was contracted inwards with the bone pushing out thinning out the tissue in that area and R20's circulation was not great either leading to even more compromise of the area. On 2/22/2024 at 10:39 AM, Surveyor asked RN UM-F why no depth was documented on R20's wound assessments by RN UM-F. RN UM-F stated R20's wound was very superficial, and RN UM-F does not put in a depth because if RN UM-F would take a sterile swab to measure the depth, RN UM-F would not get the right depth. Surveyor reviewed with RN UM-F the documentation RN UM-F wrote when describing the tissue to the wound bed. Surveyor asked RN UM-F why percentages of tissue type were not documented in order to see either a progression or decline of the wound. RN UM-F stated RN UM-F can tell if a wound is scabbed or has eschar, but slough, granulation, or epithelial tissue RN UM-F is unclear about describing. RN UM-F stated RN UM-F asks Wound Physician-L about the Staging and tissue type and RN UM-F stated RN UM-F does not want to chart the wrong thing if RN UM-F does not know what they are looking at. On 2/22/2024 at 12:40 PM, Surveyor shared with DON-B the concern R20's left lateral ankle Stage 4 pressure injury was not comprehensively assessed weekly. No further information was provided at that time. 2) R29 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, morbid obesity, diabetes, chronic kidney disease, anxiety, depression, peripheral vascular disease, and fibromyalgia. R29's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R29 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. R20's Self Care Deficit Care Plan initiated on 4/13/2023 assessed R29 as needing assist of one with bed mobility, dressing, and toileting needs. R29 did not have an activated Power of Attorney. On 4/11/2023 on the Head to Toe Skin Check, nursing charted R29 was admitted with an Unstageable pressure injury to the right heel and an Unstageable pressure injury to the coccyx. No measurements or wound descriptors were documented on this form. On 4/11/2023 on the Admit/Readmit Assessment form, Director of Nursing (DON)-B documented the following: -left heel Deep Tissue Injury measuring 5 cm x 5 cm -coccyx Stage 2 pressure injury measuring 7 cm x 5 cm x 0.1 cm -coccyx Stage 2 pressure injury measuring 2 cm x 0.5 cm x 0.1 cm -coccyx Stage 2 pressure injury measuring 2 cm x 0.5 cm x 0.1 cm -coccyx Stage 2 pressure injury measuring 1 cm x 1 cm x 0.1 cm Surveyor noted no descriptors of the wound bed were documented. Surveyor noted DON-B documented the skin assessment on 5/9/2023, four weeks after R29 was admitted . A treatment was obtained on 4/11/2023 for the left heel and coccyx pressure injuries. On 4/12/2023, R29's wounds were assessed by Wound Physician-L. R29's Unstageable coccyx wound measured 5 cm x 4 cm x 0.1 cm with 50% slough, 20% granulation, and 30% skin. R29's Unstageable right heel wound measured 4 cm x 3 cm x 0.1 cm with 60% slough and 40% granulation. Wound treatments were changed by Wound Physician-L at that time. R29's Skin Integrity Care Plan was initiated on 4/13/2023 with the following interventions: -Administer treatments as ordered and monitor effectiveness. -Apply an alternating pressure mattress to the bed, check function every shift for proper inflation. -Assess pain level and administer pain medication as ordered. -Braden assessment on admission and per policy. -Encourage adequate hydration. -Encourage to float heels when in bed. -Encourage to turn and reposition every 2-3 hours. -Monitor/document/report to physician as needed for changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size, stage. -Notify physician for new orders, administer treatments as ordered, inform family. -Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. -Skin inspection weekly and with cares. R29's pressure injuries were comprehensively assessed weekly. R29's coccyx pressure injury healed on 4/26/2023 and R29's right heel wound healed on 6/7/2023. On 6/14/2023, R29 was admitted to the hospital and returned to the facility on [DATE]. On 6/16/2023 on the Admit/Readmit Assessment form, Registered Nurse (RN) Unit Manager (UM)-F documented the following: right heel Unstageable pressure injury measuring 1 cm x 1.7 cm. Surveyor noted a thorough assessment of the pressure injury was documented, no depth was documented and no wound characteristics were documented. Surveyor noted RN UM-F documented the skin assessment on 6/19/2023, three days after R29 was readmitted to the facility. A treatment was ordered for the right heel Unstageable pressure injury on 6/19/2023. Surveyor noted no treatment was ordered or administered to the wound for three days. On 6/21/2023, R29's right heel Unstageable pressure injury was comprehensively assessed by Wound Physician-L. The pressure injury measured 3 cm x 2 cm x 0.1 cm with 30% slough and 70% granulation. Wound Physician-L changed the treatment at that time. R29's right heel Unstageable pressure injury was comprehensively assessed weekly from 6/21/2023 until 8/9/2023. No documentation was found on 8/9/23 of a comprehensive assessment of R29's right heel Unstageable pressure injury. R29's right heel Unstageable pressure injury was comprehensively assessed weekly until 9/27/2023 when the wound healed. Surveyor noted the treatment continued to the right heel until 10/9/2023. On 10/13/2023 on the Head to Toe Skin form, RN UM-F documented R29's right heel opened up and is an Unstageable pressure injury measuring 3 cm x 1.2 cm with no depth documented. Surveyor noted no wound descriptors were documented. A treatment was obtained at that time. On 10/14/2023, R29 was sent to the hospital after a fall from bed. The hospital documentation referred to the right heel wound as a diabetic ulcer. R29 reported to the hospital staff the right heel had increased drainage over the past few weeks. The clinical exam showed the right heel ulcer to have minimal serosanguineous drainage with erythema to the peri ulcer and minimal tenderness. R29 did not have an elevated blood count indicating an infective process was not present, and x-ray results showed no osteomyelitis. The ulcer measured 3 cm x 3 cm x 0.1 cm with a granular base and eschar to the edges of the wound. No warmth, drainage, or malodor was present. R29 was ordered antibiotic for cellulitis with no indications of an infection while hospitalized . On 10/18/2023, R29 was readmitted to the facility. On 10/18/2023, R29's right heel Unstageable pressure injury was comprehensively assessed by Wound Physician-L. The pressure injury measured 3 cm x 2 cm x 0.1 cm with 10% slough and 90% granulation. A treatment order was obtained at that time. R29's right heel Unstageable pressure injury was comprehensively assessed weekly from 10/18/2023 until 11/22/2023 when R29 was at an appointment and could not be seen by Wound Physician-L. On 11/22/2023 on the Skin and Wound Evaluation form, DON-B documented R29's right heel Unstageable pressure injury measured 2 cm x 2 cm with no depth documented with 100% slough. R29's right heel Unstageable pressure injury was comprehensively assessed weekly by Wound Physician-L. Wound Physician-L ordered a wound culture on 1/17/2024 that came back positive for Methicillin Resistant Staphylococcus Aureus (MRSA) and an antibiotic was ordered for 14 days. On 2/21/2024, at 2:25 PM, Surveyor observed R29 in bed with heels floated on pillows. Wound Physician-L, RN UM-F, and RN UM-E came into the room to do the weekly comprehensive assessment of the right heel Unstageable pressure injury. Wound Physician-L stated R29's right heel has a chronic wound that they have tried many different approaches to heal such as and MRI and CT of the heel which all came back negative for an infective process. Wound Physician-L stated a wound culture was obtained because the wound was not healing when they discovered MRSA in the wound and started an antibiotic to promote healing. Wound Physician-L stated R29 was wearing heel boots and the location of the wound could possibly have been affected by the boots, so they tried to float the heels on pillows instead. Wound Physician-L stated R29 was good about offloading the heels, but the wound just keeps returning after it has been healed. RN UM-F stated R29's heel wound has healed twice and then a couple of week later it would open up again. Wound Physician-L stated the skin on the heel is fragile with the opening and closing of the wound, so it is more susceptible to opening up again. The wound measured 2.5 cm x 2.5 cm with a superficial depth and healthy pink tissue to the wound bed with dark tissue to the peri wound. In an interview on 2/22/2024 at 10:39 AM, Surveyor asked RN UM-F what the etiology of R29's right heel wound was. RN UM-F stated R29 had told them R29 had stepped on a piece of glass many years ago and has had problems with that heel ever since, but the daughter said that never happened. RN UM-F stated at one time Wound Physician-L thought the wound was a diabetic ulcer, but after the area reopened, Wound Physician-L categorized it as a pressure injury. Surveyor asked RN UM-F when the wound healed on 9/27/2023, why the treatment was not discontinued. RN UM-F stated R29 had such high anxiety, that R29 wanted the treatment to continue, hoping that would keep the wound from reopening. RN UM-F stated they decided not to put heel boots on because of R29's anxiety and they thought maybe the boot was causing the wound to reopen. RN UM-F stated they tried many different things to heal the wound like taking the boot off when up in a chair, and then trying with no boots at all. Surveyor asked RN UM-F why comprehensive assessments were not completed when R29 was readmitted to the facility. RN UM-F stated RN UM-F was not in the building when R29 came back. RN UM-F stated they are trying to teach staff to do complete assessments on residents, but that has not always happened. On 2/22/2024 at 12:40 PM, Surveyor shared with DON-B the concerns R29's right heel Unstageable pressure injury that was not comprehensively assessed on admission and readmission, a wound treatment was not ordered for three days after readmission on 6/16/2023, and the wound was not comprehensively assessed weekly. No further information was provided at that time. 3) R5 was admitted to the facility on [DATE] with diagnoses of fractures to the lumbar vertebra, ribs, and thorax, chronic kidney disease, diabetes, and chronic respiratory failure. R5's Admission Minimum Data Set (MDS) assessment dated [DATE] indicated R5 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8 and the facility assessed R5 as needing assist with all activities of daily living including eating and is dependent on staff for bathing and dressing. R5 had an activated Power of Attorney. On 1/26/2024 on the Admit/Readmit Assessment form, Registered Nurse (RN) Unit Manager (UM)-F documented R5 had a Stage 3 pressure injury to the right buttock that measured 4 cm x 4 cm with no depth documented. The open area was red in color at the base of the wound. R5's Skin Integrity Care Plan was initiated on 1/26/2024 with interventions to encourage/assist R5 with repositioning as needed and skin will be assessed weekly with findings documented. A treatment order was obtained on 1/29/2024 for the right buttock Stage 3 pressure injury, three days after admission. On 1/31/2024, R5's right buttock Stage 3 pressure injury was assessed by Wound Physician-L. R5's pressure injury measured 4 cm x 3 cm x 0.1 cm with 20% granulation and 80% skin. On 2/7/2024 on the Skin and Wound Evaluation form, RN UM-F documented the right buttock Stage 3 pressure injury measured 4 cm x 3.1 cm with no depth documented. Surveyor noted no wound descriptors were documented. On 2/14/2024, Wound Physician-L documented the right buttock pressure injury had healed. On 2/21/2024 at 2:18 PM, Surveyor observed R5 in bed. R5 had an air mattress on the bed and the heels were floated. In an interview on 2/22/2024 at 12:32 PM, RN UM-F stated RN UM-F did not complete the skin section of the Admit/Readmit Assessment form on 1/26/2024 because when RN UM-F did an audit of the new admission paperwork on 1/29/2024, RN UM-F saw that it had not been completed so RN UM-F used the measurements from the nurse that had done the admission. RN UM-F stated the right buttock pressure injury was a Stage 2 and there was a treatment for barrier cream and that was appropriate for a Stage 2 pressure injury. RN UM-F stated when Wound Physician-L saw R5, Wound Physician-L said the pressure injury was a Stage 3, so RN UM-F changed the staging at that time to reflect the Stage 3. Surveyor reviewed R5's orders and R5 did not have an order for barrier cream. On 2/22/2024 at 12:40 PM, Surveyor shared with DON-B the concerns R5's right buttock Stage 3 pressure injury that was not comprehensively assessed on admission, a wound treatment was not ordered for three days, the wound was not comprehensively assessed until seen by Wound Physician-L, 5 days after admission, and the wound was not comprehensively assessed weekly. No further information was provided at that time. 20025 4) R72 was admitted to the facility on [DATE] with diagnoses of traumatic brain injury, dysphagia, epilepsy and asthma. R72 was admitted to the facility with right buttock unstageable pressure injury that is healing. The alteration in skin integrity care plan dated 1/16/22 indicate encourage to float heels when in bed. On 2/19/24 at 9:12 am, Surveyor observed R72 in bed laying on the left side with no offloading of heels and R72 contracted knees did not have any offloading between the bony prominence On 2/20/24 at 8:04 a.m., Surveyor observed R72 in bed laying on the left side with no offloading of heels and R72 contracted knees did not have any offloading between the bony prominence. On 2/20/24 at 12:13 p.m., Surveyor observed R72 in bed laying on the left side with boots on the heels but there still wasn't any offloading between the knees Surveyor was unable to observed treatment on R72 right buttock unstageable pressure injury due to R72 being sent to the hospital for a change in condition. On 2/22/24 at 10:29 a.m., Surveyor interviewed DON (Director of Nursing)-B. Surveyor explained the observations made on R72 without any offloading for the heels and between the knees. DON-B stated she understood the concern and would look into therapy for R72 regarding positioning and help with offloading areas when R72 returned to the facility.

Based on interview and record review, the Facility did not ensure adequate supervision to prevent accidents for 1 (R59) of 2 residents reviewed for accidents. R59 had an unwitnessed fall outside in the Facility courtyard on 11/23/23. The fall resulted in a hematoma to the left side of the face. The Facility did not complete a thorough investigation to identify the root cause of the fall and implement interventions to prevent future falls. Findings include: R59 was admitted to the facility on [DATE] and had diagnoses including Dementia, Malnutrition and Fracture of Unspecified parts of Lumbosacral Spine and Pelvis related to a fall. R59's most recent quarterly Minimum Data Set Assessment, dated 1/12/24, assessed R59 had a Brief Interview for Mental Status of 2, indicating R59 had severe cognitive impairments and assessed R59 to need partial to moderate assistance with transfers and mobility using either a walker or a wheelchair. R59's care plan, entitled Resident has the potential for falls, accidents, and incidents r/t (related to) Alzheimer's, dementia, cognitive impairment, noncompliance to safety interventions, unaware of safety needs, initiated on 10/10/23 had interventions including: -2/5/2024: Body pillow (or two pillows together) to the side closest to the doorway: right side when looking at the bed from the foot of the bed. -1/24/2023: bed in lowest position -10/11/2023: encourage to be in common areas when up. -10/11/2023: Resident in view of staff for increased monitoring -10/9/2023: move room closer to nurse's station Surveyor reviewed R59's Electronic Medical Record and noted the following documented in progress notes: On 11/23/2023 at 2:50 PM, a nurse documented, Patient had an unwitnessed fall around 1100 (am). Family and DON (Director of Nursing) was called and On Call [sic]. MD (Medical Doctor) wanted patient to be sent out to be evaluated. Neuro check started at every 15 minutes vitals were taken 136/69, 18, 97%. Noted injury Hematoma to left side of face above eye and scar to the left check. On 11/24/2023 at 10:37 AM, an Interdisciplinary Team (IDT) follow up note documented, IDT post unwitnessed fall 11/23/22: Writer discussed with the IDT team in relation to resident's unwitnessed fall. Resident was found in the courtyard by staff. She presented at that time with blood to her lip and hematoma to the left eye. Vital signs stable. No incontinence noted. Resident stated was looking for her room. On call [name of medical provider] was notified and orders were given for resident to go out to [name of hospital]. Resident returned with no new orders and CT (computed tomography) scan was negative. Intervention: All previous fall interventions are in place. Resident is now on 15-minute checks through Monday 11/27/23. All parties of the care team have been updated and family. Surveyor reviewed R59's fall investigation which documented R59 fell in the courtyard after opening the door thinking it was R59's room. R59 was found with a bloody lip and R59 told staff I was going to my room. The post fall findings included R59 was found on the ground and beginning to get less responsive, and the MD wanted R59 to be sent out. Per the investigation, R59 was last seen in the hallway, however the initial fall investigation given to Surveyor did not include when R59 was last seen, how long R59 was outside, nor what R59 was doing when last seen, i.e. walking or using wheelchair for mobility. Surveyor noted the fall investigation documented R59 was ambulatory without assistance, however review of R59's care plan showed R59 was only to ambulate with staff assistance. On 02/21/24 at 11:34 AM, Surveyor interviewed Unit Manager, Registered Nurse (RN)-F. RN-F stated she was not working the day R59 fell in the courtyard. Per RN-F it was Thanksgiving day. RN-F stated the door to the courtyard is in the activities room which is down the hallway from R59's room. RN-F stated the door to the courtyard is not alarmed because that is where residents go to smoke. RN-F stated, R59 was put on 15-minute checks after the fall and R59's family and DON-B were updated. RN-F did not have any additional information for Surveyor. On 02/21/24 at 11:52 AM, Surveyor interviewed DON-B, Regional Consultant (RC)-C and RC-D. Surveyor asked if there was any additional information related to R59's fall in the courtyard in November 2023. Surveyor asked if staff were interviewed and if information was gathered such as when was R59 last seen and was R59 walking independently or using a wheelchair at the time of the fall? DON-B stated she would look and get back to Surveyor. On 02/21/24 at noon, DON-B provided Surveyor with an additional information for R59's fall investigation which appeared to be part of the initial fall investigation. It was dated 11/23/23 1:22 PM, as was the rest of the fall investigation Surveyor previously reviewed. This document had a section entitled witnesses and had a typed statement from Licensed Practical Nurse (LPN)-O which read: LPN-O stated resident was last seen in hallway walking with walker just 10 minutes prior to being outside, as she needs to be redirected [sic]. This document also included a statement from an unnamed Certified Nursing Assistant (CNA) which read: CNA stated resident was in hallway just prior to going outside. On 02/21/24 at 12:47 PM, Surveyor interviewed LPN-O. LPN-O informed Surveyor she was working the day R59 fell in the courtyard, but she was not R59's nurse that day. Per LPN-O, R59's care was assigned to an agency nurse on 11/23/23. LPN-O informed Surveyor she did not see R59 until after staff brought R59 inside from the fall. LPN-O stated R59 had a bloody lip and she, LPN-O, told the agency nurse what needed to be done as far as taking staff statements, filling out the fall investigation paperwork, and updating the family/physician. Surveyor showed LPN-O the typed statement documenting LPN-O stating she saw R59 ten minutes prior to falling. Per LPN-O she did not write that statement or tell anyone that statement. LPN-O informed Surveyor she did not see R59 prior to the fall. Per LPN-O, R59 would not be walking in the hallway by self and if she, LPN-O, had seen R59 walking by self, she would have assisted R59 to wherever R59 wanted to go. Per LPN-O, she has only seen R59 walking with one of the Facility's restorative staff. LPN-O stated it was my understanding the staff found R59s' wheelchair by the exit door where they found R59. LPN-O did not have any additional information regarding R59's fall on 11/23/23. On 02/21/24 at 2:12 PM, Surveyor interviewed DON-B, RC-C and RC-D. Surveyor asked how the statements from LPN-O and the unnamed CNA were obtained. Per DON-B, the author of the fall investigation (agency nurse) would have obtained the statements and then documented the statements in the fall investigation. DON-B stated we do not make our staff write statements. Surveyor explained the concern that LPN-O denied seeing R59 prior to R59's fall. Surveyor relayed the concern for a lack of a thorough investigation because the Facility did not determine who last saw R59, what was R59 doing prior to the fall, if R59 was walking independently or in a wheelchair, how long R59 was outside/on the ground and who found R59. DON-B stated LPN-O reported the fall to us (management) because we were not there due it being Thanksgiving. Per DON-B, LPN-O stated she saw R59 ten minutes prior to the fall walking in the hall. Surveyor explained LPN-O denied seeing R59 prior to the fall and LPN-O informed Surveyor R59 would not have been walking down the hall by self. Given that information, Surveyor explained, Surveyor still didn't know if R59 was in the wheelchair or walking at the time of the fall or how long R59 was on the ground outside. Surveyor questioned if staff saw R59 walking down the hall by self what should be done? Per RC-C, staff redirected R59 as written in the fall investigation. Surveyor explained, LPN-O denied that statement. DON-B stated maybe the nurse was confused to the staff names because she was an agency nurse. Surveyor relayed the concern of the lack of a thorough investigation and asked for any additional information. On 02/21/24 at 2:36 PM, Surveyor interviewed DON-B and RC-C. DON-B informed Surveyor the agency nurse stated she found R59 at the door of the courtyard and in the Facility's IDT note it said R59 was seen ten minutes prior to the fall. DON-B stated the Facility did 15-minute checks throughout the weekend. Per DON-B the Facility knew how R59 was found, R59 was seen ten minutes prior to falling and then R59 was sent to the hospital for evaluation. Per DON-B, the agency nurse recorded LPN-O's statement and DON-B didn't question it because LPN-O was the one who called DON-B regarding the fall. Per DON-B, LPN-O did say a CNA saw R59 in the hallway prior to the fall. DON-B explained R59 gets up and walks impulsively all the time. Surveyor asked if R59 should be walking by self. DON-B stated no. Surveyor asked what should staff do if they see R59 walking by self. RC-C replied, the staff redirected R59 as stated in the fall investigation. Surveyor asked what redirection meant for R59. Did staff assist R59 back to R59's room or did staff provide verbal redirection? Surveyor explained the concern R59 went to the end of the hallway, through the activities room, opened the door and fell outside in the courtyard without staff supervision. Surveyor explained the Facility's investigation was not clear as to who last saw R59 and what R59 was doing. RC-C explained the Facility's investigation was thorough and DON-B didn't investigate the fall further because LPN-O was the one who informed them of the fall. Surveyor again explained LPN-O denied seeing R59 prior to the fall and LPN-O informed Surveyor if R59 was seen walking down the hall by self, staff should have physically assisted R59. Surveyor relayed the concern for the lack of a thorough investigation to determine the root cause of R59's fall that would allow staff to identify appropriate interventions to prevent future falls.

Based on observations, interviews and record review the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 5 (R59) residents reviewed for nutrition and weight loss. *R59 was identified to have weight loss one month after admission and the Facility initiated interventions. R59 continued to have documented weight loss in the following three months and the Facility did not revise or implement new interventions. Findings include: The Facility policy entitled, Weight Monitoring, date revised on 10/2023, documented, Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 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 . R59 was admitted to the facility on [DATE] and had diagnoses including Dementia, Malnutrition and Fracture of Unspecified parts of Lumbosacral Spine and Pelvis related to a fall. R59's most recent quarterly Minimum Data Set Assessment, dated 1/12/24, documented R59 had a Brief Interview for Mental Status of 2, indicating R59 had severe cognitive impairments and R59 weighed 112 lbs (pounds) and R59 had a weight loss of 5% or more in one month or 10% or more in six months, not on a physician prescribed weight loss regime. R59's care plan, initiated 10/10/23 and revised on 2/9/24 documented, Regular diet with regular textures and thin liquids, 10/10/23 wt (weight) 123.6# (pounds) and skin free of pressure wounds; 11/7/23 wt 120# and skin free of pressure wounds; 12/6/23 wt 116# - >7.5% loss in 6 months- skin intact; 1/5/23 wt 112# - 7.5% wt loss x 3 months -skin intact and 2/6/24 wt 110# - >7.5% loss x 3 months and >10% loss x 6 months - skin intact. This care plan had the following interventions: Monitor meal intake % (percentage) of food and fluids Date Initiated: 10/10/2023 Offer food preferences Date Initiated: 10/10/2023 Offer snacks between meals Date Initiated: 10/10/2023 Supplement: 120mL (mililiters) Med Pass BID (twice a day) (480kcal (kilocalories) and 20g (grams) protein) Date Initiated: 10/10/2023 Revision on: 12/06/2023 Surveyor noted R59's care plan documented weight loss in November 2023, December 2023, January 2024 and February 2024; however, the only care planned intervention revised or added was in December 2023 which was changing R59's supplement from once a day to twice a day. Surveyor reviewed R59's Electronic Medical Record (EMR) and noted the following weights recorded: 2/6/2024 110.0 Lbs 1/16/2024 115.0 Lbs 12/20/2023 112.0 Lbs 12/5/2023 116.0 Lbs 11/7/2023 120.0 Lbs 10/24/2023 119.1 Lbs 10/23/2023 118.1 Lbs 10/10/2023 123.6 Lbs Surveyor noted from admission weight in October 2023 to February 2024 R59 had a 10.57% weight loss. Surveyor reviewed R59's EMR and noted the following active physician's order: Med Pass 2.0, two times a day for supplement nutrition, Provide 120mL Med Pass. This order had an active date of 01/26/24. However, Surveyor noted R59's Med Pass supplement was originally changed from once a day to twice a day on 11/08/23. From 01/23/24 to 01/26/23 the Med Pass supplement was changed to Mighty Shake due to unavailability of Med Pass. On 01/26/23, when the facility could obtain Med Pass, R59's order was changed back to Med Pass BID. Surveyor noted the following documented in R59's progress notes: On 11/8/2023 a Dietary Note documented, Recommend increasing 120mL Med Pass 2.0 from once daily to BID (480kcal and 20g protein) to supplement nutrition. Recent high nutrition risk progress note approved by RD (Registered Dietician). On 12/6/2023 a Dietary Note documented, High Risk Follow Up - wt loss Resident triggers for >7.5% wt loss in 3 month. R59's CBW (Current Body Weight) is 116# as of 12/5/23 compared to 3 months ago when R59 was 130.8# as of 8/8/23 (8/8/23 weight was from a previous admission). Weight loss is not desirable at this time .Will continue to monitor and follow up monthly and as needed. On 12/21/2023 a weight warning note documented, WEIGHT WARNING: Value: 112.0 [lbs] Vital Date: 2023-12-20 12:47:00.0 -7.5% change [ 9.4% , 11.6 ] -10.0% change [ 14.4% , 18.8 ] Re-weight confirms weight loss. Will continue to monitor and follow up monthly and as needed. On 2/9/2024 a Dietary Note documented, Late Entry: High Risk Follow Up - wt loss Resident receives a regular diet with regular textures and thin liquids. R59 receives MedPass BID (480kcal and 20g protein) for wt maintenance. Resident was not available at time of assessment, so writer spoke with CNA (Certified Nursing Assistant) on monthly progress. CNA reports that resident eats well but needs to be up in chair to eat better. CNA states R59 eats about 75% of meals but does not usually eat the whole meal. R59 currently triggers for significant wt loss of 8.3% in 3 months and16.2% in 6 months (2/6/24 110#, 1/16/24 115#, 11/7/23 120#, 8/15/23 131.2#) .BMI (Body Mass Index) is low for age so wt loss is not desirable at this time .Goals: PO (per oral) intake >/=75%, wt maintenance (wt gain of 5-10% is desirable). Will continue to monitor and follow up monthly and as needed. Surveyor noted R59's Med Pass was increased on November 8th; however, after that increase R59 continued to have weight loss and there were no other documented interventions. On 02/19/24 at 11:50 AM, Surveyor observed R59 sitting upright in wheelchair in the lounge area by R59's unit. R59 was brought lunch. Surveyor noted other residents were in the lounge area, but the other residents had come from the dining room and had already eaten. On 02/19/24 at 11:56 AM, Surveyor observed R59 feed self lunch at one of the tables in the lounge area. There were six other residents in the lounge area and only one other resident was eating. Surveyor noted R59 and the other resident that was eating were sitting at different tables. On 02/20/24 at 12:21 PM, Surveyor observed R59 eating lunch in the lounge area. Three other residents were at R59's table, but those residents had already eaten in the dining room and were talking amongst themselves while R59 ate. Surveyor noted R59 ate approximately 50%. On 02/21/24 at 10:01 AM, Surveyor interviewed Registered Dietician (RD)-K. RD-K informed Surveyor she is made aware of weight changes either when she reviews a resident's chart, gets a notification from the charting system, or a nurse/CNA informs her of a weight change. Per RD-K, if there is a resident who is experiencing weight changes, RD-K will monitor that resident monthly. Surveyor asked what was being done for R59. Per RD-K, R59 is someone she (RD-K) follows monthly. RD-K informed Surveyor R59 receives Med Pass BID and the staff are encouraging snacks between meals. RD-K informed Surveyor the Med Pass was changed to BID in November and snacks were being offered since admission. Surveyor asked if any interventions had been added/revised recently? RD-K reviewed R59's nutrition notes and stated I think we are encouraging snacks and giving verbal cues. Surveyor explained the concern of a lack of revised/new interventions for R59 since November 2023 and R59 continued with weight loss, with R59's current weight being down ten pounds since the documented November weight. Surveyor asked why the care planned interventions had not been revised even though R59 continued to lose weight. RD-K was unsure. Surveyor asked if RD-K updated the physician in regards to residents with weight loss. RD-K stated nursing staff updates the physician. RD-K was uncertain if R59's physician was updated regarding R59's weight loss, but RD-K stated R59 was discussed at the weekly meetings and RD-K thought nursing updated the physician after those meetings. RD-K did not have any additional information for Surveyor. On 02/21/24 at 11:07 AM, Surveyor interviewed Unit Manager, Registered Nurse (RN)-F. RN-F informed Surveyor the facility has Nutrition at Risk (NARs) meetings every week where the staff address weight changes with the dietician. Per RN-F, the Nurse Practitioner (NP) is not physically in the meetings, but nursing staff update her afterwards. RN-F informed Surveyor R59 is on a nutritional supplement BID and offered snacks. Surveyor asked if R59 was talked about at the NARs meeting on 2/8/23. Per RN-F we talked about her and at that point we decided to stay with the plan of care, and nothing changed. RN-F was reviewing R59's EMR and stated R59's last dietary note stated R59 eats well. RN-F stated R59's dietary note says goal would be to take in 75% of meals, which CNAs are charting R59 does. Surveyor asked if the NP was aware of R59's weight loss. Per RN-F, the NP did not have much to say about the weight loss. RN-F explained after the NARs meetings an email is usually sent to the NP addressing residents/concerns that were addressed. Surveyor asked RN-F if she spoke with the NP regarding R59's weight loss. RN-F informed Surveyor she could not recall if she spoke with the NP. Per RN-F, R59 does need cues and sometimes R59 eats fine and sometimes R59 does not. Surveyor asked for additional information including NP/physician notification of weight loss and revised/implemented interventions. RN-F stated she would investigate it. Prior to the end of the day, RN-F provided Surveyor with a copy of an email she sent to the NP on 12/22/23 which documented a list of residents with weight concerns including R59 and stated all residents have been reweighed and we have addressed concerns and put plans in place during NARs meeting. This email did not include how much weight was lost or gained or what type of plans were in place for any specific resident. On 02/22/24 at 9:12 AM, Surveyor interviewed Director of Nursing (DON)-B and Regional Consultant (RC)-C. DON-B informed Surveyor the facility has the NARs meetings and update the NP after those meetings. DON-B stated when the nurses enter the weights in the chart they (nurses) should reweigh the resident and update the physician/family if there are abnormal weights or weight changes outside of the parameters. Per DON-B, the dietician suggests interventions during the NARs meetings. Surveyor asked about interventions for R59. DON-B reviewed R59's EMR and stated there is a nutrition at risk note from 2/8/24 and the NP was aware and there were no new interventions. DON-B stated not knowing why there were no revised interventions, but according to DON-B, RD-K probably did not have any additional interventions. Surveyor relayed the concern of R59 having weight loss with no new/revised interventions. DON-B continued to read R59's nutrition at risk note and stated the note says continue to monitor monthly. Surveyor asked for any additional information on interventions for R59's weight loss. No additional information was provided.

Based on interview and record review, the facility did not comprehensively assess 1 (R43) of 1 resident reviewed for bowel and bladder. The facility did not ensure that a resident who is incontinent of bowel and bladder receives appropriate treatment, services and monitoring to restore as much normal bowel and bladder function as possible. R43 was admitted to the facility 1/22/24 with orders for a bowel and bladder assessment that was not fully completed per order. The data collected was not comprehensively assessed and resident had continued loose stools while at the facility. During visits by Nurse Practitioners on 2/1/24, 2/9/24 and 2/16/24 instructions were to monitor bowel irregularities and patterns which was not completed. Resident ended up needing a stool sample sent out for C. Diff testing that was not followed up on. Findings include: R43 was admitted to the facility 1/22/24 with diagnoses that included End Stage Renal Disease, Type 2 Diabetes Mellitus, Obesity, Difficulty in Walking and Unspecified Escherichia Coli (E. Coli) as the Cause of Diseases Classified Elsewhere. Surveyor reviewed R43's Admission Minimum Data Set (MDS) with an assessment reference date of 1/29/24 documented R43 had a Brief Interview Mental Status (BIMS) score of 15 which indicated R43 was cognitively intact. Surveyor reviewed R43's MD (Medical Doctor) orders. Documented with a start date of 1/22/24 was Monitor for s/s (signs and symptoms) of infection (ex: Fever, chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea every shift. Documented with a start date of 1/22/23 and an end date of 1/25/24 was Complete a 3 day bowel and bladder assessment upon admission, every shift for monitoring for 3 Days. Surveyor reviewed the 3 Day Bowel and Bladder assessments for R43. Completed on chart were 1/23/24 night shift, 1/24/24 night shift and 1/25/24 day shift. Documentation was not completed for 1/23/24 day and PM shifts, 1/24/24 day and PM shifts and 1/25/24 PM and night shifts. There was no assessment of the data that was collected in R43's chart. Surveyor reviewed Nurse Practitioner (NP)-P's visit note for R43 from 2/1/24. Documented was .Chief Complaint: Loose stools, type 2 diabetes . Subjective: Patient seen up in bathroom with therapist present noting that she has been having frequent loose stools. Medications reviewed, senna oral tablet once daily discontinued . Assessment and Plan: .*K59.00 - Constipation*: Scheduled senna discontinued. Monitor bowel pattern for irregularities . Surveyor reviewed R43's chart and no bowel pattern irregularity charting was completed. Surveyor reviewed NP-Q's visit note from 2/9/24. Documented was Subjective: The patient is seen today seated comfortably in chair. No reports of pain, shortness of breath or audible cough. Appetite is fair, does report that she has poor dentition which has affected her appetite. Patient reports intermittent diarrhea and constipation, declined need for medication changes at this time. No additional concerns when discussed with nursing staff . Assessment and Plan: . *K59.00 - Constipation*: Scheduled senna discontinued. Notes intermittent constipation and diarrhea, declined need for further medication adjustments at this time. Monitor for bowel irregularities. Surveyor reviewed R43's chart and no bowel pattern irregularity charting was completed. Surveyor reviewed R43's Medication Administration Record. Documented under Monitor for s/sx of infection (ex: Fever, chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea every shift was Y denoting yes on the following shifts: 2/8/24 PM 2/8/24 Night 2/9/24 Day 2/9/24 PM 2/9/24 NOC 2/10/24 Day 2/10/24 PM 2/10/24 NOC 2/11/24 Day 2/11/24 PM 2/11/24 NOC 2/11/24 Day 2/11/24 PM Surveyor reviewed NP-P's visit note from 2/16/24. Documented was .Chief Complaint: Loose stool . Subjective: Patient states she has been having loose stool. She denies abdominal pain with this. Medications reviewed, patient not currently on any stool softeners though she is on allopurinol. Discussed with nephrology that we would hold the allopurinol to see if that resolves the loose stool. Order placed for stool for C. difficile . Documented in R43's MD orders with a start date of 2/17/24 was Send stool sample for C diff, one time only for loose stool for 1 Day. Surveyor reviewed R43's Progress Notes. Documented on 2/19/24 at 5:58 AM was Stool specimen collected to check for C-diff and placed in fridge for pick-up. Lab faxed and called to retrieve specimen. No GI upset, no nausea. Bowel sounds present to all quads . On 2/20/24 at 2:57 PM, Surveyor interviewed R43. Surveyor asked if she had any bowel or bladder concerns. R43 reported having loose stools to Surveyor. Surveyor asked how long she has been having loose stools. R43 stated ever since she came here. Surveyor asked if she had told anyone. R43 stated yes, plus they know because they have to clean me up. Surveyor asked if she needs assistance with toileting. R43 stated yes, sometimes it comes too fast and I can't hold it. Surveyor asked how often she has loose stools. R43 stated several times a day up to all day. Surveyor asked if the facility has talked to her or done anything about her loose stools. R43 stated they took a sample yesterday, but I haven't heard anything. On 2/22/24 at 1:52 PM, Surveyor interviewed Infection Preventionist (IP)-J. Surveyor reviewed the NP visit notes from 2/1, 2/9 and 2/16 for R43 in regards to loose stools and no documentation of bowel irregularity charting. IP-J stated that they discontinued Senna but she does not see where the bowel monitoring was done. Surveyor asked about the bowel and bladder assessment not being completed per order. IP-J stated Nope, it wasn't. Surveyor asked if any of the data that was collected was analyzed for bowel or bladder patterns or irregularity. IP-J stated not that she can see. Surveyor asked if the results of the C-Diff sample that was sent to the lab on 2/19 should be back. IP-J stated we need to follow up on that. Surveyor asked who is responsible for making sure the results are received. IP-J stated the nurses. I am. IP-J stated the results should be in and the lab should have been called on and results followed up on. On 2/22/24 at 2:14 PM Surveyor expressed concerns about R43's bowel and bladder assessment not being completed as ordered every shift for 3 days on admission to Director of Nursing (DON)-B, Consultant-C and Nursing Home Administrator (NHA)-A. Surveyor also expressed concerns with bowel pattern irregularity charting not being completed. Surveyor asked for any additional completed documentation and any analysis of the data that was completed. No additional information was provided.

Based on observation, interview and record review the facility did not ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 2 (R13 and R48) 2 residents reviewed for accommodation of needs. R13 reported he needed his incontinence brief changed. Facility staff did not respond to his request for a period of over 1 hour. R48 reported he was uncomfortable and wanted to get out of bed. His call light was not answered for an extended period time. Findings include: The facility policy titled Call Lights: Accessibility and Timely Response implemented 6/1/22 documents (in part) . Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 2. All residents will be educated on how to call for help by using the resident call system. 3. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. 4. Special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly (examples include touch pads, larger buttons, bright colors, etc.) 5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. R13 admitted to the facility on [DATE] and has diagnoses that include Emphysema, Rheumatoid Arthritis (RA), hand contractures, Dementia and Peripheral Vascular Disease. R13's Quarterly MDS (Minimum Data Set) dated 12/7/23 documents: Urinary/bowel incontinence - always incontinent. R13 has a Brief Interview for Mental Status (BIMS) score of 15, indicating he is cognitively intact. R13's Care plan focus area revised 2/29/20 documents: At risk for falls related to weakness, artificial right and left hip joint, right artificial knee joint. Interventions include: Make sure my call light/personal belongings are in reach. I have a physical functioning deficit related to weakness, RA, fracture left leg. Interventions include: Bed mobility assistance of (1). Call bell within reach. Personal Hygiene assistance of (1). Toileting assistance of (1). R13's current Certified Nursing Assistant (CNA) care card, printed 2/20/24 documents: 1 assist with dressing, bathing, bed mobility, transferring. Uses bedpan for bowel movements and bladder. BRIEF - check and changes as needed and when requested. On 2/19/24, at 9:53 AM, Surveyor observed R13 lying in bed on his back, wearing a gown, with a pillow under his head and between his knees. R13 was holding the bed control with both hands and was able to raise the head of the bed. Surveyor observed his right (closed) eye and left (open) eye were both crusted, and the resident was unshaven. R13 reported he needed help and was not able to reach his call light, stating it's under my elbow. Surveyor asked if he could reach his call light. R13 stated: No, I can't use my hands. At this time Certified Nursing Assistant (CNA)-G entered R13's room. Surveyor advised CNA-G that R13 reported he needed help and could not reach his call light. Surveyor left the room and stood outside of the open door. Surveyor heard CNA-G ask R13 what he needed. R13 stated: I need a change. CNA-G stated: Here's your call light and left the room. Surveyor entered R13's room and observed the call light lying next to him, but was not on. R13 began calling out help me. Surveyor left the room. On 2/19/24, at 9:58 AM, Surveyor observed CNA-G talking to another staff member (unknown name) who said: I can hear him yelling, I'll get in there. Surveyor remained in the hallway, no staff entered R13's room. On 2/19/24, at 10:03 AM, Surveyor observed the call light on outside of R13's room. CNA-G entered the room and began clipping R13's roommates fingernails. On 2/19/24, at 10:05 AM, Surveyor observed the call light outside of R13's room was turned off. Surveyor observed CNA-G standing next to R13's roommates bed while she continued to cut his nails. R13 was calling out: Hello, my pants are full. On 2/19/24, at 10:09 AM, Surveyor observed while CNA-G was still cutting his roommates nails, R13 was calling out Help me. Surveyor noted no other staff had entered R13's room. On 2/19/24, at 10:19 AM, Surveyor observed CNA-G standing next to R13's bed. Surveyor entered the room and observed R13 had shaving cream on his face and CNA-G reported she was getting ready to shave him. No other staff had been in R13's room. On 2/19/24, at 10:28 AM, CNA-G left the room. Surveyor entered, noting R13 was clean shaven, but his eyes remained crusted. Surveyor asked R13 if his incontinence brief had been changed. R13 stated: No, not yet. Surveyor asked if his brief was dirty. R13 stated: It's full of pee. On 2/19/24, at 11:00 AM, while Surveyor remained on the unit, Surveyor noted no other staff entered R13's room. Surveyor then left the area. On 2/19/24, at 12:26 PM, Surveyor observed R13 lying in bed with the head of bed elevated. Surveyor observed his eyes were no longer crusted. Surveyor asked R13 if his incontinence brief had been changed. R13 reported someone did come in and change his brief earlier, but was unable to report what time. Surveyor noted R13 reported to CNA-G that he needed help, could not reach his call light and needed to be changed. R13 continued to call out for help, and that his pants were full while CNA-G was in the room helping R13's roommate. Surveyor noted no other staff entered R13's room or changed his incontinence brief for at least 1 hour, 3 minutes before Surveyor left the unit. On 2/21/24, at 10:16 AM, Surveyor spoke with CNA-G about R13. CNA-G reported she is on light duty from a back injury, and can assist with feeding and light duty tasks, but cannot help with toileting or changing residents. CNA-G stated: I remember that first day you were here. He (referring to R13) said he needed to be changed, I couldn't do it, so I told his aide. CNA-G stated: Between you and me, he waited a long time. Surveyor asked CNA-G if she knew what time someone did go in to change R13. CNA-G stated: No, no-one came to change him while I was there. 2) R48 admitted to the facility on [DATE] and has diagnoses that include Congestive Heart Failure, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Diabetes Mellitus Type 2, Dementia, Bell's Palsy, Benign Prostatic Hyperplasia and unilateral primary Osteoarthritis. R48's Quarterly MDS (Minimum Data Set) assessment dated [DATE] documents: Frequently incontinent urine, always incontinent bowel. BIMS (Brief Interview of Mental Status) score of 13 indicating R48 is cognitively intact. R48's Care plan focus area initiated 11/5/22 documents: Resident has a self care deficit r/t (related to) Activity intolerance, falls, weakness, dementia, anxiety, depression, Bells' Palsy, CI (Cerebral Infarction), pain, OSA (Obstructive Sleep Apnea). Interventions include: Assist of 1/2 with bed mobility. Transfers with walker and 1 assist. Assist of 1 with toileting needs. Resident has the potential for falls, accidents and incidents r/t Activity intolerance, falls, weakness, dementia, anxiety, depression, Bell's Palsy, pain. Interventions include: Provide a reacher in room as needed for resident to help get items off the floor if he does not use call light to ask for help - initiated 2/1/24. Reminded to use his call light when he would like to transfer - initiated 12/3/23. On 2/19/24, at 9:32 AM, Surveyor observed R48 lying in bed awake, with the head of bed elevated. Surveyor observed a touch pad call light on a small night stand table next to the bed, not within reach. R48 appeared restless and was bending his right knee. R48 reported he was uncomfortable and stated: I want to get up. Surveyor asked R48 if he wanted Surveyor to put the call light on for him, R48 stated: Yes. Surveyor turned R48's call light on at 9:35 AM, left the room and remained on the unit. On 2/19/24, at 10:01 AM, Surveyor observed a staff member entered R48's room and close the door. The call light was turned off. Surveyor noted R48 reported he was uncomfortable and wanted to get out of bed. R48 could not reach his call light and Surveyor asked if R48 wanted Surveyor to turn the call light on for him. R48's call light remained on and unanswered for a period of 26 minuets. On 2/19/24, at 10:07 AM, Surveyor noted R48's door remained closed. The unit nurse reported staff was getting the resident up. On 2/19/24, at 10:21 AM, Surveyor observed R48 sitting up in his wheelchair in the room. R48 was dressed and well groomed. Surveyor observed the touch pad call light remained on the small nightstand table next to the bed. Surveyor asked R48 how he was feeling, to which he stated: Fine. Surveyor asked F48 if he was comfortable or having any pain. R48 stated: No, I'm OK now. On 2/20/24, at 11:34 AM, Surveyor observed R48 sitting in the wheelchair in his room watching TV. The touch pad call light remained on the small nightstand table next to the bed. On 2/22/24, at 8:30 AM, Surveyor advised Director of Nursing (DON)-B and Regional Consultant-C of the above observations and concerns regarding the call light wait times for R13 and R48. No additional information was provided.

