Every finding on record at Dove Healthcare - Fennimore

Based on interview and record review, the facility did not ensure each resident's right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care and the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This had the potential to affect all 42 residents residing in the facility. The facility enrolled residents in a service provided by a third party without the consent of each resident or their representative. Findings includeAccording to facility documentation, in September of 2025 the facility entered into an agreement with a technology-based company to provide Remote Patient Monitoring (RPM), Chronic Care Management (CCM), Collaborative Care Management (CoCM) and Advanced Primary Care Management (APCM). Further details of the agreement describe detail elements of these services:~CCM elements: Monthly review on chronic conditions vs vital trends Tracking for any changes in vital trends Identifying medication and dosing changes to balance out vital signs Communication with facilities on any recommended changes in care to better improvepatients care~APCM elements: Ongoing assessment and personalized care planning Regular in-person or virtual follow-ups Care coordination with other providers Medication management Monitoring of chronic conditions Support for social and behavioral health needs Patient education and engagement 24/7 clinical support access~RPM elements: Vital Collections Abnormal vitals flagging and detections. Prompt reporting of any abnormal vitals Proper documents on all critical vital bindings and documentation Proper coordination and communication btw care team including nurse practitioner andcare manager.~CoCM elements: Participating in diagnosis and treatment planning coordinating treatment Providing proactive follow-up of treatment response Alerting the PCP when the patient is not improving Supporting medication management Facilitating communication with the psychiatric consultant regarding treatment changes,offer brief counseling (using evidence-based techniques such as motivationalinterviewing, behavioral activation, and problem-solving treatment) R1 was admitted to the facility on [DATE]. She has an activated POA (Power of Attorney) which has been activated since November 2025.On 7/1/26, the state Survey Agency received a complaint that Residents had been receiving Explanation of Benefits (EOB) documents detailing denials of Medicare coverage for services by providers that were not the primary care provider and were unknown providers.R1's Medicare Summary Notice for part B shows R1 was billed as a result of the services by this third party on 12/15/26, 1/4/26, 1/19/26, and 2/3/26. Of note, facility visitor logs dating back to December 2025 does not show the providers listed on these EOBs and Medicare summaries had been in the building. On 7/6/26 at 12:33 PM, Surveyor interviewed DCO D (Director of Clinical Operations), who works with the third party company working with the facility. DCO D indicated that the company is a preventative care company that provides RPM services that integrate into the facility's EHR (Electronic Health Records) system. DCO D indicated that they can then monitor resident information remotely, look for trends and if anything is identified that is outside of resident baseline parameters, they will contact the facility directly via phone call. DCO D indicated that the APCM involves a once a month visit from the provider. The provider will go over notes, parameters and trends. DCO D also indicated that residents/resident representatives are not expected to pay for anything out of pocket, that Medicare part B is billed. DCO D indicated that they get a verbal consent from the resident and that should be documented, but they also have a document giving residents the right to accept or decline provider visits and monitoring, although all resident information is still available to them.It should be noted that DCO D was unable to provide documentation that residents gave consent for these services. Additionally, it should be noted that in an interview on 7/6/26 at 3:33 PM with VPCO C (Vice President of Clinal Operations), who works for the facility and signed the initial agreement with the third party company, VPCO C stated she was unaware if the facility or third party company had received verbal consents and documented those consents. No such consents were provided to Surveyors. On 7/6/26 at 1:33 PM, Surveyor interviewed POA E (Power of Attorney) who indicated that she did not know who the providers were that were listed on R1's EOB and Medicare part B statements. POA E indicated that she had contacted R1's physician, who also did not know who these providers were. POA E indicated that R1 has had the same primary care physician for 4 years and did not understand why other providers she didn't know were seeing R1 or what was being provided to her. POA E indicated that she did not become aware of these services until she got R1's mail in May of 2026 at which point she notified the facility, who had few answers for her and why she was not notified about the services. POA E stated that neither she nor R1 had been billed directly by the third party company to this point.On 7/6/26 at 2:14 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who indicated that the agreement with this third party was put in place before he began working for the facility and he was unaware of the services and the providers involved until POA E brought it to his attention at which time he addressed the issue with all the heads of the facility and nursing staff. NHA A stated that there should have been consents in place for all residents to ensure they were aware of these services and potential costs.The consent form referenced by DCO D was implemented on 5/21/26 and states, in part: By agreeing to participate in CoCM, I understand and acknowledge the following:1 . The treating practitioner has explained the CoCM program to me, including the roles of the care team, and has advised that the physician overseeing my care has determined participation is medically necessary and that I may benefit from it.2. My medical and mental health information may be shared among the CoCM team to support coordinated, comprehensive care.3. I may be responsible for cost-sharing, including deductibles, copayments, or coinsurance for both in-person and non-face-to-face services provided under the program.The facility identified the need for residents to give consent for these services. The facility put an action plan in place on 5/21/26 that included the following:~The consent process was implemented on 5/21 in morning meeting with all department heads. The consent was delegated to the Social Services Director to be placed in the admission packets.~The consent was reviewed with all current residents where they were given the opportunity to opt in or out the consent (attached) has a paragraph explaining financial responsibility for the in person visits. It also explains the program. ~The Social Services Director met with each resident/representative to present and obtain consent or opt out. ~The consent is now presented at admission for all new residents with all other consents.

Based on interview and record review, the facility did not ensure that all resident records were kept confidential except when release is for treatment, payment, or health care operations. This has the potential to affect all 42 residents residing in the facility.The facility entered a business agreement with a third party company that had access and used resident information to provide treatment and health care operations that residents were unaware were occurring, did not consent to and were being billed for.Findings includeAccording to facility documentation, in September of 2025 the facility entered into an agreement with a technology-based company to provide Remote Patient Monitoring (RPM), Chronic Care Management (CCM), Collaborative Care Management (CoCM) and Advanced Primary Care Management (APCM). Further details of the agreement describe detail elements of these services:~CCM elements: Monthly review on chronic conditions vs vital trends Tracking for any changes in vital trends Identifying medication and dosing changes to balance out vital signs Communication with facilities on any recommended changes in care to better improvepatients care~APCM elements: Ongoing assessment and personalized care planning Regular in-person or virtual follow-ups Care coordination with other providers Medication management Monitoring of chronic conditions Support for social and behavioral health needs Patient education and engagement 24/7 clinical support access~RPM elements: Vital Collections Abnormal vitals flagging and detections. Prompt reporting of any abnormal vitals Proper documents on all critical vital bindings and documentation Proper coordination and communication btw care team including nurse practitioner andcare manager.~CoCM elements: Participating in diagnosis and treatment planning coordinating treatment Providing proactive follow-up of treatment response Alerting the PCP when the patient is not improving Supporting medication management Facilitating communication with the psychiatric consultant regarding treatment changes,offer brief counseling (using evidence-based techniques such as motivationalinterviewing, behavioral activation, and problem-solving treatment) R1 was admitted to the facility on [DATE]. She has an activated POA (Power of Attorney) which has been activated since November 2025.R1's Medicare Summary Notice for part B shows R1 was billed as a result of the services by this third party on 12/15/26, 1/4/26, 1/19/26, and 2/3/26. On 7/6/26 at 12:33 PM, Surveyor interviewed DCO D (Director of Clinical Operations), who works with the third party company working with the facility. DCO D indicated that the company is a preventative care company that provides RPM services that integrate into the facility's EHR (Electronic Health Records) system. DCO D indicated that they can then monitor resident information remotely, look for trends and if anything is identified that is outside of resident baseline parameters, they will contact the facility directly via phone call. DCO D indicated that the APCM involves a once a month visit from the provider. The provider will go over notes, parameters and trends. DCO D also indicated that residents/resident representatives are not expected to pay for anything out of pocket, that Medicare part B is billed. DCO D indicated that they get a verbal consent from the resident and that should be documented, but they also have a document giving residents the right to accept or decline provider visits and monitoring, although all resident information is still available to them.It should be noted that DCO D was unable to provide documentation that residents gave consent for these services.On 7/6/26 at 1:33 PM, Surveyor interviewed POA E (Power of Attorney) who indicated that she did not know who the providers were that were listed on R1's EOB and Medicare part B statements. POA E indicated that she had contacted R1's physician, who also did not know who these providers were. POA E indicated that R1 has had the same primary care physician for 4 years and did not understand why other providers she didn't know were seeing R1 or what was being provided to her. POA E indicated that she did not become aware of these services until she got R1's mail in May of 2026 at which point she notified the facility, who had few answers for her and why she was not notified about the services. POA E stated that neither she nor R1 had been billed directly by the third-party company to this point.On 7/6/26 at 2:14 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who indicated that the agreement with this third party was put in place before he began working for the facility and he was unaware of the services and the providers involved until POA E brought it to his attention at which time he addressed the issue with all the heads of the facility and nursing staff. NHA A stated that there should have been consents in place for all residents to ensure they were aware of these services and potential costs.The consent form referenced by DCO D was implemented on 5/21/26 and states, in part: By agreeing to participate in CoCM, I understand and acknowledge the following:1 . The treating practitioner has explained the CoCM program to me, including the roles of the care team, and has advised that the physician overseeing my care has determined participation is medically necessary and that I may benefit from it.2. My medical and mental health information may be shared among the CoCM team to support coordinated, comprehensive care. 3. I may be responsible for cost-sharing, including deductibles, copayments, or coinsurance for both in-person and non-face-to-face services provided under the program. The facility, in collaboration with this third-party technology company, used resident information in effort to provide healthcare services and bill residents for those services despite the resident and/or their representatives being unaware they were occurring and did not consent to.The facility identified the need for residents to give consent for these services. The facility put an action plan in place on 5/21/26 that included the following:~The consent process was implemented on 5/21 in morning meeting with all department heads. The consent was delegated to the Social Services Director to be placed in the admission packets.~The consent was reviewed with all current residents where they were given the opportunity to opt in or out the consent (attached) has a paragraph explaining financial responsibility for the in person visits. It also explains the program. ~The Social Services Director met with each resident/representative to present and obtain consent or opt out. ~The consent is now presented at admission for all new residents with all other consents.

.Based on document review, interview and policy review, the facility failed to protect the resident's rights for one of two residents (R1) reviewed for abuse to be free from verbal abuse. Facility failed to protect R1 from verbal abuse.Findings include:Review of the facility's policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program dated October 2023 revealed, Purpose.to protect its residents from abuse.Policy: Each resident has the right to be from abuse.Abuse includes verbal abuse.Review of the facility's investigative file revealed on 09/11/25 at approximately 6:00PM (evening meal), revealed that two Certified Nurse Aides (CNA) 2 and CNA3 witnessed an incident involving R1 and CNA1. During the evening meal, R1 was asking for reassurance about what he should eat or drink. R1 uses repetitive phrases and words as part of his normal communication style. CNA 2 and CNA3 stated that they witnessed CNA1 respond to R1's repetitive vocalizing by leaning close to him and saying R1, R1, R1, do you hear me? Well, I can hear you. You don't like that either, do you. CNA2 and CNA3 stated that CNA1 appeared visibly annoyed. CNA2 noted that R1 lowered his head and said okay. CNA2 stated that R1 appeared sad.During an interview on 10/14/25 at 3:30 PM, the Abuse coordinator (Administrator) confirmed that CNA1 had verbally abused R1 during the evening meal on 09/11/25.Facility failed to protect R1 from verbal abuse.

.Based on document review, interview and policy review, the facility failed to thoroughly investigate an allegation of verbal abuse for one of two residents (R1) reviewed for abuse. The failure to thoroughly investigate an allegation of abuse had the potential to negatively impact residents in the facility.Findings include:Review of the facility's policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program dated October 2023 revealed, .Investigation would include interviews with staff working on the shift when the abuse occurred as well as include interviews with staff that worked the previous shift.Review of the facility's investigative file revealed on 09/11/25 at approximately 6:00PM (evening meal), two Certified Nurse Aides (CNA) 2 and CNA3 witnessed an incident involving R1 and CNA1. During dinner, R1 was asking for reassurance about what he should eat or drink. R1 uses repetitive phrases and words as part of his normal communication style. CNA2 and CNA3 stated that they witnessed CNA1 respond to R1's repetitive vocalizing by leaning close to him and saying R1, R1, R1, do you hear me? Well, I can hear you. You don't like that either, do you. CNA2 and CNA3 stated that CNA1 appeared visibly annoyed. CNA2 noted that R1 lowered his head and said okay. CNA2 stated that R1 appeared sad.Review of the facility's investigative file for R1 revealed that the abuse coordinator (Administrator) confirmed that CNA1 had verbally abused R1 during the evening meal on 09/11/25.During an interview on 09/14/25 at 3:30 PM, the Administrator reviewed the nursing schedule for 09/11/25 and stated that Registered Nurse (RN)1, Licensed Practical Nurse (LPN)2, CNA1, CNA2 and CNA3 worked the evening shift on 09/11/25, which included the evening meal.Review of the facility's investigative file revealed that there were no statements from RN1 or LPN2. In addition, the investigative file did not include staff interviews from the previous shift.During the interview on 09/14/25 at 3:30 PM, the Administrator confirmed that the investigative file did not include the staff interviews as indicated in the facility's Abuse policy.

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents (R7) reviewed for falls out of a total sample of 12.R7 had a history of falls including one that resulted in a T11 spinal fracture and another that resulted in a laceration with 2 staples and a subdural hematoma. The facility did not complete a thorough root cause analysis on the falls or ensure that care planned interventions were in place for R7.As evidenced by:Facility policy, titled Fall Prevention Program, with last revision date of 8/2024, includes, in part: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: . 5. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. A. Interventions will be monitored for effectiveness. B. The plan of care will be revised as needed. 6. When any resident experiences a fall, the facility will. e. Review the resident's care plan and update as indicated. 7. Review each fall/fall investigation during the next morning meeting/clinical meeting with the interdisciplinary team (IDT). Actions may include: a. Review investigation and determination of potential root cause of fall; b. Review of fall risk care plan and update; c. Additional revisions to the care plan; Education of staff as to any care plan revisions as needed.R7 was admitted to the facility on [DATE] with diagnoses that include, in part: Parkinson's Disease, Weakness, Other Chronic Pain, Unsteadiness on Feet, Pain in Right Knee, and History of Falling.R7's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/31/25, indicates R7 has a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating R7 is cognitively intact. Section GG (Functional Abilities) of R7's MDS indicates R7 requires substantial/maximum assistance with toileting and partial/moderate assistance with transfers and ambulating. Section H of R7's MDS indicates that R7 is occasionally incontinent of both bowel and bladder, and that a toileting program had not been trialed, and a bowel program was not currently being used.R7's comprehensive care plan, includes, in part:--Focus: The resident is at risk for falls r/t (related to) deconditioning, gait/balance problems secondary to Parkinson's disease, frequent falls at home. Date Initiated: 11/22/23. Revision on: 11/22/23.--Goal: The resident will be free of major injury r/t falls through the review date. Date Initiated: 11/22/23. Revision on: 8/20/25.--Interventions include, in part: Grip strips at side of bed to provide traction when he is transferring to/from bed. (Date Initiated: 12/31/24). Gripper socks when not wearing shoes (Date Initiated: 10/21/24). Education provided to wear gripper socks when not wearing shoes. (Date Initiated: 1/13/25). Assure resident . has appropriate size gripper socks. (Date Initiated: 1/16/25). When weighing resident, use portable scales on end of 200 wing to take to room. (Date Initiated: 3/24/25). Dycem in recliner chair. (Date Initiated: 4/10/25). Make sure that resident has gripper socks with grips on both sides and remove and replace grip strips on the floor. (Date Initiated: 5/2/25). Replace grip strips on floor. (Date Initiated: 7/21/25). Risk vs. benefits of having oversized chair placing resident at risk for sliding out and doesn't provide enough core stability to manage balance problems. Resident is refusing to get or try a different chair that places him at risk for injury, fracture, or even death. (Date Initiated: 7/21/25). Adjust dimension of chair stabilizer behind chair from square to triangular to fit in the corner. (Date Initiated: 8/6/25).--Focus: The resident as an ADL (Activities of Daily Living) self-care deficit r/t Parkinson's disease, DM (Diabetes Mellitus). Date Initiated: 11/22/23. Revision on: 11/22/23.--Interventions: Toilet Use: ambulate to/from bathroom with assist of 1 with gait belt and FWW (front wheeled walker). Date Initiated: 10/24/24. Revision on: 10/24/24 . Transfer: assist of 1 with gait belt and walker. Date Initiated: 11/22/23. Revision on: 8/7/24.On 10/14/24 at 1:15 AM, R7 had an unwitnessed fall in his room. The fall incident report indicates, in part: Resident was found. lying on the floor. head against the recliner in his room. Resident was not wearing gripper socks or shoes, he was barefoot . Injuries: bruise to right forearm, skin tear to right forearm, skin tear to left forearm. Resident was incontinent at time of fall. No root cause identified. Progress Note linked to this fall report indicates on 1/8/25: New result from MRI showing a T11 fracture. This does explain the pain. (R7 did not have a Power Chair/Recliner Screen completed prior to this fall or after falling from his recliner chair.)On 1/12/25 at 5:30 AM, R7 had an unwitnessed fall in his room. The fall incident report indicates, in part: Resident was found. laying on his back on the floor. in the doorway between his bathroom and bedroom. he had removed his left sock and it was sitting on his bedside table. Injuries: skin tear to left toe, skin tear to left forearm. No root cause identified.(Of note, on 1/12/25, the facility Fall Risk Evaluation was completed, with a score of 17, indicating R7 was a high risk for falls). On 3/22/25 at 12:15 PM, R7 had a witnessed fall while being weighed. The fall incident report indicates, in part: . CNA was attempting to weigh the resident with the stand up scale per usual and resident stepped off the left side of the scale causing him to lose his balance and fall. hitting his head on the night stand and hitting his left arm on the recliner. Injuries: abrasion to left arm. No root cause identified.(Of note, on 3/22/25, the facility Fall Risk Evaluation was completed, with a score of 9, indicating R7 was a low risk for falls).On 4/9/25 at 8:40 PM, R7 had a witnessed fall in his bathroom. The fall incident report indicates, in part: Resident was sitting in his recliner. the CNA (Certified Nursing Assistant) went to his closet to get his clothes out and during that time he had raised his electric recliner all the way up. he attempted to stand up out of his chair and slid. to the floor. Injuries: skin tear to right elbow, skin tear to back of left hand, skin tear to right knee.Root cause: weakness following hospitalization .(Of note, on 4/9/25, the facility Fall Risk Evaluation was completed, with a score of 15, indicating R7 was a medium risk for falls).On 5/1/25 at 9:20 AM, R7 had an unwitnessed fall in his room. The fall incident report indicates, in part: . The resident stated that he was attempting to go to the bathroom when he fell. states that he did hit his head on the way to the floor. Injuries: skin tear to left elbow. No root cause identified.(Of note: On 5/1/25 the facility Fall Risk Evaluation was completed, with a score of 15, indicating R7 was a medium risk for falls).On 7/15/25 at 10:50 PM, R7 had an unwitnessed fall in his room. The fall incident report indicates, in part: Resident found sitting in front of recliner. states he slid out of chair. No injuries. No root cause identified.(Of note: this is the 2nd time R7 has fallen out of his recliner. R7 does not have a Power Chair/Recliner Screen. Risk vs benefits were added to the care plan on 7/19/25).On 7/19/25 at 4:40 PM. R7 had an unwitnessed fall in his room. The fall incident report indicates, in part: . Resident states that he did not use the call light to self-transfer to the bathroom and that he knew he should have. Injuries: skin tear to left elbow. Root cause: ill-fitting chair.(Of note: this is the 3rd fall revolving around the bathroom, and R7's toileting pattern has not been assessed, and he does not have a toileting program. On 7/19/25 the facility Fall Risk Evaluation was completed, with a score of 15, indicating R7 was a medium risk for falls.)On 8/6/25 at 2:00 AM, R7 had an unwitnessed fall in his room. The fall incident report indicates, in part: .resident was found to be laying on his back in front of electric recliner that was positioned in the maximum upright position, dysom (sic) and chair cushion on floor near chair. resident states he was trying to reposition himself in the chair and slipped. blood found on floor near resident. resident was found to have head injury. when attempting to reposition patient to prepare to transfer resident, resident c/o (complained of) extreme pain to lower back. it was found that resident had an episode of emesis, resident does not know if this happened prior to or after fall. Injuries: laceration to back of head. Root cause: slipped.R7's ER notes on 8/6/25 states, in part: Patient. found on the floor in front of his wheelchair. There was emesis in front of the chair. Patient states that he might of slid out of his chair but does not remember falling out of his chair or hitting his head or vomiting. Laceration of scalp without foreign body. 1.5 cm (centimeter) posterior scalp laceration noted in the occipital area. 2 staples placed. subdural hematoma along the interhemispheric fissure.(Of note: this is R7's 3rd time falling out of his recliner, R7 did not have a Power Chair/Recliner Screen completed prior to this fall and this fall resulted in a head injury requiring staples.)R7's most recent fall risk assessment, dated 8/8/25, indicated a score of 16, indicating that R7 is a high fall risk.R7's Power Chair/Recliner Screen, dated 8/21/25, indicated that R7 was able to use his power recliner with no restrictions.(Of note, there were no other Recliner evaluations completed before 8/21/25, although R7 had had 2 previous falls from the recliner).On 9/8/25 at 10:52 AM, Surveyor observed R7 in his room in his recliner with the feet up. Surveyor asked R7 about his recent falls. R7 laughed and stated that he has had many falls and feels increasingly unsteady. R7 indicated that he uses his walker to ambulate and that he tries to get staff to go with him to the bathroom.On 9/10/25 at 10:29 AM, Surveyor observed R7 being wheeled to his room via wheelchair. R7 stated he just got back from being weighed in the shower room. Surveyor stepped out of the room while CNA C (Certified Nursing Assistant) assisted R7 with completing dressing. Surveyor re-entered R7's room and observed R7 sitting in his recliner. Surveyor observed the dycem anti-slip mat on the table next to the recliner. Surveyor asked R7 if he had any dycem in his recliner at that time. R7 stated no, that he was supposed to have a cushion in the chair but that the staff were unable to locate it. R7 stated that the dycem was supposed to be for the cushion, but that it was not in his chair and that it gets worn and slides off.On 9/10/25 at 10:33 AM, Surveyor interviewed CNA C who confirmed that there was no dycem or cushion under R7 in his recliner, only a soaker pad. Surveyor asked CNA C if the dycem should be in the recliner if it was one of his care planned interventions. CNA C stated yes, if dycem was on his care plan than he should have it in his chair.On 9/10/25 at 11:19 AM, Surveyor interviewed RN D (Registered Nurse) and asked what R7's current fall interventions were. RN D accessed R7's EHR (Electronic Health Record) and stated that grip strips in front of the recliner, gripper socks on when not wearing shoes, assure he has the appropriate sized gripper socks, and dycem in the recliner were some of R7's current fall interventions. RN D stated that R7 had been educated on his chair being too large for him. RN D stated that recently the recliner has been a big issue, and they had talked to him and his wife about getting fitted for a new recliner but that R7 is not willing to give it up his current recliner.On 9/10/25 at 11:27 AM, Surveyor interviewed CNA C about R7's current fall interventions. CNA C stated that R7's current fall interventions include having two staff assistance when they can, strips in front of his chair, making sure that he has gripper socks on and that his feet are firmly planted before moving forward.On 9/10/25 at 11:32 AM, Surveyor interviewed CNA E about R7's current fall interventions. CNA E stated that R7's current fall interventions include gripper socks if he doesn't have his shoes on, black strips in front of his chair, and a sign that says don't stand up and to call for assistance.On 9/10/25 at 2:12 PM, Surveyor interviewed DON B (Director of Nursing) about R7's multiple falls. DON B stated that they have tried about everything with R7 and tried to get him to go with a different chair because his current recliner doesn't fit him anymore. Surveyor asked DON B about R7's current fall interventions. DON B accessed R7's EHR and indicated R7's current fall interventions include gripper socks when not wearing shoes, PT (physical therapy) to evaluate, make sure he has the appropriate size gripper socks or his shoes for transfers, and dycem in the recliner. DON B stated that they like him to put the dysem between the recliner seat and the cushion and then also to put dycem on top of the cushion to keep him from sliding out. Surveyor asked DON B how they determine if the fall interventions for R7 are effective. DON B stated that they just monitor to make sure that something is working. Surveyor asked DON B if they had identified a root cause for each of R7's falls. DON B stated that yes, the IDT (interdisciplinary team) identified the root cause during the next morning's huddle. Surveyor asked DON B if just indicating slipped was a true root cause of a fall. DON B indicated no, that was probably not the true root cause. Surveyor asked DON B if R7 had a toileting schedule or bladder and bowel program initiated. DON B stated that R7 had been on a toileting schedule, but that she couldn't find any documentation of it. Surveyor shared with DON B her observations and asked DON B if she would expect R7's care plan to be followed. DON B stated yes, that was her expectation.The facility failed to identify a true root cause for R7's repeated falls, and failed to ensure that the fall interventions on R7's care plan were adequately enforced. R7 had multiple falls, including two that resulted in major injury.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the ability to affect all 34 residents.Food items were not dated or were expired.Food items were improperly storedA scoop was found in dry ingredients.Evidenced by:On 9/8/24 at 9:51 AM, Surveyor observed, along with DM I (Dietary manager), the following inside the main kitchen's walk-in refrigerator:*An opened pack of sliced cheese with no open date or use by date.*An opened pack of 3 tortillas with no open date or use by date.*2 baked potatoes in a Ziplock bag with 8/25 written on bag.*5 loaves of bread with no use by or expiration dates.*An apple on the floor At 10:15 AM, Surveyor observed an open bag of milk crystals with no date in the dry storage area. At 10:19 AM, DM I indicated to Surveyor that the above food items should be dated and discarded the baked potatoes and apple. Example 2On 9/08/2025, Surveyor observed the following, along with DM I, in the facility's main kitchen:*At 10:03 AM: box of pork ribs on the floor inside the walk-in freezer.*At 10:14 AM: a box of orange juices, a box of elbow macaroni, a box of canned vegetables and a box of rhubarb pie mix on the floor in the dry storage room. DM I stated to surveyor at 10:19 AM that she had been gone the previous week on Friday and was unable to ensure the items in the dry storage were put away timely and removed from the floor. Example 3On 9/8/25 at 10:09 AM, Surveyor observed, in the facility kitchen's dry storage area, a 20-liter container of corn starch with a scoop inside.At 10:19 AM, DM I stated to Surveyor that the scoop should not be inside the corn starch as this is an infection control concern.

Based on observation and interview, the facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 34 residents.Garbage was observed surrounding the garbage dumpster.Evidenced by:On 9/8/2025 at 9:51 AM, Surveyor and DM I (Dietary Manager) observed the following outside the facility in the garbage dumpster area:*Used napkins*Approximately 10 used latex gloves*Various unknown food items crushed into the ground*Condiment packetsIt should be noted that these items were surrounding the dumpster area and also along the small hillside on the backside of the garbage dumpsters.On 9/8/25 at 9:53 AM, DM I indicated to Surveyor that there was too much garbage on the ground, and it was dirty and needed to be cleaned up. DM I was unable to identify the food items that were crushed on the ground.

Based on interview and record review the Facility did not have evidence all alleged violations of mistreatment were thoroughly investigated for an allegation of abuse involving 2 residents (R26 and R15)On 8/31/25, R26 reported to the facility staff that another resident came into his room and was yelling at R26 and poured urine on R26's shoes. The facility did not thoroughly investigate this allegation.This is evidenced by:The facility's policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program, last revised on 10/23, states: Alleged violation is a situation or occurrence that is observed or reported by staff, resident.but not yet been investigated. 5. Investigation: All of the following are promptly investigated per facility policies and practices. All resident accidents and incidents including: .Any other incident occurring to a resident. All concerns including loss or misuse of a resident personal belongings or money; and any concern/grievance brought forward by or to facility staff related to resident care and/or safety. All investigations will be thorough, well-documented, and immediate to determine if mistreatment occurred and, if so, to what extent. A thorough investigation may include: Identifying staff responsible for the investigation; collecting and preserving physical and documentary evidence. Interviewing alleged victim(s) and witness(es); interviewing accused individual(s) (including staff, visitors, resident's relatives, etc.) allegedly responsible for mistreatment. interviewing other residents to determine if they have been abused or mistreated; interviewing staff who worked on the same shift as the accused to determine if they ever witnessed any mistreatment by the accused; observation of resident and staff behaviors during the investigation; environmental considerations. Conduct and document interviews of staff and residents that include actual words of interviewees. A complete written report of the investigation will be retained by the facility.R26 admitted to the facility on [DATE] with diagnoses including diffuse traumatic brain injury (brain injury caused by an outside force) and mild cognitive impairment (a brain condition that causes noticeable but mild memory problems).R26's 7/16/25 Brief Interview for Mental Status (BIMS) has a score of 12, indicating R26 has moderate cognitive impairment.R15 admitted to the facility on [DATE].R15's 8/21/25 BIMS has a score of 11, indicating R15 has moderate cognitive impairment.R26's nurses progress note, written by LPN H (Licensed Practical Nurse), dated 8/31/25 at 9:47 AM, states: Resident (R26) voiced to therapy aide that another resident, [R15], went into residents' room (R26's room) early this morning and was yelling at him. Resident (R26) states that he isn't able to put on any pairs of his shoes because they are wet with urine. Resident (R26) states that [R15] spilled his urinal out on his (R26) shoes and now he (R26) cannot wear any of his shoes. [R15] was questioned and states he never went into residents (R26) room. [R15] was not noted by staff to have been in [R26] room.On 9/9/25 at 3:00 PM, Surveyor called LPN H and was unsuccessful in contacting LPN H.On 9/9/25 at 3:20 PM, Surveyor interviewed DON B (Director of Nursing) regarding the incident between R15 and R26. DON B indicated the incident could be viewed as an allegation of abuse because it was a resident-to-resident altercation. DON B indicated she believed SS G (Social Services) and NHA A (Nursing Home Administrator) investigated the incident.Surveyor reviewed the facility's grievance/complaint log for August 2025 and September 2025. There was no grievance listed for R26 related to this incident.On 9/9/25 at 4:00 PM, SS G handed surveyor a redacted, hand-written grievance form. The grievance form states the following: Date occurred: 8/31/25 appox 5 am (Approximately 5:00 AM). Discovery date 8/31/25. Reported by: RN D (Registered Nurse). Concern: [R26] told a nurse that his neighbor [R15] entered his room and emptied a urinal into [R26]'s shoes . Investigation: [R15] stated: Resident stated I had nothing to due [sic] with this. [R26] stated: see attached.Of note, the attached paper included two progress notes from R26's electronic medical record. One progress note was the note from LPN H dated 8/31/25 at 9:47 AM.The second note, dated 9/2/25 at 10:45 AM, was a late entry written by NHA A, states: This writer spoke to [R26] on 9/2/25 and asked him about this incident. [R26] was unable to provide detail on this incident other than he stated that the neighboring resident, [R15], had entered his room at some point during the night or early morningand [sic] emptied a urinal into his shoes. He also stated to staff that maybe it could have been water, but he didn't think so. Writer asked [R26] if his shoes had been cleaned appropriately, and he stated yes, writer offered new shoes, and he refused. Writer also asked [R26] if he had any concerns about his safety around the other resident. [R26] laughed and said it was fine, and not to worry about it. Writer offered to file grievance on his behalf and he stated, 'it was in the past' and not to worry about it. Writer asked [R15] if he had been in [R26] room and emptied urine into his shoes. [R15] stated he didn't do this and that he didn't know what I was talking about. [R15] does not have any previous history of entered other residents' rooms anddisturbing [sic] their personal property. Informed [R26] that if [R15] entered his room again or made any statements that made him feel uncomfortable to please tell staff right away. Of note, this note was entered on 9/9/25 at 3:50 PM. This was 20 minutes after surveyors interviewed DON B regarding the allegation of abuse.On 9/10/25 at 7:27 AM, Surveyor interviewed RN D regarding the incident between R15 and R26. RN D indicated she had worked the night shift and was logged out of the computer and was getting ready to leave the facility when R26 reported to her that between 3:00 AM and 5:00 AM, R15 came into R26's room and attacked R26. RN D indicated she called NHA A to report this incident. RN D indicated after calling NHA A, RN D obtained more information. RN D indicated she was made aware that R26 stated R15 poured urine into R26's shoes. RN D indicated R26's shoes were wet. RN D indicated R26's shoes were taken to laundry to get cleaned. RN D indicated the oncoming nurse, LPN H, was aware of the incident. Surveyor asked RN D why she called NHA A at the end of her night shift (approximately 6:30 AM) regarding R26's statement. RN D stated I called the admin (NHA A) because this may need to have been reported in the 2-hour window because of potential abuse. RN D indicated this incident flagged her that this could be abuse.On 9/10/25 at 9:25 AM, Surveyor interviewed SS G regarding this incident. SS G indicated she was made aware of the incident on 9/2/25 after returning from the Labor Day weekend. SS G indicated she saw the note written on 8/31/25 by LPN H. SS G indicated this could have been abuse but she does not make that decision. SS G indicated NHA A makes the decision on abuse and reporting.On 9/10/25 at 9:41 AM, Surveyor interviewed NHA A regarding this incident. NHA A indicated on 9/2/25 she spoke with R15 and R26 regarding the incident. NHA A indicated she received a call in the middle of the night or early in the morning from the nurse on 8/31/25. NHA A indicated the nurse told her R26 stated R15 came into his room and R15 spilled urine on R26's shoes. NHA A indicated she asked the staff to verify if urine was spilled on R26's shoes and staff informed NHA A that R26's shoes were wet. NHA A indicated it did not make sense because the floor was not wet. NHA A stated, It's hard to say what actually transpired. Surveyor asked NHA A if a resident stated another resident poured urine on his shoes and now his shoes are wet, would that count as an allegation of abuse. NHA A stated I feel like there is a lot of grey area there. Aside of wet shoes, there wasn't any evidence. Surveyor asked for documentation of an investigation and NHA A indicated she did not have documentation of an investigation. Surveyor asked NHA A if an immediate and thorough investigation would have helped to determine the facts in the incident and NHA A indicated she should have reported and investigated this incident as an allegation of abuse and did not.

