Every finding on record at Dove Healthcare - Lodi

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infection for 2 or 3 residents (R5 and R2) reviewed for infection control with personal cares out of the sample of 5 residents. CNA C (Certified Nursing Assistant) had a breach in infection control when performing pericare (cleansing of the genital area). LPN D (Licensed Practical Nurse) had a breach in infection control when performing perineal care for R2. Evidenced by: The facility's Hand Hygiene policy, dated 12/24, states, in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand Hygiene Table Condition: .After handling contaminated objects.After handling items potentially contaminated with blood, body fluids, secretions, or excretions.After assistance with personal body functions (eg. Elimination, hair grooming, smoking) . Example 1: On 7/14/26 at 10:10 AM, Surveyor observed CNA C (Certified Nursing Assistant) performing pericare for R5. CNA C donned gloves and cleansed R5 of stool. Without the removal of gloves and without hand hygiene being performed CNA C opened the bedside cabinet, obtained a tube of barrier cream, applied barrier cream to R5's bottom, then applied a clean incontinence brief. CNA C moved a package of cleansing wipes from R5's bed, repositioned R5's bed linens, and adjusted the bed using the bed controller. Surveyor asked CNA C if gloves are contaminated after performing pericare. CNA C stated yes. Surveyor asked CNA C about infection control with pericare. CNA C stated I should have removed my gloves after pericare, before touching other things. Example 2: On 7/14/26 at 8:52 AM, Surveyor observed LPN D perform perineal care for R2 while she was lying down in bed after having wound care completed. LPN D was wearing a gown and gloves. LPN D used two wipes to clean R2's perineal area and R2's brief was changed. LPN D proceeded to assist R2 with repositioning in bed, adjusted R2's bedding, and moved items closer to R2's bedside. On 7/14/26 at 9:12 AM, Surveyor asked LPN D if she should have changed her gloves and completed hand hygiene after completing perineal care for R2. LPN D said yes. On 7/14/26 at 11:00 AM, Surveyor interviewed DON B (Director of Nursing) and asked about infection control with pericare. DON B stated you need to wash hands and apply gloves, then remove gloves appropriately. You don't go from dirty to clean without a change; you need to change gloves and wash hands to ensure that you don't get clean things dirty. Surveyor asked if staff are to have clean hands prior to touching clean brief, bedside cabinet, barrier cream, linens, bed control. DON B stated yes.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 46 residents who reside in the facility.Surveyor observed kitchen staff directly touching food with dirty gloves.Surveyor observed kitchen staff not properly disinfecting thermometer while taking the temperature of food.Evidenced by:The facility policy, Food Safety Requirements, dated 6/2025, states, in part;.7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects.b. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas.The facility policy, Record of Food Temperatures, dated 3/2024, states, in part;.14. Food temperatures will be verified using a thermometer which is both clean, sanitized and calibrated to ensure accuracy.Example 1On 2/16/26 at 11:41AM, Surveyor observed [NAME] K wash his hands and put on gloves. Surveyor observed [NAME] K touch his neck, pants, multiple papers and then directly touch a hotdog with same gloves on. Surveyor observed [NAME] K while wearing a different pair of gloves touching the microwave, his pants, and then directly touching bread that was being served for lunch.On 2/17/26 at 11:30 AM, [NAME] K indicated you should use clean gloves or tongs when directly touching food. [NAME] K indicated if you touch other items around the kitchen with gloves on you must take off gloves, wash hands, and then put a clean pair of gloves on if you have to directly touch food.Example 2On 2/16/26 around noon, Surveyor observed [NAME] K taking the temperature of a hotdog. [NAME] K took out a thermometer; he temped the hotdog and then directly temped a hamburger. [NAME] K then rinsed the thermometer under running water and placed the thermometer back in the case. [NAME] K failed to properly sanitize the thermometer between food items.On 2/17/26 at 11:12 AM, Surveyor observed [NAME] L temping food. [NAME] L took a thermometer and temped the chicken. [NAME] L then rinsed the thermometer with running water and put thermometer back in case. [NAME] L failed to properly sanitize the thermometer.On 2/17/26 at 12:40PM, Nutritional Service Director J (NSD), indicated staff must use tongs or clean gloves if they have to directly touch food. NSD J indicated staff must properly sanitize thermometers after each use. NSD J indicated understanding of the above concerns.On 2/18/26 at 1:14PM, Nursing Home Administrator A (NHA) indicated staff should wear clean gloves when directly touching food. NHA A indicated staff should sanitize thermometer after each use. NHA A indicated understanding of the above concerns.The facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed.

Based on observation, interview, and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), and each resident with pressure injuries (PI) receives necessary treatment and services, consistent with professional SOP, to promote healing, and prevent infection for 1 of 3 residents (R1) reviewed for PI out of a sample of 16 residents.R1's PIs were not cleaned properly during wound care and R1's PI care was not completed per physician orders.This is evidenced by:The facility's policy Wound Treatment Management, dated 2/26, includes: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Reference: European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance.The facility's policy Pressure Injury Prevention and Management, dated 2/26, includes: 4. Interventions for Prevention and to Promote Healing. d. Evidenced-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present.The facility's Dressing Change Competency observation list, undated, includes: 9. Cleanse wound per MD (Medical Doctor) order, working from inside out and pat dry with clean 4x4 (gauze). 13. Apply prescribed dressing, and secure per MD order.R1 admitted to the facility on [DATE] and has a diagnosis of pressure ulcer.R1's BIMS (Brief Interview for Mental Status), dated 1/9/26, has a score of 15, indicating R1 is cognitively intact.Pressure Injury 1R1's wound care notes, dated 2/13/26, written by MD I, includes:Stage 4 pressure wound (a full-thickness wound extending through the skin to expose muscle, tendon, or bone) of the left ischium. Wound Size: 11 x 3 x 4 cm. Exudate (drainage): Moderate Sero-sanguinous (moderate amount of thin, water, and pale red/pink drainage). Dressing Treatment Plan Primary Dressing(s) Sodium hypochlorite solution (dakins) apply once daily for 9 days. Secondary Dressing(s) ABD pad (a highly absorbent, multi-layered dressing designed for managing wounds with heavy drainage) apply once daily for 9 days: vs silicone border dressing.R1's physician orders for January 2026, includes: Wound care to lt. (left) ischium: Cleanse with antibacterial soap and water using a washcloth, rinse completely and pat dry with clean wash cloth or towel. Wet to moist kerlix packing. Ensure a long tail and complete removal of prior packing before packing more. Cover with silicone dressing or abd. Change daily and prn (as needed) start date 1/3/26.Pressure Injury 2R1's wound care notes, dated 2/13/26, written by MD I, includes:Stage 4 pressure wound Coccyx. Wound Size: 2 x 2 x 2 cm. Exudate: Moderate Sero-sanguinous. Dressing Treatment Plan Primary Dressing(s) Sodium hypochlorite solution (dakins) apply twice daily for 9 days. Secondary Dressing(s) ABD pad apply twice daily for 9 days: vs silicone border dressing.R1's physician orders for January 2026, includes: Wound care to coccyx.: Cleanse with antibacterial soap and pat dry. Use 2 inch kling (rolled gauze) moistened with dakins solution and lightly pack Change twice daily and PRN. start date 1/3/26.Pressure Injury 3R1's wound care notes, dated 2/13/26, written by MD I, includes:Stage 4 pressure wound of the right hip. Wound Size: 3 x 4 x 1.5 cm. Exudate: Moderate Sero-sanguinous. Dressing Treatment Plan Primary Dressing(s) Sodium hypochlorite solution (dakins) apply twice daily for 9 days. Secondary Dressing(s) ABD pad (a highly absorbent, multi-layered dressing designed for managing wounds with heavy drainage) apply twice daily for 9 days: vs silicone border dressing.R1's physician orders for January 2026, includes: Wound care to . rt (right hip): Cleanse with antibacterial soap and pat dry. Use 2 inch kling (gauze wrap) moistened with dakins solution and lightly pack Change twice daily and PRN. start date 1/3/26.(Of note: R1's Pressure injuries have been present greater than a year)On 2/17/26 at 10:32 AM, Surveyor observed R1's wound care that was provided by LPN F (Licensed Practical Nurse) and LPN C. LPN F provided the wound care while LPN C was repositioning and assisting R1. Surveyor observed LPN F remove the abd (abdominal) pads that were covering R1's ischium and coccyx PIs. LPN F removed the kerlix packing from R1's ischium and coccyx PIs. LPN F used a soapy washcloth and wiped over top of R1's PIs without cleansing the wound beds of the ischium and coccyx PI. LPN F covered R1's ischium and coccyx PIs with silicone border dressings. LPN F removed R1's right hip dressing. Surveyor observed the dressing to contain a moderate amount of exudate on the old dressing and exudate on the wound bed of R1's right hip PI. LPN F used a soapy washcloth and wiped over top of R1's right hip PI. LPN F packed R1's right hip PI with dakins soaked kerlix while there was still exudate on the wound bed of R1's right hip PI. LPN F covered the wound with a silicone border dressing.On 2/17/26 at 11:40 AM, Surveyor interviewed LPN F. Surveyor asked LPN F about cleansing the wound bed of wounds prior to redressing the wounds and asked if the wound beds should also be washed prior to packing the wounds. LPN F indicated the dakins cleanses the wound bed because it has bleach in the solution. Surveyor asked LPN F about the exudate that was left on the wound bed of R1's right hip. LPN F indicated that's all they are supposed to do because of the dakins.On 2/17/26 at 1:02 PM, Surveyor interviewed MD I regarding wound care. MD I indicated the wound bed should be cleansed prior to dressing the wounds, stating cleansing the wound bed before the wound is dressed is fundamentals of wound care.On 2/17/26 at 1:43 PM, Surveyor interviewed LPN F regarding R1's wound care. Surveyor asked LPN F what standard of practice the facility uses for wound care. LPN F indicated she was unsure of the standard of practice but follows the doctor's orders. Surveyor asked LPN F if cleansing the wound bed would be a standard of practice and LPN F indicated it is a standard to cleanse the wound bed, but it would depend on the order. LPN F indicated she did not cleanse the wound bed because that's what the order states and she just did what the order said to do. Surveyor asked LPN F if an abd pad should have been used per MD I's order instead of a silicone border dressing. LPN F indicated she did not believe she should have used an abd pad since she had previously seen MD I use the silicone border dressings before, and the silicone border dressings is what is supplied for R1.On 2/17/26 at 1:58 PM, Surveyor interviewed LPN C. LPN C indicated she frequently rounds with MD I when he is doing wound rounds. Surveyor asked LPN C what standard of practice the facility uses for wounds and PIs. LPN C indicated she was unsure what standards of practice the facility uses. LPN C indicated the wound bed should be cleansed prior to applying the new dressing. LPN C reviewed MD I's orders regarding applying an abd vs silicone border dressing and indicated R1 should have had an abd applied and not the silicone border dressing.On 2/17/26 at 2:05 PM, Surveyor interviewed ADON E (Assistant Director of Nursing). ADON E indicated she reviewed MD I's notes after MD I performs wound rounds. ADON E indicated she updates the orders in the electronic health record based on MD I's orders. ADON E indicated, while reviewing MD I's wound round notes from 2/13/26 with the surveyor, ADON E did not enter the order correctly. ADON E stated she misunderstood MD I's order of abd pad vs silicone border dressing and thought the facility could use either the abd pad or silicone border dressing.On 2/17/26 at 2:14 PM, Surveyor interviewed DON B (Director of Nursing) regarding wound care. DON B indicated the standard of practice is in the PI policy. DON B indicated a wound bed should be cleansed prior to applying a dressing. DON B indicated the facility should be following doctor's orders including the types of dressings used for wound care.

Based on interview and record review, the facility did not ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for 1 of 1 residents (R3) reviewed out of 16 sampled residents.R3 has a diagnosis of obsessive compulsive disorder (OCD) her comprehensive care plan does not include known triggers, resident specific goals, or personalized interventions related to her OCD.This is evidenced by:The facility's policy Trauma Informed Care, dated 12/24, includes: Purpose: To provide guidance to staff regarding provision of care and services to residents who have experienced trauma. Policy: It is the policy of [Facility] to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The facility will work to facilitate the principles of.care which include: b. trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident. c. Peer support and mutual self-help - If practicable, assist the resident in locating and arranging to attend support groups. d. Collaboration - an emphasis on partnering between residents and/or their family or representative, and all staff and disciplines involved in the resident's care in developing their individualized plan of care. e. Empowerment, voice and choice - Ensuring that resident's choice and preferences are honored and that resident's are empowered to be active participants int heir care and decision-making, including recognition of, and building on resident's strengths. The facility will use a multi-pronged approach to identifying a resident's history of trauma. This will include asking the resident about triggers that may be stressors or may prompt recall of a pervious traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the residents care plan. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.R3 admitted to the facility on [DATE] with diagnoses including obsessive compulsive disorder.R3's Brief Interview for Mental Status (BIMS), dated 1/9/26, has a score of 15, indicating R3 is cognitively intact.R3's level II PASRR (Preadmission Screening and Resident Review), dated 9/3/24, includes: Reason for referral: .was referred to BCS with a diagnosis of .OCD. First Criterion: Does the person have a major mental disorder meeting the diagnostic requirements in DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition).? Yes.OCD . Second Criterion: Has the person's functioning, as a result of the mental disorder, been limited continuously or intermittently during the past three to six months in at least one of the following areas of major life activity? Yes. Adaptation to change. She does not deal well with change in routine. She is very particular regarding how things are done; if told ahead of time adjusts better.R3's comprehensive care plan, printed 2/18/25, does not include R3's OCD, triggers, or interventions related to R3's OCD.On 2/17/26 at 4:03 PM, Surveyor interviewed CNA G (Certified Nursing Assistant). CNA G indicated R3 likes to micromanage her care and likes things done a particular way. CNA G indicated R3 will become upset if she has to repeat herself and it can be very stressful for R3. On 2/17/26 at 4:06 PM, Surveyor interviewed CNA H. CNA H indicated he has a good rapport with R3. CNA H indicated R3 can be demanding and does display OCD behaviors. CNA H indicated R3 is particular about how things should be done. CNA H indicated he listens to R3 and completes the tasks per her preference.On 2/18/26 at 9:08 AM, Surveyor interviewed SS D and NHA A (Nursing Home Administrator) regarding R3's OCD. Surveyor asked SS D and NHA A how staff are caring for R3 in relation to her diagnosis of OCD. SS D and NHA A indicated staff utilize R3's care plan. NHA A indicated R3 is very vocal and able to voice her concerns. SS D and NHA A indicated the care plan does not have details related to R3's OCD. NHA A indicated R3 has a routine and can take staff more than an hour to complete her morning routine. NHA A indicated R3's routine is very precise and has a preference. NHA A stated, for example, R3 is detailed on how she wants her socks, pillows placed, and hand placement and things like that. SS D and NHA A indicated R3's OCD behaviors and interventions should be part of R3's care plan.

Based on interview and record review, the facility did not ensure trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 residents (R3) reviewed for trauma informed care out of a sample of 16 residents. R3 has a diagnosis of PTSD (Post Traumatic Stress Disorder) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions.This is evidenced by:The facility's policy Trauma Informed Care, dated 12/24, includes:Purpose: To provide guidance to staff regarding provision of care and services to residents who have experienced trauma. Policy: It is the policy of [Facility] to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The facility will use a multi-pronged approach to identifying a resident's history of trauma. This will include asking the resident about triggers that may be stressors or may prompt recall of a pervious traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the residents care plan. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.R3 admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD).R3's Brief Interview for Mental Status (BIMS), dated 1/9/26, has a score of 15, indicating R3 is cognitively intact.R3's level II PASRR (Preadmission Screening and Resident Review), dated 9/3/24, includes: Reason for referral: .was referred to BCS with a diagnosis of .PTSD. First Criterion: Does the person have a major mental disorder meeting the diagnostic requirements in DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition).? Yes.PTSD. Second Criterion: Has the person's functioning, as a result of the mental disorder, been limited continuously or intermittently during the past three to six months in at least one of the following areas of major life activity? Yes. Adaptation to change. She does not deal well with change in routine. She is very particular regarding how things are done; if told ahead of time adjusts better.On 2/18/26 at 9:12 AM, Surveyor requested R3's trauma assessment. SS D (Social Services) indicated R3 did not have a trauma assessment.R3's comprehensive care plan, printed 2/18/25, does not include R3's PTSD, triggers, or interventions to prevent re-traumatization.The facility provided a resolved care plan for R3 with a discontinued date of 10/27/25 that includes: Focus: I have a behavior problem r/t (related to) anxiousness, restlessness and panic d/t (due to) depression, chronic pain and new living environment, agoraphobia, PTSD. Goal: I will have fewer episodes of anxiousness, restlessness and panic fewer them [sic] once per week.Interventions: Explain all procedures before starting and allow adequate time to adjust to changes.On 2/17/26 at 4:03 PM, Surveyor interviewed CNA G (Certified Nursing Assistant). CNA G indicated R3 likes to micromanage her care and likes things done a particular way. CNA G indicated R3 will become upset if she has to repeat herself and it can be very stressful for R3. CNA G was not aware of R3's PTSD, triggers, or interventions.On 2/17/26 at 4:06 PM, Surveyor interviewed CNA H. CNA H indicated he has a good rapport with R3. CNA H indicated R3 has mentioned she had experiences in the past but did not go into detail about her PTSD with him. CNA H was not aware of any triggers or interventions related to R3's PTSD.On 2/18/26 at 9:08 AM, Surveyor interviewed SS D and NHA A (Nursing Home Administrator) regarding R3's PTSD. NHA A indicated there is a trauma assessment the facility uses if something occurs with a resident. NHA A indicated a diagnosis alone would not be reason enough to complete a trauma assessment for a resident. SS D indicated a resident newly admitted to the facility may not want to discuss their trauma and the facility would not want to open old wounds. Surveyor asked SS D and NHA A how the facility would know a resident's triggers if the facility does not assess or ask the resident. NHA A indicated the facility would not know the resident's triggers until something triggers the trauma. SS D indicated they may open up to the facility after their trauma is triggered by an event. Surveyor asked SS D and NHA A how staff are caring for R3 in relation to her diagnosis of PTSD. SS D and NHA A indicated staff utilize R3's care plan. NHA A indicated R3 is very vocal and able to voice her concerns. SS D and NHA A indicated they did not know R3's triggers and indicated the care plan does not list the triggers or interventions. SS D and NHA A indicated R3's PTSD, triggers, and interventions should be part of R3's care plan.R3 did not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions.

Based on observation, interview, and record review, the facility did not ensure food was served in a manner that conserved palatability and temperature for 1 resident (R30) and one test tray.R30 voiced concern regarding hot food being served cold. Surveyor's test tray temped cold.Evidenced by:The facility policy, Record of Food Temperatures, dated 3/24, states, in part;.2. Hot foods will be held at 135 degrees Fahrenheit or greater.11. No food will be served that does not meet the food code standard temperatures.On 2/17/26 at 9:58 AM, R30 voiced concerns regarding food temperatures and palatability. On 2/18/26 at 12:31PM, Surveyor followed back up with R30. R30 indicated she eats in her bedroom, and she is down the hallway that gets served room trays first. R30 indicated that her hot food is often served cold and she is one of the first served so the rest of the trays must be cold as well. R30 indicated she has heard other residents voice concerns regarding the food temperatures as well.On 2/18/26 at 12:21 PM, Surveyor received test tray. The meat/peppers/cheese sandwich temperature was 110.4. The potatoes temped at 107.9. The food was not palatable and tasted cold.On 2/18/26 at 1:14 PM, Nursing Home Administrator A (NHA) indicated hot foods should be served hot. NHA A indicated food temperatures are something they have been working on and realize it is an issue. NHA A indicated she understands the above concern.The facility did not ensure food was served in a manner that conserved palatability and temperature.

Based on record review, interview, and facility document review, the facility failed to prevent significant medication errors for two out of a total of five residents reviewed for medication administration (R2, and R3) out of a total sample of 13 residents. This failure had the potential for R2 and R3 to experience adverse reactions from receiving a wrong medication or wrong dosage of medication that was not prescribed for R2 and R3. Findings include: Review of the facility's policy Medication Administration dated 01/01/25 indicated, .Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation [sic] .Compare medication source (bubble pack, vial, etc.) with the MAR [Medication Administration Record] to [NAME] resident name, medication name, form, route, and time . 1.Review of R1's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] with the diagnosis of diabetes mellitus. Review of R1's Physician Orders located under the Orders tab in the EMR indicated R1 had an order dated 04/17/25 Insulin Lispro Injection 100 Unit/ML (milliliter) Inject 12 units subcutaneously two times a day at lunch/dinner. Review of R2's undated Face Sheet located under the Profile tab in the EMR indicated R2 was admitted to the facility on [DATE] with the diagnosis of diabetes mellitus, chronic respiratory failure, and stroke. Review of R2's Physician's Orders located under the Orders tab in the EMR indicated R2 had an order dated 04/23/24 for Insulin Glargine Solution Inject 18 units subcutaneously in the morning daily. R2 also had an order dated 04/23/24 for blood sugar checks one time a day every Sunday. Review of R2's Medication Administration Record dated April 2025 indicated R2 had received Glargine insulin 18 units subcutaneously at approximately 8:00 AM each day. R2's blood sugars were obtained at approximately 8:00 AM each day and ranged from 67 to 92. Review of the Medication Error Investigation dated 04/30/25 at 6:00 PM, RN1 asked the Certified Nursing Assistant (CNA) what the resident's name was. CNA stated it was [R1]. RN1 proceeded to give R2, who she thought was R1, Lispro 11 unit subcutaneously. Later RN1 recognized she had given the insulin to R2 instead of R1, which was the wrong resident. At 7:00 PM, RN1 checked R2's blood sugar and it was 118. Snacks were given. R2's blood sugar was again checked at 10:30 PM, at which time the blood sugar was 106 and R2 was easily awakened. No further interventions were documented in the electronic medical record for R2. Further review of the Medication Error Investigation indicated the physician was notified of the error on 04/30/25 at 9:30 PM with no documentation stating if the physician ordered any further monitoring for R2. Education was documented as being completed on 04/30/25 with RN1 that consisted of printing off a . document that goes over the 6 [sic] rights of medication administration and went over it with the RN [RN1] who made the medication error . educated RN [RN1] on importance of updating NP/MD for advisement of treatment and reporting the error. During an interview on 06/12/25 at 6:40 PM, RN1 stated, I gave the insulin to the wrong patient. I should have given the insulin to [R1]. Instead, I gave it to [R2]. 2. Review of R3's undated Face Sheet located under the Profile tab in the EMR indicated R3 was admitted to the facility on [DATE] with the diagnosis of Alzheimer's Disease, and anxiety disorder. Review of R3's Physician's Orders located under the Orders tab in the EMR indicated R3 had an order dated 10/18/24 for Alprazolam 0.25 mg (milligram) Give 0.25 mg by mouth in the morning for anxiety. Review of R8's undated Face Sheet located under the Profile tab in the EMR indicated R8 was admitted to the facility on [DATE] with the diagnosis of panic disorder and anxiety disorder. Review of R8's Physician's Orders located under the Orders tab in the EMR indicated R8 had an order dated 11/15/24 for Lorazepam 1 mg 0.5 tablet by mouth three times a day for anxiety. Review of the Medication Error Investigation dated 01/17/25 indicated, During the morning medication pass I [Registered Nurse (R)2] pulled Lorazepam 0.5 mg tablet accidentally from another resident's medication [R8] rather than pulling resident's scheduled Alprazolam 0.25 mg. As soon as medication error was realized VS [vital signs] [sic] were assessed and error was reported. Further review of the Medication Error Investigation indicated the on-call physician was notified of the medication error on 01/17/25 at 3:05 PM with no documentation stating if the physician ordered any further monitoring for R3. During an interview on 06/13/24 at 11:05 AM, the DON stated, Education was given to [RN2] on the six rights of safe medication administration and an information print out of potential look alike sound alike drug names were also given. During an interview on 06/13/25 at 5:15 PM, RN2 stated, I know it was extremely busy that morning and I had a lot of distractions. I pulled the Lorazepam from [R8's] card and gave it to [R3] by mistake. At shift change is when the count was off for Lorazepam is when I realized what had happened. Asked RN2 what the milligram of Lorazepam she administered to R3 and RN2 stated, Whatever the order was for [R8] I gave it to [R3]. 3. Review of R3's undated Face Sheet located under the Profile tab in the EMR indicated R3 was admitted to the facility on [DATE] with the diagnosis of Alzheimer's Disease, and anxiety disorder. Review of R3's Physician's Orders located under the Orders tab in the EMR indicated R3 had an order dated 10/18/24 for Alprazolam 0.25 mg (milligram) Give 0.25 mg by mouth in the morning for anxiety. Review of R9's updated Face Sheet located under the Profile tab in the EMR indicated R9 was admitted to the facility on [DATE] with the diagnosis of anxiety disorder. Review of R9's Physician Orders located under the Orders tab in the EMR indicated R9 had an order dated 11/04/24 for Alprazolam 0.5 mg give one tablet by mouth three times a day for anxiety. Review of the Medication Error Report dated 10/21/24 indicated on 10/19/24 [Licensed Practical Nurse (LPN)3] administered Alprazolam 0.5 mg to [R3] instead of administering Alprazolam 0.25 mg to [R3]. LPN3 stated she took the medication from [R9's] medication card and gave it to [R3]. During an interview on 06/13/25 at 10:40 AM, the Director of Nursing (DON) stated, For anyone that makes a medication error I go over the five rights of medication administration. Was asked if there were any audits, or medication administration observations that were done after any of the medication errors that were reviewed and the DON stated, No, there wasn't. The DON was asked if the facility had a phone number for [LPN3] and she stated, We don't have any contact information on file for [LPN3]. During an interview on 06/13/25 at 8:29 PM, the (DON) was asked what her expectations were when a nurse administered a medication. The DON stated, I expect them to follow the ten rights of medication administration which are the right resident, right medication, right dose, right route, right time, right documentation, right reason, right response, right education, and right to refuse.