Based on record review and interviews, the facility did not ensure treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 (R1) of 6 residents. On 1/14/24, R1 was outside from 1:16:49 am until 3:28 am. Review of video footage found R1 was stuck in the snow and unable to propel his wheelchair inside. R1 was brought in from the outside on 1/14/24 at 3:28am; there was no assessment of R1's vital signs including temperature until six hours later. R1 was sent to the emergency roiagnom on [DATE] after staff identified what appeared to be frostbite to R1's fingers. The emergency department clinical impression documents: Atrial fibrillation, unspecified type, Acute congestive heart failure, unspecified heart failure type, pneumonia of right lower lobe due to infectious organism and frostbite, initial encounter. The facility did not complete appropriate assessments timely, did not notify an RN (Registered Nurse,) and did not notify the physician of R1's change in condition timely. The facility's failure to inform a registered nurse that R1 had been outside in the cold for two hours and 12 minutes, to complete an appropriate assessment by an RN after R1 was brought inside, and failure to promptly consult with a physician timely created a finding of Immediate Jeopardy (IJ) which began on 1/14/24. NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, and Regional Nurse Consultant-J were notified of the immediate jeopardy on 1/23/24 at 4:10 p.m. The immediate jeopardy was removed and corrected on 1/15/24. This is being cited as past noncompliance. Findings include: According to N6.04(1), Wisconsin Nurse Practice Act, a licensed professional nurse (LPN) is responsible to: (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan . According to N6.03(1), Wisconsin Nurse Practice Act, a registered nurse (RN) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. The Change in a Resident's Condition or Status policy updated 12/22 documents under Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.) The Policy Interpretation and Implementation section documents: 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident . The National Library of Medicine, National Center for Biotechnology Information, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9592504/ Practical Review of the Current Management of Frostbite Injuries documents in part under Summary: Frostbite is an injury that occurs when the skin and tissues are exposed to temperatures below their freezing point. This type of injury can lead to various complications such as functional loss, chronic pain, and psychological trauma. As such, understanding frostbite management is crucial for optimal patient care.Rapid rewarming in warm water (40-42 degrees C) remains the standard of care. R1 was admitted to the facility on [DATE]. R1 has an activated Power of Attorney for Healthcare (POAHC.) R1's diagnoses includes COPD (chronic obstructive pulmonary disease,) atherosclerotic heart disease, delusional disorders, dementia, PVD (peripheral vascular disease,) insomnia, and right above knee amputation. R1's smoking care plan initiated 8/12/19 & revised 9/26/23 includes interventions of: independent smoker outside initiated 2/27/20 and is able to keep their smoking materials and smoke independently initiated 8/12/19 & revised 2/27/20. The smoking assessment dated [DATE] indicates R1 smokes 5-9 times a day, remains alert during the course of smoking at all times, is able to communicate the need for help if lit materials fall on them, does not have dexterity problems or tremors, and is able to extinguish a cigarette safely. Resident's primary mode of locomotion documents wheelchair propels independently. The quarterly MDS (Minimum Data Set) with an assessment reference date of 12/14/23 has a BIMS (Brief Interview Mental Status) score of 14 which indicates R1 is cognitively intact. R1 is assessed as not having any behavior including refusal of cares or wandering. Yes is checked for does this resident use a w/c (wheelchair) or scooter. The nurses note dated 1/10/24 documents: Resident admitted to [Name] Hospice. Hospice nurse gave the admitting diagnosis of end stage COPD with protein cal (calorie) malnutrition secondary. NP [Name] notified and Hospice updated family. This nurses note was written by UM/RN (Unit Manager/Registered Nurse)-L. SW (Social Worker)-D documented: On Friday 1/12/24, the weather outside was poor due to a snowstorm. Resident, [R1's name] is a frequent smoker and will often sit outside and smoke several cigarettes in a row. Writer spoke with med tech regarding need to monitor resident going outside to smoke, due to the weather, and gave her his cigarettes to keep in medication cart. Writer spoke with resident regarding the bad weather and that it was recommended for everyone to stay inside. Writer told him we were going to keep his cigarettes in the med cart for the weekend, so that staff would know when he was going to go outside to smoke. Resident is familiar with this routine of going to the nurse on the weekend, as his extra cigarettes are kept in the med cart to cover him for Saturday and Sunday. A nurses note dated 1/14/24 at 10:00 p.m. documents: Resident came to writer at 1:45 a.m. and asked writer for cigarettes to go smoke outside. Writer declined giving resident cigarettes due to care plan orders. Resident found by writer outside of courtyard doors at 3:00 a.m. Writer asked resident why he was outside, and Resident stated, I was smoking. Writer assessed resident and no bodily harm to resident noted at the time of incident. Resident hands blancheable, no signs of edema or pain noted by resident. Right and Left hand grip firm. Resident able to move left leg and right above the knee ligament w/o (with out) pain or discomfort noted. Resident escorted back into room. Writer sat down with resident and had a conversation with resident about the risk of going outside unattended and educated resident. Writer expressed to him how important his safety is and resident stated, I understand. Resident assisted into bed with an assist of two. Resident received hourly checks. This note was written by LPN (Licensed Practical Nurse)-I. According to facility video footage and timeline, R1 was outside from 1:16 a.m. until 3:28 a.m. ~At 1:28:47 a.m. R1 pushes the button to open the door which is handicap accessible and the door opens. Surveyor was able to observe R1 was wearing a black jacket which was not zipped up, shirt, pajama bottoms with an incontinence product, and a hat. Surveyor observed R1's pants were not pulled up all the way and R1 was not wearing any gloves/mittens on his hands. After R1 pushes the button, R1 attempts to wheel his wheelchair through the open door but R1's wheelchair appears stuck in a rut and R1 can not move his wheelchair. R1 pushes on the door button multiple times including at 1:29:01 a.m. door opens & closes, 1:29:36 a.m. door opens & closes, 1:30:20 a.m. door opens & closes and 1:30:37 a.m. door opens and closes. Surveyor observed after R1 pushes the door button each time he attempts to wheel his wheelchair with his bare hands on the silver metal wheel rims and is rocking his upper body back & forth in an attempt to move the wheelchair which R1 is unable to do. NHA-A informed Surveyors R1 doesn't stop this until LPN-I finds R1. Surveyor observed R1 continues to rock back & forth to move his wheelchair and continues attempting to wheel the wheelchair back into the building. ~At 2:15 a.m., Surveyor observed R1's hands are red and R1 continues to be rocking back & forth in the wheelchair & trying to wheel the wheelchair. ~At 2:44:50 a.m., Surveyor observed R1's movements have slowed and his hands which are red are on his lap. Facial grimacing is observed. R1 is rocking back & forth in the wheelchair. ~At 3:00:25 a.m., R1 is shivering and his hands are shaking. Surveyor noted an increased shaking in R1's hands. ~At 3:14:19 a.m., R1 is shivering, is trying to cover his left hand with right hand. R1's left hand is very red. Surveyor noted R1's ears are covered by his hat. ~At 3:19:54 a.m., R1 attempts to try the door button again, and again at 3:20:59 a.m. ~At 3:28:51 a.m., the door which leads from the activities room into the courtyard opens & R1 is removed from the courtyard. ~At 3:29:26 a.m., LPN-I is observed wheeling R1. According to wunderground.com/history/daily/us/wi/waukesha/KMKE/date/2024-1-14, on 1/14/24 at 1:22 a.m., the temperature was 5 degrees Fahrenheit with 16 mph (miles per hour) winds from the west with 25 mph wind gusts and light snow. On 1/14/24 at 2:52 a.m., the temperature was 4 degrees Fahrenheit, 18 mph winds from the west with 30 mph wind gusts and cloudy. According to the Wind Chill Chart, frostbite can occur within 30 minutes when the temperature is 5 degrees and winds are 15-20 miles per hour. https://www.weather.gov/media/owlie/wind-chill-brochure.pdf A head to toe skin check was completed on 1/14/24 at 03:43 (3:43 a.m.) which shows skin integrity is checked for intact skin, for the question nails cleaned and trimmed yes is answered, and under notes documents No skin issues noted. This was completed by LPN-I and signed date is documented as 1/15/24. Contrary to N6, Wisconsin Nurse Practice Act, there was no evidence of an RN notification or assessment immediately after the event, no physician notification, and no family notification. There are no documented vital signs including R1's temperature and the camera surveillance did not show LPN-I bringing any equipment into R1's room to obtain vital signs. Contrary to LPN-I's later statement, there is no evidence of rapid rewarming of R1's hands. According to video footage provided by the facility: ~At 3:30:04 a.m. LPN-I wheels R1 into his room. ~At 3:30:27 a.m., 0.23 seconds later, LPN-I leaves R1's room is at the linen cart, and then goes back into R1's room. Surveyor observed LPN-I did not take anything off the linen cart and there is nothing in LPN-I's hands. ~At 3:30:59, LPN-I comes out of R1's room. Surveyor observed there is no other staff with LPN-I. ~At 3:47:56 a.m., LPN-I is observed walking in the hallway. ~At 3:48:05 a.m., LPN-I is in the hallway and has only a cell phone in her hand. ~At 3:48:11 a.m., LPN-I enters R1's room and at 3:48:34 a.m., LPN-I is observed in R1's doorway (0.23 seconds later) and then walks down the hall towards the activities room. ~At 3:49:49 a.m., LPN-I is walking out of the activities room, down the hallway with a soda in her hand. ~At 4:57:57 a.m., LPN-I enters R1's room. LPN-I does not enter R1's with any equipment. Surveyor verified with NHA-A from 3:48 a.m. until 4:57 a.m. no staff entered R1's room. ~At 5:02:39 a.m., LPN-I is observed making rounds on R1's hallway. After this time there is no further video for Surveyor to observe. The facility's timeline indicates at 05:25 (5:25 a.m.) a CNA is in R1's room for several minutes, at 05:31 (5:31 a.m.) CNA back in R1's room for several minutes, at 06:32 (6:32 a.m.) Nurse in R1's room, and at 0636 (6:36 a.m.) Nurse returns to R1's room. The nurses note with an effective date of 1/14/24 at 6:47 a.m. created on 1/16/24 at 8:01 p.m. documents: LATE ENTRY Writer checked on resident numerous times after bringing resident back inside, hourly checks initiated by writer. Writer checked on resident and asked if he was ok, if he was warm, if resident had any pain or discomfort. He said, Yes I am warm, I have no pain. Resident checked on by CNA (Certified Nursing Assistant) during rounds. No concerns noted. Writer woke resident up at the end of the NOC (night) shift and asked resident, are you okay? Resident stated yes I'm okay. Resident stated, No I'm not in any pain. Writer assessed full body once more and no signs of distress or abnormalities noted. This note was written by LPN-I. A head to toe skin check from 1/14/24 at 0900 (9:00 a.m.) indicates there is a new skin integrity issue of frostbite to bilat (bilateral) hands. It goes on to document, bilats (bilateral) hands and fingers, redness and swelling to hands. This was completed by LPN-K. The nurses note with an effective date of 1/14/24 at 9:08 a.m. created on 1/14/24 at 1:14 p.m. documents: Team made aware resident was outside for a long amount of hours. Resident hands appeared to be reddened and swollen with intact blisters. Complaints of slight tenderness to some fingers. VSS (vital signs stable). Unable to obtain O2 (oxygen) levels. Resident appears to be in no resp (respiratory) distress. Ronchi heard in lungs on expiration. PRN (as needed) neb (nebulizer) tx (treatment) given. NP (Nurse Practitioner) made aware. Orders to do a stat chest x ray, CBC (complete blood count) and BMP (basic metabolic panel) stat. This note was written by LPN-K. Surveyor noted this assessment and notification to the NP was over 5 1/2 hours after R1, who was outside in the middle of the night for over two hours, was brought inside. Surveyor noted the first time facility staff obtained R1's vital signs after R1 had been outside for over two hours was on 1/14/24 at 0930 (9:30 a.m.) Blood pressure 142/72 lying right arm, Temperature 97.6 degrees Fahrenheit forehead (contact), pulse 70 bpm (beats per minute) regular, and respirations 19 breaths/minute. These vital signs were recorded by DON-B for LPN-K. The nurses note dated 1/15/24 at 4:05 p.m. documents: LATE ENTRY Per [Name of LPN-K] day shift nurse statement: Between 0800-830 [name] from [Name of] Hospice is here to round of her residents, sees [Name of R1], notes his hand to be blue in color, skin intact, ask for pain med, Norco administered. Hospice was made aware that he was outside for an undetermined amount of time this point but didn't give any new orders. POA (power of attorney) also called hospice leaves. Around 0900 (9:00 a.m.) LPN-K, nurse for day shift calls [Name] to state hands are red, and small blisters occurring and also that lungs have Ronchi sounds, gets answering service. Gets vitals and tells them to on call service. Vitals normal. Around 1000 (10:00 a.m.) NP calls back and states: if nebulizer not helpful, call us back. Nurse calls NP back and states had [sic-hands] still are discolored and new blisters, voiced her concern for Frostbite, she said she was not worried but did give orders for STAT labs and STAT chest XRAY. The NP earlier gave nurse her direct cell number, nurse text NP at 1451 (2:51 p.m.) and states: his hands are now turning purple. NP responds likely has frostbite, I am not sure he needs to be sent out for the hospital for that. Nurse replies, OK. This nurses note was written by DON-B. The nurses note with an effective date of 1/14/24 at 5:05 p.m. and created on 1/15/24 at 4:06 p.m. documents: Per [Name of LPN-K] day shift nurse 1-14-23 Med tech calls the on call nurse manager [Name of UM/RN (Unit Manger/Registered Nurse)-L] and states Have to [sic] been updated on [first name of R1]. She says no. She then proceeds to tell her about the event and the condition of his hands. [First name of UM/RM-L] speaks with the nurse and has them contact hospice again, the POA, [medical group] suggests xray to hands at this point. But POA would like resident to be sent to ER (emergency room ) all aware. Day shift nurse did not realize resident was full hospice, this is why she called [medical group], [medical group] NP did not say they were not following. This nurses note was written by DON-B. The nurses note with an effective date of 1/14/24 at 6:40 p.m. documents: Resident sent to [Hospital's initials] via ambulance for evaluation per MOD (manager on duty). This nurses note was written by LPN-K. Surveyor noted R1's CBC & BMP were drawn with abnormal results for WBC (white blood count) 10.83 H (high) reference range 4.00-10.80 K/mcL (thousands of cells per microliter of blood), RDWSD (red cell distribution width standard deviation) 54.8 (H) reference range 35.0-46.0 fL (femtoliter), Glucose 127 (H) reference range 70-99 mg/dL (milligrams/deciliters), and Albumin 3.1 (L) reference range 3.4-5.0 g/dL (grams/deciliters). There is a handwritten notation which documents R1 went to ER (emergency room ) before results came through 1/14/24. The hospital ED (Emergency Department) provider notes dated 1/14/24 at 1957 (7:57 p.m.) under ED course for narrative document: This patient presents with frostbite of both hands; I discussed the case with plastic surgery and outpatient follow-up is most appropriate at this time. The injury will need to be allowed to demarcate. (Determining and marking off boundaries. In reference to damaged tissue the boundary between living and necrotic tissue.) Hands are warm to the touch. There is no further warming needed at this time. The patient has new symptoms of respiratory distress; he has rhonchorous breath sounds. Work up is consistent with congestive heart failure but also shows possible right lower lobe pneumonia in the absence of clear indications of sepsis. The patient was given IV (intravenous) antibiotics, breathing treatment, and admitted with diuresis for close monitoring and possible echocardiogram evaluation. Under history of present illness, it documents: [R1's name] is a 76 y.o. (year old) male. He is sent in by his facility with concern for frostbite; the patient was apparently stuck outside for about 3 hours last night, in a jacket, but with exposed hands because he goes outside to smoke and staff is unaware. He was brought in and warmed up but has since had significant discoloration especially of the right hand. Under Pertinent Exam for under Musculoskeletal for comments its documented: There is significant discoloration of all the fingers on both hands with swelling; there is discoloration which is worse on the right side with some decent lamination. The patient has good movement but decreased sensation to soft touch. On 1/22/24 at 10:14 a.m., Surveyor spoke with R1's family member on the telephone. Surveyor was informed R1 had been moved to a residential hospice and family felt R1 wouldn't be there if it wasn't for the past weekend. The family member informed Surveyor that R1 wheels himself, was outside and couldn't get in. Surveyor inquired if R1 has gone outside before. R1's family member replied, multiple times and stated R1 is very smoking motivated. R1's family member informed Surveyor R1's cigarettes are kept at the nurses' station so that R1 only gets a couple cigarettes at a time otherwise he would sit outside and smoke the whole pack. R1's family member informed Surveyor facility staff didn't try to rewarm R1's hands. R1's family member informed Surveyor R1 doesn't want to live as he was already an amputee, his fingers are black, and he doesn't want to lose his fingers. On 1/22/24 at 12:42 p.m., Surveyor spoke with Hospice RN-M on the telephone. Surveyor inquired why Hospice LPN-N was at the facility on 1/14/24. Hospice RN-M explained Hospice LPN-N had a PRN (as needed) visit with R1 on the 14th (1/14/24). Surveyor asked what prompted this visit. Hospice RN-M explained R1 was admitted to hospice on the 10th (1/10/24) and it's their protocol to see residents every day for the first 7 days. Hospice RN-M informed Surveyor the visit was not related to any phone call. Hospice RN-M informed Surveyor their visit note documents R1 complained of discomfort to his hands and his hands were pink with bluish finger tips. Surveyor inquired what time Hospice LPN-N was at the facility. Hospice RN-M informed Surveyor in the morning, 8:00 a.m. Of note is that R1 was not sent to the hospital until 7:00 p.m. On 1/22/24 at 4:44 p.m., Surveyor spoke with LPN-I, who worked during the night on 1/14/24, on the telephone. Surveyor asked LPN-I to explain to Surveyor what occurred on 1/14/24 with R1. LPN-I stated R1 had previously received a cigarette at 10:00 p.m. and at approximately 1:00 a.m. asked for another cigarette. LPN-I explained she thought the weather conditions were worse so she did not give R1 another cigarette and thought R1 went back to his room. Surveyor asked LPN-I if she saw R1 enter his room. LPN-I replied no. LPN-I informed Surveyor she goes down the hall, checks rooms and sometimes goes into the activity room for a soda. LPN-I informed Surveyor she went into the activities room, the vending machines are on the right side and the door to courtyard is on the left side. LPN-I explained that she looked to left, that's when she saw R1 (outside,) hurried to him and got R1 inside. LPN-I informed Surveyor this was at 3:00 a.m. Surveyor asked LPN-I what R1 was wearing. LPN-I informed Surveyor R1 always wears a jacket, had on a shirt, pajama bottoms, and shoes. LPN-I confirmed that was what R1 was wearing on 1/14/24. Surveyor asked if R1 was wearing a hat or gloves. LPN-I informed Surveyor R1 usually has black gloves on which he takes off when R1 receives his medication. LPN-I informed Surveyor she can't remember if R1 was wearing a hat. Surveyor asked LPN-I what R1 was wearing on his hands when she found him. LPN-I informed Surveyor she wasn't really sure, doesn't remember. LPN-I informed Surveyor after she found R1 she warmed him up, asked R1 if he was in any pain and if he was okay. R1's vitals were fine, they put R1 in bed, kept his clothes & jacket on & covered R1 with two blankets. LPN-I informed Surveyor she was shocked R1 was outside. LPN-I informed Surveyor she checked on R1 every hour, kept asking R1 if he was in pain and if he was okay. Surveyor asked LPN-I if she looked at R1's hands. LPN-I informed Surveyor there weren't any blisters or abnormalities; she thought R1 was going to be okay. Surveyor asked LPN-I if she called anyone after finding R1 outside. LPN-I replied no, it was his normal routine and didn't think anything was wrong. LPN-I informed Surveyor she didn't call the doctor or anything. LPN-I then stated she called her boss, RN-P. Surveyor asked LPN-I what did she tell RN-P; LPN-I then stated she didn't say anything to RN-P in regard to R1. Surveyor asked LPN-I if she observed R1 anytime between 1:00 a.m. & 3:00 a.m. LPN-I replied no, not until she found him. LPN-I informed Surveyor she went back at 4:00 a.m., 5:00 a.m., & 6:00 a.m. to assess R1. Surveyor asked what she did. LPN-I indicated she looked at his body, hands, feet, legs, & asked if in any pain. Surveyor asked LPN-I who transferred R1 into bed. LPN-I replied, me and CNA-Q. Surveyor inquired if she informed anyone on the day shift R1 was outside in the middle of the night. LPN-I indicated she reported it to Med Tech-O. LPN-I informed Surveyor she told Med Tech-O the whole story that R1 was outside from 1:00 a.m. to 3:00 a.m., needed to be checked a little and said R1 was fine. On 1/22/24 at 2:24 p.m., Surveyor spoke with LPN-K on the telephone. LPN-K informed Surveyor she worked the AM (morning) and PM (evening) shift on 1/14/24. LPN-K explained she was working with a med tech. The med tech was working R1's hall passing medication and lets her know if there is anything going on. LPN-K informed Surveyor she was working the other hall. Surveyor asked LPN-K if she received report on the morning of 1/14/24. LPN-K informed Surveyor she was given a few highlights. Surveyor asked LPN-K if she was given any information related to R1. LPN-K replied, Absolutely not, not one single thing. Surveyor asked LPN-K if she was aware the hospice nurse was there on 1/14/24. LPN-K informed Surveyor she knew a hospice nurse was there but wasn't aware the hospice nurse was R1's hospice nurse. LPN-K informed Surveyor around 8:30 a.m. on 1/22/24, there was a group of staff talking at the nurses' station about R1 being left outside but no one said anything about R1's hands. LPN-K explained about 30 to 40 minutes later Med Tech-O came up to her medication cart and told her she needs to look at R1's hands. LPN-K informed Surveyor that R1 had some blisters on his hands that looked like they were scabbed over. LPN-K informed Surveyor she didn't know R1 so she asked Med Tech-O if R1 had blisters before. LPN-K informed Surveyor they did look at the 24-hour report but there was no information. LPN-K indicated R1's lungs were not clear and she administered a PRN treatment. LPN-K stated she called [Name of medical group], thinks the NP's name was [name] and first called around 9:00 a.m. LPN-K stated R1 was still receiving the nebulizer treatment when she called the NP. LPN-K informed the NP about R1's hands stating to Surveyor she didn't know if it was frostbite as she has never seen frostbite before. LPN-K indicated when she saw R1 he was wearing his jacket, pants, shirt, and his hands were under the sheet. LPN-K stated the NP didn't give her any orders regarding R1's hands and told her to call back if R1's lungs didn't clear. LPN-K indicated she called the NP back maybe an hour later as R1's lungs were still not clear. The NP ordered stat chest x-ray, CBC (complete blood count) & CMP (complete metabolic panel). LPN-K informed Surveyor R1's hands were still red and asked R1 if his hands hurt. LPN-K stated she also asked R1 if he could feel his hands which R1 said he could. LPN-K indicated later on, a 2nd shift CNA told her R1's hands were blue. LPN-K indicated she went in and noted R1's hands were purple. LPN-K stated the NP had given her NP's phone number so she sent her a text message. LPN-K stated NP wrote back that she didn't think there was anything for R1's hands for frostbite. Surveyor asked LPN-K if there was an RN in the building on 1/14/24. LPN-K replied I don't think so, everyone was agency. On 1/22/24 at 3:25 p.m., Surveyor attempted to reach Med Tech-O and left a message requesting a return call. Med Tech-O did not return Surveyor's call. On 1/23/24 at 9:32 a.m., Surveyor spoke with MD (Medical Doctor)-T on the telephone. Surveyor asked MD-T if he received a call regarding R1 during the night on 1/14/24. MD-T informed Surveyor he didn't personally receive a call but maybe their answering service did. MD-T asked what happened with R1. Surveyor informed MD-T that R1 was outside for over two hours during the middle of the night and was inquiring when someone was notified and what instructions were given. MD-T informed Surveyor he would get back to Surveyor. On 1/23/24 at 9:42 a.m., MD-T called Surveyor back with APNP-U who was also on the call. MD-T informed Surveyor since they have an answering service for after hours, weekends, and holidays, the contact was made through the answering service. APNP-U informed Surveyor there is a note that was created on 1/14/24 at 10:07 a.m. and a follow up note at 11:47 a.m. Surveyor inquired if these were the times the facility contacted on call NP-S. APNP-U informed Surveyor it was the time the note was created. Surveyor asked MD-T what his expectations would have been if the facility had contacted him promptly when R1 was found outside. MD-T informed Surveyor he would tell them to do an assessment and if they find any concerns to notify them. If there is no issue it can wait. Surveyor asked MD-T what he would expect if it was a LPN on duty. MD-T replied they should contact the nurse on call and call him. The chain of command should be followed. On 1/23/24 at 9:59 a.m., Surveyor spoke again to LPN-I on the telephone. Surveyor asked if RN-P assessed R1. LPN-I replied no, she (RN-P) sent another resident out (to the hospital) on her side (Rehab side). Surveyor asked LPN-I what R1 had on in bed. LPN-I informed Surveyor R1 was wearing a jacket, shirt, and pajama bottoms and when outside had white shoes. On 1/23/24 at 11:48 a.m., Surveyor asked DON-B how she became aware of R1 being outside in the middle of the night for over 2 hours. DON-B explained it was Sunday evening, doesn't know the exact time thinks it was 5 or 6 PM but it was during the [NAME] game she received a text from UM/RN (Unit Manager/Registered Nurse)-L who was the on-call manager. Med Tech-O had expressed concerns the provider was not doing enough for R1's hands. UM/RN-L asked Med Tech-O what was going on and Med Tech-O told UM/RN-L R1 had been outside. DON-B informed Surveyor she thought this had just happened and it took about half an hour through phone chain to figure out what happened. DON-B explained they have a group chat which consists of the Administrator, UM (unit managers,) DON, MDS nurse, HR (human resource) and the scheduler. DON-B informed Surveyor that LPN-I didn't think it was a change of condition. She brought R1 inside, his hands were cold, checked R1's hands and offered R1 blankets. DON-B informed Surveyor they educated staff on notification and added to the notification if someone goes outside and they are not sure how long need to call. DON-B stated LPN-I did not identify it as a change in condition. Surveyor asked DON-B if she asked LPN-I why she did not have an RN assess R1. DON-B replied because she did not think anything was wrong; to her, his hands were cold. On 1/23/24 at 12:11 p.m., Surveyor asked UM/RN-L how she became aware R1 had been outside in the cold for over two hours. UM/RN-L explained about 6:45 p.m. Sunday (1/14/24) she received a text message from the med tech asking if she was notified of R1's hands. Surveyor asked if this was Med Tech-O. UM/RN-L replied yes. UM/RN-L explained she told the med tech no she had not been notified and Med Tech-O informed her R1's hands were discolored, blistering, and red. UM/RN-L asked Med Tech-O if a nurse had seen them and Med Tech-O indicated LPN-K had. UM/RN-L asked if the MD knew and Med Tech-O said yes. UM/RN-L informed Surveyor she did call the POA (power of attorney,) explained the extent of the discoloration and asked permission to send R1 out. UM/RN-L informed Surveyor she asked Med Tech-O why R1 was not sent to the hospital and was told LPN-K did not have any orders. UM/RN-L informed Surveyor she didn't find out until later R1 had gone out on the NOC (night) shift. Surveyor inquired about the stat x-ray. UM/RN-L informed Surveyor it wasn't done as R1 had been sent to the hospital. Surveyor asked UM/RN-L if LPN-I should have contacted her. UM/RN-L replied 100%, no indication as to how long R1 was outside. The facility's failure to appropriately assess R1 timely after having been outside in 4-5 degree weather for more than 2 hours, the failure to notify an RN in order to conduct an appro [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure each resident's environment was as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents for 4 (R1, R6, R2, & R5) of 6 Residents. *On Friday 1/12/24, the facility became aware of poor weather conditions due to a snowstorm. The facility was aware of R1's frequent smoking noting he would often sit outside and smoke several cigarettes in a row. The Social Worker (SW) spoke to the Med Tech regarding the need to monitor R1 going outside to smoke due to the weather and gave the Med Tech R1's cigarettes to keep in the medication cart. The SW informed R1 they would keep his cigarettes in the med cart for the weekend, so that staff would know when he was going outside to smoke. On 1/14/24 at approximately 1:00 am, R1 asked Licensed Practical Nurse (LPN)-I for a cigarette to go outside to smoke. LPN-I declined giving to R1 the cigarette due to the weather. According to camera footage reviewed, on 1/14/24 at 1:16 am, R1 was observed outside in the courtyard wheeling himself towards the smoking [NAME]. R1 was observed in the smoking [NAME] until 1:27 am when he is observed wheeling himself out of the smoking [NAME] toward the facility. At 1:28 am, R1 is observed attempting to push the button to open the handicapped door to get into the facility. R1 is observed pushing the door button multiple times with the doors opening and closing. R1's wheelchair is stuck in a rut. On 1/14/24, R1 was outside from 1:16 am until 3:28 am (2 hours and 12 minutes) before staff LPN-I noticed R1 outside. Staff were not aware of R1 being outside on 1/14/24 from 1:16 am until he was brought in at 3:28 am. According to the facility's timeline and video footage, the last time R1 was observed in his on room on 1/14/24 (prior to being found outside at 3:28 am,) was when a nurse conducted rounds on 1/14/24 at 00:50 (12:50 am). Surveyor noted no further supervision was provided to R1 after 12:50 am. There was no staff present to provide supervision on R1's unit on 1/14/24 from 1:20 am to 3:38 am. There was no staff supervision of R1 from 1:14 am to 3:38 am to ensure R1's environment is free from safety hazards and for the prevention of accidents which is an unexpected or unintentional incident which results or may result in injury to the resident. On 1/14/24 at 7:00 pm, R1 was transferred to the emergency department and admitted into the hospital with frostbite on both hands. There was a significant discoloration of all the fingers on both hands and swelling. The emergency department also indicated R1 presented with new symptoms of respiratory distress. Work up was consistent with congestive heart failure also showing possible right lower lobe pneumonia. Upon hospital discharge, R1 did not return to the facility. Failure to provide adequate supervision to ensure R1's environment was as free of accident hazards as possible and to prevent accidents created a finding of Immediate Jeopardy (IJ), which began on 1/14/24. NHA (Nursing Home Administrator)-A , DON (Director of Nursing)-B and Regional Nurse Consultant-J were notified of the immediate jeopardy on 1/23/24 at 4:06 p.m. The immediate jeopardy was removed on 1/26/24. However, the deficient practice continues at a severity/scope level of E (potential for more than minimal harm/pattern) as the facility continues to implement its removal plan & as evidenced by the following examples: * R6's falls on 9/13/23 & 10/8/23 were not thoroughly investigated and the root cause was not determined to help prevent further falls. * On 11/6/23 R2's fall interventions were not implemented as R2 was transferred from the bed to chair by a pivot transfer instead of a Hoyer lift. R2's legs became weak and R2 fell to the floor. R2's falls on 9/25/23 & 1/2/24 were not thoroughly investigated and the root cause was not determined to help prevent further falls. * R5's falls on 8/24/23, 9/3/23, 9/25/23, 10/4/23, 11/8/23, & 11/8/23 were not thoroughly investigated and the root cause was not determined to help prevent further falls. Findings include: The CNA (Certified Nursing Assistant) Role and Responsibilities not dated includes Communicate with other CAN's [sic/CNAs] to be sure call lights and residents are accounted for. The Other reminders!! not dated includes documentation of Frequent rounds: - Residents should be checked and changed at least every two hours unless otherwise indicated. - No double briefing: this causes friction, wounds and can lead to infection. - At night residents should be in gowns, pajamas, or provided nigh sic (night) gowns. R1 was admitted to the facility on [DATE]. R1 has an activated power of attorney for healthcare (POAHC). R1's diagnoses includes COPD (chronic obstructive pulmonary disease), atherosclerotic heart disease, delusional disorders, dementia, PVD (peripheral vascular disease), insomnia, and right above knee amputation. The at risk for injury related to active smoker of tobacco products care plan initiated 8/12/19 & revised 9/26/23 includes interventions of independent smoker outside initiated 2/27/20 and is able to keep their smoking materials and smoke independently initiated 8/12/19 & revised 2/27/20. The smoking assessment dated [DATE] indicates R1 smokes 5-9 times a day, remains alert during the course of smoking at all times, is able to communicate the need for help if lit materials fall on them, does not have dexterity problems or tremors, and is able to extinguish a cigarette safely. For resident's primary mode of locomotion documents wheelchair propels independently. The quarterly MDS (Minimum Data Set) with an assessment reference date of 12/14/23 has a BIMS (Brief Interview Mental Status) score of 14 which indicates cognitively intact. R1 is assessed as not having any behavior including refusal of cares or wandering. R1 is 70 inches tall (5 feet 10 inches) and weight is 142 pounds. R1 is assessed as being dependent with toileting hygiene, mobility roll left to right is substantial /maximal, and transfers are substantial/maximal. R1 is always incontinent of urine and bowel. Yes is checked for does this resident use a w/c (wheelchair) or scooter. R1 has fallen since prior assessment with 2 or more falls with no injury. The nurses note dated 1/10/24 documents Resident admitted to [Name] Hospice. Hospice nurse gave the admitting diagnosis of end stage COPD with protein cal (calorie) malnutrition secondary. NP [Name] notified and Hospice updated family. This nurses note was written by UM/RN (Unit Manager/Registered Nurse)-L. SW (Social Worker)-D's statement not dated documents, On Friday 1/12/24, the weather outside was poor due to a snowstorm. Resident, [R1's name] is a frequent smoker and will often sit outside and smoke several cigarettes in a row. Writer spoke with med tech regarding need to monitor resident going outside to smoke, due to the weather, and gave her his cigarettes to keep in medication cart. Writer spoke with resident regarding the bad weather and that it was recommended for everyone to stay inside. Writer told him we were going to keep his cigarettes in the med cart for the weekend, so that staff would know when he was going to go outside to smoke. Resident is familiar with this routine of going to the nurse on the weekend, as his extra cigarettes are kept in the med cart to cover him for Saturday and Sunday. The nurses note with an effective date of 1/14/24 at 3:16 a.m. created on 1/14/24 at 10:00 p.m. begins by documenting resident came to writer at 1:45 a.m. and asked writer for cigarettes to go smoke outside. Writer declined giving resident cigarettes due to care plan orders. This was written by LPN (Licensed Practical Nurse)-I. On 1/22/24 at 4:44 p.m., Surveyor spoke with LPN-I, who worked during the night on 1/14/24, on the telephone. Surveyor asked LPN-I to explain to Surveyor what occurred on 1/14/24 with R1. LPN-I informed Surveyor R1 had previously received a cigarette at 10:00 p.m. and at approximately 1:00 a.m. asked for another cigarette. LPN-I explained she thought the weather conditions were worse so she did not give R1 another cigarette and thought R1 went back to his room. Surveyor asked LPN-I if she saw R1 enter his room. LPN-I replied no, thought he went in the room. On 1/23/24 at 10:16 a.m. Surveyors reviewed the recording from the cameras and the facility's timeline with NHA (Nursing Home Administrator)-A in NHA-A's office. Surveyor noted the following: According to the facility's timeline on 1/13/24 at 22:36 (10:36 p.m.) CNAs and Nurse leave R1's room with dirty laundry/linens in bag. On 1/14/24 according to the facility's timeline at 00:50 a nurse rounds on R1's unit, look in R1's room and R1 is present. At 1:07:02 a.m. R1 is in the doorway of his room, R1 goes into his room at 1:07:29 a.m. and stays in his room until 1:14:54 a.m. when R1 is observed wheeling himself down the hallway, into the carpet hallway which leads into the activities room which is approximately 75 feet from his room. Surveyor observed when R1 was wheeling down the hallway into the activities room there are no staff observed in the hallway. At 1:16:49 a.m. R1 is outside in the courtyard with his back toward the camera wheeling towards the smoking [NAME]. Surveyor was able to observe R1 was wearing a jacket & hat at this time and there was a light coat of snow on the walkway. At 1:17:44 a.m. R1 enters the smoking [NAME] which according to NHA-A is like a bus stop. The front portion is open to the weather elements and the back is covered. Surveyor observed R1 stayed in the smoking [NAME] until 1:27:54 a.m. when R1 is observed wheeling out of the smoking [NAME]. While R1 was out in the smoking [NAME] Surveyor was able to observe lit cigarette/cigarettes. At 1:28:47 a.m. R1 pushes the button to open the door which is handicap assessable and the door opens. Surveyor was able to observe R1 was wearing a black jacket which was not zipped up, shirt, pajama bottoms with an incontinence product and a hat. Surveyor observed R1's pants were not pulled up all the way and R1 is not wearing any gloves/mittens on his hands. After R1 pushes the button, R1 attempts to wheel his wheelchair through the open door but R1's wheelchair appears stuck in a rut and R1 cannot move his wheelchair. R1 pushes on the door button multiple times including at 1:29:01 a.m. door opens & closes, 1:29:36 a.m. door opens & closes, 1:30:20 a.m. door opens & closes and 1:30:37 a.m. door opens and closes. Surveyor observed after R1 pushes the door button each time R1 attempts to wheel the wheelchair with his bare hands on the silver metal wheel rims and is rocking his upper body back & forth in an attempt to move the wheelchair which R1 is unable to do. NHA-A informed Surveyors R1 doesn't stop this until LPN-I finds R1. Surveyor observed R1 continues to rock back & forth to move his wheelchair and continues attempting to wheel the wheelchair. At 1:31:22 a.m. R1 pushes on the door button but the door doesn't open. NHA-A stated maybe his hands are too cold and didn't push it hard enough. At 2:15 a.m. Surveyor observed R1's hands are red and R1 continues to be rocking back & forth in the wheelchair & trying to wheel the wheelchair. At 2:44:50 a.m. Surveyor observed R1's movements have slowed and his hands, which are red, are on his lap. Facial grimacing is observed. R1 is rocking back & forth in the wheelchair. At 2:46:25 a.m. R1's hands are shaking. R1 is shaking and shivering. At 3:00:25 a.m. R1 is shivering and his hands are shaking. Surveyor noted an increased shaking in R1's hands. At 3:14:19 a.m. R1 is shivering, is trying to cover his left hand with right hand. R1's left hand is very red. Surveyor noted R1's ears are covered by his hat. At 3:19:54 a.m. R1 attempts to try the door button again and again at 3:20:59 a.m. At 3:28:17 a.m. LPN-I is observed walking down R1's hallway towards the activities room. Surveyor observed LPN-I does not turn her head to look in any Resident's room while walking in the hallway and enters the small hallway which leads to the activities room. At 3:28:37 a.m. R1 is still outside. At 3:28:51 a.m. the door which leads from the activities room into the courtyard opens & R1 is removed from the courtyard. At 3:29:26 a.m. LPN-I is observed wheeling R1. At 3:30:04 a.m. LPN-I wheels R1 into his room. On 1/23/24 while observing the video surveillance with NHA-A at 11:12 a.m., Surveyor verified with NHA-A from the time R1 left his room at approximately 1:20 a.m. until LPN-I brought R1 inside from the courtyard at 3:28 a.m. no staff were observed on R1's unit. Surveyor noted there were no rounds after 00:50 a.m. Surveyor noted according to wunderground.com/history/daily/us/wi/waukesha/KMKE/date/2024-1-14 on 1/14/24 at 1:22 a.m. the temperature was 5 degrees Fahrenheit with 16 mph (miles per hour) wind from the west with 25 mph wind gust and light snow. On 1/14/24 at 2:52 a.m. the temperature was 4 degrees Fahrenheit, 18 mph winds from the west with 30 mph wind gusts and cloudy. According to the Wind Chill Chart by the National Weather Service, frostbite can occur within 30 minutes when the temperature is 5 degrees and winds are 15-20 miles per hour. https://www.weather.gov/media/owlie/wind-chill-brochure.pdf On 1/23/24 at 6:33 a.m., Surveyor spoke with CNA-R. CNA-R informed Surveyor she had the aqua assignment which is on the Rehab unit and there were 3 CNAs that night in the building. CNA-R informed Surveyor she remembers seeing R1 before she took a break maybe around 1:00 a.m. but did not do any cares on R1. CNA-R explained R1 gets around by himself. Surveyor inquired about the courtyard and how would they know if someone were outside in the courtyard. CNA-R explained on the rehab side the door is alarmed so they know whenever anyone goes out there. Surveyor asked if she heard what happened to R1. CNA-R informed Surveyor she heard he was outside for a while and got frostbite, thinks he got stuck on something. CNA-R informed Surveyor R1 had a problem one other time and thought he got stuck in the same spot and tipped over. CNA-R informed Surveyor that R1 has a mind of his own and that R1 goes outside multiple times. Surveyor asked if R1 has his own cigarettes. CNA-R informed Surveyor he gets them from the nurse. On 1/23/24 at 8:26 a.m., Surveyor spoke with CNA-Q who worked during the night on 1/14/24. Surveyor asked CNA-Q who she was working with. CNA-Q replied me & the nurse for 50 residents and they were short staffed. CNA-Q informed Surveyor she worked the other hall, not the hall R1 resided on. Surveyor asked CNA-Q what she could tell Surveyor about R1. CNA-Q informed Surveyor R1 is kind of independent, a cigarette smoker believes he smokes 2 to 4 cigarettes at a time and stays to himself. CNA-Q informed Surveyor R1 is suppose to get assistance with transfers but most of the time he transfers himself. CNA-Q informed Surveyor R1 didn't put his call light on a lot but at the end he was using the call light more. CNA-Q informed Surveyor R1 needed help to get into bed. CNA-Q informed Surveyor her shift starts at 10:30 p.m. CNA-Q informed Surveyor she did her first rounds when she got there to make sure no one was on the floor stating basically it's a safety check. CNA-Q informed Surveyor since they were short staffed she took the long hall and the other hall they usually get help from the CNAs working on the other unit (Rehab). Surveyor asked CNA-Q if she saw R1 on her first round. CNA-Q replied no, he's an independent smoker the care plan says he can go out whenever he wants. CNA-Q informed Surveyor she didn't have R1 for cares. Surveyor asked if she knew who had R1. CNA-Q replied no. Surveyor asked CNA-Q if she remembers seeing R1. CNA-Q informed Surveyor she remembers seeing R1 two times in his room but couldn't tell Surveyor the first time but the last time was towards the end of the shift after LPN-I brought R1 in. Surveyor asked CNA-Q if she helped transfer R1 into bed after he was found outside with LPN-I. CNA-Q replied no, didn't do any cares on R1. Surveyor asked CNA-Q if LPN-I told her R1 shouldn't go outside. CNA-Q informed Surveyor it's the residents' rights to let them do what they want to do, they can't stop them from going outside. The IDT (interdisciplinary team) note with an effective date of 1/16/24 documents, .Between 0830 (8:30 a.m.) and 0900 (9:00 a.m.) [on 1/14/24] resident hands started to show signs of discoloration seen by hospice nurse which they did not give any new orders, only offered him a PRN (as needed) Norco which was effective. Later around 0900 (9:00 a.m.) the day shift nurse called the on call for [medical group] (not [medical group] as previously reported) and updated her that [R1's first name] hands were red and swollen and had intact blisters and some tenderness to fingers. Also that he had rhochi and unable to obtain POX (pulse oximetry) the NP ordered a STAT chest XRAY and STAT labs, did not give orders for hands or possible frostbite. Over the course of the day the nurse calls back the NP and expressing her concern for worsening discoloration and blisters, the on call NP states, It is probably frostbite he does not have to go out or have orders for his hands, the nursing staff reached out to RN manager on call through [Facility's name] who spoke with DON also. RN unit manager and DON encouraged the nurse to call back the NP, hospice and POA to express their concerns and ask if he can go to the ER. All parties agreed. This nurses note was written by DON-B. The hospital ED (Emergency Department) provider notes dated 1/14/24 at 1957 (7:57 p.m.) under ED course for narrative documents This patient presents with frostbite of both hands; I discussed the case with plastic surgery and outpatient follow-up is most appropriate at this time. The injury will need to be allowed to demarcate. (Determining and marking off boundaries. In reference to damaged tissue the boundary between living and necrotic tissue.) Hands are warm to the touch. There is no further warming needed at this time. The patient has new symptoms of respiratory distress; he has rhonchorous breath sounds. Work up is consistent with congestive heart failure but also shows possible right lower lobe pneumonia in the absence of clear indications of sepsis. The patient was given IV (intravenous) antibiotics, breathing treatment, and admitted with diuresis for close monitoring and possible echocardiogram evaluation. Under history of present illness documents [R1's name] is a 76 y.o. (year old) male. He is sent in by his facility with concern for frostbite; the patient was apparently stuck outside for about 3 hours last night, in a jacket, but with exposed hands because he goes outside to smoke and staff is unaware. He was brought in and warmed up but has since had significant discoloration especially of the right hand. He has no additional complaints but does have baseline dementia. Family notes that he has had increased trouble breathing and a rhonchorous cough, with wet lung sounds which appears new for him. He has chronic atrial fibrillation on Eliquis; he has severe peripheral vascular disease with a prior above the knee amputation on the right side. He is a 2 to 3 pack/day smoker, still. Under Pertinent Exam for under Musculoskeletal for comments documents Prior above the knee amputation on the right lower extremity. There is significant discoloration of all the fingers on both hands with swelling; there is discoloration which is worse on the right side with some decent lamination. The patient has good movement but decreased sensation to soft touch. On 1/22/24 at 10:14 a.m., Surveyor spoke with R1's family member on the telephone. Surveyor was informed R1 had been moved to a residential hospice and felt R1 wouldn't be there if it wasn't for the past weekend. The family member informed Surveyor R1 wheels himself, was outside and couldn't get in. R1's family member informed Surveyor R1 stated someone put him outside and wouldn't let him in. Surveyor inquired if R1 has gone outside before. R1's family member replied oh my gosh multiple times and stated R1 is very smoking motivated. R1's family member informed Surveyor R1's cigarettes are kept at the nurses station so that R1 only gets a couple cigarettes at a time otherwise would sit outside and smoke the whole pack. R1's family member informed Surveyor Facility staff didn't try to rewarm R1's hands. R1's family member informed Surveyor R1 doesn't want to live as he was already an amputee, his fingers are black and he doesn't want to lose his fingers. On 1/22/24 at 3:47 p.m., Surveyor asked Med Tech-C how they know if a resident has gone outside to the courtyard. Med Tech-C informed Surveyor now they have a 15 minute check and there's a log that has to be signed. Surveyor inquired how long they have been doing these 15 minute checks. Med Tech-C informed Surveyor about a week. Surveyor asked Med Tech-C where this log is. Med Tech-C showed Surveyor the folder on the nurses station. At 3:49 p.m. Surveyor reviewed the weather safety check log. Surveyor noted today's log (dated 1/22/24) is completed from 0600 (6:00 a.m.) to 1145 (11:45 a.m.) Surveyor noted from 12:00 p.m. to 3:45 p.m. has not been completed. The failure to supervise a R1 who was known to go outside to smoke prevented staff from learning earlier that R1 was not in his room, which created a reasonable likelihood for serious harm. This created a finding of Immediate Jeopardy. The facility removed the jeopardy on 1/26/24 when it completed the following: * The Administrator and/or DON provided 1:1 education to staff who were directly involved in the resident's weather-related injury. An emphasis was placed on ensuring residents who go outdoors are supervised and staff conduct every 2 hour rounding. * The DON and designee identified all residents who go outdoors to smoke. * The DON and designee ensured all residents identified as at risk for going outdoors to smoke had safety measures, as well as specific interventions, added to their care plans. * The DON and designee ensured the safety measures and resident specific interventions that were added to the care plans were also reflected on the care card so that the CNA's had access to this information. * The DON and designee instructed the CNA's to review the updated care card prior to their next shift. * The DON or designee educated all staff on supervision of residents who go outdoors and staff conducting every 2 hour rounding with staff placement to ensure there is always a staff member on a unit. * The Administrator or designee will perform random audits of the camera surveillance system daily for 2 weeks, then weekly for 2 weeks, then monthly for 2 months to ensure residents who go outdoors are supervised and every 2 hour rounding is conducted. * The DON or designee implemented a every 2 hour rounding sign in sheet for CNA's. * The DON or designee will review all rounding sign in sheets at the daily stand up meeting with the IDT for three months to ensure documentation is completed. * The Administrator will have a camera surveillance monitor placed at the nurses station for staff to view the smoking area and courtyard door. * A QAPI (quality assurance performance improvement) PIP (performance improvement plan) has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. The deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern based on the following examples: 2. R6's diagnoses includes schizoaffective disorder, hypertension, and diabetes mellitus. R6 is her own person and does not have an activated power of attorney. The potential for falls care plan initiated 1/27/22 & revised 5/23/22 documents the following interventions: * 1/27/22 educated on asking for help and using call light for transfers. Initiated 1/27/22. * Initial orientation to room and call light system. Initiated 1/27/22. * PT/OT (physical therapy/occupational therapy) eval and treat prn (as needed). Initiated 1/27/22. *Call for help sign placed in resident's room near the bed. Re-educated on use of call light for assistance and waiting for help. Initiated 3/24/22. * 4/18/22 Dycem to wc (wheelchair). Initiated 4/18/22. * 4/19/22 Therapy eval (evaluate) for transfers. Initiated 4/19/22. * 6/14/22: Will update therapy on being lowered to floor d/t (due to) weak legs. Initiated 6/15/22. * 6/30/22 Enc (encourage) resident to sit farther back on bed for safety while sitting at edge of bed. Initiated 6/30/22. * 10/3/22 Resident reminded she needs to use call light and ask for help, also to have shoes on at all times when out of bed to allow better traction when moving around in wheelchair, also ask for help with bed making as needed. Initiated 10/10/22. * 12/6/22 Reminded to not self transfer and to keep gripper socks on at HS (hour sleep). Initiated 12/6/22. * 5/15/23: Encourage to use the call light. Initiated & revised 5/15/23. * 5/15/23: Ensure floor is uncluttered. Initiated & revised 5/15/23. * 5/15/23: Re-educate resident. Initiated & revised 5/15/23. * 9/13: Encourage gripper socks on at bed time. Initiated & revised 9/13/23. * 10/8/23: Reeducated on compliance with care plan and gripper socks at night and shoes in the morning. Initiated 10/9/23. * 10/24/23 Resident reeducated on not self-transferring, that she needs assistance with the squat pivot transfer with a gait belt. Reminded of the call don't fall interventions for safety. Initiated 10/25/23. The annual MDS (Minimum Data Set) with an assessment reference date of 11/24/23 has a BIMS (Brief Interview Mental Status) score of 15 which indicates cognitively intact. R6 has no behavior including refusal of care or wandering. R6 is assessed as requiring partial/moderate assistance for toileting hygiene, is independent with mobility roll left to right, and transfers is supervision/touching assistance. R6 is frequently incontinent of urine and bowel. R6 has fallen since the previous assessment with two or more with no injury and one with injury, except major. The fall CAA (care area assessment) dated 12/5/23 under nature of the problem/condition documents Resident has had 3 falls since last quarterly MDS. One with minor injury of a laceration to upper left nose on 9/13/23 and two falls with no injury on 10/8/23 & 10/22/23. The nurses note dated 9/13/23 at 7:10 a.m. documents resident seen at approximately 0610 (6:10 a.m.) on floor of resident's room leaning against resident's bed. Blood noted to resident's face and hands. Resident immediately checked for any other injuries, changes in condition etc. none noted. Vitals were as follows Temp (temperature) 97.6, Pulse 88, Respirations 18, BP (blood pressure) 136/84, O2 (oxygen) 98%. Resident assessed by RN (Registered Nurse) [Name] then assisted into w/c and cleaned off blood. See risk manager for details. The fall risk assessment dated [DATE] has a score of 10 which indicates low risk. The incident report dated 9/13/23 for incident description for nursing description documents Resident seen sitting on floor leaning against bed, blood noted on resident's nose and hand, and small abrasion on resident's nose. No immediate changes in cognition noted. For Resident description documents Resident stated she was attempting to self transfer from her bed to her wheelchair when she fell , hitting her nose on her table on the way down. Under Witnesses section documents No Witnesses found. Surveyor was also provided with head to toe skin check dated 9/13/23 and post fall assessment dated [DATE]. Surveyor noted the facility did not conduct a thorough investigation as this assessment does not include any staff statements or which staff were spoken to, who last saw R6, why was R6 transferring herself, were prior interventions in place etc. to help prevent further falls. The facility did not determine a root cause. The intervention of wearing gripper socks had already been implemented on 12/6/22. The nurses note dated 10/8/23 at 6:27 a.m. documents: Resident was found sitting on buttock in the bathroom. Her back leaning against the toilet. Resident denied any injury. Resident stated, I slide down off of the toilet. I was trying to get ready for the day and I slid onto the floor. Resident did not hit her head. No apparent injuries noted. Vitals were stable. ROM WNL (range of motion within normal limits). Neuro checks were negative. Resident had no shoes on and a gown. Resident was assisted off of floor by staff with Hoyer. Resident verbalized understanding of needing to ask for help with cares. On call [Name] NP (Nurse Practitioner) notified. Will continue to monitor resident per fall policy and update with any change in condition. The fall risk assessment dated [DATE] has a score of 8 which indicates low risk. The incident report dated 10/8/23 for incident description for nursing description documents: Resident was found sitting on buttock in the bathroom. Her back leaning against the toilet. Resident denied any injury. Resident stated I slide down off of the toilet. I was trying to get ready for the day and I slide onto the floor. Resident did not hit her head. No apparent injuries noted. Vitals were stable. ROM WNL. Neuro checks were negative. Resident had no shoes on and a gown. Resident was assisted off of floor by staff with Hoyer. Resident verbalized understanding of needing to ask for help with cares. On call [Name] NP notified. Will continue to monitor resident per fall policy and update with any change in condition. Under Resident Description documents, Resident stated I was trying to get ready for the day and I slid onto the floor. Under the witnesses section documents No witnesses found. Surveyor was also provided with head to toe skin check dated 10/8/23 and post fall assessment dated [DATE]. Surveyor noted the facility did not conduct a thorough investigation as this assessment does not include any staff statements or which staff were spoken to, who last saw R6, when was R6 last toileted, were prior interventions in place such as gripper socks, was R6's call light activated to help prevent further falls. The facility did not determine a root cause. On 1/22/24 at 9:50 a.m., Surveyor spoke with R6. Surveyor asked R6 if she has fallen at the facility. R6 replied yes and explained she is supposed to get help getting into bed and with the bathroom but she goes by herself. R6 informed Surveyor she puts her call light on but staff take a long time to answer it so she goes by herself. Surveyor asked R6 what happens when she falls. R6 replied, nothing, I know how to fall so I don't get hurt. On 1/22/24 at 2:57 p.m., DON (Director of Nursing)-B was asked about obtaining staff statements after a resident falls to determine who last saw the Resident and what was the resident doing. DON-B stated there is a section within the post fall investigation for employee statements. On 1/23/24 at approximately 11:30 a.m., DON-B was informed information provided to Surveyor regarding R6's falls on 9/13/23 & 10/8/23 does not include staff statements, whether prior interventions were in place at the time of the fall or the root cause of R6's falls. On 1/23/24 at 4:20 p.m. NHA (Nursing Home Administrator)-A and DON-B were informed of the above. 38829 3. R2 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Morbid Obesity, Type 2 Diabetes, Chronic Pulmonary Edema, Cervicalgia, Hypertensive and Chronic Kidney Disease with Heart Failure, and Hyperlipidemia. R2 is his own person. R2's Annual Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score of 15, indicating R2 is cogniti [TRUNCATED]

