Every finding on record at East Troy Manor

Based on record review, interview, document review and policy review, the facility failed to ensure that fall risks were assessed and that adequate fall interventions were developed, implemented and revised for one of three residents (Resident (R)2) reviewed for falls. R2 was admitted to the facility following a fall at home where R2 sustained a subdural hematoma. The subdural hematoma was still present and in need of monitoring post admission to the facility. Upon admission, R2 was assessed to be at risk for falls with initial safety interventions including a low bed and frequent rounding (frequency not specified). On 4/20/25 the facility placed a sensor alarm to prevent falls. Progress notes indicate R2 frequently setting off the alarms related to impulsivity and frequent self-transfers. On 4/24/25 R2's Nurse Practitioner noted, in their neuro psych initial evaluation of R2: (R2) is oriented times 1(oriented to self), unable to answer questions appropriately. Walking unsteadily in room while self-transfers to bathroom. Poor safety awareness and impulsivity noted. Foley catheter remains intact. Despite assessment documenting R2 is unable to answer questions appropriately, is unsteady, frequently self-transferring and impulsive, these factors were not addressed as risk factors and addressed in R2's care plans to prevent falls. Review of R2's overall care plans include interventions such as 1:1 (one on one) support as indicated without specifying what would be a circumstance to provide 1:1 support. The care plans encourage R2 to be as independent as possible yet R2 is assessed to be at risk for falls and staff are to anticipate needs.On 4/30/25 R2 sustained a fall in their room at approximately 2:15 pm. R2 was found on the floor between the end table and under the television. The motion sensor was not on at the time of the fall. The fall documents indicate prior to staff seeing R2 in their room, R2 was last seen in activities. The fall report does not indicate who assisted R2 back to their room after activities and whether fall interventions were implemented at that time, including activating the sensor alarm. The root cause of the fall was resident was spontaneous with ambulation and forgetting they needed assistance, R2 had motion sensor in place but not on. The intervention post fall was to educate staff on the importance of alarm being on. Staff statements as part of the fall report indicate R2 frequently self-transfers and R2 stood up and fell. The call light was in place but not activated. The fall investigation does not include whether frequent rounding, as a care plan intervention, had been implemented or when R2 was last toileted. The last meal R2 was offered was lunch. There is no indication R2's care plan was revised to address R2's frequent self-transfers or review of R2's routine to assess/implement interventions to prevent falls.R2 was hospitalized [DATE]-[DATE] related to having a change in condition and ultimately having their gallbladder removed. R2 returned to the facility still having a catheter in place with treatment for a urinary tract infection (UTI). The fall risk assessment upon readmission indicated R2 is at risk for falls. There is no notation or assessment post readmission of R2's cognitive status post anesthesia related to R2 having surgery to remove R2's gall bladder. On 5/16/25 R2 had a follow up brain scan where scan results indicated worsening of R2's subdural hematoma since R2's original admission to the facility on 4/17/25. Consultation documentation indicates R2's subdural hematoma increased in size from 9mm to 11mm. On 5/17/25 at approximately 9:00 am R2 was found by a dietary aide on the floor in the dining room. R2 shared they hit their head, and their hip hurt. It was noted in the fall report R2's wheelchair was pushed back, and the brakes were noted to not be on. Statements from staff post fall indicate different timelines of when R2 was last observed or when the breakfast meal took place. The post fall investigation does not include details regarding whether R2 had concluded eating breakfast or if R2 still had a meal in front of them at the time of the fall. R2 had a care plan intervention indicating R2 required supervision and assistance with meals; supervision and assistance is not defined on R2's care plan. There is no indication anyone was supervising R2. R2 was sent to the hospital for evaluation due to noted pain in their head and hip and noted change in mental status. The root cause analysis indicates R2 tried to stand up without a call light because they were in the dining room, the wheelchair was unlocked and R2 requires assistance and is unsteady on their feet. The intervention is to not leave R2 unattended in the dining room. Review of the documentation of R2's initial emergency department visit on 5/17/25 notes the scan results from 5/16/25 and worsening results of the subdural hematoma and indication it may measure a further increase in the bleed than the scan from 5/16/25. Risk management: hospitalization considered but decision made not to admit. Diagnosis includes fall, initial encounter, subdural hematoma, contusion of right hip. R2 was discharged from the hospital at 12:15 pm. Review R2's record post return to the facility on 5/17/25 indicates R2's risk assessment was scored lower than previous fall assessments. No changes were made to R2's care plan regarding worsening subdural hematoma or need for increased monitoring for changes in status beyond the intervention to supervise in the dining room.On 5/17/25 at approximately 3:35 pm R2 was found on the floor in their room with a noted area of discoloration to the left occipital near post temporal line on their head. Statements from staff include different explanations of what R2 was doing at the time of fall including attempting to get something, changing chairs, or adjusting blankets. The fall documentation indicates Certified Nursing Assistant (CNA)1 was in R2's room just prior to R2's fall from the chair. CNA1 did not notice or ensure R2's sensor alarm was in place or activated at the time they were in the room before the fall. CNA1 indicated they were not aware of the safety intervention. R2 was transferred to the emergency department post fall. The emergency department evaluation indicated R2 had a small rebleed on top of the previous intercranial hemorrhage, likely due to recent fall. Transfer to (name of hospital with neurological surgery team) ICU (intensive care unit) for further evaluation and management. Clinical impression: traumatic subdural hematoma with unknown loss of consciousness, initial encounter. The facility's failure to assess R2's risk factors to include frequent self-transferring, impulsivity, and unsteadiness to establish individualized interventions to prevent falls, its failure to develop specific/detailed care plans, and its failure to consistently implement care-planned interventions created a reasonable likelihood for serious harm. R2 sustained 3 avoidable falls in the facility with two fall on 5/17/25 resulting in R2 hitting his head and requiring transfer to the hospital. This created a situation of immediate jeopardy for R2 starting 5/17/25. The Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Corporate Consultant -(CC) were notified of the immediate jeopardy on 7/10/25 at approximately 8:55 pm. The immediate jeopardy was removed on 5/23/25. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) related to the residents at risk for falls in the facility, as the facility continues to implement its action plan. Findings include: The facility's policy titled, Fall Risk Assessment last revised March 2018 revealed, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for fall and establish a resident-centered falls prevention plan based on relevant assessment information.Upon admission, quarterly, annually, and with significant change, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. Review of the facility's policy titled, Falls-Clinical Protocol last revised March 2018 revealed, Assessment and Recognition:.3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record.5. The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc.Cause Identification.3. The staff and physician will continue to collect and evaluate information until the cause of the falling is identified.Treatment/Management.1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.Monitoring and Follow-Up.4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. The facility's policy titled, Assessing Falls and Their Causes last revised March 2018 revealed, Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.residents must be assessed upon admission and regularly afterward for potential risk of falls.If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities.Evaluate chains of events or circumstances preceding a recent fall. Review of the facility's policy titled, Falls and Fall Risk Managing last revised March 2018 revealed, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Resident-Centered Approaches to Managing Falls and Fall Risk.1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.5. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.8. Position-change alarms will not be used as the primary or sole interventions to prevent falls but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Review of the undated facility's policy titled, Kardex policy and procedure. revealed, Policy Statement: The facility will maintain an up-do-date Kardex for each resident to provide nursing staff and caregivers with a quick-reference summary of the resident's care needs, routines, and preferences. The Kardex is intended to supplement the comprehensive care plan and ensure continuity and quality of care. Purpose: To provide a concise, accessible reference tool that assists nursing staff in delivering personalized, consistent, and safe care in accordance with the resident's care plan. Scope: Applies to all nursing staff, caregivers, and interdisciplinary team members involved in direct resident care.Kardex: A non-legal, working document summarizing essential care plan components. Care Plan: A legally required document outlining assessed needs and interventions developed by the interdisciplinary team.Each Kardex should include the following sections:.Safety precautions (e.g., fall risk.) .Responsibilities:.CNA [Certified Nursing Assistant]-Use Kardex as a reference for daily care tasks and report changes. According to https://my.clevelandclinic.org/health/diseases/21183-subdural-hematoma, What are the risk factors for subdural hematoma? Anyone can get a subdural hematoma from an accidental head injury. But certain factors can increase your risk, including: Age: People 65 and older and babies are more at risk for getting subdural hematomas. As you age, your brain shrinks inside your skull. The space between your skull and brain widens. This makes the tiny veins in the membranes between your skull and brain stretch. These thinned, stretched veins are more likely to tear, even if you experience a minor head injury. What are the complications of subdural hematoma? Without treatment, large hematomas can lead to coma and death. Other complications include: Brain herniation: Increased pressure from a pool of blood can squeeze and push brain tissue so it moves from its normal position. A brain herniation is often fatal. Repeated bleeding: People older than 65 who are recovering from a hematoma have a higher risk of another hemorrhage due to changes in their brain tissues. Seizures: Seizures may develop even after you receive treatment for a hematoma. R2's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R2 was admitted to the facility on [DATE] with diagnosis of traumatic subdural hemorrhage without loss of consciousness due to a fall at home. Additional diagnoses include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 4/17/25 at 10:01 pm progress notes indicate: Resident being monitored d/t (due to) being 72hr (hour) new admission to facility post hospitalization d/t fall at home and became increasingly confused was taken to hospital and diagnosed w (with)/Subdural Hematoma and has HX (history) of Dementia; resident also had urinary retention while in hospital and currently has indwelling foley catheter. Resident is alert to name but does not answer simple questions when asked but will make eye contact when being talked too; resident has been non-verbal for nurse this shift and staff to anticipate resident's needs as he is unable to communicate them at this time. Resident has call light within reach but will do 15 min (minute) checks to ensure resident has no needs d/t being unsure if resident is aware of his surroundings. Resident awake/alert this shift did assist w/taking drinks from his sippee (sic) cup when writer giving him meds (medications) tonight.Resident had a fall at home and had AMS (altered mental status) and generalized weakness. He was admitted to the hospital on 4/6 for subdural hematoma. History of dementia, bipolar disorder, PE (pulmonary embolism), HTN (hypertension), AFIB (atrial fibrillation) with long term anticoagulation. VSS (vital signs stable). No s/s (signs/symptoms) of pain. DNR (Do Not Resuscitate). Alert. Nonverbal currently, did not respond to questions. Transferred with assist of 2 with gait belt and [NAME] steady (sic). Surveyor noted R2 was initially placed on 15-minute checks related to not being familiar with the facility. On 4/17/25 a care plan with a problem for agitation related to/manifested by unfamiliar care staff, new living environment, diagnosis of dementia was implemented. Interventions dated 4/17/25 include approach in a calm, non-threatening manner; depression screens PRN (as needed); encourage expression of feelings; encourage resident family to seek out social services with concerns/problems; monitor for changes in mood or behaviors, report to social services & nursing; offer choices; offer quiet setting; psych consult as indicated; re-approach as necessary; speak in a calm soothing voice. Surveyor noted 15 minute checks were not part of R2's initial adjustment/agitation plan of care . On 4/17/25 a care plan for potential for adjustment issues was initiated. Interventions dated 4/17/25 include to allow /encourage to direct care as able; encourage active participation; encourage resident/family to communicate likes/dislikes with staff, share questions/ concerns; encourage to make decisions as able; encourage visits by support system (family, friends, church etc.); provide 1:1 support as needed. The care plan did not specify what would require 1:1 support. On 4/17/25 R2's care plan for alteration in thought process/confusion related to/manifested by traumatic subdural hemorrhage & dementia diagnosis was initiated. Interventions dated 4/17/25 include allow to be as independent as possible; allow time to respond as necessary; attempt to anticipate needs as needed; explain procedures; if appears lost, offer direction; monitor for changes in cognitive behavior and report to social services & nursing; offer choices appropriate with level of ability; offer gentle reminders as needed; offer quiet setting; speak in calm voice. On 4/18/25 a care plan for I am in a new situation with interventions dated 4/18/25 included: accompany to meals, therapy, bathroom, activities as needed; check on resident on how they are adjusting to the facility; describe layout of the facility. Review of R2's admission Minimum Data Set (MDS), located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 04/22/25, revealed a Brief Interview for Mental Status (BIMS) had no score out of 15, which indicated severe cognitive impairment and R2 was rarely or never understood. According to the MDS, R2 required substantial/maximum assistance from staff for rolling left and right, and dependent with toileting, sit to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfers. The resident had a fall in the last month prior to admission/entry or reentry. R2's initial assessment documentation located in the EMR under the Resident Documents tab dated 04/17/25 documented the resident was nonverbal with dementia. Fall preventions identified included gripper socks and grab bars. The resident was assessed to be a fall risk but did not require fall mats or alarms. The care plan for falls was initiated on 04/18/25 and did not include these assessed interventions of gripper socks and grab bars. R2's Care Plan located in the EMR under the Care Plan tab initiated 04/18/25 revealed R2 was at risk for falls as he had a fall at home. Goal documented is Reduction in chance of falls. Interventions included frequent rounding and low bed initiated on 04/18/25. The care plan did not specify what constituted frequent rounding. Review of R2's John Hopkins Fall Risk Assessment Tools located in the EMR under the Observations tab revealed the resident had multiple assessments completed during his stay:Upon admission on [DATE], his score was assessed at 13.0, which indicated moderate fall risk. However, the care plan still identified only the two interventions noted above. Review of R2's Progress Notes located in the EMR under the Progress Notes tab revealed regular and consistent documentation of the resident attempting to self-ambulate and walk, placing himself at risk of falls. However, the resident's care plan failed to identify the resident's history of falling, which included a subdural hematoma from a fall at home. The care plan failed to include a resident-centered approach to R2's confusion and documented frequent attempts to self-ambulate. On 4/18/25 at 1:42 PM documentation includes admit: Resident admitted post hospitalization related to fall at home resulting in a subdural hematoma . Resident 2 assist using gait belt and EZ stand at this time. Resident self-transferred this morning and OT (Occupational Therapist) found him standing beside his dresser. Resident was incontinent of bowel at this time. Resident has a foley catheter and a follow up appointment with urology. Resident has been nonverbal since admission. Resident smiled at writer and will answer yes or no questions by shaking his head. Surveyor noted R2's care plan to address problem of my ability to dress & toilet without assistance includes an intervention dated 4/18/25 to perform self-cares with the assistance of 1 staff member. Surveyor noted there isn't a care plan to address R2's bowel incontinence. On 4/19/25 at 9:46 AM progress notes document . Eats meals in the dining room, needs assist with meals. Transfers with assist of 2 with EZ stand. Resident was leaning to the right in his w/c (wheelchair), pillow placed. On 4 /19/25 at 5:38 PM documentation includes: . Trace edema present to bilateral lower legs, ankles and feet. Resident is using EZ stand for all transfers with 2 staff assistance. Resident needs verbal cues throughout any task and ongoing encouragement. When sitting in wheelchair resident leans to his right side. Staff only used wheelchair for meal this shift as it does not appear safe for resident to sit in chair. He leans forward and will fall out. Goal is for resident to workwith therapy for strengthening. Surveyor noted the use of a pillow to position R2 in the wheelchair was not an added intervention to R2's care plans. Review of R2's Progress Notes located in the EMR under the Progress Notes tab documented on 04/20/25 at 9:49 AM . Eats meals in the dining room, fed self breakfast today. Transfers with assist of 2 with EZ stand. Resident attempting to get out of his w/c several times after breakfast. Resident was then transferred to his recliner. Soft touch call light within reach, uses it at times. R2's Progress Notes located in the EMR under the Progress Notes tab Dietitian (RD) documented on 04/20/25 at 6:49 PM, Motion sensor alarm placed in room as resident tries to get out of his chair on his own without using the call light at times. The intervention to add the motion sensor alarm was initiated on 04/20/25. R2's Care Card information provided by the Administrator on 07/10/25 at 12:32 PM, revealed the resident was identified with interventions for falls on 04/20/25 that included, Motion alarm on when he is in the room by himself for safety. No additional interventions were documented on the Care Card for CNA use. R2's Progress Note located in the EMR under the Progress Notes tab documented on 4/21/25 at 1:08 PM: Resident was observed by another nurse that resident was pushing on the front entrance/exit door while sitting in his w/c. Writer observed resident was restless, attempting to stand up from his w/c. When asked if he had pain he stated yes. PRN (as needed) Tylenol given. Resident was then redirected and assisted to the dining room. Wander guard placed on right wrist. POA (power of attorney) notified. Surveyor noted there is no care plan to address R2's risk for/attempts to exit the facility or a care plan to address R2 wearing a wanderguard. On 4/21/25 at 4:59 PM Medicare charting documents: Medicare. Resident is alert to self and wife only. He does not answer questions appropriately. He is restless and frequently trying to stand unassisted or self-transfer. Motion sensor alarm on while in room alone. He is assisted to common areas as much as possible to be supervised. He is transferring with EZ stand. He does propel self in w/c short distances. He has foley in place draining clear yellow urine. He was incontinent of small BM in brief. He needs assist with eating and drinking. He has occasional facial grimace during transfers and repositioning. Has prn pain medication ordered. He is working with therapy for strengthening, will continue to monitor. Surveyor noted facility nursing staff continue to document about R2's restlessness and frequent attempts to stand or transfer without assistance. This note indicates the need for increased supervision however, increased supervision with specified details is not an intervention on R2's plan of care. On 4/23/25 a SNF Progress Note was completed by Nurse Practitioner (NP1). Under NEURO/PSYCH it is documented - Oriented x1, unable to answer questions appropriately. Walking unsteadily in room while self-transferring to bathroom. Poor safety awareness and impulsivity noted. Foley catheter remains intact draining yellow urine. Under assessment and plan it is documented: G30.1 - Alzheimer's disease with late onset: POA activated. Further decline expected. Longterm (sic) goal to move to Mauston where his son is moving within the next year. Patient continues on memantine for underlying dementia. Due to his underlying dementia, poor safety awareness, and impulsivity, falls are inevitable. Patient is oriented x1 and unable to answer questions appropriately. Surveyor noted R2's care plan for risk for falls does not include R2 receiving memantine (Namenda) which has a side effect of dizziness. Additionally, despite NP1 noting R2's unsteady walking, self-transferring to the bathroom, poor safety awareness, and impulsivity, there are no revisions to R2's care plan to address these risk factors. Surveyor noted it is not documented if the motion sensor was in place and on when NP1 witnessed R2 walking and self-transferring in their room. A progress note dated 4/24/25 documents: Constantly trying to pull off brief and pull at catheter and stand at edge of bed on own. Resident re-positioned and toileted many times. Did have one large BM, but after continues to not sleep and self-transfer. CNAs got resident dressed and up in w/c d/t being safety issue. Is currently sitting in nursing station with staff to better monitor for safety. Resident states that he wants to leave and go home. Explained to resident that he is too weak to safely discharge currently and needs rehab for strengthening. Resident nods head in aggreance (sic) but continues to try and stand from w/c or propel towards doorways. Wander guard in place to right wrist at this time. Surveyor also noted staff implementing increased supervision and increased supervision as a safety measure is still not part of R2's fall risk care plan. On 4/24/25 at 11:29 AM progress notes document: Writer obtained verbal consent from APOA/ (name of) for resident to change rooms closer to nurse's station. Resident will be moved to rm (room number documented). Resident status change form completed and put in med recs, nursing notified of consent. A progress note recorded as Late Entry on 04/28/2025 09:52 PM for 4/26/25 at 3:00 AM documents: Resident being monitored d/t having behaviors and wandering t/o (sic) night couple nights ago and also d/t having +UA (positive urinalysis) w/pending culture. Resident has been sleeping this shift w/out any concerns and VSS as noted. On 4/29/25 at 3:45 PM a late entry note for 4/26/25 at 6:40 PM documents: Resident has dementia dx (diagnosis) and has sundown behaviors in the evening, very restless and trying to stand up unassisted. He also tries to get out of bed unassisted all night long, per night nurse report does not sleep much, and motion sensor alarm frequently sounding. He becomes very anxious when his wife is not in the room with him. NP updated and new orders received. Progress notes dated 4/27/25 at 6:50 PM documents new order received to give Melatonin 3mg QHS (at bedtime) for sleep PRN. Surveyor noted R2's care plan was not updated to identify when R2 should receive Melatonin as a PRN and if there is an increased risk for falls with the new medication. On 4/29/25 orders were received for R2 to receive scheduled 5 mg of Melatonin nightly. R2's Progress Note located in the EMR under the Progress Notes tab documented on 04/30/25 at 3:20 PM that R2, .continued to be monitored at this time r/t [related to] unobserved fall in room.found sitting on the floor in between his end table and chair underneath the television by RA [resident aide] .resident stated that he was getting up from his recliner and fell. When asked where he was going, he stated he wasn't sure.Has motion sensor alarm.was not sounding and was turned off. Per orders, motion sensor alarm is to be on at all times when resident is alone in room. Staff re-education to be started on ensure sensor alarm is to be on and frequent rounding. Paper to be signed by staff before starting shift. The fall investigation revealed that the motion sensor was not turned on, according to the fall care plan intervention. Review of staff statements, and the fall investigation details indicate R2 fell at 2:15 PM and was last seen at 1:15 PM in activities and R2's last meal was at 12:00 PM. There isn't detail regarding whether R2 was incontinent/continent of bowel at the time of fall or when R2 was last toileted related to a bowel movement. Certified Nursing Assistant (CNA)7 indicates in their statement R2 was last seen at 2:00 PM but does not specify who saw R2. RN2's statement documented for the question did you ask resident what happened? What was the response? Frequently self-transfers + (and) stood up from recliner + fell. RN2 documents R2 was confused at the time of the fall per baseline. CNA7's statement does not include details of where R2 was seated when observed at 2:00 pm or who made the observation (whether it was CNA7 or other individual). The written statement by CNA7 documents: RA (resident assistant) told staff (referred to as room number) was on (sic) floor. Me (CNA7) and the nurse went and checked on the resident. Checked vitals and then assisted resident up. Resident put feet flat on the floor and stood with minimal assistance. R2's care plan was updated to include: ensure the sensor alarm is turned on prior to leaving the resident in room unsupervised, and call light within reach. Reeducation was provided. The facility root cause analysis completed on 5/1/25 documents Problem statement: was found sitting on floor between table next to recliner under tv. The documented answers to the five why questions include frequently stands up thinking he can walk unassisted; needs assistance; had motion alarm for intervention/not on; call light in reach, call light not on; A+O (alert & oriented) x 2, forgetful. The Root Cause(s): Resident is spontaneous with ambulation forgetting he needs assistance had motion alarm in place was not on. Intervention to re-educate staff on the importance of motion alarms needing to be on. The fall investigation does not include relevant details to help complete a thorough root cause analysis. The investigation does not include a statement from activity staff to determine who assisted R2 back to his room and whether intervention were in place at that time. The intervention to retrain staff on the motion sensor alarm did not address the factors of R2 forgetting he needs assistance and R2 frequently stands up. The Fall Risk Assessment Tool completed on 4/30/25 indicates a score of 20 indicating R2 is at high risk for falls (greater than 13 is considered high risk). Surveyor notes despite R2 having a foley catheter, the risk question for patient care equipment: any equipment that tethers patient (which included a catheter as an example) was not scored as a risk factor. Progress notes on 5/1/25 at 11:12 AM document . Resident continues to attempt to self-transfer. Resident has motion alarm on at all times when resident is in room alone . R2 was transferred to the hospital on 5/1/25 for a change in condition. R2 was admitted and ultimately had gallbladder surgery. R2 readmitted to the facility on [DATE]. The fall assessment completed on 5/9/25 assesses R2 to have a fall risk score of 21 indicating R2 is at high risk for falls. Upon return to the facility there are no revisions to R2's care plans to monitor for any changes related to R2 having received anesthesia during the hospitalization and potential effects that may have on R2 given diagnoses of dementia and subdural hematoma. On 5/10/25 at 1:09 PM progress notes document: Resident readmitted s/p (status post) hospitalization for lap chole (laparoscopic cholecystectomy - gallbladder removal) on 05.06.25. Resident has dementia. He seems more confused than previous. He is attempting multiple times to get up out of wheelchair. He is unable to sit still. Continuous redirection given this shift. Transfers with gait belt, staff and walker. Resident denies any pain, lungs clear throughout, bowel sounds active. On 5/12/25 R2's medical record includes documentation of clarifying orders to re-start Tamsulosin (Flomax) (medication to trea

Based on interview and record review, the facility did not ensure 6 of 6 direct care staff, chosen at random, received required training on effective communication. Licensed Practical Nurse (LPN)-2, and Certified Nursing Assistants (CNA) CNA1, CNA8, CNA9, CNA10 and CNA11 did not receive effective communication training. This deficient practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents: Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers. 3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas of training.6. Required training topics include the following:a. Effective communication with Residents and family (direct care staff) .7. Training requirements are met prior to staff providing services to Residents, annually, and as necessary based on the facility assessment.8. Completed training is documented by staff development coordinator, or his or her designee and includes:a. Date and time of the trainingb. Topic of the trainingc. Method used for trainingd. A summary of the competency assessmente. Hours of training completed On 7/24/25, at 11:05 AM, Surveyor randomly selected direct care staff for review related to receiving required training. Surveyor reviewed the employee records for LPN2, CNA1, CNA8, CNA9, CNA10, and CNA11. The facility was unable to provide documentation verifying LPN2, CNA1, CNA8, CNA9, CNA10, and CNAQ received the required training for effective communication. On 7/24/25, at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding LPN2, CNA1, CNA8, CNA9, CNA10, and CNA11 not having required training on effective communication. NHA-A stated, Whatever I don't have, I just don't have it. NHA-A indicated NHA-A has no further documentation of completed required trainings for the selected staff.On 7/24/25, at 2:32 PM, NHA-A and Director of Nursing (DON)-B were informed of the of the above findings. NHA-A stated, Education is a problem. NHA-A is looking at designating a training coordinator. NHA-A understands Surveyor's concern of staff not having completed the required trainings.

Based on interview and record review, the facility did not ensure 4 facility staff, chosen at random, received required training on resident rights and responsibilities. Dietary Aide (DA)1 and Certified Nursing Assistants (CNAs), CNA1, CNA8, and CNA9 did not receive required training on resident rights and responsibilities. This practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas of training.6. Required training topics include the following: .b. Resident rights and responsibilities7. Training requirements are met prior to staff providing services to Residents, annually, and as necessary based on the facility assessment.8. Completed training is documented by staff development coordinator, or his or her designee and includes:a. Date and time of the trainingb. Topic of the trainingc. Method used for trainingd. A summary of the competency assessmente. Hours of training completedOn 7/24/25, at 11:05 AM, Surveyor randomly selected staff for review for completing required training. Surveyor reviewed the employee records for DA1, CNA1, CNA8, and CNA9. The facility was unable to provide documentation verifying DA1, CNA1, CNA8, and CNA9, received the required resident rights and responsibilities training.On 7/24/25, at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A iregarding DA1, CNA1, CNA8, and CNA9 not having required resident rights and responsibilities training. NHA-A stated, Whatever I don't have, I just don't have it. NHA-A indicated NHA-A has no further documentation of completed required trainings for the selected staff.On 7/24/25, at 2:32 PM, NHA-A and Director of Nursing (DON)-B were informed of the of the above findings. NHA-A stated, Education is a problem. NHA-A is looking at designating a training coordinator. NHA-A understands Surveyor's concern of staff not having completed the required trainings.

Based on interview and record review, the facility did not ensure 4 facility staff, chosen at random, received training on abuse prevention, activities that constitute abuse, procedures for reporting abuse and dementia management and resident abuse prevention. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA10 and CNA11 did not receive this required training. This deficient practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas of training.6. Required training topics include the following: .c. Preventing abuse, neglect, exploitation or misappropriation of Resident property including:(1) Activities that constitute abuse, neglect, exploitation or misappropriation of Resident property(2) Procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of Resident property(3) Dementia management and Resident abuse prevention .g. Compliance and Ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating 5 or more facilities)7. Training requirements are met prior to staff providing services to Residents, annually, and as necessary based on the facility assessment.8. Completed training is documented by staff development coordinator, or his or her designee and includes:a. Date and time of the trainingb. Topic of the trainingc. Method used for trainingd. A summary of the competency assessmente. Hours of training completed .On 7/24/25, at 11:05 AM, Surveyor randomly selected staff to review for completion of required training. Surveyor reviewed the employee records for CNA1, CNA8, CNA10 and CNA11. The facility was unable to provide documentation verifying CNA1, CNA8, CNA10 and CNA11 received the required training on abuse prevention, activities that constitute abuse, procedures for reporting abuse and dementia management and resident abuse prevention. On 7/24/25, at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to CNA-1, CNA-8, CNA-10 and CNA-11 not having abuse prevention, activities that constitute abuse, procedures for reporting abuse and/or dementia management training . NHA-A stated, Whatever I don't have, I just don't have it. NHA-A indicated NHA-A has no further documentation of completed required trainings for the selected staff.On 7/24/25, at 2:32 PM, NHA-A and Director of Nursing (DON)-B were informed of the of the above findings. NHA-A stated, Education is a problem. NHA-A is looking at designating a training coordinator. NHA-A understands Surveyor's concern of staff not having completed the required trainings.

Based on interview and record review, the facility did not ensure 4 facility staff, chosen at random, received required training on Quality Assurance Performance Improvement (QAPI) training. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA9 and Dietary Aide (DA)1 did not receive required QAPI training. This practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas of training.6. Required training topics include the following: .d. Elements and goals of the facility QAPI program7. Training requirements are met prior to staff providing services to Residents, annually, and as necessary based on the facility assessment.8. Completed training is documented by staff development coordinator, or his or her designee and includes:a. Date and time of the trainingb. Topic of the trainingc. Method used for trainingd. A summary of the competency assessmente. Hours of training completed.On 7/24/25, at 11:05 AM, Surveyor randomly selected staff for review regarding completion of required training for QAPI. Surveyor reviewed the employee records of CNA1, CNA8, CNA9 and DA1. The facility was unable to provide documentation verifying CNA1, CNA8, CNA9 and DA1 received the required QAPI training.On 7/24/25, at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A fregarding CNA1, CNA8, CNA9 and DA1 not completing required QAPI training . NHA-A stated, Whatever I don't have, I just don't have it. NHA-A indicated NHA-A has no further documentation of completed required trainings for the selected staff.On 7/24/25, at 2:32 PM, NHA-A and Director of Nursing (DON)-B were informed of the of the above findings. NHA-A stated, Education is a problem. NHA-A is looking at designating a training coordinator. NHA-A understands Surveyor's concern of staff not having completed the required trainings.

Based on interview and record review, the facility did not ensure 4 facility staff chosen at random, received required training on infection prevention and control. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA9 and Dietary Aide (DA)1 did not receive required training on infection prevention and control. This practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education.2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas of training.6. Required training topics include the following: .e. The infection prevention and control standards, policies and procedures .7. Training requirements are met prior to staff providing services to Residents, annually, and as necessary based on the facility assessment.8. Completed training is documented by staff development coordinator, or his or her designee and includes:a. Date and time of the trainingb. Topic of the trainingc. Method used for trainingd. A summary of the competency assessmente. Hours of training completed On 7/24/25, at 11:05 AM, Surveyor randomly selected staff to review for completion of required trainings. Surveyor reviewed the employee records for CNA1, CNA8, CNA9 and DA1. The facility was unable to provide documentation verifying CNA1, CNA8, CNA9 and DA1 received the required infection prevention and control training. On 7/24/25, at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding CNA1, CNA8, CNA9 and DA1 not having required training on infection prevention and control. NHA-A stated, Whatever I don't have, I just don't have it. NHA-A indicated NHA-A has no further documentation of completed required trainings for the selected staff.On 7/24/25, at 2:32 PM, NHA-A and Director of Nursing (DON)-B were informed of the of the above findings. NHA-A stated, Education is a problem. NHA-A is looking at designating a training coordinator. NHA-A understands Surveyor's concern of staff not having completed the required trainings.

Based on interview and record review, the facility did not ensure 5 facility staff, chosen at random, received required training on compliance and ethics which includes training on standards, policies, and procedures of the facility's compliance and ethics program. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA10 and CNA11 and Dietary Aide (DA)1 did not receive the required compliance and ethics training. This practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education.2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas of training.6. Required training topics include the following: .g. Compliance and Ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating 5 or more facilities)7. Training requirements are met prior to staff providing services to Residents, annually, and as necessary based on the facility assessment.8. Completed training is documented by staff development coordinator, or his or her designee and includes:a. Date and time of the trainingb. Topic of the trainingc. Method used for trainingd. A summary of the competency assessmente. Hours of training completedOn 7/24/25, at 11:05 AM, Surveyor randomly selected staff for review for completion of required training. Surveyor reviewed the employee records of CNA1, CNA8, CNA10, CNA11 and DA1 . The facility was unable to provide documentation verifying CNA1, CNA8, CNA10, CNA11 and DA1 received the required compliance and ethics training.On 7/24/25, at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding CNA1, CNA8, CNA10, CNA11 and DA1 not completing required compliance and ethics training. NHA-A stated, Whatever I don't have, I just don't have it. NHA-A indicated NHA-A has no further documentation of completed required trainings for the selected staff.On 7/24/25, at 2:32 PM, NHA-A and Director of Nursing (DON)-B were informed of the of the above findings. NHA-A stated, Education is a problem. NHA-A is looking at designating a training coordinator. NHA-A understands Surveyor's concern of staff not having completed the required trainings.

Based on interview and record review, the facility did not ensure 5 Certified Nursing Assistants (CNAs) reviewed completed the required 12 hours of educational inservice hours. CNA1, CNA8, CNA9, CNA10 and CNA11 did not receive 12 hours of annual inservice education training. This had the potential to affect all 39 Residents who reside in the facility.Findings include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas of training.6. Required training topics include the following:a. Effective communication with Residents and family(direct care staff)b. Resident rights and responsibilitiesc. Preventing abuse, neglect, exploitation or misappropriation of Resident property including:(1) Activities that constitute abuse, neglect, exploitation or misappropriation of Resident property(2) Procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of Resident property(3) Dementia management and Resident abuse preventiond. Elements and goals of the facility QAPI programe. The infection prevention and control standards, policies and proceduresf. Behavioral healthg. Compliance and Ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating 5 or more facilities)7. Training requirements are met prior to staff providing services to Residents, annually, and as necessary based on the facility assessment.8. Completed training is documented by staff development coordinator, or his or her designee and includes:a. Date and time of the trainingb. Topic of the trainingc. Method used for trainingd. A summary of the competency assessmente. Hours of training completed .The 2025 Facility Assessmentlast does not document the assessment details related to the requirement for Certified Nursing Assistants to receive a minimum of 12 hours of training per year based on their date of hire.On 7/24/25, at 11:05 AM, Surveyor randomly selected 5 staff for review. Surveyor reviewed the employee records of CNA1, CNA8, CNA9, CNA10 and CNA11. The facility was unable to provide documentation verifying CNA1, CNA8, CNA9, CNA10 and CNA11, received the required 12 hours of inservice education training annually based upon their date of hire. CNA1-date of hire 5/23/24. No information was provided to verify CNA1 received 12 hours of required inservice hours during the period of 5/23/24-5/23/25.CNA8-date of hire 7/17/23. No information was provided to verify CNA8 received 12 hours of required inservice hours during the period of 7/1/24-7/1/25.CNA9-date of hire 5/1/24. No information was provided to verify CNA9 received 12 hours of required inservice hours during the period of 5/1/24-5/1/25.CNA10-date of hire 7/8/24. No information was provided to verify CNA10 received 12 hours of required inservice hours during the period of 7/8/24-7/8/25.CNA11-date of hire 6/5/24. No information was provided to verify CNA11 received 12 hours of required inservice hours during the period of 6/5/24-6/5/25.On 7/24/25, at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding CNA1, CNA8, CNA9, CNA10 and CNA11 not having the required 12 hours of inservice education training. NHA-A stated, Whatever I don't have, I just don't have it. NHA-A indicated NHA-A has no further documentation of completed required trainings for the selected staff.On 7/24/25, at 2:32 PM, NHA-A and Director of Nursing (DON)-B were informed of the of the above findings. NHA-A stated, Education is a problem. NHA-A is looking at designating a training coordinator. NHA-A understands Surveyor's concern of staff not having completed the required trainings.

Based on interview and record review, the facility did not ensure 8 of 8 facility staff, chosen at random, received required training on behavioral health. Licensed Practical Nurse (LPN)2, Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA9, CNA10, CNA11, Housekeeper (HK)1, and Dietary Aide (DA)1 did not receive the required behavioral health training. This deficient practice had the potential to affect all 39 Residents in the facility.Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training.Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education.2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the Resident's quality of life and quality of care and can demonstrate competency in the topic areas of training.6. Required training topics include the following: .f. Behavioral health7. Training requirements are met prior to staff providing services to Residents, annually, and as necessary based on the facility assessment.8. Completed training is documented by staff development coordinator, or his or her designee and includes:a. Date and time of the trainingb. Topic of the trainingc. Method used for trainingd. A summary of the competency assessmente. Hours of training completedOn 7/24/25, at 11:05 AM, Surveyor randomly selected staff for review for completion of required training. Surveyor reviewed the employee records of CNA1, CNA8, CNA9, CNA10, CNA11 and LPN2, HK1, and DA1. The facility was unable to provide documentation verifying CNA1, CNA8, CNA9, CNA10, CNA11, LPN2, HK1, and DA1 received required training on behavioral health. On 7/24/25, at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding CNA1, CNA8, CNA9, CNA10, CNA11, LPN2, HK1, and DA1 not completing required behavioral health training. NHA-A stated, Whatever I don't have, I just don't have it. NHA-A indicated NHA-A has no further documentation of completed required trainings for the selected staff.On 7/24/25, at 2:32 PM, NHA-A and Director of Nursing (DON)-B were informed of the of the above findings. NHA-A stated, Education is a problem. NHA-A is looking at designating a training coordinator. NHA-A understands Surveyor's concern of staff not having completed the required trainings.