Based on observation, interview, record review, and facility policy review, the facility staff failed to document monitoring of the temperatures for the freezers and refrigerators located in the kitchen, document monitoring of the temperature and sanitizing solution for the dish machine, date numerous spices with open dates, and maintain the tile kitchen flooring. This failure had the potential to negatively impact all 47 residents currently residing in the facility who ate food from the kitchen. Findings include: Review of the facility's policy titled, Monitoring of Cooler/Freezer Temperature, dated 06/15/23, revealed, Policy: It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety . Policy Explanation and Compliance Guidelines:1 . a. Temperatures will be checked and logged at least twice per day by designated personnel . Review of the facility's policy titled, Dishwasher Temperature, dated 06/15/23, revealed, Policy: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. Policy Explanation and Compliance Guidelines: 1. All items in the dishwasher will be washed in water that is sufficient to sanitize any and all items . 4. For low temperature dishwashers (chemical sanitizations): a. The wash temperature shall be 120 degrees Fahrenheit. B. The sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse . 6. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes . Observation on 9/26/24 at 12:30 PM, in the kitchen, indicated the temperature logs for the two freezers and two refrigerators were not completed for the AM and PM on a daily basis. Findings were as follows for the past five months: May - 31 days of temperatures not being recorded for the AM; June - 30 days of temperatures not being recorded for the AM; July - 31 days of temperatures not being recorded in the AM; August - three days of temperatures not being recorded for the AM and PM, 28 days of temperatures not being recorded for the PM; September - three days of temperatures not being recorded for the AM and PM, nine days of temperatures not being recorded for the AM, seven days of temperatures not being recorded for the PM. Observation on 9/26/24 at 12:40 PM in the kitchen indicated the temperature and chemical logs for the dish machine were not completed in the AM and PM on a daily basis. Findings were as follows for the past six months: April - five days of temperatures and chemical tests were not recorded for the AM and PM, six days of temperatures and chemical tests not being recorded for the PM; May - 16 days of temperatures and chemical tests not being recorded for the AM and PM, three days of temperatures and chemical tests not being recorded for the AM, two days of temperatures and chemical tests not being recorded for the PM; June - zero days missed; July - three days of temperatures and chemical tests not being recorded for the AM and PM; August - seven days of temperatures and chemical tests not being recorded for the AM and PM; September - four days of temperatures and chemical tests not being recorded for the AM and PM. Observation on 9/26/24 at 12:45 PM, in the kitchen, indicated several spices were not dated when they were opened. The 12 undated spices were: poultry, paprika, garden seasoning, smoked paprika, pumpkin spice, cinnamon and sugar, celery seed, dill weed, caraway seeds, rosemary leaves, basil leaves, and rotisserie chicken seasoning. Observation on 9/26/24 at 12:50 PM, in the kitchen, indicated numerous floor tiles that were cracked which did not allow for adequate cleaning: four cracked tiles near the steam table, five cracked tiles in the dish machine room, and a minimum of 15 cracked tiles in the kitchen area. During an interview on 9/26/24 at 12:55 PM, Cook1 was asked who was responsible for taking refrigerator/freezer temperatures. He stated, Everyone does it, and usually he did it when he came in for his shift. During an interview on 9/27/24 at 1:05 PM, the Dietary Manager (DM), stated she had been at the facility since May 2024. When the DM was asked why she did not throw out the undated spices, she stated the spices had always been there, and she had not noticed that some of the spices were outdated. The DM stated taking and recording the temperatures for freezers and refrigerators was the responsibility of the cooks to complete each shift, in the AM and PM. The DM stated there was a big meeting about the temperature taking/recording where the kitchen staff received training about this task. The DM stated not having steady staff had been an issue, and the three cooks who were hired over the summer were adjusting to the long-term care regulations. The DM stated the dietary aides (DAs) were responsible for recording the temperatures and chemical ratios for the dish machine, and there was usually a DA in AM and one in PM. During an interview on 09/27/24 at 2:20 PM with the Administrator, she stated on 7/23/24 a meeting/educational session was held with the kitchen staff where the process of taking the temperatures for the freezers, refrigerators and dish machine were reviewed. The Administrator was surprised to find this remained an issue for the kitchen staff. The Administrator stated there was a corporate plan to replace the kitchen floor in 2025. The Administrator confirmed the spices were undated and should have been removed. During an interview on 9/27/24 at 2:30 PM, Cook2 stated he began working for the facility on 07/02/24. Cook2 stated the DAs were the staff who usually completed the chemical testing for the dish machine, but the cook did it if the DA was not there. Cook2 stated the freezer/fridge temperatures were supposed to be done by the cooks every AM and PM.

Based on observation, interview, and record review, the facility did not ensure each resident receives cares, consistent with professional standards of practice to prevent pressure injuries (PIs) for 2 of 3 residents (R) sampled out of a total sample of 9 (R2 and R8). R8 was admitted on [DATE], without a pressure injury or catheter. R8 was hospitalized on [DATE], returning on [DATE] with a foley catheter in place. The facility did not develop a care plan addressing the catheter until [DATE], after erosion to the penis was identified.The facility failed to ensure interventions to prevent medically related pressure injuries (PI) were implemented correctly to prevent PI development, failed to complete weekly measurements and assessments, and failed to get orders for treatments. R8 subsequently developed a full thickness wound that extended from the tip of the penis where the catheter is placed, through the meatus, and down to the shaft. These failures created a finding of immediate Jeopardy (IJ) which began on [DATE]. The NHA (Nursing Home Administrator) was notified of the IJ on [DATE] at 3:55 PM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as evidenced by the following example: R2 was admitted to the facility on [DATE] without a pressure injury. The facility did not complete weekly skin checks and did not identify new pressure injuries. This is evidenced by: Example 1 An article from the National Library of Medicine (NIH) at pubmed.ncbi.nih.gov/21205992 from, [DATE] states in part . Medical devices often are overlooked as a potential cause of pressure ulcers. Indwelling urinary catheters have been described as a cause of urethral erosion. In men, the resultant partial-thickness or full-thickness wound can involve a small area of the glans penis or [NAME] the glans or penile shaft, requiring reconstructive surgery or urinary diversion. An article from the NIH at pubmed.ncbi.nih.gov/36493361 from [DATE] states in part . Urethral erosion secondary to a medical device-related pressure injury (MDRPI) is preventable, understudied , not well understood, and often overlooked. The facility document titled Pressure Injury Prevention Guidelines, dated 2023, states in part . Preventive Skin Care: 1. Inspect skin while providing care, paying close attention to bony prominences. 2. Inspect skin underneath medical devices at least twice daily. Keep skin clean and dry underneath. Adjust devices as needed for proper fit. Repositioning: Avoid positioning the resident directly onto medical devices (i.e., tubes, drainage systems). The facility policy titled, Pressure Injury Staging Guidelines, last reviewed ,d+[DATE], states in part . Purpose: To provide a common language for the description of the depth of pressure related injuries. These guidelines are to be utilized for pressure related injuries, no other wound should be utilized using this language. This common language is adopted from the National Pressure Ulcer Advisory Panel (NPUAP). National Pressure Ulcer Advisory Panel Pressure Injury Stages: Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The pressure injury will present as intact skin and may be painful. A pressure injury will present as an open ulcer the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture; nutrition; perfusion; co-morbidities; and condition of the soft tissue. Stage 4 Pressure Injury: Full -thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth caries by anatomical location. If slough or eschar obscures the wound bed, it is an Unstageable Pressure Injury. Medical Device Related Pressure Injury: Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. The facility policy titled Catheter Care, last reviewed ,d+[DATE], states in part . Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 1. Catheter care will be performed every shift and as needed by nursing personnel. Compliance Guidelines: 7. Perform hand hygiene. 8. [NAME] gloves. Both: 20. Ensure the catheter tubing is secured by use of stat lock or leg secure device. The cath secure should be alternated each day. 21. Report abnormal findings to the nurse and document any care that needs to be in the resident record. 25. Perform hand hygiene. The facility policy titled, Hand Hygiene, last reviewed [DATE], states in part . Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table: - Before performed resident care procedures. - When, during resident care, moving from a contaminated body sit to a clean body site. - Before applying and after removing personal protective equipment (PPE), including gloves. - After handing items potentially contaminated with blood, body fluids, secretions, or excretions. R8 was admitted to the facility on [DATE]. R8's diagnoses include Flaccid hemiplegia affecting right dominant side, diabetes mellitus type 2, cerebral infarction, benign prostatic hyperplasia, neuromuscular dysfunction of bladder, and urinary retention. R8's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of [DATE] indicates R8 has a Brief Interview of Mental Status (BIMS) of 11, indicating moderate cognitive impairment. R8 is dependent on staff for toileting hygiene, shower/bathe, upper and lower body dressing, bed mobility, and toilet transfers. R8 requires moderate/substantial assistance with upper body dressing, personal hygiene, sit to stand, and transfers from chair/bed to chair. Urinary continence is not rated due to urinary catheter in place and R8 is always incontinent of bowel. R8 was hospitalized on [DATE] and returned on [DATE] with foley catheter in place. R8's Braden Scores include in part . [DATE], indicates a 12, High Risk. [DATE], indicates 13, Moderate Risk [DATE], indicates 15, At Risk [DATE], indicates 14, Moderate Risk [DATE], indicates 15, At Risk [DATE], indicates 14, Moderate Risk [DATE], indicates 14, Moderate Risk [DATE], indicates 15, At Risk R8's care plan includes . Problem: The resident has Foley Catheter d/t (due to) retention of urine, neurogenic bladder. Date Initiated: [DATE]. Goal: The resident will be/remain free from catheter-related trauma through review date. Date Initiated: [DATE]. Interventions: Monitor Stat lock or catheter leg strap for tension on catheter. Catheter should be tension free. Date Initiated: [DATE]. Note: R8's catheter was placed at the hospital in ,d+[DATE] but his care plan was not initiated until [DATE], after erosion to the meatus was already identified. R8's Certified Nursing Assistant (CNA) Kardex, printed [DATE], states in part . Bladder/Bowel: Monitor stat lock or catheter leg strap for tension on catheter. Catheter should be tension free. Resident Care: Provide pericare after each incontinent episode. Nurses Note from [DATE] at 12:29 PM states, catheter changed today clear yellow urine noted changed with DON (Director of Nursing), noted to have tip of penis split, NP (Nurse Practitioner) updated on this. Progress Note by NP (Nurse Practitioner) from [DATE] at 3:30 PM states in part . On exam, significant urethral erosion noted. Urology following, next scheduled appointment is in November but recommending patient to be seen sooner to discuss options. No S/S (signs or symptoms) infection, catheter draining dilute yellow urine. Physical Examination: GU (genitourinary) - indwelling Foley catheter, significant ureteral erosion with intermittent mild pain, no sign of infection. Assessment and Plan: Urethral erosion by catheter: Indwelling Foley catheter for urinary retention. Urology following, last seen ,d+[DATE]. Continue cath (catheter) exchanges as needed. Follow-up November, requesting sooner appointment given noted urethral erosion. Orders to monitor Stat Lock strap every shift to secure catheter but prevent tension on urethral meatus. Progress Note by NP from [DATE] at 1:00 PM states in part . Physical Examination: GU (genitourinary) - indwelling Foley catheter, significant ureteral erosion with intermittent mild pain, no sign of infection. Assessment and Plan: Urinary retention due to benign prostatic hyperplasia: Continue Flomax. Continue indwelling Foley catheter for retention. Urology following, last seen ,d+[DATE]. Continue cath exchanges as needed. Follow-up November, requesting sooner appointment given noted urethral erosion. Orders to monitor Stat Lock/leg strap every shift to secure catheter but prevent tension on urethral meatus. Urethral erosion by catheter: Indwelling Foley catheter for urinary retention. Urology following, last seen ,d+[DATE]. Continue cath (catheter) exchanges as needed. Follow-up November, requesting sooner appointment given noted urethral erosion. Orders to monitor Stat Lock strap every shift to secure catheter but prevent tension on urethral meatus. Of Note: Despite the nursing staff documenting tip of penis split and NP writing significant urethral erosion to the penis the facility did not implement weekly assessments, complete weekly measurements, or implement any treatments of this area. Urology HPI (History of Present Illness): ***On [DATE] at 2:17 PM, clinic staff wrote to MD, DON at [facility name] states she assisted in a foley exchange for R8 today and noticed his meatus is open the entire length of the tip of his penis. She states this has not be [sic] documented/noticed in the past. The meatus is red and inflamed. He is reporting no pain. There is no documentation of trauma or issues with his previous catheter exchanges. She does state R8 is confused at baseline, pulls at the catheter and has no knowledge of what could have happened. They are requesting an appointment. Exam Constitutional: GU: Penis: normal penis (urethral erosion due to tension from foley) and circumcised; no lesions. Urology Clinic Visit Note from [DATE] states in part . Follow up incontinence: Patient with indwelling foley with recent issue noted of urethral erosion. Exam today showed that his Foley catheter was rerouted posteriorly underneath his depends undergarment creating tension on the Foley catheter. It was affixed to his inner thigh with a Stat Lock. We repositioned his Foley catheter in a manner to get off tension to prevent the ongoing urethral erosion. Tissue did not look infected. We did note the urethral erosion can be seen only back to the penoscrotal junction and some men [sic]. An additional option would be given that the nursing facility finds it difficult to maintain it off tension while riding into posteriorly underneath the depends undergarment they can create a small window within the depends and around the catheter out that was we can to drainage [sic]. Skilled Nursing Facility (SNF) Progress Note by NP from [DATE] at 1:45 PM states in part . Physical Examination: GU (genitourinary) - indwelling Foley catheter, significant ureteral erosion with intermittent mild pain, no sign of infection. SNF Monthly Compliance Note by Medical Doctor (MD) from [DATE] at 6:15 PM states in part . At the underlying obstructive uropathy with Foley catheter in place. Has urethral erosion secondary to chronic Foley catheter followed by urology. Additionally has significant issues with self-induced trauma recommend suprapubic but defer to urology for input. Care discussed with nursing staff EHR (electronic health record) is reviewed. SNF Progress Note by NP from [DATE] at 1:45 PM states in part . Physical Examination: GU (genitourinary) - indwelling Foley catheter, significant ureteral erosion with intermittent mild pain, no sign of infection. Wound Physician document titled, Wound Evaluation & Management Summary, dated [DATE], states in part . Unstageable (Due to A Device/Dressing) Penis Undetermined Thickness. Etiology: Pressure. Wound Size (L x W x D): 1 x 2 x 0.2 cm (centimeters). Exudate: Moderate Sero - sanguinous. Expanded Evaluation Performed: Reviewed off-loading surfaces and discussed surfaces care plan. Considered patient behavior as factor that is complicating wound healing and discussed it further with staff and/or family. Discussed wound healing trajectory and expectations with patient and/or family. Patient requiring an increase in the level of care. Rec to consider removal of cath vs if ongoing need, consult with urology for SP (suprapubic) placement. Dressing Treatment Plan: Triple antibiotic ointment apply twice daily for 30 days. Registered Nurse (RN) Weekly Wound Assessment, dated [DATE], states in part . A. Communication. 1a. Date MD/Alternate Notified/Last Updated: [DATE]. 1b. Details: NP. B. Observation/Data: 1. Location: penis. 2a. Indicate whether this site was acquired during the residents stay or whether it was present on admission: 2b. Acquired. Date acquired: [DATE]. 3a. Type: pressure. 4. Pressure Ulcer Stage. 4a. Original: SDTI (suspected deep tissue injury). Current: SDTI. 5. Visible Tissue. 5a. Overall Impression: First observation, no refence. 5f. Moist. 6. Drainage. 6a. Type: Serosanguinous. 6b. small. 8a. Length: 2. 8b. Width: 2. 8c. Depth(cm) or UTD (unable to determine): 0.2. C. Treatment. 2. Current treatment plan: TAO BID (triple antibiotic ointment twice a day). Evaluation. Wound Progress: Unstageable d/t (due to) device. Comments: Wound progress: exacerbated d/t pt (patient) seen by urology. Per wife declined void trial for cath removal or SP cath placement. Wound Physician document titled, Wound Evaluation & Management Summary, dated [DATE], states in part . Unstageable (Due To A Device/Dressing) Penis Undetermined Thickness. Etiology: Pressure. Wound Size (L x W x D): 2 x 2 x 0.2 cm (centimeters). Exudate: Light Sero - sanguinous. Wound Progress: Exacerbated due to patient seen by urology, per report wife declined void trial for cath removal or SP cath placement. Expanded Evaluation Performed: Counseling offered to optimize wound healing regarding relevant conditions including Diabetes. Reviewed off-loading surfaces and discussed surfaces care plan. Discussed signs of atypical ulceration and consideration of biopsy with patient and/or family. Discussed wound healing trajectory and expectations with patient and/or family. Dressing Treatment Plan: Triple antibiotic ointment apply twice daily for 23 days. Recommendations: Reposition per facility protocol; Off-load wound: ensure foley is secured so cath is off tension and not placing tension along glans of penis. RN Weekly Wound Assessment, dated [DATE], states in part . A. Communication. 1a. Date MD/Alternate Notified/Last Updated: [DATE]. 1b. Details: NP. 3. Special Equipment/Preventative measures: ensure foley is secured so cath is off tension and not placing tension along glans of penis. B. Observation/Data: 1. Location: penis. 2a. Indicate whether this site was acquired during the residents stay or whether it was present on admission: 2b. Acquired. Date acquired: [DATE]. 3a. Type: pressure. 4. Pressure Ulcer Stage. 4a. Original: SDTI (suspected deep tissue injury). Current: SDTI. 5. Visible Tissue. 5a. Overall Impression: Unchanged. 5f. Moist. 6. Drainage. 6a. Type: Serosanguinous. 6b. small. 8a. Length: 2. 8b. Width: 2. 8c. Depth(cm) or UTD (unable to determine): 0.2. C. Treatment. 2. Current treatment plan: TAO BID (triple antibiotic ointment twice a day). Evaluation. Wound Progress: Unstageable d/t device (catheter). Comments: Wound progress: exacerbated d/t pt was seen by urology. Per wife declined void trial for cath removal or SP cath placement. Wound Physician document titled, Wound Evaluation & Management Summary, dated [DATE], states in part . Unstageable (Due To A Device/Dressing) Penis Undetermined Thickness. Etiology: Pressure. Wound Size (L x W x D): 2 x 2 x 0.2 cm (centimeters). This visit's measurements are noted by the clinician to be exactly the same as the previous visit. Exudate: Light Sero - sanguinous. Wound progress: Not at Goal. Dressing Treatment Plan: Triple antibiotic ointment apply twice daily for 16 days. Recommendations: Reposition per facility protocol; Off-load wound: ensure foley is secured so cath is off tension and not placing tension along glans of penis. RN Weekly Wound Assessment, dated [DATE], states in part . A. Communication. 1a. Date MD/Alternate Notified/Last Updated: [DATE]. 1b. Details: NP. 3. Special Equipment/Preventative measures: ensure foley is secured so cath is off tension and not placing tension along glans of penis. B. Observation/Data: 1. Location: penis. 2a. Indicate whether this site was acquired during the residents stay or whether it was present on admission: 2b. Acquired. Date acquired: [DATE]. 3a. Type: pressure. 4. Pressure Ulcer Stage. 4a. Original: SDTI (suspected deep tissue injury). Current: SDTI. 5. Visible Tissue. 5a. Overall Impression: Worsening. 5f. Moist. 6. Drainage. 6a. Type: Serosanguinous. 6b. small. 8a. Length: 2. 8b. Width: 3. 8c. Depth(cm) or UTD (unable to determine): 0.2. C. Treatment. 2. Current treatment plan: TAO BID (triple antibiotic ointment twice a day). Evaluation. Wound Progress: Unstageable d/t device (catheter). Comments: Expanded Evaluation Performed: Counseling offered to optimize wound healing and relevant conditions were addressed through management changes or investigations regarding conditions including patient with chronic foley, patient needs SP cath placed to offload however wife (poa [sic] (power of attorney)) declines pursuing this or even repeat voiding trial to assess ability to remove caths [sic]. Reviewed off-loading surfaces and discussed surfaces care plan. Considered patient healing trajectory and expectations with patient and/or family. Wound Physician document titled, Wound Evaluation & Management Summary, dated [DATE], states in part . Unstageable (Due To A Device/Dressing) Penis Undetermined Thickness. Etiology: Pressure. Wound Size (L x W x D): 2 x 3 x 0.2 cm (centimeters). This visit's measurements are noted by the clinician to be exactly the same as the previous visit. Exudate: Light Sero - sanguinous. Wound progress: Not at Goal. Expanded Evaluation Performed: Counseling offered to optimize wound healing and relevant conditions were addressed through management changes or investigations regarding conditions including patient with chronic foley, patient needs SP cath placed to offload however wife (poa (power of attorney)) declines pursuing this or even repeat voiding trial to assess ability to remove caths [sic]. Reviewed off-loading surfaces and discussed surfaces care plan. Considered patient healing trajectory and expectations with patient and/or family. Dressing Treatment Plan: Triple antibiotic ointment apply twice daily for 30 days. Recommendations: Reposition per facility protocol; Off-load wound: ensure foley is secured so cath is off tension and not placing tension along glans of penis. R8's Medication Administration Record (MAR) states in part . - Shower weekly on Wednesday complete skin assessment. Only document (In Health Status) if skin issue found, every day shift every Wednesday. Start Date: [DATE]. - Monitor stat-lock or leg strap for indwelling catheter Q (every) shift. Ensure catheter is secure but relaxed, preventions of tension on urethral meatus due to urethral erosion noted. Every shift for monitor secure catheter, prevent tension to urethral meatus. Start Date: [DATE]. - Lidocaine HCI (low hydrochloric acid) External Gel 2 %. Apply to urethral meatus topically every 12 hours as needed for urethral erosion pain. (lidocaine uro-jet). Start Date: [DATE]. - Wound care to penis: Cleanse and dry, apply triple antibiotic ointment twice daily. May use equivalent. Every day and evening shift for wound care. Start Date: [DATE]. Of Note: Wound Physician Note from [DATE] states in part . Primary Dressing: Triple antibiotic ointment apply twice daily for 30 days. The facility did not start the treatment or place it on R8's MAR until [DATE]. On [DATE] at 8:45 AM, Surveyor observed CNA D (Certified Nursing Assistant) and CNA E completed catheter care with R8. Surveyor observed R8's stat lock on the right thigh with catheter connected. Surveyor observed the tubing to be slack and without tension at this time. Surveyor observed R8's penis to be open from the tip through the meatus, down to the shaft. CNA D washed hands and placed gloves, peri area cleansed, gloves changed. CNA D applied clean gloves and patted dry the area. Powder placed in groin per standing orders. On [DATE] at 9:00 AM, Surveyor interviewed CNA D. Surveyor asked CNA D if hands should be washed when going from dirty to clean and when changing gloves. CNA D stated, yes. On [DATE] at 9:08 AM, Surveyor interviewed NHA A and ADON C. Surveyor asked ADON C when it is appropriate to wash hands. ADON C stated, before cares, when changing gloves and before leaving a room. Surveyor asked ADON C if she would expect staff to wash hands when going from dirty to clean. ADON C stated, yes. On [DATE] at 10:55 AM, Surveyor interviewed NHA A and ADON C (Assistant Director of Nursing). Surveyor asked ADON C when R8's catheter was placed. ADON C stated, [DATE] during a hospitalization . Surveyor asked ADON C if R8 has always had a Stat Lock or strap in place to secure the catheter. ADON C stated, should always be a stat lock or securing device so would have/should have came back with that as well. There is a note when R8 returned from the hospital on [DATE] to follow up with Urology for irritation due to repeated cathing. Surveyor asked ADON C when R8 was seen by Urology. ADON C stated [DATE]. Surveyor asked ADON C if measurements and assessment should have been completed when the area was first discovered on [DATE]. ADON C stated, the area should have been assessed at the time of the note, [DATE]. The NP did see R8 on [DATE] and wrote a note but did not complete measurements. Surveyor asked ADON C if she would have expected this area to be assessed and measurements completed. ADON C stated, I would have hoped that would have been done but I can't speak on their behalf. Surveyor asked ADON C when R8 had measurements completed on the area. ADON C stated, the first measurements were completed by Wound MD G on [DATE]. Surveyor asked ADON C what the initial date of discovery was for R8's penile erosion. ADON C stated, [DATE] according to the nurses notes. Surveyor asked ADON C when on the RN Wound Assessment sheet from [DATE] it indicates the date of discovery or date acquired as [DATE]. ADON C stated, I used that date as Wound MD G put in his documentation that the wound duration was greater than 17 days. What I did was go off Wound MD G's estimated date not the actual charting that identified the area. This area should have been measured weekly from the time of discovery. On [DATE] at 12:00 PM, Surveyor interviewed Wound MD G. Surveyor asked Wound MD G about R8's wound. Wound MD G stated this area to the glans penis is considered a medical device related pressure injury which is common in long-term catheter use. Surveyor asked Wound MD G about staging of this area. Wound MD G states, the charting system we use for documentation locks out the depth but this is a full-thickness, stage 4 pressure injury to the penis. Surveyor asked Wound MD G if he considered this to be avoidable. Wound MD G stated, initially this would have been considered avoidable but R8's wife has declined other interventions, such as, SP catheter or voiding trial to remove the Foley. Since those things have been declined, I would say this is now unavoidable. There is usually some expected erosion from catheter placement but the extent of this is avoidable. Long-term catheter use will have some degree of erosion. On [DATE] at 12:15 PM, Surveyor interviewed NP F (Nurse Practitioner). Surveyor asked NP F if she would have expected the area on R8's penis to have been assessed and measured at time of discovery. NP F states, yes, they should have. I would have expected an assessment, measurements, and treatment. Surveyor asked NP F if she completed any measurements of the area when she assessed R8 on [DATE]. NP F stated, I did not do any measurements, but I placed orders for R8 to be seen on wound rounds and a Urology referral. Surveyor asked NP F if the pressure injury to R8's penis was avoidable. NP F states, the catheter puts R8 at risk, but the degree is likely avoidable. When I went to assess R8 on [DATE] his catheter was not in a good position. The catheter was tight, and the tubing was under his leg instead of over causing significant tension on the catheter. I did educated staff at that time about ensuring the tubing was loose and not tight. The facility's failure to implement interventions to ensure a medical device did not cause a pressure injury, failure to complete weekly assessments and measurements created a harm, leading to a finding of immediate jeopardy. The facility removed the immediacy on [DATE], when they completed the following: - The facility conducted a sweep of all residents with an indwelling Foley catheter to ensure robust interventions are in place to prevent PI development. - The facility completed skin assessments on all residents with an indwelling Foley catheter. - Education will be provided to nursing staff prior to their next working shift on the following. - All Nursing Staff (nurses, nurse aides and ha (hospitality aides)): All residents with an indwelling foley will wear a leg strap or utilize a stat lock. Education and competency checks for nurses and nurse aides will be completed to ensure correct positioning to prevent tubing from being taunt or causing pressure on the urethra. - Monitoring of skin integrity on residents with catheters during cares paying special attention to skin impairment. Immediately reporting any skin impairment to licensed nurse. - Licensed Nurses: Documentation of any skin impairment. Wound documentation to include weekly measurements and assessments. - Obtain treatment orders upon discovery. - On [DATE] the Facility reviewed the Policy and Procedure for Prevention of Pressure Injury F686 - On [DATE] the Facility reviewed the Policy and Procedure for Change of Condition notification. - On [DATE] the Facility initiated re-education with all Licensed Nursing Staff and nurse aides on identifying and reporting Changes of Condition when newly identified changes in health status are identified. - On [DATE] the Facility initiated re-education with all Licensed Nursing Staff on completion of a comprehensive assessment on all skin events with a noted change in size, shape, and clinical presentation at the time of discovery. - On [DATE] the Licensed Nursing Staffand nurse aide were re-educated on catheter care including but not limited to pressure ulcer prevention and treatment. - The Facility will complete random audits 3x weekly with Licensed Nurses to gauge understanding related to completion of Changes of Condition. Remedial education will be provided at the time of completion of audits if indicated. - The Facility will complete random audits 3x weekly on catheters to ensure care is provided per clinical standards. To include proper placement of leg strap/stat loc to prevent pressure. Remedial education will be provided at the time of completion of audits if indicated. - The facility will complete random audits 3x weekly on pressure ulcers to ensure care is provided per clinical standards. Remedial education will be provided at the time of completion of audits if indicated. - The facility will complete random audits 3x weekly on treatment records and weekly skin assessments to ensure care is provided per clinical standards. Remedial education will be provided at the time of completion of audits if indicated. - The facility will audit residents with medical device pressure injuries 3x weekly to ensure weekly assessments are documented in the medical record including measurements. - The results of the audits will be reported to the quality assurance and performance improvement (QAPI) committee and adjustments will be made to frequency of audits based on findings. Example 2: R2 was admitted to the facility on [DATE]. R2's diagnoses include hepatic encephalopathy, alcoholic cirrhosis of liver with ascites, chronic kidney disease (CKD), hepatic failure, degeneration of nervous system due to alcohol, splenomegaly, anesthesia of skin, and paresthesia of skin. R2's significant change Minimum Data Set (MDS) assessment, with an assessment reference date of [DATE] indicates R2 has a Brief Interview of Mental Status (BIMS) of 13, indicating R2 is cognitively intact. R2 is dependent on staff for toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, and transfers. R2 requires substantial/maximum assistance with rolling left to right. R2 is frequently incontinent of urine and always incontinent of bowel. R2's care plan includes . Problem: The resident has DTI (deep tissue injury) pressure ulcer of right heel (present on readmission [DATE]) r/t (related to) immobility secondary to cirrhosis of the liver. Date initiated: [DATE]. Interventions: Administer treatments as ordered and monitor for effectiveness. Date Initiated: [DATE]. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: [DATE]. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: [DATE]. Inform the resident/family/caregivers of any new skin breakdown. Date Initiated: [DATE]. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated: [DATE]. Monitor wound to ensure it is intact without bandage (open to air). Date Initiated: [DATE]. The resident needs partial/mod (moderate) assistance to turn/reposition routinely during waking hours, and as needed or requested. Date Initiated: [DATE]. The resident requires full alternating air mattress on bed and booties on bilateral feet when in bed with heels floated. Date Initiated: [DATE]. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Date Initiated: [DATE]. Admission Braden Scale from [DATE] indicating

Based on observation and interview, the facility did not ensure each resident has the right to privacy and confidentiality for 7 of 9 residents (R) reviewed. (R3, R4, R5, R6, R7, R8, and R9) During the survey, a camera was observed to be used for surveillance in the facility dining room. The dining room is used throughout the day for meals and visits. Evidenced by: On 8/14/24 at 11:00 AM, Surveyor observed a camera in the dining room, just inside the doorway from the hallway. Surveyor noted the dining room is used throughout the day by residents for meals and visits. This includes R3, R4, R5, R6, R7, R8, and R9. Surveyor noted there was no signage or posted notification to any resident, family, or staff who may use the dining room that the room was under surveillance by a camera. On 8/14/24 at 12:00 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if there were any cameras in the dining room NHA A stated not to her knowledge. NHA A opened the camera feed on her computer. NHA A and Surveyor observed a video of the dining room with residents eating the noon meal. NHA A stated she did not know there was a camera in the dining room NHA A stated there should not be a camera in the dining room. NHA A stated the camera will be removed. Surveyor requested a copy of the facility's camera surveillance policy. On 8/14/24 at 4:00 PM, NHA A informed Surveyor she was unable to find a camera surveillance policy.

Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R1) reviewed for fall concerns out of a total sample of 9 residents. R1 had a fall on [DATE] and the facility did not ensure that R1's fall was investigated or that care planned fall interventions were placed on R1's plan of care and implemented. This is evidenced by: The facility's policy titled, Fall Prevention Program, last reviewed [DATE], states, in part: . Purpose: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. Policy Explanation and Compliance Guidelines: 8. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. b. The plan of care will be revised as needed. 9. When any resident experiences a fall, the facility will: a. assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. R1 was admitted to the facility on [DATE] with diagnoses including, chronic obstructive pulmonary disease (COPD; a long-term lung condition that makes it difficult to breathe), malignant neoplasm right bronchus/lung, centrilobular emphysema (form of COPD that affects the upper lobes of the lungs), hypertension (HRN), and major depressive disorder. R1's quarterly Minimum Data Set (MDS) on [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. R1 required partial/moderate assistance for toileting hygiene, shower/bathe self, upper and lower body dressing. Set up, clean up assistance with oral hygiene, sit to stand and chair/bed-to-chair transfers. Supervision/touching assistance with toilet transfers. Independent with rolling left to right. R1's Fall Risk Assessment from [DATE] has a score of 12, indicating R1 is At Risk for falls. R1's Comprehensive Care Plan states in part . Problem: The resident is at risk for falls r/t (related to) Gait/balance problems d/t (due to) decline in status requiring admission to SNF (skilled nursing facility) for therapy secondary to lung cancer with COPD. Date Initiated: [DATE]. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: [DATE]. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: [DATE]. Follow facility fall policy. Date Initiated: [DATE]. PT (physical therapy) evaluate and treat as ordered or PRN (as needed). Date Initiated: [DATE]. Hospice Care Plan states in part . Fall Prevention Plan, starting [DATE]. Collaborate post fall with facility staff and determine if additional safety measures are needed and determine facility specific interventions which include frequent rounding, ensure walkway is clear, use of call light system, bed locked and in lowest position. Interventions: Fall Prevention Plan. Patient's fall prevention/harm reduction measures: Perform gait assessment. Reinforce bed in low position and wheels locked at all times. Of Note: The facility care plan did not include bed in low position as indicated in the hospice plan of care. R1 had a fall on [DATE] when she was found expired on the floor next to her bed. The bed at the time of the fall was at waist level. The facility completed a self-report following R1's death which includes a timeline. This document states in part . On [DATE] at approximately 4:20 AM R1 was found on the floor unresponsive without apparent injury; R1 is a DNR (Do Not Resuscitate). CNA H (Certified Nursing Assistant) checked on R1 at approximately 4:15 AM and observed R1 laying comfortably in her bed. Approximately 5 minutes later, while CNA H was making rounds, she observed R1 on the floor and immediately obtained the nurse. The nurse then call [sic] hospice, family, director of nursing, etc. On [DATE] at approximately 5:30 AM, RN (Registered Nurse) with Hospice pronounced (R1's death). All interviewable residents were interviewed they reported that no one has physically neglected or harmed them; no one has verbally neglected or harmed them; they feel safe in the facility; they know who to report abuse to; and they have not witnessed any abuse, neglect, or mistreatment. Of Note: The facility completed an investigation to ensure there was no abuse, neglect, or mistreatment to R1, but did not investigate the events of R1's fall. On [DATE] at 12:45 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and ADON C (Assistant Director of Nursing). Surveyor asked NHA A and ADON C about R1's fall. ADON C stated, R1 was terminally restless. Surveyor asked ADON C where I could find documentation indicating R1 was terminally restless. ADON C stated, Staff should be documenting when giving medications for and follow up to ensure it was effective. Surveyor requested a copy of the facility fall investigation related to R1's fall. ADON C indicates she did not find anything in the risk management documentation that would show a fall investigation was done. Surveyor asked ADON C if a fall investigation should have been completed on R1. ADON C stated, yes, there should have been a risk management/fall investigation. Surveyor asked ADON C if care plan interventions in the hospice plan of care should be also added to the facility plan of care. ADON C stated, the hospice care plan should be tied to our care plan. If a low bed is on the hospice care plan it should also be on the facility care plan. On [DATE] at 1:32 PM, Surveyor interviewed CNA H. Surveyor asked CNA H about R1's fall on [DATE]. CNA H stated, R1's bed was at waist level at the time of the fall. No one ever said she should have had a low bed. Surveyor asked CNA H when she last saw R1 prior to finding her on the floor. CNA H stated, I rounded on her every 15 minutes due to her being at end of life. Surveyor asked CNA H if R1 was leaning in bed when she last saw her. CNA H stated, R1 was not leaning in bed at all the last time I saw her. I don't remember the exact time that I saw her prior to the fall. R1 had a fall while at the facility. The facility did not update R1's fall care plan with interventions identified in the hospice plan of care and did not investigate the fall.

Based on record review and interviews, during an investigation of [NAME] ncident of verbal abuse of R3, the facility did not conduct interviews for potential abuse for other residents, and did not monitor R3 for potential negative psychosocial outcomes following incident. Findings include: Facility policy entitled Abuse, Neglect and Exploitation, implemented on 02/03/2024, under section V. Investigation of alleged abuse, neglect and exploitation, states in part 5, Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. Under section VI. Protection of Resident, states in part, Providing emotional support and counseling to the resident during and after the investigation as needed. The facility filed a self-report regarding verbal abuse that occurred towards R3 on 12/22/23. On that morning R3 expressed the coffee tasted like water. Dietary Manger (DM) D swore at R3 and told R3 to stop his f------ bi------. The facility did immediately suspend DM D and began an investigation. Surveyor reviewed R3's medical record and was unable to find any monitoring of potential negative psychosocial outcomes following the incident of verbal abuse towards R3. On 3/19/24 at 9:20 am, Surveyor interviewed R3 regarding incident that occurred on 12/22/23. R3 stated being aware of the incident and knows the staff member was let go. R3 denied any negative outcomes. On 3/19/24 at 10:36 AM, Surveyor requested and reviewed the facility's file on the reported incident of abuse and was unable to find any interviews with other residents who may have had similar concerns of abuse occurring towards them from DM D. On 03/19/24 at 10:47 AM, Surveyor interviewed Director of Nursing (DON) B regarding investigation and asked if interviews of other residents were conducted to determine the potential extent of abuse. DON B stated DON B had no awareness of any other resident interviews conducted. During the interview DON B confirmed there was no documentation of ongoing monitoring of R3 for potential negative psychosocial outcomes. On 03/19/24 at 11:30 AM, Surveyor interviewed Social Worker (SW) C who confirmed that no further resident interviews were conducted following incident and no further monitoring of potential negative psychosocial outcomes were conducted/documented.

Based on observation, interview, and record review, the facility did not ensure that food was stored, distributed, and served in accordance with professional standards for food service safety. This has the potential to affect all 40 residents residing at the facility. Surveyor observed: -An unknown matter in dishwasher area. -Machine washing and sanitation. The facility did not monitor dishwasher readings consistently. -Two instances of cross contamination. -Two instances of improper food storage. -Three instances of improper containment of garbage and refuse. The facility policy, entitled Sanitation Inspection, dated [DATE], states: It is the policy of this facility, as a part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations . 5. Inspections will be conducted but not limited to the following areas: a. dry storage b. freezer c. refrigerator d. dish room e. pot wash f. main production area g. food preparation area h. general dietary observations .7. Inspection Score (from Sanitation Inspection Report): The dietary manager, as part of the department's QAPI (Quality Assurance and Performance Improvement) program, will perform an in-depth analysis of the data obtained during the inspection .8. Inspection score will be formulated on each are being evaluated. Scores will then be compared to department goals. 9. Feedback will be reported to the food services staff and the QAPI committee. On [DATE] at 11:14 PM, surveyor requested the sanitation inspection report and inspection score from NHA A (Nursing Home Administrator). NHA A indicated that the sanitation inspection report and inspection score could not be found, and the facility would be starting the process today. Example 1 On [DATE] at 9:02 AM, Surveyor observed an unknown matter on the white paneling above the sink and backsplash to the right of the facility dishwashing machine. The unknown matter encompassed an area of four feet by three feet of paneling. The surface of the paneling is texturized with small groves and raised bumps. Surveyor did not observe a seam filler or sealant such as caulk or silicone in the seams and edging of the paneling. The unknown matter was black in color and significantly concentrated around the panel divider trim (strip of material that covers the seams of the paneling), power switch to the garbage disposal, and paneling edges covering up to 100% of the paneling surface area and extending up to three inches from the panel divider trim, power switch to the garbage disposal, and edges. The remainder of the four feet by three feet of paneling had circular areas where the unknown matter had colonized, with growth and concentration increased in the center of circular area. On [DATE] at 9:03 AM, Surveyor interviewed DA O (Dietary Assistant) regarding the unknown matter. Surveyor asked DA O what the unknown matter was, DA O stated, Mold, it affects me, it causes me to wheeze. DA O indicated that she scrubs the unknown matter, and it returns. DA O indicated that she had addressed the unknown matter with management over six months ago. DA O indicated that a maintenance employee installed a strip of edging that is supposed to stop mold from growing. On [DATE] at 2:03 PM, Surveyor observed the four feet by three feet of white paneling that had the unknown black matter had been cleaned. Areas that had been covered with the unknown matter were observed by Surveyor to be stained black. Example 2 The facility policy, entitled Sanitation Inspection, dated [DATE], states: Sanitation inspections will be conducted in the following manner: a. daily: . dishwasher temperatures daily . The facility policy, entitled Dishwasher Temperature dated [DATE] states: Policy explanation and Compliance Guidelines: . 4. For low temp dishwashers (chemical sanitization): a. The wash temperature shall be 120 F . 6. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. On [DATE] at 9:06 AM, Surveyor observed the temping and testing of the dishwasher PPM during the facility dishwashing process. DA N indicated that staff is to be taking temps of the dishwasher every meal. DA N completed the dishwashing internal temperature process using a dishwasher temperature test strip from package 1 of 3 packages readily available for use. DA N indicated that test strip was orange after the internal temping process. On [DATE] at 9:10 AM, Surveyor and DA N examined package 1 of dishwasher temperature test strips manufactured by [NAME] with a product number of 8766. Surveyor and DA N observed all the bars of the dishwasher temperature test strips in package 1 to be orange. The dishwasher temperature test strips in package 1 states, pass when blue bar turns orange .160 F. Surveyor asked DA N to read expiration the date on package 1, DA N stated, ,d+[DATE]. DA N indicated that the strips were expired. Surveyor and DA N examined package 2 of dishwasher temperature test strips manufactured by [NAME] with a product number of 8766. Surveyor and DA N observed all the bars of the dishwasher temperature test strips in package 2 to be orange. The dishwasher temperature test strips in package 2 states, pass when blue bar turns orange .160 F. Surveyor asked DA N to read expiration the date on package, DA N stated, 2019. DA N indicated that the strips were expired. (It is important to note that all the dishwasher temperature test strips in packages one and two were expired and not functioning properly. All strips indicator bars were orange, and not blue, the test strip bars are to start out blue and turn orange once the internal temp of the dishwasher reached 160 F.) Surveyor and DA N examined package 3 of dishwasher temperature test strips manufactured by Ecolab. The dishwasher temperature test strips in package 3 states 160 F. Surveyor asked DA N to read the expiration date on package, DA N stated, 2019. DA N indicated that the strips were expired. On [DATE] 9:08 AM, Surveyor asked DA N to run the dishwasher and read the external thermometer temperatures aloud during the wash and rinse cycles. Surveyor observed and DA N indicated the wash temp reach 111 F (Fahrenheit). Surveyor asked DA N if the dishwasher was a low or high temperature dishwasher, DA N indicated that he did not know. (It is important to note that wash temperature did not reach the 120 F, the washing temperature recommendation set forth by the US Department of Health and Human Services Public Health Services and Food and Drug Administration Food Code, as well as the facility in the facility policy, entitled Dishwasher Temperature.) On [DATE] at 9:25 AM, Surveyor interviewed DM M (Dietary Manager) regarding dishwasher temperature test strips, internal, and external temperatures of the facility dishwasher. Surveyor showed DM M the three packages of dishwasher temperature test strips, Surveyor and DM M observed the three packages of test strips to be expired. DM M stated these (three packages of dishwasher temperature test strips) aren't the right strips for a low temp dishwasher. DM M indicated that the facility uses a low temp dishwasher. Surveyor observed DM M run a dishwasher cycle. Surveyor observed and DM M read aloud the external thermometer of the dishwasher reached 93 F during the wash cycle. DM M indicated that the dishwasher temperature should be 120 F -130 F degrees the whole time during the dishwashing cycle. DM M indicated that the dishwasher was not reading properly due to dishwasher door being opened prior to cycle and the machine must run a few times before processes. (It is important to note that Surveyor began observing the dishwashing process 9:06 AM on [DATE] and had observed multiple dishwashing cycles run before the external temperatures of the facility dishwasher observed by Surveyor documented to be 111 F by DA N. It is important to note that 0 of 2 observations made of the facility dishwashers external temperatures reached 120 F.) Surveyor asked DM M if the dishwashing cycle is reaching the correct temperature, DM M stated, it (temperature) should be higher. Surveyor and DM M reviewed the facility dishwasher temperature log, entitled, Dishwashing Record High temperature for the month of [DATE]. The log for the breakfast meal shows the PPM entries for ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] are blank. The log for the breakfast meal shows the external dishwasher temperature entries for ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] are blank. The log for the breakfast meal does not have an area dedicated for staff to document internal temperatures. The [DATE] log for the lunch meal shows the PPM entries for ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] are blank. The log for the lunch meal shows the external dishwasher temperature entries for ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] are blank. The log for the lunch meal does not have an area dedicated for staff to document internal temperatures. The [DATE] log for the dinner meal shows the PPM entries for ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE] are blank. The log for the dinner meal shows the external dishwasher temperature entries for ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE] are blank. The log for the dinner meal does not have an area dedicated for staff to document internal temperatures. Surveyor asked DM M if staff should have filled in the log each day. DM M indicated that staff should be filling out the log. DM M indicated that she has trained the staff to do so. (It is important to note that the facility is not documenting internal dishwasher wash cycle temperatures.) Example 3 On [DATE] at 8:55 AM, Surveyor observed DA N during the facility dishwashing process. Surveyor observed DA N with gloves on hands pre-rinsing dirty dishes, DA N moved to the clean side of the dishwasher. DA N opened the dishwasher, grabbed an adaptive bar. DA N hooked bar to the tray full of clean dishes and pulled bar to remove tray. DA N was unable to remove the tray of clean dishes from dishwasher. Surveyor observed DA N reach into the dishwasher with a dirty glove on, DA N touched and moved a clean metal pan and freed the tray of clean dishes. During the dishwashing process DA N indicated that his gloves were dirty after pre-rinsing dirty dishes, Surveyor observed DA N remove gloves and wash hands. On [DATE] at 8:59 AM, Surveyor observed DA N remove a tray of clean dishes from the dishwasher. The tray contained resident personal plastic storage containers that were filled with dishwasher water during dishwashing process. Surveyor observed DA N grab a towel from storage drawer and dry dishes using towel. DA N poured the dishwasher water from the plastic storage containers and used the towel to dry plastic containers and other dishes. DA N placed the towel on the damp drying table. On [DATE] at 9:04 AM, Surveyor interviewed DA N regarding dish washing process. Surveyor asked DA N if the residents personal plastic storage containers were clean after coming out of the dishwasher filled with dishwasher water. DA N stated, No. DA N indicated that the water was dirty. DA N indicated that drying the dirty dishes and then drying clean dishes using the towel could cause cross contamination. On [DATE] at 9:20 AM, Surveyor interviewed DA N regarding the use of a towels during the dish drying process. DA N indicated that he uses a towel daily to dry dishes during the process, and that he changes the towel out for a new one when the towel becomes to damp. On [DATE] at 9:45 AM, Surveyor interviewed DM M regarding towel drying. DM M stated, Dishes need to air dry to prevent cross contamination. DM M indicated that staff is not supposed to towel dry dishes. On [DATE] at 9:01 AM, Surveyor observed a scoop to be laying on the surface of sugar inside a bin. Surveyor interviewed DM M who stated, It's (the scoop) always been there since I have been here. DM M indicated that she should take it (scoop) out. Example 4 The facility policy, entitled Food Safety Requirements, dated [DATE] states: Policy . Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety . 3 . ensure timely and proper storage . c . Practices to maintain safe refrigerated storage include: . iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date or frozen . v. Keeping foods covered or in tight containers. On [DATE] at 2:08 PM, Surveyor and DM M observed a bag of food in the facility walk-in freezer to be open. DM M indicated that the bag left open contained cinnamon rolls. DM M indicated that food should be stored in an airtight container. Surveyor observed DM M remove the bag of cinnamon rolls and dispose in trash. On [DATE] at 2:09 PM Surveyor observed four undated Ziploc bags containing frozen food on the first bottom shelf on the left-hand side of facility walk in freezer. DM M indicated that the bag contained chicken thighs and legs. DM M was unable to locate a date on the four Ziplock bags. DM M indicated that she was unaware when the four Ziplock bags containing chicken thighs and legs were placed in the freezer. DM M disposed of the four Ziplock bags containing chicken thighs and legs. Example 5 The facility policy, entitled Food Safety Requirements, dated [DATE] states: Policy . Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety . 6. All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination . a. Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. On [DATE] at 10:45 AM, Surveyor requested a kitchen cleaning schedule and check off list/log from NHA A (Nursing Home Administrator). NHA A indicated that the facility had obtained the Cleaning Schedule and Procedures on [DATE] and will be using the Cleaning Schedule and Procedures moving forward. The facility was not able to provide a kitchen cleaning schedule and check off list/log. On [DATE] at 1:58 PM, Surveyor observed the facility stand mixer to have a white substance coating the bottom of the head unit and collections of a substance hanging from the area the moving part of the mixer meets the head of mixing unit. On [DATE] at 2:29 PM, Surveyor and DM M viewed the white substance coating the bottom of the head unit and collections of a substance hanging from the stand mixer. DM M stated, Oh gross, that's gross. That needs to be cleaned. DM M indicated that the substance on the stand mixer was probably cheesecake. On [DATE] at 2:01 PM, Surveyor observed the inside bottom and door seal guard of the facility convection oven to have burned debris on the surface. On [DATE] at 2:26 PM, Surveyor interview DM M who indicated that the debris was burned crumbs/pieces of food that should not be in the convention oven as they could burn. DM M indicated that they convection oven is supposed to be cleaned once a week. Example 6 The facility policy, entitled Disposal of Garbage and Refuse dated [DATE] states: Policy explanation and Compliance Guidelines: 1. Garbage shall be disposed of in refuse container with plastic liners and lids. 2. Garbage and refuse containers shall be durable, cleanable, and free from cracks or leaks and covered when not in use . 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. On [DATE] at 2:03 PM, Surveyor observed a large trash bin between the stove and a food prep area to be uncovered and a large trash bin between the entry door to the kitchen and food prep area to be uncovered. On [DATE] at 2:31 PM, Surveyor interviewed DM M. DM M indicated that there was not a lid on the two trash bins located between the stove and a food prep area and the trash bin between the entry door to the kitchen and food prep area. DM M indicated that there has never been lids on these trash bins. On [DATE] at 9:35 AM, Surveyor and DM M observed lids to two of two dumpsters to be opened. DM M indicated that she has educated staff to close the lids to the dumpster, but staff continues to leave the lids to the dumpsters open. 38882 Example 7 On [DATE] at 10:11 AM, Surveyor observed expired, undated, opened food, and unsealed food in the cabinets located in the facility's activity room, including: aged white popcorn opened with no open date; Tostitos opened no open date; wheat flour opened with no open date; ginger snaps with expiration date of [DATE] and opened date of [DATE]; a bag of pretzels that had been removed from original packaging with no open date; 2 mini frosted donuts with expiration date of [DATE] and 2 mini powdered donuts with expiration date [DATE]; Swiss Miss hot chocolate with expiration date of [DATE]; baking powder with open date of [DATE] and best by [DATE], an opened package of Oreos with expiration date of ,d+[DATE]; Club House crackers - removed from the original package with no date and the packaging was not sealed; an open package of granulated sugar with best by date of [DATE]; a jar of granulated sugar that had been removed from the original package with no open date or expiration date; a package of flour with better if used date of [DATE]; and baking powder with best by date of [DATE]. On [DATE] at 10:35 AM, AD P (Activity Director) indicated the food should have been thrown out and it is her responsibility to check dates on the food and make sure it is properly sealed, dated, and labeled. AD P indicated there is potential for residents to get into the expired food. On [DATE] at 10:46 AM, DON B (Director of Nursing) and NHA A (Nursing Home Administrator) indicated it is AD P's responsibility to maintain the cabinets and refrigerator in the Activity Room. NHA A indicated she should have thrown out undated or expired food due to the potential of a resident getting into it.

Based on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director, or his/her designee, at least three other members of the facility's staff at least one of whom must be the administrator, owner, a board member or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 40 Residents residing within the facility. QAPI meetings did not consist of the required attendees/members for the month of January 2023, April 2023, and July 2023. This is evidenced by: The facility policy, entitled Quality Assurance and Performance Improvement (QAPI), dated 7/01/22, states, in part: . Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . Policy Explanation and Compliance Guidelines: . 2. The QAA (Quality Assessment and Assurance) Committee shall be interdisciplinary and shall: a. Consist at a minimum of: i. The Director of Nursing Services ii. The Medical Director or his/her designee. iii. At least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member, or other Individual in a leadership role; and iv. The Infection Preventionist b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program . As part of the entrance conference, Surveyor requested sign in sheets for the past year of QAPI meetings to review. The QAPI sign in sheet for January 30, 2023, indicates Medical Director, Administrator, and Director of Nursing/Infection Preventionist. This is not the required 6 attendees. The QAPI sign in sheet for April 26, 2023, indicates Medical Director, Administrator, and Director of Nursing/Infection Preventionist. This is not the required 6 attendees. The QAPI sign in sheet for July 20, 2023, indicates Medical Director, Administrator, and Director of Nursing/Infection Preventionist. This is not the required 6 attendees. On 8/29/23 at 2:36 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked who is required to attend QAPI meetings. NHA A indicated the DON (Director of Nursing), MD (Medical Director), NHA, IP (Infection Preventionist) and two other members. Surveyor asked NHA A and NHA A indicated no. Surveyor asked NHA A looking at the QAA signatures for July, April, and January 2023 are the required signatures in attendance, NHA A indicated no because we were short department heads as they resigned.

Based on observation, interview, and record review, the facility did not provide a safe environment and adequate supervision to prevent accidents. This had the potential to affect 1 out of 12 sampled residents (R40) and 4 out of 4 supplemental residents (R22, R19, R37, R27). Surveyor observed the stove/oven unit in the facility's activity room to be connected to a power source and was able to turn on the burners and the oven. Surveyor also observed R40, R22, R19, R37, and R27 in the activity room unsupervised. Evidenced by: Facility policy entitled Activity Department Stove/Oven, undated, includes the following, in part: date implemented: (blank), date reviewed/revised: (blank), reviewed/revised by: (blank) . Policy: A safe and healthful work environment will be provided for all employees, residents, and visitors. Pursuant to this end, the activity stove/oven will be properly cleaned and maintained to support the functioning of the activity stove/oven. Policy explanation and Compliance Guide: the activity stove/oven will be turned off immediately after use on the stove as well as the breaker located in the central supply closet on breaker number 16. the facility activities director and/or her designee will ensure the activity stove/oven is properly inspected and maintained. Residents will not be left in the activity room unattended when the stove/oven is on/in use. R27 admitted to the facility on [DATE] and has diagnoses that include dementia. R37 was admitted to the facility on [DATE]. R37's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/2/23, indicates R37's cognition is severely impaired with a Brief Interview for Mental Status (BIMS) score of 5 out of 15. R37's MDS also indicates R37 walks with set up help only and supervision. R40 admitted to the facility on [DATE]. She has diagnoses that include dementia. Her most recent MDS with ARD of 7/19/23, indicates R40's cognition is severely impaired with a BIMS score of 0 out of 15. R22 was admitted to the facility on [DATE]. Her diagnoses include dementia, Huntington's disease, and anxiety disorder. R22's most recent MDS indicate R22 has long term memory problems, short term memory problems, her cognitive skills for daily decision making are moderately impaired, and R22 has a behavior of unorganized thinking that comes and goes. R19 admitted to the facility 8/29/18 and has diagnoses including dementia. R19's MDS with ARD of 3/15/23 indicates R19's cognition is severely impaired with a BIMS score of 2 out of 15. R19's MDS also indicates R19's locomotion is completed with set up help and supervision. On 8/25/23 at 4:24 PM, Surveyor observed the facility's stove/oven unit to have a time blinking on the digital clock atop the stove. Surveyor reached out and turned the burners on and could feel them beginning to heat up. Surveyor turned on the oven and the oven began producing heat. On 8/29/23 between 10:00 AM and 10:32 AM, Surveyor observed the stove/oven unit in the facility activity room to have a time blinking on it over the stove top. Surveyor activated the burners atop the stove and the burners turned red and heat could be felt rising from the burners. Surveyor also observed R40, R22, R19, R37, and R27 to be in the activity room unsupervised. On 8/29/23 at 10:35 AM, Activity Director P indicated it is her responsibility to switch the breaker off in the facility's central supply closet so that a resident does not try to use stove and get burned. Activity Director P indicated she forgot to do this when she made cookies on 8/22/23. Activity Director P indicated residents wander in and out of this room daily and spend unsupervised time in the room daily to look out the windows, to sit in a quiet place, or to visit in small groups. Activity Director P indicated there is potential for a resident to get burned if they activate the stove/oven while unsupervised. On 8/29/23 at 10:46 AM, during an interview DON B (Director of Nursing) and NHA A (Nursing Home Administrator) indicated the stove should not be able to activate because staff are to switch off the breaker of the stove/oven unit. NHA A and DON B indicated it was Activity Director P's responsibility to make sure this is done. NHA A and DON B indicated there is a potential for residents with dementia to turn on the burners or the oven and get burnt when they are left in the room unsupervised. DON B indicated the last time she is aware the stove/oven was used was on 8/22/23 when it was used by a staff and resident group to make cookies.

