Every finding on record at Complete Care at Maple Grove LLC

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 103 residents who reside in the facility.Surveyor observed food not properly covered in the walk-in refrigerator.Surveyor observed a scoop left in the flour bin.Surveyor observed a kitchen staff with facial hair not wearing a beard restraint.Surveyor observed food brought in by family members not properly labeled and dated.Evidenced by:The facility policy, Food Safety requirements, dated 1/26, states, in part;.labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date.keeping foods covered or in tight containers.Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food.The facility policy, Use and Storage of Food Brought in by Family or Visitors, dated, 3/26, states, in part.All food items that are already prepared by the family or visitor brought in must be labeled with content and dated.On 6/29/26 at 9:00 AM, during the initial walk through of the kitchen, Surveyor observed a scoop left in the flour bin. Surveyor observed bacon and pie crusts uncovered with no label and date in the walk-in refrigerator. Dietary Manager AA (DM) indicated the scoop should not be left in the bin and DM AA would provide staff education. DM AA indicated food items should be covered, labeled, and dated.On 6/30/26 at 1:08PM, Surveyor observed staff with facial hair, not wearing a beard restraint.On 6/30/26 at 2:40PM, Surveyor observed items in the 100-hallway refrigerator to not be labeled and dated. Dietary Manager AA (DM) indicated the two items were some sort of fruit that was brought in by a family. DM AA indicated these items should be labeled and dated. DM AA indicated staff should be wearing a beard restraint if staff has facial hair and that he has talked to this staff regarding this concern.On 7/2/26 at 3:15 PM, Nursing Home Administrator A (NHA) indicated understanding of the above concerns.The facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed.

Based on observation, interview, and record review, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene for 5 of 21 residents reviewed for accommodation of needs out of a sample of 25. R15 was observed in bed without access to a call light. R41 was observed in bed without access to a call light. Surveyor observed R11 to not have a call light within reach. Surveyor observed R24 to have long facial hair. R75 was observed in bed without access to a call light. Evidenced by: The facility's Call Lights: Accessibility and Timely Response policy, dated 1/26, states, in part: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. 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. Example 1 On 6/29/26 at 11:15 AM, during initial screening, Surveyor observed R15 in bed with call pendant in windowsill, out of R15's reach. There was no call light plugged into the wall. RN D (Registered Nurse) entered R15's room. Surveyor asked RN D how residents contact staff for assistance. RN D stated with the call light. Surveyor asked where R15's call light was located. RN D stated it looks like it is in the windowsill. Surveyor asked if R15 could reach it. RN D stated no, it shouldn't be there. On 7/2/26 at 9:10 AM, Surveyor interviewed DON B (Director of Nursing) about call lights. DON B stated all residents should have access to the bracelet or necklace pendant or the wall call light. Example 2 On 6/29/26 at 2:14 PM, during initial screening, Surveyor observed R41 in bed with call light clipped to the cord hanging from the wall behind R41's bed, out of R41's reach. No pendant noted. CNA E (Certified Nursing Assistant) entered R41's room. Surveyor asked CNA E how residents call for assistance. CNA E stated with the call light, R41 doesn't have a pendant. Surveyor asked if R41's call light was within reach. CNA E stated no, R41 should have access to the call light. On 6/29/26 at 2:19 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) and asked how residents call for assistance. LPN F stated they use the call light or pendant. Surveyor asked LPN F about R41. LPN F went to R41's room asked CNA E about R41's pendant. CNA E stated that R41 doesn't currently have a pendant. LPN F stated I will check about getting one, everyone needs to be able to call for assist. On 7/2/26 at 9:10 AM, Surveyor interviewed DON B (Director of Nursing) about call lights. DON B stated all residents should have access to the bracelet or necklace pendant or the wall call light. Example 3 The facility policy, Activities of Daily Living, dated, 1/26, states, in part;.Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. R24 was admitted to the facility on [DATE] with a diagnoses including dementia and neurocognitive disorder with lewy bodies. R24's most recent care plan, states, in part;.the resident has an ADL self-care performance deficit.PERSONAL HYGIENE/ORAL CARE: 1 Assist. On 6/29/26 at 11:14 AM, Surveyor met R24. R24 had long facial hair. R24 indicated R24 would like to be cleaned shaved. On 6/30/26 at 10:20 AM, Surveyor observed R24. R24 had long facial hair. Certified Nursing Assistant BB (CNA) indicated R24 has never declined a shower or to be assisted with shaving when she assists R24. CNA BB indicated R24 prefers to be clean shaved and can utilize electric razor with the assistance of staff. CNA BB indicated R24 needs staff assistance for all ADL's. CNA BB and Surveyor observed R24 and CNA BB indicated that R24 does need to be shaved. CNA BB indicated staff assist residents with shaving on shower days and as needed. CNA BB indicated R24 had a shower this morning. CNA BB indicated she knows there was a cord missing from R24's electric razor and perhaps that is why R24 hasn't been shaved. On 7/2/26 at 1:20PM, Director of Nursing B (DON) indicated she would expect residents to receive assistance with shaving if they need assistance. Example 4 On 6/30/26 at 12:44PM, Surveyor observed R111's call light wrapped around bed. R111 was sitting in wheelchair and unable to reach call light. On 6/30/26 at 12:45PM, Certified Nursing Assistant CC (CNA) indicated R111's call light should be within reach of resident. CNA CC placed call light near resident, so resident had access to call light. Example 5 On 6/29/26 between 10:36 AM and 11:26 AM during initial screening, Surveyor overheard R75 yelling out for help from his room several times with staff responding. Surveyor entered R75's room at 11:30 AM. R75 indicated that he waits a long time for his call light to be answered. Surveyor looked around R75's room but did not see a call light or call light pendant near him. Surveyor asked R75 where his call light was, but he did not know. At 11:37 AM, HD U (Housekeeping Director) entered R75's room with a call light pendant and put it around his neck so it was within reach for him. On 7/1/26 at 2:48 PM, Surveyor interviewed HD U and asked what had been going on with R75's call light on 6/29. HD U indicated maintenance had been fixing his call light pendant and asked her to bring it back up to R75. HD U was unsure how long it took to be fixed. On 7/2/26 at 8:32 AM, Surveyor interviewed MD T (Maintenance Director) about R75's call light. MD T indicated he had a bunch of call lights (13) to fix on 6/29. MD T indicated SW C (Social Worker) had emailed him at approximately 9:00 AM that morning to let him know that R75 needed a call light. MD T indicated his priority is to get them fixed and working, so he addressed this immediately. On 7/2/26 at 1:56, Surveyor spoke with SW C (Social Worker). SW C provided a copy of the email that she sent to MD T. The email was sent at 10:59 AM on 6/29/26 and asked MD T if he could get R75 a call light because he did not have one in his room. On 7/2/26 at 1:40 PM, Surveyor interviewed DON B (Director of Nursing) about R75's missing call light. DON B indicated residents should always have access to a call light and said a building audit was just done to ensure all call lights are in working order.

Based on interview and record review, the facility did not ensure trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents (R102) reviewed for trauma informed care out of a sample of 25 residents.R102 disclosed trauma and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions.This is evidenced by:The facility's policy, Trauma Informed Care, dated 1/26, includes: It is the policy of this facility to provide care and services. and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The facility will use a multi-pronged approach to identifying a resident's history of trauma. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan. R102 admitted to the facility on [DATE] with diagnoses including depression, anxiety, and skin-picking disorder.R102's BIMS (Brief Interview for Mental Status), dated 6/8/26, has a score of 14, indicating R102 is cognitively intact. On 6/30/26 at 8:38 AM, Surveyor interviewed R102. R102 disclosed sexual assault in her past. R102's Trauma Informed Care Assessment, dated 6/8/26, includes:1. Part 1Listed below are a number of difficult or stressful things that sometimes happen to people. For each event choose one or more of the options.4. Serious accident at work, home or recreational activity. Answer was left blank6. Physical assault. Answer is blank12. Life threatening illness or injury. Answer is blank.13. Severe human suffering. Answer is blank. 17. Any other very stressful event or experience. 1. Happened to me. 2. Part 2A. If you select numbers 1-4 as an answer to any of the above questions, briefly identify the event(s) you were thinking of: Answer is blank.3. PC-PTSD-5The PC-PTSD-5 screening is designed to identify individuals with probable PTSD (Post Traumatic Stress Disorder). Those screening positive require further assessment. Resident will answer yes or no to the following 5 questions.All 5 questions are left blank. R102's comprehensive care plan, printed 7/1/26, does not include trauma specific focus, goals or interventions. On 7/1/26 at 10:09 AM, Surveyor interviewed SW C (Social Worker) regarding the process of Trauma Informed Care Assessments in the facility. SW C indicated she completes a Trauma Informed Care Assessment soon after a resident is admitted to the facility. SW C indicated if a resident indicates a history of trauma, SW C will care plan the trauma along with known triggers. Surveyor asked SW C about R102's trauma. SW C indicated on 6/25/26 or 6/26/26, R102 informed SW C about a traumatic sexual incident that occurred when R102 was a teenager. SW C indicated a new Trauma Informed Care Assessment should have been completed and R102's care plan should have been updated. SW C indicated she did not complete a new assessment nor did she update R102's care plan but should have.

Based on interview and record review, the facility did not ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility for 1 of 1 resident (R44) reviewed for hospice services out of sample of 25 residents. R44 was receiving hospice services and the facility failed to obtain hospice care plan and notes. Evidenced by: The facility policy titled Coordination of Hospice Services, dated 1/26, states, in part: Policy: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being. Policy Explanations and Compliance Guidelines: . 2. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice. 3. The plan of care will identify the care and services that each entity will provide in order to meet the needs of the resident and his/her expressed desire for hospice care. The Hospice-Nursing Facility Services Agreement states, in part, . Agreements. the parties agree to the following terms and conditions: 1. Definitions:. (e) Hospice Plan of Care means a written care plan established, maintained, reviewed, and modified, if necessary, at intervals identified by the Hospice IDT (Interdisciplinary Team) in coordination with Facility and each Hospice Patient's attending physician. The Hospice Plan of Care must reflect goals of each Hospice Patient and his or her family and interventions. Specifically, the Hospice Plan of Care includes: (i) identification of the Hospice Services. and Facility Services needed to meet a Hospice Patient's needs and the related needs of his or her family. 2. Responsibilities of Facility. (i) Facility Services. Facility shall comply with each Hospice Patient's Hospice Plan of Care. and ensure that the level of care provided is appropriate based on the individual Hospice Patient's needs. (ii) Design of Hospice Plan of Care. Facility shall coordinate with Hospice in developing a Hospice Plan of Care for each Hospice Patient that is consistent with the hospice philosophy and is responsive to the unique needs of each Hospice Patient and his or her expressed desire for hospice care. The Hospice Plan of Care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Hospice Plan of Care. R44 was admitted to the facility on [DATE] with diagnoses that include, in part: Malignant neoplasm of connective and soft tissue of right lower limb including hip, Non-pressure chronic ulcer of other part of right foot with unspecified severity, Non-pressure chronic ulcer of other part of right lower leg with fat layer exposed, Other chronic pain, and Pain in right leg. R44 was admitted to hospice services on 1/13/26 with primary hospice diagnosis of Primary angiosarcoma of right lower extremity. R44's Comprehensive Care Plan states, in part: Focus: Dignity/Alteration in Body Image and Social Isolation r/t (related to) Fungating Tumor Malodor: Resident presents with a malignant, malodorous fungating tumor of the right lower extremity (RLE). resident is currently monitored by Nursing and Hospice services for targeted wound palliation.Date Initiated: 4/27/26. Revision on 6/30/26.Interventions: . Refer directly to hospice protocols, guidelines, and directives to safely implement alternative and advanced interventions for the mitigation and management of right lower extremity (RLE) wound malodor. Date Initiated: 4/27/26.Focus: Patient is on Hospice care related to: End of life care for malignant neoplasm of connective tissue of rt (right) lower limb/hip. Date Initiated: 5/1/26. Revision on 7/1/26.Interventions: . Allow patient to verbalize fears and concerns about dying process. Date Initiated: 5/1/26. Keep family informed of change in condition. Date Initiated: 5/1/26. Notify hospice of any change in condition or medication changes. Date Initiated: 5/1/26. Provide emotional support to patient and family during decline in the dying process. Date Initiated: 5/1/26. Provide for any patient request within reason such as any food (including fast food), flowers, music, special pictures, church on DVD, pets, etc. Date Initiated: 5/1/26. Revision on: 5/4/26. Meds/Labs/Treatments as ordered per provider/accepted. Date Initiated: 7/1/26. On 7/1/26 at 2:51 PM, Surveyor interviewed CNA J (Certified Nursing Assistant) about R44's hospice services. CNA J indicated that hospice manages R44's wound and pain medications. Surveyor asked where R44's hospice care plan was located. CNA J stated there is a care plan located in the bathroom. On 7/1/26 at 3:01 PM, Surveyor interviewed LPN K (Licensed Practical Nurse) about R44's hospice services. LPN K stated that hospice comes out and addresses R44's pain and leg treatments. Surveyor asked where R44's hospice care plan was located. LPN K indicated that it was included in PCC (Point Click Care) electronic health record. On 7/2/26 at 8:00 AM, Surveyor interviewed DON B (Director of Nursing) and asked where R44's hospice care plan was located. DON B indicated that hospice notebooks were at the nurse's station. On 7/2/26 at 9:59 AM, Surveyor interviewed LPN G while at the nurse's station and asked to review R44's hospice binder. LPN G looked and stated that she couldn't find R44's hospice binder. On 7/2/26 at 10:08 AM, Surveyor interviewed RN H (Registered Nurse) while at the nurse's station and asked to review R44's hospice binder. RN H could not locate a hospice binder. RN H stated that usually hospice fills it out and brings it back to the nurse's station, but it was not there today. RN H stated he would look around for the binder and get back to Surveyor. On 7/2/26 at 1:50 PM, Surveyor interviewed LPN G about R44's hospice care plan and binder. LPN G stated that the unit manager brought it back earlier today. LPN G stated that if a resident is on hospice, their care plan is also posted in their bathroom. LPN G took Surveyor to R44's room and showed her what she was referring to. One page of the CNA Kardex was posted on R44's bathroom wall with information on R44's ADLs (Activities of Daily Living) such as transfer status. On 7/2/26 at 1:51 PM, Surveyor interviewed MT I (Medication Technician) and asked to review R44's hospice binder with her. MT I showed Surveyor a binder with three sheets of paper that had hospice contact information on them, but no plan of care. MT I then obtained R44's paper chart and showed Surveyor that the plan of care from hospice was in the paper chart under the hospice tab. Surveyor pointed out the date in the corner of the hospice care plan, and MT I stated yes, it was just printed today. Surveyor pointed out that the hospice plan of care in R44's paper chart indicated that R44 was still living at home with home health services. MT I stated that it needed to be updated. MT I indicated that the hospice providers also print up their notes and they are included in the paper chart, but MT I stated that she did not see any evidence of those visit notes in R44's chart. On 7/2/26 at 2:26 PM, Surveyor interviewed DON B about how the facility coordinates care with hospice for R44. DON B indicated that the hospice providers will check in with facility staff when they visit and if there is any problems or changes the staff will notify hospice with updates and get their input on R44's care. Surveyor asked DON B how often the IDT team meets with hospice. DON B stated that the IDT team meets with hospice and the resident and family when they are admitted to hospice and then monthly after that. Surveyor asked DON B if there was documentation of these meetings. DON B stated that the facility gets hospice notes every time they come to visit. Surveyor asked DON B who was responsible for obtaining these notes and keeping the hospice care plan updated. DON B indicated that it was the floor nurses and unit managers who do that. Surveyor asked DON B where this information was kept. DON B stated that the hospice care plans are kept in binders on the unit, but that she was aware that R44's was printed today because it wasn't there. Surveyor asked DON B how she ensures coordination with the hospice plan of care if there was no hospice documentation in the facility. DON B stated that in R44's case it was a fluke, and she should have had a binder with all that information in it, but it just happened to be missing. The facility did not ensure collaboration and coordination with hospice for a complete plan of care for a resident in their facility who was receiving hospice services.

Based on observation, interview, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent infections or complications for 1 of 1 resident (R95) reviewed for catheters out of 25 sampled residents.Surveyor observed R95's suprapubic indwelling catheter bag to be resting in direct contact with the floor.This is evidenced by:The facility's policy, titled Catheter Care, implemented 11/2025, states in part: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy while indwelling catheters are in use. Policy Explanation: .2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.The CDC (Centers for Disease Control and Prevention) lists the following recommendation from the Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009): Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor (https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html). R95 initially admitted to the facility on [DATE] with diagnoses that include, in part: neuromuscular dysfunction of the bladder, presence of urogenital implants, and retention of urine.R95's physician orders include the following, in part: May change.suprapubic catheter every 4 weeks. Every 6th catheter change, resident must be seen by urology to evaluate SP (suprapubic) tract - Order date: 5/7/26. R95's care plan, revised on 1/19/26, includes the following information related to catheter care, in part: Focus: Actual / at risk / and/or potential for complications with use of suprapubic catheter. Goal: Will be free of serious complications r/t (related to) device use through next review. Interventions/Tasks: Dignity bag for foley when not in room.Of note: Review of R95's progress notes indicated that she was treated for a UTI (urinary tract infection) in 5/2026.On 6/29/26 at 12:24 PM, Surveyor observed R95 eating lunch in the dining room. R95 was sitting in her wheelchair with her catheter bag hooked on the bottom of the wheelchair and resting in direct contact with the floor. At 12:30 PM, Surveyor notified CNA P (Certified Nursing Assistant) about the catheter bag touching the floor. CNA P notified another CNA who was working that the bag should not be touching the floor. They took R95 back to her room, placed a dignity bag over the catheter bag, and hung it on R95's wheelchair so it was below her bladder but not in contact with the floor. At 12:46 PM, Surveyor notified LPN Q (Licensed Practical Nurse) about R95's catheter bag. LPN Q said the catheter bag should not have been in contact with the floor. On 7/1/26 at 8:17 AM, Surveyor observed R95 eating breakfast in the dining room. R95 was sitting in her wheelchair with her catheter bag hooked on the bottom of the wheelchair and resting in direct contact with the floor. Surveyor notified CNA P about the catheter bag touching the floor. CNA P indicated that she would address this with the CNA working with R95. At 9:09 AM, Surveyor informed RN Y (Registered Nurse) about R95's catheter bag being on the floor. On 7/2/26 at 1:40 PM, Surveyor reviewed findings of R95's catheter bag being on the floor with DON B (Director of Nursing). DON B indicated catheter bags should not be touching the floor and said this would be addressed with staff.

Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents from occurring for 1 of 4 residents (R31) of 25 sampled residents reviewed for safety concerns.R31's Care Plan instructed that he was to be given plastic silverware at meals; however, he was repeatedly observed to be given regular silverware at meals.This is evidenced by:The facility's policy, titled Accidents and Supervision, reviewed/revised in 3/2026, states in part: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary.Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks - the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident.3. Implementation of Interventions - using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff b. Assigning responsibility c. Providing training as needed d. Documenting interventions (e.g., plans of action developed through the QAA (Quality Assessment and Assurance) Committee or care plans for the individual resident) e. Ensuring that the interventions are put into action.R31 was admitted to the facility on [DATE] with diagnoses that include the following, in part: dementia - mild with anxiety, bipolar disorder, personality disorder, impulse disorder, and anxiety disorder. R31's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/22/26 states that R31 has a BIMS (Brief Interview for Mental Status) of 3 out of 15, indicating he is severely cognitively impaired. R31 has an activated HCPOA (Health Care Power of Attorney). On 6/29/26 at 12:24 PM, Surveyor was observing residents dining for lunch. Surveyor noted R31 sits at a table by himself in the dining room. Surveyor observed CNA R (Certified Nursing Assistant) approach R31 and take his metal fork and knife away from him. CNA R approached MT S (Med Tech) and informed her that R31 had asked CNA R to take away his fork and knife because he was going to stick them in his throat. MT S called the charge nurse immediately and then informed the unit nurse, LPN Q (Licensed Practical Nurse) about the incident. CNA R gave R31 a plastic spoon to use to finish eating his meal.Surveyor reviewed R31's Care Plan. R31's Care Plan states in a banner at the top of the page, in part: Special Instructions: Plastic silverware to be used for meals.Surveyor reviewed R31's progress notes and noted the following: -5/2/26 at 7:38 PM: During suppertime meal resident was [sic] had aggressive outburst towards another resident, screaming vulgar slurs, leaping up out of their wheelchair with their fork in their hand pointed at resident. Resident was removed from dining room and taken to their room to finish their supper with CNA staff staying with resident. Writer notified charge nurse.-5/28/26 at 7:15 AM - Psychiatry Follow Up: .History of Present Illness: .On 5/14/26, nurse.reported worsening outburst behaviors including spitting on staff members, verbal threats to other resident, and throwing utensils at other residents, primarily in the evening.-6/11/26 at 1:58 PM: Resident blurted out 'I am going to kill you' while sitting in the dining room. Behavior was not directed at any specific person. Resident removed immediately from dining room and placed in room with call light within reach.-6/17/26 at 6:58 PM: Resident had aggressive outburst at dinner table in general dining room at supper time. Resident, unprovoked by anything, began yelling vulgar obscenities, raising their fists in the air and spitting while yelling. CNA staff made attempt to speak to resident and resident picked up their glass of juice and with throwing motion made threat to hit CNA staff with glass of juice. Resident was removed from the dining room by CNA staff and taken to their room to have a moment to cool down.-6/27/26 at 9:42 PM: Resident had difficult time during breakfast meal in general dining room with disruptive behaviors that included swearing, making very loud inappropriate noises and slamming their hands off the table numerous times however, resident redirectable after discussion. On 6/29/26 at 2:00 PM, Surveyor interviewed CNA R about R31's behaviors. CNA R indicated R31 acts out when he is not getting attention. He makes threats often but then says he won't actually do anything. CNA R indicated she had to treat the silverware incident as a real threat and report it. Surveyor asked if R31 can use regular silverware for meals and CNA R said yes but indicated she would ask the kitchen to send plastic silverware for now. On 6/29/26 at 2:05 PM, Surveyor spoke with LPN Q and informed her that R31's care plan instructs that he should use plastic silverware for meals. LPN Q said she is still training but will look into that and will report this incident during shift change.On 6/30/26 at 8:43 AM, Surveyor observed R31 eating breakfast using metal silverware. On 6/30/26 at 8:52 AM, Surveyor interviewed CNA Z and asked if R31 should be using plastic silverware for meals. CNA Z said yes and told kitchen staff serving breakfast about using plastic silverware for R31 going forward. CNA Z indicated she had been told about the plastic silverware during shift change this morning but had forgotten about it. Of Note: CNA Z did not take the metal silverware away from R31.On 7/1/26 at 8:39 AM, Surveyor observed R31 eating breakfast using metal silverware. On 7/1/26 at 8:41 AM, Surveyor interviewed CNA P and asked if R31 should be using plastic silverware for meals. CNA P indicated she just realized R31 had metal silverware and told another CNA that he was not supposed to have that. CNA P then walked over to R31 and switched the metal silverware out with plastic silverware.On 7/1/26 at 9:09 AM, Surveyor informed RN Y (Registered Nurse) about R31's metal silverware being used.On 7/2/26 at 1:40 PM, Surveyor spoke with DON B (Director of Nursing) about R31's dining utensils and behaviors. DON B indicated that staff typically keep R31 separated from other residents in the dining room because of his behaviors and they are supposed to be monitoring him more closely right now due to a medication change. DON B made note of the plastic silverware intervention not being followed and said she would address it with staff members. Additionally, DON B spoke with DM AA (Dietary Manager), who indicated R31 does not have plastic silverware use instructions listed on his kitchen meal tickets.

Based on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) for 1 of 1 residents (R1) reviewed for pressure injuries of a total of 25 sampled residents.R1 is at risk for PI (pressure injury) development and has a history of pressure injuries. Staff did not obtain measurements for two weeks of a newly developed pressure injury, and failed to ensure that care planned interventions were in place to prevent worsening of the pressure injury.Evidenced by:The AMDA (American Medical Directors Association) clinical practice guideline titled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer, and identify related causes and complications. The National Pressure Injury Advisory Panel (NPIAP) at www.NPIAP.com defines PIs in the following categories:Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister.Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location.Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV.The facility's policy titled Pressure Injury Prevention and Management, dated 3/25, with last revision date of 3/26, states in part, 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. 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. Findings should include type of wound, wound measurements (measured upon discovery and at least weekly thereafter), other wound characteristics (color, exudate, odor, pain, tissue type in wound bed), and treatment and interventions implemented. 4. Interventions for Prevention and to Promote Healing. 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.). f. Interventions will be documented in the care plan and communicated to all relevant staff.R1 was admitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes Mellitus with diabetic chronic kidney disease, Peripheral Vascular Disease unspecified, and Other skin changes.R1's Comprehensive Care Plan, states in part:Focus: Skin Integrity: At Risk/ and/or Potential for complications with impaired skin integrity including skin tears, bruising, history of blisters AND/OR pressure R/T (related to) current medical/physical status. Has meds/dx (medications/diagnoses) that can/may affect skin integrity. Right heel pressure wound. Date Initiated: 2/7/23. Revision on: 6/2/26.Goal: Will have clean, dry, intact skin through next review date. Date Initiated: 2/7/23. Revision on: 5/18/26. Target Date: 12/16/26.Interventions: Medications/Labs. Treatments as ordered per provider/accepted. Date Initiated: 2/7/23. Revision on: 2/2/26. Assist/encourage pressure relief as needed/accepted. Date Initiated: 2/7/23. Follow community skin protocol. Date Initiated: 2/7/23. Reposition per standards of care and as accepted/requested. Date Initiated: 4/5/23. Revision on: 5/5/26. Observe skin with AM/PM cares and with toileting for redness, rashes, open areas, pain, swelling and report them to team leader. Weekly skin check. Lotion to dry skin. Review skin concerns with MD. Date Initiated: 5/17/23. Offloading boots to bilateral feet when in bed and recliner at ALL TIMES. Date Initiated: 5/17/23. Revision on: 5/13/26.Focus: Actual/at risk / and/or potential for complications with Diabetes. Concern of DMII (Diabetes Mellitus Type 2), INSULIN DEPENDENT - daily and/or sliding scale. Takes hypoglycemic medication. Date Initiated: 4/4/23. Revision on: 10/31/25.Interventions: Monitor bilateral feet daily for any skin issues. Date Initiated: 4/17/24. Revision on: 2/28/25.Of note, R1's last Braden Scale assessment was completed on 1/29/25 with a score of 13, indicating R1 had a moderate risk for developing pressure injuries.On 4/1/26, R1 was seen by NP O (Nurse Practitioner), whose visit notes indicate, in part: Chief Complaint: 'I found a wound to the right heel during her skin assessment'. Removed Mepilex that nursing applied this AM after finding wound. Objective: Nontender with palpation. Surrounding tissue without erythema or warmth. Wound with surrounding dark tissue. Sanguineous drainage to Mepilex.Assessment and Plan: Pressure Injury of deep tissue of right heel (primary encounter diagnosis). Comment: Discussed with nursing who notes that [Resident Name] has a history of skin blisters that open and turn into ulcers. They wonder if that is the case today. Reviewed history of bullous pemphigoid with previous NP who noted presentation was more widespread and bilateral to feet/shins in 2024. I do not see evidence of blistering anywhere else to legs at this time. Rather, wound is localized to bony prominence of heel with surrounding tissue darker in color as well as deeper/discolored injury to center of wound bed. Wound is also non-itching. Given the above, more likely a deep tissue injury that opened. Plan: Heels in offloading boots at all times in recliner and bed. Visit Diagnoses: Pressure injury of deep tissue of right heel.On 4/1/26 the following physician orders were initiated for R1:-Offloading boots to bilateral feet when in bed and recliner at ALL TIMES every shift for offloading to BL (bilateral) feet. Order Date: 4/1/26. Start Date: 4/1/26. End Date: 7/2/26.-Wound care: Location: RIGHT Heel: Rinse with saline, pat dry. Apply Calcium Alginate with silver to wound bed. Cover with Mepilex. Change daily and PRN (as needed) if soiled, loose, or dislodged, as needed for right heel wound care. May change PRN if soiled, loose, or dislodged, AND every day shift for right heel wound care. Order Date: 4/1/26. Start Date: 4/1/26. End Date: 4/17/26.On 4/2/26 R1's Weekly Skin Review indicated, Right heel has an open area that was addressed when found 4/1/26. Treatment orders are in place and completed per orders. Resident has green booties to wear to aid in healing and protection. No other new skin concerns noted at this time. Site: Right Heel. Description: Open area - Not newOf note, there are no wound measurements or wound characteristics.On 4/3/26 an IDT (Interdisciplinary Team) Skin/Wound Follow up note indicates the following: IDT review of left heel wound noted 4/1/26. [Resident Name] has a history of significant PVD (peripheral vascular disease) and her diabetes was uncontrolled for several years before being admitted to the SNF. She suffers many complications related to these two disease processes. She has a documented history of bullae spontaneously forming on her BLE (bilateral lower extremities) resulting in wounds that can take several months to heal. Per her care plan her heels are off-loaded with heel boots when in bed and her heels hang off the end of her reclining chair when she spends time in it. Her heel boots were in place per care plan prior to discovery of left heel wound. Right heel assessed by writer with scar tissue present and no skin breakdown noted.On 4/9/26 R1's Weekly Skin Review indicates the following: Right heel with open area - treatment orders in plave (sic). Dressing is clean dry and intact at this time. Site: Right heel. Description: Current wound - treatment orders in placeOf note, there are no wound measurements or wound characteristics.On 4/9/26 the following physician orders were initiated for R1:-Juven one time a day for pressure wound/risk of malnutrition. Order Date: 4/10/26. Start Date: 4/11/26. No end date.On 4/14/26, R1's Skin and Wound Evaluation indicates the following: 2.9 cm length; 3.0 cm width; 0.2 cm depth. In-house acquired. Type: Stage 2: Partial-thickness skin loss with exposed dermis. Wound bed: 100% granulation tissue. Moderate serosanguineous exudate. Edges: Attached: Edge appears flush with wound bed or as a sloping edge.Of note, these are the first measurements that are taken of the wound that was discovered on 4/1/26.On 4/17/26 the following physician orders were initiated for R1:-Wound Care: Location: RIGHT Heel. Rinse with wound cleanser, pat dry. Cut Hydrofera Blue to fit wound bed. Wet with saline and squeeze out excess saline. Apply to wound bed. Cover with ABD (abdominal pad) and Kerlix. Change daily and PRN if soiled, loose, or dislodged, as needed for right heel wound care. May change PRN if soiled, loose or dislodged AND every day shift for right heel wound care. Order Date: 4/17/26. Start Date: 4/17/26. End Date: 5/5/26.On 4/21/26, R1's Skin and Wound Evaluation indicates the following: 2.8 cm length; 3.5 cm width, 0.2 cm depth. In-house acquired. Type: Stage 2: Partial-thickness skin loss with exposed dermis. Wound bed: 100% granulation tissue. Moderate serosanguineous exudate. Faint odor. Edges: Attached: Edge appears flush with wound bed or as a sloping edge.On 4/21/26 the following physician orders were initiated for R1:-R (right) heel ulcer Cleanse with Saline and wipe debris away from ulcer, pat dry. Apply Medi-honey to bandage and apply to R (right) heel ulcer, wrap with Kerlix one time a day for wound ulcer. Order Date: 4/22/26. Start Date: 4/23/26. End Date: 5/5/26.On 4/23/26, R1's Weekly Skin Review indicates the following: Tight (sic) heel open area - treatment in place.R1 was discharged to the hospital on 4/23/26 and returned to the facility on 5/5/26. R1's Admit/Readmit Assessment, dated 5/5/26, indicates the following, in part: Section C: Skin Integrity/Braden Score of 15: Low Risk.Skin condition: Right heel has an open area that was addressed when found 4/1/26. Treatment orders are in place and completed per orders. Skin Integrity: Deep tissue injury to right heel, plantar aspect. 4 cm by 6 cm. Eschar covers about 95% of wound base. Eschar feels hard, thick and non-tender to touch. No active drainage and no odor. No granulation tissue noted. [NAME] pink tissue noted around the edges of the eschar. Surrounding skin appears darkened and dry and feels like callus. Right heel does not have any open areas but appears dry and calloused as well.On 5/5/26 the following physician orders were initiated for R1:-Wound Care: Location: RIGHT Heel. Cleanse daily with normal saline or soap and water, pat dry. Paint with betadine. Cover with dry gauze. Change daily and PRN if soiled, loose or dislodged, as needed for right heel wound care. May change PRN if soiled, loose or dislodged AND every day shift for right heel wound care. Order Date: 5/5/26. Start Date: 5/5/26. End Date: 5/14/26.-Apply Heel Medix Boots for off-loading every shift for heel boots. Order Date: 5/5/26. Start Date: 5/5/26. End Date: 7/2/26.R1's Skin and Wound Evaluations and Weekly Skin Reviews indicate the following measurements:On 5/12/26: 4.3 cm length, 6.5 cm width, 100% eschar. Stage: Unstageable: Obscured full-thickness skin and tissue [NAME] 5/13/26, R1's care plan was updated to include the following intervention: Check feet for any skin issues daily.On 5/14/26 the following physician orders were initiated for R1:-Right Heel Treatment: Wash with soap and water, apply Silvadene cream to right heel eschar, cover with gauze every other day, as needed for right heel wound care. May change PRN if soiled, loose or dislodged AND one time a day for right heel wound care. Order Date: 5/14/26. Start Date: 5/15/26. End Date: 5/24/26.R1's Skin and Wound Evaluations and Weekly Skin Reviews indicate the following measurements:On 5/19/26: 4.5 cm length, 6.4 cm width, 100% eschar. Stage: Unstageable: Obscured full-thickness skin and tissue [NAME] 5/24/26 the following physician orders were initiated for R1:-Right Heel Treatment: Wash with soap and water, apply Silvadene cream to right heel eschar, cover with gauze every other day, one time a day for right heel wound care AND as needed for right heel wound care. May change PRN if soiled, loose or dislodged. Order Date: 5/24/26. Start Date: 5/25/26. End Date: 6/11/26.R1's Skin and Wound Evaluations and Weekly Skin Reviews indicate the following measurements:On 5/26/26: 5.0 cm length, 5.6 cm width, 90% eschar. Stage: Unstageable: Obscured full-thickness skin and tissue [NAME] 6/2/26: Right heel. 4.5 cm x 6 cm. No description of wound bed or characteristics of wound.On 6/9/26: Right heel. 4.5 cm x 5.5 cm. No description of wound bed or characteristics of wound.On 6/11/26 the following physician orders were initiated for R1:-Silvadene External Cream 1% (Silver Sulfadiazine). Apply to R (right) heel topically every day shift for skin integrity maintenance until healed. Silvadene (sic) Cream 90 gm tube. Order Date: 6/11/26. Start Date: 6/11/26. No end date.R1's Skin and Wound Evaluations and Weekly Skin Reviews indicate the following measurements:On 6/16/26: 4.5 cm x 6.5 cm. No description of wound bed or characteristics of wound.Of note, on 6/23/26 there was no skin assessment or wound measurements taken.On 6/30/26: Right heel. 4.5 cm x 6.0 cm. No description of wound bed or characteristics of wound.R1's CNA (Certified Nursing Assistant) Kardex states the following, in part: Offloading boots to bilateral feet when in bed and recliner at ALL TIMES.On 6/29/26 at 10:43 AM, Surveyor observed R1 in her room asleep in her recliner. R1 was wearing gripper socks but not offloading boots. Surveyor observed that the offloading boots were sitting in the windowsill next to the bed. On 6/29/26 at 4:19 PM, Surveyor observed R1 in her room sitting in the wheelchair with the foot pedals on. R1 was wearing gripper socks but not offloading boots. Surveyor observed that the offloading boots were still sitting in the windowsill next to the bed. 7/1/26 at 8:04 AM, Surveyor interviewed RN/UM M (Registered Nurse/Unit Manager) about R1's right heel wound. RN/UM M stated that she called the provider about it yesterday because the measurements were stable but not improving. RN/UM M stated that at that time the provider didn't want to make any changes because R1 is scheduled to see podiatry today. RN/UM M indicated that R1 has a history of getting areas that bubble up and blister so initially they did not label it as a pressure ulcer but because of the location it was changed to a pressure ulcer. RN/UM M stated that R1 has offloading boots for when she lays down. RN/UM M indicated that R1 does not refuse to wear the offloading boots that she is aware of, but that will refuse the foot cradle when she is in bed because she is often cold and wants to feel the blankets on her feet.On 7/1/26 at 1:38 PM, Surveyor interviewed IP/ADON N (Infection Preventionist/Assistant Director of Nursing) about R1's right heel wound. IP/ADON N stated that the pressure injury was discovered on 4/1/26 as an open area and the NP was contacted at that time. IP/ADON N stated that the wound on the right heel was in the exact same spot as a wound a couple years ago that she admitted with. IP/ADON N stated that R1 would get spontaneous blisters on top and bottom of her feet and shins. IP/ADON N stated that it looked like exactly that last time with the blistering started again so she didn't feel like it was pressure and didn't end up staging it at that time. IP/ADON N indicated that after she had further discussions with NP O and the doctor, they felt it was pressure, so they classified it as stage two. IP/ADON N indicated that when R1 went out to the hospital and then returned back to the facility, the entire wound had eschar and was much larger and was classified as unstageable at that time. At this time, IP/ADON N asked RN/UM M to join the interview. RN/UM M reiterated that some of R1's pressure interventions included foot boots when R1 is in the recliner or bed. Surveyor asked when R1 was supposed to be wearing the off-loading boots. Both RN/UM M and IP/ADON N stated R1 was to be wearing the off-loading boots at all times. Surveyor asked how often wound assessments and measurements should be taken. RN/UM M stated weekly. Surveyor asked why no measurements were taken until 4/14/26. IP/ADON N stated that NP O saw R1 on 4/1/26 but that it was not classified as a pressure ulcer until 4/14/26.On 7/1/26 at 3:47 PM, Surveyor interviewed NP O (Nurse Practitioner) via telephone about R1's right heel wound. NP O stated that she had conversations with the facility about it because she felt it was a pressure injury instead of a diabetic foot ulcer because of the location of on a bony prominence. NP O indicated that when the doctor came to see R1 she agreed it was a pressure injury. NP O stated that the facility asked her about them being the bullous blisters that she had in the past, but NP O stated those would be all over and not in just one location. Surveyor asked NP O what her expectation for R1 was regarding the off-loading boots. NP O indicated that she expected R1 to be wearing the off-loading boots at all times, including in the bed, recliner or wheelchair to protect her heels.On 7/2/26 at 8:01 AM, Surveyor interviewed DON B (Director of Nursing) about R1's right heel wound. DON B indicated that R1 had those wounds in the past and they've been healed since 2022. DON B indicated that R1 would get these blisters on her feet and the one on the left heel had osteomyelitis, so they just thought it was another one of those ulcers that started out as a blister. DON B stated that IP/ADON N and NP O had back and forth discussions trying to decide what it was and because it was on the heel they went with a pressure ulcer. DON B stated that then R1 went out to the hospital and when she came back it was covered with necrotic tissue. Surveyor asked DON B how often wound assessments and measurements were completed. DON B stated it was her expectation that wounds be measured weekly. DON B stated that they started measuring R1's wound when it was declared a pressure injury on 4/14/26.The facility did not ensure complete and accurate documentation of the wound including weekly measurements and did not ensure that care planned interventions were being followed to prevent worsening or additional pressure injuries.

