Every finding on record at Complete Care at Southpointe

Based on observation, interview and record review, the facility did not ensure 1 out of 2 residents (R20) admitted to the facility with a history of pressure injuries received the necessary care and treatment services to avoid developing a pressure injury.R20 has a significant past medical history of pressure injuries, including needing surgical intervention with skin flaps to heal previous pressure injuries. R20 was at risk for the development of pressure injuries based upon this history. The facility failed to recognize R20's risk factors and implement resident specific measures to prevent the development of pressure injuries. R20 developed a facility acquired, full thickness, unstageable pressure injury.Findings include:Policy review: Pressure Injury Prevention Guidelines date implemented 1/26.Policy: to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidenced-based interventions for all residents who are assessed at risk or who have a pressure injury present.Policy Explanations and Compliance Guidelines: (includes)1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics).4. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care and will notify physician to obtain orders.Pressure Relieving Devices:4. The standard mattress for all facility beds are pressure redistribution mattresses.5. The standard seat cushion for wheelchairs are pressure redistribution seat cushions.6. Provide alternative support surfaces as needed. Considerations for utilizing specialized support surfaces:a. medical condition and weight7. Do not use ring or donut shaped devices, synthetic sheepskin pads or mattresses, or egg-crate type mattresses for residents with or at risk for pressure injuries. R20 was admitted to the facility on [DATE] with diagnoses that included: morbid (severe) obesity due to excess calories, end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, chronic obstructive pulmonary disease, disorder of muscle and other abnormalities of gait and mobility. A review of the admission MDS (Minimum Data Set), dated 12/16/25, documents for an assessment R20 has a BIMS (brief interview for mental status) score of 15- cognitively intact. R20 has impairment in his range of motion on 1 side of his upper extremity. R20 was receiving therapy services upon admission. R20 was determined to be at risk for developing a pressure injury but did not have any unhealed areas at the time of the assessment reference period. R20 has pressure reducing device for his bed and chair.The Admit/Readmit Assessment, dated 12/11/25, documents under section: C. Skin Integrity/Braden that (R20) has slightly limited sensory perception. (R20) has occasionally moist skin, requiring extra linen change approximately once a day. (R20) walks occasionally and has slightly limited mobility/ ability to change and control body position. (R20) has adequate nutrition. Under friction/shear the assessment documents that (R20) has a problem with this and requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring repositioning with maximum assistance. Skin Observation: skin color is normal. Temperature is warm. Circulation is equal. Moisture is dry. Skin turgor is normal. Skin Integrity: bruising to abdomen, lumbar back, left hip surgical scar, posterior thigh surgical scar, abrasion right wrist and right knee, left knee and left elbow. The assessment also documents that R20 is continent of bowel and bladder.The facility conducted a Braden Assessment on 12/26/25 for R20. The score was 17 points, indicating low risk for developing a pressure ulcer.Surveyor conducted a review R20's individual plan of care and noted that R20 has potential/actual impairment to skin integrity r/t (related to) abnormalities in gait and mobility, DM (diabetes mellitus). This care plan was initiated on 12/11/25 with the following interventions: The resident will have no complications r/t wounds through the review date. Date Initiated: 12/11/2025Revision on: 12/29/2025 The resident will maintain or develop clean and intact skin by the review date. Date Initiated: 12/11/2025 Revision on: 12/29/2025 Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 12/11/2025 Encourage me to off my load heels. Date Initiated: 12/11/2025 Encourage/assist me with reposition as needed Date Initiated: 12/11/2025 Follow facility protocols for treatment of injury. Date Initiated: 12/13/2025 Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 12/13/2025 Keep skin clean and dry. Use lotion on dry skin. Do not apply on sites of injury. Date Initiated: 12/11/2025. My skin will be assessed on a weekly basis on my scheduled bath day and document findings on a weekly skin assessment. Date Initiated: 12/11/2025 Report any skin redness/impaired integrity areas to my nurse. Date Initiated: 12/11/2025 Risk and benefits of (Specify reposition, positioning devices, good skin care, etc.) were explained. Date Initiated: 12/11/2025 The resident needs monitoring/reminding/assistance to turn/reposition at least every 1-2 hours, more often as needed or requested. Date Initiated: 12/11/2025 Revision on: 03/06/2026 The resident needs pressure relieving/reducing cushions, pillows, sheepskin padding etc. to protect the skin while up IN CHAIR. The resident needs pressure relieving/reducing mattress, pillows, sheepskin padding etc. to protect the skin while IN BED. Date Initiated: 12/11/2025 Revision on: 12/11/2025 Use a draw sheet or lifting device to move resident. Date Initiated: 12/11/2025 Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date Initiated: 12/11/2025 Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date Initiated 12/11/2025.R20's plan of care also documents that R20 has alteration in kidney function due to end stage renal disease (ESRD). Date initiated: 12/13/2025. Interventions included:* Pressure -redistribution cushion to go with resident to dialysis. Initiated 12/13/2025* Resident specific dialysis schedule. Tuesdays, Thursdays, Saturdays. Time: 5:30 AM to 9:30 AM. Transportation pick-up time 1 hour prior to dialysis at 4:30 AM. Initiated 12/13/2025.Surveyor reviewed the product information for the pressure redistribution cushion that R20 was using in his wheelchair, both at the facility and then also taken to dialysis. The cushion is a emerald Selectis Foam Cushion. This cushion is said to be designed for comfort, pressure redistribution and durability. The weight capacity is 300 pounds. In R20's electronic medical record, located in the miscellaneous section, the facility had scanned in admission/referral information, dated 12/4/25 from the discharging hospital. This hospital paperwork contained past medical history and past surgical history information. 3/2/21 - sacral ulcer repair3/16/21 - gluteal flap debridement and readvancement3/23/21 - sacral ulcer repair3/31/21 - STSG (split thickness skin graft) to left buttocksR20's history of sacral injury repair, gluteal flap debridement and skin graft to the left buttocks was not documented, by the facility, in any other part of the medical record. R20's plan of care for potential/ actual skin impairment did not take this significant history of pressure injury care and treatment into account when assessing R20's risk factors and developing a plan of care and interventions. The facility assessed R20 to be at low risk for developing a pressure injury, even though there was a documented history of pressure injury treatment.On 2/8/2026 at 9:15 PM, eINTERACT SBAR (Situation, Baseline, Assessment, Recommendation) Summary for Providers: Situation: The Change In in Condition (CIC)/s reported on this CIC Evaluation are/were: Skin wound or ulcer. Resident/Patient is in the facility for: Long Term Care Primary Diagnosis is: M62.82 RHABDOMYOLYSIS. Relevant medical history is: COPD (chronic obstructive pulmonary disease), Diabetes, Chronic Renal Failure/ESRD (end stage renal disease). Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: (blank). Skin Status Evaluation: Wound - Pain Status Evaluation: Does the resident/patient have pain? (blank). observations, evaluation, and recommendations are: Open area noted to sacrum/buttocks. Describe with measurements. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: APN (Advanced Practice Nurse), Wound care to evaluate and treat. B. New Testing Orders: C. New Intervention Orders (none noted) This was written by LPN (Licensed Practical Nurse) - U. Surveyor noted there were no measurements or description of the wound/wound bed included in this information including the specific side/location of the pressure injury except sacrum/buttocks.A nursing note dated 2/8/2026 at 9:43 PM; Wound noted to right buttock during cares. Site was cleaned and dressing was applied. MD notified. On 2/8/26 at 9:58 PM, LPN U documented on an admission head to toe skin form. New pressure injury to right buttock measures 1.8 cm x 0.2 cm x 0.2. No drainage. No signs/ symptoms of infection. No complaints of pain. Surveyor noted there was no admission on 2/8/26. There is no indication an RN assessed R20's pressure injury to determine stage and document the characteristics of R20's facility acquired pressure injury.On 2/8/26, the facility conducted a Braden Skin Assessment. The score was 16 and indicated R20 is at low risk for pressure injury development. Surveyor was also provided a copy of the skin injury report dated 2/8/26 7:00 PM prepared by LPN- U. Small bleeding open area noted to right gluteal cleft/sacrum area during cares. Resident stated, I don't notice anything there. MD updated, wound care to follow. (R20) denies pain. Immediate intervention: area cleansed, and dry dressing applied. DON (Director of Nursing) notified 2/8/26 9:43 PM. MD notified on 2/8/26 at 9:43 PM. Family notified on 2/8/26 at 9:26 PM.A nursing note dated 2/9/2026 at 03:08AM documents; R20 is being monitored for an open area on the right buttock. TX (treatment) applied, and no pain or discomfort noted. On 03/12/2026 7:51 AM Surveyor conducted a review of the information that DON- B provided regarding R20's sacrum wound, and original assessment completed by Wound Care RN- I. The following was reviewed:Wound assessment 2/9/26sacrum/ buttock (left) Surveyor noted the documented information from 2/8/26 (date pressure injury was originally noted) indicated the area was located on the right side.11.0 cm x 7.0 cm by depth is undetermined. Unstageable.70 % slough, 20 % epithelial, 10% sloughpoorly defined (wound edges), hyperpigmentedChamoysyn q (each) shift (treatment ordered) This assessment was signed by Wound RN- I on 2/9/26. 2/9/26 IDT (interdisciplinary team) review: Alert and orientated x4, able to make needs known. Synopsis: Open area to sacrum/ buttocks. DX (diagnoses): ESRD with dialysis, HTN (hypertension), COPD (chronic obstructive pulmonary disease), GERD (gastroesophageal reflux disease), HLD (hyperlipidemia), Hyperparathyroidism, OSA (obstructive sleep apnea), DM11 (diabetes mellitus type 2), OA (open area). Interventions in place: offer to off load heels, pressure reducing mattress, foam w/c (wheelchair) cushion, Nephro (kidney), check for incontinence every 2 hours. Root Cause: Pressure possibly due to prolonged sitting, Interventions: ROHO cushion and dialysis updated to use ROHO cushion during treatments, heel boots, a/p (alternating pressure) air mattress, Prostat (nutritional supplement), reposition every 2 hours, [NAME]-Vite, offer to lay down after lunch. The following physician orders were obtained on 2/9/26:*A/P (alternating pressure) Air mattress to bed. Ensure function and placement every shift. Settings between 260lbs -300lbs. Every shift for prevention/healing. Active 2/9/2026 2:00 PM *Reposition every two hours. every 2 hours for prevention/wound healing. Active 2/9/2026 11:00 AM*Pressure relieving boots while in bed as much as tolerated or allowed. every shift for protection. Active 2/9/2026 2:00 PM.*Roho Cushion in w/c. Check for proper inflation q-shift (each shift). every shift for wound care. Active 2/9/2026 2:00 PM. *Cleanse sacrum/ buttocks wounds with soap and water followed by apply Chamoysn ointment each shift and as needed. Every shift for wound care. Active 2/9/26 at 9:09 AM.R20's individual plan of care was updated on 2/9/26 for the potential/ actual impairment to skin integrity due to abnormalities in gait and mobility. The plan documents that R20 on 2/8/26 has a pressure ulcer to the sacrum/ buttocks. Interventions were updated:*A/P air mattress to bed. Ensure function and placement every shift. Settings between 260- 300 pounds. Initiated 2/9/26.*Offer to lay down after lunch. Initiated 2/10/26.*Reposition every 2 hours. Initiated 2/9/26. * Pressure relieving boots while in bed as much as tolerated or allowed. Initiated 2/9/26.* Roho cushion in wheelchair. Check for proper inflation each shift. Initiated 2/9/26. Nursing note dated 2/9/2026 at 9:55 PM; (R20) on report for OA (open area) to R (right) buttock, treatment in place. Encouraged to ambulate and reposition every 2 hours.Nursing note dated 2/10/2026 05:16 AM; (R20) is being monitored for open area on the right buttock. Nursing note dated 2/10/2026 at 1:43 PM; Remains on report for open area to buttocks. (R20) has no complaints of pain or discomfort. Treatment applied per order. Tylenol administered for 6/10 pain. No other complaints or concerns at this time.Nursing note dated 2/10/2026 at 9:32 PM; (R20) on report for open wound to R (right) buttock. Chamosyn cream applied as ordered. Repositioned 2 hrs. at this time.Nursing note dated 2/11/2026 at 3:43AM; (R20) on report for open wound at the right buttocks. Denies any pain. Treatment applied.Nursing note dated 2/11/2026 at 1:20 PM; (R20) monitored for o/a (open area) R buttock. Seen per wound team. (R20) out of facility with friends at this time. Prior to leaving, no c/o (complaints of) pain or discomfort. Ate breakfast and took all medications.Nursing note dated 2/11/2026 at 9:36PM; (R20) monitored for OA to Right buttock. Tx (Treatment) applied. No c/o pain. Repositioned in bed q2hrs (Every 2 hours). Toileting cares provided by staffOn 2/11/26, APNP (Advanced Practice Nurse Practitioner)-S conducted an initial assessment of R20's new acquired pressure injury. The following is from the progress note:Reason: Wound Initial Visit Type: Wound Care Initial Evaluation Date: 02/11/2026. Chief Complaint: wound of Left side sacrum. (R20) is a pleasant [AGE] year old who is a resident at (name of facility). He/ she has a medical history of HTN, incontinence, ESRD, DM, and morbid obesity. I am consulted to assess a new pressure injury to the left side of his/her sacrum. (R20) is seen today sitting up in his wheelchair and can stand with assistance and his/her walker. (R20) has a good appetite and sleeps well. There is significant scarring noted during assessment which appears surgical, (R20) stated that he had wounds in this area in the past and has had a previous flap during the covid pandemic, per patient. No fevers or chills or additional skin concerns. Interventions in Place: Pressure reduction devices, mattress per facility protocol, cushion per facility protocol; nursing and wound care, nutritional support, PT/OT (physical therapy/occupational therapy) if needed. Diagnosis that could affect wound healing: Previous wound with flap closure, morbid obesity, diabetes mellitus, ESRD (end stage renal disease) on HD (hemodialysis), Rhabdo (rhabdomyolysis), history of incontinence of stool and some urine. Physical Examination: L sacrum- unstageable Wound measuring approximately 8 x 7 cm by UTD (unable to determine) consisting of 60% stable eschar, 10% dry granular tissue and 30% epithelial scar tissue. There is evidence of a surgical incision which (R20) says he did have a previous flap closure in the past on the same area. Scant serous drainage noted. Wound edges are well-defined. No obvious sign of infection or any odor Status: New. Assessment and Plan: Pressure ulcer of unspecified buttock, unstageable * Located in the left side of his/her sacrum. Ordered Santyl and dry dressing to affected (sic) area. Continue offloading efforts, alternating pressure mattress and diligent peri care with toileting. (R20) states he had a wound here in the past, unsure if it was a pressure injury or other type of wound as R20 doesn't remember the origin, but he did have a surgical flap many years ago. Unable to find any surgical history amongst (sic) his DC (discharge) summary with more information regarding his previous wound in this area. Discussed with wound (RN- I) general wound care instructions: Keep the wound clean and dry - Monitor for signs of infection (increased redness, warmth, swelling, drainage, odor, or pain) - Maintain adequate nutrition and hydration to support healing- Report any changes in wound appearance or symptoms to healthcare team. Wound care re-evaluation in 1 week.Surveyor noted the initial wound documentation and ongoing reference to R20's pressure injury by facility nursing staff document the facility acquired area to be located on R20's right side. Wound RN-I and APNP-S assessed the area to be located on R20's left side.On 2/18/2026 at 08:30AM, Wound APNP-S completed an assessment/wound care follow-up for R20. Chief complaint: Wound of Left side sacrum. (R20) is seen today lying in bed. He has no pain complaints in the wound. He eats and sleeps well, eating all his/her breakfast. No fever or chills or additional skin concerns. Diagnosis that could affect wound healing: Previous wound with flap closure, morbid obesity, HTN, DM, ESRD on HD, Rhabdo history of incontinence of stool and some urine. Physical Examination: L (left) sacrum- unstageable. Full thickness wound measuring approximately 4 x 11 cm by UTD consisting of 60% stable eschar, 10% granular tissue and 30% epithelial scar tissue bridge. There is evidence of a surgical incision which (R20) says he did have a previous flap closure in the past on the same area. Scant serous drainage noted. Wound edges are well-defined with new epithelial growth noted. No obvious sign of infection or any odor. Status: stable. Plan: Cleanse wound, apply Santyl to necrotic tissue and cover with xeroform and dry dressing daily and prn (as needed). On 2/25/2026 at 08:45AM, Wound APNP-S completed an assessment/follow-up wound care. Chief Complaint: wound of Left side sacrum. (R20) is seen today lying in bed. He has no pain complaints in the wound and appears comfortable during assessment. He eats and sleeps well, eating most of his meals. Physical Examination: L sacrum- unstageable. Full thickness wound measuring approximately 4 x 10 cm by UTD consisting of 60% softening eschar, 10% granular tissue and 30% epithelial scar tissue bridge. Moderate malodorous serous drainage noted. Wound edges are well-defined with new epithelial growth noted. No obvious sign of infection or any odor after cleansing wound. Status: improving. Plan: Cleanse wound, apply Santyl to necrotic tissue, fb (followed by) Dakin's moist gauze (1 - 4x4) and cover with dry dressing daily and prn.On 3/4/2026 at 08:15AM, Wound APNP- S completed an assessment/ follow-up wound care. Chief Complaint: Wound of Left side sacrum. (R20) is seen today lying in bed. He has no pain complaints in the wound and appears comfortable during assessment. He eats and sleeps well, eating most of his/her meals. No fever or chills or additional skin concerns. (R20) is agreeable to a sharp debridement today after reviewing risks and benefits. He gave verbal consent. Physical Examination: L sacrum- unstageable. Full thickness wound measuring approximately 3.5 x 6 cm by UTD with an undermine from 12-2 o'clock with the deepest at 1' o'clock measuring 4 cm. Consisting of 80% loosened soft eschar, 20% granular tissue. Moderate malodorous serous drainage noted. Wound edges are well-defined with new epithelial growth noted. No obvious sign of infection or any odor after cleansing wound, sharp debrided 100% of the necrotic eschar revealing well adherent slough. Status: improving. Plan: Cleanse wound, apply Santyl to necrotic tissue, fb Dakin's moist gauze (1 - 4 x 4) and cover with dry dressing daily and prn. Procedure: bedside surgical excisional debridement of the L side of his sacrum. Reason for procedure: presence of necrotic tissue. Description of wound: Full thickness wound measuring approximately 3.5 x 6 cm by UTD with an undermine from 12-2 o'clock with the deepest at 1 o'clock measuring 4 cm. Consisting of 80% loosened soft eschar, 20% granular tissue. Moderate malodorous serous drainage noted. Wound edges are well-defined with new epithelial growth noted. Size of wound after procedure: no change in measurement. Depth of procedure: approximately 2 cm. Tissue type removed: soft loose eschar. Instruments used: forcep and iris scissor Patient (R20) tolerance: tolerated well, denied pain. No bleeding. Dressing applied: yes, Santyl and Dakin's moist gauze. Treatment plan: Cleanse wound, apply Santyl to necrotic tissue, fb Dakin's moist gauze (1 - 4x4) and cover with dry dressing daily and prn.On 3/12/26 at 8:45 AM, Surveyor interviewed Wound RN-I regarding R20's facility acquired pressure injury to the sacrum/buttocks. Surveyor asked why the assessment on 2/8/26, performed by LPN-U was very different from the assessment that RN- I completed on 2/9/26. Surveyor was referring to LPN- U documenting a small bleeding open area to R20's right gluteal cleft/sacrum and Wound RN-I (12 hours later) documenting R20 had an unstageable pressure ulcer to the sacrum/buttocks measuring 11 cm x 7 cm by unable to determine depth. Wound RN- I stated that he believes LPN- U only measured the open area that had the small amount of bleeding, and his assessment referenced the entire area on the skin that appeared soft, spongy and with dark colored slough. Wound RN- I stated R20 has dark skin color so it may have been difficult for LPN- U to observe the entire area. Wound RN-I stated that the treatment was obtained in the morning of 2/9/26 and then Wound Nurse Practitioner (APNP-S) came on 2/11/26 and assessed the area and changed the treatment to something a bit more aggressive. Surveyor asked Wound RN-I why staff were documenting on the pressure injury being located on the right buttocks in the progress notes and weekly skin checks. Wound RN- I stated that he is not sure why, the area was on the sacrum and left side. They may have been following LPN- U's initial assessment. Surveyor asked Wound RN-I why R20 developed the unstageable pressure injury. Wound RN-I stated that there were interventions in place prior to the area developing. R20 had a cushion in his wheelchair but we don't know what (R20) is sitting on when he is at dialysis. Wound RN- I stated that he obtained orders for a ROHO cushion and alternating air mattress after the area developed and also encouraged (R20) to rest in bed after lunch. Wound RN-I stated the wound is evolving, they needed to break down the slough and it is now forming granulation pockets. The Santyl treatment is doing its job. On 03/12/2026 at 11:11 AM, Surveyor conducted an interview with DON- B. DON- B stated that the initial assessment, completed by LPN-U measured the open area, the area that actually was seen with blood. DON- B stated that if it isn't open, sometimes they (Nursing) don't measure the whole thing. LPN- U measured the area he found concerning, where it was bleeding. Surveyor asked DON-B about Wound RN-I's assessment. DON- B stated Wound RN- I's measurements, the next morning, were documented on paper, which is what he prefers. He saw the area about 12 hours after LPN-U assessed it. DON-B stated it did not grow that much in size; it is just different measurements. DON-B stated that the treatment ordered is for sacrum/buttock area, not just the right buttock. Surveyor shared concerns that staff continued to document that they were treating and monitoring the right buttocks. DON- B stated that the team discusses wounds in morning meeting, saw there was an open area, and Wound RN- I saw wound around 9:30AM or so.On 3/12/26 at 1:13 PM, Surveyor interviewed Wound APNP-S regarding R20's pressure injury to the sacrum. Wound APNP- S stated that she recalls first seeing the wound and it was a large area, and it was all eschar. Wound APNP-S stated that it does not seem like the area would just happen overnight. Wound APNP-S shared R20 had significant scar from his hip across the back. R20 told Wound APNP- S that he had surgery where they did a flap repair. Wound APNP-S stated that she was not aware of that medical history and did look in the medical record. Surveyor shared that hospital paperwork, prior to admission, contained medical history documenting on 3/2/21 - sacral ulcer repair, 3/16/21 - gluteal flap debridement and readvancement, 3/23/21 - sacral ulcer repair, 3/31/21 - STSG (split thickness skin graft) to left buttocks. Wound APNP-S stated there is concern for how long he is sitting in his wheelchair and sitting at dialysis without changing positions. Wound APNP-S stated that an unstageable area, on dark colored skin, is easily missed. Wound APNP-S stated an LPN may not be able to identify soft eschar with dark pigmented skin. Wound APNP- S stated that wound is improving due to the area being debrided, the necrotic tissue is going away. On 3/12/26 at 12:45 PM, Surveyor observed R20 receive wound care provided by Wound RN- I and Unit Manger- L. The following was observed by the Surveyor. EBP (enhanced barrier precautions) and hand hygiene performed appropriately. R20 lying on their right side with a towel over left thigh. A large scar noted traveling from left hip to top of buttocks with indentation of skin (CDI-clean dry & intact) in fold. Left buttocks wound: (12 noon to 3 o'clock) ABD (abdominal) pad dated 3/11. ABD pad removed, gauze packing removed with no drainage noted. Wound measures 3.5cm x 6 cm. No eschar noted, 30% granulation, 70% slough. Tunneling noted going up towards head/neck. Measured at 4.5 tunneling. Edges noted with fine line of slough. Santyl applied to gauze, wound packed and FBD (foam border dressing) applied dated 3/12. Right buttocks CDI, dime size healed previous wound noted at 10 o'clock on left buttocks.On 3/12/26 at 1:00 PM, Surveyor interviewed DON-B regarding the above treatment observations and concerns that R20 was not provided with the appropriate services to avoid the development of the unstageable pressure ulcer to his sacrum. DON-B stated that the facility had a pressure-reducing cushion in his wheelchair and a pressure-reducing mattress on the bed. R20 was more mobile when he was first admitted . Therapy never said there was a need for more pressure relief. DON-B stated that she can't control what happens at Dialysis and that they did call dialysis to make sure that R20 was using the ROHO cushion during treatments. Surveyor asked if this was after the pressure injury developed. DON-B indicated yes and stated that the facility did everything they needed to. Surveyor asked if DON-B was aware of R20's history of pressure injuries to the sacral area and surgical repair. DON-B stated that everyone saw that R20 had big scars but R20 never told us what they were from. On 3/16/26 the facility submitted additional information to review regarding R20 developing a facility acquired unstageable pressure injury. The information included discharge documents, the SBAR, nurse practitioner documents, Braden assessments, communication with dialysis dated 2/12/26, etc. The facility shared R20 had been with the facility for nearly two months before the pressure injury developed. The facility contended R20 was admitted with the wheelchair & cushion from hospitalization at the VA (Veterans Affairs) stating the VA would have been aware of R20's history and risk when providing this equipment. Surveyor noted the facility did not assess the equipment and risk factors for R20's routine after moving into the facility to determine appropriateness of equipment or set clear parameters for repositioning and offloading to address possible risk factors for R20. The facility also shared the initial nurse (LPN) deferred obtaining a measurement due to the complexity of the skin presentation at the time. Surveyor noted LPN-U did document a measurement (1.8 x .2 x 0.2) which was very different than the measurement obtained on 2/9/26 (11 x 7 x UTD) by Wound RN-I. Surveyor noted concern facility staff did not notice a change in R20's skin until the skin opened and was determined to be unstageable and individualized risk factors for R20 were not assessed by the facility and addressed in a preventative plan of care.

Based upon interview and record review, the facility did not ensure the mandatory staffing data submitted for the fourth quarter of 2025 (July 1- September 31) was accurate based on payroll and other verifiable and auditable data in a uniform format according to specifications established by Centers for Medicare and Medicaid Services (CMS). During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for excessively low weekend staffing. This had the potential to affect all 92 residents. Findings include: The facility's Assessment was reviewed, including staffing hours and acuity levels of care being provided. The facility's assessment documented the ratio for staffing needs per resident in the facility and triggered for low weekend staffing for the fourth quarter of 2025. Surveyor reviewed nursing schedules, along with the nurse staff posting hours for that time period and noted that there were no documented trends or gaps in weekend staff coverage. On 3/11/2026, at 12:41 PM, Surveyor interviewed Scheduler-M about the nurse and Certified Nursing Assistant (CNA) schedules. Scheduler-M stated they had been in this role since 2023. Scheduler-M stated the weekend staffing is the same as the staffing during the week. Scheduler-M stated there is a weekend supervisor in the facility during the weekend that is not accounted for during the week, but all other staffing is the same. Surveyor shared with Scheduler-M the concern the facility triggered for low weekend staffing from July 1 through September 30, 2025. Scheduler-M stated the facility switched systems that they were using to report PBJ staffing data in January 2026. Scheduler-M was not sure who did the actual submission of data but knew that prior to using the new system for reporting, Scheduler-M had to give Human Resources the additional information if a salaried employee covered a shift. Scheduler-M stated the new system picks up those staff members because they now clock in if they are working an additional shift or duty so PBJ staffing data is correct. Scheduler-M stated the facility always has enough staff; if there are any call-ins, Scheduler-M can find someone to cover the shift. Scheduler-M stated they do not use any agency staff and employees are willing to cover the shifts because they offer bonuses and overtime. Scheduler-M stated Scheduler-M is also a CNA so Scheduler-M will occasionally cover a shift as well as the nursing managers. On 3/11/2026 at 12:51 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the facility triggered for low weekend staffing for the fourth quarter (July 1-September 30, 2025). NHA-A stated the facility switched payroll systems which is what is used to report PBJ data starting in September 2025 and was rolled out fully January 2026. No additional information was provided as to why the facility did not ensure that mandatory staffing data submitted for the fourth quarter of 2025 (July 1- September 30) was accurate based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

Based on interview and record review, the facility did not ensure their abuse policy and procedure was implemented for 1 of 8 employees reviewed for 4-year background checks potentially affecting a portion of the 97 residents residing in the facility. Certified Nursing Assistant (CNA)-R did not have an up-to-date background check completed within the four-year time frame. Findings include: The facility policy and procedure titled Abuse, Neglect and Exploitation dated 3/2/2026 documents: 1. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred. On 3/10/2026, Surveyor requested from Nursing Home Administrator (NHA)-A the personnel files for eight employees to review for the required background checks. CNA-R was hired on 11/2/2020. CNA-R's Background Information Disclosure (BID) form, the Department of Justice (DOJ) letter, and the Interagency Border Inspection System (IBIS) form were completed on 9/25/2020, prior to CNA-R beginning employment, and on 3/10/2026, after Surveyor had requested the information. Surveyor noted six years between background checks; a background check should have been completed in September 2024. In an interview on 3/11/2026 at 9:44 AM, Surveyor asked Director of Human Resources (DHR)-G if there was a background check completed for CNA-R between 2020 and yesterday, 3/10/2026. DHR-G stated when Surveyor had asked for CNA-R's background check information, DHR-G noticed it had not been completed in the last four years. DHR-G stated DHR-G did an audit of all employee records and DHR-G was the only employee DHR-G could not find current paperwork for. NHA-A stated the facility was purchased by another company in 2022 and all employees had background checks completed at that time. Surveyor asked NHA-A when had the background checks been completed. NHA-A stated the background checks were completed in June and July of 2022. NHA-A stated NHA-A understood documentation was needed to show the background checks were completed and they were unable to find any forms at that time. On 3/12/2026 at 3:54 PM, NHA-A provided the DOJ letter dated 2/10/2022. NHA-A stated NHA-A and DHR-G were still looking for the BID and IBIS and will provide them when they are located. On 3/13/2026 at 4:34 PM, NHA-A sent an email with CNA-R's BID form signed on 2/10/2022. No IBIS form was provided. Surveyor noted CNA-R's BID form and DOJ letter were both dated 2/10/2022; a new background check for CNA-R should have been completed by 2/10/2026, a month prior to the recertification survey. The facility completed a background check on 3/10/2026, one month beyond the four-year timeline, after it was requested by Surveyor.

Based on observation, interview, and record review, the facility did not store food in accordance with professional standards for food service safety on the unit refrigerators for three of the four units in the facility, potentially affecting the residents residing on 3 units in the facility. *Unit 1 refrigerator was 52 degrees, above the facility determined temperature range. *Unit 2 refrigerator was 34 degrees, below the facility determined temperature range. *Unit 3 did not have a thermometer in the freezer as indicated in the facility policy. An undated bag of opened, unsealed mixed fruit was observed in the freezer. Findings include: The facility policy and procedure titled Monitoring of Refrigerator Temperature dated 5/2025 documents: Policy: It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. This policy also addresses refrigerated storage. Policy Explanation and Compliance Guidelines: 1. Logs will be kept at the nurses station for the freezer or refrigerator unit. a. Temperatures will be checked and logged once per day by designated personnel. b. Logs will be changed out and filed each month. 2. Thermometers shall be placed inside each cooler/freezer. 3. All refrigerators must be kept between 36 and 46 degrees F. The United States Food and Drug Administration (FDA) website https://www.fda.gov/food/buy-store-serve-safe-food/refrigerator-thermometers-cold-facts-about-food-safety documents: To ensure that your refrigerator is doing its job, it's important to keep its temperature at 40 degrees F or below; the freezer should be at 0 degrees F. The facility policy and procedure titled Use and Storage of Food Brought in by Family or Visitors dated 3/2026 documents: 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. 1.) On 3/12/2026 at 10:31 AM, Surveyor observed the refrigerator and freezer on Unit 1. The thermometer in the refrigerator read 52 degrees F. Surveyor noted Registered Nurse Unit Manager (RNUM)-L went into the refrigerator after Surveyor stepped away. Surveyor asked RNUM-L if there was a temperature log for the refrigerator. RNUM-L stated Director of Nursing (DON)-B wanted all the logs the day before so RNUM-L would have to go get it from DON-B. RNUM-L returned to the unit at 10:41 AM with the temperature log in hand. The log documented the refrigerator temperature was consistently 40 degrees F. RNUM-L stated temperatures are taken on the night shift. Surveyor shared with RNUM-L the observation of the temperature of the refrigerator was 52 degrees F. RNUM-L stated RNUM-L saw that was the temperature and turned the thermostat down. RNUM-L stated the refrigerator was being cleaned before and maybe, when they were wiping it out, they bumped the thermostat setting. Surveyor and RNUM-L looked at the thermometer and the temperature was 48 degrees F. 2.) On 3/12/2026 at 10:44 AM, Surveyor observed the refrigerator and freezer on Unit 2. The thermometer in the refrigerator read 34 degrees F. Licensed Practical Nurse Unit Manager (LPNUM)-K made the same observation. LPNUM-K stated LPNUM-K had just gone through the refrigerator to make sure all was right prior to Surveyor coming to look at it. LPNUM-K stated the refrigerator was a little too cold and adjusted the thermostat to bring it into the desired range. 3.) On 3/12/2026 at 10:51 AM, Surveyor observed the refrigerator and freezer on Unit 3. No thermometer was found in the freezer. Surveyor observed a bag of mixed fruit in the freezer. The bag was open to the air and did not have any label or date on it. LPN-C was present when Surveyor observed the freezer and bag of fruit. Surveyor asked LPN-C if there was a thermometer for the freezer. LPN-C did not see a thermometer and stated LPN-C has never logged a temperature for the freezer; the log only asks for a refrigerator temperature. Surveyor shared with LPNUM-K the observation of no thermometer in the freezer on Unit 3 and the opened, unlabeled bag of mixed fruit. Surveyor brought LPNUM-K to the Unit 3 refrigerator. The bag of mixed fruit had been discarded into the garbage can. LPNUM-K stated LPNUM-K did not observe the mixed fruit in the freezer; Surveyor shared that other staff members on Unit 3 observed the fruit and most likely threw it away because it was unlabeled and open to the air. LPNUM-K provided a thermometer for the Unit 3 freezer. On 3/12/2026 at 3:41 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the observations made on Unit 1, Unit 2, and Unit 3. Surveyor shared the concerns that two of the refrigerators were not in the range the facility determined was acceptable, the freezer on Unit 3 did not have a thermometer in it, and an opened, unlabeled bag of mixed fruit was in the freezer of Unit 3. Surveyor shared with NHA-A that staff members were present when these were observed and the staff members addressed the concerns after it was brought to their attention by Surveyor. On 3/13/2026 at 4:25 PM, NHA-A emailed a response to surveyor indicating the observations made by Surveyor during the survey process were investigated by the facility and confirmed that each of the concerns brought forward by Surveyor were addressed by staff after they were brought to their attention by Surveyor.

Based on interview and record review the facility did not ensure 1 (R62) of 2 residents reviewed abuse, neglect, misappropriation and exploitation was free from misappropriation of funds and possible exploitation.On 10/31/25 the facility was notified by Adult Protective Services of an allegation Certified Nursing Assistant (CNA)-Q had misappropriated R62's funds. Investigation revealed CNA-Q misappropriated funds from R62 using their debit card but also convinced R62 to provide R62 with cash, R62's PayPal account information to link R62's PayPal account to CNA-Q's account, and use of R62's cell phone. Findings include:The facility policy titled Code of Conduct revised 11/2025 documents: Policy: The purpose of this policy is to guide employees with respect to standards of conduct expected by this company as part of its compliance and ethics program. Improper activities could damage the company's reputation and otherwise result in serious adverse consequences. All employees are expected to adhere to acceptable business practices and exhibit a high degree of personal integrity and professionalism at all times. Procedure: 1. Conduct that interferes with the safe operation of our company brings discredit to the company or its residents or staff, or is offensive to a resident, family member, visitor, or employee will not be condoned and can be grounds for disciplinary action. 2. Examples of conduct and behavior that are considered inappropriate and are therefore prohibited by this policy may include: .a. Misuse or abuse of nursing home funds, dishonesty, theft, misrepresentation, conflict of interest, or false statement in connection with any aspects of employment.t. Misappropriation of facility/ patient funds, securities, supplies or other assets.6. Am employee may be subject to disciplinary action, up to and including termination when: .b. The employee violates any of our company's policies, rules, regulations, or procedures.The facility policy titled Abuse, Neglect, Exploitation revised 3/2/2026 documents: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. II. Employee Training:A. New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property and exploitation.B. Existing staff will receive annual education through planned in-services and as needed.C. Training topics will include:1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property .4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property .III. Preventing Abuse, Neglect, and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property . F. Provide residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed .H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors.VII. Reporting/ Response:A. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services (APS) and to all other required agencies . within specified timeframes .2. Assuring that reporters are free from retaliation or reprisal.R62 was admitted to the facility on [DATE]. R62's quarterly minimum data set (MDS) dated [DATE] indicated R62 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13 and the facility assessed R62 being dependent on 2 staff for activities of daily living (ADLs). R62 is their own person and in charge of their own finances.Surveyor reviewed a facility self-report regarding misappropriation of funds for R62 by a staff member, certified nursing assistant (CNA)-Q. The facility self-reported documents:- On 10/31/2025, at 11:30AM, two APS workers entered the facility and notified nursing home administrator (NHA)-A about an anonymous notification indicating CNA-Q was using R62's uber and paypal accounts.- Police were notified. R62 and CNA-Q were interviewed; CNA-Q admitted getting $400.00 from R62, ordering extra food for herself when R62 made food orders, and having R62's PayPal account linked to CNA-Q's PayPal account. R62 admitted to giving CNA-Q $100.00, use of a cell phone, and card information. The facility self report documents the relationship of R62 and CNA-Q was that of a close relationship. The facility self report documents R62 acknowledges that she would purchase additional meals for them to enjoy together.On 3/9/2026, at 10:44 AM, Surveyor interviewed R62 who remembered giving CNA-Q R62's bank card so when R62 wanted to order food, CNA-Q would already have the information to go ahead and order the food. Surveyor asked R62 if R62 asked for the bank card back from CNA-Q. R62 denied asking for R62's card back and let CNA-Q hold onto it but was not aware CNA-Q was making more purchases. R62 stated the facility provided R62 with a locked drawer in the nightstand, but R62 gave CNA-Q the bank card and it was not taken without R62 knowing. R62's 10/31/2025 trauma assessment documents: Financial struggle trauma- not having control of my finances/not being aware of my financial situationOn 3/9/2026, at 3:09 PM, Surveyor interviewed APS-P who stated they received an anonymous call regarding possibility CNA-Q was using R62's money. APS-P entered the facility and alerted administration of the concerns. Surveyor asked APS-P if the anonymous tip came from another employee or someone else. APS-P was not sure who the anonymous person was and could not say if it was another facility employee or someone else. APS-P stated once the police were notified and entered the facility there was not much more for APS-P to do and APS-P did not look further into the concern other than reporting to the State Agency.On 3/12/2026, at 1:09 PM, Surveyor interviewed NHA-A who stated NHA-A was not aware of CNA-Q having R62's bank card until APS-P came into the facility. NHA-A stated the facility called the police and initiated an investigation right away, during staff interviews, no one noted knowing that CNA-Q was using R62's bank card or had taken money from R62. Surveyor asked if all facility staff were educated on the abuse policy specifically misappropriation of resident funds. NHA-A stated about 85 - 90% of the facility was educated and had to complete a quiz. Surveyor asked what facility staff did not complete the education. NHA-A replied NHA-A would have to look at the listing and see who has not completed the education yet. Surveyor shared concern with NHA-A CNA-Q took R62's money and card even though it was given by R62 and used for personal gain. NHA-A understood the concern.Surveyor noted upon review of the facility self report, investigation and training post incident the facility initiated training on abuse, neglect, misappropriation and mistreatment but did not train all staff. Surveyor noted Post incident, the facility has not assessed or established a plan of care for R62's desire to order takeout food and the need for staff to assist with ordering leaving R62 vulnerable to possible further exploitation. Additionally, R62 expressed she believed R62 was a friend and R62 ordered extra food to have CNA-Q's company. There is no indication the facility assessed R62's need for friendship and/or whether R62 was lonely leading her to foster a friendship with staff that make her vulnerable to possible additional misappropriation and exploitation post incident. On 3/24/26 the facility submitted additional information to review regarding possible concerns related to abuse and neglect. Surveyor noted the explanation of details did not specifically address concerns identified with R62.

Based on observation, interview and record review, the facility did not ensure that 1 (R5) of 7 Residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.R5 has an active MD order for a left palm guard to be worn. Surveyor observed R5 without a left palm guard in place multiple times during survey. R5's left palm guard was not part of R5's Comprehensive Care plan or Certified Nursing Assistant (CNA) Kardex.Findings include: The facility policy with an implemented date of 1/26 and titled, Range of Motion, document, in part: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. The facility will provide treatment and care in accordance with professional standards of practice. This includes but is not limited to: Appropriate services (specialized rehabilitation, restorative, maintenance), Appropriate equipment (braces or splints. Care plan interventions will be developed and delivered through the facility's restorative program or through specialized rehabilitative services as ordered by the attending practitioner. Interventions will be documented on the resident's person-centered care plan. A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions.R5 was admitted to the facility on [DATE] with diagnosis that include Cerebrovascular disease (condition affecting blood vessels in the brain often leading to stroke, Stroke, Gastrostomy tube (medical device that delivers food, liquids and medication directly in the stomach, and contractures (permanent, rigid tightening of muscles, tendons, skin, or tissues that restrict joint movement and cause deformity).R5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R5 is severely cognitively impaired. R5 has impairments on both the right and left sides of R5's upper and lower extremities. R5 is dependent on staff for R5's care, mobility and transfers.R5's active MD order with a start date of 3/14/24 documents: Left hand palm guard on x 24 hours, may remove for hand hygiene. Every shift.R5's active MD order with a start date of 1/30/26 documents: Resident is [to] wear right palm on am and off at [night] as tolerated. One time a day for right palm guard and remove per schedule.Surveyor noted R5 had an active order to wear a right- and left-hand palm guard; there is no order discontinuing R5's active use of a left palm guard.R5's Contracture to bilateral hands care plan initiated on 3/13/24 documents the following pertinent interventions: Resident is [to] wear right palm on am and off at [night] as tolerated (initiated on 1/30/26).R5's resolved care plan interventions include the following: Receiving splint/brace assistance (Initiated 3/13/24 and resolved on 1/20/26). Assist the resident with the use of supportive devices left palm guard. (initiated 3/13/24 and resolved on 1/20/26). Surveyor noted R5's Contracture care plan has an active intervention to wear a right palm guard but does not have an active intervention to wear a left palm guard. On 3/09/2026 at 12:18 PM, Surveyor observed R5 lying in bed. R5 is wearing a right-hand palm guard. R5's left hand is contracted and partly hanging off R5's bed. R5 is not wearing a palm guard on R5's left hand.On 3/10/2026 at 8:15 AM, Surveyor observed R5 lying in bed. R5 is wearing a right-hand palm guard. R5's left hand is contracted. R5 is not wearing a palm guard on R5's left hand. On 3/10/2026 at 1:43 PM, Surveyor observed R5 lying in bed. R5 is wearing a right-hand palm guard. R5's left hand is contracted. R5 is not wearing a palm guard on R5's left hand. On 3/11/2026 at 7:58 AM, Surveyor observed R5 lying in bed. R5 is wearing a right-hand palm guard. R5's left hand is contracted. R5 is not wearing a palm guard on R5's left hand.On 3/11/2026 at 12:50 PM, Surveyor observed R5 lying in bed. R5 is wearing a right-hand palm guard. R5's left hand is contracted. R5 is not wearing a palm guard on R5's left hand. On 3/11/2026 at 1:03 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H. Surveyor asked if R5 wears any braces, splints or palm guards. CNA-H stated that R5 is supposed to wear a palm guard on R5's right hand. CNA-H stated that R5 will sometimes take it off and throw it. Surveyor asked where staff find what type of brace/splint/palm guard needs to be worn by residents. On 3/12/26 at 10:19 AM, CNA-H returned to Surveyor and informed Surveyor that braces, splints and palm guard use is listed in the CNA Kardex/Care plan. R5's CNA Kardex as of 3/11/26 documents, in part: Under dressing/Splint care is listed, Resident is [to] wear right palm on am and off at [night] as tolerated.Surveyor noted CNA-H stated that R5 wears a right palm guard and the right palm guard is listed on the CNA Kardex. Surveyor noted that CNA-H did not mention R5 wearing a left palm guard despite a continuing order for R5 to ear one. On 3/12/2026 at 10:08 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E. Surveyor asked if R5 wears any braces, splints or palm guards. LPN-E stated that LPN-E has been using palm guards or carrots (a soft cone-shaped orthotic device designed to be inserted into a severely contracted hand to prevent fingers from digging into the palm) on both hands. LPN-E stated that LPN-E would look in the medical record and check to make sure. LPN-E looked in R5's medical record and stated that R5 should be wearing a palm guard on R5's left hand. LPN-E stated that R5 did recently receive Occupational Therapy (OT) for the right hand. LPN-E stated that R5 has had a palm guard for the left hand for a long time but thinks the right hand was recently added. Surveyor asked what R5 was wearing on R5's hands today. Surveyor and LPN-E walked to R5's room. R5 was observed lying in bed. R5 had a palm guard on R5's right hand. R5 was not wearing a palm guard on R5's left hand. LPN-E stated that LPN-E had put a carrot in R5's left hand earlier in the morning. LPN-E stated that R5 will sometimes take the palm guard or carrot off and will throw it. LPN-E found the carrot under R5's bed.On 3/12/2026 at 10:19 AM, Surveyor interviewed LPN Unit Manager (LPN UM)-K. Surveyor asked what was being done for R5's right- and left-hand contractures. LPN UM-K stated that R5 has palm guards in place. LPN UM-K stated that LPN UM-K wanted to check the medical record to make sure. LPN UM-K stated that R5 has a left-hand palm guard order in place. LPN UM-K stated that R5 should have a right palm guard as well. LPN UM-K stated that R5 saw OT earlier in the year and a right palm guard was ordered. LPN UM-K entered the order, and care planned the right palm guard. Surveyor asked if the left palm guard was discontinued at that time. LPN UM-K indicated that R5 has had the left palm guard for ages and does not think it was discontinued.On 3/12/26 at 10:37 AM, LPN-E returned to Surveyor. LPN-E stated that R5 has always had a palm guard on R5's left hand. Staff noticed that R5's right hand had some contracture and that is why OT was ordered. OT completed sessions with R5 and ordered a right-side palm guard. The order and care plan intervention was put in place for the right side. OT never discontinued the palm guard to the left hand. LPN-E stated that the left palm guard was accidentally removed from the care plan. LPN-E provided a therapy communication form to Surveyor.R5's Therapy Communication Form dated 1/29/26 and signed by OT-O documents, in part: [Patient] to wear right palm guard during the day, off at night as she tolerates.On 3/12/26 at 11:10 AM, Surveyor interviewed OT-O. Surveyor asked what is in place for R5's hand contractures. OT-O stated that R5 has had a left palm guard in place since 2024. The right palm guard was ordered in January of this year. Surveyor asked if the left palm guard was discontinued after the right palm guard was put in place. OT-O stated No. OT-O R5 should have both in place. On 3/12/26 at 12:38 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor informed DON-B of the concern that R5 has an active order for a right- and left-hand palm guard to be worn. Surveyor observed R5 without R5's left palm guard multiple times, on different days during the survey. DON-B stated that LPN UM-K had put R5's left palm guard on in the morning on the first day of survey. Surveyor informed DON-B that Surveyor observed R5 in the afternoon and the palm guard was off. Surveyor informed DON-B that R5's left palm guard was not part of R5's active care plan or Kardex. Surveyor asked if it should be care planned. DON-B stated it should be care planned.On 3/12/2026 at 2:10 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the concern that R5 had an active order for a left palm guard. Surveyor had multiple observations of the left palm guard not in place. R5's left palm guard is not part of R5's active comprehensive care plan or CNA Kardex.

Based on interview and record review, the facility did not ensure that proper notification was sent to the State Long-Term Care Ombudsman for 6 (R1, R2, R3, R8, R10 and R103) of 6 residents reviewed for transfers or discharges. *R1 was transferred to the hospital on 8/5/25 and 10/23/25. The facility did not notify the State Ombudsman of R1's hospitalizations. *R2 was transferred to the hospital on [DATE]. The facility did not notify the State Ombudsman of R2's hospitalization. *R3 was transferred to the hospital on [DATE]. The facility did not notify the State Ombudsman of R3's hospitalization. *R8 was transferred to the hospital on [DATE]. The facility did not notify the State Ombudsman of R8's hospitalization. *R10 was transferred to the hospital on [DATE] and 2/3/26. The facility did not notify the State Ombudsman of R10's hospitalizations. *R103 was transferred to the hospital on 1/8/26. The facility did not notify the State Ombudsman of R103's hospitalization. Findings include: On 3/11/26, Nursing Home Administrator (NHA)-A provided a report titled, Admission/Discharge to/from report. Discharges 5/1/25 to 3/10/2026 to Surveyor. NHA-A indicated that this report lists the discharged residents that the State Ombudsman was made aware of from May 2025 through 3/10/26. On 3/11/2026 at 1:14 PM, Surveyor interviewed Social Work Director (SWD)-J. Surveyor asked about the process of notifying the State Ombudsman of transfers and discharges. SWD-J stated that SWD-J sends the transfer/discharge report by email at the beginning of each month. Included in the report is any resident who is discharged home, transferred/discharged to the hospital and any resident death. Surveyor informed SWD-J that not all residents reviewed for transfers/discharges are found on the report provided to Surveyor. SWD-J stated that SWD-J would look at the report. SWD-J pulled up the report on the facility electronic health record (EHR) system. SWD-J confirmed that not all residents were listed on the report. SWD-J stated that if a resident's status is not listed as discharged in the EHR, then the resident will not appear in this report. SWD-J indicated that SWD-J will work on finding a report that will include all residents that are transferred/discharged to the hospital. On 3/12/2026 at 2:10 PM Surveyor informed NHA-A of the concern that the State Ombudsman was not notified when R1, R2, R3, R8, R10 and R103 were transferred to the hospital. NHA-A stated that NHA-A was trying to figure out a report that would include all the necessary residents that could be sent to the Ombudsman each month. 1.) R3 was admitted to the facility on [DATE] with diagnoses that include Colon cancer, Colostomy, Stroke and Type 2 Diabetes. On 12/8/25, R3 experienced a change of condition and was transferred to the hospital. Surveyor reviewed the Admission/Discharge to/from report. Discharges 5/1/25 to 3/10/2026 document provided by NHA-A for evidence that the State Ombudsman was notified of R3's hospitalization. Surveyor noted R3's 12/8/25 hospitalization was not listed in the report that was sent to the State Ombudsman. 2.) R8 was admitted to the facility on [DATE] with diagnosis that include Alzheimer's, Dementia, Stage 3 chronic kidney disease, and Anemia. On 10/13/25, R8 experienced a change of condition and was transferred to the hospital. Surveyor reviewed the Admission/Discharge to/from report. Discharges 5/1/25 to 3/10/2026 document provided by NHA-A for evidence that the State Ombudsman was notified of R8's hospitalization. Surveyor noted R8's 10/13/25 hospitalization was not listed in the report that was sent to the State Ombudsman. 3.) R10 was admitted to the facility on [DATE] with diagnosis that include heart disease and type 2 diabetes. On 11/21/25, R10 was transferred to the hospital after a clinic visit in which R10 experienced a change of condition. On 2/13/26, R10 was transferred to the hospital for a planned surgical procedure. Surveyor reviewed the Admission/Discharge to/from report. Discharges 5/1/25 to 3/10/2026 document provided by NHA-A for evidence that the State Ombudsman was notified of R10's hospitalizations. Surveyor noted R10's 11/21/25 and 2/13/26 hospitalizations were not listed in the report that was sent to the State Ombudsman. 4.) On 8/4/2025, R1 experienced a change of condition and was transferred to the hospital for further evaluation per physician recommendation and was admitted to the hospital. On 10/23/2025, R1 experienced a change in condition and was transferred to the hospital for further evaluation per physician recommendation and admitted was admitted to the hospital. Surveyor reviewed the Admission/Discharge to/from report. Discharges 5/1/2025 - 3/10/2026 document provided by Nursing Home Administrator (NHA)-A for evidence that the State Ombudsman was notified of R1's hospitalizations. Surveyor noted R1's 8/5/2025, and 10/23/2025 hospitalizations were not listed on the report that was sent to the State Ombudsman. 5.) On 11/5/2025, R2 experienced a change of condition and was transferred to the hospital for further evaluation per physician recommendation and was admitted to the hospital. Surveyor reviewed the Admission/Discharge to/from report. Discharges 5/1/2025 - 3/10/2026 document provided by NHA-A for evidence that the State Ombudsman was notified of R2's hospitalization. Surveyor noted R2's 11/5/2025 hospitalization was not listed on the report that was sent to the State Ombudsman. On 3/11/2026 at 1:14 PM, A Surveyor interviewed Social Work Director (SWD)-J who stated SWD-J sends the transfer/discharge report to the State Ombudsman via email at the beginning of each month. SWD-J stated the report includes any resident who is discharged home, transferred/discharged to the hospital, and any resident death. A Surveyor informed SWD-J that not all residents reviewed for transfers/discharges are found on the report provided to Surveyors. SWD-J pulled up the report on the facility electronic health record (EHR) system and confirmed not all residents were listed on the report. SWD-J stated if a resident's status is not listed as discharged in the EHR, the resident will not appear in the report. SWD-J shared concerns and will work on finding a report that will include all residents that are transferred/discharged to the hospital. On 3/12/2026 at 2:10 PM A Surveyor informed NHA-A of the concern the State Ombudsman was not always notified when R1, R2, R3, R8, R10 and R103 were transferred and admitted to the hospital. NHA-A stated NHA was aware of the concern and was trying to figure out a report that would include all the necessary residents that should be sent to the Ombudsman each month. 6.) On 1/8/26, R103 was transferred to the hospital for a change in condition. R103 was admitted for acute renal failure and did not return to the facility. On 3/11/26, Nursing Home Administrator (NHA)-A provided a report titled, Admission/Discharge to/from report. Discharges 5/1/25 to 3/10/2026 to Surveyor. NHA-A indicated that this report lists the discharged residents that the State Ombudsman was made aware of from May 2025 through 3/10/26. Surveyor conducted a review and noted that R103 was not on the provided discharge/transfer list. On 3/12/2026 at 2:10 PM Surveyor informed NHA-A of the concern that the State Ombudsman was not notified R103 were transferred to the hospital. NHA-A stated that NHA-A was trying to figure out a report that would include all the necessary residents that could be sent to the Ombudsman each month.

Based on observation, record review, interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to accurately code the Minimum Data Set (MDS) for three of 26 sampled residents (Resident (R) 23, R27, and R89) reviewed for MDS assessments. This deficient practice increased the potential for missed opportunities of care or services. Findings include: 1. Review of R23's undated Admission Record located in the electronic medical record (EMR) under the Profile tab indicated an admitted [DATE] and diagnoses of chronic obstructive pulmonary disease (COPD), pulmonary hypertension and anxiety. Review of R23's quarterly MDS with an Assessment Reference Date (ARD) of 10/08/24, located in the EMR under the MDS tab, revealed the resident was marked No for receiving hospice services. Review of R23's Progress Notes located in the EMR under the Progress Note tab, revealed R23 was receiving hospice services until her passing on 10/15/24. 2. Review of R27's undated Admission Record located in the EMR under the Profile tab, indicated an admitted [DATE] and diagnoses of chronic obstructive pulmonary disease (COPD), nicotine dependence and anxiety. Review of R27's annual MDS with an ARD of 12/22/23, located in the EMR under the MDS tab, revealed the resident was marked No for smoking. R27 was a current smoker. Review of R27's quarterly MDS with an ARD of 09/22/24, located in the EMR under the MDS tab, indicated R27 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Observations on 10/16/24 at 2:00 PM and on 10/17/24 at 11:00 AM, R27 smoked independently, in the designated smoking area and no difficulties noted. 16752 3. Review of R89's Admission Record located in the resident's EMR Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R89's Admission Smoking assessment dated [DATE] located in the resident's EMR Assessment tab documented that the resident smokes three to four times a day and did not wish to quit smoking. Review of R89's Admission MDS with an ARD of 08/05/24 located in the MDS tab documented the resident had a BIMS score of 12 out of 15 points which indicated the resident had moderately impaired cognition and decision-making ability. The assessment tool documented that the resident did not smoke. Review of the facility's list of smokers that was provided to the survey team on 10/14/24, revealed R89 was listed as a smoker. Interview on 10/17/24 at 3:35 PM, the MDSC stated she felt she read the assessment to mean the resident had desired to smoke but would not. During an interview on 10/17/24 at 1:35 PM, the Minimum Data Set Coordinator (MDSC) stated R23's MDS with an ARD of 10/08/24 was coded incorrectly and should have been Yes to reflect that R23 was receiving hospice services. The MDSC stated that R27's MDS with an ARD of 12/22/23 should have been Yes for smoking. The MDSC stated the facility MDS nurses followed the RAI manual for coding. Review of the RAI 3.0 manual dated October 2023 indicated, .Code the Hospice section yes if the resident is receiving hospice services . and for residents who use tobacco the manual indicated, .Code the tobacco section yes if the resident indicates they used tobacco in some form during the seven-day look back period .

Based on record review, interview, and policy review, the facility failed to develop a care plan for one of five residents (R)89) identified for smoking behaviors in the sample of 26. This failure has the potential to place the resident risk for unmet care needs and the inability to meet the maximum practicable level of functioning. Findings include: Review of the facility's policy titled Resident Smoking dated 05/31/23 indicated, .All safe smoking measures will be documented on each resident's care plan . Review of the facility's policy titled Comprehensive Care Plan dated 9/2024 indicated, The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. Review of R89's Admission Record located in the resident's EMR in the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease with dyskinesia (involuntary movements of the face, arms, legs, or trunk), spondylopathy in the lumbar region, systemic atrophy affecting the central nervous system, and striatonigral degeneration (progressive neurodegenerative disease). Review of R89's Admission Smoking assessment dated [DATE] located in the resident's EMR tab titled Assessment documents the resident smokes three to four times a day and did not wish to quit smoking. Review of R89's care plan dated 08/13/24 in the EMR Care Plan tab did not reveal a smoking care plan had been developed for this resident. Interview on 10/16/24 at 1:45 PM, the Administrator stated that R89 only smokes with family members and they maintain his cigarettes, which should be documented in R89's care plan. Interview on 10/16/24 at 1:20 PM, the Unit Manager stated that R89's smoking care plan was not developed.

Based on observation, interview and record review, the Facility did not ensure that Residents with pressure injuries or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 5 (R15, R406, R19, R24, and R83) of 6 sampled residents reviewed for pressure injuries. *When R15 was identified to have a new open area to the left buttock on 01/05/23, the facility failed to immediately assess R15's new open area and failed to adjust R15's plan of care to prevent the open are from declining to a stage 4 pressure injury on 03/02/23. *R406 returned to the facility on [DATE] after surgery with a new back brace. Facility staff not were not properly trained on how to put the brace on and take it off. Staff statements indicate monitoring back brace every shift, but sometimes R406 would be up all shift and would go long periods without the monitoring of brace. R406 developed a stage 4 pressure injury from the back brace that required surgery. Facility failure to provide care and treatment to prevent the development of stage 4 pressure injuries created a finding of immediate jeopardy that began on 03/02/23. The Nursing Home Administrator (NHA) - A and DON-B were notified of IJ (Immediate Jeopardy) at F686 on 08/01/23 03:33 PM. The jeopardy was removed on 08/07/23, however, the deficient practice continues at a scope/severity of G (harm/isolated) as the facility continues to implement its action plan and as evidenced by the following. *R19 developed a facility acquired stage 3 pressure injury to the coccyx. There was no assessment of wound when it was first observed and no root cause for Moisture Associated Skin Damage (MASD). *R24 Developed a pressure injury due to neck brace. *R83 is at risk of developing pressure injuries and has a care plan intervention to have pressure relieving boots on at all times. Surveyor observations during survey of pressure relieving boots not on while in bed. Observations were made after care observations. Findings include: The Facility Pressure Injury Prevention Guidelines dated 01/05/23 states: Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Policy Explanation and Compliance Guidelines: 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders. 5. Prevention devices will be utilized in accordance with manufacturer recommendations (e. g., heel flotation devices, cushions, mattresses). 6. Guidelines for prevention may be utilized in obtaining physician orders. The facility may use facility specific guidelines or see Pressure Injury Prevention Guidelines below. a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. When physician orders are present, the facility will follow the specific physician orders. 7. Interventions will be documented in the care plan and communicated to all relevant staff. 8. Compliance with interventions will be documented in the medical record. a. For at-risk residents: treatment or medication administration records. b. For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure injury. b. Lack of progression towards healing or changes in wound characteristics. c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. Under the Facility Skin Integrity - Incontinence Associated Dermatitis (IAD) policy dated 11/22/23 {sic}, it states: Policy: Residents who are incontinent will receive appropriate treatment and services for the prevention and management of incontinence-associated dermatitis (IAD). Definition: Incontinence-associated dermatitis refers to skin damage caused by prolonged or recurrent contact with stool and/or urine. Affected skin areas involve the perineum, and may extend to involve the buttocks, hips, and sacrum. Policy Explanation and Compliance Guidelines: 1. Residents who are incontinent are at risk for developing incontinence-associated dermatitis (IAD). 2. Prolonged or recurrent contact with stool and/or urine may lead to the following: a. Overhydrated or macerated skin. b. Inflamed skin c. Fungal or bacterial skin infections d. Friction damage 3. The facility's approach to the prevention and management of IAD is two-fold: a. Reverse or manage incontinence b. Structured skin care regimen 4. Reverse or Manage Incontinence: a. The facility shall identify causes of incontinence through the comprehensive assessment and implement measures to restore continence as possible. b. A variety of absorbent products may be used to manage incontinence: underpads, pads in clothing, pull-up briefs, and traditional briefs. The product used will be in accordance with the resident's care plan, goals. and preferences. c. Indwelling or external collection devices may be utilized in complicated cases with a physician's order. Indwelling devices will be used in accordance with the facility policy for those devices (i.e. catheter, rectal tube). 5. Structured Skin Care Regimen: a. Cleansing of skin affected by incontinence: i. Cleanse routinely in accordance with plan of care, and promptly as needed upon soiling. ii. Use soft nonabrasive cloths and gentle technique. Do not scrub the skin. iii. Select a cleanser with pH that is neutral or mildly acidic that minimizes potential irritants. A no-rinse pH balanced cleanser is recommended, but mild soap and water may be used. iv. Consider the presence and severity of IAD when determining which cleansing agent or cloth to use. v. Gently dry skin after cleansing with a towel. b, Enhance moisture barrier of the resident's skin by applying moisturizer to affected skin once or twice as daily, as indicated. i. Emollients are designed to prevent dehydration and soften the skin. These are appropriate for routine use. ii. Humectants are designed to pull water into the skin and are intended for use on very dry skin. c. Protect skin from urine and stool by applying a barrier product to affected skin in accordance with plan of care (i. e. twice daily or after each incontinent episode). Examples include: i. Liquid skin sealants containing polymers ii. Dimethicone-based products iii. Petrolatum-based products iv. Combination products d. For residents with candidiasis (fungal skin infection), apply antifungal products as ordered by physician. Examples include: i. Moisture barrier containing an azole agent - this may replace routine moisture barrier product. ii. Antifungal powder - apply to skin prior to applying the routine moisture barrier product. 6. Monitoring and Modification of Interventions: a. Monitor response to interventions for managing incontinence and to skin care regimen. b. Notify physician of changes in bowel and bladder habits, including the onset or worsening of incontinence. c. Notify the physician of the presence and severity of IAD. d. Notify the physician of the presence and severity of any skin loss or presence of fungal or bacterial skin infection. e. Modify interventions as needed. Considerations for needed modifications include: i. Changes in medical condition or continence status. ii. New onset or worsening of a pressure injury in area affected by incontinence. iii. Lack of progression towards healing, iv. Resident non-compliance. v. Changes in the resident's goals and preferences. 1.) R15 admitted to facility on 03/05/14 with diagnoses that include Type 2 Diabetes, Peripheral Vascular Disease, Osteomyelitis in the left ankle and foot, and Chronic Kidney Disease Stage 2. R15 was admitted to hospice services on 04/30/22 with weights deferred, indicating the facility would not be conducting routine weighing of the resident. R15's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, suggesting that R15 as cognitively intact. The MDS further documents that R15 is an extensive assist for bed mobility, totally dependent for transferring, total dependence for toileting, and extensive assist for hygiene. The assessment also documents R15 has having an indwelling catheter, is always incontinent of bowel with no bowel toileting program. R15's weight is documented at 116 pounds. The MDS assessment documents that R15 is at risk for (PI) pressure injury development. R15's Braden Scale assessment, completed 01/05/23, showed a score of 15, which indicated at risk for pressure injury. The care plan documents: Focus: [R15's Name] has actual impairment to skin integrity of RLE (right lower extremity) r/t (related to) peripheral vascular disease, history of chronic vascular wounds, decreased mobility, wheelchair use, and diabetes mellitus Date Initiated: 08/04/2017 Revision on: 03/24/2023 Interventions include Assist resident with repositioning as needed. Resident is able to complete on own. Date Initiated: 02/07/23; Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date Initiated: 02/07/23; Compression stockings to bilateral lower legs to asset with blood flow return decreasing vascular wound risk. Date Imitated: 02/07/23; Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Date Initiated: 02/07/23; Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 02/07/23; Follow Facility protocols for treatment of injury. Date Initiated: 02/07/23; Observe/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. Date Initiated: 02/07/23; Foot cradle on bed. Date Initiated: 06/13/23; Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 02/07/23; Keep skin clean and dry. Use lotion on dry skin. House barrier cream to buttocks with peri care. Date Initiated: 02/07/23; Observe/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. Date Initiated: 02/07/23; Provide treatment as ordered. 06/07/23; The resident needs assistance to apply protective garments, Pressure relieving boots. Date Initiated: 02/07/23; The resident needs pressure relieving/reducing mattress, cushion, to protect the skin while up IN CHAIR. Date Initiated: 02/07/23; Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date Initiated: 02/07/23 Focus: [R15's Name] has potential for pressure ulcers lt (left) and rt (right heels) or potential for pressure ulcer development r/t disease process profound vascular disease of both lower extremities (BLE) Date Initiated: 08/04/2017 Revision on: 03/24/2023 Obtain and observe lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 08/10/2017; Pressure relieving boots at all times as much as [R15's Name] will allow or tolerate. Date initiated: 06/13/2023; Pressure relieving boots at all times as much as [R15's Name] will allow or tolerate. May remove for cares and therapy. Date Initiated: 07/06/2022 Revision: 02/07/2023; The resident needs a pressure reliving mattress to protect the skin while IN BED. Keep air mattress set by weight (Weight range 110-120 pounds) Date Initiated: 12/02/2022 Revision: 02/07/2023; Turn and reposition every 12 [sic] hours in bed and chair and more frequently as needed for comfort. Date Initiated: 01/25/2023 Revision: 07/26/2023; Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Date Initiated: 04/01/2021 Revision: 02/07/2023. Focus: [R15's Name] has potential for pressure ulcers lt and rt heels or potential for pressure ulcer development r/t disease process profound vascular disease of BLE Date Initiated: 08/04/2017 Revision on: 03/24/2023 Administer treatments as ordered and observe for effectiveness. Date Initiated 08/20/2017 Revision on: 02/07/2023; Assist [R15's name] to reposition and/or turn at frequent intervals to provide pressure relief. Date Initiated 01/25/2023 Revision on: 02/07/2023; Avoid positioning the resident on sacrum/coccyx. Date Initiated: 03/01/2023 Revision on: 03/01/2023; Complete a full body check weekly and document. Date Initiated: 08/10/2017 Revision on: 02/07/2023; Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: 08/10/2017 Revision on: 02/07/2023; Encourage to keep the bed as flat as possible to reduce shear. Date Initiated: 03/01/2023 Revision on: 03/01/2023; Follow facility policies/protocols for the prevention/treatment of skin breakdown/ Date Initiated: 08/10/2017 Revision on: 02/07/2023; IDT (Interdisciplinary Team) referrals as indicated, i.e. RD (Registered Dietician), PT (Physical Therapist), OT (Occupational Therapist), or other Date Initiated: 04/01/2021 Revision on: 04/21/2023; If the resident refuses treatment confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 04/01/2021 Revision on: 02/07/2023; NP/MD classify sacral wound as unavoidable. Date Initiated: 03/01/2023 Focus: {R15's Name] has actual impairment to skin integrity of right lower extremity due to peripheral vascular disease, history of chronic vascular wounds, decreased mobility, wheelchair use, and diabetes mellitus. Date Initiated: 11/06/2018 Revision: 07/23/2023 Assist resident with repositioning as needed. Resident is able to complete on own. Date Initiated: 02/07/2023; Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date Initiated: 02/07/2023 Compression stockings to bilateral lower legs to assist with blood flow return decreasing vascular wound risk. Date Initiated: 02/07/2023 Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Date Initiated: 02/07/2023 Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 02/07/2023 Follow Facility protocols for treatment of injury. Date Initiated: 02/07/2023 Foot cradle on bed. Date Initiated: 02/07/2023 Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 02/07/2023 Keep skin clean and dry. Use lotion on dry skin. House barrier cream to buttocks with peri care. Date Initiated: 02/07/2023 Observe/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. Date Initiated: 02/07/2023 Provide treatment as ordered. Date Initiated: 06/07/2023 The resident needs pressure relieving/reducing mattress, cushion, to protect the skin while up IN CHAIR. Date Initiated: 02/07/2023 Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date Initiated: 02/07/2023 On 01/05/2023, at 03:15 (3:15 AM), R15's Medical Record documents, R15 continues to be monitored for open area to coccyx, treatment in place no complaints of pain or discomfort noted this shift. On 01/05/2023, at 03:30 (3:30 AM) R15's Medical Record documents under Wound Care Follow Up, Staff notes new wound to L (left) buttock. On 01/05/2023, at 22:45 (10:45 PM), R15's Medical Record documents, R15 with new open area to sacrum. R15 was assessed today by wound team. Drsg (Dressing) c/d/i (Clean/Dry/Intact). Denies c/o (complaints of) pain or discomfort to sacral wound. Continues with c/o pain to R (right) heel. Surveyor notes that on 01/05/2023, R15's medical record documents open area to coccyx, new wound to left buttock, and open area to sacrum with no documentation of measurements and/or description of the open area, and no documentation of a change to R15's care plan to reverse or manage R15's incontinence, increase R15's check and change schedule, no assessment of R15's turning and repositioning schedule while in bed, and there is no documentation that R15's air mattress setting was reassessed to reduce pressure to the sacrum. R15's January 2023 TAR (Treatment Administration Record) documents that R15 had an order for Coccyx site, open skin, clean saline and zinc cream apply and put foam dressing daily, one time a day for wound care coccyx site. Order Date: 01/04/2023 2229 (10:29 PM) D/C Date: 01/05/2023 1403 (2:03 PM) On 07/27/23, at 10:21 AM Surveyor reviewed IQI system notes provided by the facility. The notes document Not Applicable noted for the wound stage. Not Applicable is noted for the wound stage from 01/05/23 - 02/16/23. Surveyor interviewed Corporate DON - K regarding staging noted as Not Applicable. Corporate DON - K stated, Generally that should be staged. We should have staged it. It's a stage 4 though. That's what the nurse practitioner noted. On 07/27/2023, at 11:45AM, At daily exit meeting, Surveyor requested all progress notes and NP notes related to Sacrum pressure ulcer. Wound Nurse Practitioner Notes Review On 01/12/2023, at 17:26 (5:26 PM), The Wound NP (Nurse Practitioner) - GG documents the open area as a Moisture Associated wound to Left Buttock. The wound was measured at 2.5 x 1.5 x 0.1 centimeters. 100% granular tissue. Moderate serosanguineous drainage. Peri-wound dry blanchable erythema, intact. No signs or symptoms of infection. Surveyor notes that this the documentation of R15's open area changes from the Sacrum to the Left Buttock. This assessment is completed eight days after R15 is first identified as having a new open area to the sacrum. There is no thorough investigation to identify the root cause of the moisture associated skin damage. R15 was admitted to the facility at risk for the development of pressure ulcers. R15's January 2023 TAR (Treatment Administration Record) documents cleanse wound to sacrum with NS (Normal Saline) f/b (followed by) xerofoam gauze to wound bed f/b foam dressing qd (every day) and pm (afternoon). Notify MD (Medical Doctor) of s/s (signs or symptoms) of infection every evening shift for wound care. Order Date 01/05/2023 1404 D/C (Discontinue) Date 01/12/2023 1324. Surveyor notes that there are no interventions to address sacrum care prior to this intervention. Surveyor notes that R15's January 2023 TAR documents a new intervention to cleanse wound to sacrum with NS (Normal Saline) f/b (followed by) Calcium Alginate to wound bed f/b foam dressing 3x/wk (three times per week) Notify MD (Medical Doctor) of s/s of infection every evening shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for wound care. Order Date: 01/12/23 D/C (Discontinue) Date 01/24/23. On 01/19/2023, at 03:30 (3:30 AM) Wound NP - GG progress notes document (wound) left buttock moisture associated, measuring 2.5 x 1.5 x 0.1 cm. Surveyor notes that the Wound NP documents R15's wound as a moisture associated wound to the left buttock with no documentation of a wound to the sacrum or coccyx. On 01/25/2023 an intervention was added to R15's care plan to turn and reposition every 12 [sic] hours in bed and chair and more frequently as needed for comfort. Revised on 07/26/23. On 01/26/2023, at 03:30 (3:30 AM), The wound NP progress notes document, The Wound RN (Registered Nurse) notes buttock wound has declined, plan of care was changed to medihoney and bordered foam. Full thickness wound measuring, 6 x 4.5 x UTD (Unable To Determine) cm. 10% granular, 10% epithelial, 80% slough/eschar. Moderate serosanguineous drainage. Peri-wound dry blanchable erythema, intact. No signs or symptoms of infection. Status - Decline - suspect wound declined due to prolonged pressure on there, although the original etiology of wound still Moisture Associated Skin Damage (MASD). Plan - Cleanse with wound cleanser. Apply medihoney and cover with bordered foam daily and PRN (when needed). Surveyor notes that R15 remains on air mattress with weight setting at 110-120 pounds. R15 is not weighed by facility as weights were deferred to hospice on 04/03/2022. No indication that nursing has asked hospice for a recent weight. On 02/02/2023, at 03:15 (3:15 AM), the wound NP progress notes document a wound to left buttock moisture associated, full thickness wound measuring 4.8 x 3.3 x UTD cm. 30% granular, 70% slough/eschar. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No signs or symptoms of infection. Plan - Cleanse with wound cleanser. Apply medihoney and cover with bordered foam daily and PRN (when needed). On 02/09/2023, at 03:30 (3:30 AM), the wound care follow up note documents wound as left buttock moisture associated, full thickness wound measuring 4 x 3 x UTD cm. 30% granular, 70% slough/eschar. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No signs or symptoms of infection. Status improved. Plan - Cleanse with NS. Apply medihoney and cover with foam daily and PRN. On 02/16/2023, at 03:30 (3:30 AM), the wound care follow up note documents wound as left buttock moisture associated, full thickness wound measuring 4 x 3 x UTD cm. 30% granular, 70% slough/eschar. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No signs or symptoms of infection. Status- Stable - necrotic tissues beginning to soften. Plan - Cleanse with NS. Apply medihoney and cover with foam daily and as needed. Sacral/buttock wound original etiology MASD (Moisture Associated Skin Damage), likely complicated by pressure. Likely unavoidable as all preventative measures in place. Surveyor notes that R15's care plan has no documentation of an increase in turning or repositioning or intervention to avoid positioning R15 on sacrum. Surveyor interviews with staff indicated that R15 remained on a two hour repositioning schedule with no toileting schedule. On 02/23/2023, at 03:30 (3:30 AM), R15's Wound NP progress note documents Sacrum (unstageable pressure injury). Full thickness measuring. 6.5 x 7 x 1.3 cm 100% slough. Moderate serosanguineous drainage. Peri-wound dry, blanchable, erythema, intact. No s/sx infection. Status - Decline - Likely unavoidable as all preventative measures in place due to patient's medical condition. All protective measures in place. On 03/02/2023, at 3:30 (3:30 AM), R15's Wound NP progress note documents, Sacrum (stage 4 pressure injury). Full thickness wound measuring 6.1 x 3.5 x 0.7 cm. 100% slough/eschar; able to visualize fascia at wound base. Sacral/buttock wound original etiology MASD, likely complicated by pressure. Likely unavoidable as all preventative measures in place. Status - Improved-likely unavoidable given patient's medical condition. All protective measures in place. Surveyor notes that R15's open area to coccyx, that was initially documented as moisture associated skin damage, has declined to stage 4 pressure injury to sacrum. Surveyor notes that R15's air mattress is not reassessed at this time and remains at 110-120 pounds setting. On 03/09/2023, at 3:30 (3:30 AM), R15's Wound NP progress note documents, Sacrum (stage 4 pressure injury). Full thickness wound measuring 7 x 3.2 x 1.4cm. 100% slough/eschar; able to visualize fascia at wound base. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No s/sx infection. Status-Stable-likely unavoidable given patient's medical condition. All protective measures in place. Plan-Cleanse with NS. Gently pack with Dakin moistened kerlix and cover with bordered foam BID and PRN. On 03/16/2023, at 4:30 (4:30 AM), R15's Wound NP progress notes document Sacrum (stage 4 pressure injury). Full thickness wound measuring 8 x 5 x 2.1 cm. 80 slough/eschar, 20% granular tissue; Small area of palpable bone at proximal aspect of wound. Moderate serosanguinous drainage. Peri-wound dry, blanchable erythema, intact. No s/sx infection. Status - Decline - likely unavoidable given patient's medical condition. All protective measures in place. On 03/16/2023, R15's medical record documents R15 having, Copious amounts of liquid stool. Surveyor notes that R15's bowel incontinence care plan is not updated with any further interventions at this time. Through staff interview, Surveyor is informed that R15 was a check and change and remains a check and change. On 03/23/2023, at 4:30 (4:30 AM), R15's Wound NP progress notes document Sacrum (stage 4 pressure injury. Full thickness wound measuring 8 x 4.5 x 1.8 cm. 20% slough/eschar, 80%granular tissue; Small area of palpable bone at proximal aspect of wound. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No s/sx infection. Status - Improved - likely unavoidable given patient's medical condition. All protective measures in place. On 03/30/2023, at 04:30 (4:30 AM), R15's Wound NP progress notes document Sacrum (stage 4 pressure injury). Full thickness wound measuring 7.4 x 4.2 x 1.1 cm. Undermining from 7:00 to 4:00 - 2.3 cm at 11:00. 40% slough/eschar, 60% granular tissue; Small area of palpable bone at proximal aspect of wound. Moderate serosanguineous drainage. Peri-wound dry, blanchable, erythema intact. No s/sx infection. Status - Improved - likely unavoidable given patient's medical condition. All protective measures in place. Plan - cleanse with NS. Gently pack Dakin's moistened kerlix and cover with bordered foam BID (twice per day) and PRN. On 04/06/2023, at 05:15 (5:15 AM), R15's Wound NP progress notes document Sacrum (stage 4 pressure injury). Full thickness wound measuring 6.5 x 4.0 x 0.4 cm. Undermining 9-12, ~2.5 cm at 12. 100% granular tissue; Small area of palpable bone at proximal aspect of wound. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No s/sx infection. Status - Improved - likely unavoidable given patient's medical condition. All protective measures in place. Plan - cleanse with NS. Apply collagen powder, silver alginate, and BF (bordered foam) daily and PRN. On 04/13/2023, at 13:21 (1:21 PM), R15's Wound NP progress notes document Sacrum (stage 4 pressure injury). Full thickness wound measuring 7.2 x 4.5 x 0.6 cm. Undermining from 9-12, ~18 cm at 12. 80% granular tissue, 20% slough: Small area palpable bone at proximal aspect of wound. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No s/sx infection. Status - Stable - likely unavoidable given patient's medical condition. Plan - cleanse with NS. Apply collagen, hydrofera blue, and BF 3x per week and PRN. R15's Care Area Assessment, completed, 04/18/23, documents R15 requires a full body lift for transfers but rarely wants to get out of bed. Resident has a suprapubic catheter in place for urination and is always incontinent of bowel. No recent falls. No psychotropic medication use. R15 has a Stage 4 to the sacrum and a R heel that is unstageable per the Nurse Practitioner (NP) notes. Treatments are in place. R15 reports frequent pain that affects sleep as well as day to day activities and R15 rates the pain as an 8 of 10 in the past 5 days. R15 takes norco and has morphine available which was taken once during the look back period. On 04/20/2023, at 13:50 (1:50 PM), R15's Wound NP progress notes document Sacrum (stage 4 pressure injury). Full thickness wound measuring 7.2 x 4.5 x 0.4 cm. Undermining from 9-12, ~ 2.4 cm at 12. 80% granular tissue, 20% slough; Small area of palpable bone at proximal aspect of wound. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No s/sx infection. Status - Stable - likely unavoidable given patient's medical condition. Plan - cleanse with NS. Apply collagen, hydrofera blue, and BF 3x per week and PRN. On 04/27/2023, at 13:44 (1:44 PM), R15's Wound NP progress notes document Sacrum (stage 4 pressure injury). Full thickness wound measuring 7.3 x 5.0 x 0.4 cm. Undermining from 9-12, ~ 2.4 cm at 12. 100% granular tissue, 20% slough; Small area of palpable bone at proximal aspect of wound. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No s/sx infection. Status - Stable - likely unavoidable given patient's medical condition. Plan - cleanse with NS. Apply collagen, hydrofera blue, and BF 3x per week and PRN. On 05/04/2023, at 07:00 (7:00 AM), R15's Wound NP progress notes document Sacrum (stage 4 pressure injury). Full thickness wound measuring 8.0 x 5.5 x 0.4 cm. Undermining resolved. 100% granular tissue; Small area of palpable bone at proximal aspect of wound. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No s/sx infection. Status - Stable - likely unavoidable given patient's medical condition. Plan - cleanse with NS. Apply collagen wafer, hydrofera blue, and BF 3x per week and PRN. Surveyor notes that undermining has resolved as of 05/04/2023. On 05/10/2023, at 05:15 (5:15 AM), R15's Wound NP progress notes document Sacrum (stage 4 pressure injury). Full thickness wound measuring 7.2 x 4.5 x 0.4 cm. Undermining resolved. 10% DTI (Deep Tissue Injury), 80% granular tissue. Bone is covered by viable tissue but there is no visible tendon sheath in the middle of the wound. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No s/sx infection. Status - Decline - wound is likely to decline given patient's medical condition. All protective measures are in place. Plan - cleanse with NS. Apply collagen wafer, hydrofera blue, and BF 3x per week and PRN. On 05/18/2023, at 09:10 (9:10 AM), R15's Wound NP progress notes document in part: Sacrum (stage 4 pressure injury). Full thickness wound measuring 6.9 x 5.3 x 0.5 cm. Undermining from 10-2 o'clock, deepest at 11 o' clock ~3.3 cm. 20% slough, 80% granular tissue; Bone is covered by viable tissue but there is no visible tendon sheath in the middle of the wound. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No s/sx infection. Surveyor notes R15's wound declines again and undermining has returned. On 05/25/2023, at 05:30 (5:30 AM), R15's Wound NP progress notes document in part: Sacrum (stage 4 pressure injury). Full thickness wound measuring 7.2 x 4.5 x 0.5 cm. Undermining from 6-12 o'clock, deepest at 12 o'clock ~1.5 cm. 100% granular tissue; Bone is covered by viable tissue. Moderate serosanguineous drainage. Peri-wound dry, blanchable erythema, intact. No s/sx