Based on interview and record review, the Facility did not ensure allegations of abuse, suspected neglect, and/or injury of unknown origin were reported to the State Agency during the required timeframe for 1 of 12 residents (R26) reviewed.On 8/31/25, R26 reported to the facility staff that another resident came into his room and was yelling at R26 and poured urine on R26's shoes. The facility did not report this to the state agency.This is evidenced by:The facility's policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program, last revised on 10/23, states: Each resident of [Facility Name] has the right to be free from abuse, neglect. Residents will not be subjected to abuse by anyone, including but not limited to,.any other individuals. Alleged violation is a situation or occurrence that is observed or reported by staff, resident.but not yet been investigated. Reporting/Response: [Facility Name] ensures all staff/covered individuals are trained.on reporting requirements which includes: What is to be reported - Any reasonable suspicion of a crime against a resident or individual receiving care from the facility, and all alleged violations of abuse. Who is required to report - The facility and any covered individual, which means owner, operator, employee, manager, agent or contractor of the facility. To whom to report - To the Administrator, State Survey Agency, local law enforcement, and adult protective services; and When to report - .All alleged violations, report immediately but not later than 2 hours if the alleged violation involves abuse. The Administrator or designee will report immediately all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property to the Division of Quality Assurance (DQA) via the online reporting system and maintain a copy of the report.R26's nurses progress note, written by LPN H (Licensed Practical Nurse), dated 8/31/25 at 9:47 AM, states: Resident (R26) voiced to therapy aide that another resident, [R15], went into residents room (R26's room) early this morning and was yelling at him. Resident (R26) states that he isn't able to put on any pairs of his shoes because they are wet with urine. Resident (R26) states that [R15] spilled his urinal out on his (R26) shoes and now he (R26) cannot wear any of his shoes. [R15] was questioned and states he never went into residents (R26) room. [R15] was not noted by staff to have been in [R26] room.On 9/9/25 at 3:00 PM, Surveyor called LPN H and was unsuccessful in contacting LPN H.On 9/9/25 at 3:20 PM, Surveyor interviewed DON B (Director of Nursing) regarding the incident between R15 and R26. DON B indicated the incident could be viewed as an allegation of abuse because it was a resident to resident altercation. DON B indicated she believed SS G (Social Services) and NHA A (Nursing Home Administrator) investigated the incident.Surveyor reviewed the facility's grievance/complaint log for August 2025 and September 2025. There was no grievance listed for R26 related to this incident.On 9/9/25 at 4:00 PM, SS G handed surveyor a redacted, hand-written grievance form. The grievance form states the following: Date occurred: 8/31/25 appox 5 am (Approximately 5:00 AM). Discovery date 8/31/25. Reported by: RN D (Registered Nurse). Concern: [R26] told a nurse that his neighbor [R15] entered his room and emptied a urinal into [R26]'s shoes . Investigation: [R15] stated: Resident stated I had nothing to due [sic] with this. [R26] stated: see attached.Of note, the attached paper included two progress notes from R26's electronic medical record. One progress note was the note from LPN H dated 8/31/25 at 9:47 AM.The second note, dated 9/2/25 at 10:45 AM, was a late entry written by NHA A, states: This writer spoke to [R26] on 9/2/25 and asked him about this incident. [R26] was unable to provide detail on this incident other than he stated that the neighboring resident, [R15], had entered his room at some point during the night or early morningand [sic] emptied a urinal into his shoes. He also stated to staff that maybe it could have been water, but he didn't think so. Writer asked [R26] if his shoes had been cleaned appropriately, and he stated yes, writer offered new shoes, and he refused. Writer also asked [R26] if he had any concerns about his safety around the other resident. [R26] laughed and said it was fine, and not to worry about it. Writer offered to file grievance on his behalf and he stated, 'it was in the past' and not to worry about it. Writer asked [R15] if he had been in [R26] room and emptied urine into his shoes. [R15] stated he didn't do this and that he didn't know what I was talking about. [R15] does not have any previous history of entered other residents' rooms anddisturbing [sic] their personal property. Informed [R26] that if [R15] entered his room again or made any statements that made him feel uncomfortable to please tell staff right away. Of note, this note was entered on 9/9/25 at 3:50 PM. This was 20 minutes after surveyors interviewed DON B regarding the allegation of abuse.On 9/10/25 at 7:27 AM, Surveyor interviewed RN D regarding the incident between R15 and R26. RN D indicated she had worked the night shift and was logged out of the computer and was getting ready to leave the facility when R26 reported to her that between 3:00 AM and 5:00 AM, R15 came into R26's room and attacked R26. RN D indicated she called NHA A to report this incident. RN D indicated after calling NHA A, RN D obtained more information. RN D indicated she was made aware that R26 stated R15 poured urine into R26's shoes. RN D indicated R26's shoes were wet. RN D indicated R26's shoes were taken to laundry to get cleaned. RN D indicated the oncoming nurse, LPN H, was aware of the incident. Surveyor asked RN D why she called NHA A at the end of her night shift (approximately 6:30 AM) regarding R26's statement. RN D stated I called the admin (NHA A) because this may need to have been reported in the 2-hour window because of potential abuse. RN D indicated this incident flagged her that it could be abuse.On 9/10/25 at 9:25 AM, Surveyor interviewed SS G regarding this incident. SS G indicated she was made aware of the incident on 9/2/25 after returning from the Labor Day weekend. SS G indicated she saw the note written on 8/31/25 by LPN H. SS G indicated this could have been abuse but she does not make that decision. SS G indicated NHA A makes the decision on abuse and reporting.On 9/10/25 at 9:41 AM, Surveyor interviewed NHA A regarding this incident. NHA A indicated she received a call in the middle of the night or early in the morning from the nurse on 8/31/25. NHA A indicated the nurse told her R26 stated R15 came into his room and R15 spilled urine on R26's shoes. NHA A indicated she asked the staff to verify if urine was spilled on R26's shoes and staff informed NHA A that R26's shoes were wet. NHA A indicated it did not make sense because the floor was not wet. NHA A stated she used the flowchart to see if this was reportable and determined it was not because the nurse said the residents were fine and everything was normal. Surveyor reviewed the Resident-to-Resident Altercation Flowchart (DQA form) with NHA A. Surveyor referenced the Note box on the flowchart that states Use of this flowchart must provide for immediate reporting (see F609) or the facility must clearly document the rationale for not reporting. Surveyor asked NHA A for the documented rationale for not reporting. NHA A indicated she did not have documentation for not reporting. NHA A stated, It's hard to say what actually transpired. Surveyor asked NHA A if a resident stated another resident poured urine on his shoes and now his shoes are wet, would that count as an allegation of abuse. NHA A stated I feel like there is a lot of grey area there. Aside of wet shoes, there wasn't any evidence. Surveyor reviewed the nurses progress note written by LPN H dated 8/31/25 with NHA A. NHA A indicated staff had not mentioned R15 was yelling at R26 and when NHA A spoke with R26, on 9/2/25, R26 had not said anything about it. NHA A indicated after reviewing the Resident-to-Resident flowchart and reading the progress notes with the surveyor, in retrospect, I would have done things differently. NHA A indicated she should have reported this incident as an allegation of abuse and did not.

Based on observation, interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 (R3) of 4 sampled residents.R3 has diagnoses including cerebral infarction (stroke), type 2 diabetes with retinopathy and neuropathy (diabetes causing damage to the nerves and retina), morbid obesity, cognitive communication deficit, generalized muscle weakness, and dementia. R3 developed a diabetic ulcer of his right great toe in the facility that became infected. R3 had a change of condition, became febrile with emesis and the facility failed to notify the physician immediately with this change of condition. R3 was later admitted to the hospital with a wound infection requiring Intravenous (IV) antibiotics. This is evidenced by:The facility does not have a diabetic foot check policy.The facility policy entitled, Notification of Changes, dated 1/2025, states, in part: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Circumstances requiring notification include: . 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: . b. Clinical complications . The facility policy entitled, Documentation of Wound Treatments, dated September 2024, states, in part: Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Policy Explanation and Compliance Guidelines: . 3. Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact). 4. Additional documentation shall include, but is not limited to: a. Date and time of wound management treatments b. Weekly progress towards healing and effectiveness of current intervention c. Any treatment for pain, if present d. Modifications of treatments or interventions e. Notifications to physician and/or responsible party regarding wound or treatment changes. The Interact Standard of Practice guidelines indicate immediate notification is require for 2 or more episodes of vomiting within 12 hours with or without abdominal pain, bleeding, distention/fever. Non-immediate notification is required for intermittent recurrent vomiting without meeting immediate notification criteria. The guidelines also require immediate notification of a new onset temperature over 100.5 F regardless of any other symptoms. Non-immediate notification is required for recurrent daily temperature spikes for more than two days. R3 was admitted to the facility on [DATE], with diagnoses that include, in part: cerebral infarction (stroke), type 2 diabetes with retinopathy and neuropathy (diabetes causing damage to the nerves and retina), morbid obesity, chronic venous hypertension (high blood pressure in veins), cognitive communication deficit, generalized muscle weakness, and dementia. R3's Minimum Data Set (MDS), with Assessment Reference Date of 6/13/25, states that R3 has a BIMS (Brief Interview for Mental Status) of 6 out of 15, indicating that R3 is severely cognitively impaired. Section GG indicates R3 utilizes a wheelchair mobility device and requires substantial/maximal assistance for self-cares including toileting hygiene, shower/bathe self, and lower body dressing. Section GG also indicates R3 is dependent on staff for putting on and taking off footwear. Finally, Section GG indicates R3 requires substantial/maximal assistance for mobility including moving from sitting to lying, lying to sitting, sitting to standing, chair/bed-to-chair transfers, toilet transfers, tub/shower transfers and that R3 could not attempt to walk 10 feet due to a medical condition or safety concerns. R3's Comprehensive Care Plan indicates:Focus: The resident has an ADL self-care performance deficit r/t (related to) hx (history) of CVA (cerebrovascular accident or stroke) with left sided weakness, TIAs (transient ischemic attack, small stroke that resolves itself), morbid obesity, chronic back pain d/t (due to) disc disorders, osteoarthritis bilateral knees. Date Initiated: 11/20/2024Interventions:AMBULATION/LOCOMOTION: No ambulation at this time d/t safety. Assist resident if he gets up by himself as his legs are weak. Date Initiated: 11/20/2024BATH: Prefers Shower. Date Initiated: 11/20/2024BATH: Prefers Whirlpool/Tub. Date Initiated: 11/20/2024BATHING/SHOWER: Substantial/max assist of 1. Avoid scrubbing & pat dry sensitive skin. Check nail length and trim prn. Report changes to the nurse. Nurse to cut nails d/t being diabetic. Date Initiated: 11/22/2024BED MOBILITY: Substantial/max assist of 1 to turn and reposition routinely. Date Initiated: 11/22/2024DEVICES: front wheeled walker (FWW). Date Initiated: 11/20/2024DEVICES: Wheelchair- Standard. Date Initiated: 11/20/2024DRESSING: Provide partial/mod assist 1 for upper and lower ADLS including shoes/socks. (MDS indicates he is dependent). Date Initiated: 11/20/2024Oral Care: Set Up. Date Initiated: 01/21/2025PERICARE: substantial/max assist of 1 for toileting hygiene and clothing and incontinent product management. Date Initiated: 11/20/2024TRANSER: Hoyer assist of 2. Date Initiated: 02/11/2025Focus: The resident has impaired cognitive function/dementia or impaired thought processes r/t Impaired decision making. Date Initiated: 11/27/2024Interventions:Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 11/27/2024Communicate with the resident/family/caregivers regarding residents capabilities and needs. Date Initiated: 11/27/2024Monitor/document/report PRN (as needed) any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Date Initiated: 11/27/2024 Focus: Alteration in endocrine system r/t DMT2 with unstable sugars, insulin dependent. Date Initiated: 12/05/2024Interventions:1/15/25 - Risk vs Benefit discussion held regarding following recommended DMT2 diet. Date Initiated: 01/15/2025Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Date Initiated: 12/05/2024Diabetic foot care. Date Initiated: 12/05/2024Dietary consult for nutritional regimen and ongoing monitoring. Date Initiated: 12/05/2024Educate resident/family/caregiver: Diabetes is a chronic disease, and that compliance is essential to prevent complications of the disease, Review complications and prevention with the resident/family/caregiver, elicit a verbal understanding from the resident/family/caregiver, that nails should always be cut straight across, never cut corners. File rough edges with emery board. Date Initiated: 12/05/2024Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Continue until comfort level with procedures is achieved. Date Initiated: 12/05/2024Monitor/document/report PRN (as needed) for s/sx (signs and symptoms) of hyperglycemia: increased thirst and hunger, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, Abd (abdominal) pain, deep, labored (Kussmaul) breathing, acetone breath (smells fruity), stupor, coma. Date Initiated: 12/05/2024Nurse to provider nail care. Date Initiated: 12/05/2024 Focus: The resident has potential for impaired skin integrity r/t (related to) at risk for skin breakdown and has actual impairment to skin integrity as evidenced by open wounds, scabs, scratches, and self-inflicted lesions. Date Initiated: 11/20/2024Goal: The resident will have all other skin remain intact, free of redness, blisters or discoloration by/through review date. Date Initiated: 11/20/2024. Target Date: 07/03/2025Goal: The resident's multiple skin issues will show signs of healing and remain free from infection by/through review date. Date Initiated: 11/22/2024. Target Date: 07/03/2025Interventions:Administer treatments as ordered and monitor for effectiveness. Date Initiated: 11/20/2024Inform the resident/family/caregivers of any new area of skin breakdown. Date Initiated: 11/20/2024S/P (Status Post) Fall 4/9/25 Intervention - The resident needs to wear off-loading boots when out of bed except when transferring. Remove boots when in recliner chair with foot-rest elevated. Has wedge pillow in bed for off-loading heels in bed. Date Initiated: 03/18/2025Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Date Initiated: 11/20/2024Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Date Initiated: 11/20/2024Wound dressing to be inspected by nursing staff post bath. Date Initiated: 01/15/2025 Focus: The resident has infection, cellulitis of the right toe. Date Initiated: 07/01/2025Goal: The resident will be free from complications related to infection through the review date. Date Initiated: 07/01/2025. Target Date: 07/14/2025Interventions:Administer antibiotic as per MD orders. Update provider with any side effects. Date Initiated: 07/01/2025Follow facility policy and procedures for line listing, summarizing and reporting infections. Date Initiated: 07/01/2025Maintain universal precautions when providing resident care. Date Initiated: 07/01/2025(Of note: This care plan was not initiated until 7/1/25, when R3 returned from the hospital following treatment for his right great toe infection. R3 was initially diagnosed with cellulitis of right toe on 5/19/25.) R3's Physician Orders state, in part:Bathing: Check skin weekly with bath, Update MD (Medical Doctor) with any abnormalities. DIABETIC - nursing to perform nail care and diabetic foot check one time a day every Tue, Fri for bathing and skin check. Order date: 1/30/25. Discontinued: 6/24/25Bathing: Check skin weekly with bath, Update MD (Medical Doctor) with any abnormalities. DIABETIC - nursing to perform nail care and diabetic foot check one time a day every Wed, Fri for bathing and skin check. Order date: 6/24/25. Active Order.Site #21. Non-pressure wound of the right, first toe. Apply alginate, cover with gauze island with border daily and as needed in the evening for wound treatment. Order date: 5/12/25. Discontinued: 5/19/25.Site #21. Non-pressure wound of the right, first toe. Cleanse wound with sterile water, apply alginate calcium w/ (with) silver (cut to size of wound), cover with gauze island with border BID (twice a day) and PRN (as needed) if saturated, soiled, or dislodged. Order date: 5/20/25. Discontinued: 5/26/25.Site #21. Non-pressure wound of the right, first toe. Cleanse wound with sterile water, apply leptospermum honey and alginate calcium w/ (with) silver (cut to size of wound), cover with gauze island with border BID (twice a day) and PRN (as needed) if saturated, soiled, or dislodged. Order date: 5/26/25. Discontinued: 6/16/25.Site #21. Non-pressure wound of the right, first toe. Cleanse wound with sterile water, apply Santyl to wound bed and alginate calcium w/ silver (cut to size of wound), cover with gauze island with border BID (twice a day) and PRN if saturated, soiled, or dislodged. Two times a day for Wound treatment. Order date: 6/17/25. Discontinued 6/23/25.R3's Treatment Administration Record for June 2025, indicates R3 missed an ordered wound treatment date at 18:00 (6:00 PM) on 6/23/25. On 6/24/25, the physician's orders of wound treatment to be completed twice a day was not prescribed correctly and the 06:00 (6:00 AM) treatment was not completed. Through interview, as recorded below, the staff member who signed out R3's wound treatment on 6/24/25 at 18:00 stated that they did not complete the wound treatment, and it was recorded in error. This signifies three wound treatments not completed in a row from 6/23/25 at 18:00 through 6/24/25 at 18:00.R3's Progress Notes and Hospice Notes indicate, in part:On 6/20/26 at 15:58 (3:58 PM) a Nurses Note is written that states: The resident had a podiatry appointment today. MD stated, debrided all 9 toenails, wound care looks good and will continue as directed, F/U (follow up) in 3 months. On 6/23/25 at 08:14 (AM) Wound/Skin Healing Note is written by RN C, that states, in part: Wound information: Right toe(s) - Other (specify): non-pressure: Length = 1, Width = 1.9, Depth = 0.1, The wound seems to be worsening at this time . The skin/wound is showing no s/s (signs and symptoms) infection at this time . There is no wound odor present. Wound Bed reviewed and as follows: Granulation %: 70 . Slough %: 30 . Wound bed: Full Thickness . Current treatment includes: Cleanse wound with sterile water, apply Santyl to wound bed and alginate calcium w/ silver (cut to size of wound), cover with gauze island with border BID (twice a day) and PRN if saturated, soiled, or dislodged. Two times a day for Wound treatment . Provider last updated on 6/23/25 at 2:00 PM. Will continue the current plan of care for resident .On 6/24/25 at 14:20 (2:20 PM) a Diabetic Foot Check note is written that states, in part: . Right Foot: Warm, Dry, not cracked, Toenails Thick, Edema . On 6/25/25 at 08:45 (8:45 AM), a Call Documentation note is written by a Hospice RN (Registered Nurse), that states, in part: . Reason for call: GI (gastrointestinal) Problem (Emesis at breakfast) and Fever (100.9). Calling to report that pt (patient) is not feeling well this morning. Told one nurse that he ached all over At breakfast, he had an emesis, while he was throwing up, he was still trying to eat his food . Confirmed he took his scheduled meds (medications), including Tylenol and anti-hypertensives . Confirmed that CNA (Certified Nursing Assistant) and RN are scheduled to visit today .)(Of note: Hospice does not indicate an MD was contacted).On 6/25/25 at 10:36 AM, a Hospice Note is written by a Hospice RN (Registered Nurse), that states, in part: . [Staff Name] reports that patient was eating breakfast and that he eats fast and does not [sic] take the time to chew foods thoroughly and that he started coughing this morning and committed/spit up food that he was eating . Assessment completed. Patient reporting 7/10 generalized discomfort, which was reported to SNF (Skilled Nursing Facility) RN who administered PRN (as needed) oxycodone (pain medication) during RN visit . Wound assessment done . 30% Slough, 70% Granulation . On 6/25/25 at 15:27 (3:27 PM) a Nurses Note is written that states, in part: Resident had an emesis at 0810 (8:10 AM) this morning. VS (Vital Signs) were within normal limits other than his temp (temperature) was 100.9 (Fahrenheit). Residents' shirt was changed and taken back out to breakfast. Resident was throwing up his [Brand Name] juice and was coughing a small chunk of food the size of a dime. Resident finished eating and stated he felt fine. Hospice, family and DON (Director of Nursing) were updated. Residents temp was taken later after lunch, and it was 98.7 (Fahrenheit) . On 6/25/25 at 17:00 (5:00 PM) a Hospice: Communication note is written that states, in part: To whom: [Provider Name] Hospice Triage Nurse. Hospice note/updates provided: Resident having pain to lower back 7/10 pain ad (pain scale). Administered Oxycodone 5 mg PRN at 15:41 (3:41 PM). While on phone with Hospice update given vitals BP 140/82, Pulse 77 resp (Respirations per Minute), 24. Blood glucose 207. Resident is DNR (Do Not Resuscitate) and told by Hospice to not send out unless notified of family wishing to send. Resident also c/o (complains of) Nausea. During conversation resident stated no relief of pain and worsening. Nurse will contact on call Nurse to come visit with resident and will call with arrival .(Of note: Surveyor unable to identify a physician or provider notification).On 6/25/25 at 17:03 (5:03 PM) a Call Documentation note was signed by a Hospice RN that states, in part: . Pain description . Severe lower back pain . [Staff Name] states pt (patient) vomited this morning around breakfast time. She states pt is just not right . [Staff Name] states pt still c/o nausea . Writer assured [Staff Name] that an [Hospice Provider Name] RN will make visit for assessment. [Staff Name] questioned if she should send pt to the ER. Writer informed [Staff Name] that plan for now is to have an [Hospice Provider Name] make visit for assessment and writer will contact pts (patients) AHCPOA (Activated Healthcare Power of Attorney), wife [Name] to determine if she would like him sent to the ER .(Of note: Surveyor unable to identify a physician or provider notification).On 6/25/25 at 17:25 (5:25 PM) a Call Documentation note was signed by a Hospice RN that states, in part: . Symptoms reported: anxiety and restlessness . [Staff Name] states pt is grimacing, restless, anxious, and looks miserable .(Of note: Surveyor unable to identify a physician or provider notification).On 6/25/25 at 19:44 (7:44 PM) a Hospice Note is written by a Hospice RN that states, in part: . Issues: drowsy, fatigue, forgetfulness . Focused visit performed d/t: Acute pain . Patient noted pain has improved with medications given . Discussed goals of care? Yes. Discussion included the following domains symptoms management and medical interventions. The following individuals were involved in the discussion: Daughter, facility nurse .(Of note: Surveyor unable to identify a physician or provider notification).On 6/26/25 at 0947 (9:47 AM), a Call Documentation note was signed by a Hospice RN that states, in part: . Narrative: Caller reports that yesterday at breakfast at 0810 (8:10 AM) pt has emesis and again today at 0810 had emesis. Yesterday at time of emesis temp was 100.9 and today Temp was 100. Caller reported yesterday pt only had a bite of food and some [Brand Name] juice and today patient only ate a banana. Caller reports patient is a diabetic and received his morning medication prior to eating . Collaborated with: writer sent email update to RN [Staff Name] assigned to visit today .On 6/26/25 at 13:38 a Communication: Provider note is written that states, in part: This nurse updated wound MD (MD's Name) about resident's right great toe, wound has had significant change since seen by wound MD on 6/23/25. Toe is swollen/weeping, top of foot red and warm to touch. Wound edges undermining/tunneling with wound bed mushy/boggy. Resident has also had 2 emesis over last 36 hours with increased temp both days after emesis. Resident has flatter affect and appears to have decreased appetite, increase c/o pain to back. Hospice here and is updating family and going over options d/t (due to) wound MD suggesting resident be sent to local ER (Emergency Room) for evaluation.(Of note: No physician notification was made following these fevers or episodes of emesis until this date and time.) On 6/26/25 at 16:41 (4:41 PM), with noted Visit Time of 12:40 PM - 1:20 PM, a Hospice Note is written by a Hospice RN that states, in part: . 6/26- erythema (redness), warmth and pain to right great toe, weeping edema (swelling) to R (right) great toe . On arrival patient is sitting up in his WC (wheelchair) in the dining room with feet dependent, Tubi grips in place. Patient is pale/gray in color. Appears drowsy. Alert/oriented to person only. PAINAD-2, facility staff report increased pain and restlessness over last 3-4 days Visible discomfort with palpation of BLE (Bilateral Lower Extremities). Vital signs are stable, patient is afebrile during visit, however staff report fever last 2 mornings, patient is receiving scheduled Tylenol . Right foot is red, hot to the touch and swollen. Right toe is extremely swollen with notable blistered periwound near the toe joint. Wound bed is boggy and gray, tunneling to a depth of 0.3cm (centimeters), with foul smelling drainage . Facility RN [Staff Name] messaged wound care provider photos of wound . [Doctor's Name] (MD ***) as he assessed the wound on Monday 6/23 confirms worsening of wound and based on assessment recommends patient be seen in ED, concerning need for amputation . On 6/26/25 at 16:41 (4:41 PM), a Transfer to Hospital note is written that states, in part: . Reason(s) for Transfer: Other - Right great toe wound . R3's Hospital Documentation includes: On 6/26/25 at 8:52 PM, an ED (Emergency Department) Provider Note is written by an ED Physician that states, in part: . presents with toe infection. Patient has been battling infection in his toe for some time. Worsened today Patient and family do not wish to have amputation . Musculoskeletal: . Comments: . There is an open wound roughly couple centimeters wide overlying the proximal phalanx (tubular long bone in toe) and MTP (metatarsophalangeal/joint in foot) of the first toe. Does have intact capillary refill. No sensation. There is obviously necrotic surrounding tissue, and the area was boggy with some slightly yellowish cloudy drainage. There is mild acute erythema superimposed on chronic venous stasis changes to the foot. There is some mild increased warmth . On 6/26/25 at 11:09 AM, a History and Physical Note is written by an Internal medicine Physician that states, in part: .Assessment/Plan: Assessment: 1. Diabetic foot ulcer - continue IV Merrem, Vanco (Antibiotics) - plan to transition to orals as patient clinically improves - continue wound care - not surgical candidate . On 6/26/25, a Clinical Note was documented by a hospital RN that indicates the wound bed contains 100% Slough. On 6/29/25, R3's Blood Cultures resulted finding Staph aureus (bacteria) in R3's blood.On 6/30/25, a Progress Note is written by an Internal Medicine Physician that states, in part: . -reviewed with patient and wife positive blood cultures . Assessment and Plan 1. Diabetic foot ulcer stage III - continue IV Merrem, Vanco - clinical improvement noted . 2. Bacteremia (Bacteria in the blood) - currently hemodynamically stable - continue IV antibiotics as above .R3's After Visit Summary, dated 7/1/24, indicates a principal diagnosis for hospitalization as a Diabetic foot infection.On 7/3/25 at 9:26 AM, Surveyor interviewed CNA/Nurse Tech I (Certified Nursing Assistant/Nursing Technician/Student). Surveyor asked CNA/MedTech I if she noted any changes to R3's wound when she completed wound treatment on 7/24/25 on the PM shift. CNA/Nurse Tech I indicates she did not complete that treatment and did not know why the TAR (Treatment Administration Record) indicated that she was the one who completed that treatment. CNA/Nurse Tech I also indicates she does not complete wound treatments at the facility.On 7/3/25 at 9:43 AM, Surveyor interviewed LPN D (Licensed Practical Nurse). Surveyor asked LPN D if wound treatment is complete, should it be documented. LPN D indicates, yes.On 7/3/25 at 10:55 AM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C if she was the one who put in the order for R3's wound treatment order on 6/23/25 to start 6/24/25. RN C indicates, yes. Surveyor asked RN C if she knew what time and date the order was set for. RN C indicates it should have popped up for 6:00 AM on 6/24/25. Surveyor asked RN C if the order should have been set to start on AM shift on 6/24/25 instead of on PM on 6/24/25 due to the treatment being ordered twice a day. RN C indicates, yes. Surveyor asked RN C if the treatment should have been completed in the AM on 6/24/25 per physician order. RN C indicates, yes. Surveyor asked RN C if symptoms of a fever and emesis considered a change of condition. RN C indicates, yes. Surveyor asked RN C if symptoms of a fever and emesis require physician notification. RN C indicates, yes.On 7/3/25 at 12:18 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and DCO G (Director of Clinical Operations). Surveyor asked DCO G what does it mean on the MAR (Medication Administration Record)/TAR (Treatment Administration Record) if a space is left blank? DCO G indicates, it is not complete. Surveyor asked DCO G what it means on the MAR (Medication Administration Record)/TAR (Treatment Administration Record) if there is an X. DCO G indicates, it means the order was not scheduled for that time. Surveyor asked DCO G if Nurse Techs are allowed to complete wound care. DCO G indicates she is not sure and would have to check their individual competencies. Surveyor asked DCO G who should be signing off the administration of medications or treatments. DCO G indicates, whomever administered the medication or treatment and whomever witnessed it being completed. Surveyor asked DCO G if providers orders should be carried out as they are ordered. DCO G indicates, yes. Surveyor indicates, on 6/23 there is a blank space for the PM shift wound treatment. Surveyor asked DCO G should the treatment have been documented if it was completed. DCO G indicates, yes. Surveyor asked DCO G if a provider should have been notified if the treatment was not provided. DCO G indicates, yes. Surveyor indicates, on 6/24 there is an X for the AM wound treatment. Surveyor asks DCO G, should the order have been placed to start on 6/24 in the AM instead of the PM. DCO G indicates, if that's when it was ordered it should have been administered on the 24th in the AM. Surveyor asked DCO G if a provider should have been notified if the treatment was not provided. DCO G indicates, yes. Surveyor indicates, on 6/24 there is now a blank space, which was previously filled with CNA/Nurse Tech I's initials, for the PM shift wound treatment. Surveyor asks DCO G should the treatment have been documented if it was completed. DCO G indicates, yes. Surveyor asked DCO G if a provider should have been notified if the treatment was not provided. DCO G indicates, yes. Surveyor asked DCO G what are some examples of when staff are expected to notify a physician. DCO G indicates, the facility expects staff to utilize the Interact standard of practice. Surveyor asked DCO G if she would expect staff to notify a physician for emesis and a fever. DCO G indicates, yes. Surveyor asked DCO G when she would expect a provider to be notified. DCO G indicates she would expect staff to follow Interact guidelines. Surveyor asked DCO G if she would expect staff to write a progress note regarding when a provider was contacted. DCO G indicates yes.