Based on observation, interview, and record review, the facility did not ensure that the daily nurse staff posting included all required information accurately. This deficient practice has the potential to affect a pattern of all 39 residents residing in the facility.The facility's nurse staff posting did not accurately reflect the correct number of staff members on each daily nurse staff posting.Findings Include:The facility's Posting Direct Care Daily Staffing Numbers policy and procedure revised August 2022 documents:. Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to Residents.Policy Interpretation and Implementation.1. Within two(2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and Nas) directly responsible for Resident care is posted in a prominent location (accessible to Residents and visitors) and in a clear and readable format.2. The information recorded on the form shall include the followinga. The name of the facilityb. The current datec. The Resident census at the beginning of the shift which the information is postedd. 24 hour shift schedule operated by the facilitye. The shift for which the information is postedf. Type and category of nursing staff working during that shift who are paid by the facilityg. The actual time worked during that shift for each category and type of nursing staffh. Total number of licensed and non-licensed nursing staff working for the posted shift.3. Within 2 hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the Nurse Staffing Information form. The charge nurse completes the form and posts the staffing information in the location(s) designated by the administrator.On 7/24/25, at 8:56 AM, Surveyor reviewed the documented daily postings from 7/11/25-7/24/25. The daily postings do not document the total nursing staff hours for each category for the following dates: 7/14/25, 7/15/25, 7/16/25, 7/21/25, and 7/23/25.On 7/24/25, at 9:02 AM, Surveyor observed the daily posting for 7/24/25 and notes there are no total nursing staff hours documented for each category.On 7/24/25, at 9:05 AM, Surveyor interviewed Scheduler (SCH)-1 in regard to the daily postings. SCH-1 confirmed SCH-1 is responsible for completing the daily postings for nursing staff. SCH-1 stated the third shift nurse usually posts the schedule for the following day. Surveyor asked SCH-1 if SCH-1 writes in the hours when the nursing staff schedule is posted. SCH-1 stated the hours can change during the day and the hours are not adjusted as the change may occur. SCH-1 stated the nursing hours are completed the next morning after the posted schedule and forwarded to the facility corporation. SCH-1 stated if there are blank documented nursing staff hours then, I didn't do it.On 7/24/25, at 1:33 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to the required nursing staff posted information including nursing staff hours. NHA-A stated the expectation is that the hours are documented on the bottom of the schedule and nursing staff hours should be adjusted throughout the day as needed. NHA-A stated the nursing staff hours for the weekend are pre-filled out, but the actual hours should be adjusted on a daily basis. NHA-A confirmed that the expectation is that daily postings of actual working nursing staff should also document actual working nursing staff hours and should be documented on a daily basis. NHA-A and Surveyor both observed the daily nursing staff posting for 7/24/25 at this time and the nursing staff posting did not have documentation of the actual nursing staff hours currently working in the facility. NHA-A understands the concern that the required posting of actual nursing staff working has not been done. No further information has been provided by the facility regarding the posting of nursing staff hours.

Based on facility document review and interview, the facility failed to establish a training program to include an effective system of communication with contracted agency staff related to the level of care a resident requires. Findings included: During an interview on 04/01/2025 at 4:35 PM, the Administrator stated that contracted agency staff were required to read resident care information contained in a binder prior to their first shift, and were to use care cards to determine a resident's transfer status. She stated she would provide the agency binder. An untitled facility document provided by the Administrator from a binder the facility used for agency staff, dated 01/06/2025, revealed, Topic: Care Cards. The document revealed, Care Cards are in residents [sic] rooms in their closet. Cares must be done according to the care card to meet the residents [sic] needs in the safest way possible. The document revealed that Agency CNAs (ACNAs) signed the document; however, ACNA K and ACNA M had not signed the document. During an interview on 03/31/2025 at 5:30 PM, ACNA K stated she was an agency CNA and worked at the facility on a regular basis. She stated she received report either from staff on the prior shift or a nurse. She stated she did not remember signing forms in a binder when she first began working at the facility. During a telephone interview on 04/01/2025 at 2:40 PM, ACNA M stated she worked as an agency CNA and worked at the facility often. She stated she conducted walking rounds with staff and asked questions regarding how to provide care to the residents. She stated the facility did not conduct much, if any, training with agency staff. She stated that it was fairly difficult to know how to take care of the residents. She stated that some facilities did really well with providing information regarding facility policies, but this facility did not. During an interview on 04/01/2025 at 10:49 AM, Licensed Practical Nurse (LPN) B stated that staff were to refer to care cards in residents' closets to determine what level of assistance a resident required for transfers. During an interview on 04/01/2024 at 3:00 PM, the Director of Nursing (DON) stated she expected staff to transfer residents according to the care cards, which were located inside a resident's closet. She stated staff did not always follow the care cards, noting she could determine that from some of the falls residents had experienced. She stated the facility provided a substantial amount of education with staff during nurses' meetings. The DON stated the nurses were required to call her after each resident fall. She stated that whenever it was a preventable fall, they posted a sign-up sheet and had the nurse review it, noting staff then signed off that they had been educated. During an interview on 04/01/2025 at 5:30 PM, the Administrator stated the agency staff binder was clearly not working. When she provided the sign-in sheet for education on the care cards she stated, Clearly, we have more agency staff than had signed off on the sheet. She stated that when she went to retrieve the agency binder, she stopped to ask three agency staff if they knew about the care cards in the resident closets, and two of the three did not.

Based on interview, facility document review, and facility policy review, the facility failed to establish an effective Quality Assurance and Performance Improvement (QAPI) program that obtained program feedback, utilized data, took action to conduct structured, systematic investigations, and analyzed underlying causes or contributing factors of problems affecting facility-wide processes that impacted quality of care, quality of life, and resident safety. Specifically, the facility QAPI program failed to track and trend falls. Findings included: A facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revised 02/2020, revealed, This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. The Policy Interpretation and Implementation revealed, The objectives of the QAPI Program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Establish systems through which to monitor and evaluate corrective actions. The policy revealed the Implementation included 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance; b. Establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies; d. Systematically analyzing causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. 3. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. A facility document titled, All Falls for Facility, for the timeframe from 10/01/2024 through 03/31/2025, revealed that there were 37 falls during the time period. During an interview on 03/31/2025 at 1:45 PM with the Director of Nursing (DON) and Administrator, the DON stated she did not really track or trend falls because she did not think there was much of a pattern. The Administrator stated they usually talked about falls in the QAPI meetings. At this time, the DON printed the All Falls for Facility report for the previous six months, which revealed who fell , what time they fell , and the location of the fall. After looking through the list, the DON stated they did have a lot of falls overnight and on the evening shift. During an interview on 04/01/2025 at 4:40 PM, the DON stated that to get ready for the QAPI meetings, she reviewed falls, printed out the previous three months of falls, and looked at the time of day of the falls. She stated she did not look at the days of the week, as that did not seem to have any bearing. She stated she looked at when they occurred and if the resident was experiencing some sort of illness like an urinary tract infection or upper respiratory infection. She stated that she normally wrote out the falls and handed them out, but she did not for the previous quarter. She stated that she did not know why she did not. During an interview on 04/01/2025 at 4:35 PM, when the Administrator was asked how the DON was tracking and trending falls at the facility she stated, She's clearly not. She stated she expected the DON to be tracking and trending falls. She stated that it should be a large part of their QAPI meetings.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure staff used the appropriate method of transferring residents, which affected 1 (Resident #3) of 4 residents reviewed for falls. Specifically, staff transferred the resident using only one staff person on two separate occasions, and used an improper lift during one of those occasions, which resulted in the resident falling on both occasions. Findings included: A facility policy titled, Lift Machine, Using a Mechanical, revised 07/2017, revealed, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. The policy's General Guidelines included 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift, 3. Types of lifts that may be available in the facility are: a. Floor-based full body sling lifts; b. Overhead full body sling lifts; and c. Sit-to-stand lifts, and 4. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using specific machines or devices utilized in the facility. A facility policy titled, Falls - Clinical Protocol, revised 03/2018, revealed, 5. The staff will evaluate, and document falls that occur while the individual is in the facility; for example when and where they happen, and observations of the events, etc [et cetera]. A facility policy titled, Falls and Fall Risk, Managing, revised 03/2018, revealed, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A Resident Face Sheet revealed the facility admitted Resident #3 on 06/15/2022. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of muscle wasting and atrophy; cognitive communication deficit; anemia; morbid (severe) obesity due to excess calories; vascular dementia, severe, without behavioral disturbance; psychotic disturbance, mood disturbance, and anxiety; and pain. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2025, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for moving from a seated position to a standing position, for transferring to and from their bed to a chair or wheelchair, and with toilet transfers. The MDS indicated the resident had active diagnoses that included arthritis. Per the MDS, the resident had experienced one non-injury fall since the previous assessment. Resident #3's Care Plan included a problem statement initiated 06/16/2022, that indicated the resident was at risk for falling related to their new to nursing home placement, weakness, and their impaired mobility. The Care Plan indicated the resident had a history of falls, which included a witnessed fall on 10/12/2024 and a fall on 02/09/2025. Interventions directed staff to have signs posted in the resident's room to remind staff to transfer the resident with two staff members at all times (initiated 02/12/2025); re-educate staff on the proper transfer device to be used to transfer the resident, a Sara Steady, with two staff assisting. The Care Plan indicated the resident's knees must be touching/together before the resident being lifted; indicated that if the resident's knees start to spread, start over and make sure the resident's knees remain stable and together; (initiated 10/13/2024 and edited 02/10/2025). The Care Plan revealed a problem statement initiated 12/05/2022, that indicated the resident had a restorative nursing program in place, which included sit-to-stand exercises using a Sara Steady to maximize tolerance. Interventions directed staff to make sure the resident's legs were in line with the leg supports on the Sara Steady, ask the resident to reach for the second bar on the Sara Steady, and tell the resident to squeeze their legs together while pulling their self up (initiated 02/25/2025); monitor the resident's tolerance of the program; and adjust the program if the resident was unable to participate or if improvements were noted (initiated 12/05/2022). The Care Plan revealed a problem statement initiated 02/06/2025, that indicated the resident experienced symptoms of fatigue, weakness, and confusion related to anemia. Interventions directed staff to assist the resident with activities of daily living during periods of lethargy (initiated 02/06/2025) and observe the resident for weakness and provide safety measures, which included assistance with ambulation, transferring, and fall precautions (initiated 02/06/2025). Resident #3's care card titled, Resident Profile, revealed an approach that indicated the resident was to be transferred with the assistance of two staff using a Sara Steady only. The record indicated the resident could transfer from bed to and from the wheelchair and from their wheelchair to and from the toilet with the use of a Sara Steady, with a start date of 09/25/2024. The care card included an approach to re-educate staff on the proper transfer device to be used to transfer the resident, indicating that a Sara Steady was to be used with assistance from two staff, with a start date of 10/13/2024. The record indicated the resident's knees must be touching together before the resident being lifted; and if their knees start to spread, staff were to start over and make sure the knees remained stable and together. The record indicated an approach to ensure the resident's legs were in line with the leg supports on the Sara Steady, with directions for staff to ask the resident to reach for the second bar on the Sara Steady, and tell the resident to squeeze their legs together as they pulled their self up. Resident #3's Occupational Therapy [OT] OT Progress Report, for the service timeframe from 09/12/2024 through 10/10/2024 revealed the resident's baseline on 09/12/2024 was that the resident required assistance from two staff to use a Sara Steady. An Event Report revealed that, on 10/12/2024 at 4:00 PM, Resident #3 had a witnessed fall. The report indicated Resident #3 was transferring to the bathroom with an EZ stand when the resident's legs began to feel weak and buckled. The report indicated staff assisted with lowering the resident to the ground. Per the report, Resident #3 was free from injury and denied pain. The report indicated that Resident #3 was unable to support themselves in an EZ stand lift. The report indicated that safety devices/interventions in place at the time of the fall included the use of a Sara Steady with the assistance of two staff. Per the report, immediate measures taken following the fall included to educate staff on the use of a Sara Steady lift. An Incident Report, dated 10/12/2024 and signed by Registered Nurse (RN) A, indicated that a certified nurse aide (CNA) was transferring the resident to the bathroom via an EZ stand lift when Resident #3's knees buckled. The report indicated the resident was lowered to the floor by staff. An Ad Hoc [completed for a particular purpose] QAPI [Quality Assurance and Performance Improvement] Meeting/Four Point Plan of Correction Agenda and Summary, dated 10/14/2024, indicated that a resident was lowered to the floor by staff from an EZ-stand lift and indicated that staff needed to use Sara Steady lift. The document indicated the Root Cause(s) was due to the resident being transferred with an EZ-stand lift. Per the document, interventions included to re-educate staff on the importance of following the care plan, indicating that staff needed to use the Sara Steady lift. A handwritten facility document, dated 10/15/2024, provided as part of the facility's investigation of Resident #3's fall revealed,[Resident #3's room and name] All Transfers Use Sara Steady with 2 Staff Or Hoyer Lift Only! No Easy Stand. Sign when starting shift. The document included 22 staff signatures to indicate they reviewed the information. During an interview on 04/01/2025 at 10:30 AM, the Nursing Scheduler stated that the name of the CNA assigned to Resident #3 on 10/12/2024 listed on the assignment sheet was contracted Agency Certified Nurse Aide (ACNA) P. The Nursing Scheduler pulled up ACNA P's profile on her calendar and pointed out that the facility had blocked her from working at the facility anymore on 10/14/2024. The Nursing Scheduler stated, and the profile showed that they blocked her because of an unsafe transfer causing a resident to fall. Resident #3's Occupational Therapy Treatment Encounter Note(s) revealed a note, dated 12/04/2024, that indicated that staff were instructed to use a Hoyer lift to transfer the resident as needed, and recommended using two staff to transfer the resident with a Sara Steady lift. An Event Report revealed that on 02/09/2025 at 10:26 AM, Resident #3 was lowered to the ground during a transfer from their wheelchair to a recliner using the Sara Steady. The report indicated the CNA stated that the resident's knees came out of the back knee holders, and the resident began to slide to the floor. Per the report, the CNA called for assistance and the resident was lowered to the ground with the assistance of three staff members. The report indicated that there were no injuries noted, and the resident did not hit their head. The note indicated that safety devices/interventions in place at the time of the fall included that two staff were to provide assistance with a gait belt. The Notes section of the report indicated that Resident #3 required the use of a Hoyer lift with the assistance of two staff until further assessment. The report indicated that an Education sheet was provided to staff regarding the resident's prior transfer status, which was the assistance of two staff (at all times) with a gait belt and Sara Steady, and reminders to call for assistance with transfers at all times. The Evaluation portion of the report indicated the fall was attributed to one staff transferring and indicated that education was provided. An Incident Report, dated 02/09/2025 and signed by CNA O, revealed she received a call over a two-way radio indicating that help was needed in Resident #3's room. The report indicated that when she entered the room, she noted that Resident #3 was sliding down out of their recliner. Per the report, staff tried to get the resident to stand up so they could reposition the resident, but Resident #3 was unable to stand, so staff guided the resident to sit on the floor. An Incident Report, dated 02/09/2025 and signed by CNA G, revealed Resident #3 was being transferred with a Sara Steady lift. The report indicated that the lift was locked, and Resident #3 was positioned over the recliner. The report indicated the resident's knees came out of the back knee holders and the resident began to slide to the floor. Per the report, CNA G called a nurse to the room, and CNA O also came, and they lowered the resident to the floor. An Ad Hoc QAPI/Four Point Plan of Correction Agenda and Summary, dated 02/10/2025, revealed that a resident had an assisted fall to ground in room. The document indicated that one staff member was transferring the resident at the time of the fall. The form indicated the that the Root Cause(s) revealed the resident required two people to assist with transfers and the transfer was attempted with one person. The document revealed, Education was provided. A typed facility document titled, [Resident #3's room number and name] Resident transfers with assist of 2 (AT ALL TIMES) with the Sara Steady. Please ask for assistance with transfers and always use a gait belt. *Currently [the resident] is a hoyer [sic] transfer with 2 assist until further evaluation. PLEASE SIGN BELOW. The document revealed 19 staff signed the sheet to indicate they reviewed the information. During an interview on 04/01/2025 at 10:38 AM, the CNA Supervisor stated that the difference between the EZ stand and the Sara Steady was the EZ stand was mechanical and the Sara Steady was more of a staff-guided transfer lift, where staff put a gait belt on the resident and assisted them to stand. She stated the EZ stand was all mechanical. She stated physical therapy staff evaluated the residents and made the decision on what lift was used for each resident. During an interview on 04/01/2025 at 12:30 PM, the Occupational Therapist stated that therapy staff determined a resident's transfer status upon admission or with any declines in status. She stated she had worked with Resident #3. The Occupational Therapist stated that she had provided a lot of education with the staff about how to transfer the resident with the Sara Steady and to always use two staff. She stated Resident #3 wanted to use that lift because the resident could still use the toilet, but the resident's knees tended to turn outward if there were not two staff there to ensure the resident was appropriately positioned in the lift. She stated Resident #3 needed two people, I've made that very clear. She stated she worked with the resident between 08/22/2024 and 12/04/2024, and during that time, they worked on using the Sara Steady with staff. She stated she had worked with Resident #3 from 02/10/2025 to 02/25/2025 after the resident was downgraded to requiring a Hoyer lift after slipping out of the lift, but had been upgraded back to the Sara Steady. During an interview on 04/01/2025 at 1:21 PM, Licensed Practical Nurse (LPN) N stated Resident #3 was transferred incorrectly once and fell . She stated that when Resident #3 fell , the re-education was only a paper to read. She stated that the she assisted the CNA with lowering Resident #3 to the floor during the most recent fall because the resident did not have the gait belt on. She stated two staff were always supposed to be used to transfer the resident using the Sara Steady. During an interview on 04/01/2025 at 3:00 PM, the Director of Nursing (DON) stated she expected staff to transfer residents according to the care cards, which were located inside the resident's closet. She stated staff did not always follow the care cards, and she could see that from some of the falls they had had. She stated they provided a lot of education with staff at the nurses' meetings. The DON stated the nurses had to call her with each fall. She stated that whenever it was a preventable fall, they put up a sign-up sheet and had the nurse reviewed it with staff, and staff would sign off that they had been educated. She stated that with Resident #3's falls, they just educated the staff who were on the shift at the time of the falls. She stated they had had issues with staff not knowing which residents needed to have one or two staff for transfers. She stated the CNA Supervisor provided the retraining, but she did not know if she documented all the staff's retraining, and stated that she thought it was only with the staff on duty who transferred the resident. She stated they provided a yearly education skills fair and retraining was provided after a fall when the resident was not transferred correctly. During an interview on 04/01/2025 at 3:33 PM, the Administrator stated she expected staff to follow the facility policy regarding transfers. She stated that Hoyer lifts and EZ stand lifts always required a two-person assist, and staff should reference the resident's care card when using a Sara Steady lift. She stated regarding Resident #3's fall in February 2025, the CNA admitted she transferred the resident by herself and that was not their policy. She stated the CNA knew about the care card.

Based on interview and record review, the facility did not ensure 1 of 1 resident (R291) reviewed with a significant change in condition had a comprehensive assessment performed consistent with professional standards of nurse practice (N6, Wisconsin Nurse Practice Act,) the comprehensive person-centered care plan, and the resident's choices. *On [DATE], R291 was having increased difficulty with transfers and eating. The difficulty continued to worsen and on [DATE] at approximately 12:41 a.m., R291 required use of a mechanical lift and had difficulty speaking. The Registered Nurse (RN) on duty did not take vital signs (other than an undocumented pulse oximetry) and did not perform a comprehensive assessment into the change in condition. There was no physician notification of the change in condition. On [DATE] at approximately 7:50 a.m., R291 became unresponsive and was transferred and admitted into the hospital with a diagnosis of severe sepsis. R291 subsequently expired while in the hospital on [DATE]. The facility's failure to perform a comprehensive assessment into a change in condition created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA (Nursing Home Administrator) A of the immediate jeopardy on [DATE] at 3:05 p.m. The immediate jeopardy was removed on [DATE] when the facility began implementing their action plan. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy and procedure titled Change of Resident Condition Physician/NP Notification (no date) was reviewed and documents: During hours when the office is not open, the attending physician or physician on call should be notified of any change in condition, change in health status, or incident that includes but is not limited to: Change in basic vital signs, significant change in mental status or other conditions as deemed necessary. According to N6.03(1), Wisconsin Nurse Practice Act, a registered nurse (RN) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. R291 was admitted to the facility on [DATE] with diagnoses that included Transient Ischemic Attack, Vascular Dementia, Chronic Kidney Disease stage 3, Chronic Obstructive Pulmonary Disease, and Diabetes type 2. R291 had an Activated HCPOA (Power of Attorney) for healthcare with advanced directives for a full code, hospitalization , and antibiotics if needed. R291's Initial Minimum Data Set (MDS) dated [DATE] documented R291 needed supervision of one with ambulation and standing/transfers and had a Brief Interview for Mental Status (BIMS) Score of 12, indicating that R291 was moderately cognitively impaired. R291's quarterly MDS dated [DATE] documented her BIMS score remained unchanged at a 12. On [DATE], R291's care plan titled Activities of Daily Living functional status with a start date of [DATE] and current on [DATE] was reviewed and documented: independent with assist of wheeled walker. R291's progress note dated [DATE] at 11:46 AM written by LPN (Licensed Practical Nurse)-E documented: R291 is having difficulty transferring and standing up. She was a max (maximum) assist with cares. She was also a max assist with transferring using a gait belt and w/w (wheeled walker) this morning. She is refusing activities and refusing to eat meals in the dining room today. Continues to c/o (complain of) RUE (right upper extremity) and left flank pain. Scheduled analgesics given as ordered, states that oxycodone doesn't work. R291 moaning throughout the shift. Refusing ice packs to left flank. Will continue to monitor. Nurse Practitioner in facility and updated. R291's progress note dated [DATE] at 1:08 PM written by LPN-E documented: R291 initially refused her lunch stating, I don't know why, but I can't do anything. C/o (complained of) RUE pain at times. When her sister visited, she fed resident her lunch. R291's baseline is set-up for meals and she is able to feed herself. Earlier in the morning R291 was applying make-up and hair spray while sitting in front of the bathroom sink in her w/c (wheelchair). She has been requiring assist of one with transfers, as she states that she cannot stand up on her own. NP (Nurse Practitioner) in facility and updated. R291's progress note dated [DATE] at 12:47 AM written by RN-E documented: R291 was incontinent of urine while sitting in her chair. R291 is unable to use her voice. R291 told CNA that she is unable to walk or use her arms. Used the Sara Steady (mechanical lift) to transfer and R291 was kicking her leg off of the machine and started to shake stated, No, I can't do this. R291 was put in a brief and placed in bed. Daughter came to visit with her aunt and daughter was crying uncontrollably, asked to speak with the nurse. When asking her what's wrong, daughter asked, Is my mom dying? Reassurance given. Asked daughter if she would like to have the resident sent to the hospital and she stated No. Offered her hospice services and she declined at this time. There were no vital signs documented and no documentation of a nurse assessment. R291's progress note dated [DATE] at 8:11 AM written by Director of Nurses (DON)-E documented: R291 was found unresponsive by dietary staff, sternal rub applied with no reaction, Blood sugar 149 BP (blood pressure) ,d+[DATE] HR (heart rate) 124, RR (respiratory rate) 20 could not get an oxygen level, O2 (oxygen) applied via NC (nasal cannula) at 3 LPM (liters per minute), Lungs course diminished at the base. skin was warm to touch, fingertips were blue. 911 was called at 0750 am and were here and gone by 805 am. Daughter/POA called and updated, resident was sent to hospital per daughter who will meet her there. Surveyor reviewed R291's medical record for vital signs and the last vital signs documented were on [DATE]. No others were documented until R291 was found unresponsive on [DATE]. On [DATE] at 9:56 AM, Surveyor interviewed Director of Nurses (DON)-B who indicated Registered Nurse (RN)-E should have done a full set of vitals with R291's change of condition on [DATE] and did not. On [DATE] at 10:30 AM, Surveyor interviewed R291's activated power of attorney for healthcare (HCPOA)-J who indicated she knew R291 was getting worse on the night of [DATE] but RN-E assured her that R291 was fine and she was overreacting. Due to this conversation, the HCPOA-J told RN-E she didn't want R291 sent to the hospital because she was assured R291 was acting this way because her dementia was progressing. On [DATE] at 12:27 PM, Surveyor interviewed NP (Nurse Practitioner)-I who indicated she was not made aware of changes to R291's transfer status or her difficulty talking. NP-I indicated a full set of vital signs should have been taken with R291's change of condition and stated she (NP-I) would have probably ordered for R291 to be sent to the hospital if she had been notified. On [DATE] at 2:39 PM, Surveyor interviewed RN (Registered Nurse)-E who indicated she did not call R291's physician on [DATE] when R291 had trouble talking and transferring. RN-E indicated she did not know if R291 was faking her condition. RN-E indicated R291 was having trouble transferring and had a hoarse voice. RN-E indicated that she checked R291's O2 level and it was 96% (this was not charted) but did not check her b/p, temperature, or pulse. RN-E indicated she saw R291 several times during the shift and R291 was talking at the time. When asked, RN-E indicated signs of sepsis would include high heart rate, low blood pressure, increased lethargy, decreased appetite, and elevated temp. RN-E indicated R291 was having a decline and she did not take vitals other than her oxygen level and she should have done a thorough assessment with a full set of vitals. On [DATE] at 8:47 AM, Surveyor interviewed LPN-D who indicated R291's pain and confusion was getting worse so she called NP-I on [DATE]. LPN-D indicated it was new for R291 to need help eating and R291 was really shaky. LPN-D indicated she didn't get vitals on R291 but did call NP-I. LPN-D indicated she never knew R291 to need a mechanical lift for transfers and she would call her physician and let therapy know if that happened. On [DATE] at 11:56 AM, Surveyor interviewed Medical Director (MD)-H who is also R291's primary physician. MD-H indicated he would expect to be called with R291's change of condition and he was not. MD-H indicated he would expect the nurse to take a full set of vitals before calling him as irregular vitals would be a main indicator of possible sepsis. On [DATE], Surveyor reviewed R291's hospital medical record which documented: R291 admitted to the emergency roiagnom on [DATE] at 8:44 AM. diagnosed with Severe Sepsis and Acute Metabolic Encephalopathy. Chief complaint of altered mental status. R291 was unable to provide history secondary to acute metabolic encephalopathy and somnolence. Family reported concerns to staff at the skilled nursing facility where she lives but there was no intervention per family. Temperature 104.2, heart rate ,d+[DATE]s, respiratory rate 30, Oxygen level 95% on room air. Urinalysis positive for infection. [NAME] blood cell 17.10 (normal ,d+[DATE].8), Lactic acid 3.3 (normal 0XXX,d+[DATE].7). Sinus tachycardia. Severe sepsis criteria is noted as heart rate above 90, respiratory rate above 20, temperature above 100.4, white blood cell count above 12, and lactate above 2. Hospital social worker notes dated [DATE] at 12:32 PM documented: HCPOA states she has concerns about how the nurse treated R291 last night (at the facility.) She wanted R291 brought to the hospital last night but the night nurse stated R291 was likely faking. Has had issues with this nurse in the past. admitted to the Intensive Care Unit on [DATE] at 3:05 PM. The discharge note from the hospital for R291 dated [DATE] documented: Diagnosis: septic shock, streptococcal bacteremia, aortic valve vegetation embolic strokes, from septic emboli, acute on chronic toxic metabolic encephalopathy, due to sepsis as well as embolic strokes from septic emboli. R291 was admitted to the hospital what initially thought sepsis secondary to the urinary tract infection, but unfortunately further investigation showed septic emboli, with multiple infarcts. Finding were discussed with R291's family who decided on comfort measures. Transitioned to in-house hospice. R291 expired with hospice services on [DATE] at 11:04 AM. Surveyor requested additional information, if available, as to why R291 was not given a thorough assessment including vital signs when she experienced a change in condition and why R291's physician was not consulted, however, none was provided. The facility's failure to complete ongoing, thorough assessments including taking and recording vital signs and the failure to notify the primary physician when a resident was experiencing a significant change in condition resulted in a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. Surveyor notified NHA-A of the immediate jeopardy on [DATE] at 3:05 p.m. The facility removed the immediate jeopardy on [DATE] when they began implementing the following action plan: The Change of Condition policy has been reviewed by DON and modified with the following modifications: - Examples of Change of Condition - Use of Interact tools - include the change of condition pathways and Stop and Watch - VS will be taken immediately or a soon as possible with any change of condition. Once VS and immediate assessment is completed, MD will be notified. VS will be taken a minimum of every 4 hours and more frequently as indicated by the change in condition or MD order. - All changes in condition will be listed on the 24-hour report board Nurse practitioner will provide education to all nurses related to recognition of physiological changes of condition as well as behavioral responses that may indicate a physiological change in condition. Education will include response including interventions, notifications, and documentation. This education will be taped and all nurses not present will be required to view the in-service prior to their next working shift. Nurse involved in incident was part of the NP's education and was also provided one on one education by the DON and ADON on physiological change of condition and behavioral responses that may indicate a change of condition and expectations for response and notification. Interact tools have been implemented and are available electronically within the electronic medical record as well as all Interact tool change of condition pathways have been printed and are located at each nursing station. All licensed staff have been educated on the use of Interact tools as well as their location. All direct care staff will be educated on the Stop and Watch Early Warning tool as well as reporting any resident change of condition to a nurse. Post tests will be given following the education to ensure competency. Medical Director consulted during the development of this corrective action plan. The DON and ADON will review progress notes and 24-hour report board daily for any changes of condition to ensure audits will continue daily for 1 month with ad hoc training provided as necessary for any missed opportunities. Audits will continue 3 x per week for 2 months. All audits and results will be brought to the quality improvement committee for review.

Based on observation, interview, and record review, the facility did not ensure that 1 (R24) of 2 residents reviewed was provided adequate supervision and assistance devices to prevent accidents. R24 was identified by the facility as a wander/elopement risk due to altered mental status/dementia in June 2023. The facility did place a Wanderguard bracelet, however, at one point they placed it on the resident's wheelchair even when it was known resident was physically capable of standing up from her wheelchair and ambulating without assistance. Resident was able to elope from the facility and was found outside of the facility on two separate occasions, once when it was raining, and once at 1 am. The facility's failure to provide adequate supervision and proper assistance devices to R24 created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 06/27/2024. The immediate jeopardy was removed on 8/15/24, however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings include: The facility's policy, undated and titled: Wander/Elopement Policy & Procedure, documents in part: Elopement definition: When a resident leaves the facility property without the knowledge of the staff. Facility property is defined as: area outside of property lines/plot lines as governed by [NAME] County. Procedure: 3. Residents at risk will have an assessment done on admission, then quarterly, or if a change in condition arises. A resident at risk will have a wander guard placed around their ankle (or different area depending on resident) and placed on the wanderer list. The wanderer list is located in each nurse's station. 4. Wander guards are assessed for proper functioning and placement daily, and the main system checked by the maintenance supervisor on a weekly basis; not only functioning but also response time. 5. The residents care plan will be developed or modified by the intra disciplinary team to indicate the resident is at risk for elopements and specific individual interventions will be developed to encourage alternate behavior from attempting to exit the building. 6. Should an elopement occur: the contributing factors as well as the interventions tried will be documented in the nurse's notes and an incident report will be filled out. Update the administrator and director of nursing immediately. 1.) R24 was readmitted to the facility on [DATE] with diagnoses to include Alzheimer's, Dementia, Anxiety, Obsessive Compulsive Disorder, and Post-Traumatic Stress Disorder. R24's Annual Minimum Data Set (MDS), dated [DATE], documents R24 requires partial/moderate assistance with a helper doing less than half the effort with transitions from sitting to standing. R24's MDS also documents R24 requires partial/moderate assistance to walk 10 feet and requires supervision or touching assistance when wheeling 150 feet in a corridor or similar space. R24's most recent Quarterly MDS dated [DATE], documents R24 has a Brief Interview for Mental Status (BIMS) score of 4, indicating that R24 is severely cognitively impaired. R24's Quarterly MDS also documents that R24 has wandering behavior that occurred 4 to 6 days of the assessment which was less than daily. R24's Wander/Elopement care plan, with a start date of 06/21/2023 and last revised on 07/15/2024, documents that R24 is at risk for wandering/elopement due to an altered mental status related to dementia. R24's physician order dated 7/29/23 documents, Monitor wander guard placement to right ankle every shift. R24's physician order dated 8/10/23 documents, Monitor wander guard placement to left ankle every shift. R24's progress note dated 08/13/2023 at 01:07 PM documents, Resident up and self-propelling around common area this AM. Resident tearful and very upset. Resident anxious and repeatedly asked staff why she is here, what is happening, where should she go, and what she should be doing. Resident very confused and anxious. Resident required 1:1 support from staff due to her emotional state and confusion. R24's physician order dated 8/20/23 documents, Discontinue order to monitor wander guard placement to right ankle every shift. R24's progress note dated 08/20/2023, at 07:39 PM documents, (R24) was up walking in hallway x 2 this shift, very limited safety awareness. She has been repeatedly asking why she is here and where her family is. Will continue to monitor. R24's progress note dated 09/01/2023, at 07:55 PM documents, Resident walking in hall several times without walker or staff assist. Able to re-direct her to sit in w/c (wheelchair) until staff can ambulate with her. R24's progress note dated 10/04/2023 at 08:20 PM documents, Resident has been looking for her daughter since after dinner. Resident began going into the closets and other resident's room. Unable to get her to calm down. Called the daughter so resident could speak to her. Resident was scared that her daughter had ran away. R24's progress note dated 10/28/2023 at 01:47 PM documents, Staff noted resident to be attempting to elope from facility out front door. Resident stated that she was going home. Visitors that were in the facility were leaving at this time and resident thought she should leave as well. Resident was easily redirected away from the front door. No further attempts noted. R24's progress note dated 11/14/2023 at 11:02 AM documents, Continues to self-transfer and walk around independently in spite of reeducation and redirection from staff. Motion alarm activated when she's in room so staff aware when she's moving around independently. Will continue to monitor. R24's physician order dated 11/30/24 documents, Place wander guard to left wrist for safety and due to elopement attempt. R24's progress note dated 11/30/2023 at 05:42 PM documents, Wanderguard replaced to left wrist. R24's progress note dated 01/28/2024 at 05:17 AM documents, This morning resident took sensor alarm and hid it under her pillows and then ambulated herself into the bathroom. Call light was within reach and 15 minute checks being implemented but, resident did not use call light this morning and was asleep during check. Resident assisted from bathroom back to bed and encouraged to use call light and again shown where call light located. R24's progress note dated 02/15/2024 at 04:48 PM documents, Call placed to 911, dnr (do not resuscitate) bracelet on right arm. Wanderguard removed from left wrist. No glasses, dentures or shoes were sent with resident. R24's progress note dated 03/01/2024 at 05:58 PM documents, Resident very distraught this evening. Looking for her mother, husband and children. Thinks she is leaving, refuses to sit in wheelchair, attempting to transfer self with purse and bible out of room into hallway to leave the facility. Not easily redirectable at this time. R24's progress note dated 03/15/2024 at 11:17 AM documents, NP (nurse practitioner) updated: Resident continues to have behaviors/confusion on PM shift. Resident requires 1:1 attention/re-direction after 4 PM which most of the time is not effective. Last evening, resident was confused/crying, and very anxious. We do not have anything to give her PRN. Awaiting response at this time. R24's progress note dated 03/15/2024 at 01:00 PM documents, New order received from Psych NP to increase her sertraline to 150 mg: currently scheduled 100 mg daily. POA and order updated. R24's progress note dated 03/23/2024 at 10:46 AM documents, Behaviors: Resident was found self-ambulating down the hallway without staff or her WC. Resident very anxious and confused. Ativan was given as re-direction and 1:1 support was not effective. PRN was effective. Resident was able to calm down, eat her meal, and then attended the activity. R24's progress note dated 03/27/2024 at 06:30 PM documents, 1830 Writer observed resident self-propelling in her wheelchair towards an exit door with her purse around her shoulder. Resident was looking for her son; he was going to be picking her up. Writer kindly tried to explain to Resident that her son was not in the bldg (building); and that others here were in their rooms winding down for the night. R24's progress note dated 03/31/2024 at 05:45 AM documents, Resident went to bed late last night & did not sleep well night before & has been up since 0300 this morning & asking about going to Chicago and what we are doing & trying to enter other resident's rooms & not being easily redirected as she is looking for her family and unable to redirect her and/or distract her thus, PRN Lorazepam given this morning which was starting to be effective at this time. Will continue to monitor resident. R24's progress note dated 05/15/2024 at 05:56 PM documents, Resident anxious and requesting to go home. Resident reports she lives next door. Resident asked writer to open the door leading outside so she could go home. Writer tried redirecting resident by telling her she needed to wait for family to come. Resident started talking in German and headed toward to exit door. Resident attempted to exit building at that time. Writer and admissions director redirected resident and moved resident away from exit door. Writer administered prn anxiety medication at this time. Admissions director brought her dog to see resident and resident became calm. Wander guard placed on residents wheelchair at this time and POA notified of resident's exit seeking. Resident became calm and went in to dining room for dinner. No further exit seeking attempts. Will continue to monitor. R24's progress note dated 05/20/2024 at 03:38 PM documents, Residents POA called and updated in regard to room change. POA in agreement. Resident will move to 132 5/21/24 once cleaned. On 08/14/24 at 11:12 AM, Surveyor asked NHA (Nursing Home Administrator)-A why R24 had a room change. NHA-A informed Surveyor that a deer came in through another resident's window and exited through R24's window. R24 was relocated due to the window being broken. R24's progress note dated 06/27/2024 at 02:58 PM documents, received from APNP for Ativan PRN (as needed) every 8 hours times 14 days for anxiety. Order entered and initiated. Will continue to monitor. First elopement: R24's progress note dated 06/27/2024 at 03:54 PM, Staff updated writer that resident was found outside by another residents family member in the front of the building standing on her own on the sidewalk. Resident had left her wheelchair in the building and walked out, therefore no alarm sounded d/t her wander guard is attached to her wheelchair. Updated DON and Administrator. R24's physician order dated 06/27/2024 documents, place wander guard to left wrist for safety. R24's Risk for Wandering/Elopement care plan with a start date of 6/27/2024 documents, Monitor for placement of wander guard to LEFT WRIST every shift and check function of wander guard to LEFT WRIST weekly on Monday morning. On 08/13/2024 at 12:20 PM, Surveyor interviewed NHA-A regarding R24 elopement attempt on 6/27/2024 as documented above. NHA-A informed Surveyor there is no investigation for R24's 06/27/2024 elopement. NHA-A stated R24's wander guard was removed from R24's wheelchair and placed on R24's left wrist at that time. On 08/13/2024 at 01:21 PM, Surveyor interviewed MDS coordinator-G regarding R24's wander guard placement on 05/15/2024. MDS coordinator-G informed Surveyor that R24 would not allow staff to put the wander guard on her wrist and it was extremely overwhelming for R24. MDS coordinator-G informed Surveyor that during that time, R24 rarely got out of her chair without assistance. MDS coordinator-G informed Surveyor that she figured that if the wander guard was on the wheelchair, it would still alarm if R24 went to push the door open. MDS coordinator-G informed Surveyor that she brought it up to management as well, and it was agreed to place the wander guard on R24's wheelchair. On 08/13/2024 at 02:56 PM, Surveyor interviewed RN-E and NHA-A regarding R24's elopement on 06/27/2024. RN-E informed Surveyor that a CNA supervisor was informed that someone went out the door and that R24 was by the door. RN-E stated there were a lot of visitors coming in and out, and that R24 had parked her wheelchair and made it about 10 feet out the door, holding the railing, and that a CNA helped R24 back inside. RN-E stated that R24 was maybe outside less than 1 minute. RN-E informed Surveyor that R24's wander guard was on chair because R24 took it off. NHA-A informed Surveyor that R24 would get so angry about having the wander guard on. RN-E informed Surveyor that R24 has eloping behaviors but had not made it outside before. RN-E informed Surveyor she called NHA-A and DON-B and made them aware of R24's elopement on 6/27/2024. NHA-A informed Surveyor that the facility's policy does not consider an elopement to have occurred unless the resident makes it off the facility grounds. NHA-A informed Surveyor that a care conference with R24's son occurred where they discussed placement for R24 at a better fit facility, that is more secure for R24. RN-E informed Surveyor that R24's care conference explained safety and that R24 has not tried to remove the wander guard after putting back on because staff are telling R24 it's a heart monitor and R24 has had no other elopements. On 08/13/24 at 03:35 PM, Surveyor attempted to call the witness who found R24 when R24 eloped on 06/27/2024. The witness did not answer, and Surveyor left a voicemail with contact information for witness to return the call. Second elopement: R24's progress note dated 07/14/2024 at 12:27 AM documents, Front door alarm alerting, writer found pt in parking lot in wheelchair. Pt (patient) stated, I have a brother that doesn't live far from here. Escorted pt back inside, pt in nurse's station with writer. offered pt ice water and snack. R24's progress note dated 07/14/2024 at 08:18 AM documents, NOC (night) shift Nurse reported to writer that resident had an Elopement event at approximately 0130. Nurse stated that she did not hear the alarm from the front door sounding. NOC shift CNA reported that she found resident sitting in her WC in the parking lot. Resident states that she was out looking for Brother. CNA reports that resident was anxious and confused most of NOC shift. PRN medication was given at approximately 0400. Medication effective. Resident sleeping in her bed at this time. Motion sensor in place. Wanderguard in place to left wrist. Resident's Wander documents are posted in both Nurse's stations. Per Elopement Policy & Procedure, Writer initiated 15-minute checks and contacted. On call Nurse, DON (director of nursing), Administrator, MD (medical doctor), and POA (power of attorney) given update. R24's progress note dated 07/14/2024 at 08:36 AM documents, Writer checked proper functioning of Wanderguard System. System functioning properly. Alarm sounded and door locked. Door unlocked after 15 seconds of continuous pressure. R24's risk for Wandering/Elopement care plan documents, 1 hr checks Q shift. x 6 days per policy with a start date of 07/15/2024. No further revisions to care plan interventions documented. On 08/14/2024 at 08:17 AM, Surveyor interviewed LPN (Licensed Practical Nurse)-F regarding LPN-F's progress note documenting R24's elopement on 07/14/2024. LPN-F informed Surveyor that LPN-F arrived to work at 6 AM and there was an agency nurse coming off 3rd shift. LPN-F informed Surveyor that after medication count, LPN-F was going down the board and asked the 3rd shift nurse what happened for R24 to be put on the board. LPN-F informed Surveyor that during early morning hours R24 got out of the building unattended. LPN-F informed Surveyor that LPN-F then began to implement the facility's policy and procedure on elopement. LPN-F informed Surveyor that it was raining that night, and a CNA was coming back in from break and saw R24 in the middle of the driveway, unattended, in front of the building. LPN-F informed Surveyor the CNA was called back in to come do a witness statement. An elopement event was created, notified NHA-A, DON-B and the Medical Director. LPN-F informed Surveyor the CNA was on their 15-minute break and states R24 was outside maybe less than 15 minutes. LPN-F informed Surveyor that another agency CNA was inside at the time but did not hear the alarm. On 08/14/2024 at 08:28 AM, Surveyor asked NHA-A if she was aware of R24's 07/14/2024 elopement. NHA-A stated yes and provided Surveyor with R24's elopement investigation. The facility provided Surveyor with a copy of the wander guard manual. On the manual, DON-B noted that she called the wander guard company, and the wander guard should be placed on arm, wrist, or ankle. Surveyor took pictures of outside the facility. Surveyor captured pictures of the entrance to the facility, from the front door of the facility looking to the road, the posted speed limits, and name of the road in front of the facility. Surveyor noted the speed limit posted looking west on the road is 55 miles per hour (mph) and looking east is 45 mph. Surveyor measured the distance from the front door of the facility to the edge of the road and documented 83 feet 4 inches. On 08/15/2024 at 08:02 AM, Surveyor observed a camera on R24's dresser across from the bed. On 08/15/2024 at 08:05 AM, Surveyor interviewed NHA-A who informed Surveyor R24 is now a one on one (1:1), assigned staff will monitor R24 on camera only while R24 sleeps. The staff member who is assigned to the 1:1 role with R24 has the monitor with them. The 1:1 staff is a resident assistant who is not certified to do care. While R24 is sleeping, the 1:1 can work on other tasks until R24 is awake, and then when R24 is awake, the assigned 1:1 will be tasked only with being with R24. The facility's failure to provide adequate supervision to a resident identified as being at risk for wandering and elopement led to R24 exiting the facility on 2 separate occasions. This created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 06/27/2024. The immediate jeopardy was removed on 8/15/24 when the facility completed the following: - Elopement assessment completed on the identified resident. All residents had an elopement assessment completed as of 8/14/24. Any residents identified as at risk had their care plan reviewed, and interventions modified as needed to ensure safety. - Resident identified in citation is a high risk for elopement. Care plan reviewed and the following interventions were immediately put in place: o Wanderguard was checked for function and for proper placement, checks for placement and function are on the electronic medical record for every shift. o One on one staff supervision for resident implemented. o A comprehensive assessment will be completed using historical data as well as a new interview with residents and their representative to identify any past trauma not already identified and or routines or missed needs. o This resident or any other resident that has exit seeking behaviors or history of elopement will be redirected using individualized interventions for distraction and diversion. Staff will enlist help with other visible staff as needed and maintain a calm presence. The administrator or director of nursing will be notified of any attempts to leave the building. - Elopement policy reviewed, modified and reimplemented by educating all staff to the policy as well as the definition of elopement, interventions to prevent elopement, response to elopement and reporting elopement. Staff have also been educated on the residents currently identified as at risk including the identified resident and interventions developed to prevent elopement and resident safety. - Licensed nurses educated by DON (Director of Nursing) or designee on documentation expectations related to supervision and interventions which is to document on identified resident each shift for effectiveness of interventions. - Medical Director consulted during the development of this corrective action plan. - DON or designee will review progress notes and 24-hour report board daily for 2 weeks and 3 times a week for 4 weeks and then weekly for intervention documentation and effectiveness of same. No additional information was provided as to why the facility did not ensure that R24 was provided adequate supervision and assistance devices to prevent elopement on two separate occasions.