Based on observation, record review and interview, the facility did not thoroughly assess, document and provide services consistent with professional standards of practice to prevent development or worsening of pressure injuries for 3 (R42, R14, R56) of 7 residents reviewed for pressure injuries. * R42 had no pressure injuries upon admission but was assessed to be at risk for pressure injuries. R42's care plan did not address providing pressure relief between R42's contracted lower legs nor did it address providing pressure relief in R42's chair. On 6/7/21 R42 developed an unstagable pressure injury to the right inner calf. On 6/7/21 the facility updated R42's care plan to include placing a pillow between R42's legs/knees at all times. On 7/12/21, the facility identified the right inner calf pressure injury as a stage 3 pressure injury. On 6/16/21 R42 developed an unstagable pressure injury to the left buttock. The new intervention on 6/16/21 was to place a gel cushion on R42's [CONDITION(S)] chair. On 7/12/21, this area was identified as a Stage 3 pressure injury. On 7/14/21, R42 was seated in his [CONDITION(S)] chair without the gel cushion. *R14 developed a stage 3 pressure injury that was not assessed weekly. On 8/5/20 R14 was discovered to have an excoriation to the right posterior thigh noted to be where R14's leg rests on the edge of the wheelchair. On 8/12/20, the wound was assessed as a stage 3 pressure injury. The stage 3 pressure injury was comprehensively assessed from 8/12/20 through 9/23/20. The stage 3 pressure injury was not assessed weekly from 9/24/20 to 10/7/20. R14 went 14 days before the area was assessed. The area was assessed weekly again from 10/7/20 through 12/30/20 when again it was not assessed from 12/30/20 through 1/13/20. This pattern of the pressure injury being assessed weekly and then not being assessed for a 14 day period continued, with the measurements fluctuating throughout. On 6/7/21 antibiotics were ordered for a wound infection. As of 7/12/21, the stage 3 pressure injury measured 1.9 X 2.9 X 01. cm with 100 % granulation. On 7/14/21, Surveyor observed the pressure injury area which lined up with the edge of the wheelchair seat. On 7/14/21, R14 was observed sitting in her wheelchair multiple times throughout the day and it was determined, R14 had no seat cushion in her wheelchair during these observations. *R56 was noted to have a Pressure injury to the right buttock on 4/1/21. On 4/8/21 this area was described with having 50% slough and 50% pink tissue. On 4/19/21 the area was described as a stage 2 pressure injury. According to the National Pressure Ulcer Advisory Panel (NPUAP), a stage 2 pressure injury is without slough and which is present in stage 3 and 4 pressure injuries. On 5/3/21 the area was described as a deep tissue injury. On 5/10/21 and 5/24/21 the area was described as a stage 2 pressure injury. There is no further assessment, other than nurses notes reference the open area to the buttock. There is no indication whether this area healing. On 7/12/21, a wound assessment was completed. The assessment indicated a stage 3 pressure injury to the sacrum-proximal and a stage 3 pressure injury to the right sacrum-distal. Director of Nursing (DON) - B was unaware if the wounds identified on 7/12/21 were new wounds or if they were a continuation of the pressure injury from April. Findings include: The facility policy and procedure entitled, Pressure Ulcers/Skin Breakdown - Clinical Protocol updated on 10/2019 states: Assessment and Recognition: 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses 1. R42 is [AGE] years old and was admitted to the facility on [DATE] with a Stroke that affected his left, non-dominant, side. R42 has contractures to both arms and both legs and receives [CONDITION(S)] on Monday, Wednesday, and Friday. R42 is non-verbal, but will occasionally nod or shake his head to simple yes or no questions. On 3/30/21, R42 had a physical therapy screen completed. It recommended to nursing staff that R42 receive range of motion to both legs and positioning in the Geri chair to prevent further contractures and to decrease the risk for skin breakdown. It was not exactly clear what the positioning plan was for R42, but the screen noted that a pillow was placed between R42's knees for improved positioning. On 4/7/21, R42 had an Admission Minimum Data Set (MDS) completed. R42 was noted to require extensive assistance from 2 staff for bed mobility. R42 was totally dependent on 2 staff for transfers. R42 had impaired Range of Motion (ROM) to both legs and both arms. R42 was frequently incontinent of bowel and bladder. R42 had no pressure injuries upon admission, but was noted to be at risk for pressure injuries. The 4/12/21 Care Area Assessment Summary for pressure injuries noted the following information. R42 is a risk for developing pressure injuries due to limited mobility, contractures, and incontinence. His skin remains free from breakdown. R42 has contractures of both upper and lower extremities. The Braden Scale was completed on 4/10/21. R42 had a score of 17, indicating that he was at low risk for pressure injuries. On 4/5/21 the facility initiated a care plan for R42 related to pressure injuries. R42 was noted to have a potential for alteration in skin integrity due to scar tissue to his buttocks, medications, pain, and a decrease in mobility. The goal was for his skin to remain intact without redness or open areas. Interventions included applying barrier cream after incontinent episodes, encouraging adequate hydration, encouraging to turn and reposition every 2-3 hours, monitor/document/report to MD changes in skin status, observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. A weekly skin inspection was to be completed with cares. However, the care plan did not address providing pressure relief between R42's contracted lower legs nor did it address providing pressure relief in R42's chair. RIGHT INNER CALF On 6/7/21, R42 was evaluated by Nurse Practitioner (NP) - L and was noted to have a pressure injury to his right inner calf. It was noted to be a facility acquired Unstageable Pressure Injury that measured 2.0 cm x 2.5 cm x 0.1 cm. The base was 100% yellow slough covered and there was a moderate amount of seosanguineous drainage. The periwound was intact and there were no signs or symptoms of infection. Interventions in place at the time included an alternating pressure air mattress to R42's bed and heel offloading boots. The new plan documented by NP - L included: a pillow to off load the area at all times. NP - L ordered the following treatment to the wound: [MEDICATION(S)] and bordered foam daily. The facility updated the care plan on 6/8/21 to include placing a pillow between R42's legs/knees at all times. It is unclear why the facility had not implemented this intervention prior to the development of the pressure injury to R42's right inner calf in order to prevent the pressure injury from occurring. NP - L continued to assess R42's right inner calf weekly. On 7/12/21, NP - L staged the injury as a stage 3 pressure injury. It was described as a full thickness wound measuring 1.5 cm x 0.5 cm x 0.1 cm. The base was 100% granular and there was a moderate amount of serosanguineous drainage. The periwound was intact and there were no signs or symptoms of infection. NP - L noted that the wound was improved. The following treatment was in place: border foam to be changed three times a week. A pillow was to be used to offload the area at all times. LEFT BUTTOCKS On 6/16/21, LPN - I documented the following assessment completed by Nurse Practitioner (NP) - N. R42 was noted to have an open area to his left buttock that measured 4.0 cm x 3.0 cm. It was described as 100 % slough surrounded by Moisture Associated Skin Damage (MASD). The area was noted to be an Unstageable Pressure Injury. NP - N ordered the following treatment to the wound: [MEDICATION(S)] followed by bordered foam dressing to be changed daily and as needed. It was noted that R42 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The new intervention was to place a gel cushion in R42's [CONDITION(S)] chair. R42 was noted to spend 3-5 hours in his [CONDITION(S)] 3 times per week and otherwise preferred to be in bed. The facility updated the care plan on 6/16/21 to include a gel cushion in R42's [CONDITION(S)] chair. It is unclear why the facility had not implemented this intervention prior to the development of the pressure injury to R42's left buttock in order to prevent the pressure injury from occurring. NP - L continued to assess R42's left buttock weekly. On 7/12/21, NP - L staged the injury as a Stage 3 Pressure Injury. It was described as a full thickness wound measuring 2.0 cm x 1.4 cm x 0.2 cm. The base was 25% granular and 75% yellow slough covered with a moderate amount of serosanguineous drainage. The periwound was intact and there were no signs or symptoms of infection. NP - L noted that the wound had declined. The plan was to for [MEDICATION(S)] and border foam to be changed daily. R42 was to be turned every two hours while in bed. OBSERVATION On 7/14/21 at 8:34 am R42 was observed at the [CONDITION(S)] center, which is located on the lower level of the facility. R42 was seated in his [CONDITION(S)] chair without a gel cushion. R42 returned to his living unit from the [CONDITION(S)] center at 12:10 PM. CNA - O and CNA - P transferred R42 from his [CONDITION(S)] chair to his bed via a Hoyer Lift. There was no gel cushion in R42's [CONDITION(S)] chair, nor was there a gel cushion between R42 and the Hoyer Sling. CNA - O confirmed that R42 did not have a gel cushion in his [CONDITION(S)] chair. CNA - O said that the night shift CNA had transferred R42 from his bed to the [CONDITION(S)] chair and would have been responsible for placing the gel cushion in the chair. INTERVIEW WITH INTERIM DIRECTOR OF REHAB On 7/14/21 at 2:12 PM, Director of Rehab (DOR) - K was interviewed. DOR - K said that he was a physical therapist and was the interim DOR. The 3/30/21 physical therapy screen (as noted above) was reviewed with DOR - K. When asked, DOR - K said that the specific positioning plan for R42 was to place a pillow between R42's knees. INTERVIEW WITH FACILITY On 7-15-21 at 3:20 PM, the preceding information was shared with Director of Nursing (DON) - B. On 7/19/21 at 8:01 am, DON - B provided the following information. The manufacturer's specifications for R42's [CONDITION(S)] chair indicated that the chair consisted of Thermo-sensitive, pressure-reduction seat foam. DON - B did not know if the chair provided pressure relief for a Stage 3 pressure injury, which was what R42 had on his left buttock. DON - B said that she would attempt to get more information about the chair. DON - B said that she had spoken with former Director of Rehab (DOR) - Q. DOR - Q said that the placement of the pillow between R42's legs was not a recommendation to nursing from therapy. The surveyor told DON - B that DOR - K had indicated it was the specific positioning plan for R42. If the pillow between the legs was not a specific positioning recommendation; DON - B was asked what interventions had been implemented to address R42's bilateral leg contractures and the skin-skin contact between his legs. DON - B said that she would follow-up. On 7/19/21 at 2:20 PM, DON - B was interviewed again. DON - B said that she had no information as to what specific recommendations therapy had made to nursing regarding R42's positioning needs. DON - B had no additional information as to what nursing had implemented to prevent pressure injuries to R42's contracted legs. DON - B said that she was unable to obtain additional information related to the effectiveness of the [CONDITION(S)] chairs for a Stage 3 Pressure Injury. 2. R14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's significant change Minimum Data Set (MDS) assessment dated [DATE] coded R14 as needing extensive assistance with bed mobility and transfers, and a Brief Interview for Mental Status could not be completed due to [CONDITION(S)] and was determined by staff to have moderate cognitive impairment. R14 had a Potential Impaired Skin Integrity Care Plan initiated 2/24/2012 with the following interventions in place on 8/5/2020: -Administer treatments as ordered and monitor for effectiveness -Barrier cream as ordered -Encourage to turn and reposition every 2-3 hours -Inform R14/family/physician/wound care nurse specialist of any new area of skin breakdown; follow recommendations per wound care nurse; notify if treatment does not promote healing -Pressure relieving mattress on the bed and pressure relieving cushion on wheelchair -Monitor skin condition with cares and bathing -Monitor, document, and report to physician as needed any changes in skin status -Obtain and monitor lab/diagnostic work as ordered and report results to physician -Shower on Tuesday PM and Friday AM On 8/5/2020 at 2:09 PM in the progress notes, nursing charted R14 was discovered to have an excoriation to the right posterior thigh measuring 5.0 cm x 2.0 cm. The area was noted to be where the leg rests on the edge of the wheelchair. The physician was notified and a treatment order was obtained. Physical therapy was to assess R14 for an appropriate wheelchair size and cushion. No documentation was found indicating the Registered Dietician was notified of the Stage 3 pressure injury. On 8/12/2020, the wound was assessed by the wound care nurse practitioner and it was determined the wound was a Stage 3 pressure injury that measured 3.0 cm x 5.0 cm with an indeterminate depth with 50% slough and 50% granulation. The nurse practitioner documented R14 sits and sleeps in the wheelchair refusing to get into bed per nursing staff. R14 has been known to take the dressings off. The injury to the right posterior thigh was caused by R14 repetitive motion of trying to remove the cushion on the wheelchair. The Stage 3 pressure injury was comprehensively assessed weekly from 8/12/2020 through 9/23/2020. R14's care plan was updated on 9/3/2020 with R14 prefers not being in bed and prefers sleeping in the wheelchair with the following interventions: -bed will be in lowest setting whenever R14 is in bed -Physical Therapy to evaluate for appropriate wheelchair for sleeping when R14 refuses to stay in bed -R14 has the right to crawl out of bed -R14 will be encouraged to sleep in bed, but if refuses, R14 will be made comfortable in wheelchair On 9/23/2020, the Stage 3 pressure injury measured 3.5 cm x 8.5 cm x 0.4 cm with a dry red/dark red wound base. The Stage 3 pressure injury was not documented on from 9/23/2020 through 10/7/2020, 14 days. On 10/7/2020, the Stage 3 pressure injury was smaller and measured 2.6 cm x 4.9 cm x 0.4 cm with hyper-granulation. The Stage 3 pressure injury was comprehensively assessed weekly from 10/7/2020 through 12/30/2020. On 12/30/2020, the Stage 3 pressure injury was again smaller and measured. 1.0 cm x 3.0 cm x 0.1 cm with 100% hyper-granulation. The Stage 3 pressure injury was not documented on from 12/30/2020 through 1/13/2021, 14 days. On 1/13/2021, the Stage 3 pressure injury measured 0.5 cm x 2.5 cm x 0.1 cm with 100% granulation. The Stage 3 pressure injury was comprehensively assessed weekly from 1/13/2021 through 3/3/2021. On 3/1/2021, an order was obtained for a multiple vitamin tablet daily and protein liquid, 30 cc, daily. On 3/3/2021, the Stage 3 pressure injury had gotten larger and measured 2.0 cm x 2.0 cm x 0.1 cm with 100% granulation. The Stage 3 pressure injury was not documented on from 3/3/2021 through 3/17/2021, 14 days. On 3/17/2021, the Stage 3 pressure injury measured 1.8 cm x 2.0 cm with no depth documented, with 100% granulation. The Stage 3 pressure injury was not documented on from 3/17/2021 through 4/1/2021, 14 days. On 4/1/2021, the Stage 3 pressure injury was larger and measured 2.6 cm x 2.2 cm x 0.1 cm with 50% slough and 50% granulation. The Stage 3 pressure injury was not documented on from 4/1/2021 through 4/15/2021, 14 days. On 4/5/2021 at 1:11 PM in the progress notes, the Registered Dietician (RD) charted R14 was visited regarding the wounds. The RD charted nursing staff indicated R14 eats well and without difficulty. The RD charted the unit manager did not recommend a nutritional supplement at that time due to R14's history of [CONDITION(S)] and limited mobility impacting R14's skin and weight gain was discouraged. R14 told the RD that R14 is getting enough to eat. On 4/15/2021 at 1:24 PM in the progress notes, nursing charted R14 was seen by the wound care nurse practitioner and the Stage 3 pressure injury was smaller and measured 1.5 cm x 2.0 cm with no depth documented, with granular tissue. The Stage 3 pressure injury was comprehensively assessed weekly from 4/15/2021 through 5/24/2021. On 5/24/2021, the Stage 3 pressure injury measured 0.9 cm x 1.5 cm x 0.1 cm with 100% granulation. The Stage 3 pressure injury was not documented on from 5/24/2021 through 6/7/2021, 14 days. On 6/7/2021, the Stage 3 pressure injury was larger and measured 2.0 cm x 3.0 cm x 0.1 cm with 50% slough and 50% granulation. Antibiotics were ordered for a wound infection. The Stage 3 pressure injury was not documented on from 6/7/2021 through 6/21/2021, 14 days. On 6/21/2021, the Stage 3 pressure injury was slightly larger and measured 2.0 cm x 3.3 cm x 0.1 cm with 50% slough and 50% granulation. On 6/28/2021, the Stage 3 pressure injury measured 1.5 cm x 3.0 cm x 0.1 cm with 100% granulation. The Stage 3 pressure injury was not documented on from 6/28/2021 through 7/12/2021, 14 days. On 7/12/2021, the Stage 3 pressure injury measured 1.9 cm x 2.9 cm x 0.1 cm with 100% granulation. The Stage 3 pressure injury had treatments that were changed when indicated per the wound care nurse practitioner. The pressure injury was not comprehensively assessed weekly. R14 was non-compliant with off-loading pressure by refusing to stay in bed to keep pressure off the back of the leg while in the wheelchair. On 7/14/2021 at 2:05 PM, Surveyor observed R14 sleeping in the wheelchair in the communal area on the unit. Tubigrips were in place to bilateral lower legs. On 7/14/2021 at 2:30 PM, Surveyor observed Licensed Practical Nurse Unit Manager (LPN UM)-I assisted by Director of Nursing (DON)-B complete the treatment to R14's right posterior thigh pressure injury. DON-B stated the wound was caused by pressure per the nurse practitioner. R14 was in bed laying on the back. R14 lifted the right leg up so LPN UM-I and Surveyor could see the wound. LPN UM-I removed the dressing that was saturated with yellow serous drainage. Surveyor observed the wound and the location of the wound lined up with the edge of the wheelchair seat when R14 was sitting. Surveyor observed the wheelchair to have no cushion in the seat. Surveyor asked DON-B if R14 should have a cushion in the wheelchair. DON-B stated all residents have cushions in their wheelchairs. Surveyor shared with DON-B the observation of no cushion in R14's wheelchair. R14 had been observed multiple times by Surveyor that day to be sitting in the wheelchair. DON-B stated a Certified Nursing Assistant (CNA) may have taken the cushion out of the chair when R14 was transferred to the bed. On 7/14/2021 at 3:05 PM, Surveyor asked CNA-S if CNA-S transferred R14 into the bed from the wheelchair prior to doing the wound treatment. CNA-S stated she assisted with the transfer. Surveyor asked if the wheelchair had a cushion in it and if the cushion had been removed for cleaning or for any other purpose. CNA-S stated she did not know if there was a cushion in the chair because R14 is gotten up in the morning by the night shift staff. CNA-S stated the cushion was not removed at this time and maybe the cushion had been taken down to the laundry to be cleaned last night. In an interview on 7/19/2021 at 1:32 PM, Surveyor asked RD-T if RD-T was updated on R14's wounds, including the pressure injury to the right posterior thigh. RD-T stated wounds are talked about during morning meetings, but RD-T had not been given any details regarding the wounds. Surveyor asked RD-T if the facility alerts RD-T to any new skin concerns. RD-T stated no. Surveyor asked RD-T when would RD-T do an assessment or document interventions for resident conditions. RD-T stated she charts on residents that are receiving protein supplements or if they have weight loss. On 7/19/2021 at 1:42 PM, Surveyor shared the above findings with DON-B. Surveyor shared the concern R14's Stage 3 pressure injury was not comprehensively assessed weekly. DON-B agreed there were missing assessments. No further information was provided at that time. 3. R56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R56's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R56 needed extensive assistance for bed mobility and total dependence for transfers, personal hygiene and toileting. Cognitive skills for daily decision making is severely impaired. R56 has risk of pressure with one stage 2 pressure ulcer indicated on the MDS. R56's care plan, initiated on 12/28/16 and revised on 5/12/21, states a focus of R56 has potential for altered skin impairment r/t (related to) decreased mobility, incontinence, cognitive impairment, B&B (bowel and bladder) incontinence. 5/2021 - pressure wounds to sacrum, buttock and r (right) heel; 5/2021 - sacrum and heel resolved. R56's treatment administration record for July 2021 has the following scheduled treatment orders: 1. Right buttock wound: bordered foam q (every) day/pm one time a day for wound. Order date 5/26/21 with discontinue date of 7/13/21. 2. Wound care: sacrum: proximal: wound wash f/b (followed by) bordered foam, change 2x week and PRN until healed in the evening every Wednesday, Saturday for wound care. Order date 7/14/21. 3. Wound care: sacrum: proximal and distal: wound wash f/b (followed by) bordered foam, change 2x week and PRN until healed in the evening every Wednesday, Saturday for wound care. Order date 7/12/21 with discontinue date of 7/14/21. Braden Scale for R56 was completed on 4/6/21 with a score of 10 indicating high risk of developing a pressure injury. On 4/1/21, a wound care assessment was completed by Nurse Practitioner (NP)-W stating Right lateral open area noted by CNA (certified nursing assistant) during cares on 4/1/21 night shift to early a.m. shift. Appears to be an abrasion type wound, looks like it might have been a blood blister that had opened up. This appeared overnight. Right buttock open area 4.8 cm x 1.3 cm and 0.1 cm no active drainage. Wound bed is pink. On 4/1/21, a weekly skin review was completed by Registered Nurse (RN)-X documenting a new open area with right buttock site described as 1.5 cm eschar area with superficial area going down and left buttock site described as .5 cm red spot with scratch going down. On 4/8/21, a wound care assessment was completed by NP-W documenting Right buttock wound 3.5 cm x 1.2 cm x 0.1 cm 50% slough, 50% pink tissue. Right buttock area likely associated with uremia rather than pressure injury, treatment santyl followed by bordered foam change daily and as needed. Follow up in one week. On 4/19/21, a wound care assessment was completed by NP-L documenting Wound to right buttock, sacrum and right heel. Stage 2 pressure injury to right buttock, partial-thickness wound measuring 2.0 cm x 2.0 cm x 0.1 cm. The base is 100% smooth red and here is a small amount of serosanguineous drainage. Periwound with blanchable [CONDITION(S)]. Status: declined in size. Plan: border foam change daily and as needed, turn every 2 hours while in bed, pericare q (every) 2-3 hours while wound is healing is recommended. Interventions in place included dietary following. Follow up in one week. Surveyor noted, according to the Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/19/21, the facility incorrectly staged the wound to the right buttock as a stage 2 pressure injury when on 4/8/21, the wound was described as having slough. On 5/3/21, a wound care assessment was completed by NP-L documenting Wound to right buttock, sacrum and right heel. DTI (deep tissue injury) to right buttock, partial thickness wound measuring 0.7 cm x 1.6 cm x 0.1 cm. The base is 100% smooth red and there is a small amount of serosanguineous drainage. Periwound deep purple hue. Status: declined. Plan: Border foam change daily and as needed. Interventions in place included dietary following. Follow up in one week. On 5/10/21, a wound care assessment was completed by NP-L documenting Wound to right buttock, sacrum and right heel. Stage 2 PI (pressure injury) to right buttock, partial thickness wound measuring 1.5 cm x 1.5 cm x 0.1 cm. The base is 100% smooth red and there is a small amount of serosanguineous drainage. Periwound blanchable [CONDITION(S)]. Status: declined. Plan: bordered foam change daily and as needed. Interventions in place included dietary following. Follow up in one week. On 5/24/21, a wound care assessment was completed by NP-L documenting Wound to right buttock. Stage 2 PI (pressure injury) to right buttock, partial-thickness wound measuring 0.8 cm x 1.0 cm x 0.1 cm. The base is 100% smooth red and there is a small amount of serosanguineous drainage. Periwound blanchable [CONDITION(S)]. Status: improved. Plan: border foam EOD (every other day). Interventions in place included dietary following. Follow up in one week. On 6/18/21, RN-Y wrote in the nurses note Resident is being monitored for OA (open area) to buttock area. Area remains red/dark pink. Resident washed, cream applied per order, resident repositioned. On 6/19/21, RN-Y wrote in the nurses note OA (open area) to buttock remains open. Redness remains. Area cleaned and tx (treatment) applied. Resident repositioned. On 6/20/21, LPN-Z wrote a general note stating O/A (open area) remains to buttocks. Surveyor reviewed R56's medical records and noted no further wound care assessment's for R56's right buttock pressure injury until 7/12/21. No medical documentation was found regarding healing of the buttock pressure injury. No dietary interventions or dietary notes were found in R56's medical records regarding dietary interventions for wounds. Surveyor found R56's progress notes to include statements regarding dressing in place for right buttock wound on 5/27, 5/28, 5/29, 5/30, 5/31, 6/1, 6/2, 6/3, 6/4, 6/5, 6/8, 6/9, 6/16, 6/17 and 6/24/21. On 7/12/21, a wound care assessment was completed by NP-L stating Wound to sacrum. No longer a DTI (deep tissue injury). Stage 3 pressure injury sacrum-proximal. Full thickness wound measuring 2.0 cm x 2.4 cm x 0.3 cm. The base is 100% granular and there is a moderate amount of serosanguineous drainage. Periwound with blanchable [CONDITION(S)]. Status: New. Plan: Border foam change twice weekly, up and down schedule with patient back to bed after lunch, every 2 hours turns while in bed. Stage 3 pressure injury right sacrum-distal. Full thickness wound measuring 1.4 cm x 0.4 cm x 0.3 cm. The base is 100% granular and there is moderate amount of serosaguineous drainage. Periwound with blanchable [CONDITION(S)]. Status: New. Interventions in place included dietary following. Follow up in one week. On 07/14/21 at 2:11 PM, Surveyor observed DON-B apply treatment to R56's 2 right buttock pressure injuries. On 7/19/21 at 9:58 AM, Surveyor interviewed Dietician-T. Dietician-T was not aware of the pressure injuries to R56 as Dietician-T was not made aware by staff of a concern or a need for follow up. Dietician-T received some documentation on 7/12/21 for R56's wounds so will be following up soon. On 7/19/21 at 12:30 PM, Surveyor interviewed DON-B and Nurse Consultant-R. DON-B stated the expectation for a new pressure injury is to notify the DON or nurse manager if find a skin concern or pressure injury. The nurse or nurse practitioner would asses it on the same day, determine treatment, obtain orders, contact the physician and the family if needed and document the assessment. Documentation and assessment would be done weekly thereafter. There should be an incident report if there is a new area found. There were issues with charting upstairs with wound logs not being sent out and when management found out, it was dealt with. DON-B is in the process of reviewing wounds. Wound logs are sent to the dietician for follow up and talk about wounds at daily meetings. DON-B did not have documentation that R56's wounds have healed and there was no further documentation or assessment of the pressure wounds between 5/24 and 7/12/21. DON-B stated she was unsure if there was a new wound on 7/12 to R56's buttock/sacrum area or if it was a continuation of the pressure injury from April. No further documentation was provided.

Based on observation, record review and interviews, the facility did not ensure 3 (R59, R79, and R46) of 3 residents reviewed for accidents received care and services to prevent accidents. * R59 fell off a shower bed and received staples to their scalp. The resident was assessed as needing assist of two staff for bed mobility and care planned to have two staff while using the shower bed/gurney. The facility did not ensure the agency certified nursing assistant (CNA)-AA was aware of the equipment safety warnings prior to use and resident care plan/Kardex information prior to proving cares to R59. R59 indicated to the Surveyor the staff had not used the cart appropriately when the fall occurred because they did not have the pins in place to have the side rails in place. There is no indication the facility thoroughly investigated the root cause of the fall to prevent future falls from occurring. This resulted I actual harm to R59 in the form of receiving a laceration requiring staples for treatment. * R79 had 2 falls that were not thoroughly investigated to determine causative factors to ensure interventions were developed and implemented to prevent future falls. * R46 has a history of wandering in and out of resident rooms and hallways within the facility and a known history of a fall where R46 got themselves up off of the floor and back to bed. On 6/6/21 R46 wandered out of the facility when attempting to get milk and reported that they had fallen while outside. The facility determined after the event R46 was not at risk for wandering because R46 was not exit seeking. The facility did not complete a thorough review of the incident and R46's history of wandering to determine a root cause to address R46's wandering behaviors. Findings include: 1. On 07/13/21 at 10:38 AM Surveyor spoke with R59. R59 indicated he had a fall 2 weeks ago. R59 shared he slid off the shower bed and hit his head. A staff member was putting lotion on R59's feet and R59 was drying his head off and he just slid out of the shower bed. R59 indicated he went to the hospital and received staples to his head. R59 has no cognitive impairments and has a diagnosis of [CONDITION(S)]. R59 is dependent on staff for bathing/hygiene and bed mobility. R59's medical record was reviewed by Surveyor. The 6/08/21 Quarterly MDS (minimum data set) assessment indicates no cognitive impairments and 1 assist with bathing. The MDS indicates R59 requires extensive assistance from 2 plus staff members for bed mobility. Review of the progress notes indicate the following: - 6/29/2021 11:15 Resident being showered by an Agency CNA (Certified Nursing Assistant) (Nurse on duty) called to shower room. Per Nurse, resident slid off the shower cart during cares. Res complained of alteration in comfort to posterior head- open laceration noted. Denies any dizziness or headache. No nasal drainage or [CONDITION(S)] fluid noted. LOC (level of consciousness) at baseline. VSS (vital signs stable)- BP (blood pressure) 92/56. NP (Nurse Practitioner) in house, resident order received to send resident to ER (emergency room ) to evaluate and treat. Resident declined family update. - 6/29/2021 at 22:10 Resident returned from (name of hospital) at 1536 via (name of ambulance company), vitals were stable, Head CT was negative- no acute intracranial finding, resident has 3 staples put in to lac (laceration) on head, staples to be removed in 7 days. The facility self-report investigation was reviewed by Surveyor. The facility self-report investigation indicates R59 was receiving a shower utilizing the shower bed when the CNA (AA) attempted to reposition the resident by rolling the resident to the side of the bed where the CNA (AA) was standing the resident rolled off of the cart and on to the floor of the shower room. The report indicates after the fall the resident's care plan was reviewed and on the resident's Kardex it indicates the resident requires assistance of 2 staff members when using the shower bed and at the time of the fall only one CNA was assisting the resident. The facility administrator was notified of the resident's care plan and Kardex stating the resident requires the assistance of two staff when in the shower bed and the resident fell when only one was assisting. The facility investigation goes on to state that CAN-AA did not know of Kardex or the need for two staff. The facility investigation indicates while reviewing (R59's) care plan and Kardex it was discovered that the date the care plan and Kardex were updated to included needing two staff was 7/9/20. The facility self-report goes on to reference a therapy evaluation indicating R59 requires assist of two to transfer to the shower bed however the nurse manager at the time of the revision took the recommendation further to be an assist of two when bathing on the shower bed. The report includes a reference to a (facility) review of the progress notes the nurse manager documented and the therapy recommendation found that there were no recommendations stating the resident should have two care givers assist when on the shower bed. The only mention of a shower bed is that the resident should utilize the shower bed when receiving a shower and that the resident should be transferred to the shower bed with a mechanical lift and two care givers. The facility goes on to indicate the resident does not require two caregivers when on the shower bed and his care plan and Kardex did not need to include this information . Surveyor noted this is all determined after the fall occurred. On 07/15/21 at 01:33 PM Surveyor spoke with Administrator-A and reviewed the facility self-report investigation. Administrator-A first thought the plan of care was not followed and through the investigation process they determined R59 only needs 1 assist for showers. Surveyor asked NHA-A if the facility had a policy and procedure for the shower gurney/bed. Administrator-A did not have any additional information and indicated they will look for a policy and procedure for shower gurneys. On 7/21/21 the facility submitted additional information for surveyor to review and consider. On 7/22/21 at approximately 1:51 pm Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A and asked how did staff bathe R59 on the shower bed/gurney prior to this incident. DON-B indicated they used two staff. Surveyor asked DON-B and NHA-A if the only time R59 fell from the shower bed was this incident, when staff did not ensure two were present and only one provided cares. DON-B and NHA-A agreed that the fall occurred when one staff provided cares instead of two. NHA-A confirmed the facility did not have a policy or procedure related to use of the shower gurney/bed. Surveyor noted the 6/8/21 quarterly MDS indicates R59 requires extensive assist of two staff for bed mobility but assist of one for bathing which has not been clarified in R59's plan of care. Surveyor reviewed the OT (Occupational Therapy) assessment from 7/9/2020 (a year ago) This does not address any shower assistance. On 07/14/21 at 12:47 PM Surveyor spoke with R59. R59 indicated they used the flat bed for their shower yesterday. That was their first bathing since the fall 2 weeks ago. R59 indicated there are no straps on the gurney to his knowledge. R59 went on to say the fall from a couple weeks ago was because the shower bed railing was not secured. R59 shared the shower bed rail has pins and they were not in the rail. R59 indicated he fell because the railing was not secured to the shower bed. Surveyor noted there is no indication in the facility investigation whether the device itself was used properly was investigated. There is no indication the facility spoke to R59 about the fall in order to obtain information. Surveyor review of the manufacturer's information with a hand written date of 4/13/15 indicates for step 4: secure railing: secure railing with wore lock pin (lock pin on opposite sides of fitting). There is a note on the assembly instructions indicating casters, railing, wire lock pin must be checked and properly secured prior to using shower gurneys. Warning not securing all the above can create a serious safety hazard. Additional warnings on the manufacturer information include: ~ This device is intended for use by or under the supervision of trained and licensed healthcare providers . ~ Always adhere to the device's weight limitations. Do not allow user to lean out of the device or shift weight in any manner which may pose a tipping risk to the user or device. ~ Always use your device's safety belt if a safety belt is provided. ~ Read and follow all directions and warnings before using this device. Do not operate this device without first reading and understanding the contents of this manual. Death or injury may result from the improper use of this device or failure to follow all directions and warnings. On 07/14/21 at 01:00 PM Surveyor observed the shower gurney and noted it has PVC pipe rails that need to be secured with removable pins on the side. On 07/15/21 at 01:23 PM Surveyor spoke with OT-J who completed the assessment on 7/9/2020. OT-J indicated they did not assess for a shower bed. R59 was using assist of 2 staff for toileting. Due to R59's disease progression they recommended a Hoyer lift transfer. R59 Is dependent on staff for cares. They have not seen R59 since 12/20 and had no changes in plan of care at that time. OT-J was not aware of R59's need for two staff for bed mobility as indicated on the MDS. 2. The facility's policy entitled Fall Management, dated 5/2021, states: The Fall Risk Evaluation (completed on admission) will determine fall risk factors. The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Procedure: 1. Assess and review resident risk factors for falls and injuries upon admission, re-admission, quarterly and a significant change or after a fall. a. Review the completed Nursing Comprehensive Admission Assessment. b. Complete the Fall Risk Assessment within the Electronic Medical Record (EMR) when applicable. 2. Implement goals and interventions with resident/patient/family for inclusion in the interdisciplinary Plan of Care (IPOC) based on individual needs. 3. Communicate interventions to the care giving teams and family/responsible party. 4. Provide training to staff as needed. 5. Review and revise Interdisciplinary Plan of Care at time of fall and update as indicated. 6. Educate resident/patient and family as indicated. Post Fall/Injury Resident Management: 7. Obtain neurological checks per policy for any unwitnessed fall or any fall with evidence of injury to head. . 10. The nurse will complete an incident report. 11. Contact physician and family and document in the medical record, including time and person spoken with. If transferred, document transferring agency/responders. 12. Resident fall will be evaluated for 72 hours post fall, including full vital signs every shift. 13. The Director of Nursing (DON) will be notified immediately for falls resulting in injury and/or transfer. The DON will notify State agency per state specific requirements. . Fall Injury Prevention - Post Fall: 1. Assess the resident and immediately implement appropriate measures to prevent injury. a. Wipe up spills, improve lighting, call light in reach, appropriate footwear. b. Document in medical record. 2. Complete a Fall Risk Evaluation to identify any changes in fall risk 3. Complete the Post Incident Summary 4. Complete a Pain Evaluation 5. Review the Plan of Care - Fall Risk Reduction. 6. Discuss findings and interventions with the resident/patient/family for inclusion in the Interdisciplinary Plan of Care (IPOC). 7. Adjust/add interventions on the Plan of Care - Fall Risk Reduction. 8. Present resident/patient at the next scheduled Resident at Risk Meeting: a. Review current nursing evaluations and resorts. b. Compare data from previous evaluations. c. Discuss identified trends or potential new risk factors. 11. Verify completion of the Accident/Incident Process. R79 was admitted to the facility on [DATE] with diagnoses that include: chronic kidney disease, major depressive disorder, dysphagia, unspecified dementia with behavioral disturbance, [CONDITION(S)] heart disease, history of [CONDITION(S)], difficulty in walking, unsteadiness on feet, abnormalities of gait and mobility and lack of coordination. R79's Minimum Data Set (MDS) significant change assessment dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 99 meaning R79 was unable to complete the interview. Section G, functional status, of the MDS for R79 documents for transfer, toileting, and bed mobility total dependence with 2 person assistance; dressing and hygiene are extensive assistance with 1 person assistance. R79's Care Plan initiated on 1/3/20, with last revision on 6/10/21, documents the focus as: At risk for falls related to meds, pain, decrease in mobility, dementia, infection, incontinence. Interventions include Anticipate my needs, and potential fall times, assess for pain, autolock brakes to wheelchair, make sure my call light/personal belongings are in reach, encourage to toilet q (every) 3 hours or change if incontinent, assess for pain, med review by psych services, and place perimeter edge on mattress to help resident identify when getting close to edge of mattress. R79 had a witnessed fall on 3/30/21 at 2:25 PM. A post fall assessment form was completed on 3/30/21 at 4:34 PM by Licensed Practical Nurse (LPN)-H. The post fall assessment states level of pain was 0, oriented to person, no environmental factors, with a name of a CNA witness and states the resident becomes verbally and physically combative at times. Re-approach when calm. The review of post fall findings indicate Re-approach when calmer. Talk and explain what doing. There were no listed suggestions or referrals to be made as a result of the fall. Incident description was documented as (LPN-H) called to (R79's) room by staff. Resident laying on left side on the floor near bathroom door. Staff reported to (LPN-H) that when they went to the room and was about to change (R79) when (R79) started fighting staff and becoming combative, lost balance and fell . LPH-H stated that Neuro (neurological) checks became initiated but resident refused and became combative. R79 was sent to the hospital for evaluation. On 7/19/21, Surveyor reviewed R79's medical record. On 3/30/21, a general progress note at 7:07 PM states R79 back from ER post fall with a contusion of scalp. Neurological assessment documentation shows checks were not fully completed after the 3/30/21 fall for the neuro checks. Two 72 hour checks were not completed as indicated by facility policy. Surveyor noted upon review of the 3/30/21 fall there are no statements by staff or details of what staff were doing that lead up to R79 becoming agitated and falling. There is no indication the facility reviewed what occurred to help prevent R79 from becoming agitated again possibly leading to a fall. R79 had another fall on 6/23/21 at 11:30 PM. The Post fall report was completed documenting staff found R79 on the floor next to her bed when doing rounds. No apparent injury noted and staples in right thigh and leg remained in place. Vital signs taken. Assisted to bed by staff with Hoyer lift, Registered Nurse Manager made aware, Nurse Practitioner made aware. New order to x-ray right leg. On 7/19/21, Surveyor reviewed R79's medical records which shows neurological assessment checks were not documented after the 6/26/21 fall including all of the 48 hour and 72 hour checks. Surveyor noted there was no further documentation of an investigation or assessment of the incident, including staff interviews, for the 6/6/21 fall to determine proper interventions to prevent falls. On 7/19/21 at 12:30 PM, Surveyor interview Director of Nursing (DON)-B and Nurse Consultant-R. DON-B confirmed there was no further documentation of investigation or assessment other than the post fall assessment by the nursing staff. DON-B was not sure of how information was gathered to determine care plan interventions and that no further investigation was likely done. There was no incident report or any other documentation DON-B could find. Neurological flowsheets were reviewed with DON-B. DON-B stated all neuro check slots should all be completed and does not understand why any of them were left empty. On 7/19/21, Surveyor informed DON-B and Nurse Consultant-R of the concern that R79's falls on 3/30/21 and 6/26/21 were not thoroughly investigated, documented and a root cause of each fall was not identified. No further documentation or information was provided. 3. The facility Policy and Procedure entitled Wandering, Unsafe Resident dated 3/2021 states: 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: Examine a. the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); d. Notify search teams that the resident has been located; Complete e. and file an incident report; and f. Document relevant information in the resident's medical record. R46 was admitted to the facility on [DATE] with diagnoses of diabetes, Alzheimer's disease, chronic obstructive pulmonary disease, depression, chronic kidney disease, anxiety, myopia (nearsightedness), astigmatism (blurred distance and near vision), and presbyopia (farsightedness). R46's Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated severe cognitive deficit with a Brief Interview for Mental Status (BIMS) score of 4. R46 needed limited assistance with bed mobility and transfers. The Care Area Assessment for Cognition stated R46 displays some memory problems and difficulty with problem solving. Surveyor reviewed R46's medical record. On 1/8/2021 at 11:53 AM in the progress notes, Social Worker (SW)-F charted a care conference was held and R46 goes into other resident rooms. On 2/23/2021 at 2:26 PM in the progress notes, nursing charted R46 was wandering the halls and going into other resident rooms. On 2/24/2021 at 10:25 AM in the progress notes, nursing charted R46 was wandering the halls and entering other resident rooms. On 3/1/2021 at 11:20 AM in the progress notes, activity staff charted R46 had difficulty sitting in a group activity due to wheeling around the facility and required re-direction. On 3/7/2021 at 12:58 PM in the progress notes, nursing charted R46 continued to wander into other resident rooms. On 3/10/2021 at 10:20 PM in the progress notes, nursing charted R46 continued to go into other resident rooms and this is happening on a daily basis. On 3/16/2021 at 4:29 PM in the progress notes, SW-F charted R46 spends time wheeling around the hallways on the first floor, going into other resident rooms uninvited and the other residents get upset. On 4/7/2021 at 9:29 PM in the progress notes, nursing charted R46 continues to go into other resident rooms uninvited and R46 is non-compliant when redirected out of those rooms. On 5/12/2021 at 8:49 AM in the progress notes, nursing charted R46 fell out of bed onto the mat on the floor. No injuries were noted. Staff went to get a lift to get R46 off of the floor and into bed. R46 did not wait for the lift but pulled themselves up onto the bed without assistance. On 6/6/2021 at 6:25 AM in the progress notes, nursing charted R46 was wandering the halls requesting milk. Water was offered and attempts were made multiple times to redirect R46 which were ineffective. R46 was found by another staff member outside of the building past the employee parking lot. R46 stated R46 fell and hands were visibly dirty. On 6/6/2021 at 4:39 PM in the progress notes, nursing charted R46 was observed outside of the building at 5:50 AM that morning by the nurse writing the progress note. R46 stated R46 was trying to get back to their room. R46 was on the sidewalk past the employee parking lot. Nursing charted R46 stated they had fallen and dirt was observed on their clothing. The incident was reported to the nurse and the shift supervising nurse. On 6/6/2021, the Elopement Risk Assessment was completed and concluded R46 was not at risk for elopement due to no desire to leave the building. On 6/7/2021 at 11:26 AM in the progress notes, nursing charted the Interdisciplinary team (IDT) met and discussed the self-reported fall by R46 without specific details and R46 being outside of the building. R46 was interviewed and stated R46 was looking for milk and got lost. The Elopement Risk Assessment was reviewed and the IDT determined all interventions for falls were in place and the IDT was not convinced R46 had an actual fall. No documentation of an investigation was found regarding R46 exiting the building without any employee knowledge. R46's Potential for Falls, Accidents and Incidents Care Plan was initiated on 10/7/2019. The intervention added to the Care Plan on 6/6/2021 was: continue with current interventions. R46's Potential for Wandering/Elopement Care Plan related to a history of attempts to leave the facility without notifying staff was initiated on 6/7/2021 with the following interventions: -distract R46 from wandering by offering pleasant diversions, structured activities, food, conversation, television, books/magazines -elopement assessment on admission, quarterly, with significant change, annually and as needed -identify a pattern of wandering: is it purposeful, aimless, or escapist, are they looking for something, intervene as appropriate On 7/13/2021 at 10:26 AM, Surveyor observed R46 in a wheelchair, going in and out of resident rooms on the second floor unit. Surveyor was in another resident's room when R46 entered the room, saw Surveyor, and turned around and exited the room. On 7/13/2021, Surveyor observed the exit door R46 went out of on 6/6/2021: the kitchen was to the left of a T intersection with a short hallway into a room with a door that was propped open, the outside door was immediately to the right with no hallway and a door that had to physically be pushed open; the outer door had a large window on the upper half. The door led to the employee parking lot which was located on a side street. The side street had a sidewalk that, if going to the left towards the street where R46 was found, went down a hill. Once at the bottom of the hill, the sidewalk turned onto the main street. The nurse that found R46 on 6/6/2021 at 5:50 AM was an agency staff member and was unavailable for interview. In an interview on 7/15/2021 at 11:15 AM, Director of Nursing (DON)-B stated the IDT determined R46 did not fall when R46 got out of the building on 6/6/2021. DON-B stated R46 does not always give clear answers to questions. DON-B stated initially they did the fall assessments, but if R46 had fallen, R46 would not have been able to get up off the ground without assistance. DON-B stated the facility looked at the camera recording and R46 did not fall. DON-B stated no changes were made to R46's fall care plan. Surveyor asked if R46's elopement was investigated. DON-B stated R46 was looking for milk and just went the wrong way. DON-B stated this event occurred on the second day DON-B was at the facility and DON-B kept bringing the elopement up at morning meeting, but nothing was really done other than talking to the family. DON-B stated other residents had said R46 had been observed to go to the kitchen on other occasions, so they didn't look any further into it. Surveyor asked if R46 knows where the kitchen was, how did R46 end up outside of the building. DON-B did not have an explanation. DON-B stated R46 had been on the first floor and was moved up to the second floor. In an interview on 7/15/2021 at 11:15 AM, Social Worker (SW)-F stated R46 was looking for milk on 6/6/2021, but went the wrong way and the IDT decided upstairs would be a better place for R46 so they moved R46 to the second floor on 7/1/2021. SW-F stated R46 knows the floor plan of the building and knows where the kitchen is. Surveyor asked SW-F if R46 knows where everything is, how did R46 get outside of the building. SW-F stated R46 just made a wrong turn. SW-F stated an elopement investigation was done by looking at the cameras by the kitchen and they interviewed staff in the morning. SW-F stated R46 gave a couple of different versions of the event, changing what happened each time R46 was asked, but R46 doesn't display exit-seeking behavior. SW-F stated R46's intent was not to elope but took a wrong turn. Surveyor asked SW-F if SW-F participated in the investigation. SW-F said no. SW-F stated R46 knows who to go to when R46 wants something, and SW-F now makes sure milk is available at all times for R46. On 7/19/2021 at 1:38 PM, Surveyor reviewed the above findings and concerns with DON-B. R46 left the building on 6/6/2021 with no staff knowledge and was found outside at 5:50 AM by an employee driving to work. No documentation was provided showing an investigation was completed on R46's elopement indicating what time R46 left the building or for how long R46 was outside alone. No further information was provided at that time. (Cross-reference F744).