Based on observation, interview and record review the facility did not ensure 5 (R106, R24, R83, R206 & R103) of 11 residents reviewed were kept free from accidents and hazards. * On [DATE], R106 was provided incontinence care with improper technique by a Certified Nursing Assistant leading to a fall with cervical spine fracture, broken rib and scalp laceration. R106 returned to the facility on [DATE]. On [DATE], R106 expired at the facility. The medical examiner's office ruled R106's cause of death was due to injuries R106 sustained from their fall from bed on [DATE]. *On [DATE] R24, who is severely cognitively impaired and lives on the dementia unit, eloped from the facility and was found by an employee lying in a large pothole in the facility's parking lot with their wheelchair tipped over. R24 was subsequently hospitalized and sustained a cervical spine fracture from the fall in the facility's parking lot on [DATE]. The facility did not conduct a thorough investigation related to R24's elopement, including how R24 was able to leave the dementia unit. The facility's failure to use proper technique when caring for R106 and the failure to ensure that R24 was properly supervised created a finding of immediate jeopardy. The Immediate Jeopardy began on [DATE]. NHA (Nursing Home Administrator)-A was notified of the Immediate Jeopardy on [DATE] at 3:15 PM. The Immediate Jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan and as evidenced by the following examples. *R83 was observed throughout the survey without multiple fall interventions in place. R83 sustained multiple falls which the facility did not thoroughly investigate *R206 sustained multiple falls and a thorough investigation was not completed to determine the root cause of the falls and fall prevention interventions to address the root cause were not identified and implemented. *R103 sustained a fall that resulted in a fractured wrist. Post fall, R103 was assessed by an Licensed Practical Nurse (LPN) with no RN assessment. The LPN determined there was no injury. R103 continued to experience wrist pain and was found to have a fractured wrist. Findings include: According to MedlinePlus.gov, The following steps should be followed when turning a patient: If you can, raise the bed to a level that reduces back strain for you. Make the bed flat. Get as close to the person as you can. You may need to put a knee on the bed to get close enough to the patient. Place one of your hands on the patient's shoulder and your other hand on the hip. Standing with one foot ahead of the other, shift your weight to your front foot (or knee if you put your knee on the bed) as you gently pull the patient's shoulder toward you. Then shift your weight to your back foot as you gently pull the person's hip toward you. (Emphasis added.) https://medlineplus.gov/ency/patientinstructions/000426.htm 1.) R106 was admitted to the facility on [DATE] with diagnoses of Pneumonia, Left sided weakness related to Cerebral Vascular Accident, Legal blindness and hearing loss. R106's admission MDS (Minimum Data Set) with ARD (Assessment Reference Date) of [DATE] indicated R106 required extensive assist with of 1 staff member with bed mobility at the time of admission. Surveyor reviewed R106's closed medical record including care, therapy notes and fall investigation. R106's care plan with an initiation date of [DATE] and revision date of [DATE] reads, This resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) recent CVA (Cerebral Vascular Accident) w/ (with) L (left) sided hemiparesis and weakness. Cervical Fracture. Rib Fracture. A care plan intervention initiated on [DATE] includes use of bilateral hearing aids to be worn during cares. On [DATE], at 9:32 AM, Surveyor reviewed R106's physical therapy evaluation dated [DATE] which reads minimal assist with rolling-required 1 person, pelvis, upper body, legs. A physical therapy note dated [DATE] which indicates R106's baseline requires minimal assist for rolling in bed. R106's medical record documents, on [DATE] on NOC (night) shift R106 was in bed without their bilateral hearing aids in. CNA (Certified Nursing Assistant)-NN was assisting resident with incontinence care in bed. R106 was rolled away from the CNA-NN at this time. R106 slid off of their alternating air mattress at this time and fell directly onto the floor on their right side. CNA-NN called LPN (Licensed Practical Nurse)-OO for help at this time. Per statements and facility's fall incident report, a large amount of bleeding was noted from a laceration on R106's head. R106 complained of severe neck pain at this time. No RN assessment was conducted at this time. Director of Nursing (DON)-B was notified of R106's fall from bed and directed facility staff to call 911. The facility determined that R106's inflatable air mattress was the root cause of their fall. R106 returned to the facility on [DATE] with displaced cervical spine fracture, right rib fracture and scalp laceration which required sutures. CNA-NN is no longer employed by the facility and was unavailable for interview. LPN-OO was unavailable for interview. According to a statement obtained on [DATE] by the facility from CNA-NN, As I was providing care, resident asked me if I needed [resident] to rollover more and I told [resident] no, I was doing OK. Patient proceeded to roll over and I noted that [resident] was sliding off the bed. I started to scream for help and tried to hold onto [resident] but I couldn't and [resident] fell . Note that R106 rolled in the direction that CNA-NN had rolled R106 and that because R106 did not have their hearing aids in, it was more likely that R106 did not hear CNA-NN's response. On [DATE], at 3:40 PM, Surveyor conducted interview with CNA-KK. Surveyor asked CNA-KK whether you should roll a resident away from you or towards you when providing incontinence care. CNA-KK responded that they would check if a resident is a 1 or a 2 assist first for bed mobility. CNA-KK continued that if a resident is a 1 assist with bed mobility, they would make sure to position them properly in bed so they are not next to the opposite edge and roll the resident towards themselves and not away to the opposite side. On [DATE] the facility initiated fall interventions including a low bed, extensive assistance of 2 staff for bed mobility and a bolstered mattress for safety. R106 was readmitted to the facility on [DATE] with a code status of DNR (Do Not Resituate). On [DATE] at approximately 8:30 AM, Staff noted R106 pulseless and not breathing. DON-B was notified and confirmed that resident was pulseless and apneic. The facility contacted the doctor and the resident's representative. The facility's DON notified the medical examiner office of resident's passing. On [DATE], Surveyor requested R106's medical examiner report. R106's report dated [DATE] reads: Immediate Cause of Death: Complications of Cervical Spine Fracture, Due To: Recent stroke; History of pulmonary embolism; Atrial Fibrillation; Hypertension; Congestive Heart Failure, Final Manner of Death: Accident, How Injury Occurred: Rolled out of bed onto floor. On [DATE] at 11:00 AM, Surveyors conducted interview with DON (Director of Nursing)-B. Surveyor asked DON-B of their involvement with R106's fall on [DATE]. DON-B told Surveyor that R106 was sent out 911 per their request due to R106 bleeding from the head. Surveyor inquired as to if there had been any follow up with the medical examiner's office as to R106's cause of death. DON-B said they had not had further contact with the medical examiner's office after reporting R106's death due to their fracture. Surveyors notified DON-B of the serious concerns related R106 being rolled off the bed by CNA-NN during toileting while not wearing hearing aids per care plan, R106 sustaining a cervical spine fracture, right rib fracture, scalp laceration and death at the facility on [DATE] as a result of injuries from the fall at the facility on [DATE]. No further information was provided at this time by the facility. Staff failure to roll R106 towards them rather than away from them, especially on an air mattress, and staff failure to ensure R106 had hearing aids in place during cares to assist with communication during cares created a reasonable likelihood for serious harm. 2.) R24 was admitted to the facility [DATE] with a diagnosis of Vascular Dementia. R24's Quarterly MDS with an ARD of [DATE] indicates R24 requires extensive assistance of 1 staff with transfers and locomotion. R24 is unsteady on their feet and requires staff assistance to maintain their balance. R24 has a BIMS (Brief Interview for Mental Status) score of 6, which indicates significant cognitive impairment for daily decision making. On [DATE], a fall risk assessment indicated resident was a low risk for falls. On [DATE] a quarterly elopement assessment was conducted by the facility indicating that the resident was low risk for elopement. R24 resides on the facility's dementia unit which is not a locked unit. There is a set of heavy doors to the unit, which will alarm if someone with a Wanderguard bracelet attempts to leave the unit. R24 did not have a Wanderguard bracelet because R24 was assessed as being at low risk for elopement. Unless the doors to the unit were propped open, as was observed at times during survey, It would be difficult for residents to leave the unit because the doors are heavy. It would be especially difficult for someone who is smaller and in a wheelchair, like R24, to open the doors by self and leave the unit. On [DATE] at 8:54 AM, Surveyor observed R24 in the unit dining room sitting in their wheelchair. R24 was noted with extensive bruising to their face and was wearing a hard cervical collar. Surveyor requested any self-reports or fall investigations for R24. Surveyor reviewed a fall investigation dated [DATE]. On [DATE] at approximately 6:10 AM, Head of Maintenance-E was outside in the facility parking lot making repairs to a sign on the facility's grounds. Head of Maintenance-E heard a scream and began looking around the facility's parking lot. Head of Maintenance-E found R24 on the ground in the facility parking lot. R24 was subsequently hospitalized after the fall and sustained a cervical spine fracture requiring a neck brace. On [DATE] at 10:00 AM, Surveyor conducted interview with Head of Maintenance-E. Surveyor asked Head of Maintenance-E to tour the facility's parking lot. Head of Maintenance-E showed Surveyor where they had found R24 on [DATE]. A large pothole was noted near the end of the facility's driveway with large crumbling pieces of asphalt. Head of Maintenance-E told Surveyor that they had found R24 lying on the ground with their wheelchair tipped over. Head of Maintenance-E had asked R24 what they were trying to do. R24 told Head of Maintenance-E I want to go home. Head of Maintenance-E told Surveyor that they did not want to leave R24 alone outside because they had already fallen and was afraid that they could get hit by a car in the parking lot. Head of Maintenance-E attempted to call the facility's main number multiple times and there was not any staff picking up the telephone. Head of Maintenance-E told Surveyor that they didn't know what to do next so they proceeded to pick R24 off of the ground and transfer them into their wheelchair. Surveyor asked Head of Maintenance-E if they had ever had training to transfer residents or worked in the capacity of a CNA (certified nursing assistant). Head of Maintenance-E told Surveyor that they had never been trained on how to transfer residents. Head of Maintenance-E added that they probably shouldn't have moved R24 at this time, but they were scared to leave them alone and didn't know what else they could do at the time. Head of Maintenance-E then brought R24 inside the facility to the dementia unit's nursing station. Nursing staff called 911 at this time and R24 was taken to the hospital. Surveyor asked Head of Maintenance-E if they had reported the condition of the facility's parking lot to any other staff members. Head of Maintenance-E told Surveyor that they have been requesting repairs to the parking lot for years and nothing ever seems to happen. Head of Maintenance-E showed Surveyor copies of requisition forms with quotes from [DATE] from an asphalt company at this time. Surveyor asked Head of Maintenance-E if the facility's main entrance is ever locked. Head of Maintenance-E told Surveyor that after hours you would need a code to get into the facility's main entrance but to leave the facility's main entrance, the door will open automatically any time of the day. Head of Maintenance-E told Surveyor the maintenance department had received training not to transfer or move residents sometime after R24's fall but they couldn't remember the exact date. Surveyor notes R24's fall occurred in the facility parking lot near the entrance to the facility grounds from the street. The facility is located on [NAME] Road, which is Business Highway 36, which is a highly trafficked 4 lane highway with a speed limit of 40 miles per hour. On [DATE], at 3:40 PM, Surveyor conducted interview with CNA-KK. CNA-KK worked NOC (night) shift on [DATE] on the facility's dementia unit. Surveyor asked CNA-KK if they recalled assisting R24 on [DATE]. CNA-KK told Surveyor that on [DATE] at approximately 5:30 AM, R24 was toileted, dressed and assisted into their wheelchair by CNA-KK. CNA-KK told Surveyor it was not unusual for R24 to get up at this time of day and that they had last seen R24 at this time in the doorway of R24's room in their wheelchair. CNA-KK told Surveyor they continued with finishing their night shift rounds at this time. Approximately 30 minutes later, CNA-KK was taking dirty linen to the laundry when they were notified by facility's Director of Nursing (DON)-B that R24 had been found outside on the ground. Surveyor asked CNA-KK if R24 was allowed to be outside the facility without staff supervision. CNA-KK told Surveyor that there was no way that R24 should ever be alone outside and that they are still not sure how R24 got all the way to the front of the facility without anyone noticing. On [DATE], at 1:15 PM, Surveyor conducted interview with CNA-LL. Surveyor asked CNA-LL if they recalled assisting R24 on [DATE]. CNA-LL told Surveyor at approximately 5:40 AM they saw R24 self-propelling their wheelchair near the nursing station which neighbors the dementia unit. CNA-LL told Surveyor that R24 was telling CNA-LL about how they had an appointment to go to this morning and that CNA-LL wished the resident a good day. CNA-LL told Surveyor at this time that they had confused R24 with another resident from a different unit at the facility who was alert and oriented. CNA-LL does not frequently work on the facility's dementia unit and did not recognize R24 at this time as they had never seen R24 out of bed. CNA-LL told Surveyor that had they had known the resident they were speaking to was R24 that they would have notified a staff member on the dementia unit that R24 was off of the dementia unit wandering. Surveyor asked CNA-LL if R24 should have been outside of the facility without staff supervision. CNA-LL told Surveyor that they do not believe R24 should have been allowed outside the facility without staff supervision because of their dementia. On [DATE], at 4:12 PM, Surveyor conducted interview with Licensed Practical Nurse (LPN)-MM. Surveyor asked LPN-MM if they recall seeing R24 on [DATE]. LPN-MM told Surveyor that they do not usually have too much interaction with R24 on NOC shift because they do not receive medications on NOC shift. Surveyor asked LPN-MM if it was unusual for R24 to be up that early in the morning. LPN-MM responded that they didn't think it was odd that R24 was out of bed. LPN-MM remembered R24 sitting by the nursing station on [DATE] speaking to CNA-LL but did not recall whether or not R24 was on the dementia unit at this time or outside of the dementia unit's doors. LPN-MM left the nurses station at this time to find the oncoming day shift nurse to conduct shift change reporting. Surveyor asked LPN-MM if R24, a resident with dementia, should have been allowed outside the facility without staff supervision. LPN-MM responded, I don't think it would be a good idea for someone with dementia to be outside alone. On [DATE], at 9:40 AM, Surveyor conducted interview with LPN Unit Manager-M. LPN Unit Manager-M told Surveyor that they were not involved with R24's fall on [DATE] as DON-B is usually the staff person who follows up on major falls and incidents. Surveyor asked if there should be statements from all staff members on duty at the time of a resident's fall. LPN Unit Manager-M responded Ideally, yes. Surveyor asked LPN Unit Manager-M if R24 or any resident with a diagnosis of dementia should be allowed outside the facility without staff supervision. LPN Unit Manager-M responded they were not sure what all the circumstances were but now R24 has a Wanderguard and is not able to get around very easily since their fall with cervical spine fracture. On [DATE], at 11:00 AM, Surveyors conducted interview with DON-B. Surveyor asked how often elopement assessments are conducted. DON-B responded that elopement assessments are conducted quarterly and as needed if staff notice residents being exit seeking. DON-B told surveyor that R24 likes to be outside when the weather is good. DON-B added that R24 was outside around 6:00 AM in the morning on [DATE] and that they were probably hoping to get some sun. DON-B told Surveyor that R24 was never exit seeking and that their intent was never to leave the facility. Surveyor asked DON-B if residents with dementia should be allowed to go outside without staff supervision. No further information was shared at this time. Surveyor reviewed R24's care plan. Surveyor did not note any care plan to address R24 being allowed outside facility independently. Surveyor reviewed facility's investigation of R24's fall with major injury. Surveyor noted a thorough investigation including statements from all working staff including where and when staff had last seen R24 previous to their fall, how R24 had been able to leave the unit, and if the unit's doors had been propped open at the time R24 was observed on another unit was not completed. On [DATE] at 12:30 PM, NHA (Nursing Home Administrator)-A and DON-B were informed of serious concerns related to R24's lack of staff supervision on [DATE] which resulted in R24 leaving the facility where they sustained a fall in the facility's parking lot. R24 was moved without an RN assessment by unlicensed staff and hospitalized with a cervical spine fracture. Surveyor shared concerns of a lack of thorough investigation related to R24's elopement and fall with severe injury including a cervical spine injury, root cause analysis and complete staff statements. No additional information was provided at this time. Staff failure to ensure R24 could not leave the dementia unit unsupervised, staff failure to recognize that a resident from the dementia unit was off the unit, and staff failure to thoroughly investigate the circumstances that allowed R24 to exit the building unnoticed created a reasonable likelihood for serious harm. Surveyor noted CNA-NN received training on [DATE] related to proper bed mobility for residents. Training materials read Repositioning in Bed. Description: this checklist identifies the steps needed to properly position a person in bed. It also provides rationale to explain why these steps are performed. Referenced and adapted from: [NAME]. (2019). [NAME] nursing procedures (8th ed.). Author. [NAME], R. (2018). Safe patient handling, transfer, and positioning. In A. G. [NAME], P. A. [NAME], & W. R. [NAME] (Eds.), Clinical skills & nursing techniques (9th ed.). Elsevier. A check off list was provided for CNA-NN which includes following .Central Placement: Description: position the person in the center of the bed away from the edges. Use the drawsheet when positioning and use at least 2 caregivers who demonstrate proper ergonomics and techniques. Rationale: prevents falling out of bed . Facility completed the checklist with CNA-NN. Surveyor did not see evidence of any further in-services for additional staff related to R106's fall. The immediate jeopardy was removed on [DATE] when the facility implemented the following: *All other residents that have the potential for falls and other safety concerns were assessed and care plans reviewed. *All other residents who have the potential to leave out the doors were assessed. *Wander books were updated. *Staff were educated on: -Residents at Risk to Wander -Communication and Resident Impairment -Kardex and Falls -Root Cause Analysis -Completing Witness Statements *Director of Nursing/designee ensured the safety measures and resident specific interventions were added to care plans and care kardexes. *Quotes obtained to repair outdoor spaces. Repairs to to be completed. *Skills fair completed to ensure staff are competent in performing job duties related to bed mobility, skin and communication. *Facility reviewed the following policies: -Change in Condition -Fall Prevention Program -MD (medical doctor) Notification -RN assessments -Elopement and Wandering Residents -Accidents and Supervision *Witness statements form was revised to include additional details, including root cause analysis. *24 hour condition report was reviewed and revised. Additional information added was changed in condition. *New admission chart review will be conducted within 24 hours. These audits will be completed on new admissions to ensure fall risk assessments are completed. Audits will be reviewed daily by the IDT (Interdisciplinary Team) stand up and stand down meetings. *Outdoor environmental safety sweep will be conducted 3 times per week for one month, weekly for one month and then monthly for 6 months. *All falls will continued to be reviewed at daily stand up/stand down meeting with IDT meeting for proper interventions. *The Facility Assessment was reviewed and updated. *Audits will be brought to QAPI (Quality Assurance and Performance Improvement) for review and advisement of continuation. 20483 3.) R83's diagnoses includes diabetes mellitus, aphasia, cerebrovascular disease, and hypertension. The at risk for falls care plan initiated [DATE] & revised [DATE] documents the following interventions: * 42 inch bed keep needed items within reach ask resident what to place in reach. Initiated [DATE] & revised [DATE]. * Floor matt. Initiated [DATE] & revised [DATE]. * Low bed position. Initiated [DATE] & revised [DATE]. * Med review and [name] consult [DATE] MD (medical doctor) ordered labs. Initiated [DATE] & revised [DATE]. * Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Initiated [DATE]. * Body pillow to right side when in bed to define bed parameters. Initiated [DATE] & revised [DATE]. * Bolstered Mattress. Frequent checks and incontinent care. Initiated & revised [DATE]. * Continue current fall interventions. Initiated [DATE] & revised [DATE]. * Dycem to wc (wheel chair) at all times. Initiated [DATE] & revised [DATE]. * Early get up: Resident to be up in day room by 7 B/4 (before) breakfast, for social stimulation. Initiated [DATE] & revised [DATE]. * I am non ambulatory and forget I can't walk and try to get up anyway due to my poor memory. Initiated [DATE] & revised [DATE]. * If resident awake offer to get up between ,d+[DATE] am. Initiated & revised [DATE]. * Keep bed at a 45 degree incline or less. Initiated [DATE]. * Keep in dayroom when awake to reduce fall risk especially when noted to be restless in bed. Initiated [DATE] & revised [DATE]. * Med review. Sleep assessment. Initiated [DATE]. * Offer to lay resident down after meals. Initiated [DATE] & revised [DATE]. * Pain assessment and medication review. Initiated [DATE]. * PT (physical therapy) evaluate and treat as ordered or PRN (as needed). New chair. Initiated [DATE] & revised [DATE]. * Rearrange bed. Initiated [DATE]. * Replace mattress to bed. Initiated [DATE]. * Staff to make frequent checks to ensure body pillow is positioned properly on NOCs (nights). Initiated [DATE] & revised [DATE]. * Up for all meals. Initiated [DATE]. The nurses note dated [DATE] at 11:45 p.m. documents Resident found on floor on mat in room, trying to pick-up something from floor. ROM WNL (range of motion within normal limits) Neuro check is negative. No bleeding. No pain. VSS (vital signs stable). MD (medical doctor) aware. VA (Veterans Administration) aware. Son aware. DON (Director of Nursing) aware. On [DATE] at 1:04 p.m. during the end of the day meeting with Nursing Home Administrator-A and DON-B Surveyor requested R83's fall investigations. On [DATE] at 8:52 a.m. Surveyor reviewed the [DATE] fall investigation provided by the Facility which included an incident report dated [DATE], head to toe skin check dated [DATE], pain evaluation [DATE], head to toe skin check dated [DATE], post fall assessment dated [DATE], and follow up 72 hours post fall dated [DATE]. The incident report dated [DATE] at 00:44 (12:44 a.m.) under the section incident description for nursing description documents Resident found on mat on floor in room trying to pick up something on floor. No injuries. ROM WNL (range of motion within normal limits). No bleeding. No pain. For resident description documents What are you looking at? Surveyor noted there are no staff statements or any indication staff was spoken to regarding R83's fall and the investigation didn't indicate whether prior fall prevention interventions other than the fall mat were in place. On [DATE] at 11:05 a.m. Surveyor reviewed the additional information provided to Surveyor for R83's fall on [DATE]. Surveyor noted this is the same information as previous provided with the exception of neuro checks and a witness statement fall for incident date [DATE] with the date of interview as [DATE] and signed by Certified Nursing Assistant (CNA)-CC on [DATE]. Surveyor noted the Facility did not conduct a thorough investigation to help prevent further falls as there were no staff interviewed at the time R83 fall on [DATE] and there is no evidence the Facility investigated whether prior interventions other than the fall mat were in place. The fall risk assessment dated [DATE] has a score of 12 which indicates moderate risk. The quarterly MDS (minimum data set) with an assessment reference date of [DATE] has a BIMS (brief interview mental status) score of 3 which indicates severe impairment. R83 is assessed as requiring extensive assistance with bed mobility & toilet use, dependent with two plus person physical assist for transfer, and does not ambulate. R83 has fallen since the prior assessment with two or more falls with no injury. The fall risk assessment dated [DATE] has a score of 14 which indicates moderate risk. The CNA (Certified Nursing Assistant) Kardex as of [DATE] under the safety section documents * 42 inch bed keep needed items within reach ask resident what to place in reach. * Floor matt. * Low bed position. * Med review and [name] consult [DATE]. MD (medical doctor) ordered labs. * Body pillow to right side when in bed to define bed parameters. * Bolstered Mattress. Frequent checks and incontinent cares. * Continue current fall interventions. * Dycem to w/c (wheel chair) cushion at all times. * Early get up: Resident to be up in day room by 7 B/4 (before) breakfast for social stimulation. * Encourage the resident to use bell to call for assistance. * If resident awake offer to get up between ,d+[DATE] am. * Keep bed at a 45 degree incline or less. * Keep bed away from wall. * Keep in dayroom when awake to reduce fall risk especially when noted to be restless in bed. * Offer to lay resident down after meals. * Rearrange bed. * Replace mattress to bed. * Staff to make frequent checks to ensure body pillow is positioned properly on NOCs (nights). * Up for all meals. On [DATE] at 10:51 a.m. Surveyor observed LPN/UM (Licensed Practical Nurse)-M speaking with R83 who is in bed on his back. LPN/UM-M lowered the height of R83's bed down as the bed was not at the lowest position. Surveyor observed the bed is near the wall on the right side and on the floor on the left side there is a floor mat. Surveyor observed there is not a body pillow on the right side nor is there a body pillow on the left side. On [DATE] at 11:26 a.m. Surveyor observed R83 sleeping in bed on his back. Surveyor observed there is not a body pillow along the right side of R83's bed. On [DATE] at 11:48 a.m. Surveyor entered R83's room with CNA-W and CNA-AA. CNA-W & CNA-AA placed gloves on, CNA-W raised the height of the bed up and CNA-AA removed the floor mat. At 11:53 a.m. CNA-X entered R83's asking CNA-W & CNA-AA if they needed help. Surveyor noted CNA-X placed gloves on and CNA-AA removed her gloves and left R83's room. At 11:54 a.m. IP (Infection Preventionist)-D entered R83's room. Surveyor observed incontinence cares for R83 until 12:03 p.m. Surveyor noted at 12:06 p.m. after staff involved in R83's cares left R83's room the floor mat was not placed on the left side of the floor and a body pillow was not placed. On [DATE] at 12:07 p.m. Surveyor observed IP-D enter R83's with R83's lunch tray. IP-D raised the height and head of the bed up in a high position, which Surveyor noted to be greater than 60 degrees and began feeding R83. On [DATE] at 1:19 p.m. Surveyor observed R83 in bed on his back with the head of the bed elevated high which Surveyor noted to be greater than 45 degrees. Surveyor observed there is still not a floor mat on the left side and there is no body pillow on R83's bed. On [DATE] at 1:21 p.m. Surveyor observed LPN (Licensed Practical Nurse)-Y enter R83's room with treatment supplies. On [DATE] at 1:32 p.m. Surveyor observed LPN-Y enter R83's room with a straw. On [DATE] at 1:33 p.m. Surveyor observed R83 in bed on his back with the head of the bed up high, greater than the 45 degrees as indicated on the falls care plan. Surveyor observed there is still not a floor mat on the left side and there is no body pillow on R83's bed. On [DATE] at 1:47 p.m. Surveyor observed R83 in bed on his back with the head of the bed up high, greater than the 45 degrees as indicated on the falls care plan. Surveyor observed there is still not a floor mat on the left side and there is no body pillow on R83's bed. On [DATE] at 3:44 p.m. Surveyor observed R83 continues to be in bed on his back. Surveyor observed the head of the bed is now at a 45 degree angle and there is a floor mat on the left side of R83's bed. Surveyor observed there is still not a body pillow on R83's bed. On [DATE] at 7:13 a.m. Surveyor observed R83 in bed on his back with the head of the bed slightly elevated. Surveyor observed there is a floor mat on the left side of R83's bed. The call light is hanging down on the left side of R83's bed frame and is not within R83's reach. There is not a body pillow on the bed according to R83's fall care plan. On [DATE] at 7:19 a.m. Surveyor spoke with CNA-Z who has R83 on her assignment. Surveyor asked CNA-Z if R83 would be getting up today. CNA-Z informed Surveyor she had went in R83's room [NAME] [TRUNCATED]

Based on interview and record review the facility did not ensure adequate hydration for 1 (R108) of 1 resident reviewed for hydration. *R108 became dehydrated and needed to receive Intravenous (IV) rehydration. The facility did not implement interventions to prevent dehydration from occurring again, and R108 had to be sent to the hospital for IV insertion to receive IV fluids a second time. Findings include: The facility policy entitled, Hydration, dated 10/12/2022 documented, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health . 1. The facility will utilize a systemic approach to optimize the resident's hydration a. Identifying and assessing each resident's hydration status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary 2. Identification/assessment: a. Nursing staff shall assess hydration status upon admission and throughout the resident's stay in accordance with assessment protocols. b The dietary manager or designee shall obtain the resident's beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay. c. The dietitian will assess hydration as part of the comprehensive nutritional 72 hours of admission, annually, and upon significant change in condition assessment will be completed as needed. 3. Evaluation/analysis: a. The assessment shall clarify the resident's current hydration status and individual risk factors for dehydration or fluid imbalance. b. The dietician shall use data gathered form the nutritional assessment to the resident's fluid needs and whether intake is adequate to meet those needs . R108 was admitted to the facility on [DATE] and had diagnoses including fracture of right lower leg, reduced mobility, cognitive communication deficit, and need for assistance with personal care. R108 discharged from the facility on 03/23/23. R108's quarterly Minimum Data Set (MDS) Assessment, dated 3/18/23, documented R108 had a Brief Interview for Mental Status score of 13, indicating R108 is cognitively intact; R108 required extensive assistance of one staff member for transfers, toileting, dressing and locomotion on the unit and one staff assist with set up help only for eating. Surveyor reviewed R108's Electronic Medical Record (EMR) and noted on 01/03/23 the Nurse Practitioner, (NP)-V documented in a progress note: .Increase fluids and oral hydration. Continue to monitor labs . Surveyor noted on 1/6/23 and 1/11/23 NP-V continued to document in progress notes, . Increase fluids and oral hydration. Continue to monitor labs ., in progress notes. On 1/13/23, NP-V documented, .Ordered CBC (Complete Blood Count) and BMP (Basic Metabolic Panel) as patient has been feeling fatigued and has loss of appetite, will start IV (Intravenous) fluids based on labs . Surveyor noted the following physician's order, dated 1/13/23 and discontinued on 1/14/23, in R108's EMR, Sodium Chloride Solution 0.45 %, 1 liter intravenously . Surveyor noted there were no updates to R108's care plan after the need for IV fluids on 01/13/23. Surveyor continued to review R108's EMR and noted the following documentation: On 01/18/23, NP-V documented, .Increase fluids and oral hydration . On 01/20/23, NP-V documented .Increase fluids and oral hydration .Patient states [they] is not drinking water, discussed with patient in regards to increasing oral fluids. Patient was agreeable . On 01/25/23, a physician documented, .Increase fluids and oral hydration .Patient states [they] is not drinking water, discussed with patient in regards to increasing oral fluids. Patient was agreeable . On 01/28/23, NP-V documented, .Increase fluids and oral hydration .Patient states [they] is not drinking water, discussed with patient in regards to increasing oral fluids. Patient was agreeable . On 02/03/23, NP-V documented, .Increase fluids and oral hydration .patient states [they] are not drinking water discussed with patient in regards to increasing oral fluids. Patient was agreeable . On 02/05/2023, a nurse documented, F/U (follow up) fall NOC (night shift) 2/4, hypotensive AM (morning) BP (blood pressure) meds held, PO (by mouth) fluids encouraged, neuro check negative, ROM (range of motion) per baseline, denied pain when asked, on call NP [name of NP] from [name of clinic] updated, UA (urine analysis) and STAT (immediately) CBC & BMP ordered. On 02/06/23, a nurse documented, Labs ordered in relation to fall and weakness, NOR (new order received) for PIV (peripheral intravenous access) 0.45% NS (Normal Saline) @ (at) 100 mL(milliliters)/hr (hour) x 2L (liters). Resident and emergency contact updated with NOR. 1 attempt made for PIV insertion to left hand, unsuccessful. Bruising to site after attempt. Call placed to [name of company] ambulance for insertion of IV (intravenous access). On 02/06/23, a nurse documented, [Name of company] ambulance attempted PIV, unsuccessful. Hydrodermaclysis running. On 02/07/23, a nurse documented, Apparently hydrodermaclysis to abd (abdomen) not in place; abd dressings saturated after 15 min of fluids administration. IV fluids on hold until IV resertion [sic] in am. On 02/07/23, R108 was sent to the emergency room for IV insertion and returned to the facility the same day. Surveyor noted there were no physician orders in R108's EMR to increase fluids, there was no care plan addressing dehydration and there was no documentation from staff assessing fluid intake verses fluid needs. Surveyor noted one progress note on 02/05/23 which documented, .RN (Registered Nurse) pushed fluids . Surveyor could not locate any other documentation in R108's EMR relating to staff offering, encouraging, or pushing additional fluids. Surveyor reviewed dietician progress notes and dietician nutrition assessments. Surveyor noted these documents did not mention dehydration, nor fluid needs. On 07/31/23, at 11:46 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-I. LPN-I was the floor nurse on the unit where R108 resided while in the facility. LPN-I informed Surveyor he could not remember anything specific about R108. LPN-I stated some NPs at the facility will put their own orders in the resident's EMR and some will not. Per LPN-I if the NP wanted to push/encourage fluids the NP would either give a specific amount or give an order to encourage fluids or something like that. On 08/01/23, at 7:51 AM, Surveyor interviewed Registered Nurse (RN)-G. Surveyor asked how RN-G would know if a resident needed additional fluids. Per RN-G, she always gives extra fluids with med pass, but there can also be an order in the resident's Electronic Medication Administration Record (EMAR) documenting push fluids or a specific amount of fluids to give. On 07/31/23, at 11:57 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C. ADON-C was the unit manager for the unit where R108 resided while in the facility. Per ADON-C, the NP would either put an order in the EMAR themselves or have the nurse managers do it. Surveyor asked if the NP documented something in their progress notes relating to increase fluids/oral hydration how would that be relayed to staff. Per ADON-C, if the NP wrote something in her progress note she would/should relay it nursing staff, either as a verbal order or written order. ADON-C stated, there should be an order on the EMAR reflecting the need for increased fluids if the NP is documenting that in her progress notes. Surveyor asked if R108 had any physician orders in their EMAR to increase fluids. ADON-C reviewed R108's EMR and stated if I would have received an order I would have put something in the EMAR. Per ADON-C she could not find an order in R108's EMAR to increase fluids. Surveyor relayed the concern of NP-V continuously documenting the need for increased fluids for R108 but no order for increased fluids and R108 needing IV rehydration two times. Surveyor asked for additional information. On 07/31/23, at 12:59 PM, Surveyor interviewed Registered Dietician (RD)-J. RD-J informed Surveyor she had only worked at the facility for one-two months. Surveyor noted RD-J was not the dietician at the time R108 was in the facility. Per RD-J she would be informed of the need for increased fluids either during the morning stand up meeting or communication directly from the NP or nursing staff. RD-J stated the NP might give her a specific amount of fluids to increase by. RD-J stated she would play a role in configuring fluid needs, assessing actual intake and collaborating with the NP/nursing staff to address additional fluid needs. RD-J stated she unfortunately would not have any information relating to R108. On 07/31/23, at 1:23 PM, Surveyor interviewed Director of Nursing (DON)-B. Per DON-B when NP-V was documenting the need to increase fluids in R108's chart, she was only encouraging/educating the resident to drink more. DON-B stated NP-V was not giving orders to the staff to increase fluids. Per DON-B, if the NP tells the staff to monitor fluids, or increase fluids then an order would have been put in. DON-B stated, like for a dementia resident who is not orientated there would be an order to increase fluids. DON-B stated since R108 was their own person and was alert and orientated, NP-V was providing education to R108 to drink more fluids. NP-V was not giving orders to the staff to increase R108's fluids. Surveyor asked DON-B what the facility staff did to prevent dehydration between the first need for IV rehydration on 01/13/23 and the second need on 02/07/23. Surveyor brought up NP-V's continued documentation for the need to increase fluids and asked how the facility followed through on this. Surveyor asked for any information regarding the facility assessing R108's need for additional fluids, updating R108's care plan to reflect fluid needs to prevent dehydration, dietician interventions to prevent dehydration and/or any documentation relating to interventions to assist R108 with hydration. On 07/31/23, at 12:56 PM, RN Consultant (RN)-K approached Surveyor after Surveyor left DON-B's office. RN-K questioned whether NP-V's documentation was some sort of template and maybe NP-V did not mean to continuously document increase fluids. Surveyor informed RN-K, NP-V did not start documenting the need for increased fluids until 01/03/23 and then continued until R108 needed IV rehydration. Surveyor questioned if there was no order in R108's EMAR how would the nursing staff know to increase fluids? RN-K stated the nurses would know because of the labs and asked Surveyor how do you know they weren't pushing fluids? Surveyor stated there is a lack of documentation in R108's EMR relating to the facility pushing/encouraging fluids. Surveyor asked for documentation relating to the facility staff addressing R108's need for increased fluids. RN-K informed Surveyor NP-V was Turkey and unavailable for questions. On 07/31/23 at 3:03 PM, during the end of the day meeting with Nursing Home Administrator (NHA)-A, DON-B, RN-K and Infection Preventionist (IP)-D Surveyor asked for any additional information on interventions taken by the facility to prevent dehydration in R108 and any assessments relating to R108's fluid intakes verse fluid needs. Prior to Surveyor exit, Surveyor was provided with R108's EMAR which had a physician's order from R108's admission to document bedside snacks and fluids. There was no mention of additional/increasing fluids, and this order remained the same throughout R108's stay. Surveyor noted the order was not revised when R108 needed IV rehydration. Surveyor was also provided with R108's estimated fluid intakes for the month of March which was documented by Certified Nursing Assistant staff. Surveyor noted there was no information given on staff who may have assessed these values and then put interventions in place based on those assessments. No additional information was given prior to survey exit.

Based on observations, interviews, and record reviews, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 99 residents residing in the facility. *The facility's Water Management Plan (WMP) did not identify the two water fountains (bubblers) as a potential risk for Legionella growth and did not identify appropriate control measures for prevention of Legionella growth in the dead legs of the water fountains (bubblers). Findings include: The facility water management policy, titled, Water Management Program, date revised 07/2023 documented, .3) A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems .5) Based on the risk assessment, control points will be identified. The list of identified points shall be kept in the Water Management program binder 6) Control measures will be applied to address potential hazards at each control point. While onsite Surveyor noted two water fountains (bubblers) that had tape around them and labeled do not use. One of the water fountains (bubblers) was in the front lobby by the restrooms and the other water fountain (bubbler) was located on a resident unit. Surveyor reviewed the facility's water management program and noted multiple control points and control measures for areas such as closed units, ice machines, tubs, etc. Surveyor noted the risk assessment listed water fountains as 0 in the building and 0 risk. There were no control measures mentioned to prevent Legionella in the unused water fountains (bubblers). On 07/27/23, at 9:52 AM, Surveyor interviewed Head of Maintenance (HM)-E. Per HM-E the water fountains (bubblers) have been shut off since the Covid pandemic. HM-E informed Surveyor the water valve is shut off to the water fountains (bubblers) and HM-E put Aqua Seal in the drain to stop backflow. On 07/27/23 at 10:45 AM, Surveyor interviewed Infection Preventionist (IP)-D. Surveyor questioned IP-D if the water fountains (Bubblers) were identified as a potential source for Legionella growth and what control measures were being taken to prevent Legionella. IP-D reviewed the water management program and stated the facility does bi-annual testing for Legionella and rounds to identify breaks in any pipes. IP-D stated the pipes to the water fountains (bubblers) might be capped; IP-D would have to confirm with HM-E. Surveyor relayed the concerns of not addressing the water fountains (bubblers) in the risk management section of the water management program. IP-D reviewed the water management plan. Surveyor pointed to the line addressing water fountains in the risk management section. Per IP-D, the bubblers would be included in the water fountains risk assessment. Surveyor questioned why the amount of water fountains was 0 and the risk for Legionella was assessed at a 0. Per IP-D, that is because the water fountains (bubblers) are not and have not been in use. Surveyor explained because the water fountains (bubblers) are not in use they would be considered dead legs (Dead legs are sections of potable water piping systems that are no longer used, or rarely used and leads to stagnation. Stagnant or slow-moving water can cause conditions that increase risk for Legionella and other bio-film-associated bacteria. When water is stagnant, temperatures can decrease or increase to the Legionella growth range (77 degrees - 113 degrees F). Stagnant water can also lead to low or undetectable levels of disinfectant, such as chlorine. The dead leg has the potential to seed the main portion of the potable water) and therefore a risk for Legionella growth. On 07/27/23, at 11:04 AM, Surveyor interviewed HM-E. Per HM-E the water fountain pipes are not capped and it would be difficult due to the 1/2 inch line. Surveyor relayed the concern for possible Legionella growth due to the water fountains (bubblers) not being used although the water valve was shut off. Surveyor expressed concern the water fountains (bubblers) should be considered dead legs in the facility risk assessment of their water management plan. Surveyor asked HM-E to explain the use of Aqua Seal in the water fountain (bubblers). HM-E explained the Aqua Seal is used to create a film/seal over the water left in the water fountain pipes to prevent odors from being emitted and the seal would not prevent water backflow when the water fountain water valve was turned back on. On 07/27/23 11:15 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and IP-D. NHA-A and IP-D questioned the difference between using the aqua seal in the drain and capping the drain. Surveyor explained that HM-E informed the Surveyor the Aqua Seal would not prevent stagnant water from moving through the pipes if the water fountain water was turned back on. Capped pipes or unused water fountains would need to be identified as dead legs on the Facility Water Management Plan. Dead legs lead to water stagnation. Stagnant or slow-moving water can cause conditions that increase risk for Legionella. NHA-A IP-D relayed understanding. On 07/27/23 11:38 AM, during the end of the day meeting with NHA-A, Director of Nursing (DON)-B and IP-D, Surveyor asked for any additional information related to the water management program and the unused water fountains (bubblers). During Survey on 08/01/23, Surveyor noted the water fountains had been removed with the previous area dry-walled over.

Based on observation and interview the Facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety for 96 of 99 Residents that reside at the facility. On 07/26/23, Dietary Aide - JJ was observed touching ready to eat food with contaminated gloves and place the food on plates for residents to eat. Dietary Aide-JJ was observed removing their gloves and re-gloving without washing their hands. Findings include: On 07/26/23, at 11:58 a.m., Surveyor observe Dietary Aide- JJ begin the lunch tray line service that services all residents that eat meals prepared by the facility. Dietary Aide-JJ was observed to don gloves without washing her hands. At 12:00 PM, Dietary Aide-JJ was observed touch a bin with her gloved hands then pick up a plate with the same gloved hand. Dietary-JJ then picked up a large rectangular loaf of dinner rolls that were baked into a solid form with her left contaminated gloved hand, pull 3 dinner rolls off the larger rectangle with her right contaminated gloved hand, place one dinner roll on a plate and place the 2 other dinner rolls on top of the larger solid rectangle of baked dinner rolls. Dietary Aide-JJ then touched the serving utensils with her right gloved hand and moved the plate along the food tray line with the left gloved hand filling the plate with food using the right gloved and touching the serving utensils. At 12:01 PM, Dietary Aide-JJ was observed taking the plated meal and picking it up with right gloved hand and placing it on top of the steam table tray line touching the top of the steam table with her right gloved hand. Dietary Aide-JJ was observed taking the tongs and placing a piece of corn on the cob on to the plate with her right gloved hand and moving the corn on the cob over a little on the plate with her left contaminated gloved hand to make room for other food items to be placed on the plate. At 12:02 PM, Dietary Aide-JJ was observed touching the tray line with her left gloved hand while holding a red plate holder with a plate in it, then picking up a dinner roll with her contaminated left gloved hand and placing it on the plate. At 12:03 PM, Dietary Aide-JJ was observed touching red plate holders with the left gloved hand and placing them on the tray line while touching the tray line with the right gloved hand. Dietary Aide-JJ was observed picking up the large rectangle of dinner rolls with the left hand and pulling 2 dinner rolls off with the right contaminated gloved hand and placing them on the plates on the tray line. At 12:04 PM, Surveyor observe Dietary Aide-JJ remove both gloves and re-glove without washing their hands and then put a second glove on their left hand over the first glove. On 08/01/23, at 9:02 AM, Surveyor interviewed Dietary Manager-II who stated, all staff are trained to always wash their hands. Dietary Manager-II stated they have enrolled the team in Serve Safe training. Dietary Manager-II stated anybody that is serving ready to eat foods have to have gloved hands. Dietary Manager-II stated it is expected that staff perform handwashing anytime you leave the line, anytime you touch your hair. Dietary Manager-II stated their preference for the staff is to have a tong and use gloved hands to touch the ready to eat food. On 08/01/23, at 9:10 AM, Surveyor notified Dietary Manager-II of the above concerns of observations of Dietary Aide-JJ serving ready to eat food with contaminated gloved hands and the concern for hand washing prior to donning gloves.

Based on observation, interview and record review the facility did not ensure 1 (R11) out of 3 residents reviewed for indwelling catheters received the appropriate care. *R11 was admitted to the facility with an indwelling catheter and three weeks later was transferred to the hospital with a Urinary Tract Infection. Upon return to the facility, the facility did not assess the need for the indwelling catheter nor follow up with urology as recommended in the hospital discharge summary. Two months later in July, R11's catheter became clogged, and the facility was unable to irrigate it. At this point the physician noted R11's hospital discharge instructions and ordered a voiding trial. Findings include: Facility policy entitled, Indwelling Catheter Use and Removal, dated 10/22/23 documented, Policy Explanation: Indwelling urinary catheters are catheters that remain in the bladder to assist with urinary elimination. The use of indwelling catheters for managing incontinence is not appropriate and increase the risk of urinary tract infections. While there are some justifications for indwelling catheter use in long-term care setting, prompt removal of such catheters is indicated when inappropriately used. Compliance Guidelines: .2) Residents that admit with an indwelling catheter or subsequently receives one will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that the catheter is necessary. R11 was admitted to the facility on [DATE] with diagnoses including, cerebral vascular disease, dysphagia, and obstructive and reflux uropathy. R11's Minimum Data Set (MDS) Assessment, dated 7/11/23, documented R11's Brief Interview for Mental Status (BIMs) was not conducted due to R11 rarely/never being understood and R11 had an indwelling catheter during the look back period. R11's admission MDS assessment, dated 04/10/23 documented R11 had an indwelling catheter during that look back period. On 07/25/23 ,at 8:27 AM, Surveyor observed R11 laying in bed. Surveyor did not observe an indwelling catheter. Surveyor reviewed R11's Electronic Medical Record (EMR) and noted R11's indwelling catheter was removed on 07/5/23 and R11 had a voiding trial for the next three days, which per documentation went well. Per documentation R11 was voiding without issues and the indwelling catheter was not re-inserted. Surveyor noted R11 was sent to the hospital on 4/30/23 due to an elevated potassium level. R11's hospital discharge summary dated, 5/03/23, documented, Patient recently had labs drawn at the facility and was found to have a potassium of 7 and a white blood cell count of 32, patient was also found to have hematuria on presentation, UA (Urine analysis) is positive, was started on antibiotics and admitted to the floor for further management. R11's urology consult, while in the hospital, dated 05/01/23, documented, Plan: .Light pink urine does not necessitate urgent cystoscopy, but [R11] does need one to complete hematuria work up .Consider voiding trial when and if patient regains more neurological function and ambulation .Consider SP (Suprapubic) catheter for long term bladder management. Surveyor reviewed R11's care plan which documented, The resident has an indwelling catheter r/t (related to) Obstructive Uropathy. This care plan was initiated on 4/7/23 and resolved on 7/10/23. Surveyor noted multiple interventions initiated on 04/07/23 and two interventions initiated on 05/11/23: Urology Consult PRN (As needed) and Catheter Strap-check placement of catheter strap every shift. From R11's return to the facility on [DATE] until 07/05/23, Surveyor could not locate documentation in R11's EMR that the facility staff had followed up on the indwelling catheter regarding a urology appointment and/or possible removal of catheter with a voiding trial. On 07/05/23 a physician documented in R11's progress notes, OBSTRUCTIVE AND REFLUX UROPATHY, UNSPECIFIED *: 16 Fr. (French) with 10 cc(milliliter) Foley. Last seen by NP (nurse Practitioner) [name of NP] on 5/1/23:consultation reviewed: recommended to do voiding trial if unsucceful [sic] then suprapubic cath [sic] is recommended for long-term use . This was the only documentation Surveyor could locate either by a physician/NP or the facility nursing staff which addressed R11's catheter. On 07/31/23 at 10:40 AM, Surveyor interviewed Registered Nurse (RN)-DD. RN-DD informed Surveyor R11 no longer had the indwelling catheter and the catheter had been discontinued a couple of weeks ago. RN-DD stated she was unsure why the catheter was discontinued, but the facility did a voiding trial for three days and R11 was voiding without issues, so the catheter was not reinserted. On 07/31/23 at 10:46 AM, Surveyor interviewed Unit Manager, RN-F. RN-F informed Surveyor when someone is admitted with an indwelling catheter she will ensure the resident has a proper diagnosis, schedule a voiding trial and follow up with urology if the resident is unable to void. Surveyor asked RN-F if R11's indwelling catheter had been addressed prior to 7/5/23 or if R11 had a urology consultant or cystoscopy as mentioned in the hospital discharge. RN-F stated, reading from R11's EMR, R11's hospital discharge summary recommended a cystoscopy and said consider voiding trial if regains more neurological function and/ or ambulation. Per RN-F, R11's catheter was removed on 07/05/23. RN-F continued to review R11's EMR and stated to Surveyor it appeared as though R11's catheter was clogged, and they were unable to irrigate it so the physician ordered a voiding trial. RN-F informed Surveyor R11 was voiding, so the catheter remained out. Surveyor asked about any follow up appointments with urology or a cystoscopy between 5/4/23 and 7/5/23. RN-F informed Surveyor she believes there would have been a plan to have R11 follow up with urology. Surveyor asked RN-F for any information relating to R11's indwelling catheter between 05/04/23 and 07/05/23. RN-F stated she would look into it. On 07/31/23 at 1:21 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor relayed the concerns of R11 coming back from the hospital after a UTI on 05/04/23 with orders for a cystoscopy, urology follow up for possible voiding trial and/or Suprapubic catheter for bladder management. Surveyor informed DON-B there was a lack of documentation by facility staff addressing those recommendations. Surveyor asked why it took from 05/04/23 to 07/05/23 for the facility to attempt a voiding trial? Surveyor also asked if R11 had a follow up cystoscopy or urology appointment? Surveyor asked DON-B for any additional information. On 07/31/23 at 3:03 PM, during the end of the day meeting with DON-B, Nursing Home Administrator (NH)A-A, Infection Preventionist (IP)-D, and Regional Nurse Consultant (RNC)-K, Surveyor relayed the above concerns and asked for any additional information. Prior to leaving the facility for the day, DON-B gave Surveyor a sheet of paper entitled, Appointment, dated 05/08/23 which documented a physician had canceled the appointment. DON-B informed Surveyor since R11's hematuria had resolved the physician had canceled the cystoscopy. Surveyor brought up the concern R11's catheter was still not removed until 07/05/23 and Surveyor asked for documentation for the delay or any other documentation relating to the management of the catheter between 05/04/23 and 07/05/23. No additional information was provided. After Survey exit, the facility sent an admission catheter assessment and an initial catheter care plan, both dated 4/7/23. Surveyor had already reviewed these forms while on Survey and these forms did not provide additional information. After Survey exit the facility also sent R11's hospital discharge from 05/01/23 documenting voiding trial when and if R11 regains neurological function and/or ambulation. Surveyor had already reviewed these documents while on Survey.

Based on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 1 (R458) of 5 Residents reviewed. R458's physician orders does not include parameters of when to notify the physician if R458 were to have low/high blood sugars. Findings include: The Insulin Pen policy revised 10/22 under policy explanation and compliance guidelines documents 5. Monitor blood sugar as ordered by physician. R458 was admitted to the facility on [DATE] with diagnosis which includes diabetes mellitus. The physician orders dated 7/13/23 documents Insulin Aspart Solution 100 unit/ml (milliliter) (Insulin Aspart) Inject 12 units subcutaneously three times a day related to Type 2 Diabetes Mellitus with unspecified complications. The physician orders dated 7/13/23 documents Insulin Glargine-yfgn Subcutaneous Solution 100 unit/ml (Insulin Glargine-yfgn) Inject 25 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with unspecified complications. Review of R458's July MAR (medication administration record) reveals R458's blood sugar was obtained three times a day with the administration of Insulin Aspart. Surveyor noted R458's physician orders or July MAR does not indicate the parameters when R458's physician should be notified regarding low/high blood sugar values. On 7/31/23 at 10:02 a.m. Surveyor asked LPN (Licensed Practical Nurse)-Y how she knows when to notify a Resident's physician regarding their blood sugar value. LPN-Y informed Surveyor the majority have parameters if less than or more than to call the MD (medical doctor). Surveyor asked if there are no parameters ordered when would she notify the doctor. LPN-Y replied if too low or too high. Surveyor asked LPN-Y what she would consider to low or high. LPN-Y informed Surveyor if the blood sugar was 50 or 60 she would try to give a supplement and retake the blood sugar. Too high is usually over 400 or 450. On 7/31/23 at 10:06 a.m. Surveyor asked RN (Registered Nurse)-O how she knows when to notify a Resident's physician regarding their blood sugar value. RN-O informed Surveyor if less than 60 it's our protocol. Surveyor asked if the blood sugar is high when would she notify the doctor. RN-O replied usually 3 or 4 hundred usually see 400. RN-O explained if a resident never runs in 300 she would retake the blood sugar and let the practitioner know but for the most part 400 or more and 60 or less. On 7/31/23 at 10:10 a.m. Surveyor asked RN-DD how she knows when to notify a Resident's physician regarding their blood sugar value. RN-DD replied if it's under 70 or over 400. On 7/31/23 at 10:25 a.m. Surveyor asked LPN-O how he knows when to notify a Resident's physician regarding their blood sugar value. LPN-O replied there is an order for lows and highs. LPN-O explained it depends on each particular resident or he calls for a high number. Surveyor inquired what the low number is. LPN-O replied 70 and obviously if the machine reads high need to call right away as high means over 500 on the glucometer. Surveyor asked LPN-O when he would call the doctor for R458's blood sugars. LPN-O informed Surveyor the parameters. Surveyor asked LPN-O if he could show Surveyor the physician order for R458's blood sugar parameters. LPN-O looked in R458's electronic medical record and replied no, not with this one. On 8/1/23 at 7:58 a.m. Surveyor asked ADON (Assistant Director of Nursing)-C how staff know when to notify a Resident's physician regarding their blood sugar value. ADON-C replied well most of them have parameters especially if have a correction dose. Surveyor asked what happens if there isn't a physician order for parameters. ADON-C replied I really don't have an answer for that. Surveyor informed ADON-C R458 does not have an order for blood sugar parameters and Surveyor had interviewed staff with staff responding with different responses of when the physician would be notified. On 8/1/23 at 8:10 a.m. Surveyor rechecked R458's physician orders and noted the following two new physician orders: Physician order dated 8/1/23 documents Call if blood sugar less than 70 or greater than 350. Physician order dated 8/1/23 documents Call MD if blood glucose above 400 or below 70 every shift. On 8/1/23 at 11:54 a.m. Nursing Home Administrator-A and DON (Director of Nursing)-B were informed of the above. On 8/7/23 Surveyor received additional information from the facility which was R458's blood glucose values. This additional information does not change the deficient practice.

Based on record review and staff interview, the facility did not ensure the required information was provided to residents at the time of a transfer to the hospital. This was observed with 6 (R64, R59, R89, R103, R11, and R80) of 6 residents reviewed for hospital transfers. *R64's transfer notice did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request when transferred to the hospital on: 3/27/2023, 4/25/2023, 5/22/2023, and 7/8/2023 *R59's transfer notice did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request when transferred to the hospital on 4/13/2023 and 5/3/2023. *R89's transfer notice did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request when transferred to the hospital on 5/12/2023. *R103's transfer notice did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request when transferred to the hospital on 5/4/2023. *R11's transfer notice did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request when transferred to the hospital on 4/30/2023. *R80's transfer notice did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request when transferred to the hospital on 5/17/2023. Findings include: 1) R64's medical records indicated R64 was transferred to the hospital on 3/27/2023, 4/25/2023, 5/22/2023, and 7/8/2023 related to changes of condition. Surveyor requested evidence from the facility that a notice of transfer was provided to R64 when R64 was hospitalized . On 7/31/2023 at 9:12 AM Surveyor received R64's Transfer and Discharge Bed Hold Notice for 3/27/2023, 4/25/2023, 5/22/2023, and 7/8/2023. The information on the notice included: - Reason for discharge or transfer. - Medicaid bed hold policy. - Private pay bed hold policy. - Contact information for the Ombudsman. - Contact information for Disability Rights of Wisconsin. Surveyor noted that the Transfer and Discharge Bed Hold Notice did not include: o An explanation of the right to appeal the transfer or discharge to the State Agency. o The name, address (mail and email), and telephone number of the State entity which receives such appeal hearing requests. o Information on how to obtain an appeal form. o Information on obtaining assistance in completing and submitting the appeal hearing request. On 7/31/2023 at 9:12 AM Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the unit managers usually gather the paperwork and send it out with the resident when they are transferred and that was the only sheet NHA-A was aware of that was given to residents at the time of transfer. On 7/31/2023 at 10:23 AM Surveyor interviewed Licensed Practical Nurse Unit Manager (LPN)-M who stated when a resident gets sent out to the hospital, staff send the resident's medication administration record (MAR), physician orders, resident's face sheet, the resident's history and physical, and lab work if it applies to the reason the resident is being sent out. Surveyor asked LPN-M if a transfer notice is given along with the other information. LPN-M stated the Transfer and Discharge Bed Hold Notice gets sent with and an eInteract form on Point Click Care (Electronic Medical Records) gets filled out to send along as well but it includes medical information regarding the needs of the resident. LPN-M was not aware of any other notices pertaining to the transferring of the resident. On 7/31/2023 at 3:02 PM Surveyor informed NHA-A and Director of Nursing (DON)-B of Surveyors concern that not all the required information is included on the Transfer and Discharge Bed Hold Policy when a resident is transferred to the hospital. NHA-A and DON-B stated they were not aware that an explanation of the right to appeal the transfer or discharge to the State Agency, the name, address (mail and email), and telephone number of the State entity which receives such appeal hearing requests, information on how to obtain an appeal form and information on obtaining assistance in completing and submitting the appeal hearing request had to be included on the transfer notice. No other information was provided at this time. 2) R59's medical records indicated that R59 was transferred to the hospital on 4/13/2023 and 5/3/2023 related to a change of condition. Surveyor requested evidence from the facility that a notice of transfer was provided when R59 was hospitalized . On 7/31/2023 at 9:12 AM Surveyor received R59's Transfer and Discharge Bed Hold Notice for 4/13/2023 and 5/3/2023. The information on the notice included: - Reason for discharge or transfer. - Medicaid bed hold policy. - Private pay bed hold policy. - Contact information for the Ombudsman. - Contact information for Disability Rights of Wisconsin. Surveyor noted that the Transfer and Discharge Bed Hold Notice did not include: o An explanation of the right to appeal the transfer or discharge to the State. o The name, address (mail and email), and telephone number of the State entity which receives such appeal hearing requests. o Information on how to obtain an appeal form. o Information on obtaining assistance in completing and submitting the appeal hearing request. On 7/31/2023 at 9:12 AM Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the unit managers usually gather the paperwork and send out with the resident when they get transferred and that was the only sheet NHA-A was aware of that was given to residents at time of transfer. On 7/31/2023 at 10:23 AM Surveyor interviewed Licensed Practical Nurse Unit Manager (LPN)-M who stated when a resident gets sent to the hospital, staff send the resident's medication administration record (MAR), physician orders, resident's face sheet, and the resident's history and physical and lab work if it applies to the reason the resident is being sent out. Surveyor asked LPN-M if a transfer notice is given along with the other information. LPN-M stated the Transfer and Discharge Bed Hold Notice gets sent with and an eInteract form on Point Click Care (healthcare software provider) gets filled out to send along as well but it includes medical information regarding the needs of the resident. LPN-M was not aware of any other notices pertaining to the transferring of the resident. On 7/31/2023 at 3:02 PM Surveyor informed NHA-A and Director of Nursing (DON)-B of Surveyors concern that not all the required information is included on the Transfer and Discharge Bed Hold Policy when a resident is transferred to the hospital. NHA-A and DON-B stated they were not aware that an explanation of the right to appeal the transfer or discharge to the State Agency, the name, address (mail and email), and telephone number of the State entity which receives such appeal hearing requests, information on how to obtain an appeal form and information on obtaining assistance in completing and submitting the appeal hearing request had to be included on the transfer notice. No other information was provided at this time. 3) R89's medical records indicated that R89 was transferred to the hospital on 5/12/2023 related to a change of condition. Surveyor requested evidence from the facility that a notice of transfer was provided when R89 was hospitalized . On 7/31/2023 at 9:12 AM Surveyor received R89's Transfer and Discharge Bed Hold Notice for 5/12/2023. The information on the notice included: - Reason for discharge or transfer. - Medicaid bed hold policy. - Private pay bed hold policy. - Contact information for the Ombudsman. - Contact information for Disability Rights of Wisconsin. Surveyor noted that the Transfer and Discharge Bed Hold Notice did not include: o An explanation of the right to appeal the transfer or discharge to the State. o The name, address (mail and email), and telephone number of the State entity which receives such appeal hearing requests. o Information on how to obtain an appeal form. o Information on obtaining assistance in completing and submitting the appeal hearing request. On 7/31/2023 at 9:12 AM Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the unit managers usually gather the paperwork and send out with the resident when they get transferred and that was the only sheet NHA-A was aware of that was given to residents at time of transfer. On 7/31/2023 at 10:23 AM Surveyor interviewed Licensed Practical Nurse Unit Manager (LPN)-M who stated when a resident gets sent to the hospital, staff send the resident's medication administration record (MAR), physician orders, resident's face sheet, and the resident's history and physical and lab work if it applies to the reason the resident is being sent out. Surveyor asked LPN-M if a transfer notice is given along with the other information. LPN-M stated the Transfer and Discharge Bed Hold Notice gets sent with and an eInteract form on Bootlicker (healthcare software provider) gets filled out to send along as well but it includes medical information regarding the needs of the resident. LPN-M was not aware of any other notices pertaining to the transferring of the resident. On 7/31/2023 at 3:02 PM Surveyor informed NHA-A and Director of Nursing (DON)-B of Surveyors concern that not all the required information is included on the Transfer and Discharge Bed Hold Policy when a resident is transferred to the hospital. NHA-A and DON-B stated they were not aware that an explanation of the right to appeal the transfer or discharge to the State, the name, address (mail and email), and telephone number of the State entity which receives such appeal hearing requests, information on how to obtain an appeal form and information on obtaining assistance in completing and submitting the appeal hearing request had to be included on the transfer notice. No other information was provided at this time. 38829 4) R103 was admitted to the facility on [DATE] with Alzheimer's Disease, Repeated Falls, Type 2 Diabetes Mellitus, Fibromyalgia, Chronic Kidney Disease, Obstructive Sleep Apnea, Stage 3, Personality Disorder, Major Depressive Disorder, and Anxiety Disorder. R103 has an activated Health Care Power of Attorney (HCPOA). R103 discharged from the facility on 5/4/23. On 5/4/2023, at 1:53 PM, R103 medical record documents R103 was discharged to the emergency room due to pain and swelling in left wrist after sustaining a fall the previous evening. On 7/31/23, at 3:07 PM, Surveyor shared with Nursing Home Administrator (NHA)-A that Surveyor had received a 'transfer and discharge bedhold notice' for R103 that only discussed bedhold information with the daily basic rate documented on the form. On the bottom of R103's form it states that per spouse, declined bedhold. Surveyor shared the concern that the transfer notice does not contain the location of where R103 was being transferred to, the explanation of the right to appeal the transfer and how to appeal, including how to obtain assistance with an appeal. Surveyor shared with NHA-A the concern the name, address, phone number of the state entity, ombudsman, and disability rights contact is not documented on the form. On 8/1/23, at 6:59 AM, NHA-A informed Surveyor that the facility was in the process of revising the form for bedhold and transfer notice. On 8/1/23, at 11:56 AM, Surveyor shared the concern that R103's bedhold and transfer notice was missing important information about the appeal rights and the state agencies to contact. NHA-A understands and provided Surveyor with an updated facility transfer and discharge notice form that now contains the required regulatory required information and will be used going forward. 46517 R11 was admitted to the facility on [DATE] with diagnoses including, cerebral vascular disease, dysphagia, and obstructive and reflux uropathy. Surveyor noted R11 was sent to the hospital on 4/30/23 due to an elevated potassium level. R11's hospital discharge summary dated, 5/03/23, documented, Patient recently had labs drawn at the facility and was found to have a potassium of 7 and a white blood cell count of 32, patient was also found to have hematuria on presentation, UA (Urine analysis) is positive, was started on antibiotics and admitted to the floor for further management. R11 returned to the facility on [DATE]. Surveyor reviewed R11's bed hold and transfer form from that hospital transfer and noted it did not contain the State agency's contact information or appeal rights. On 07/31/23 at 10:23 AM, Surveyor interviewed Unit Manager, Licensed Practical Nurse (LPN)-M. LPN-M informed Surveyor when someone is sent to the hospital the facility sends the resident's physician orders, face sheet, recent labs if needed and an eInteract transfer form which is found in Point Click Care (electronic medical record). LPN-M stated a bed hold form is done in house and the eInteract transfer form only contains medical information, not regulatory requirements. On 07/31/23 at 3:02 PM, during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Infection Preventionist (IP)-D, and Regional Nurse Consultant (RNC)-K, Surveyor relayed the concern that transfer paperwork send with a resident when going to the hospital does not include appeal rights or information on how to appeal a transfer or discharge. NHA-A stated she was not aware that information needed to be on the sheet. On 08/01/23, NHA-A provided Surveyor with a copy of the new transfer form which contains all the needed information. NHA-A stated she got the form from a sister facility and that is what they will be using from now on. 21855 6) R80's medical record was reviewed by Surveyor. Surveyor noted R80 had a change in condition at the facility and was transferred to the hospital on 5/17/23. A Progress Note documented on 5/17/2023, at 6:30 PM a Late Entry: Writer spoke with POA (Power of Attorney) in regards to COC(change in condition), notified resident being sent to ER (emergency room ) for evaluation and treatment. Behold discussed, POA declined bedhold at this time. Surveyor noted R80's medical record does not contain documentation R80 was provided information related to their appeal rights contact information, Ombudsman and/or Disability Agency contact information or the State Agency the regulates nursing homes. On 07/27/23, at 8:29 AM, Surveyor spoke with NHA (Nursing Home Administrator)-A who indicated the nurse on the unit, and the Nurse Managers, ensure the transfer information is provided to the resident. Nursing Home Administrator-A provided a copy of R80's Transfer and Bedhold form. Surveyor noted the required appeal rights information is not documented on the form. On 07/27/23, at 8:39 AM, Surveyor attempted to interview R80. R80 was not able to verbally communicate and used only hand gestures. On 08/01/23, at 10:07 AM, Surveyor spoke with R80's Unit Manager, Assistant Director of Nursing (ADON)-C related to information regarding R80's transfer to the hospital. ADON-C indicated the transfer paperwork for bed-hold is provided on a paper form or verbally. The resident's POA is notified for a bed hold. We do a change in condition progress note and the eInteract transfer form. ADON-C states they just review the bed hold information but does not provide any other written information at time of transfer. On 07/31/23, at 02:05 PM, at the Facility Exit Meeting Surveyor shared the concerns that R80's transfer information not including the required appear rights information.