Based on interview and record review, the facility did not ensure 4 of 4 facility infectious outbreaks were thoroughly investigated. The facility had a Covid 19 outbreak in August 2023 and November 2023, a norovirus outbreak in December 2023 and an influenza outbreak in January 2024. All of the infectious outbreaks were not thoroughly investigated. Findings include: 1.) On 8/13/24, Surveyor reviewed the facility's binder of infectious disease outbreaks. The facility had a Covid 19 outbreak that began on 8/24/23. The documents provided were line lists for residents and staff and PPE (personal protective equipment) and handwashing training. No other documentation was included with this outbreak. The facility had another Covid 19 outbreak that began on 11/20/23. The documents provided were line lists for residents and staff and PPE and handwashing training. No other documentation was included with this outbreak. The facility had a norovirus outbreak that began on 12/10/23. The documents provided were line lists for residents and staff and PPE and handwashing training along with norovirus information. No other documentation was included with this outbreak. The facility had an influenza outbreak that began on 1/11/24. The documents provided were line lists for residents and staff and PPE and handwashing training. No other documentation was included with this outbreak. On 8/13/24 at 1:21 p.m., Surveyor interviewed Infection Preventionist (IP)-C. Surveyor explained the infectious outbreaks did not have any documented investigation into the source of the outbreak. Surveyor explained the only documentation was the line list and the type of education provided. IP-C stated she was not aware she needed to complete an investigation and document any and all findings that were completed during the outbreak and the cause of the outbreak. IP-C stated she has emails from those outbreaks of her communication with the county public health department. On 8/13/24 at 3:00 p.m., during the daily exit meeting, Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the above findings. DON-B understood the concern and had no additional information at that time. On 8/14/24, after the survey team exited the facility, the facility provided Surveyor with copies of email correspondence between IP-C and the county public health nurse. The email contained line list and documentation of interventions that were implemented during the outbreak, such as cleaning and isolation. No other documentation was provided as to the source of the outbreaks. No additional information was provided as to why 4 of 4 facility infectious outbreaks were thoroughly investigated.

3) On 8/2/24, R34 experienced a change in condition and was sent to the hospital for evaluation. R34 was admitted to the hospital for UTI and C-Diff (clostridium difficile)infection. R34 returned to the facility on [DATE]. On 8/12/24 at 3:00 p.m. during the daily exit meeting with DON-B and NHA-A, Surveyor asked for the transfer notice for R34 when he was sent to the hospital on 8/2/24. On 8/14/24 NHA-A spoke with Surveyor and stated they have no evidence a transfer notice was given to R34 on 8/2/24. 4.) R17 admitted to the facility on [DATE] with primary diagnosis of Alzheimer's disease. R17 was sent out of the facility with a discharge, return anticipated, on 11/27/2024 through 11/29/2024 and on 03/03/2024 through 03/06/2024 per R17's Minimum Data Set (MDS). On 08/13/2024, at 12:15 PM, Surveyor requested transfer notification documents for R17 from NHA-A. On 08/14/2024, at 03:31 PM, NHA-A indicated to Surveyor that she does not have any transfer consent documentation for R17. No additional information was provided as to why the facility did not ensure that R2, R17, R30 and R34 received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. 22692 Based on interview and record review, the facility did not ensure 4 (R2, R17, R30 and R34) of 4 sampled residents reviewed for discharge documentation received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. Findings include: On 8/13/24, the facility's policy titled Transfer or Discharge Facility-Initiated dated 10/22 was reviewed and documented: Notice of transfer is provided to the resident and representative as soon as practicable before the transfer. On 08/14/24 at 12:41 PM, Nursing Home Administrator (NHA)-A was interviewed and indicated no transfers notices were given to R2, R17, R30 or R33. NHA-A indicated no one in the facility is responsible for issuing transfer notices and that is the main problem. 1.) On 8/13/24, R2's medical record was reviewed and indicated R2 was transferred and admitted to the hospital on 6/25/24 and returned to the facility on [DATE]. No transfer notice could be found in R2's medical record for the 6/25/24 transfer. The above finding was shared with NHA-A on 8/14/24 at 3:05 PM at the daily exit meeting. Additional information was requested as to why a transfer notice wasn't given to R2 with her transfer to the hospital on 6/25/24/24. None was provided. 2.) On 8/13/24, R30's medical record was reviewed and indicated R30 was transferred and admitted to the hospital on 2/12/24 and returned from the hospital on 2/13/24. No transfer notice could be found in R30's medical record for the 2/12/24 transfer. The above finding was shared with NHA-A on 8/14/24 at 3:05 PM at the daily exit meeting. Additional information was requested as to why a transfer notice wasn't given to R30 with his transfer to the hospital on 2/12/24. None was provided. 49845 4 of 4 reviewed for transfer notifications R30, R2, R34 and R17 did not have transfer notices [NAME] will do based on Resident #17 hospitalization 08/12/24 01:22 PM triggered Hosp from 11/27/2023- 11/29/2023 11/27/2023 07:11 PM Chest x ray shows bilat infiltrates. HCPOA called and would like sent to hospital. Rescue called and will go to WMH. bed hold? yea transfer notice? NHA08/14/24 03:31 PM does not have

Based on record review and staff interviews, the facility did not always ensure that 1 (R13) out 1 injury of unknown origin investigations reviewed were reported to the state survey agency as required. R13 was observed to have bruising to her inner left thigh and knee and R13 could not state how the injuries occurred. This injury of unknown origin was not reported to the state survey agency as required. Findings include: The facility's policy dated 12/20/2018 and titled Abuse , Neglect, Mistreatment and Misappropriation of Resident Property documents: G.) Reporting and Response It is the policy of this facility that abuse allegations ( abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The alleged violations will be reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Alleged violations will be reported immediately to the Administrator and Director of Nursing of the facility and to other officials (including State Survey Agency and adult protective services). In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Initial reporting of allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial ( immediate or within 24 hours) report to the state survey agency. A follow-up investigation will be submitted to the State Agency within 5 working days. 1.) R13 was admitted to the facility on [DATE] with diagnosis that included Parkinson's Disease with dyskinesia, major depressive disorder with recurrent psychotic symptoms, panic disorder, and Dementia with other behavioral disturbances. R13's Significant Change in Status MDS ( Minimum Data Set) dated 5/17/24 documents that R13 has a BIMS ( brief interview for mental status) score of 14, indicating that R13 is cognitively intact. The MDS documents that R13 is dependent on staff for lower body dressing and needs substantial, requires maximum assistance from staff for personal hygiene and that R13 has limited range of motion on both sides of her upper and lower extremities. R13's nursing note dated 08/09/2024 at 01:29 p.m. documents, Care staff reports she was giving resident ( R13) a bed bath as resident refused her shower today. Care staff reports resident had fading bruises to her left thigh and left knee. Writer went in and spoke to resident. Resident unable to say how she got the bruises. Resident denies pain and denies anyone hurting her. Resident reports she would tell writer if someone hurt her as she knows writer would take care of it. Resident thanked writer for checking on her. Writer left the room at this time. R13's weekly nursing summary, dated 8/9/24, documents that R13 needs 2 staff members and the use of a hoyer left for transfers. R13's skin condition is documented to be fair and bruising is not checked on the summary. Surveyor conducted further medical record review and noted that on 8/2/24, staff assisted R13 with a bath and completed the bath/ shower skin audit sheet. Documentation stated that R13 had a bruise on the left thigh. No information was documented as far as a description or size of the bruise. This form was signed by both the Certified Nursing Assistants whom provided assistance with R13's bath and the Nurse who signed off on the skin audit. On 08/14/24 at 10:32 AM, Surveyor interviewed Nursing Home Administrator (NHA)- A and Director of Nursing (DON)-B regarding R13 having bruising to her thigh and knee. Surveyor requested any type of investigation into the bruising, as the facility and resident did not indicate how the bruising was obtained. NHA- A stated to Surveyor that I'm still working on it. Surveyor asked NHA-A when an investigation begin. NHA- A stated I will admit, I started yesterday. I have not been able to get a hold of all the staff that may have worked with her. I did interview some residents though. Surveyor asked why an investigation was not started earlier. NHA- A stated I was not made aware of it; If I was made aware of it, I would have started an investigation and treated it like an Injury of Unknown Origin. NHA-A stated that she would normally find out about any incidents from the DON. DON- B then stated that she was on vacation, so she didn't not have knowledge of it either. DON- B stated that the nurse is supposed to let her know about any skin issues. Surveyor clarified that a bath sheet, dated 8/5/24, identified that a bruise was located on R13's inner left thigh. DON- B was to be made aware of this. Surveyor asked NHA- A if the facility submitted, to the state survey agency, that R13 obtained an injury of unknown origin. NHA- A stated that the facility did not report anything regarding R13. The facility did not provide additional information as to why they did not report, to the state survey agency within 24 hours, that R13 had an injury of unknown origin. In addition, there was no additional information provided as to why the facility did not submit, within 5 working days, the findings of their investigation to the state survey agency.

Based on record review and staff interviews, the facility did not always ensure that they thoroughly investigated 1 (R13) out 1 injury of unknown origin investigations. * R13 was observed to have bruising to her inner left thigh and knee and R13 could not state how the injuries occurred. The facility was aware of the injuries but did not investigate as to how the injuries may have occurred. The bruising to the inner thigh is an area that is not vulnerable to trauma and R13 is depended on staff for activities of daily living . Findings include: The facility's policy with a revision date of 12/20/2018 and titled, Abuse , Neglect, Mistreatment and Misappropriation of Resident Property documents: Definitions of abuse and neglect: g.) Injuries of Unknown Origin : An injury should be classified as an injury of unknown source when both of the following conditions are met: i.) The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident. ii) The injury is suspicious because of the extent of the injury or the location of the injury ( e.g., the injury is located in an area not vulnerable to trauma) or the number of injuries observed at on particular point in time or the incidence of injuries over time. E. Investigation: b. Investigation of Injuries of Unknown Origin or Suspicious injuries: must be immediately investigated to rule out abuse: i.) injuries include, but are not limited to, bruising of the inner thigh, chest, face, and breast, bruises of an unusual size, multiple unexplained bruises, and/ or in an area not typically vulnerable to trauma. 1.) R13 was admitted to the facility on [DATE] with diagnosis that included Parkinson's Disease with dyskinesia, major depressive disorder with recurrent psychotic symptoms, panic disorder, and Dementia with other behavioral disturbances. R13's Significant Change in Status MDS ( Minimum Data Set) dated 5/17/24 documents that R13 has a BIMS ( brief interview for mental status) score of 14, indicating that R13 is cognitively intact. The MDS documents that R13 is dependent on staff for lower body dressing and needs substantial, requires maximum assistance from staff for personal hygiene and that R13 has limited range of motion on both sides of her upper and lower extremities. R13's nursing note dated 08/09/2024 at 01:29 p.m. documents, Care staff reports she was giving resident ( R13) a bed bath as resident refused her shower today. Care staff reports resident had fading bruises to her left thigh and left knee. Writer went in and spoke to resident. Resident unable to say how she got the bruises. Resident denies pain and denies anyone hurting her. Resident reports she would tell writer if someone hurt her as she knows writer would take care of it. Resident thanked writer for checking on her. Writer left the room at this time. R13's weekly nursing summary, dated 8/9/24, documents that R13 needs 2 staff members and the use of a hoyer left for transfers. R13's skin condition is documented to be fair and bruising is not checked on the summary. Surveyor conducted further medical record review and noted that on 8/2/24, staff assisted R13 with a bath and completed the bath/ shower skin audit sheet. Documentation stated that R13 had a bruise on the left thigh. No information was documented as far as a description or size of the bruise. This form was signed by both the Certified Nursing Assistants whom provided assistance with R13's bath and the Nurse who signed off on the skin audit. On 08/14/24 at 10:32 AM, Surveyor interviewed Nursing Home Administrator (NHA)- A and Director of Nursing (DON)-B regarding R13 having bruising to her thigh and knee. Surveyor requested any type of investigation into the bruising, as the facility and resident did not indicate how the bruising was obtained. NHA- A stated to Surveyor that I'm still working on it. Surveyor asked NHA-A when an investigation begin. NHA- A stated I will admit, I started yesterday. I have not been able to get a hold of all the staff that may have worked with her. I did interview some residents though. Surveyor asked why an investigation was not started earlier. NHA- A stated I was not made aware of it; If I was made aware of it, I would have started an investigation and treated it like an Injury of Unknown Origin. NHA-A stated that she would normally find out about any incidents from the DON. DON- B then stated that she was on vacation, so she didn't not have knowledge of it either. DON- B stated that the nurse is supposed to let her know about any skin issues. Surveyor clarified that a bath sheet, dated 8/5/24, identified that a bruise was located on R13's inner left thigh. DON- B was to be made aware of this. Surveyor asked NHA- A if the facility submitted, to the state survey agency, that R13 obtained an injury of unknown origin. NHA- A stated that the facility did not report or investigate anything regarding R13. No additional information was provided as to why the facility did not thoroughly investigate R13's injury of unknown origin.

3.) On 8/2/24 R34 experienced a change in condition and was sent to the hospital for evaluation. R34 was admitted to the hospital for UTI and C-Diff (clostridium difficile)infection. R34 returned to the facility on [DATE]. On 8/12/24 at 3:00 p.m. during the daily exit meeting with DON-B and NHA-A, Surveyor asked for the bed hold notice for R34 when he was admitted to the hospital on 8/2/24. On 8/14/24 NHA-A spoke with Surveyor and stated they have no evidence a bed hold notice was given to R34 on 8/2/24. No additional information was provided as to why the facility did not ensure that R2, R30, and R33 received written information of the duration of the bed hold policy, the reserve bed payment payment policy and the right to return to the facility upon being transferred to the hospital. 22692 Based on interview and record review, the facility did not ensure that 3 of 4 Residents (R2, R30, and R33) reviewed for hospitalization s received written information of the duration of the bed hold policy, the reserve bed payment payment policy and the right to return to the facility upon being transferred to the hospital. Findings include: On 8/13/24, the facility's policy titled Bed-holds and Returns dated 10/22 documents: All residents/representatives are provided written information regarding the facility and state bed-hold policies which addresses reserving a resident's bed during periods of absence. Residents are provided written notice about these policies at the time of transfer, or if the transfer was an emergency, within 24 hours. On 08/14/24 at 12:41 PM, Nursing Home Administrator (NHA)-A was interviewed and indicated no written bed hold information was given to R2, R30 or R33. NHA-A indicated no one in the facility is responsible for issuing written bed hold information and that is the main problem. 1.) On 8/13/24, R2's medical record was reviewed and indicated R2 was transferred and admitted to the hospital on 6/25/25 and returned to the facility on [DATE]. No written bed hold information could be found in R2's medical record for the 6/25/24 transfer. The above finding was shared with NHA-A on 8/14/24 at 3:05 PM at the daily exit meeting. Additional information was requested as to why written bed hold information wasn't given to R2 with her transfer to the hospital on 6/25//24. None was provided. 2.) On 8/13/24, R30's medical record was reviewed and indicated R30 was transferred and admitted to the hospital on 2/12/24. No written bed hold information could be found in R30's medical record for the 2/12/24 transfer. The above finding was shared with NHA-A on 8/14/24 at 3:05 PM at the daily exit meeting. Additional information was requested as to why written bed hold information wasn't given to R30 with her transfer to the hospital on 2/12/24. None was provided.

Based on observation, interview, and record review, the facility did not ensure residents with a pressure injury or those at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 (R31, R35, & R20) of 3 residents reviewed for pressure injuries. * R31 was admitted with a pressure injury which the facility identified as a Stage 3. The weekly assessments were not comprehensive and not accurate as assessments dated 5/16/23, 5/23/23, 5/30/23, & 6/6/23 document 100% epithelial tissue for R31's stage 3 pressure injury which would indicate the pressure injury was healed. On 7/5/23, R31's pressure injury was assessed as a Stage 4. R31's physician was not notified, there was no change in treatment, and the care plan was not revised. * R35 was identified on 7/7/23 with an open area on top of gluteal fold. This area was not assessed until 7/11/23. * R4 had a ruptured blister which declined and became infected. There was no RN (Registered Nurse) assessment from 1/27/23 to 2/12/23. R31 & R4 are being cited at a scope/severity of G. Findings include: The Pressure Injuries Overview from 2001 Med-Pass Inc., (Revised March 2020) under Staging (National Pressure Injury Advisory Panel Classification System) for Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis documents Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-intact blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage including continence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure injury: Full-thickness skin loss documents Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges are often present). Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, this is an Unstageable PI (pressure injury). 1.) R31 was admitted to the facility on [DATE] with diagnoses which includes osteomyelitis of vertebra, sacral and sacrococcygeal region, protein-calorie malnutrition, dementia, Alzheimer's disease, and hypertension. The hospital discharge summary dated 5/4/23 documents for admission diagnoses pressure injury of skin of sacral region, unspecified injury stage. Under discharge diagnoses includes: 1. sacral wound with possible osteomyelitis. Under hospital course documents [R31's name] is a [AGE] year old male who presented on 4/12/23 with complaints of wound infection. Has past medical history of advanced dementia, coronary artery disease, s/p (status post) CABG (coronary artery bypass graft), hypertension, sacral pressure sore. Presented with sacral wound pain. Patient also was having change in mentation. Patient was admitted and treated as follows: #Sacral wound with possible osteomyelitis. Had initial leukocytosis, mild anemia initially. Culture from the wound has grown Enterococcus faecalis, Pseudomonas aeruginosa, Bacteroides uniformis, para bacteroides distasonis. MRI (magnetic resonance imaging) 4/14. Large midline deep soft tissue ulcer extending to the cortical margin of the sacrum and coccyx. There is a large air-filled cavity with moderate surrounding soft tissue inflammation and cellulitis. There is osseous erosion of the coccyx with osteomyelitis within the distal sacrum. Patient treated with IV(Intravenous) Zosyn during his stay, patient to continue total 6 weeks of IV antibiotic. Plan to continue IV Zosyn per ID (infectious disease) recommendation, total 6 weeks, day 14/42 on discharge. Per wound care: Wound care plan: Acetic acid moist gauze and secondary dressing, change daily and PRN (as needed). Moisturize intact skin. Offloading: Needs aggressive off-loading with low air loss mattress or equivalent, frequent turning/repositioning at least every 2 hours, offloading chair cushion (ROHO) and heel offloading boots at all times while in bed. Included in the hospital information is a complete wound care dated 5/2/23 which documents pressure injury Stage 4. There are no measurements or description of the wound bed. The pressure injury care plan with a start date of 5/4/23 & edited 7/10/23 documents the following approaches: * Apply skin prep to left elbow Q (every) shift for redness. Start date of 5/30/23 & created 6/1/23. * Staff to transfer me to a high back wheelchair for all meals, for no longer than 2 hours at a time. Start date & created 5/15/23. * Incontinence care approximately every 2 hours. Start date 5/4/23 & created 5/15/23. * Monitor for skin breakdown during bathing and hygiene cares with special attention to heels. Start date 5/4/23 & created 5/15/23. * Off load heels; Prevalon boots on while in bed. Start date 5/4/23 & created 5/15/23. * Pressure relieving mattress. Start date 5/4/23 & created 5/15/23. * Reposition approximately every _2_ hours. Start date 5/4/23 & edited 7/10/23. * Treatments as ordered. Start date 5/4/23 and created 5/15/23. * W/C (wheelchair) cushion. Start date 5/4/23 & created 5/15/23. Surveyor noted the facility is back-dating the plan of care. The CNA (Certified Nursing Assistant) care card located inside R31's closet dated 5/4/23 documents non verbal will moan when in pain. Bed mobility is full assist. For skin breakdown documents change/turn q (every) 2 hours, tubi grips on in am (morning) off at hs (hour sleep), air mattress, Prevalon boots bilateral. The physician order dated 5/5/23 documents For aggressive off-loading, Air mattress and ROHO chair cushion to be used every shift NOC (night), AM (morning), PM (evening). The sacral wound assessment dated [DATE] documents for length 4 cm (centimeters), width 3 cm, & depth 3 cm. Exudate is documented as light Serosanguineous (pale red to pink, thin and watery), Stage is Stage III (3), Sinus tract/tunneling measurement (centimeters) documents 3, tissue type is Slough, Wound edges/margins documents well defined wound edges and wound healing status is stable. Surveyor noted this assessment does not document the percentage of slough. The sacral wound assessment dated [DATE] documents for length 4.5, width 5 cm, & depth 2 cm. Exudate is documented as light Serosanguineous (pale red to pink, thin and watery), Stage is Stage III (3), Sinus tract/tunneling measurement (centimeters) documents 4, tissue type is Epithelial Tissue , Wound edges/margins documents well defined wound edges and wound healing status is stable. Surveyor noted this assessment does not document the percentage of epithelial tissue. The nurses note dated 5/9/23 documents Stage 3 sacral wound present. 4.5 cm x 4 cm, depth 2 cm, and tunneling 4 cm from 9 o'clock - 3 o'clock. Well defined wound edges. Wound bed pink. Slight serosanguineous drainage noted. No odor noted. Writer in agreement with wound care orders. Wound care completed per orders. The admission MDS (minimum data set) with an assessment reference date of 5/10/23 assesses R31 as having short term & long term memory problems and is severely impaired cognitively for daily decision making. R31 is assessed as having no behavior concerns including refusal of care. R31 is assessed being dependent with two plus person physical assist for bed mobility, transfer, & toilet use, doesn't ambulate and is dependent with one person physical assist for eating. R31 is always incontinent of urine and bowel, is at risk for pressure injury development and has one Stage 3 pressure injury which was present on admission. The Braden scale assessment dated [DATE] has a score of 13 which indicates moderate risk for the development of pressure injuries. The pressure injury CAA (care area assessment) dated 5/16/23 under analysis of findings documents: [R31's first name] is currently being treated with IV (intravenous) ABT (antibiotic) for osteomyelitis to his distal sacrum with a pressure injury. Refer to wound management. Aggressive off-loading with air mattress and ROHO cushion to chair. He receives a nutritional supplement TID (three times daily) and is on a turning program. He is severely impacted by the dementia process and all of his needs are anticipated and met by staff. The sacral wound assessment dated [DATE] documents for length 5, width 5 cm, & depth 1 cm. Exudate is documented as heavy Serosanguineous (pale red to pink, thin and watery), Stage is Stage III (3), Sinus tract/tunneling measurement (centimeters) documents 8, tissue type is Epithelial Tissue, Tissue Percent of wound covered by epithelialization tissue 100%, Wound edges/margins documents macerated/soft; rolled under/thickened, and wound healing status is declining. This wound assessment is inaccurate as a wound that is 100% epithelial tissue would be healed. This assessment was completed by Prior DON (Director of Nursing)-Q. Surveyor was unable to interview Prior DON-Q as she is no longer at the Facility. The nurses note dated 5/16/23 documents Stage 3 sacral wound remains present. 5 cm x 5 cm, depth 1 cm, and tunneling 4 cm from 12 o'clock - 4 o'clock. Wound edges macerated/soft and rolled. Wound bed pink with beefy red areas, that are actively bleeding. Heavy serosanguineous drainage noted on dressing. No odor noted. Writer remains in agreement with wound care orders. The Braden scale assessment dated [DATE] has a score of 16 which indicates at risk for the development of pressure injuries. The sacral wound assessment dated [DATE] documents for length 5, width 4 cm, & depth 3 cm. Exudate is documented as heavy Serosanguineous (pale red to pink, thin and watery), Stage is Stage III (3), Sinus tract/tunneling measurement (centimeters) documents 5.5, tissue type is Epithelial Tissue, Tissue Percent of wound covered by epithelialization tissue 100%, Wound edges/margins documents macerated/soft; rolled under/thickened, and wound healing status is stable. This wound assessment is inaccurate as a wound that is 100% epithelial tissue would be healed. This assessment was completed by Prior DON (Director of Nursing)-Q. The nurses note dated 5/23/23 documents Stage 3 sacral wound remains present. 5 cm x 4 cm, depth 3 cm, and tunneling 5.5 cm from 12 o'clock - 4 o'clock. Wound edges remain macerated/soft and rolled. Wound bed remains pink with beefy red areas, that are actively bleeding. Heavy serosanguineous drainage noted on dressing. No odor noted. Writer remains in agreement with wound care orders. The Braden scale assessment dated [DATE] has a score of 11 which indicates high risk for the development of pressure injuries. The sacral wound assessment dated [DATE] documents for length 6, width 3.5 cm, & depth 3.5 cm. Exudate is documented as heavy Serosanguineous (pale red to pink, thin and watery), Stage is Stage III (3), Sinus tract/tunneling measurement (centimeters) documents 6, tissue type is Epithelial Tissue, Tissue Percent of wound covered by epithelialization tissue 100%, Wound edges/margins documents macerated/soft; rolled under/thickened, and wound healing status is declining. This wound assessment is inaccurate as a wound that is 100% epithelial tissue would be healed. This assessment was completed by Prior DON (Director of Nursing)-Q. The nurses note dated 5/30/23 documents: Stage 3 sacral wound continues to be present. Wound has increased in size. 6 cm x 3.5 cm, depth 3.5 cm, and tunneling 6 cm from 12 o'clock - 4 o'clock. Wound edges continue to be macerated/soft and rolled. Wound bed remains pink with beefy red areas, which continue to actively bleed. Heavy serosanguineous drainage remains present. No odor noted. Writer remains in agreement with wound care orders. The Braden scale assessment dated [DATE] has a score of 12 which indicates high risk for the development of pressure injuries. The sacral wound assessment dated [DATE] documents for length 4.8, width 4.4 cm, & depth 3 cm. Exudate is documented as heavy Seropurulent (yellow or tan, cloudy and thick), Stage is Stage III (3), Sinus tract/tunneling measurement (centimeters) documents 5.5, tissue type is Epithelial Tissue, Tissue Percent of wound covered by epithelialization tissue 100%, Wound edges/margins documents: Irregular wound edges; Macerated/soft; Rolled under/thickened , and wound healing status is declining. This wound assessment is inaccurate as a wound that is 100% epithelial tissue would be healed. This assessment was completed by ADON (Assistant Director of Nursing)-C. The nurses note dated 6/6/23 documents Stage 3 sacral wound continues to be present. Wound size currently 4.8 x 4.2 and tunnels 5.5 cm, with a depth of 3.5 cm. Wound edges continue to be macerated/soft and rolled. Wound bed remains pink with beefy red areas, moderate serosanguinous/bloody drainage noted on old dressing and actively. No odor noted. Writer remains in agreement with wound care orders. The sacral wound assessment dated [DATE] documents for length 5, width 5 cm, & depth 2.4 cm. Exudate is documented as moderate Serosanguineous (pale red to pink, thin and watery), Stage is Stage III (3), Sinus tract/tunneling measurement (centimeters) documents 5.5, tissue type is slough, Wound edges/margins documents Irregular wound edges, and wound healing status is declining. Surveyor noted this assessment does not document the percentage of Slough. This assessment was completed by ADON (Assistant Director of Nursing)-C. The nurses note dated 6/13/23 documents Stage 3 sacral wound continues to be present. Wound size currently 5 x 5 cm and tunnels 5.5 cm, with a depth of 2.4 cm. Wound edges continue to be macerated/soft and rolled. Wound bed remains pink with beefy red areas, moderate serosanguinous/bloody drainage noted on old dressing and actively. Mild-moderate slough present at wound bed. No odor noted. Writer remains in agreement with wound care orders. The sacral wound assessment dated [DATE] documents for length 4.5, width 4.5 cm, & depth 3.2 cm. Exudate is documented as moderate Seropurulent (yellow or tan, cloudy and thick), Stage is Stage III (3), Sinus tract/tunneling measurement (centimeters) documents 5.5, tissue type is slough, and wound healing status is stable. Surveyor noted this assessment does not document the percentage of Slough. This assessment was completed by ADON (Assistant Director of Nursing)-C. The nurses note dated 6/20/23 documents Wound dressing changed today. Stage 3 sacral wound continues to be present. Wound size currently 4.5 x 4.5 cm and tunnels 5.5 cm, with a depth of 3.2 cm. Wound edges improving with mild macerated/soft edges. Wound bed remains pink with beefy red areas, moderate yellow/tan drainage noted on old dressing. Mild-moderate slough present at wound bed. No odor noted. Writer remains in agreement with wound care orders. The wound clinic progress note dated 6/23/23 documents Sacral wound granular base. No exposed bone to base. Continues to undermine/tunnel @ (at) 11/12 o'clock peri-wound breakdown improving The nurses note dated 6/23/23 documents Resident returned from follow up with wound clinic. New orders are as follows: Vashe moist packing, gently pack tunneling, cover with abd (abdominal) pad and secure with tape. Do not use tegaderm. Apply Calazime or barrier cream to periwound macerations. Change dressing daily and PRN. Limit time in chair to no more than 3 hours a day. Surveyor noted R31's pressure injury care plan was not revised to include the approach recommended by the wound clinic to limit R31's time in the chair to no more than 3 hours a day. The sacral wound assessment dated [DATE] documents for length 5, width 4 cm, & depth 3.2 cm. Exudate is documented as moderate Seropurulent (yellow or tan, cloudy and thick), Stage is Stage III (3), Sinus tract/tunneling measurement (centimeters) documents 5.5, tissue type is slough, percent of wound covered by slough tissue 75, wound edges/margins is macerated/soft and wound healing status is improving. Surveyor noted this assessment documents 75% of the wound bed is slough but does not indicate what the remaining 25% of the wound bed is. This assessment was completed by Prior DON-Q. The nurses note date 6/27/23 documents Stage 3 sacral wound continues to be present. Wound appears to be improving. 5 cm x 4 cm, depth 3.2 cm, and tunneling 5.5 cm from 12 o'clock - 4 o'clock. Wound edges continue to be macerated and soft. Slough present to 75% of wound bed. All other surface areas of wound bed pink with beefy red areas, which continue to actively bleed. Moderate serosanguineous drainage present. No odor noted. Writer remains in agreement with wound care orders. The Braden scale assessment dated [DATE] has a score of 13 which indicates moderate risk for the development of pressure injuries. The wound assessment dated [DATE] documents for length 5 cm, width 4 cm, & depth 4 cm. Exudate is documented as heavy Serosanguineous (pale red to pink, thin and watery), Stage is IV (4), Sinus tract/tunneling measurement (centimeters) documents 7.3, tissue type is granulation tissue, percent of wound covered by epithelialization tissue is 0, percent of wound covered by granulation tissue is 75, and percent of wound covered by clean, non-granulation tissue 25. Wound edges/[NAME] is rolled under/thickened and wound healing status is stable. Under comments documents Wound stable, palpable bone in wound bed. Resident continues to have air mattress in place, resident turned every 2 hours and wheelchair time limited to 2 hours. The nurses note dated 7/5/23 documents Sacral Wound stable, palpable bone in wound bed. Resident continues to have air mattress in place, resident turned every 2 hours and wheelchair time limited to 2 hours. Surveyor noted after R31's pressure injury was identified as a Stage 4 on 7/5/23, R31's physician was not notified, there was no change in treatment and the care plan was not revised. On 7/10/23, at 9:11 a.m., Surveyor observed R31 sitting in a high back wheelchair in R31's room wearing bilateral green pressure relieving boots. R31 has his eyes closed and did not respond when Surveyor spoke to him. Surveyor observed there is an air mattress on R31's bed. On 7/10/23, at 10:39 a.m., Surveyor observed R31 in bed on an air mattress on the left side. There is a pillow under R31' right side, another pillow between R31's knees and R31 is wearing pressure relieving boots. On 7/10/23, at 11:22 a.m. Surveyor observed R31 continues to be in bed on the left side. On 7/10/23, at 12:38 p.m., Surveyor observed R31 sitting in a high back wheelchair in the dining room being fed lunch. R31 is wearing bilateral green pressure relieving boots. On 7/10/23, at 3:30 p.m., Surveyor observed R31 in bed on his back wearing bilateral pressure relieving boots with a pillow between R31's knees. Surveyor checked R31's wheelchair and observed a ROHO cushion in the wheelchair. On 7/11/23, at 7:53 a.m., Surveyor observed R31 sitting in the high back wheelchair in the dining room wearing bilateral pressure relieving boots with R31's breakfast of scrambled eggs & cut up pancakes in front of R31. On 7/11/23, at 10:09 a.m., Surveyor observed R31 in bed on the left side wearing pressure relieving boots. On 7/11/23, at 10:51 a.m., Surveyor asked CNA-R if she was assigned to care for R31 today. CNA-R informed Surveyor she was. Surveyor informed CNA-R Surveyor would like to look at R31's feet and inquired what time R31 would be getting up. CNA-R informed Surveyor they will be getting R31 up about 11:15 a.m. as he can stay up for only a certain amount of time. At 11:23 a.m. Surveyor observed R31's feet with CNA-R. Surveyor did not observe any redness or open areas on R31's feet. On 7/12/23, at 7:31 a.m., Surveyor observed R31 in bed on the left side. There is a pillow between R31's knees, another pillow leaning against the transfer bar on the left side and R31 is wearing bilateral pressure relieving boots. On 7/12/23, at 7:55 a.m., Surveyor observed the assessment and treatment of R31's pressure injury with Assistant Director of Nursing (ADON)-C and DON-B. ADON-C washed her hands, DON-B cleansed her hands and staff placed gloves on. DON-B informed R31 they were going to do his treatment. ADON-C cleaned off the over bed table with a bleach wipe & moved the bed away from the wall. ADON-C & DON-B removed their gloves, performed hand hygiene, and placed gloves on. ADON-C & DON-B repositioned R31 up in bed, R31 was positioned on his side, and ADON-C placed treatment supplies on a barrier on the over bed table. DON-B wiped R31's rectal area with a disposable wipe to remove stool, ADON-C & DON-B removed their gloves, performed hand hygiene, and placed gloves on. At 8:01 a.m. ADON-C removed the dressing from R31's sacral pressure injury & removed packing. DON-B stated the wound does have granulation tissue and does have bone exposed. ADON-C cleansed the wound bed of R31's pressure injury with normal saline, cleansed around the pressure injury with a disposable wipe, removed her gloves and placed new gloves on. At 8:04 a.m. ADON-C measured R31's pressure injury obtaining measurements of 4.4 cm length, 3.6 cm width, & depth 3.1. Tunneling at 1 o'clock is 5.3 cm, 11 o'clock is 2 cm and at 12 o'clock is 7.8 cm. ADON-C removed her gloves, cleansed her hands and placed gloves on. DON-B asked ADON-C if she felt bone stating 99% of the time when there is bone they have osteomyelitis. ADON-C poured Vashe on a 4 by 4 gauze, stated will open up the gauze and pack the wound loosely. R31's wound bed has granulation tissue and fibren. Surveyor inquired about bone. DON-B stated you can feel it when you go up, hooks your glove. ADON-C using a cotton applicator packed R31's pressure injury with the Vashe on 4 by 4 gauze, applied skin prep around the peri wound, removed her gloves, cleansed her hands, and placed gloves on. ADON-C applied barrier cream around the pressure injury, removed her gloves, cleansed her hands, placed gloves on, covered the pressure injury with a dry dressing, & taped the dressing. A blue pad & incontinence product was placed under R31, R31 was positioned from side to side to remove the soiled incontinence product & linen and to straighten out the blue pad & product. The incontinence product was fastened, R31 was positioned towards the left side of the bed, R31 was positioned on his right side and a pillow was placed under R31's left side along with a pillow between R31's knees & under R31's right arm. ADON-C & DON-B removed their gloves & performed hand hygiene. On 7/12/23, at 8:23 a.m., Surveyor met with ADON-C & DON-B to discuss R31's pressure injury. Also in the room was Administrator-A. Surveyor asked if the wound assessment just says slough or granulation tissue does this mean the percentage is 100% of wound bed. DON-B replied no, not necessarily, and informed Surveyor there should be percentages. Surveyor asked if the wound bed is described as slough what stage would the pressure injury be. DON-B informed Surveyor if there is a little slough then the pressure injury can be staged and it would depend on how much slough there is. Surveyor informed ADON-C & DON-B R31's assessments which just document slough or epithelial without the percentages. Surveyor inquired about the assessments with 100% epithelial tissue and being staged as a Stage 3. DON-B informed Surveyor 100% epithelial would mean it would be healed. Surveyor inquired about R31's pressure injury when it was assessed as a Stage 4. DON-B informed Surveyor to be honest she didn't think to go back and look at the interventions. DON-B informed Surveyor this is the first time she assessed R31's pressure injury and explained to ADON-C how to measure the pressure injury. DON-B informed Surveyor they didn't notify the doctor & didn't do anything different. ADON-C informed Surveyor she's not wound certified and asked Prior DON-Q for education, would complete the assessments with Prior DON-Q & asked her for recommendations. ADON-C informed Surveyor she looked at R31's pressure injury with Prior DON-Q. ADON-C informed Surveyor she thinks R31's pressure injury looks better and since DON-B started she has been well educated with the type of tissue and percentages. DON-B informed Surveyor she didn't think the measurements were correct, stating, to be honest. DON-B informed Surveyor she thinks R31's pressure injury should of been staged as a Stage 4 because the pressure injury had osteomyelitis when R31 was admitted . On 7/17/23 Surveyor received additional information for R31 which was emailed to Surveyor. This information was sacrum pressure injury wound measurements dated 6/23/23, 5/23/23, 3/23/23, & 11/29/22 and outpatient wound care progress note dated 6/23/23. This additional information does not change the deficient practice. 2.) R35's diagnoses includes Shy [NAME] syndrome (a movement disorder which is often referred to as a Parkinson plus syndrome or multiple system atrophy), dementia, and anxiety. R35's care plan documents: The skin tear to top of right hand with a start date of 5/18/22 & edited 6/9/23 documents the following approaches: * Zinc barrier cream to gluteal fold with a start date of 3/14/23. * Cushion in w/c (wheelchair) and recliner with a start date of 12/14/22. * Assist [R35's first name] with repositioning frequently with a start date of 7/4/22. * Braden Monthly with a start date of 7/4/22. * Float heels while in bed with a start date of 7/4/22. * Incontinence care as needed with a start date of 7/4/22. * Monitor for s/s (signs/symptoms) of infection with a start date of 7/4/22. * Nutritional consult PRN (as needed) with a start date of 7/4/22. * Pressure relieving mattress with a start date of 7/4/22. * Reduce pressure to buttocks and heels with a start date of 7/4/22. * Supplements as ordered with a start date of 7/4/22. * Treatment orders per MD (medical doctor) orders with a start date of 7/4/22. * W/C pressure relieving cushion with a start date of 7/4/22. * Wound care consult PRN with a start date of 7/4/22. The potential for skin problems care plan with a start date of 7/4/22 and edited 6/9/23 documents the following approaches: * Assist [R35's first name] with repositioning frequently with a start date of 7/4/22. * Braden monthly with a start date of 7/4/22. * Pressure relieving mattress with a start date of 7/4/22. * W/C pressure relieving cushion with a start date of 7/4/22. The significant change MDS (minimum data set) with an assessment reference date of 6/1/23 assesses R35 as having short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R35 is assessed as requiring extensive assistance with one person physical assist for bed mobility, extensive assistance with two plus person physical assist for transfer & toilet use and does not ambulate. R35 has an indwelling urinary catheter and is frequently incontinent of bowel. R35 is at risk for pressure injuries and is assessed as not having any pressure injuries. The Braden assessment dated [DATE] has a score of 18 which indicates at risk for the development of pressure injuries. The nurses note dated 7/7/23 documents: Small open area noted during transfer in the shower to top of gluteal fold. Skin prep applied and covered with duoderm. Orders entered. Will monitor. This note was written by LPN (Licensed Practical Nurse)-O. The physician order dated 7/7/23 documents: Cover open area to top of gluteal crease with duoderm q (every) Tuesday and prn (as needed). Special instructions: With wound rounds Once a day on Tue (Tuesday) AM (morning). On 7/10/23 Surveyor reviewed R35's medical record and was unable to locate an RN (Registered Nurse) assessment of R35's open area identified on 7/7/23. On 7/10/23, at 12:02 p.m., Surveyor observed the personal type recliner in R35's room has a green pressure relieving cushion. On 7/10/23, at 12:25 p.m., Surveyor observed R35 sitting in a wheelchair in his room. Surveyor observed there is a green pressure relieving cushion in the wheelchair. On 7/10/23, at 3:06 p.m., during the end of the day meeting with Administrator-A and DON (Director of Nursing)-B, Surveyor informed Facility staff Surveyor would like to observe R35's treatment tomorrow. On 7/11/23, at 7:20 a.m., Surveyor asked LPN-E about R35's treatment. LPN-E informed Surveyor she had spoken to ADON (Assistant Director of Nursing)-C and they were going to look at the area together as she was unaware of an open area and thinking it may be scar tissue. Surveyor informed LPN-E Surveyor would like to observe R35 being transferred and when she & ADON-C go in to assess R35. On 7/11/23, at 8:50 a.m., Surveyor observed R35 sitting in a personal type recliner with his legs extended. R35's eyes are closed and appears to be sleeping. On 7/11/23, at 10:14 a.m., Surveyor observed R35 continues to be sitting in the personal type recliner with legs extended and appears to be sleeping. On 7/11/23, at 10:54 a.m., Surveyor observed R35 continues to be sitting in the personal type recliner with legs extended and appears to be sleeping. On 7/11/23, at 1:16 p.m., Surveyor entered R35's room with LPN-E and ADON-C. Surveyor observed R35 is in bed on his back, R35's heels are not being offloaded and R35 is covered with bedding. ADON-C, with gloves on, raised the height of R35's bed and pulled the blanket down. LPN-E washed her hands, placed gloves on, lowered the head of the bed and unfastened R35's incontinence product. R35 was positioned on his right side. Surveyor observed a Stage 2 pressure injury on the top of R35's gluteal crease. LPN-E stated they did duoderm for a long period of time and did not know about it. LPN-E stated to ADON-C they can switch sides so she can measure and cleanse the open area. R35 was positioned on his back and ADON-C covered R35 with bedding. LPN-E & ADON-C removed their gloves, washed their hands and placed gloves on. Surveyor asked ADON-C if she was the wound nurse. ADON-C replied no, not technically and explained DON (Director of Nursing)-B is wound certified. R35 was positioned on his right side and ADON-C measured R35's pressure injury with measurements of .3 cm (centimeters) for length times and .4 cm width. ADON-C cleansed the pressure injury with normal saline. Surveyor inquired if there was any depth. ADON-C then measured the depth stating I will say .1. ADON-C applied skin prep around the pressure injury, covered the area with duoderm and dated the dressing. ADON-C and LPN-E removed their gloves and washed their hands. On 7/11/23, at 1:29 p.m., Surveyor asked ADON-C what should happen when an LPN identifies a pressure injury. ADON-C explained if a RN is in the building they would assess the area and if not the nurse should notify herself or the DON. ADON-C indicated they would do their best to give recommendations on the phone and would assess as soon as they can. The nurse should write a progress note on what is identified and intervention and identify [name of medical group]. Surveyor asked ADON-C if she was aware of this pressure injury. ADON-C replied no and explained she was not aware until LPN-E brought it to her attention. Surveyor asked ADON-C if today was the first RN assessment for R35's pressure injury. ADON-C replied yes. On 7/11/23, at 1:33 p. [TRUNCATED]