Based on interview, and record review, the facility did not ensure that Residents receive treatment and care in accordance with professional standards of practice for 1 (R5) of 6 residents reviewed for assessments out of a sample of 25 residents.R5 fell and facility did not complete on-going monitoring and assessments, and the following evening R5 went to ER by ambulance.The facility policy, Fall Prevention Program, dated 1/25, states, in part;.monitor for changes in resident's cognition, gait, ability to rise/sit, and balance.monitor vital signs in accordance with facility policy.document all assessments and actions.R5 was admitted to the facility on [DATE], with a diagnoses including stroke, difficulty in walking, and unspecified fall.R5's most recent MDS (Minimum Data Set) indicates R5 has a BIMS (Brief Interview for Mental Status) score of 8 indicating R5 is moderately cognitively impaired.R5's most recent care plan states, in part;.resident is at risk for falls and history of falls.R5 experienced a fall on 3/21/26 around 7:45PM. The fall report states, in part;.writer went to answer resident's call light. Found resident in bathroom on the floor on knees with arms up on grab bars beside toilet, trying to get up.At a standing position, resident able to march both feet with more difficulty on the right side. Resident rating pain immediately after fall a 10/10 on the right side. Nonverbal signs of pain with movement include facial grimacing.On call MD notified- gave orders to treat skin tear left wrist. States that further evaluation may be needed if resident becomes unable to bear weight.Facility completed Post Fall Assessment and Head to Toe checklist form at the time of R5's fall. Facility completed Follow up post fall document on 3/22/26 at 5:24am.On 3/22/26 at 8:37AM, documentation shows that R5 indicated pain was at an 8/10. Facility staff provided a PRN (as needed medication) which was effective. The facility did not notify primary of increase in pain.Surveyor was unable to locate follow up assessments for R5 or provider notification. It is important to note, through record review, R5 does not typically have pain at an 8/10.Facility did not complete any nursing assessments until the evening of 3/22/26 at 5:01 PM in which R5 went to ER by ambulance.On 7/2/26 at 1:20 PM, Director of Nursing B (DON) indicated nursing should provide on-going monitoring and assessment after someone experiences a fall. DON B indicated she would expect staff to notify primary physician if a resident is experiencing an increase in pain after a fall.The facility did not complete on-going nursing assessments after a resident experienced a fall.

Based on interview and record review, the facility did not follow through with the appropriate steps of the PASARR (Preadmission Screening and Resident Review) process for 1 of 9 residents (R2) reviewed for PASARR screening out of a sample of 25.R2 did not have a level II PASARR screening completed.This is evidenced by:The facility's policy, Specialized Rehabilitative Services, dated 1/26, includes: It will also ensure that residents with Mental Disorder (MD), Intellectual Disability (ID) or related conditions receive services as determined by their Preadmission Screening and Resident Review (PASARR). R2 admitted to the facility on [DATE] with diagnoses including major depressive disorder.R2's quarterly MDS (Minimum Data Set) assessment, accepted date 6/12/26, has a BIMS (Brief Interview for Mental Status) score of 15. This indicates R2 is cognitively intact. R2's PASARR Level I Screen Summary, undated, includes:Does this person have a major mental disorder? YESScreening Result Resident is suspected of having a serious mental illness. AGREESurveyor reviewed R2's medical record. R2's medical record does not include a PASARR Level II Screen.On 7/1/26 at 2:11 PM, Surveyor interviewed SW C (Social Worker). SW C indicated she is responsible for obtaining the PASARR screenings for residents. SW C indicated R2 did not have a PASARR Level II Screen. SW C indicated R2 should have had a PASARR Level II Screen completed but did not.

Based on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 3 residents (R121) from a total sample of 25 residents reviewed for grievances.R121 voiced a grievance to the facility. Staff did not write his concern up as a grievance, complete an investigation, or follow up with the complainant. This is evidenced by:The facility's policy, titled Resident and Family Grievances, reviewed/revised in 2/2026, states in part: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal.Policy Explanation and Compliance Guidelines: 1. The Administrator has been designated as the Grievance Official. The Grievance Official or their designee is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintain the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident. 3. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (long term care) facility stay.6. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official.8. Procedure: .b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form.c. Forward the grievance form to the Grievance Official as soon as practicable. D. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form.e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress toward resolution of the grievances.g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation.R121 was admitted to the facility on [DATE] with diagnoses that include, in part: polyneuropathy, cervical disc disorder with myelopathy, spinal stenosis - lumbar & cervical region with neurogenic claudication, and osteoarthritis of both knees. R121's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/18/26 states that R121 has a BIMS (Brief Interview for Mental Status) of 13 out of 15, indicating he is cognitively intact. R121's care plan, dated 6/24/26, lists the following focus area: The resident was admitted to the facility on [DATE] following a hospital stay. The goal is to return home.upon completion of short-term rehabilitation services.On 6/30/26 at 9:55 AM, Surveyor interviewed R121 about his stay at the facility. R121 expressed frustration with therapy that he's been participating in because they don't schedule therapy appointments at a specific time. R121 said this automatically puts residents who are doing therapy into a state of chaos, and compared it to waiting around all day for a repair person to come to your house to fix an appliance. R121 indicated his goal is to complete therapy and go home, so he puts off other activities during the day because he does not want to miss his therapy appointment. [Of note: R121 was not the only resident who expressed concerns with not having therapy scheduled at specific times during the day. Surveyor reviewed the Grievance Log provided by the facility, dated 4/1/26 to 6/29/26, and there were no grievances listed regarding therapy scheduling.]On 6/30/26 at 2:25 PM, Surveyor spoke with RD W (Rehab Director). RD W indicated there is no set time for therapy appointments due to changing activities and schedules. Therapy does not want to set specific times in case appointments run over the time limit. Therapists try to work with resident preferences for therapy timing (ex: morning vs. afternoon scheduling) and try to give them a time frame (ex: 10 AM-12 PM or between lunch and dinner). Therapists also try to alert staff members to get residents ready for therapy. If a resident isn't in his or her room, the therapist will look in the resident's usual spots to try to find them but may end up moving the appointment time if they can't be located. Surveyor asked if residents have complained about not knowing when they are going to therapy. RD W said yes; many residents do not like not having a set schedule - especially when they first get to the facility, but it is very difficult to have a set time followed.On 7/2/26 at 9:05 AM, Surveyor observed medications being administered with LPN V (Licensed Practical Nurse). LPN V was administering medications to a resident who had been taken to therapy without LPN V's knowledge, so we had to track the resident down and interrupt her therapy session so she could take her medications. LPN V indicated she must often interrupt therapy sessions to administer medications and said it's hard when therapy comes to get residents and she doesn't know when it is scheduled so she must track the resident down.On 7/2/26 at 11:14 AM, Surveyor interviewed PT X (Physical Therapist). PT X indicated therapists are upfront with residents about no set therapy times. Therapists try to accommodate scheduling preferences. Therapists are typically in the building between 7:00 AM and 5:00 PM. They choose their start time and work until the last resident is seen. Surveyor asked if residents ever complain about the scheduling. PT X indicated yes - not everyone, but a small handful. These complaints get passed to RD W. Surveyor asked if these complaints are ever documented as grievances. PT X indicated she wasn't sure. They might be written down as preferences in a note. RD W may put the information in the schedule for future reference to try to accommodate resident wishes.On 7/2/26 at 1:40 PM, Surveyor spoke with DON B (Director of Nursing) about therapy complaints. DON B indicated she was not aware of residents' concerns about therapy scheduling, but could understand where they are coming from. DON B indicated she would reach out to therapy to ensure preferences are being honored.On 7/2/26 at 1:56 PM, Surveyor spoke with SW C (Social Worker) about therapy complaints. SW C indicated residents have voiced concerns about wanting therapy at a certain time. Staff try to inform residents when their therapy appointments are coming up during the day. Some residents end up being okay with the scheduling process and some residents really don't like it. SW C indicated she explains to residents that the facility is not a rehab hospital when they arrive. SW C indicated she has discussed having more specific time frames provided to residents with the therapy department. Surveyor discussed residents expressing experiencing anxiety about missing therapy appointments, feeling like they are waiting around all day, and wanting therapy to feel like a priority. SW C asked Surveyor if she should have logged these concerns as grievances if she keeps hearing them from residents. SW C indicated she would work on a grievance regarding therapy scheduling that she would follow up on. [Of note: Additional information on R121's Care Plan (6/29/26) indicates the following: Focus: Resident exhibits behaviors related to psychosocial distress regarding his immediate environment and daily routines. When expressing concerns or unmet needs, the resident frequently utilizes staff splitting or triangulation techniques to achieve a preferred outcome.Interventions/Tasks: Manage the resident's fixed expectations regarding strict therapy appointment times by providing gentle reality orientation that therapy schedules fluctuate daily rather than operating on fixed hour blocks; if the resident insists he has a specific 10:00 AM session, offer to contact the therapy department directly to verify their projected window for the day, while reinforcing that therapy coordinates directly with nursing staff if specific early mobilization is required, and notify the Therapy team, RN case manager, and Social Worker for interdisciplinary guidance if the fixated behavior or associated agitation persists. This indicates awareness that R121 has expressed concerns with therapy scheduling.]On 7/2/26 at 2:34 PM, Surveyor spoke with NHA A (Nursing Home Administrator). NHA A walked Surveyor through the facility's grievance process. NHA A indicated anyone can fill out a grievance form. They are located throughout the facility. Minor grievances can be reported verbally and staff members know how to complete the forms if a grievance is reported to them. Surveyor asked NHA A if he has received any grievances about therapy scheduling. NHA A indicated RD W had mentioned something about this to him, but said it had been taken care of, so he didn't look into it. Surveyor indicated RD W and SW C had knowledge about residents voicing concerns about therapy schedules, but these concerns were not documented as grievances. NHA A indicted things change with therapy schedules and staffing, so it may difficult to schedule exact therapy times, but if this is an issue, he will address it with RD W to see if any changes need to be implemented.

Based on observation, interview and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 residents (R2) observed with medications at bedside out of a sample of 25. R2 was observed on 2 separate occasions to have medications left on her bedside table for her to take independently. R2 does not have an assessment for self-administration of medications indicating that she is safe to administer medications independently.This is evidenced by:The facility's policy, Resident Self-Administration of Medication, dated 1/26, includes: A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. The care plan must reflect resident self-administration and storage arrangements for such medications.R2 admitted to the facility on [DATE] with diagnoses including polyneuropathy and vitreous degeneration of unspecified eye.R2's quarterly MDS (Minimum Data Set) assessment, accepted date 6/12/26, has a BIMS (Brief Interview for Mental Status) score of 15. This indicates R2 is cognitively intact. On 6/29/26 at 10:33 AM, Surveyor observed two medications in a medication cup on R2's bedside table. R2 indicated the medications were a cranberry and a vitamin. On 7/1/26 at 9:28 AM, Surveyor observed all of R2's morning medications in a medication cup on her bedside table. R2 indicated the nurse brought the medication in but R2 had not taken them yet. On 7/1/26 at 9:37 AM, Surveyor interviewed MT L (Medication Tech). MT L indicated she had left the medications for R2 to take. MT L indicated R2 was able to self-administer medications. MT L indicated staff knows who can self-administer medications because the information is in the resident's medical record. MT L indicated there would be a physician's order on the resident's MAR (Medication Administration Record) and in the resident's care plan. On 7/1/26 at 9:43 AM, Surveyor interviewed RN H (Registered Nurse). RN H stated if a resident can self-administer medications, there would be a physician's order on the resident's MAR and in the resident's care plan. RN H indicated if there is not an order for self-administration of medications the resident should be observed taking their medications. RN H indicated R2 has her own thing going on in regard to taking her medications. RN H indicated resident's do not like the staff standing over top of them while they take their medications. RN H indicated if a resident doesn't want us watching, we just leave the medications and will go back to check on them later to see if they took their medications. RN H indicated R2 is supposed to be watched while taking her medications, but prefers to take them on her own. R2's Quarterly/Annual/Significant Change Assessment, dated 5/27/26, includes: Self Administration of medications a. Does the resident desire to self administer his/her own medications? No. R2's physician orders, printed 7/1/26, does not contain an order for self-administration of medications. R2's comprehensive care plan, printed 7/1/26, does not contain information for self-administration of medications. On 7/1/26 at 10:37 AM, Surveyor interviewed DON B (Director of Nursing) regarding the process for a resident to self-administer medications. DON B indicated the facility will complete a self-administration of medication assessment, obtain a physician's order and put the information into the resident's care plan. Surveyor shared with DON B the observations of R2's medications being left at bedside. DON B indicated R2 should not have medications left at bedside.

Based on observation, interview, and record review, the facility did not ensure Residents are free of significant medication errors for 1 of 10 sampled Residents (R3) Facility staff did not administer R3's scheduled Parkinson's medications as ordered. Findings include: Review of the package insert, Sinemet CR, dated 03/2020, and located at https://mohpublic.z6.web.core.windows.net/IsraelDrugs/Rishum_14_228460120.pdf, indicated, Always take SINEMET CR exactly as instructed by your doctor. Take them at regular time intervals according to your doctor's instructions. Do not change the times at which you take your tablets. You should not take SINEMET CR tablets at intervals of less than 4 hours apart. If you forgot to take SINEMET CR at the specified time do not take a double dose to make up for a forgotten dose. Resume your regular dosing schedule and consult the doctor. Review of the manufacturer [NAME] Pharmaceuticals access data, Sinemet CR, located on the FDA website, revised 07/2014, and located at https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/019856s016s024s028lbl.pdf, indicated, . SINEMET CR contains. 25 mg of carbidopa and 100 mg of levodopa in a sustained-release dosage form designed to release these ingredients over a 4- to 6-hour period. The interval between doses of SINEMET [carbidopa-levodopa] CR should be 4-8 hours during the waking day. Review of the facility's policy titled, Medication Administration, dated 01/26, indicated, . Ensure the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, and right documentation . Administer within scheduled shift until otherwise ordered by physician. Review of the facility policy titled, Medication Errors, dated 01/26, indicated, . Definitions: 'Medication error' means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication; or accepted professional standards and principles which apply to professionals providing services. The facility shall ensure medications will be administered as follows: according to physician's orders. Review of R3's Census located under the Census tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE]. Review of R3's Medical Diagnosis located under the Med Diag tab of the EMR reviewed R3 had diagnoses of polymyalgia rheumatica, inflammatory spondylopathy, Parkinson's Disease, Alzheimer's Disease, restless legs syndrome, ankylosing hyperostosis, major depressive disorder, and anxiety disorder. Review of R3's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/18/26 and located under the MDS tab of the EMR, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R3 was cognitively intact. During an interview on 06/24/25 at 10:25 AM, R3 stated, I don't get my Parkinson's medications on time. The doctor said my medications need to be on time. Sometimes they are about an hour late. Review of R3's Orders located under the Orders tab of the EMR revealed R3 had a physician's order for Carbidopa-Levodopa [a Parkinson's medication] ER [extended release] 25-100 mg [milligrams] give one tablet by mouth every six hours for Parkinson's Disease. Swallow whole; do not break, chew, or crush tablet, which originated 07/03/25. Review of R3's Medication Administration Record (MAR), dated December 2025 and located under the Orders tab of the EMR, revealed Carbidopa-Levodopa was scheduled for administration at 5:00 AM, 11:00 AM, 5:00 PM, and 11:00 PM. Review of the Medication Admin Audit Report, dated 12/01/25 through 12/15/25 and provided by the facility, revealed the above medication was administered late on the following dates and times: 12/01/25 – The 11:00 AM dose of Carbidopa-Levodopa was not administered until 1:06 PM. The 5:00 PM dose of Carbidopa-Levodopa was administered at 8:12 PM. The 11:00 PM dose of Carbidopa-Levodopa was administered at 5:05 AM, resulting in a double dose of Carbidopa-Levodopa on 12/02/25 at 5:05 AM 12/02/25 – The 11:00 AM doses of Carbidopa-Levodopa was administered at 1:05 PM. 12/07/25 – The 11:00 PM doses of Carbidopa-Levodopa was given at 4:32 AM 12/08/25 – The 11:00 AM doses of Carbidopa-Levodopa was given at 1:16 PM. The 11:00 PM dose of Carbidopa-Levodopa was given at 12:24 AM. 12/09/25 – The 11:00 AM doses of Carbidopa-Levodopa was given at 12:25 PM. The 11:00 PM dose of Carbidopa-Levodopa was given at 1:02 AM. 12/12/25 – The 11:00 AM doses of Carbidopa-Levodopa was given at 2:06 PM. The 11:00 PM dose of Carbidopa-Levodopa was given at 12:18 AM 12/13/25 – The 5:00 AM doses of Carbidopa-Levodopa was given at 7:00 AM. 12/14/25 - The 11:00 AM doses of Carbidopa-Levodopa was given at 12:15 PM. 12/15/26 – The 11:00 AM dose of Carbidopa-Levodopa was given at 1:51 PM. The 5:00 PM dose of Carbidopa-Levodopa was given at 6:24 PM. Review of R3's Medication Administration Record (MAR), dated June 2026 and located under the Orders tab of the EMR, revealed Carbidopa-Levodopa was scheduled for administration at 5:00 AM, 11:00 AM, 5:00 PM, and 11:00 PM. Review of the Medication Admin Audit Report, dated 06/07/26 through 06/24/26 and provided by the facility, revealed the above medication was administered late on the following dates and times: 6/12/26 – The 11:00 PM dose of Carbidopa-Levodopa was given at 3:37 AM 6/15/26 – The 11:00 PM dose of Carbidopa-Levodopa was given at 12:40 AM. 6/16/26 – The 11:00 AM dose of Carbidopa-Levodopa was given at 12:19 PM. 6/18/26 – The 11:00 PM dose of Carbidopa-Levodopa was given at 2:35 AM. During a medication administration observation and interview on 06/24/26 at 10:50 AM, Licensed Practical Nurse (LPN) 3 stated, Scheduled medications need to be given within one hour before or one hour after the scheduled time. I don't know if a dose scheduled for 11:00 AM and administered at 2:00 PM would be a medication error. I would have to review the policy. I don't know if there are any risks associated with Carbidopa-Levodopa being administered late or if two doses were administered at same time. During an interview on 06/25/26 at 3:30 PM, the Director of Nursing (DON) stated, Medications are administered and she [R3] forgets and calls her daughter. For scheduled medications, we try to administer medications within one hour before or after the scheduled time. I'm not sure if this is a medication error, I would have to review the policy. I don't know if there are any risks associated with not administering carbidopa/levodopa as ordered.Review of the National Library of Medicine article, Delayed Administration and Contraindicated Drugs Place hospitalized Parkinson's Disease Patients at Risk, dated 01/2018, and located at https://pmc.ncbi.nlm.nih.gov/articles/PMC5737245/, indicated, Inpatients with Parkinson's disease require precise medication management. Patients with Parkinson's disease require strict adherence to an individualized, timed medication regimen of antiparkinsonian agents. Dosing intervals are specific to each individual patient because of the complexity of the disease. When medications are not administered on time and according to the patient's unique schedule, patients may experience an immediate increase in symptoms.2 Delaying medications by more than one hour, for example, can cause patients with Parkinson's disease to experience worsening tremors, increased rigidity, loss of balance, confusion, agitation, and difficulty communicating. Review of Kaiser Permanente's Carbidopa ER 25 mg-levodopa 100 mg tablet, extended release, dated 03/2026 and located at https://healthy.kaiserpermanente.org/health-wellness/drug-encyclopedia/drug.carbidopa-er-25-mg-levodopa-100-mg-tablet-extended-release.169093, indicated, . Some patients may experience a wearing-off (worsening of symptoms) before the next dose is due. An on-off effect might also occur, in which sudden short periods of stiffness occur. If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose. Take your next dose at the regular time. Do not double the dose to catch up.

Based on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible for 1 of 1 incident reviewed.RN C (Registered Nurse) burned sage in the facility and the facility did not verify that the sage was extinguished and did not provide education to the staff regarding safety.Evidenced by:Surveyor requested policy related to fire safety / flames in building. No policy provided.Facility email from RN D to NHA A (Nursing Home Administrator) and DON B (Director of Nursing), dated 7/18/25, states, in part: .came into work today, 7/17/25.at about 11:30 PM, smelled marijuana so strong, so I started to walk through all the units, but the smell remained at the atrium.asked RN C about the smell and RN C admitted stating it is me don't say nothing please I am burning sage the smell will go away. Then she demanded for me to give her the narcotic box key stating want to count.I walked away.RN C came back to me erratic requesting the narcotic box key the second time then I became suspicious that she is impaired at this time and will not give her the narcotic box key. I called DON B but was unable to reach then decided to call NHA A to notify about the incident. On 7/29/25 at 11:14 AM, Surveyor called RN D with message left requesting return call. RN D did not return Surveyor's call.On 7/29/25 at 11:52 AM, Surveyor interviewed RN E who stated that, a few nights previous, RN D had called RN E asking for RN E to come to RN D's side of the building because RN D thought someone was smoking marijuana in the building. RN E indicated that on arrival to that area, RN E was not certain about marijuana, but noted there was something smoky in the air; haze and smoky smell. RN E indicated that on arrival, RN D was in the center of the lounge and RN C came out of one of the unit hallways and asked RN D to come and count narcotics with RN C. RN E stated that RN D refused, saying that RN D thought it was not a normal task at that time of night. RN E stated that a few words were exchanged and RN C went into the office. RN E stated that RN C's eyes looked a little red and RN C seemed nervous / wouldn't look at RN E. Surveyor asked if the facility had asked RN E about the incident. RN E stated that RN D had asked RN E to write a statement, but there was not contact from anyone else from the facility. RN E indicated uncertainty about the origin of the smoke but stated that the smoky haze appeared to be in the lounge, near the office.On 7/29/25 at 3:33 PM, Surveyor interviewed NHA A who indicated getting a frantic call around midnight from RN D stating that RN C was smoking in the office. NHA A indicated that RN C had been working, at that time, on a concern related to narcotic medications. NHA A indicated then speaking with RN C on the phone, regarding the allegation and that RN C denied smoking marijuana and indicated that RN C had been burning sage in the office. NHA A indicated that NHA A ordered RN C to leave the building and told RN D that statements would be needed. NHA A stated that RN D told NHA A that the smell was dissipating. NHA A indicated that the next morning, RN C came to the facility and showed NHA A the sage on a dish in the office and voluntarily completed a drug test which was negative. NHA A stated RN C made a mistake and there was no reason to believe that RN C was under the influence at work. Surveyor asked if anyone had gone into the office. NHA A stated I don't think so, I think staff may have stepped in / near and smelled the smell. NHA A stated they confirmed the next day that there was no drug paraphernalia. Surveyor asked if anyone looked into the allegation that night. NHA A stated no, RN C was told to leave. Surveyor asked if anyone walked RN C out. NHA A indicated no, they were able to verify the next day on camera. Surveyor asked if there was any education provided following the incident. NHA A stated that RN C was educated; there is no facility policy on not burning sage, but that facility refers to federal regulation and educated on not burning anything in the facility. Surveyor asked if facility staff were educated. NHA A stated no.On 7/29/25 at 4:04 PM, Surveyor interviewed RN C and asked if smoking or burning of substances is allowed on facility premises. RN C stated no. Surveyor asked about incident. RN C indicated RN C did not smoke anything. We grow sage in my mother's garden; I took a bit and burned it to try to curb the bad energy. RN C stated it was an error in judgement. Surveyor asked what happened to the sage after it had been lit. RN C stated it sat in a meal tray cover (hard plastic covering for a dinner plate). RN C indicated that it remained there until the next morning. RN C indicated speaking to NHA A on the phone and NHA A asking RN C to write a statement. RN C expressed exhaustion and NHA A indicated that the statement could be written in the AM. RN C stated that RN C did not recall if NHA A told RN C to leave the building. RN C stated that RN C did not recall if RN C finished up some tasks prior to leaving or just went home. RN C indicated returning to work the next day and meeting with NHA A and DON B, at which time RN C wrote a statement and completed a drug test that RN C brought along to the building.On 7/29/25 at 5:20 PM, Surveyor asked NHA A if anyone in the building was asked to verify that the smoking substance was put out. NHA A stated no.On 7/29/25 at 5:45 PM, Surveyor asked RN C if sage was extinguished prior to RN C leaving building. RN C stated yes.Important to note: The facility did not verify that the smoking substance was extinguished at the time of the incident and staff were not educated to prevent further incidents from occurring.

