Every finding on record at Edenbrook Lakeside

Based on observation, interview, and record review, the facility did not ensure that 2 (R1, R3) of 3 residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. *On 8/2/26 R1 was transferred by staff into a high-back wheelchair when the wheelchair tipped backwards and R1 fell sustaining a head laceration that required 2 staples in the emergency department (ED). R1's care plan documented R1 required a Broda wheelchair. R1 did not have post-fall assessments for monitoring completed every shift on 8/4/26. *R3 sustained a fall on 7/19/26 and did not have post-fall assessments for monitoring completed every shift on 7/20/26, 7/21/26, or 7/22/26. Findings include: The facility policy titled Fall Prevention, Post Fall, and Communication with issue date 1/21/26 documents: . Purpose: to promote resident safety by identifying fall risk, implementing individualized fall-prevention interventions, ensuring timely post-fall evaluation, and reviewing outcomes to prevent recurrence. Fall-prevention interventions: interventions will be individualized by the interdisciplinary team (IDT) and may include supervision level, transfer status, mobility assistance and therapy involvement, medication review, toileting plans, environmental safety measures, assistive device use, and resident preference considerations. Interventions must be implemented consistently and revised when not effective. Monitoring and Re-evaluation: document on residents' condition at a minimum of every shift for 72 hours; staff should document relevant post-fall clinical findings, such as vital signs, pain, swelling, bruising, and changes in function or cognitive status; staff will have increased awareness that the resident has recently fallen and report any changes in function, increased pain, and changes in cognition to the nurse for further evaluation; monitor for signs of head injury, including but not limited to, reduced level of consciousness, lethargy, significant weakness in one or more of the extremities, and rapid deterioration in neurological function. The facility did not have a policy on transfer techniques. 1). R1 admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis (MS), schizophrenia, and Type 2 Diabetes Mellitus. R1 had a guardian for healthcare decisions. R1's Care Area Assessment (CAA) for functional abilities dated 4/22/26 documented R1 had a primary diagnosis of MS, quadriplegia, and muscle wasting. Proceed to care plan to prevent decline in function and mobility. R1's Quarterly Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment, R1 was dependent on staff for transfers to and from a bed and a wheelchair, and R1 did not have any falls since the last MDS assessment. R1's fall scale dated 7/23/26 documented a score of 35.0, indicating R1 was at a moderate risk for falling. R1's care plan for care area limited physical mobility due to MS and tetraplegia with initiated date 5/14/21 and revised date 6/26/26 documented the following interventions: -ambulation/locomotion: non-ambulatory, Broda chair- manual (10/20/23) -bed mobility assist – two (6/26/26) -non-ambulatory – totally dependent on one staff with Broda chair (5/14/21) -transfer assist – full body lift and assist of two, large sling (8/18/22) Surveyor noted R1's care plan did not specify how the Broda chair should be positioned when transferring R1 in and out of the wheelchair. R1's care plan for care area at risk for falls with initiated date 5/14/21 and revised date 8/3/26 documented the following interventions: -anticipate and meet my needs (5/14/21) -educate me and my family/caregivers about safety measures and what to do if a fall occurs (5/14/21) -ensure my call light is within reach (5/14/21) -ensure my environment is free from clutter and hazards (5/14/21) -keep bed control out of reach, as resident confuses TV remote with bed control (2/11/22) -monitor labs, HgA1C every month (5/14/21) -physical therapy (PT)/occupational therapy (OT) evaluation and treatment as indicated (5/14/21) R1's nursing progress note dated 8/2/26 documented nurse requested writer call 911 due to a head injury to resident from a witnessed fall during a transfer. Writer came to room and assessed resident. Resident had a bleeding head injury to posterior cranium that the nurse was controlling. Resident was alert and oriented (A&O). 911 was called, paramedics dispatched and transported resident to the hospital for treatment. R1's nursing progress note dated 8/2/26 documented resident returned to the facility around 1400 via ambulance. Computed tomography (CT) done in hospital which was negative for brain bleed and fracture. Two staples placed to head laceration. R1's hospital after visit summary dated 8/2/26 documented head CT without brain bleed. Wound was cleaned and 2 staples placed in laceration. R1's ED visit note dated 8/2/26 with printed date 8/18/26 at 12:38 PM documented a 2.5 centimeter (cm) laceration to the occipital scalp. Surveyor reviewed R1's post-fall assessments conducted between 8/2/26 and 8/6/26 and noted the following assessment dates and times: -8/2/26 18:37 (6:37 pm) -8/3/26 3:55 am -8/3/26 7:17 am -8/3/26 15:40 (3:40 pm) -8/3/26 23:41 (11:41 pm) -8/4/26 8:42 am -8/4/26 19:44 (7:44 pm) -8/5/26 7:31 am -8/5/26 17:59 (5:59 pm) -8/6/26 6:25 am Surveyor noted a post-fall assessment was not completed on the night shift for R1 on 8/4/26. On 8/18/26 at 11:38 AM, Surveyor interviewed Director of Nursing (DON)-B who stated staff shifts are 6:00 am – 2:30 pm (first shift), 2:00 pm – 10:30 pm (second shift), and 10:00 pm – 6:30 am (night shift). DON-B stated post-fall assessments include monitoring of a resident's neurological status and cognition after a fall and are completed each shift for 72 hours after a fall occurs for all falls, regardless of if the fall was witnessed or unwitnessed or if a resident hit their head. DON-B stated if the post-fall assessments were not in the electronic documentation system, they were not completed. Surveyor reviewed R1's post-fall assessments 8/2/26-8/6/26 and shared the concern that no post-fall assessment was completed on the night shift on 8/4/26. DON-B stated a post-fall assessment should have been completed on this shift. On 8/18/26 at 10:06 AM, Surveyor interviewed R1, who denied any pain and stated the area of the laceration was doing well. R1 remembered the fall and stated the wheelchair fell backwards and he hit his head. R1 stated that had never happened before. Surveyor observed a Broda chair in R1's room and asked R1 if that was the wheelchair that was in his room at the time of the fall. R1 stated it was a different wheelchair at the time of the fall, and the facility provided him with the current Broda chair after the fall. R1 was not sure what kind of wheelchair was in his room before. On 8/18/26 at 11:09 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D, one of the CNAs who transferred R1 into the wheelchair on 8/2/26. CNA-D stated they gave R1 a bed bath and afterwards asked if R1 wanted to get up into the wheelchair for a little while and R1 was agreeable. CNA-D stated they got CNA-E to assist with the full body lift transfer. CNA-D stated CNA-E moved the full body lift while CNA-D assisted with positioning R1 into the wheelchair. CNA-D confirmed R1 was transferred into a high-back wheelchair that was present in R1's room at the time, and that R1 was not transferred into a Broda chair. CNA-D stated the back of the high-back wheelchair was in a reclined position at the time of the transfer. CNA-D stated as soon as the full body lift sling was unhooked from the lift, the wheelchair immediately tipped backwards and R1 hit his head on the floor which started bleeding. CNA-D stated they gave CNA-E a towel and got a nurse right away. CNA-D stated they have worked at the facility for five months, and this was the first time CNA-D got R1 up into the wheelchair because he prefers to stay in bed most of the time. CNA-D stated there was not a Broda chair in R1's room at the time, only the high-back wheelchair. On 8/18/26 at 1:59 PM, Surveyor asked CNA-D how far back R1's wheelchair was reclined at the time of the transfer on 8/2/26, and CNA-D stated the back of the high-back wheelchair was reclined in between fully upright and all the way flat. Surveyor demonstrated a 45 degree recline to CNA-D with Surveyor's hands, and CNA-D stated the wheelchair was reclined to that angle. On 8/18/26 at 11:38 AM, Surveyor left a message for CNA-E via phone call to return Surveyor's call, but Surveyor did not receive a call back. CNA-E is no longer employed at the facility. On 8/18/26 at 10:25 AM, Surveyor observed CNA Supervisor-F and CNA-G transfer R1 from bed into R1's Broda chair using a full body mechanical lift. During the transfer, Surveyor observed R1's Broda chair was in a reclined position until CNA Supervisor-F and CNA-G completed the transfer and unhooked the full body lift sling from the lift, then CNA Supervisor-F and CNA-G placed the Broda into a more upright position per R1's preference. On 8/18/26 at 1:59 PM, CNA Supervisor-F confirmed this is how R1 is always transferred into his wheelchair with the Broda chair in a reclined position. On 8/19/26 at 2:07 PM, DON-B stated when transferring a resident from bed into a Broda wheelchair or any wheelchair with a total body mechanical lift, the CNA and nursing staff should follow the steps outlined in the Total Lift document. DON-B stated that staff were trained on this technique upon hire, and staff were re-trained on these steps after R1 suffered the fall on 8/2/26. Surveyor reviewed the Total Lift form, which documented: resident transfers for all non-weight-bearing or significantly contracted residents should be done using a total lifting device. The steps below were outlined on the form: -bring equipment to the beside. Use the proper size sling for the resident. The sling and lift should be inspected. Evaluate the resident and explains the lift procedure to the resident. -a caregiver on each side of the bed. Must be two caregivers present for this. The height of the bed is adjusted into a safe work zone for the caregivers. -roll resident toward one caregiver; place the sling so that is low down on (under) the resident's back. -roll resident toward the second caregiver across the sling so that the resident is squarely in the center. -secure the wheelchair (if applicable) from movement. -roll the lift to the side of the resident's bed. Open the base of the lift to its widest point. Place the base under the bed so that the guide handles are next to the bed and the overhead bar of the lift is directly over the resident. The second caregiver grabs the bar as the lift is lowered so it does not strike the resident. -hook the loops on to the bar of the lift according to the size of the resident. -provide support for the resident's head if there is not a head support on the sling. -check all connections on the lift to be sure that they are secure and will support the resident. -raise the resident off the bed. One caregiver operates the controls and uses one hand to assist with guiding the lift. The other caregiver uses both hands to control the lift. -when the sling is high enough to move the resident easily and safely, roll the lift away from the bed. -roll the lift over the chair until the chair is inside the base of the lift, directly under the sling. The caregiver should try to avoid turning the lift if possible. -slowly turn and lower the resident gently into the chair. -when the resident is securely seated, release the attachments. Remove the sling from under the resident and roll the lift out of the way. To remove the sling: lift one leg of the resident at a time and slide the sling outward and remove. Explain to the resident what you are doing and ask him/her to lean forward so you can slip the sling upward. -allow the resident to remain seated according to the physician's orders. Make certain the resident is comfortable and the call button is within easy reach of the resident. -wash hands after the procedure is completed. Surveyor noted the steps for the total lift transfer did not specify how the wheelchair should be positioned or if the wheelchair should be upright or reclined. On 8/18/26 at 1:36 PM, Surveyor interviewed Director of Rehabilitation (DOR)-H who stated all long-term care and short-term care residents are assessed by PT/OT to determine transfer status, which is then communicated to nursing staff. DOR-H stated long-term care residents are also screened every 3 months to make sure their transfer status has stayed the same. DOR-H stated when transferring a resident from a bed into a Broda or a high-back wheelchair, the chair could be reclined depending on resident needs, such as if the resident had poor trunk control or spasms. DOR-H stated a Broda or high-back wheelchair could also be reclined during the transfer so the resident could be positioned properly in the wheelchair before being lifted into an upright position. DOR-H stated they were familiar with R1 and R1 has worked with therapy in the past. DOR-H stated R1 required a full body lift and a Broda wheelchair at baseline. DOR-H stated R1 did not have good trunk strength and had quadriplegia, so it would be appropriate for the wheelchair to be reclined during transfers into the wheelchair. Surveyor requested R1's most recent PT or OT discharge status and screen from DOR-H. R1's Therapy Recommendations to Nursing document dated 4/3/26 documented R1 was dependent with bed mobility and transfers with a full body lift and 2-person assistance and dependent with ambulation, continue with current transfer method. R1's OT Discharge summary dated [DATE] documented R1 uses a Broda chair and full body lift, dependent assistance for transfers from a bed to chair. Surveyor noted the Therapy Recommendations to Nursing form and OT Discharge summary did not specify if R1 required the Broda wheelchair to be reclined during transfers in and out of the wheelchair. On 8/19/26 at 2:07 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A, DON-B, and Regional Director of Clinical Services-C that R1 fell on 8/2/26 after being transferred by staff into a high-back wheelchair in a reclined position and sustained a 2.5 cm laceration to the scalp requiring two staples in the ED. Surveyor shared concern that R1's care plan documented R1 required a Broda wheelchair for transfers, and R1's care plan did not specify R1's wheelchair should be reclined during transfers. Surveyor shared concern that there was not evidence that the facility assessed the optimal positioning of a Broda or high-back wheelchair during a total body lift transfer to include if the wheelchair should be in a reclined position. Surveyor shared concern that a post-fall assessment with monitoring was not completed every shift for 72 hours after R1's fall on 8/2/26. 2.) R3 was a [AGE] year-old resident who was admitted to the facility on [DATE]. R3's diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R3's minimum data set (MDS) documented R3's brief interview of mental status (BIMS) score of 10. That indicated R3 had moderate cognitive impairment. The MDS documented R3 had 2 or more falls since admission. R3's care area assessment (CAA) for falls triggered due to R3 having previous falls and being on an antidepressant. R3's fall care plan initiated on 5/14/2025, documented the following interventions: place pillows in R3's bed to define the perimeter, initiated on 2/19/2026; rotate R3's bed and place a wedge on R3's right side, initiated on 2/23/2026; place R3's items in reach, initiated on 3/19/2026; educate roommate's family to open the privacy curtain after visits, initiated on 7/19/2026; get R3 ready for the day by 9:00 AM, initiated on 9/22/2025. Surveyor reviewed R3's electronic medical record (EMR). Surveyor noted R3 had a fall on 7/19/2026. Surveyor reviewed R3's fall investigation from 7/19/2026. Surveyor reviewed the facility's policy for post fall assessments. The policy stated post fall assessments were to be completed every shift for 72 hours. Surveyor noted R3 had missing post fall assessments. On 7/20/2026, three post fall assessments were missing. On 7/21/2026, one post fall assessment was missing. On 7/22/2026, one post fall assessment was missing. On 8/18/2026, at 11:58 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-L regarding the documentation required after a resident falls. LPN-L stated after a resident falls, post falls assessments are required every shift for 72 hours. On 8/18/26, at 11:38 AM, Surveyor interviewed Director of Nursing (DON)-B regarding post fall assessments. Surveyor informed DON-B that there were 5 missing post fall assessments for R3's fall on 7/19/2026. DON-B stated they were not sure why the assessments were not completed. DON-B stated if the post fall assessments are not in the resident's medical record, then the assessments were not completed. DON-B stated post fall assessments are to be completed every shift for 72 hours after a fall. On 8/19/2026, at 2:07 PM, Surveyor shared the concern with DON-B and RDOCS-C that post fall assessments were not completed every shift for 72 hours after R3's fall on 7/19/2026.

Based on interview and record review the facility did not ensure residents received necessary care and treatment in accordance with professional standards of practice for 1 (R6) of 3 residents reviewed for non-pressure injuries.*R6 had an arterial wound on their left great toe. The left great toe wound had multiple treatments not documented from May 2026 to July 2026.The facility policy titled Procedure Dressing Change - Clean, initiated on 8/26/2018 and last revised on 2/24/2023 documented . Medical record documentation and follow up as applicable: 1. The date and time the dressing was changed. 2. Any problems or complications. 3. If the resident refused the treatment and the reason(s) why. 4. Notify the supervisor if the resident refuses the dressing change. 5. Report other information in accordance with facility policy and professional standards of practice.R6 was an [AGE] year old resident that was admitted to the facility on [DATE]. R6's diagnoses included peripheral vascular disease and stage 3 chronic kidney disease. R6's quarterly minimum data set (MDS) documented R6 to have a short-term and long-term memory problem. The MDS documented R6 had 1 venous or arterial wound. R6's skin integrity care plan implemented on 4/22/2026, documented the following interventions: R6 sent to emergency room for evaluation, initiated on 4/22/2026; apply treatment as ordered, initiated on 5/5/2026; and keep R6's legs in a neutral position, initiated on 5/5/2026.Surveyor reviewed R6's physician orders as follows: R6's treatment to their left great toe was to apply betadine two times a day. The start date was 5/5/2026, with an end date of 6/11/2026.Surveyor noted there was no documentation of this treatment on the following dates: 5/6/2026 in the morning, 5/12/2026 in the afternoon, 5/16/2026 in the morning, 5/17/2026 in the morning, 5/21/2026 in the morning, and 5/30/2026 in the morning.R6's treatment to their left great toe was to apply betadine and gauze every other day. The start date was 6/11/2026, with an end date of 7/21/2026. Surveyor noted there was no documentation of this treatment on the following dates: 6/19/2026, 6/27/2026, 7/1/2026, 7/13/2026, 7/15/2026, and 7/17/2026.On 8/19/2026, at 3:41 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-K. ADON-K stated they are the wound care nurse for the facility. Surveyor provided ADON-K a copy of R6's treatment administration record (TAR) to review. Surveyor asked ADON-K if they knew why the treatments were not completed on the dates listed above. ADON-K stated they were not sure why the treatments were not completed. ADON-K stated the floor nurses are responsible for completing treatments for their shifts. ADON-K stated they expect treatments to be completed per physician orders and documented by the end of the nurse's shift. On 8/19/2026, at 3:45 PM, Surveyor shared the concern regarding R6's missing treatment dates. DON-B stated they expect staff to complete the treatment as ordered and complete the associated documentation by the end of their shift. DON-B stated they are aware the facility staff have ongoing issues with charting completed tasks and are currently working on educating the staff to complete their charting for assigned tasks at the end of the shift.

Based on observation, record review, and staff interviews, the facility did not ensure they provided an environment free from accident hazards for 2 of 4 residents (R) reviewed for accidents and supervision (R59 and R110.) Certified Nursing Assistant (CNA)-E rolled R59 away from them while providing care in bed and R59 rolled out of bed on to the floor. The facility's investigation into the fall identified R59's specialty air mattress was not appropriately attached to the bedframe allowing the mattress to flip upright when R59 was rolled onto their right side causing R59 to fall. R59 suffered a L2 lumbar fracture as a result of the fall from the bed to the floor. R110 has been assessed to need the assistance of 1 staff member and a gait belt for safety for transfers. Surveyor observed R110 being transferred by 1 staff member without the use of a gait belt for safety. Evidenced by: 1.) R59 was admitted to the facility on [DATE] with diagnoses that included conversion disorder with seizures or convulsions, congenital deformity of knee, developmental disorder of scholastic skills, and morbid obesity. A review of the quarterly MDS (Minimum Data Set) dated 1/29/26, documents R59 has a BIMS (Brief Interview for Mental Status) score of 15 indicating R59 is cognitively intact. R59 is assessed to have limited range of motion on 1 side of the upper extremity and impairment on both sides of the lower extremities. R59 is dependent on staff when rolling left to right, from lying position on her back while in bed. R59 is dependent on staff for Activities of Daily Living such as incontinence cares and personal hygiene. Surveyor conducted a review of R59's individual plan of care and noted the following: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) obesity, seizure, bipolar disorder, healing foot fracture, deformity of knee. Date Initiated: 05/14/2025. Revision on: 05/22/2025. Interventions include: Personal Hygiene/assist of one. Date Initiated: 05/14/2025 The resident has limited physical mobility r/t obesity and congenital deformity of knee. Date Initiated: 05/14/2025. Revision on: 05/14/2025. Interventions include:*Ambulation. Locomotion-wheelchair manual. Date Initiated: 05/14/2025*Bed mobility assist–Two. Date Initiated: 04/18/2026. Surveyor notes this intervention was updated after R59's fall on 4/17/26.*PT (Physical Therapy) and OT (Occupational Therapy) eval (evaluation) and treatment per MD (Medical Doctor) orders. Date Initiated: 05/14/2025.*Transfer assist - sit-to-stand-Two. Date Initiated: 07/10/2025*Transfer assist-Two. Date Initiated: 05/14/2025 The resident is at risk for falls r/t repeated falls, osteoarthritis, fibromyalgia. Date Initiated: 05/14/2025. Revision on: 04/19/2026. (Surveyor notes this care plan was updated after R59's 4/17/26 fall.)Interventions included:*I will be free from further incident/falls through the review date. Date Initiated: 05/14/2025.*4/17-ED (Emergency Department) to eval (evaluate) and tx (treat). Bed rearranged to promote safety. PT/OT to eval and treat for positioning. Air mattress discontinued. Resident changed to a 2 person assist with bed mobility. Date Initiated: 04/17/2026. Surveyor notes this intervention was updated after R59's fall on 4/17/26.*PT/OT to evaluate and treat. Date Initiated: 05/14/2025.*Gripper socks on when up. Date Initiated: 05/14/2025. R59 is at risk for alteration in skin integrity related to type two diabetes, obesity. Date initiated 5/14/25.Interventions included:* Use a pressure relieving cushion for my wheelchair and pressure reducing mattress to my bed. On 2/10/26, the facility completed a MORSE fall scale (a clinical tool used to assess a patient's likelihood of falling) for R59. R59 was assessed to be at moderate risk for falls. Nursing note dated 4/17/2026 at 10:07 PM, documents around 9pm, writer (Assistant Director of Nursing-C) was called into resident's room, R59 had witnessed fall. Resident assessed, PERRLA (Pupils Equal, Round, and Reactive to Light) intact, resident remains A&Ox4 (alert and oriented times four,) C/O (complaint of) 8/10 pain to right arm and right leg. R59 requesting to go to ER. [Name of transport company] ambulance notified. Vitals: BP (blood pressure) 118/82, HR (heart rate) 86, SPO2 (oxygen saturation) 97%, RR (respiratory rate) 18. R59 assisted to back side. ROM (Range of Motion) passively provided, and able to move WNL (within normal limits.) [Name of transport company] ambulance arrived, R59 transported to [name of hospital] around 9:45 PM. Verbal bed hold obtained, resident unable to sign. R59's mother updated, Physician on call notified, NHA (Nursing Home Administrator)-A, and DON (Director of Nursing)-B notified. Nursing Note dated 4/18/2026, at 2:17 AM, (R59) Back from ER, alert and awake, denies pain at this time. Has L2 lumbar fx (fracture) per ER report, pt (patient) to follow up with Neurologist. BP 129/77, HR 69, pox 98, on RA, temp 98.7. support provided. Nursing note dated 4/18/2026, at 6:10 AM, CT (Computed Tomography) results received from hospital. Fracture of the L2 vertebral body. It is unclear if this is acute or chronic. NHA-A notified. Surveyor conducted a review of the after-visit summary dated 4/17/26 and provided by the hospital. The summary stated R59 injured multiple areas with her fall today but the only area that is broken is the L2 vertebra in the lower back. This should heal with time without surgery. However, it does need follow-up with the neurosurgeon to monitor the area as it heals. The ribs, shoulder, hip etc. had negative x-rays and are just bruised. R59 may use prescribed medications for pain. Continue other home medicines as prescribed. Follow-up with primary care provider for recheck of other areas of injury/pain. Return to emergency room as needed for new or worsening concerns. You (R59) have a crushed vertebra. This is a compression fracture of one or more bones in your spine. This kind of break usually happens in older people with thinning of the bones called osteoporosis. It may happen after a ground-level fall or even with a very minor force. This means the spine doesn't need to be surgically realigned or fused. And it usually doesn't cause any injury to the spinal cord or nerves. The injury often takes 1 to 3 months to heal. It can be treated at home with short-term bed rest and pain medicine. A back brace or abdominal binder may be prescribed. This reduces pain by limiting motion at the fracture site. Surveyor conducted a review of the facility's Misconduct Incident Report submitted to the State Survey Agency on 4/24/26. The report documents that on 4/17/26 at approximately 9:00 PM, R59 sustained a witnessed fall from bed while receiving cares from CNA (Certified Nursing Assistant)-E. At the time of the incident, R59's care plan identified R59 as requiring an assist of one staff for cares and staff was following the current care plan. R59 sustained a fracture of lumbar spine. The incident summary documents R59 was positioned on her right side facing the window. The bed positioned against the window wall. Staff reported the bed suddenly lifted on the window side, causing R59 to fall to the floor. Staff immediately called for assistance and 911 was contacted and R59 was transported out to the emergency department for further evaluation. The Investigation findings document a post-incident inspection identified a broken plastic clip securing the air mattress strap to the frame on R59's left side. The mattress was immediately removed from service and replaced. R59 was reassessed following the fall. R59's level of assist was updated from assist of one to assist of two. R59's care plan was revised accordingly. Corrective Actions documented, all facility air mattresses were inspected for defects, securement clips, and proper function. All beds were inspected for proper functionality. Any identified variances were corrected immediately. Residents utilizing air mattresses were reassessed for level of assistance needs, their care plans updated as indicated. Maintenance system was updated to include preventative maintenance checks on air mattress tie-down clips and functionality. The incident investigation identified a failed mattress securing clip during equipment inspection. Surveyor notes the facility's investigation included a signed statement from Maintenance Director-D, dated 4/19/26, documenting the Maintenance Department inspected all air mattress beds to ensure the plastic tie down clips were not cracked or broken and functioning as intended. The inspection of tie down clips was added to the Maintenance Department PM log under the Tels system. Surveyor did request to review the PM log in the Tels system and was not provided a log for inspection of tie down clips completed by the Maintenance Department. Surveyor conducted a review of the facility's fall investigation dated 4/17/26 which documents writer (Assistant Director of Nursing (ADON)-C) was called into room by CNA due to resident rolling out of the bed during cares. Upon entering room, the resident was on the floor. The resident was noted between the right side of the bed and the heater. The air mattress was off of the bed frame, and left side in the air, and leaning against the wall. Writer removed everything in the way including the bed and air mattress. Resident was lying completely on her right side, with her head in the air. Her shoulders protected her head from hitting the ground. R59 stated, I don't know what happened. Writer assisted R59 back onto back. R59 complained of pain to right arm and right leg. R59 was asked to lift arms, R59 unable to independently lift right arm. Writer provided passive range of motion, R59 stated ouch. R59 rated pain 8/10. Ambulance called and R59 transported to hospital. On 4/20/26, the investigation included a root cause. Root Cause: Cares were being performed and resident air mattress flipped up and R59 slid off the bed to the floor. Intervention: Immediately sent to emergency department for eval and mattress changed while at emergency department. Permanent intervention regular mattress and room rearranged. On 6/1/26, at 12:05 PM, Surveyor interviewed Director of Maintenance (DM)-D regarding routine maintenance of resident beds and mattresses. DM-D stated the maintenance department will put a new mattress in place, such as a specialty air mattress, when requested by nursing. DM-D stated the specialty air mattress has 3 straps on each side that are clipped together around the bed frame. There would be a total of 6 straps holding the air mattress in place on the bed frame. Surveyor asked DM-D if he was aware R59's air mattress had a broken clip. DM-D stated he was not aware and if 1 clip was broken, the other clip/straps would still hold the mattress in place. DM-D stated he does not routinely check the beds and air mattress after they put them in place for resident use. DM-D stated the nursing staff are the eyes and ears and would notify the maintenance department if something was broken or not working properly. On 6/1/26, at 1:40 PM, Surveyor interviewed CNA-E who provided cares to R59 on 4/17/26. CNA-E stated R59's plan of care allows for 1 staff person to provide cares to R59. R59 needs the assistance of 2 staff for transfers. CNA-E stated R59 was lying in her bed when she rolled R59 towards the window to finish providing incontinence cares. CNA-E stated it happened so quickly when R59 was rolling over she rolled off of the bed onto the floor. R59 is heavier and the motion of the fall caused the bed to move towards CNA-E, and she couldn't grab R59 fast enough to prevent the fall. CNA-E stated the air mattress never came off of the bed frame, but the bed did move, resulting in R59 lying on the floor between the bed and the wall. CNA-E stated she was not aware there was a broken clip on the air mattress. CNA-E stated R59 is now 2 staff assist for cares and this is much better for everyone. According to https://www.pioneernetwork.org/wp-content/uploads/2018/07/Restorative-Transfers.pdf: Dependent Roll - Set-up - Make sure that the resident has plenty of room on the side direction he/she wishes to roll. Pre-roll Positioning - The person assisting positions him/herself on the side of the bed toward which the resident is to roll. Cross the lower leg farthest away from you over the extremity closest to you. Cross the arm farthest away from you over the chest, supporting the arm as necessary. Place one hand on the back of the pelvis and one hand on the shoulder blade. Roll - Gently roll the resident toward you onto his/her side. Encourage the resident to turn his/her head in the direction of the roll. Position arms and legs with pillows as needed. Encourage the resident to assist in the following ways: Flexing the opposite hip and knee, placing the foot flat and aiding the roll by reaching forward with the pelvis. Turn the resident's head in the direction of the roll. If the roll is toward the affected side, have the resident place his/her unaffected arm in the direction of the roll. If the roll is toward the unaffected side, have the resident clasp his/her hands together (as in praying), and reach with both arms in the direction of the roll. The Headmaster (WI Nurse Aide Candidate Handbook) mock skills for peri-care document includes: The test observer stands on the side of the bed where the rail would have been raised. The test observer doesn't move there until the candidate tells them to, so it is clear the candidate was thinking of what safety precautions need to be in place before starting the skill. So, if there was no side rail raised, a second staff member would have to be present on that side of the bed for safety. On 6/1/26, at 2:07 PM, Surveyor interviewed ADON-C regarding R59's fall from bed on 4/17/26. ADON-C stated when she arrived to R59's room, R59 was observed on the floor between the bed and the window, and the air mattress was flipped up and remained in the air. ADON-C stated they moved items out of the way, the bed and air mattress, to get to R59 and roll her onto her back. R59 did complain of pain to the right arm and leg. R59 was immediately transported out for further evaluation. Surveyor questioned ADON-C again about the air mattress and the position after the fall. ADON-C stated the air mattress was definitely upright and not on the bed frame. Surveyor notes CNA-E rolled R59 towards the window, away from CNA-E to complete incontinence care. R59 was being rolled and rolled off the bed on to the floor. Surveyor also notes CNA-E stated the air mattress never came of R59's bed which conflicts with ADON-C's account of the incident. ADON-C was called to the room following R59's fall. ADON-C statement after the fall documents the resident was on the floor, noted between the right side of bed and heater. The air mattress was off of the bed frame, left side in the air. ADON-C confirmed to Surveyor in an interview that R59 was on the floor when she arrived to the room and the air mattress with upright and not on the bed frame. On 6/1/26, at 2:45 PM, Surveyor made observations of R59's room arrangement and bed/mattress while R59 was out of the room. R59's head of the bed was now against the wall with the window, and the left side of the bed was up against the wall. It was noted there was a bariatric mattress (48 inches wide) on a twin-size bedframe. Surveyor observed the mattress was hanging over the bedframe, on the left side, approximately 5 inches. The entire left side of the mattress was not supported by the bedframe and could easily be lifted up on the bedframe. The entire mattress was easily moved from the bed frame as it was not appropriately attached and too big for the bed frame itself, preventing it from fitting in the bed frame brackets. This made for an unsafe environment for R59 as the mattress could fall off the bedframe if R59 rolled to her left side. On 6/1/26, at 3:13PM, Surveyor interviewed DM-D and asked if he could confirm Surveyor's observation regarding R59's mattress being too large for the frame. DM-D confirmed that after R59 fell from the bed on 4/17/26, the air mattress was replaced with a regular pressure reduction mattress. DM-D stated the bedframe itself was not switched out. DM-D confirmed the mattress that was currently on R59's bed was a bariatric mattress that was 48 inches wide. DM-D confirmed the mattress must fit in between the bed frame brackets in order for it to be secure. During this observation, DM-D confirmed that no one in the maintenance department had been up to adjust R59's bedframe, although the bedframe had been adjusted after Surveyor's observation at 2:45 PM on 6/1/26. The mattress was now positioned correctly as the bedframe itself had been widened. DM-D stated he does not regularly get into each resident's room and depends on staff to alert him if there is something not working properly. On 6/1/26, at 3:30 PM, Surveyor interviewed Nursing Home Administrator-A and DON-B regarding Surveyor's observation of R59's mattress being too large for the bedframe with a 5-inch overhang on the side (width) of the bed being observed. Nursing Home Administrator-A and DON-B stated they had not been in R59's room to observe the bedframe. At this time, Surveyor stated there are additional safety concerns for R59 and the bed was a continued accident hazard. Nursing Home Administrator-A was asked if the facility is conducting routine maintenance on resident beds. Nursing Home Administrator-A stated he would provide Surveyor with the Tells report that is used to log the resident bed checks completed by maintenance. As of the time of exit, the Tells report provided was a check for bed rail inspection. This inspection was conducted for 1 resident who uses a bed rail. As of the time of exit, the facility was unable to provide additional evidence they had provided a safe environment free of accident hazards for R59. R59 was placed in bed with an air mattress that had a broken clip/strap. When R59 was on their side and rolled away from CNA-E, the air mattress was said to have flipped upright, causing R59 to fall to the floor. This fall resulted in R59 fracturing the L2 vertebra. Surveyors made observations of R59's bed on 6/1/26 and the mattress was not properly fitted to the bedframe, potentially becoming an accident hazard for R59. 2.) The facility's policy titled Gait-Transfer Belt and last revised 1/17/22 documents under purpose: To transfer or ambulate an individual with lower extremity weakness safely. Under procedure Transfer from bed to chair, commode, or wheelchair documents 1. Wheelchair is next to the Resident's strong side. 2. Remove armrests and footrests or raise foot pedals if applicable. 3. Explain procedure to Resident. 4. Resident may assist by using bed rail, head of bed, or trapeze for support as assistant(s) help Resident to sit up on side of bed. 5. Remove your transfer/gait belt. 6. Stand close to Resident with your feet about 18 inches apart. 7. Place belt around Resident's waist; snug but not tight. Avoid ribs, hipbone, or breasts. 8. Assistants stand on either side of Resident facing each other if two person transfer is required. Assistant stands directly in front of resident if one person transfer. 9. Staying close to the Resident, the assistant(s) rock back and forth, synchronizing movements and weight shifting from one leg to the other while maintaining a backward pelvic tilt. Hips and knees are bent, and on the count of three, the Resident is lifted up with use of transfer/gait belt and assisted to chair. 10. The same principles of this process shall be used when transferring with assistance to bed, commode or other appliances or furniture. R110's diagnoses include polyneuropathy (simultaneous malfunction of many peripheral nerves in the body,) spinal stenosis (narrowing of the spaces within the spine which puts pressure on the spinal cord and nerves,) peripheral vascular disease (circulatory condition which narrows blood vessels reducing blood flow to the limbs,) unspecified visual loss, and history of falling. R110's Morse Fall scale assessment dated [DATE] has a score of 25 which indicates moderate risk for falling. R110's BIMS (Brief Interview for Mental Status) assessment dated [DATE] has a score of 11 which indicates moderate cognitive impairment. R110's physician progress note dated 5/28/26 under assessment and plan documents: male nursing facility resident with no past medical history with extensive foraminal stenosis and b/l (bilateral) lower extremity weakness. #Chronic BLE (bilateral lower extremity) weakness. # Peripheral neuropathy. # Limited mobility d/t (due to) above. R110's transfer and mobility evaluation dated 5/29/26 under the section for evaluation criteria and transfer method #3. 1 assist gait belt transfer, stand, and turn is checked for: a. Cooperative with transfer. b. Can follow directions/cues. c. Able to sit unassisted at side of bed. d. Needs assistance only from sitting to standing (no lifting). e. Bear full weight throughout entire transfer. R110's CNA (Certified Nursing Assistant) Kardex as of 6/2/26 under the mobility/transfer section documents *transfer assist – one. On 6/2/26, at 9:33 a.m., Surveyor observed R110 in the bathroom sitting on the toilet. Surveyor left R110's room. CNA-G stated to Surveyor I'm going in to help him and entered R110's room. On 6/2/26, at 9:34 a.m., Surveyor observed CNA-G in the bathroom with R110. CNA-G assisted R110 with standing by holding onto his back and telling R110 to hold onto the bar. CNA-G wiped R110 and pulled up R110's incontinence product and pants. CNA-G stated to R110 to turn around, asked R110 to place his hand on the armrest of the wheelchair and assisted R110 to sit in the wheelchair. CNA-G removed her gloves, wheeled R110's wheelchair over by his bed, placed the overbed table in front of R110, and call light within reach. Surveyor noted during this observation, CNA-G did not transfer R110 using a gait belt and observed a gait belt hanging on the wall next to R110's room door. On 6/2/26, at 9:38 a.m., Surveyor asked CNA-G if she should use a gait belt when transferring R110. CNA-G replied yes. Surveyor stated to CNA-G, but you didn't use one. CNA-G replied to Surveyor, sorry about that. On 6/2/26, at 10:14 a.m., Surveyor asked Assistant Director of Nursing (ADON)-C if a resident is an assist of one for transferring should staff use a gait belt when transferring the resident. ADON-C replied yes. Surveyor informed ADON-C of the observation of CNA-G transferring R110 without a gait belt. On 6/2/26, at 10:22 a.m., Surveyor met with Director of Nursing (DON)-B and Regional Director of Clinical Services-H. Surveyor asked DON-B if a resident is an assist of one for transfers should staff use a gait belt when transferring the resident. DON-B replied yes. Surveyor informed DON-B and Regional Director of Clinical Services-H of the observation of R110 not being transferred with a gait belt.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 of 1 resident (R) on enhanced barrier precautions (R110.)On 6/2/26, Certified Nursing Assistant (CNA)-F and CNA-G did not wear appropriate personal protective equipment when providing morning cares and toileting with R110 who is on enhanced barrier precautions.Findings include:The facility's policy titled Enhanced Barrier Precautions and dated 3/26/24 documents under policy: It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with chronic wounds requiring a dressing, indwelling medical devices or residents with infection or colonization with an MDRO. Overview documents: Enhanced Barrier Precautions will not only focus on residents with infection or colonization with MDROs but will also address residents at risk for developing or becoming colonized. Enhanced Barrier Precautions are precautions that are between Standard Precautions and Contact Precautions. Enhanced Barrier Precautions require gown and glove use for residents with a novel or targeted MDRO or any resident with a wound or indwelling medical device during specific high-contact resident care activities.High-Contact Resident Care Activities include: *Dressing, *Bathing/showering, *Transferring, *Providing hygiene, *Changing linens, *Changing briefs or assisting with toileting, *Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. *Wound care: any skin opening requiring a dressing.R110 was admitted to the facility on [DATE] with an unstageable deep tissue sacrum and left heel pressure injury.R110's diagnoses include polyneuropathy (simultaneous malfunction of many peripheral nerves in the body,) spinal stenosis (narrowing of the spaces within the spine which puts pressure on the spinal cord and nerves,) peripheral vascular disease (circulatory condition which narrows blood vessels reducing blood flow to the limbs,) unspecified visual loss, and history of falling.R110's at risk for wound infection care plan initiated and revised 5/26/26 includes an intervention of Enhanced Barrier Precautions for BLE (bilateral lower extremities) Partial Thickness Wounds R (greater than) >L. Initiated and revised 5/26/26.On 6/1/26, at 10:10 a.m., Surveyor observed an EBP (enhanced barrier precaution) sign on R110's room door.On 6/1/26, at 10:12 a.m., Surveyor observed R110 sitting in a wheelchair in his room. Next to the dresser in R110's room there is a PPE (Personal Protective Equipment) cart.R110's Certified Nursing Assistant (CNA) Kardex as of 6/2/26 under the section safety/monitor documents: *Enhanced Barrier Precautions for BLEs Partial thickness wounds R>L.On 6/2/26, at 7:26 a.m., Surveyor observed R110 sitting on the edge of the bed with his bare feet resting on the floor.On 6/2/26, at 7:33 a.m., Surveyor observed CNA-F and CNA-G enter R110's room and place gloves on. CNA-F asked R110 if he was wet. R110 touched the brief covering his frontal area and replied yes. CNA-F then asked R110 if it's okay with the bed going up so she can oil his legs. R110 replied yes. CNA-F raised the height of R110's bed and applied lotion to R110's bilateral lower extremities. CNA-F placed a pull up incontinence product and jeans up to R110's knees and lowered the bed down. CNA-F removed R110's gown and T-shirt. CNA-F handed R110 a wet washcloth asking R110 if he could wash his face. After R110 washed his face, CNA-F wiped R110's head with the wet washcloth. CNA-G handed CNA-F a partial wet bath towel. CNA-F washed R110's upper body, applied deodorant, and placed a T-shirt on R110. CNA-F ripped the sides of R110's incontinence product, R110 washed his frontal area. CNA-F had R110 roll on his side and the incontinence product was removed. CNA-F washed R110's rectal area and buttocks and applied barrier cream. CNA-F pulled up the incontinence product stating, Lets not pull up pants as they are going to do wound care. CNA-F asked R110 to scoot up in the bed, raised the head of the bed, and covered R110 with sheet. CNA-F placed soiled items in a cart outside R110's room, removed her gloves, and washed her hands. Surveyor noted during this observation CNA-F only had gloves on and did not wear a gown.On 6/2/26, at 8:23 a.m., Surveyor observed Infection Control Preventionist (ICP)-K place an EBP sign on R110's door. Surveyor asked ICP-K why there wasn't a sign on the door this morning. ICP-K replied, we have some residents that like to take it off, it was there yesterday. Surveyor asked ICP-K if R110 should be on enhanced barrier precautions. ICP-K replied yes.On 6/2/26, at 9:30 a.m., Surveyor asked CNA-F if R110 is on any precautions. CNA-F replied, not that I'm aware of. Surveyor asked CNA-F if R110 is on enhanced barrier precautions. CNA-F replied, not that I'm aware of. On 6/2/26, at 9:31 a.m., Surveyor observed CNA-F ask Assistant Director of Nursing (ADON)-C if R110 is on EBP. ADON-C replied yes.On 6/2/26, at 9:33 a.m., Surveyor observed R110 in the bathroom sitting on the toilet. Surveyor left R110's room. CNA-G stated to Surveyor I'm going in to help him and entered R110's room.On 6/2/26, at 9:34 a.m., Surveyor observed CNA-G wearing gloves in the bathroom with R110. CNA-G assisted R110 with standing by holding onto his back telling R110 to hold onto the bar. CNA-G wiped R110 and pulled up R110's incontinence product and pants. CNA-G stated to R110 to turn around, asked R110 to place his hand on the armrest of the wheelchair, and assisted R110 to sit in the wheelchair. CNA-G removed her gloves, wheeled R110's wheelchair over by his bed, placed the overbed table in front of R110, and call light within reach. During this observation, Surveyor noted CNA-G was not wearing a gown.On 6/2/26, at 9:37 a.m., CNA-G stated to Surveyor, I forgot to put gown on. I was in a rush to get him off (referring to the toilet.)On 6/2/26, at 10:15 a.m., Surveyor asked ADON-C if R110 is on enhanced barrier precautions. ADON-C replied yes. Surveyor informed ADON-C of the observations of CNA-F and CNA-G not wearing the appropriate PPE while providing cares to R110.On 6/2/26, at 10:21 a.m., Surveyor met with Director of Nursing (DON)-B and Regional Director of Clinical Services-H. Surveyor asked DON-B if a resident is on EBP what is the expectation. DON-B informed Surveyor standard PPE for enhanced barrier precautions. Surveyor asked what this is. DON-B informed Surveyor she would have to check a sign, so she doesn't mis speak off memory. Surveyor asked DON-B if she could check an EBP sign. DON-B left the conference room and returned a minute later. At 10:22 a.m., DON-B informed Surveyor gloves and gown and then read the tasks off the sign when it is necessary. Surveyor then informed DON-B and Regional Director of Clinical Services-H the observations of staff not wearing appropriate PPE when providing cares to R110.

Based on observation, interview, and record review the facility did not ensure proper inspection of resident's beds for 2 (R110 & R59) of 5 beds. *A gap of approximately five inches was observed between R110's air mattress and foot board on 6/1/256 & 6/2/26. *On 4/17/26, staff reported R59's bed suddenly lifted on the window side causing R59 to fall on the floor. Post-incident inspections identified a broken clip securing the air mattress strap to R59's bed frame. There is no evidence that R59's bed was inspected after the air mattress was placed. On 6/1/26, surveyors observed approximately five inches of R59's mattress was not supported by the bed frame on the left side. Findings include: R110 was admitted to the facility on [DATE] with diagnoses which include polyneuropathy (simultaneous malfunction of many peripheral nerves in the body), spinal stenosis (narrowing of the spaces within the spine which puts pressure on the spinal cord and nerves), peripheral vascular disease (circulatory condition which narrows blood vessels reducing blood flow to the limbs), unspecified visual loss, and history of falling. R110's physician order dated 5/29/26 documents: Air mattress setting 150 based on resident's weight. May be adjusted per preference every shift for wound care. On 6/1/26, at 10:12 a.m. surveyor observed R110's bed. Surveyor observed there is approximately a five-inch gap between R110's air mattress and foot board. On 6/1/26, at 11:54 a.m., surveyor observed there continues to be an approximate five-inch gap between R110's air mattress and foot board. On 6/1/26, at 12:15 p.m., surveyor asked Maintenance Director (MD)-D who ensures air mattresses properly fit a resident's bed. MD-D replied that would be us. MD-D explained air mattresses and bed are seven feet long unless it is a larger bed and then there is a foam insert that goes in there if the footboard is extended. Surveyor asked who puts the foam insert in. MD-D replied not me. Surveyor asked MD-D if he knew who did. MD-D replied no. On 6/1/26, at 1:19 p.m., surveyor observed there continues to be an approximate five-inch gap between R110's air mattress and foot board. On 6/2/26, at 7:16 a.m., surveyor observed R110 sitting on the edge of the bed with his bare feet on the floor. Surveyor observed there continues to be an approximate five-inch gap between R110's air mattress and foot board. On 6/2/26, at 9:20 a.m., surveyor asked Registered Nurse (RN)-I the process for a new admission receiving an air mattress. RN-I explained they normally get a report from the hospital. RN-I informed surveyor she would let her manager know and MD-D is very good at getting them a mattress. Surveyor asked RN-I who ensures the air mattress is the right size for the bed. RN-I informed surveyor MD-D & Maintenance Assistant (MA)-L are very good and Assistant Director of Nursing (ADON)-M checks. Surveyor asked RN-I what she does if she observes a gap between the end of the mattress and foot board. RN-I informed surveyor she normally places a pillow until MD-D can let her know what to do. On 6/2/26, at 9:40 a.m., surveyor asked Licensed Practical Nurse (LPN)-J what the process is for a new admission receiving an air mattress. LPN-J informed Surveyor usually she checks with the manager, and they set it up when the new admission arrives. Surveyor asked LPN-J who ensures the mattress is the right size for the bed. LPN-J replied unsure, but I would think maintenance. On 6/2/26, at 10:04 a.m., Surveyor asked ADON-C what the process is for a new admission receiving an air mattress. ADON-C informed surveyor typically if they have a wound on the sacrum an air mattress is placed. ADON-C informed surveyor they like to see what therapy says for repositioning. Surveyor asked ADON-C how they obtain an air mattress. ADON-C they call maintenance; maintenance puts it on. Surveyor asked what happens if there is a gap between the end of the air mattress and foot board. ADON-C replied we let them know. Surveyor inquired who they let know. ADON-C replied maintenance. Surveyor asked if maintenance places something in the gap. ADON-C replied you'd have to ask them. Surveyor asked if nursing places anything in the gap. ADON-C replied no. At 10:17 a.m., surveyor asked ADON-C to accompany surveyor to R110's room. Before entering R110's room, ADON-C stated to surveyor I see what you mean. On 6/2/26, at 10:27 a.m., surveyor met with Director of Nursing (DON)-B and Regional Director of Clinical Services-H. Surveyor asked DON-B what the process is for a new admission receiving an air mattress. DON-B informed surveyor if they are alerted before an air mattress is placed by maintenance before their arrival. If the mattress was not caught by admission, then the mattress is switched out as quickly as possible by maintenance. Surveyor asked DON-B who ensure the mattress fits the bed frame. DON-B replied I would guess maintenance when they install it. Surveyor asked DON-B what she does if there is a gap between the mattress and foot board. DON-B replied I let maintenance know. Surveyor informed DON-B and Regional Director of Clinical Services-H of the approximate five-inch gap between R110 air mattress and foot board. Surveyor inquired if there is a mattress policy. On 6/2/26, at 10:38 a.m., DON-B informed Surveyor she put a spacer between R110's mattress and bedframe. On 6/2/26, at 11:22 a.m., Surveyor asked DON-B if there was a mattress policy. Regional Director of Clinical Services-H stated there is not explaining she has corporate looking for it. Surveyor was not provided with a mattress policy. 2.) Surveyor conducted a review of the facility's Misconduct Incident Report that was submitted to the State Survey Agency on 4/24/26. The report documents that on 4/17/26 at approximately 9:00 PM, R59 sustained a witness fall from bed while receiving cares from CNA (Certified Nursing Assistant)- E. At the time of the incident, R59's care plan identified R59 as requiring assist of one staff for cares and staff were following the current care plan. R59 sustained a fracture of lumbar spine. The incident summary documents that R59 was positioned on her/his right side facing the window. The bed positioned against the window wall. Staff reported the bed suddenly lifted on the window side, causing R59 to fall to the floor. Staff immediately called for assistance and 911 was contacted and R59 was transported out to the emergency department for further evaluation. The Investigation findings document that post-incident inspection identified a broken plastic clip securing the air mattress strap to the frame on R59's left side. The mattress was immediately removed from service and replaced. Corrective Actions documented all facility air mattresses were inspected for defects, securement clips and proper function. All beds were inspected for proper functionality. Any identified variances were corrected immediately. Maintenance system was updated to include preventative maintenance checks on air mattress tie-down clips and functionality. Incident investigation identified a failed mattress securing clip during equipment inspection. In addition, the facility's investigation included a signed statement from Maintenance Director- D, dated 4/19/26, documenting the Maintenance Department inspected all air mattress beds to ensure the plastic tie down clips were not cracked or broken and functioning as intended. The inspection of tie down clips was added to the Maintenance Department PM log under our Tells system. Surveyor did request to review the PM log in the Tells system and was not provided a log for inspection of tie down clips completed by the Maintenance Department. On 6/1/26 at 12:05 PM, Surveyor interviewed Director of Maintenance (DM)- D regarding routine maintenance of resident beds and mattresses. MD-D stated they do not have a log of routine maintenance checks on resident beds as they cannot physically check every bed. MD-D stated the maintenance department will put a new mattress in place, such as a specialty air mattress, when requested by nursing. DM-D stated the specialty air-mattress has 3 straps on each side that are clipped together around the bedframe. There would be a total of 6 straps holding the air mattress in place on the bed frame. Surveyor asked DM- D if he was aware R59's air mattress had a broken clip. DM- D stated he was not aware and if 1 clip was broken, the other clip/straps would still hold the mattress in place. DM-D stated he does not routinely check the beds and air mattress after they put them in place for resident use. DM-D stated the nursing staff are the eyes and ears and would notify the maintenance department if something was broken or not working properly. On 6/1/26 at 2:45 PM, Surveyor made observations of R59's room arrangement and bed/mattress while R59 was out of the room. R59's head of the bed was now against the wall with the window, and the left side of the bed was up against the wall. It was noted there was a bariatric mattress (48 inches wide) on a twin-size bedframe. Surveyor observed the mattress was hanging over the bedframe, on the left side, approximately 5 inches. The entire left side of the mattress was not supported by the bedframe and could easily be lifted up on the bedframe. The entire mattress was easily moved from the bed frame as it was not appropriately attached and too big for the bed frame itself, preventing it from fitting in the bed frame brackets. This made for an unsafe environment for R59 as the mattress could fall off the bedframe if R59 rolled to her left side. On 6/1/26 at 3:13PM, Surveyor interviewed DM-D and asked if he could confirm Surveyors observation regarding R59's mattress being too large for the frame. DM- E confirmed that after R59 fell from the bed on 4/17/26, the air mattress was replaced with a regular pressure reduction mattress. DM- D stated that the bedframe itself was not switched out. DM- D confirmed the mattress that was currently on R59's bed was a bariatric mattress that was 48 inches wide. DM- E confirmed the mattress must fit in between the bed frame brackets in order for it to be secure. During this observation, DM- E confirmed that no one in the maintenance department had been up to adjust the bedframe, although the bedframe had been adjusted after Surveyors observation at 2:45 PM on 6/1/26. The mattress was now positioned correctly as the bedframe itself had been widened. DM- D stated he does not regularly get into each resident's room and depends on staff to alert him if there is something not working properly. On 6/1/26 at 3:30 PM, Surveyor interviewed Nursing Home Administrator A and DON- B regarding Surveyors observation of R59's mattress being too large for the bedframe with a 5-inch overhang. Administrator- A and DON- B stated they had not been in R59's room to observe the bedframe. At this time, Surveyor stated there were additional safety concerns for R59 and the bed was a continued accident hazard. Nursing Home Administrator- A was asked if the facility is conducting routine maintenance on resident beds. Nursing Home Administrator- A stated he would provide Surveyor with the Tells report that is used to log the resident bed checks completed by maintenance. As of the time of exit, the Tells report provided was a check for bed rail inspection. This inspection is conducted for 1 resident who uses a bed rail.

Based on observation, interview, and record review, the facility did not ensure residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 7 of 8 residents (R2, R11, R15, R47, R74, R85, and R105) reviewed for pressure injuries. *R2 was admitted to the facility without any pressure injuries (PIs) and was assessed to be at risk for PIs. R2 developed an unstageable PI to the sacrum. The facility failed to implement an air mattress and implement a turning and repositing program prior to sacrum pressure injury development. The sacrum PI became infected requiring intravenous antibiotics and a 2-week hospitalization. The sacrum PI is currently a stage 4. *R11 was admitted to the facility with no documentation of pressure injuries and was assessed to be at risk for PI development. R11 developed an unstageable left heel PI and a right DTI (deep tissue injury). Prior to development of these pressure injuries, R11's skin impairment care plan did not include interventions to offload R11's heels. An x-ray of R11's unstageable left heel documented suspicion of osteomyelitis and an MRI was recommended. MRI documented findings suggestive of posterior calcaneal osteomyelitis. R11 was prescribed an antibiotic. *R15 admitted to the facility with two unstageable DTIs which healed shortly after admit. R15 developed a non-pressure sacrum wound characterized by Wound MD (Medical Doctor)-DD as a brief abrasion. Wound MD-DD changed the area to an unstageable PI which declined to a Stage 4 PI. Facility did not revise R15's care plan, R15's heels were not being offloaded, and treatments were not completed according to physician orders. The facility's failure to provide care to prevent the development of pressure injuries including implementing an air mattress, implementing turning/repositioning programs, offloading heels, revising care plans, and completing treatments per MD order created the finding of Immediate Jeopardy (IJ) that began on 6/24/25. Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Director of Clinical Services (RDCS)-C of the immediate jeopardy on 3/26/2026, at 3:38 PM. The immediate jeopardy was removed on 3/30/26, however, the deficient practice continues at a scope and severity of E (potential for harm/pattern) as the facility implements its action plan and related to the following examples: *R47 did not have an air mattress in place as ordered for R47's stage 4 PI. *R74 is at risk for PI development. R74 did not have R74's heels offloaded during multiple observations during survey. * R85's Physician orders were not implemented until 4 days after admission for a stage 3 PI to coccyx. R85's heels were not floated during the survey process. R85's mattress on bed was rated for a stage 1 and 2 PI, not for a stage 3 PI. *R105's heels were not offloaded per R105's care plan during the survey process and no pressure reducing cushion was observed on R105's wheelchair per care plan interventions. Findings Include: The facility's policy titled Pressure Injury Prevention and Wound Care Management, dated 8/26/2018, revised on 8/25/25, documents the following: Purpose: To identify factors that places the residents at risk for the development of pressure injuries and to implement appropriate interventions to prevent the development of clinically avoidable wounds. To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. To promote healing of existing pressure injuries and wounds. Policy: The facility will ensure that a resident who is admitted without a pressure injury does not develop a pressure injury, unless clinically unavoidable. A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers. Risk identification and assessment - a complete assessment is essential to an effective pressure injury prevention and treatment program. A comprehensive assessment helps the facility to identify residents at risk of developing pressure ulcers, as well as the level of nature of their risks. A Braden scale (a tool developed to assess a resident's risk of developing pressure injuries) should be completed for all residents upon admission/readmission for a total of 4 consecutive weeks, then quarterly with Minimum Data Set (MDS) assessments and when a significant change of condition occurs. Residents with a Braden score of 12 or less should be considered to be at high risk for pressure injury development. Skin impairments – including pressure injuries, diabetic wounds, venous wound, arterial wounds, surgical wounds, and device-related injuries – will be assessed and documented at least weekly by the wound nurse (or designee) using the Electronic Medical Record (EMR) weekly wound assessment. Weekly documentation will include pertinent characteristics of existing ulcers, including location, size, depth, mass erosion, color of the ulcer and surrounding tissues and a description of any drainage, scar, necrosis, odor, tunneling or undermining. Staging and terminology: Pressure injuries shall be staged per National Pressure Injury Advisory (NPIA): stage 1, stage 2, stage 3, stage 4, unstageable, and deep tissue pressure injury (DTPI). Do not reverse stage or down stage healing pressure injuries, instead, document healing process with measurements and wound descriptors. Documentation of the wound characteristics will be completed in the resident's EMR using the EMR skin and wound assessment. Daily, the clinicians responsible for caring for the resident will assess the status of the dressing if present, (intact, soiled or leaking) and evaluate for complications such as infection and/or uncontrolled pain. Wound and skin care interventions will be monitored and evaluated for effectiveness. Care plans will include specific and measurable goals and interventions. The care plan will be reviewed and revised at least quarterly, or with a significant change in condition. Prevention and treatment guidelines- the skin care program will be utilized following the guidelines of the Agency for Healthcare Research and Quality (AHRQ), the National Pressure ulcer/ Injuries Advisory Panel (NPIAP) and current standards of clinical practice. Pressure-reduction surfaces should be provided on beds and chairs for at risk residents unless tolerance or lack of need is noted and documented. Repositioning frequency is individualized based on skin/tissue tolerance, support surface, risk and clinical condition. Air mattress settings will be set per manufacturer guidelines and communicated to staff via care plan and Kardex. Wound cultures are generally not indicated as most chronic wounds are colonized and a swab culture would not provide clinically helpful information. If infection is suspected, notify the physician, and obtain clinically appropriate orders. 1.) R2 was admitted to the facility on [DATE] with diagnoses that include Traumatic Brain Injury (a brain injury from an outside force that can greatly affect how the person functions, cares for self and interacts with others,) Acute Respiratory Failure (inability of the lungs to oxygenate blood or remove carbon dioxide,) and Chronic Leukemia (slow growing cancer of the white blood cells.) R2's Quarterly Minimum Data Set (MDS) dated [DATE], documented R2 has long-term and short-term memory problems. R2 has severely impaired cognitive skills, with never or rarely making decisions. R2's MDS assessed R2 to have: impairment to one side of R2's upper extremity, and impairment to both sides of R2's lower extremities; R2 is always incontinent of bowel and bladder. R2 is at risk of developing pressure injuries and assessed to have one stage 4 pressure injury at the time of the assessment on 3/5/26. R2's pressure injury Care Area Assessment (CAA) dated 6/11/25, documented in part: . Triggered by indications of R2 with frequent urinary and bowel incontinence, R2 is at risk for pressure ulcers and R2 with one or more pressure ulcers on current assessment. R2's Braden Scale assessment (a tool developed to assess a resident's risk of developing pressure injuries) dated 5/30/25, documented a score of 14, which indicates R2 is at moderate risk for developing a pressure injury. R2's admission Screener dated 5/30/25, section C, documented R2's skin to be normal, warm, and dry. Documentation of R2's skin integrity (which identifies bruises, pressure ulcers, rashes, surgical incisions, skin tears, abrasions, etc.) was documented as no skin alterations noted. Surveyor noted R2 had a skin integrity care plan initiated on 5/30/25 and revised on 8/19/25. The 5/30/25 skin integrity care plan and 8/19/25 revision did not list any interventions. On 6/2/25, interventions were added to R2's skin integrity care plan including: Keep R2's skin clean and dry (initiated 6/2/25.) Routinely turn and reposition as tolerated by R2 (initiated 6/2/25 and resolved on 8/19/25.) Special mattress to relieve pressure alternating low air loss setting for or equal to 250 lbs., may adjust per R2's preference. Check each shift for proper inflation (initiated 6/2/25 and revised on 2/8/26.) Use a draw sheet and 2 people when pulling R2 up in bed (to prevent friction) (initiated 6/2/25.) Surveyor noted air mattress was care planned for 6/2/25 but not placed until 6/8/25. On 6/6/25, R2's weekly skin assessment documented no skin alterations. On 6/8/25, at 1:09 PM, a health status note documented: I'm not sure why this says R4. I will change to R2 but may want to confirm. R2 has change in skin integrity. Tried to notify R2's mother. Left message to call facility for an update at 1237. On 6/8/25, at 9:46 PM, a health status note documented R2 had three loose BMs (bowel movements) this PM (shift.) MD was updated. R2 is on ferrous sulfate (iron) and imatinib mesylate 400 mg for chronic myeloid leukemia. MD gave an order for loperamide 2 mg PRN (as needed) every 12 hours. Dressing on R2's bottom is dry and intact. R2 is resting at present, with no issues noted. On 3/24/26, Surveyor could not locate an initial skin assessment of R2's change in skin integrity on 6/8/25, indicating location of wound, measurements, and wound bed assessment. On 6/9/25, Wound MD-DD documented: open DTIs (deep tissue injuries) to buttocks. Recommended treatment is xeroform/border gauze. Border gauze daily and PRN. Active consult pending. On 6/9/25, R2's skin integrity care plan was updated with the following interventions: Use a pressure relieving cushion for R2's wheelchair (initiated 6/9/25.) Use skin barrier cream on R2's skin as needed for protection from moisture and friction (initiated 6/9/25 and revised on 8/19/25.) Heel suspension boots while R2 is in bed (initiated 6/9/25.) Manage R2's clinical conditions and contributing factors to decrease R2's risk of skin breakdown (initiated 6/9/25.) Monitor my weights per policy and notify MDs and/or RD (registered dietician) of any significant changes (initiated 6/9/25.) Position R2's body with pillows/support devices and protect bony prominences (initiated 6/9/25.) Turn and reposition R2 at least every two hours, per R2's particular tolerance and schedule (initiated 6/9/25.) On 6/9/25, an order was placed for treatment to sacrum and left buttocks: cleanse with normal saline wash, followed by foam border Xeroform, followed by border gauze every evening shift for wound care and as needed. On 6/10/25, Wound MD-DD documented an initial wound assessment which documented the following: Unstageable DTI to the sacrum, measured 6 x 4 x 0.1 cm. The wound had light serous drainage with no signs or symptoms of infection. Wound MD-DD was monitoring 2 surgical sites that healed without complication, and 2 unstageable DTIs located on the left superior and inferior buttock. The unstageable DTI on the left superior buttock resolved on 7/15/25, without complications. The unstageable DTI on the inferior buttock resolved on 6/24/25, without complications. On 6/17/25, Wound MD-DD documented an unstageable (due to necrosis) sacrum full thickness wound measuring 6 x 3.5 x 0.1 cm, with moderate serous drainage, 100% necrotic tissue and no signs or symptoms of infection. On 6/24/25, Wound MD-DD documented an unstageable (due to necrosis) sacrum full thickness wound measuring 6 x 3.5 x 0.1 cm, with heavy purulent drainage, 100% necrotic tissue and no signs or symptoms of infection. The progress of this wound and the context surrounding the progress were considered in greater detail at the time of assessment on 6/24/25. R2 is requiring an increase in the level of care and is recommending the emergency room for evaluation and treatment with possible operating room debridement, antibiotics and imaging to rule out osteomyelitis. The clinical team was updated. On 6/24/25, R2 was admitted to the hospital with excessive drainage to the infected wounds. R2 was started on two antibiotics. A Computed Tomography (CT) was completed and negative for osteomyelitis. Blood cultures were completed and noted to be negative for sepsis. Surveyor noted R2 developed an infection in the sacral pressure ulcer under the care of the facility. On 3/25/26, at 3:28 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D regarding how R2 developed the sacral pressure ulcer and how it became infected. ADON-D informed Surveyor the causes of the pressure wound are due to R2 moving self in small increments and positioning self on R2's crack. ADON-D stated the cause of R2's infected wound is due to R2 having frequent loose stools. ADON-D stated the facility implemented pillows on bony prominences after discovering the wound and did not add any other interventions. On 3/26/26 at 12:40 PM, Surveyor interviewed Wound MD-DD who stated loose stools can cause infections on wounds in the sacral and buttock areas. On 3/25/26, Medical Doctor (MD)-EE who is R2's primary doctor, documented the following in a progress note: R2 is receiving tube feeding, which has a tendency to cause liquidity/very soft stools. With liquid stools, it can cause MASD (Moisture Acquired Skin Damage.) The diagnosis of chronic myeloid leukemia gives R2 low immunity, making it difficult for R2 to fight infection. This is what happened to R2, when R2 developed a DTI to the sacrum with MASD, it progressed with new infection. On 3/26/26, at 10:10 AM, Director of Nursing (DON)-B provided Surveyor documentation as follows: Alteration in skin integrity documented 6/8/25 documented in part: .CNA (Certified Nursing Assistant) was providing R2 with daily cares. It was noted that R2 had a change in skin integrity on R2's coccyx and pressure like area on the right buttocks. Area was covered with foam dressing and R2 was placed on R2's side. Assistant Director of Nursing (ADON) – E was notified, and R2 was placed on an air mattress. The MD and Power of Attorney (POA) were notified. On 6/11/25, the facility completed a root cause analysis for R2's PI which is as follows: R2 was admitted to the facility on [DATE], at approximately 3:00 PM. Report was taken by ADON-E and passed along to the floor nurse that R2 has a red blanchable area to the sacrum which needs to be addressed in the skin check. The floor nurse completed the skin check indicating skin was intact. CNA was present for the skin check and wrote a statement stating the skin was bruised and [there was] a purple area to R2's buttocks. A treatment order was placed on admission for R2's sacral area. The area was then identified as open on 6/9/25. At this time, an air mattress was placed on the bed. The floor nurse was instructed to take the wound pictures and open a risk management. On 6/10/25, the pictures were not found, and the nurse stated the phone battery was dead. DON-B spoke with the admission director regarding why an air mattress was not placed prior to R2's admission and an education was completed stating that all non-ambulatory tracheostomy residents should be on an air mattress. Education was also provided to the admitting nurse who failed to document the area to the R2's sacrum. Wound pictures were taken, and a conference call was held with the Wound MD-DD, DON-B, ADON-D and Wound MD-DD who gave new treatment orders at that time. The wound team evaluated R2's wounds in person on 6/10/25. Charging cords for the wound phone/camera were ordered on 6/1/25 and arrived on 6/11/25. The CNA written statement given was signed but not dated which documented: R2 was admitted on [DATE], and CNA performed a body check with the nurse, and the CNA noted a purple bruise on R2's tailbone. On 7/7/25, R2 returned to the facility after the 6/24/25 hospital admission. R2 was followed by Wound MD-DD with weekly assessments being performed. On 7/8/25, Wound MD-DD documented an unstageable (due to necrosis) sacrum full thickness wound measuring 5.5 x 3.5 x 2 cm, with undermining of 7 cm at 5 o'clock position, with moderate serous drainage, 80% necrotic tissue and 20% granulated tissue. On 7/22/25, Wound MD-DD documented an unstageable (due to necrosis) sacrum full thickness wound measuring 4 x 4 x 2 cm, with 5 cm of undermining at the 5 o'clock position, moderate serous drainage, 70% necrotic tissue and 30% granulated tissue. On 7/29/25, Wound MD-DD documented an unstageable (due to necrosis) sacrum full thickness wound measuring 4.5 x 3.5 x 2 cm, with 4.5 cm of undermining at the 5 o'clock position, with moderate serous drainage, 70% necrotic tissue and 30% granulated tissue. On 8/12/25 Wound MD-DD documented: R2 was not seen due to a non-wound related hospitalization since last visit (put the date of the last visit). On 8/19/25, Wound MD-DD documented a stage 4 pressure wound sacrum full thickness measuring 5 x 3 x 3 cm, with 4 cm undermining at the 7 o'clock position, with moderate serous drainage, 40% necrotic tissue and 60% granulated tissue. Surveyor noted the DTI became a stage 4 PI on this date. On 9/2/25 Wound MD-DD documented: R2 was not seen due to a non-wound related hospitalization since last visit (put the date of the last visit). On 9/16/25, Wound MD-DD documented a stage 4 pressure wound to the sacrum with full thickness measuring 4.5 x 3 x 2.5 cm, with moderate serous drainage, 2.5 cm undermining at 9 o'clock, 30% necrotic tissue and 70% granulated tissue. R2's stage 4 pressure wound to the sacrum remained and was evaluated by Wound MD-DD weekly with minor changes and no staging changes. On 3/24/26, Wound MD-DD documented a stage 4 pressure wound to the sacrum with full thickness measuring 3.5 x 2 x 1.5 cm, with moderate serous drainage, 20% necrotic tissue and 80% granulation tissue. On 3/26/26, at 11:26 AM, Surveyor interviewed Regional Director of Clinical Care Services (RDCCS)-C who stated R2 had loose stools, but the facility implemented zinc oxide to protect the skin. RDCCS-C stated the infection started due to R2's health conditions rather than the loose stools. RDCCS-C stated the facility has more information but is concerned about the delivery as it could incriminate the facility - and feels the information will be best given in IDR (Informal Dispute Resolution.) RDCCS-C admitted the facility started off slow with preventative interventions for R2 but ramped up care soon after. The facility failed to complete a comprehensive assessment of R2's unstageable pressure injury noted on 6/8/25. The facility did not implement interventions such as an air mattress or implementing a turning/repositioning program prior to pressure injury development on 6/8/25. R2 developed infection to the sacrum pressure injury on 6/24/25, requiring IV antibiotics and a 2-week hospitalization. 2.) R11 was admitted to the facility on [DATE] without any pressure injuries. R11's diagnoses included acute respiratory failure (lungs cannot adequately exchange oxygen and carbon dioxide,) congestive heart failure (heart doesn't pump enough blood to meet the body's needs,) cognitive impairment, cardiomyopathy (serious disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body,) atherosclerotic heart disease (buildup of fats, cholesterol, and plaque in the artery walls of the heart which restrict blood flow to the heart,) and hypertension (high blood pressure.) R11's admission MDS with an assessment reference date of 10/30/25 documents a BIMS (Brief Interview for Mental Status) score of 5 indicating severe cognitive impairment. R11 is assessed as requiring set up for eating, roll left and right is partial/moderate assistance, and toileting hygiene and chair/bed to chair transfer is dependent. R11 has an indwelling urinary catheter and is frequently incontinent of bowel. R11 is at risk for pressure injuries and is assessed as not having any pressure injuries. R11's pressure injury CAA dated 11/3/25 documents under analysis of findings for nature of problem/condition section: Triggered by indications of resident with frequent bowel incontinence, resident is at risk for developing pressure ulcers, and resident requiring ADL (Activities of Daily Living) assistance for bed mobility on current assessment. Care plan considerations documents: Resident is at risk for developing pressure ulcers. Goal is for resident to maintain good skin integrity. See care plan for further related information. R11's at risk for alteration in skin integrity care plan initiated 10/24/25 documents the following interventions: *Apply moisturizer to my skin as needed. Do not massage over my bony prominences. *Keep my skin clean and dry. *Manage my clinical conditions and contributing factors to decrease my risk of skin breakdown. *Monitor my weights per policy and notify MD (medical doctor) and/or RD (Registered Dietitian) of any significant changes. *Position my body with pillows/support devices and protect bony prominences. *Provide diet, supplements, vitamins, and/or fortified foods per order. *Routinely turn and reposition as tolerated by resident. *Turn and reposition me at least every 2 hours per my particular tolerance and schedule. *Use a draw sheet and 2 people when pulling me up in bed (to prevent shear). *Use a pressure relieving cushion for my wheelchair. *Use A&D, Baza or other skin barrier cream on my skin as needed. *11/18 updated 12/16 ensure residents' [sic] heel boots are on at all times during rounds. Initiated 11/18/25 and revised 12/16/25. *Monitor alternating low air loss mattress with setting at 220# (pounds) or as close to 220# per settings; may be adjusted for resident comfort. Initiated 12/16/25. R11's Braden scale assessment dated [DATE] has a score of 15 which indicates at risk for pressure injuries. R11's weekly skin check dated 11/14/25 does not reveal any skin impairments and answers no for edema. Wound MD (Medical Doctor)-DD's assessed R11 on 11/18/25 and documented: moderate edema for left and right lower extremities. Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 6 x 8 x 0.1, 100% necrotic tissue. Treatment of Xeroform gauze and gauze island with border dressing daily was ordered. Unstageable DTI of right heel, etiology is pressure, measurements are 3.5 x 3.5 x not measurable; skin documents: intact with purple/maroon discoloration. Treatment of skin prep daily was ordered. A lower extremity arterial doppler was recommended on 11/18/25. R11's nurses note dated 11/18/25 at 10:33 a.m., written by Registered Nurse (RN)-W documents: Resident has bilateral deep tissue injury wounds to bilateral heels. [Name] the unit manager is aware. [Physician's name] was also contacted that the wound team is involved. Dopplers are being ordered by the wound team along with his treatment plan. RN notified his case manager about the DTI (deep tissue injury) to his heels. Bilateral boots have been applied. Resident is his own person at present time and was made aware. Surveyor noted prior to R11's right and left heel pressure injuries being identified on 11/18/25, there is no evidence R11's heels were being offloaded. R11's alteration in skin integrity care plan initiated 11/18/25 and revised 3/24/26 documents the following interventions: *11/18 BLE (bilateral lower extremities) arterial doppler ordered to r/o (rule out) PAD (peripheral artery disease). Initiated 11/18/25. *11/18 Encourage use of heel boots or offload with pillows while in bed. Initiated and revised 11/18/25. *Administer my treatments as ordered. Initiated 11/18/25. *Assess/monitor the alteration in my skin integrity and document status weekly. Initiated 11/18/25. *Keep my linen clean, dry, and wrinkle free. Initiated 11/18/25. *Prevent trauma and ensure I have proper fitting footwear. Initiated 11/18/25. *12/16 Tx (treatment) change. Initiated 12/16/25. Wound MD-DD's assessment dated [DATE] documents: Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 5 x 6 x 0.1, 100% necrotic tissue. Wound progress improved evidenced by decreased surface area. Same treatment was continued. Stage 3 pressure wound of the right heel. Etiology is pressure, measurements are 3 x 3 x 0.1 cm and 100% granulation tissue. Wound progress improved evidence by decreased surface area. R11's right heel treatment was changed to Xeroform gauze and gauze island with border daily. Under investigations documents: Lower extremity arterial doppler (left) performed on 11/18/25. No signs of PAD. Lower extremity arterial doppler (right) performed on 11/18/25. No signs of PAD. Wound MD-DD's assessment dated [DATE] documents: Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 4 x 5 x 0.1, 100% necrotic tissue. Wound progress improved evidence by decreased surface area. Treatment was changed to Santyl, alginate calcium, gauze island with border dressing daily. Stage 3 pressure wound of the right heel. Etiology is pressure, measurements are 1.5 x 1.5 x 0.1 cm and 100% granulation tissue. Wound progress improved evidence by decreased surface area. Same treatment was continued. Wound MD-DD's assessment dated [DATE] documents: Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 3.5 x 5.5 x 0.1, 100% necrotic tissue. Wound progress is at goal. Treatment is the same. Stage 3 pressure wound of the right heel. Etiology is pressure, measurements are 0.8 x 0.8 x 0.1 cm and 100% granulation tissue. Wound progress improved evidence by decreased surface area. Same treatment was continued. Wound MD-DD's assessment dated [DATE] documents: Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 3.5 x 5.5 x 0.1, 100% necrotic tissue. Wound progress is at goal. Treatment was changed to acetic acid 0.25% and gauze island with border dressing once daily. Right heel staging was changed to unstageable DTI. Etiology is pressure, measurements are 2 x 1.5 x not measurable cm and skin is intact with purple/maroon discoloration. Wound progress documents exacerbated due to generalized decline of patient. Treatment was changed to skin prep and border foam dressing three times a week. Wound MD-DD's assessment dated [DATE] documents: Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 3.5 x 5.5 x 0.1, 100% necrotic tissue. Wound progress is at goal. Treatment remained the same. Unstageable DTI of right heel. Etiology is pressure, measurements are 2 x 1.5 x not measurable cm and skin is intact with purple/maroon discoloration. Wound progress documents at goal. Treatment remained the same. Wound MD-DD's assessment dated [DATE] documents: Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 4 x 4.5 x 0.1, 100% necrotic tissue. Wound progress is at goal. Treatment was changed to acetic acid 0.25% and gauze island with border dressing three times a day. Unstageable DTI of right heel. Etiology is pressure, measurements are 2 x 1.3 x not measurable cm and skin is intact with purple/maroon discoloration. Wound progress documents improved evidenced by decreased surface area. Treatment remained the same. Wound MD-DD's assessment dated [DATE] documents: Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 4 x 4.5 x 0.1, 100% necrotic tissue. Wound progress is at goal. Treatment was not changed. Unstageable DTI of right heel. Etiology is pressure, measurements are 2 x 1 x not measurable cm and skin is intact with purple/maroon discoloration. Wound progress documents improved evidenced by decreased surface area. Treatment remained the same. Wound MD-DD's assessment dated [DATE] documents: Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 4 x 4.5 x 0.1, 100% necrotic tissue. Wound progress is at goal. Treatment was not changed. Under expanded evaluation performed documents: The progress of this wound and the context surrounding the progress were considered in greater detail today. Patient requiring an increase in the level of care. Cellulitis: Doxycycline 100 mg (milligrams) po (by mouth) bid (twice daily) x (times) 14 days, probiotics 2 tab (tablets) daily x 30 days. Under additional recommendations related to performed expanded evaluation documents: [Lab Name] X-ray r/o (rule out) osteomyelitis. Unstageable DTI of right heel. Etiology is pressure, measurements are 0.8 x 0.8 x not measurable cm and skin is intact with purple/maroon discoloration. Wound progress documents improved evidenced by decreased surface area. Treatment remained the same. Wound MD-DD's assessment dated [DATE] documents: Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 4 x 4.5 x 0.1, 70% necrotic tissue & 30% granulation tissue. Wound progress is improved evidenced by decreased necrotic tissue. Treatment was not changed. Unstageable DTI of right heel. Etiology is pressure, measurements are 0.8 x 0.8 x not measurable cm and skin is intact with purple/maroon discoloration. Wound progress documents at goal. Treatment remained the same. Under investigations: Recommended and/or reviewed documents X-Ray of unstageable (due to necrosis) of the left heel demonstrates suspicious of osteomyelitis, recommended MRI on 1/14/26. Interpretation: MRI ordered by primary, on oral antibiotics. Wound MD-DD's assessment dated [DATE] documents: Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 4 x 4.5 x 0.1, 50% necrotic tissue & 50% granulation tissue. Wound progress is improved evidenced by decreased necrotic tissue. Treatment was not changed. Unstageable DTI of right heel. Etiology is pressure, measurements are 0.8 x 0.8 x not measurable cm and skin is intact with purple/maroon discoloration. Wound progress documents improved evidenced by decreased necrotic tissue. (Surveyor noted the right heel does not have necrotic tissue.) Treatment remained the same. Wound MD-DD's assessment dated [DATE] documents: Unstageable (due to necrosis) of left heel, etiology is pressure, measurements are 5 x 4 x 0.1, 40% necrotic tissue & 60% granulation tissue. Wound progress is improved evidenced by decreased necrotic tissue. Treatment was not changed. Unstageable DTI of right heel. Etiology is pressure

Based on interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility did not designate a licensed nurse to serve as a charge nurse on each tour of duty. * The facility did not designate a charge nurse for each tour of duty on each daily nursing schedule.* The facility triggered for excessively low weekend staffing for the months of October through December in 2025.This deficient practice has the potential to affect 98 of 98 residents in the Facility.Findings include: 1.) Surveyor reviewed 30 days of nursing staff schedules. Surveyor noted that the facility's nursing staff schedules did not designate who the charge nurse was for each tour of duty.On 03/26/2026, at 12:02 PM, Surveyor interviewed Staff Development Director-M regarding how a charge nurse is designated for each tour of duty. Staff Development Director-M replied that during the day the Director of Nursing (DON) or Assistant DONs or infection preventionist are in the building. Staff know who the evening and night nurse charge nurses are. Surveyor asked if these individuals work 7 days a week as charge nurses, or if there would be change in charge nurse when these individuals were not working at the facility. Per Staff Development Director-M, there is an on call rotation schedule that is followed. Surveyor stated it is a concern that charge nurse is not designated consistently on the schedules, and that it's sometimes only listed for the evening second shift on the facility's staffing schedules. On 03/26/2026, at 2:13 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the staffing schedules. Surveyor let NHA-A know of concern related to the facility's schedules not designating who the charge nurse would be for each tour of duty on the facility's nursing staff schedules.The facility did not provide any additional information as to why it did not ensure there was a designated charge nurse for each tour of duty.2.) The facility's assessment last reviewed and updated November 2025 documents: Licensed nurses providing direct care will have a 1:20 ratio on days, evenings and nights. Medication technicians will be utilized to assist nurses. Direct care staff, Certified Nursing Assistants (CNA), will have a 1:10 up to 1:14 ratio days, 1:14 ratio evenings and 1:20 ratio on nights.The facility' s assessment also documents: Staffing is completed based on census and acuity. 1st floor: staffing can change daily related to census and acuity. Dayshift - 2 nurse and 3 CNA, evening shift - 2 nurse and 6 CNA, and NOC shift 1 nurse and 2 CNA. 2nd floor dayshift - 2 nurse and 6 CNA, evening shift - 2 nurse and 6 CNA, and NOC shift - 2 nurse and 4 CNA. 3rd floor dayshift - 1 nurse and 1 CNA, evening 1 nurse and 1 CNA and NOC 1 nurse and 1 CNA.On 03/26/2026, at 12:02 PM, Surveyor interviewed Staff Development Director-M whom completes the nursing schedule. Surveyor learned that the staffing ratios/minimum to staff for each shift are: 1st and 2nd shift: 1st floor: 2 CNA, 1 nurse or med tech2nd floor: 4 CNA, 2 nurse or med techs3rd floor: 1 CNA, 1 nurse or med tech3rd shift: 1 CNA or nurse per floorSurveyor noted the facility assessment allotted more staff per shift than what was being utilized on the schedule. Surveyor noted that in October 2025, the facility had reduced staffing than what was documented in the facility's assessment and the minimum staffing ratios per Staff Development Director-M. Surveyor asked Staff Development Director-M about the average census and was told that 1st floor has about 16 residents, 2nd floor has about 52 residents and 3rd floor has about 10 residents. Surveyor asked if it was noticed that the facility had low weekend staffing from October to December of 2025. Staff Development Director-M felt that low staffing could be related to the holidays. Staff Development Director-M stated that recently a policy was started that if you call in on the weekend you automatically get scheduled for the next weekend. Staff Development Director-M stats that this has been helping with staffing.Surveyor reviewed the staffing schedules for October 2025 and noted that the facility had less staff scheduled and working on the weekends based on the minimum staffing rations per Staff Development Director-M. On 03/26/2026, at 2:13 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A about the facility triggering for excessively low weekend staffing and was told that in October, the facility had staffing challenges. No additional information was provided.