Based on interview and record review, the facility did not ensure that each resident received needed supervision to prevent accidents for 13 of 13 residents reviewed for the use of lifts and 2 of 4 residents reviewed for falls out of total sample of 16 (R1, R2, R3, R6, R8, R9, R10, R11, R12, R13, R14, R15, and R16). R1 was transferred via a Hoyer lift with assist of 2. R1 fell out of the Hoyer lift and struck her head on the floor. The fall caused several facial fractures, a subdural hematoma, neck fractures, and a large laceration to the right side of the head. R1 expired the following day as a result of her injuries. Facility staff had not been educated on the type of sling/harness or size of sling/harness to be used for R1. Facility staff did not ensure that the sling was properly secured on the lift prior to lifting the resident and moving her from one surface to another. R3, R8, R10, R12 and R15 (R15 uses a full body lift PRN (as needed)) all currently reside in the facility and require full body lifts for transfer. Facility staff have not been educated on the use the full-body lift used for each resident or which sling/harness is to be used, including the correct size. The facility has no documentation that any assessments have been completed on residents that require the use of lifts. R15, R6, R14 (or [NAME] steady), R2, R11, and R16 (PRN) currently reside in the facility and require a sit-to-stand lift for transfers. Facility staff have not been educated on the use of the sit-to-stand lifts used for each resident or what sling/harness is to be used, including the correct size. R14 (utilizes an EZ stand), R16, and R13 all currently reside in the facility and require a [NAME] steady lift for transfers. Facility staff have not been educated on the use of the [NAME] steady used for each resident. The facility's failure to ensure each resident is transferred safely created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on [DATE] at 8:31 AM. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. The facility also had deficient practice regarding a fall for R2. R2 had a fall in which she complained of hip pain. The staff moved the resident from the floor to her bed without first having the resident assessed by an RN. This is evidenced by: The Facility's Policy and Procedure entitled Assessing Falls and Their Causes last revised [DATE] documents, in part: .Purpose: The purpose of this procedure are to provide guidance for assessing a resident after a fall and to assist staff in identifying causes of falls. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. General Guidelines: 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. Steps in the Procedure: After the Fall: 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings . Note: The Assessing Fall and Their Causes policy does not identify for a resident's need to be assessed for injury by a RN (registered nurse). The Facility's Policy and Procedure entitled Low Lift/No Lift Policy and Procedure, dated [DATE], documents the following, in part: .Policy: To ensure the safety of residents and staff, it is the policy of [Facility Name] to minimize/avoid manual lifting of resident during transfers, to provide specific transfer instructions to CNAs/nursing department on each resident, and to facilitate communication between departments and staff. Procedure: c. EZ stand lift. iii. Must have permission form therapy and/or nurse prior to use, if not written on the care plan worksheet. v. All EZ stand lift transfers are 2 assist unless care plan states assist of one. d. Hoyer Lift. ii. Must be 2 assist . The Facility's Policy and Procedure entitled Safe Lifting and Movement of Residents, last revised [DATE], documents the following, in part: .Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding us of equipment and safe lifting techniques. 9. Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, resident with lifting and movement needs will be provided with single-resident use disposable slings. 10. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. 11. All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints. 12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies; c. Provides training on safety, ergonomics and proper use of equipment; and d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies. The facility currently has approximately 11 different types of lifts by 7 different manufacturers that are used for mechanically transferring residents. The Manufacturer's recommendations and instructions provided by the facility for the lifts observed being used by Surveyors during the survey are as follows, in part . The Manufacturer's User Manual for the Joerns Hoyer Presence, (Full Body Lift) documents the following, in part, on pages 9 and 18: .4. Safety Precautions. Warning: DO NOT lift a patient unless you are trained and competent to do so. ALWAYS carry out DAILY CHECK LIST located towards the end of the manual before using the lift. DO NOT use a sling unless it is recommended for use with the lift. ALWAYS check the sling is suitable for the particular patient and is of the correct size and capability. DO NOT use a sling unless it is recommended for use with the lift. NEVER use a sling, which is frayed or damaged. ALWAYS fit the sling according to the instructions provided (user instructions). HOYER RECOMMENDS THE USE OF GENUINE HOYER PARTS. Hoyer slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver . The Manufacturer's User Manual for the Joerns Hoyer HPL 600, (Full Body Lift) was not provided to Surveyor by the facility. Surveyor attempted to obtain the User Manual from the manufacturer's website, but this particular model is no longer listed as one of their products. The Manufacturer's User Manual for the Invacare Reliant 450 RHL450-I; Invacare Reliant 450 RPL450-I, and the Invacare Reliant 600 RPL600-I, (Full Body Lift) documents the following, in part, on pages 7 and 9: .2. Safety: General Guidelines: ACCESSORIES WARNING: Invacare products are specifically designed and manufactured for us in conjunction with Invacare accessories. Accessories designed by other manufacturers have not been tested by Invacare and are not recommended for use with Invacare products. 2.2. Operating Information: Invacare slings and patient lift accessories are specifically designed to be used in conjunction with Invacare patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of Invacare's patient lift system. Using the Sling: WARNINGS: Be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair or commode). Lifting the Patient: WARNING: When elevated a few inches off the surface of the stationary object (wheelchair, commode, or bed) and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not in place, lower the patient back onto the stationary object (wheelchair, commode, or bed) and correct this problem. Invacare slings are made specifically for use with Invacare Patient Lifts. For the safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers. Warranty will be voided. The Manufacturer's User Manual for the Medline, (Sit-to-Stand Lift) documents the following, in part . General Warnings: Never operate the stand assist unless you have been properly trained on all procedures and safe handling methods. Practice using the stand assist prior to performing actual patient lifting so that you are familiar with its operation. Personal Injury Warnings: Use only Medline slings on Medline patient lifts. Use of non-Medline slings could be unsafe and may result in injury to the patient or caregiver. Inspect the slings prior to each use. Do not use a sling that has worn thread or frayed straps. Operating Warnings: Do Not lift a patient unless you are trained and competent to do so. The Manufacturer's User Manual for the EZ Way Smart Stand, (Sit-to-Stand Lift) documents the following, in part . Safety Notes: EZ Way harnesses are made specifically for EZ Way stands. For the safety of the patient and caregiver, only EZ Way harnesses should be used with EZ Way stands. WARNING: For safe operation of the EZ Way Smart Stand, the stand must be used by trained personnel in accordance with the operator's manual, video and training checklist to avoid injury to patient. Example 1 R1 was admitted to the facility on [DATE]. R1 had the following diagnoses, in part: Low back pain, cervicalgia (neck pain), pain in the right and left shoulders, age-related osteoporosis, occlusion and stenosis of unspecified carotid artery, chronic obstructive pulmonary disease, carcinoma in situ of skin (skin cancer), muscle weakness, and unsteadiness on feet. R1's care plan documented the following, in part: Problem: R1 at risk for falling R/T (related to) new to nursing home placement, weakness, impaired mobility. Approach: Transfer status changed to Hoyer lift only, due to inability to use EZ stand r/t shoulder pain and unable to pull self-up for [NAME] steady. Problem: ADL (activities of daily living)/Mobility Deficit related to: Weakness. Approach: Transfer with assist of: 2 staff and Hoyer. R1's CNA care plan documented the following, in part: .Updated [DATE]: Hoyer Sling Color: Blank; Transfers: Hoyer at all times; Total Transfer: 2 assist with Hoyer. Surveyor noted: Hoyer Sling Color is blank on the CNA care plan and does not give staff a way to identify which sling/harness is to be used with R1. R1's Minimum Data Set's (MDS) documented the following, in part: Annual MDS dated [DATE]- .Bed mobility: extensive of one staff. Transfer, Dressing, Toileting, and Hygiene are dependent of two staff. R1 is always incontinent of bowel and bladder . R1's Nurses' Progress Note documented the following: [DATE] at 9:37 AM, At approximately 9:05 AM writer heard CNA yell, 'we need a nurse now!' Writer entered the doorway of room (the number to R1's room). Resident was lying face down on her floor with a large puddle of blood around her head. Writer yelled to staff running towards resident's room to call 911. Admin (Administrator) entered room. Writer grabbed gloves and blanket. Blanket placed under resident's forehead to apply pressure. Resident responded appropriately to writer's questions. Stated that her head and knees hurt. Writer sent CNA for a gown, washcloths, and Hoyer sling. With support to resident's neck and head, resident was turned on her back with the Hoyer sling and placed under her. A gown was placed over resident. Pressure was applied to laceration on right side of forehead. EMS (Emergency Medical Services) arrived. Writer prepared red folder with bed hold notice and transfer paperwork included. DNR (Do Not Resuscitate) bracelet was placed on resident's left wrist. Long Term nurse placed call to resident's Emergency Contact. Resident was lifted by Hoyer sling onto EMS cot. Resident in route at this time to [Hospital Name]. The Facility document titled, Safety Events - Fall report documents the following, in part: .Description: Fall. Event Details: FALL: Location of Fall: Resident Room. Describe exactly what happened; why it happened; what the causes were. If any injury, state part of body injured. If property or equipment damaged, describe damage. Resident fell out of Hoyer lift during transfer. Fall was witnessed by 2 CNAs. Nurse responded. Resident was face down on the floor in the middle of her room. Blood actively draining from laceration on forehead. Resident stated that her forehead and knees hurt. Pain Observation: Does resident exhibit or complaint of pain related to the fall? If so, describe location: Yes (location) - forehead and knees. On a scale of ,d+[DATE], how does resident rate intensity of pain if able, or indicate based on observation: 10 - Excruciating Pain - Worst Possible - Interferes with ability to carry on with daily routines, socialization or sleep. Body Observation: Note any injury to the head, extremities, or trunk: Skin tear. Neurological Check: Level of Consciousness: Alert Wakefulness - Perceives the environment clearly and responds appropriately to stimuli. Possible Contributing Factors: None. Interventions: First Aid, Direct Pressure to Wound, Other - EMS called, and Send for CT (Computerized Tomography) of Head. Note: The facility has no documentation that staff were educated prior to the event on the use of the lift or which sling/harness was to be used for R1. CNA's indicated during interviews that the slings/harnesses were universal and that they used slings/harnesses interchangeably between lifts and residents. Note: The manufacturer recommendations for the lifts indicate staff must be trained on the use of the lift prior to completing any transfers, the sling is the appropriate size and capability, never use a sling that is frayed or damaged, complete the daily check list prior to using the lift, Hoyer recommends the use of genuine Hoyer parts, Hoyer slings and lifters are not designed to be interchangeable with other manufacturer's products, and using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver. Note: During the survey, Surveyors inspected sling used at the time of the fall with R1. The sling was noted to have fraying along the upper right side along the seam. The sling contained no markings or labels to indicate the brand, size, or compatibility with the lift it was to be used with. On [DATE] CNA C completed the facility document titled, Employee Statement which states in part . Time incident occurred: 9:05 AM. If any physical evidence of injury occurred, was any part of their body bumped or hit on any object: Yes. If yes, please explain injury type and location: Head injury to R (right) side. Employee statement: Give a full description of all of the facts: Other CNA and I were transferring resident from bed to shower chair using Hoyer. As we were opening legs of Hoyer resident flipped face first on the ground due to left upper sling strap becoming unattached. We grabbed a nurse right away and started applying pressure to head wound until EMS (Emergency Medical Services) arrived. On [DATE] CNA D completed the facility document titled, Employee Statement which states in part . Time incident occurred: 9:05 AM. If any physical evidence of injury occurred, was any part of their body bumped or hit on any object: Yes. If yes, please explain injury type and location: Head, bleeding R (right) side. Employee statement: Give a full description of all of the facts: Me and another CNA were transferring a resident with a Hoyer. We were transferring her to the shower chair. As we were opening up the legs of the Hoyer the top left strap came unattached, and the resident fell landing face first on the ground. We grabbed a nurse right away and started applying pressure to head wound until EMS arrived. Note: Both CNA statements indicate that the top left strap came undone but in the fall investigation and during interviews with both CNA's they indicate it was the left lower strap that came undone. Director of Nursing (DON) B assisted Licensed Practical Nurse (LPN) E in R1's room but no statement was completed by her. On [DATE] Nursing Home Administrator (NHA) A completed the facility document titled, Employee Statement which states in part . Time incident occurred: 9:05 AM. If any physical evidence of injury occurred, was any part of their body bumped or hit on any object: N/A. Employee statement: Give a full description of all of the facts: Writer heard a call out for help and when approaching the living room writer was asked by LPN E to call 911. Writer immediately called 911 and requested emergency assistance. Writer waited at the front door and directed emergency personnel to R1's room. Writer did not see resident or observe event while happening. Emergency Medical Services (EMS) Report titled, Prehospital Care Report, dated [DATE] at 10:02 AM, states in part: .Ambulance dispatched to [Facility Name] for a patient that fell out of a Hoyer lift. Upon arrival we found a 91 y/o (year old) female lying on the floor in care of facility staff. Patient is A/Ox4 (Alert and Oriented). Patients C/C (chief complaint) is a head injury, and neck pain due to a fall from the Hoyer lift. Staff on scene stated they were lifting the patient up with the Hoyer to give her a bath, when one of the straps snapped causing her to fall about 4 feet face first to the ground. Patient denied any LOC (loss of consciousness). However, she was complaining of neck pain along with a 5 inch laceration to her forehead. Bleeding was controlled on scene by EMS with cling wrap and Coban bandages. A soft collar made from a rolled blanket was also used to help support the patients neck. Due to anatomy, the soft collar was used because the rigid collar wouldn't fit properly. Patient was then lifted from the floor and secured to the cot. Once out in the ambulance, all vitals were obtained and noted. A 20G (gauge) IV (intravenous) was established in her left hand. Trauma assessment was performed with no other findings. Patients mental status along with her condition were continually monitored throughout transport to [hospital name]. Upon arrival patient showed no changes in airway, breathing, circulation, or mentation. The Emergency Department Note, dated [DATE] at 10:24 AM, states in part: . 91 y.o. (year old) female presenting after 4 foot fall from Hoyer lift. On initial encounter, patient alert, GCS (Glasgow Coma Scale) 15 (best response), vital signs reassuring. Physical exam significant for right eye proptosis (protrusion of eye socket), posterior midline neck pain, significant right-sided facial blunt trauma, equal grip strength bilaterally. Shortly after arrival right intraocular pressure was checked and was elevated at 50 (normal is ,d+[DATE]), 23 on the left concern for retro-orbital hematoma (accumulation of blood in the retrobulbar space) with progressively worsening vision changes requiring emergent canthotomy (urgent surgical procedure for orbital compartment syndrome) and canthal lysis (tendon release) which was performed as below. Scans showed significant findings involving multiple right facial fractures with evidence of right or retro-orbital hematoma, small SDH (subdural hematoma), C1 and C2 fractures. I did speak with oculoplastics whom recommended transfer to tertiary center. While in the emergency department patient had acute onset of increased trouble breathing and then had an episode of emesis. This is the second episode of emesis first was prior to arrival. Patient was intubated without difficulty. Around the time of intubation patient had increased blood pressures to over 210 systolic. Hospital CT C-Spine WO (without) Contrast, states in part: . 1. There is horizontally oriented fracture through the body of the dens with mild anterior displacement of the distal fracture fragment (type II dens fracture) (is an upward extension of C2 cervical vertebrae (i.e., axis) up into the C1 cervical vertebrae (i.e., axis)). 2. There is a vertically oriented fracture through the anterior arch of C1. There are also fractures through the bilateral aspects of the posterior arch of C1. 3. There is questionable nondisplaced fracture through the left inferior facet at C4. Hospital CT Facial Bones WO Contrast, states in part: . 1. There are multiple highly comminuted right-sided facial fractures with extensive soft tissue swelling. This includes fractures of the nasal bone, the anterior wall of the right maxillary sinus, the posterior wall of the right maxillary sinus, the lateral right obits and zygoma as well as the right zygomatic arch. 2. There is prominent right retrobulbar fat stranding with an ill-defined gas containing fluid collection along the inferior aspect of the right orbit, consistent with an extraconal retrobulbar hematoma. There is associated right-sided proptosis. R1 was transferred to a Level I trauma center and succumbed to her injuries and expired at 2:00 PM on [DATE]. On [DATE] at 2:00 PM Surveyor interviewed ME N (Medical Examiner). ME N stated R1's death certificate indicated R1's cause of death was blunt force trauma to her head and neck due to fall. On [DATE] at 10:10 AM, Surveyor interviewed EMS staff members H and I. Surveyor asked EMS staff if they could describe what they saw and did upon entering the facility on [DATE] and during transport to the hospital. EMS I stated when we entered the room R1 was lying on the floor on her back. It appeared as if facility staff had already turned her over. R1 had a cloth on forehead and was awake. Staff indicated that the strap broke on the lift during the transfer resulting in the fall. R1 stated that she remembered falling and being on the floor, she also indicated that she was 4 feet in the air at the time of the fall. Surveyor asked EMS staff what type of aide they gave on scene. EMS H stated, We used a blanket the facility provided to make a soft collar, as a rigid color would not fit the resident. We needed to ensure we protected the airway of the resident. Surveyor asked EMS staff if they were able to identify what R1 hit causing the injury. EMS I stated, Based on the extent of the injuries she could have hit the base of the Hoyer, the floor, or both. She had injuries to the mid forehead, bridge of the nose, and over the right eye. The right eye was also swollen with blood pooled behind it. R1 was provided with first aide and pressure to the forehead. On [DATE] at 10:30 AM, Surveyors interviewed CNA C along with DON B. Surveyors asked CNA C to describe what happened during the transfer of R1. CNA C stated, It was just after breakfast. CNA D and I were going to assist R1 to get a bath. R1 liked baths. I informed R1 that I was going to go get the bath ready. When I returned, we transferred R1 from the recliner to the bed with the Hoyer. CNA D placed the shower sling under R1 and hooked her up the Hoyer as I was getting the shower chair and towels. Surveyor asked CNA C where staff were standing when moving the lift. CNA C indicated she was behind the shower chair and CNA D was in front of the Hoyer moving R1. Surveyor asked CNA C if either she or CNA D had their hands on R1 as they were moving the Hoyer. CNA C stated, No we did not. The left side lower (left leg) strap came undone and R1 fell to the ground onto her knees and then fell face forward. I am guessing that the strap was not on all the way. Surveyor asked CNA C if it appeared that R1 had attempted to break her fall. CNA C stated, When she was rolled over, she still had her arms crossed in front of her. DON B brought Surveyors out to common area to show the lift and sling used during the incident. Surveyors noted that the sling is frayed along the right upper strap. Surveyors asked DON B about sling and DON B indicated she was not sure how old the sling was, did not know where it came from, as it did not have an labels or markings to indicate, and she was unsure if it was approved for use with the Hoyer lift. Surveyors asked CNA C how staff determine what lifts and slings to use and how many people are required to use the lifts. CNA C stated, We use the same slings for all brands of lifts. They are interchangeable. DON B stated, We use slings based on the residents height and weight. We use 2 assist for Hoyer lifts and 1 assist with EZ stands or [NAME] steady's unless care plan states otherwise. On [DATE] at 12:30 PM, CNA C came back to Surveyor stating she wanted to correct a statement that was made by DON B during the interview. CNA C stated, We use 2 assist for all full body and sit-to stand lifts and 1 assist for [NAME] steady, unless the care plan indicates otherwise. On [DATE] at 1:29 PM, Surveyor interviewed CNA D. Surveyors asked CNA D if she could tell Surveyors about the events of [DATE] and R1. CNA D stated, CNA C and I were getting R1 ready for a bath. I was assisting R1 in her room with getting undressed. The bath chair was by the closet. I hooked up R1 to the lift and began lifting her off the bed. I began moving the lift towards the shower chair and about to start opening the legs of the lift when R1 fell on to the floor. Surveyor asked CNA D where she and CNA C were in relation to R1. CNA D stated, I was by the bed moving the Hoyer and CNA C was by the shower chair. Surveyor asked CNA D if any staff were guiding or had hands on the resident. CNA D stated, No one had their hands on resident or the sling. Surveyor asked CNA D if staff should have hands on resident when moving them in the lift. CNA D stated, Yes. Surveyor asked CNA D if R1 hit the floor or lift. CNA D stated, I saw the resident fall. When she fell she did not hit the Hoyer. I looked up and saw the sling unattached to the left lower loop by legs. R1 fell right between the legs of the Hoyer onto the floor with head towards the Hoyer and her feet straight out towards the shower chair. R1's knees hit first I think. R1 was awake and did complain of knee pain. Surveyor asked CNA D how she determines what sling to use for residents. CNA D stated, There is a sticker on the top side of the Hoyer beam indicating what size sling to be used. Surveyor asked CNA D if each resident has a specific sling they should be using. CNA D stated, There are no specific slings for residents. Mostly we use the same slings on everyone. I had never gotten R1 into the shower before and had never used this particular sling on her before. Surveyor asked CNA D if any education was completed with her following the fall. CNA D stated, We watched a video on using a lift and had to complete a return demonstration. Surveyor asked CNA D if she learned anything from the video she watched or any of the education she received. CNA D stated, I learned about needing to guide the resident in the sling and having my hands on the resident. On [DATE] at 1:57 PM, Surveyor interviewed LPN E (Licensed Practical Nurse). Surveyor asked LPN E if she could describe the events of the fall for R1. LPN E stated, I was the on the rehab unit that day and had just come over to the long-term area to cover that Nurse's break. At approximately 9:00 AM I head yelling and I couldn't tell where it was coming from so, I yelled Where are you. Staff yelled back R1's room number. I then stepped into the doorway and saw the resident face down in a pool of blood. I yelled for the NHA (Nursing Home Administrator) to call 911. I took bath blanket and put it up to R1's head. The DON and I then supported R1's neck and rolled her onto her back to assess injuries. The DON kept pressure on R1's head. At this time, I could already hear the siren. I put a gown on the resident and then went to get the transfer paperwork ready to send with the resident. On [DATE] at 4:05 PM, Surveyor interviewed CNA L. Surveyor asked CNA L how she decides what lift or lift sling to use on a resident. CNA L stated, Depends on the size of the resident. Blue is large or x-large. Also go off the size chart. Surveyor asked CNA L if she had competency training on the use of the lifts and slings. CNA L stated, We had education last week and prior to that was when I was training in another facility to get my license. Note: The size chart showed to Surveyor by CNA L was a list of slings by cradle type for the full body lift. The cradle type listed on the chart was not a cradle that the facility has. This document was laminated and posted for staff on the CNA desk. On [DATE] at 4:15 PM, Surveyor interviewed CNA M. Surveyor asked CNA M how she decides what lift or lift sling/harness to use on a resident. CNA M stated, Depends on the resident weight. We are able to use all slings on all Hoyer's. Surveyor asked CNA M if she had completed any training for lifts or slings/harnesses. CNA M stated, Yearly refresher training and competencies are done. On [DATE] at 4:30 PM, Surveyor interviewed CNA O. Surveyor asked CNA O how she determines what lift and sling/harness to use with each resident. CNA O stated, I ask if I am unsure. There is a chart at the CNA desk and the resident care sheet says what lift to use for transfers. All Hoyer/full body lift slings/harnesses are all interchangeable. Surveyor asked CNA O if this includes the shower slings. CNA O states, I don't know if those are different sizes. Surveyor asked if CNA O received any education on how to use the lifts in the facility. CNA O stated, I had education during clinicals at another facility. No education prior to January in this facility. Surveyor asked CNA O how many staff are required to use a lift. CNA O stated, You are never to use a lift alone. Note: The facility was unable to provide any competencies for lift or sling/harness selection training for any staff prior to R1's fall. The facility did complete training following the fall on the lift involved in the fall, but no others, they did not complete any training or assessments on sling/harness selection. On [DATE] at 8:15 AM, [TRUNCATED]