Based on observation, interview and record review, the facility did not ensure resident environments remained free of potential accidents/hazards for 1 of 1 residents (R2) reviewed for electric wheelchairs. R2 utilizes a power wheelchair for mobility, which was noted to be charging in his room. As evidenced by: Facility policy, titled Motorized Assistive Device Policy and Procedure, dated May 2024, states, in part: Policy Statement: it is the policy of the facility to promote the safety of all residents, staff members and contractors, and visitors as well as the integrity of the facility grounds by defining allowable use and limitations for resident's personal motorized assistive devices Procedure: . If a resident chooses to utilize a motorized assistive device, resident will agree to do the following: . 1 . e. Availability of safe storage and electrical charging location. f. The resident will agree to abide by the motorized assistive device policy for use on facility property . R2 admitted to the facility on [DATE] with Quadriplegia. R2 utilizes a power wheelchair for mobility. R2's care plan, dated 3/3/25, states, in part: Focus: The resident has an ADL (Activities of Daily Living) deficit r/t (related to) Quadriplegia secondary to C4 and C7 spinal cord injury from an MVA (Motor Vehicle Accident) in November 2023 . Intervention: Devices: Electric Wheelchair. Is safe to use indoors and outdoors without supervision. WC (wheelchair) to be charged in the beauty shop at night. Date Initiated: 3/3/35. Revision on: 3/3/25 . On 7/2/25 at 10:08 AM, Surveyor observed R2's power wheelchair in his room but it was not plugged in. R2 stated, They charge it in my room, but I don't think it's supposed to. R2 stated that when the staff would drive his electric wheelchair out of his room to go charge it elsewhere, that they would ram it into the wall or door and pieces of the arm rests would be clipped off. R2 stated that it was an expensive wheelchair, and he wouldn't be able to get another one, so he wanted it to be taken care of properly. R2 stated the wheelchair was charging in his room per his request, because he didn't want staff driving it and damaging it further. On 7/2/25 at 1:33 PM, Surveyor interviewed CNA F (Certified Nursing Assistant) about R2's power wheelchair. CNA F stated that R2's wheelchair was charged in his room, per his request, because one of the staff members banged it against the wall and now R2 didn't want anyone to touch his wheelchair. On 7/3/25 at 9:55 AM, Surveyor interviewed CNA E about R2's power wheelchair. CNA E stated that they charge R2's wheelchair in his room because that is what he wants. On 7/3/25 at 10:32 AM, Surveyor interviewed CNA/Med Tech I, who stated that she did not know where R2's power wheelchair was being charged, but that they were supposed to be charged in the beauty salon. On 7/3/25 at 11:12 AM, Surveyor interviewed RN C (Registered Nurse) who stated she wasn't sure where R2's power wheelchair was being charged, but that they should be charged in the salon. On 7/3/25 at 11:23 AM, HR H (Human Resources) took Surveyor to the beauty salon and stated that was where the power wheelchairs were normally charged. HR H showed Surveyor a small tan cord and indicated that was R2's cord for his power wheelchair. On 7/3/25 at 11:28 AM, Surveyor observed that neither R2 nor his power wheelchair were in his room, but that a thick black cord was plugged into the wall outlet in R2's room. On 7/3/25 at 11:31 AM, Surveyor asked DCO G (Director of Clinical Operations) to join her in R2's room to see if the thick black cord was the charging cord for his power wheelchair. R2 came down the hallway and observed Surveyor and DCO G at the doorway of his room. R2 stated, yes, that is my charger there. I know it's not supposed to be charged in here, but I don't think anyone should be able to bust up a $10,000 chair except me. On 7/3/25 at 11:32 AM, DCO G indicated power wheelchairs should not be charging in resident rooms. DCO G stated she would have a chat with NHA A (Nursing Home Administrator) about it and provide some education to staff about safe charging of electric wheelchairs.

Based on interview and record review, the facility failed to ensure basic life support measures including cardiopulmonary resuscitation (CPR) were in place immediately, when needed, for a resident requiring emergency care for 1 of 2 residents (R35) reviewed during closed record review. R35 was a full code (wanted CPR). On [DATE], R35 stated she had chest pain rating at a ,d+[DATE] or ,d+[DATE]. RN E (Registered Nurse) gave Tums and Tylenol which were not effective for R35's chest pain. R35's blood pressure was below R35's baseline. R35 continued to complain of chest pain. After 1 hour and 43 minutes from R35's initial complaint of chest pain, the facility called 911 for emergency medical services (EMS). The facility did not prepare to provide basic life support by failing to place R35 on a hard surface to initiate CPR, failing to have a crash cart in the room, and failing to provide supplemental oxygen. When EMS arrived, R35 was completely unresponsive to all stimuli, and was apneic (lack of breathing). RN E did not initiate basic life support, including CPR, when R35 presented with apnea. Upon arrival EMS initiated CPR. Resident was transported to hospital where she passed away. The facility's failure to provide basic life support, including cardiopulmonary resuscitation to a resident who wished to be full code created a finding of immediate jeopardy that began on [DATE]. Surveyors notified NHA A (Nursing Home Administrator), DON B (Director of Nursing), and VPCO D (Vice President of Clinical Operations) of the immediate jeopardy on [DATE] at 3:15 PM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a severity/scope of D (Potential for Harm/Isolated) as the facility continues to implement its action plan. This is evidenced by: Per Centers for Medicare and Medicaid Services (CMS) Cardiopulmonary resuscitation (CPR) memo ,d+[DATE] revised [DATE], CPR refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. When addressing full-code residents: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition,) facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services. Facility policy titled, Code Status, implemented ,d+[DATE] and last reviewed ,d+[DATE], states in part: Purpose: To provide guidelines to staff with regards to determining and recording resident wishes related to code status and initiating cardiopulmonary resuscitation (CPR). Policy: It is the policy of this facility to properly identify and assess residents that are pulseless and unresponsive and provide timely and appropriate treatment. CPR will be initiated on all residents that have chosen CPR .When a cardiac arrest has been determined the following basic steps will be taken: .The facility staff is notified of the emergency by activating the emergency call light system/yelling for help by stating Code Blue. Verify the resident's code status .Designate someone to call 911. Staff begins CPR according to established standards of practice while designating someone to get AED (Automated External Defibrillator. A portable device that can be used to treat a person whose heart has suddenly stopped working.) and crash cart. Bare resident's chest and attach AED. Following the instructions as noted on the machine until EMS arrives. Other items that may be necessary to treat symptoms are available on the crash cart include ambu bag (a hand-held device commonly used to provide ventilation to a person who is not breathing or not breathing adequately), suction machine and supplemental oxygen. R35 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, bulimia, hyperlipidemia, personal history of non-Hodgkin's lymphoma, and major depressive disorder. R35's Minimum Data Set (MDS) dated [DATE] indicates R35 has a Brief Interview for Mental Status (BIMS) of 4, indicating R35 had a severe cognitive impairment. R35 has an activated power of attorney (POA) which names her sister as the POA. R35's physician orders indicated that R35 chose to be a full code. R35's care plan states in part: .Focus: I am a Full code. Goal: My request will be honored during my stay at this facility. Interventions: Call 911 for transportation to the hospital. Initiate CPR in the absence of a pulse. Notify family and physician of changes in condition . R35's Weights and Vitals Summary Report indicates, in part, blood pressures on the following dates: [DATE] BP - ,d+[DATE] [DATE] BP - ,d+[DATE] [DATE] BP - ,d+[DATE] [DATE] BP - ,d+[DATE] Late entry Nurses Notes dated [DATE] at 20:30 (8:30PM), written by RN E (Registered Nurse) states: This writer went into the resident's room; resident is complaining of her chest hurting. Resident had family at the facility today visiting and everyone just left within the past few hours. Resident also complained of her stomach hurting. Asked if she ate anything unusual-she was not able to recall what she had to eat. Resident stated her pain is at a ,d+[DATE] or ,d+[DATE], with moaning and continuing to move her feet being unable to sit still at times because of pain. No pain in arm, neck, or jaw. 8:35pm: Resident had a loose stool and sat back down on couch, I elevated her legs on a pillow, and she stated that she felt some better. We have standing physician orders in the facility for tums 500mg-2 chewable tabs po (by mouth) q (every) 4hrs (4 hours) for indigestion prn (as needed). I asked resident if she would like to try the two tums first and go from there; she voiced understanding and agreed to try this first. I then followed up at 9:00pm- resident states she feels some better, but she is still hurting. We have standing physician orders in the facility for Tylenol 650mg po q 4hrs for pain or fever. Not to exceed 4,000mg daily. Resident voiced understanding and agreed to try a 650mg acetaminophen for the pain. I stayed with resident and assessed her every ,d+[DATE] minutes for an hour to monitor her vitals and pain: 8:35pm: ,d+[DATE]-bp (blood pressure), 97.2-temp (temperature), 69-pulse, 96-O2 (oxygen saturation), rr-17 (respiratory rate) 8:40PM: ,d+[DATE]-bp, 96.4-temp, 72-pulse, 97-O2, rr-17 8:55pm: ,d+[DATE]-bp, 96.4-temp, 55-pulse, 98-o2, rr-17 9:10pm: ,d+[DATE]-bp, 96-temp, 62-pulse, 96-o2, rr-17 9:25pm: ,d+[DATE]-bp, 96.2-temp, 64-pulse, 96-o2, rr-18 9:40pm: ,d+[DATE]-bp, 97.1-temp, 73-pulse, 98-O2, rr-18 9:55pm: ,d+[DATE]-bp, 97.7-temp, 62-pulse, 97-O2, rr-17 I asked the resident to follow me down to the nurse's station if she was able to, and to sit on the bench, because I need to call (Sister's Name) and advise her of what is going on, and see what she wants to do, because resident needs to be seen at the hospital. Resident voiced understanding and agreed to follow me up to the nurse's station. She placed her shoes on but never made it up to the nurse's station; 2 minutes after leaving the resident's room, I was calling (Sister's Name) when I asked the CNAs (Certified Nursing Assistant) to check on resident and was notified that I needed to come to resident's room ASAP as she was not responsive. I tried to awake resident with a sternum rub, no response, Eyes-pupils were fixed and equally 4mm in size. Resident was breathing, her eyes were wide open, with BP of ,d+[DATE] pulse 44 then went to 22 right before rescue squad showed up, temp-97.7, O,d+[DATE] RR 22. Resident is a full code-notified rescue squad of this, printed off current med review list, and face sheet-handed this to rescue squad however they still left this behind in resident's room. 10:05pm: ,d+[DATE] (bp), 97.2-temp, 44-pulse went to 22, 100-o2, rr-17. 10:13am: [sic] As I continued to assess resident again, delegated to CNA to call (City Name) Rescue Squad and inform them that we have an emergency with resident not responding and vitals are faint and need their assistance asap. 10:20pm-Called resident's sister-(Sister Name) to inform her that resident is complaining of ,d+[DATE] ,d+[DATE] chest pain and is showing signs of bradycardia (slow heart rate), and that resident has agreed to be sent out to the hospital to be evaluated and assessed. Resident stated that she wants her sister by her side as she trusts her with any decisions that are needed to be made on her behalf . Of note, according to National Heart, Lung, and Blood Institute from National Institute of Health (nhlbi.nih.gov), warning signs of cardiac arrest include belly pain, nausea, and chest pain. Of note, according to National Institute of Health, fixed pupils in cardiac arrest are a result of inadequate blood supply to the brain (pubmed.ncbi.mln.[NAME].gov). EMS report dated [DATE], states in part: . unit notified: [DATE] 22:13:41 (10:13PM) .arrived at Pt (patient): [DATE] 22:23:13 (10:23PM) Respirations 22:26:10 Apneic .Patient Care Report Narrative: (City Name) EMS paged to (Facility Name) for a patient that was breathing but not responsive. Crew responded to scene without delay. Once crew arrived on scene, they were met by a nursing home staff that pointed crew in the direction of the patients room. Once crew made it to patient side it was asked right away what the patients code status was. Patient was laying supine (laying face upward) on a couch completely unresponsive to all stimuli. Patient was immediately hooked up to vital monitor including a 4 lead (a machine that uses four electrodes to record the heart's electrical activity) while feeling for a pulse on the patient. While doing all this crew asked for a medical history on patient and all the nursing home staff stated was Alzheimer's but also stated patient had chest pain an hour before we called and another staff worker also stated, patient said they had bad chest pain and passed out. No pulses were palpable and 4 lead revealed asystole (no heartbeat) and with patient being a full code CPR was started immediately .Every 2 minutes rhythm was assessed as well as a pulse check. Patient remained in asystole while on scene . Of note, asystole is a type of cardiac arrest, which is when the heart stops beating entirely. This can cause someone to become unresponsive, not breathing or only gasping breaths (gasping breaths are not life sustaining) (American Heart Association, www.heart.org). Hospital records from the Emergency Department (ED) dated [DATE] at 10:54PM, states in part: .Chief Complaint: Cardiac Arrest .presented to ED today via EMS from (Facility Name) with ongoing CPR. Reported that patient was having chest pain .(facility) Staff then noted she became unresponsive, EMS (Emergency Medical Services) was called, reported they felt a weak pulse and patient was breathing, but quickly became pulseless. CPR started; airway was placed by EMS . On [DATE] at 8:14AM, Surveyor interviewed EMS H. EMS H indicated it took 10 minutes from the time the facility called 911 until EMS arrived at R35's side. Upon arrival to R35, she did not have a pulse and was apneic (lack of voluntary breathing). Surveyor asked EMS H about the hospital record stating felt a weak pulse and patient was breathing; Surveyor asked EMS H was the resident breathing upon your arrival. EMS H stated no, the resident was apneic, unresponsive, with no pulse. EMS H stated he would have expected facility staff to be performing CPR on R35 upon their arrival. EMS initiated CPR immediately. EMS H indicated the crew was not prepared to find R35 pulseless based on the call they received which was unresponsive but breathing. On [DATE] at 10:03AM, Surveyor interviewed CNA F (Certified Nursing Assistant). CNA F indicated she worked the evening shift on [DATE]. CNA F stated she worked on a different unit than R35. CNA F stated RN E was the nurse for the unit CNA F was working and was also the nurse for R35. CNA F indicated she needed RN E around 9:30PM on [DATE] because of a resident issue. CNA F indicated it took RN E about 15 minutes to come to the unit because RN E was dealing with R35. CNA F indicated at the end of her shift and after she had given report to the oncoming CNA, she left the unit and was walking by the nurse's station. CNA F saw RN E sitting at the nurse's station. CNA F saw another CNA from R35's unit coming up to the nurse's station to request RN E to come to R35's room because R35 was unresponsive. CNA F indicated the other nurse on duty called 911 and CNA F went down to assist with getting the room ready for EMS. CNA F indicated when she saw R35, R35 was laying on her couch, completely unresponsive, mouth agape. CNA F indicated staff attempted to obtain vital signs by using a blood pressure cuff and a pulse oximeter (device used to measure pulse and oxygen levels) and neither device could pick up a reading. CNA F indicated she was instructed to wait for EMS and direct EMS where to go when they arrived. CNA F indicated she waited for EMS at the front by the nurse's station and told them where to go. CNA F indicated after EMS had arrived, RN E instructed her to bring the crash cart and the other nurse told her where the crash cart was located. It should be noted despite R35 having recent known chest pain and being unresponsive with bradycardia, the facility did not provide basic life support including placing R35 on a hard surface to initiate CPR, did not have a crash cart in the room, and was not providing supplemental oxygen. On [DATE] at 11:20AM, Surveyors interviewed DON B (Director of Nursing) and VPCO D (Vice President of Clinical Operations). DON B indicated if a resident complains of chest pain, the nurse should immediately notify the physician. DON B indicated an hour is too long to wait before notifying a physician or sending a resident out if they are complaining of chest pain. DON B indicated EMS can take up to 20 minutes to arrive to facility and RN E should have had the crash cart ready while waiting for EMS. DON B stated she could not speak to RN E's actions but obviously that is an unacceptable way to handle the situation and she should have started CPR. VPCO D indicated as soon as R35 was unresponsive they should have initiated CPR. VPCO D indicated she was not familiar with RN E since RN E was no longer working at the facility. VPCO D did agree there were inconsistencies with RN E's nurse's notes. VPCO D indicated a nurse consultant had completed an investigation on the event because it raised concerns about notifying a physician when there is a change in condition. VPCO D was not sure when the consultant completed the investigation. VPCO D shared a copy of the investigation report with the surveyors. The investigation report titled Investigation of Circumstances Surrounding Medical Transfer [DATE] is not dated or signed by the person completing the report. The report states, in part: .had clinical indications of a significant change in condition that RN E did not respond to adequately delaying the resident's [R35] discharge from the facility .issue with RN E's ability to make appropriate nursing decisions involving recognition of basic changes in resident condition . On [DATE] at 10:20AM, Surveyor called RN E to obtain an interview. Surveyor left a message on the voicemail but was unable to interview RN E. On [DATE] at 11:24AM, Surveyor interviewed MD G (Medical Doctor). MD G was the primary physician for R35. MD G indicated R35 should have notified a physician immediately upon R35's complaint of chest pain. Surveyor asked MD G what a physician's response would be if a nurse calls and states a resident is complaining of new onset of ,d+[DATE] or ,d+[DATE] chest pain with a blood pressure of ,d+[DATE]. MD G indicated a physician would have ordered the resident to be seen. MD G agreed CPR should have been started because R35 was a full code. On [DATE] at 8:30PM, R35 complained of significant chest pain. RN E gave tums and Tylenol which were not effective. RN E monitored R35's vital signs for 1 hour and 43 minutes during which time R35's blood pressure remained abnormally low. RN E did not notify a physician. RN E did not provide basic life support when R35 became unresponsive and did not initiate CPR when RN E was apneic. The failure to ensure R35, a resident who had chosen to be full code, received basic life support when R35 presented with a change of condition created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when the facility completed the following: 1) RN E no longer employed at the center 2) Reeducation to nursing staff on CPR and competencies completed on [DATE] or prior to the start of their first shift 3) All residents at center records reviewed for care planning regards to code status 4) Education to staff provided by DON and VPCO on: 5) Immediate provider notification in acute change of condition 6) AMDA guidelines (American Medical Directors Association) 7) Location of crash cart and AED with emphasis on immediately bringing to patient bedside for immediate access if needed. 8) Detailed protocols and procedures for CPR 9) Automated external defibrillator use including policy review 10) Code sample procedures and drills 11) Adult basic life support including detailed assessment documentation 12) CPR drills completed on random shifts x 1 shift/week x 6 weeks then bimonthly x 2 months (random shifts) note work 12 hours shifts 13) Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting conducted to review current policies and procedures including CPR 14) All residents at center reviewed for valid code status On [DATE], facility held an ad hoc QAPI meeting and reviewed policy on CPR as well as events. CPR drills will be completed on random shifts once a week x 6 weeks then bimonthly x 2 months or until further reviewed by QAPI for substantial compliance. CPR drills will include randomized situations to provide various critical thinking scenarios.

Based on observation, interview and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 31 residents. The facility did not know what PPM (Parts Per Million) to use for their low temperature, sanitizing dishwasher and had no record that the three compartment sink sanitizing agent was being monitored. Food items with no dating or past the use by dates Findings include. Example 1 The facility's policy titled, Dishwasher Temperature, states, For low temperature dishwashers (chemical sanitization) the wash temperature shall be 120 F. The sanitizing solution shall be 50 PPM (parts per million) hydro chlorite (chlorine) on dish surface and final rinse. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded. The facility uses a low temperature, sanitizing dishwasher that is leased and serviced by an outside vendor. On 7/25/24 at 9:30 AM, Surveyor observed staff using the dishwasher in the main kitchen. Next to the dishwasher was a sheet titled Low-temperature dishwasher chart. This sheet is used to track the temperature and PPM of the dishwasher each shift (3x daily). The bottom of the sheet indicates the temperature shall be no less than 120 degrees Fahrenheit and the PPM should be between 50 and 100 PPM. No record of the temperature or PPM was gathered on 4 days in July as seen on the wall (July 16, 17, 20 and 21). Surveyor then went to the three-compartment sink in the kitchen, which is used to clean pots and pans. There was no visible record of the monitoring of the three-compartment sink's sanitizing agent. A large sign above the three-compartment sink, created by the company that services the facility's mechanical dishwasher, states the PPM of the dishwasher should be 50-75 PPM and the three compartment sink PPM should be 200. Surveyor then, along with DM K (Dietary Manager), used a test strip to test the sanitizing agent in the three-compartment sink. The color on the test strip turned blue, which appeared to be much higher than the 200-400 PPM color chart (dark green indicates 400 PPM) that was affixed to the test strip case. DM K agreed the sanitizer appeared to be too concentrated. When asked if the three-compartment sink is monitored, DM K stated it is sometimes tested , but there is no record of the testing. When asked if the PPM of the dishwasher should be 50-100 or 50-75, DM K stated she was unsure but would be in contact with the service company. Surveyor asked for copies of May, June, and July dishwashing records for the facility's low temperature, sanitizing dishwasher. The records indicated 50 times in which the PPM of the dishwasher exceeded 75 PPM. Example 2 On 7/22/24 at 11:04 AM Surveyor, along with DM K, observed: *In the dry storage area: 4 bags of unopened frosted flakes and a bag of unopened brown sugar with no open, received or use by dates *In the refrigerator: a bag of lettuce with a use by date of 7/20/24 *In the refrigerator: a tuna salad sandwich, dated as prepared on 7/19/24 with no use or consume by date On 7/24/24 at 11:14 AM, DM K stated to Surveyor that they commonly prepare tuna salad sandwiches for a resident in the building who really likes them, and staff are supposed to throw them out, if not consumed, in a few days. DM K removed the sandwich from the refrigerator.

Based on observation, interview, and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 31 residents (R) in the facility. The facility's policies have not been updated annually. The facility did not track infection control rates by infection type. The facility did not have a staff infection control line list prior to June 2024. The facility did not maintain an accurate staff infection control line list. The facility allowed staff to return to work before the recommended time frame for illness. The facility did not maintain an accurate resident line list. The facility did not place residents into isolation precautions timely. Staff did not complete hand hygiene per standards of practice. This is evidenced by: The facility policy titled Infection Control Program with a last reviewed date of March 2024, states in part: It is the policy of (Facility Name) to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection .The facility will prevent the spread of infection by: 1) Determining what a resident needs to prevent the spread of infection and taking special precautions; 2) Prohibiting employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease . The facility policy titled Infection Surveillance with a last review date of September 2023, states in part: Purpose: To assure the Infection Preventionist with the Quality Assurance Performance Improvement Committee guides the facility in both process and outcome surveillance .1. Process surveillance to monitor the practices that directly relate to resident care is accomplished in the following manner: a. Auditing staff performance with proper hand hygiene .2. Outcome Surveillance is accomplished in the following manner and is completed for both residents and staff. A. Infections or potential infections related to residents are identified and reported through the nurse charting system, verbal communication and review of antibiotics use. B. Staff illnesses are tracked in nursing through the documentation system all other departments provide a verbal or written report to the Director of Nurses. C. Action is taken related to the data collected this may include reporting to the local or state health agencies as prescribed. D. The Director of Nurse or designee completes this information to standard written definitions of infection. (Appendix A) E. the facility tracks existing cases of infections both old and new. F. Documentation of the surveillance data will be completed by the designated Infection Preventionist reviewed by the Quality Assurance Performance Improvement Committee. G. Documentation will be completed on a line listing form tracking symptoms that may be representative of potential infective processes. This information is evaluated by the Director of Nurses or designee on an ongoing basis. DON B (Director of Nursing) is the facility's Infection Preventionist. Example 1: On 7/23/24 at 8:34AM, Surveyor interviewed DON B (Director of Nursing) and VPCO D (Vice President of Clinical Operations). They indicated infection control policies and procedures should be reviewed annually. Surveyor informed them some of the infection control policies and procedures were beyond the one-year review timeframe. They stated they would look for updated ones. DON B provided Surveyor with updated infection control policies and procedures for the following items: Infection Disease Surveillance, Infection Control Program, and Antimicrobial Stewardship Procedure. The following facility Infection Prevention and Control policies have not been reviewed annually: COVID 19 response plan last reviewed date of May 2023 Isolation precaution guidance last reviewed date of January 2023 Prevention and control of influenza last reviewed date of June 2023 Resident Immunization Program last reviewed date of June 2023 Influenza, Pneumococcal Immunizations, Tetanus and TB testing last reviewed date of June 2023 Example 2: On 7/22/24 at 11:30AM, Surveyor requested infection control rates for the past year. DON B provided monthly infection control rates as a total percentage of all infections each month. The monthly rates are not broken down by infection type each month. Example 3: On 7/22/24 at 11:30AM, Surveyor requested staff line lists for the past 3 months. DON B provided a staff line list for the month of June. On 7/23/24 at 8:34AM, DON B indicated she was still working on the staff line list for July and there was no staff line list prior to June 2024. DON B indicated things had not been done prior to her taking the infection preventionist role at the end of June 2024. Example 4: Surveyor reviewed June 2024 staff line list. The line list was missing Date Last Worked for 3 staff members and one staff member was missing the Well Date. On 7/23/24 at 8:34AM, DON B indicated the staff line list should be filled in completely and it was not. Example 5: Surveyor reviewed June 2024 staff line list. The line list indicated 4 staff with gastrointestinal symptoms (vomiting or diarrhea) returned to work too early. On 7/23/24 at 8:34AM, Surveyor interviewed DON B. DON B reviewed the staff line list for June. DON B indicated the staff should have stayed out for at least 48 hours after last symptoms and agreed there were staff that returned to work too early following their illness. Example 6: Surveyor reviewed resident line list for the months of April, May, June, and July. The resident infection control line list were missing the following items: -Symptoms for 2 residents -Date Well for 6 residents -MD updated date for 11 residents -Monitoring/Care plan updates for 8 residents -Diagnostic (Labs/cultures/x-ray) for 3 residents -Treatment End date for 1 resident On 7/23/24 at 8:34AM, Surveyor interviewed DON B. DON B indicated there were items missing on the resident line list. DON B indicated the line list should be filled in completely and it was not. Example 7: Surveyor reviewed resident line list for the months of April, May, June, and July. 2 residents were placed on droplet/contact precautions the day after their symptoms had started. On 7/23/24 at 8:34AM, Surveyor interviewed DON B. DON B indicated residents requiring precautions should be placed on precautions the day their symptoms start and there should not be a delay. 30992 Example 8: The facility policy, Hand Hygiene, dated 9/2009, states in part, as follows: Purpose: To provide guidance to the staff regarding proper hand washing/hand hygiene techniques. Indications for hand washing and hand antisepsis - Before: Having contact with residents; Putting on gloves; Caring for a for any invasive device, such as catheter; Handling food; Administering medications. Right After: .Having contact with resident items, such as dressings, dirty laundry, dishes, or trash; Taking off gloves. The CDC (Centers for Disease Control and Prevention) document titled, Hand Hygiene for Healthcare Workers, indicates recommendations: Know when to clean your hands: Immediately before touching a patient, Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, Before moving from work on a soiled body site to a clean body site on the same patient, After touching a patient or patient's surroundings, After contact with blood, body fluids, or contaminated surfaces, Immediately after glove removal. The above information can also be found at: https://www.cdc.gov/clean-hands/hcp/clinical-safety/?CDC_AAref_Val=https://www.cdc.gov/handhygiene/providers/index.html with the page last reviewed on February 27, 2024. R8 was admitted to the facility 8/10/23. R8's diagnoses include, but are not limited to, Diabetes Mellitus Type 2. R8 has a Physician Order for Lantus Solostar Subcutaneous Solution Pen-Injector 100 units/ml (milliliter) (Insulin Glargine) Inject 28 units subcutaneously in the morning related to Type 2 Diabetes Mellitus with unspecified complications. On 7/25/24 at 7:25 AM, Surveyor observed LPN C (Licensed Practical Nurse) administer R8's morning medications during the Medication Pass. Surveyor observed LPN C preparing R8's Lantus Solostar Insulin Pen. Surveyor observed LPN C doff (remove) gloves, don (apply) new gloves, touch the laptop keyboard, use an alcohol pad to clean the tip of the insulin pen before applying the needle. On 7/25/24 at 7:30 AM, Surveyor spoke with LPN C. Surveyor asked LPN C, did you sanitize your hands in between glove changes. LPN C stated, No. Surveyor asked LPN C, should you have sanitized your hands in between glove changes. LPN C stated, Yes. Surveyor ask LPN C, after donning the second pair of gloves you touched the laptop keyboard and then used an alcohol pad to clean the tip of the insulin pen before applying the needle. Surveyor asked LPN C, should you have removed gloves, sanitized your hands after and donned clean gloves after touching the laptop keyboard and before using an alcohol pad to clean the tip of the insulin pen. LPN C stated, Yes. On 7/25/24 at 1:49 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, when do you expect staff to wash their hands. DON B stated, A lot of times! DON B added, the 5 moments, in and out of a room, before and after touching things people/belongings, before and after glove use. Surveyor asked DON B, should staff wash/sanitize hands after removing gloves? DON B replied, Yes, absolutely. Surveyor shared observation that LPN C (Licensed Practical Nurse) did not sanitize/wash her hands in between glove changes. Surveyor asked DON B, would you have expected LPN C to sanitize/wash her hands in between glove changes. DON B stated, Yes. Surveyor asked DON B, should LPN C have removed her gloves, sanitize/wash hands, and donned new gloves after touching the laptop and before using alcohol to clean the alcohol pen. DON B stated, she expects that LPN C would use hand sanitizer and change her gloves before using alcohol to clean the tip of the insulin pen and then administer the insulin.

Based on interview and record review, the facility did not ensure 2 Certified Nursing Assistants (CNAs; CNA L and CNA M) of 5 CNA's employed by the facility received 12 hours per year of in-service training. This practice had the potential to affect multiple residents in the facility. CNA L was hired on 6/21/22 and did not have 12 hours of in-service training during the most recent anniversary of hire year. CNA M was hired on 3/3/22 and did not have 12 hours of in-service training during the most recent anniversary of hire year. Evidenced by: On 8/1/24, Surveyor reviewed documents that indicated the following: - CNA L received 10.8 of the required 12 hours of in-service training. - CNA M received 7.45 of the required 12 hours of in-service training. On 8/1/24 at 2:20 PM, Surveyor interviewed DON B (Director of Nursing) who stated that the facility had identified in February of 2024 that they had problems with finding and/or verifying the annual trainings of their staff members. When asked if both CNA L and CNA M should have had their 12 hours of annual training by now, DON B stated Yes.

Based on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 16 sampled residents (R6) and 1 of 1 supplemental residents (R32) reviewed for antibiotic stewardship. R6 was on an antibiotic for urinary tract infection without an appropriate indication. R32 was on an antibiotic for urinary tract infection without an appropriate indication. This is evidenced by: The facility policy titled Antimicrobial Stewardship Procedure with a last review date of March 2024, states in part: .Purpose: To ensure judicious use of antibiotics, optimize clinical outcomes while minimizing unintended consequences of antimicrobial use including toxicity, to prevent the development of pathogenic organisms (Clostridium Difficile), and the emergence of resistance .The facility has developed a systematic approach to the review of symptoms and communication of those symptoms to the physician utilizing resources that include but not limited to: The McGeer Criteria .Antibiotic treatment will be determined by the medical provider based on individual resident condition and clinical practice standards .True infections: growth of an infective organism in or on a suitable host, producing clinical signs and symptoms or a change in status (e.g., fever, delirium, cough, dysuria, purulent exudates) .The medical provider will base their decision for antibiotic/antimicrobial orders on the basic premise described above .The Infection Preventionist or designee reviews any antibiotic orders entered in the electronic medical record. This review will include but not be limited to: i. Obtaining further documentation for the necessity of the treatment plan will be obtained from the medical provider as necessary ii. Taking an antibiotic time out to review culture results and the responsiveness of the resident to the treatment plan iii. Communicating findings to the medical provider as necessary. Example 1 R6 was admitted to the facility on [DATE]. Surveyor reviewed the facility infection control line list for June 2024. R9 was listed on the line list for UTI (Urinary Tract Infection). The line list indicated positive UA (Urinalysis), contaminated UC (Urine Culture). R6's Physician Orders for June 2024 include Keflex oral capsule (antibiotic) 500mg by mouth three times a day for Positive UTI for one week, start date 6/17/24, stop date 6/24/24. R6's Urine Culture report dated 6/18/24 states Multiple bacterial morphotypes present. This may indicate a poorly collected specimen. Of note, due to a contaminated urine sample, the urine culture does not meet criteria as a true infection because there is not growth of an infective organism. DON B (Director of Nursing) is currently the facility's Infection Preventionist. On 7/23/24 at 12:59PM Surveyor interviewed DON B. Surveyor asked DON B how the facility knows if the antibiotic would be effective since there is no culture and sensitivity indicating what antibiotic to use or if there was even a need to continue the antibiotic. DON B indicated R6 completed her antibiotic course without knowing if the pathogen was susceptible to the antibiotic. DON B indicated the antibiotic use does not follow their antibiotic stewardship program. Example 2 R32 was admitted to the facility on [DATE]. Surveyor reviewed the facility infection control line list for June 2024. R32 was listed on the line list for UTI (Urinary Tract Infection). The line list indicated positive UA (Urinalysis), contaminated UC (Urine Culture). R32's Physician Orders for June 2024 include Keflex oral capsule (antibiotic) 500mg by mouth three times a day for Positive UTI for 7 days, start date 6/17/24, stop date 6/24/24. R32's Urine Culture report dated 6/18/24 states Multiple bacterial morphotypes present. This may indicate a poorly collected specimen. Of note, due to a contaminated urine sample, the urine culture does not meet criteria as a true infection because there is not growth of an infective organism. On 7/23/24 at 12:59PM Surveyor interviewed DON B. Surveyor asked DON B how the facility knows if the antibiotic would be effective since there was no culture and sensitivity indicating what antibiotic to use or if there was even a need to continue to the antibiotic. DON B indicated R32 completed his antibiotic course without knowing if the pathogen was susceptible to the antibiotic. DON B indicated the antibiotic use does not follow their antibiotic stewardship program.