Based on observation, interview, and record review, the Facility did not ensure Residents with pressure injuries receive appropriate care, treatment, & preventative measures to promote healing for 2 (R406 & R400) of 4 Residents with pressure injuries reviewed. * R406 was readmitted to the facility on [DATE] with a Stage 2 pressure injury to the left buttocks. On 5/17/22 R406 developed a Stage 3 pressure injury to the coccyx. There were no revision to R406's skin integrity care plan until 6/3/22. On 5/24/22 R406's left buttocks pressure injury had declined to unstageable. There were no revisions to R406's skin integrity care plan until 6/3/22. On 6/28/22 a Surveyor observed [MEDICATION(S)] being applied to the coccyx & left buttocks wound bed when the physicians order was for collagen. There were multiple observations of R406's heels not being offloaded and not wearing the pressure relieving boots. There is no evidence daily foot inspections were being conducted according to the plan of care after R406 returned from the hospital on 5/9/22. On 6/28/22 R406 was identified as having a DTI (deep tissue injury) on the right heel. * R400 acquired a coccyx pressure injury on 6/16/22. R400 did not have a low air loss mattress. Surveyor observed R400 without heel boots and did not observed consistent repositioning, Treatment orders were not updated on 6/23/22 and on 6/29/22 a second coccyx pressure injury developed. Findings include: 1.) R406 was originally admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/23/22 R406 was placed on hospice. The diabetes mellitus care plan initiated & revised on 2/13/22 documents an intervention of Inspect feet daily for open areas, sores, pressure areas, blisters, [CONDITION(S)] or redness. Initiated 2/13/22. The potential for pressure ulcer development care plan initiated 2/15/22 & revised 6/28/22 has the following interventions: * Administer treatments as ordered and observe for effectiveness. Initiated 2/15/22. * Assess/record/observe wound healing: Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (medical doctor). Initiated 2/15/22 & revised 6/3/22. * Assist [R406] to float heels while in bed. Initiated 6/25/22. * Assist [R406] to reposition and/or turn at frequent intervals at least Q2-3H (every two to three hours), to provide pressure relief. Initiated & revised 2/15/22. * Complete a full body check weekly and document. Initiated 2/15/22. * Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . * IDT (interdisciplinary team) referrals as indicated, i.e. RD (registered dietitian), PT (physical therapy), OT (occupational therapy) or other. Initiated 2/15/22 & revised 6/3/22. * Inform the resident/family/caregivers of any new area of skin breakdown. Initiated 2/15/22. * Observe nutritional status. Serve diet as ordered, observe intake and record. Initiated 2/15/22. * Reposition in chair frequently for comfort and pressure reduction. Provide resident/family education as needed. Initiated 2/15/22 & revised 6/3/22. * The resident needs assistance to turn/reposition at least every 2-3 hours, more often as needed or requested. Initiated 2/15/22 & revised 6/3/22. * The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Initiated 2/15/22. * The resident requires a pressure relieving/reducing device on (bed/chair). Initiated 2/15/22 & revised 6/3/22. * Treat pain as per orders prior to treatment/turning etc to ensure the resident's comfort. Initiated 2/15/22. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Initiated 2/15/22. On 5/4/22 R406 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & [CONDITION(S)] (urinary tract infection). R406 returned to the facility on [DATE]. The admission data collection dated 5/9/22 for the question Is residents skin intact? no is answered. For the question, Does the resident have pressure injury? yes is answered. Site is 53) Sacrum. There are no measurements or stage on this admission data collection. Left Buttocks The weekly pressure ulcer record dated 5/10/22 for date of onset documents 5/9/2022. Site is documented as 32) Left Buttocks, Type Pressure, Length 2.0, Width 0.5, Depth 0.1 and Stage II (2). Description of site documents 100% smooth pink wound bed, no drainage, edges attached, surrounding skin pink blanchable, no sign of infection, no c/o (complaint of) pain. Treatment is [MEDICATION(S)] paste. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. The weekly pressure ulcer record dated 5/17/22 for date of onset documents 5/9/2022. Site is documented as 32) Left Buttocks, Type Pressure, Length 1.1, Width 1.4, Depth 0.1 and Stage II (2). Description of site documents 100% smooth pink wound bed, small sero-sang. drainage, edges attached, surrounding skin pink blanchable, no sign of infection no c/o pain. Under describe resident's response to treatment no change is marked. Under notes documents stable. Treatment was changed to [MEDICATION(S)]/border foam. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. The weekly pressure ulcer record dated 5/24/22 for date of onset documents 5/9/2022. Site is documented as 32) Left Buttocks, Type Pressure, Length 1.6, Width 1.9, Depth 0.1 and Stage Unstageable. Description of site documents 80% slough 10% purple 10% granulation wound bed. Under describe resident's response to treatment deteriorated is marked. Under notes documents increase in surface area. There was no change in treatment. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. Surveyor noted there was no revision in R406's skin integrity care plan until 6/3/22. Surveyor notes R406's care plan did not reference an air mattress or pressure relieving boots despite reference to being specialized interventions in the weekly pressure ulcer record. The weekly pressure ulcer record dated 5/31/22 for date of onset documents 5/9/2022. Site is documented as 32) Left Buttocks, Type Pressure, Length 1.6, Width 1.6, Depth utd (unable to determine) and Stage Unstageable. Description of site documents 100% slough wound bed, moderae sic (moderate) sero-sang. drainage, edges attached, surrounding skin pink blanchable, no sign of infection, no c/o pain. Under describe resident's response to treatment improved is marked. Under notes documents decrease in surface area. There was no change in treatment. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. The weekly pressure ulcer record dated 6/7/22 for date of onset documents 5/9/2022. Site is documented as 32) Left Buttocks, Type Pressure, Length 1.1, Width 1.4, Depth utd and Stage Unstageable. Description of site documents 100% slough wound bed, moderate serous drainage, edges attached, surrounding skin dark discolored, no sign of infection, no c/o pain. Under describe resident's response to treatment improved is marked. Under notes documents decrease in surface area. There was no change in treatment. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. The weekly pressure ulcer record dated 6/14/22 for date of onset documents 5/9/2022. Site is documented as 32) Left Buttocks, Type Pressure, Length 1.3, Width 1.0, Depth utd and Stage Unstageable. Description of site documents 100% slough wound bed, moderate serous drainage, edges attached, surrounding skin dark discolored, no sign of infection, no c/o pain. Under describe resident's response to treatment improved is marked. Under notes documents decrease in surface area. There was no change in treatment. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. The weekly pressure ulcer record dated 6/16/22 for date of onset documents 5/9/2022. Site is documented as 32) Left Buttocks, Type Pressure, Length 1.3, Width 1.0, Depth utd and Stage N/A (non applicable). Description of site documents 100% slough wound bed, moderate serous drainage, edges attached, surrounding skin dark discolored, no sign of infection, no c/o pain. Under describe resident's response to treatment no change is marked. Under notes documents stable. There was no change in treatment. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. The weekly pressure ulcer record dated 6/23/22 for date of onset documents 5/9/2022. Site is documented as 32) Left Buttocks, Type Pressure, Length 1.5, Width 1.5, Depth 0.1 and Stage III (3). Description of site documents 100% granulation wound bed, moderate sero-sang. drainage, edges attached, surrounding skin pink blanchable, no sign of infection, no c/o pain. Under describe resident's response to treatment deteriorated is marked. Under notes documents increase in surface area. Treatment was changed to collagen/border foam. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. Coccyx The weekly pressure ulcer record dated 5/17/22 for date of onset documents 5/17/2022. Site is documented as 23) Coccyx, Type Pressure, Length 1.0, Width 0.5, Depth 0.2 and Stage III (3). Description of site documents 100% granulation wound bed, scant sero-sang. drainage, edges attached, surrounding skin pink blanchable, no sign of infection, no c/o pain. Treatment is [MEDICATION(S)]/border foam. Surveyor noted there was no revision in R406's skin integrity care plan until 6/3/22. The weekly pressure ulcer record dated 5/24/22 for date of onset documents 5/17/2022. Site is documented as 23) Coccyx, Type Pressure, Length 1.5, Width 1.2, Depth 0.1 and Stage III (3). Description of site documents 25% slough, 75% granulation wound bed, moderate sero-sang. drainage, edges attached, surrounding skin pink blanchable, no sign of infection, no c/o pain. Under describe resident's response to treatment deteriorated is marked. Under notes documents increase in surface area. There was no change in treatment. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. Surveyor noted there was no revision in R406's skin integrity care plan until 6/3/22. The weekly pressure ulcer record dated 5/31/22 for date of onset documents 5/17/2022. Site is documented as 23) Coccyx, Type Pressure, Length 0.9, Width 0.7, Depth 0.1 and Stage III (3). Description of site documents 100% granulation wound bed, moderate sero-sang. drainage, edges attached, surrounding skin pink blanchable, no sign of infection, no c/o pain. Under describe resident's response to treatment improved is marked. Under notes documents decrease in surface area. There was no change in treatment. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. The weekly pressure ulcer record dated 6/7/22 for date of onset documents 5/17/2022. Site is documented as 23) Coccyx, Type Pressure, Length 0.9, Width 0.7, Depth utd and Stage Unstageable. Description of site documents 100% slough wound bed, moderate serous drainage, edges attached, surrounding skin dark discolored, no sign of infection, no c/o pain. Under describe resident's response to treatment no change is marked. Under notes documents stable. There was no change in treatment. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. Surveyor noted R406's wound bed declined to 100% slough and the care plan was not revised until 6/25/22 with an intervention of float heels while in bed implemented. The weekly pressure ulcer record dated 6/14/22 for date of onset documents 5/17/2022. Site is documented as 23) Coccyx, Type Pressure, Length 0.9, Width 0.7, Depth utd and Stage Unstageable. Description of site documents 100% slough wound bed, moderate serous drainage, edges attached, surrounding skin dark discolored, no sign of infection, no c/o pain. Under describe resident's response to treatment improved is marked. Under notes documents decrease in surface area. There was no change in treatment. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. Surveyor noted this pressure injury did not improve as the measurements continue to be the same and the wound bed is still 100% slough. The weekly pressure ulcer record dated 6/16/22 for date of onset documents 5/17/2022. Site is documented as 23) Coccyx, Type Pressure, Length 0.9, Width 0.7, Depth utd and Stage Unstageable. Description of site documents 100% slough wound bed, moderate sero-sang drainage, edges attached, surrounding skin dark discolored, no sign of infection, no c/o pain. Under describe resident's response to treatment no change is marked. Under notes documents stable. There was no change in treatment. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. The weekly pressure ulcer record dated 6/23/22 for date of onset documents 5/17/2022. Site is documented as 23) Coccyx, Type Pressure, Length 0.7, Width 0.4, Depth 0.1 and Stage III (3). Description of site documents 100% granulation wound bed, moderate sero-sang drainage, edges attached, surrounding skin pink blanchable, no sign of infection, no c/o pain. Under describe resident's response to treatment improved is marked. Under notes documents decrease in surface area. Treatment was changed to collagen/border foam. Under specialty interventions for bed type documents air mattress and under other interventions documents pressure relieving boots. The Braden assessment dated [DATE] has a score of 14 which indicates moderate risk. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May remove for cares and therapy. Check for placement q (every) shift. Surveyor noted weekly head to toe skin checks dated 5/10/22, 6/14/22, 6/21/22, & 6/28/22. The nurses note dated 5/12/22 documents IDT weekly wound note [R406] has an admitted with wound to the left buttock with his last re admission from the hospital. Treatment is in place. He has nutritional supplements in place. MD and brothers are aware and agreeable with the treatment plan. Care plan is updated. He will continue to be monitored per facility protocol. The quarterly MDS (minimum data set) with an assessment reference date of 5/14/22 documents a BIMS (brief interview mental status) score of 6 which indicates severe impairment. R406 is coded as not having any behaviors including refusal of care. R406 requires extensive assistance with bed mobility, does not ambulate, requires supervision with set up help only for eating, is dependent with one person physical assist for toilet use, is checked for an indwelling catheter and is always incontinent of bowel. R406 is at risk for pressure injury development and is coded as having one Stage 2 pressure injury. The nurses note dated 5/16/22 includes documentation of .There sic (there) are 2 skin tears on but (sic) cheeks. No bleeding present. Cream and paste was applied. Continue to monitor the resident. This note was written by LPN (Licensed Practical Nurse)-M. The nurses note dated 5/20/22 documents IDT weekly wound note - [R406] an an admitted wound to the left buttock and a newly acquired wound to the coccyx. The wound to the left buttock is stable. Treatment recently changed. Treatment in place for the wound to the coccyx. He has nutritional supplements in place. He is declining as a whole. Family has been considering hospice R/T (related to) his decline. Care plan is up to date. MD and family agreeable to the current POC (plan of care). He will be monitored per facility protocol. The significant change MDS with an assessment reference date of 5/25/22 documents a BIMS score of 5 which indicates severe impairment. R406 is not coded as having any behavior including refusal of cares. R406 requires extensive assistance with two plus person physical assist for bed mobility, does not ambulate, requires extensive assistance with one person physical assist for eating, and dependent with one person physical assist for toilet use. R406 is checked for an indwelling catheter and is always incontinent of bowel. R406 is at risk for pressure injury development and is coded as having one Stage 3 and one Unstageable - slough &/or eschar pressure injury. The Pressure injury CAA (care area assessment) dated 5/26/22 under analysis of care for nature of the problem/condition documents Resident is a LTC (long term care) resident who was recently readmitted from [name of hospital] secondary to septic shock, [CONDITION(S)], dehydration and severe protein-calorie malnutrition. Pt (patient) has had multiple hospitalization s in the recent past and has had a decline since re-entry. He has now signed onto hospice for end of life cares. Resident is rarely getting out of bed at this time. During the look back period he has a catheter in place for urination and is always incontinent of bowel. No recent falls noted. He has two pressure injuries, a stage three pressure injury to the coccyx and an unstageable pressure injury to his L (left) buttocks. Treatments in place and a protein supplement is ordered. He takes [CONDITION(S)] medications Venlafaxone, [MEDICATION(S)] and [MEDICATION(S)] which he takes as ordered. He reports no pain in the past 5 days. The nurses note dated 5/26/22 documents IDT weekly wound note - [R406] has acquired wound to the coccyx and a left buttock wound that he was admitted with. Treatments will remain the same. He is now on hospice R/T his adult failure to thrive. He has nutritional supplements in place. Care plan has been updated. MD and family are aware and agreeable to the current POC. He will continue to be monitored per facility. The nurses note dated 6/10/22 documents [R406] has an acquired wound to the coccyx and admitted wound to the left buttock. The wound to the left buttock has improved and wound to the coccyx in sic (is) stable. He remains on hospice care. Nutritional supplements remain in place. Care plan is updated. MD and family aware and agreeable to the current POC. He will continue to be monitored per facility protocol. The nurses note dated 6/16/22 documents IDT weekly wound note - [R406] has an acquired wound to the coccyx and admitted with wound to the left buttock. The wounds have both improved. Treatment will remain the same. Nutritional supplements are currently in place. MD and brother are aware and agreeable to the current POC. Care plan in place and up to date. He continued to be followed per facility protocol. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Cleanse (L) buttocks with normal saline f/b (followed by) skin prep to peri wound f/b collagen to wound bed, f/b border foam three times a week & PRN (as needed). Notify MD of S/S (signs/symptoms) of infection. 2. Cleanse coccyx wound with normal saline f/b skin prep to peri wound f/b collagen to wound bed, f/b border foam three times a week & PRN. Notify MD of S/S of infection. The nurses note dated 6/24/22 documents IDT weekly wound note - [R406] has an acquired wound to the coccyx and admitted with wound to the left buttock. Both wounds have improved. Both treatments were changed this week. Nutritional supplements are currently in place. MD and brother are aware and agreeable to the current POC. Care plan in place and up to date. He continue to be followed per facility protocol. On 6/27/22 at 12:02 p.m. Surveyor observed R406 in bed on his back with the head of the bed elevated on a proactive air mattress. R406 is wearing beige gripper socks and R406's heels are resting directly on the mattress. R406 is not wearing pressure relieving boots. On 6/27/22 at 1:05 p.m. Surveyor observed R406 in bed on his back with the head of the bed elevated on a proactive air mattress. R406 is wearing beige gripper socks and R406's heels are resting directly on the mattress & the balls of R406's feet are pressing against the foot board. R406 is not wearing pressure relieving boots. On 6/27/22 at 2:33 p.m. Surveyor observed R406 in bed on his back with a pillow case around R406's head and the head of the bed elevated on a proactive air mattress. R406 is wearing beige gripper socks and R406's heels are resting directly on the mattress & the balls of R406's feet are pressing against the foot board. R406 is not wearing pressure relieving boots. On 6/27/22 at 3:56 p.m. Surveyor observed R406 in bed on his back with the head of the bed elevated on a proactive air mattress. R406 is wearing beige gripper socks and R406's heels are resting directly on the mattress. R406 is not wearing pressure relieving boots. On 6/28/22 at 8:19 a.m. a Surveyor observed R406 in bed on his back wearing beige gripper socks. R406's heels were resting directly on the mattress and R406 was not wearing pressure relieving boots. On 6/28/22 at 9:50 a.m. a Surveyor observed R406 sitting in a Broda chair wearing bilateral pressure relieving boots. On 6/28/22 at 11:54 a.m. a Surveyor observed R406's left buttock and coccyx pressure injury treatment with Wound Care RN-F and LPN Unit Manager-L. Surveyor observed R406 is in bed on his back with his heels resting directly on the mattress. Surveyor observed Wound Care RN-F cleansed the left buttocks & coccyx with normal saline, applied [MEDICATION(S)] to the wound beds, and covered each pressure injury with border foam dressing. Surveyor noted the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked Wound Care RN-F & LPN Unit Manager-L to look at R406's heels. R406's left heel is red and soft. LPN Unit Manager-L indicated R406 needs boots. The right heel has a DTI (deep tissue injury) which is a closed purple like blister. Wound Care RN-F indicated this is a brand new DTI and will measure. Wound Care RN-F applied skin prep to the right heel and then applied a border foam dressing on. R406 asked LPN Unit Manager-L for new socks as he has had these socks on for three days. The nurses note dated 6/28/22 documents Inadvertently applied [MEDICATION(S)] to wound instead of collagen. Wound NP (nurse practitioner) called and also updated. Writer did explain to NP that slough was still slightly present in wounds. NP conveyed to writer to change orders to [MEDICATION(S)]. NP also updated on new wound to R (right) heel. Tx (treatment) order confirmed. The SBAR (situation, background, assessment (RN)/Appearance (LPN), Response, Recommendations) note dated 6/28/22 documents RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: Wound care reports a DTI (deep tissue injury) to R heel, noted during wound care, for coccyx. Area is 2.2 x 2.0 x utd (unable to determine). 100% deep purple, wound bed w/ (with) blister. NO drainage at this time, edges intact. Surrounding skin pink and blanchable. On 6/29/22 at 1:32 p.m. Surveyor spoke with LPN-M on the telephone regarding the nurses note she wrote on 5/16/22 which documented R406 had two skin tears on the buttocks. Surveyor asked LPN-M if she notified a RN regarding these skin tears. LPN-M informed Surveyor she didn't as when she was giving report the nurse told her the wound nurse knew about the skin tears and he can treat it. LPN-M explained to Surveyor she works the night shift. On 6/30/22 at 8:10 a.m. Surveyor spoke with Wound Care RN-F on the telephone regarding R406's pressure injuries. Surveyor asked Wound Care RN-F how R406 developed the coccyx pressure injury. Wound Care RN-F replied I don't know. I just write the order. Surveyor inquired who revises skin integrity care plans. Wound Care RN-F informed Surveyor he put the care plan in and changes or adds to the care plan. Surveyor informed Wound Care RN-F R406 was identified as having a coccyx pressure injury on 5/17/22 and the care plan was not revised until 6/3/22. Wound Care RN-F informed Surveyor he may have added interventions late. Surveyor asked why R406's coccyx pressure injury wasn't identified until it was a Stage 3. Wound Care RN-F replied that's a good question and explained staff are suppose to do skin checks with showers. Wound Care RN-F informed Surveyor staff calls him when they see something and may have been small. Wound Care RN-F informed Surveyor he didn't think it was real big and could have looked like white scar tissue and opened. Wound Care RN-F informed Surveyor he reminds staff to turn R406. Surveyor informed Wound Care RN-F of the observations on 6/27/22 of R406 on his back. Wound Care RN-F replied there you go. and informed Surveyor he's seen pillows behind R406's back. Surveyor informed Wound Care RN-F of the observations of R406's heels resting directly on the mattress, not wearing pressure relieving boots, and developed a DTI. Wound Care RN-F informed Surveyor he doesn't have an answer for that and doesn't check Residents every day. Wound Care RN-F explained he would see Residents on Tuesday for wound rounds but now wound rounds are on Thursdays. Wound Care RN-F informed Surveyor he knows R406 has boots but doesn't check to see if he is wearing them. On 6/30/22 at 8:55 a.m. Surveyor spoke with DON (Director of Nursing)-B on the telephone regarding R406. Surveyor informed DON-B R406's Diabetes Mellitus care plan has an intervention for daily inspection of feet and inquired where Surveyor would be able to locate this is being completed. DON-B informed Surveyor this would be on the MAR (medication administration record). Surveyor informed DON-B Surveyor reviewed the MAR & TAR (treatment administration record) starting after R406 returned to the facility on [DATE] and wasn't able to locate this. DON-B informed Surveyor it looks like it was on the MAR and dropped off after he returned from the hospital. On 6/30/22 at 12:00 p.m. Surveyor informed DON-B of the concerns R406's coccyx pressure injury not being identified until it was a stage 3 on 5/17/22 and the care plan not revised until 6/3/22. R406's left buttocks pressure injury declined from a Stage 2 to unstageable on 5/24/22 and there was no revision in the skin integrity care plan until 6/3/22. On 6/28/22 the Surveyor observed [MEDICATION(S)] being applied to the coccyx & left buttocks wound bed when the physicians order was for collagen. Observations of R406's heels not being offloaded and not wearing the pressure relieving boots. No evidence daily foot inspections were being conducted. On 6/28/22 R406 was identified as having a DTI on right heel. 2.) R400 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R400's Quarterly MDS (Minimum Data Set), dated 4/12/22 indicated severe cognitive impairment, Bed Mobility required extensive assistance with 2 staff and toileting was dependent with 2 staff. R400's Section M indicated no repositioning program. R400 was identified as being at risk for pressure injury development. R400's Care Plan, dated 7/9/21, revised 6/16/22, indicated R400 has pressure injury on coccyx with interventions: Administer treatments as ordered (7/9/21), Assist (R400) to reposition and/or turn at frequent intervals (7/9/21) Provide Incontinence care (7/9/21), (R400) requires pressure relieving/reducing device on (Specify:bed/chair) (6/26/22), Weekly Treatment documentation to include measurement, of each area of skin breakdown's width, length, depth, type of tissue, and exudate (6/16/22). R400's CNA (certified nursing assistant) Care card, dated 6/29/22 indicated check and change every 2-3 hours and as needed for incontinence. R400's care card does not address repositioning, heel boots, or an air matress. R400's Assessment record indicated on 6/15/22 at 12:12 PM a Head to Toe skin check identified an open area to coccyx. Facility wound rounds are completed on Thursdays which would be 6/16/22. There is no documentation to indicate R400 was assessed byt he wound team on 6/16/22. R400's Weekly Pressure Injury record was completed on 6/20/22 indicating an Acquired Wound to Coccyx-Stage 2 measuring 1 x 0.7 x 0.1 cm with 100% smooth red wound bed, scant drainage, pink tissue surrounding. Treatment order indicated [MEDICATION(S)] followed by border foam dressing. R400's NP (Nurse Practitioner) Wound Care Assessment on 6/23/22 indicated a coccyx wound measuring 0.7 x 0.5 x 0.1 cm. Plan of Care/Orders include a pressure reducing cushion to Broda chair, Low air loss mattress, every 2 hours turns with assist and as needed. Treatment: Cleanse with wound cleanser, apply skin prep to surrounding area, Collagen sheet secure with Border foam dressing. No treatment was documented for R400 on 6/25/22. On 6/27/22, at 9:45 AM, Surveyor observed R400 lying flat in bed, heel boots on bilaterally and no air loss mattress. On 6/27/22, at 1:00 PM, Surveyor observed R400 in bed remaining on Back-head of bed elevated with feeding assistance. CNA-J (Certified Nurse Assistance) stated R400 would remain in bed today. R400's Weekly Pressure Injury record was completed on 6/28/22 indicating the acquired wound to Coccyx-Stage 2 measuring 0.7 x 0.5 x 0.1 cm, and documentation indicated a low Air Loss Mattress but it was not observed on the bed. Review of R400's Treatment orders indicate the orders were not changed until 6/28/22 to Collagen per Nurse Practitioner order. R400's Treatment done on 6/28/22 was still documented as [MEDICATION(S)]. R400's care plan was not updated to reflect every 2 hours turns with assist. On 6/28/22, at 8:14 AM Surveyor observed R400 up in Broda chair with cushion in the dining room. On 6/28/22, at 11:54 AM, Surveyor observed R400 remains in Broda chair in dining room for lunch. On 6/28/22, at 9:50 AM, LPN-L (Licensed Practical Nurse-Unit Manager) notified Surveyor that R400 remains up in the Broda chair and for Surveyor to observe treatment, the staff would have to lay R400 down. LPN-F stated if R400 wanted to be up for lunch then he would lie down at 1:00 PM otherwise R400 would go to bed for lunch at 11:30 AM. Surveyor stated R400 should be able to choose the care and Surveyor would follow up with R400. On 6/28/22, at 2:00 PM, Surveyor observed R400 in bed lying flat. CNA-I stated R400 went to bed at 1:15PM. R400 was observed on 6/27 for 4 hours without being repositioned in bed. R400 was observed on 6/28 for 5 hours up in chair without repositioning. On 6/28/22, at 2:13 PM, WCRN-F (Wound Care Registered Nurse) stated to Surveyor that R400's dressing changes are T/Th/Sat and Surveyor would need to come right now to see wound and treatment. Surveyor was unable and stated will check with nurse in am to review skin before R400 got out of bed. WCRN-F stated the dressing would probably be soiled and need c [TRUNCATED]

Based on observation, interview and record review the facility did not ensure residents were treated with dignity and respect for 1 (R407) of 18 sampled residents. *R407 was observed from the hallway with his legs spread open exposing a heavily saturated brief. Brown colored matter was observed coming out on the edges of the brief. The smell of urine and bowel matter was evident when the Surveyor entered his room. R407 was observed tapping at his brief with his hand multiple times appearing to try to draw attention to his need to be changed. R407 was assessed by facility staff to identify Spanish as his preferred language and need/want an interpreter to communicate with his physician and Health Care staff. Findings include: R407 was admitted to the facility on [DATE] and has diagnoses that include, but are not limited to, cerebral infarction, dysphagia following cerebral infarction, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side, [CONDITION(S)] and chronic kidney disease. R407's Minimum Data Set (MDS) Quarterly assessment dated [DATE] Section A: Identification Information - Language identifies R407 as needing and wanting an interpreter to communicate with a doctor or health care staff and his preferred language is Spanish. Section C: Cognitive Patterns documents a R407's Brief Interview for Mental Status (BIMS) was scored at 6 which indicated severe cognitive impairment; Patient Health Questionnaire (PHQ-9) score of 9, indicating mild depressive symptoms; R407 is dependent on 2 + staff for transfers, requires extensive assist of 2 + staff for bed mobility, dressing and toilet use; dependent on 1 person for eating and personal hygiene; has limited range of motion to upper and lower extremities on one side; is occasionally incontinent of bladder and frequently incontinent of bowel, the facility has not trialed a toileting program and is not currently using a toileting program. On 6/27/22 at 12:21 PM, Surveyor reviewed R407's care plan which documents: R407 has an Activities of Daily Living (ADLs) self-care performance deficit due to [CONDITION(S)] ([CONDITION(S)]). Date initiated, 3/10/21 and revised on 6/3/22, interventions include: Resident is totally dependent on (1) staff for toilet use; Bowel incontinence due to [CONDITION(S)] with [CONDITION(S)]; Check resident frequently and assist with toileting as needed, Date initiated 3/10/21 and revised on 6/20/22 Care plan also documents R407 has a communication problem due to language barrier, speaks Spanish with very little English, date initiated 3/10/21. Interventions include: Observe/document for physical/nonverbal indicators of discomfort or distress and follow up as needed. On 6/27/22, at 11:58 AM, Surveyor observed R407 lying in bed on his back. The head of the bed (HOB) was elevated. Resident was wearing a hospital gown that was draped open exposing his bare chest and legs. R407 was wearing a brief that appeared to be saturated as it was bulging between his legs. On 6/27/22, at 2:00 PM, Surveyor observed R407 lying in bed on his back. R407 was wearing a hospital gown that was draped open and exposing his bare chest and legs. R407's legs were spread open exposing the heavily saturated brief. Brown colored matter was observed coming out on the edges of the brief. Surveyor noted the smell of urine and bowel matter in the room. R407 was observed tapping at his brief with his hand multiple times. On 6/27/22, at 3:21 PM, Surveyor observed R407 lying in bed on his back. R407 was wearing only a brief. Brown colored matter was observed coming out on the edges of the brief. The bedsheet under R407 was stained with yellow and brown matter. Surveyor noted the smell of urine and bowel matter in the room. On 6/28/22, at 10:00 AM, Surveyor interviewed Licensed Practical Nurse-C (LPN-C) and asked how staff communicates with R407. LPN-C stated most of the time he speaks in Spanish. He does say some words in English, like he will ask for a urinal. LPN-C stated we ask him questions if we don't understand him or find a staff person who speaks Spanish. R407 was not treated with dignity as he was not fully clothed or covered and visible from the hallway wearing a soiled, bulging brief with brown colored matter observed coming out the edges of the brief. R407's bedsheet was stained with yellow and brown matter and the smell of urine was noted in the room. R407 was aware of his incontinence and was attempting to communicate this to others by tapping on his brief multiple times.

Based on record review and interviews, the facility did not immediately notify the resident representative of R66's change in condition including wound care and lethargy which may have required the facility to alter treatment or commence a new form of treatment for 1 (R66) of 5 sampled residents. R66's resident representative was not notified with changes in wound treatments/plan, change in mental state (lethargy), significant change in functioning, and psych referral for sadness, anger and depression. Findings include: The facility policy, Changes in Resident Condition, dated April 2005, revised February 2017, indicated the nursing staff, the resident, the attending physician, and the resident's legal representative are notified when changes in the resident's condition occur. R66 was admitted to the facility on [DATE] and recently hospitalized from 4/19/22 to 5/4/22 and 5/5/22 to 5/19/22. R66's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R66's 5/27/22 Significant Change MDS indicated R66 was cognitively intact requiring extensive assistance with 1-2 staff for bed mobility, and functional limitation with impairment on one side for upper and lower extremity. Surveyor reviewed R66's medical records and available hospital records. R66 was noted by the podiatrist on 3/23/22 to have 3 wounds with redness and swelling of right foot with recommendation for hospitalization for evaluation and treatment. R66 refused and was treated with antibiotics by NP (Nurse Practitioner) with plan for the Physician and Wound Nurse to see him as soon as possible. On 4/12/22, R66's diabetic foot ulcer to the right hallux/right medial foot was noted to be a full thickness wound with 100% brown adhesive slough with drainage and was debrided by the Wound NP. *Wound NP did not update R66's significant other (spouse) of the debridement and treatment. WCRN-F (Wound Care RN) documented his wound information on 4/12/22 in the Skin non-pressure weekly condition record and indicated notification of self (R66). *WCRN-F did not update R66's significant other (spouse) of the wound assessment and plan. On 4/19/22, Wound NP documented in R66's Wound Assessment that Patient appears lethargic, lying in bed. Per nursing staff, he has been not acting himself for the last couple of days, especially requiring more assistance with transfers and increasing lethargy. Today, he arouses to touch. He reports he feels out of it today. In the past, he has declined ER transport but today is agreeable. No fevers/chills per nursing staff, he is afebrile at 97.5 F. Blood sugars reviewed and in acceptable range, continue glycemic control. *The facility did not update R66's significant other (spouse) of his increased lethargy or not acting himself for the last couple days. R66 was transferred to the hospital on 4/19/22 and returned to the facility on [DATE] with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/5/22, R66's IDT (Interdisciplinary Team Risk Meeting) progress note indicated resident is his own RP (Responsible Party) and agreeable to the treatment plan. *The facility IDT did not update R66's significant other (spouse) of the treatment plan despite recent lethargy, not acting himself and infection. R66's 5/5/22 progress note indicated spouse called several times this shift trying to get through to the nurses desk. Spouse stated concern as R66 stated having 3 new wounds and wants him sent back to the hospital. R66 was transferred to the hospital on 5/5/22 and returned to the facility on [DATE] with Right BKA (Below Knee Amputation). On 5/25/22, R66's SW- K (Social Worker) progress note indicated meeting with R66 who presented as sad with flat affect and appeared depressed and angry regarding BKA. SW-K offered psych services and referral accepted with skepticism. *SW-K did not update R66's significant other (spouse) of the psych services and referral. On 5/26/22, R66's IDT progress note indicated R66 had a significant change discussing nursing and therapy documentation. *The facility IDT did not update R66's significant other (spouse) of the significant change in performance and change to plan. On 5/29/22, R66's nursing progress note indicated R66 was lethargic during shift with poor appetite. On 6/29/22, at 3:00 PM, the Survey Team shared concerns regarding R66's lack of notification to resident representative with updates on changes/plan of care and requested change in condition/notification policy. No further information was provided.

Based on interview and record review, the facility did not have a system to ensure that there was someone working each shift who was certified in CPR (cardiopulmonary resuscitation, which had the potential to affect 93 of 144 residents who are full code. The facility did not immediate basic life support, including Cardio Pulmonary Resuscitation (CPR) to 1(R188) of 2 residents who was unresponsive. On [DATE] during the night shift, R188 was found unresponsive by Certified Nursing Assistant (CNA) L. CNA L told Registered Nurse (RN) H about R188 being unresponsive and RN H did not immediately perform life saving measures. RN H did not assess R188's breathing or pulse. RN H did not use the paging system for assistance, but instead went to a different unit to get Assistant Director of Nursing (ADON) K to assist. Agency Licensed Practical Nurse (LPN) AA was told R188 needed CPR. Agency LPN AA checked R188's breathing and found him to not be breathing and began CPR. The facility's failure to immediately perform basic life support when R188 was found unresponsive and the failure to have a system that ensured each shift had CPR-certified staff created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA) A of the immediate jeopardy on [DATE] at 12:00 p.m. The immediate jeopardy was removed on [DATE] however, the deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: The facility's policy Medical Emergency Management with revised date of February 2017 indicates: The facility ensures residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's airway, breathing, and circulation are maintained until emergency personnel arrive. Staff is aware of each resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Guidelines: 1. Licensed nursing staff in the facility must obtain their CPR certification during their probationary period and keep their certification current during their employment. It is recommended that unlicensed staff that provide direct resident care also maintain a current CPR certification. 4. The facility will maintain an Automated External Defibrillator (AED) if required by state regulation. 5. Once a medical emergency is identified, qualified staff assesses the resident, initiate the appropriate emergency procedure (s) in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff continues to provide care and monitor the resident until the emergency personnel arrive. 1.) R188 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (minimum data set) dated [DATE] indicates R188 is alert and cognitively intact, needs extensive assistance of two staff for bed mobility and hygiene. It also indicates R188 had a urinary catheter due to urinary retention. R188 was full-code. The nurses note dated [DATE] at 5:46 a.m. indicates: RN called to room per CNA (certified nursing assistant) during rounding. observed resident unresponsive. 911 called immediately. CPR (cardiopulmonary resuscitation) initiated. (Physician) paged. ADON (assistant director of nursing) updated. Surveyor reviewed the facility self report dated [DATE] which includes RN H's statement indicating: found patient had a change in status. She called the doctor (paged X 2). Called 911 immediately, as the patient was a full code. (RN) reviewed the chart and found 0 family contacts. While awaiting 911 to come, all necessary documents were printed. DON (Director of Nursing)/NHA were notified. ADON (who was in the building) was notified . RN H completed an SBAR (situation, background, assessment and recommendation) dated [DATE]. The SBAR indicates RN H was called to R188's room per CNA L. RN H observed resident to be unresponsive. 911 called immediately. The SBAR had vital signs dated [DATE]. The SBAR had the following conditions to assess during a change in condition: Mental status changes, Functional status changes, respiratory, GI/abdomen and GU/urinary changes. RN had marked NA for all changes. The SBAR assessment section asks the nurse completing the SBAR for an assessment of what may be the problem with the patient and RN did not complete an assessment and only wrote called 911 immediately. The facility self report does not have any other staff statements. The facility self report does not indicate who began CPR and when R188 was assessed to need CPR. On [DATE] at 9:00 a.m. Surveyor interviewed Paramedic I. Paramedic I stated the rescue squad arrived at the facility on [DATE] at 5:11 a.m. and arrived at the resident's bedside at 5:13 a.m. Paramedic I stated when they arrived at the resident's bedside, the facility staff were performing CPR. Paramedic I stated they let the facility staff continue with CPR until rescue squad got their equipment ready to take over CPR. Paramedic I stated R188 remained asystole (state of total cessation of electrical activity from the heart) through the whole call. Paramedic I stated they pronounced R188 dead at the facility with the permission of their medical director. Paramedic I stated R188 had all signs of death. On [DATE] at 8:09 AM Surveyor interviewed CNA L. CNA L stated she worked the night shift on [DATE] into [DATE]. CNA L stated she's not sure about the time but about 3 or 4 am CNA L went into R188's room to empty out his catheter and saw R188 had turned a different color. CNA L immediately told RN H. CNA L stated RN H went to look for ADON K for help. CNA L stated she did not participate in CPR only doing rounds on the rest of the residents on the unit. On [DATE] at 10:32 a.m. Surveyor interviewed RN H. RN H stated she remembers that day because it was the worse night of my nursing career. Surveyor asked RN H when was she made aware R188 was unresponsive. RN H stated about 5:00 a.m. CNA L told her R188 was unresponsive. Surveyor asked RN H what specifically did CNA L tell her about R188's condition. RN H said CNA L told her R188 was unresponsive. RN H stated she immediately went to R188's room and saw he was unresponsive. Surveyor asked RN H what did R188 look like. RN H stated he just looked unresponsive. Surveyor asked if RN H did an assessment, RN H stated no she did not because he looked like he needed 911. RN H stated she then ran down the hall to the Rehab unit to get ADON K. RN H stated ADON K and an agency nurse from another unit went to R188 to perform CPR and RN H called 911. Surveyor asked RN H at 5:00 a.m. when she found R188 unresponsive, did R188 have his [CONDITION(S)] on. RN H stated she doesn't remember. At no point during the interview did RN H explain why basic life support wasn't started immediately when R188 was found unresponsive. Surveyor asked RN H if she had a current CPR certification card. RN H stated her CPR certification expires in [DATE]. On [DATE] at 9:02 AM Surveyor interviewed ADON K. ADON K stated she was on the rehab unit and R188 was on LTC 1 unit. RN H came from LTC 1 to rehab unit to tell ADON K that R188 was unresponsive. Surveyor asked ADON K approximately how long does it take to go from LTC 1 unit to the Rehab unit where ADON K was located. ADON K indicated it would be at least a minute each way. ADON K stated she went to R188's room and saw R188 wasn't breathing. ADON K stated R188's lips were purple in color and there was foam around his mouth. ADON K stated his [CONDITION(S)] was not on. ADON K stated they started CPR and another nurse called 911. Surveyor asked ADON K if there was a paging system when there is a code situation. ADON K stated (incorrectly) there isn't a paging system which is why RN H had to walk to get help. On [DATE] at 12:50 p.m. Surveyor interviewed Agency LPN AA. Agency LPN AA stated on [DATE] she doesn't remember who told her but she was made aware of R188 needing CPR. Agency LPN AA stated when she arrived to R188's room with a medication tech (doesn't remember the name of the med tech), Agency LPN AA saw R188 laying on his back, his right arm hanging off the side of the bed and his eyes closed. Agency LPN AA listened for R188's breath sounds and didn't hear anything so immediately started CPR with the assistance of the medication tech. Agency LPN AA stated ADON K came into the room shortly and took over for the medication tech. Agency LPN AA stated RN H did not participate in the code situation. Agency LPN AA stated RN H called 911. Agency LPN AA stated R188 did not have his [CONDITION(S)] on and heard that he sometimes was noncompliant with putting it on. Agency LPN AA stated she and RN H continued with CPR until the paramedics arrived. The facility staff did not begin CPR immediately upon finding R188 unresponsive. RN H did not use the paging system but, instead, went to another unit to find a nurse to assist. According to a 2019 Division of Appeals Board (DAB) hearing decision, The driving force behind the American Heart Association guidelines .and regulatory requirements is that CPR must be initiated immediately when a full code resident is found to be nonresponsive. Time is of the essence in initiating CPR. Any delay endangers a nonresponsive individual's safety and his or her life. With CPR, seconds may mean the difference between resuscitation and death. https://www.hhs.gov/about/agencies/dab/decisions/alj-decisions/2019/alj-cr5339/index.html 2.) The total facility census was 144 and total of 93 residents had a full code status at the time of the survey. On [DATE] at 9:52 AM Surveyor asked NHA A for a list of all nursing staff and their CPR certification status. NHA A stated HR (human resources) has not been keeping track of staff's CPR certification status. On [DATE] at 12:16 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated every nurse should be CPR certified, but DON-B was not sure if they were or not since the facility has not been tracking that data. DON-B stated it is unknown which staff are or are not certified when they are scheduled to work at this time. DON-B hopes to have CPR training here within the next few days. Subsequently, NHA A gave Surveyor a copy of Agency LPN AA and ADON K CPR certification card. Agency LPN AA's CPR Certification expires [DATE]. ADON K's CPR certification expires [DATE]. The facility was unable to verify the certification status of Registered Nurse (RN) D who successfully provided CPR to R92 on [DATE] when R92 was found unresponsive. Surveyor reviewed RN H personnel file and there wasn't any evidence of a CPR card being obtained at the time of hire. Surveyor reviewed the Facility Assessment which indicates licensed nurses are to annually update their CPR certification. The facility assessment indicates this was reviewed in QAPI (quality assurance performance improvement) on [DATE]. On [DATE] at 10:30 a.m. Surveyor spoke with NHA A. Surveyor explained to NHA A the concern R188 was found unresponsive and an immediate assessment of R188's breathing or pulse was not done. RN H went to a different unit to get another nurse to help. Immediate action was not done when R188 was found unresponsive. Surveyor also explained the concern the facility has no record of their nursing staff CPR certification and no system on keeping track of CPR certification. These failures created a reasonable likelihood that serious harm could occur, thus creating a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: ~ The Medical Director was contacted by the NHA A and advised of deficiency on [DATE]. ~ The Human Resource Director audited licensed nursing staff employee files to determine CPR status. Copy of CPR cards were verified with each licensed nurse and if CPR status is not current employee to be provided with CPR certification class information. ~ An in facility CPR certification class to be held Wednesday, [DATE]. ~ The Human Resource Director will be educated on requirements for mandatory CPR education for licensed nursing staff. Human Resource Director will be responsible for verifying nursing CPR status prior to beginning employment and maintaining current licensed nursing staff CPR status. Copy of CPR cards will be placed in employee files and list expiration dates monitored by Human Resource Director. ~ All licensed nursing staff was educated by the Nurse Manager related to the requirement to maintain an up to date CPR certification at all times while employed at the facility. ~ All licensed nursing staff was educated on the procedure of handling a change of condition and what to do in an emergent situation to avoid delay in treatment. See steps below: If licensed staff/ RCS (CNA) notices change in condition: If RCS (Resident Care Staff/CNA), they would verbally advise licensed staff member of change. If licensed staff member notices the change with the resident, they would follow the following steps: - Call for help verbally and pull call light - CODE BLUE announced through paging system - Chart/PCC would be checked for code status - 911 called - Physician and RP notified regarding change of condition - Based on resident's CPR status, CPR is initiated immediately and continued until 911 arrives. ~ Education was completed. ~ The Scheduler will be provided with a list of current CPR certified licensed nursing staff to ensure at least one CPR certified nurse is working each shift. ~ HRM (Human Resources Manager) or designee audited new licensed nurse employee files weekly to ensure CPR status is verified. ~ DON or designee audited list of CPR certified staff weekly to ensure CPR status is being maintained and review any upcoming expiration dates. ~ DON or designee audited licensed nursing schedules daily (M-F) x 2 weeks to ensure at least one CPR certified licensed nurse is working.

Based on interview and record review the facility did not ensure 1 (R188) of 1 resident experiencing a change in condition and eventually becoming unresponsive received the necessary RN assessment to prevent further decline. On [DATE] into [DATE] during the night shift, R188 experienced a change in condition. R188 was having vomiting episodes and Certified Nursing Assistant (CNA) L twice notified Registered Nurse (RN) H. RN H did not assess R188. Around 5:00 a.m. R188 was found unresponsive; an assessment still was not completed and R188 died at the facility. The facility's failure to assess R188 immediately after the change in condition and after being found unresponsive created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA) A of the immediate jeopardy on [DATE] at 12:00 p.m. The facility removed the jeopardy on [DATE]. However, the deficient practice continues at a scope/severity of an E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: Facility policy regarding Changes in Resident Condition with revision date [DATE] indicate: The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Communication with the Interdisciplinary Team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. Guidelines: 1. For life-threatening events, call 911 if initial assessment indicates that such action is necessary 4. The SBAR communication form and the progress note are used to a. assess and document changes in condition in an efficient and effective manner; b. Provide assessment information to the physician, and c. Provide clear comprehensive documentation Professional standards of practice for a registered nurse in Wisconsin are delineated in N6, Wisconsin Nurse Practice Act. According to N6, Wisconsin Nurse Practice Act: An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. R188 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (minimum data set) dated [DATE] indicates R188 was alert and cognitively intact, needed extensive assistance of two staff for bed mobility and hygiene. It also indicates R188 had a urinary catheter due to urinary retention. The nurses note dated [DATE] 11:41 p.m. indicates UA (urinary analysis) obtained. C and S (culture and sensitivity) pending. Slight bleeding from penis. Has new foley. Is obese. Keeps pulling on tube. Cranberry juice encouraged. Ate 100 percent. No sob (shortness of breath). No n/v (nausea/vomiting). vss (vital signs stable). The nurses note dated [DATE] at 4:15 a.m. indicate observed resting comfortably in bed. UA was sent per lab pick up. no c/o (complaints of ) pain or discomfort. foley intact. monitored for bleeding. call light in reach at all times. This nurses note was written by RN H. On [DATE] at 8:09 AM Surveyor interviewed CNA L. CNA L stated she worked the night shift on [DATE] into [DATE]. CNA L stated sometime earlier in her shift (not sure the time) R188 was vomiting and he had his [CONDITION(S)] (continuous positive airway pressure device) off at the time. CNA L stated R188 asked her to let the nurse know he was vomiting. CNA L stated she told RN H R188 had vomited. CNA L stated RN H just said ok. CNA stated she was doing her rounds and about 2 am R188 had his call light on. CNA L answered R188's call light. R188 had vomited again, and CNA L cleaned the basin. CNA L stated R188 asked again if she told the nurse. CNA L stated she told R188 she did tell the nurse. CNA L stated she told RN H again that R188 had vomited again. CNA L stated she's not sure about the time but about 3 or 4 am CNA L went into R188's room to empty out his catheter. She saw R188 had turned a different color, and CNA L immediately told RN H. CNA L stated RN went to look for ADON K for help. CNA L stated she did not participate in the CPR (cardiopulmonary resuscitation) because she continued doing rounds on the rest of the residents on the unit. RN H completed an SBAR (situation, background, assessment and recommendation) dated [DATE]. The SBAR indicate RN H was called to R188's room per CNA L. RN H observed resident to be unresponsive. 911 called immediately. The SBAR had vital signs dated [DATE]. (There were no vital signs from the current shift.) The SBAR had the following conditions to assess during a change in condition: Mental status changes, Functional status changes, respiratory, GI/abdomen and GU/urinary changes. RN had marked NA for all changes. The SBAR assessment section asks the nurse completing the SBAR for an assessment of what may be the problem with the patient and RN did not complete an assessment and only wrote called 911 immediately. The nurses note dated [DATE] at 5:46 a.m. indicates RN called to room per CNA (certified nursing assistant) during rounding. observed resident unresponsive. 911 called immediately. CPR (cardiopulmonary resuscitation) initiated. (Physician) paged. ADON (assistant director of nursing) updated. (Cross reference F678. Nursing did not immediately call 911 or begin CPR.) On [DATE] at 9:00 a.m. Surveyor interviewed Paramedic I. Paramedic I stated the rescue squad arrived at the facility on [DATE] at 5:11 a.m. and arrived at the resident's bedside at 5:13 a.m. Paramedic I stated R188 remained asystole (state of total cessation of electrical activity from the heart) through the whole call. Paramedic I stated they pronounced R188 dead at the facility with the permission of their medical director. Paramedic I stated R188 had all signs of death. On [DATE] at 10:32 a.m. Surveyor interviewed RN H. RN H stated she remembers that day because it was the worse night of my nursing career. RN H stated when she arrived on her shift [DATE] at 11:00 p.m. she was made aware that she would be working on LTC 1 and Rehab unit. RN H stated both units would total 70 residents for RN H to care for, and she said she couldn't do it. RN H stated she called Former Director of Nursing (DON) J and ADON K that she couldn't do both units and she needed help. RN H stated ADON K came in at 12:00 a.m. to work the rehab unit. Surveyor asked RN H how many residents did she have on LTC 1. RN H stated about ,d+[DATE] residents on LTC 1. Surveyor asked RN H when was she made aware R188 was unresponsive. RN H stated about 5:00 a.m. CNA L told her R188 was unresponsive. Surveyor asked RN H what specifically did CNA L tell her about R188 condition. RN H said CNA L told her R188 was unresponsive. RN H stated she immediately went to R188 room and saw he was unresponsive. Surveyor asked RN H what did R188 look like. RN H stated he just looked unresponsive. Surveyor asked if RN H did an assessment, RN H state no she did not because he looked like he needed 911. RN H stated she then ran down the hall to the Rehab unit to get Assistant Director of Nursing (ADON) K. RN H stated ADON K and an agency nurse from another unit went to R188 to perform CPR and RN H called 911. Surveyor asked RN H if at any point during the shift, prior to 5:00 a.m., did CNA L tell her R188 was vomiting. RN H stated I don't remember. Surveyor asked RN H at 5:00 a.m. when she found R188 unresponsive if R188 had on his [CONDITION(S)]. RN H stated she doesn't remember. RN H stated at 2:00 a.m. she went into R188's room to attend to R188's roommate. RN H stated R188's roommate bed was high and his TV was on, so she lowered the bed because R188's roommate was a fall risk and turned off the TV. Surveyor asked if she looked at R188 while she was in the room. RN H stated she saw R188 sleeping. Surveyor asked if R188 had his [CONDITION(S)] on. RN H stated she doesn't remember. Surveyor asked RN H if she was aware R188 was bleeding from his penis on the previous shift. RN H stated she was aware a UA was collected but was not aware of R188 bleeding from his penis. Throughout the interview RN H kept repeating how horrible it was that the facility wanted RN H to work 2 units. At no point during the interview did RN H explain why an assessment was not completed on [DATE]. RN H failed to follow the Nurse Practice Act by failing to assess, plan, and intervene. This prevented nursing from assessing the significance of R188's change in condition. Although vomiting is often symptomatic of an innocuous condition, according to Healthline, Vomiting accompanied by the following symptoms should be treated as a medical emergency: severe chest pain sudden and severe headache shortness of breath blurred vision sudden stomach pain stiff neck and high fever blood in the vomit https://www.healthline.com/health/vomiting-causes-treatment#see-a-doctor On [DATE] at 10:30 a.m. Surveyor spoke with NHA A. Surveyor explained to NHA the concern R188 was experiencing a change in condition, with episodes of vomiting and RN H did not assess R188. Surveyor explained through interviews RN H did not assess R188 when he was found unresponsive. Surveyor explained RN H completed the SBAR dated [DATE] with vital signs from [DATE] and the areas for assessment were not completed. NHA A stated she was not aware R188 was vomiting that night and was not aware RN H did not assess R188 at the time of the change in condition and at the time he was found unresponsive. The failure to follow the Nurse Practice Act by failing to assess R188 after R188 experienced a potentially significant change in condition and after being found unresponsive created a reasonable likelihood for serious harm, thus creating a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE] when it had implemented the following: ~ The Medical Director contacted by the NHA and advised of deficiency. ~ All licensed nursing staff were educated by the Nurse Manager related to identifying resident change of condition, ensuring completion of a comprehensive assessment, physician/RP notification and ensuring clear comprehensive documentation. ~ Education was provided regarding prompt notification being required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention: a significant change in the residents attending physical, mental or psychosocial status, including a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications: or need to alter treatment significantly. ~ Current residents with noted change of condition as of [DATE] were reviewed for SBAR documentation including comprehensive assessment, physician/RP notification and clear comprehensive documentation. If licensed staff/ RCS (CNA) notices change in condition: If RCS notices a change of condition, they will immediately notify licensed staff as well as fill out the STOP & WATCH form. If licensed staff member notices the change, they would do an assessment/evaluation of the resident, notify physician for further instructions, notify RP and complete SBAR. If resident is unresponsive, they would follow the following steps: - Call for help verbally and pull call light - Chart/PCC (PointClick Care) would be checked for code status - CODE BLUE announced through paging system - 911 called - Physician and RP notified regarding change of condition Based on resident's CPR status, CPR is initiated immediately and continued until 911 arrives. ~ Changes of condition will be communicated shift to shift through change of report as well as the 24-Hour Report. For life threatening events call 911 if initial assessment indicates that such action is necessary. ~ Changes in resident that affect the problem(s)/goal(s) or approach(es) on his/her care plan are documented as revisions and communicated by the IDT (interdisciplinary team) to direct care staff. ~ Director of Nursing (DON) or Nurse Manager will audit 2 resident medical records that have been identified to experience a change of condition, per day x 2 weeks (M-F) to ensure elements of the change of condition procedure have been met. ~ DON or Nurse Manager will review PCC dashboard, 24-hour board, for any noted resident change of condition daily (M-F) for 2 weeks, then 3 times a week for 2 weeks, then weekly thereafter until QA committee deems appropriate. ~ MDS (Minimum Data Set Nurse)/Designee will audit 3 residents care plans from noted resident change of condition for appropriate interventions being care planned 2 times a week for 2 weeks, then weekly thereafter until QA committee deems appropriate. ~ All weekly AT RISK meeting notes will be reviewed and submitted to QAPI monthly to identify trends x 3 months or until QA committee deems appropriate.

Based on interview and record review, the Facility did not immediately consult with a Resident's physician for 1 (R93) of 29 sample residents reviewed for physician notification. R93 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/22 at 3:39 PM, the Final Report of the lab test results indicate the order was reported and resulted. The results of the lab test were noted to be abnormal, specifically with the white blood count as being high. The physician was not notified of the lab results until 3/25/22. Once the physician was notified of the abnormal lab results, the physician ordered to send R93 to the hospital for evaluation and treatment. R93 was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R93 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R93's Quarterly MDS (Minimum Data Set) dated 12/14/21 documents that R93 has a BIMS (Brief Interview for Mental Status) assessment score of 00 indicating R93 demonstrates severe cognitive impairment for daily decision making. R93 has a Healthcare Power of Attorney. On 3/22/22, there is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/22/22, the Wound Care Assessment in R93's electronic health record documents (in part): Wound to sacrum.Afebrile at 98.4.Stage 4 pressure injury to sacrum.There is a large amount of malodorous serosanguineous drainage. Periwound with scar tissue. Status: declined. Wound infection with odorous declining wound. Plan: CBC, CMP, [MEDICATION(S)] and vanco. culture taken - modify antibiotics based on culture results. On 3/22/22 at 6:02 PM, the Wound RN (Registered Nurse)-GG writes a skin/wound note stating Culture obtained of Sacral wound. Floor nurse to send to lab for C&S. Also floor nurse to call and have PICC line place and labs drawn. On 3/22/22 at 8:35 PM, the Final Report from the laboratory indicates the blood specimen was collected from R93. On 3/22/22 at 9:00 PM, a nursing note documents the following New order for [MEDICATION(S)] (antibiotic) 1 gram twice daily via IV, Stat CBC/CMP and Sacral wound C&S. Lab made aware of lab orders via telephone and fax, awaiting lab draw and specimen pick up. On 3/23/22 at 3:39 PM, the Final Report of the lab test results indicate the order was reported and resulted. Surveyor noted there were no comments in the progress notes on 3/23/22 regarding the lab results and physician notification. On 3/24/22 at 4:40 PM, the Wound RN-GG wrote a nursing note that states Lab results obtained and faxed to pharmacy at pharmacy request for vanco dosing. Also pharmacy to call to have PICC line inserted. Surveyor noted there were no comments in the progress notes on 3/24/22 regarding physician notification of the lab results that were sent to the pharmacy. On 3/24/22 at 10:38 PM, a nursing note documents PICC line placed this evening. Left upper arm. 1st dose of Vanco given as ordered. Surveyor noted this is two days after ordered by the physician. On 3/25/22 at 1:50 PM, the Wound RN-GG wrote a skin/wound note indicating Writer notified Wound NP (Nurse Practitioner) of lab results with WBC (White blood cell count) of 22.8. Instructed to call MD. MD called back and order to send to Hospital received. Floor nurses to send resident to hospital. Wound NP said would notify POA. According to the American Medical Directors Association (AMDA), Acute Change of Condition in the Long-Term Care Setting, Clinical Practice Guideline, page 17, Table 14 Framework for Reporting Changes in Vital Signs or Laboratory Values to a Practitioner, Complete blood count WBC>12,000 Report Immediately. On 3/25/22 at 2:03 PM, a nursing note states Doctor informed of abnormal labs of 3/24/22. New orders received to send resident to ER (emergency room ) for Eval and Treatment. Daughter informed of pending transfer. On 3/25/22 at 2:10 PM, a nursing note documents Hospital called regarding transport for eval and treatment regarding abnormal labs. Ambulance called for transport to hospital. On 3/25/22 at 2:33 PM, a nursing note states Ambulance here to transport resident to hospital. On 3/25/22 at 10:45 PM, an infection progress note documents Was contacted by hospital emergency room . R93 has been admitted to the hospital this evening. Admitting Dx (diagnosis): Acute [MEDICATION(S)], [CONDITION(S)], Ulcer. On 03/29/22 at 11:20 AM, Surveyor interviewed NP (Nurse Practitioner)-MM. NP-MM stated she wanted immediate labs drawn on 3/22/22 as there was concern about R93's wound evaluation that day. NP-MM stated she wasn't notified until Friday 3/25/22 of the abnormal WBC which is when she recommended to call the doctor right away. NP-MM stated she would have sent R93 out when notified of the high WBC numbers and knew the doctor would too. NP-MM indicated R93 should have gone to the hospital earlier when the results were available, but we didn't hear from the facility about the labs until Friday (3/25/22). NP-MM said it was a concern that it took so long to get the lab results to the doctor as R93 could have gotten a work up at the hospital quicker. NP-MM stated from now on, Wound RN-GG will be following up on all of NP-MM's labs so they will be checked regularly and will talk to Facility administration to make sure this doesn't happen again. On 3/29/22 at 12:30 PM, Surveyor interviewed Wound RN-GG. Wound RN-GG stated he did send in the lab results to pharmacy on Thursday, 3/24/22, but did not look at the results and assumed they were already sent to the doctor. Wound RN-GG believed the other floor nurses would check the labs daily so assumed that part was done, but on Friday 3/25/22, Wound RN-GG printed out the labs and noticed the doctor was not notified so then contacted NP-MM to see what to do. Wound RN-GG stated the lab used to fax the results, but now the staff have to go in to the computer system to print them out. Wound RN-GG was not sure of the procedure for who can do this or when it should be done, but will now make sure to print out all of the Wound labs and keep the doctor up to date timely. On 03/30/22 at 10:45 AM, LPN-LL was interviewed by Surveyor. LPN-LL said labs should be checked every shift, printed out, call the doctor, write a progress note, file and put new orders in if necessary. LPN-LL stated nurses need access to the lab results with a password and was not sure if everyone had access. LPN-LL was not sure why there was a delay in notifying the physician of R93's abnormal lab results, but believes it is tough with the agency nursing staff to make sure they know procedure or have access. On 3/30/22 at 12:08 PM, Surveyor interviewed DON-B. DON-B stated labs should be checked daily online and then contact the doctor with the results. DON-B stated R93's lab results were not looked at timely and someone missed it. DON-B indicated there was no policy or procedure for the nursing staff on laboratory results and notification to the physician. On 3/30/22 at 12:18 PM, Surveyor notified NHA-A of the concern that R93's lab results were not shared with the physician timely which then delayed the evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review the facility did not ensure residents received adequate supervision and assistance to prevent accidents for 2 of 8 (R69 and R340) residents reviewed for accidents. R340 sustained a fall from a mechanical lift, which resulted in a head injury requiring staples, due to the care plan not being followed. R69 sustained a fall from bed due to the care plan not being followed. Findings include: The Facility policy titled: Fall Management revised [DATE] documents (in part) . .Policy The center assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Care Plan is developed and implemented, based on this evaluation, with ongoing review. Fall Event 1. When a fall occurs, the resident is assessed for injury by the nurse. 4. The nurse will discuss recommended interventions to reduce the potential for additional falls with the resident and/or resident's representative and document in the Care Plan and Progress Notes. 7. The IDT reviews all resident falls within ,d+[DATE] hours at the IDT meeting to evaluate circumstances and probable cause for the fall. 6. The IDT (Interdisciplinary Team) designee will discuss recommended significant changes to the Care Plan to minimize repeat falls with the resident and/or resident's representative. The Care Plan will be reviewed and/or revised as indicated. Care Kardexes are updated as appropriate. 1.) R340 admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], Diabetes Mellitus Type 2, [CONDITION(S)] [CONDITION(S)], Malnutrition, [CONDITION(S)], Hypertensive [CONDITION(S)], history of [CONDITION(S)] and Cerebral Infarction without residual deficits. R340's Care Plan Focus area initiated and revised on [DATE] documented: (R340) has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) Confusion, Dementia, Fatigue, Impaired balance. Interventions: RESOLVED: TRANSFER: The resident requires SIT -STAND Mechanical Lift with (2) staff assistance for transfers. Date Initiated [DATE], Revision on [DATE], Resolved Date [DATE]. TRANSFER: The resident requires FULL BODY Mechanical Lift with (2) staff assistance for transfers. Date Initiated [DATE] Facility Progress notes documented: [DATE] 9:24 AM Nursing Note (entered by Licensed Practical Nurse (LPN)-XX): Resident fell from the sit to stand, blood loss noted to the back of the head, pupils are uneven, writer unaware if that is [CONDITION(S)] ([CONDITION(S)]) residual or new. MD (Medical Doctor) and family aware resident being sent out. [DATE] 9:30 AM SBAR (Situation, Background, Assessment, Recommendation) documented: Situation: Resident fell from sit to stand. Writer was called to room, walked into room, noted resident laying supine and blood noted on floor. Pupils uneven and reactive to light and hand grasps weak. Resident denied pain, HA (Headache), dizziness Hx (history) shows [CONDITION(S)] ([CONDITION(S)]) unaware as to if that is why her pupils are uneven. Sent to (hospital) per family request. MD aware. Temperature 97.7 Pulse 101 Respirations 20 Blood pressure ,d+[DATE]. [DATE] Orders - Administration Note: Sent out [DATE] at 9:45 AM. [DATE] 2:50 PM Nursing Note: Resident back from ER (emergency room ) 7 staples to the back of her head. CT (Computerized Tomography) scan negative. [DATE] ED (Emergency Department) note documented: Pt (patient) comes in via EMS (Emergency Medical Services) who state patient at (facility) where staff were using a sit to stand and the patient fell . Pt has laceration to the posterior scalp. Is A&O (Alert and Oriented) x 1, no LOC (Loss of Consciousness). Left sided facial droop and unequal pupils. Staff and family were not aware of any residual [CONDITION(S)] effects such as are present. [DATE] AVS (After Visit Summary) documented: Diagnoses - fall from standing, laceration of scalp. Imaging CT cervical spine, CT chest abdomen pelvis, ECG (Electrocardiogram), head CT. No cervical spine fracture, no evidence trauma to chest, abdomen or pelvis. No acute intracranial abnormality. [DATE] NP (Nurse Practitioner) Provider Note: Patient seen sitting in wheelchair in common room. She was sent to theER on [DATE] after sustaining a fall with abnormal pupil dilation following. Patient returned from ER with staples to laceration on posterior scalp. She denies any pain at the site. Patient denies any nausea, vomiting, constipation, lightheadedness, dizziness. [DATE] NP Provider Note: Patient is lying in bed this morning. She fell earlier in the week and had staples placed in the back of her head. She did not appear to be in any pain during exam. No fevers or chills noted. She remains afebrile at 97.7. Surveyor reviewed the facility self report dated [DATE] which documented: Resident fall from sit to stand [DATE] approximately 9:20 AM. Certified Nursing Assistant (CNA)-YY statement: I was getting resident up, I got her into the sit to stand and up in the air. The sit to stand stopped working, it would not let the resident down by remote, so I then turned to call the other aide to the door to help, and the resident slid through the sling. We went to the supervisor who was at the nurses station and she came in. The sling was still attached to sit to stand as I placed it. Resident was lying head back on the floor. Surveyor noted CNA-YY did not follow R340's care plan. CNA-YY transferred R340 with a mechanical lift alone, not with 2 person assist as indicated on the care plan. CNA-ZZ statement: I was waiting by the nurse station when my coworker yelled my name from hallway for help. When I went in the room, the resident was laying on her back with blood coming from her head. I asked resident was she OK, she responded yes. After that I quickly went and got the nurse supervisor (LPN-XX). LPN-XX statement: I was called to the room by a CNA and other CNA came out of the room both telling me and talking at the same time. I had to stop them and redirect, asking one to get BP (Blood Pressure) machine and allowing the other to tell me what happened. She stated she was transferring the resident and she slipped out of the straps, the other CNA came in and stated the lift was broken, it would go up, but not down. LPN-N statement: I was called to resident's room. Upon entrance CNA x 2 and supervisor (LPN-XX) were assisting resident back onto bed. Registered Nurse (RN)-O statement: I did not know anything about (R340)'s fall. Nobody notified me. Prior Interim Director of Nursing (DON)-J statement: I came into the facility at 1300 (1:00 PM). I spoke with (CNA-YY) and asked where was the sit to stand. It was taken to the shower room (tagged out of service pending maintenance inspection-contacted). (CNA-YY) demonstrated how the sling was placed on resident, inappropriate noted, the strap was very loose the way she showed me on herself. I noted she did not use all the devices on the sling to put the straps through. She verified therapy went over proper use of the sit to stand with her. She was asked why would she use the device without another person, stated other facilities used only 1 person. Education provided immediately that we use 2 person assist with all mechanical lifts. Findings: Improper use of sit to stand, requires 2 person assist and CNA did not request assistance. Improper use of sling when applying it to the resident person and to the sit to stand. Surveyor reviewed Supplemental Education forms dated [DATE]: CNA-YY: Sit to stand requires two person assist when operating. Education by PT (Physical Therapy) on use/proper use of sling. LPN-YY: Fall on [DATE] not assessed by RN. RN to assess the resident/situation on all incidents in the building. Facility-wide education CNA's/nurses on proper uses/transfer with sit to stand 2 person assist. On [DATE] at 12:26 PM Surveyor advised Corporate Administrator-BBB of concern related to R340's fall. CNA-YY transferred R340 with a mechanical lift alone and not with 2 person assist as indicated on R340's care plan. Failure to follow the care plan resulted in R340's fall which required staples to a head laceration. Surveyor advised of concern there was no RN assessment following the fall. LPN and CNA's assisted R340 back to bed, and R340 was sent to the hospital. 2.) R69 admitted to the facility on [DATE] with diagnoses that include Heart Failure, Alcoholic Polyneuropathy, [CONDITION(S)] of liver, Personality Disorder, Anxiety disorder, Dementia, major Depressive Disorder, Cerebral Atherosclerosis, [CONDITION(S)] and Arthritis, multiple sites. R69's Brief Interview for Mental Status dated [DATE], documents a score of 14, indicating R69 is cognitively intact. R69's Quarterly MDS (Minimum Data Set) dated [DATE], documents bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) as Extensive assistance, Two+ persons physical assist. R69's Care Plan focus area initiated [DATE] and revised [DATE] documents: (R69) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) mobility. Interventions include: Bathing/Showering: The resident requires assistance by (2) staff with bathing/showering. Date Initiated [DATE], Revision on [DATE]. Bed Mobility: The resident requires assistance by (2) staff to turn and reposition in bed. Date Initiated [DATE], Revision on [DATE]. R69's Care plan focus area initiated [DATE] and revised [DATE] documents: (R69) is at risk for falls r/t Confusion, Deconditioning, Incontinence, Unaware of safety needs. (R69) has had an actual fall. Interventions include: - Anticipate and meet the resident's needs - initiated [DATE] - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance - initiated [DATE] - Educate the staff to keep resident's bed against the wall per resident's choice - initiated [DATE] - The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach - revised [DATE]. Surveyor reviewed the facility Point of Care documentation from [DATE] through [DATE]. Bed Mobility Self Performance - How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture documented R69 required extensive assist 9 times and and total dependence 20 times. On [DATE] at 1:31 PM Surveyor observed R69 lying in bed with the head of bed elevated, eating lunch. Surveyor noted the bed was near the window approximately 3 feet from the wall. Surveyor stood between the bed and the wall to speak with R69. R69 informed Surveyor he fell out of bed 2 weeks ago on a Tuesday. R69 stated: That's the only problem I have here. Everything else is OK. R69 stated: I can't turn or roll by myself. The aide (CNA-Y) was rolling me. They should have 2 people, but didn't. I told her I can't roll any further, but she still tried to roll me and I fell right out of bed. R69 reported he hurt his arm, hip and leg. R69 reported he had no fractures or lacerations. R69 stated: But just because I wasn't injured doesn't mean anything. I could have died . It scared the hell out of me. I want a settlement for this and it better be good. R69 reported no one from the facility spoke to him or interviewed him after the fall. R69 stated: I don't have any other problems with this place, except for falling out of bed - they should've had 2 people, 1 on each side so it wouldn't have happened. Surveyor asked R69 if he had any arm, hip or leg pain as a result of the fall, to which he replied: No. I just have real bad arthritis (showed surveyor hands/noted some finger deformity) that's about it. Surveyor review of R69's medical record revealed an SBAR (Situation, Background, Assessment and Recommendation) dated (Tuesday) [DATE] which documented: During care resident rolled down from bed. No apparent injuries noted. ROM (Range of Motion) WNL (Within Normal Limits). Denied hit head. no c/o (complaints of) pain at this this time. Neuro (neurological) check negative. R69 had no falls the previous 6 months. Surveyor asked Director of Nursing (DON)-B for R69's fall investigation and was provided paperwork titled: Fall/Attended. Surveyor asked if this was the entire fall investigation. DON-B stated: Yes. Surveyor review of the Fall report dated [DATE] at 11:23 AM documented: Nursing Description: During care resident rolled down from bed. No apparent injuries notes. ROM WNL. Denied hit head. time, neuro check negative. Resident description: Resident unable to give description. Immediate action taken: Check vitals, skin check, transferred to bed with hoyer lift. offered pain med, H20 (water) and snacks. Stay with him ,d+[DATE] min. Taken to hospital - No. No injuries observed at time of incident. Mental status: Oriented to person, place, time and situation. Predisposing environmental, physiological, situation factors: NONE Witnesses: No witnesses found. IDT Post Fall Review: Date and time of fall: [DATE] 10:15. Witnessed. No injury. During care resident rolled down from bed. No apparent injuries noted. ROM WNL. Denied hit head. No c/o pain at this time, neuro check negative. Where was the resident prior to the fall? Bed What was the resident doing at the time of the fall? checked other Does the resident have any of the following predisposing diseases? checked [CONDITION(S)] ([CONDITION(S)]). Does the resident have any of the following conditions that may contribute to the fall? checked other - during peri care, rolled down from bed. Intervention recommendations: Staff education. Indicate all intervention recommendations: Care plan revision. Surveyor noted the fall investigation did not include an interview with the Certified Nursing Assistant (CNA) assigned to R69 at the time of the fall. On [DATE] at 11:03 AM Surveyor spoke with CNA-Y who was assigned to R69 at the time of the fall. CNA-Y reported she was washing R69 up/getting him ready in bed. CNA-Y reported she is familiar with R69 he likes to talk a lot while you're doing cares. CNA-Y reported R69 used to be in another room and his bed was against the wall. CNA-Y stated: I have him roll over and cross his leg over the other and tell him not to move while I wash his back side. CNA-Y stated: He moved to another room, and his bed wasn't against the wall anymore. So that day, I was washing him up and had him roll over, that's when he rolled out of bed. I've never had that happen before, I got the nurse right away. Surveyor asked CNA-Y if R69 needed assist of 1 or 2 people for bed mobility, to which CNA-Y stated: He was 1 assist. On [DATE] at 11:23 AM Surveyor observed R69's bed not positioned against the wall according to the care plan. On [DATE] at 12:11 PM Surveyor spoke with CNA-Z. CNA-Z reported R69 should have 2 person assist to turn and roll over in bed, he can't roll by himself. On [DATE] at 12:19 PM Surveyor asked Director of Nursing (DON)-B about R69's fall from bed. DON-B stated: That fall was literally like my first day working here. I thought he needed 2 assist with cares because he was grabby and sexually inappropriate. Surveyor advised DON-B that R69's MDS documented the need for extensive assistance, two+ persons physical assist, and the Care Plan documents R69 requires assistance by (2) staff to turn and reposition in bed. Surveyor asked DON-B if, during the fall investigation, the facility identified concern related to CNA-Y not following R69's care plan for 2 assist with bed mobility, which resulted in R69's fall from the bed. DON-B stated: I seem to remember something about there was confusion between the care card and the care plan. Surveyor advised DON-B that R69's Care Plan and MDS indicated 2 person assist with bed mobility and asked if this was noted during the fall investigation. DON-B stated: I see that. I don't think so. DON-B reported education and training was not completed with facility staff following R69's fall. DON-B stated: Looking back on it now, we should have done education with all the CNAs. I'm thankful he wasn't injured. Surveyor advised DON-B of observations of R69's bed not positioned against the wall as indicated on the care plan. On [DATE] at 3:30 PM Nursing Home Administrator (NHA)-A and DON-B were advised of concerns regarding R69's fall: A thorough investigation was not completed, which identified the care plan was not followed, resulting in R69's fall. In addition, observations during survey revealed R69's bed not positioned against the wall as indicated on the care plan. On [DATE] at 8:01 AM NHA-A provided Surveyor a Supplemental Education form dated [DATE] for CNA-Y. No additional information was provided.