Based on observation, interview, and record review, the facility did not ensure fall interventions were in place per the care plan and each residents received adequate supervision to prevent accidents for 3 of 23 sampled Residents (R27, R59, & R82) reviewed for falls and supervision. R27 is being cited at scope/severity level 3 (isolated/actual harm). R27 was a fall risk and has had 23 falls since admission on [DATE]. R27's falls typically occurred in the dining room or resident room; there were similarities to the falls including location and time of day. The facility completed a root cause analysis (RCA) and collected data on the falls; however, there is no evidence the interdisciplinary team (IDT) comprehensively reviewed the data or considered increasing R27's supervision. R27 fell resulting in a head injury requiring sutures. R59 is at risk for falls and is care planned to walk with her walker and to have a sign in her room to remind her to walk with her walker. Surveyor observed two instances on different days of R59 walking without her walker. Surveyor was unable to locate a sign in R59's room reminding her to walk with her walker. R82 has long-standing behaviors that include wandering into other residents' rooms as well as acting out toward staff and other residents. The facility staff did not provide increased supervision to prevent R82 from wandering into other Residents' rooms, which puts R82 at risk for potential resident to resident altercations to occur. This is evidenced by: The facility's fall policy titled Fall Prevention Program, dated 2/28/25, states in part: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy and Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. a. The risk assessment categorizes residents according to low, moderate or high risk. b. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate on the (specify location) the residents' s fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. 5. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of resident falling including, but not limited to: a. A clear pathway to the bathroom and bedroom doors. ii. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. iv. Adequate lighting. V. Wheelchairs and assistive devices are in good repair. b. Implement routine rounding schedule. c. Monitor for changes in resident's condition, gait, ability to rise/sit, and balance. D. Encourage residents to wear shoes or slippers with non-slip soles when ambulating. e. Ensure eye glasses, if applicable, are clean and the resident wears them when ambulating. f. Monitor vital signs in accordance with facility policy. g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. 6. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. ii. Place Fall Prevention Indicator (such as star, color coded sticker) on the name plate to resident's room. iii. Place Fall Prevention Indicator on resident's wheelchair. B. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications psychological, cognitive status, or recent change in functional status. D. Provide additional interventions as directed by the resident's assessment including but not limited to i. Assistive devices ii. Increased frequency of rounds iii. Sitter, if indicated iv. Medication regime review v. Low bed vi. Alternate call system access vii. Schedule ambulation and toileting assistance viii. Family/caregiver or resident education ix. Therapy services. 7. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program. 8. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 9. When any resident experiences a fall, the facility will: a. Assess the resident b. Complete a post-fall assessment c. Complete an incident report d. Notify the physician and family e. Review the resident's care plan and update as indicated f. Document all assessments and actions g. Obtain witness statements in the case of injury. R27 was admitted to the facility on [DATE] with diagnoses that include dementia, seizure disorder, psychotic disturbance, mood disturbance and anxiety, altered mental status, and malaise (weakness). R27's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/25 indicates Brief Interview for Mental Status (BIMS) was unable to be performed. A staff assessment of R27's mental status indicates R27 has moderate cognitive impairment. Section C1310 of the assessment indicates R27 has periods of inattention and disorganized thinking. Section GG indicates R27 requires setup assistance with eating, supervision for oral hygiene and upper body dressing, partial to moderate assistance for toileting and personal hygiene, and substantial to maximum assistance for showers, lower body dressing, and footwear. R27's mobility indicates she requires partial to moderate assistance for rolling left to right, sitting to standing, lying to sitting, chair to bed transfer, toilet transfer and walking 50 feet. R27 utilizes a wheelchair and is dependent on locomotion of 150 feet while in the wheelchair. Section J1800 any falls prior assessment indicates yes. Section J1900 number of falls since admission or prior assessment indicates the following: No Injury two or more. B. Injury two or more. C. Major injury indicates one. R27's Activities of Daily Living (ADL) care plan initiated 9/4/24 revised on 11/25/24 states: Focus: At risk and/or potential for complications with deficits with ADLs r/t current medical/ physical status. Has meds/dx (medications/diagnosis) that can/may affect ADLs dated initiated 9/4/24 revised 9/7/24. Goal: Will be clean, dry, dressed appropriately and maintain ability to participate in ADLs through next review date 9/7/24 revised 11/25/24. Will be more independent with ADLs after set-up, cues and able to return to assisted living by discharge date . Interventions: Ambulation - may ambulate in room or hallway with w/c (wheelchair) trail 9/4/24 revised 2/28/25. Bed mobility: 1 assist 9/4/24 revised 2/28/25. Locomotion: 1 assist in Broda Chair 4/1/25. Transfers: 1 assist pivot with gait belt 9/4/24 revised 2/28/25. Prefers to get up around 7:00 AM and goes to bed around 8:00 PM 9/7/24. R27's Safety/Falls care plan date initiated 9/7/24 and revised on 12/16/24 states: Focus: At risk/and/or Potential for complications with or falls r/t (related to) current medical / physical and mental status. Has meds/dx (medication/diagnoses) that can/may affect fall risk. Goal: Reduce risk of fall related injuries date initiated 9/7/24. Revised on 12/18/24. Interventions/Tasks: Assist resident to sit up to table at mealtimes 9/14/24 revised on 2/28/25. Busy box on side of the bed 12/30/24 revised on 2/28/25. Do not recline resident back in wheelchair when resident is agitated 3/12/25 revised on 2/28/25. Due to increasing behaviors, support resident in her room with low lighting, low noise level, no visual stimulation 10/8/24 revised on 2/28/25. During the night when she is restless, frequent attempts to get out of bed offer shower and/or weighted blanket for comfort 1/9/25 revised on 2/28/25. Elevate HOB (head of bed) in seated position for comfort 12/30/24 revised on 2/28/25. Immediate intervention s/p (status post) fall - increased monitoring, given breakfast, NP (nurse practitioner) to see resident. Will re-educate the staff regarding current interventions 1/24/25 revised on 2/28/25. Immediate intervention s/p fall offered/received snack and placed into bed. Discussion with guardian for a perimeter mattress. Guardian in agreement. IDT (Interdisciplinary Team) to review recommendation. Add perimeter mattress to bed 1/3/25 revised on 2/28/25. Immediate intervention s/p (status post) fall send to ER (emergency room) for further evaluation 1/21/25 revised on 2/28/25. Immediate Intervention: Heated blanket placed on resident for comfort and 1:1 with staff. Suggest medication review. Medicated with Tylenol, pain gel and Melatonin 10/16/24 revised on 2/28/25. Move resident closer to the nurses station for increased supervision. Immediate intervention s/p fall 2/11/25 resident moved closer to the nurses station for increased monitoring 11/21/24 revised on 2/28/25. Nonskid socks when up in wheelchair 11/18/24 revised on 2/28/25. Offer a snack during the evening hours, around the time she is going to bed for the night and as requested 1/7/25 revised on 2/28/25. Offer assistance with ambulation in hallway if resident is restless or repeatedly attempting to stand 12/28/24 revised on 2/28/25. Offer hydration and/or snack at change of shift from PM to NOC shift if resident is awake. IDT: During routine rounding and as needed staff to ensure resident has fresh ice water or fluid of choice 12/15/24 revised on 2/28/25. Offer toileting IMMEDIATELY after meals 12/30/24 revised on 2/28/25. Perimeter mattress to better define edges of bed 1/6/25 revised on 2/28/25. Provide a quiet space to be able to rest and relax. Provide her soft lighting and white noise via the light and sound machine provided 12/27/24 revised on 2/28/25. Staff to offer assistance with walking to and from the dining room (per resident's choice) 4/1/25. Therapy to screen and treat for possible BRODA chair till current w/c (wheelchair) is fixed so resident's feet can touch the floor 4/28/25. Walk to the dining room every meal 2/14/25 revised on 2/28/25. When resident is restless, upset, crying, speaking of family offer warm heated blanket and/or busy box for comfort 10/17/24 revised on 2/28/25. Will have therapy eval for w/c positioning and safety 2/12/25 revised on 2/28/25. Call light positioned for easy access 9/7/24. Check for unmet needs: pain, toileting, hunger, thirst, temperature 9/7/24. Do not leave unattended in the Bathroom [ROOM NUMBER]/7/24. Encourage / Assist with non-skid shoes / socks 9/7/24. Ensure environment is free of clutter 9/7/24. Have commonly used articles within easy reach 9/7/24. Scoop mattress to bed 1/22/25 revised on 2/28/25. Other: (Specify) - Nonskid mat to wheelchair 11/18/24. R27's Care plan for Mood/Behavior dated 9/7/24 and revised on 12/17/24 states: Focus: Has a dx of MDD (mood disturbance disorder). She is at risk for changes in mood and cognition. She experiences episodes of tearfulness and heightened anxiety. Curses and makes derogatory statements to people who are not there likely r/t previous stay at ALF (assisted living facility) or past trauma. Also exhibits aggression toward staff as evidenced by grabbing, hitting, and spitting d/t cognitive impairment. Anxiety related to death of parents. She makes paranoid statements about staff at times. Goal: Mood / Behavior will not interfere with ADL status through next review 9/7/24 revised 11/25/24. Will have choices and able to make decisions through next review date 9/11/24 revised 11/25/24. Interventions/Tasks: Offer resident one of her robotic cats to assist with keeping resident calm 11/11/24 revised on 2/28/25. Offer weighted blanket 1/10/25 revised 2/28/25. Provide a quiet space for [Resident's name] to be able to rest and relax. Provide her soft lighting and white noise via the light and sound machine provided date initiated 12/27/24 revised 2/28/25. Provide a warm blanket when she is in bed and agitated 11/11/24 revised 2/28/25. Provide music therapy with resident's CDs (compact disc) 11/11/24 revised 2/28/25. Remove from noisy environment and take to a quiet area to decrease external stimuli 11/20/24 revised on 2/28/25. Resident to be on floor mate [sic] while in room [ROOM NUMBER]/17/25. Allow resident to wander within unit 9/7/24. BIMS / PHQ9 completed upon admission, quarterly, annually, and PRN (as needed) - Notify MD as needed with concerns 9/7/24 revised 2/28/25. Calm approach. Remove stressors i.e.: noisy/overstimulating area or other residents in personal space who are too close 9/7/24. Check for comfort levels - pain, thirst, hunger, temperature - offering comfort as able / accepted 9/7/24. Encourage / Assist to activities of choice 9/7/24. Encourage resident to be out of room [ROOM NUMBER]/7/24. Meds / Labs / Treatments as Ordered 9/7/24. Observe / Monitor / Document behaviors/mood and notify supervisor, SW (social worker), and / or MD as needed 9/7/24. Offer opportunities for resident to express feelings 9/7/24. PASARR Level II - Review & Follow Recommendations as able / accepted 9/7/24. Remind / Redirect and/or reassure as needed 9/7/24. Turn white noise machine on at bedtime. Progress notes dated 9/14/2024 at 12:04 PM state in part: Resident seated in w/c at dining room table. CNA (Certified Nursing Assistant) at nurse station when resident slid out of w/c (wheelchair) and onto to left LUE (left upper extremity) and LLE (left lower extremity) making contact with the carpeted area of floor. CNA alerted wtr (writer) and nurse assessment was completed. Resident was baseline A&O (alert and oriented) and able to state her name and DOB (date of birth ), denied injury, and reported she was trying to scootch closer to the table. No apparent injuries noted on assessment, resident denied pain, nonverbal indicators of pain not present AEB (as evidenced by) a score of 0 on PAINAD scale (scale used to measure pain levels). Dr.'s nurse on call notified. Charge nurse notified. POA (power of attorney) notified. Progress notes dated 9/14/2024 at 13:17 (1:17 PM) state in part: Resident transferred by staff into w/c (wheelchair) and engaged with other residents in activities at table nearest nurse station. Resident was monitored and observed by staff the remainder of the shift. Progress notes dated 9/14/2024 at 16:13 (4:13 PM) state in part: IDT (Intradisciplinary Team) met to review fall. Root cause determined to be resident failed attempt at scooting self closer to the table. Intervention added for staff to assist resident to sit up to table at mealtimes. Kardex up to date. Therapy notes dated 9/20/2024 at 08:04 AM state: patient discharging from physical, occupational, and speech therapy today, 9/20/24. Recommend continued 1 assist with transfers, ambulation, and ADLs. Diet consistency is accurate and appropriate. Patient will remain in this LTC (long-term care) facility which is most appropriate for patient. Patient scored 3.2 on the ACL ([NAME] Cognitive Level screen - a test to assess cognitive function) cognition assessment indicating patient is appropriate for 24-hour supervision. Progress note dated 9/26/2024 at 20:44 (8:44 PM) states: resident had an unwitnessed fall in evening after supper. The resident was lying on the floor on her left side and reports that she did not hit her head. Vitals within normal limits, pain minimal to the left elbow and butt cheek. Resident reports that she was trying to move her wheelchair herself when she slipped out onto the floor. Nurse sat with the resident for an hour to monitor vitals and neuro status. Resident was baseline. Guardian contacted, nurse manager contacted, NP (nurse practitioner) contacted. Will continue to monitor. Progress notes dated 9/27/2024 at 14:41 (2:41 PM): IDT met to review fall. Root cause of fall noted to be resident scooting to move wheelchair into place. Intervention related to root cause: non-skid pad placed in wheelchair. Therapy notes dated 10/2/2024 at 15:51 (3:51 PM) state: PT (physical therapy) evaluated w/c positioning on 10/1/24. Patient is very short making it difficult for her to keep herself properly positioned in the wheelchair and causes her to slide forward in the wheelchair. Therapist searched through all wheelchairs in the building and in extra rooms to see if there was an appropriate w/c for patient. Patient needs a super hemi-wheelchair which most supply companies cannot provide. PT completed work order for seat to be adjusted for drop seat/seat slope: 1.5 (higher front) to see if this helps with better w/c positioning. Progress notes dated 10/3/2024 at 13:20 (1:20 PM) state: IDT Risk. Risk Factors: Frequent Falls, Wheelchair Mobility, Height challenged, Dx Related to Risk: Unspecified Dementia, Failure to Thrive, Disc Disorder, Osteoarthritis, CKD 3 (chronic kidney disease), Unspecified Convulsions, Muscle Weakness. Nursing Issues: Pain control, Decreased mobility, Incontinence, Medications that can attribute to risk: Keppra and Sertraline. Behaviors that can attribute to risk: Noncompliance related to memory issues, Heightened startle reflex, Nutrition Risk Factors: Pureed Diet (no teeth). Weights are good - good intakes. Care Plan review and Risk intervention updates: Nonskid added to wheelchair. CP (care plan) updated. Wheelchair is being adjusted to drop the seat. Plan of care ongoing. Progress notes dated 10/3/2024 at 20:18 (8:18 PM): Patient attempted to stand up multiple times during the shift. States that she left let [sic] hurt. Behavior improved with supper and once she laid down for the evening. Did encourage to elevate leg in WC which the resident did accept and that did help some of the behavior. Progress notes dated 10/6/2024 at 06:00 AM: excerpt from fall report: resident was found lying in prone position on the bedside floormat in resident's bedroom. Resident was log rolled and transferred back to bed with 2 assists by mechanical lift after assessing for injury, no injury was noted, and resident did not verbalize pain. All extremities moved well per residents' baseline. Unit RN completed Neuro (neurological checks - check for potential head injury). Assessed and found to be without injury. Transferred off floor via Hoyer lift and 2 staff assist. Guardian updated. MD updated. DON updated. Care plan updated. Progress notes dated 10/7/2024 at 15:16 (3:16 PM) state: IDT met to review fall. Root cause analysis determined root cause of fall to be resident sitting up on side of bed without assistance (lacking trunk strength/coordination to successfully lay herself back down in bed). Immediate intervention related to root cause: Care plan and Kardex updated to reflect that resident should not be left alone while sitting on the edge of her bed. Progress notes dated 10/8/2024 at 18:21 (6:21 PM): patient was observed self-transferring writer ran to assist patient back to wheelchair patient became weak was lowered to floor, assessed patient from head to toe no injuries observed, performed rom (range of motion - check for injury to extremities) no complaints of pain, vitals measured started neuro checks, nurse on call notified order to call if any new abnormal symptoms occur, guardian notified, educated patient to ask for assistance when needed, distract patient with activities of choice offer snacks. Progress notes dated 10/9/2024 at 12:57 PM Late Entry: IDT met to review fall. Root cause analysis performed. Root cause determined to be resident restlessness and weakness upon standing. Assessment info relayed to NP - new orders received and noted for labs (TSH lab to check thyroid function), change of sertraline timing to HS (at bedtime), and seeing psych (physician for psychiatric/behavioral health) next week. Progress note dated 10/10/2024 at 12:43 PM: IDT clarification regarding root cause: Prior to falling, resident was sitting up at the side of her bed. CNA had offered to assist resident to lay down in bed, and resident refused. Progress note dated 10/17/2024 at 03:02 AM: resident noted sitting on floor mat; her back against the bed with feet extended outwards toward bathroom door. Bed noted in lowest position at this time. Resident stated, I got to go to my momma's house. Resident noted restless, crying and breathing rapidly. Resident denied hitting her head but stated, her legs hurt. Tylenol administered for pain and pain gel rubbed on bilateral legs. No injuries or bruises noted this shift. Neuros WNL (within normal limits). ROM WNL (Range of Motion within normal limits) for resident. PRN (As needed) Melatonin given for sleep. A heated blanket placed on resident for comfort and 1:1 with staff. Charge nurse, On-call physician, and emergency contact notified. Fall intervention suggestion: Medication review needed. All needs met at this time. Call light within reach. Will continue to monitor. Progress note dated 10/17/2024 at 09:28 AM Late Entry: IDT met to review fall. Root cause analysis (RCA) performed. Root cause identified as agitation related to bad dreams/delusions. Intervention related to root cause: Labs, Change of Zoloft to HS and Psych follow-up scheduled. It should be noted the IDT RCA review, dated 10/17/24, is 8 days after R27's fall on 10/9/25. Progress note dated 10/17/2024 at 15:31 (3:31 PM) Activity Progress Note: The writer is updating about a busy box that was created for the patient. Inside this busy box will be a number of things that the patient has seem to take interest in there is some jewelry in there for her to sort due to the fact she loves jewelry. Furthermore, there is a fake pet cat in there along with some puzzles and lastly coloring pages. This is to be located in the dining room of her unit and on her table of where she sits. This is to be used for when activity staff isn't present or to occupy her. Therapy notes dated 10/24/2024 at 13:27 (1:27 PM): Pt's (Patient's) guardian came to writer's office today asking about getting patient a different wheelchair. Guardian feels the wheelchair is not working for her. Discussed that patient has not had any falls from current wheelchair and pt (patient) had two falls from previous wheelchair. Guardian still adamant about therapy trialing different wheelchairs. Guardian requested that elevating wheelchair footrests be on patient's w/c, to have wheelchair footrests slightly elevated, and for footrest cushion to be on patient's wheelchair at all times. Guardian also requested we trial a recline back wheelchair. Writer educated guardian that we [sic] therapy can attempt to trial different chairs but will discuss with IDT before changing anything. Progress notes dated 10/25/2024 at 18:14 (6:14 PM): nurse was advised by CNA (Certified Nursing Assistant) that patient was on the floor in the dining room. Upon assessment, patient was observed laying on the floor in dining room, in front of wheelchair. Inquired about incident and patient stated, I was looking for the door to use the restroom. Nurse assessed for injuries. No apparent injuries noted. ROM (range of motion) applied and patient complained of lower right leg pain. Received routine acetaminophen 1000 mg. Assisted patient off the floor x 2 staff members using Hoyer lift. Patient toileted. Vitals obtained bp (blood pressure): 128/114 p (pulse): 96 r (respirations): 16 O2 (oxygen): 96% room air and t (temperature): 97.1. NP notified. Received orders for neuro checks. Call placed to (guardian name). Voicemail left to call facility back. Currently sitting in wheelchair in dining room coloring. Voiced no concerns at this time. It should be noted R27 has had several falls in the dining room however there is no evidence the IDT discussed not leaving R27 alone in the dining room or increasing supervision for R27 r/t (related to) falls in the dining room. Progress notes dated 11/1/2024 at 16:37 (4:37 PM) state IDT note: 10/25/24, unwitnessed fall without injury. Resident observed lying on the dining room floor. Resident relayed looking for the bathroom door. She most likely needed to use the bathroom. Her dx include Dementia, weakness, failure to thrive, malaise, osteoarthritis. She has poor safety awareness, severe cognitive impairment with a BIMS of 3. Neuro checks initiated. NP, Guardian, and Family Care RN notified. Care plan and CNA Kardex updated to include toilet before and after meals. Will monitor the effectiveness of the interventions and modify as necessary. Of note, toileting before and after meals should be a normal standard of practice for all residents. Toilet upon rising, before and after means at HS (bedtime) and as needed was a care planned intervention dated 9/7/24 on R27's bowel and bladder care plan. Progress notes dated 11/20/2024 at 23:17 (11:17 PM): CNA found the resident on the floor and notified nurse. Doctor was notified as well as POA (power of attorney) and director. There was no apparent injury. Resident was checked and put back in bed. Neuro checks within normal limits and low bed and mat continue to be in place. No new interventions at this time, staff is updated to round frequently throughout the night. NOC (night) charge updated. It should be noted there is no evidence the staff asked R27 what she may have been attempting to do or if R27 had an unmet need; the facility simply returned R27 to her bed. Progress notes dated 11/22/2024 at 08:09 AM state: IDT note unwitnessed fall 11/20/24 without injury. Resident observed on the floor beside her bed. Resident with severe cognitive impairment, BIMS (Brief Interview Mental Status) of 3, dx (diagnosis) of dementia and unable to relay how the incident occurred. She has poor safety awareness and attempted to get out of bed unassisted and slid out of bed onto the fall mat. Bed in lowest position and call light within reach at the time of the incident. No c/o (complaints of) pain. Resident was monitored frequently thru out the night and will be moved closer to the nurses station for increased monitoring. Dr. and guardian notified. Care plan and CNA Kardex updated. Will monitor the effectiveness of the interventions and modify as necessary. Progress notes dated 12/14/2024 at 23:00 (11:00 PM): CNA coming down the hall at 2220 (10:20 PM) and heard resident talking from her room. CNA went to res room and found resident laying on the floor mat with bed in low position. Due to cognitive impairment per res baseline, res unable to articulate what she was attempting to do. VSS (vital signs stable) with neuro checks WNL (within normal limits) to res baseline. No reports of physical pain or signs of injury. PERRLA (pupils equal, round, reactive to light and accommodation - normal eye exam - check for head injury). Res incontinent pad was dry. Res was rambling with rapid speech tearful and frustrated talking about going home to be with her mother. Speech is mostly word salad per res baseline. Res thirsty and asking for something to drink. Hydration provided. Resident's primary care provider notified as residents guardian and case manager. Administrator and DON for facility also updated of fall without injury. New intervention added to POC to offer hydration and/or snack at PM to NOC (night) shift change if res awake. 1:1 provided to resident by staff with active listening and validation of resident sadness and frustration provided. Neuro checks initiated per facility policy. Will monitor. Progress notes dated 12/16/2024 at 21:00 (9:00 PM): resident was found sitting on the floor in front of her bed on the floor mat. The resident did not appear to be in any pain or discomfort, she does not report any injuries. The resident was able to move all extremities without issue. The resident was able to stand up with 2-assist and a gait belt and into the bed. A footrest pillow was placed under her feet to elevate her legs and keep her lower extremities in bed for increased comfort. The resident then became upset and agitated with staff and began yelling and asking not to be touched. The charge nurse was notified of no injuries with the incident. A phone call was placed to the GNP (geriatric nurse practitioner) to alert her of the incident. POA (power of attorney) notified of the incident. Will continue neuro checks and vitals assessments. Progress notes dated 12/17/2024 at 12:50 PM Addendum: IDT NOTE: unwitnessed fall 12/14/24 without injury. Resident observed on the floor parallel to bed. Resident with severe cognitive impairment, BIMS of 3, dx of dementia and unable to relay how the incident occurred. She has poor safety awareness and most likely attempted to get out of bed unassisted and slid out of bed onto the fall mat. Bed in lowest position, gripper socks, and brief clean and dry at the time of the incident. No c/o (complaints of) pain. Neuro checks initiated. Resident verbalized being thirsty and hydration provided. Will offer hydration and/or snack at pm night shift change. Staff will ensure during routine rounds and as needed she has fresh ice water or fluid or choice. Dr. and guardian notified. Care plan and CNA Kardex updated. Will monitor the effectiveness of the interventions and modify as necessary. Progress notes dated 12/18/2024 at 13:15: IDT note met to review resident's recent fall. Fall was in her room. Root cause analysis completed. Root cause identified as confusion and attempting to get out of bed. Resident has been experiencing recent behavioral episodes. Resident was yelling out at the time of assessment. Bed was in lowest position and fall mat was in place. She had been toileted and had been offered snacks. New interventions: positioning the bed at transfer height with fall mat in place and maintaining a low stim environment in resident's room. Progress notes dated 12/18/2024 at 13:41 (1:41 PM): IDT met to review resident's recent fall. Root cause analysis completed. Root cause identified as resident feeling thirsty. Immediate intervention was resident was assisted with a beverage. New interventions: ensure bedside pitcher will be filled with resident's drink of choice. Plan of care ongoing. Progress notes dated 12/19/2024 at 15:15 (3:15 PM): Resident was in the dining [sic] at about 3:15pm when writer heard resident fall in the dining area. When writer looked, resident was laying on her back on the floor, wheelchair by the feet, she had non-slip socks on, she was screaming and calling out, using profanities on staff. Meanwhile, all shift today, resident was up and down in her wheelchair, standing up and dragging her wheelchair while walking around. Staff tried each time to redirect but resident kept fighting and swatting at staff. Assessment completed, VSS wnl (Vital signs stable and within normal limits), resident had a bump on the back of her head from the fall but denies pain, no other injuries noted at the time of assessment. Patient was transported to the hospital via 911. It should be noted that resident was self-transferring in her w/c, standing up and dragging her w/c all day. Staff did attempt to redirect however this was not successful. However, this behavior should have put staff on notice of the high potential of a fall occurring. There is no evidence the facility increased supervision despite this known behavior throughout the day. Progress notes dated 12/19/2024 at 20:45 (9:45 PM): Resident returned from the ER at 8:45pm, no new orders, follow up with primary PCP for symptom management in one week. Resident is currently eating. Floor nurse to complete skin assessment after resident is done eating and in bed. Progress notes dated 12/20/2024 06:43 AM: Repeated fall review-Repeated falls occur due to behavioral outburst and unable to redirect of [sic] touch resident during violent outburst. Injury prevention, resident safety are intervention focus. MD team inform[TRUNCATED]

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 94 residents who reside at the facility. Surveyor observed staff taking temperatures of food during lunch meal. Staff did not take temperatures of all foods on steam table. Surveyor observed staff taking temperatures of food during lunch meal. Staff did not allow time for thermometer to dry after using alcohol wipe and placed directly into food. Evidenced by: The facility policy, Record of Food Temperatures, dated, 2/25, states, in part; .6. Measure and record the temperatures for each food product and milk at all meals. Record temperature on temperature log. 7. When holding hot foods for service, food temperature should be measured when placing it on the steam table line .14. Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy . On 4/30/25 at 11:03 AM, Surveyor observed DA Q (Dietary Aide) taking the temperature of the food being placed into steam table. DA Q was observed cleaning thermometer with alcohol wipe and placing directly into food, not allowing time for thermometer to dry. DA Q was observed doing this with all foods being temped. DA Q failed to take the temperature of ground and pureed food items in steam table. Surveyor asked DA Q if DA Q was going to temp all the food. DA Q indicated DA Q only temps the foods that are important. On 5/1/25 at 9:12 AM, DM P (Dietary Manager) indicated all food temps should be taken at every meal. DM P indicated thermometer should be dry before placing it into the next food. DM P indicated understanding of the above concerns. The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Based on observation, interview, and record review, the facility did not ensure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable for 1 of 3 medication carts reviewed for compliance. Surveyor observed the following: R36's fluticasone propionate nasal spray did not have an open date and R36's Systane Ultra Ophthalmic Solution 0.4- 0.3% eye drops had an open date of 3/15/25. R45's PRN (as needed) Hydralazine card expired on 2/22/25. R32's PRN Chest Congestion Relief card expired 2/27/24 and PRN ondansetron card expired on 2/22/25. R48's PRN stimulant laxative card expired on 2/27/24. R194's PRN calcium antacid card expired on 2/25/24. R16's PRN ondansetron card expired on 2/22/25. Evidenced by: The facility's policy titled Medication Storage dated 2/28/25 states in part .4. Unused Medications: All medication rooms are routinely inspected by the consultant pharmacist for discontinued, defective, or deteriorated medications with worn, illegible, or missing labels. On 4/28/25 at 11:55 AM, Surveyor observed medication cart #1 with LPN N (Licensed Practical Nurse). Surveyor found R36's fluticasone propionate nasal spray did not have an open date and R36's Systane Ultra Ophthalmic Solution 0.4- 0.3% eye drops had an open date of 3/15/25. Surveyor found R45's PRN Hydralazine card expired on 2/22/25. Surveyor found R32's PRN Chest Congestion Relief card expired 2/27/24 and PRN ondansetron card expired on 2/22/25. Surveyor found R48's PRN stimulant laxative card expired on 2/27/24. Surveyor found R194's PRN calcium antacid card expired on 2/25/24. Surveyor found R16's PRN ondansetron card expired on 2/22/25. On 4/28/25 at 12:04 PM, Surveyor interviewed LPN N. Surveyor reviewed the expired medications, nasal spray, and eye drops with LPN N. Surveyor asked how long eye drops are good for after being opened, LPN N reported 28 days. Surveyor asked LPN N if nasal sprays should have an open date, LPN N stated yes. Surveyor asked LPN N what the process is for checking the medication carts for expired medications, LPN N stated that the cards should be checked every time the medications is being administered. Surveyor asked LPN N what the process is for checking PRN medications for expired medications, LPN N stated that they should be checked before they are given. Surveyor asked LPN N if the expired medications should have been discarded, LPN N stated yes. On 5/1/25 at 2:05 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the process is for ensuring that expired medications are removed from the medication carts and medication rooms, DON B stated that the pharmacist is supposed to come and audit the carts and room, and expired medications should be taken out and sent back to the pharmacy. Surveyor asked DON B how often the carts and rooms should be checked, DON B stated that she thought is was monthly, but that she has to call and schedule it ahead of time.