Based on interview and record review the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents reviewed for unnecessary medications (R22). R22 was taking a psychotropic medication, and a Gradual Dose Reduction (GDR) was not attempted due to family preference. Findings include. The facility's policy titled, Psychotropic Medication Evaluation and Utilization states, Psychotropic medications and other medications with black box warnings are specifically identified as requiring additional monitoring or have additional regulatory requirements. These medications require more in-depth review and medical provider involvement at particular times due to the potential for limited effect and higher potential for significant side effects .All psychotropic medications require individualized monitoring, which may include sleep studies, targeted behavior monitoring and or routine quarterly assessment. R22 was admitted to the facility on [DATE] and has diagnoses of dementia and depression. She takes Cymbalta (Duloxetine), 120 mg by mouth one time a day for depression. Additionally, R22's orders include scheduled and as needed (PRN) Lorazepam for anxiety and depression. On 7/11/24, the facility's consultant pharmacist recommended a GDR of duloxetine, stating, Would she (R22) benefit from trying a dose reduction of the Cymbalta (duloxetine) at this time to try to find the lowest effective dose? At this time, the pharmacist recommended a decrease from 120 mg daily to 90 mg daily. The form left by the pharmacist, dated 7/11/24, was not initialed or signed by the doctor, indicating whether he (the doctor) would attempt the GDR or if it was contraindicated and the reasoning for the contraindication. The facility made the following notes for R22: *7/11/24 at 12:50 PM: Consultant pharmacist recommendation: Chart reviewed .Discussed with nursing the possibility of reducing the Cymbalta dose. Recommendation for Cymbalta GDR. *7/17/24 at 1:50 PM: Resident seen today by MD (R22's physician) on rounds .discussed that POA (Power of Attorney) is not ready to decrease duloxetine at this time. MD states this is progression and has no new orders/suggestions at this time. *7/17/24 at 2:32 PM: Pharmacy recommendation to decrease duloxetine, POA does not want decrease at this time . *7/18/24 at 10:57 PM: Put fax on MD board asking to decrease duloxetine to 90mg 1 time/day due to resident's POA agreeing to pharmacy recommendation but not until August rounds when MD will have next visit with resident. Asked MD to change order at that time. A physician progress note, dated 7/17/24, states, She does continue on high dose duloxetine, but the family is not willing to have that reduced at this time. Later in the note, the physician writes, Dementia with behaviors, which include paranoia, mood disturbance. No change in medications today. She often will respond to redirecting and lorazepam has been generally helpful. On 7/24/24 at 3:24 PM, Surveyor interviewed RN I (Registered Nurse) who stated that R22 does not display behaviors indicative of depression. RN I stated that she has known R22 since she (RN I) was a little girl. According to RN I, R22 has fear, which Lorazepam has helped with. RN I stated that R22 was put on Cymbalta a long time ago, before she came to the facility due to psychotic behaviors. RN I stated the doctor tried to reduce the dose a while ago and the POA said, No. RN I stated that R22 has been yelling a lot recently and she (RN I) asked the doctor if this has to do with discontinuing a different antipsychotic and he said, No. Additionally, RN I stated the doctor had told her months earlier that he thought she (R22) was overmedicated. It should be noted that RN I wrote the 7/18/24 note regarding the fax to the MD. On 7/25/24 at 10:29 AM, Surveyor interviewed DON B (Director of Nursing) regarding the GDR request for the Duloxetine. DON B stated that there was not a point to wait until August to put a GDR in place. DON B stated R22's doctor, who is also the facility's medical director, just goes along with what the family wants. DON B also stated that there should be a response from the doctor whenever there is a GDR recommendation by the consultant pharmacist. When asked if the family should be making pharmacy decisions as it pertains to psychotropic medications for R22, DON B stated, No. The facility pharmacist recommended a GDR of duloxetine, but this was declined due to family preference with no other indication for why the medication should not be reduced or contraindication noted for its continued use at the current dose.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are thoroughly investigated for 2 of 16 sampled residents (R31 and R35). R31 was noted to have bruising to his left hip measuring 11 cm by 7.5 cm of unknown source. The injury of unknown source was not investigated at the time it was noted. R35 reported to a nurse that two CNAs requested that R35 have sex with them. This allegation of abuse was not investigated. Evidenced by: The facility policy titled Resident Abuse, Neglect, Misappropriate of Property, and Exploitation Prevention Program with last review date of October 2023, states, in part: .The facility will do all that is within its control to protect its residents from abuse, neglect, misappropriation of resident property, and exploitation. Abuse and neglect prevention includes but is not limited to, the following seven key components: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting/Response . Investigations: All of the following are promptly investigated per facility policies and practices .All resident accidents and incidents including: bruising, skin tears, lacerations, and abrasions; witnessed and un-witnessed falls; any other incident occurring to a resident; and injury of unknown source . any concern/grievance brought forward by or to facility staff related to resident care and/or safety .All investigations will be thorough, well-documented, and immediate to determine if mistreatment occurred and, if so, to what extent. A thorough investigation may include: identifying staff responsible for the investigation; collecting and preserving physical and documentary evidence that could be used in a criminal investigation; interviewing alleged victim(s) and witness(es); interviewing accused individual(s) (including staff, visitors, resident's relatives, etc.) allegedly responsible for mistreatment, or suspected of causing an injury of unknown source; interviewing other residents to determine if they have been abused or mistreated; interviewing staff who worked on the same shift as the accused to determine if they ever witnessed any mistreatment by the accused; interviewing staff who worked previous shifts to determine if they were aware of an injury or incident; observation of resident and staff behaviors during the investigation; environmental considerations; and involving other regulatory authorities who may assist . Definitions: Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but not yet been investigated and, if verified could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source . Injuries of unknown source an injury should be classified as an injury of unknown source when all the following are met: the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury . Mistreatment is defined as inappropriate treatment or exploitation of a resident. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Example 1 R31 was admitted to the facility on [DATE] with diagnoses that include neurocognitive disorder with Lewy bodies, Parkinson's disease, anemia, restlessness and agitation, and visual hallucinations. R31's Minimum Data Set (MDS) dated [DATE] indicates R31 has a Brief Interview for Mental Status (BIMS) of 9, indicating R31 has moderate cognitive impairment. R31's Nurses Notes dates 6/14/24 states: Report from CNA (Certified Nursing Assistant) resident has bruising to left hip - etiology unknown. Outer area yellow in color 11 (cm) x 7.5 (cm), darker bruising - 7.2 (cm) x 4.5 (cm). Resident states only [NAME] some when touched. Sending fax to provider, will notify family in morning. On 7/23/24 at 3:36 PM, Surveyor interviewed ADON J (Assistant Director of Nursing). ADON J indicated the facility abuse protocol should have been followed and the nurse should have reported the bruise, and an investigation should have been completed. ADON J indicated the nurse should have notified the facility on-call nurse about a bruise of unknown source. On 7/23/24 at 3:51 PM Surveyor interviewed DON B (Director of Nursing). DON B indicated the abuse policy should have been followed the nurse should have reported the bruise and an investigation should have been completed for a bruise of unknown source and was not. Example R35 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, bulimia, hyperlipidemia, personal history of non-Hodgkin's lymphoma and major depressive disorder. R35's Minimum Data Set (MDS) dated [DATE] indicates R35 has a Brief Interview for Mental Status (BIMS) of 4, indicating R35 had a severe cognitive impairment. R35's Nurses Notes for 4/15/24 at 22:15 (10:15 PM) states: Resident approached me up front by nurses station as she was walking back to her room, as she has been sitting up here on the bench since about 1900 (7:00 PM). She stated to me, that the two CNAs (Certified Nursing Assistant) upfront by the nurses station (CNA Names) approached her and requested that she have sex with them. I spoke to her and reassured her that there was a misunderstanding, and they did not request hat from her. I apologized and informed her that she is safe and secure. I spoke with both CNAs about this, and they informed me that they asked the resident if she was ready to go back to her room for the night. On 7/25/24 at 8:57 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated this is an allegation of abuse and she would have expected the facility abuse protocol to be followed. DON B indicated the nurse should have reported the incident immediately and an investigation should have been completed.

Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the administrator and appropriate agencies for 2 of 16 sampled residents (R31 and R35). R31 was noted to have bruising to his left hip measuring 11 cm by 7.5 cm of unknown source. The nurse did not report this injury of unknown source to the State Agency. R35 reported to a nurse that two CNAs requested that R35 have sex with them. This allegation of abuse was not reported to the State Agency or Law Enforcement. Evidenced by: The facility policy titled Resident Abuse, Neglect, Misappropriate of Property, and Exploitation Prevention Program with last review date of October 2023, states, in part: The facility will do all that is within its control to protect its residents from abuse, neglect, misappropriation of resident property, and exploitation. Abuse and neglect prevention includes but is not limited to, the following seven key components: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting/Response .Reporting/Response: [Facility] ensures all staff/covered individuals are trained, upon hire and at least annually, on reporting requirements which includes: What is to be reported - Any reasonable suspicion of a crime against a resident or individual receiving care form the facility, and all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of property; Who is required to report - The facility and any covered individual, which means owner, operation, employee, manager, agent or contractor of the facility; To whom to report - To the Administrator, State Survey Agency, local law enforcement, and adult protective services; and When to report - If serious bodily injury, report immediately but not later than 2 hours after forming the suspicion and if no serious bodily injury report not later than 24 hours .All staff/covered individuals are required to immediately report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property to the administrator .In addition, the facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the State Survey Agency, and other proper officials (e.g. local law enforcement and adult protective services) within the prescribed timeframe. Definitions: Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but not yet been investigated and, if verified could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source . Injuries of unknown source an injury should be classified as an injury of unknown source when all of the following are met: the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury . Mistreatment is defined as inappropriate treatment or exploitation of a resident. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Example 1 R31 was admitted to the facility on [DATE] with diagnoses that include neurocognitive disorder with Lewy bodies, Parkinson's disease, anemia, restlessness and agitation, and visual hallucinations. R31's Minimum Data Set (MDS) dated [DATE] indicates R31 has a Brief Interview for Mental Status (BIMS) of 9, indicating R31 has moderate cognitive impairment. R31's Nurses Notes dates 6/14/24 states: Report from CNA (Certified Nursing Assistant) resident has bruising to left hip - etiology unknown. Outer area yellow in color 11 (cm) x 7.5 (cm), darker bruising - 7.2 (cm) x 4.5 (cm). Resident states only hurts some when touched. Sending fax to provider, will notify family in morning. On 7/23/24 at 3:36PM, Surveyor interviewed ADON J (Assistant Director of Nursing). ADON J indicated the facility abuse policy should have been followed and the nurse should have reported the bruise but did not. ADON J indicated the nurse should have notified the facility on-call nurse about a bruise of unknown etiology. On 7/23/24 at 3:51PM Surveyor interviewed DON B (Director of Nursing). DON B indicated the abuse policy should have been followed for a bruise of unknown etiology and was not. Example 2 R35 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, bulimia, hyperlipidemia, personal history of non-Hodgkin's lymphoma and major depressive disorder. R35's Minimum Data Set (MDS) dated [DATE] indicates R35 has a Brief Interview for Mental Status (BIMS) of 4, indicating R35 had a severe cognitive impairment. R35's Nurses Notes for 4/15/24 at 22:15 (10:15PM) states: Resident approached me up front by nurses station as she was walking back to her room, as she has been sitting up here on the bench since about 1900 (7:00PM). She stated to me, that the two CNAs (Certified Nursing Assistant) upfront by the nurses station (CNA Names) approached her and requested that she have sex with them. I spoke to her and reassured her that there was a misunderstanding, and they did not request that from her. I apologized and informed her that she is safe and secure. I spoke with both CNAs about this, and they informed me that they asked the resident if she was ready to go back to her room for the night. On 7/25/24 at 8:57AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated this is an allegation of abuse and she would have expected the nurse to follow the facility abuse policy. DON B indicated the nurse should have reported the incident immediately and the nurse did not report it.

Based on interview, record review, and review of facility policy, the facility failed to inform the resident representative of a change in condition for one resident (R) (R5) of four residents reviewed for change in condition. The facility failed to inform R5's representative of increased respiratory symptoms including being positive for the respiratory syncytial virus (RSV) for two days prior to having to be transferred to the hospital. This failure placed the resident representative at risk of not being aware of the care and services provided by the facility. Findings included. Review of the facility's policy titled, Notification of Change, dated 02/2023 revealed, .The purpose of this policy is to ensure the facility promptly informs the . resident's representative when there is a change requiring notification .Circumstances requiring notification include .Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status .This may include .Life threatening conditions or clinical complications . Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R5 was admitted to the facility on [DATE] with diagnoses that included heart failure, irregular heart rhythm, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/21/23 revealed R5 had a Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated she was severely impaired in cognition. Review of a Progress Note dated 01/16/24 located in the Progress Note tab of the EMR revealed R5 was complaining of not feeling well. It was noted that she had a cough, headache, and sore throat since Sunday (01/14/24) and was swabbed for RSV and influenza (flu). There was no documentation in the EMR to show that R5's resident representative was notified of the changes. Review of a Progress Note dated 01/17/24 located in the Progress Note tab of the EMR revealed that R5 continued to not feel well. She had a worsening cough which was documented as harsh, increased tiredness and confusion. Staff noted that she was falling asleep while eating. Lung sounds revealed increased abnormal sounds, and her appetite was decreased. The swab for the RSV was positive and she was placed on droplet precautions. There was no documentation in the EMR to show that R5's resident representative was notified of her significant change in condition or the positive RSV swab. Review of a Progress Note dated 01/18/24 located in the Progress Note tab of the EMR revealed, CNA [Certified Nurse Aide] came to get this nurse stating residents' lips were purple, pupils dilated, not very responsive, and hot .Resident's lung sound full of fluid .Ambulance notified .Called ER [emergency room ] with update .Daughter called with update message left . During an interview on 03/27/24 at 1:00 PM, Family Member (FM)1 was asked if the facility had notified her on 01/16/24 and 01/17/24 of R5's changes in her condition. FM1 stated, No, they did not. During an interview on 03/28/24 at 6:12 AM, the Director of Nursing (DON) was asked why R5's FM 1 was not updated on 01/16/24 when she began having a change in condition or on 01/17/24 when the RSV swab was positive. The DON stated, I don't know why Licensed Practical Nurse (LPN) 3, who was on duty, did not notify her daughter. The DON was asked what her expectations regarding resident representative notification are. The DON stated, The family should have been called. R5's family member was not notified when R5 had a change in condition and was positive for RSV.

Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) to a resident requiring emergency care for 1 of 3 Residents (R3) reviewed for code status. Additionally, the facility does not have a process for ensuring a CPR certified staff member is available on each shift. This has the potential to affect 10 full code residents that reside in the facility. R3 was a full code (wanted cardiopulmonary resuscitation) and was found pulseless and nonbreathing on [DATE]. An LPN (Licensed Practical Nurse) failed to initiate CPR when R3 was found to be cyanotic in the face, pulseless and not breathing. Facility failure to begin cardiopulmonary resuscitation, and its failure to ensure CPR-certified staff on each shift, created a finding of immediate jeopardy that began on [DATE]. Surveyors notified DON B (Director of Nursing) and RCN C (Regional Clinical Nurse) of the immediate jeopardy on [DATE] at 11:50 AM. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a severity/scope of E (Potential for Harm/Pattern) as the facility continues to implement its action plan. This is evidenced by: Per CMS (Centers for Medicare and Medicaid Services) Cardiopulmonary resuscitation (CPR) memo ,d+[DATE] revised [DATE] CPR refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. When addressing full-code residents: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition,) facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services. Facility policy titled, Cardiopulmonary Resuscitation (CPR), implemented [DATE], states in part, .Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Police Explanation and Compliance Guidelines: 1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or . c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition. 3. CPR certified staff will be available at all times. 4. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable. Facility policy titled Medical Emergency Response, dated [DATE], states in part .Policy: 1. It is the policy of this facility to respond to medical emergencies for residents, staff, and visitors. Policy Explanation and Compliance Guidelines: 1. The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance. 2. CPR will continue unless: a. There is a DNR order in place. b. There are obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transection, or decomposition). 8. If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or c. if the resident does not show obvious signs of clinical death. 11. The facility will ensure that CPR certified staff are available at all times. 12. Current certified staff must maintain CPR-Certification for Healthcare Providers through a CPR provider whose training includes hands-on skills practice and in-person assessment and demonstration of skills. Online certification is not acceptable. 1. R3 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, diabetes mellitus type 2, chronic kidney disease, old myocardial infarction, history of venous thrombosis and embolism on anticoagulation therapy, coronary angioplasty, occlusion, and stenosis of right coronary artery. R3's most recent Minimum Data Set (MDS) dated [DATE] states that R3 has a Brief Interview for Mental Status (BIMS) of 15, indicating that R3 is cognitively intact. The MDS also indicates that R3 requires supervision and set up help only for transfers, supervision of one staff for bed mobility, limited assistance of one staff for dressing and toileting and extensive assistance of one staff member for hygiene. R3 is always continent of bowel and bladder. R3's Advance Directives dated [DATE] state that R3 chose to remain a full code. R3's care plan, initiated [DATE], states in part . Focus: I am a Full Code. Interventions: Call 911 for transportation to the hospital. Initiate CPR in the absence of a pulse. Provide privacy during code. Nurse's note dated [DATE] at 13:41 PM (1:41 PM) states in part, Note Text: resident was going to go out with a friend when he passed out. Friend was able to get him back into chair. Resident was pale, jerking in wheelchair, unresponsive, with low O2 (Oxygen) at 84% and high heart rate at 96, blood sugar 141. Irregular heart rate and slurring words. O2 applied at 3L (Liters). O2 measured 94% with O2 on. Resident sent out via ambulance. ER called. family called . Nurse's note dated [DATE] at 17:50 PM (5:50 PM) states in part, Late Entry: Note Text: Call placed to [Hospital Name] ER (emergency room ) and requested update on resident. Nurse stated resident had a vasovagal response they did a CT scan (x-ray to look at internal organs) which was fine, urinalysis and other tests on him and everything seems good, mentioned Lasix (diuretic) and push fluids. Nurse's note dated [DATE] at 18:30 PM (6:30 PM) states in part, Late Entry: Condition: laughing, talking, mobile via ambulation. Resident was witnessed getting up from ambulance cot and ambulated into their room with the assistance of their walker. Resident was provided supper meal in their room, and then proceeded to go on with the rest of the day. Resident was joking and kidding with staff members throughout the night. Per hospital, via phone communication, Resident was seen, and labs were drawn as well as monitoring of vitals. Hospital then proceeded to deem resident fit to return. Transferring resident back to facility via Ambulance. Hospital stated that resident had no signs of medical issues. No paperwork was received about resident. Note Text: Resident returned back to facility per ambulance. Ambulance staff came in dropped (Resident Name) off and then left absent of giving handoff report. Resident upon initial evaluation upon return appeared to be in normal . Nurse's note dated [DATE] at 01:53 AM (1:53 AM) states in part, Note Text: During rounds performed by CNAs, Resident was discovered to be displaying no respirations. CNA staff reported to nurse, that something was wrong with resident. Nurse went down and observed no respirations, no pulse felt, no O2 obtained, and skin to be cyanotic. Director of Nursing notified, family notified, fax sent out to doctor, ER called for pronunciation of death. Administrator notified per DON . Of note, there is no documentation to indicate CPR should not be started. Cyanotic skin is not an indicator to not initiate CPR. There is no contemporaneous documentation of rigor mortis or lividity. Nurse's note dated [DATE] at 02:45 AM (2:45 AM) states in part, Late Entry: Note Text: ER contacted, they stated, I should contact the coroner due to the circumstances of the untimely death and the ER visitation of the resident falling with less than 24 hours . Nurse's note dated [DATE] at 04:45 AM (4:45 AM) states in part, Note Text: Coroner contacted due to unexpected death at 0249. Coroner arrived at facility at around 0330 and left at around 0430. Coroner is going to gather information from (Hospital Name) in the morning and will fax information back to the facility. (Funeral Home) was contacted by Coroner to remove the body. Body has been removed; belongings left in the room. (Funeral Home) will contact family and discuss funeral arrangements and stated that he will let the family know that resident's belongings are still located in their room and that they can come and sort through them when they are ready. More information to follow after coroner gathers information from hospital . On [DATE] at 6:42 AM, Surveyor interviewed HA G (Hospitality Aide). Surveyor asked HA G about incident on [DATE] and if she could walk Surveyor through what she observed and knew about the incident. HA G stated, I was passing water around 1:00 AM and noticed R3's lower body was off the bed, and he had, had a BM. I couldn't find CNA F. Around 1:25 AM a light was going off and I saw CNA F and asked her to check on R3, so he didn't fall out of bed. R3 had one leg straight like he sat on the edge of the bed then laid over to the side with his head resting on the bed. One hand was still holding his cane. On [DATE], HA G's written statement to the facility states, At 1:00 AM, I HA G was passing out water, when I passed water to R3 I noticed his legs were over the bed while sitting in bowel. I notified the CNA, CNA F, about the bowel. CNA F went to help R3 with cares and found resident non-responsive. CNA F asked me to go get the nurse in charge, LPN D (Licensed Practical Nurse). LPN D asked CNA F to prep resident for the morgue once clarified he was decreased. As CNA F was cleaning up the resident, she found an IV was left in the resident's right forearm. CNA F also found what could possibly be saliva on the bedding where his face [sic]. I noticed that the resident had blood coming from his mouth. While CNA F was cleaning the bowel, I noticed there was blood in his stool. CNA F finished cleaning up resident and positioned him in bed. CNA F notified the nurse of the finding, and that the resident was ready for the morgue. Resident was found unresponsive around 1:30 AM on [DATE]. On [DATE] at 5:57 AM, Surveyor interviewed CNA F. Surveyor asked CNA F if CNAs are allowed to perform CPR in the facility and if she has a current CPR certification. CNA F stated, I need to renew my CPR certification. I have no clue if a CNA can perform CPR here in this facility. Surveyor asked CNA F to talk through what she remembers and saw from R3's death on [DATE]. CNA F stated, HA G reported to me that R3 was sitting on the edge of the bed, R3 was lying to the side with head on the mattress and feet up due to head of the bed being flat and R3 smelled of BM. I went down to R3's room and turned on the light. I had HA G go get the LPN. R3 was purple in the face, had had a bowel movement with blood in stool, and puddle of saliva which appeared to have blood in it. It appeared as if R3 had bit his tongue. This all happened around 1:15 AM or 1:30 AM. I had saw R3 last around midnight. I did not know R3 was a full code, but LPN D indicated that he was aware. I think that is why they now put dots on the doors. That should have been done before this happened. LPN D checked R3 for a pulse then told me to get R3 ready for the funeral home. I did note he still had an IV from ER visit in the right arm, which I removed. On [DATE], CNA F's written statement to the facility states, HA G passed water for the night. She notified me, CNA F, that the resident was lying in bed with feet and legs off bed. She also stated the resident was laying in bowel. I CNA F went to help the resident with cares and found the resident non-responsive with HA G shadowing me. I immediately asked HA G to get the nurse on shift, LPN D. LPN D asked that I prep the resident for the morgue once clarified he was deceased . As I was cleaning up the resident, I found an IV was left in the resident's right forearm. I also found what appeared to possibly be saliva on the bedding where his face was laying. The resident also had blood at the corner of his mouth, I then examined his tongue was clenched between his teeth. I finished cleaning the resident's body, positioned him in bed and notified the nurse of findings and that he was ready for when the morgue would be arriving. Resident was found unresponsive around 1:30 AM on [DATE]. On [DATE] at 9:25 AM, Surveyor interviewed LPN D. Surveyor asked LPN D to walk through the incident with R3 from [DATE]. LPN D stated, on the previous shift R3 was sent out to the ER (emergency room ); he returned to the facility between 6:00 PM and 6:30 PM. When I saw him come back, he appeared fine. Later that night I called for the discharge paperwork from the hospital, including labs and images. I did notice his Troponin was high on initial draw as well as his D-dimer. I did call the DON (Director of Nursing) about discharge paperwork after R3 was expired. I did look at it earlier for medication changes but that was all. Earlier in the evening I talked with ambulance driver who took R3 to his room. R3 was able to walk into his room using a walker at his normal gait. I then got R3 a tray for supper. From 6:00 PM until 6:00 AM I am the only nurse here. The day shift nurses were here that day until 6:30 PM or 7:00 PM. R3 was independent in his room, and he does not get night medications. At night he will call for staff to take his hearing aids, but he normally is up until 1:00 AM or 2:00 AM. At about 11:00 PM or 11:30 PM staff were passing water and CNA walked out the room next to R3's and noted he was still up watching TV at that time. At about 1:00 AM staff walked by R3's room and noted something was off. R3 was in the fetal position and had bowel on the bed. The CNA noted that R3 was blue in the face, cold to the touch and stiff. Staff yelled for me, and I went down to R3's room. R3 was in BM, cold to the touch, and blue in the face. I called the DON right away. DON told me to get paperwork. It was at that time that it dawned on me that I needed to call the coroner due to unexplained death. Coroner got the facility around 2:30 AM. I asked the coroner some questions. R3 still had the IV in his arm from the hospital. The IV was removed and placed next the R3's arm. During conversation with the DON, I informed her that R3 was cold to the touch, was in fecal matter, was in the fetal position, and blue in the face. The DON told me to fill out forms, call ER, family and she would contact the NHA (Nursing Home Administrator). R3 was a full code, and they are giving me a warning for this. That is what I was told. Of note: Per CNA F (Certified Nursing Assistant) statement and interview R3 was last seen at midnight alive and well. During interview with HA G (Hospitality Aide) she indicates that she was passing water at 1:00 AM and noted R3 smelled of BM (bowel movement) and alerted CNA G of this between 1:15 AM and 1:30 AM at which time CNA G entered R3's room and found him unresponsive, approximately 1 ,d+[DATE] to 1 ,d+[DATE] hours after last seen alive and well. According to the National Institute of Health, Rigor mortis appears approximately 2 hours after death in the muscles of the face, progresses to the limbs over the next few hours, completing between 6 to 8 hours after death. Rigor mortis then stays for another 12 hours (till 24 hours after death) and then disappears. Of note: LPN D indicates that the CNA noted R3 to blue in the face, cold to the touch, and stiff, but only indicates that he noted R3 to be cold to the touch and blue in the face. A CNA is unable to assess a resident for rigor mortis. There is no mention of R3 being stiff or in rigor mortis. On [DATE] at 2:50 PM, Surveyor again interviewed LPN D. Surveyor asked LPN D if he was aware of R3's code status prior to entering his room. LPN D stated, I did know his code status. Surveyor asked LPN D about calls placed to DON B. LPN D stated, The first time I called her I only told her that R3 was found dead, but I did not get into the nitty gritty until after I talked with the hospital and family. On [DATE] at 9:59 AM, Surveyor interviewed DON B. Surveyor asked DON B if she could walk through her conversation with LPN D the morning of [DATE] following R3's death. DON B stated, LPN D called me about 1:30 AM and told me they had went into R3's room and found resident gone - passed away. He said that when he went to check on R3 he was cold, stiff and had no pulse. LPN D then told me he had already called the ER for R3's hospital paperwork from the previous day and notified the family of R3's passing. LPN D had called me immediately following the incident but did not give me any details, just said resident was found expired and that he had to go someone was at the door and he would call back. He called me back 15 minutes later to inform me of what happened and that he was going to call the coroner or that he had called the coroner, I am not sure which. He told me he had just found him, but it could not have been just. Of note: DON B's statement of He told me he had just found him, but it could not have been just indicates that DON B believed that R3 had been deceased for some time prior to LPN D calling her. Surveyor asked DON B what her expectation was for finding a resident pulseless and non-breathing. DON B stated, LPN D should have known R3's code status and started CPR, that is my expectation. Nurse's note dated [DATE] at 12:54 PM (12:54 PM) states in part, Late Entry: Note Text: Spoke with Coroner this am. Corner (Name), about whether autopsy was going to be performed. Per Coroner report: Due to the significant medical history pertaining to heart issues there will be no autopsy performed. The coroner spoke with the family, and they understood their rights and refused the procedure. The family told the coroner that they knew it was coming due to the way he wanted to live. Corner and Medical examiner /pathologist examined body and reviewed medical records, and these were their findings. Resident in the past had refused to go see a Cardiologist. Resident stating I feel fine and refusing treatment. He was advised by his primary physician (Physician Name) in the past to see a cardiologist for which he refused. He also has a history of coronary artery disease, CVA, atrial fibrillation, type 2 diabetes, hypertension, and chronic kidney disease. This nurse explained to coroner that resident had an unresponsive episode earlier and was sent to the emergency room to be evaluated. This nurse explained to coroner, per staff reporting that resident was unresponsive for ,d+[DATE] minutes. Coroner and Medical pathologist both agreed that resident threw a clot which would explain the increase troponin and d-dimer. D-dimer 674 and troponin 81 were both elevated. (Labs completed D-dimer which indicates possible clot formation and troponin muscle damage). The coroner asked this nurse if the resident was taking any medications such as coumadin or Eliquis. The nurse told the medical examiner that the resident was currently on Eliquis 2.5mg BID (twice a day). The coroner examined the body and found blood in his stool, and blood coming from mouth, which indicates bleeding noted. Coroner stated that the blood in the mouth was caused by resident gritting his teeth in his mouth, due to the pain from another clot, possibly coming from the lungs due the pulmonary edema, that lodged in his heart which stopped it immediately. He called it a type of seizure caused by clots that go to the heart. Coroner also stated, that even if resident was at the hospital or at the facility, there would have been nothing anyone could have done to prevent his death. No type of resuscitation would have brought the resident back especially after rigor mortis already present . Of note: Nurses Notes indicate the coroner was called to come to the facility at approximately 2:45 AM and arrived at approximately 3:30 AM. Per interview with LPN D and review of progress notes there was no indication CPR was not started due to rigor mortis but only that the resident was cold and blue. Cold and blue is not an indication not to start CPR. The coroner did not arrive to the facility until 2 plus hours after resident expired and one would expect some rigor mortis at this point. 2. On [DATE], Surveyor reviewed nursing staff CPR certifications and noted that the facility employs 15 Nurses and Med Tech's, which includes the DON and Nurse Managers. Of those 15 Nurses and Med Tech's only 6 have current up to date and appropriate CPR certifications. Nursing Schedules reviewed showed that on [DATE] from 10:00 PM to 6:00 AM the only staff in the building with a valid CPR certification was CNA H. Of note: Facility staff are unaware of whether a CNA can perform CPR in the facility and Nurses interviewed indicate that they had been told that CNAs cannot perform CPR in the facility. On [DATE] at 4:30 PM, Surveyor interviewed CNA K. Surveyor asked CNA K if she was CPR certified. CNA K stated, I don't have a current CPR certification. Surveyor asked CNA K if she was aware whether a CNA could perform CPR in the facility. CNA K stated, Nurses have to do CPR. On [DATE] at 4:40 PM, Surveyor interviewed CNA L. Surveyor asked CNA L if she was CPR certified. CNA L stated, I don't have a CPR certification. Surveyor asked CNA L if she was aware whether a CNA could perform CPR in the facility. CNA L stated, I am not sure if CNA's can-do CPR or not. I would have to ask. On [DATE] at 5:57 AM, Surveyor interviewed CNA F. Surveyor asked CNA F if CNAs are allowed to perform CPR in the facility and if she has a current CPR certification. CNA F stated, I need to renew my CPR certification. I have no clue if a CNA can perform CPR here in this facility. On [DATE] at 6:22 AM, Surveyor spoke with RN E (Registered Nurse). RN E stated that DON B and RCN C (Regional Clinical Nurse) told her that CNA's can only do CPR on the street. In this facility they say CNAs can't do CPR. On [DATE] at 6:25 AM, Surveyor again spoke with LPN D. Surveyor asked LPN D if he knew or was aware whether CNAs could do CPR in this facility. LPN D stated, I was not aware this facility did not allow CNAs to do CPR until my conversation with RNC C. RNC C and I discussed CNAs doing CPR and RNC C stated No, No, they can't do that. Surveyor asked HA G if she was aware whether the facility allowed CNAs to do CPR. HA G indicated she was not aware whether they could or not. On [DATE] at 7:37 AM, Surveyor interviewed CNA/Med Tech J. Surveyor asked CNA/Med Tech J whether she was able to perform CPR in the facility. CNA/Med Tech J stated, As a CNA, no I cannot do CPR but as a Med Tech I can. On [DATE] at 7:40 AM, Surveyor interviewed LPN I. Surveyor asked LPN I if she was aware whether a CNA could perform CPR in this facility. LPN, I stated, DON B told us CNAs can't do CPR. On [DATE] at 9:15 AM, Surveyor interviewed CNA H. Surveyor asked CNA H is she knew whether she was allowed to perform CPR in the facility. CNA H stated that yes, she was able to perform CPR as a CNA. RCN C called me yesterday to educate me and inform me that I would be the only person CPR certified in the building at times that could do CPR, so I took that as I can do CPR. On [DATE] at 9:48 AM, Surveyor interviewed DON B. Surveyor asked DON B prior to Surveyors coming into the building who was able to perform CPR. DON B stated, Nurses only. I did tell the Nurses that CNAs are not allowed to perform CPR in the facility. On [DATE] at 9:52 AM, Surveyor interviewed RNC C. Surveyor asked RNC C if prior to Surveyors coming into the building who was able to perform CPR. RNC C stated, Certified staff. We do prefer Nurses to do it. This was related to a licensed staff member so that is who we educated, licensed staff. Surveyor asked RNC C if he had informed Nursing staff that CNAs were not able to perform CPR in the building prior to Surveyors entering the building. RNC C stated, Not sure I said that exactly, but yes. The failure to ensure R6's wishes were accurately and consistently identified in the medical record and the failure to ensure CPR-certified staff worked each shift 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: On ,d+[DATE].23 the facility recognized the concern and completed the following: Education by DON or designee to all licensed clinical staff on Medical Emergency Response policy by [DATE]. Competency evaluation conducted of all licensed clinical staff no later than [DATE] by DON or designee. Verbal verification of 3 licensed staff random shifts per week x6 weeks on CPR competency Audit conducted monthly for 12 months by HE director of designee that all staff have annual CPR training. Audit completed on crash cart/AED update items as necessary by DON or designee by [DATE]. Audit conducted by DON or designee not later than [DATE] and weekly x6 weeks. SSD to audit new admission Code status from [DATE] by [DATE]. Present to QAPI team on [DATE]. The facility did not identify on [DATE] the need to educate all staff on CPR and did not have a system in place to ensure a CPR certified staff member was always working until [DATE] when the facility implemented the following . 1. A system was put into place to ensure a CPR certified staff is on duty each shift: - The NHA and/or DON will review the nursing schedule daily to ensure there is a CPR certified staff on schedule (Marked with a capital C) after their name. - The facility created a master list of current licensed employees noting Certified CPR expiration dates with the DON in conjunction with the HR Director to monitor monthly. - The facility reviewed employees creating a list of employees that are CPR certified in the facility as alternatives if there shall be a call in. - The Scheduler and Nurse's station was provided a list of Certified CPR employees to utilize if a call in occurs, the nurse on duty and/or scheduler will alert the DON for replacement options. - The DON and/or HR Director will review any new hire for Certification in CPR noting expiration date if applicable. - The Facility has set up Mandatory CPR Certification for [DATE] and [DATE] to ensure adequate staffing that are certified in CPR. - The Facility will continue to offer Certification in CPR on an annual basis. 2. Education was provided to all staff Certified in CPR that they may perform CPR when directed by a licensed nurse. 3. Education was provided to all staff to report to nurse if a resident is found PNB 4. Education was provided to the NHA, DON and Scheduler on providing adequate staff certified in CPR for every shift and the list of employees Certified in CPR to utilize for replacement in case of a call in. 5. Education was provided to the licensed nurses on replacing a staff member who was Certified in CPR with another employee Certified in CPR for after hour shifts (Pm's, Nights, Weekends) and will alert the DON 6. The DON and/or designee will audit: - Five random employees' random shifts with verbal validation on who may perform CPR per week x 6 weeks to ensure understanding. - The nursing schedule to ensure a CPR certified staff is on duty each shift per week to ensure compliance. - The Certified CPR list monthly to ensure compliance with valid Certification in CPR - Mock codes with the involvement of all staff are conducted weekly x 6 weeks - Competency for CPR were completed on all staff who are Certified in CPR