Based on observation, record review and interview, the facility did not ensure that 1 (R4) of 2 residents reviewed for elopement had adequate interventions in place to prevent elopement and accidents. After assessing that R4, who is severely cognitively impaired and frequently voiced that she was leaving, was at risk for elopement, the facility failed to develop and implement interventions to prevent R4 from leaving the facility. Subsequently, R4 eloped from the facility sometime after 1:30 a.m. on 12/3/21 and was found by police walking on a divided four-lane road in the dark, fog, and rain at 3:28 a.m. The failure to put interventions in place to prevent elopement after R4 was assessed to be at risk of elopement and the failure to ascertain R4's whereabouts when she was not in bed at 1:30 a.m. created a finding of immediate jeopardy that began on 12/3/21. NHA (Nursing Home Administrator)-A and RN (Registered Nurse) Consultant-H were informed of the finding of immediate jeopardy on 1/4/21 at 3:51 p.m. The immediate jeopardy was removed on 12/7/21, however the deficient practice continues at a scope/severity level of E, (potential for more than minimal harm/pattern) as the facility continues to monitor their immediate jeopardy action plan and as the facility continues to train their staff on conducting resident rounds during the night and what to do if a resident is not in bed. Findings include: The facility's policy dated as revised July 2021 and titled Elopement Management documents, The goal of the Elopement Management System is to identify residents with potential exit-seeking behavior, to ensure the Care Plan and Kardex reflect effective and consistent interventions and safety measures, and to assure staff are educated regarding the Elopement Management System and resident specific interventions. Under the Practice Guidelines it documents, 3.) Upon admission or readmission, if the resident is identified to be at risk for elopement, interventions are developed and implemented in accordance with the Care Plan .6.) An individualized Care Plan is developed upon admission. If the resident is identified as at risk for elopement, the Care Plan and Care Kardex should address the contributing risk factors, including, but not limited to: a. Cognitive impairment; b. Ambulation status; c. Mental status; d. Resistance to long term placement; e. History of elopement; f. Disease or medications that may cause confusion/disorientation and; g. Indications or diagnosis of dementia .8.) Care Plan interventions are individualized to the resident and are based on the assessed risk of elopement. The facility's policy dated as revised June 2021 and titled Resident Elopement documents, It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Director of Nursing and the Administrator immediately and to document the occurrence. Under the Procedure section it documents, Missing Resident: 1.) Should an employee discover that a resident is missing from the center, he or she should: a) Determine if the resident is out on an authorized leave or pass. If not; b) Notify the Administrator and Director of Nursing services immediately; c) Make a thorough search of the building(s) and premises. 1. R4 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infraction, [CONDITION(S)] and [CONDITION(S)], Frontal Lobe and Executive Function Deficit following Cerebral Infraction and Cognitive Communication Deficit. R4's Quarterly MDS (Minimum Data Set) dated 11/18/21 documents a BIMS (Brief Interview for Mental Status) score of 5, indicating that R4 is severely cognitively impaired. Section G (Functional Status) documents that R4 requires supervision and set up help for her transfer, walking in room and corridor and locomotion on and off the unit needs. Section G0300 (Balance During Transitions and Walking) documents that R4 is steady at all times when walking, moving from seated to standing position and turning around and facing the opposite direction while walking. Section G0400 (Functional Limitation in Range of Motion) documents that R4 has no impairment to either side of her upper and lower extremities. R4's Cognitive Loss/Dementia CAA (Care Area Assessment) dated 5/1/21 documents under the Care Plan Considerations section, Resident triggered for CAA 2 Cognitive Loss / Dementia related to BIMS score of 0 screening for severe cognitive impairment as identified through BIMS assessment conducted and scored by OT (occupational therapy). Resident is a recent new admission to the facility here for short-term rehab with potential to be LTC (long term care). Resident has an activated HCPOA (health care power of attorney) who is actively involved and appropriately supportive of resident's care at this time. Resident is able to make daily decisions at times and has a HCPOA involved to assist with important healthcare decisions. Resident is able to make her needs known and staff are able to anticipate and meet her needs at this time as well. IDT (interdisciplinary team) will continue to monitor. R4's Function Performance admission assessment dated [DATE] documents that R4 is independent with her self-care, indoor mobility and ambulation, stairs and functional cognition needs. R4's Admission Data Collection assessment dated [DATE] documents an elopement risk score of 7, indicating that R4 is at risk for eloping. Surveyor was unable to locate any care plan or documentation that the facility put measures in place to address R4's assessed risk for wandering/elopement. R4 was previously admitted to the facility on [DATE] and was discharged from the facility on 2/12/19. During that time, Surveyor noted R4 was deemed to be at risk for wandering and had a wander guard placed during her previous stay at the facility. R4's elopement assessment dated [DATE] documents a score of 12, indicating that R4 was at risk for elopement. R4's elopement assessments dated 7/28/21 and 11/12/21 document a score of 6, indicating that no risk of elopement was identified for R4. Surveyor was unable to locate any documentation of any changes in R4's mental status or behavior that would indicate that R4 was no longer at risk for elopement. Surveyor was unable to interview the nursing staff whom completed R4's elopement assessments dated 7/28/21 and 11/12/21 as they no longer were employed at the facility as of the time of the survey. R4's nursing note dated 12/3/21 documents, What I think is going on with the resident is: Resident appeared confused yet amused with the fact that she was able to walk around. Kept repeating how much fun she had. Additional Nursing Notes as applicable: Family/Health Care Agent Notified: 12/03/2021 5:25 AM. Primary Care Clinician Notified: 12/03/2021 5:30 AM. R4's facility's self-report dated 12/10/21 to the state agency documents, On December 3, 2021 the facility was made aware that a resident, R4 went on leave without supervision. On the NOC (night) shift, a resident care specialist reported that at midnight on December 3, 2021, the above-mentioned resident, was seen going to bed for the night. At 1:30 AM, the resident care specialist was doing her rounds and noticed that the resident was not in bed. The resident care specialist stated that she thought the resident was outside smoking. At 4:30 AM, the nurse for R4 was outside on break and the police approached the building stating that R4 was found on [NAME] Blvd. and stated that she was meeting a friend .The nursing staff immediately removed wet clothing, showered the resident, completed skin assessments, completed neurological checks and elopement assessment. The resident's skin was intact, no pain was reported. The nursing staff stated that the resident was in good spirits and enjoyed her walk. The resident was not in distress upon her return. Per the nurse, she (R4) appeared confused yet amused and perseverating on all the fun she had on her walk. A head count of every resident in the facility was initiated and completed .The facility immediately launched an investigation, it was determined that the resident went out the front door. On this night, the automatic door lock was unlocked and the door was opening automatically when anyone either is going out or coming in. This is in contrast to how the door operates normally. The receptionist leaves at 8 PM and locks the front door, if someone approaches the door to either go out or come in, it will not open automatically. The door code must be punched in when you are going in or out of the building. On this particular night, we think staff unlocked the front door to make it easier for them to enter and exit the building to go on break, go get lunch or even to go to their cars to retrieve items .This particular resident did not exhibit exit seeking behaviors and was not wearing a wander guard. She (R4) was re-evaluated after this incident and now she has a wander guard (placed). Included in the facility's self-report investigation were statements from staff that documented R4's behavior prior to her elopement on 12/3/21. The following statements were included: Statement from LPN (Licensed Practical Nurse)-F dated 12/3/21 documents, I was sitting outside on break and a police car pulled up. I approached the car and the officer asked if we had a resident named R4. I stated yes. Resident stated she was trying to go meet a friend and had candy. She was wet from the rain. We got her in her room and changed her clothes. Statement from CNA (Certified Nursing Assistant)-E dated 12/3/21 documents, On December 3, 2021 at about 3:45 AM the police called the unit. It was at this time I was informed R4 was walking on [NAME] Avenue. I had saw her about 12 AM and she said she was going to bed. When I went in her room she wasn't there at about 1:30 AM, I thought she went out for a smoke. I didn't think anything of it and went on with rounds. While helping her to change into dry clothes, all she keep saying was 'how much fun she had walking.' I tried to convince her of how dangerous this was, but she only laughed. Statement from CNA-I dated 12/14/21 documents, I, CNA-I, has never witnessed R4 leave or attempt to leave the building. I have occasionally heard the resident state that her daughter would be here to pick her up around 5:00 p.m. It is always the same time every time. Statement from Medication Technician-M dated 12/14/21 documents, I Medication Technician-M, observed R4 saying throughout the day, all day she's going home and her daughter Is picking her up at 5:00 PM on multiple occasions. I've never observed R4 leave the building or try to leave the building. Statement from CNA-N dated 12/14/21 documents, I, CNA-N, have heard R4 say she's going home or on her way home at least 2 time a week when working with her but she always smiles and only go smoke. Statement from CNA-O dated 12/14/21 documents, R4 has always voiced she was going home as well as she was going home to make lasagna when she got there. R4 packs her belongings and stores them in her room. She has always went out to the smoking area unsupervised prior to her elopement and has always returned without any problems. On 1/3/22 at 10:26 a.m., Surveyor observed R4 standing independently at the nursing station, requesting water from facility staff. Surveyor observed R4 standing without difficulty and while waiting for a CNA to get her water, Surveyor heard R4 tell facility staff in a loud and clear voice that she wanted to go home. On 1/3/22 at 10:26 a.m., Surveyor asked CNA-I, if it was normal for R4 to state she wants to go home. CNA-I informed Surveyor that R4 is always stating that she wants to go home and that her daughter is going to pick her up. CNA-I informed Surveyor that while she has not observed R4 attempt to leave the facility, she has observed R4 pack up her belongings in her room because of R4's belief that she is going home. On 1/3/22 at 3:13 p.m., Surveyor interviewed CNA-E, whom was the CNA assigned to R4 when R4 eloped from the facility on 12/3/21, regarding R4's elopement. Surveyor read CNA-E her written statement and asked CNA-E if her statement was accurate. CNA-E informed Surveyor that her written statement was accurate and informed Surveyor that it was not uncommon for R4 to go smoke and or be out of her room late at night. CNA-E informed Surveyor that on 12/3/21, CNA-E did not see R4 in her room when she did her rounds at approximately 1:30 p.m. CNA-E informed Surveyor that at the time, she did not think anything of it, and instead went to another wing to assist another CNA as she was the float CNA on the night shift that night. Surveyor asked CNA-E if she informed any other staff member that R4 was not in her room at 1:30 a.m. so that other staff could attempt to locate her (R4) as she (CNA-E) had left to work on another unit. CNA-E informed Surveyor that she could not recall if she told any staff member that she did not see R4 in her room at 1:30 a.m. Surveyor asked CNA-E if she had checked on R4 at 3:30 a.m., during her two hour rounds. CNA-E informed Surveyor that she did not see R4 again until approximately 4:30 a.m. when she was informed that R4 had eloped from the facility and was brought back to the facility by the police. CNA-E informed Surveyor that she did not round every two hours after 1:30 a.m. as the facility was short staffed that night and because she was working on another unit as the float CNA. Surveyor asked CNA-E if she had ever heard R4 state she wanted to go home. CNA-E informed Surveyor that she had heard R4 stating she wanted to go home with her daughter but that she (CNA-E) never got the 'vibe' that R4 would leave during the night. CNA-E informed Surveyor that she figured that if R4 would ever elope from the facility it would be during the morning and not at night during her shift. On 1/3/22 at 4:16 p.m., Surveyor informed NHA (Nursing Home Administrator)-A and RN Consultant-H of the above findings. Surveyor asked NHA-A and RN Consultant-H why facility staff had deemed R4 not at risk of elopement on R4's elopement assessments dated 7/28/21 and 11/12/21, as Surveyor was unable to locate any documentation of any changes in R4's mental status or behavior that would indicate that R4 was no longer at risk for elopement. NHA-A and RN Consultant-H informed Surveyor that they just became aware of the R4's previous elopement assessments and informed Surveyor that R4 had not tried to elope from the facility previously. NHA-A and RN Consultant-H informed Surveyor that they could not provide any additional information as to why R4 was not deemed at risk for elopement on 7/28/21 and 11/12/21 as both facility staff member whom completed the assessments were no longer employed at the facility. Surveyor asked NHA-A and RN Consultant-H why the facility did not put elopement interventions in place for R4, as facility staff were aware that R4 made statements of wanting to leave the facility. NHA-A and RN Consultant-H informed Surveyor that they were not aware that facility staff were aware R4 made statements of wanting to leave the facility and informed Surveyor that they could not provide any additional information as to why the facility did not put elopement interventions into place for R4. On 1/4/22 at 7:24 a.m., Surveyor interviewed PO (Police Officer)-G regarding R4's elopement from the facility on 12/3/21. Surveyor asked PO-G to describe where and how she found R4 on the morning of 12/3/21. PO-G informed Surveyor that she was driving down [NAME] avenue (a divided 4 lane road) on a cloudy/foggy and rainy morning when she observed R4 standing on the road appearing confused at 3:28 a.m. PO-G informed Surveyor that she picked up R4, who was wet and not wearing a coat at the time. PO-G informed Surveyor that she asked R4 if she could give her a ride home and that R4 provided PO-G with a home address that was not the facility's address. PO-G informed Surveyor that she (PO-G) drove R4 to the address R4 provided but when they arrived, PO-G saw that the house was empty and had a for sale sign on the front lawn. PO-G informed Surveyor that she then searched R4 and found a card with the facility's name, phone number and address. PO-G informed Surveyor that she then drove R4 to the facility. PO-G informed Surveyor that upon arriving to the facility, she saw facility staff outside at the front of the facility. PO-G informed Surveyor that she then asked facility staff if R4 lived at the facility to which staff stated yes and then PO-G handed R4 off to facility staff. PO-G informed Surveyor that when she dropped off R4, she overhead a facility staff member, whom she could not recall her name, state that she saw R4 go outside but that she never observed R4 go back into the facility. Surveyor reviewed the historical weather for [NAME], Wisconsin on the morning of 12/3/21. According to Weatherunderground.com, on 12/3/21 at 12:52 a.m., the temperature was 43 degrees Fahrenheit with cloudy conditions. On 12/3/21 at 1:52 a.m. and 2:27 a.m. the temperature was 42 degrees Fahrenheit with light rain conditions. On 12/3/21 at 2:52 a.m., the temperature was 41 degrees Fahrenheit with light rain conditions. On 12/3/21 at 3:52 a.m., the temperature was 39 degrees Fahrenheit with light rain conditions. On 1/4/22 at 7:53 a.m., Surveyor informed NHA (Nursing Home Administrator)-A and RN (Registered Nurse) Consultant-H of the above findings. At the time no additional information regarding R4's elopement was provided. On 1/4/22 at 8:39 a.m., Surveyor interviewed Maintenance Director-L regarding the facility's wander guard system. Surveyor asked Maintenance Director-L if he had checked the functionality of the wander guard system at the facility on 12/2/21. Maintenance Director-L provided Surveyor with a copy of the wander guard alarm system audits that document that Maintenance Director-L had checked the functionality of the wander guard alarm system on the day R4 eloped from the facility. Maintenance Director-L informed Surveyor that at night, the front doors of the facility are set up to let anyone leave but are closed from the outside, which means that you are unable to enter the facility without pressing in a code or using the intercom system. Maintenance Director-L informed Surveyor that staff are the only ones with the code and that if a resident with a wander guard approached the front doors, the doors would set off an alarm that staff could hear and respond to. Surveyor asked Maintenance Director-L how R4 was able to elope from the facility if the wander guard system was functional on the night that R4 eloped. Maintenance Director-L informed Surveyor that R4 was able to elope from the facility because R4 was not wearing a wander guard and thus when R4 exited the building, R4 did not set off any alarms. Maintenance Director-L informed Surveyor that it was also possible that R4 was unable to re-enter the building once she left as he believed that R4 did not know the door code to get back into the building. The faciity's failure to put interventions in place to prevent elopement after R4 was assessed to be at risk of elopement and the failure to ascertain R4's whereabouts when she was not in bed at 1:30 a.m. on 12/3/21 created a reasonable likelihood that serious harm to R4 could occur, thus leading to the finding of immediate jeopardy that began on 12/3/21. The immediate jeopardy was removed on 12/7/21 when the facility completed the following: - On 12/06/2021 the facility Interdisciplinary team reviewed current residents Elopement Assessments and resident assessments are current and accurate. Each resident care planned to wear a wander guard bracelet to prevent elopement was verified for placement. - A system was put into place requiring each unit to complete a visual count of residents q (every) shift. - An Adhoc QAPI meeting was held on 12/07/2021 and the facility self-identified areas of opportunities in the areas related to Elopement/Missing resident and supervised smoking. Current staff were educated beginning on 12/03/2021 by the Nursing Home Administrator and Director of Nursing in relation to the Facility Elopement/Missing Person policy and the newly developed supervised smoking policy and procedure. This education continued through 12/07/2021, is ongoing and included: - Review of the facility Elopement Management System/Resident Elopement policy and practice guidelines. - It was emphasized that it is the responsibility to report to their immediate supervisor, Director of Nursing or Administrator when a resident is missing. - There is a photographic director [sic] of residents identified at risk for elopement located at each nursing unit and the front reception desk. These books are to be maintained, updated and used in the event of an alleged elopement. These books are updated by the Social Services department. - If a resident is believed to be missing an employee should determine if the resident is possibly out on an authorized leave, notify the supervisor, Director of Nursing or Nursing Home. While the immediate jeopardy was removed on 12/7/21, it was noted the facility did not conduct staff training on resident rounds at night and what to do if a resident is not in bed.

Based on interview and record review, the facility did not ensure 1 of 4 residents (R12) reviewed for falls received adequate supervision and assistance devices to prevent accidents. R12 was at risk for falls and was care planned to need the assistance of 2 staff for bed mobility. While R12 was in bed, the nurse provided wound care without the assistance of a second staff person. R12 fell off of the bed and was sent to the hospital for evaluation. R12 sustained a closed head injury and a 3 cm hematoma (bad bruise) to the back of her head. Findings include: R12 is [AGE] years old and was admitted to the facility on [DATE]. She has diagnoses of [CONDITION(S)], [CONDITION(S)], and Respiratory Disorder. The 8/18/21 Admission Minimum Data Set (MDS) noted the following. R12 was cognitively intact. She required the extensive assistance of 2 two staff persons for her bed mobility. R12 required the assistance of 2 staff persons for transfers. R12 had an unsteady balance. Although R12 had no history of falls and had not fallen at the facility, the Fall Care Area Assessment (CAA) was triggered due to R12's balance problems. The fall care plan was developed on 8/13/21 and noted that R12 was at risk for falls due to balance problems, [CONDITION(S)], and [CONDITION(S)]. The ADLs (Activities of Daily Living) CAA was triggered due to weakness and and a decline in R12's ADL function and ability to transfer. The facility developed an ADL care plan on 8/14/21 for R12. It noted that R12 had an ADL self-care deficit related to impaired balance and R12's preference to not participate in ADLs. Interventions for bed mobility were developed on 8/17/21 and indicated that R12 required the assistance of two staff to turn and reposition in bed. R12's care plan also noted that she had been prescribed a blood thinning medication. This would put R12 at risk for bleeding or further injury if she fell . R12 had an 8/13/21 physician's order for the blood thinning medication, [MEDICATION(S)]. R12 was to take 5 mg twice daily for [CONDITION(S)]. The September 2021 Medication Administration Record indicated that R12 had received the [MEDICATION(S)] twice daily from 9/1 - 9/12/21. On 9/13/21, R12 only received the medication one time as she had fallen that day and was sent to the hospital. The 9/13/21 progress note stated that R12 fell out of bed at 2:15 PM when LPN - W was providing wound care to R12's left and right buttocks. LPN - W wrote the following statement. As LPN - W was starting to do the treatment, he turned to grab the supplies. At that time, R12 rolled and slid out of the bed. LPN - W wrote that R12 was trying to get to the side on her own to help with the treatment. LPN - W said that R12 hit her head on the dresser at the side of her bed. R12 told LPN - W that she was feeling light headed prior to the fall. R12 was sent to the hospital for evaluation. The 10/1/21 hospital discharge summary noted that R12 sustained a closed head injury with a 3 cm hematoma. On 10/12/21 at 12:40 PM, R12 was interviewed. R12 said that when she fell she was lying on her right side facing the door and LPN - W was on the other side of her bed nearest the window. R12 estimated that she was 10 inches from the side of the bed. R12 said that when she fell out of bed she hit the left side of her head on the dresser and landed on the floor on the left side of her body. R12 said she does not recall how or why she fell . R12 said that LPN - W had not rolled her to her right side when she fell . R12 said that she had already been positioned on her right side. R12 could not see LPN - W when she fell and could only assume that he was on the other side of the bed. R12 said that she did remember feeling light headed prior to falling. R12 said that there were no other staff in the room besides LPN - W. R12 said that her wound treatment and cares were always performed with 1 staff person. R12 said that after returning from the hospital, there were always 2 staff persons in the room when providing cares to her. On 10/12/21 at 1:25 PM, Director of Nursing (DON) - B was interviewed and asked why there were not two staff in the room when LPN - W provided wound care to R12. DON - B provided a copy of the facility's 9/14/21 Supplemental Education Form. This form had been provided to LPN - W. The form stated: Employee was educated on following the Kardex [care plan] when doing ADLS and transfers. If unsure check the Kardex. The form was signed by LPN - W and RN Supervisor - X. On 10/12/21 at 3:30 PM, the preceding information was shared with Nursing Home Administrator (NHA) - A and DON - B. No additional information was provided to the survey team.

Based on observation, interview, and record review the facility failed to ensure that 6 of 11 (R410, R71, R96, R131, R9 and R10) residents did not develop avoidable pressure injuries. R410 was admitted to the facility on [DATE] and developed an avoidable Stage 4 PI (Pressure Injury) to the Coccyx with transfer and admission to the hospital with an infected Stage 4 PI on 12/30/19 following the facility's failure to implement measures to prevent the development as identified with the following: * R410'S skin was not assessed until 3 days after admission. * The facility did not implement R410's skin care plan until 3 days after admission. * The facility did not assess the R410's skin until 11/25/19 when two RN's separately assessed the resident. One RN indicated there was shearing on the left iliac crest and redness stage 1 on the sacrum while the other RN indicated there was a stage 2 pressure injury on the left buttock measuring 4 x 0.3 x 0 cm. * R410's 11/22/19 Admission Braden score was completed on 1/14/20 after discharge. Weekly Braden scores were not completed per facility protocol. * The facility implemented a generic care plan for skin care including reposition frequently, bowel and bladder per facility protocol, and check nutritional status. The facility did not implement an individualized care plan. The facility did get an air mattress for the bed and a cushion for her wheelchair. * The facility did not follow through with physician's orders [REDACTED]. * The facility did not document how frequently staff was turning the resident or if it was ensuring the resident remained up only for the amount of time prescribed by the physician. Facility staff did not put the resident to bed on 11/28/19 until after the resident and her friend had called the police. * The facility did not prevent the complication of an associated soft tissue or systemic infection in R410's coccyx wound. DR-G had ordered a stat CBC on 12/23/19 but the facility did not follow through with this order. The facility's failure to provide necessary treatment and care to prevent R410's pressure injury and prevent it from worsening created a finding of Immediate Jeopardy for R410 beginning on 12/16/19. Administrator-A, Corporate Consultant-C, RN Consultant-C were informed of the Immediate Jeopardy on 3/5/20 at 12:10 p.m. The Immediate Jeopardy was removed on 3/5/20; however, the deficient practice continues at a scope and severity level of G (harm/isolated) for R71, R96, R131, R9, and R10, as evidenced below; * R71 developed an unstageable pressure injury on her left heel on 12/27/19. There was no RN (Registered Nurse) assessment until 12/30/19, 3 days later. R71 was hosptalized on [DATE]. The hospital history and physical dated 1/2/20 under plan states seen by surgery for [REDACTED]. R71's pressure injury was debrided down to the bone due to a concern of osteo[DIAGNOSES REDACTED]. On 1/10/20 R71 returned to the Facility. The admission data collection documents a Stage 3 with no assessment of the wound bed. Three days later R71's pressure injury is staged as a Stage 4. On 1/20/20 the R71's left heel pressure injury increased in length & width without any revision in R71's care plan. On 3/3/20 R71 was observed multiple times in bed without pressure relieving boots. * R96 developed two open areas on her sacrum on 3/1/20. The open areas were not staged and there are no descriptions of the wound bed. R96's skin care plan was not revised until 3/4/20. On 3/2/20 R96 was not repositioned in her Broda chair for approximately five hours * R131 was observed without pressure relieving boots in bed according to his care plan. * R9's heels were not floated as care planned. * R10 admitted with multiple pressure injuries and did not have consistent assessments that included measurements, staging and a description of each wound. R10's heels were not floated as care planned. Findings include: The state received a FRI (facility reported incident) which indicated R410's family expressed concerns regarding neglect related to pressure injury/wound care. Surveyor reviewed R410's closed records and conducted facility staff and administration interviews. The facility policy, Skin Management, revised July 2017, indicated in part . Policy: Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assess and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. Fundamental Information: A pressure ulcer is defined as any [MEDICAL CONDITION] caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are usually over bony prominences and are staged to determine to degree of tissue damage observed. Unavoidable Pressure Ulcers: In accordance with CMS guidelines, unavoidable means that the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. All of this must be clearly documented in the resident's medical record. The NPIAP (National Pressure Injury Advisory Panel) 2019 Guideline defines PIs as localized damage to the skin and underlying soft tissue as a result of intense pressure, prolonged pressure or pressure in combination with shear: A Stage 1 PI is non-blanchable [DIAGNOSES REDACTED] in a localized area of intact skin. A Stage 2 PI is partial thickness skin loss with exposed dermis. No fat or deeper tissues are visualized. A Stage 3 PI is full thickness skin loss with fat tissue visible. Muscles, bone, and tendons are not visualized. Slough or eschar (black necrotic tissue) could be present. A Stage 4 PI is full thickness skin and tissue loss with exposed or directly palpable muscle, bone, or tendon. An Unstageable PI is obscured full thickness skin and tissue loss in which the extent of damage cannot be determined. A DTI (Deep Tissue Injury) is persistent non-blanchable deep red, maroon, or purple discoloration from intense and/or prolonged pressure. R410 was admitted to the facility with [DIAGNOSES REDACTED].Sepsis due to E.Coli (blood infection from bacteria), [MEDICAL CONDITION] Bladder (inability to urinate without using a catheter-tube), and Need for assistance with Personal care. R410's Hospital Medical Records indicated admission on 11/18/19 with weakness and not being able to care for herself. R410 had been found on the toilet after a couple hours by case worker. R410's Hospital Medical Records indicated a PMH (Past Medical History) of Coccyx PI, dated 6/2014, which had been an ongoing issue since 2007. R410's Hospital Discharge Summary, dated 11/22/19, does not indicate a Coccyx PI or any Physician wound treatment orders. R410's 11/22/19 Hospital Transition Care Report, dated 11/22/19, indicated under skin assessment: left abdomen friction and shear. R410's 11/22/19 Hospital Paper Skin Integrity, completed by an RN, indicated a circle on left abdomen named friction/shear and a circle on the sacral/coccyx area named redness. R410's Admission assessment, dated 11/22/19, indicated a skin integrity section on the form, dated 11/25/19, which was 3 days after admission. R410's skin integrity section indicated no to pressure ulcers and left iliac crest (pelvis) shearing and sacrum redness as Stage 1. R410's weekly PI record completed by RN-O (Registered Nurse-Wound Care), dated 11/25/19, indicated left buttock PI measuring 4 x 0.3 x 0 cm, Stage 2, beefy red, no drainage, surrounding tissue intact, with date of onset 11/22/19. Plan specialty interventions: WC cushion, pressure relieving boots, Continue treatment which was Barrier Cream to Coccyx area and left buttock every shift for facility protocol. *Surveyor noted the 11/25/19 PI record and the 11/25/19 Admission skin integrity record completed by 2 different RN's have different assessments in size, site, and staging of PI. R410's Admission assessment, dated 11/22/19, indicated a Braden Scale for predicting pressure sore risk section on the form was dated 1/14/20 which was completed after R410's transfer to the hospital on [DATE] for an infected PI. R410's Braden score indicated 10-12 which was high risk. R410's 5 day Admission MDS (Minimum Data Set), dated 11/28/19, indicated clear speech, usually understood and usually understands, BIMS (Brief Interview Mental Status) score of 10 which indicates moderately cognitively impaired, no rejection of care, and no functional impairment of arms or legs. R410's MDS indicated it was very important to be able to choose own bedtime and required extensive assistance with 2+ staff physical assistance for bed mobility and transfers. R410's MDS Section M indicated R410 was at risk for skin breakdown, admitted with two Stage 2 PI's present on admission; and Interventions included a pressure reducing device for chair and bed, and No turning/repositioning program, (response locked 12/2/19). R410's Care plan, dated 11/25/19, indicated in part . R410's focus was coccyx pressure ulcer and a left butt ulcer. R410 has potential for pressure ulcer development r/t decreased mobility. The goal was R410's pressure ulcer would show signs of healing and remain free from infection, initiated 11/25/19, revised 12/5/19. R410's Interventions, dated 11/25/19, indicated: R410 requires the bed as flat as possible to reduce shear. Administer medications as ordered. Observe/document for side effects and effectiveness. Administer treatments as ordered and observed for effectiveness. Air mattress. Assist R410 to reposition and/or turn at frequent interval to provide pressure relief. Blue pressure relieving boots to be when in bed. Complete a full body check weekly and document. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. IDT (Interdisciplinary Team) as indicated, RD (Registered Dietician), PT (Physical Therapy), OT (Occupational Therapy) or other. Observe Nutritional status. Serve diet as ordered, observe intake and record. Observe/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length x width x depth), stage. Obtain and observed lab/diagnostic work as ordered. Report results to MD and follow up as needed. Provide incontinence care after each incontinence episode, or per established toileting plan. Reposition in chair frequently for comfort and pressure reduction. Provide resident/family education as needed. Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. R410 needs staff assistance to turn/reposition at least every 2 hours, more often as needed or requested. Weekly treatment documentation to include measurement of each area of skin breakdown width, length, depth, type of tissue, and exudate. R410's focus was an ADL (Activities of Daily Living) performance deficit r/t Limited Mobility, initiated 11/25/19. R410's Interventions include: R410 would like to be up in WC (Wheelchair) by 10:00 AM and back to bed before dinner at 5:00 PM, initiated 11/29/19. Transfer: R410 requires mechanical lift sit to stand lift with 2 person assist for transfers, initiated 11/25/19. Encourage R410 to use bell to call for assistance. R410's Care plan, dated 1/14/20 (R410 was discharged [DATE]), indicated in part . R410's focus was potential/actual skin issues r/t: (nothing inserted). The goal was R410's skin would remain intact without signs of breakdown, initiated 1/14/20. R410's Interventions, dated 1/14/20, included: Provide wound care/preventative skin care per order. Skin checks weekly per facility protocol, document findings. Turn and reposition frequently to decrease pressure. *Surveyor noted the 1/14/20 date on the care plan for potential/actual skin issues after R410 was admitted to the hospital on [DATE]. R410's CNA Care Card, indicated in part .R410 would like to be up in WC by 10:00 AM and back to bed before dinner at 5:00 PM, Blue pressure relieving boots to be on when in bed, air mattress, and turn/reposition frequently to decrease pressure. Surveyor reviewed R410's facility weekly pressure ulcer record, facility skin-head to toe skin checks, and Wound Care Consultants TA (Tissue Analytics) evaluations. R410's 11/27/19 Head to toe check completed by LPN-DD (Licensed Practical Nurse) indicated a left buttock PI, beefy red. LPN-DD note a new order, dated 11/27/19, clean wound with NS (normal saline), pat dry, skin prep peri-wound, nickel thick Santyl to wound base followed by fluffed 4 x 4, covered with border foam, one time a day for open wound on bottom. R410's progress note, dated 11/28/19 at 7:00 PM indicated R410's friend came to visit the resident and complained R410 had been sitting up in the WC since the morning. R410's care plan indicated bed time at 5:00 PM and was 2 hours late going to bed as well as sitting all day. R410's friend called the police and the police responded to the call. The facility responded to R410's issue. *Surveyor noted the extensive length of time R410 was sitting in the WC. Pressure Ulcers in the Elderly, as a Public Health Problem notes, Lying in bed or sitting in a chair without movement induces pressure on the skin and sub-cutaneous tissues, and are predisposing factors for PU (pressure ulcer) .The pressure on the skin and subcutaneous tissue during prolonged lying on a bone prominence, as well as immobility without repositioning compresses the blood perfusion and induces oxygen deprivation. https://www.omicsonline.org/open-access/pressure-ulcers-in-the-elderly-as-a-public-health-problem-2329-9126XXX 74.php?aid= R410's 11/29/19 Braden score was 18 which indicated at risk for pressure sore risk. R410's 12/2/19 TA evaluation by NP-BB (Wound Care Nurse Practitioner) indicated Coccyx PI measured 3.55 x 2.23 x 0.7 cm, Unstageable, tan wound bed, small serous drainage, peri-wound clean, dry, intact. R410's physician orders [REDACTED].½ strength Dakin's solution, protect periwound with skin prep, apply Santyl to wound bed, cover wound with bordered gauze, change daily, change PRN for soiling and/or saturation; ROHO cushion please, Up in WC 1 hour/day, [MEDICATION NAME] lab level now and in 3 weeks, and Prostat (liquid protein supplement) 300cc 2 times/day. * There was no documentation for how frequently staff turned R410 or monitored R410 being up in WC 1 hour/day. The physician ordered labs for a pre-[MEDICATION NAME], but the facility did not follow through with this. R410's 12/9/19 TA evaluation by NP-BB indicated Coccyx PI measured 2.86 x 4.38 x 1.2 cm, Unstageable, tan wound bed, small serous drainage. NP-BB debrided R410's PI noting wound undermining from 12-12 o'clock at 2 cm depth and indicated a wound treatment addition of lightly moistened gauze with ½ strength Dakin's applied after Santyl and Bedrest except for 1 hour of PT (Physical therapy). R410's 12/9/19 weekly PI record completed by RN-O indicated Coccyx PI was a Stage 3 with Interventions now including side to side repositioning. * There was no documentation for staff performing side to side repositioning or monitoring R410's Bedrest. R410's 12/16/19 TA evaluation by NP-BB indicated Coccyx PI measured 3.2 x 5.68 x 1.5 cm, Unstageable, tan wound bed, small serous drainage. NP-BB noted undermining 12-12 o'clock at 3 cm depth and indicated a wound treatment of [REDACTED]. * NP-BB changed R410's treatment for [REDACTED]. R410's 12/23/19 TA evaluation by DR-G indicated Coccyx PI measured 5.66 x 5.56 x 2.2 cm, Stage 4 with early/partial granulation, moderate serous drainage. DR-G noted undermining 8-6 o'clock at 2 cm depth with wound treatment clarification to change gauze lightly moistened in ½ strength Dakin's 2 times/day. DR-G ordered a stat CBC (Complete Blood Count) with a WBC (White Blood Cell-cells that fight infection by attacking bacteria). * DR-G ordered a pre-[MEDICATION NAME] for 12/23/19, but the facility, again, did not follow through with this order. R410's WBC increased from 12.8 (12/2/19) to 13.1 (12/19/19) to 17 (12/19/19) and 18.6 on 12/30/19. DR-G had ordered a stat CBC on 12/23/19 but the facility did not follow through with this order. R410's WBC was getting higher, and MD-R( Physician) ordered an IV antibiotic [MEDICATION NAME], on 12/25/19 and on 12/29/19 the IV antibiotic was changed to [MEDICATION NAME]. R410's 12/30/19 TA evaluation by DR-G indicated Coccyx PI measured 5.79 x 6.58 x 2.3 cm, Stage 4 with early/partial granulation, moderate serous drainage. DR-G debrided R410's PI noting wound undermining 8-5 o'clock with 3.5 cm depth. The physician transferred R410 to the hospital because the WBC was even higher than what it had been and the coccyx wound was infected. On 3/04/20, at 7:47 AM, Surveyor interviewed RN-O who stated R410 had some issues like agoraphobia and preferred staying up, and kicked off her boots so the facility had to float the heels. Surveyor asked RN-O about the increasing size of R410's Coccyx PI and the deterioration. RN-O stated DR-G debrided twice which is why the PI got bigger. RN-O stated she did not recall any admission issues. On 3/4/20, at 09:02 AM, Surveyor requested NHA-A provide R410's care plan with revisions and closed records. Surveyor reviewed R410's issues with NHA-A regarding discrepancy with dates on assessments and Bradens and requested further information and documents. On 3/4/20, at 1:10 PM, RN-O and NC-D (Nurse Consultant) requested to meet with Surveyor to review R401's information. RN-O pulled up the wound physician's TA records on R410's Coccyx PI in color on the computer. RN-O explained to Surveyor the interpretation of each week's assessments and facility's response and protocols. R410's 12/2/19 color coccyx wound picture demonstrated barely reddened area around the wound. Surveyor questioned RN-O how the facility followed the orders for ROHO cushion and Up in the WC 1 hour/day. RN-O stated it would be written as an order, and facility staff and therapy would be notified. Surveyor questioned RN-O how the facility would track the chair time and RN-O stated the order would be care planned, on the CNA Care card and should be documented in the task care tracker. R410's 12/9/19 color coccyx wound picture demonstrated some red/purplish induration around wound. RN-O stated she did not remember R410's medical history but RN-O thinks R410 had a DTI (Deep Tissue Injury) before admission. RN-O stated R410 had debridement when DR-G started to clean out the wound but [MEDICATION NAME] and slough were still attached to the coccyx wound with new undermining and epibole (rolled edges). Surveyor questioned RN-O how the facility followed the orders for Bedrest except 1 hour for therapy. RN-O stated it would be written as an order, and facility staff and therapy would be notified. RN-O stated the order would be care planned, on the CNA Care card and should be documented in the task care tracker. R410's 12/16/19 color coccyx wound picture demonstrated more pink/induration around wound. RN-O stated R410's coccyx wound had increased undermining, increased depth and the coccyx wound treatment was changed to 2 times/day due to slough returning. R410's 12/23/19 color coccyx wound picture demonstrated red/black new necrotic tissue increased depth, increased length. RN-O stated not much viable tissue, Stage 4. RN-O stated she did not note at the time the change in Staging otherwise she would have asked him. R410's 12/30/19 color coccyx wound picture demonstrated length decreased, width increased, and depth increased. RN-O stated there was moderate drainage and tough [MEDICATION NAME] slough with worsening undermining at 3.5 cm. RN-O stated DR-G [MEDICATION NAME] the coccyx wound made R410's wound bigger prior to hospitalization . RN-O stated the area surrounding the wound now had a decreased purplish look after Bedrest. RN-O stated R410 was discharged to the hospital on [DATE] with an infected coccyx wound. RN-O stated she used DR-G's assessments and measurements for the facility weekly tracking. Surveyor questioned RN-O regarding the Braden score 10-high risk, dated 1/14/20 after 12/30/19 discharge and RN-O stated she followed up and care planned the risk. Surveyor questioned RN-O regarding the Braden scores completed on 11/29/19 (18 at risk) and 12/6/19 (17 at risk) and the discrepancies in risk. RN-O stated the facility completes Braden scores every week for 4 weeks and that is facility protocol. RN-O stated there were no further Braden scores completed in R410's assessments. Surveyor questioned RN-O about R410 being up in the chair all day on 11/28/19 could be the causation of possible DTI. RN-O stated she did not know if R410 was repositioned. Surveyor questioned RN-O when she noted R410's wound was infected. RN-O stated the facility did a coccyx wound culture and R410 was started on IV (Intravenous) Antibiotics on 12/26/19 for an infected wound. RN-O stated R410's coccyx wound was not getting any better and getting worse with increase in size and increase in drainage. RN-O stated R410 was admitted to the hospital for deteriorating cocyx wound on 12/30/19. RN-O stated R410 had an indwelling foley catheter (tube inserted into bladder to drain urine) the whole time R410 was in the facility. *Surveyor noted R410 had an indwelling catheter inserted on 12/17/19. On 3/4/20, at 3:35 PM, Surveyor had requested R410's hospital records on 12/30/19 from the NHA-A and CC-C. NHA-A stated the facility was unable to obtain and provided fax confirmation of request to the hospital. On 3/5/20, at 7:38 AM, Surveyor met with NHA-A and CC-E to discuss discrepancies in documentation and paperwork that had been requested that was still pending including progress notes, task list for repositioning and bedrest, skin head to toe assessments, [MEDICATION NAME] results, foley order and policy. On 3/5/20, at 2:54 PM, Surveyor interviewed NHA-A and CC-C and requested task list again for repositioning and bedrest. CC-C stated the facility was having trouble finding documentation for bedrest and repositioning so we don't have it. CC-C stated the facility follows standard of practice for repositioning. A standard of practice is found in the NPIAP 2019 Guidelines which indicate strong positive recommendations/definitely do it for Repositioning and Early Mobilization: 5.1 Reposition all individuals with or at risk of PI on an individualized schedule, unless contraindicated. 5.2 Determine repositioning frequency with consideration to the individual's level of activity, mobility and ability to independently reposition. *Surveyor noted the facility did not follow a standard of practice for repositioning. No further information was provided by the facility. On 3/6/20, Surveyor obtained R410's 12/30/19 Hospital records which indicated R410 presented to the hospital for evaluation of an ongoing wound infection. R410 was positive for pain on her buttocks. Documentation on 12/30/19 indicated a large sacral ulceration extending to soft tissue, tendon, and bone. R410 received 2 new IV Antibiotics: [MEDICATION NAME] and [MEDICATION NAME]. Final Diagnosis: [REDACTED]. The failure to prevent the development of an infected stage 4 pressure injury created a finiding of immediate jeopardy. The Immediate Jeopardy was removed as of 3/5/20 when the facility: * Advised the Medical Director of the deficiency. * Completed a head to toe skin assessment on all in-house residents and skin incident reports completed for those residents with skin alterations. * Residents with skin alterations were evaluated, with updates made to the plan of care and interventions in place as appropriate. * Licensed and unlicensed staff were educated on the Skin Management program prior to their next scheduled shift. * Licensed staff were educated on assessment, documentation, and physician order [REDACTED]. * Identified Wound Care nurse received directed education on Skin Management program by the Wound physician. * The Director of Nursing or designee is reviewing the Point Click Care dashboard, the 24 hour board, and progress notes for all new admissions and skin incidents to ensure assessment completion, interventions initiated based on skin condition, and for the completion of physician orders [REDACTED]. The deficient practice continues at a scope and severity level of a G (harm/isolated) as evidenced by the following; 2. R71 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The potential skin issue care plan initiated 8/29/19 and revised on 1/28/20 documents interventions of; Provide wound care/preventative skin care per order. Inititated 8/29/19. Skin checks weekly per facility protocol, document findings. Inititated 8/29/19. Turn and reposition frequently to decrease pressure. Prevalon boots in place. Inititated 8/29/19 & revised 1/19/20. The admission MDS (minimum data set) with an assessment reference date of 9/4/19 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R71 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfer, and does not ambulate. R71 is at risk for developing pressure injuries and is coded as not having any pressure injuries. The pressure ulcer/injury CAA (care area assessment) dated 9/5/19 under analysis of findings for nature of the problem/condition documents Resident admitted s/p (status [REDACTED]. Resident was on IV (intravenous) antibiotics in the hospital and has since competed her course of oral antibiotics while at the facility. She is working with therapy to help improve her functional ADL's (activities daily living). Resident was previously w/c (wheelchair) bound in her assisted living facility and has not been ambulatory for over 5 years. She has impaired ROM (range of motion) to her upper extremities but it does not interfere with function mobility. She is dependent on staff for transfers with the use of a full body lift. During the look back period she was frequently incontinent of both bowel and bladder. No falls while at the facility. No noted pressure injuries. She denies any pain or discomfort. The Braden Scale assessment dated [DATE] has a score of 13 which indicates moderate risk for pressure injury development. The pressure ulcer care plan initiated 12/29/19 and revised on 12/31/19 documents interventions of Administer treatments as ordered and observe for effectiveness. Inititated 10/1/19. Assess/record/observe wound healing: Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (medical doctor). Inititated and revised on 1/12/20. Assist R71 to reposition and/or turn at frequent intervals to provide pressure relief. Inititated 1/12/20 & revised 1/21/20. Complete a full body check weekly and document. Inititated 9/5/19. Diathermy from therapy. Inititated 3/2/20. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care of ambulating/mobility, good nutrition and frequent repositioning. Inititated 10/1/19. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. IDT (interdisciplinary team) referrals as indicated, i.e. RD (registered dietitian), PT (physical therapy) OT (occupational therapy) or other. Inititated & revised 9/5/19. Inform the resident/family/caregivers of any new area of skin breakdown. Inititated 9/5/19. Observe nutritional status. Serve diet as ordered, observe intake and record. Inititated 9/5/19. Obtain and observe lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Inititated 10/1/19. Pressure relieving boots. initiated 3/2/20. Provide incontinence care after each incontinence episode, or per established toileting plan. initiated 9/5/19. Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. initiated 10/1/19. The resident needs extensive staff assistance to turn/reposition at least every 2 hours, more often as needed or requested. initiated & revised 1/12/20. The resident requires a pressure relieving/reducing device on chair. initiated 1/12/20 & revised 3/2/20. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. initiated 1/12/20. The head to toe skin check dated 12/27/19 under skin integrity is checked for new pressure ulcer. Under site documents left heel, type pressure, length 6.0, width 4.3 and stage unstageable. Under further description of skin issues documents appears to have been a blister, black in color, skin intact. This was completed by LPN (Licensed Practical Nurse)-Q. There is no RN (Registered Nurse) assessment. The SBAR (situation, background, assessment, request) dated 12/27/19 under assessment for LPNs documents Pressure ulcer noted to left heel. Area measures 6.0 x (times) 4.3. Appears as if it was a blister. Skin is intact. Area is black in color. Resident does c/o (complain of) pain to heel. Under nursing notes documents Physician-R updated. New orders received for [MEDICATION NAME] to heel and for wound care team to follow. This was completed by LPN-Q. The weekly pressure ulcer record with an effective date of 12/30/19 and signed on 12/31/19 for site of this assessment documents L (Left) Lat (lateral) heel. Date of onset is documented as 12/27/19. Under length documents 3.56, width 5.48 and stage Suspected Deep Tissue Injury. Description of site documents black. Surveyor noted this assessment was completed by a RN, 3 days after the identification of the pressure injury. The head to toe skin check with an effective date of 12/28/19 and signed on 1/12/20 under skin integrity is checked for existing pressure ulcer. Under site documents lt (left) heel, length 6 cm (centimeters), width 6cm, depth 0.5cm and stage III (3). Under notes documents lt heel open skin 6x6cm and depth 0.5cm, applied wound vac Dr. order and bilat (bilateral) hand/arm Iv inj. (injection) site remained bruise. Surveyor noted the wound vac was a treatment started during hospitalization . The hospital history and physical dated 1/2/20 under presenting complaint documents altered mental status-staring episode and weakness, fevers. Under skin documents left heel wound, black tissue, no surrounding [DIAGNOSES REDACTED] or fluctuance warm and dry. Under plan documents Seen by surgery for [REDACTED]. Altered mental status most likely secondary to [MEDICAL CONDITION] induced by left foot ulcer/wound. The i (TRUNCATED)

Based on observation, interview and record review the facility did not ensure 2 (R4 and R3) of 2 residents needing care and treatment of [REDACTED]. On 7/23/19 R4 developed a skin tear to the left 2nd toe and an assessment was not conducted. R4's skin tear worsened on 8/13/19 and an order for [REDACTED]. The orthopedic physician noticed the toe was fractured and decided the toe needed to be amputated. Facility failure to assess R4's skin tear and to provide ongoing assessment of the skin tear after it worsened, created a finding of immediate jeopardy that began on 8/13/19. Surveyor notified NHA A of the immediate jeopardy on 9/30/19 at 12:10 p.m. The immediate jeopardy was removed on 10/1/19 when: Head to Toe Skin assessmentswerer completed on in-house residents. Skin incident report completed as appropriate for those residents with skin alterations. Residents with skin alterations were evaluated, and updates made to the plan of care as appropriate. Licensed staff educated on Skin Management program prior to their next scheduled shift. . Licensed staff educated on wound monitoring, assessment, documentation, and physician notification according to standards of practice. Referrals completed to wound doctor when indicated by attending physician. Identified Unit Manager and LPN received directed education Skin Management program. Licensed therapy staff educated on use of communication form for incidents and accidents. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan and as evidenced by the following: * R3 had an order for [REDACTED]. Findings include: The facility's Skin Management policy with revision date of (MONTH) (YEAR) indicates, Non-pressure wounds: 1. The resident, the resident' representative, and the attending physician are notified of the development of the wound. 2. The attending physician determines the etiology of the wound, as well as the treatment plan. 3. An SBAR Communication Form and Progress note (UDA) is completed to document the wound, notification and new treatment orders, as received. 4. The licensed nurse will document skin tears upon occurrence and on a weekly basis until healed using the Weekly non-pressure skin condition record (UDA). 5. Wounds will be assessed weekly and status/progress documented on the Weekly non-pressure skin condition record (UDA). 6. The resident is assessed for pain, and appropriate interventions are implemented and care planned. 7. Begin resident teaching and document in the Resident/Family education record (UDA) or progress notes as appropriate. 8. The resident is added to the 24-hour report via progress note. Care plan interventions are implemented and discussed during shift report with members of the care team. 9. The nurse will monitor the area closely during treatment to evaluate appropriateness of treatment regime. 10. Nursing staff will monitor placement of the affected limb to prevent further injury. This is especially important if underlying [MEDICAL CONDITION] is a factor. 11. Consult with rehabilitation services for evaluation and options for treatment intervention, such as [MEDICAL CONDITION] management. 12. Consultation with a certified wound care nurse, wound consultant, or surgeon may be appropriate. 1.) R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The ankle fracture was non-surgical and R4 wore a cam-boot (walking boot) on her left foot. The admission MDS (minimum data set) indicates R4 is severely cognitively impaired and needs extensive assistance with bed mobility, transfers and hygiene. The medical record indicates R4 has an activated POAHC (power of attorney for health care). The nurses note dated 7/23/19 indicates R4 sustained a skin tear to left toe during physical therapy. Bright red in color. The nurses note dated 7/24/19 indicates monitored for ST (skin tear) to L (left) 2nd toe. Band-aid intact. No c/o (complaints of) pain/discomfort noted. Will monitor. The physician orders, MAR (medication administration record) and/or TAR (treatment administrator record), do not indicate there was an order for [REDACTED]. There are no documented ongoing assessments of the wound. Despite indicating that staff will monitor there is no documentation that this was done. The nurses note dated 8/13/19 indicates new orders received for left foot 2nd toe. The MAR indicated [REDACTED]. The medical record does not indicate any assessment of R4's left 2nd toe. There is nothing in the record to indicate what change had occurred the necessitated the need for a [MEDICATION NAME] agent. Despite the change, there in no ongoing monitoring or assessment of the resident's toe. R4 did not have a care plan that addressed the skin tear wound or that the wound worsened. The orthopedic surgeon note dated 9/6/19 indicates, Physical examination: On physical examination, this is a pleasant-appearing female in no acute distress. Her left foot is in a boot. There is an open PIP joint on the residual second toe with bloody drainage, no evidence of infection, the surrounding skin is eburnated consistent with a friction injury she in insensate, her toe and ankle are non tender. Her foot is cold to touch. Plan: To prevent infection, we will admit the patient for a completion amputation of her residual second toe. Due to unknown NPO (nothing by mouth) status, we will schedule this for 730am start Saturday. The nurses note dated 9/6/19 indicates the facility received a phone call from the hospital pharmacy requesting the resident's medication administration list related to her admission. Resident was admitted with left toe fracture. The facility conducted an investigation into R4's left toe fracture and subsequent amputation. The investigation includes a statement from LPN D that indicates, I was doing the treatment since the injury in (MONTH) to her (R4) left 2nd toe. Around mid (MONTH) (8/14/19), the area appeared to be worsening. I contacted the MD and got new orders for Santyl to the area and continued to complete treatments as ordered. I did not see any exposed bone but the treatment was working to clean up the cap (scab) and I thought it was looking much better. I did the treatment on 9/5/19 and did not notice any bone exposed or s/s (signs or symptoms) infection. On 9/30 19 at 9:35 a.m. Surveyor interviewed LPN D regarding R4 skin tear wound. LPN D stated she works 2nd shift and saw the skin tear the day it happened. LPN D describes the wound as the top layer of the skin was off on top of the left 2nd toe and it was red. LPN D stated she would clean the area with NS and apply a bandaid every day. LPN D stated on 8/12/19 she noticed the wound looked like it got bigger. LPN D stated she left a message for RN Manager C to look at it the next day. LPN D stated she did not see any slough. When surveyor asked LPN D who is responsible for assessment of wounds she stated it was RN Manager C. LPN D stated on 8/13/19 she was directed by RN Manager C to call the physician for an order for [REDACTED]. LPN D stated R4 did not complain of pain, there was no odor to the wound and she did not notice any deformity to the toe that would indicate the toe was fractured. On 9/30/19 at 10:20 a.m. Surveyor interviewed RN Manager C. RN Manager C stated on 8/13/19 she became aware of R4 skin tear not healing and assessed the wound. RN Manager C stated she noticed slough in the wound and directed LPN D to call the physician to get an order for [REDACTED]. Surveyor asked RN Manager C if LPNs can assess wounds. RN Manager C stated, Well technically they can't. Surveyor explained there is no assessment of R4 skin tear and when the wound worsened and any follow up assessments regarding the healing progression of the wound. Again RN Manager C stated any supervisor can assess a wound. On 9/30/19 at 9:30 a.m. Surveyor interviewed NHA A regarding R4's skin tear wound. NHA A stated the nurse that first observed R4's skin tear no longer works for the facility. NHA A stated they are not sure who was the therapist that worked with R4 when she sustained the skin tear. On 9/30/19 at 10:45 a.m. Surveyor spoke with DON B. Surveyor explained to DON B the concern that R4 sustained a skin tear and there wasn't an assessment of the skin tear. The weeks after that incident there are no follow up assessments as to how the skin tear is healing. Then the skin tear wound worsens and an order is changed but there is no assessment of the wound at that point either. The daily band-aid application was not documented in the medical record. Surveyor also explained RN Manager C was not taking responsibility for assessing R4's wound and couldn't tell who was responsible for this assessment. The care plan was never updated regarding the skin tear wound. DON B stated she understood the concern but had no additional information. The failure to assess and treat R4 non-pressure wound created a finding of immediate jeopardy. The jeopardy was removed on 10/1/19 when the facility began implementing the following: The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement this plan and as evidenced by the following: 2.) R3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R3's Quarterly MDS (Minimum Data Set) dated 7/10/19 documents a BIMS (Brief Interview for Mental Status) score of 7, indicating that R3 is severely cognitively impaired. Section G (Functional Status) documents that R3 requires extensive assistance and a one person physical assist for his bed mobility needs. R3's nursing note dated 9/17/19 documents, Nursing Note Text: At 1547 (3:47 PM), writer notified resident had unwitnessed fall in rm (room) 171 B with a head injury. Observed resident lying on his L (left) side on the floor at foot of bed, L head bleeding. Writer applied pressure to area. Resident stated he was getting up to answer the phone. R3's emergency room after Visit Summary dated 9/17/19 documents under the [DIAGNOSES REDACTED]. Under the Instructions section it documents, Laceration, Scalp: Sutures or Staples. Follow up around 9/24/19 for: suture removal. R3's physician order [REDACTED]. On 9/25/19 at 11:54 a.m., Surveyor observed R3 sitting in his wheelchair with his left elbow skin tear uncovered and with no bandage. On 9/25/19 at 4:01 p.m., Surveyor observed R3 sitting in his wheelchair with his left elbow skin tear uncovered and with no bandage. On 9/25/19 at 4:03 p.m., Surveyor asked RN (Registered Nurse)-E if R3's left elbow skin tear should have a dressing covering it, per R3's physician order. RN-E confirmed to Surveyor that R3's left elbow skin tear should be covered with a dressing and that R3 did not currently have a dressing on his left elbow skin tear. On 9/30/19 at 8:48 a.m., Surveyor reviewed R3's (MONTH) 2019 TAR (Treatment Administration Record) and noted that R3's physician order, Dermalevin to L (left) elbow skin tear q (every) 3 days every day shift every 3 day(s) was signed as completed and in place by LPN (Licensed Practical Nurse)-F. On 9/30/19 at 11:59 a.m., Surveyor observed R3 sitting in his wheelchair with his left elbow skin tear uncovered and with no bandage. On 9/30/19 at 12:00 p.m., Surveyor interviewed LPN-F regarding R3's left elbow skin tear dressing being documented as completed and in place for R3. Surveyor asked LPN-F if she had placed a dressing on R3's left elbow skin tear as it was documented in R3's (MONTH) 2019 TAR. LPN-F informed Surveyor that although she had signed R3's left elbow skin tear dressing change as complete in R3's (MONTH) 2019 TAR, she had not changed R3's left elbow skin tear dressing change. Surveyor asked LPN-F if R3's left elbow skin tear should have a dressing covering it, per R3's physician order. LPN-F confirmed to Surveyor that R3's left elbow skin tear should be covered with a dressing and that R3 did not currently have a dressing on his left elbow skin tear. On 9/30/19 at 2:15 p.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B if R3's left elbow skin tear should have a dressing covering it, per R3's physician order. DON-B confirmed to Surveyor that R3's left elbow skin tear should be covered with a dressing.

Based on observation, interview and record review, the facility did not keep 1 of 12 residents (R3) free from sexual abuse. R1 made non-consensual sexual contact with R2 on 5/3/19. After this incident occurred, the facility did not assess R1 and develop a care plan with specific interventions to prevent R1 from making sexual contact with residents. On 6/5/19, R1 had non-consensual sexual contact with R3, who is cognitively impaired. After the incident with R3, the facility did not assess R1 and develop a care plan with specific interventions to prevent R1 from making sexual contact with residents. R1's care plan related to his non-consensual sexual contact was not developed until 7/3/19. When R1 made non-consensual sexual contact with R3 on 6/5/19, this created actual harm for R3 based on the reasonable person concept. CMS (Centers for Medicare and Medicaid) defines the reasonable person concept as follows. The absence of a reaction from a cognitively impaired resident who lacks the ability to understand and react to most stimuli, including those affected by the situation, does not make the deficiency any less serious. In this case the survey team should use the 'reasonable person' concept to determine the severity level of the psychosocial outcome for that person. R3 has a [DIAGNOSES REDACTED]. When interviewed, R3 was unable to provide her reaction to the incident. Using the reasonable person concept, R3 experienced actual harm when she was the victim of non-consensual sexual contact in which R1 rubbed her groin area and attempted to put his hand down her pants. Findings include: The facility's Abuse and Neglect Prohibition Policy Update Summary (undated) was provided to the survey team on 7/10/19. The policy provides the following definitions. Sexual abuse: is now defined as 'non-consensual (the resident does not consent) sexual contact of any type with a resident'. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual intended to inflict injury or harm. R1 is [AGE] years old and has [DIAGNOSES REDACTED]. R1 uses a wheelchair for mobility and was observed to independently propel his wheelchair throughout the dining room during lunch on 7/3/19 at 1:31 PM. R1 had a Minimum Data Set (MDS) completed 4/4/19. R1 was noted to be severely cognitively impaired. However, the MDS indicated that R1 was able to be be understood and to understand when communicating. R1's cognitive care plan, initiated 4/13/18, had a goal for R1 to communicate basic needs on a daily basis . Care plan interventions included asking R1 yes/no questions in order to determine his needs. R1 had no behaviors identified on his 4/4/19 MDS. The 4/13/19 care plan had no goals related to inappropriate behaviors for R1. INCIDENT WITH R1 AND R2 On 5/3/19 at 2:05 PM, R1 and R2 were seated in their wheelchairs in the dining room on the Dementia Unit. Facility staff saw R1 with his hand between the legs of R2. Staff was unable to see what R1 was doing with his hands. Staff immediately separated R1 and R2. R2 was wearing pants and R1's hands were above her clothing. R2 was immediately assessed with [REDACTED]. R2 has Dementia and was unable to remember what happened to her. R1 was interviewed and could not recall the incident. R1 was placed on 15 minute checks. The facility self-reported this incident between R1 and R2 to the state agency. The facility's report indicated that this was a isolated incident and was a first time behavior for (R1). Facility could not determine the root cause of this behavior but will continue to monitor and have IDT (Inter-Disciplinary Team) review. Due to (R2's) inability to inform facility of consent; the facility is taking the stance of it not being consensual. Facility will continue to monitor (R1's) and (R2's) health, status, medication management and psychosocial wellbeing. Both residents' care plans updated. The facility did not indicate whether or not R1's behavior was willful. R1 remained on 15 minute checks from 5/3 - 5/10/19. The facility completed a Social Services Assessment Note dated 5/9/19. The assessment indicated that R1 had no behaviors. The incident between R1 and R2 on 5/3/19 was not addressed on this assessment. There was no other assessments of R1 and his behaviors. The facility did not develop a care plan related to R1's inappropriate touching, until 7/3/19. INCIDENT WITH R1 AND R3 On 6/5/19 at 11:30 am, R1 and R3 were in the dining room on the Dementia Unit. R3 is independent in her ambulation and sat down next to R1, who was seated in his wheelchair. CNA - L observed R1 and R3 holding hands. CNA - L separated R1 and R3 and then walked away to get clothing protectors. When CNA - L turned around, R1 was rubbing R3 in her groin area. As CNA - L walked over to separate R1 and R3, R1 started to put his hands in the inside of R3's pants. CNA - L separated the two residents and R1 was placed on 15 minute checks. R3 was immediately assessed with [REDACTED]. Due to R3 being independent in her ambulation, the facility placed R3 on 1:1 supervision. This was discontinued after 5 hours because the 1:1 supervision seemed to increase R3's agitation. R3 was then placed on 15 minute checks. The facility self-reported this incident between R1 and R3 to the state agency, which included the following interviews. R1 stated that he remembered holding hands with a female, but denied any further contact. Resident was asked 3 times about touching a female anywhere other than her hands; each time he stated that there was no further contact. Resident stated that he remembered a woman kissing him at some point. He could not identify the female who he thought kissed him, nor could he remember who he held hands with. The facility attempted to interview R3, but noted that she could not verbalize any issue; her cognitive impairment negatively impacts her ability to speak coherently. R3's MDS, dated , 5/9/19, notes that she is severely cognitively impaired and has unclear speech. The facility's report indicated that: Facility could not determine the root cause of this behavior but will continue to monitor and have IDT (Inter-Disciplinary Team) reviews. Due to (R3's) inability to inform facility of consent; the facility is taking the stance of it not being consensual. Facility will continue to monitor (R1's) and (R3's) health status, medication management and psychosocial wellbeing. Both residents' care plans updated. The facility did not indicate whether or not R1's behavior was willful. R1 remained on 15 minute checks from 6/5 - 6/10/19. No assessment was completed related to R1's behaviors. The facility did not develop a care plan related to R1's inappropriate touching until 7/3/19. OBSERVATIONS On 7/3/19 at 1:30 PM, R1, R2, and R3 were observed in the dining room on the Dementia Unit during the lunch meal. When he had finished eating, R1 independently propelled his wheelchair from one end of the dining room to the middle of the dining room where the TV was located. R1 propelled his wheelchair past R3 and R2. Although staff were in the dining room, R1 did not appear to be directly supervised by staff. As he propelled his wheelchair, staff were engaged with other residents and were not directly observing R1. R1 had no interaction with any residents at this time and began to watch TV. CARE PLAN FOR R1 R1's care plan was reviewed on 7/8/19. It had a initiation date of 6/5/19 and a start date of 7/3/19. It noted that R1 may be sexually inappropriate when approached by female residents. The goal was for R1 to have no evidence of behavior problems. The interventions appeared to be general and not based on a specific assessment of R1. Staff were directed to: administer medications; provide positive interactions; discuss R1's behaviors with him; and redirect female residents away from R1. On 7/8/19 at 2:05 PM, RN Manager - C and Social Worker (SW) - D were interviewed. RN - C and SW - D confirmed that the facility had not developed a care plan related to R1's inappropriate touching until 7/3/19. RN - C said that the first incident on 6/5/19 was an isolated incident and so a care plan was not developed at that time. When asked why the care plan indicated an initiation date of 6/5/19; RN - C said that the care plan was back dated to show that R1's behaviors began on 6/5/19; but the care plan was not developed until 7/3/19. The surveyor indicated that once R1 exhibited the inappropriate behaviors, other residents were at risk unless a specific care plan was developed in an attempt to decrease the inappropriate behaviors. RN - C said that the facility did not develop at risk care plans because it was expected that staff would protect all residents from any inappropriate behaviors exhibited by any resident. RN - C and SW - D provided additional information. R1's behaviors were seen as more opportunistic, than aggressive. RN - C said that both R2 and R3 had positioned themselves next to R1 when the incidents occurred. R2, with her Dementia, sees herself as a caretaker. R2 often tries to console other residents by touching them and rubbing their arms. RN - C said that it appeared that R1 misinterpreted this behavior as R2 being sexually interested in R1. R3 is ambulatory and very confused. R3 is known to walk up to other residents and approach them in a way that may invade the residents' space. The surveyor indicated that R1's care plan did not include specific interventions to prevent him from inappropriately touching other residents. RN - C confirmed this. The surveyor asked what the current plan was to prevent R1 from inappropriately touching other residents. RN - C said that staff were to keep R1 in sight in the day room. RN - C said that R1's anti-depressant medication had been changed to [MEDICATION NAME], which has the side effect of decreasing sexual desire. On 7/9/19 the facility provided an updated care plan for R1. R1 was to remain in full view of staff in common area when not in bed. Additionally, the facility updated the care plans of R2 and R3. Staff were to re-direct R2 and R3 if they were making inappropriate physical contact with other residents.