Based on observation, interview, and record review, the facility did not ensure that every resident was treated with respect and dignity for 2 of 2 sampled Residents (R71 & R146) and 2 of 2 supplemental Residents (R13 & R67) reviewed for Resident rights. R13, R67, R71, and R146 expressed concerns about R82 wandering into their private rooms uninvited. This is evidenced by: The facility policy titled Promoting/Maintaining Resident Self-Determination dated 4/22/25 states: It is the practice of this facility to protect and promote resident rights by facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as food, interests, and preferences. Example 1 R13 was admitted to the facility on [DATE] with diagnoses that include: vascular dementia, hypertension (high blood pressure), chronic kidney disease, congestive heart failure, and intervertebral disc degeneration (breakdown of discs that separate the bones of the spine). R13's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R13 scored 15 out of 15 on her Brief Interview for Mental Status (BIMS), indicating she is cognitively intact. On 4/30/25 at 9:52 AM, Surveyors observed R82 enter R13's room without knocking on the door. R82 proceeded into the room and sat in R13's wheelchair while R82 was resting in her recliner. One surveyor stayed with R13 and R82 while another Surveyor alerted LPN X (Licensed Practical Nurse), who was the nearest staff member. LPN X escorted R82 out of R13's room. On 4/30/25 at 9:56 AM, Surveyors interviewed R13. R13 stated R82 comes into her room uninvited all the time. Surveyor asked R13, when R82 comes into your room what does she do. R13 stated, When she comes in, she sits down. Sometimes she touches me. I don't like it. They should take care of her so she doesn't come in here. I don't like it. Surveyor asked R13 if she feels safe. R13 stated she feels safe. R13 added, I don't want her around here; she's crazy. R13 was unable to specify where R82 touches her. On 4/30/25 at 10:30 AM, Surveyors spoke with LPN X. Surveyor asked LPN X, are there residents that wander into other residents' rooms uninvited. LPN X stated, R82. LPN X stated, R82 will wander the whole unit as well as the other units (within the Memory Care Units). Surveyor asked LPN X, are there any residents that get upset by R82 wandering into their room uninvited. LPN X stated, no, they know the routine and say oh there she (R82) is again. Surveyor asked LPN X, what is the facility doing to prevent R82 from wandering into other resident rooms uninvited. LPN X stated, staff will redirect R82. Surveyor asked LPN X, does R82 become aggressive, LPN X stated, no, not usually. Surveyor asked LPN X, what does R82 do when she wanders into other residents' room. LPN X stated, R82 is looking for something familiar, is bored or lost. LPN X stated, R82 has no intent she's just wandering and confused. Surveyor asked LPN X, is it acceptable for a resident to go into another resident's room uninvited. LPN X stated, no. LPN X added, if she was a resident she would not want a resident coming in her room either. Example 2 R67 was admitted to the facility on [DATE] with diagnoses that include: post-concussion syndrome (symptoms that persist after a concussion has occurred), dysphagia (difficulty swallowing), anxiety disorder, history of ischemic attack (TIA - mini stroke) and cerebral infarction (stroke). R67's admission Minimum Data Set (MDS) dated [DATE] indicates R67 scored 3 out of 15 on her Brief Interview of Mental Status (BIMS), indicating she is severely cognitively impaired. On 4/30/25 at 4:22 PM, Surveyor interviewed R67. Surveyor observed R67's room is directly across from R82's room. R67 stated R82 often comes into her room uninvited, and said it bothers her because she shouldn't do that, but said that R82 seems to like when R67 talks to her. R67 said staff grabs R82's arm and pull her away and tell her to sit down when they find her in R67's room. R67 stated she feels safe in the facility. Example 3 R71 was admitted to the facility on [DATE] with diagnoses that include spinal stenosis (spinal narrowing), major depressive disorder, type 2 diabetes, dementia, generalized anxiety disorder, insomnia (difficulty falling or staying asleep), hypertensive chronic kidney disease (kidney disease caused by high blood pressure), and repeated falls. R71's Significant Change Minimum Data Set (MDS) dated [DATE] indicates R71 scored 6 out of 15 on his Brief Interview of Mental Status (BIMS), indicating he is severely cognitively impaired. On 4/30/25 at 8:10 AM, Surveyor interviewed R71 while R82 was sitting nearby in the common area. R71 indicated R82 comes into his room when he is in the bathroom on the toilet and at the sink. R71 stated R82 will sit on his bed while he is in bed. R71 stated, See? She's checking me out. Wherever I go she's there. She's like a bad dream. R71 stated, R82 usually comes in his room uninvited two (2) times a day. R71 stated, he has expressed concerns to multiple staff members regarding his concern with R82 wandering into his room uninvited. On 5/5/25 at 8:57 AM, Surveyors spoke with SW CC (Social Worker). Surveyor asked SW CC, can you tell us about R82 wandering into other residents' rooms uninvited and what is being done to prevent it. SW CC indicated, she can't recall off the top of her head. Surveyor asked SW CC, are any residents upset by R82 wandering into their rooms uninvited. SW CC stated, R71. SW CC added, we have a grievance open about this. SW CC stated, she does not know when it happened. SW CC stated, R71 expressed to her that he is frustrated that R82 comes in his room. SW CC stated, she has had conversations with R71 that R82 doesn't mean any harm but validated that it is frustrating to him. On 5/5/25 at approximately 9:15 AM, SW CC shared the grievance R71 filed on 4/30/25 with Surveyors. The grievance indicates R71 is frustrated with R82 wandering into his room. SW CC has talked with R71 regarding this concern. As of 5/5/25, the grievance was still open. Example 4 R146 was admitted to the facility on [DATE] with diagnoses that include aftercare following joint replacement surgery, presence of left artificial knee joint, infection and inflammatory reaction due to internal left knee prosthesis (artificial joint), arthritis due to other bacteria - left knee, hypertension (high blood pressure), dementia, and chronic kidney disease. R71's admission Minimum Data Set (MDS) dated [DATE] indicates R146 scored 8 out of 15 on her Brief Interview of Mental Status (BIMS), indicating she is moderately cognitively impaired. On 4/29/25 at 8:12 AM, Surveyors interviewed R146. R146 stated, on 4/28/25, her first night at the facility, R82 walked into her room uninvited behind a nurse and sat on her legs. R146 added, she just had surgery on her left knee. R146 stated, That shock and that pain I will never forget. R146 stated, of course it shocked the person she followed in and it shocked me more. R146 stated, staff apologized profusely, but it still happened. On 4/28/25 at 11:45 PM, R146's Progress Notes document the following: The resident is adjusting well. At bedtime, the resident was about to sleep when another resident entered her room and sat on her new surgery Knee. The medical doctor was notified and instructed me to monitor the resident. If the pain became unbearable we were to send the resident to the hospital . On 4/30/25 at 3:00 PM, Surveyor spoke with RN H (Registered Nurse). RN H stated, on the evening of 4/28/25, she was at the nurses' station when the CNA (Certified Nursing Assistant) notified her that R82 sat on R146's surgical knee. RN H stated, the CNA got R146 an ice pack, and she called the physician to report it. RN H stated, the physician stated to monitor R146's pain level and if it is still painful in the morning to call to call the orthopedic physician. RN H stated, she checked on R146 in the morning. RN H stated, R146 was shaken up but okay. RN H stated, she reported this off to other nurses. RN H stated, R82 has Alzheimer's disease and cognitive challenges. RN H stated, the only solution is 1:1 which challenging with staff. RN H stated, the facility implemented 1:1 quite a while ago. RN H stated, R82 likes to enter other residents' room. RN H stated, R71 gets upset when R82 wanders into his room uninvited. RN H stated, staff will take R82's hand and guide her out of the room which can be challenging. RN H stated, she will need to point to help R82 to understand what is being communicated. RN H stated, R82's family member would be a good resource. Surveyor asked RN H, is it acceptable for a resident to wander into other residents' rooms uninvited. RN H stated, no, it's not. RN H added, it's challenging with R82. RN H added, staff have tried games, coloring and other activities. RN H added, however, R82's attention span is short. RN H reiterated, 1:1 may be the only solution. On 4/30/25 at 10:12 AM, Surveyors spoke with CNA Y. Surveyor asked CNA Y, are there any residents that wander into other resident rooms uninvited. CNA Y stated, yes, R82. CNA Y added, on 4/28/25 R82 wandered into other resident rooms uninvited all day and night but it depends on the day. CNA Y stated, R82 will lay on other residents' beds, get into the beds, sit on couches and chairs in other residents' rooms. CNA Y stated, taking R82 back to her room does not work and she will get combative with staff. Surveyor asked CNA Y, is R82 able to open closed doors. CNA Y stated, yes. CNA Y added, R82 wanders onto other units as well (within the Memory Care Units). CNA Y stated, R82 will speak multiple words in her native language. Surveyor asked CNA Y, does the facility use any alarm or stop signs for R82. CNA Y stated no, she is unsure if the facility has tried these interventions. On 5/2/25, R82's Progress Notes document the following: Resident continues to wander into other resident's room and bed while residents are asleep. Writer was able to take resident for walk around the building and this was not effective. Resident showed physical aggression to staff during cares. Staff reports that resident hitting, kicked and scratched them during Pm cares. Resident was able to be redirected but continued with wandering shortly after. Staff have to take turns sitting with resident to prevent her from entering another resident room while they're asleep. resident is currently resting in recliner near burses [sic] station with eyes closed. On 5/5/25 at 8:20 AM, Surveyors spoke with DON B (Director of Nursing). Surveyor asked DON B, is it acceptable for a resident to wander into other residents' rooms uninvited. DON B stated, it's memory care so we definitely work hard to redirect wandering residents. DON B added, the residents have care plans due to their behaviors. Surveyor asked DON B, are you aware that R82 wanders into other residents' rooms uninvited. DON B stated, R82 used to have these behaviors (wandering) which slowed down a bit and now they are resurfacing. DON B added, it has been a challenge over the last week or two. Surveyor asked DON B, do other residents gets upset with R82 wandering into their rooms uninvited. DON B stated, R146. DON B added, she thinks that was the only wandering into a resident's room. DON B stated, R82 does go to activities and sometimes she just paces in a circle. Surveyor shared observations on 4/30/25 of R82 being checked on twice in 1 hour and then wandering into R13's room uninvited. Surveyor shared that R82 sat in R13's wheelchair while R13 remained silent in her recliner. Surveyor shared additional resident concerns from R67, R71 and R146 regarding R82 wandering into their rooms uninvited, sitting on their bed, sitting on their legs, entering their bathroom while they are on the toilet. Surveyor asked DON B, what has been done to address R82's wandering. DON B stated, we offered R146 a different room and staff redirect R82. R146 stated she does not want a different room. DON B stated, we offer to walk with R82, offer snacks/fluids, redirect her to the chair in her room. DON B stated, staff walk with R82 around the building. DON B stated, On 5/2/25 staff were taking turns sitting with R82. DON B added, she did not look at the care plan but instead looked at recent documented events. Surveyor asked DON B, why is it important that R82 (or other residents) do not wander in other residents' rooms. DON B stated, it can be uncomfortable for the other residents and put R82 at risk as well. Surveyor asked DON B, has the facility tried STOP signs (velcro signs that go across a doorway). DON B stated, she thinks the facility tried that and it was not effective. DON B stated, she had a history of wandering at home and would wander at night. Surveyor asked DON B, how often do you expect staff to check on R82. DON B stated, every one - two (1-2) hours. DON B stated, R82 is either right there into everything or relaxed and settled. On 5/5/25 at 2:30 PM. Surveyors spoke with NHA A (Nursing Home Administrator). Surveyors asked NHA A to tell us about R82 wandering into other residents' rooms and what is being done to address it. NHA A stated, historically the facility trialed 1:1 with R82. NHA A stated, R82 worked as a schoolteacher. NHA A stated, in the dining room we sometimes will see unmet needs or tendencies from her past when she will reach out and pat other residents' heads while in the dining room. When R82 was at high risk of falls we did 1:1. NHA A stated, we found 1:1 made her more agitated especially at night. NHA A stated, the facility did trial STOP signs with her wandering and that was more of a reason for her to enter a room when curiosity took over. NHA A added, it wasn't effective. The facility was aware that R82 is wandering into other residents' rooms uninvited. The facility did not implement interventions to prevent this from occurring. R13, R67, R71, and R146 voiced they do not want R82 wandering into their rooms uninvited. Cross reference F689

Based on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 residents (R17) reviewed for self- administration of medications. R17 was observed to have a cup of medications left on her bedside table for her to take independently. R17 does not have an assessment for self-administration of medications indicating that she is safe to administer medications independently. Evidenced by: The facility's policy titled Resident Self- Administration of Medication dated 4/17/25 states in part, .3. When determining if self- administration is clinically appropriate for a resident, the interdisciplinary team should, at a minimum consider the following: a. The medications appropriate and safe for self- administration; b. The resident's physical capacity to open medication bottles, administer injections. c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for. d. The resident's capability to follow directions and tell time to know when medications need to be taken. e. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff . R17 was admitted to the facility on [DATE] with diagnoses that include polyosteoarthritis (arthritis in five or more joints simultaneously), type 2 diabetes mellitus, muscle weakness, and unspecified macular degeneration (a type of age- related macular degeneration where the specific stage is not clearly defined- symptoms include: blurred or fuzzy vision, difficulty recognizing faces, wavy lines, or a blind spot in the center of vision). R17's most recent Minimum Data Set (MDS) dated [DATE] states that R17 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R17 is cognitively intact. The MDS indicates that R17 requires substantial/ maximal assistance for completing Activities of Daily Living (ADLs), including bathing, oral care, dressing, and personal hygiene. The MDS also states that R17 has limited range of motion of her bilateral upper extremities (shoulder, elbow, writs, and hand). The facility's assessment titled Self- Administration of Medications Review Tool dated 11/27/24 states in part .B. Approval 1. Physician order to self- administer medication(s): 2. No, 2. Approval to self- administer medication(s) granted: 2. No, 3. Reason for approval not granted, if applicable: Resident is unable to elaborate enough information regarding medications or administration to safely administer medications. The facility's document titled Self- Administration of Medications with a completed date of 4/28/25 states A. Assessment 1. Is the resident cognitively impaired? 2. No. 2. Does the resident have a visual deficit? 2. No. 3. Is fine motor coordination impaired? 2. No. 4. Can the resident name medication dosages, frequency, and reason for use? 2. No .B. Conclusions .B. Based on the entire assessment and answers to these listed question numbers the resident WOULD BE considered safe to self- administer medications. WOULD BE. C. Plan 1. Does the resident want to self- administer all or some of their medications? 1. Yes .2. If the nurse feels the resident would be able to successfully administer their own medication, they will discuss it with their physician and plan set up for the resident per facility policy and procedure .Resident has requested that the nurse/ MAA (Medication Administration Aide) prepared meds be left by the bedside. Provider ordered. It is important to note that R17 has a diagnosis of macular degeneration and polyosteoarthritis. It is also important to note that the assessment dated [DATE] was not completed, nor the order obtained until after Surveyor made the observation of the medications at bedside. On 4/28/25 at 9:42 AM, Surveyor interviewed R17. Surveyor noticed R17's medications sitting on the bedside table. Surveyor asked R17 if staff always leave the medications for her to take by herself, R17 stated no, lately she has needed help. R17 reported that she called for someone to help with the pills, and no one had come to help. On 4/28/25 at 12:12 PM, Surveyor interviewed MAA FF (Medication Administration Aide). Surveyor asked MAA FF if she administered R17's medications this morning, MAA FF stated yes and that R17 gets upset if her medications aren't there and then she goes back to R17's room and helps her take them. Surveyor asked MAA FF if R17 has a self- administer assessment or order, MAA FF reported that it says to observe her take mediations, but that recently they have been having to give the medications to her. On 4/2825 at 12:27 PM. Surveyor interviewed LPN N (Licensed Practical Nurse). Surveyor asked LPN N if R17 has an assessment or order to self-administer medications, LPN N stated no. Surveyor asked LPN N if R17's medications should be left in her room unattended, LPN N stated no. Nurse's note dated 4/28/25 at 4:18 PM states: Nrs (nurse) manager notified that resident prefers her meds to be self-administered and will not eat her breakfast unless they are nurse/MAA prepared and left at the bedside. CP (Care Plan) updated, assessment completed, and banner updated as well. Order to self-administer bedside meds obtained at an earlier date. Will continue to follow plan of care. On 4/29/25 at 2:58 PM, Surveyor interviewed LPN GG, who is also the Unit Manager. Surveyor asked LPN GG how she was made aware that R17 wanted to self- administer her medications, LPN GG stated that the medication aide told her that R17 will only eat breakfast if the medications were present and that R17 won't eat breakfast if the medications are not on the bedside table. Surveyor asked LPN GG if R17 not eating breakfast is an appropriate reason for leaving the medications at bedside, LPN GG stated no, but they aim to please. Surveyor asked if R17 qualifies to self- administer based on the assessment that was performed, LPN GG stated that R17 does not meet all the qualifications and that R17 is not able to identify the medications. Surveyor asked LPN GG if R17 is physically able to self- administer medications, LPN GG stated yes. Surveyor asked LPN GG if she observed R17 taking her medications, LPN GG stated no, and she was going from the information reported by the med aide. On 4/30/25 at 10:32 AM, Surveyor interviewed R17. Surveyor asked R17 if staff are allowing her to take medications independently, R17 stated no, and that she used to be able to take them independently but now that her condition has deteriorated, she needs help. Surveyor asked R17 if she refuses to eat breakfast until the medications are in the room, R17 stated no and that she wants to have something in her stomach before taking the medications. Surveyor asked R17 if she would be agreeable to having staff bring the medications in after she has eaten breakfast R17 stated yes. Surveyor asked R17 if LPN GG has ever discussed her medications with her, R17 stated no. On 4/30/25 at 10:52 AM, Surveyor interviewed LPN GG. Surveyor asked LPN GG if she ever spoke with R17 about her medications when completing the assessment for self- administration, LPN GG stated no. Surveyor asked LPN GG if she had ever discussed R17's preference with her, LPN GG stated no and that she was going off the information provided by the med aide. Surveyor asked LPN GG how many of the criteria on the assessment need to be met to self- administer medications, LPN GG stated that she was not sure. On 5/1/25 at 2:05 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the process is for determining if a resident is safe to self- administer medications, DON B reported that staff need to complete an assessment, get an order, update the banner, and update the care plan. Surveyor asked DON B if resident has to meet all of the criteria on the assessment, DON B stated no and that the form they are using does not give a score based on the answers and that residents should know what the medications are. Surveyor asked DON B if staff that are performing the assessments should meet with the resident, DON B stated yes.

Based on observation, interview, and record review, the facility failed to ensure that each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 3 residents reviewed for restraints (R27). R27 was placed in a low Broda chair (a specialty wheelchair that assists with positioning) that has brakes located on the back of the wheels at the bottom of the chair. R27's brakes were engaged while R27's was at the dining table, not allowing R27 to move the chair. Evidenced by: The facility's policy titled Restraint Free Environment dated 2/2025 states in part .Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: .Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents the resident from rising. Placing a resident in a chair that prevents the resident from rising . R27 was admitted to the facility on [DATE] with diagnoses that include dementia, seizure disorder, psychotic disturbance, mood disturbance and anxiety, altered mental status, and malaise. R27's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/25 indicates a Brief Interview for Mental Status (BIMS) was unable to be performed. A staff assessment of R27's mental status indicates R27 has moderate cognitive impairment. Section C1310 of the assessment indicates R27 has periods of inattention and disorganized thinking. Section GG indicates R27 requires setup assistance with eating, supervision for oral hygiene and upper body dressing, partial to moderate assistance for toileting and personal hygiene, and substantial to maximum assistance for showers, lower body dressing, and footwear. R27's mobility indicates she requires partial to moderate assistance for rolling left to right, sitting to standing, lying to sitting, chair to bed transfer, toilet transfer and walking 50 feet. R27 utilizes a wheelchair and is dependent on locomotion of 150 feet while in the wheelchair. Section J1800 any falls prior assessment indicates yes. Section J1900 number of falls since admission or prior assessment indicates the following: No Injury two or more. B. Injury two or more. C. Major injury indicates one. R27's Activities of Daily Living (ADL) care plan initiated 9/4/24 revised on 11/25/24 states: Focus: At risk and/or potential for complications with deficits with ADLs r/t (related to) current medical/ physical status. Has meds/dx (medications/diagnosis) that can/may affect ADLs dated initiated 9/4/24 revised 9/7/24. Goal: Will be clean, dry, dressed appropriately and maintain ability to participate in ADLs through next review date 9/7/24 revised 11/25/24. Will be more independent with ADLs after set-up, cues and able to return to assisted living by discharge date . Interventions: Ambulation - may ambulate in room or hallway with w/c (wheelchair) trail 9/4/24 revised 2/28/25. Bed mobility: 1 assist 9/4/24 revised 2/28/25. Locomotion: 1 assist in Broda Chair 4/1/25. Transfers: 1 assist pivot with gait belt 9/4/24 revised 2/28/25. Prefers to get up around 7:00 AM and goes to bed around 8:00 PM 9/7/24. On 5/5/25 at 8:30 AM, Surveyor observed R27. R27 was noted to be sitting close to the table in the Broda chair with the wheels locked, waiting for breakfast. On 5/5/25 at 9:33 AM, Surveyor observed R27 still sitting at the dining room table in the Broda chair with the wheels locked. R27 was attempting to move the chair with her hands by grabbing onto the wheels, but the brakes remain locked. On 5/5/25 at 10:40 AM, R27 was repositioned in the Broda chair, and the brakes were unlocked. It is important to note that the brakes of the Broda chair are located on the back lower wheels, in a location that R27 is unable to physically reach. Additionally, this was a continuous observation of R27. On 5/5/25 at 10:42 AM, Surveyor interviewed CNA R (Certified Nursing Assistant). Surveyor asked CNA R if R27 is able to self- propel in the Broda chair, CNA R stated that R27 used to be able to self- propel in her old wheelchair, but she hasn't seen R27 do it in the new chair. On 5/5/25 at 1:50 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R27 is able to self- propel in her current chair, DON B stated yes. Surveyor asked DON B if the Broda chair brakes are located in a position that R27 cannot reach, and they are locked, and R27 is sitting up close to the table, would that be considered a restraint, DON B reported that it is hard to say. Surveyor asked DON B if R27 was attempting to move the wheels on the chair and was unable to do so because the wheels were locked, would that be considered a restraint, DON B did not reply. On 5/5/25 at 2:40 PM, Surveyor observed R27 sitting in the Broda chair, up against the table with the wheels locked. On 5/5/25 at 2:40 PM Surveyor interviewed RN DD (Registered Nurse). Surveyor asked RN DD if R27 can self-propel the Broda chair, RN DD stated yes, and that he has seen R27 do it. Surveyor asked RN DD if having the brakes locked is considered a restraint, RN DD stated yes. R27's brakes were engaged while R27's was at the dining table, not allowing R27 to move the chair.

Based on observation, interview, and record review, the facility did not document a thorough investigation and did not resolve grievances as outlined in the facility policy for 1 of 4 residents (R26) reviewed for grievances. R26 voiced concern about staff being on their cell phones. The facility failed to follow up on the grievance. Evidenced by: The facility policy, Resident and Family Grievances, dated 10/23, states, in part; .3. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances and notifying the person filing the grievance of the decisions and outcome . Surveyor reviewed January 2025 Resident Council Minutes. Minutes indicate R26 voiced concern about staff on their personal cell phones while working. On 4/30/25 at 1:53 PM, Surveyor observed LPN HH (Licensed Practical Nurse) on their personal cell phone attempting to open a bank account. On 4/30/25 at 1:57 PM, Surveyor observed LPN GG on their cell phone on a Facetime call while this Surveyor was completing the Medication Storage task. On 4/30/25 at 3:10 PM, Surveyor observed LPN II on their personal cell phone talking about a resident. On 5/5/25 at 8:21 AM, Activities Director J (AD) indicated any grievances discussed during Resident Council will go to the specific department to follow up on. AD J indicated she remembers R26 voicing a concern with cell phones. AD J indicated she brought the concern to the Director of Nursing. AD J indicated this was a previous DON, and she is unsure if there was any follow up. AD J indicated staff using cell phones during their work hours is an ongoing concern and has been brought up before by management. Surveyor reviewed grievance log and did not see R26's concern. On 5/5/25 at 8:43 AM, R26 indicated no one followed up with her regarding concern with staff on their personal cell phones during work hours. R26 indicated it is still a concern. On 5/5/25 at 10:28 AM, DON B (Director of Nursing) indicated there wasn't specifically a grievance regarding cell phones, but everyone reviewed the cell phone expectations in February 2025. DON B indicated she would expect a thorough investigation and follow up on grievances. The facility did not document a thorough investigation and did not resolve grievances as outlined in facility policy.

Based on interview, record review, and policy review the facility failed to ensure that the facility was free of accident hazards in 1 of 7 residents R9 reviewed for accident hazards of 14 sample residents. The facility failed to prevent a fall for R9 Findings include: Review of the facility's policy titled, Fall Prevention Program, dated 02/28/25, indicated Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor or other level, but not as result of an overwhelming external force .Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. A. The risk assessment categorizes resident according to low, moderate, or high risk .5. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of resident falling .b. Implement routine rounding schedule. C. Monitor for changes in resident's cognition, gait, ability to rise/sit and balance .g. Complete a fall risk assessment every 90 days and as indicated when resident's condition changes .8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care . Review of the facility's policy titled, Elopements and Wandering Residents, dated 02/28/25, indicated Policy: This facility ensures that residents who exhibit wandering behavior and/or risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions .Elopement occurs when a resident leaves the premises or a safe area without authorization .and or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risks, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 2. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering. A Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team .Procedure Post-Elopement a. A nurse will perform a physical assessment, document and report findings to physician .d. The resident and family/authorized representative will be included in the plan of care. E. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior .g. Documentation in the medical record: findings from nursing and social service assessments, physician/family notification, care plan discussion . Example 1 Review of R9's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R9 was admitted to the facility on [DATE] with diagnoses of anemia, history of falling, age related osteoporosis, major depression disorder, and dementia. Review of R9's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/24/25, located under the Resident Assessment Instrument (RAI) tab indicated R9 was substantial/ maximum assistance for eating; partial/ moderate assistance for oral hygiene; dependent on toileting hygiene, dressing, transfers, and personal hygiene; and substantial/ maximum assistance to dependent for bed mobility. The MDS revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating R9 was cognitively intact. Review of R9's Progress Notes under the Progress Note tab of the EMR, dated 10/24/24 Note Text: CNA reported resident noted sliding out of recliner. Writer immediately assessed resident and noted resident sitting in recliner with legs sliding off recliner. No fall. Writer and 2 CNA's repositioned resident into recliner appropriately with BLE's elevated. Writer called Therapy department to request non slip gripper for recliner or recommendations to prevent a fall and therapy recommended green Posey non-slip matting available in med room to prevent fall. Writer updated ADON and states will update care plan. Resident in no apparent distress, in good spirits. Resident denies pain or discomfort. Will continue to monitor until end of shift. Review of R9's Progress Notes under the Progress Note tab of the EMR, dated 11/05/24, indicated Resident noted on the floor, on her back with feet towards the door and head towards recliner. Remote to recliner in resident's hand and recliner noted tilted in the highest position. Resident assessed at this time. She denies any pain or discomfort. Tylenol administered as scheduled. No new injuries or bruises noted at this time. Neuros WNL [within normal limits]. ROM [range of motion] WNL for resident. Resident stated, she does not know why she held button until falling out of it. VSS [vital signs stable]. -New intervention: Unplug recliner due to resident's lack of safety awareness. CP [care plan] and Kardex updated. Charge nurse, nurse manager .NP [Nurse Practitioner], and POA [power of attorney] notified. R9's plan of care states in part; Complications with or falls related to current medical physical status. Goal: Reduced risk with falls with interventions through next review date. Interventions: Unplug recliner due to resident lack of safety awareness, initiated date: 11/5/24. Resolved date: 11/6/24. Reinforce nonskid strips in front of recliner intiated date: 11/6/24. It should be noted R9's lift chair was plugged back in allowing R9 to use the lift function, the facility did not have evidence of assessing R9's safety to utilize the lift chair safely prior to plugging the lift chair back in. It should be noted R9 had a fall out of the lift chair on 1/20/25 due to lifting the chair in upright position this resulted in a femur fracture, Review of R9's Progress Notes under the Progress Note tab of the EMR, dated 01/20/25, indicated writer found resident in her room on the floor around 8pm. Resident had used electric control for recliner and put the chair all the way up causing her to fall out on her left side. Fully clothed with shoes on, her head was toward the bed and feet next to the recliner and throw blanket was under her. All needed items were on table next to chair with call button on her neck. Stated she did not hit her head. Review of R9's Progress Notes under the Progress Note tab of the EMR, dated 01/21/25, indicated IDT [Interdisciplinary Team] NOTE . The recliner chair was observed all the way up at the time of occurrence. Most likely she used the electric control and put the recliner all the way up causing her to fall out onto her left side. Increased rounding after dinner provided. Upon return from hospital therapy to eval for recliner safety and therapy needs s/p [status post] left femur fracture with ORIF (open reduction internal fixation) .Will monitor the effectiveness of the interventions and modify as necessary. Review of R9's Progress Notes under the Progress Note tab of the EMR, dated 01/24/25, indicated SW [Social Worker] contact .Son to inform, recliner has been removed due to non-usage and inability to safely operate furniture . Review of R9's Fall Risk Screening Tool under the Assessments tab of the EMR indicated the following completed screenings: 09/28/24 no falls; 11/05/24 - three to no falls, resident was incontinent, had cognitive impairment, resident did not always use call light appropriately, problem with cognition, judgement, memory and safety awareness; unsteady with gait, patient alert to self; 01/04/25 quarterly no falls, was resident at risk for falls - no. During an interview on 03/28/25 at 3:24 PM, the Administrator stated we really do not have fall prevention education for staff that is specific at orientation but when CNAs go to floor fall prevention is covered when they review the Kardex. Said no specific fall prevention training for staff in past 6 months. Explained that they have a charge nurse that is over building each shift and that nurse attends stand up and stand down meeting where falls and new interventions would be discussed and then brought to unit staff and Kardex changed. Surveyor inquired about R9's falls from the lift chair. Administrator stated he could not locate a document or discussion between Therapy and Nursing regarding why R9's recliner control was plugged back in. The Administrator explained the therapy group is no longer employed by the facility and documentation for R9 is not been located. The Administrator stated Therapy/Nursing discussion about recliner and plugging back in was done between staff and will try to locate something about decision. Said have one PT that is still here that may have knowledge. No further information is provided. The facility failed to assess R9's ability to safely operate a lift chair. R9 was found sliding out of the lift chair on 10/24/24, had a fall out of the lift chair on 11/5/24 when R9 raised the chair in the upright position and slid out of the chair on to the floor. The facility is unable to produce evidence they assessed R9's ability to safely use the lift chair. R9 had a second fall out of the lift chair when R9 lifted the chair in the upright position R9 fell out of the lift chair and was found with a femur fracture. The facility completed a performance improvement plan related to the fall with fracture however there the facility was unable to provide evidence of staff education regarding the changes in recliner/lift chair process.

Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R5) reviewed for supervision and accidents. R5 was served coffee while in his bed and dropped the coffee cup in the bed on his right side which pooled up against him. R5 sustained superficial partial thickness burns to right flank and right buttocks, estimated approximately 7% Total Body Surface Area (TBSA). Facility had no process in place regarding safety to residents with hot liquid temping or any type of safety assessment. After the incident occurred, coffee brewers were temped at 185 Fahrenheit. Evidenced by: The facility policy titled Food Safety: Preventing Burns dated 2021, states, in part: Policy: Hot food and beverages will be served at a safe temperature that prevents burns. Procedure: 1. Staff will monitor hot food and beverage temperatures at the point of service . 5. Appropriate supervision to obtain hot beverages and/or reheat foods in a microwave will be provided to any individual demonstrating decreased safety awareness and/or anyone who is at risk for burns or scalds based on clinical assessments . The chart below shows the estimated time for persons to receive second and third degree burns at various temperatures. Water Temperature Time to Receive 2nd Degree Burn Time to Receive 3rd Degree Burn 120 F 8 minutes 10 minutes 124 F 2 minutes 4.2 minutes 131 F 17 seconds 30 seconds 140 F 3 seconds 5 seconds . R5 was admitted to the facility on [DATE], and has diagnoses that include traumatic shock, major depressive disorder, and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain). R5's Quarterly Minimum Data Set (MDS) Assessment, dated 8/9/24, shows that R5 has a Brief Interview of Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. Section GG shows that R5 uses a wheelchair for mobility and R5 has no impairment to upper extremities with range of motion and has impairment with range of motion on both lower extremities. R5 requires substantial/maximal assistance with showering/bathing and upper body dressing. R5 is dependent on staff for toileting, transfers, and dressing lower body. R5's Care Plan, dated 11/2/23, states, in part: Focus: Nutrition/Hydration - At risk/and/or Potential for Complications with Nutrition/Hydration d/t (due to) ESRD (End Stage Renal Disease), Lymphedema, quadriplegia and obesity . Date Initiated: 11/2/23. Revision on: 8/1/24 . Interventions: Fluid- Thin/Regular Liquids . Set-up meal per resident request. Honor food requests as able. Date Initiated: 11/2/23. Revision on: 6/21/24 . Focus: Safety/Hot Liquids: Actual/Potential for injury related to spillage of hot liquids. Date Initiated: 10/15/24. Revision on: 10/17/24. Goal: Resolved: Resident will remain free of serious injury related to handling of hot liquids. Date Initiated: 10/15/24. Revision on: 10/17/24. Target Date: 11/1/24. Resolved Date: 10/17/24. Resident will remain free of serious injury related to handling of hot liquids. Date Initiated: 10/13/24. Revision on: 10/17/24. Target Date: 11/1/24. Interventions: - Resolved: Evaluate for the presence of risk factors for spills and potential of injury from hot liquids on admission/readmission/quarterly and/or significant change. Date Initiated: 10/15/24. Revision on: 10/17/24. Resolved Date: 10/17/24. - Evaluate for the presence of risk factors for spills and potential of injury from hot liquids on admission/readmission/quarterly and/or significant change. Date Initiated:10/17/24 . -Resolved: Staff to assist with pouring/serving hot liquids. Date Initiated: 10/15/24. Revision on: 10/17/24. Resolved Date: 10/17/24. -Need to utilize cup with Coban added for texture to assist with grip. Date Initiated: 10/17/24 . R5's Incident Report dated 10/13/24, at 7:00AM, states, in part: . Incident Location: Resident's Room . Incident Description: Nursing Description: I was walking out of the resident in (Resident Room Number) room when CNA (Certified Nursing Assistant) was walking out of the clean linen closet. She yelled for me to come to the resident in (R5's Room Number) room right away. When I entered the resident's room CNA had the resident out of his clothing and in a brief and was changing the bedding. I asked the resident what happened (see resident's description for response). I observed the resident's skin and saw a reddened area and blisters extending from the resident's right thigh to the right abdomen up to the ribcage. I took the resident's vitals and completed a pain assessment. Resident stated he was trying to change hands from the left hand to the right hand holding his coffee thermos when it spilled. Immediate Action Taken: All the bedding and clothing was removed from the resident and bed. After the resident was cared for the coffee pot was emptied and the appropriate people were notified including the on-call physician who gave the order to send the resident to the ER (emergency room ) for evaluation . Injuries Observed at Time of Incident: Injury Type: Injury Location: Burn 19) Right iliac crest (front) Burn 21) Right iliac crest (rear) Burn 31) Right Buttock Burn 64) Other (Describe) Level of Pain: Numerical: 0 Level of Consciousness: Alert Mobility: Wheelchair bound. Mental Status: -Baseline for individual -Oriented to Place -Oriented to Time -Oriented to Person Predisposing Environmental Factors: -None Predisposing Physiological Factors: -None Predisposing Situation Factors: -None . Email to Medical Director from DON B (Director of Nursing), dated 10/13/24, at 3:54 PM, states, in part: . Updating you that early this morning R5 sustained a significant burn to parts on his torso and buttock after dropped his coffee while in bed. R5 was sent to the ER and has returned with new treatment orders and an order for oxy prn (Oxycodone as needed, A pain medication) . Per R5, he was attempting to transfer his coffee from his good hand (L) to his bad hand (R) when the mug fell . R5 states he will only use his left hand when handling hot beverages from here on out. We are also looking over our process around serving hot beverages/checking temps, and updating for safety . R5's Progress Note dated 10/13/24, at 8:12AM, states, in part: Note Text: At 7 AM writer called to resident's room by CNA. Resident stated he was switching hands he was holding his coffee thermos cup with and spilled. Assessed resident's skin to find reddened area with fluid filled blisters on resident's right upper thigh to right lower abdomen and on resident's back. Resident denied any pain. Vitals taken. Charge nurse notified and On-Call provider notified. Order to send resident to ER (emergency room ) . R5's Progress Note dated 10/13/24, at 3:01 PM, states: Returned from hospital. New orders received: Oxycodone 5 mg (milligrams) take one tab every 6 hours as needed for pain. Wound Care: Wash wound daily with Dial soap and water. Use a washcloth to scrub the area, cover with bacitracin and place cuticerin on top, cover with dry gauze, wear compression t-shirt to hold dressing in place. Follow up in 1 week. R5's Progress Note dated 10/16/24, at 2:31PM, states, in part: . Late Entry: Note Text: Wound Observation Completed . Wound Location & Description: Type of Wound: Other superficial partial thickness burn (2nd degree) . Wound Base/Bed: Granulation Slough: % Granulation- 50% Slough: 50 Drainage Amount: Heavy Right side of back/buttock 24 x 30 x 0.1cm (centimeters) Right Breast 10 x 8 cm Burn surface is a mixture of yellowish white slough and pink tissue. Drainage Color: Serous Surrounding Tissue: Intact . Pain Associated with wound: Yes, Pain noted with treatment . Treatments: Current Treatment/Dressing: Yes Bacitracin, cuticerin, gauze . R5's Dietary Progress Note dated 10/17/24, at 2:14 PM, states, in part: . Notified by RN (Registered Nurse) that R5 is having fluid losses from his burns. The TBSA is 7%. Due to wounds, he receives Vitamin C 500 mg, ZnSo4 (zinc sulfate) 220 mg, Juven bid (twice a day) to support healing . Hospital Discharge, dated 10/13/24, states, in part: . Date of Service: 10/13/24 9:17AM . S: accidentally spilled coffee on self this morning; does not feel pain, history of cervical injury, also history of poor wound healing on legs requiring VAC and at a skilled nursing facility. O: see picture of approximately 7% TBSA superficial partial thickness to right flank/buttock A/P: 2nd degree thermal burn and patient was history of cervical injury and ongoing wound care concerns and transferred to burn center for debridement and follow-up wound care after discussion with them. Tetanus updated here. Chief Complaint: Burn (coming from (Skilled Nursing Facility Name). Alert and Oriented (A&O) x 4. Spilled coffee on his abdomen, to his back, right upper thigh. Reddened areas and fluid filled blisters . Physical Exam: . Skin: Warm and dry. Superficial partial thickness burn present to right flank and right buttocks approximately 7% TBSA. Neuro: Awake. A&O x 3. Quadriplegic . Medical Decision Making, ED (Emergency Department) Course & Medical Complexity: . Patient with associated superficial partial thickness burn to right flank, right buttocks estimated approximately 7% TBSA . Patient declining any pain, additionally non-sensate to region given chronic quadriplegia. Care discussed with burn consult doctor with recommendations for ED transfer for formal burn consult/local wound debridement. Given no local burn consult, care at (Skilled Nursing Facility Name) will require transfer for higher burn consult. Per burn team, likely need for local wound debridement and discharged home with continued care at patient's current care facility with further burn follow-up without likely need for admission or other complicated cares . Diagnosis: Superficial partial thickness burns of abdominal wall . Emergency Department Notes, dated, 10/13/24, state, in part: . ED: 10/13/24 . Date of Service: 10/13/24 Chief Complaint: Patient presents with Burn. History: Patient with a history of tetraplegia (medical condition that causes partial or total loss of function in the arms, hands, trunk, legs, and pelvic organs) of from previous spinal cord injury who presents to the Emergency Department via EMS (Emergency Medical Services) for evaluation of burn injury. Patient states that earlier this morning he accidentally spilled hot coffee on his right lower flank and lateral hip area. Initially seen at (Hospital Name) Emergency Department where his tetanus status was updated, and the burn surgery team was consulted who recommended transfer to . Emergency Department for further wound evaluation . Physical Exam: Skin: . Findings: Burn present. Superficial partial-thickness burn with blister formation noted over the right lower flank and lateral hip/buttock. No obvious involvement of the inguinal region or penis/scrotum. TBSA about 5% . Medical Decision Making: . On exam he has a superficial partial thickness burn with blister formation noted over the right lower flank and lateral hip/buttock without obvious involvement of the inguinal region or penis/scrotum. TBSA about 5% . Burn surgery resident was consulted and evaluated patient at bedside, wound care was performed while in the ED. The following wound care recommendations were provided: -Pain control with Tylenol and PRN (as needed) ibuprofen. -Premedicate with 5 mg (milligrams) oxycodone. -Wash wound with soap and water. -Wound cares with bacitracin and cuticerin. -Wear a compression t-shirt. Post-discharge wound care: -Wash wound daily with Dial soap and water. -Use a washcloth to scrub the area. -Cover with bacitracin and place cuticerin on top. -Cover with dry gauze. -Wear a compression t-shirt to hold dressings in place. -Follow-up in clinic in 1 week . Impression: -Superficial partial thickness burn of abdominal wall (primary encounter diagnosis) -Superficial partial thickness burn of buttock, initial encounter . R5's Hot Liquids Safety Assessment, dated 10/13/24, at 10:09AM, states, in part: . -R5 has no memory problems and/or mental function. -R5's mood does not vary over course of day/easily agitated. -R5 does not have frequent impulsive acts/short tempered. -R5 does not have tremors in upper extremities. -R5 does have contractures in fingers/hands/wrists/elbows/shoulders. -R5 does have weakness/paresis in upper extremities. -R5 does not have loss of mobility/reduced movement in upper extremities. Care Plan-Hot Liquid Risk: R5 is at risk for hot liquid injury . R5's Hot Liquids Safety Assessment, dated 10/15/24, at 1:26PM, states, in part: . -R5 has no memory problems and/or mental function. -R5's mood does not vary over course of day/easily agitated. -R5 does not have frequent impulsive acts/short tempered. -R5 does not have tremors in upper extremities. -R5 does have contractures in fingers/hands/wrists/elbows/shoulders. -R5 does have weakness/paresis in upper extremities. -R5 does have loss of mobility/reduced movement in upper extremities. Care Plan-Hot Liquid Risk: R5 is at risk for hot liquid injury . Kitchen cart log for hot liquids dated 10/17/24 shows: 10/17/24- breakfast coffee temp - 135* 10/17/24- lunch coffee temp - 132* On 10/17/24 at 10:10 , Surveyor interviewed PT E (Physical Therapist). PT E indicated R5 has quadriparesis (a condition that causes muscle weakness in all four limbs.) R5 can use both arms and legs to propel in wheelchair. R5's sensation is intact. R5 is currently working with OT (occupational therapy) on standing tolerance, sitting balance, shoulder strength, grip strength, shoulder range of motion, and wheelchair propulsion. R5 is currently working with PT (physical therapy) on transfers, ambulation, pain management, and bed mobility. PT E indicated R5 has chronic muscular pain in bilateral thighs. On 10/17/24 at 10:20 AM, Surveyor interviewed R5. R5 indicated every day he drinks coffee in bed with the head of the bed up. CNAs bring coffee in every morning in R5's thermos cup/insulated coffee cup. R5 uses left hand to hold coffee but on 10/13/24, R5 indicated he got cocky and switched coffee to right hand, which is his bad hand. R5 dropped the coffee on the right side of bed alongside of him and the coffee pooled there, and he received burns to right side, back, and his butt. R5 indicated the cup he uses is his personal cup. It is a thermos cup with no handle but has a lid. R5 indicated the lid stayed on when he dropped the cup and the coffee poured out of the drinking area. R5 indicated he yelled out AHHHH!!! and CNA D (Certified Nursing Assistant) entered his room immediately and turned R5 and cleaned him up. RN G (Registered Nurse) came in right away with a couple other nurses. They sent me to the hospital. R5 indicated the burn lady told him he has 2nd degree burns. Surveyor asked R5 approximately how long after he received the coffee did he drop the cup into his bed and R5 indicated maybe 10 minutes after receiving the coffee. On 10/17/24 at 10:35, Surveyor interviewed RN G. Surveyor asked RN G if she could tell Surveyor about the morning R5 spilled his coffee in bed. RN G indicated around 6:55 AM - 7:00 AM, CNA D called for RN G to come to R5's room. When RN G arrived R5 just had a brief on. CNA D removed R5's pants and t-shirt and removed brief and had put a new one on R5. CNA D was in process of changing R5's bedding. R5 indicated he switched from holding his thermos cup of coffee from left hand to his right hand. R5's right hand does not work as well as the left hand. R5 dropped his thermos cup onto the right side of the bed. RN G indicated the thermos cup had a lid on it and the coffee had come out of the drinking portion of the cup and spilled onto R5's right side. R5 was rolled and skin was reddened. The on-call physician was called and R5 was sent to the ER. Surveyor asked how R5 typically gets his coffee and RN G indicated the CNAs get the coffee every morning for R5 in his personal thermos cup. Surveyor asked if R5 was care planned to receive coffee in his room unsupervised and RN G indicated previously no and RN G did not know if R5 was now care planned since incident. Surveyor asked if residents are assessed for safety regarding hot liquids and RN G indicated just meal tickets, but no indication for hot liquid safety for residents. Surveyor asked how would staff know if it is safe for residents to receive hot coffee unsupervised and RN G indicated the staff knows what residents need assistance with meals and if a resident drinks from a sippy cup, we would not give hot liquids unsupervised. Surveyor asked what the process is for serving hot liquids to residents and RN G indicated if residents are independent with meals staff will just give coffee or hot fluids with no assessments. On 10/17/24 at 10:55 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) and asked what the process is for serving residents hot liquids unsupervised. LPN C indicated by the MDS section GG, looking at residents' movements and whether they can move their upper body. Surveyor asked if there were assessments completed for residents to determine safety with hot liquids and LPN C indicated this week we started completing them for all residents. Surveyor asked LPN C how staff know if it is safe to give residents hot fluids in their rooms and LPN C indicated the CNA Kardex lists the diet orders, but she is not sure. On 10/17/24 at 11:06 AM, Surveyor interviewed CNA H and asked how staff know if a resident is safe to be served hot liquids in their room unsupervised and CNA H indicated if a resident drinks out of a normal cup, we just give it to them. Surveyor asked what the process was prior to incident on 10/13/24 to administer hot liquids/coffee to residents. CNA H indicated prior to 10/13/24 staff would make coffee in the kitchenettes and just pour the coffee in a cup and take it to residents. CNA H indicated now staff must get the coffee from the main kitchen and the kitchen temps the coffee prior to getting it to staff on the floor. CNA H indicated coffee cannot be over 130 degrees Fahrenheit. CNA H indicated some residents want their coffee warmed in microwave and staff can use the microwave, but staff must temp the coffee to be sure it does not exceed 130 degrees. On 10/17/24 at 11:20 AM, Surveyor interviewed VPC F (Vice President of Culinary). Surveyor asked to see the coffee temp log that was on the cart about to leave kitchen going to unit. VPC F had a dietary aide temp it and Surveyor observed temp at 138.7 degrees F. Surveyor asked when temping hot liquids started and VPC F indicated right after the incident with R5 spilling coffee. VPC F indicated prior to the incident the brewers on the units were not being temped. VPC F indicated right after the incident the brewers on the floor were temped and all were at 185 degrees Fahrenheit. VPC F indicated the facility brought in a technician for the brewers to see if they could bring the temperatures down on the brewers. The technician indicated the temps could not be brought down below 185 degrees due to a sanitation issue. VPC F indicated the facility cools the coffee down to 140 degrees or under by adding ice. The brewers upstairs on the units are not being used anymore and the facility is working on getting new brewers. Surveyor asked if residents could get coffee when the kitchen is not open and VPC F indicated the facility does not offer coffee during the night, only when the kitchen is open now. VPC F indicated prior to incident we were not temping the brewers/coffee but now the facility is which started 10/13/24 the day of the incident. On 10/17/24 at 1:00 PM, Surveyor interviewed CNA D and asked CNA D to tell Surveyor about the morning R5 spilled his coffee in bed. CNA D indicated she had taken R5 his coffee in his personal cup with a screw-on lid at 6:50 AM. CNA D indicated she placed the coffee cup in R5's left hand and left room. CNA D got to another room and heard R5 moaning and went back into R5's room. R5 indicated to CNA D that he had spilled his coffee. CNA D indicated telling RN G that R5 spilled coffee and then removed R5's clothes immediately and changed the bedding. CNA D indicated the whole right side of R5 was red and started blistering. R5 indicated to CNA D that he went to put coffee cup into his right hand and spilled the coffee in bed. CNA D indicated R5 is left hand dominant and does better with left hand. CNA D indicated it is normal for R5 to have coffee in his personal cup in his bed in the mornings. Surveyor asked what the process is for staff to serve coffee to residents. CNA D indicated staff gets the coffee from the coffee pot in the kitchenette. CNA or staff on the floor makes the coffee. CNA D indicated staff has never had to temp coffee, it was never a thing. When staff take R5 his coffee we put it in his left hand. Surveyor asked how staff know if a resident is deemed safe for hot liquids and CNA D indicated she assumed the facility coffee pots are safe to give to residents temp wise. Surveyor asked CNA D if care plans indicate safe for hot liquids in rooms unsupervised and CNA D indicated no. CNA D indicated any resident that can have thin liquids she would just give it to them. CNA D indicated the process has changed since the incident. The temps on the coffee pots in the kitchenettes were checked immediately after the incident of R5 spilling his coffee and found to be hotter than they were supposed to be and are now marked out of order. If a resident requests coffee now the kitchen temps it and brings it up for staff on the floor to administer the coffee. CNA D indicated the kitchen now sends pots of coffee up with the meals or if a resident requests a cup and temps it. On 10/17/24 at 1:41 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B about the incident on 10/13/24. DON B indicated R5 is a partial quadriplegic. When DON B met with R5, R5 indicated to DON B that he tried to hold his personal coffee cup in his right hand, which is his weaker hand. R5 indicated to DON B that he got cocky and tried to switch hands from left hand to right hand and dropped the coffee cup into his bed on his right side where the fluid pooled alongside him. DON B indicated it was R5's personal insulated coffee cup with no handle, but had a lid. Surveyor asked DON B what the process is for staff to serve coffee to residents in their rooms and DON B indicated with general services if a resident with no precautions such as, no supervision with meals or swallowing difficulties they could have hot fluids in rooms. The facility had nothing in place regarding safety with hot liquids. Unless a resident had something stating they could not have coffee or hot liquids unsupervised they could. Surveyor asked if this were something you would care plan and DON B indicated we have never had hot liquid assessments before but since incident we should have. DON B indicated hot liquids and coffee should be temped for safety. DON B indicated since incident with R5 the facility immediately halted service of hot liquids/soups that day. When hot liquids/soups resumed they were to be in temperature parameters of 140 degrees or below. Thermometers are on the units now. 1:1 on liquid temperatures with nursing staff and dietary and a reminder was put on dashboard in PCC (Point Click Care; the electronic health record). Dietary staff are now responsible to temp hot liquids and bring hot liquids/coffee up from the kitchen to the floor. The brewers upstairs are not in use. DON B indicated after the incident, therapy assessed R5 and ordered a U-drink adaptable holder that goes around cup and hand straps in so if resident lets go of cup it won't slip out of hand. DON B indicated if residents request coffee during times the kitchen is not open, we tell them we are working on it. They are not able to get coffee outside of kitchen hours currently. Surveyor asked DON B about the education and DON B indicated she would get back to Surveyor. On 10/17/24 at 2:30 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A what facility has done to ensure what happened with R5 does not happen to another resident. NHA A indicated that the brewers on the units are marked Not in Service, and the facility has spoken with the manufacturer of the brewers to find the brewers can't be turned down in temperature because they would be susceptible to bacteria growth. The facility diverted coffee service to the kitchen and the kitchen will be temping coffee temperatures. The kitchen is using the same coffee dispensers but now add ice to the coffee to bring the temperatures down. Dietary staff is now responsible for temping the coffee/hot water or hot chocolate. Surveyor asked if residents request coffee like on night shift or at a time the kitchen is not open could they get coffee. NHA A indicated there has been no formal request for coffee on the night shift, but the assumption would be for nursing to go to the kitchen and make coffee or the staff could get coffee in the break room and whoever brings the coffee to the resident would be responsible to temp the coffee. NHA A indicated education has been started and was focused on identifying residents for hot liquid risk. NHA A indicated residents have had a hot liquid assessment. Surveyor asked if all residents have had the assessment completed and NHA A indicated (the corporate group) is working on them he would get back to Surveyor. OT (Occupational Therapy) evals on any residents deemed at risk for hot liquids completed. Clothing protectors have been ordered. The facility is not sure how to implement those yet. The facility is ordering special coffee lids for facility coffee cups. Surveyor asked NHA A if he would have expected hot liquids to have been temped prior to incident and NHA A indicated yes, he believed they were. The facility failed to ensure they were monitoring temperatures of hot liquids including coffee. R5 was served hot coffee and received secondary burns requiring emergency treatment at the burn unit. As a result of the incident with R5 the facility began education with staff, implemented a new procedure for dietary staff to bring coffee to the units and to temp the coffee/hot liquids. Additionally, the facility completed hot liquid assessments on all residents. At the time of survey not all staff received education and were educated on 10/18/24 after survey had begun.

Based on interview and record review, the facility failed to ensure each resident (R) received adequate supervision to prevent accidents for 1 of 3 residents (R2) reviewed for altered diets out of a total sample of 6. R2 has had two choking episodes within a month's time. On [DATE], R2 choked on a hot dog. The Heimlich maneuver was performed, and R2 was sent to the emergency room and admitted to the hospital for acute hypoxic respiratory failure, aspiration event/choking on a hot dog, and aspiration pneumonitis. On [DATE], R2 was to receive a Level 6: soft and bite sized (no hot dogs), thin liquids consistency diet. CNA G (Certified Nursing Assistant) provided R2 a bowl of chunked honeydew that was not part of a Level 6 soft and bite sized diet with his supper, resulting in an aspiration event and another hospitalization . The facility's failure to supervise R2 and ensure R2 received food items consistent with R2's prescribed diet created a finding of Immediate Jeopardy (IJ) that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the IJ on [DATE] at 12:10 PM. The IJ was removed on [DATE]; however, the deficient practice continues at a scope/severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The International Dysphagia Diet Standardization Initiative (2019), or IDDSI, developed the IDDSI Framework which is intended to provide a common terminology for describing food textures and drink thicknesses to improve safety for individuals with swallowing difficulties. The IDDSI framework has a range of 8 levels. Drinks are measured from levels 0 through 4, while foods are measured from levels 3 through 7. Level definitions are as follows . (https://iddsi.org/Framework) Level 5 - Minced and Moist. Can be eaten with a fork or spoon, should be soft and moist with no separate thin liquid. Particles should be easily separated when pressed with a fork. Small lumps - equal to or less than 4mm width (about the gap between the prongs of a standard dinner fork) and no longer than 15mm in length for adults - may be present but should be easy to squash with tongue. Level 6 - Soft & Bite-Sized. Can be eaten with a fork, spoon, or chopsticks and can be mashed or broken down with these utensils. Food should be soft, tender, and moist throughout but with no separate thin liquid. Chewing is required before swallowing. Food piece sizes are designed to minimize choking risk . should be equal to or less than 1.5cm pieces. R2 was admitted to the facility [DATE] and has diagnoses that include Pneumonitis (a general term for lung tissue inflammation that's not caused by an infection) due to inhalation of food and vomit, dysphagia (difficulty swallowing), Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and dementia (a group of thinking and social symptoms that interferes with daily functioning). R2's Quarterly Minimum Data Set (MDS), dated [DATE], shows that R2 has a Brief Interview of Mental Status (BIMS) score of 8 indicating R2 has moderate cognitive impairment. Section K indicates R2 does not have a swallowing disorder and is not on an altered mechanical diet. Section GG indicates R2 requires set up assistance with meals and is dependent on staff for transfers from chair/bed to chair. R2's Care Plan, dated [DATE], states: Focus: Nutrition/Hydration: At Risk for Complications with Nutrition/Hydration d/t (due to) aspiration and long-standing dysphagia; tendency to eat/drink too fast. Date Initiated: [DATE] Revision: [DATE] . Interventions: Set up meal per resident direction and assist with eating as/if needed. Honor food requests as able. Encourage resident to slow down while eating. Date Initiated: [DATE] Revision on: [DATE]. RESOLVED: Serve prescribed diet of regular, regular thin liquids. Date Initiated: [DATE]. Revision on: [DATE]. Resolved Date: [DATE]. Adaptive Equipment: divided plate. Date Initiated: [DATE] Revision on: [DATE]. General Diet, Level 5 texture: moist and minced with divided plate/thin liquids. Resident to eat in doorway of room. Staff cue to slow down . Date Initiated: [DATE] Revision on: [DATE]. Monitor for changes in texture tolerance. Date Initiated: [DATE] . Interventions: Eating - supervision. Bring resident to room door threshold to monitor during meals. Date Initiated: [DATE]. Revision on: [DATE] . R2's CNA Kardex dated [DATE] shows R2 is on a General Diet, Level 6 texture: soft and bite sized (no hot dogs), thin liquids. R2's CNA Kardex dated [DATE] shows R2 is on a General Diet, Level 5 texture: moist and minced (no hot dogs) thin liquids. Focus: ADL (activities of daily living) At risk and/or Potential for Complications with Deficits with ADLs R/T (related to) current medical/physical status. Has meds/dx (medication/diagnoses) that can/may affect ADLs. Date Initiated: [DATE] Revision on: [DATE] . R2's diet initiated [DATE], regular thin liquids. R2's Discharge Summary from the hospital dated [DATE], states, in part: Date of Admission: [DATE] Date of Discharge: [DATE] HPI (history of present illness): Patient with schizophrenia, seizures, and dysphagia with recurrent aspiration events who presented to the ED after choking on a hot dog that required the Heimlich maneuver and is admitted with hypoxia . Hospital Course: Acute hypoxic respiratory failure Aspiration event/choking on a hot dog on [DATE] Aspiration pneumonitis Chronic dysphagia with the recurrent aspiration events . Patient presented to emergency room after choking on a hot dog which required Heimlich maneuver. He was mildly hypoxic in the emergency room 89% on room air and placed on a 2L of oxygen. Chest x-ray was negative in the ER, he continues to remain afebrile with normal WBC (white blood cell count). Diet was continued since he has a prior episode of aspiration, requested SLP (Speech Language Pathologist) evaluation. He will be at risk for aspiration pneumonia, continue to monitor closely . Your Discharge Diagnosis: Aspiration into airway . R2's signed Physician Telephone orders dated [DATE], states, in part: Diet Clarification: Level 6 (Soft and Bite Sized) with bread, no hot dogs. R2's meal ticket dated [DATE] shows: - R2's diet: Level 6 Soft Bite - Meal: [DATE] Tuesday Supper - Divided Plate - Supper Specials: Fruit, canned (chopped), soup, cream cauliflower (chopped), peas. Sugar snap (chopped) and scalloped potatoes & ham (ground). R2's Incident Report dated [DATE], at 5:39PM, states, in part: Incident Description: R2 finished eating dinner and started coughing while brushing his teeth. Resident started coughing, nurse went to check on resident. Resident was audible, but breathing was labored. Emergency code was activated, code team came with crash cart, suctioning started, 8L (Liter) O2 administered via face mask. BP (Blood Pressure) ,d+[DATE], O2- 85%, P (Pulse)-101, R (Respirations)-22, T (Temperature)- 97.8. Nurse called on call and got order to send out to hospital via ambulance. Nurse placed order in resident's chart and have copy to charge nurse. POA, PCP (Primary Care Physician), DON notified. Immediate Action Taken: .call 911 transferred to ER (emergency room ). POA, PCP, DON notified . Mental Status: Baseline for Individual, Increased Monitoring/Observation . R2's Progress Note dated [DATE], at 5:30 PM, states: Resident finished eating dinner and started coughing while brushing his teeth. Resident started coughing, nurse went to check on resident. Resident was audible, but breathing was labored. Emergency code was activated, Code Team came with crash cart, suctioning started, 8L O2 administered via face mask. BP-,d+[DATE], O2- 85%, P-101, R-22, T- 97.8. Nurse called on call and got order to send out to hospital via ambulance. Nurse placed order in resident's chart and have copy to charge nurse. POA, PCP, DON notified. R2's Progress Note, dated [DATE] at 6:00 PM, states: Call to ER RN (Registered Nurse) regarding choking episode, resident sent to ER by 911. Report given. R2's Discharge Summary from the hospital dated [DATE], states, in part: Date of Admission: [DATE] Date of Discharge: [DATE] Final Diagnosis: Aspiration event, s/p (status/post) laryngoscopy (a procedure that uses a thin tube with a light, lens, and video to examine your larynx (hollow tube in the middle of your neck-voice box) with retrieved foreign body (potato) . Hospital Course: Patient was admitted into the hospital after an aspiration event. He aspirated a potato. Given ketamine in the ER and ENT (Ears, nose, and throat doctor) did laryngoscopy with removal of foreign body . R2's ENT Progress Note dated [DATE] at 8:35 AM, states, in part: . .History of Parkinson's disease with dysphagia, currently admitted with aspiration pneumonia .On [DATE], he was eating dinner and aspirated mashed potatoes. In ER unresponsive initially, then able to awaken and answer questions. He spoke with difficulty with altered phonation and gurgling, and sounded as though a foreign body were obstructing. Dr. saw patient and multiple attempts were made to dislodge the foreign body with heavier cough, positioning, and Heimlich maneuvers without success. The patient was sedated in the ED (Emergency Department) and a 1 [NAME] blade was used to visualize the area. Initial attempts with the suction did not work. Then a [NAME] forceps was used to remove an approximately 4.5 by 4 cm (centimeter) potato in one piece. Following the procedure, there was some non-obstructive edema of the arytenoids but no other signs of trauma. Patient tolerated the procedure well and was given Decadron in the ED to reduce the risk of delayed laryngeal edema. Of note, the hospital records state a 4.5 x 4 centimeter potato was retrieved. (It was actually a honeydew melon.) This type and size of food was not consistent with the resident's care pakn and his dietary restrictions. RN D's (Registered Nurse) statement, dated [DATE], states: R2 was eating in his room. He has a soft bite size diet which is soft foods that can be easily chewed. Raw fruit is not appropriate for this diet. Residents diet is determined by care plan and the dietary ticket that is generated. The server checks the ticket and serves up the appropriate meal. The CNA checks the ticket and meal for appropriateness and serves it to the residents. I did not notice any breathing issues before eating but after he was coughing . CK F's (Cook) statement undated, states: Around 5:30 PM, I was serving food to the resident (gave R2 food that was on the ticket). Staff took the honeydew melon and gave it to R2 with his food . Of note, honeydew melon is not on R2's diet. It was, however, part of the general menu served at supper on [DATE]. On [DATE] at 11:15 AM, Surveyor interviewed CNA I (Certified Nursing Assistant) who indicated CNAs and the dietary aide who dishes up the residents' meals are both responsible that the residents receive the correct diet. Surveyor asked CNA I how CNAs know what diet residents are to receive and CNA I indicated by the meal ticket on the trays. CNA I showed Surveyor the CNA Kardex that lists the resident's diet in R2's bathroom. On [DATE] at 11:25 AM, Surveyor interviewed RN D. RN D stated he came into R2's room with Surveyor and CNA I and indicated after R2's incident on [DATE], R2's diet changed to Level 5 texture: moist and minced and R2 eats meals in his doorway. RN D could not recall R2's diet at time of incident. Surveyor asked RN D to tell her about the incident. RN D indicated he was one of the nurses to respond to R2 the evening of the incident on [DATE]. RN D indicated R2 was in his room coughing and he entered R2's room to check on him. RN D indicated R2 was coughing and getting air. R2 was breathing, Emergency Code was called, and more nurses came to R2's room with the crash cart. RN D indicated it happened after supper. The staff did a mouth sweep and attempted suctioning oral cavity with a Yankauer and only had phlegm return with no food. RN D indicated vital signs were stable at first but as they were waiting for the ambulance to arrive vital signs became unstable. Surveyor asked RN D what led to the incident, and RN D indicated R2 choked on food and aspirated but could not recall what R2 choked on. Surveyor asked RN D who is responsible to check the residents' meal tickets for correct diet to prevent choking or hazards; RN D indicated CNAs and the dietary staff. On [DATE] at 12:23 PM, Surveyor interviewed ST C (Speech Therapist) who indicated R2 has a history of dysphagia and a tendency to eat quickly. R2 does not take time to chew. Surveyor asked ST C if she was aware of the incident with R2 on [DATE]. ST C indicated R2 was to be a Level 6: soft and bite sized at that time. Pieces were to be no bigger than 1.5cm (centimeters). On Level 6 diet, cantaloupe, pineapple, honeydew, melons are not allowed. R2 was given honeydew at supper and should not have had it. R2 ended up going to ER for choking on honeydew. ST C indicated the facility has a lot of agency staff that don't look at the meal tickets and just serve the trays. ST C indicated R2 is now on a Level 5 texture: moist and minced diet, this was a change after [DATE]. ST C indicated on [DATE] the dietician and herself are conducting an in-service to CNAs and dietary staff regarding each level of diets in detail and meal tickets which will be videotaped. Surveyor asked ST C who is responsible for checking that residents are receiving correct diet and ST C indicated it is collaborative between CNAs and dietary aides. ST C indicated in the kitchen there is a binder that lists all the diets with as much detail as possible staff use this if there is a question on what is being served and how to serve it. On [DATE] at 1:00 PM, Surveyor interviewed LPN E (Licensed Practical Nurse) who indicated she was another nurse that was there on [DATE] when R2's incident occurred. LPN E indicated she was doing her medication pass and RN D was at the nurse station, we both heard R2 trying to clear his throat. We both encouraged coughing and R2 was unable to clear. We called an Emergency Code where the charge nurse and two other nurses responded with the crash cart. His oral cavity was suctioned with only fluid return. There was nothing lodged in his mouth. 911 was called and while waiting for ambulance vital signs were declining. R2's oxygen level was in 80s - we applied oxygen at 6 or 8 L via face mask which brought R2 up into the 90s. R2's BP and P (blood pressure and pulse) were high. He was sent to the ER. Surveyor asked who is responsible for checking the meal tickets with what is served, LPN E indicated the CNAs serve the trays and the kitchen staff sets the tray up with meal ticket. The food is served according to the meal ticket. On [DATE] at 3:25 PM, Surveyor interviewed CNA G and asked what he can recall with R2's incident on [DATE]. CNA G indicated he served R2 his supper tray on [DATE]. CNA G indicated R2 received the correct diet except for the bowl of honeydew. CNA G indicated he can't remember if the dietary aide handed him the bowl of honey dew or if someone had told CNA G to give a bowl of honeydew melon to R2. CNA G put the bowl of honeydew on R2's tray and served it. Surveyor asked CNA G who checks the meal tickets and CNA G indicated CNAs and dietary check the meal ticket with what is on the tray. Surveyor asked CNA G did R2 eat the honeydew and CNA G stated yes, he ate most of his meal. CNA G indicated R2 is now a pureed diet and eats out of doorway where staff can monitor him, and he is closer to the nurses' station. On [DATE] at 3:55 PM, Surveyor interviewed CK F (Cook). Surveyor asked what the process is for obtaining resident meal tickets. CK F indicated the kitchen supervisor prints the meal tickets out. The meal tickets go to each neighborhood. CK F indicated he looks at the meal tickets and serves what is on the meal ticket onto the residents' trays. The CNAs then grab the desserts and put them on the trays before serving to the residents. R2 was supposed to get canned fruit but the CNA gave R2 a bowl of honeydew. CK F indicated R2 was not to have honeydew; R2 was to have canned fruit. CK F indicated R2 had a choking spell after supper and 911 was called. Surveyor asked CK F if he had received any training or education on diets or meal tickets and CK F indicated no, not at all. Following this incident, R2's signed Physician Telephone orders dated [DATE], state, in part: Diet Clarification: Level 5 minced and moist. Use divided plate. Have resident sit outside room with room tray. Provide Ensure shakes per request from POA (Power of Attorney). Staff cue to slow down. On [DATE] at 9:35 AM, Surveyor interviewed DON B (Director of Nursing) and asked if she would expect residents to receive their ordered diet and DON B indicated yes. Surveyor asked what is the CNAs responsibility regarding serving meal trays and meal tickets? DON B indicated CNAs get the residents' order on the meal ticket from the residents. Dietary aides are responsible for serving all the food. The CNAs should verify the items on the tray are what is on the ticket. The CNAs are not responsible for checking the texture of the food. DON B indicated the facility is working on training with CNAs on diet textures and the meal slips. Surveyor asked DON B what interventions were put into place after the incident on [DATE]. DON B indicated R2's diet changed on [DATE] to a general diet - soft and bite sized consistency and no hot dogs. Surveyor asked DON B what interventions were put into place from the incident on [DATE] and DON B indicated R2 is to eat meals in the threshold of his room doorway where staff are to supervise R2, and his diet changed to minced and moist. Surveyor then asked DON B if education was provided to staff on supervision and cueing during meals, and DON B indicated education was assigned to a nurse manager that no longer is employed at facility. DON B indicated she would look and see if it was done. Surveyor asked DON B if she would expect education to have been provided and DON B indicated yes. Surveyor asked DON B if any audits have been completed on meals being served and meal tickets. DON B indicated I don't believe so, but multiple observations were done. Surveyor asked if they had been documented and DON B indicated she would have to look into it. Surveyor asked if DON B would expect audits to be completed and documented and DON B indicated yes. Surveyor asked DON B if any competencies with the nursing staff on the Heimlich maneuver had been completed and DON B indicated no, but all nurses are CPR (cardiopulmonary resuscitation) certified. On [DATE] at 10:15 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if it is the expectation that residents receive their ordered diets and NHA A indicated yes. Surveyor asked what the responsibilities of the CNAs and dietary aides regarding meal tickets are and serving the correct diets. NHA A indicated the CNAs get the information from the residents on what they would like to order then the meal ticket goes to the server. The dietary aide/server is to ensure it is the correct diet and plate the food on the trays. The CNA verifies the food to the meal ticket. Surveyor asked NHA A what education was provided to the CNAs and dietary staff. NHA A indicated the dietary staff received verbal education and an in-service by the dietician and speech therapist is scheduled for today. NHA A indicated for the CNAs the nurse manager was to write up a sheet and ensure they received it. That nurse manager is no longer employed by the facility. NHA A indicated she has no documentation to verify it was completed. Surveyor asked NHA A if any audits on serving meals and meal tickets had been completed and NHA A indicated the dietary manager does meal observations. NHA A indicated she asked the dietary manager for a log and no documentation was done. NHA A indicated she would expect audits to have been completed and documented. According to http://www.emedicinehealth.com/choking/article_em.htm, Choking is a blockage of the upper airway by food or other objects, which prevents a person from breathing effectively. Choking can cause a simple coughing fit, but complete blockage of the airway may lead to death. Choking is a true medical emergency that requires fast, appropriate action by anyone available. Emergency medical teams may not arrive in time to save a choking person's life.When someone is choking with a completely blocked airway, no oxygen can enter the lungs. The brain is extremely sensitive to this lack of oxygen and begins to die within four to six minutes. It is during this time that first aid must take place. Irreversible brain death occurs in as little as 10 minutes. According to https://www.webmd.com>Lung Disease & Respiratory Health article, Aspiration is when something you swallow goes down the wrong way and enters your airway (trachea or windpipe) or lungs. It can also happen when something goes back into your throat from your stomach. With aspiration, your airway isn't completely blocked, unlike with choking. People who have a hard time swallowing are more likely to aspirate. Up to 15 million Americans have trouble swallowing, called dysphagia. It can be temporary or part of a more serious condition Aspiration Symptoms . Feel something stuck in your throat, cough while or after you eat or drink, have a gurgling or wet sounding voice . The facility's failure to supervise R2 and ensure r2 received a meal consistent with his care plan and dietary restrictions created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when it had completed the following: -The facility will complete mock drills and competency tests for all licensed nursing staff including how to support a resident with partial obstructed airway, choking, Heimlich etc. prior to their next working shift. -The facility will educate nursing, culinary and activities staff on altered diets/IDDSI. The training will include how to determine foods/fluids safe to consume on prescribed/altered diets. A competency will be completed following education. -The facility will provide instruction to culinary, activities and nursing staff on where to find a resident's diet prior to working next shift. -The facility has created a system where all meal tray cards for residents on an altered diet will be printed in a different orientation format, so it will be easily recognizable to staff to determine the appropriate diet and food/fluids safe to consume per the prescribed diet. -The facility will ensure that a licensed nurse is assigned to each dining room. -The facility will audit all resident diet orders, tray cards, care plan and Kardex to ensure correct orders and that orders match and include ST recommendations for residents who have been on ST caseload in the last 90 days. -The facility will complete meal audits to ensure receiving proper diet breakfast, lunch, and dinner in 2 dining rooms each meal. -The facility will audit all employee records for licensed nurses to ensure CPR certification. The facility will ensure a licensed nurse is assigned to each dining room during all meals.