Based on interview and record review, the facility did not ensure that a resident who enters the facility without a Pressure Injury (PI) does not develop a PI and receives appropriate care, treatment and preventative measures to promote healing for 1 of 3 (R1) residents reviewed for pressure injuries. R1 resided at the facility and was determined to be at risk for pressure injuries and developed a stage 2 pressure injury on her coccyx. The Facility did not implement appropriate interventions or consult with the Physician in a timely manner when the wound showed signs of infection and deterioration. R1 was subsequently admitted to the hospital for a large, infected stage 4 pressure injury with bone exposed, and passed away 4 days later. The facility's failure to implement appropriate interventions to facilitate healing and prevent further deterioration of the pressure injury, in addition to the failure to consult with the Physician when the pressure injury increased in size, depth and showed signs of infection created a finding of Immediate Jeopardy (IJ) that began on 12/4/19. The Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Corporate Nurse Consultant-C of the IJ on 2/5/20 at 2:30 PM. The immediate jeopardy was removed on 2/5/20, The deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: The Facility's policy and procedure titled: Wounds, Prevention and Management - Pressure Relief Devices revised 9/16/18 documents, in part: Purpose: To provide an appropriate surface that reduces pressure for residents at risk while they are in the bed or chair. Policy statement: Appropriate Pressure Reduction devices will be available in each facility. Types of pressure reduction devices and indicated use: 1. Generally, three (3) types of specialty mattresses are used for residents that experience Stage III or IV ulcers or who have multiple Stage II ulcers. a. Low air loss mattresses's (LAL) - for residents that experience skin moisture, a LAL surface is recommended. b. Alternating Pressure Mattress (AP) - for residents that do not have issues with excessive skin moisture. c. Tru-turn LR mattress - for residents that require extensive assistance with turning or movement in the bed. This surface requires the approval of Regional Clinical Management. 3. Residents utilizing wheelchairs must have a cushion in the seat of the chair. The Facility's P&P (policy and procedure) titled: Wounds, Prevention and Management - Monitoring and Staging revised 9/16/18 documents, in part: Purpose: To promote healing, prevent infections, and prevent new pressure ulcers from developing. Policy statement: Residents will receive appropriate treatment for [REDACTED]. A pressure ulcer is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. General information: A licensed nurse will assess the pressure ulcer weekly and keep the Physician informed of progress with prescribed treatments. Procedure: 4. Daily documentation will reflect if dressing is intact, drainage noted, pain associated with the wound, any odor and condition of surrounding skin which is visual around dressing. 5. Determine stage of pressure ulcer a. Stage 1: Persistent area of skin redness (without a break in the skin) that doesn't disappear within 30 minutes when pressure is relieved. Epidermis remains intact. Condition is reversible with intervention. Non-blanchable [DIAGNOSES REDACTED] of intact skin. b. Stage 2: A partial thickness loss of skin layers involving epidermis and penetration into, but not through dermis, that presents clinically as an abrasion, blister or shallow crater. c. Stage 3: A full thickness of tissue is lost, exposing the subcutaneous tissue - presents as a deep crater with or without undermining adjacent tissue. d. Stage 4: A full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structure. Undermining and sinus tracts may be present. e. Unstageable: Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or back) in the wound bed. 6. Determine types of pressure reducing devices needed. Establish turning and positioning routine. The Facility's P&P titled: Wound Assessments revised 9/16/18 documents, in part: Purpose: To establish a standardized system of weekly measurement so that week to week assessments can be utilized to evaluate changes and/or response to treatment. Procedure: 1. All nursing staff is expected to observe for and report any change in the condition of a patient's skin to a nurse immediately. The Facility's P&P titled: Notification of Change revised 9/16/18 documents, in part: Policy: The community will consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative when there is: - Acute illness or a significant change in the resident's physical, mental or psychosocial status (i.e., deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). A need to alter treatment significantly (i.e., a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment). Criteria: - Clinical complications are such things as development of a stage 2 pressure sore when no ulcers were previously present at stage 2 or higher. Appropriate notification time: Immediate (as soon as possible/no longer than 24 hours). - A need to alter treatment significantly means a need to stop a form a treatment or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure or therapy that has not been used on the resident before). Notification: Depending on the nursing assessment, appropriate notification may be immediate to 48 hours. Procedure: The community will contact the resident's Physician or their primary care professional responsible for the residents care with changes as described above. The community will notify an interested family member with changes as described above. R1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R1 attended [MEDICAL TREATMENT] three times a week with a chair time of 3 hours. R1's Minimum Data Set (MDS) with an Annual Reference Date of 11/12/19 indicated bed mobility requiring extensive 2 person assist, always incontinent of bowel and bladder, and her Brief Interview for Mental Status (BIMS) indicated severe cognitive impairment. R1's Braden dated 8/2/19 documented a score of 14 (moderate risk), however section 2 of the assessment (degree to which skin is exposed to moisture) was marked as rarely moist when in fact, the MDS and facility documentation showed R1 to be always incontinent of bowel and bladder. R1's January 2020 bowel and bladder documentation revealed R1's incontinence of bladder 2-3 times per day, and incontinence of bowel 1-2 times per day. R1's care plan documented: At risk for alteration in skin integrity interventions: *Apply barrier cream after incontinence PRN (as needed) - initiated 10/8/18, *educate her/family/caregivers as to causes to skin breakdown including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning - initiated 3/18/17. *Follow facility policy/protocols for the prevention/treatment of [REDACTED]. * Inform her family of any new area of skin breakdown - initiated 3/18/17. * Monitor/document/report to MD (Medical Doctor) changes in skin status - initiated 3/18/17. * Provide with pressure relieving mattress on bed and wheelchair cushion - initiated 3/18/17. * Resident to lay down between meals - initiated 11/25/19. * Turn and reposition every 2-3 hours - initiated 2/21/18. * Self care deficits related to decreased mobility interventions: APM (alternating pressure mattress) mattress initiated 10/23/19. * High back wheelchair imitated 11/1/19. R1's progress notes documented: 10/14/19 Redness and skin excoriation to left buttock. Nurse Practitioner notified. New order to apply barrier cream twice daily for 5 days. Surveyor noted there were no changes made to the care plan. 10/21/19 Open skin area to left buttock. Physician notified. New order to apply 2 x 2 [MEDICATION NAME] dressing and follow up with wound care team tomorrow. Son (Activated Healthcare Power of Attorney) notified. Surveyor noted there were no changes made to the care plan. Surveyor noted an SBAR (Situation, Background, Assessment) was completed this date which documented: Open skin area to left buttock. Things that make the condition worse are: Moisture, Long time sitting in same position. R1's Weekly Wound Tracking notes documented: 10/23/19 Left buttocks- date acquired 10/21/19. Stage II (2) measured 1.5 x 2.0 (measurements are in centimeters). Shearing of skin with bright pink wound with fluid filled intact blister. Treatment: [MEDICATION NAME] dressing every 3 days and PRN. Care plan revisions: Reposition every 2-3 hours. Surveyor noted this intervention was not new - it was initiated 2/21/18. APM applied to R1's bed 10/23/19. Surveyor noted per the facility policy and procedure, this mattress is indicated for residents that do not have issues with excessive skin moisture, and R1 was always incontinent of bowel and bladder. The facility P&P indicated more appropriate/recommended mattress should have been utilized. Surveyor further noted no changes made to R1's care plan in regard to her wheelchair cushion and the facility did not address shearing. 10/30/19 Left buttocks - Stage U (incorrect stage documented) measured 1.3 x 1.1. Intact blister distal to wound bed. Surrounding skin pink. Treatment: Skin prep blister, [MEDICATION NAME]. 11/6/19 Left buttocks - Stage 2 measured 1.2 x 1.4. 100% pink, scant serous drainage. Treatment: [MEDICATION NAME] every 3 days and PRN (as needed). 11/13/19 Left buttock - stage 2 measured 0.8 x 0.6. Pink granulation tissue, shiny new tissue, surrounding small (0.3) blister formation. Treatment: [MEDICATION NAME] every 3 days and PRN. Barrier surrounding. 11/20/19 Left buttock - stage 2 measured 0.8 x 0.8. Pale pink bed with fluid filled blister intact at center. Treatment: Skin prep twice daily (BID). 11/27/19 Further documented as Sacrum due to blister sheared off and extended to sacrum. Unstageable, measured 2.1 x 2.6 x 0.2. Surrounding (entire) mushy adhered slough. Physician notified - New treatment ordered: Calcium Alginate with silver followed by border foam daily. Note read: Blister sheared off, under blister is actual wound. Care plan intervention: Resident to lay down between meals - initiated 11/25/19. Surveyor noted despite the increase size and deterioration of the wound, R1 was not provided with a wheelchair cushion that was appropriate for a stage 3 or 4 pressure injury, even when having to sit at [MEDICAL TREATMENT] for more than 3 hours at a time. Surveyor also noted the intervention to lie down between meals would not be an applicable intervention on the three days R1 is at [MEDICAL TREATMENT] with chair and transport time. 12/4/19 Sacrum - Unstageable measured 3 x 2 x UTD (Unable to Determine) 95% adhered Slough. 5% pink. Moderate odorous. Surveyor noted the facility did not consult with the physician regarding the increased size and moderate odor to the wound. There was no change in treatment and no modifications to the care plan. The facility had still not provided an appropriate wheelchair cushion for a stage 3 or 4 pressure injury, despite the fact R1 attends [MEDICAL TREATMENT] 3 times a week where she is required to sit for more than 3 hours. 12/11/19 Sacrum - Unstageable measured 5.0 x 2.5 x UTD Eschar 90%, pink 10%, Foul Odor. On this date, an SBAR (Situation, Background, Assessment, and Recommendation) was completed which documented: Increased pain related to open area on the sacrum. The Physician ordered [MEDICATION NAME] 50 mg (milligrams) every 6 hours PRN increased pain. There was no evidence the facility consulted with the physician on the foul odor, increased size, and now present eschar to the wound which may have contributed to the increased pain. There was no change in treatment to the pressure injury, and no modifications to the care plan. 12/18/19 Sacrum - Unstageable measured 5.4 x 2.7 x UTD Necrotic with Foul odor (no percentage of necrosis documented). The Physician was consulted and the treatment was changed to Santyl followed by fluffed gauze for padding and border dressing daily. The Physician also ordered laboratory tests of CBC (complete blood count) BMP (basic metabolic panel) C-Reactive protein for 12/19/19 related to sacral wound. There was no modifications to the care plan. Surveyor noted this was the first time the Physician was consulted on the deterioration of the wound, including the presence of odor dating back to 12/4/19. 12/19/19 CBC results documented: WBC (white blood cell count) of 18.4 (high) reference range 3.9-11.2 Hemoglobin 9.5 (low) reference range 11.3-15.1, [DIAGNOSES REDACTED] Absolute 14.41 (high) reference range 1.90- 7.80, C-Reactive Protein 12.60 (high) reference range 00-0.50. These results indicate inflammation, infection and blood loss. The Physician was consulted and ordered [MEDICATION NAME] 2.25 grams IV (intravenous) every 12 hours for 10 days for wound infection and a wound consult was also ordered. 12/25/19 Sacrum - Unstageable measured 5.6 x 3.0 x UTD Necrotic 50%, yellow/pink 50%. Continue same treatment. Surveyor noted the last dose of IV [MEDICATION NAME] (antibiotic) was given on 12/30/19 1/1/20 Sacrum - Unstageable measured 6.4 x 4.9 x UTD. Necrotic area (an arrow marked downward) with Santyl. Foul odor. There was no description of the wound or percentage of necrosis documented. There was no documentation the Physician was consulted with regarding the foul odor to the wound, despite the fact R1 completed course of IV antibiotics 2 days prior and no documentation he was notified of the increased size of the wound. No change in treatment, no modifications to the care plan. The facility had still not provided an appropriate wheelchair cushion for a stage 3 or 4 pressure injury, despite the fact R1 attends [MEDICAL TREATMENT] 3 times a week where she is required to sit for more than 3 hours. 1/8/20 Sacrum - Unstageable measured 8 x 3.5 x UTD 50% adhered Slough/Necrotic tissue, pale pink. No change in treatment. The Physician was not consulted with on the continued increase in size of the wound. Note on bottom read: Wound Clinic 1/16/20 at 0830 (8:30 AM) (1st appointment). Surveyor noted the wound clinic consult was ordered by the physician on 12/19/19 (28 days prior). 1/15/20 Sacrum - Unstageable measured 8.2 x 6.1 x UTD Copious purulent drainage. Strong odor. Adhered slough. There was no documentation the Physician was consulted. There was no change in treatment and no modifications to the care plan. Surveyor noted the resident had still not been provided a wheelchair cushion appropriate for a stage 3 or 4 pressure injury. On 1/16/20 R1 had an appointment with the wound clinic. The wound clinic sent R1 to the hospital and she was subsequently admitted . The wound clinic progress notes documented: Large sacral ulcer measured 6 x 6 x 3.5 that had a strong anaerobic odor extended close to the bone with necrotic tissue at the base and surrounding induration. The hospital discharge summary dated 1/17/20 documented: CT Pelvis - large posterior midline decubitus ulcer suspicious for sacrococcygeal osteomyeitis. At the inferior margin of the decubitus ulcer, there is a bandlike subcutaneous soft tissue and a punctate gas density extending to the posterior anorectal wall. A fistula cannot be excluded. Patient admitted for bacteremia, sacral wound, osteo[DIAGNOSES REDACTED], transition to hospice care. On 2/3/19 at 10:45 AM Surveyor spoke with Licensed Practical Nurse (LPN)-F. LPN-F stated R1 attends [MEDICAL TREATMENT] 3 times a week. Her pick up time is 10:30 AM, has a chair time of 3 hours and returns to the facility between 3:30 and 4:00 PM. LPN-F reported on 10/14/19 R1's buttock was only red and didn't open until 10/21/19 - that's when they began to follow on wound rounds. LPN-F stated: If it's only red, we do not change anything, just monitor. LPN-F reported prior to the pressure injury development, R1 had the standard facility pressure reduction mattress on her bed and the standard cushion in her wheelchair. LPN-F reported after the PI developed, the facility put a APM mattress on her bed. LPN-F stated wound team does rounds together and DON-B is present to do the assessment. LPN-F stated a wound certified nurse comes in once a month and also rounds with the team. She does not provide any documentation, only advises on treatment. LPN-F stated the doctor comes in every week and is given a sheet of the wound care notes. LPN-F reported if the doctor is updated, it should be documented. LPN-F stated she notified the doctor on 12/18/19 of the wound and got orders. Surveyor was unable to locate any documentation the physician was consulted with regarding the increase in size, presence of slough and/or eschar and foul odor on on 12/4/19 or 12/11/19. On 2/3/19 at 2:00 PM Surveyor spoke with LPN-F and reviewed wound progress notes dated 12/4/19 and 12/11/9. Surveyor asked if the presence of slough, eschar and foul odor would be considered a change or decline in the wound, requiring physician notification - to which LPN-F stated: Yes. Surveyor advised LPN-F of the inability to locate any documentation the physician was consulted on the deterioration of the wound, including increased size, presence of slough and/or eschar and the documented presence of odor starting on 12/4/19. LPN-F was unable to provide evidence the physician was consulted. On 2/3/20 at 3:00 PM DON-B advised Surveyor the facility was looking for documentation the physician was notified of changes in R1's wound related to the decline, increased size, slough, eschar and odor. DON-B stated He's (referring to the doctor) given the wound sheets every week when he come in to review them. Surveyor asked if R1 was seen by the physician every week. DON-B stated: I believe so. I've handed him the wound sheets to review them. Surveyor asked for evidence the physician was consulted regarding the information on the wound sheets (i.e., the wound characteristics, increase in size, presence of odor). No such evidence or documentation could be provided. Surveyor asked DON-B if placing the wound sheet in the doctors' mailbox every week for him to review when he come to the facility would be considered consulting with the physician. DON-B stated: No. I see what you're saying. Review of R1's medical record revealed 2 physician progress notes [REDACTED]. On 2/4/20 at 8:40 AM Surveyor spoke with Unit Coordinator-E and asked about R1's wound clinic appointment which was ordered 12/19/19. UC-E stated LPN-F gave her the TO (telephone order) on 12/20/19 and she didn't get to it right away. UC-E reported she called on 12/24/19, but the clinic closed early for the holiday. UC-E stated she was off for a week after Christmas with illness. UC-E stated she called on 1/6/20 and made the appointment for 1/16/20. Surveyor asked if she was informed of any sense of urgency to try to get R1 an appointment with the wound clinic. UC-E stated: No. LPN-F didn't say anything, just that she (R1) needed an appointment with the wound clinic. On 2/4/20 at 10:15 AM Surveyor spoke with DON-B and asked what type of cushion R1 had in her wheelchair prior to the pressure injury development. DON-B reported R1 had the standard house pressure reduction cushion and mattress. DON-B stated R1 got a new wheelchair and cushion, but was not sure of the date. Surveyor asked DON-B if R1's wheelchair cushion was appropriate for an unstageable or stage 3 or 4 pressure injury. DON-B stated: I don't know. Surveyor was provided a picture and literature of R1's new wheelchair and reviewed it with DON-B. The literature documented 'tapered led abductors, deep lateral and medial contours and coccyx relief. Surveyor asked if this was appropriate for an unstageable or stage 3 or 4 pressure injury. DON-B replied: I don't know. There was no evidence the facility provided R1 with an appropriate chair cushion for her stage 4 pressure injury. On 2/4/20 at 11:15 AM Surveyor spoke with Certified Nursing Assistant (CNA)-H who stated: The last few months she (R1) was really declining. She needed help with eating and wouldn't initiate herself. I remember the wound was pretty bad. She really changed around December, I think. On 2/4/19 at 11:35 AM DON-B informed Surveyor the Social Worker told her (yesterday) that the [MEDICAL TREATMENT] center had contacted her to ask if we noticed the decline and they were thinking of suggesting hospice. Surveyor asked if hospice was discussed before or after the pressure injury development and progression. DON-B stated: After. Surveyor located no documentation regarding the discussion of hospice. Surveyor advised DON-B of serious concern regarding R1's pressure injury. On 2/4/20 at 11:40 AM Surveyor spoke with CNA-I who reported working with R1 daily. CNA-I stated: Before the wound she spent more time up in the chair. If she was wide awake, she would stay up. She started to get really bad after the wound on her butt. She wouldn't talk much, wouldn't eat much, she went pretty much down hill after that. On 2/4/20 at 3:10 PM Surveyor spoke with RN-G regarding her progress note dated 12/19/19. RN-G stated she updated R1's son that the wound was infected and antibiotics were ordered. Surveyor asked if she advised the son of the size or anything else about the wound. RN-G stated: No. I try to keep it at the bare minimum. I probably just told him it was infected and we'd be starting an antibiotic. On 2/5/20 at 10:30 AM Surveyor spoke with Medical Doctor (MD)-J. MD-J stated he does not measure or round with the wound care team, but has seen the wound and is involved in R1's wound care. MD-J stated: They put the weekly wound logs in my mail box and I look at them, but I don't see the resident every week. MD-J stated: I remember it had a foul odor and was getting bigger, so there was a concern for infection. That's why I ordered labs and IV antibiotics. Surveyor confirmed by asking: If you noted foul odor, is that why you ordered labs? MD-J stated: Yes. Surveyor asked MD-J if he was aware documentation indicated the wound was getting bigger and had a foul odor 2 weeks prior, on 12/4/19. MD-J stated: No, but foul odor could be from anything, like soiling of the patient. I was concerned when it was getting bigger. Surveyor advised MD-J that the documentation indicated foul odor was from the wound and not from soiling. MD-J reported he would be most concerned if a wound was getting bigger. Surveyor asked MD-J if he was aware R1 did not have an appointment to be seen at the wound clinic until 28 days after he wrote the wound consultation order. MD-J stated he was not aware. Surveyor asked MD-J if he would have wanted R1 to be seen sooner in the clinic. MD-J indicated he would have preferred a week or two earlier but knew of the 1/16/20 appointment. No additional information was provided to Surveyor. The facility's failure to ensure R1 received appropriate care and treatment of [REDACTED]. The immediate jeopardy was removed on 2/5/20 when the facility implemented the following action plan: ~ Licensed and non-licensed staff will be educated before their next tour of duty on reporting any change in skin conditions during cares to DON. New skin breakdown will be assessed by RN, MD updated and information documented in the medical record. ~ Licensed staff will be educated before their next tour of duty on proper notification of changes, documentation, new policies & updated interventions ~ Residents with Pressure injuries will be audited for appropriate documentation, assessment and treatment by wound certified RN. Care plans will be updated to reflect any changes that result from the wound rounds. ~ Weekly skin checks will be reviewed at morning clinical meeting for variances from previous week. ~ Wound rounds will be completed weekly by wound team and overseen by certified wound nurse for treatment recommendations. ~ Policy and Procedures used will be from NPIAP. ~ Policy and Procedures will be updated to new standard of practice. Audits will be completed 3x/wk x 2 months or until substantial compliance on appointment/consultants to ensure scheduled timely. ~ Audits will done on residents with a change of condition and verification that Care Plans are updated timely 3x/week for 2 months or until substantial compliance.

Based on interview and record review the facility did not ensure that 1(R1) of 3 residents was free from chemical restraints imposed for purposes of convenience, and not required to treat the resident's medical symptoms. * R1 was given [MEDICATION NAME] and [MEDICATION NAME] on 11/5/18 sometime between the timeframe of 3:00PM to 7:00 PM related to behaviors RN-C described as causing RN-C to go crazy. R1's [MEDICATION NAME] had been discontinued earlier in the shift. RN-C administered the new medications ([MEDICATION NAME] and increased [MEDICATION NAME]) along with the discontinued [MEDICATION NAME]. He told a certified nursing assistant (CNA) that this should calm him down and make him sleep awhile. When R1 woke up ten minutes later and started yelling and screaming, RN-C took [MEDICATION NAME] from another resident's supply and administered it to R1 without an order. Subsequently, R1 experienced unresponsiveness and difficulty breathing and had to be administered [MEDICATION NAME] and sent to the hospital via 911. The facility's failure to ensure R1 was free from chemical restraints created a finding of Immediate Jeopardy, beginning on 11/5/18. Nursing Home Administrator-A and Director of Nursing (DON)-B were informed of the Immediate Jeopardy and substandard quality of care on 12/5/18 at 1:00 pm. The immediate jeopardy was removed on 12/6/18, however the deficient practice continues at a scope/severity of an D (potential for harm/isolated) as the facility continues to implement its removal plan. Findings include: The facility's policy and procedure titled Abuse, Neglect and Exploitation dated 9/16/17 states: The facility must ensure the resident is free from chemical restraints imposed for purposes of discipline or convenience. Recognize signs of burnout, frustration and stress in employees that may lead to abuse. R1 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's care plan for use of anti-anxiety/anti-depressant/anti-psychotic medication related to adjustment issues, anxiety disorder, behavior management dated 10/10/18 indicates: interventions-send to emergency room , talk to R1 about being a disc jockey, administer medications, monitor for side effects of medication, monitor/ record effective interventions for behavior management (does not indicate what those interventions are), monitor/record targeted behaviors, refer to behavior management. No specific care plan for R1's behavior was developed. On 12/4/18 a facility self-report with a facility discovery date of 11/6/18 was reviewed and read: R1 routinely has behaviors of screaming out, urinating in public, disrobing and striking out at staff. On 11/5/18 at around 7:00 PM R1 began to have difficulty breathing. He began to have episodes of apnea and went unresponsive. The nurse on the unit called a code blue and 911 was called. R1 was brought to Waukesha Memorial Hospital and was admitted with acute metabolic [MEDICAL CONDITION]. On 11/6/18 our admissions department received a call from the hospital to inform us that R1's urine tested positive for [MEDICATION NAME] and the drug was not on his prescribed medication list that we provided to them. We spoke to Registered Nurse (RN)-C who stated that R1 was very behavioral and screaming at everything he said, he tried to calm him and gave him his [MEDICATION NAME] for pain and his Tylenol. He attempted to toilet him as he was yelling about that as well, but he didn't go. He called the psychologist and obtained new orders to discontinue his bedtime dose of [MEDICATION NAME] 50 milligrams (MG) and start [MEDICATION NAME] 5 mg at bedtime and to increase [MEDICATION NAME] 250 mg three times a day. RN-C gave R1 the [MEDICATION NAME] and [MEDICATION NAME] that had been discontinued. R1 fell asleep for about 10 minutes and then began yelling again. RN-C states he was very frustrated and overwhelmed because his yelling was agitating the other residents on the unit. When we told RN-C that [MEDICATION NAME] was found in R1's urine he confessed to giving R1 [MEDICATION NAME] from another resident (R2) on the unit. RN-C stated he was only trying to help R1 as he was complaining of pain and had no intention of harming him. RN-C was sent home. RN-C the agency nurse will not be allowed to return to the facility. Review of R1's physician's telephone orders dated 11/5/18 at 2:50 PM given by R1's psyhiatrist and written by RN-C indicate: Discontinue [MEDICATION NAME], Increase [MEDICATION NAME] sprinkles to 250mg three times a day, [MEDICATION NAME] ([MEDICATION NAME]) 5mg at bedtime. R1's progress notes dated 11/5/18 at 7:49 PM indicates: New medication orders noted, was screaming first 1/3 of shift. R1's progress notes dated 11/5/18 at 8:39 PM indicate: CNA reported to writer that R1 was not breathing well. R1's respirations were low 8/minute R1 not responsive. 911 was called. Both progress notes were writtem by RN-C. Surveyor reviewed the facility self-report including interviews with Certified Nursing Assistants (CNA)-E, CNA-F and RN-C indicating: * CNA-E no date of statement: I came into work and (R1) was acting like his normal self, yelling. (RN-C) said that he had already given him his PM medication early because of his behavior. Soon after the medication still hadn't kicked in so I guess (RN-C) called R1's psychologist and he prescribed a new medication, discontinued another, and increased dosage on another one. (RN-C) said it would calm him down and pretty much make him sleep awhile. (R1) fell asleep about 10 minutes and started back with the yelling and screaming. (RN-C) said this is crazy nothing is working he should have been knocked out for a while. (R1) ate dinner and then was at the nurse's station and (R1) was drenched with sweat. I asked (RN-C) what was wrong with (R1) and (RN-C) said (R1) is just hot, its hot by the nurses station lets push him by the fan. So we did (CNA-F) and I kept saying that's not regular sweat somethings wrong. (RN-C) said no its just hot and then he took a second look at him and said oh he's sweating a lot let me get some ice and put it behind (R1's) back. At that time (R1) was still out of it slurring words as he moved him not making sense at all. (CNA-F) and I then said again something isn't right with him and (RN-C) went back into the nursing office and (CNA-F) and I realized (R1's) breathing was off. I checked and I didn't feel a pulse and saw no respirations. Then (R1) would breathe again sporadically and stop. We told (RN-C) and he said he was dead or at deaths door call 911 and the supervisor. For the rest of the shift (RN-C) just worried and was frantic about the situation. * CNA-F's statement dated 11/7/18 indicates: After laying another resident down for the night I believe sometime after 7:00 PM I walked into the dining room and noticed (R1) in his chair leaning back as if he was sleeping. He was very sweaty, so I asked if he was ok. I got the attention of another aide and the nurse. The nurse saw that (R1) wasn't responding to the cold towel. We watched to see his breathing and he breathing different. That's when the nurse called for a stat to be called, the supervisor came. They called 911. * RN-C's statement dated 11/6/18 indicates: I gave (R1) his medication all of them including his [MEDICATION NAME] and [MEDICATION NAME]. He fell asleep and would wake up and yell and fall asleep again. He did start really sweating around 7:00 PM. The aides were saying he was sweating. I put him by the window and gave him some ice. After that the aide said he was breathing funny. I went and looked at him and called 911. I gave him a dose of (R2's) [MEDICATION NAME]. I know I shouldn't have and I've been living with it since then. I did not ask the supervisor for help. I was going crazy. On 12/4/18 at 11:35 AM RN-C was interviewed and indicated R1 would scream and get all the other residents on the floor riled up. RN-C indicated on 11/5/18 he was trying to maintain his sanity, called his wife and swore at her. RN-C indicated he was totally stressed out. RN-C indicated he didn't call the supervisor for help because he knew she would say she's too busy. RN-C indicated he called R1's psychologist at the beginning of the shift and received orders to discontinue R1's [MEDICATION NAME], increase his [MEDICATION NAME] to three times a day and start [MEDICATION NAME] 5 mg at bedtime. RN-C indicated that he gave R1 [MEDICATION NAME] and about an hour latter [MEDICATION NAME]. RN-C also indicated he gave R1 the discontinued [MEDICATION NAME] 50 mg, [MEDICATION NAME] and [MEDICATION NAME] around supper time. RN-C indicated that about 7:00pm he put him by the window because the unit was hot and R1 was complaining of sweating. RN-C indicated that little while later a Certified Nursing Assistant (CNA) came to him while he was charting at the desk and reported R1 wasn't breathing right. RN-C indicated he called 911 right away and the supervisor came to help. RN-C indicated he didn't get any training on dealing with difficult behaviors or stress management before or during his working at the facility. RN-C indicated he never meant to hurt R1 and he only wanted to help him settle down. RN-C indicted he didn't call R1's doctor when his behavior continued just tried to handle it myself. R1's Situation, Background, Assessment, Recommendation, documentation dated 11/5/18 at 8:29 PM written by RN-C indicates: R1 unresponsive, Pulse 58, Respiration 12, and Blood Pressure/64. Few/low respirations. 911 called. The medication error report completed by DON-B dated 11/5/18 indicates: R1's [MEDICATION NAME] 50mg at bedtime was discontinued and [MEDICATION NAME] was ordered. The nurse gave [MEDICATION NAME] and the [MEDICATION NAME]. The nurse gave a [MEDICATION NAME] 5/325 mg from another resident. R1 did not have an order for [REDACTED]. [MEDICATION NAME]: sweating, [MEDICAL CONDITIONS] difficulty breathing. [MEDICATION NAME]: difficulty breathing and [MEDICAL CONDITION]. [MEDICATION NAME]: drowsiness, sweating. On 12/4/18 R1's emergency room report dated 11/5/18 was reviewed and indicates: R1 presents with somnolence. R1 is positive for [MEDICATION NAME] which he is not prescribed, however he was given first 1 mg and then 2 mg of [MEDICATION NAME] with no response. He does have evidence of a urinary tract infection without fever or elevated white blood cell count however I doubt that the urinary tract infection is the cause of the quite impressive somnolence. Blood pressure 187/91, Heart rate 115, Respirations 16. Opiate group detected. [MEDICATION NAME] detected. On 12/4/18 R1's Hospitalist Admission History and Physical dated 11/5/18 was reviewed and indicates: Acute metabolic [MEDICAL CONDITION], completely unresponsive; usually is combative. Has [MEDICATION NAME] in urine, not prescribed; initially responded to [MEDICATION NAME] per emergency medical services, but no response to [MEDICATION NAME] in the emergency room . On 12/4/18 R1's Hospitalist Progress Note dated 11/6/18 was reviewed and indicates: Acute metabolic [MEDICAL CONDITION]. During presentation R1 was unresponsive however this morning he was eating his breakfast. As per information this is likely from [MEDICATION NAME] use for which R1 was not on. On 12/4/18 at 12:50 PM RN-D was interviewed and indicated she was the supervisor on PM shift 11/5/18 and was downstairs when the stat was called, dropped everything and went upstairs. RN-D indicated R1 was unresponsive verbally, could feel a pulse and R1's breathing was rapid then slow. RN-D indicated RN-C did not tell her anything about the medication he gave. RN-D also indicated RN-C never told her he is stressed R1's behavior but that she has worked with R1 and it is stressful. RN-D indicated that If RN-C would have said something she would have offered to switch jobs with him, but he always wanted to work up there and was upset if he was assigned somewhere else. On 12/4/18 at 1:45PM Director of Nurses (DON)-B was interviewed and indicated that only 2 pool staff was educated on dealing with difficult residents, administering meds without an order and stress management after the medication incident with RN-C. DON-B indicated several more agency nurses have worked without training in those areas since the incident with RN-C. Sometimes up to 6 pool nurses a day. DON-B indicated it was her idea to send the R1 to the emergency room if the facility can't handle his behaviors. DON-B indicated R1's psychologist has been adjusting his medication and he has improved a lot. DON-B also indicated the facility needs to add more behaviors to R1's behavior sheets and more interventions need to be added to R1's care plan. On 12/4/18 R1's Medication Administration Record [REDACTED]. On 12/4/18 R2's controlled drug record sheet for [MEDICATION NAME] 5/325 mg was reviewed and indicated that RN-C took one pill from R2's blister pack on 11/5/18 at 3:00 PM. The previous dose taken from this blister pack was 7/21/18 at 9:00 AM. R2's physician's orders [REDACTED]. On 12/5/18 at 10:00 AM DON-B was interviewed an indicated narcotics should be destroyed within one week of them being discontinued and R2's should have been destroyed several months ago. On 12/4/18 R1's controlled drug record sheet for [MEDICATION NAME] 50 mg was reviewed and indicated that RN-C took one pill from R1's blister pack on 11/5/18 at 6:30 PM. On 12/5/18 the Alliance Agency (Agency RN-C was employed by) Services agreement was reviewed dated 2/22/18 and signed by Administrator-A and read: Alliance Services shall comply with applicable Joint Commission (Joint Commission does not regulate skilled nursing facilities and has different training requirements) standards as follows: Education and training that is consistent with applicable legal and regulatory requirements. The facility's failure to ensure R1 was free from chemical restraints created a situation of immediate jeopardy. The immediate jeopardy was removed on 12/6/18 when the facility implemented the following: * R1 care plan, behavior logs and interventions were reviewed and updated as well as all other residents in the facility with behaviors. * A behavior binder was created for each unit that included interventions. * Nursing staff were educated on the use of the binders and interventions, dementia care, chemical restraints and use of non-pharmacological interventions before medication is used. * All agency staff will be educated in person prior to working in the facility. * Auditing with be completed of behavior logs three times a week at the clinical meeting for four weeks or until substantial compliance to verify staff are using non-pharmalogical interventions. Audits will be brought to QUAPI for review. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement their removal plan.

Based on interview and record review the facility did not provide care and services so that 1 of 2 sampled residents who had a [DIAGNOSES REDACTED]. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R1's medical record indicates R1 receives medications for behaviors including inappropriate language and continuous yelling/screaming despite records indicating R1 demonstrates multiple additional types of agitated behavior. R1's plan of care only includes two individualized interventions including to send R1 to the emergency room (ER) for behaviors and talking to R1 about music and being a DJ and does not include specific reasons for R1 receiving medications for behaviors and nonpharmacological interventions to help assist with R1's behaviors. On 11/5/18 RN-C indicated R1's behaviors were making him go crazy and RN-C proceeded to administer, over a course of 4 hours, [MEDICATION NAME], Tylenol, [MEDICATION NAME] and [MEDICATION NAME] to try to quiet R1's behaviors. Two of the medications ([MEDICATION NAME] and [MEDICATION NAME]) RN-C administered were either not ordered for R1 or had been discontinued earlier in the day. R1 became unresponsive and required 911 transport to the hospital and administration of [MEDICATION NAME] to revive R1 (Cross-reference F605). R1's plan of care did not include individualized interventions based upon a comprehensive assessment of R1's behaviors to assist staff in working with R1 to decrease his behaviors. The facility did not have a comprehensive training plan to ensure pool/agency staff working in the facility had the necessary training and resources to work with residents with [DIAGNOSES REDACTED]. The facility's failure to ensure R1 received Dementia care based on a comprehensive assessment so appropriate interventions could be developed and utilized created a finding of Immediate Jeopardy, beginning on 10/4/18. Nursing Home Administrator-A and Director of Nursing (DON)-B were informed of the Immediate Jeopardy and substandard quality of care on 12/5/18 at 1:00 pm. The immediate jeopardy was removed on 12/6/18 as the facility implemented their action plan however, the deficient practice continues at a scope/severity of an E (potential for harm/isolated) as the facility continues to implement their plan. Findings include: The facility's policy and procedure titled Behavioral Management Program dated 9/16/18 states: Assessment Behaviors shall be identified through the RAI process and through staff interaction. Identified behaviors should be evaluated for frequency, duration and intensity for a pattern. The interdisciplinary team should decide which residents need a behavior management program versus residents that are care planned with appropriate interventions, by evaluating the pattern . R1 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R1's Hospital records dated 9/30/18-10/2/18; prior to R1's admission to the facility indicate: 10/1/18 (R1) demonstrating bizarre behavior and thought process. (R1) has reportedly been throwing feces around his room. Lying naked in bed declining to put on his gown. Adjustment disorder: (R1's) confrontational behavior likely is secondary to Adjustment disorder secondary to his stroke. (R1) is extremely argumentative. Referrals sent to skilled nursing facilities. 3 have declined him thus far. Surveyor noted despite advanced documentation of behaviors no evidence could be found that a plan was put in place for (R1) once he arrived to the facility on [DATE]. R1's Admission Minimum (MDS) data set [DATE] indicates R1 had no behaviors during the reference period even though several behaviors were documented in the progress notes and on behavior logs. On 12/4/18 R1's medical record was reviewed and no comprehensive dementia assessment could be found. R1's care plan dated 10/10/18 for use of anti-anxiety/anti-depressant/anti-psychotic medication related to adjustment issues, anxiety disorder, behavior management includes for interventions:-send to emergency room , talk to R1 about being a disc jockey, administer medications, monitor for side effects of medication, monitor/ record effective interventions for behavior management (Surveyor noted the care plan does not indicate what those interventions are), monitor/record targeted behaviors, refer to behavior management. R1's behavior intervention monthly flow record for October, (MONTH) and (MONTH) were reviewed and indicated the only behavior of R1 being monitored was inappropriate language despite several other behaviors noted in R1's progress notes. The behavior intervention monthly flow sheets for (MONTH) and (MONTH) indicate the behaviors being monitored were inappropriate language and continuous yelling/screaming again despite several other behaviors being noted in R1's progress notes. Review of R1's behaviors in the progress notes include: - 10/4/18 5:52 PM R1 admitted to facility with history of violent outbursts. Paramedics stated R1 can be very vulgar and angry per the nurses at the hospital. - 10/11/18 9:14 PM R1 was at nurse's station earlier in shift yelling at times using foul language. - 10/13/18 11:05 AM R1 swearing and yelling at times at staff. - 10/14/18 2:58 PM Even though R1 toileted will take out penis and urinate on floor in dining, activity area. - 10/14/18 6:32 PM R1 agitated at times yelling out and hitting table. Also has been taking penis out and waving it around and at times urinates on the floor. - 10/21/18 1:40 AM R1 was pulling apart depends (incontinence brief) and throwing cotton pieces on the floor. R1 also yelling out. - 10/22/18 5:30 PM R1 was sitting by the nurses station yelling, cursing, hitting the wall, stating call the police. Tried to calm him down, offering snacks, fluids but R1 refused and demanded that the police be called. Would stop for a while then continue the behavior of hitting the wall and would not allow staff to move him. - 10/22/18 6:00PM Dr. called regarding R1's behavior, ordered to send to be evaluated. - 10/22/18 9:37 PM Received a call from hospital that R1 is quite now and does not display aggressive behavior. - 10/22/18 8:50 PM R1 returned from the emergency room . - 10/23/18 10:14 PM R1 was extremely agitated at beginning of this shift. Loud verbal outburst and striking out at staff. Upset someone had taken his tools. Taken to nurse's station, continued to be upset about his tools. R1 said he had to pee and pulled it out and peed on the floor. When placed back at the nurse's station he started hitting the wall as hard as he could with his fist. Staff moved his chair and he began hitting the table with his fist. R1 sent to hospital via ambulance. - 10/24/18 5:41 AM R1 banging hard on the wall next to his bed. Swearing and foul language. - 10/26/18 4:03 AM R1 has been up all night yelling and demonstrating destructive behavior. R1 would hit wall or table, pulling at runner along wall, and pulling on staff. R1 has awoken several of the residents. - 10/26/18 9:02 AM R1 sent to emergency room for escalated behaviors. Combative with staff and yelling. - 10/26/18 2:48 PM R1 continues to have verbal outbursts, swearing and yelling behavior frightening to other peers. Spoke with psychologist to start [MEDICATION NAME] twice a day, [MEDICATION NAME] ordered twice a day as needed. - 10/27/18 11:31 AM R1 was yelling and took out penis and urinated everywhere in the TV room visitors around. Also ripped the wall guard off screws and all. - 10/28/18 2:05 PM R1 was yelling and pounding on the wall and ripped brief into pieces. - 10/28/18 11:26 PM R1 calm at the beginning of the shift. AM nurse told me she did not give any of his as needed meds so I gave them to him as soon as I could to try to get ahead of the behaviors. Attempt failed. He fell out of bed with bowel movement everywhere. - 10/30/18 3:28 AM R1 yelling and pounding on wall next to bed at beginning of shift. As needed [MEDICATION NAME] and [MEDICATION NAME] given with no result s noted during fist 2 hours after administered. - 11/1/18 2:44 AM Gave R1 ordered Tylenol, [MEDICATION NAME], and [MEDICATION NAME]. Was also given food. Resident still yelling out continuously, yelling help or please. R1 also continuously takes off his clothes and depends. - 11/1/18 5:18 AM R1 had been yelling all night and not responding to questions for what we could do to help, Due to history of being a disc jockey we tried a radio in his room to see if that would calm him, it did not. R1 ripped open the pillow and when that was taken began ripping sheets. All medications available were dispensed. R1 could be heard outside the building as well as through the unit. fell asleep about 5:15 AM. On 12/4/18 R1's physician's telephone orders dated 11/5/18 at 2:50 PM given by R1's psychologist and written by RN-C were reviewed and read: Discontinue [MEDICATION NAME], Increase [MEDICATION NAME] sprinkles to 250mg three times a day, [MEDICATION NAME] ([MEDICATION NAME]) 5mg at bedtime. Progress note dated 11/5/18 at 7:49 PM indicates: New medication orders noted, was screaming first 1/3 of shift. Progress note dated 11/5/18 at 8:39 PM indicates: CNA reported to writer that R1 was not breathing well. R1's respirations were low 8/minute R1 not responsive. 911 was called. Surveyor noted both notes on 11/5/18 were written by RN-C. On 11/5/18 at 8:29 pm a Situation, Background, Assessment, Recommendation (SBAR), documents: (R1) unresponsive, Pulse 58, Respiration 12, and Blood Pressure/64. Few/low respirations. 911 called. A facility self-report with a facility discovery date of 11/6/18 regarding R1 indicates: R1 routinely has behaviors of screaming out, urinating in public, disrobing and striking out at staff. On 11/5/18 at around 7:00 PM R1 began to have difficulty breathing. He began to have episodes of apnea and went unresponsive. The nurse on the unit called a code blue and 911 was called. R1 was brought to Waukesha Memorial Hospital and was admitted with acute metabolic [MEDICAL CONDITION]. On 11/6/18 our admissions department received a call from the hospital to inform us that R1's urine tested positive for [MEDICATION NAME] and the drug was not on his prescribed medication list that we provided to them. We spoke to Registered Nurse (RN)-C who stated that R1 was very behavioral and screaming at everything he said, he tried to calm him and gave him his [MEDICATION NAME] for pain and his Tylenol. He attempted to toilet him as he was yelling about that as well, but he didn't go. He called the psychologist and obtained new orders to discontinue his bedtime dose of [MEDICATION NAME] 50 milligrams (MG) and start [MEDICATION NAME] 5 mg at bedtime and to increase [MEDICATION NAME] 250 mg three times a day. RN-C gave R1 the [MEDICATION NAME] and [MEDICATION NAME] that had been discontinued. R1 fell asleep for about 10 minutes and then began yelling again. RN-C states he was very frustrated and overwhelmed because his yelling was agitating the other residents on the unit. When we told RN-C that [MEDICATION NAME] was found in R1's urine he confessed to giving R1 [MEDICATION NAME] from another resident (R2) on the unit. RN-C stated he was only trying to help R1 as he was complaining of pain and had no intention of harming him. RN-C was sent home. RN-C the agency nurse will not be allowed to return to the facility. The facility self-report includes statement from Certified Nursing Assistants E and D along with RN-C stating: * CNA-E's undated statement: I came into work and (R1) was acting like his normal self, yelling. (RN-C) said that he had already given him his PM medication early because of his behavior. Soon after the medication still hadn't kicked in so I guess (RN-C) called (R1's) psychologist and he prescribed a new medication, discontinued another, and increased dosage on another one. (RN-C) said it would calm him down and pretty much make him sleep awhile. (R1) fell asleep about 10 minutes and started back with the yelling and screaming. (RN-C) said this is crazy nothing is working he should have been knocked out for a while. (R1) ate dinner and then was at the nurse's station and (R1) was drenched with sweat. I asked (RN-C) what was wrong with (R1) and (RN-C) said (R1) is just hot, its hot by the nurse's station lets push him by the fan. So we did (CNA-F) and I kept saying that's not regular sweat somethings wrong. (RN-C) said no its just hot and then he took a second look at him and said oh he's sweating a lot let me get some ice and put it behind (R1's) back. At that time (R1) was still out of it slurring words as he moved him not making sense at all. (CNA-F) and I then said again something isn't right with him and (RN-C) went back into the nursing office and (CNA-F) and I realized (R1's) breathing was off. I checked and I didn't feel a pulse and saw no respirations. Then (R1) would breathe again sporadically and stop. We told (RN-C) and he said he was dead or at deaths door call 911 and the supervisor. For the rest of the shift (RN-C) just worried and was frantic about the situation. * CNA-F's statement dated 11/7/18: After laying another resident down for the night I believe sometime after 7:00 PM I walked into the dining room and noticed (R1) in his chair leaning back as if he was sleeping. He was very sweaty, so I asked if he was ok. I got the attention of another aide and the nurse. The nurse saw that (R1) wasn't responding to the cold towel. We watched to see his breathing and he breathing different. That's when the nurse called for a stat to be called, the supervisor came. They called 911. * RN-C's statement dated 11/6/18: I gave (R1) his medication all of them including his [MEDICATION NAME] and [MEDICATION NAME]. He fell asleep and would wake up and yell and fall asleep again. He did start really sweating around 7:00 PM. The aides were saying he was sweating. I put him by the window and gave him some ice. After that the aide said he was breathing funny. I went and looked at him and called 911. I gave him a dose of (R2's) [MEDICATION NAME]. I know I shouldn't have and I've been living with it since then. I did not ask the supervisor for help. I was going crazy. The emergency room report dated 11/5/18 for R1 indicates: R1 presents with somnolence. R1 is positive for [MEDICATION NAME] which he is not prescribed, however he was given first 1 mg and then 2 mg of [MEDICATION NAME] with no response. He does have evidence of a urinary tract infection without fever or elevated white blood cell count however I doubt that the urinary tract infection is the cause of the quite impressive somnolence. Blood pressure 187/91, Heart rate 115, Respirations 16. Opiate group detected. [MEDICATION NAME] detected. The Hospitalist Admission History and Physical dated 11/5/18 states: Acute metabolic [MEDICAL CONDITION], completely unresponsive; usually is combative. Has [MEDICATION NAME] in urine, not prescribed; initially responded to [MEDICATION NAME] per emergency medical services, but no response to [MEDICATION NAME] in the emergency room . R1's Hospitalist Progress Note dated 11/6/18 states: Acute metabolic [MEDICAL CONDITION]. During presentation R1 was unresponsive however this morning he was eating his breakfast. As per information this is likely from [MEDICATION NAME] use for which R1 was not on. The On 12/4/18 R1's medication error report completed by DON-B dated 11/5/18 was reviewed and read: R1's [MEDICATION NAME] 50mg at bedtime was discontinued and [MEDICATION NAME] was ordered. The nurse gave [MEDICATION NAME] and the [MEDICATION NAME]. The nurse gave a [MEDICATION NAME] 5/325 mg from another resident. R1 did not have an order for [REDACTED].>On 12/4/18 at 11:35 AM RN-C was interviewed by Surveyor and indicated R1 would scream and get all the other residents on the floor riled up. RN-C indicated on 11/5/18 he was trying to maintain his sanity, called his wife and swore at her. RN-C indicated he was totally stressed out. RN-C indicated he didn't call the supervisor for help because he knew she would say she's too busy. RN-C indicated he called R1's psychologist at the beginning of the shift and received orders to discontinue R1's [MEDICATION NAME], increase his [MEDICATION NAME] to three times a day and start [MEDICATION NAME] 5 mg at bedtime. RN-C indicated that he gave R1 [MEDICATION NAME] and about an hour latter [MEDICATION NAME]. RN-C also indicated he gave R1 the discontinued [MEDICATION NAME] 50 mg, [MEDICATION NAME] and [MEDICATION NAME] around supper time. RN-C indicated that about 7:00pm he put him by the window because the unit was hot and R1 was complaining of sweating. RN-C indicated that little while later a Certified Nursing Assistant (CNA) came to him while he was charting at the desk and reported R1 wasn't breathing right. RN-C indicated he called 911 right away and the supervisor came to help. RN-C indicated he didn't get any training on dealing with difficult behaviors or stress management before or during his working at the facility. RN-C indicated he never meant to hurt R1 and he only wanted to help him settle down. RN-C indicted he didn't call R1's doctor when his behavior continued just tried to handle it myself. On 12/4/18 at 12:50 PM RN-D was interviewed and indicated she was the supervisor on PM shift 11/5/18 and was downstairs when the stat was called, dropped everything and went upstairs. RN-D indicated R1 was unresponsive verbally, could feel a pulse and R1's breathing was rapid then slow. RN-D indicated RN-C did not tell her anything about the medication he gave. RN-D also indicated RN-C never told her he is stressed R1's behavior but that she has worked with R1 and it is stressful. RN-D indicated that If RN-C would have said something she would have offered to switch jobs with him, but he always wanted to work up there and was upset if he was assigned somewhere else. On 12/4/18 at 1:45PM Director of Nurses (DON)-B was interviewed about dementia care and behavioral training provided to staff. DON-B indicated that only 2 pool staff are educate on dealing with difficult residents, administering meds without an order and stress management after the medication incident with RN-C. DON-B indicated several more agency nurses have worked without training in those areas since the incident with RN-C. DON-B asked Surveyor who is responsible for training agency staff? Would it be the agency? DON-B provided Surveyor with a list of the number of pool/agency staff the facility has working in the facility each day and confirmed sometimes up to 6 pool nurses a day are working in the facility. When discussing R1's behaviors, DON-B indicated staffs just know R1 when asked about the care plans and interventions. Surveyor noted R1's records indicate to send R1 to the emergency room for behaviors and who suggested that intervention. DON-B indicated it was her idea to send the R1 to the emergency room if the facility can't handle his behaviors. DON-B indicated they have done that but now the hospital wants the facility to call the police prior to sending to the hospital to chapter R1. DON-B indicated the police will come but they will not chapter R1 because of his [DIAGNOSES REDACTED]. DON-B indicated R1's psychologist has been adjusting his medication and he has improved a lot. DON-B also indicated the facility needs to add more behaviors to R1's behavior sheets and more interventions need to be added to R1's care plan. On 12/5/18 the Alliance Agency (Agency RN-C was employed by) Services agreement was reviewed dated 2/22/18 and signed by Administrator-A and read: Alliance Services shall comply with applicable Joint Commission (Joint Commission does not regulate skilled nursing facilities and has different training requirements) standards as follows: Education and training that is consistent with applicable legal and regulatory requirements. The facility's failure to ensure R1 received care and services related to his dementia to assist him in reaching his highest practicable well being created a situation of immediate jeopardy when the facility implemented the following action plan. The deficient practice continues at a scope/severity of an E (potential for harm/pattern) as the facility continues to implement its plan. ~ R1's care plan, behavior logs and interventions were reviewed and updated as well as all other residents in the facility with behaviors. ~ A behavior binder was created for each unit that included interventions. ~ Nursing staff were educated on the use of the binders and interventions, dementia care, chemical restraints and use of non-pharmacological interventions before medication is used. ~ All agency staff will be educated in person prior to working in the facility. ~ Auditing with be completed of behavior logs three times a week at the clinical meeting for four weeks or until substantial compliance to verify staff are using non-pharmacological interventions. Audits will be brought to QUAPI for review.