Based on interview and record review, the facility did not conduct care conferences which included the participation of the Interdisciplinary Team (IDT) and the resident or resident's representative after completion of each comprehensive assessment (at least quarterly) or include an explanation in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan for 10 of 12 residents (R) sampled (R33, R38, R29, R2, R7, R39, R28, R23, R30, and R8). R33, R38, R29, R2, R7, R39, R28, R23, R30, and R8 did not have quarterly care conferences completed. This is evidenced by: The facility policy, entitled Care Planning-Resident Participation, dated 8/02/22, states, in part: . Policy: This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). Policy Explanation and Compliance Guidelines: 1. The facility will inform the resident, in a language he or she can understand, of his or her rights regarding planning and implementing care, including the right to be informed of his or her total health status . 3. The facility will notify the resident and/or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care . 9. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will try to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident's representative after discussion or viewing of the care plan. 10. If the participation of the resident and/or resident representative is determined not practicable for the development of the resident's care plan, an explanation will be documented in the resident's medical record. The facility information sheet, entitled Nursing Home Residents' Rights, undated, states, in part: . Residents of nursing homes have rights that are guaranteed to them under federal and state laws. The laws require nursing homes to treat each resident with dignity and respect and care for each resident in an environment that promotes and protects their rights . Right to be Fully Informed of: -The type of care to be provided, and risks and benefits of proposed treatments -Changes to the plan of care, or in medical or health status . Care conference documentation since the last recertification survey was requested from the facility for R33, R38, R29, R2, R7, R39, R28, R23, R30, and R8. Example 1 R33 was admitted to the facility on [DATE]. Documentation notes in the progress notes R33 had a care conference completed on 3/7/23. On 8/23/23 at 10:32 AM, R33 indicated to Surveyor she has never had a care conference since she has been residing at the facility. Example 2 R38 was admitted to facility on 9/1/22. Documentation notes R38 had a care conference completed on 5/18/23. On 8/23/23 at 2:17 PM, R38 indicated he has heard they have care conferences, but he has never been invited to one. Example 3 R29 was admitted to the facility on [DATE]. Documentation notes R29 had care conferences on 8/24/23, 5/03/23 then 2/23/21. On 8/24/23, at 9:56 AM, POA K (Power of Attorney) indicated they had a care conference for R29 today and one a month or so ago but then it was over a year ago. Example 4 R2 was admitted to the facility on [DATE]. Documentation notes that R2 had care conferences completed on 4/13/22 and 4/11/23. On 8/23/23 at 1:47 PM, Surveyor completed a family interview with POA L via telephone as R2 was not interviewable. R2's HCPOA (Health Care Power of Attorney) stated that they have only had one care conference this year and they used to have them quarterly. He feels the conferences are good because it keeps him updated. Example 5 R7 was admitted to the facility on [DATE]. Documentation notes that R7 had a care conference on 8/3/23 and then the last one before that date was 7/23/19. Example 6 R39 was admitted to the facility on [DATE]. Documentation notes that R39 had only one care conference completed on 8/15/23. Example 7 R28 was admitted to the facility on [DATE]. Documentation notes that R28 had a care conference 8/24/21. Example 8 R23 was admitted to the facility on [DATE]. Documentation notes that R28 had last care conference on 7/28/20. On 8/24/23 at 7:40 AM, R23 indicated to Surveyor she cannot recall the last care conference and is not aware whether the facility is having her care conferences. Example 9 R30 was admitted to the facility on [DATE]. Documentation shows the last care conference was 7/15/21. On 8/23/23 at 3:33 PM, R30 indicated to Surveyor the facility does not have regular care conferences. Example 10 R8 was admitted to the facility on [DATE]. Care conference documentation since the last recertification survey was requested from the facility and notes that R8 had care conferences completed on 4/20/23, 5/25/23, and 8/22/23. On 8/28/23 at 3:17 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked how often care conferences should be held. NHA A indicated every three months or if anything major occurs, upon admission, and at discharge. Surveyor asked NHA A if care conferences have been being completed as they should and NHA A indicated no. Surveyor asked NHA A who would be responsible for scheduling care conferences. NHA A indicated social services, director of nursing, assistant director of nursing and the NHA A. NHA A indicated now the MDS (Minimum Data Set) nurse notifies the social worker when they are to be scheduled. NHA A indicated the reason why care conferences have not been being completed is because of losing all the department heads and the few of us trying to fill in.

Based on interview and record review, the facility did not ensure that all staff had background checks completed every four years which is part of preventing abuse. This affected 2 of 9 staff reviewed. CNA H (Certified Nursing Assistant) did not have a background check completed every four years. CNA/MT I (Med Tech) did not have a background check completed every four years. This is evidenced by: The facility's Policy and Procedure entitled Background Investigations dated 7/2023 does not speak to completing background checks every four years, only speaks to upon hire. Example 1 CNA H's hire date was 2/21/19. Her last completed background check was completed on 2/21/19. CNA H should have had a background check completed by 2/21/23. Example 2 CNA/MT I's hire date was 2/15/19. Her last background check was completed on 2/15/19. CNA/MT I should have had a background check completed by 2/15/23. On 8/29/23 at 3:36 PM, Surveyor interviewed BOM J (Business Office Manager). Surveyor asked BOM J when background checks are supposed to be completed, BOM J said prior to hire. Surveyor asked BOM J if there is any other time in which a background check should be completed, BOM J stated every 4 years staff is to have them ran. On 8/29/23 at 3:48 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if she would expect staff to have a background check ran every four years, NHA A replied yes.

Based on observation, interview, and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 1 of 12 residents (R38) out of a total sample of 15. Surveyor observed R38's room to be unclean and odorous. This is evidenced by: The facility policy, entitled Routine Cleaning and Disinfection, dated 6/1/23, states, in part: . POLICY: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible . Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms . 4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: . c. Tray tables . g. Toilet seats h. Monitor control panels, touch screens and cables . 12. Horizontal surfaces with infrequent hand contact (windowsills and hard surface flooring) in routine resident-care areas should be cleaned: a. On a regular basis b. When soiling and spills occur . 13. Cleaning of walls, blinds and window curtains will be conducted when visibly soiled . The facility information sheet, entitled Nursing Home Residents' Rights, undated, states in part: . Residents of nursing homes have rights that are guaranteed to them under federal and state laws. The laws require nursing homes to treat each resident with dignity and respect and care for each resident in an environment that promotes and protects their rights. Right to a Dignified Existence . Be treated with consideration, respect, and dignity, recognizing each resident's individuality, wishes and preferences .A home-like environment and use of personal belongings . R38 was admitted to the facility on [DATE], and has diagnoses that include: Depression, Adult Failure to Thrive, and Generalized Anxiety Disorder. R38's Minimum Data Set (MDS) Quarterly Assessment, dated 5/31/23, shows that R38 has a Brief Interview of Mental Status (BIMS) score of 12 indicating R38 has a moderate cognitive impairment. On 8/23/23 at 2:17 PM, Surveyor observed R38's room to contain a strong urine smell and numerous flies swarming around R38, a visitor, and Surveyor. On 8/23/23 at 2:17 PM, Surveyor interviewed R38 and R38's VTR G (visitor). VTR G voiced concern with the odor in room, flies, and uncleanliness of R38's room. VTR G indicated R38's room has a very strong urine odor, and the room is not kept clean. VTR G indicated she had to clean R38's countertop; it was filthy with dust and debris. VTR G pointed out under the bed there was a spilled Mountain Dew bottle. VTR G indicated she talked to the Certified Nursing Assistant (CNA) today on how bad R38's room smelled when she opened the door. R38 indicated he talked to the CNA's more than once regarding the smell in his room. VTR G indicated to Surveyor the flies are so bad in this room and the smell is so bad she was going to have to bring an air freshener in for R38's room. Surveyor observed R38 swatting at flies that were swarming around him as R38 was talking with Surveyor. R38 indicated to Surveyor that housekeeping comes in every 1 to 2 days. On 8/23/23 at 2:40 PM, Surveyor brought CNA C into R38's room and asked if the room had an odor and CNA C indicated yes. Surveyor asked CNA C what the odor smelled like to her, and CNA C indicated body odor and body fluids. Surveyor asked CNA C if VTR G had voiced concerns to her regarding the odor in R38's room and CNA C indicated yes, VTR G asked for Febreze spray. CNA C indicated R38's room always smells like this. On 8/28/23 at 1:08 PM, two Surveyors entered R38's room and observed approximately a 3 inch blackened strip around base board of room; dusty window blinds; window valance full of thick visible dust; water streak marks running down under the window, a dead fly on top of the heat radiator along with dust and debris; floor sticky and crumbs and debris on it in numerous areas; R38's walker tray full of crumbs and debris; bed side table has dried fluid spillage and appears very dirty; top of clock hanging on wall has a thick layer of dust on it; wall light fixtures have thick dust; and ceiling vents have a thick layer of dust. Surveyors observed in R38's toilet seat with large amount of dried blood on it and tracks of blood on bathroom floor; part of the seal around toilet missing with an orange ring around the toilet; two broken bathroom tiles; and the floor strip from carpet to R38's room has thick back grime/debris. On 8/28/23 at 1:10 PM, Surveyor interviewed MT F (Maintenance) and asked if R38's room had an odor, and MT F indicated yes, and he avoids that room. MT F indicated urine can seep into cracked bathroom tiles and where the seal around toilet is not intact. MT F indicated there is only one housekeeper due to a shortage in staff. On 8/28/23 at 1:14 PM, Surveyor accompanied CNA D into R38's room and asked if there was an odor in the room. CNA D indicated yes. Surveyor asked how often housekeeping cleans R38's room and CNA D indicated if housekeeping is here, we try to get them in there. CNA D indicated the facility goes days without housekeeping and there is only one housekeeper in the facility. CNA D indicated there has been days with no housekeeping in the facility. Surveyor walked CNA D around R38's room and asked if CNA D could see a 3-inch blackened strip around the base board of R38's room and CNA D indicated yes. Surveyor asked if CNA D could see dust on valance, blinds, wall fixtures, and clock, and CNA D indicated yes. Surveyor asked CNA D if the floor was sticky and could see visible crumbs and debris on it and CNA D indicated yes. Surveyor showed CNA D the blood on toilet seat and on the floor, the broken seal around the toilet, and two cracked tiles in bathroom and CNA D indicated it needed cleaning. Surveyor asked CNA D if there were flies flying around in the room and CNA D indicated yes. Surveyor asked CNA D if R38's tray on walker was dirty and CNA D indicated yes, it needed cleaning. Surveyor asked CNA D if the vents in the ceiling were thick with dust and CNA D indicated yes. CNA D indicated the room needed cleaning. On 8/28/23 at 1:38 PM, Surveyor interviewed HSKG E (Housekeeping). HSKG E indicated every room should be cleaned every day. Surveyor asked if every room does get cleaned every day and HSKG E indicated no, that is not possible with one housekeeper that would take four days to get all hallways done. Surveyor took HSKG E around R38's room and asked HSKG E if the seal around toilet and the two tiles in R38's bathroom was broken and HSKG E indicated yes. Surveyor asked HSKG E if he could see the gunk/debris build up in the strip between carpet from hallway to the flooring in R38's room and HSKG E indicated yes. Surveyor asked HSKG E if he could see the build-up of dust on the clock, wall fixtures, blinds, and window valance, and HSKG E indicated yes. Surveyor asked HSKG E if there was an approximate 3-inch blackened strip around the base board of R38's room and HSKG E indicated yes. Surveyor asked HSKG E if there were flies in the room and he indicated yes. Surveyor asked if R38's room needed cleaning and HSKG E indicated yes. On 8/28/23 at 1:55 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and informed of the findings in R38's room that included dust on wall fixtures, clock, valance and blinds, and blackened strip around the base board of room, the blood on toilet seat and on floor, the broken seal around the toilet and two broken tiles in the bathroom. Surveyor asked what the expectation for everyday resident room cleaning was and NHA A indicated mopping floors, main priority areas, and all high-touch surfaces.

Based on interview and record review, the facility did not immediately consult with the Resident's Physician when there was need to alter treatment for 2 of 15 residents (R42, R23). R42 experienced a change in condition and the facility did not notify NP U (Nurse Practitioner) of R42's change in condition so that NP U could direct the care of R42. R23 had an abnormal x-ray and staff did not notify the medical doctor timely. Evidenced by: The facility policy, entitled Notification of Changes, date implemented 7/6/23, includes in part: The facility must inform the resident, consult with the resident's physician, and/or notify the resident's family member or legal representative when there is a change requiring such notification: Circumstances requiring notification include: Circumstances that require a need to alter treatment . 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 . R42 admitted to the facility on [DATE] with diagnoses including: adult failure to thrive, chronic atrial fibrillation, hypertension, Alzheimer's disease, and anxiety disorder. R42's Nurse Note, dated 7/11/23, include, in part: 1:00 AM: . At approximately 12:45 AM resident complained of shortness of breath and feeling like she couldn't breathe. Writer noted that resident had removed oxygen cannula. Oxygen saturation was between 83-85% on room air, reapplied oxygen cannula and had resident complete deep breathing exercises. Wheezing heard throughout with diminished lower lobes bilaterally. Completed albuterol neb treatment and resident's oxygen levels and heart rate stabilized. Humidifier added to resident's oxygen concentrator as well as it was noted that resident had small amount of dried blood inside nostrils. Resident calmed down and was able to fall back asleep. Lungs sounds improved and decreased wheezing heard with auscultation. Will continue to monitor. On 8/29/23 at 2:24 PM, during an interview NP U indicated she would have expected RN Q (Registered Nurse) to consult with her or an on-call medical doctor when R42 experienced diminished lung sounds and wheezing. On 8/29/23 at 3:33 PM, DON B (Director of Nursing) indicated she expected RN Q to notify NP U or an on-call medical doctor of R42's change in condition, including wheezing and diminished lung sounds. On 8/29/23 at 2:43 PM, RN Q indicated she was working on 7/11/23 and R42 had a change in condition; however, she was told by the RN who worked on the previous shift that NP U and R42's Power of Attorney were already aware of her condition. RN Q indicated she should have called the on-call medical doctor and consulted with him when R42 was found to have wheezing and diminished lung sounds. 46863 Example 2 R23 was admitted to the facility on [DATE] and has diagnoses that include: quadriplegia (paralysis of all four limbs), neurogenic bowel (loss of normal bowel function due to a nerve problem), autonomic dysreflexia (sudden onset of excessively high blood pressure), polyneuropathy (type of neuropathy, or nerve disease, that affects many nerves), major depressive disorder, and ileus (when intestine stops making wave-like movements). R23's Minimum Data Set (MDS) assessment, dated 6/30/23, indicates that R23 has a Brief Interview for Mental Status (BIMS) score of 15 indicating that R23 is cognitively intact. On 7/1/23 at 11:24 AM, a fax was sent from facility's outsourced diagnostic laboratories and radiology vendor to the facility. The fax contained results from R23's abdomen X-ray and states in part, X-ray abdomen 1 view . Results: There is marked colonic dilatation consistent with ileus or obstruction . Follow-up advised. The findings are worse than 4/13/2023. (It is important to note an ileus or obstruction indicates an abnormal test result) On 8/29/23 at 4:45 PM, Surveyor interviewed RN Q. RN Q indicated that on the morning of 7/3/23 she had found the fax containing the test results for R23's abdominal X-ray sent on 7/1/23 at 11:24 AM. RN Q indicated she immediately passed results to the AM nurse. On 8/29/23 at 3:33 PM, Surveyor interviewed DON B regarding notification of change of condition. Surveyor and DON B reviewed R23's progress/nursing notes from 6/28/23 to 7/10/23 entries related to condition are as follows .6/30/23 at 3:25 PM .call for X-ray order of distended ABD (abdomen) .this will be done today .7/3/23 at 12:07 PM . in the hospital . 7/10/23 at 3:12 PM . Resident is back in the facility at 2:30 PM . (It is important to note the facility did not notify R23's provider, NP U, or the on-call provider with R23's abnormal X-ray result.) DON B indicated the fax received on 7/1/23 indicating abnormal X-ray results would require notification to be made to R23's provider, NP U, or the on-call MD (Medical Doctor). Surveyor asked who should have been notified when R23's provider, NP U is unavailable. DON B stated, Should have updated on call MD. On 8/29/23 at 2:26 PM, Surveyor interviewed NP U regarding notification of R23's change of condition on 7/1/23. NP U indicated that she is in the facility on Tuesdays and Fridays and can be reached by phone. NP U indicated that when she is unavailable the facility should contact on call provider. NP U indicated that she would expect to be notified of all abnormal labs/test/X-ray results; when she is unavailable NP U expects to facility to contact the on-call provider. (It is important to note the facility received R23's abnormal test results on 7/1/23, failed to notify NP U or call provider with results. It is important to note the facility acknowledged R23's abnormal test results on 7/3/23.)