UNCORRECTED AT VERIFICATION VISIT. See SOD for Event ID OC8I11. Based on observation, interview, and record review, the facility did not ensure adequate supervision or fall interventions were in place for residents who required increased supervision to prevent accidents/hazards from occurring for 2 of 5 sampled Residents (R5 and R7). R5 did not have fall interventions in place. R5's care plan documents: Do not leave unattended in the Bathroom. R5 ambulated independently to the bathroom and her alarm was sounding. CNA N (Certified Nursing Assistant) heard the alarm sounding and identified that R5 ambulated independently to the toilet. CNA N turned the alarm off, exited the room, and shut the door leaving R5 unattended in the bathroom. CNA N did not assist R5 or alert other staff that she had self-transferred on the toilet. CNA N is aware that R5 is not to be left alone in the bathroom and does not use her call light for assistance. Ten (10) minutes later R5 ambulated independently from the bathroom and fell sustaining multiple right pelvic fractures. The facility did not speak with CNA N or identify that CNA N turned off R5's alarm and did not assist her. Surveyor observed staff leave R5 unattended in the bathroom. The facility has no policy for alarms and no process to monitor alarm implementation dates, expiration dates, and function to ensure safety. This is evidenced by: The facility policy, Accidents/Falls, revised October 2022, documents, in part: The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. All fall is defined as an occurrence characterized by the failure to maintain an appropriate lying, sitting, or standing position resulting in an individual's abrupt, undesired relocation to the ground. The definition of a fall extends to include the following factors: .When a resident is found on the floor, a fall is considered to have occurred Resident care plans should be evaluated and updated with each fall with a new and applicable intervention based on root cause. The focus is to be on prevention and maintaining a safe environment. Each incident/accident or fall must be investigated and/or assessed to determine the root cause of the episode to prevent any further injury. Witness statements should be obtained as applicable. The administrator and Director of Nursing/Wellness should have knowledge of all reports. The interdisciplinary team will review all incidents/accidents. The resident's individualized care plan is to be updated with any changes or new interventions post fall/incident/accident, communicated to appropriate staff, and implemented. R5 was admitted to the facility 12/7/22 with diagnoses including, but not limited to: Alzheimer's disease, history of falls, displaced trimalleolar fracture of left lower leg open fracture with routine healing, Methicilin-resistant Staphylococcus aureaus (MRSA; a type of bacteria that can cause serious infections) removal of internal fixation device chronic multifocal osteomyelitis left ankle and foot, spinal stenosis, muscle weakness, and reduced mobility. R5's most recent Minimum Data Set (MDS) dated [DATE] documents the following: R5 is severely cognitively impaired. R5 has had 1 fall since admission and no falls with major injury. R5's Visual/Bedside Kardex Report, dated 1/3/24, indicates, in part, the following interventions: ADL (Activities of Daily Living): Ambulation: Therapy only at this time; Bathing: 1 assist; Bed Mobility: 1 assist; Daily Routine: Assist resident to activities, enjoys crossword puzzles, word games and trivia, loves to talk, seat with other residents that will engage; Resident has a neck pendant call light (note, she does not use her neck pendant). Dressing: 1 assist; Eating: Set up; Hygiene: 1 assist; Locomotion: Wheelchair self-propel; Toilet use: 1 assist; Transfers: 1 assist ex stand may be used for increased weakness or fatigue. Bladder/Bowel: Toilet upon rising, between meals, at HS (bedtime) and as needed. Cognition Break tasks into subtasks, providing simple one-step instructions. Remind/redirect and/or reassure as needed. Resident has a call pendant but is not using it. Anticipate needs. Round throughout shift. Safety-Fall Interventions: 12/8/23 Fall intervention: Staff will ask resident is she is tired after she returns from activity and offer her to rest in recliner chair after toileting resident. Bed/Chair sensor at all times. Check for unmet needs: pain, toileting, hunger, thirst. Do not leave unattended in the Bathroom. If resident refuses cares, re-attempt in 30 minutes. Keep bathroom door shut at all times. Low bed. Floor mat. R5's comprehensive Care Plan indicates the following: Safety/Falls Focus: Actual potential for complications with OR fall R/T (related to) current medical/physical status. 5/14/23 12/8/23 unwitnessed fall in room; Goal: Will be free of falls, but if does, will be free from serious injuries r/t (related to) falls through next review date. Interventions: 12/8/23 Fall intervention: Staff will ask resident is she is tired after she return from activity and offer her to rest is recliner chair after toileting resident. 5/22/23 Complete rounds per standards of care to ensure needs are met, before leaving the room ask if there is anything else needed or would like assistance with. 5/22/23 If resident refuses cares, re-attempt in 30 minutes. 4/16/23 low bed 4/16/23 floor mat 3/7/23 Bed/Chair sensor at all times 2/27/23 Call light positioned for easy access. 2/27/23 Check for unmet needs: pain, toileting, hunger, thirst, temperature *3/7/23 Do not leave unattended in the Bathroom. R5's Fall risk assessments indicate she is at risk for falls. R5 fell on [DATE] at 4:11 PM. R5's fall report documents the following: Incident Description: Nursing Description: Pharm Tech J (Pharmacy Technician) heard somebody knocking on the door entered the resident room and found the resident sitting on the floor in the doorway. Writer found the resident sitting on the floor with her leg extended out, her back resting on the wall. Resident reported pain in her right ankle and knee. Resident alert oriented x1 has a short memory problem dementia and she stated that she was trying to perform self-transfer but tripped on her feet and fell , but she couldn't give more detail. Resident Description: Resident reported pain in her right ankle and knee. Resident alert oriented x1 has a short memory problem dementia and she stated that she was trying to perform self-transfer but tripped her feet and fell , but she couldn't give more details. Description of action taken: NP (Nurse Practitioner) notified, POA (Power of Attorney) contacted, care plan was updated. RN Charge Nurse M (Registered Nurse/Charge Nurse) documented the following Progress Note: Fall - Unwitnessed Incident Description: Pharm Tech J (Pharmacy Technician) heard somebody knocking on the door entered the resident room and found the resident siting on the floor in the doorway. Writer found the resident sitting on the floor with her leg extended out, her back resting on the wall. Resident reported pain in her right ankle and knee. Resident alert oriented x1 has a short memory problem dementia and she stated that she was trying to perform self-transfer but tripped on her feet and fell , but she couldn't give details. During the assessment writer found no changes in resident condition compared to her baseline. No changes in skin color or swelling. No lumps or skin discoloration on the scalp/head were noted during assessment. Vital signs BP (blood pressure) 110/67, P (pulse) 65, )2 sat (oxygen saturation) 93% RA (room air), temp (temperature) 97.1. After the resident was assessed and no sign of injury was found she was transferred back to the bed with mechanical lift with no sign of pain during transfer. In 10 minutes, writer reassessed the patient in the bed in the lying position and noted that resident reported pain in right inner thigh. According [SIC] staff resident was watching TV concert in the west atrium with activity department till 3:30 PM. Resident Description: Resident reported pain her right ankle and knee. Resident Alert x1 has a short memory problem dementia and she stated that she was trying to perform self-transfer but tripped her feet and fell , but she couldn't give more details. Immediate Action Taken: Notified provider extender, POA (Power of Attorney) contacted. Care plan was updated. Injury Observed at Time of Incident: Fracture - right trochanter (hip) Mental Status: Oriented to Situation Injuries Reported Post Incident: Bruise right shoulder (rear) Predisposing Psychological Factors: Impaired memory Predisposing Situation Factors: Other (see description - self transfer) R5's Interdisciplinary Team (IDT) documents the following Post Fall Review, in part: Date and time fall occurred: 12/8/23 4:11 PM Location: resident's (R5's) room What was the resident doing prior to the fall, if known: sitting WC (wheelchair) watching TV. Did the resident sustain an injury? If yes, describe yes, mons pubis fracture. Fall History: 1-3 falls in 3 months. Underlying Disease or Conditions: Cardiac diagnosis or pacemaker, Orthopedic/joint/arthritis, Medications: Psychotropics, Antihypertensives Sensory, Cognitive, Psychological Status: Does the resident have problems with cognition, judgement, memory, and safety awareness? (Indicates yes). Is the resident able to communicate their needs? (Indicates yes), Does the resident express pain, have signs of any pain, or take pain medications? (Indicates yes). Environmental Status/Equipment Factors: Are there any environmental factors that may have contributed to the fall? Yes Review of Post Fall Findings: Summarize the post-fall findings: IDT review of root cause analysis determined resident is impulsive and noncompliant with using call light and waiting for assistance to toilet. Describe new fall prevention interventions to be implemented as a result of the assessment: Resident to be toileted after activity then provided the option to rest in her recliner. List suggestions of referrals to be made as a result of the fall: Therapy. R5 was sent to the emergency department. The hospital report documents, in part, as follows: Chief Complaint: Pain Hip and Fall (Patient fell when transferring back to her bed. Pt report her right leg gave out, now having severe right hip pain. No deformity noted. Denies hitting head. Not anticoagulated. Chest x-ray is personally interpreted with right-sided pubic rami fractures noted without further acute fracture or other acute abnormality such as pneumothorax. Discharge Diagnosis: Fall, initial encounter. Closed fracture of multiple pubic rami, right, initial encounter. R1 was discharged and returned to the facility that evening. Pharm Tech J's (Pharmacy Technician) statement documents the following: This is a written statement of my finding on Friday 12/8/23. I, Pharm Tech J, was delivering medications to Wingra, the 200 unit, somewhere between 4:15 PM and 4:20 PM. I placed the medications in the nurses medication cart and was walking back to the pharmacy when I heard a loud bang (knock) on R5's room. I stopped and knocked on her door which was closed, and I opened it saying R5's name as I opened the door, she was lying against the wall with feet out straight with her back propped up against the wall. I found her about 2 or 3 feet from her door. I immediately popped my head out of her door and hollered down to the nurses station where I saw RN K and CNA L sitting and said, We have a resident who fell and is on the floor. I then talked to R5 to reassure her that help was on the way. She told me that she fell out of her chair. I also did not hear any alarms going off as I entered the room. Once medical staff came, R5 said I am glad you heard me knocking on the door. CNA N's statement documents the following: *1. What did you last note the resident doing prior to fall? on the toilet. *2. What time was cares last given or resident visualized? she isn't my resident today, so I don't know. 3. Was resident continent or incontinent when located on the floor? Continent *4. Last time toileted? 10 mins (minutes) prior to fall *5. What care plan or safety measure were in place? I'm not sure. 6. How do you think the fall could have been prevented? I'm not sure. 7. What was determined the immediate intervention by nurse/CNA? Tell patient to call for help. Document staff education given if needed and by which nurse: RN Charge Nurse M CNA L's statement documents the following: R5 as in room after the musical busy time preparing dinner. Nurse asked was R5 out in kitchen. I told her no she comes down, but I have to go get her to remind her after 4:15 PM. I usually get her she doesn't like to come down to [SIC] early. Sometimes she is playing cards in kitchen. Resident transfers herself constantly. Turns off call light. Sometimes she calls or comes out the room when she needs to toilet. Today she did neither and self-transfer and Pharm Tech J said she was down on floor as she walked by. RN K's statement 1. What did you last note the resident doing prior to fall? I did not see resident prior to the fall. 2. What time was cares last given or resident visualized? No idea 3. Was resident continent or incontinent when located on the floor? RN Charge Nurse M did assessment, No idea 4. Last time toileted? No idea, assessment done by RN Charge Nurse M 5. What care plan or safety measure were in place? N/A (not applicable) 6. How do you think the fall could have been prevented? N/A 7. What was determined the immediate intervention by nurse/CNA? N/A sent to ER (emergency room ) Document staff education given if needed and by which nurse: N/A On 1/4/24 at 8:39 AM, Surveyor observed R5's empty wheelchair in her room and the bathroom door closed. Surveyor observed CNA O walk from the end of the hallway to R5's room. Surveyor entered R5's room and R5 agreed to Surveyor observing cares. Surveyor observed R5 in the bathroom sitting on the toilet while connected to the stand lift. CNA O left R5 in the bathroom unattended. Surveyor observed R5's Kardex posted on the cabinet in the bathroom which indicates Do not leave unattended in the Bathroom. CNA provided cares to R5, and Surveyor spoke with R5 prior to CNA O transporting her to breakfast. On 1/4/24 at 8:51 AM, CNA O left R5's room and Surveyor spoke with R5. Surveyor spoke with R5. Surveyor asked R5 if the staff take good care of her. R5 stated, Always. Surveyor asked R5 if she gets help when she needs it. R5 stated, I don't need much help, I do pretty well by myself. Surveyor asked R5 if she could show me her call light/pendant. R5 pointed to the call pendant around her neck. (Care Plan indicates she does not utilize this.) Surveyor asked R5, have you had any falls recently. R5 stated, No. Surveyor asked R5 have you broken any bones recently. R5 stated, Not since I was young. Surveyor asked R5, do you feel safe here. R5 stated, Perfectly safe. Surveyor asked R5 if she currently has any pain. R5 stated, No. On 1/4/24 at 8:53 AM, CNA O returned to R5's room. Surveyor asked CNA O, should staff stay with R5 while she is in the bathroom. CNA O stated, sometimes R5 transfers herself and forgets she needs assistance to the toilet. CNA O stated, R5 tries to transfer frequently and doesn't think she needs help. Surveyor asked CNA O to read R5's Kardex and pointed out the intervention: Do not leave unattended in the Bathroom. Surveyor asked CNA O, should you have stayed with R5 while she was in the bathroom on the toilet. CNA O stated, Yes, I should have. On 1/4/24 at 9:54 AM, Surveyor spoke with Pharm Tech J (Pharmacy Technician). Surveyor asked Pharm Tech J to describe what she witnessed on 12/8/23 when she discovered R5 on the floor. Pharm Tech J stated around 4:15 - 4:20 PM she was delivering medications to the 200 unit. Pharm Tech J stated, when she is walking down the hall, she heard a knock. Pharm Tech J stated she knocked on R5's door before entering and saw R5 on the floor. Pharm Tech J stated she was leaning against the wall with the nightlight (Surveyor observed this to be the wall next to the door and just around the corner from R5's bathroom). Pharm Tech J stated, R5 said, Help me up. Pharm Tech J told R5 she needed to get help and opened the door and asked for help and saw the CNA L and RN K sitting at the desk. Pharm Tech J stated CNA L and a tall male CNA (identified as CNA N) asked if R5 was ok and if she was hurt. Pharm Tech J stated, R5 said her ankle hurt. Pharm Tech J stated RN-Charge Nurse M came in to assess R5. Pharm Tech J stated, No alarms sounded. Pharm Tech J stated, R5 stated she fell out of her chair and added she was unsure if it was her wheelchair or stationary chair. Pharm Tech J stated, CNA N told R5, you need to call and not get up. On 1/4/24 at 10:05 AM, Surveyor spoke with RN K. Surveyor asked RN K to describe what he witnessed on 12/8/23 when R5 fell . RN K stated, she thinks she was passing medications when Pharm Tech J brought her medications and then yelled to me that a resident is on the floor with her legs stretched out. RN K stated, she went to R5's room and saw RN Charge Nurse M. RN K stated, she had medications in her hand and RN Charge Nurse M took over. Surveyor asked RN K, was R5's alarm sounding. RN K stated, I don't think so. On 1/4/24 at 10:46 AM, Surveyor spoke with CNA N. Surveyor asked CNA N to describe what he witnessed on 12/8/23 when R5 fell . CNA N stated, I heard an alarm going off, she (R5) was already on the toilet. CNA N stated, R5 transferred independently onto the toilet and no lift was in use. CNA N stated, he turned off the alarm, exited the room, closed the door, and did not assist R5 as she was not his resident. Surveyor asked CNA N, did you return to R5's room to assist her. CNA N stated, No. Surveyor asked CNA N, did you tell anybody R5 was on the toilet and transferred independently. CNA N stated, No, I didn't let anybody know. Surveyor asked CNA N, are your familiar with R5's care plan. CNA N stated, Yes. Surveyor asked CNA N, does R5 self-transfer often. CNA N stated, Yes, every day. Surveyor asked CNA N, if you see a resident self-transfer what do you do. CNA N stated, If she was my patient, I would help her. Surveyor asked CNA N, if a resident that is not on your assigned wing that needs assistance would you help them. CNA N stated, I would if I had time, I saw she was safe and left the room. (Note, her wheelchair was not within reach and Care Plan indicates Do not leave unattended in the Bathroom.) Surveyor asked CNA N, is it okay to leave R5 unattended in the bathroom. CNA N stated, No. Surveyor asked CNA N, if this same situation presented itself again what would you do differently. CNA N stated, I would stay with her, assist her back to her chair and turn her alarm on. Surveyor asked CNA N, did anybody provide education to you following this fall. CNA N stated, RN Charge Nurse M and the previous DON (Director of Nursing) provided education to him. Surveyor requested documentation of education to CNA N. Regional Nurse Consultant C stated there is no documented education to CNA N regarding this incident. On 1/4/24 at 11:41 AM, RN Charge Nurse M was out of the country on vacation and unavailable for interview. On 1/4/24 at 11:45 AM, RN P toileted R5. When R5 was in the bathroom Surveyor observed her chair and bed alarms. Surveyor observed R5's chair alarm, Posey TLC Posey Total Location Coverage. First Use Date and Expiration Date were both blank. The alarm documents: Warranty: This product is warrantied for thirty (30) days from date of first use. CAUTION: Sensor pad beyond expiration date is out of warranty and may not function properly causing false alarm or no alarm. Surveyor observed R5's bed alarm, Posey Single Patient Use Bed Sensor Pad (30-day). Warranty: This product is warranted for thirty (30) days from date of first use. It is important to note the facility has no policy or process for alarms and labeling First Use Date and Expiration Date. The facility also has no system nor documentation in place to monitor the function of the alarms. Surveyor asked RN P, how long an alarm is good for upon being implemented. RN P stated, I have absolutely no idea, it has always been on there (R5's chair and bed). Surveyor asked RN P, does the facility document the function of the alarms. RN P stated, I don't believe so. RN P stated, it would be the right thing to check it, but I don't know if we document it. Surveyor asked RN P, should R5's alarms be dated with the First Use Date and Expiration Date. RN P stated, If that's what the manufacturer instruction indicate then yes. On 1/4/24 at 12:49 PM, Surveyor spoke with RN Q. Surveyor asked RN Q, does the facility document, and check the function of resident alarms. RN Q stated, no, there is no schedule nor documentation to check the function of alarms. RN Q stated the extra alarms are in the Medication Rooms and there is no process when implementing or replacing an alarm. On 1/4/24 at 1:09 PM, Surveyor spoke with CS R (Central Supply). Surveyor asked CS R, is there a process for resident alarms. CS R stated, there is a supply in her office and in the medication rooms. CS R stated, there is no sign out sheet for alarms or tracking. On 1/4/24 at 4:08 PM, Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A to tell me regarding R5's fall on 12/8/23. NHA A stated R5 resides on MCU (Memory Care Unit), she is very impulsive, transfers by herself and didn't use the call light. NHA A stated, I think she transferred to the bathroom independently. NHA stated, Pharmacy Tech J found her on the floor and got nursing to assist her. NHA A stated, at first, they were going to get a mobile X-ray; however, a few minutes after the fall she was complaining of further pain, and we sent her to the ER (emergency room ). NHA A stated, CNA N was not assigned to R5. NHA A added, I know he saw her on the floor. Surveyor asked NHA A, are you aware that CNA N turned off R5's alarm after he observed her on the toilet and was aware that she transferred independently and then exited R5 without assisting her or notifying other staff. NHA A stated, CNA N turned off R5's alarm? NHA A added, That's news to me. NHA A stated, she is of the mindset of not having alarms and is working to reduce the usage of alarms in the facility. NHA A stated, staff have told her that R1 will turn off her alarm. NHA A stated, it's not effective if the resident can turn the alarm off. NHA A stated, R5's alarm is in place because family want her to have it. Surveyor asked NHA A, are you aware that CNA N saw that R5 self-transferred herself onto the toilet. NHA A stated, No. NHA A stated, she did not realize the transfer was not complete. Surveyor asked NHA A, what would you expect CNA N to have done in this situation. NHA A stated, either stay with her or call for additional help since she was not his assigned resident. NHA A stated, we've been doing a lot of education since another resident fell and passed away because of injuries. Surveyor asked NHA A, would you expect staff to stay with R5 and follow her care plan. NHA A stated, Yes. Surveyor shared observation (above) of CNA O leaving R5 unattended on the toilet in the bathroom this morning while hooked up to the sit to stand lift. Surveyor asked NHA A, would you expect staff to not leave R5 unattended in the bathroom per her care plan. NHA A stated, Yes. Surveyor asked NHA A, would you expect CNA O to be aware of R5's care plan interventions. NHA A stated, Yes. Surveyor asked NHA A, Surveyor shared with NHA A, that the facility has no process to check resident alarms for function. Surveyor asked NHA A, should the facility be checking alarms for function. NHA A stated, Yes. Surveyor asked NHA A, were you aware there's not facility policy/procedure regarding checking alarms for function. NHA A stated, Not that I know of. Surveyor asked NHA A, are you aware that pad alarms expire. NHA A stated, she was not aware. 44552 The following example is cited at a isolated/potential for harm. Example 2 R7 indicated on 1/5/24 R7 had her call light on for over an hour before receiving assistance off commode. R7 was admitted to the facility on [DATE] with a diagnoses including: diabetes, congestive heart failure, muscle weakness, kidney failure, and other reduced mobility. R7's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/13/23, indicates R7 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R7 is cognitively intact. R7 is own person. R7's Certified Nursing Assistant (CNA) Care Card states, in part; ADL .TRANSFERS: 2 assist bariatric mechanical stand. On 1/8/24, R7 indicated that R7 sat on commode for two hours. R7 indicated that R7's call light was not on the entire time. R7 indicated call light was on for over an hour and then R7 began yelling for assistance. R7 voiced concerns with the assistance R7 received with transfer, CNA's overall attitude, and the long call light wait time. R7 indicated R7 has voiced concerns with long call light wait times in the past. R7 indicated that R7 utilizes an EZ stand and that R7 requires 2 staff assistance for transfer. R7 indicated filing a grievance regarding the concerns with the transfer. Surveyor reviewed call light wait times for R7 on 1/5/24. Call light wait times, states, in part; .event time 10:43 .Clear time .11:52 .Response time .1:09:15 On 1/8/24 at 5:00 PM, RNC C (Regional Nurse Consultant) indicated the goal is for call lights to be answered within 20 minutes. RNC C indicated over an hour is too long of a wait time. NHA A (Nursing Home Administrator) indicated NHA A has concerns with this call light wait time as well. RNC C indicated a person left on a commode for this amount of time would be at greater risk for falls. NHA A and RNC C indicated the facility is now running call light audits daily and reviewing documentation.