Based on observation, interview, and record review the facility failed to protect residents right to be free from verbal and physical abuse by Resident (R1). This has the potential to affect all 12 residents who reside on the 100 unit with R1. The facility failed to protect residents right to be free from physical abuse by Registered Nurse (RN U) for 2 of 3 residents reviewed for abuse. R1 has a history at the facility of resident-to-resident incidents including slapping a resident, shaking a resident, grabbing the shirt of a resident, and yelling and swearing at other residents. In addition, R1 has grabbed arms and throat of staff, threw staff against the wall, and punched and hit staff during cares and when walking in the hallway. Supervision for R1 was not increased to prevent further incidents. On [DATE] at 4:55 AM R1 entered R4's room and grabbed R4's forearms while R4 was sitting in her recliner. R4 was screaming. R1 was monitored 1:1 (one on one) from [DATE] at 5:00 AM through [DATE] at 12:00 AM. On [DATE], he became agitated in the dining room and wielded a knife back and forth toward a staff member. On [DATE] at 9:15 AM R1 went over to R9's room, while staff members attempted to intervene, R1 grabbed a staff member by both arms and proceeded to punch/strike R9 in the face with a closed fist. The facility was aware R1's behaviors of hitting, punching, grabbing, yelling, and swearing at other residents and staff. The facility's failure to increase supervision resulted in R1 abusing R4 and R9 created a finding of Immediate Jeopardy (IJ) that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the Immediate Jeopardy on [DATE] at 4:08 PM. The Immediate Jeopardy was removed on [DATE]. However, the deficient practice continues at a scope/severity of E (no actual harm with potential for more than minimal harm, pattern) as the facility continues to implement their action plan. Evidenced by: The facility's Abuse, Neglect and Exploitation policy, revised [DATE], includes, in part, the following: 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. III. Prevention of Abuse, Neglect and Exploitation B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment. D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. IV. Identification of Abuse, Neglect and Exploitation B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff, or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body 5. Verbal abuse of a resident overheard 6. Physical abuse of a resident observed IV. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: C. Increased supervision of the alleged victim and residents D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator R1 was admitted [DATE]. R1's diagnoses include dementia with agitation, anxiety, restlessness, insomnia, and depression. R1's MDS (Minimum Data Set), dated [DATE], indicates R1 has severe cognitive impairment, has delusions, is physical toward others, is verbal towards others, has other behaviors, rejects cares and wanders. R1 ambulates with supervision, R1's Care Plan includes, in part, the following: Focus: Resident does not usually stay in a group activity long. He will participate more when it is 1:1 or with just 1 or 2 other people. Resident enjoys spending time outdoors and his wife visits him frequently. Date Initiated: [DATE], Revised on [DATE]. Interventions: Provide 1:1 visits weekly, Provide with leisure materials for room such as magazines. Take resident outside, with another staff, if he is having behaviors. When resident is agitated attempt to provide a lower stimulating activity in a quiet area. Date Initiated: [DATE]. Focus: The resident is an elopement risk/wanderer r/t (related to) disoriented to place. History of attempts to leave facility unattended, impaired safety awareness, dementia. Date Initiated: [DATE]. Interventions: At HS (hour of sleep) and through the night shift, observe resident q (every) 2 hours. If resident is awake restless, or wandering, offer toileting and return to bed. Date Initiated: [DATE]. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (please note there is nothing after this) Date Initiated: [DATE]. Provide structured activities toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date Initiated: [DATE]. Focus: The resident has a behavior problem r/t agitation. Physical aggression to others. Resident may require 1:1's with behaviors PRN (as needed). Lashing out at staff and resident unprovoked. Date Initiated: [DATE]. Revision on: [DATE]. Interventions: Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Date Initiated: [DATE]. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: [DATE]. Loud noises, patients yelling trigger me. Please redirect me to a lesser stimuli environment. Date Initiated: [DATE]. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. Date Initiated: [DATE]. Provide program of activities that is of interest and accommodates residents' status. Date Initiated: [DATE]. Focus: The resident is/has potential to be physically aggressive towards staff r/t dementia, hallucinations, and delusions. Date Initiated: [DATE]. Interventions: Administer medications as ordered. Analyze times of day, places, circumstances, triggers and what de-escalates behavior and document. Anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Modify environment as needed. Encourage to go to his room or Serenity room (if unoccupied) where there is less stimulation. When the resident becomes agitated: Intervene before agitation escalates.; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Date Initiated: [DATE]. Focus: I use anti-anxiety medication r/t anxiety disorder secondary to dementia. Date Initiated: [DATE]. Interventions: Monitor occurrence of for (sic) target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc. and document per facility protocol. Date Initiated: [DATE]. The facility's Misconduct Incident Report includes, in part the following: Date occurred: [DATE]. Briefly Describe the incident: CNA was walking past R1's room when she heard a noise, CNA went to room immediately to see what had happened. CNA noticed (residents' wife/visitor) was laying on the floor next to bed. CNA asked if she was ok and not to move that she was going to go get a nurse. Before CNA left, she had another CNA remove R1 from the room until wife was able to be assessed by nurse. Nurse went to room and check on (wife). Nurse checked vitals and range of motion to make sure that there were no injuries. Vitals were good and (wife) was able to move all extremities without any pain. Nurse asked wife if she had hit her head, and she stated No Nurse asked (wife) if she could recall what happened. she stated I was standing in front of R1's chair and he was reaching for the show (sic) box to put his old shoes in, and he pushed me to get out of the way and I tripped on the mat on the floor. I know that he didn't mean anything by this. Describe the Effects: This did have a little effect on wife as she got teary eyed as she stated that I know that he doesn't realize what he has done, and it is just hard for me to see him like this. The facility implemented the following after the incident: Fifteen-minute checks implemented and will continue until midnight ([DATE]), then 30- minute checks till 6am ([DATE]), 45-minute checks until 12pm ([DATE]) and then 1-hour checks till midnight ([DATE]). Staff informed of this, and forms given to staff to fill out and return to the administrator when completed. The facility's Misconduct Incident Report includes, in part the following: Date occurred: [DATE]. Briefly describe the incident: Staff member was talking to resident (R1) in the hallway, resident took off down the hallway and before staff member could get caught up with (R1) he had entered another resident's room (R4) and grabbed her forearms. Staff entered (R4's) room and seem (sic) that (R1) had grabbed (R4's) forearms. Staff member was able to get (R1) away from (R4), than (sic) (R1) grabbed staff members arms and was pushing the staff member and trying to hit staff member in the face. Another staff member came to help and was able to get (R1) redirected and back to his room. One on one intervention in place, staff interviews and investigation have all started. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: Residents were separated immediately. 1 on 1 initiated for resident (R1). MD (Medical Doctor) was notified of incident and behaviors. Medications were adjusted and will continue to monitor for effect. Educational session for all clinical staff on how to appropriately approach dementia residents was initiated. NHA (Nursing Home Administrator) or designee to complete ongoing training with all staff on dementia behaviors. Licensed nurse to be present in the dementia wing during AM and PM shifts along with CNA and HA (Hospitality Aide) staff to monitor behaviors and assist with ensuring resident and staff safety and intervene appropriately to (R1's) behaviors. Contact to local psychiatric providers for referral to additional support for resident (R1) in progress. (sic) Resident's care plan will be reviewed and modified appropriately. Continue with non-pharmacological approaches as appropriate. Continue to work with MD, staff, and residents POA (Power of Attorney) for additional resources and approaches to resident (R1) behaviors. CNA N's (Certified Nursing Assistant's) statement, dated [DATE], includes, in part, the following: As I was walking towards the top of the hall, I noticed (R1) leaning against the med room door. (R1) has been very unsteady and has a swollen lf (left) ankle. So, I asked him if he'd like to go and sit in a chair in his room. He said no, I then tried to start a conversation with him, asking him if his ankle hurt. He then became angry and very aggressive. He quickly took off down the hall. He entered (R4's) room before I could get there. As I entered her room, (R1) had leaned over her and grabbed her forearms. (R4) was sitting in her recliner at that time. (R4) was screaming. I radioed for help as (R1) had a hold of my arms and was pushing me and trying to hit me in the face. (CNA H) came and helped. He was pushing both of us up the hall. (CNA H) was able to get (R1) to his room and calm him down. R1's Progress Notes include, in part, the following: [DATE], 4:55 AM, Called to memory unit by CNA over walkie talkie for help. Upon entering unit noted (R1) had a strong hold upon (CNA N) wrist and was pulling her backwards, resident eventually calmed down. Was informed by staff the (sic) this resident had a hold of another resident, grabbed both wrists and (R4) was sitting in her recliner chair crying emotional support given, resident returned to his room without further incident. Tylenol given for pain scale of 5. Snack given and drank 2 cans of pop, residents separated and taken to room, redirected by CNA, and calmed down and let go of CNA. Assessed other resident (R4) very faint bruising noted to right arm. Resident denied pain or discomfort, resident resting quietly at this time DON (Director of Nursing), Administrator notified will notify wife and Dr. in the AM. Resident placed on 1:1 supervision. Of note, a dependent person would likely experience extreme fear and anxiety when someone enters their living space unprovoked and grabs them to the point of bruising. R4 was emotionally upset and crying after the incident. R1's Resident One to One Supervision Record shows that R1 was on one to one from [DATE], 5:00 AM - [DATE], 12:00 AM. There is no other evidence of increased supervision after this incident, On [DATE] at 9:20 AM Surveyor interviewed CNA H (Certified Nursing Assistant) via telephone. CNA H stated on [DATE], early morning, CNA N radioed for assistance on the 100 wing. CNA H observed R1 in R4's room. R1 was in front of R4 holding CNA N's wrists. R1 refused to let CNA N's wrists go. CNA H assisted with guiding R1 and CNA N out of R4's room while R1 held onto CNA N's wrists. Once R1 was outside R4's room he switched to being calm and let go of CNA N's wrists. CNA H stated R4 was very upset. [DATE], 19:53 (7:53 PM): Resident was up in room, voided on floor, CNA came in to clean up the floor and try and help the resident change his brief and clothes. Resident became angry, yelling at CNA to get out of his room and using profane language. Resident holding arms out and clenched, but never struck staff. CNA was able to get the floor cleaned but not successful in changing resident's shirt. Resident calmed down on his own. [DATE], 14:30 (2:30 PM): Resident was resistive to cares. Was incontinent and staff attempted to change clothes and resident was striking out at staff became angry and agitated. Resident left safely alone with a staff member in close range. Unable to sit still and pacing in hallway, snack and activity provided and was helpful. [DATE], 09:19: CNA reported resident became agitated and was swinging at CNA he tripped on a chair in the hallway and fell . When the nurse arrived on 100 hall resident was observed standing up from the floor. No injuries noted, but unable to look under the resident's clothes or to obtain vitals d/t (due to) resident's mood behaviors. This nurse was able to direct resident back to his room, give him something to drink, have him sit in his chair, and was calm prior to me leaving the hall. Of note, per Misconduct Report Dated [DATE] the facility had an intervention including a licensed nurse to be present in the dementia wing during AM and PM shifts along with CNA and HA (Hospitality Aide) staff to monitor behaviors and assist with ensuring resident and staff safety and intervene appropriately to (R1's) behaviors. Per progress note date [DATE] a nurse was called to the 100 wing and not present on the wing. [DATE], 09:53: Resident's mood/behavior continue to be monitored d/t changes in medication. He did have some behaviors while trying to change his pants. He was striking out, but with two assist we were able to change pants. No behaviors noted after that. [DATE], 12:33: Called to 100 wing for assistance. Entered dining room and resident was yelling out and very agitated. Staff moving other residents from his table for safety. Attempted to keep resident back away from others and keep both him, staff, and residents safe. Resident then picked up his knife and began to wield it back and forth towards me. I continued to reinforce he needed to put the knife down, he finally did put it on table (sic) but then started to push chairs toward another table of residents and I attempted to stop him when he grabbed both of my wrists and hurt me. I looked straight on and asked him to stop that he is hurting me, he as quick as he started, stopped, looked at me and became very calm. He stated I won't hurt you, at this time I was able to lead resident to his room and he was then calm all the way. [DATE], 18:07 (6:07 PM): Med tech (Medication Technician) walked into the dining room to check in on the CNA's working on 100. CNA reported that (R1) was swinging and chased her out of the room. CNA then reapproached resident (R1) to have him to move another seat. (R1) then grabbed CNA by the neck. CNA continued to scream and yell. Resident let go and was removed of the dining room. CNA was assessed for injury, she is ok. (sic) Resident assessed for injury, no injury. DON called; administrator called. Family updated and doc (doctor) faxed, police coming to assess the situation further. [DATE], 12:09: Spoke to (R1 spouse) about incident that occurred [DATE]. Stated she is not sure what is triggering him to have these behaviors. Spouse is hoping we can figure out what is causing these issues. DON also part of call. [DATE], 20:01 (8:01 PM): Writer attempting to do v/s (vital signs) at time of fall resident was swearing and looked at CNA present in room and stated I will kill you. Resident grabbed CNA by scrub top and was punching CNA in stomach. Resident has been pushing chairs and going in and out of other rooms and refusing to leave. At this time is sitting in another resident's recliner and will not come out. ,d+[DATE] redirected, activity, left safely alone, food, drink and attempted to toilet. All ineffective and some attempts make aggression worse. PRN (as needed) Risperdal given. DON is aware of incident. [DATE], 21:34 (9:34 PM): Called to 100 wing by CNA stated resident slid from chair. Resident was already up and sitting in a chair as was restless and not wanting to stay on floor. Resident went to sit in chair and did not sit back far enough causing a slide to floor. CNA assisted rest of way to floor. Notified DON, notified wife, (R1's Physician) updated. Resident refused v/s and skin assessment. Resident has been agitated and aggressive. Of note, per Misconduct Report Dated [DATE] the facility had an intervention including a licensed nurse to be present in the dementia wing during AM and PM shifts along with CNA and HA (Hospitality Aide) staff to monitor behaviors and assist with ensuring resident and staff safety and intervene appropriately to (R1's) behaviors. Per progress note date [DATE] a nurse was called to the 100 wing and not present on the wing. [DATE], 10:49: Pt (patient) continues to have reported increased behaviors. Pts behaviors including trying to swing or hit staff. Being resistive to cares. Exit seeking. Yelling/shouting. Pt has given PRN Ativan and Risperdal this AM and was very effective. Pt later was resting in bed. No look of restlessness or anxiety noted when sleeping. Pt then awoke and is starting to get anxious and restless and agitated easily. Pt gave another dose of Risperdal and Lorazepam to assist with these behaviors' d/t limited nonpharmacological options available that help aid in pts increased behaviors. [DATE], 16:19 (4:19 PM): Pts wife came in around 1430 (2:30 PM). Pts wife began to try and get Pt to change his wet clothes d/t urinary incontinence and not letting staff assist with cares d/t aggression. After several attempts (R1's spouse) did get (R1) changed. (R1's spouse) began to cry when husband began to get angry at her and is upset that husband has been having increased behaviors. Pt was given PRN Risperdal and Ativan x2 (times two) today d/t increased aggression towards others. Pt is one on one with staff ,d+[DATE]. Pt did appear to have unsteady gait when trying to get him back into his room to lie down. Pt is sound asleep at this time. Staff sitting next to him in his room. Talked with (R1's spouse) again that he is probably exhausted d/t being up for 2 days straight and with the medication kicking in is what is making him tired and unsteady gait. Reassured her that staff with be with him (sic) all evening. Scheduled medications were not given this evening d/t increased lethargy. Of note there is no evidence R1 was on 1:1 ,d+[DATE]. R1 was on 1:1 as needed. [DATE], 05:43: Lorazepam Oral Tablet 0.5 mg (milligrams), Give 0.5 mg by mouth every 4 hours as needed for aggression/behaviors. Recommended that resident gets medication every 4 hours exactly. Resident woke up in aggravations, hitting, kicking, and yelling out. (sic) Resident is unsafe to environment and residents surrounding them. [DATE], 21:30 (9:30 PM): Lorazepam Oral Tablet 0.5 mg (milligrams), Give 0.5 mg by mouth every 4 hours as needed for aggression/behaviors. Moderate behavioral outburst with mild forms of aggression. Resident received a lorazepam and will be monitored for residual effects of tiredness. Attempts to be made so resident doesn't continue to sleep constantly. [DATE], 21:59 (9:59 PM): Resident stated his scrotum hurt, he did spill coffee this AM on his lap and has refused being changed all shift. Staff assisted resident per his request to have it looked at. Due to resident becoming agitated quickly staff didn't have much time to look but no redness or blisters were observed. Resident did swing, kick, and pull at scrubs toward both staff members who were assisting resident. Resident pulled pants up and refused a brief, staff let resident be. Staff did get both incontinent briefs off that resident had on. [DATE], 11:40: IDT Risk Note: Primary Diagnosis: anxiety disorder, [NAME] (major) depression disorder, unspecified dementia - unspecified severity but w/ (with) agitation, restlessness and agitation, insomnia, risk for malnutrition. Risk(s): behaviors with other residents and staff, may need one-on-one with aggression, multiple falls, wandering within the unit not elopement behaviors. Malnutrition. Medication Review: citalopram, lamotrigine for agitation/mood stabilization, melatonin, lorazepam PRN for behaviors, Risperdal PRN, Risperdal for behaviors. Working with (Physician's Name) and PCP (Primary Care Provider) to determine best options for meds (medications) or order for inpatient review at geriatric psych unit. Behaviors: When agitated with staff approach, he lashes out. Meals are triggers, redirections, bathing issues, ADL (activities of daily living) assistance triggers, queuing for toileting, using soft music, verbal aggression. Activities to take him outside in courtyard when he is calm. Not to take outside when agitated. [DATE], 04:47: Resident had a slight issue with behaviors upon waking up this morning, resident swung at a staff member while guiding the resident back to room. Upon entering room resident de-escalated and began apologizing and talking with staff. Resident was eventually given a snack and laid down to go back to sleep, no medical intervention needed at this time. Redirection worked appropriately. The facility's Misconduct Incident Report includes, in part the following: Date occurred: [DATE]. Briefly describe the incident: On Friday, [DATE], resident (R1) struck (R9) in the face with a closed fist. Describe the effect: No injuries occurred, and no negative psychosocial effects noted. Neither resident remembers incident. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct. Residents were immediately separated, 1 to 1 initiated. Police contacted and stated resident is in a safe environment, and they could not assist. Of note, a dependent person would likely experience extreme fear and anxiety when someone enters their living space unprovoked and punches them in the face. The facility Resident to Resident Altercation Investigation Questions, dated [DATE], includes, in part, the following: Please describe the hitting the other resident: (R9) was in his room, opened his door and was swearing at (R1). (R1) ran to (R9). CNA Staff tried to calm (R1) down. (R1) grabbed CNA arms. He then proceeded to go after (R9). (R1) punched (R9) in the face. CNA tried to get in between them. CNA yelled for help twice. CNA was the only staff member down 100 Hall. Of note, per Misconduct Incident Report dated [DATE] the facility implemented an intervention of Licensed nurse to be present in the dementia wing during AM and PM shifts along with CNA and HA (Hospitality Aide) staff to monitor behaviors and assist with ensuring resident and staff safety and intervene appropriately to (R1's) behaviors. According to the Resident-to-Resident Altercation Investigation the CNA was in the hall alone during this incident. [DATE], 10:29: Spoke to resident about incident with another resident. Resident stated come back I have no information. Asked resident how he is feeling today resident stated pretty good and that well you know [NAME] died . Asked the resident who [NAME] was, and the resident could not tell this information. Resident said he was not worried about anything. Resident is in room and away from another resident. (Local Police Department) notified. POA (Power of Attorney) notified and will be coming to the facility. On [DATE] at 10:00 AM Surveyor observed R1 ambulating independently up and down the hallway. Staff were in the hallway interacting with other residents. Of note, R1 was not on 1:1 and did not have increased supervision. On [DATE] at 4:10 PM Surveyor heard R1 yelling at staff in his room. The room door was closed. RN Q (Registered Nurse) exited R1's room, RN Q was visibly shaken. RN Q stated she and another staff were attempting to change R1 and he was not cooperating. RN Q stated R1 was yelling, kicking, and hitting at staff. The facility's Misconduct Incident Report includes, in part the following: Date occurred: [DATE]. Briefly describe the incident: Resident (R4) alleged (R1) molested her. Describe the effect: Incident unfounded the resident has no negative physical or psychosocial effects noted. All residents including R4 felt safe. This worker and Regional Corporate Nurse C (RNC) reviewed footage from ([DATE]) supper time through 6:50 PM. Footage shows R1 did enter a room for 1.5 minutes on 100 hall. He grabbed a stuffed animal (dog) and walked out of the room. The room entered and exited appears to be either resident R10 or R4, however it is difficult to tell via footage. During the time R1 entered and exited the room another resident was roaming the halls. He appeared calm and relaxed. Staff did not report any loud noises or screaming during this time. This worker (Nursing Home Administrator/NHA A) along with RCN C interviewed resident R4 who stated she felt safe. She had no concerns regarding residents. She was unable to recall any negative events. During the interaction R4 was calm. Action Taken: 1:1's was implemented. Incident reported to Police Officer (Name) who stated there was not much they could do given the resident was only in the room for 1.5 mins. One on One (1:1) supervision initiated indefinitely. [DATE], 13:45 (1:45 PM): Resident woke up this AM on his own, came down to the dining room. Was upset and yelled at staff, walked away from resident and within ,d+[DATE] min (minutes) resident waived (sic) at nurse to come over to his table. Resident apologized and was then in a pleasant mood. Resident ambulated up and down the hall. After lunch resident was walking out of the dining room and another resident was standing in the hallway outside of the dining room door and made a hissing noise. This upset (R1) and he raised his hand and talked mean toward the other resident. CNA had the residents walk separate ways and there were no further altercations. Resident then happily allowed staff to give him a bath without any behaviors and has been in pleasant mood since. [DATE], 15:34 (3:34 PM): Fax out to (on call physician) as (R1's physician) is out of office today with request for diagnosis of PTSD (Post Traumatic Stress Disorder) and Bipolar d/t resident having flashbacks of being ex-[NAME] and acts out with hitting/punching/grabbing other residents or staff. Police have been called numerous times and refuse to take him d/t him being in a safe environment and a secure unit. Not a threat to public. Geodon and med list attached. On [DATE] at 8:30 AM Surveyor observed R1 ambulating independently up and down the hallway. R1 was looking into other resident rooms and going into other resident rooms uninvited. Staff were in and out of the hallway. On [DATE] at 10:00 AM Surveyor observed R1 ambulating independently up and down the hallway. R1 was looking into other resident rooms and going into other resident rooms uninvited. Staff were in and out of the hallway. Of note, R1 was not on 1:1 and did not have increased supervision. On [DATE] at 8:55 AM Surveyor interviewed HSK O (Housekeeper). HSK O stated R1 can be aggressive with other residents, staff, and visitors. HSK O has observed R1 push staff, grabbed staff arms, and raise his hands to staff. On [DATE] at 9:00 AM Surveyor interviewed RN E (Registered Nurse). RN E stated R1 will swear, shake his hand at staff, visitors, and other residents. On [DATE] at 10:05 AM Surveyor interviewed CNA P (Certified Nursing Assistant). CNA P stated she observed R1 grab R4's wrist. CNA P stated she asked R1 to let R4 go and R1 did. On [DATE] at 4:15 PM Surveyor interviewed RN Q (Registered Nurse). RN Q stated R1's behavior triggers are never the same. RN Q stated staff try to keep R1 away from other residents, so he does not hurt them. On [DATE] at 4:20 PM Surveyor interviewed CNA L (Certified Nursing Assistant). CNA L stated R1 has grabbed her arm and caused leg bruises. CNA L stated nothing in particular sets off R1's behavior. There are not enough staff, so when R1's behaviors increase it is difficult to do 1:1. On [DATE] at 4:35 PM Surveyor interviewed CNA K (Certified Nursing Assistant). CNA K stated R1 shook his fist at her. CNA K stated R1's behaviors flip in an instant. CNA K stated R1 goes to many resident doors and will go into other resident rooms. Other residents, including R10, do not like R1 entering their rooms. On [DATE] at 4:50 PM Surveyor interviewed CNA S (Certified Nursing Assistant). CNA S stated it is very difficult caring for R1, especially on PM shift, when R1 is having behaviors as R1 can flip instantly from being calm to being aggressive. CNA S stated R1 had grabbed her wrists and drug her down the hall. On [DATE] at 5:57 AM Surveyor interviewed CNA F (Certified Nursing Assistant). CNA F stated R1's aggression is a hit or miss. CNA F stated R1 hit and choked staff on multiple occasions. CNA H stated it can be difficult at times to calm R1 down when he is being aggressive toward others, including other residents, staff, and visitors. CNA H stated R1 will go into R10's room and sits in R10's recliner, this is very upsetting to R10. It is very difficult to keep R1 out of R10's room, it is across the hall from R1's room. On [DATE] at 3:10 PM Surveyor interviewed R10. R10 stated he is afraid of R1, R1 comes into R10's room uninvited and touches R10's belongings and sits in R10's chair. R10 does not want R1 in his room, has informed staff he does not want R1 in his room but R1 continues to enter R10's room uninvited. < [TRUNCATED]