Based on observation and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure expired medications were removed from 2 of 3 medication carts.*An expired stock bottle of Acetaminophen 325 mg (milligrams) was observed in the first-floor south medication cart.*R95's Lispro insulin pen was not dated when opened & used.*2 blister packs of Hydralazine 100 mg (milligrams) containing 30 tablets each for R45 were expired on 8/31/25 and 9/30/25.*R59's Cyclobenzaprine 10 mg blister pack containing 22 tablets was expired on 2/28/26.Findings include:The facility's policy titled, Medication Storage and last revised 2/12/24 documents under the Purpose section: To ensure that medications and biological are stored in a safe, secure storage and safe handling. Under the general guidelines section it documents: 4. Expired medications are to be removed from areas medication carts prior to or at the time of expiration. Under Stock Medications it documents: 1. Medications will be stored in accordance with manufacturer guidance and not to exceed expiration dates unless a shortened shelf-life once opened.1.) On 3/24/26, at 3:32 p.m., Surveyor observed in the 1st floor South medication cart a stock bottle of Acetaminophen 325 mg (milligrams) 1000 tablet bottle with the expiration date of 2/2026.On 3/24/26, at 3:40 p.m., Surveyor asked Licensed Practical Nurse (LPN)-S who checks the medication cart for expired medication. LPN-S replied to my PM (evening) supervisor. Surveyor then showed LPN-S the expired Acetaminophen 325 mg bottle.2.) On 3/24/26, at 3:43 p.m., Surveyor observed in the top drawer of the 2 [NAME] medication cart a Lispro insulin pen for R95 that is opened & used. Surveyor observed that R95's insulin pen is not dated.3.) On 3/24/26, at 3:49 p.m., Surveyor observed in the bottom drawer of the 2 [NAME] medication cart two blister packs containing 30 tablets each of Hydralazine 100 mg (milligram) tablets with directions to administer one tablet by mouth every 8 hours for R45 which has expired. One blister pack had an expiration date of 8/31/25 and the second blister pack had an expiration date of 9/30/25.4.) On 3/24/26, at 3:50 p.m., Surveyor observed in the bottom drawer of the 2 [NAME] medication cart a blister pack containing 22 tablets of Cyclobenzaprine 10 mg (milligrams) with directions to administer one tablet every 8 hours as needed for R59 which is expired. The expiration date is 2/28/26.On 3/24/26, at 3:45 p.m., Surveyor asked Registered Nurse (RN)-U if insulin pens are dated when they are opened. RN-U replied yes. Surveyor asked RN-U who checks the medication cart for expired medications. RN-U informed Surveyor the supervisor. Surveyor showed RN-U R95's insulin pen which was not dated when it was opened and the expired medication for R45 & R59.No additional information was provided.

Based on record review and interviews, the facility did not ensure that residents received specialized respiratory therapy provided by and performed by qualified personnel for no less than three residents while Respiratory Therapist (RT)-L was employed at the facility.*Respiratory Therapist (RT)-L was hired [DATE]. RT-L's RT license expired on [DATE]. RT-L worked in the facility from [DATE] until [DATE] with an expired license.Findings include:The facility does not have a policy for the credentialing respiratory therapists.The facility's assessment last reviewed and updated [DATE] documents the facility has special treatments consisting of tracheostomy care with 10-18 average residents receiving tracheostomy care. Specific practices consist of respiratory therapy that is provided to residents. Surveyor reviewed RT-L's employee file. RT-L was hired on [DATE]. RT-L's RT license expired on [DATE]. RT-L was no longer employed at the facility effective [DATE]. RT-L worked in the facility from [DATE] until [DATE] with an expired license.On [DATE], at 10:29 AM, Surveyor reviewed Department of Human Services (DHS) online license look-up. RT-L's RT license was granted [DATE] and expired on [DATE]. Surveyor noted that RT-L has since been denied for renewal of his respiratory license. On [DATE], at 3:42 PM, Surveyor verified RT-L's time clock punches and confirmed that RT-L did work in a respiratory therapist capacity in the facility while RT-L's license was expired. Based on time clock punch time logs, it appears that RT-L last worked on [DATE].On [DATE], at 3:54 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A was not aware that RT-L's license lapsed on [DATE]. NHA-A stated NHA-A found out yesterday at 4:00 PM. NHA-A agreed it is a concern. NHA-A stated that RT-L left employment at the facility to not be a RT anymore. NHA-A informed Surveyor that the human resources manager (HR) who no longer works here would have been responsible for keeping track of employee licenses. On [DATE], at 9:55 AM, Surveyor interviewed RT-N who currently works in the facility. RT-N states that the primary role of respiratory therapists in the facility is to monitor all residents with tracheostomys. On [DATE], at 3:50 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Regional Director of Clinical Care Services (RDC)-C that RT-L was working as a respiratory therapist with no current respiratory therapist license.On [DATE], at 8:20 AM, NHA-A informed Surveyor that NHA-A spoke with RT-L who stated that RT-L was told by DHS RT-L could keep working while RT-L's license was in pending status. Surveyor requested additional documentation at this time. On [DATE], at 8:33 AM, Surveyor interviewed Staff Development Director (SDD)-M. SDD-M stated that SDD-M's procedure to maintain licenses is SDD-M developed a check off list on day of hire and a spreadsheet with all employees with certifications and licenses to make sure all certifications and licenses are renewed on time. SDD-M explained the old human resources manager would have been responsible for monitoring RT-L's license status.On [DATE], at 9:29 AM, NHA-A informed Surveyor that the average census of tracheostomies in the facility while RT-L worked was 14 residents.No additional information was provided.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 4 (R11, R15, R3, & R46) of 4 residents reviewed. *Appropriate hand hygiene was not observed during incontinent cares for R11.*Certified Nursing Assistant (CNA)-Y did not wear appropriate PPE (Personal Protective Equipment) while providing incontinence cares for R15 who is on enhanced barrier precautions.*Licensed Practical Nurse (LPN)-T touched R3's medication with her bare hands.*During G (gastrointestinal)-tube medication administration the syringe was observed to fall on the floor. Registered Nurse (RN)-U rinsed the syringe off and proceed to use the syringe to administer R46's medication.Findings include:The facility's policy titled, Hand Hygiene and last revised 5/8/24 under documents: To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. Under washing hands with soap and water includes documentation of 1. Staff will perform hand hygiene by washing hands for at least twenty (20) seconds with antimicrobial or non-antimicrobial soap and water s huld be performed under the following conditions:.e. Before moving from a contaminated body site to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier or other treatments. Under using alcohol-based hand gel includes documentation of 1. If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations:.f. Before moving from a contaminated body site to a clean body site during resident care; example: after providing peri-care, before applying moisture barrier or other treatments.The facility's policy titled, Enhanced Barrier Precautions and dated 3/26/24 under documents: It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with chronic wounds requiring a dressing, indwelling medical devices or residents with infection or colonization with an MDRO. Under Procedures includes documentation of 3. EBP are used in conjunction with standard precautions and expand the use of PPE (personal protective equipment) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. 5. For residents form whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: 1. Dressing. 2. Bathing/showering. 3. Transferring. 4. Providing hygiene. 5. Changing linens. 6. Changing briefs or assisting with toileting. 7. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. 8. Wound care: any skin opening requiring a dressing.1.) R11's diagnoses includes acute respiratory failure (lungs cannot adequately exchange oxygen and carbon dioxide), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), cognitive impairment, cardiomyopathy (serious disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), atherosclerotic heart disease (buildup of fats, cholesterol and plaque in the artery walls of the heart which restrict blood flow to the heart), and hypertension (high blood pressure).R11's quarterly MDS with an assessment reference date of 2/21/26 has a BIMS of 00 which indicates severe cognitive impairment. The MDS documents that R11 was assessed to be dependent on toileting hygiene, roll left to right, chair/bed to chair transfer. The MDS also documents that R11 has an indwelling urinary catheter and is frequently incontinent of bowel. On 3/23/26, at 10:59 a.m., Surveyor observed Certified Nursing Assistant (CNA)-Y and CNA-Z wash their hands. CNA-Y informed R11 they were going to get him up and go to activities. CNA-Y then asked R11 if he was ready. R11 replied yes. CNA-Y and CNA-Z placed PPE (personal protective equipment) on. CNA-Y lowered R11's head of the bed down, removed the bedding off R11, R11's gown and unfastened the incontinence product. CNA-Y washed R11's face, asked R11 to raise his arms which R11 was able to and washed R11's under arms. CNA-Y washed R11's frontal area, tubing of catheter and inner thighs. CNA-Z positioned R11 on his left side. CNA-Y asked R11 if he was done pooping. CNA-Y wiped R11's buttocks with the incontinent product to remove the stool, then washed R11's rectal and buttocks. CNA-Y did not remove her gloves and perform any hand hygiene. CNA-Y asked CNA-Z for cream, R11 was positioned on his back and CNA-Z handed CNA-Y barrier cream. CNA-Z positioned R11 on the left side, CNA-Y applied barrier cream on R11's buttocks, removed the soiled incontinence product and threw the product in the garbage. CNA-Y placed a clean incontinence product under R11, R11 was repositioned on his back, CNA-Y adjusted R11's oxygen tubing, pulled the incontinence product between R11's legs and fastened. CNA-Y informed R11 they were all done.On 3/23/26, at 11:11 a.m., CNA-Y removed her gloves and placed gloves on. CNA-Y did not perform any hand hygiene. CNA-Y placed a graduate directly on the floor. CNA-Y did not place a barrier on the floor. CNA-Y cleaned the drainage spigot with an alcohol pad, drained urine into the graduate removing 250 cc (cubic centimeters) of urine, placed the spigot in the drainage bag, emptied the urine in the toilet and rinsed the container. CNA-Y removed her gloves and washed her hands. CNA-Z asked R11 if he was getting up. R11 replied no and then R11 was covered with a sheet. At 11:21 p.m. CNA-Y removed her gown and left R11's room. CNA-Z then went over to R11's roommate side of the room.On 3/25/26, at 1:34 p.m., Surveyor asked IP (Infection Preventionist)-JJ when staff are doing continence cares, after they finish providing continence cares & before they proceed to a clean task should they remove their gloves and perform hand hygiene. IP-JJ replied yes this is basic infection control. Surveyor asked IP-JJ when staff are going to empty an urinary collection bag should a barrier be placed on the floor before placing the graduate on the floor. IP-JJ replied yes indicating they have been drilled this, stating we just had a skills fair. Surveyor informed IP-JJ of the observation with R11.2.) R15's diagnoses include quadriplegia (paralysis of all four limbs), hypertension (high blood pressure), history of cardiac arrest (heart abruptly stops pumping blood), prediabetes (blood sugar levels are higher than normal but not high enough for diabetes diagnoses), neuromuscular dysfunction of bladder (condition where the nerves and muscles that control bladder function are impaired leading to abnormal urinary symptoms), neurogenic bowel (loss of normal bowel functions due to nerve damage).R15 is on enhanced barrier precautions.R15's quarterly MDS (minimum data set) with an assessment reference date of 12/26/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R15 is dependent upon staff for toileting hygiene, roll left to right and chair/bed to chair transfer. R15 is assessed as being always incontinent of urine and frequently incontinent of bowel. R15 is assessed as having one Stage 4 pressure injury.On 3/25/26, at 11:05 a.m., Surveyor observed Certified Nursing Assistant (CNA)-NN wash her hands, place a gown & gloves on, and inform R15 she is going to get him ready for Assistant Director of Nursing (ADON)-D to do his treatment. R15 informed CNA-NN he moved his bowels again. CNA-NN repositioned R15 so R15 was straight in bed, removed her gloves & washed her hands. At 11:08 a.m., ADON-D entered R15's room, CNA-NN informed ADON-D R15 had moved his bowels, and ADON-D stated she will go get an aide & left R15's room.On 3/25/26, at 11:12 a.m., CNA-Y entered R15's room, washed her hands and placed gloves on. Surveyor observed CNA-Y did not put a gown on. CNA-Y stated to R15 going to change you and removed the pillow from between R15's legs. CNA-Y washed R15's frontal perineal area, inner thighs, and Foley tubing. CNA-NN positioned R15 on the right side. CNA-Y washed R15's rectal area and buttocks to remove stool. CNA-Y removed her gloves and placed new gloves on. CNA-Y did not perform any hand hygiene.On 3/25/26, at 11:17 a.m. CNA-Y placed a gown on. CNA-Y asked R15 if he was ready, R15 was positioned on the right side, a new draw sheet & incontinence product was placed under R15. R15 was positioned to the other side, the draw sheet & incontinence product was straightened out, & soiled items were removed. CNA-Y handed CNA-NN the soiled items who placed them in a bag. CNA-NN removed her gloves & washed her hands. CNA-Y pulled R15's gown down, informed R15 they were going to do his treatment, removed her PPE and washed her hands.On 3/25/26, at 1:32 p.m. Surveyor asked IP (Infection Preventionist)-JJ when staff are providing incontinence cares for a resident who is on EBP what should staff wear. IP-JJ replied gown and gloves. Surveyor informed IP-JJ of the observation with R15. IP-JJ replied that's wrong.3.) On 3/25/26, at 8:08 a.m., Surveyor observed Licensed Practical Nurse (LPN)-T prepare R3's medication which consisted of quetiapine 100 mg (milligrams) one tablet, buspirone 5 mg one tablet, gabapentin 100 mg 1 capsule, methenamine [NAME] 1 gram one tablet, losartan potassium 50 mg one tablet, metformin 500 mg one tablet, pantoprazole 40 mg one tablet, simvastatin 10 mg 1/2 tablet, cranberry one tablet, olanzapine 5 mg one tablet, and vitamin D3 two tablets. On 3/25/26, at 8:19 a.m., Surveyor informed LPN-T Surveyor would like to verify the number of pills there are in the medication cup. LPN-T removed a second medication cup from the medication cart and using the tip of her fingernail moved R3's pills one at time into the second medication cup. On 3/25/26, at 8:22 a.m., LPN-T administered R3's medication to R3.On 3/26/26, at 8:11 a.m., Surveyor informed Director of Nursing (DON)-B of the observation with LPN-T using her fingernail to move R3's medication from one med cup to another to verify the number of pills with Surveyor. 4.) On 3/25/26, at 9:16 a.m., Surveyor observed Registered Nurse (RN)-U prepare R46's G-tube medication.On 3/25/26, at 9:31 a.m., RN-U informed R46 she was going to check R46's vital signs and give her the medication. RN-U checked R46's vital signs, removed her gloves, stating she's looking for more gloves. RN-U removed her gown, washed her hands and left R46's room.On 3/25/26, at 9:36 a.m., RN-U returned to R46's room and placed a gown & gloves on. RN-U filled a graduate with water and added 30 cc of water into R46's crushed medication. Surveyor observed the syringe fall onto the floor. RN-U picked this syringe off the floor, rinsed off the syringe with water, and withdrew 30 cc of water from the graduate into the syringe. RN-stoppedR46's feeding, flushed R46's tube and then administered R46's G-tube medications from the syringe that had fallen on the floor.On 3/25/26, at 1:33 p.m., Surveyor asked IP (Infection Preventionist)-JJ during a G-tube medication administration if the nurse drops the syringe on the floor what should the nurse do. IP-JJ replied get a new one. What I would do is toss it out and get a new one, it's obviously contaminated. Surveyor informed IP-JJ of the observation of the syringe during R46's G-tube medication observation falling on the floor, RN-U rinsing off the syringe and then using the syringe.No additional information was provided.

Based on observation and interviews, the facility did not ensure 1 (R77) of 22 residents reviewed were provided with reasonable accommodations for resident needs and preferences. *R77 was provided an over toilet riser with bilateral handles by therapy, and the over toilet riser was removed without a medical or safety reason. Findings include:The facility's policy titled Accommodation of Needs dated 4/10/25 documents:Policy Statement: The facility is committed to providing care and services that accommodate the individual needs, preferences, and rights of each resident in accordance with federal and state regulations, including the Americans with Disabilities Act (ADA) and CMS Requirements of Participation under 42 CFR 483. The facility will make reasonable accommodations to ensure residents attain or maintain their highest practicable physical, mental, and psychosocial well-being.Purpose: To ensure all residents receive individualized care and services that reflect their unique needs, choices, cultural preferences, communication abilities, and disabilities.2. Reasonable AccommodationsThe facility will provide reasonable accommodations including, but not limited to:Physical Environment-Accessible rooms, bathrooms, and common areas-Adaptive equipment(e.g. grab bars, specialized beds, mobility aids) .6. Resident choice and Rights-Residents have the right to make choices about their care and daily life-The facility will support resident autonomy while ensuring safety.R77 was admitted to the facility on [DATE] with diagnoses of Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Cellulitis(bacterial skin infection affecting deep dermis and subcutaneous tissue) of Right Lower Limb, Essential Hypertension(chronic condition of persistently high blood pressure), Hypothyroidism(underactive thyroid), and Hyperlipidemia(high levels of fat particles in blood). R77's admission Minimum Data Set (MDS) completed 2/16/26 documents a Brief Interview for Mental Status (BIMS) score to be 14, indicating R77 is cognitively intact for daily decision making. R77's MDS documents R77 has no depressive and behavior symptoms. R77's MDS documents: ROM (range of motion) impairment on one side of lower extremity; that R77 requires set-up for eating, partial/moderate assistance for mobility, and is dependent for toileting, hygiene, showers, upper and lower dressing, and transfers.R77's Functional Abilities Care Area Assessment (CAA) completed 2/16/26 documents: R77 currently requires staff assistance for Activities of Daily Living (ADL) completion. Goal is for R77 to increase independence with ADL performance.R77's Kardex, instructing certified nursing assistants (CNAs) on how to care for R77, documents that R77 requires the assistance of two for toilet transfers.On 3/23/2026, at 9:27 AM, R77 informed Surveyor R77 had an overbed toilet seat riser on the toilet and that R77 needed it because R77 holds onto the toilet riser bars to transfer. R77 stated that the toilet riser is gone and that R77 has no idea why. Surveyor observed no over toilet riser with bars in R77's bathroom. On 3/24/2026, at 10:37 AM, Surveyor observed no over toilet riser with bars in R77's bathroom. On 3/24/2026, at 1:44 PM, Surveyor observed no over toilet riser with bars in R77's bathroom. On 3/25/2026, at 7:59 AM, Surveyor observed no over toilet riser with bars in R77's bathroom. R77 informed Surveyor that R77 is frustrated because R77 was using one and needs help with toileting, but now feels like R77 is not working to be independent with toileting.On 3/25/2026, at 11:24 AM, Surveyor interviewed Physical Therapist Aide (PTA)-J. PTA-J confirmed that PTA-J has been working on transfers with R77 utilizing the over toilet riser. PTA-J recommended that R77 transfers with the use of the over toilet riser. PTA-J stated that R77 should not be transferring alone. PTA-J confirmed that it is recommended for R77 to use the over toilet riser because therapy has been working on R77's transfers as R77's goal is to go home.On 3/25/2026, at 11:25 AM, Certified Occupational Therapist Aide (COTA)-I. COTA-I verified that COTA-I personally placed an over toilet riser with bars a couple of weeks ago over R77's toilet. COTA-I is not sure why the over toiler riser would have been taken out of R77's bathroom.On 3/25/2026, at 11:43PM, Certified Nursing Assistant (CNA)-H informed Surveyor that CNA-H recalled an over toilet riser in the bathroom, but thought it was used by the resident living in the next room whom shared the bathroom with R77.On 3/25/2026, at 12:11 PM, Surveyor observed COTA-I bring an over toilet riser with bars and place it over R77's toilet. R77 was very happy.On 3/25/2026, at 3:15 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Regional Director of Clinical Care Services (RDC)-C that R77 was provided an over toilet riser by therapy to assist with toilet transfers and during the survey process. Surveyor observed that there was no over toilet riser in R77's bathroom prior to 3/25/26. Surveyor shared the concern that therapy recommended R77 use the over toilet riser to work towards the goal of discharge back to the community and that the over toilet riser was removed without a safety or medical concern.No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure 1 (R70) of 1 residents reviewed was clinically appropriate to self-administer medications.* R70 was observed with approximately 11 medication pills in a medication cup on the over bed table next to R70. R70 did not have a self administration assessment of medication completed.Findings include:The facility's policy titled, Medication Self Administration, last revised 2/12/2024, documents: 1. The resident shall have an screen completed by a licensed nurse to determine factors that may impact the safe administration of medications.R70 was admitted to the facility on [DATE] with a diagnoses that included heart failure.R70's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition for R70. The MDS documents that R70 was assessed to have no behaviors and documented that R70 received scheduled pain medication during the MDS assessment period. R70's self-administration of medication assessment dated [DATE] answers no, indicating that R70 was assessed to not be safe to self administer medication.On 03/23/2026, at 9:17 AM, Surveyor observed R70 sitting in bed in R70's room watching television. Surveyor observed on the over bed table in front of R70, a medication cup containing more than 4 pills of medication. R70 indicated to Surveyor that R70 informed the nurse R70 would take the medications but forgot to take the rest of them. Surveyor observed there was not a licensed nurse &/or medication tech in R70's room to supervise R70's self administration of medications.On 03/25/2026, at 8:41 AM, Surveyor observed Licensed Practical Nurse (LPN)-X bring R70's medications into R70's room. Surveyor went into R70's room after observing LPN-X leave the room. Surveyor observed R70 holding a medication cup containing approximately 11 pills of medications. R70 informed Surveyor that the nurse left the medications with R70 and R70 is working on self administering the medications.On 03/25/2026, at 8:42 AM, Surveyor interviewed LPN-X regarding R70's self-administration of medications. LPN-X informed Surveyor that there are no residents on LPN-X's hall that take their own medications. Surveyor asked LPN-X if R70 has an order for self-administration of medications, LPN-X informed Surveyor that R70 does not have an order to administer medications. LPN-X indicated that LPN-X was going to go back in by R70 after getting water.On 03/25/2026, at 10:32 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who indicated that R70 was not assessed to self-administer medications and should not be self-administering medications. ADON-D indicated the only time self-administration of medications occurs is usually with inhalers, eye drops or self-injecting insulin pens.On 03/25/2026, at 11:09 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated R70 does not have a self-administration of medication assessment completed and should not be self-administering medications.On 03/25/2026, at 3:04 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Regional Director of Clinical Care Services-C of the above findings. No additional information was provided as to why the facility did not ensure that R70 was clinically appropriate and assessed to be safe to self-administer medications.

Based on interview and record review the facility did not ensure a comprehensive person-centered care plan was developed for 3 (R11, R77 & R85) of 22 residents reviewed. *R11 did not have an oxygen care plan. *R77 did not have a care plan for tubi grips. *R85 did not have a dehydration care plan. Findings include: The facility's policy titled, Care Plan – Baseline and Comprehensive and last revised 7/18/24 documents: To ensure that each resident care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative. Under the Policy section it documents: The Interdisciplinary Team will develop an individualized, comprehensive care plan for each resident based on their medical condition, medical history, assessments from different members of the interdisciplinary team, lifestyle, and current resident goals. 1.) R11's diagnoses include acute respiratory failure (lungs cannot adequately exchange oxygen and carbon dioxide) with hypoxia (low level of oxygen), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), and hypoxemia (abnormally low level of oxygen in the blood), and hypertension (high blood pressure). R11's physician order dated 10/24/25 documents: Check oxygen saturation every shift and titrate 02 (oxygen) @ (at 0-5 l/min (liters per minute) to keep sats (saturations) 92% or better via nasal cannula continuously every shift and as needed for shortness of breath. On 3/23/26, at 9:52 a.m., Surveyor observed R11 in bed on his back with the head of the bed elevated. Surveyor observed R11receiving oxygen via nasal cannula at 1.5 l/min. On 3/23/26, at 12:12 p.m., Surveyor observed R11 sitting in a Broda chair in his room. R11 was observed receiving oxygen via nasal cannula from a portable oxygen tank located on the back of R11's Broda chair. On 3/24/26, at 11:32 a.m., Surveyor observed R11 in bed on the left side receiving oxygen via nasal cannula. R11's nurses note dated 3/24/26, at 12:09 p.m., written by Assistant Director of Nursing (ADON)-D documents: Writer was notified by staff that resident was sleeping most of the morning. Writer assessed resident, resident was sleeping, easily arousable. Vitals BP (blood pressure) 108/60, Temp (temperature) 98.1, HR (heart rate) 72, RR (respiratory rate) 14, POX (pulse oximetry) 98% on 2.5 LPM (liters per minute) of oxygen via NC (nasal cannula). MD (medical doctor) notified NOR (new order received) to monitor resident, and if not improved send resident to ER (emergency room) for eval (evaluation) and treat. Resident is own person and notified. On 3/24/26, at 1:10 p.m., Surveyor observed R11 in bed on his back with the head of the bed elevated receiving oxygen via nasal cannula. On 3/24/26 Surveyor reviewed R11's care plans and noted the following care plans: Activities initiated 10/24/25, Resident is here for short term rehabilitation stay initiated 10/24/25, ADL (activities daily living) self-care performance deficit initiated 10/24/25, Advanced directive initiated 10/24/25, Behavior symptoms initiated 1/16/26, Congestive heart failure initiated 10/28/25, Hypertension initiated 10/28/25, Impaired cognitive function or impaired thought processes initiated 10/28/25, Discharge plan initiated 10/28/25, Actual alteration in elimination initiated 11/6/25, Moderate risk for falls initiated 10/24/25, Resident has bilateral heel ulcers with confirmed left heel infection with necrosis initiated 1/14/26, Resident has new onset respiratory symptoms and is at risk for further respiratory infections initiated 3/23/26, Resident has limited physical mobility initiated 10/24/25, Potential for altered nutritional status initiated 10/24/25, Resident has acute pain initiated 10/24/25, Resident has potential psychosocial well-being problem initiated 10/24/25, At risk for alteration in skin integrity initiated 10/24/25, Resident uses antianxiety medication initiated 3/22/26, Alteration in skin integrity initiated 11/18/25, Resident has sleep pattern disturbances initiated 10/28/25, and Vulnerability initiated 11/12/25. Surveyor noted the facility did not develop an oxygen care plan for R11. On 3/26/26, at 10:51 a.m., Surveyor asked ADON-D how care plans are developed for residents. ADON-D explained care plans are opened upon admission and then everyone tweaks the care plans afterward. Surveyor informed ADON-D Surveyor was unable to locate an oxygen care plan for R11. ADON-D replied okay. On 3/30/26, at approximately 8:00 a.m., Director of Nursing (DON)-B provided Surveyor with a care plan for R11 which documented: The resident has altered respiratory status/difficulty breathing initiated & revised on 3/26/26 which documents the following interventions all initiated on 3/26/26 of *Administer medication/puffers as ordered. Monitor for effectiveness and side effects. *Elevate head of bed. *Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. *Oxygen per MD order. *Position resident with proper body alignment for optimal breathing pattern. No additional information was provided. 2.) R77 was admitted to the facility on [DATE] with diagnoses of Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Cellulitis(bacterial skin infection affecting deep dermis and subcutaneous tissue) of Right Lower Limb, Essential Hypertension(chronic condition of persistently high blood pressure), Hypothyroidism(underactive thyroid), and Hyperlipidemia(high levels of fat particles in blood). R77's admission Minimum Data Set (MDS) completed 2/16/26 documents R77's Brief Interview for Mental Status (BIMS) score to be 14, indicating R77 is cognitively intact for daily decision making. R77's physician orders document: Apply Tubi grips Size F to BLE in the AM, and remove at NOC (night time) every day and evening shift for promote skin integrityActive 2/11/2026 R77's Kardex as of 3/26/26 documents that R77 is on a fluid restriction of 1500ml per day. On 2/18/26, Nurse Practitioner (NP)-LL documents: R77 was admitted to the hospital due to bilateral lower extremity swelling and pain, exacerbated by R77's pre-existing conditions, including hypertension, peripheral artery disease, transient ischemic attack, varicose veins, and hypothyroidism. R77's hospital course included treatment for bilateral lower extremity cellulitis. Surveyor noted that R77's bilateral lower extremity swelling and pain is not addressed on R77's Kardex and could not locate a comprehensive care plan for R77 that included the intervention of physician ordered bilateral tubi-grips to promote skin integrity. On 3/25/2026, at 3:15 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Regional Director of Clinical Care Services (RDC)-C that R77's tubi-grips to be placed on daily daily to address bilateral lower extremity swelling was not updated and documented within R77 comprehensive care plan. No additional information was provided. 3.) R85 was admitted to the facility on [DATE] with diagnoses of Osteoarthritis(degenerative joint disease), Morbid Obesity(too much body fat), Spondylosis(age related degeneration of spine), Adult Failure to Thrive(decline in overall health in older adults), Protein-Calorie Malnutrition Moderate(significant, but not severe, deficiency in nutrient intake), Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R85's admission MDS completed 2/23/26 documents R85's BIMS score to be 15, indicating R85 is cognitively intact for daily decision making. R85's Dehydration/Fluid Maintenance Care Area Assessment (CAA) completed 2/24/26 documents: Goal is acceptance of adequate fluids/improve oral intake to prevent fluid deficit. R85 received intravenous fluids(IV) in hospital on 2/15/26-2/17/26 due to fluid deficit as evidenced by metabolic acidosis, starvation ketosis, hypoglycemia and poor oral intake. On 2/24/26, Registered Dietitian (RD)-K completed a hydration assessment and documents: R85 is admitted following hospitalization for failure to thrive, multiple wounds, and hypoglycemia due to poor oral intake. IV fluids were provided from 2/25/26-2/17/26 due to starvation ketosis and hypoglycemia as well as metabolic acidosis. Will continue to monitor oral intake and wounds and reassess as needed. On 3/24/2026, at 11:49 AM, Surveyor interviewed RD-K. Surveyor asked RD-K based on R85 triggering for dehydration, how is R85's hydration status being monitored. RD-K explained that the facility monitors R85's fluid intake on a daily basis and informed Surveyor that R85 is on Lasix having the potential for fluid overload. RD-K stated that R85 received water with all medications, jello at lunch, and fluids should be kept within reach. On 3/24/2026, at 1:37 PM, Surveyor informed RD-K that Surveyor was unable to locate a dehydration or fluid monitoring care plan for R85. RD-K informed Surveyor I always put in dehydration care plans. I pride myself on being thorough. I have no idea how it got missed. It should have been there. Surveyor noted that a care plan addressing potential for dehydration was not in place until after the interview with RD-K when Surveyor brought it to RD-K's attention. On 3/25/2026, at 1:27 PM, Assistant Director of Nursing (ADON)-E confirmed that the interdisciplinary team (IDT) is responsible for completing the comprehensive care plan depending on the focused problem. On 3/25/2026, at 3:15 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Regional Director of Clinical Care Services (RDC)-C that R85's at risk for dehydration care plan was not developed and part of R85's comprehensive care plan. No additional information was provided.

Based on interview, and record review, the facility did not update the comprehensive person-centered care plan for 1 (R10) of 22 residents to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment.R10's care plan was not updated after R10 was removed from hospice services.Findings include:The facility's policy and procedure titled Care Plan-Baseline and Comprehensive last revised 7/18/24, documents: Purpose- To ensure that each resident receives care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative. Policy: The Interdisciplinary Team will develop an individualized, comprehensive care plan for each resident based on their medical condition, medical history, assessments from different members of the interdisciplinary team, lifestyle, and current resident goals.Procedure:7. Throughout the course of rehabilitation and the resident's stay in the facility, the identified risk factors, goals, interventions, and outcomes on the care plans will be evaluated at least quarterly and revised as necessary . 12. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 13. The Interdisciplinary Team must review and update the care plan:a. When there has been a significant change in the resident's condition. R10 was admitted to the facility on [DATE] with pertinent diagnoses that include Parkinson's disease with dyskinesia (a progressive neurodegenerative disorder that primarily affects movement by damaging dopamine-producing neurons in a specific area of the brain called the substantia nigra), aphasia (complete inability or refusal to swallow), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), conversion disorder (a psychiatric condition where emotional or psychological stress causes real physical, neurological symptoms (e.g., paralysis, blindness, seizures) without an underlying organic medical cause), dysphagia (difficulty swallowing), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (a serious neurological condition characterized by paralysis (hemiplegia) or weakness (hemiparesis) on the right side of the body, with the right hemisphere of the brain being dominant), vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), and adult failure to thrive.R10's Significant Change in Status Minimum Data Set (MDS) with an assessment reference date of 2/12/26, does not document a Brief Interview for Mental Status (BIMS). The MDS assesses: R10 is rarely or never is understood or understands others; R10's Patient Depression Questionnaire (PHQ-9) score to be 00 indicating no depressive symptoms; R10 exhibited no behaviors during the look back period of the MDS assessment; R10 was coded as receiving hospice care. R10's care plan Resident is on hospice services r/t (related to) physical decline d/t (due to) dx (diagnosis) of hemiplegia following cerebral infraction affecting right dominant side. Date initiated 3/6/25. Pertinent interventions include: Follow hospice care plan along with family care plan. Date initiated: 3/6/25 Hospice will provide support to the resident and family: emotionally, psychosocially, and spiritually. Date initiated: 3/6/25 Notify hospice and family if resident passes. Follow hospice instructions for release of body. Date initiated: 3/6/25 Notify hospice if increased s/sx (signs/symptoms) of dyspnea, anxiety and/or pain is not controlled. Date initiated: 3/6/25 Notify hospice of changes in condition. Date initiated: 3/6/25R10's care plan discharge plan: Resident will remain at the facility for LTC (long term care) and under Holistic hospice care. Date initiated: 2/12/25. R10's care plan Resident uses antianxiety mediation r/t hospice status and periods of agitation. Date initiated: 2/12/25.Surveyor noted 3 care plans related to R10 being on hospice services. On 03/24/2026, at 1:47 PM, Surveyor interviewed Registered Nurse (RN)-W about where R10's hospice communication binder is located. RN-W stated that R10 is no longer on hospice. RN-W stated will check with Assistant Director of Nursing (ADON)-E though because the computer still indicates R10 is on hospice.On 03/25/2026, at 8:02 AM, Surveyor interviewed ADON-E and was told that R10 is no longer on hospice and that R10 was removed from hospice a month or so ago on 2/1/26. Surveyor questioned why care plan and orders still say hospice and was told I don't know why.Surveyor asked if the expectation would be to remove hospice services from the care plan after services end. ADON-E replied yes most reasonably, however it doesn't change the treatment R10 receives. Surveyor noted that R10's care plan Resident is on hospice services r/t (related to) physical decline d/t (due to) dx (diagnosis) of hemiplegia following cerebral infraction affecting right dominant side has five interventions that instruct staff to utilize hospice services. On 03/25/2026, at 3:04 PM, at the end of day meeting, Surveyor informed Nursing Home Administrator-A, Director of Nursing-B and Regional Director of Clinical Care Services-C know concerns regarding R10's care plan not being updated after R10 was removed from hospice services.No additional information was provided regarding R10's care plan not being updated after hospice services ended.

Based on interview and record review, the facility did not ensure that 1 (R105) of 4 residents reviewed for ADL (Activities of Daily Living) assistance received the necessary services to maintain ability to practice good grooming and personal hygiene.*R105, whom requires assistance from facility staff, did not receive any showers in the last 30 days and was observed in the same clothes during survey. Findings include:The facility policy entitled, Activities of Daily Living (ADLs), last revised 2/25/2025 documents: 1. A resident will be given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living.2. The facility will provide care and services for the following activities of daily living:Bathing and hygiene: Assistance with bathing or showering and maintaining personal hygiene.Dressing: Helping residents put on or remove clothing.Based on the assessments, a personalized care plan is created. It outlines the level of assistance needed for each ADL. The care plan is adjusted over time as the resident's condition changes.5. ADLs will be individualized, considering factors like physical abilities, cognitive function, and mental health. ADL cares will be provided based on the resident preferences.9. If a resident refuses care, this shall be reported to the nurse and the resident reapproached. Documentation of refusal shall be completed in the electronic medical record.R105 was admitted to the facility on [DATE] with diagnoses of Fracture of One Rib, Left Side, Repeated Falls, Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Emphysema(long term lung condition causing shortness of breath), Marfan Syndrome(genetic connective tissue disorder), Unspecified Protein-Calorie Malnutrition (deficiency of both protein and energy), Depression(mood disorder that causes persistent feelings of sadness and loss of interest) and Schizophrenia(chronic brain disorder characterized by distortions in thinking, perception, emotions, and behavior).R105 does not have a completed Minimum Data Set (MDS). Surveyor noted that based on interviews with R105, R105 is alert and oriented to person, place, and time.R105's comprehensive care plan dated 3/18/26 which documents: R105 has an ADL self-care performance deficit r/t (related to) fracture of one rib left side, emphysema, Marfan syndrome, weakness, Pain, TIA, cerebral ischemia, cachexia Under the Interventions section it documents: BATHING/SHOWERING ASSIST - ONE; DRESSING ASSIST - ONE; DRESSING: Allow sufficient time for dressing and undressing; DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self.; PERSONAL HYGIENE/ORAL CARE ASSIST - ONEOn 3/23/2026, at 2:09 PM, Surveyor observed R105 with very disheveled hair and wearing a long sleeve blue shirt and dark gray pants.On 3/24/2026, at 11:38 AM, Surveyor observed R105 with very disheveled hair and wearing the same long sleeve blue shirt and dark gray pants as yesterday. On 3/25/2026, at 8:04 AM, R105 is wearing the same long sleeve blue shirt and gray pants from 3/24/26 and R105's hair remained very disheveled.On 3/25/2026, at 11:17 AM, Surveyor observed R105 wearing the same clothes and R105's hair is matted in some areas on the back of R105. On 3/25/2026, at 11:20 AM, Surveyor interviewed R105 who believes R105 may have had one shower since admission but is not for sure. R105 informed Surveyor that R105's hair is wild. R105 informed Surveyor that R105 does not have any other clothes to change into. Surveyor noted that per the CNA assignment book, R105 is scheduled for showers on Tuesday AM and Fridays PM.Surveyor reviewed R105's shower documentation that documents R105 has not had a shower since admission. Surveyor noted there is no documentation in R105's electronic medical record (EMR) that R105 has refused showers.On 3/25/2026, at 11:29 AM, Surveyor interviewed CNA-KK who stated that if a resident refuses a shower, CNA-KK would re-approach the resident or find another CNA to try and give a shower. On 3/25/2026, at 11:43 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H regarding R105. CNA-H stated that CNA-H was unsure if R105 has not refused a shower for CNA-H because CNA-H has not worked or been assigned to R105 on R105's shower days.On 3/25/2026, at 1:03 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-E in regard to R105 receiving showers. ADON-E stated that if a resident refuses showers it should be documented in a resident's EMR. Surveyor reviewed with ADON-E that R105 has not had a shower since admission. ADON-E stated R105 has refused all showers and both Surveyor and ADON-E looked for documentation in R105's EMR of R105's refusal of showers. ADON-E informed Surveyor there was no documentation of R105 refusing showers but was going to document R105's refusals showers today. ADON-E then informed Surveyor that CNA-H has informed ADON-E that R105 has refused all showers. Surveyor shared with ADON-E that Surveyor had already interviewed CNA-H and CNA-H informed Surveyor that R105 has not refused showers because CNA-H has not been assigned to R105 on R105's shower days. ADON-H then informed Surveyor that R105 should have taken a shower at home yesterday when R105 went home on a pass.On 3/25/2026, at 1:13 PM, ADON-E and Surveyor went to observe and speak with R105. ADON-E asked R105 if R105 took a shower at home yesterday. R105 stated R105 did not take a shower because R105 did not have time. R105 stated R105 really wants a shower. On 3/25/2026, at 1:49 PM, ADON-E documented in R105's EMR: Resident did not receive bath/shower in past 7 days. Spoke with resident a few days ago and resident reported he was going to take a shower when he got home. Resident reported he was going to take a taxi home for a few hours and do a few things and take a shower. Will continue to follow.On 3/26/26, at 12:09 PM, CNA-H informed Surveyor that R105 was not scheduled for a shower today but received a shower.On 3/26/2026, at 12:20 PM, Surveyor spoke with R105. R105 is very happy R105 received a shower and stated that the facility even gave R105 clean clothes.On 3/25/2026, at 3:15 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Regional Director of Clinical Care Services (RDC)-C that R105 had not received a shower since admission to the facility.No additional information was provided.

Based on interview and record review, the facility did not ensure that 2 (R5, R47 and R105) of 4 residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene.*R5, who is dependent on staff, only received 1 shower in 30 days, with no documented refusals. R5, who is also dependent on staff for toileting, was not checked or changed for incontinence and was observed with a saturated brief.*R47, who is dependent on staff, did not receive any showers in the last 30 days, with no documented refusals. R47, who is totally dependent on staff, was not checked or changed for incontinence per R47's care plan.Findings include:The facility policy entitled, Activities of Daily Living (ADLs), last revised 2/25/2025 documents: 1. A resident will be given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living.2. The facility will provide care and services for the following activities of daily living:Bathing and hygiene: Assistance with bathing or showering and maintaining personal hygiene.Dressing: Helping residents put on or remove clothing.Based on the assessments, a personalized care plan is created. It outlines the level of assistance needed for each ADL. The care plan is adjusted over time as the resident's condition changes.5. ADLs will be individualized, considering factors like physical abilities, cognitive function, and mental health. ADL cares will be provided based on the resident preferences.9. If a resident refuses care, this shall be reported to the nurse and the resident reapproached. Documentation of refusal shall be completed in the electronic medical record.1.) R5 was admitted to the facility on [DATE] with diagnoses that include, Dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life) and acute cystitis with hematuria (bladder inflammation causing blood in the urine).R5's comprehensive Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 00, indicating R5 has severe cognitive impairment. The MDS documents that R5 does not exhibit behaviors or rejection of care, is always incontinent of bowel and bladder, has impairment on both sides in upper and lower extremities and is dependent on staff assistance for all Activities of Daily Living (ADL).Survey reviewed the facility provided document for R5, titled Care Plan Report, which documents R5 has an Activity of Daily Living (ADL) self-care deficit, initiated 1/30/2026, requiring an assist of 1 with showering/bathing with interventions including: provide sponge bath when a full bed bath or shower cannot be tolerated, use simple, short instructions to promote independence.On 03/24/2026, at 8:05 AM, Surveyor observed R5 in the dining room. R5's hair was uncombed and flat in the back from laying on hair for extended time and sticking straight up and unkept. Surveyor noted that R5 could not be interviewed due to cognitive status.On 03/24/2026, at 10:51 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-HH regarding showers. CNA-HH indicated residents will usually receive 2 showers per week and that showers/bath schedules for residents are in the book at nurse station.Surveyor reviewed the Facility shower/bath schedule for R5 and noted the following:R5's shower days are Tuesdays AM and Friday PMSurveyor noted R5 was scheduled to have a shower on the morning of (Tuesday) 3/24/2026 but did not appear to have been showered as evidence by R5's unkept appearance.On 03/25/2026, 8:51 AM, Surveyor interviewed CNA-Z who indicated that sometimes R5 will get up early in the morning. 3rd shift will get R5 up and shower on R5's shower days. R5 will get showers 2 times per week or more if requested but was unsure if R5 received a shower yesterday.Surveyor reviewed the facility provided task log for the last 30 days of R5's showers. Surveyor noted R5 was given 1 shower and R5's hair was washed 1 time in the last 30 days, with no documented refusals. Surveyor noted R5 should have had 9 showers between 02/24/2026 and 03/24/2026 but only received 1 shower and 3 bed baths, with no documented refusals.On 03/25/2026, at 10:32 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C regarding how often R5 should have a shower and if there were any refusals. While looking up the information, ADON-C indicated only 1 shower and 3 bed baths in 30 days for R5. ADON-C indicated R5 is supposed to have a shower twice per week. ADON-C indicated R5 can be combative and say no but that it should be document as a refusal.On 03/25/2026, at 11:09 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R5's showers. DON-B informed Surveyor that showers are scheduled 2 times per week. If the resident does not want to go to the shower room, a bed bath is preformed and done as alternative. The expectation is that the CNA would need to document refusals and the ADON or floor nurse would follow up on the alert in the system. DON-B stated there were no alerts in the system for shower refusals for R5.Toileting:Survey reviewed the facility provided document for R5, titled Care Plan Report, which documents R5 has an Activity of Daily Living (ADL) self-care deficit, initiated 1/30/2026, requiring an assist of 1 with toileting needs.Under the interventions section it documents: Check and change resident every 2 hours and assist with toileting needs, provide bed pan/bedside commode and provide loose fitting, easy to remove clothing. Surveyor noted this resolved on 2/2/2026.Survey reviewed the facility provided document for R5, titled Care Plan Report, which documents: R5 has an alteration in elimination, initiated 2/3/2026 and indicates the following interventions: check and change as needed due to incontinence, incontinent of bladder and incontinent of bowel.On 03/24/2026, at 10:45 AM, Surveyor began continuous observations of R5. Surveyor noted R5 sitting in the common area in R5's Broda wheelchair at a table.On 03/24/2026, at 12:53 PM, Surveyor noted staff brought R5 to R5's room and administered R5's tube feeding but did not check or change R5 during that time.On 03/24/2026, at 1:05 PM, R5 was brought back to the common area in R5's Broda chair and placed at a table. On 03/24/2026, at 1:56 PM, Surveyor observed Certified Nursing Assistant (CNA)-BB and Registered Nurse (RN)-CC bring R5 to R5's room to change R5. Surveyor noted R5's pants were wet with urine. CNA-BB indicated R5's pants are wet, and urine soaked through R5's brief. Surveyor noted R5's brief to be completely saturated in urine. R5 was provided with new pants after being changed by CNA-BB and RN-CC. Surveyor asked both staff when R5 was last changed, both staff indicated not being sure.Surveyor stopped continuous observation after R5 was changed and noted it was over 3 hours since R5 was checked and changed.Surveyor observed R5 continuously from 10:45 AM to 1:56 PM and noted that R5 was not checked and changed every two hours per R5's plan of care and that it was over 3 hours since R5 was last checked and changed by facility staff.On 03/25/2026, at 10:32 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C regarding Surveyors observations. ADON-C indicated that R5 should be checked and changed every 2-3 hours as needed.On 03/25/2026, at 11:09 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B informed Surveyor that R5 requires assistance with toileting and should be checked and changed at least every 2-3 hours.On 03/25/2026, at 3:04 PM, Surveyor informed the facility of the above concerns, no additional information was provided.2.) R47 was admitted to the facility on [DATE], with diagnoses including Dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life), acute cystitis with hematuria (bladder inflammation causing blood in the urine) and pressure injury to left hip.R47 's MDS (Minimum Data Set), dated 12/19/2025documents a BIMS (Brief Interview for Mental Status) score of 03, indicating R47 has severe cognitive impairment. The MDS documents that R47 was assessed to have no behaviors or rejection of care, that it is very important for R47 to choose between a tub bath, shower, bed bath or sponge bath, has no impairment in upper or lower extremities, and is dependent on staff for toileting and dependent on staff for showering.Survey reviewed the facility provided document for R47, titled Care Plan Report, which documents R47 has an Activity of Daily Living (ADL) self-care deficit, initiated 12/20/2025, and indicates R47 is totally dependent on staff for toilet use and assist of 1 for shower/bathing.Surveyor reviewed the facility's shower/bath schedule for R47 and noted the following:R47's shower days are Friday AM Monday PM.Surveyor reviewed the facility provided task log for the last 30 days of R47's showers. Surveyor noted that R47 did not receive any showers, received 4 bed baths in the last 30 days, with no documented refusals.R47 should have had 8 showers between 02/26/2026 and 3/24/2026 but did not receive any showers, with no documented refusals.On 03/25/2026, at 10:32 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C regarding how often R47 should have a shower and if there were any refusals.R47 did not receive any showers in the last 30days and received 4 bed baths 4 in the past 30 days. ADON-C indicated R47 should have 2 showers per week but just came to the 2nd floor unit from another unit in the facility on 3/20/26. ADON-C indicated that R47 receives showers on Sundays in the evening and Thursday in the evening. ADON-C informed Surveyor R47 received a shower this past Sunday evening but was marked not applicable in the tasks.On 03/25/2026, at 11:09 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R47's showers. DON-B informed Surveyor that showers are scheduled 2 times per week. If the resident does not want to go to the shower room, a bed bath is preformed and done as alternative. The expectation is that the CNA would need to document refusals and the ADON or floor nurse would follow up on the alert in the system. DON-B stated that no alerts in the system for refusals for R47.Toileting:Survey reviewed the facility provided document for R47, titled Care Plan Report, which documents R47 has an Activity of Daily Living (ADL) self-care deficit, initiated 12/20/2025, and indicates R47 is totally dependent on staff for toilet use.Survey reviewed the facility provided document for R47, titled Care Plan Report, which documents R47 has an alteration in elimination, initiated 12/20/2025, and indicated the following interventions: Apply barrier cream after each incontinence episode, check and change as needed, incontinence care after each incontinence episode, incontinent brief, incontinent of bladder and incontinent of bowel.On 03/24/2026, at 10:45 AM, Surveyor began continuous observation of R47. Surveyor observed R47 in the dining area attending activities. On 03/24/2026, at 1:08 PM, Surveyor noted R47 to still be in the dining area in R47's wheelchair, sitting at a table.On 03/24/2026, at 1:56 PM, Surveyor observed that R47 still had not been checked or changed at this time.Surveyor observed R47 from 10:45 AM to 1:56 PM and noted that R47 was not checked and changed every two to three hours per R47's plan of care and that it was over 3 hours since R47 was last checked and changed by facility staff.On 03/25/2026, at10:32 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C regarding Surveyors observations. ADON-C indicated that R47 should be checked and changed every 2-3 hours and as needed.On 03/25/2026, at 11:09 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B informed Surveyor that R47 requires assistance with toileting and should be checked and changed at least every 2-3 hours.On 03/25/2026, at 3:04 PM, Surveyor informed the facility of the above concerns, no additional information was provided.

Based on observations, interviews, and record review, the facility did not ensure residents received necessary care and treatment in accordance with professional standards of practice for 1 (R77) of 22 residents reviewed for quality of care.*R77's physician orders document that R77 is to wear bilateral tubi-grips during the day and off at night. Surveyor observed R77 not wearing bilateral tubi-grips during the survey process.Findings include:R77 was admitted to the facility on [DATE] with diagnoses of Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Cellulitis(bacterial skin infection affecting deep dermis and subcutaneous tissue) of Right Lower Limb, Essential Hypertension(chronic condition of persistently high blood pressure), Hypothyroidism(underactive thyroid), and Hyperlipidemia(high levels of fat particles in blood).R77's admission Minimum Data Set (MDS) completed 2/16/26 documents a Brief Interview for Mental Status (BIMS) score to be 14, indicating R77 is cognitively intact for daily decision making. R77's MDS documents: R77 has no depressive and behavior symptoms; It is very important for R77 to choose R77's clothes and to choose between a tub bath, shower, bed bath or sponge bath; R77 has no upper extremity range of motion (ROM) impairment and has ROM impairment on one side of lower extremity; R77 requires set-up for eating, partial/moderate assistance for mobility, and is dependent for toileting, hygiene, showers, upper and lower dressing, and transfers.R77's physician orders document: Apply Tubi grips Size F to BLE in the AM, and remove at NOC (night) every day and evening shift for promote skin integrityActive 2/11/2026.Surveyor noted that R77's tubi grips to be placed to bilateral lower extremities physician orders are not on R77's Certified Nursing Assistant (CNA) Kardex, which instructs CNAs on how to care for R77 and are not included in R77's comprehensive care plan.On 2/11/2026, at 3:34 PM, Registered Dietitian (RD)-K documented: Resident is admitted following hospitalization for leg swelling and bilateral lower extremity cellulitis. R77 was also diagnosed with hypokalemia. On previous admission in 2024, R77's weight was 110#. CBW is 125.2# likely related to swelling. Tubi-grips are in place. She reports UBW as ranging from 115-130#, depending on swelling in lower legs.On 3/23/2026, at 9:16 AM, Surveyor observed R77 not wearing tubi-grips per physician orders. R77 informed Surveyor that R77 has tubi-grips at home and was wearing them but has not been wearing them here.On 3/23/2026, at 12:14 PM, Surveyor observed R77 not wearing tubi-grips. On 3/24/2026, at 10:36 AM, Surveyor observed R77 in a wheelchair, no foot pedals on the chair, legs dangling and no tubi-grips on bilateral legs. On 3/24/2026, at 1:40 PM, Surveyor observed R77 not wearing tubi-grips on R77's bilateral lower extremities. On 3/25/2026, at 8:00 AM, Surveyor observed R77 not wearing tubi-grips on R77's bilateral lower extremities.On 3/25/2026, at 11:29 AM, Surveyor interviewed CNA-KK who stated that CNA-KK was unfamiliar with how to take care of a resident, CNA-KK would check the resident's kardex for guidance.On 3/25/2026, at 11:43PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H. CNA-H stated that CNA-H would consult a resident's Kardex to determine how to take care of a resident. CNA-H informed Surveyor that CNA-H has never seen tubi-grips in R77's room.On 3/25/2026, at 1:27 PM, Surveyor along with Assistant Director of Nursing (ADON)-E observed R77 not wearing R77's tubi-grips. ADON-E agreed R77 was not wearing physician ordered tubi-grips.Surveyor noted that R77's Treatment Administration Record (TAR) for March 2026 does not accurately reflect Surveyor's observations of R77's tubi-grips not being worn. Surveyor observed that on 3/23/26, 3/24/26, and 3/25/25, R77 was not wearing tubi-grips. R77's TAR documents R77 having tubi-grips on but Surveyor has observations of R77 not having tubi- grips on. On 3/25/2026, at 3:15 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Regional Director of Clinical Care Services (RDC)-C that R77 has not had bilateral tubi-grips per physician orders on during the survey process to effectively address R77's edema concerns. No additional information was provided.

Based on interview and record review the facility did not provide the opportunity for 2 (R77 and R105) of 2 residents reviewed to participate in the development and implementation of their person-centered plan of care by not facilitating the inclusion of R105 and R77 in the care planning process. *R77 was admitted on [DATE], and there is no documentation in R77's electronic medical record that R77 and/or representative participated in the development and implementation of R77's person-centered plan of care.*R105 was admitted on [DATE], and there is no documentation in R105's electronic medical record that R105 and/or representative participated in the development and implementation of R105's person-centered plan of care.Findings include:The facility's policy titled Care Plan-Baseline and Comprehensive policy dated as revised 7/18/24 documents:Purpose: To ensure that each resident receives care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative.2. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.6. Every effort will be made to schedule care plan meetings at the best time of the day for the resident, resident's representative, and family.14. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals will be document in the resident's clinical record.1.) R77 was admitted to the facility on [DATE] with diagnoses of Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Cellulitis(bacterial skin infection affecting deep dermis and subcutaneous tissue) of Right Lower Limb, Essential Hypertension(chronic condition of persistently high blood pressure), Hypothyroidism(underactive thyroid), and Hyperlipidemia(high levels of fat particles in blood).R77 is her own person. Surveyor noted that R77 had a Registered Nurse (RN) and a Case Manager from an outside entity involved in the care of R77.R77's admission Minimum Data Set (MDS) completed 2/16/26 documents R77's Brief Interview for Mental Status (BIMS) score to be 14, indicating R77 is cognitively intact for daily decision making.On 3/24/26, at 9:05 AM, Surveyor interviewed R77 and asked R77 if R77 had a care planning meeting to discuss R77's goals while residing in the facility. R77 stated R77 does not know what is going on with discharge planning. R77 informed Surveyor that R77 has not had a care conference meeting that R77 can remember.Surveyor reviewed R77's electronic medical record (EMR) and was unable to locate any documentation that R77 has had a care planning meeting involving the interdisciplinary team (IDT) and/or R77 or R77's representative.On 3/26/26, at 11:56 AM, Surveyor interviewed Director of Social Services (DSS)-G and Social Services Coordinator (SSC)-F. DSS-G has been the social worker on the third floor for a month where R77 resides. DSS-G stated that care conferences should be held when a resident admits, ready to discharge, change of condition, upon request, and when a request for services is made.DSS-G stated that 'third party entities and other providers should be invited to attend as well and if a resident has health care power of attorney or guardian and the resident. DSS-G stated the care conference is usually held the same day of admission. DSS-G stated that nursing, therapy, social services, and dietary if available attends the care conference. Both DSS-G and SSC-F informed Surveyor that the expectation is that there should be documentation of a care conference being held, who attended, and a recapitulation of what was discussed would be located under social service progress note in a resident's electronic medical record.DSS-G and SSC-F informed Surveyor that there is no documentation that a care conference occurred involving the interdisciplinary team (IDT) for R77.On 3/26/2026, at 3:50 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Regional Director of Clinical Care Services (RDC)-C that there is no documentation that R77 had a care conference involving the IDT, R77 or R77's representative, and outside entities, in order to participate in the development and implementation of their person-centered plan of care.No additional information was provided. 2.) R105 was admitted to the facility on [DATE] with diagnoses of Fracture of One Rib, Left Side, Repeated Falls, Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Emphysema(long term lung condition causing shortness of breath), Marfan Syndrome(genetic connective tissue disorder), Unspecified Protein-Calorie Malnutrition (deficiency of both protein and energy), Depression(mood disorder that causes persistent feelings of sadness and loss of interest) and Schizophrenia(chronic brain disorder characterized by distortions in thinking, perception, emotions, and behavior).R105 is currently his own person. Surveyor noted that R105 had a Registered Nurse (RN) and a Case Manager from an outside entity involved in the care of R105.R105 did not have a completed MDS. Surveyor noted that based on interviews with R105, R105 is alert and oriented to person, place, and time.On 3/23/2026, at 12:38 PM, Surveyor interviewed R105. R105 stated R105 has not met R105's social worker. R105 informed Surveyor that R105 has not had a meeting to discuss discharge plans, and has no idea what is going on. R105 has not received a list of medications and is anxious about what R105 is taking. R105 has not participated in any meeting.Surveyor reviewed R105's electronic medical record (EMR) and was unable to locate any documentation that R105 has had a care planning meeting involving the interdisciplinary team (IDT) and/or R105 or R105's representative.On 3/26/26, at 11:56 AM, Surveyor interviewed Director of Social Services (DSS)-G and Social Services Coordinator (SSC)-F. DSS-G has been the social worker on the third floor for a month where R105 resides. DSS-G stated that care conferences should be held when a resident admits, ready to discharge, change of condition, upon request, and when a request for services is made. DSS-G stated that 'third party entities and other providers should be invited to attend as well and if a resident has health care power of attorney or guardian and the resident. DSS-G stated the care conference is usually held the same day of admission. DSS-G stated that nursing, therapy, social services, and dietary if available attends the care conference. DSS-G and SSC-F informed Surveyor that the expectation is that there should be documentation of a care conference being held, who attended, and a recapitulation of what was discussed would be located under social service progress note in a resident's electronic medical record.DSS-G and SSC-F informed Surveyor that there is no documentation that a care conference occurred involving the interdisciplinary team (IDT) for R105.On 3/26/2026, at 3:50 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Regional Director of Clinical Care Services (RDC)-C that there is no documentation that R105 had a care conference involving the IDT, R105 or R105's representative, and outside entities, in order to participate in the development and implementation of their person-centered plan of care.No additional information was provided.

Based on observation and interviews, the facility did not ensure each resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 2 (R77 & R105) of 22 residents reviewed for dignity.*R77 was observed to be in a gown during the survey process. R77 would prefer to wear clothes.*R105 was in the same soiled clothes during the survey process. R105 preferred to wear clean clothes.Findings include:The facility's policy titled Resident Rights dated as revised 10/24/23 documents:Policy: The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents.Procedure:1.The resident has the right to exercise his or her rights to all residents of the facility and as a citizen or resident of the United States.2.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existenceb. be treated with respect, kindness, and dignity.1.) R77 was admitted to the facility on [DATE] with diagnoses of Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Cellulitis(bacterial skin infection affecting deep dermis and subcutaneous tissue) of Right Lower Limb, Essential Hypertension(chronic condition of persistently high blood pressure), Hypothyroidism(underactive thyroid), and Hyperlipidemia(high levels of fat particles in blood). R77's admission Minimum Data Set (MDS) completed 2/16/26 documents a Brief Interview for Mental Status (BIMS) score to be 14, indicating R77 is cognitively intact for daily decision making. R77's MDS documents: R77 has no depressive and behavior symptoms; It is very important for R77 to choose R77's clothes and to choose between a tub bath, shower, bed bath or sponge bath; R77 has no upper extremity range of motion (ROM) impairment and has ROM impairment on one side of lower extremity. R77's MDS also documents R77 requires set-up for eating, partial/moderate assistance for mobility, and is dependent for toileting, hygiene, showers, upper and lower dressing, and transfers.R77's Functional Abilities Care Area Assessment (CAA) completed 2/16/26 documents: R77 currently requires staff assistance for Activities of Daily Living (ADL) completion. Goal is for R77 to increase independence with ADL performance.R77's comprehensive care plan states: R77 has an activities of daily living (ADL) self-care performance deficit r/t osteoporosis, HTN, abnormalities of gait and mobility, muscle wasting and atrophy, edema, history of falling, arthritis left knee.BATHING/SHOWERING ASSIST - ONE; BATHING/SHOWERING: Check nail length and trim and clean on bath days as necessary. Report any changes to the nurse; BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated.DRESSING ASSIST- ONE; DRESSING: Allow sufficient time for dressing and undressing; DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self.; DRESSING: Make sure shoes are comfortable and not slippery.PERSONAL HYGIENE/ORAL CARE ASSIST- ONE; TOILET USE ASSIST - TWOOn 3/23/2026, at 12:14 PM, Surveyor observed R77 sitting in a wheelchair eating lunch and wearing a hospital gown with a black zip up sweatshirt. On 3/24/2026, at 10:36 AM, Surveyor observed R77 sitting in a wheelchair with a hospital gown on.On 3/24/2026, at 1:40 PM, Surveyor observed R77 still wearing a hospital gown with same black zip up sweatshirt, self-propelling wheelchair up and down the hallway. On 3/25/2026, at 8:00 AM, Surveyor observed R77 wearing a hospital gown and self-propelling self in wheelchair in/out of room. On 3/25/2026, at 11:43PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who stated CNA-H has observed R77 wearing a gown all the time with a shirt underneath it. CNA-H stated R77 has a black sweatshirt. CNA-H stated that if a resident needs a change of clothes, CNA-H would go to CNA-H's supervisor, Assistant Director of Nursing (ADON)-E.On 3/25/2026, at 11:51 AM, Surveyor interviewed R77. R77 stated R77 would prefer to wear clothes. R77 states R77 would especially wear sweatpants because I wear a brief. R77 stated: I only have one change of clothes here, the clothes I came here with. I don't want to wet my pants and lose them. On 3/25/2026, at 1:27 PM, ADON-E and Surveyor observed R77 in the hallway wearing a hospital gown. On 3/25/2026, at 3:15 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Regional Director of Clinical Care Services (RDC)-C that R77 was observed wearing a gown during the survey process. Surveyor informed NHA-A and DON-B that R77 prefers to wear clean clothes. No additional information was provided. 2.) R105 was admitted to the facility on [DATE] with diagnoses of Fracture of One Rib, Left Side, Repeated Falls, Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Emphysema(long term lung condition causing shortness of breath), Marfan Syndrome(genetic connective tissue disorder), Unspecified Protein-Calorie Malnutrition (deficiency of both protein and energy), Depression(mood disorder that causes persistent feelings of sadness and loss of interest) and Schizophrenia(chronic brain disorder characterized by distortions in thinking, perception, emotions, and behavior). R105 did not have a completed MDS (Minimum Data Set). Surveyor noted that based on interviews with R105, R105 is alert and oriented to person, place, and time.R105's comprehensive care plan documents: R105 has an ADL self-care performance deficit r/t (related to) fracture of one rib left side, emphysema, Marfan syndrome, weakness, Pain, TIA, cerebral ischemia, cachexia. Under the Interventions section, it documents:BATHING/SHOWERING ASSIST- ONE; BATHING/SHOWERING: Check nail length and trim and clean on bath days as necessary. Report any changes to the nurse; BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated; DRESSING ASSIST- ONE; DRESSING: Allow sufficient time for dressing and undressing; DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self.On 3/23/2026, at 2:09 PM, Surveyor observed R105 wearing a long blue sleeve shirt and dark gray pants while outside smoking.On 3/24/2026, at 11:38 AM, Surveyor observed R105 wearing the same blue long sleeve shirt and dark gray pants.On 3/25/2026, at 8:04 AM, R105 is observed by Surveyor wearing the same blue long sleeve shirt and dark gray pants. Surveyor noted the clothes were soiled with dried food and liquid. On 3/25/2026, at 11:17 AM, R105 is still wearing the same blue long sleeve shirt and dark gray pants that were soiled with dried food and liquid. On 3/25/2026, at 11:20 AM, Surveyor interviewed R105. R105 stated that R105 does not have any other clothes to put on. On 3/25/2026, at 11:29 AM, Surveyor interviewed CNA-KK who stated that if a resident does not have a change of clothes, CNA-KK would offer a gown to the resident. On 3/25/2026, at 1:03 PM, Surveyor interviewed ADON-E. ADON-E informed Surveyor that the expectation is that staff should try to find clothing items for residents. ADON-E stated that the facility does have donated clothing items and hasn't had a resident refuse donated clothing items. On 3/26/2026, at 9:53 AM, Surveyor observed R105 wearing the same blue long sleeve shirt and dark gray pants that were soiled with dried food and liquid. On 3/26/2026, at 12:20 PM, R105 informed Surveyor that R105 got some free clean clothes and is very happy. On 3/25/2026, at 3:15 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Regional Director of Clinical Care Services (RDC)-C that R105 has been wearing the same soiled clothes during the survey process and that R105 would like to wear clean clothes.No additional information was provided.

Based on interview and record review, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's (Housekeeper-V) Integrated Background Information System (IBIS) background check was not obtained before the employee started working at the facility. Findings include:The facility policy and procedure titled Vulnerable Adult Abuse and Neglect Prevention last revised 3/25/25 documents::Purpose: To provide residents a safe environment t that is free from harm.1. Screening and Training of New Employees and Volunteers:A. Employees:i. Screen potential employees for a history of abuse, neglect, exploitation, or mistreatment. That includes . checking with the appropriate licensing boards and registries.iv. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks, using the state specified criminal background system.On 3/26/26 at 8:50 am, Surveyor interviewed Nursing Home Administrator (NHA)-A about two employees that were sampled for background check forms that were missing some background check information. NHA-A stated NHA-A would look into the missing background check documentation. On 3/26/26, at 2:14 pm, Staff Development Director-M and NHA-A informed Surveyor that after searching all employee files, around the time Housekeeper-V was hired they could not locate an IBIS background form for Housekeeper-V. No additional documentation was provided as to why the facility did not ensure that Housekeeper-V had a complete background check to ensure the safety of resident's per the facility's abuse and neglect policy.