Based on interview and record review, the facility did not ensure that each staff implemented proper safety interventions as directed by a resident's plan of care and did not ensure residents were free from accidents and hazards for 1 of 3 residents (R1) reviewed for falls. On [DATE], a Certified Nursing Assistant (CNA) attempted to provide care to R1 without maintaining the proper safety interventions as directed in R1's care plan. R1 rolled off the bed and fell approximately 2 feet to the floor, hitting her head. R1 suffered multiple fractures and a subarachnoid hemorrhage (bleeding in the space surrounding the brain), resulting in death. This created a finding of immediate jeopardy that began on [DATE]. The facility's failure to to ensure all staff follow proper safety interventions to prevent accidents created a finding of Immediate Jeopardy that began on [DATE]. Surveyor notified the NHA A (Interim Nursing Home Administrator) of the Immediate Jeopardy on [DATE] at 1:30 PM. The Immediate Jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: According to the Center for Disease Control (CDC,) Twenty to thirty percent of people who fall suffer moderate to severe injuries such as lacerations, hip fractures, or head traumas. According to the CDC, falls are the most common cause of traumatic brain injuries; traumatic brain injury accounts for 46% of fatal falls among older adults (those 65 or older). Among older adults, falls are the leading cause of injury death and are the most common cause of nonfatal injuries and hospital admissions for trauma. The CDC notes that in 2008, over 19,700 older adults died from unintentional fall injuries. (http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html) The facility's mechanical lift policy states the following: *Type of lift will be included on resident care plan as well as CNA care sheet. *Staff of ,d+[DATE] person will depend on individual resident's need as indicated on residents care plan and CNA care sheet. *Full body lifts (Hoyer) require 2 staff members at all times. R1 was a [AGE] year-old resident who was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease. Her Minimum Data Set (MDS) dated [DATE] shows a Brief Interview for Mental Status (BIMS) was not conducted, indicating her low cognition level renders her as rarely or never understood. R1's [DATE], [DATE], and [DATE] MDS indicate she is a 1 person assist for bed mobility and a 2 person assist for transfers. Her [DATE] MDS shows that R1 requires a helper due to all the effort in transferring her from bed to her wheelchair. R1's care plan stated, Mood/Behavior: .resident is physically abusive, other residents or staff were hit, shoved, scratched .resident resists care .Safety/Falls: bed in low position with floor mat .Ambulation: non-ambulatory .Bed mobility: 1 assist .Transfers: 2 assist mechanical lift. The facility submitted a self-report on [DATE] describing an incident that occurred on the morning of [DATE] at approximately 6:45 AM in which R1 fell from her bed. In the incident, CNA H was performing cares on R1 while R1 was in bed. CNA H removed R1's fall mat from near the bed and turned her back from R1, at which time R1 rolled out of bed and onto the floor. CNA H alerted her floor nurse who then alerted the charge nurse. Upon assessment by the charge nurse, R1 was lying on her right side on the floor with blood around her head. The facility got orders from R1's physician to send her to the hospital. Emergency Medical Service (EMS) records show R1 arrived at the hospital at 7:24 AM. The hospital conducted x-rays and a CT scan (medical imaging) with results showing a pelvis fracture, femoral neck fracture, and a subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane.) R1 expired at the hospital at 12:10 PM. On [DATE] at 10:27 AM, Surveyor interviewed CNA H, who stated that she had worked third shift the night before, on [DATE], and had stayed into the first shift of [DATE] to help get residents up and out of bed. CNA H stated that she had gotten R1 dressed and was walking around the room back and forth getting toiletries and other items to prepare R1 for the day and she kept tripping on R1's fall mat, so she (CNA H) picked it up to move it to the other side of the room and when she got to the other side of the room, she heard R1 fall to the floor. CNA H stated R1 was on her left side in her bed before she fell and when she (CNA H) turned around to see R1 on the floor, R1 was lying on the floor on her right side. Before turning her back to R1, CNA H stated the bed was at about knee height. CNA H stated that she was not sure how close to the edge of the bed she left R1 but did not think she was close enough to fall. Additionally, CNA H stated that R1 had been somewhat restless the night before, asking all sorts of questions in the middle of the night like, Is it time to get up? CNA H also stated that R1 could be fidgety and would kick her legs and stated she thinks R1 kicked her legs in a way that rolled her off the bed. CNA H stated that she had not received any education from the time the incident occurred until yesterday ([DATE]) before she started her evening shift. CNA H stated that at that time ([DATE]), she was educated on proper positioning in bed before transfers, not turning her back to residents, not moving fall mats until the time of transfer and making sure a resident's bed is in its lowest position before leaving a resident to get a lift. Surveyor again asked CNA H if she had received any of this education or any similar education the morning of the incident or any time while she was off work pending the investigation, to which she replied, No. On [DATE] at 9:49 AM, Surveyor interviewed LD I (Lead Detective,) who headed the local police department's investigation into the incident. LD I stated that when the police arrived on [DATE] after 7:00 PM they measured the height of R1's bed to be 25 off the ground. LD I did not have any additional information for Surveyors that the facility did not already have in their internal investigation, nor was the local police department able to find any criminal misconduct. On [DATE], RN P (at 11:12 AM) and CNA K (at 11:18 AM) demonstrated for Surveyors what low bed meant. In both demonstrations, these staff employed a current resident's bed and lowered the bed to its lowest point via the bed remote until the bed stopped moving. On [DATE] at 11:21 AM, CNA L demonstrated low bed in R1's room, which is now vacant. CNA L lowered the bed until it would not lower any further. In each demonstration, staff stated the bed was approximately ,d+[DATE] off the ground. Additionally, on [DATE] Surveyors interviewed CNA G at 10:05 AM and LPN N at 11:28 AM and CNA M on [DATE] at 10:20 AM. All 3 stated that low bed means the bed is lowered to the ground until it cannot go any further. Surveyor gathered the following additional interviews: *[DATE] at 3:00 PM, RN O stated that CNA H should not have turned her back to R1 when providing cares without the fall mat or bed in the low position. RN O was the charge nurse on the night of the incident. *[DATE] at 3:55 PM, RN Q stated the bed in R1's room at the time of the incident was about 2 feet off the ground and was not at its lowest position. RN Q was the floor nurse who responded to CNA H's request for help on the morning of [DATE]. *[DATE] at 4:38 PM, DON B (Director of Nursing) stated that low bed is different depending on the resident. DON B provided Surveyor with documentation the next morning, *[DATE] at 11:21 AM, CNA L stated she regularly worked with R1 and that R1 would grab out at times and could move her legs. CNA L also stated that R1 could absolutely have rolled out of bed if she were lying on her side if she kicked her legs the way she (CNA L) had seen her do in the past. Not following R1's care plan by removing her fall mat, leaving her bed at a height greater than lowest position without supervision resulted in R1 falling, resulting in death. The facility removed the jeopardy on [DATE] when it had completed the following: The facility conducted an investigation following the event and did the following: *Immediately suspended CNA H *Contacted local law enforcement *Interviewed residents and staff *Educated staff The education included a review of the facility's mechanical lift policy with the following additional information: *Before leaving room, ensure bed is in low position and resident has call light. *Hoyer lifts always require two people. *Do not move fall mat until Hoyer lift is in room and ready to be put in place. *If you need to walk away from a resident to go get a lift, you must ensure the resident is positioned safely in their bed or recliner. The facility educated CNAs, Licensed Practical Nurses (LPN,) and Registered Nurses (RN.) Staff signatures were captured on a number of sign-in sheets to indicate staff had received the training. CNA H's signature was not found on any of the education forms or sign-ins. On [DATE] at 4:31 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding CNA H's education after the incident. NHA A stated that she did talk with CNA H after the incident, but did not have anything documented or written down. NHA A then brought an undated, handwritten note to Surveyor that stated she had talked with a CNA (name was not that of CNA H) stating, .educated on not removing fall mat prior to transfer and not leaving resident with back turned on edge of bed. The facility provided the following documentation to Surveyors on [DATE] showing CNA H had received education on [DATE]. The education included the following: *Position resident in center of bed prior to beginning and after transfers. *Do not ever turn back on a resident if they are not positioned completely centered. *Residents with fall mats cannot have the mat removed until ready to complete transfer. *If going to get a lift, ensure bed is in lowest possible position. *Hoyer sling should not be placed under resident until transfer is ready to begin. According to facility records and timesheets, between [DATE] when the incident occurred and [DATE] when Surveyors identified the absence of CNA H's education, CNA H worked 15 shifts on 14 days. The facility's removal plan indicated it had or would be completing the following: *Follow-up was done by NHA on the incident on [DATE] to ensure completeness. Staff assigned to R1 were interviewed by NHA on [DATE]-[DATE]. Local law enforcement was notified [DATE] by NHA. *NHA/ DON will review all falls with injury on [DATE] to ensure no other education requirements are identified. Any negative findings will be properly investigated and reported as required. Negative findings will be reported to the QAPI team. *Education began on team members on Hoyer lift procedures, removing fall mats, resident positioning safety and the turning back on resident by nurse manager on [DATE]. *Education began on team members on bed in low position and breaks locked by DON on [DATE]. *Education from (RDO) Regional Director of Operations and Regional Director of Clinical Operations to Administrator on investigation requirements, what to do when completing and making corrections during investigations and educational requirements, was completed on [DATE]. Education with CNA H was completed by NHA and RN House Supervisor on [DATE] with direct how to with repeat back and in person training with positioning, fall mat use, low bed to be in low position when resident in bed. *Education continues with team members on low bed, mechanical lifts, removing fall mats, resident positioning safety in bed and the turning back on resident, and Resident Abuse/Reporting by NHA/DON on [DATE]. Clinical staff will be educated prior to working. *Incident Reports to be reviewed for thoroughness prior to final submission by RDO or RDQCS to ensure staff discipline, witness statements, staff interviews, resident interviews have been completed and followed up on. 5x a week x 3 months. *All falls with major injury will be followed up on, investigated and reported as required by regulations daily ongoing by NHA/DON. Any negative findings will be properly investigated and reported as required. Negative findings will be reported to the QAPI team. Audits to include: 1) Beds in lowest position when in bed 5x a week x 2 weeks, 3 x a week x 2 weeks and 1 x week x 2 months and 2) Fall mats in place until time of transfer 5x a week x 2 weeks, 3 x a week x 2 weeks and weekly x 2 months. Results of Audits will be reported to QAPI.

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PI) from worsening for 1 of 5 residents reviewed for PIs, out of a sample of 34 residents (R104). The facility did not ensure weekly measurements/assessments and treatments were being completed to R104's sacral PI. MD (Medical Doctor) notifications were not done when changes were noted to the wound. R104 was admitted to the facility with a stage 2 PI which progressed into a stage 4 PI causing R104's PI to become infected and R104 was placed on antibiotics. This is evidenced by: The facility's policy, entitled Pressure Injuries (Management/Treatment,) with a revision date of 12/22, states, in part: The purpose of the policy is to help assure residents with pressure injuries prompt assessment, treatment, and services by the Interdisciplinary Team (IDT) to promote healing, prevent infections and prevent new injuries from developing while maintaining optimal quality of life and functional ability .Definitions: *Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue . *Stage 2 Pressure Injury: Partial- thickness skin loss with exposed dermis . *Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer . *Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar . PROCESS: I. Pressure injuries will be reported to the MD/Provider as indicated, and orders will be obtained for treatment as indicated . The course of treatment will be documented until the pressure injury is resolved . II. Wound assessment and measurements will be completed for pressure injuries at least weekly . A. Pressure Injury Assessment: .2. Assess and measure wounds weekly: (Measure the injury length (head to toe), width (side to side), and depth . Indicate condition of peri-wound; tissue surrounding the wound or macerated/denuded skin. Note condition of wound edges. Document percentage of tissue type such as slough (yellow/white fibrous tissue) or granulation (red, healthy tissue). If tunneling is present, document location (using face of clock) and depth. Document undermining (edge of wound opening underneath parameter) if present. Note scar tissue. Note any warmth or induration, (hard, thickened tissue). i. Measure wound size, (in centimeters (cm)) length, width and depth, location ii. Tunneling or undermining iii. Drainage: type, amount iv. Infection-color, odor, heat, inflammation v. Wound bed: color, presence of granulation, slough, or necrotic tissue vi. Wound edges: color and condition vii. Peri-wound: maceration, induration, edema, excoriation, erythema viii. Wound Progress: improvement, deterioration, healed ix. Presence or absence of pain 3. With each dressing change observe for developments that indicate a need for change in treatment (e.g., deterioration, sign of infection or complications). If change in treatment is warranted update MD/Provider, plan of care and treatment plan. VII. Methods for monitoring healing: . B. Licensed nurse will re-evaluate the pressure injury, the plan of care and the resident's status if the pressure injury does not show progress of healing. C. Report signs of deterioration in pressure injury to MD/Provider. D. Assessment and Treatment of Infections: 1. Assess for the following which may indicate the presence of infection: i. Presence of erythema ii. Edema iii. Induration iv. Heat/fever v. Foul odor (after cleansing) purulent drainage vi. Streaking vii. Increased pain in the wound viii. Increasing wound size x. Crepitus . XII. Healed Pressure Injuries: . B. Continue to provide daily skin observations and weekly skin assessments . The facility policy, entitled Skin/Hydration Assessment, with a revision date of 12/22, states, in part: Skin and Hydration assessments will be completed and documented on all residents on admission, weekly, and as needed. Weekly skin/hydration assessments will take place on residents' individual shower/bath day . PROCESS - SKIN ASSESSMENT: . V. Once a pressure injury has been identified, it will be: . B. Assessed, measured, and documented on by the Wound Nurse, or Nurse Manager in his/her absence, weekly. This includes: 1. Stage 1-4 Pressure Injuries 2. Unstageable Pressure Injuries . D. MD/GNP (Adult Gerontology Nurse Practitioner) will be notified if: 1. Pressure injury worsens or enlarges. 2. It shows signs of infection. 3. No improvement is noted in 2 weeks. 4. Improved and/or alternative treatment options are available . Example 1 R104 was admitted to the facility on [DATE] and has diagnoses that include Pressure Ulcer of Sacral Region, Non-Pressure chronic ulcer of unspecified part of right lower leg and left lower leg, and Morbid Obesity due to excess calories. R104's MDS (Minimum Data Set) Admission Assessment, dated 9/7/22, indicated that R104 has a BIMS (Brief Interview of Mental Status) score of 9 indicating moderate cognitive impairment. Section G indicates R104 is totally dependent with two assists for bed mobility, transferring, and toilet use. R104 requires total dependence of one staff for locomotion on and off unit. R104's Care Plan, dated 9/1/22, states, in part: Problem: Impaired Skin Integrity .Manifested by: Stage 1 Pressure Ulcer to coccyx, Surgical wounds Goal: No sign or symptom of infection Goal Time: 12/1/22 Nurse Aide: Skin Care: Apply barrier cream as delegated by nurse. Keep skin clean and dry. Assist with hygiene and general skin care. Report worsening skin condition to nurse immediately. Nurse Aide: Positioning Device: Use draw sheet when repositioning to prevent shearing. Nurse Aide: Bed Positioning: Turn and reposition every two hours to prevent skin breakdown .Nurse Aide: MATTRESS: PressureGuard Custom Care Convertible with Pump .Nurses: Develop and monitor turning schedule . Nurses: Weekly skin assessment. Nurses: Implement and initiate weekly wound assessment and documentation per facility protocol . R104's Braden Scale, dated 9/1/22, shows a score of 14 indicating R104 is at moderate risk for skin breakdown. R104's Braden Scale, dated 9/8/22, shows a score of 16 indicating R104 is at mild risk for skin breakdown. R104's Braden Scale, dated 9/15/22, shows a score of 16 indicating R104 is at mild risk for skin breakdown. R104's Braden Scale, dated 9/22/22, shows a score of 18 indicating R104 is at mild risk for skin breakdown. R104's Mini Nutritional Assessment, dated 10/27/22, shows a score of 7 indicating R104 is malnourished. R104's skin assessments show the following: 9/2/22: Type of Wound: Pressure Ulcer Origination: Upon Admission Stage Of Pressure Injury: Stage 2 Location: Sacrum Peri-wound Description: Red, blanching Edges: Red Length (Head to toe): 7cm (centimeters) Width (left to right): 10 cm Wound Bed: Non Blanchable redness with subtle blistering noted to areas of wound bed Odor Present: No Drainage: None Progress: Initial Assessment Pain related to treatment: No Recommendations: Apply sacral mepilex after cleansing skin, change weekly on shower day and prn (as needed) if soiled. RN J (Registered Nurse) R104's Physician's Orders for sacral PI are as follows: 9/2/22 - Treatment to Sacral Stage 2: 1 time per week Tuesday 1x/Day EVES 1. Cleanse skin and dry 2. Apply sacral Mepilex Dressing Discontinued 11/15/22 9/10/22: Type of Wound: Pressure Ulcer Origination: Upon Admission Stage Of Pressure Injury: Stage 2 Location: Sacrum Peri-wound Description: Healthy Edges: Pink Length (Head to toe): 7.5 cm Width (left to right): 12 cm Depth: 0.1 cm Wound Bed: 2 distinct open areas within measurements with pink wound beds, the rest of the skin involved is red and non-blanching Odor Present: No Drainage: Type: Serosanguinous Amount: Small Progress: Affected areas has opened as anticipated. No s/sx of infection noted. Pain Related to Treatment: Yes, Explain: Tender to touch Recommendations: Continue treatment as ordered. RN J 9/16/22: Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 Location: Sacrum Peri-Wound Description: Healthy Edges: Pink Length (Head to toe): 5 cm Width (left to right): 9 cm Depth: 0.1 cm Wound Bed: Pink Odor Present: No Drainage: Type: Serosanguinous Amount: Small Progress: Improved: measuring smaller Recommendations: Continue treatment as ordered Assessed by: RN J 9/25/22: Type of Wound: Pressure Late Entry for 9/24/22 Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 Location: Sacrum Peri-Wound Description: Healthy Edges: Pink Length (Head to toe): 0.5 cm Width (left to right): 0.5 cm Depth: 0.1cm Wound Bed: Pink Granulation: 100% Odor Present: No Drainage: Type: Serosanguinous Amount: Scant Progress: Improved: Only a small open area remains, the rest of the wound has healed and epithelialized and presents as pink scar tissue Pain Related to Treatment: No Recommendations: Continue treatment as ordered Assessed by: RN J 9/30/22: Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 Location: Sacrum Peri-Wound Description: Healthy Edges: Pink Length (Head to toe): 0.5 cm Width (left to right): 0.5 cm Depth: 0.1 cm Wound Bed: Bleeding Odor Present: No Drainage: Type: Sanguineous Amount: Small Progress: No significant changes. A small open area remains present. Pain related to treatment: No Recommendations: Continue treatment as ordered Assessed by: RN J R104's eTAR (Electronic Treatment Administration Record) for September shows: Entry Date: 9/7/22 - Turn and reposition every 2 hours. Repositioning Schedule: 12am-2am (Left side), 2am-4am (right side), 4am-6am (left side), 6am-8am (right side), 8am-10am (left side), 10am-12pm (right side), 12pm-2pm (left side), 2pm-4pm (right side), 4pm-6pm (left side), 6pm-8pm (right side), 8pm-10pm (left side), 10pm-12am (right side) (sacral pressure injury): The following times were left blank on eTAR for September: 9/10/22- 4am, 9/20/22- 8am,10am, noon, 2pm, 9/28/22- 12am 9/29/22- 12am, 8am, 4pm, 6pm, 8pm, 10pm. (Please note there is no documentation of the PI after 9/30/22 until 10/25/22. Additionally, the PI was not measured from 9/30/22 - 11/17/22.) R104's eTAR (Electronic Treatment Administration Record) for October 2022 shows: Entry Date: 9/2/22 Treatment to Sacral Stage 2: 1 time per week Tuesday 1x/Day EVES 1. Cleanse skin and dry. 2. Apply sacral mepilex Dressing The following dates were left blank on eTAR for October: 10/18/22 The following entries show changes: 10/25/22- Type of Wound: Pressure Stage of Pressure Injury: Stage 2 Location: Sacrum Odor Present: No Drainage: None Procedure Done: open area noted. Wound bed yellow with dark spots, no signs of infection (Note: change noted to R104's wound bed including yellow wound bed with dark spots and no MD notification) R104's eTAR (Electronic Treatment Administration Record) for October 2022 shows: Entry Date: 9/7/22 - Turn and reposition every 2 hours. Repositioning Schedule: 12am-2am (Left side), 2am-4am (right side), 4am-6am (left side), 6am-8am (right side), 8am-10am (left side), 10am-12pm (right side), 12pm-2pm (left side), 2pm-4pm (right side), 4pm-6pm (left side), 6pm-8pm (right side), 8pm-10pm (left side), 10pm-12am (right side) (sacral pressure injury): The following times were left blank on eTAR for October: 10/1/22- 10pm 10/2/22- 4am, 6pm, 8pm, 10pm 10/3/22- 4pm, 6pm, 8pm, 10pm 10/5/22- 6pm, 8pm, 10pm 10/6/22- 4pm, 6pm, 8pm, 10pm 10/9/22- 10am, noon, 2pm, 4pm, 6pm, 8pm, 10pm 10/16/22- 8am, 10am, noon 10/17/22- 4pm, 6pm, 8pm, 10pm 10/18/22- 4pm, 6pm, 8pm, 10pm 10/19/22- 10pm 10/26/22- 4pm, 6pm, 8pm, 10pm 11/1/22 - Type of Wound: Pressure Stage of Pressure Injury: Stage 2 Location: Sacrum Odor Present: No Drainage: None Procedure Done: open area noted. Wound bed yellow with dark spots, no signs of infection. (Note: 2nd week with changes noted to R104's wound bed, no measurements, and no MD notification indicated) 11/5/22 - Type of Wound: Pressure Stage of Pressure Injury: Stage 2 Location: Sacrum Odor Present: no odor from pressure area but foul odor from dressing, could be due to soiling Drainage: no active drainage noted from pressure area, but noted moderate darkish discoloration on old dressing 11/9/22 - Type of Wound: Pressure Late Entry for 11/8/22 Stage of Pressure Injury: Stage 2 Location: Sacrum Odor Present: yes Drainage: dressing wet, wound bed soft yellow tissue treated as ordered and notified Hospice of odor and increased drainage noted with dressing change 11/11/22 - Stage 2 noted upon admission was essentially healed with a 0.5 x 0.5 cm open area remaining, wound subsequently deteriorated and is currently presenting as an unstageable slough covered wound. Location: Sacrum Peri-wound Description: Erythema (redness) Edges: Bright Red Length (Head to toe): 4 cm Width (left to right): 3 cm Wound Bed: Slough (dead skin tissue) Slough: 100% Slough Color: Yellow- green Slough Characteristic: Adherent Odor Present: Yes- Strong pungent smell Drainage: Type: Purulent Amount: Large Progress: Deteriorated: As noted above, presentation today concerning for infectious process at site Pain related to treatment: Yes, Explain: tender to touch Recommendations: MD/GNP notified. Suggest oral antibiotic course and treatment change as follows: Irrigate wound thoroughly with normal saline, dry. Apply Santyl. Cover with foam border type dressing supplied by Hospice daily until healed. R104's progress note, dated 11/11/22, at 11:58am, states: Conversation with: NP (Nurse Practitioner) Regarding: Presentation of sacral wound Result: New orders received and noted: (Specify briefly) Wound culture and sensitivity. RN J Physician Orders dated 11/11/22 - Wound culture and sensitivity. Physician Orders dated 11/11/22 - Clindamycin 300mg (milligrams) by mouth every 8 hours 3x/Day 3pm 11pm 7am x 7 days (wound infection) Discontinued on 11/16/22 11/15/22 - Type of Wound: Pressure Stage of Pressure Injury: Stage 2 Location: Sacrum Odor Present: Yes Drainage: None Procedure Done: Dressing in place, Hospice nurse in today, also GNP (Geriatric Nurse Practitioner)/wound nurse new orders tx (treatment) written for wound, continues with oral abx (antibiotic) for infection, (Please note this wound should be indicated as an unstageable and not a stage 2.) Physician orders dated 11/15/22 - Treatment to Sacral Wound: 1x/Day until healed 1. Irrigate thoroughly with Normal Saline and dry 2. Apply Medihoney to wound bed 3. Cover with foam border dressing **Supplies to be supplied by Hospice** Discontinued 12/2/22 Physician orders dated 11/16/22 Cefprozil 500 mg by mouth 2x/day Breakfast: HS (hour of sleep) x 14 days (sacral wound infection) Discontinued 11/30/22. 11/17/22 - Late entry for 11/16/22 Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Initially a stage 2 now presenting as unstageable Location: Sacrum Peri-Wound Description: Reddened 2 cm circumference to peri-wound Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 1.5 cm Wound Bed: Slough Slough Color: Yellow Slough Characteristic: Adherent Odor Present: Yes Drainage: Purulent Amount: Large Progress: Remains on oral antibiotics for wound infection. Presentation today consistent with ongoing infectious process at site. Pain related treatment: Yes Explain: Tender to touch Recommendations: Continue tx as ordered Assessed by: RN J R104's eTAR for November 2022 shows: Entry Date: 11/15/22 Treatment to Sacral Wound: 1x/Day until healed 1. Irrigate thoroughly with Normal Saline and dry 2. Apply Medihoney to wound bed 3. Cover with foam border dressing **Supplies to be supplied by Hospice** The following times were left blank on eTAR for November 2022: 11/19/22 & 11/23/22 11/30/22 - Late Entry for 11/23/22 Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Initially a stage 2 now presenting as unstageable Location: Sacrum Peri-Wound Description: Reddened 2 cm circumference to peri-wound Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 1.5 cm Wound Bed: Slough Slough Color: Yellow Slough Characteristic: Adherent Odor Present: Yes Drainage: Purulent Amount: Moderate Progress: Remains on oral antibiotics for wound infection. Less drainage noted today, less odorous as well. Pain related to treatment: Yes Explain: Tender to touch Recommendations: Continue treatment as ordered Assessed: RN J R104's eTAR (Electronic Treatment Administration Record) for November 2022 shows: Entry Date: 9/7/22 - Turn and reposition every 2 hours. Repositioning Schedule: 12am-2am (Left side), 2am-4am (right side), 4am-6am (left side), 6am-8am (right side), 8am-10am (left side), 10am-12pm (right side), 12pm-2pm (left side), 2pm-4pm (right side), 4pm-6pm (left side), 6pm-8pm (right side), 8pm-10pm (left side), 10pm-12am (right side) (sacral pressure injury): The following times were left blank on eTAR for November: 11/1/22- 10am, noon 11/3/22- 4am 11/5/22- 8am, 10am, noon, 2pm 11/6/22- 8am, 10am, noon, 2pm 11/8/22- 4pm, 6pm, 8pm, 10pm 11/11/22- 4pm, 6pm, 8pm, 10pm 11/12/22- 6pm, 8pm, 10pm 11/13/22- 10pm 11/15/22- 2am, 4am 11/17/22- 8pm, 10pm 11/19/22- 4pm 11/27/22- 10pm 11/29/22- 4pm, 10pm Physician Orders dated 12/2/22 - Treatment to Sacral Wound (per Hospice recommendations) 1x/Day until healed 1. Cleanse with normal saline or wound cleanser and pat dry. 2. Apply AG Rope (supplied by Hospice) to wound bed. 3. Apply skin prep to peri-wound. 4. Dress with mepilex border. Discontinued 12/9/22. 12/9/22 - Type of Wound: Pressure Ulcer Origination: Upon Admission Stage 2 at admission, now stage 4 Location: Sacrum Peri-Wound Description: Denuded (loss of the epidermal skin layer) Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 2 cm Wound Bed: 25% slough from 10 - 1 o'clock, 75% exposed muscle fascia Slough: 25% Slough Color: Yellow green Slough Characteristic: Tacky Odor Present: Yes Drainage: Type: Purulent Amount: Moderate Progress: 14-day antibiotic course of cefprozil and flagyl completed on 11/30/22. Since last week's assessment the peri-wound has deteriorated with areas of denuded skin and what appears to be areas of further deep tissue injury around the 10 o'clock and 6 o'clock peri wound regions. The drainage has returned to being purulent and malodorous and has increased as well. Medihoney continues to debride slough well but overall, the wound and peri-wound are concerning for unresolved/returning infectious process at site. Pain related to treatment: Yes, Explain: Tender to touch Recommendations: Changes recommended: Restart oral antibiotics, may need maintenance antibiotics for duration of wound. Also concern for c-diff infection post antibiotic course, resident had loose mucousy stool present during dressing change today. Topical treatment remains appropriate. MD/GNP notified. Assessed by: RN J R104's eTAR for December 2022 shows: Entry Date: 12/2/22 - Treatment to Sacral Wound (per Hospice recommendations) 1x/Day until healed 1. Cleanse with normal saline or wound cleanser and pat dry. 2. Apply AG Rope (supplied by Hospice) to wound bed. 3. Apply skin prep to peri-wound. 4. Dress with mepilex border. The following date was left blank on eTAR for December 2022: 12/4/22 Physician orders dated 12/9/22 - Treatment to Sacral Wound: (per Hospice recommendations) 1x/Day until healed 1. Cleanse with normal saline or wound cleanser and pat dry. 2. Apply non-sting barrier spray to peri-wound 3. Apply medihoney to slough. 4. Gently pack AG Rope (supplied by Hospice) to wound bed. 5. Cover with sacral mepilex border or Hospice supplied foam dressing that is large enough to cover wound and peri wound. 12/14/22 - Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Initially a stage 2 upon admission, now presenting as stage 4 Location: Sacrum Peri- wound Description: Denuded Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 2 cm Undermining: 2 cm from 9 o'clock to 3 o'clock Wound Bed: 90% exposed muscle fascia, 10% slough from 10 o'clock to 12 o'clock, with slough noted to be superficially attached to wound and not extending the depth of the wound Slough Color: Yellow- green Slough Characteristic: Tacky Odor Present: No Drainage: Type: Yellowish, greenish, reddish Amount: Moderate Progress: No odor noted today. Less slough noted. No s/sx (signs/symptoms) of infection noted. Pain related to treatment: Yes Explain: Tender to touch, tolerable per resident report, subsides immediately after touch as complete Recommendations: Continue treatment as ordered Assessed by: RN J (R104 now has undermining indicated, no indication that the MD or hospice was updated on this change.) (NO WEEKLY MEASUREMENT for 12/23/22) 12/30/22 - Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 upon admission, currently presenting at stage 4 Location: Sacrum Peri- wound Description: Red, non-inflamed appearance, some areas of excoriated skin but overall peri-wound excoriation improved Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 2 cm Undermining: 9 o'clock to 3 o'clock, deepest measurement of 4 cm noted at 2 o'clock Wound Bed: Slough noted from 10 o'clock to 1 o'clock the remainder of the wound bed is exposed muscle fascia Slough: 25% Slough Color: Yellow Slough Characteristic: Adherent Odor Present: No Drainage: Type: Serosanguinous Amount: Large Progress: No significant changes Pain related to treatment: Yes Explain: Tender to touch but tolerable per resident Recommendations: Continue treatment as ordered Assessed by: RN J (Undermining continues, and R104 now has a large amount of drainage, no evidence that the MD or Hospice were updated.) R104's eTAR (Electronic Treatment Administration Record) for December 2022 shows: Entry Date: 9/7/22 - Turn and reposition every 2 hours. Repositioning Schedule: 12am-2am (Left side), 2am-4am (right side), 4am-6am (left side), 6am-8am (right side), 8am-10am (left side), 10am-12pm (right side), 12pm-2pm (left side), 2pm-4pm (right side), 4pm-6pm (left side), 6pm-8pm (right side), 8pm-10pm (left side), 10pm-12am (right side) (sacral pressure injury): The following times were left blank on eTAR for December: 12/8/22- 6pm, 8pm, 10pm 12/9/22- 4pm 12/10/22- 10pm 12/11/22- noon 12/12/22- 12am, 2am, 4am, noon, 2pm, 4pm, 6pm, 8pm, 10pm 12/13/22- 6am, 8am, 4pm, 6pm, 8pm, 10pm 12/14/22- 4pm, 6pm, 8pm, 10pm 12/17/22- 4pm, 6pm, 8pm, 10pm 12/18/22- 4pm, 6pm,8pm,10pm 12/19/22- 10pm 12/20/22- 10pm 12/22/22- 4pm, 6pm,8pm,10pm 12/23/22- 4pm, 6pm,8pm,10pm 12/24/22- 4pm, 6pm,8pm,10pm 12/25/22- 4pm, 6pm,8pm,10pm 12/26/22- 4pm, 6pm,8pm,10pm 1/6/23- Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 upon admission, currently presenting at stage 4 Location: Sacrum Peri-wound Description: Pink with some areas of excoriation present but overall improved from past assessments Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 2 cm Undermining: 9 o'clock to 3 o'clock, deepest measurement of 4 cm noted at 2 o'clock Wound Bed: Slough noted hanging from wound perimeter at 1 o'clock, the remainder of the wound bed is exposed muscle fascia Slough: Less than 5% Slough Color: Yellow Slough Characteristic: Adherent Odor Present: No Drainage: Type: Serosanguinous Amount: Moderate Progress: No significant changes. Wound bed is clean and without s/sx of infection Pain Related to Treatment: Yes Explain: Tender to touch but tolerable per resident Recommendations: Continue treatment as ordered. Assessed by: RN J R104's eTAR for January 2023 shows: Entry Date: 12/9/22 - Treatment to Sacral Wound: (per Hospice recommendations) 1x/Day until healed. Cleanse with normal saline or wound cleanser and pat dry. 2. Apply non-sting barrier spray to peri-wound 3. Apply medihoney to slough. 4. Gently pack AG Rope (supplied by Hospice) to wound bed. 5. Cover with sacral mepilex border or Hospice supplied foam dressing that is large enough to cover wound and peri wound. The following times were left blank on eTAR for January 2023: 1/10/23. 1/13/23 - Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 upon admission, currently presenting at stage 4 Location: Sacrum Peri-wound: Pink with some areas of excoriation present but overall improved from past assessments Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 1.5 cm Undermining: 9 o'clock to 3 o'clock, deepest measurement of 3 cm noted at 2 o'clock Wound Bed: Clean-wound bed is exposed muscle fascia Odor Present: No Drainage: Type: Serosanguinous Amount: Moderate Progress: No significant changes. Wound bed is clean and without s/sx of infection. Pain related to treatment: Yes Explain: Tender to touch but tolerable per resident Recommendations: Continue treatment as ordered Assessed by: RN J 1/18/23 - Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 upon admission, currently presenting at stage 4 Location: Sacrum Peri- wound Description: Pink Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 1.5 cm Undermining: 9 o'clock to 3 o'clock, deepest measurements of 3.5 cm noted at 2 o'clock Wound Bed: Clean-wound bed is exposed muscle fascia Odor Present: No Drainage: Type: Serosanguinous Amount: Moderate Progress: No significant changes. Wound bed is clean and without s/sx of infection Pain Related to Treatment: Yes Explain: Tender to touch but tolerable per resident Recommendations: Continue treatment as ordered Assessed by: RN J 1/27/23 - Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 upon admission evolving to current stage 4 presentation Location: Sacrum Peri- wound Description: Intact, healthy appearing Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 1.5 cm Undermining: 9 o'clock to 3 o'clock, deepest measurements of 3 cm noted at 2 o'clock Wound Bed: Clean-wound bed is exposed muscle fascia Odor Present: No Drainage: Type: serosanguinous Amount: Moderate Progress: No significant changes. Wound is clean, without s/sx of infection Pain related to treatment: No Recommendations: Continue treatment as ordered Assessed by: RN J R104's eTAR for January 2023 shows: Entry Date: 12/9/22 - Treatment to Sacral Wound: (per Hospice recommendations) 1x/Day until healed. Cleanse with normal saline or wound cleanser and pat dry. 2. Apply non-sting barrier spray to peri-wound 3. Apply medihoney to slough. 4. Gently pack AG Rope (supplied by Hospice) to wound bed. 5. Cover with sacral mepilex border or Hospice supplied foam dressing that is large enough to cover wound and peri wound. The following times were left blank on eTAR for January 2023: 1/28/23 R104's eTAR (Electronic Treatment Administration Record) for January 2023 shows: Entry Date: 9/7/22 - Turn and reposition every 2 hours. Repositioning Schedule: 12am-2am (Left side), 2am-4am (right side), 4am-6am (left side), 6am-8am (right side), 8am-10am (left side), 10am-12pm (right side), 12pm- 2pm (left side), 2pm-4pm (right side), 4pm-6pm (left side), 6pm-8pm (right side), 8pm-10pm (left side), 10pm-12am (right side) (sacral pressure injury): The following times were left blank on eTAR for January: 1/2/23- 4pm, 6pm, 8pm, 10pm 1/5/23- 8am, 10am, noon, 2pm, 4pm, 6pm, 8pm, 10pm 1/6/23- 12am, 4am 1/7/23- 8pm, 10pm 1/9/23- 4am 1/10/23- 4am, 6am, 8am, 10am 1/11/23- 4am 1/12/23- 12am, 2am, 4am 1/13/23- 12am, 2am, 4am 1/19/23- noon 1/21/23- 12am, 2am, 4am 1/28/23- 4pm, 6pm, 8pm, 10pm 1/30/23- 4am 2/3/23 - Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 upon admission evolving to current stage 4 presentation Location: Sacrum Peri-wound Description: Intact, healthy appearing Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 1.5 cm Undermining: 9 o'clock to 3 o'clock, deepest measurements of 3 cm noted at 2 o'clock Wound Bed: Clean-wound bed is exposed muscle fascia Odor Present: No Drainage: Type: serosanguinous Amount: Moderate Progress: No significant changes. Wound is clean, without s/sx of infection Pain related to treatment: No Recommendations: Continue treatment as ordered Assessed by: RN J R104's eTAR for February 2023 shows: Entry Date: 12/9/22- Treatment to Sacral Wound: (per Hospice recommendations) 1x/Day until healed 1. Cleanse with normal saline or wound cleanser and pat dry. 2. Apply non-sting barrier spray to peri-wound 3. Apply medihoney to slough. 4. Gently pack AG Rope (supplied by Hospice) to wound bed. 5. Cover with sacral mepilex border or Hospice supplied foam dressing that is large enough to cover wound and peri wound. The following times were left blank on eTAR for February 2023: 2/5/23 & 2/6/23 2/10/23 - Type of Wound: Pressure Ulcer Origination: Upon Admission Stage of Pressure Injury: Stage 2 upon admission evolving to current stage 4 presentation Location: Sacrum Peri- wound Description: Intact, healthy appearing Edges: Pink Length (Head to toe): 4.5 cm Width (left to right): 4.5 cm Depth: 1.5 cm Undermining: 9 o'clock to 3 o'clock, deepest measurements of 3 cm noted at 2 o'clock Wound Bed: Clean-wound bed is exposed muscle fascia Odor Present: No Drainage: Type: serosanguinous Amount: Moderate Progress: No significant changes. Wound is clean, without s/sx of infection Pain related to treatment: No Recommendations: Continue treatment as ordered Assessed by: RN J 2/20/23 - Type of Wound: Pressure Ulcer Origination: Upo

Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation), for 1 of 3 residents (R2) reviewed, in accordance with the resident's directives. On [DATE], upon re-admission to the facility, R2 designated that she would like CPR if her heart stopped beating or she would stop breathing. On [DATE], R2 was found without blood pressure or pulse and not breathing. Nursing staff did not initiate CPR despite R2's directives to be provided CPR in accordance with her wishes The facility's failure to ensure R2 received basic life support, including CPR, in accordance with her wishes, per her signed CPR Preference form and facility policy, created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ finding on [DATE] at 2:40 PM. On [DATE], the facility recognized the deficient practice by the facility nursing staff and took steps to correct the deficient practice and ensure compliance at the time of the complaint survey. Based upon this determination, the IJ was removed and corrected on [DATE]. Evidenced by: The facility's Advanced Directives (CPR) policy, dated (YEAR), revised [DATE], includes, in part, the following: (SSM Health St. [NAME]'s Care Center) Staff will follow the resident's wishes regarding CPR as indicated on the CPR Sheet signed by the resident and found in the resident's medical record. 8. If the resident is found pulseless and non-breathing and the resident is a Full CPR or undecided: a. CPR will be started. b. The Charge Nurse or designee will call 911, notify the physician and family of the resident's status and transfer to the hospital. c. Staff will continue to provide oxygen and continue CPR until emergency staff arrives. d. Nursing will provide necessary information to emergency staff. R2 was readmitted to the facility following a hospitalization on [DATE]. R2's [DIAGNOSES REDACTED]. R2 was her own decision maker. R2's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] indicates R2 is cognitively intact. R2's CPR Preference form, signed by R2 on [DATE], included, in part, the following: I have received information about CPR attempts and I understand my choices regarding treatment in the event that my heart and breathing should suddenly stop. My treatment preference, in the event of cardiopulmonary arrest, is as follows: (check mark) YES. I want CPR attempts. In the event that my heart stops beating or I have stopped breathing, I elect to have the facility staff to apply force to my chest with their hands, thus compressing the heart and breathe into my mouth, filling my lungs with air. I understand that despite CPR attempts, irreversible brain damage and/or physical damage may result following a cardiopulmonary arrest and CPR attempts. I understand that in addition to the provision of CPR by facility staff, Emergency Medical Personnel will be summoned to begin Advance Life Support measures. R2's MAR (Medication Administration Record) includes, in part, the following: Code Status: CPR. R2's Nursing Notes include, in part, the following entry: [DATE] 10:37 AM: Note: Writer was called to room at this time stating she was without blood pressure and pulse. Upon entering the room she was still in her wheelchair, was gotten up per her normal routine, was washed and dressed, had breakfast . Nurse stated she was sitting in the chair and staff had last checked on her at 10:00 AM. At 10:10 AM, Priest, along with Chaplin, went to her room to give her last rites and anoint her. Upon entering the room, she was still sitting in the chair, yet she did not appear to be breathing. Writer was called down unable to assess or auscultate blood pressure, no pulse detected. On [DATE], Surveyor interviewed RN C (Registered Nurse) via telephone. RN C is the Nurse Manager on R2's Unit. RN C stated she was called to R2's room by the nurse on the Unit. R2 was not breathing and without pulse. CPR was not started. RN C stated she did not ask about R2's code status, she thought the Unit Nurse had already checked into R2's code status prior to calling. It was not brought to my attention that she was a Full Code until later and I was re-educated about what to do when someone wishes to have CPR. RN C stated R2 was a Full Code and wished to have CPR performed; this was not done when she was found without pulse or breathing. RN C stated CPR should have been initiated, a facility-wide Medical Emergency called, 911 called and R2 should have been sent to the hospital. Surveyor was unable to interview the Unit Nurse who was working with R2 on [DATE], when she was found without pulse or breathing. The facility's failure to ensure R2 received CPR following her wishes, as stated on the CPR Preference form, signed [DATE], created a situation of IJ on [DATE] when R2 was found without pulse or breathing and CPR was not provided to R2 by nursing staff. The facility recognized the deficient practice and took the following corrective steps to ensure that deficient practice did not occur again: [DATE] 1. Contacted (Agency Name) after interviewing RN (RN D) regarding (R2) and code status. (RN D) was previously orientated to (Facility) CPR policy prior to working. 2. (RN D) stated that the resident was noted cold and did not have vital signs. 3. (RN D) was sent home and his agency contacted. 4. NHA (A) interviewed (RN C) Unit Manager. (RN C) was contacted by (RN D) that resident had expired. Re-educated (RN C) regarding questioning Code Status. 5. All staffing agencies contacted by NHA (A) to provide a copy of the code status policy and education. All staffing agencies requested to educate their nurses on the code policy prior to working at (Facility). All staffing agency staff complied and completed and sent back. 6. Immediately completed a code drill times 3 on [DATE] to capture shift-to-shift changes. The drills were completed per policy. The drills were run by Nurse Managers post the re-education. Another drill was completed [DATE], which was run by (DON B) and Nurse Managers at 2:45 PM. 7. Random Code Drills will be run weekly at random times each week for 3 months then monthly thereafter. The results of the drills will be reviewed by the QAPI (Quality Assurance and Performance Improvement) Committee monthly. 8. All staff, including non-nursing staff, have been re-educated regarding the code status policy and protocol and roles they would play in the process. Completed [DATE]. 9. Any PRN (as need) staff that has not worked (due to school or vacations or scheduling) have been notified that they may not work until they have been re-educated. This is being tracked by the schedule. 10. Any agency staff scheduled to work will be re-educated by their agency prior to working their shift, with the signature sheet scanned to the Administrator's email. This has been pre-arranged with all agencies on [DATE]. Administrator has been receiving all signatures for education. All agency staff working are also being educated prior to their shift onsite. 11. Previously discharged resident code status reviewed and all were appropriate. This was completed by MRS E (Medical Records Supervisor). Per (MRS E), all code status were followed over the past year. 12. NP (Nurse Practitioner) was involved in resident case. Was noted that a palliative approach would be discussed with resident. This was confirmed with SW (Social Worker) as well. 13. Interviewed Chaplin regarding the resident's request of last rites to be provided. Resident had requested for last rights to be given on [DATE]. It is notable that resident requested her last rites on [DATE]. No Priest was available until [DATE]. Monsignor and Chaplin went into the room on [DATE], per resident request, as she thought that she would be passing, to provide last rites. Upon entering, Monsignor stated that resident appeared to have already passed. Monsignor provided absolution. Chaplin went to get the nurse and stated that resident appears to have passed away. Nurse came in and took vitals, resident was cold to the touch. 14. Interviewed staff on [DATE]. The staff stated that they did get resident out of bed and had her sitting in her wheelchair. Resident did eat some fruit for breakfast. The time between last seen by staff and then Priest was approximately 2 hours. 15. All Nurse CPR certifications confirmed to be current. 16. This plan was reviewed by the QAPI Team on [DATE]. (MD) was not present, however, updated via phone. This meeting was a special meeting to review.

Based on interview and record review, the facility did not provide care, consistent with professional standards of practice, to prevent pressure ulcers from developing unless the individual's clinical condition demonstrates that they were unavoidable in 1 of 2 residents (R1) reviewed for wound care. R1 has a history of pressure injuries (PI) to the coccyx region. R1's care plan intervention for skin integrity was not followed resulting in the re-opening of R1's coccyx PI. In addition, the facility did not initially identify the injury as the result of pressure and did not immediately notify the physician when the PI worsened. This is evidenced by the following: R1's [DIAGNOSES REDACTED]. R1 was reviewed as a closed record. R1's pressure ulcer CAA (Care Area Assessment), dated [DATE], states: Risk for ulcers with fragile skin, incontinence. Resident is on a repositioning schedule every 2 hours with end of life care. Staff assists with incontinence cares. Staff monitors skin and reports changes as needed. Has a hx (history) of a pressure ulcer to coccyx though it is healed. Staff continues to monitor area to prevent re-occurrence. Specialized bed and cushion used. R1's Braden Scale, dated [DATE], gave a score of 12 indicating R1 was at high risk for PIs. R1 re-developed a PI on [DATE]. R1's care plan, at the time of the [DATE] PI development, has a care plan area, dated [DATE], which states: Impairment of skin integrity manifested by skin breakdown - coccyx . Interventions to this care plan area include: offloading, develop and monitor turning schedule every 2 hours with pillows, encourage fluids, pressure reducing device in chair, pressure reducing mattress (air mattress) and Do not place sensor pad on top of pressure relieving cushion in chair. This intervention was dated [DATE]. R1's Nurses Notes, dated [DATE], states R1 developed a superficial wound to her coccyx measuring 0.5 cm (centimeter) by 0.2 cm. The documentation states: Coccyx re-opened by known caused (sic) by chair sensor pad head cord. Resident sitting on it and resident coccyx very fragile and gets chronic open areas easily. Cleansed with NS (Normal Saline), pat dry and [MEDICATION NAME] applied, repositioned, CP (care plan) updated to put sensor pad in between recliner and cushion, GNP (Geriatric Nurse Practitioner) updated, left message to family - awaiting for call back. (As noted above: R1's care plan at the time of this PI development already included the care plan intervention of: Do not place sensor pad on top of pressure relieving cushion in chair.) Facility staff initially, and until [DATE], identified this wound as OTHER (rash etc.) On [DATE], at 3:45 PM, Surveyor spoke with RN (Registered Nurse) Manager C regarding the development of R1's PI, on [DATE]. Surveyor asked RN Manager C if R1's wound was indeed a PI. RN Manager C stated, The staff were just calling it an open area, not pressure. Surveyor reviewed the documentation from the Nurses Notes with RN Manager C, which states the area re-opened by known caused (sic) by chair sensor pad head cord. Resident sitting on it and resident coccyx very fragile and gets chronic open areas easily. RN Manager C then told Surveyor that she did identify that a particular staff person was documenting wounds as other and educated that particular staff member by sending an email. RN Manager C provided Surveyor with this email, which is dated [DATE] and included charting from [DATE] - [DATE], and states: In reviewing charting noted her area on coccyx re-opened. Yet this was not charted as pressure area? Why not? If it was pressure before and it is the same spot over bony prominence it would be the same . Or is there another cause? It needs to be charted specifically if it is an abrasion or moisture associated area. Otherwise most likely pressure. Surveyor asked RN Manager C what caused R1's coccyx to re-open, on [DATE]. RN Manager C stated, Pressure from the cord I would think. It is important to note that despite RN Manager C having sent out an email on [DATE] regarding identifying PIs correctly, R1's PI from [DATE] was not identified as a PI until [DATE]. On [DATE], at 9:05 AM, Surveyor again spoke with RN Manager C regarding R1 and her PI, of [DATE]. RN Manager C stated that it was not until [DATE], that she became aware R1's wound was from pressure when the charge nurse noted the wound to be worsening and came to speak with her (RN Manager C) about it. RN Manager C states she just goes off the nurses charting and the nurses were not identifying it as pressure. RN Manager C stated when she saw it, on [DATE] she classified it as a PI. RN Manager C stated she does the MDSs (Minimum Data Sets) but since she was unaware this wound was from pressure, she did not code it as a PI. RN Manager C again confirmed that R1's coccyx wound that re-opened, on [DATE], was a PI. Surveyor than reviewed with RN Manager C, R1's care plan intervention, from [DATE], which states: Do not place sensor pad on top of pressure relieving cushion in chair and then again reviewed the nursing documentation which states: Coccyx re-opened by known caused (sic) by chair sensor pad head cord. Resident sitting on it and resident coccyx very fragile and gets chronic open areas easily. Surveyor than pointed out the new intervention, from [DATE], which states: sensor alarm under pressure relieving cushion on recliner. PLACE IN BETWEEN RECLINER AND CUSHION (emphasis in original document) (to prevent pressure to coccyx and buttocks.) Surveyor asked RN Manager C if R1's care plan intervention, from [DATE], was followed with regards to the sensor pad. RN Manager C stated: I guess not. I didn't realize that (intervention) was already in place and not followed (on [DATE]). Nursing Notes, from [DATE] through [DATE], documents R1's coccyx PI as other (rash, etc.) and was treated with NS cleanse and a [MEDICATION NAME] pad to be changed every 3rd day and as needed. (This is the same treatment that was already being done to R1's coccyx as a preventative treatment since a PI to R1's coccyx had developed on [DATE] and healed on [DATE].) On [DATE], R1 was seen by the GNP for an acute visit. There is no evidence that the GNP assessed or addressed R1's PI. Nursing Notes show that R1's coccyx PI, which re-opened on [DATE], at .5 cm x .2 cm, increased in size to 1.5 cm to 1.5 cm, on [DATE]. On [DATE], the wound color was described as yellowish, white center with pink perimeter and had scant serosanguinous drainage. There is no evidence a physician or practitioner was notified of these change. R1's record shows a dietary quarterly note, from [DATE]. This note identifies R1 to have a coccyx superficial o/a (open area) with nutritional interventions to be: hydration program . provide foods as tolerated / preferred, follow fluid balance and next weights. Resident directs when she eats. Goals are palliative. On [DATE], at 12:00 PM, Surveyor spoke with RD D (Registered Dietitian) regarding R1 and her PI. Surveyor asked why she had not reviewed R1 sooner than [DATE], given she had a PI. RD D stated once a week she pulls all pressure wound documentation to review. RD D stated since R1's wound was not initially identified as pressure this wound did not trigger me to review. RD D stated had she known R1 had a PI she would have completed an assessment sooner. On [DATE], a Hospice referral was made for R1. On [DATE], R1 was seen by her physician for a routine visit. The physician's note makes no specific reference to R1's PI. On [DATE], Hospice documentation states: The wound is almost completely with escar . There is no evidence a physician or practitioner was notified of this change. On [DATE], Hospice documentation states: . pt's (patient's) coccyx wound has increased in size and is now with purulent drainage and odor. On [DATE], facility Nursing Notes state: 9:30 PM call from (GNP E) asking nurse manager (RN Manager C) to call her with update on wound tomorrow - (GNP E) received call from Hospice nurse that wound on coccyx worse. massage (sic) left for (RN Manager C) with GNP request. On [DATE], facility Nursing Notes state: Conversation with (GNP E) treatment - she received a call from Hospice yesterday requesting tx (treatment) orders. New orders received and noted: Neutrashield to peri wound, ,[DATE] strength Dakins moistened gauze, ABD pad. Change daily. (This is the first evidenced consult with a practitioner regarding R1's coccyx PI, since [DATE], and the first change of treatment to this area, since [DATE], prior to the re-opening of R1's coccyx wound.) On [DATE], the facility documentation states the pressure ulcer to the coccyx is unstageable measuring 2.2 cm x 2.6 cm with black escar, odor, and scant amount of serous drainage. The injury is noted to be deteriorated. On [DATE], the Hospice documentation states: . Measurement for coccyx 2.2 cm x 2.6 cm . On [DATE], a care conference was held regarding R1 and her care. Present were facility staff, Hospice staff and family. Documentation states: Decline noted. (Family member), IDT (Interdisciplinary team) team and Hospice all noted a physical decline in (R1). She is increased in bed, losing weight, needing encouragement to eat / go to activities, may decline to participate in doing range of motion . At this point the team agrees that the ulcer pressure (sic) will likely not heal up IDT team explained that at EOL (end of life), appetite usually decreases, wounds are not healing as well any longer, and increased sleep / resting is to be expected. The common consent is to go with the flow, taking (R1's) lead, ensuring comfort care, respecting that (R1) increased prefers to stay in bed, or does not have an appetite at times On [DATE], R1 was seen by GNP E. GNP E's note states: . increased pain of non-healing pressure areas. Area #1 of sacrum is stage IV / unstageable with tunneling, exudative eschar, with odor . Sacral spine - approximately 2 x 2 x 1 cm with foul drainage, grey wound bed with escar .felt to be terminal ulcer - healing is unlikely. Goals should be odor and pain control . increase Dakins solution to ,[DATE] strength for the daily treatment / ABD pad for drainage . R1 expired on [DATE]. On [DATE], at 9:55 AM, Surveyor spoke with GNP E via telephone regarding R1 and her PI. GNP E told Surveyor that when she assessed R1, on [DATE], R1 was actively dying. GNP E clarified that when she stated the wound was terminal she meant that it was not going to heal. GNP E stated at the time of her assessment, on [DATE], she did not palpate for bone but that the wound had a foul odor with escar and was probably a stage 4. GNP E stated that at this point their main focus was to provide pain control. On [DATE], Surveyor received additional information from the facility including a summary from GNP E which states in part: She (R1) had a superficial open area to her sacral area on / off for many months. The tensile strength (the resistance of a material to breaking under tension) of the skin declines after once a wound - making the site more vulnerable in the future. I believe it last re-opened sometime in [DATE]. Standard treatment for [REDACTED]. I do not usually get involved in the clean superficial open areas unless a concern develops. Sometime in August, there were increased concerns of weakness and Hospice was resumed. After that, I was called to adjust her sacral treatment to Dakin's solution by Hospice team - which I supported. I believe that Hospice began to take an active role in her wound management from that point forward. I also believe that is when the wound really started to change. Hospice had left me a message the following week that she was rapidly declining with decreased intake and increased fatigue. R1 had a history of [REDACTED]. In addition, R1's wound was not initially identified as a PI and therefore was not identified as such on the MDS, nor initially identified by dietary as a PI. The Practitioner was not notified, on [DATE], when the wound began to deteriorate.

Based on interview and record review the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents in 1 of 18 residents reviewed for fall concerns (Resident 25). Contrary to R25's plan of care, R25 did not have gripper socks on and was not offered toileting as per plan of care and R25 fell . As a result, R25 sustained a hip fracture. This evidenced by the following: The facility's Fall Assessment Policy undated, includes in part: Policy: All newly admitted residents will receive a fall risk assessment by the admissions nurse and a quarterly assessment thereafter. All newly admitted residents will have a potential for fall care plan. Procedure: 6. a. Team Nurse should gather all interdisciplinary staff together for a post-fall debriefing to determine root cause of fall. b. Document fall and subsequent assessment, interventions, and notifications .7. A Registered Nurse (RN) will c. verify actions taken and approaches put into place to prevent further falls. Essential Points: The nurse manager will assess the circumstances of every fall and offer proactive suggestions to the clinical team. Post fall documentation may include: review of current interventions, new interventions notifications and care plan adjustments. Post fall goal is to determine the root cause of the fall and implement a new intervention to prevent the fall from occurring in the future. Example 1 R25's [DIAGNOSES REDACTED]. R25's Minimum Data Set (MDS) with an observation end date of [DATE] (prior to fall with fracture [DATE]) documents that R25 has no behaviors, has a BIMS (Brief Interview for Mental Status) of 6 indicating R25 has severe cognitive impairment, and needs extensive assistance with transfers, ambulation and toileting. R25's significant change of condition MDS with an observation end date of [DATE] (after the [DATE] fall with fracture) documents R25's BIMS shows R25 has moderate cognitive impairment and requires total assistance with transfers, ambulation and toileting which did not occur. R25's Fall assessment dated [DATE] shows that R25 had a score of 15 indicating R25 is at risk for falls. R25's care plan for falls shows the following interventions: Gripper socks when in bed to provide for non-slip footwear if she does attempt to get up unassisted ([DATE]), complete rounds per standards of care to ensure needs are met every 2 hours ([DATE]), Ensure call pendant is within reach and encourage resident to call for assistance ([DATE]), Does not always use call light to make needs known ([DATE]), Keep routine consistent - see toileting schedule ([DATE]). R25's toileting schedule dated [DATE] shows the following interventions: Scheduled Toileting AM- 7 am, 11 am, and 2 pm, PM - 5 pm, 8 pm, and 10 pm, NOC (night) Cue and prompt schedule every 3 hours. It is noteworthy the care plan at the nurse's station and the care card for R25 did not match per interview with CNA O and RN P. R25's care plan and care card for [DATE] was not provided. R25's Nurses Notes for [DATE] at 3:03 AM state in part: Date of fall: [DATE], Time of fall: 12:58 AM, Witnessed Incident: No, incident was not witnessed. Motor Strength: resident unable to move left lower leg. Physical Assessment: rates pain ,[DATE] in left leg states This is the worst misery I have ever been in in my life. Left leg is externally rotated and moderate swelling noted. First Aid: Tylenol 650 milligrams (mg) give at 1:30 AM for ,[DATE] left leg pain. Fall Type: fall by ambulating resident self-transferred from bed to toilet. Activity at Time: resident was attempting to transfer from bed to bathroom for toileting. Last Time Toileted: not toileted this shift, last on pm shift. Summary of fall: Resident self-transferred from bed to toilet, bed alarm sounding (of note R25 per interview and review of plan of care did not have an alarm). CNA O responded to alarm and found resident on the floor in bathroom on left side still holding on to walker yelling out Help. Resident did not have call light on. CNA O notified writer of fall immediately and staff did not move resident, called on call MD for orders to send to emergency room (ER) for evaluation of possible left leg fracture. Root Cause: Poor safety awareness, history of falls, dementia. Current Interventions in Place: Ensure call pendant is within reach and encourage resident to call for assistance. Cognitive Modifications: Does not always use call light to make needs known. Complete rounds per standards of care to ensure needs are met. Environmental Modifications: Gripper socks when in bed, to provide for non-slip footwear if she does attempt to get up unassisted. New Interventions Implemented: No new interventions at this time. Care plan remains the same, will discuss current care plan with nurse manager. Nurse's notes dated [DATE] at 4:26 AM state in part: when reviewing care card, it was noted that grippy {sic} socks were not on resident. Coached CNA regarding this {sic}. On [DATE] at 4:25 PM Surveyor interviewed RN Q regarding the fall for R25. RN Q stated she vaguely remembered the details of the fall. Surveyor asked RN Q if she recalled R25's plan of care was not followed. RN Q stated yes, I remember I spoke to the CNA about the resident not wearing grippy socks. Of note RN Q could not recall the name of the CNA she spoke with. Surveyor asked RN Q if she knew what she discussed with the CNA. RN Q stated she just told the CNA R25 was to have grippy socks on. Surveyor asked RN Q if she shared this information with other members of the Interdisciplinary Team (IDT). RN Q stated she did not; RN Q stated she knows the management team read her notes the next morning. On [DATE] at 5:45 PM Surveyor interviewed Certified Nursing Assistant (CNA) O regarding the incident and fall that occurred with R25 on [DATE]. CNA O stated she was not the primary CNA for R25 but was working on the hall to help out. CNA O stated she was following R25's care plan that was located at the nurse's station in the care plan binder. This care plan indicated R25 would use the call light for assistance. CNA O stated R25 did not ring for assistance so she entered R25's room around 1:00 AM to assist R25 with toileting and found R25 lying on the floor in the bathroom. CNA O stated it was after the fall that she was told by Registered Nurse (RN) P that the CNA care card and R25's care plan did not match. CNA O stated R25's care plan stated R25 would ring her call light for assistance however R25's up-to-date care card stated to check on R25. CNA O stated she was not aware of the changes as the care plan was not up-to-date. Surveyor asked CNA O if there were other care plan concerns. CNA O stated R25 was not wearing gripper socks per her plan of care. CNA O stated R25 was sleeping when she started her shift and she did not check R25's feet to see if she had gripper socks on. CNA O stated R25 should have had gripper socks on. Of note, the facility failed to investigate the root cause for why R25 was not wearing her gripper socks and why R25's care card and care plan did not match. There is no evidence the facility educated nursing staff on the need to assure resident's plan of care is followed and the resident care plan and care card match. On [DATE] at 5:55 PM Surveyor interviewed RN P regarding the incident and fall that occurred with R25 on [DATE]. RN P stated CNA O was not the primary CNA for R25. RN P stated there was a discrepancy with the care plan. RN P stated the care card in R25's bathroom and the care plan, in the binder at the nurse's station, did not match. RN P stated the care plan at the nurses station, the one CNA O was following, was not up-to-date. The care plan CNA O was using was not the correct, most up-to-date care plan for R25. RN P stated CNA O thought she was following the correct care plan. CNA O thought R25 used her call light but R25 did not use her call light anymore. The new up-to-date care plan stated to offer toileting more frequently. CNA O did not realize she was not following the correct plan of care. Surveyor asked RN P if there were other care plan discrepancies. RN P stated R25 was not wearing gripper socks. RN P stated 2 care plan errors occurred with staff not following R25's plan of care; these errors played a role in R25's fall. On [DATE] Surveyor interviewed Interim Nursing Home Administrator (INHA) A and Interim Director of Nursing (IDON) B regarding R25's fall. Surveyor asked INHA A if R25 was a fall risk. INHA A stated yes. Surveyor showed INHA A R25's plan of care with an intervention to wear gripper socks at night. Surveyor stated it is my understanding R25 was not wearing her gripper socks. INHA A stated I think she had her gripper socks on. Surveyor then showed INHA A R25's nursing notes dated [DATE] at 4:26 AM that states when reviewing care card, it was noted that grippy {sic} socks were not on resident. Coached CNA regarding this {sic}. Surveyor asked INHA A if she would expect R25 to have her gripper socks on per plan of care. INHA A stated yes. Surveyor asked INHA A if she had any additional information on what the CNA was coached on or if other staff received education after this incident. INHA A stated she was certain there was nothing in writing regarding the CNA coaching. Nursing notes dated [DATE] at 3:39 AM state in part: Date of Discharge: [DATE]. Time of Discharge: 2:05 AM; discharged To: Acute care hospital (hospital name). Nursing notes dated [DATE] at 5:13 AM state in part: 5:11 AM call from emergency room nurse updating that resident had been admitted for a hip fracture. X-ray Report dated [DATE] states in part: Transverse fracture of the distal shaft of the femur is again identified, just superior to the prosthesis. R25 was admitted to the hospital on [DATE] for a left hip fracture. Internal Medicine History and Physical dated [DATE] states in part; R25 here today for fall and left knee pain. Patient resides at (long-term care facility name) and had an unwitnessed fall. Found to have a fracture of left distal femur above the knee arthroplasty (joint replacement). Assessment and Plan: Distal femur fracture after fall-place in knee immobilizer and pain control. Nursing notes dated [DATE] at 10:37 AM IDT Fall Review states in part: resident had a fall on [DATE] fall reviewed by IDT on [DATE]. Description of fall: Fall by ambulating, resident was walking to use bathroom. Root Cause: toileting need, slip/fall. Risk Factors: cognitive impairment, impulsive behaviors, need for staff assist with mobility and attempted to go on own, lack of insight to safety aware {sic} does not consistently make needs known {sic} using call light. Call pendent report did not show that resident used device to make needs known or to request staff to help. Current Interventions: reviewed and remain appropriate; toileting plan in place for staff to assist resident to bathroom. New Interventions: will be developed further when resident returns from hospital. It is noteworthy that the IDT did not mention or review the fact R25's care plan was not followed (i.e. gripper socks not on) and the discrepancy as noted in R25's care plan and care card. Nursing notes dated [DATE] at 4:21 PM state in part: admitted for : femur fracture and end of life care (EOL). Reason for Admission: Hospice Care. Nursing notes dated [DATE] at 10:47 PM state in part: resident admitted due to hip fracture, non-weight bearing uses mechanical lift 2 person assist transfer. Of note this is a significant change of condition for R25. Prior to R25's fall on [DATE] R25 required extensive assist of 1 for activities of daily living (ADL's) and was able to ambulate with assist of 1 with a walker. After the fall on [DATE] R25 required total assistance for ADL's and was unable to ambulate. Nursing notes dated [DATE] at 8:24 AM state in part: pain assessment total ,[DATE] equals severe pain. Nursing notes dated [DATE] at 8:30 AM state in part: Call placed to (physician name) regarding pain management. Nursing notes dated [DATE] at 9:15 AM state in part: return call (physician name) regarding pain management. Relayed Nurse Practioner was here to see resident and pain management concerns were addressed with her. Staff will utilize as needed morphine order for breakthrough pain. Nursing notes dated [DATE] at 11:58 AM state in part: call placed to hospice regarding pain management. New orders received to increase liquid morphine to 10 milligrams (mg) every 4 hours scheduled and increase as needed morphine to 5 mg every 2 hours as needed for pain. Nursing notes dated [DATE] at 3:35 PM state in part: resident is at (facility name) for long term palliative care after hospitalization for fall with distal femur fracture. Currently on scheduled morphine 10 mg every 4 hours around the clock and as needed morphine 5 mg every 2 hours as needed. Current pain regimen is effective. Nursing notes dated [DATE] at 9:17 AM conversation with hospice nurse new orders received and noted discontinue non-comfort medication. Nursing notes dated [DATE] at 1:46 PM state in part: date of death [DATE] time of death 3:30 AM. R25's plan of care was not followed and R25's care plan and care card noted discrepancies regarding her plan of care. R25 fell on [DATE] resulting in a hip fracture. R25 expired shortly after the fall with fracture.