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (R2) reviewed for change of condition. R2 experienced a change of condition with an onset of new/ increased pain and difficulty with walking and with transfers; the facility failed to assess R2's pain, transfer ability, notify the physician of R2's pain. R2 continued to have complaints of pain was sent to hospital and found to have a fracture. Evidenced by: The facility's policy titled, Pain Management last reviewed on 8/2/2022 states in part: .Recognition: 1. In order to help a resident attain or maintain his/ her highest practicable level of physical, mental, and psychosocial well- being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain .b. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain) .2. The facility will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: a. Change in gait .b. Loss in function or inability to perform activities of daily living (ADLs) .e. Behaviors such as : resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/ or social activities .h. Decline in activity level .Pain Assessment: 2. Based on professional standards of practice, and assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident: .e. identifying key characteristics of the pain: i. Duration of pain ii. Frequency iii. Location iv. Timing v. Pattern (e.g., constant, or intermittent) vi. Radiation of pain. F. Obtaining descriptors of the pain (e.g., stabbing, aching, pressure, spasms) .h. Impact of pain on quality of life .i. Current prescribed pain medications .l. Additional symptoms associated with pain (e.g., nausea, anxiety). Pain Management and Treatment: 1. Based on the evaluation, the facility in collaboration with the attending physician/ prescriber, other health care professionals, and the resident and/ or resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain . The facility's policy titled Notification of Changes dated 8/2/2022, states in part: .Circumstances requiring notification include: .2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status . 3. Circumstances that require a need to alter treatment. This may include a. new treatment . R2 was admitted to the facility on [DATE] with diagnoses that include osteoporosis, peripheral vascular disease, congestive heart failure, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (stroke with left sided weakness). R2's most recent MDS (Minimum Data Set) dated 5/5/23 states that R2 has a BIMS (Brief Interview of Mental Status) of 6 out of 15 indicating that R2 has severe cognitive impairment. R2's MDS also indicates that R2 requires extensive assist of 1 person for bed mobility, transfers, walking in room, and toileting. R2's Pain Evaluations, in part, are as follows: 8/8/22: 1a. Does resident have diagnosis which give reason to believe he/ she would be in pain? Answer: No 2a. Does the resident verbalize pain? Answer: No 11/8/22: 1a. Does resident have diagnosis which give reason to believe he/ she would be in pain? Answer: No 2a. Does the resident verbalize pain? Answer: No 2/12/23: 1a. Does resident have diagnosis which give reason to believe he/ she would be in pain? Answer: No 2a. Does the resident verbalize pain? Answer: No N. Comments: No current complaints of pain. 5/15/23: 1a. Does resident have diagnosis which give reason to believe he/ she would be in pain? Answer: Yes 2a. Does the resident verbalize pain? Answer: No 5/30/23: 1a. Does resident have diagnosis which give reason to believe he/ she would be in pain? Answer: Yes 1b. If yes, describe cause and origin of pain: left knee 2a. Does the resident verbalize pain? Answer: Yes 2b. Date of onset: 5/30/23 Resident description: 1. Aching .5. Tender .10. Hot/ burning .12. Throbbing C. Location and frequency: Site: Left knee (front) Description: bruising, swelling, and warm to touch. D. Intensity .1b. At present: 8 1c. 1 hour after medication: 6 G. Resident Changes: Has the resident had any of the following changes in daily activities or habits .3. Loss of appetite/ weight loss .6. Decreased ability to concentrate, 7. Withdrawal from activities or relationships. 8. Decrease/ Increase in physical activity. 9. Changes in mood/ emotions (e.g., anger, crying). H. Nonverbal Noncognitive- Facial .Facial Expressions: 1a. Grimacing/ distorted face .1c. Frowning/ scowling .1f. Wrinkled brow. I. Nonverbal Noncognitive- Vocalization .2a. Moaning. 2b. Grunting . 2f. Cursing. J. Nonverbal Noncognitive- Actions Behaviors: .3f. Rubbing body parts . 3i. Knees pulled up into abdomen. 3j. Fidgeting . 3l. Irritability . 3o. Increased hand/ finger movements. 3p. Striking out at others . L. Pain Increase: 5a. Pain is increased by .: Movement. 5b. Activities pain prevents resident from doing ADLs and activities . R2's care plan dated 8/10/22 states in part: .Focus: The resident has potential for pain r/t (related to) Arthritis, Osteoporosis, scoliosis, and kyphosis of the spine (abnormally curved spine). Goal: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain .Interventions: *Administer analgesia per orders .*Identify, record, and treat the resident's existing conditions which may increase pain and or discomfort .*Monitor/ document for probable cause of each pain episode .Monitor/ record pain characteristics q (every) shift and PRN (as needed): Quality .Severity .Anatomical location .Onset; Duration .*Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain . Nurse's Notes state the following: 5/24/23: Standing order put into place, due to increased pain, for acetaminophen 650 mg (milligrams) every 4 hours PRN. 5/24/23: acetaminophen 650mg administered at 9:11 AM, documented as effective at 11:50. No pain scale or assessment provided. 5/26/23: acetaminophen 650mg administered at 5:46 PM for Resident c/o (complains of) knee pain, documented as effective at 7:19 PM. Pain level 4 5/27/23: acetaminophen 650mg administered at 7:58 PM for Resident states pain is 8-10 upon standing, but goes away when sitting in recliner, documented as effective at 11:55 PM. 5/28/23: acetaminophen 650mg administered at 6:59 AM, documented as effective at 11:57 AM. No pain scale or assessment provided. 5/28/23: acetaminophen 650 mg administered at 4:13 PM, documented as effective at 7:40 PM. Pain level 5. 5/29/23: acetaminophen 650mg administered at 3:08 PM for increased pain, documented as effective at 8:53 PM. No pain scale or assessment provided. 5/29/23 at 3:36 PM: Resident is still having increased pain, knee is swelled {sic} and painful. 5/30/23 at 8:00 AM: Called to resident's room this AM and found resident lying in bed very confused. Resident's left knee appeared swollen and kneecap [sic] has purple discoloration, was warm to touch. Resident stating things like you are evil, you are the devil, you are trying to kill me. Resident refused any meds, leaned towards her, and attempted to softly ask her if she was in pain or needed anything and she just attempted to hit and was very confused/ combative. Resident refused to let me do vitals. I was able to get a temp. of 98.8. DON (Director of Nursing) arrived, and I requested she attempt to reassess resident, of which she did and seen swollen knee with discoloration. Decision made to call family and send to ER (emergency room ). Of note, this is 6 days after resident was started on acetaminophen for new/increased onset of pain. There was no prior assessment of R2's knee despite complaints of knee pain. 5/30/23 at 10:56 AM: Resident was complaining to staff that she was going to die today. She was having generalized pain. Complained of pain in her left knee .Left knee was very swollen, hot to touch, with bruising on the knee area. Resident was trying to move her knee away from nurse and stating, that hurts. Nurse asked resident what happened to her knee? [sic] Resident stated, I don't remember and to just let me die. Grimacing, frowning, and cussing at staff about her knee and pulling knee up to her chest area .Rated pain at a six . It is important to know that prior to 5/24/23, R2 was not receiving any medications for pain and facility staff was not monitoring her pain. R2's PCP (Primary Care Physician) was not updated on her increased pain and use of acetaminophen, except for a faxed request for a PT (Physical Therapy) evaluation for increased difficulty with transfers and new left knee pain. Facility staff did not complete a pain assessment when initiating the use of acetaminophen and they did not assess the status of R2's left knee despite complaints of increased pain. Hospital ER note dated 5/30/23 state, in part: .Assessment and ED (Emergency Department)/UC (urgent Care) Department Course: Assessment 1. Altered mental status .2. Fall, initial encounter 3. Closed sleeve fracture of left patella (a small bone located in front of the knee joint), initial encounter. Patient coming with complaints of altered mental status .Denies history of fall. Patient combative with EMS (Emergency Medical Services) .Patient with a history of [NAME] arthritis and bilateral knees that enlarged and do not straighten. Patient walks with a walker. There is bruising on the left forearm and left knee. Xray of the forearm, pelvis, and right knee are negative. Left knee with patellar fracture .Patient placed in knee immobilizer .Patient to be admitted for observation . It is important to note that R2 remained in the hospital until 6/1/23. R2 returned to the facility with orders for Tylenol Extra Strength tablet 500mg- Give 1000mg by mouth 3 times a day for pain and oxycodone 5mg- give 0.5 tablet by mouth every 6 hours as needed for pain for 6 days, for pain not relieved with Tylenol. On 7/6/23 at 8:14 AM Surveyor interviewed LPN I (Licensed Practical Nurse). Surveyor asked LPN I what the facility's process is when a resident has a new onset of pain, LPN I stated that start with repositioning, try ice or heat, fax the physician, and apply a topical cream if there is one ordered. Surveyor asked LPN I if she would perform a pain assessment, LPN I stated that there is a form in the computer for them to fill out. Surveyor asked LPN I if she updated R2's physician on 5/24/23 that she was having increased or new pain, LPN I stated that she did not update the physician because she did not know it was new pain. Surveyor asked LPN I if she completed the form for R2 when she initiated her standing order for acetaminophen, LPN I stated that she did and that it would be in the computer. LPN, I stated that she did go look at R2's knee and it was swelled up, but she did not think it was anything out of the ordinary. LPN I also reported that prior to initiating the acetaminophen order, R2 did not have anything ordered for pain. It is important to note that Surveyor reviewed the documentation with LPN I and there was no documentation regarding a pain assessment or assessment of R2's knee found in the computer. On 7/6/23 at 10:04 AM, Surveyor interviewed CNA M (Certified Nursing Assistant). Surveyor asked CNA M what R2's status was prior to her going to the hospital, CNA M reported that the last time she worked with R2 was the Friday (5/26/23) before she went to the hospital and that she had been reporting to the nurses that R2 was not transferring right and that she was having a hard time walking. CNA M reported that previously, R2 was able to walk in her room with her walker. On 7/6/23 at 10:13 AM, Surveyor interviewed RN E (Registered Nurse). Surveyor asked RN E about what R2's condition leading up to her going to the hospital, RN E stated that R2 was complaining of pain in her knee and that she had given her Tylenol a couple of times. RN E stated that the CNAs had reported that she was getting harder to transfer and that a day or 2 before R2 went to the hospital, they started using a bed pan on her because they didn't trust her to stand. Surveyor asked RN E if the physician was notified, RN E stated that she would have to look; RN E stated that she was not aware that the physician had not been updated because R2 had an order for the medication. Surveyor asked RN E if she did a pain assessment, RN E stated that there is a pain scale attached to the administration of a PRN (as needed0 medication. RN E stated that it would not be out of the ordinary for R2 to be in pain, it would be out of the ordinary for her to take something for pain. Surveyor asked RN E if she completed an assessment of R2's knee RN E stated she did not. On 7/6/23 at 2:06 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectations were for nursing staff when a resident has a new onset or increased pain, DON B stated that she would expect staff to assess the resident, rate the pain, location of pain, how long the pain has been going on for, and to offer pain medication. Surveyor asked DON B if she would expect that staff would update the physician, DON B stated yes. Surveyor asked DON B if staff should have assessed and monitored R2's pain and assessed R2's knee due to complaints of pain DON B stated that usually they have something. Surveyor asked DON B if staff should have updated the physician with R2's increased pain, DON B stated that they requested a PT evaluation. Surveyor asked DON B if the nurses should have been assessing her pain every shift, DON B stated yes. Surveyor asked DON B if R2 was refusing medications, would she expect her staff to offer non-pharmacological interventions, DON B stated yes, they should offer ice or heat, elevation, and assess for injury. Surveyor asked DON B when she was made aware that R2 was having increased difficulty with transferring, DON B stated she was made aware on the day that she sent R2 to the hospital. DON B stated that R2 complained of pain all the time so they didn't think it was anything serious. Surveyor asked DON B would you have expected the staff to complete an assessment of R2's knee as this was the source of pain DON B stated yes. R2 had a new onset of pain in the knee facility staff failed to recognize this change of condition and complete a thorough assessment of R2's knee, complete a pain assessment, update the MD of new onset of knee pain. R2 was not assessed for 6 days after she began complaining of pain and was found to have a patella (knee) fracture.

Based on observation, interview and record review, the facility did not ensure 1 (R1) of 2 supplemental residents on specialized diets received food in an assessed consistency so as not to create a hazardous environment and received supervision to prevent a choking accident. Facility staff did not follow the care plan for 1 of 1 supplemental residents (R26), which led to a fall that resulted in a [CONDITION(S)], and did not review and revise the care plans of 2 of 15 sample residents (R20 and R10) after they had multiple falls. R1 has [CONDITION(S)] and dysphagia and is at risk for choking. R1 is to receive a pureed diet and is to be cued while eating. On 2/9/22 and 2/10/22 R1 was given meals that were not pureed. In addition, R1 was left alone in his room to eat. The facility's failure to ensure R1 received the appropriate diet consistency and supervision during meals created a finding of IJ (Immediate Jeopardy) beginning on 2/9/22. The NHA (Nursing Home Administrator) NHA A was informed of the IJ finding on 2/10/2022 at 4:34 PM. The facility removed the immediate jeopardy on 2/12/22. The IJ continues at a scope severity of G as the facility continues to implement their action plan and as evidenced by the following: R26 has severe cognitive impairment. R26 had two falls. During the first fall the facility did not put interventions into place post fall. During the second fall staff did not follow R26's care plan by having a bed/chair alarm correctly placed under R26 while in bed. This second fall resulted in a right hip fracture. R20 and R10 each had multiple falls. The facility did not always immediately assess the circumstances leading to the fall and, when appropriate, implement changes to the care plan to prevent further falls. This is evidenced by: Example 1 R1 was admitted on [DATE] with diagnoses of [CONDITION(S)] (a progressive neuro-system disorder that affects movement) and dysphagia in the oropharyngeal phase. Dysphagia is the medical term for swallowing problems. People with dysphagia may have difficulty forming a food bolus in their mouth or experience a delay when they try to swallow it. This increases their risk of choking or breathing in food while they're eating. It also makes it more difficult to eat enough, in turn increasing their risk of not getting enough nutrients. . many healthcare professionals recommend a puréed diet to patients with dysphasia to reduce their risk of choking and potentially breathing food into their lungs while ensuring they meet their nutritional needs. https://www.healthline.com/nutrition/pureed-food#basics People with dysphagia are also at risk for aspirating food into their lungs. 8 Signs of Dying from Aspiration Pneumonia notes that Mortality estimates for aspiration pneumonia vary. At least 5 percent of people who are hospitalized for aspiration will die .Among geriatric populations, mortality skyrockets. A 2013 study of elderly patients put 30-day mortality at 21 percent. First responders, doctors, nurses, and other healthcare providers must always treat aspiration pneumonia as a medical emergency with a high mortality risk .In the immediate aftermath of aspiration, a patient may be unable to breathe or swallow, presenting a medical emergency. After the risk of [CONDITION(S)] has passed, the dangers of aspiration pneumonia have not. Aspiration pneumonia can cause numerous complications, including: [CONDITION(S)] Respiratory failure Acute respiratory distress syndrome (ARDS) Bacterial pneumonia https://blog.sscor.com/8-signs-of-dying-from-aspiration-pneumonia R1 had a speech therapy (ST) evaluation on 4/17/2020 which states in part .the resident has been on a NDD (National Dysphagia Diet) level 3 diet with ground meats. Referral now is due to a recent coughing episode witnessed by staff. This is likely due to his progression of PD ([CONDITION(S)]) or decreased memory of swallow safety strategies. Per facility records, R1 had physician orders dated 9/29/2020 for a Regular diet, Level 2 with pureed meats and slurried, soaked bread. R1 had another ST evaluation on 12/15/2020 which states in part .R1's skills had declined with oral residue and prolonged chew time for meats. Downgraded to a NDD#2 which includes slurried, soaked bread and pureed meats. Resident best tolerates-in terms of safety-as well as without prolonged oral transmit times, ground meats with NDD#2. On 6/21/2021, R1 had another ST evaluation which states in part, R1's current speech production and intelligibility: Moderate/severe-25% intelligible, limited mainly to words or phrases. Diet: NDD 2, mechanical altered; swallowing .safe only in structured settings .reinforce safe swallowing strategies. R1's care plan includes in part, identified needs and interventions as follows in regards to diet and speech: *Resident has potential for communication problems related to slow, garbled speech: Ask yes/no questions, if appropriate. Praise all response efforts. *Resident has an ADL (activities of daily living) self-care performance deficit related to (R/T) [CONDITION(S)]: Resident is able to feed self and use a right handed curved spoon. Resident is not to eat grapes without supervision. Resident is to go down to meals early to give enough time to eat. Resident can have clothing protector on for drooling and for meals. If resident is eating in room; ensure he is in good postural alignment in the wheel chair; face the TV with tray table in front with feet over lower bar on table to prevent the table from sliding away. Lipped plate, cups with lids and straws pointing toward resident, food cut up if needed, silverware on right side, drinks on left side, napkin tucked into shirt. Oral care: Assist with set up after each meal to clear any food residue. *The resident is risk for potential nutritional problem R/T [CONDITION(S)] .dysphagia, history of pocketing food. Choking hazard. Can feed self. Very slow eater: Avoid foods that are hard for resident to chew and monitor for pocketing and chewing or swallowing problems. Diet as ordered, Regular Level 2-Mechanical texture, regular/thin fluid consistency, pureed meat and slurried, soaked bread .Plate guard, bent spoon, built up utensils, straws, beverages in plastic cups with lid. Resident able to feed self with adaptive equipment; staff provide assistance as needed. Resident preferences for meal times/patterns honored. 1. Decreased rate of feeding, small bites. 2. Must be seated at 90 degrees for eating/drinking. 3. Staff assist if needed. Provide resident with reminders/verbal cues to do liquid swish every 2 bites to clear residue. Provide supervision and assist as needed. Of note; R1's plan of care states to provide resident with reminders/verbal cues to do a liquid swish every 2 bites to clear residue. This cannot occur without direct supervision at meals. On 2/9/22, at 11:47 AM, Surveyor observed R1 sitting in a wheelchair in R1's room eating ground beef meat loaf that had been served. R1 did not have staff supervision. On 2/09/22, at 11:47 AM, Surveyor interviewed Licensed Practical Nurse (LPN) R and asked what diet is ordered for R1. LPN R stated, Ground meat. Surveyor asked LPN R, has there been any recent changes to R1's diet? LPN R indicated 'No. On 2/09/22, at 11:56 AM, Surveyor asked Registered Nurse (RN) U, what type of diet is ordered for R1? RN U looked at the physician's order and indicated mechanical texture, pureed meats, and slurried/soaked bread. On 2/10/22, at 11:25AM, Surveyor observed R1 alone in R1's room sitting in a wheel chair eating chili. The chili had chunks of tomatoes and ground beef. R1 did not have staff supervision. On 2/10/2022, at 4:35PM, Surveyor observed R1 sitting in a wheelchair in R1's room eating pureed casserole. Surveyor took some of the very thick and sticky casserole from R1's spoon and turned the spoon upside down. The casserole slowly plopped off. R1 did not have staff supervision. On 2/14/22, at 1:00 PM, Surveyor asked Registered Dietician (RD) H, what diet is R1 currently on? RD H stated, Mechanical soft with pureed meats. R1 can have soft foods like mashed potatoes, soft cooked vegetables, and soft foods. Surveyor asked RD H, is chili considered a pureed food? RD H stated, No chili should be pureed because there is meat in it. Surveyor asked RD H, is ground beef meat loaf a pureed meat? RD H replied, No ground meat loaf should be pureed. On 2/10/22, at 12:05, Surveyor interviewed Maintenance Manager (MM) L. MM L is the maintenance manager for the facility and has been cooking in the kitchen due to lack of dietary staff. Surveyor asked MM L, how do you know what diet is ordered for residents? MM L stated, I look at the resident's dietary card along with the attached white menu slip for that day. Surveyor asked MM L, what diet is ordered for R1? MM L looked at R1's dietary card and responded, Pureed meat with soaked bread. Surveyor asked MM L, is chili considered pureed? MM L stated, I was informed by Cook E that all soups and chili are considered pureed. Surveyor asked MM L, is ground beef meat loaf considered pureed? MM L pointed at a food processor and stated, All pureed meat goes through the machine. R1 is the only resident on pureed meat. The facility did not have a backup system to catch errors in food consistency because there was minimal information on the card that is on the food tray that is served to residents. Consequently, a person serving the food would not be aware if the food was the wrong consistency, as evidenced below. On 2/7/2022 at 11:45, Surveyor observed resident meal tray line. Cook E was plating food and passed it to DA I who then covered foods. After the food is plated by Cook E, it is covered and placed on a transport cart by Dietary Aide (DA) I. There isn't a resident tray card present which identifies who the tray belongs to, what type of diet and consistency of food and liquids and any allergies or special precautions on any of the meal trays. There was a small label on the transport cart that had each resident's name and minimal information (such as John Doe, NAS (no added salt)). There were no further instructions on the cart for staff to follow. A carafe of coffee sat on top of the cart. The cart is taken to the nursing units for delivery by staff including office, administrative, and nursing staff. On 2/8/22 at 7:50 AM, Surveyor observed tray line. DA G received a meal from Cook E and placed the food tray on the service cart. Surveyor asked DA G, how do you know which resident the tray belongs to? DA G stated, I guess because the cook tells me. Surveyor asked DA G, have you ever seen a tray card on the resident tray that identifies the resident, what diet and consistency the diet and fluid should be? DA G stated, No, I haven't. Surveyor asked DA G, have you ever put the tray in the wrong place on the delivery cart? DA G replied, I don't think so. On 2/9/2022 at 8:10 AM, Surveyor asked Certified Nursing Assistant (CNA) D, how do you know which tray goes to which resident? CNA D stated, By the label on the cart. Surveyor asked CNA D, what if the dietary staff put the wrong tray in the wrong slot? CNA D stated, I don't know. Surveyor asked CNA D, how would a new staff or an agency staff know if a resident was receiving the wrong tray? CNA D stated, Well, usually one of us old gals are with the new ones. Surveyor asked CNA D, how would I know if someone needed thickened liquids and they asked for coffee (the coffee sits in a carafe on top of the service cart in regular thin liquid form)? CNA D responded, I guess you wouldn't. Surveyor asked, have you ever seen tray cards with the resident name, diet and consistency listed on the resident meal trays? CNA D replied, I have seen that before, but not for a long time. On 2/9/22 at 8:15, Surveyor asked Registered Dietician (RD) H, how long have you been at the facility? RD H stated, I have been supporting the facility since October 2021. Surveyor asked RD H, does the facility use meal tray cards? RD H stated, No, the carts are labeled with the resident name. On 2/9/22 at 3:32 PM, Surveyor asked Interim Nursing Home Administrator (INHA) A, How do staff know residents are receiving the correct meal upon tray pass? INHA A stated, By the labeling identifier on the service cart. Surveyor asked INHA A, what about the coffee on top of the service carts; would a new CNA know if a resident should have thickened liquids by the current system? INHA A stated, I don't know. Failure to ensure R1's environment was free of accident hazards (i.e., R1 was served food in a consistency that would not create a choking hazard) and that R1 received care-planned supervision while eating created a reasonable likelihood that serious harm could occur. This led to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 2/12/21 when it implemented the following: 1. On 2/10/22 at 4:50 PM, the facility immediately checked to ensure that the identified resident (R1) had received the correct altered textured dinner tray and confirmed and validated INHA/Director of Nursing B (DON). 2. On 2/10/22 at 4:50 PM, R1 was provided supervision during meal by DON B. 3. On 2/11/22 the physician and power of attorney (POA) were notified that R1 had potentially received incorrect therapeutic meal two times 2/12/22 by DON B. 4. Chest X-ray was ordered and obtained to ensure that the identified resident PB did not show any signs of aspirations and X-ray validated that the lungs were clear with no abnormalities noted on 2/10/22. 5. Respiratory assessment was completed on the identified resident and no issued identified by the RN charge nurse on 2/10/22. 6. Respiratory assessments were completed on the other like residents who receive altered textured diets by the RN Charge Nurse and no issues were identified on 2/10/22. 7. Corporate Dietician reviewed Dietary orders for all residents who receive altered texture diets. Orders were verified and updated as deemed appropriate on 2/11/22 by 9/pm. 8. Physician orders were obtained for Speech Therapy to evaluate & treat 17 other residents with potential to be affected by the DON on 2/11/22. 9. Dietary care plans were reviewed for accuracy and updated to reflect any new orders and recommendations for all residents by the DON on 2/11/22. 10. Speech Therapy recommendations were updated on meal tray tickets, Two (2) residents were downgraded 2/11/22. II. EDUCATION 11. All staff education initiated on 2/11/22 to ensure that physician order, including appropriate dietary recommendations are in place for all residents. Staff will receive education prior to starting their next working shift by DON/Administrator. 12. All staff educated initiated on the procedure on tray ticket system for resident meal delivery and appropriate diet 2/11/22. Competency and validation will be completed on staff to ensure that tray ticket is present on meal tray, that the meal validates what the tray ticket indicates is the appropriate diet for the resident. Staff will receive education prior to starting their next working shift by Dietician/DON/ or Administrator. Education will also include what to do if there is no ticket or if the tray ticket does not match what is on the actual resident plate or tray. 13. All staff educated initiated regarding immediate steps to take if the tray ticket does not match the meal on the tray and what immediate steps to ensure that resident receives appropriate therapeutic diet on 2/11/22. Staff will receive education prior to starting their next working shift Administrator/DON. 14. All staff educated on two step validation for proper therapeutic diet for meal delivery for residents; first at tray line with plating food per the resident meal ticket and secondly at the point of delivery of staff prior to being received by resident. Staff will be educated prior to starting their next shift by Administrator/DON. 15. All staff educated initiated on definition and oversite of Direct Supervision and Intermittent Supervision for residents during mealtime. Staff will be educated prior to starting their next shift by Administrator/DON. 16. Dietician and Dietary Manger educated on importance of tray ticket system and requirement of updating tickets for any changes to resident diet orders 2/11/22 17. Dietary staff educated on menus and recipes to properly make any altered textured diets per the physician orders by the Dietician 2/11/22 18. All staff educated initiated on 2/11/22 on resident care plan to include resident current dietary order and resident required level of supervision during mealtime. Staff will be educated prior to starting their next shifty DON/Administrator. 19. Competencies and education will be conducted by Dietician and/or Administrator and DON who have passed the competency education and has been designated to provide education. Staff will be able to verbalize where the menus are located and where they can obtain the recipe for making therapeutic altered diets such at Pureed or Mechanical Soft (Dental Soft). They will additionally state how to validate a tray for accuracy and what to do if the tray is not correct. Lastly, staff will explain where they can obtain this information for a resident and describe what Supervision verses Intermittent Supervision means. Ill. System Policy and Procedures 20. Tray ticket system has been created to reflect current diet orders for all residents by facility Dietician 2/11/22 21. Facility Policies and procedures including: (Acceptance of Therapeutic Diet) reviewed by Corporate Dietician on 2/12/22 and remain up to date. 22. Facility meal textures have been revised by Corporate Dietician and approved by facility Medical Director on 2/11/22 to improve consistency of meal preparation on 2/12/22. 23. Facility care plan template was reviewed on 2/11/22 to update approaches related to level of supervision required for a resident during mealtime. 24. Facility Recipes and meal preparation reviewed by the facility Dietician and updated to reflect instructions on altered texture diet preparation per the recipes on 2/11/22. 25. QAPI Committee including facility Medical Director reviewed and approve plan on 2/11/2022 IV. Monitoring and Audits 26. Two step validation for proper altered diet meal delivery for residents was implemented for every meal beginning breakfast on 2/11/22. The audit includes 100% verification of accuracy at tray line with plating food per the resident meal ticket and secondly at the point of delivery by staff prior to resident receiving food tray. This shall continue every meal for the next 30 days than 10 meals per week for two weeks. 27. One (1) staff interview shall be conducted daily for the next 30 days to assure understanding of immediate facility changes implemented and staff responsibility with changes. 28. QAPI for cooks to understand how to follow the recipes specific to altered textured diets and where they would obtain those recipes. Audit three (3) times per week to ensure correct consistency for altered diets 29. Staff will be able to verbalize understanding of what Supervised versus Intermittent Supervision means and where they can obtain this information of which residents require this. 30. Ongoing frequency and duration of the monitoring shall be reviewed and determined by the facility QAPI Committee On 2/14/22 at 7:30 AM, Surveyors observed all residents with altered diets to ensure the residents received the correct diet and consistency per the resident tray card and dietary order provided to Surveyors on 2/7/2022. The diets and consistency appeared appropriate. On 2/14/2021 at 8:20 AM, Surveyor observed meal pass at breakfast and lunch to ensure meal tray cards were present on each resident tray and that diets with specialized consistencies were being followed. The deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by: Example 2 The facility's policy entitled, Comprehensive Resident Centered Care Plans, undated, states, in part: Intent- .It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident .The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident . It is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care . Developing the Care Plan: . 3a) The intervention statements describe those measures performed by the staff to help the resident achieve the expected outcomes . The facility's policy entitled, Falls and Fall Risk, Managing, with a revision date of March 2018, states, in part: Policy Statement- Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . Resident- Centered Approaches to Managing Falls and Fall Risk- 1) The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .5) If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . 7) In conjunction with the attending physician, staff will identify and implement relevant interventions .to try to minimize serious consequences of falling . The facility's policy entitled, Assessing Falls and Their Causes, with a revision date of March 2018, states, in part: .Documentation- When a resident falls, the following information should be recorded in the resident's medical record: .6) Appropriate interventions taken to prevent future falls . R26 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, Type 2 Diabetes Mellitus with [CONDITION(S)] and Mild Cognitive Impairment. R26's MDS (Minimum Data Set) Quarterly Assessment, dated 12/22/21, indicates R26's BIMS (Brief Interview of Mental Status) is 00 indicating severe cognitive impairment. Section G Functional Status, Transfers: Extensive two assist, Toileting: Extensive two assist, Mobility Devices: walker Walk in Room: Limited one assist. Section J indicates R26 had one fall without injury since admission. R26's Care Plan, dated 8/25/21, with a target date of 03/29/22, states in part: . Focus: The resident is high risk for falls r/t Confusion, Gait/balance problems, Incontinence, Unaware of safety needs, Wandering, History of falls and fall with major injury (left 8-9 rib fractures) Goal: The resident will be free of falls through the review date. Interventions: .The resident uses bed and chair electronic alarms. Ensure the devices are in place as needed . Fall Report dated 12/01/2021, states in part: .PT was found lying on right side in front of the bathroom in fetal position with head resting on a pillow .RN assessed, no injuries .neuro(neurological) checks initiated .ROM (range of motion) without signs of pain . Note: No intervention added to R26's care plan in regards to this fall . On 2/10/22 at 08:50, Surveyor interviewed Director of Nursing (DON) B in regards to R26's fall on 12/1/21. Surveyor asked DON B to recall cause and DON B indicated R26 had moved onto the 400 unit due to COVID and he was unfamiliar with surroundings, confused, very ill, not cooperative with cares, and restless. Surveyor asked DON B what intervention was put into place after fall and DON B indicated checking on R26 more often. DON B was unable to find this documented or care planned. DON B then indicated no intervention was added to care plan or put in documentation. Nurse Progress Note dated 2/5/22 at 07:55 states in part: .Note Text: Was called to res room as he was found in the middle on his room on the floor lying on his right side. Res stated he was heading to the bathroom. Vitals WNL (Within Normal Limits), Small abrasion to the right wrist, no other injury noted. Res states he isn't hurt at all. Res was gotten up off the floor using a total lift with assist of 2. Res does have a bed and chair alarm however the bed alarm did not sound as it was plugged into the chair alarm still. Fall Report dated 2/5/2022 07:55, states in part: . Resident: R26 Incident Location: Resident room Person Preparing Report: LPN R . [Licensed Practical Nurse] Notes: 2/9/2022: 2/5/2022 07:55 AM resident was found on floor by his bed on his right side. Legs toward bathroom, head toward bed. He was not wearing his glasses. He had gripper socks on. Resident was noted to be restless, and he was not using any assistive devices. He was last seen minutes prior when CNA [certified nursing assistant] walked by his room. He was last toileted @ 06:44 am and was incontinent of urine at that time and at time of fall. Resident had not used call light for assistance, does at times. Alarm was not sounding. A/O [alert and oriented] to self, confused & forgetful. Resident had [MEDICATION(S)] in 8 hours prior to fall. Last BM [bowel movement] Resident only noted injury at time of fall was abrasion on right wrist. Resident was assisted to bed via Hoyer and assist of 2. Approximately 1130am CNA reported resident was c/o [complaining of] right hip pain. Resident had been lying in bed since eating breakfast and had no c/o until now. Was having facial grimacing and wanted to go to ER [emergency room ]. (son/POA) was notified of change. Ambulance was called for transfer. Report called to [GRHC]. It was determined that he had fractured his right hip and required surgery. The surgery will be done on Monday at [GRHC] . Predisposing Physiological Factors .Incontinent (checked) . Predisposing Situation Factors .Alarm did not sound (checked) . Immediate Action Taken: Description: .Res does have a bed and chair however the bed alarm did not sound as it was plugged into the chair alarm still . Witness Statement, signed and dated by CNA T 2/5/22 at 07:55, states in part: .Any alarms: type- yes; Was it sounding - no . Hospital History and Physical, dated 2/5/202, at 4:12 PM, states in part: . [R26] is an [AGE] year old male who fell at the nursing home today and unfortunately has a right hip fracture .Principal Problem: Closed displaced fracture of right femoral neck (HCC) (2/5/2022) . Hospital Discharge Summary, dated 2/8/2022, states, in part: .Diagnosis: Principal Problem: Closed displaced fracture of right femoral neck .02/10- Surgery, right hip endoprosthesis (Right), cemented utilizing a [NAME] cemented Summit stem size 7, with a 53 [CONDITION(S)] head with a 1.5 neck length . On 2/10/22, at 08:40 AM, Surveyor interviewed LPN R about R26's fall on 2/05/22. LPN R indicated CNA T found R26 on the floor when passing breakfast trays. LPN R indicated CNA T called out to LPN R indicating R26 was on the floor. LPN R indicated R26 had an alarm but it was not sounding. LPN R indicated R26 was observed lying on right hip on the floor in R26's room. LPN R indicated LPN R had asked R26 to roll over and then assessed range of motion and vital signs on R26. LPN R indicated R26 was able to move all limbs and indicated he had no pain and was fine. LPN R indicated the Hoyer lift was used to get R26 up off the floor and into the recliner in his room. LPN R indicated R26 then ambulated into bathroom with assist with no complaints of pain. LPN R indicated all that morning R26 had no complaints of pain up until 11:10 AM. LPN R indicated at that time LPN S was called over to assist. It was at that time R26's right leg was observed to be slightly shorter than the left leg. LPN R indicated LPN S called the hospital and completed the paperwork to send R26 out. Surveyor asked LPN R if a registered nurse assessed R26 at the time of the fall and LPN R indicated no. LPN R indicated R26 and family agreed to have R26 sent to emergency room . On 2/10/22 at 08:50, Surveyor asked Director of Nursing (DON) B about R26's fall on 2/5/22 resulting in right hip fracture. Surveyor asked DON B if there was an intervention put into place post fall. DON B looked over documentation and indicated R26 was to be alarmed and the alarm did not sound. DON B indicated the intervention was to check on the alarms more often. DON B could not find documentation for this. DON B then indicated no there was not. Surveyor asked DON B if a new intervention should be put into place after falls and DON B indicated yes. The facility failed to follow R26's care plan to prevent falls for R26 resulting in a fall with a right hip fracture. Example 3 R20 was admitted on [DATE] with diagnoses of arthritis, history of falls and generalized weakness. On 12/14/2021, the facility recorded that R20 has a BIMS (Brief Interview of Mental Status) score of 15 which indicates R20 is cognitively intact. Per facility documentation, R20 fell on [DATE] while one CNA transferring R20 with a stand lift. There were no new interventions added to the care plan. R20 slid to the floor with while staff were attending on 8/29/2021 and was lifted off the floor by three staff without a registered nurse assessment. R20 was transferred to the emergency room per daughter's request. There were no updates to the care plan. On 9/8/2021 at noon, R20 was being transferred via stand lift and slid out of the sling. R20 urinated on the floor. There were no updates to the care plan. On 9/8/2021 at 6:40 PM, R20 was confused and fell out of wheel chair. No changes to the care plan could be found until 9/14/2021. The new care plan interventions included: Transfer with the assist of two staff and toilet every 2 hours and as needed. On 10/18/2021, the care plan was revised to: 1 staff if using the bedpan and 2 staff to assist with stand lift for transfers to the toilet/commode. The facility MDS (minimum data set-a standardized tool for assessments) dated 9/24/2021 fails to capture in section J1800, that R20 had fallen three times in the last month. On 2/10/2022 at 2:30 PM, Surveyor interviewed Registered Nurse (RN) C who completes the MDS assessments for the facility. Surveyor asked RN C, since R20 fell three times before the 9/24/2021 MDS, should question J1800, which asks if the resident has fallen since the prior assessment, have been answered no? RN C, stated, That was before I started, but it should have been answered yes. Surveyor asked RN C, if it would have been answered yes, would the system have cued the reporter to put in place care plan interventions? RN C, Probably. Surveyor asked RN C, should the care plan be reviewed and possibly interventions added after each fall? RN C indicated yes. Example 4 R10 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease, dementia with behavioral disturbances, anxiety disorder, and muscle weakness. R10's care plan dated 4/1/21 states, in part: Focus: The resident is at risk for falls r/t (related to) gait/ balance problems. Goal: The resident will be free from falls through the review date. Interventions: Ensure that the resident is wearing appropriate footwear (non-slip shoes or gripper socks) when ambulating or transferring. Follow facility fall protocol. R10 had a fall on 11/22/21. R10 was found on the floor in her bathroom. R10 was not assessed by a RN (Registered Nurse) and her care plan