Based on Observation, Interview, and Record Review the facility did not ensure that all residents remain free from accidents by implementing interventions identified to reduce hazards and risks to prevent falls for 3 of 22 residents (R66, R57, and R51) reviewed for falls. * R66 fell in (MONTH) of (YEAR) and sustained a fractured wrist after facility staff did not follow R66's plan of care and implement safety interventions intended to prevent falls. During the survey, facility staff were observed not implementing R66's plan of care by leaving R66 unattended in her room and not ensuring R66 wore grippy socks as care planned *R57 has a history of bruising under the arms from the sling of a sit to stand lift that was used to assist the resident with transfers. The sit to stand was discontinued after the resident was assessed by therapy. The lift was determined unsafe for R57 to use because R57 was hanging in the lift versus holding onto the handgrips. On 4/19/18 the facility transferred R57 in an unsafe manner using the sit to stand lift. *R51 who had left [MEDICAL CONDITION] and left side neglect was pivot transferred in such a way that his left leg became twisted behind his right leg. R51 was lowered into the wheelchair with the left leg still behind the right leg, increasing his risk for injury. The Certified Nursing Assistant (CNA) care card did not inform staff of the left side neglect. Findings include: 1.) Resident (R66) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R66's Minimum Data Set (MDS) assessment, dated 9/19/17, indicated that R66's cognitive status is severely impaired and that she needs extensive assistance of two staff with moving in bed and transfers. R66 does not walk in her room. R66 was identified as not steady and only able to stabilize with human assistance with moving from a seated to standing position, walking, and surface to surface transfers. R66 uses a wheelchair for mobility. The MDS assessment identified that R66 had two or more falls since the prior MDS assessment. R66's Care Plan, initiated on 3/20/17, states R66 is at risk for falls, accidents and incidents related to cognitive impairment, history of falls with fracture, bowel and bladder incontinence, diabetes mellitus, immobility, medication side effects, and impaired vision. Interventions include: floor mat at bedside dated 3/20/17, review information on past falls and attempt to determine cause of falls, record possible root causes and alter/remove any potential causes if possible. Educate the resident, family, caregivers, and interdisciplinary team (IDT) as to causes, dated 5/02/17. R66 is to wear gripper socks while in bed, dated 5/17/17. R66 is to be up early on day shift as the first person the CNA assists in the section, dated 5/26/17. The facility's Certified Nursing Assistant (CNA) care card for R66, undated, shows under safety devices and appliances column, that R66's bed should be placed against the wall, staff to encourage R66 to wear gripper socks while in bed, place a mat on the floor, Dycem should be placed on top and under the wheelchair cushion, and her bed should be in a low position. Night shift staff should assist R66 to get up. A body pillow should be used while R66 is in bed. Offer R66 to use the toilet at or around midnight, every night. Remove the floor mat from the floor when R66 is in her wheelchair. Offer R66 to use the toilet before lunch. R66 has a ½ side rail on her bed. Do not leave R66 up in her wheelchair in her room unattended. R66 should be up around 7am. The facility submitted a facility reported incident, on 11/17/17, indicating the facility is self-reporting to the State Agency that R66 fell on [DATE] at 8am and fractured her wrist when the Risk for Falls Care Plan for was not followed. R66 had an unwitnessed fall in her room resulting in a subtle radial [MEDICAL CONDITION]. R66's Plan of care shows that she is to wear gripper socks when in bed and assisted up with first rounds on the day shift. R66 was wearing regular socks when she was found on the floor. The CNA staff went to assist R66 and she was sleeping so he went to assist another resident. Upon return to R66's room she was found on the floor. The CNA staff was educated to follow the Care Plan interventions and weekly audits were completed for 30 days to ensure they could identify the Care Plan interventions. On 4/23/18, at 9:16am, Surveyor observed Certified Nursing Assistant (CNA L) assist R66 to her bedroom to assist her to bed. Prior to assisting R66 to bed CNA L exited the room to obtain a gait belt leaving R66 alone in her room. CNA L did not follow R66's Care Plan that identified R66 is at risk for falls and that R66 should not be left in her room unattended. On 4/25/18, at 9:22am, Surveyor observed CNA L assist R66 to her room to assist her into her bed. After assisting R66 into her room CNA L left the room for two minutes leaving R66 alone and unattended in her wheelchair. CNA L assisted R66 into bed, removed her shoes, and covered her with a blanket. Surveyor requested to see R66's feet. CNA L exposed R66's feet to reveal plain dark colored socks. CNA L stated R66 does not have to wear gripper socks when she has shoes on, does she? Surveyor asked CNA L what R66's plan is on the CNA Care Card and CNA L identified that for R66 gripper socks must be worn in bed and that she cannot be left alone in her room seated in her wheelchair. CNA L acknowledged that R66 did not have gripper socks on and that she left R66 alone in the room to obtain her gait belt. CNA L stated she will assist R66 with putting on her grippy socks. Surveyor interviewed Director of Nursing (DON B) on 4/25/18 at 9:32am, reviewing Surveyor's observations with CNA L and DON B stated that she understands there is a problem with some staff still not following R66's care plan. The facility did not follow R66's Care Plan for at risk for falls as R66 is not to be left alone in her wheelchair unattended when in her room and R66 should wear gripper socks when in bed. Surveyor Reviewed R66's medical record and fall investigations, from 11/13/17 to 4/25/18 and identified that R66 sustained a fall on 1/06/18, at 12am, where R66 was observed sitting on the floor mat on her bedside. The fall investigation listed that R66 had socks on when she fell and the immediate action was to apply gripper socks. The facility did not follow R66's Care Plan for at risk for falls as R66 is to wear gripper socks when in bed. 2.) On 4/19/18 the Surveyor reviewed R57's medical record. The record indicates R57 has [DIAGNOSES REDACTED]. The Resident Incident Report dated 8/13/17 at 7:45 PM indicates R57 was found with a large dark bruise on her right arm. The report indicates that R57 possibly sustained the bruise during a transfer. The report indicates that the Registered Nurse (RN) Manager observed R57 during a transfer and witnessed R57 not holding on properly (very well), and that the sit to stand lift sling lined up with the location of the bruise on R57's arm. The Therapy/Nursing Communication Form, dated 9/12/17, indicates R57 was screened by therapy. The form indicates R57 should be assisted from a sitting position to a standing position/transferred with maximum assistance of 2 staff with a gait belt (verses the sit to stand lift). The significant change Minimum Data Set (MDS,) dated 11/27/17, indicates R57 has a Brief Interview for Mental Status (BIMS) score of 7 (severe cognitive impairments), is dependent on 2 staff for transfers and toilet use, does not ambulate and has not had a fall since the prior assessment. The quarterly MDS dated [DATE] indicates R57 has a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairments), is dependent on 2 staff for transfers, dependent on 1 person for toilet use, does not ambulate and has not had a fall since the prior assessment. The plan of care for Activities of Daily Living (ADL)s/self care performance related to dementia, limited mobility, impaired balance, safety awareness and coordination, dated 1/24/18 and revised on 3/08/18, includes the interventions for 2 staff to participate with transfers. The plan of care does not include the use of a mechanical lift. The Certified Nursing Assistant care card, undated, indicates R57 uses assist of 2 staff and gait belt for transfers. The plan of care does not include the use of a sit to stand lift. On 04/18/18 at 09:52 AM The Surveyor observed Certified Nursing Assistant (CNA)-E assisting R57 with wheel chair mobility (Broda chair) to the resident's to room for incontinence cares. On 04/18/18 at 09:54 AM the Surveyor observed CNA-E and CNA-F assisting R57 with incontinence cares. The CNAs attached a sling to R57 and raised R57 to a standing position using the sit to stand lift. While R57 was standing in the sling the resident's brief was removed, incontinence cares were provided using incontinence wipes, a barrier cream was provided and a new brief was placed on the resident. R57 was wearing slippers while using the sit to stand. The sling was applied and was positioned under R57's arms. R57 was not able to fully grab onto and hold onto the hand grips of the sit to stand. R57 was not able to fully bear weight and her legs were not fully extended when up in the sit to stand. This positioning caused R57 to be partially held up in the lift by the sling that was positioned under R57's arms. On 04/18/18 at 10:00 AM the Surveyor spoke with CNA-E, who indicated R57 uses the toilet. CNA-E also indicated R57 is a check and change and is sometimes provided incontinence cares while in bed. On 04/18/18 at 10:00 AM the Surveyor spoke with R57 who indicated standing in the lift is difficult for her and that she would rather sit on the toilet during incontinence cares. On 04/19/18 at 01:32 PM the Surveyor spoke with Registered Nurse(RN)/Nurse Manager-G who indicated R57 requires transfer assistance of 2 staff with the use of a gait belt. The RN Manager indicated that the Resident used a sit to stand in past and she developed a bruise under her arms while the lift was being used. The RN Manager indicated R57 was assessed by therapy and it was determined unsafe for R57 to use sit to stand lift because R57 was hanging in the lift verses holding onto the handgrips. The RN Manager indicated the lift was discontinued. The RN Manager indicated R57 was assessed to require assistance of 2 and the use of a gait belt for transfers. The RN Manager indicated the plan of care was updated to indicate R57 required assistance of 2 staff with the use of a gait belt for transfers. The RN Manager indicated the CNA staff should have followed the plan of care and should have transferred R57 to the bed or the toilet with assist of 2 and a gait belt for incontinence cares. In addition, the RN Manager indicated that any resident being assisted with transfers using the sit to stand lift should have non skid footwear on and not slippers. On 04/23/18 at 11:24 AM the Surveyor spoke with Nurse Manager RN-G and reviewed the documented assessment of R57's areas under her bilateral arms. The nurse manager indicated R57 was assessed on 4/19/18 and that there were no issues or discoloration under the resident's arms. The documentation on the Shower/Weight Form, dated 4/19/18, indicates no concerns or redness under the bilateral arms. 3.) R51 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R51's Admission Minimum Data Set ((MDS) dated [DATE] indicated R51 has impairment on one side, in both the upper and lower extremities. The Certified Nursing Assistant (CNA) care sheet indicated R51 required a 2 person assist with a pivot transfer. The care sheet did not mention R51's left side neglect. On 4/24/18 at 8:15 AM, the surveyor observed CNA-O and Agency CNA-Q transfer R51 from bed to wheelchair. Agency CNA-Q placed the gaitbelt around R51's waist. CNA-O placed the wheelchair directly in front of R51, to allow R51 to hold on to the wheelchair once standing, to allow the CNA's to pull up R51's jeans. Both CNA's grasped the gait belt and R51's arms and assisted R51 to a standing position. R51 was pivoted in such a way that his left leg ended up behind his right leg, The left leg remained behind the right leg as R51 was lowered in to the wheelchair. Because his legs were twisted, R51 ended up being very crooked in the wheelchair. Once seated the CNA's moved the left leg from behind the right leg and repositioned R51 in the wheelchair. On 4/24/18 at 11:02 AM the surveyor spoke with Rehab Director-N, who stated R51 has both left side [MEDICAL CONDITION] and left side neglect. Neither the care plan, nor the CNA care card mention left sided neglect. During the transfer the CNA's did not maintain proper position of R51's left leg, resulting in the left leg twisting behind the right leg prior to being lowered into the wheelchair. This placed R51 and increased risk for injury. The observation of the transfer was shared with Rehab Director-N and RN Manager-G on 4/24/17.

Based on record review and staff interviews, the facility did not ensure allegations, involving 4 of 15 residents (#13, #10, #8, #11) who were allegedly abused were immediately reported to the Administrator, thoroughly investigated and reported to the appropriate officials, including law enforcement and the state regulatory agency. In 8 out of 11 additional investigations of resident grievances (Residents #7, #2, #15, #16, #4, #5, #6, #19) and injuries of unknown origin, investigations were not found to be thoroughly investigated and acted upon or ruled out as abuse, neglect or suspicious injuries and properly reported to the State Regulatory Agency. * Resident #10 was observed to be abused by a licensed nurse (LPN-J) on 4/13/16 when LPN-J punched Resident #10 in the back. The nurse aides (CNA-M and N) who witnessed this abuse did not act upon the abuse to protect the resident. The nurse aides did not immediately report what was witnessed to the Administrator. The licensed nurse abuser was allowed to work following these witnessed acts on 4/13/16 and 8 more shifts following this witnessed abuse which allowed further actual and potential abuse to occur. * Resident #13 was observed to be abused by a licensed nurse (LPN-J) on 4/13/16 when LPN-J threw Resident #13 20-25 feet into bed. The nurse aide (CNA-N) who witnessed this abuse did not act upon the abuse to protect the resident. The nurse aide did not immediately report what was witnessed to the Administrator. The licensed nurse abuser was allowed to work 8 shifts following this witnessed abuse which allowed further actual and potential abuse to occur. * Resident #8 was observed to be abused by a licensed nurse (LPN-J) on an unknown date (presumably end of April, 2016, per police report). LPN-J held down Resident #8's wrists and yelled at her for two minutes. The nurse aides (CNA-L and M) who witnessed this abuse did not act upon the abuse to protect the resident. The nurse aides did not immediately report what they had witnessed to the Administrator and LPN-J continued working at the facility. * Resident #11 was verbally and physically abused by a nurse aide (CNA-K) on 4/27/16. This verbal abuse was witnessed by a Medication Technician (Med Tech-V) who reported the verbal abuse to Licensed Practical Nurse (LPN-W), who reported the verbal abuse to the supervisor (RN-U). Med Tech-V also was told by Resident #11 on 4/27/16 that CNA-K was picking at her anus following a bowel movement, told the nurse aide to stop because it was hurting her and the nurse aide would not stop. This allegation was not acted upon or reported immediately for further investigation. There was no immediate investigation of the physical abuse allegation. The Administrator was not immediately notified of these allegations. There is no evidence that any action was taken following the knowledge of verbal and physical abuse to prevent further actual or potential abuse to occur. CNA-K continued to work with residents on 4/27/16 and 4/28/16 according to time clock detail. Staff failure to immediately report allegations of abuse, which prevented immediate investigation and which prevented the facility from taking action to prevent further potential abuse (as the alleged abusers continued to work) created a finding of immediate jeopardy, which had the potential to affect all 114 of the facility's residents. The jeopardy began on 4/13/16 when two residents were allegedly abused. Because the abusive acts were not reported properly, the abusing staff member continued to work with residents for 8 shifts following 4/13/16 until it became known that abuse may be occurring in the facility through an anonymous phone call to the facility hotline on 4/28/16. On 7/11/16, the facility Administrator A, Director of Nursing B and RN Corporate Consultant G were notified of the Immediate Jeopardy. The immediate Jeopardy was removed on 5/5/16. The deficient practice, however, continues at a scope/severity of E (potential for harm/pattern) as evidenced by the following. * Resident #7 had a grievance filed in the grievance file that was not investigated thoroughly to rule out abuse or neglect. On 5/16/16, Resident #7 alleged problems when given a shower that indicated 2 staff members were washing her and Resident #7 was fighting them off. During this grievance, Resident #7 alleged he hit me and then, when asked again, He was touching me. The investigation conducted was not thorough and the State Regulatory Agency was not notified of this allegation at any time during this or after this investigation. * Resident #2 had a fracture of unknown origin on 6/6/16 after a family member and CNA-Q discovered Resident #2 to have a misshapen right leg. This suspicious injury was immediately reported to the Administration and the State Regulatory Agency and an investigation was immediately started on 6/6/16. On 7/13/16, Surveyor interviewed CNA-Q who discovered the injury along with the family. On 7/13/16, additional information became known to the surveyor through CNA-Q that was not communicated to the facility Administration when the fracture was found on 6/6/16 and being investigated. A thorough investigation was not completed for this suspicious fracture of Resident #2's leg. * Resident #15 was found to have a swollen right upper lip and right side of mouth to be swollen and slightly discolored on 4/26/16 at 7:30 AM. It was noted that there was a couple dried blood on the corner of Resident #15's mouth. This suspicious injury was reported to the Administrator on 4/26/16 and an investigation was completed that included staff statements, however there is no evidence the reason for this suspicious injury was found out. Action taken included instructing staff to be more careful in conducting cares for Resident #15. The investigation does not indicate what problem with cares was found in this investigation. The investigation did not rule out abuse. This suspicious injury investigation was not reported to the State Regulatory Agency. * Resident #16 was discovered with a yellowish bruise under her left eye that was discovered by her guardian on 7/4/16. Resident was unable to say how it happened but did tell the nurse they beat me up all the time, Resident was unable to say who they were. In a later interview, resident indicated an aide hit her in the eye. CNA-T met the description of the nurse aide who cared for Resident #16 2 days in a row and action was taken with this CNA. The investigation also indicted that Resident falls asleep with glasses on and the oxygen tubing placement was in the same place as both of the contoured lines under the bruised area. The investigation determined that CNA-T did not provide cares for Resident #16 during the 16 hour shift she was assigned to Resident #16 and CNA-T was determined to neglect Resident #16. The information related to the resident being neglected was not submitted to the State Regulatory Agency with the self report submitted on 7/4/16. * Resident #4 filed a grievance on 5/6/16 related to a nursing assistant yelling at a resident that was witnessed by 2 other staff members. The review of this investigation was found to be incomplete without staff statements and information regarding the review of the security cameras to rule out abuse. Acts of pointing a finger in a resident face and yelling were not identified as abuse. The Administrator signed off on this grievance 3 days after the allegation was witnessed. This allegation was not reported to the State Regulatory Agency. * Resident #5 filed a grievance on 5/31/16 alleging a CNA was yelling at her for having her light on. Resident #5 also alleged the CNA was looking at pictures on her phone for 10 minutes in Resident #5's room. The investigation into this grievance did not have enough information to determine abuse did not occur. This allegation was not reported to the State Regulatory Agency. * Resident #6 alleged on 6/9/16 that he put on his call light to ask for a blanket to be applied. The allegation included that the CNA allegedly threw the blanket on top of resident and told resident not to use his call light for at least 30 minutes. The Administrator signed off on this grievance on 6/16/16 and inserviced the nursing assistant on good customer service. This allegation was not identified as abuse and not reported to the State Regulatory Agency. * Resident #19 alleged that on 6/21/16, neglect occurred after Resident #19 returned from a doctors appointment and needed assistance with incontinence care. The caregiver did not assist resident with incontinence care. The facility did not identify this as neglect and the grievance was not fully investigated to rule out neglect. This allegation did not get reported to the State Regulatory Agency. Findings include: 1) A review of the facility grievance file conducted by Surveyor on 7/6/16 and 7/7/16 revealed abuse allegations for Residents #8, #10 and #11. Surveyor requested the internal investigations of these allegations discovered in the facility grievance file. The internal facility grievance reviewed indicated that on 4/28/16 the facility received knowledge of allegations of abuse that was occurring in their facility on the night shift on the 2 Center unit through a corporate hotline phone call. The caller gave no staff or resident names. The facility immediately reported this anonymous information to the Administrator and the State regulatory agency on 4/28/16. The facility acted upon this anonymous allegation immediately and began an investigation. Resident interviews and employee interviews were started on 4/28/16. On 7/7/16, Surveyor interviewed the Corporate Nursing Home Administrator- I by telephone. Corporate NHA-I told the surveyor that the call had come in to the corporate hotline on 4/28/16 at 1:30 PM by an anonymous caller. This caller did not give any names, but did indicate she had raised the issue with previous nurse managers and Director of Nursing. The Corporate NHA-I indicated she alerted the facility Administrator immediately after receiving the hot line phone call and an investigation was started. The facility investigation revealed that during employee interviews the following allegations were received: 1. Resident #10. The medical record review for Resident #10 revealed Resident #10 having [DIAGNOSES REDACTED]. On 7/7/16 Surveyor discovered another written statement in the folder of the facility internal investigation, dated 5/8/16, and signed by CNA-N. On 5/8/16, CNA-N had written and signed a statement describing an incident when she was in Resident #10's room and had witnessed LPN-J slap Resident #10 on the arm during care provision. CNA-N also indicated that she had witnessed LPN-J calling Resident #10 rude names either behind his back or to his face. Certified Nursing Assistant CNA-M also reported during this investigation that on 4/13/16, she witnessed Resident # 10 being punched in the back by LPN-J after Resident #10 called LPN-J a [***] . Resident #10 indicated he was going to call the police and then LPN-J told Resident #10 she didn't mean to hit him so hard. At the time of this onsite investigation, Resident #10 was no longer in the building and was unable to be observed or interviewed. A review of the Waukesha police report with incident date of 4/29/16 revealed that the police officer who also conducted an investigation did interview Resident #10 about the allegation of abuse and Resident #10 was unable to recall any events that may have occurred. Resident #10 did tell the police officer that he knew who LPN-J was, and indicated he did not like LPN-J, but he could not recollect any events between himself and LPN-J. CNA-N and CNA-M did not act upon this witnessed abuse and did not protect Resident #10 or other residents from abuse by LPN-J. This abusive act was not immediately reported to the Nursing Home Administrator. 2) Resident #13. The medical record review indicated that Resident #13 was admitted to the facility 2/12/16 for care and had [DIAGNOSES REDACTED]. The medical record review indicated Resident to have inpatient behavioral health hospitalization in February, 2016, for severe agitation, combativeness, distrust in hospital staff and declines in memory. Resident was then admitted to this facility following this hospitalization and cared for on a 1:1 basis. Included in the written statement, dated 5/8/16, from CNA-N was an incident in which CNA-N witnessed LPN-J throw Resident #13 into his bed. CNA-N wrote in her statement that she (CNA-N) witnessed LPN-J kind of bear hug picked him up and threw him into his bed. CNA-N wrote that he (Resident #13) was standing 20-25 feet away from his bed and she lifted and threw him so hard that his feet left the ground. CNA-N indicated in her written statement that after LPN-J left CNA-N kept asking if Resident #10 had pain anywhere and Resident #13 stated he did not have any pain anywhere. CNA-N did not report this incident; consequently, there was no immediate investigation and LPN-J was allowed to continue working. There is no date in this investigation as to when this event may have occurred. The date in which this may have occurred was not addressed in the facility investigation. The date in which this may have occurred was not explored until Surveyor questioned it between 7/7/16 and 7/13/16. On 7/13/16, it became known after reviewing schedules that this incident may have occurred on 4/13/16. The facility did not conduct a thorough investigation at the time it became known on 5/8/16 that this abusive act occurred. As of 7/13/16, the act against Resident #13 had not been reported to the State Regulatory Agency. Resident #13 was no longer in the facility at the time of this State investigation. Resident had a decline in condition in April of 2016 and was enrolled in Hospice care at that time. 3) Surveyor reviewed the medical record of Resident #8. The medical record indicates that Resident #8 has Dementia and was first admitted to the facility on [DATE]. The plan of care for Resident #8 identifies Resident #8 as having altered cognitive status, impaired memory, judgment and problem solving, safety awareness and decision making and has sensorineural hearing loss. Certified Nursing Assistant (CNA)-L reported that mistreatment of [REDACTED].#8 having hit CNA-L by pushing Resident #8 into her room and shutting the door. Both CNA-L and CNA-M listened as LPN-J asked Resident #8 why she was acting like a child. When Resident #8 went to cover her ears, LPN-J grabbed resident wrists and held them down on her lap so Resident #8 had to listen. LPN-J held Resident #8's wrists down for another 2 minutes and continued yelling at Resident #8. The last thing LPN-J said was, I hope you understand this is how babies act. Now, do you understand? A written and signed statement on 4/28/16 from CNA-L, indicated that there have been a few occasions when LPN-J has grabbed residents and talked inappropriately. CNA-L also indicated in this statement that she had witnessed LPN-J calling residents (derogatory) names. There were many occasions when LPN-J had called the residents childish and saying that she has had enough of their (expletive). CNA-L indicated she felt unsafe reporting this at first, but realized it has gone too far and something has to be done. CNA-L indicated she should have made sure that the resident was safe, but her fear took over. CNA-L indicated that LPN-J had gotten so far out of hand that something needs to be said and many CNAs and nurses have noticed it. Certified Nursing Assistant CNA-M reported mistreatment of [REDACTED].#8, told Resident #8 she was acting childish, needs to settle down and act like an adult. When Resident #8 put her hands over her ears and replied to LPN-J Yes Madame, I understand, LPN-J pulled her hands down into her lap and continued to yell and tell her to act as an adult and not a child. A written and signed statement on 4/28/16 from CNA-M indicated she had witnessed LPN-J being verbally abusive to residents, telling them that they are being childish, if they don't eat a certain amount of their meal they will not go to activities, that they need to shut up and they are too old to act the way they do. Surveyor review of the facility investigation noted documentation dated 4/29/16 at 1:30 PM with Resident #8's name on it. The notes indicated Resident indicating she felt safe, but was still afraid. When asked what she was afraid of, resident responded not being worthy of God. The notes continue to say some of them-they are mean, they tell me to go to my room, I need my oxygen, they tell me I don't need it, (name) is trying to find me another place and I don't like it here. On 7/18/16, Surveyor reviewed the police report from the Waukesha Police Department. In this police report, on page 6 of 9, the police detective wrote that the incident between LPN-J and Resident #8 occurred approximately at the end of April, 2016. This was mentioned in an interview the police detective had with CNA-L. Witnessed abuse by facility staff LPN-J towards Resident #8 sometime at the end of April, 2016 did not get immediately reported to the Nursing Home Administrator, or thoroughly investigated to determine the date in which this abusive act occurred. Residents were not protected from possible further abuse by LPN-J because it was not properly acted upon and reported when it was witnessed. 4. Resident #11. On 7/7/16, it became known to Surveyor through review of the grievance file that Resident # 11 reported being abused by CNA-K during the facility internal investigation on 4/28/16. Surveyor asked to review the facility investigation. The investigation revealed that on 4/27/16, CNA-K verbally and physically abused Resident #11. Resident #11 reported during the interviewing conducted by the facility that she had concerns as to how she was spoken to by CNA-K on 4/27/16. On 4/28/16, Resident #11 told the facility corporate NHA-O that CNA-K said, I'm the black [***] that is going to take care of you tonight. Resident #11 also indicated that Medication Technician-V heard her say this and that Resident #11 told LPN-W about this, too. The facility investigation also indicated that Resident #11 alleged that CNA-K had Resident #11 in the sit to stand lift digging at her anus and was hurting her. Resident #11 told CNA-K to stop and CNA-K would not stop. Resident #11 indicated CNA-S was also present in the room and did not respond. CNA-S was also questioned by the facility corporate NHA-O and indicated Resident #11 had no complaints at that time. The investigation into this allegation began on 4/28/16 by the facility. Medication Technician (MT)-V was also interviewed about this allegation and indicated she had heard CNA-K say what she did to Resident #11. MT-V also told the facility that earlier in the shift, Resident #11 had made the allegation to MT-V about the incident of CNA-K picking at her anus. The investigation into this allegation also identified that LPN-W knew about what CNA-K said to Resident #11 and investigated this dialog, but after speaking with CNA-K felt the dialog was poor customer service. The investigation also revealed that RN-U knew on 4/27/16 about what CNA-K said to Resident #11, but felt it was poor customer service and not verbal abuse, therefore did not report this dialog to the Administrator on 4/27/16. The investigation also revealed that RN-U did not know about the allegation of Resident #11 describing CNA-K digging at Resident's anal area, that CNA-K was hurting Resident #11, that Resident #11 asked CNA-K to stop and CNA-K would not stop. The failure to identify abuse, promptly report, investigate, and to put measures in place to protect residents from the potential for further abuse created a finding of immediate jeopardy. The immediate jeopardy was removed on 5/5/16 based on the following: Interviews with facility administration on 7/7/16 through 7/13/16 revealed that the facility Administration first became aware of the abuse on 4/28/16. The facility administration and the corporate level of administration acknowledged acting upon these allegations immediately.The facility began to interview all facility personnel on 4/28/16 about any knowledge of abusive events in their facility. Once identified, the perpetrators were removed from contact with residents on 4/28/16 and the facility terminated LPN-J and CNA-K on 5/2/16. The facility began re-training all staff both at the facility level and also the corporate level. The facility showed evidence of having most of the facility staff trained on abuse policies and procedures by 5/5/16. The deficient practice continues at a scope/severity level of an E, (potential for harm that is not immediate jeopardy/pattern) as evidenced by the following: 5. Resident #7 filed a grievance on 5/16/16 indicating problems that occurred while being showered. Resident #7 indicated that there were two of them in the shower with me. The gal was washing me up. I was yelling and screaming trying to fight them off - he hit me. Twenty five minutes later, Resident #7 was asked about this again and indicated there were two of them in the shower. She was washing me up and he was touching me. I was yelling and screaming trying to fight them off. Resident did not say anything else the rest of the day, was pleasant and no further complaints noted. The grievance report indicated that the NHA was notified at 8:20 AM and the Director of Nursing at 8:40 AM. The immediate action taken was that resident was comfortable and happy resident there after. The Corporate NHA-O signed following up to this grievance on 5/17/16 with follow up results that it was well documented in the medical record of Resident #7 that resident is resistive to showers and always screams loudly and a buddy system was in place and No male caregivers. There was a note, unsigned and undated, attached to this grievance that indicated reviewed all incident logs, no injuries, interviewed staff, CNA-R had not returned the phone call and CNA-M indicated CNA-R did not touch Resident #7 and that Resident #7 was not combative in the shower. The note also indicates that the Nurse Educator was scheduling Dementia Behaviors and an investigation protocol was mentioned. A questionnaire dated 5/17/16 was used to ask questions related to this grievance. Resident was interviewed on 5/17/16 at 11:15 AM using this questionnaire. This is signed by Corporate NHA-O. Resident answered the questionnaire when asked how she was doing today with the response of not good, I'm sick. I lost my sweater in the laundry. When asked Resident how are things going here? Resident replied, pretty good except for my shower the other night. When asked who gave resident her shower, Resident #7 answered a CNA (name) and a tall man, (description met that of CNA-R). Resident then said she asked them to stop but they wouldn't. When resident was asked if she felt safe there, Resident replied yes, except for the shower. Surveyor expressed concern to the Director of Nursing on 7/7/16 that this allegation was not thoroughly investigated to rule out abuse and questioned why it had not been reported to the State Agency. The Director of Nursing indicated that she had reviewed the plan of care regarding refusal of cares but not refusing showers. The DON indicated that Resident #7 usually does pretty good with showers if its someone she knows and it is not late in the day. The DON indicated at this time, she has now made Resident #7 a morning shower and left no male caregivers on the plan of care. The DON indicated that the 5/16/16 shower is the only incident the facility is aware of. The DON indicated that she spoke with Corporate NHA-O who indicated she did not interview staff, only the resident. On 7/11/16, Surveyor reviewed additional information regarding the grievance filed by Resident #7. This additional information was in response to Surveyor's questioning of this incident as an allegation of abuse versus a Resident grievance. The following was read: On 7/8/16, CNA-M wrote a statement regarding events that occurred on 5/16/16. CNA-M indicated that Resident #7 began to yell as soon as we entered the shower room that he is trying to (expletive) with me. I asked what she meant and she said that I knew what she was talking about, but as soon as she was in the shower and the water was on, she was fine. On 7/8/16, the Director of Social Services (SSD)-D, interviewed the LPN-P, who wrote the grievance for Resident #7. LPN-P told the SSD-D she was talking to Resident #7 and she was talking about her shower. Her story kept changing and then she started laughing about something. She seemed happy at the time, so I called and left a message for the Administrator. Then I told her in person, I filled out the form, folded it in half so no one could read it. I stapled the top and put it under the Administrator's door because it was closed. On 7/8/16, a printed email from Corporate NHA-O was given to Surveyor for review. This printed email indicated what was done to conduct the investigation into the grievance by Resident #7 and that the grievance was investigated by speaking with the primary nurse caring for Resident #7, a chart review was done noting issues with weekly showers, a skin check that indicated no skin issues, that there was no changes in resident's daily routine, to dining room for meals and appetite good, that resident was admitted on [DATE] and resided on 2 North since admission and that Resident had a [DIAGNOSES REDACTED]. This email also acknowledged resident having a BIMS (Brief Interview of Mental Status) score of 6. The corporate email acknowledged that all of this was discussed with the NHA-A and they were in agreement that the grievance could be closed at that time and the care plan updated to reflect no male caregivers. The email does not address speaking with staff who cared for Resident #7 in the shower or any other statements from any residents receiving shower care from staff to determine if there was a problem with the shower, or not. Surveyor reviewed documentation from Resident #7's medical record. The surveyor observed that all behavior charting from 5/17/16-5/31/16 were documented as 0. The behavior monitoring was for screaming/yelling with ADLs (activities of daily living). Surveyor also reviewed nursing progress notes following this alleged incident and there were no behaviors documented related to any shower behavior or acting out behaviors. Surveyor observed Resident #7 on 7/11/16 at 2:10 PM. Resident appeared comfortable with no signs of any distress while seated up in her wheelchair. When Surveyor asked Resident if everything was okay, Resident replied she was fine. 6. Resident #2 was reviewed by Surveyor regarding a fracture of unknown origin. The facility investigation was reviewed on 7/11/16 regarding a fracture that was discovered on Resident #2 on 6/6/16. Resident #2 presented with right hip swelling and the right leg rotated. There was no bruising or redness noted to the area when discovered. There were no other signs of trauma noted. Resident was calm when this was discovered and indicated pain with movement. The resident was transferred to the hospital and diagnosed with [REDACTED]. The investigation indicated the resident was interviewed prior to transfer to the hospital. Resident indicated she did not know how she hurt her leg and indicated she thought she had fallen on Memorial Day. An investigation was started immediately regarding this injury of unknown origin. Staff members were interviewed regarding cares provided for Resident #2. The investigation indicated that staff were interviewed who cared for resident in the shifts prior to the discovery of the right femur fracture. The investigation revealed that staff had offered toileting and stated she did not need to be changed. At 5:00 AM on 6/6/16, the resident did indicate she had pain to her right leg. This was assessed by the RN and was within normal limits for the resident. Resident was given her scheduled pain medication. The investigation revealed that on the morning shift of 6/6/16, resident refused toileting again prior to breakfast and did not really want to eat breakfast but told the CNA she was fine. At 10:00 am on 6/6/16, the Medication Technician brought in medication for Resident #2, resident sat up, took medicine without complaint of any pain. The daughter then came in to visit and discovered the change in resident's behavior at that time and notified the CNA. On 7/13/16 at 1:40 PM, CNA-Q was interviewed about Resident #2. CNA-Q indicated that morning, she did not give resident her breakfast tray. Resident #2 indicated that sometime around 9:00 AM, she noticed she had not touched her breakfast tray, which was unusual. CNA-Q indicated she offered to toilet resident around 9:30 AM-10:00 AM and she said no. CNA-Q indicated resident was still clothed and CNA-Q did not notice any issue with her legs as they were under covers. CNA-Q indicated Resident #2 did not express any pain to her and never said anything about her legs. CNA-Q indicated resident would normally eat at the side of her bed, but this time, she layed there looking out the window. CNA-Q indicate that there were times that Resident #2 would wear her clothing to bed. CNA-Q indicated the daughter of Resident #2 then came in and assisted CNA-Q with cares. When Resident #2's pants began to get pulled down, is when it was noticed there was a swollen right hip. Resident #2 acted in pain when the pants were pulled down. CNA-Q told the surveyor at this time that resident's roommate, Resident # 17 told CNA-Q that Resident #2 had fallen during the night. The surveyor told CNA-Q that there was no mention in the investigation of Resident #17 knowing about a fall during the night. CNA-Q indicated she did not tell the facility when the investigation was happening that Resident #17 said that to her. CNA-Q indicated she did not know why she didn't tell Administration what Resident #17 told her, thinking she didn't want Resident #17 to be involved in this investigation. Surveyor attempted to interview Resident #17 at 2:15 PM on 7/13/16. Resident #17 acknowledged she was having trouble understanding Surveyor and it was then determined that Resident #17 was not able to be interviewed about events in the past. The investigation was reported to the State Regulatory Agency, but was not a thorough investigation as this piece of information which may, or may not have had an impact into determination how the injury of unknown origin may have happened. CNA-Q indicated to the surveyor that if the resident fell and broke her hip, she would not have been able to get back into her bed without assistance. The closed medical record review for Resident #2 identifies Resident #2 having [MEDICAL CONDITION] and previous pathological fractures requiring surgery. 7. Resident #15 investigation of injury of unknown origin was reviewed by Surveyor on 7/13/16. The injury of unknown origin was randomly selected from a list of facility investigations of injuries of unknown origin. On 4/26/16 at 7:30 AM, when morning cares were began, Resident #15 was observed to have a swollen right upper lip and right side of mouth. There was also a couple areas of dried blood on the corner of the mouth. The Administrator was notified of this at 9:00 AM and an investigation into this finding was started. The investigation consisted of the completion of an incident report. This incident report indicates resident replying,

Based on record reviews and staff interviews, the facility did not implement policies and procedures for 4 of 15 residents (Residents #13, #10, #8 and #11) who were verbally or physically abused and 8 of 11 residents (Residents #7, #2, #15, #16, #4, #5, #6, and #19) who made an allegation of abuse, neglect or had a suspicious injury of unknown origin. Allegations of possible abuse and witnessed acts of abuse were not immediately reported to the Administrator, were not identified as abusive, were not thoroughly investigated and were not reported to the appropriate officials, including the police department and the State Regulatory Agency. The facility did not implement measures to prevent further potential abuse. Two abusive employees continued working after abusive acts; six different employees who either witnessed or had knowledge of the abusive acts failed to report the acts. This deficient practice had the potential to affect all residents who resided in the facility and had a potential to work with LPN-J and/or CNA-K . LPN-J worked 8 shifts following three different staff members witnessing abusive acts to residents. The witnessed abusive acts, which included both verbal and physical abuse to Resident #8, #10 and #13, were identified as early as 4/13/16. CNA-K worked the remainder of her shift on 4/27/16 and 4.75 hours on 4/28/16 after 3 staff members were aware of allegations of verbal abuse and 1 staff member was aware of physical abuse to Resident #11 on 4/27/16. There was a potential for all residents in the facility to be abused in the facility, depending on the staffing assignment for CNA-K. The failure of the facility to follow written policies and procedures when an abuse was witnessed, created a situation of Immediate Jeopardy. The Immediate Jeopardy began on 4/13/16, when there was witnessed abuse to 2 residents by LPN-J and no action was taken to protect residents directly and indirectly affected by this abuse. On 4/13/16, there was no reporting immediately to the Administrator, police department or the State Regulatory Agency. On 7/11/16, the facility Administrator A, Director of Nursing B and RN Corporate Consultant G were notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 5/5/16, however, the deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as 8 out of 11 additional resident grievances and injuries of unknown origin (Residents #2, #4, #5, #6, #7, #15, #16 and #19) were not identified as allegations of abuse, facility staff did not immediately report allegations to the Administrator, did not conduct thorough investigations of grievances to rule out abuse/neglect and did not report all allegations to the State Regulatory Agency. Findings include: A. Surveyor # and # reviewed the facility's Skilled Nursing Facility Policies & Procedures titled, Abuse Prevention/Resident Treatment-HDGR, origination date April 1, 2008, Revision date: September 2011, November 2011, March 2014. This policy states: It is the policy of this facility to take appropriate steps to prevent the occurrence of: Abuse, Neglect, Misappropriation of resident property. It is also the policy of this facility to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property (alleged violations) are reported immediately to the administrator of the facility. Such violations are also reported immediately to state agencies in accordance with existing state law. The facility investigates each such alleged violation thoroughly and reports the results of all investigations to the administrator, as well as to state agencies as required by state and federal law. Definitions (Federal Misconduct) Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . verbal abuse is defined as the use of oral, written, or gestured language 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 . Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . Neglect failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Procedure: Identification: Incidents of possible abuse or neglect, such as suspicious bruising of residents, occurrences, patterns, and trends will be identified through ongoing assessment of resident conditions, incidents, resident interviews, family or resident councils, and verbal or written report of observations. Investigation: a. Any person who knows or has reasonable cause to suspect that a resident has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion to the administrator. b. The administrator, director of nursing, or designee will notify the appropriate regulatory, investigative, or law enforcement agencies immediately, in accordance with state regulations. c. Allegations of abuse, neglect, or exploitation will be thoroughly investigated. The investigation will be initiated upon receipt of the allegation. The administrator, or designee, will complete the investigation process. d. The investigation can include, but is not limited to: The name (s) of the resident (s) involved, The date and time the incident occurred, The circumstances surrounding the incident, where the incident took place, the names of any witnesses, the name of the person (s) alleged with committing the act. Note: Immediately means as soon as possible but ought not exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement. On 7/8/16, Director of Nursing (DON) B formulated an Incident Investigation Guidelines for staff so that there is consistent investigation procedures everyone doing the same type of investigation. DON B provided Surveyors # and #7157 with a copy of the Incident Investigative Guidelines. The facility did not operationalize its policies and procedures, as listed above, to protect, report and investigate all allegation of abuse. This failure affected 4 of 15 residents reviewed for allegations of abuse: 1. Resident #13 was observed to be abused by a licensed nurse (LPN-J) on 4/13/16, when LPN-J threw Resident #13 into bed from 20-25 feet away. The nurse aide (CNA-N) who witnessed this abuse did not act upon the abuse to protect the resident. The nurse aide did not immediately report what was witnessed to the Administrator. Because there was no reporting, no investigation, and no measures put in place to prevent further potential abuse, LPN-J was allowed to work 8 shifts following this witnessed abuse which allowed further actual and potential abuse to occur. 2. Resident #10 was observed to be abused by a licensed nurse (LPN-J) on 4/13/16 when LPN-J punched Resident #10 in the back. The nurse aides (CNA-M and N) who witnessed this abuse did not act upon the abuse to protect the resident. The nurse aides did not immediately report what was witnessed to the Administrator. Because there was no reporting, no investigation, and no measures put in place to prevent further potential abuse, LPN-J was allowed to work 8 shifts following this witnessed abuse which allowed further actual and potential abuse to occur. 3. Resident #8 was observed to be abused by a licensed nurse (LPN-J) on an unknown date (presumably end of April, 2016, per police report) when LPN-J held the resident's hands down and yelled at her for two minutes. The nurse aides (CNA-L and M) who witnessed this abuse did not act upon the abuse to protect the resident. The nurse aides did not immediately report what they had witnessed to the Administrator. Because there was no reporting, no investigation, and no measures put in place to prevent further potential abuse, LPN-J was allowed to continue to work, creating the potential for further abuse. 4. Resident #11 was verbally and physically abused by a nurse aide (CNA-K) on 4/27/16. This verbal abuse was witnessed by a Medication Technician (Med Tech-V) who reported the verbal abuse to Licensed Practical Nurse (LPN-W), who reported the verbal abuse to the supervisor (RN-U). Med Tech-V also was told by Resident #11 on 4/27/16 that CNA-K was picking at her anus following a bowel movement, told the nurse aide to stop because it was hurting her and the nurse aide would not stop. This allegation was not acted upon or reported immediately for further investigation. RN-U investigated the allegation of verbal abuse and decided it was poor customer service. There was no immediate investigation of the physical abuse allegation. The Administrator was not immediately notified of these allegations. There is no evidence that any action was taken following the knowledge of verbal and physical abuse to prevent further actual or potential abuse to occur. CNA-K continued to work with residents on 4/27/16 and 4/28/16 according to time clock detail. Cross reference F223 and F225. The failure of the facility to follow/implement written policies and procedures when an abuse was witnessed, created a situation of Immediate Jeopardy. The Immediate Jeopardy began on 4/13/16, when there was witnessed abuse to 2 residents by LPN-J and no action was taken to protect residents directly and indirectly affected by this abuse. On 4/13/16, there was no reporting immediately to the Administrator, police department or the State Regulatory Agency. The Immediate Jeopardy was removed on 5/5/16 when: - On 4/28/16, the facility Administration received an allegation of abuse via the corporate hotline. The facility acted upon this allegation and began an investigation that identified LPN-J and CNA-K as abusing residents. These employees were removed from patient care and terminated from employment on 5/2/16. - The State Regulatory Agency was notified on 4/28/16 and the police were notified on 4/29/16. - A majority of the investigation and staff training was completed by 5/5/16. The deficient practice continues at a scope/severity level of an E, (potential for harm that is not immediate jeopardy/pattern) as evidenced by the following: B. Surveyor # reviewed the facility's not dated, Policy and Procedure-Referral/Grievance Form. The Policy states: The referral/grievance form is used to formally document resident and family concerns and ensure timely resolution of concerns. Key Players: Unit Manager, Social Worker, Director of Nursing, Administrator, Directors of Dietary Services, Activities, and/or Rehab services as indicated. Procedure: Upon learning of a resident/family concern, the following will occur: a. The person receiving the initial concern/grievance information will initiate the Referral/Grievance/Information Form and give the original form to Social Services. b. Social Services will provide a copy of the form to the Administrator and involved departments. c. Involved departments will discuss, brainstorm, and/or investigate concerns: Gather and review the facts. What are the key problems according to staff and resident? Who has been involved at this point? What has been done at this point to provide resolution? Gather and review family and/or residents perspective of the situation. Gather information from other team members in the building if necessary. Using the attached Referral/Grievance form, create a plan for resolution. d. Communicate the resolution to the resident and/or family member. e. Using the same form, document the outcome and any follow-up needed. f. Completed original Referral/Grievance/Information form is to be returned to Social Service to be filed into Grievance log binder. Surveyor # and # 's review of the facility's Referral/Grievance Form policy and procedure does not address or include the need to review Resident's Grievance to determine whether Resident's grievance may be considered an allegation of abuse or neglect. Upon review of Resident grievances, Surveyor # and # noted the following grievances which are allegations of abuse/neglect. The facility did not identify these grievances as allegations of abuse/neglect, did not have evidence that these allegations were thoroughly investigated, and did not notify the appropriate regulatory, investigative, or law enforcement agencies immediately, in accordance with state regulations per facility policy. The facility did not send their completed investigations to the state agency within 5 days of the allegation. 5. Resident #7 had a grievance filed in the grievance file that was not investigated thoroughly to rule out abuse or neglect. On 5/16/16, Resident #7 alleged problems when given a shower that indicated 2 staff members were washing her and Resident #7 was fighting them off. During this grievance, Resident #7 alleged he hit me, then when asked again he was touching me. There is no evidence that a thorough investigation was completed and the State Regulatory Agency was not notified. 6. Resident #2 had a fracture of unknown origin on 6/6/16 after a family member and CNA-Q discovered Resident #2 to have a misshapen right leg. This suspicious injury was immediately reported to the Administration and the State Regulatory Agency and an investigation was immediately started on 6/6/16. On 7/13/16, Surveyor interviewed CNA-Q who discovered the injury along with the family. On 7/13/16, additional information became known to the surveyor through CNA-Q that was not communicated to the facility Administration when the fracture was found on 6/6/16. A thorough investigation was not completed for this suspicious fracture of Resident #2's leg. 7. Resident #15 was found to have a swollen right upper lip and right side of mouth to be swollen and slightly discolored on 4/26/16 at 7:30 AM. It was noted that there was a couple dried blood on the corner of Resident #15's mouth. This suspicious injury was reported to the Administrator on 4/26/16 and an investigation was completed that included staff statements, however there is no evidence the reason for this suspicious injury was found out. Action taken included instructing staff to be more careful in conducting cares for Resident #15. The investigation does not indicate what problem with cares was found in this investigation. The investigation did not rule out abuse. This suspicious injury investigation was not reported to the State Regulatory Agency. 8. Resident #16 was discovered with a yellowish bruise under her left eye that was discovered by her guardian on 7/4/16. Resident was unable to say how it happened but did tell the nurse they beat me up all the time. Resident was unable to say who they were. In a later interview, resident indicated an aide hit her in the eye. CNA-T met the description of the nurse aide who cared for Resident #16 2 days in a row and action was taken with this CNA. The investigation also indicted that Resident falls asleep with glasses on and the oxygen tubing placement was in the same place as both of the contoured lines under the bruised area. The investigation determined that CNA-T did not provide cares for Resident #16 during the 16 hour shift she was assigned to Resident #16 and CNA-T was determined to neglect Resident #16. This information was not submitted to the State Regulatory Agency with the self report submitted on 7/4/16. 9. Resident #4 filed a grievance on 5/6/16 related to a nursing assistant yelling at a resident that was witnessed by 2 other staff members. The review of this investigation was found to be incomplete without staff statements and information regarding the review of the security cameras to rule out abuse. Acts of pointing a finger in a resident face and yelling were not identified as abuse. The Administrator signed off on this grievance 3 days after the allegation was witnessed. This allegation was not reported to the State Regulatory Agency. 10. Resident #5 filed a grievance on 5/31/16 alleging a CNA was yelling at her for having her light on. Resident #5 also alleged the CNA was looking at pictures on her phone for 10 minutes in Resident #5's room. The investigation into this grievance did not have enough information to determine abuse did not occur. This allegation was not reported to the State Regulatory Agency. 11. Resident #6 alleged on 6/9/16 that he put on his call light to ask for a blanket to be applied. The allegation included that the CNA allegedly threw the blanket on top of resident and told resident not to use his call light for at least 30 minutes. The Administrator signed off on this grievance on 6/16/16 and inserviced the nursing assistant on good customer service. This allegation was not identified as abuse and not reported to the State Regulatory Agency. 12. Resident #19 alleged that on 6/21/16, incontinence care was not provided to Resident #19 after returning from a doctors appointment. The caregiver did not assist resident with incontinence care. The facility did not identify this allegations as neglect and the grievance was not fully investigated to rule out neglect. This allegation did not get reported to the State Regulatory Agency. Administrator A, Director of Nursing B and RN Corporate Consultant G were notified of the above findings on 7/11 and 7/13/16.