Based on observation, interview and record review, the facility did not ensure policies and procedures for cleaning and disinfecting glucometers were being followed potentially spreading infection to 6 (R70, R96, R26, R27, R54, and R1) of 8 residents that were sharing a glucometer. On 1/31/19 RN-R was observed placing a glucometer on the medication cart without sanitizing the glucometer. Upon further interview about disinfection practices, the RN indicated to Surveyor that she only sanitizes the glucometer after she completes collecting all of the resident's blood sugar levels on the wing that she works. Review of the residents residing on the unit indicates 8 residents utilize the same glucometer for blood sugar checks. 2 of the residents that have their blood sugar checked have [DIAGNOSES REDACTED]. By not properly disinfecting the glucometer between each resident use, the RN exposed 6 additional residents to possibly contracting [MEDICAL CONDITION]. The failure to properly sanitize a glucometer created a situation of immediate jeopardy that started on 1/31/19. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the determination of immediate jeopardy on 1/31/19 at 11:25 AM. The immediate jeopardy was removed on 1/31/19. The deficient practice continues at a scope and severity of an F (potential for harm/widespread) for the following additional identified deficient practices. The facility did not have an infection control program that accurately identified and reported all infections or have a system of surveillance to identify any infections potentially affecting 162 of 162 residents. Additionally, observations were made of cares being provided to 3 (R104, R10, and R69) of 3 residents without proper hand hygiene. Medications were administered after touching medications with bare hands to 2 (R3 and R40) of 6 residents observed during medication administration, and eye drops were administered without proper hand hygiene after washing resident's face to 1 (R89) of 6 residents observed during medication administration. Findings include: Breach in Glucometer Sanitization: According to the Centers for Disease Control and Prevention, If shared, blood glucose meters should be cleaned and disinfected after every use. The facility policy and procedure entitled Point-of-care testing, blood glucose, ambulatory care dated 2/16/2018 states: Clean and disinfect the blood glucose meter following the manufacturer's instructions after each patient use. The manufacturer's instructions for cleaning the EvencareG2 glucometer, p. 47 of the manual, states: Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use. If the meter or lancing device is being operated by a second person who is providing testing assistance to the user, the meter or lancing device should be disinfected prior to use by the second person. On 1/31/2019 at 8:20 AM, Registered Nurse (RN)-R was observed checking R97's blood sugar with an EvencareG2 glucometer. After obtaining the blood sugar, RN-R pushed R97 to the dining room for breakfast, keeping the glucometer in hand. RN-R continued with the medication pass after placing the glucometer on the medication cart. When asked how many residents had their blood sugars checked, RN-R stated there are eight residents on this unit that get checked every morning. On 1/31/2019 at 9:03 AM, Surveyor asked RN-R if the glucometer that had been used to test R97's blood sugar had been cleaned or disinfected. RN-R stated the glucometer is cleaned at the end of medication pass and then demonstrated how the glucometer is cleaned. RN-R took a Cavi wipe, wiped off the glucometer, wrapped the glucometer in the wipe and placed it inside a glove to keep it wet. When asked if the glucometer is cleaned between each resident use, RN-R stated, no, the glucometer is only cleaned at the end of the medication pass. When asked what the facility policy was regarding cleaning and disinfecting glucometers, RN-R stated the glucometers are cleaned after the med pass is completed. RN-R provided the names of the eight residents who have their blood sugars checked: R70, R96, R26, R97, R27, R54, R1, and R63. RN-R stated R27 refused to have the blood sugar checked this morning and R63 was out of the building before the blood sugar could be checked. On 1/31/2019 at 9:15 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-S regarding the facility policy on cleaning and disinfecting glucometers. LPN-S stated the glucometer is cleaned after each resident use and is cleaned with Cavi wipes. There are two glucometers on the cart and are rotated so while one is wrapped in a Cavi wipe, the other one can be used. On 1/31/2019 at 9:38 AM, Surveyor asked RN-R what order the residents were checked this morning. RN-R stated the order was R70, R1, R54, R26, R97, and R96. When asked if the blood sugars of the residents were always obtained in the same order, RN-R stated each day is different, depending on what time each resident is out of bed and ready for breakfast. R97 was admitted to the facility with a history of chronic [MEDICAL CONDITION] with onset of 7/9/1998. R97 is being treated with Rifaximin ,an antibiotic, twice daily since admission on 8/28/2017. R63 was admitted to the facility with a history of chronic [MEDICAL CONDITION] with onset of 2/19/2013. R63 is being treated with Rifaximin twice daily since admission on 4/18/2018. [MEDICAL CONDITION] is a liver infection with symptoms that can include abdominal pain, fatigue, fever, jaundice, joint pain, poor appetite, nausea and vomiting. WebMD states: About 75% to 85% of people who have it get a long-term infection called chronic [MEDICAL CONDITION]. If the condition goes untreated, it can lead to: [MEDICAL CONDITION], or scarring of the liver; [MEDICAL CONDITION]; liver failure. According to the Centers for Disease Control and Prevention, An underappreciated risk of blood glucose testing is the opportunity for exposure to [MEDICAL CONDITION] (HBV, [MEDICAL CONDITION] virus, [MEDICAL CONDITION].through contaminated equipment and supplies if devices used for testing and/or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. In the last [AGE] years, alone, there have been at least 15 outbreaks of HBV infection associated with providers failing to follow basic principles of infection control when assisting with blood glucose monitoring. Due to under-reporting and under recognition of acute infection, the number of outbreaks due to unsafe diabetes care practices identified to date are likely an underestimate. Although the majority of these outbreaks have been reported in long-term care settings, the risk of infection is present in any setting where blood glucose monitoring equipment is shared or those assisting with blood glucose monitoring and/or insulin administration fail to follow basic principles of infection control. In addition to concerns with possible transmission of [MEDICAL CONDITION] it was also noted: R96 was admitted to the facility with a history of [MEDICAL CONDITION] (MRSA) to the wound in the right hand on 3/7/2017.[MEDICAL CONDITION] was present again in (YEAR). According to the Centers for Disease Control and Prevention,[MEDICAL CONDITION] is [MEDICAL CONDITION]-resistant Staphylococcus aureus, a type of staph bacteria that is resistant to several antibiotics. In the general community,[MEDICAL CONDITION] most often causes skin infections. In some cases, it causes pneumonia (lung infection) and other issues. If left untreated,[MEDICAL CONDITION] infections can become severe and [MEDICAL CONDITION] - a life-threatening reaction to severe infection in the body. In a healthcare setting, such as a hospital or nursing home,[MEDICAL CONDITION] can cause severe problems such as bloodstream infections, pneumonia and surgical site infections . On 1/31/2019 at 10:26 AM, Surveyor met with Director of Nursing (DON)-B regarding RN-R's practice of cleaning the glucometers and the medical status of R97, R63, and R96. DON-B agreed RN-R was not following the facility policy and procedure when cleaning the glucometers. DON-B stated training on the glucometers had been done in August, (YEAR), but would find the paperwork to verify. On 2/1/2019 at 8:16 AM, DON-B provided the paperwork showing training had been done to all nursing staff on the cleaning of the glucometers on 10/16/2018. RN-R had completed training at that time and had completed a glucometer cleaning checklist monitoring the technique of cleaning the glucometer on 8/22/2018. The facility's failure to ensure glucometers were properly sanitized led to a situation of immediate jeopardy. The facility removed the immediate jeopardy on 1/31/19 when they implemented the following action plan: ~ The facility provided immediate training to RN-R and ensured return demonstration of sanitizing techniques. ~ All glucometers in the facility were sanitized. ~ The facility established training on the facility's policies and procedures and proper techniques to sanitize glucometers between resident use. ~ The facility established a system for ongoing monitoring of sanitization practices by facility nursing staff. ~ A QAPI plan was established to ensure ongoing compliance. ~ The facility established a system to monitor potentially affected residents health status. The deficient practice continues at a scope and severity of an F (potential for harm/widespread based upon the additional examples. Infection Surveillance: The facility's INFECTION PREVENTION SURVEILLANCE policy and procedure, revised 2/2018, states the purpose of the policy is to To conduct a surveillance of resident and employee communicable diseases and infection to guide prevention activities. The policy states Healthcare-associated infections shall be reported monthly on the: A. Healthcare-associated Infection Summary Report . Surveillance documentation is maintained on the: A. Surveillance Line Listing & Antibiotic Tracking Tool B. Log of Employee Infections C. Infection Surveillance Summary Reports. On 2/1/19 at 10:57 am the surveyor interviewed IP (Infection Preventionist)-Q. The surveyor reviewed December's line listing and rates of infection. The surveyor asked how a resident is placed on the line listing. IP-Q stated she puts them on there. The surveyor asked if there was a (MONTH) line listing. IP-Q stated not yet. IP-Q stated she was using McGeer Sheets (definition of infection sheets/infection verification report sheet) for current tracking and trending for January. The surveyor asked if on the line listing are resident's that are not on an antibiotic are being tracked. IP-Q stated on the line listing she is only tracking resident's being treated. On 2/4/19 at 11:14 AM the surveyor interviewed IP-Q. IP-Q confirmed she was only tracking residents on antibiotics. The surveyor asked if a resident had influenza if that would be tracked on the facility's line listing. IP-Q stated it would be tracked through their outbreak. The surveyor asked what if it was an isolated incident. IP-Q stated they would not be put on the line listing and would not have a McGeer's (infection verification form filled out). The surveyor noted that if a resident developed an infection that was not treated with antibiotics the facility's surveillance for infections would not be accurate is it would not identify resident's with an infection not being treated on an antibiotic. The surveyor reviewed the facility's (MONTH) (YEAR) HEALTHCARE ASS[NAME]IATED INFECTION SUMMARY REPORT BY RESIDENT DAYS. The report documents under common cold syndrome or pharyngitis 1-for unit 2, 6 for unit 3, and 1 for unit 4. Under TOTAL the report documents see separate line listing. The surveyor reviewed the separate (MONTH) line listing related to an outbreak the facility had in September. The surveyor observed the facility's definition of infection report sheet documents under criteria for common cold syndrome or pharyngitis MUST HAVE at least 2 of the follow: Runny nose or sneezing, Dry cough, Stuffy nose (i.e., congestion), Sore throat or hoarseness or difficulty in swallowing, Swollen or tender glands in neck (cervical lymphadenopathy). The surveyor observed the listing contained 6 residents on it. The surveyor observed the line listing did not document the total number of residents with a common cold infection. The surveyor observed 3 other residents on the line listing were documented as having a cough and congestion; however the information on the line listing did not contain information related to what type of cough. The surveyor observed the line listing documented for R11 under symptoms cough congestion sore throat. A box on the line listing documents Does not meet infection criteria. The surveyor observed the facility's definition of infection report sheet documents under criteria for common cold syndrome or pharyngitis MUST HAVE at least 2 of the follow: Runny nose or sneezing, Dry cough, Stuffy nose (i.e., congestion), Sore throat or hoarseness or difficulty in swallowing, Swollen or tender glands in neck (cervical lymphadenopathy). The surveyor observed R2 met infection criteria. The surveyor observed the line listing documented for R34 under symptoms nasal congestion sore throat. A box on the line listing documents Does not meet infection criteria. The surveyor observed the facility's definition of infection report sheet documents under criteria for common cold syndrome or pharyngitis MUST HAVE at least 2 of the follow: Runny nose or sneezing, Dry cough, Stuffy nose (i.e., congestion), Sore throat or hoarseness or difficulty in swallowing, Swollen or tender glands in neck (cervical lymphadenopathy). The surveyor observed R2 met infection criteria. On 2/4/19 at 11:14 AM the surveyor interviewed IP-Q related to R74 and R34 being documented as not meeting infection criteria on the line listing. The surveyor reviewed the line listing with IP-Q. IP-Q stated that must have been a mistake. Surveyors reviewed the facility's Infection Prevention and Control Review, MONTHLY INFECTION RATES BY SITE, which is used by the facility to review infections for their QAPI (quality assurance and performance improvement). The surveyor observed total respiratory infections for September, which includes cold and sinusitis infections, is documented as 0. On 2/4/2019 at 11:19 AM the surveyor interviewed Nursing Home Administrator (NHA)-A to discuss the QAPI program. The surveyor discussed the concern of the infection control program placing residents on the line list if they are being treated for [REDACTED]. When asked how residents with flu-like symptoms are tracked when there is no treatment for [REDACTED]. When asked if NHA-A was aware of the inaccurate data presented at the QAPI meetings for the infection control program, NHA-A did not acknowledge he was aware. NHA-A thought there might have been a Performance Improvement Project (PIP) for infection control at one time, but was unable to find any documentation. Surveyor reiterated the concern with QAPI in regards to the infection control program: the data presented was inaccurate and therefore could not be reviewed to develop and implement an appropriate plan of action to correct any deficiencies. No further information was provided at that time. (Cross-reference F867). Antibiotic Stewardship: The facility's Infection Prevention Manual for Long Term Care with a revised date of 2/2018 was reviewed. Under Antibiotic Stewardship Program Policy documented The facility will establish a multidisciplinary antibiotic stewardship program (ASP) that outlines responsibilities and provides guidance for optimal antibiotic use, promotes the appropriate use of antibiotics, and helps minimize the risk of antibiotic over use and resistance. The Antibiotic Stewardship Program (ASP) Committee is accountable to the facility's Quality Assurance & Performance Improvement (QAPI) Committee. The ASP Committee will meet on at least quarterly and report identified trends, opportunities for improvement, and recommendations for action plans/Performance Improvement Projects related to antibiotic use to the QAPI Committee. Treatment with antibiotics is appropriate when the physician or licensed provider determines, on the basis of an assessment, that the most likely cause of the patient's symptoms is a bacterial infection. Antibiotics will be used only for as long as needed to treat infections, minimize the risk of relapse, or control active risks to others. Antibiotics are generally not used to treat colonization or [MEDICAL CONDITION] illness such as colds, influenza, and [MEDICAL CONDITION] gastroenteritis. On 2/4/19 at 11:19 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor requested and reviewed ASP Committee notes from past year. Surveyor was provided meeting notes from 2/22/18, 5/23/18, 8/22/18 and 10/24/18. Surveyor asked if there were any Performance Improvement Plans related to Infection Control which includes antibiotic use over the past year. NHA-A stated no. Per above policy the ASP Committee is compromised of the following members, at a minimum: a. Medical Director, b. Director of Nursing, c. Infection Preventionist, d. Consultant Pharmacist. There is no documentation of Medical Director or Consultant Pharmacist in attendance at the 2/22/18, 5/23/18, 8/22/18 and 10/24/18. Per above policy Medical Director duties at a minimum are: e. Evaluates the effectiveness of an antimicrobial stewardship program through the measurement of outcomes, for example, leadership commitment, accountability, drug expertise, action, tracking, reporting and education. There is no documentation of Medical Director measuring outcomes related to antibiotic use documented on the 2/22/18, 5/23/18, 8/22/18 and 10/24/18 notes. Per above policy Consultant Pharmacist duties at a minimum are: a. Coordinates with ASP to provide presentations to educate staff on the Antibiotic Stewardship Program and h. Provides to the ASP Committee a report of the dispensing/electronic medical record information on the use of antibiotics per prescriber at each committee meeting. There is no documentation of the Consultant Pharmacist providing presentations on the ASP to staff or proving any reports to the committee documented on the 2/22/18, 5/23/18, 8/22/18 and 10/24/18 notes. ~ On 2/1/19 at 10:57 am the surveyor interviewed IP-Q. The surveyor asked to see R79's infection verification report sheet. R79's progress notes state 1/22/2019 14:55 (2:55 pm) SBAR (situation, background, assessment, recommendation form) RN (registered nurse) Assessment/LPN (licensed practical nurse) Appearance of resident - What I think is going on with the resident is: Resident c/o having loose stools since last night stating he had his first episode last night and has had two episodes today. Resident denies any other symptoms of being sick, denies pain, and is afebrile. VSS. MD updated, ordered to collect a stools specimen to rule out c.diff and norovirus .IP-Q stated she did not have a sheet for R79. The surveyor asked didn't R79 have more than 3 loose stool (in a 24 hour period). IP-Q stated he was tested and didn't have [MEDICAL CONDITIONS] or [MEDICAL CONDITION]. The facility's Infection Verification Report states for criteria of infection for gastroenteritis MUST HAVE at least 1 of the following: 3 or more loose or water stools above what is normal for resident within a 24 hour period .at least 1 of the following: nausea, vomiting, diarrhea, abdominal pain, or tenderness. The surveyor asked why R79 was noted tracked for gastroenteritis if he had more than 3 loose stools in 24 hours. IP-Q stated because he was not treated. The surveyor asked if on the line listing if resident's that are not on an antibiotic are being tracked. IP-Q stated on the line listing she is only tracking resident's being treated. The surveyor noted there was not accurate surveillance of infection in the facility related to R79's gastroenteritis not being tracked and trend as an infection. ~ R97's nurse practitioner note dated 1/8/19 states Patient has c/o (complaints of) burning with urination . The surveyor reviewed R97's infection verification report for an infection first noted on 1/8/19 for a UTI (urinary tract infection) without catheter. The surveyor noted acute dysuria or acute pain . was not checked. On 2/1/19 at 10:57 am the surveyor interviewed IP-Q. IP-Q stated she was using McGeer Sheets (definition of infection sheets/infection verification report sheet) for current tracking and trending. The surveyor informed IP-Q of the nurse practitioner note stating the resident had complaints of burning with urination, and that was not checked as a symptom R97 was exhibiting on the Infection Verification Report. IP-Q checked dysuria on the report. The surveyor noted R97's Infection Verification Report was not accurate. ~ The facility's Staff Development Manager/RN (SDM/RN) - Q, is in charge of the facility's Infection Control Program. SDM/RN - Q was interviewed by Surveyor # on 2/1/19. SDM/RN - Q said that that the facility's current tracking and trending of infections is based on the facility's Infection Verification (IV) Reports, using the McGeer's Criteria. However, the IV Reports were not kept up to date. R31 had been prescribed an antibiotic for an infection on 1/12/19. The IV Report was not completed until 2/4/19. On 1/12/19, R31 was prescribed the antibiotic medication, [MEDICATION NAME] 500 mg, to be taken one time daily for infection. R31 received the [MEDICATION NAME] from 1/12 - 1/17/19. On 2/4/19 at 920 am, Surveyor # met with SDM/RN - Q and requested the IV Report for R31. The IV report indicated that the infection was first noted on 1/6/19. The IV Report documented that the report had been prepared by SDM/RN - Q; however the Date of the report was left blank. The form indicated that the infection site for R31 was Urinary Tract Infection [MEDICAL CONDITION] with a catheter. The section titled, Criteria. Check off only the signs and symptoms that resident exhibits, had not been completed. (There were no signs or symptoms noted.) SDM/RN - Q said that R31 had a change in his mental status. This was one of the criteria listed for the UTI. According to the IV Report, R31 also had to have a Urinary catheter specimen culture with at least 10,000 cfu/mL (colony-forming units/per milliliter) of any organism. When asked about this, SDM/RN - Q said that she needed to obtain the lab report for the urinalysis. On 2/4/19 at 9:40 am, SDM/RN - Q said that the antibiotic had been given to R31 for green drainage at the site where the catheter had been inserted. For this reason, no urinalysis had been completed. SDM/RN - Q then turned to section on the IV Report, titled skin infections. She then completed this section, which had been blank. SDM/RN - Q then documented that the infection site was soft tissue. SDM/RN - Q then documented that R31 had the following signs and symptoms: pus, redness at site, swelling at site tenderness and pain at site. Handwashing During Medication Administration and Cares: The Hand Hygiene policy revised 2/2018 under policy documents Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues. Although antiseptics and other handwashing/hand hygiene agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination, the agent used the presence of residual activity and the handwashing/hand hygiene technique followed. Antiseptics should not, as a rule, be used to disinfect inanimate surfaces. Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens (such as [MEDICAL CONDITION] and Bacillus anthracis) is strongly suspected or proven, and after using the restroom. Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, non intact skin, or wound dressings (if hands aren't visibly soiled); after removing gloves; before eating, and after contact with inanimate objects in the patient's environment. The CDC (Center Disease Control) recommends performing hand hygiene with soap and water before eating, and the World Health Organization (WHO) recommends using either an alcohol-based hand rub or soap and water before preparing food and handling medication. * On 1/31/19 at 9:08 a.m. Surveyor observed Med Tech-J administer R89 her oral medication. At 9:09 a.m. Med Tech-J informed R89 she was going to give R89 her eye drops. Med Tech-J washed her hands and placed gloves on. R89 who laid back in bed after receiving her medication sat up in bed and threw up phelm. Med Tech-J got a towel wiped R89 face, removed her gloves, washed her hands and placed gloves on. Med Tech-J wet a wash cloth, informed R89 she was going to wash her face, and washed R89's face. After washing R89's face, Med Tech-J administered one drop into each eye of refresh eye drops lubricant, removed her gloves and washed her hands. Med Tech-J did not remove her gloves and wash her hands prior to administering R89's eye drops. * R104's quarterly MDS (minimum data set) with an assessment reference date of 1/8/19 and signed as complete on 1/10/19 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R104 requires extensive assistance with two plus person physical assist for bed mobility & toilet use and did not transfer or ambulate. R104 is coded as frequently incontinent of urine and always incontinent of bowel. On 1/24/19 at 10:36 a.m. Surveyor observed CNA (Certified Nursing Assistant)-M in R104's room wearing gloves. CNA-M informed R104 she was going to check her bottom to see if she was dry, went into the bathroom and wet washcloths. CNA-M removed the pillows, raised the height of the bed, and unfastened R104's incontinent product which contained urine. CNA-M washed R104's frontal perineal area from front to back. Surveyor observed stool on the wash cloth. After washing R104's frontal area, CNA-M positioned R104 on her left side. Surveyor observed stool on R104's buttocks and rectal area. CNA-M washed R104's buttocks and rectal area to remove the stool, placed an incontinent product under R104 and placed barrier cream on her buttocks. CNA-M did not remove her gloves and wash her hands prior to placing the clean incontinence product under R104. R104 was positioned on her back and then on her right side to remove the soiled product and sheet which CNA-M placed in a bag. CNA-M fastened the incontinence product, moved the bed control and straighten out the fitted sheet. R104 stated the incontinence product as pulling on her sore on the left side. CNA-M adjusted R104's incontinence product, removed R104 hospital gown and placed a new gown on R104. CNA-M positioned R104 from side to side to place a draw sheet under her and placed a pressure relieving boot on her left foot. CNA-M raised the head of the bed up, removed her gloves, stated she was going to get a coworker and left R104's room. CNA-M did not wash or cleanse her hands prior to leaving R104's room. * R69's significant change MDS (minimum data set) with an assessment reference date of 1/16/19 and signed as complete on 1/21/19 documents a BIMS (brief interview mental status score of 6 which indicates severe impairment. R69 requires extensive assistance with one person physical assist for bed mobility, transfer, & toilet use and does not ambulate. R69 is coded has frequently incontinent of urine and always incontinent of bowel. On 1/29/19 at 11:28 a.m. Surveyor observed CNA (Certified Nursing Assistant)-K enter R69's room, place gloves on, remove the body pillow and ask R69 if she was going to read a book. CNA-K then asked R69 if she could wash her up, removed her gloves and left the room. CNA-K returned a couple minutes later, placed gloves on and removed a basin from the closet. CNA-K filled the wash basin, raised the height of the bed, lowered the head of the bed and removed the pillow from between R69's knees. CNA-K washed R69's face, removed the gown, washed R69's upper body, placed deodorant on and a new gown was placed on R69. CNA-K pulled on the draw sheet to position R69 towards the left, unfastened R69 incontinence product and washed R69's frontal perineal area and inner thighs. CNA-K pulled the incontinence product out from under R69 and placed zinc oxide cream on R69's inner thighs and part of her buttocks. CNA-K did not remove her gloves and did not wash or cleanse her hands. CNA-K positioned R69 from side to side to place an incontinence product under R69 and fastened the product. CNA-K positioned R69 in the middle of the bed, covered her with a sheet and placed the beige body pillow along the left side. CNA-K removed her left glove, placed the soiled items in a bag, placed a bag in the garbage container, removed her right glove and washed her hands. On 1/31/19 at 8:13 a.m. Surveyor asked SDM (Staff Development Manager)/RN (Registered Nurse)-Q when she would expect staff to wash their hands. SDM/RN-Q informed Surveyor in between clean and dirty, anytime they touch something dirty, they should wash their hands when they enter a Resident's room, after they set up a Resident they should wash their hands again, before they begin and when they are done. Surveyor informed SDM/RN-Q of the observations with R104 and R69. The facility's Perineal Care of the Female Patient policy and procedure, revised (MONTH) 14, (YEAR) states Completing the procedure -After cleaning the perineum, apply a moisture-barrier skin protectant, as needed, to protect and maintain intact skin or to treat nonintact skin. Reposition the patient comfortable. Remove the bath blanket, sheet, or towel and fluid-impermeable pad and then replace the bed linens if necessary. Return the bed to the lowest position to prevent falls and maintain the patient's safety. Dispose of soiled article in the appropriate receptacle. Don't flush disposable cloths down the toilet. Remove and discard your gloves. Perform hand hygiene. ~ On 1/24/19 at 9:22 am the surveyor observed CNA (certified nursing assistant)-C T enter R10's room to provide morning cares. At 9:30 am the surveyor observed CNA-T provide incontinence care to R10. The surveyor observed R10 had been incontinent of urine and stool. The surveyor observed CNA-T clean R10's perineal and anal area, including cleansing R10's bottom of stool, with gloved hands. CNA-T did not remove her gloves or wash her hands after providing incontinent care to R10. The surveyor observed CNA-T grab the barrier cream with the same gloved hands that had been on when CNA-T had provided incontinence care. The surveyor observed CNA-T touch R10's shirt that was on the bedside table, apply gripper socks on R10, open R10's closed, take a bra and a sweater from the closet, take off R10's gown, apply deodorant, dress R10 in a b (TRUNCATED)

Based on observation, interview, and record review the Facility did not ensure 7 (R69, R104, R3, R13, R103, R111, & R118) of 8 Residents reviewed for pressure injuries received the necessary treatment and services to promote healing and prevent new pressure injuries from developing. * R69 was identified as having a Stage 2 pressure injury on her coccyx on 1/14/19. There is no RN (Registered Nurse) assessment on this date. R69's coccyx pressure injury wasn't assessed and measured until 1/21/19, 7 days later. R69's pressure injury declined from a Stage 2 to Stage 3. There were no revisions in R69's care plan after this decline. On 1/21/19 R69 was identified as having a deep tissue injury to the left heel. The left heel was staged incorrectly as the description indicates a Stage 2. There were no documented interventions in place until after R69 developed the heel pressure injury. Observations were made of R69's heels not being offloaded. * R104 was observed to have a Stage 2 pressure injury on the right buttocks on 1/24/19. This area was not assessed by Facility staff until 1/29/19. R104's right heel was observed not to be offloaded. * R3 is at risk for pressure injury development and was observed without her heels being offloaded. * R13 is at risk for pressure injury development. There were no interventions in place to prevent pressure injuries while R13 was at [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. * R103 did not have a care plan in place for pressure injury development and developed an unstageable pressure injury to the right heel. There were no treatment orders in place or documentation of any treatments. After R103 developed the pressure injury there was no revisions to the care plan implemented. * R111 is at risk for developing pressure injuries and was observed with his heels not being offloaded. * R118 does not have a care plan to prevent pressure injuries and was observed without pressure relieving devices in place. Examples regarding R69 and R103 are cited at the scope and severity of G (actual harm/isolated). Findings include: The facility's Skin Management System: Policy, Practice Guidelines, Resources & References, and Skin Management System Algorithm with a revision date of (MONTH) (YEAR) indicates under Practice Guidelines: 4. Residents admitted with skin impairments will have: a. Interventions implemented to promote healing. b. A physician's orders [REDACTED]. A Care Plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, and the interventions implemented to promote healing and prevent further breakdown . 9. A physician's orders [REDACTED]. Under Ongoing Skin Assessments, 1. A Weekly Skin Check will be completed in the resident's record using the Head to Toe Skin Check (UDA). 2. An SBAR Communication Form and Progress Note (UDA) is completed and a new physician's orders [REDACTED]. 3. The nurse will initiate treatments, interventions, Care Plan, and the appropriate skin documentation records in a timely manner according to Practice Guidelines. 1.) R69's [DIAGNOSES REDACTED]. The pressure ulcer care plan initiated 1/14/19 and revised 1/23/19 has interventions of Administer medications as ordered. Observe/document for side effects and effectiveness. initiated 4/28/16, Administer treatments as ordered and observe for effectiveness. initiated 4/28/16, Complete a full body check weekly and document. initiated 4/28/16, Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. initiate 4/28/16, Elevate heels off bed. Use pillows between knees and to position. initiated 1/23/19, Foley to be placed for stg (stage) 3 wound healing. initiated 1/23/19, Follow facility policies/protocols for the prevention/treatment of [REDACTED].e. RD (Registered Dietitian), PT (Physical Therapy) OT (Occupational Therapy) and other initiated 4/28/16 & revised 5/26/17, Inform the resident/family/caregivers of any new area of skin breakdown. initiated 4/28/16, Observe nutritional status. Serve diet as ordered, observe intake and record. initiated 4/28/16, Obtain and observe lab/diagnostic work as ordered. Report results to MD and follow up as indicated. initiated 4/28/16, Position on right/back and avoid pressure to the left; Hospice care to provide air mattress. initiated 1/15/19, Provide peri-care after each incontinence episode. initiated 4/28/16 & revised 12/6/16, Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. initiated 4/28/16 and The resident requires pressure reducing device on bed and chair. initiated 4/28/16 & revised 7/12/17. The significant change MDS (minimum data set) with an assessment reference date of 11/27/18 and signed as complete on 11/29/18 documents a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R69 requires extensive assistance with one person physical assist for bed mobility, transfer, & toilet use and is frequently incontinent of bowel and bladder. R69 is at risk for pressure injury development and is coded as not having any pressure injuries. The Braden assessment dated [DATE] has a score of 16 which indicates at risk. The SBAR (situation, background, assessment, recommendation) note dated 1/14/19 documents RN (Registered Nurse) Assessment/LPN (Licensed Practical Nurse) Appearance of resident - What I think is going on with the resident is: Resident has stage 2 ulcer on the left buttock, cream applied to the area, Resident is on repositioning every 2 hours, Hospice is at bedside. Unit manager aware, MD (Medical Doctor) updated. Surveyor noted this SBAR note is written by LPN-S. There is no RN assessment of R69's Stage 2 pressure injury. Surveyor noted there are no measurements of R69's pressure injury. The nurses note dated 1/15/19 documents Repositioned when in bed for assist w/ excoriated areas to buttock. Zinc Rx in place. Refuses up. Toileted and am (morning) cares done in bathroom, then back to bed. Color good, skin dry et warm. Ate 50% at breakfast w/(with) staff assist. Afebrile. Surveyor noted there are no measurements of R69's pressure injury. The head to toe skin check dated 1/16/19 under skin integrity is checked for intact skin. The significant change MDS with an assessment reference date of 1/16/19 and signed as complete on 1/21/19 has a BIMS score of 6 which indicates severe impairment. R69 requires extensive assistance with one person physical assist for bed mobility, transfer, & toilet use, does not ambulate, is frequently incontinent of bladder and always incontinent of bowel. R69 is at risk for pressure injury development and is coded as having one Stage 2 pressure injury. The pressure injury CAA (care area assessment) dated 1/17/19 under analysis of findings documents stg (stage) 2 - coccyx. Admit to hospice. Very weakened condition. ROM (range of motion) adeq. (adequate). Speech clear and able to express self. Stg 2 w (with) tx (treatment) 1/14. Tyl (Tylenol) and Melaxacam sched. (scheduled). Ext (extensive) assist w (with) ADLs (activities daily living). Unable to propel w/c (wheelchair). Cardiac/ BP (blood pressure) meds (medication) Linzess hx (history) bowel/abdominal issues. [MEDICATION NAME], acidophilus. Monitor for change/comfort. Pressure reducing device to bed and chair. Pain monitored. Needs anticipated as well as res (resident) able to express needs. Update Hospice as needed. The weekly pressure ulcer record dated 1/21/19 under date of onset documents 1/14/2019, under site documents coccyx under type pressure, length 6.5, width 4, depth 0 and Stage III (3). Under description of site documents There is and island of [MEDICATION NAME] tissue inside wound bed which measures 1.2 x (by) 1 there is slough noted to about 20% of wound with scant drainage of serous type. surrounding tissue intact with no maceration at this time. Surveyor noted this assessment & measurement of R69's coccyx pressure injury is 7 days after it was identified and has declined from a Stage 2 on 1/14/19 to Stage 3 on 1/21/19. The weekly pressure ulcer record dated 1/21/19 under date of onset documents 1/21/2019. Under site documents left heel, under type Pressure, length 2, Width 1.5, Depth 0 Stage Suspected Deep Tissue Injury. Under description of site documents 100% intact serous blister to left heel from pt (patient) crossing her legs and putting heels into mattress. no drainage or odor. Surrounding tissue intact. Surveyor noted this pressure injury is incorrectly staged as a suspected deep tissue injury. A Stage 2 pressure injury is defined on this form as Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. A suspected deep tissue injury is defined on this form as Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Surveyor noted there were no care plan interventions implemented to offload R69's heels until after R69 developed a pressure injury on her left heel. The CNA kardex dated 1/24/19 documents foley to be placed for stg 3 wound healing. Under bed mobility documents elevate heels off bed use pillows between knees and to position on right/back and avoid pressure to the left hospice care to provide air mattress. On 1/24/19 at 11:03 a.m. Surveyor observed R69 in bed on her right side on an air mattress. Surveyor observed R69's heels are not being offloaded. On 1/24/19 at 3:53 p.m. Surveyor observed R69 on her right side. Surveyor observed R69's heels are not being offloaded. The weekly pressure ulcer record dated 1/28/19 under site documents coccyx, under type pressure, length 3, width 2, depth 0 and stage III (3). Under description of site documents wound bed is light pink in color with scant drainage and no odor wound measurements are 3 x 2 with [MEDICATION NAME] island in the middle of area. surrounding tissue intact and natural tone in color. wound edges are clearly defined and natural tone. The weekly pressure ulcer record dated 1/28/19 under site documents left heel, under type documents Pressure, length 1.5, width 2.0, depth 0, and Stage II. Under description documents intact deflated serous fluid filled blister. blister is deflated with no drainage or odor noted. skin tact although a little darker tone then the natural tone of foot. On 1/29/19 at 10:21 a.m. Surveyor observed R69 in bed on her right side. Surveyor noted R69's bed has been moved so the right side is against the wall. There is a body pillow along R69's left side. Surveyor observed R69's heels are resting on the mattress and are not being offloaded. On 1/29/19 at 11:28 a.m. Surveyor observed CNA (Certified Nursing Assistant)-K enter R69's room, place gloves on, remove the body pillow and ask R69 if she was going to read a book. CNA-K then asked R69 if she could wash her up, removed her gloves and left the room. CNA-K returned a couple minutes later, placed gloves on and removed a basin from the closet. CNA-K filled the wash basin, raised the height of the bed, lowered the head of the bed and removed the pillow from between R69's knees. CNA-K washed R69's face, removed the gown, washed R69's upper body, placed deodorant on and a new gown was placed on R69. CNA-K pulled on the draw sheet to position R69 towards the left, unfastened R69's incontinence product and washed R69's frontal perineal area and inner thighs. CNA-K pulled the incontinence product out from under R69 and placed zinc oxide cream on R69's inner thighs and part of her buttocks. CNA-K positioned R69 from side to side to place an incontinence product under R69 and fastened the product. Surveyor observed there is not a dressing on R69's coccyx. CNA-K positioned R69 in the middle of the bed, covered her with a sheet and placed the beige body pillow along the left side. On 1/29/19 at 11:57 a.m. Surveyor observed CNA-K place gloves on and placed 2 pillows under R69's legs with her heels resting on pillow. Surveyor observed R69's heels are not being offloaded. On 1/29/19 at 1:56 p.m. Surveyor asked CNA-K if R69 is suppose to have any dressings covering her pressure injury. CNA-K replied no. On 1/29/19 at 1:57 p.m. Surveyor asked SDM (Staff Development Manager)/RN (Registered Nurse)-Q if R69 is suppose to have a dressing on. SDM/RN-Q replied yes on coccyx and then explained she tries to divide up the treatments so they are not all on one shift. Surveyor asked SDM/RN-Q if anyone told her the dressing wasn't on. SDM/RM-Q replied no I take it it's not on, will take care of it right now. On 1/29/19 at 2:04 p.m. Surveyor observed the treatment for [REDACTED]. There were no concerns identified with this observation. After the treatment was completed Surveyor asked Med Tech-J if R69's incontinence product was wet or dry. Med Tech-J informed Surveyor she thinks it was from the wound because R69 was dry. On 1/31/19 at 7:52 a.m. Surveyor asked SDM/RN-Q what the system is when a Resident is identified with a pressure injury. SDM/RN-Q informed Surveyor they have weekly wound rounds. She is responsible for the wounds on Layton Park & Story Hill units and ADON (Assistant Director of Nursing)-SS has [MEDICATION NAME] Hill & Walker Point units. Surveyor asked what should the CNA's should do if they observe a skin impairment on a Resident. SDM/RN-Q informed Surveyor they should report this to their nurse & manager and one of the three will come and let her know. Surveyor asked who assesses and stages pressure injuries. SDM/RN-Q informed Surveyor that is a loaded question as it depends on the time of the day. SDM/RN-Q explained if it's Monday through Friday and they are here, then either she, ADON-SS or DON-B would stage it and put a treatment in place. If they are not in the building then the nurse should call the physician and get an appropriate treatment at that time. The nurse would also complete an SBAR and call the family. Surveyor informed SDM/RN-Q R69 was identified as having a Stage 2 pressure injury on 1/14/19, the head to toe skin checks dated 1/16/19 indicates the skin is intact, and on 1/21/19 the pressure injury on R69's coccyx is a Stage 3. Surveyor asked why there wasn't an assessment for one week. SDM/RN-Q informed Surveyor it should have been there. SDM/RN-Q informed Surveyor R69 was added to the wound list and on 1/21/19 she started to follow her. SDM/RN-Q indicated she put a Foley in due to incontinence, started a treatment with Santyl as there was a little bit of slough which was cleaned up by the following week. Surveyor asked SDM/RN-Q why she staged R69's left heel as a suspected deep tissue injury as the blister was described as having serous fluid. SDM/RN-Q informed Surveyor initially it was serous fluid but she anticipated it would change, has seen pressure injuries change to deep tissue injury and that's why she staged it this way. Surveyor informed SDM/RN-Q of the observations of R69's heels not being offloaded. 2.) R104 has a [DIAGNOSES REDACTED]. The pressure ulcer resolved 8/20/18 and has potential for further pressure ulcer development care plan initiated 8/21/18 & revised 9/17/18 has interventions of Complete full body check weekly and document initiated 8/21/18, IDT (interdisciplinary team) referrals as indicated, i.e. RD (Registered Dietitian), PT (Physical Therapy), OT (Occupational Therapy), or other initiated & revised on 8/21/18, Inform the resident/family/caregivers of any new area of skin breakdown. initiated 8/21/18, Observe nutritional status. Serve diet as ordered, observe intake and record. initiated 8/21/18, Provide incontinence care after each incontinence episode, or per established toileting plan. initiated 8/21/18, The resident needs assistance of 1- 2 staff to turn/reposition at least every 2-3 hours, more often as needed or required. Use pillows to maintain position when on side. Use pillows/towel rolls to elevate arms and position hands. initiated 8/21/18 & revised 8/30/18, and The resident requires air mattress, cushion in w/c (wheelchair). initiated 8/21/18 & revised 9/17/18. The Braden assessment dated [DATE] has a score of 14 which indicates moderate risk. R104's quarterly MDS (minimum data set) with an assessment reference date of 1/8/19 and signed as complete on 1/10/19 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R104 requires extensive assistance with two plus person physical assist for bed mobility & toilet use and did not transfer or ambulate. R104 is coded as frequently incontinent of urine and always incontinent of bowel. R104 is at risk for pressure injury development and is coded as not having any pressure injuries. On 1/24/19 at 7:51 a.m. Surveyor asked R104 if she gets out of bed. R104 explained it's her choice to stay in bed because she has sores around her tail bone and sitting in the chair puts pressure on them. On 1/24/19 at 8:12 a.m. Surveyor observed R104 in bed on her back. R104 has a pressure relieving boot on her left foot and her right foot is resting on a folded sheet. On 1/24/19 at 10:36 a.m. Surveyor observed CNA (Certified Nursing Assistant)-M in R104's room wearing gloves. CNA-M informed R104 she was going to check her bottom to see if she was dry, went into the bathroom and wet washcloths. CNA-M removed the pillows, raised the height of the bed, and unfastened R104's incontinent product which contained urine. CNA-M washed R104's frontal perineal area from front to back. Surveyor observed stool on the wash cloth. After washing R104's frontal area, CNA-M positioned R104 on her left side. Surveyor observed stool on R104's buttocks and rectal area. CNA-M washed R104's buttocks and rectal area to remove the stool. At 10:44 a.m. Surveyor observed on the right buttocks, near the top of the glueteal crease, a Stage 2 pressure injury the approximate size of a dime. CNA-M placed an incontinent product under R104 and placed barrier cream on her buttocks. R104 was positioned on her back and then on her right side to remove the soiled product and sheet which CNA-M placed in a bag. CNA-M fastened the incontinence product, moved the bed control and straighten out the fitted sheet. R104 stated the incontinence product is pulling on her sore on the left side. CNA-M adjusted R104's incontinence product, removed R104's hospital gown and placed a new gown on R104. CNA-M positioned R104 from side to side to place a draw sheet under her and placed a pressure relieving boot on her left foot. CNA-M raised the head of the bed up, removed her gloves, stated she was going to get a coworker and left R104's room. On 1/24/19 at 1:32 p.m. Surveyor observed R104 in bed on her back with the head of the bed elevated high. R104 is wearing a pressure relieving boot on her left foot and the right foot is resting on a folded sheet and is not being offloaded. The SBAR note dated 1/29/19 documents RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: resident has two small stage two pressure areas on her buttocks, resident has chronic excoriation issues to her buttocks. Areas are 1.0 cm (centimeters) x (times) 0.8 cm and 0.8 cm x 0.4 cm. Areas red with scant amount of blood. Surrounding skin excoriated. Current barrier cream order in place, cream applied to area. Resident lays in bed all day on her bottom, staff attempts to reposition, however resident does not stay on her sides very long always ending up back on her bottom. Additional Nursing Notes as applicable: MD (medical doctor) updated, ordered to continue with attempting to reposition resident q 2 hrs (every two hours), continue with barrier cream to buttocks until the wound team can assess the areas and determine if a new treatment order is necessary. Resident is her own person, family care case worker called, voicemail left. On 1/31/19 at 7:15 a.m. Surveyor noted the head to toe skin check dated 1/24/19 under skin integrity is checked for intact skin. Surveyor observed a Stage 2 pressure injury on R104's right buttocks on 1/24/19. On 1/31/19 at 7:40 a.m. Surveyor asked CNA-M, last week when Surveyor observed her taking care of R104 is that the how R104's buttocks usually looked like. CNA-M informed Surveyor she has been putting cream on but it didn't look as bad as it did. Surveyor asked if CNA-M was referring to the previous week. CNA-M replied yes. On 1/31/19 at 8:07 a.m. Surveyor spoke to SDM (Staff Development Manager)/RN (Registered Nurse)-Q, who is the wound nurse for R104's unit, regarding R104's pressure injury. SDM/RN-Q informed Surveyor she just got an email today and is ordering an air mattress and they are putting cream on. SDM/RN-Q informed Surveyor R104 is non compliant with repositioning. Surveyor informed SDM/RN-Q Surveyor observed a Stage 2 pressure injury on R104's buttocks on 1/24/19 and there isn't any assessment until 1/29/19. SDM/RN-Q informed Surveyor obviously there is some communication breakdown and she was not aware until the email on the 30th. Surveyor informed SDM/RN-Q Surveyor always observed R104 wearing a pressure relieving boot on her left foot but what interventions are in place to prevent a pressure injury from developing on the right heel as Surveyor has observations of the right heel not being offloaded. SDM/RN-Q informed Surveyor she will investigate and get back to Surveyor. On 1/31/19 at 8:27 a.m. Surveyor observed R104 in bed on her back with the head of the bed elevated. There is a pillow under R104's left arm and wash cloth in her hand. Surveyor observed there is a pressure relieving boot on R104's left foot and her right heel is resting on a folded sheet. R104's right heel is not being offloaded. On 1/31/19 SDM/RN-Q provided Surveyor with Resident/Family Education Record dated 1/31/19. Under document details of what was taught to Resident documents that the boots are better pressure relievers then floating feet. feet can fall off pillows where as boots will stay on no matter what position you want your feet. Under comments documents pt. (patient) states she does not want other boot because she has had a plate put in her ankle and the boot bothers that and she just don't want it. 3.) R3's [DIAGNOSES REDACTED]. The potential for pressure ulcer care plan initiated 5/9/17 and revised 9/18/17 includes interventions of Administer medications as ordered. Observe/document for side effects and effectiveness initiated 5/9/17, Administer treatments as ordered and observe for effectiveness initiated 5/9/17, Assist resident to turn q (every) 2-3 hrs (hours) and prn (as needed) initiated 9/18/17 & revised 10/23/18, Complete a full body check weekly and document. initiated 5/9/17, Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. initiated 5/9/17, Float heels with two pillows one under each legs. initiated 9/18/17 & revised 10/23/18, Observe nutritional status. Serve diet as ordered, observe intake and record. initiated 5/9/17, Obtain and observe lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. initiated 5/9/17, Provide incontinence care after each incontinence episode, or per established toileting plan. initiated 5/9/17, Reposition in chair frequently when up for comfort and pressure reduction. Provide resident/family education as needed. initiated 5/9/17 & revised 7/21/17, The resident has a pressure relieving device bed/chair initiated & revised on 5/9/17, and The resident needs assistance to turn/reposition at least every 2-3 hours, more often as needed or requested. initiated and revised on 5/9/17. The Braden scale assessment dated [DATE] has a score of 16 which indicates at risk. The quarterly MDS (minimum data set) with an assessment reference date of 1/24/19 and signed as complete on 1/25/19 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R3 requires extensive assistance with one person physical assist for bed mobility, is dependent with two person physical assist for transfer, and doesn't ambulate. R3 is at risk for pressure injury development and is coded as not having any pressure injuries. On 1/23/19 at 9:47 a.m. Surveyor observed R3 in bed on her back with the head of the bed up. R3 is wearing a hospital gown and is not covered with a sheet. Surveyor observed R3's heels are resting directly on the mattress and there are not any pillows under R3's legs. R3's heels are not being offloaded. On 1/24/19 at 8:54 a.m. Surveyor observed R3 in bed on her back with the head of the bed elevated high. There are two visitors at the bed side, R3's legs are straight without any pillows under them and her heels are resting directly on the mattress. R3's heels are not being offloaded. On 1/24/19 at 9:58 a.m. Surveyor observed R3 continues to be in bed on her back. Surveyor did not observe any pillows under R3's legs and her heels are resting directly on the mattress. On 1/24/19 at 12:04 p.m. Surveyor observed R3 in bed on her back with her heels resting on the mattress. Surveyor asked R3 if staff floats her heels. R3 informed Surveyor when she eats the pillows are removed and when she's not eating she lets them put pillows under her legs to raise her heels up. Surveyor noted R3 did not have her lunch. On 1/29/19 at 10:37 a.m. Surveyor observed R3 in bed on her back with the head of the bed elevated. R3's heels are resting directly on the mattress and Surveyor did not observe any pillows under R3's legs. On 1/29/19 at 12:26 p.m. Surveyor observed R3 in bed on her back with her legs straight. Surveyor observed there are not any pillows under R3's legs and her heels are resting directly on the mattress. On 1/31/19 at 8:21 a.m. Surveyor asked SDM (Staff Development Manager)/RN (Registered Nurse)-Q, who is the wound nurse for R3's unit, what they are doing to prevent pressure injuries on R3's heels. SDM/RN-Q informed Surveyor R3 doesn't like boots and she has pillows under her feet to offload her heels. Surveyor informed SDM/RN-Q Surveyor has not observed any pillows and R3's heels have been resting directly on the mattress. On 1/31/19 at 8:29 a.m. Surveyor observed R3 in bed with the head of the bed slightly elevated. Surveyor observed there are pillows under R3's legs but R3's heels are resting on the pillows and are not being offloaded. Surveyor noted this is the first time Surveyor has observed pillows under R3's legs. 4.) R13's [DIAGNOSES REDACTED]. R13 leaves the Facility at approximately at 11:15 a.m. every Monday, Wednesday, and Friday for [MEDICAL TREATMENT], returning around 4:00 or 4:30 p.m. The potential for pressure ulcer development care plan initiated & revised on 9/6/17 includes interventions of Change of positions q (every) 2-3 hours. initiated 9/11/17, Complete a full body check weekly and document: initiated 9/6/17, IDT (interdisciplinary team) referrals as indicated, i.e. RD (Registered Dietitian), PT (Physical Therapy), OT (Occupational Therapy) or other. imitated & revised 9/6/17, Observe nutritional status Serve diet as ordered, observe intake and record initiated 9/6/17, Resident to have foam boots on when in bed per MD (Medical Doctor). initiated 7.20/18, The resident needs bed bars with use of bed etc for resident to assist with turning initiated & revised 9/6/17, The resident requires pressure reducing device on bed/chair initiated & revised on 9/6/17, and Treat pain as per orders prior to treatment/turning etc to ensure the resident's comfort. initiated 9/6/17. Surveyor noted there are no interventions to provide pressure relief when R13 is at [MEDICAL TREATMENT]. The quarterly MDS (minimum data set) with an assessment reference date of 11/7/18 has a BIMS (brief interview mental status) score of 15 indicates cognitively intact. R13 requires extensive assistance with two plus person physical assist for bed mobility, transfer, & toilet use and does not ambulate. R13 is frequently incontinent of urine and is continent of bowel. R13 is at risk for pressure injury development and is coded as not having any pressure injuries. On 1/23/19 at 10:40 a.m. Surveyor observed R13 sitting in a wheelchair in her room. There is a pressure relieving cushion in the wheelchair and a sling under R13. Surveyor asked R13 when she goes to [MEDICAL TREATMENT] and they transfer her into the [MEDICAL TREATMENT] chair do they also transfer her cushion. R13 informed Surveyor she just sits on the [MEDICAL TREATMENT] chair. On 1/31/19 at 8:18 a.m. Surveyor asked SDM (Staff Development Manager)/RN (Registered Nurse)-Q, who is the wound nurse for R13's unit, what they are doing to prevent pressure injuries when R13 is at [MEDICAL TREATMENT]. SDM/RN-Q replied nothing and informed Surveyor R13 has never spoken about being uncomfortable and hasn't had any redness. SDM/RN-Q informed Surveyor she can put something in place for [MEDICAL TREATMENT] and have them pull her cushion. The nurses note dated 1/31/19 documents writer called [MEDICAL TREATMENT] center to question about preventative pressure releasing while at [MEDICAL TREATMENT]. they stated facility is to send notice to inform them that pt. needs pressure re leaving (relieving) devices in place. writer will send notification to transfer cushion to [MEDICAL TREATMENT] chair with resident to [MEDICAL TREATMENT] tomorrow. 5.) Review of the facility's Skin Management System: Policy, Practice Guidelines, Resources & References, and Skin Management System Algorithm with a revision date of (MONTH) (YEAR). Under Practice Guidelines indicates: 4. Residents admitted with skin impairments will have: a. Interventions implemented to promote healing. b. A physician's orders [REDACTED]. A Care Plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, and the interventions implemented to promote healing and prevent further breakdown . 9. A physician's orders [REDACTED]. Under Ongoing Skin Assessments, 1. A Weekly Skin Check will be completed in the resident's record using the Head to Toe Skin Check (UDA). 2. An SBAR Communication Form and Progress Note (UDA) is completed and a new physician's orders [REDACTED]. 3. The nurse will initiate treatments, interventions, Care Plan, and the appropriate skin documentation records in a timely manner according to Practice Guidelines. R103 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R103's Braden Scale for Predicting Pressure Sore Risk with an ass (TRUNCATED)

Based on observation, interview, and record review the facility did not implement interventions to reduce hazards and risks, did not provide assistive devices to prevent avoidable accidents, did not identify, evaluate, and analyze hazards and risks, and did not provide adequate supervision to prevent accidents for 3 (R10, R30, and R31) of 9 residents at risk for falls and 1 (R118) of 1 residents with sexually inappropriate behaviors. -R10 sustained a fall with a fracture when her care planned assistive device of her wheelchair next to bed was not in place at the time of the fall. R10 was observed with care planned interventions to prevent falls not in place. -R30 and R31 were observed with care planned interventions to prevent falls not in place. -R118 has sexually inappropriate behaviors including a history of sexually touching peers inappropriately. R118 was not assessed to identify the risks that influences R118 to engage in sexually inappropriate behaviors with peers. Resident specific interventions were not developed in attempt to prevent these behaviors from occurring. Findings include: 1.) R10 has [DIAGNOSES REDACTED]. The facility's Fall Management Policy and Procedure, with a revision date of (MONTH) (YEAR), states When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring. Progress notes on 10/10/18 at 2 am document Writer called to resident's room. Resident found sitting on the floor in bathroom, holding on to left leg. Resident was assessed, denied hitting head. However writer noted deformity to left thigh. MD/OPTUM notified, spoke with (MD) and OPTUM on call (Nurse Practitioner). Resident sent out to St. Francis Hospital . An Incident/ Accident Report related to the fall documents the incident occurring at 12:50 am. The report documents the incident was an un-witnessed fall, that the resident was found sitting on the floor in the bathroom. The report documents under How Did Fall Occur as Other-taking self to bathroom. The report documents under Resident's comments What did they say happened? Trying to get back to bed -took myself to BR (bathroom). A post incident questionnaire documents Was the wheelchair locked? . w/c(wheelchair) was in hallway. The questionnaire also documents Was the resident using a device(s)? (no is checked). The questionnaire documents Based on your knowledge of this resident and what was happening on the unit, what can be done in the future to prevent an incident (be specific on type ie Fall) with this resident? (R10) already has notices posted on the wall to remind her to call for help-that is not working. (R10) still gets up by herself to bathroom. Tonight the RCS (resident care specialist) was in (R10)s room at about 11:40 (pm) (As stated in her notes). (R10) was not wet and was not ready to go. It is not usual that resident still forgets and gets herself up to bathroom. Is is therefore advisable to leave w/c (wheelchair) within resident's reach, check frequently, offer to take resident to bathroom. A facility self-report documents a statement by CNA (certified nursing assistant)-BB which states I was assigned to (R10) that night shift that she fell . I went to check on her when I started at 22:30 (10:30 pm) and again at 1140 pm. I woke her and asked her if she needed to go to the bathroom and (R10) told me no. I checked her brief and she was dry. She rolled over and I put body pillow behind her back and left the room. I was called to room by (RN) at 12:50 am. I saw (R10) sitting on bathroom floor with a crooked leg. (RN) stayed with resident and I called 911 per her instruction. The wheelchair was in hallway drying from being cleaned but she fell in bathroom. I guess she walked over to the bathroom without a wheelchair. The call light was not on for the bathroom or the room. R10's plan of care includes a focus area of (R10) is at risk for falls r/t (related to) Deconditioning, Gait/balance problems, Incontinence, New Admission, Psychoactive drug use and recent fall w (with) freq. (frequent) fall Hx (history) with an initiation date of 3/16/17. Interventions included Per POA wheelchair to be kept next to bed with an initiation date of 12/6/17. This intervention is documented as resolved on 12/13/18 (after the 10/10/18 fall). On 2/4/19 at 9:42 am the surveyor interviewed DON (Director of nursing)-B. The surveyor informed DON-B R10's wheelchair was not in the room at the time of the fall. DON-B stated from what she surmised there was not a wheelchair at the bedside. The surveyor informed DON-B of R10's care plan intervention stating the wheelchair to be kept at bedside. DON-B stated she believed R10 had furniture walked to the bathroom. The surveyor informed DON-B of the concern that R10's care planned intervention to have her wheelchair next to the bed was not in place at the time of her fall on 10/10/18. The surveyor asked if there was any additional information related to the 10/10/18 fall. DON-B stated there was not. Progress notes on 10/10/18 at 4:55 am document .Writer was informed that Resident was admitted with left femur fracture. The facility's Summary of factual investigative findings state Resident was admitted to hospital from 10/10/18 to 10/15/18. She had ORIF (open reduction and internal fixation, a type of surgery used to fix broken bones) of left femur and returned to facility for aftercare. On 2/4/19 at 9:08 am the surveyor interviewed RN (registered nurse) Unit Manager-E. The surveyor reviewed R10's plan of care with RN Unit Manager-E. RN Unit Manager-E confirmed that the intervention to have R10's wheelchair next to the bed was an active intervention at the time of the 10/10/18 fall, and was discontinued after the fall because it was determined it was no longer a safe intervention for R10. R10's plan of care for the focused area of R10 is at High risk for falls r/t Deconditioning, Gait/balance problems, Incontinence, New Admission, Psychoactive drug use and recent fall w/ freq. fall Hx includes interventions of Body pillow when in bed with an initiated date of 12/7/18, place body pillow when in bed with an initiated date of 12/7/18, Place garbage can next to bed within reach when in bed with an initiated date of 8/16/18, and Fall mat at bedside with an initiated date of 12/5/18. On 1/24/19 from 7:53 am-9:22 am the surveyor observed R10 in bed in a low position with a mat on the floor with no body pillow observed in the bed or a garbage can next to bed within reach when in bed. At 9:22 am the surveyor observed CNA-T enter R10's room to provide morning cares. The surveyor observed CNA-T raise the bed to a high position, remove the mat from next to the bed and began assisting to wash R10. RN Unit Manager-E knocked on the door during the cares and placed a body pillow in the closet. The surveyor observed CNA-T walk away from the bed to go to R10's closet. The surveyor observed R10 remained in the bed in the high position with no fall mat at bedside as CNA-T had her back turned to R10 and was away from the bedside. The surveyor observed CNA-T return to the bedside and continue to assist R10 with cares. The surveyor then observed CNA-T again leave the bedside to go to R10's bathroom to gather supplies. The surveyor observed R10 remained in bed in a high position with no fall mat at bedside as CNA-T was in R10's bathroom, out of sight of R10 and away from the bedside of R10. At 9:45 am the surveyor observed CNA-T assist R10 to sit at the edge of the bed while the bed was in the high position. The surveyor observed R10's feet were unable to reach the ground. The surveyor observed CNA-T walk away from the bed into R10's bathroom to get R10's wheelchair. The surveyor observed the bed was in a high position with no fall mat on the floor. At 9:48 am the surveyor observed CNA-T walk away from the bedside, leaving R10 on the bed in a high position with no fall mat on the floor, to open R10's room door and look down the hall. At 9:49 am the surveyor observed CNA-T return to the bedside and state she was going to put R10's bed in a low position because she has to go get a lift. The surveyor observed CNA-T place the bed in a low position and place the fall mat at bedside. The surveyor observed no body pillow was placed in R10's bed. The surveyor observed there was no garbage can next to R10's bed. On 1/24/19 at 1:44 pm the surveyor observed R10 in bed with no body pillow in the bed or trash can by her bed. On 1/31/19 at 1:57 pm the surveyor interviewed RN Unit Manager-E. The surveyor asked if staff should leave R10's bed in a high position when away from bedside during cares. RN Unit Manager-E stated never. The surveyor informed RN Unit Manager-E of the observations of R10 being left in bed in a high position as staff was away from the bedside. The surveyor asked if R10 should a body pillow in bed. RN Unit Manager-E stated it's a new pillow. RN Unit Manager-E stated she thought that she went in (R10's room) and took a look around and caught that we didn't have one, so we got one. The surveyor informed RN Unit Manager of the observations of R10 in bed with no body pillow in place. 2.) R30 has [DIAGNOSES REDACTED]. R30's quarterly minimum data set assessment with a target date of 11/16/18 documents R30 has a brief interview for mental status score of 3 indicating R30 is severely cognitively impaired. R30's plan of care includes a focus area revised on 6/26/18 for (R10) has Potential Fall Risk related to History of Falls, Falls related to Disease Process, SHE HAS [MEDICAL CONDITION], INCONTINIENCE (sic), ARTHRITIS, [MEDICAL CONDITION], COG (cognitive) LOSS, DEMENTIA, DEPRESSION, VISUAL IMPAIRMENT, C/O (complains of) PAIN, AND FATIGUE/WEAKNESS. ALL PLACE HER AT INCREASED RISK FOR FALLS TO [NAME]CUR. She also attempts self transfers and does not use her call light. Interventions on R30's plan of care include Resident to have gripper socks or shoes on at all times initiated on 9/2/16 and encourage (R30) to take a nap after lunch. R30's plan of care also includes a focus area revised on 5/31/17 for (R10) has history of falls, Poor Balance, Unsteady gate, confused. Will transfer self and not use the call light. History of getting up frequently when at home during the night. Interventions on R30's plan of care include OFFER assistance with toileting after meals and rest period after lunch initiated on 10/25/17 and Offer/Assist to toilet frequently as accepted revised on 5/31/17. On 1/24/19 from 10:43 am-2:30 pm the surveyor continuously observed R30 in the common/dining area in her wheelchair with fuzzy socks on her feet. The surveyor observed R30 was not offered or assisted to toilet during this time, including after lunch. R30 was not checked and changed for incontinence during this time. The surveyor observed the socks were not gripper socks or shoes during this time, but were fuzzy socks. The surveyor observed R30 was not encouraged to take a nap during this time and after lunch. On 1/31/19 at 1:57 pm the surveyor interviewed RN (registered nurse) Unit Manager-E. The surveyor asked if a care plan states to offer assistance with toileting after meals when you would expect staff to toilet. RN Unit Manager-E stated it depends, but between 1:30-2:30 (pm). The surveyor asked if she would expect it to be done prior to shift change (which is 2:30 pm). RN Unit Manager-E stated yes, it should be done prior to staff leaving. The surveyor informed RN Unit Manager-E of the observation of R30 not being offered to be toileted or checked and changed from 10:43 am to 2:30 pm, of the observation of R30 not wearing gripper or socks or shoes, and not being offered a rest period after lunch. RN Unit Manager-E stated yes, and that is actually part of her fall care plan because she gets so fatigued in the afternoon. 3.) R31 has [DIAGNOSES REDACTED]. Personal history of [MEDICAL CONDITION], lack of coordination, reduced mobility, need for assistance with personal care, and [MEDICAL CONDITION]. R31 is incontinent of bowel. R31's quarterly minimum data set assessment with a target date of 11/20/18 documents R31 having a brief interview of mental status score of 0, indicating R31 is severely cognitively impaired. R31's plan of care includes a focus area initiated 1/25/18 of (R31) is at High risk for falls r/t (related to) Confusion, Deconditioning, Gait/balance problems, Incontinence, New admission, Poor communication/comprehension w/ (with) poor safety awareness, Psychoactive drug use, Unaware of safety needs. (R31) has had multiples falls here at the facility. Interventions include Nap after lunch initiated 2/21/18 and Anticipate and meet resident's needs initiated 1/25/18. R31's plan of care also includes a focus area of (R31) has bowel incontinence r/t dementia which includes an intervention to Check resident frequently and assist with toileting as needed initiated on 1/26/18. On 1/23/19 from 11 am-2:36 pm the surveyor continuously observed R31 in his wheelchair in the common/dining area. At 12:06 pm the surveyor observed CNA (certified nursing assistant)-Z ask R31 is he was tired. R31 nodded indicating yes. CNA-Z stated will lay down after lunch. R31 nodded indicating yes. The surveyor observed at 1:35 pm R31 was moved from a dining room table to in front of a television (in the common/dining area). The surveyor observed R31 was not offered to be toileted, offered to nap, or checked and changed for incontinence. The surveyor continued to observe through 2:36 pm and observed from 11am-2:36 pm R31 was not offered to take a nap after lunch, was not offered to be toileted, and was not attempted to be checked and changed for incontinence. On 1/31/19 at 1:57 pm the surveyor interviewed RN (registered nurse) Unit Manager-E. The surveyor asked if a resident's care plan states should nap after lunch when would she expect that to be done. RN Unit Manager-E stated by shift change (which is 2:30 pm). The surveyor asked if a residents care plan states check resident frequently (related to incontinence), how often would you expect staff to do that. RN Unit Manager-E stated every 2-3 hours, which is typically how I write them. The surveyor asked how she would expect that to be done. RN Unit Manager-E stated physically take to room. The surveyor informed RN Unit Manager-E of the observation of R31 from 11am-2:36 pm not being offered to be toileted or checked and changed for incontinence, and not being offered to lay down after lunch. 4.) R118 has a [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE] for respite care. Prior to his admission, R118 had lived at home with his wife. At the 8/13/18 care conference, family indicated that R118 would remain at the facility for long-term care; as his wife was no longer able to care for him. The 8/15/18 progress note indicated that R118 has been exhibiting [MEDICAL CONDITION] as demonstrated by suggestive remarks to others in the dining room. He has also demonstrated signs/symptoms of loss/depression related to long term care; verbalizing frustration and sadness over stay, longing for home, wife, and pets, and isolating self from most residents on the unit. Call out to MD to discuss above observations. The 8/17/18 progress note indicated that R118 continued to be sexually inappropriate and that he remains on 15 min (minute) checks. On 8/21/18, R118 had been referred for a psychological consult. It was recommended that R118 be placed on the medication [MEDICATION NAME] because a side effect of the medication is to decrease sexual desire. The plan was then to re-evaluate R118 in 3 months. On 9/2/18 a female resident wandered into R118's room. R118 removed his penis from his pants and wiggled it at the female resident. This was discovered while nursing staff were completing 15 minute checks for R118. The nursing assistant removed the female resident from the room immediately. On 9/6/18 R118 was placed on 1:1 supervision, according to RN Manager (Mgr) - E, who was interviewed on 1/29/19 at 3:30 PM. On 9/11/18 1:1 supervision was discontinued and 15 minute checks were restarted. This is according to Director of Nursing (DON) - B, who was interviewed on 1/29/19 at 3:30 PM. On 10/2/18 the 15 minute checks were discontinued when it was determined that R118 had no behaviors since 9/11/18. This information was not documented in R118's record. DON - B was interviewed on 1/29/18 at 3:30 PM and said that she had received this information from Social Service Manager (SSM) - P. SSM - P had told DON - B that she remembered that this decision had been made at an inter-disciplinary care conference. SSM - P said that she had not documented this information. On 11/12/18 at approximately 4:10 PM, R118 had propelled himself close to R53 in the common area. R118 had his hand inserted into the waistband of R53's pants. R118 was instructed to stop touching R53 and he complied immediately. The residents were immediately separated and R118 was placed on 1:1 monitoring. R118 was transferred to another unit by staff at 4:45 PM. RN Mgr - E was interviewed on 1/29/19 at 3:30 PM. She stated that she had witnessed the entire incident, when she was seated at the nurses' station directly across from the common area. RN Mgr - E said that she had intervened immediately. The facility had implemented increased supervision and had obtained a psychological consult for R118. However, the facility had not assessed R118 to identify the risks that influenced the likelihood that R118 would be involved in sexually inappropriate behaviors with peers. The facility had not developed resident specific interventions in an attempt to prevent these behaviors from occurring. NOVEMBER 11/12/18 TO FEBRUARY 2019 R118 continues to live on the same unit that he was transferred to on 11/12/18. According to the record, R118 had not exhibited any sexually inappropriate behavior. R118's current care plan, with a target date of 4/2/19, notes that he may show signs of hypersexuality. The goal is for R118 to have fewer episodes of hypersexuality, sexually suggestive remarks to residents, and inappropriate contact with female peer . The interventions are as follows: administer medications, allow choices, anticipate needs, psychological consultations, explain procedures ahead of time, intervene as necessary, notify physician, and provide a program of activities. The aforementioned interventions are general, in that these interventions would apply to all residents. There was no evidence in the record that the facility had identified the risks that influenced the likelihood that R118 would be involved in sexually inappropriate behaviors with peers. The facility did not develop resident specific interventions in an attempt to prevent these behaviors. Without identifying the risks and implementing resident specific interventions; it was not clear how the facility would keep other residents safe and prevent R118 from engaging in sexual behavior. The preceding information was shared with Administrator - A and DON - B on 1/31/19 at 3 PM. On 2/1/19, the facility provided a Psychoactive Medication Evaluation dated 1/31/19 and list of dates when staff had provided assurance to R118 or consulted with medical staff. No risk assessment nor resident specific interventions were provided.

Based on a complaint investigation, record review and interview, the Facility did not provide 2 (Resident #1 and #3) of 3 Residents reviewed for the prevention and treatment of [REDACTED]. * Resident #1 was admitted to the facility on [DATE] without any pressure injuries. The Facility did not develop an initial plan of care, did not conduct daily diabetic foot checks as indicated on the diabetes plan of care, and did not revise the potential for skin integrity care plan that was initiated on 6/1/16 after Resident #1 developed a DTI (deep tissue injury) on 6/2/16. Resident #1 was discharged to the hospital on [DATE] and did not return to the Facility. * Resident #3 was observed to not to have a prevalon boot on her right foot to relieve pressure on her right heel per her plan of care. Findings include: 1. Surveyor # reviewed Resident #1's medical record on 10/24/16 & 10/26/16. Resident #1 was admitted to the facility on [DATE] without any pressure injures. [DIAGNOSES REDACTED]. The diabetes mellitus care plan initiated 5/25/16 includes an intervention dated 5/25/16 of Inspect feet daily for open areas, sores, pressure sores, blisters, [MEDICAL CONDITION], or redness. Review of Resident #1's May 2016 TAR (treatment administration record) does not indicate daily foot checks were completed during the month of May. The admission MDS (Minimum Data Set) with an assessment reference date of 5/30/16 and signed as complete on 6/1/16 documents a BIMS (brief interview mental status) score of 13 which indicates Resident #1 is cognitively intact. Resident #1 requires extensive assistance with two plus person physical assist for bed mobility & transfers, does not ambulate, has an indwelling urinary catheter, and is continent of bowel. Resident #1 is at risk for developing pressure injuries and is coded as not having any pressure injuries. The pressure ulcer CAA (care area assessment) dated 6/1/16 under analysis of findings documents He is at risk as he currently requires extensive staff assist with bed mobility. Newly admitted with no current pressure ulcers. Due to functional decline and increased risk. He has been given a pressure reducing w/c (wheelchair) cushion and pressure relieving mattress. He is weak and deconditioning from recent hospitalization requiring staff assist with repositioning. Under care plan considerations documents Admit Braden scale = 23. He has decreased activity, increased weakness & fatigue, and balance deficits during transition and gait, requiring rehabilitation stay for fluctuating ADL (activities daily living) status. All place him at increased risk for skin breakdown to occur. He has no pressure ulcers noted at this time. Will cont. (continue) w/(with) current CP (care plan) to minimize pressure by supplying appropriate pressure relieving equipment, repositioning, and providing PT/OT (physical therapy/occupational therapy) services, to maximize strength and mobility, manage [MEDICAL CONDITION], incontinence, and pain, w/ (with) an overall goal to prevent pressure areas from developing. The potential for impairment to skin integrity care plan initiated 6/1/16 includes the following interventions all dated 6/1/16 of: (Resident #1) needs pressure relieving/reducing cushion to protect the skin while in chair.(Resident #1) needs pressure relieving/reducing mattress to protect the skin while in bed. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry skin. Do not apply on (SPECIFY: site of injury). Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against sharp or hard surfaces. Review of Resident #1's June 2016 TAR (treatment administration record) does not indicate daily foot checks were completed during the month of June through the discharge date of [DATE]. Surveyor # was unable to locate an initial skin care plan when Resident #1 was admitted on [DATE]. The SBAR (situation, background, assessment recommendation) dated 6/2/16 under situation documents opened blister to L (left) heel. Under assessment or appearance documents blister formed to L heel and opened with pressure/shifting in bed. The weekly pressure injury record dated 6/2/16 under stage documents Presents as stage DTI (deep tissue injury), under size (length x width) documents 4 x (times) 3.5, under depth documents UTD (unable to determine). Initial evaluation is checked. Under progress notes documents Area noted to have developed a blister to (L) (left) heel & center of blister has opened. Res. (Resident) was admitted with surgery to (L) arm. Res. has dx (diagnosis) with [MEDICAL CONDITIONS], DM II (diabetes mellitus 2) heart failure & Res is a smoker. Res. has a Braden of 23 - no risk, keen cushion placed. Begin hydrogel to center of wound (o/a) (open area) & [MEDICATION NAME] to peri wound. Cover with gauze & wrap with kerlix. Resident #1's potential for skin integrity care plan was not revised after Resident #1 was identified with a DTI on his left heel on 6/2/16. The nurses note dated 6/3/16 documents F/u left heel blister. No c/o (complaint of) pain. Dressing remains intact. Sleeping well. Will monitor. The nurses note dated 6/4/16 documents DSD (dry sterile dressing) changed to L heel wound. Large amt. (amount) of bloody drainage on old drsg. (dressing). [MEDICATION NAME] to surrounding tissue, hydrogel to center. Denies pain. Alert, appropriate, afebrile. The nurses note dated 6/5/16 documents Monitoring for left heel blister. No signs of infection. The nurses note dated 6/6/16 documents Returned from urology appointment. Foley removed. Continue monitoring for urine output. Wife took resident to St. Francis ER (emergency room ) due to left heel bleeding. ER duplicated treatment our facility ordered and assured wife that foot was healing. The nurses note dated 6/7/16 documents Tx (treatment) done to left heel. No signs or symptoms of infection. The SBAR dated 6/8/16 under situation documents elevated periodic non prod (productive) cough/CCL nasal drng (drainage). Under assessment or appearance documents Infection Respiratory or wound. NP (Nurse Practitioner)-F was notified. The nurses note dated 6/8/16 documents Pt (patient) while out to Ortho Appt. (appointment) this s/s (signs/symptoms) worsen, per clinic staff transfer to SFH ER (name of Hospital emergency room ). Update from Hosp. (hospital) per admit w/ s/s (with signs/symptoms) infection. 24hr (hour) board updated, covering NP (nurse practitioner) and unit manager also made aware. The nurses note dated 6/8/16 documents Resident admitted to (name of hospital) hospital with [DIAGNOSES REDACTED]. On 10/26/16 at 12:07 p.m. Surveyor # met with ADON (Assistant Director of Nursing)-C, who was the unit manager when Resident #1 was at the Facility, to discuss Resident #1. Surveyor # asked ADON-C if she ever looked at Resident #1's feet. ADON-C informed Surveyor # when she was notified of the blister to Resident #1's heel. Surveyor # asked ADON-C where diabetic foot checks would be documented as being done. ADON-C informed Surveyor # that they should be on the TAR. Surveyor # showed ADON-C a copy of the June 2016 TAR which does not document any diabetic foot checks. Surveyor # and ADON-C then looked in the computer at the May 2016 TAR which documented No order data found for Treatment Administration Record. Surveyor # informed ADON-C that the potential for skin integrity is dated 6/1/16 and that Surveyor # was unable to locate any other care plans regarding Resident #1's skin. ADON-C informed Surveyor # that they have 21 days to develop a care plan. Surveyor # asked ADON-C doesn't the Facility develop an initial care plan. ADON-C informed Surveyor # that they do develop an initial plan of care which is part of the 8 assessments that are completed upon admission. ADON-C explained that these assessments include Braden, fall, pain, elopement, head to toe, transfer, bowel & bladder and the initial plan of care. ADON-C then looked under Resident #1's assessment tab in the computer and clicked on the initial plan of care. The computer screen showed no records found. ADON-C verified that the initial plan of care was not completed. ADON-C informed Surveyor # that the nurse that should have completed the initial plan of care for Resident #1 no longer works at the Facility. On 10/26/16 at 2:02 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed that an initial skin care plan was not developed when Resident #1 was admitted on [DATE], diabetic foot checks were not done according to the diabetic care plan which was initiated on 5/25/16, and after Resident #1 developed the pressure injury on 6/2/16 the potential for skin integrity care plan which was initiated on 6/1/16 was not revised. Surveyor # asked if there was any additional information. DON-B indicated that she was going to look into this. On 10/26/16 at 2:34 p.m. Administrator-A informed Surveyor # that there is no initial care plan and did not provide Surveyor # with any additional information. 2. Surveyor # reviewed Resident #3's medical record from 10/24/16 to 10/26/16. Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #3's change in condition MDS (Minimum Data Set) with a reference date of 9/25/16 documents a BIMS (Brief Interview for Mental Status) of 15, indicating that Resident #3 is cognitively intact. Section M0150 documents that Resident #3 is at risk for developing pressure ulcers and currently has one unstageable pressure ulcer on her left foot. Resident #3's Pressure Ulcers CAA (Care Area Assessment) dated 9/27/16 documents under the Care Plan Considerations section Staff to continue to minimize pressure by supplying appropriate pressure relieving equipment .w/an (with) an overall goal to heal the current area and prevent further pressure areas from developing. Resident #3's Braden Scale for Predicting Pressure Ulcer Risk dated 9/12/16 documents a score of 14. Per the scoring guidelines for Braden Scale for Predicting Pressure Ulcer Risk, a score of 14 indicates that Resident #4 is at moderate risk of developing a pressure ulcer. Resident #3's Skin Impairment care plan dated as initiated on 9/14/16 documents under the Interventions section Resident #3 should wear prevalon boots on both feet while in bed. Resident #3's most current physician orders [REDACTED]. On 10/24/16 at 10:42 a.m., Surveyor # observed Resident #3 sleeping in bed. Surveyor # observed that Resident #3 was only wearing a prevalon boot on her left foot and that Resident #3's right foot and heel was resting directly on the mattress. Surveyor # noted that Resident #3 was not wearing prevalon boots on her right foot to relieve pressure on her right heel per her plan of care. On 10/24/16 at 11:57 a.m., Surveyor # observed Resident #3 sleeping in bed. Surveyor # observed that Resident #3 was only wearing a prevalon boot on her left foot and that Resident #3's right foot and heel was resting directly on the mattress. Surveyor # noted that Resident #3 was not wearing prevalon boots on her right foot to relieve pressure on her right heel per her plan of care. On 10/24/16 at 2:04 p.m., Surveyor # observed RN (Registered Nurse)-G finish a wound treatment on Resident #3's left foot as Resident #3 laid in bed. Surveyor # observed RN-G put on a prevalon boot to Resident #3's left foot but not on Resident #3's right foot. On 10/24/16 at 3:05 p.m., Surveyor # observed Resident #3 sleeping in bed. Surveyor # observed that Resident #3 was only wearing a prevalon boot on her left foot and that Resident #3's right foot and heel was resting directly on the mattress. Surveyor # noted that Resident #3 was not wearing prevalon boots on her right foot to relieve pressure on her right heel per her plan of care. On 10/24/16 at 3:45 p.m., Surveyor # observed Resident #3 sleeping in bed. Surveyor # observed that Resident #3 was only wearing a prevalon boot on her left foot and that Resident #3's right foot and heel was resting directly on the mattress. Surveyor # noted that Resident #3 was not wearing prevalon boots on her right foot to relieve pressure on her right heel per her plan of care. On 10/26/16 at 7:06 a.m., Surveyor # observed Resident #3 sleeping in bed. Surveyor # observed that Resident #3 was only wearing a prevalon boot on her left foot and that Resident #3's right foot and heel was resting directly on the mattress. Surveyor # noted that Resident #3 was not wearing prevalon boots on her right foot to relieve pressure on her right heel per her plan of care. On 10/26/16 at 8:30 a.m., Surveyor # observed Resident #3 sleeping in bed. Surveyor # observed that Resident #3 was only wearing a prevalon boot on her left foot and that Resident #3's right foot and heel was resting directly on the mattress. Surveyor # noted that Resident #3 was not wearing prevalon boots on her right foot to relieve pressure on her right heel per her plan of care. On 10/26/16 at 9:03 a.m., Surveyor # observed RN Unit Manager-H put a prevalon boot on Resident #3's right foot while Resident #3 laid in bed. On 10/26/16 at 10:45 a.m., Surveyor # interviewed Resident #3 regarding her use of prevalon boots while in bed. Surveyor # asked Resident #3 if she wore prevalon boots on both feet while in bed. Resident #3 informed Surveyor # that she (Resident #3) never wears a prevalon boot on her right foot and did not know why RN Unit Manager-H had put on a prevalon boot on her right foot. On 10/26/16 at 11:01 a.m., Surveyor # informed RN Unit Manager-H of the above findings. Surveyor # asked RN Unit Manager-H if Resident #3 had a prevalon boot for her right foot. RN Unit Manager-H informed Surveyor # that Resident #3 had a physician order [REDACTED]. Surveyor # asked RN Unit Manger-H why she only provided Resident #3 with one prevalon boot for her left foot. RN Unit Manager-H informed Surveyor # that she did not know why she had only provided Resident #3 with one prevalon boot for her left foot but that as of today (10/26/16) she would ensure that Resident #3's physician order [REDACTED]. Surveyor # asked RN Unit Manager-H if Resident #3 was supposed to be wearing prevalon boots on both feet while in bed per physician orders. RN Unit Manager-H informed Surveyor # that Resident #3 was supposed to be wearing prevalon boots on both feet while in bed per physician orders. On 10/26/16 at 1:55 p.m., Surveyor # informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not ensure that Resident #3 received consistent measures to prevent the development of pressure ulcers.