Based on observations, interviews, and record review, the facility did not ensure 1 (R3) of 3 residents reviewed for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing. -R3 was admitted to the facility on [DATE]. R3 developed a facility-acquired, unstageable pressure injury to the right heel on 10/25/23. R3 was hospitalized from 11/8/23 through 11/15/23. The infectious disease Medical Doctor (MD) in the hospital ordered an antibiotic for R3's infected right heel pressure injury that was to continue when R3 returned to the facility. R3 did not receive the antibiotic for the right heel infection for 5 days upon return to the facility. On 11/22/23, R3's right heel wound was documented as red, swollen, tender and warm with drainage. R3's MD ordered a culture of R3's right heel wound for gram stain. (A gram stain would involve swabbing the wound and sending it to a Laboratory. After processing the culture swab, the physician would know if bacteria were present and what bacteria was in the wound). The culture of the wound was never completed by the facility. On 11/28/23, R3 went to the hospital for Hemoptysis (throwing up blood). R3 was hospitalized until 12/12/23. During this hospitalization , R3 had a right, below the knee amputation on 12/8/23. -R3 developed a facility-acquired, unstageable pressure injury to the sacrum on 10/28/23. The facility's wound Registered Nurse (RN)-D measured the wound but did not include a thorough initial assessment of the wound bed upon discovery. The facility's documentation of the Braden's score for predicting pressure injuries was inconsistent in the weeks preceding the development of the sacral pressure injury and continued to be inconsistent after the development of the pressure injury. The Braden score ranged from 8 to 15. The lowest score of 8 indicating a very high risk for pressure injury and the highest score 15 indicating a mild risk for pressure injury development. On 12/19/23, R3's sacral wound had increased in size and a new treatment was recommended by the physician. The facility did not process the new order and continued completing the previously ordered treatment until a new order was added on 1/2/24. On 12/19/23, when the sacral wound was assessed to have increased in size R3's care plan was not reviewed or revised to implement new interventions to prevent the wound from worsening or to promote healing. On 1/2/23, R3's sacral wound was assessed to have increased in size again. R3's care plan interventions were not reviewed or revised to prevent the wound from worsening or to promote healing. Findings include: Surveyor reviewed the facility's Pressure Injury Prevention and Wound Care Management Policy and Procedure with a revision date of 2/24/23. Documented, in part, was: Purpose: The purpose of the policy is to provide healthcare staff with the standards of care and processes to be followed for all residents: -To identify factors that places the residents at risk for the development of pressure injuries and to implement appropriate interventions to prevent the development of clinically avoidable wounds. -To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. -To promote healing of existing pressure injuries and wounds. Policy: It is the policy of this facility that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care. The facility will ensure that a resident who is admitted without a pressure injury does not develop a pressure injury, unless clinically unavoidable. A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers. Procedure: A complete assessment is essential to an effective pressure injury prevention and treatment program. A comprehensive assessment helps the facility to identify residents at risk of developing pressure ulcers as well as the level and nature of their risks. -A Braden Scale should be completed for all residents upon admission/readmission . -Residents with a Braden Scale score of 12 or less should be considered to be at high risk for pressure injury development. -Risk factors identified by the Braden Scale, Minimum Data Set (MDS), or other assessment should be reviewed and addressed as determined appropriate through the Resident Assessment Instrument (RAI) process, including the resident's care plan . -The clinicians responsible for the residents' care will review risk factors and identify whether and to what extent those risks can be modified, stabilized or removed. -Resident's skin will be monitored daily during cares by nursing assistant and skin check will be completed weekly by licensed nurse. -Resident at risk for the development of a pressure injury will have their individualized care interventions and approaches documented in the resident care plan. -Skin impairments, including pressure injuries, non-pressure injury wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, using the PCC (electronic medical record) Weekly Wound Assessment: -Weekly documentation will include pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues and a description of any drainage, eschar, necrosis, odor, tunneling or undermining . -Daily, the clinicians responsible for caring for the Resident will assess the status of the dressing if present . and evaluate for complications such as infection and/or uncontrolled pain . -Wound and skin care interventions will be monitored and evaluated for effectiveness. Care plans will include specific and measurable goals and interventions. The care plan will be reviewed and revised at least quarterly, or with significant change in condition. Prevention and treatment Guidelines: The skin care program will be utilized following the guidelines of the Agency for Healthcare Research and Quality (AHRQ), the National Pressure Ulcer/Injuries Advisory Panel (NPIAP) and current standards of Clinical practice. -Pressure reduction surfaces should be provided on beds and chairs for at-risk residents . -The goals of wound treatment are to: Keep the ulcer bed moist and the surrounding skin dry, protect the ulcer from contamination, and promote healing . -If infection is suspected, notify the physician, and obtain clinically appropriate orders . R3 was admitted to the facility on [DATE] with pertinent diagnosis of Chronic Respiratory Failure with tracheostomy, Protein Calorie Malnutrition, Chronic Congestive Heart Failure, Gastrostomy, Non-traumatic intracranial hemorrhage, Cognitive communication deficit, Encephalopathy, Neurogenic bladder with suprapubic catheter, Anemia, and hypertension. Surveyor reviewed R3's Admission Minimum Data Set (MDS) with an assessment reference date of 9/13/23. Documented under Section C (Cognition) was a Brief Interview for Mental Status (BIMS) score of '0 which indicates a severe cognitive impairment. Documented under section M (skin conditions) were questions regarding pressure ulcers. Is the resident at risk for developing pressure ulcers. Yes. Does this resident have one or more unhealed pressure ulcers at stage 1 or higher. No. Surveyor reviewed R3's Braden Scale for predicting pressure sore risk with an assessment date of 9/7/23. The Braden Score documents the resident's Sensory perception (ability to respond meaningfully to pressure-related discomfort), Moisture (Degree to which skin is exposed to moisture), Activity (Degree of physical activity), Mobility (Ability to change and control body position), Nutrition, Friction and Shear. Under Sensory Perception was very limited. Under Moisture was occasionally moist. Under Activity was chairfast. Under mobility was completely immobile. Under Nutrition was adequate. Under Friction and Shear was potential problem. Documented was a score of 13 indicating that R3 was at Moderate Risk for developing pressure injuries. Surveyor reviewed R3's skin integrity care plan with an initiation date of 9/8/23. Care plan documented under focus was I am at risk for alteration in skin integrity. Documented under goal was I will be free from skin breakdown through the review date. Documented under interventions was: -Apply moisturizer to my skin as needed. -Do not massage over my bony prominences. -Float my heels while I am in bed. - Keep my skin clean and dry. -Position my body with pillows/support devices and protect bony prominences. -Routinely turn and reposition as tolerated by resident. -Use a draw sheet and 2 people when pulling me up in bed (to prevent shear). -Use A&D [vitamin A and D] Ointment, BAZA [moisture barrier cream], or other Skin Barrier Cream on my skin as needed. Surveyor noted an addition to the Skin integrity care plan on 9/13/23 added to the interventions was: -I use a special Mattress to relieve pressure. Settings at as close to 130 [pounds] but may be adjusted for comfort. Surveyor reviewed R3's Braden Scale for predicting pressure sore risk with an assessment date of 9/14/23. Under Sensory Perception was completely limited. Under Moisture was constantly moist. Under Activity was bedfast. Under mobility was completely immobile. Under Nutrition was adequate. Under Friction and Shear was problem. Documented was a score of 9 indicating R3 was a Very High Risk for developing pressure injuries. Surveyor noted the Braden score was significantly worse one week after the admitting date. Surveyor reviewed R3's MD's orders. With a start date of 9/7/2023 was, House barrier cream to buttocks every shift and PRN (as needed) to promote skin integrity. With a start date of 9/8/23 was, float heels or pressure redistribution boots in bed to promote skin integrity. With a start day of 9/13/23 was, Check air mattress for functioning every shift and Head to toe skin assessment weekly on shower day Monday AM. With a start date of 9/29/23, Air mattress with settings at 130 lbs. (pounds) or as close to 130 lbs. per settings. May adjust per comfort. Surveyor reviewed R3's Braden Scale for predicting pressure sore risk with an assessment date of 9/21/23. Under Sensory Perception was very limited. Under Moisture was occasionally moist. Under Activity was chairfast. Under mobility was completely immobile. Under Nutrition was adequate. Under Friction and Shear was potential problem. Documented was a score of 13 indicating R3 was at Moderate Risk for developing pressure injuries. Surveyor reviewed R3's Braden Scale for predicting pressure sore risk with an assessment date of 9/29/23. Under Sensory Perception was completely limited. Under Moisture was constantly moist. Under Activity was bedfast. Under mobility was completely immobile. Under Nutrition was adequate. Under Friction and Shear was problem. Documented was a score of 8 indicating R3 was a Very High Risk for developing pressure injuries. Surveyor reviewed R3's Braden Scale for predicting pressure sore risk with an assessment date of 10/6/23. Under Sensory Perception was very limited. Under Moisture was very moist. Under Activity was chairfast. Under mobility was very limited. Under Nutrition was adequate. Under Friction and Shear was potential problem. Documented was a score of 13 indicating R3 was a Moderate Risk for developing pressure injuries. Surveyor reviewed R3's Braden Scale for predicting pressure sore risk with an assessment date of 10/14/23. Under Sensory Perception was completely limited. Under Moisture was constantly moist. Under Activity was bedfast. Under mobility was very limited. Under Nutrition was adequate. Under Friction and Shear was no apparent problem. Documented was a score of 11 indicating R3 was at a High Risk for developing pressure injuries. Surveyor reviewed R3's Braden score for predicting pressure sore risk with an assessment date of 10/21/23. Under Sensory Perception was very limited. Under Moisture was occasionally moist. Under Activity was chairfast. Under mobility was very limited. Under Nutrition was adequate. Under Friction and Shear was no apparent problem. Documented was a score of 15 indicating that R3 was at Mild Risk for developing pressure injuries. Surveyor noted the facility's Braden score documentation for the weeks preceding the development of a pressure ulcer were inconsistent. Per the facility's policy and procedure on Pressure Injury Prevention and Wound Care Management, a Braden Scale sore of 12 or less should be considered to be at high risk for pressure injury development. Four out of the seven Braden scores documented from admission until R3 developed a pressure injury were documented above a score of 12 indicating R3 was not at high risk, when his clinical presentation would make them a high risk. Surveyor reviewed the weekly skin check documentation with an assessment date of 10/21/23. Documentation stated R3's skin turgor had good elasticity. Skin color was normal for ethnic group. Temperature was warm (normal). Moisture was normal. Condition was normal. New skin alterations identified? No. Surveyor reviewed progress note dated 10/25/23. Registered Nurse (RN)-D documented, Staff notified that resident has pressure injury to right heel. Resident area assessed unstageable noted to right heel. Boots in place and air mattress working effectively. Area assessed, cleansed and tx. (treatment) applied. Guardian updated and [MD-C] updated. Verbal consent obtained from [Guardian] for wound MD to eval (evaluate) and treat. Resident placed on 24-hour board for f/u (follow-up) monitoring. On 10/25/23, at 6:11 PM, RN-D documented the assessment under wound evaluations. Right heel wound measured 2.77 x 2.6 centimeters (cm). Type: Pressure. Stage: Unstageable due to slough and/or eschar. Exudate (drainage): Moderate, Serous (clear, thin, watery drainage). Acquired in house. Wound age: New. RN-D cleansed the pressure injury with Normal Saline and covered the wound with Xeroform and Foam dressing. Surveyor noted that there was not a thorough assessment of the wound bed. There was no explanation of the wound bed except to say that it had slough and/or eschar but did not state which. Surveyor reviewed new MD order. With a start date of 10/26/23, was Treatment to right heel: Cleanse with Normal Saline Wash f/b (followed by) Xeroform f/b foam dressing. Surveyor reviewed new care plan with an initiation date of 10/26/23. Documented under focus was: I have a Pressure Ulcer unstageable on the R (right) heel r/t (related to) bedfast, cognitive impairment. Air mattress assessed and properly functioning and heal boots in place. Documented under goal was: Healing- My pressure ulcer will show signs of healing without associated complications (infection) by/through the review date. Documented under interventions was: - Encourage offloading of heels with heels up or pillows. -Administer my treatments as ordered and monitor for effectiveness. -Turn and re position me at least every 2 hours, and on a schedule that is specific to my routine and tolerance. -To prevent Shearing-lower the head of my bed and keep as flat as possible when boosting up in bed. Use draw sheet and 2 people to pull up in bed. -Use mild cleansers for peri care and washing my skin. -Float heels as I allow. Keep my linen clean, dry, and wrinkle free. - Lift, rather than slide me in bed, to decrease friction. -Position my body with pillows/support devices and protect bony prominences. Surveyor reviewed R3's Braden Scale for predicting pressure sore risk with an assessment date of 10/27/23. Under Sensory Perception was very limited. Under Moisture was very moist. Under Activity was bedfast. Under mobility was slightly limited. Under Nutrition was adequate. Under Friction and Shear was potential problem. Documented was a score of 13 indicating R3 was at Moderate Risk for developing pressure injuries. Surveyor noted that even after a recent development of an unstageable right heel pressure ulcer, the Braden Scale score was not assessed at a high risk for developing pressure injuries. Surveyor reviewed R3's Braden Scale for predicting pressure sore risk with an assessment date of 10/28/23. Under Sensory Perception was very limited. Under Moisture was very moist. Under Activity was bedfast. Under mobility was very limited. Under Nutrition was adequate. Under Friction and Shear was potential problem. Documented was a score of 12 indicating R3 was at High Risk for developing pressure injuries. Surveyor reviewed the weekly skin check documentation with an assessment date of 10/28/23 at 12:17 PM. Documentation stated that R3's skin turgor had good elasticity. Skin color was normal for ethnic group. Temperature was warm (normal). Moisture was normal. Condition was normal. New skin alterations identified? No. Weekly skin Summary: No new skin issues. Surveyor reviewed R3's progress note dated 10/28/23. RN-D documented, Resident was noted to have an area on his buttocks. Area was cleansed and dressing applied per MD-C order. On 10/28/23, at 10:25 PM, RN-D documented the assessment under wound evaluations. Sacral wound measured 3.71 x 1.34 cm. Type: Pressure. Stage: Unstageable due to slough and/or eschar. Acquired in house. Wound age: New. Exudate: Moderate, Serous. RN-D cleansed the pressure injury with Normal Saline and covered the wound with Xeroform and Foam dressing. Surveyor noted there was not a thorough assessment of the wound bed. There was no description of the wound bed except to say it had slough and/or eschar but did not state which. Surveyor interviewed RN-D and Director of Nursing (DON)-B on 11/23/24, at 1:16 PM. Surveyor asked RN-D if she did a complete wound bed assessment of the right heel and sacral pressure injuries when they were found. RN-D stated the right heel wound was unstageable. RN-D indicated the heel wound was purple in color and RN-D would not put anything else in the documentation because it is a deep-tissue injury (DTI), and it was not open. Surveyor asked where this information was documented. RN-D stated they would have to check. Surveyor asked for clarification if the heel wound was a DTI or unstageable pressure injury. RN-D indicated she believed it was a DTI. Surveyor stated the wound MD, MD-E assessed the heel wound as an unstageable pressure injury and 100% eschar. RN-D indicated she would have to check. RN-D and DON-B left interview to retrieve a computer. RN-D returned to Surveyor and stated the right heel wound was unstageable and the wound had moderate exudate from eschar. Surveyor asked about the sacral pressure wound bed assessment on 10/28/23. RN-D stated the sacral wound was unstageable and that the wound bed was pink. Surveyor asked where the wound bed assessment would be found. RN-D stated they would only describe the wound bed as eschar or slough in their documentation. Surveyor asked if there was granulation, or epithelial (skin) tissue where would that be documented. RN-D stated it is not an option in the charting systems drop down box so she would not chart that. Surveyor asked if she could put that in the note section where typing could be done. RN-D stated she could. RN-D stated wound bed assessments would only be charted as slough or eschar and you would not chart epithelial, skin or granulation. Surveyor asked what standard of practice they were following for the wound assessments. DON-B stated she would have to investigate and return with an answer. On 1/24/24, at 9:00 AM, DON-B provided this Surveyor with the facilities Policy and Procedure on Pressure Injury Prevention and Wound Care Management which noted the standard of practice followed as the National Pressure Ulcer/Injuries Advisory Panel. Surveyor interviewed MD-E on 1/23/24 at 12:56 PM. Surveyor asked what the cause of the right heel and sacral pressure injuries were. MD-E Stated the initial cause was due to pressure. Surveyor reviewed new MD order placed on 10/28/23 to sacral wound. Documented was, Normal saline Wash f/b Xeroform f/b Foam dressing daily to buttocks/coccyx. On 10/31/23, MD-E and RN-D, assessed and treated R3's right heel and sacral wound. MD-E measured R3's heel wound as 6 x 8 (depth is unmeasurable due to presence of nonviable tissue and necrosis). 100% eschar. Exudate: Moderate, Serous. MD-E completed a sharp debridement on the heel wound. MD-E changed R3's treatment plan for the heel to cleanse wound with 1/2 strength Daikin's, followed by wet to moist with gauze soaked in 1/2 strengths Daikin's, gently pack wound followed by Abdominal gauze pad (ABD) pad and kerlix. MD-E measured R3's sacral wound as 6 x 6 x 0.1. 80% eschar. 20% dermis. Exudate: Moderate, Serous. MD-E completed a sharp debridement on the sacral wound. MD-E kept the wound treatment to the sacral wound the same. On 11/1/23, the right heel wound treatment changed to tx (treatment) to right heel: cleanse with 1/2 strength Daikin's f/b wet to moist gauze soaked in 1/2 strength Daikin's f/b ABD pad, f/b Kerlix BID (two times a day) and PRN (as needed). Tx to sacrum: Cleanse with NS (Normal Saline Wash) f/b Xeroform f/b Foam dressing. Surveyor reviewed R3's care plan. Added to the pressure ulcer care plan focus on 11/1/23 was: Unstageable Sacrum noted unavoidable secondary to enteral feeding positioning. Interventions in place and appropriate for resident. Added to the interventions was: Encourage side to side repositioning. On 11/7/23, MD-E and RN-D, assessed and treated R3's right heel and sacral wound. MD-E measured R3's heel wound as 6 x 8. Depth is unmeasurable due to presence of nonviable tissue and necrosis. 100% eschar. Exudate: Moderate, Serous. MD-E completed a sharp debridement on the heel wound. MD-E documented that the treatment to R3's right heel should remain the same. MD-E measured R3's sacral wound as 6 x 4 x 0.1. 100% eschar. Exudate: Moderate, Serous. MD-E completed a sharp debridement on the sacral wound. MD-E changed R3's treatment plan for the sacrum. Treatment changed to cleanse daily with NS Wash, followed by a nickel thick application of Santyl, followed by a foam dressing. Surveyor reviewed new MD orders with a start date of 11/7/23, documented was, Tx to sacrum: Cleanse with NS wash f/b a nickel thick application of Santyl, f/b foam dressing every day shift. One time order for Arterial Doppler to BLE (Bilateral Lower Extremities) to r/o (rule out) PAD (Peripheral Artery Disease). Surveyor reviewed the results of the Arterial Doppler. The Radiologist documented plaques noted in bilateral (both) lower extremity arteries and decreased blood flow to both lower extremities. Surveyor reviewed R3's progress note. On 11/8/23, at 10:27 PM, Licensed Practical Nurse (LPN)-F documented, [LPN-F] was called to room. Resident was having bright red blood in his brief with his stool. Supervisor was updated, [MD-C] was updated and new order to send [R3] to ER (emergency room ) for eval (evaluation) . R3 was hospitalized from 11/8/23 until 11/15/23 for a GI (gastrointestinal) Bleed, Urinary tract infection (UTI) and Pneumonia. Surveyor reviewed the infectious disease progress note from the hospital dated 11/14/23. MD-G documented, in part: At presentation [R3's] physical examination showed a necrotic decubitus ulceration of the right heel with foul-smelling discharge. Wound Care was consulted for the management. Empirically on IV (intravenous) vancomycin and IV cefepime. We will add IV metronidazole (Flagyl) for anaerobic coverage. Under assessment was pertinent documentation of the following: 1. Aspiration pneumonia involving the right lower lobe and right middle lobe. Infected right heel unstageable necrotic decubitus ulceration with underlying osteomyelitis of the right calcaneum . 3. Infected right heel unstageable necrotic decubitus ulceration with underlying osteomyelitis of the right calcaneum-the wound is necrotic with foul-smelling purulent discharge . Surveyor reviewed the list of Discharge Medications that should be ordered upon return to facility. Documented, in part, was Amoxicillin-Pot Clavulanate (Augmentin) 875-125mg, take one tablet by Gastrostomy tube (g-tube) in the morning and one tablet in the evening-Do this for 14 days. Metronidazole (Flagyl) 500 mg, take one tablet by g-tube every 8 hours for 14 days. Surveyor noted that wound care in the hospital started Flagyl for anaerobic coverage. Surveyor reviewed the R3's admission orders with a start date of 11/15/23 ordered was: Amoxicillin-Pot Clavulanate (Augmentin) Oral Tablet 875-125 MG, give 1 tablet via G-Tube two times a day. Metronidazole (Flagyl) Oral Tablet 500 MG, give 1 tablet via G-Tube every 8 hours until 12/4/23. Surveyor reviewed the Medication Administration Record (MAR). R3's Augmentin was given as ordered starting on 11/15/23. R3's first dose of Flagyl was not given until 11/21/23 at the 4 PM med pass. R3 did not receive the ordered Flagyl from admission on 11/15/23 until 11/21/23 at 4 PM. Surveyor noted R3 missed 14 doses of Flagyl after return from the hospital. Surveyor reviewed R3's Braden Scale for predicting pressure sore risk with an assessment date of 11/15/23. Under Sensory Perception was very limited. Under Moisture was occasionally moist. Under Activity was bedfast. Under mobility was very limited. Under Nutrition was adequate. Under Friction and Shear was potential problem. Documented was a score of 13 indicating that R3 was at Moderate Risk for developing pressure injuries. On 11/15/23, at 11:05 PM, RN-D documented the right heel pressure injury assessment under wound evaluations. Right heel wound measured 5.25 x 4.87cm. Type: Pressure. Stage: Unstageable. 100% Eschar. Exudate Moderate, Serous. RN-D documented in notes: Wound deteriorated since prior assessment, continue current treatment. Surveyor noted that RN-D included a complete assessment of the wound bed documenting that the wound was 100% eschar. On 11/15/23, at 11:14 PM, RN-D documented the sacral pressure injury assessment under wound evaluation. Sacral wound measured 6.87 x 3.4 6 cm. Type: Pressure. Stage: Unstageable due to slough and/or eschar. Present on admission. Wound age: New. Exudate: Moderate, Serous. RN-D cleansed the pressure injury with Normal Saline and covered the wound with Xeroform and Foam dressing. RN-D documented in notes: Wound improved since prior assessment, continue current treatment. Surveyor noted there was not a thorough assessment of the wound bed. There was no explanation of the wound bed except to say that it had slough and/or eschar but did not state which, and the area was identified to be present upon admission but was initially a facility acquired pressure injury that was present upon readmission to the facility. Surveyor reviewed new MD orders with a start date of 11/15/23, documented was, tx to right heel: cleanse with 1/2 strength Daikin's f/b wet to moist gauze soaked in 1/2 strength Daikin's f/b ABD pad f/b Kerlix BID and PRN. Tx to sacrum: Cleanse with NS wash f/b a nickel thick application of Santyl, f/b foam dressing every day shift. On 11/21/23, MD-E and RN-D, assessed and treated R3's right heel and sacral wound. MD-E measured R3's heel wound as 5 x 7 (depth is unmeasurable due to presence of nonviable tissue and necrosis. Eschar 100%. Exudate: Moderate, Serous. MD-E completed a sharp debridement on the heel wound. MD-E noted: Wound progress improved evidenced by decreased surface area. MD-E documented the treatment to R3's right heel should remain the same. MD-E measured R3's sacral wound as 4 x 2 x 0.1. 30% Slough and 70% Granulation tissue. Exudate: Moderate, Serous. MD-E completed a sharp debridement on the sacral wound. MD-E noted wound progress: Improved evidenced by decreased surface area. MD-E documented the treatment to R3's sacrum should remain the same. Surveyor reviewed a McGeer's Infection Criteria assessment with a date of 11/22/23, at 4:48 PM. Documented under Skin, Soft tissue and mucosal infections was: Pus present at a wound, skin or soft tissue site. Heat at the affected site. Redness at the affected site. Swelling at the affected site. Tenderness or pain at the affected site. Serous drainage at the affected site. Documented under Communication with Physician was, in part: Resident with drainage and signs of infection Right foot wound New order received for Doxycycline 100mg BID for 10 days . Wound Culture of right foot wound ordered. Surveyor reviewed new MD orders with a start date of 11/22/23 was, Culture of R (right) heel wound for gram stain one time only. Doxycycline 100mg two times a day for R heel wound infection for 14 days. Surveyor reviewed R's new infection care plan with an initiation date of 11/22/23. Care plan documented under focus was [R3] has presumptive infection Right foot heel wound as evidenced by heat, redness, swelling, tenderness, or pain, serous draining to affected site. Current antibiotic use. Documented under goal was [R3] will return to baseline function without complications from infection. Documented under interventions was Antibiotics per MD order, Doxycycline 100 mg BID 14 days. Monitor for adverse reactions. Assist resident with hand washing. Diagnostic tests as ordered. Monitor for pain or discomfort and report findings. Monitor infected site daily and report changes as applicable to provider. Monitor vital signs per facility protocol. Notify family/decision-maker with changes in condition. Notify MD/NP (Nurse Practitioner) with any change in condition. Oxygen as ordered. Surveyor reviewed the MAR (Medication Administration Record). The culture of the right heel wound was documented as completed on 11/23/23. Surveyor interviewed RN-D and DON-B on 11/23/24 at 3:40 PM. Surveyor asked for the results of the blood culture. RN-D and DON-B stated the facility had issues getting the correct swabs to collect the sample. DON-B indicated the wound culture was never taken. DON-B stated the Doxycycline was started as ordered. Surveyor asked how they would know if the Doxycycline was effective if there was no culture taken. RN-D indicated R3 did not have a fever from 11/23/23 thru 11/28/23 which would be an indication of infection. Surveyor noted the infection care plan and the McGeer's infection Criteria assessment documented all the signs and symptoms of infection that R3 was experiencing. On 11/28/23, MD-E and RN-D, assessed and treated R3's right heel and sacral wound. MD-E measured R3's heel wound as 5 x 7 x 1. Eschar 100%. Exudate: Moderate, Serous. MD-E completed a sharp debridement on the heel wound. MD -E noted: Wound progress at goal. MD-E documented that the treatment to R3's right heel should remain the same. MD-E measured R3's sacral wound as 3 x 2 x 0.1. 30% Slough and 70% Granulation tissue. Exudate: Moderate, Serous. MD-E completed a sharp debridement on the sacral wound. MD-E noted wound progress: Improved evidenced by decreased surface are. MD-E documented the treatment to R3's sacrum should remain the same. Surveyor reviewed progress note dated 11/28/2023, at 10:08 AM. LPN-H documented: Resident continue to vomit up bright red blood. [temp] 97.6 [pulse] 72 [respirations]18 [blood pressure] 116/70 [pulse ox] 97%. Called [MD-C] and he wants resident sent to hospital . Call out to bell ambulance and . ER. Surveyor noted R3 was hospitalized from 11/28/23 until 12/12/23 for hemoptysis (throwing up blood) hypovolemia (decrease volume of circulating blood in the body) and hyponatremia (low blood sodium). Surveyor reviewed hospital record dated 12/6/23. Documented under Interval history was: Seeing [R3] today for inpatient follow up with wound care RN team. [R3's] right heel wound is necrotic, and surgery was consulted for debridement but recommend BKA (below the knee amputation) due to PAD (peripheral artery disease [TRUNCATED]

Based on record review and interview, the facility failed to provide basic life support, including Cardiopulmonary Resuscitation (CPR) to a resident who required emergency care for 1 (R6) of 3 residents reviewed for CPR. The facility currently has 73 out of 98 residents who desire CPR (Full Code). R6 was a full code (wanted CPR) and was found pulseless and nonbreathing on [DATE]. An LPN (Licensed Practical Nurse) failed to initiate CPR when R6 was found to be pulseless and not breathing. The LPN checked the resident's code status (which was full code,) then called the on-call nurse, contacted the physician, contacted the Power of Attorney, went up 1 floor to get a nurse, returned to the 1st floor, called 911, and then after approximately 15 minutes of R6 first being found unresponsive, facility staff moved her to her room and CPR was initiated. Facility failure to immediately call a code for R6 to alert staff to the need for assistance, the failure to call 911 immediately, and the failure to not start CPR immediately created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on [DATE] at 2:30 PM. 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. Findings include: The facility policy and procedure entitled Advanced Directives - Code Status dated [DATE] states: Policy: . 5. CPR is to be initiated unless: obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. Procedure: If a resident is FULL CODE the following applies 1. Determine unresponsiveness by shouting Are you okay and/or gently shaking or tapping resident. 2. If no response, call for help of other staff members. 3. Instruct other staff responding to scene to obtain emergency supplies, including AED (Automated External Defibrillator) if available, and notify [DATE] or emergency personnel. DO NOT leave resident. 4. If resident is not face-up, re-position to a face-up position while supporting head, neck and back. To perform CPR ensure resident is placed on a backboard or hard surface. 5. Check resident for breathing or gasping of breath while simultaneously checking for pulse. If either or both are absent initiate CPR. 6. Follow CPR instructions as per American Healthcare Association Healthcare Provider steps (see attached). 7. When EMS arrives, they become lead in the resuscitation effort. Follow their directives. 8. Contact resident's physician and family. 9. Document events in medical record. R6 was admitted to the facility on [DATE] with diagnoses of cancer of the liver, gall bladder, and bile ducts, dementia, and paranoid schizophrenia. R6's Admission Minimum Data Set (MDS) assessment dated [DATE] indicated R6 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 0 and the facility assessed R6 as needing total assistance with bed mobility, transfers, dressing, toilet use, hygiene, and bathing, and needing supervision with eating. R6's Power of Attorney (POA) was activated on [DATE]. R6's code status was Full Code (perform CPR) as elected by R6's POA on admission. On [DATE] at 9:59 AM in the progress notes, nursing charted R6's vital signs: blood pressure ,d+[DATE], temperature 97.2 degrees, pulse 72, respirations 18, and oxygen saturation 96%. Nursing charted R6 was alert and staff would continue to observe and monitor R6. On [DATE] at 7:10 PM in the progress notes, Assistant Director of Nursing (ADON)-C charted ADON-C was notified around 7:10 PM that R6 had possibly stopped breathing. ADON-C charted ADON-C immediately went to assess R6 and upon assessment, R6 was noted to be pulseless and breathless. ADON-C charted R6's code status was confirmed, compressions were initiated immediately after, and the AED (Automated External Defibrillator) was placed on R6 during compressions. ADON-C charted the Fire Department arrived and took over. R6's time of death was noted on [DATE] at 7:27 PM. ADON-C charted the staff nurse notified the physician and the Power of Attorney. On [DATE] at 7:28 PM in the progress notes, the physician charted the physician was paged by the nurse at the facility regarding R6. The physician charted per the nurse, R6 was in the common area at the facility this evening and was last seen normal around 5:00 PM. At 7:00 PM, a nurse went to the common area to give R6 the nighttime medications and R6 was found to be deceased . R6 felt cold to the touch and had no pulse, no heart sounds, and no breath sounds. Family was notified by the facility nurse. On [DATE] at 1:09 PM, Surveyor requested from NHA-A and DON-B an investigation summary completed by the facility for R6's death in the facility. Surveyor was provided a copy of ADON-C's progress note from [DATE] at 7:10 PM; no other information was provided. Surveyor noted the nurse assigned to care for R6 on [DATE] on second shift did not write anything in R6's medical record in relation to the events surrounding R6's death. No incident summary of R6's code or death was completed by the facility. In an interview on [DATE] at 1:46 PM, Surveyor asked ADON-C to describe the events of [DATE] with R6. ADON-C stated R6 resided on the first floor and ADON-C was working on the second floor that shift. ADON-C stated the other nurse working on the second floor told ADON-C about R6 being unresponsive. Surveyor asked ADON-C how the other second floor nurse was notified of the situation. ADON-C stated Licensed Practical Nurse (LPN)-E physically came to the second floor. ADON-C stated ADON-C checked the code status of R6 and went to the first floor and started CPR on R6. Surveyor asked ADON-C what staff members were involved in performing CPR. ADON-C stated ADON-C, LPN-E, and Certified Nursing Assistant (CNA)-D did the CPR. Surveyor asked ADON-C if a CPR recording sheet or timeline was completed at the time of R6's code. ADON-C stated normally a flow sheet is completed if the code occurs on day shift, but one was not done for R6's code because it was on second shift and there were not enough staff to have someone recording. Surveyor asked ADON-C if a code event was reviewed afterwards and if so, who would review it. ADON-C stated either DON-B or NHA-A would do a recap after a code. Surveyor asked ADON-C who the nurse was that was taking care of R6 on [DATE]. ADON-C stated that nurse no longer is employed at the facility. In an interview on [DATE] at 3:22 PM, Surveyor asked CNA-D to describe the events of [DATE] with R6. CNA-D stated CNA-D was down the hall in a resident room providing cares when CNA-D heard a commotion in the hallway. CNA-D stated CNA-D saw LPN-E pushing R6 in a wheelchair down the hallway and LPN-E said R6 was coding. CNA-D stated CNA-D helped put R6 onto the floor of R6's room from the wheelchair. CNA-D stated LPN-E asked CNA-D if they were CPR certified and CNA-D said yes, so CNA-D started doing chest compressions while someone else used the bag mask from the crash cart that had been brought to the room. CNA-D stated CNA-D passed off compressions to ADON-C just as the paramedics arrived and took over the scene. On [DATE], Surveyor made observations of the location of the common area, the crash cart, and R6's room. The common area, which also serves as a dining room, was adjacent to the nurses' station, completely visible from the desk. The crash cart was located in the corner of the common area closest to the nurses' station. R6's room was the fourth door on the left which was the first resident room in the hallway from the common area and nurses' station. Surveyor noted R6 had been in the common area next to the crash cart and was moved to R6's room, away from the crash cart prior to CPR being started. In a phone interview on [DATE] at 8:33 AM, Surveyor asked LPN-E to describe the events of [DATE] with R6. LPN-E stated from 3:00 PM until almost 4:00 PM, LPN-E was in the common area braiding a resident's hair and R6 was in the common area as well and was fine. LPN-E stated from 4:00 PM to 6:00 PM, LPN-E passed medications and then took a break. LPN-E stated LPN-E walked past R6 on the way to break and on the way back from break. LPN-E stated R6 was in the common area at that time and LPN-E was aware R6 was there but did not specifically pay attention to R6. LPN-E stated after break, LPN-E sat at the nurses' station to do charting so was not looking directly at R6 at that time. LPN-E stated the nurse that was caring for R6 came into the common area to give R6 their nighttime medications and LPN-E noticed that something was not right with R6, so LPN-E got up to see what was going on. LPN-E stated LPN-E touched R6 and R6 was as cold as ice. Surveyor asked LPN-E what time all of this happened? LPN-E stated 6:35 PM. LPN-E stated LPN-E looked at R6's code status (which was Full Code) and called the on-call nurse (Charge Nurse-F). LPN-E stated LPN-E then called or paged the physician and then called R6's daughter. LPN-E stated LPN-E then went to the second floor to get the nurse manager (ADON-C) and the nurse manager told LPN-E that if the resident is a full code, you have to do CPR. LPN-E stated LPN-E came back downstairs to the first floor and called 911. LPN-E stated R6 was pushed back to the resident's room, someone grabbed the crash cart with the defibrillator, and they started CPR. Surveyor asked LPN-E who performed CPR. LPN-E stated LPN-E and CNA-D, and ADON-C did one round of CPR when the paramedics took over. Surveyor asked LPN-E if LPN-E took the stairs or the elevator when going to the second floor and returning to the first floor. LPN-E stated LPN-E took the stairs both times. On [DATE] at 9:25 AM, Surveyor shared with NHA-A and DON-B the interview with LPN-E and the concern LPN-E discovered R6 was cold to the touch at 6:35 PM, LPN-E called the on-call nurse, the physician, and the family before getting assistance from ADON-C, and ADON-C was not made aware until 7:10 PM when 911 was called and CPR started. Surveyor shared the timeline of events had 35 minutes of time that were not accounted for with no CPR being performed. Surveyor asked NHA-A if there were any cameras that could assist with the sequence of events or any other documentation to show what occurred on that day. NHA-A stated no cameras were used in the common area and the footage from any hallway cameras had been overridden due to the amount of time that had passed since that event. On [DATE] at 9:45 AM, NHA-A and DON-B entered the conference room with LPN-E on the phone. NHA-A stated LPN-E disagreed with the time of 6:35 PM Surveyor had written down from the previous interview. Surveyor asked LPN-E to clarify the time R6 was noted to be cold to the touch. LPN-E stated LPN-E was going to start med pass and LPN-E always starts med pass between 6:45 PM and 7:00 PM so R6 was found cold to the touch between 6:45 PM and 7:00 PM, not 6:35 PM. Surveyor asked LPN-E to state the events as they occurred on [DATE]. LPN-E stated LPN-E went over to touch R6 and saw that R6 was dead; R6 was cold to the touch. LPN-E stated LPN-E called Charge Nurse-F who was on call at that time and Charge Nurse-F told LPN-E that LPN-E had to call the physician, the family, and the DON. Surveyor asked LPN-E if Charge Nurse-F had told LPN-E to call 911. LPN-E did not recall Charge Nurse-F telling LPN-E to call 911. LPN-E stated LPN-E went to the second floor to get ADON-C and the other second floor nurse and they came back to the first floor, called 911, and pushed R6 in the wheelchair to R6's room. LPN-E stated after R6 was moved to the floor, they started CPR. Surveyor asked LPN-E where the crash cart was kept. LPN-E stated the crash cart is kept in the corner of the common area and it was brought to R6's room. Surveyor asked LPN-E why R6 was moved out of the common area and CPR not started in the common area. LPN-E stated they moved R6 because there were a lot of residents and visitors in the common area on phones saying there was someone that had died . Surveyor shared with NHA-A and DON-B, who were present for the interview with LPN-E, the concern R6 did not receive CPR immediately after being found unresponsive; LPN-E made three phone calls and went up to the second floor and back to the first floor before 911 was called and CPR was started in addition to R6 being moved from the common area to R6's room. In an interview on [DATE] at 11:07 AM, Surveyor asked Charge Nurse-F to describe the events of [DATE] with R6. Charge Nurse-F stated Charge Nurse-F was on-call that night. Charge Nurse-F stated LPN-E called Charge Nurse-F to say that R6 was cold to the touch. Charge Nurse-F told LPN-E to call the physician and the family. Charge Nurse-F looked on the cell phone and stated LPN-E called Charge Nurse-F at 7:02 PM and the phone conversation lasted four minutes. Charge Nurse-F stated LPN-E gave Charge Nurse-F R6's background and diagnoses and it was not until the end of the call that LPN-E told Charge Nurse-F that R6 was a Full Code. Charge Nurse-F said as soon as LPN-E told Charge Nurse-F R6's code status, Charge Nurse-F told LPN-E to start CPR. Charge Nurse-F stated Charge Nurse-F told LPN-E to move R6 to R6's room because the facility had a COVID-19 outbreak at that time and there were so many people in the common area. Charge Nurse-F stated Charge Nurse-F sent a text to ADON-C at 7:08 PM to alert ADON-C of the situation and to go down to help with the situation. Charge Nurse-F stated another phone call was coming in and that was why the text was sent rather than calling ADON-C. Charge Nurse-F stated ADON-C did not return a text verifying that it was received. On [DATE] at 2:30 PM, Surveyor shared with NHA-A and DON-B the decision of Immediate Jeopardy for CPR not being provided to R6 immediately upon discovery and 911 not being called immediately. No further information was provided at that time. On [DATE] at 9:30 AM, Surveyor received via email the 911 report from the Fire Department. The 911 call was initiated on [DATE] at 7:17 PM, 15 minutes after LPN-E called Charge Nurse-F after finding R6 unresponsive. The report indicated a defibrillator (AED) was not available. This contradicted the documentation of a defibrillator being placed during compressions. The failure to immediately call a code for R6 to alert staff to the need for assistance, the failure to call 911 immediately, and the failure to not start CPR immediately led to serious harm for R6 which created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], when the facility completed the following: * In person education for all licensed and CPR staff will be provided. In addition, phone education will require in person education prior to their next shift. * Education for all licensed staff and CPR certified staff on the following: - How to verify code status. - When CPR must be initiated without delay. - CPR procedure. - Summary of CPR expectations. - Documentation post CPR. - Review of CPR scenarios. * Facility policy for advanced directives code status was reviewed at the corporate level on [DATE]. * Latest standards of practice were reviewed as well as discussion with current DQA (Department Quality Assurance) leadership. * CPR drill will be conducted every shift until all CPR certified employees have received education. CPR drills will then be conducted 1x (times) per shift per week times 4 weeks. 1 x per shift per every other week times 2 weeks. Results of the audit will be reviewed at the QAPI (Quality Assurance Performance Improvement) meeting potential opportunities will be addressed.

Based on observation, interviews, and record review, the facility failed to ensure 1 of 1 resident (R16) reviewed for abuse was free from sexual abuse. The facility did not ensure R16 was free from sexual abuse by another resident (R17.) On 12/01/23, R17 was found in R16's room by a CNA. R17 was on top of R16; R16's gown was pulled up over her abdomen, R16's brief was torn, and R17's hand was observed moving back and forth on R16's vagina. R17 had also engaged in fondling R16's breasts and sucking on her nipples. R16 had activated her call light and shouted for assistance 16 minutes prior to staff responding and removing R17 from R16's room. The facility's failure to keep R16 safe from sexual abuse created a finding of immediate jeopardy that began on 12/1/23. Surveyor notified NHA (Nursing Home Administrator) A of the immediate jeopardy on 12/6/23 at 1:24 PM. The immediate jeopardy was removed on 12/2/23, however, the deficient practice continues at a scope/severity of F (potential for harm/widespread) while the facility continues to monitor the effectiveness of its removal plan. Findings include: Surveyor reviewed the facility's Policy and Procedure, Vulnerable Adult Abuse and Neglect Prevention, last revised 7/2/19 and noted the following as applicable: .Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. Procedure: All Residents are susceptible to maltreatment and exploitation due to their need for nursing home care. Due to physical, emotional, and mental inabilities, Residents may be dependent upon us to meet their needs. It is the policy to enhance the life of all Residents through strong programming and appropriate care and treatment. Additionally, Residents and staff will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated and Residents and staff will be monitored for protection. The facility will strive to educate all participants in techniques to protect all parties. 4. Resident to Resident Abuse: The Resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, exploitation, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other Residents, consultants, or volunteers, staff of other agencies serving the Resident, family members or legal guardians, friends or other individuals. Surveyor also reviewed the facility's undated Procedures for an Allegation of Sexual Abuse policy and procedure which includes: .The Facility affirms the right of our Residents to be free from all types of abuse. The facility is committed to protecting our Residents. If an allegation of sexual abuse is reported by but not limited to a Resident, family member, staff, volunteer and/or visitor, the facility will: -Separate Resident from the person accused. From time of discovery, do not leave the victim unprotected and the person accused unsupervised, for even a moment. Do not go into hallway to summon help and leave the Resident and the accused person alone. -Resident (victim) will remain with a same gender staff person until transferred to the hospital. -The person accused will remain 1:1 with a staff person until police arrive for questioning. -Assess Resident for injury. -Do not shower or change Resident. -Do not discard clothing or bed linen, of either Resident or person accused. Preserve both parties clothing and linen for possible crime scene. -Contact the police immediately. This should be the first call. -Inform Resident's physician. -If the attending physician of a Resident or a physician on call for an attending physician of the facility declines for a Resident to be sent out to the emergency room for an evaluation, the nurse must inform the facility's medical director. -Inform Residents HCPOA/guardian/responsible party. -Inform Director of Nursing, Administrator, or the management person on call at that time. -Inform the OHFC within (2) hours. On 12/4/2023 at 12:24 PM, Surveyor initiated an investigation regarding an allegation of a sexual assault between R16 and R17. Surveyor reviewed R16 and R17's medical record which included in part: 1) R16 was admitted to the facility on [DATE] with diagnoses of Spastic Non-Dominant Hemiplegia due to Traumatic Brain Injury, Hereditary Spastic Paraplegia, Neuromuscular Dysfunction of Bladder, Moderate Protein-Calorie Malnutrition, Insomnia, and Major Depressive Disorder. R16 is her own person. R16's Quarterly Minimum Data Set (MDS) dated [DATE] documents R16's Brief Interview for Mental Status (BIMS) score to be 15, indicating that R16 is cognitively intact for daily decision making. R16's MDS also documents that R16 is total care for bed mobility, transfers, dressing, eating, and toileting. R16's MDS documents that R16 is always incontinent of bowel and has a suprapubic indwelling catheter. R16's comprehensive care plan contains the following significant focused problems with interventions: 1. Vulnerability-self and/or others due to being bed bound, unable to protect themselves-Initiated 5/26/21, Revised 8/30/23 -Be alert for changes in mood, behavior, pain, change in appetite, suspicious injuries that could be a sign of abuse. Alert MD/NP (Nurse Practitioner) and R16's representative as applicable-Initiated 5/26/21 -Discuss behavioral issues with IDT (Interdisciplinary Team) members-Initiated 5/26/21 -If issues are noted, evaluate for possible causative factors. Notify MD and family as needed-Initiated 5/26/21 -Observe for potential pain, discomfort, and/or mental anguish-Initiated 5/26/21 -Resolved: Provide safe environment for individual and others to ensure the safety of others-Resolved 9/13/23 -Resolved: Remove R16 from potentially abusive situations-Resolved 9/13/23 2. R16 has a mood problem due to diagnosis of depression. Not on current medications, doing well with non-pharmacological interventions. Followed by psych services as needed-Initiated 9/7/22, Revised 12/12/22 -Arrange for psych consult, follow up as indicated-Initiated 9/7/22 -Monitor/document/report as needed any signs/symptoms of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness-Initiated 9/7/22 -Non-Pharmacological Interventions: 1) Active listening 2) Offering reassurance 3) Activities of choice 4) Visits/calls from family and friends 5) Psych services/social services/pastoral services-Initiated 3/7/23 RESOLVED: R16 is at risk for abuse and neglect due to limited mobility and dexterity issues-Initiated 5/26/21 Resolved 9/15/21 3. R16 has experienced events and/or circumstances which have been (physically and/or emotionally) harmful, which have adverse effects on my individual functioning and/or well being. Sexual assault.-Initiated 12/1/23 Revised 12/2/23 -Approach R16 warmly and positively-Initiated 12/2/23 -Discuss feelings of anger with R16-Initiated 12/2/23 -R16 wants to stay in contact with friends/family-Initiated 12/1/23 -Staff are to avoid power struggles-delay a treatment or care if R16 resists-12/2/23 R16's social history on admitted d 8/18/18 does not contain documentation that past trauma was assessed. R16's Social Service Data Collection/assessment dated [DATE] contains the following documentation: Vulnerability-considered vulnerable Trauma Informed Care-nothing new to report, previously reported but denies anything life threatening or traumatic. Triggers: being in completed darkness, not having call light within reach, room door being closed. Sexual Abuse Vulnerability-questions applicable: 4. R16 is not able to protect self physically from sexual abuse 5. R16 would be able to call out if abuse is occurring 8. R16 would be able to recall a sexual abuse incident 12. Based on the above evaluation, R16 is at high risk for sexual abuse Surveyor noted that a new trauma assessment was not initiated and completed on R16 after the sexual assault on 12/1/23. However, a care plan was initiated on 12/1/23 with interventions initiated on 12/2/23. R16's current weight dated 12/1/23 is 99.8 pounds. During the survey process from 12/4/23 - 12/6/23, Surveyor observed R16's room is located towards the end of the right hall, 2nd to the last room on the right side. Surveyor noted R16's room location is far from the nurse's station and not in a high traffic area but is in view of security cameras. Surveyor made multiple observations of R16 in bed, with the touch pad call light clipped on R16's gown within reach. R16 appears to be frail and compromised. On 12/5/23 at 5:52 AM, Surveyor observed R16 from the doorway. Surveyor noted that R16's TV was on, room was dark, however, light was coming in from the hallway. Pillow was placed on either side of R16. R16's face was turned towards the door and R16's eyes were closed. R16 did open R16's eyes and made eye contact with Surveyor in the doorway and then closed R16's eyes again. 2) R17 was admitted to the facility on [DATE] with diagnoses of Severe Protein-Calorie Malnutrition, Alcohol Dependence, Unspecified Psychosis, Dementia, Moderate with Other Behavioral Disturbance, Cognitive Communication Deficit, Heart Failure, and Psychotic Disorder. R17 has an activated Health Care Power of Attorney (HCPOA). R17's Quarterly MDS dated [DATE] documents R17's BIMS (Brief Interview for Mental Status) score to be a 4, indicating R17 is severely impaired for daily decision making. R17's MDS also documents that R17 requires supervision for bed mobility and toileting, is independent for transfers, set-up assistance for dressing. R17's MDS indicates that R17 is ambulatory, steady at all times, and has periods of incontinence. R17's comprehensive care plan contains the significant following focused problems with interventions: 1. R17 exhibits behavior symptoms related to making inappropriate comments to staff.-Initiated 10/4/22 Revised 12/2/23 -10/19/22 R17 took personal belongings from another Resident. Staff did return the items -11/1/22 Threatening to hit others and sexual inappropriate behaviors towards staff -11/1/22 Self report made due to Resident to Resident altercation -11/2/22 Hitting staff -R17 will have episodes of incontinence but will be in denial and get agitated when staff attempt to assist with cares -12/1/23 Self report due to Resident to Resident SA (Resident=initiator) R17 on 1:1 Interventions -11/1/22 Consulting with psychiatric services regarding behaviors. Recommendation was in agreement with Interdisciplinary Team (IDT) to have family come in to help calm R17, allow R17 to express self, give R17 space, and avoid power struggle. Initiated 11/3/22 Revised 2/8/23 -11/2/22 psychiatric services came in to physically meet with R17. Recommendation was to clear any medical issues (pending results), psychiatric team to further consult on addressing psychosis and agitation, and staff at the facility to: maintain a low stimulation, make no demands on R17, keep interactions low-key and short to reduce any further escalation Initiated 11/3/22 Revised 2/8/23-11/2/22 -R17 sent to emergency room for further medical and psychiatric evaluation-Initiated 11/4/23-12/1/23 -!!R17 on 1:1!! Created 12/2/23 -Consult with psychiatry for recommendations as ordered-Initiated 10/4/22 -NON-PHARMACOLOGICAL Behavior Intervention-1) Maintain a low stimulation 2) Make no demands on R17 3) Avoid power struggles 4) Keep interactions low-key and short to reduce any further escalation 5) Have family come in or phone call, to help calm R17 6) Allow R17 to express self 7) Give R17 space-Initiated 2/8/23 -Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert Attention. Remove from situation and take to alternate location as needed-Initiated 10/4/22 Revised 2/8/23-If reasonable, discuss behavior with R17. Explain/reinforce why behavior is inappropriate and/or unacceptable-Initiated 10/4/22 2. R17 is care planned as an elopement risk/at risk to leave facility without notice due to R17 leaving the building unannounced. Revised 8/18/23 PREFERS: To wear a Wander Guard on both ankles. -7/6/22 R17's risk assessment indicates low risk and generally R17 stays in his room. IDT feels that this incident likely related to a positive COVID test and behavior changes -7/18/22 Elopement risk assessment indicates low risk but due to R17's decreased BIMS score, and poor safety awareness, IDT and HCPOA in agreement to keep R17 on wander guard and continue to review quarterly. -1/11/23 Elopement risk assessment indicates high risk due to R17's BIMS score, dementia diagnosis, and history of exit seeking. IDT (Interdisciplinary Team) and HCPOA in agreement to keep R17 on wander guard and continue to review quarterly. Interventions -Monitor and document episodes for exit seeking or wandering behavior. R17 is usually looking for or trying to get home or previous home. R17 will attempt to get on buses or walk in order to get to his destination. Interventions for exit seeking behaviors: 1) Staff reorienting R17 back to room or unit 2) Offering snacks/beverages per dietary recommendation 3) R17 likes keeping busy by doing word searches 4) Talking about R17's life-Initiated 7/28/23 -Report to nurse supervisor if R17 is trying to exit seek, talk about exit seeking, and agitation related to wanting to go home Created 11/21/22 Revised 2/18/23 -Treatment for acute clinical conditions contributory to acute change in mental status-7/7/22-Wander Risk Assessment per facility policy. Re-assess risk periodically according to policy-Initiated 7/6/22-Wander-Guard placement ankle. Check for placement q shift and function q noc shift. Prefers to wear a wander-guard on both ankles. Created 7/6/22 Revised 8/18/23 3. R17 has a mood problem due to diagnosis of Unspecified Dementia, Unspecified Severity with Other Behavioral Disturbance, Psychotic Disorder-Initiated 2/8/23 Revised 4/18/23 -Administer medications as ordered. Monitor/document for side effects and effectiveness-Initiated 2/8/23 -Arrange for psychiatric consult, follow up as indicated-Initiated 2/8/23 -Monitor/document/report as needed any signs/symptoms of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, tearfulness.-Initiated 2/8/23 -Monitor/record/report to physician as needed risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons-Initiated 2/8/23 -NON-PHARMACOLOGICAL INTERVENTIONS: 1) Active Listening 2) Offering reassurance 3) Redirection 4) Activities of choice 5) Offer R17 a calm and safe space 6) Offer to calls/visits with family 7) Avoid power struggles 8) Psych services/social services/pastoral services-Initiated 2/8/23 Revised 2/18/23 Surveyor reviewed R17's Admission Social Services Data Collection/assessment dated [DATE] and noted the following: Vulnerability Review-considered vulnerable Trauma Informed Care-nothing reported Surveyor reviewed R17's most recent Social Services Data Collection dated 10/12/23 and noted the following: Vulnerability-considered vulnerable Trauma Informed Care-nothing reported Sexual Abuse Vulnerability-R17 is able to physically protect self from sexual abuse and call out if abuse is occurring but not have the ability to recall a sexual abuse incident. Based on the evaluation R17 is at high risk for sexual abuse. Surveyor noted that R17 did not have a new trauma informed care assessment completed after being affected by a facility fire which occurred on 11/30/23. R17's current weight on 12/1/23 is 146.2 pounds. Surveyor reviewed R17's current active physician orders which document that R17 is on Seroquel (antipsychotic), 50mg two times a day (BID) for Dementia with Behavioral Disturbance. R17's Medication Administration Record (MAR) for the month of November 2023 documents R17 is to be monitored for TARGET BEHAVIORS: 1) Agitation/Restlessness 2) Physical/Verbal aggression every shift. Surveyor notes that R17's MAR contains 0 - indicating no behavior, N, or NA. Surveyor reviewed R17's progress notes located in R17's electronic medical record (EMR) dated 11/1/23 through 12/6/23 which contain no documentation of behavior issues by the IDT leading up to the sexual assault incident, however; Surveyor reviewed R17's psychiatric consults from admission (5/18/22) and the following documentation is pertinent in regard to R17's history of behaviors since admission to the facility: On 11/18/22, APNP (Advanced Practice Nurse Practitioner)-N documented .R17s behaviors of threatening others and being sexually inappropriate towards staff. Often yells/curses at staff. 11/1/22 R17 kept coming out of R17s room into another Resident room. Other Resident kept asking R17 to not come into his room. R17 became aggressive and belligerent using profanity. CNA (Certified Nursing Assistant) stated that R17 hit other Resident with remote and walker . R17 also had behavioral health consults and the following document is pertinent: On 11/2/22 Psychologist (Psych-O) documented .R17 has become increasingly agitated, self-protective, belligerent and aggressive recently. R17 became angry with neighbor and has become threatening. There are reports that R17 has made sexual advances toward staff. R17 has not been accepting of boundaries or limits set for R17. R17 appears upset, anxious, self-protective, wary and paranoid. Recommend to maintain low stimulation, make no demands on R17, keep interactions low-key and short . On 11/18/22, Psych-O documented, R17 is rather evasive and elusive in R17's responses to me . Surveyor completed a criminal background check on R17 which had no results. During this investigation, Surveyor was informed that on 11/30/23 at approximately 3:11 AM, a fire broke out in a resident room down the hall from R17. The fire was put out but created lots of smoke. R17 was removed from R17's room and was monitored in the dining room by Social Worker (SW-Q). R17's room (prior to the fire) had been on a separate wing but on the same floor as R16. R17's room prior to the fire was the first room on the right side of the wing, within eyesight of the nurse's station and in a high traffic area. After the fire on 11/30/23, R17 was then placed in a room up on the 3rd floor. On 12/1/23, R17 was then moved to the 2nd floor to a room directly across the hall from R16, (which was not R17's original room prior to the fire.) R17 residing in the room directly across the hall from R16 means R17's room was the 2nd room from the end of the hallway, not close to the nurse's station and not in a heavy traffic area but in view of security cameras. During the survey process from 12/4/23 to 12/6/23, Surveyor made multiple observations on all 3 shifts of R17 and his room which is now upstairs on the 3rd floor and no longer on the same unit as R16. Surveyor noted R17 has 1:1 supervision at all times. R17 was observed lying in bed, watching television, and eating snacks. Surveyor observed verbal interaction and communication between R17 and R17's 1:1 monitor. On 12/4/23 at 2:15 PM, Surveyor attempted to interview R17, however, R17 was pleasantly confused with some answers. R17 informed Surveyor that R17 did not recall any significant events from the weekend. On 12/5/23 at 12:17 PM and on 12/6/23 at 9:38 AM, Surveyors along with NHA-A viewed the security camera footage of the night of the sexual assault which occurred on 12/1/23. The security camera footage showed R17 in R17's doorway at 8:22 PM. At 8:22:56 PM, R17 is observed going into another resident room next to R17. At 8:23:42 PM, R17 is observed coming out of the room. R17 is observed pacing up and down the hallway. At 8:29:07 PM, R17 is observed peering into R16's room and at 8:29:29 PM, R17 goes into R16's room. At 8:30 PM, R17 is observed coming out of R16's room. At 8:30:20 PM, R16's call light is visibly seen going on. R17 returns to R17's room. At 8:37:30 PM, R17 comes out of R17's room and stands in the doorway of R16. R17 goes back into R16's room at 8:38:03 PM. At 8:38:11 PM, R17 is observed to step out of R16's room and is observed clearly looking down the hallway towards the nurse's station. At 8:38:13 PM, R17 re-enters R16's room. At 8:42:09 PM, R17 is observed leaving R16's room. A total of approximately 4 minutes, R17 was in R16's room. At 8:42:17 PM, R17 is back in R17's room. At this time, CNA-K is observed to be in the hallway with a linen cart. R16's call light remains on. At 8:43:37 PM, R17 comes out of R17's room, walks to the room on the right and goes in that room. At 8:44:26 PM, R17 comes out of that room. At 8:44:42 PM, R17 goes back into the room on the right. Registered Nurse (RN-M) sees R17, talks to R17 and at 8:44:47 PM, R17 leaves the room. At this time, R16's call light remains on since 8:30 PM. At 8:45 PM, R17 is observed in and out of R17's room, and is pacing. At 8:45:48 PM, R17 re-enters R16's room. At 8:46:09 PM, CNA-K is observed entering R16's room and that is when R17 was found on top of R16. At 8:46:58 PM, RN-M is observed running down the hall and entering R16's room. At 8:47:33 PM, CNA-K is observed bringing R17 out of R16's room. After reviewing the security camera footage, Surveyor notes the following: R17's first entrance to R16's room is at 8:30 PM. R16 put R16's call light on at this time. RN-M and CNA-K are observed multiple times in the hallway while R16's light is on. R17 re-enters R16's room from 8:38 PM-8:42 PM, a total of approximately 4 minutes. R16's call light is observed to be on at this time. At 8:45 PM, R17 re-enters R16's room for the third time until CNA-K is observed bringing R17 out of R16's room at 8:47 PM. Based on the observation of the security camera footage, R17 is observed clearly looking down the hallway towards the nurse's station and entering R16's room on three occasions when staff are not observed in eyesight. On 12/1/23, R16's call light remained on from 8:30 PM-8:47 PM. On 12/5/23, Surveyor was provided documentation by the facility of an ongoing investigation of the sexual assault of R16 by R17. The documentation provided by the facility provides the following information: On 12/1/23, R16 and R17 are separated immediately after staff found R17 on top of R16 in the process of sexually assaulting R16. R17 is placed in R17's room and supervised by 2 CNAs. At 9:17 PM, the police arrived and statements were obtained. No sexual assault team had come out. The police indicated they will not be removing R17 from the facility, but charges will be filed. Physicians for both R16 and R17 were notified. The facility preserved any evidence. A head to toe assessment is completed. R16 refused to go to the hospital. R17 was sent to the emergency room for a psychiatric evaluation, but was medically cleared and returned to the facility. R17 was transferred to a room up on the 3rd floor upon return on 12/2/23 and remains on 1:1. R17 has been given a 30 day discharge notice. Surveyor notes the facility submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report on 12/1/23 at 10:22:47 PM within the two hour reporting requirement. Surveyor reviewed R17's hospital discharge summary dated 12/2/23 and notes the following: .HCPOA states there was a fire at the facility earlier today and R17 was moved to a new room. HCPOA believes the move caused some disorientation and more agitated behavior. On 12/2/23, a physician progress note written by medical director (MD-P) indicated the medical director came into the facility and convinced R16 to go to the hospital for an evaluation and R16 agreed. Surveyor reviewed the 12/2/23 dated discharge summary from the hospital which indicated R16 was evaluated for sexually transmitted diseases and determined to be medically cleared. On 12/2/23, while at the facility, R16 was evaluated by the psychologist (Psych-O) who documented that .R16 is angry and anxious about what happened and R16 is clear minded, fully aware, fully oriented and displayed intact memory and cognition. The plan is for Psych-O to return and see R16 to allow R16 to process the situation and address any residual emotional impact. On 12/2/23, Psych-O also evaluated R17 in the facility and documented .I was asked to speak to R17 about the incident, as in the past incidents in which I attempted to interview R17, R17 would not admit to his behavior. Certainly, R17 is diagnosed with cognitive deficits and has impulse control issues. However, it is my opinion that his behavior was by R17's choice. R17 does not appear to be psychotic, confused or unaware of R17's interactions. I do not see this as behavior related to dementia. This appears to be anti-social behavior and in this case, R17's memory appears to be selective. On 12/5/23 at 10:44 AM, Surveyor interviewed R16 in the presence of Social Worker (SW-J). R16 stated R16 remembers 'Dateline' being on the television at the time of the sexual assault. R16 stated the first time that R17 touched R16, R17 tried to choke R16, ripped R16's brief off, and pulled R16's suprapubic catheter out. R16 stated R16 put R16's call light on and told R17, R16 was going to kill R17. R16 stated that R17 walked out of the room. R16 stated then R17 came back into R16's room, jumped on me and assaulted me for a good 5 minutes. R16 stated R17 pushed R16's gown up and, put his fingers in my vagina. Was fondling my breasts and sucking on my nipples. R16 stated when R17 was sucking on R16's breasts, it brought me back to when I was raped as a child. R16 informed Surveyor that R16 was in shock, distressed in the moment .Had that moment of being scared, very upset. R16 indicated R16 is angry but is okay. R16 recalls R16's call light being on the whole time from when R17 first entered the room the first time. R16 confirmed that R16 had refused to go to the hospital initially because R16 did not think it would do anything because R17 did not stick his penis in me. R16 also confirmed the police were called and spoke with R16. R16 stated that R16 had never seen R17 before the incident. SW-J informed Surveyor in the hallway right after R16's interview that, R16's story has remained consistent with everyone. Surveyor reviewed the police report with case number 233350149 dated 12/1/23 and noted the following documentation: .R16 stated R17 entered R16's room without consent. R16 then stated that R17 got on top of R16 and R16 told R17 get the F .outta here. R16 then stated that R17 then intentionally and without consent pulled R16's brief to the side and with R17's right hand began fingering R16's vagina. R16 then stated that R17 intentionally and without consent placed R17's mouth on both of R16's breasts and started sucking them. R16 stated that these acts were done intentionally and without consent, and that it made R16 really uncomfortable and disgusted. R16 also stated that R16 was unable to fight R17 off as R16 cannot defend herself due to R16's medical condition. On 12/4/23 at 2:25 PM, Surveyor interviewed CNA-K regarding the incident. CNA-K was the CNA-K who found R17 on top of R16. CNA-K stated that CNA-K was bringing another resident to his room to get the resident ready for bed. CNA-K heard R16 yell about 8:45ish PM, Get the F out of here. CNA-K informed Surveyor that CNA-K went into the hall, saw R16's light on, R16 kept screaming. CNA-K recalled R16's door was open and CNA-K went into the room. CNA-K stated CNA-K found R17 on top of R16. CNA-K stated that CNA-K observed R17's right hand moving back and forth in R16's vagina. CNA-K yelled R17's name. R16 then told CNA-K to please get R17 off of me, his hand is in my crotch. Please get R17 off. CNA-K held onto R17's hands and pulled R17 off of R16 and observed R16's brief was half off (shredded.) R16 informed CNA-K that R17 had been massaging R16's breasts and sucking on R16's nipples. R16 informed CNA-K that R16 had been re-traumatized as R16 had been sexually assaulted before. CNA-K removed R17 from R16's room and yelled for the nurse. While CNA-K had R17 in R17's room, R17 threatened CNA-K and stated R17 told CNA-K, Shut up, mind your own business, I will do it to you. CNA-K then informed Registered Nurse (RN-M) that R17 just sexually assaulted R16 and R16 is stating that R17's fingers were in R16's vagina and R17 was fingering R16. CNA-K informed Surveyor that CNA-K stayed with R17 until two other CNAs arrived to supervise R17 and CNA-K returned to R16 and stayed with R16 until the police arrived. CNA-K observed R16 to be in shock and saw disbelief and R16's eyes were traumatized. CNA-K stated that R16 was so distraught and adamant that the police be called. CNA-K stated R16 just wanted it to be over. CNA-K informed Surveyor that there had been a previous incident with R17 being touchy with staff. CNA-K stated R17 would step out of R17's room and look around in a creepy way but had no other significant behaviors. On 12/4/23 at 2:09 PM, Surveyor interviewed RN-M regarding the incident. RN-M stated that prior to the incident on 12/1/23, R17 had been acting strange that night going in and out of other resident rooms. RN-M stated RN-M had to stop R17 several times from going into other resident rooms. RN-M heard CNA-K yell for help and RN-M went running to R16's room. RN-M observed CNA-K holding on to R17's hands, CNA-K explained to RN-M that CNA-K had found R17 sexually assaulting R16. RN-M observed R16's gown pushed up to R16's abdomen and R16's brief was partially off. R16 yelled call 911. RN-M ran out of the room and called 911, the Administrator (NHA-A,) and Director of Nursing (DON-B). On 12/5/23 at 9:01 AM, Surveyor interviewed Social Worker (SW-J). SW-J informed Surveyor that R17 had been having periods of aggression but was doing better and stable on medications. SW-J stated there had been occasions where R17 was sexually inappropriate with staff. SW-J stated R17 possibly could have been disoriented with the recent room changes. SW-J confirmed that SW-J has been providing intense psychosocial support on a daily basis to R16 and that R16's daily routine has remained the same. R16 has been eating and sleeping per norm. SW-J stated R16 shared R16 was more tired despite sleeping the same. On 12/5/23 at 1:40 PM, Surveyor interviewed SW-Q. SW-Q stated that SW-Q obtained R16's statement the night of the incident. R16's statement to SW-Q was that R17 had entered R16's room and tried to choke R16. R16 put the call light on and screamed and then R17 had come back into R16's room and went on top of R16. SW-Q stated R16 also informed SW-Q that R17 was sucking on R16's nipples, pulled R16's gown up, and placed R17's fingers in R16's vagina. SW-Q spoke with the family of R17 after the incident and asked about any history of behaviors for R17. SW-Q stated one family member would not make eye contact with SW-Q which SW-Q thought was unusual. SW-Q also informed Surveyor that SW-Q had only had contact with R17 one time prior to the incident which was on the morning of the fire on 11/30/23 in which SW-Q was monitoring R17 in the dining room. SW-Q stated SW-Q had introduced SW-Q to R17. SW-Q stated that three days later, R17 remembered SW-Q was a social worker and SW-Q's name. On 12/4/23 at 2:20 PM, CNA-G informed Surveyor that R17's behavior changed after the fire on 11/30/23. CNA-G stated that CNA-G observed R17 to be more anxious and confused with more pacing. CNA-G stated CNA-G is unaware of any previous behaviors with R17 and understood the incident to be out of the norm for R17. <b [TRUNCATED]

Based on observation, interview, and record review the facility did not ensure that all Residents remain free from accidents by implementing interventions identified to reduce hazards and risks to prevent falls for 3 of 3 Residents (R1, R2 and R3) reviewed for falls. *On 11/24/21, R1 received a fracture of both left and right proximal tibia and fibula with mild displacement. The facility self-report investigation indicated a gait belt was not used and R1's care plan indicated a gait belt should be used with all transfers. *R2 was observed to not have a fall mat on the floor on the door side of the bed, call light was not within reach, bed was not in the lowest position, and urinal was not at bedside in order to prevent falls and or reduce injury from a fall. *R3 was observed to not have a fall mat at bedside and the bed was not in the lowest position in order to prevent falls and or reduce injury from a fall. Findings include: Surveyor reviewed the facility's care plan/conference policy and procedure revised 1/25/21 and notes: the Interdisciplinary Team (IDT) must review and update the care plan when there is a significant change in Resident's condition, when desired outcome is not met. Surveyor reviewed the facility's post fall policy and procedure established 3/23/20 and notes: as part of the root cause analysis the Resident's plan of care should be updated with new interventions. Surveyor also reviewed the facility's fall reduction policy and procedure revised 6/30/20 and notes the following applicable: Purpose: .To provide an environment that remains as free of accident hazards as possible .To identify Residents who are at risk for falling and to develop appropriate interventions .To promote a systematic approach and monitoring process for the care of Residents who have fallen and/or those who are determined to be at risk. Procedure: Risk Identification and Assessment: 1. A systematic approach data collection to evaluate and identify the presence of risk factors, related causes, and complications 2. Each Resident will be evaluated for risk of falls using the Morse Fall Scale 5. Residents identified to be at risk for falling along with interventions to manage that risk will be communicated to caregivers via the care planning process Prevention and treatment guidelines 1. Any risk factors identified by the Morse Fall Scale, Minimum Data Set (MDS), or other assessments should be reviewed and addressed as determined appropriate through the care plan. 9. Immediate intervention will be added to the plan of care and communicated to caregivers 13. The care plan will be reviewed after every fall and updated with a new intervention 14. Summary of incident will be completed by IDT and include care plan review, effectiveness of interventions, and root cause of fall Systems for quality assurance 2. Resident with falls will be reviewed at FOCUS meetings to identify root cause, effectiveness for interventions, and make care plan revision as appropriate. 1) R1 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Unsteadiness on Feet, Other Abnormalities of Gait and Mobility, Chronic Kidney Disease, Stage 1, Generalized Anxiety Disorder, Major Depressive Disorder, and [CONDITION(S)] Disorder. R1 is her own person. R1 discharged to the hospital on 12/15/21 and currently remains in the hospital. R1's Significant Change Minimum Data Set (MDS) dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) score of 14, indicating R1 is cognitively intact for daily decision making. R1 is totally dependent on staff for bed mobility, transfers, bathing and toileting. R1 requires extensive assistance for dressing, eating, and hygiene. R1 has range of motion (ROM) impairment on both sides of lower extremity. Surveyor notes on R1's care area assessment (CAA) dated 12/8/21, documents that R1 now requires total assistance with all mobility, transfers, and activities of daily living (ADL) due to recent bilateral lower extremity fractures. R1 wears bilateral splints to bilateral lower extremities at all times. Surveyor reviewed R1's comprehensive care plan and notes the following care plan focused problems were revised on 12/27/21 due to the the bilateral lower extremities (BLE) fractures: 1. R1 has ADL self-care performance deficit due to disease process. BLE fractures (tibia/fibula); 2. R1 has limited physical mobility due to disease process, BLE tibia and fibula fractures; 11/30/21 R1 to wear continuous BLE splints continuous; 11/24/21 transfer assist, full body lift, assist two with large sling; 3. R1 is at risk for falls related to history of fall with fracture; Re-evaluation of transfer status. Changed from 2-person gait belt transfer to full mechanical lift; 5/27/21 high fall risk due to history of falls with fracture of right femur. Refuses to wear braces to BLE. Encourage use of brace; 4. R1 has potential for acute and chronic pain, history of femur fracture, lower extremity fractures; 5. R1 is at risk for alteration in skin integrity related BLE leg braces secondary to fractures to keep on at all times and perform skin checks Q (every) shift The investigative summary indicates R1 was in the shower and was raised out of R1's wheelchair by Certified Nursing Assistant(CNA-S). CNA-S was facing R1 and was lifting R1 with CNA-S's arms wrapped around R1. When CNA-S obtained a standing position with R1, CNA-T was behind R1 pulling up R1's briefs. At this time CNA-S began to lose CNA-S's grip on R1 and CNA-S readjusted CNA-S's grip causing R1 to change plane. CNA-S again lost CNA-S's grip and readjusted R1 two more times. During the readjustment CNA-T continued to attempt to pull R1's pants up. Additionally, during this time period R1 yelled ouch and CNA-S and CNA-T placed R1 back in R1's wheelchair and brought R1 back to R1's room. Licensed Practical Nurse(LPN-U) was notified of R1's pain, gathered information of what happened to R1 and reported it to Assistant Director of Nursing(ADON-V). ADON-V assessed R1 noting both the pain and slight swelling below the knee. Physician was updated with the incident and complaints of knee pain and would decide what should be done after assessing R1 in person. CNA-T's statement indicated that CNA-S was holding R1 the whole time and continued to reposition R1 in CNA-S's arm because CNA-S was losing CNA-S's balance with R1. CNA-T indicated CNA-T pulled the wheelchair behind R1. CNA-T stated that R1 did not hit the floor. CNA-S's statement was that CNA-S lifted R1 off the shower chair into a standing position told R1 to lock R1's legs as R1 normally does. R1's legs buckled three times, but R1 never hit the floor due to CNA-S holding R1 up. CNA-S stated that CNA-S tightened CNA-S's grip on R1 and lifted R1 to get R1's shorts on. R1 did yell out in a bit of pain when R1's legs buckled. ADON-V re-interviewed both CNA-S and CNA-T and determined that both CNA-S and CNA-T did not use a gait belt when transferring R1. Surveyor notes that Administrator (NHA-A) was immediately notified, both employees were suspended pending the investigation, and a formal investigation was started. Surveyor also notes that the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report was reported within 24 hours and the Misconduct Incident Report was reported to the State Survey agency within five days, utilizing the required documents per regulation. Surveyor reviewed the nurse practitioner (NP) documentation. The nurse practitioner assessed R1 in person after the incident on 11/24/21. R1 indicated that R1's knee's buckled. Pain at time of assessment was 4/10. NP documented there was some puffy/swollen areas just under both knee caps. R1 agreed to x-rays at the facility but did not immediately want to be transferred to the hospital. R1 indicated that if the x-rays showed a fracture R1 would agree to go to the hospital. The NP indicated that R1 did not have full functionality to bend knees normally at baseline. Appears more upset over incident than in acute distress. Surveyor notes the x-ray documentation dated 11/24/21 at 2:25 PM, indicate 'acute fracture of left proximal tibia and fibula with mild displacement'. Per documentation, R1 was sent to the emergency room (ER) for evaluation and treatment. Surveyor notes after reviewing documentation that R1 was assessed by both physical and occupational therapy and switched from a gait belt transfer to a hoyer lift transfer. Immediate education initiated to all licensed nurse's and CNA's on: -Gait belt transfer(1 person) -Gait belt transfer(2 person) -Sit to stand mechanical lift The NP assessed R1 in person at the facility on 11/30/21 and notes that the hospital stay was unremarkable and orthopedics did not recommend any surgical interventions. Surveyor reviewed R1's hospital discharge summary dated 11/29/21 which documents R1 had bilateral minimally displaced fractures of proximal tibia and fibula heads and splinting of bilateral lower extremities. On 1/13/22 at 8:20 AM, Surveyor spoke to Rehabilitation Director (RD-N) in regards to R1. RD-N states that prior to the incident, R1 was an assistance of 2 with a gait belt for transfers. RD-N states that R1 had significant deformities in the lower extremities and had club feet. RD-N stated that R1's knees had not buckled previously to incident while at the facility. RD-N stated that R1 was switched to a hoyer lift after the incident. On 1/13/22 at 9:31 AM, Surveyor reviewed the incident with Director of Nursing (DON-B). DON-B confirmed that a gait belt had not been used. DON-B informed Surveyor of the training that occurred with all licensed nurses and CNA's on the proper transfer of assistance of 1 or 2 with a gait belt. DON-B stated that every room now has a hangar in the room with each Resident having a gait belt on the hangar. DON-B stated a lot of education was completed and audits with return demonstration for both transfers with a gait belt and a lift. DON-B also stated that R1 did not get out of bed much after the incident and had braces on R1's legs and needed encouragement of adjustment of the braces for skin integrity. Surveyor notes per investigative summary dated 12/1/21 submitted to the state agency, that the allegation of neglect is substantiated. The CNA's involved in the event of R1 failed to follow the plan of care when they did not use a gait belt to transfer R1. R1 sustained acute fractures of both the left and right proximal tibia and fibula with mild displacement. As a result, Surveyor notes both CNA-S and CNA-T were terminated. 2) R2 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction Affecting Left Non-Dominant Side, Essential Hypertension, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, and Major Depressive Disorder. R2 has an activated Health Care Power of Attorney (HCPOA). R2's Annual MDS (Minimum Data Set) assessment, dated 12/28/21, documents R2's Brief Interview for Mental Status (BIMS) score to be a 9, indicating R2 demonstrates moderately impaired skills for daily decision making. R2's MDS also documents R2 requires extensive assistance for bed mobility, dressing, transfers, and toileting. R2 requires total dependence for bathing. R2 has range of motion(ROM) impairment on both sides for upper and lower extremities. Surveyor notes R2's most recent Morse Fall Scale (fall assessment), dated 12/26/21, documents R2 to be at high risk for falling. Surveyor reviewed the fall investigation related to R2's fall on 11/22/21 and notes a root cause analysis was completed with notification to physician and representative. R2's Care plan was updated and complete neurochecks (neurological) were documented. Surveyor notes R2's kardex provided as of 1/13/22 documents, R2 should have call light within reach, mat to floor door side of bed, low bed, and urinal at bedside. Surveyor reviewed R2's comprehensive care plan and notes the following: R2 is high risk for falls due to generalized weakness and cerebelar stroke syndrome Initiated 12/23/21, Revised 1/4/22 Interventions currently in place 12/23/20 urinal at bedside 1/1/21 air mattress properly inflated 1/3/21 bedside table is close to bed so R2 can reach personal items 1/17/21 low bed 2/16/21 call light within reach 11/22/21 maintenance to check broda chair for proper function and foot plate added to broda chair to prevent sliding On 1/12/22, at 1:15 PM, Surveyor observed R2 in bed, bed is slightly elevated, but not in low position, and R2 is eating lunch. R2 has an air mattress in place and R2's call light is observed on the floor. Surveyor observes no urinal with-in reach or a bedside table next to bed. Surveyor observes no fall mat next to R2's bed. On 1/12/22, at 2:36 PM, Surveyor observed R2's bed slightly elevated, bed is not in low position, no fall mat on the floor next to R2's bed. Surveyor observes no bedside table next to bed or urinal within reach, call light is within reach. On 1/13/22 at 7:05 AM, Surveyor observed R2 sleeping in bed. Surveyor notes R2's bed is in the regular position. There is no urinal next to the bed and R2's overbed table with breakfast tray is located across the room. Call light is within reach and a thin mat is located on the door side of the bed. On 1/13/22 at 10:13 AM, Surveyor observed R2 in bed, resting with eyes closed. Surveyor notes R2's bed is not in the low position. There is no mat next to the bed and no urinal at bedside. R2's overbed table is across the bed in front of R2. Surveyor interviewed Certified Nursing Assistant(CNA-L) at this time. Surveyor asked CNA-L if the bed was in the low position. CNA-L stated R2's bed was not in the low position because R2 has the overbed table in front of R2 and demonstrated the bed can be placed in a lower position. Surveyor observed no difficulty with the bed being in a lower position. CNA-L placed the mat next to the bed and removed the breakfast tray. Surveyor notes, CNA-L left the overbed table across the bed and the bed in normal height position. Surveyor observed R2's call light next to R2's face clipped high on the pillow on the left side. Surveyor asked R2 if R2 could reach the call light. R2 attempted with right hand to reach the call light but was unable to do so. R2 has a contracted left hand with [CONDITION(S)] and [CONDITION(S)] on the left side. 3) R3 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Type 2 Diabetes Mellitus, Chronic Kidney Disease, Stage 4, Dyspagia, and Bilateral Amputation. R3 is R3's own person. R3's Admission MDS dated [DATE] documents R3 has a BIMS score of 12, indicating R3 demonstrates moderately impaired skills for daily decision making. R3's MDS also documents R3 requires extensive assistance for bed mobility, dressing and toileting. R3 requires total dependence for transfers and bathing. R3 has range of motion impairment on both lower extremities. Surveyor notes R3's most recent Morse Fall Scale (fall assessment), dated 12/8/21, documents R3 to be at high risk for falling. Surveyor reviewed the fall investigations related to R3's four falls. Surveyor notes a root cause analysis was completed with notification to physician and representative. R3's Care plan was updated and complete neurochecks (neurological) were documented. 12/8/21-R3 stated R3 put self on floor and denied falling 12/15/21-R3 stated R3 self transferred and denied falling, found on the mat 12/17/21-R3 stated R3 crawled out bed and denied falling 1/4/22-R3 stated R3 rolled of the bed onto the floor Surveyor notes R3's kardex provided as of 1/13/22 documents, R3 should have call light within reach, mat to floor next to bed, and a low bed. Surveyor reviewed R3's comprehensive care plan and notes the following: R3 is at risk for falls moderate related to bilateral amputation/left sided weakness Initiated 12/9/21 Revised 1/4/22 Interventions currently in place: 12/13/21 Anticipate and meet my needs 12/9/21 Ensure call light is within reach 12/17/21 High back wheelchair for proper body alignment and mobility 12/8/21 Fall mat cushion at bedside. Bed in lowest position On 1/12/22 at 1:01 PM, Surveyor observed R3 sitting on R3's bed. R3's bed is not in the lowest position. Overbed table with lunch tray is next to the bed. R3's mat cushion is across the room in the diagonal position, not next to R3's bed. Surveyor asked CNA-K what the cushion mat was on the floor. CNA-K stated, He is a fall risk. CNA-K did not lower the bed or move the cushion next to R3's bed. Surveyor notes R3's door is open. On 1/12/22 at 2:37 PM, Surveyor observed R3 on R3's bed, observed R3's bed not in the lowest position. Surveyor observed a thin mat next to R3's bed and call light is within reach. Surveyor notes R3's door is open. On 1/13/22 at 7:10 AM, Surveyor observed R3 sleeping in bed. The call light is on the floor and not within reach of R3. Bed is low position with a thin mat next to the bed. Surveyor notes R3's door is open. On 1/13/22 at 10:00 AM, Surveyor observed R3 from the open doorway. R3 is sitting on R3's bed with no sheets on the bed. R3's reclining highback wheelchair was located next to R3's bed. Surveyor observed no mat in place next to R3's bed, mat was located across R3's room. Surveyor observed R3's bed in the high position. Surveyor notes R3's door is open. On 1/13/22 at 10:02 AM, Surveyor interviewed Licensed Practical Nurse(LPN-E) in regards to R3. Surveyor asked LPN-E why R3's door was open(due to being COVID-19 positive). LPN-E stated, because he is a fall risk. Surveyor had LPN-E go to R3's room with Surveyor. LPN-E confirmed that R3's bed was not in the low position. LPN-E saw the wheelchair next to R3's bed and stated, they must have been getting him up. LPN-E informed R3 should not have been left alone with the chair next to the bed because of being a fall risk. LPN-E moved the wheelchair away from R3's bed, lowered the bed, and placed the mat next to R3's bed. On 1/13/22 at 2:55 PM, Surveyor shared the concern that R1's self report was substantiated due to no gait belt used during transfer resulting in R1's fractures. R2 and R3's fall interventions were not in place during the survey process in order to prevent falls and reduce injuries from falls with Administrator(NHA-A) and Director of Nursing(DON-B). No further information was provided by the facility at this time.