Based on record review and interview the facility did not provide care consistent with professional standards of practice to prevent pressure ulcers and a resident does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. This affected 1 of 3 residents with pressure ulcers out of a total sample of 6 (R2). R2 developed 3 unstageable pressure injuries due to lack of skin observation and assessment while resident had a hard splint in place to right lower extremity following a pathological fracture. The facility sent a fax to R2's physician to update. This documentation was not signed for 5 days after the discovery of these 3 unstageable pressure injuries, creating a delay in treatment for [REDACTED]. This is evidenced by: The Facility's Policy and Procedure entitled Change in a Resident's Condition or Status, dated [DATE], documents, in part: .1. The nurse will notify the resident's Attending Physician on call when there has been a (an): .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; .2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing stated disease related clinical interventions (is not Self-limiting): . The Facility's Policy and Procedures entitled New Wound Procedure, undated, documents, in part: 6. Update MD (Medical Doctor) for wound treatment orders . Per NPIAP (National Pressure Injury Advisory Panel), Best Practices for Prevention of Medical Device-related Pressure Injury in Long Term Care, dated [DATE], documents, in part: .Cushion and protect skin with dressings in high risk areas .Inspect the skin under and around the device at least daily (if not medically contraindicated) .Be aware of [MEDICAL CONDITION] under device(s) and potential for skin breakdown . Per NPIAP Pressure Injury Prevention Points, dated 2016, documents in part: .Skin care .3. assess pressure points .beneath medical devices .Reposition and Mobilization .14. Place thin foam or breathable dressing under medical device . R2 is a [AGE] year old female with the following Diagnoses: [REDACTED]. R2's Braden Scale for Predicting Pressure Sore Risk, dated [DATE], documents that R2 scores 11, which indicates she is at High Risk for pressure injuries. High Risk is documented as scores of ,[DATE]. R2's Skin Observation Tool, dated [DATE], documents, in part; .Skin intact, a. Yes On [DATE], while providing AM care, facility RN (Registered Nurse) pulled back R2's blankets and noted that she has a deformity and bruising in her right leg. The on-call physician was contacted and an x-ray was ordered. R2's x-ray results, dated [DATE], documented the following; .Moderately displaced, proximal tibia and fibula fractures are seen. R2's POA (Power of Attorney) was contacted and the decision was made to send her to the ER (emergency room ). Documentation from R2's ER visit includes, in part: .Nursing staff called today with concern about new evidence of swelling, bruising and signs of pain in her right knee and lower leg. Staff reports that this was not present last night on assessment, but was found this morning. She has severe dementia, with history of previous fractures, very debilitated, not weight-bearing and hip and knee contractures. X-ray was done at facility, report shows proximal tibial and proximal fibular fractures with mild displacement. Patient's POA agreed to have her be seen in the ED (Emergency Department) for evaluation and splinting. They are in agreement that she would not be a surgical candidate, which is very certain .General: She is in acute distress (Intermittently) .Comments: She is very thin and frail .Musculoskeletal: Right knee: She exhibits ecchymosis (Appears to be evolving) and deformity (Gross deformity distal to the knee, with instability on exam) .Splint type: OCL (this is a two piece splint which is held in place with an acewrap) placed posteriorly from a mid-thigh down to foot. With additional splint anteriorly from mid-thigh to anterior ankle. Pain: Improved, Sensation: Normal, Patient tolerance of procedure: Tolerated well, no immediate complications, Knee was splinted at approximately 30 degrees flexion .Assessment and Plan: .Unlikely to tolerate a long leg cast at this point. She has underlying contractures at the knees presenting a full straight knee splinting. Fracture stabilized well with current splint, more definitive or long-term splinting versus casting may need to be discussed. Primarily consideration will need to be made about how she will tolerate treatment . It is important to note that there is no mention of padding being applied while splinting R2's leg. Order received from R2's primary Physician on [DATE] for Repeat Tib/Fib X-ray of Right Lower Leg on [DATE]. R2 was seen on [DATE] in person by her physician. Progress note documents,the following, in part: .She has a [MEDICAL CONDITION] tib-fib on the right side. It is in a very nicely assembled splint that keeps her leg well positioned. There is good distal circulation. She appears to be in no pain, and nursing staff delivers a good report .I reviewed the discovery of her fracture recently with nursing staff. There does not appear to be any suspicious or concerning circumstances. Her leg swelling and deformity were discovered in the process of routine care. My suspicion is that her immobility and contractions as well as significant [MEDICAL CONDITION] gave rise to the pathologic fracture. X-rays did not demonstrate evidence of other concerning features either, and I believe that the conservative management that we have engaged for her are the most appropriate plan of care. R2's monthly Physician order [REDACTED]. R2's x-ray results dated [DATE], documented the following; .Moderately displaced proximal tibial and fibular fractures, unchanged in position. Detail obscured by the overlying cast. Demineralization and [MEDICAL CONDITION] change. On [DATE], R2's Physician documents leave splint in place 4 more weeks. It should be noted the R2 had a hard splint in place to align a fracture. Nursing staff did not question the physician if a skin check should be completed per standards of practice. R2 was seen on [DATE] via telemedicine (due to COVID pandemic) by her Physician. Progress note documents, the following, in part: .She has a splint on her leg for immobility and palliative reasons for a fracture that was evaluated in the emergency room just over a month ago. She seems to be doing well. Repeat x-ray was completed, and I will watch for these results .We will continue with current supportive cares and leave the splint in place as long as it is appropriate after I have reviewed the x-ray for interval changes. R2 was seen on [DATE] via telemedicine (due to COVID restrictions) by her Physician. Progress note documents the following, in part: .She recently had a lower extremity fracture, which has been managed with a very supported splint. She has no pain or problems with this. Of course, she has underlying [MEDICAL CONDITION] and [MEDICAL CONDITION] and is managed very supportively only .We will continue with her current plan of care. R2 had two televisits performed by her physician the nursing staff did not advocate for R2 or question the physician if skin checks should have been performed to prevent skin breakdown in a resident with severe contractures. On [DATE], Staff removed the splint from R2's RLE (right lower extremity) and discovered three unstageable pressure injuries to her leg from the splint. Definition of Unstageable is the wound has full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, unable to visualize true depth to tissue destruction, until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore, stage, cannot be determined. (Wound Care Education Institute) Documentation of wounds as follows: 1) Unstageable wound to right knee measured 2.8 cm (centimeters) by 6.5 cm (length by width) wound bed had 75% white/yellow slough and 25% scab present, with redness and warmth to peri-wound. 2) Unstageable wound to right heel measured 3 cm by 2.5 cm, wound bed had 50% brown slough/necrotic tissue and 50% white slough, slight redness noted to peri-wound. 3) Unstageable wound to right lateral foot measured 1.6 cm by 1.5 cm by 0.2 cm (length by width by depth), wound bed had 20% brown necrotic tissue and 80% white slough. On [DATE] after discovery of the above wounds, RN/WCC C (Registered Nurse/Wound Care Certified) wrote a fax to R2's primary Physician that included the above descriptions of the pressure injuries, asked if he would like wounds cultured (checked for bacteria growing in them), requested step by step wound treatment orders for daily and PRN (as needed), reported blanchable redness to anterior ankle/foot, and requested a step by step treatment order for this area as well. This fax was signed by R2's Physician and faxed back to the facility on [DATE]. This was a 4 day delay in physician notification of R2's development of three unstageable wounds to RLE from splint. Review of R2's [DATE] TAR (Treatment Administration Record) documents that R2 did not have treatments started until [DATE] due to part of the treatment order not being delivered from pharmacy until [DATE]. This was a total of a 6 day delay in beginning wound care. R2's wound culture results document the following, in part: .collected [DATE] . received [DATE] .verified on [DATE] .Culture Routine: Heavy mixed Gram-positive organisms (Abnormal) .Gram Stain: (Abnormal) Primary specimen description Right Foot, Few Squamous [MEDICATION NAME] cells, Rare Polymorphonuclear cells, Heavy Gram-positive cocci, Moderate Gram-positive bacilli, Few Gram-negative bacilli . R2's Physician replied to these results on [DATE] with a signature and question Is she on treatments? Facility faxed to R2's Physician response of what her wound care orders were and Resident is not receiving any oral treatments. Vital signs are WNL (Within Normal Limits). Physician replied with a signature and date [DATE]. There is no evidence in R2's medical record that she was treated with antibiotic therapy. R2's weekly wound measurements show improvement from [DATE] to her death on [DATE]. On [DATE] at 2:00 PM, Surveyor interviewed RN/WCC C. Surveyor asked RN/WCC C what she could remember about R2 in regard to her fracture and wounds, RN/WCC C explained that R2 sustained a pathological fracture of her right leg that was splinted with a hard splint wrapped in ace wraps that they were instructed not to remove. When Surveyor asked RN/WCC C what portion of R2's leg was splinted, RN/WCC C said from mid-thigh to mid-foot, toes visible. Surveyor asked RN/WCC C if R2 ever had pain to her right leg, RN/WCC C said no. When Surveyor asked RN/WCC C if there was ever any odor noted from right leg, RN/WCC C replied no. On [DATE] at 9:35 AM, Surveyor interviewed RN D. When Surveyor asked RN D if R2's splint ever had an odor, RN D said no. When Surveyor asked RN D if R2 had any pain to her right leg, RN D said no. When Surveyor asked RN D if she had anything to do with splint removal on [DATE], RN D said yes, she removed ace wraps and then lifted off hard piece of splint off top of leg and noted two wounds at that time along with drainage present to that top piece of splint. Surveyor asked RN D if the wounds had an odor that that time. RN D said no. RN D reported this to RN/WCC C and DON (Director of Nursing) that was employed at the time. Surveyor asked RN D what happened next. RN D explained that RN/WCC C came to assess, they removed the rest of the splint pieces and noted the third wound to R2's heel. Surveyor asked RN D who notified the Physician. RN D said RN/WCC C did. When Surveyor asked RN D if you were updating the Physician about this change of condition what method would be used, RN D stated I would have called. On [DATE] at 9:46 AM, Surveyor interviewed LPN E (Licensed Practical Nurse). Surveyor asked LPN E if R2's splint ever had an odor, LPN E said not that I heard about. LPN E then explained that she didn't work on R2's hall so she only knew about R2's change of condition from co-workers. Surveyor asked LPN E how she would contact the Physician if she discovered unstageable pressure injuries after removing a splint, LPN E said telephone or fax, but personally, call. When Surveyor asked LPN E when an order is received to culture a wound, how soon should that occur, LPN E said as soon as possible. On [DATE] at 10:31 AM, Surveyor interviewed RN/WCC C. Surveyor asked RN/WCC C how things transpired the day R2's splint was removed. RN/WCC C explained that when floor RN was removing the splint and discovered the wounds, she alerted her right away. RN/WCC C then said she assessed and applied a dressing, faxed R2's Physician and called her POA. When Surveyor asked if R2's POA had any questions or concerns at that time, RN/WCC C said no. Surveyor asked RN/WCC C if R2's Physician typically replies timely. RN/WCC C said yes, usually. Surveyor asked RN/WCC C if she knew why the wound culture that was ordered on [DATE] was not obtained until [DATE]. RN/WCC C stated she had forgotten to take that order off when she transcribed the other orders on the fax, and once discovered that it hadn't been completed, she entered and obtained. When Surveyor asked RN/WCC C how long after the order is received should a culture be obtained, RN/WCC C said 24 hours. Surveyor asked RN/WCC C why the Santyl (prescription ointment) was marked in R2's TAR as drug not available on [DATE]. RN/WCC C said because it hadn't been delivered from pharmacy yet. When Surveyor asked RN/WCC C if faxing R2's Physician was the most efficient way to communicate, RN/WCC C stated probably should have called. On [DATE] at 11:05 AM, Surveyor interviewed DON B. It is important to note that DON B was not employed in the facility during this incident. Surveyor asked DON B what her expectation would be for contacting a Physician to update on newly discovered unstageable pressure injuries. DON B stated a call to the Physician. When Surveyor asked DON B if she was aware of any concerns that R2's family may have had in relation to her pressure injuries, DON B said no, she was not. Surveyor asked DON B what her expectation would be if this situation arose again. DON B said there would be more assessments. When Surveyor asked DON B to clarify what type of assessments, DON B replied CMS (Circulation, Movement, Sensation). Surveyor asked DON B how they could have prevented R2 from developing the unstageable pressure injuries. DON B stated with R2's contractures, I don't think we could have prevented them. Surveyor asked DON B if they could have assessed the skin under the splint if that could have helped, DON B said it could have. Additional information sent from DON B on [DATE] was reviewed. Letter dated [DATE] from R2's Physician documents, in part: .Some areas of skin breakdown were noted, which is expected for a [AGE] year old with impaired nutrition and cognition. Unfortunately, wound care was initiated several days later . It is important to note that pressure injury development is not a normal part of growing older.

Based on observation, record review, and interview, the Facility did not ensure that each Resident receives adequate supervision and assistance devices to prevent accidents in 1 of 4 Residents reviewed for fall concerns (Resident 1). R1 was left without direct supervision, in a mechanical lift tub chair, in the raised position, without a seatbelt in place. R1 fell from the tub chair and sustained blunt head trauma, a non-displaced C (cervical) 7 - T (thoracic) 1 (neck) fracture, bilateral nasal bone fractures, laceration to the lower lip and a partial dehiscence of her left knee surgical wound. The failure to adequately supervise R1 while in a mechanical lift tub chair in the raised position and without a seatbelt in place resulted in an Immediate Jeopardy to the health and safety of R1. The Immediate Jeopardy began on [DATE]. Interim NHA (Nursing Home Administrator) A, DON (Director of Nursing) B, and SDN (Staff Development Nurse) C were notified of the Immediate Jeopardy on [DATE] at 3:45 PM. The Immediate Jeopardy was removed on [DATE]. The noncompliance of F323 continues at a severity and scope level of D (potential for more than minimal harm/isolated) as the facility continues to train staff as they report to work. This is evidenced by the following: The Facility's Procedure for Bathing, issued [DATE] with revision dates to include ,[DATE] and ,[DATE], states in part: . 2. Use appropriate safety measures and equipment to prevent accidents. Manufacturer's directions should be followed for use of bathing equipment. Safety belts for bathing units, shower chairs, and bathing lifts should be used at all times. The Cascade Patient Transfer Lift System manual states (in part): WARNING: Only personnel who have been thoroughly trained in the operation of the Pacific Transfer Chair Lift should operate this equipment. Operation of this equipment by untrained personnel could result in injury to the operator or patient . 9 All (emphasis in original document) Residents must always be securely belted at waist when using the Penner Swivel Lift System. For Residents who are unable to support themselves in an upright position, Penner supplies a second (chest) belt, which allows you to secure the Resident in an upright position . Upon completion of the bath, the Manuel gives the following instructions: . 21. Before you move the Transfer away from the tub, make sure the lower extremities have been towel dried so the bath room floor stays dry. Insure the Transfer is raised high enough to clear the tub seat. You may now unlock the casters and move the Transfer out of the tub and away, ensuring the Resident is still belted correctly and the Residents hands, arms, and legs are clear. 22. Once the Transfer is clear of the tub, lower the Transfer to the lowest position and push the Resident back to the area. 23. Position the Penner Transfer for a transfer back to bed or to another chair. Lock the casters. 24. Release the seatbelts from around the Resident and transfer the Resident, using proper nursing techniques and assistance if required. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) R1's initial MDS (Minimum Data Set), with an end observation date of [DATE], shows that R1 has a BIMS (Brief Interview for Mental Status) score of 13 (cognitively intact), needs extensive assistance with transfers, and has a history of falls. R1's Initial Fall Assessment, dated [DATE], gives R1 a score of 20 which places R1 in the High risk category for falls. R1's CAA (Care Area Assessment) with an ARD (Assessment Review Date) of [DATE] states R1 has a history of falls. She forgets to request assistance at times when she would need it. Staff reminds her often to use her call light. She does have some intermittent confusion. Her current Care Plan has fall interventions in place. R1's Care Plan at the time of her fall on [DATE] includes a Focus area that states: The Resident is at risk for falls R/T (related to) confusion, pervious (sic) fall, surgery to left knee, ([DATE]). The goal of this Focus area is Resident will be free of falls through the review date Target date [DATE]. Interventions to this fall Focus area include: Personal Alarm: Bed alarm used to alert staff to Resident's movement and to assist staff in monitoring movement. Silenced in room to prevent sleep disturbances, ([DATE]), and Ensure a safe environment: Ensure Resident has call light at all times and remind her to request assistance with transfers, ([DATE]). (Please note that on [DATE], a 2 day trial of no bed alarm was initiated. If R1 always uses call light for assist and nursing team agrees patient has been safe and using call light, discontinue bed alarm. Per DON B, R1's bed alarm was discontinued [DATE].) R1's Care Plan, at the time of her fall, has another Focus area that states: The Resident has an ADL (Activities of Daily Living) self-care performance deficit R/T (related to) Left total knee replacement E/B (evidenced by) need for assistance with ADLs, ([DATE]). Interventions to this Focus area include: Transfers: Resident requires 1 assist with sit to stand Large sling. Remind her to hold onto grab bars. (Revised [DATE]). At the time of R1's [DATE] fall, R1 was taking the blood thinning medication Coumadin, 7.5 mg every Tuesday and Friday, and 5 mg every Sunday, Monday, Wednesday, Thursday, and Saturday. R1's Nurses Notes contain the following documentation: *[DATE] 8:40 PM: At 1840 (6:40 PM) Resident had completed her whirlpool bath. Resident fell out of shower chair landing on her face. She had bloody nose and mouth with lip laceration. Also, her knee incision was split open approx. (approximately) 2 inches and was bleeding. C/o (complaint of) pain ,[DATE] in her mouth and nose. C-spine maintained due to facial injury. Pressure applied to nose to control bleeding. Bleeding did ease. Left knee covered with telpha and wrapped for protection. Neuro (neurological) check completed. Vitals obtained. At 1848 (6:48 PM), called (Physician) with an update and received an order to transfer to (Area) ER (emergency room ) Rescue squad arrived at 1905 (7:05 PM) and left at 1920 (7:20 PM) . R1's Hospital Emergency Report from [DATE] states: .frail 79 y.o. (year old) .arrived to ER via EMS (Emergency Medical Service) from local NH (Nursing Home) .c/c (chief complaint) fell forward off shower chair striking face and left anterior knee against floor one hour ago. She is s/p Left total knee athroplasty [DATE] (physician) here. NH reports dehiscence of lower aspect Left knee surgical wound (5 cm (centimeters) long x 1 cm deep) with mild bleeding. Also lac (laceration) x 2 lower midline lip region presenting with neck pain and facial injury . Encounter Diagnosis: [REDACTED]. 2. Lip laceration . 3. Blunt head trauma 4. Closed fracture of nasal bone . 5. Dehiscence of laceration wound . The Facility self-reported this incident to the State Agency. The Misconduct Incident Report states: Resident was transferred out of the tub. Resident chair was in a raised position and her seatbelt was removed so she could dry herself. CNA (Certified Nursing Assistant) remained in bathroom but walked away from Resident and went to curtain to ask nurse about weather. Resident fell and sustained injury. The Facility's summary of the incident states: At Approximately 6:40 PM on [DATE], Certified Nursing Assistant (CNA) D was transferring Resident (R1) out of the (Brand) bath tub. CNA D raised the Resident up using the mechanical lift tub chair so the Resident's legs would clear the side of the bathtub. She then pulled her (R1) away from the tub and unbuckled her seatbelt to allow Resident to dry self-off. CNA D states she then walked to the curtain as she had heard thunder and wanted to ask the nurse about thunder and the storms. At this time, the Resident fell out of the chair face first onto the bathroom floor. CNA D did not leave the bathroom but was not within reach of the Resident; who was unbuckled and still in a raised position. Resident was bleeding from the nose, lip, and healing incision on the knee. Resident was immediately assessed and the doctor / rescue squad was called. Resident was taken to the hospital where she was further evaluated. When CNA D was asked if she knew that policy / procedure states transfers are supposed to be buckled and lowered to the floor as part of proper protocol she said she did. She said she just didn't think. I should've never have went to ask about the thunder. I thought she would be ok in the chair as she does everything on her own in her wheelchair. CNA D stated she had forgotten to lower her back down after getting her out of the chair. CNA D's statement states: At approximately 6:40 PM, I took (R1) out of the bath tub with the whirlpool chair slightly raised. When I removed her completely, I unstrapped the seatbelt and put it over the back of the chair. I then poked my nose around the curtain, Resident was drying, to ask (nurse) about the weather. I did not leave the bathroom. When I looked back I saw (R1) falling out of the chair as she was attempting to dry her legs. I attempted to try and catch her but she hit her face on the floor and I called for help. (Nurse) then yelled for (nurse) and they both came running to help. She had a bloody nose, had a split lip, and her scar from knee surgery was open. On [DATE] at 12:35 PM, Surveyor, DON A, and SDN C went to the 100 wing tub room where R1's [DATE] fall occurred. Surveyor observed there to be a curtained entryway leading from the 100 wing hall into an anteroom. Once in the anteroom, there is approximately 5 feet to the entry of the tub room. This tub room has a door and, per SDN C, this door is kept open due to the small size of the tub room and the curtain between the anteroom and the 100 wing hall remains closed. In this tub room, there is a side entry tub and a mechanical lift tub chair. DON B sat in the tub chair and once she was belted in, SDN C raised the tub chair so DON B's feet could clear the tub entrance and maneuvered the chair into the tub via the side entry door. SDN C then maneuvered the chair back out of the tub, with DON B still belted in the chair, and brought it to the center of the tub room. At this time, DON B's seat was raised approximately 2 ,[DATE] feet off the floor. SDN C stated it was here, in the center of the tub room, where R1 was when she fell forward from the chair. SDN C stated CNA D did not lower the tub chair, but had unbuckled R1, left R1's side, crossed the anteroom to the curtain, and pulled the curtain back (remaining in the anteroom) to speak with the nurse in the 100 wing hall. Upon turning back, SDN C stated, CNA D witnessed R1 fall forward from the chair. SDN C stated it was during this fall investigation that the facility was made aware there is an added piece of equipment, a chest strap, that can be used for Residents with fall concerns. This would be a strap that goes around the Resident's chest and secures to the chair. SDN C stated the facility does not have this add on piece of equipment. Surveyor, DON B, and SDN C then went to look at the 200 wing tub. This tub, as well as the tub on the 300 wing, is an end entry tub. SDN C stated it was during this fall investigation that she became aware there are two types of tubs in the facility (side entry and end entry). SDN C showed Surveyor that the chair lift on the end entry tubs have a safety bar that flips down in front of the Resident's chest as they are seated in the chair. SDN C stated the tub chair representative told her it is because the side entry tub chairs do not have this safety bar they (side entry tubs) have the chest strap available. On [DATE] at 1:05 PM, SDN C told Surveyor that CNA D did not feel R1 was at risk for falling so I'm not sure she (CNA D) would have applied it (chest strap) even if the facility had one, stating the chest strap is an add on to be used only if there is a concern about fall. SDN C also informed Surveyor that during general orientation, CNAs are trained on safety during transfers, but not specifically on transfers with the tub chair or specific use of the tub chair. SDN C stated the training on how to use the tub chair is done during peer to peer training. New CNAs are paired up with experienced CNAs who will show the new CNAs how to use the tub chair. SDN C stated the Facility does not have a process to ensure the experienced CNAs are using the tub chair correctly and thus training the new CNAs correctly. On [DATE] at 3:42 PM, DON B told Surveyor that it would be her expectation that Residents would be lowered in the tub chair as soon as possible and the seat belt would remain in place until the Resident is ready to be removed from the tub chair. According to the Center for Disease Control (CDC), Twenty to thirty percent of people who fall suffer moderate to severe injuries such as lacerations, hip fractures, or head traumas. According to the CDC, falls are the most common cause of traumatic brain injuries; traumatic brain injury accounts for 46% of fatal falls among older adults (those 65 or older). Among older adults, falls are the leading cause of injury death and are the most common cause of nonfatal injuries and hospital admissions for trauma. The CDC notes that in 2008, over 19,700 older adults died from unintentional fall injuries. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. On [DATE] at 3:45 PM, Interim NHA A, DON B, and SDN C were informed of the Immediate Jeopardy of F323 beginning on [DATE] with the immediacy removed on [DATE] after the Facility: 1. Had trained CNA D to include a return demonstration on the use of the mechanical lift tub chair. 2. Began spot audits during Resident baths to assure proper safety measures are being followed. 3. Placed tub manuals in the tub rooms for quick reference if needed. 4. Memos addressing the need for seatbelts to be worn at all times and the chair being in the raised position only when moving in and out of the tub, placed in tub rooms, CNA charting room, and the nurses book to be passed along in report.