Based on review of the facility grievance file, the facility internal investigation, the Waukesha Police Department investigation, staff interviews, policy review and medical record review, the facility did not ensure that 4 of 15 sampled residents (#13, #10, #8, #11) were free of verbal and physical abuse. * Resident #10 was observed to be abused by a licensed nurse (LPN-J) on 4/13/16 when LPN-J punched Resident #10 in the back. The nurse aides (CNA-M and N) who witnessed this abuse did not act upon the abuse to protect the resident. The nurse aides did not immediately report what was witnessed to the Administrator. The licensed nurse abuser was allowed to work following these witnessed acts on 4/13/16 and 8 more shifts following this witnessed abuse which allowed further actual and potential abuse to occur. * Resident #13 was observed to be abused by a licensed nurse (LPN-J) on 4/13/16 when LPN-J threw Resident #13 20-25 feet into bed. The nurse aide (CNA-N) who witnessed this abuse did not act upon the abuse to protect the resident. The nurse aide did not immediately report what was witnessed to the Administrator. The licensed nurse abuser was allowed to work 8 shifts following this witnessed abuse which allowed further actual and potential abuse to occur. * Resident #8 was observed to be abused by a licensed nurse (LPN-J) on an unknown date (presumably end of April, 2016, per police report). LPN-J held down Resident #8's wrists and yelled at her for two minutes. The nurse aides (CNA-L and M) who witnessed this abuse did not act upon the abuse to protect the resident. The nurse aides did not immediately report what they had witnessed to the Administrator. * Resident #11 was verbally and physically abused by a nurse aide (CNA-K) on 4/27/16. This verbal abuse was witnessed by a Medication Technician (Med Tech-V) who reported the verbal abuse to Licensed Practical Nurse (LPN-W), who reported the verbal abuse to the supervisor (RN-U). Med Tech-V also was told by Resident #11 on 4/27/16 that CNA-K was picking at her anus following a bowel movement, told the nurse aide to stop because it was hurting her and the nurse aide would not stop. This allegation was not acted upon or reported immediately for further investigation. There was no immediate investigation of the physical abuse allegation. The Administrator was not immediately notified of these allegations. There is no evidence that any action was taken following the knowledge of verbal and physical abuse to prevent further actual or potential abuse to occur. CNA-K continued to work with residents on 4/27/16 and 4/28/16 according to time clock detail. The failure to keep residents free from abuse created a finding of immediate jeopardy that began on 4/13/16, when a facility staff member (LPN-J) was known to have abused 2 residents (Residents #10 and #11). On 7/11/16, the facility Administrator A, Director of Nursing B and RN Corporate Consultant G were notified of the Immediate Jeopardy. The facility removed the jeopardy on 5/2/16; the deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) while the facility continues to implement its action plan. Findings include: A review of the facility grievance file conducted by Surveyor on 7/6/16 and 7/7/16 revealed abuse allegations for Residents #8, #10 and #11. Surveyor requested the internal investigations of these allegations discovered in the facility grievance file. The internal facility grievance reviewed indicated that on 4/28/16 the facility received knowledge of allegations of abuse that was occurring in their facility on the night shift on the 2 Center unit through a corporate hotline phone call. The caller gave no staff or resident names. The facility immediately reported this anonymous information to the Administrator and the State regulatory agency on 4/28/16. The facility acted upon this anonymous allegation immediately and began an investigation. Resident interviews and employee interviews were started on 4/28/16. On 7/7/16, Surveyor interviewed the Corporate Nursing Home Administrator- I by telephone. Corporate NHA-I told the surveyor that the call had come in to the corporate hotline on 4/28/16 at 1:30 PM by an anonymous caller. This caller did not give any names, but did indicate she had raised the issue with previous nurse managers and Director of Nursing. The Corporate NHA-I indicated she alerted the facility Administrator immediately after receiving the hot line phone call and an investigation was started. The facility investigation revealed that during employee interviews the following allegations were received: 1) Resident #10. The medical record review for Resident #10 revealed Resident #10 having [DIAGNOSES REDACTED]. On 7/7/16 Surveyor discovered another written statement in the folder of the facility internal investigation, dated 5/8/16, and signed by CNA-N. On 5/8/16, CNA-N had written and signed a statement describing an incident when she was in Resident #10's room and had witnessed LPN-J slap Resident #10 on the arm during care provision. CNA-N also indicated that she had witnessed LPN-J calling Resident #10 rude names either behind his back or to his face. Certified Nursing Assistant CNA-M also reported during this investigation that on 4/13/16, she witnessed Resident # 10 being punched in the back by LPN-J after Resident #10 called LPN-J a [***] . Resident #10 indicated he was going to call the police and then LPN-J told Resident #10 she didn't mean to hit him so hard. There is evidence that the above allegations were reported to the State Regulatory Agency on 5/4/16 as a follow-up report to the initial anonymous allegation that was reported to the State Regulatory Agency on 4/28/16 at the start of the investigation. At the time of this onsite investigation, Resident #10 was no longer in the building and was unable to be observed or interviewed. A review of the Waukesha police report with incident date of 4/29/16 revealed that the police officer who also conducted an investigation did interview Resident #10 about the allegation of abuse and Resident #10 was unable to recall any events that may have occurred. Resident #10 did tell the police officer that he knew who LPN-J was, and indicated he did not like LPN-J, but he could not recollect any events between himself and LPN-J. 2) Resident #13. The medical record review indicated that Resident #13 was admitted to the facility 2/12/16 for care and had [DIAGNOSES REDACTED]. The medical record review indicated Resident to have inpatient behavioral health hospitalization in February, 2016, for severe agitation, combativeness, distrust in hospital staff and declines in memory. Resident was then admitted to this facility following this hospitalization and cared for on a 1:1 basis. Included in the written statement, dated 5/8/16, from CNA-N was an incident in which CNA-N witnessed LPN-J throw Resident #13 into his bed. CNA-N wrote in her statement that she (CNA-N) witnessed LPN-J kind of bear hug picked him up and threw him into his bed. CNA-N wrote that he (Resident #13) was standing 20-25 feet away from his bed and she lifted and threw him so hard that his feet left the ground. CNA-N indicated in her written statement that after LPN-J left CNA-N kept asking if Resident #10 had pain anywhere and Resident #13 stated he did not have any pain anywhere. On 7/7/16, it became known to Surveyor that the 5/8/16 statement about CNA-N witnessing LPN-J throw Resident #13 into his bed did not get included in the investigation that was reported to the State Agency. There is no date in this investigation as to when this event may have occurred. The date in which this may have occurred was not addressed in this investigation. On 7/13/16, it became known that the event that occurred with Resident #13 likely occurred on 4/13/16. Corporate Nurse Consultant-G told Surveyors and this on 7/13/16 at 3:25 PM when discussing facility staff schedules. It is unknown as to why this information was not explored as part of a thorough investigation. At the time of this State investigation, CNA-N is no longer employed at the facility and could not be interviewed for more information. Resident #13 was no longer in the facility at the time of this State investigation. Resident had a decline in condition in April of 2016 and was enrolled in Hospice care at that time. 3) Surveyor reviewed the medical record of Resident #8. The medical record indicates that Resident #8 has Dementia and was first admitted to the facility on [DATE]. The plan of care for Resident #8 identifies Resident #8 as having altered cognitive status, impaired memory, judgment and problem solving, safety awareness and decision making and has sensorineural hearing loss. Certified Nursing Assistant (CNA)-L reported that mistreatment of [REDACTED].#8 having hit CNA-L by pushing Resident #8 into her room and shutting the door. Both CNA-L and CNA-M listened as LPN-J asked Resident #8 why she was acting like a child. When Resident #8 went to cover her ears, LPN-J grabbed resident wrists and held them down on her lap so Resident #8 had to listen. LPN-J held Resident #8's wrists down for another 2 minutes and continued yelling at Resident #8. The last thing LPN-J said was, I hope you understand this is how babies act. Now, do you understand? A written and signed statement on 4/28/16 from CNA-L, indicated that there have been a few occasions when LPN-J has grabbed residents and talked inappropriately. CNA-L also indicated in this statement that she had witnessed LPN-J calling residents (derogatory) names. There were many occasions when LPN-J had called the residents childish and saying that she has had enough of their (expletive). CNA-L indicated she felt unsafe reporting this at first, but realized it has gone too far and something has to be done. CNA-L indicated she should have made sure that the resident was safe, but her fear took over. CNA-L indicated that LPN-J had gotten so far out of hand that something needs to be said and many CNAs and nurses have noticed it. Certified Nursing Assistant CNA-M reported mistreatment of [REDACTED].#8, told Resident #8 she was acting childish, needs to settle down and act like an adult. When Resident #8 put her hands over her ears and replied to LPN-J Yes Madame, I understand, LPN-J pulled her hands down into her lap and continued to yell and tell her to act as an adult and not a child. A written and signed statement on 4/28/16 from CNA-M indicated she had witnessed LPN-J being verbally abusive to residents, telling them that they are being childish, if they don't eat a certain amount of their meal they will not go to activities, that they need to shut up and they are too old to act the way they do. Surveyor review of the facility investigation noted documentation dated 4/29/16 at 1:30 PM with Resident #8's name on it. The notes indicated Resident indicating she felt safe, but was still afraid. When asked what she was afraid of, resident responded not being worthy of God. The notes continue to say some of them-they are mean, they tell me to go to my room, I need my oxygen, they tell me I don't need it, (name) is trying to find me another place and I don't like it here. On 7/18/16, Surveyor reviewed the police report from the Waukesha Police Department. In this police report, on page 6 of 9, the police detective wrote that the incident between LPN-J and Resident #8 occurred approximately at the end of April, 2016. This was mentioned in an interview the police detective had with CNA-L. 4) Resident #11. On 7/7/16, it became known to Surveyor through review of the grievance file that Resident #11 reported during the facility internal investigation on 4/28/16 of being abused by CNA-K. Surveyor asked to review the facility investigation. The investigation revealed that on 4/27/16, CNA-K verbally and physically abused Resident #11. Resident #11 reported during the interviewing conducted by the facility that she had concerns as to how she was spoken to by CNA-K on 4/27/16. On 4/28/16, Resident #11 told the facility corporate NHA-O that CNA-K said, I'm the black [***] that is going to take care of you tonight. Resident #11 also indicated that Medication Technician-V heard her say this and that Resident #11 told LPN-W about this, too. The facility investigation also indicated that Resident #11 alleged that CNA-K had Resident #11 in the sit to stand lift digging at her anus and was hurting her. Resident #11 told CNA-K to stop and CNA-K would not stop. Resident #11 indicated CNA-S was also present in the room and did not respond. CNA-S was also questioned by the facility corporate NHA-O and indicated Resident #11 had no complaints at that time. The investigation into this allegation began on 4/28/16 by the facility. Medication Technician (MT)-V was also interviewed about this allegation and indicated she had heard CNA-K say what she did to Resident #11. MT-V also told the facility that earlier in the shift, Resident #11 had made the allegation to MT-V about the incident of CNA-K picking at her anus. The investigation into this allegation also identified that LPN-W knew what CNA-K had said to Resident #11 and had investigated this dialog, but after speaking with CNA-K felt the dialog was poor customer service. The investigation also revealed that RN-U knew on 4/27/16 about what CNA-K said to Resident #11, but felt it was poor customer service and not verbal abuse, therefore did not report this dialog to the Administrator on 4/27/16. The facility became aware of this event on 4/28/16 through interviews with Residents and staff. The investigation also revealed that RN-U did not know about the allegation of Resident #11 describing CNA-K's method of cleaning her bowel movement, that CNA-K was hurting Resident #11, that Resident #11 asked CNA-K to stop and CNA-K would not stop. On 7/7/16, Surveyor was not able to interview Resident #11 as resident was no longer residing at this facility and was transferred out of the facility in June, 2016. Surveyor reviewed CNA-K's punch detail from the facility time clock, which revealed CNA-K in work status on 4/28/16 for 4.75 hours prior to being suspended pending the investigation. The facility did report the allegation of abuse to Resident #11 to the State regulatory agency appropriately on 4/28/16 at 6:39 PM with the final investigatory information submitted to the State regulatory agency on 5/4/16. There is evidence of re-training to RN-U on 5/5/16 on reporting abuse to the Administrator. Surveyor reviewed the medical record of Resident #11. Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident did have a plan of care, dated 3/24/16 that addressed Resident's anxiety disorder and [MEDICAL CONDITION] medication use. Resident #11's plan of care for the problem of deconditioning and limited mobility addresses resident's use of assist of 2 caregivers and using the sit to stand lift. The plan of care is initiated on 9/19/15 and revised on 12/21/15. The use of the sit to stand is also addressed as a care approach to assisting resident to the toilet. Resident is described as having intact cognition on Minimum Data Screens (MDS) 9/25/15 and 6/2/16, with a Brief Interview of Mental Status score of 15, the highest score on this screen. Resident #11's plan of care, dated 12/14/15 and revised on 4/14/16 addresses resident's behavior of presenting with racing thoughts/slight of thought and hyperverbalizations, with resident being easily frustrated by staff and peers, sarcastic and argumentative with others. Interventions listed for this behavior problem includes administration of medications, behavior health consultation, encouraging resident to express her feelings, and to explain/reinforce why resident's behavior is inappropriate and attempting to redirect resident. On 4/4/16, Resident #11's medical record has documentation from the Nurse Practitioner that resident was hyperverbal and irritable, hypomanic, sleeping well, appetite good and weight being stable (120.6#). The resident was upset with the nurse practitioner at the time of this examination, but unable to articulate reasons why. On 5/11/16, Resident #11's medical record has documentation from the Nurse Practitioner that resident was pleasant and cooperative that day and mood was stable. Resident indicated she was sleeping okay and appetite was good. Resident's abdominal/rectal exam indicated resident to be obese, nontender, nondistended, bowel sounds normoactive all 4 quadrants, no palpable masses, no suspicious rashes/[MEDICAL CONDITION]/moles. On 2/22/16, the physician documentation addresses resident's constipation, but not wanting any medication. At this time, resident'[MEDICAL CONDITIONS] was improved. On 6/8/16 documentation in the nursing notes begin to describe resident's behaviors deteriorating until resident's transfer to another level of care on 6/13/16 related to resident's diagnoses. Interviews with facility administration on 7/7/16 through 7/13/16 revealed that the facility Administration first became aware of the abuse occurring in the facility on 4/28/16. The facility administration and the corporate level of administration acknowledged acting upon these allegations immediately in conducting an investigation, reporting to police and also the State Regulatory Agency. The failure to ensure that residents were free from verbal and physical abuse created a finding of immediate jeopardy. The immediate jeopardy was removed on 5/2/16 when the facility: Once the facility identified perpetrators, the perpetrators were removed from contact with residents on 4/28/16 and the facility took action in preventing further potential abusive situations by these perpetrators on 5/2/16 when both LPN-J and CNA-K were both terminated from employment. The facility began to interview all facility personnel on 4/28/16 about any knowledge of abusive events in their facility along with re-training of all staff both at the facility level and also the corporate level in abuse protocols. On 4/29/16, the local police department was alerted to these allegations once it became known to the facility that 2 of its employees were allegedly abusing residents. The facility did show evidence of having most of the facility staff trained on abuse policies and procedures by 5/5/16.

Based on record review and staff interviews, the facility did not ensure allegations, involving 4 of 4 residents who alleged abuse or misappropriation of property, were immediately reported to the Administrator, thoroughly investigated and reported to the appropriate officials, including the state survey and certification agency. Additionally, the facility did not implement measures to prevent further potential abuse while investigations were in progress. * On 10/19/15 during a Resident group interview with Surveyors # and # , Resident #35 stated that she was inappropriately touched by a staff member but the facility had taken care of it. On 10/22/15, Surveyor # spoke with Administrator-A and SSD (Social Service Director)-N both of whom had no knowledge of this allegation. SSD-N in the presence of Surveyor # interviewed Resident #35 on 10/22/15. During this interview, Resident #35 stated she had reported this to RN (Registered Nurse)/Nursing Supervisor-CC. RN/Nursing Supervisor-CC did not report the allegation to Administrator-A or DON (Director of Nursing)-B. An investigation was not started, the accused staff member (CNA-BBB) was not removed to protect Resident #35 and other Residents residing at the Facility, and the State agency was not notified. The failure of the facility to promptly report and conduct a thorough investigation to rule out abuse, protect residents during the investigation, and report the allegations to the appropriate authorities, created a situation of Immediate Jeopardy. This had the potential to affect all residents with whom CNA-BBB has worked. CNA-BBB worked 14 evening shifts in June 2015, 11 evening shifts in July 2015, 16 evening and 1 day shift in August 2015. Additionally, copies of the nurse staff schedules from 9/2 through 9/30/15 and from 10/1/15 through 10/21/15 indicate CNA-BBB worked the 2 Center unit, second shift, a total of 22 shifts. The resident census on 2 Center ranged anywhere between 33 to 37 residents from 9/2 through 10/21/15. The Immediate Jeopardy began on an unknown date prior to 6/28/15, when Resident #35 reported to RN/Nursing Supervisor-CC of her concerns about CNA-BBB. Nursing Home Administrator-A, Director of Nurses-B, and Interim Administrator-CCC were notified on 10/26/15 that an Immediate Jeopardy existed. The Immediate Jeopardy was removed on 10/26/15, but the deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) until all staff are trained and processes fully implemented, and as evidenced by the following: * Residents #19, #25 and #26 had missing rings. The facility did not conduct through investigations into the missing rings nor did the facility report the missing rings to the state agency. Findings include: 1. On 10/19/15 at 3:00 p.m., Surveyors # & # conducted the group interview with seventeen Residents the Facility had identified as being alert & oriented. During this meeting, while the Surveyors were discussing if the Residents in the group felt that Facility staff treated them with dignity, Resident #35 stated that a staff member had touched her inappropriately. Resident #35 stated that the Facility took care of it. On 10/22/15 at 4:15 p.m., Surveyor # asked Administrator-A if he had an investigation for Resident #35 being touched inappropriately. Administrator-A looked through his files and informed Surveyor # that the only investigation in the last year that he has regarding Resident #35 is for missing money. Surveyor # asked Administrator-A if he was aware of an allegation of Resident #35 being touched inappropriately. Administrator-A informed Surveyor # that he does not recall that and this type of allegation is a no brainer and would have been reported to the State. Administrator-A stated that he didn't have any information but maybe SSD (Social Service Director)-N has some information. On 10/22/15 at 4:28 p.m., Surveyor # asked SSD-N if she was aware of a staff member touching Resident #35 inappropriately and the Facility took care of this. SSD-N informed Surveyor # that she has no awareness of this. SSD-N informed Surveyor # that Resident #35 came from a Facility that closed and maybe she was thinking of something from there. SSD-N informed Surveyor # that she needs to go up and speak with Resident #35 about this. According to Resident #35's medical record, Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #35 is her own person. Resident #35 was hosptalized on [DATE] to 7/1/15 with UTI listed as an active problem. The quarterly MDS (Minimum Data Set) signed as complete on 7/29/15 has a BIMS (brief interview mental status) total score of 15 meaning that she is cognitively intact. On 10/22/15 at 4:34 p.m., Surveyor # entered Resident #35's room with SSD-N. SSD-N informed Resident #35 that she wanted to speak with her about an allegation that Surveyor # brought forward to her. SSD-N asked Resident #35 if anyone touched her inappropriately or made her feel uncomfortable. Resident #35 informed SSD-N that she spoke to RN (Registered Nurse)/Nursing Supervisor-CC and informed her that every time a certain person cleaned her up she would take her fingers & hands and go back and forth. Resident #35 stated, I'm so embarrassed to say this. Resident #35 stated that this staff member did this with a wash cloth and then did really deep with her hands, it was skin on skin. Resident #35 stated that the staff member said, I have to make sure that you're clean. SSD-N asked Resident #35 if she thought RN/Nursing Supervisor-CC spoke to the person. Resident #35 replied, I think she had because she said she can't come in by herself. Resident #35 informed SSD-N that at this time her concern is for other elderly people that can't express themselves. Resident #35 stated, I still can. Resident #35 informed SSD-N that she (referring to the caregiver/staff member) said, If I don't check you like this you're going to get a UTI (urinary tract infection). SSD-N asked Resident #35 where the staff member put her hands: was it on her front, inner thighs? SSD-N then stated maybe she wasn't asking the right way. Surveyor # asked Resident #35 if the staff member placed her hand in her vagina. Resident #35 replied, Yes. SSD-N asked Resident #35 if she explained this to RN/Nursing Supervisor-CC at the time. Resident #35 stated that she told her (RN/Nursing Supervisor-CC) that she (caregiver/staff member) washed her hard and put her hands, fingers up her. SSD-N asked Resident #35 if she told the person that it made her uncomfortable. Resident #35 informed SSD-N that she did but the person said she had to do it. SSD-N asked Resident #35 when this happened. Resident #35 stated within two to three months ago. SSD-N asked Resident #35 if she knew who the staff member was. Resident #35 was able to tell SSD-N the CNA's (Certified Nursing Assistant) first name, what she looked like and that there were two CNAs with this first name but she is the one that hasn't been at the facility as long and is not the person working today. SSD-N asked Resident #35 if this CNA has taken care of her since this by herself. Resident #35 indicated that she (the caregiver) has been with other staff and told the girl that she wasn't allowed to be in alone and that she is just trying to stop her (Resident #35) from getting an UTI. Resident #35 stated, Weird cause I did get a UTI (which occurred on 6/28/15). SSD-N asked Resident #35 if she spoke to anyone about this. Resident #35 indicated that she spoke to one of her friends and hasn't told her husband. Resident #35 stated, When I see her I want to throw up. Just thinking about it makes me nauseous. SSD-N informed Resident #35 that they would be doing an investigation and part of the investigation is that the police can be called. SSD-N asked Resident #35 about the police coming to talk to her and that it could be done confidentially. Resident #35 stated, I think it's too late. SSD-N explained that it's not too late and that her protection is SSD-N's utmost concern. Resident #35 replied, because of the time and I'm afraid she will retaliate. SSD-N informed Resident #35 that wouldn't be a concern. Resident #35 replied, I see her walking down the hall, and I cringe and for her to say, 'See didn't I tell you you would get a UTI?' Resident #35 then agreed to speak with the police. SSD-N inquired if this CNA has touched her since. Resident #35 indicated that this CNA has not touched her since and stated, Bothers me a whole lot. What if she's doing it to someone else? It bothers me this long. Resident #35 stated that she told RN/Nursing Supervisor-CC right away and didn't speak to anyone else because of the stress. Resident #35 stated that there have been male CNA's that have given her showers and they didn't make her feel the way she did. SSD-N again asked what this CNA said when she touched her. Resident #35 stated that she needed to make sure she was clean. Resident #35 stated that she told her that it hurt but she said she had to be thorough. Resident #35 stated that she did tell the CNA that thorough was one thing but it hurt. Resident #35 stated, I was basically just saying please stop. SSD-N offered the services of the psychologist, which Resident #35 accepted. Surveyor # noted during this conversation, Resident #35 was visibly upset. At approximately 5:20 p.m. SSD-N and Surveyor # left Resident #35's room. SSD-N informed Surveyor # that she would be reporting this to Administrator-A and DON (Director of Nursing)-B. On 10/22/15 at 5:35 p.m., Surveyor # spoke with Administrator-A who informed Surveyor # that they are self reporting this allegation. DON-B is trying to get hold of RN/Nursing Supervisor-CC and CNA-BBB (the alleged abuser) would not be working. The psych consult dated 10/23/15 under narrative documents, c/o (complained of) sexual assault concerned about retaliation from reporting the experience fears someone outside the nursing home staff might retaliate. Under general appearance & manner documents, upset about what she described as a sexual assault. On 10/26/15 at 8:15 a.m., Surveyor # met with SSD-N regarding Resident #35. SSD-N informed Surveyor # that Resident #35 was agreeable to speak to the officer, that they had a lengthy conversation and somethings in the story changed a little bit. Surveyor # inquired what the changes were. SSD-N indicated that Resident #35 stated the incident occurred more than one time and that it occurred during incontinence care and while she was caring for her in the shower. SSD-N informed Surveyor # that she had spoken with RN/Nursing Supervisor-CC and that RN/Nursing Supervisor-CC had gone to Resident #35's room for another reason. Before RN/Nursing Supervisor-CC left, Resident #35 said since you're here Resident #35 wanted to tell her something. Resident #35 informed her that Resident #35 feels uncomfortable with CNA-BBB taking care of her. SSD-N indicated that RN/Nursing Supervisor-CC asked her why and she (Resident #35) said that she washes her too hard when doing peri care and is uncomfortable. RN/Nursing Supervisor-CC then went and spoke with CNA-BBB. CNA-BBB wasn't aware of any issues with Resident #35 and in their discussion felt that CNA-BBB wouldn't take care of Resident #35 anymore. RN/Nursing Supervisor-CC went back to Resident #35 and told Resident #35 if you are uncomfortable then CNA-BBB won't take care of her but would help with transferring her since it takes four people. Surveyor # asked SSD-N if she asked RN/Nursing Supervisor-CC why she didn't report this. SSD-N replied, Not in so many words, probably should have asked her. On 10/26/15 at 8:53 a.m., Surveyor # met with SSD-N and DON-B regarding Resident #35. DON-B informed Surveyor # that it had been agreed upon that CNA-BBB would not do direct care but would assist. Surveyor # asked if it is typical for a nursing supervisor to make a decision like this and not let anyone know. DON-B informed Surveyor # what RN/Nursing Supervisor-CC gathered was that CNA-BBB wiped Resident #35 too many times. Surveyor # asked if Resident #35 has ever voiced to them that she feels uncomfortable with any other staff. SSD-N replied, No. Surveyor # asked DON-B if she asked RN/Nursing Supervisor-CC why she didn't report this. DON-B replied that she didn't ask her because she had an answer. According to them (RN/Nursing Supervisor-CC), they had run this by me but honestly, I don't remember. DON-B informed Surveyor # that she knows the proper channels and knows what she is suppose to do. On 10/26/15 at 12:35 p.m., DON-B provided Surveyor # with her typed statement which documents, On 10/26/15 writer entered room of Resident #35 with permission of resident asked resident if we could discuss allegations of sexually inappropriate touching made to state surveyor. Resident told writer that CNA would typically clean her front part, resident then proceeded to state, normally cleaned me 3-4 x (times) wiping is normal, CNA-BBB would say, I'm just tying to get you clean, I never said anything but she would wipe 8-10x, and when she was washing me would grab down there with a wash cloth, I was assuming it was her fist. Resident then stated, then she would go over it with her hand, it was starting to feel sexual. Writer question if CNA was applying cream? Resident stated, I don't know I didn't ask her, I never said anything to her, I just felt her cleaning was over cleaning, I just kept my thought to myself because I felt awkward. Writer questioned if resident ever told anyone or said anything to CNA I told the CNA to stop, I felt embarrassed, CNA did say that she had to get in there to clean me. Resident stated, I'm not making this up. Writer reassured resident that the facility takes these things very seriously and her well being is very important to us, therefore; we will do whatever it takes to ensure residents safety and comfort. Resident thanked writer. Writer exited residents room. Surveyors # and # noted that CNA-BBB worked 14 evening shifts in June 2015, 11 evening shifts in July 2015, 16 evening and 1 day shift in August 2015. Additionally, copies of the nurse staff schedules from 9/2 through 9/30/15 and from 10/1/15 through 10/21/15 indicate CNA-BBB worked the 2 Center unit, second shift, a total of 22 shifts. The resident census on 2 Center ranged anywhere between 33 to 37 residents from 9/2 through 10/21/15. The failure to promptly report, investigate, and to put measures in place to protect residents from further potential abuse while an investigation was in progress created a finding of immediate jeopardy. The jeopardy was removed on 10/26/15 when the facility: 1. Conducted a comprehensive physical assessment on 10/22/15. Resident #35 was seen for a psychological evaluation on 10/23/15. Resident #35 will have her psychosocial well-being assessed and documented on daily for 1 week, then 2 times per week for 3 additional weeks. 2. All other residents on the second floor had skin checks completed on 10/24/15. 3. All alert residents on the second floor were interviewed to identify any safety concerns related to abuse on 10/24/15. Non-alert residents will have their behavior documentation reviewed to see if there are any increased behaviors that may indicate that abuse is occurring on 10/26/15. 4. All Department Heads including the Director of Nursing and Administrator were educated on the facility's policy on Abuse, neglect and misappropriation along with the Center for Medicare and Medicaid Services (CMS) and Division of Quality Assurance (DQA) reporting requirements and investigation protocols that included, keeping residents safe during an investigation. These employees were also re-education on the facility's policy and procedure for abuse, neglect and misappropriation focusing on the investigation process and keeping residents safe during an investigation on 10/26/15. 5. Before working their next shift, all staff will be educated on the facility's policy on Abuse, neglect and misappropriation along with the CMS and DQA reporting requirements and investigation protocols that included, keeping residents safe during an investigation. These employees were also re-educated on the facility's policy and procedure for abuse, neglect and misappropriation focusing on the investigated process and keeping residents safe during an investigation by 10/26/15. This education will also be provided upon hire and annually. The Executive Director (ED) will ensure compliance. 6. Grievance forms will be readily accessible on all units to staff. All staff will be educated on utilizing the Grievance forms; grievance forms will be used for all staff to report any concerns/grievances and to report any concerns/grievances to the Director of Nursing and ED no matter how minimal they are by 10/30/15. This education will also be provided upon hire and annually. The Executive Director (ED) will ensure compliance. 7. A Quality Assurance meeting was held on 10/26/15 and the Medical Director was notified on 10/26/15. On 10/26/15 at 7:57 a.m., Surveyor # met with DON-B to discuss what the Facility has done regarding Resident #35's allegation of being touched inappropriately. DON-B informed Surveyor # that they are doing an investigation, gathering statements, have done resident interviews and the CNA has been suspended. DON-B stated that Resident #35 was seen by the psychologist on Friday (10/23/15), and the police were called on Thursday (10/22/15). Surveyor # inquired if the police spoke with Resident #35. DON-B informed Surveyor # that they came in. Surveyor # asked DON-B if she was able to get hold of RN/Nursing Supervisor-CC. DON-B replied, briefly and said that RN/Nursing Supervisor-CC said she didn't know anything about it but SSD-N has a statement from RN/Nursing Supervisor-CC. This deficient practice continues at a scope and severity level of E (potential for harm/pattern) based upon the following: 2. On 10/19/15 at 3:00 p.m., Surveyors # & # conducted the group interview with seventeen Residents the Facility had identified as being alert & oriented. During this meeting while the Surveyors were discussing if there were any problems with their personal items missing. Resident #19 stated about three and a half months ago she had a ring that was her mother's that was missing. Resident #19 indicated that she had notified the Facility of her missing ring. On 10/21/15 at 2:09 p.m., Surveyor # asked SSD-N for the investigation for Resident #19's ring. On 10/22/15, Surveyor # reviewed the missing items log and noted Resident #19 is listed on 7/21/15. Under date given to NHA (Nursing Home Administrator) documents, 8/5/15 and under resolution documents unable to locate lost item. The missing item report is dated 7/21/15. Under description of item documents, silver ring & turquoise stones. Oval shape. Under where is item usually kept documents, usually wears ring most of time. Takes off occasionally when washes hands or at times at bed time. Under social services investigative summary documents; 7/21/15 room & unit searched. Spoke to resident & dtr. (daughter). Resident unsure when she wore it last or where she put it. Item not found at this time. 7/30/15 Search of Rm (room) & unit. item not found. No rings/jewelry found by laundry, housekeeping kitchen. Resident still unable to provide any other information r/t (related to) missing item. Under executive direction investigation summary dated 8/5/15 documents; Item unable to be located & Resident not (circle with a line) able to identify where she left it. Surveyor # noted there are no staff statements or evidence that the ring was reported to the State agency. On 10/21/15 at 2:09 p.m., Surveyor # asked SSD (Social Service Director)-N about the Facility's investigation. SSD-N informed Surveyor # that she verbally spoke to staff but didn't take any statements or who she spoke with. Surveyor # inquired if the missing ring was reported to the State agency. SSD-N stated that it was not reported. Surveyor # asked why it wasn't reported? SSD-N stated because she thought Resident #19 lost the ring and the daughter indicated that it wasn't an heirloom. Surveyor # informed SSD-N that the Facility should have conducted a thorough investigation, reported the missing ring to the State agency and the ring must have been important to Resident #19 because she reported to the surveyors that her ring was missing three months after she reported it to the facility. On 10/22/15 at 3:13 p.m. during the daily exit conference with Administrator-A and DON (Director of Nursing)-B were informed that Resident #19's missing ring was not thoroughly investigated and reported to the State agency as required. 3. On 10/22/15, Surveyor # reviewed the missing items log and noted Resident #25 is listed on 9/30/15. The following sections are blank: investigation complete, date given to NHA (Nursing Home Administrator), Resolution, & initials. The missing item report dated 9/30/15 documents under description of item mothers ring with 4 stones in it. Gold. Under where is item usually kept documents, wears on finger. Under briefly describe circumstances surrounding disappearance of item documents, roommate noticed resident did not have ring on finger & notified staff. Under social services investigation summary documents; 9/30/15 Room & unit searched. Dining rm (room) hallway, shower room & activity rooms were searched item not found. Resident unsure when she last had ring on. Resident stated she does not usually take it but does not know where it could have gone. Resident denies having concerns with staff/peers & missing item. Will continue to search. Dtr. (daughter) in & aware of missing item. Is not sure when she last saw item. Dtr. aware resident more forgetful lately & not keeping track of her things. Surveyor # noted there are no staff statements or evidence that the ring was reported to the State agency. On 10/22/15 at 9:08 a.m., Surveyor # asked SSD-N when would the Facility report a missing item. SSD-N informed Surveyor # that it depends on the information. If the resident can't remember where it was last and maybe it was misplaced then it's not reported. Surveyor # informed SSD-N that a resident may not remember where they had it last and how does the Facility know that after the Resident placed an item down that someone didn't take it. Surveyor # asked why Resident #25's ring wasn't thoroughly investigated and reported to the State agency? SSD-N replied that daughter thought maybe it was lost. On 10/22/15 at 3:13 p.m., during the daily exit conference with Administrator-A and DON (Director of Nursing)-B were informed that Resident #25's missing ring was not thoroughly investigated and reported to the State agency as required. 4. On 10/22/15, Surveyor # reviewed the missing items log and noted Resident #26 is listed on 10/13/15. The following sections are blank: investigation complete, date given to NHA (Nursing Home Administrator), Resolution, & initials. The missing item report dated 10/13/15 under briefly describe circumstances surround disappearance of item documents; Family was in on Fri (Friday) 10/9 & saw resident with rings on. Family visited 10/10 & noticed rings were not on residents (L) (left) ring finger. Under Social Service Investigation summary documents; 10/13/15 Spoke with Resident's son. Family last saw rings on Fri 10/9 & noticed them missing on Sat. (Saturday) 10/10. Family did not take rings home. Room & unit searched items not located. 10/14/15 Spk. (spoke) with resident's son. Clarified when item last seen & when noticed missing. Resident's son noticed item missing over weekend. Last saw item on Fri. 10/9/15. Reviewed resident's behavior restless, taking off clothing, wraps dentures in paper towel. Writer found balled up Kleenex & paper towel in pants pockets. Laundry staff searching laundry rm (room) & manager will check washer traps. Surveyor # noted there are no staff statements or evidence that the ring was reported to the State agency. On 10/22/15 at 9:14 a.m., Surveyor # spoke with SSD-N about Resident #26's missing ring. Surveyor # inquired why it wasn't thoroughly investigated and reported to the State agency? SSD-N informed Surveyor # that she is still speaking with staff and that they did a room search. SSD-N indicated that they didn't have an indication that the ring was stolen and it was more likely lost. On 10/22/15 at 3:13 p.m., during the daily exit conference with Administrator-A and DON (Director of Nursing)-B were informed that Resident #25's missing ring was not thoroughly investigated and reported to the State agency as required.