Based on interview and record review, the facility did not provide necessary treatment and services to promote healing for a pressure injury. This was observed with 1 (R1) of 3 residents reviewed for pressure injuries. R1 was admitted to the facility without pressure injuries. R1 developed two unstagable facility acquired pressure injuries. The facility did not comprehensively assess R1's pressure injuries and notify the MD timely to determine treatment. The comprehensive care plan was not updated timely. There was no change in treatment or interventions to advance healing of the pressure injuries. R1's care plan which identified refusals did not include interventions to address the refusals nor did it indicate the risks and benefits of R1's refusals. Findings include: The facility's Pressure Injury and Wound Care Management Policy, revision date of 4/27/21, states the following: .The facility will ensure that a resident who is admitted without a pressure injury does not develop a pressure injury, unless clinically unavoidable. A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers. Procedure: . 6. Residents at risk for the development of a pressure injury will have their individualized care interventions and approaches documented in the resident care plan. 7. Skin impairments, including pressure injuries, non-pressure injury wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, using the PCC (point click care) Weekly Wound Assessment. a. Weekly documentation will include pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues, and a description of any drainage, eschar, necrosis, odor, tunneling or undermining. 8. Documentation of the wound characteristics will be completed in PCC using the PCC Skin and Wound Assessment. 12. Wound and skin care interventions will be monitored and evaluated for effectiveness. Care plans will include specific and measurable goals and interventions. The care plan will be reviewed and revised at last quarterly, or with significant change in condition. R1's medical record was reviewed by Surveyor. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/1/21, R1 had a Braden score of 15 indicating mild risk of developing a pressure injury. On 9/1/21, the facility's Admission Screener form reports R1 had no pressure injuries at admission. R1's care plan, created on 9/2/21, indicates the following: Resident is at risk for skin breakdown related to decreased mobility following a [CONDITION(S)] ([CONDITION(S)]) with dense [CONDITION(S)], obesity, incontinence, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I will be free from skin breakdown through the review date. Interventions include: -Apply moisturizer to my skin as needed. Do not massage over bony prominences. Date initiated: 9/2/21. -Float my heels or use heel suspension boots while I am in bed. Date initiated: 9/2/21. -Keep my skin clean and dry. Date initiated: 9/2/21. -Manage my clinical conditions and contributing factors to decrease my risk of skin breakdown. Date initiated: 9/2/21. -Monitor my weights per policy and notify MD of any significant changes. Date initiated: 9/2/21. -Position my body with pillows/support devices, and protect bony prominences. Date initiated: 9/2/21. -Use a pressure reducing cushion in resident's chair. Date initiated: 9/2/21. -Use A&D ointment, BAZA or other skin barrier cream on my skin as needed. Date initiated: 9/2/21. -Provide diet, supplements, vitamins and fortified foods per orders. Date initiated: 9/2/21. -Routinely turn and reposition as tolerated by resident. Date initiated: 9/2/21. -Use a draw sheet and 2 people when pulling me up in bed. Date initiated 9/2/21. -I use a side rail/trapeze/grab bar to help myself move in bed. Date initiated 9/3/21. -Apply barrier cream to resident's skin following peri and incontinence cares. Date initiated: 9/8/21. -Apply bilateral off loading boots while resident is in bed. Date initiated: 9/8/21. -Assist resident to keep skin clean and dry. Date initiated: 9/8/21. -Reposition resident while in bed and up in chair frequently. Date initiated: 9/8/21. R1's kardex report states Bed mobility: bed mobility assist - one. Turn and reposition me at least every 2 hours, and on a schedule that is specific to my routine and tolerance Skin: apply barrier cream to resident's skin following peri and incontinence cares. Apply bilateral off loading boots while resident is in bed. Provide the treatment to all wounds as ordered by the physician. Use a pressure reducing cushion in resident's chair. R1's Admission MDS (Minimum Data Set) assessment dated [DATE] indicates R1 has a Brief Interview for Mental Status score of 12 which indicates R1 has moderate impaired cognition. The MDS indicates R1 is at risk for developing pressure injuries and had no pressure injuries at admission. Skin and ulcer/injury treatments included pressure relieving device for chair and bed. The MDS did not indicate a turning or repositioning program. Under rejection of care, the MDS indicates behavior is not exhibited. On 9/14/21, R1's CAA (Care Area Assessment) worksheet was completed for pressure ulcer/injury. The analysis of findings section indicates Resident is at risk for pressure injury, (R1) has no skin concerns at this time except MASD (moisture-associated skin damage). (R1) scores a 15 on the braden scale which indicates moderate risk for pressure ulcer. On 9/29/21, Physical, occupational and speech therapy was discontinued as highest practicable level was achieved. Surveyor interviewed Therapy Director (TD) -J on 10/27/21 at 12:39 PM. TD-J stated that therapy was stopped due to insurance as well as the highest practicable level was achieved at that time. R1 received about 90 minutes of therapy every day Monday-Friday until approximately September 30th. TD-J indicated R1 would show some behaviors such as flailing, groaning, during the therapy sessions, but would not totally refuse to the point that therapy could not be done. On 10/1/21 at 10:53 PM, Licensed Practical Nurse (LPN)-E documents a health status note stating: CNA noticed while changing resident that there is an area on (R1's) sacrum where the skin looks irritated. It needs to be monitored and treated if necessary. * Surveyor noted no RN assessment of this area. No further documentation was found on the changing skin area on R1's sacrum on 10/2/21. On 10/3/21 at 10:44 PM, LPN-C documents a health status note stating: Resident was noted to have some excoriation to buttocks message left for wound team and dry dressing applied. Surveyor interviewed LPN-C on 10/26/21 at 2:50 PM regarding R1's wounds. LPN-C stated a message was left on 10/3/21 for the wound team regarding R1's excoriation. LPN-C said that was the normal procedure and assumed someone would listen to it for follow up. LPN-C indicated that barrier cream was used to protect the skin. LPN-C said R1 did often refuse to get up and move as R1 only wanted to lay in bed. If R1 was out of bed, R1 would be upset. LPN-C does not remember documenting any refusals. On 10/4/21 at 1:38 AM, Registered Nurse (RN)-G documents a health status note stating Excoriation in the sacrum remains. Barrier cream applied. Staff will continue to monitor. On 10/4/21 at 10:59 AM, Assistant Director of Nursing (ADON)-H documents an alert note stating Skin issue. No skin issues noted at time of reassessment. Staff will continue to monitor. On 10/5/21 at 1:29 PM, RN-I documented a general note Resident has barrier cream for his bottom, being monitored for excoriation for his bottom. No other concerns noted, staff will continue to monitor. On 10/5/21 at 9:51 PM, ADON-H reported a new pressure injury to the coccyx and documents the following: 1) Coccyx - New Pressure. Writer went into resident's room to assess possible wound on coccyx, resident has coccyx wound measuring 0.7 x 0.2. No odor noted, no drainage noted, wound is very superficial. Area cleaned with normal saline followed by barrier cream. Dr notified. Family notified. Root cause: resident declines repositioning and spends the majority of time in bed. Measures are in place to prevent skin breakdown. * Surveyor noted there is no comprehensive assessment of the Coccyx pressure injury such as staging or wound bed description 2) Right buttock - MASD (moisture associated skin damage). Right buttocks excoriation noted approx 0.5 x 0.5. Clean with normal saline, barrier cream applied. Dr notified. Family notified. Root cause: resident spends the majority of time in bed. Declines repositioning. All safety measures in place to protect skin. * Surveyor noted there is no indication if there are any open areas associated with the right buttock excoriation. On 10/5/21, a new intervention was added to the care plan: Treatment to excoriation to buttocks. Clean with normal saline, apply Xeroform gauze followed by foam dressing. *Surveyor noted R1's care plan identified R1 refusing repositioning, and spending the majority of time in bed however R1's care plan did not identify any approaches/interventions for repositioning. R1's care plan and/or progress notes do not indicate whether risks and benefits of refusal were discussed with R1. * Surveyor noted no new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor noted the care planned treatment to apply normal saline, apply Xeroform gauze to R1's excoriated buttock was not transcribed onto the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/6/21, a facility weekly skin check documents Resident has open areas noted to the left side of the knee (Vascular wound) and open areas to buttocks. (R1) is followed by the wound team. On 10/6/21 at 11:45 AM, ADON-H documented a wound evaluation as follows (pictures with computerized measurement): 1) Right buttock, unstageable pressure injury. Measuring 4.07 x 1.24. 100% slough. Moderate serous exudate. No odor. Edges attached. Fragile surrounding tissue. No induration. No pain. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Cares include cushion, heel protection, incontinence management, mattress with pump, moisture barrier, and repositioning program. 2) Sacrum (Coccyx), unstageable pressure injury. Measuring 4.83 x 1.73. 100% slough. Moderate serous exudate. No odor. Edges attached. Fragile surrounding tissue. No induration. No pain. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Cares include mattress with pump. * Surveyor noted the deterioration of both the right buttock and sacrum/coccyx areas in regards to their measurements and both documented as now being unstagable Pressure injuries having 100% slough. DON B informed Surveyor the facility has a computerized measurement system used for pressure injuries that is not always accurate in regards to measurements. DON B reported the measurements taken on 10/6/21 were taken by the facility's computerized measurement system which is not always accurate. * Surveyor noted ADON H had measured the areas on 10/5/21 indicating the coccyx pressure injury was 0.7 x 0.2 but did not include staging or the description of the wound bed. ADON H measured the right buttock on 10/5/21 which indicated the excoriated area was 0.5 X 0.5 but did not descibe whether the area contained open wounds. Surveyor noted on 10/6/21 the right buttock excoriation is now identified an unstagable pressure injury. Surveyor noted there is no reconciliation between the different measurements knowing the computerized system they use is not always accurate. * Surveyor noted after the 10/6/21 increased measurements and noted 100% slough in both pressure injuries the facility did not notify the MD of the changes in order to discuss the deterioration. When the facility notified the MD on 10/5/21 of the Coccyx pressure injury the area was smaller in size, was noted to be superficial versus unstagable as noted on 10/6/21. The right buttock which was described on 10/5/21 as MASD was now on 10/6/21 being documented as an unstagable pressure injury with 100% slough. On 10/11/21, the TAR reflects Check on wound dressing to buttocks every shift to ensure dressings are in place. Replace dressings as needed if dressing is missing or not adhered, every shift. * Surveyor noted this is not specific to which wound this treatment is for, and does not describe the type of wound dressing to use. On 10/11/21 (5 days after R1's pressure injuries deteriorated), a new care plan was created by DON-B which states; I have a pressure ulcer on my coccyx related to bedfast, impaired mobility and functional ability. Interventions: -I have a pressure relieving air mattress for my bed. -I decline being repositioned off of my back/buttocks. I will occasionally decline my offloading boots. -Administer my treatments as ordered and monitor for effectiveness. -Turn and reposition me at least every 2 hours and on a schedule that is specific to my routine and tolerance. -Encourage me to make micro-shifts in position throughout the day. -Keep my linen clean, dry and wrinkle free. -Keep my skin clean and dry. - Monitor my nutritional status. Serve diet as ordered. Monitor intakes and notify MD of significant decreases in intake or weight loss. On 10/12/21, wound care consultation report by Doctor (MD)-K states: Site 1: Unstageable right buttock pressure wound. Measuring 0.5 x 1 x not measurable. 100% slough. Site 2: Unstageable sacrum pressure wound. Measuring 4 x 2.5 x 0.1. 100% slough. treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/12/21 at 8:46 AM, RN-F completed the skin and wound evaluation forms in the facility's electronic health record which indicate: Site 1: Unstageable right buttock pressure injury. Measuring 0.6 x 0.3 x 0.1. 100% slough. Site 2: Unstageable sacrum pressure injury. Measuring 3.6 x 1.1 x 0.1. 100% slough. Notes: MD-K made his initial assessment of resident's unstageable pressure injuries on the sacrum and right buttock. MD-K provided a light debridement of devitalized tissue to promote healing. Will apply xeroform gauze and foam dressing to both sites daily and prn. Resident has an air mattress and off loading boots in place. * Surveyor noted the difference in the wound measurement from RN-F to MD-K on the same date. On 10/12/21, RN-F revised the care plan to include: Resident has an unstageable pressure injury on his sacrum and right buttock as well as a venous wound on his left calf. New interventions: -Provide the treatment to all wounds as ordered by the physician. -Specialty air mattress; check for proper inflation and function every shift. - Resolved intervention of treatment to excoriation on buttocks. On 10/13/21 (7 days after both pressure injuries were noted to be unstagable), the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Treatment to right buttock. Normal saline wash followed by Xeroform gauze. Cover with a foam dressing and change daily and PRN every day shift. Treatment to sacrum. Normal saline wash followed by Xeroform gauze. Cover with a foam dressing and change daily and PRN every day shift. On 10/19/21, R1 was discharged to the hospital. Surveyor requested hospital records and no skin or wound concerns were noted in the records received. On 10/26/21 at 11:00 AM, Surveyor interviewed wound nurse, RN (Registered Nurse)-F. RN-F stated the wound team was not available to receive messages for the wound team from the end of September to around October 12th as RN-F was out of the office. RN-F was not aware of R1's pressure injuries until October 12th when rounds were completed with the wound doctor and was back to work. The first time RN-F and the wound physician assessed R1 was on October 12th. RN-F then updated the orders and care plan. RN-F indicated that the DON-B and ADON-H were to be contacted in RN-F's absence, but was not sure if this was told to all the nursing staff. On 10/26/21 at 3:50 PM, Surveyor interviewed DON-B. DON-B said the facility reviewed the progress notes and found the nursing note regarding R1's skin excoriation. DON-B said no one was notified initially as the RN was new and the regular wound nurse was out of the office at this time. DON-B stated ADON-H was sent to assess R1's skin and did not see any open areas on 10/4/21 therefore only barrier cream was necessary. DON-B indicated on 10/5/21 when the CNA brought a wound concern to their attention, then ADON-H did an assessment and contacted the doctor and family at that time. DON-B said refusals were an issue with R1 and the facility did note this on the care plan, but did not have any more follow up on what the staff should do if refused. Surveyor was unable to interview ADON-H as they were not in the facility at the time of survey. On 10/27/21 at 3:07 PM, Surveyor met with DON-B and NHA-A. No further information or documentation was provided.

Based on interview, and record review, the facility did not provide necessary treatment and services to promote healing for 2 (R5 & R6) of 3 residents reviewed for pressure injuries. * R5 was identified with a left buttock pressure injury on 4/23/21. This unstageable pressure injury wasn't assessed by a registered nurse (RN) until 4/26/21, 3 days later and a physician treatment wasn't ordered until 4/26/21. R5 was on a hospital donated mattress. Facility did not provide evidence this mattress was appropriate for an unstageable pressure injury and R5 didn't receive an air mattress until 5/4/21, 8 days later. R5's care plan was not revised after the pressure injury declined. * R6's heels were not floated according to the plan of care. Findings include: 1.) R5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The at risk for alteration in skin integrity care plan initiated 1/12/21 & revised 5/4/21 documents interventions of: * Apply bilateral off loading boots at all times. Initiated 3/23/21. * Apply moisturizer to my skin as needed. Do not massage over my bony prominences. Initiated 1/12/21 & revised 3/2/21. * Keep my skin clean and dry. Initiated 1/12/21 & revised 3/2/21. * Manage my clinical conditions and contributing factors to decrease my risk of skin breakdown. Initiated 1/12/21. * Monitor my weights per policy, and notify MD (medical doctor) and/or RD (registered dietitian) of any significant changes. Initiated 1/12/21. * Position my body with pillows/support devices, and protect bony prominences. Initiated 1/12/21 & revised 3/2/21. * Provide all treatments as ordered by the physician. Initiated 3/29/21. * Provide Diet, Supplements, Vitamins, and/or fortified foods per orders. Initiated 1/12/21. * Routinely turn and reposition as tolerated by resident. Initiated 1/12/21 & revised 3/2/21. * Staff to place a pillow between resident's legs and the side rail of her bed. Initiated 3/29/21. * Use a draw sheet and 2 people when pulling me up in bed (to prevent shear). Initiated 1/12/21 & revised 3/2/21. * Use a pressure reducing cushion for my wheelchair. Initiated 1/12/21 & revised 3/4/21. * Use A & D ointment, Baza, or other skin barrier cream on my skin as needed. Initiated 1/12/21 & revised 3/2/21. The Braden assessment dated [DATE] documents a score of 12. A score of 10-12 indicates high risk for pressure injury development. The quarterly MDS (minimum data set) with an assessment reference date of 3/11/21 documents R5 is at risk for pressure injuries and is coded as not having any pressure injuries. The weekly skin check dated 4/19/21 is blank for location of skin alterations. For the question new skin alteration identified no is answered. The nurses note dated 4/23/21 (Friday) at 11:06 p.m. documents CNA (Certified Nursing Assistant) reported to writer that resident has a open area on left buttock. Wound was cleaned with normal saline and covered with foam dressing. Message was left for the wound nurse, MD (medical doctor) and family will be contacted in the morning. Staff will continue to monitor. This note was written by LPN (Licensed Practical Nurse)-J. Surveyor noted there are no measurements or description of the wound bed and there is not an RN assessment of R5's pressure injury. The Braden assessment dated [DATE] documents a score of 16. A score of 15-18 indicates at risk for pressure injury development. The nurses note dated 4/24/21 documents Dressing on OA (open area) on resident's Lt (left) bottom remains, no bleeding noted, VSS (vital signs stable). Resident is responsive, denies pain at this time, will cont. (continue) to monitor. This note was written by RN (Registered Nurse)-K. The nurses note dated 4/26/2 documents [Family Member-L] and Physician-M were updated on 4/25/21 regarding resident's open area of the left buttock. The wound evaluation dated 4/26/21 documents Pressure - Unstageable (slough and/or eschar). Body location documents left buttock. Length is 1.42 cm (centimeters), Width 1.18 cm and depth 0.1 cm. Under wound bed documents granulation 50% and slough 50%. Under progress notes documents Writer was updated by nsg (nursing) staff on this newly developed unstageable pressure injury today. Physician-M updated and a new tx (treatment) order received. Resident has a specialty hospital mattress for pressure reduction already in place. WD (Wound Doctor)-N will assess in the am (morning). This assessment was completed by RN-C who is the wound nurse for the Facility. Surveyor noted this RN assessment is 3 days after the pressure injury was discovered. The physician's treatment was not ordered until 3 days after the pressure injury was discovered and there were no revisions in the care plan. Surveyor reviewed R5's April TAR (treatment administration record) and noted the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound evaluation dated 5/4/21 documents Pressure - Unstageable (slough and/or eschar). Body location documents left buttock. Length is 1.3 cm (centimeters), Width 1.15 cm and depth 0.1 cm. Under wound bed documents granulation 50% and slough 50%. Under progress notes documents WD-N examined this wound today and observed an increase in the surface area of this unstageable pressure injury this week. Awaiting delivery of an air mattress. Will change the tx (treatment) order to santyl oint. (ointment). The nutrition note dated 5/4/21 documents Resident with an unstageable wound to Lt (left) buttock that is shown as worsened 5/4/21, noted has air mattress coming. Lt knee abrasion is noted to be resolved. Regular, level 7 easy to chew diet remains in place. Meal intakes have decreased since last RD (Registered Dietitian) review and now mostly < (less than) 51% of meals. Readycare 120ml (milliliter) TID (three times a day) in pace with 100% intakes. Will increase this to four times daily with goal of meeting estimated needs for wound healing Wt (weight) is stable without loss at this time. RD to follow wts (weights), intakes and progress of wound and re-eval (evaluate) as indicated. The wound evaluation dated 5/11/21 documents Pressure - Unstageable (slough and/or eschar). Body location documents left buttock. Length is 1.86 cm (centimeters), Width 1.7 cm and depth 1.0 cm. Under wound bed documents for slough 100%. Under progress notes documents WD-N evaluated this unstageable pressure injury today and noted a decrease in the surface area since last week. Will continue with santyl oint for enzymatic debridement of the devitalized tissue. Surveyor noted the surface area did not decrease but increased as the wound evaluation 5/4/21 had a surface area of 1.11 cm and this evaluation 5/11/21 has a surface area of 2.3 cm. The wound bed is now 100% slough. Surveyor also noted there has been no revision in R5's care plan. Surveyor noted weekly wound evaluations from 5/11/21 to 6/8/21. The wound evaluation dated 6/8/21 documents Pressure - Unstageable (slough and/or eschar). Body location documents left buttock. Length is 1 cm, Width 0.91 cm and depth 0.2 cm. Under wound bed documents for granulation 30% and slough 70%. Under progress notes documents WD-N noted a decrease in the percentage of slough within the wound bed this week. Will continue with santyl oint. The quarterly MDS with an assessment reference date of 6/11/21 documents a BIMS (brief interview mental status) score of 3 which indicates severe impairment. R5 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfers, does not ambulate and requires extensive assistance with one person physical assist for eating & toilet use. R5 is always incontinent of urine and bowel. R5 is at risk for pressure injury development and is coded as having one unstageable slough &/or eschar pressure injury. The wound evaluation dated 6/15/21 documents Pressure - Unstageable (slough and/or eschar). Body location documents left buttock. Length is 2.48 cm, Width 1.91 cm and depth 0.3 cm. Under wound bed documents for slough 100%. Under progress notes documents WD-N evaluated this unstageable PI (pressure injury) today and despite resident having an air mattress, being repositioned, etc, there is an increase in surface area and slough this week. A new tx order was received for calcium alginate+ (plus) foam daily and prn (as needed). Surveyor noted there was no revision in R5's care plan including a change in R5's repositioning schedule. The wound evaluation dated 6/22/21 documents Pressure - Unstageable (slough and/or eschar). Body location documents left buttock. Length is 8.45 cm, Width 5.55 cm and depth 1 cm. Under wound bed documents for granulation 20 & slough 80%. Under progress notes documents WD-N evaluated this unstageable pressure injury today and noted a decrease in the percentage of slough within the wound bed this week. Will continue with current tx plan. Surveyor noted although the percentage of slough decrease the size of the pressure injury increased from the previous week's evaluation and there was not change in R5's plan of care. Surveyor noted weekly wound evaluations from 6/29/21 to 7/13/21. The wound evaluation dated 7/13/21 documents Pressure - Unstageable (slough and/or eschar). Body location documents left buttock. Length is 2.3 cm, Width 1.47 cm and depth 2 cm. Under wound bed documents for granulation 80% and slough 20%. Under progress notes documents WD-N examined this unstageable pressure injury today and observed a decrease in the surface area. Will continue with current tx (treatment) plan. On 7/15/21 at 10:43 a.m. Surveyor observed R5 in bed on her back with the head of the bed elevated. R5 is wearing bilateral pressure relieving boots and has a pillow between her legs and by the side rail. On 7/15/21 from 10:53 a.m. to 11:05 a.m. Surveyor observed the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/19/21 at 11:20 a.m. Surveyor asked RN-C, who is the Facility's wound nurse, if a CNA observes a pressure injury on a Resident what should they do. RN-C explained they should immediately notify the nurse taking care of that Resident and let them know there is a change in skin. If for some reason the nurse does not [MEDICATION(S)] the CNA should notify ADON (Assistant Director of Nursing)-D, herself or DON (Director of Nursing)-B. Surveyor asked RN-C what she meant by not taking action. RN-C explained if the nurse doesn't call the physician to get a treatment. Surveyor asked after the CNA informs the nurse of the pressure injury what should the nurse do. RN-C informed Surveyor the nurse should notify her and if it's on a shift when she is not there the nurse should notify the doctor and family right away, obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-C informed Surveyor they also ask the nurse to do an incident report under risk management. Surveyor asked if the pressure injury is reported to a LPN when is the pressure injury assessed by a RN. RN-C informed Surveyor the LPN makes his/her note then the next shift for the following day she will, ADON-C or DON-B will assess the pressure injury. RN-C informed Surveyor they provided the nurses with an inservice for appropriate treatments with the company in which they receive their treatment supplies. RN-C explained if it's a pressure injury with no depth then the nurse should place on [MEDICATION(S)] & a foam dressing and if there is a little more depth then alginate with foam dressing. RN-C informed Surveyor the nurses were shown these products. Surveyor asked RN-C who reviews the skin integrity care plans. RN-C replied that would be me. Surveyor asked who revises these care plans. RN-C replied that would be me. Surveyor asked RN-C about the hospital mattress R5 was on prior to her pressure injury development and then an air mattress was recommended. RN-C informed Surveyor the Facility received a donation of mattresses from a hospital. RN-C indicated the hospital donated mattresses were a step up from their mattresses and R5 was a candidate for one of the donated mattresses. RN-C informed Surveyor after R5 developed the pressure injury she requested an air mattress and the air mattress was placed on 5/4/21. RN-C showed Surveyor an email dated 5/4/21 which indicates the mattress is being changed. Surveyor asked RN-C for the manufacturer's recommendation for the hospital donated mattress. Surveyor asked RN-C why R5's pressure injury wasn't assessed for 3 days. RN-C informed Surveyor she didn't know if there was a supervisor to do that over the weekend. Surveyor informed RN-C R5's physician wasn't notified of the pressure injury until 2 days later on 4/25/21 and a treatment wasn't obtained until 4/26/21. Surveyor asked RN-C why R5 developed the unstageable pressure injury. RN-C informed Surveyor R5's appetite varies, pretty fragile, has a history of pressure injuries, scar tissue, very immobile and doesn't move around very much. Surveyor informed RN-C after R5 developed the pressure injury Surveyor did not note R5's care plan was revised. RN-C informed Surveyor she forgot to place the air mattress on the care plan and included this intervention today. Surveyor informed RN-C when R5's pressure injury declined there was no revision in the care plan. RN-C reviewed R5's care plan and informed Surveyor looks like I did not. On 7/19/21 at 11:49 a.m. Surveyor asked RN-C when she requested the air mattress for R5. RN-C informed Surveyor on 4/26/21 during their stand up meeting. Surveyor asked why R5's pressure injury wasn't identified until it was unstageable. RN-C informed Surveyor it should of been seen earlier. On 7/19/21 at 12:37 p.m. Surveyor reviewed the manufacturer's information for the Hill-Rom NP 100 Prevention Surface mattress. Surveyor noted documentation of The NP 100 prevention surface offers superior, yet affordable pressure redistribution. Designed by engineers and clinicians, this surface is comprised of high-density, multi-layered, multi-zoned foam with a shear liner and durable, soft, bi-stretch ticking to help protect the skin and enhanced patient comfort. The surface has RF welded seams to prevent fluid penetration and is easy-to-clean, stain-resistant and durable. Additionally, the NP 100 prevention surface is available with nano Ag+ technology: a safe, cost effect and long [MEDICATION(S)] method for protecting surfaces from stain and odor-causing bacteria, mold and mildew. Under at a glance includes Multi-zoned foam prevention surface allows for improved pressure redistribution points by area. The manufacturer's information provided to Surveyor did not include information as to whether this mattress is appropriate for a Resident with a unstageable pressure injury. On 7/19/21 at 1:02 p.m. Administrator-A and DON Director of Nursing)-B were informed of the above. 2.) R6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (minimum data set) with an assessment reference date of 4/23/21 documents a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. R6 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfer, and does not ambulate. R6 is at risk for pressure injury development and is coded as not having any pressure injuries. The at risk for alteration in skin integrity care plan initiated & revised on 5/13/21 documents an intervention dated 5/3/21 of Protect heels. Bilateral off loading boots when in bed. Remove for cares/skin inspection and therapy. float heels if refuses to wear boots. The Braden assessment dated [DATE] documents a score of 16 which indicates at risk for pressure injury development. The CNA (Certified Nursing Assistant) Kardex as of 7/15/21 under the skin section documents Protect heels. Bilateral off loading boots when in bed. Remove for cares/skin inspection and therapy. float heels if refuses to wear boots. On 7/15/21 at 9:47 a.m. Surveyor observed R6 in bed on her back, wearing gripper socks with her heels resting directly on the mattress. Surveyor asked R6 if she was getting out of bed today. R6 informed Surveyor she is staying in bed. Surveyor inquired if staff puts anything under feet to keep her heels off the mattress. R6 pointed to the pressure relieving boots which were on top of boxes. Surveyor asked R6 why she wasn't wearing the pressure relieving boots now. R6 informed Surveyor staff puts them on in the afternoon. On 7/15/21 at 10:12 a.m. Surveyor observed CNA-E in R6's room. Surveyor asked CNA-E what she was planning to do. CNA-E replied cares and explained she was waiting for another staff. At 10:21 a.m. CNA-F entered R6's room to assist CNA-E. Surveyor observed personal cares for R6 with CNA-E & CNA-F until 10:45 a.m. During this observation neither CNA-E or CNA-F offered to place the pressure relieving boots on R6 or a pillow under her calves to float R6's heels. R6's heels were resting directly on the mattress at the completion of the observation. On 7/15/21 at 10:47 a.m. Surveyor asked CNA-E what else she will do for R6 today. CNA-E replied that's about it unless rings call light for snack or needs to be changed. On 7/15/21 at 11:14 a.m. Surveyor observed R6 continues to be in bed on her back with her heels resting directly on the mattress and is not wearing the pressure relieving boots. On 7/15/21 at 12:24 p.m. Surveyor observed R6 in bed on her back with the head of the bed elevated. R6's heels continue to be resting directly on the mattress and R6 is not wearing any pressure relieving boots. On 7/15/21 at 3:03 p.m. Surveyor observed R6 in bed on her back with her heels resting directly on the mattress watching Judge [NAME]. R6's heels were not being offloaded and R6 was not wearing pressure relieving boots. Surveyor noted R6's pressure relieving boots were still on top of the boxes. Surveyor asked R6 if anyone asked her about wearing her pressure relieving boots. R6 replied no. On 7/19/21 at 7:26 a.m. Surveyor observed R6 in bed on her back wearing gripper socks on her feet with her heels resting directly on the mattress. R6 was not wearing the pressure relieving boots and the boots continue to be on the boxes near the foot of R6's bed. On 7/19/21 at 11:03 a.m. Surveyor observed R6 in bed on her back with the head of the bed elevated. R6's heels are resting directly on the mattress and are not being offloaded. Surveyor observed R6 is not wearing the pressure relieving boots. On 7/19/21 at 11:04 a.m. Surveyor asked CNA-G if she is assigned to R6 today. CNA-G informed Surveyor she was. Surveyor asked CNA-G when does R6 wear the pressure relieving boots. CNA-G replied when in bed and then indicated R6 does refuse. Surveyor asked CNA-G if she asked R6 today about wearing the pressure relieving boots. CNA-G replied no but I can. On 7/19/21 at 1:02 p.m. Administrator-A and DON Director of Nursing)-B were informed of the above.

Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation), for 2 (R1 & R2) of 3 residents reviewed, in accordance with the resident's advance directives. This deficient practice has the potential to affect 48 of 75 residents residing at the facility whom were full code and desired CPR per their advance directives. - On [DATE] R2 was found by nursing staff to be pulseless and not breathing. Nursing staff did not initiate CPR despite R2's advance directives and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - On [DATE] R1 was found by nursing staff to be pulseless and not breathing. Nursing staff did not initiate CPR despite R1's advance directives and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to ensure that R1 & R2 received basic life support, including CPR, in accordance with their advance directives and wishes created a finding of Immediate Jeopardy beginning on [DATE]. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy finding on [DATE] at 11:10 a.m. The facility removed the immediacy on [DATE] with the implementation of their action plan. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement their plan. Findings include: The facility's policy dated as revised [DATE] and titled Advance Directives documents, Purpose: To ensure that the Advanced Directives for all residents are individualized by for that resident, documented, and effectively implemented at the facility. Residents without an advanced directive or DNR (Do Not Resuscitate) order, full CPR is performed unless clinically contraindicated; Policy: It is the policy of [NAME] Senior Care that all facilities will ensure: 1) A code status form and/or POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Completed form will be placed in the front of each resident's chart or in a separate binder as soon as possible after admission to be easily accessible to all staff; 5) If a resident becomes unresponsive (either witnessed or unwitnessed) the resident's Advanced Directives / POLST will be followed; 6) CPR is to be initiated unless: a.) obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or b.) initiating CPR could cause injury or peril to the rescuer. Procedure: If a resident is FULL CODE the following applies: 1. Determine unresponsiveness by shouting Are you okay and/or gently shaking or tapping resident; 2. If no response, call for help of other staff members; 3. Instruct other staff responding to scene to obtain emergency supplies, including AED (Automated External Defibrillator) if available, and notify [DATE] or emergency personnel. DO NOT leave resident; 4. If resident is not face-up, re-position to a face-up position while supporting head, neck and back. To perform CPR ensure resident is placed on a backboard or hard surface; 5. Check resident for breathing or gasping of breath while simultaneously checking for pulse. If either or both are absent initiate CPR; 6. Follow CPR instructions as per American Healthcare Association Healthcare Provider steps (see attached) 7. When EMS (Emergency Medical Services) arrives, they become lead in the resuscitation effort. Follow their directives. 1.) R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Admission MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 0, indicating that R2 was severely cognitively impaired. R2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Emergency Resuscitation Guidelines dated [DATE] documents, The following boxes were checked, indicating R2's wishes: Recommended Action: Call 911, CPR (Cardiopulmonary Resuscitation), Medical Response Will Provide: Full Treatment as appropriate. Surveyor noted that R2's Emergency Resuscitation Guidelines document was signed by R2's POA (Power of Attorney) on [DATE] and R2's physician on [DATE]. R2's nursing note dated [DATE] documents, Writer received verbal consent for resident to be full code per POA. POA to come [DATE] ~ (approximately) 1030 (10:30 AM) to sign form. R2's nursing note dated [DATE] documents, Signed code status form received from POA, placed in MD (medical doctor) box for signature. R2's nursing note dated [DATE] at 7:42 a.m. and written by RN (Registered Nurse)-E documents, One of the staff notified me that it appears that the resident was not breathing. On getting to her room, the resident was assessed, and she had no pulse, no heart beat was noted when listened. Doctor was updated through text message, not to reply, her POA- daughter was updated and DON (Director of Nursing) was updated. First shift nurse will follow up with the family to find out their arrangement with the funeral home. Surveyor was unable to locate any documentation in R2's medical record that documented that CPR (Cardiopulmonary Resuscitation) was performed by facility staff on R2 per R2's advance directives. Surveyor was unable to locate any documentation that R2's condition had been assessed by an RN, CPR was initiated and or that 911 had been called to provide additional life support to R2, per R2's advance directives. Surveyor was also unable to locate any assessment performed by RN-E or any contemporaneous documentation that R2 did not require CPR due to the presence of rigor mortis, decapitation, dependent lividity or decomposition. On [DATE] at 12:55 p.m., Surveyor interviewed RN-E regarding the above events. Surveyor read RN-E the nursing note he (RN-E) wrote on [DATE] and asked RN-E if he had performed CPR on R2 when he was informed that R2 was not breathing and had no pulse on [DATE]. RN-E informed Surveyor that he could not recall if he performed CPR on R2 on [DATE] and informed Surveyor that when resident's expire and are full code, he usually calls 911 and begins CPR. RN-E again informed Surveyor that he could not recall if he performed CPR on R2 on [DATE]. On [DATE] at 2:56 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. Surveyor asked Administrator-A and DON-B if the facility had any staff statements, assessments and or documentation as to why R2 did not receive CPR per his advance directives on [DATE]. DON-B informed Surveyor that she believed that at the time of R2's death, the facility was attempting to change R2's code status from full to DNR (Do Not Resuscitate) but that she was unsure if that had actually occurred. DON-B informed Surveyor that she would review R2's medical record and speak with staff and let Surveyor know. On [DATE] at 8:01 a.m., Surveyor interviewed CNA (Certified Nursing Assistant)-I regarding the above events. Surveyor asked CNA-I if she had informed RN-E that R2 was not breathing or had a pulse on [DATE]. CNA-I informed Surveyor that she informed RN-E that R2 was not breathing or had a pulse on [DATE]. CNA-I informed Surveyor that she last observed R2 to be alive at around 2:10 a.m. when she completed toileting cares on R2. CNA-I informed Surveyor that at the time, R2 was alive and that she (CNA-I) did not notice anything out of the ordinary in R2 and that R2 appeared in no distress. CNA-I informed Surveyor that around 4:35 a.m., she went in to check on R2 and found R2 to be not breathing and not responding. CNA-I informed Surveyor that she noticed R2 was cold and stiff and informed Surveyor that upon noticing this she (CNA-I) went and immediately informed RN-E. Surveyor asked CNA-I if she had witnessed RN-E began CPR on R2 and or if 911 was called for R2. CNA-I informed Surveyor that she did not witness anyone begin CPR on R2 and informed Surveyor that she did not see anyone call 911 or arrive to the facility from the fire department. On [DATE] at 8:40 a.m., DON-B informed Surveyor that the facility had obtained statements from staff and that due to R2 being found in rigor mortis, facility staff had not performed CPR on R2. The facility provided Surveyor with written statements signed and obtained on [DATE] from CNA-I, RN-E and RN-J. CNA-I's statement with no date documents, I did walking round on R2 at 10:35 p.m. I did care's on R2 at 12:15 a.m. I did cares on R2 at 2:10 a.m. When I went in R2's rom to do my last round at 4:35 a.m. R2 appeared to not be breathing and stiff and I immediately got the nurse and the nurse went straight in R2's room. RN-E's statement signed on [DATE] documents, I was confronted by CNA-I that R2 was not breathing. When I entered the room she was cold, stiff and pale. I went and called RN-J to verify that R2 had rigor mortis. RN-J verified that R2 was stiff, cold and pale. RN-J's statement signed on [DATE] documents, RN-E called me to verify that R2 had rigor mortis set in. When I went into the room R2 was stiff and cold especially on upper and lower extremities. Surveyor noted that the facility did not provide any contemporaneous documentation and or assessment from RN-E or RN-J documenting that R2 did not require CPR due to the presence of rigor mortis, decapitation, dependent lividity or decomposition. Surveyor informed Administrator-A and DON-B that the above statements did not include an assessment of R2's condition at the time R2 was found on [DATE]. No additional information was provided why the facility did not provide R2 with basic life support, including CPR, in accordance with the R2's advance directives and wishes. 2.) R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Significant Change in Condition MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 14, indicating that R1 was cognitively intact. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Advance Directive care plan dated as initiated on [DATE] documents under the Focus section, R1 has advance directives/code status in place. Under the Intervention section it documents, Code Status: Full code. R1's nursing note dated [DATE] at 12:00 p.m. documents, Health Status Note: Res (Resident) having c/o (complains of) cough and [MEDICATION(S)]. Cough medication given. R1's nursing note dated [DATE] at 2:05 p.m. and written by LPN (Licensed Practical Nurse)-D documents, Counting narcotics with LPN (Licensed Practical Nurse)-C, oncoming nurse and resident coming up hall verbalized that resident was on the floor. Resident on his stomach. LPN-C went to check vitals while this nurse went to nurse's station and called 911. Gave information to 911. Made copies of MAR (Medication Administration Record) and transfer information. Nurse called Optum and received order to send resident to ER (emergency room ) . Went to resident's room and firemen and paramedics performing CPR (Cardiopulmonary Resuscitation). R1's nursing note dated [DATE] at 6:31 p.m. and written by LPN-C documents, This LN (licensed nurse) was notified by a resident that was on the floor. This LN along with Day shift LN went into room to assess, upon seeing resident Day shift LN (LPN-D) stated to send out this LN agreed. Day shift LN went to desk to place call to paramedics. This LN assess resident further, Resident was lying face down perpendicular to bed, laying in emesis of dark brown color emesis still wet not dry. [CONDITION(S)] intact. No pulse was noted, did have respirations 10 per min (minute) very shallow, upon seeing no rise or fall of ribcage, this LN further listen for lung sound no air movement noted and no heart beat noted. At this time approx. (approximately) 1415 (2:15 p.m.), fire department and paramedics came in started CPR. Paramedics along with fire department called time of death at 1438 (2:38 p.m.). Police department came in after this, and medical examiner clear for release of body . Order received to release body to funeral home. The facility's self-report as submitted to the state agency on [DATE] documents, Resident was found on the floor at approximately 2:15PM on [DATE]. 911 was called and he ultimately passed away. A staff person felt that the nurse did not respond appropriately. The nurse has been placed on administrative leave while the incident is being investigated. It was reported to DON that Resident passed at the facility and some staff are stating the nurses that were working with Resident did not respond to the situation appropriately/timely. The facility self-report includes statements from both LPNs whom responses to R1's change in condition and statements from 3 CNAs (Certified Nursing Assistants) whom were present during the event. CNA-F's written statement documented: LPN-D asked CNA-H and I to go into the room with LPN-C. LPN-C wanted to get him into bed and I said we should leave him like he is until paramedics got there and said, I'm not telling you how to do your job. LPN-C did an assessment and he had respirations. His skin was really pale. We went and got towels so we could clean him up. CNA-H did state that his lips were turning blue. On [DATE] at 1:47 a.m., Surveyor interviewed CNA-F regarding the above events. Surveyor asked CNA-F to review her above statement and confirm its accuracy. CNA-F reviewed her above statement and confirmed to Surveyor its accuracy. CNA-F informed Surveyor that she went into R1's room with CNA-H and that she observed R1 lying face down on the floor breathing. CNA-F informed Surveyor that she did not observe LPN-C roll over R1 and that she observed R1's lips to begin turning blue while he was on the floor. CNA-F informed Surveyor that she asked LPN-C if R1 should get oxygen and that LPN-C informed her that they should clean R1 up as R1 had a brown emesis around him. CNA-F informed Surveyor that she then told LPN-C that they should not touch R1 and wait for paramedics to arrive. CNA-F informed Surveyor that LPN-C then left R1's room and that she was gone for approximately two to three minutes. Surveyor asked CNA-F if at any time she observed any facility staff member begin CPR on R1. CNA-F informed Surveyor that she did not observe any staff member began CPR on R1. Surveyor asked CNA-F if any staff member had turned R1 over and or provided R1 with oxygen. CNA-F informed Surveyor that no staff member turned R1 over and that no one provided R1 with oxygen. CNA-H's written statement said: .When R1 fell , CNA-F and I were asked to go into the room with LPN-C by LPN-D. After we saw him we went to grab some towels to clean him up. LPN-C took vitals and I did see his chest rise and fall and his wrist move. LPN-C went out to get a stethoscope and I noticed that the resident's lips were turning blue. When LPN-C came back to check his pulse again, I told her his lips are turning blue and does he need some oxygen. The paramedics came in very shortly after LPN-C came back. On [DATE] at 11:23 a.m., Surveyor interviewed CNA-H regarding the above events. Surveyor asked CNA-H to review her above statement and confirm its accuracy, which she did. CNA-informed Surveyor that she was called into R1's room and observed R1 laying on the ground prone with a brown emesis around him. CNA-H informed Surveyor that CNA-F told LPN-C to not touch R1 and that LPN-C was not aware of the procedures of what to do when residents fell . CNA-H informed Surveyor that she did observe R1 to have chest rise and fall and observed R1's lips turning blue. CNA-H informed Surveyor that she observed LPN-C leave the room for approximately two minutes and that when she (LPN-C) returned, paramedics arrived and began CPR on R1. Surveyor asked CNA-H if at any time she observed any facility staff member begin CPR on R1. CNA-H informed Surveyor that she did not observe any staff member began CPR on R1. Surveyor asked CNA-H if any staff member had turned R1 over and or provided R1 with oxygen. CNA-H informed Surveyor that no staff member turned R1 over and that no one provided R1 with oxygen. LPN-D's written statement included: .I went back early on lunch because LPN-C the second shift nurse came in .LPN-C then said, Do you want to give me report? LPN-D then gave him report. A resident was rolling down the hallway and then pointed to R1's room and said He fell . Both nurses went down there. LPN-D said, I could have left because was done with him and gave him report, but I still went down with her (LPN-C). I (LPN-D) ran down there, saw his color, and said, I'm calling 911. LPN-C then stayed in the room with him. LPN-C then reported to LPN-D that respirations were at 10. I then gave the phone to LPN-C and ran downstairs to make copies of his (R1) face sheet and medications. When I came back up with papers, I asked where LPN-C was told I think she's in the room. Paramedics were getting off the elevator at that time and went into the room and asked is he a full code, I didn't see it on the face sheet and ran back and asked Is he a DNR or full code I yelled down the hallway then he's a full code. LPN-D stated she did not initiate or think to start CPR because she immediately left the room to call 911 and thought he was alive. LPN-C remained in the room to do the assessment. I called 911 and got the papers printed. On [DATE] at 10:43 a.m., Surveyor interviewed LPN-D regarding R1's change in condition on [DATE]. LPN-D informed Surveyor that when she was informed R1 was on the floor she and LPN-C went down to R1's room and that she observed R1 laying on the ground. LPN-D informed Surveyor that she left LPN-C with R1 and left to call 911. Surveyor asked LPN-D if she called for a CPR crash cart or observed anyone began CPR on R1. LPN-D informed Surveyor that she did not call for a CPR crash cart and that she did not observe anyone begin CPR on R1 because she still believed that R1 was alive when she observed him (R1) on the ground. LPN-C's written statement said: LPN-D and I were counting a little after 2 PM, as soon as we finished narc (narcotics) count, a resident waived (sic) us down and let us know someone is on the floor. So both LPN-D and I head down that way. We both see R1 face down perpendicular to the bed. You could see his rib cage that he was breathing. LPN-D said we should send him out. I said ok I'll finish assessing him if you call. I did see rising of the rib cage about 10 per minute, but couldn't find a pulse. I saw the rib cage stopped moving and went to get my stethoscope and by the time I returned paramedics were there shortly after and initiated CPR. LPN-C stated she didn't think to start CPR at the time because he (R1) was alive. I eventually would have called for oxygen and initiated CPR if the paramedics wouldn't have shown up right after my assessment. On [DATE] at 2:35 p.m., Surveyor interviewed LPN-C regarding R1's change in condition on [DATE]. Surveyor asked LPN-C to review her above statement and confirm its accuracy. LPN-C reviewed her above statement and confirmed to Surveyor its accuracy. LPN-C informed Surveyor that on [DATE] she and LPN-D were informed by another resident that R1 had fallen. Upon arriving to his room, LPN-C informed Surveyor that LPN-D told her (LPN-C) that she was calling 911 to send R1 and that she (LPN-C) stayed with R1 to assess him. LPN-C informed Surveyor that she observed R1 to be prone on the ground with brown emesis around him. LPN-C informed Surveyor that she observed R1 to still be breathing and observed R1 to have chest rise and fall. LPN-C informed Surveyor that R1 was not responsive to verbal or painful stimuli and that she observed R1's breathing to be decreasing and then stopped. LPN-C then informed Surveyor that when she observed R1's breathing to stop, she left R1's room to go get her stethoscope to confirm that R1 was no longer breathing. Surveyor asked LPN-C if she ever rolled over R1 and or performed CPR on R1 on [DATE]. LPN-C informed Surveyor that she wanted to roll over R1 but that CNA-F had informed her that it was best to leave R1 alone on the floor. LPN-C informed Surveyor that she did not perform CPR on R1. Surveyor asked LPN-C why she did not begin CPR on R1 when she observed R1 to stop breathing and no longer have chest rise and fall. LPN-C informed Surveyor that she did not begin CPR on R1 when she observed R1 to stop breathing because she second doubted herself and wanted to confirm with her stethoscope that R1 was no longer breathing. At the conclusion of the interview, Surveyor asked LPN-C if she had any questions for Surveyor. LPN-C asked Surveyor if the facility policy stated that residents were to be rolled over to perform CPR. Surveyor informed her that the facility policy (listed above) documented that residents should be rolled over to perform CPR. LPN-C then asked Surveyor if she (LPN-C) needed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor informed LPN-C that the facility had emergency guidelines in place and that she should speak with administration to get clarification. LPN-C then asked Surveyor where the oxygen concentrator and the crash (emergency equipment) cart was located in case that CPR was needed on a resident. Surveyor then walked over with LPN-C and showed her where the CPR/Emergency Equipment cart was located on the unit. LPN-C thanked Surveyor and informed Surveyor that she did not previously know (prior to Surveyor showing her) where the CPR/Emergency Equipment cart had been located. Surveyor asked LPN-C if she had performed any CPR/Emergency drills at the facility so that she became familiar with the CPR/Emergency Equipment cart and the facility's emergency/CPR policies. LPN-C informed Surveyor that she had not previously participated in any emergency/CPR drills at the facility. On [DATE] at 2:56 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. Surveyor requested any additional information the facility may have regarding R1's change in condition on [DATE]. DON-B informed Surveyor that she would review R1's medical record and let Surveyor know. DON-B provided Surveyor with a copy of CPR drills that the facility conducted on [DATE], [DATE] [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Surveyor noted and pointed out to DON-B that the drill sheets did not include all three shifts and that the drill sheets did not list or have any staff names or signatures listed on them, making it impossible for Surveyor to know who was present during the drills. On [DATE] at 8:45 a.m., DON-B provided Surveyor with a copy of a text message between her (DON-B) and LPN-C. The text message that was printed on an email dated [DATE] with no specific time stamps documents, Question (DON-B)- you really did not know where the crash cart was until today? And also, two of the drills were done on your shift on days you worked; Response (LPN-C): I knew where the crash cart was but honestly I have never really looked at it and totally passed my mind that there is oxygen on it too. DON-B informed Surveyor that LPN-C had been previously shown where the crash (CPR/Emergency) cart was and that LPN-C was being dishonest when she told Surveyor that she did not participate in CPR drills. DON-B informed Surveyor that LPN-C had been working when CPR drills had occurred and would look for documentation that showed she (LPN-C) participated in a drill. At the time, no additional information was provided by Administrator-A or DON-B. No additional information was provided why the facility did not provide R1 with basic life support, including CPR, in accordance with the R1's advance directives and wishes. The facility's failure to ensure R1 and R2 received CPR per R1's advance directives and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility removed the immediacy on [DATE] when the implemented the following steps: - All clinical staff were educated on change of condition, notification to RN on change in condition, completing an assessment on residents with a change in condition and documenting code response/CPR response, locations of emergency equipment and timely documentation requirements. - Policies and procedures for advance directives, code status and change in condition were reviewed. - Code drills were implemented and continued on every shift until all staff have successfully participated. Post-test competencies were obtained to verify knowledge retention. Change in condition (Rapid Response) drills were implemented and continued on every shift until all staff have successfully participated. - Code status audits to be completed weekly x (for) 4 weeks, then monthly x 2 months, results will be reviewed in QAPI (Quality Assurance and Performance Improvement).

Based on record review and interview, the facility did not ensure that 1 (R1) of 3 sampled residents received assessment and appropriate medical care when R1 experienced a significant change in her medical condition and complained about chest pain, difficulty breathing and not feeling well. The licensed practical nurse (LPN) did not collect data and did not ensure an RN assessment of a resident experiencing a significant change in condition. These failures created a finding of Immediate Jeopardy beginning on [DATE]. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy finding on [DATE] at 11:10 a.m. The facility removed the immediacy on [DATE] with the implementation of their action plan. The deficient practice continues at a scope and severity of D (potential for more than minimal harm/widespread) as the facility continues to implement their plan. Findings include: According to N6.04(1)(e)1 of the Wisconsin Nurse Practice Act, a licensed practical nurse (LPN) shall Assist with the collection of data. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Significant Change in Condition MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 14, indicating that R1 was cognitively intact. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Advance Directive care plan dated as initiated on [DATE] documents under the Focus section, R1 has advance directives/code status in place. Under the Intervention section it documents, Code Status: Full code. R1's nursing note dated [DATE] at 12:00 p.m. documents, Health Status Note: Res (Resident) having c/o (complains of) cough and [MEDICATION(S)]. Cough medication given. The facility's self-report dated as submitted to the state agency on [DATE] documents, Resident was found on the floor at approximately 2:15PM on [DATE]. 911 was called and he ultimately passed away. A staff person felt that the nurse did not respond appropriately. The nurse has been placed on administrative leave while the incident is being investigated. It was reported to DON (Director of Nursing) that Resident passed at the facility and some staff are stating the nurses that were working with Resident did not respond to the situation appropriately/timely. The facility self-report includes statements from both LPNs who responsed to R1's change in condition and statements from 3 CNAs (Certified Nursing Assistants) who were present during the event. The statements document: CNA-G's written statement noted: R1 did not eat Saturday saying he was in pain in his abdomen and didn't eat .On Sunday [[DATE]], I went to wash him up. R1 said to me, Can you tell the nurse it [CONDITION(S)] when I breath (sic) and hurts to breath (sic) and I'm coughing up all this junk. I went to tell LPN-D, and LPN-D said Why does everything get kicked to me, why didn't noc (night) shift handle that. Then I said I know, but now it's on you. Then I went on to do my work. Went in there (R1's room) for lunch, and he (R1) didn't eat his lunch but wanted me to leave it. I took another resident to the bathroom . then I told LPN-D, It's 1:,d+[DATE]:45 (PM), they should be good until second shift. I did a walk through and everyone was good, then I left. On [DATE] at 1:37 p.m., Surveyor interviewed CNA-G regarding the above events. Surveyor asked CNA-G to review her above statement and confirm its accuracy, which she did. CNA-G informed Surveyor that she was not present when R1 fell . CNA-G informed Surveyor that on the morning of [DATE], she was in R1's giving R1 his breakfast tray when R1 informed her that it 'burned when he breathed and that his chest hurt' and to please let LPN-D know. CNA-G informed Surveyor that CNA-H witnessed telling LPN-D this. CNA-G informed Surveyor that she did not see if LPN-D went in and evaluated R1 as she continued her work. CNA-G informed Surveyor that she again saw R1 during lunch when she noticed that R1 did not eat his lunch tray. CNA-G informed Surveyor that R1 directed her to leave his lunch tray in his room and that shortly after she left the facility. CNA-H's written statement noted: Earlier that day, I would say around 0830 (8:30 AM), CNA-G went to tell LPN-D that R1 was breathing funny. I can't tell you if LPN-D went in and did anything because I was doing my job . On [DATE] at 11:23 a.m., Surveyor interviewed CNA-H regarding the above events. Surveyor asked CNA-H to review her above statement and confirm its accuracy. CNA-H reviewed her above statement and confirmed to Surveyor its accuracy. Surveyor asked CNA-H if she had observed CNA-G tell LPN-D that R1 was not feeling well. CNA-H informed Surveyor that she observed CNA-G tell LPN-D that R1 was breathing funny but that she did not see if LPN-D checked on R1 as she was busy with other residents. LPN-D written statement said: I had a hall and a half and completed first med (medication) pass. CNA-G approached me and she stated he (R1) wasn't feeling well and had a cough, when I went in on first med (medication) pass he didn't say anything . I did R1 first, he showed me a med cup and said, I'm trying to cough this up, and then he asked for cough medication. I then gave him cough medication and his other medications. I then went down to the other hallway to pass medications and help with the other assessments . On [DATE] at 10:43 a.m., Surveyor interviewed LPN-D regarding R1's change in condition on [DATE]. Surveyor asked LPN-D to review her above statement and confirm its accuracy. LPN-D reviewed her above statement and confirmed to Surveyor its accuracy. Surveyor asked LPN-D if she was informed by CNA-G that R1 was having difficulty breathing. LPN-D confirmed to Surveyor that CNA-G informed her (LPN-D) that R1 was not feeling well and coughing up phlegm. LPN-D informed Surveyor that R1 came up to her during her medication pass and handed her a medication cup that had phlegm in it. LPN-D informed Surveyor that that she then gave R1 cough medicine and continued her medication pass. Surveyor asked LPN-D if she performed an assessment on R1 after she was informed by CNA-G that R1 was not feeling well and coughing up phlegm. LPN-D informed Surveyor that she did not perform an assessment on R1 because she observed R1 to be fine and R1 did not voice any problems or complaints to her. Surveyor asked LPN-D if she evaluated R1's breathing and effectiveness of the medication after she administered cough medicine to R1. LPN-D informed Surveyor that she did not perform any assessment on R1. Surveyor asked LPN-D if she went into R1's room to check on R1 after administering cough medicine to R1. LPN-D informed Surveyor that she did not go into R1's room to check on R1. LPN-D informed Surveyor that she did observe R1 sitting on his bed as she walked by his room when returning from her medication pass. Surveyor asked LPN-D if it was normal for R1 to be coughing up phlegm or having respiratory issues. LPN-D informed Surveyor that she knew R1 well, as she was his smoking buddy and that it was not normal for R1 to be coughing up phlegm or having respiratory issues. Surveyor asked LPN-D why she did not notify an RN about R1 not feeling well and or having difficulty breathing. LPN-D informed Surveyor that at the time, there was no RN working in the building and that R1 looked fine to her. Surveyor asked DON-B why LPN-D had not completed an assessment on R1 when CNA-G informed her R1 was not feeling well and having difficulty, and before and after administering cough syrup to R. DON-B informed Surveyor that she could not provide any information at this time. On [DATE] at 2:56 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. Surveyor requested any additional information the facility may have regarding R1's change in condition on [DATE]. DON-B informed Surveyor that she would review R1's medical record and let Surveyor know. No additional information was provided why the facility did not provide R1 with an assessment and appropriate medical care when R1 experienced a significant change in her medical condition. R1's nursing note dated [DATE] at 2:05 p.m. and written by LPN (Licensed Practical Nurse)-D documents, Counting narcotics with LPN (Licensed Practical Nurse)-C, oncoming nurse and resident coming up hall verbalized that resident was on the floor. Resident on his stomach. LPN-C went to check vitals while this nurse went to nurse's station and called 911. Gave information to 911. Made copies of MAR (Medication Administration Record) and transfer information. Nurse called Optum and received order to send resident to ER (emergency room ) . Went to resident's room and firemen and paramedics performing CPR (Cardiopulmonary Resuscitation). R1's nursing note dated [DATE] at 6:31 p.m. and written by LPN-C documents, This LN (licensed nurse) was notified by a resident that was on the floor. This LN along with Day shift LN went into room to assess, upon seeing resident Day shift LN (LPN-D) stated to send out this LN agreed. Day shift LN went to desk to place call to paramedics. This LN assess resident further, Resident was lying face down perpendicular to bed, laying in emesis of dark brown color emesis still wet not dry. [CONDITION(S)] intact. No pulse was noted, did have respirations 10 per min (minute) very shallow, upon seeing no rise or fall of ribcage, this LN further listen for lung sound no air movement noted and no heart beat noted. At this time approx. (approximately) 1415 (2:15 p.m.), fire department and paramedics came in started CPR. Paramedics along with fire department called time of death at 1438 (2:38 p.m.). Police department came in after this, and medical examiner clear for release of body . Order received to release body to funeral home. Surveyor was unable to find any data gathered by LPN-D concerning R1 (e.g., vital signs, heart of lung sounds) by LPN-D at any time on [DATE] in R1's medical record, including any evaluation of the effectiveness of the cough syrup that was given. Surveyor was unable to locate any assessment of R1 by an RN (Registered Nurse) at any time on [DATE]. Failure to monitor vital signs, to listen to the resident's heart and lungs, and to ensure RN assessment of a resident complaining of pain or burning pain when breathing, prevented staff from ascertaining as much about the resident's condition as possible, from differentiating possible causes, and from determining the potential seriousness of the symptom, given the many conditions with which it may be associated. According to Chest Burning Sensation, A burning feeling in the chest is a common symptom of heart conditions, lung problems, gastrointestinal disorders, and even panic attacks. Chest burning can result from heart pain due to spasm or lack of blood flow, pain in the esophagus due to heartburn or lung pain due to inflammation, or infection and musculoskeletal pain in the chest area. Heart conditions, such as [CONDITION(S)], pericarditis, or heart attack, are common causes of a burning sensation in the chest. Other causes include pulmonary embolism (blockage in a blood vessel in the lungs) that reduces blood flow to the lungs and leads to chest burning and pain. Pleurisy (inflammation of the lining around the lungs) may also cause a burning sensation in the chest .Chest burning sensation can be a sign of a serious condition https://www.healthgrades.com/right-care/symptoms-and-conditions/chest-burning-sensation The facility's failure to ensure that R1 was assessed and evaluated when he experienced a change in condition (complained about chest pain, difficulty breathing and not feeling well) created a situation of immediate jeopardy on [DATE]. The facility removed the immediacy on [DATE] when the implemented the following steps: - All clinical staff were educated on change of condition, notification to RN on change in condition, completing an assessment on residents with a change in condition and documenting code response/CPR response, locations of emergency equipment and timely documentation requirements. - All clinical staff were educated on requirement for RN documentation of assessment for changes in condition. Education to be completed with staff prior to next shift worked. - Resident 24 hours report logs were reviewed for potential changes in condition and follow up RN assessment verified for those instances. MD (Medical Doctor) Notification, POA (Power of Attorney) notification verified as well as care plan updates as indicated. - Policies and procedures for advance directives, code status and change in condition were reviewed. - Code drills were implemented and continued on every shift until all staff have successfully participated. Post-test competencies were obtained to verify knowledge retention. Change in condition (Rapid Response) drills were implemented and continued on every shift until all staff have successfully participated. - Change in condition audits to be completed 3 weekly x (for) for 1 month, then 2x weekly for 2 months, results will be reviewed in QAPI (Quality Assurance and Performance Improvement).

Based on observation, record review and interview, the facility did not ensure that 1 (R9) of 6 residents reviewed and at risk for developing pressure injuries received consistent measures to prevent the development of pressure injuries. * R9 developed an unstageable pressure injury at the facility as a result of laying on a call light cord. R9's pressure reducing mattress was also found to not be working per R9's plan of care. Findings include: R9 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Quarterly MDS (Minimum Data Set) dated 11/20/20 documents under section B0100 (Comatose) documents Yes indicating that R9 is in a persistent vegetative state and has no discernible consciousness. Section G (Functional Status) documents that R9 has total dependence and requires a two personal physical assist for his bed mobility and transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents that R9 has impairment to both sides of his upper and lower extremities. R9's Pressure Injury CAA (Care Area Assessment) dated 8/20/20 documents under the Care Plan Considerations section, Risk for impaired skin integrity care plan was developed with the overall goal for skin to remain intact without breakdown and be free from pressure related injury. Care plan interventions were added for Braden scale score and according to Braden scale flow chart. Additional interventions will be added as needed to maintain skin integrity. Staff will monitor for changes in B/B (bowel and bladder) and update toileting plan as needed. Staff will continue to complete Braden scale assessments as scheduled and prn. Staff will monitor for changes and add interventions as needed. Staff will monitor for changes in physical and medical conditions and report changes to MD (medical doctor). Care plan will be reviewed and updated as needed. R9's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 15, indicating that R9 is at risk for the development of pressure injuries. R9's Skin care plan dated as initiated on 10/30/15 documents under the Interventions section, Specialty air mattress; check for proper function q (every) shift; Date Initiated: 10/30/2015. R9's nursing note dated 1/30/21 documents, Health Status Note Text: PT (patient) has a nine centimeter bruise on the lower back side that is in the shape of a call light. R9's nursing note dated 1/31/21 documents, Health Status Note Text: Resident comatose with sleep wake cycles. Unable to make needs known to staff. Monitored for bruising/pressure area with break in skin to lower back/coccyx area. Scant bleeding present. Site deep purple in color. No apparent pain or discomfort noted. Resident turned and repositioned for pressure relief. Continues to be monitored per facility protocol. R9's nursing note dated 1/31/21 documents, Health Status Note Text: Noted dark purple pressure area remains on coccyx, resident positioned with pillows, barrier cream applied, no s\s (signs or symptoms) of pain, discomfort, all needs anticipated and met via staff. VSS (vital signs stable). R9's nursing note dated 2/1/21 documents, Health Status Note Text: Late entry for 1/31/21. Resident has a purple and cranberry mark to sacrum area . No s/s (signs or symptoms) of discomfort . No pain. R9's February 2021 MAR (Medication Administration Record) documents the following order, TX (treatment) TO SACRAL WOUND: NSW (normal saline wash) F/B (followed by) XEROFORM GAUZE AND A FOAM DRESSING. CHANGE DAILY AND PRN (as needed) every day shift; Order Date: 02/01/2021. R9's Wound Evaluation dated 2/3/21 documents, Pressure- Deep Tissue Injury; Length: 7.73 cm (centimeters); Width: 2.52 cm; Deepest Point: 0.1 cm; Notes: This DTI with a small open area is r/t (related to) inadvertent contact with a call light cord. A new tx (treatment) order was received and Resident is being repositioning (sic) side to side , on an air mattress and with off loading boots in place. R9's Skin & Wound Evaluation dated 2/3/21 documents, Stage: Deep Tissue Injury; Location: Sacrum; Acquired: In-House, Length: 7.7 cm (centimeters); Width: 2.5 cm; Depth: 0.1 cm; 80% Epithelial; 20% Granulation; Notes: This DTI (deep tissue injury) with a small open area is r/t (related to) inadvertent contact with a call light cord. A new tx (treatment) order was received and Resident is being repositioning side to side, on an air mattress and with off loading boots in place. R9's Wound Evaluation dated 2/9/21 documents, Pressure; Length: 4.3 cm; Width: 2.28 cm; Deepest Point: 0.1 cm; Notes: Wound MD (Medical Doctor)-E was in to see resident and assess the unstageable DTI (deep tissue injury) on his sacrum. There is an improvement noted this week as evidenced by a decrease in surface area. Will continue with current tx (treatment) plan with repositioning, air mattress and wound care. R9's Skin & Wound Evaluation dated 2/9/21 documents, Stage: Deep Tissue Injury; Location: Sacrum; Acquired: In-House, Length: 4.7 cm (centimeters); Width: 2.3 cm; Depth: 0.1 cm; Wound bed: 30% Epithelial; 70% Slough; Notes: Wound MD (Medical Doctor)-E was in to see resident and assess the unstageable DTI (deep tissue injury) on his sacrum. There is an improvement noted this week as evidenced by a decrease in surface area. Will continue with current tx (treatment) plan with repositioning, air mattress and wound care. Surveyor was unable to locate any care plan intervention that ensured staff did not leave the call light cord in R9's bed. On 2/10/21 at 8:49 a.m., Surveyor observed R9's wound treatment during wound rounds with Wound RN (Registered Nurse)-F. Wound RN-F informed Surveyor that R9's pressure injury started as a call light cord that was left underneath him (R9) which caused skin breakdown. During R9's wound treatment observation, Wound RN-F informed Surveyor that R9's wound was healing from the call light cord but that you could still see the brown skin outline from the cord. During the wound treatment, Surveyor observed R9's mattress to have a significant dip and Surveyor asked Wound RN-F if R9's mattress was functioning properly. Wound RN-F informed Surveyor that she has to watch R9's mattress as it deflates at times. Surveyor asked Wound RN-F if R9 needed a new pressure reducing mattress as the one he was on was deflated. Wound RN-F informed Surveyor that R9 needed a new mattress. On 2/10/21 at 10:09 a.m., Wound RN-F informed Surveyor that the facility is placing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/10/21 at 2:22 p.m., Surveyor informed Wound RN-F of the above findings. Surveyor asked Wound RN-F to confirm the cause of R9's pressure injury. Wound RN-F informed Surveyor that the cause of R9's pressure injury was due to a call light cord left in R9's bed that caused R9's skin breakdown. Surveyor asked Wound RN-F why R9's care plan did not include any interventions that ensured staff did not leave the call light cord in R9's bed. Wound RN-F informed Surveyor that she would update R9's care plan to include an intervention that reminded staff to not leave the call light cord in R9's bed. No additional information was provided as to why R9 did not have pressure relieving interventions in place to prevent the development of pressure injuries.

Based on interview and record review the facility did not ensure it recognized, evaluated and addressed the needs 1 (R322) of 4 residents at risk for impaired hydration. -R322 was admitted to the facility on [DATE] following a hospitalization for COVID-19 complications including [CONDITION(S)]. Hospital documentation indicates the resident as having decreased oral intake. Upon admission the facility did not assess R322's hydration status, did not develop a baseline care plan addressing risk factors R322 had for dehydration, and did not assess R322's fluid intake needs until 2/8/21, at which time were inaccurately calculated based on an inaccurate weight. Staff interview and documentation indicates the resident was having poor intakes. There is no documentation the physician was notified of R322 having poor oral intake. On 2/8/21, R322 was sent to the hospital following a lab indicating his sodium level was critically high. R322 was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The facility Hydration Policy, undated, states Adequate nutrition and hydration are essential for overall functioning. Water is essential to maintain adequate body functions. As a major component of blood, water dissolves vitamins, minerals, glucose, amino acids, etc.; transports nutrients into cells; removes waste from the cells; and helps maintain circulating blood volume as well as fluid and electrolyte balance. It is critical that each resident at risk for hydration deficit or imbalance .be identified and assessed to determine appropriate interventions .The purpose of this policy is to provide tools and guidance in the identification of fluid needs, recognition of potential for fluid deficit/dehydration to minimize the occurrence of dehydration and interventions for monitoring fluid intake as well as a protocol for ongoing monitoring of residents on fluid restrictions. Under PROCEDURE the policy states in part; 1. Upon admission, each resident will be assessed by the R.D. [registered dietitian] to determine estimated fluid needs and risk for dehydration. Fluid needs and risk for dehydration will be documented in the Registered Dietitian Nutritional Assessment . 4. Upon admission, Nursing will also assess physical status, including, but not limited to skin turgor, mucous membranes, urinary status and vitals to determine if resident has adequate hydration or risk factors are present. Results will be documented in the Admission/Re-admit screen. 5. Residents who already a resident in the building will be assessed for risk or symptoms of dehydration on a quarterly bases, or as needed if risk increases or symptoms are present . 7. Conditions that contribute to increased risk of dehydration include, but are not limited to the following: a. On a diuretic or increase in diuretic . c. Acute illness or fever . g. Poor fluid intake . h. Present of an infection (e.g. [CONDITION(S)] [urinary tract infection], URI [upper respiratory infection]) j. Dependence on staff for all fluids. 8. If resident is at elevated risk of dehydration or symptoms of fluid deficit/dehydration are present, resident will be immediately referred to the I-team and/or MD for further review and assessment. 9. Symptoms of dehydration include, but are not limited to the following: . c. Dry mucous membranes . e. Decreased urine output or concentrate urine. f. Change in ADL [activities of daily living] g. Increased confusion, weakness or h. Change in lab values (esp. [especially] electrolytes, BUN (blood urea [MEDICATION(S)]) and Creatinine). i. change in mental status . 10. If resident is at elevated risk of dehydration or symptoms of fluid deficit or dehydration are present, any or all of the following interventions will be implemented and the Care plan will be updated; a. MD notification b. Daily Intake and Output monitoring c. PUSH fluids order d. Daily weights e. Basic metabolic panel or other labs f. IV hydration g. Alert staff of increased fluid needs h. Monitor vitals per protocol i. Start resident on Hydration Program. 11. Prevention of dehydration is dependent on thorough assessment of risk factors and symptoms. Strategies for prevention include but are not limited to the following: a. Emphasis on the importance of hydration daily, including alternate sources of fluids b. Prompt reporting of symptoms, especially decrease in fluid intake, to nursing c. Awareness by all staff of risk factors and signs/symptoms of dehydration d. Encouragement of involvement by families and activity staff to promote fluid intake e. Availability of and provision of preferred beverages f. Providing adaptive cups or straws for resident to increase independence g. Assistance for those residents that are dependent h. Encouraging fluids with and between meals i. Regular medication review (esp. diuretics and laxatives). 12. Hydration Program to include the following interventions: A. update fluid preferences regularly. B. Review existing diet orders and liberalize if needed. C. Hold or reduce ABT [antibiotic] or diuretics if contributing to fluid losses. D. Provide 2-4 oz of fluid with each interaction. E. Schedule fluids with med pass and/or snack pass. F. Provide Gatorade or other re-hydration solutions as ordered by MD. G. Provide alternate fluid sources such as popsicles, ice cream, sherbert or pudding if fluids are not accepted. H. Monitor I & O [input and output] and adjust fluids as needed . l. Continue to update care plan as changes occur. Under RESPONSIBILTIES the policy states, Registered Dietitian: Completes assessment of fluid needs on admission, annually, with Significant Changes and as needed .Monitors hydration status by periodic review of intakes, labs, and physical status . Nursing Department: Ensures that residents are assessed for risk factors and symptoms of dehydration. Notified MD of changes in hydration status. Follows orders regarding fluid restrictions or Intake and Output monitoring and makes changes to Care Plan as appropriate. R322 was hospitalized [DATE]-[DATE] with a primary discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Active problems during the hospitalization included, [CONDITION(S)] (acute on chronic)-most likely due to [CONDITION(S)] from COVID-19 pneumonia in addition to probable baseline dementia. The hospital course documents, .History obtained primarily per brother and sister-in-law, confusion x5 days however states that patient has had a progressive cognitive decline over about the past 2 years. He reportedly lives alone currently. Also associated decreased oral intakes, weakness. The hospital documents R322's sodium levels to be 137 on 1/27/21, 140 on 2/1/21, 143 on 2/2/21 and 142 and 2/3/21. The hospital documents its reference range for normal levels of sodium to be 136-145. R322 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R322's medications included [MEDICATION(S)] (a diuretic) 20mg daily. Progress notes on 2/3/21 at 10:01 PM document .Appetite and Fluid intake: no issues noted An Admission Screener, signed as completed on 2/3/21, documents R322 required extensive assistance with eating. The screener documents, Resident has very dry skin on his lower extremities . The Admission Screener does not address R322's hydration status. On 2/3/21 a baseline care plan was developed. A focus area for The resident has potential for altered nutritional status r/t dx COVID pneumonia, [CONDITION(S)]. Poor dentition, resident does not wear dentures. Mechanically altered diet in place. Decreased appetite. BMI [body mass index] above standard. Interventions include, Eating-Provide assistance: Assist of one initiated on 2/4/21, Encourage small bites/sips and to eat/drink slowly initiated on 2/3/21, Fluids- Level 0 thin (regular) initiated on 2/3/21. R322's care plan did not address hydration status. The surveyor reviewed R322's medical record and was unable to find documentation of a hydration assessment completed when R322 was admitted to the facility on [DATE]. Progress notes on 2/4/21 at 05:38 AM document .Appetite and Fluid intake: Adequate intake and on thin liquids . A Baseline Nutrition Data Collection, with an effective date of 2/4/21 at 11:00 AM, documents, yes for Recent change in appetite or weight per resident or family? Under Explain it documents, Decreased appetite for roughly 2 weeks per family. The summary documents, Writer met with resident on today's date (2/4/21), resident appeared confused and unable to recall UBW [usual body weight] or how appetite has been. Writer spoke with resident's sister .who states that resident's appetite has been poor for roughly two weeks now. While hospitalized , appetite would vary day to day. Res was receiving Ensure TID [three times a day] d/t [due to] poor intakes. UBW [usual body weight] is around 230#. Pudding to be provided w/ [with] breakfast and yogurt w/lunch. The Data collection documents R322's most recent weight as 297. Progress notes on 2/4/21 at 11:10 AM document, .Resident appears alert and eager to converse. Conversation reflected some confusion at times Progress notes on 2/4/21 at 2:56 PM document, .Appetite and Fluid intake: adequate resident is a feeder . Progress notes on 2/4/21 at 5:00 PM document, .Resident is Alert, disoriented, but can follow simple instructions .Appetite is very poor. Very Poor: Never eats a complete meal. Rarely eats more than a bite of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO [nothing by mouth] and/or maintained on clear liquids or IVnoResident [sic] has no signs or symptoms of possible swallowing disorder. No notification required. No notification required Intervention [sic]: Continue to observe and monitor condition. Intervention: encourage to rest. Intervention: monitor weight as ordered . R322's plan of care charting documents under, Fluid intake at meals & PRN [as needed] under How much did the resident drink? (in mLs)'s documents R322 had 1,320 mLs on 2/4/21. Progress notes on 2/5/21 at 3:41 PM document .Emotional/Psychosocial Concerns: yelling out cussing, resistive with cares, hitting wall. Appetite and Fluid intake: poor PO [oral] intake . Progress notes on 2/5/21 at 5:00 PM document, .Appetite is very poor. Very poor: Never eats a complete meal. Rarely eats a complete meal. Rarely eats more than a bite of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO and/or maintained on clear liquids or IVnoResident [sic] has no signs or symptoms of possible swallowing disorder. No notification required. No notification requiredIntervention: [sic] Continue to observe and monitor condition. Intervention: encourage to rest. Intervention: monitor weight as ordered .Education provided to resident and/or family:yesEducation [sic] provided: nutrition and fluid intake. Progress notes on 2/5/21 at 5:05 PM document .Res [resident] is alert/oriented with noted baseline confusion. Prior to admission, resident was living at home alone without any prior cares R322's plan of care charting documents under, Fluid intake at meals & PRN [as needed] under How much did the resident drink? (in mLs)'s documents R322 had 480 mLs on 2/5/21, noting that the resident refused during the evening 2-10pm documentation. Progress notes on 2/6/21 at 5:00 PM document .Appetite is very poor .Continue to observe and monitor conditionno [sic] Progress notes on 2/6/21 at 10:09 PM document Active COVID Symptoms: malaise, confusion .Appetite and Fluid intake: poor . R322's plan of care charting documents under Fluid intake at meals & PRN [as needed] under How much did the resident drink? (in mLs)'s documents R322 had 1,120 mLs on 2/6/21. Progress notes on 2/7/21 at 5:00 PM document .Appetite is very poor .Continue to observe and monitor condition. Intervention: encourage to rest. Intervention: monitor weight as ordered .Intervention: maintain prescribed diet. Intervention: Monitor vital signs . Progress notes on 2/7/21 at 10:40 PM document, [MD] was updated re strong urine and resident more confused. New order for ua [urine analysis] C and S [culture and sensitivity obtained. Urine was obtained and lab was called for pickup . Progress notes on 2/7/21 at 10:42 PM document, Active COVID Symptoms: Confused poor appetite ADL/functional declines or recent falls noted: requires complete assist .Appetite and Fluid intake: poor . R322's plan of care charting documents under, Fluid intake at meals & PRN [as needed] under How much did the resident drink? (in mLs)'s documents R322 had 1080 mLs on 2/7/21. Progress notes on 2/8/21 at 10:06 AM document, Writer went in to resident's room multiple times due to resident pulling off gown and appearing restless. Resident did not appear to be in any pain. Shook head no when writer asked. Writer attempted to put gown back on resident, fixed bed sheets and covered resident up. Writer gave resident some water and he appeared to calm down some . Progress notes on 2/8/21 at 2:12 PM document, 81 y/o [year old] male admitted with dx [diagnosis] including [CONDITION(S)], DM2 [diabetes mellitus type 2] COVID 19, PNA [pneumonia], dementia. Diet is Regular, Level 7 Easy to chew, Level 0 thin liquids. Has dentures but does not wear. Meal intakes are 26-100%, mostly 26-75%, with the exception of today) refused both breakfast and lunch). Wt [weight] 297# [pounds] question this admission weight as his family report UBW [usual body weight] 230#. Hospital wts [weights] 207.8# (on d/c [discharge] summary and 216.5#. His family reports poor appetite x2 weeks. He had Ensure TID [three times a day] in hospital r/t [related tp] his appetite .Recommending Medpass Readycare 2.0 120mL TID between meals for nutritional support. Intakes, weights, and blood sugars will be followed for supplement (frequency and amount) appropriateness. It is noted that d/t [due to] sodium level, resident is being sent out to the hospital at this time. Will review and f/u [follow up] as indicated upon readmis [readmission]. A Registered Dietitian Nutrition Assessment, with an effective date of 2/8/21 at 2:21 pm documents R322's estimated fluid requirements as 1841. The assessment documents R322's average fluid intakes at meals as <[less than] 1200ccs. The assessment documents dehydration risk factors as infection, receiving diuretics, and poor fluid intake at meals. The assessment documents other potential risk factors to hydration as assist with ADLS and confusion. The assessment documents yes for symptoms of dehydration being present. The assessment documents drop in blood pressure and NA [sodium] 157 lab as symptoms present. The assessment documents no for Does intake of meals, supplements, other meet estimated minimum needs? The comments document recommending Readycare 120mL TID. Under Recent unplanned weight change? the assessment documents yes with comments stating UBW 230#, hospital d/c wt 207.8# shows ;10.6%. Await another facility wt to verify. The surveyor noted this is the first assessment identifying R322's fluid needs since his admission on 2/3/21. The surveyor noted this is the first assessment to document assessment of signs and symptoms of dehydration. Progress notes on 2/8/21 at 2:45 PM document, Resident had critical lab for Sodium chloride 157. Call out to [MD-N]. Answering machine on, left message. Resident continue to yell out . Progress notes on 2/8/21 at 3:28 PM document, Writer updated [MD-N] re [regarding] critical lab values and residents refusing to eat. [MD-N] gave new orders to send resident to [Hospital] ER [emergency room ] for eval and treat . The surveyor noted this is the first time a physician was notified of R322 not eating. There is no documentation the physician was notified related to R322's fluid intake. Progress notes on 2/8/21 at 8:48 PM document, Resident was admitted to [hospital] with dx of [CONDITION(S)] [high sodium levels] dehydration, acute [CONDITION(S)] pneumonia and [MEDICATION(S)] [CONDITION(S)] . On 02/10/21 at 08:16 AM, the surveyor interviewed LPN (licensed practical nurse)-S. The surveyor asked what LPN-S would do if informed a resident wasn't drinking. LPN-S stated she would tell the aides to encourage to drink, she would encourage the resident to drink, and would report to the supervisor and doctor. LPN-S stated they would look at the resident's fluid status to see if urinating, check skin turgor, check for [CONDITION(S)], and look at their mucous membranes. On 02/10/21 at 08:38 AM, the surveyor interviewed ADON (Assistant Director of Nursing)-O. The surveyor asked ADON-O how aides know how much fluids to give to someone not on fluid restrictions. ADON-O stated it would be per resident preference. ADON-O stated milk, juice and coffee are offered every meal, water is offered every shift and with medpass and as requested. The surveyor asked how staff know how much someone is drinking. ADON-N stated staff keep track of what everyone is giving them and that the aides chart in their ADL (activities of daily living charting). ADON-O stated sometimes, for example, if someone is on fluid restrictions the nurse charts on it too. The surveyor asked what if someone is not drinking well. ADON-O stated they would call the doctor, get orders to push fluids and the doctor may order labs. The surveyor informed ADON-O of the concern of R322 documenting not drinking fluids well and being unable to see the physician being notified. ADON-O stated they did not tell her R322 wasn't drinking and she believed the physician was contacted because R322 was having increased behaviors and ordered labs and knows a UA was ordered with R322 having concentrated urine. The surveyor informed ADON-O of being unable to find a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON-O stated they are not. On 02/10/2021 at 10:00 AM, the surveyor interviewed RD (Registered Dietitian)-P. RD-P informed the surveyor another dietitian had completed R322's nutritional assessments offsite and had not physically seen the resident. RD-P informed the surveyor fluid needs are determined by the RD assessment using a calculation based on body weight and BMI (body mass index). The surveyor asked when the fluid needs are determined for new admissions. RD-P stated the RD assessment is due the last day of the reference period (7 days after admission), but try to do them as soon as possible, goal is 48-72 hours. RD-P stated they like to get a day or two to get a baseline of intakes. RD-P stated the RD looks at hospital notes to review to see if there is a concern, which R322 did have as he wasn't eating or drinking in the hospital. RD-P stated with R322's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RD-P stated on the 8th (2/8) R322 started refusing fluids and the doctor was notified and got labs. The surveyor asked what should happen if a resident isn't drinking well. RD-P stated if the CNAs see, they should report to the nurse who would report to dietary. If dietary sees that when looking at reports would notify the DON (Director of nursing), the nurse practitioner or MD, and would normally do a dehydration care plan then too. RD-P stated she knew the doctor was notified in this case. The surveyor informed RD-P of being unable to find documentation of the physician being notified of R322's fluid intake or where the orders for the lab came from. RD-P informed the surveyor R322's weight listed of 297 was not correct. RD-P stated R322's weights in the hospital ranged from 207-216. RD-P stated she believed the weight of 297 was because they didn't take out the wheelchair weight. RD-P stated a reweight had been requested but the resident had gone out before then. RD-P stated looking at R322's meal intakes, it wasn't great, but it wasn't horrible until he went out; that day he refused. RD-P stated R322 was on [MEDICATION(S)], but only 20mg. RD-P stated she thinks with R322's Covid and [CONDITION(S)] that led to the poor intake that led to the (critically high) sodium level. On 02/10/21 at 03:30 PM, the surveyor interviewed LPN-Q. LPN-Q recalled R322 was total cares. LPN-Q recalled she had seen the resident when he was admitted at the end of her shift and then had two days off. When she came back, the resident seemed a little worse, a little more confused. The surveyor asked how the resident had been eating and drinking. LPN-Q stated the first day the resident had not come in until after dinner. The 2nd day she worked with the resident he seemed to drink a little bit then not much. LPN-Q stated the resident had taken his medicine, seemed more confused, and had concentrated urine. LPN-Q stated she had called the physician that the resident had seemed more confused and had concentrated urine, that the physician had ordered a UA but not labs with her. The surveyor asked if the physician was made aware of anything about fluid intakes. LPN-Q stated she had told him his drinking and appetite was poor. The surveyor noted this was not documented in R322's medical record. The surveyor asked if an RN did an assessment on him. LPN-Q stated she knows an RN had been in the resident's room that night. The surveyor asked LPN-Q if they had checked R322's skin turgor or mucous membranes at all. LPN-Q stated the resident had food in his mouth when she had looked at him, but his skin turgor was fine. The surveyor asked LPN-Q if she knew what day that was on. LPN-Q stated no. The surveyor noted no documentation of R322's skin turgor in the medical record. On 02/10/21 at 3:41 PM the surveyor interviewed LPN-R. The surveyor asked LPN-R how R322 had been doing with food and fluids. LPN-R stated R322 hadn't been eating or drinking too much from their understanding. LPN-R stated they had been offering him lots of fluids and R322 would just throw the cup and food. On 02/11/21 at 07:28 AM the surveyor interviewed RN (registered nurse)-N. RN-N informed the surveyor R322 had seemrd more confused to him than when they had first worked with R322. The surveyor asked RN-N if they had assessed R322's hydration status. RN-N stated he had looked at R322s mouth, didn't seem dehydrated. RN-N stated from report he had gotten R322 was refusing fluids and food, that was why they were trying to give him fluids in the night. RN-N stated the resident would take a small sip and throw it on the floor. RN-N stated when checked his skin turgor didn't see that he was dehydrated. The surveyor asked RN-N about physician notification. RN-N stated he had let the physician know about a fall and increased confusion from the day he fell . RN-N stated he had tried to call the physician but he didn't answer, and later had texted him to do a CBC and CMP. RN-N stated he never actually spoke with the physician and had told first shift to follow up with the physician since he hadn't been able to actually talk with the physician about the resident. The surveyor reviewed R322's documentation and was unable to find documentation that the physician had been notified until 2/8/21 when R322's sodium came back as critical. On 02/11/21 at approximately 1:00 PM the surveyor informed DON (Director of Nursing)-B of the concern of R322's fluid needs not being determined upon admission, not being assessed for hydration status or dehydration risk factors, no documentation of the physician being notified of R322's poor fluid intake, and having no care plan in place related to R322's risk factors for dehydration. DON-B informed the surveyor they will be doing dehydration risk assessments in the future, and if high risk will be putting it on the care plan. On 02/11/21 at 1:29 PM, the facility provided the surveyor with an e-mail from RD-P. The email states, I have recalculated [R322's] estimated fluid needs based on his hospital weight of 209 lbs (since the weight used for the calculation was obviously inaccurate). And using the obesity factor (since BMI >30). Based on these numbers estimated fluid needs are 1650 mL per day .Based on intake of fluids documented, he was averaging 100mL/ day at meals (2/4-1320mL, 2/5-480mL, 2/6-1120mL, 2/7-1080) the 4 days prior to being sent out. Based on intake of med pass supplement, he was getting an additional 360 Ml/day [the surveyor noted R322 is not documented as having received the supplement during his admission]. Based on his food intake of 50%, you can assume he was averaging about 320mL of fluid, based on the fluid content of foods .Give the above information, he was meeting his estimated fluid needs. Fluid at meals: 1000mL, Fluids with med pass: 360 ML [the surveyor noted no documentation R322 was taking fluids with med pass], Fluid content of foods: 320mL, Total fluids taken: 1680 mL/day (102% of estimated needs). The surveyor shared the concern with the facility that R322's fluid intake needs was not accurately assessed during his admission, and the concern related to no evidence the fluids estimated with med pass were consumed.