Based on interview and record review, the facility did not follow their grievance process for 1 of 15 Residents (R38). VTR G (R38's visitor) and R38 voiced concern to staff regarding odor in R38's room and facility did not follow the grievance process. This is evidenced by: The facility policy, entitled Resident and Family Grievances, dated 7/01/23, states, in part: . Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal . Policy Explanation and Compliance Guidelines: . 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary considering specific allegations . 4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (Long Term Care) facility stay . 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. b. Written complaint to a staff member or Grievance Official . 10. Procedure: . b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. i. Take any immediate actions needed to prevent further potential violations of any resident right . c. Forward the grievance form to the Grievance Official as soon as practicable. d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form . g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation . 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 12. The facility will make prompt efforts to resolve grievances. The facility information sheet, entitled Nursing Home Residents' Rights, undated, states, in part: . Residents of nursing homes have rights that are guaranteed to them under federal and state laws. The laws require nursing homes to treat each resident with dignity and respect and care for each resident in an environment that promotes and protects their rights. Right to a Dignified Existence: -Be treated with consideration, respect, and dignity, recognizing each resident's individuality, wishes and preferences . -Quality of life is maintained or improved . -A home-like environment and use of personal belongings when possible . Right to Voice Grievances . -Prompt efforts by the facility to resolve grievances and provide written decision upon request . R38 was admitted to the facility on [DATE], and has diagnoses that include: Depression, Adult Failure to Thrive, and Generalized Anxiety Disorder. R38's Minimum Data Set (MDS) Quarterly Assessment, dated 5/31/23, shows that R38 has a Brief Interview of Mental Status (BIMS) score of 12 indicating R38 has a moderate cognitive impairment. On 8/23/23 at 2:17 PM, Surveyor interviewed R38 and R38's VTR G (visitor). VTR G voiced concern with the odor in room, flies, and uncleanliness of R38's room. VTR G indicated R38's room has a strong urine odor, and the room is not kept clean. VTR G indicated she had to clean R38's countertop that it was filthy with dust and debris. VTR G pointed out under the bed there was a spilled mountain dew bottle. VTR G indicated she talked to the Certified Nursing Assistant (CNA) today on how bad R38's room smelled when she opened the door. R38 indicated he talked two CNA's more than once regarding the smell in his room. VTR G indicated to Surveyor the flies are so bad in this room and the smell is so bad she was going to have to bring air freshener in for R38's room. Surveyor observed R38 swatting at flies that were swarming around him as R38 was talking with Surveyor. R38 indicated to Surveyor that housekeeping comes in every 1 to 2 days. On 8/23/23 at 2:40 PM, Surveyor asked CNA C (Certified Nursing Assistant) if VTR G had voiced concerns to her regarding the odor in R38's room and CNA C indicated yes. CNA C indicated VTR G asked for Febreze spray to help with the odor. CNA C indicated R38's room always smells like this. On 8/28/23 at 1:55 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if she had received a grievance from R38 or VTR G. NHA A indicated no. Surveyor informed NHA A of VTR G and R38's concerns with odor in room. Surveyor informed NHA A VTR G and R38 took their concerns to a CNA on 8/23/23. Surveyor asked NHA A what the expectation is when a resident or visitor takes a concern to a staff member. NHA A indicated the CNA should have reported the concern to the nurse and the concern should have been put on paper as a grievance. Surveyor asked NHA A what the grievance process consisted of and NHA A indicated if a resident, visitor, vendor, or anyone has a concern the room number gets wrote down along with the concern. NHA A indicated the staff who takes the grievance is to document what they did to address the concern immediately. NHA A indicated she as the Grievance Official would then check in with the resident and follow up with the resident and document it. NHA A indicated this was the first she has heard of this concern.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R8) reviewed for wandering, 1 of 3 residents (R4) reviewed for abuse, and 2 of 4 residents (R1 and R6) reviewed for falls. R8 was assessed as a high risk to wander. R8's most recent Minimum Data Set (MDS), dated [DATE], indicated R8 wandered in the previous 1-3 days. R8 has long and short-term cognitive impairment and has severely impaired cognitive skills for daily decision making. R8 wore a Wander Guard bracelet. R8 was known to wander throughout the facility on a regular basis, especially on the PM shift. On 9/10/22, early PM shift, CNA M (Certified Nursing Assistant) silenced the Wander Guard alarm on the laundry exit door. On 9/10/22, 6:41 PM, R8 was found outside the facility, face down with her wheelchair on top of her by a passerby, who called 911. R8 was hospitalized with bilateral nasal bone fractures, right frontal process of maxilla and anterior nasal septum fracture, closed fracture of first lumbar vertebra, compression fracture of T4 vertebra and a right humeral diaphysis fracture. Approximately 7:00 PM the facility staff were informed by EMS Chief I that R8 had been found outside the facility. The facility's failure to provide adequate supervision for a resident, with known wandering, created a finding of Immediate Jeopardy (IJ) that began on 9/10/22. On 9/30/22 at 10:58 PM NHA A (Nursing Home Administer), DON B (Director of Nursing), and RCN C (Regional Clinical Nurse) were notified of the IJ. On 9/10/22 the facility recognized the deficient practice and took steps to correct the deficient practice and ensure compliance by the time of the survey. Based on this determination, the IJ was removed on 9/10/22 and corrected on 9/10/22. This is being cited as past noncompliance. On 7/26/22, R4 pushed R5 down causing R5 to sustain a [CONDITION(S)] requiring an emergency room visit and staples to R5's [CONDITION(S)]. On 7/26/22, the facility failed to update R4's care plan to prevent another resident-to resident event. On 8/17/22 there is evidence that R4 had another resident-to resident event of sexually touching R1. The facility failed to adequately supervise R4 to prevent aggressive behaviors to other residents. R6 had falls on 7/9/22, 8/9/22 and 8/19/22. The fall from 8/19/22 resulted in a [CONDITION(S)] requiring sutures. The facility did not ensure that they completed a fall investigation or identified the root cause of the fall to ensure proper intervention were put into place to prevent further falls. R1 had repeated falls on 7/14/22, 7/21/22, 7/24/22, 8/3/22, 8/7/22, 8/12/22, 9/7/22 without fall investigations completed by the facility. Evidenced by: The facility's Elopements and Wandering Residents policy, dated 8/1/22, includes, in part, the following: Policy: This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering . 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering d. Adequate supervision will be provided to help prevent accidents or elopements. Example 1 R8 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's, Cerebral Infarct and [CONDITION(S)]. R8's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/3/22, indicates R8 has Short term memory problem, Long term memory problem, and has severely impaired cognitive skills for daily decision making. In addition, R8 has wandered 1 to 3 days. R8's most recent Wandering Risk Scale, dated 7/12/21, indicates, in part, the following: C. Mobility: The resident can move without assistance while in wheelchair. E. History of Wandering: The resident has history of wandering. F. Diagnosis: The resident has medical diagnosis of dementia/cognitive impairment: diagnosis impacting gait/mobility or strength. H. Complete at 1 Month, Quarterly, Annually, with Sig Change and ADHOC Screening: The resident has wandered in the past month. Score: 11, Above High Risk to Wander. R8's Care Plan includes, in part, the following: (R8) has potential for elopement R/T (related to) dementia and impaired safety awareness. Date Initiated 11/24/2020. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Provide structured activities, toileting, reorientation strategies, including signs, pictures, and memory boxes. Personal Alarm: Wander Guard, used to alert staff to (R8's) movement and to assist staff in monitoring. Please engage (R8) in the following activities when she presents with increased wandering or fatigue. 1. Coloring, 2. Basic crafts, 3. Music/singing, 4. Looking at magazines, 5. Folding laundry, 6. Crafts, 7. Facility activities. (R8) will require cues to initiate and continue to engage in tasks. R8's Progress Notes include, in part, the following: 6/6/22, 3:28 (AM), . She does exhibit exit seeking behaviors and has a wander guard on her WC (wheelchair). Resident is redirected easily. 8/12/22, 10:30 (AM), . Wanderguard (sic) placed on new w/c (wheelchair) per care plan. 9/10/22, 20:35 (8:35 PM), At 6:45 PM nurse was notified resident was missing. Internal search initiated, at 7:00 PM, EMS (Emergency Medical Services) appeared at front door and stated resident was located. Resident transported to (Hospital Name). 9/21/22, 9:37 (AM), . On hospice after elopement. Significant change in condition due to injury from elopement. Risk for falls, [CONDITION(S)], choking. Elopement risk reduced due to not getting out of bed. R8's hospital Discharge Summary, dated 9/15/22, includes, in part, the following: This patient presents as a Level II trauma, involved in a Fall Downstairs (18 stairs). She lives at (Name of Facility) and had an unwitnessed fall 18 stairs and was found to have her wheelchair on top of her. Unknown loss of consciousness with obvious deformity to right upper extremity and dry blood on face. Known history of dementia. Multiple closed fractures of facial bone, overview, bilateral nasal bone fractures, right frontal process of maxilla and anterior nasal septum fracture. Closed fracture of first lumbar vertebra. Compression fracture of T4 vertebra. Humerus fracture, right humeral diaphysis fracture. On 9/29/22 at 11:42 AM Surveyor interviewed CNA K (Certified Nursing Assistant). CNA K stated R8 wandered up and down hallways every day. Staff written and signed statements include, in part, the following: On September 10, 2022, after dinner I turned off an alarm, because no one was around, and everyone always just turned them off. I don't remember what time it was. Signed by CNA M. On 9/10/22, I started my shift at 6 PM. Reported Resident in bed early. I went to (R8's room number) to check . before giving medications. Resident was not in her bed. Writer started looking for resident called on walkie asking for help to locate resident. CNA and writer doing room door to room door search when EMT (Emergency Medical Technician) came to front door about resident. Signed RN O (Registered Nurse). 9/10/22 On 9/10/22, I (CNA I) was informed by (RN O), our nurse, that (R8) had not been seen recently. This took place around 6:40 PM. I immediately began searching with (RN O). I walked out to the front of the building and looked by laundry area and the Courtyard, but still was unable to locate her. At that point I saw the ambulance and another emergency vehicle at (address next door). I honestly did not think much of that because it is very common to have emergency vehicles at (address next door). I went back inside to continue my search for (R8). It was shortly after that when I was called on my walkie talkie to come up front. A police officer was there to let us know that (R8) had fallen over at (address next door). This was around 7:00 PM. The last time I saw (R8) was around 6:10 PM, after my lunch break, when she appeared to be going to her room. On 9/10/22, (CNA I) stated he couldn't find (R8). I started checking room to room with him. Upon going down by the laundry door, I saw an ambulance with lights on out the window. I headed up front to see what was going on and met the EMT at the front door. He asked if we had a resident named (R8) I stated yes, we are looking for her. He stated she was in the ambulance and that she had fallen down some stairs at (address next door). We then went to check the doors and found the laundry door open. Signed LPN M (Licensed Practical Nurse) The facility's recapitulation of R8's elopement investigation includes, in part, the following: On 9/10/22 at approx. (approximately) 6:40 PM it was noted that patient (R8) was not in her room. The last time the patient was seen was after supper heading down 100 hall towards her room at approx. 6:10 PM. At approx. 6:40 PM staff noted patient was not in her room. Staff immediately initiated a search with all staff internally checking rooms, bathroom, common areas as well as external outside around the facility. Staff did note EMS next door at (address next door) which is not uncommon around 6:40 PM. At approx. 7:00 PM (EMS J) notified the facility that the patient was in front of (address next door) and at the time the facility staff were actively looking for patient and was being sent to the Hosp (hospital) for eval (evaluation) and treatment. Patient was fully clothed per EMS and staff, noting temp (temperature) outside at 64.4. Writer reviewed re-enactment with (EMS J) of how patient got to where she was found and concurred. . During investigation was noted new CNA had turned alarm off without validating patient safety. On 9/29/22 at 12:48 PM Surveyor interviewed EMS J via telephone. EMS J stated a passerby called 911 on 9/10/22 at 6:41 PM and an ambulance and staff arrived on scene at 6:45 PM. EMS staff found R8 lying at the base of the stairs of the building next to the facility, R8 was lying face down with her wheelchair on top of her. R8 stated her name and said she was visiting someone. R8 did not answer any further questions. No one in the immediate area knew who R8 was or where she came from. R8 did have a bracelet on with her name and room number. EMS J stated it was raining outside and R8 was wet. After R8 was loaded into the ambulance, which took approximately 15 - 20 minutes, EMS J went to the facility around 7:15 PM. EMS J found a staff nurse and asked if R8 was a resident. The staff nurse stated they had been looking for R8 and had been looking for R8 since around 6:00 PM. On 9/29/22 at 2:05 PM Surveyor interviewed RCN C (Regional Clinical Nurse). RCN C stated CNA M had silenced the laundry exit door and R8 went out this door, which has a downgraded ramp, going approximately 100 feet to the apartments next door. On 9/29/22 at 2:28 PM Surveyor interviewed CNA M via telephone. CNA M stated she had worked at the facility for approximately a month and worked the PM shift. CNA M stated on 9/10/22 between 5:30 PM - 6:30PM she had silenced the Wander Guard alarm, assuming it was staff leaving. CNA M stated during her employment she noticed that other staff had just silenced the alarm when it went off. CNA M stated she thought the alarm resets itself. On 9/29/22 at 2:35 PM Surveyor interviewed CNA I. CNA I stated that on 9/10/22 at approximately 6:30 PM RN O informed CNA I that R8 was missing. CNA I started searching the hallways and rooms and alerted other staff via walkie and verbally. CNA I stated he went out the front door to search in the immediate area in front of the facility, reentered the facility by the laundry exit. CNA I stated it was raining outside and it was dark. CNA I stated the laundry exit door magnet was not working properly and had not been working properly for over two months which management was aware of. CNA I stated the alarm did not always sound. CNA I stated the door was not alarming. The fire doors, at the end of 100 hall, which R8 had to go through to get to the laundry exit door, were closed. The tab alarm on the fire doors, which is to be activated when activity staff leave, was not alarming. CNA I stated R8 always tries to get out the laundry exit door, that's her go to door. CNA I stated R8 exit seeks everyday CNA I works. CNA I stated that if staff are not directly on the 100 hallway, not in a room, it is difficult to hear the laundry exit alarm or the tab alarm on the fire doors. On 9/29/22 at 2:45 PM Surveyor interviewed MD L (Maintenance Director). MD L stated the sensor on the laundry exit door should have alarmed when R8 left, but if the alarm was silenced and not reset, it will not alarm until the alarm is reset. MD L stated he put a new magnet and sensor on the laundry exit door on 9/11/22. R8 was at risk for wandering. R8 exited the facility and set off the Wander Guard alarm. A staff member turned off the alarm and did not check to see if a resident had exited the building. R8 was found with face down at the bottom of a staircase with multiple fractures. The facilities failure to monitor R8's whereabouts and silencing the alarm on the laundry exit door resulted R8 eloping from the building. R8 was found with significant injuries from falling from her wheelchair. These failures created a situation of immediate jeopardy that began on 9/10/22. On 9/10/22 the facility recognized the deficient practice and took steps to correct the deficient practice and ensure compliance by the time of the survey. Based on this determination, the IJ was removed on 9/10/22 and corrected on 9/10/22 when the facility implemented the following: Performed a head count, noting everybody else in the facility. Patients with wander guards were visually validated with wander guard and functioning, validated, reviewed, and ensured patients with wander guards had appropriate care plans, orders, placement checks per shift and functioning daily which were in order. All the external doors were reviewed for functioning of wander guard system and in proper working order. Reviewed maintenance weekly logs for door checks noting to be complete. During investigation was noted new CNA had turned alarm off without validating patient safety. Initiated education on elopement and wandering policy and procedure with emphasis on alarm procedure immediately with all staff present and continued for all employees prior to start of next shift. Maintenance director-initiated elopement drill immediately for all following consecutive shifts to ensure a drill was completed for all three shifts (am, pm, noc) further stressing understanding of process. Opportunities was on new hire orientation with emphasis on wandering and elopement policy and procedure and responding to door wander guard alarm. Employee's personnel file was reviewed noting education on HIPPA, QAPI program, Resident rights, Customer service, Elder abuse, Infection control, Bloodborne pathogens, Behaviors in the workplace, Safety/OSHA, Fire code, Dementia care and Ergonomics). The employee did have clinical education prior to working with residents on the floor and then hand in hand training with front line staff during orientation with residents. After a thorough and complete investigation and reviewing all data but not limited to staff interviews, EMS Chief interview, record review noting plan of care, orders, documentation, facility assessment r/t (related to) external doors, wander guard system and facility initiating proper procedure to search for patient immediately showed competency. The patient was assessed prior to incident and was noted to be at risk for wandering/elopement with interventions implemented and followed per plan of care to ensure a decreased risk of elopement with injury. The facility ensued a QAPI plan including but not limited to ensuring the affected patient is safe, all other residents identified at risk for elopement were accounted for, all other residents in the facility were accounted for, education, multiple audits focused on compliance and understanding of policy and procedures, facility revised the orientation packet to bolster understanding of elopement/wandering policy r/t responding to wander guard alarm. Example 2 - Harm Citation On 7/26/22, R4 pushed R5 down causing R5 to sustain a [CONDITION(S)] requiring an emergency room visit and staples to R5's [CONDITION(S)]. R5 was admitted to the facility on [DATE] with a diagnosis of Dementia with Behavioral Disturbance. R5 was ambulatory with a walker. R5's Progress Notes include in part: On 7/26/22 at 6:45 PM, Writer was called to front common area, when arrived noted resident was on the floor bleeding from back right side of head . complained of pain to back of head, laceration noted. Rated head pain 8/10 . contacted emergency services, DON (Director of Nursing) and family to notify. Resident stated she slipped and fell . Residents that were present reported that another resident had pushed resident with both hands and resident fell back and hit head . On 7/26/22, emergency room notes R5 presented in ER after being pushed by another resident. R5 had a hematoma (bruise) and laceration to the back of her head which required closure using 2 staples. R4 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance. On 7/26/22, R4's physician progress notes states in part: . Increasing behaviors with dementia in the form of sundowning. Add [MEDICATION(S)] at 25 milligrams at 3 PM and increase bedtime dose for 25 to 50 milligrams. Continue to monitor closely . On 9/26/22, R4's quarterly MDS (Minimal Data Set) assessment notes a BIMS (Brief Interview for Mental Status) score of 5 out of 15 indicating severe cognitive impairment. R4 can self-propel in her wheelchair. R4's comprehensive care plan includes in part: -Focus (dated- 12/01/21, Revision on 6/10/22): (R4) is/has potential to be physically aggressive (sic) toward staff during care and redirection related to behaviors r/t (related to) Dementia, cognitive deficits, poor impulse control, infatuation with another resident (male). Displays striking out, kicking, and attempting to hit staff. Does not respond consistently to redirection or separation from male resident. Recent incident with male resident requiring separation-resident became agitated as evidenced by striking out at staff and verbalizing in a loud tone of voice. -Goal (Dated 12/01/21, Revision on 6/10/22): (R4) will have fewer than 3 episodes of agitated/physically aggressive behaviors toward staff weekly during cares or residents. -Interventions (dated 12/01/21): Administer medication as ordered. Analyze times of day, places circumstances, triggers and what de-escalates behavior and document. Anticipate resident's needs . Provide physical and verbal cues to alleviate anxiety . Give resident as many choices as possible . Monitor & Document observed behavior and attempted interventions in behavior log . Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of resident posing danger to self and others . Review of R4's behavior care plan notes revisions on 8/19/22: . Interventions: (R4) triggers for physical aggression are ADL (Activities of daily living) cares, male individuals, and other residents. Her behaviors are de-escalated by redirection, calm voice, escort to quiet area, distraction, activities . Offer black stuffed cat as needed for psychosocial comfort and emotional support . Of note, there is no evidence the facility reviewed or updated R4's care plan after R4 pushed R5 on 7/26/22. There were no new interventions put in place for R4 until after 8/17/22, when R4 interacted with R18, those inventions were noted on 8/19/22. Review of R4's Behavior Monitoring on TAR (Treatment Administration Record) notes: Behavior Monitoring (Start date 10/18/21): (Physical/verbal aggression towards staff, verbal aggression towards residents/sexual behaviors with male residents) Document (number) of episodes days, evenings, and night shift. (Of note: There is no indication on this document as to what specific behaviors R4 is presenting on each date.) -June 2022 (total each day) 6/5/22-3 (behavioral episodes) 6/6/22-10 6/7/22-6 6/16/22-2 6/19/22-3 -July 2022 7/1/22 many is documented 7/8/22- 1 7/11/22-1 7/12/22-2 7/28/22-1 Of note, on 7/26/22 0 behaviors are documented for all 3 shifts, the date when R4 pushed R5. -August 2022 8/3/22-5 8/5/22-4 8/7/22-1 8/9/22-1 and many 8/11/22- many 8/13/22- many 8/15/22- many 8/17/22 - many 8/18/22- many 8/24/22-1 -September 2022 9/1/22- many 9/8/22- 1 9/11/22- 1 9/12/22-2 9/28/22-1 R4's Progress Notes include in part: On 7/19/22 at 6:00 PM (Late Entry): Resident (R4) agitated this evening . At present time, whenever another resident passes by this resident, this resident curses at the one who just went past. Attempted to redirect resident without success. This nurse made sure that all other residents passed by this resident without troubles. It is important to note there is no documentation in R4's progress notes on 7/26/22, when R4 pushed R5 causing R5 to fall with injury. On 7/28/22 at 7:19 PM: Resident started yelling at a male resident for no apparent reasons. This nurse attempted to redirect resident when resident turned around and attempted to hit nurse and the male resident. No physical contact was made by this resident. This nurse attempted to redirect resident with no success. This nurse kept this resident away from other residents. Offered resident an ice cream cup for a snack which resident took 100% of ice cream. On 8/8/22 at 9:44 PM: Resident was holding hands approximately 5 times with a male resident and discussing getting out of here with the same resident. Informed both that they needed to keep hands to themselves. Resident yelled and swore at resident each time behavior was addressed. On 8/9/22 at 2:44 PM (Late entry): Resident was arguing with other residents, upset with staff, cursing, and attempting to hit. On 8/9/22 at 9:42 PM: Resident was in another resident's room and when staff attempted to take her out of the room, she grabbed the handrail and pulled herself to the floor. The administrator and DON (Director of Nursing) were notified. On 8/17/22 at 9:47 PM: resident (R4) was in the lobby, touching male resident genitalia, hit staff, cursing, and calling names, arguing with staff and other residents. She (R4) was redirected to dining room, refused cares at bedtime, staff re-approached successfully and she finally went to bed around 10 PM. On 8/19/22, at 9:30 AM, R4's IDT (Interdisciplinary Team) Risk Note: . Behaviors: Sexually inappropriate with male residents. Makes comments to male staff but not exhibiting behaviors towards staff. OT (Occupational Therapy) working with her (R4) last 2 weeks .Need cognitive behavioral management. Will make referral to (name of facility) memory clinic for additional support. PCP (Primary Care Physician) updated on behaviors recommended [MEDICATION(S)]. Will look into black automated cat for comfort. Care Plan review/updates: Care Plan interventions in place. Triggers updated to include seeking males . On 9/29/22 at 4:00 PM, Surveyor interviewed CNA I (Certified Nursing Assistant) about R4, asking if CNA I was aware of R4 having any contact with male residents. CNA I indicated R4 had interest in a male resident in the past. CNA I recalled when CNA I was working on 8/17/22, just before supper time, R16 was in the resident lobby area sitting in a green lounge chair. CNA I stated he saw R4 was in her wheelchair sitting adjacent to R16, near R16's knees. CNA I stated he witnessed R4 and R16 were holding hands, CNA I said R16 was wearing shorts and he witnessed R16's penis was out of R16's shorts and saw R4 and R16's hands move to place hands on R16's penis. CNA I stated he saw other staff were moving toward R4 and R16 to separate them, so he did not intervene. On 9/30/22 at 9:45 AM, Surveyor interviewed DON B (Director of Nursing) about the incident between R4 and R5 on 7/26/22. Surveyor asked DON B besides getting new orders to increase R4's behavior medications on 7/26/22, what did the facility do to keep R4 and other residents safe? DON B stated she would look for information on this. On 9/30/22 at 10:10 AM, DON B provided Surveyor with copies of documentation of staff completing 15-minute checks for R4 dated 8/4/22-8/10/22. DON B stated the facility had started these checks after 7/26/22 but DON B could not find the papers as the former NHA (Nursing Home Administrator) had them. The facility had no evidence of immediate interventions put in place to protect R4 from having contact with other residents between 7/26/22 and 8/4/22. The facility was aware of R4's behaviors toward other residents before 7/26/22 as noted on R4's care plan dated 6/10/22 and staff interviews. The facility provided no further evidence of staff completing a review of R4's behaviors, a review of R4's care plan, or implementing new non-pharmacologic interventions to keep other residents safe from R4 including increasing supervision after 7/26/22 when R4 pushed R5, resulting in a fall with injury. R4 was not adequately supervised by staff and R4 continued to have behaviors and contact with other residents including contact with R16 on 8/17/22. Example 3 R1 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] ([CONDITION(S)] or sudden temporary loss of consciousness) and Collapse, History of Falling with fractures, Unspecified Dementia with Behavioral Disturbance, Anxiety Disorder, and Psychotic Disorder. On 8/24/22, R1's quarterly MDS (Minimum Data Set) assessment notes a BIMS (Brief Interview for Mental Status) score of 8 out of 15, indicating moderate cognitive impairment. Section J of R1's MDS notes no falls since previous assessment on 6/1/22. R1's quarterly Fall Risk assessment on 7/29/22 notes a score of 10 indicating R1 is at risk for falls. This assessment notes Resident has history of putting herself onto the floor from either wheelchair or bed and scooting to doorway for assist. R1 pivot transfers with assist of 1 with a gait belt. R1's comprehensive Care Plan initiated on 6/12/20 and revised on 5/2/22, includes in part: Focus:(R1) is as risk for falls r/t (related to) Gait/balance problems, side effects of medications, hx (history) of falls, vision impairment, changes in mobility (wrist fracture), impaired ability to use devices, cognition and poor safety awareness. 5/2/22 (R1) is stating if she (DON (Director of Nursing) doesn't come to talk to me. I will fall on the floor. Goal: (R1) will not sustain a serious injury due to fall . Interventions: Alarm on bed and in w/c (wheelchair) .anticipate and meet (R1's) needs, Be sure (R1's) call light is within reach and encourage her to use it for assistance as needed. (R1) needs prompt response to all requests for assistance . Follow facility fall protocol . Place fall mat on left side of bed and bed in low position when (R1) is in bed, PT (Physical Therapy) evaluate and treat as ordered or PRN (as Needed), Use inclined wheelchair, Visual reminders placed to use call light and wait for staff if resident needs help. (Initiated 6/2/22). On 9/29/22 at 9:10 AM, Surveyor observed R1 in a low bed with floor mat on left side of bed, bed alarm in place, call light in place and sign on wall to remind R1 to use call light for help. R1's Progress Notes note the following: On 7/14/22: . Around 7pm notes resident's alarm sound and call light on. Found residents crawling on floor in room to hallway . Assisted back up and into bed . On 7/21/22 at 9:47 PM, Resident did place herself on her floor, and stated that she was being poisoned. She was reassured that we were not poisoning her and was helped back to bed . On 7/24/22 at 9:57 PM, (R1) found on floor crawling, stated she was going to fire department. Pt. (patient) has no injury and is charted in care plan pt. can be on the floor. (It is important to note R1's Care Plan for falls, states to follow facility fall protocol, and there is no documentation in R1's care plan that R1 can be on the floor and no documentation of vital signs or neuro checks being completed.) On 8/3/22 at 3:16 PM, writer found resident sitting on the floor, inquired if she is hurt, hit her head, what she was doing and if she wanted to use the bathroom. She denied pain, said that she just wanted to sit there. Writer convinced her to go back to be and assisted her back to be. No neuro or VS (Vital sign) checked per care plan. On 8/7/22 at 8:02 PM, writer (sic) was found on the floor sitting in front of her door. She denies falling, I took myself there she said, because nobody wants to help me. Bed alarm was pulled out of patch, call light was in her bed but she did not press it to turn it on and call for help Resident was helped back to bed by staff, bed alarm was reactivated, writer reinforced education on safety, on proper call light use, keeping her bed alarm on. Resident verbalized understand and stated, it doesn't change anything nobody want to help me. On 8/12/22 at 8:30 PM, writer found resident sitting in the hallway . resident was helped in her chair and brought to the lobby .she put herself on the floor in front of the couch and had a bowel movement there . resident returned to her bed was cleaned up and laid back in her bed. No neuro checks stated by resident care plan. On 9/7/22 at 2:17 PM, resident was found on the floor, she was helped back to bed by staff .neuro and VS WNL (within normal limit). On 9/30/22 at 9:10 AM, Surveyor interviewed DON B (Director of Nursing) about R1 being found on the floor on 7/14/22, 7/21/22, 7/24/22, 8/3/22, 8/7/22, 8/12/22, and 9/7/22 as documented in R1's record. Surveyor asked DON B if there were fall investigations for R1's falls, DON B stated there were not. Surveyor asked if R1 lowering herself to the floor from her bed or wheelchair would be considered a fall? DON B stated yes it would be a fall, as R1 moved from one plane to a lower plane. Surveyor asked if R1's care plan includes that R1 can be on the floor? DON B stated no it doesn't. Surveyor asked if fall investigations should have taken place for R1's falls (7/14/22-9/7/22). DON B stated there should have been fall investigations for R1's falls and there were not. Example 4: The facility policy titled, Fall Risk Assessment, dated 2021, states in part . Policy: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Policy Explanation and Compliance Guidelines: 1. The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when significant change is identified. 6. When a resident has a near miss or a fall, the nurse will assess immediately for s/sx (signs and symptoms) of injuries including vitals and Neurological checks if indicated. The facility policy titled, Fall Prevention Program, dated 2021, states in part . Policy: Each resident will be assessed f [TRUNCATED]