Based on record reviews and staff interviews, the facility did not implement policies and procedures when 4 of 4 residents made an allegation of abuse or misappropriation of property. The allegation of possible abuse was not immediately reported to the Administrator, was not thoroughly investigated and not reported to the appropriate officials, including the state survey and certification agency. Additionally, the facility did not implement measures to prevent further potential abuse. This deficient practice has the potential to affect all residents with whom CNA-BBB has worked. CNA-BBB worked 14 evening shifts in June 2015, 11 evening shifts in July 2015, 16 evening and 1 day shift in August 2015. Additionally, copies of the nurse staff schedules from 9/2 through 9/30/15 and from 10/1/15 through 10/21/15 indicate CNA-BBB worked the 2 Center unit, second shift, a total of 22 shifts. The resident census on 2 Center ranged anywhere between 33 to 37 residents from 9/2 through 10/21/15. * On 10/19/15 during a Resident group interview with Surveyors # and # , Resident #35 stated that she was inappropriately touched by a staff member but the facility had taken care of it. On 10/22/15 Surveyor # spoke with Administrator-A and SSD (Social Service Director)-N both of whom had no knowledge of this allegation. SSD-N in the presence of Surveyor # interviewed Resident #35 on 10/22/15. During this interview, Resident #35 stated she had reported this to RN (Registered Nurse)/Nursing Supervisor-CC. The facility did not operationalize their policy and procedure when RN/Nursing Supervisor-CC did not report the allegation to Administrator-A or DON (Director of Nursing)-B, an investigation was not started, the accused staff member was not removed to protect Resident #35 and other Residents residing at the Facility, and the State agency was not notified. The failure of the facility to follow written policies and procedures when an allegation of abuse was made, created a situation of Immediate Jeopardy. The Immediate Jeopardy began on an unknown date prior to 6/28/15, when Resident #35 reported an allegation of possible abuse to RN/Nursing Supervisor-CC. Nursing Home Administrator-A, Director of Nursing-B, and Interim Administrator-CCC were notified on 10/26/15 that an Immediate Jeopardy existed. The Immediate Jeopardy was removed on 10/26/15 but continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) until all staff are trained and corrective measures are fully implemented and as evidenced by the following: * Residents #19, #25 and #26 had missing rings. The facility did not conduct through investigations into the missing rings nor did the facility report the missing rings to the state agency. Findings include: The Facility's Abuse Prevention/Resident Treatment policy and procedure with the latest revision date of March 2014 documents, It is the policy of this facility to take appropriate steps to prevent the occurrence of: Abuse, Neglect, Misappropriation of residents' property. It is also the policy of this facility to take appropriate steps to ensure that all alleged violations federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property (alleged violations) are reported immediately to the administrator of the facility. Such violations are also reported immediately to state agencies in accordance with existing state law. The facility investigates each such alleged violation thoroughly and reports the results of all investigations to the administrator, as well as to state agencies as required by state and federal law. Under investigation documents: a. Any person who knows or has reasonable cause to suspect that a resident has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion to the administrator. b. The administrator, director of nursing, or designee will notify the appropriate regulatory, investigative or law enforcement agencies immediately in accordance with state regulations. c. Allegations of abuse, neglect, or exploitation will be thoroughly investigated. The investigation will be initiated upon receipt of the allegation. The administrator, or designee, will complete the investigation process. 1. On 10/19/15 at 3:00 p.m., Surveyors # & # conducted the group interview with seventeen Residents the Facility had identified as being alert & oriented. During this meeting, while the Surveyors were discussing if the Residents in the group felt that Facility staff treated them with dignity, Resident #35 stated that a staff member had touched her inappropriately. Resident #35 stated that the Facility took care of it. On 10/22/15 at 4:15 p.m., Surveyor # asked Administrator-A if he had an investigation for Resident #35 being touched inappropriately. Administrator-A looked through his files and informed Surveyor # that the only investigation in the last year that he has regarding Resident #35 is for missing money. Surveyor # asked Administrator-A if he was aware of an allegation of Resident #35 being touched inappropriately. Administrator-A informed Surveyor # that he does not recall that and this type of allegation is a no brainer and would have been reported to the State. Administrator-A stated that he didn't have any information but maybe SSD (Social Service Director)-N has some information. On 10/22/15 at 4:28 p.m., Surveyor # asked SSD-N if she was aware of a staff member touching Resident #35 inappropriately and the Facility took care of this. SSD-N informed Surveyor # that she has no awareness of this. SSD-N informed Surveyor # that Resident #35 came from a Facility that closed and maybe she was thinking of something from there. SSD-N informed Surveyor # that she needs to go up and speak with Resident #35 about this. According to Resident #35's medical record, Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #35 is her own person. Resident #35 was hosptalized on [DATE] to 7/1/15 with UTI listed as an active problem. The quarterly MDS (Minimum Data Set) signed as complete on 7/29/15 has a BIMS (brief interview mental status) total score of 15 meaning that she is cognitively intact. On 10/22/15 at 4:34 p.m., Surveyor # entered Resident #35's room with SSD-N. SSD-N informed Resident #35 that she wanted to speak with her about an allegation that Surveyor # brought forward to her. SSD-N asked Resident #35 if anyone touched her inappropriately or made her feel uncomfortable. Resident #35 informed SSD-N that she spoke to RN (Registered Nurse)/Nursing Supervisor-CC and informed her that every time a certain person cleaned her up she would take her fingers & hands and go back and forth. Resident #35 stated, I'm so embarrassed to say this. Resident #35 stated that this staff member did this with a wash cloth and then did really deep with her hands, it was skin on skin. Resident #35 stated that the staff member said, I have to make sure that you're clean. SSD-N asked Resident #35 if she thought RN/Nursing Supervisor-CC spoke to the person. Resident #35 replied, I think she had because she said she can't come in by herself. Resident #35 informed SSD-N that at this time her concern is for other elderly people that can't express themselves. Resident #35 stated, I still can. Resident #35 informed SSD-N that she (referring to the caregiver/staff member) said, If I don't check you like this you're going to get a UTI (urinary tract infection). SSD-N asked Resident #35 where the staff member put her hands: was it on her front, inner thighs? SSD-N then stated maybe she wasn't asking the right way. Surveyor # asked Resident #35 if the staff member placed her hand in her vagina. Resident #35 replied, Yes. SSD-N asked Resident #35 if she explained this to RN/Nursing Supervisor-CC at the time. Resident #35 stated that she told her (RN/Nursing Supervisor-CC) that she (caregiver/staff member) washed her hard and put her hands, fingers up her. SSD-N asked Resident #35 if she told the person that it made her uncomfortable. Resident #35 informed SSD-N that she did but the person said she had to do it. SSD-N asked Resident #35 when this happened. Resident #35 stated within two to three months ago. SSD-N asked Resident #35 if she knew who the staff member was. Resident #35 was able to tell SSD-N the CNA's (Certified Nursing Assistant) first name, what she looked like and that there were two CNAs with this first name but she is the one that hasn't been at the facility as long and is not the person working today. SSD-N asked Resident #35 if this CNA has taken care of her since this by herself. Resident #35 indicated that she (the caregiver) has been with other staff and told the girl that she wasn't allowed to be in alone and that she is just trying to stop her (Resident #35) from getting an UTI. Resident #35 stated, Weird cause I did get a UTI (which occurred on 6/28/15). SSD-N asked Resident #35 if she spoke to anyone about this. Resident #35 indicated that she spoke to one of her friends and hasn't told her husband. Resident #35 stated, When I see her I want to throw up. Just thinking about it makes me nauseous. SSD-N informed Resident #35 that they would be doing an investigation and part of the investigation is that the police can be called. SSD-N asked Resident #35 about the police coming to talk to her and that it could be done confidentially. Resident #35 stated, I think it's too late. SSD-N explained that it's not too late and that her protection is SSD-N's utmost concern. Resident #35 replied, because of the time and I'm afraid she will retaliate. SSD-N informed Resident #35 that wouldn't be a concern. Resident #35 replied, I see her walking down the hall, and I cringe and for her to say, 'See didn't I tell you you would get a UTI?' Resident #35 then agreed to speak with the police. SSD-N inquired if this CNA has touched her since. Resident #35 indicated that this CNA has not touched her since and stated, Bothers me a whole lot. What if she's doing it to someone else? It bothers me this long. Resident #35 stated that she told RN/Nursing Supervisor-CC right away and didn't speak to anyone else because of the stress. Resident #35 stated that there have been male CNA's that have given her showers and they didn't make her feel the way she did. SSD-N again asked what this CNA said when she touched her. Resident #35 stated that she needed to make sure she was clean. Resident #35 stated that she told her that it hurt but she said she had to be thorough. Resident #35 stated that she did tell the CNA that thorough was one thing but it hurt. Resident #35 stated, I was basically just saying please stop. SSD-N offered the services of the psychologist, which Resident #35 accepted. Surveyor # noted during this conversation, Resident #35 was visibly upset. At approximately 5:20 p.m. SSD-N and Surveyor # left Resident #35's room. SSD-N informed Surveyor # that she would be reporting this to Administrator-A and DON (Director of Nursing)-B. On 10/22/15 at 5:35 p.m., Surveyor # spoke with Administrator-A who informed Surveyor # that they are self reporting this allegation. DON-B is trying to get hold of RN/Nursing Supervisor-CC and CNA-BBB (the alleged abuser) would not be working. The psych consult dated 10/23/15 under narrative documents, c/o (complained of) sexual assault concerned about retaliation from reporting the experience fears someone outside the nursing home staff might retaliate. Under general appearance & manner documents, upset about what she described as a sexual assault. On 10/26/15 at 8:15 a.m., Surveyor # met with SSD-N regarding Resident #35. SSD-N informed Surveyor # that Resident #35 was agreeable to speak to the officer, that they had a lengthy conversation and somethings in the story changed a little bit. Surveyor # inquired what the changes were. SSD-N indicated that Resident #35 stated the incident occurred more than one time and that it occurred during incontinence care and while she was caring for her in the shower. SSD-N informed Surveyor # that she had spoken with RN/Nursing Supervisor-CC and that RN/Nursing Supervisor-CC had gone to Resident #35's room for another reason. Before RN/Nursing Supervisor-CC left, Resident #35 said since you're here Resident #35 wanted to tell her something. Resident #35 informed her that Resident #35 feels uncomfortable with CNA-BBB taking care of her. SSD-N indicated that RN/Nursing Supervisor-CC asked her why and she (Resident #35) said that she washes her too hard when doing peri care and is uncomfortable. RN/Nursing Supervisor-CC then went and spoke with CNA-BBB. CNA-BBB wasn't aware of any issues with Resident #35 and in their discussion felt that CNA-BBB wouldn't take care of Resident #35 anymore. RN/Nursing Supervisor-CC went back to Resident #35 and told Resident #35 if you are uncomfortable then CNA-BBB won't take care of her but would help with transferring her since it takes four people. Surveyor # asked SSD-N if she asked RN/Nursing Supervisor-CC why she didn't report this. SSD-N replied, Not in so many words, probably should have asked her. On 10/26/15 at 8:53 a.m., Surveyor # met with SSD-N and DON-B regarding Resident #35. DON-B informed Surveyor # that it had been agreed upon that CNA-BBB would not do direct care but would assist. Surveyor # asked if it is typical for a nursing supervisor to make a decision like this and not let anyone know. DON-B informed Surveyor # what RN/Nursing Supervisor-CC gathered was that CNA-BBB wiped Resident #35 too many times. Surveyor # asked if Resident #35 has ever voiced to them that she feels uncomfortable with any other staff. SSD-N replied, No. Surveyor # asked DON-B if she asked RN/Nursing Supervisor-CC why she didn't report this. DON-B replied that she didn't ask her because she had an answer. According to them (RN/Nursing Supervisor-CC), they had run this by me but honestly, I don't remember. DON-B informed Surveyor # that she knows the proper channels and knows what she is suppose to do. On 10/26/15 at 12:35 p.m., DON-B provided Surveyor # with her typed statement which documents, On 10/26/15 writer entered room of Resident #35 with permission of resident asked resident if we could discuss allegations of sexually inappropriate touching made to state surveyor. Resident told writer that CNA would typically clean her front part, resident then proceeded to state, normally cleaned me 3-4 x (times) wiping is normal, CNA-BBB would say, I'm just tying to get you clean, I never said anything but she would wipe 8-10x, and when she was washing me would grab down there with a wash cloth, I was assuming it was her fist. Resident then stated, then she would go over it with her hand, it was starting to feel sexual. Writer question if CNA was applying cream? Resident stated, I don't know I didn't ask her, I never said anything to her, I just felt her cleaning was over cleaning, I just kept my thought to myself because I felt awkward. Writer questioned if resident ever told anyone or said anything to CNA I told the CNA to stop, I felt embarrassed, CNA did say that she had to get in there to clean me. Resident stated, I'm not making this up. Writer reassured resident that the facility takes these things very seriously and her well being is very important to us, therefore; we will do whatever it takes to ensure residents safety and comfort. Resident thanked writer. Writer exited residents room. Surveyors # and # noted that CNA-BBB worked 14 evening shifts in June 2015, 11 evening shifts in July 2015, 16 evening and 1 day shift in August 2015. Additionally, copies of the nurse staff schedules from 9/2 through 9/30/15 and from 10/1/15 through 10/21/15 indicate CNA-BBB worked the 2 Center unit, second shift, a total of 22 shifts. The resident census on 2 Center ranged anywhere between 33 to 37 residents from 9/2 through 10/21/15. The failure to promptly report, investigate, and to put measures in place to protect residents from further potential abuse while an investigation was in progress created a finding of immediate jeopardy. The jeopardy was removed on 10/26/15 when the facility: 1. Conducted a comprehensive physical assessment on 10/22/15. Resident #35 was seen for a psychological evaluation on 10/23/15. Resident #35 will have her psychosocial well-being assessed and documented on daily for 1 week, then 2 times per week for 3 additional weeks. 2. All other residents on the second floor had skin checks completed on 10/24/15. 3. All alert residents on the second floor were interviewed to identify any safety concerns related to abuse on 10/24/15. Non-alert residents will have their behavior documentation reviewed to see if there are any increased behaviors that may indicate that abuse is occurring on 10/26/15. 4. All Department Heads including the Director of Nursing and Administrator were educated on the facility's policy on Abuse, neglect and misappropriation along with the Center for Medicare and Medicaid Services (CMS) and Division of Quality Assurance (DQA) reporting requirements and investigation protocols that included, keeping residents safe during an investigation. These employees were also re-education on the facility's policy and procedure for abuse, neglect and misappropriation focusing on the investigation process and keeping residents safe during an investigation on 10/26/15. 5. Before working their next shift, all staff will be educated on the facility's policy on Abuse, neglect and misappropriation along with the CMS and DQA reporting requirements and investigation protocols that included, keeping residents safe during an investigation. These employees were also re-educated on the facility's policy and procedure for abuse, neglect and misappropriation focusing on the investigated process and keeping residents safe during an investigation by 10/26/15. This education will also be provided upon hire and annually. The Executive Director (ED) will ensure compliance. 6. Grievance forms will be readily accessible on all units to staff. All staff will be educated on utilizing the Grievance forms; grievance forms will be used for all staff to report any concerns/grievances and to report any concerns/grievances to the Director of Nursing and ED no matter how minimal they are by 10/30/15. This education will also be provided upon hire and annually. The Executive Director (ED) will ensure compliance. 7. A Quality Assurance meeting was held on 10/26/15 and the Medical Director was notified on 10/26/15. On 10/26/15 at 7:57 a.m., Surveyor # met with DON-B to discuss what the Facility has done regarding Resident #35's allegation of being touched inappropriately. DON-B informed Surveyor # that they are doing an investigation, gathering statements, have done resident interviews and the CNA has been suspended. DON-B stated that Resident #35 was seen by the psychologist on Friday (10/23/15), and the police were called on Thursday (10/22/15). Surveyor # inquired if the police spoke with Resident #35. DON-B informed Surveyor # that they came in. Surveyor # asked DON-B if she was able to get hold of RN/Nursing Supervisor-CC. DON-B replied, briefly and said that RN/Nursing Supervisor-CC said she didn't know anything about it but SSD-N has a statement from RN/Nursing Supervisor-CC. This deficient practice continues at a scope and severity level of E (potential for harm/pattern) based upon the following: 2. On 10/19/15 at 3:00 p.m., Surveyors # & # conducted the group interview with seventeen Residents the Facility had identified as being alert & oriented. During this meeting while the Surveyors were discussing if there were any problems with their personal items missing. Resident #19 stated about three and a half months ago she had a ring that was her mother's that was missing. Resident #19 indicated that she had notified the Facility of her missing ring. On 10/21/15 at 2:09 p.m., Surveyor # asked SSD-N for the investigation for Resident #19's ring. On 10/22/15, Surveyor # reviewed the missing items log and noted Resident #19 is listed on 7/21/15. Under date given to NHA (Nursing Home Administrator) documents, 8/5/15 and under resolution documents unable to locate lost item. The missing item report is dated 7/21/15. Under description of item documents, silver ring & turquoise stones. Oval shape. Under where is item usually kept documents, usually wears ring most of time. Takes off occasionally when washes hands or at times at bed time. Under social services investigative summary documents; 7/21/15 room & unit searched. Spoke to resident & dtr. (daughter). Resident unsure when she wore it last or where she put it. Item not found at this time. 7/30/15 Search of Rm (room) & unit. item not found. No rings/jewelry found by laundry, housekeeping kitchen. Resident still unable to provide any other information r/t (related to) missing item. Under executive direction investigation summary dated 8/5/15 documents; Item unable to be located & Resident not (circle with a line) able to identify where she left it. Surveyor # noted there are no staff statements or evidence that the ring was reported to the State agency. On 10/21/15 at 2:09 p.m., Surveyor # asked SSD (Social Service Director)-N about the Facility's investigation. SSD-N informed Surveyor # that she verbally spoke to staff but didn't take any statements or who she spoke with. Surveyor # inquired if the missing ring was reported to the State agency. SSD-N stated that it was not reported. Surveyor # asked why it wasn't reported? SSD-N stated because she thought Resident #19 lost the ring and the daughter indicated that it wasn't an heirloom. Surveyor # informed SSD-N that the Facility should have conducted a thorough investigation, reported the missing ring to the State agency and the ring must have been important to Resident #19 because she reported to the surveyors that her ring was missing three months after she reported it to the facility. On 10/22/15 at 3:13 p.m. during the daily exit conference with Administrator-A and DON (Director of Nursing)-B were informed that Resident #19's missing ring was not thoroughly investigated and reported to the State agency as required. 3. On 10/22/15, Surveyor # reviewed the missing items log and noted Resident #25 is listed on 9/30/15. The following sections are blank: investigation complete, date given to NHA (Nursing Home Administrator), Resolution, & initials. The missing item report dated 9/30/15 documents under description of item mothers ring with 4 stones in it. Gold. Under where is item usually kept documents, wears on finger. Under briefly describe circumstances surrounding disappearance of item documents, roommate noticed resident did not have ring on finger & notified staff. Under social services investigation summary documents; 9/30/15 Room & unit searched. Dining rm (room) hallway, shower room & activity rooms were searched item not found. Resident unsure when she last had ring on. Resident stated she does not usually take it but does not know where it could have gone. Resident denies having concerns with staff/peers & missing item. Will continue to search. Dtr. (daughter) in & aware of missing item. Is not sure when she last saw item. Dtr. aware resident more forgetful lately & not keeping track of her things. Surveyor # noted there are no staff statements or evidence that the ring was reported to the State agency. On 10/22/15 at 9:08 a.m., Surveyor # asked SSD-N when would the Facility report a missing item. SSD-N informed Surveyor # that it depends on the information. If the resident can't remember where it was last and maybe it was misplaced then it's not reported. Surveyor # informed SSD-N that a resident may not remember where they had it last and how does the Facility know that after the Resident placed an item down that someone didn't take it. Surveyor # asked why Resident #25's ring wasn't thoroughly investigated and reported to the State agency? SSD-N replied that daughter thought maybe it was lost. On 10/22/15 at 3:13 p.m., during the daily exit conference with Administrator-A and DON (Director of Nursing)-B were informed that Resident #25's missing ring was not thoroughly investigated and reported to the State agency as required. 4. On 10/22/15, Surveyor # reviewed the missing items log and noted Resident #26 is listed on 10/13/15. The following sections are blank: investigation complete, date given to NHA (Nursing Home Administrator), Resolution, & initials. The missing item report dated 10/13/15 under briefly describe circumstances surround disappearance of item documents; Family was in on Fri (Friday) 10/9 & saw resident with rings on. Family visited 10/10 & noticed rings were not on residents (L) (left) ring finger. Under Social Service Investigation summary documents; 10/13/15 Spoke with Resident's son. Family last saw rings on Fri 10/9 & noticed them missing on Sat. (Saturday) 10/10. Family did not take rings home. Room & unit searched items not located. 10/14/15 Spk. (spoke) with resident's son. Clarified when item last seen & when noticed missing. Resident's son noticed item missing over weekend. Last saw item on Fri. 10/9/15. Reviewed resident's behavior restless, taking off clothing, wraps dentures in paper towel. Writer found balled up Kleenex & paper towel in pants pockets. Laundry staff searching laundry rm (room) & manager will check washer traps. Surveyor # noted there are no staff statements or evidence that the ring was reported to the State agency. On 10/22/15 at 9:14 a.m., Surveyor # spoke with SSD-N about Resident #26's missing ring. Surveyor # inquired why it wasn't thoroughly investigated and reported to the State agency? SSD-N informed Surveyor # that she is still speaking with staff and that they did a room search. SSD-N indicated that they didn't have an indication that the ring was stolen and it was more likely lost. On 10/22/15 at 3:13 p.m., during the daily exit conference with Administrator-A and DON (Director of Nursing)-B were informed that Resident #25's missing ring was not thoroughly investigated and reported to the State agency as required.

Based on staff and resident interview observation, and record review, the Facility did not provide the necessary care and services to prevent development of pressure ulcers and promote healing of a pressure ulcer once developed for 4 (Residents #7, #1, #2, and #3) of 4 sampled Residents at risk for pressure ulcers. ~ Resident #7 was admitted to the facility on [DATE] without any pressure ulcers. On 3/14/15 during a weekly body check it was noted that Resident #7 had an open area on his coccyx that measured 0.2 by 0.2 cm. The LPN (Licensed Practical Nurse) did not document this area in the nurse's notes or on the 24 hour nursing/change of condition report. There was no RN (Registered Nurse) assessment and the physician was not notified. Therapy had issued Resident #7 an anti-thrust cushion due to his falls, but this was not pressure relieving. The Facility did not assess this cushion and did not make any changes to the CNA assignment sheets. On 3/18/15 documentation showed that the pressure ulcer had deteriorated to 6 cm x 4 cm x 1.2 cm, unstageable. Resident #7 was discharged to the hospital where the emergency department notes that bone can be seen. This created a finding of Immediate Jeopardy for Resident #7 beginning on 3/14/15. The Administrator, Director of Nursing and Corporate Consultant-H were informed of the Immediate Jeopardy on 4/16/15 at 1:07 p.m. The Immediate Jeopardy was removed on 3/31/15, however, the deficient practice continues at a scope and severity of E (potential for harm that is not immediate jeopardy/pattern) as evidenced by the following examples: ~ Resident #1 had a change of condition following a fall on 2/26/15 & 3/2/15 and was less mobile and spent more time in bed. The Facility did not revise Resident #1's plan of care and Resident #1 subsequently developed an avoidable pressure ulcer on her coccyx & right elbow. ~ Resident #2 treatment was not done on 3/23/15 as ordered by the physician. ~ Resident #3 who has a Stage 3 pressure ulcer on his coccyx was observed lying in bed with the air mattress off. Findings include: The pressure ulcers/skin integrity/wound management policy and procedure revised September 13, 2011 documents under assessment and treatment, "It is important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that may have influenced its development, the potential for development of additional ulcers or for the deterioration of the pressure ulcer(s) be recognized, assessed, and addressed as follows: a. Differentiate the type of ulcer (pressure related versus non pressure related) because interventions may vary depending on the specific type of ulcer; b. Determine the ulcer's stage; c. Describe and monitor the ulcers characteristics; d. Monitor the progress toward healing and for potential complications; e. Determine if infection is present; f. Assess, treat, and monitor pain, if present; and g. Monitor dressings and treatments." Under routine/ongoing documentation it notes, "Daily and/or routine ongoing documentation should be conducted by the licensed nurse related to the resident's skin condition and the resident's response to the care and treatment of [REDACTED]." 1.) Surveyor # reviewed Resident #7's closed medical record on 4/14/15 to 4/16/15. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7 was admitted without any pressure ulcers. The Braden Scale for predicting pressure sore risk dated 4/10/14 has a total score of "13" which is moderate risk. The CNA (Certified Nursing Assignment) assignment sheet not dated for Resident #7 documents "elevate heels when resident allows, use pillows for positioning if needed, enc. (encourage) resident to lay down after lunch, enc. off loading when up in w/c (wheelchair)." The potential for pressure ulcer development r/t (related to) decreased mobility dated 5/9/14 has interventions also dated 5/9/14 of: ~ Follow facility policies/protocols for the prevention/treatment of [REDACTED].#7 ~ Resident #7 has pressure reducing wheelchair cushion ~ Resident #7 requires a pressure relieving/reducing device on bed/chair ~ Inform Resident #7/family/caregivers of any new area of skin breakdown ~ Monitor nutritional status. Serve diet as ordered, monitor intake and record ~ Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. There is also an intervention dated 12/23/14 of "Barrier cream to scrotum and peri area BID (twice daily) and PRN (as needed)." The nurse's note dated 8/20/14 documents, "This AM CNA (Certified Nursing Assistant) during cares on Res. (Resident) noted o/a (open area) coccyx. Writer notified noted o/a 3 x 1 x 0.3 with 50% slough and 50% red base with redness around o/a without drainage without odor." The wound assessment progress report documents for initial identification a date of 8/20/14. Under location is "coccyx", Stage "PT (partial thickness)" wound type "excoriation moisture (chemical)." size "3 length 1 width .3 depth" and color "thin 50% slough 50% pink." Weekly measurements continue with the last measurement prior to hospitalization is dated 9/9/14. The measurements are .6 length by .2 width. Stage is documented as "PT/excoriation". Color "pink with yellow febrinous". Under treatment documents "9/10/14 Tx. (treatment) changed to Santyl to ¿(decrease) small amt. (amount) yellow febrinous tissue." The actual impaired skin integrity care plan for site coccyx is dated 8/20/14. The approaches/interventions checked on 8/20/14 are: ~ monitor skin with AM/PM cares ~ wound care as ordered see Treatment record ~ monitor wound healing via interdisciplinary wound round ~ keep skin clean, dry and moisturized ~ consult wound care specialist PRN ~ wheelchair cushion ~ position body with pillows and other support devices ~ reposition every 2 hrs (hours) and PRN ~ avoid pressure to affected areas ~ teach weight shifting techniques encourage ~ encourage ambulation and mobility as tolerated ~ diet as ordered Resident #7 was hospitalized [DATE] to 9/19/14 [MEDICAL CONDITION] secondary to bilateral parotitis [MEDICAL CONDITIONS] bacteremia. The nursing comprehensive admission assessment dated [DATE] for skin assessment documents "scar" at coccyx and does not document any wounds. This form does not have a section for pressure ulcers and directs staff to designate area on diagram for wounds, scars, bruises, skin tears, rashes, incisions, and other. The Braden scale for predicting pressure sore risk dated 9/18/14, 9/27/14, 10/10/14 & 11/10/14 all have a total score of "16" mild risk. The nurse's note dated 11/10/14 documents, "Resident was found to have by aide on coccyx 2 o/a #1 is 0.5 circular without drainage without odor with 0.1 cm depth. #2 is just below #1 with 0.25 circular with 0.1 depth. Wound nurse aware, MD updated, guardian updated & stated this area is scarred from old wound occurrence. Requests new cushion. Therapy Director-Q aware. NOR (new order received) for [MEDICATION NAME] (cut to size) q (every) 3 days." On 11/10/14 after the coccyx reopened, the facility re-initiated 11/10/14 the actual impaired skin integrity interventions from 8/20/14. Surveyor # noted this was the exact same care plan with interventions that was initiated on 8/20/14. Under the comments documents "12/9/14 closed." The annual MDS with an assessment reference date of 3/5/15 documents that Resident #7 has short and long term memory problems and is severely impaired for cognitive skills for daily decision making. Resident #7 requires extensive assistance with one person physical assist for bed mobility, transferring, & toileting, is checked as having an ostomy and is always incontinent of urine. Resident #7 is checked as being at risk of developing pressure ulcers and does not have any unhealed pressure ulcers. For skin and ulcer treatments pressure reducing device for chair, pressure reducing device for bed and application of nonsurgical dressing (with or without topical medications) other than to feet are checked. The pressure ulcer CAA (care area assessment) for ARD (assessment reference date) 3/5/15 documents under care plan considerations "Resident is long term at facility and is at risk for pressure ulcer development r/t (related to) limited mobility and history of pressure ulcer. Pressure reducing devices are in place and skin is monitored with cares and bathing. Staff assists with hygiene and dressing and manages incontinence episodes. Goal is to maintain hygiene and skin integrity." The weekly body check dated 3/7/15 does not document any pressure ulcers for Resident #7. The therapy tracking note dated 3/9/15 documents, "Eval (evaluation) completed see 700 form for details. Taller w/c & anti-thrust cushion green min/mod for transfers no highback /reclining w/c available @ (at) this time. Forward anti-tilt pedals ordered by maintenance." On 4/26/15 at 10:55 a.m. Surveyor # asked Therapy Director-Q if the anti-thrust cushions are also pressure relieving. Therapy Director-Q informed Surveyor # that some are and some aren't. Surveyor # asked if the anti-thrust cushion that therapy provided to Resident #7 was pressure relieving. Therapy Director-Q replied, "No" and explained that they were concerned about Resident #7's falls so she knows it wasn't. The weekly body check dated 3/14/15 documents, "open wound .2 cm (centimeters) x (times) .2 cm." There is a circle drawn on the coccyx/ buttocks area of the body diagram. This form is signed by CNA-O and LPN (Licensed Practical Nurse)-P. The Braden scale for predicting pressure sore risk dated 3/14/15 has a total score of "16" mild risk. On 3/14/15 LPN-P initiated an impaired skin integrity actual care plan. The interventions checked are: ~ monitor skin with AM/PM cares ~ wound care as ordered see Treatment record ~ monitor wound healing via interdisciplinary wound round ~ keep skin clean, dry and moisturized ~ consult wound care specialist ~ specialty mattress/bed ~ wheelchair cushion ~ reposition every 2 hrs and PRN (as needed) ~ avoid pressure to affected areas ~ diet as ordered" is checked. The nurse's notes dated 3/14/15 at 3:46 a.m, 10:45 a.m., and 8:00 p.m. discuss a fall and follow-up. Surveyor # noted the nurse's notes on 3/14/15 do not document on the open area found during the weekly skin check on 3/14/15 nor is there any documentation that Resident #7's physician and legal representative were notified of the new open area. There is no RN (Registered Nurse) assessment and the CNA assignment sheet was not updated to reflect the open area and what new interventions were implemented to prevent the pressure ulcer from getting worse. Resident #7 is listed on the 24 hour nursing/change of condition report sheet on 3/14/15 for Fall with cran/body checks. There is no documentation regarding Resident #7's pressure ulcer. According to the March 2015 TAR the [MEDICATION NAME] was changed according to physician orders [REDACTED].#7's pressure ulcer. The nurse's note dated 3/15/15 documents, "Pt. (patient) placed in recliner in 2C lounge across from 2C nurses station so pt. could be closely monitored. Staff instructed/educated to make sure they take pt. to lounge and transfer him to recliner, not leave him in hallway as to prevent further falls." On 4/15/15 at 10:52 a.m. Surveyor # spoke with CNA-F regarding Resident #7. CNA-F informed Surveyor that most of the time Resident #7 was up and would lie down if he was really tired. Surveyor # reviewed the nurse's notes dated 3/15/15, 3/16/15, and 3/17/15. There is no documentation regarding the open area that was identified during the weekly body check on 3/14/15. Resident #7 is listed on the 24 hour nursing/change of condition report sheets on 3/15/15, 3/16/15, and 3/17/15 for fall with cran/body checks. There is no documentation regarding Resident #7's pressure ulcer. The nurse's note dated 3/18/15 at 1700 (5:00 p.m.) by the DON (Director of Nursing) documents, "Staff nurse reported to writer resident had open area to coccyx resident noted open are to (L) (left) inner coccyx unstageable, noted increased drainage. Stat labs obtained ordered stat UA (urinalysis) & stat CXR (chest x ray) updated Physician-R, NP (Nurse Practitioner)-S & sister, discussed with sister concerns with wound & identification of wound. sister stated "prior to admitting to your facility had had large wound there before" noted maturation/scar tissue, explained risks & benefits of hx. (history) of infections & tx resident in facility sister ok with keeping resident in facility & starting IV 's on resident for tx., sister would like frequent updates on any changes as necessary discussed appetite & labs with sister explained resident had excoriation noted prior that had healed sister stated "yeah I knew about that" explained tx in place for protection." The nurse's note dated 3/18/15 at 2330 (11:30 p.m.) documents, "Late Entry 1430 (2:30 p.m.) Resident had increased respiration 30 bounding pulse 126 T (temperature) 102.4 B/P (blood pressure) 130/80 Ox (oxygen) 94% RA (room air). Resident hands were shaking more than usual per CNA BS (bowel sounds) (+) x (times) 4, LCTA (lungs clear to auscultation). Resident had change mental status & was nonverbal. Physician-R evaluated PT (patient) & order stat UA (urinalysis), CXR (chest x-ray) & CBC (complete blood count) BMP (basic metabolic panel). Wound coccyx area was updated to DON. Wound in coccyx area measuring 6 x 4 x 1.2 area is red w/ (with) a moderate amount of serosanguinous drainage. Per DON wound tx to be applied 3x (three times) daily. Wound to be check q 4 hours as well as vitals. Wound culture was obtained & sent out. Orders from NP-S give Vanco 30 mg (milligram)/kg (per kilogram) BID (twice daily) x 10 days & 0.45 normal saline 100 cc (cubic centimeter)/hr. (hour) to give stat in place until Vanco started. Physician-R was updated w/CXR, chem. urinalysis result. New orders give [MEDICATION NAME] 500 mg PO (by mouth) daily for 7 days. Repeat BMP tomorrow (3/19/15) [MEDICATION NAME] 1 gm (gram) q (every) 12 hrs. (hours) & trough to be taken 3/20 am dose, 0.45 normal saline total 3 liters to be infused." The laboratory report for collected date of 3/18/15 documents WBC (white blood count) is 20.9 H (high) reference range is 4.0-10. Sodium is 173 critical reference range is 136-145. BUN (blood urea nitrogen) is 48 H reference range 6-23. The urinalysis for collected date of 3/18/15 under final report documents, "> (greater) 100,000 cfu/ml (colony forming unit) per milliliter) Escherichia coli. The coccyx wound collected 3/18/15 documents under final report "4+ Escherichia coli, 4+ Proteus mirabilis, 4+ Streptococcus agalactiae (group B), 1+ [MEDICAL CONDITION]-Resistant Staphylococcus aureus, 4+ Mixed skin flora." The wound assessment progress report dated 3/18/15 documents for stage "FT (full thickness)/abscess/hx (history) excoriation to area" Length "6", Width "4", Depth "1.2" tunneling/undermining 10 o'clock is circled with "1.2" documented. Color is "ruddy with some necrotic tissue present" Necrotic tissue "5%" Granulation tissue "95%" Surrounding tissue "9 x 9 inflamed red/purple discoloration infection without." Resident #7 is listed on the 24 hour nursing/change of condition report sheet on 3/18/15 for fall with cran/body checks. There is no documentation on the 24 hour report for the pressure ulcer to Resident #7's coccyx. The March 2015 TAR (treatment administration record) documents "3/18/15 Tx. (treatment) to coccyx: NS (normal saline) wound wash cleanse f/b (followed by) skin prep/f/b santyl nickel thick f/b dankins 1/2 strength moistened gauze, f/b dry gauze. change BID (twice daily) is crossed out and (Tx 3X (times) per day) & PRN (as needed)" is written. Surveyor # noted on 3/18/15 the evening shift did not initial the treatment as being completed. The nurse's note dated 3/19/15 0900 (9:00 a.m.) documents "late entry" "Upon doing body check with weekly shower on 3-14-15 writer noted @ error a small area to coccyx .2 cm x .2 cm in size superficial, pink in color. without drng. (drainage) or odor noted. Surrounding tissue is pink, wnl (within normal limits) without maceration noted, without s/s (signs/symptoms) of infection. Area distal to coccyx is discolored but blanchable. without c/o pain to area without outward signs of pain (groaning, guarding, or flinching) to area when palpated. 2 x 2 [MEDICATION NAME] placed to area as a preventative measure. CNA & writer transferred pt. (patient) to w/c with use of a gait belt." Resident #7 is listed on the 24 hour nursing/change of condition report sheet on 3/19/15 for "IV abt./fluids/abnormal lab values/wound." Surveyor # noted this is the first time that Resident #7's wound is documented on the 24 hour report 5 days after it was discovered. The hospital records for admission date of [DATE] documents under primary diagnosis, "Sepsis, most likely secondary to a stage IV decubitus ulcer with likely osteo[DIAGNOSES REDACTED], polymicrobial with strep and proteus. " Under hospital course documents, "This is a [AGE] year old gentleman admitted with signs [MEDICAL CONDITION]. At the time of admission he was nonverbal. He had been noted to have a new sacral decubitus ulcer and had profound [MEDICAL CONDITION] to a sodium of 169." The emergency department chart for arrival date of 3/19/15 documents under chief complaint "wound check of the buttocks." Under triage documents "Wound on coccyx. Currently being treated at Waukesha Springs with IV (intravenous) antibiotics. Sent to ED (emergency department) today for increased WBC (white blood count)." Under nursing assessment for skin/soft tissue documents "Normal skin color. Skin is warm. Decubitus ulcer noted over sacral area open 1 cm (centimeter) x (times) 3 cm open, per md can see the bone. Skin intact no acute injury. Exam of the sacrum and coccyx reveals open sacral area." Under physical exam for skin documents "Skin color is normal. Grade 4 sacral decubitus ulcer 1 by 3 cm." Under disposition documents "Condition at disposition - poor." The infectious disease consultation dated 3/20/15 under exam documents "Buttocks: There is evidence of scarring in the sacral area presumed secondary to prior sacral wound. There is a stage IV sacral decub down to the level of the sacrum. Bone is palpable. There is also an area distal to this with a purple blanched skin appearance. There is definitely some odor and necrotic tissue present within the wound bed." Under assessment documents "A [AGE] year old male with organic [MEDICAL CONDITION]/dementia, admitted for [MEDICAL CONDITION] secondary to advanced sacral decub, tracks to the sacrum so the patient has probably osteo[DIAGNOSES REDACTED]." On 4/15/15 at 1:15 p.m. Surveyor # spoke with LPN-P via the telephone regarding Resident #7. Surveyor # asked why she didn't write a note in Resident #7's medical record about the open area she observed during the weekly body check on 3/14/15 until 3/19/15. LPN-P informed Surveyor # that sometimes they get so busy they have to do the notes three to four days later. LPN-P stated that sometimes she is at home and thinks about what she needs to document. LPN-P stated that unfortunately get so distracted, the call lights are going off, the CNA's need you. Sometimes the DON will say to her that she forgot to do that paperwork referring to falls or open areas. Surveyor # asked LPN-P if the DON asked her to write the late entry note. LPN-P replied, "No I forgot." Surveyor # asked LPN-P when she told the DON, who is the Facility's wound nurse, about Resident #7's open area. LPN-P replied, "I don't know, can't remember." Surveyor # asked if she called the physician. LPN-P replied "not immediately" and explained that she's not full time. LPN-P informed Surveyor # that she thinks she updated LPN-T on Monday (3/16/15) regarding Resident #7. On 4/15/15 at 1:45 p.m. Surveyor # spoke with the DON, who is also the wound nurse for the Facility, regarding Resident #7. Surveyor # asked if she would expect LPN-P who found the open area on 3/14/15 to document, notify her and the physician. The DON replied "yes" and informed Surveyor # that she gave her an inservice for notification, documentation, and that this was not acceptable to her. Surveyor # inquired how she was informed of the open area. The DON explained that the evening nurse told her something was going on with Resident #7 so she went up there and assessed Resident #7. The DON stated that she told LPN-U that she needed to do a wound occurrence sheet and that this should have been done. The DON informed Surveyor # that she called LPN-P and told her that she needed to do a wound sheet. The DON informed Surveyor # that they had preventative treatment in place. The facility's failure to aggressively respond to the identification of a pressure ulcer on 3/14/15 and which, subsequently, developed into an infected, unstageable pressure ulcer where the bone could be seen, created a finding of immediate jeopardy. The facility removed the jeopardy on 3/31/15 by which time the Facility conducted skin sweep for Residents on the 2nd floor, updated Braden assessments, in-serviced licensed nurses and certified nursing assistants on Facility policy and procedure for pressure ulcers, and brought in a wound consultant to provide in-service training to licensed nurses and nursing assistants on pressure ulcers. The deficient practice, however, continues at a scope/severity level of E (potential for harm that is not immediate jeopardy/pattern) as evidenced by the following examples: 2.) Surveyor # reviewed Resident #1's medical record on 3/24/15 & 3/25/15. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden scale for predicting pressure sore risk dated 9/12/14 has a total score of 18. A score of 15-18 is mild risk. The admission MDS (minimum data set) signed as completed on 9/25/14 has a BIMS (brief interview mental status) score of "7" which indicates severe impairment. Resident #1 requires extensive assistance with two plus person physical assist for bed mobility & transfers, requires extensive assistance with one person physical assist for toileting, is occasionally incontinent of urine and continent of bowel. Resident #1 is at risk for developing pressure ulcers and currently does not have any pressure ulcers. For skin and ulcer treatments pressure reducing device for chair, pressure reducing device for bed, and applications of ointments/medications other than to feet are checked. The pressure ulcer CAA (care area assessment) dated 9/25/14 documents under care plan considerations: "Resident is at risk for pressure ulcers due to decreased mobility and incontinence. Goal is to maintain skin integrity. Staff to monitor skin with all cares and bathing." The potential for pressure ulcer development care plan initiated and revised on 10/14/14 has interventions of: ~ Resident #1 requires a pressure relieving/reducing device on chair ~ Follow the facility policies/protocols for the prevention/treatment of [REDACTED]. ~ Monitor nutritional status. Serve diet as ordered, monitor intake and record. ~ Obtain and monitor/lab/diagnostic work as ordered. Report results to MD and follow up as indicated. The quarterly MDS signed as completed on 12/24/14 has a BIMS (brief interview mental status) score of "12" which indicates moderately impaired. Resident #1 requires extensive assistance with two plus person physical assist for bed mobility, transfers and toileting, is occasionally incontinent of urine and bowel. Resident #1 is at risk for developing pressure ulcers and currently does not have any pressure ulcers. For skin and ulcer treatments pressure reducing device for chair, pressure reducing device for bed, and applications of ointments/medications other than to feet are checked. On 2/26/15 Resident #1 was found lying on the floor on her right side. Resident #1 sustained a laceration on the right side of her head, was transferred to the hospital and received 21 sutures. On 3/2/15 Resident #1 was found face down on the floor. The nurses note on 3/2/15 documents "Overall seems more confused since last fall in general. ROM (range of motion) to (R) (right) should/arm decreased." The nurse's note dated 3/5/15 documents, "Neuro checks (-) (negative) however noted resident is more tired and occ. (occasionally) confused ... " The nurse's note dated 3/6/15 documents, "Significant pain this AM. [MEDICATION NAME] 10 ml (milliliters) given. Decreased ROM (B)UE More significant weakness noted on right. Requires assistance w/ (with) feeding. Did not want any breakfast. Extensive assist with ADL's (activities daily living)/cares. Bruising remains throughout face. Sutures to forehead C/D/I (clean/dry/intact). Incision shows without s/s (signs/symptoms) infection." The nurse's note dated 3/6/15 addendum late entry for 3/3/15 documents, "Weakness noted on (r) side, PRN pain medications given as requested. ___in AM, needed assistance with breakfast d/t (due to) weakness. Needed assistance with cares and ADL's. Layed down post breakfast. Mood affect decreased/negative." The nurse's note dated 3/7/15 documents "Generalized weakness. Assist two for transfers and max. (maximum) assist for ADL's. Coughing noted post drinking screen referral sent to ST (speech therapy). Having difficulty holding head up, voice increase quiet. Needs must be anticipated." After Resident #1 fell twice within four days, and was noted to be weaker, requiring more assistance with her ADL's the Facility did not revise her plan of care to prevent the development of pressure ulcers. The nurse's note dated 3/9/15 documents, "CNA (Certified Nursing Assistant) alerted writer to the open area on resident's coccyx. Area measures 3 cm (centimeters) x (times) 3 cm with eschar. New treatment implemented. " The wound assessment progress report for initial identification of a pressure ulcer, dated 3/9/15 notes: ~ location: "coccyx" ~ stage: "unstag. (unstageable)" ~ wound type: "pressure" ~ length "3" ~ width "3" ~ color "yellow adherent" ~ drainage "sero/sang." The actual impaired skin integrity care plan for site coccyx dated 3/9/15 has approaches/interventions checked of "Monitor skin with AM/PM cares," "Wound care as ordered: see Treatment record," "Keep skin clean, dry and moisturized," "Reposition every 2 hrs (hours) and PRN (as needed)." On 3/9/15 Resident #1 was admitted to hospice. On 3/10/15 facility staff identified a second pressure ulcer. The wound assessment progress report for initial identification dated 3/10/15 notes: ~ location: "(R) (right) elbow " ~ stage: "II" ~ wound type: "pressure" ~ length: "1" ~ width: "1," ~ color: "pink" ~ drainage: "sero/sang." The actual impaired skin integrity care plan for R elbow, which is not dated, under approaches/interventions is checked for "Monitor skin with AM/PM cares," "Avoid pressure to affected area" and "Consult wound care specialist." The CNA (Certified Nursing Assistant) assignment sheet dated 3/11/15 includes sections of ADLs (activities daily living), Devices & oral care, mobility, toileting, eating, fall precautions, special needs, & nurse's notes. Under special needs documents "Encourage Resident #1 to wait for staff assist. Poor short term memory and safety awareness; sleeps in recliner at night per Resident/daughter preference." Under nursing notes documents "Resident's daughter is her guardian and very involved in care. Resident to lie down after meals." The nurse's note dated 3/12/15 documents, "Wanted to stay in bed at breakfast. Staff in to feed. Gen (generalized) weakness. Marked function decline and decreased ROM (range of motion). Freq. (frequent) requiring assist two for transfer. O/a (open area) to coccyx changed. pain meds (medication) scheduled now. Per Hospice RN (Registered Nurse)-BB new pressure relieving mattress ordered to be delivered today." On 3/24/15 at 9:54 a.m. following the treatment observation for Resident #1' coccyx, Surveyor # inquired about the bruising on Resident #1's face. LPN (Licensed Practical Nurse)-C informed Surveyor # that Resident #1 fell twice, received 21 sutures after first fall and found in room face down three days later. Surveyor # asked LPN-C how Resident #1 developed the pressure ulcer on her coccyx. LPN-C informed Surveyor after the falls she has been spending more time in bed. LPN-C indicated that on a Friday the pressure ulcer wasn't there and then on a Monday it was reported to her. On 3/25/15 at 8:05 a.m. Surveyor # spoke with LPN-C regarding Resident #1. LPN-C informed Surveyor # that before the Resident #1's two falls (2/26/15 & 3/2/15) Resident #1 was for the most part very cooperative, she was a one assist and could feed herself. LPN-C informed Surveyor # that Resident #1 could be a little stubborn, would tell staff when she needed to go to the bathroom, refused to sleep in her bed and would sleep in the recliner. Surveyor # inquired if there was a pressure reducing cushion in the recliner. LPN-C replied "no" and explained because she would slide down so there was dycem but after the falls Resident #1 slept in her bed. LPN-C informed Surveyor # that before the falls she could reposition herself a little but after she fell she couldn't and staff would have to reposition her. Surveyor # asked LPN-C after Resident #1 fell was the plan of care changed in terms of how often to reposition her. LPN-C informed Surveyor # that staff should go in and turn her every two hours. Surveyor # asked LPN-C how Resident #1 received the pressure ulcer on her right elbow. LPN-C replied "I think from constantly being on right." On 3/25/15 at 9:30 a.m. Surveyor # spoke with CNA (Certified Nursing Assistant)-CC regarding Resident #1. CNA-CC informed Surveyor # that before the falls Resident #1 was more independent. Surveyor # asked if there was a change in the CNA care plan for Resident #1. CNA-CC informed Surveyor that now Resident #1 is a two assist and now lays down after meals. Surveyor # inquired how often Resident #1 would be repositioned. CNA-CC indicated that Resident #1 was repositioned every two hours and after the pressure ulcer it's every hour. On 3/25/15 at 11:02 a.m. Surveyor # informed the DON (Director of Nursing) of the concerns regarding Resident #1's development of pressure ulcers on her coccyx and right elbow. At 1:58 p.m. the DON informed Surveyor # the Facility had completed a Braden assessment on 12/13/14 which had a score of "16" which was mild risk. The DON informed Surveyor # that Resident #1 could move her legs and that staff knew they were supposed to reposition Resident #1. The DON informed Surveyor # that she has been working on pressure ulcer prevention on Resident #1's unit. The DON provided Surveyor # with a memo to staff dated 1/28/15 which documents "In the past several weeks there have been no fewer than 5 new wounds on this unit (2N). Based on the types of wounds and locations it is evident these are a result of 1. Improper and untimely skin/peri/incontinence care. 2. Residents being improperly repositioned and/or untimely if at all. 2. Plan of care regarding wounds care not be followed." This memo goes on to address what the expectations are for the CNA's and nurses. 3.) Surveyor # reviewed Resident #2's medical record on 3/24/15 & 3/25/15. On 12/15/14 Resident #2 developed an unavoidable unstageable pressure ulcer on her right lateral heel. The quarterly MDS (minimum data set) signed as completed on 2/4/15 documents a BIMS (brief interview mental status) total score of "15" which indicates cognitively intact. The physician telephone orders dated 3/19/15 documents "D/c (discontinue) wound vac." "NS (normal saline) wash, f/b (followed by) skin prep f/b [MEDICATION NAME] (a type of wound dressing) to wound base, f/b alginate & meplix border change every Mon/Thur (Monday/Thursday). Use ca (calcium) alginate f/b ly