Based on observation, interview and record review, the facility did not ensure policies and procedures for cleaning and disinfecting glucometers were being followed, potentially spreading infection to 2 (R4 and R5) of 3 residents that were sharing a glucometer on the first floor unit and 5 of 5 residents sharing a glucometer on the second floor unit. On 10/22/2020, a Licensed Practical Nurse (LPN)-H was interviewed about disinfection practices of shared glucometers on the first floor unit. LPN-H stated the glucometer is cleaned between each resident with an alcohol pad. Review of the residents residing on the first floor unit indicated three residents utilized the same glucometer for blood glucose (sugar) checks. One of the residents (R6) who had their blood sugar checked had a [DIAGNOSES REDACTED]. In addition, Glucometers on the second floor unit were being disinfected between residents with an unapproved solution potentially spreading infection to 5 (R7, R8, R9, R10, and R11) of 5 residents who were sharing a glucometer. The failure to properly disinfect a glucometer with an EPA approved germicidal disinfectant created a situation of immediate jeopardy that started on 10/22/2020. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the determination of immediate jeopardy on 10/22/2020 at 2:00 PM. The immediate jeopardy was removed on 10/23/20 and continues at a scope and severity level of E (potential for harm/pattern) as the facility continues to implement its removal plan. Findings: 1. According to the Centers for Disease Control and Prevention website https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html, If shared, blood glucose meters should be cleaned and disinfected after every use. The facility Policy and Procedure entitled Cleaning and Disinfection of a Glucometer dated 6/1/2020 states: All glucometers will be cleaned and disinfected using a 1:10 bleach (sodium hypochlorite) solution or commercially prepared EPA (Environmental Protection Agency) germicidal (bleach) wipe. All glucometers that are shared among multiple residents will be thoroughly wiped with the disinfectant and allowed to air dry after every use and between each resident. Cleaned and disinfected glucometers should be stored in approved containers in a clean location, such as a medication room or medication cart. Cleaned and disinfected glucometers should not be stored in pockets of scrubs, uniforms or lab jackets. [MEDICATION NAME] alcohol will not provide disinfection and is not recommended. The Ultra TRAK Complete glucometer owner's manual, p.16-17, states: The meter must be cleaned prior to the disinfection. Use one disinfecting wipe to clean exposed surfaces of the meter thoroughly and remove any visible dirt, blood, or any other body fluid with the wipe. Use a second wipe to disinfect the meter by following the disinfecting procedure below. Follow the instruction on the package label of disinfecting wipe. On 10/22/2020 at 11:30 AM, Surveyor interviewed LPN-H regarding the use of glucometers on the unit. LPN-H stated the residents share a glucometer. When asked how the glucometer is disinfected between each resident, LPN-H stated the glucometer is cleaned with an alcohol wipe. LPN-H then took an alcohol pad out of the top drawer of the medication cart to show Surveyor what LPN-H had used to clean the glucometer. Surveyor asked LPN-H if a bleach wipe was used on the glucometer. LPN-H stated no. LPN-H showed Surveyor the Ultra TRAK Complete glucometer that was in the medication cart. Surveyor asked how many residents had blood sugar checks done on the unit that morning (10/22/20). LPN-H stated four residents were checked, but record review showed the four residents LPN-H named had insulin administered while three of the four residents LPN-H named had blood sugars checked: The three residents who had their blood sugars checked were R6, R4, and R5. LPN-H stated R6 was tested first followed by R4 and then R5. R6 had a [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is a liver infection, with symptoms that can include abdominal pain, fatigue, fever, jaundice, joint pain, poor appetite, nausea and vomiting. WebMD states: About 75% to 85% of people who have it get a long-term infection called chronic [MEDICAL CONDITION]. If the condition goes untreated, it can lead to: [MEDICAL CONDITION], or scarring of the liver; [MEDICAL CONDITION]; liver failure. According to the Centers for Disease Control and Prevention website https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html, An underappreciated risk of blood glucose testing is the opportunity for exposure to [MEDICAL CONDITION] (HBV, [MEDICAL CONDITION] virus, [MEDICAL CONDITION].through contaminated equipment and supplies if devices used for testing and/or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. In the last [AGE] years, alone, there have been at least 15 outbreaks of HBV infection associated with providers failing to follow basic principles of infection control when assisting with blood glucose monitoring. Due to under-reporting and under recognition of acute infection, the number of outbreaks due to unsafe diabetes care practices identified to date are likely an underestimate. Although the majority of these outbreaks have been reported in long-term care settings, the risk of infection is present in any setting where blood glucose monitoring equipment is shared or those assisting with blood glucose monitoring and/or insulin administration fail to follow basic principles of infection control. On 10/22/2020 at 1:25 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the observation and conversation with LPN-H with regards to cleaning and disinfecting glucometers. DON-B stated wiping off the glucometers with alcohol wipes was better than nothing. Surveyor shared the concern of R6 having a [DIAGNOSES REDACTED]. 2. On 10/22/20 around 12:28 PM Surveyor observed the medical/clinical supply areas in the facility with AD-G (Admission Director). There was no evidence of bleach products or disinfectant products. On 10/22/20 at 12:36 PM Surveyor requested from Administration the last order supply for equipment disinfecting. DON-B (Director of Nurses) supplied Surveyor with an order dated 9/30/20. The order indicates 25 boxes of 80 count surface disinfecting wipes were ordered. On 10/22/20 at 1:25 PM Surveyor spoke with LPN-E (Licensed Practical Nurse). LPN-E had already completed her blood sugar checks on the following residents: R7, R8, R9, R10 and R11. LPN-E showed Surveyor the Lysol spray can she personally purchased. LPN-E indicated she sprays the Lysol on paper towel and wipes off the glucometer. LPN-E indicated there has been no disinfecting wipes the last couple days so they do the best they can. LPN-E indicated there have been bleach wipes on and off. The facility's failure to use an EPA approved disinfectant product to clean and disinfect a multi resident use glucometer after using it on a resident with a blood borne pathogen and then using the same glucometer to test the blood glucose of additional residents R4 and R5 created a finding of immediate jeopardy. The jeopardy was removed on October 23, 2020 when the facility implemented the following: - All like residents (all residents using glucometers) were reviewed and found to have no signs or symptoms of infection related to a spread by improper disinfecting of glucometers. All med carts now have sufficient quantities of appropriate disinfectants to clean the glucometers. - Bleach wipes (1:10 concentration) or comparable EPA approved cleaning product were provided to all medication carts for ready availability of the cleaning product to use between residents. The Medical Director was on was immediately notified. - Licensed Nurse Education was initiated on the following: - Glucometers are to be disinfected between residents using the manufacturer guidelines for the cleaning product including ensuring the wet time is met between resident uses. - Competency completed with licensed nursing staff currently working in the building on 10/22/20. All license staff not working today will complete the competency prior to their next shift. - Any licensed nursing staff not receiving the education by 10/22/2020 will receive education prior to their next shift. Education is being issued via in-person in-servicing. Phone education is being implemented to target staff members who are not in the facility with validation by signature prior to the start of their next shift. A facility Master Licensed Nursing Staff List is presently utilized to ensure licensed nursing staff members receive education. - An audit will be completed daily x 2 weeks of each medication cart to validate the cleaning solution is available and being used per manufacturer guidelines. After 2 weeks, the audit will then be completed 3 x per week for each medication cart x 2 weeks, then weekly for each medication cart x 2 months. The results of the audits will be presented to the QAPI committee for further review and recommendations. - Monitoring and Audits will be completed by the Administrator or designee. Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI (Quality Assurance Performance Improvement) Committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits will be determined at that time. If issues are identified, re-education will be completed. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed and revisions will be made as deemed necessary. - The Medical Director was updated on this Correction and Removal Plan as well as occurrences of which this plan pertains.

Based on interview and record review, the facility failed to ensure that allegations of abuse for 1 of 1 resident (R1) alleged to be sexually abused was reported immediately, (no later than two hours when the allegation involves abuse) to the administrator and to other officials, including the state agency, local law enforcement and adult protection services. In the morning of 1/9/20, R1 was found to have a torn brief without an explanation of how it happened. R1 was also known to have had a male visitor spend the night (1/8 - 1/9/20) in her room who was also noted to smell of alcohol. Facility staff failed to report this event to Administration on 1/9/20, which did not allow the Administrator of this facility to take action and implement their abuse policy and procedure to prevent further potential abuse of R1. The facility failure to report this potential abuse prevented timely investigation and subsequent implementation of steps to safeguard R1 and resulted in a second potential allegation of sexual abuse. The male visitor spent an additional night (1/9- 1/10/20) in R1's room and was observed by staff to be standing over R1 while she lay in bed with her eyes shut with his hand down the front of her brief. The facility did not report this allegation to the state agency until 1/16/20 after the state agency initiated an investigation into this allegation. Additionally, the facility did not report this allegation to law enforcement as a potential allegation of a crime until 1/16/20. The facility's failure to immediately report the suspicion of abuse/exploitation to the Administrator, state agency and other officials that may provide protection to R1 created a finding of Immediate Jeopardy (IJ) that began on 1/9/20. Surveyor notified Nursing Home Administrator- A and Director of Nursing- B of the immediate jeopardy on 1/16/20 at 3:30 p.m. The immediate jeopardy was removed on 1/20/20. 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 action plan. Findings include: The facility policy titled Policy and Procedure Vulnerable Adult Abuse and Neglect Prevention, revised 7/2/2019, states in part: Purpose: To provide residents a safe environment that is free from harm. Resident Protection Program Policy & Procedure: 6.) Reporting of Incidents a.) All allegations and/or suspicious of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's designee. b.) The facility must report to the State Agency immediately, but no 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 suspicion do not result in serious bodily injury. c.) What is the procedure for reporting within the facility? 1. After safeguarding the resident as well as his/her rights, report the information to the Supervisor immediately. 2. The supervisor in turn will immediately report all suspected maltreatment to the Administrator, Director of Nursing (DON), Social Service Director an to other officials in accordance with state law. 3. If you cannot report the information to your supervisor, you may call the Social Services Director or DON. 4. Call law enforcement officials if suspected concern is criminal in nature ( theft, assault, unwanted touch, etc.) 5. For allegations or incidents of sexual abuse, aside for the immediate preliminary report to the state health department, the policy of the facility is to make a police report with the local police department. R1 is a female resident who was admitted on [DATE]. R1 was admitted with [DIAGNOSES REDACTED]. According to documentation within R1's medical record, on 10/1/2018, a Letters of Guardianship of the Person due to incompetency was filed with the Circuit Court system in Milwaukee County, Wisconsin. A guardian for R1 was appointed through Supportive Community Services, put into place on 10/1/2018. Referral and Discharge summary from hospital stay, dated 8/9/18, states that R1 has an open case with Brief Services in the Elder Abuse Unit at Milwaukee County and this why a petition for guardianship had been developed. In addition, on 10/1/2018, an Order on Petition for Protective Placement or Protective Services was filed with the Circuit Court of Milwaukee County, Wisconsin. The order for protective placement states that the ward (R1) has a need for protective placement as follows: The ward (R1) was adjudicated incompetent in Wisconsin on 10/1/2018 and this is within the last 12 months of the filing of this Petition for Protective Placement or Services. The ward (R1) meets the standards for protective placement because the ward has a primary need for residential care and custody as a result of a [MEDICAL CONDITION] brain disorder. The recommended placement in the least restrictive environment and in the least restrictive manner consistent with the needs of the ward to be protected and with the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriate to match state funds in a community based residential facility (CBRF) with wander guard system or a skilled nursing facility. Protective placement was granted on 10/1/2018. According to the PASARR (Preadmission Screen and Resident Review) Level 2 screen, dated 10/31/18, R1 is being screened due to severe cognitive impairments or deficits due to [MEDICAL CONDITION], Dementia or related disorder. Placement in a nursing home was said to be appropriate and no need for specialized services. R1's medical record states that R1 has a legal guardian in place and this is the only contact listed for updates and emergencies. There are no other family members, friends or acquaintances listed for the facility to contact regarding updates involving R1. The most recent Minimum Data Set (MDS) was conducted due to a significant change in R1's condition and was completed on 11/4/19. According to the MDS, R1 has a BIMS (brief interview for mental status) score of 3 indicating severe cognitive impairment. The MDS also states that R1 has no family or significant other. The MDS does state that R1's Guardian participated in this assessment. R1's primary physician conducted an annual wellness visit on 11/10/19. The report states that (R1) has disorientation to time, date and place. (R1) has speech difficulties, difficulty expressing formulated concepts, difficulty with fine manipulative tasks, difficulty writing/ copying. The report also states that R1 has poor insight, in addition to not being orientated to time and place. A review of the plan of care for R1 documents the following: (R1) is at risk for abuse and neglect due to [DIAGNOSES REDACTED]. Listed interventions included immediately report any episodes of unknown injury, abuse or change in resident's behaviors to Administrator for immediate intervention and review. (R1) has impaired cognitive function/ dementia or impaired thought process due to Dementia. Legal guardian in place. Interventions include to cue, reorient and supervise as needed. Monitor/ document/ report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Night of 1/8 - 1/9/20 Written statement obtained by the facility on 1/10/20 from CNA- [NAME] reporting on date of incident 1/8 into 1/9/20 (first night of visitor overnight stay). Writer reports there was a 1st shift aide walking the hall and noticed (R1) had the call light on. CNA- [NAME] entered room and noticed a man laying at the foot of (R1's) bed. Writer asked him did he have the light on for assistance? He replied everything was alright. The visitor smelled of liquor. Writer left the room and right away told the nurse of a man being in bed with (R1). Then the nurse went into (R1's) room to check things out. The CNA (additional staff member) later noticed (R1's) brief was messed with from behind to where it was torn but still strapped up. Written statement obtained by the facility on 1/10/20 from Licensed Practical Nurse (LPN)- F indicates she was working on 2-south (date) when passing medication a CNA made mention of a resident having a visitor. She said she thinks he visited all night. Writer asked her does she no (sic) for sure he visited all night? She said she didn't know. Then went to (R1's) room to do her treatment, at the time the CNA said look at her brief this is how I found it. One side was fastened and one was not fastened. Writer is not aware of what happened or why her brief was unfastened. It was noted that these statements were taken on 1/10/20 and that there was no reporting to Administration on 1/9/20 that R1 had a male visitor overnight (1/8 - 1/9/20) nor were concerns shared with Administration that the brief R1 was wearing (on 1/9/20) was partially torn. Staff was noted to have the concern, but did not report to the DON or Administration for further follow-up for potential abuse of R1. Night of 1/9 - 1/10/20 Per statement from CNA-J obtained by the Director of NursesWhen questioned what she saw exactly when she walked into the room, she (CNA-J)stated that she saw what was on her statement. Statement reads: She stated that she saw the visitor sitting on the edge of the bed with his hand in her (R1's) brief at the location of her private area. She stated that he did not pull his hand back when she entered. She stated that the visitor was fully clothed. She stated that the resident was sleeping. She stated that the resident was under the covers. She stated that the cover was pulled back some. On 1/16/20 at 10:12 a.m., Surveyor interviewed DON- B who stated she has begun (on 1/16/20) getting statements from staff who worked 3rd shift on 1/8-1/10/19. DON- D stated she did speak with LPN- I who worked 10:00 p.m.- 6:00 a.m. 1/9-1/10/20 as the nurse on the unit in which R1 resides. DON- B stated LPN- I reported CNA- J came up to him and told him (time unknown) that she walked into R1's room and the male visitor had his pants down and his hand in R1's brief. DON- B stated LPN- I reported to her that he remembers at approximately 10:30 p.m. on 1/9/20 he was made aware that R1's male visitor was still in her room and he went into the room and asked him to leave. The male visitor told LPN- I he was waiting for a ride and would be leaving shortly. LPN- I stated he again asked the male visitor to leave, after some time had passed, and that the male visitor again stated he was waiting for a ride. LPN- I was unable to provide a time for this conversation. DON- B stated she asked LPN- I why he did not report this and he did not have an answer. DON- B stated to Surveyor she would have expected LPN- I to have reported this incident immediately, he did not. On 1/16/20 at 12:19 p.m., Surveyor interviewed LPN- I via telephone. LPN- I stated he did not report the concern (of an overnight male visitor) to anyone in administration and today (1/16/20) is the first time he has talked about it with anyone since it happened. LPN- I stated he really didn't think this was a problem because R1 knew her male visitor, although after he heard that the male visitor had his hands down R1's brief, he insisted the male visitor leave. Written statement provided by ADON- C on 1/20/20 states that upon arriving to 2nd floor (on the morning of 1/10/20), writer is approached by CNA stating that R1 had a gentleman who stayed the night in her room. Per CNA statement when she entered the resident room (R1's), the gentleman was sitting on the edge of the bed of the resident. R1 had her brief undone and gentleman had his hand down her pants. Per CNA statement, at the time the resident had her eyes closed and no signs of distress. CNA updated floor nurse of findings. Writer to check on resident after report received and it was noted the gentleman had left the facility. R1 in a safe area with staff attendance. Writer to update DON and administration immediately. Writer and Social Worker to interview R1 regarding incident. Writer to ask R1 is she is aware she had any visitors night before. R1 states yes, name given. Writer ask resident did she feels safe when said visitor comes. She stated yes, I like when he comes he brings me food. Writer asked if there is any physical contact when visitor comes. R1 stated yes and she is comfortable with visitor touching her sexually. On 1/15/20 at 12:09 p.m., Surveyor interviewed ADON (Assistant Director of Nursing)/ Unit Manager- C in regard to R1 having an overnight male visitor. ADON- C shared that yes, she is aware that R1 had a male visitor that stayed overnight in R1's room and that R1 does have a female roommate in the shared room. ADON stated that it was determined the overnight visitor was considered R1's boyfriend before she was admitted to the facility and that R1 does recognize him as her friend. ADON- C stated that she is not aware of R1's male friend visiting in the recent past and stated it could have been almost a year ago since he last visited. ADON -C stated that on 1/10/20, she was told by the morning shift (6 am start time) that R1 had a male visitor who stayed overnight in R1's room. ADON- C stated she immediately spoke with R1 along with Social Services- D. ADON- C stated R1 said she felt safe and was happy her boyfriend had visited her because he brought her chicken to eat. ADON- C also stated she asked R1 if her male friend had touched her and R1 replied yes and she was all right with it. ADON- C stated some staff were interviewed about the incident and this information was forwarded to the Director of Nursing (DON)- B. ADON- C stated she is not aware R1's male friend has visited R1 since and that the friend may have some medical issues or even be homeless. ADON- C stated after the staff was made aware R1 had an overnight visitor they were going to put into place that the male visitor would need to leave by 9 p.m. On 1/15/20 at 12:39 p.m., Surveyor interviewed DON- B in regard to an investigation that was initiated regarding R1 having a male visitor overnight and that an observation had been made of R1 being touched in her lower private area by the male visitor while she was sleeping. DON- B stated she was aware of the incident and she reviewed the surveillance footage from the facility's security cameras. DON- B stated that R1's male friend actually stayed 2 nights in her room, 1/8/20 and 1/9/20. DON- B stated that the camera footage shows R1's male visitor come to the building on 1/8/20 and come and go and then not leave in the evening. The camera footage also shows that R1's visitor stayed the evening of 1/9/20 and does not provide a timeline of when R1's visitor actually left on 1/10/20. DON- B stated that all of the interviews she conducted happened on 1/10/19 after she was notified that R1 had a male visitor overnight. DON- B stated at this time she did not interview any staff who worked the 3rd shift on 1/8/19 or 1/9/19 who may have knowledge that R1 had a male visitor overnight for 2 nights. DON- B stated nothing has been added to the plan of care for R1 in regard to this incident and that she only communicated with 2nd shift that if R1's visitor is here again, he must leave by 9:00 p.m. DON- B stated that it was told to her that R1's male visitor was found to have his hand down R1's pants/ brief. DON- B stated R1 was only wearing a gown and brief. Surveyor asked DON- B if the facility had reported this incident to the state survey agency, or any other officials involving the protection of R1. DON- B stated they had not reported this to any other officials. DON- B stated due to R1 having a prior relationship with the male visitor and R1 stating she was fine with the visitor, no further consideration was given that this was a problem. On 1/15/20 at 2:18 p.m., Surveyor interviewed SS- D in regard to the incident involving R1. SS- D stated that on the morning of 1/10/20 she was made aware there was a concern R1 had a male visitor overnight and he was seen touching her under her brief. SS- D stated she did not report this concern to the state agency or any other agency and that the DON would be responsible for this. On 1/15/20 at 3:42 p.m., Surveyor interviewed Administrator- A in regard to R1 having a male visitor overnight. Administrator- A stated, I don't know this visitor really spent the night. Administrator A stated the DON- B has been updating her on the investigation as she gathers information. Surveyor told Administrator- A that DON- B stated she was sure the male visitor stayed 2 nights in the facility and confirmed this by watching the surveillance footage. Administrator- A stated, I know that visitor was seen pulling his hand out of R1's brief and yes he had his pants down. Administrator- A stated the facility did not report this incident or conduct an investigation because there was no need to explode on it because this visitor is not a new person to R1 and they are respecting R1's wishes to have him visit. On 1/16/20 at 1:40 pm Regional Nurse Consultant L informed Surveyors they felt there was no need to investigate as R1 and her visitor had a long standing relationship. Regional Nurse Consultant L reported the 2 initial interviews conducted by the facility and provided to surveyor was the result of the facility asking questions as to who this male visitor was. They did investigate to make sure it was just not some guy. Once they determined who the visitor was, and that R1 was OK, they determined it no longer needed to be investigated. Regional Nurse Consultant L indicated that this was why the facility did not report this to other entities. In addition, this is why no investigation was considered necessary. Regional Nurse Consultant L stated the facility had now sent an initial facility Misconduct Incident Report (Self-Report) to the state regarding R1 and her visitor based on conversation with the State (surveyors) wanting them to report it, so they reported it. Cross reference F600 The failure of facility staff to ensure that allegations of suspected abuse or exploitation are immediately reported, to the administrator and other agencies that may assist in the protection of a resident created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 1/20/20, when it completed the following: ~ NHA made aware on 1/10/2020. ~ Investigation was initiated on 1/15/2020. ~ Guardian notified on 1/15/2020. ~ Physician/medical director on 1/15/2020. ~ Notified police on 1/16/2020. ~ Initial abuse report made (to Office of Caregiver Quality) at 12:34pm on (MONTH) 16th 2020. Like Residents/System Correction: ~ Staff will be interviewed to determine if there are any other non-consensual residents identified as having potentially abusive visitors and their capacity to consent. ~ Upon any allegations of abuse, the resident will be kept safe and will be reported to the state of Wisconsin and law enforcement and protective services. ~ Regional Supervisors will be notified of initiation of any potential abuse investigations. Education: ~ Beginning (MONTH) 16th 2020, staff were educated prior to the start of their next scheduled shift on protection, investigation, and reporting until all staff have completed education. ~ The facility has posted how to respond to any reasonable suspicion of a crime, serious bodily injury or potential abuse with emphasis on reporting any potential abuse immediately to the administrator and the requirement to report abuse to law enforcement and the state of Wisconsin within two hours. Protective Services will also be called. ~ NHA and Social Services were re-educated on Abuse policy and above on 1/16/2020 All staff inservice will be held 1/22/20 Monitoring/Audits: ~ NHA and/or designee will audit timely notification to Administrator and law enforcement and follow up and re-educated as needed. Potential abuse situations and reporting which will be reviewed in the daily morning meeting. Adverse findings will be immediately addressed. These findings and other unusual occurrences will be reported to QAPI Committee for further review and consideration. ~ The Medical Director was updated on this Correction and Removal-Abatement Plan as well as occurrences of which this plan pertains to. ~ Monitoring will be initiated and completed by the Director of Nursing and/or designee as indicated above. Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI (Quality Assurance Performance Improvement) Committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits; will be determined at that time. If issues are identified, re-education will be done. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed and revisions will be made as deemed necessary.

Based on interview and record review, the facility failed to ensure that all allegations of abuse were thoroughly investigated and that the facility implemented measures to prevent the potential for further abuse to occur while an investigation was in progress for 1 of 3 residents (R1) reviewed for abuse. R1 has been assessed to be severely cognitively impaired, is protectively placed in the facility, has a legal guardian in place and, per facility assessment, has no family or significant other. R1 had a male visitor spend 2 nights in the facility (1/8-1/9/20 and 1/9-1/10/20) in her room. R1 was observed to have a torn brief the morning of 1/9/20 following the first overnight visit. It was then observed by staff that on the 2nd night of the overnight stay (1/9-1/10/20), the male visitor had his hands down the front of R1's brief while she lay in bed with her eyes closed. The facility failed to immediately report these incidents to administration and administration did not thoroughly investigate or take immediate action to protect R1 once they were made aware of the situation. The facility failed to immediately obtain statements from staff who had knowledge of these incidents, failed to assess R1's capacity to give consent to a sexual relationship and failed to put a plan in place to protect R1. These failures created a finding of Immediate Jeopardy (IJ), which began on 1/9/20. Surveyor notified Nursing Home Administrator- A and Director of Nursing- B of the immediate jeopardy on 1/16/20 at 3:30 p.m. The immediate jeopardy was removed on 1/20/20. However the deficient practice continues at a scope/ severity D (potential for more than harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The facility policy titled Policy and Procedure Vulnerable Adult Abuse and Neglect Prevention, revised 7/2/2019, states in part: Purpose: To provide residents a safe environment that is free from harm. Resident Protection Program Policy & Procedure: 7. Internal Facility Investigation of Reports of Resident Maltreatment. a. Each alleged report will be individually investigated b. The local Police Department will be notified of incidents involving any criminal activity. c. Appropriate measures will be taken to remove the affected resident(s) from the situation d. If appropriate, the facility will report to the department of health via website e. The appropriate person, usually the DON or Social Service Director, or designee will conduct interviews with the appropriate staff, volunteers, visitors, etc. if needed. f. Within 5 business days, an investigation report will be completed and turned into the department of health and to the facility administrator or designed, This report includes: 1. The resident's name, how long he/she has been at the facility and which unit they reside on. 2. The care plan interventions and if they were being followed, the reason why, and how the staff are made aware of the plan of care. 3. Details of facility investigation. This includes a summary of information obtained from interviews of residents, staff, and witnesses as appropriate. Also include if the information is obtained from a credible source. 4. Any injuries sustained by the resident. 5. How was the resident's ability and lifestyle been affected. 6. Details on the alleged perpetrator 7. Any action that has been taken to prevent recurrence of the incident. According to documentation within R1's medical record, on 10/1/2018, a Letters of Guardianship of the Person due to incompetency was filed with the Circuit Court system in Milwaukee County, Wisconsin. A guardian for R1 was appointed through Supportive Community Services, put into place on 10/1/2018. Referral and Discharge summary from hospital stay, dated 8/9/18, states that R1 has an open case with Brief Services in the Elder Abuse Unit at Milwaukee County and this why a petition for guardianship had been developed. In addition, on 10/1/2018, an Order on Petition for Protective Placement or Protective Services was filed with the Circuit Court of Milwaukee County, Wisconsin. The order for protective placement states that the ward (R1) has a need for protective placement as follows: The ward (R1) was adjudicated incompetent in Wisconsin on 10/1/2018 and this is within the last 12 months of the filing of this Petition for Protective Placement or Services. The ward (R1) meets the standards for protective placement because the ward has a primary need for residential care and custody as a result of a [MEDICAL CONDITION] brain disorder. The recommended placement in the least restrictive environment and in the least restrictive manner consistent with the needs of the ward to be protected and with the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriate to match state funds in a community based residential facility (CBRF) with wander guard system or a skilled nursing facility. Protective placement was granted on 10/1/2018. The most recent Minimum Data Set (MDS) was conducted due to a significant change in R1's condition and was completed on 11/4/19. According to the MDS, R1 has a BIMS (brief interview for mental status) score of 3 of 15, indicating severe cognitive impairment. The MDS also states that R1 needs extensive assistance of 2 persons for most activities of daily living including bed mobility, R1 does not walk in room or corridor, R1 uses a wheelchair for mobility, has impairments of both sides of her lower extremities, is on scheduled pain medications and has no family or significant other. The MDS does state that R1's Guardian participated in this assessment. A review of the plan of care for R1 documents the following: R1 is at risk for abuse and neglect due to [DIAGNOSES REDACTED]. Listed interventions included immediately report any episodes of unknown injury, abuse or change in resident's behaviors to Administrator for immediate intervention and review. R1 has impaired cognitive function/ dementia or impaired thought process due to Dementia. Legal guardian in place. Interventions include to cue, reorient and supervise as needed. Monitor/ document/ report as needed any changes in cognitive function, specifically changes in decision, making, ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Night of 1/8-1/9/20 Written statement obtained by the facility on 1/10/20 from CNA- [NAME] reporting on date of incident 1/9/20 (first night of visitor overnight stay). Writer reports being a 1st shift aide and walking the hall and noticed R1 had the call light on. CNA- [NAME] entered room and noticed a man laying at the food of R1's bed. Writer asked him did he have the light on for assistance? He replied everything was all right. The visitor smelled of liquor. Writer left the room and right away told the nurse of a man being in bed with R1. Then the nurse went into R1's room to check things out. The CNA (additional staff member) later noticed R1's brief was messed with from behind to where it was torn but still strapped up. Written statement obtained by the facility on 1/10/20 from LPN- F states that she was working on 2-south when passing medication a CNA made mention of a resident having a visitor. She said she thinks he visited all night. Writer asked her does she know for sure he visited all night? She said she didn't know. Then went to R1's room to do her treatment, at the time the CNA said look at her brief this is how I found it. One side was fastened and on was not fastened. Writer is not aware of what happened or why her brief was unfastened. It was noted that these statements were taken on 1/10/19 and that there was no reporting that R1 had a male visitor overnight on 1/8-1/9/20 nor were concerns that the brief R1 was wearing on 1/9/20 was partially torn. Staff was noted to have the concern, but did not report to the DON or Administration. As a result, there was no investigation of what had occurred and no measures put in place to prevent further potential abuse of R1. Night of 1/9-1/10/20 Per statement from CNA-J obtained by the Director of NursesWhen questioned what she saw exactly when she walked into the room, she (CNA-J)stated that she saw what was on her statement. Statement reads: She stated that she saw the visitor sitting on the edge of the bed with his hand in her (R1's) brief at the location of her private area. She stated that he did not pull his hand back when she entered. She stated that the visitor was fully clothed. She stated that the resident was sleeping. She stated that the resident was under the covers. She stated that the cover was pulled back some. On 1/16/20 at 10:12 a.m., Surveyor interviewed DON- B who stated she has begun (on 1/16/20) getting statements from staff who worked 3rd shift on 1/8-1/10/19. DON- D stated she did speak with LPN- I who worked 10:00 p.m.- 6:00 a.m. 1/9-1/10/20 as the nurse on the unit in which R1 resides. DON- B stated LPN- I reported CNA- J came up to him and told him (time unknown) that she walked into R1's room and the male visitor had his pants down and his hand in R1's brief. DON- B stated LPN- I reported to her that he remembers at approximately 10:30 p.m. on 1/9/20 he was made aware that R1's male visitor was still in her room and he went into the room and asked him to leave. The male visitor told LPN- I he was waiting for a ride and would be leaving shortly. LPN- I stated he again asked the male visitor to leave, after some time had passed, and that the male visitor again stated he was waiting for a ride. LPN- I was unable to provide a time for this conversation. DON- B stated she asked LPN- I why he did not report this and he did not have an answer. + On 1/16/20 at 12:19 p.m., Surveyor interviewed LPN- I via telephone. LPN- I stated he did not report the concern (of an overnight male visitor) to anyone in administration and today (1/16/20) is the first time he has talked about it with anyone since it happened. LPN- I stated he really didn't think this was a problem because R1 knew her male visitor, although after he heard that the male visitor had his hands down R1's brief, he insisted the male visitor leave. Written statement provided by ADON- C on 1/20/20 states that upon arriving to 2nd floor (1/10/20), writer is approached by Certified Nursing Assistant (CNA) stating R1 had a gentleman who stayed the night in her room. Per CNA statement when she entered the resident room (R1's), the gentleman was sitting on the edge of the bed of the resident. R1 had her brief undone and gentleman had his hand down her pants. Per CNA statement, at the time the resident had her eyes closed and no signs of distress. CNA updated floor nurse of findings. Writer to check on resident after report received and it was noted the gentleman had left the facility. R1 in a safe area with staff attendance. Writer to update DON and administration immediately. Writer and Social Worker to interview R1 regarding incident. Writer to ask R1 is she is aware she had any visitors night before. R1 states yes, name given. Writer ask (sic) resident did she feel safe when said visitor comes. She stated yes, I like when he comes he brings me food. Writer asked if there is any physical contact when visitor comes. R1 stated yes and she is comfortable with visitor touching her sexually. On 1/15/20 at 12:09 p.m., Surveyor interviewed ADON (Assistant Director of Nursing) / Unit Manager- C in regards to R1 having an overnight male visitor. ADON- C stated yes, she is aware that R1 had a male visitor that stayed overnight in R1's room and R1 does have a female roommate in the shared room. ADON-C stated it was determined the overnight visitor was considered R1's boyfriend before she was admitted to the facility and R1 does recognize him as her friend. ADON- C stated she is not aware of R1's male friend visiting in the recent past and stated it could have been almost a year ago since he visited. ADON stated on 1/10/20, she was told by the morning shift (6 am start time) that R1 had a male visitor that had stayed overnight in her room. ADON- C stated that she immediately spoke with R1 along with Social Services- D. ADON- C stated said she felt safe and that she was happy her boyfriend had visited her because he brought her chicken to eat. ADON- C also stated that she asked R1 if her male friend had touched her and R1 replied yes and she was all right with it. ADON- C stated some staff were interviewed about the incident and this information was forwarded to the Director of Nursing (DON)- B. ADON- C stated she is not aware R1's male friend has since visited with R1 and that the friend may have some medical issues or even be homeless. ADON- C stated after the staff was made aware that R1 had an overnight visitor they were going to put into place that the male visitor would need to leave by 9 p.m. On 1/15/20 at 12:39 p.m., Surveyor interviewed DON- B in regards to an investigation that was initiated regarding R1 having a male visitor overnight and that an observation had been made of R1 being touched in her lower private area by the male visitor while she was sleeping. DON- B stated she was aware of the incident and she reviewed the surveillance footage from the facility's security cameras. DON- B stated R1's male friend actually stayed 2 nights in her room, 1/8/20 and 1/9/20. DON- B stated that the camera footage shows R1's male visitor come to the building on 1/8/20 and come and go and then not leave in the evening. The camera footage also shows that R1's visitor stayed the evening of 1/9/20 and does not provide a timeline of when R1's visitor actually left on 1/10/20. DON- B stated all of the interviews she conducted happened on 1/10/19 after she was notified that R1 had a male visitor overnight. DON- B stated at this time she did not interview any staff who worked the 3rd shift on 1/8/19 or 1/9/19 who may have knowledge that R1 had a male visitor overnight for 2 nights. DON- B stated nothing has been added to the plan of care for R1 in regards to this incident and that she only communicated with 2nd shift that if R1's visitor is here again, he must leave by 9:00 p.m. DON- B stated it was told to her that R1's male visitor was found to have his hand down R1's pants/ brief. DON- B stated R1 was only wearing a gown and brief. DON- B was asked by Surveyor what was put in place to keep R1 safe any further potential sexual contact with male visitor. DON- B responded by saying she understood what Surveyor was saying and could not provide any additional information on this topic. DON- B stated that the facility has not conducted any type of assessment on R1's capacity to consent to sexual activity and that the focus was that R1 knew the male visitor and it was her old boyfriend. Surveyor interviewed Licensed Practical Nurse (LPN)- K on 1/15/20 at 1:00 p.m. LPN -K stated she was not made aware there are any concerns or restrictions for R1 to have male visitors. LPN- K is the 1st shift nurse working on the unit in which R1 resides. Surveyor interviewed LPN- H on 1/15/20 at 3:17 p.m. LPN- H stated he is not aware of any restrictions to R1's visitors and he is working as the nurse on 2nd shift for the unit in which R1 resides. On 1/16/20 at 3:20 p.m., Surveyor interviewed CNA- G who was assigned on the 2nd shift to work with R1. CNA- G stated he is not aware of any restrictions on his visits with R1. On 1/15/20 at 2:18 p.m., Surveyor interviewed Social Services (SS)- D in regards to the incident involving R1. SS- D stated on the morning of 1/10/20 she was made aware there was a concern R1 had a male visitor overnight and he was seen touching her under her brief. SS- D stated she talked with R1 and who said she knew who the visitor was and she liked his visits. R1 was asked about the sexual contact and R1 responded he does touch her and she likes it. SS-D stated she left a message for the guardian on 1/10/20 and the Guardian did return the call and left a voicemail message which SS- D did not listen too until her return to the facility on [DATE]. SS- D stated the Guardian didn't mind if R1 had visitors but had no idea who the male visitor could have been. SS- D stated as of this time of the interview that she still had not actually spoken with the Guardian to disclose full details of the situation and that no one else had tried to reach out to the Guardian other than her. SS- D was asked if any type of assessment had been conducted about R1's capacity to give consent to a sexual relationship after they were made aware that R1's male visitor had been touching her. SS- D stated that no assessment had been conducted and she was also able to verify that no documentation about the incident was documented in the medical record or on the plan of care. SS- D stated moving forward she hoped to talk with R1's male friend and get more details from him and would try to catch him the next time he visited. SS-D stated she has never met the male visitor and is aware he has not followed the visitor sign-in policy when he has visited in the recent past. SS- D stated she would have to be alerted by other staff that the visitor was in the building and would approach him at that time. A review of R1's progress notes in the EMR did not provide any documentation that R1 had a male visitor who stayed overnight, was observed to have been sexually touched by male visitor or that a call was placed to the legal guardian for notification. The plan of care did not show any updates about R1's male visitor or that an assessment had been conducted regarding R1's ability to provide consent to further sexual activity with male visitor. On 1/15/20 at 3:42 p.m., Surveyor interviewed Administrator- A in regards to R1 having a male visitor overnight. Administrator- A stated, I don't know this visitor really spent the night. Administrator A stated DON-B has been has been updating her on the investigation as she gathers information. Surveyor told Administrator- A that DON- B stated she was sure the male visitor stayed 2 nights in the facility and confirmed this by watching the surveillance footage. Administrator- A stated, I know that visitor was seen pulling his hand out of R1's brief and yes that he had his pants down. Administrator- A stated the facility did not report this incident or conduct an investigation because there was no need to explode on it because this visitor is not a new person to R1 and they are respecting R1's wishes to have him visit. Administrator- A stated it is unusual to have an overnight visitor and again she is not sure he really spent the night with R1. Administrator- A stated R1's roommate had no issues with the visitor and she was not aware of any future plans to restrict the male visitor from visiting again. Administrator- A stated they would only make changes if R1 says it is not all right for the male visitor to visit. Administrator A was asked by Surveyor why the facility had begun to take staff statements even though they were not considering it an investigation. Administrator- A stated they still wanted to make sure it was ok. Administrator- A stated there was a disgruntled employee who was fired during this time and was probably who called in the complaint. As of the time of exit on 1/16/20, there was no evidence that R1 had been assessed for the capacity to consent to a sexual relationship or that R1's male visitor had been restricted in his visits to R1. Surveyor was provided with an updated copy of R1's care plan showing that on 1/15/20, Administrator -A documented in the plan that R1 chooses to have an intimate and interpersonal relationship with male friend, initiated 1/15/20. Listed interventions include to encourage R1 to discuss issues/ concerns with staff, monitor for changes in mood and behavior that would indicate R1 is distressed, provide education that R1 is able to understand regarding what is considered abuse and resident right to say no, respect resident rights, staff to be respectful of residents rights to form intimate and companion relationships with others. Surveyor noted this plan of care was established without the facility having a full understanding of the allegation of abuse regarding R1 and without a comprehensive assessment related to R1's ability to understand and provide consent. Cross reference F600 and F609. The facility's failure to initially investigate what had occurred, including assessing the resident's ability to consent, and its failure to put interventions in place that could prevent further potential abuse created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 1/20/20, when it completed the following: ~ The facility will thoroughly investigate any alleged violation, prevent further abuse, exploitation and mistreatment from occurring while the investigation is in progress and take appropriate corrective action as a result of the investigation findings within 5 working days. Depending upon the type of allegation received, the investigation would include, but is not limited to: ~ Conducting observations of the alleged victim, including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between offender and the alleged victim and/or other residents, and interactions/relationships between resident to other residents; ~ Conducting interviews with, as appropriate, the alleged victim and representative, alleged perpetrator, witnesses, practitioner, interviews with personnel from outside agencies such as other investigatory agencies, and hospital or emergency room personnel; ~ Conducting record review for pertinent information related to the alleged violation, as appropriate, such as progress notes (Nurse, social services, physician, therapist, consultants as appropriate, etc.), financial records, incident reports (if used), reports from hospital/emergency room records, laboratory or x-ray reports, medication administration records, photographic evidence, and reports from other investigatory agencies. The facility will attempt to maintain any potential evidence as instructed per law enforcement, transfer the resident to the emergency room for examination including obtaining a rap kit, if appropriate. ~ The alleged perpetrator will not be allowed to have access to the alleged victim and/or other vulnerable residents. ~ NHA made aware on 1/10/2020. ~ Investigation was initiated on 1/15/2020. ~ Guardian notified on 1/15/2020. ~ Physician/medical director on 1/15/2020. ~ Notified police on 1/16/2020. ~ Initial abuse reported to [NAME]Q was made 2417 at on (MONTH) 16th 2020. Like Residents/System Correction: ~ Staff will be interviewed to determine if there are any other non-consensual residents identified as having potentially abusive visitors and their capacity to consent. ~ Upon any allegations of abuse, the resident will be kept safe and will be reported to the state of Wisconsin within two hours, and report to law enforcement and protective services. Education: ~ Beginning (MONTH) 16th 2020, staff were educated prior to the start of their next scheduled shift on protection, investigation, and reporting until all staff have completed education. The facility has posted how to respond to any reasonable suspicion of a crime, serious bodily injury or potential abuse with emphasis on reporting any potential abuse immediately to the administrator and the requirement to report abuse to law enforcement and the state of Wisconsin within two hours. Protective Services will also be called. NHA and Social Services were re-educated on Abuse policy and above on 1/16/2020 ~ All staff inservice will be held 1/22/20 ~ Regional Supervisors will be notified of initiation of any potential abuse investigations. Monitoring/Audits: ~ NHA and/or designee will audit timely notification to Administrator and law enforcement and follow up and re-educated as needed. Potential abuse situations and reporting which will be reviewed in the daily morning meeting. Adverse findings will be immediately addressed. These findings and other unusual occurrences will be reported to Quality Assessment Performance Improvement (QAPI) Committee for further review and consideration. ~ The Medical Director was updated on this Correction and Removal-Abatement Plan as well as occurrences of which this plan pertains to. ~ Monitoring will be initiated and completed by the Director of Nursing and/or designee as indicated above. Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI Committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits; will be determined at that time. If issues are identified, re-education will be done. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed and revisions will be made as deemed necessary.

Based on observation, interview, and record review, the facility failed to prevent sexual abuse/ exploitation or the likelihood of sexual abuse/exploitation from occurring for 1 of 3 residents (R1) reviewed for abuse. R1 was deemed incompetent on 10/2/18 and a court appointed guardian and protective placement was put into place for R1. R1 has been assessed to have severe cognitive impairments, difficulty expressing formulated concepts and is at risk for abuse and neglect due to [DIAGNOSES REDACTED]. Per facility assessment in (MONTH) 2019, R1 has no family or significant other. On the nights of 1/8 - 1/9/20 and 1/9 - 1/10/20 a male visitor stayed overnight in R1's room. Staff reported on the first night (from 1/8 to 1/9/20) that R1's visitor smelled of alcohol, was sleeping at the foot of R1's bed and staff found R1 in the morning (1/9/20) to have a torn brief with no explanation for how it happened. R1's visitor was also observed on the 2nd night's stay (1/9/20 to 1/10/20) to be standing over R1 with his hand down R1's brief while she lay in bed with her eyes closed. The facility staff did not assess R1's capacity to consent to a sexual relationship, did not update the plan of care or put in a plan to keep R1 safe from further potential sexual abuse or exploitation. The facility's failure to assess R1's capability of consenting to a sexual/intimate relationship in order to keep R1 safe and free from further potential sexual abuse/ exploitation created a finding of Immediate Jeopardy (IJ) that began on 1/9/20. Surveyor notified Nursing Home Administrator- A and Director of Nursing- B of the immediate jeopardy on 1/16/20 at 3:30 p.m. The immediate jeopardy was removed on 1/20/20. However the deficient practice continues at a scope/ severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility policy titled Policy and Procedure Vulnerable Adult Abuse and Neglect Prevention, revised 7/2/2019, states in part: Purpose: To provide residents a safe environment that is free from harm. Procedure: All residents are susceptible to maltreatment and exploitation due to their need for nursing home care. Due to their need for nursing home care. Due to physical, emotional, and mental inabilities, residents may be dependent upon us to meet their needs. It is the policy to enhance the life of all residents through strong programming and appropriate care and treatment. Additionally, residents and staff will be protected from abuse, neglect and harm while they are residing at the facility. No abuse or harm of any type will be tolerated and residents and staff will be monitored for protection. The facility will strive to educate all participants in techniques to protect all parties. According to Wisconsin Case Law the following are guidelines for determining a person's ability to consent to sex. An individual is capable of consenting to sexual activity only if there is a yes answer to each of the following: 1. The person understands the distinctively sexual nature of the conduct .the acts have a special status as sexual. 2. The person understands that their body is private and that they have the right to refuse. 3. The person understands there may be health risks associated with the sexual act. 4. The person understands there may be negative societal response to the conduct. Surveyor initiated a review of R1's EMR (electronic medical record) on 1/15/20, due to a complaint that was submitted to the Division of Quality Assurance (DQA). R1 is a female resident who was admitted on [DATE]. R1 was admitted with [DIAGNOSES REDACTED]. According to documentation within R1's medical record, on 10/1/2018, a Letters of Guardianship of the Person due to incompetency was filed with the Circuit Court system in Milwaukee County, Wisconsin. A guardian for R1 was appointed through Supportive Community Services, put into place on 10/1/2018. Referral and Discharge summary from hospital stay, dated 8/9/18, states that R1 has an open case with Brief Services in the Elder Abuse Unit at Milwaukee County and this why a petition for guardianship had been developed. In addition, on 10/1/2018, an Order on Petition for Protective Placement or Protective Services was filed with the Circuit Court of Milwaukee County, Wisconsin. The order for protective placement states that the ward (R1) has a need for protective placement as follows: The ward (R1) was adjudicated incompetent in Wisconsin on 10/1/2018 and this is within the last 12 months of the filing of this Petition for Protective Placement or Services. The ward (R1) meets the standards for protective placement because the ward has a primary need for residential care and custody as a result of a [MEDICAL CONDITION] brain disorder. The recommended placement in the least restrictive environment and in the least restrictive manner consistent with the needs of the ward to be protected and with the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriate to match state funds in a community based residential facility (CBRF) with wander guard system or a skilled nursing facility. Protective placement was granted on 10/1/2018. According to the PASARR (Preadmission Screen and Resident Review) Level 2 screen, dated 10/31/18, R1 is being screened due to severe cognitive impairments or deficits due to [MEDICAL CONDITION], Dementia or related disorder. Placement in a nursing home was said to be appropriate and no need for specialized services. R1's medical record states that R1 has a legal guardian in place and this is the only contact listed for updates and emergencies. There are no other family members, friends or acquaintances listed for the facility to contact regarding updates involving R1. The most recent Minimum Data Set (MDS) was conducted due to a significant change in R1's condition and was completed on 11/4/19. According to the MDS, R1 has a BIMS (brief interview for mental status) score of 3 indicating severe cognitive impairment. The MDS also states that R1 has no family or significant other. The MDS does state that R1's Guardian participated in this assessment. R1's primary physician conducted an annual wellness visit on 11/10/19. The report states that (R1) has disorientation to time, date and place. (R1) has speech difficulties, difficulty expressing formulated concepts, difficulty with fine manipulative tasks, difficulty writing/ copying. The report also states that R1 has poor insight, in addition to not being orientated to time and place. A review of the plan of care for R1 documents the following: (R1) is at risk for abuse and neglect due to [DIAGNOSES REDACTED]. Listed interventions included immediately report any episodes of unknown injury, abuse or change in resident's behaviors to Administrator for immediate intervention and review. (R1) has impaired cognitive function/ dementia or impaired thought process due to Dementia. Legal guardian in place. Interventions include to cue, reorient and supervise as needed. Monitor/ document/ report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Surveyor conducted a review of the visitor log which is located at the front reception desk. The facility asks that each visitor signs in with their name, date and time of visit and person visiting. A review of the log showed that no one had signed-in to visit R1 for the month of January, 2020. Night of 1/8 - 1/9/20 Written statement obtained by the facility on 1/10/20 from CNA- [NAME] reporting on date of incident 1/8 into 1/9/20 (first night of visitor overnight stay). Writer reports there was a 1st shift aide walking the hall and noticed (R1) had the call light on. CNA- [NAME] entered room and noticed a man laying at the foot of (R1's) bed. Writer asked him did he have the light on for assistance? He replied everything was alright. The visitor smelled of liquor. Writer left the room and right away told the nurse of a man being in bed with (R1). Then the nurse went into (R1's) room to check things out. The CNA (additional staff member) later noticed (R1's) brief was messed with from behind to where it was torn but still strapped up. Written statement obtained by the facility on 1/10/20 from Licensed Practical Nurse (LPN)- F indicates she was working on 2-south (date) when passing medication a CNA made mention of a resident having a visitor. She said she thinks he visited all night. Writer asked her does she no (sic) for sure he visited all night? She said she didn't know. Then went to (R1's) room to do her treatment, at the time the CNA said look at her brief this is how I found it. One side was fastened and one was not fastened. Writer is not aware of what happened or why her brief was unfastened. It was noted that these statements were taken on 1/10/20 and that there was no reporting to Administration on 1/9/20 that R1 had a male visitor overnight (1/8 - 1/9/20) nor were concerns shared with Administration that the brief R1 was wearing (on 1/9/20) was partially torn. Staff was noted to have the concern, but did not report to the DON or Administration for further follow-up for potential abuse of R1. Night of 1/9 - 1/10/20 Per statement from CNA-J obtained by the Director of NursesWhen questioned what she saw exactly when she walked into the room, she (CNA-J)stated that she saw what was on her statement. Statement reads: She stated that she saw the visitor sitting on the edge of the bed with his hand in her (R1's) brief at the location of her private area. She stated that he did not pull his hand back when she entered. She stated that the visitor was fully clothed. She stated that the resident was sleeping. She stated that the resident was under the covers. She stated that the cover was pulled back some. Written statement provided by ADON- C on 1/20/20 states: upon arriving to 2nd floor (1/10/20), writer is approached by CNA stating that (R1) had a gentleman who stayed the night in her room. Per CNA statement when she entered the resident room (R1's), the gentleman was sitting on the edge of the bed of the resident. (R1) had her brief undone and gentleman had his hand down her pants. Per CNA statement, at the time the resident had her eyes closed and no signs of distress. CNA updated floor nurse of findings. Writer to check on resident after report received and it was noted the gentleman had left the facility. (R1) in a safe area with staff attendance. Writer to update DON and administration immediately. Writer and Social Worker to interview (R1) regarding incident. Writer to ask (R1) if she is aware she had any visitors night before. (R1) states yes, name given. Writer ask (sic) resident if she feels safe when said visitor comes. She stated yes, I like when he comes he brings me food. Writer asked if there is any physical contact when visitor comes. R1 stated yes and she is comfortable with visitor touching her sexually. On 1/15/20 at 12:09 p.m., Surveyor interviewed ADON (Assistant Director of Nursing)/ Unit Manager- C in regard to R1 having an overnight male visitor. ADON- C shared that yes, she is aware that R1 had a male visitor that stayed overnight in R1's room and that R1 does have a female roommate in the shared room. ADON stated that it was determined the overnight visitor was considered R1's boyfriend before she was admitted to the facility and that R1 does recognize him as her friend. ADON- C stated that she is not aware of R1's male friend visiting in the recent past and stated it could have been almost a year ago since he last visited. ADON-C stated that on 1/10/20, she was told by the morning shift (6 am start time) that R1 had a male visitor that had stayed overnight in her room. ADON- C stated that she immediately spoke with R1 along with Social Services- D. ADON- C stated that R1 stated she felt safe and was happy her boyfriend had visited her because he brought her chicken to eat. ADON- C also stated she asked R1 if her male friend had touched her and R1 replied yes and she was alright with it. ADON- C stated some staff were interviewed about the incident and this information was forwarded to the Director of Nursing (DON)- B. ADON- C stated she is not aware R1's male friend has visited her since her admission and that R1's friend may have some medical issues or even be homeless. ADON- C stated after the staff were made aware R1 had an overnight visitor they were going to put into place that the male visitor would need to leave by 9 p.m. On 1/16/20 at 12:19 p.m., Surveyor interviewed LPN- I via telephone. LPN-I confirmed what he had told DON- B in a previous interview; that he was aware R1 had a male visitor and that he had asked the visitor to leave twice, but he was waiting for a ride. LPN-I stated he was then told by another staff member that the male visitor was possibly dying and was scheduled for surgery and that is why he may be staying with (R1) as late as he is, so LPN- I thought that maybe the late visit was alright. LPN- I stated he was then alerted by (CNA- J) that she had observed the male visitor with his hands down (R1's) brief and that he immediately told the male visitor he had to leave now. LPN-I stated that staff called a cab for the male visitor and followed him outside the facility where the cab was waiting. LPN-I stated he watched the male visitor get into the cab and then then went over to the cab driver because they had not left. LPN-I stated the male visitor was having trouble giving the cab driver an address to take him too. LPN-I stated the cab did eventually leave although he is unaware of the time frame in which this all occurred during his shift. LPN- I stated he did not report the concern to anyone in administration and that today (1/16/20) is the first time he has talked about it with anyone since it happened. LPN- I stated he really didn't think this was a problem because (R1) knew her male visitor, although after hearing that the male visitor had his hands down (R1's) brief, he insisted the male visitor leave. Surveyor's review of R1's progress notes in the EMR (electronic medical record) did not provide any documentation that R1 had a male visitor who stayed overnight. The EMR did not contain any documentation that a male visitor had his hand down R1's brief or that a call was placed to the legal guardian for notification. The plan of care did not show any updates about R1's male visitor or that an assessment had been conducted regarding R1's ability to provide consent to sexual activity. On 1/15/20 at 2:18 p.m., Surveyor interviewed SS- D in regard to the incident involving R1. SS- D stated that on the morning of 1/10/20 she was made aware that there was a concern that R1 had a male visitor overnight and he was seen touching her under her brief. SS- D stated she talked with R1 and R1 said she knew who the visitor was and she liked his visits. R1 was asked about the sexual contact and R1 responded he does touch her and she likes it. SS-D stated she left a message for the guardian on 1/10/20 and the Guardian did return the call and left a voicemail message which SS- D did not listen to until her return to the facility on [DATE]. SS- D stated that the Guardian didn't mind if R1 had visitors but had no idea who the male visitor could have been. SS- D stated at the time of this interview (1/15/20) she still had not actually spoken with the Guardian to disclose full details of the situation and that no one else at the facility had tried to reach out to the Guardian other than her. SS- D was asked if any type of assessment had been conducted about R1's capacity to give consent to a sexual relationship after they were made aware R1's male visitor had been touching her. SS- D stated no assessment had been conducted and she was also able to verify that no documentation about the incident was in R1's medical record or on R1's plan of care. SS- D stated moving forward she hoped to talk with R1's male friend and get more details from him and would try to catch him the next time he visited. SS-D stated she has never meet the male visitor and is aware he has not followed the visitor sign-in policy when he has visited in the recent past. SS- D stated she would have to be alerted by other staff that the visitor was in the building and would approach him at that time. Written statement from SS- D obtained by the facility on 1/10/20 states that (on 1/10/20) she left a voicemail for R1's legal guardian requesting any knowledge of resident having a boyfriend or male visitor and if she had concerns. SS- D wrote she was awaiting a return call. Written statement from SS- D obtained by the facility on 1/14/20 stated that on today's date (1/14/20) writer received voicemail from (R1's) legal Guardian stating she was not concerned of (R1) having visitors, but is not aware of who the male visitor is. Writer called back and left another voicemail for legal guardian to touch base regarding visitor, Waiting (sic) for call back. Writer will approach visitor the next time he is in the building to collect more information for staff and legal Guardian. As of 1/16/20, the last scheduled date of the survey, no further evidence had been provided that the facility was able to discuss the above situation with R1's guardian in full detail. On 1/15/20 at 12:39 p.m., Surveyor interviewed DON- B.DON- B stated she reviewed the surveillance footage from the facility's security cameras. DON- B stated R1's male friend actually stayed 2 nights in her room, on 1/8/20 and 1/9/20. DON- B shared that the camera footage shows R1's male visitor coming into the building on 1/8/20 and then he seemed to come and go in and out of the facility but he did come in and then did not leave in the evening. The camera footage also shows that R1's visitor stayed the evening of 1/9/20 and does not provide a timeline of when R1's visitor actually left on 1/10/20. DON- B stated it was told to her (on 1/10/20) that R1's male visitor was found to have his hand down R1's pants/ brief. DON- B stated (on 1/10/20) R1 was only wearing a gown and brief. DON- B was asked by Surveyor what was put in place to keep R1 safe from any further potential sexual contact with the male visitor. DON- B responded by saying she understood what Surveyor was saying and could not provide any additional information on this topic. DON- B stated the facility has not conducted any type of assessment on R1's capacity to consent to sexual activity and that the focus was that R1 knew the male visitor and it was her old boyfriend. DON-B stated she believes that R1's roommate was not impacted and that the plan is to make sure if R1's visitor comes to the facility in the future, he must leave by 9:00 p.m. DON- B stated due to R1 have a prior relationship with the male visitor and R1 stating she was fine with the visitor, no further consideration was given that this was a problem. DON- B stated that she was not aware of the last time R1's male friend came to visit prior to 1/8 and 1/9/20. On 1/16/20, Surveyor made observations of R1's room and noted there was a hand written sign above R1's bed which if R1 is asking for (male visitor's name), please call and a phone number is listed. On 1/16/20 at 3:20 p.m., Surveyor interviewed CNA- G who was assigned on the 2nd shift to work with R1. CNA- G indicated he does not know exactly how long the sign has been up above R1's bed and it probably has not been there very long. CNA- G shared the name listed on the paper is R1's friend and he visits from time to time and CNA- G stated he is not aware of any restrictions on his (friends) visits with R1. Surveyor was provided with an updated copy of R1's care plan showing that on 1/15/20, Administrator -A documented in the plan that (R1) chooses to have an intimate and interpersonal relationship with male friend, initiated 1/15/20. Listed interventions include to encourage (R1) to discuss issues/ concerns with staff, monitor for changes in mood and behavior that would indicate (R1) is distressed, provide education that (R1) is able to understand regarding what is considered abuse and resident right to say no, respect resident rights, staff to be respectful of residents rights to form intimate and companion relationships with others. There was no evidence that R1 had been assessed for the capacity to consent to a sexual relationship or that a plan was clearly established to address any potential visits R1 may have from the male visitor and that staff was fully aware of such plan. Surveyor noted this plan of care was established without the facility having a full understanding of the allegation of abuse regarding R1 and without a comprehensive assessment related to R1's ability to understand and provide consent. The facility's failure to evaluate R1's capability to consent to a sexual relationship, and to protect R1 from the potential for sexual abuse/exploitation, created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 1/20/2020, when it initiated the following: ~ The relationship of (R1) was thoroughly investigated to assess her capability to consent to intimate relationships. (R1's) visitations will be monitored to protect the resident from any form of abuse. ~ NHA made aware on 1/10/2020. ~ Investigation was initiated on 1/15/2020. ~ Guardian notified on 1/15/2020. ~ Physician/medical director on 1/15/2020. ~ Notified police on 1/16/2020. ~ An assessment was completed by nursing on 1/16/2020. ~ Initial abuse report (to Office of Caregiver Quality) made at 12:34 pm on 1/16/20. ~ Visitor removed pending investigation. ~ Resident's roommate cognitively intact and denies any inappropriate issues related to the visitor. ~ Affected residents' written plan of care has been reviewed and updated as deemed necessary 1/17/2020. ~ Staff member identified in the deficiency was educated in abuse policy and abuse reporting and notification. Like Residents/System Correction: ~ Staff will be interviewed to determine if there are any other non-consensual resident identified as having visitors and their capacity to consent. ~ Upon any allegations of abuse, the resident will be kept safe and will be reported to the state of Wisconsin and law enforcement and protective services. ~ Residents with Severely Impaired cognition or safety awareness will be assessed for any potential abuse and follow up as appropriate, including notification of law enforcement, protective services and State of Wisconsin ~ Residents will be assessed upon admission for capacity to consent and vulnerability for abuse including sexual abuse and care planned appropriately. Newly admitted residents will be encouraged to notify staff if any feelings of mistreatment occur without fear of retaliation. (Staff reporting will be reinforced) ~ All staff inservice will be held 1/22/20 ~ Regional Supervisors will be notified of initiation of any potential abuse investigations. Education: ~ Beginning (MONTH) 16th 2020, staff were educated prior to the start of their next scheduled shift on protection, investigation, and reporting until all staff have completed education. The facility has posted how to respond to potential abuse with emphasis on reporting any potential abuse to the administrator. ~ NHA reeducated on Abuse policy on 1/16/2020. Monitoring/Audits: ~ NHA and/or designee will conduct ongoing audit which will be reviewed in the daily morning meeting. Adverse findings will be immediately addressed. These findings and other unusual occurrences will be reported to QAPI Committee for further review and consideration. ~ The Medical Director was updated on this Correction and Removal-Abatement Plan as well as occurrences of which this plan pertains to. Monitoring will be initiated and completed by the Director of Nursing and/or designee as indicated above. Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI (Quality Assurance Performance Improvement) Committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits; will be determined at that time. If issues are identified, re-education will be done. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed and revisions will be made as deemed necessary.