Based on observation, staff interview, record review and policy review, the Facility did not maintain and implement an infection control program designed to prevent the development and transmission of infection. The Facility's infection control program failed to prevent the spread of a gastrointestinal illness because the facility did not promptly recognize an outbreak of GI (gastrointestinal) illness at the facility and immediately implement measures to break the chain of infection to prevent other Residents from becoming ill when three Residents on the LTC3 (long term care) 3 also known as the Reflections unit experienced vomiting during the early morning hours on 4/3/14. The Facility did not: * Quarantine the LTC3 (Reflections Unit) until approximately 36 hours after the first Residents became ill. * Ensure that Residents who exhibited GI signs and symptoms were separated from Residents who were non ill on the LTC3 (Reflections Unit). * Place isolation signs on or near the Residents door to ensure that staff implemented appropriate precautions. * Suspend resident dining rooms to ensure that residents who were not ill and had no symptoms were not exposed to residents who were presenting with signs/symptoms of acute gastroenteritis and to prevent further transmission of a potentially infectious agent. * Effectively clean 7 metal food carts. Staff cleaned these carts with a Multi Quat sanitizer, which is not effective in eliminating norovirus. * Maintain a separate up-to-date line listing for Residents with GI signs/symptoms. * Calculate and trend baselines for each infection type or causative organisms. Staff only calculated the total number of infections. They did not calculate infection rates for their most common infections so baseline rates could be identified and used to quickly identify potential outbreaks. The failure of the facility to immediately implement appropriate procedures to limit the transmission of disease created a situation of Immediate Jeopardy, which began on 4/3/14 when facility did not promptly recognize an outbreak of GI (gastrointestinal) illness at the facility when three Residents on LTC3 (Reflections Unit) developed signs/symptoms of GI illness. The Administrator and Director of Nursing were notified on 4/7/14 at 3:50 p.m. by Surveyor # that an Immediate Jeopardy situation existed. The finding of Immediate Jeopardy was removed on 4/9/14. However, the deficient practice continues at a scope and severity of an F (potential for more than minimal harm that is not immediate jeopardy/widespread) until all components of the facility's plan of correction has been fully implemented, including ongoing monitoring for effectiveness. Continued noncompliance is also evidenced by the following: ~Staff did not properly disinfect the glucometer after checking the blood sugar for 2 of 4 The glucometer was not properly disinfected after checking Residents #45 & #6 blood sugar. The glucometer is used for multiple Residents. ~ Staff did not wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice during 3 (Resident #4 with two observations, #17, & #18 with two observations) of 18 Residents observed. This deficient practice has the potential to affect all 164 Residents currently residing in the Facility. Findings include: MANAGEMENT OF GI OUTBREAK: On November 14, 2010, the Department of Health Services, Division of Quality Assurance sent out via email list serve an announcement that directed providers to the link <http://www.dhs.wisconsin.gov/rl_DSL/Publications/pdfmemos/10-033attach.pdf> to view DQA Memo 10-033/Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in WI Long-Term Care Facilities (LTCF). This document notes the following to include but is not limited to: Facilities are required to maintain an infection prevention and control program that includes a surveillance program for infections common to LTCFs including viral gastrointestinal disease. An outbreak of viral gastroenteritis should be suspected when two or more residents and/or staff develop new onset of vomiting and/or diarrhea within one to two days. On 12/15/10, the Wisconsin Division of Public Health (WDPH) revised the definition to state: an outbreak of viral gastroenteritis should be suspected when three or more cases of illness among residents and/or staff within a 72 hour period with vomiting and diarrhea. The WDPH recommendations indicate facility staff should use only chlorine bleach or a U.S. Environmental Protection Agency approved disinfectant in controlling Norovirus outbreaks. This memo also notes, "Norovirus outbreaks can be detected early by recognizing the typical symptoms of illness, and can be controlled by promptly implementing aggressive infection control measures to prevent the virus from being transmitted from person to person. When appropriate prevention and control measures are not implemented immediately, outbreaks can continue for weeks causing many illnesses, some hospitalization s and the occasional death from dehydration and other complications of vomiting and diarrhea... It is the responsibility of the LTCF to implement aggressive infection control measures quickly and to notify the appropriate agencies of the outbreak or suspected outbreak." 1. On 4/3/14 at 3:10 p.m. during the infection control interview with ADON (Assistant Director of Nursing)-G, who is responsible for the infection control program, Surveyor # asked how ADON-G tracks infections to prevent the spread of an infection. ADON-G informed Surveyor # that she looks at the pink order sheets in morning report for the antibiotics, reviews the new admissions to see if they are on an antibiotic, reviews the twenty four hour board, and then puts them on the infection line listing. ADON-G informed Surveyor # that if a resident has cold symptoms she will place them on the line listing for a possible infection and if it's not an infection she will yellow it out. Surveyor # asked ADON-G how often this is done. ADON-G informed Surveyor # daily. Surveyor # asked about the weekends. ADON-G informed Surveyor # that the supervisor or nurse would call her and she would come in. At 4:00 p.m. Surveyor # asked to review February, March and April 2014 Infection Line Listings. ADON-G provided Surveyor # with the February & March infection line listing for all units and for April with only the Transi Unit and LTC1 unit infection line listing. Surveyor # noted for the Transi unit there were ten Residents listed on the infection line listing. The infections for these Residents included clogged tear ducts, conjunctivitis,[DIAGNOSES REDACTED] (clostridium difficile), COPD (chronic obstructive pulmonary disease), MRSA (methicillian resistant staphylococcus aureus), four Residents with UTI (urinary tract infection) and one Resident without an infection listed. The LTC1 unit has five Residents listed on the infection line list. The infection for these Residents are yeast under breasts, redness, pneumonia, and two UTI's. There are no infection line listings for the LTC2 and LTC3 (Reflections) units. Surveyor # asked why there weren't any infections line listing for these units. ADON-G informed Surveyor # that she didn't get a chance to do them yet. At 4:07 p.m. Surveyor # asked ADON-G if she could tell Surveyor # who had infections or signs/symptoms of an illness today. ADON-G informed Surveyor # that she didn't know and would have to find out. On 4/7/14 at 7:10 a.m. Surveyor # observed when entering the Facility's rehab Transi Unit entrance there was a sign on the door which informed visitors that the Facility was experiencing an increase of GI symptoms in the Facility. Surveyor # also observed this notice was on the main entrance doors. On 4/7/14 at 9:00 a.m. Surveyor # met with ADON-G regarding the GI outbreak. Surveyor # informed ADON-G that when the Surveyor entered the Facility, Surveyor # noted the sign on the door and inquired about what was occurring in the Facility. ADON-G informed Surveyor # that she had been notified Thursday (4/3/14) morning that three Residents on the LTC3 (Reflections) unit had emesis of undigested food and thought it had to do with carrots they all received. ADON-G informed Surveyor # that they were suppose to be kept in their room and given a brat diet. ADON-G stated that on Friday (4/4/14) evening at approximately 4:00 p.m. she was informed that two more Residents on LTC3 had emesis and loose stool. ADON-G informed Surveyor # that this is when she contacted the Administrator, DON (Director of Nursing), and spoke with the kitchen and notified staff to place them on contact isolation. ADON-G stated that she telephoned the Health Department Friday (4/4/14) night & left a message and notified the Medical Director at 5:30 p.m. on Friday. ADON-G informed Surveyor # that they sent samples to the lab to test for norovirus and they did receive positive results back. Surveyor # asked when she was notified of a positive result. ADON-G informed Surveyor # on Saturday (4/5/14). Surveyor # asked when ADON-G started a line listing. ADON-G replied that she started the line listing yesterday (Sunday, 4/6/14) to get all caught up. ADON-G also informed Surveyor # that she didn't do a separate line listing but placed the Residents with GI symptoms on the monthly infection line listing. Surveyor # informed ADON-G that Surveyor # had observed on LTC3 (Reflections) unit Residents who had been identified with GI symptoms next to well Residents in the center area of the unit which is where activities and dining are held. ADON-G informed Surveyor # because there are so many Residents ill with GI symptoms that it hard to keep them contained so they are out on the unit. ADON-G informed Surveyor # that she knows that Residents should be in their rooms. Surveyor # asked ADON-G if staff are trying to keep Residents in their rooms or are they just leaving them in the lounge. ADON-G replied "just leaving them." Surveyor # asked ADON-G if there were any staff who were sick. ADON-G informed Surveyor # that there was a Certified Nursing Assistant (CNA) who worked on LTC3 who was sick with GI symptoms. Surveyor # asked if she was back to work. ADON-G replied, "No." Surveyor # asked if there were any dietary staff that were sick. ADON-G informed Surveyor # that she wasn't aware of any. Surveyor # asked ADON-G when did she consider that there was a GI outbreak in the Facility. ADON-G first informed Surveyor # if there was 10% of Residents in the building sick then stated, "When I had 5 to me that was a GI outbreak." Surveyor # asked if ADON-G thought there was an outbreak when there were three Residents on the LTC3 unit with emesis. ADON-G replied, "No." Surveyor # asked what ADON-G meant about 10% of Residents. ADON-G informed Surveyor # that she thought she read 10% somewhere. Surveyor # asked ADON-G to show Surveyor # the April 2014 infection line listing. Surveyor # noted on the Transi unit there were 2 Residents with GI s/s (signs/symptoms), LITC1 there were 2 Residents with GI s/s, LTC2 did not have any Residents with GI s/s, and LTC3 (Reflections) had 12 Residents with GI s/s on the infection line listing. Surveyor # noted LTC3 had 16 Residents with GI s/s and that ADON-G did not have 4 Residents (Resident #27, #28, #30, & #52) on the infection line listing. 2. On 4/07/14, at 9:30 a.m., during an identified Norovirus outbreak in the facility, Surveyor # observed dietary staff returning unit food trays to the kitchen in enclosed metal carts. These carts are not designated for specific units and can be taken to any unit. On 4/07/14, at 9:30 a.m., Surveyor # spoke with Dietary Manager-E regarding the Norovirus outbreak and the sanitizing of the metal food carts. Dietary Manager-E indicated that on 4/04/14, she was notified of the potential Norovirus outbreak in the facility. Dietary Manager-E indicated the facility was using 7 metal food carts to transport food trays to the facility units, including the units that were identified as having the Norovirus outbreak. Dietary manager-E indicated the food trays were then returned to the kitchen, cleaned with Multi-Quat Sanitizer, and used again to transport food trays for the next scheduled meal. Dietary manager-E indicated that from 4/04/14 through the 4/07/14 at 9:30 a.m., the facility was using the Multi-Quat Sanitizer, in spray bottles at a higher mix concentration, for disinfection of the metal food carts. On 4/07/14, at 9:40 a.m., Surveyor # spoke with Eco Lab representative-F who indicated Multi-Quat Sanitizer, at any concentration, is not identified as an agent that kills the Norovirus. On 4/07/14, Surveyor # reviewed the Multi-Quat Sanitizer Product Specification Document, dated 4/26/11. The product specifications indicate the sanitizer is proven effective against a list of microorganisms. The Norovirus is not a listed microorganism that Multi-Quat is an effective sanitizer against. On 4/07/14, Surveyor # reviewed the Ecolab product list. Multi-Quat is listed as a product that is important for a comprehensive cleaning program, but does not carry claims against Norovirus. On 4/07/14, Surveyor # reviewed the Ecolab facts about Norovirus. The fact sheet indicates Norovirus is found in the stool or vomit of infected people. The fact sheet indicates that people can become infected with the virus in several ways, including contact with contaminated surfaces, touching surfaces or objects contaminated with Norovirus, then touching their mouths. 3. On 4/7/14 at 9:42 a.m. Surveyor # interviewed the DON (Director of Nursing) regarding the GI outbreak. Surveyor # asked what involvement she has had. The DON informed Surveyor # that she has let ADON-G handle the outbreak but did give ADON-G the phone number and the DON's name of a sister facility that ADON-G could call for assistance. DON indicated that ADON-G has been keeping her and the Administrator in the loop. Surveyor # asked the DON why ill Residents were commingled with well Residents on the LTC3 unit. The DON explained that on Friday and Saturday (4/4 & 4/5/14) Residents were isolated in their rooms and not brought to the dining room but when the number became too many they decided to stop isolation. The DON informed Surveyor # that they didn't have enough staff and it wasn't safe to keep Residents in their rooms. The DON stated that a CNA can't feed 7 to 10 Residents in their rooms and they can't be monitored. The DON informed Surveyor # that they did get an extra nurse for the night shift so one nurse could stay in the LTC3 unit and the other nurse could just be on LTC2. On 4/7/14 at 10:27 a.m. Surveyor # asked ADON-G asked why Residents from LTC1 were still going to the dining room when there are cases of the GI outbreak on their unit. ADON-G informed Surveyor # because the Residents with symptoms are kept in their room. Surveyor # inquired if CNA's were given any instruction as to whom they should care for first, the sick or well Residents. ADON-G replied, "No." Surveyor # asked if the Residents who are sick on the same assignment or would different CNA's care for the sick Residents. ADON-G informed Surveyor # that the sick Residents are on different assignments. Surveyor # asked ADON-G if other departments are to inform her if any of their staff become sick with GI symptoms. ADON-G indicated that they should let her know. Surveyor # asked if anyone from dietary or housekeeping has become sick with GI symptoms. ADON-G replied, "No." On 4/8/14 at 9:28 a.m. the Administrator and Director of Nursing were informed that the survey team had observed dining rooms still being open and asked if any Resident has come down with GI signs/symptom after they ate in the dining rooms. The Director of Nursing replied, "Yes." The Administrator and Director of Nursing were asked how are they controlling the outbreak when the dining rooms continue to be open. The Administrator and Director of Nursing informed the survey team that they will have to relook at having the dining rooms open. LTC3 (Reflections) GI/Norovirus outbreak 4. On 4/7/14 at 7:50 a.m. Surveyor # toured the LTC3 Reflections unit. Surveyor # observed Resident #30, who on RN (Registered Nurse) Manager-CC's list for Residents with GI symptoms, sitting in a broda chair in the center area of the unit which is used for activities and dining. Resident #30 was sitting less than six inches next to a well Resident. Surveyor# observed there were 10 other residents in the area. At 7:56 a.m. Surveyor # observed Resident #33 in the dining room by the sink. There were other Residents in the vicinity. Resident #33 was identified as having GI symptoms. At 7:58 a.m. Surveyor # observed Resident #32 (identified Norovirus) sitting in a wheelchair in the hallway by the center area of the unit near other well Residents. At 8:05 a.m. Surveyor # observed Residents #33 & #47 who were identified as having GI symptoms sitting with two well Residents at a table in the dining room. At 8:08 a.m. Surveyor # observed Residents #43 & #30 identified with GI symptoms sitting near two well Residents. At 8:08 a.m. Surveyor # observed Resident #53 identified with GI symptoms sitting with a well Resident at a table in the back of the dining room. At 8:09 a.m. Surveyor # observed at the table by Resident #53's table was Resident #54 who was identified as having GI symptoms. At 8:09 a.m. Surveyor # observed Resident #55 identified with GI symptoms sitting at a table with a well Resident in the dining room. 5. Surveyor # initiated a medical record review of Resident #11 on 4/2/14. The medical record contained communication with Resident #11's primary physician that Resident #11 had vomiting twice on this date and the physician was notified at 7:30 a.m. A physician order [REDACTED]. Nursing note dated 4/4/14 at 6:15 p.m. states that Resident #11 had a loose stool 1 time this a.m. and not nausea or vomiting at this time. A physician clarification order was obtained at 7:30 p.m. to obtain a stool sample. 6. Surveyor # initiated a medical record review of Resident #43 on 4/7/14. Nursing note dated 4/3/14 at 4:30 a.m. states that Resident #43 has had 2 vomiting of orange liquid with undigested food particles, denies pain. Abdomen soft and tender with bowel sounds positive times 4. The medical record contained a fax to the primary physician dated 4/3/14 at 4:37 a.m. that stated for the physician to please review and Resident #43 was the 3rd patient with the same symptoms tonite- was told Resident #43 had carrots for dinner on 4/2/14. It was noted the physician order [REDACTED].#43. Nursing note dated 4/4/14 at 6:15 p.m. stated that Resident #43 has diarrhea one time this morning, refusing to eat supper. On 4/4/14 at 7:30 p.m. a physician order [REDACTED]. Nursing note dated 4/5/14 at 5:20 p.m. states that a stool sample was collected, Resident #43 had a vomiting 1 time. The facility received the lab results on 4/7/14 at 12:47 p.m. stated that Norovirus was not detected. 7. Surveyor # reviewed Resident #27's medical record on 4/7/14-4/9/14. Nurses' Notes include: 4/7/14 3:30 a.m. T (temperature) 97.2, no emesis, has lose stool x (times) 2. BS (bowel sounds) + (positive)..." 4/7/14 2:00 p.m. Up per usual with peers, N/C (no complaints). Appears without immediate distress. No N/V (nausea/vomiting). No loose stools reported. 4/7/14 8:00 p.m. No emesis; small diarrhea... 4/8/14 6:45 p.m. Stool specimen results back, + (positive) for Norovirus. Dr. paged to update... Surveyor # reviewed a Dynacare Laboratories Infectious Disease report dated 4/8/14 for a specimen collected on 4/7/14 from Resident #27. The report indicated the specimen was positive for Norovirus Genogroup II. The results were called to the facility on [DATE] at 11:54 a.m. and reported to RN (Registered Nurse)-L, and faxed to the facility at 11:55 a.m. Facility staff hand-wrote on the form that the MD (Medical Doctor) was paged at 6:45 p.m. (as also noted in the nurses' notes), 7 hours after they were informed of a positive Norovirus result. 8. Surveyor # reviewed Resident #28's medical record on 4/7/14-4/9/14. A "SBAR" (Situation-Background-Assessment-Request) Communication Form dated 4/6/14 at 7:00 p.m. is included in the medical record stating "Resident had emesis x (times) 1 medium, denies pain or any discomfort. Up in Broda chair, resident appears comfortable." Surveyor # reviewed a Telephone Order for Resident #28 dated 4/7/14 stating "BRAT diet to be advanced as tolerated." (BRAT stands for bananas, rice, applesauce and toast) and is often suggested during periods of GI (gastrointestinal) upset and diarrhea. 9. Surveyor # reviewed Resident #29's medical record on 4/7/14-4/9/14 which includes a "SBAR" (Situation-Background-Assessment-Request) Communication Form stating "4/3/14 3:30 a.m. - called to patient's room-patient had orange emesis with undigested food. Patient oblivious to same. HOB (head of bed up), BS (bowel sounds) + (positive/present) x 4- also had large formed stool- no evidence of discomfort. 4/3/14 4:00 a.m. Hospice updated." Surveyor # did not observe any further Nurses' notes for Resident #29 on 4/3/14 after the above 4:00 a.m. note; the only note on 4/4/14 is an SBAR form related to an abrasion; there are no nurses' notes for 4/5/14. On 4/6/14 nurses' documented on 4/6/14 at 2:00 p.m. and 6:00 p.m. Resident #29 had no emesis or loose stools. Nurses' Notes on 4/7/14 at midnight state a stool specimen for Norovirus was obtained, lab notified, no emesis... A Nurses' Note dated 4/8/14 at 6:45 p.m. states "Received results of positive Norovirus. No emesis or looses stools... Surveyor # reviewed a Dynacare Laboratories Infectious Disease report dated 4/8/14 at 11:54 a.m. for a specimen collected on 4/7/14 from Resident #29. The report indicated the specimen was positive for Norovirus Genogroup II. The results were called to the facility on [DATE] at 11:54 a.m. and reported to RN (Registered Nurse)-L, and faxed to the facility at 11:55 a.m. On 4/9/14, Surveyor # confirmed with DON (Director of Nursing)-B there were no additional Nurses' Notes for Resident #29 for the time period of 4/1/14 through present, other than what was noted above. DON-B confirmed there were no additional notes. 10. Surveyor # reviewed Resident #30's medical record on 4/7/14-4/9/14, including a "SBAR" (Situation-Background-Assessment-Request) Communication Form stating "4/7/14 midnight - Patient had loose stool x 2 and emesis x 1 with undigested food...stool specimen for Norovirus obtained, lab notified..." Resident #30's Nurses' Notes include: 4/7/14 1:30 p.m. "Had loose stool x 1." 4/8/14 3:15 a.m. "Large amount diarrhea x 1." 4/8/14 6:45 p.m. "Stool + (positive) for Norovirus. Isolation precautions maintained. Refused supper. T97.8. Taking sips of fluid, no emesis or loose stool this shift so far." Surveyor # reviewed a Dynacare Laboratories Infectious Disease report dated 4/8/14 for a specimen collected on 4/7/14 from Resident #30. The report indicated the specimen was positive for Norovirus Genogroup II. The results were called to the facility on [DATE] at 11:54 a.m. and reported to RN (Registered Nurse)-L, and faxed to the facility at 11:55 a.m. Facility staff hand-wrote on the form "4/8/14 1845 (6:45 p.m.) MD (Medical Doctor) aware, NNO (no new orders). Staff notified the MD seven hours after they were informed of a positive Norovirus result. 11. Surveyor # reviewed Resident #31's medical record on 4/7/14-4/9/14. A "SBAR" (Situation-Background-Assessment-Request) Communication Form dated 4/6/14 was reviewed. The SBAR states "4/6/14 5:30 a.m. Patient had projectile emesis x 2 of undigested food- no stool- abdomen with BS (bowel signs) + (present) x 4- HOB (head of bed) up- isolation initiated." The nurses noted on the SBAR that the facility was "having an outbreak of flu s/sx's" (signs and symptoms). Resident #31's Nurses' Notes do not include any further Notes for 4/6/14 after the SBAR note at 5:30 a.m. so it is not known if Resident #6 had additional emesis or any loose stool on day shift or PM shift on 4/6/14. The next note is on 4/7/14 at 1:00 a.m., indicating Resident #31 has had no emesis or loose stool thus far on that shift. On 4/8/14 at 8:15 a.m., it is noted Resident #31 is no longer on isolation after being symptom free for 48 hours. On 4/9/14, Surveyor # confirmed with DON (Director of Nursing)-B that there was no additional documentation or Nurses' Notes for Resident #31 for 4/6/14. 12. Surveyor # reviewed Resident #32's medical record on 4/7/14-4/9/14. A "SBAR" (Situation-Background-Assessment-Request) Communication Form dated 4/5/14 was reviewed. The SBAR states "4/5/14 2:15 a.m. Patient had a large liquid yellow/gold foul smelling stool- no emesis, denies nausea...MD called, new order received to obtain stool for Norovirus-specimen obtained...lab called for pick-up. 4/5/14 3:00 a.m. Isolation initiated." and "Loose liquid stool x 3." Surveyor # reviewed a Dynacare Laboratories Infectious Disease report dated 4/5/14 for a specimen collected on 4/5/14 from Resident #32. The report indicated the specimen was positive for Norovirus Genogroup II. The results were called to the facility on [DATE] at 11:19 a.m. and reported to RN (Registered Nurse)-FF. After the SBAR note at 2:15 -3:00 a.m., Nurses' notes for Resident #32 do not include any documentation for 4/5/14 or 4/6/14 until 4/6/14 at 2:00 p.m., so it is unknown if Resident #32 had any further loose stools or any emesis on day or evening shift on 4/5/14, or on night shift on 4/6/14. The Nurses' Note on 4/6/14 states "+ (positive) Norovirus. On isolation. Continue to monitor." There is no documentation regarding when Resident #32's physician was notified of the positive Norovirus results- neither in the Nurses' notes nor written on the lab report. On 4/9/14, Surveyor # confirmed with DON (Director of Nursing)-B that there were no additional Nurses' Notes or documentation regarding Resident #32 on 4/5/14 or 4/6/14. 13. Surveyor # reviewed Resident #33's medical record on 4/7/14-4/9/14. A "SBAR" (Situation-Background-Assessment-Request) Communication Form dated 4/5/14 was reviewed. The SBAR states "4/5/14 4:30 a.m. Patient had a large very loose foul smelling stool-no emesis. Denies nausea. BS (bowel sounds) + (present)." On 4/5/14 at 10:40 a.m. staff added to the SBAR note: "No BM so far this AM. Appetite fair. Denies N/V (nausea/vomiting). Will obtain stool sample when occurs. T98.4" There are no further Nurses' Notes or other documentation regarding Resident #33 from the above SBAR notes on 4/5/14 at 10:40 a.m. until 4/7/14 at 4:00 a.m., when it was noted Resident #33 had no loose stool thus far on night shift. So it is not known if Resident #33 had additional loose stools or any nausea/vomiting from the morning of 4/5/14 through the evening shift on 4/6/14, a day and a half later. Surveyor # confirmed with DON (Director of Nursing)-B that there was no additional documentation regarding Resident #33 during that time period. 14. Surveyor # reviewed Resident #47's medical record from 4/7/14- 4/9/14. A "SBAR" (Situation-Background-Assessment-Request) Communication Form dated 4/3/14 was reviewed. The SBAR states "4/3/14 2:30 a.m.- Called to room-patient had a large loose stool and small emesis of undigested food..." On 4/5/14 at 11:25 a.m., staff added to the SBAR Note: "Lab called with stool specimen results. Resident is positive for Norovirus. MD and family aware. Keep resident hydrated." Surveyor # Reviewed Resident #47's Nurses' Notes which include: 4/3/14 2:30 a.m. "Patient had large loose stool with small emesis of undigested food. See SBAR." 4/3/14 12:15 p.m. "Patient complained of nausea at lunch, no emesis. skin pale...Call out to MD to update on nausea. Awaiting call back." 4/3/14 12:45 p.m. "MD aware of nausea. NOR (new order received) for [MEDICATION NAME] 4 mg. (milligrams) PO BID PRN (by mouth, twice a day, as needed) for 3 days." 4/3/14 9:00 p.m. "No emesis or c/o nausea this shift. Ate her regular diet 100% and was taking other food wherever she found it. T97.2." 4/4/14 4:30 a.m. "[MEDICATION NAME] given for c/o (complaint of) nausea." 4/4/14 7:30 p.m. "No emesis or diarrhea this p.m...Order for lab received to r/o (rule out) Norovirus." 4/4/14 9:00 p.m. "Stool sample obtained. Lab faxed for pick up." 4/5/14 11:25 a.m. "Lab called. Resident positive for Norovirus...MD updated..." 4/5/14 5:30 p.m. "Resident positive for Norovirus. Resident on isolation. Resident refused to stay in her room on isolation. She has been told repeatedly to stay in her room and is non-compliant with this." 4/5/14 8:00 p.m. Resident continues to be non-compliant with staying in her room; she is touching other residents and all inanimate objects. Tried to get her to wear gloves; she refused." Surveyor # reviewed a Dynacare Laboratories Infectious Disease report dated 4/5/14 for a specimen collected on 4/5/14 from Resident #47. The report indicated the specimen was positive for Norovirus Genogroup II. The results were called to the facility on [DATE] at 11:26 a.m. and reported to RN (Registered Nurse)-HH. Surveyor # reviewed Resident #47's MDS (Minimum Data Set) dated 2/26/14 and noted she is assessed to have severely impaired cognitive skills. Transi Unit/Rehab GI/Norovirus outbreak On 4/7/14 at 7:12 a.m. Surveyor # asked RN (Register Nurse)-Q, who was working on the Transi Unit if there are any Residents who are ill with GI symptoms. RN-Q replied "no, that's LTC3. 15. On 4/7/14 at approximately 9:00 a.m. Surveyor # reviewed the Transi Unit Infection Line listing and noted that Resident #42 is listed as having loose stools. On 4/7/14 Surveyor # reviewed Resident #42's medical record. The nursing admission intake form dated 3/31/14 documents that Resident #42 is alert and orientated to person, place, and time. The nurses note dated 4/5/14 documents, "Pt. (patient) reports "loose stools" but not seen by staff. Adv. (advised) need to collect stool sample and contact precautions in place. The nurses note dated 4/7/14 documents, "Pt. c/o (complained of) having loose stools but staff not seeing them. Contact precaution in place. Resident has had no c/o pain and slept well. Will cont. (continue) to monitor." On 4/7/14 at 11:03 a.m. Surveyor # observed there was not an isolation sign or PPE (protective personal equipment) cart outside Resident #42's room. On 4/7/14 at 11:08 a.m., Surveyor # asked CNA-MM if anyone on the Transi unit is on isolation. CNA-MM replied, "No." Surveyor # then asked if Resident #42 was on isolation. CNA-MM replied, "No." On 4/7/14 at 12:39 a.m. Surveyor # asked ADON-G why there wasn't an isolation sign and PPE cart outside Resident #42's room. ADON-G replied that she told the nurse to get one out. Surveyor # asked when ADON-G told the nurse this. ADON-G replied "honestly can't answer that question." Surveyor # informed ADON-G that there wasn't an isolation sign or PPE cart outside Resident #42's room. On 4/7/14 at 1:05 p.m. Surveyor # asked OTA (Occupational Therapy Assistant)-NN if Resident #42 had therapy in the therapy gym today. OTA-NN replied "not yet" and informed Surveyor # that she had just spoken to Resident #42 and that Resident #42 was eating lunch. Surveyor # 3 asked OTA-NN to show Surveyor # where Resident #42 was. OTA-NN brought Surveyor

Based on observation, interview, and record review the Facility did not ensure that Residents with pressure ulcers received the necessary treatment and services to promote healing and prevent new ulcers from occurring for 3 (Resident #4, #3, & #1) of 10 Residents reviewed with pressure ulcers. Resident #4 was admitted to the Facility with a pressure ulcer on her left heel and coccyx. Surveyor # observed an unstageable pressure ulcer on her right heel on 4/3/14. The Facility staff was unaware of the pressure ulcer until Surveyor # brought it to their attention on 4/7/14. Resident #4 was also observed with her heels resting on the mattress. Resident #3 was admitted to the Facility with a pressure ulcer on her coccyx. Resident #3 was observed with her heels not being floated. Resident #1 was admitted to the facility with a Deep Tissue Injury to the left heel. On 4/01/14 and 4/02/14, Resident #1's left heel was not elevated off the surface of the mattress, and Resident 1's knees were positioned with the inner surface of the knees in direct contact with each other, causing pressure over the bony prominence's of the knees. Example 1 involving Resident #4 is determined to be an example at the scope and severity of "G" actual harm/isolated. The remaining examples are determined to be severity level 2, potential for more than minimal harm. Findings include: According to the National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP) Clinical Practice Guideline dated 2009: " Ensure that the heels are free of the surface of the bed ... Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. " 1.) Surveyor # reviewed Resident #4's medical record on 4/2/14 to 4/7/14. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (minimum data set) signed as complete on 3/25/14 documents that Resident #4 requires extensive assistance with two plus person physical assist for transferring & bed mobility, does not ambulate, is continent of bowel and frequently incontinent of bladder. Resident #4 is checked as being at risk for development of pressure ulcers and was admitted with two Stage 2 pressure ulcers. The pressure ulcer CAA (care area assessment) dated 3/31/14 under care plan considerations documents "Admit Braden scale = (equals) 15. Recent decline in functional status [REDACTED]. She underwent a ORIF (open reduction and internal fixation surgery) which she tolerated well. Once stabilized she admitted to us for further rehab as she is too weak to return home at this time. She has decreased activity, increased weakness & fatigue and balance deficits during transitions and gait. Requiring rehabilitation stay for fluctuating ADL (activities of daily living) status. All place her at increased risk for skin breakdown to occur. She is frequently incontinent of urine and staff provide peri-cares after incontinent episodes and apply protective barrier cream. Will cont. (continue) w/(with) current cp (care plan) to minimize pressure by supplying appropriate pressure relieving equipment, repositioning and providing pt/to (physical therapy/occupational therapy) services to maximize strength and mobility, manage [MEDICAL CONDITION], any incontinence and pain w/overall goal to heal current areas and to prevent further pressure areas from developing." On 4/2/14 at 9:11 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-MM & CNA-Z in Resident #4's room with a sit to stand lift. CNA-MM removed the covers off Resident #4. Surveyor # observed that there was a heel lift pad under Resident #4's calves but Resident #4's heels were resting directly on the mattress. Resident #4 was observed to have socks on her feet. On 4/3/14 at 7:38 a.m. Surveyor # observed Resident #4 in bed on her back. CNA-W informed Resident #4 that she was going to get her washed and dressed. CNA-W informed Surveyor # that Resident #4 upper body is washed in the bathroom. CNA-W placed gloves on, filled a wash basin and removed Resident #4's bedding. Surveyor # observed there was a heel lift pad under Resident #4's calves. Resident #4's left heel was floated but her right heel was resting on the mattress. CNA-W washed Resident #4's feet and legs. Surveyor # observed the pressure ulcer on Resident #4's left heel as documented in the record. Surveyor # also observed an unstageable pressure ulcer the size of a dime on Resident #4's right heel. Surveyor # did not note documentation regarding this pressure ulcer in Resident #4's medical record. CNA-W placed lotion on Resident #4's legs, tubi grips, socks, and pants on Resident #4. CNA-W then informed Resident #4 that she was going to get the sit to stand and another CNA to help get her up. CNA-W removed her gloves, washed her hands, and left Resident #4's room. On 4/3/14 at 10:05 a.m. after RN (Registered Nurse)-Y completed the treatment on Resident #4's coccyx pressure ulcer, RN-Y and CNA-W transferred Resident #4 from her bed into her wheelchair. RN-Y with gloves on removed Resident #4's shoes, stated that Resident #4 has anti-embolism socks on, and placed a towel on the floor. While Resident #4 was sitting in the wheelchair with her legs dependent and her feet resting on the floor, RN-Y removed Resident #4's left sock and pulled up the tubi grip socks, raised Resident #4's left foot off the floor slightly, and placed skin prep on the left heel. RN-Y then replaced the tubi grip and placed Resident #4's left sock back on. At 10:11 a.m. RN-Y removed Resident #4's right sock and pulled up Resident #4's right tubi grip. RN-Y raised Resident #4's right foot up slightly, informed Surveyor # that he didn't see or feel anything, and placed skin prep on the right heel. RN-Y placed the tubi grip and sock back on Resident #4's right foot and placed Resident #4's shoes back on. On 4/3/14 at 11:03 a.m. Surveyor # reviewed the weekly pressure ulcer record for Resident #4. Surveyor # noted there was a wound sheet for Resident #4's Stage 3 pressure ulcer on her coccyx and Stage 2 pressure ulcer on Resident #4's left heel. Surveyor # noted there were no other weekly pressure ulcer records for Resident #4. On 4/7/14 at 11:09 a.m. Surveyor # asked CNA-MM if Surveyor # could look at Resident #4's heels. Surveyor # then accompanied CNA-MM to Resident #4's room where Resident #4 was in bed. Surveyor # asked Resident #4 if Surveyor # could look at her feet. Resident #4 gave her permission and CNA-MM removed Resident #4's sock and tubi grip from her right foot. CNA-MM then lifted Resident #4's right foot up. Surveyor # again observed an unstageable pressure ulcer on Resident #4's right heel and noted that the area had increased to the approximate size of a nickel. On 4/7/14 at 11:20 a.m. Surveyor # asked RN-Q where Resident #4's pressure ulcers are. RN-Q informed Surveyor # that Resident #4 has one on the left heel and one on the coccyx. Surveyor # asked RN-Q if Resident #4 has any pressure ulcers on her right heel. RN-Q replied "no" and informed Surveyor # that for protection they are off loading Resident #4's heels and also place skin prep on them. Surveyor # asked RN-Q if she completed Resident #4's treatment. RN-Q informed Surveyor # that she already completed the treatments. Surveyor # asked RN-Q to accompany the Surveyor to Resident #4's room to look at her right heel. Surveyor # showed RN-Q the unstageable pressure ulcer on Resident #4's right heel. RN-Q stated. "Oh my goodness." Surveyor # informed RN-Q that Surveyor # had observed the pressure ulcer last Thursday (4/3/14). RN-Q stated "I did not obviously." Surveyor # asked RN-Q when she placed the skin prep on Resident #4's heels does she look at the heels. RN-Q informed Surveyor # that she just feels for bogginess and that it was her mistake. On 4/7/14 at 11:27 a.m. Surveyor # informed RN Manager-H of Surveyor # observation of the pressure ulcer on 4/3/14 and staff not aware of the pressure ulcer until it was brought to their attention by Surveyor # . Surveyor # asked for a copy of the weekly pressure ulcer record after RN Manager-H measured the area. On 4/7/14 RN Manager-H provided Surveyor # with the weekly pressure ulcer record for Resident #4's right heel. Surveyor # noted that the unstageable pressure ulcer measured 2 cm (centimeters) by 1.4 cm. 2.) Surveyor # reviewed Resident #3's medical record on 4/2/14 to 4/8/14. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 was admitted with a Stage 2 pressure ulcer on her mid back and coccyx. The CNA (Certified Nursing Assistant) care card dated 2/28/14 under the skin integrity section is checked for pressure ulcer with location documented as "coccyx." The admission MDS (minimum data set) signed as complete on 3/7/14 documents a BIMS (brief interview mental status) score of "13" which indicates cognitively intact. Resident #3 requires extensive assistance with two plus person physical assist for bed mobility & transfers, is always incontinent of bowel and frequently incontinent of bladder. Resident #3 is marked as having two Stage 2 pressure ulcers. The pressure ulcer CAA (care area assessment) dated 3/7/14 under care plan considerations documents "Admit Braden scale = (equals) 15. Recent decline in functional status [REDACTED]. W/u (work up) for fractures was negative. She was found to have LLE [MEDICAL CONDITION] (left lower extremity [MEDICAL CONDITION] and [MEDICAL CONDITION] emboli. She was treated medically and once stabilized she admitted here for further rehab. She has decreased activity, increased weakness & fatigue and balance deficits during transitions and gait requiring rehabilitation stay for fluctuating ADL (activities of daily living) status all place her at increased risk for skin breakdown to occur. She was admitted with 2 open areas. She is incontinent of B & B (bowel and bladder) and staff provide peri-cares after incontinent episodes and apply protective barrier cream. Will cont. (continue) w/(with) current CP (care plan) to minimize pressure by supplying appropriate pressure relieving equipment, repositioning and providing PT/OT (physical therapy/occupational therapy)services to maximize strength and mobility, manage [MEDICAL CONDITION], any incontinence and pain w/ (with) an overall goal to prevent pressure areas from developing." On 4/2/14 at 10:16 a.m. Surveyor # observed Resident #3 in bed. There is a pillow under her back along the left side and Resident #3's heels resting on a pillow. Resident #3's heels were not being floated. On 4/2/14 at 10:55 Surveyor # observed Resident #3 continues to be on her right side with a pillow under her heels. Resident #3's heels were not being floated. On 4/2/14 at 12:39 p.m. Surveyor # observed Resident #3 on her left side. Surveyor # observed that Resident #3's heels are not floated and are resting on a pillow. On 4/2/14 at 1:44 p.m. Surveyor # observed Resident #3 on her right side. At 1:45 p.m. Surveyor # observed CNA (Certified Nursing Assistant)-Z enter the room and inform Resident #3 that he was going to reposition her. CNA-Z repositioned Resident #3 on her left side and asked Resident #3 if she was comfortable. Resident #3 replied "no" and asked for a pillow between her legs. CNA-Z placed a pillow between Resident #3's knees but Surveyor # observed that CNA-Z did not float Resident #3's heels and that they were resting directly on the mattress. On 4/3/14 at 7:26 a.m. Surveyor # observed Resident #3 on her back in bed. Surveyor # observed that Resident #3's heels were resting directly on the mattress. On 4/3/14 at 9:22 a.m. Surveyor # observed Resident #3 on her right side with her heels resting directly on the mattress. Resident #3's heels were not being floated. On 4/3/14 at 12:03 p.m. Surveyor # observed Resident #3 on her left side with her heels resting directly on the mattress. Resident #3's heels were not being floated. On 4/3/14 at 1:26 p.m. Surveyor # asked CNA-W if Surveyor # could check Resident #3's heels. Surveyor # observed Resident #3's heels were resting directly on the mattress. CNA-W removed Resident #3's gripper socks and raised Resident #3's feet off the mattress. Surveyor # did not observe any open areas. CNA-W placed the gripper socks back on Resident #3. CNA-W did not float Resident #3's heels after placing on her gripper socks. On 4/8/14 at 11:09 a.m. Surveyor # asked RN (Registered Nurse) Manager-H why staff aren't floating Resident #3's heels when she is at risk for pressure ulcers and currently has a pressure ulcer on her coccyx. RN Manager-H informed Surveyor # that she could find that out but Resident #3 has a specialty bed and there shouldn't be anything on there. Surveyor # informed RN Manager-H of the observations of Resident #3's heels not being floated and asked to see the manufacturers information on the mattress which would indicate that a Resident heels would not need to be floated with their mattress. On 4/9/14 at 1:22 p.m. Maintenance Supervisor-GG provided Surveyor # the specifications for the DermaFloat LAL mattress which is on Resident #3's bed. Maintenance Supervisor-GG informed Surveyor# he had printed out the information from the Joerns web site. The information provided to Surveyor # does not address whether a person's heels would not need to be floated on their mattress. On 4/9/14 at 12:19 p.m. the Administrator and Director of Nursing were informed of the observations of Resident #3's heels not being floated. 3.) During the initial tour of the facility, on 4/01/14 at 9:50 a.m., Surveyor # observed Resident #1 in bed. Resident #1's heels were not floated and were positioned directly on the mattress. On 4/01/14, Surveyor # reviewed Resident #1's medical record. The record indicates Resident #1 was readmitted to the facility on [DATE]. The Weekly Pressure Ulcer Record, dated 3/14/14, and the Nursing Admission Assessment, dated 3/14/14, indicate Resident #1 was readmitted with a Deep Tissue Injury (DTI) to the left heal measuring 5 centimeters (cm) X 4.6 cm. The Record indicates no specialty interventions were put in place. The plan of care for pressure ulcers, dated 3/20/14, indicates Resident #1 has a DTI (deep tissue injury) to the left heel and includes interventions to turn and reposition for pressure reduction. The Weekly Pressure Ulcer Record, dated 3/25/14, indicates Resident #1 has a DTI to the left heal measuring 5.2 cm X 4.6 cm, purple in color. The Record indicates no specialty interventions were put in place. The 14 day scheduled Minimal Data Set (MDS), dated [DATE], indicates Resident #1 has a Brief Interview for Mental Status score of 9 (moderately impaired cognition), requires extensive staff assistance of 2 staff for bed mobility, is dependent on staff for transfers, is at risk for pressure ulcers, and has one unstageable pressure ulcer with suspected DTI in evolution. The Resident Care Specialist Assignment Sheet, dated 4/01/14, includes using pillows to off load heels in bed. On 4/01/14, at 2:30 p.m., Surveyor # observed Resident #1 in bed. Resident #1 had a pillow under the upper part of the calves, but Resident #1's right leg was crossed over the left leg and the pillow was ineffective in ensuring that the left heel was elevated off the surface of the mattress. Resident #1's knees were positioned with the inner surface of the knees in direct contact with each other, causing pressure over the bony prominence's of the knees. On 4/02/14, at 9:50 a.m., 10:20 a.m., and 10:40 a.m., Surveyor # observed Resident #1 in bed. Resident #1 had a pillow under the upper part of the calves, but Resident #1's right leg was crossed over the left leg and the pillow was ineffective in ensuring that the left heel was elevated off the surface of the mattress. Resident #1's knees were positioned with the inner surface of the knees in direct contact with each other, causing pressure over the bony prominence's of the knees. On 4/02/14, at 10:55 a.m., Surveyor # and the Director of Nursing (DON) observed Resident #1 in bed. The DON verified Resident #1 had a pillow under the upper part of the calves, but Resident #1's right leg was crossed over the left leg and the pillow was ineffective in ensuring that the left heel was elevated off the surface of the mattress. The DON also verified that Resident #1's knees were positioned with the inner surface of the knees in direct contact with each other, causing pressure over the bony prominence's of the knees. Surveyor # and the DON observed Resident #1's heels and the inner aspect of both knees. The left heel had a 4 cm by 6 cm DTI. The inner aspect of both knees had blanchable pink areas. On 4/02/14, at 11:10 a.m., Resident #1 was provided with a heel riser to elevate the heels off the mattress and was provided with a pillow to be position between her knees to prevent pressure over the bony prominence's of the knees. The Weekly Pressure Ulcer Record, dated 4/02/14, indicates Resident #1's left heel DTI was assessed and noted to be to be dark purple/black in color and to have increased in size, measuring 4.0 cm by 6.1 cm. The Record indicates specialty interventions include a Kein cushion to elevate heels and a pillow between legs.

Based on observation, record review and interview, the facility did not ensure that 5 of 22 residents (Resident #1, 2, 8, 3, and 19) received adequate supervision and assistance devices to prevent accidents. The facility also did not ensure that 1 of 1 prepared medication cups for Resident #46 were properly secured when a nurse was not present at the medication cart. * Resident #1 is at high risk for falls. Resident #1's care plan indicates the resident requires assistance of one person and a gait belt for transfers. On 3/05/14, Resident #1 was assisted with a transfer without the use of a gait belt. Resident #1 fell during the transfer and sustained a left hip fracture. * Resident #2 is at high risk for falls and utilizes a low bed. On 4/01/14 and 4/03/14, Resident #8's was observed in bed with the bed left in a high position. * Resident #8 was not always observed to have tubigrip protective sleeves (geri-sleeves) or stockings in place for protection of her fragile skin. Resident #8 has sustained skin tears on 9/21/13, 1/31/14, 3/18/14 and 3/29/14. * Resident #3's bedside cup contained thin water with ice cubes. The physician telephone order dated 3/27/14 indicates that Resident #3 should receive nectar thick liquids. * Resident #46's medication was observed in a medication cup on top of the medication cart unattended in the hallway on the Transi unit. * Resident #19 was not supposed to be left alone in the bathroom. On 2/15/14 Resident #19 was left alone in the bathroom and fell . Example 1 involving Resident #1 is determined to be an example at the scope and severity of "G" actual harm/isolated. The remaining examples are determined to be severity2, potential for more than minimal harm. Findings include: 1. On 4/01/14, Surveyor # reviewed Resident #1's medical record. The record indicates Resident #1 has [DIAGNOSES REDACTED]. Resident #1's plan of care for mobility, dated 3/22/10, includes the approach to use a gait belt to transfer the resident. The Certified Nursing Assistant (CNA) Care Card, dated 9/12/13, indicates Resident #1 transfers with assist of staff and the use of a gait belt. The Fall Risk Assessment, dated 10/02/13, indicates Resident #1 is at high risk for falls. The quarterly Minimum Data Set (MDS), dated [DATE], indicates Resident #1 has severe cognitive impairments, requires extensive assistance of staff for transfers and has had 1 fall without injury since admission to the facility. The Fall Risk Assessment, dated 2/05/14, indicates Resident #1 is not at high risk for falls. The annual MDS, dated [DATE], indicates Resident #1 has moderately impaired cognition, requires extensive assistance of staff for transfers and has had no falls since the prior assessment. The SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note, dated 3/05/14, indicates Resident #1 fell with the CNA while transferring. The note indicates one CNA was assisting Resident #1 with a transfer into the bed. The note indicates the resident crossed her legs around the CNA, and took herself and the CNA down to the floor. The note indicates the Resident landed on top of the CNA. The note indicates that after the fall Resident #1 complained of pain to the left hip area, the physician was called and x-rays were ordered. The hospital admission record, dated 3/06/14, indicates Resident #1 was brought into the emergency room after the fall. The record indicates the Resident was diagnosed with [REDACTED]. The Incident/Accident Investigation Follow-Up, dated 3/06/14, indicates the CNA was transferring Resident #1 from the wheelchair to the bed. During the transfer the resident crossed her legs and interfered with the CNA's balance. The Incident/Accident Follow-Up did not indicate if CNA-C was using a gait belt during the transfer. On 4/02/14, at 4:00 p.m., Surveyor # spoke with the Administrator and the Director of Nursing (DON) who indicated CNA-C was assisting Resident #1 with a transfer on 3/05/14 without the use of a gait belt. The Administrator and the DON indicated Resident #1 fell during the transfer and sustained a left hip fracture. On 4/03/14, Surveyor # reviewed the Gait Belt Use policy, dated June 2013. The policy indicates that to ensure the safety of residents staff is to use a gait belt to provide appropriate level of assistance during transfers. The policy indicates the use of a gait belt is a requirement for residents that require minimum assist, moderate assist, maximum assist, limited assist and extensive assist. 2. During the initial tour of the facility, on 4/01/14 at 9:30 a.m., Surveyor # observed Resident #2 in bed. Resident #2 was in a "Hi to Low" bed. The bed was not in a low position. On 4/01/14 Surveyor # reviewed Resident #2's medical record. The record indicates Resident #2 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], indicates Resident #2 has moderate cognitive impairments, requires extensive assistance of staff for bed mobility and transfers and has had no falls since prior assessment. The Fall Risk Assessment, dated 2/05/14, indicates Resident #2 is at high risk for falls. The annual MDS, dated [DATE], indicates Resident #2 has severe cognitive impairments, requires extensive assistance of staff for bed mobility and transfers and has had 1 fall without injury since prior assessment. The Resident Care Specialist Assignment Sheet, dated 4/02/14, indicates Resident #2's safety information includes a low bed with a bed buddy. On 4/03/14 at 8:20 a.m., Surveyor # observed Resident #2 in bed. There was no staff in the room. Resident #2 was in a "Hi to Low" bed. A Bed Buddy was in place; however the bed was not in a low position. On 4/03/14, at 8:25 a.m., Surveyor # inquired about the position of Resident #2's bed. Resident Care Specialist, Certified Nursing Assistant-D verified that Resident #2's bed was left in a high position and that the bed should be in the lowest position. On 4/08/14 at 2:15 p.m., Surveyor # spoke with the Director of Nursing (DON) who indicated Resident #2 is at risk for falls and the bed should be kept in a low position. 3. Resident #8 was observed during this survey by Surveyor # . Resident #8 was not always observed to have tubigrip protective sleeves (geri-sleeves) or stockings in place for protection of her fragile skin. Resident has a care plan problem, dated 9/21/13, identified to have fragile skin and has sustained skin tears on 9/21/13, 1/31/14, 3/18/14 and 3/29/14. The medical record indicates that on 1/31/14, an investigation was conducted into skin tears on the left shin. The plan and new intervention following this was to administer first aide and apply tubigrips to bilateral lower extremities to protect the skin. Surveyor # observed during the orientation tour on 4/1/14 at 10:20 AM. Resident #8 to be seated up in her wheelchair without any tubigrip stockings on her lower legs or forearms to provide added protection from skin tears while assisting resident with cares and daily activities. A telfa pad/gauze dressing was observed to be slid down the leg and resting around Resident's ankle. On 4/1/14 at 2:50 PM, Resident was observed to be seated in a large group activity with no protective sleeves on forearms or lower legs. On 4/2/14 at 8:30 AM, Resident was observed to be seated in wheelchair watching the morning news. No protective sleeves were observed on forearms or lower legs. On 4/3/14 at 8:12 AM, Surveyor # observed care provision for Resident #8 and was able to view skin during this care. Resident #8's skin was observed to be very thin with multiple areas of darker discolorations and abraded skin. Resident #8 had abraded areas to both lower legs partially covered with loose gauze dressings wrapped around lower legs and adhesive tape to hold the gauzes dressings in place. No tubigrip stockings or sleeves on forearms were observed for dermal fragility. The resident was also noted to have long toenails when feet were observed that could be a potential for skin tears. There was no instructions to the care giving staff to place tubigrip stockings on resident following care provision. Instructions to use tubigrip stockings for Resident #8 was placed on the treatment sheet on 4/3/14. Surveyor # interviewed LPN (Licensed Practical Nurse)- EE on 4/3/14 during care provision about Surveyor # 's observation and concern about strong binding tape being used to adhere dressings for Resident #8's fragile skin. LPN-EE told the surveyor that she is getting treatment to the lower legs every day and would get an order for [REDACTED]. 4. Surveyor # reviewed Resident #3's medical record on 4/2/14 to 4/8/14. The CNA (Certified Nursing Assistant) care card dated 2/28/14 under fluids is checked for thickened consistency with a handwritten notation dated 3/28 "nectar." The physician telephone orders dated 3/27/14 documents "Speech to eval (evaluate) coughing with foods & fluids nectar/mech (mechanical) soft until speech eval." The nurse's notes dated 3/31/14 documents "Ref (refusing) OOB (out of bed) prn (as needed) Vicodin offers adeq. (adequate) pain control. HS (hour sleep) xanax for anxiety nectar fluids without cough magic cup only for solids." On 4/3/14 at 8:34 a.m. Surveyor # observed Resident #3 awake in bed. Next to the bed was an over bed table with a Styrofoam glass with a straw and lid. Surveyor # asked Resident #3 if it was alright if Surveyor # checked her water glass. Resident #3 gave her permission and informed Surveyor # that the water was cold. Surveyor # removed the lid and observed there was thin water with ice cubes. On 4/3/13 at 8:53 a.m. Surveyor # spoke with ST (Speech Therapist)-AA to inquire if the speech evaluation was completed for Resident #3. ST-AA informed Surveyor # that she saw Resident #3 on 3/31/14, was off and would be seeing Resident #3 today, and that Resident #3 didn't like the thickened liquids. Surveyor # asked ST-AA how would staff know if they could give Resident #3 thin liquids or that Resident #3 was to continue with nectar thick liquids. ST-AA informed Surveyor # that they would write an order. Surveyor # asked until the order is written should Resident #3 be receiving nectar thick liquids. ST-AA replied "yes." On 4/3/14 at 9:08 a.m. Surveyor # observed ADON (Assistant Director of Nursing)-G leaving Resident #3's room with her Styrofoam glass. Surveyor # asked ADON-G if there was any water in the glass. ADON-G replied "no." Surveyor # asked ADON-G if she knew whether Resident #3 drank the water or did someone dump out the water. ADON-G informed Surveyor # that she didn't know. On 4/3/14 at 9:13 a.m. ADON-G informed Surveyor # that she found out that CNA-Z gave Resident #3 the water and CNA-V dumped it out. Surveyor # asked ADON-G how would a CNA know that a Resident should have thickened liquids. ADON-G informed Surveyor # that there would be an order, there is a green dot on the door and on the arm band. Surveyor # did observe there was a green dot next to Resident #3's name outside her door. On 4/3/14 at 9:14 a.m. Surveyor # asked CNA-V why she emptied Resident #3's water glass with the thin water. CNA-V replied because she was told to. Surveyor # asked CNA-V who told her to empty the water glass. CNA-V replied "DON (Director of Nursing)-B." On 4/3/14 at 9:23 a.m. Surveyor # asked CNA-Z if he gave Resident #3 thin water today. CNA-Z replied "yes" and explained that Resident #3 had thin liquids in her cup. CNA-Z informed Surveyor # that Resident #3 had been getting thin liquids and was told yesterday that she gets thin. Surveyor # asked CNA-Z how would he know if a Resident is suppose to be getting thickened liquids. CNA-Z informed Surveyor # that it would be on their care card. Surveyor # asked CNA-Z if Surveyor # could look at Resident #3's care card. CNA-Z informed Surveyor # that he didn't have one because he had been taking care of Resident #3. On 4/8/14 at 2:25 during the daily exit conference the Administrator and Director of Nursing were informed of the above. 5. On 4/8/14 at 10:51 a.m. Surveyor # observed a medication cart left unattended by the nurses station in the hallway on the Transi unit. On top of the medication cart was medication cup with three pills. Surveyor # noted there were Residents in the vicinity. At 10:53 a.m. RN (Registered Nurse)-BB approached the medication cart stating that she had just remembered the medication. Surveyor # asked who's medication and what medication was in the cup. RN-BB informed Surveyor # that it was Resident #46's and the medication cup contained Docusate, Vitamin D-3, and Allopurinol. On 4/8/14 at 2:02 p.m. Surveyor # asked RN Manager-H if medication should be left in a medication cup unattended on the medication cart. RN Manager-H replied "absolutely not." Surveyor # informed RN Manager-H of the observation of Resident #46's medication left unattended on the medication cart. On 4/8/14 at 2:25 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. 6. Surveyor # reviewed Resident #19's medical record on 4/8/14 and 4/9/14. Resident #19 is at risk for falls. The quarterly MDS (minimum data set) signed as completed on 3/25/14 documents a BIMS (brief interview mental status) score of 10 which indicates moderately impaired. Resident #19 requires extensive assistance with one person for transfers and is frequently incontinent of bladder. This MDS is coded as Resident #19 as having no falls but Surveyor # noted this was incorrectly coded. The MDS should have been coded "yes" as having had any falls since prior assessment. The nurses note dated 2/15/14 documents "Res. (Resident) assessed by writer s/p (status [REDACTED]. Neuro checks (-) (negative). ROM WNL (range of motion within normal limits) in BLE's (bilateral lower extremities) & BUE's (bilateral upper extremities). Res. left in bathroom briefly while supplies gathered. Sat self in seated position on floor attempting to self transfer from toilet to w/c (wheelchair). No s/sx's (signs/symptoms) pain, vital WNL (within normal limits), Will cont. (continue) to monitor. The interdisciplinary post fall review for 2/15/14 fall documents under summary of interdisciplinary team documents "Staff education - residents requiring assistance are not left unattended when on the toilet." On 4/9/14 at 11:20 a.m. Surveyor # informed RN (Registered Nurse) Manager-R that Surveyor # noted that Resident #19 fell in the bathroom on 2/15/14 and asked if Resident #19 should have been left alone on the toilet. RN Manager-R replied "no." Surveyor # asked RN Manager-R if a Resident requires assistance are staff suppose to stay with them. RN Manager-R replied "yes." Surveyor # asked RN Manager-R if staff are aware of this. RN Manager-R replied "yes." RN Manager-R stated "she should not have been left alone, especially her."

Based on interviews and review of facility and hospital records, the facility did not ensure that 2 (Resident #3 & #1) of 11 sampled residents received the necessary care and services to attain the highest practicable physical well-being. * Resident #3 was sent to the hospital after a fall on 11/6/13. The hospital discharge summary [DIAGNOSES REDACTED]." Both Resident #3's son and Certified Nursing Assistant (CNA)-E stated that for several weeks prior to the hospitalization that Resident #3 had been restless in her wheelchair, constantly shifting and scooting herself forward in the wheelchair. Resident #3 had been having Medseptic, a barrier cream, applied since mid-September 2013. Despite no improvement in the perineal and buttocks redness, the facility nursing staff had not contacted Resident #3's hospice nurse to request a change in treatment. * Resident #1 injured her ankle on 7/5/13, and did not receive adequate pain relief because of confusion caused by an older non-valid order for [MEDICATION NAME] still being present on the July 2013, physician's orders [REDACTED]. Findings include: 1. Surveyor # reviewed Resident #3's record as part of a complaint investigation on 12/9-12/12/13. Resident #3's son had submitted pictures of the monilial [MEDICAL CONDITION] noted when Resident #3 arrived at the hospital. The pictures reveal deeply reddened areas on the perineum, lower buttocks following the gluteal crease up to the coccyx, and inner upper thighs. According to WebMD, yeast (monilial) infections are caused by yeast-like fungi called candida. They occur when yeast on the skin grows more actively and causes a red, scaling, itchy rash on the skin. Yeast infections are most likely to occur in warm, moist, creased areas including the groin and are especially common among people who have diabetes. Signs and symptoms of yeast infection in skin folds include rash, itching and burning. Yeast skin infections are highly treatable with medicated (anti-fungal) creams. When interviewed by Surveyor # on 12/10/13 at 10:45a.m., Resident #3's son stated that for several weeks prior to the post fall hospitalization on [DATE], Resident #3 had been exhibiting irritability and was restless when sitting in her wheelchair. Resident #3 would constantly be shifting her weight in the wheelchair and scooting forward on the cushion of the wheelchair. Resident #3's son stated after he saw Resident #3's buttocks when she was hospitalized , he figured the irritability and constant shifting in the wheelchair must have been due to the discomfort caused by the itching and burning caused by the infection. Surveyor # interviewed Certified Nursing Assistant (CNA)-E on 12/12/13 at 9:55a.m. CNA-E had cared for Resident #3 in the weeks preceding the 11/6/13, hospitalization . CNA-E stated that for several weeks prior to the hospitalization , Resident #3's "butt" had been red and sore. Resident #3 had been scooting herself in the wheelchair which was a new behavior. Resident #3 also had been refusing more cares during that time. CNA-E stated that the regular nurse that worked with Resident #3 (who no longer works in the facility) was repeatedly told about Resident #3's sore, red "butt," but there was no change in the ointment. CNA-E stated the area never improved. Surveyor # showed CNA-E the picture of Resident #3's buttocks received with the complaint. CNA-E stated that Resident #3's buttock had looked like what the picture demonstrated, for a few weeks prior to going to the hospital. A review of Resident #3's hospital record from the 11/6-11/8/13, hospitalization reveals the following: In the Emergency Department (ED) Provider Notes, [MEDICAL CONDITION] assessment reveals "severe [DIAGNOSES REDACTED] (redness) and skin irritation to the vulva, groin, buttocks, and perineal skin." The hospital discharge summary dated 11/8/13, lists as one of the discharge Diagnoses: [REDACTED]. A review of Resident #3's facility record reveals the following: Resident #3 was receiving hospice services prior to the 11/6/13 hospitalization . On 9/17/13, the facility received a physician's orders [REDACTED]. Documentation on the "Head to Toe Skin Checks" form on 9/13/13, indicates Resident #3 had open areas on the right "butt" and coccyx. Surveyor # reviewed Resident #3's record for documentation regarding the reddened perineal and buttocks areas. There are "Nursing/Weekly/Monthly Summary" forms dated 10/1, 10/15, 10/22 & 10/29/13, none of which mention any skin concerns. Documentation on the "Head to Toe Skin Checks" form (which the facility uses to document skin checks by licensed nurses with resident baths) indicates Resident #3 had an excoriated "butt" on 10/1, 10/8, 10/15, 10/22 & 10/29/13. The "Head to Toe Skin Checks" form dated 11/5/13, indicates "red groin." There are no narrative nursing notes addressing Resident #3's skin condition during the time period of 10/1/13 through 11/5/13. The size and extent of the redness is not documented (cross reference F514), nor are the "new behaviors" of increased refusals of care and Resident #3 scooting herself forward on the cushion of the wheelchair included in the nursing documentation. On 12/10/13 at 8:30a.m., Surveyor # observed LPN-F apply [MEDICATION NAME] cream to Resident #3's buttocks. There were very faint slightly discolored areas in the gluteal folds. The skin was intact. On 12/10/13 at 10:00a.m., Surveyor # spoke with LPN-F, who currently cares for Resident #3. LPN-F stated she was not the regular nurse during the time prior to Resident #3's hospitalization , but she had cared for her periodically during that time. LPN-F stated Resident #3's buttocks had been more reddened in October before she had gone to the hospital, and the Medisept did not help the redness. LPN-F stated the area improved after Resident #3 returned to the facility and was treated with [MEDICATION NAME] (an antifungal cream). On 12/11/13 at 11:00a.m., Surveyor # spoke with the Director of Nursing (DON), who is also the facility wound nurse, about Resident #3's reddened buttocks prior to her hospitalization on [DATE]. Surveyor # showed the DON the pictures of Resident #3's buttocks provided by Resident #3's son. The DON stated she had not been informed of the reddened buttocks prior to Resident #3 being admitted to the hospital and if she had seen the area she would have recommended changing the treatment. Despite no improvement in the perineal and buttocks redness, the facility nursing staff had not contacted Resident #3's hospice nurse to request a change in treatment. 2. Surveyor # reviewed Resident #1's closed medical record on 12/09-12/12/13 as part of a complaint investigation. Resident #1 was admitted to the facility on [DATE]. Nurse's Note documentation on 07/16/13 at 9:50a.m., indicates, "At 8:45a.m. Certified Nursing Assistant (CNA) states she was pushing Resident #1 forward in w/c (wheelchair) and Rt foot was caught underneath footrest and dragged. Resident #1 complained of increased pain with rotation of right ankle 10/10(pain), 2+ ankle [MEDICAL CONDITION] to outer aspect. Tylenol given along with ice and elevation. MD faxed." A Change of Condition Note (SBAR) dated 07/16/13 and faxed to Resident #1's physician noted, "Rt (Right) ankle pain after getting foot caught under wheelchair while being moved. Rates pain 10 out of 10, Rt ankle +2 swelling. Requesting Rt ankle x-ray" Resident #1's physician ordered and x-ray of the right ankle and to apply ice prn for 24 hours. Results of the ankle x-ray obtained 07/16/13 were negative for a fracture. Nurse's Note documentation on 07/16/13 at 12:00p.m., indicates, "...No valid order on file for Hydro-cod-Acetimin 5/500. Pharmacy will notify MD for Stat (Immediate) order." Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's prn Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A physician fax order dated 07/18/13, indicates an order for [REDACTED]. The MAR indicated [REDACTED]. On 12/12/13 at 9:15a.m., Surveyor # spoke with Registered Nurse (RN)-C. RN-C stated she reviewed Resident #1's July 2013, physician's orders [REDACTED]. RN-C stated she did not ask Resident #1's physician for anything stronger than Tylenol because she believed there was a valid order for [MEDICATION NAME]. RN-C stated Resident #1's pain was significant and not relieved with prn Tylenol. RN-C indicated the prn Tylenol only improved Resident #1's pain from 10 out of 10, to 7 out of 10 and had she known Resident #1's [MEDICATION NAME] order was not valid, she would have asked the physician for a stronger medication when she faxed him on 07/16/13. On 12/11/13 at 10:45a.m., Surveyor # asked the Director of Nursing (DON) about the delay in obtaining [MEDICATION NAME] to treat Resident #1's right foot pain. On 12/11/13 at 1:00p.m., the DON stated that she had contacted the pharmacy and was informed the pharmacy had never sent the original (03/03/13), order of [MEDICATION NAME] and prior to 07/19/13, Resident #1 had never received prn [MEDICATION NAME] and the order had lapsed due to non-use. The DON indicated the facility had trouble reaching Resident #1's physician 07/18/13. This caused a delay in obtaining Resident #1's [MEDICATION NAME] from the pharmacy.

Based on record review and staff interviews the facility did not always ensure that 2 of 2 residents (#10 and #3) who experienced falls at the facility, out of a total sample of 11, were provided with adequate supervision and assistive devices per their plan of care to prevent accidents. Resident #10 was noted to be at high risk for falls and had a plan of care to have a bed alarm on and mat on the floor when resident is in bed. Resident #10 had a fall from bed on 9/13/13 and suffered several lacerations to her head. Facility staff did not have the mat on the floor, as per Resident #10's plan of care, which may have prevented Resident #10 from suffering injuries when she fell from the bed to the floor. Resident #10 was also experiencing a change in condition by displaying an increase in restlessness and this was not reported to staff who was responsible for caring for her on the 3rd shift. Resident #3's Certified Nursing Assistant (CNA) Care Card indicates a fall intervention dated 9/25/13, for the use of dycem to the wheelchair seat. The dycem was not observed in the seat of the wheelchair, and CNA's assigned to care for Resident #3 stated she never has used dycem in the wheelchair. On 11/6/13, Resident #3 fell out of the wheelchair, when she unexpectedly planted her feet on the floor, while the wheelchair was being pushed. Resident #3 sustained a hematoma to the forehead and a skin tear to the right elbow. There was no evidence that the facility had evaluated whether the use of leg rests might prevent further falls. Even though Resident #3 does not use her feet to self propel, the use of leg rests had not been evaluated. Resident #3 has leg rests for her wheelchair in her room, but was observed on 12/9-12/11/13, without leg rests on the wheelchair. This is evidenced by: 1. Resident #10's closed medical record was reviewed by Surveyor # on 12/11/13 as a result of a complaint investigation. Resident #10 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility conducted a "Fall Risk" assessment on 8/6/13 which stated that Resident #10 is at high risk for falls. According to the most recent quarterly Minimum Data Set, dated dated [DATE], Resident #10 is severely impaired in cognitive skills for daily living, has short and long term memory impairment and has not had any recent falls. Additional record reviewed showed that Resident #10 was on hospice care, and needed total dependence on staff for all cares, was mostly non-verbal and up in a broda chair when out of bed. The medical record also did not contain documentation that Resident #10 had persistent behaviors, other than she lacked awareness of her own needs. The most recent individual plan of care, dated 8/6/13 states that Resident # 10 has the potential for injury, at risk for falls related to new admission, mental status (Alzheimer Dementia diagnosis), history of previous falls, poor vision (legally blind), Cerebral Vascular Accident and anxiety at times. The listed interventions included alarms on chair and bed and a mat on the floor. The medical record for Resident #10 contained a "Change of Condition- SBAR- Physician/ NP/ PA communication and Progress Note," dated 9/13/13 at 10:45 p.m. The progress note states Resident #10 had an unwitnessed fall with head injury. The note states Resident #10 was found on the floor in her room and was lying on her back with her head underneath her wheelchair pedal's. Noted that there was was reddened drainage (blood) that was on the floor, no coagulation noted, multiple cranial lacerations noted to head/scalp area. Pressure was applied followed by towel and cling wrap to ensure pressure to help with controlling current bleeding to cranial area. Ice was applied surrounding the circumference around cranial area. Noted that there was no loss of consciousness during this occurrence. Behavior was described and whining with unclear associations with current topic, loose rambling speech noted with no current associations on this occurrence. Unable to get vital signs due to Resident #10's symptoms. Resident #10 was shaking her hands and not cooperating with the writer of the report. Physician was notified, order given to send to hospital for evaluation and treatment, ambulance called and hospice nurse alerted. The ambulance was noted to have arrived at 11:00 p.m. and was on unit until 11:30 p.m., when they transported Resident #10 to hospital emergency room . The "Resident Transfer Form," dated 9/13/13 stated that Resident #10's Power of Attorney was notified that Resident #10 was being transferred to the emergency room and she was "found on the floor in pool of blood, multiple head lacerations." Surveyor # reviewed the "Interdisciplinary Post Fall Review" dated 9/13/13 at 10:45 p.m. which stated that Resident #10 was "agitated during the p.m. shift (2:00 p.m.- 10:00 p.m.) and was sent to emergency room -911, hospice agency and hospital to assist with cares. The review stated that Resident #10 was in her room, in bed prior to fall. The review states Resident #10 has cognitive deficits and on medications that may contribute to the fall. The activity at the time of fall is unknown. The review does not state if the falls interventions of bed alarm and mat on the floor were in use prior to the fall. The summary of the falls investigation states that upon investigation, it was determined that Resident #10 became restless with cares and that the Certified Nursing Assistant stated Resident #10 had cares provided to her at 8:30 p.m. and was found on the floor at 10:40 p.m.. Surveyor # was provided with an additional timeline of events for the evening of 9/13/13 and Resident #10's fall from bed. The timeline states that earlier at approximately 3:00 p.m., Resident #10 was restless and attempting to get out of her chair (this was not a behavior that was common for Resident #10). Resident #10 was placed by the nurses station for closer observation. At 5:00 p.m. on 9/13/13 staff reported that Resident #10 continued to be restless and rocking and leaning forward in her chair during the evening meal. Staff reported that 2 staff provided cares to Resident #10 at 8:30 p.m. and when finished Resident #10 was lying in bed in the fetal position with the tab alarm attached to her nightgown. The staff reported Resident #10 was resistive to cares during this time. All staff reported that when they walked by Resident #10's room from 9:00 p.m. to 10:15 p.m., Resident #10 remained in the fetal position in bed. It was noted that the additional information for the fall investigation did not state if Resident #10's alarm was sounding at the time of the fall, or if the mat was on the floor as per her plan of care. Nursing note dated 9/14/13 at 3:15 a.m. stated that the facility received a call from St. Luke's Medical Center emergency room stating Resident #10 would be returning to the facility and it was noted Resident #10 had a C-2 fracture (Cervical Spine fracture) and would be returning with an Aspen Collar - to be worn at all times. It was stated that Resident #10's family did not want any further interventions at the hospital and that Resident #10 has has sutures across her forehead. Surveyor # interviewed Director of Nursing- A on 12/11/13 at 12:50 p.m.. DON- A reported she spoke with staff who worked on 9/13/13 with Resident #10 and that she (resident) was restless that day, which was a new behavior for Resident #10. DON- A stated Resident #10's family even reported they saw a change in Resident #10 just prior to the incident. Resident #10 was seen trying to push up out of her broda chair. Surveyor # asked DON- A if she was aware if Resident #10's bed alarm was sounding prior to the fall, as the investigation did not include this information. DON- A stated she believed the clip alarm was attached to Resident #10's gown and she had taken off her gown prior to the fall. DON- A stated she was not sure about the other fall interventions being in place at the time of the fall and would need to do additional follow- up. On 12/11/13 at 2:25 p.m., Surveyor # interviewed CNA- H in regards to Resident #10's fall on 9/13/13. CNA- H stated she was working the 3rd shift on 9/13/13 and had just started her shift at 10:00 p.m. CNA- H reported she was making her rounds and when she approached Resident #10's room around 10: 20 p.m., she saw Resident #10 on the floor and saw a lot of blood on the floor. CNA- H stated she immediately got help and when she entered Resident #10's room, Resident #10 was on the floor facing her bed. CNA- H stated there was no alarm going off because Resident #10 had removed her gown and the clip alarm was still attached to the gown. CNA- H reported there was not a mat on the floor and that she remembers one side of the bed was up against the wall and the mat was upright between the heater and the bed, not in use on the floor. CNA- H stated she was never given report or told by the staff who earlier cared for Resident #10 that she (resident) was experiencing an increase in behaviors and was very restless that evening. CNA- H stated that normally Resident #10 doesn't even talk and all she would move in bed is her feet so she can't believe she fell to the floor. On 12/11/13 at 2:49 p.m., Surveyor # interviewed DON- A. Surveyor # asked DON- A if she was aware that the mat was not on the floor at the time of the fall on 9/13/13. DON- A stated she was not aware of this until today (12/11/13). DON-A stated she had come in early 9/14/13 to conduct the investigation into the fall and was dealing with the severity of everything that happened and never really asked staff what was and what was not in place at the time of the fall. DON- A stated that on 9/16/13 the facility was made aware by the hospital that the C-2 fracture Resident #10 suffered was noted to be an old fracture and not a result of the fall on 9/13/13. On 12/12/13, Surveyor # was able to verify by review of documentation present from the Radiologist at St. Luke's hospital the Resident #10's C-2 fracture was considered a "chronic fracture." It was noted Resident #10 did return to the facility on [DATE] with sutures to the lacerations across her forehead. Resident #10 was described in nursing note documentation to have remained unresponsive upon her return, and staff provided continuous monitoring of her condition. Hospice care was aware of her condition and also provided care to her. Resident #10 did expire on 9/15/13. Nursing note dated 9/16/13 stated that facility staff spoke with the coroner's office and the reason for death was listed as "failure to thrive." 2. Surveyor # reviewed Resident #3's record on 12/9-12/12/13. A review of Resident #3's Certified Nursing Assistant (CNA) Care Care reveals instructions dated 9/25/13, for staff to use dycem in the wheelchair seat. Resident #3 has a falls care plan in place (undated) that indicates a floor mat, bed buddy and dycem to the wheelchair seat are the needed interventions. Nursing documentation dated 9/5/13, indicates the interdisciplinary team met to discuss removing Resident #3 from the falling stars program. It was noted that the last fall had occurred in March 2013. The team recommended discontinuing Resident #3 from the falling stars program, and recommended to continue the falls interventions of the dycem for the wheelchair, the bed buddy and the floor mat. On 12/10/13 at 8:30a.m., Surveyor # observed CNA-F complete morning cares for Resident #3. Surveyor # noted there was no dycem in the seat of Resident #3's wheelchair. Surveyor # asked CNA-F, who has cared Resident #3 for the past several months, about the dycem for the wheelchair seat. CNA-F stated she has never known Resident #3 to use dycem in her wheelchair. During the daily meeting with the Director of Nursing (DON) on 12/10/13 at 3:00p.m., Surveyor # asked why Resident #3 did not have a dycem for the wheelchair when the plan of care indicated the dycem should be present. The DON indicated she would look into the concern and provide feedback on 12/11/13. On 12/11/13 at 2:15p.m., Physical Therapist (PT)-G informed Surveyor # that a wheelchair evaluation had been completed on 12/11/13, and Resident #3 does not need dycem as she is able to maintain her position in the wheelchair without scooting forward on the seat cushion. The care plan was updated to discontinue the dycem. According to documentation in the Nurse's Notes, on 11/6/13 at noon Resident #3 was being taken to the toilet by a CNA, when Resident #3 put her feet down on the floor and the wheelchair stopped abruptly and Resident #3 fell forward hitting her head on the floor. The physician was notified and Resident #3 was sent to the hospital for evaluation. A review of the hospital Emergency Department (ED) record reveals that upon arrival, Resident #3 had an abrasion and hematoma to the right anterior forehead, a skin tear to the right elbow, and bruising and an abrasion over the right knee. On 12/10/13, Surveyor # asked if the facility had completed a post fall review of the 11/6/13 fall. On 12/11/13, Surveyor # was given a copy of an Interdisciplinary Post Fall Review for the 11/6/13 fall. The form description of the fall stated the resident tipped out of wheelchair during transporting to her room. In the section of the form titled, "Summary of Interdisciplinary Team", "Resident sent to emergency room " was written. There were no intervention recommendations. On 12/11/13 at 3:00p.m., Surveyor # asked the DON if the "team" had evaluated whether or not Resident #3 should or should not use wheelchair leg rests. On 12/12/13, Surveyor # was given a copy of an "Incident/Accident Investigation Follow-Up" form. The description of the incident indicated that Resident #3 was being transported to her room via wheelchair by the CNA. Resident #3 put her feet on the ground during transport which caused her to tip out of her chair. In the section titled, "Summary of Investigation (Reasonable Conclusion)", was written "Resident was wet and needed to be changed by CNA." The section of the form titled, "Past Interventions Attempted (Include Dates)" was blank. In the section of the form titled, "Recommendations/New Interventions" was written "When resident was initially assessed it was determined she did not need to be hospitalized . Staff nurse called ADON (Assistant Director of Nursing) and informed her resident's lump on head was getting larger. Directed to call MD and send resident for a CT scan." There was no documentation in the record of an evaluation to determine the need or no need for wheelchair leg rests. Surveyor # observed Resident #3 up in her wheelchair during multiple observations on 12/9-12/11/13. There were no leg rests on the wheelchair. Surveyor # observed wheelchair leg rests lying on the floor beside Resident #3's wardrobe on 12/10/13, at 8:30a.m. On 12/11/13, Resident #3 was evaluated by a Physical Therapist (PT) for wheelchair positioning. Recommendations are to use leg rests and a 34 inch Incredihugger back cushion insert to maintain proper posture in the wheelchair. On 12/11/13 at 2:15p.m., PT-G stated that leg rests were being tried to help Resident #3 stay straighter in her wheelchair. PT-G stated that as far as she knows, Resident #3 does not use her feet to self propel the wheelchair. On 12/12/13 at 9:50a.m., Surveyor # observed Resident #3 sitting up in a high back wheelchair with leg rests. On 12/12/13 at 12:35a.m., CNA-E who routinely cares for Resident #3 stated Resident #3 does not use her feet to self propel her wheelchair. There was no evidence that the facility evaluated the use of leg rests after Resident #3 sustained injury after a fall caused by putting her feet down when being transported with her wheelchair.