Based on observation, interview and record review, the facility did not provide adequate supervision and assistive devices to prevent accidents for 1 (R1) of 3 sampled residents identified by the facility as at risk for falls. R1 experienced falls when facility care planned fall interventions were not implemented or updated with new interventions after each fall occurrence. Findings include: Review of facility policy titled;East Troy Manor Fall Policy and Procedure ( no date) Policy states, East Troy Manor will use every effort to prevent falls among our residents while maintaining the least restrictive environment, through the identification of those at risk for falls, identifying precipitating events leading up to falls that do occur, identifying patterns in falls, and implementing interventions to prevent or reduce the incidence of further falls. Procedure: The term falls means when a resident has lost his/her balance and fallen; when a resident is found on the floor. It is still considered a fall when a resident rolls out of bed on to a fall mat, or if a resident was lowered to the floor by staff. Additional steps listed under procedure include; In the event of a fall, nurse to complete the fall assessment on matrix under events and update both the MD and family. Implement interventions immediately to prevent fall such as toileting more frequently, alarm, frequent checks, proper footwear, medication review, labs, environmental factors and 1:1's. Update care plan with new interventions. Falls will be reviewed by the interdisciplinary team within 72 hours of the fall. R1 was originally admitted to the facility on [DATE] and had a re-admission date of [DATE]. [DIAGNOSES REDACTED]. R1 was also admitted following a fall at home and a fractured humerus. According to the most recent quarterly Minimum Data Set (MDS), dated [DATE], R1 has long and short- term memory problems, moderately impaired cognitive skills for decision making and needs limited/ 1 person assistance from staff for all activities of daily living. R1 was also noted to be frequently incontinent of both bowel and bladder. The MDS states R1 has had 1 fall since admission with no injuries and 1 fall with injury that is considered not to be a major injury. Surveyor conducted a review of the most recent plan of care for R1. The care plan states that R1 is at risk for falling due to nursing home placement, weakness, impaired mobility and Epileptic [MEDICAL CONDITION]. This plan of care was initiated on 5/7/19 (admission). Interventions included assure the floor is free of glare, liquids, and foreign objects. Be sure the sensor alarm next to bed is on and functioning. Bed in lowest position, Encourage resident to use environmental devices such as hand grips, hand rails etc. Fall mat next to bed when in bed. Give resident verbal reminders not to ambulate/ transfer without assistance until cleared from therapy. Keep call light in reach at all times when in room. Keep personal items and frequently used within reach. Provide proper, well -maintained footwear. Provide resident an environment free of clutter. Surveyor conducted a review of the progress notes kept in the electronic medical record (EMR). Review of the progress notes showed that R1 had falls on the following dates: 6/6/19, 7/8/19, 7/9/19, 8/4/19, 8/5/19, 8/7/19 and 9/12/19. Surveyor requested to review the fall investigations for the above mentioned falls and noted the following details upon review: R1 experienced a fall on 6/6/19 at 7:30 p.m. in the day room of the facility. The description states that R1 was attempting to throw away her empty ice cream container by getting out of her wheelchair and walking to the garbage can. She fell and was found sitting on her bottom on the floor of the main TV room. No injuries were noted for this fall. Interventions listed to already be in place at the time of the fall included fall mat and bed in the lowest position. Interventions to prevent further falls stated chair alarm- i.e.- pad alarm. The evaluation notes stated , fall discussed with the interdisciplinary team (IDT). Fall prevention interventions initiated include fall mat and bed in lowest position. Care plan updated. Will continue to monitor. It was noted that no new interventions were put into place after the fall from the wheelchair including the referenced pad alarm when R1 was in the day room. Listed new interventions were already in place upon admission and were interventions to prevent falls that may occur in R1's room from her bed not her wheelchair. R1 experienced a fall on 7/8/19 at 11:01 p.m. in her room. The description states it was a unwitnessed fall without injury. Staff found resident sitting on floor in front of wheelchair, no injury occurred. Resident was leaning over reaching for Kleenex on floor. The falls investigation did not indicate any possible contributing factors and stated that interventions already in place prior to fall were other - Dycem in wheelchair seat. Interventions listed to prevent further falls stated Dycem to wheelchair seat, fall mat and bed in lowest position. The evaluation notes stated, discussed with IDT. Fall prevention interventions implemented to include, call bell within reach, low bed in lowest position, Dycem applied to wheelchair seat. Will continue to monitor. A review of R1's plan of care showed that the intervention of Dycem to the wheelchair seat had not been added. It was noted as of time of review on 10/1/19, this intervention was not on the most current copy of the care plan. R1 experienced a fall on 7/9/19 at 11:14 p.m. (Surveyor noted that the time the progress note was created for this fall was 2:40 p.m so questioning actual documented time of fall) in the front common area of the facility. The description states that R1 was found on the floor in the front common room, in front of wheelchair bleeding from mouth, fall witnessed by a visitor stating she was sleeping and fell forward to the floor. This writer removed dentures and found and removed fragments of broken upper dentures from mouth. Pressure applied to bleeding upper lip, resident is awake, Hoyered to bed in supine position. No possible contributing factors were listed on the fall investigation. Unknown last time that R1 was last toileted. Interventions already in place prior to fall included 15 minute checks, fall mat and bed in lowest position. It was noted that the investigation did not note if Dycem was in place in the wheelchair seat as stated to be a intervention to be in place from the previous fall. Interventions to prevent further falls included 15 minute checks, fall mat and other- Dycem. The evaluation notes stated, discussed with IDT. Fall prevention interventions implemented to include call bell with in reach, low bed in lowest position, Dycem applied to wheelchair seat. Will continue to monitor. It was noted that there was no new interventions put into place. The fall occurred in the common area and the intervention of fall mat and low bed would not have prevented a further fall from happening at this time. It was also noted that the Dycem to the wheelchair seat had not been added to the plan of care and was not noted to be in place at the time of this fall from the wheelchair. Progress note dated 7/9/19 at 2:40 p.m. stated that R1 fell forward in common room out of wheelchair on floor hitting nose and mouth. Immediate moderate bleeding form mouth. Found upper dentures cracked and pieces removed from mouth, pressure applied, did mouth sweep and found small fragments from upper denture. R1 verbalizing face pain. Moves all extremities at this time, pupils 2 brisk and equally reactive. Health Care Power of Attorney notified and is coming to take resident to emergency room for evaluation. Ice applied to face, continue to monitor. Progress note dated 7/9/19 at 7:11 p.m. stated that R1 returned form ER Lakeland by family car. CT of head and neck negative, 2 views of left shoulder negative. CXR (chest x-ray) negative. Inner upper lip laceration repaired and sutures intact. New order for soft diet, no straws and Tylenol 500 milligrams- 2 tablets as needed. Resident received [MEDICATION NAME] at hospital and is sleepy. R1 experienced a fall on 8/4/19 at 3:45 p.m. The progress note states unwitnessed fall from wheelchair to floor on left side, in front common area. R1 said she bumped her head, no lumps - bumps palpated at this time. Moves all extremities without difficulty, no deformity, no pain in extremities. A review of the fall investigation form dated 8/5/19 at 8:30 a.m. states R1 experienced a fall in the day room of the facility (facility stated this is the fall investigation for fall on 8/4/19 and the time stamp of the fall is the time information was entered into computer). The description stated that resident was sitting in wheelchair in common area and reached for a piece of paper on the floor and fell out of wheelchair. Resident is free from injury. The investigation does not list any possible contributing factors. Interventions already in place prior to fall indicated auto-lock brakes to wheelchair, fall mat and motion alarm. Interventions to prevent further falls listed other- motion alarm. The evaluation notes stated, discussed with IDT. Fall preventions implemented to include bed in lowest position while in bed, fall mat, call bell within reach and sensor alarm. Neuro checks initiated per protocol. It was noted that plan of care was never updated to include the use of auto-lock brakes to wheelchair. The investigation did not state if Dycem was in place in the seat of the wheelchair at the time of the fall and it continued to not be a listed intervention. It was also noted that this fall was from the wheelchair in the common area, the listed new interventions of motion alarm would not be helpful to the resident unless she was in bed. No new interventions were put into place to prevent a further fall from the wheelchair in the common areas. R1 experienced a fall on 8/5/19 at 3:30 a.m. in her room. The description states that resident slid from bed to mat in sitting position without injury. Bed in lowest position. Alarm functioning. Back against mattress. The fall investigation does not list any possible contributing factors and states that R1 was incontinent at the time of the fall. The last time R1 was toileted states at 2:00 a.m. The listed interventions already in place prior to fall stated bed/chair alarm, bed alarm, fall mat and bed in lowest position. Interventions to prevent further falls- nothing was checked. The evaluation note stated, discussed with IDT. Fall prevention interventions implemented to include, low bed in lowest position while in bed, fall mat, call bell within reach and sensor alarm. Neuro checks initiated per protocol. It was noted that no new interventions were put into place after this fall. It was not addressed that R1 was incontinent at the time of the fall from bed. R1 experienced a fall on 8/7/19 at 3:22 p.m. in the day room. The description states that resident fell out of wheelchair and hit her head on chair that was next to her. Found on the ground face down, unable to state if anything hurts. The investigation does not indicate any possible contributing factors. Intervention already in place prior to fall indicated bed alarm, auto-lock brakes to wheelchair, fall mat and bed in lowest position. It was noted that there was no indication a chair alarm was in place or Dycem to the seat of the wheelchair. These interventions were listed as being present during previous falls and they were not added to the plan of care for R1. The fall investigation indicates that R1 was sent to the emergency room for further evaluation. The evaluation notes stated, Resident returned form Lakeland ER via ambulance. Pelvic x-ray showed displaced fracture of left superior pubic ramus and left ischiopubic ramus. Orders for no weight bearing, evaluation by PT ( physical therapy). The investigation stated that inventions to prevent further falls is the use of a broda chair. Physical Therapy evaluation on 9/5/19 indicates that R1 stood and used sara steady and is to be transferred from the use of the broda chair back to a standard wheelchair. Patient appears to be safe and upright in standard wheelchair. R1 experienced a fall on 9/12/19 at 4:06 p.m. The falls investigation states that R1 leaned forward and to the left while sitting in the shower chair in the shower room. CNA present and fall was witnessed. Resident did not hit her head. Writer was entering the shower room with the ez-stand. Resident's range of motion within normal limits. Denies any pain or discomfort at this time. The investigation listed Pneumonia as a possible contributing factor. Interventions already in place prior to fall listed sensor alarm and fall mat. Interventions to prevent further falls indicated 15 minute checks. The evaluation notes stated fall mat, bed in lowest position, frequent checks, neuro checks per protocol, motion alarm in place at bedside. It was noted that no new interventions were recommended, as these listed interventions were already to be in place and would be beneficial for a fall occurring in the room not in the shower room. Surveyor conducted a further review of R1's plan of care. Under the listed problem of R1 being at risk for falls, the facility added the intervention of a clip alarm on 9/12/19 when R1 is in the wheelchair per request of Power of Attorney. An intervention of monitoring R1 for [MEDICAL CONDITION] activity and increase visual checks during these times was added on 8/14/19. On 9/12/19 the listed intervention of the use of a broda chair was discontinued from the plan of care. It was noted that the care plan still did not include the use of auto-lock brakes on the wheelchair or Dycem in the seat of the wheelchair as previously stated to be listed interventions to be in place to prevent falls. The care plan also stated that on 8/9/19- 15 minute checks times 3 days had been discontinued. On 10/1/19 at 3:52 p.m., Surveyor made observations of R1 up in her wheelchair in the common area. It was noted that 2 staff members were present in the area and that a clip alarm was in place on R1. R1 was wearing regular shoes and it was not observed by Surveyor that auto-lock brakes were in place on the back of R1's wheelchair. On 10/1/19 at 3:20 p.m., Surveyor interviewed Director of Nursing-( DON- B) regarding R1's fall on 8/7/19 that resulted in a fracture. DON- B stated that R1 had been put in the common area to increase supervision and that R1 just goes over so quickly in her wheelchair. She will fall forward from straight up in her wheelchair. DON- B stated that R1 was placed in a broda chair after she returned with the fracture for comfort and safety. DON- B stated that there were no falls when R1 was using the broda chair but she is now back in her regular wheelchair with the use of a clip alarm that was requested by family. DON- B stated that R1 does self-propel in her wheelchair and that further use of the broda chair would be restricting R1's mobility. DON- B also explained the intervention of 15-minute checks that is a listed intervention for R1. DON- B stated that the 15- minute checks are part of the protocol for 3 days after a fall and coincide with neuro checks as well. Surveyor reviewed the CNA Care Card that is to be used by direct care staff to indicate what cares and interventions should be in place for each individual resident. These care cards are located in the individual resident bathrooms. R1's care card indicates it was updated on 9/24/19. The ambulation listed that R1 is assist of 2 with wheeled walker. Alarm/ mats indicates sensor alarm, fall mat, clip alarm on when in wheelchair. Fall risk is also indicated on the care card. It was noted that the care card does not list Dycem to wheelchair seat or the use of anti-lock brakes to the wheelchair. Surveyor interviewed Certified Nursing Assistant (CNA) - C on 10/1/19 regarding R1's interventions that are in place to prevent falls. CNA- C stated that the use of the clip alarm is new for R1 and that there is a sensor alarm by the door that indicates if R1 is moving from the bed. CNA-C was not able to confirm if R1 had Dycem in her wheelchair seat and had to ask Surveyor what Dycem was. On 10/2/19 at 1:30 p.m., Surveyor made observations of R1 up in her wheelchair in her room. At this time it was noted that the very visible auto-lock brakes were in place on the back of the wheelchair. Surveyor interviewed DON- B at this time and asked when the auto-lock brakes were put into place on R1's wheelchair. DON- B stated that they have always been there and that Surveyor must have missed them on the previous observations on 10/1/19. On 10/2/19 at 1:45 p.m., Surveyor interviewed DON- B and Administrator- A regarding R1's falls and updates to the plan of care. DON- B stated that R1 already had a mat on the floor and low bed upon admission to the facility due to R1 having a history of falls. DON- B stated that over time, R1 had changes to her [MEDICAL CONDITION] medication and does have a history of [MEDICAL CONDITION] activity. DON- B is not able to confirm if any of the listed falls were as a result of [MEDICAL CONDITION] activity. DON- B stated that R1 had Pneumonia in May, 2019 and this may have contributed to her weakness and increased confusion. Surveyor discussed the use of the anti-lock brakes on R1's wheelchair. DON- B was able to confirm that on 6/7/19 there was a request to place anti-lock brakes on the wheelchair. DON- B was unable to provide any documentation or evidence of the day the anti-lock brakes were actually put into place. Surveyor provided notes about the fall investigation on 7/9/19 that did not indicate the auto-lock brakes were in place as an intervention at the time of the fall from the wheelchair. Surveyor also asked DON- B why the use of the auto-lock brakes had not been added to the care plan for R1 or the CNA care card. DON- B was able to confirm the care plan was not updated with this intervention. Surveyor asked DON- B about the use of Dycem to the wheelchair as a new intervention listed after the fall on 7/8/19. DON- B confirmed that this intervention was to be in place and also confirmed is had not been added to the plan of care or the CNA care card. DON- B was asked about the inconsistencies within the falls investigations for R1. DON- B stated that after the event happens the nurse is to complete the event report and takes statements and is to list the current interventions that were in place at the time of the fall and what interventions will be used immediately after the fall to prevent further falls from occurring. DON- B stated that she will then look at the falls investigation and they are also reviewed by the IDT to determine what further interventions may be needed and any updates to the care plan happen at this time. DON - B was unable to state why the use of Dycem to the wheelchair and the use of anti-lock brakes were never added to R1's plan of care. DON- B was also not able to provide additional information as to any new updates to R1's falls care plan after she was removed from the broda chair and is now back to using the regular wheelchair. As of the time of the exit on 10/2/19, no additional information had been provided as to why after each time R1 experienced a fall from the wheelchair or bed that new falls interventions were not in place. No additional information was provided as to why the falls investigations were not thorough and inconsistent and why the plan of care was not updated.

Based on observation, interview and record review the facility did not provide adequate supervision and assistive devices to prevent accidents for 2 (R286 and R26) of 5 sampled residents identified by the facility to be at risk for falls. ~ R286 sustained 3 falls from 11/23/16 to 6/16/17. On 6/6/17 R286 sustained a fall at 7:30 AM while sitting in a Broda chair in the day room waiting for breakfast. She leaned forward in her chair and fell out head first striking her head on the floor. R286 sustained a bloody nose, bruising to the right side of the head and under her right eye. Neurological assessments completed post fall indicate R286 experienced a neurologic change in condition on 7/7/17 when R286 was noted to have a pinpoint left pupil with sluggish reaction and appeared to be only semi-conscious. The facility did not complete a thorough investigation to determine why R286 was left in an improperly positioned Broda chair leading to the fall and who placed R286 in this position. R286's injuries would typically have required hospital evaluation related to a head injury however, the facility did not consult with F286's physician (Cross-reference F580) when the changes in condition occurred. R286 was on hospice at the time of the fall. R286 passed away on 7/16/17. ~ Certified Nursing Assistant staff did not transfer R26 with a gait belt nor did they ask R26 about placing a gait belt on him according to R26's plan of care. Findings Include: 1.) R286 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. R286's Admission MDS (Minimum Data Set) assessment dated [DATE] documents a fall within the last month and a fracture related to a fall within the last 6 months. No Change of Status MDS could be located for R286 admission to hospice care on 12/8/16. (Cross-reference F637.) R286's Plan of Care dated 10/3/16, with a target date of 7/7/17, states R286 has a history of falling related to recent fall prior to admission; unwitnessed fall out of bed; unwitnessed fall out of recliner. Interventions include: fall mat when in bed; assure the floor is free of glare, liquids, foreign objects; give verbal reminders not to ambulate/transfer without assistance; keep light in reach at all times; keep personal items and frequently used items within reach; place resident in a fall prevention program; and provide resident an environment free of clutter. R286's Fall Event Report dated 6/6/17 documents, resident sitting in Broda chair in the day room waiting for breakfast and she leaned forward in her chair and fell out head first. Has sustained a contusion with dark purple bruising to the right side of her head, bruising under her right eye and a nose bleed 3 times. R286's Fall Event Report dated 6/6/17 documents for description of why the fall happened, what the causes were: (R286's) Broda chair should have been in the reclined position. Possible contributing factors: orthopedic condition; recent decline in ADL (Activity of Daily Living) abilities and recent change in medication. Order received on 6/1/17 to increase R286's [MEDICATION NAME] to 300mg two times a day related related to tremors. Interventions put into place to prevent future falls: bed and chair alarm. Surveyor noted this intervention does not address the concern related to the Broda chair not being placed in the reclined position to prevent future falls. Resident Incident/Accident Report, Employee Statement dated 6/6/17 completed by Dietary Aide-O documents: (R286) was sleeping prior to the incident. Dietary Aide-O was walking through the living room area and saw (R286) tilt forward and just fall frontward out of her chair and laid there limp (on the floor). At first (R286) was unresponsive and blood dripping out of her nose. Another staff member called for help. On 12/6/17 at 7:30 AM Surveyor spoke with Dietary Aide-O about R286's falls requesting further clarification in regards to her written statement. Dietary Aide-O stated that she was passing room trays that morning when she walked past the living room area. Dietary Aide-O informed Surveyor that she noted R286 leaning forward in her chair. Dietary Aide-O told R286 to sit back and with her one free hand, Dietary Aide-O helped guide R286's shoulder back to sit back and prevent R286 from leaning forward in her chair. As Dietary Aide-O stepped away she heard a loud smack and saw R286 on the floor with blood coming out of her nose. Dietary Aide-O did not feel that R286 was awake after she fell to the floor. She thought R286 was dead. Dietary Aide-O called for help and another staff member was able to get the nurse to help R286. Dietary Aide-O stated that it felt like a long time before R286 opened her eyes. Dietary Aide-O could not recall if she told staff of her concern for R286 being unresponsive because she was upset and crying about the incident. During the interview Surveyor asked if Dietary Aide-O knew what CNA had been assigned to R286 or who had placed R286 in the common area. Dietary Aide-O indicated she did not know. On 6/6/17 at 8:30 AM R286's medical record documents, (per hospice nurse) visit to assess patient post fall. Patient sitting up in Broda chair feeding self breakfast. Patient appears lethargic and complained of a headache with Tylenol effective for comfort. Patient bump on right side of head and developing bruising beneath right eye. Patient taken to room and toileted when started with nose bleed from right nostril [MEDICATION NAME] 10 minutes without recurrence. VSS (Vital Signs Stable) at this time. Patient continues on [MEDICATION NAME] 300 mg (milligrams) by po (per oral) BID (Two times per day) with no tremors noted at this time. On 6/6/17 at 9:30 AM R286's medical record documents, fall at 7:30 AM out of Broda chair in the day room. Resident has contusion to the right side of her forehead above the temple that measures 4.5 cm (centimeters) across. Area cleaned with normal saline and ice applied. Has small bruise to the upper right side of her nose where her glasses bumped when she fell , R286 did get a bloody nose with small about of blood 3 times and developing bruising under right eye. Hospice, Doctor and POA (Power of Attorney) updated. R286 denies pain. Is alert and oriented per usual. VSS (Vital Signs Stable) and as charted. Neurological checks have been negative, continue to monitor. On 6/6/16 at 2:57 R286's medical record documents, assessment by Medical Doctor (MD)-L, leaned forward this morning and fell forward out of Broda chair striking head on the right side of the face. Denies problems with pain at this time, no breathing difficulties, hospice aware. Right frontal parietal contusion from fall. Continue with current medication and cares as well as hospice involvement. On 6/7/17 at 2:06 AM R286's medical record documents, resident is being monitored post fall and is very anxious and restless at the beginning of the shift. Bruising beginning to develop around around eyes. On 6/7/17 at 10:43 AM R286's medical record documents, resident is rather lethargic this morning. Easily aroused and answers questions appropriately. Vital signs stable. Bruising around right eye continues to darken. On 6/7/17 at 4:15 PM R286's hospice charting documents, routine visit to assess patient's condition and well being. R286 presents with a change in condition in her level of consciousness. R286 semi-conscious with only a moan with brisk sternal rubbing. Staff reports that R286 has not voided in 8 hours. Respirations slow and even. Breathing pattern is deep inspirations without accessory muscle use. Neurological checks with left pupil pinpoint and sluggish. Extremities are flaccid and without tone. R286 with small blink reflex. R286 in fragile condition and appears comfortable. Facility nurse and family update on R286's status and encouraged to contact Allay Hospice with any changes in R286's condition. Surveyor unable to locate documentation that physician was notified of the change in condition. On 6/7/17 at 6:41 PM R286's medical record documents, 24 hour report related to recent fall and change in condition; resident has become increasingly difficult to arouse, no longer answering questions; makes unintelligible noises. Resident appears comfortable no signs or symptoms of pain. Hospice and POA (Power of Attorney) aware. Vital signs stable. Not alert enough to eat supper or drink and fluids. Surveyor unable to locate documentation that physician was notified of the change in condition. On 6/7/17 at 7:00 PM R286's Neurological Check Assessment documents a decline in R286's blood pressure to 104/60 and left pupil is 1 cm (centimeter) and slow to react. Surveyor unable to locate documentation that R286's physician was made aware of the change in condition On 6/7/17 at 9:00 PM R286's Neurological Check Assessment, documents a blood pressure decrease to 104/60, left eye 1 cm (centimeter) and slow to react. Surveyor unable to locate documentation that physician was notified of the change in condition. Additional review of R286's neurological check assessment indicates: 6/8 0500 - 104/60, pupils- left 1cm the right doesn't react due to an intraoccular lens implant. 6/8 0945 - 84/54, pupil reaction the same 6/8 1530 - 90/56, pupil reaction Right cloudy, Left 1 cm 6/9 no time documented -98/60, pupil reaction the same 6/9 0730 - 94/68, pupil reaction the same. On 12/05/17 at 3:53 PM Surveyor spoke with Licensed Practical Nurse (LPN)-N requesting clarification about Dietary Aide-O's written statement of R286's fall. LPN-N informed Surveyor that Dietary Aide-O did not inform her of her belief that R286 was unresponsive after the fall. When LPN-N arrived in the living room area R286 was still on the floor. LPN-N informed Surveyor that R286 is hard of hearing and has poor vision. So when LPN-N first called R286's name it was hard to know if she could hear what was being said. LPN-N proceeded to do a sternal rub and R286 responded right away. LPN-N stated that in her professional opinion she did not agree with Dietary Aide-O's assessment that R286 was unresponsive after the fall. LPN-N also informed Surveyor that R286's hospice nurse arrived to the facility within 10 minutes of the fall and completed her assessment. LPN-N could not recall who informed R286's doctor of the fall but believes it was the hospice nurse. LPN-N also informed Surveyor of her attempt to contact R286's family was initially unsuccessful but did speak to them later in the day after the hospice nurse spoke with them. On 12/6/17 at 8:55 AM Surveyor spoke with Hospice Director-P for further clarification of R286's fall and assessment of residents condition after the fall. Hospice Director-P informed Surveyor that the nurse that assessed R286 on 6/6/17 and 6/7/17 is no longer with the company. Hospice Director-P was able to locate the treatment notes for 6/6/17 and 6/7/17. On 6/6/17 Hospice note document, unknown if patient lost consciousness. R286 is in the dining room feeding herself a bacon toast sandwich. Patient keeps eyes closed with delayed speech though appropriate. Patient complained of a headache for which facility staff gave Tylenol. Facility nurse and family were made aware of the change in condition. Assessment of injuries shows a large contusion with scant bleeding to the right side of patient's head above the temple region. Patient also has some bruising developing below the right eye. Patient also has an abrasion to the right side of the bridge of her nose caused from her glasses when she fell . Neurological checks are WNL (within normal limits) for patient. Speech is garbled per usual. Staff nurse updated on patients status and nose bleed with assessments on going for next 24 hours. Family updated and patients status and will make a visit later today. On 12/6/17 at 11:45 AM Surveyor informed DON-B of concern regarding R286 being left in Broda chair in the day room unsupervised while the Broda chair was in the upright position resulting in a fall; head first out of the Broda chair. The fall resulted in injuries of bruising to right side of temple area and below the eye as well as abrasion to the right side of the nose. A change in condition with a decline in vital signs, pupil reaction and increased lethargy also occurred as a result of the fall. Surveyor also informed DON-B of the concern that the intervention put into place to prevent further falls of applying a bed and chair alarm does not address the reason for the fall which is documented as incorrect positioning of R286's Broda chair. DON-B informed Surveyor that residents should not have Broda chairs left in the upright position unless they are seated at a table. Staff neglecting to place the Broda chair in the reclined position resulted in an avoidable fall with injury for R286. During the survey, the Surveyor reviewed the manufacturer's operating manual for a Broda Chair and noted the following safety details regarding use of the Broda chair for an individual resident. Before the chair is put into service, this manual must be read thoroughly by the caregiver(s) directly responsible for the resident's care. After the chair is put into service, this manual must be read thoroughly by any new caregivers prior to operating or moving the chair. For the purpose of this manual, a resident's family member who shares responsibility for their care is considered a caregiver and is subject to the same competency before being permitted by the resident's primary caregiver to operate of move the chair. Prior to first use, the customer must arrange for an in-service on the operation and safety requirements in this manual, must be given to the resident's caregivers by the local BRODA representative who supplied the chair. The primary caregiver must maintain a list of caregivers who have read this manual and who they have authorized to operate and move the chair. The resident's primary caregiver is responsible for ensuring that anyone who is unfamiliar with, unwilling, or unable to adhere to the safety and operating instructions, is not permitted to operate or move the chair. The operations of the chair must be performed by the resident's primary caregiver who is responsible for seating. All The operations and adjustments performed should be done in a manner to ensure the overall safety, comfort and well-being of the resident, caregiver and third party. All operations and adjustments required for the resident should be determined by the resident's primary caregiver who is responsible for seating. 2.5 Hazards 2.5.1 Position of Chair - Danger of Falling Immediately after a resident is transferred into a chair, we recommend that the chair's seat be tilted sufficiently to prevent the resident from sliding or falling forward off the chair. The amount of seat tilt used should be determined by the resident's caregiver who is responsible for seating. On ClearPath models in which a leg rest is included, we recommend that the resident's feet be correctly positioned on the footplate and slightly to fully elevated when applicable, to prevent the resident from sliding or falling forward off the chair. The amount of elevation used should be determined by the resident's caregiver who is responsible for seating. 2.5.2 Position of Seat Tilt - Danger of Tipping We recommend that the chair's seat be tilted sufficiently to prevent the resident from tipping the chair forward or backward, or from slumping and sliding in the chair. The amount of seat tilt used should be determined by the resident's caregiver who is responsible for seating. Always ensure that the resident is properly positioned before operating the seat tilt. 2.5.3 Location of Chair - Danger of Tipping or Falling Objects We recommend that when a resident has been moved to their destination, the chair is placed where the resident cannot reach handrails or other objects, fixed or movable. This is to prevent the resident from pulling the chair over or pulling themselves off the seating surface and to prevent the resident from pulling movable objects onto the chair and themselves. We recommend that the chair be used in a supervised area to prevent untrained residents, caregivers, or third parties from unauthorized operation, movement, or unsafe actions such as sitting or leaning on the reclined back, elevated footrest, or the armrests. These actions, if not prevented, put the chair at risk of tipping or damage to the chair. We recommend that a chair only be located on a level surface to minimize the risk of tipping over. 7 2.6 Improper Use As outlined, the improper use of the chair is dangerous to the resident, caregivers, or third parties, and can consist of, but is not limited to the following: 1) Unauthorized operation of the chair's functions. 2) Unauthorized movement of the chair. 3) Inappropriate use of the chair for a resident who has not been assessed by a qualified caregiver responsible for their seating. 4) Failure to frequently reposition the resident in the chair 5) Attempting to operate of multiple chair functions simultaneously by one or more caregivers. 6) Attempting to move the chair with the brake(s) applied. 7) Leaving the resident unattended in the chair near other objects. 8) Leaving an agitated resident in the chair in an unsupervised area. 9) Leaving a resident unattended. 10) Leaving a resident in a chair on a sloping surface. 11) Leaving a chair unattended on a sloping surface. 12) Using non-BRODA accessories on the chair. 13) Using the chair at temperatures below 0ºC. 14) Using the chair as a shower or bathing chair. 15) Using the chair for any use other than its intended purpose. 2.9 Resident Specific Instructions The primary caregiver responsible for the specific resident's seating shall add additional instructions necessary for the safe and effective use of the chair based on their professional experience and knowledge of the resident's specific conditions and requirements. BRODA representatives are not professional caregivers and will not know the specific requirements of the individual using the chair. BRODA relies on the knowledge, experience, and judgment of the resident's professional caregiver to ensure the specific resident's safety and comfort needs are satisfied while using the chair. These instructions form an essential part of the Safety Requirements for using the chair and must be made available to all caregivers. Space is provided below to include these instructions . Surveyor noted there is no indication the facility established an individualized plan of care specific to F286 and the use of her Broda chair as specified in the manufacturer's instructions. Additionally there is no indication the facility thoroughly investigated the circumstances surrounding F286's fall to complete a root cause analysis and ensure ongoing safety when using a Broda chair. On 12/6/17 at 3:00 PM Surveyor informed Administrator-A and DON-B of the above concerns. No further documentation was provided. 2.) Surveyor reviewed R26's medical record on 11/30/17 to 12/6/17. The admission MDS (minimum data set) with an assessment reference date of 10/27/17 has a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R26 requires extensive assistance with two plus person physical assist and is coded has having two falls with no injury and two falls with injury not major since admission. The falls CAA (care area assessment) with a worksheet start date of 10/31/17 documents under analysis of findings resident at risk for falls care plan updated. alarms in place at this time. Resident behaviors put resident at risk for falls. The CNA (Certified Nursing Assistant) care card not dated and provided to Surveyor on 11/30/17 under transfers documents Gaitbelt Transfer 1 assist with wheeled walker. On 11/30/17 at 11:44 a.m. Surveyor entered R26's room with CNA (Certified Nursing Assistant)-H. Surveyor observed R26 was in bed. CNA-H assisted R26 to sit on the edge of the bed, CNA-H placed the alarm box on the wheelchair and assisted R26 to stand by holding under R26's left arm. CNA-H assisted R26 with sitting in the wheelchair, placed the foot pedals on the wheelchair, and asked R26 if he needed to go to the bathroom. R26 informed CNA-H that he had already gone. CNA-H wheeled R26 out of the room and down the hallway. Surveyor noted CNA-H did not transfer R26 with a gait belt nor did she ask R26 about placing a gait belt on him according to R26's plan of care. On 12/5/17 at 9:24 a.m. Surveyor observed CNA-F enter R26's room and ask R26 what he would like to wear. CNA-F picked out clothing from the closet, placed gloves on and placed pants on R26 who was in bed. CNA-F moved the wheelchair close to R26's bed and swung R26's legs down so R26 was sitting on the edge of the bed. CNA-F assisted R26 to stand by holding under R26's left arm and then assisted R26 to sit in the wheelchair. CNA-F then wheeled R26 into the bathroom. Surveyor observed CNA-F did not transfer R26 with a gait belt nor did she ask R26 about placing a gait belt on him according to his plan of care. On 12/5/17 at 12:34 p.m. Surveyor met with DON (Director of Nursing)-B to discuss R26. Surveyor asked DON-B how R26 should be transferred. DON-B informed Surveyor R26 is an assist of one. Surveyor asked if staff should use a gait belt when transferring R26. DON-B replied yes and then explained sometimes R26 stands up before they can place a gait belt on him. Surveyor informed DON-B of the observations of staff not placing a gait belt on R26 nor did they speak to R26 about placing a gait belt on him. Surveyor also informed DON-B Surveyor did not observe the CNA's wearing a gait belt or a gait belt in R26's room. .