Based on observation, record review and interview, the resident environment did not remain free of accident hazards and each resident received adequate supervision and assistance devices to prevent accidents for 13 of 18 residents (R49, R9, R98, R61, R64, R29, R77, R40, R104, R24, R99, R102, R27) reviewed for accident hazards. On 6/25/19 and 6/26/19, the alarms on the exit doors for all 3 resident living floors were not functioning. The alarms on the doors consist of the emergency door alarm and/or wanderguard system alarms. Each of the resident floors 1, 2, and 3 have residents who have been identified to wander and wear a wanderguard. The Administrator, Director of Nursing and staff on the 3 floors were not aware the wanderguard alarms on the doors were not working. The Director of Nursing and the staff on the 3 floors did not know the emergency door alarms to the exits were not working. No provision was made for staff to provide continual supervision of the exit doors as per the facility's elopement policy and no provision was made to increase resident supervision for those residents wearing a wanderguard. According to the front desk wanderguard book, there are presently 9 residents in the facility identified as at risk for wandering/elopement (R49, R9, R98, R61, R64, R29, R77, R40, R104). The facility failure to ensure emergency door alarms and wanderguard systems were functional to alert staff should a resident wander off the unit and staff not aware of door alarms not functioning properly created a finding of immediate jeopardy that began on 6/25/19. The Nursing Home Administrator (NHA) A, Director of Nursing (DON) B, Corporate RN NN, Regional Operations MMM were notified of the immediate jeopardy on 6/26/19 at 3:24pm. The immediate jeopardy was removed on 6/27/19, however the deficient practice continues at a scope/severity of [NAME] based on the following examples: * R24 is identified at risk for falls. On 5/20/19, R24 did not receive the assistance of 2 staff members when dressed as per the MDS assessment, resulting in R24 falling out of bed. On 6/20/19, R24 was in bed while the bed was in the high position with no floor/fall mat on one side of the bed. * R99 is at at risk for falls. On 6/19/19 during care observations, R99 was left in bed with the bed in high position and no staff member present. On 6/24/19, R99 was observed in bed with the bed up in high position and no staff member present. * R102 is at risk for falls. On 6/18/19 and on 6/20/19, R102 was observed in bed with the bed in high position and with no staff member present in the room. * R27 who is at risk for falls had a bed side rail which was broken. R27 stated he reported the broken side rail approximately a month earlier and as of 6/18/19, the side rail had not been repaired. Findings include: On 6/26/19 the facility's policy titled, Elopement Policy dated 1/5/08 was reviewed and read: Residents who have been assessed at risk for elopement shall be provided at least one of the following safety precautions by the facility. 1 a. An adult electronic monitoring safety device. b. Door alarms placed on facility exits. c. Keypad controlled elevators. 4. At no time shall a door alarm be turned off, without the continual supervision of the exit. In the event that the door locks/ alarms of a secure unit become disabled the facility must ensure a temporary protective system is in place. 1. The facility is made up of an entrance ground level floor and 3 residential living floors consisting of first floor, second floor, and third floor. The hallway exit doors on the 3 residential living floors have alarms on them. The alarms may consist of either one or a combination of alarms which may include an emergency door alarm, a wanderguard alarm and/or a magnetic door alarm. On 6/25/19, Surveyor observed Receptionist NNN updating the wanderguard book located at the front desk. Receptionist NNN stated there are 9 residents presently on the wanderguard list and showed Surveyor the names of the 9 residents which consisted of; First Floor: R104; Second Floor: R61, R49, R98, R9; Third floor: R77, R64, R29, R40. Surveyor asked Receptionist NNN if there were any concerns brought to her attention in regards to the wanderguard system or door alarms. Receptionist NNN stated, No, not that I am aware of and I have not been told of any concerns with doors. Surveyor observed a surveillance video running on a monitor located at the Receptionist's desk. Receptionist NNN informed Surveyor that this is a 24 hour video showing the entrance, exit areas, smoking area, nurses desk etc. Receptionist NNN stated most of the time she keeps her eye on the surveillance system. Receptionist NNN thought that the 'higher ups' also had access to the surveillance video. Receptionist NNN informed Surveyor she was going to have to reset the system and it was presently not on. Receptionist NNN stated, my computer (monitor) likes to freeze up. Receptionist NNN stated she keeps an eye on the monitor and that she works 6 hours a day. Receptionist NNN reported there is a receptionist from 8:00 am to 8 pm. 7 days a week, the front doors lock at 8 pm and then the back ambulance entrance is used. Interview with Director of Maintenance Director (DM) - C: On 6/26/19 at 11:59 AM, DM - C was interviewed. DM - C said that on 6/25/19 the State Agency Life Safety Code Surveyor completed a tour of the building. DM - C and NHA - A were present on the tour. It was during the tour that DM - C learned that some of the emergency exit door alarms were not working. DM - C said that parts of the emergency door were not working. On some doors the emergency alarm was not sounding and on other doors the 15 second delay egress was not working. These doors would open immediately. It was at this same time that DM - C learned that the Wanderguard Alarm was not working on some of the doors. The Wanderguard Alarm doors have next to the door a box with a light. If the light is not illuminated, the Wanderguard Alarm is not operational. DM - C said that he noticed that some of the lights on the boxes where there is a Wanderguard Alarm were not illuminating during the tour on 6/25/19. DM - C did not share this information with NHA - A or the Life Safety Code Surveyor. DM - C said that he needed to call an outside company to fix the emergency alarm/15 second egress doors. DM - C said that he planned to have this same company fix the Wanderguard Alarmed Doors. Second Floor 2. On 6/26/19 at 10:23 AM, the surveyor exited the second floor via the stairwell door that has a Wanderguard Alarm. The surveyor disarmed the Wanderguard Alarm by punching a code into the key pad. R49 followed the surveyor through the doorway and into the stairwell. The surveyor called for Licensed Practical Nurse (LPN) - P who was at the nurses' station. LPN - P assisted R49 out of the stairwell and back onto the unit. The surveyor asked LPN - P if R49 wore a Wanderguard Bracelet on her person and if the door should have alarmed. LPN - P asked the Director of Social Services (DSS) - U, if R49 wore a Wanderguard Bracelet. DSS - U said that R49 wore an alarm and the alarm should sound. LPN - P then showed the surveyor that R49 had a Wanderguard Alarm on her ankle. LPN - P then called the maintenance department to determine if there was a problem with the Wanderguard System. At 10:27 AM, Director of Maintenance Director (DM) - C came to the 2nd Floor and informed LPN - P and the surveyor that the Wanderguard Alarm was not working on the 2nd Floor stairwell door. DM - C said that on 6/25/19 he learned that the 2nd Floor stairwell alarm door and 3 alarmed doors on the Third Floor were not working. DM - C said that the doors were supposed to be working by the end of the day on 6/26/19. On 06/26/19 at 10:37 AM, the surveyor informed Nursing Home Administrator (NHA) - A that the Wanderguard Alarm on the 2nd Floor Stairwell Door was not working and that DM - C said that some additional door alarms were not working. NHA - A said that he was not aware that the Wanderguard Alarm System was not working. The surveyor asked what plan was in place to keep residents safe while the system was not working. NHA - A said, I will check with them to see what they are doing. Interviews with staff: On 6/26/19 at 11:03 am, LPN - V was interviewed. LPN - V had been told about 30 minutes earlier that the Wanderguard Alarm was not working on the 2nd Floor Stairwell Door. LPN - V had worked on 6/25/19 and was not told on 6/25/19 that the Wanderguard Alarm was not working on the 2nd Floor stairwell door. On 06/26/19 at 11:06 AM RN Manager - W was interviewed. RN - W said that the Wanderguard Alarm on the elevator doors was working. RN - W said that she had not been informed on 6/25/19 that the Wanderguard Alarm was not working on the 2nd Floor Stairwell Door. On 6/26/19 at 11:20 AM, NHA - A was interviewed. NHA - A said that he had not known that the Wanderguard Alarm was not working on the 2nd Floor until the surveyor had informed him. NHA - A said that he had been aware on 6/25/19 that the 15 second emergency egress door alarms were not working; but he had not been informed about the Wanderguard Alarm not working. NHA - A said that the 15 second emergency doors had a magnetic mechanism that was not working. The doors were supposed to stay locked for 15 seconds; but they were opening immediately. On 6/26/19 at 11:45 AM, the surveyor checked all of the exit doors on the 2nd Floor. All of the exit doors on the 2nd Floor have 2 alarm systems: a Wanderguard Alarm and an emergency alarm. Review of doors on the 2nd floor indicated as of 6/16/19 at 11:45 am, 1 of 5 exit doors did not have a functional wanderguard alarm and did not have a functional emergency door alarm. Additionally 1 of the 5 exit doors emergency alarms had been turned off when the wanderguards were being tested . The emergency alarm had been turned back on when LPN Y and Surveyor noticed that the emergency alarm did not activate. On the West Hallway, the door at the end of the hallway was tested . The Wanderguard Alarm sounded when the door was opened. The emergency alarm did not sound. LPN - Y said that facility staff had just turned off the emergency alarm when the Wanderguard Alarms were being tested . LPN - Y could not remember who turned the alarm off; but was certain it was turned off to check the Wanderguard Alarm. LPN - Y used a key to turn the emergency alarm back on and the emergency alarm now sounded when the door was opened. The 2nd Floor Stairwell Door. Neither the Wanderguard Alarm, nor the emergency alarm was operational on this door. The remaining 3 doors on the 2nd Floor had a Wanderguard Alarm and a emergency alarm that was operational when tested . There are 2 elevators on the 2nd Floor. The door to the freight elevator in the dining room was locked. The elevator could only be accessed with a key. The other elevator is across from the nurses' station. R9, who wears a Wanderguard bracelet, walked into the elevator. The Wanderguard Alarm sounded, demonstrating that the Wanderguard Alarm on this elevator was operational. Second floor Residents with Wanderguards: 3. R49 is [AGE] years old and has [DIAGNOSES REDACTED]. During the survey, R49 was observed to walk/pace about the 2nd Floor Unit independently. R49 was observed to walk continuously, without having a specified destination. R49 had an Annual Minimum Data Set (MDS), dated [DATE], that indicated R49 wandered daily. The MDS noted that the wandering placed R49 at significant risk of getting to a potentially dangerous place (stairs, outside of the building). The facility had completed a Wandering Risk Scale on 5/8/19. R49 was noted to be at a High Risk to Wander. R49 has a care plan, initiated 9/27/17, that notes R49 is at risk for elopement related to her [DIAGNOSES REDACTED]. Interventions include the use of the Wanderguard. The medical record contains no information that R49 has wandered off of the unit; with one exception. R49 followed the surveyor off of the unit onto the 2nd Floor Stairwell on 6/26/19. (See Above) In addition to being at risk for wandering, R49 is at high risk for falls according to her 9/1/17 care plan. The care plan documents that R49 is at risk for falls due to her wandering. Although R49 is noted to only wander about the unit; if the Wanderguard Alarm was not working and R49 was able to enter the stairwell she could be at risk for falling down the stairs. 4. R9 is [AGE] years old and has [DIAGNOSES REDACTED]. During the survey, R9 was observed to walk about the 2nd Floor Unit independently. R9 was admitted to the facility on [DATE]. R49 had an initial Minimum Data Set completed 3/27/19 and a Quarterly MDS completed 6/21/19; both indicate that R9 has not wandered. However, R9 has a care plan, dated 3/20/19, that indicates R9 is at risk for wandering due to a past history of wandering and eloping from facilities/placements. Interventions include the use of a Wanderguard. R9's progress note on 5/11/19 documented the following incident. Writer observed resident and resident in room ( ) on elevator on first floor. Resident stated that he was taking resident in room ( ) to bank, both residents taken back to 2nd floor. Advised resident that he cannot take another resident out of building, he was very receptive and had no problem returning to unit. The (MONTH) 2019 Medication Administration Record [REDACTED]. On 6/4/19, this behavior occurred 6 times on the PM shift. On 6/8/19, this behavior occurred 3 times on the PM shift and 3 times on the Night Shift. No additional information was documented. 5. R98 was observed walking independently in halls of the second floor unit. R98 was assessed to be as risk for wandering and had a wanderguard in place. R98 resided on the second floor unit where the non-functioning wanderguard alarm was located. R98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R98's Wander Risk Assessment, dated 6/3/19, documents a score of 11. Indicating R98 is at high risk for wandering behavior. R98's Quarterly Minimum Data Set (MDS) assessment, dated 6/4/19, documents: long and short term memory problems, severely impaired decision making; wandering behavior occurring daily; ability to walk independently in her room and on the unit; inability to speak and rarely/never makes self understood or understands others. R98's Care Plan, dated 3/1/19, documents: R98 is an elopement risk/wanderer r/t (related to) hx (history) of wandering at previous facility, cognitive impairment, being mobile enough to exit unit or facility. Interventions included Wanderguard in place, 3/4/19. 6. Surveyor reviewed R61's medical Record. R61's quarterly Minimum Data Set (MDS) with an assessment reference date of 05/14/19 indicates R61 is moderately cognitively impaired for daily decision making skills with a Brief Interview for Mental Status (BIMS) score of 11. The MDS indicates R61 had not exhibited wandering behaviors. A Wandering Risk Scale assessment was completed on 5/13/19 which indicated R61 was at low risk for wandering. The comments/notes on the assessment documents, Resident will wander on unit. He does not leave unit without speaking with staff. He does not wander outside of the building. A Wandering Risk Scale assessment completed the next day on 5/14/19 indicated R61 is at high risk to wander, R61's, care plan identifies R61 is at risk for elopement related to previous elopement attempts, being mobile, deemed incompetent, legal guardian in place. Initiated 01/06/16. Interventions consist of in part, has wanderguard due to elopement risk. Check for placement every shift and inform nurse if not in place .initiated 04/04/16. Third floor: 7. On 06/26/19 at 11:01 AM, Health Unit Coordinator (HUC)-BB took the Surveyor to each of the exit doors on the 3rd floor. Out of 6 doors 3 did not sound when they were opened and were observed to be unsupervised. The doors were called the south, west and east doors by HUC-BB. All 3 doors that did not sound lead directly to un unalarmed exit on the ground floor. HUC-B was unable to get the south and west emergency door alarm to function but was able to turn on the east emergency door alarm. Immediately after the above observation Maintenance Director-C and Administrator-A were brought to the south and west doors. Maintenance Director-C was able to turn on the emergency door alarms on the doors with a key and indicated the alarm were turned off when they were fixed last night 6/25/19 and he was aware they were off. On 6/26/19 at 11:19 AM, Certified Nursing Assistant (CNA)- N was interviewed and indicated she was not made aware that door alarms weren't working. On 6/26/19 at 11:20 AM, CNA- EE was interviewed and indicated she was not made aware that door alarms were not working. On 6/26/19 at 11:22 AM, Licensed Practical Nurse (LPN)- M was interviewed and indicated she did not know until 10:00 AM today that the east door alarm was not working. LPN-M indicated Assistant Director of Nurses (ADON)-I told her the east door alarm was not working at 10:00 today and to watch the residents. LPN-M was asked how they were doing that and LPN-M stated, I don't know. On 6/26/19 at 11:25 AM, ADON-I was interviewed and indicated that she was unaware that the south, east, and west emergency door alarms were not working and did not give any instructions to staff. ADON-D then went around with the Surveyor to verify that R64, R40 and R29 were visualized on the unit as they are all at risk for wandering and wear wanderguard transmitters. ADON-I also indicated R77 was also at risk for wandering but was at a medical appointment. R77 was visualized in the building on 6/26/19 at 1:30 PM when she returned from her appointment. On 06/26/19 at 11:48 AM, Maintenance Assistant-D was interviewed and indicated the east and west exit door have magnetic alarm locks, however they are not currently functioning and have not been since yesterday 6/25/19. 8. R64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R64's Quarterly Minimum (MDS) data set [DATE] indicated R64 had a Brief Interview for Mental Status score of 11 (moderately impaired). On 6/27/19 R64's care plan for wandering risk dated 11/2/16 was reviewed and read: R64 is at risk for elopement related to [DIAGNOSES REDACTED]. wanderguard. On 6/27/19 R64's Wandering risk scale dated 6/18/19 was reviewed and read: At risk to wander. No episodes in the last 6 months. On 6/26/19 at 11:25 AM Assistant Director of Nurses-I indicated R64 currently had a wanderguard device in place and was at risk for wandering. R64 was seen in his room at this time. 9. R29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/27/19 R29's care plan for wandering risk dated 5/24/19 was reviewed and read: R29 is at risk for elopement related to [DIAGNOSES REDACTED]. wanderguard in place On 6/27/19 R29's Wandering risk scale dated 5/24/19 was reviewed and read: At risk to wander. Has wandered in the past month. On 6/26/19 at 11:25 AM Assistant Director of Nurses-I indicated R29 currently had a wanderguard device in place and was at risk for wandering. R29 was seen in the common area at this time. 10. R77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R77's Annual Minimum (MDS) data set [DATE] indicated R77 had a Brief Interview for Mental Status score of 6 (severely impaired). On 6/27/19 R77's care plan for wandering risk dated 11/7/17 was reviewed and read: R77 is at risk for elopement related to [DIAGNOSES REDACTED]. wanderguard in place On 6/27/19 R77's Wandering risk scale dated 5/21/19 was reviewed and read: low risk to wander. Has wandered in the past month. At times will leave unit due to confusion. Interdisciplinary team has met and decided to keep wanderguard. On 6/26/19 at 11:25 AM Assistant Director of Nurses (ADON)-I indicated R77 currently had a wanderguard device in place and was at risk for wandering. ADON-I indicated R77 was out of the building at a medical appointment at this time. R77 was visualized this day on the unit at 1:30 PM. 11. R40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R40's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R40 had a Brief Interview for Mental Status score of 15 (fully intact). On 6/27/19 R40's care plan for wandering risk dated 11/2/16 was reviewed and read: R40 is at risk for elopement related to [DIAGNOSES REDACTED]. Intervention: wanderguard in place. On 6/26/19 at 11:25 AM Assistant Director of Nurses-I indicated R40 currently had a wanderguard device in place and was at risk for wandering. R40 was was seen in the common area at this time. On 6/27/19 R40's Wandering risk scale dated 4/29/19 was reviewed and read: at risk to wander. Has wandered in the past month. Leaves the unit frequently and often states she wants to leave facility and go out by herself to stores, restaurants, etc, wanderguard in place for safety. First floor: 12. On 6/26/19 at 11:04 a.m., Surveyor asked LPN (Licensed Practical Nurse)-F if the wanderguard system on the first floor is working. LPN-F informed Surveyor it should be working. Surveyor asked LPN-F if anyone said anything to her about the wanderguard system not working. LPN-F replied, No. On 6/26/19 at 11:07 a.m., Surveyor asked CNA (Certified Nursing Assistant)-T if anyone said anything to her today or yesterday about the wanderguard system not working. CNA-T informed Surveyor no one mentioned anything. On 6/26/19 at 11:08 a.m., Surveyor asked LPN-H if there is a list of Residents who wear a wanderguard on the first floor. LPN-H replied maybe at the desk I don't have one. Surveyor asked LPN-H if anyone said anything to her about the wanderguard system not working to her. LPN-H replied, No. On 6/26/19 at 11:10 a.m., Surveyor asked LPN-F if there is a list of Residents who wear a wanderguard on the first floor. LPN-F replied, Yes there is a list. LPN-F then showed Surveyor a binder located at the nurses station with an orange sheet on the cover entitled wanderguard book. Surveyor noted for the first floor R104 is listed. On 6/26/19 at 11:14 a.m., Surveyor asked CNA-DDD if anyone mentioned any problems with the wanderguard system for the first floor. CNA-DDD replied, No. Surveyor then asked CNA-DDD to accompany Surveyor to see if R104 has a wanderguard alarm on. Surveyor observed R104 laying in bed. CNA-DDD showed Surveyor R104 is wearing a wanderguard alarm on her right ankle. On 6/26/19 at 11:24 a.m., Surveyor asked ADON (Assistant Director of Nursing)-J, who is the first floor nursing manager, if the wanderguard system is working. ADON-J replied, Yes. Surveyor asked if there was a transmitter to test the alarm. ADON-J replied, Yes on one of the medication carts. On 6/26/19 at 11:37 a.m., Surveyor accompanied HUC-BB to test the doors on the first floor. HUC-BB tested the wanderguard alarm on the door near room [ROOM NUMBER]. Surveyor noted the alarm was working. At 11:38 a.m., HUC-BB opened the exit door next to room [ROOM NUMBER]. Surveyor noted the Pilfur (Emergency alarm) guard alarm did not activate. HUC-BB then turned the alarm on. Surveyor asked if the alarm was off. HUC-BB replied, yes, now it's activated. At 11:40 a.m., Surveyor observed the west stairway alarm sounded. At 11:41 a.m., Surveyor observed the south hallway Pilfur guard alarm sounded. At 11:42 a.m., HUC-BB opened the stairway door inside the dining room. This door did not alarm. HUC-BB then turned the alarm on this door. At 11:43 a.m., HUC-BB tested the wanderguard system for the doors outside the freight elevator which is located inside the dining room. Surveyor noted the two doors are open and the wanderguard alarm did not sound. Surveyor verified with HUC-BB the wanderguard system is not working on the two doors before the elevator and stated, It should have. Surveyor noted 3 of the 6 door with alarms did not activate when tested . HUC-BB turned on the alarm at 2 of the doors. 1 of the 6 doors had a wanderguard alarm which was not working. 13. R104 has a [DIAGNOSES REDACTED]. The Resident is at risk for elopement r/t (related to) dx (diagnosis) of dementia, being deemed incompetent and being able to ambulate off unit and out of building, often states she needs to get out of here and get home has gotten on elevator in past and is looking for exit care plan was initiated on 4/5/17 and revised 6/18/19. The wandering risk assessment dated [DATE] has a score of 9 which indicates at risk for wandering. The quarterly MDS (minimum data set) with an assessment reference date of 6/6/19 documents R104 has short & long term memory problems and is moderately impaired for cognitive skills for daily decision making. For the question has the resident wandered 0 is coded indicating the behavior is not exhibited. R104 requires limited assistance with one person physical assist for transfer, is independent in ambulation in the room and requires limited assistance with one person physical assist for ambulation in corridor, locomotion on & off unit. The wandering risk assessment dated [DATE] has a score of 9 which indicates at risk for wandering. Under the comments/note section documents WANDERGUARD/WANDER RISK: Resident is at risk for elopement r/t dx of dementia, being deemed incompetent and being able to ambulate off unit and out of building, often states she needs to get out of here and get home, has gotten on elevator in past and is looking for exit. On 6/26/19 at 2:50 pm, Maintenance Director Assistant D informed Surveyor he checks all the pilfer doors (doors with emergency alarms) on a daily basis. On 6/26/19, Surveyor was provided with the maintenance logs for door testing. A Daily Alarm door test for dates of 6/24/19 to 6/30/19 indicated the 24 door alarms were checked on Monday 6/24, Tuesday 6/25, and Wednesday 6/26. Under comments, is written, 3rd floor alarms mag not working 6/25/19. The surveyor was also presented with daily Wanderguard door sensor checklist for 6/10/19 through 6/26/19 at the following locations: Main Entrance, Employee Entrance, Parking Garage Stairwell, First Floor Center Stair, First Floor Freight Elevator, Second Floor Center Stair, Second Floor Freight Elevator, Third Floor Center Stair, Third Floor Freight Elevator. These daily checks do not indicate any non-functioning wanderguard door alarms. The failure to ensure door alarms and wanderguard systems were functional to alert staff should a resident wander off the unit and staff not aware of any door alarms not functioning properly, created a finding of immediate jeopardy. The facility removed the jeopardy 6/27/19, when it had completed the following: Floor Maps of the center were reviewed and a walk-thru completed as a means to identify all secured/armed doors, elevator keypads and Wanderguard systems. Exits identified as not having an appropriate and/or functioning alarm system were reviewed, individually, and the temporary protective system deemed most appropriate was put into place (battery operated alarm, staff monitoring, etc.). These temporary protective systems will remain until identified alarm systems are repaired. The Environmental Services Director was educated on his notification requirements regarding the safety expectations involving residents. Stanley and RF Technologies were both contacted on Wednesday, (MONTH) 6th and reported to the center on Thursday, (MONTH) 7th at approximately 11:00 am to evaluate the WanderGuard systems in question. It was reported that some had antenna damage and/or wiring damage and the older models simply needed to be replaced with a newer system because parts could no longer be procured. The door alarms which consisted of the wanderguard system was repaired on 6/27/19 and the delayed egress mag locks were repaired and operational by 7/11/19. All residents most recent Wander Risk Assessments were reviewed; new assessments completed as deemed necessary. Residents who indicate Moderate and/or High Risk for Wandering were reviewed for appropriateness of wanderguard placement. Those identified as needing a wanderguard were reviewed to ensure devices were in place, functioning and within expiration date. Care Plans and Treatment Records updated to ensure that placement and functionality are checked according to policy. Elopement Binder(s) reviewed, updated and placed at Nursing Station(s) and Reception area. Residents identified as needing a Wanderguard will reside on Floor 2 where Elevators are secured with a Wanderguard system. The Exit identified on Floor 2, that does not have a functioning alarm/Wanderguard, will be monitored by a designated staff member at all times until alarm is serviced and functioning properly. As part of the facility's Preventative Maintenance Program, all secured doors, elevator keypads AND Wanderguard Systems will be checked for proper function daily. Preventative Maintenance Checks will documented. Procedure for How to respond when an Armed Door Alarms, was laminated and posted by all Armed Exits on the nursing units. A monitoring tool was developed to ensure ongoing and sustained compliance as it pertains to residents identified as At Risk for Wandering. In addition, an audit was developed to be utilized when an attempted elopement takes place. This audit ensures appropriate assessments, charting and interdisciplinary review take place following an attempted or successful elopement attempt. Any discrepancies will be immediately addressed and additional follow-up will be reviewed and monitored at the QAPI (Quality Assurance Performance Improvement) meeting. Beginning Wednesday, (MONTH) 26, 2019, personnel were educated regarding centers Elopement Policy. Review of this Policy included education related to: Who to immediately notify if alarms are malfunctioning Elopement Drill (Code Yellow) Elopement Book/Binder Procedure for Responding to an Armed/Alarming Door Identification and Monitoring of At Risk Residents Additionally, mandatory staff-wide in-services scheduled on 7/1, 7/3, and 7/5/2019 to further review the requirements of F689 as it pertains to the requirements of the facility to provide a safe, functional, sanitary, and comfortable environment for resident, staff and the public. Specifically, this education reiterates the responsibility of the facility to ensure resident environment(s) remain free of accident hazards as is possible and the facility is to prevent accidents by providing an environment that is free from hazards over which the facility has control. All new employees will be educated on this plan as part of their General Orientation. Administrator and/or designee will audit the compliance of this plan via random staff/resident interviews, environmen

Based on interview and record review the facility did not immediately consult with a resident's physician of a significant change in the resident's physical status for 1 of 22 residents (R32) reviewed for significant change notifications. R32 sustained a fall with a head injury during van transport on 6/10/19. R32 was transported to the hospital for evaluation and treatment and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Upon return, the facility did not consult with the physician of a change in condition occurring on 6/11/19 at 5:09 PM. The facility waited until 10:30 PM, when R32 experienced another change in condition. R32's physician was consulted at 11:53 PM on 6/11/19. R32 was transferred to the hospital at 12:30 AM on 6/12/19. R32 was diagnosed with [REDACTED]. The facility's failure to immediately consult R32's physician of the change of condition on 6/11/19 at 5:09 PM and waiting until R32 experienced another change of condition on 6/11/19 at 10:30 PM, and finally consulting with the physician at 11:53 pm, created a finding of immediate jeopardy on 6/11/19. On 7/12/19 at 12:30 PM, Surveyor informed Director of Nursing (DON)-B of the immediate jeopardy that began on 6/11/19. The immediate jeopardy was removed on 7/13/19, however the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) based on the following example: * On 6/24/19, R22's blood sugars were very high. The facility did not consult with R22's physician regarding R22's blood sugars. Findings include: The facility policy entitled, Change in Condition, dated 12/19/18, states: Purpose: To ensure prompt notification of the resident, the attending physician, and Durable Power of Attorney/Responsible Party of changes in the resident's physical, psychosocial and/or mental condition and/or status. Procedure: 1. The physician and Durable Power of Attorney/responsible party will be notified when there has been a change that is sudden in onset, a change that is marked difference in usual sign/symptoms and/or signs/symptoms are unrelieved by measures already prescribed. 4. If the physician cannot be reached, the Medical Director will be notified to report the change in condition until the physician can be reached. Procedure: 1. The licensed nurse may perform the neurological status evaluation without a physician's orders [REDACTED]. Assessment results that need to be reported to the physician are: a. Any pupil reaction changes, especially with a decrease in level of consciousness; b. Any decrease in level of consciousness from baseline assessment or from resident normalcy; c. Any sensory or motor loss or decline; d. Any marked changed in vital signs; e. Any changes in resident condition. Other significant neurological symptoms include: a. Nausea and vomiting; b. [MEDICAL CONDITION] activity; c. Visual disturbance; d. Headache. R32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R32's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/15/19, documents: A Brief Interview of Mental (BIMS) score of 14, indicating R32 is cognitively intact. On 6/10/19, R32 was transported to [MEDICAL TREATMENT] by a contracted transport company. On 6/10/19, hospital discharge paperwork documents: . was brought to the ED (emergency Department) by EMS (Emergency Medical Services). He fell in the transport van. He was left at the [MEDICAL TREATMENT] unit. He was sent to ED by [MEDICAL TREATMENT] unit staff to get evaluated after he gave h/o fall. He fell out of his wheelchair and hit his head. He denies cp (chest pain), sob (shortness of breath). He has mild headache. CT (Computerized [NAME]ography) head shows left sided subdural hematoma. Patient denies being buckled in and that there was erratic driving.Hospital course: 6/10/19: Admission with acute on subdural hematoma; 6/11/19: CT scan overnight mildly improved, [MEDICAL TREATMENT] stable. discharged to facility with [MEDICATION NAME] BID (2 times a day) to complete 7 days total treatment for [REDACTED]. Plan for follow up CT scan of head in 2 weeks with neurosugery appointment to follow. On 6/11/19 at 2:45 PM, R32's medical record documents: R32 returned from CMS (Columbia Saint [NAME]'s) with DX (diagnosis) of a resolving subdural hematoma as a result of a fall in transport vehicle. VSS (Vital Signs Stable). Assessments completed, NNO (No New Orders) Daughter .aware of readmit. Surveyor could not find evidence the facility completed a neurological assessment for R32 upon return to the facility (cross reference F684) and the facility did not order the [MEDICATION NAME] 500 mg (milligrams) by mouth, every 12 hours, that was listed on the patient medication schedule that was provided to the facility upon R32's return to the facility. (Cross Reference F755) On 6/11/19 at 5:09 PM, R32's medical record documents: Was called to resident's room for report of resident vomiting. Resident was observed lying almost flat eating food that family had brought in. Resident HOB (Head Of Bed) elevated and he was educated on the importance of eating in an upright position. Resident's visitors also educated. [MEDICATION NAME] provided. Surveyor could not find evidence the facility completed a neurological assessment of the resident or updated the physician on R32's change in condition. The facility Neurological Status Evaluation policy and procedure identifies any change in condition including nausea and vomiting as a significant neurological symptom that should be monitored and reported to the physician. On 6/11/19 at 10:30 PM, R32's medical record documents: Writer went into assess how resident was feeling and found he had vomited undigested food. Resident's speech is very slurred at this time and is not answering questions when asked. VS (vital signs) remain stable. Dr (doctor) paged-awaiting return call. On 6/11/19 at 11:53 PM, R32's medical record documents: Writer with follow up call to MD (Medical Doctor). On call MD updated on resident condition. Resident continues with nausea and vomiting with slurred words unable to answer yes or no questions when prompted. Writer received orders to send resident out to CMS for eval (evaluation) and treatment as indicated. Responsible party updated and aware. Message left with DON (Director of Nursing). Surveyor could not find evidence the facility attempted to contact the physician on call or the medical director when the attending physician did not return the facility call timely An hour and 23 minutes (10:30 pm to 11:53 pm) passed before another nurse contacted the on call physician to consult with the MD and received an order to transfer R32 to the hospital. On 6/12/19 at 12:30 AM, R32's medical record documents: ambulance arrived to transport R32 to the hospital. R32 was hospitalized from [DATE]-7/4/19. Hospital discharge paperwork dated 7/4/19, documents: . On (MONTH) 13 repeat CT head showed increase in size of subdural hematomoa. He had a cranitomy done on (MONTH) 13. Patient slowly improved. He had mild right-sided weakness from previous [MEDICAL CONDITION]. Course of [MEDICATION NAME] was completed in the hospital. Patient on a puree diet here. He was not eating enough and frequently refused to eat. He has a POA (Power of Attorney) daughter living in Indiana. Patient and daughter agreeable to the PEG tube and so PEG tube was placed. R32 returned to the facility with newly placed PEG tube on 7/1/19. On 7/11/19 at 12:48 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B was unable to state why R32's physician was not notified of the change in condition at 5:09 PM when vomiting occurred. DON-B was unable to state why facility staff waited over an hour to contact another physician or the Medical Director when R32 experienced another change in condition at 10:30 PM with vomiting, slurred speech and inability to answer questions. DON-B stated she would expect R32's physician to be notified immediately of the change in condition. On 7/11/19 at 2:22 PM, Surveyor interviewed, Registered Nurse (RN)- LL, who stated: She was on duty when R32 returned from the hospital. RN-LL was informed R32 fell from the wheelchair while being transported to [MEDICAL TREATMENT] on 6/10/19. RN-LL was able to recall R32's change in condition on 6/11/19 at 5:09 PM. RN-LL stated she did not feel it was necessary to call R32's physician to notify him of the vomiting, as RN-LL believed the vomiting was related to R32 eating while laying flat on his back in bed. RN-LL stated she felt R32 was doing fine and had eyes on him while he sat in the common area. RN-LL stated, later in the shift, she checked on R32 who was noted to be vomiting and having slurred speech so she called the physician to inform of the change in condition. RN-LL was unable to explain the delay in notification of the physician and stated that in hindsight neurological checks should have been completed and the physician should have notified of the vomiting at 5:09 PM. RN-LL was unable to explain the delay of over an hour in contacting the physician of the change of condition observed at 10:30 PM On 7/11/19, at 4:06 PM, Surveyor informed Interim Administrator - MM, Director of Nursing-B and Corporate Registered Nurse (RN)-NN of the concern R32 experienced a change in condition at 5:09 PM, on 6/11/19 and the physician was not notified. The physician was also not immediately notified of the change in condition identified at 10:30 PM with staff notifying the physician on 6/11/19 at 11:53 PM. The failure to immediately consult with the physician regarding R32's change in condition, created a finding of immediate jeopardy. The facility removed the jeopardy 7/13/19, when it had completed the following: R32 has been assessed by nursing and the primary physician and is currently medically stable. Treatment plan has been reviewed with the MD. Registered Nurse who failed to implement facility policy and procedures for neuro checks post head injury and failed to identify and report change in Resident condition timely has been terminated due to multiple failures to adhere to facility policy. All nurses in-serviced regarding facility policy and procedure on change in resident condition, notification of house supervisor for acute changes, and prevention of delay in treatment. All nurses have been re-educated prior to their next scheduled shift. Re-education of all scheduled nurses prior to working was completed on 07/13/19. All unwitnessed falls or admissions with head injury [DIAGNOSES REDACTED]. All nurses have been educated on timely notification of MD with change of condition, pertinent medical information and consultation with MD regarding treatment plan. Neuro Check Policy and Procedure has been reviewed and revised to reflect the addition of conducting neuro checks X 5 days post admission for any Resident with [DIAGNOSES REDACTED]. All acute significant changes in Residents condition will be reported to the House Supervisor immediately. The house supervisor will also notify the DON. All nurses have been educated regarding facility policy and procedure on change in resident condition, notification of house supervisor for acute changes, prevention of delay in treatment, and notification of MD with pertinent information. Daily Stand Up tool implemented with all morning meetings. Review of items in Daily Stand up tool includes changes in resident condition, returns to hospital, incidents for previous 24 hours. Review identifies if there have been any failures to recognize immediacy of changes in condition, notify the MD, or provide timely treatment. Review also identifies any failure to notify house supervisor or DON of significant changes in medical condition. Follow up and appropriate re-education or disciplinary action will be on-going. Stand Up Tool and Results of findings will be reviewed by QAPI (Quality Assurance Program Improvement) daily X 5, weekly X 4, and monthly thereafter. The Medical Director was updated on this Correction and Removal-Abatement Plan as well as occurrences of which this plan pertains. Monitoring will be initiated and completed by the Administrator and/or designee as indicated above. Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI Committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits will be determined at that time. If issues are identified, re-education will be completed. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed and revisions will be made as deemed necessary. 2. On 06/24/19 at 9:10 am, Surveyor reviewed R22's medical record which indicated that R22's physician was not consulted when R22 had high blood glucose readings. * On 06/21/19 at 7:57 am, R22's blood glucose results were 415; * On 06/21/19 at 12:05 pm, R22's blood glucose was 411; * On 06/21/19 at 4:54 pm, R22's blood glucose was 513. According to the standards of practice normal limits for blood glucose target range is between 70 to 100. R22 had [MEDICAL CONDITION] (high blood glucose) throughout the day and as indicated above on 06/21/19. Record review did not indicate that nursing staff followed up with R22's primary physician. On 06/24/19, Surveyor reviewed R22's plan of care dated on 03/29/19. The care plan indicated R22 had Diabetes Mellitus. The care plan interventions for R22's blood glucose monitoring were to monitor/document/report to the physician when needed for signs and symptoms of [MEDICAL CONDITION] including: increased thirst and appetite, frequent urination, weight loss, fatique, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (deep and labored breathing pattern often associated with severe metabolic acidosis particularly diabetic ketoacidosis (DKA) but also kidney failure.) . The facility did not follow the plan of care by contacting R22's MD when R22's blood sugars were high. On 06/24/19, Surveyor reviewed the facility's policy entitled, Change in Condition dated on 12/19/18 was read and indicated: Nurse will complete assessment and document findings in resident record including but not limited to vital signs, pain, respiratory status as applicable, cardiac status as applicable, etc. Notification of medical professional and resident representative will be documented in medical record. On 06/25/19 at 8:36 am, Director of Nursing (DON)-B indicated that elevated blood glucose should have been followed up with R22's physician as soon as possible . On 06/24/19 at 10:30 am, Assistant Director of Nursing (ADON)- I indicated blood glucose of less then 70 or greater then 400 need to be reported to the primary physician immediately. On 06/24 at 3:00 pm Administrator-A and DON-B were made aware of the findings above.

Based on interview and record review the facility did not ensure that 2 of 2 residents (R32 & R22) reviewed received treatment and care in accordance with professional standards of practice. * R32 sustained a fall with a head injury during van transport on 6/10/19. R32 was transported to the hospital for evaluation and treatment and returned to the facility on [DATE] with a diagnosed acute subdural hematoma. Upon return, the facility staff did not order the anti-[MEDICAL CONDITION] medication that was prescribed at the hospital and did not provide ongoing neurological status evaluations to identify possible changes in neurological status. On 6/11/19 at 11:53 PM. the facility consulted with the physician who requested a transfer of R32 to the hospital. R32 was transferred to the hospital at 12:30 AM on 6/13/19. R32 was diagnosed with [REDACTED]. The facility's failure to assess and monitor R32's neurological status and to order and give anti-[MEDICAL CONDITION] medication created a finding of immediate jeopardy on 6/11/19. On 7/12/19 at 12:30 PM, Surveyor informed Director of Nursing-B of the immediate jeopardy. The immediate jeopardy was removed on 7/13/19, however the deficient practice continues at a scope/severity of D (potential for harm/isolated) based on the following example: * On 6/24/19, R22 did not receive medical treatment after elevated blood glucose levels. Findings include: The facility policy entitled, Neurological Status Evaluation, dated 12/13/18, states: Purpose: Neurological assessment will be performed by a licensed nurse when resident status warrants, such as head injury, [MEDICAL CONDITION] (stroke), and/or witnessed fall to identify a change in condition related to a possible head injury or otherwise upon physical order. Procedure: 1. The licensed nurse may perform the neurological status evaluation without a physician's orders [REDACTED]. 2. Change in the level of consciousness constitutes the most significant or earliest sign of neurological deterioration. If there is a declining level of alertness or orientation, then the completed neurological assessment should be performed. 4. Neurological Assessments should be preformed as follows for 72 hour period, unless otherwise ordered by the attending physician; Every 15 minutes X (times); Every 30 minutes X 2; Every 1 hours X 2; Every shift for 72 hours or until stable. 5. When reforming a neurological assessment, record the assessment data on the Neurological Status Evaluation. Blood pressure usually increased with widening pulse pressure with ICP (Intracranial Pressure); Check pupil reaction. Darken room. Open eyelid with your fingers. Turn on the flashlight and observe size and reaction of pupil. Repeat for other eye; Determine motor ability. Have resident move all extremities and squeeze caregiver's fingers. Note strength bilaterally; Indicate if resident obeys commands, localizes pain; Withdraws, reacts to pain, or has no response; Determine sensation in extremities. ; Have resident smile to determine if there is any facial drooping and document according; 6. Neurological evaluation should be complete, specific, and compare the right side of the body to the left; 7. Any additional information shall be recorded as narrative documenting/progress notes in the medical record. Assessment results that need to be reported to the physician are: a. Any pupil reaction changes, especially with a decrease in level of consciousness; b. Any decrease in level of consciousness from baseline assessment or from resident normalcy; c. Any sensory or motor loss or decline; d. Any marked changed in vital signs; e. Any changes in resident condition. Other significant neurological symptoms include: a. Nausea and vomiting; b. [MEDICAL CONDITION] activity; c. Visual disturbance; d. Headache. R32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R32's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/15/19, documents: A Brief Interview of Mental (BIMS) score of 14, indicating R32 is cognitively intact; requires extensive assist of 2 staff for bed mobility, transfers, dressing and toilet use; extensive assist of 1 staff for locomotion on and off the unit and personal hygiene; range of motion impairment of bilateral upper and lower extremities. On 6/10/19, R32 was transported to [MEDICAL TREATMENT] by a contracted transport company. On 6/10/19, hospital discharge paperwork documents: .was brought to the ED (emergency Department) by EMS (Emergency Medical Services). He fell in the transport van. He was left at the [MEDICAL TREATMENT] unit. He was sent to ED (Emergency Department) by [MEDICAL TREATMENT] unit staff to get evaluated after he gave h/o fall. He fell out of his wheelchair and hit his head. He denies cp (chest pain), sob (shortness of breath). He has mild headache. CT (Computerized [NAME]ography) head shows left sided subdural hematoma. Patient denies being buckled in and that there was eratic driving.Hospital course: 6/10/19: Admission with acute on subdural hematoma; 6/11/19: CT scan overnight mildly improved, [MEDICAL TREATMENT] stable. discharged to facility with [MEDICATION NAME] BID (2 times a day) to complete 7 days total treatment for [REDACTED]. Plan for follow up CT scan of head in 2 weeks with neurosugery appointment to follow. On 6/11/19 at 2:45 PM, R32's medical record documents: R32 returned from CMS (Columbia Saint [NAME]'s) with DX (diagnosis) of a resolving subdural hematoma as a result of a fall in transport vehicle. VSS (Vital Signs Stable). Assessments completed, NNO (No New Orders) Daughter .aware of readmit. Surveyor could not find evidence the facility completed a neurological assessment upon R32's return to the facility. The facility did not order the [MEDICATION NAME] 500 mg (milligrams) by mouth, every 12 hours, that was listed on the patient medication schedule that was provided to the facility upon R32's return to the facility. (Cross Reference F755.) On 6/11/19 at 5:09 PM, R32's medical record documents: Was called to resident's room for report of resident vomiting. Resident was observed lying almost flat eating food that family had brought in. Resident HOB (Head Of Bed) elevated and he was educated on the importance of eating in an upright position. Residents visitors also educated. [MEDICATION NAME] provided. Surveyor could not find evidence the facility completed a neurological assessment of the resident or update the physician of R32's change in condition. (Cross Reference F580.) On 6/11/19, at 10:30 PM, R32's medical record documents: Writer went into assess how resident was feeling and found he had vomited undigested food. Residents speech is very slurred at this time and is not answering questions when asked. VS (vital signs) remain stable. Dr (doctor) paged-awaiting return call. Surveyor could not find evidence the facility completed a neurological assessment of the resident. On 6/11/19, at 11:53 PM, R32's medical record documents: Writer with follow up call to MD (Medical Doctor). On call MD updated on resident condition. Resident continues with nausea and vomiting with slurred words unable to answer yes or no questions when prompted. Writer received orders to send resident out to CMS for eval (evaluation) and treatment as indicated. Responsible party updated and aware. Message left with DON (Director of Nursing). Surveyor could not find evidence the facility completed a neurological assessment when the change in condition was identified or attempted to contact the physician on call or the medical director when the attending physician did not return the facility call. An hour and 23 minutes passed before another nurse contacted the on call physician to update on R32's change in condition and received an order to transfer R32 to the hospital. On 6/12/19, at 12:30 AM, R32's medcial record documents: ambulance arrived to transport R32 to the hospital. R32 was hospitalized from [DATE]-7/4/19. Hospital discharge paperwork dated 7/4/19, documents: . On (MONTH) 13 repeat CT head showed increase in size of subdural hematomoa. He had a craniotomy done on (MONTH) 13. Patient slowly improved. He had mild right-sided weakness from previous [MEDICAL CONDITION]. Course of [MEDICATION NAME] was completed in the hospital. Patient on a puree diet here. He was not eating enough and frequently refused to eat. He has a POA (Power of Attorney) daughter living in Indiana. Patient and daughter agreeable to the PEG tube and so PEG tube was placed. R32 returned to the facility with newly placed PEG tube on 7/1/19. On 7/11/19, at 12:48 PM, Surveyor interviewed Director of Nursing (DON)-B, who stated: No neurological check flow sheets could be located for R32. Facility Neurological Status Evaluation policy and procedure does state that neurological assessments should be completed after a resident suffers a head injury. DON-B is unable to state why neurological assessments were not completed when R32 returned to the facility. On 7/11/19, at 2:22 PM, Surveyor interviewed, Registered Nurse (RN)- LL, who stated: She was on duty when R32 returned from the hospital. RN-LL reviewed R32's medical records and was then able to recall R32's return to the facility from the hospital after the fall during van transport. RN-LL was able to recall R32's change in condition on 6/11/19 at 5:09 PM. RN-LL stated she did not do neurological checks on R32 at anytime after his readmission and did not feel it was necessary to call R32's physician to notify him of the vomiting as RN-LL believed the vomiting was related to eating while laying flat on his back. RN-LL stated, she felt R32 was doing fine and had eyes on him while he sat in the common area. RN-LL stated, later in the shift she checked on R32 who was noted to be vomiting so she called the physician to inform of the change in condition. RN-LL is unable to explain the timeframe for the delay in notification of the physician and stated that in hindsight neurological checks should have been completed. RN-LL does not recall if [MEDICATION NAME] was ordered upon R32's return from the hospital and stated the supervisor would have noted the order and she isn't certain if that occurred due to the Medication Administration Record [REDACTED]. On 7/11/19, at 2:42 PM, Surveyor interviewed DON-B, who stated, upon review of R32's discharge orders from the hospital on [DATE], [MEDICATION NAME] 500 mg, every 12 hours was ordered for R32 but the facility did not order it. DON-B was unable to state why the medication wasn't ordered by the facility. DON-B also confirmed, R32 missed a dose of [MEDICATION NAME] at 9:00 PM on 6/11/19. The failure to order and give [MEDICATION NAME] as ordered and the failure to closely monitor this resient's neurological status so that changes could be detected quickly and relayed to the physician so that prompt intervention could be taken created a finding of immediate jeopardy. The facility removed the jeopardy 7/13/19, when it had completed the following: R32 has been assessed by nursing and the primary physician and is currently medically stable. Treatment plan has been reviewed with the MD. Registered Nurse who failed to implement facility policy and procedures for neuro checks post head injury and failed to identify and report change in Resident condition timely has been terminated due to multiple failures to adhere to facility policy. All nurses in-serviced regarding facility policy and procedure on change in resident condition, notification of house supervisor for acute changes, and prevention of delay in treatment. All nurses have been re-educated prior to their next scheduled shift. Re-education of all scheduled nurses prior to working was completed on 07/13/19. All unwitnessed falls or admissions with head injury [DIAGNOSES REDACTED]. All nurses have been educated on timely notification of MD with change of condition, pertinent medical information and consultation with MD regarding treatment plan. Neuro Check Policy and Procedure has been reviewed and revised to reflect the addition of conducting neuro checks X 5 days post admission for any Resident with [DIAGNOSES REDACTED]. All acute significant changes in Residents condition will be reported to the House Supervisor immediately. The house supervisor will also notify the DON. All nurses have been educated regarding facility policy and procedure on change in resident condition, notification of house supervisor for acute changes, prevention of delay in treatment, and notification of MD with pertinent information. Daily Stand Up tool implemented with all morning meetings. Review of items in Daily Stand up tool includes changes in resident condition, returns to hospital, incidents for previous 24 hours. Review identifies if there have been any failures to recognize immediacy of changes in condition, notify the MD, or provide timely treatment. Review also identifies any failure to notify house supervisor or DON of significant changes in medical condition. Follow up and appropriate re-education or disciplinary action will be on-going. Stand Up Tool and Results of findings will be reviewed by QAPI (Quality Assurance Program Improvement) daily X 5, weekly X 4, and monthly thereafter. The Medical Director was updated on this Correction and Removal-Abatement Plan as well as occurrences of which this plan pertains. Monitoring will be initiated and completed by the Administrator and/or designee as indicated above. Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI Committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits will be determined at that time. If issues are identified, re-education will be completed. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed and revisions will be made as deemed necessary. 2. On 06/24/19 at 9:10 am, Surveyor reviewed R22's medical record which indicated that R22 did not received a medical treatment after blood glucose was high: * On 06/21/19 at 7:57 am, R22's blood glucose results were 415; * On 06/21/19 at 12:05 pm, R22's blood glucose was 411; * On 06/21/19 at 4:54 pm, R22's blood glucose was 513. According to the standards of practice normal limits for blood glucose target range is between 70 to 100. R22 had [MEDICAL CONDITION] (high blood glucose) throughtout the day without interventions provided by the nursing staff. Record review did not indicate that nursing staff followed up with R22's primary physician. There were no further information provided by the facility. On 06/24/19, Surveyor reviewed the facility's policy entitled Hyperglycemic Protocol dated on 08/01/15, was read and indicated: Diabetic residents presenting with signs/symptoms of [MEDICAL CONDITION] will be further assessed and treated in accordance with the facility protocol. Hyperglycemic treatment protocol: administer hypoglycemic agents and/or insulin per individual physician orders, offer 16-24 ounces of water or sugar free beverage over two hours unless clinically contraindicated, recheck blood glucose level, report findings to the physician. On 06/24/19, Surveyor reviewed the facility's policy entitled Change in Condition dated on 12/19/18 was read and indicated: Nurse will complete assessment and document findings in resident record including but not limited to vital signs, pain, respiratory status as applicable, cardiac status as applicable, etc. Notification of medical professional and resident representative will be documented in medical record. On 06/24/19, Surveyor reviewed R22's plan of care dated on 03/29/19. The care pan indicated R22 had Diabetes Mellitus. The care plan interventions for R22's blood glucose monitoring were to monitor/document/report to the physician when needed for signs and symptoms of [MEDICAL CONDITION] including: increased thirst and appetite, frequent urination, weight loss, fatique, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure. It is a form of hyperventilation, which is any breathing pattern that reduces carbon [MEDICATION NAME] in the blood due to increased rate or depth of respiration), [MEDICATION NAME] breath (smells fruity), stupor (a state of near-unconsciousness or insensibility), or coma (a prolonged state of unconsciousness). The facility did not follow the plan of care. On 06/25/19 at 8:36 am, Director of Nursing (DON)-B indicated that elevated blood glucose should have been followed up with R22's physician as soon as possible, assessment and recheck of the blood glucose should have been, and proper interventions provided to R22. DON-B also indicated she was not sure why the facility did not provide further care and treatment. On 06/24/19 at 10:30 am, Assistant Director of Nursing (ADON)- I indicated blood glucose of less then 70 or greater then 400 need to be reported to the primary physician immediately. On 06/24 at 3:00 pm Administrator-A and DON-B were made aware of the findings above.

Based on record review and interviews, the facility did not ensure nursing staff notified the physician with a significant change of condition for 1 (R1) of 19 sampled residents. R1 experienced a change of condition on 9/13/17, which included poor appetite and fluid intake, a drop in SpO2 (blood oxygen saturation level) to 78%, and a temperature elevation. (SpO2 reflects the amount of oxygen carried in the hemoglobin and should be 90% or greater). A review of routine SpO2's for R1 revealed R1 routinely maintained SpO2's of 90% or greater. Oxygen at 2 liters per nasal cannula was initiated. Later in the evening R1's SpO2 was noted to be at 98% on oxygen. The facility uses the INTERACT (Interventions to Reduce Acute Care Transfers) tool to assist nursing staff in determining the need for physician notification. According to the INTERACT tool, oxygen saturation under 90% should be reported to the physician immediately. On the morning of 9/14/17, R1 was found not responding to verbal and tactile stimuli. R1's SpO2 was 80% on 2 liters of O2. O2 was increased up to 5 liters to maintain a SpO2 of 89 - 92%. R1 was sent to the hospital and found to be in acute hypoxemic [MEDICAL CONDITION] requiring intubation. R1 was admitted to the Intensive Care Unit and treated for [REDACTED].) The failure of the facility to ensure immediate physician notification of a significant change in condition led to a finding of immediate jeopardy, which began on 9/13/17. Administrator-A was notified of this finding on 3/22/18 at 1:40pm. The immediate jeopardy was removed and corrected on 10/25/17. This is being cited as past noncompliance. Findings include: The surveyor reviewed R1's record on 3/15-3/29/18. R1 had [DIAGNOSES REDACTED]. R1 had resided in the facility since (MONTH) of (YEAR). R1 was hospitalized for [REDACTED]. A Quarterly Minimum Data Set (MDS) date 1/11/18, revealed R1 was cognitively intact. Documentation on 9/9, 9/10 and 9/11/17, indicated R1 was alert and responsive per normal. On 9/12/17 at 3:25pm, nursing documented R1 was sleeping most of the shift, aroused easily but had a hard time staying awake. R1 did not know when she had returned from the hospital or what day it was. R1's SpO2 was 92% on room air. On 9/12/17 at 11:01pm, nursing documented R1 was sleeping during the entire shift, was easily aroused from sleep by tactile (touch) and when name was called. R1 was encouraged to eat, but refused. Vital signs were stable. On 9/13/17 at 2:38pm, nursing documented R1 was alert and oriented in the am, sleeping in the afternoon. Skin warm and dry, respirations even and non labored. No cough or congestion. On 9/13/17 at 10:54pm, Licensed Practical Nurse (LPN)-D documented, Resident (R1) sleeping on and off in bed. Appetite poor and refusing snacks. Requires much encouragement to drink fluids. Fluid intake also poor. Resident easily aroused from sleep by tactile (touch) and when name is called. Pulse ox was 78% earlier and resident now on O2 (oxygen) at 2 liters via NC (nasal cannula). Resident appears comfortable. Temperature at 9:30pm was 99.9 and received APAP (Tylenol) and temp down now to 99.1. Will continue to anticipate needs. The surveyor reviewed documentation of R1's SpO2 results in the vital sign documentation tab in the electronic record. SpO2's in (YEAR) and (YEAR) usually ranged from 90 to 96%. There was one documented SpO2 of 88%. The only SpO2 with oxygen was on 9/13/17, all other SpO2's were on room air. LPN-D did not notify the physician of R1's decreased SpO2 on 9/13/17. On 9/14/17 at 8:13am, R1 was not responding to verbal and tactile stimuli. O2 at 2 liters/minute resulted in a SpO2 of 80%. The O2 was increased to 3 liters/minute with no change in SpO2. O2 was increased to 5 liters/minutes with a SpO2 between 89 - 92%. BP (Blood pressure) was 92/64, pulse was 108, respirations were 16. The physician was paged and an order was received to send R1 to the hospital. When the ambulance arrived, R1 was diverted to the closest hospital due to her critical condition. A review of the hospital discharge summary of the 9/14/17 - 10/3/17 hospitalization reveals R1 had a [DIAGNOSES REDACTED]. A review of the Infectious Disease Consult from the 9/14/17 hospital admission, indicated R1 was febrile (had an elevated temperature), [MEDICAL CONDITION] (rapid heart rate), and hypoxemic (low level of oxygen in blood). R1 was intubated in the emergency department and admitted to the Intensive Care Unit. Common causes of hypoxemia include pneumonia, asthma, [DIAGNOSES REDACTED] (which, without prompt treatment causes death in 90% of people), [MEDICAL CONDITION], and [MEDICAL CONDITIONS]. The treatment for [REDACTED]. Many patients will respond to additional oxygen supplied by a nasal cannula. The quicker the oxygen level reaches normal, the better the prognosis is for the patient. However, the timing is very important because cerebral [MEDICAL CONDITION] can occur within a few minutes and in many patients, may not be reversible. https://www.medicinenet.com/[MEDICAL CONDITION]/article.htm#[MEDICAL CONDITION]/or_hypoxemia_be_prevented On 3/20/18 at 10:40am, the surveyor spoke with Registered Nurse (RN) Manager-F regarding physician notification with changes of condition. RN Manager-F stated LPN-D should have notified the physician of R1's SpO2 of 78% on 9/13/17. The facility's failure to ensure nurses immediately notified the physician of a significant change in condition created a situation of immediate jeopardy. The facility removed and corrected the immediate jeopardy on 10/25/17, when: *On 9/21/17, the facility developed an action plan which included: The Director of Nursing (DON) and nursing management team attending shift to shift reports- two per day on rotating units. Inservice department heads on stop and watch. Stop and watch pads to be available for all staff, visitors and residents. Inservice nursing staff on eINTERACT program and PCC (Point Click Care) alert system on dashboard. Instruct the nursing staff that the Supervisor is to be called with any acute changes of condition and unplanned discharges. Weekly conference call to review discharges for the week, to identify opportunities for improvement. * Nurses were inserviced on completing a head to toe assessment and nurses/CNAs were inserviced on identifying and reporting changes of condition utilizing the eINTERACT tool. This training was completed on 10/25/17. On 3/22/18 at 11:30am, the surveyor spoke with Regional Nurse Consultant (RNC)-C regarding training of nursing staff regarding physician notification of changes of condition. RNC-C stated the facility had identified concerns related to assessments and physician notification affecting rehospitalization rates. The facility provided the above information summarizing staff education including use of the INTERACT tool, which helps identify changes of condition that require immediate physician notification. RNC-C indicated that an INTERACT recommendation for SpO2 was to notify the physician immediately with findings less than 90%.

Based on record review and interviews, the facility did not ensure nursing staff completed ongoing physical assessments after an identified change of condition for 1 (R1) of 19 sampled residents. R1 experienced a change of condition on 9/13/17, which included poor appetite and fluid intake, a drop in SpO2 (blood oxygen saturation level) to 78%, and a temperature elevation. (SpO2 reflects the amount of oxygen carried in the hemoglobin and should be 90% or greater). A review of routine SpO2's for R1 revealed R1 customarily maintained SpO2's of 90% or greater. Nursing staff on the night shift did not complete a physical assessment including checking R1's temperature which had been elevated the evening of 9/13/17, and did not check R1's SpO2 which had been decreased the evening of 9/13/17. On the morning of 9/14/17, R1 was found not responding to verbal and tactile stimuli. R1's SpO2 was 80% on 2 liters of O2. O2 was increased up to 5 liters to maintain a SpO2 of 89 - 92%. R1 was sent to the hospital and found to be in acute hypoxemic [MEDICAL CONDITION] requiring intubation. R1 was admitted to the Intensive Care Unit and treated for [REDACTED].) The failure of the facility to ensure nursing staff completed ongoing assessments after a significant change in condition led to a finding of immediate jeopardy, which began on 9/14/17. Administrator-A was notified of this finding on 3/22/18 at 1:40pm. The immediate jeopardy was removed and corrected on 10/25/17. This is being cited as past noncompliance. Findings include: The surveyor reviewed R1's record on 3/15-3/29/18. R1 had [DIAGNOSES REDACTED]. R1 had resided in the facility since (MONTH) of (YEAR). R1 was hospitalized for [REDACTED]. A Quarterly Minimum Data Set (MDS) date 1/11/18, revealed R1 was cognitively intact. Documentation on 9/9, 9/10, and 9/11/17, indicated R1 was alert and responsive per normal. On 9/12/17 at 3:25pm, nursing documented R1 was sleeping most of the shift, aroused easily but had a hard time staying awake. R1 did not know when she had returned from the hospital or what day it was. R1's SpO2 was 92% on room air. On 9/12/17 at 11:01pm, nursing documented R1 was sleeping during her entire shift, was easily aroused from sleep by tactile (touch) and when name was called. R1 was encouraged to eat, but refused. Vital signs were stable. On 9/13/17 at 2:38pm, nursing documented R1 was alert and oriented in the morning, sleeping in the afternoon. Skin warm and dry, respirations even and non labored. No cough or congestion. On 9/13/17at 10:54pm, Licensed Practical Nurse (LPN)-D documented, Resident (R1) sleeping on and off in bed. Appetite poor and refusing snacks. Requires much encouragement to drink fluids. Fluid intake also poor. Resident easily aroused from sleep by tactile and when name is called. Pulse ox was 78% earlier and resident now on O2 (oxygen) at 2 liters via NC (nasal cannula). Resident appears comfortable. Temperature at 9:30pm was 99.9 and received APAP (tylenol) and temp down now to 99.1. Will continue to anticipate needs. The surveyor reviewed documentation of R1's SpO2 results in the vital sign documentation tab in the electronic record. SpO2's in (YEAR) and (YEAR) usually ranged from 90 to 96%. There was one documented SpO2 of 88%. The only SpO2 with oxygen was on 9/13/17, all other SpO2's were on room air. On 9/14/17 at 5:56am, LPN-E documented Resident in bed sleeping well thru the nite. No complaints of pain or discomfort. A review of the Vital Signs section of the electronic record revealed no documented BP, pulse, respiration, temperature or SpO2 on the night shift of 9/13-9/14/17. On 9/14/17 at 8:13am, R1 was not responding to verbal and tactile stimuli. O2 at 2 liters/minute resulted in a SpO2 of 80%. The O2 was increased to 3 liters/minute with no change in SpO2. O2 was increased to 5 liters/minutes with a SpO2 between 89 - 92%. BP (Blood pressure) was 92/64, pulse was 108, respirations were 16. The physician was paged and an order was received to send R1 to the hospital. When the ambulance arrived, R1 was diverted to the closest hospital due to her critical condition. A review of the hospital discharge summary of the 9/14/17 - 10/3/17 hospitalization reveals R1 had a [DIAGNOSES REDACTED]. A review of the Infectious Disease Consult from the 9/14/17 hospital admission, indicated R1 was febrile (had an elevated temperature), [MEDICAL CONDITION] (rapid heart rate), and hypoxemic (low level of oxygen in blood). R1 was intubated in the emergency department and admitted to the Intensive Care Unit. R1 was treated for [REDACTED]. Common causes of hypoxemia include pneumonia, asthma, [DIAGNOSES REDACTED] (which, without prompt treatment causes death in 90% of people,) [MEDICAL CONDITION], and [MEDICAL CONDITIONS]. The treatment for [REDACTED]. Many patients will respond to additional oxygen supplied by a nasal cannula. The quicker the oxygen level reaches normal, the better the prognosis is for the patient. However, the timing is very important because cerebral [MEDICAL CONDITION] can occur within a few minutes and in many patients, may not be reversible. https://www.medicinenet.com/[MEDICAL CONDITION]/article.htm#[MEDICAL CONDITION]/or_hypoxemia_be_prevented On 3/20/18 at 11:25am, the surveyor spoke with Registered Nurse (RN) Manager-F regarding nursing assessments with changes of condition. RN Manager-F stated LPN-E should have at least taken a set of vital signs during the night shift of 9/13-9/14/17. On 3/20/18 at 2:30pm, the surveyor spoke with LPN-E, who was the nurse assigned to care for R1 on 9/13-9/14/17. LPN-E stated she does not usually work the night shift. LPN-E stated she documents vital signs when she takes them. LPN-E did not remember if she took R1's vital signs the night of 9/13-9/14/17. Regarding the documentation in the nurses notes indicating R1 slept all night, LPN-E stated if she charted it, that is what had occurred. The facility removed and corrected the Immediate Jeopardy on 10/25/17, when: *On 9/21/17, the facility developed an action plan which included: The Director of Nursing (DON) and nursing management team attending shift to shift reports- two per day on rotating units. Inservice department heads on stop and watch. Stop and watch pads to be available for all staff, visitors and residents. Inservice nursing staff on eINTERACT program and PCC (Point Click Care) alert system on dashboard. Instruct the nursing staff that the Supervisor is to be called with any acute changes of condition and unplanned discharges. Weekly conference call to review discharges for the week, to identify opportunities for improvement. * Nurses were inserviced on completing a head to toe assessment and nurses and CNAs were inserviced on identifying and reporting changes of condition utilizing the eINTERACT tool. This training was completed on 10/25/17. On 3/22/18 at 11:30am, the surveyor spoke with Regional Nurse Consultant (RNC)-C regarding training of nursing staff regarding physical assessments after changes of condition. RNC-C stated the facility had identified concerns with assessments and physician notification affecting re-hospitalization rates. The facility provided the above information summarizing staff education including head to toe physical assessments.

Based on interview and record review, the facility did not consult with the resident's physician when there was an accident which resulted in injury and has the potential for requiring physician intervention, nor did the facility notify a resident's interested family member before the transfer of a resident to hospital. The facility did not ensure this for 2 of 24 residents (Residents #24 and #18) included in the sample. Although the facility informed the physician extender that Resident #24 had fallen on 9-12-13, the facility did not fully consult with the physician extender because the nurse failed to inform the physician extender that Resident #24 had hit his head hard when he fell on [DATE]. This was critical information to pass along because Resident #24 had been receiving a high dose of an anticoagulant and was at risk for bleeding into the brain. Sixteen hours after the fall, staff found Resident #24 unresponsive. He was admitted to the hospital in "critical condition and required immediate attention." He subsequently underwent two surgeries to evacuate the bleeding in his brain. The failure to fully consult with the physician extender created a finding of immediate jeopardy, which began on 9-12-13. The facility administrative staff - administrator, director of nurses and consultants - were informed of the immediate jeopardy situation that exists for Resident #24 on 1-15-14 at 3:10 PM. The immediate jeopardy was removed on 1-17-14 but the deficient practice continues at scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as evidenced by: The facility did not notify the family member listed as first medical contact for Resident #18 before transferring the resident to hospital on 12-25-13. Findings include: 1) Resident #24 was admitted to the facility on [DATE], after a lengthy hospitalization for surgical repair for an abdominal aortic aneurysm and post stroke care; Resident #24 was admitted to the facility for rehabilitation services. His medications included 10 mg. [MEDICATION NAME] daily, which is a medication that thins the blood and makes individuals more susceptible to bleeding. The typical maintenance dose of [MEDICATION NAME] is 2 to 10 mg. daily. According to medlineplus, "[MEDICATION NAME] may cause severe bleeding that can be life-threatening and even cause death ...Bleeding is more likely ...during the first month of [MEDICATION NAME] treatment. Bleeding is also more likely to occur for people who take high doses of [MEDICATION NAME] ...." <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 7.html> The initial MDS (Minimum Data Set) dated 8-19-13 indicates Resident #24 is severely cognitively impaired, and requires total assistance from one to two staff members for all of his ADLs (activities of daily living) i.e., bathing, eating, hygiene needs, toilet needs and transfer needs. The MDS also indicates the resident is at high risk for falling and had fallen twice within the assessment reference "look back" period of 8-12-13 to 8-19-13. On 9-12-13 at 9:30 AM, Resident #24 fell while in his wheelchair, when he was positioned near the nurses' desk. The facility completed a resident incident report for the 9-12-13, which indicates that Resident #24 had been placed near the nurses' desk for closer supervision, because as the documented nurses' note from 9-12-13 at 7:38 AM indicates: "about 5:15 AM was restless and CNA (certified nursing assistant) got him up this (morning)." The report further notes just prior to the fall at 9:30 AM, RN-H who had been at the nurses' desk with the resident, left momentarily to notify another resident of a phone call that had come in through the nurses' desk. When RN-H heard the commotion of the fall, she returned to the nurses' desk to find the resident on the floor lying on his left side with the wheelchair on top of him. The fall was witnessed by Resident #32 who was in the area visiting with family. The incident report includes a statement from Resident #32 dated 9-13-13. Per RN-H (1/15/14 at 11:29 am), Resident #32 is alert and oriented. Resident #32 stated she observed Resident #24 leaning forward in the wheelchair. She told the resident to sit down; he did not and fell forward to the floor. Resident #32's statement indicates Resident #24 hit the right side of his forehead and right shoulder and that he "hit hard." Surveyor # interviewed RN-H on 1-15-14 at 11:29 AM and asked if she was aware Resident #24 hit his head. RN-H indicated she did question Resident #32 at the time of the fall and was told Resident #24 hit his head on the floor. Surveyor # also asked RN-H if she was the nurse who contacted the physician extender NP-J (nurse practitioner) at the time of the fall; RN-H stated she was. Surveyor # then asked whether she (RN-H) informed NP-J that Resident #24 had hit his head, RN-H indicated she did not inform NP-J that the resident hit his head when he fell . Guidelines from the American Medical Directors Association indicate the nurse should inform the physician of the "...details of circumstances of the fall" when reporting a fall. RN-H did not inform NP-J of all the details of the fall because she did not report that Resident #24 had hit his head hard. The resident's clinical record contains a notation by NP-J, dated 9-12-13 at 5:00 PM. NP-J had come to the facility at that time; NP-J conducted an interview and physical examination of Resident #24. Surveyor # asked RN-H if she was still in the facility when NP-J was in the building and whether she took the opportunity to inform NP-J, that Resident #24 hit his head with the fall he sustained earlier in the day. RN-H indicated she did not inform the nurse practitioner of the head injury. Surveyor # interviewed NP-J on 1-15-14 at 1220. NP-J was asked if she had been informed that Resident #24 had fallen on 9-12-13, and whether she knew the resident hit his head on the floor. NP-J indicated she had been told of the fall around 1:00 PM that day, but was not informed the resident hit his head when he fell . Surveyor # asked NP-J, had she been told the resident hit his head during the fall, would she have changed treatment for [REDACTED]. NP-J indicated given the resident's high risk for falling, his being treated with [MEDICATION NAME], she would have transferred Resident #24 to acute care for a brain scan. Resident #24's clinical record contains an entry by RN-I on 9-13-13 at 3:15 AM, that documents Resident #24 was found at 1:45 AM in an unresponsive state. Resident #24 was then transported to a nearby emergency department (ED) on 9-13-13 and arrived there at 2:34 AM. Surveyor # reviewed Resident #24's hospital clinical record on 1-15-14. The ED physician's documents the resident presented to the ED in "critical condition and required immediate attention". The hospital clinical record indicates a breathing tube was placed in the resident, and he was prepared for surgery. The hospital record indicates Resident #24 was taken to surgery twice in order to evacuate the bleeding in his brain sustained when he hit his head from the fall on 9-12-13. According to the hospital record, Resident #24 did not regain consciousness after the surgical intervention. The failure to consult with the nurse practitioner and to inform her of the pertinent information related to Resident #24's fall, given that he was on a high dose of [MEDICATION NAME], created a finding of immediate jeopardy. The jeopardy was removed on 1-17-14 when the facility completed the following: ~ The facility established training for all licensed staff on ensuring that information related to a fall or injury is conveyed timely, completely, and accurately to the physician or physician extender to allow for appropriate consultation. ~ The facility developed a checklist for staff to use as a tool to assure the accurate & detailed collection of information. ~The facility established a training system to ensure that all licensed staff have been trained prior to starting their next rotation. ~The facility established a process for policy review involving their Medical Director. ~ The facility established a system to review situations and information that should be shared with a physician or physician extender on a daily basis utilizing the facility's daily clinical start up meeting. ~ The facility established a system for ongoing monitoring utilizing their quality assurance process. Noncompliance continues at a scope/severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as evidenced by the following: 2.) Resident #18 was admitted to the facility on [DATE] after hospitalization for neck and [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #18 has a [MEDICAL CONDITION] (breathing tube). Resident #18 has designated a member of her family to be notified of changes in her medical, psychosocial condition that would necessitate the resident to be transferred to acute care. On 12-25-13 when Resident #18 experienced a critically low blood count, the resident's physician was consulted. The physician gave orders to transfer Resident #18 to the hospital, however, the resident's first medical contact, i.e., family, was not notified of the resident's transfer to the hospital. On 1-13-14, at 3:00 PM, Surveyor # asked the administrative staff, the administrator and director of nurses, if Resident #18's family had been notified before the resident's transfer to hospital. On 1-14-14 at approximately 8:00 AM, the director of nurses presented Surveyor # with a notation from Resident #18's clinical record that notes the resident's son, who was visiting at the time, was told of the transfer, the note does not the first medical contact was notified of the transfer to hospital. Resident #18's son is not noted as the first medical contact.

Based on record review and interview, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. The facility did not ensure 1 (Resident #24) of 15 residents identified at risk for falling, received interventions, including adequate supervision consistent with his needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident. Resident #24, who was on Warfarin, a blood thinner, experienced seven falls between 8-12-13 and 9-12-13; the 9-12-13 fall resulted in Resident #24 hitting his head, his eventual loss of consciousness and his being transported to the hospital. Per the plan of care, Resident #24 was to be supervised one-to-one when restless. Resident #24 had been moved to the nurse's station because he had been restless and flailing about in bed, but had been left unattended by staff at the time of the fall. The facility administrative staff - administrator and director of nurses, and consultants, were informed of the immediate jeopardy situation that exists for Resident #24 on 1-15-14 at 3:10 PM. The immediate jeopardy was not removed on 1-17-14 and continues at scope/severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) while the facility fully implements its removal plan. Findings include: Resident #24 was admitted to the facility on [DATE], after a lengthy hospitalization for surgical repair for an abdominal aortic aneurysm and post stroke care. Resident #24 was admitted to the facility for rehabilitation services. Resident #24's medications included Warfarin 10mg alternating with 12.5 mg (blood thinner), every other day for stroke prevention. According to Rxlist.com, "This medication can cause heavy bleeding. To lower the chance of getting cut, bruised, or injured, use great caution with sharp objects like safety razors and nail cutters... Avoid activities such as contact sports. If you fall or injure yourself, especially if you hit your head, call your doctor immediately. Your doctor may need to check you." The initial Minimum Data Set ((MDS) dated [DATE] indicates Resident #24 is severely cognitively impaired, and requires total assistance from one to two staff members for all of his ADLs. The MDS also indicates the resident had fallen twice during the assessment "look-back" period of 8-12-13 to 8-19-13. Resident #24's clinical record documents the resident fell a total of seven times between 8-12-13 and 9-12-13. The facility completed a "Resident Incident Report" after each of the incidents wherein an attempt was made to ascertain the root cause for each of the incidents. The above report made recommendations for interventions and/or change in interventions to the resident's plan of care. The plan of care dated 8-12-13 indicates Resident #24 is at risk for falls due to being post stroke, with right sided-weakness. The plan of care indicates Resident #24 is restless and attempts to get out of bed unassisted, attempts to throw self on floor, flailing, restless, weakness, cognitive and communication deficits and flails (his) body around. An undated typed intervention on the plan of care indicates that Resident #24 is to receive 1:1 supervision with hand written addition of "as needed." On 8-22-13 "place (in) 1:1 while restless" was added to the plan of care. Resident #24's plan of care does not describe objective criteria to assist staff in determining if Resident #24 should be placed under 1:1 supervision. On 1-15-14 at 11:29 AM, Surveyor # interviewed RN-H and asked what the interdisciplinary team learned about the nature of the incidents. RN-H indicated when the resident became agitated or restless, this was when the resident would crawl into or out of bed or try to stand up from his wheelchair. RN-H stated when the resident is restless he exhibits "spontaneous movements, flails and tries to throw himself to the floor." RN-H indicated that the impulsivity requires Resident #24 to receive PRN (as needed) Ativan (Lorazepam) in addition to scheduled Ativan. RN-H also stated the resident was progressing functionally with rehabilitation services, and thus attempted more self-transfers from surface to surface thinking that he could now safely make those movements but he could not. A notation in the resident's clinical record dated 9-12-13 at 7:38 AM, documents Resident #24 had a quiet night until 5:15 AM when the resident became restless. Staff then assisted Resident #24 to get up into his wheelchair. According to RN-H, Resident #24 was seated near the nurses' desk at 9:30 AM, due to the restlessness. RN-H stated the resident was watching television. RN-H was in the area, but left moments before to inform another resident of a telephone call that had come through at the nurses' desk. In her written statement dated 9-12-13, RN-H documents "heard resident fall. Alarm not sounding. Resident was in sitting area by nurses' station in wheelchair. fell forward with entire wheelchair. Landed on left side. Witnessed by (Resident #32)." RN-H indicated the alarm was not sounding because the entire wheelchair with the alarm attached had fallen with the resident, in order words the alarm was still attached to the wheelchair. RN-H indicated she interviewed Resident #32, an alert and oriented resident who witnessed the fall, shortly after the fall. RN-H indicated Resident #32 saw Resident #24 fall forward from the wheelchair. According to Resident #32, she observed Resident #24 leaning forward in the wheelchair and trying to stand up. She told the resident to sit down; he did not and fell forward to the floor. Resident #32's statement indicates Resident #24 hit the right side of his forehead and right shoulder and that he "hit hard." Surveyor # asked RN-H who made the determination as to when Resident #24 should be placed under 1:1 supervision. RN-H indicated that it was at the discretion of the nurse manager or nursing supervisor and would be based on Resident #24's level of agitation. RN-H also stated the resident was restless most of the time on the evening and night shifts. RN-H indicated that Resident #24 had just recently been taken off of 1:1 supervision just a few days prior to the fall. RN-H was asked if she knew why the 1:1 supervision had been discontinued; RN-H indicated that she was not certain. RN-H was asked if the determination to have 1:1 supervision for Resident #24 initiated or discontinued was specifically documented anywhere to all staff were informed of Resident #24's supervision needs; RN-H indicated that she did not think so. RN-H was asked if the facility had a policy that designates the manner in which a resident in 1:1 monitoring is carried out. RN-H indicated she didn't know if there was policy; RN-H was also asked if information about residents being monitored 1:1 was communicated via the 24 hour report log, RN-H indicated that information did not necessarily get communicated via the 24 hour report log; that it was not unusual for the process to be carried out verbally. The September 2013 MAR (medication administration record) documents Resident #24 received Lorazepam 0.5 mg (antianxiety) three times a day scheduled for 12 noon, 2 PM and 9 PM. On 9-12-13 Resident #24 received three additional as needed (PRN) doses of Lorazepam 0.5 mg at 8 AM, 2:30 PM and 6 PM, due to increased restlessness. On 1-15-14 at approximately 12:20 pm Surveyor # interviewed Nurse Practitioner (NP) - J regarding her understanding of the level of supervision that Resident #24 was to receive on 9-12-13 related to his fall risk and restlessness. NP-J indicated that it was her understanding that Resident #24 was to be receiving 1:1 supervision at the time of the fall and that level of supervision was to be continued throughout that day as reflected in her medical record entry for that day. The early morning after the fall, Resident #24's clinical record contains an entry by RN-I on 9-13-13 at 3:15 AM that Resident #24 was found at 1:45 AM in an unresponsive state. Resident #24 was then transported to a nearby emergency department (ED) on 9-13-13 and arrived there at 2:34 AM. Surveyor # reviewed Resident #24's hospital clinical record on 1-15-14. The ED physician's documents the resident presented to the ED in "critical condition and required immediate attention". The hospital clinical record indicates a breathing tube was placed in the resident, and he was prepared for surgery. The hospital record indicates Resident #24 was taken to surgery twice in order to evacuate the bleeding in his brain sustained when he hit his head from the fall on 9-12-13. According to the hospital record, Resident #24 did not regain consciousness after the surgical intervention. The failure to provide Resident #24 the supervision needed to prevent accidents after he was found restless and flailing created a finding of immediate jeopardy. The jeopardy was removed on 1-17-14 when the facility implemented the following: ~ The facility established training for all licensed staff regarding 1:1 supervision guidelines that include physical proximity expectations of staff and evaluation and documentation of the 1:1 supervision status. ~The facility established a training system to ensure that all licensed staff have been trained prior to starting their next rotation. ~The facility established a process for policy review involving their Medical Director.

Based on observation, record review, review of the facility's policy and interview, the facility did not ensure that 1 of 5 residents (Resident #1) reviewed who received tube feeding received adequate fluids to meet his assessed needs. Facility staff did not monitor resident's fluid status, did not follow up on recommended dietary changes did not care plan Resident's hydration status, and did not give sufficient fluids to meet the resident's assessed fluid needs. This resulted in Resident #1's hospitalization with a [DIAGNOSES REDACTED]. Findings include: Surveyor # and Surveyor # reviewed Resident #1's medical record on 5/28/13-5/31/13. Resident #1's medical record indicates Resident #1 was admitted to facility on 5/1/13 from the hospital with [DIAGNOSES REDACTED]. The Hospital Progress Note, prior to resident's admission into the facility, and dated 04/30/13 indicated on 04/29/13 Resident #1's Sodium value was 140 (normal range 135 - 145). The 24 Hour Patient Record & Plan of Care from the Hospital dated 4/30/13 indicated Resident #1 received Nepro 50mL (milliliters)/hour with 250mL water flush every 4 hours. A hospital nephrologist documented on 5/1/13"[MEDICAL CONDITION]- stable on water flushes." Per the facility's physician's admission note dated 5/1/13, Resident #1 is non-verbal, able to open eyes, but not following commands. The physician's admission note also states,"dehydration - add H20 flush." The facility's initial physician's orders [REDACTED]." Per the May 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Per Physician's Telephone Orders also dated 05/01/13, Resident #1's Water flush orders were changed to 100mL every 6 hours. On the May 2013 MAR indicated [REDACTED]. Surveyor noted this new order was a decrease in water flushes from a total of 1500 mL per 24 hours to 400 mL per 24 hours. No Dehydration Risk Assessment was found in resident's medical chart and computer chart during Resident #1's stay at facility from 05/01/13 - 05/10/13. Resident #1's 5-Day MDS (Minimum Data Set) with an Assessment Reference date of 5/8/13 indicates Resident #1 is totally dependent on staff for food and fluids, and receives >51% of his intake via tube, and >501 cc's (cubic centimeters) of fluid via feeding tube. Resident #1's undated"Fixed" Care Plan does not address Dehydration as a Problem. (The Fixed care plans appear to be pre-printed generic initial care plans as subsequent care plans are computer generated, and printed with the most recent care plans located in resident's medical record on the unit.) Tube Feeding is identified in Resident #1's undated Fixed Care Plan. The goal is stated that Resident #1's Nutritional Status will be maintained to the extent possible for the next 30 days. The approaches noted to attain the goal are; administer enteral feedings/flushes as per orders, HOB up as per guidelines, monitor for complications as per guidelines; report any concerns to Physician, medications to be administered thru tube unless otherwise ordered, NPO status, monitor for patency as per guidelines, and activities/social services to monitor for any psychosocial needs. Nutrition is also identified as a problem in Resident #1's undated Fixed Care Plan. The goal is stated as resident will have no unidentified Nutritional issues to the extent possible for the next 30 days. One of the generic approaches is to " evaluate resident's food preference/needs" even though Resident #1 is NPO. During surveyor's # and # interview of Dietitian-O on 5/30/13 at 1:52 PM, Dietitian-O stated that nursing staff was confused over the conflicting water flush orders both dated 05/01/13 (referring to the physician's orders [REDACTED]. 100mL every 6 hours). Dietitian-O verbally recommended the staff clarify the orders with the MD. Dietitian-O did not know if nursing staff followed through on this clarification. Labs drawn on 05/06/13 show the following: sodium level = 146 (Normal Level 136 - 145), BUN = 52 (Normal Level 6-23), Creatinine = 1.41 (Normal Level 0.70 - 1.30). The Enteral Evaluation completed by Dietitian-O and dated 05/07/13, indicates Resident #1's Estimated Fluid Needs equals 2120mL per 24 hours or 25mL/Kg/24 hours. As of 05/07/13, per Dietitian-O's assessment, Resident #1's was receiving 1199 mL per 24 hours or 20mL/Kg/24 hours (100mL of Water per 6 hours = 400mL + 799mL Free Fluid in Formula = 1199mL per 24 hours or 20mL/Kg/24 hours). This amount of fluid/water Resident #1 was receiving on 05/03/13 - 05/07/13 was 920mL less (43% less) than the estimated fluid needs of 2120mL per 24 hours. The Enteral Evaluation conducted by Dietician-O dated 05/07/13 references the original water flush order from admission on 05/01/13 and has documented,"Will clarify with MD." The evaluation also states,"Will suggest increase TF to 60mL/hour and to increase flushes to 250mL q 4 hours." Surveyors # and # noted the recommendations to increase Resident #1's water flushes to 250mL every 4 hours = 1500mL/24 hours. During an interview of Dietitian-O on 5/30/13 at 1:52 PM, Dietitian-O stated that in the evening of 05/07/13, Dietitian-O called the MD to discuss the recommendation of increasing the flush and tube feeding per the Enteral Evaluation dated 05/07/13. Dietitian-O received the MD's answering service. The answering service transferred Dietitian-O to the Nurse Practitioner's phone, and Dietitian-O left a message. Dietitian-O informed surveyors that the Nurse Practitioner did not call back. Dietitian-O stated by the next day, the Nurse Practitioner had still not called back, and nursing staff was calling the MD regarding"other health issues" for the Resident #1. Dietitian-O also stated that 1199mL per 24 hours or 20 mL/Kg/24 hours is too low for Resident #1. Dietitian-O also reported that given Resident #1's infection diagnosed on [DATE] (pneumonia), Resident #1 would need even more fluids than the Estimated Fluid Needs of 2120 mL per 24 hours or 25 mL/Kg/24 hours. Surveyor # asked Dietician-O whether Resident #1's large"denuded area" to his buttocks, noted in facility Quality Assurance Skin Record to be 8x5 cm. (centimeters), moist, deep pink on 5/7/13, would also have increased Resident #1's estimated fluid needs. Dietician-O stated, yes, Resident #1 loses"a lot of fluid through that large wound." Per Nurses' notes on 05/07/13 at 10:37 PM, Resident #1 had a stat chest X-Ray, CBC, BMP, and sputum culture sample taken. The nurse's note indicated thick yellow/greenish sputum. On 05/08/13 at 6:40 AM, nurse's notes indicate that [MEDICATION NAME] 750 mg daily times 7 days was ordered for left lung infiltrate (pneumonia) for Resident #1 at 2:30 AM, and that staff was awaiting the rest of the labs and culture. Per Nurses' notes dated 05/08/13 at 1:00 PM, lab was called for results, and message was left for Nurse Practitioner to update on labs and sputum culture. The May 2013 MAR, physician's orders [REDACTED]. Departmental Notes from Dietary dated 05/10/13 5:41 PM show that Dietitian-O was asked to review the current formula due to Resident #1's elevated blood sugars. The current order for the Dietitian to review was,"TF @ 50mL/hour provides ...799ml free fluid. Flushes increased to 200ml q 6 hours for a total of 1599ml fluid/day." Surveyors again noted that the amount that Resident #1 was receiving starting on 05/10/13 was 520mL less (25% less) than the estimated fluid needs of 2120 mL per 24 hours from the Enteral Evaluation dated 05/07/13. Dietitian-O informed surveyors on 5/30/13 at 1:52 PM that Resident #1's fluid levels were not addressed in her assessment on 05/10/13. Per Nurses' notes dated 05/10/13 at 7:52 PM, Resident #1 was transferred to the emergency room (ER) per wife's request after Resident #1's wife was updated as to Resident #1's current condition. Interdisciplinary Notes dated 5/10/13 at 7:52 p.m. by RN (Registered Nurse)-Y states Resident #1's gazed is fixed; he has in the past been able to make eye contact and visually track when spoken to ...AP (apical pulse 96, RR (respiratory rate) 40-48 (normal 12-20), pulse oxygen 88-925 on 3 liters of oxygen [MEDICAL CONDITION]; blood glucose was 426 (normal 65-99) ...orders received to give 16 units insulin ...Resident's respiration rate remained rapid 44-50 and blood glucose rose to 422 despite receiving additional insulin ... The 05/16/13 Columbia-St. Mary's Hospital Extended Care Facility Report contains documentation that Resident #1 was hosptalized on [DATE] with [DIAGNOSES REDACTED]." On 05/10/13, the hospital labs indicate that Resident #1's Sodium Level = 151 (Normal 135 - 145), BUN = 103 (Normal 6-23), and Creatinine = 2.8 (Normal 0.7 - 1.3). All these lab values were elevated in comparison to what they had been on 5/6/12. The Hospital Transfer Summary dated 05/16/13, reflects Resident #1 was discharged from hospital back to the facility on [DATE] with an order for [REDACTED]. A Dehydration Risk Assessment was performed by LPN (Licensed Practical Nurse)-NN on 05/16/13. The Assessment was not completely filled out; five parameters of Fluid Intake/Eating, Weight, Continence, Risk Factor, and Medication were not filled out. The parameters that were completed were: Skin- mucous membranes moist 0 pts.; Mobility-bed bound 2 pts.; and pre-disposing conditions- 3 or more present 2 pts. The Assessment gave a Total Score = 4 (a total score of 8 or above represents high risk). The Narrative Nurse's Note states:" Resident is a tube feeder and he receives water flushes q (every) 6 hours 250." The note does not compare the fluid intake to assessed estimated needs. Dietitian-O completed an Enteral Evaluation dated 05/23/13. Resident #1's Estimated Fluid Needs equals 2200mL per 24 hours or 25mL/Kg/24 hours. At Resident #1's current status, there is 250mL of Water per 6 hours = 1000mL + 799mL Free Fluid in Formula = 1799mL per 24 hours. This amount is 400mL less (18% less) than the estimated fluid needs of 2200mL per 24 hours. The Enteral Evaluation documentation indicates,"Would recommend increase rate of TF to 60 mL/hour. Possibly consider Prostat 101 30ml/day via [DEVICE]." Dietitian-O also reported that given Resident #1's pressure ulcers, Resident #1 would need even more fluids than the Estimated Fluid Needs of 2200 mL per 24 hours or 25 mL/Kg/24 hours. During Dietitian-O's interview with Surveyors # and # on 5/30/13 at 1:52 PM, Dietitian-O explained that the evening of 05/23/13, she wrote the recommendations from the Enteral Evaluation dated 05/23/13, on an additional form as well. Dietitian-O stated on 05/23/13 she left the additional form with the recommendations on the desk of Dietary Director-AA who would, the next day, pass the additional form onto the nursing staff, who would then bring the recommendations to the attention of the MD. Dietitian-O stated that she had just learned that same day (05/30/13 - the day of the interview) that nursing did not receive the 05/23/13 recommendation form, and the orders were not changed. Dietitian-O stated that as Resident #1 did not return from the hospital until 05/16/13, Dietitian-O waited 1 week to compare Resident #1's weights before recommending any new dietary changes, even though Resident #1 was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. Labs drawn on 05/27/13 show BUN of 54 (Normal 6-23), Sodium of 144 (Normal 136-145), Creatinine of 1.03 (Normal 0.7 - 1.3), and as of 05/30/13 at 1:52, Dietitian-O stated she had not yet reviewed the lab results. These lab values were higher than they had been when the resident had been discharged from the hospital. The facility did not address this trend, the fact that the resident was receiving 400 mL less than the estimated fluid needs of 2200 mL per 24 hours, or the fact that the same pattern (gradual increase in lab values) shown before hospitalization might be repeating itself. On 05/31/13 at 9:45 AM, Surveyor # and # were provided with a change in physician's orders [REDACTED]. Surveyor noted that this increase water flush totaled 1500 mL/24 hours which was the very original physician's orders [REDACTED]. Surveyor noted that this change in water flushes and tube feeding orders now meet the Estimated Fluid Needs of Resident #1. On 5/31/13 at 8:05 a.m. RN Consultant-KK presented Surveyors with a document (Medication Administration Total 17 Doses) showing re-calculations of Resident #1's fluid intake from May 1-10, now taking into consideration the water he receives with medication pass. RN-KK stated they compiled this information on the evening of 5/30/13 after talking with Surveyors and Dietician-O. The "Medication Administration Total 17 Doses" document now showed Resident #1 receives: 15 medications diluted with 10 cc's (cubic centimeters) for each medication totaling 150 cc's of water; (Surveyor noted the facility's Enteral Feeding Policy indicates that the medications should be diluted/mixed with 30 cc's) 5 cc water flushes between each of 17 medications totaling 85 cc's of water; Iron 30 cc's twice a day totaling 60 cc's; [MEDICATION NAME] 15 cc's twice a day totaling 30 cc's; 8 scheduled medication administration times with 30 cc water flushes before and after each totaling 480 cc's a day. The Medication Administration times listed are: 5:00 a.m.; 7:00 a.m.; 8:00 a.m.; 9:00 a.m.; 1:00 p.m.; 3:00 p.m.; 8:00 p.m.; and 11:00 p.m. The document states when these amounts (150+85+60+30+480) are totaled it equals 805 cc's/ day. 805 cc's added to the scheduled water flushes of 400 cc's /day=1205 cc's/day; plus 799 cc's/free fluid from the tube feeding formula =2004 cc's of fluid/day, not including any additional water flushes for PRN medication. Surveyor # noted when interviewing Dietician-O on 5/30/13, Surveyor # specifically asked about the water Resident #1 receives with his tube feeding medications and how that figures into the calculation of whether or not Resident #1 is receiving his estimated fluid needs. Dietician-O stated that unless a resident was receiving 8 ounces of water with [MEDICATION NAME], for example, she would not add that amount of water into the calculation to see if the Resident was provided the estimated fluid needs- she would consider it a "cushion." Surveyor # stated Dietitian-O also confirmed during interview on 5/30/13 the estimated fluids needs calculated on 5/23/12 were 2200 cc's based on the 25ml/kg body weight formula, and did not include additional calculations for Resident #1's skin conditions: a large sacral pressure ulcer noted on 5/28/13 Quality Assurance Skin Record to be possibly a Kennedy Terminal ulcer, 4.5 cm x 5.0 x 2.5 cm; a denuded area secondary to moisture and fungal rash- 5.0 x 2.5 cm. on right buttocks and 1.0 x 1.0 cm. on left buttocks; and an area of eschar on Resident #1's left ear- 4.0 x 1.0. Dietician-O stated that is where the "cushion" of free fluids (from the medication pass) is helpful. Surveyor # noted that not all the cc's of tube feeding formula are free fluid since it contains other components in addition to water, and the same would hold true for the facility's calculation of iron and [MEDICATION NAME], seeing many medications are hypertonic. Surveyor # noted that even with counting every cc/day per the facility's recalculation, the amount provides 2004 ccs/day. On 5/23/13, Dietician-O calculated Resident #1's estimated needs to be 2200 cc's/day not including any additional fluid needs related to his skin conditions, still leaving a deficit of 196 cc's/day. On 5/31/13 at 9:23 a.m., Surveyor # interviewed LPN-QQ who was passing medications on Resident #1's unit, asking if she has combined Resident #1's 7:00 a.m. medication pass with his 8:00 a.m. medication pass and 9:00 a.m. medication pass, considering nurses have an hour before and an hour after the scheduled time to administer medications if there are no other contraindications. LPN-QQ stated nurses frequently combine the three medication passes and administer the medications and 8:00 a.m. since it is time consuming to administer medications via tube, and they would be within the time restrictions giving them at 8:00 a.m. instead of three separate times, barring any incompatibilities of medications. Surveyor # noted that this would further reduce the amount of free water Resident #1 receives, since the facility's re-calculation added 30 cc water flushes before and after each scheduled medication administration time, (7:00, 8:00 and 9:00 a.m. shown to contribute 180 cc's pre/post flushes when in fact it would be one medication administration at 8:00 a.m. for 60 cc's of water, an additional reduction of 120 cc's of free fluid a day.) This 120 cc's less (compared to recalculated figure) plus the built-in shortage of 196 cc's per day leaves a shortage of 316 cc's/day not provided to Resident #1 per day, and Resident #1 is totally dependent on staff for his nutritional and fluid needs.