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PI) from worsening for 2 of 3 resident reviewed for PIs, out of a sample of 18 residents (R29 and R35). The facility did not ensure interventions were in place to prevent the PI from developing or worsening. R29 developed a Stage 2 PI, on 7/11/21, which progressed to a stage 3 PI on 8/07/21. R35's care plan interventions for PI healing were not followed. This is evidenced by: The facility's policy, Pressure Injuries (Ulcer) Prevention, undated, states, in part . Purpose: The purpose of this procedure is to provide information regarding pressure injury (formerly pressure ulcers) prevention. General Guidelines: 2. The most common site of a pressure injury is where the bone is neat the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, ankles, and toes. 4. Pressure injuries are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. Interventions and Preventive Measures: General: General Preventative Measures: standard measure expected to be provided to all residents by the nursing staff. 1. Identify risk factors for pressure ulcer development. 2. For a person in bed: d. Float heels off the bed if the person needs assistance with positioning. 3. For a person in a w/c (wheelchair), geri chair, etc. a. Change position at least every hour. 5. Risk Factor - Immobility. c. When in bed, every attempt should be made to float heels (keep heels off the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician. Example 1 R29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R29's admission Braden Score, completed on 7/16/19, shows a score of 18, indicating R29 is at risk for PI development. R29's Comprehensive Care Plan, dated 7/16/19, states in part . R29 has an ADL (Activities of Daily Living) self-care performance deficit r/t [related to] [CONDITION(S)] C5-C7 E/B [Evidenced by] inability to independently do ADL's [activities of daily living]. Bed Mobility: R29 requires total assist by 2 staff to turn and reposition in bed every two hours and as necessary. R29's Comprehensive are Plan, dated 8/01/19, states in part . R29 is resistive to care declining to be repositioned during nights. - If possible, negotiate a time for ADL's so that the resident participates in the decision-making process. Return at the agreed upon time. R29 agreed to be turned between 0300 [3:00 AM] and 0400 [4:00 AM]. R29's Comprehensive Care Plan, dated 7/16/19, states in part . R29 has potential for pressure ulcer development r/t [CONDITION(S)] E/B inability to independently do ADL's. 9/22/21: Bilateral metatarsals. - Encourage R29 to use tilt feature in w/c for pressure reduction. - Inform the resident/family/caregivers of any new area of skin breakdown. - Reposition R29 using full lift throughout the day as needed. - R29 needs monitoring/assistance to turn/reposition at least every 2 hours, more often as needed or requested. - R29 requires pressure relieving device for bed/chair R29's most recent Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview of Mental Status (BIMS) of 15, indicating R29 is cognitively intact and is her own decision maker. In R29's most recent MDS, section G0110 indicates extensive assist of two staff is needed with bed mobility and dressing. R29 is dependent of two staff members for transfers and toileting. R29 needs extensive assistance of one staff member for hygiene. Section G0400 states, Function limitation in ROM [Range of Motion]: Upper extremities - impairment on both sides and Lower extremities - impairment on both sides. R29's Certified Nursing Assistant (CNA) Care Plan states in part . Repositioning/Skin Care: Allow R29 to make decisions about treatment regime, to provide sense of control. Assess/record/monitor wound healing weekly and as needed. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD [Medical Doctor]. (Note: Interventions used to prevent and heal pressure injuries are not listed on the Comprehensive or CNA care plans.) On 5/15/22 at 10:43 AM, Surveyor interviewed R29 during screening. Surveyor asked R29 how long she has had her pressure injuries. R29 stated, I have had them for months. Surveyor asked R29 if staff recognized her wounds timely and took appropriate action. R29 stated, No, I think they could have done something sooner. Surveyor asked R29 if she was being repositioned prior to getting the wounds. R29 stated, No. Surveyor asked R29 if she can reposition herself. R29 stated, No. Surveyor asked R29 how long she has had an air mattress. R29 stated, Since admission. R29's most current Treatment Administration Record (TAR) dated 5/01/22, states in part . 1. Remove old dressing. 2. Spray wound beds thoroughly with [MEDICATION(S)] cleanser. 3. Pat dry with gauze. 4. Generously apply skin prep barrier wipe to entire peri wound area, up to but not in wound bed. 5. Apply [MEDICATION(S)] to wound bed. 6. When skin prep dry, apply 4x4 bordered foam dressing. 8. Apply white ted hose stockings GENTLY to ensure that dressing remains intact. Every day for BL [bilateral lower] pressure ulcers. R29's Weekly Skin assessment dated , 7/11/21 at 12:46 PM, states in part . A. Communication: 3. Special Equipment/Preventative measures (i.e., gel mattress/pad, special bed/Mattress, side rail pads etc.). Pressure-reducing mattress. 4. Resident is on turning and repositioning routine. B. Observations/Data: 1. Location: Lateral aspect of R [Right] distal phalange. Pressure Ulcer Stage: 4a. Original: a. SDTI [Suspected Deep Tissue Injury] . 5. Visible Tissue. 5a. Overall Impression. First Observation, no reference. 6. Drainage. None. 7. Odor. 7a. Odor Present, None. 8a. Length. 1.5 cm. 8b. Width. 2.2 cm. 9a. Description of peri-wound tissue: intact. Treatment: 2. Current treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . R29's Weekly Skin assessment dated , 7/11/21 at 12:48 PM, states in part . A. Communication: 3. Special Equipment/Preventative measures (i.e., gel mattress/pad, special bed/Mattress, side rail pads etc.). Pressure-reducing mattress. 4. Resident is on turning and repositioning routine. B. Observations/Data: 1. Location: Lateral aspect of L (Left) distal phalange. Pressure Ulcer Stage: 4a. Original: a. SDTI. 5. Visible Tissue. 5a. Overall Impression. First Observation, no reference. 6. Drainage. None. 7. Odor. 7a. Odor Present, None. 8a. Length. 1.3 cm. 8b. Width. 1.3 cm. 9a. Description of peri-wound tissue: intact. Treatment: 2. Current treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . (Note: U-shaped pad and blue boots are not on comprehensive nor CNA care plan.) R29's Progress Note, on 7/11/21 at 18:59 (6:59 PM), indicates Pressure area SDTI noted at the lateral aspect of left proximal phalanx of the 5th toe 1.3 cm [Centimeter] by 1.3 cm and pressure area SDTI noted at the lateral aspect of right proximal phalanx of the 5th toe 1.5 cm by 2.2 cm skin intact. U shaped pad and blue boots on both feet to off load pressure areas. R29's Weekly Skin assessment dated , 8/07/21 at 12:25 PM, states in part . A. Communication: 3. Special Equipment/Preventative measures (i.e., gel mattress/pad, special bed/Mattress, side rail pads etc.). Alternating pressure mattress and pressure-reducing boots. 4. Resident is on turning and repositioning routine. B. Observations/Data: 1. Location: Lateral aspect of L (left) distal phalange. Pressure Ulcer Stage: 4a. Original: a. SDTI. Stage at the highest level, do not down-stage as the wound heals. 4b. Current. d. Stage III. 5. Visible Tissue. 5a. Overall Impression. d. Worsening. 5c. Granulation tissue present. 5f. Moist. 6. Drainage. Serosanguinous. 7. Odor. 7a. Odor Present: Yes. 7b. Odor present upon removal of dressing. 8a. Length. 2.1 cm. 8b. Width. 1.8 cm. 8c. Depth: 0.4 cm. 9a. Description of peri-wound tissue: intact. 9b. Describe wound edges and shape: irregular d/t [due to] macerated skin [MEDICATION(S)] with gentle cleansing. 9d. Wound initially covered with macerated tissue that debrided with gentle cleaning by writer. 10. Infection suspected? 10b. Describe: Odor present when dressing removed; dissipated with cleansing. Treatment: 2. Current treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Evaluation. Wound progress: worsening as evidenced by newly open ulceration. R29's Weekly Skin assessment dated , 8/07/21 at 14:31 PM (2:31 PM), states in part . A. Communication: 3. Special Equipment/Preventative measures (i.e., gel mattress/pad, special bed/Mattress, side rail pads etc.). Alternating pressure mattress and pressure-reducing boots. 4. Resident is on turning and repositioning routine. B. Observations/Data: 1. Location: Lateral aspect of R distal phalange. Pressure Ulcer Stage: 4a. Original: a. SDTI. Stage at the highest level, do not down-stage as the wound heals. 4b. Current. d. Stage III. 5. Visible Tissue. 5a. Overall Impression. d. Worsening. 5c. Granulation tissue present. 5f. Moist. 6. Drainage. Serosanguinous. 6b. Amount: Moderate. 7. Odor. 7a. Odor Present, Yes. 7b. Odor present upon removal of dressing. 8a. Length. 5.5 cm. 8b. Width. 2.52 cm. 8c. Depth: 0.2 cm. 9a. Description of peri-wound tissue: SDTI tissue still present, which is measured above. Open area as follows: 2.5 cm x [by] 2.5 cm x 0.2 cm. 9b. Describe wound edges and shape: irregular d/t [Due to] macerated skin [MEDICATION(S)] with gentle cleansing. 10. Infection suspected? 10b. Odor present when dressing removed; dissipated with cleansing. Treatment: 2. Current treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Evaluation. Wound progress: worsening as evidenced by newly open ulceration. Nurses Note from 8/06/21 at 19:30 (7:30 PM), Late Entry: Note Text: Stage III full thickness pressure sore discovered on lateral aspect of the bottom of the right heel. No undermining or tunneling noted, scant amt [amount] of slough present in wound bed. Wound bed approximately 2.5cm x 2.5cm x 2mm with small amt of purulent drainage, slight foul odor noted. Peri wound extends approximately 3cm in length from wound bed and 0.2cm in width from wound bed. Peri wound reddish-purple in color, boggy, skin fragile and thin closer to wound bed, becoming firmer moving outward from wound bed. Cleansed wound with NS and sterile gauze, applied metahoney [sic] and calcium alginate to wound bed, covered with non-adhesive absorbent dressing and wrapped with gauze to secure in place. Resident informed regarding situation and updated on plan of care at this time, ADON [Assistant Director of Nursing] updated and will assess AM shift 8/7/21. (It is important to note that PIs were initially discovered on 7/11/21; interventions to prevent and/or heal pressure injuries were never placed on the comprehensive or CNA care plan. R29 did not have an intervention to offload the feet/heels prior to PI development, nor was this intervention added to the care plan or CNA care card after development.) R29's Weekly Skin assessment dated , 5/12/22 at 14:13 PM (2:13 PM), states in part . A. Communication: 3. Special Equipment/Preventative measures (i.e., gel mattress/pad, special bed/Mattress, side rail pads etc.). pressure relief mattress, always offloading boots, protein supplements. 4. Resident is on turning and repositioning routine. B. Observations/Data: 1. Location: Left distal foot. Pressure Ulcer Stage: 4a. Original: a. SDTI. Stage at the highest level, do not down-stage as the wound heals. 4b. Current. d. Stage III. 5. Visible Tissue. 5a. Overall Impression. b. improving. 5b. Epithelial tissue present (pink). 6. Drainage. None. 7. Odor. 7a. Odor Present, No. 8a. Length. 0.5 cm. 8b. Width. 0.9 cm. 9a. Description of peri-wound tissue: 100% granulated. 9b. Describe wound edges and shape: well, defined. Treatment: 2. See order. R29's Weekly Skin assessment dated , 5/12/22 at 14:28 PM (2:28 PM), states in part . A. Communication: 3. Special Equipment/Preventative measures (i.e., gel mattress/pad, special bed/Mattress, side rail pads etc.). pressure relief mattress, always offloading boots, protein supplements. 4. Resident is on turning and repositioning routine. B. Observations/Data: 1. Location: Right distal foot. Pressure Ulcer Stage: 4a. Original: a. SDTI. Stage at the highest level, do not down-stage as the wound heals. 4b. Current. d. Stage III. 5. Visible Tissue. 5a. Overall Impression. b. improving. 5f. Moist. 6. Drainage. Serosanguinous. 6b. Amount: Scant. 7. Odor. 7a. Odor Present, No. 8a. Length. 0.4 cm. 8b. Width. 0.3 cm. 9a. Description of peri-wound tissue: dry, scabbed. 9b. Describe wound edges and shape: well, defined. Treatment: 2. See MAR [medication administration record]. On 5/16/22 at 10:08 AM, Surveyor observed LPN F (Licensed Practical Nurse) complete wound care on R29. LPN F entered room and washed hands and put on gloves. LPN F removed old dressing from the left foot without gloves. LPN F put on gloves and cleansed wound bed, applied skin prep, Medi-honey, and gauze bordered foam dressing to wound. Gloves removed and discarded. LPN F removed old dressing from the right foot without gloves and discarded. New gloves applied and wound cleansed. Skin prep, Medi-honey, and gauze bordered foam dressing applied to wound. Gloves removed and discarded. LPN F cleaned up supplies and washed hands (Note: LPN F washed hands prior to beginning and after wound care was complete. LPN F did not wash her hands or change her gloves after removing old dressings, after cleaning and prior to applying clean dressings to the left and right foot. Cross reference F880.) On 5/17/22 at 7:35 AM, Surveyor interviewed Med Tech/CNA G (Medication Technician/Certified Nursing Assistant). Surveyor asked Med Tech/CNA G if she is aware of when R29 starting offloading heels in bed and wearing offloading boots. Med Tech/CNA G stated, I started here in November, and she has had the boots and heels up since I have been here. Surveyor asked Med Tech/CNA G where she would look to find interventions being used for pressure reduction on residents. Med Tech/CNA G stated, The CNA or regular care plan. On 5/17/22 at 8:42 AM, Surveyor interviewed CNA H. Surveyor asked CNA H if she is aware of when R29 starting offloading heels in bed and offloading boots. CNA H stated, That has been a few months. Since she got her PI's. Heels up with pillows have always been used. R29 has had the air mattress since she has been here. R29 has not been repositioned every 2 hours as she refuses at times. We do tell her it is best for her. On 5/17/22 at 9:06 AM, Surveyor interviewed DON B. Surveyor asked DON B about interventions for R29. DON B stated, R29 always wears boots, when wounds developed the boots were put into place. Heels up always have been. On 5/17/22 at 3:13 PM, Surveyor interviewed CNA I. Surveyor asked CNA I where he would find the information on how to care for a resident or what their needs were. CNA I stated, I would be able to find that information on the CNA care plan. On 5/17/22 at 3:16 PM, Surveyor interviewed CNA N. Surveyor asked CNA N where she would find the information for a resident's needs to changes to their care plan. CNA N stated, The CNA Kardex would let me know if someone's needs to care plan has changed. On 5/17/22 at 3:22 PM, Surveyor interviewed DON B. Surveyor asked DON B how staff are aware of changes made to a resident's plan of care. DON B stated, By reviewing the residents care plan. On 5/18/22 at 7:51 AM, Surveyor interviewed RN J (Registered Nurse). Surveyor asked RN J where staff go to find out how to care for a resident or their needs. RN J stated, The computer care plan or the CNA Kardex. Facility provided Surveyor with a copy of a Performance Improvement Action Plan - Skin Management Program, dated 4/04/22, that states in part . Root Cause: Residents not being repositioned, causing skin issues - standards of care not being consistently implemented; wound charting not completed following wound rounds. Action Items: R29, 8/07/21, treatment not initiated, care plan and care card reviewed and updated, as well as proper notification. 100% skin sweep completed. Residents identified with skin issues, or those to have potential to develop skin issues have interventions in place. All Licensed nurses and CNAs will be educated in Pressure Injury and preventions, which will include a post test. All new LN (Licensed Nurses) and CNA staff will be educated on this material. Wound rounds charting will be completed when wounds rounds done. (Note: All Action Items are listed as completed with the exception of wounds round charting which is ongoing.) (Note: R29's comprehensive and CNA care plan have not been updated to include interventions to heal and prevent pressure injuries.) (Note: Only 21 of the 37 listed Licensed Nurses and CNAs had been educated on the Performance Improvement Action Plan.) R29 was admitted without a PI. The facility did not ensure that interventions were in place to prevent PI development, comprehensive and CNA care plans were updated with current interventions to prevent and heal pressure injuries. Example 2 R35 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R35 has a BIMS score of 5 recorded on 4/26/2022 which indicates severe cognitive impairment. R35's care plan included in part . focus area of stage 4 pressure ulcer of sacrum related to immobility .will show signs of healing and remain free of infection R35 is to be up in the wheel chair for all meals, then back in bed at least 30 minutes after finishing meal, with limited pressure to right side of buttocks .needs assistance to turn/reposition at least every 2-3 hours, more often as needed or requested . The information regarding repositioning was also present on the CNA (Certified Nursing Assistant) care card. On 5/17/2022, Surveyor made the following observations of R35. At 8:25 AM, R35 was seated in her wheelchair at the breakfast table. At 10:14 AM, Surveyor noted R35 sitting in the wheelchair in her room. R35 attended lunch in the dining room in her wheelchair at 11:48 AM and remained in the wheelchair until 12:55 PM, when Surveyor observed staff transfer R35 to bed. Surveyor observed R35 in her wheelchair at 4:10 PM and R35 remained there until at least 6:20 PM when Surveyor exited the building. Surveyor observed the resident call light on from 6:02-6:11 PM and then a staff member came in and could be overheard stating, We will put you to bed in a little bit and exited the room. On 05/18/22 at 07:20 AM Surveyor asked CNA R (Certified Nursing Assistant), did you care for R35 yesterday? CNA R stated, Yes. Surveyor asked CNA R, do you feel you have enough time to care for R35? CNA R answered, Yes. Surveyor asked, do you have R35's care card available to you? CNA R stated, Yes. Surveyor asked CNA R, how long is R35 supposed to be up in the chair? CNA R stated, About two hours, she goes back to bed after lunch. Surveyor asked, R35 only returns to bed after lunch? CNA R stated, I believe so, but I am still learning. Surveyor asked CNA R, may I see her care card? CNA R stated, It's on the computer, I don't have it with me. On 5/18/22 at 8:10 AM, Surveyor observed CNA S transfer R35 to the wheelchair. Surveyor asked CNA S, how do you know how to care for the residents? CNA S stated, Their care card. Surveyor asked CNA S, do you print it off and carry it with you? CNA S stated, No, it's on the computer. Surveyor asked, how do you learn of updates? CNA S stated, In nursing report. Surveyor asked CNA S, how long is R35 to be up in the wheelchair? CNA S replied, R35 is to be up for meals and then back to bed 30 minutes after she finishes. Surveyor asked CNA S, is 4 hours too long for R35 to be up in the wheelchair? CNA S stated, Yes. On 5/18/2022 at 10:34 AM, Surveyor observed R35 was still in her wheelchair from breakfast. At 11:48 AM, R35 was in her room and then was observed being transported to lunch in the wheelchair. At 12:35 PM, Surveyor observed R35 asleep in the wheelchair in front of her window and at 1:41 PM, R35 was observed being transferred to bed. On 5/18/2022 at 1:10 PM, Surveyor asked DON B (Director of Nursing), what is R35's repositioning plan? DON B replied, R35 is up for meals and then back to bed, 30 minutes after eating so her wounds heal. Surveyor asked DON B, do you expect your CNAs to put R35 back to bed 30 minutes after each meal? DON B stated, Yes. Surveyor informed DON B that R35 was observed in the wheelchair for over four hours yesterday and today. DON B stated, OK, I will take care of that. Of note, in R35's room was a notice which stated in part . R35 needs to be repositioned every 2 hours and should never be placed on her buttocks. Side to side repositioning ONLY. Please see and sign off sheet in her room with every reposition. NO EXCEPTIONS. Upon Surveyor review of the repositioning sign off, there were days missing and on the days of 5/17/2022 and 5/18/2022, R35 was signed out as repositioned twice daily. The facility failed to follow the resident care plan and standards of care in repositioning to promote wound healing.

Based on interview and record review, the facility did not promptly consult with the physician when 1 of 3 residents reviewed (R1) of a total sample of 5 residents had a significant change in condition following a fall from bed. On [DATE], R1 fell approximately four feet from his bed to the floor when a certified nursing assistant provided care without assistance of a second person, as directed in R1's care plan. The nurse failed to consult with an MD before moving R1 off of the floor or inform the physician of a change in R1's pain level compared to baseline. Later, when R1 experienced acute changes in mental status, pain, and oxygen saturation levels, the nurse failed to promptly consult with a physician. The facility's failure to immediately consult a physician with a significant change in condition resulted in a delay of treatment and alternative hospital interventions for R1. R1 later expired at the hospital as a result of his injuries. This created a finding of Immediate Jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) of the Immediate Jeopardy on [DATE] at 11:00 AM. The Immediate Jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action/corrective plan. Evidenced by: The facility policy entitled Notification of Change, revised ,d+[DATE], includes, in part: A facility must immediately inform the resident, consult with resident's physician and notify, consistent with his or her authority, the resident representative when there is: an accident involving the resident which results in injury and has the potential for requiring physician intervention, a significant change in resident's physical, mental, or psychosocial status, . a decision to transfer or discharge the resident from the facility for one of the following reasons: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . the safety of the individuals in the location is endangered due to clinical or behavioral status . When making notification to the physician, the facility must ensure that all pertinent information is available and provided upon request When the facility transfers or discharges a resident under any circumstances, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving healthcare institution . R1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of [DATE] indicates R1 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. R1's MDS indicates he requires extensive physical assistance of two or more staff to meet his needs in dressing, toileting, bed mobility, bathing, and personal hygiene. R1's CNA (Certified Nursing Assistant) Care Card, includes, in part: . Bathing: R1 is totally dependent on staff to provide a bath with two assist . Dressing: R1 requires two staff participation to dress. Bed mobility: Turn side to side, two staff assist and total lift . Toileting: check and change approximately every 2 hours . R1's Physician Order, dated [DATE], includes, in part: oxygen on 2 liters/Nasal Cannula via concentrator at night. R1's Pain history, dated [DATE]- [DATE], includes: January: 1 time R1 reported 1 out of 10 pain, all other times he reported 0 out of 10 pain February: 3 times R1 reported 2 out of 10 pain, 1 time R1 reported 4 out of 10 pain, 1 time R1 reported 5 out of 10 pain, all other times he reported 0 out of 10 pain. R1's Incident Report, dated [DATE], includes: Writer Licensed Practical Nurse (LPN) D called to room when resident rolled out of bed and onto floor during cares this morning. Resident was lying on his back/right side on the floor between bed and window when writer arrived. Resident stated that he fell out of bed while being rolled by Certified Nursing Assistant (CNA) C during cares. Resident reported that right hip and right knee were experiencing pain, but stated he didn't believe he hit his head. Vitals and Neuro checks, assessed, both stable and within normal limits, assisted from floor to bed with full lift and 3 staff members . -Assessment . Incident date/time: [DATE] 5:15 AM . mental status: oriented x 4, no injuries observed post incident. Vitals: Temperature: 96.9, Pulse: 67, Respirations: 20, Blood Pressure: ,d+[DATE] . pupils: equal and reactive to light, can follow finger with eyes, responds to simple commands, verbal expression of pain at a 4 out of 10, grimaces, withdraws, shows nonverbal signs of pain, movement and sensation intact in extremities, yes, resident has no mobility in extremities but sensation is intact. It is important to note, R1 fell from 4ft and has no mobility in extremities and is complaining of new onset pain. There was no immediate consultation with a physician. On [DATE] at 3:38 PM during an interview LPN D indicated 4 out of 10 pain and 8 out of 10 pain was not R1's baseline (it was not his usual). LPN D stated, In hindsight, I should have left him on the floor and called 911. On [DATE] at 2:29 PM during an interview DON B indicated LPN D should have called 911 when R1 complained of pain after a fall from approximately 4 ft. DON B stated, I would have called 911 immediately. According to the Incident Report: At 7:00 AM resident began experiencing altered mental status, although he was oriented x 4 resident displayed slurred speech, difficulty articulating words, and slow to respond verbally. Oxygen saturation declined and had difficulty maintaining oxygen greater than 90 % on 5 Liters/ Nasal Cannula. Sent to emergency department for evaluation at 8:00 AM. In her note at 7:32 AM, LPN D noted . last set of vitals and neuros at 7:00 AM, RN E reported oxygen at ,d+[DATE]% on 2 Liters via nasal cannula. Also reported that resident was having difficulty coming up with words, speech slow and slightly slurred, and kept repeating himself. Resident's tongue veers right when asked to stick it out straight. Voicemail left for PCP (MD F) to call facility. NHA A updated regarding condition. In her note at 7:26 AM, RN E noted: When I Registered Nurse (RN) E came to assess resident for vitals and neuro checks, observed resident would not [sic] able to come up with words to communicate and would look at nurse long time without blinking or moving his eyes. At the same time, resident was on supplemental oxygen on 1 Liter/ Nasal Cannula and sats were in ,d+[DATE]'s, increased to 5 Liters/Nasal Cannula, sats went up to low 90's and stay up, but when resident would fall asleep sats were dropping to upper 70's on 5 Liters/Nasal Cannula. Resident had asymmetrical smile, and right side lips were thinner and tongue protruding to the left side. Contacting PCP (Primary Care Provider). According to the Mayo Clinic, [CONDITION(S)] is a sign of some other condition .Because [CONDITION(S)] is often a sign of a serious problem, such as a stroke, seek emergency medical care if you suddenly develop: Difficulty speaking Trouble understanding speech Difficulty with word recall Problems with reading or writing https://www.mayoclinic.org/diseases-conditions/[CONDITION(S)]/symptoms-causes/syc- 518 On [DATE] at 12:09 PM during an interview, RN E indicated on [DATE] she worked the AM shift and upon arrival she was given report from LPN D. LPN D indicated to RN E that R1 had a fall and she went into R1's room at about 6:45 AM. RN E indicated she noticed a change in R1's mental status almost immediately upon trying to interact with him. RN E indicated she noticed R1 wasn't responding appropriately, he was staring, and his oxygen was on 1 Liter and is usually at ,d+[DATE] Liters. RN E checked R1's vitals and his oxygenation levels. His oxygen was ,d+[DATE] %. RN E changed R1 to a mask and turned oxygen machine up to 5 Liters. RN E indicated she told LPN D, We need to call the doctor. Things are not going right. It is important to note at 7:32 AM, while nursing had left a message for the physician, neither nurse (LPN D or RN E) had yet spoken to R1's PCP/ MD F or any Physician. On [DATE] at 2:29 PM during an interview DON B indicated LPN D should have called 911 when R1's Medical Doctor did not answer. On [DATE] at 1:41 PM during an interview, MD F, who is R1's PCP, indicated he missed two calls from the facility on [DATE] in the morning and he returned the call around 7:30 AM. Surveyor asked R1's MD F if staff were not able to get hold of him what should they do. MD F stated, I cannot answer that. Surveyor asked if R1 falling from 4 ft. high and complaining of pain created a need for emergency action. MD F stated, I cannot answer that. (It is important to note MD F is also the facility's Medical Director.) R1's hospital notes, dated [DATE], include, in part: . presenting today after a fall at skilled nursing facility, He presents with hip pain, [CONDITION(S)], and altered mental status . MUSKOSKELETAL: shortened and externally rotated left limb. Gross abnormality of left hip. Effusion of right knee. Pain with passive flexion of right and left knee/hip. Per documentation, the patient was in his typical state of health until this morning at about 5:15 AM when he was moved at his facility and had an accidental fall off the bed (approximately 4 ft.). He fell on to his right hip and side per facility documentation. At the facility vital checks and neuro checks were initiated. At approximately 7:00 AM they noticed an altered mental status. He began repeating himself, slower to speak, slightly slurred speech. He was complaining of 8 out of 10 pain in right knee and hip pain. He was also hypoxic on 5 Liters compared to his baseline of ,d+[DATE] Liters at night. Upon arrival to Emergency Department, patient was able to answer simple questions with one to two word answers. He was slow to respond. He endorsed pain in his right knee and right hip. He denied chest pain. He endorsed some difficulty breathing. Appreciated to be hypoxic to the 70's. Initially placed on non-rebreather briefly and then transitioned to [CONDITION(S)] . STAT films of pelvis, bilateral knees, and bilateral femurs showed bilateral proximal femur fractures (possibly acute on chronic) and acute right distal femur fracture. Imaging: Bilateral ununited fractures of the proximal femurs, acute fracture of the right distal femur, suspicious for subcapital fracture of the left hip. Of note, the patient had a fall from his wheelchair in ,d+[DATE] resulting in right hip and left femur fractures that were treated conservatively. His long bone fracture may also implicate fat emboli as possible cause of [CONDITION(S)] . He was no longer responding to verbal stimuli. Upon family arriving to emergency department, it was further determined the patient would want to be comfortable. Upon arriving to the hospital hospice unit, the patient was not responsive to verbal or painful stimuli. Oxygen and Foley in place. Appeared to be in respiratory distress and very congested on exam. Staff worked diligently to provide comfort for patient .Family was escorted to bedside and the patient passed away peacefully at 2:00 PM on [DATE] . On [DATE] at 1:02 PM during an interview with R1's ME G (Medical Examiner), she stated,R1 had a clear disfiguration of his leg. There was a dip on the top of his leg that comes to a V and you could set a coffee mug in it. I don't know how they would not see this. The facility's failure to immediately consult with a physician for a significant change of condition created a situation of immediate jeopardy, starting on [DATE]. The jeopardy was removed on [DATE] when the facility implemented the following: 1) On [DATE] a full house sweep was completed to determine if there were any residents who presented with evidence of any change of condition that would require implementation of residents' assessments, changes of condition, notification to physician/provider, resident and/or resident's responsible party, and requiring documentation of immediate follow up. 2) On [DATE] the 24 hour report sheet was reviewed to recognize any areas of concerns requiring immediate follow up, any concerns requiring implementation of a resident assessment, and change in condition requiring immediate follow up reporting/notifying physician and/or provider and/or responsible party of changes in condition. 3) On [DATE] a medical record review was completed on all residents in the facility to determine any areas of concern requiring immediate follow up, any concerns requiring implementation of a resident assessment, and any change of condition requiring immediate follow up reporting/notifying physician and/or provider or resident and/or responsible party of changes of condition. 4) Prior to their next working shift, licensed nurses will be educated by the DON/Designee on recognition of a change of condition per recognized standards of practice and the need to immediately notify the physician per recognized standards of practice of a change in resident treatment when required. 5) Prior to their next working shift, licensed nurses will be educated by the DON/Designee not to move a resident who has had a fall/accident until a full head to toe assessment is completed by an RN. If there is an indication of moving the resident that will cause the potential for further harm, the RN will then make the resident comfortable and call the physician or 911 if warranted. 6) Prior to their next working shift, all licensed nurses will be competency checked by the DON/Designee on the recognition of a change in condition. 7) Prior to their next working shift, all RNs will be competency checked by the DON/Designee on completing thorough heat to toe assessments. LPNs will be instructed to immediately contact an RN to complete an assessment for any change of condition. If an RN is not in house, the LPN will be instructed to call the on-call RN. 8) Prior to their next working shift, licensed nurses will be educated by the DON/Designee on how to complete a full head to toe assessment. Return demonstrations by licensed nursing staff (to be monitored by the Nurse Manager/Designee) to validate competency will be performed. Certified Nursing Assistants will be educated by the Nurse Manager/Designee on how to report changes in condition of resident to the licensed nurses. Certified nursing assistants will also be evaluated via post-test to determine competency.