Based on record review and interview, facility staff did not monitor, assess for changes and take appropriate action when 1 (Resident #10) of 1 Residents had a change in bowel patterns after his Senna S medication was discontinued. Resident #10 developed a partial small bowel obstruction with [MEDICATION NAME] ischemia. Additionally, 1 (Resident #10) of 1 Residents expressing pain did not have their pain managed appropriately. Resident #10 had orders for PRN (as needed) [MEDICATION NAME] 0.5 ml. every hour as needed when the decision was made for Resident #10 to receive comfort care after the bowel obstruction diagnosis. Resident #10 lived less than 24 hours after returning to the facility. During that time, nurses on all three shifts did not follow facility policies to identify and document: location/source of the pain, pain ratings before and after medication/intervention, effectiveness of the medication and duration of medication effectiveness. Night shift gave Resident #10 [MEDICATION NAME] at 3.5 and 5 hour intervals; Resident #10 reported pain ratings of ,[DATE] on that shift. The facility's failure to ensure proper bowel management and treatment of [REDACTED]. The Administrator, Director of Nursing and Corporate Consultant-H were informed of the Immediate Jeopardy on [DATE] at 1:07 p.m. The Immediate Jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of a D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan regarding bowel management and pain management. Findings include: Surveyor # reviewed Resident #10's closed medical record on [DATE] and [DATE]. Resident #10 was admitted to the facility [DATE] after a hospitalization following a stroke. Resident #10 had major [DIAGNOSES REDACTED]. BOWEL MANAGEMENT Resident #10's Resident ADL(Activities of Daily Living) flow sheet (where staff are to "Indicate # of episodes per shift") shows Resident #1- had two continent bowel movements on day shift on [DATE], then no recorded bowel movement until evening shift [DATE]. Most of the shifts had "0" entered; some were left blank. Resident #10 then had continent bowel movements on the next three shifts. Resident #10's Nurses' Notes include: [DATE] 2300 (11:00 p.m.) ...BS (bowel sounds) + (present) x 4 (in all four abdominal quadrants) abdomen soft, non-tender... Throughout the shift Resident seemed agitated and wanted to get up from bed. Eventually he had a BM (bowel movement) and had no further complaints... Surveyor # observed a Telephone Order dated [DATE] for Senna S one tablet to be given two times a day. Senna S is a combination of [MEDICATION NAME] (a stool softener that makes bowel movements easier to pass) and Senna (a laxative that stimulates muscle movement in the intestines). Resident #10's MAR (Medication Administration Record) for January shows Resident #10 then received the Senna S in the morning ,[DATE], ,[DATE] and [DATE], but PM/evening shift only signed the Senna out as given on [DATE]- not [DATE] or [DATE]. Both shifts signed the Senna S out [DATE] through [DATE]. Nurses' Notes show staff were unable to replace Resident #10's urinary Foley catheter on [DATE] and he was sent to the hospital at 5:00 p.m. Resident #10 was admitted to the hospital with [REDACTED]. Resident #10 was readmitted to the facility on [DATE] at 5:00 p.m. on an antibiotic for pneumonia and [MEDICATION NAME] (a [MEDICATION NAME], used to restore normal flora in the digestive tract that is altered by taking an antibiotic). Resident #10's readmission orders [REDACTED]. There is no evidence Facility staff noticed the Senna S was not included in the readmission orders [REDACTED]. A review of Resident #10's bowel patterns shows staff document bowel movements in two different locations. As noted above, staff are to document number of continent and incontinent bowel movement episodes on the Resident ADL Flow Sheet. Staff also document bowel movements on the Bristol Stool Chart Flow Sheet. This flow sheet includes a chart with diagrams and descriptions 7 types of bowel movements. Staff are instructed to "Use chart to the left and enter the numbers that resembles the Resident's stool, and if more than one stool per shift, enter for each stool the number it resembles. If there is no stool, please indicate with a "0". The categories range from Type 1 stool is separate, hard lumps, difficult to pass; and Type 7 is watery stool, no solid pieces, entirely liquid. Sometimes staff document in one location and not another, sometimes there is no documentation for a shift, sometimes the documentation for the same shift did not match. Overall, Resident #10 had one "4" stool (smooth and soft like a sausage or snake) on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE] (extra large); a small "6" (mushy stool, ragged edges, fluffy) on ,[DATE] and one "5" (soft blobs with clear cut edges, passed easily) on ,[DATE]. Upon Resident #10's readmission to the facility on [DATE], staff conducted another Bowel and Bladder Assessment, stating Resident #10's "Normal Bowel Pattern-Regular (but leaves blank "Time of day" and "Number per day/week); bowel sounds present in four quadrants; no history of hemorrhoids." It is noted Resident #10 has some short term memory loss, has a urinary Foley catheter, is incontinent of bowel, receives a calcium channel-blocker ([MEDICATION NAME]) -(which has a side effect of causing constipation). Staff left blank the question of "Resident has constipation: yes/no- If "yes", bowel program." This should have prompted staff to question whether or not Resident #10 needed the Senna S as he received prior to the hospitalization , since he was on a bowel program two days earlier before he was sent to the hospital. After Resident #10 returned from the hospital on the evening of [DATE], (no longer receiving Senna S), the Bristol Stool Chart documentation shows he had a medium ",[DATE]" that shift; no BM ,[DATE]; then "6" (mushy) on day shift [DATE], evening shift ,[DATE], day shift ,[DATE], small "6" on night shift [DATE], "6" on day shift ,[DATE]; with no other BMs documented in-between these "mushy" stools. Resident #10 had been passing bowel movements rated "4" before his hospitalization when he was receiving Senna S twice a day. A "6" is only one step/category above "7"- (watery, no solid pieces, entirely liquid) on the Bristol Stool Chart. According to the Bristol Stool Chart documentation, Resident #10 went 10 shifts without passing stool (from PMs ,[DATE] until a "small 6" BM on night shift ,[DATE]). However, on the ADL Flow Sheet there is unclear documentation indicating Resident #10 may or may not have had a bowel movement on the evening of ,[DATE] (notation is unclear, not mentioned in Nurses Notes). After Resident #10's bowel movement on ,[DATE], he had one additional "6" bowel movement on day shift ,[DATE] before he was sent back to the hospital at 12:30 a.m. on [DATE]. Prior to being sent out, Resident #6 had not had a documented bowel movement for seven consecutive shifts. A physician progress notes [REDACTED]. Surveyor # asked if the physician routinely reviews the bowel records or if staff informed him of the change in Resident #10's bowel patterns since returning from the hospital. DON-A stated on [DATE] the physician does not review the bowel records and would rely on nurses to alert him to any concerns. There is no documentation in the Nurses' Notes indicating nurses were monitoring Resident #10's bowel patterns, especially considering that Resident #10 was no longer receiving Senna S twice a day. Some individuals become dependent on a laxative and their bodies then do not respond normally to colonic distension and they need the laxative to have a bowel movement. In addition, individuals developing a fecal impaction (a solid, immobile bulk of feces) exhibit paradoxic diarrhea, or soft stool oozing around and past the obstruction. Resident #10's bowel patterns/ stool consistency had changed from an almost daily "4" pre-hospital while receiving Senna S, to more of an every-three-day "6" post-hospital while not receiving Senna S (,[DATE]-,[DATE], ,[DATE]-,[DATE]). Resident #10 had physician's orders [REDACTED]. (milliliters) by mouth once daily as needed for constipation; and [MEDICATION NAME] 10 mg. (milligrams) suppository to be inserted rectally once a day as needed for constipation. Neither medication was signed out on the February 2015 MAR (Medication Administration Record) as given to Resident #10 during February. Nurses' Notes on [DATE] at 5:00 p.m. state Resident #10 complained of pain ,[DATE] to LUE/LLE (left upper extremity and left lower extremity). States current pain regimen not effective. Pain assessment completed. Needs to follow up with PCP (primary care physician) to provide different pain control regimen ...BS (bowel sounds) (present) x 4. Incontinent of BM ...T 97.2, BP ,[DATE], P68, R16, SPO2 96% on room air. Resident #10's Nurses' Notes on [DATE] at 12:30 a.m. state Resident #10 had 5 vomiting episodes with bile, complained of pain in his stomach and feeling sick. ABD (Abdomen) auscultated-hypoactive sounds. Resident complained of pain left upper and lower quadrant of ABD. Skin cold and clammy. T (Temperature) 96.5, P (Pulse) 74, R (Respirations) 18, SPO2 (oxygen saturation of blood) 84%, pain ,[DATE]. Resident #10's physician was contacted and Resident #10 was sent to the hospital. Nurses' Notes on [DATE] at 2:00 p.m. state Resident #10 was admitted to the hospital with [REDACTED]. The Hospital Admission History and Physical (H&P) dated [DATE] states: Assessment/Plan: 1. Acute abdominal pain with lactic acidosis: Mostly SBO (small bowel obstruction)/ [MEDICATION NAME] ischemia. Poor prognosis was discussed with family in the ED. Decided to do Comfort Care. Will start on [MEDICATION NAME] for pain control... (It was noted in the ED Resident #10 had hypoactive bowel sounds and tenderness in abdomen with palpation.) The H&P labs show Resident #10's venous lactic acid was 10.44 mmol/L (millmole/Liter). The lab's reference range for normal values are 0XXX,[DATE].70 mmole/L. (The National Library of Medicine, National Institutes of Health, Medline reference states: Conditions that can increase lactic acid levels include ...not enough blood containing oxygen getting to a certain area of the body; <http://www.nlm.nih.gov/medlineplus/ency/article/ 7.htm>) (Note: According to [MEDICATION NAME], "The [MEDICATION NAME] arteries are the arteries that supply blood to your large and small intestines. Ischemia occurs when your blood cannot flow through your arteries as well as it should, and your intestines do not receive the necessary oxygen to perform normally. [MEDICATION NAME] ischemia usually involves the small intestine, but it may also involve other intra-abdominal organs such as the colon, liver, and stomach." <https://www.vascularweb.org/vascularhealth/Pages/[MEDICATION NAME]-ischemia.aspx> The Hospital Discharge Summary dated [DATE] states: Discharge Diagnoses: [REDACTED]. -Acute abdominal pain -SBO (small bowel obstruction -Lactic acidosis -Shock with [MEDICAL CONDITION] -AKI (acute kidney injury) -Vomiting -Pneumonia -Chronic [MEDICAL CONDITION] Hospital Course: ...In the ED (Emergency Department) he was found to be hypotensive with BPs (blood pressures) in the 60's systolic. Further workup including CT scan of abdomen revealed evidence of partial small bowel obstruction, his lactic acid was >10 and also was noted to be in [MEDICAL CONDITION]. The imaging study was done without contrast and therefore there is concern of possible bowel ischemia. Discussion was made with patient's family members last evening on his code status. Patient was made comfort care and transition to hospice. Included under Significant Diagnostic Studies (and under "Imaging") it states: Significant/large amount stool within the rectum and rectosigmoid colon, which may imply a degree of underlying constipation. Resident #10's Bowel and Bladder section of the undated Initial Care Plan states he has a Foley catheter and is incontinent of bowel. Goals are he will be free of skin impairment related to incontinence, and will exhibit no signs or symptoms of infection. There is no mention of Resident #10's constipation episode [DATE], or receipt of the telephone order on [DATE] for Senna S. The care plan does not address the change in Resident #10's bowel patterns upon readmission to the facility on [DATE]. DON-A provided Surveyor # with a form dated "Rev. [DATE]," titled "Bowel Elimination Follow Up." The instructions at the bottom of the form states: Residents who have had no BM documented during a three-day period will be listed on form every 24 hours by night shift staff. This list will be reviewed by day staff who will establish interview and visually check listed residents, establish that the resident has had a recent BM, or initiate physical abdominal follow-up. Based on information gathered by the follow-up-if abnormal, MD is notified immediately, or appropriate intervention is implemented if resident is irregular or constipated. All information is documented and charted. The form provided to surveyors was blank. Staff could not locate any completed forms that would have demonstrated staff were conducting the above procedure. A "Bowel and Bladder Management" policy and procedure, originated [DATE] and revised [DATE], discusses bowel and bladder assessments completed on admission, annually and with a decline in continence status; three-day tracking tools to also be completed; developing toileting schedules and/or training programs, and quarterly review of residents assessed to be incontinent. The policy does not address constipation management. PAIN MANAGEMENT Surveyor # reviewed the facility's policy "Pain Management" dated [DATE] and revised [DATE]. It includes: -A comprehensive pain assessment will be completed for each resident upon admission, annually, and when indicated by a Resident's change of condition or when the Resident's pain significantly changes ... -Residents are also screened for pain regularly through observing the Resident during daily care and/or observing for signs and symptoms of pain ... -The Resident's descriptive words regarding the type, location, and intensity of pain will be used to evaluate the pain and to identify changes in pain ... -The reason for PRN (as needed) pain medication administration, as well as effectiveness of the administration, will be recorded in the medication administration record (MAR). -Any identified pain issues at the time of admission will be addressed on the initial/immediate care plan; -Pain that is unresolved or worsening will be reported to the physician. Nurses' Notes at 6:35 p.m. on [DATE] state Resident #10 was readmitted to the facility. BP (blood pressure) ,[DATE], SPO2 94% on 4 liters of oxygen, T 97.2, R26, P108. Alert and oriented x1. Patient moaning, and complaining of being in pain. Orders/authorization received for [MEDICATION NAME] oral suspension (100mg. /5ml (20 mg. /1 ml), take 0.5 ml. every hour as needed). Bowel sounds faint in all quadrants. Crackles heard in all lung fields with inspiration and expiration. Foley is patent and draining clear yellow urine. Skin intact. Patient is bedridden during this shift. Assist of 2 with bed mobility. Despite having pain on admission, neither the Nurses' Notes nor the MAR indicates Resident #10 received PRN pain medication on the PM shift after returning from the hospital. However, the Controlled Drug Use Record documents MT (Medication Technician)-N signed out 0.5 ml (milliliters) of [MEDICATION NAME] (20 milligrams per 1 ml.) for Resident #10 on [DATE] at 8:30 p.m., 9:30 p.m. and 10:30 p.m. There is no pain rating, no description or location of Resident #10's pain, and no assessment and documentation regarding how long the [MEDICATION NAME] was effective at relieving or reducing Resident #10's pain. Surveyor # interviewed MT (Medication Technician)-N, who signed out three doses of [MEDICATION NAME] on the PM shift ([DATE]) when Resident #10 returned from the hospital. MT-N stated she should have documented on the MAR when she administered the medication, but the RN does an assessment prior to directing her to administer the medication, and the RN assessment should have been documented. MT-N stated she remembers when Resident #10 returned to the facility on [DATE] he was "more out of it" than before he went out to the hospital. The next Nurses' Note, on [DATE] at 7:00 a.m., documented "VS (vital signs): BP ,[DATE], T98.7, P56, R18, SPO2 89% on 5 liters oxygen via NC (nasal cannula). Responsive after a few seconds, some "gurgling" with sleep. C/O (complaint of) ,[DATE] pain. PRN MSO4 ([MEDICATION NAME]) given x 2 - + results." Again, the MAR does not include any documentation regarding the [MEDICATION NAME] administration. While the nurse documents the [MEDICATION NAME] had good results, it does not indicate where Resident #10's pain was (left upper and/or lower extremity as he had reported in previous weeks, or pain in his abdomen), for how long the good results lasted, when he complained of pain ,[DATE]- before both administrations of [MEDICATION NAME]? The Controlled Drug Use Record shows RN-K signed out 0.5 ml. doses of [MEDICATION NAME] at 2:00 a.m. and 7:00 a.m. Perhaps if staff did not wait 3.5 hours and 5 hours between administration of the [MEDICATION NAME] Resident #10's pain would not have gotten to a level of ,[DATE]- worst pain imaginable, but there is no evidence staff assessed Resident #10's pain and the effectiveness of the pain medication (dose/duration/etc.), which is imperative for a Resident on "comfort measures." Surveyor # interviewed RN-K by phone. RN-K worked night shift (late [DATE] into early morning [DATE]). RN-K stated the vital signs she documented at 7:00 a.m., at the end of her shift, were obtained around 5:30 a.m. before she gave him some 6:00 a.m. medication because she needs to take his blood pressure before giving the medication. RN-K stated she did a head to toe assessment between 1:,[DATE]:00 a.m. That is when she noted he responded after a few seconds, and she heard "gurgling". Surveyor # asked what she did regarding the "gurgling" because she did not document any further assessment or intervention. RN-K stated the "gurgling" was coming from his throat, not lungs, so she raised the head of his bed up to see if that helped. RN-K stated Resident #10 could clear the "gurgling" by coughing. RN-K stated she remembers Resident #10 grimacing and moaning in pain, but he was not guarding any particular body part. RN-K did not recall whether the pain rating of ,[DATE] was for the first or second [MEDICATION NAME] administration, or both. RN-K stated she gets very busy and sometimes does not document all the pertinent information on the MAR. RN-K acknowledged it is better pain management for the Resident to maintain a steady level of pain medication to keep the pain under control versus letting the pain get very bad then try to "catch up" with pain medication. The next Nurses' Note is on [DATE] at 11:30 a.m. documented by DON (Director of Nursing)-A, stating the MD pronounced Resident #10 to be without vital signs, they may release the body, and staff called the coroner. The only other Notes are documented by RN-I stating at 12:15 p.m. she called the funeral home; and at 12:50 p.m., stating the body was released to the funeral home. There are no additional Nurses' Notes pertaining to Resident #10. There was no documentation regarding interventions taken when Resident #10 was noted to have "gurgling" on night shift. There is no documentation at all from the day shift nurse (RN-I), even though Resident #10's change in vital signs from PM shift on [DATE] to night shift on [DATE] show Resident #10's condition was deteriorating (temperature rising, BP and pulse dropping, SPO2 lower even though Resident #10 was receiving more oxygen). These vital signs (evening shift ,[DATE] and night shift ,[DATE]) were documented on the 24 hour report sheet. The "Reason" Resident #10 was on report was "Hospital return; Comfort Care- small bowel obstruction, increased lactic acid." The Controlled Drug Use Record documents RN-I signed [MEDICATION NAME] out for Resident #10 at 8:00 a.m. and 9:00 a.m. on [DATE]. This differs from the MAR, which shows RN-I documenting [MEDICATION NAME] administration at 7:00 a.m., 8:00 a.m., and 10:00 a.m. on [DATE]. The MAR does not include any pain ratings, location of pain, effectiveness of medication, or length of time medication is effective. On [DATE] at 11:00 a.m., Surveyor and interviewed RN-I who cared for Resident #10 on day shift [DATE] before he died . RN-I stated she did not recall any cares, treatments, assessments or medication administrations that morning for Resident #10, or any other information regarding Resident #10. RN-I did not know why she did not document any assessment for Resident #10 that morning, even though he was on the 24 hour report sheet for a small bowel obstruction and needed [MEDICATION NAME] twice on the night shift. On [DATE] at 1:15 p.m. Surveyor # interviewed Certified Nursing Assistant (CNA)-J who cared for Resident #10 the morning he passed away. CNA-J did recall Resident #10. CNA-J stated she performed morning cares for Resident #10 and reported to RN-I that Resident #10 was having pain, though CNA-J was not sure if it was the left sided pain he routinely experience of some other pain. CNA-J stated she thought RN-I took Resident #10's vital signs and gave him pain medication. CNA-J stated mid-morning, she checked on Resident #10 and he appeared worse, so she informed RN-I Resident #10 did not look well. CNA-J stated a short time later she was informed Resident #10 had passed away. Surveyor # went back to interview RN-I again, in case CNA-J's recollections helped RN-I recall Resident #10. RN-I stated if a CNA tells her a resident is not doing well she does an assessment, but could not say for sure that she assessed Resident #10 on [DATE]. She does not remember what she did that day with Resident #10. RN-I stated if the CNA said he was in pain she probably gave him pain medication. Surveyor # informed RN-I that she signed out [MEDICATION NAME] for Resident #10 twice on the Controlled Drug Use Record that day, and asked why she did not document Resident #10's pain location, rating, and effectiveness of the medication. RN-I stated she does not know what she did that day nor does she know why she did not document any care provided. RN-I stated perhaps the chart was gone when she went to document regarding care provided to Resident #10. The facility's failure to monitor Resident #10's bowel patterns and ensure that Resident #10's bowel medications were properly reviewed, ordered and reconciled to prevent constipation along with the facility's failure to ensure proper pain management when receiving comfort care created a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when the facility implemented the following. 1. A new bowel management policy and protocol was implemented that includes standing orders for all Residents and a process for daily monitoring of each Resident bowel movement status. 2. All Resident had their current monthly orders reviewed to ensure no medications are listed under the ancillary section and to ensure that each Resident has the new standing house orders for bowel management. 3. All Residents were re-assessed for bowel management by physical assessment and review of patterns. 4. All Residents receiving end of life care and/or hospice care had their pain regime reviewed to ensure that an order for [REDACTED]. Records were reviewed to ensure proper assessment and care planning related to end of life care. 5. All Residents identified as receiving end of life care had pain assessments completed. 6. The facility updated their policy on end of life care to reflect pain management. 7. Comprehensive and CNA care plans were reviewed and updated related to bowel management and end of life care. 8. All nursing staff were re-educated regarding bowel management, documentation prior to death and end of life care, pain management, and interventions. 9. A system for auditing was established by the facility. 10 A system was established to monitor the facility's 24 hour boards for changes in conditions, end of life care issues and bowel management to ensure proper care. 11. QA meeting was held and the Medical Director was consulted with.

Based on interview and record review, the Facility did not ensure that 1 (Resident #7) of 1 resident reviewed for hydration was provided with sufficient fluids to meet assessed needs. There is no evidence that staff analyzed Resident #7's daily fluid intake, alerted the Dietitian to Resident #7 refusing fluids and/or implemented approaches to assist Resident #7 with meeting his daily fluid intake. On 3/19/15 Resident #7 was admitted to the hospital with [REDACTED]. Resident #7's water deficit was calculated to be approximately 6.9 liters. The Facility's failure to ensure that Resident #1 received sufficient fluids to ensure proper hydration created a finding of immediate jeopardy. The immediate jeopardy began on 3/14/15. The Administrator, Director of Nursing (DON) and Corporate Consultant-H were informed of the Immediate Jeopardy on 4/16/15 at 1:07 p.m. The immediate jeopardy was removed on 4/20/15. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as all of the portions of the correction actions have not been fully implemented. Findings include: The Hydration policy and procedure revised April 2009 documents under policy "The facility assesses all residents for their risk of hydration problems at admission and annually, as well as with a significant change of condition. There is a system for identification of those residents who require thickened liquids and/or fluid restrictions as well as providing sufficient fluids to maintain proper hydration and health (unless contraindicated) for all residents." Under procedure the policy documents the following: 1. Fluids are encouraged for all residents unless contraindicated (for example, fluid restrictions). 2. Residents who are on thickened liquids are offered thickened fluids between meals. 3. Residents on fluid restrictions have a plan in place between Dietary and Nursing as to how fluids are divided between the two departments. 4. Residents who require assistance to reach/pour or drink fluids are provided assistance as needed during meals and between meals. 5. Residents are offered additional fluids during extremely hot weather. 6. Fluids are available at the bedside unless contraindicated. 7. Other strategies for providing additional fluids could include things as: a. Fluids provided during activities such as tea times and happy hours. b. Fluid rounds mid-morning and late afternoon. c. Offering fluids during and after therapy sessions. Under assessment will address the individual's usual fluid intake pattern such as: · "Estimated daily fluid needs · Do they consume most of their fluids during meals? · At what time of the day do they consume the most fluids? · What types of fluids are preferred? · Resident's ability to obtain fluids independently · Resident's ability to drink fluids independently." Surveyor # reviewed Resident #7's closed medical record on 4/14/15 to 4/16/15. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly hydration assessment dated [DATE] documents "Resident assisted with eating & drinking. Readily takes fluids offered." The annual MDS with an assessment reference date of 3/5/15 documents, "Resident #7 has short and long term memory problems and is severely impaired for cognitive skills for daily decision making. Resident #7 requires extensive supervision with set up for eating." Resident #7 is not checked for having any swallowing disorder and is checked for mechanically altered diet. The hydration assessment dated [DATE] is checked "no" for the question " Based on the professional judgment of the assessor, is resident at risk for dehydration? " " If NO explain rationale " documents, "Pt. (patient) will drink fluids when ever offered, will usually consume all fluids on tray." On 3/14/15 a dehydration potential care plan was developed. Under related to documents "*resident Ø (not) assessed @ risk, however due to residents new open area staff to encourage fluids & nutrition." The approaches that are circled are "Encourage increase fluid intake" "TPR (temperature, pulse, respirations) B/P (blood pressure) q (every) shift" "Check tissue turgor, mucus membranes q shift" "Monitor level of consciousness" "Monitor appetite" "Consider I & O (intake and output)" "Monitor labs as ordered and report abnormal to MD." Surveyor # did not locate any documentation from 3/14/15 until his date of discharge on 3/19/15 to indicate that staff monitored Resident #7's skin turgor or mucus membranes every shift. The CNA assignment sheet was not updated to include approaches for increasing Resident #7's fluid intake. The annual nutritional screening/assessment form dated 3/16/15 documents fluids needs 30 cc (cubic centimeter) per kilogram is 2397 cc fluids per day. Review of the meal and nourishment intake log reveals the following for Resident #7's fluid intake: Date Breakfast Lunch Supper March 8, 2015 refused blank blank March 9, 2015 blank blank 240 cc (cubic centimeter) March 10, 2015 blank blank blank March 11, 2015 120 cc blank blank March 12, 2015 10 cc blank blank March 13, 2015 blank blank blank March 14, 2015 blank blank blank March 15, 2015 blank blank blank March 16, 2015 240 cc 240 cc blank March 17, 2015 refused refused blank March 18, 2015 refused refused blank March 19, 2015 blank went to hospital evening shift Resident #7 is listed on the 24 hour nursing/change of condition report sheets on 3/12/14, 3/13/14, 3/14/15, 3/15/15, 3/16/15, 3/17/15, & 3/18/15 for fall with cranial/body checks. There is no documentation regarding Resident #7's fluid intake or monitoring skin turgor/mucus membranes. The nurse's note dated 3/18/15 at 2330 (11:30 p.m.) documents, "Late Entry 1430 (2:30 p.m.) Resident had increased respiration 30 bounding pulse 126 T (temperature) 102.4 B/P (blood pressure) 130/80 Ox (oxygen) 94% RA (room air). Resident hands were shaking more than usual per CNA BS (bowel sounds) (+) x (times) 4, LCTA (lungs clear to auscultation). Resident had change mental status & was nonverbal. Physician-R evaluated PT (patient) & order stat UA (urinalysis), CXR (chest x-ray) & CBC (complete blood count) BMP (basic metabolic panel). Wound coccyx area was updated to DON. Wound in coccyx area measuring 6 x 4 x 1.2 area is red w/ (with) a moderate amount of serosanguinous drainage. Per DON wound tx to be applied 3x (three times) daily. Wound to be check q 4 hours as well as vitals. Wound culture was obtained & sent out. Orders from NP-S give Vanco 30 mg (milligram)/kg (per kilogram) BID (twice daily) x 10 days & 0.45 normal saline 100 cc (cubic centimeter)/hr. (hour) to give stat in place until Vanco started. Physician-R was updated w/CXR, chem. urinalysis result. New orders give [MEDICATION NAME] 500 mg PO (by mouth) daily for 7 days. Repeat BMP tomorrow (3/19/15) [MEDICATION NAME] 1 gm (gram) q (every) 12 hrs. (hours) & trough to be taken 3/20 am dose, 0.45 normal saline total 3 liters to be infused." The laboratory report for collected date of 3/18/15 documents WBC (white blood count) is 20.9 H (high) reference range is 4.0-10. Sodium is 173 critical (reference range is 136-145). BUN (blood urea nitrogen) is 48 H (reference range 6-23). The urinalysis for collected date of 3/18/15 under final report documents "> (greater) 100,000 cfu/ml (colony forming unit) per milliliter) Escherichia coli. The coccyx wound collected 3/18/15 documents under final report "4+ Escherichia coli, 4+ Proteus mirabilis, 4+ Streptococcus agalactiae (group B), 1+ [MEDICAL CONDITION]-Resistant Staphylococcus aureus, 4+ Mixed skin flora." The laboratory report for collected date of 3/19/15 documents the WBC is 25.5 H (high) reference range 4.0-10. Sodium is 176 critical reference range is 136-145. BUN is 60 (high) reference range (6-23). Resident #7 is listed on the 24 hour nursing/change of condition report sheet on 3/19/15 for "IV abt./fluids/abnormal lab values/wound." Surveyor # noted this is the first time that Resident #7's fluids are on the 24 hour nursing/change of condition report sheet. Resident #7 was discharged to the hospital on [DATE]. The hospital records for admission date of [DATE] documents under primary diagnosis "Sepsis, most likely secondary to a stage IV decubitus ulcer with likely osteo[DIAGNOSES REDACTED], polymicrobial with strep and proteus. Under hospital course documents "This is a [AGE] year old gentleman admitted with signs [MEDICAL CONDITION]. At the time of admission he was nonverbal. He had been noted to have a new sacral decubitus ulcer and had profound [MEDICAL CONDITION] to a sodium of 169." The emergency department chart dated 3/19/15 under physical exam for ENT (ear, nose, throat) documents "ENT inspection normal. The mucous membranes are dry." Under disposition documents "Condition at disposition - poor." The history and physical dated 3/19/15 documents under chief complaint, "Dehydration,[MEDICAL CONDITION]." Under history of present illness documents "Patient is a [AGE] year old male with a history of organic [MEDICAL CONDITION], dementia due to chronic alcoholism in the past who is a nursing home resident at Waukesha Springs who presents to the hospital due to dehydration, worsening leukocytosis and signs [MEDICAL CONDITION]. The patient is completely nonverbal and all the information is obtained from records both provided from the nursing home as well as from the emergency room . The patient has a noted sacral decubitus ulcer which is fairly new. It appears to track to the sacrum. He is afebrile in the emergency room . Labs show profound [MEDICAL CONDITION] with a sodium of 169. The patient had been on IV [MEDICATION NAME] at the nursing home but due to worsening of his white blood cell count and worsening dehydration was sent to the emergency room for further evaluation and treatment. Again the patient is completely nonverbal and unable to provide any history. I spoke with the patient's sister who is his legal guardian with paperwork from Waukesha Springs showing this. The patient does carry a DO NOT RESUSCITATE order from the nursing home as well which ____ , his guardian, has confirmed. He had additionally in the emergency room today a lactic acid that was elevated at 4.7. There does not appear to have been a chest x-ray done at this time. The patient has been started on several liters of normal saline and is being admitted to the hospital for further treatment." Under physical exam for neck documents "Supple. He has very dry mucous membranes. Under assessment and plan documents "[MEDICAL CONDITION] manifested by [MEDICAL CONDITION] leukocytosis and lactic acid of 4.7 with probable infections source of grade IV sacral decubitus ulcer." "Severe [MEDICAL CONDITION]. Under plan documents "Vigorous IV fluid hydration initially with normal saline for hydration." The nephrology consultation dated 3/21/15 documents under history of present illness "He was admitted 2 days ago because of dehydration [MEDICAL CONDITION]. He was found to have a sodium of 169 at admission." Past medical history documents "History of [MEDICAL CONDITION], including during his spring 2014 admission. Sodium was down to 140 and creatinine 1.2 as of the last labs from that admission." Under assessment and plan documents "1. [MEDICAL CONDITION] related to [MEDICAL CONDITION] and poor intake. His IV fluid has been changed to D5W at 125 per hour. His water deficit was calculated approximately 6.9 liters. (The current IVF (intravenous flow)) rate should give approximately half of that for 24 hour, which seems appropriate. Will check another metabolic panel this afternoon to make sure there is progress in the right direction. 2. Acute kidney injury - likely volume depletion, improving." On 4/15/15 at 10:30 a.m. Surveyor # asked MT (Medication Tech)-V if the CNA's keep track of what a resident eats and drinks. MT-V replied, "They are supposed to." Surveyor # inquired where this information would be kept. MT-V informed Surveyor it would be in the appetite book. On 4/15/15 at 10:33 a.m. Surveyor # asked CNA-W if Resident #7 was able to drink fluids by himself. CNA-W informed Surveyor # that she had to hand it to him because of his dementia and even with eating he had to be cued. Surveyor # asked if Resident #7 had a water glass in his room would he be able to pick it up and drink the water by himself. CNA-W replied, "I don't believe so." On 4/15/15 at 10:40 a.m. Surveyor # asked CNA-J how Resident #7 ate and drank. CNA-J informed Surveyor that some days he would eat and other days he wouldn't. CNA-J indicated that Resident #7 required reminders to eat and other days they had to feed him. CNA-J informed Surveyor # that sometimes Resident #7 would drink his fluids before he ate. Surveyor # asked CNA-J if Resident #7 received fluids in between meals. CNA-J indicated that if he was in activities they would give him something to drink and she also did. On 4/15/15 at 10:52 a.m. Surveyor # spoke with CNA-F regarding Resident #7. CNA-F informed Surveyor # that towards the end of his stay he was declining and he wouldn't eat very much. Surveyor # asked about his fluid intake. CNA-F informed Surveyor # that he would drink some and that she attempted to feed him but he was too tired. Surveyor # asked CNA-F if there was a water glass in his room, could Resident #7 drink the water himself. CNA-F informed Surveyor # that Resident #7 was on thickened liquids so there wouldn't be a water glass in his room. On 4/15/15 at 11:04 a.m. Surveyor # spoke with CNA-X regarding Resident #7. CNA-X informed Surveyor # that Resident #7 would drink his liquids before he ate his meal. CNA-X informed Surveyor that she told the nurse that Resident #7 wasn't looking too good and that she did remember that he was given a high back wheelchair also. Surveyor # asked if Resident #7 was given fluids between meals. CNA-X informed Surveyor # that they don't have thickened water upstairs so he would receive his fluids with meals. On 4/15/15 at 11:10 a.m. Surveyor # asked RN (Registered Nurse) Manager-Y who reviews the appetite book. RN Manager-Y informed Surveyor # that the Dietitian reviews it and the nurses do also because the nurse keeps an eye on fluid intake. RN Manager-Y indicated that the nurse in the front hall is responsible for the front dining room and the nurse for back hall is responsible for the back dining room. Surveyor # asked if the CNA's document what a Resident eats and drinks. RN Manager-Y replied, "Yes." On 4/15/15 at 11:35 a.m. Surveyor # spoke with Dietitian-Z. Dietitian-Z informed Surveyor # that the back dining room on the 2C unit is for Residents who require more assistance or are total assist. Surveyor # informed Dietitian-Z that it is the Surveyor's understanding that the CNA's are supposed to document in the appetite book what a Resident eats and drinks. Dietitian-Z replied, "Correct, each meal." Surveyor # asked who reviews the appetite sheets. Dietitian-Z informed Surveyor # that she uses it as a tool for her assessments and only when she has to do an assessment does she look at the sheets. Surveyor # asked Dietitian-Z if she wrote the dietary note dated 3/16/15. Dietitian-Z informed Surveyor # that the diet tech wrote it but she is out on medical leave. Dietitian-Z reviewed the note and informed Surveyor # that it looks like they were going to start honey thick fortified milk instead of regular milk to give more protein. Surveyor # asked about the fluids. Dietitian-Z informed Surveyor # that she couldn't accurately answer that at this time as the fluids are not specifically addressed in the note. Surveyor # asked Dietitian-Z if the nursing staff informed her that Resident #7 was refusing his meals and fluids. Dietitian-Z replied, "No, I have a log and I know they didn't." Surveyor # asked if she knew if the diet tech was informed. Dietitian-Z informed Surveyor # that they share an office and if she received the call she would have written it down on the log so she is sure that the diet tech didn't receive a call either. Surveyor # asked Dietitian-Z if she would have expected nursing to contact her regarding Resident #7's meal & fluid intake. Dietitian-Z informed Surveyor # that it alarmed her that it was two straight days but wasn't sure if they have a policy or not regarding this. On 4/15/15 at 1:15 p.m. Surveyor # asked LPN (Licensed Practical Nurse)-P who reviews the appetite book. LPN-P replied that the nurse on duty is supposed to make sure they have been filled out but wasn't sure if it was their job or the unit manager's. Surveyor # asked the last week that Resident #7 was at the Facility did she review the appetite sheets. LPN-P replied, "No I didn't." On 4/15/15 at 1:45 p.m. Surveyor # asked the DON (Director of Nursing) who reviews the appetite book. The DON informed Surveyor # that the nurse manager monitors and that she would expect the nurses to. The DON explained that it's the Dietitian over all that is responsible. Surveyor # informed the DON that Dietitian-Z informed Surveyor that she only reviews these when there is an assessment due and does not review them on a weekly basis. The DON replied, "This is an issue. I am fully aware of the system failure. I was aware of him being sick and giving him IV fluids." Surveyor # informed the DON that there are multiple days on the appetite sheet that is not filled out and refusals for Resident #7. The DON replied, "To be honest, you beat me to these sheets. Obviously there is a huge system failure with the CNA and nurses." On 4/16/15 at 9:30 a.m. Surveyor # asked RN (Registered Nurse)-AA if she usually worked the second floor. RN-AA informed Surveyor # that she has been floated up there two maybe three times. Surveyor # inquired if she reviews the appetite book. RN-AA informed Surveyor # not all the time, but if a CNA brought to her attention a Resident wasn't eating then she would look at the book. Surveyor # asked when she worked in March on the 2 Central unit did she review the appetite book. RN-AA replied, "I didn't. " Failure to ensure that Resident #7 received adequate fluid intake created a finding of immediate jeopardy, which began on 3/14/15 when a dehydration potential care plan was developed because of the resident ' s new open area, but which was not implemented. Five days later, the resident was admitted to the hospital with [REDACTED]. According to a study published by the National Institute of Health (<http://www.ncbi.nlm.nih.gov/pubmed/ 084>), " an overall mortality rate of 29.8% was found in elderly persons who were hospitalized with dehydration. This increased to 33.3% for those whose sodium levels were 151-153 and to 71.4% whose sodium level exceeded 154." The facility removed the jeopardy on 4/20/15, by which time it had implemented the following: 1. All Residents were reassessed for dehydration. 2. Current meal intake & fluid intake sheets were assessed along with intake and output (I&O) sheets and physical assessments were completed. 3. Care plans were reviewed and updated to reflect current assessed needs and risk factors. 4. All nursing staff were educated on documenting food and fluid intake and refusals, notification when a resident refuses a meal or has eaten less than 25%, assessment for dehydration, daily monitoring of intake sheets and notification to the physician. 5. A system was established to audit Residents and nursing care for proper hydration care/management. 6. The facility held a Quality Assurance (QA) meeting to establish ongoing plans for improvement.

Based on observation, staff interview, and record review the Facility did not consistently implement care-planned approaches for preventing falls and did not consistently implement new interventions for 1 (Resident #1) of 1 Residents reviewed for falls. Resident #1 is assessed as being at risk for falls and has a history of falls prior to admission. On 9/9/14 Resident #1 fell and the Facility implemented an intervention that the bed should be against the wall. On 9/16/14 Resident #1 had another fall and intervention of the bed against the wall was not implemented. On 9/22/14 Resident #1 fell and the Facility did not modify the interventions. Resident #1's bed was observed in the high position while staff walked away from the bedside. Findings include: Surveyor # reviewed Resident #1's medical record on 3/24/15 & 3/25/15. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The incident report dated 9/9/14 documents "lying prone on floor next to bed all caught up in blanket." The I team note for incident 9/9/14 documents "I team reviewed incident on 9/9/14 at 0330 (3:30 a.m.) resident found lying on floor on mat wrapped up in blankets, provided resident with scoop mattress & moved bed up against wall post further discussion with daughter." The fall risk assessment dated [DATE] documents a total score of "14." A total score > (greater) 8 represents high risk. The incident report dated 9/16/14 document "Lying on back on floor on fall mat." Under immediate action taken to prevent further injury to resident is checked for "anticipate resident needs" and "bed against wall." There is a handwritten notation of "out to supervised area and bed against wall." Surveyor # noted that the bed against wall was an intervention that was implemented after the 9/9/14 fall. CNA (Certified Nursing Assistant)-L writes for the question "what was the environment like? Was the lighting appropriate? is the room cluttered? "room uncluttered and dry bed was not against the wall." Resident #1's plan of care was not followed. The I team notes for incident 9/16/14 documents "IDT (interdisciplinary team) reviewed incident on 9/16/14. Resident was found lying on back on floor on floor mat without injury noted ROM WNL (range of motion within normal limits). Resident was assisted back to bed with the staff. Current POC (plan of care) reviewed. According to the family resident prefers to sleep on recliner, placed one in the room to prevent further falls & injury." The admission MDS (minimum data set) with an assessment reference date of 9/19/14 documents that Resident #1 has a total BIMS (brief interview mental status) score of "7" which indicates severe impairment. Resident #1 requires extensive assistance with two plus person physical assist for bed mobility & transfers, requires extensive assistance with one person physical assist for toileting, is occasionally incontinent of bladder, continent of bowel, had a fall within the last month prior to admission and fell on e time since admission with no injury. The incident report dated 9/22/14 documents under describe incident "Observed resident on the floor, next to recliner chair. Observed in sitting positron requested to go in recliner earlier. Bruise on right buttocks 2 x (times) 2 cm (centimeter) Nero check negative. No c/o (complain of) pain or discomfort. Without tremors. No c/o headache pain. Hand grasps. Recliner behind her." The I team notes for incident 9/22/14 documents "IDT reviewed resident's incident on 9/22/14. Resident was found on the floor next to recliner chair in sitting position. Bruise noted to (R) (right) buttock. denies pain, ROM WNL, staff assisted the resident back to recliner current POC (plan of care) reviewed resident & family requested to sleep in recliner, scoop mattress placed in bed, bed against the wall, matt on floor. care card/care plan updated. Goal is to prevent fall & injury." Surveyor # noted these interventions had been in place prior to the 9/22/14. The Facility did not implement any new interventions to prevent Resident #1 from falling from the recliner. The falls CAA (care area assessment) dated 9/25/14 documents under care plan considerations "Resident requires assist for all transfers and mobility. Goal is to prevent falls and maintain safety. Participates in therapy per poc (plan of care)." The incident report dated 10/9/14 documents under describe incident "Resident was found lying on (L) (left) side in front of recliner, knees bent slightly and head on blanket that had come off from recliner." The I team note for incident of 10/9/14 documents "IDT reviewed fall on 10/9/14. Resident was found on floor in front of recliner lying on rt (right) side with head on blanket. Redness noted to Lt. (left) hip, lf. back and lt. shoulder. No other injuries noted. Resident assisted with two to toilet and back to chair. Reminded resident to use call light before attempting to self transfer." On 10/14/14 facility implemented an intervention of dycem placed on recliner. The at risk for falls plan of care initiated and revised on 10/13/14 includes interventions also dated 10/13/14 of "Anticipate and meet Resident #1's needs," "Be sure Resident #1's call light is within reach and encourage to use it for assistance as needed," "Resident #1 needs a safe environment with even floors fee from spills and/or clutter, adequate glare-free light, a working and reachable call light, personal items within reach," "Encourage Resident #1 to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as therapy," "Ensure that Resident #1 is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair)," "Follow facility fall protocol," "Pt (physical therapy) evaluate and treat as ordered or PRN (as needed)," "Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter or remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes." Dated 10/14/14 is an intervention "Dycem placed on recliner." Dated 2/26/15 is an intervention "If resident in room unattended, needs to be in recliner" and dated 3/2/15 is "Resident #1 to lie down post meals." The quarterly MDS with an assessment reference date of 12/11/14 documents a BIMS total score of "12" which indicates moderately impaired. Resident #1 requires extensive assistance with two plus person physical assist for bed mobility, transfers, & toileting, is occasionally incontinent of bowel & bladder, and has not had any falls since prior assessment. The incident report dated 2/26/15 documents under describe incident "found on floor laying on (r) (right) side of body. Writer was called to room by CNA on 2 North to get to residents room "as soon as possible." d/t (due to) fall & bleeding. Writer & CNA rushed to room to find resident laying on her (R) side with head laceration, which was bleeding actively. Resident stated she had pain to her (L) (left) arm area/shoulder area & resident stated she did not know how she fell . CNA seen resident in w/c (wheelchair) in room 3-5 min. (minutes) prior to fall. ROM (range of motion) for resident was not WNL (within normal limits) - a lot of pain for resident." Resident #1 was transferred to the emergency room and received 21 sutures. The I team notes for incident 2/26/15 documents "I team reviewed incident from 2/26/15 at 1530 (3:30 p.m.) where resident was found lying on R (right) side next to bed w/c (wheelchair) behind resident. Laceration to forehead obtained. Sent to WMH (Waukesha Memorial Hospital) ER (emergency room ) for eval and treat. If resident in room unattended, resident needs to be in recliner or bed." The incident report dated 3/2/15 documents under describe incident "Found in prone position on floor parallel to bed. Face turned to left." CNA-M's statement dated 3/5/15 documents for What was the resident doing immediately prior to fall? "sitting by her bed side with her legs resting on the mattress." Under describe fall CNA-M writes "I seen her laying on the floor on her belly with the call light and the wheel chair leg under her." Under when and where did you last see resident ? CNA-M writes "in her room about 15 min. (minutes) prior to the fall walking past." Surveyor # noted Resident #1's plan of care was not followed as Resident #1 is to be in her recliner or bed if unattended. The I team notes for incident dated 3/2/15 documents "IDT reviewed incident from 3/2/15 at 11:15 where resident was found in prone position on floor parallel to bed. Resident stated she was trying to pick up something off the ground. Reddened area noted to R (right) shoulder. Resident to be in common area when up and laid down post meals." On 3/24/15 at 9:39 a.m. Surveyor # observed LPN (Licensed Practical Nurse)-C completing the treatment to Resident #1's right elbow pressure ulcer. LPN-C removed her gloves and placed new gloves on. LPN-C removed Resident #1's left sock & tubi grip and the dressing from the left medial ankle. LPN-C placed normal saline on gauze and dabbed the wound bed. LPN-C went to the treatment cart in the doorway, removed skin prep and applied skin prep around the wound. Surveyor # observed Resident #1's bed is in the high position and the treatment cart is located in the doorway of Resident #1's room. LPN-C went back to the treatment cart, removed cotton applicator, placed Santyl on the cotton applicator, and placed the Santyl on the wound bed. Surveyor # noted Resident #1's bed continues to be in the high position and the treatment cart is still in the doorway. LPN-C then went to the treatment cart for measurement device, measured the left ankle, removed her gloves and placed new gloves on. Surveyor # noted Resident #1's bed continues to be in the high position and the treatment cart is still in the doorway. LPN-C cut a piece of adaptic placed the adaptic over the wound bed with the Santyl, placed gauze over and an adhesive dressing over the gauze. LPN-C placed the tubi grip & sock on Resident #1's left foot and stated that she needs to do Resident #1's bottom. LPN-C removed her gloves and placed new gloves on. LPN-C informed Resident #1 that she need to roll on her side. LPN-C positioned Resident #1 from side to side to lower her pants and unfastened her incontinence product. LPN-C asked Resident #1 if she was ready and positioned Resident #1 on her side. LPN-C removed the dressing from Resident #1's coccyx, sprayed saline wash on coccyx pressure ulcer and dabbed the wound bed with gauze. LPN-C went to the treatment cart, opened the drawer to remove a measuring device. Surveyor # noted Resident #1's bed continues to be in the high position and the treatment cart is still in the doorway. LPN-C measured Resident #1's coccyx pressure ulcer, applied skin prep around the wound, and went back to the treatment cart in the door way. Surveyor # noted Resident #1's bed continues to be in the high position. LPN-C came back to the bedside, placed Santyl on a cotton applicator, and applied the Santyl to the wound bed. LPN-C went to the treatment cart, opened the drawer and removed calcium alginate. Surveyor # noted Resident #1's bed continues to be in the high position and the treatment cart is still in the doorway. The calcium alginate was placed on the wound bed, and a dressing over. LPN-C then applied barrier cream around the dressing. LPN-C removed Resident #1's brief, informed Resident #1 that she was almost done, and placed the incontinence product under Resident #1. LPN-C fastened the incontinence product and pulled up Resident #1's pants. LPN-C lowered Resident #1's bed to the lowest position. On 3/25/15 at 11:02 a.m. Surveyor # met with the DON (Director of Nursing) to discuss Resident #1's falls. The DON informed Surveyor # that she wasn't involved when Resident #1 fell in September and October 2014 as the prior Director of Nursing was reviewing the falls and she wouldn't have any information. The Director of Nursing informed Surveyor # that she did know Resident #1's daughter was very involved. Surveyor # informed the DON that when Resident #1 fell on [DATE] her plan of care was not being followed. Surveyor # informed the DON of the observation of Resident #1's bed not being lowered down when LPN-C left the bedside to go to the treatment cart multiple times during the treatment observation on 3/24/15.

Based on a complaint investigation, record review, observation and staff interview, the facility did not provide adequate supervision and assistive devices to prevent accidents for 2 (#1 & #5) of 6 residents reviewed. On 07/21/12, Resident #1 was provided a hot water heat pack by a facility Certified Nursing Assistant (CNA), for Resident #1's neck pain. Resident #1 manipulated the heat pack which then opened, spilling hot water on her thighs, abdomen, hips and groin area. Resident #1 sustained 1st and 2nd degree burns from the hot water. In addition, when the hot water spilled on Resident #1 she stood up, slipped in the water and fell , sustaining a bump to her head. The use of a heat pack is not an identified intervention to control Resident #1's neck pain. Resident #5, who has been identified as at risk for falls, has a falls care plan intervention to have her call light within reach. On 08/14/12, Resident #5's call light was observed out of her reach. Findings include: 1. Surveyor # reviewed Resident #1's medical record on 08/14-08/16/12. Resident #1 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Resident #1 began complaining of right neck, face and jaw pain on the day of admission and almost daily thereafter until approximately 07/31/12. physician's orders [REDACTED].? Lidoderm 5% patch (on 12 hours off 12 hours), Percocet 5/325mg every 6 hours, analgesic cream and Gabapentin 300mg 4 times daily. Orders also include Tylenol 600mg every 4 hours as needed and Vicodin 5/500mg every 4 hours as needed. Review of Resident #1's plan of care dated 07/03/12, indicates a problem of Pain related to Fracture of left distal radius. Interventions for this problem include, administer pain medication as per MD orders and note the effectiveness and give PRN (As Needed) med's (medications) for breakthrough (pain) and note the effectiveness. There was no intervention identified to apply heat for pain relief. Review of Nurses' Note documentation from 06/22-07/30/12, indicates nursing staff were also applying an ice pack to resident #1's neck for comfort. Nurse's Note documentation on 07/21/12 at 5:00p.m., indicates, "Writer called to room at approximately 3:30p.m. Resident spilled heat pack filled with warm H2O causing redness to abdomen, thighs and hips, then stood up and fell (slipped in H2O). Resident initially denied pain, but now states reddened areas are painful." An interview obtained from CNA-A regarding this accident, dated 07/21/12, indicates, " I was told by the resident (Resident #1) that "I can not have ice bags but am allowed hot packs." I continued to get one and had several people check the temperature including Resident #1, I warned her not to move it due to heat but she squeezed it and it broke open after I left. She then tried to to get up and fell due to the water." Surveyor # spoke with CNA-A on 08/16/12 at approximately 10:07a.m. CNA-A indicated that on 07/21/12 at the beginning of the p.m. shift, Resident #1 told him that physical therapy would no longer allow ice packs but she could use heat packs. (An interview conducted with the Therapy Director on 08/15/12 at approximately 9:50a.m., revealed therapies had never used heat to treat Resident #1's neck pain.) CNA-A also indicated he was not aware he was not allowed as a CNA to place a heat pack on any resident without the consent of nursing staff. CNA-A indicated he retrieved a "cold pack" (plastic Ziploc bag covered by a cloth material meant to contain ice), and asked an unknown dietary employee to fill the bag with water and heat it in a microwave oven. CNA-A confirmed he had two other staff and the resident test the temperature of the bag before he placed it on Resident #1's right neck/shoulder area. CNA-A indicated he instructed Resident #1 to use the call light if Resident #1 wanted the bag moved. On 8/15/12 at 11:20a.m., Surveyor # observed the treatment to Resident #1's burns. Resident #1 has multiple healing second degree burns. Areas observed included the right upper thigh and right inner groin areas. The burns on the right side are smaller than those on the left. Second degree burns are observed on the left abdomen, left groin and left upper thigh. The largest burn area is the left upper thigh, which is estimated to be approximately 3 x 7 inches. Resident #1 continues to recieve twice daily treatments to these burns. 2. Surveyor # reviewed Resident #5's record on 8/15 & 8/16/12. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #5 has a fall risk care plan developed 1/10/12, which includes the intervention to "be sure the resident's call light is within reach and encourage resident to use it for assistance as needed." On 6/19/12 at 8:00 p.m., Resident #5 was found on the floor next to her bed. She stated she was trying to get from the bed to her recliner. She complained of left arm pain, but stated the pain had been present before the fall. On 6/20/12 an X-ray of the left arm was negative for a fracture. On 6/21/12 at 2:30 a.m., Resident #5 was found on her back on the floor. There was blood on the bed frame and floor. Resident #5 had a 3 cm laceration to the back of her head, and a skin tear to the left elbow. Resident #5 was sent to the emergency room , and admitted to the hospital for altered mental status. Resident #5 returned to the facility on [DATE]. While hospitalized , Resident #5 had been diagnosed with [REDACTED]. Documentation during the night shift of 6/27/12, indicated staff were monitoring Resident #5 every 10 minutes for safety. On 6/29/12 at 3:00 a.m., Resident #5 was found lying on her left side on the floor next to her bed. There were no injuries. Resident #5 was placed on 1:1 supervision for the rest of the night. Resident #5 had another fall on 7/6/12, when she attempted to stand up from her wheelchair in the dining room. The post fall assessment completed after the fall on 7/6/12, indicated Resident #5 is able to utilize the call light independently. On 8/14/12 at 1:30 p.m., Surveyor # observed Resident #5 lying in bed. Her bed was in the low position and a mat was on the floor beside the bed. Resident #5 was asking for a drink of water. Surveyor # suggested Resident #5 pull her call light for assistance. Resident #5 stated she did not know where her call light was. Surveyor # found the call cord lying on the floor behind the bed, near the wall. Surveyor # secured the call light to Resident #5's bedding. Resident #5 then used the call light to alert staff she needed assistance. This observation was shared with administrative staff during the exit meeting on 8/16/12 at 3:15p.m. The Director of Nursing acknowledged Resident #5 needs to have her call light cord within reach.