Based on interview, record review, and observation, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 self-report reviewed involving 2 of 15 sampled residents (Residents 7 and 6). On 7/22/16 at 5:01 PM Resident 7 was making sexual comments to staff and rubbing a staff member's leg. At 6:39 PM Resident 7 was making sexual comments to other residents and was taken back to his room. Despite this change in the resident's behavior, staff left Resident 7 unsupervised. At 7:00 PM staff found Resident 7 in Resident 6's room with his left hand under her sheet rubbing her upper left thigh. Resident 6 has [DIAGNOSES REDACTED]. Resident 7 was removed from the situation and immediate interventions included Resident 7 could only be up in his wheelchair to go to meals and activities where he can be in direct supervision of staff until a motion sensor alarm for his door arrived. Staff interviews indicated Resident 7 continued to get out of his room and was found entering Resident 6's room a few days later. A cloth strip was put across Resident 7's room that was attached to clip alarms, Resident 7 would lift one end of the cloth strip and go underneath it to get out of his room with no alarm going off and Resident 7 continues to wander in the hallway unsupervised per staff interviews. Failure to ensure systems were in place and that Resident 7 has received adequate supervision to prevent him from being sexually aggressive towards a resident created a finding of immediate jeopardy. The immediate jeopardy began on 7/22/16. Nursing Home Administrator (NHA) A was officially notified of the immediate jeopardy on 9/16/16. The facility removed the immediate jeopardy on 9/15/16, however, the deficient practice continues at a scope/severity level D as the facility continues to implement its removal plan. Evidenced by: Resident 6's [DIAGNOSES REDACTED]. Resident 6's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/30/16 indicates Resident 6 has severe cognitive impairment. Resident 7's [DIAGNOSES REDACTED]. Resident 7's most recent MDS with an ARD of 8/18/16 indicates Resident 7 has severe cognitive impairment. Resident 7's previous MDS with an ARD of 5/26/16 indicated Resident 7 had moderate cognitive impairment. Resident 7's Progress Notes include, in part, the following entries: 7/15/16, 9:16 PM, Resident was very combative after supper. Resident wanted to leave building and go home. He was hitting, kicking, swearing, yelling and trying to bite staff. Daughter was called and she came up. Several attempts made to redirect resident. Resident still not cooperative at this time. Resident stated that he was incontinent of bowel and bladder and that he wanted for us to change him in the front entry way. Resident yelling and swearing at daughter as well. 7/17/16, 3:29 PM, Resident combative and yelling at staff. Resident is hitting kicking, biting, swearing, and yelling at staff. Trying to get out the front door. Several attempts to redirect without success. 7/17/16, 2:45 PM, Ativan (lorazepam, an antianxiety medication) Solution 2 MG (milligrams) /ML (milliliters) inject 0.5 mg intramuscularly every 4 hours as needed for agitation. Resident agitated and very combative. Several attempts from various staff members to redirect without success. 7/17/16, 4:16 PM, Resident was given Ativan 0.5 mg IM at 15:30 (3:30 PM) with effectiveness. 7/18/16, 8:56 AM, (Resident 7's Physician) office contacted in regards to resident mood/behaviors over weekend and beginning to become increasingly agitated this AM. Requested additional orders, message left with (Clinic Personnel). 7/19/16, 4:35 PM, Behavior committee meeting note from 7/14/16 - Reviewed resident's behaviors for the month of June 2016 - had 0 episodes of exit seeking and 0 episodes of reporting bugs on body documented. He has been having more confusion recently. He becomes very upset and agitated as well. Had to get a PRN (as needed) Ativan order recently because of this. Also did a UA (urinalysis) dip which was essentially negative so didn't pursue any further UA testing. Also review current psych (psychiatric) medications. Will continue and address concerns as they arise. 7/22/16 5:02 PM, Resident rubbed a CNA's leg and asked if he could zip up her zipper. He then stated that he was ready for a piece of ass. 7/22/16, 6:45 PM, Resident making sexual comments to other residents. Saying things like I really like you. I'll be nice to you. I've had several good ladies like you, I'll suck you to the limit, I'll kiss your p***y, yes I will, and I won't hurt you. Resident was separated from other residents and brought to his room. Despite the change in the resident's behavior, staff left the resident unsupervised. 7/22/16, 7:00 PM, CNA reported to this nurse male resident was in female resident's room with his hand under her sheet rubbing her leg. This nurse asked CNA if she removed male resident she replied, Yes I took him to his room. This nurse went down to (Resident 7's) resident's room right away and noticed male resident sitting in his room with his head down sleeping. 7/22/16, 10:30 PM (describing earlier incident): Staff reported that they noticed that (Resident 7) was not in his room, which is unlike him. Looked across the hall and noticed him in another resident's room. He had his hand under the sheets and was rubbing the other resident's leg. When asked what he was doing, he did not respond. (Resident 7) was pulled away from resident by staff and staff reported that there was resistance. Resident was removed from room by staff member. Resident was removed from other resident's room and was assisted to bed shortly after. Resident has bed alarm in place that is connected into the call system so staff will be notified if resident attempts to get out of bed. On 9/14/16 at 3:30 PM Surveyor interviewed CNA C. CNA C stated she found Resident 7 in Resident 6's room with his left hand under the blankets massaging Resident 6's upper thigh area. CNA C stated she pulled Resident 7 out of the room. CNA C stated Resident 6's expression when she walked into the room was stiff and terrified. The facility's Incident Witness Statement form included a statement from RN D. This nurse went down to talk with (Resident 6) shortly after incident occurred. At first with every question that was asked, (Resident 6) would state three thousand. After a while she started answer a few questions. When asked if she felt danger she stated three thousand. When asked if he hurt her? She responded with three thousand the first time and the second time she said no. When asked if she felt safe, she stated yes. When asked if he make her feel uncomfortable she stated yes. Resident did not respond when asked what happened but when asked if he put his hand on her leg she stated yes. When asked if she told him to stop, she stated yes. When asked if he did stop she stated yes. On 9/14/16 at 3:20 PM Surveyor interviewed Resident 6. Resident 6 stated a man came into her room one night; he had never been in her room before. Surveyor asked what did the man do, Resident 6 stated, He touched me down there and pointed to her groin area. Surveyor asked what you did? Resident 6 stated, Told him to get lost. Surveyor asked did he, Resident 6 stated, Not for a while. Surveyor asked did he leave, Resident 6 stated someone took him. Surveyor asked did this bother you, Resident 6 stated, Oh yes - I don't do that. Nursing notes continue: 7/23/15, 12:05 AM, Phone call placed by this nurse and acting charge nurse. Nursing updated daughter that resident was located in a female resident's room. This nurse informed her that the new intervention for now would be that he will not roam the facility in his wheel chair unsupervised and that while not under direct supervision of a staff member he will be in an alarmed stationary chair or have a bed sensor alarm while in bed. She agreed with this and asked what else we were doing to find out what is wrong with her dad. The nurse stated we would update the doctor and seek his advice for labs/treatment. She was satisfied with this. 7/25/16, 11:22 AM . (Resident 7) currently has an alarm on his bed, w/c & recliner. His whereabouts are being monitored when he is in his wheelchair .We are checking into a possible door alarm for his room. Resident 7's care plan focus. The resident has displayed inappropriate sexual advances towards another resident R/T dementia E/B found in another resident's room touching her; sexual comments to staff, dated 7/25/16. Interventions include, in part, the following: Monitor whereabouts when out of his room. Has strip across doorway with tab alarms on either side on his doorway to alert staff when he is exiting his room. Dated 7/25/16 and revised 8/11/16. Sexually inappropriate behavior/comments with residents/staff - Behavior - Non-pharmacological: Attempt non-pharmacological interventions. Monitor whereabouts with alarms; redirect from situation; explain why behavior is inappropriate; redirect to another activity. Dated 7/25/16. 7/29/16, 2:13 PM, Received door alarm today to alert staff if he is leaving his room. He hasn't had any sexually inappropriate behaviors this past week. Will allow him to be in his w/c when in his room so he can use his reading machine and look out the window. Will still have him under supervision when he leaves the room at this time. On 9/15/15 from 9:00 AM until 11:00 AM Surveyor did a continuous observation of Resident 7 as he was in the front lounge. There were 2 female residents in wheelchairs, 1 female resident in a standard chair and 1 male resident in a wheelchair in the front lounge. From 9:03 AM - 9:10 AM Resident 7 was in the front lounge area. There was no staff in visual of Resident 7. From 9:25 AM - 9:40 AM Resident 7 was in the front lounge area and maneuvering himself in the hallway by the laundry. There were no staff in visual of Resident 7. From 10:02 AM - 10:15 AM Resident 7 was in the hallway by the nursing station and watching television. There was no staff in visual of Resident 7. On 9/14/16 at 3:25 PM, Surveyor interviewed Licensed Practical Nurse (LPN) E. LPN E stated the cloth strip across Resident 7's doorway is to keep him from entering the ladies room across the hall. LPN E stated sometimes he goes underneath the cloth strip and the alarms do not go off. We try to redirect him back to his room. On 9/15/16 at 1:35 PM Surveyor interviewed CNA F. CNA F stated she has observed Resident 7 exit his room by taking one side of the strap off and going underneath it, the alarm did not activate. CNA F stated approximately 5 - 7 days after the incident she found Resident 7 in the doorway of Resident 6's room. He had exited his room and the alarm was not sounding. CNA F stated she told the nurse who was on that night. CNA F stated Resident 7 is to be monitored, this means keep an eye on him; make sure his is not in other's rooms. Surveyor asked who watches him when you are in other resident's rooms and Resident 7 is in the hallway. CNA F stated everyone helps; we just need to know where he is. On 9/15/16 at 1:45 PM Surveyor interviewed CNA C. CNA C stated she knows Resident 7 has exited his room without the alarms going off. CNA C stated the alarms sound probably 90% of the time and we know he is exiting the room. The other 10% of the time he has exited without us knowing. CNA C stated we just have to keep an eye on him, know where he is and what he is doing. Surveyor asked who watches him when you are in other resident's rooms and Resident 7 is in the hallway. CNA C stated I hope the nurses are helping. CNA C stated Resident 7 has been in the hallway with no one else to watch him, we just hope he stays in the hallway. On 9/15/16 at 1:50 PM Surveyor interviewed CNA G. CNA G stated she has seen Resident 7 lift one side of the cloth strip that is across his door and go underneath it without the alarm sounding. CNA G stated he has also exited his room and the alarm sounds, however it is difficult to hear if we are in another room. CNA G stated we are to watch him when he is out so he does not go into other resident rooms. On 9/15/16 at 2:00 PM Surveyor interviewed CNA H. CNA H stated she has observed Resident 7 exit his room by going under the strip and no alarm sounds. CNA H stated Resident 7 will wander up and down the hallway. On 9/15/16 at 2:10 PM Surveyor interviewed CNA I. CNA I stated staff are to monitor Resident 7 when he is out of his room, meaning to just watch him, see if he is going towards other resident rooms. CNA I stated we do not have to stay with him, just know where he is. Surveyor asked who watches him when you are in other resident's rooms and Resident 7 is in the hallway. CNA I stated when he is in the hall and we are in another resident's room we hope he does not go into another resident's room. CNA I stated everyone knows to watch for him. On 9/14/16 at 3:50 PM Surveyor interviewed Registered Nurse (RN) D. RN D stated Resident 7 has a cloth strip across his doorway because he went into Resident 6's room across the hall and put his hands on her under the sheets. RN D stated she was the charge nurse that evening and went to talk with Resident 6, she stated Resident 6 knew it happened but did not want to talk about it. RN D stated a when Resident 6's therapist was informed of the incident he told us not to bring it up unless she talked about it. RN D stated Resident 6 has had a past history of sexual abuse. RN D stated she was not aware of any time Resident 7 exited his room without staff knowing. On 9/15/16 at 2:40 PM Surveyor interviewed Director of Nursing (DON) B. DON B stated she would expect staff who observed Resident 7 exiting his room without the alarm sounding to inform the nurse. DON B stated she had not been informed that Resident 7 had exited his room without the alarm sounding. DON B did stated she knew about Resident 7 being found at Resident 6's doorway a few days after the incident and this should have been documented in Resident 7's medical record. DON B stated she expects staff to monitor Resident 7 while he is out of his room, meaning to keep an eye on him when he is coming up and down the hallways. DON B stated this does not mean direct supervision as he has not been in any other resident rooms since the initial incident. On 7/22/16 Resident 7 made inappropriate sexual comments to staff and then to residents. Resident 7 was taken to his room; no interventions were put in place to prevent Resident 7 from approaching other residents. A half an hour later Resident 7 was found in Resident 6's room with his hand on her upper left thigh under the blankets. Resident 6 has a history of sexual abuse. Resident 7's intervention to know where he is when he is out in the hallway does not always work as staff interviews show that he can get out of his room unwitnessed when he lifts the cloth strip and goes underneath it. On one occasion Resident 7 was found in Resident 6's doorway trying to enter the room. The facility's failure to prevent Resident 7 from wandering into the hallway, entering Resident 6's room, putting his hand on Resident 6's upper thigh area and not following Resident 7's care plan to monitor him when he is in the hallway created an Immediate Jeopardy. The facility removed the Immediate Jeopardy on 9/15/16 by implementing the following interventions: 1. Doorbell motion sensor will be placed on the outside of the door with the beam facing opposite door frame so to alert when he tries to leave the room. 2. The cloth strip will be placed across the door from frame to frame and make sure that the monitor cord is tight so it goes off if resident leaves the room. 3. When in bed, bed sensor that is hooked into the call light will be activated and chair sensor will be activated when in his recliner. Chair sensor in wheelchair. 4. When he is in the dining room. Staff will observe him at all times. If he leaves the dining room staff will leave with him, monitoring his whereabouts at all times. 5. Motion sensor, bed, chair and door alarms will be checked and tested each shift to assure working appropriately. 6. He will be visually in sight of staff when outside of his room at all times. 7. Education: Immediate education of staff will be done before their next working shift. Above action will be read and staff will sign that they have heard and understand. A sign will be placed by the timeclock, reminding staff that if they have not had the mandatory training, they are to report to Charge Nurse, DNS (Director of Nursing Services), or Administrator before starting work. The Charge Nurse will assure that all staff receive training before starting their shift. A list of staff will be used to assure all staff received the training. All staff will receive review of the training at the next all staff training in October, 2016.

Based on observation, interviews and record reviews facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well being for 1 of 13 (Resident 6) sampled residents. Resident 6 was observed exhibiting pain as demonstrated by facial grimacing and moaning when her left leg was moved or touched during cares and treatments. The facility did not adequately assess pain, stop cares and provide pain relief before proceeding, consult with the physician, and update the plan of care to alleviate pain. This is evidence by the following: The resource titled American Geriatrics Society Pharmacological Management of Persistent Pain in Older Persons, 2009 notes "An effective pharmacological approach to the treatment of [REDACTED]. Routine screening and careful assessment of all older patients is crucial, because pain that is causing severe impairment may not be spontaneously revealed for a variety of personal, cultural or psychological reasons...The current best indicator of the pain experience is the patient's own report which must include an assessment of the pain intensity and an evaluation of the effect of the pain on daily function." The facility policy titled "Pain Data Collection Tool", dated December 2010, indicates the following; Use: Required for all residents experiencing pain on admission, readmission, and when experiencing onset of new type and/or location of pain... Purpose: to provide baseline screening for pain. When to complete: 1. If the resident exhibits pain upon admission... 2. If the resident exhibits pain upon readmission... 3. With onset of new type and/or location of pain. Instruction: 1. To assist in measuring resident pain. 2. If the resident is cognitively impaired, complete PAINAD (Pain assessment in advanced dementia) section. 3. If the resident is unable to verbalize, please see for other symptoms that may indicate the presence of pain and complete the entire form according to the resident's ability... Resident 6 was admitted to the facility on [DATE]. Resident 6's current [DIAGNOSES REDACTED].The resident was readmitted [DATE] after a hospitalization following a femur fracture. Resident 6's Physician order [REDACTED].), [MEDICATION NAME] with [MEDICATION NAME] 5/325 mg 2 tablets as needed every 4 hours for pain, [MEDICATION NAME] Patch 25 Micrograms (mcg) every 72 hours, [MEDICATION NAME] 0.25 mg 1 tablet every 6 hours for pain..., [MEDICATION NAME] 0.25 mg 2 tablets every 6 hours as needed for more severe pain... [MEDICATION NAME] 50 mg 1 3 times a day for rotator cuff tendonitis... Resident 6's care plan titled Alteration in comfort indicates the following: Problem Alteration in comfort related to right ankle fracture, ileus, [MEDICAL CONDITION] joint disease, sore tongue, rotator cuff tendonitis, complaint of general discomfort leg and ankle pain, occasional mid upper back pain, shoulder pain, and left femur fracture with ORIF. Goal: Resident 6 will report when having pain or discomfort and effectiveness of medication. Interventions: 1. Medications as ordered and as needed. 2. Update the physician as needed. 3. Have Resident 6 rate her pain on a scale of 0 (no pain) to 10 (worst pain) or per Dementia scale (It is important to note Resident 6 scored a 3 on her cognitive score which indicates Resident 6 is severely impaired) to be completed 4 times a day per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Have Resident 6 tell what precipitates pain or relieves pain and/or discomfort. 5. Offer diversional activities such as 1 to 1, repositioning, television, back rub, activities... 6. Administer [MEDICATION NAME] ([MEDICATION NAME]) as ordered for anxiety in anticipation of pain with movement. 7. Rule out pain and/or discomfort if increased restlessness, agitation is noted and notify the nurse. 8. Hotpacks to shoulder and neck area 4 times a day as needed for stiffness and/or soreness. Resident 6's brief interview for mental status (BIMS), dated 11/21/11, indicates the following: 1. Resident 6's Repetition of words score was a 3. 2. Resident 6's temporal orientation score was a 0. 3. Resident 6's recall score was a 0. The total BIMS score for Resident 6 was a 3 indicating Resident 6 has severe cognitive impairment. Resident 6's comprehensive significant change of condition Minimum Data Set (MDS), completion date of 11/23/11 indicates the following: 1. B0800 - Ability to understand others. The area is mark as a 2 which indicates Resident 6 is able to understand others sometimes and responds adequately to simple and direct communication only. 2. C0500 - Cognitive Summary score is a 3, which indicates Resident 6 has severe cognitive impairment. 3. J0100c - Pain management: Received non-medication intervention for pain. The answer was marked as 0 indicating no. 4. J0400 - Pain frequency the corresponding answer was mark as 1. Almost constantly. 5. J0500 - Pain effect on function: B. Have you limited your day to day activity because of pain. The answer was mark as 1- Yes. 6. J0600 - Pain intensity: 4. Very severe horrible. Resident 6's Pain data collection tool, dated 10/21/11, on the top of the form direction is written "If the resident has advanced dementia or is unable to respond to questions go directly to page 3 complete PAINAD and complete number 11 on page 2". The Pain data collection tool indicates Resident 6 has no pain. PAINAD section of the assessment was completed on 10/21/11. Resident 6's pain review, dated 11/3/11, indicates the following: Resident 6 is alert to self and family. Resident 6 has had a decline in cognition since her last review... Resident 6 is able to voice pain and/or discomfort but her reports are not always consistent with what is observed by the staff. Resident 6 is monitored for pain QID (4 times a day) per the MAR (medication administration record) and PRN (as needed). A dementia scale is most effective (The PAINAD assessment). Resident 6 will chant "ouch etc". Resident 6 does not necessarily speak to anyone that she has pain; Resident 6 may say it through her chanting. Resident 6 has had a previous fracture to an ankle. Resident 6's pain is currently controlled with [MEDICATION NAME] 20 milligrams (mg) twice a day. If this is not effective in controlling her pain, Resident 6's physician will consider a trial of a [MEDICATION NAME] Patch. Resident 6 also has an as needed Tylenol order and this was used 10 times during October for right leg pain. The facility will continue to monitor and address any issues that arise. Resident 6's Clinic Referral physician note, dated 1/17/12 indicates the following: Do not handle Resident 6 by pressure on the left lower extremity. Resident 6's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The times to Rate Resident 6's pain are 8:00 AM, 12:00 Noon, 5:00 PM, and 8:00 PM. The pain rating on the MAR for the days 1/1/12 to 1/19/12 a 0 is placed in each box for each time of day the nurse was to rate Resident 6's pain. (It is important to note the pain scale of 0 to 10 was used and not the pain scale PAINAD which is indicated for Resident 6.) On 1/18/12, at 11:50 AM, Surveyor observed Licensed Practical Nurse (LPN) E perform a wet to dry treatment to Resident 6's Stage 4 pressure ulcer to Resident 6's left Achilles area. LPN E lifted Resident 6's left leg with her hand to remove the gauze wrap dressing from Resident 6's left Achilles area. Resident 6 had facial grimacing and verbalized in a loud tone Ouch. LPN E asked Resident 6's if she hurt. Resident 6 verbalized Yes. LPN E continued with Resident 6's treatment. On 1/18/12, at 12:01 PM, Surveyor observed LPN E peel the wet to dry dressing from Resident 6's left Achilles Stage 4 pressure ulcer area. Resident 6 again had a strong facial grimacing, verbalized the word Ouch Ouch Ouch and Resident 6 pulled her left leg away from LPN E. LPN E continued with the dressing change without asking Resident 6 about her pain or stopping to relieve Resident 6's pain. On 1/18/12, at 12:03 PM, Surveyor observed LPN E Lift Resident 6's left leg holding the leg with her hand and re-wrapped Resident 6's Stage 4 pressure ulcer to the left Achilles with a dry gauze wrap. Resident 6 expressed a strong facial grimace, moaning of ooh, ooh, ooh, repeatedly and pulled her left leg away from LPN E. LPN E finished wrapping Resident 6's left Stage 4 pressure ulcer and placed Resident 6's leg on the edge of the pillow pressing Resident 6's pressure ulcer into the pillow. LPN E questioned Resident 6 if she had pain. Resident 6 verbalized yes. On 1/18/12, at 12:07 PM, Surveyor spoke with LPN E regarding Resident 6's pain and if Resident 6 received pain medication prior to her treatment. LPN E stated she would have to check with the nurse on currently taking care of Resident 6 to see if Resident 6 was due for pain medication at this time. LPN E also indicated Resident 6 did not receive pain medication prior to her treatment. On 1/18/12, at 12:25 PM Surveyor observed LPN E ask Resident 6 to rate her pain from her left leg on a scale of 0 to 10. LPN E showed Resident 6 a pain scale with numbers from 0 to 10 and faces to Resident 6. Resident 6 pointed to the number 2 on the pain scale with a corresponding smiley face. LPN E asked Resident 6 if the number 2 as LPN E was pointing to the pain scale faces was the amount of pain Resident 6 was having. Resident 6 stated yes Sunny. LPN E again asked Resident 6 to rate her pain pointing to the 2-3 on the pain scale and Resident 6 stated "I don't know" and turned her head away from LPN E and the pain scale sheet. LPN E asked Resident 6 to describe her pain if it was achy, sharp or dull. Resident 6 answered "I don't know". LPN E repeatedly asked Resident 6 to rate her pain while LPN E pointed to the 2 and 3 on the pain scale. Resident 6 was unable to verbalize her amount of pain using the pain scale. LPN E then verbalized I will put a 2 to 3 for Resident 6's pain rating. Resident 6 did not confirm her pain was at a level 2 or 3 to LPN E. LPN E did not use the PAINAD during the interview with Resident 6 to assess Resident 6's pain. LPN E left Resident 6's room and reported Resident 6's pain to LPN H as a 2 by use of the 0 to 10 pain scale. On 1/18/12, at 12:27 PM Surveyor spoke with LPN H regarding Resident 6's current pain medication. LPN H stated Resident 6 can have a [MEDICATION NAME] at 2:00 PM, but it is too early for the [MEDICATION NAME]. LPN H the indicated she was going to Give Resident 6 Tylenol 500 milligrams (mg) 2 tablets for her current complaint of pain. Resident 6's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The PAINAD scale was not used with Resident 6 prior to receiving the Tylenol. (It is important to note there are no results or effectiveness of the Tylenol documented in Resident 6's medical Record.) On 1/18/12, at 3:00 PM, Surveyor reviewed Resident 6's medical record nursing notes for an entry regarding Resident 6's pain during the treatment of [REDACTED]. Resident 6's nursing notes do not show an entry from LPN E for the day of 1/18/12. On 1/19/12, at 9:55 AM Surveyor interviewed Certified Nursing Assistant (CNA) F regarding Resident 6's pain during cares and repositioning Resident 6. CNA F stated she does ask the nurse taking care of Resident 6 if Resident 6 has had her pain medication prior to doing morning cares. CNA F also indicated even after Resident 6 receives her pain medication Resident 6 still has pain when doing her cares and with repositioning. In addition, CNA F indicated she reports to the nurse if any resident has pain with cares. On 1/19/12, at 1:00 PM Surveyor observed CNA F and CNA G reposition Resident 6 in her bed. Resident 6's head was lowered from a sitting position to a lying position. Resident 6 sat up from the lying position and with a grimacing face and grabbed her left leg and began to chant ouch. Resident 6 was rolled to her right side and CNA F placed a cloth sheet under Resident 6. Resident 6 began to moan ooh, ooh, ooh, and had a strong facial grimace and Resident 6 rubbed her left leg. Resident 6 was then rolled onto her left side. Resident 6 again with a strong facial grimace began to push back with her hand on the siderail to move her body off her left leg. Resident 6 continued to chant ooh ooh ooh while pushing back on the side rail. Resident 6's facial grimace remained throughout the turning process. CNA F indicated to Resident 6 it would be just one more minute and continued to reposition Resident 6. Resident 6 was moved off of her left leg again moaned ooh, ooh, place her head on her pillow closed her eyes and began to moan. CNA F lifted Resident 6 left leg and placed a pillow under Resident 6's leg Resident 6 yelled out "God Dammit" leaned forward and held her left leg. Resident 6 was expressing a strong facial grimace while holding her left leg. Resident 6 was covered and CNA F and CNA G left Resident 6's room. CNA F and CNA G did not ask Resident 6 if she was in pain and CNA F and CNA G did not stop the repositioning or request a nurse when Resident 6 was experiencing and showing outward signs of pain. On 1/19/12, at 2:00 PM, Surveyor spoke with DON B regarding the type of pain assessment to be used on Resident 6 due to her advanced Dementia. DON B stated Resident 6 should have the PAINAD assessment used due to her Dementia. DON B also indicated the nurses should be using the PAINAD whenever asking any resident with Dementia regarding the residents' pain. In addition, DON B indicates she would have expected LPN E to use the PAINAD assessment when assessing her pain to decide which pain medication Resident 6 would need. On 1/19/12, at 2:00 PM, Surveyor spoke with DON B regarding Resident 6's current pain management and treatment of [REDACTED]. DON B indicates she would expect a pain assessment to be completed on admission, on readmission, with any significant change of condition, and with any new onset or location of pain. DON B also indicated a pain assessment should have been done for Resident 6 when her left femur fracture occurred and again when Resident 6 developed the pressure ulcer to her left Achilles area On 1/19/12, at 2:00 PM, Surveyor spoke with DON B regarding Resident 6's current pain management and treatment of [REDACTED]. DON B stated she would expect Resident 6 to be pre-medicated prior to the treatment and when Resident 6 exhibited pain during the treatment the nurse is to stop and give pain medication and wait for the pain medication to become affective prior to continuing the treatment. In addition, DON B stated she would expect the nurse to document in the nursing notes pain with treatment and to call the physician will uncontrolled pain during a treatment or with movement. On 1/18/12 at 4:25 PM Surveyor interviewed FM (Family Member) P. FM P is Resident 6's Health Care Power of Attorney and daughter. FM P stated she visits Resident 6 between 3 - 5 times a week. FM P stated that Resident 6 screams out and grimaces when she is in pain. FM P stated that she did not think Resident 6 could state that she was in pain. On 1/19/12 at 1:15PM Surveyor interviewed CNA (Certified Nursing Assistant) G. CNA G stated during cares observed by Surveyor on 1/19/12 at 1:00 PM, Resident 6 pushed back when being turned. CNA G stated she believed Resident 6 was in pain at that time. CNA G stated when she notices that Resident 6 is in pain she tells the nurse.

Based on observation, interview, record review and a review of the facility's policy and procedure related to pressure ulcers, the facility did not ensure that 1 of 10 (Resident 6) sampled residents having pressure ulcers or were at risk for pressure ulcers, received necessary treatment and services to promote healing. Resident 6 developed a suspected deep tissue injury over her left Achilles area on 11/16/11, after a leg brace was applied following a femur fracture on 10/16/11. Resident 6's left leg was casted with a full leg cast on 11/22/11, covering the deep tissue injury on the Achilles area. On 12/6/11 an odor was documented, the orthopedic physician was updated and on 12/8/11 the wound was observed by the orthopedic physician who indicated to the facility that if and when the cast became smelly enough he would window the cast again to check the wound if necessary. On 12/28/11 charting indicated an odor was noted coming from the cast area. The primary care physician was notified 1/12/12, the orthopedic physician was notified 1/17/12, as Resident 6 had a previously scheduled appointment with him on this date. On 1/17/12 the cast was removed and left Achilles area had developed to a Stage 4 pressure ulcer. Resident 6's left Achilles area was observed to be lying directly on the mattress on 3 occasions during the 3 day survey period from 1/17/11 - 1/19/11. The facility did not: develop a complete and accurate care plan related to monitoring the cast for odor or changes in the left Achilles area; document any monitoring of the cast for changes; promptly notify information to the physician regarding changes in the cast odor; and, follow orders after the cast was removed to keep pressure off the left Achilles area. Evidenced by: The facility's Pressure Ulcer Policy, dated 5/01, with the newest revision date of 3/07, documents the following: - Purpose: To provide appropriate assessment and prevention of pressure ulcers as well as treatment when necessary - Policy: Based on the resident's comprehensive assessment, the center will utilize prevention and assessment interventions to ensure that a resident entering the center without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable. A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Residents will receive appropriate assessments and services to promote and maintain skin integrity... The AMDA (American Medical Directors Association) Pressure Ulcers in the Long-Term Care Setting Clinical Practice Guideline, 2008, includes the following: Step 8 Manage pressure. Proper positioning, turning and transferring techniques are important to manage pressure and shearing forces, ensure weight redistribution on support surfaces, and protect uninvolved skin ... Patients who have or are at risk of developing heel ulcers (e.g. (such as), postoperative hip or knee surgery patients) will require offloading or pressure-redistribution devices (e.g., heel boot, heel elevator, heel lift, suspension boot, or a device that "floats" the heel) to relieve pressure on the heels and prevent skin breakdown ... Resident 6 was originally admitted to the facility on [DATE] and readmitted to 10/21/11 after a hospitalization following a femur fracture. Resident 6's [DIAGNOSES REDACTED]. Resident 6's MDS (Minimum Data Set) with an ARD (Assessment Reference Date, 10/28/11 includes the following: Cognitive Status, Summary Score = 4, indicating severe impairment. On 1/17/12 at 4:00 PM Surveyor observed Resident 6 lying in bed with both heels directly on the mattress. Resident 6's left heel area was wrapped with a dressing. On 1/18/12 at 3:50 PM Surveyor observed Resident 6 lying in bed with both heels directly on a pillow. Resident 6's left heel area was wrapped with a dressing. On 1/18/12 at 8:10 AM Surveyor reviewed Resident 6's medical record. The following information was found. Resident 6's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 11/21/11, had a score of 15, meaning moderate risk. The Braden Scale Reference Tool included the following interventions at the level of moderate risk: pressure reduction support surface, protect heels... Resident 6's Alteration in skin integrity R/T (related to) L (left) Achilles included the following: 2 Monitor status of ulcer, surrounding skin and dressing, 5. Provide support surfaces as appropriate (list). (There is nothing listed here on the care plan.) Resident 6's Orthopedic Physician Encounter Note Addendum, dated 12/19/11, included the following: ... the patient (Resident 6) on 11/22/11 had a long leg cast applied at that time with appropriate padding ... a sore had been noted over the distal Achilles/heel area, this from the universal knee brace that kept her out in extension ... A few days later, I also talked with the head of nursing at the nursing facility, and explained this treatment to her as being a medically indicated treatment and actually the most desirable given the circumstances. I indicated to her that if and when the cast became smelly enough, we would window the cast to check the wound if necessary... Resident 6's Interdisciplinary Progress Notes included the following: 12/6/11, 1440 (2:40 PM), Today it was noticed a foul odor coming from the top of the cast, called (Orthopedic Physician's name) office and spoke with (nurse's name) who will give the message to him ... 12/8/11, 5:00 PM, Returned from (Orthopedic Physician's name) appt (appointment) to check wound under cast... It is important to note the Director of Nursing was present at the 12/8/11 physician's appointment. Resident 6's Physician's Encounter Note, dated 12/8/11, included the following: The patient comes today for a check of her long leg cast ... The cast has started smelling lately, and she comes in specifically for a check on this ... A window in the cast was made over the distal Achilles and heel area. Indeed the cast lining was odiferous, however the wound was absolutely "clean" as is typically seen under a cast. The patient does have skin loss down to the Achilles, but it is intact, some areas has granulation tissue growing through the Achilles tendon itself... Resident 6's Interdisciplinary Progress Notes included the following: 12/28/11, 5:45 AM...odor noted from cast area. 1/12/12, 1630 (4:30 PM),...faxed to (Primary Physician's name) (with) update and also that bottom of heel left cast spongy. It is important to note that this is the first time a physician was made aware of a change in the cast as noted on 12/28/11. 1/13/12, 5:00 PM, (Primary Physician's name) ... also f/u (follow up) with (Orthopedic Physician's name) for cast, which she has appt on Tue (Tuesday), Jan (January), 17... 1/16/12, 12:00 PM, Discussed with (Primary Physician's name) the odor from the cast while she was on rounds examining patient and informed her of appt with (Orthopedic Physician's name) tomorrow. We discussed that (Orthopedic Physician's name) choose to keep wound covered by the cast and last month she had an odor too which upon exam the wound looked healthy, that (Orthopedic Physician's name) said odor is to be expected but healing is in progress 1/17/12, 1600 (4:00 PM), Res (resident) returned from appt with (Orthopedic Physician's name), cast removed, new orders noted ... L Achilles has strong odor, tendon noted, 75% slough, minimal yellow drainage surrounding tissue pink and intact ... Resident 6's Clinic Referral (For visits to Doctor or Hospital Outpatient), dated 1/17/12, included the following odors: 1. Dressing change wet to dry daily or bid (twice a day) on L heel Achilles area. 2. Bed rest for 2 wks (weeks). 3 Do not "handle patient" by pressure on LLE (left lower extremity). 4 Consult gen (general) surgery ... for evaluation and Rx (treatment) of wound L heel area. 6. Pillow under left calf to keep heel off of bed. Resident 6's physician's orders [REDACTED]. It is important to note that Resident 6's chart did not contain documentation of any cast monitoring. On 1/19/12 at 1:45 PM Surveyor interviewed DON (Director of Nursing) B. DON B stated she would expect the nursing staff to do an assessment of the cast, including if there were any odors. DON B stated that no documentation could be found in Resident 6's medical record of monitoring of the cast. DON B stated that she would expect the nurse to update the physician when the cast odor was noted on 12/28/11. Resident 6 had a known deep tissue injury with an open area over her left Achilles area prior to a long leg cast being applied to the left leg on 11/22/11. The Orthopedic Physician contacted the Director of Nursing stating if the cast became smelly he would check the wound. No care plan was written or documentation completed of any monitoring of the cast for changes. The cast was noted to have an odor on 12/6/11. The Orthopedic Physician cut a window in the cast to observe the wound on 12/8/11. The cast was again noted to have an odor on 12/28/11. A physician was not informed of the odor until the Primary Physician was informed of the odor 1/12/12. The Orthopedic Physician was informed of the odor on 1/17/12, when Resident 6 went to a previously set up appointment to see the Orthopedic Physician. On 1/17/12 Resident 6 had the cast removed; the wound at the Achilles area was now at a Stage 4. After the cast was removed 3 observations were made, during the survey, of the left Achilles area being directly on a surface after the physician ordered a pillow under the left calf to keep the heel off the bed. Resident 6's clinic referral note, dated 1/17/12, indicates the following. 1. Problems to be evaluated: Left leg cast follow-up for a fracture. The left leg cast is odorous and mushy at the heel. 2. Physician orders: Pillow under Resident 6's left calf to keep the heel off the bed. On 1/18/12, at 11:50 AM, Surveyor observed Licensed Practical Nurse (LPN) E perform a treatment on Resident 6's stage 4 pressure ulcer to her left Achilles area. LPN E Remove the soiled wet to dry dressing from Resident 6's left Achilles area. Resident 6's left Achilles area was present with a strong foul odor. LPN E soaked each dressing with wound cleanser prior to removal of the wet to dry dressing used for wound debridement. LPN E the cleansed Resident 6's Achilles pressure ulcer area with the wound cleanser. Resident 6's left Achilles pressure ulcer measured approximately 3 centimeters (cm) by 3 cm. Resident 6's left Achilles pressure ulcer was completely encircled by red swollen tissue approximately 1 cm in width. Resident 6's left Achilles pressure ulcer was visually present with approximately 50% dark green slough. LPN E applied normal saline to 2 dry 4 x 4 dressing and saturated both dressings. LPN E then applied both saline saturated dressings to Resident 6's entire back ankle area covering the 3 cm by 3 cm pressure ulcer and Resident 6's intact skin surrounding Resident 6's pressure ulcer. LPN E wrapped the left lower leg with a gauze wrap. On 1/18/12, at 12:07 PM, Surveyor observed LPN E place Resident 6's entire back ankle to include the Achilles area on the edge of a pillow to elevate Resident 6's heel. Resident 6's pressure ulcer was lying directly on the edge of the pillow and Resident 6's left heel was lying on the bed over the end of the pillow. Resident 6's right heel was lying directly on the mattress. LPN E covered Resident 6 and left the room On 1/18/12, at 3:24 PM, Surveyor observed Resident 6 lying in bed with her feet uncovered and exposed. Resident 6's left Achilles pressure ulcer was lying pressed against the edge of a pillow and her left heel was lying directly on the mattress. Resident 6's left Achilles area was not elevated to relieve pressure from the stage 4 pressure ulcer to the Achilles area. On 1/19/12, at 2:00 PM, Surveyor spoke with Director of Nursing (DON) B regarding Resident 6's pressure ulcer to her left Achilles. DON B stated as of 12/8/11 Resident 6's pressure ulcer is a Stage 4. DON B stated she attended the physician visit with Resident 6 and viewed her left Achilles to see the pressure ulcer was visual to the tendon. DON B also indicated Resident 6 was receiving a wet to dry dressing for debridement of Resident 6's pressure ulcer and the soiled dressing to Resident 6's left Achilles pressure ulcer should be removed dry to debride the tissue. In addition, DON B indicated Resident 6's entire pressure ulcer and heel should be floated from the bed and the pillow should not rest on Resident 6's pressure ulcer.