Based on observation, interview, and record review the Facility did not ensure 5 (R26, R22, R29, R6 and R19) of 6 Residents at risk for pressure injury development received the necessary treatment and services. * R26 developed an unstageable pressure injury on his right heel on 11/2/17. There was no RN (Registered Nurse) assessment until 11/8/17 (six days later) the at risk for skin breakdown care plan did not include any approaches to offload R26's heels prior to the development of the unstageable area and after R26 developed the unstageable pressure injury to the right heel the at risk for skin breakdown care plan was not revised. R26 showed Surveyor an unstageable pressure injury on his right ankle on 11/30/17. There is no evidence the Facility was aware of this pressure injury until 12/1/17. The Facility was not performing diabetic foot checks for R26. * The facility did not ensure that R29, who was assessed at risk for pressure injuries, would not develop pressure injuries. R29 was assessed to have 13 stage 2 pressure injuries to the upper, bilateral, posterior thighs after the Surveyor brought R29's skin concerns to the facility's attention. * R22's at risk for skin breakdown care plan does not include approaches to prevent pressure injuries to R22's heels and R22's heels were observed not being offloaded. * R6's at risk for skin breakdown care plan does not include approaches to prevent pressure injuries to R6's heels. * R19's pressure injury to her buttocks was not assessed timely by a RN. R26 and R29 are being cited at a scope/severity level of G (harm/isolated). Findings include: The Skin Care Policy & Procedure which is not dated under purpose documents To ensure that a resident entering the facility without pressure injuries does not develop pressure injuries unless the individuals' clinical condition demonstrates unavoidable skin breakdown. East Troy Manor will consider all residents as at risk for skin impairment and will implement the following interventions to prevent the development of pressure injuries: · Reduce occurrence of pressure over bony prominences to minimize injury · Protect against the adverse effects of external mechanical forces (pressure, friction, shear) · Increase the awareness of pressure injury prevention through educational programs East Troy Manor also recognizes even the most vigilant nursing care may not prevent the development and/or worsening of pressure injuries in some residents. In those cases, intensive efforts will be directed at the following: · Managing risk factors · Providing preventative interventions · Providing treatment 1.) Surveyor reviewed R26's medical record on 11/30/17 to 12/6/17. R26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R26's admission skin assessment dated [DATE] has no documentation for any skin impairment on R26's feet/heels. The at risk for skin breakdown care plan with a problem start date of 10/20/17 documents the following approaches: Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible with a start date of 10/20/17, Avoid shearing resident skin during positioning, transferring, and turning with a start date of 10/20/17, Conduct a systematic skin inspection with cares and on bath days. Pay particular attention to the bony prominence. Start date of 10/20/17 Diet as ordered by MD with a start date of 10/20/17 Encourage fluids q (every) shift with a start date of 10/20/17 Encourage physical activity, mobility, and range of motion to maximal potential with a start date of 10/20/17 Keep clean and dry as possible. Minimize skin exposure to moisture. Start date of 10/20/17 Keep linen clean, dry, and wrinkle free with a start date of 10/20/17 Report any signs of skin breakdown (sore, tender, red, or broken areas) with a start date of 10/20/17 Supplements PRN (as needed) with a start date of 10/20/17 and Use pressure reduction cushion when resident is in chair with a start date of 10/20/17. Surveyor noted there are not interventions regarding offloading or pressure relieving boots documented on R26's at risk for skin breakdown. The CNA (Certified Nursing Assistant) care card which is not dated and provided to Surveyor on 11/30/17 does not have any interventions regarding off loading R26's heels or wearing pressure relieving boots. The Braden assessment dated [DATE] has a score of 18. A score of 15-18 indicates at risk for pressure injury development. The nurses note dated 10/22/2017 documents, Resident alert and oriented, able to make needs known. Resident admitted for rehab, working with PT and OT. Resident pleasant and cooperative. Transfers with ext 1 assist and wheeled walker. Wheelchair for mobility. Resident has Dycem to wheelchair d/t (due to) recent fall, slipped from chair. Resident does have pressure area to buttocks, educated on importance of repositioning and relieving pressure to buttocks. Resident able to shift weight while in wheelchair. Resident denies pain or discomfort today. The admission MDS (minimum data set) with an assessment reference date of 10/27/17 documents a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R26 requires extensive assistance with two plus person for transfer & toilet use, and extensive assistance with one person physical assist for bed mobility. R26 is at risk for pressure injuries and is coded as having two Stage 2 pressure injuries. The pressure ulcer CAA (care area assessment) with a worksheet start date of 10/31/17 under analysis of findings documents resident is at risk for pressure areas and has a pressure area to coccyx resident seen by wound nurse will continue with care plan. The Braden assessment dated [DATE] has a score of 16. A score of 15-18 indicates at risk for pressure injury development. The nurse's note dated 11/02/2017 documents: Resident has a 1.5 x 1.5 cm pressure area noted to his right heel. No drainage or odor noted. Resident states that area hurts when being dressed. Surrounding skin peeling. Order received: Cleanse right heel with wound wash. Pat dry. Apply S/P to periwound. Apply Hydrogel to wound bed and change e/o (every other) day and PRN (as needed). Heel protector boot in place to heel. Resident currently takes Prosource protein powder to promote wound healing. Will continue to monitor. This note was written by LPN (Licensed Practical Nurse)-E. The telephone order dated 11/3/17 documents: cleanse o/a (open area) to (R) (right) heel with wound wash. pat dry. skin prep periwound apply hydrogel to wound bed cover with [MEDICATION NAME] change e/o (every other) day & prn (as needed) until healed. The nurses note dated 11/04/2017 documents: Resident is alert, able to make needs known. Resident on 24 hour board d/t (due to) behaviors/start of [MEDICATION NAME], no behaviors noted this AM. Resident attended therapy this AM. Dressing change done to pressure area to right heel. Resident complains of pain 8/10 to coccyx/bottom. PRN medication and repositioning effective for pain relief Resident has pressure reduction cushion for wheelchair and recliner, educated on importance of repositioning. VSS. (vital signs stable). Review of the wound section for the right heel which was identified on 11/2/17 and dated 11/8/17 documents: measurements of 1.5 cm (centimeters) length x 1.5 cm width. Stage 2. There is serosanguineous light exudate, the tissue type is granulation and the surrounding tissue pink. Surveyor noted this assessment was completed by DON (Director of Nursing)-B and the assessment was 6 days after R26's pressure injury was identified. Surveyor also noted R26's at risk for skin breakdown care plan was not revised. Wisconsin Chapter N6 entitled, Standards of Practice for Registered Nurses and Licensed Practical Nurses, specifies the minimum practice standards for which RNs and LPNs are responsible and clarifies the scope of practice for RNs and LPNs. N6.03 Standards of practice for registered nurses (1) states, General Nursing Procedures. An RN shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to LPNs or less skilled assistants . N6.04 Standards of practice for licensed practical nurses (1) Performance of acts in basic patient situations. In the performance of acts in basic patient situation, the LPN shall, under the general supervision of an RN or the direction of a provider: (a) Accept only patient care assignments which the LPN 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 LPN knows or should know a delegated act may harm a patient. (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. An RN's role is to perform a patient assessment and analyze the data collected during the assessment. An RN would plan interventions and change current nursing interventions as needed with the ultimate goal as the promotion and healing for the patient. On 11/15/17 R26's right heel continues to measure 1.5 cm length x 1.5 cm width with bloody light exudate, there is granulation tissue, and the surrounding tissue pink. There is no stage documented. On 11/22/17 R26's right heel measurements are 3 cm length x 3 cm width. The Stage is unstageable The tissue type is slough 100%, there is no exudate and the surrounding tissue is pink. The wound healing status documents declining. Surveyor noted there is a change in the treatment but there is no revision in R26's at risk for skin breakdown care plan. The telephone order 11/22/17 documents: d/c (discontinue) current tx (treatment) to right heel cleanse rt (right) heel oa (open area) with wound cleanser skin prep peri wound apply Santyl to slough of wound bed cover with [MEDICATION NAME] every day and prn until resolved. The nurses note dated 11/27/2017 documents: Resident continues on [MEDICATION NAME] at HS (hour sleep). No adverse reactions noted. Resident alert and very friendly with staff. Consumed 100% of his breakfast and asked for seconds. Dressing changed to right heel. Area improving. Slough diminishing to center of wound bed. Skin prep applied to peri wound. Pink granulation tissue present around slough of wound bed. Santyl applied to slough area of wound bed. Covered with [MEDICATION NAME]. Scant amount of yellow drainage present on dressing. Prevalon boot in place. Will continue to monitor. On 11/29/17 R26's right heel measures 3 cm length x 3 cm width, there is no depth documented with serosanguineous light exudate. The Stage is unstageable 90% slough with the surrounding tissue pink. The wound healing status documents stable. On 11/30/17 at 11:08 a.m. Surveyor observed R26 in bed on his left side. R26 is wearing blue Prevalon boots and has an air mattress on his bed. Surveyor asked R26 why he was wearing the blue boots. R26 replied, You don't know I have ulcer on my heel? R26 also informed Surveyor he has one on his butt which hurts and that's why he is laying down on his side. R26 informed Surveyor that they said his heel is draining off but doesn't know about his butt. On 11/30/17 at 3:00 p.m. Surveyor observed R26 in bed on right side. R26 has a pressure relieving boot on left foot. The right heel has dressing on heel. R26 showed Surveyor his right inner ankle with an unstageable eschar pressure injury. On 11/30/17 at 3:09 p.m. Surveyor asked R26 how long he has had pressure ulcer on his right inner ankle. R26 replied about three days, they haven't done anything for it. Surveyor asked if staff did a treatment today. Resident replied, No, not since got it. Surveyor also noted on the right heel next to dressing on inner aspect is an additional unstageable pressure injury and R26's heel resting directly on mattress. The telephone order dated 12/1/17 documents: s/p (status [REDACTED]. The nurses note dated 12/01/2017 documents: New treatment ordered for right medial ankle bone: Apply skin prep to medial ankle bone for protection. Cover with [MEDICATION NAME] and change Q 3 days. Order processed. On 12/04/17 at 3:34 p.m. Surveyor observed R26 sitting in wheelchair in room with tv on. R26 has a pressure relieving cushion in his wheelchair and has Prevalon boots on. Surveyor asked R26 when staff does treatment for [REDACTED]. R26 replied, Oh sure. Surveyor asked R26 how he developed the pressure ulcers. Resident stated he didn't know. Surveyor asked R26 if he wore the blue Prevalon boots before he had the pressure ulcers. R26 informed Surveyor after. On 12/05/17 at 7:16 a.m. Surveyor observed R26 in bed slightly on left side. R26 has only a Prevalon boot on his left foot and the right heel is resting directly on a pillow. R26's right heel is not being offloaded. On 12/05/17 at 8:00 a.m. Surveyor observed R26 continues to be in bed slightly on his left side. The head of the bed is elevated up high and R26's right heel continues to be resting directly on a pillow and is not being offloaded. On 12/05/17 at 8:33 a.m. Surveyor reviewed the wound management section and was unable to locate an assessment for R26's right medial ankle pressure injury that Surveyor observed on 11/30/17. On 12/05/17 at 8:48 a.m. Surveyor observed CNA (Certified Nursing Assistant)-F in R26's room telling R26 she is going to take off his boot and pants. R26 stated that this one has been hurting all night referring to his right heel. CNA-F removed the Prevalon boot from R26's left foot and pants. While CNA-F was removing these items, R26 told CNA-F to be careful. CNA-F then removed her gloves and washed her hands. On 12/5/17 at 8:52 a.m. Surveyor observed the treatment for [REDACTED]. LPN-E informed R26 she was going to get things set up, removed the garbage can and mat from the side of the bed and cleansed her hands. R26 showed Surveyor an unstageable pressure ulcer on his heel and informed Surveyor it's suppose to be nursed. LPN-E cleaned the over bed table with a wipe. R26 asked LPN-E if she was going to do his left foot. LPN-E replied, I'm doing your right heel but I can check. R26 stated the doctor says it's suppose to be nursed. LPN-E placed her treatment supplies on the over bed table and R26 asked LPN-E if she doesn't do the left foot who does. LPN-E went into the bathroom washed her hands. LPN-E raised the height of R26's bed, informed R26 she was going to do the treatment on his foot first, and removed the pillows from R26's bed. LPN-E opened treatment supplies, cleansed her hands, and placed gloves on. LPN-E removed the dressing from R26's right heel, removed her gloves and cleansed her hands. LPN-E placed gloves on and cleansed the wound bed with wound wash. LPN-E placed Santyl on a cotton applicator, placed the Santyl on the slough in the wound bed of R26's right heel pressure injury and applied skin prep around the peri wound. LPN-E removed her gloves, cleansed her hands, and covered R26 right heel pressure injury with a bordered [MEDICATION NAME] dressing. LPN-E removed her gloves, dated the dressing, and lowered the bed down. LPN-E placed a sock on R26' right foot, looked at the left heel stating she will have DON-B measure it & get a treatment and then placed a sock on R26's left foot. LPN-E went into the bathroom and washed her hands. The nurses note dated 12/05/2017 documents: Writer provided wound care to resident this shift. Dressing was changed to resident's right heel. Yellow drainage and slough noted to center of dressing when removed. Peri wound remains pink and small amounts of dry flaky skin. Santyl applied to the slough remaining in the center of his wound. Peri wound skin prepped. [MEDICATION NAME] was applied to cover wound. Dressing changed to coccyx this shift. Area was cleansed and pat dried. Hydrogel was placed to wound bed. Skin prep applied to periwound. [MEDICATION NAME] was put in place to cover. Writer complained of pain to his left heel. A scabbed impaired area was noted to left heel. Wound care nurse/DON was given update. Resident's wound will be assessed when he returns to his bed post lunch. POA (power of attorney) was given updated a new TX (treatment) will be ordered. Will continue to monitor. On 12/05/17 at 11:54 a.m. Surveyor asked LPN-E where surveyor would find diabetic foot checks. LPN-E informed Surveyor she would probably would say treatments but it would be general. LPN-E explained that the Facility used to have in their paper MARs (medication administration record) for lower extremities, wash, dry, lotion and check feet. LPN-E looked in the computer and informed Surveyor she doesn't personally see one. Surveyor asked if diabetic foot checks are done. LPN-E informed Surveyor we do especially if the Resident has impaired skin. On 12/05/17 at 12:04 p.m. Surveyor informed LPN-E R26's right heel pressure injury was identified on 11/2/17 and inquired why there wasn't an assessment until 11/8/17. LPN-E explained DON-B does wound rounds. LPN-E informed Surveyor wound rounds are on Wednesday and the 8th would have been the next time DON-B rounded. Surveyor then inquired why the right ankle treatment was started on 12/1/17 and not 11/30/17 when Surveyor observed the pressure injury. LPN-E informed Surveyor she wasn't aware of the pressure injury and she first became aware on 12/1/17 she noted a black scratch line by his grippy socks. LPN-E indicated she spoke with DON-B who informed her to put on a dressing for protection. Surveyor inquired if DON-B assessed this pressure injury. LPN-E informed Surveyor she didn't know but she informed DON-B of R26's pressure injury on his left ankle. LPN-E informed Surveyor today is the first day she had noted this pressure injury and there is nothing in the wound section about the left ankle. Surveyor inquired who develops the plan of care as there aren't any interventions regarding pressure relieving boots or offloading R26's heels. LPN-E informed Surveyor that would be a DON-B or MDS (minimum data set) Coordinator-M question. Surveyor asked LPN-E when R26 started wearing the Prevalon boots. LPN-E informed Surveyor she believes R26 received the boots after he developed the right heel pressure injury. On 12/05/17 at 12:42 p.m. Surveyor met with DON-B. Surveyor inquired what happens when a Resident is discovered with a pressure injury. DON-B informed Surveyor the nurse should fill out an event form and she will look at it. DON-B informed Surveyor if she is not in the building the nurse should measure the pressure injury and put the information in the computer. Surveyor informed DON-B R26's right heel pressure injury was identified on 11/2/17 and there is no RN assessment until 11/8/17, six days later. DON-B informed Surveyor LPN-E found the pressure injury on a Thursday and she measured it on the following Wednesday. Surveyor asked DON-B if this was the first time she saw R26's pressure injury. DON-B informed Surveyor she may have seen it but didn't document. Surveyor asked DON-B if she assessed R26's right medial ankle which Surveyor observed on 11/30/17 and staff identified on 12/1/17. DON-B informed Surveyor she hasn't seen it. Surveyor informed DON-B Surveyor was unable to locate any assessment for this unstageable pressure injury. On 12/5/17 at 3:42 p.m. Administrator-A and DON-B were informed of the above. On 12/6/17 at 1:01 p.m. Surveyor reviewed the wound management section of R26's medical record and noted DON-B's assessment of R26's left heel lateral documents date observed 12/5/17 with measurements of 3 cm (centimeter) times 2 cm, no exudate and this pressure injury is staged as unstageable. 2.) R29 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R29's Change in Status MDS (Minimum Data Set) assessment, dated 11/09/17, indicates that R29 is at risk for development of pressure injuries. BIMS (Brief Interview of Mental Status) score of 15 indicates R29 is cognitively intact. No behavior concerns are documented. The Facility Roster Matrix dated 11/30/17 does not indicate R29 is at risk for pressure injuries or has any new or worsening pressure injuries. R29's Care Plan, dated 5/26/17, with target date of 2/26/18, states that resident is at risk for pressure ulcers due to friction and shear; resident at risk for pressure ulcer due to activity and chair fast. Cleanse left bunion with normal saline, apply skin prep around bunion; [MEDICATION NAME] to bunion and cover with [MEDICATION NAME] dressing, change PRN (as needed). Monitor and leave open to the air scabbed area to top of left foot every shift until resolved. Every shift; night, day and evening apply [MEDICATION NAME] topically to bilateral lower extremities daily. Long term goal: Intact skin without evidence of redness, irritation, maceration or open areas. Approaches: minimum of 2 people plus draw sheet to lift resident while in bed; resident to assist as much as possible by using positioning drag areas at top of Adriatic bed; consider postural alignment, weight distribution, balance stability, and pressure relief when positioning in chair or wheelchair; consider Physical Therapy consult for conditioning and wheel chair assessment; consider specialty chair pad; skin assessment weekly with close attention to heels; teach or do frequent small shifts of body weight. On 11/17/17 R29's Bath Shower Skin Audit documents, no new skin issue findings. On 11/21/17 R29's Bed Shower Skin Audit documents, no new skin issue findings. On 11/23/17 R29's Bed Shower Skin Audit documents, no new skin issue findings. On 11/28/17 R29's Bed Shower Skin Audit documents, red spots located on the front and back of upper thigh area. Surveyor could not locate any information in the medical record addressing the new reddened areas, reason for the area or treatment of [REDACTED]. On 12/1/17 R29's Bed Shower Skin Audit documents, no new skin findings. On 11/30/17 at 10:20 AM R29 informed Surveyor of his concerns with his foot that is bandaged and that his back side is sore and bloody. R29 showed Surveyor the soiled dressings from his foot in the garbage can, in the room and the blood streaks on the toilet which he reported were from his bottom. R29 stated everyone does the treatment to his foot differently. Some keep it open to air and some bandage it and staff tell him that he doesn't have any skin issues with his bottom but he believes he does due to the blood streaks on the toilet seat. Surveyor observed that R29 was leaning forward in the wheelchair, using his foot and a rocking motion to move the wheelchair towards the garbage can to allow Surveyor to visualize the soiled foot dressing. Again, R29 used his foot and a rocking motion to move his wheelchair forward to open the bathroom door to allow Surveyor to visualize the blood streaks on the toilet seat. Surveyor noted this motion could cause shearing. On 11/16/17 at 3:51 PM R29's medical record documents, staff called to (R29's) room to assess buttock/back of thigh area related to (R29) believing there is an open area. Areas of buttocks and bilateral thighs assesses and no open areas noted. Slight blanchable redness noted to right lower back of thigh area, appears to be from cushion that (R29) has in wheelchair rubbing. Zinc Oxide barrier cream applied to buttocks and back of bilateral thighs. (R29) informed that there are no open areas. (R29) became upset because nobody believes him. (R29) using a paper towel on top of the Zinc to his right thigh area; stating it helps relieve pain. Staff educated (R29) that the use of paper towels is not a good idea and gauze should be used if he wants an added protective layer and nursing would assist with that. Surveyor was unable to locate any documentation that staff assessed (R29's) wheelchair cushion options to reduce rubbing on the thigh area or that gauze was provided. On 12/4/17 at 4:10 PM Surveyor spoke with Director of Nursing (DON)-B about the pressure injury on R29's foot. DON-B informed Surveyor that the Matrix program (facility's electronic medical records program) requires staff to documented the area as a pressure injury even though it is not. DON-B explained that if you want to track and measure an area it has to be documented as pressure even if it isn't. DON-B informed Surveyor the area on R29's foot is not pressure but when resident transferred from the toilet his bunion area scrapped on the floor causing the skin to peel away. (R29 does not wear socks or shoes). A treatment is ordered due to the skin being removed when his foot scraped across the floor. Surveyor also asked for further information about R29's expressed concern for bleeding areas on his bottom. DON-B informed Surveyor a barrier cream is being applied to his bottom as preventative measures. R29 continues to put brown paper towels over the barrier cream because he doesn't want it to rub off on his hospital gown. When the staff assist with washing up the paper towels act as sand paper and rub the area and stick to the skin causing part of the skin to pull off and bleed a small amount. Staff has provided education to R29 about the poor practice but he continues to do so. R29 is also in the process of discharge planning and wants an air mattress for the new facility. DON-B states R29's insurance company states he is not eligible for the mattress since there are no skin issues that would warrant an air mattress. DON-B informed Surveyor that R29 has exhibited self injurious behavior to his bottom area in the hope that his insurance company will approve the air mattress. Surveyor was unable to locate documentation in the plan of care addressing R29's self injurious behavior. (Cross-reference F656.) DON-B also informed Surveyor that she would be assessing R29's skin tomorrow; 12/5/17. R29's Wound Management, Wound Information dated 12/5/17 documents: 4 stage 2 open areas on the left buttock and two stage 2 open areas to the right buttock. The four areas on the left buttock measure: 0.5 cm (centimeters) by 0.5 cm; 0.8 cm by 2 cm; 1.8 cm by 2.5 cm and 3.5 cm by 2 cm. The 2 open areas on the right buttock measure: 5 cm by 6 cm and 2 cm by 1 cm. At this time a new order was received for treatment to the open areas to include; cleanse open areas to right and left buttock with normal saline. Apply skin prep to periwound, apply hydrogel to wound bed; cover with ABD pad and secure. Change daily and as needed. R29's plan of care was updated on 12/5/17 to included the new treatment to the right and left buttocks. 12/06/17 at 09:05 AM Surveyor observed the dressing change to the open areas on R29's posterior noting the open areas are not on R29's bottom as informed and documented; they are actually on R29's bilateral, posterior thighs. RN-C informed surveyor that the open areas on bilateral, posterior thighs occurred due to shearing. Surveyor verified with RN-C that R29 now has 7 scattered open areas to the upper left thigh that are Stage 2. The wound bed areas are pinkish red. RN-C also confirmed R29 now has 6 scattered open areas to right upper posterior thigh. The wounds are Stage 2's with the wound beds on areas described as pinkish red. Surveyor's observation now records a total of 13 stage 2 scattered open areas on R29's posterior upper right and left thighs when wound documentation from 12/5/17 only documents a total of 6 areas. Surveyor was unable to locate any documentation of new interventions put into place to prevent further pressure injuries due to shearing. R29 was assessed to have 13 stage 2 pressure injuries to the bilateral, posterior thighs after Surveyor told facility of residents expressed concern for skin issues that were not previously identified. On 12/6/17 at 3:00 PM Surveyor informed Administrator-A and DON-B of the above concerns. No further documentation was provided as to why the facility did not prevent the development of pressure injuries to a resident that was assessed at risk for the development of pressure injuries. 3.) Surveyor reviewed R22's medical record on 11/30/17 to 12/6/17. The at risk for skin breakdown care plan with a problem start date of 2/5/16 documents approaches of Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. with a start date of 2/5/16, Conduct a systematic skin inspection weekly. Monitor skin for changes daily with cares and dressing. Pay particular attention to the bony prominences. with a start date of 2/5/16, Encourage physical activity, mobility, and range of motion to maximal potential. with a start date of 2/5/16, Keep clean and dry as possible. Minimize skin exposure to moisture. with a start date of 2/5/16, Keep linen clean, dry, and wrinkle free. with a start date of 2/5/16, Supplements: as indicated. See dietary notes. with a start date of 2/5/16, and Use w/c (wheelchair) cushion for pressure reduction when resident is in chair. with a start date of 2/5/16. R22's care plan does not include any approaches to offload R22's heels or pressure relieving boots. The CNA (Certified Nursing Assistant) care card which is not dated and provided to Surveyor on 11/30/17 does not have any interventions regarding off loading R22's heels or wearing pressure relieving boots. The quarterly MDS (minimum data set) with an assessment reference date of 10/24/17 documents R22 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R22 requires extensive assistance with one person physical assist for bed mobility, requires extensive assistance with two plus person physical assist for transfers and does not ambulate. R22 is at risk for pressure injuries and is coded as not having any pressure injuries. The Braden assessment dated [DATE] has a total score of 15. A score of 15-18 indicates at risk for pressure injury development. On 12/04/17 at 7:32 a.m. Surveyor observed R22 on her left side with knees flexed. Surveyor observed R22's heels not being offloaded. On 12/05/17 at 7:21 a.m. Surveyor observed CNA (Certified Nursing Assistant)-F and Hospice CNA-G in R22's room. Surveyor reintroduced self asked permission to observe cares. Hospice CNA-G washed her hands then placed gloves on. CNA-F placed gloves on. CNA-F informed R22 she was going to put her gripper socks on, CNA-F then removed the bedding and placed gripper socks on R22. Surveyor observed R22's heels were resting directly on mattress. Hospice CNA-G sat R22 on the edge of bed and an EZ stand lift was placed in front of R22. R22's legs were buckled in and the sling was attached to the lift. R22 was raised up off the bed and Surveyor checked R22's buttocks. No open areas or redness was observed. R22 was then transferred into a shower chair. <br (TRUNCATED)

Based on record review and interviews, facility staff did not provide 1 of 11 Residents with treatment and services to attain their highest practicable level of physical well-being. Resident #11 was not provided pain management in accordance with current standards of practice. Findings include: 1.) Surveyor # reviewed Resident #11's closed medical record. Resident #11 was admitted to the facility 4/23/14 with [DIAGNOSES REDACTED]. A "Clinical Admission Documentation" form completed for Resident #11 on admitted d 4/23/14 states Resident #11 has "No Pain." Resident #11's Initial MDS (Minimum Data Set) dated 4/30/14 indicates Resident #11 reported frequent moderate pain that limits her day-to-day activities. Resident #11 did not receive any scheduled pain medication or non-medication interventions for pain in the previous 5 days, but did receive PRN (as needed) pain medication for her pain. Resident #11's Pain CAA (Care Area Assessment) dated 4/30/14 notes Resident #11 has limited her day-to-day activities due to pain, and reported frequent moderate pain over the past 5 days. Related [DIAGNOSES REDACTED]. "Characteristics of pain", "Location", "Type of pain-constant, intermittent, varies of time, etc.", "What makes it better", "What makes it worse", "Words that describe it", "Supporting documentation", "Frequency and Intensity", "Time or situation of onset", and "How long it lasts" are all left blank. "Pain effect on function", "Adversely affects mood", "Limits day-to-day activities" and "Limits independence with at least some Activities of Daily Living" are checked as affecting Resident #11 on Resident #11's CAA. "Associated signs and symptoms" is marked "none of the above", even though "agitation" is one of the options listed and staff mention agitation in Nurses' Notes and on the PRN [MEDICATION NAME] form when administering a PRN (as needed) medication. The CAA Notes "Other Considerations" and staff checked "Immobility" and "Insufficient pain relief (from resident/staff interview, clinical record, direct observation)." "Analysis of findings" states "Resident with chronic back pain worsened since recent fall and subsequent hospital stay. Resident indicates pain is controlled fairly well with current pain management regimen. Will address pain control needs with plan of care." Resident #11's Plan of Care dated 5/13/14 indicates Resident #11 has Pain/Alteration in Comfort related to chronic pain in back and history of fall at home with rhabdomyolysis. The care plan asks what an acceptable level of pain is for Resident (#11) and staff circles "mild." The care plan goals are: Resident will have amelioration of immediate pain; Resident will not exhibit any non verbal signs and symptoms of pain; Resident will not have a functional decline related to pain. "Approaches" include: Administer pain medication as ordered; attempt to use non-pharmacuetical interventions to alleviate discomfort, i.e. smooth linen, assist with position change, reassure resident, encourage mobility/physical activity if this relieves pain; contact physician for further orders if pain is not relieved by current pain management measures; discuss concerns regarding pain medication with resident and family; monitor for signs and symptoms of pain every shift; Offer [MEDICATION NAME] if resident's pain is above the acceptable/tolerable level of pain; Observe for signs and symptoms of pain during activities, procedures, therapy. Resident 11's Physician order [REDACTED]. -Monitor for s/s (signs and symptoms) of pain every shift; -[MEDICATION NAME] 325 mg. (milligrams)-give two tablets PO (by mouth) Q (every) 4 hours as needed for pain/fever; -[MEDICATION NAME] 500 mg. tablet -Take 1,000 mg. PO every 6 hours as needed for pain; -[MEDICATION NAME] 5/325 (5 mg. [MEDICATION NAME] with 325 mg. [MEDICATION NAME])- Take one tablet PO every 6 hours as needed for pain; -[MEDICATION NAME] 50 mg. -Take one tablet PO every 6 hours as needed for pain. [MEDICATION NAME] is also referred to as APAP and/or Tylenol. Resident #11 also had orders for [MEDICATION NAME] ([MEDICATION NAME]) 25 mg. -Take one tablet PO three times daily as needed. ([MEDICATION NAME] is used to treat itching). On 4/29/14 staff obtained orders for [MEDICATION NAME] 25 mg. at HS (bedtime/hour of sleep) and Loratidine 10 mg. every morning - both for puritis (itching). On 5/5/14, the MD (Medical Doctor)-C was in to see Resident #11 and discontinued the PRN (as needed) [MEDICATION NAME] and Loratidine; and start [MEDICATION NAME] 25 mg. scheduled three times a day, and [MEDICATION NAME] 25 mg. every 4 hours as needed for itching. MD-C's note on 5/5/14 notes Resident #11 was in the hospital for falls, lower back and coccyx pain...Also has chronic puritis...Main concern today coccyx pain and chronic puritis. The Assessment notes "chronic puritis without objective findings, metastatic [DIAGNOSES REDACTED]type 2 diabetes and dementia. Plan- schedule [MEDICATION NAME], PRN [MEDICATION NAME], If puritis still a problem, add [MEDICATION NAME]. Accu-checks- doing well without oral medication. (The assessment and plan do not mention Resident #11's coccyx pain). Surveyor # reviewed Resident #11's Nurses' Notes which include: APRIL 4/25/14 12:19 p.m. "...Resident complained of pain in her tailbone. Received [MEDICATION NAME] and 50 mg. APAP, which she said was helpful, but pain still present. Order for [MEDICATION NAME] ([MEDICATION NAME]/APAP) noted also, but Resident states pain is at an acceptable level so far..." 4/26/14 10:47 a.m. "...is somewhat agitated today saying her periarea burns. It is slightly red and Medseptic (barrier cream) applied. She was also saying her upper inner thighs are burning too although they are not red at all..." 4/27/14 11:04 a.m. "...Resident also complaining of pain in her coccyx. Refused to get up for most of the morning until after her pain went away. Administered [MEDICATION NAME] 50 mg. as well as 2 Tylenol. After about 1/2 hour Resident stated her pain was at a more acceptable level and agreed to let CNA (Certified Nursing Assistant) perform cares and get her up for breakfast. Peri-area cleansed and Zinc Oxide cream applied as ordered. Spoke with Pharmacy this morning regarding Resident's order for [MEDICATION NAME] /APAP, which has not arrived yet. Awaiting call back from Pharmacist. Resident ate breakfast in her room this a.m., seems to be in a better mood, less anxious and more comfortable at this time." 4/27/14 11:19 a.m. "Received call back from Pharmacy with Authorization code to obtain 4 [MEDICATION NAME] 5/325 mg. from contingency." 4/27/14 12:24 p.m. "Resident continues to exhibit anxiety/agitation on night shift and in early morning. Resident has verbally expressed experiencing feelings of moderate anxiety at times. Will update MD..." 4/28/14 2:12 p.m. "...C/o (complained of) tailbone pain. [MEDICATION NAME] given and effective. 4/29/14 1:18 p.m. "...Continues to complain of pain in her coccyx area. [MEDICATION NAME] and Tylenol administered for pain and have been effective..." Surveyor # reviewed Resident #11's PRN [MEDICATION NAME] Record/Pain Flow Sheet for April 2014 and noted staff made 10 entries from 4/24/14 through 4/30/14. Nine of the 10 were for pain ratings of 7 on a scale of 0-10, though on 4/25 at 7:15 a.m., 4/27 at 8:30 a.m., 4/29 at 7:30 a.m. and 4/30 at 9:00 a.m., the [MEDICATION NAME] and [MEDICATION NAME] are given at the same time and staff documented the same rating for both medications. The facility Pain Scale shows a rating of 7-10 indicates severe pain. The other rating was a 5- moderate pain. All 10 entries document Resident #11 verbalized her pain, and five of those 10 also indicated Resident #11 was agitated. Nurses only record Results/ pain relief ratings for one of the 10 PRN medication administrations (Resident #11 had rated her pain a "5"; it improved to a "2.") No effectiveness ratings/ pain relief was assessed for the nine times Resident #11 rated her pain as severe (7/10). Only one PRN medication was given outside of 7:15 a.m.- 9:00 a.m., according to the PRN/Pain Flow Sheet (4/24 at 3;10 p.m.). Nurses documented non-pharmacologic interventions of positioning and distraction were used. For a rating of "7", on 4/24 the nurse administered one [MEDICATION NAME], while the other times Resident #11 rated her pain as a "7", a different nurse gave her [MEDICATION NAME] plus two Tylenol all at the same time. In addition, not all the instances of PRN pain medication administration are recorded on the PRN [MEDICATION NAME] Record/ Pain Flow Sheet. For example, the Nurses' Notes (above) document Resident #11 received [MEDICATION NAME] on 4/28/14, but there are no entries on the PRN/Pain Flow sheet at all for 4/28. If staff assess a Resident's use of PRN medications by looking at the Flow Sheet, they would not have an accurate picture of how many PRN's the Resident takes if the documentation is not complete. The [MEDICATION NAME] is initialed on the front of the MAR (Medication Administration Record), but no pain rating is documented. Also, where nurses document on Resident #11's pain every shift on the front of the MAR, 4/28 shows Resident #11 had no pain, but the Nurses' Notes document complaint of tailbone pain and [MEDICATION NAME] given. Surveyor # reviewed Resident #11's Controlled Drug Record for the [MEDICATION NAME] which indicates almost all (18 out of 24 administrations of [MEDICATION NAME]) were given between 7:30 and 8:30 a.m. from 4/24/14 through 5/26/14. No [MEDICATION NAME]/APAP was documented as given in April, though four were approved to be taken from contingency on 4/27/14. MAY Nurses' Notes: 5/3/14 11:11 a.m. "Resident complained of pain in her tailbone this morning at breakfast, received a [MEDICATION NAME] and 2 Tylenol for pain. Upon re-assessment, medication was not effective and Resident beginning to agitated about the pain in her tailbone. Nurse assessed, Resident was angry, balling her fists and shaking/trembling. Resident was agitated, stating "It itches all over!" despite recent initiation of [MEDICATION NAME] and Loratidine scheduled. Resident would flail her hands in the air and shout "Oooo, I'm shaking all over!" Nurse administered one [MEDICATION NAME] ([MEDICATION NAME]/APAP) 5/325 for discomfort, will monitor for effectiveness..." 5/4/14 6:30 p.m. "...Complained of pain in her tailbone. Received one [MEDICATION NAME] 5/325, which has been effective." 5/6/14 1:20 p.m. "...Resident also received [MEDICATION NAME] 50 mg. as well as Tylenol for pain in her tailbone, which has been effective." 5/18/14 1:44 p.m. "Resident complained of pain in her tailbone this morning around 9:00 a.m. Was given [MEDICATION NAME] and Tylenol. This was effective for a couple of hours. Resident layed in her bed for a while and was comfortable. Resident became agitated around 11:00 a.m., was yelling and shaking, stating that she was in pain and her "crack burns!" and yelling "Oh I can't stand the itching! I can't stand it!" Resident was flailing her arms around. Administered one [MEDICATION NAME] ([MEDICATION NAME]/APAP) for pain along with scheduled [MEDICATION NAME] ate in dining room and stated her pain was much better shortly after." 5/20/14 12:12 p.m. "Resident complained of pain in her tailbone this morning, stated she was very uncomfortable and that it hurt and burned. Administered 1 [MEDICATION NAME] 5/325, which was effective upon re-assessment." The only Nurses' Notes after 5/20/14 is a note on 5/22/14 regarding a discharge planning meeting held on 5/21/14, until 5/30/14 when the note indicates Resident #11 was discharged from the facility. However Surveyor # reviewed Resident #11's Controlled Drug Record for the [MEDICATION NAME]/[MEDICATION NAME] (referred to by staff as [MEDICATION NAME] and [MEDICATION NAME]). This record indicates Resident #11 received the PRN [MEDICATION NAME]/APAP twice on 5/21/14-(1:15 a.m. and 8:30 a.m.), once on 5/22 (8:30 a.m.), twice on 5/23-(8:30 a.m. and 11:00 p.m.), and daily from 5/24 through 5/30 between 7:30 a.m. and 8:30 a.m. Twelve of eighteen tablets (two-thirds) were given between 7:30 a.m. and 8:30 a.m. Resident #11 continued to receive [MEDICATION NAME] between 5/20 and 5/30, too, but Nurses' Notes do not mention the need for continued PRN pain medication. Surveyor # reviewed Resident #11's PRN [MEDICATION NAME] Record/Pain Flow Sheet for May 2014. Nurses made 39 entries on the flow sheet, though five of the entries are paired entries- one line for [MEDICATION NAME] and and one line/entry for the APAP/Tylenol given at the same time. Resident #11 received PRN medication at 34 separate times in May 2014. Sixteen times Resident #11 reported her pain as 5-6 (moderate pain); eighteen times Resident #11 reported her pain as 7-9, (severe). There was no consistent pattern for what medication nurses administered to Resident #11 based on her pain rating. Sometimes when Resident #11 rated her pain as a 5 or 6 (moderate), she was given the [MEDICATION NAME], while other times when she rated her pain 7, 8 or 9 (severe) she was given [MEDICATION NAME], sometimes with Tylenol and sometimes without, and at other times Resident #11 was given [MEDICATION NAME]/APAP for severe pain. For example, on 5/3 Resident #11 verbally reported pain of "5" (moderate) on a 0-10 scale and received [MEDICATION NAME] and APAP; on 5/5 Resident #11 reported pain level of "5" and received only APAP; and on 5/22 and 5/23 Resident #11 reported pain level of "5" and received [MEDICATION NAME]/APAP. Either a "+" sign or "effective" was documented for only half of the administrations. If Resident #11 was able to rate her pain prior to administration of PRN pain medication, it may be helpful for staff to document the pain rating post-administration to assess the amount of relief she is getting from the different medications. When effectiveness is documented as noted, it is always one hour after administration, so that information does not inform staff as to how long the pain relief lasts for Resident #11. At least one of the Nurses' Notes documented the [MEDICATION NAME] was not effective after two hours. Surveyor # reviewed a "Pain Management -Pain Observation for Cognitively Aware" assessment completed for Resident #11 on 5/13/14, three weeks after Resident #11's admission to the facility. The assessment states Resident #11 is independent with cognitive skills for daily decision-making, decisions are consistent and reasonable. Resident #11 was not currently expressing pain, and [MEDICATION NAME] are used to control pain. The form asks if the Resident had pain or was hurting in the past 5 days- the answer is "No" (though the Control drug Record shows Resident #11 received [MEDICATION NAME] on three of the five days, plus Tylenol.) The assessment indicates Resident #11 expresses pain through anxiety; has moderate, aching pain occasionally, it comes and goes- usually in the evening, [MEDICATION NAME] are effective along with rest, and contributing factors are history of [DIAGNOSES REDACTED] and [DIAGNOSES REDACTED]. (Note: Every time staff document the location of Resident #11's pain it has been to her "tailbone", which is not mentioned; Resident #11's melanoma is on her left arm and hip. The vast majority of the PRNs used are when Resident #11 gets up in the morning.) In a section asking staff to "Describe [MEDICATION NAME] ordered, dose, frequency, etc.", they listed Resident #11's PRN pain medication orders, but staff did not assess how often Resident #11 was requesting PRN pain medication, how effective each medication was and for how long it was effective, when staff should use what medication (for example- Tylenol for mild, [MEDICATION NAME] for moderate and [MEDICATION NAME]/APAP for severe)- since different staff gave different medications for the same pain rating. No documentation was located in the record indicating staff assessed Resident #11's use of PRN pain medication (requested daily, often upon rising), considering how many times she reported moderate and severe pain in the 6 weeks she resided at the facility, and discussed interventions that may prevent Resident #11's pain from getting to moderate and severe levels. The care plan indicated Resident #11's goal for pain relief is "mild pain", but Resident #11 had numerous, repeated reports of moderate and severe pain without staff reassessing Resident #11's pain management regimen. On 6/12/14 Surveyor # asked DON (Director of Nursing)-B: -If there was any additional information showing what PRN [MEDICATION NAME] nurses should use when Resident #11 reported pain? - noting different nurses gave different medications for the same pain rating, including one nurse who repeatedly gave [MEDICATION NAME] with two Tylenol even though there was no documentation indicating why she did this or if that was effective or why the other nurses did not administer the medications that way; -Was the effectiveness and duration of effectiveness assessed for the various pain medications? -Did anyone look at the patterns of PRN pain medication usage (almost always in the morning when she got up) to consider interventions to prevent Resident #11's pain from getting to the moderate and severe level of pain when it is harder to control, such as possibly scheduling around-the-clock dosing of medication? -Were non-pharmecuetical interventions discussed with Resident #11 such as cold, heat, etc., as nurses document only positioning and distraction as non-pharmacologic interventions? (Resident #11 is noted to need only limited assistance with bed mobility on the Inital MDS dated [DATE].) No additional information was provided regarding these concerns. Surveyor # reviewed the facility's Policy "Pain Program" effective 4/23/2004 and most recently updated 3/2009. The Policy states: Policy: It is East troy Manor Inc. policy to keep residents as pain free and comfortable as possible for optimum care and resident independence. All residents have the right to appropriate pain management. Procedure: 1. Complete a pain data tool upon admission within the first 24 to 48 hours for baseline information and review/complete again within the initial assessment period. 2. All residents will be monitored for the presence, absence or history of pain on admission, quarterly, with a significant change in status using the Pain Data Tool. 3. All Residents will be monitored daily for any signs and symptoms of pain. 4. A pain/[MEDICATION NAME] flow sheet/record will be used for all residents who have any PRN pain medication orders. 5. If increase need for pain management noted from PRN pain/[MEDICATION NAME] record, inform attending MD and obtain order for pharmacological and/or non-pharmacological interventions. 6. Initiate and/or update care plan to include type of pain requiring monitoring including pain management plan and a measurable goal related to the management plan. 7. Educate residents and families regarding pain management and medication as indicated. No additional information was provided.