Based on record review, observation, and staff interview the facility did not ensure that 2 of 9 residents with pressure ulcers received the necessary treatment and services to promote healing and prevent new ulcers from developing. Resident #5, who is receiving hospice care, has a facility acquired stage 3 pressure ulcer on her "mid back". Based on the comprehensive assessment and plan of care, Resident #5 is identified as being at risk for pressure ulcer development, is dependent on staff for repositioning (full mechanical lift), and should receive repositioning assistance every 2 hours (including the approach to be up for meals only). On 4/15/13 Resident #5 was up in a Broda chair from 8:50 a.m. through 12:45 p.m. without repositioning. On 4/16/13 Resident #5 was up in her Broda chair from 7:00 a.m. through 1:10 p.m. without repositioning. Resident #5 did have a pillow behind her back in the Broda chair, which was indicated as an intervention on her plan of care. As a result of the facility's failure to provide repositioning and pressure redistribution, based on Resident #5's plan of care, the pressure ulcer failed to progress toward healing. Resident #9 has a stage 2 pressure ulcer on the left heel. On 4/17/13 at 1:30 p.m., Resident #9 did not have an EZ boot on the left foot when in bed, as directed on the plan of care. Findings include: 1. On 4/11/13, Surveyor # reviewed Resident #5's clinical record. The record indicates Resident #5 is [AGE] years old, was admitted to the facility on [DATE], receives hospice care and has [DIAGNOSES REDACTED]. The significant change Minimal Data Set (MDS), dated [DATE], indicates Resident #5 has severely impaired cognitive skills (never/rarely made decisions), requires total staff assistance for bed mobility, toilet use, and transfers, does not ambulate, is incontinent of bowel and bladder, is at risk for pressure ulcers and has no pressure ulcers. The quarterly MDS, dated [DATE], indicates Resident #5 has severely impaired cognitive skills (never/rarely made decisions), requires total staff assistance for bed mobility, toilet use, and transfers, does not ambulate, is incontinent of bowel and bladder, is at risk for pressure ulcers and has one unstageable pressure ulcer. The Braden Scale for Predicting Pressure Score Risk, dated 04/02/13, indicates Resident #5 is at high risk for pressure ulcer development. The plan of care for Pressure Ulcers, dated as rewritten on 4/02/13, includes the approaches for staff to reposition/shift resident's weight in chair, to place a pillow behind the residents back when up in Broda chair, to be up for meals only, and to provide "check and change" incontinence cares before and after meals. The Weekly Pressure Ulcer Records, dated 1/24/13 through 2/11/13, indicates Resident #5 developed a stage 2 pressure ulcer on her mid back on 1/24/13 that was healed on 2/11/13. The Weekly Pressure Ulcer Records, dated 3/07/13 through 4/09/13, indicates Resident #5 developed a stage 2 pressure ulcer on her mid back on 3/07/13, measuring 0.5 centimeters (cm) by 1.0 cm. (no depth documented), that progressed to a stage 3 pressure ulcer, measuring 1.9 cm by 1.2 cm by less than 0.1 cm depth, on 4/09/13. The progress note, documented on the pressure ulcer record, indicates the wound bed is yellow with 90% slough and 10% red, small exudate on old dressing. Peri wound pink, surrounding skin non-blancheable red, continue same treatment. The checked box for wound bed indicates that it is yellow with the surrounding skin color being bright red. On 4/15/13, Surveyor # made a continuous observation from 8:50 a.m. through 11:55 a.m. of Resident #5 sitting in a Broda chair in the Reflections unit TV lounge area/dining room. Resident #5 did not receive assistance with incontinence "check and change" care or repositioning during this observation time frame. Resident #5 had a pillow placed in the Broda chair, behind her back. On 4/15/13, at 11:55 p.m., Surveyor # spoke with Certified Nursing Assistant (CNA)-E, who indicated Resident #5 was last assisted with incontinence cares before being transferred out of bed and into her Broda chair, by the hospice CNA in the morning hours. CNA-E indicated she was not sure of the time Resident #5 was assisted out of bed. CAN-E indicated Resident #5 would be transferred out of the Broda chair, and into her bed, after lunch. On 4/15/13, at 12:50 p.m., Surveyor # observed CNA-E and CNA-K transfer Resident #5 from her Broda chair to her bed, using a full mechanical lift, to provide incontinence care. Surveyor # observed Resident #5 was incontinent of bladder and she had a dressing over the pressure ulcer on her mid back that was partially off. On 4/15/13 at 1:00 p.m., Surveyor # observed Licensed Practical Nurse (LPN)-Q removed the dressing. LPN-Q and Surveyor # observed Resident #5's mid back pressure ulcer and noted it to be an approximate 1.5 centimeters (cm) by 1.5 cm. stage 3 pressure ulcer with a pink wound bed and dark red periwound skin color. On 4/16/13, Surveyor # and Surveyor # , made a continuous observation from 8:20 a.m. through 1:10 p.m. of Resident #5 sitting in a Broda chair in the Reflections unit TV lounge area/dining room. Resident #5 did not receive assistance with incontinence "check and change" care or repositioning during this observation time frame. Resident #5 had a pillow placed in the Broda chair, behind her back. On 4/16/13, at 12:35 p.m. and at 1:10 p.m., Surveyor # spoke with Certified Nursing Assistant (CNA)-I, who indicated Resident #5 was last assisted with incontinence cares before being transferred out of bed and into her Broda chair, by the hospice CAN and CAN-I, at about 7:00 a.m. On 4/16/13, at 12:50 p.m., Surveyor # observed CNA-I and CNA-J transfer Resident #5 from her Broda chair to her bed, using a full mechanical lift, to provide incontinence care. Surveyor # observed Resident #5 was incontinent of bladder and she had an intact dressing over the pressure ulcer on her mid back. Resident #5 did not have any redness or additional pressure ulcers on the buttocks area or back. On 4/16/09, at 1:10 p.m., Surveyor # informed LPN-Q that Resident #5 had been observed up in her Broda chair since 8:20 a.m. LPN-Q indicated Resident #5 should be repositioned out of her Broda chair every 2 hours and as necessary. On 4/16/13, at 1:20 p.m., Surveyor # informed the Director of Nursing (DON) that Resident #5 was up the Broda chair on 4/15/13, from 8:50 a.m. through 12:45, and on 4/16/13 from 7:00 a.m. through 1:10 p.m., without receiving repositioning and incontinence cares. The DON verified Resident #5 has a pressure ulcer on her mid back and should be receiving repositioning every 2 hours, and incontinence cares after breakfast and before lunch, as directed in the plan of care. The Weekly Pressure Ulcer Record, dated 4/16/13, indicates resident #5 has a stage 3 pressure ulcer on her mid back, measuring 1.7 cm by 1.3 cm with no depth and no undermining. The checked characteristics of the wound bed include yellow and black with the surrounding skin color being dark red/purple. The form indicates that the physician was notified on 4/16/13 and that the response to treatment is improved. The progress note, documented on the pressure ulcer record, indicates the wound bed is 5% necrotic tissue and 95% yellow slough with a dark red peri wound. The progress note on the record indicates Resident #5 needs to be repositioned every 2 hours and to continue [MEDICATION NAME]. Surveyor # noted that this documents a change in the characteristics of the wound since 4/9/13. On 4/22/13 the facility submitted additional information for Surveyor # and Surveyor # to review regarding Resident #5's pressure ulcers. Review of the submitted information confirms the above documented information that shows a change in the characteristics of Resident #5's pressure ulcer on her back from 4/9/13 to 4/16/13. On 4/16/13 the wound bed is now made up of 5% necrotic tissue and 95% slough and is yellow and black in its characteristics compared with the wound bed on 4/9/13 which was 90% slough and 10% red and the wound bed characteristic was yellow. The facility also submitted nurse's notes for review including a note dated 4/16/13 at 17:00 (5:00 pm) stating: Dr. contacted re: OA (open area) on spine. he states "d/t (due to) the resident's end stage dementia, immobility, and poor nutrition and the area it is, it will be difficult to heal. Continue to lay her down after meals and position her off of her back after meals. And with the wound care nurse also monitoring we are doing what we can for her." Surveyor # noted that this note was obtained following Surveyor # 's sharing of the concerns regarding Resident #5's wound care and the observations of her not being repositioned as per plan of care over two days. Surveyor # also noted that Resident #5's dementia, immobility, and poor nutrition are all factors that increase the risk of Resident #5 to develop a pressure ulcer and increase the need to appropriately reposition and provide other preventative measures to Resident #5 in order to avoid not having the wound progress towards improvement/healing. 2.) Resident #9's medical record was reviewed by Surveyor # . Resident #9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#2 has a stage 2 pressure ulcer. The nurse's notes indicate on 2/10/13 a fluid filled blister was discovered on Resident #2's left heel. Resident #9's current Treatment Administration Record (TAR) indicates a treatment to use a EZ boot on the left foot at all times when in bed. Resident #9's Plan of Care for Pressure Ulcers with a review date of 2/11/13, indicates use of a heel boot when in bed. On 4/17/13 at 1:30 p.m. Surveyor # and RN-H (Registered Nurse) observed Resident #9 lying in bed. Resident #9 did not have a EZ boot on the left heel. Resident #9 had a wound dressing on the left heel. Resident #9 left heel was not free from surface contact with the bed. RN-H indicated that Resident #9's left heel just re-opened yesterday and the Eschar peeled off. RN-H indicated that Resident #9 should have a boot on and would go get one. There were no EZ boot (s) in Resident #2 room.

Based on observation, interview and record review the Facility did not ensure that a Resident who is incontinent of bladder receives appropriate treatment and services to restore as much normal bladder function as possible for 3 (Resident #1, #5, and #8) of 12 sampled residents with incontinence. Resident #8 had a decrease in urinary continence and the Facility did not complete a voiding diary and a timely comprehensive assessment to develop an individualized plan of care. Resident #5 was not checked for incontinence for multiple hours on 4/15/13 and 4/16/13. Resident #1 was admitted with a Foley catheter, which was removed 3/28/13 and did not have an assessment of her bladder function. Findings include: 1.) Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/17/13 Surveyor # reviewed Resident #8's Initial Minimum Data Set, dated dated dated complete 1/7/13. Section H0300 was coded as Resident #8 being occasionally incontinent of bladder (less than 7 episodes in 7 days). Resident #8 was coded as needing extensive assistance for toileting needs. Review of Resident #8's care tracker data indicates that Resident #8 was incontinent 2 times during this period of time. On 4/17/13 Surveyor # reviewed Resident #8's bowel and bladder care tracker from 1/17/13 to 1/23/13 Resident #8 was documented as having 12 episodes of incontinence (a change from the initial assessment). From 1/24/13 to 1/30/13 Resident #8 was documented as having 10 episodes of incontinence. From 1/31/13 to 2/6/13 Resident #8 was documented as having 10 episodes of incontinence. From 2/7/13 to 2/13/13 Resident #8 was documented as having 12 episodes of incontinence. From 2/14/13 to 2/20/13 Resident #8 was documented as having 15 episodes of incontinence. From 2/21/13 to 2/27/13 Resident #8 was documented as having 11 episodes of incontinence. From 2/28/13 to 3/6/13 Resident #8 was documented as having 18 episodes of incontinence (another marked increase). From 3/7/13 to 3/13/13 Resident #8 was documented as having 12 episodes of incontinence. From 3/14/13 to 3/20/13 Resident #8 was documented as having 11 episodes of incontinence. From 3/21/13 to 3/27/13 Resident #8 was documented as having 15 episodes of incontinence. From 3/28/13 to 4/3/13 Resident #8 was documented as having 22 episodes of incontinence (another marked increase and more than triple the amount of incontinence from the initial assessment. From 4/4/13 to 4/10/13 Resident #8 was documented as having 16 episodes of incontinence. Every week from 1/17/13 Resident #8 is documented as having 7 or more episodes of incontinence. On 4/17/13 Surveyor # reviewed Resident #8's evaluation for bowel and bladder training dated 1/10/13 which indicated Resident #8 had 2 episodes of incontinence from 12/31/13 to 1/10/13 and was placed on a prompted toileting program. Resident #8 had a 3 day bladder collection completed from 1/2/13 to 1/4/13 where no episodes of incontinence were recorded. The wheel consisted of hourly documentation for a 3 day period. On 4/17/13 Surveyor # reviewed Resident #8's evaluation for bowel and bladder training dated 4/9/13 which indicated Resident #8 was incontinent daily with no voiding pattern. The narrative read: perception to void declining, for bladder 14 continent and 34 incontinent episodes (does not specify a time frame). No 3 day bladder collection tool was found for Resident #8 the time the decline was found. The provided bladder care tracker documentation only lists the number of incontinence episodes a shift and does not break down to hourly documentation to evaluate if a pattern can be found. On 4/17/13 at 10:30 a.m. Surveyor # interviewed Resident #8 who stated she did not wish for Surveyor # to watch any care being done with her and stated everything is fine. On 4/18/13 at 9:00 a.m. Surveyor # interviewed Registered Nurse (RN)-C who completed the bladder assessment on Resident #8 on 4/9/13. RN-C stated she was doing the routine quarterly assessment when she noticed the change in Resident #8's bladder incontinence. RN-C stated is did not complete the hourly 3 day bladder collection and should have. RN-C stated she looked at the bladder care tracker which does not break down the incontinence to hourly only by shift. RN-C stated a 3 day bladder collection was now in progress for Resident #8 after Surveyor # brought this concern to the facility. Surveyor # visualized a 3 day bladder collection tool to be partially completed for Resident #8. On 4/17/13 Surveyor # reviewed Resident #8's care plan titled Urinary incontinence dated 4/9/13. Interventions included a toileting schedule every 2-3 hours, around activities, upon awakening, before and after meals, mid-morning/afternoon, before bed at night. This toileting plan is not based on a comprehensive assessment of Resident #8's bladder which would include monitoring for wetness or dryness every 2 hours, according to the facility policy even though the bladder collection tool allows for hourly monitoring. On 4/17/13 Surveyor # reviewed the policy titles Bowel and Bladder Management dated 8/12 which read: 4.a. Establish an elimination pattern, monitor voiding patterns using the bowel and bladder care tracker reports and/or Bladder Data Collection forms. Monitor wetness and dryness every 2 hours. The above findings were shared with the Administrator and Director of Nurses at the exit meeting on 4/17/13 at 3:00 p.m. Further information was requested if available. On 4/23/13 Surveyor # received additional information from the facility to review regarding Resident #8's bladder status. The additional information received was the detailed bowel and bladder report from care tracker pertaining to Resident #8. This report documents the time that staff document into care tracker what Resident #8's continence status is and what the toileting activity was that was completed. Surveyor # noted upon review of the detailed report that the data confirms the number of continent vs. incontinent episodes detailed earlier in this deficiency showing a progressive increase in incontinence episodes for Resident #8 since admission. Additionally, Surveyor # noted that despite the care tracker report showing times that Resident #8 is continent or incontinent there is no documented assessment that shows that details from this report were utilized to determine the type of incontinence that Resident #8 has, what type of voiding pattern does Resident #8 have and the development of an individualized care plan that is based upon the assessment to restore or maintain Resident #8's continence status. 2.) Resident #1 was admitted to the facility on [DATE]. Resident #1 has [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility for short term Rehab. Resident #1 had an admission MDS (Minimum Data Set) completed on 3/27/13. The MDS indicates that Resident #1 is cognitively intact with some signs of Depression. The MDS indicates that Resident #1 has an indwelling Foley catheter in place to manage urinary continence. On 4/16/13 Surveyor #3328 was reviewing the medical record for Resident #1. The medical record contained a bowel and bladder assessment dated [DATE]. The assessment indicates that Resident #1 has an indwelling Foley catheter and is currently continent of bladder. The medical record indicates that on 3/28/13 Resident #1 had his/her Foley catheter removed. The medical record did not have a bowel and bladder assessment completed after the Foley catheter was removed. Surveyor reviewed the care plan for Resident #1 and there was no care plan that addressed bladder incontinence. On 4/16/13 at 10:45 a.m. Surveyor #3328 was speaking with RN-F regarding Resident #1's bladder incontinence. RN-F indicated that the facility policy is when a Foley catheter is removed a 3 day voiding wheel is started and a comprehensive bladder assessment is completed based on the findings of the voiding wheel. RN-F indicated that according to the care tracker documentation Resident #1 is having episodes of bladder incontinence. RN-F indicated that a 3 day voiding wheel will be started immediately to address Resident #1's bladder continence. RN-F indicated that an assessment will be developed and an appropriate care plan will be put in place to manage Resident #1's bladder incontinence. On 4/17/13 at 10:00 a.m. Surveyor #3328 spoke with Resident #1. Resident #1 indicated that she had episodes of bladder incontinence after the Foley catheter was removed. Resident #1 indicated that she would ask staff for assistance when she needed to use the bathroom. This observation was shared with the Nursing Home Administrator and the Director of Nursing on 4/16/13 at 2:30 p.m. and no additional information was presented to Surveyor #3328. 3.) On 4/11/13, Surveyor # reviewed Resident #5's clinical record. The record indicates Resident #5 is [AGE] years old, was admitted to the facility on [DATE], receives hospice care and has [DIAGNOSES REDACTED]. The significant change Minimal Data Set (MDS), dated [DATE] and quarterly MDS, dated [DATE], indicate Resident #5 has severely impaired cognitive skills (never/rarely made decisions), requires total staff assistance for bed mobility, toilet use, and transfers and is incontinent of bowel and bladder. The Evaluation For Bowel and Bladder Training, dated 1/10/13, indicates Resident #5 is a full mechanical lift transfer, has functional incontinence and has incontinence daily. The evaluation indicates Resident #5 is unable to participate in a bladder program and is a "check and change". The evaluation includes a plan for management of the incontinence, to "check and change" upon arising, before and after meals, mid-afternoon, at hours of sleep and as necessary. On 4/15/13, Surveyor # made a continuous observation from 8:50 a.m. through 11:55 a.m. of Resident #5 sitting in a Broda chair in the Reflections unit TV lounge area/dining room. Resident #5 did not receive assistance with incontinence "check and change" care during this observation time frame (including after the breakfast meal and before the lunch meal). On 4/15/13, at 11:55 p.m., Surveyor # spoke with Certified Nursing Assistant (CNA)-E, who indicated Resident #5 was last assisted with incontinence cares before being transferred out of bed and into her Broda chair, by the hospice CNA in the morning hours. CNA-E indicated she was not sure of the time Resident #5 was assisted out of bed. CNA-E indicated Resident #5 would be transferred after lunch time out of the Broda chair, and into her bed, to receive incontinence cares. On 4/15/13, at 12:50 p.m., Surveyor # observed CNA-E and CNA-K transfer Resident #5 from her Broda chair to her bed, using a full mechanical lift, to provide incontinence care. Surveyor # observed Resident #5 was incontinent of bladder. On 4/16/13, Surveyor # and Surveyor # , made a continuous observation from 8:20 a.m. through 1:10 p.m. of Resident #5 sitting in a Broda chair in the Reflections unit TV lounge area/dining room. Resident #5 did not receive assistance with incontinence "check and change" care during this observation time frame (including after the breakfast meal or before the lunch meal). On 4/16/13, at 12:35 p.m. and at 1:10 p.m., Surveyor # spoke with Certified Nursing Assistant (CNA)-I, who indicated Resident #5 was last assisted with incontinence cares before being transferred out of bed and into her Broda chair, by herself and the hospice CNA at about 7:00 a.m. On 4/16/13, at 12:50 p.m., Surveyor # observed CNA-I and CNA-J transfer Resident #5 from her Broda chair to her bed, using a full mechanical lift, to provide incontinence care. Surveyor # observed Resident #5 was incontinent of bowel and bladder. On 4/16/13, at 1:10 p.m., Surveyor # informed LPN-Q that Resident #5 had been observed up in her Broda chair, without incontinence cares being provided, since 8:20 a.m. LPN-Q indicated Resident #5 should be provided with incontinence cares after breakfast and before lunch, as directed in the plan of care. On 4/16/13, at 1:20 p.m., Surveyor # informed the Director of Nursing (DON) that Resident #5 was up the Broda chair on 4/15/13, from 8:50 a.m. through 12:45, and on 4/16/13 from 7:00 a.m. through 1:10 p.m., without receiving incontinence cares. The DON indicated Resident #5 should have received incontinence cares after breakfast and before lunch, as directed in the plan of care.

Based on record reviews, interviews and observations, the facility failed to ensure that 1 of 3 residents safety was maintained during the course of care. On 02/04/13, Certified Nursing Assistant (CNA)-C did not check to ensure that the Hoyer sling strap was securely hooked onto the Hoyer Lift prior to transferring Resident #1. The sling broke away during the transfer and Resident #1 fell approximately four feet to the floor. Resident #1 sustained significant injury and decline after a fall from the mechanical lift during a transfer from the bed to the wheelchair. Findings include; Resident #1 had been residing in the facility since 05/10 and experienced Morbid Obesity, Depression and Diabetes. Resident #1's most recent MDS (Minimum Data Set) of 01/20/13, identified Resident #1 with a BIMS of 15 and to be alert, oriented with no evidence of any cognitive deficits. Although the resident had an identified Power of Attorney for Health Care, she remained her own person. Resident #1 required assistance from staff for all of her activities of daily living including her mobility. Resident #1's mobility status included being transferred via the use of mechanical lift (Hoyer Lift). The use of the Hoyer Lift was identified and addressed on the resident's care plan dated 05/03/11. The care plan identified that Resident #1's mode of transfers would be via the mechanical lift with the presence of two staff. These same directives were noted on the nurse aide care card as well. On 02/04/13 at approximately 8:00 a.m. during the administration of care to Resident #1 by CNA-C, Resident #1 was being transferred from the bed to her wheelchair. Per facility investigation, after Resident #1 was placed in the appropriate sling and the straps of the sling hooked to the Hoyer lift, LPN-D (Licensed Practical Nurse) entered the room to assist CNA-C with the transfer. CNA-C elevated Resident #1 off of the bed. LPN-D was positioned behind the wheelchair to guide the Resident to the chair while CNA-C was operating the lift. As the Resident was positioned over the wheelchair the strap to the lift broke away and Resident #1 fell prone to the floor with her face and lower extremity hitting the legs of the Hoyer lift. Per Surveyor # interview with LPN-D on 02/19/13 at 11:00 a.m., LPN-D stated, "We left her on the floor, we did not want to move her and 911 was called, it happened so fast." Surveyor also interviewed CNA-C on 02/18/13 at 2:00 p.m. as to what occurred and per CNA-C, " I put the sling under her and hooked her to the lift, called the nurse to come assist to transfer her to the chair." CNA-C stated when the nurse arrived, the CNA "elevated" the resident off of the bed and moved her over the wheelchair and "she just fell ." When questioned if she had checked if the straps of the sling were in place, CNA-C stated "yes." Per review of the facility investigation and interview with the Nursing Home Administrator (NHA)-A on 02/18/13 at 9:20 a.m. all in house Hoyer lifts were evaluated and checked along with all the slings with no evidence of malfunction or wear and tear of any of the equipment. Per interview with the Director of Nursing -B(DON) on 02/19/13 at 10:15 a.m., it was "believed that the she (CNA-C) did not have the strap secured in the hook." The 911 transported the resident to the hospital trauma ER (emergency room ) for evaluation and care. A review of the hospital record by Surveyor # at 2:30 p.m. on 02/19/13 revealed that Resident #1 had fallen approximately 4 feet to the floor from the lift (per 911 paramedic communication to ER). resident sustained [REDACTED]. Per ER documentation, Resident #1 also sustained head contusions, laceration and edema to the left forehead and left eye area and closed fractures of one or more of her "phalanges" (toe bones). Resident #1 did receive surgical treatment for [REDACTED]. Resident #1 has since been transferred from the hospital to a speciality hospital for support of her respiratory status. The failure of CNA-C to check the secured placement of the Hoyer sling strap on the Hoyer Lift created an accident with substantial injury to Resident #1 that was avoidable.

Based on observation, staff interview and record review, the Facility did not ensure that the Resident environment remained as free of accident hazards as is possible; and each Resident received adequate supervision and assistance devices to prevent accidents for 6 of 6 Residents reviewed who were at risk for falls (Resident #6, Resident #1, Resident #5, Resident #4, Resident #3 and Resident #2). The Facility did not consistently assess behavior/fall trends and identify root causes for unwanted self-transfers, did not consistently implement new interventions to prevent falls when past interventions had proven ineffective, and did not consistently implement care-planned approaches for preventing falls. * Resident #6 has had nine falls since 4/16/12. During seven of the falls (6/9/12, 7/13/12, 7/22/12, 8/25/12, 9/30/12, 11/5/12, and 11/25/12 ) the alarms were disconnected. On 6/9/12 and 8/25/12 Resident #6 indicated that she was going to the bathroom. Staff did not assess and develop a toileting schedule to reduce the number of attempts at independent transfer. Staff continued to rely on alarms even though these fall interventions were proven to be ineffective because the resident could disconnect them. On 12/13/12, Resident #6 was observed without the sensor alarm on her bed and wheelchair. * Resident #1, who is assessed as high risk for falls, has had 7 falls since 4/15/12 (4/15/12, 5/1/12, 7/10/12, 7/17/12, 9/12/12, 11/7/12, 12/3/12). The facility did not ensure fall prevention strategies listed on Resident #1's care plan were current. The facility did not ensure fall prevention strategies identified by the interdisciplinary team were acted upon, such as the use of an alarmed seat belt. The facility did not evaluate the effectiveness of current facility fall prevention interventions such as the effectiveness of the seat belt. The facility did not identify the root causes for Resident #1's falls. On 12/3/12, Resident #1 sustained a head injury above the left eye consisting of a 1 cm (centimeter) abrasion surrounded by swelling. * Resident #5 has experienced three falls since 4/14/12 with the last fall on 10/2/12 resulting in a four by three centimeter hematoma to the right side of her head. Revisions were not consistently made to the plan of care to prevent the same or similar types of falls from re-occurring. * Resident #4 was assessed to be at high risk for falls and is to have an alarm on at all times while she is in the bed or wheelchair. On 12/12 and 12/13/12, Resident #4 was observed without an alarm while she was in bed and in her wheelchair. * Resident #3 had two falls a week apart. After the first fall the Facility's plan was to check the toileting schedule for Resident #3. The Facility did not follow through on this planned fall prevention strategy. Resident #3 fell a week later, fracturing her wrist, which required surgery. * Resident #2 had 4 falls from 8/2/12 to 8/30/12. Facility staff did not investigate circumstances/root causes of Resident #2's falls in an effort to prevent future falls. On the fall 8/30/12, staff had not connected Resident #2's alarm. On 12/12/12, Surveyor # observed a thick gray cushion in Resident #2's wheelchair, but no Dycem or wedge cushion as per the IDT 8/29/12 fall prevention recommendation. The facility was aware that falls were occurring and the interdisciplinary team (IDT) met during morning report to discuss the falls; however, the facility failed to systematically address the falls by analyzing the circumstances relating to the falls in order to put effective measures in place, including increased supervision. The facility's failure to have an effective fall prevention program in place by determining the root cause to resident falls, the failure to determine if care planned interventions had been implemented and the failure to determine if other interventions are needed to prevent or to reduce the probability of further falls occurring placed residents in a situation of immediate jeopardy beginning 8/12/12. The Administrator and Director of Nurses were notified of the immediate jeopardy at 3:14 p.m. on 12/18/12. The facility removed the immediate jeopardy on 12/21/12; however, the deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as the facility needs to continue implementing and monitoring for an effective falls prevention program. The facility needs to ensure the circumstances of residents falls are thoroughly investigated and analyzed, determining fall patterns or trends, ensuring the implementation and effectiveness of planned interventions, determining the root causes of Resident falls and establishing/implementing fall prevention strategies identified through the analysis and root causes of the fall. Findings include: The Fall Management policy/procedure with a revision date of August 2012 documents under overview "Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The interdisciplinary team (IDT) evaluates each resident's fall risk. A Plan of Care is developed and implemented, based on this evaluation, with ongoing review. If a fall occurs, the IDT conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls." 1. Surveyor # reviewed Resident #6's medical record on 12/13/12. Resident #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6 has an activated power of attorney. The falls plan of care has an original date of 8/15/11 and was reviewed on 10/1/12. Under problems dated 12/20/11 documents, "Resident often non compliant removes tabs alarm & attempts to self transfers." Under approaches the plan of care is checked for chair and bed alarms. Also under approaches there are handwritten notations reflecting: "3/15/12 new slippers, sensor in w/c (wheelchair)," "6/9/12 sensor pad in bed,, and "10/2/12 laser motion sensor on bed." Under the goal section there is a handwritten notation, not dated, which documents; "In past pt. (patient) has removed alarms both tab and sensor. Very poor safety awareness." The annual MDS (minimum data set) completed on 4/11/12 documents that Resident #6 has short term memory problems, is severely impaired for decision making, frequently incontinent of bladder, has fallen since prior assessment, and sustained an injury with one fall. a. On 4/16/12, Resident #6 had an unwitnessed fall at 6:30 p.m. The interdisciplinary post fall review for fall dated 4/16/12 documents under description of fall, "Res. (Resident) in w/c (wheelchair) beside bed - reached for her shoes & slid to floor to reach. Alarm sounded as CNA (Certified Nursing Assistant) was going to door. without c/o (complaint of) pain - denies hitting head." The summary of interdisciplinary team documents "goal met/no injury." b. On 6/9/12, Resident #6 had an unwitnessed fall at 2:00 a.m. The change of condition SBAR (situation, background, assessment, request) Physician/NP (Nurse Practitioner)/PA (Physician Assistant) communication and progress note dated 6/9/12 under nurses notes documents, "was found on back in Room __ by closet door. Stated "I was trying to go to the bathroom." Had disengaged her alarm so alarm was not sounding. Body check was done by RN (Registered Nurse) (RN assessment was done) Skin tear noted to (L) (left) calf area. Area cleansed (2) steri strips were applied f/b (followed by) bioclusive dressing. Tx (treatment) done, was then transferred back to bed without further incident. Small abrasion noted to Rt. (right) wrist area. Toileting needs was also provided post event." The interdisciplinary post fall review documents under summary of interdisciplinary team documents "sensor pad in bed." c. On 7/13/12, Resident #6 had an unwitnessed fall at 2:40 p.m. The interdisciplinary post fall review for date of fall 7/13/12 at 2:40 p.m. documents under description, "Res. (Resident) found sitting on floor with legs extended in front of her b/t (between) w/c (wheelchair) & bed. Unwitnessed. Without alarms sounding when writer entered room." Under summary of interdisciplinary team documents, "+(positive) UA (urinalysis) dip, waiting C & S (culture and sensitivity)." The Facility did not identify the root cause for the fall, did not implement interventions to help prevent further falls and continued with the tab and sensor alarm intervention, which was ineffective. d. On 7/22/12, Resident #6 had an unwitnessed fall at 11:45 a.m. The nurses note dated 7/22/12 documents, "called to resident's room for a fall. Upon entrance noted resident on the floor next to her bed slightly sitting in w/c (wheelchair) but w/w/c (with wheelchair) leaning over her. Resident was alert and she denied disc. (discomfort) or hitting her head. ROM (range of motion) wnl (within normal limits) and there was no apparent injuries. Resident was assisted back into her w/c with alarm replied." The incident/accident investigation follow up question is circled "no" to the question If tabs alarm in use was alarm sounding? If no why? "alarm was not on." The interdisciplinary post fall review for 7/22/12 fall documents under summary of interdisciplinary team, "Patient education done with roommate about need for door to stay open." The Facility did not identify the root cause for the fall, did not implement interventions to help prevent further falls, did not address whether the sensor alarm was on, and continued with the tabs alarm intervention which was ineffective. e. On 8/25/12, Resident #6 had an unwitnessed fall at 2:30 a.m. The incident/accident investigation follow up questions dated 8/25/12 documents "disengaged alarm." The interdisciplinary post fall review for date of fall 8/25/12 documents under description, "was found sitting on the floor next to her bed. States, 'I've got to use the bathroom.' Slid out of bed in an attempt to use the bathroom." Under summary of interdisciplinary team, "Goal met/no injury." The Facility did not identify the root cause for the fall, did not implement interventions to help prevent further falls and continued with the tabs and sensor alarm intervention which was ineffective, as Resident is able to disengage the alarm. f. On 9/30/12, Resident #6 had an unwitnessed fall at 3:00 a.m. The change of condition SBAR physician/NP/PA communication and progress note dated 9/30/12 documents under progress note, "Res. (Resident) sitting on floor next to bed. Tab alarm disconnected. 'I just sat down on the floor.' Res. stated bed was wet and she was changing the linen." The incident/accident investigation follow up question is circled "no" to the question If tabs alarm in use was alarm sounding? If no why? "Removed by Resident." The interdisciplinary post fall review for date of fall of 9/30/12 documents under summary of interdisciplinary team, "UA obtained. Laser alarm initiated when available." The Facility did not identify the root cause for the fall, did not address whether the sensor alarm was on, and continued with the tabs alarm intervention which was ineffective. The fall risk assessment completed on 10/4/12 has a total score of "21." A total score of 10 or above represents high risk. The quarterly MDS completed on 11/5/12 has a BIMS (brief interview for mental status) score of 10 which is moderately impaired. This quarterly MDS indicates Resident is frequently incontinent of bladder and has fallen since prior assessment with 2 falls without injury. g. On 11/5/12, Resident #6 had an unwitnessed fall at 4:45 a.m. The change of condition SBAR physician/NP/PA communication and progress note dated 11/5/12 documents under progress note "Res. (Resident) found @ (at) 445 on her back between her w/c (wheelchair) & wardrobe. Stated she had been "hanging up a blouse & slipped. Able to move all extremities. Has limited motion historically in (L) (left) arm. Without new pain noted. Able to bear weight when lifted to a standing position with two and gait belt. Res. had self removed her tab alarm." The interdisciplinary post fall review for date of fall of 11/5/12 documents under summary of interdisciplinary team, "Goal met. All interventions in place. Resident tends to disregard safety. Poor safety awareness." The Facility did not identify the root cause for the fall, did not implement interventions to help prevent further falls,did not address whether the sensor alarm was on, and continued with the tabs alarm intervention which was ineffective. h. On 11/25/12, Resident #6 had an unwitnessed fall at 2:45 a.m. The change of condition SBAR physician/NP/PA communication and progress note dated 11/25/12 documents under progress note, "Res. (Resident) found sitting on floor with her back resting on the bed. "I slid to the floor because I couldn't reach the w/c (wheelchair)." Legs extended. AROM (active range of motion) x (times) 4. Res. self removed." The incident/accident investigation follow up question is circled "no" to the question If tabs alarm in use was alarm sounding? If no why? "self removed." The interdisciplinary post fall review for date of fall of 11/25/12 documents under summary of interdisciplinary team, "+ (positive) UA awaiting C & S. Moved closer to the nurses station." The Facility did not identify the root cause for the fall, did not address whether the sensor alarm was on, and continued with the tabs alarm intervention which was ineffective. i. On 12/6/12, Resident #6 had an unwitnessed fall at 4:30 p.m. The change of condition SBAR physician/NP/PA communication and progress note dated 12/6/12 documents under progress note, "Pt. (patient) found on the floor in front of w/c (wheelchair) sitting on her bottom with legs out in front of her, tab alarm sounding. VS (vital signs) taken, stable. Pt. denies any pain. Assisted pt. into w/c. Pt. assisted to bathroom, no injury apparent. Pt. denies pain with transfers. Pt. unable to state why she fell . Pt. w/c cushion has a trash bag wrapped around it. Staff education given. Reminded pt. to call with call light for assistance with transfers." The interdisciplinary post fall review for date of fall of 12/6/12 documents under summary of interdisciplinary team, "Goal met no injury." The Facility did not identify the root cause for the fall and did not implement interventions to help prevent further falls. On 12/13/12 at 7:43 a.m., Surveyor # asked CNA (Certified Nursing Assistant)-U what time Resident #6 usually gets up. CNA-U informed Surveyor # that it depends on Resident #6's mood and explained that Resident #6 used to work third shift so she will often sleep through breakfast. On 12/13/12 at 7:44 a.m., Surveyor # reviewed the care card located in the binder at the nurses station dated 8/2/12 for Resident #6. The care card indicates Resident #6 is transferred with 1 person assist, has scheduled toileting upon rising, before and after meals, mid-afternoon, HS (hour of sleep), PRN (as needed), and with NOC (night) shift rounds. Under tabs alarms, the care card indicates "laser alarm on bed, Tab in chair & bed, sensor pad in w/c (wheelchair), sensor pad in bed." j. On 12/13/12 at 8:09 a.m., Surveyor # observed Resident #6 sleeping in bed. Surveyor # observed Resident #6's bed is against the wall on the right side and there is a tabs alarm in the bracket on the wall and the string is under Resident #6's right side. Surveyor # did not observe any other alarms (laser and/or sensor alarm) on the bed. On 12/13/12 at 9:50 a.m. Surveyor # observed Resident #6 continues to be sleeping in bed. k. On 12/13/12 at 10:57 a.m., Surveyor # entered Resident #6's room with CNA-U. Surveyor # checked Resident #6's wheelchair and noted there was a sensor pad on the wheelchair but the cord was not connected to an alarm box. CNA-U asked Resident #6 what she wanted to wear. Resident #6 informed her that she didn't want to get up. CNA-U informed Surveyor # that she was going to let the nurse know. At 11:07 a.m. RN (Registered Nurse) Unit Manager-V spoke to Resident #6 about getting up. Resident #6 continued to refuse and RN Unit Manager-V informed Resident #6 that CNA-U would be back in half an hour. l. On 12/13/12 at 11:33 a.m., Surveyor # observed CNA-U enter Resident #6's room and inform Resident #6 that she was going to change her and let her eat lunch in bed. CNA-U asked Resident #6 if she had to go to the bathroom. Resident #6 replied no. CNA-U unfastened Resident #6's incontinence product and washed her frontal perineal area. CNA-U assisted Resident #6 with rolling onto her right side and washed her buttocks. CNA-U removed the soiled incontinence product and placed a new incontinence product on Resident #6. CNA-U then dressed Resident #6. Surveyor # noted that while Resident #6 was being positioned on her side, the sensor alarm did not activate. At 11:49 a.m. while Resident #6 was in her bed, CNA-U with the assistance of another CNA changed the bed linen. After staff removed the linen, Surveyor # observed there was no sensor alarm on the bed. Surveyor # also did not observe a laser alarm. m. On 12/13/12 at 2:19 p.m., Surveyor # observed Resident #6 in the bathroom washing her hands. Surveyor # observed the tabs alarm was connected to the back of Resident #6's sweater but the sensor pad alarm cord was wrapped around the bar under the wheelchair and not connected to an alarm box. n. On 12/13/12 at 2:22 p.m., Surveyor # observed Resident #6 sitting in her wheelchair in her room. The sensor alarm continues not to be connected. Resident #6 informed Surveyor # that she was going to go to bed. On 12/13/12 at 2:33 p.m., Surveyor # observed Resident #6 sitting in her wheelchair next to her bed. On 12/13/12 at 3:04 p.m., Surveyor # observed Resident #6 laying crossways on her bed with her feet resting on the seat of the wheelchair. Surveyor # observed that the tabs alarm was still on the wheelchair with the string hanging. At 3:05 p.m., CNA-W entered Resident #6's room, placed gloves on, and asked Resident #6 if she wanted to be straightened out. CNA-W then asked Resident #6 "Did you transfer yourself? You can't do that." Resident #6 replied, "I know but there was no one around that could help me." On 12/17/12 at 11:17 a.m., Surveyor # met with RN Unit Manager-V to discuss Resident #6's falls. Surveyor # informed RN Unit Manager-V that Surveyor # noted an intervention of a laser alarm on the bed on 10/2/12 but Surveyor # did not observe this. RN Unit Manager-V informed Surveyor # that they didn't have the correct brackets so they didn't implement this intervention. RN Unit Manager-V informed Surveyor # that Resident #6 is able to remove her tabs alarms so they initiated sensor alarms in bed and wheelchair but Resident #6 is able to undo these also. Surveyor # informed RN Unit Manager-V that during seven of Resident #6's falls Resident #6 had disengaged her alarm and that the Facility continues this intervention that is ineffective. Surveyor # informed RN Unit Manager-V that Surveyor # had observed the tabs alarm is attached on the wall within reach of Resident #6 while Resident #6 is in bed. RN Unit Manager-V informed Surveyor # that she had never thought about this and would have maintenance move the bracket. Surveyor # informed RN Unit Manager-V that during two falls on 6/9/12 and 8/25/12 Resident #6 indicated that she was going to the bathroom. After these falls, staff did not assess and develop a toileting schedule to reduce the number of attempts at independent transfers. Surveyor # informed RN Unit Manager-V of the observation on 12/13/12 of Resident #6 in bed without the sensor alarm. RN Unit Manager-V replied, "I know it was not on the bed but it is now." Surveyor # informed RN Unit Manager-V of the observation on 12/13/12 of Resident #6 in her wheelchair without the sensor cord being attached to the alarm box and Resident #6 self transferring herself on 12/13/12 into bed without staff knowledge as she had disengaged the tabs alarm. 2. Surveyor # reviewed Resident #1's medical record on 12/13/12 through 12/16/12. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/13/12 at 7:47 a.m., Surveyor # reviewed Resident #1's care card located in the binder at the nurses station dated 8/2/12. According to the care card Resident #1 is transferred with one person assist, has a tabs alarm in bed and a self releasing seat belt, and is continent of bowel and bladder. The falls plan of care with an original date of 6/3/11 and last reviewed on 9/25/12 includes approaches of 7/5/11 "Resident requests a seat belt able to self release." 3/12/12 "Sensor pad in bed." 4/17/12 "Sensor in w/c (wheelchair), 1/2 lap tray." 5/2/12 "Signage on lap tray to flip up" and 7/10/12 PT (physical therapy) picked up." a. On 4/15/12 at 2:00 a.m., Resident #1 had an unwitnessed fall. The change of condition SBAR (situation, background, assessment, request) Physician/NP (Nurse Practitioner)/PA (Physician Assistant) communication and progress note dated 4/15/12 documents under progress note, "At 0200 (2:00 a.m.) Res. (Resident) leaning forward in her chair, suddenly slid forward and onto her knees. States she "blacked out." Cran (cranial) checks initiated though resident did not hit head. Cran. check was negative." The interdisciplinary post fall review for date of fall of 4/15/12 documents under summary of interdisciplinary team, "Goal met/no injury WC (wheelchair) sensor in chair, half lap tray." The Facility continued to use the self releasing seatbelt (initiated on care plan on 7/5/11) in the wheelchair despite Resident #1 not connecting the seat belt properly. b. On 5/1/12 at 7:00 a.m. Resident #1 had an unwitnessed fall. The change of condition SBAR Physician/NP/PA communication and progress note dated 5/1/12 documents under nurses notes, "Res. (Resident) reported to writer & unit nurse that resident stated she fell to knees & got herself up into w/c." The nurses notes further documents, "Resident stated, 'I was leaning forward. My seat belt gave way. I fell to me knees. I guess I didn't have my seat belt on right.' Side tray not up & in place when writer asked about it resident stated, 'I forgot to put it up, there is too much to remember.' Writer attached seat belt properly, put tray up." The incident/accident investigation follow up questions dated 5/1/12 is circled "no" for if tabs alarm in use was alarm sounding. If no why? "Resident transfers self @ (at) x's (times) & doesn't ask staff to put alarm on." The interdisciplinary post fall review for date of fall of 5/1/12 documents under summary of interdisciplinary team, "change to alarmed seat belt trial if one available, signage to "put tray up." The Facility continued to use the self releasing seatbelt in the wheelchair despite Resident #1 not connecting the seat belt properly. The fall risk assessment dated [DATE] has a total score of "16." A total score of 10 or above represents high risk. c. On 7/10/12 at 6:30 a.m., Resident #1 had an unwitnessed fall. The interdisciplinary post fall review for date of fall of 7/10/12 documents under description of fall, "Resident had already picked herself off floor to w/c. When questioned resident stated she fell on floor while trying to get into bed from w/c." The summary of interdisciplinary team documents, "Res. states she went down to her knee." The Facility did not identify the root cause for the fall, did not determine if the sensor alarm or half lap tray was on, and did not implement interventions to help prevent further falls. The Facility continued to use the self releasing seatbelt in the wheelchair despite Resident #1 not connecting the seat belt properly. d. On 7/17/12 at 6:30 a.m., Resident #1 had an unwitnessed fall. The interdisciplinary post fall review for date of fall of 7/17/12 documents under description of fall, "Writer states "Resident was in her w/c sleeping and she fell on the floor. She wasn't wearing her seat belt. She states, 'I hit my (R) (right) knee on the ground.' Resident was found facing the bathroom door with legs straight out in front of her." Under summary of interdisciplinary team documents, "Despite staff continual reminding and discussing use of safety belt resident still chooses to not fasten seat belt." The Facility did not identify the root cause for the fall, did not determine if the sensor alarm or half lap tray was on, and did not implement interventions to help prevent further falls. The Facility continued to use the self releasing seatbelt in the wheelchair despite Resident #1 not connecting the seat belt properly and/or choosing not to fasten the seat belt. e. On 9/12/12 at 6:00 a.m., Resident #1 had an unwitnessed fall. The interdisciplinary post fall review for date of fall of 9/12/12 documents under description of fall, "Slid to floor while going to the bathroom. Small 25 cent circular area to back of pt. (patient) shoulder." Under summary of interdisciplinary team documents, "Encourage resident to ask for assistance." The Facility did not identify the root cause for the fall, did not determine if the sensor alarm or half lap tray was on, and did not implement interventions to help prevent further falls. Facility staff did not also assess and develop a toileting schedule to reduce the number of attempts at independent transfer. The fall risk assessment dated [DATE] has a total score of "17." A total score of 10 or above represents high risk. f. On 11/7/12 at 10:00 p.m., Resident #1 had an unwitnessed fall. The interdisciplinary post fall review for date of fall of 11/7/12 documents under description of fall, "found lying next to bed face down. Stated feet were slippery from lotion. Unable to describe what she was doing or how fall occurred. Stated 'evil forces sometimes push me.'" The summary of interdisciplinary team documents, "Poor safety awareness d/t (due to) total disregard of staff making her aware of bending to far forward in wc (wheelchair) and during self transfers as in this case." The Facility did not identify the root cause for the fall, did not determine if the sensor alarm was on, and did not implement interventions to help prevent further falls. g. On 12/3/12 at 2:00 a.m., Resident #1 had an unwitnessed fall. The incident/accident investigation follow up question dated 12/3/12 documents for the question what does resident say happened, "she felt herself going forward. Seat belt was not connected." The interdisciplinary post fall review for date of fall of 12/3/12 documents under description of fall, "Heard resident fall & crying out. Lying face down in front of w/c in her room. Head injury above (L) (left) eye. 1 cm (centimeter) abrasion surrounded by swelling. Able to bear weight. (R) (right) knee (L) shin tender. PERL (pupils equal reactive light)." Under summary of interdisciplinary team documents, "therapy also looking at alternative chair options." The Facility did not determine if the sensor alarm or half lap tray was on and continued to use the self releasing seatbelt in the wheelchair despite Resident #1 not connecting the seat belt properly. h. On 12/13/12 at 8:56 a.m. Surveyor # observed the call light outside Resident #1's flashing. On 12/13/12 at 8:58 a.m. Surveyor # entered Resident #1's bathroom with CNA (Certified Nursing Assistant)-U. When Surveyor # and CNA-U entered the bathroom, Resident #1 was standing next to the toilet holding onto the grab bar. CNA-U pulled Resident #1's pants up and then Resident #1 sat in her wheelchair. On 12/13/12 at 9:01 a.m., Surveyor # asked CNA-U if Resident #1 goes to the bathroom herself. CNA-U replied "yes" and explained that sometimes Resident #1 can pull her pants up herself and other times she will put the light on for assistance. CNA-U informed Surveyor # that Resident #1 is pretty independent and goes in and out of bed by herself. Surveyor # asked CNA-U if Resident #1 has a tabs alarm when she is in bed. CNA-U replied, "that's for when she is really sleepy" and explained this is when they use the tabs alarm because she has had falls. On 12/13/12 at 9:10 a.m. Surveyor # asked CNA-U if Resident #1 is able to attach her own seat belt. CNA-U replied "yes" and explained that Resident #1 wanted the seat belt because she leans forward when sitting in her wheelchair. Surveyor # asked CNA-U if the seat belt was alarmed. CNA-U replied that she wasn't sure. Surveyor # and CNA-U went into Resident #1's room to check the wheelchair. Surveyor # observed that Resident #1's seat belt was connected and there was a cord with a telephone type clip at the end under the wheelchair that was not attached to anything. i. On 12/13/12 at 12:28 p.m. Surveyor # observed Resident #1 sitting at a table in the dining room. Surveyor # observed the alarm cord is not attached to anything. j. On 12/17/12 at 7:37 a.m. Surveyor # observed Resident #1 sitting in her wheelchair leaning forward looking in a drawer. Resident #1 informed Surveyor # that she needed to get dressed because she had therapy. Surveyor # observed the alarm cord is hanging down and not connected to anything. On 12/17/12 at 11:37 a.m., Surveyor # spoke with RN (Registered Nurse) Unit Manager-V regarding Resident #1's falls. Surveyor # asked RN Unit Manger-V if Resident #1 has a tabs alarm in bed. RN Unit Manager-V replied, "Yes, but she doesn't spend much time in the bed?" Surveyor # then inquired if the seat belt was alarmed, are there any alarms on Resident #1's wheelchair, and is there suppose to be a sensor pad in bed. RN Unit Manager-V informed Surveyor # that Resident #1 doesn't have any alarms in her wheelchair, the seat belt is not alarmed, and Resident #1 is supposed to have a sensor pad in bed. Surveyor # asked when the interventions of the alarmed seat belt and the sensor pad in the wheelchair were discontinued as they appear on Resident #1's falls plan of care. RN Unit Manager-V informed Surveyor # that she would get back to Surveyor # . Surveyor # asked if the half lap tray was a current intervention as Surveyor # has not observed the half lap tray. RN Unit Manager-V informed Surveyor # that the lap tray is a current intervention however after Resident #1 fell on [DATE] therapy issued her a new wheelchair and they have not placed the lap tray back on. Surveyor # asked how Resident #1 is supposed to be transferred and can she transfer herself. RN Unit Manager-V replied, " I still have her as one assist" and explained that Resident #1 does transfer herself but staff is supposed to assist her. Surveyor # inquired why the Facility continues the intervention of the seat belt. RN Unit Manager-V explained to Surveyor # that Resident #1 requested the seat belt. Surveyor # informed RN Unit Manager-V that Surveyor # noted that during the falls Resident #1 did not have her seat belt on properly and was often going to the bathroom. Surveyor # informed RN Unit Manager-V that the Facility did not address the fact that the alarm was not an effective intervention, did not address Resident #1's toileting schedule, and was unable to locate a plan of how staff were going to monitor the seat belt. On 12/18/12 at 9:14 a.m., RN Unit Manager-V informed Surveyor # that Resident #1 never received an alarmed seat belt. Surveyor # asked what happened with the wheelchair sensor pad. RN Unit Manager-V informed Surveyor # that they took it off because Resident #1 had a seat belt. Surveyor # asked RN Unit Manager-V when the sensor pad was discontinued. RN Unit Manger-V replied, "I don't remember." On 12/18/12 at 9:29 a.m. Surveyor # informed Rehab Director-X that Sur

Based upon observation, interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable well-being of each resident. This is evidenced by the number and seriousness of the citations issued at this survey. Three deficiencies F309 (services to promote highest practicable well-being), F314 (services to prevent and treat pressure ulcers), and F323 (supervision to prevent accidents) (other than F490) identify immediate jeopardy at this survey. Two deficiencies F157 (notification of changes in resident condition) and F242 (resident self-determination of care) identify actual harm at the scope and severity of G level deficiencies (actual harm/isolated). * The facility administration failed to ensure that systems were in place so that residents receiving painful treatments for pressure ulcer care were properly assessed for pain and if indicated, properly provided with medication prior to the treatment to prevent pain and discomfort. Facility administration also failed to ensure that even when pain medication is administered it is monitored and assessed for effectiveness. In addition to F309 being identified as deficient practice at the level of immediate jeopardy; a second distinct example has also been identified related to pain experienced by a resident from a vascular ulcer when the facility administration failed to ensure that proper equipment such as wheelchairs and foot rests was made available to residents to allow for proper positioning and for positioning that did not cause harm and pain to residents with vascular ulcers. This example is identified as causing actual harm/isolated at a scope and severity of G. * The facility administration failed to ensure that systems were in place so that residents with pressure ulcers received proper assessment, monitoring and treatment based upon current standards of practice. The facility failed to ensure that residents did not develop facility acquired pressure ulcers. The facility administration also failed to ensure that care plan measures to prevent pressure ulcers from developing or deteriorating such as timely repositioning were carried out by facility staff. * The facility administration failed to develop a system so that residents who are at risk for falls or have actively fallen receive services to ensure safety. The facility failed to consistently assess behavior/fall trends and identify root causes for unwanted self-transfers. The facility did not consistently implement new interventions to prevent falls when past interventions had proven ineffective, and did not consistently implement care-planned approaches for preventing falls. In addition to the citations at the level of immediate jeopardy at this survey, two deficiencies, F157 (notification of changes in resident condition) and F242 (resident self-determination of care) were cited at the actual harm/isolated level (scope/severity = G). This deficient practice led to a resident receiving a painful treatment to a pressure ulcer once the "protective cap" (eschar) fell off. Staff did not notify and consult with the physician to ensure that proper treatment was provided to a pressure ulcer with changed characteristics. Additionally, these deficient practices lead to a resident experiencing severe psychosocial distress at the end stage of life when the resident expressed the desire to just lie down and facility staff did not respond to this simple request. In total, 9 deficiencies were cited during this complaint/self-report survey. This deficiency, at F490, has the potential to affect the residents in the facility with pain, pressure ulcer, falls/safety concerns as well as residents requiring physician consultation and residents who want to make choices in their care. The failure to ensure that the facility was administered in a manner that enabled it to use its resources in a manner that promoted the health and well-being of residents created a finding of immediate jeopardy, which began on 5/2/12. The facility Administrator, Director of Nursing and Corporate Clinical Director were notified of the immediate jeopardy on 12/18/12 at 3:14 pm. The immediate jeopardy was removed on 12/21/12. The deficient practice continues at a scope and severity of an E (potential for more than minimal harm that is not immediate jeopardy/pattern) as the facility needs to establish effective systems to address based upon policies and procedures and current standards of practice that lead to the immediate jeopardy citations, provide for continued monitoring for effectiveness of the immediate jeopardy removal plans and to achieve regulatory compliance with current deficiencies. Findings include: 1. The facility administration failed to ensure that systems were in place so that residents receiving painful treatments for pressure ulcer care were properly assessed for pain and if indicated, properly provided with medication prior to the treatment to prevent pain and discomfort. Facility administration also failed to ensure that even when pain medication is administered it is monitored and assessed for effectiveness. Following admission to the facility, Resident #7 developed a facility acquired pressure ulcer to her left heel. Resident #7 developed a "protective cap" (eschar) over her heel pressure ulcer, 95% of which came off on 12/13/12. The facility, however, continued treating the exposed raw tissue with Dakin's solution, which contains either a 0.5% or 0.25% sodium hypochlorite (bleach). Surveyor # observed this treatment on 12/13/12, which was done by a new nurse who was not familiar with the resident. Surveyor # observed that the nurse never looked at the resident's face while applying the treatment. During the treatment, while the nurse was scrubbing and scrubbing the heel, the resident grabbed the side bar and had an expression of "excruciating pain" as if she was "going through the roof." Surveyor # talked with the nurse and med tech and both stated that the resident had not been pre-medicated. The PM Nurse gave the Resident [MEDICATION NAME] on 12/14/12 at 8:45 p.m. - but the treatment was done on days. Nursing did not give [MEDICATION NAME] on 12/15/12 or 12/16/12 but did give [MEDICATION NAME] on 12/17/12 before the treatment at 2:30 PM since Surveyor # did speak with the manager earlier that day expressing her concern of how much pain the treatment seemed to cause the resident on 12/13/12. The facility pre-medicated the resident with [MEDICATION NAME] on 12/18/12. However, the nurse stated on 12/18/12 that even with pre-medication an hour before the treatment, the resident had excruciating pain. This created a finding of immediate jeopardy (Cross reference F309, scope/severity (s/s) - J, immediate jeopardy/isolated). 2. The facility administration failed to ensure that systems were in place so that residents with pressure ulcers received proper assessment, monitoring and treatment based upon current standards of practice. The facility failed to ensure that residents did not develop facility acquired pressure ulcers. The facility administration also failed to ensure that care plan measures to prevent pressure ulcers from developing or deteriorating such as timely repositioning were carried out by facility staff. Resident #7 was admitted to the facility on [DATE] with her left leg in an immobilizer and [DIAGNOSES REDACTED]. However, the facility did place the resident on an air mattress and directed staff to elevate her heels with pillows. On 4/15/12, staff noticed that Resident #7's heels were mushy (skin soft) and began using skin prep without an order and EZ boots. On 12/18/12 the hospice nurse assessed this resident - and documented that due to the resident's foot drop, the boot she had been wearing since April did not provide pressure relief/ reduction since her heel didn ' t fit in the boot correctly. On 5/2/12, a note suggests that a nurse tried contacting the physician regarding an open area to the resident's left heel. There is no evidence that the physician ever responded to this; there was no change in treatment or the resident's care plan until 5/9/12 when an order was obtained for [MEDICATION NAME]. From 5/9 until 7/10/12 there were no measurements of the pressure ulcer on the heel. On 7/10/12, the area was measured as 2 x 4 cm. and unstageable. The facility went back to using skin prep but made no other changes to the resident's care plan. Surveyor # noted that documentation regarding the stage 4 pressure ulcer was limited until September. On 9/4/12, notes indicate that Resident #7's left heel did smell foul and that the nurse spoke with hospice. On 9/10/12 notes indicate that the heel ulcer would be cultured. This was canceled the following day and not followed up on. A note on 9/11/12 also indicates that there was no odor or exudate present. On 9/21/12 the resident was diaphoretic and had labored breathing. At the insistence of the resident's husband, the resident was sent to the hospital, where her heel ulcer was noted to be foul smelling with pus, measuring 3 x 4 x 1 cm. The resident was diagnosed with [REDACTED]. This created a finding of immediate jeopardy (Cross reference F314, scope/severity (s/s) - J, immediate jeopardy/isolated). 3. The facility administration failed to develop a system so that residents who are at risk for falls or have actively fallen receive services to ensure safety. The facility failed to consistently assess behavior/fall trends and identify root causes for unwanted self-transfers. The facility did not consistently implement new interventions to prevent falls when past interventions had proven ineffective, and did not consistently implement care-planned approaches for preventing falls. Example 1: Resident #6 has had nine falls since 4/16/12. During seven of the falls (6/9/12, 7/13/12, 7/22/12, 8/25/12, 9/30/12, 11/5/12, and 11/25/12) the alarms were disconnected. On 6/9/12 and 8/25/12 Resident #6 indicated that she was going to the bathroom. Staff did not assess and develop a toileting schedule to reduce the number of attempts at independent transfer. Staff continued to rely on alarms even though these fall interventions were proven to be ineffective because the resident could disconnect them. On 12/13/12, Resident #6 was observed without the sensor alarm on her bed and wheelchair. Example 2: Resident #1 who is assessed as high risk for falls has had 7 falls since 4/15/12 (4/15/12, 5/1/12, 7/10/12, 7/17/12, 9/12/12, 11/7/12, and 12/3/12). The facility did not ensure fall prevention strategies listed on Resident #1's care plan were current. The facility did not ensure fall prevention strategies identified by the interdisciplinary team were acted upon, such as the use of an alarmed seat belt. The facility did not evaluate the effectiveness of current facility fall prevention interventions such as the effectiveness of the seat belt. The facility did not identify the root causes for Resident #1's falls. On 12/3/12, Resident #1 sustained a head injury above the left eye consisting of a 1 cm (centimeter) abrasion surrounded by swelling. Example 3: Resident #5 experienced three falls since 4/14/12 with the last fall on 10/2/12 resulting in a four by three centimeter hematoma to the right side of her head. Revisions were not consistently made to the plan of care to prevent the same or similar types of falls from re-occurring. Example 4: Resident #4 was assessed to be at high risk for falls and is to have an alarm on at all times while she is in the bed or wheelchair. On 12/12 and 12/13/12, Resident #4 was observed without an alarm while she was in bed and in her wheelchair. Example 5: Resident #3 had two falls a week apart. After the first fall the Facility's plan was to check the toileting schedule for Resident #3. The Facility did not follow through on this planned fall prevention strategy. Resident #3 fell a week later, fracturing her wrist which required surgery. Example 6: Resident #2 had 4 falls from 8/2/12 to 8/30/12. Facility staff did not investigate circumstances/root causes of Resident #2's falls in an effort to prevent future falls. On the fall 8/30/12, staff had not connected Resident #2's alarm. On 12/12/12, Surveyor # observed a thick gray cushion in Resident #2's wheelchair, but no Dycem or wedge cushion as per the IDT 8/29/12 fall prevention recommendation. This created a finding of immediate jeopardy (Cross reference F323, scope/severity (s/s) - K, immediate jeopardy/pattern). 4. Administrative staff did not ensure that systems were in place to make certain that residents received appropriate care and services as demonstrated by the following additional deficiencies: * F157 - s/s G. The facility did not ensure that a resident's physician was immediately contacted and consulted with when the resident demonstrated a change in medical condition requiring a need to alter treatment. (Cross reference F157) * F164 - s/s E. The facility did not ensure that the privacy of individual residents was maintained. (Cross reference F164) * F225 - s/s D. The facility did not ensure that an injury of unknown origin was thoroughly investigated and reported to the state agency. (Cross reference F225) * F242 - s/s G. The facility did not ensure that residents were allowed the ability to determine and dictate their care preferences. (Cross reference F242) * F280 - s/s E. The facility did not ensure that care plans were reviewed and revised to reflect current care needs. (Cross reference F280) The failure to administer the facility in a manner that enabled it to use its resources effectively and efficiently in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident created a finding of immediate jeopardy. The immediate jeopardy was removed on 12/21/12 at which time the facility's corporate representative established a system to: 1. Complete a systematic review of the facility's system for addressing falls, pain management and pressure ulcer care. The corporation developed action plans and initiated the plans to address strengths and areas of opportunity for each system. 2. A plan was established at the corporate level to ensure that the facility administration achieves regulatory compliance and maintains compliances with each system. 3. The Regional Clinical Director and Regional Vice President of operations will review the implemented action plans for pain, skin and falls with the director of nursing and the administrator on a weekly basis. The results of the weekly meetings will be shared with the Division Vice President of Clinical Services and the Division Presidents until sufficient progress has been achieved. 4. An audit system has been established to include review of documentation along with visual audits of documented assessments of care. 5. A system has been established to discuss the education needs of the facility. 6. A coordinated meeting was established between administration and outside agencies providing cares for example hospice and a communication tool has been established ensure consistent communication. 7. The Regional Quality Assurance Performance Committee will meet on a monthly basis and will review the facility's performance improvement and determine if further action is warranted and whether the facility is maintaining sustained compliance.

Based on observations, interviews and record review, facility staff did not provide necessary care and services to help 2 of 7 residents reviewed for quality of care to attain or maintain their highest practicable level of physical well-being. * Staff did not pre-medicate Resident #7 before a painful pressure ulcer treatment with Dakin's solution, nor did they receive in a timely manner a new order for a different treatment that would be less painful once the characteristics of the ulcer changed (the eschar cap fell off of Resident #7's left heel, exposing raw tissue and a Stage 3 pressure ulcer.) The Dakins solution treatment staff utilized from 12/13/12 through 12/18/12 was a treatment meant to help dry the eschar cap in an effort to get it to fall off so healing could begin. Because it contains hypochlorite (bleach), it can be very painful to new, exposed skin. Once the eschar cap fell off, the treatment needed to be changed to reflect the current status of the ulcer. The treatment was very painful for Resident #7 as observed on 12/13/12 by Surveyor # . On 12/18/12, the RN MGR (Registered Nurse Manager)-C did the treatment and reported Resident #7 had significant pain with the treatment even after Resident #7 was pre-medicated with [MEDICATION NAME]. Staff had also performed the Dakins treatment on 12/14/12, 12/15/12, 12/16/12 and 12/17/12. (On 12/17/12, staff did pre-medicate Resident #7 after Surveyor # informed RN MGR-C of how much pain Resident #7 was in on 12/13 during the treatment and notes state Resident #7 had "some discomfort"). Pain assessments were not conducted for what should have been known to be a painful experience (pressure ulcer treatment to a Stage 3 wound). Facility staff did not attempt pain management strategies to try to minimize Resident #7's recurring, episodic excruciating pain related to a situation where pain could be anticipated (treatment of [REDACTED]. Resident #7 was subjected to a treatment facility staff should have known was painful on 12/13/12 through 12/16/12 with no premedication, and was significantly painful on 12/18/12 even after premedication with [MEDICATION NAME]. This created a finding of Immediate Jeopardy beginning on 12/13/12. NHA (Nursing Home Administrator)-A was informed of the Immediate Jeopardy on 12/18/12 at 3:14 p.m. The Immediate Jeopardy was removed on 12/21/12. The deficient practice remains ongoing as the Quality Assurance Committee will continue reviewing compliance of the pain management protocol on a monthly basis. The Director of Nurses/designee will continue with daily audits of the 24 hour report checking for any change of condition related to pain in the resident with a pressure ulcer. The Interdisciplinary Team will audit/review weekly at the Risk Review Meeting those residents with pressure ulcers to ensure the appropriate pain management program is in place. The deficient practice continues at a scope and severity level of G (actual harm that is not immediate jeopardy /isolated) for 1 of 1 residents reviewed with regards to the provision of care and services for a Resident (Resident #3) with a vascular ulcer on her left toe. Resident #3 had a vascular ulcer on her left toe that was getting larger (and a pressure ulcer on her left heel -cross reference F314). Surveyor # made multiple observations of Resident #3 in her wheelchair with only a left foot rest attached to the chair. Resident #3 wore a blue pressure relief boot on her left foot and would frequently place her right foot on top of her left foot- sometimes over the toe area of her left foot, sometimes more over the arch-area which would press down on the left heel- since there was no right foot pedal on Resident #3's wheelchair for Resident #3 to rest her right foot. The deterioration in the status of Resident #3's vascular ulcer caused increased pain to Resident #3. Findings include: 1. Surveyor # reviewed Resident #7's medical record on 12/12/12 - 12/18/12. On 12/12/12, RN MGR (Registered Nurse Manger)-C stated she measures Residents' pressure ulcers once a week, most recently done 12/11/12, and she has those Weekly Pressure Ulcer Records in her office. Resident #7's record indicates the following: Resident #7 was admitted to the facility on [DATE] with major [DIAGNOSES REDACTED]. Nurses' Notes document staff identified a "soft left heel" on Resident #7 on 4/15/12 and a "decubitus ulcer- left heel on 4/25/12. RN MGR-C's Weekly Pressure Ulcer Records identify Resident #7 as having a facility acquired unstageable pressure ulcer on her left heel that was with a date of onset of May 2, 2012. Numerous Nurses' Notes, Weekly skin checks, Weekly Pressure Ulcer Reports, Hyperbaric Wound Care Associates consultant reports and hospital records from 9/21-9/25/12 document the presence of an unstageable pressure ulcer on Resident #7's left heel. For specifics, please see F314. On 12/13/12, RN-C provided Surveyor # with Resident #7's Weekly Pressure Ulcer Records, which indicate on 12/11/12, the most recent measurements, Resident #7's left heel pressure ulcer measured 4.0 x 5.0 cm., had scant exudate, foul odor present, wound bed black, pain-no, treatment-Santyl. On 12/13/12 at 8:30 a.m., Surveyor # observed HCNA (Hospice Certified Nursing Assistant)-N provide morning cares for Resident #7. RN-Q, Staff Development, was also present for the start of the cares. After pulling back Resident #7's covers, HCNA-N carefully removed Resident #7's EZ boot from her left foot. HCNA-N stated quietly to Surveyor # that the bad odor was coming from Resident #7's foot, and he pointed to Resident #7's left heel. The boot had stains in the heel section. Resident #7's left foot was wrapped in gauze. HCNA-N set Resident #7's foot on the sheet on her bed as she lay in bed. A short time later, HCNA-N moved Resident #7's left foot and there was a half-dollar-sized area of serosanguinous drainage on the sheet that had seeped through the dressing. Every time HCNA-N would gently move Resident #7's left foot she would grimace or wince. HCNA-N completed morning cares, transferred Resident #7 to her Broda chair with assist of facility CNA-E, and took her out to the dining room. On 12/13/12 at 10:15 a.m., Surveyor # observed RN-G and CNA (Certified Nursing Assistant)-D transfer Resident #7 to her bed from her wheelchair using a Hoyer lift. Every time staff touched or moved Resident #7's left lower leg, she winced in pain but made no sound. RN-G removed a small, pink stuffed bunny Resident #7 was holding and set it on the dresser. Resident #7's physician's orders [REDACTED]. This is scheduled in the TAR (Treatment Administration Record) on day shift. On 12/13/12 on 10:15 a.m., Surveyor # observed RN-G perform Resident #7's left heel treatment once Resident #7 was transferred back to bed. Any time Resident #7's left foot was touched or moved during the transfer, and when RN-G removed Resident #7's left heel boot and dressing, Resident #7 would wince and grimace, appearing to be in pain. After the boot and dressing were removed, Surveyor # observed Resident #7's pressure ulcer to be approximately 3.0 x 4.0 x 1.0 cm., mostly bright red, some bleeding, with a small amount of eschar on one side of the ulcer. The old gauze dressing had dried and fresh blood on it. The eschar cap that had covered the pressure ulcer had come off sometime between 12/11/12 when the wound was assessed and measured and this 12/13/12 treatment observation. While Resident #7 winced every time her left foot was moved, when RN-G cleansed the wound with Dakin's solution on a piece of gauze, Resident #7 arched her back- looking up at the ceiling, gritted her teeth, clenched the bottom bed sheet with both hands, and her eyes became moist. Resident #7 did not make a sound. While a treatment to a fresh Stage 3 pressure ulcer with even normal saline is often very painful on the raw tissue, Dakin's solution is hypochlorite, or a weak bleach solution which states "For External Use Only" on the product information. CNA-D was standing near Resident #7's foot, holding Resident #7's foot up so RN-G could do the treatment. RN-G was next to CNA-D, closer to Resident #7's foot and the foot of the bed than CNA-D. CNA-D was in-between RN-G and Resident #7's head and the head of the bed. RN-G would have to lean forward and look around CNA-D for RN-G to observe Resident #7's facial expressions. As Surveyor # observed Resident #7's facial expressions and body language expressing great pain during the treatment, Surveyor # noted RN-G and CNA-D were focused on Resident #7's foot and they did not look at Resident #7 other than her left foot. Surveyor # asked RN-G if Resident #7 had been pre-medicated for pain prior to the treatment. RN-G stated she did not know as she was not passing medications that day, a med. tech. (medication technician) was passing pills. Surveyor # observed Resident #7 exhibit facial expressions and body language indicating excruciating pain while RN-G cleansed the wound with Dakin's solution and gauze, applied Santyl to gauze and then placed that gauze in the pressure ulcer, covered that with more dry gauze, then wrapped Resident #7's foot with Kerlix. Surveyor # observed a laminated "Faces Pain Scale" on both the bulletin board on the wall for Resident #7 and the bulletin board for her roommate, and Resident #7's facial expressions equaled a pain scale rating of "9-10." Surveyor # stated Resident #7 seemed to be in a lot of pain. RN-G completed the treatment and dressing before looking around CNA-D at Resident #7's face and the rest of her body for the first time since she began the treatment. CNA-D looked at Resident #7's face for the first time at that time, too. Once RN-G covered Resident #7's heel with gauze and started wrapping it with Kerlix, Resident #7 somewhat lessened her facial expressions of pain (clenched teeth/jaw, eyes wide open staring at ceiling), relaxed her body which had been tense with somewhat arched back, and let go of her grasp of the sheets/ bedding she had been clutching during the treatment, but Resident #7 did continue to have a less intense wince/ grimace when her foot was moved. After the treatment to Resident #7's left heel, RN-G and CNA-D repositioned Resident #7 on her side and RN-G performed a treatment to an almost-healed pressure ulcer on her buttock. When RN-G had just finished the treatments and CNA-D went to get the Hoyer lift to transfer Resident #7 back into her wheelchair, Resident #7's family member knocked on the door and entered the room, asking what was taking so long, stating he had to get going soon. The family member then went over to the dresser, picked up the pink bunny and gave it to Resident #7, saying the bunny comforts Resident #7 and he has asked staff to give it to her to hold (which CNA-E did at the completion of morning cares earlier). Then MT (Medication Technician)-H entered Resident #7's room with her morning medications. When asked by Surveyor # if Resident #7 had received any pain medication prior to the treatment, MT-H stated he did not give Resident #7 any pain medication that morning, but did just remove her old [MEDICATION NAME] and apply a new pain patch on her shoulder/chest area (after the treatment). Surveyor # informed MT-H Resident #7 seemed to be in excruciating pain during the treatment of [REDACTED].#7's treatment and when he sees Resident #7 out in the lounge area, she doesn't seem to be in pain. Surveyor # reviewed Resident #7's December 2012 Physician order [REDACTED]. (micrograms per hour) [MEDICATION NAME] to be changed every 3 days. The [MEDICATION NAME] is the only scheduled pain medication Resident #7 receives. On 12/17/12 at approximately 10:00 a.m., Surveyor # reviewed Resident #7's December 2012 PRN (as needed) MAR and noted the only PRN pain medication ([MEDICATION NAME] sulfate 10 mg./ 0.5 ml. to be given every hour as needed by mouth or sublingual) given was on evening shift. Resident #7 received the [MEDICATION NAME] on PM shift on 12/3 at 9:00 p.m., 12/11 at 7:50 p.m., 12/14 at 8:45 p.m., even though the treatment was done on day shift. Surveyor # did not see Tylenol or any other pain medication listed on the PRN MAR. On 12/18/12, Surveyor # checked the MAR with LPN-R who confirmed Resident #7 did not have Tylenol or other prn pain medications listed on the MAR. LPN-R stated that was unusual since most if not all residents have standing orders for Tylenol for pain or fever. On 12/17/12 at approximately 8:30 a.m., Surveyor # observed a Nurses' Note dated 12/13/12 at 2:30 p.m. from RN-G which stated, "Pt. (patient) had some facial grimacing during treatment to left heel but denied pain appeared to feel better after wound care was completed..." According to the medical record, Resident #7 received Dakin ' s treatment each day 12/13 through 12/17/12. On 12/18/12 at 9:15 a.m., Surveyor # interviewed RN MGR-C, who stated that based on the observations of pain with treatment shared on 12/17/12 by Surveyor #1672, she had the unit nurse, LPN (Licensed Practical Nurse)-R, give Resident #7 [MEDICATION NAME] an hour prior to the treatment on 12/17/12. RN-C stated even with the [MEDICATION NAME], Resident #7 was in significant pain during the treatment, and even had pain with positioning -her facial expressions showed she was in pain. Surveyor # asked RN-C to rate Resident #7's pain based on her facial expressions, but RN-C stated she did not have a pain scale in front of her so she couldn't give a number. Surveyor # noted there are laminated facial pain scales on each resident ' s bulletin board on that unit, and would she say Resident #7 had a little pain, some pain, or a lot of pain. RN-C stated during the treatment, probably a lot. RN-C stated they will look at changing Dakin's to normal saline, since Resident #7 "really cringed" when the Dakin's was applied. RN-C stated since Surveyor # brought it to their attention on 12/17 that Resident #7 was having pain during the treatment now that the eschar cap is mostly off, they pre-medicated Resident #7 with [MEDICATION NAME] an hour or so before treatment on 12/17 and 12/18, and they will continue to do so as long as Resident #7 seems to be experiencing pain during treatment. On 12/17/12 at 2:30 p.m., RN-I documented in the nurses' notes: Resident given MSO4 ([MEDICATION NAME]) per orders prior to dressing change at 1:00 p.m. Dressing change done at 1:45 p.m. per orders. Resident expressed some discomfort during treatment but denied pain afterwards. Will continue to monitor. (Resident #7 had the order for [MEDICATION NAME] since admission to hospice.) ASSESSMENTS AND ORDER CHANGES Surveyor # reviewed Pain Evaluations completed for Resident #7. Pain Evaluations were conducted on admission 4/2/12 for Resident #7, and also on 6/28/12, 7/20/12, 9/25/12, and most recently 10/23/12. Resident #7's Initial Pain Evaluation is the only Evaluation that identifies Resident #7's pain management goal- which is 0-2 on a scale of 0-10, with 0 being "no hurt" and 10 being "hurts worst." Surveyor # reviewed Resident #7's Pain Care Plan dated 9/26/12 which states Resident #7 has potential for pain/discomfort related to joint pain, skin ulcer butt/heel," and chronic disease process. The Goals for 1/23/13 are: Resident will have reduced pain as measured by verbal expressions and/or decrease in behaviors associated with pain; resident will have increased function/ ADL (activities of daily living) abilities associated with decreased pain; resident will verbally express increased satisfaction with pain control; resident will continue to be pain free; PRN [MEDICATION NAME] will provide acceptable pain relief. Approaches include: positioning support; relaxation; administer [MEDICATION NAME] as ordered; see physician's orders [REDACTED]. (Resident #7 enrolled in hospice in July 2012). On 12/17/12 at 8:50 a.m., Surveyor # interviewed RN-MGR-C, asking if she or the hospice wound nurse had assessed Resident #7's left heel ulcer and pain with treatment (Surveyor # had not observed any documentation regarding Resident #7's ulcer by hospice or facility staff after 12/13/12, when RN-G noted Resident #7 grimaced during the treatment, but did not note the eschar cap was mostly off.) RN-C stated she did not know if hospice had been in, but she had not seen the wound. Surveyor # shared the observations from 12/13/12- that most of the eschar "cap" had come off Resident #7's left heel, and most of the wound base was open, red and raw-looking, and Resident #7 appeared to be in great pain during the treatment on 12/13/12. Surveyor # noted the Dakin's solution was to be used while the eschar cap was on, but since most of the eschar cap was off as of at least 12/13/12 when Surveyor # saw it, Surveyor questioned RN-C if facility or hospice staff contacted the MD for a more appropriate treatment. RN-C stated she would look into it. On 12/18/12 at 9:15 a.m., Surveyor # interviewed RN MGR-C, asking if Resident #7's MD had been informed the eschar cap was off, if the MD wanted a new treatment for [REDACTED]. RN-C stated they had not called Resident #7's MD yet as she just assessed Resident #7's left heel ulcer based on the observations shared by Surveyor # on 12/17/12 regarding Resident #7's pain with treatment. RN-C stated that the previous week, on 12/11/12, she did not see Resident #7's pressure ulcer, and when she last saw it on 12/4/12, the eschar cap was still on Resident #7's left heel and the Dakin's treatment was appropriate. RN-C stated she first learned most of the eschar cap was off when Surveyor # informed her of that on 12/17/12. RN-C stated neither the regular hospice nurse nor hospice wound nurse had been in to see the wound since Surveyor # observed the cap off Resident #7's heel on 12/13/12. RN-C stated she was going to call them again that day, because she had expected them the past Thursday. RN-C stated they will look at changing Dakin's to normal saline, since Resident #7 "really cringed" when the Dakin's was applied. RN-C stated Resident #7's left heel pressure ulcer is now a stage 3, measuring 2.8 x 4.0 x 1.0 cm., with a red and yellow wound base, purulent drainage with odor was present, 90% granulation tissue, 10% slough. RN-C stated she thought the EZ boot also had a bad odor, and she threw it out and obtained a new one just like the previous one. On 12/18/12 at 10:03 a.m., RN-C called the hospice agency and left a message for hospice RN-P to call her back, explaining hospice would then call the MD. RN-C stated she really wants to talk with hospice since "even with the [MEDICATION NAME], it was not effective today for pain relief with that treatment. The Dakin's on (Resident #7)'s raw skin is causing her a lot of pain. We need to DC (discontinue) the Dakin's, get a new treatment, and get pain meds. She's having a lot more pain, raw tissue-that Dakin's would hurt now that the cap is off. They (hospice) need to get her something stronger- she has PRN Tylenol and [MEDICATION NAME]" (as RN-C looked at Resident #7's monthly orders). On 12/18/12 at 10:15 a.m., Surveyor # called hospice RN-P who stated she was unaware until a few minutes earlier when she spoke with RN-C by phone that Resident #7's eschar cap was mostly off her left heel. RN-P stated nursing home staff does not have to wait for hospice to call the MD, noting if there is an urgent need or after hours, that would cause an unnecessary delay. RN-P stated since they were unaware the cap had fallen off, they did not update the MD or obtain a new treatment order. When Surveyor # noted facility RN-C stated she was waiting for the hospice wound nurse to assess Resident #7's heel, RN-P stated until the cap came off, there was no need for the wound nurse to assess Resident #7's left heel, the cap was on the last time she saw the wound (12/11) and hospice staff was not informed until that morning (12/18) the cap had come off. RN-P stated "if the eschar cap is off, the treatment needs to be changed since the Dakin's is no longer appropriate- it would hurt. The treatment is probably painful now if the cap is off, which was the goal so healing could start, but the eschar cap was covering other sensitive tissue. With that gone, it would be painful...I hope they at least gave her the [MEDICATION NAME] before the treatment" (which they did not until 12/17/12). On 12/18/12, Surveyor # reviewed the Nurses' Note regarding Resident #7's left heel ulcer treatment done on 12/17/12, after she was pre-medicated with [MEDICATION NAME] for the first time (pre-treatment) and it states: Resident given MSO4 ([MEDICATION NAME]) per orders prior to dressing change at 1:00 p.m. Dressing change done at 1:45 p.m. per orders. Resident expressed some discomfort during treatment but denied pain afterwards. Will continue to monitor. On 12/18/12 at 10:30 a.m. and 12:50 p.m., Surveyors # and # asked DON (Director of Nursing)-B and NHA (Nursing Home Administrator)-A if there was any additional information regarding pain management for Resident #7's pressure ulcer. DON-B provided Surveyor # with the facility's Pain Management Policy, revision date August 2012. The Pain Management Policy states under Evaluation of Pain, "Best Practice, All staff should inquire if resident is comfortable or uncomfortable during each interaction. Observe for any signs or symptoms of pain or discomfort....For those residents who screen positive or "trigger" on the MDS, conduct an in-depth evaluation of their pain, including such things as the intensity and characteristics of pain, and effectiveness of prior treatments. You also have to do an in-depth evaluation any time the resident has a new complaint of pain or when you suspect pain may be present... On 12/18/12 at approximately 1:15 p.m., Surveyor # returned to Resident #7's unit to see if any changes had been made to Resident #7's left heel pressure ulcer treatment. Surveyor # reviewed a hospice Progress Note dated 12/18/12 written by hospice RN-P stating she had received a call that morning asking her to assess Resident #7's pressure ulcer and pain related to wound. Upon arrival, RN-P asked facility LPN-R to administer [MEDICATION NAME] 10 mg. prior to wound care for comfort. Hospice wound care RN-O assisted with the treatment and she also assessed the ulcer. New orders were approved by Resident #7's MD to discontinue the current wound treatment and to discontinue the pressure relief boots (Resident #7's foot drop causes heel to not fit in boot properly- boot does not provide pressure relief). Staff are now to pre-medicate Resident #7 with 10 mg. MSO4 ([MEDICATION NAME]) 15 minutes prior to dressing change. The new treatment to the left heel Stage 3 pressure ulcer is: normal saline wash, pat dry, apply skin prep to peri-wound with a 2 inch border. Apply [MEDICATION NAME] powder to wound bed followed by Santyl. Cover with 4 x 4's and secure with Kerlix. Change twice a day. No further information was provided. The failure to provide care to prevent recurring, episodic excruciating pain created a finding of immediate jeopardy. The Immediate Jeopardy was removed on 12/21/12 when: * The facility reassessed Resident #7 to determine necessary interventions for pain control. New orders were obtained for pain control prior to treatment on pressure area of left heel. Treatment orders has been reviewed and new orders received. Care plan and care kardex have been updated to reflect the needs of the resident. * The facility completed Pain Assessments on other residents with pressure areas. Orders were received where appropriate for additional pain control measures during treatment. Treatment orders were reviewed for each resident with a pressure ulcer to ensure the appropriate treatment has been implemented. * The facility's pain management policy and procedure was reviewed and consists of: Pain assessments are completed for all residents with pressure ulcers on admission, quarterly, annually and with any significant change in condition or new onset of pain. Pain intensity and pain relief will be evaluated and re-evaluated at regular intervals. These evaluations will be used by the Interdisciplinary Team (IDT) to decide the appropriate therapeutic intervention, which may include pharmacological and non-pharmacological techniques. Any resident report of inadequate pain control or identified with a new onset of pain, displays new signs or symptoms of pain or identified through the Resident Assessment Instrument (RAI) process or otherwise will have a full evaluation of pain. Following the pain evaluation, the physician will be notified of the findings and any new orders received will be implemented. Each resident identified for pain will have a pain management care plan with individualized interventions for individualized pain management. The Resident Care Specialist care Kardex will be updated to reflect the need of the resident. The Licensed Nurse will implement a Medication Administration Record for documentation of pain, interventions and outcome for all pain medication. The Licensed Nurse will communicate any new onset or change of resident pain or change in resident pain through the 24 hour report process. At any time through the process of pain management, the Interdisciplinary team may conduct an at-Risk Review Meeting on the Resident, in conjunction with other Risk areas reviewed. The Medical Director and the Quality Assurance Committee reviewed the above facility policy with no additional changes made to the above. * Inservice for licensed staff was conducted regarding pain assessments of the resident with pressure ulcer was conducted through 12/21/12, with no licensed staff able to work until they have completed this training. * The Quality Assurance Committee will continue to review the pain management protocol compliance monthly. The Director of Nurses/designee will daily audit the 24 hour report checking for any change of condition related to pain in the resident with a pressure ulcer. The Interdisciplinary Team will audit/review weekly at the Risk Review Meeting those residents with pressure ulcers to ensure the appropriate pain management program is in place. Recommendations will be made as necessary to ensure sustained compliance with the pain management protocol. Continued noncompliance at F309 is evidenced by the following: 2. Surveyor # reviewed Resident #3's medical record from 12/13/12- 12/18/12. The record reveals Resident #3 was [AGE] years old, admitted to the facility on [DATE] with major [DIAGNOSES REDACTED]. Resident #3 returned to the facility on [DATE]. Surveyor # reviewed Resident #3's Admission Nursing assessment dated [DATE] indicating Resident #3 has positive pedal pulses and trace bilateral pedal [MEDICAL CONDITION]. Surveyor # observed a physician's telephone order dated 8/15/12 stating: "Single layer tubi grips BLE (bilateral lower extremities) for [MEDICAL CONDITION] and elevate legs as much as possible." Surveyor # reviewed Resident #3's CNA (Certified Nursing Assistant) Care Card originally dated 7/23/12 with updates in August, October and December. The Care Card had an intervention to elevate Resident #3's right arm on a pillow after she broke her wrist on 8/11/12 (cross reference F323) but it makes no mention of elevating Resident #3's legs as much as possible. Surveyor # reviewed a Change of Condition SBAR Physician Communication and Progress Note dated 12/3/12 which states Resident #3 has increased pain to her left leg, noting Resident #3 moaning almost continually and has an open area on her left inner leg/knee, a black area to left heel and dry, black eschar to outer aspect of left great toe. (Resident #3's [MEDICATION NAME] was increased.) Surveyor # reviewed a "Non-pressure Skin Condition Record" dated 12/4/12 showing Resident #3 developed a venous/stasis ulcer on her left big toe on 12/4/12 measuring 2.0 x 0.5. The wound bed is black, no exudate, no pain. MD informed, treat with skin prep. The Non-pressure Skin Condition Record shows on 12/11/12, Resident #3's venous/stasis ulcer measured 3.0 x 1.8; staff note the wound has deteriorated and she has an appointment at the wound clinic. On 12/12/12 at 2:50 p.m., Surveyor # interviewed RN MGR (Registered Nurse Manager)-C who stated Resident #3 had been seen at the Wound Clinic that day since her wounds were not improving. (Resident #3 also had a pressure ulcer on her left heel- Cross reference F314 and another venous/stasis ulcer on her left thigh). On 12/13/12 at 7:26 a.m., Surveyor # observed Resident #3 sitting in her wheel chair in the TV lounge area near the dining room and nurses' station. Resident #3's left foot was in a blue boot, resting on the foot rest/pedal of the wheelchair. There was no right foot pedal on Resident #3's wheel chair. Resident #3 wore a tan gripper sock on her right foot. Surveyor # made numerous observations of Resident #3 on 12/13/12 from 7:26 a.m. to 8:05 a.m. when Resident #3 was moved to a table in the dining room. During that time, Surveyor # observed Resident #3 crossing her lower right leg over her left leg and placing her right foot on top of her left foot, since there was no foot pedal on the Resident #3's wheel chair for her to rest her right foot. Sometimes, Resident #3's right foot rested on top of the toe area of her left foot, including resting on top of her left great toe. Sometimes, Resident #3's right foot slipped down and rested over the arch of her left foot, which due to the angle of the foot pedal, put increased pressure on Resident #3's left heel which was in a boot but pressed against the metal foot pedal. On 12/13/12 from 9:30 a.m. to 9:50 a.m., Surveyor # again made many observations of Resident #3 sitting in her wheel chair in the TV lounge area. Resident #3 would place her right foot on top of her left foot toe area since there was no right foot pedal on the wheelchair, then after a while, her right foot would slip down over the arch area of her left foot, then eventually Resident #3's right foot would slip off her left foot all together, and she would repeat the process. Sometimes, Resident #3's left foot would slip partially off or all the way off the foot pedal, too. Staff at times, would then try to reposition Resident #3's left foot back on the pedal when they noticed it. On 12/13/12 at 9:50 a.m., Surveyor # observed RN (Registered Nurse)-G take Resident #3 from the TV lounge back to her room to do the treatment to her ulcers. Resident #3 winced when RN-G removed her gripper sock from her left foot. Surveyor # observed Resident #3's left great toe was half red and half black and brown surrounded by by a red area. RN-G applied skin prep to Resident #7's left great toe and put her gripper sock back on. When RN-G was done with the left toe and heel treatments, Resident #3 asked if she could lay down for a nap. (Cross reference F242). RN-G stated she would get one of the CNAs to assist her to bed, and started taking Resident #3 back to the TV lounge. Surveyor # asked RN-G if Resident #3 had a wheelchair foot pedal for her right foot. RN-G made