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 3 residents reviewed (R1) of a total sample of 5 residents. After R1 fell four feet from the bed to the floor, the licensed practical nurse (LPN) failed to follow professional standards of practice as outlined in N6, Wisconsin Nurse Practice Act. The LPN did not report the fall to a registered nurse (RN) so the RN could perform a complete comprehensive assessment before determining whether R1 could be moved off the floor and perform ongoing monitoring and assessment of R1's condition. R1 was transferred to the hospital several hours post fall and found to have multiple fractures. R1 expired, later that day, from his injuries. The failure to complete an immediate comprehensive assessment and to perform ongoing monitoring delayed medical treatment. This created a finding of Immediate Jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) of the Immediate Jeopardy on [DATE] at 11:00 AM. The Immediate Jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action/corrective plan. Evidenced by: The facility policy, entitled Fall Prevention and Management, revised ,d+[DATE], includes, in part: .for fallen residents: Do not move resident . For a fall with injury, do the following: . a nurse must observe the resident and perform a full-body exam to determine if there may be suspected injury and direct whether to move the resident. Do not attempt to move the resident if spinal or [CONDITION(S)] is suspected. Obtain blood pressure, pulse, respiratory rate, pulse oximetry and temperature. If fall is not witnessed, neurological checks are required and must be documented in the medical record. Continue to monitor resident's condition; communicate updates as needed .Complete fall scene huddle worksheet. For residents with injury complete after resident is stabilized and/or transferred. When there is no injury use a total lift to transfer the resident off the floor. The facility policy entitled Pain Management, Data Collection and Assessment and Non-pharmacological Pain Interventions, revised ,d+[DATE], includes, in part: Purpose: To provide resident assistance in pain management, to promote well-being by ensuring that residents are as comfortable as possible, to determine what pain relief interventions specific to the resident can be used to aid in maintaining a comfortable level of function and quality of life . Policy: We will engage all employees within the scope of their individual training and licensure in the recognition, skilled observation/assessment, treatment, management, and monitoring of pain. The Registered Nurse will assess current pain levels and develop with the physician and interdisciplinary team interventions . The Registered Nurse will review response to medication intervention and work closely with the Physician to assist in the individualized pain management plan. According to N6, Wisconsin Nurse Practice Act, Standards of practice for licensed practical nurses (LPN) include: (1) In the performance of acts in basic patient situations, the L.P.N. shall under the general supervision of an R.N or the direction of a provider: (a) Accept only patient care assignments which the L.P.N is competent to perform (b) Provide basic nursing care (c) Record nursing care given and report to the appropriate person changes in the condition of a patient. (d) Consult with a provider in cases where an L.P.N. knows or should know a delegated acts may harm a patient. (e) Perform the following other acts when applicable: 1. Assist with the collection of data . R1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of [DATE] indicates R1 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. R1's MDS indicates he required extensive physical assistance of two or more staff to meet his needs in dressing, toileting, bed mobility, bathing, and personal hygiene. R1's Comprehensive Care Plan, includes in part: . [DATE] Bathing: R1 is totally dependent on staff to provide a bath with two assist . Dressing: R1 requires two staff participation to dress. Bed mobility: Turn side to side, two staff assist and total lift . Toileting: check and change approximately every 2 hours. R1's CNA (Certified Nursing Assistant) Care Card, includes, in part: . Bathing: R1 is totally dependent on staff to provide a bath with two assist . Dressing: R1 requires two staff participation to dress. Bed mobility: Turn side to side, two staff assist and total lift . Toileting: check and change approximately every 2 hours . R1's Pain history, dated [DATE]- [DATE], includes: January: one time R1 reported 1 out of 10 pain, all other times he reported 0 out of 10 pain. February: Three times R1 reported 2 out of 10 pain, one time R1 reported 4 out of 10 pain , one time R1 reported 5 out of 10 pain, all other times he reported 0 out of 10 pain. R1's Incident Report, dated [DATE], includes: Writer Licensed Practical Nurse (LPN) D called to room when resident rolled out of bed and onto floor during cares this morning. Resident was lying on his back/right side on the floor between bed and window when writer arrived. Resident stated that he fell out of bed while being rolled by Certified Nursing Assistant (CNA) C during cares. Resident reported right hip and right knee were experiencing pain, but stated he didn't believe he hit his head. Vitals and Neuro checks, assessed, both stable and within normal limits, assisted from floor to bed with full lift and 3 staff members . -Assessment 5:15 AM mental status: oriented x 4, no injuries observed post incident. Vitals: Temperature: 96.9, Pulse: 67, Respirations: 20, Blood Pressure: ,d+[DATE] . pupils: equal and reactive to light, can follow finger with eyes, responds to simple commands, verbal expression of pain at a 4 out of 10, grimaces, withdraws, shows nonverbal signs of pain, movement and sensation intact in extremities, yes, resident has no mobility in extremities but sensation is intact. On [DATE] at 3:38 PM during an interview LPN D indicated she has never called an RN to do a fall assessment. She has always done them herself. LPN D indicated 4 out of 10 pain and 8 out of 10 pain was not R1's baseline (it was not his usual). LPN D stated, In hindsight, I should have left him on the floor and called 911. LPN D indicated her assessment consisted of checking R1's skin and vitals. Surveyor asked LPN D if she checked to see his legs were the same length, LPN D could not recall, stating, There was an RN coming in, in about 20 minutes. We just got him in bed. It is important to note, R1 fell from 4ft and has no mobility in extremities and was complaining of new onset pain. LPN D did not observe for deformities even though R1 was complaining of new onset pain in hip and knee. She did not observe for positioning of lower extremities or note if the extremities were rotated externally or internally (sign of possible fracture). She did not check for range of motion in R1's limbs. LPN D made a decision to move R1 off of the floor without consulting a RN or calling 911. There was no assessment of R1 by an RN until 7:00 AM, at which time the RN identified a significant change in condition. The incident report continues by noting: At 7:00 AM resident began experiencing altered mental status, although he was oriented x 4 resident displayed slurred speech, difficulty articulating words, and slow to respond verbally. Oxygen saturation declined and had difficulty maintaining oxygen greater than 90 % on 5 Liters/ Nasal Cannula. Sent to emergency department for evaluation at 8:00 AM. 7:32 AM LPN D: . last set of vitals and neuros at 7:00 AM, AM Nurse (RN E) reported oxygen at ,d+[DATE]% on 2 Liters via nasal cannula. Also reported that resident was having difficulty coming up with words, speech slow and slightly slurred, and kept repeating himself. Resident's tongue veers right when asked to stick it out straight. Voicemail left for Primary Care Provider/MD F to call facility. NHA A updated regarding condition. According to the Mayo Clinic, [CONDITION(S)] is a sign of some other condition .Because [CONDITION(S)] is often a sign of a serious problem, such as a stroke, seek emergency medical care if you suddenly develop: Difficulty speaking Trouble understanding speech Difficulty with word recall Problems with reading or writing (Emphasis added.) https://www.mayoclinic.org/diseases-conditions/[CONDITION(S)]/symptoms-causes/syc- 518 R1's Nurses Notes, dates [DATE], include: 7:26 AM when I Registered Nurse (RN) E came to assess resident for vitals and neuro checks, observed that resident would not {sic} able to come up with words to communicate and would look at nurse long time without blinking or moving his eyes. At the same time, resident was on supplemental oxygen on 1 Liter/ Nasal Cannula and sats were in ,d+[DATE]'s, increased to 5 Liters/Nasal Cannula, sats went up to low 90's and stay up, but when resident would fall asleep sats were dropping to upper 70's on 5 Liters/Nasal Cannula. Resident had asymmetrical smile, and right side lips were thinner and tongue protruding to the left side. Contacting PCP (Primary Care Provider). (It is important to note this is the AM Nurse and she came on duty at 6:30 AM.) On [DATE] at 12:09 PM during an interview, RN E indicated on [DATE] she worked the AM shift and upon arrival she was given report from LPN D. LPN D indicated to RN E that R1 had a fall. RN E went into R1's room at about 6:45 AM. RN E indicated she noticed a change in R1's mental status almost immediately upon trying to interact with him. RN E indicated she noticed R1 wasn't responding appropriately, he was staring, and his oxygen was on 1 Liter and is usually at ,d+[DATE] Liters. RN E checked R1's vitals and his oxygenation levels. His oxygen was ,d+[DATE] %. RN E changed R1 to a mask and turned oxygen machine up to 5 Liters. RN E indicated she told LPN D, We need to call the doctor. Things are not going right. R1's hospital notes, dated [DATE], include, in part: . presenting today after a fall at skilled nursing facility He presents with hip pain, [CONDITION(S)], and altered mental status . MUSKOSKELETAL: shortened and externally rotated left limb. Gross abnormality of left hip. Effusion of right knee. Pain with passive flexion of right and left knee/hip. Per documentation, the patient was in his typical state of health until this morning at about 5:15 AM when he was moved at his facility and had an accidental fall off the bed (approximately 4 ft.). He fell on to his right hip and side per facility documentation. At the facility vital checks and neuro checks were initiated. At approximately 7:00 AM they noticed an altered mental status, he began repeating himself, slower to speak, slightly slurred speech. He was complaining of 8 out of 10 pain in right knee and hip pain. He was also hypoxic on 5 Liters compared to his baseline of ,d+[DATE] Liters at night. Upon arrival to Emergency Department, patient was able to answer simple questions with one to two word answers. He was slow to respond. He endorsed pain in his right knee and right hip. He denied chest pain. He endorsed some difficulty breathing. Appreciated to be hypoxic to the 70's. Initially placed on non-rebreather briefly and then transitioned to [CONDITION(S)] . STAT films of pelvis, bilateral knees, and bilateral femurs showed bilateral proximal femur fractures (possibly acute on chronic) and acute right distal femur fracture. Imaging: Bilateral ununited fractures of the proximal femurs, acute fracture of the right distal femur, suspicious for subcapital fracture of the left hip. Of note, the patient had a fall from his wheelchair in ,d+[DATE] resulting in right hip and left femur fractures that were treated conservatively. His long bone fracture may also implicate fat emboli as possible cause of [CONDITION(S)] . He was no longer responding to verbal stimuli. Upon family arriving to emergency department, it was further determined the patient would want to be comfortable. Upon arriving to the hospital hospice unit, the patient was not responsive to verbal or painful stimuli. Oxygen and Foley in place. Appeared to be in respiratory distress and very congested on exam. Staff worked diligently to provide comfort for patient .Family was escorted to bedside and the patient passed away peacefully at 2:00 PM on [DATE] . It should be noted R1 was not transferred to the hospital until several hours post fall. R1 was noted to have shortened and externally rotated left limb. Gross abnormality of left hip. Effusion of right knee. Pain with passive flexion of right and left knee/hip. As noted despite R1's new onset of lower extremity pain LPN D did not observe R1's lower extremities for rotation, shortening or deformity. Additionally, although RN E recognized R1 had a change of condition, altered mental status and low oxygen saturation RN E did not complete a comprehensive assessment. Upon transfer to the hospital the facility was unaware R1 had gross abnormalities of the lower extremity. On [DATE] at 2:29 PM during an interview DON B indicated LPNs cannot perform assessments and R1 should have been assessed by an RN before being moved from floor. DON B also indicated LPN D should have called 911 when R1's Medical Doctor did not answer and when R1 complained of pain after a fall from approximately 4 ft. DON B stated, I would have called 911 immediately. On [DATE] at 5:32 AM during an interview NHA A indicated LPN D has the training for assessing and should be able to do them. Surveyor asked NHA A what she is classified on their employee roster, NHA A indicated an LPN. NHA A indicated the facility policy is that RNs do the assessments and LPN D should have called the on-call RN to complete assessment before moving R1 off of the floor. On [DATE] at 1:02 PM during an interview with R1's Medical Examiner (ME) G she stated,R1 had a clear disfiguration of his leg. There was a dip on the top of his leg that comes to a V and you could set a coffee mug in it. I don't know how they would not see this. The facility's failure to complete an immediate comprehensive assessment, moving a resident post fall without an assessment and delay in emergency medical treatment created a situation of immediate jeopardy, starting on [DATE]. The jeopardy was removed on [DATE] when the facility implemented the following: 1) On [DATE] a full house sweep was completed to determine if there were any residents who presented with evidence of any change of condition that would require implementation of residents' assessments, changes of condition, notification to physician/provider, resident and/or resident's responsible party, and requiring documentation of immediate follow up. 2) On [DATE] the 24 hour report sheet was reviewed to recognize any areas of concerns requiring immediate follow up, any concerns requiring implementation of a resident assessment, and change in condition requiring immediate follow up reporting/notifying physician and/or provider and/or responsible party of changes in condition. 3) On [DATE] a medical record review was completed on all residents in the facility to determine any areas of concern requiring immediate follow up, any concerns requiring implementation of a resident assessment, and any change of condition requiring immediate follow up reporting/notifying physician and/or provider or resident and/or responsible party of changes of condition. 4) Prior to their next working shift, licensed nurses will be educated by the DON/Designee on recognition of a change of condition per recognized standards of practice and the need to immediately notify the physician per recognized standards of practice of a change in resident treatment when required. 5) Prior to their next working shift, licensed nurses will be educated by the DON/Designee not to move a resident who has had a fall/accident until a full head to toe assessment is completed by an RN. If there is an indication of moving the resident that will cause the potential for further harm, the RN will then make the resident comfortable and call the physician or 911 if warranted. 6) Prior to their next working shift, all licensed nurses will be competency checked by the DON/Designee on the recognition of a change in condition. 7) Prior to their next working shift, all RNs will be competency checked by the DON/Designee on completing thorough heat to toe assessments. LPNs will be instructed to immediately contact an RN to complete an assessment for any change of condition. If an RN is not in house, the LPN will be instructed to call the on-call RN. 8) Prior to their next working shift, licensed nurses will be educated by the DON/Designee on how to complete a full head to toe assessment. Return demonstrations by licensed nursing staff (to be monitored by the Nurse Manager/Designee) to validate competency will be performed. Certified Nursing Assistants will be educated by the Nurse Manager/Designee on how to report changes in condition of resident to the licensed nurses. Certified nursing assistants will also be evaluated via post-test to determine competency.

Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents in 1 of 3 residents reviewed for fall concerns, out of a total sample of 5 (R1). On [DATE] a certified nursing assistant attempted to provide care to R1 without waiting for a second person to assist, as directed in R1's care plan. R1 rolled off the bed and fell approximately 4 ft. to the floor. R1 suffered multiple fractures as a result of the fall and expired at the hospital. This created a finding of immediate jeopardy that began on [DATE]. The NHA A (Nursing Home Administrator) was informed of the Immediate Jeopardy on [DATE] at 11:00 AM. On [DATE] the facility recognized the deficient practice by the CNA and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed on [DATE] and corrected on [DATE]. This is being cited as past noncompliance. Evidenced by: The facility policy, entitled Fall Prevention and Management, revised ,d+[DATE], includes, in part: . Purpose: to promote well-being by developing and implementing a fall prevention management program, to identify risk factors and implement interventions before a fall occurs, to give prompt treatment after a fall occurs, to prevent further injury, Procedure: care plan the appropriate interventions, including personalizing all areas, communicate fall risks and interventions to prevent a fall before it occurs . R1, who was 74-years-old, was admitted to the facility on [DATE] with a diagnosis of progressive multiple [CONDITION(S)] and later diagnosed with [CONDITION(S)] on [DATE]. R1's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of [DATE] indicates R1 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. R1's MDS indicates he required extensive physical assistance of two or more staff to meet his needs in dressing, toileting, bed mobility, bathing, and personal hygiene. MDS definitions: bed mobility - How resident moves to and from lying position, turn side to side, and positions body while in bed or alternate sleep furniture . toilet use- how resident uses the toilet room, commode, bedpan, or urinal, transfers on and off toilet, cleanses self after elimination, changes pad, manages ostomy or catheter, and adjusts clothes . Dressing- How resident puts on, fastens and takes off all items of clothing, including donning and removing prosthesis or TED hose, pajamas, and house dresses. R1's Comprehensive Care Plan, includes in part: . [DATE] Bathing: R1 is totally dependent on staff to provide a bath with two assist . Dressing: R1 requires two staff participation to dress. Bed mobility: Turn side to side, two staff assist and total lift . Toileting: check and change approximately every 2 hours. R1's CNA (Certified Nursing Assistant) Care Card, includes, in part: . Bathing: R1 is totally dependent on staff to provide a bath with two assist . Dressing: R1 requires two staff participation to dress. Bed mobility: Turn side to side, two staff assist and total lift . Toileting: check and change approximately every 2 hours . R1's Incident Report, dated [DATE], includes: Writer called to room when resident rolled out of bed and onto floor during cares this morning. Resident was lying on his back/right side on the floor between bed and window when writer arrived. Resident stated that he fell out of bed while being rolled by CNA during cares. Resident reported that right hip and right knee were experiencing pain, but stated he didn't believe he hit his head. Vitals and Neuro checks, assessed, both stable and within normal limits, assisted from floor to bed with full lift and 3 staff members . At 7:00 AM resident began experiencing altered mental status, although he was oriented x 4 resident displayed slurred speech, difficulty articulating words, and slow to respond verbally. Oxygen saturation declined and had difficulty maintaining oxygen greater than 90 % on 5 Liters/ Nasal Cannula. Sent to emergency department for evaluation at 8:00 AM. On [DATE] at 3:38 PM during an interview, LPN D indicated CNA C was providing cares such as bed mobility and dressing and should have had a second aide in there to assist as R1 required 2 staff to meet his needs. 7:32 AM LPN D: Resident experienced fall from bed at about 4 feet high at 5:15 AM. Resident was rolled by CNA C during cares and rolled off his bed. Landed on right hip and right knee during repositioning or movement. Obtained abrasion to lower back/coccyx area and left shoulder. Bruise and swelling to posterior right forearm, applied ice . last set of vitals and neuros at 7:00 AM, AM Nurse (RN E) reported oxygen at ,d+[DATE]% on 2 Liters via nasal cannula. Also reported resident was having difficulty coming up with words, speech slow and slightly slurred, and kept repeating himself. Resident's tongue veers right when asked to stick it out straight. Voicemail left for Primary Care Provider/ MD F to call facility. NHA A updated regarding condition. -CNA C: witness statement, dated and signed [DATE], includes: I went in to care for R1 and on the [DATE] went in, cut the lights, started talking to him, waited for a reply, it was hard for him to talk, so gave him a drink of water. It cleared him, got everything ready- basin, water, towels, pad, clothes, stockings. I washed the front half of body, this is all normal routine. Put his creams on, put his pants on, then his shirt, called for help, went to roll on side a bit to tuck a dirty pad and to check his back side having my hand on his hip I felt a jolt and before I could grab him, his body went over. I checked on him then called for help emergency. On [DATE] at 4:14 PM during an interview, CNA C indicated she should have waited for help to come. On [DATE] at 12:09 PM during an interview, RN E indicated R1 required 2 staff to assist him in bed mobility, dressing, toileting, transferring, and bathing. On [DATE] at 2:29 PM during an interview DON B indicated R1 required 2 staff to assist him with bed mobility, bathing, dressing, transferring, and only 1 staff assist for personal hygiene. DON B indicated rolling a resident on the bed or shifting his weight side to side is bed mobility, putting clothing on a resident is dressing, and assisting with a dirty pad is toileting. DON B indicated 2 CNAs should have been caring for R1 when he fell out of bed, but only one was. R1's hospital notes, dated [DATE], include, in part: . presenting today after a fall at skilled nursing facility He presents with hip pain, [CONDITION(S)], and altered mental status . MUSKOSKELETAL: shortened and externally rotated left limb. Gross abnormality of left hip. Effusion of right knee. Pain with passive flexion of right and left knee/hip. Per documentation, the patient was in his typical state of health until this morning at about 5:15 AM when he was moved at his facility and had an accidental fall off the bed (approximately 4 ft.). He fell on to his right hip and side per facility documentation. At the facility vital checks and neuro checks were initiated. At approximately 7:00 AM they noticed an altered mental status he began repeating himself, slower to speak, slightly slurred speech. He was complaining of 8 out of 10 pain in right knee and hip pain. He was also hypoxic on 5 Liters compared to his baseline of ,d+[DATE] Liters at night. Upon arrival to Emergency Department, patient was able to answer simple questions with one to two word answers. He was slow to respond. He endorsed pain in his right knee and right hip. He denied chest pain. He endorsed some difficulty breathing. Appreciated to be hypoxic to the 70's. Initially placed on non-rebreather briefly and then transitioned to [CONDITION(S)] . STAT films of pelvis, bilateral knees, and bilateral femurs showed bilateral proximal femur fractures (possibly acute on chronic) and acute right distal femur fracture. Imaging: Bilateral ununited fractures of the proximal femurs, acute fracture of the right distal femur, suspicious for subcapital fracture of the left hip. Of note, the patient had a fall from his wheelchair in ,d+[DATE] resulting in right hip and left femur fractures that were treated conservatively. His long bone fracture may also implicate fat emboli as possible cause of [CONDITION(S)] . He was no longer responding to verbal stimuli. Upon family arriving to emergency department, it was further determined the patient would want to be comfortable. Upon arriving to the hospital hospice unit, the patient was not responsive to verbal or painful stimuli. Oxygen and Foley in place. Appeared to be in respiratory distress and very congested on exam. Staff worked diligently to provide comfort for patient .Family was escorted to bedside and the patient passed away peacefully at 2:00 PM on [DATE] . According to For Elderly, Even Short Falls Can Be Deadly: Adults 70-Plus Three Times as Likely to Die Following Low-Level Falls (Science Daily [DATE]), .ground level falls, essentially falls from a standing position, with feet touching the ground prior to the fall, have traditionally been considered minor injuries. But, the new study found elderly adults - [AGE] years of older - who experience ground-level falls are much more likely to be severely injured and less likely to survive their injuries compared to adults younger than [AGE] years. Elderly patients are three times as likely to die following a ground-level fall compared to their under-70 counterparts .approximately 4.5 percent of elderly patients ([AGE] years and above) died following a ground-level fall, compared to 1.5 percent of non-elderly patients. Elderly patients remained in the hospital and the intensive care unit longer and only 22 percent were able to function on their own after they left the hospital, compared to 41 percent of non-elderly patients. https://www.sciencedaily.com/releases/[DATE].htm According to the Center for Disease Control (CDC), Twenty to thirty percent of people who fall suffer moderate to severe injuries such as lacerations, hip fractures, or head traumas. According to the CDC, falls are the most common cause of traumatic brain injuries; traumatic brain injury accounts for 46% of fatal falls among older adults (those 65 or older). Among older adults, falls are the leading cause of injury death and are the most common cause of nonfatal injuries and hospital admissions for trauma. The CDC notes that in 2008, over 19,700 older adults died from unintentional fall injuries. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. The facility's failure to follow R1's Care Plan resulted in R1's fall with multiple fractures. R1 later expired at the hospital. These failures created a situation of immediate jeopardy that began on [DATE]. On [DATE] the facility recognized the deficient practice by the CNA and took steps to correct the deficient practice and ensure compliance at the time of the survey. Based on this determination, the IJ was removed on [DATE] and corrected on [DATE] when the facility implemented the following: [DATE]-In-person education was provided to nurses and certified nursing assistants regarding bed mobility/transfers and following the care plan as written. Point Click Care (electronic charting system) was updated as well as current list of 2-assist residents reviewed and posted for clarity and reiteration. [DATE]-A house sweep of 2-assist resident care plans for reposition, changing and transfers were reviewed and edited if warranted. [DATE]-[DATE]-In-person audits were performed with nursing staff and yielded compliance in the areas of following care plan for proper bed mobility, personal care and transfers. Competency checks were performed during these audits by the DON. [DATE]- Reviewed fall care plans for accuracy and completeness. All the following reviewed in QAPI.

Based on observation, interview and record review the facility did not ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents who wear a roam alert safety bracelet (Resident 1). R1 (Resident 1) is to wear a Roam Alert bracelet (wanderguard) on his wrist. Although R1 was known by staff to remove this wrist bracelet, the facility did not have a plan in place for ensuring its placement, except to check once per shift. Additionally, R1's care plan did not specifically address R1's agitation / anxiety manifested when his wife would leave. On 12/19/16 R1 did not have his Roam Alert wrist bracelet on and was able to exit the building after his wife had left without staff's knowledge. Facility staff was alerted by a neighbor that R1 was 75 feet from the facility entrance, having fallen from his wheelchair. R1 was found half on the sidewalk and half in the street. The temperature that day ranged from a high of 15 to a low of minus 11. The failure to ensure adequate supervision when R1 was known to remove his Roam Alert bracelet created a finding of immediate jeopardy that began on 12/19/16. NHA (Nursing Home Administrator) A was notified of the immediate jeopardy on 1/6/17 at 3:45PM. The immediate jeopardy was removed on 1/6/17, however the deficient practice continues at a severity / scope of D (no actual harm / isolated) until all the components of training are completed. This is evidenced by the following: The facility's policy and procedure on Elopement issued on 2/2013 and revised on 4/16 states: . All residents will be assessed for risk of elopement through the pre - admission and / or admission process and as needed. Each location will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan. R1's [DIAGNOSES REDACTED]. On 1/6/17 at approximately 3:30 PM Surveyor observed R1 sitting in his high back reclining wheelchair with a wander sensor attached, with a plastic strap, to a vinyl coated cable at the back of wheelchair. This sensor was approximately 2 inches from the metal tube support brace. R1 also had a wander sensor attached to his right wrist with a plastic strap. R1's current physician orders [REDACTED]. R1's most current MDS (Minimum Data Set), also current at the time of the 12/19/16 elopement, with an observation end date of 11/16/16 states that R1 usually understands, has moderately impaired vision, and scores 3 out of 15 for BIMS (Brief Interview for Mental Status) indicating severe cognitive impairment. In addition, this assessment states that R1 wanders daily, needs supervisory oversight with locomotion on the unit, and limited assistance with locomotion off the unit. R1's care plan current at the time of the 12/19/16 elopement contains the following focus areas and interventions: *The resident has behavioral symptoms R/T (related to) advancing dementia. Enters others rooms, more prevalent with sundowning . attempt to exit building Initiated 1/9/15. Revision on 9/19/16. Interventions include: Behavior - Non pharmacological: Wanderguard in place, scheduled checks. Initiated 1/30/15. Revision on 1/13/16. *The resident has impaired cognitive function / dementia evidenced by s/t (short term) memory deficit, impaired decision - making. Initiated 11/15/14. Revised on 11/15/14. Interventions include: Personal alarm: wanderguard bracelet used to alert staff to resident's movement and to assist staff in monitoring movement wander outside unattended. Initiated 12/4/14. Revision: 12/4/14. *The resident has had recent history of an actual fall with minor injury R/T CHF (Congestive Heart Failure), E/B (evidenced by) unsteady gait, weakness. Initiated 11/14/14. Interventions include: Environmental: Assist with hs (bedtime) cares around 8 pm. Redirect resident back to LTC (Long Term Care) unit if wandering halls after supper. Offer walk in hallway after meals. If resident restless wandering in w/c (wheelchair), offer toileting. Provide activity basket for use when restless, encourage family visits after supper. If awake, restless at night, assist up to w/c, provide snack, warm milk. Initiated 12/22/14. Revised on 4/20/15. R1's TAR (Treatment Administration Record) for 12/2016 shows entries from 12/1/16 through 12/19/16 which state Check wander guard patency and replace wander guard as needed one time a day related to unspecified dementia without behavioral disturbance. Start date 5/2/15 and May have wanderguard placed r/t wandering behaviors every night shift for wandering behaviors related to unspecified dementia without behavioral disturbance. Check placement and battery every night. Start date 12/4/14. Each of these entries has an area each day for facility staff to place initials when this task is completed. On 1/6/17 at approximately 10:30 am Surveyor asked RN (Registered Nurse) Manager J the difference between the 2 TAR entries. RN Manager J stated one refers to the functionality of the battery, and the other refers to the placement of the bracelet. R1's record contains the following entry: 10/11/16 6:41 pm: Staff heard wanderguard alarm sounding. Went to therapy doors and found resident outside in parking lot in w/c heading away from the building. Stated he was going home. Easily redirected and brought back into the building. The facility's investigation report into this incident documents that this incident happened on 10/11/16 at 3:55 pm. Corrective action taken includes: Care plan amended, toileting plan updated. The result of the investigation states: Nursing updated care plan. Staff re - educated on utilizing toileting plan in the evening. R1's record contains the following entries: *10/22/16 1:31 am eAdmin Record (default note). Note Text: Check wanderguard patency and replace wanderguard as needed one time a day related to unspecified dementia without behavioral disturbance. Unable to locate remote. (The remote is the tool used to check patency or functionality of the battery.) *12/19/16 11:56 pm (late entry for 8:42 pm): Resident was seen heading towards the door after his wife had left. Writer was busy passing medications along with the Medicare RN and moments later we received a phone call from someone at (Assisted Living next door) around 8:42 pm stating that there is a man lying on sidewalk and half in the road on his left side. The wheelchair was on his right side next to him. Medicare RN called DON (Director of Nursing) and resident's family while writer and two CNAs (Certified Nursing Assistants) got the lift and got him in his wheelchair. Resident was taken to his room and put into bed and assessed. No signs of injury were noted and no bruising was found. Resident stated that he was not in any pain. Vital signs and neuro checks are stable. Resident did not have his wander guard on and that is why no one heard him leave the building. Talking with other nurses and CNAs they reported to me that there have been times where resident has taken off his wanderguard and a new one was placed. *12/19/16 11:35 pm: eAdmin Record (default note). Note Text: Check wander guard patency and replace wander guard as needed one time a day related to unspecified dementia without behavioral disturbance. Wander guard off. Unable to find any bracelets. Will monitor closely a d (sic) pass along to day nurse and nursing administration. *12/19/16 11:38 pm: eAdmin Record (default note). Note Text: Check wanderguard patency and replace wander guard as needed one time a day related to unspecified dementia without behavioral disturbance. Wander guard off. Unable to find bracelets. Will monitor closely and pass information to day nurse. Resident has no adverse effects from leaving the building earlier this PM. *12/20/16 3:12 am: Resident has rested well this shift. No adverse effects noted due to going outside earlier this PM. No wander guard on at this time. Will apply when bracelets are found. Will monitor closely and pass information on to the day nurse. According to The Weather Channel the recorded high temperature in the facility's town on 12/19/16 was 15 degrees Fahrenheit. The recorded low was -11 degrees Fahrenheit. Sunset that day was 4:25 pm. The facility's Fall Scene Huddle Worksheet dated 12/19/16 at 8:42 pm states R1's fall occurred outside of the building on premises. The report states R1 was trying to see his wife and that he had been given his evening medications 5 minutes before he was found outside on the ground. The report states R1 had slipped, was incontinent of urine and that his personal alarm was removed. The report states: Resident wanted to see his wife after she had left. He did not have a wanderguard on. This was not known to staff until after the fall. The Investigation into this elopement again states: Resident was trying to see his wife after she visited and resident did not have wanderguard on Resident needs a new wanderguard. The Narrative Comments of this report state: The wanderguard bracelet was found dismantled. Replace wanderguard onto wheelchair & on wrist. On 1/6/17 at 10:10 am Surveyor spoke with IDON (Interim Director of Nursing) B regarding R1 and his elopement on 12/191/16. IDON B stated R1's wife lives next door and when she comes over to visit, R1 will get worked up when she leaves stating you can almost bet he will want to leave as well. This tends to happen after his wife leaves. We need to work on this. We can't have her stop coming over . They called me after they got him inside, of course it was a freezing cold night . It's my understanding someone from assisted living called to say there was a man in a wheelchair who fell outside. On 1/18/17 at 9:50 am IDON B told Surveyor that at the time of R1's elopement on 12/19/17 R1 was dressed in street clothes with no jacket, no hat, and no gloves. IDON B told Surveyor that R1's temperature on 12/19/16 at 9:15 pm was 98.8 degrees Fahrenheit and 98.6 degrees Fahrenheit at 9:45 pm on 12/19/16. R1's care plan does not specifically address R1's agitation / anxiety associated to his spouses leaving after their visits. On 1/6/17 at 10:42 am Surveyor spoke with CNA C regarding R1 and his recent elopement. CNA C told Surveyor she is aware that R1 will take off his wanderguard. CNA C stated I don't know how he gets it off Sometimes he will just hand it to you; sometimes we find it on his bedside table. Surveyor asked CNA C if she herself had seen R1 take off the wanderguard. CNA C stated I have never seen it off. This is just what I understand happens with him. On 1/6/17 at 12:28 pm Surveyor spoke with CNA D who is familiar with R1. CNA D stated she is aware R1 had eloped about 2 weeks ago stating that is the only time she is aware that he has ever eloped. CNA D00 told Surveyor that R1 plays with his wanderguard, but she was not aware of any other time that he had taken it off. On 1/6/17 at 12:35 pm Surveyor spoke with RN E regarding R1 and his wandering tendencies. RN E sated she is familiar with R1. RN E confirmed that R1 had eloped a few weeks ago. RN E stated she is aware that R1 now has 2 wanderguards, one on his wrist, and one on his wheelchair. Surveyor asked RN E if she is aware of R1 ever removing his wanderguard. RN E stated I remember I had to replace it once. We couldn't find it on him. He must have taken it off. Surveyor asked RN E when this happened. RN E stated a while ago, it was in the summer. On 1/6/16 at approximately 12:49 pm Surveyor spoke with CNA G via telephone, regarding R1 and his wandering tendencies. CNA G was working the night R1 eloped on 12/19/16. CNA G stated 12/19/16 was the first time she was aware R1 had ever eloped, but that she is aware R1 had removed his wanderguard plenty of times stating, I myself have not seen it, but I've been told he does it. On 1/6/17 at approximately 2:00 pm Surveyor spoke with NHA A and IDON B regarding R1, his wandering tenancies, and his elopement on 12/19/16. Surveyor asked if they were aware facility staff are stating R1 has a history of removing his wanderguard. IDON B stated she was not aware of this. On 1/6/17 at 3:40 pm Surveyor spoke with LPN (Licensed Practical Nurse) H via telephone, regarding R1 and his tendencies to wander. LPN H was working with R1 the evening of 12/19/16. LPN H stated she was passing medications when a phone call came in from a resident at the assisted living next door telling her a man had fallen on the sidewalk. LPN H went on to state: We went outside over by the steps that go up to the assisted living. He (R1) was half on the curb, and half in the road. (The other nurse) went to get the lift and we got him up and back inside. LPN H stated the alarm did not go off and that R1 did not have his wanderguard on. Surveyor asked LPN H if she had ever known R1 to remove his wanderguard. LPN H stated Not me personally but I heard from others he does. Surveyor asked LPN H if she had known when it was that R1 had previously removed his wanderguard. LPN H stated a couple days before 12/19/16 they had found a wanderguard bracelet on the table and all assumed it was R1's. Surveyor asked LPN H if she was aware of any other time R1 had eloped. LPN H stated she was not aware of any other time other than 12/19/16. Surveyor asked LPN H if R1 gets upset when his wife leaves after their visits. LPN H stated R1 does get anxious and stated he will keep wandering toward the door saying 'where's my wife'. LPN H stated on 12/19/16 she had seen R1 heading toward the door and after that we didn't know where he was. LPN H stated they did not redirect R1 when they saw him toward the door, they just knew he was over there. On 1/6/17 at 3:42 pm Surveyor spoke with LPN I, via telephone, regarding R1 and his wandering tendencies. LPN I worked with R1 the late night of 12/19/16 and early morning hours of 12/20/16. Surveyor asked LPN I if she checks the function of the wanderguard on the night shift. LPN I stated: I have to be honest with you, until that night (12/19/16) I was not doing it. I don't know who was doing it on the night shift, but I wasn't doing it. (LPN I later clarified in a phone call stating she does check placement, but was not checking functionality of the wanderguard on the night shift until after R1's elopement on 12/19/16.) Surveyor asked LPN I if she is aware R1 takes his wanderguard off. LPN I stated she is aware R1 takes his wanderguard off stating: I've seen it lying around . like on the table in the living room area I assumed it was his because he plays with it all the time and takes it off and on. I gave it to one of the CNAs. I presumed they put it back on him like I asked them to. Despite staff knowledge and belief that R1 played with his wanderguard bracelet and would take it off, there was no plan for checking the placement of his bracelet more frequently than once per shift. On 1/6/17 at 4:20 pm Surveyor asked IDON B if elopement risk assessments were completed on residents. IDON B stated they were completed. Surveyor requested a copy of R1's most current elopement risk assessment. On 1/6/17 at 4:55 pm Surveyor was informed by RN Manager J that elopement risk assessments are not completed on residents. The failure to ensure that Resident 1 received supervision to prevent an elopement when the temperature ranged between -11 and 15 degrees and which staff became aware of only because a neighbor saw the resident lying half on the sidewalk and half in the street created a finding of immediate jeopardy. The facility removed the jeopardy on 1/6/17 when the facility: *Began immediate education for all staff before they work on elopement, Roam Alert system, and the policy and procedure on elopement and wandering. *adjusted care plan for Resident 1 to do a 1 to 1 activity when his wife leaves the building. *Identified how the resident was removing the bracelet and change it every month. *Develop elopement risk assessment do be done on admission, quarterly assessments/MDS and completed elopement risk assessments. *Audit elopement risk assessment for completion *Audit for all residents at risk for eloping check all Roam Alert bands in place and working. *QA -Audit weekly X4 then Monthly X4.