Based on record review and interview, the facility did not ensure the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents. The facility did not ensure Certified Nursing Assistant (CNA)-P used the Apollo tub chair safely for 1 of 1 residents (Resident #1); the facility did not implement interventions including adequate supervision for for 5 (Resident #3, Resident #4, Resident #5, Resident #8 and Resident #9) of 9 residents, with repeated incidents of falls/accidents. Findings includes: Apollo Tub 1) The significant change in condition dated 9-15-11 and quarterly update to the MDS dated [DATE] indicates Resident #1 is cognitively intact and requires extensive assistance from one staff member with her bathing needs. The facility submitted a self-report to the Division of Quality Assurance (DQA) on 5-18-12 that documents Resident #1 fell on [DATE] from the Apollo bath tub chair; CNA-P was assisting the resident while transferring her from the chair to the wheelchair. According to the investigation documents, an inspection of the bath tub and chair was conducted immediately and concluded there to be no malfunction with the tub or the chair; instead the resident incident occurred because CNA-P did not lock the brakes on the base of the tub chair. During the transfer from the tub chair Resident #1 and the tub chair "tipped backward;" Resident #1 sustained a laceration to the right side of her head as well as injuries (bruising and contusions) to her right leg. On 5-31-12 at approximately 1:00 PM, Surveyor # asked Licensed Practical Nurse (LPN)-E, staff development, if CNA-P had been trained and demonstrated safe use of the Apollo tub prior to using the equipment. LPN-E indicated CNA-P had not demonstrated safe use of the Apollo tub. Falls On 6/1/12 DON (Director of Nursing) B provided Surveyor # a copy of the facility's fall prevention guideline with an effective date of 2/1/09 and a Revision date of 5/31/12. Fall Prevention Guideline: All residents will be assessed on admission and quarterly for fall risks. Individualized fall precautions will be developed for each resident. Preventative measures will be taken to attempt to decrease the number of falls whenever possible Purpose: 1. To consistently identify and evaluate residents who fall. 2. To define significant injuries associated with incidents 3. To achieve each residents maximum potential of physical functioning. 4. To prevent/reduce injuries related to falls 5. To enhance resident dignity and self worth Procedure: 1. A fall risk assessment will be completed at the following times: upon admission/readmission, Quarterly and a significant change. 2. If the assessment finds the resident at risk, implementation of appropriate interventions/precautions will be put in place 3. The fall will be reported to the nurse, POA (Power of Attorney), residents' doctor, and the DON 4. The fall committee will review and interventions will be suggested 5. Falls with significant injuries, fractures, head injury with loss of consciousness and those that require hospitalization will be reported to the appropriate state agency. 6. All new interventions will be monitored for their effectiveness 7. Trending and tracking will be done by nursing on a quarterly basis. This information will be shared with the administrator. Psychosocial Affect Surveyor # conducted an interview with Resident #1 on 5-29-12 at 10:45 AM. Resident #1 stated during the interview, she is nervous about taking a bath in the Apollo since the fall on 5-11-12 and doesn't know if she would get into the bath tub again. Surveyor # approached Resident #1 again on 5-31-12 at approximately 1:00 PM and asked if she would consider taking a tub bath again: Resident #1 indicated she would never go back into the Apollo tub again. Surveyor # reviewed the resident bath schedule and found Resident #1 is scheduled for a tub bath on Mondays. After reviewing the schedule for Monday 5-28-12, the signature portion of the list for Resident #1 was left blank. On 5-31-12, during the daily exit conference, Surveyor # asked why the list was left blank; Director of Nurses- B, indicated it was blank because the resident had refused the bath. Surveyor # asked whether Resident #1 had refused her previous scheduled Monday tub baths i.e., 5-14-12 and 5-28-12; Director of Nurses-B acknowledged the resident had refused the previous two scheduled tub baths. On 6-1-12 at approximately 2:58 PM, Director of Nurses-B indicated to Surveyor # , Resident #1 was approached and options were discussed with the resident about alternative forms of bathing, prior to 6-1-12 the facility had not presented bathing options to Resident #1. 2) Resident #8 has been residing in the facility since December 2009 and has [DIAGNOSES REDACTED]. The annual MDS dated [DATE] and 5-11-12 quarterly update to the MDS indicates Resident #8 has moderately impaired decision-making skills, but both short and long-term memory is intact. The MDS indicates Resident #8 required extensive assistance with his transfer, toilet needs and bed mobility. The MDS indicates the resident has impaired balance and is not able steady himself without staff assistance. Resident #8's clinical record documents the resident sustained [REDACTED]. According to the investigation, the fall was unwitnessed, and happened during a self-transfer from his electric recliner chair to the wheelchair. The report documents the resident was not injured. The report also indicates the resident was able to self-transfer at the time of the incident, and that the resident's feet became tangled during the transfer. The clinical record indicates Resident #8 again fell on [DATE] at 12:05 AM; Resident #8 was noted to slide off the bed, and again was not injured. On 2-16-12 at 5:20 AM, Resident #8 again fell from bed, again sliding out of the bed, however the resident was noted to have an abrasion to the left knee. On 5-23-12 at 3:05 AM, Resident #8 was found on the floor on the mat. The clinical record documents the resident's physician was consulted, and an X-ray was ordered; the X-ray later diagnosed a possible torn rotator cuff of the right shoulder. On 5-30-12 at approximately 3:30 PM during the daily exit conference, Surveyor # asked the administrative staff about revisions to Resident #8's plan of care in the light of the three falls from bed. On 6-1-12 at 2:40 PM, Surveyor # spoke with PTA-S (physical therapy assistant); PTA-S indicated a PT screen was conducted on 5-21-12, and it was determined at that time Resident #8 should be transferred with the use of an EZ-Stand, and no longer able to self-transfer safely. Director of Nurses-B also stated at this time Resident #8 has an independent mindset, and essentially offered no additional information. 3.) Surveyor # reviewed Resident #5's medical record 5/29 - 6/1/12. Resident #5 is [AGE] years old and has a [DIAGNOSES REDACTED]. Resident #5 uses a wheelchair for mobility. On 1-4-12, the facility completed a Quarterly MDS (Minimum Data Set) for Resident #5. He was noted to have a history of falls. According to the Resident Progress Notes, Resident #5 had 4 falls from 2/29 - 4/2/12. On 5-31-12, Surveyor # asked the DON for additional information showing that the facility had assessed and monitored each fall. The DON provided Surveyor # with the Incident/Accident Report for each of Resident #5's falls. However, the Incident/Accident Reports did not: note the fall interventions in place prior to the fall, monitor the effectiveness of the interventions, and indicate whether or not the interventions needed to be modified. FALL #1 On 2-29-12 at 9 a.m., Resident #5 was found in the hallway where he had slid out of his chair. He complained of lower back pain. An X-ray was ordered and was negative for a fracture. The facility had not reviewed the fall interventions that were in place prior to the fall. The Incident/Accident Report noted that the chair alarm was working, but were there other interventions other than the chair alarm? The facility had not monitored/assessed the effectiveness of the interventions. The facility had not noted if modifications to the fall interventions were necessary. FALL #2 On 3-7-12 at 4:45 am, Resident #5 was heard yelling in his room and a CNA found him holding on to the bed rail and kneeling on the mat on the floor. He sustained no injury. The facility had not reviewed the fall interventions that were in place prior to the fall. The Incident/Accident Report noted that the chair alarm was working, but was it necessary? It appeared that the CNA was called to Resident #5's room by his yelling. The facility had not monitored/assessed the effectiveness of the interventions. The facility had not noted if modifications to the fall interventions were necessary. FALL #3 On 3-12-12 at 9 am a CNA heard Resident #5's wheelchair alarm and a crash to the floor. The resident was found on the floor in his room. Resident #5 said that he wanted to go to bed and had attempted to transfer himself from his wheelchair to the bed. Resident #5 sustained a skin tear to his right hand. The facility had not reviewed the fall interventions that were in place prior to the fall. Was the chair alarm effective, if staff did not reach the resident prior to his fall? Were there interventions other than the chair alarm? There was no evidence that the facility had monitored the effectiveness of the fall interventions and determined if modifications to the fall interventions were necessary. FALL #4 On 4-2-12 at 2:45pm, Resident #5 was found on the floor sitting next to his bed. He sustained no injury. Resident #5 had been resting in bed. In response to the fall, Resident #5 had told staff that "it was 3pm and time to get up." He sustained no injury. The Incident/Accident Report noted that the bed alarm was working, but was it effective? Was staff in the area and how quickly were they able to respond to the alarm? Were there other interventions in place? Did Resident #5 fall onto the mat and was this effective to prevent injury from the fall? There was no evidence that the facility had monitored the effectiveness of the fall interventions and determined if modifications to the fall interventions were necessary. On 4-3-12, the facility completed a Full MDS (Minimum Data Set) for Resident #5, which triggered the CAAS (Care Area Assessment Summary). The CAAS noted that Resident #5 was at risk for falls, due to sliding forward and out of his wheelchair. Different positioning devices had been tried, as well as a frequent "change of position" for Resident #5 from his wheelchair to a recliner chair. The CAAS did not note if these interventions were effective in reducing Resident #5's falls. The CAAS noted: "See plan of care revisions for same." Surveyor # reviewed Resident #5's current Fall Care Plan which had a goal date of 6/12. However, the last revision was dated 9/11 and stated: "Care Plan reviewed/appropriate." The fall care plan had no new approaches/interventions to address the 4 falls that Resident #5 had from 2/29 - 4/2/12. 4.) Surveyor # reviewed Resident #9's medical record 5/29 - 6/1/12. Resident #9 is [AGE] years old and has a [DIAGNOSES REDACTED]. A Full MDS (Minimum Data Set) was completed on 3-5-12 and noted that Resident #9 was at risk for falls. The CAAS (Care Area Assessment Summary) was triggered and noted the following risk factors for Resident #9: significantly ataxic gait, balance issues, medications, and lack of safety awareness. According to the Resident Progress Notes, Resident #9 had a fall on 3-12-12. On 6-1-12, Surveyor # asked the DON for additional information about the fall. The DON provided Surveyor # with the Incident/Accident Report for Resident #9's fall. According to report, Resident #9 had an unwitnessed fall on 3-12-12 at 5:45pm. A CNA heard the alarm sounding, entered the room and found the resident kneeling on the mat at the foot end of his bed. Resident #9 said that he did not fall, but that "the bed was too low to get out of." The resident sustained [REDACTED]. However, the Incident/Accident Report did not: note the fall interventions in place prior to the fall, monitor the effectiveness of the interventions, and indicate whether or not the interventions needed to be modified. Resident #9 had a second incident related to falls. Although he did not fall, on 3-27-12, Resident #9 was found turning off his bed alarm. The Progress Note indicated that at 3:54am, Resident #9's bed alarm was sounding. When staff entered the room, Resident #9 was in the process of turning the bed alarm off. The facility did not monitor the effectiveness of this intervention to to determine if modifications were needed. Surveyor # asked for additional information about this incident related to Resident #9 and his risk for falls. On 6-1-12 the DON said that she was unaware that Resident #9 had attempted to turn off his alarm and had no additional information that this fall intervention had been assessed to determine if modifications were needed. Resident #9's fall care plan, dated 4-14-12, was reviewed; but provided no additional information about the use of the bed alarm to prevent falls. The care plan noted the following interventions: "Bed in low position with brakes locked. Supervised area when out of bed. Mat to floor when in bed." The use of the bed alarm was not documented, although it was still being used according to the 5-25-12 Progress Note. 5.) 5/29/12-5/31/12 Surveyor # reviewed Resident #4's medical record and noted the following: Resident #4 was admitted to the facility on on 8/15/09 with [DIAGNOSES REDACTED]. The last completed MDS (Minimum Data Set) 12/21/11 indicates that Resident #4 did not sustain any falls. CAA (Care Area Assessment) related to falls dated 12/26/11 indicates that Resident is at risk for falls related to mobility and weakness issues. His balance is limited as well since recent pneumonia and sepsis. He is using medications which may also impact fall risk. Transfer accomplished with a Hoyer lift as he is not able to bear weight. He is able to convey some of his needs such as when he wants to go to bed or get up. No recent falls. It indicates to continue to care plan. The Fall Data collection tool dated 2/15/12 indicates that Resident #4 is at moderate risk for falls -score of 5. Conclusion indicates that legs are very weak and if tries to self transfer he would not bear weight and fall. Nurse's Notes on 2/17/12 at 9:00 AM indicate that CNA's (Certified Nursing Assistants) were transferring him to his w/c (wheelchair) and after he was put in he stiffened up and fell out of it and landed with his buttock on the floor. Informed Resident #4's wife that we may have to put him in a Broda chair. There was another w/c that we tried that social services found that had a higher back but Resident #4's wife did not like it. DON (Director of Nursing)-B provided Surveyor # a copy of a incident/accident report dated 2/17/12. The form indicated that it was a witnessed fall and had a statement provided by one of the CNA's. The is no indication on the form that the w/c may have been a factor in causing the fall or whether CNA technique during the transfer or other factors may have contributed to the fall. No update was made to the plan of care related to the fall. Nurse's note dated 2/19/12 at 3:11 AM indicates that Resident #4 was reportedly having problems sitting in regular w/c may need Broda chair. Nurse's note dated 2/27/12 at 7:16 AM indicates that Resident #4 uses w/c for mobility propelled by staff. No further documentation of w/c positioning or attempts at obtaining a different w/c for Resident #4. Nurses Note dated 3/16/12 at 2:59 PM indicates that Resident #4 was assisted to the floor after being Hoyered to chair, while CNA was removing the sling the resident slid out of w/c. Wife is requesting new chair/Broda for a trial. 3/16/12 at 9:19 PM-New Broda chair delivered this evening for trial. Will place him in it in the morning. DON-B provided Surveyor # a copy of an incident/accident report dated 3/16/12. It indicated that Resident #4 was on the floor in front of his wheelchair. The form indicated that it was an assisted fall and that he was in the w/c prior to the incident. CNA witness statements were taken. No root cause analysis was done to determine the cause of the fall or possible interventions to prevent a reoccurrence The CNA Care card dated 3/21/12 has written in all caps PLEASE CENTER RESIDENT IN W/C FROM SIDE TO SIDE AND BE SURE HE IS BACK IN THE W/C ENOUGH. The care card also indicates to place a bolster on each side of the w/c armrest and ROHO cushion on the w/c. On 5/29/12 at 10:48 AM Surveyor # observed Resident #4 being wheeled to the dining room by CNA-F. The wheelchair appeared the appropriate size for Resident. On 5/30/12 at 10:15 Surveyor # observed Resident #4 sitting up in his recliner in his room. Resident #4's w/c was against the wall in the room. The w/c was observed to be oversized with a high back, bolsters on each arm rest and an ROHO cushion filled the seat. On 5/31/12 at 3:30 PM Surveyor # shared the above information with NHA (Nursing Home Administrator)-A and DON-B. Surveyor # questioned the delay in obtaining a different w/c after the fall on 2/17/12 and prior to his 3/18/12 fall. Surveyor # asked if observations and training of the CNA's involved in the transfers was completed to assure appropriate techniques were used. On 6/1/12 at 10:05 AM DON-B told Surveyor # that Resident #4 was not on the therapy case load. She indicated that on 3/18/12 they tried a Broda chair and it didn't work so they ordered an Adva Care high back chair that he is currently in. DON-B stated that there was no follow up with staff as nothing could be done for the fall. DON-B indicated that the interdisciplinary team discusses all the falls during morning meeting and she would be responsible for any follow up. DON-B stated that she does not recall any inservices or training for staff regarding the 2/17/12 fall. On 6/1/12 at 1:00 PM RN (Registered Nurse)-T told Surveyor # that she assessed Resident #4 after the 2/17/12 fall. RN-T indicated that Resident #4 was acting stiff and the w/c wasn't working and he put himself out stiff and went from his w/c to his buttocks. RN-T indicated that the w/c was not appropriate and that the one he has now is ok. RN-T indicated that Resident #4's wife did not care for the Broda chair, felt it was a dignity issue. Discussed different chairs with CNA's. RN-T told Surveyor # that the CNA's transfer technique was good. On 6/1/12 at 1:50 PM OT (Occupational Therapist)-M told Surveyor # that she does not recall doing a w/c evaluation after Resident #4's 2/17/12 fall. OT-M indicated that he was not on the case load but recalled he did not have trunk and leg control and was weak from hospitalization . She indicated that Resident #4's chair was changed 3 times and that his wife did not care for the Broda so he went back into his old chair. OT-M indicated that she was not involved with this chair. OT-M told Surveyor # that DON-B had Physical Therapy Aide-S measure Resident #4 for his current chair. On 6/1/12 at 3:15 PM Surveyor # spoke to Resident #4's wife in person regarding the w/c. She indicated that she did not like ones that were offered and felt that 1 of the falls may have had to do with positioning. She indicated that the current wheelchair is adequate. No additional information was provided. 6.) On 5/29-5/31/12 Surveyor # reviewed Resident #3's medical record and noted the following: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) dated 1/20/12 indicates that Resident #3 requires supervision for transfers and ambulation Review of the record indicates that Resident #3 was independent with ambulation/transfers prior to a right toe amputation on 3/1/12. After amputation Resident #3 required assistance of 1 for transfers/ambulation. Nurse's note dated 3/2/12 at 10:37 PM indicates that Resident #3 normally toilets himself, but since his toe amputation he has been asking for assistance with transfers. On 3/21/12 a care plan was developed related to falls with the problem as: Resident at risk for falling related to decreased mobility secondary to w/c bound and decrease in balance secondary to recent toe amputation and peripheral neuropathy. The goal is that Resident will remain free from injury with target date 6/21/12. Approaches include: Assure the floor is free of glare, liquids and foreign objects, encourage to use environmental devices such as hand grips, hand rails etc. Give verbal reminders not to ambulate/transfer without assistance when he is feeling weak or dizzy etc. Nurse's note dated 3/31/12 at 8:24 PM indicates that Resident #3 completes the majority of ADL's (Activities of Daily living) independently, occasionally requires some assistance with his pants, request this as needed. Nurse's note dated 4/6/12 at 2:48 PM indicates that Resident #3 has been complaining of spasm like pains in his left thigh. Will grimace and moan and then hold his thigh. Did have a fall yesterday but had no injury. There is no note in medical record regarding Resident #3's 4/5/12 fall-(Cross reference F514). X-ray report dated 4/6/12 indicated that Resident #3 had a nondisplaced intertrochanteric femoral fracture. Resident #3 was hospitalized ,[DATE]-[DATE] after surgical repair of the fracture. Resident #3 had orders for Physical and Occupational therapy upon return to the facility. Nurse's note dated 4/15/12 at 3:19 AM indicates that Resident #3 is weight bearing and transfers with 2 assist. No root cause analysis was done as to other factors that may have led to Resident #3's fall nor was the 3/21/12 care plan updated with new interventions to prevent falls. A Significant change of condition MDS was completed 4/20/12 which indicates that Resident #3 requires extensive assistance with transfers and ambulation. The CAA (Care Area Assessment) related to ADL's dated 4/25/12 indicates that Resident #3 had a recently fell and fractured hip, had surgery and is weaker than he was previously. He is working with therapy at this time, but needs more help with all of his daily needs. The CAA related to falls dated 4/25/12 indicates that he recently fell while doing things in his room. He was independent in room and with most of his cares when this occurred. He is at risk for further falls related to multiple medical problems. No comprehensive assessment/root cause analysis completed related to the fall nor was the care plan updated to reflect individualized approaches to assist in preventing further falls. DON (Director of Nursing)-B provided Surveyor # a copy of an Incident/Accident report dated 4/5/12 related to Resident #3's fall. Resident stated "I was pushing the wheelchair back toward my bed when the wheelchair scooted away from me, my feet slipped and I landed on my left hip. If feels ok and I didn't hit my head. The form indicates that Resident #3 is a medium fall risk, that his call light was in reach and that Resident walks by himself. The form indicated that the floor was not slippery. The form indicates that Resident #3 toilets himself. On 5/30/12 RN-K told Surveyor # that she was called to Resident #3's room and that she found him lying on the floor in the bathroom. RN-K stated that Resident #3 was able to move all extremities and did not complain of pain. RN-K reviewed Resident #3's nurses notes and was aware that there is no documentation of the fall or her follow up assessments on 4/5/12. She indicated that Resident #3 was independent until the toe amputation. On 5/30/12 at 3:55 PM RN-J told Surveyor # that she worked the night shift on 4/6/12 and was aware of Resident #3's fall on the evening shift. On 5/30/12 at 4:30 PM Surveyor # informed NHA (Nursing Home Administrator)-A and DON-B of the above information. Surveyor # questioned if there was any follow up related to the fall and what new interventions may have been discussed and placed on the plan of care. On 6/1/12 at 9:00 AM NHA-A told Surveyor # that they discuss every fall in the last 24 hours at the morning meeting. She recalls discussing Resident #3's fall and that there did not appear to be any injury but later he had pain. NHA-A stated that Resident #3 felt it was his own fault and he shouldn't have gotten up on his own. NHA-A stated the team would have discussed Resident #3 after he was found to have a fracture. At 9:45 NHA-A told Surveyor # that she had some notes for 4/13/12 prior to Resident #3's return to the nursing home. The note indicated that he would return on Saturday and doesn't recall anything else that was discussed. On 6/1/12 at 1:50 PM Surveyor # discussed therapy interventions for Resident #3 with OT (Occupational Therapist)-M. OT-M indicated that Resident #3 was and still is a good candidate for therapy and that therapy was provided after his fracture. OT-M stated that he was cooperative with therapies except for the last time she saw him. OT-M stated that Resident #3 felt like she was making him do things and appeared depressed, down in the dumps, not himself. She indicated that his willingness for therapy changed daily. OT-M felt that his depression overrides everything. This information was addressed in the assessment or added to the plan of care related to fall prevention for Resident #3. No additional information was provided.

Based on observation, interview and record review the facility did not ensure that 1 of 1 residents with psychosocial adjustment difficulty received the appropriate treatment and services. Following admission to the facility, Resident #3 experienced life changing events including significant medical delines involving surgery, a request for a divorce and expressed feelings of being worthless. Resident #3 displayed outward signs and symptoms of [MEDICAL CONDITION] including suicidal ideation The facility did not comprehensively assess, develop, implement, evaluate and update Resident #3's care plan to address these ongoing issues. The facility did not have one individual advocating and coordinating Resident #3's mental and psychosocial services to ensure that Resident #3 worked towards adjusting to the changes and challenges in his life. Findings include: On 5/29/12 at 8:50 AM Surveyor # observed Resident #3 lying in bed with the privacy curtain drawn between he and his roommate. Resident #3's bed is on the side of the room without a window. On 5/29/12 at 10:55 AM Resident #3 told Surveyor # that he missed going outside. He told Surveyor # that he gets ornery at times because he gets frustrated because he can't do things for himself. Surveyor # noted that Resident #3's affect was flat and his voice dropped when he made these statements to Surveyor # . He indicated that he was put in this room because his roommate had a stroke and so did he so they (the facility) thought he could help his roommate's family. Surveyor # noted that Resident #3's voice became stronger and he became more animated/expressive when he made this statement. On 5/29/12 at 2:30 PM Surveyor # observed Resident #3 sitting up in his room in his recliner. Resident #3 told Surveyor # that he was not sleeping well. On 5/30/12 at 6:00 AM Surveyor # observed Resident #3 sleeping in bed. At 7:45 AM Surveyor # observed Resident #3 sleeping. On 5/30/12 at 9:00 AM-5/31/12 Surveyor # began review of Resident #3's medical record and noted the following: Resident #3 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's signed a POAHC (Power of Attorney for Health Care) titled Five Wishes on 10/5/11 designating his daughter to make health care decisions for him if he was not able to. The POAHC was activated on 10/7/11 at the hospital designating his daughter to make health care decisions. Surveyor # noted a sticker on the inside of Resident #3's chart dated 10/23/11 that reads-Resident #3 is NOT to ever go out with Baptist church group. There is no indication in Resident #3's medical record as to why this is indicated and who made the decision. The current care plan initiated by activities dated 10/25/11 indicates: PROBLEM- Resident #3 is social and enjoys being involved in variety of activities. Does follow the activity calendar and attends independently. Resident likes to be involved in bible studies, music and socials. GOAL-Resident will experience pleasure and socialization in weekly socials, bible studies, one on ones, music programs. Goal date 1/25/12. APPROACH: Staff will provide activity calendar in room and give reminders and give reminders before activities. Resident #3's current medications include [MEDICATION NAME] 300 mg daily for depression. Initial Psychiatrist consultation for depression note written 11/4/11 indicates: Resident #3 has a long history of depression and that his medical condition was so profound he could not live alone any longer so was admitted to the nursing facility. The note indicated that Resident #3 has had at least one psychiatric hospitalization , presumably for depression. Mental status exam indicated that Resident #3's affect was often sad and tearful and his mood was described as "I just want to die." His insight was fair and his judgment was grossly intact. Impression: [MEDICAL CONDITION], recurrent, severe with psychotic features, Dependent Personality Disorder, suspicion of possible history of being a perpetrator of some kind since the wife and daughter do not seem to want to discuss any particulars: history of alcohol dependence. Plan: 1. Increase [MEDICATION NAME] to 225 mg for ongoing depression 2. Routine [MEDICATION NAME] as an adjust medication for refractory depression and to assist with sleep 3. Consult with psychologist as resident may be at high risk for trying to harm himself, although he vehemently denied that he would actively do so. Instead he seems to wish that he would die quickly. 4. Follow up in December 2011. Surveyor # reviewed Resident #3's record and noted that following the recommendation to involve a Psychologist facility staff did not contact the Psychologist to evaluate Resident #3. Psychiatrist note 12/7/11 indicates: Resident #3 had [MEDICAL CONDITION], recurrent without psychotic features. Data: Resident #3 has been having trouble with weight loss and diarrhea. Resident #3 did not discuss with me. He did receive the divorce papers last week and went over those with the SW(Social Worker). He seems to be grieving appropriately and has been enthused about his improvement in physical therapy. Plan: 1. It did not appear that the Psychologist had yet been consulted and I would recommend again that he be included in the treatment team. Despite repeated recommendation from the Psychiatrist, the facility staff did not contact the psychologist. Nurse's note dated 1/9/12 at 10:51 indicates that: Resident #3 continues with negative attitude throughout shift. No additional assessment was noted following documentation in the nurse's notes. Current care plan with a problem start date of 1/12/12 initiated by SW-C PROBLEM: Resident #3 has a [DIAGNOSES REDACTED]. He has made statements to staff and psychiatrist that he sometimes thinks of suicide but does not have a plan. GOAL: Resident #3 will feel comfortable expressing his feelings of hopelessness with staff and his psychiatrist. His statements of suicidal ideation will decrease to less than 4 times per year. Goal date 3/12/12 APPROACH: 1. Staff will administer medications as ordered 2. Staff will allow 1:1 time to express his feelings and build relationship of trust. This will also build pride in resident as he expresses his individuality 3. Staff will continue to schedule visits with psychiatrist and keep physician and psychiatrist updated regarding resident psychosocial needs and mood 4. Staff will encourage resident to participate in activities. 5. Staff will follow protocol if resident makes suicidal statements 6. Staff will keep daughter, who is activated POAHC informed of residents mood and psychosocial changes. Surveyor # noted that the care plan does not contain specific goals or individualized approaches related to Resident #3's mood, depression, and attitude. Nurse's Note dated 1/15/12 at 3:39 PM indicates that Resident mood positive today. Does fluctuate from up to down. Progress note created by SW (Social Worker)-C dated 1/18/12 includes the following: Care plan meeting held on Monday 1/16/12. Resident was present. Resident is independent in his room, very happy to be toileting himself. Has had a burst of energy over the weekend and was proud to show this writer how he had organized his closet, drawers and his room. Very up beat today. Enjoys socializing with staff and enjoys being with peers and looks out for them and lets staff know if a resident needs assistance when he is near them. POAHC is activated, daughter is agent. Nurse's Note dated 1/17/12 at 7:01 AM indicates that Resident #3 was crying and talking about family troubles this AM really feeling depressed and "worthless" tried to encourage him but was not very successful. Surveyor # was unable to locate in the record whether this information was communicated to other staff or followed up on. Current care plan created by SW-C dated 1/19/12 indicates that Resident #3 has been improving in his independence. Goal: with target date of 4/18/12 Resident #3 will be able to move to an assisted living with financial assistance through the family care program. Approaches include staff keeping daughter (who is Activated POAHC) informed of progress in caring for himself and level of assistance needed. The Quarterly MDS (Minimum Data Set) dated 1/20/12 related to cognition indicates a BIMS (brief interview of mental status) score of 14 indicating that Resident #3 is cognitively intact. The MDS has no indication that Resident #3 exhibited signs of [MEDICAL CONDITIONS] or behaviors that would inhibit him from making his own decisions. Section D related to Mood has total severity score of 3/27 (3 out of 27) indicating minimal depression. 2/1/12 Psychiatrist Note: Resident #3 was completely different from the update. Staff had felt that he was more upbeat and settling in at the facility. I did remind him that the SW would contact the psychologist for some psychotherapy. He essentially stated that he continued to think about suicide frequently. Plan: Resident #3 continues to be very self-pitying and almost seems to thrive on misery, perceived or otherwise. I did ask the SW to please contact the Psychologist for some supportive psychotherapy. Surveyor # noted that this is the third note from the Psychiatrist referencing Resident #3's need to see a psychologist/psychotherapist. Surveyor # noted that the SW contacted the Psychologist on 2/9/12 at 4:52 PM and indicated that a consent form will be faxed for the POAHC to sign. Nurse's Note dated 2/8/12 at 9:29 PM indicates that Resident #3 seemed depressed this evening-went to bed early. It was noted that there was no specific details or follow up on this observation noted. Nurse's Note dated 2/9/12 at 7:44 PM indicated that Resident stated to nurse tonight that he is addicted to eating salt and will often fill up the artificial sweetener packets with salt and take them back into his room. Nurse did find sweet and low packet in his room with salt in it. Nurse explained that it is important to watch salt intake when you are diabetic due to impaired kidney function. Resident stated that he is aware of this fact but seemed distressed over his "addiction" to salt. Surveyor # noted that there was no facility follow up to the knowledge that Resident #3 is inappropriately ingesting salt. Nurse's note dated 2/11/12 at 7:55 AM indicates that resident is very depressed. 10:13 AM note indicates that Resident #3 is alert and oriented x 3 and is able to make his need known. Has contact with children and a few friends. Attempts to contact ex-wife despite divorce. Attitude and mood is generally depressed. Resident voices his sadness to staff regularly. Often despairs over health status. Can often be redirected by talking with resident. Will sit in living room with the other residents, but mostly interacts with staff. Will attend activities that he is interested in at will. 5:34 PM Mood remains very sour:verbalizing over and over that he wishes he would just "die already." Verbalizing negative statements about his family. Complained of general aches and pains. Tylenol was given and was moderately effective. Spent time with resident, allowed him to talk about his feelings and "vent", but was ultimately unable to redirect. Resident received a phone call from a friend, seemed to lift his spirits a bit. Nurse's note dated: 2/18/12 at 2:58 AM: Resident #3 will converse with staff and peers, sometimes he will complain about everything and the next time he has all kinds of good things to say, depends on his mood. Nurse's note dated 2/20/12 at 8:24 PM: Resident in foul mood. Improved a little following daughter's visit. Mood continues little improved following medication changes. Had seen some improvement but now seems to have reverted to previous outlook of negativity. Nurse's noted dated 2/21/12 at 9:47 AM: resident has highs and lows. Needs encouragement at times and assurance that the staff here cares about his health. Nurse's note dated 2/22/12-written as late entry on 2/23/12: PCP (Primary Care Physician)-N made aware of resident's negative statements, and statements re: suicide. No new orders received. Put on 15 minute checks and licensed staff is observing as he is taking/swallowing medications. Had long discussion with daughter who stated that in the past he has often made such statements at home, when not happy with circumstances or "didn't get what he was expected." Stated was not concerned at all. 10:03 AM Just put on 15 minute checks per DON (Director of Nursing) due to talking about suicide yesterday saying he has pills and he can do it. Pleasant at the moment with no talk about negative things. 8:40 PM-Continues on 15 minute checks. Statements of "I'm going to quit eating" and "still having pain and nobody's listening" were made during this shift. Reassurances were met with negative replies. Surveyor # noted that the facility did not complete a comprehensive assessment by IDT members or update the care plan related to Resident #3's fluctuating mood and suicidal ideation. The facility did not establish parameters related to when to put Resident #3 on or take off of suicide precautions. SW note 2/23/12 at 7:20 PM indicates: a referral was made to Psychologist last week and sent daughter consent for signature. Information was faxed to Psychologist. Review of SW-C's documentation gives no indication that the SW was involved in addressing Resident #3's mood changes and suicidal ideation. There was no update by nursing or SW to Psychiatrist related to Resident #3's mood fluctuations and suicidal ideation. Nurse's Note dated 2/26/12 at 4:01 PM: Resident awoke very cheerful again today. Around lunch had a sudden change and temperament and became depressed and was verbalizing negative, hopeless statements. Nurse's note dated 2/27/12 at 7:11 AM: Resident has had loose stools. Becomes very depressed when this happens. Nurse's note dated 2/29/12 at 1:43 PM: stated to several staff members that this will be his last day on earth. Appears in good spirits since a friend came in. On 3/1/12 Resident #3 had his right great toe amputated. Nurse's note dated 3/2/12 at 1:17 AM: states that Resident has been quiet tonight, checking him every 15 minutes for suicide behaviors. Says his happy pills are working. Psychiatrist Note dated 3/16/12: Resident discussed how his wife and family basically let him know he is worthless and that "I know I won't die of natural causes." When asked if he were suicidal, he replied "I've been suicidal for [AGE] years." I believe the Psychologist will be seeing him for the first time next week. Plan: I think resident actually enjoys the misery that he repeats every time I come in. I would be curious to see if the Psychologist did any cognitive testing as I am not sure if he really did not remember that he had a toe amputated or if that was simply part of an act. Surveyor # noted that the psychiatrist referenced that as of 3/16/12 Resident #3 still has not been seen by a psychotherapist despite initially recommending such services for Resident #3 11/4/11. Nurse's Note dated 3/17/12 at 10:02 PM: Resident on medication for depression, secondary to chronic illnesses. Psychiatrist following and adjusting medications. Moods are labile and shift quickly at times. Resident attends some activities and participates. Will continue to monitor. Nurse's note dated 3/26/12 at 3:56 PM: Resident unhappy with staff taking small cups of salt away from him today and threatening to call his ex wife and stated that she would take him out of this facility. The Initial Evaluation and Treatment plan by Psychologist dated 3/22/12 indicates: Appeared alert and oriented x 3 and a fair historian. Affect and demeanor with some lability. Acknowledged depression and at times harbors death wishes but not imminent. Stopped working in 2009 due to health issues. Also stated he worked as a "peer counselor" for churches in his home town and did that sort of volunteer work since he was 18. Plan: 1. Establish support and trust 2. Address adjustment issues 3. Monitor mood and behavior 4. Attempt cognitive-behavioral treatment approach. PCP-N note dated 3/30/12: he has a salt habit. He states he has been eating salt since he was [AGE] years old, breaking chunks off of salt blocks on the farm. He keeps salt in cups and eats it. He states he is not going to give it up. Nurse's note dated 3/31/12 at 2:12 PM indicates: that PCP-N aware of resident's salt consumption, and not worried about it and stated something we can not change. But take away any salt without upsetting him. Psychiatrist Note dated 4/4/12: Has been taking salt shakers off the tables and pouring salt into empty med cups or into creamer packages and stated that he had craving for salt. He is also wiggling his teeth to the point of bleeding and picking at scabs on his arms for the past couple of weeks. Suicidal ideation discussed. Indicated that the Resident has a clear tendency toward the melodramatic and no insight as to how his behaviors affect others. Plan: 1. Strongly suspect that he has tried to find solace in counseling some of the younger staff here and is being rebuffed. He is clearly trying to play staff off of each other and it's not working. Subsequently, his level of frustration is rising proportionately and he is finding that he has to make more desperate measures to get attention. Staff still should be observant for any signs of him trying to harm himself, such as twisting his teeth and picking at scabs. Nurse's Note 4/4/12 at 10:52 AM Behavioral Team Meeting review with Psychiatrist, SW-C, DON-B and nursing. Psychiatrist challenged him with regards to his history and his lack of ability to accept any of the things that have happened to him. He stated that he has no worth, yet when she asks how he has been able to help people in the past he has very strong Axis (positive feelings/mood) per Psychiatrist. He did not have any answer for any of the questions she asked him. He tends to play people off of each other and works the angles and is at borderline risk for self harm. If he does continue or advance with his verbalizations, he may need to be sent out for further evaluation. He does indicate that he wants to die and would like to kill himself, but he does not have a plan. He is around so much "real psychiatric Illness" that he is trying to present himself as more confused and demented. He is doing some self mutilation type behaviors with the teeth tugging and getting them to bleed. He tends to feed off the people who have dementia and if he is "losing his Mind" he does not need to be accountable for his behaviors. Recommendation of possible assisted living facility. Will continue to monitor. Surveyor # noted that there was no follow up assessment or conversation with Resident #3 regarding risks and benefits of his behaviors/actions. The facility did not allow Resident #3 to be involved regarding his own decisions regarding salt consumption and updating the care plan accordingly. The facility did not complete a comprehensive assessment and establish individualized care plan goals related to manipulative behavior, suicidal ideation, self mutilating behaviors, and possible feigned confusion. Psychologist note 4/6/12: He expressed concerns regarding his tendencies toward depression. He portrays himself in somewhat of a martyr like manner. He also expresses great religious faith and convictions yet he himself has made suicidal gestures in the past. Will address these issues with him at a later point. Plan will be to follow-up with him on every 2 week basis given his history of depression and probable personality disorder. Resident #3 was hospitalized from [DATE]-4/13/12 for surgical repair of a femur fracture. During hospitalization he was evaluated by a Psychiatrist on 4/10/12 The consult note indicates that Resident #3 presents seriously depressed. He indicates he has given up and feels abandoned. He is angry and feels hopeless and wishes to die. Recommendations: 1. Resume his [MEDICATION NAME] at 300 mg a day as soon as possible. 2. Gentle encouragement is warranted to participate in his care. 3. He would benefit from seeing a therapist once he is discharged . Psychologist note dated 4/17/12 indicates that Resident #3's overall presentation appears to be more improved to when I last saw him. He seems somewhat more sarcastic and manipulative in his tone. A Significant Change in Condition MDS dated [DATE] indicates that Resident #3's BIMS score was 14 indicating that Resident #3 is cognitively intact. The MDS mood severity score was 23 indicating severe depression. The MDS Section related to preferences for customary routine and activities indicated that Resident #3 found it very important to have things to read, music he likes, be around pets, keep up with the news, do favorite activities, go out side and participate in religious services while he is at the facility. The CAA (Care Area Assessment) for Psychosocial well being indicates that Resident picks and chooses the activities he likes to attend. Does like 1:1 with staff or peers. The CAA related to mood state indicates that Resident has stated on occasion that he has felt he would be better off dead. He feels this way because of his health issues, divorce and dependence on others for cares. Sees psychiatrist on a monthly basis. The CAA for activities indicates: has definite activity interests, mostly with regards to helping people and church/religious activity. The CAA related to [MEDICAL CONDITION] Medications indicates: long history of depression and psychiatric issues. Uses antidepressant medication. Nurse's note dated 4/20/12 at 3:53 PM: During MDS interview, resident indicated that he is depressed and feels as though he would be better off dead. He did state that he does not have any thoughts of suicide or of harming himself in any way. He indicated that he does not sleep at night and is bothered by the fact that his family is not his family and they do not do things for him, never come to see him and have forbidden his "adopted' daughter to see him. LPN ( Licensed Practical Nurse)-E explained to Resident #3 that she is not on the list of responsible party people and that his daughter is his POAHC for healthcare, assisting him with making decisions. He became very upset with LPN-E over the fact that the family has no right to make decisions, he gave her the permission (the daughter who is the POAHC), and he has every right to take it away. Surveyor # noted that there was no IDT discussion, comprehensive assessment or initiation of an individualized care plan to deal with the findings from the 4/20/12 MDS, CAA and Psychiatrist notes to deal with Resident #3's depression. The facility did not establish individualized psychosocial care plan related to his preferences of how he would like to spend his days while he is at the facility. Nurse's note dated 4/21/12 at 2:10 PM: Depressed, sarcastic and rude today. Voicing complaints loudly during breakfast and aggravating other residents. Calmed down after asked to voice concerns quietly. Nurse's note dated 4/24/12 at 1:34 PM: refused AM blood draw. Nurse's note dated 4/27/12 at 10:24 AM: Nurse assessed and found an open area with uneven edges and a flap of skin covering part of the wound on Residents xyphoid process. Stated that he couldn't stop running his fingers over the area all night long and kept trying to dig his fingernails under the flap of skin. He stated that he tried to stop himself but he just couldn't do it. Nurse's note dated 4/28/12 3:44 PM: had episodes of grumpiness on day shift, but was easily redirected. Nurse's note dated 4/29/12 at 10:49 AM: Refusing to get up out of bed this AM. Nurse's note dated 4/30/12 at 3:15 PM: in foul, hostile mood all AM shift. Rude, sarcastic and resistive. Resident had an altercation with a female resident from B wing who is very elderly with advanced dementia. Female resident was calling out repeatedly as she commonly does. Res. began verbally berating her, turned toward her and began propelling his wheelchair towards her menacingly. Resident (#3) was redirected down the hall towards his room, but turned to female resident and yelled"Bi---!" (expletive) at her loudly. (Cross reference F225). Adamantly refused to go to appt. with vascular surgeon. Nurse's note dated 5/1/12 at 1:42 PM: Psychiatrist updated on behaviors. Discussed with resident the implications of refusal of seeing the vascular MD. He states that he understands that by not treating this issue he could not only lose his foot but his life, and "what kind of a life do I have anyway?" continues to pick at sores stating "so what? It is my body to do with what I want." 3:40 PM: Resident continues to pick at self inflicted wound to chest, removes dressings when applied. He stated he does not want to be poked anymore and wants God to take him home. Talked with POAHC about possible hospice care, POAHC not ready at this time. 6:03 PM stated: "I wish everyone would just leave me alone." Psychiatrist Note 5/2/12: Had surgery last month and apparently came out of that extremely depressed. He remains passively suicidal. Plan: 1. Needs to have more behavioral modification as his intervention. Medication is not going to do a whole lot to change his behaviors. However I will increase the [MEDICATION NAME] sprinkles as he has been quite verbally aggressive towards at least one female peer. Surveyor # noted that the facility did not complete a comprehensive assessment of the issues related to self mutilation, choosing not to have medical treatments and appointments and increased aggression including aggression towards peers and his quality of life. No behavioral modification interventions were added to the plan of care. Resident #3 was hospitalized ,[DATE]-[DATE] for revision of right toe amputation and placement of a wound vac dressing to his right foot. The CNA (certified nursing assistant) care card dated 5/15/12 does not have any behavioral interventions indicated to assist staff in caring for Resident #3. A Significant Change in Condition MDS dated [DATE] indicates that Resident #3 had a BIMs score of 13 indicating that Resident #3 is cognitively intact. The MDS mood total severity score is 8 indicating mild depression. The MDS section related to preferences for customary routine and activities shows a change in preferences in that area Resident #3 listed on the 4/20/12 MDS as very important are now listed as somewhat important except for music and religious services. The CAA indicates that Resident #3 receives anti-psychotic and antidepressant medications. Nurse's note dated 5/20/12 at 2:02 PM: stated that he just wants to be left alone. 3:19 PM: Spoke with daughter regarding resident's decline in condition, poor appetite, difficulty swallowing, weakness and lethargy and his multiple verbalizations about wanting to be left alone. Discussed the possibility of a Hospice referral. 8:24 PM: in foul mood, very demanding and rude to staff. Does not want to be bothered except for repositioning. Dietary note dated 5/21/12 at 10:28 AM: Writer reviewed that sodium is not good for him as resident takes salt shakers and pours them into other plastic cups. States that he was not going to do it anymore but when writer walked away he did attempt this. Spoke to nursing. Surveyor # noted that the salt issue still has not been comprehensively assessed or updated on the Resident #3's care plans done by IDT. SW-C note dated 5/21/12 indicates that he had a very positive attitude and denied suicidal ideation. Resident #3 is not sure about pursuing relocation funding. Spoke with resident's daughter this morning and she would like to meet with PCP-N and nursing home staff to discuss resident's physical decline and refusals of med's, etc. Daughter would like to discuss possible palliative care. SW note dated 5/22/12 at 5:00 PM: Daughter who is POAHC is concerned about resident's refusal to go to Dr appt. today and previous refusals, in the morning he did not want to go to his appt. and started to cry saying he has no rights any more. "I want to get back into bed and not go anywhere and just be left alone. I'm tired of being poked and prodded." Daughter feels that comfort care or hospice may be best for resident. In the note SW-C talked with daughter regarding transportation van not willing to pick Resident #3 up any longer due to the refusals to keep appointment. Surveyor # noted that there is no indication that SW-C spoke with Resident #3 about his appointments or possible changes in is care status. Nurse's note dated 5/24/12 at 8:14 PM: Was in a very bad mood, was demanding to be put in bed. Nurse's note dated 5/25/12 at 11:21 PM: spends most of his time in bed. Wants to be left alone. Nurse's note dated 5/27/12 at 10:18 PM: Less short-tempered than previously but still not very pleasant. Nurse's note dated 5/28/12 at 2:28 PM: PCP-N in to assess resident today. Discontinued several medications, noted in MAR. 8:05 PM PCP-N spoke to POAHC who would like other family members to be able to decide on Hospice. Nurse's note dated 5/29/12 at 7:13 AM: Reported that the resident had tried to hit the lab tech when she was here to draw his blood. A telephone order dated 5/29/12 indicates to discontinue Resident's [MEDICATION NAME] (anti-psychotic) and [MEDICATION NAME] (used for depression). On 5/30/12 at 10:50 AM DON-B told Surveyor # that she is not aware of why PCP-N discontinued Resident #3's Psychiatric medications. DON-B stated that the Psychiatrist Resident #3 was seeing is no longer seeing Residents here due to relocation and a new Psychiatrist has not reviewed him yet. On 5/30/12 at 11:20 AM Resident #3 was observed sleeping on his right side. CNA-I told Surveyor # that his mood is about 50%. He has been eating all his meals in his room. CNA-I stated that she understands that he takes his frustrations out on staff and feels he can't control it. On 5/30/12 at 12:40 PM Surveyor # observed Resident #3 pulling/picking at skin on his Xyphoid process and he stated "I shouldn't be doing this" but continued to do it. CNA-I asked him to stop and he stated "that's what you always say." On 5/30/12 at 11:15 AM DON-B told Surveyor # that she spoke to PCP-N who told her that Resident #3 has had increased lethargy lately and thought it may be due to medications. PCP-N told DON-B that she was meeting with daughter on Friday to discuss issues regarding refusals of treatment and hospice care. On 5/30/12 at 11:30 AM Surveyor # spoke to SW-C regarding Resident #3's Psychosocial needs. SW-C stated that Resident #3's POAHC was activated due to making poor decisions and it was based on mood more than not understanding. SW-C indicated that Resident #3 can't make concrete decisions due to his mood fluctuating so much. SW-C indicated that she has not considered discussions with Resident #3 or his POAHC regarding deactivation although resident is cognitively intact. SW-C feels the POAHC still needs to be activated because he changes his mind often and is very reactive. Surveyor # asked if not being allowed salt was an obstacle for him. SW-C stated that they couldn't stop him from eating it and had not discussed the risks and benefits with him and allowed him to make a decision regarding if he wanted to continue to eat it. Surveyor # and SW-C discussed how it could make him feel having to sneak to get salt. SW-C indicated that Resident #3 enjoys music, pet visits, religious activities and helping others. SW-C indicated that there has been no assessment of his abilities to help others and develop a plan of care based on the results. SW-C stated that when Resident #3 has suicidal ideation they do 15 minute checks with him and 1:1. SW-C stated that he usually doesn't have anything in mind. He doesn't open up a lot. SW-C stated that he has opened up to the Psychiatrist. (Surveyor # noted that Resident #3 is no longer able to see the Psychiatrist that he has developed a rapport with and the facility has not identified an alternative Psychiatrist). SW-C was informed by Surveyor # that no comprehensive assessment or specific directions for staff related to suicidal ideation are listed on the plan of care. SW-C indicated that Resident #3 has dealt with chronic depression his whole life. SW-C indicat