Based on observation, interviews and record reviews, facility staff did not prevent nor provide treatment and services to promote healing for 2 of 3 residents identified with pressure ulcers. Resident #7 was admitted to the facility on [DATE] and developed a facility-acquired pressure ulcer on her left heel on 4/25/12, after her heel was noted to be "soft" on 4/15/12. Staff did not get physician orders [REDACTED]. Staff did not measure or assess Resident #7's left heel, right buttock or left buttock ulcers weekly, nor did they conduct weekly skin checks on bath days or do daily diabetic foot exams. On 9/21/12, Resident #7 was sent to the hospital where the ulcer was noted to be foul smelling with pus, and was diagnosed as [MEDICAL CONDITION] and possible osteo[DIAGNOSES REDACTED]. The Weekly Pressure Ulcer Record noted the heel ulcer to have foul smelling, purulent drainage on 9/18/12 (not noted on 9/11/12), yet there was no physician notification or further documentation regarding the condition of the ulcer prior to Resident #7 being sent to the hospital. While Surveyor # observed Resident #7's pressure ulcer to be mostly without the eschar "cap" on 12/13/12, Resident #7's physician was not notified until 12/18/12 that the cap was mostly gone and the treatment needed to be changed. (Continuing the treatment meant for when the eschar cap was covering the wound caused Resident #7 great pain when the treatment was applied to her now-open wound. Cross reference F309 and F157.) On 12/18/12, when the hospice wound nurse assessed Resident #7's wound, in addition to changing the treatment order now that most of the eschar had fallen off, she noted the boot facility staff had been using since 4/15/12 intended for pressure relief was not providing pressure relief since Resident #7 has foot drop and the boot did not fit properly. The failure of staff to address Resident #7's risk factors (pressure relief boot used for almost nine months was ineffective due to foot drop), to obtain a treatment and measurements when Resident #7's pressure ulcer was first identified and consistently thereafter, to monitor the pressure ulcer after 9/18/12 when foul smelling purulent drainage was observed until Resident #7 was sent to the hospital on [DATE], and failure to identify the fact the eschar cap came off Resident #3's left heel- continuing the treatment ordered for when the eschar cap was in place- when a new treatment order was needed due to the change in the ulcer, constituted a finding of Immediate Jeopardy, beginning May 2, 2012. The NHA (Nursing Home Administrator)-A was informed of the Immediate Jeopardy on 12/18/12 at 3:14 p.m. The Immediate Jeopardy was removed on 12/21/12. The deficient practice remains ongoing as the facility Quality Assurance Committee will continue to review compliance of the Skin Management System policy and procedure on a monthly basis, with the Director of Nursing/designee reviewing the 24 hour report to ensure follow through with any identified wound. The Director of Nurses will review on a weekly basis the Weekly Pressure Ulcer Assessment Form to validate appropriateness and effectiveness of the treatment. The deficient practice continues at a scope and severity level of D (potential for harm that is not immediate jeopardy /isolated). Resident #3 developed a facility-acquired unstageable pressure ulcer on her left heel. On 12/13/12 Surveyor # observed Resident #3 without a right foot pedal on her wheel chair. Resident #3 has physician's orders [REDACTED].#3 Care Plan states she should only be up for meals. Surveyor # observed Resident #3 up from before breakfast until after lunch on 12/13/12. Without a right foot pedal, Resident #3 continually placed her right foot on top of her left foot, which was in a blue boot resting on the left metal foot rest. This causes an increase in the amount of pressure on Resident #3's deteriorating pressure ulcer on the left heel. Findings include: Surveyors # and # entered the facility on 12/12/12 to investigate a complaint that residents who reside on the Reflections unit are not receiving care to prevent pressure ulcers and, once a pressure ulcer develops, residents are not receiving proper care to heal the pressure ulcers. Surveyors requested a list of residents who had pressure ulcers. Surveyors were provided with a list dated 12/11/12 for the Reflections unit, indicating out of 31 residents on the unit, there were 5 residents with pressure ulcers: 5 facility-acquired pressure ulcers on residents' heels, one facility-acquired pressure ulcer on a resident's buttock, and one facility-acquired pressure ulcer on a resident's bunion (two residents had two pressure ulcers each.) 1. Resident #7 was identified as having a facility acquired unstageable pressure ulcer on her left heel that was identified May 2, 1012, and a facility acquired Stage 2 pressure ulcer on her right buttock that was identified June 21, 2012. Surveyor # reviewed Resident #7's medical record on 12/12/12- 12/18/12. On 12/12/12, RN MGR (Registered Nurse Manger)-C stated she measures Residents' pressure ulcers once a week, and she has those Weekly Pressure Ulcer Records in her office. Resident #7's record indicates the following: Resident #7 was admitted to the facility on [DATE] with major [DIAGNOSES REDACTED]. INITIAL ASSESSMENTS Staff completed an admission nursing assessment for Resident #7 on 4/2/12, indicating Resident #7 had a Stage 1 pressure ulcer on her coccyx, the nurse was "unable to feel pedal pulses," she had short term memory problems /Alzheimer's dementia since August- oriented to name and date- "unable to answer some questions-husband helped." A "Braden Scale for Predicting Pressure Sore Risk" was completed on 4/2/12 for Resident #7, totaling "13"; a score of 12 or less represents high risk. Scores on 4/9/12 and 4/21/12 were 13 and 14 respectively. The additional point on 4/21 was for Resident #7's nutrition improving from "probably inadequate" to "adequate." All the Braden Assessments identified Resident #7 as having slightly limited sensory perception, skin often moist, was chairfast, mobility slightly limited and friction and shear is a problem- requires moderate to maximum assistance in moving, "complete lifting without sliding against sheets is impossible." Braden Scales completed on 6/28/12, 7/20/12, 9/25/12, 10/2/12, 10/9/12 and 1016/12 all scored 13 (except 10/9 scored 14), indicating Resident #7 is at moderate risk of developing pressure ulcers. Surveyor # reviewed Resident #7's Initial MDS (Minimum Data Set) dated 4/8/12 indicating Resident #7 was at risk for pressure ulcers and had one Stage 1 pressure ulcer. The MDS notes Resident #7 has short and long term memory problems and has severely impaired cognitive skills for daily decision-making. Resident #7 had limited range of motion on one side of her lower extremities. Resident #7's CAA (Care Area Assessment) dated 4/8/12 notes Resident #7 is at risk for pressure ulcers due to diabetes, dementia, [MEDICAL CONDITION], incontinent of bowel, (has urinary catheter), does not make needs known, requires total care by staff. Resident #7 had physician's orders [REDACTED]. An air mattress was provided for Resident #7 on admission. CARE PLANS Resident #7's Initial Plan of Care dated 4/2/12 indicates Resident #7 has an actual Stage 1 pressure ulcer on her coccyx due to decreased mobility and incontinence. Interventions include: provide wound care/ preventative skin care per order; skin checks weekly per facility protocol- document findings; notify MD of changes in wounds, or emerging wounds; turn and reposition frequently to decrease pressure. Resident #7's Care Plan dated 4/2/12 titled, "Skin Integrity" states she is at risk for impaired skin integrity due to decreased mobility and Stage 1 pressure ulcer on her coccyx. The Goal is "skin to remain intact." Interventions include: wash with soap and water after each incontinent episode; apply moisture barrier after each incontinent episode and with daily cares; apply lotion to lower extremities and dry skin daily with cares; reposition every two hours and as needed; nurse to do body check weekly with bath or shower and document; shower/bath weekly as per policy; refer to therapy as needed for positioning; encourage good fluid intake; toilet/change resident every two hours, as needed or upon request; report any red or open areas to unit nurse; update MD on any open areas found; and refer to wound nurse/ committee as per appropriate for evaluation. Resident #7's Care Plan dated 4/2/12 titled, "Pressure Ulcers" states she had an "Actual pressure ulcer -coccyx" due to impaired mobility, status [REDACTED]. The Goals are: pressure ulcer will show signs of healing; and pressure ulcer risk will be minimized with interventions. Interventions include: frequent repositioning by self and staff; protect heels with EZ boots and pillows; pressure reduction surface if bed or chair bound-wheelchair cushion; manage moisture, nutrition, friction and shear. Maintain good hydration. Use pillows for 30 degree lateral positioning; and low air loss mattress. Resident #7's Diabetes Care Plan dated 4/2/12 states, "Unit nurse to assess skin weekly on bath day and document in nurses' notes." Resident #7 has a Care Plan for Activities of Daily Living dated 4/2/12, which includes an approach of "Monitor for skin Breakdown." Resident #7 also has a care plan dated 4/5/12 for "Cognitive Loss", which states Resident #7 has a BIMS (Brief Interview for Mental Status) score of 5, indicating severe impairment; "resident is alert but very confused and forgetful." They indicate Resident #7 is alert but not oriented, has short and long term memory loss, difficulty recalling and finding words. She is not able to recall current season, location of room or staff names and faces, but does know she is in a nursing home. Nurses' Notes dated 4/6/12 state Resident responds to her name but is unable to state her name. NURSES' NOTES AND HEAD-TO-TOE WEEKLY SKIN CHECKS On 4/15/12, Resident #7's narrative Nurses' Notes documented on the Nursing Daily Skilled Summary state: left heel soft- Skin prep and EZ boots placed when in bed. The Nursing Daily Skilled Summary notes for the next week make no further mention of Resident #7's soft left heel, though nurses did initial the TAR (Treatment Administration Record) on most days that Skin Prep was applied on a.m. and p.m. shifts, and Resident #7 had heel protectors on when in bed. The daily notes either leave the "Skin" section blank, or indicate "no problems" or that Resident #7's incision on her left hip is "OTA" (open to air). Other notes indicate Resident #7 frequently yells out "help me, help me" when they have tried to meet all her needs, and her appetite and food intake is poor. On 4/25/12, ten days after Resident #7's soft left heel was identified, staff checked "Decubitus-See Weekly/Daily documentation" on the Nursing Daily Skilled Summary "Skin" section, and wrote "Left heel." The notes also state Resident #7 is very lethargic, has poor skin turgor, oral mucosa very dry. Resident #7's physician was contacted, who ordered staff to push fluids, use [MEDICATION NAME] and [MEDICATION NAME] for anxiety, recheck blood pressure and if it remains low, to speak with Resident #7's husband regarding use of IV (intravenous) fluids...and if she declines further a family conference should be called. There is no mention that the MD was informed of Resident #7's "soft heel" identified 4/15/12 or the "decubitus- left heel" identified 4/25/12 and there were no orders for changes in treatment. Despite the "soft heel" identified on 4/25/12, the Daily Skilled Summary notes on 4/26/12 state: "Skin- no problems"; on 4/29 it states "poor turgor, [MEDICATION NAME] powder needed for breast folds." Surveyor # reviewed "Head to Toe Skin Checks" documented for Resident #7. These are to be done weekly on bath day per facility policy and Resident #7's Care Plan. The first Head to Toe Skin Check documented on the April 2012 form was completed on 4/13/12 and notes, "Redness at bottom," and notes this area was previously identified and preventative measures are in place. The corresponding anatomical diagrams and feet/heel diagrams are left blank. While there are sections to document six weekly assessments, the 4/13 skin check is the only one documented on the April 2012 sheet for Resident #7. (Resident #7 was admitted on [DATE].) On 5/2/12, Resident #7 was transferred to another unit. The narrative Nurses' Notes (as opposed to the Nursing Daily Skilled Summary forms) dated 5/2/12 states, "Received transfer from TransiCare (unit). Report from RN MGR (Registered Nurse Manager)-L reports as follows- no OA's" (open areas)... Surveyor # noted a SBAR (Situation/Background/Assessment/Request) Change of Condition Physician Communication and Progress Note dated 5/2/12 that states Resident #7's physician was informed on the PM shift that Resident #7 has an "area-left heel"- that is all the nurse documented on the form, none of the rest of the form is completed. The "Background" section, which asks staff about changes in skin or wounds is crossed out; as is the "Assessment" section. The "Situation" section simply states "area left heel" all the other areas are blank- such as when did the problem start, what has been done so far, etc. The "Request" section is also blank, as is the Nurse's signature who informed the MD of this "area" and staff did not check if the communication with the MD was via phone, fax or in person. Stating there is an "area-left heel" does not indicate if the heel is red, pink, brown, black, soft, firm, open, closed, painful, drainage, odor, Stage 1, 2, 3, 4, etc. or how large the area is. The section on the back for "physician's orders [REDACTED].# , nor were any orders pertaining to Resident #7's skin note until 5/9/12. There was no nurses' note indicating the nurse called or faxed the information to the MD, or that the MD was in the facility, and informed in person. Despite the presence of an open area on the heel, there was no immediate change in treatment. The "skin" section of the Nursing Daily Skilled Summary form dated 5/2/12 is left blank. On the back of the 5/2/12 Daily Skilled Summary, nurses documented for 5/7/12, 5/8/12 and 5/9/12 as follows: (The "treatment" is skin prep to left heel.) 5/7/12: Treatment done to left heel - area pink with small amount of serosanguinous drainage. Boot on, no complaints. 5/8/12: Treatment done to left heel. Slight superficial changes noted. Area measured per RN manager. Boot on. 5/9/12: Treatment done, no change. Boot on. Resident #7's record includes a physician's orders [REDACTED]. Resident #7's Care Plans for Skin Integrity and Pressure Ulcers, both originally dated 4/2/12, were updated 5/9/12 (the first update since 4/2/12), stating; [MEDICATION NAME] to left heel. The care plans had not been updated when nurses' documented on 4/15/12 that Resident #7 had a soft heel, nor was it updated on 4/25/12 when a nurse wrote "decubitus- left heel." The Nursing Daily Skilled Summary dated 5/9/12 states: Skin- superficial OA (open area) left heel. On 5/10/12, Daily Skilled Summary states: Skin- decubitus, left heel, Stage 2; notes section states, "[MEDICATION NAME] to Stage 2 OA left heel, EZ boot on." Staff continue to check the Nursing Daily Skilled Summary notes "Skin: Decubitus- See weekly/Daily documentation." Surveyor # reviewed the narrative Nurses' Notes (these are long-hand notes, separate from the Nursing Daily Skilled Summary) and observed on 5/7/12 the notes states: (Family member) aware of new medications, boot and dressing left foot. Subsequent notes are dated 5/14/12, 5/16/12 and 5/17/12. The next note is not until 7/9/12, more than seven weeks later. None of the narrative nurses notes in May 2012 address Resident #7's heel. The Daily Skilled Summary dated 5/22/12 states, "Decubitus left heel- Dressing changed and treatment done to necrotic area left heel." On 5/24/12 the Summary states: Left heel left open to air, area dry, scabbed. EZ boots on...on calorie count... The Daily Skilled Summary Notes 5/25 to 5/28 state, Resident #7's left heel is open to air, boots on. (It is unclear how the heel is open to air if Resident #7 is wearing an EZ boot.) No May 2012 weekly Head to Toe Skin Check sheets could be located for Resident #7, although staff started skin prep and EZ boots on 5/2/12, and they received an order for [REDACTED]. Notes on 6/5/12 indicate Resident #7's family member and MD discussed Resident #7's poor intake and agreed no tube feeding will be utilized. The Daily Skilled Summary notes throughout June 2012 either leave the "Skin" section blank or write "left heel" and check "Decubitus- See Weekly/Daily documentation." Sometimes nurses write "left heel ulcer dry." On 6/21/12 the Daily Skilled Summary Note states, "RCS (Resident Care Specialist) reported a 3 cm. (centimeter) blister on Resident's right buttock and a 4 cm. dark blue area right posterior thigh. Areas not open, Skin Prep applied. Positioned on side with pillow for good alignment. Surveyor # observed a SBAR Change of Condition form dated 6/21/12 and noted the nurse called the MD regarding the above and Resident #7's poor nutrition, and received new orders for [MEDICATION NAME] to open blister on right buttock after NS (normal saline) wash. Change every 3 days and PRN (as needed). Summary Notes indicate Resident #7's right buttock blister opened on 6/24/12. Notes on 6/25/12 state: Blister now open, [MEDICATION NAME] applied. Appetite remains poor. Treatment done to dry scabbed heel. EZ boots worn. Notes on 6/26/12: Necrotic area to left heel persists. Resident #7 was hospitalized from [DATE] to 6/25/12 for pneumonia and [MEDICAL CONDITION] decompensation. The June 2012 Head to Toe Skin Check form, to be done weekly, indicates on 6/1/12, a nurse documented Resident #7's skin was intact, there were no previously identified areas, and "preventative measures" was left blank. The diagrams of the Resident's feet and heels are left blank, even though Resident #7 was receiving a treatment for [REDACTED]. On 6/8/12, the nurse noted Resident #7 had intact skin, and her left heel had a black, necrotic area. On 6/15/12, the nurse simply checked Resident #7's skin was intact, and made no mention of "previously identified areas"- such as Resident #7's left heel. On 6/22/12, it was checked skin intact, no bruises, skin tears, abrasions or rashes. No previously identified areas were indicated, nor was preventative measures addressed. On 6/29/12, only the date was filled in, nothing else, though Resident #7 was identified as having a pressure ulcer on her right buttock on 6/25/12. Notes on 7/1/12: [MEDICATION NAME] replaced to Stage 2 on right buttock due to soiling. Treatment done to heel necrotic area, EZ boots on. Nursing Daily Skilled Summaries continue through 7/16/12 and most "Skin" sections are blank, some indicate left heel and/or right buttock decubitus; but none have any further description. No further documentation was noted in the narrative Nurses' Notes during that time frame. Resident #7 was admitted to hospice on 7/17/12. The Hospice Assessment Summary of Decline/ Need for Hospice dated 7/17/12 states "...Pt. (Patient) hospitalized for [REDACTED]. has decreased appetite, OA (open area) on right buttock... (Note: no mention of the necrotic heel.) The Hospice Comprehensive Assessment/Addendum dated 7/17/12 that reviews each care area individually (i.e. pain/comfort, elimination- urinary and bowel, cardiorespiratory, nutritional/GI, emotional, spiritual, etc.) was left blank for "Integumentary Status" (skin). The nurse had the option of selecting: no problem; actual problem- care plan opened; or potential problem- care plan opened; but it was all left blank. While the Hospice Care Plan did not include a "Problem" regarding skin, the Problem #3 Alteration in Nutrition Interventions state: When potential or actual impairment present, check skin every visit. Include: location, size, color, drainage (amount and color), temperature. Problem #5 Self-Care Deficit states "Assess skin integrity, pain related to immobility, etc." Surveyor # reviewed notes from Hyperbaric Wound Care Associates for Resident #7. Notes dated 7/18/12 indicate Resident #7's left heel measured 1.7 cm. x 2.7 cm. x 0.? cm. (a crease/ blank line in the copy left the measurement un-readable), no drainage, 100% peri-wound intact. Left heel with adherent eschar. Bilateral buttocks with granular ulcers. No signs of infection, no ischemia. Diagnoses: [REDACTED]. 2.) Unstageable left heel pressure ulcer. 3.) Diabetes. Plan: Continue [MEDICATION NAME] to bilateral buttock ulcers, change every 3 days and as needed. Continue off-loading and nutritional support. Continue skin prep daily to left heel ulcer and apply dry dressing. (*Note: Previously in the Nurses' Notes, only a right buttock pressure ulcer was identified. The Wound Consult describes bilateral ulcers; it is not known when Resident #7's left buttock pressure ulcer developed.) Surveyor # reviewed a Significant Change in Status Assessment completed for Resident #7 on 7/23/12. Even though numerous Nurses Notes (7/1/12 for example), describe Resident #7's necrotic left heel and eschar on her left heel, and the Hyperbaric Wound Care Associates consult dated 7/18/12 [DIAGNOSES REDACTED].#7 had two Stage 2 pressure ulcers, with the most severe tissue type being "granulation" tissue (red or pink with shiny moist appearance), not "necrotic" tissue (black, brown or tan tissue that adheres firmly to wound bed or ulcer edges). On this MDS, staff identified Resident #7's unstageable (due to necrotic tissue) left heel pressure ulcer as a "[MEDICAL CONDITION]." No July 2012 Head to Toe Skin Check form, to be completed weekly, was noted by Surveyor # , though Hyperbaric Wound Associates documented Stage 2 pressure ulcers on Resident #7's bilateral buttocks on 7/18/12 and necrotic left heel. (Previously in the Nurses' Notes, only a right buttock pressure ulcer was identified.) Facility Narrative Nurses' Notes dated 8/9/10 indicate Resident #7's dressing came off the decubiti on her right buttock- noting the area is too moist for [MEDICATION NAME]. Message left for hospice nurse to assess for new treatment. On 8/10/12, a new treatment order was received. Notes continue: 8/24/12 ...boots in place 8/27/12 Dressing to right buttock C/D/I (clean, dry and intact). Dressing and boot in place - left heel... 8/27/12 Dressing change to left heel. No c/o (complaint of) pain or discomfort at this time. The August 2012 weekly Head to Toe Skin Check form indicates on 8/3/12, Resident #7 has a "red area on butt, [MEDICATION NAME] applied" and they circled the entire buttocks area on the diagram- not indicating right, left or both buttocks. The nurse did not indicate any skin impairment on Resident #7's left heel. On 8/10/12, the nurse documented Resident #7's skin was not intact, and they circled Resident #7's left buttock and left heel. Where the form asks the staff if the resident's skin is intact, it states: "If no, specify," but nothing is documented. Previously identified areas and preventative measures sections are blank. The Skin checks on 8/17 and 8/24 are similar to 8/10, circling the left buttock and heel. The Skin Check on 8/31/12 identifies the "OA right butt," but does not identify the heel ulcer. Surveyor # noted a Weekly Pressure ulcer record dated 8/22/12 indicating Resident #7 has two new Stage 2 pressure ulcers on her left buttock, 2.0 cm. x 1.5 and 0.4 cm. x 0.4. It is unclear if the notation of "OA right butt" on 8/31/12 refers to Resident #7's June 25th pressure ulcer on her right buttock, or if they confused the right and left sides, and they are referring to the two newly identified pressure ulcers on Resident #7's left buttock. Similarly, the first supporting documentation regarding pressure ulcers on Resident #7's left buttock is dated 8/22/12 on the Weekly Pressure Ulcer Record, but nurses circled the left buttock on 8/10/12 and 8/17/12. So it is unknown if the pressure ulcers present on 8/10/12 and 8/17 Skin Checks were new and should have been measured and the Weekly Pressure Ulcer Records started on 8/10/12, or if they were referring to the right buttock pressure ulcer but circled the left side. 9/4/12 Spoke with hospice re: foul smelling left heel decubitus. Area more necrotic. New order for Dakins solution cleanse and Santyl QD EZ boots on, no socks or shoes. (Note: Surveyor # reviewed the physician's telephone order dated 9/4/12 which states "Cleanse necrotic area -heel with Dakin's solution f/b (followed by) Santyl QD (every day). Skin Prep around edges of wound. Wrap with 4 x 4 dressing. On 12/18/12, Surveyor # called the facility's pharmacy and asked what strength Dakins solution they delivered to the facility, since there are different strengths. Pharmacy staff said the order was rejected and never filled since the strength was not noted. The Pharmacy staff also said many facilities have Dakins as a stock supply.) 9/5/12 ...Left boot in place. 9/8/12 Resident #7 was started on [MEDICATION NAME] 500 mg. (milligrams) a day for 7 days for a UTI (urinary tract infection). Foley (urinary catheter) draining dark cloudy foul smelling urine. 9/10/12 "MD called to update on order for culture of left heel and that it was hospice who ordered this." (Surveyor # observed a note on Resident #7's Care Plan dated 9/10/12 stating "Wound Culture left heel" (which RN Manager-C marked "DC'd (discontinued) during an interview on 12/13/12 when Surveyor # asked what the results showed. RN-C stated they never obtained the culture, preferring instead to wait until Resident #7 finished her antibiotics for UTI.) Surveyor # reviewed Hyperbaric Wound Care Associates notes dated 9/12/12 state, ROS (Review of Systems) unable to obtain, Resident (#7) non-verbal. Exam: Right buttock with two Stage 2 wounds- mainly granular, 2.1 x 2.5 x 0.1 cm, and 1.9 x 2.0 x 0.1 cm. Left heel unstageable, 3.5 x 4.7 cm., 100% adherent eschar, no odor or purulent drainage. Non-tender to palpation. Plan: Santyl to buttock wounds daily. Skin prep daily to left heel to maintain dry eschar. Continue off-loading and nutritional support. (Weekly Pressure Ulcer Record on 9/18/12 indicates left heel pressure ulcer had foul smelling, purulent drainage, not present on weekly note 9/11/12; no documentation MD called. Cross reference F157.) The next facility note is dated 9/19/12 at 1:00 a.m. stating simply, "Dressing to OA coccyx/ right butt/ Left heel C/D/I" (clean, dry and intact). Surveyor # reviewed Resident #7's September 2012 Head to Toe Skin checks and noted nurses identified pressure ulcers on Resident #7's left heel and two on left buttock on 9/4 and 9/11. The Skin Checks for 9/18/12 and 9/25/12 are blank. The next nursing note is dated 9/21/12 at 3:50 p.m. and part of it is hard to read. Surveyor # and DON (Director of Nursing)-B could make out the following: Resident (#7) noted with increased SOB (shortness of breath), diaphoretic skin, labored breathing, respirations 126-128. Oxygen saturation 95-99% on 5 liters per nasal canula. BP (Blood pressure) 118/64. HR (heart rate) 84. Blood sugar at 3:30 p.m. was 160. Family wants patient sent to ER (emergency room ) for evaluation. Supervisor called both MD and hospice. 911 called to transport to Froedtert ER for evaluation. The on-call MD returned the call at 4:30 p.m. and was updated on the transfer to the ER. The Hospice nurse called back at 7:45 p.m. and was updated. At 11:45 p.m., facility staff were informed Resident #7 was admitted with altered mental status and UTI. HOSPITAL RECORD Surveyor # reviewed the hospital Internal Medicine Admission History and Physical date 9/21/12 at 9:52 p.m. The History of Present Illness states Resident #7's husband was concerned Resident #7 was not responding to him and she was breathing faster than normal...Per the ED (Emergency Department), the Foley (urinary catheter) looked infected and they exchanged it for a new Foley. She is also coming in with a complaint of left heel ulcer and right buttock ulcer that is described as being new and the heel looks infected and has a bad smell...In the ED, her BP was low 88 systolic and was given 1.5 liters of fluid [MEDICATION NAME] in addition to a dose of [MEDICATION NAME]. After this she woke up but is not oriented. The Physical Exam portion states: General appearance: alert, mild distress, slowed mentation, appears stated age. Neurologic: Oriented X 0, will hardly answer any questions to me, is moaning quite loudly...Extremities: The left heel has an approximately 3 x 4 cm. wound that is black and about 1 cm. deep. There is white puss coming from the wound and it appears to be infected. ..Skin: The right buttock has a Stage 3 ulcer that is 1 x 2 cm. in diameter. No sign of infection. The Assessment and Plan states: ...exam shows infected heel ulcer. 1.) AMS (Altered mental status)- multifactorial etiology- most likely combo deal from infected ulcer vs UTI vs. [MEDICAL CONDITION]. 2.) [MEDICAL CONDITION]- ...UTI cultures pending, UA (urinalysis) looks dirty. WBC (white blood count) 12.4 with left shift (indicates body fighting overwhelming infection, [MEDICAL CONDITION] developing.)... 4.) Left heel ulcer: appears infected, blood cultures taken, start on [MEDICATION NAME], consult wound care (also for right buttock wound). 6.) Has severe [DIAGNOSES REDACTED] stage 4... A Medicine Progress note dated 9/23/12 states one blood culture is growing gram positive cocci in clusters, usually characteristic of Staphylococcus, such as S. aureus. Surveyor # reviewed the Wound Consult from the hospital dated 9/24/12 which states, "Patient seen to evaluate left heel and buttock pressure ulcers present on admission. Patient awake, non-verbal and requires full assist to reposition...left heel unstageable pressure. Black eschar covers wound bed, soft with fluctuance. Tan drainage from proximal edge. + odor. Surrounding [DIAGNOSES REDACTED] extends about 1 cm. Questionable osteo[DIAGNOSES REDACTED] per MD note...Right buttock superficial Stage 3 pressure ulcer. Base pink with scattered thin yellow slough. Small yellow drainage, no odor or [DIAGNOSES REDACTED]. Recommendations: Cleanse heel cover with Carraklenz. Cover with Dakin's solution 1/4% damp gauze to manage bioburden and odor... Surveyor # reviewed the hospital Discharge Summary dated 9/25/12 stating Resident #7 had WBC 12.4 with left shift on admission, now down to 8.1. "4.) Left heel ulcer: X-ray shows possible underlying osteo[DIAGNOSES REDACTED]." READMISSION CARE PLAN Surveyor # reviewed Resident #7's Pressure Ulcer Care Plan dated 9/26/12 indicating Resident #7's Braden score is 13 (moderate risk), she has actual pressure ulcers on her "right butt" and left heel, has a history of pressure ulcers, is incontinent of bowel, has cardiovascular disease and diabetes, and nutrition deficits. Interventions include: EZ boots, pillows, Broda chair (as of 10/23/12), pressure reduction surface bed and chair, manage nutrition, low air loss mattress. Treatment to both areas with Santyl (though hospital wound consult recommended Carraklenz followed by Dakins solution). Resident #7 also has a Skin Integrity Care Plan dated 9/26/12 noting decreased mobility, diabetes, non-weight bearing. That Care Plan also notes 10/2/12, treatment of XRED

Based on record review and interview, facility staff did not notify 1 of 7 Residents' physicians when there was a significant change in a Resident's physical status and a need to alter treatment. Resident #7 developed a soft left heel on 4/15/12, and a "decubitus ulcer" on her left heel on 4/25/12. Resident #7's physician was not notified until possibly 5/2/12 (unknown if partially filled out SBAR form was ever communicated to MD- there was no reply from MD) or 5/9/12, when staff received treatment orders for the heel. Staff did not notify Resident #7's MD on 9/18/12 when Resident #7's left heel pressure ulcer presented with foul smelling, purulent exudate. Resident #7 was sent to the Emergency Department then hosptalized on [DATE] [MEDICAL CONDITION] and possible osteo[DIAGNOSES REDACTED] of her left heel. Staff did not notify hospice staff and Resident #7's MD until 12/18/12 that Resident #7's eschar cap came off her left heel between 12/11/12 and 12/13/12, necessitating a treatment change. The eschar cap formed a protective shell over Resident #7's heel, so she did not experience pain with the treatment. Once the eschar cap fell off (which is the goal), raw tissue was exposed causing the previous treatment to be very painful. (Cross reference F309 (re: pain) and F314 (re: pressure ulcers). Findings include: Surveyor # reviewed Resident #7's medical record on 12/12/12- 12/18/12. Resident #7's record indicates the following: Resident #7 was admitted to the facility on [DATE] with major [DIAGNOSES REDACTED]. On 4/15/12, Resident #7's narrative Nurses' Notes documented on the Nursing Daily Skilled Summary state: left heel soft- Skin prep and EZ boots placed when in bed. The Nursing Daily Skilled Summary notes for the next week make no further mention of Resident #7's soft left heel, though nurses did initial the TAR (Treatment Administration Record) on most days that Skin Prep was applied on a.m. and p.m. shifts, and Resident #7 had heel protectors on when in bed. The daily notes either leave the "Skin" section blank, or indicate "no problems" or that Resident #7's incision on her left hip is "OTA" (open to air). Other notes indicate Resident #7 frequently yells out "help me, help me" when they have tried to meet all her needs, and her appetite and food intake is poor. On 4/25/12, ten days after Resident #7's soft left heel was identified, staff checked "Decubitus-See Weekly/Daily documentation" on the Nursing Daily Skilled Summary "Skin" section, and wrote "Left heel". The notes also state Resident #7 is very lethargic, has poor skin turgor, oral mucosa very dry. Resident #7's physician was contacted on 4/25/12 at 12:00 p.m., who ordered staff to push fluids, use [MEDICATION NAME] and [MEDICATION NAME] for anxiety, recheck blood pressure and if it remains low, to speak with Resident #7's husband regarding use of IV (intravenous) fluids...and if she declines further a family conference should be called (Surveyor # noted that there was no mention in this entry that the MD was informed of Resident #7's "soft heel" identified 4/15/12 or the "decubitus- left heel" identified 4/25/12). On 5/2/12, Resident #7 was transferred to another unit. The narrative Nurses' Notes (as opposed to the Nursing Daily Skilled Summary forms) dated 5/2/12 states "Received transfer from TransiCare (unit). Report from RN MGR (Registered Nurse Manager)-L reports as follows- no OA's" (open areas)... Surveyor # noted a SBAR (Situation/Background/Assessment/Request) Change of Condition Physician Communication and Progress Note dated 5/2/12 that states Resident #7's physician was informed on the PM shift that Resident #7 has an "area-left heel"- that is all the nurse documented on the form, none of the rest of the form is completed. The "Background" section, which asks staff about changes in skin or wounds is crossed out; as is the "Assessment" section. The "Situation" section simply states "area left heel"; all the other areas are blank- such as when did the problem start, what has been done so far, etc. The "Request" section is also blank, as is the Nurse's signature who informed the MD of this "area", and staff did not check if the communication with the MD was via phone, fax or in person. Stating there is an "area-left heel" does not indicate if the heel is red, pink, brown, black, soft, firm, open, closed, painful, drainage, odor, Stage 1, 2, 3, 4 etc. or how large the area is. The section on the back for "physician's orders [REDACTED].# , nor were any orders pertaining to Resident #7's skin noted until 5/9/12. There was no nurses' note indicating the nurse called or faxed the information to the MD, or that the MD was in the facility, and informed in person. The "skin" section of the Nursing Daily Skilled Summary form dated 5/2/12 is left blank. On the back of the 5/2/12 Daily Skilled Summary, nurses documented for 5/7/12, 5/8/12 and 5/9/12 as follows: 5/7/12: Treatment done to left heel - area pink with small amount of serosanguinous drainage. Boot on, no complaints. 5/8/12: Treatment done to left heel. Slight superficial changes noted. Area measured per RN manager. Boot on. 5/9/12: Treatment done, no change. Boot on. (In an interview on 12/13/12 with RN MGR (Registered Nurse Manager)-C, she informed Surveyor # the "treatment" done prior to 5/9/12 was the skin prep to Resident #7's left heel, and they do not need an MD order to apply the skin prep. Surveyor # did not not observe a physician's orders [REDACTED].) Resident #7's record includes a physician's orders [REDACTED]. The 5/9/12 physician order [REDACTED].#7's left heel pressure ulcer, that was first identified as a soft heel on 4/15/12 and a decubitus ulcer on 4/25/12. Surveyor # reviewed Resident #7's Weekly Pressure Ulcer Record dated 9/18/12 indicating Resident #7's left heel pressure ulcer had foul smelling, purulent drainage. The weekly documentation dated 9/11/12 indicates no exudate, no odor. While the 9/11/12 entry notes Resident #7's MD was updated, there is no documentation on or after 9/18/12 that Resident #7's MD was called with the new development of foul smelling purulent drainage now coming from the ulcer, until Resident #7's family member requests Resident #7 be sent to the hospital. The next facility note is dated 9/19/12 at 1:00 a.m. stating simply "Dressing to OA coccyx/ right butt/ Left heel C/D/I" (clean, dry and intact). The next note is dated 9/21/12 at 3:50 p.m. and part of it is hard to read. Surveyor # and DON (Director of Nursing)-B could make out the following: Resident (#7) noted with increased SOB (shortness of breath), diaphoretic skin, labored breathing, respirations 126-128. Oxygen saturation 95-99% on 5 liters per nasal canula. BP (Blood pressure) 118/64. HR (heart rate) 84. Blood sugar at 3:30 p.m. was 160. Family wants patient sent to ER (emergency room ) for evaluation. Supervisor called both MD and hospice. 911 called to transport to Froedtert ER for evaluation. The on-call MD returned the call at 4:30 p.m. and was updated on the transfer to the ER. The Hospice nurse called back at 7:45 p.m. and was updated. At 11:45 p.m., facility staff were informed Resident #7 was admitted with altered mental status and UTI. Subsequent hospital record [MEDICAL CONDITION] probably from UTI and infected heel ulcer, and possible osteo[DIAGNOSES REDACTED]. (Cross reference F314). On 12/13/12, Surveyor # observed RN-G perform the treatment to Resident #7's left heel, which, as of a 11/16/12 physician's orders [REDACTED]. Prior to observing the treatment, on 12/13/12 RN MGR-C informed Surveyor # Resident #7's left heel pressure ulcer was last assessed and measured on wound rounds 12/11/12, when Resident #7's left heel was covered with black eschar. (For further specifics, please cross reference F314.) On 12/13/12 at 10:15 a.m., Surveyor # observed RN-G perform Resident #7's treatments after she was transferred back to bed. After RN-G removed Resident #7's left heel dressing, Surveyor # observed Resident #7's pressure ulcer to be approximately 3.0 x 4.0 x 1.0 cm., mostly bright red, some bleeding, with a small amount of eschar on one side of the ulcer. The old gauze dressing had dried and fresh blood on it. RN-G cleansed the open, raw, wound/ tissue with the prescribed Dakin's solution. (While Resident #7 winced every time her left foot was moved, when the Dakin's was applied, Resident #7 arched her back- looking up at the ceiling, clenched her teeth, clenched the bottom bed sheet with both hands, and her eyes became moist. Cross reference F309 regarding pain management for Resident #7, and F242 regarding timing of treatment. The Dakin's product information states "for external use only.). On 12/13/12, RN MGR-C informed Surveyor # she thought the Hospice wound nurse was coming in that day to look at Resident #7's wound. RN MGR-C stated she usually does the wound rounds, but she did not actually see Resident #7's wound on 12/11/12. She was working on the floor filling in for a staff nurse when the hospice nurse and Santyl representative assessed Resident #7's left heel pressure ulcer on 12/11/12. They then gave her the measurements and description of the wound, which she recorded on her Weekly Pressure Ulcer Report. RN-C stated she hasn't seen Resident #7's wound since 12/4/12. RN-C stated the hospice nurse told her the wound was black with some yellow slough around the edges. On 12/17/12 at 8:50 a.m., Surveyor # again interviewed RN-MGR-C, asking if she or the hospice wound nurse had assessed Resident #7's left heel ulcer (Surveyor # had not observed any documentation regarding Resident #7's ulcer by hospice or facility staff after 12/13/12, when RN-G noted Resident #7 grimaced during the treatment, but did not note the eschar cap was mostly off.) RN-C stated she did not know if hospice had been in, but she had not seen the wound. Surveyor # shared the observations from 12/13/12- that most of the eschar "cap" had come off Resident #7's left heel, and most of the wound base was open, red and raw-looking, and Resident #7 appeared to be in great pain during the treatment on 12/13/12. Surveyor # noted the Dakin's solution was to be used while the eschar cap was on, but since most of it was off as of at least 12/13/12 when Surveyor # saw it, had facility staff or hospice staff contacted the MD for a more appropriate treatment. RN-C stated she would look into it. On 12/17/12 at the daily exit meeting Surveyor # asked if there was additional information regarding when Resident #7's MD was originally notified of the left heel ulcer. Surveyor # noted staff documented a "soft heel" on 4/15/12 and "decubitus - left heel" on 4/25/12 and started skin prep and heel boots on that date. But the first MD treatment order is not until 5/9/12, it is not clear if staff ever relayed the info on the 5/2/12 SBAR stating "area-left heel" since there was no reply from the MD and it is not indicated if the information was relayed in person, over the phone or fax. If the SBAR was faxed, all it states is "area-left heel", which does not provide enough information for developing a treatment plan. On 12/18/12 at 9:15 a.m., Surveyor # interviewed RN MGR-C, asking if Resident #7's MD had been informed the eschar cap was off and if a new treatment was ordered for Resident #7's left heel. RN-C stated they had not called Resident #7's MD yet as she just assessed Resident #7's left heel ulcer, and based on the observations shared by Surveyor # on 12/17/12 regarding Resident #7's pain with treatment, she had the unit nurse, LPN (Licensed Practical Nurse)-R, give Resident #7 [MEDICATION NAME] prior to the treatment. RN-C stated even with the [MEDICATION NAME], Resident #7 was in significant pain when the Dakin's treatment was applied. (Cross reference F309). Surveyor # asked why Resident #7's MD had not been contacted as of 12/18/12, since Surveyor # and RN-G (who did the treatment 12/13), nurses who did Resident #7's treatment on 12/14/12, 12/15/12, 12/16/12 and 12/17/12 were aware the wound is significantly different- the eschar cap is mostly off, and it needs a new treatment, and Surveyor # reported on 12/17/12 to RN-C the cap was off. RN-C stated again that the previous week, on 12/11/12, she did not see Resident #7's pressure ulcer, and when she last saw it on 12/4/12, the eschar cap was still on Resident #7's left heel and the Dakin's treatment was appropriate. RN-C stated she first learned most of the eschar cap was off when Surveyor # informed her of that on 12/17/12. RN-C stated neither the regular hospice nurse or hospice wound nurse had been in to see the wound since Surveyor # observed the cap off Resident #7's heel on 12/13/12, but she was going to call them again that day, because she had expected them the past Thursday. RN-C stated they will look at changing Dakin's to normal saline, since Resident #7 really cringed when the Dakin's was applied. RN-C stated Resident #7's left heel pressure ulcer is now a stage 3, measuring 2.8 x 4.0 x 1.0 cm., with a red and yellow wound base, purulent drainage with odor was present, 90% granulation tissue, 10% slough. RN-C stated she thought the EZ boot also had a bad odor, and she threw it out and obtained a new one just like the previous one. RN-C, after reviewing Resident #7's medical record, stated facility nurses had not notified Resident #7's physician that the eschar cap was off, nor did hospice staff contact the MD for new orders since they had not seen the wound either. RN-C stated hospice notifies the MD weekly of the resident's status. RN-C stated facility staff can call the MD directly if they need an order right away, and update hospice later, but they (hospice) can usually get through faster (to MD). RN-C informed Surveyor # Resident #7's MD was in the facility on 12/11/12, and hospice notes indicate they spoke with the MD; and that is the last MD update regarding Resident #7's pressure ulcers. The Hospice note dated 12/11/12 states the MD was informed of "open wound to left heel. Yellow, foul smelling, applying Santyl. Assisted RN with wound (dressing) change. Measures 4.5 x 3.0, slough, moderate amount of drainage to bandage. Rep. for Santyl arrived for wound care." (The eschar cap was still on as of 12/11/12.) Surveyor # and RN-C reviewed a SBAR Change of Condition form informing Resident #7's MD of a bilateral axillary red rash, noted on 12/4/12. Resident #7's family was informed of the rash on 12/4/12, but the MD was not called until 12/12/12. The MD ordered [MEDICATION NAME] powder on 12/14/12. RN-C did not know why the MD was not called for over a week after Resident #7's family was informed. At 10:03 a.m. RN-C called the hospice agency and left a message for hospice RN-P to call her back, explaining hospice would then call the MD. At 10:15 a.m. on 12/18/12, Surveyor # called hospice RN-P who stated she was unaware until a few minutes earlier when she spoke with RN-C by phone that Resident #7's eschar cap was mostly off her left heel. RN-P stated nursing home staff does not have to wait for hospice to call the MD, noting if there is an urgent need or after hours, that would cause an unnecessary delay. RN-P stated since they were unaware the cap had fallen off, they did not update the MD or obtain a new treatment order. When Surveyor # noted facility RN-C stated she was waiting for the hospice wound nurse to assess Resident #7's heel, RN-P stated until the cap came off, there was no need for the wound nurse to assess Resident #7's left heel, the cap was on the last time she saw the wound (12/11/12) and hospice staff was not informed until that morning (12/18/12) the cap had come off. RN-P stated if the eschar cap is off, the treatment needs to be changed since the Dakin's is no longer appropriate- it would hurt. The treatment is probably painful now if the cap is off, which was the goal so healing could start, but the cap was covering other sensitive tissue. With that gone, it would be painful... At 10:30 a.m. and 12:50 p.m., Surveyors # and # asked DON (Director of Nursing)-B and NHA (Nursing Home Administrator)-A if there was any additional information regarding Resident #7's pressure ulcers. DON-B provided Surveyor # with information showing Resident #7 has had an air mattress since admission, and the "Skin Management" policy, revised August 2012, but no other information. Surveyor # reviewed the August 2012 Skin Management policy which states: (page 2) Residents with skin impairments will have: appropriate interventions implemented to promote healing; a physician's orders [REDACTED]. The following forms are completed and placed with the resident's treatment record- Weekly Pressure Ulcer Record... (page 3) "weekly Skin Check" will be transcribed onto the Treatment Record including day and shift on which the check will be conducted...skin assessment findings will be documented weekly on the Head to Toe Skin Check form. Alterations or changes in skin integrity, any break in the resident's skin including skin tear, bruises, abrasions, ulcers, rash, surgical wounds, etc are to be recorded on the form. A Change of Condition form is to be completed and new physician's orders [REDACTED]. The nurse will assure treatments, interventions, Care Plan, and the appropriate skin documentation records are initialed in a timely manner according to Practice Guidelines. Pressure Ulcers are measured and staged weekly... At approximately 3:30 p.m. on 12/18/12, Surveyor # returned to Resident #7's unit to see if any changes had been made to Resident #7's left heel pressure ulcer treatment. Surveyor # reviewed a hospice Progress Note dated 12/18/12 written by hospice RN-P stating she had received a call that morning asking her to assess Resident #7's pressure ulcer and pain related to wound. Upon arrival, RN-P requested facility LPN-R administer [MEDICATION NAME] 10 mg. prior to wound care for comfort. Hospice wound care RN-O assisted with the treatment and she also assessed the ulcer. New orders were approved by Resident #7's MD to discontinue the current wound treatment and to discontinue the pressure relief boots. Staff are now to pre-medicate Resident #7 with 10 mg. MSO4 ([MEDICATION NAME]) 15 minutes prior to dressing change. The new treatment to the left heel Stage 3 pressure ulcer is: normal saline wash, pat dry, apply skin prep to peri-wound with a 2 inch border. Apply [MEDICATION NAME] powder to wound bed followed by Santyl. Cover with 4 x 4's and secure with Kerlix. Change twice a day. Surveyor # also reviewed documentation from the hospice wound nurse, RN-O, dated 12/18/12 stating "Came to assess patient's left heel wound. Patient lying in bed upon arrival. Malodor noted in room even prior to removing old dressing. Patient complained of pain, was premedicated with 10 mg. [MEDICATION NAME] prior to dressing change and wound assessment. Writer noted patient wearing a protective boot to left foot, however patient has foot drop and heel is not properly resting in boot. Boot is not effective at removing/ reducing pressure to wound. Upon assessment of wound, wound bed is 30% slough, 70% granulation tissue. Thin, clear drainage noted on old dressing. New treatment applied to wound. Spoke with MD... No further information was provided.

Based on observations, interviews and record review, facility staff did not provide care to 2 of 7 sampled residents (Residents #3 and #7) and 1 supplemental resident (#8), consistent with the residents' interests and choices about aspects of their lives that are significant to the resident. ~ On 12/13/12 facility staff did not honor Resident #3's request to lay down for a nap for approximately 4 hours. Resident #3, who is on hospice, requested at 9:55 a.m. to lay down after the treatment to her foot was completed. The nurse instead took her back out to the lounge until a CNA (Certified Nursing Assistant) was available to lay her down. Resident #3 was up until after lunch, and when staff finally did assist Resident #3 to bed, they then had to get her up a short time later since a new bed was delivered for her. Resident #3 was then assisted to bed by second shift staff. Resident #3's Plan of Care states she should be up for meals only. On 12/17/12 at approximately 7:15 a.m., a CNA provided Resident #3 with morning cares (partial bed bath, got Resident #3 dressed, transferred her to her wheel chair) while Resident #3 slept throughout the cares. Resident #3 would mumble when the CNA would call her name. Resident #3 continued to sleep at the dining room table, and was too sleepy to eat or drink. Surveyor # questioned why Resident #3 had to get up if she was so sleepy. Staff transferred Resident #3 back to bed at 9:55 a.m. On 12/18/12 at approximately 4:15 pm Surveyor # observed a priest visit Resident #3. Resident #3 passed away on 12/20/12. ~ On 12/13/12, Resident #7 was taken to her room for pressure ulcer treatments while a family member was visiting. Once in her room, Resident #7 had to wait for staff to transfer her to bed since they needed a Hoyer lift and two staff assist. At the end of the treatment, Resident #7's family member came to the room to ask if it would be much longer since he had to leave and wanted to say goodbye to Resident #7. Staff had no reason the treatment needed to be done while the family member visited; it could have been done after they left and not interrupt their visit. ~ On 12/17/12, Resident #8 came to the nurses' station twice asking that her bed be made; the second time Resident #8 stated she wanted to lay down. Both times, staff told Resident #8 that housekeeping had washed it and it needed to dry. Surveyor # accompanied Resident #8 to her room and noted the bed was dry, except where they stacked wet pillows on top of each other. The staff at the desk made no attempt to determine if the bed was dry and if it could be made as requested by Resident #8. Findings include: 1. On 12/13/12 at approximately 9:50 a.m., Surveyor # observed RN (Registered Nurse)-G take Resident #3 from the TV lounge back to her room to do the treatment to her ulcers. Resident #3 winced when RN-G removed her gripper sock from her left foot. Surveyor # observed Resident #3's left heel was black, approximately 4 x 4 cm., with a red circle around the black eschar. The edges of the eschar were starting to pull away in some places. RN-G applied skin prep to Resident #3's left heel and put her gripper sock back on (after doing treatment (skin prep) to left toe). When RN-G was done with the left toe and heel treatments, Resident #3 asked if she could lay down for a nap. RN-G stated she would get one of the CNAs to assist her to bed, and started taking Resident #3 back to the TV lounge. Resident #3 asked RN-G where RN-G was taking her. RN-G stated Resident #3 would have to wait in the TV lounge until a CNA was available to assist her to lay down. Surveyor # reviewed Resident #3's Care Card which indicated Resident #3 could be transferred with one assist and a gait belt. Resident #3 is 60 inches (5 feet) tall and weighs less than 100 pounds. Surveyor # observed Resident #3 until 10:14 a.m. During the observations, Resident #3 repeated the motions of putting her right foot on top of her left toes to try to hold up her right foot. During this time, Resident #3 was seated in a balloon toss activity. Resident #3 was observed sitting and eyes closed, leaning her head on her left hand, when AA (Activity Assistant)-M would call her name, Resident #3 would slightly open her eyes and bat the balloon away, then close her eyes again, without lifting her head. AA-M did try to put Resident #3's left foot back on the left foot pedal, but it just slipped off again. Surveyor # observed Resident #3 at 10:48 a.m. to 11:15 a.m. and at 11:38 a.m. Resident #3 continued trying to support her right foot on top of her left foot. At 11:40 a.m., staff took Resident #3 to one of the tables in the dining room, with still just one foot pedal on the wheel chair. Surveyor # always observed the left wheel chair foot pedal in the dependent or down position- this does not elevate Resident #3's left leg. (Resident #3 has a physician's orders [REDACTED].) At 11:40 a.m. Surveyor # asked RN-G if Resident #3 had been assisted to lay down after she requested to lay down a little before 10:00 a.m. RN-G stated "I don't think so, she looks pretty drowsy". On this and each of the previous observations of Resident #3 in her wheel chair, she had her left elbow propped on the left arm rest, and her head rested on her left hand, with her eyes closed. Resident #3's Pressure Ulcer Care Plan states she should be up for meals only. At 2:08 p.m., Surveyor # observed Resident #3 sitting in her wheel chair as described above, in the TV lounge. Surveyor # asked RN MGR-C if Resident #3 ever laid down since she was assisted to get up that morning. RN MGR-C stated staff did assist Resident #3 to lay down after lunch, but they had to get her up right away since the air mattress hospice ordered was delivered. At 2:15 p.m. Surveyor # observed a new air mattress on Resident #3's bed. At 2:48 p.m., two second shift CNAs brought Resident #3 back to her room. They made her bed and assisted Resident #3 to lay down. Resident #3 got to bed at 3:00 p.m. after making her request to lie down at approximately 9:55 a.m.; over 4 hours later. On 12/17/12 at 7:25 a.m. Surveyor # observed 15 residents sitting in either wheel chairs or Broda chairs in the TV lounge area on the Reflections unit. Only 4 of the 15 residents has their eyes open and appeared to be awake. The other 11 residents appeared to be sleeping. On 12/17/12 at 7:28 a.m. Surveyor # observed CNA-F assisting Resident #3 with morning cares. CNA-F had put a fresh brief and Resident #3's slacks on already. CNA-F tried to assist Resident #3 to sit up, but Resident #3 was very sleepy, and kept her eyes closed throughout. Resident #3 did say her back hurt, and "ow,ow, ow." When CNA-F did sit Resident #3 up to place the gait belt around her, Resident #3 immediately started to slump over, eyes closed. CNA-F quickly caught Resident #3 and put the gait belt around her while holding Resident #3 up as Resident #3 leaned far to her left. Surveyor # asked CNA-F why she was getting Resident #3 up since Resident #3 was so sleepy, and she is receiving hospice services. Surveyor # asked if Resident #3 could sleep until she woke up naturally. CNA-F stated "they don't want them staying in bed" and "they need to get to breakfast". Surveyor # asked if Resident #3 could have breakfast later. CNA-F stated Resident #3 might be on the first breakfast seating, and would need to get up at that time. Any time CNA-F let go of Resident #3, she would immediately start leaning/ falling over. CNA-F stated "Wow, she's really out of it." CNA-F transferred Resident #3 to the Broda chair by mostly picking up Resident #3, holding on to the gait belt and around Resident #3's waist in effect giving her a bear hug, and pivoted to the chair. Resident #3 did not bear any weight during the transfer, and kept her eyes closed. CNA-F took Resident #3 out to the dining room and set her at a table. Surveyor # observed Resident #3 until 8:16 a.m. Resident #3 slept in her Broda chair the whole time. At 8:16 a.m., CNA-E served Resident #3 her breakfast, tried to wake her up several times, and walked away, unsuccessful. Resident #3 briefly opened her eyes, then closed them again and appeared to be sleeping. At 8:20 and 8:27 a.m., CNA-E tried to wake Resident #3 up again for breakfast, but Resident #3 was too sleepy to eat. CNA-E said to Surveyor # that Resident #3 used to feed herself, but she only ate by herself once in recent days. CNA-E stated Resident #3 usually likes coffee in the morning, but she could not get Resident #3 to take a drink. Surveyor # observed Resident #3 sleep in her Broda chair until 8:50 a.m., when Surveyor # informed RN MGR-C of the observations of Resident #3 being so sleepy, yet not allowed to stay in bed, though she slept through breakfast. The observations on 12/17/12 follow the 12/13/12 observation when Resident #3 wanted to go to bed before 10:00 a.m., but was not laid down until after lunch, and she slept in her wheel chair the whole time. Resident #3 was enrolled in hospice on 12/13/12. Surveyor # reviewed Resident #3's Plan of Care-Activities of Daily Living dated 7/27/12 and updated 10/3/12, which states "Resident to wash when he/she rises and at HS (hour of sleep). Resident #3's Plan of Care for Activity: Impaired Cognition dated 7/27/12 and updated 10/3/12 includes "Approach: Balance need for stimulation with needs for solace and relaxation." On 12/17/12 at 9:50 a.m. RN-Q provided Surveyor # with a document dated 12/17/12 titled "Follow-up of State Surveyor Complaint" which stated RN-Q and SW (Social Worker)-T inserviced CNAs and nurses on several issues, including "Resident Care Specialists and nurses are to acknowledge patient requests and follow up with the request..."Patient Centered Care" and resident rights were described. For example, if a patient is sleepy, the Resident Care specialist is to allow the resident to continue to sleep until they desire to get up and inform the nurse." On 12/17/12 at 9:55 a.m. RN MGR-C informed Surveyor # staff are assisting Resident #3 to lay down. RN-C stated if a resident is sleepy, staff do not have to get the resident up. On 12/17/12 at 2:45 p.m. Surveyor # reviewed Nurses' Notes for Resident #3 dated 12/17/12 at 1:30 p.m. stating Resident #3 refused meals and medications, has been sleeping since breakfast time. At 1:00 p.m., patient appeared restless and was moaning. MSO4 ([MEDICATION NAME]) administered per orders. Temperature 99, will continue to monitor. On 12/17/12 at the daily exit meeting, Surveyor # shared the above observations with DON (Director of Nursing)-B, noting Resident #3 is on hospice and had rested her head on her left hand, leaning to her left, with her eyes closed on every observation that morning and afternoon. The above observations were shared with DON (Director of Nursing)-B at the daily exit meeting on 12/17/12 and 12/18/12. On 12/18/12 at approximately 4:15 pm Surveyor # observed a priest arriving to visit with Resident #3. Resident #3 passed away on 12/20/12. 2.) On 12/13/12 at 8:30 a.m., Surveyor # observed HCNA (Hospice Certified Nursing Assistant)-N provide morning cares for Resident #7. RN-Q, Staff Development, was also present for the start of the cares. After pulling back Resident #7's covers, HCNA-N carefully removed Resident #7's EZ boot from her left foot. HCNA-N stated quietly to Surveyor # that the bad odor was coming from Resident #7's foot, and he pointed to Resident #7's left heel. The boot had stains in the heel section. Resident #7's left foot was wrapped in gauze. HCNA-N set Resident #7's foot on the sheet on her bed as she lay in bed. A short time later, HCNA-N moved Resident #7's left foot and there was a half-dollar-sized area of serosanguinous drainage on the sheet that seeped through the dressing. Every time HCNA-N would gently move Resident #7's left foot she would grimace or wince. After performing pericare, HCNA-N applied Remedy barrier cream liberally on Resident #7's bottom, covering Resident #7's small pressure ulcer on her right buttock. At 9:30 a.m., HCNA-N completed morning cares, transferred Resident #7 to her Broda chair with assist of facility CNA-E. CNA-E gave Resident #7 her pink bunny to hold, and took her out to the dining room, where Resident #7's family member and companion were waiting for her. On 12/13/12 at 10:15 a.m., Surveyor # observed RN (Registered Nurse)-G approach Resident #7 and her family member as they were seated in the TV lounge/ Activity area. RN-G stated she was going to take Resident #7 to her room to do her treatments at that time. Earlier that morning, Surveyor # spoke with RN-G, informing her that when RN-G did several residents' pressure ulcer treatments, Surveyor # would like to observe the treatments. Surveyor # stressed that whenever RN-G would normally do the treatments, Surveyor # would be available; no special arrangements need to be made, just whenever it is best for the residents. RN-G took Resident #7 in her Broda chair to her room. RN-G asked CNA (Certified Nursing Assistant)-D if she could assist RN-G transfer Resident #7 to bed and help with positioning Resident #7 during the treatment. CNA-D stated she had assisted another resident on to the toilet and was going back to transfer the resident off the toilet, but she would look for another CNA to assist RN-G. A few minutes later, CNA-D reported back that she could not find the other CNA, so if RN-G would help CNA-D transfer the other resident off the toilet and back into her chair, she could then help RN-G with the transfer and treatment. Both RN-G and CNA-D left Resident #7 in her room and went to assist the other resident. Surveyor # noted that Resident #7 still had visitors waiting to spend time with her at this time. A short time later, Surveyor # observed RN-G and CNA-D return to Resident #7's room and transfer Resident #7 to her bed from her wheel chair using a Hoyer lift. Every time staff touched or moved Resident #7's left lower leg, she winced in pain but made no sound. RN-G removed a small, pink stuffed bunny Resident #7 was holding and set it on the dresser. Resident #7's physicians orders for treatment of [REDACTED]. This is scheduled on the TAR (Treatment Administration Record) to be completed on day shift (no time specified, just shift). Surveyor # observed RN-G perform Resident #7's left heel treatment treatment once Resident #7 was transferred back to bed. Any time Resident #7's left foot was touched or moved during the transfer, and when RN-G removed Resident #7's left heel boot and dressing, Resident #7 would wince and grimace, appearing to be in pain. After the boot and dressing were removed, Surveyor # observed Resident #7's pressure ulcer to be approximately 3.0 x 4.0 x 1.0 cm., mostly bright red, some bleeding, with a small amount of eschar on one side of the ulcer. The old gauze dressing had dried and fresh blood on it. RN-G cleansed the open, raw, wound/ tissue with the prescribed Dakin's solution and gauze. While Resident #7 winced every time her left foot was moved, when RN-G cleansed the wound with Dakin's solution on a piece of gauze, Resident #7 arched her back- looking up at the ceiling, gritted her teeth, clenched the bottom bed sheet with both hands, and her eyes became moist. Resident #7 did not make a sound. While a treatment to a fresh Stage 3 pressure ulcer (eschar cap had come off sometime between 12/11/12 when the wound was assessed and measured and the 12/13/12 treatment observation) with even normal saline is often very painful on the raw tissue, Dakin's solution is hypochlorite, or a weak bleach solution which states "For External Use Only" on the product information. Surveyor # stated Resident #7 seemed to be in a lot of pain. RN-G completed the treatment and dressing before looking around CNA-D at Resident #7's face and the rest of her body for the first time since she began the treatment. CNA-D looked at Resident #7's face for the first time at that time, too Once RN-G covered Resident #7's heel with gauze and started wrapping it with Kerlix, Resident #7 somewhat lessened her facial expressions of pain (clenched teeth/jaw, eyes wide open staring at ceiling), relaxed her body which had been tense with somewhat arched back, and let go of her grasp of the sheets/ bedding she had been clutching during the treatment, but Resident #7 did continue to have a less intense wince/ grimace when her foot was moved. RN-G completed the treatment to Resident #7's foot, and proceeded to reposition Resident #7 on her left side, with assistance from CNA-D, to do the treatment to Resident #7's right buttock. RN-G had to scrub the barrier cream off Resident #7 to visualize the pressure area and apply the zinc oxide 20% ointment. Surveyor # asked why staff don't coordinate the treatments with morning cares, so the CNA doesn't apply barrier cream that then is scrubbed off a short time later to apply the zinc. Given that Resident #7 is on hospice, had poor nutritional status, and has had multiple pressure ulcers on her bilateral buttocks, scrubbing the barrier cream off doesn't seem to promote healthy tissue. And if the nurse did Resident #7's treatment to her left heel while Resident #7 was still in bed, Resident #7 would not have to go through the painful process of being transferred back to bed since every time staff move Resident #7's left foot, she grimaces; Resident #7 even grimaces when the boot is taken off and put back on. In addition, why is RN-G doing Resident #7's treatment while her family member is here to visit- couldn't the treatment wait until they were gone and Resident #7 was back in bed later in the day. RN-G stated she usually works on another unit and is not familiar with which residents receive which treatments, until she goes through the treatment book. RN-G was going through the book, doing the treatments as she came across them; no one gave any other guidance or directions regarding when to do the treatments or residents' usual routines. When RN-G had just finished the treatments and CNA-D went to get the Hoyer lift to transfer Resident #7 back into her wheel chair, Resident #7's family member knocked on the door and entered the room, asking what was taking so long, stating he had to get going soon. The family member then went over to the dresser, picked up the pink bunny and gave it to Resident #7, saying the bunny comforts Resident #7 and he has asked staff to give it to her to hold (which CNA-E did at the completion of morning cares earlier). Resident #7's family member leaned over and kissed her, and waited for staff to transfer Resident #7 back to her chair, then left the facility. This information was shared at the daily exit meeting on 12/17/12. No further information was provided. 3.) On 12/17/12 at 8:28 a.m., Surveyor # was standing at the nurses' station on the Reflections unit and observed Resident #8 approach the nurses' station asking if someone would make her bed. RN MGR (Registered Nurse Manager)-C stated housekeeping staff had to wash her bed and it needs to dry. Resident #3 left the nurses' station and returned to her room. At 8:44 a.m., Resident #8 returned to the nurses' station and asked again if someone would make her bed so she could lay down. RN MGR-C again said housekeeping had to wash her bed and it needs to dry. RN MGR-C went back to some paper work she was working on. Surveyor # accompanied Resident #8 back to her room and with Resident #8's permission, checked to see if her bed was dry. Resident #8's bed was totally dry except where staff had stacked two wet pillows on top of each other. The top of the top pillow was dry; the underside of the top pillow was damp where it laid on top of the second pillow as was the second pillow and the spot on the bed where the pillows were stacked at the head of the bed. With the wet pillows stacked in such a manner, it would have taken a very long time for the pillows and the spot on the bed to dry. Once the pillows were moved, the spot on the bed dried quickly. Surveyor # laid the pillows out so they would dry, per Resident #8's request. Surveyor # then went back to RN MGR-C and informed of Resident #8's bed was dry and could be made, and informed her the pillows were separated so they would dry. Surveyor # then asked why RN MGR-C did not try to assist Resident #8 or try to get someone else to assist Resident #8. RN MGR-C stated "You should have seen what she (Resident #8) did to her bed before housekeeping got to it." Surveyor # noted Resident #8 was on a dementia unit and regardless of the resident's behaviors, the residents still need staff assistance. No further information was provided. Surveyor # shared the above observations with DON (Director of Nursing)-B at the daily exit meeting on 12/17/12.