Based on observations, record reviews, and interviews, the facility did not ensure that 4 (Residents #13, #6, #14 & #12) of 7 residents with pressure ulcers received the necessary treatment and services to promote healing, prevent infections and prevent new sores from developing. Resident #13 has a Stage 2 pressure ulcer of the coccyx. Observations during the survey revealed Resident #13 was not always repositioned as specified in her plan of care, and did not have her pressure relief air mattress inflated. The size of Resident #13's pressure ulcer has increased from 0.6 x 0.3cm on 2/14/13, to 1.0 x 0.5cm on 2/21/13. Resident #6 has a Stage 4 pressure ulcer of the right elbow. A review of the Treatment Administration Record revealed several days in February that the treatment for [REDACTED]. According to an incident report, the facility confirmed that Registered Nurse (RN)-G had not completed the wound treatment on 2/2, 2/3, 2/16 & 2/17/13. A review of weekly wound assessments reveal the pressure ulcer has not deteriorated. Resident #14 has a healed pressure ulcer of the left lateral foot and a small superficial scab on the right lateral foot. Resident #14 was observed on 2/20 & 2/21/13, in bed with Prevalon boots, with her lateral foot area resting against the mattress. On 2/20/12, Resident #14's air mattress pump was not turned on or set at the correct setting for maximum pressure relief. Resident #12 has an unstageable pressure ulcer of the lateral right heel. Resident #12 was observed on 2/18 and 2/21/12, positioned in his Broda chair, with Prevalon boots on, but with the lateral right heel area positioned against the foot rest. Findings include: 1.) Surveyor # reviewed Resident #13's record on 2/19 - 2/21/13. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #13 has had a recurring pressure ulcer of the coccyx, which had been slowly improving through 2/14/13. A review of the nursing care plan reveals pressure relief interventions including chair cushion, air overlay mattress, free float heels and reposition every 2 hours. The Quarterly Minimum Data Set ((MDS) dated [DATE], indicates Resident #13 is at risk for pressure ulcers, and currently has a Stage 2 pressure ulcer. Resident #13 requires extensive assistance with most activities of daily living. On 2/19/13, Resident #13 was observed by Surveyor # lying on her back with heels floated at 9:05a.m., 10:45a.m., and 11:55a.m., without a change in position. This was 2 hours and 50 minutes without repositioning. On 2/20/13 at 1:10p.m., Surveyor # spoke with Certified Nursing Assistant (CNA)-K, who had cared for Resident #13 on 2/19/13. CNA-K stated she must have been running a little late getting Resident #13 up for lunch. CNA-K stated she did not reposition Resident #13 between lying her down after breakfast, and getting her up for lunch. CNA-K stated she usually gets Resident #13 up for lunch between 11:15- 11:30a.m. On 2/20/13, Surveyor # observed Resident #13 lying in bed at 9:30a.m., 9:55a.m., and 10:25a.m. The overlay air mattress was flat, and there was no pump attached to the bed to inflate the mattress. Resident #13 got up for lunch at 11:00a.m. At 11:25a.m., Surveyor # and RN Manager-E went to check the air mattress. RN Manager-E stated there should be a pump at the end of her bed to inflate the mattress and she did not know what had happened to the pump. A new mattress was provided before Resident #13 laid down after lunch. A review of weekly wound documentation reveals the area on the coccyx had been unchanged for the assessments completed 2/7 & 2/14/13. For both of those assessments the coccyx pressure ulcer was determined to be a Stage 2 pressure ulcer which measured 0.6 x 0.3 x 0.2cm. On 2/21/13 at 10:10a.m, Surveyor # observed LPN-J complete the treatment to the coccyx pressure ulcer. LPN-J, who is wound certified measured the coccyx pressure ulcer and informed Surveyor # that the area was still a Stage 2 pressure ulcer, but now measured 1.0 x 0.5cm, which was larger than the previous measurement. 2.) Surveyor # reviewed Resident #6's medical record on 02/14-02/25/13. Resident #6 was admitted to the facility 02/26/12, with [DIAGNOSES REDACTED]. Review of wound documentation revealed Resident #6 developed a Stage 4 pressure ulcer measuring 1.0 X 0.40cm to his right elbow on 12/05/12. Due to the location of Resident #6's pressure ulcer (elbow), any development of a pressure ulcer would be considered Stage 4, due to the lack of underlying tissue. Review of Resident #6's Treatment Administration Record (TAR), for the month of February 2013, revealed Resident #6's treatment to his right elbow had not been signed out as being completed on 02/1, 02/02, 02/14, 02/16 and 02/17/13. On 02/20/13, Surveyor # informed the Director of Nursing (DON), that Resident #6's treatment to his right elbow had not been initialed as being completed for 5 days on the February 2013 TAR. On 02/21/13 at approximately 8:50a.m., Surveyor # spoke with Registered Nurse (RN)-F. RN-F indicated she had completed Resident #6's treatment on 02/14/13, but had not initialed the TAR as having completed the treatment. On 02/22/13 at approximately 11:00a.m., the DON presented Surveyor # with a facility Resident Incident Report dated 02/21/13. Review of the facility Incident Report revealed that Registered Nurse (RN)-G, was responsible for completing Resident #6's right elbow wound treatment on 02/02, 02/03, 02/16 and 02/17/13. The Incident Report also indicates, "When asked about missed treatments, RN-G stated they were not completed on all 4 of the above dates. On 2/19/13 at 10:15a.m., Surveyor # observed the treatment to Resident #6's right elbow. By appearance, the area had not increased in size. The peri-wound area was dry, but with intact skin. Review of Resident #6's wound documentation revealed the pressure ulcer had not deteriorated as a result of the missed treatments. 3.) Surveyor # reviewed Resident #14's medical record on 02/14-02/25/13. Resident #14 was admitted to the facility 06/17/98. Review of Resident #14's Nurses' Note documentation revealed an entry dated 01/29/13 at 2:15p.m, indicating, "Wound treatment note-left lateral foot wound remains closed. Wound to right lateral foot noted to have a small superficial scab surrounding tissue healthy." Review of Resident #14's February 2013, physician's orders [REDACTED]. Skin prep left lateral foot daily-prevention To lateral aspect of right foot-normal saline then skin prep peri wound then apply medi-honey to wound base, then foam dressing. Review of Resident #14's plan of care indicates a problem of risk for skin breakdown with an intervention to float Resident #14's heels in bed. Resident #14 has bilateral lower extremity contractures. When lying in bed, due to the lower extremity contractures, the pressure points are on the lateral foot areas rather than the heels. On 02/20/13 at 8:20a.m. Resident #14 was observed lying in bed. Resident #14 had Prevalon Boots applied to both her left and right feet/heels. Both lateral aspects of Resident #14's feet were observed to be resting on a pillow and her feet were not floated. Surveyor # observed Resident #14 on 2/20/13 at 8:10a.m., 8:55a.m., and 9:22a.m. Resident #14 was lying in bed on her back with her legs turned to the right (due to contractures). There was a pillow under her legs, positioned so that both of her feet, with the Prevalon boots on, were resting on the pillow. Her feet were not floated. The pump for the alternating air mattress was off during each of the above observations. The dial for the pump was set on 2. On 2/20/13 at 9:32a.m., Surveyor # accompanied Licensed Practical Nurse-J, who is Wound Care Certified, for the completion of prescribed treatments for Resident #14's feet. Surveyor # informed LPN-J that the air mattress pump was turned off and asked what the designated setting should be for the pump. LPN-J stated the pump should be labeled with the correct setting. There was no label designating the proper setting for Resident #14's air mattress pump. LPN-J turned the pump on and stated she would find out what the proper setting should be. (On 2/20/13 at 10:20a.m., LPN-J told Surveyor # that the correct setting for the pump was at 4). During the observation of the treatments for Resident #14's feet on 2/20/12 at 9:35a.m., Surveyor # asked LPN-J about the use of the pillow under Resident #14's feet. LPN-J stated the pillow wasn't really needed when Resident #14 has the boots on, as the boots provide for pressure relief. On 02/21/13 at 8:35a.m., Resident #14 was observed lying in bed. Resident #14 had Prevalon Boots applied to both her left and right feet/heels. Both lateral aspects of Resident #14's feet were observed to be resting directly on her mattress. On 02/21/13 at 10:15a.m., Resident #14 was observed lying in bed. Resident #14 had Prevalon Boots applied to both her left and right feet/heels. A pillow had been placed between Resident #14's feet and both lateral aspects of Resident #14's feet were observed to be resting directly on her mattress. On 2/21/13, Surveyor # reviewed the facility provided manufacturer's literature for the Prevalon boots. The Prevalon Pressure-Relieving Heel Protector boots are designed to protect against heel pressure ulcers and foot drop. The boot is designed with thick soft padding on the posterior portion of the boot, which floats the heels, when the wearer is in the supine position (on the back). This is the most common pressure point on the heel and the most common area of pressure ulcer development. The boot is not designed to float the lateral foot areas, which are the areas being treated on Resident #14. 4.) Surveyor # reviewed Resident #12's medical record on 02/14-02/25/13. Resident #12 was admitted to the facility 11/18/11 with [DIAGNOSES REDACTED]. Review of Resident #12's Nurses' Note documentation revealed an entry dated 02/07/13 at 12:30p.m, indicating, "Lateral aspect of right heel has open area that measures 4cm x 2cm wound base deep red surrounding tissue with in normal limits" Review of Resident #12's February 2013, physician's orders [REDACTED]. Skin prep to peri wound then apply Opti foam AG (foam with silver) daily with light [MEDICATION NAME] wrap to right lateral aspect of heel and right heel protector boot at all times. On 02/18/13 at approximately 9:55a.m., Resident #12 was observed sitting in his Broda chair in the facility's second floor dining room. Resident #12 was observed to be wearing a protective boot on his right foot/heel. The right lateral aspect of Resident #12's foot was observed to be resting directly on the foot/leg pad of his Broda chair. On 02/20/13 at 1:35p.m., Surveyor # observed LPN-J complete the prescribed treatment for [REDACTED]. On 02/21/13 at 8:15a.m., Surveyor # observed Resident #12 sitting up in a Broda chair. A Prevalon boot was on the right foot. (Resident #12 had a left lower leg amputation). There was a thin pillow under Resident #12's calf. Resident #12's right leg was slightly externally rotated, which placed the right lateral heel against the foot rest of the Broda chair. On 2/21/13 at 9:35a.m., Surveyor # observed Resident #12 sitting up in a Broda chair, positioned as noted at 8:15a.m. Surveyor # spoke with RN Manager-E regarding the positioning of Resident #12's foot. RN Manager-E placed a second pillow under Resident #12's calf, which floated the right foot/heel area. On 02/21/13 at approximately 10:30a.m., Resident #12 was observed sitting in his Broda chair across from the nurses' station. Resident #12 was observed to be wearing a protective boot on his right foot/heel. The right lateral aspect of Resident #12's foot was observed to be resting directly on the foot/leg pad of his Broda chair. On 02/25/13 at approximately 9:00a.m., Surveyor # observed Resident #12 in his Broda chair in lounge across from the nurse's station. Resident # 12's heel/foot was observed to be floated. On 2/21/13, Surveyor # reviewed the facility provided manufacturer's literature for the Prevalon boots. The Prevalon Pressure-Relieving Heel Protector boots are designed to protect against heel pressure ulcers and foot drop. The boot is designed with thick soft padding on the posterior portion of the boot, which floats the heels, when the wearer is in the supine position (on the back). This is the most common pressure point on the heel and the most common area of foot pressure ulcer development. When Resident #12 rotates his right leg, the pressure point changes to the lateral right heel, which is not the area the boot is designed to protect.

Based upon interview and record review the facility did not ensure timely pain management for 1 (Resident #21) of 5 residents reviewed for pain concerns. Resident #21 was admitted to the facility on [DATE] following significant heart surgery on 9/18/12. Upon arrival at the facility at approximately 4:30 pm Resident #21 indicated to nursing staff that she was experiencing pain. Review of her medical record indicates that Resident #21's last pain medication administration on 10/1/12 was at 10:15 am at the hospital. Despite arriving with valid pain medication prescriptions and repeated complaints of pain, the facility did not obtain authorization to obtain 5 mg tablets of [MEDICATION NAME] from contingency until 21:00 (9:00 pm). When interviewed Resident #21 expressed that her pain on 10/1/12 was a "10 out of a 10." The facility and hospitalization documentation also indicates that the pain caused Resident #21 to perseverate about her pain and lack of medications to help control it. Findings include: On 10/9/12 the Division of Quality Assurance Southeastern Regional Office received an online complaint from Resident #21 regarding the "quality and continuum of care at Lake Terrace." The complaint went on to state that the Resident was recovering from major hear surgery and that she went almost 6 hours after arriving without medications and "suffered from excruciating pain due to this oversight." The complaint goes on to state that the Resident and her friend who had transported her to the facility "implored " the Licensed Practical Nurse (LPN) and her supervisor to expedite the process. Resident #21 indicates that she finally received 5 mg of [MEDICATION NAME] after 10:00 pm that evening. Resident #21 wrote in the complaint "I was scolded for inquiring about my medication repeatedly ...The stress of everything brought on chest pains, congestion, and difficulty breathing. I ended up being re-hospitalized ...from the evening of Tuesday October 2nd to Friday, October 5th, 2012. I am now in another facility recuperating." On 11/12/12 at approximately 6:56 pm Surveyor # interviewed Resident #21 via telephone. Resident #21 communicated to Surveyor # that she and her friend arrived at the facility sometime after 4:00 pm with an envelope from the hospital that contained her hospital papers along with prescription slips for pain medication. Resident #21 indicated that she was in pain upon arrival because she had just ridden in a car to get to the facility and had just been discharged from the hospital. Resident #21 indicated that she told nursing staff when she got there that she was in pain and wanted pain medication. Resident #21 continued to communicate to Surveyor # that as the evening went on she became more and more agitated because of being in pain. When Surveyor # asked what she recalled her pain to be that night Resident #21 stated "10 out of 10." Resident #21 indicated that staff just kept coming in empty handed saying that it is coming. Resident #21 indicated that because she kept asking questions and getting mad they started to come into her room as a group of 3 which just upset her more. Resident #21 indicated that eventually the nurses would say that the person with the medicine is coming. Resident #21 indicated that she finally got up to look down the hall to see if someone was coming and that she could see a nurse down the hall passing medications but that they were not bringing hers. Resident #21 indicated that when she did finally get her pain medication it was 1 pill of [MEDICATION NAME] and it was close to 11:00 pm. Resident #21 indicated that when the nurses finally brought the [MEDICATION NAME] in she was so upset and had been told it was coming so many times and then never brought in that she was not sure, at first, that what they were bringing in was going to be pain medication. So she at first refused the medication and was upset with staff but she eventually calmed enough to take the medication. Resident #21 indicated that she was so upset about her stay at the facility that she had to be re-hospitalized . On 11/13/12 at approximately 7:35 am Surveyor # interviewed the friend who brought Resident #21 to the facility; Friend-CC. Friend-CC indicated that she brought Resident #21 to the facility from the hospital and that it seemed like a long car ride from the hospital to the facility. Friend-CC indicated that Resident #21 told the nurses right after she got there that she was in pain and that they did not give her any of the medications to get rid of her pain. Friend-CC indicated that what she observed was that as the evening went on that Resident #21's pain was "off the charts" and that she was crying and writhing in pain. Surveyor # asked Friend-CC about Resident #21's agitation on 10/1/12 and Friend-CC indicated that Resident #21's anger and agitation just kept increasing because she was so upset and in pain. Friend-CC indicated that Resident #21 called her at about 11:00 pm when they finally brought medicine in to Resident #21 and Resident #21 was so upset after being treated the way that she was by the nurses that she at first did not trust that the medications that they were bringing in was pain medication. Friend-CC indicated that Resident #21's frustration continued into 10/2/12 when Resident #21 still had questions about her medications and the Director of Nursing and Nurse Manager and eventually the Administrator tried to talk to Resident #21 about the medications it caused Resident #21 to become so upset that she had difficulty breathing and had to go to the hospital. Surveyor # reviewed Resident #21's medical record on 11/12/12-11/13/12. Resident #21 is a [AGE] year old individual who was admitted to the facility for rehabilitation on 10/1/12 with [DIAGNOSES REDACTED]. Resident #21 underwent a resection of the [DIAGNOSES REDACTED] for [MEDICAL CONDITION] with reconstruction of the aorta with a Hemashield patch, left [MEDICAL CONDITION] appendectomy and sternal closure with Talm fixator 2 on 9/18/12. Resident #21 arrived with a dressing over her upper right chest wall, a midline sternotomy scar with staples in place going from the suprasternal notch all the way down to the upper abdominal wall area where there were healing drain incision sites. Upon review of Resident #21's medical record Surveyor # observed 2 prescription slips. The first prescription slip is for [MEDICATION NAME] 5 mg with a start date of 10/1/12 to take 1 tablet by mouth every four hours as needed for pain with a prescribed fill amount of 50 tablets dated 10/1/12. The second prescription slip for [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 7.5/500mg with a start date of 9/28/12 to take 1 tablet by mouth every 6 hours as needed for pain with a prescribed fill amount of 40 tablets, with 1 refill dated 9/28/12. Both prescriptions were signed and written by the nurse practitioner at the hospital and had listed DEA (Drug Enforcement Agency) numbers. Review of the discharge papers from Resident #21's hospitalization also included documentation that indicated that medications were a focus and cause of anxiety for Resident #21 during her hospitalization post-surgery. Review of the October 2012 resident care plan indicates under a heading titled mental attitude that Resident #21 is moody, alert and agitated. The undated interim care plan indicates a primary admitting [DIAGNOSES REDACTED]. Approaches include give meds as ordered, assess pain level and response to pain, PT/INR's (prothombin time/international normalization ratio) as ordered. An additional problem identified includes depression and anxiety. Care plan approaches include: social service assessment, activity assessment, observe response to admission, orient to activity program and facility services and staff. Resident #21's Pain management assessment dated [DATE] indicates that Resident #21 has not been on a scheduled pain regimen but that Resident #21 has received PRN (as needed) pain medications and that Resident #21 has not received non-medication pain interventions. The assessment indicates that a pain assessment interview should be conducted and the results of the interview indicate that pain is present, that the frequency is frequently and that it limits daily activities and the verbal descriptor scale of the pain is severe. The assessment indicates that Resident #21 was unable to answer if the pain is making it hard to sleep. The staff interview section of the assessment was noted to be blank. The conclusion of the assessment states: PRN medication - reviewed - Hosp. record - contacted MD to get meds per order. Nurse's Note dated 10/1/12 (at either 17:00 pm (5:00 pm) or 22:00 (10:00 pm) as documentation is unclear) indicates: Resident arrival at facility 1700 (again time is unclearly documented) via friend/family car alert/oriented x3. Verbally communicates complaint of pain, waiting verifying order and authorization to give something. Resident was uncooperative starting cussing at staff, nurse and CNA's (certified nursing assistants) and supervisor went in residents room to explain to resident that we're doing what we can to get her medication as quickly as we can, resident continues to curse at staff, clinical assessment done, body check done, VSS (vital sounds) call light within reach. Nurse's Note dated 10/1/12 at 23:00 (11:00 pm) indicates [AGE] year old resident arrived to facility with friend at bedside. Escorted to room. Resident oriented to surroundings. Resident c/o (complained of) pain. Given [MEDICATION NAME]. Resident, loud using profanity, "Hell no, I'm not taking that[***] this is ludicrous." Resident grabbed meds, refused to take meds, started talking to friend on phone, then called St Luke's stating 'facility was refusing to give her, her meds.' Writer attempting to explain policy, resident continued to be loud, hostile and refused to listen. With further explanation resident took medication but refused metroprolol, patient thinks meds are wrong dosages, would not listen to facility policy...verified with Dr. (Doctor)-BB fax pharmacy ... Nurse's note 10/2/12 04:30 am...new admit. Stated she is in great deal of pain and needs her medication. Called the pharm (pharmacy) who stated he will send it out. Will monitor this shift. Surveyor # noted that this was the final nurse's note entry in Resident #21's medical record. Review of Resident #21's medical record indicates that a speech evaluation was completed with Resident #21 on 10/1/12 (time not indicated). Review of the speech therapy documentation on the evaluation and plan of care indicates that Resident #21 did not seem to demonstrate understanding of any medication with the exception of pain medications but could not state which ones were prescribed to her in the hospital ....patient given portions of the ripa test for cognition and memory patient was agitated and kept perseverating over pain medications even though she knew that the doctor had not called back to verify her orders. Patient was aware of this procedure because she must have been told by every professional six times ...the assessment summary indicates ...patient is extremely anxious and perseverated on one problem all night and could not shift focus on anything else .... On 11/12/12 at approximately 11:00 am Surveyor # interviewed Director of Nursing (DON)-B about the facility's process for handling residents who are newly admitted and pain medications. DON-B indicated that the orders have to be verified with the physician and that the new DEA rules make it more difficult to give pain medications. Surveyor # asked DON-B to follow up on the delay in giving Resident #21 her pain medications. On 11/12/12 at approximately 12:40 pm Surveyor # was given a note from DON-B that indicated that DON-B has contacted the pharmacy and that at 21:00 (9:00 pm) authorization was given by the pharmacist to take 2 oxy ([MEDICATION NAME]) from contingency. 1 was removed at 21:00 on 10/1/12 and a second was removed at 2:30 am on 10/2/12. Delivery of medication was signed for at 05:15 am on 10/2/12 when Resident #21's medications came to the nursing home. On 11/12/12 at approximately 12:45 pm Surveyor # interviewed Nurse Manager (NM)-DD about Resident #21's stay at the facility. NM-DD indicated that it was her understanding that the physician orders [REDACTED]. Surveyor # asked if a Resident arrives with a valid prescription could that be sent to the pharmacy to be filled immediately NM-DD indicated that she thought so. NM-DD indicated that she could not specifically recall if it was the first day of Resident #21 being in the facility or the second day but that she was very anxious and that she stated that she was in pain. NM-DD indicated that perhaps Resident #21 was "suffering from a rebound affect from getting stronger pain medications in the hospital than what she was getting in the facility." Surveyor # asked if a review had been done to look at that possibility NM-DD indicated that she was uncertain what pain medications Resident #21 was getting before coming to the facility. Surveyor # asked NM-DD why Resident #21 went back to the hospital. NM-DD indicated that Resident #21 was almost having a panic attack over what she thought was bad care at the facility and that the facility could not meet her needs. Surveyor # asked NM-DD if she was aware of why there was a delay in Resident #21 getting her pain medications and NM-DD indicated that she could not state when the prescriptions were faxed to the pharmacy and why couldn't give earlier. On 11/12/12 at approximately 1:07 pm Surveyor # interviewed DON-B about the facility's protocol for admission orders [REDACTED]'s in-house physician because the admitting physician may want to make changes to the orders. Once orders are clarified with the in house physician then yes they can fax the orders to the pharmacy. On 11/12/12 at approximately 2:30 pm Surveyor # interviewed Licensed Practical Nurse (LPN)-EE about Resident #21's admission to the facility. LPN-EE recalled who Resident #21 is. LPN-EE indicated that Resident #21 pretty much said that she was in pain as soon as she got to the facility but that LPN-EE thought that Resident #21 said that she could handle it. Surveyor # asked LPN-EE if that was charted and LPN-EE indicated no. LPN-EE indicated that Resident #21 was very upset, angry and cussing out staff and that they kept trying to tell her that there was a policy that was holding up the medications but she would not listen. Surveyor # asked LPN-EE to review the nurse's note entry that was written on 10/1/12 to clarify the time that it was documented and LPN-EE was not sure if it was written at 1700 or 2200. Surveyor # asked LPN-EE what is the protocol for processing medications when a resident is newly admitted to ensure timely administration. LPN-EE stated that she was aware that there is a protocol and that it requires verifying the orders but she was not 100% certain of the whole protocol but that she knew medications cannot be given without verifying orders with the facility physician. Surveyor # asked about the delay in getting the medications. LPN-EE indicated that she was not sure about the delay but felt that they did everything they could do on their end but had to wait for the pharmacy. On 11/12/12 at approximately 4:05 pm Surveyor # interviewed Pharmacy Technician (Pharm Tech)-FF regarding Resident #21's medications. Pharm. Tech-FF indicated that in order for a facility to get medications delivered the evening that someone is admitted that the facility would need to have orders faxed to the pharmacy before 7:30 pm because that is the cut off for delivery for that day unless the facility calls the pharmacy to indicate that something needs to be delivered stat. Pharm. Tech-FF indicated that on 10/1/12 the facility did not fax Resident #21's verified physician orders [REDACTED]. When Pharm. Tech-FF was specifically asked about the orders for [MEDICATION NAME] and [MEDICATION NAME] Pharm Tech-CC indicated that the facility had faxed the prescription slips to the pharmacy at 6:20 pm. Surveyor # asked Pharmacy Tech-FF why would there have been such a delay to access the medications if the prescriptions were valid prescriptions and sent in at 6:20 pm. Pharm. Tech-FF indicated that typically a facility will indicate that they want a call back from the pharmacy with authorization to access contingency once the pharmacy receives and processes the prescriptions. However, in this case the facility did not indicate such a request on the faxed prescription slips so it then was the facility's responsibility to call the pharmacy back to get authorization to access contingency. Pharm. Tech.-FF indicated that the facility did call the pharmacy for authorization to access contingency at 21:00 (9:00 pm). At that time the facility was authorized to remove 2 [MEDICATION NAME] tablets from contingency and the remaining prescribed amount of 48 was to be delivered in the morning. On 11/12/12 at the daily exit meeting with the facility Surveyor # shared concerns with the facility administration regarding the delay in addressing Resident #21's pain upon arrival at the facility. Surveyor shared that nurses that have been interviewed have shared varying descriptions of the facility's protocol for processing admission orders [REDACTED]'s attending physician before they can be used because the attending physician may want something different ordered. On 11/13/12 Surveyor # reviewed the hospital records from Resident #21's 10/2/12 admission to the hospital. Review of the hospital records indicates: Patient arrives by EMS complaining of chest pain or shortness of breath for the past 2 days. She recently had an aortic thrombus removed at St. Luke's in the middle of September. She is recently discharged from that facility and was in rehabilitation when she developed her symptoms. She states that she has felt chilled and has a productive cough now. Shortness of breath is worse with laying down and exertion. She feels comfortable laying in the gurney. She also describes sharp, intermittent, severe chest pain in her left upper chest. This is also been present for the past 2 days. She is a poor historian. She perseverates about how terrible her rehabilitation facility experience has been and that she is not getting her medications and that they have not fed her for 2 days. While speaking to the patient about her chief complaint, she continues to return to complain about her above concerns making adequate history difficult to obtain. The report goes on to indicate that Resident #21 is now resting comfortably after a dose of [MEDICATION NAME] 1mg IV. On 11/13/12 Surveyor # reviewed the facility's policy and procedure regarding admission orders [REDACTED]. The Procedure indicates: orders are obtained the day of admission either by the attending physician writing orders in person or the nurse receives admission order via telephone, all medications and treatments must be handwritten and have a diagnosis/qualifier for use, orders must be dated and noted by nurse, the information at the bottom of the order sheet must be completed, if orders do not fit on one page a blank sheet is added, one copy of the orders is sent to the pharmacy the original stays in the chart for the physician to sign, the charge nurse is to verify the admission orders [REDACTED]. The above information was shared with the facility administration upon exit from the facility on 11/13/12. On 11/14/12 the facility supplied additional information and statements from Physician-BB to review regarding Resident #21. The information presented included notation from the hospital discharge papers demonstrating Resident #21 experienced confusion and behavior problems while hospitalized and that while hosptalized on [DATE] Resident #21's pain level was a 2 on a scale of 0 to 10 noting that [MEDICATION NAME] was administered to Resident #21 once on 10/1/12 and that [MEDICATION NAME] was administered twice on 9/30/12 to give consideration that Resident #21 was going 10 hours between pain medication doses while in the hospital. The additional information also emphasizes Resident #21's psychological and psychiatric conditions suggesting that Resident #21's statements and behaviors were more a manifestation of a personality disorder than pain. Additionally the facility included for consideration the fact that Resident #21 was able to participate in physical therapy, occupational therapy and a physician assessment etc. on 10/2/12 with the facility documenting that this participation indicates that pain did not compromise her physical and psychosocial function or her ability to participate in therapy to reach her highest practicable well-being. Review of Resident #21's medical record indicates that on 10/2/12 Resident #21 received a 5 mg dosage of [MEDICATION NAME] at 7:00 am following a rating of pain as being 8 out of 10 on the pain scale, a dosage at 11:00 am for pain rated 6 out of 10 on the pain scale and an additional dosage of 5 mg [MEDICATION NAME] on 10/2/12 at 5:00 pm with no pain scale assessment indicated. Surveyor # also noted that on 10/2/12 Resident #21 received a 7.5 mg dosage of [MEDICATION NAME] at 7:00 am for pain rated 8 out of 10 on the scale. A second dosage of [MEDICATION NAME] was administered at 5:00 pm for pain with no pain scale assessment documented. Following administration of these medications the result documented includes pain dropping in intensity to a rating of 2 out of 10 or a notation that "pain is better." This would indicate that while Resident #21 participated in services on 10/2/12 Resident #21 was receiving medication for pain management that she did not receive on 10/1/12. Surveyor # also noted that upon review of Resident #21's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].

Based on observation, interviews and record review, facility staff did not maintain an effective Infection Control Program beginning November 1, 2011 when new management assumed operations of the facility. * Starting on November 1, 2011 staff did not conduct ongoing surveillance or monitoring of what infections residents currently had in the building. No tracking or monitoring of infections was done for November 2011 or December 2011 until December 12, 2011, when surveyors asked to see the facility's Infection Control surveillance data. * On 12/12/11, isolation carts containing PPE (Personal Protective Equipment) were observed outside of four resident rooms (Residents #1, 13, 20 and 31). Staff did not know what infections those residents had, nor did they know what equipment was required to care for the residents. * Staff did not properly disinfect glucometers after checking blood sugars for Residents #32 and #33 on 12/7/11 and Resident #20 on 12/8/11. The glucometers are used for multiple residents. After record review on 12/12/11, it was discovered Resident #20 has an immune deficiency blood disorder, and the glucometer used for Resident #20 is also used for 8 other residents. This created a finding of Immediate Jeopardy starting on 11/1/11. On 12/13/11 Administrator A and the Director of Nursing-B were notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 12/14/11, however, the deficient practice continues at a scope and severity of an E (potential for harm that is not immediate jeopardy/pattern) as the facility must continue to ensure all nurses/ medication technicians have received training on properly disinfecting the glucometers between resident use. The facility needs to ensure continued ongoing surveillance of infection, and maintaining current infection control logs. The Registered Nurse (RN) managers still need to receive instruction on the infection control process and logs while the Staff Development Coordinator (SDC)/Infection Control Nurse and Director of Nursing (DON) need to receive education necessary to be well informed on infection control practices. Further evidence of continued deficient practice at severity level 2 is evidenced by the following: * Staff did not follow proper hand washing techniques during 1 of 3 treatment observations (Resident #12), and during 1 of 3 care observations (Resident #14). Findings include: Disinfecting glucometers Division of Quality Assurance (DQA) memos state: DQA Memo 08-013 dated May 6, 2008, Glucose Meters and Infection Control: "...Patient-to-patient transmission of bloodborne pathogens is a well known risk when lancets, needles, and syringes are reused between patients. However, patient-to-patient transmission of pathogens facilitated through the use of devices such as glucose meters may not be as well known. The Centers for Disease Control and Prevention (CDC) has published recommendations for infection control and safe injection practices to prevent patient-to-patient transmission of bloodborne pathogens. Facility staff should evaluate practices related to glucose meter, lancet, and needle use,...Following are specific infection control recommendations published by the CDC that focus on diabetes-care procedures in healthcare and group residence settings...Glucose meters should be assigned to individual patients. If glucose meters are shared between patients, the devices should be cleaned and disinfected between each patient use..." DQA memo 11-031 dated November 29, 2011, Glucose Meters and Infection Control "...Facilities continue to be cited for failing to clean and disinfect meters between residents when the meter is used by multiple residents. One new issue that has arisen is not ensuring the cleaning and disinfecting process is effective. Observations have included staff using cleaning agents that do not kill bloodborne pathogens or staff not adhering to the manufacturers' instructions for the cleaning agents to ensure effectiveness. For example, for a given disinfecting wipe, the manufacture's instructions direct the disinfecting wipe to have contact time on the surface for 2 minutes to be effective. For this particular wipe, an observation of a violation would be staff using a wipe with a contact time of 30 seconds. Facilities should evaluate the products that are being used to clean and disinfect the glucose meters to ensure they are effective against bloodborne pathogens. Facilities should also complete surveillance to ensure staff is following the appropriate instructions for the cleaning agent being used." 1. On 12/7/11 at 7:48 a.m., Surveyor # observed LPN (Licensed Practical Nurse)- I use a glucometer to obtain Resident #32's blood sugar. LPN-I then wiped the glucometer with a PDI Super Sanicloth wipe, in one swipe. The glucometer was dry in less than one minute. The product information states to disinfect a surface, the surface must be kept wet for two minutes, then allowed to air dry. 2. On 12/7/11 at 11:33 a.m., Surveyor # observed LPN-G obtain a blood sugar on Resident #33. LPN-G wiped the glucometer in one swipe, using a PDI Super Sanicloth wipe. The glucometer was dry in less than one minute. The product information states to disinfect a surface, the surface must be kept wet for two minutes, then allowed to air dry. 3. On 12/8/11 at 8:20 a.m., Surveyor # observed LPN-G obtain a blood sugar on Resident #20. LPN-G wiped the glucometer in one swipe, using a PDI Super Sanicloth wipe. The glucometer was dry in less than one minute. The product information states to disinfect a surface, the surface must be kept wet for two minutes, then allowed to air dry. On 12/12/11, Surveyor # reviewed Resident #20's medical record, noting a [DIAGNOSES REDACTED]. Resident #20's December 2011 Physician order [REDACTED]. On 12/13/11 at 8:40 a.m., Surveyor # asked LPN-G how nurses are supposed to disinfect the glucometers after each use. LPN-G stated they are to wipe the unit with the SaniCloth wipes, then let dry for 3-5 minutes before they use it for another resident. Surveyor # showed LPN-G the instructions printed on the PDI Super Sanicloth container, which states keep surface wet for two minutes, then let air dry. LPN-G stated they received training informing them to use the wipes, but were not told the surface had to be wet for 2 minutes. Surveyor # asked how many residents' blood sugars are checked with the same glucometer. LPN-G stated she uses the same glucometer for nine residents, including Resident #20. Surveyor # checked LPN-G's medication cart and noted there was only one glucometer on the cart. On 12/13/11, Surveyor # reviewed the facility's Policy and Procedure Number 7.32 "Glucometer Cleaning" issued 7/1/11. The facility's Policy and Procedure Number 7.32 states, "The purpose of this protocol is to prevent resident -to-resident transmission of bloodborne pathogens." Under "Procedure" it states: -Complete sanitation of glucometers by wiping with approved disposable wipes between resident use. Discard wipes in appropriate receptacle. - There should be 2 glucometers per medication cart- one in use and one cleaned and drying. Infection surveillance 4. On 12/12/11 at 3:09 p.m., Surveyors # and # interviewed DON (Director of Nursing)-B and IC RN (Infection Control Registered Nurse)-F regarding the facility's infection control program. DON-B stated she has only been employed by the facility since 11/2/11, and IC RN-F began employment 11/17/11, so neither had been at the facility very long, but they were the two responsible for the infection control (IC) program. DON-B stated upon their arrival, they discovered staff had not started immunizing residents for influenza. DON-B stated they had to prioritize, and felt it was more important to work on the immunization program, and so they were unable to conduct infection control surveillance in November 2011 or thus far in December 2011. DON-B stated in the beginning of December, she had hoped to get December infection surveillance rolling, as she thought that would be more beneficial than retrospectively creating logs for November. But then surveyors entered the building (12/5/11), and Surveyor # had asked to review November and December IC monitoring logs, so on 12/12/11 she instructed IC RN-F to develop Infection Control Surveillance logs for November, using Physician Telephone orders, a report from pharmacy listing what antibiotics were ordered for residents, and some HAI (Healthcare Associated Infection) Surveillance Report Forms filled out for some residents. Surveyor # reviewed the progress IC RN-F made on the November 2011 Infection Control log. There was a log for 2nd floor and a log for third floor (the only two floors on which residents currently reside). The logs only consisted of Resident names, room numbers, and dates of telephone orders. IC RN-F stated she was not done recording the telephone orders yet. No information was documented regarding what type of infection the resident had, site, organism, culture or X-ray results, isolation needed, whether or not it was facility acquired, or date resolved- just the date a telephone order was received. IC RN-F stated she was planning on then reviewing the list from Pharmacy to create the November logs. IC RN-F stated she had not planned on using the 24 hour reports because, at that time, nurses were not consistently documenting infections on the 24 hour reports. IC RN-F then decided she may be able to pull some useful information off the 24 hour reports, so she had someone retrieve them for her, and put them in date order, but she had not reviewed them yet. IC RN-F and DON-B stated the nurses needed training in many issues, including pertinent and thorough documentation. The December 2011 infection control surveillance log had not been started as of 12/12/11 at 3:00 p.m. Surveyor # asked if they knew which residents currently had infections. DON-B and IC RN-F stated they did not know, and would have to talk with the nurses and review the 24 hour reports (which by their admission were not complete) to determine who had infections. DON-B stated they talk about residents with infections in morning standup meetings Monday through Friday, but she did not have documentation of which residents they discussed regarding infections. DON-B stated their plan is the HAI Surveillance Report Forms are to be filled out by the nurse who identifies an infection, signs and symptoms of an infection, or receives an order for [REDACTED]. DON-B stated at this time, not all the nurses were filling out the Surveillance Report Forms. Surveyor # asked if there was any type of real-time infection control surveillance being conducted in the building at the time. DON-B and IC RN-F stated no, they had not gotten IC surveillance started yet since they were focusing on influenza vaccinations. Surveyor # asked, since the standup meeting is Monday through Friday, who monitors infections for potential outbreaks on the weekends. DON-B stated she would expect the supervisors to monitor residents with infections. Surveyor # asked how they would do that if there is no infection control log, and the 24 hour reports were incomplete. DON-B stated they are going to have a binder to track GI (gastrointestinal) and respiratory symptoms, but they hadn't started that yet. Surveyor # noted just prior to the interview, isolation carts were observed outside the rooms of Resident #1, #13, #20 and #31, and asked why the carts were there, what infections the residents have, and what precautions staff are expected to follow when caring for the residents. DON-B and IC RN-F did not know which residents the carts were for, or what precautions were needed. DON-B stated some residents just came off precautions for Clostridium difficile (C. diff.), a bowel infection, because their stool is now formed. While DON-B did not know which residents this pertained to, she thought Resident #1 may have had C.diff. DON-B stated Resident #20 was immune suppressed and had requested reverse isolation (the resident would wear the protective equipment). DON-B stated some staff prefer to wear PPE because Resident #20 has some behaviors- Resident #20 spits at staff sometimes, so they provide face masks with eye protection. IC RN-F stated she did not know why the isolation carts were there, or for what residents, or what PPE staff should use since the 24 hour reports are not reliable at this point. On 12/12/11 at 4:00 p.m. Surveyor # reviewed the 24 hour reports dated 12/12/11. Of the four resident who had isolation carts outside their rooms, Resident #1 is on report for pneumonia; Resident #13 was listed for "left ankle/ Foley" but no information regarding infections was documented, nor is Resident #13 listed in the section where staff track residents receiving antibiotics; Residents #20 and #31 were not on the 24 hour report. On 12/13/11 at 8:35 a.m., Surveyor # interviewed LPN-H who was passing medication to Resident #31. LPN-H stated Resident #31 had MRSA (methicilin resistant staphylococcus auereus) in her tracheostomy, and Resident #1 had pneumonia. (DON-B thought Resident #1 had C.diff.). Residents #13 and #20 were not on LPN-H's assignment so she did not have knowledge of them On 12/8/11 at 8:20 a.m., when asked about the personal protective equipment (PPE) outside Resident #20 ' s room, LPN-G stated Resident #20 was in contact isolation. LPN-G stated she would wear gloves to obtain Resident #20's blood sugar and administer her inhaler, but Surveyor # did not need any PPE. LPN-G stated when CNAs (Certified Nursing Assistants) expect to come in contact with body fluids such as when they wash Resident #20 up for the day, or assist her with incontinence care, they wear gowns and gloves. On 12/13/11 at 8:40 a.m., Surveyor # re-interviewed LPN-G regarding Resident #20. LPN-G is regularly assigned to care for Resident #20. Surveyor # asked LPN-G when staff would wear eye protection for Resident #20's spitting behaviors reported by DON-B. LPN-G stated she had never seen or heard of Resident #20 exhibiting a spitting behavior. LPN-G stated sometimes Resident #20 requests to wear gloves if she has a runny nose, or wears a mask if she is coughing, but LPN-G stated since Resident #20 moved to that floor, no one has ever mentioned any spitting behavior. On 12/14/11, staff provided Surveyors with Infection Control logs for November and December 2011. The December log shows Resident #1 developed pneumonia 12/6/11 and it has not yet resolved, and on 12/14/11, staff sent a stool sample to the lab for possible C.diff. Resident #31 is listed as having an upper respiratory infection caused by MRSA since 7/21/11 (admitted with the MRSA on 8/19/11). The log notes Resident #31 is in isolation (does not specify what type), and is not currently on antibiotics. Resident #13 is not listed on the December log, though an isolation cart was outside his door since 12/5/11. Resident #13 was listed on the November log for a UTI (urinary tract infection) on 11/8/11, which resolved 11/30/11. Resident #13 was placed on contact isolation and an antibiotic on 11/15/11 for [DIAGNOSES REDACTED]. The contact isolation was discontinued on 11/21/11. Resident #13 was not listed on the November log for [DIAGNOSES REDACTED]. Resident #20 is not on the December or November logs. The failure of facility staff to conduct on-going surveillance from 11/1/11 to 12/12/11, and failure of staff to properly disinfect glucometers used on multiple residents, including a resident who has an immune deficiency blood disorder, led to the finding of immediate jeopardy on 12/13/11. On 12/13/11 at 2:10 p.m., NHA (Nursing Home Administrator)-A and DON-B were informed of the immediate jeopardy, beginning on 11/1/11. The Immediate Jeopardy was removed on 12/14/11 when: - As of 12/14/11, 27 nurses and medication technicians had been inserviced regarding the glucometer cleaning process per manufacturers' guidelines, emphasis placed on the two minute moisture necessity for germicidal effect. Education will continue with all nurses prior to the start of their shift. Any staff member not working and re-educated by 12/16/11 will be contacted via telephone. - A card will be placed in the isolation cart top drawers to inform staff of what precautions and personal protective equipment is required to enter the room. Isolation cart usage will be reviewed weekly. -Infection control logs have been completed for November 2011 and are current as of December 14, 2011. The log will be maintained each working day by the infection control nurse. The log will be reviewed each working day by the DON for the next four weeks. Then the log will be reviewed weekly by the DON for the next four weeks. The nurse supervisors will be instructed on the infection control process and logs so weekend and holiday coverage is provided when the DON and/or SDC (staff development director- infection control nurse) are absent. The SDC and DON will receive education necessary to be well informed on infection control practices. - An audit will be sent to the Corporate Nurse by the Administrator each week for review for the next eight weeks. Infection Control date (tracking and trending) will be reviewed monthly at the Quality Assurance Committee. The Infection Control policy will be reviewed at the next QA meeting with the medical director present. Continued noncompliance at F441 is evidenced by the following: Handwashing 5. Resident #12 is a [AGE] year old male admitted to the facility on [DATE] with diabetic foot ulcer on his right foot. On 12/13/11 at 9:46 a.m., Surveyor # observed the treatment for [REDACTED]. Resident #12 was sitting in the wheelchair in his room and RN-R had removed the dressing prior to Surveyor # entering Resident #12's room. RN-R removed her gloves, washed her hands, and placed new gloves on. LPN-P placed saline on a 4 by 4 gauze. RN-R cleansed the wound with the 4 by 4 gauze and then measured the wound stating "1.4 length times 2.2 wide." RN-R did not remove her gloves and wash her hands after cleansing Resident #12's wound. RN-R placed gauze with Dakins solution over the wound and then covered the gauze with Medfix tape. RN-R placed Resident #12's sock and shoe on his right foot, placed the right foot on the foot rest, removed her gloves and washed her hands. 6. Resident #14 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #14 is incontinent of bowel and bladder and is dependant upon staff with his ADL's (activities of daily living). On 12/12/11 at 1:39 p.m., Surveyor # observed CNA (Certified Nursing Assistant)-S wheel Resident #14 down the hall into his room. CNA-S placed gloves on, unclipped the alarm and removed the foot rests from the wheelchair. CNA-S removed Resident #14's wet shirt and placed a new shirt on Resident #14. CNA-S placed a sling around Resident #14, hooked the sling to the sit to stand lift, and raised Resident #14 off the wheelchair. CNA-S lowered Resident #14's pants, removed the wet incontinence product, and placed Resident #14's penis in the urinal propping the urinal inside the pants. CNA-S removed his gloves, turned on the water but did not wash his hands, and placed new gloves on. CNA-S placed a towel on the wheelchair and lowered Resident #14 onto the wheelchair. CNA-S unhooked the sling, removed the blue boots and pants, and asked Resident #14 to hold the urinal. CNA-S removed his gloves and washed his hands. CNA-S placed sweat pants and the blue boots on Resident #14 and then placed gloves on. CNA-S removed the urinal, removed his gloves, and rinsed his hands. CNA-S did not wash his hands. CNA-S placed new gloves on and told Resident #14 to hold his feet up and he was going back on the machine. On 12/14/11 at 4:08 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above and requested a copy of the Facility's hand washing policy. Surveyor # was provided with the Hand Washing Policy and Procedure issued 7/1/11 which documents under the guideline, "It is the intent of the facility to use proper hand washing technique to prevent the spread of infection as per Center of Disease Control Guidelines (Guideline for Infection Control in Hospital Personnel)." Under procedure directs staff on how to wash their hands with soap & water and alcohol based hand rub.

Based on observation, record review and staff interviews, the facility did not provide adequate supervision and assistance devices to prevent accidents for 16 of 16 residents (Residents #5, #6, #7, #8, #14, #17, #28, #41, #42, #43, #44, #45, #46, #47, #48, #49) at risk for wandering/elopement. On 12/8/11, 23 alarmed (wanderguard/Pilferage alarms) exit doors were checked for proper functioning by surveyors and maintenance. 15 of the 23 alarms checked were not functioning or working properly, even though Maintenance Director-N stated that all alarms and wanderguard alarms had been checked at the beginning of day shift and all had been working properly. Resident #15 was observed shutting off wanderguard alarm in the 3rd floor dining room. The 3rd floor dining room wanderguard alarm was not functioning properly and would alarm for no reason. Staff turned off the alarm without checking to see if a resident had set off the alarm. From 9/26 to 12/18/11, maintenance identified various alarms not working 19 times (3E, 2E, 1E x4, 1W x 3, 1S x3, first floor dining room x4, second floor dining room, and two on ground floor. The facility administration indicated that there were approximately 15 residents on the wander list. A review of the facility's wander list last updated 12/8/11 identified 15 residents on the second floor who have wandering/elopement behaviors and 1 resident identified on the 3rd floor. Any of the 16 residents who were elopement risks could have gotten out and been seriously injured, either by falling down the stairwells or from hypothermia if they got outside. Older adults are at greater risk for cold injury because of the body's ability to maintain a constant internal temperature decreases with age. Resident #8 resides on the 2nd floor of the facility, which has an alarmed and key locked elevator. The facility had determined that Resident #8 was at high risk for elopement and had placed a wanderguard bracelet on him on 2/18/11 (date of admit) and reapplied after a hospitalization on [DATE], also placed on 15 minute checks. Despite the wanderguard bracelet and being on 15 minute checks, Resident #8 has eloped off the 2nd floor on 8/30/11 and 9/8/11 and was found outside the facility. On 9/10/11, 9/11/11, 9/13/11, 9/20/11, and 11/18/11 Resident #8 attempted to elope from the 2nd floor through the West wing alarmed door, and was found on the 1st and 3rd floors and in the stairwell and was redirected back to 2nd floor. On 11/22/11, Resident #8 was observed coming into the facility through the main door entrance from outside by the second shift receptionist. Resident #8's wanderguard alarm sounded upon entrance to the facility. Resident #8 was returned to the 2nd floor by the second shift receptionist. The exit door to the patio area where residents go out to smoke or just to be outside, opened when the inside handicap button was pushed to exit the building to the patio area. The handicap button outside the exit door to the patio did not work when pushed to re-enter the building from the outside from the patio. The intercom button did not work to re-enter the building from the patio area. A key pad was next to the door but, a code is needed to be entered and not all residents knew the code. Residents who did not know the code would knock on the door until another resident who knew the code would enter the code and let the residents into the facility. If no one responded, residents could wander from the area. The facility's failure to properly supervise its residents and to ensure the door alarms were functional and responded to created a situation of immediate jeopardy, which began on 12/5/11. Administrator-A and Director of Nursing-B was notified of the immediate jeopardy on 12/5/11. The immediate jeopardy was removed on 12/12/11, however, the deficient practice continues at a scope and severity level of an E (potential for harm that is not immediate jeopardy/pattern). The facility needs to continue to provide needed education and inservice to all staff on the facility's Elopement Guidelines and importance of immediate response to alarms. The facility needs to continue to ensure that all alarmed doors remain functional and that residents identified on the wander's list are adequately supervised. The facility needs to continue to monitor the facility's door alarm system and staff response to residents at risk for elopement through the Quality Assurance Committee. Further evidence of continued deficient practice at severity level 2 is evidenced as follows: - Resident #41 eloped from the third floor of the facility on 9/20/11, 9/28/11 and from the second floor of the facility on 10/22/11 and 12/26/11. Resident #41 had a wanderguard on and was on 15 minute checks each time. On 12/26/11, a staff member rode to the ground floor with Resident #41, and made no effort to stop or redirect Resident #41, or alert anyone else to his whereabouts when they exited the elevator, and Resident #41 then exited the building. - Resident #11 was identified as needing supervised smoking. Upon resident's re-admission into the facility on [DATE], resident's smoking abilities were not comprehensively assessed. In October of 2011, resident burnt himself with a cigarette. As of 12-13-11, resident is not on the list of residents who need supervised smoking. - Resident #13 is identified to be at risk for falls. Resident #13's care plan dated 11/9/11 indicates the use of a sensor alarm on bed. On 12/7/11, Resident #13's bed/sensor alarm was not working, while resident was in bed. - Resident #14 is identified to be at risk for falls. Resident #14's care plan dated 11/7/11 indicates the use of a sensor pad bed/chair. A care plan dated 9/11 indicates the use of a sensor alarm and the assist of 2 with the sit to stand. On 12/12/11, Resident #14 was observed using the sit to stand with the assistance of only 1 certified nursing assistant (CNA). On 12/13/11, Resident #14 was observed in bed and the sensor alarm was off. This is evidenced by: Elopement Policy/Procedure: On 12/8/11 at 3:55 p.m. Surveyor # was provided the facility's Elopement Policy/Procedure from Director of Nursing (DON)-B, who stated the new corporation took over on 11/1/11 and she could not find the previous elopement policy and procedure and that this policy/procedure dated 7/1/11 went into effect on 12/8/11. The facility's Elopement Policy/Procedure indicates: Guideline: It is the intent of this facility to provide for the safety of all residents. Purpose: The purpose of the elopement policy is to: 1. Identify residents at risk for elopement. 2. Minimize episodes of elopement. 3. Protect residents that are not capable of protecting themselves. 4. Provide the techniques and equipment to minimize safety risks. Responsibility: Registered Nurses, Licensed Practical Nurses, Licensed Vocational Nurses and Certified Nursing Aides. Monitoring Compliance; The following elements are in place for the facility to demonstrate satisfactory compliance with the guide: 1. Evaluate risk of elopement at admission, readmission, quarterly and change of condition. 2. Residents identified as "at risk" have picture in MAR (Medication Administration Record) book and elopement book. 3. Interdisciplinary Plan of Care (IPOC) for elopement in place and interventions are individualized. 4. Staff able to verbalize knowledge of elopement procedure. 5. Door alarms checked daily and documented. 6. Resident elopement/missing person report available and used if necessary. 7. Resident bracelet alarms are checked and documented according to manufacturer's recommendations. 8. The elopement review report is completed at least quarterly by QA&A Committee ... Door Alarms and Resident Protection Alarms: A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents. 1. When door alarms are in place, they are tested daily by maintenance. The results of the tests are then recorded on designated log. 2. Only the CEO may authorize disabling the alarm system and is responsible for the method of monitoring for residents' safety and resetting the alarm. 3. When door alarm batteries are required to be changed, the door alarm must be tested immediately after the change occurs and documented on the log. 4. Maintain documentation of bracelet battery expiration dates and replace prior to expiration date. 5. The charge nurse or designee shall test resident personal alarms/devices according to manufacturer's recommendations. 6. In the event of a power loss or disaster, refer to guidelines on providing a safe environment during power loss. Door alarms On 12/8/11, 23 alarmed (wanderguard/Pilferage alarms) exit doors were checked for proper functioning by surveyors and maintenance. 15 of the 23 alarms and wanderguard alarms checked were not functioning or working properly, even though maintenance stated that all alarms had been checked at the beginning of day shift and all were working properly: * The alarmed door when opened on ground floor West door hallway did not sound. * No alarm on basement/garage door to the outside. * First floor West alarm was shut off and not working. * Second floor West alarmed door shut off and not working. * East Center door first floor wanderguard not sounding, disabled due to construction. * East Center door not alarmed for wanderguard. * East Ground floor door alarm off due to construction, battery not working. * Exit door in stairwell between ground floor and first floor battery not working. * East door first floor alarm not working, shut off due to construction. * First floor South door alarm shut off due to construction. * First floor South door from dining area to stairwell not working. * First floor Dining Room area wanderguard alarm not working or sounding. * First floor South door between ground floor and first floor not functioning or sounding. * Ground floor South door alarm not functioning. * Second floor South exit door to kitchen elevator, wanderguard alarm not working, out of order. * On 12/7/11 at 7:04 a.m., Surveyor # walked into the 3rd floor dining room. The wanderguard alarm box was buzzing and there was no resident or staff visibly around the alarm box. CNA-O (Certified Nursing Assistant) came and turned off the wanderguard from underneath the box. At 7:06 a.m. the wanderguard box alarmed and there was no one present by the box. CNA-O came and turned off the box and LPN-G (Licensed Practical Nurse) followed behind CNA-O. LPN-G indicated that that the alarm "has been doing that." At 7:12 a.m. the wanderguard alarm box alarmed and no one was around the box. MD-N (Maintenance Director) was present and turned off the box. Everyone assumed the alarm was sounding because it was malfunctioning; no one checked to see if a resident may have set off the alarm. * On 12/8/11 at 7:33 a.m., Surveyor # observed the 3rd floor dining room area. The wanderguard alarm box was alarming and Resident #15 turned off the alarm by going underneath the alarm box. At 7:41 a.m., Resident #15 was again observed to turn off the alarm box by reaching underneath the alarm box. On 12/9/11 at around 3:30 p.m., Surveyor # shared the concerns regarding the wanderguard alarm box malfunctioning was shared with Administrator-A and the Director of Nurses-B. * Upon entry to the facility on [DATE], Surveyor # entered through the main doors off the lobby of the facility and the wanderguard alarm alerted. The receptionist on duty indicated that "the wind does that sometimes." The wanderguard demonstrated that it was not functioning properly and staff was aware. On 12/14/11, DON-B provided the Surveyor # with the facility's Wanderguard List check off form for 12/20/11. This form is initialed per day that the wanderguard is on and functioning properly. The DON-B stated she was unable to provide any documents from the previous months. On 12/14/11 at 10:55 a.m., Maintenance Assistant-Q provided Surveyor # the Pilferguard Daily Alarm Door Test forms for the months of October, November and December of 2011. Maintenance Assistant-Q stated when and if an alarm was found not working, the alarm was fixed immediately. The Pilferguard Daily alarm Door Test forms indicate: September 26th through October 30th, 2011 notes that alarms on 3rd East stairs, 2nd East Stairs and 1st East Stairs were not working when checked November 14th through November 20th, 2011 notes that 1st West Stairs, 1st South Stairs, 1st Dining Room and 1st East Stairs where not working. November 21st through November 27th, 2011 notes 2nd floor dining room alarm not working. 1st West Stairs, 1st South Stairs, 1st Dining Room and 1st East Stairs alarms not working. November 27th through December 4th, 2011 notes 1st West Stairs, 1st South Stairs, 1st Dining Room and 1st East Stairs alarms not working. December 12th through December 18th, 2011 notes 2nd floor Dining Room South alarm and wanderguard alarm not working. 1st floor Dining Room South alarm and wanderguard alarm not working. Ground Level Dietary Rear Door, and Ground Level West Exit Door alarm not working. Resident #8 On 12/8/11 at 10:30 a.m., Surveyor # reviewed the medical record of Resident #8. Resident #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/8/11 at 10:30 a.m., Surveyor # completed a record review of Resident #8. Review of the Minimum Data Set ((MDS) dated [DATE] under Wandering - Presence & frequency it is coded with a 1 which indicates; behavior of this type occurred 1 to 3 days. The Nursing Data Collection Tool dated 2/18/11 identifies Resident #8 to be at risk for wandering. The Wandering/Elopement Risk assessment dated [DATE] and updated 7/7/11, is checked that Resident #8 is at risk for wandering/elopement behaviors. Implement plan of care. Reassess needs at least quarterly and PRN (as needed). Review of the Nurses Care Plan under Alteration in behavior dated 3/3/11 notes Resident #8 continues to wander, utilize wanderguard bracelet as appropriate. According to this care plan, Resident #8 was on 1:1 observations until 7/8/11 when the 1:1 was tapered off on days and removed for nights but, continued on 15 minute checks on days and nights. Resident remained on a 1:1 for the evening shift. Resident was then removed from 1:1 on the evening shift and placed on 15 minute checks dated 8/31/11. Review of Nurse's Notes: Nurse ' s notes dated 8/30/11 at 4:57 p.m. state; Resident #8 wandered off unit and was noted by a Certified Nursing Assistant (CNA) that was looking out the window from the dining room and saw Resident #8 outside in the parking lot by the dumpster with a construction worker. Construction worker escorted Resident #8 back into the facility and Resident #8 remained on 15 minute checks. Nurses notes dated 9/7/11 7:30 p.m. state; Staff heard door alarm go off. Resident #8 had been pacing down West wing and he reopened alarmed door and walked through. Staff redirected back to unit. Continue on 15 minute checks. Nurse's notes dated 9/8/11 at 6:05 p.m. state; Resident #8 ambulated down West wing and existed out West wing alarmed door. Staff went after him, finding Resident outside at garbage bin looking for cigarettes. Staff gave Resident #8 a cigarette and returned Resident #8 to facility. Continue on 15 minute checks. Nurse's notes dated 9/10/11 at 3:17 p.m. state; Resident #8 existed West wing alarmed door and was redirected. Continue 15 minute checks. No injuries noted. Nurse's notes dated 9/10/11 at 6:35 p.m. state; Again existed the West wing alarmed door, started up stairs and was halted by staff and returned to unit. Nurse's notes dated 9/11/11 at 3:10 p.m. state; Resident #8 existed West wing alarmed door and was found on first floor, redirected back to unit. Continue 15 minute checks. Nurse's notes dated 9/13/11 at 9:30 a.m. state; Resident #8 wandered off unit to third floor, followed a staff member and was redirected back to second floor unit. Continue 15 minute checks. Nurse's notes dated 9/20/11 at 3:25 p.m. state; Resident wandered off unit to first floor. Nurses from first floor brought Resident back to second floor. Resident entered first floor from stairwell. Continue 15 minute checks. Nurse's notes dated 11/18/11 at 7:00 p.m. state; remains on 15 minute checks, continues to go down halls opens alarmed doors, attempts to get on elevator. Nurse's notes dated 11/22/11 a 8:20 p.m. state; Receptionist reported that Resident #8 came in through the main door entrance from outside. Wanderguard sounded when entered facility. Resident #8 was returned to floor by receptionist. Wanderguard on left ankle, functioning. Resident #8 on 15 minute checks but, placed on 1:1 observation until resident went to bed. No injuries noted. Incident Report Review: Surveyor # reviewed the facility's Resident Incident Report dated 11/22/11. Additional follow ups dated 11/23/11 state; Tapes reviewed, Resident own person. Outside less than 5 minutes walked around building to front door. Doors checked by DON/Administrator. Social Services to follow up with maintenance regarding door alarm status. Signed by the DON. Surveyor noted that although the incident report indicates Resident #8 is his own person, the facility identified Resident #8 to be at risk for wandering/elopement and placed a wanderguard bracelet onto his left ankle. No other incident reports were located by the present administration regarding previous attempts to elope off unit and outside. Surveyor reviewed the facility's 15 minute check form for the months of 10/11, 11/11, and 12/11 and observed the following: October Forms: On 10/18/11, the form is only filled out for the night shift. Day shift and evening shift is blank. November Forms: On 11/4/11 the form is blank for the evening shift. On 11/5/11 the form is blank for the day shift and evening shift. There is no form filled out for 11/6/11. On the 11/7/11 the form has an X through night shift and day shift. There is no form filled out for 11/11/11. On 11/12/11 the form is blank for day shift and evening shift. On 11/13/11 the form is blank for day shift. On 11/14/11 the form is blank for day shift. There is no form filled out for 11/15 or 11/16/11. There is no form filled out for 11/25/11. On 11/26/11 the form is blank for the evening shift. December Forms: There are no forms filled out for 12/9, 12/10, 12/11/11. On 12/12/11 the form is blank from 7:00 a.m. until 2:00 p.m. On 12/13/11 the form is blank from 3:00 a.m. until 10:00 p.m. Patio Door On 12/7/11 at 10:20 a.m., Surveyor # asked DON-B how to exit the door to go out on the patio. The DON-B stated, "You just push the wheelchair/handicap access button or just push the door open." Surveyor # exited the door to the patio area. Once Surveyor # was outside, Surveyor # tried to re-enter the facility by pushing the wheelchair/handicap access button. This handicap button did not work and would not let Surveyor re-enter the facility from the patio. There was an intercom button that Surveyor # pressed but, no one answered it. There also was a key pad but, you needed to know the code to enter it before the door would open. Surveyor # walked around the building and entered the front entrance. Surveyor # interviewed Receptionist-GG regarding access to entry through the door from the patio. Receptionist-GG stated that you just push the handicap button to re-enter the facility from outside by the patio area. Surveyor told Receptionist-GG that the handicap button was not working. Receptionist-GG stated sometimes it doesn't work due the cold. Surveyor also stated to Receptionist-GG that the intercom button wasn't working either. Receptionist-GG stated that the intercom was disconnected, but they will be connecting it again due to construction. Surveyor asked Receptionist-GG how do residents get back into the building if the handicap button and the intercom doesn't work. Receptionist-GG stated, "Hopefully, I would see them on my video screen and let them in." During observations of the exit door leading to the patio, Surveyor # observed residents going outside to smoke or for fresh air. Some of these residents could not re-enter the facility because the handicap button and the intercom button did not work. The residents would knock on the door trying to get someone's attention. There were some residents who knew the code to the key pad and they would come to the door, enter the key pad code to let the residents who did not know the key pad code into the building. Surveyor asked if Receptionist-GG had a wandering/elopement book at her desk. Receptionist-GG provided Surveyor a three ring binder that had a list of the names of residents that were at risk for wandering/elopement and pictures of these residents. The Receptionist-GG stated that all nurse ' s stations have the same three ring binder for residents that are at risk for wandering/elopement. On 12/7/11 at 12:05 p.m., Surveyor # observed a family member trying to enter the facility from the patio area and was unable to enter. Family member continued to knock on the door and no one answered. Surveyor # opened the door for the family member who stated that the handicap button wasn't working and stated he was visiting his wife who resided at the facility. On 12/7/11 at approximately 12:15 p.m., Surveyor # went to the units and found that each unit at the nurse ' s station there is a three ring binder with a list of residents ' names and pictures in it for residents at risk for wandering/elopement. On 12/12/11, Surveyor # also viewed the wander list for both the second and third floors. The wander lists were updated on 12/8/11 with 15 residents identified with wandering tendencies on the second floor and 1 resident on the third floor. On 12/7/11 at 3:10 p.m. Surveyor # shared the above information regarding the handicap and intercom buttons not working to reenter the facility with the Administrator-A. The Administrator-A stated the handicap button would be fixed immediately. On 12/8/11 at approximately 8:20 a.m. the Administrator-A informed Surveyor # that the handicap button was fixed and functioning properly for re-entry into the building from the patio area. The failure of facility staff to properly supervise its residents and to ensure alarmed doors were functional and responded to led to the finding of immediate jeopardy on which began on 12/5/11. The facility Administrator and Director of Nursing was notified of the immediate jeopardy on 12/5/11. The immediate jeopardy was removed on 12/12/11 by which time the facility had completed the following: - Resident #8 along with another identified Resident at risk for wandering were placed on one to one staffing until all door alarms were functional. - The facility wanderguard list was updated. - All residents on the wanderguard list were placed on 15 minute checks. - Staff were assigned to guard the doors until all door alarms were either repaired and/or replaced. As of 12/12/11, all identified door alarms were repaired and/or replaced and were functional. - Education and inservice for all staff regarding sensitivity and urgency in responding to alarm. A total of 123 employees were inserviced with 8 employees not yet inserviced. These 8 employees were removed from the schedule until education received. - The door alarms checks will continue to be conducted daily by maintenance. The Administrator will accompany the maintenance staff at least 3 times a week during the next week to ensure all alarms are working and the maintenance logs are accurately completed. Information from Services & Solutions was requested to possibly replace the entire door alarm system at the facility. - The door alarm system will be on the Quality Assurance Meeting agenda for the next 6 months to ensure the door alarm system is reviewed. - The Director of Nursing is responsible for ensuring the nursing staff perform their tasks included in the Elopement Guidelines. - The Administrator is responsible for the oversight of the entire process. Continued noncompliance at F323 is evidenced by the following: 2. On 1/5/12, Surveyor # reviewed Resident #41's medical record. Resident #41 was admitted to the facility on [DATE] with major [DIAGNOSES REDACTED]. Resident #41 has an interim Guardian ad litem appointed. Prior to admission, Resident #41 had been admitted to an out-of state hospital. Surveyor # reviewed Resident #41's Hospital Discharge Summary dated 9/19/11 which states "...During this admission, patient was also evaluated by neuropsychiatry and was found to have severe anterograde memory loss and poor executive function. Neuropsych recommended consistent supervision/ monitoring to ensure his health/ safety and as patient has no family/ friends, placement in a 24 hour supervised care facility is indicated." (Anterograde amnesia is a loss of the ability to create new memories after the event that caused the amnesia, leading to a partial or complete inability to recall the recent past). Surveyor # reviewed Resident #41's Admission Data Collection Tool dated 9/19/2011 which indicates Resident #41 has short and long term memory problems, and moderately impaired decision making skills- decisions poor, cues/supervision required. Resident #41 is also noted to have exhibited wandering behavior (moved with no rational purpose, seemingly oblivious to needs or safety) in the previous 7 days or since admission. Staff indicated, "Places resident at significant risk of getting into potentially dangerous places (e.g. stairs, outside the facility). The Activities Evaluation section of the tool notes Resident #41 is anxious, is independent with ambulation, smokes and has cognitive deficits. The "Comment" section states, "Exit seeking, alcohol abuse history, can make needs known. " Surveyor # reviewed a "Risk of Elopement/ Wandering Review" dated 9/19/11 indicating Resident #41 is cognitively impaired with poor decision-making skills, history of leaving facility without informing staff. The Summary states Resident #41 "Is at risk for elopement/ wandering, as evidenced by: wandering to exit door on unit, confusion, forgetfulness. Wanderguard placed on resident, frequent reorientation, will check Wanderguard placement Q (every) shift, and verify operational on night shift." Surveyor # reviewed Resident #41's Admission MDS (Minimum Data Set) dated 9/26/11 which states, Resident #41 wandered 1-3 days out of the previous 7 days; and noted Resident #41's wandering does place him at significant risk of getting into potentially dangerous places (i.e. stairs, outside of the facility). Surveyor # reviewed Resident #41's CAAs (Care Area Assessments) dated 9/26/11- 9/29/11 which include: -Cognitive Loss which states: "Resident has poor short and long term memory. Resident has guardian for decision making. Resident has poor judgement and safety awareness." -Communication states: "Resident with cognitive impairment, moderate to severe problem solving deficits, word finding and disorganized thought process, decreased safety awareness, history of left parietal occipital craniotomy, sever cognitive impairments, BIM score 6..." (BIM score stands for "Brief Interview for Mental Status." The highest score is 15.) -ADL (Activities of Daily Living) Function Status/ Rehabilitation Potential) states: "...exit seeking, wander risk, Wanderguard in place, resides on dementia unit...ambulates without assistive device..." -Behavioral Symptoms states: "Resident has poor safety awareness, is at risk for wandering." -Falls states: "Triggered secondary to wandering behavior, Wanderguard on place, severe cognitive impairment, BIMS score 6, poor safety awareness, poor insight, poor judgement, may have fallen in the community after having a seizure resulting in left clavicle fracture, ...supervision off unit." Surveyor # reviewed Resident #41's Care Plan. A one-page CNA (Certified Nursing Assistant) Care Plan is in the front of Resident #41's chart. It indicates Resident #41 wears a Wanderguard on right lower ankle, and is a wander risk. On 12/29/11, staff added: Be careful entering / exiting elevator when resident close to elevator. Surveyor # reviewed Resident #41's Care Plan in the medical record which includes: -Potential for alteration in behavior/ wandering (dated 9/21/11)- resident has guardian for decision-making. Resident has TBI (traumatic brain injury), seizures, poor safety awareness. Wanderguard placed on resident. Goal target date: 12/16/11; Goal- Resident will not leave facility unescorted daily for 90 days. Approaches include: Provide resident with other activity opportunities; provide supervision outside PRN (as needed)/ when appropriate; orient resident to facility, areas he may walk to; allow resident to make choices whenever safely possible; offer support. Surveyor # reviewed an Activities Initial Note, dated 9/20/11, stating, "Resident is restless and anxious, he does not see any reason to be here. He's social and likes to tell stories. Resident has no realistic idea of his situation. Wishes to return to his sister's and community." (Note: On both the 9/19/11 and 12/15/11 Risk of Elopement Reviews, staff answered "No" when asked, "Has the resident expressed a desire to go home, packed belongings or stayed near an exit door?) Surveyor # reviewed Resident #41's Nurses' Notes which include: 9/19/11- 4:10 p.m. Resident arrived on unit with Admissions Director...confused, very forgetful, Wanderguard placed for safety... 9/20/11- 11:40 a.m. (Guardian) informed of resident's missing status... (the word elopement is crossed out). 9/20/11- 1:00 p.m. Resident back in his room...Wanderguard on right leg, was activated and checked with Wanderguard machine test + green... (means Wanderguard was working properly- no dead battery). Notes indicate Resident #41 was put on 1:1 monitoring upon his return until 9/26/11 when he was placed on 15 minute checks. Staff frequently documented on Daily Nurses' Progress Note forms Resident #41's "Preferred Setting for Activity Pursuits" is "Out of the facility" and "likes to walk outside." 9/28/11- 8:45 a.m. Receptionist noted Resident leaving the facility, Wanderguard sounded. She went out after him and found him seated out on the patio. Resident told her he was no longer 1:1. Receptionist asked him to come back inside, he refused. When receptionist returned outside to again encourage Resident to return inside the facility, Resident had left. Staff were able to find him walking up the block. He returned to the facility without problem and placed on 1:1. 9/28/11- 3:00 p.m. Resident transferred to (second floor). Surveyor # reviewed a "Room Change Notification" form dated 9/28/11 stating Resident #41 was being moved from a room on the third floor to the second floor because "Resident wanders." (Accessing the second floor elevator requires use of a key, third floor elevator does not require a key.) Nursing note 10/22/11- 3:00 p.m. Resident exited unit, found seated on back patio by scheduler. Staff assisted resident back to unit, reminded not to leave unit unassisted. Remains on 15 minute checks. 12/14/11- 5:15 p.m. CNA escort called facility stating resident was released by clinic staff and left on his own. NHA, DON, guardian, physician and police aware... 12/15/11- 1:00 p.m. Resident returned to unit...went to visit sister but she moved...15 minute checks initiated. Surveyor # reviewed a facility self-report indicating on 12/14/11, CNA (Certified Nursing Assistant)-LL accompanied Resident #41 to a 1:00 p.m. medical appointment. Once there, Resident #41 went to his appointment, where they ordered additional tests to be done at 3:00 p.m. Resident #41 waited in the waiting room with CNA-LL between the appointments. When clinic staff called Resident #41 for the second appointment, CNA-LL informed clinic staff she needed to accompany Resident #41, as he is a nursing home resident requiring a chaperone. Clinic staff would not allow CNA-LL to accompany Resident #41 to the procedure