Based on observation, interview and record review the facility did not ensure each resident received the necessary care and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility did not assist 3 (Resident #3, Resident #8 and Resident #10) of 10 residents to attain and/or maintain their highest potential with respect to bowel function and 3 (Resident #3, Resident #4 and Resident #5) of 10 residents attain adequate pain management. On 3/25/12 Resident #3 experienced an episode of acute/severe pain related to abdominal distention requiring assessment at the hospital following multiple shifts of not having a bowel movement. Findings include: 1) Resident #8 has [DIAGNOSES REDACTED]. The 5-11-12 quarterly update to the MDS indicates Resident #8 has moderately impaired decision-making skills and requires extensive assistance of two staff members for his toilet needs. The 11-16-11 MDS indicates Resident #8 has a program in place to manage his bowel incontinence. Resident #8's clinical record contains a bowel evaluation dated 2-14-12. The evaluation indicates the resident does not have a history of constipation, though does use as needed (PRN) stool softeners, is aware of the need to defecate and is continent of his bowel; the evaluation does not identify Resident #8's usual bowel elimination pattern. The March and April 2012 medication administration records (MARs) indicates Resident #8 received [MEDICATION NAME] Sodium 100 mg (DSS) daily and Polyethylene [MEDICATION NAME] powder 17 gm ([MEDICATION NAME] substitute) every other day to assist with regular bowel movements (BMs), in addition to [MEDICATION NAME] 10 mg suppository once a day PRN and milk of magnesia (MOM) 30 ml once a day PRN. On 6-1-12, Director of Nurses-B presented Surveyor # with a copy of the "Policy Statement : To promote a regular bowel pattern". The procedure states it is the responsibility of every shift nurse to monitor resident's BMs. If a resident has not had a BM in two days, the nurse is to offer the resident a glass of prune juice, MOM or other laxative as ordered by the physician. If no BM after three days, administer a suppository based on individual care/personal resident choice. If no BM after suppository do a bowel assessment and update physician for further instruction. Residents will be encouraged to increase activity to promote regular BMs. Staff may suggest attempting to increase fiber such as offering fruit, fiber pudding type supplement etc. Encourage and increase fluid intake if not contraindicated. The daily bladder and bowel charting records for March 2012, April 2012 and May 2012 for Resident #8 indicates he had no BM for nine shifts between 3-2-12 and 3-4-12; no BM for nine shifts between 3-8-12 and 3-10-12; no BM for 15 shifts between 3-14-12 and 3-18-12; no BM for six shifts between 4-9-12 and 4-10-12; no BM for nine shifts between 4-16-12 and 4-18-12; no BM for 15 shifts between 4-23-12 and 4-27-12; no BM for six shifts between 5-17-12 and 5-18-12; no BM for six shifts between 5-26-12 and 5-27-12 and no BM for nine shifts between 5-29-12 and 5-31-12. The clinical record documents Resident #8 on 3-25-12 at 2:26 PM: "abdomen is distended and rigid Bowel sounds in upper quadrants are within normal limits, but are very hypoactive in the lower quadrants . . . abdomen palpated (hands on examination) and there is right lower quadrant tenderness noted on palpation. Last BM noted 3-23-12, large. Rectal check performed and is negative. . . . Resident nods his head yes when asked if he's experiencing pain and rubs his stomach when asked where." The clinical record indicates the on-call physician was consulted and gave the order to transport Resident #8 to the emergency department for further evaluation. The clinical record documents Resident #8 returned to the facility on the same date at approximately 8:00 PM and was diagnosed with [REDACTED]. The follow up physician orders [REDACTED]. Surveyor # asked Director of Nurses-B if the bowel protocol had been implemented for Resident #8 during the extended time frames when he had no BM; Director of Nurses-B indicated it had not. Surveyor # also asked about the current time frame with no BM - 5-29-12 to 5-31-12, Director of Nurses-B again indicated it had not. On 6-1-12 at approximately 3:55 PM, Surveyor # asked if Resident#8 had had a BM on 6-1-12, Director of Nurses indicated the resident had, on 6-1-12. Resident #8's hospitalization and recurrent constipation is an avoidable situation for Resident #8 as the facility has not adequately assessed, care planned and implemented measures consistently to ensure that Resident #8's needs are met regarding bowel care. According to the National Digestive Diseases Information Clearinghouse (NDDIC), Constipation is defined as having a bowel movement fewer than three times per week. With constipation stools are usually hard, dry, small in size, and difficult to eliminate. Some people who are constipated find it painful to have a bowel movement and often experience straining, bloating, and the sensation of a full bowel. To understand constipation, it helps to know how the colon, or large intestine, works. As food moves through the colon, the colon absorbs water from the food while it forms waste products, or stool. Muscle contractions in the colon then push the stool toward the rectum. By the time stool reaches the rectum it is solid, because most of the water has been absorbed. Constipation occurs when the colon absorbs too much water or if the colon's muscle contractions are slow or sluggish, causing the stool to move through the colon too slowly. As a result, stools can become hard and dry. Common causes of constipation are ? not enough fiber in the diet ? lack of physical activity (especially in the elderly) ? medications ? milk ? irritable bowel syndrome ? changes in life or routine such as pregnancy, aging, and travel ? abuse of laxatives ? ignoring the urge to have a bowel movement ? dehydration ? specific diseases or conditions, such as stroke (most common) ? problems with the colon and rectum ? problems with intestinal function (chronic idiopathic constipation) Sometimes constipation can lead to complications. These complications include hemorrhoids, caused by straining to have a bowel movement, or anal fissures-tears in the skin around the anus-caused when hard stool stretches the sphincter muscle. As a result, rectal bleeding may occur, appearing as bright red streaks on the surface of the stool. treatment for [REDACTED]. treatment for [REDACTED]. Sometimes straining causes a small amount of intestinal lining to push out from the anal opening. This condition, known as rectal prolapse, may lead to secretion of mucus from the anus. Usually eliminating the cause of the prolapse, such as straining or coughing, is the only treatment necessary. Severe or chronic prolapse requires surgery to strengthen and tighten the anal sphincter muscle or to repair the prolapsed lining. Constipation may also cause hard stool to pack the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool. This condition, called fecal impaction, occurs most often in children and older adults. An impaction can be softened with mineral oil taken by mouth and by an enema. After softening the impaction, the doctor may break up and remove part of the hardened stool by inserting one or two fingers into the anus. (Cross Reference F272 and F279) 2.) Surveyor # reviewed Resident #5's medical record on 5/29 - 6/1/12. Resident #5 is [AGE] years old and has [DIAGNOSES REDACTED]. On 2-29-12, Resident #5 fell out of his wheel chair and complained of back pain. His physician ordered an X-ray of the lumbar spine, which was negative. Resident #5 continued to complain of increased back pain and on 3-1-12 his physician increased his pain medication. Prior to his fall, Resident #5 was to receive one ([MEDICATION NAME] 7.5/500) tablet each day at breakfast and supper. This was increased to two ([MEDICATION NAME] 7.5/500) tablets each day at breakfast and supper. Resident #5 also had a "PRN" (as needed) order for 1 - 2 ([MEDICATION NAME] 7.5/500) tablets to be given, every 4 hours as needed for pain. It appeared that after this fall, Resident #5 had unrelieved pain, occurring specifically on the third shift. Resident #5's Pain Flow Sheet for March 2012 was reviewed. He took 2 "PRN" [MEDICATION NAME] tablets 17 times on the third shift. He also took 1 "PRN" [MEDICATION NAME] tablet 2 times on the third shift. This would indicate that Resident #5 had unrelieved pain for 19 of 31 days on the third shift during the month of March. Resident #5's last pain evaluation was completed 6-23-11. It noted that Resident #5 had pain in his shoulder "all the time". Resident #5 was able to rate his pain on a scale of 1 - 10, but it was also noted that he would express his pain by "yelling". The facility had not re-assessed Resident #5's pain after his 2-29-12 fall and after his increased use of "PRN" [MEDICATION NAME] to determine if Resident #5's pain was being managed. On 4-3-12, the facility completed a Full MDS (Minimum Data Set) for Resident #5. Because Resident #5 said that he had not had pain in the past five days, the CAAS (Care Area Assessment Summary) was not triggered for pain. The facility did not consider the increased use of the pain medication in March to further question Resident #5 and assess Resident #5's pain management. Resident #5's current care plan (with a goal date of 6/12) was reviewed. There was no care plan for Resident #5 related to pain. A pain care plan dated 12-19-12 was "crossed out". It noted that Resident #5 had "chronic lumbar back and chronic shoulder pain". The medical record did not document that Resident #5's chronic back and shoulder pain were resolved and that a care plan related to Resident #5's pain was no longer necessary. It should be noted that Resident #5's use of "PRN" [MEDICATION NAME] decreased dramatically in April and May of 2012. Resident #5 used the [MEDICATION NAME] 6 times on the third shift in April and 4 times on the third shift in May. The current pain assessment, dated 6-23-11 was not current. It did not reflect Resident #5's increased use of pain medication in March and decreased use in April and May to determine where Resident #5 had pain and if that pain was being managed. This information was shared with the Administrator and DON during the exit conference on 5-31-12. No additional information was shared with Surveyor # related to Resident #5's pain management. 3.) On 5/29 and 5/30 Surveyor # reviewed Resident #3's Medical Record and noted the following: Resident #3 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident is alert and oriented x 3 and able to make his needs known. BOWEL REGIME Nurse's note dated 1/07/12 at 6:52 PM indicates that Resident #3 is independent with toileting. Occasionally needs assistance with cleansing following involuntary episodes. Is aware enough to request laxatives if necessary. Nurse's note dated 1/10/12 at 8:31 AM indicates that Resident #3 had 7 loose stools throughout the night and his physician was updated and orders received for [MEDICATION NAME] Quarterly MDS Section dated 1/20/12 indicates that Resident #3 is frequently incontinent of Bowel-2 or more episodes but at least one continent bowel movement. No further assessment of the cause of the incontinence or measures taken to assist Resident #3 to become continent. Nurse's notes include the following: 2/02/12 at 1:44 PM Bowel and bladder summary: Mostly continent of bowel. Has a bowel movement every day. On no laxatives and doesn't use as needed medications. Needs little assistance. Surveyor # noted that there was no further assessment of cause of the bowel incontinence. 2/8/12 7:59 AM indicates that at 0530 Resident #3 had attempted to go to the bathroom but "didn't make it" had trailed diarrhea from bed to toilet, was very upset with the fact that no one seems to be able to fix this problem. Surveyor # noted that there was no further evaluation/assessment of Resident #3's bowel status 2/22/12 at 9:24 AM indicates that Resident #3 states his stomach feels fine but states "But I know it will come back again like it always does," which means he will get diarrhea again. 2/23/12 at 8:28 AM indicates that Resident #3's physician ordered [MEDICATION NAME] twice daily for complaints of diarrhea. 2/27/12 at 7:11 AM Resident has had soft/loose stools times 3 tonight. Becomes depressed when this happens. 3/2/12 at 1:46 PM-Bowel and bladder note: Is continent for bowel and bladder for the most part. Has occasional episodes of small incontinence when unable to get to the bathroom in time. Normally toilets himself, but since his toe amputation he has been asking for assistance for transfer. No scheduled laxatives used. - Surveyor # noted that there was no evaluation by the nurse that Resident #3 is using [MEDICATION NAME] for loose stools, when he is incontinent and what may assist Resident #3 to maintain bowel continence. Change in condition MDS dated [DATE] indicates that Resident #3 is continent of Bowel. Nurse's note dated 5/6/12 at 10:20 AM indicates that Resident #3 is alert and oriented x 3 and able to make needs known. The note indicates that Resident #3 is continent of bowel and bladder but has episodes of incontinence. Wears pull-up product. No further assessment noted. Nurse's note dated 5/15/12 at 10;24 PM indicates that Resident #3 is incontinent of bowel and bladder. No additional information provided. Change in condition MDS dated [DATE] indicates that Resident #3 is occasionally incontinent of bowel (1 episode) Re-admission bowel evaluation dated 5/23/12 indicates that the reason for incontinence is decreased mobility. The form indicates that he does not have a history of constipation and foods that stimulate elimination is lactose. No mention of Resident #3's ongoing loose stools and inability to remain continent when they occur. No further assessment regarding plans that may assist Resident #3 to remain continent during periods of loose stools. Areas of the form related to medications, mental status and ability to communicate, mobility status, length of incontinence, usual elimination pattern, consistency of stools, flatulence, Perianal problems, and perception of the need to defecate are not addressed or answered. Resident #3's medication regime included [MEDICATION NAME] 5/325 (Narcotic) every 6 hours as needed for pain, which he was taking 1-2 times daily prior to 5/23/12 bowel evaluation. Resident #3 was also receiving [MEDICATION NAME] and [MEDICATION NAME] all of which can cause constipation. [MEDICATION NAME] and [MEDICATION NAME] also can cause diarrhea. These issues were not addressed/assessed in the bowel evaluation. On 5/30/12 a note was added to the 5/23/12 Re-admission bowel evaluation for his change in condition MDS. The note indicates that Resident #3 has had occasional episodes of bowel incontinence which is a functional issue. Resident #3 knows that he needs to go but at times it comes quicker than he can get onto the bed pan. He does not want to be bothered on a regular basis. There was no update to the plan of care or CNA care plan after the above assessment. On 5/30/12 at 12:40 PM Surveyor # observed incontinence care being provided to Resident #3 after had a small soft dark brown stool. Certified Nursing Assistant (CNA)-I indicated that Resident #3 is incontinent about 50% of the time. PAIN Nurse's note dated 2/6/12 at 12:28 PM indicates that Resident #3 was experiencing muscle spasms, tremors and a "pins and needles" sensation in his right upper extremity. 5:26 PM indicates that the physician was notified and an order was obtained for occupational therapy related to [MEDICAL CONDITION]. Nurse's note dated 2/20/12 at 1:39 PM indicates that Resident #3 complained of general pain-stated he would like to schedule some Tylenol a few times a day to help ease his aches and pains. 2/21/12 at 6:40 PM an order was received for Tylenol 650 mg twice daily. No comprehensive pain assessment was completed related to non-pharmacological interventions that may help ease pain. On 3/1/12 Resident #3 had an amputation of his right great toe. Nurse's notes from 3/1/12 to 3/21/12 do not document any complaints of pain related to the toe amputation. There was no comprehensive assessment or care plan update related to pain issues conducted by the facility. Surveyor # noted that an order for [REDACTED]. A care plan dated 3/21/12 indicated that Resident has pain/alteration in comfort related to s/p right great toe amputation. Residents pain/alteration in comfort is also related to the following Diagnosis: [REDACTED]. Resident states that an acceptable/tolerable pain for his chronic pain is 4 on a scale of 0-10. Long term goal with target date 6/21/12 Resident will have amelioration of immediate pain and will show non verbal signs and symptoms of pain and will not have a functional decline related to pain. Approaches include to administer pain medications as ordered, always attempt non-pharmaceutical interventions first, unless pain is excruciating: smooth linen, assist with position change, reassure, encourage mobility/physical activity if this relieves pain. No individualized assessment indicated as to what non-pharmaceutical interventions work for Resident #3 or can be attempted to see if they alleviate pain. The care plan did not include individualized approaches to alleviate Resident #3's pain. It is a standard care plan utilized for all Residents that experience pain. Resident #3 was hospitalized from 4/7-4/13/12 for surgical repair of a femur fracture. No comprehensive pain assessment was completed upon return to the facility. A second goal was added on 4/13/12 with goal target date of 7/13/12 indicating that Resident #3 will have post surgical pain controlled to within his acceptable pain levels. One approach was added to monitor for pain q shift, both non verbal and stated pain. A change in condition MDS was completed on 4/20/10 indicates that Resident #3 has frequent, severe pain. The CAA (Care Area Assessment) related to pain dated 4/25/12 indicates that Resident had recent [MEDICAL CONDITION] with surgery as well as [MEDICAL CONDITION] and diabetic ulcer present. History of depression and other medical problems with pain impact. No further comprehensive assessment was completed that included an assessment on the impact that pain has on depression and other medical problems to assist in the development of care plans. Resident #3 was hospitalized from [DATE]-5/15/12 for debridement of the right toe amputation site and a wound vac was initiated for wound care. Pain Evaluation was completed for Resident #3 on 5/15/12 and includes the following: General Information: [DIAGNOSES REDACTED]. Resident #3 answered yes when asked if he had pain in the last 5 days. He describes the pain as aching, throbbing, hot/burning. He indicated that additional symptoms associated with pain are depression and hostility. Resident #3 indicated that pain is increased by movement and treatments Pain location/type/frequency/intensity/duration: Resident #3 indicated that he has pain in the area of the right foot and buttocks frequently. He stated that he has pain to his left hip/femur occasionally. Pain effect on function: Inability to perform ADL's (Activities of Daily Living), Participation in activities, incontinence, loss of appetite and withdrawal from activities, and changes in mood/emotions Nonverbal/noncognitive signs of pain: Facial Expressions-grimacing, frowning, wrinkled brow and turned down mouth. Vocalizations-cursing. Body Actions/observed behaviors-fidgeting, striking out at others and depressed mood. Relief of Pain: Medications, Frequent Position changes and distraction. The form indicates that Resident #3's acceptable level of pain is 1 or 2 on a scale of 1-10 with 10 being the worst possible pain. The form indicates that Resident #3 is on [MEDICATION NAME] 5/325 mg prn for pain and it is effective within 1/2-1 hour. Conclusion: Pain management intervention is necessary, refer to resident plan of care. No individualized updates to the plan of care specific to the above assessment were completed for Resident #3 Nurses Note dated 5/16/12 at 11:05 AM. Resident #3 said he had some pain to foot but more to his buttock where there is a sore, gave 2 [MEDICATION NAME] for pain and repositioned him off the coccyx to side. A Change in Condition MDS dated [DATE] indicates that Resident #3 experiences moderate pain frequently. The CAA dated 5/30/12 indicates that the Resident is having pain that prn (as needed) [MEDICATION NAME] are effective for. No further comprehensive assessment was completed. Nurses Notes include the following: 5/19/12 at 12:41 PM indicates that Resident #3 complained of pain in his legs and buttocks and back. [MEDICATION NAME] given and was effective. 5/20/12 at 10:05 AM indicates that Resident #3 complained of pain in his hips and buttocks, one [MEDICATION NAME] given and was effective. 7:20 PM complained of pain in his hips, buttock and back. 2 [MEDICATION NAME] given and were effective. 5/24/12 at 1:45 PM-talked to Residents brother on the phone as Resident #3 had called him complaining that we have pushed him aside and don't care that he has pain to his coccyx as he is sitting in his wheelchair waiting to go to the Dr. appointment. Explained to the brother that he had been given 1 [MEDICATION NAME] for pain but he is sitting right on the sore spot. At 8:14 PM Resident #3 arrived back from Dr. around 4:30 PM and was demanding to be put in bed as he was being wheeled back into the facility. Put in bed, appeared more comfortable. Received 2 [MEDICATION NAME]. 5/28/12 at 11:56 PM Short-tempered this morning. Requested one [MEDICATION NAME] around 8:30 AM, administered but not very effective. No additional information related to other interventions attempted to relieve pain for Resident #3. Review of MAR (Medication Administration Record) for 5/12 indicates the following: Resident #3 received pain medication 20 times between 5/15/12-5/31/12. He received 8 of the 20 medications between 7:25 AM and 9:30 AM for a pain rating of 6-8 out of 10 on the pain scale. Surveyor # noted that there was no indication of comprehensive assessment related to the increased use of prn medications including looking at the times of administration to address possible patterns of when pain is exhibited. On 5/31/12 at 3:30 PM Surveyor # shared the above information with the NHA (Nursing Home Administrator)- A and DON (Director of Nursing)-B. NHA-A and DON-B were informed of the lack of comprehensive assessments and individualized care plans related to Resident #3's bowel and pain status as changes occurred. Surveyor # requested any additional information or assessments/care plans related to Resident #3's bowel or pain status. No additional information was provided 4.) On 5/29-5/31/12 Surveyor # reviewed Resident #4's medical record and noted the following: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 was readmitted from the hospital to the facility on [DATE] after treatment for [REDACTED]. Resident #4's routine medications include [MEDICATION NAME] 600 mg three times daily for neuropathic pain and [MEDICATION NAME] 5/325 2 tablets at night for pain. He can also receive [MEDICATION NAME] every 6 hours prn (as needed) Pain evaluation completed 12/14/11 indicates the following: General Information: No is checked for the question-Does the resident have any [DIAGNOSES REDACTED]. Resident indicated that he has chronic, aching pain in his left shoulder in the last 5 days. The form indicates that pain is increased by activities. Pain Location/type/frequency/intensity/duration: Pain indicated to be at area of left shoulder. The Resident indicated that the pain level was currently at a 2 out of 10 (worst possible pain) and that the worst it gets is an 8. The form indicated that 1 and 3 hours after medication it will go down to a level 1 Pain effect on Function: No areas checked Non Verbal/noncognitive signs of pain: all areas checked no Relief of Pain: Medications-which are indicated to be effective, acceptable pain level is 1-2 on a scale of 0-10 Admission MDS (Minimum Data Set) dated 12/21/11 indicates Resident #4 has occasional mild pain and rated his worst pain a 4 out of 10 with 10 being the worst possible pain. No additional comprehensive pain assessments are noted after the completion of this MDS. No care plan with individualized goals and approaches was developed for Resident #4 Nurse's Notes include the following: 1/3/12 at 1:23 PM Resident #4 complained of shoulders hurting. [MEDICATION NAME] given at 12:20 PM 1/14/12 at 9:46 PM Resident has been complaining of pain in his buttock area. Resident #4 was readmitted to the facility on [DATE] after being hospitalized for [REDACTED]. Nurse's Notes include the following: 2/17/12 at 9:00 AM Resident #4 incurred a witnessed fall from his wheelchair landing on his buttocks. 2/19/12 at 10:56 AM Resident complained of pain to left ribs, repositioned in recliner but pain not relieved. [MEDICATION NAME] given per resident request for pain 5/10 2/20/12 at 1:45 PM Resident complained of lower back pain. [MEDICATION NAME] was given and effective at relieving pain. 2/20/12 at 8:00 PM discussed the need to turn off of his back to help with the back pain. A Medicare required MDS was completed on 2/20/12 which indicated that Resident #4 had occasional mild pain. No additional comprehensive assessment was completed after this MDS. No updates were made to the Resident's care plan. No additional MDS or comprehensive assessments were completed for Resident #4 related to pain. (Cross Reference F276) Nurses Notes include the following: 2/22/12 at 6:20 PM Resident complains of left rib pain. PRN [MEDICATION NAME] given 3/16/12 at 2:59 PM Resident #4 was assisted to floor when he slid out of his wheelchair. 3/27/12 a care plan was developed for Resident #4 with PROBLEM: Resident has pain/alteration in comfort related to shoulder joint pain, lower extremity joint pain, gout. Resident's pain is also related to the following Diagnosis: [REDACTED]. Resident states that an acceptable pain for his chronic pain is 0 on a scale of 0-10. GOALS include that he will have amelioration of immediate pain, show no non verbal signs and symptoms and will not have a functional decline related to pain. APPROACH: Administer pain medication as ordered, always attempt non pharmaceutical interventions first, unless pain is excruciating, Contact physician for further orders if pain is not relieved, monitor for signs and symptoms of pain every shift, during activities and procedures. The care plan did not include individualized approaches to alleviate Resident #4's pain. It is a standard care plan utilized for all Residents that experience pain. On 5/30/12 at 10:15 PM Surveyor observed Resident #4 sitting up in the recliner in his room. Resident #4 told Surveyor # that the nurse put something on his knees for pain. Would like the strong pill he gets at night. Surveyor # informed RN (Registered Nurse)-R of Resident #4's request for pain medication. On 5/31/12 Surveyor # reviewed Resident #4's prn medication administration record. Resident #4 received prn pain medication 17 times in the month of May 2012. Examples of times pain interventions were not effective and no further approaches include : 5/1/12 at 8:30 AM he received [MEDICATION NAME] for left arm pain for rating of 8/10 (8 out of 10). His position was changed and distraction was used. At 9:19 AM documentation that pain rating remains at a 4/10 (4 out of 10). 5/13/12 at 8:15 AM he received [MEDICATION NAME] for hip pain at a rating of 8/10 (8 out of 10). His position was changed and distraction was used. At 9:00 AM the pain relief rating was 4/10 (4 out of 10). 5/22/12 at 2:00 AM Resident received [MEDICATION NAME] due to yelling for pain pill and describing pain as a 7/10 (7 out of 10). His position was changed and at 3:00 AM Resident #4 pain relief Rating was 5/10 (5 out of 10). On 5/31/12 at 3:30 PM Surveyor # shared the above information with the NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B. NHA-A and DON-B were informed of the lack of comprehensive assessments and individualized care plans related to Resident #4's pain status as changes occurred. Surveyor # requested any additional information or assessments/care plans related to Resident #4's pain status. On 6/1/12 at 2:00 PM RN-R told Surveyor # that Resident #4 is on scheduled pain medications for his buttocks/shoulder and hip. Laying in bed, repositioning, cream to bottom and Ben Gay all help relieve the pain. RN-R stated that Resident #4 can go a long time without complaints of pain. On 6/1/12 at 3:30 PM RN-K told Surveyor # that Resident #4 received routine [MEDICATION NAME] at bedtime as he was up during the night because of pain issues. They change his position often-up for supper then to lounge chair and then to bed. RN-K stated that same positions bother him. On 6/1/12 at 3:15 PM Resident #4's wife told Surveyor # that she was going to discuss his pain with DON-B today. She indicated that he is sensitive to pain and his Dr. just changed him [MEDICATION NAME] wants to discuss with DON. No additional information was provided. 5.) Surveyor # completed a reviewed of Resident #10's closed medical record on 6/1/12. Resident #10 was admitted to the facility on [DATE] following a total right knee replacement. Resident #10's discharge orders from the hospital included orders for weight bearing as tolerated. Admission assessment dated [DATE] indicates for toileting: A1 (assist of 1). Underpads, briefs and liners are not checked and no toileting schedule is indicated. The Bowel Evaluation document for Resident #10 dated 4/23/12 indicates that Resident #10 is alert, that Resident #10 has transfer/standing ability and that Resident #10 is wheelchair bound and that Resident #10's vision is adequate with aid and Resident #10 has adequate hearing abilities. Surveyor # noted that the rest of the evaluation document pertaining to actual elimination details and the evaluation for training potential has been left blank. The admission Minimum Data Set ((MDS) dated [DATE] indicates that Resident #10 cognitively is capable of making decisions and that Resident #10 requires extensive assistance for toileting with one staff for physical assistance. The MDS indicates that resident #10 is continent of bowel. The Care Area Assessment (CAA) dated 5/5/12 states: "Resident with some issues with continence due to urgency and functional incontinence issues. She needs assist with toileting at this time due to her recent knee replacement and is getting this help, but often dribbles when she needs to get to the toilet in a hurry. Will proceed to care plan." Review of Resident #10's care plan regarding continence with an approach date of 4/22/12 indicates: provide toileting assistance upon every request. Provide assistance with hygiene, combing hair, toileting as needed. Review of the Bowel elimination pattern indicates: 4/21/12: 8am and 9am - bowel large (surveyor # noted that the entry

Based on observation, interview and record review, the facility did not ensure that each resident's abilities in activities of daily living (ADLs) do not diminish unless the circumstances of the resident's clinical condition demonstrate the diminution was unavoidable; the facility did not ensure this for 1 (Resident #1) of 4 residents reviewed. Resident #1 has experienced declines in her toileting, balance, transfer and ambulation abilities, as well as her dressing, hygiene and bathing abilities. Findings include: Resident #1 has been living in the facility since July 2008 and has [DIAGNOSES REDACTED]. The 9-15-11 Minimum Data Set (MDS) and 3-13-12 quarterly update indicate Resident #1 is cognitively intact and able to communicate her thoughts and needs. The 8-10-11 quarterly update of the MDS indicates the resident is cognitively intact and required limited assistance from one staff member with her dressing and bed mobility, toilet needs, hygiene and bathing needs. The same MDS indicates Resident #1 required limited assistance of one staff member with her transfer abilities and was independent in her ambulation abilities both inside and outside of her room; Resident #1 ambulated with the use of a walker. In September 2011, Resident #1 was hospitalized for [REDACTED]. The 9-15-11 significant change in condition MDS indicates Resident #1 requires extensive assistance of two staff members for her transfer needs, dressing, hygiene and bathing needs and bed mobility. Resident #1 requires total assistance of one to two staff members for her ambulation and balance needs, and her toilet needs. The 3-13-12 quarterly MDS indicates the resident's ADL abilities have not changed. On 5-29-12 at 10:45 AM, Surveyor # interviewed Resident #1; during the interview Resident #1 indicated she has not ambulated with the walker since falling in an incident in the bath tub room on 5-11-12. Upon review of Resident #1's clinical record, it is determined the Resident has not ambulated independently since before the hospitalization in September 2011. The Resident's clinical record documents the resident was evaluated by both physical therapy (PT) and occupational therapy (OT) upon return from the hospital in September 2011. Resident #1 was discharged from OT and PT on 9-29-11 and 10-5-11 respectively. The goals set forward for Resident #1 by both OT and PT was for her to return to her prior level of functional ability, but as OTR-M (occupational therapist) documented in the discharge summary "(Resident) is very guarded of right hand and is fearful to use right hand due to pain. Provided right wrist brace and (restorative nursing program) to maintain (active range of motion). (Resident) prefers to have help with ADLs and mobility. Equipment recommended upon discharge: hemi walker." These goals were not met. Surveyor # interviewed OTR-M on 5-31-12 at 8:05 AM. OTR-M indicated Resident #1, at the time of rehabilitation services in September 2011 was having pain in the right arm, was holding it close to her body, not allowing it to be touched and stated she would rather let the nursing assistants assist her with her ADLs. OTR-M acknowledged Resident #1 has not ambulated since the hospitalization . OTR-M indicated the plan was that nursing would follow through with the restorative nursing program so that the resident would not develop contractures, particularly of the right arm. Surveyor # spoke with the Administrator and the Director of Nurse's on 5-31-12 at approximately 3:30 PM during the daily exit conference and related the interview with OTR-M. Surveyor # asked the administrative staff if Resident #1 has been re-approached since the resolution of the thrombus of the resident's right arm in order to assist her to her previous functional level; the Director of Nurse's acknowledged the Resident has not been re-evaluated, with or without OT and PT input. On 5-31-12 at approximately 8:00 AM, Surveyor # observed Certified Nursing Assistant (CNA)-F and CNA-I assist Resident #1 with her ADLs. The staff were observed to provide the care, providing pericare using a disposable towelette, and applying deodorant to the Resident's underarms without having first washed the areas. The only portion of the care the Resident was allowed to do for herself was to wash her face when CNA-I handed her a wet wash cloth; CNA-G and CNA-I also chose the Resident's clothing and dressed her.