Based on observation, interview and record review the facility did not ensure that 1 of 3 residents (Resident 1) reviewed for pressure injuries, received the care and services to prevent and promote the healing of pressure injuries. When Resident 1 developed a pressure injury on 7/21/16, the facility did not promptly implement new preventative care plan interventions based on risk assessments and Resident 1's pressure injury increased in size and became infected. This is evidenced by: The facility's policy Pressure Ulcers dated 9/2012 states in part: . Based on the resident's comprehensive assessment, the center will use prevention and assessment interventions to ensure that a resident entering the center without pressure ulcer does not develop a pressure ulcer unless the individual's clinical record 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. If a resident's clinical condition makes compromise of skin integrity clinically unavoidable, this information will be documented in the medical record. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's MDS (Minimum Data Set) assessment on 5/7/16 indicates a BIMS (Brief Interview for Mental Status) score of 1 indicating severe cognitive impairment. Resident 1's Braden Scale Score, (assessment to predict risk factors for pressure injuries) was noted on 5/7/16 to be 16, indicating that Resident 1 is at risk for developing pressure injuries. Resident 1's Braden Score on 8/9/16 was noted to be 13 indicating increased risk for developing pressure injuries. Resident 1's comprehensive care plan notes in part: Problem: ADL Self Care performance deficit R/T (related to) [DIAGNOSES REDACTED]. Interventions .Turn from side to side: two staff assist, total lift and repositioning sling (Date Initiated: 2/11/16. Revision on 8/9/16) Problem: (Resident 1) has potential for pressure ulcer development R/T severe [MEDICAL CONDITION] and impaired bed mobility, (Date initiated 5/16/14.) Goal: Resident 1 will have intact skin .Interventions: Provide pressure relieving/reducing device on w/c (wheel chair) . (Revision 5/21/14) Problem: (Resident 1) has one pressure ulcer to coccyx, (Date initiated 7/21/16). Goal: pressure Ulcer will show signs of healing and remain free from infection by/through review date . Interventions . (Monitor/Remind/Assist) to turn repositions at least every 2 hours when in bed, (Date initiated 8/3/1). Avoid positioning (Resident 1) on back; turn side to side, (Date initiated 8/01/16) . Provide pressure relieving/reducing device-Roho cushion in seat of Broda Chair. Air mattress on bed, (Date initiated 8/3/16. Revision 8/10/16.) Resident 1's wound monitoring forms notes in part: -7/19/16- Weekly Skin Observation: No skin conditions observed -7/21/16- Wound RN Assessment: Pressure Ulcer, Stage 2. Wound Data Collection: Measurements: Length 1.5 cm (centimeters) Width 0.8 cm Depth 0.01 cm 20 % [MEDICATION NAME], 80% Slough . drainage: none. (It is important to note that with the presence of slough in the wound bed, the wound should be coded as a Stage 3.) - 7/26/16 - physician's orders [REDACTED]. Change q (every) 3 days and PRN (as needed) -7/30/16- Wound RN Assessment: Pressure Ulcer, Unstageable bigger in size, necrotic tissue noted . Wound Data Collection: Measurements: Length 2.6 cm (centimeters) Width 2.5 cm Depth 0.4 cm, 5 % [MEDICATION NAME], 95% Eschar. Drainage moderate, Wound Margins reddened. - physician's orders [REDACTED]. Change two times a day for wound healing . -8/2/16- Wound RN Assessment: Pressure Ulcer, Unstageable necrotic tissue, foul smelling drainage, brownish drainage, complaints of pain, redness around ulcer . Wound Data Collection: Measurements: Length 2.2 cm Width 2.6 cm Depth (is left blank), unstageable pressure wound, black necrotic tissue with white slough and 5% granulation tissue on wound edge . - 8/3/16 - physician's orders [REDACTED]. dressing, cover with foam dressing. Changed BID (twice daily) and PRN for 7 days. Re-eval wound in 7 days or sooner if needed) . -8/5/16- Wound Data Collection: Measurements: Length 2.6 cm Width 2.1 cm Depth 0.5 cm. Ring of redness around ulcer area. Ulcer with white slough tissue. Ulcer odorous. Note deeper area 1.5 cm in length inside whole ulcer. -8/9/16- Wound Data Collection: Measurements: Length 3.2 cm Width 2.5 cm Depth 1.5 cm. Redness around ulcer area, ulcer with greyish/black slough, no tunneling . - 8/12/16 - physician's orders [REDACTED].>8/12/16 [MEDICATION NAME] 500 MG (milligrams), give one tablet by mouth three times a day for Decubitus ulcer on coccyx. On 8/15/16 at 9:00 AM Surveyor observed LPN (Licensed Practical Nurse) C complete the treatment to Resident 1's coccyx pressure injury. Resident 1's pressure injury presented as a round crater, measuring: length 3.0 cm Width 2.2 cm Depth 1.5 cm. The wound bed was observed to be covered with about 95% tan slough. Surveyor observed a ReactiveAirPro mattress to Resident 1's bed with a power unit attached. Surveyor reviewed the operation manual for Resident 1's ReactiveAirPro mattress noting: The ReactiveAirPro is a convertible powered/non-powered dynamic mattress system designed to treat and/or prevent pressure ulcers .it can provide therapy in both the powered and non-powered modes .The power unit adds enhanced therapy by providing alternating pressure every 5 minutes . (It is important to note that the power mode for alternating pressure on Resident 1's ReactiveAirPro mattress was not activated until 8/10/16.) On 8/15/16 at 12:45 PM Surveyor interviewed DON (Director of Nursing) B and RN (Registered Nurse) D about Resident 1's coccyx pressure injury. When Surveyor asked DON B what she would expect staff to do when Resident 1 presented with a new pressure injury, DON B stated that she would expect the team to meet to discuss resident needs and options for care. RN D stated she thought the team met during the facility daily stand up meeting about Resident 1's new pressure injury to brainstorm possible interventions but did not recall when this was done and it was not documented in Resident 1's medical record, DON B stated this should have been documented and was not. Surveyor asked DON B if the facility had determined if Resident 1's coccyx pressure injury was avoidable or unavoidable. DON B stated that it was discussed and based on Resident 1's progressive comorbidities, general decline, refusal of cares she did not know if Resident 1's pressure injury was 100% avoidable. This information was not documented and should have been. Surveyor reviewed Resident 1's care plan with DON B noting that other than wound treatments, new preventative interventions were not placed on the care plan until after Resident 1's pressure injury worsened. DON B stated that the facility's primary wound care nurse was on vacation the day after Resident 1's coccyx pressure injury developed and that additional preventive measures should have been put in place for Resident 1 sooner and were not.

Based on interview and record review the facility did not ensure 3 out of 3 residents maintained an acceptable parameter of nutrition status and weight unless the resident's clinical condition demonstrates that it is not possible or desires to loose weight. (Residents 4, 8, and11). Resident 11 lost a significant amount of weight before the facility provided additional nutrition to prevent additional weight loss. The resident weighed 140 pounds on 1/6/11. Then on 3/17/11 she weighed 116.5. This is a weight loss of 23.5 pounds. On 1/6/11 her goal was to maintain her weight at 140 pounds. Resident 4 was noticed to have weight loss in April, 2011. Dietary notes state a recommendation for a [MEDICAL CONDITION] screen and daily weights for three days. This recommendation was not communicated to Resident 4's physician and therefore was not completed. Dietary notes state that Resident 4 should be weighed on the same scale, in order to obtain consistent, more accurate weights. Resident 4 was weighed on three different scales after this recommendation was made. Resident 8 experienced weight loss. The facility dietician recommended a supplement in January, 2011. The facility did not have evidence related to why the supplement was not started or why Resident 8's physician was not consulted. The facility started the supplement in March, 2011. Resident 8 lost weight from January, 2011 to March, 2011. The facility did not discontinue the fortified diet until 5/3/11 despite that it was ordered to be discontinued on 3/23/11. This is evidenced by: Example 1 Resident 11's Nutrition Assessment, dated 7/15/10, indicated her estimated needs were 1600 to 1900 calories per day. Her weight was 140 pounds. Her goal was to maintain her weight. She ate 85% to 90% of her meals and drank 900 to 1100 cc's daily. Small portions were ordered for her. On 1/6/11 Resident 11 weighed 140 pounds. From 1/6/11 throughout the nurses notes the notes indicated Resident 11 had a poor appetite. On 1/11/11 Resident 11 was started on food and liquid intakes. Her intakes on this day were 41.67%. There was no indication the dietitian was notified of the weight loss or poor appetite. Then on 1/12/11 her intake was for the day 91.76% total. Her meal intake was not recorded from 1/13/11 through 1/17/11. The next intake was recorded on 1/18/11 and 1/19/11 as eating 0% for the day. On 1/20/11 Resident 11's intake was 50% for the day. On 1/21/11 her intake was 0%, she refused to eat. Then on 1/22/11 and 1/23/11 her intake was 25% for the day. Resident 11's total intake on 1/24/11 was 41.67%. On 1/25/11 and 1/26/11 her intake was 37.5% each day. On 1/27/11 Resident 11's total intake was 75%. On 1/27/11 she weighed 131 pounds. This is a weight loss of 9 pounds and a significant loss. This is a 6.4% loss of weight in 21 days. No additional weight loss preventives were initiated at this time. A nutritional assessment was not done at this time. She continued to loose weight and her appetite was poor. On 1/29/11 again her total intake was 41.67% for the day. Then on 1/30 her intake was only 16.67% for the day and on 1/31 she ate 16.67% of her food. On 2/1 she only ate 37.5% of her food. On 2/2 her intake was 50%. On 2/3 her intake was 37.5%. Then on 2/3/11 she weighed 127.5 pounds. She lost an additional 3.5 pounds totaling a 9% weight loss in 26 days. This is a significant weight loss. The dietitian was not notified of the weight loss. Additionally, a nutritional assessment was not done and additional weight loss preventives were not initiated. Resident 11's intake remained poor and on 2/4 her intake was 0%. On 2/5 her intake was 50%. On 2/6 her intake was 31.25%. Then on 2/7 she ate 50% of her meals. A nutritional assessment was not done and additional interventions were not started to prevent additional weight loss and she continued to loose weight. Resident 11's care plan, dated 2/7/11 indicated to give her a pm snack. She was given yogurt but already lost a significant amount of weight without any other interventions or notifying the dietitian of the weight loss. Additionally, the resident's record did not indicate a nutritional assessment was done. Resident 11's intake on 2/8 was 75%. On 2/9 her intake was 16.67%. Then the physician ordered daily weights on 2/9/11 but the weights were not done everyday. Resident 11's weights were not done or recorded on 2/9, 2/10, 2/13, 2/14 and 2/25. In fact, the resident's daily weights did not start until 2/9, and then she weighed 129.8 pounds. This is a significant weight loss of 7.5%. On 2/10 her intake was 25%. On 2/11 her intake was 12.5%. Her 2/12 and 2/13 intake was 41.67% each day. Her 2/14 intake was 83.33%. Again on 2/15 her intake was 41.67%. Then on 2/16 she ate 90% of her meals. On 2/17 her intake was 25%. On 2/18 her intake was 75%. On 2/19 her intake was 25%. On 2/20 she ate 33.33% of her meals. On 2/21 she ate 50% of her meals. On 2/22 she ate 58.33% of her meals. On 2/23 her intake was 50%. On 2/24 and 2/25 her intake was 58.3% on each day. On 2/26 her intake was 33.33%. On 2/27 her intake was 25%. On 2/27 her intake was 43.75%. On 2/28 her intake was 75%. On 3/1, 3/2, 3/3 and 3/4 her intake was 25% on each day. On 3/5 it was 50%. On 3/6 her intake was 25%. On 3/7 her intake was 16.67%. On 3/8 and 3/9 her intake was 25% for each day. On 3/10 her intake was 33.33%. On 3/11 and 3/12 her intake was 25% for each day. On 3/13 her intake was 37.67%. On 3/14 her intake was 16.67%. On 3/15 and 3/16 her intake was 41.67% on each day. Now she weighed 116 pounds. Resident 11's physician note, dated 2/23/11 indicated daily weights were done but the resident weight was not done everyday. Additionally, the resident was not weighed in March until 3/24. On 3/16/11 a Nutrition assessment was completed by the Dietitian. The assessment indicated Resident 11 weighed 122.5 pounds, although the resident's weight recorded was 116 pounds on 3/16/11. The resident's goal was to maintain her weight. Additionally, the dietitian wrote Resident 11 had a poor appetite. The resident required 1,120 to 1400 calories to maintain her weight and needed 1400 to 1680cc's of fluid. No other nutritional assessments were noted between 1/6/10 and 3/16/10 when the resident was losing weight. On 3/17/11 the Dietitian initiated 60cc high calorie supplement three times a day secondary to weight loss and poor intake. On 3/17/11 Resident 11 weighed 116 pounds. In 2 months the resident lost 24 pounds, a 17.2% weight loss in 2 months. The physician orders [REDACTED]. The March MAR (Medication Administration Record) did not have any indication weights were recorded for Resident 11 until 3/24/11. The physician note on 3/23/11 indicated the nurses reported resident's appetite remains poor. There is a significant weight loss and weekly weights are done. Her weight on 3/17 was 116.5. "This was, however, with a mechanical lift, which is different than the usual weight-taking method." The physician ordered daily weights and dietary to review Resident 11's weights and make suggestions on 3/23/11. The daily weights were not started until 3/24/11 and a new dietary suggestion was not made until 3/29/11, 5 days later. Then on 3/29/11 the Dietitian wrote a telephone order to increase the high calorie juice supplement to 6 fluid ounces three times a day due to a 7.14% weight loss in 30 days and meal refusals. The MAR indicated [REDACTED]. Resident 11 was weighed on the standing scale, the chair scale with her wheel chair, and the mechanical lift scale. However, she continued to get weighed on different scales. On 4/13/11 hospice was ordered for the resident. On 5/17/11, at 1:20 pm Surveyor asked Dietary Director G if she had guidelines to follow when a resident looses weight. She said she does not have guidelines to follow. She said she did not have guidelines of when to start nutritional supplement or when to notify the Registered Dietitian of a resident's weight loss. She said the physician gets involved when a telephone order is sent to him with a request from the dietitian. She said when a resident has a poor appetite and weight loss the resident is placed on NAR (Nutrition at Risk) charting. The Dietary Director starts the NAR Charting then the dietitian reads it and makes her decisions from the NAR charting. The dietitian did not start new interventions until Resident 11 lost a significant amount of weight of 14.58% in two and a half months. On 5/17/11, at 3:23 pm Surveyor spoke with RD (Registered Dietitian) J on the phone. Surveyor asked RD J how she is notified of a resident's weight loss. She said residents are presented on a communication form. She said the facility uses the NAR charting. She said a nutritional assessment is done annually and with a significant change. She said one of the approaches would certainly be to add a nutritional supplement and sometimes a medication to increase a resident's appetite is recommended. She said she would need Resident 11's record to know what interventions were tried. She said the facility faxed the dietary notes to her and she did not see a note or nutrition assessment from 1/11 to 3/16 when the resident had the significant weight loss. Example 2 Resident 4 has the following diagnoses, according to "[DIAGNOSES REDACTED]., and swallowing difficulty-not consistent. Resident 4's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 2/12/11 states that Resident 4 needs one person physical assist support with eating, is 69 inches tall, 186 pounds, has not had a weight loss of 5 percent or more in the last month or 10 percent or more in the last 6 months, receives a mechanically altered diet, and has broken or loosely fitting full or partial dentures. Resident 4's "Weight Record-MDS Section K" document and weights recorded on Resident 4's "Treatment Record" (TAR) indicate the following weights and methods for obtaining weights for 2011: 1/14/11: 192.0, chair, w/c scale 1/21/11: 193.5, chair, w/c scale 1/28/11: 189.5, chair, w/c scale 2/7/11: 190.0, chair, w/c scale 2/11/11: 185.5, chair, w/c scale 2/18/11: 185.0, chair, w/c scale 2/25/11: 182.5, chair, w/c scale 3/4/11: 185.0, chair, w/c scale 3/11/11: 178.5, chair, w/c scale 3/18/11: 183.3, standing scale 3/18/11: 183.0, standing scale 3/25/11: 171.2, chair, w/c scale 3/30/11: 181.1, standing scale 4/1/11: 173.0, chair, w/c scale 4/8/11: 178.0, Mechanical lift scale 4/9/11: 182.8, chair, w/c scale 4/15/11: 179.1, no method indicated, TAR 4/15/11: 175.2, Mechanical lift scale 4/16/11: 166.0 no method indicated, TAR 4/18/11: 178.4, chair, w/c scale 4/18/11: 178.4, no method indicated, TAR 4/19/11: 178.2, no method indicated, TAR 4/19/11: 178.2, chair, w/c scale 4/20/11: 177.9, no method indicated, TAR 4/20/11: 177.9, chair, w/c scale 4/21/11: 176.6, chair, w/c scale 4/21/11: 176.6, no method indicated, TAR 4/22/11: 176.5, standing scale 4/29/11: 174.0, chair, w/c scale 5/6/11: 169.0, chair, w/c scale 5/13/11: 169.0, chair, w/c scale According to "Nutrition Assessment" notes dated 4/6/11 "NAR (Nutrition at Risk) charting-wt (weight) on 4/1=173, on 3/30=181.1, on 3/25-171.2 on 3/18 183# (pounds) ...Current wt shows variances of 6.4% ? (decrease) in 30 days, 9.97% ?(decrease), 13.9% ?-180 days. Meal intakes X 7 days=67 %. Diet order level 1 pureed c (with) nectar thick liquids. Res (resident) was seen by MD on 3/9/11 c awareness of weight loss. MD addressed hallucinations, difficult to control [MEDICAL CONDITION], prominent resting tremor and excessive drooling ...By hx (history) she had been on a wt loss program. Recommendations submitted for [MEDICAL CONDITION] screen as well as daily wts (weights) x (for) 3 days 2? (secondary to) widely variable pattern. The facility did not have evidence that the recommendations from the dietary department were relayed to the nursing staff and then communicated with Resident 4's physician. Therefore, the facility did not implement interventions for Resident 4's weight variances and possible change in nutritional status. The facility did not obtain weights for three days for Resident 4, as the recommendation suggested. The facility did not obtain a weight for Resident 4 on 4/6/11 or 4/7/11. According to "Nutrition Assessment" notes dated 4/13/11 "Nutrition reviewed at NAR meeting this date. Wt of 174# on 4/8, 182.8 on 4/9[DIAGNOSES REDACTED]erent scales being utilized. Recommend res be weighed on same scale each time. Continue c NAR tracking ...Addendum-request daily wts X 7 days." It is important to note, as described above, the facility did not obtain weights for Resident 4, as recommended on 4/6/11, 4/7/11, or 4/17/11. Surveyor spoke with Food Service Director (FSD) G on 5/17/11 about the processes the facility uses to maintain acceptable levels of nutrition. FSD G stated that the facility uses the NAR program, the facility measures daily or weekly weights, the nursing staff tell the dietary staff about weight changes, FSD G checks weights each week, the Registered Dietician comes in one time per week, and that if there is a significant change in weight right away, FSD G would recommend a supplement and the doctor would prescribe it. FSD D stated that the process for ensuring that recommendations are reported to the nursing staff and then to the doctors is through the Dietician communication sheets. FSD G stated that the dietician would make the recommendations and put the forms into the nursing mailbox so that nursing can call the doctor and then nursing would tell me (FDS G) so that I can stock items needed. Surveyor asked FSD G about the process of weighing residents. FSD G stated that the same scales should be used and that a lot of time there is a discrepancy between scales so the same scale should be used. Surveyor asked FSD G about the recommendations for Resident 4's weight monitoring and scales use. FSD G stated that she would think that the recommendation would be followed or that follow up should happen if it is not followed. FSD G stated that she will find additional information in Dietary/Nursing communication logs as well. FSD G stated that Resident 4 was on a planned weight loss at one time and was progressing and Resident 4 never really reached a plateau and that at that point Resident 4 went onto the NAR program. On 5/17/11 at 10:45 AM, FSD G provided Surveyor with a document titled "Dietary/Nursing Communication Worksheet" that states the following: "4/6/11 (Resident 4's name); NAR charting ...Recommendation: 1. [MEDICAL CONDITION] panel; 2. Please weigh daily X 3 days and notify MD of wt. status." FSD G stated that she found the communications logs and that for Resident 4, she could only find the page that the dietary department sent to the nursing department and that the nursing department usually would send it back to notify the dietary department that the recommendations were followed-up on. Surveyor spoke with Director of Nursing (DON) B on 5/17/11 at 12:55 PM. DON B stated that the facility does weekly weights on almost everyone. DON B stated that it is her expectation that if there is a five pound difference that there is a re-weigh done. DON B stated that the dietary department also follows the weights and the registered dietician will make recommendations after reviewing the weights. DON B stated that the RD will then write-up a summary and forward the information to the nurse managers or the nurse on the floor. Surveyor asked DON B for information regarding Resident 4's dietary recommendations. DON B stated that she would expect the nurses to follow up when they receive them from dietary. Surveyor asked DON B about the consistency of scales. DON B stated that the facility tries to be consistent and that if the differences are seen, then staff should use the same scale. Surveyor asked DON B if a particular scale was to be used, should it be included on the resident's plan of care. DON B stated that it should be on the care plan and that it was a good plan. Example 3 Resident 8 has the following Diagnoses: [REDACTED]. Resident 8's quarterly Minimum Data Set (MDS) assessment, dated 2/7/11 states that Resident 8 is 63 inches tall, weighs 119 pounds, and has had a weight loss of 5 percent or more in the last month or 10 percent or more in the last 6 months that is not physician prescribed. Resident 8's "Nutrition Assessment" notes dated 1/26/11 state the following: "Wt=128# (pounds) on 1/20/11, no change in 30 days, ? (decrease)5.8% in 90 days, 8.5% ? in 180 days. Diet= Level 4: Reg (regular), FIS (Food instead of Supplement), MD aware of wt status. Ave (average) 65% meal intake. Dx (diagnosis) includes dementia. BMI (body mass index)=22.7 with intake at < (less than) 75% at meals, recommend dc (discontinue) of FIS and request High Cal Sup (supplement) 60 cc (cubic centimeters) TID (three times per day) providing 360 cal (calories) and 12 g (gram) protein. Continue to monitor." Resident 8's "Nutrition Assessment" notes dated 1/28/11 states the following: " ...Res is being recommended to go on a supp the order has not been made yet ..." Resident 8's "Weight Record-MDS Section K" documents the following weights: 1/13/11: 128.0 1/27/11: 126.5 2/3/11: 124.5 3/3/11: 123.5 3/4/11: 124.5 3/10/11: 122.0 3/24/11: 123.0 4/7/11: 119.64/28/11: 116.6 5/13/11: 116.0 An order signed and hand-written on Resident 8's "Physician Orders" dated 3/23/11 states the following: "FIS diet-done; High cal supplement 60 cc TID ..." It is important to note that this order is the same recommendation initiated by the dietician on 1/26/11. The facility did not have evidence as to why the order took two months to be initiated or if consultation occurred related to the recommendation with Resident 8's physician. "Nutrition Assessment" documentation dated 4/28/11 states the following: "NAR: Current wt 119 # ? 3.25% in 30 days, ? 6.3 % in 90 days, ? 12.5 % in 180 days. Average intake at meals ~ (approximately) 50% of food on level 4 FIS diet. Resident had colonoscopy on 4/25 ...Resident accepts supplement well, 100% consumed of High Cal supplement 60 cc TID which provides 360 cal and 12 g of protein. Rec (recommend) d/c FIS diet orders, increase supplement to 120 cc TID High Cal Supplement to provide 720 kcal and 24 g protein. Continue to monitor wt, intake and follow per NAR protocol." A telephone order dated 5/3/11 states "D/C FIS diet d/t (due to) low food intakes. Increase High cal supplement to 120 cc TID d/t slow wt loss." It is important to note that this telephone order was not initiated until 5/3/11, five days after the nutrition assessment completed on 4/28/11. It is also important to note that Resident 8's physician wrote an order to discontinue the FIS diet on 3/23/11. Surveyor spoke with Food Service Director (FSD) G on 5/17/11 at 10:45 AM. FSD G stated that Resident 8 is on a supplement and that the FIS diet was discontinued because of low intakes. FSD G presented Surveyor with "Dietary/Nursing Communication Worksheet" dated 1/26/11 that states "Please notify MD of 8.5% weight loss in 180 days. Recommend dc of FIS diet 2? (secondary to) consuming < (less than) 75% and request high cal sup 60 cc TID." FSD G stated that the request from 1/26/11 does not have follow-up from the nursing department. Surveyor spoke with Director of Nursing (DON) B on 5/17/11 at 12:55 PM. DON B stated that when the nursing department receives recommendations from the dietary department, the nurse should contact the physician to get orders but if the physician is coming into the facility the next day, it could wait until then. No further information was provided.