Based on record review and staff interview the facility did not ensure that each resident received and the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being in accordance with the comprehensive assessment and plan of care for 1 of 7 residents reviewed with the [DIAGNOSES REDACTED]. * Resident #23 who has a psychiatric [DIAGNOSES REDACTED]. While the primary physician was aware of Resident #23's psychiatric medication refusals, there is no evidence that the facility contacted Resident #23's psychiatrist of Resident's ongoing refusals of his psychiatric medication for over a 4 month period. There is no evidence that the psychiatrist was aware of Resident #23's deteriorating mental health status as evidence by increased behaviors such as becoming more combative with self injurious behaviors. The facility Social Worker gave up trying to communicate with Resident #23. Staff did not seek outside help/support services, including that of his psychiatrist. According to a VA Discharge summary dated 7/29/11 the following was documented, "...though we did restart veteran's previously effective medications, his problems are not biologic in nature, but behavioral/psychological-catatonia does not resolve in this fashion... thus should behaviors return would suggest a behavioral treatment plan rather than inpatient admission/pharmacological adjustment." Upon Resident #23's return to the facility from the VA, the facility did not develop a behavioral treatment plan when Resident #23's behaviors continued. Resident #23's condition deteriorated to the point that on 10/21/11 he made a suicide attempt. This situation created a finding of immediate jeopardy that began on 6-27-11. On 12-15-11 at 10:31 a.m., Administrator -A, Director of Nursing -B and Chief Operating Officer-QQ was informed of the immediate jeopardy. The immediate jeopardy was removed on 12-16-11. The deficient practice remains ongoing as the facility must continue with staff training on the importance of increased communication between nursing staff and the psychiatrist regarding residents behaviors, such as refusal of [MEDICAL CONDITION] medications. Staff will continue to be educated on the treatment of mental illness, in that it is more than just medication management. The facility will increase its use of outside resources for educational purposes and program development with alternative interventions implemented and addressed on resident care plans as appropriate. The facility's Quality Assurance Program will continue to monitor the facility's progress in this area. The deficient practice continues at a scope and severity level of a G (actual harm that is not immediate jeopardy/isolated) for 2 of 2 residents reviewed with bowel declines. Based on observation, record review and staff interview, the facility did not ensure residents received appropriate bowel management. This was observed for 2 of 2 residents with a bowel decline. Residents' #12 and #14 had bowel continence declines between MDS (minimum data set) reference periods and no bowel assessment was conducted. Resident #12 went from occasionally incontinent of bowel to always incontinent of bowel. The facility did not assess Resident #12's decline in bowel continence. Resident #12's elimination plan of care was not developed based off of a comprehensive bowel assessment in order to develop an individualize toileting care plan to restore as much normal bowel function as possible. Resident #14 went from being continent of bowel to always incontinent of bowel. The facility did not assess Resident #14's decline in bowel continence. Resident #14's elimination plan of care was not developed based off of a comprehensive bowel assessment in order to develop an individualize toileting care plan to restore as much normal bowel function as possible. Evidence as follows: 1. Surveyor # reviewed the closed record of Resident #23 during the annual survey. Review of the history of this resident from the "Final Discharge Summary" from the inpatient psychiatry unit at the Milwaukee Veterans Administration Hospital (VA) dated 7-21-10 reveals the following: Resident #23 had been in the navy and a factory worker until the factory shut down its manufacturing area resulting in Resident #23 losing his job when he was in his mid-50's. Subsequently, he was found greatly unkempt and living in a hotel. He received treatment at the Veterans Administration Hospital in Madison on 9-11-09 for psychiatric issues and was then sent to the VA Hospital in Milwaukee on 10-5-09. Resident #23 lived at the VA in Milwaukee from 10-5-09 until 7-22-10, when he was admitted to this nursing home. His [DIAGNOSES REDACTED]. He began as a private pay resident but went through his resources and then went on Medicaid during his stay at the facility. Resident #23's routine medications included but not inclusive to: [MEDICATION NAME] 300mg bid (twice daily), [MEDICATION NAME] 2mg bid, [MEDICATION NAME] 2ml every 14 days, [MEDICATION NAME] 5mg at hour of sleep (hs), and [MEDICATION NAME] 50mg every day during his nursing home stay. Resident #23's Medication Administration Record's (MAR) revealed the following: July 2010 since admission: no refusal of psychiatric medication. Medications included: [MEDICATION NAME] 300mg bid (twice daily), [MEDICATION NAME] 2mg bid, and [MEDICATION NAME] 5mg every hs. August 2010: No days of refusal of psychiatric medication September 2010: No days of refusal of psychiatric medication October 2010: No days of refusal of psychiatric medication November 2010: No days of refusal of psychiatric medication December 2010: No days of refusal of psychiatric medication, [MEDICATION NAME] 50mg was added on 12-21-10. January 2011: No days of refusal of psychiatric medication. Psychiatric medications included: [MEDICATION NAME] 300mg bid (twice daily), [MEDICATION NAME] 2mg bid, [MEDICATION NAME] 5mg at hour of sleep, and [MEDICATION NAME] 50mg every morning which was increased to 100mg on 1-26-11. February 2011: Facility unable to locate the MAR. This was the month in which Resident #23 was sent to the hospital for [MEDICATION NAME] toxicity. Resident #23 was hospitalized from 2-9-11 to 2-17-11. March 2011: approximately 10 days of refusal of psychiatric medication. April 2011: approximately 26 days of refusal of psychiatric medication. May 2011: approximately 21 days of refusal of psychiatric medication. Resident could have received Zyprea 5mg and [MEDICATION NAME] 0.5mg either by mouth or IM (intramuscularly) on the days resident did receive the medications it did not indicate which route resident received the medications. Also this MAR (medication administration record) has an area written to update Psychiatrist-AA refusal of meds PO (by mouth) and IM (intramuscularly) on May 24. This area was not signed out by staff. After review of the nurses notes there were no entries to address this or evidence that Psychiatrist-AA was notified. June 2011: approximately 20 days of refusal of psychiatric medication July 2011: approximately 26 days of refusal of psychiatric medication. Psychiatric medications included: [MEDICATION NAME] 300mg bid, [MEDICATION NAME] 1mg tid (three times daily), [MEDICATION NAME] 10mg every hour of sleep (hs), [MEDICATION NAME] every hs. August 2011: approximately 31 days of refusal of oral psychiatric medication (the entire month). [MEDICATION NAME][MEDICATION NAME] IM (intramuscular) every 14 days was added to the medication regime. Resident did receive the IM on August 17th and 31st. September 2011: the entire month resident refused his psychiatric medication except his [MEDICATION NAME] 2ml IM which he received 9-14 and 9-28. October 2011: every day of his stay Resident refused his psychiatric medication except the [MEDICATION NAME] IM which was given on 10-12-11. Nursing sent this resident to an inpatient facility on 2/9/11, where he stayed for eight days and was treated for [MEDICATION NAME] toxicity and dehydration and physical behaviors of [MEDICAL CONDITION] and falls. Resident was readmitted back into the facility on [DATE]. Resident #23 went again to the VA on 6/27/11. According to the Discharge summary from the VA dated 7-29-11 the following is noted: "Veteran initially unable to say why he is here, when confronted with nursing home report of uncooperative history and combativeness stated, "It went both ways, they were getting upset with me too." Denies si/hi (suicide ideation/homicidal ideation), says mood has been good, not sleeping well r/t (related to) roommates listening to tv or radio, doesn't have earplugs to wear. Not particularly happy with CNH (community nursing home) however not entirely unhappy, 'it's ok.' Doesn't get to watch as much sports as he likes as his TV screen is small, other residents don't like sports as much as he does." Resident was admitted to a unit at the VA, Course of Treatment: "immediately social and interactive with familiar staff, talking about baseball games." "Though we did restart veteran's previously effective medications, his problems are not biologic in nature, but behavioral/psychological-catatonia does not resolve in this fashion. This is consistent with his presentation later in his lengthy stay last year. Thus should behaviors return would suggest a behavioral treatment plan rather than inpatient admission/pharmacological adjustment." Subsequent to his return to the facility, the resident deteriorated to the point where he refused all his psychiatric medications. According to the nurses notes, periodically the facility staff would recognize Resident #23's right to refuse and informed the primary physician of this, however the medical record displays no consistency in informing the primary physician of resident's psychiatric medication refusals. There are no nurses notes that reflect the the psychiatrist - who was the one who had ordered the resident's medications - was ever notified of Resident #23's refusal of psychiatric medications. Nurses notes reviewed indicated on 8-31-10, Resident #23 made [MEDICAL CONDITION] to staff. Again on 12-10-10, Nurses notes indicate Resident #23 made [MEDICAL CONDITION]. Nurses notes also indicate that on 2-2-11, smoldering washcloths were noted in Resident #23's garbage can in his room, while he lay on his bed. Surveyor # interviewed Social Service Director (SW)-D and SW-E on 12-14-11 at approximately 8:30 a.m. who indicated the following; SW-E stated she was Resident #23's social worker, but did not have a good rapport with him, as she "entered the room he would roll over in his bed looking the other way, so I didn't have much to do with him." The SW's further indicated that because of all the refusal of medications the facility did receive an order for [REDACTED]. SW-D indicated that Physician -Z attends 'mind over meds' , but the actual psychiatrist does not attend nor is an update sent to the psychiatrist. SW-D indicated that staff should have called Psychiatrist-AA in regards to the refusal of medications and his behavior, that would make the most sense. From admission on 7/22/10 onward, the social worker wrote only 1 3/4 pages of social work notes. The social worker notes did not address different approaches to care for Resident #23 in order to gain compliance. The social work notes do not indicate counseling of resident on his medications and the benefits of them versus the risks involved by not taking the medications. There was no mention of the incorporation of support groups or perhaps psychotherapy attempts. The social service notes contained documentation primarily about when care plan meetings were held, but no documentation to acknowledge Resident #23's behaviors or support services provided to him. SW-E did not enlist the help of staff to help her build better rapport with Resident #23 nor did she report her difficulties to staff in order to obtain help to build a better rapport with Resident #23. SW-E did not report her difficulties to the Social Services Director, who has a strong background in mental health issues. The medical record does not contain evidence that anyone referred Resident #23 to a psychologist to see if he was amenable to talking about issues that were bothering him. The medical record does not indicate that anyone attempted to talk with Resident #23 to determine why he was refusing his medications (for example, was it side effects that he didn't like?). There is no evidence that there was support for Resident #23 as he tried to deal with his mental illness and refused treatment. There is no evidence that anyone talked with Resident #23 about the consequences of his refusals, attempted to explore the reason(s) behind his refusals, or consulted with the psychiatrist about alternate interventions and support services that could be attempted. What little charting was done suggests that Resident #23 became more combative with staff during the final months and exhibited more self-injurious behavior (such as scratches to the face). Surveyor # interviewed Certified Nursing Assistant (CNA)- BB and CNA- CC on 12-14-11 at approximately 10:20 a.m. Both CNA's have worked with Resident #23 in the past. CNA-CC indicated that at one point, Resident #23 was verbal and more mobile. CNA-CC stated that Resident #23 experienced a change during his time at the facility, but was uncertain when this change occurred. CNA-CC further indicated that Resident #23 would refuse cares and he would swing out at staff. CNA-CC reported that CNA-BB was good with Resident #23 and they got along well. CNA-CC and CNA-BB both indicated during this interview that it took 2 CNA's and a nurse in order to give Resident #23 his shot, the CNA's had to hold Resident #23 down while the nurse gave him the shot. Surveyor # also asked CNA-BB and CNA-CC if the facility has ever trained them in mental illness? Both CNA's replied that they did not have any mental health training or training in caring for those with mental illness. Surveyor # reviewed Resident #23's record for his plan of care and noted the following that concerns his mental illness, but not inclusive to: Problem: Alteration in supervised/organized recreation characterized by lack of attendance related to: premorbid leisure lifestyle, isolative behavior, [MEDICAL CONDITION], and disease process. Approaches to this problem: be patient, inform resident of upcoming activities, offer weekly check ins, praise involvement, provide activities in settings that are preferred by resident. Problem: Alteration in cognition due to [DIAGNOSES REDACTED]. Approaches: offer resident choices of activities, encourage resident to attend meals in the dining room. Problem: Alteration in nutrition related to [DIAGNOSES REDACTED].refuses medications. There were no approaches regarding the refusal of medications within this care plan. Problem: Self Care Deficit. This care plan addresses refusal of cares and assessments, but does not address refusal of medications. Problem: Potential risk for adverse medication side effects related to refusal of meds. Approaches: Provide with schedule medications as per MD (medical doctor) ; update with refusals as need/per MD. (specifics of how many refusal of medications constitute a call to the physician is not indicated). Problem: Potential for alteration in behavior. Refuses meds (medications) Approach: Give meds (medications) per MD (medical doctor) order. Make psych. (psychiatric) referral as needed. This care plan does not address the issue of what staff should do when resident refuses his medications. Surveyor # interviewed the primary physician, Physician-Z, on 12-14-11 at approximately 1:00 p.m. in regards of Resident #23. Physician-Z indicated that Resident #23 was probably the worst psychiatric patient that she has treated related to his [MEDICAL CONDITION]. Physician-Z indicated she is not an expert in caring for those with psychiatric issues. Physician-Z further indicated she and staff were concerned for Resident #23 as he was losing weight and refusing to eat, until they discovered that he did not like to eat in front of others. Staff then began to serve food trays in Resident #23's room for him and that was effective. Physician-Z also indicated she was aware that Resident #23 was shutting down toward things around him and wanted to be left alone. Physician-Z indicated she was aware of Resident #23's medication refusals and it became a standing joke between her and facility staff; whenever she would visit, nursing would approach her and tell her that they were required to let her know Resident #23 was refusing his medications. When asked how frequently Physician-Z was in touch with Psychiatrist-AA, Physician-Z indicated she knows she spoke with Psychiatrist-AA at least once during Resident #23's stay. Physician-Z indicated she was unaware if facility staff called Psychiatrist -AA in regards to Resident #23's refusal of medication and behaviors. Physician-Z further indicated that it was a good point that Psychiatrist -AA should have been contacted more often and was unaware of the facility's policy and procedure in regards to notification of a physician upon refusal of medication. Surveyor # interviewed Psychiatrist -AA on 12-14-11 at approximately 2:35 p.m. During this interview Psychiatrist -AA indicated he would expect nursing home staff to call him if a resident consistently refused his/her medication. Psychiatrist -AA further indicated that consistent refusals would mean 3 times a week in a 3 week period. Psychiatric notes from visits on 1/25/11, 7/2/11, and 8/22/11 never mention that Resident #23 was refusing his medications. Psychiatrist -AA indicated that if he did not mention refusal of medication in his notes, then he was unaware that this resident was refusing his medication. Psychiatrist AA indicated if he had been aware of Resident's medication refusals, he would have documented this in his notes. Surveyor noted that the Psychiatric note dated 7-2-11 indicates Resident #23 was stable, coping and doing well on his neuropsychiatric medication regimen even though the MAR indicated [REDACTED]. Psychiatrist -AA also indicated that it is important for staff to have a good rapport with the resident and if trust is developed the resident is more likely to be compliant with medications and behaviors. Surveyor noted staff had not notified Psychiatrist-AA that Resident #23 was refusing all his medications. According to the nurses notes dated 10/21/11, a CNA who was out on the patio supervising residents who were smoking, heard a tearing of a window screen and saw legs sticking out of Resident #23's third-floor window. The CNA immediately alerted staff inside, who got to Resident #23's room. Resident #23 catatonic and unresponsive. Staff put Resident #23 on one-to-one supervision and notified Milwaukee County. Resident #23 was transferred out of the facility. The History and Physical from the hospital in which Resident #23 was sent dated 10-22-11 indicates that "most likely his symptoms could be secondary to untreated [MEDICAL CONDITION]." Resident #23 has not returned to the facility. The facility has other residents with mental illness and according to the facility's pharmacy statistics, there are approximately 20 residents in-house with a [DIAGNOSES REDACTED]. The facility staff have not been provided with inservicing on how to deal with behaviors that are often associated with mental illness, such as medication refusal. The Immediate Jeopardy was removed on 12/16/11 when: - A list of residents with a [DIAGNOSES REDACTED]. - An audit of [MEDICAL CONDITION] medications as noted on the MAR indicated [REDACTED]. - Education had been completed with approximately 28 nursing staff regarding the importance of increased communication related to resident behaviors between nursing staff and the psychiatrist. Nurses were reminded to document on the 24 hour report and in the nurses notes for any resident who refuses [MEDICAL CONDITION] medications and the need to contact the psychiatrist regarding any resident who refuses [MEDICAL CONDITION] medications for 3 days. Staff will continue to be educated on the treatment of mental illness and that it is more than just medication management. Further educational opportunities will be scheduled during the months of December and January with increased use of outside resources for education purposes and program development. -Alternative interventions related to resident's psychiatric needs will immediately be implemented using accepted standards of practice, individual resident approaches and the use of support services such as Disability Rights Wisconsin. -A review of resident's care plans who have a [DIAGNOSES REDACTED]. - F309 will be reviewed and discussed at future monthly Quality Assurance meetings for the next 3 months and at least quarterly thereafter. -The 24 hour report sheets will be reviewed in the morning Stand Up Meetings to identify possible problems. -The Director of Nursing, Director of Social Services, and Staff Development Coordinator will lead a special designated team related to resolving the F309 deficiency. - The Director of Nursing is responsible for the oversight of this plan. Continued noncompliance at F309 is evidenced by the following: Bowel decline: 2. Surveyor # reviewed Resident #12's medical record on 12/13/11. Resident #12 is a [AGE] year old male originally admitted to the facility on [DATE] and readmitted on [DATE] following a hospital admission. [DIAGNOSES REDACTED]. The resident's care plan, not dated, under bowel is checked for continent and incontinent with a handwritten notation of "@ (at) times." The admission MDS (minimum data set) with an assessment reference date of 8/26/2011 documents that Resident #12 has short and long term memory problem, requires extensive assistance with two+ persons physical assist for toilet use and is occasionally incontinent of bowel. The CAA (care area assessment) dated 8/31/11 for CAA 6. Urinary Incontinence and Indwelling Catheter documents under the analysis of findings, "Resident with chronic Foley cath (catheter) use, hx (history) [MEDICAL CONDITION] with right [MEDICAL CONDITION], incontinence of bowel, requires staff assist with toileting needs, [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) and attending [MEDICAL TREATMENT] 3x a week, no noted constipation, decreased mobility, at risk for infection and skin breakdown, admitted with red buttock and scrotal area, continue to provide fluids, assist as needed, report any signs of infection." The alteration in bowel and bladder plan of care dated 9/1/11 documents approaches also dated 9/1/11 indicate "assess for continued need of catheter, avoid obstruction in the drainage, change catheter per MD order, do not allow tubing or any part of the drainage system to touch the floor, follow up with urology prn (as needed), help resident choose new clothing that will not constrict catheter system, keep catheter system a closed system as much as possible, manipulate tubing as little as possible during care, obtain labs as ordered prn, position bag below level of bladder, provide assist with Foley cath management daily, provide catheter care daily, provide fluids, thickened to nectar thick and report signs of UTI (urinary tract infection)." Surveyor # noted that none of the approaches address Resident #12's bowels. The quarterly MDS with an assessment reference date of 11/23/2011 documents that Resident #12 has short and long term memory problem, is totally dependent with one person physical assist for toilet use and is always incontinent of bowel. Surveyor # was unable to locate an elimination patterning or a comprehensive assessment when Resident #12 had a decline in his bowel continence. On 12/13/11 at 12:45 p.m. Surveyor # informed RN (Registered Nurse)-Y that Surveyor # noted that on the admission MDS Resident #12 is occasionally incontinent of bowel and on the quarterly MDS Resident #12 is identified as always incontinent of bowel. Surveyor # informed RN-Y that Surveyor # could not locate an elimination pattering and a bowel assessment following the decline. RN-Y informed Surveyor # that she would look into this. On 12/14/11 at 9:10 a.m., RN-Y informed Surveyor # that she could not find a bowel assessment for Resident #12 and is going to be initiating one. On 12/14/11 at 4:08 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. As of 12/15/11 when Surveyor # exited the Facility a bowel assessment was not provided to Surveyor # . 3. Surveyor # reviewed Resident #14's medical record on 12/12/11 & 12/14/11. Resident #14 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (minimum data set) with an assessment reference date of 7/19/11 documents that Resident #14 has short and long term memory problems, requires limited assistance with one person physical assist for toilet use and is continent of bowel. The alteration in bowel and bladder plan of care with a problem start date of 7/25/11 and reviewed on 9/11 documents approaches dated 7/25/11 of "keep call light in reach, obtain labs as ordered prn (as needed), protective undergarment when up, provided assistance cues and reminders for toileting at regular intervals to decrease episodes of incontinence when receptive, incontinence cares every 2 hours and prn, provide fluids of choice to assist in maintaining adequate hydration, report any signs of constipation or loose stools secondary recent ABT (antibiotic) use, report any signs of skin breakdown, report signs of UTI (urinary tract infection), and urology prn." There is also an undated handwritten notation which documents "total asst. (assist) with incont. (incontinent) cares." The CAA (care area assessment) 6 Urinary Incontinence and Indwelling Catheter dated 7/26/11 documents under analysis of findings "Resident with Dx (diagnosis) of Advanced Alzheimer's dementia, cognitive impairment, periods of confusion, forgetfulness, incontinence of bowel and bladder, recent UTI (urinary tract infection), dehydration, see hospital records hx (history) of constipation, on meds to assist with bowel elimination, on [MEDICAL CONDITION] medication, elevated PSA secondary to UTI, continue to assist with toileting needs, providing reminders, cues and direction to decrease incontinence episodes, does not ask staff for assist with toileting needs, decreased awareness of toileting needs secondary to cognition, wears protective undergarment, incontinence cares and prn (as needed), skin remains intact, at risk for skin breakdown and infection, constipation" The significant change MDS with an assessment reference date of 9/28/11 documents that Resident #14 has short and long term memory problems, is totally dependent with one person physical assist for toilet use and is always incontinent of bowel. Surveyor # was unable to locate an elimination patterning or a comprehensive assessment after the Facility had identified there was a decline in Resident #14's bowel status. CAA 6 Urinary Incontinence and Indwelling Catheter dated 10/11/11 documents under analysis of findings "Resident with advanced dementia, cognitive impairment, requires extensive total assist with toileting needs, does not let staff know of toileting needs with decreased awareness of need, incontinence cares every 2 hours and prn (as needed), sit to stand lift transfer, hx (history of) UTI, skin intact, incontinence of bowel, at risk for infection and skin breakdown." On 12/8/11 at 9:36 a.m., Surveyor # observed CNA (Certified Nursing Assistant)-II wheel Resident #14 out of the lounge and into Resident #14's room. Surveyor # asked CNA-II what she was going to do. CNA-II informed Surveyor # that she was going to toilet Resident #14. CNA-HH entered the room. CNA-II and CNA-HH washed their hands and placed gloves on. The sit to stand lift was placed in front of Resident #14, staff lowered Resident #14's pants and incontinence product, and Resident #14 was wheeled into the bathroom where he was lowered onto the toilet. Surveyor # asked CNA-II if Resident #14's incontinence product was wet. CNA-II replied "no it wasn't." Resident #14 only urinated in the toilet. On 12/13/11 at 12:50 p.m. Surveyor # informed RN (Registered Nurse)-Y that Surveyor # noted that on the admission MDS Resident #14 is continent of bowel and on the significant change MDS Resident #14 is identified as always incontinent of bowel. Surveyor # informed RN-Y that Surveyor # could not locate an elimination pattering and a bowel assessment following the decline. RN-Y informed Surveyor # that she would look into this. On 12/14/11 at 9:18 a.m., RN-Y informed Surveyor # that she could not find a bowel assessment when Resident #14 had a decline. RN-Y informed Surveyor # that she is going to do a bowel assessment. On 12/14/11 at 4:08 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. As of 12/15/11 when Surveyor # exited the Facility a bowel assessment was not provided to Surveyor # .

Based upon staff interview and record review, the facility did not ensure that it was administered in a manner to ensure that highest practicable physical, mental and psychosocial well-being of each resident was attained/maintained. On 8/17/11 it was determined that the facility had 2 immediate jeopardy citations (F281 and F314) related to improper pressure ulcer care that led to a Resident (#5) developing a facility acquired stage 4 pressure ulcer and a stage 3 facility acquired pressure ulcer that is infected. Additionally, it has been determined that the overall wound care program within the facility is not being completed based upon current standards of practice by facility nursing staff as identified in a sample of 5 additional Residents with pressure ulcers (Resident's #6, #15, #16, #1 and #10). The facility's Director of Nursing left on 6/13/11 who was replaced by an interim corporate nurse. The wound care nurse left on 7/9/11. Facility administration did not immediately replace the wound care nurse and the facility was without a person specifically qualified to assess pressure ulcers, stage them and develop interventions to promote healing and prevent pressure ulcer development. Despite a facility wound sweep on 8/4/11, the facility did not know on 8/15/11 who had pressure ulcers and what stage they were. Facility's administration's failure to ensure the employment of a person to oversee and coordinate the facility's wound care program created a finding of immediate jeopardy, which had the potential to affect any of the facility's 116 Residents who may be at risk for the development of pressure ulcers. The immediate jeopardy began on 7/9/11. Surveyor # notified the Administrator of the immediate jeopardy on 8/17/11 at 3:00 pm. At the time of exit, on 8/19/11, the facility had not removed the finding of immediate jeopardy. Findings include: On 8/17/11 at 10:03 a.m. Administrator-A indicated to Surveyor # that the Staff Development/Educator's last date of employment was 5/20/11. The facility wound nurse left the faciity on [DATE] and was also a unit manager for 1st floor. The Director of Nurses last day of employment was 6/13/11 and there has been interim corporate staff since and a new Director of Nurses was hired a couple of weeks ago. The Administrator was out of the facility from 7/8/11 - 7/25/11 and the facility had corporate oversight. On 8/17/11 at 11:25 a.m. the Administrator provided Surveyor # with the facility's policy and procedures which were revised 10/09. The policy indicates that wounds evaluations will be performed upon admission and weekly. This included staging if a pressure ulcer, this also included documentation and care-planning. This was not consistently done. Resident #5 On 8/15/11 Surveyor # initiated a complaint investigation regarding concerns related to wound care for Resident #5. Resident #5 is a [AGE] year old individual who was admitted to the facility on [DATE] for rehabilitation. Resident #5's [DIAGNOSES REDACTED]. Resident #5 did not have pressure ulcers at the time of admission. On 5/27/11 Resident #5 sustained wounds related to shearing according to the facility wound list that was provided to Surveyor # by the Nursing Home Administrator (NHA)-A on 8/15/11. At the time of this investigation Resident #5 has a stage 4 sacral pressure ulcer and multiple pressure ulcers on her ankles/feet one of which is infected. All of Resident #5's pressure ulcers are facility acquired. Review of the facility wound sheets demonstrate that wound care was not being completed based upon the current standards of practice which requires weekly assessment and monitoring as Resident #5 went from 6/4/11 until 6/20/11 without monitoring; this is over 17 days. Then the resident went from 6/20/11 until 7/10/11 (13 days) without weekly assessment and monitoring. On 7/27/11 Resident #5 went out to a wound clinic for a consultation. This consultation indicates that Resident #5 has a stage 4 pressure ulcer and recommends that Resident #5 utilize a low air mattress due having a stage 4 sacral ulcer. On 8/16/11 at 10:38 a.m. Surveyor # observed LPN-G (Licensed Practical Nurse) change Resident #5 pressure ulcer dressings. Resident #5 has a bariatric bed and was lying flat on it. The mattress did not have markings on the side that indicated what type of pressure reduction/relief it provides. Surveyor # noted during the observation that there was not an air machine that would be attached to the mattress. On 8/17/11 at 10:25 a.m. Surveyor # spoke with the facility's central supply staff (CSF)-F that orders and provides equipment and supplies for Residents in the facility. CSF-F indicated that Resident #5 has been in the same bariatric bed since admission to the facility. Staff-F was not aware of nor did CSF-F have an invoice for a low air loss mattress as was recommended by the wound care clinic on 7/27/11. On 6/21/11, Resident #5's podiatrist noted that the resident's walking boot did not fit properly. The facility did not follow up with the podiatrist to change the boot, which the resident wore at all times. When the boot was removed on 7/26/11, an open area was present right above the ankle, measuring 4.3 cm. by 3.3 cm. with scant amount of bleeding, consistent with the boot applying pressure on the area. There was no follow up and no change in the resident's care. During the wound sweep on 8/4/11, staff found a right and left heel pressure ulcer that was unstageable; Resident #5's left medial ankle had a stage 3 pressure ulcer (where the boot caused pressure) and a right ischial stage 4 pressure ulcer. On 8/15/11 at 3:20 p.m. Surveyor # spoke with Administrator (NHA)-A regarding Resident #5's pressure ulcers. The Administrator indicated that there are no staff available who will be able to answer questions regarding Resident #5's development of a stage 4 sacral pressure ulcer and leg ulcers. NHA-A indicated that the staff that initially did the pressure ulcer assessments is no longer employed at the facility and there has not been a consistent staff member completing the pressure ulcer assessments. The staff member that conducted the pressure ulcer assessments left 7/9/11. NHA-A indicated that on 8/4/11 a facility sweep was done on residents to determine who had pressure ulcers however, as of 8/15/11 the facility was still uncertain of who had pressure ulcers, what the stages may be and whether the pressure ulcers were improving or worsening. This sweep (on 8/4/11) was conducted by RN-C (Registered Nurse) with the help of an outside consultant. On 8/16/11 at 3:00 p.m. Surveyor # spoke with RN-C. RN-C indicated they are doing just the clinical aspect of pressure ulcers in the facility. RN-C indicated that they are not wound care certified and that guidance is needed from an outside consultant to stage and direct the treatment of [REDACTED]. Resident #6 On 8/16/11 at 11:30 a.m. Surveyor #3328 requested from the Administrator the Wound sheets for Resident #6's most recent pressure ulcers that were identified on 7/11/11. The Administrator provided Surveyor #3328 with an Admission Skin Assessment sheet that identified 2 open areas on the right foot. This was dated 8/4/11. On 8/16/11 at 1:00 P.M. Surveyor #3328 spoke with RN-C regarding Resident #6's open areas. RN-C indicated that she had been acting as the wound nurse since the previous wound left the employment of the facility. Surveyor asked RN-C if there were any weekly wound assessments of Resident #6's open areas on the right foot. RN-C indicated that the facility had a gap in the wound treatment at the facility ever since the previous wound nurse left and when the Director of Nursing, DON, was hired. RN-C indicated that on 8/4/11 the facility did a wound sweep and identified the 2 open areas on Resident #6's right foot. RN-C indicated that there are no wound sheets that would document the size, condition and stage of Resident #6's new pressure ulcers on the right foot. RN-C indicated that she was going to measure Resident #6's wounds today. On 8/17/11 Surveyor's reviewed the policy on treatment and prevention of pressure ulcers. The policy is dated 10/09. The policy indicates that resident with pressure ulcers should have the ulcers assessed weekly. The assessment should include the description and measurements of the wounds and the stage of the wounds. Resident #6 developed 2 unavoidable pressure ulcers on 7/11/11 and had no assessment of these wounds until 8/16/11. Cross reference F314 (pressure ulcer care) and F281 (professional standards of practice) for additional examples (Resident #15, Resident #16, Resident #1, and Resident #10) of residents who developed facility-acquired pressure ulcers without appropriate and timely weekly assessments, care plan development and intervention. .

Based upon observation, record review and staff interview, the facility did not ensure that it provided pressure ulcer care to facility residents based upon current standards of practice for 6 of 17 Residents reviewed for pressure ulcers (Resident's #5, #6, #15, #16, #1 and #10). - The facility did not ensure that proper preventative care and services were provided to prevent the development of pressure ulcers. -The facility did not ensure the proper assessment of pressure ulcers and the development of appropriate care plans following the assessment. -The facility did not ensure the proper staging of pressure ulcers and documentation of status based upon current standards of practice. -The facility did not ensure that facility nursing staff carried out skills consistent with their licensure including proper assessment, planning, evaluation and intervention. -The facility did not ensure that preventative care was provided consistent with standards of practice for Residents with diabetes. This deficient practice has the potential to affect any of the facility's 116 Residents who may be at risk for the development of pressure ulcers. As a result of these failures, Resident #5 developed stage 3 and stage 4 pressure ulcers, one of which became infected. The facility's failure to ensure that pressure ulcer care was provided based upon current standards of practice created a finding of immediate jeopardy that began on 6/13/11. Surveyor # notified the Administrator of the immediate jeopardy on 8/17/11 at 3:00 pm. The facility removed the immediate jeopardy on 8/22/11. At the time of exit, on 8/19/11, the facility still had not removed the finding of immediate jeopardy. Findings include: Facility staff did not follow professional standards of practice related to the prevention and treatment of [REDACTED]. Standard of practice, as indicated by the NPUAP-EPUAP Treatment Guideline and The NPUAP-EPUAP Treatment Quick Reference Guide note: Assess the pressure ulcer initially and re-assess it at least weekly, document findings... With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications) ... Signs of deterioration should be addressed immediately. These findings include staging and treatment justification, and for individuals with pressure ulcers to use support services to reduce shearing. According to the State of Wisconsin Chapter N6: Standard of Practice for Registered and Licensed Practical Nurses: (1) GENERAL NURSING PROCEDURES. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s 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. In relation to the care of the following residents, facility nurses did not consistently assess the residents' skin condition (particularly in relation to co-morbidities that increased the chances for the development or deterioration of pressure ulcers), did not plan care, intervene as needed or when needed, and evaluate progress. Resident #5 1.) On 8/15/11 through 8/18/11 Surveyor # reviewed Resident #5's medical record. Resident # 5 is a [AGE] year old individual who was admitted to the facility on [DATE] for rehabilitation. Resident #5's [DIAGNOSES REDACTED]. and incontinence. Resident #5 did not have pressure ulcers at the time of admission. The Admission MDS (minimum data set) for Resident #5 with a reference date of 2/14/11 indicates Resident #5 is at risk for pressure ulcers and does not currently have pressure ulcers. The interventions checked are pressure reduction in the bed and chair. It also indicates Resident #5 requires staff assist with ADL's (activities of daily living) and is non-ambulatory. The Admission CAAs (care area assessment) for pressure ulcers identifies risk factors of diabetes, immobility, incontinence and obesity and a plan of care was developed. The most recent MDS is a Significant Change in Condition with an assessment reference date of 6/25/11. This MDS indicates that Resident #5 requires staff assist with ADL's and is non-ambulatory. This MDS indicates Resident #5 has 3 stage 2 pressure ulcers with an onset date of 6/13/11. The interventions checked are pressure reduction in bed and chair, nutrition and ulcer care. The Significant Change in Condition CAAs for pressure ulcers indicate Resident #5 is up in the Broda chair for short periods, has a Braden scale score of "15", which indicates that Resident #5 is at risk for pressure ulcers and remains a risk for skin breakdown. On 8/15/11 a complaint investigation was initiated for Resident #5 due to a concern with a stage 4 pressure ulcer. On 8/15/11 at 10:15 a.m. Surveyor # received the facility pressure ulcer list from the Administrator. This list dated 8/12/11 includes all of Resident #5 wound measurements since admission. Resident #5 is listed as having the following; arterial ulcers on the left and right heel and the left medial ankle; and a stage 3 pressure ulcer on the right buttock. Buttocks According to the 8/12/11 facility wound list the earliest wound assessment tracking form for Resident #5 is dated 5/27/11 and indicates Resident #5 sustained shearing on the right and left buttock and required treatment with Vitamin A&D ointment to the area. The next wound tracking is dated 6/3/11 and indicates the initial areas of Resident #5's buttocks caused by shearing have grown larger. The treatment remains the same (Vitamin A&D). Upon further review of Resident #5's medical record Surveyor # noted that there is no documentation to indicate that there was physician notification on these areas becoming larger. Surveyor # noted that there is no weekly wound tracking form again until 6/20/11, which indicates that Resident #5 has stage 2 pressure ulcers on the left buttock and 2 stage 2 pressure ulcers on the right buttock. A different treatment is noted to the pressure ulcer areas. Here, staff took no measurements of the pressure ulcers from 6/4/11 until 6/20/11, seventeen days later. At this time, the left pressure ulcer was 5.3 x 2 cm. while slough was noted in the pressure ulcers on the right buttock. All were staged as stage 2. The next weekly wound tracking form is dated 6/27/11 and indicates the same pressure ulcers and treatments as documented on 6/20/11. The next wound tracking is on 7/10/11 (13 days later). This document indicates that Resident #5's right buttock has tunneling that is 6.2 cm deep and is a full thickness wound. The treatment has changed for this particular wound. This is the last date of pressure ulcer staging and tracking using this form. On 7/27/11 Resident #5 went out to a wound clinic for a consultation. This consultation indicates that Resident #5 has a stage 4 pressure ulcer and recommends that Resident #5 utilize a low air mattress due to having a stage 4 sacral ulcer. On 8/4/11 the facility documented on Resident #5's pressure ulcers utilizing a form different from the form used for previous pressure ulcer documentation. This form now includes a description of Resident #5's pressure ulcers. Sacral ulcers: On 8/15/11 Surveyor # reviewed the plans of care (POC) related to Resident #5's sacral pressure ulcers. The POC for Alteration in skin integrity originally developed 2/20/11 indicates an onset date of 6/13/11 of a stage 2 pressure ulcer on the left buttock and 2 more on the right buttock. The POC does not include any new or updated interventions since 2/20/11. Surveyor # noted that there is 1 intervention listed that directly addresses pressure, which is to be up in the Broda chair and encourage a rest daily to relieve pressure on buttock. Surveyor # noted that the POC does not contain any reference to the 7/27/11 wound care clinic recommended low air loss mattress change or interventions to prevent shearing. On 8/16/11 at 10:38 a.m. Surveyor # observed LPN-G (Licensed Practical Nurse) change Resident #5 pressure ulcer dressings. Resident #5 has a bariatric bed and was lying flat on it. The mattress did not have markings on the side that indicated what type of pressure reduction/relief it provides. Surveyor # noted during the observation that there was not an air machine that would be attached to the mattress. On 8/17/11 at 10:25 a.m. Surveyor # spoke with the facility's central supply staff (CSF)-F that orders and provides equipment and supplies to Residents in the facility. CSF-F indicated that Resident #5 has been in the same bariatric bed since admission to the facility. CSF-F was not aware of nor did CSF-F have an invoice for a low air loss mattress for Resident #5. The bariatric bed manufacture definitions indicated that this mattress is for a person at risk for developing a pressure ulcer. Leg pressure ulcers Surveyor # noted that Resident #5 has diabetes and did not have interventions on the care plan to address diabetic foot care despite the risk that diabetes poses for pressure ulcer development. On 8/15/11 Surveyor # during review of resident #5's medical record Surveyor #2155 noted that on 5/12/11 Resident #5 sustained a right ankle fracture. An orthopedic consult dated 6/7/11 indicates that an air/walker boot was placed on the left lower extremity; even lthough Resident #5 is non-ambulatory. Within Resident #5's medical record there is a note from Resident #5's podiatrist dated 6/21/11 which indicates that the boot Resident #5 is wearing does not fit properly and that Resident #5 needs a wheelchair that supports the left leg better. There had been no follow up to the ill-fitting boot up until the time of survey. On 7/26/11 Resident #5's nurse's notes indicate that the walking boot was removed on 7/26/11 and that an open area was present right above the ankle, measuring 4.3 cm by 3.3 cm with scant amount of bleeding and that the area is consistent with the boot applying pressure on area. The documentation does not indicate why the boot was removed. Following this discovery, there is no documentation that indicates the orthopedic doctor was called regarding the determination that the boot was causing pressure. The air/walking boot was not discontinued until 8/15/11 at an orthopedic appointment despite the determination that the air/walking boot caused a pressure ulcer back on 7/26/11. Review of Resident #5's weekly wound assessment tracking form dated 8/4/11 indicates that Resident #5 has a right and left heel pressure ulcer that is unstageable; Resident #5's left medial ankle has a stage 3 pressure ulcer (where the air/walking boot caused pressure) and right ischial stage 4 pressure ulcer. On 8/16/11 at 10:38 a.m. Surveyor # observed LPN-G(Licensed Practical Nurse) change Resident #5 pressure ulcer dressings. Resident #5 is on contact isolation due to Resident #5 having an infection in an ankle pressure ulcer. LPN-G indicated that Resident #5 had the air boot on up to yesterday and that they had padded the boot to ease pressure to her ankle/leg. LPN-G indicated the boot was on at all times. Review of the 2/20/11 Plan of Care (POC) for Alteration in skin integrity does not address the fact that Resident #5 has pressure ulcers on her legs nor does it address that Resident #5 wears a boot that caused pressure. On 8/17/11 at 1:20 p.m. Surveyor # spoke with the Interim Director of Rehabilitation (IDR)-E as the current director was on leave from the facility. IDR-E indicated that they were aware of Resident #5's boot not fitting correctly from the Podiatrist note (dated 6/21/11). IDR-E indicated that Nursing Staff was responsible for calling the Orthopedic doctor to get a new boot because this was a boot that rehab could not replace. Resident #5's medical record did not reveal that the boot was ever changed or that the orthopedic physician was called. According to the reference Feet Can Last a Lifetime: A Healthcare Provider's Guide to Preventing Diabetes Foot Problems; 73% of the lower extremity amputations ....were a result of the casual consequence of minor trauma, cutaneous ulceration and wound healing failure. Estimates of the cumulative proportions of various causes indicated that 86% of amputations were attributed to initial minor trauma causing tissue damage. Administration On 8/15/11 at 3:20 p.m. Surveyor # spoke with Administrator (NHA)-A regarding Resident #5's pressure ulcers. The Administrator indicated that there are no staff available that will be able to answer questions regarding Resident #5's development of a stage 4 sacral pressure ulcer and leg ulcers. NHA-A indicated that the staff who initially did the pressure ulcer assessments is no longer employed at the facility and there has not been a consistent staff member completing the pressure ulcer assessments. The staff member that conducted the pressure ulcer assessments left 7/9/11. NHA-A indicated that on 8/4/11 a facility sweep was done on residents to determine who had pressure ulcers however, as of 8/15/11 the facility was still uncertain of who had pressure ulcers, what the stages may be and whether the pressure ulcers were improving or worsening. This sweep was conducted by RN-C (Registered Nurse) with the help of an outside consultant. On 8/16/11 Surveyor # reviewed Resident #5's recent pressure ulcer documentation that was done on 8/15/11 by RN-C (Registered Nurse) These assessments do not include any staging of the wounds nor do they indicate what the current treatment is for each wound. This document indicates that there is a 5 cm (centimeter) by 2.5 cm by 0.4 cm on the left medial ankle. This area contains yellow-green slough in the wound bed and has a mild odor. There is a 0.25 cm bleeding crack area on the left heel. There is a 3 cm by 2.5 cm by 7.2 cm area on the right buttock. The right buttock area contains tunneling that is 7.2 cm deep with yellow drainage and has a strong odor. This also indicates that there is one remaining area most lateral to wound, on the right buttocks that measures 0.8 cm by 1 cm that the facility documents as "almost healed." On 8/16/11 at 3:00 p.m. Surveyor # spoke with RN-C. RN-C indicated they are doing just the clinical aspect of pressure ulcers in the facility. RN-C indicated that they are not wound care certified and that guidance is needed from an outside consultant to stage and direct the treatment of [REDACTED]. On 8/16/11 at 3:30 p.m. at the daily exit meeting with NHA-A Surveyor # shared the pressure ulcer concerns regarding Resident #5 and requested the facility's policy and procedures on wound care. On 8/17/11 at 11:25 a.m. NHA-A provided Surveyor # with the facility's policy and procedure for wound care which were revised 10/09. The policy indicates that wound evaluations will be performed upon admission and weekly. This includes staging if the wound is a pressure ulcer. The policy also indicates that there should be documentation and care planning for wounds. 2.) Resident #6 was admitted to the facility on [DATE]. Resident #6 has [DIAGNOSES REDACTED]. Resident #6 has a long history of recurrent pressure ulcers. Resident #6 is often non compliant with treatments and interventions to prevent and heal existing pressure ulcers. Resident #6 has had amputations of toes due to non-compliance with the care and treatment of [REDACTED]. On 8/16/11 at 10:00 a.m. Surveyor #3328 reviewed the medical record for Resident #6. The medical record indicates that on 7/11/11 2 new open areas were found on the right foot on the plantar surface. The measurements are 4.2 cm X 2.5 cm. and 1.5 cm. X 1 cm. There is no indication as to the stage of these pressure ulcers. The medical record indicates that Resident #6's physician was notified of the pressure ulcers and a treatment of [REDACTED]. On 8/16/11 at 11:30 a.m. Surveyor #3328 requested from the Administrator the Wound sheets for Resident #6's most recent pressure ulcers that were identified on 7/11/11. The Administrator provided Surveyor #3328 with an Admission Skin Assessment sheet that identified 2 open areas on the right foot. This was dated 8/4/11. On 8/16/11 at 1:00 P.M. Surveyor #3328 spoke with RN-C regarding Resident #6's open areas. RN-C indicated that she had been acting as the wound nurse since the previous wound nurse left the facility. Surveyor asked RN-C if there were any weekly wound assessments of Resident #6's open areas on the right foot. RN-C indicated that the facility had a gap in the wound treatment at the facility ever since the previous wound nurse left and when the Director of Nursing, DON, was hired. RN-C indicated that on 8/4/11 the facility did a wound sweep and identified the 2 open areas on Resident #6's right foot. RN-C indicated that there are no wound sheets that would document the size, condition and stage of Resident #6's new pressure ulcers on the right foot. RN-C indicated that she was going to measure Resident #6's wounds today. On 8/16/11 at 2:00 p.m. Surveyor # went with RN-C to observe the measurement of Resident #6's pressure ulcers. Resident #6 would not allow Surveyor # to observe the pressure ulcers on her feet. RN-C provided Surveyor #3328 with the wound measurements for the 2 pressure ulcers on Resident #6's right foot. They measure 0.5 cm. X 0.3 cm and 1.5 cm X 0.6 cm. The pressure ulcers did not become larger since 7/11/11. On 8/16/11 at 1:45 p.m. Surveyor #3328 observed Resident #6 in bed. Resident #6 was on a Stage 4 specialty air flow mattress. Resident #6 has orders for boots on the feet but often refuses the boots. On 8/17/11 Surveyor's reviewed the policy on treatment and prevention of pressure ulcers. The policy is dated 10/09. The policy indicates that resident with pressure ulcers should have the ulcers assessed weekly. The assessment should include the description and measurements of the wounds and the stage of the wounds. Resident #6 developed 2 unavoidable pressure ulcers on 7/11/11 and had no assessment of these wounds until 8/16/11. 3.) On 8/17/11 at 11:05 AM Surveyor # observed Resident #15 self propelling his wheelchair from physical therapy. Resident #15 had a left leg prosthesis on and a dressing to his right [MEDICAL CONDITION] site. On 8/17/11 at 11:30 AM Surveyor # reviewed Resident #15's medical record which revealed the following: Resident #15 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The RAP (Resident Assessment Protocol) for the 9/3/10 MDS indicates that Resident #15 has a history of altered skin integrity and currently has no open areas or areas of skin impairment. The RAP indicates that Resident #15 is incontinent of both bowel and bladder The RAP indicates that Resident #15 has severe [MEDICAL CONDITION], Diabetes and left foot gangrene. The RAP indicates to proceed with a care plan. On 9/3/10 the facility developed a care plan for Resident #15 with a problem of Alteration in skin integrity related to incontinence, lack of sensation, left [MEDICAL CONDITION], right foot amputation, severe [MEDICAL CONDITION], Diabetes and refusal of scheduled toileting program. The Goal indicates that the skin to remain clean dry and intact for 90 days with a target date of 12/03/2010. The approaches include keeping the call light in reach, incontinence care every 2 hours, instructing on the importance of good skin care and note skin condition daily with cares and report any new signs of redness, irritation or open areas promptly to the team leader. Nurse's Note dated 5/17/11 at 4:30 PM indicates that Resident #15 was readmitted to the facility and had an open area to his right buttocks measuring 3 cm x 2 cm and under the right scrotum measuring 0.3 cm in diameter and left scrotum measuring 2.5 cm x 1.0 cm. The areas were indicated with measurements on the Admission skin assessment dated [DATE]. Nurses note 5/19/11 at 7:00 AM indicates that Resident #15 has an open area to the right ischium measuring 2.5 x 2.6 with round even edges and a small amount of serous exudate. Physicians order dated 5/19/11 indicate an order for [REDACTED]. Nurse's note 5/22/11 at 1:00 PM indicates that the treatment to the coccyx maintained. Nurse's note 5/24/11 at 2:00 PM indicates that the treatment was done on buttocks, area is slowly healing. and irritated areas on scrotum are healed. Resident #15 had no weekly measurements/nursing assessments done of the ischial wound. No additional nurses notes indicating the status of the wound. Resident #15 was admitted to the hospital for a [MEDICAL CONDITION] on 5/27/11 and returned to the facility on [DATE]. Resident #15's medical record does not indicate an assessment and/or measurements of the right ischial open areas. A wound/dressing change medicare documentation guideline was placed in Resident #15's medical record indicating that he had a stage 2 pressure ulcer on his right ischium and an open area to his scrotum. It indicated daily charting on the site/type of wound, odor, drainage, pain and change in status/progress. The form also indicated that nursing should document weekly on the wound site, type of wound, stage, size and description of the surrounding tissue. It also indicates to document the frequency and type of treatment, progress of wound since previous assessment, use of special equipment and other factors such as nutritional status and positioning changes. Nurse's note dated 6/14/11 at 1:20 PM indicates that open area to buttocks remains and treatment done with no signs or symptoms of infection. No additional description of the measurements or status of the wound. No description of the measurements or status of the open areas to Resident #15's scrotum. Resident #15's quarterly MDS dated [DATE] indicates that the Resident has 2 Stage 2 pressure ulcers and that one of the pressure ulcers was present upon admission. Nurse's note 6/19/11 at 12:10 AM indicates that Resident #15 has an open area to the scrotum measuring 1 cm x 0.7 cm and to the right ischium measuring 3.5 cm x 2.5 cm. The physician was notified and an order was obtained for treatments to these areas for 14 days. The physician order [REDACTED]. No additional measurements or description of wounds were noted. No indication that wounds healed. Standard of practice, as indicated by the NPUAP-EPUAP Treatment Guideline and The NPUAP-EPUAP Treatment Quick Reference Guide note: "Assess the pressure ulcer initially and re-assess it at least weekly, document findings." There were no weekly assessments on 6/26/11, 7/3/11, 7/10/11, 7/17/11, and 7/24/11. Nurses Progress notes dated 7/14 and 8/4/11 do not indicate anything under Resident #15's skin condition. Admission skin assessment form dated 8/4/11 indicates with a circle an area on Resident #15's right buttock and right upper thigh and indicate areas are old healed. There is no indication of the area noted previously on the right ischium. Daily skilled nurses notes dated 8/3, 8/4, 8/10, 8/15 and 8/16/11 all indicate that Resident #15 skin is within normal limits. Admission skin assessment form dated 8/16/11 indicates that Resident #15 has a 2.5 x 1.5 cm open area to the right ischium,as previously indicated. The area is described as red, moist with a clean wound base. The care plan was not updated to reflect the actual pressure ulcers and care needs for Resident #15. The skin assessment completed on 8/16/11 indicates the area to the right buttocks remains open. No update noted to the care plan related to Resident #15's skin integrity since it was developed on 9/3/10. On 8/17/11 at 1:00 PM Surveyor# reviewed the facility's policy and procedures related to wound care last updated 10/09. The manual indicated that wound are to be assessed and measured weekly and to notify the physician of any changes in status of the wound. On 8/18/11 at 8:00 AM NHA (Nursing Home Administrator) A provided Surveyor # a copy of Resident #15's undated CNA (Certified Nursing Assistant) care plan which had no indication of skin care needs for Resident #15. NHA A also provided Surveyor # a copy of a weekly skin documentation sheet dated 8/16/11 indicating the wound measurements and description of Resident #15's right ischial wound. No prior weekly skin documentation sheets were noted in the medical record. On 8/18/11 at 10:30 AM NHA A was informed of the above review. No additional information was provided. 4.) On 8/17/11 at 11:05 AM Surveyor # observed Resident #16 sitting up in her Broda chair with a blue foam boot and dressing to her right foot. On 8/17/11 at 12:30 PM Surveyor # reviewed Resident #16's medical record which indicated the following: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16 was readmitted to the facility on [DATE]. Nursing data collection tool dated 2/9/11 indicates that Resident #16 has no wounds or other skin conditions. The area related to foot problems indicates she has one or more foot problems-e.g.. corns, calluses, bunions, hammer toes, overlapping toes, pain, structural problems. No indication of a pressure ulcer. Podiatry exam note dated 2/16/11 indicates that Resident #16 had a large decubitus blister on her right heel. No indication in nursing notes that the area was measured weekly or when it healed. Nurses progress note dated 3/2/11 indicates that Resident #16 has buttocks reddened at times. No indication of the condition of Resident #16's right heel. Resident #16 was admitted to Hospice service on 3/4/11. Significant change in condition MDS (Minimum Data Set) dated 3/14/11 indicates that Resident #16 is at risk of developing pressure ulcers. There is no indication that Resident #16 has a pressure ulcer or healed ulcer. Podiatry note dated 4/20/11 indicates that Resident #16's decubitus blister to the posterior right heel is resolved. Quarterly MDS dated [DATE] indicates that Resident #16 is at risk for developing pressure ulcers but does not indicate current or healed pressure ulcers. Podiatrist note dated 6/21/11 indicates that Resident #16 has no foot ulcers or open [MEDICAL CONDITION] on her feet. A physician's orders [REDACTED].#16's right heel blister daily and wrap foot in abd pad and Kerlix daily and to wear foam boot. No weekly measurements (which would have been expected 7/3, 7/10, 7/17, and 7/24/11) are indicated in the nurses notes. Nurses progress notes dates 7/6 and 7/13/11 indicate that Resident #16 has a blister to the left heel. physician's orders [REDACTED]. physician's orders [REDACTED]. Physicians order dated 8/2/11 indicates to apply skin prep to dry all fluid filled blisters. Nurses progress note dated 8/8/11 indicates skin condition as intact. No weekly measurements or wound description indicated of right heel pressure ulcer (expected at least by 7/31 and 8/7/11). On 8/17/11 at 9:00 AM NHA (Nursing Home Administrator) A provided Surveyor # a copy of an admission skin assessment dated [DATE] for Resident #16. The form indicated that Resident #16 had a 2.5 x 2.5 cm pressure ulcer on her right heel. The wound base had blackish yellow slough and was moist with no active drainage. NHA A told Surveyor # that body checks were done on all facility Residents on 8/16/11. On 8/17/11 at 1:00 PM Surveyor# reviewed the facility's policy and procedures related to wound care last updated 10/09. The manual indicated that wound are to be assessed and measured weekly and to notify the physician of any changes in status of the wound. On 8/18/11 at 8:30 AM NHA A provided Surveyor # a wound treatment and progress record dated 8/18/11 which indicated that Resident #16 had a right heel open area. On 8/18/11 at 10:30 AM NHA A was informed of the above review. No additional information was provided. 5). Surveyor # conducted a medical record review on Resident #1. Resident #1 was admitted to the facility on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. According the quarterly Minimum Data Set, dated dated [DATE], Resident #1 needs extensive assistance for all activities of daily living, is incontinent of bowel and bladder and is at risk for developing pressure ulcers. At the time of this assessment, Resident #1 did not have any pressure ulcers present. The facility conducted a Braden Scale for predicating pressure sore risk on 5/23/11. The assessment indicated a score of 15, noting that Resident #1 is at risk for developing a pressure ulcer. The individual plan of care, last updated on 6/11/11, stated that Resident #1 has a potential alteration in skin integrity: recent hospitalization , weakness, decreased mobility, intermittent incontinence, end stage [MEDICAL CONDITION] and diabetes. The plan of care noted that Resident #1's skin was intact Surveyor # conducted a review of the nursing notes contained in Resident #1's medical chart. Nursing note dated 6/14/11 at 8:35 p.m. states that Resident #1 has neck cushion intact, Resident #1 has stiff guarded range of motion in neck area, slight deformity noted, no bulging of bones, able to palpate area of neck, right ear darkening skin, peeling noted. (It was noted that there was not further assessment of the area to the ear such as measurement or location on ear.) A physician order [REDACTED]. Nursing note 6/15/11 9:15 p.m. states that Resident #1 has neck- cushion intact, buttock area, surrounding skin intact has intact blisters on left side, Resident #1's neck guarded range of motion, neck deformity noted. Nursing note 6/15/11 at 9:35 p.m. states that the physician had been notified of Resident #1's change of condition and an order was made to send Resident #1 to the emergency room for further evaluation. Nursing note 6/16/11 at 2:00 a.m., states that Resident #1 was readmitted to the facility at 1:30 a.m. after being at the hospital for evaluation of lethargy, neck deformity and pain to left hand. The nursing note also stated that Resident #1 has an open blister noted to neck and left buttock with minimal drainage. ( It was noted that no further assessment of the open areas to the neck and buttock were indicated such as size and location.) A physician order [REDACTED].

On 8/17/11, the Administrator was notified that an Immediate Jeopardy existed at F281 at Resident Assessment - Services meet professional standards in regards to prevention, assessment, monitoring, treatment and services of pressure ulcers. This was cited at a scope/severity level K (immediate jeopardy/pattern) on Statement of Deficiency issued 8/19/11 (Event ID N9RF11). Based on observation, interviews and record review on 8/22/11, it was determined that the Immediate Jeopardy was removed on 8/22/11, by which time the facility: * Conducted 100 percent in-house Resident skin sweeps. * Re-educated 85 percent of the licensed staff on the facility's new Wound Care Program, which consisted of conducting weekly skin assessments and monitoring tools. * Residents at risk for skin breakdown and those residents with current wounds needs were re-assessed and addressed in their current care plan. * Identified treatments for pressure ulcers have been reviewed and are monitored daily by the unit nurses, and are documented in the Treatment Administration Record, as well as in the nurses ' notes until the wound is healed. * Licensed staff completes skin checks at bathing times and report findings to the charge nurse for appropriate follow up. Assessments continue to be completed upon admission, readmission, quarterly, and with significant changes in condition. * Weekly wound rounds are conducted with the Director of Nursing and the current Wound Nurse, who are assigned to stage the wounds. A Clinical Consultant Registered Nurse, who is familiar with wound care, will oversee that processes are in place in regards to the facility's Wound Care Program. * The facility is actively seeking a certified wound care specialist. * The facility will continue to address resident's wound care needs during weekly Quality of Care meetings between the clinical IDT (interdisciplinary team) members. The facility will continue to address any immediate related needs, including reportable events but not limited to, during the daily morning clinical meeting. All findings will be presented at monthly Performance Improvement (Quality Assurance) meetings. The deficient practice continues at a scope/severity level of an E (No actual harm that is not immediate jeopardy/pattern because the facility needs to monitor the effectiveness of the training provided to the licensed staff in regards to the facility's wound care program, which includes the prevention, assessment, treatment, following through on physicians orders and to ensure licensed staff meet professional standards of care.

On 8/17/11, the Administrator was notified that an Immediate Jeopardy existed at F490 at Administration. This was cited at a scope/severity level K (immediate jeopardy/pattern) on Statement of Deficiency issued 8/19/11 (Event ID N9RF11). Based on observation, interviews and record review on 8/22/11, it was determined that the Immediate Jeopardy was removed on 8/22/11, by which time the facility: * Will recruit; screen and hire qualified nursing staff as opening occurs. * 85 percent of all current nursing staff have been evaluated for their ability to perform their wound related nursing duties with skill and competency by observation of their bedside care, as well as skills competency observed by qualified nursing staff. Competencies included assessment, treatment observation, with return demo on how to monitor wounds. Nursing Administration will supervise and monitor the licensed nurses through random competencies and daily observation of care for adherence to acceptable standards of practice. * All nursing staff will re-educated on standards of practice on wound care management including needs assessment and tracking tools. Nursing skills will be monitored by the Clinical Services Consultant and the Director of Nursing for the ability to assess and perform duties per acceptable nursing standards. * Facility will continue to address competency skills during Human Resources and staff development meetings between clinical interdisciplinary members. The facility will continue to address any immediate related needs during the daily morning clinical meeting. All findings will be presented at the monthly Performance Improvement (QA) meeting. * Clinical Services Consultant will monitor all nursing administrative activities. The deficient practice continues at a scope/severity level of an E (No actual harm that is not immediate jeopardy/pattern as the facility must continue to be administered in a manner that enables to use its resources effectively and efficiently so that each resident attains or maintains the highest practicable physical, mental, and psychosocial well-being.

Based on staff interview, observation and record review, the facility did not ensure 6 of 17 residents received appropriate assessments and treatments for pressure ulcer care and other skin ulcer care. Residents #5, #6, #15, #16 #1 and #10 developed facility acquired pressure ulcers and did not receive necessary assessments for treatment and care of the pressure ulcers based upon current standards of practice. Weekly skin assessments were not done weekly per standard of practice, care plans were not updated as needed, and interventions to prevent pressure ulcer development or to promote healing were not implemented or were not implemented timely. Resident #5 developed a Stage 4 pressure ulcer on the buttock from shearing and a stage 3 pressure ulcer on the lower left leg from a splint boot, and did not receive the necessary assessments to provide services and treatment to prevent these pressure ulcers from developing. This prevented Resident #5 from attaining or maintaining her highest practicable well-being. The facility's failure to provide necessary assessments and services for prevention and treatment for [REDACTED]. Surveyor # notified the Administrator of this finding on 8/17/11 at 11:17 a.m. At the time of exit, on 8/19/11, the facility still had not removed the finding of immediate jeopardy. Findings include: 1.) On 8/15/11 through 8/18/11 Surveyor # reviewed Resident #5's medical record. Resident # 5 is a [AGE] year old individual who was admitted to the facility on [DATE] for rehabilitation. Resident #5's [DIAGNOSES REDACTED]. and incontinence. Resident #5 did not have pressure ulcers at the time of admission. The Admission MDS (minimum data set) for Resident #5 with a reference date of 2/14/11 indicates Resident #5 is at risk for pressure ulcers and does not currently have pressure ulcers. The interventions checked are pressure reduction in the bed and chair. It also indicates Resident #5 requires staff assist with ADL's (activities of daily living) and is non-ambulatory. The Admission CAAs (care area assessment) for pressure ulcers identifies risk factors of diabetes, immobility, incontinence and obesity and a plan of care was developed. The most recent MDS is a Significant Change in Condition with an assessment reference date of 6/25/11. This MDS indicates that Resident #5 requires staff assist with ADL's and is non-ambulatory. This MDS indicates Resident #5 has 3 stage 2 pressure ulcers with an onset date of 6/13/11. The interventions checked are pressure reduction in bed and chair, nutrition and ulcer care. The Significant Change in Condition CAAs for pressure ulcers indicate Resident #5 is up in the Broda chair for short periods, has a Braden scale score of "15", which indicates that Resident #5 is at risk for pressure ulcers and remains a risk for skin breakdown. On 8/15/11 a complaint investigation was initiated for Resident #5 due to a concern with a stage 4 pressure ulcer. On 8/15/11 at 10:15 a.m. Surveyor # received the facility pressure ulcer list from the Administrator. This list dated 8/12/11 includes all of Resident #5 wound measurements since admission. Resident #5 is listed as having the following; arterial ulcers on the left and right heel and the left medial ankle; and a stage 3 pressure ulcer on the right buttock. Buttocks According to the 8/12/11 facility wound list the earliest wound assessment tracking form for Resident #5 is dated 5/27/11 and indicates Resident #5 sustained shearing on the right and left buttock and required treatment with Vitamin A&D ointment to the area. The next wound tracking is dated 6/3/11 and indicates the initial areas of Resident #5's buttocks caused by shearing have grown larger. The treatment remains the same (Vitamin A&D). Upon further review of Resident #5's medical record Surveyor # noted that there is no documentation to indicate that there was physician notification on these areas becoming larger. Surveyor # noted that there is no weekly wound tracking form again until 6/20/11, which indicates that Resident #5 has stage 2 pressure ulcers on the left buttock and 2 stage 2 pressure ulcers on the right buttock. A different treatment is noted to the pressure ulcer areas. Standard of practice, as indicated by the NPUAP-EPUAP Treatment Guideline and The NPUAP-EPUAP Treatment Quick Reference Guide note: Assess the pressure ulcer initially and re-assess it at least weekly, document findings... With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications) ... Signs of deterioration should be addressed immediately. Here, staff took no measurements of the pressure ulcers from 6/4/11 until 6/20/11, seventeen days later. At this time, the left pressure ulcer was 5.3 x 2 cm. while slough was noted in the pressure ulcers on the right buttock. All were staged as stage 2. The next weekly wound tracking form is dated 6/27/11 and indicates the same pressure ulcers and treatments as documented on 6/20/11. The next wound tracking is on 7/10/11 (13 days later). This document indicates that Resident #5's right buttock has tunneling that is 6.2 cm deep and is a full thickness wound. The treatment has changed for this particular wound. This is the last date of pressure ulcer staging and tracking using this form. On 7/27/11 Resident #5 went out to a wound clinic for a consultation. This consultation indicates that Resident #5 has a stage 4 pressure ulcer and recommends that Resident #5 utilize a low air mattress due to having a stage 4 sacral ulcer. On 8/4/11 the facility documented on Resident #5's pressure ulcers utilizing a form different from the form used for previous pressure ulcer documentation. This form now includes a description of Resident #5's pressure ulcers. Sacral ulcers: On 8/15/11 Surveyor # reviewed the plans of care (POC) related to Resident #5's sacral pressure ulcers. The POC for Alteration in skin integrity originally developed 2/20/11 indicates an onset date of 6/13/11 of a stage 2 pressure ulcer on the left buttock and 2 more on the right buttock. The POC does not include any new or updated interventions since 2/20/11. Surveyor # noted that there is 1 intervention listed that directly addresses pressure, which is to be up in the Broda chair and encourage a rest daily to relieve pressure on buttock. Surveyor # noted that the POC does not contain any reference to the 7/27/11 wound care clinic recommended low air loss mattress change or interventions to prevent shearing. On 8/16/11 at 10:38 a.m. Surveyor # observed LPN-G (Licensed Practical Nurse) change Resident #5 pressure ulcer dressings. Resident #5 has a bariatric bed and was lying flat on it. The mattress did not have markings on the side that indicated what type of pressure reduction/relief it provides. Surveyor # noted during the observation that there was not an air machine that would be attached to the mattress. On 8/17/11 at 10:25 a.m. Surveyor # spoke with the facility's central supply staff (CSF)-F that orders and provides equipment and supplies to Residents in the facility. CSF-F indicated that Resident #5 has been in the same bariatric bed since admission to the facility. CSF-F was not aware of nor did CSF-F have an invoice for a low air loss mattress for Resident #5. The bariatric bed manufacture definitions indicated that this mattress is for a person at risk for developing a pressure ulcer. Leg pressure ulcers Surveyor # noted that Resident #5 has diabetes and did not have interventions on the care plan to address diabetic foot care despite the risk that diabetes poses for pressure ulcer development. On 8/15/11 Surveyor # during review of resident #5's medical record Surveyor #2155 noted that on 5/12/11 Resident #5 sustained a right ankle fracture. An orthopedic consult dated 6/7/11 indicates that an air/walker boot was placed on the left lower extremity; even lthough Resident #5 is non-ambulatory. Within Resident #5's medical record there is a note from Resident #5's podiatrist dated 6/21/11 which indicates that the boot Resident #5 is wearing does not fit properly and that Resident #5 needs a wheelchair that supports the left leg better. There had been no follow up to the ill-fitting boot up until the time of survey. On 7/26/11 Resident #5's nurse's notes indicate that the walking boot was removed on 7/26/11 and that an open area was present right above the ankle, measuring 4.3 cm by 3.3 cm with scant amount of bleeding and that the area is consistent with the boot applying pressure on area. The documentation does not indicate why the boot was removed. Following this discovery, there is no documentation that indicates the orthopedic doctor was called regarding the determination that the boot was causing pressure. The air/walking boot was not discontinued until 8/15/11 at an orthopedic appointment despite the determination that the air/walking boot caused a pressure ulcer back on 7/26/11. Review of Resident #5's weekly wound assessment tracking form dated 8/4/11 indicates that Resident #5 has a right and left heel pressure ulcer that is unstageable; Resident #5's left medial ankle has a stage 3 pressure ulcer (where the air/walking boot caused pressure) and right ischial stage 4 pressure ulcer. On 8/16/11 at 10:38 a.m. Surveyor # observed LPN-G(Licensed Practical Nurse) change Resident #5 pressure ulcer dressings. Resident #5 is on contact isolation due to Resident #5 having an infection in an ankle pressure ulcer. LPN-G indicated that Resident #5 had the air boot on up to yesterday and that they had padded the boot to ease pressure to her ankle/leg. LPN-G indicated the boot was on at all times. Review of the 2/20/11 Plan of Care (POC) for Alteration in skin integrity does not address the fact that Resident #5 has pressure ulcers on her legs nor does it address that Resident #5 wears a boot that caused pressure. On 8/17/11 at 1:20 p.m. Surveyor # spoke with the Interim Director of Rehabilitation (IDR)-E as the current director was on leave from the facility. IDR-E indicated that they were aware of Resident #5's boot not fitting correctly from the Podiatrist note (dated 6/21/11). IDR-E indicated that Nursing Staff was responsible for calling the Orthopedic doctor to get a new boot because this was a boot that rehab could not replace. Resident #5's medical record did not reveal that the boot was ever changed or that the orthopedic physician was called. According to the reference Feet Can Last a Lifetime: A Healthcare Provider's Guide to Preventing Diabetes Foot Problems; 73% of the lower extremity amputations ....were a result of the casual consequence of minor trauma, cutaneous ulceration and wound healing failure. Estimates of the cumulative proportions of various causes indicated that 86% of amputations were attributed to initial minor trauma causing tissue damage. Administration On 8/15/11 at 3:20 p.m. Surveyor # spoke with Administrator (NHA)-A regarding Resident #5's pressure ulcers. The Administrator indicated that there are no staff available that will be able to answer questions regarding Resident #5's development of a stage 4 sacral pressure ulcer and leg ulcers. NHA-A indicated that the staff who initially did the pressure ulcer assessments is no longer employed at the facility and there has not been a consistent staff member completing the pressure ulcer assessments. The staff member that conducted the pressure ulcer assessments left 7/9/11. NHA-A indicated that on 8/4/11 a facility sweep was done on residents to determine who had pressure ulcers however, as of 8/15/11 the facility was still uncertain of who had pressure ulcers, what the stages may be and whether the pressure ulcers were improving or worsening. This sweep was conducted by RN-C (Registered Nurse) with the help of an outside consultant. On 8/16/11 Surveyor # reviewed Resident #5's recent pressure ulcer documentation that was done on 8/15/11 by RN-C (Registered Nurse) These assessments do not include any staging of the wounds nor do they indicate what the current treatment is for each wound. This document indicates that there is a 5 cm (centimeter) by 2.5 cm by 0.4 cm on the left medial ankle. This area contains yellow-green slough in the wound bed and has a mild odor. There is a 0.25 cm bleeding crack area on the left heel. There is a 3 cm by 2.5 cm by 7.2 cm area on the right buttock. The right buttock area contains tunneling that is 7.2 cm deep with yellow drainage and has a strong odor. This also indicates that there is one remaining area most lateral to wound, on the right buttocks that measures 0.8 cm by 1 cm that the facility documents as "almost healed." On 8/16/11 at 3:00 p.m. Surveyor # spoke with RN-C. RN-C indicated they are doing just the clinical aspect of pressure ulcers in the facility. RN-C indicated that they are not wound care certified and that guidance is needed from an outside consultant to stage and direct the treatment of [REDACTED]. On 8/16/11 at 3:30 p.m. at the daily exit meeting with NHA-A Surveyor # shared the pressure ulcer concerns regarding Resident #5 and requested the facility's policy and procedures on wound care. On 8/17/11 at 11:25 a.m. NHA-A provided Surveyor # with the facility's policy and procedure for wound care which were revised 10/09. The policy indicates that wound evaluations will be performed upon admission and weekly. This includes staging if the wound is a pressure ulcer. The policy also indicates that there should be documentation and care planning for wounds. 2.) Resident #6 was admitted to the facility on [DATE]. Resident #6 has [DIAGNOSES REDACTED]. Resident #6 has a long history of recurrent pressure ulcers. Resident #6 is often non compliant with treatments and interventions to prevent and heal existing pressure ulcers. Resident #6 has had amputations of toes due to non-compliance with the care and treatment of [REDACTED]. On 8/16/11 at 10:00 a.m. Surveyor #3328 reviewed the medical record for Resident #6. The medical record indicates that on 7/11/11 2 new open areas were found on the right foot on the plantar surface. The measurements are 4.2 cm X 2.5 cm. and 1.5 cm. X 1 cm. There is no indication as to the stage of these pressure ulcers. The medical record indicates that Resident #6's physician was notified of the pressure ulcers and a treatment of [REDACTED]. On 8/16/11 at 11:30 a.m. Surveyor #3328 requested from the Administrator the Wound sheets for Resident #6's most recent pressure ulcers that were identified on 7/11/11. The Administrator provided Surveyor #3328 with an Admission Skin Assessment sheet that identified 2 open areas on the right foot. This was dated 8/4/11. On 8/16/11 at 1:00 P.M. Surveyor #3328 spoke with RN-C regarding Resident #6's open areas. RN-C indicated that she had been acting as the wound nurse since the previous wound nurse left the facility. Surveyor asked RN-C if there were any weekly wound assessments of Resident #6's open areas on the right foot. RN-C indicated that the facility had a gap in the wound treatment at the facility ever since the previous wound nurse left and when the Director of Nursing, DON, was hired. RN-C indicated that on 8/4/11 the facility did a wound sweep and identified the 2 open areas on Resident #6's right foot. RN-C indicated that there are no wound sheets that would document the size, condition and stage of Resident #6's new pressure ulcers on the right foot. RN-C indicated that she was going to measure Resident #6's wounds today. On 8/16/11 at 2:00 p.m. Surveyor # went with RN-C to observe the measurement of Resident #6's pressure ulcers. Resident #6 would not allow Surveyor # to observe the pressure ulcers on her feet. RN-C provided Surveyor #3328 with the wound measurements for the 2 pressure ulcers on Resident #6's right foot. They measure 0.5 cm. X 0.3 cm and 1.5 cm X 0.6 cm. The pressure ulcers did not become larger since 7/11/11. On 8/16/11 at 1:45 p.m. Surveyor #3328 observed Resident #6 in bed. Resident #6 was on a Stage 4 specialty air flow mattress. Resident #6 has orders for boots on the feet but often refuses the boots. On 8/17/11 Surveyor's reviewed the policy on treatment and prevention of pressure ulcers. The policy is dated 10/09. The policy indicates that resident with pressure ulcers should have the ulcers assessed weekly. The assessment should include the description and measurements of the wounds and the stage of the wounds. Resident #6 developed 2 unavoidable pressure ulcers on 7/11/11 and had no assessment of these wounds until 8/16/11. 3.) On 8/17/11 at 11:05 AM Surveyor # observed Resident #15 self propelling his wheelchair from physical therapy. Resident #15 had a left leg prosthesis on and a dressing to his right [MEDICAL CONDITION] site. On 8/17/11 at 11:30 AM Surveyor # reviewed Resident #15's medical record which revealed the following: Resident #15 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The RAP (Resident Assessment Protocol) for the 9/3/10 MDS indicates that Resident #15 has a history of altered skin integrity and currently has no open areas or areas of skin impairment. The RAP indicates that Resident #15 is incontinent of both bowel and bladder The RAP indicates that Resident #15 has severe [MEDICAL CONDITION], Diabetes and left foot gangrene. The RAP indicates to proceed with a care plan. On 9/3/10 the facility developed a care plan for Resident #15 with a problem of Alteration in skin integrity related to incontinence, lack of sensation, left [MEDICAL CONDITION], right foot amputation, severe [MEDICAL CONDITION], Diabetes and refusal of scheduled toileting program. The Goal indicates that the skin to remain clean dry and intact for 90 days with a target date of 12/03/2010. The approaches include keeping the call light in reach, incontinence care every 2 hours, instructing on the importance of good skin care and note skin condition daily with cares and report any new signs of redness, irritation or open areas promptly to the team leader. Nurse's Note dated 5/17/11 at 4:30 PM indicates that Resident #15 was readmitted to the facility and had an open area to his right buttocks measuring 3 cm x 2 cm and under the right scrotum measuring 0.3 cm in diameter and left scrotum measuring 2.5 cm x 1.0 cm. The areas were indicated with measurements on the Admission skin assessment dated [DATE]. Nurses note 5/19/11 at 7:00 AM indicates that Resident #15 has an open area to the right ischium measuring 2.5 x 2.6 with round even edges and a small amount of serous exudate. Physicians order dated 5/19/11 indicate an order for [REDACTED]. Nurse's note 5/22/11 at 1:00 PM indicates that the treatment to the coccyx maintained. Nurse's note 5/24/11 at 2:00 PM indicates that the treatment was done on buttocks, area is slowly healing. and irritated areas on scrotum are healed. Resident #15 had no weekly measurements/nursing assessments done of the ischial wound. No additional nurses notes indicating the status of the wound. Resident #15 was admitted to the hospital for a [MEDICAL CONDITION] on 5/27/11 and returned to the facility on [DATE]. Resident #15's medical record does not indicate an assessment and/or measurements of the right ischial open areas. A wound/dressing change medicare documentation guideline was placed in Resident #15's medical record indicating that he had a stage 2 pressure ulcer on his right ischium and an open area to his scrotum. It indicated daily charting on the site/type of wound, odor, drainage, pain and change in status/progress. The form also indicated that nursing should document weekly on the wound site, type of wound, stage, size and description of the surrounding tissue. It also indicates to document the frequency and type of treatment, progress of wound since previous assessment, use of special equipment and other factors such as nutritional status and positioning changes. Nurse's note dated 6/14/11 at 1:20 PM indicates that open area to buttocks remains and treatment done with no signs or symptoms of infection. No additional description of the measurements or status of the wound. No description of the measurements or status of the open areas to Resident #15's scrotum. Resident #15's quarterly MDS dated [DATE] indicates that the Resident has 2 Stage 2 pressure ulcers and that one of the pressure ulcers was present upon admission. Nurse's note 6/19/11 at 12:10 AM indicates that Resident #15 has an open area to the scrotum measuring 1 cm x 0.7 cm and to the right ischium measuring 3.5 cm x 2.5 cm. The physician was notified and an order was obtained for treatments to these areas for 14 days. The physician order [REDACTED]. No additional measurements or description of wounds were noted. No indication that wounds healed. Standard of practice, as indicated by the NPUAP-EPUAP Treatment Guideline and The NPUAP-EPUAP Treatment Quick Reference Guide note: "Assess the pressure ulcer initially and re-assess it at least weekly, document findings." There were no weekly assessments on 6/26/11, 7/3/11, 7/10/11, 7/17/11, and 7/24/11. Nurses Progress notes dated 7/14 and 8/4/11 do not indicate anything under Resident #15's skin condition. Admission skin assessment form dated 8/4/11 indicates with a circle an area on Resident #15's right buttock and right upper thigh and indicate areas are old healed. There is no indication of the area noted previously on the right ischium. Daily skilled nurses notes dated 8/3, 8/4, 8/10, 8/15 and 8/16/11 all indicate that Resident #15 skin is within normal limits. Admission skin assessment form dated 8/16/11 indicates that Resident #15 has a 2.5 x 1.5 cm open area to the right ischium,as previously indicated. The area is described as red, moist with a clean wound base. The care plan was not updated to reflect the actual pressure ulcers and care needs for Resident #15. The skin assessment completed on 8/16/11 indicates the area to the right buttocks remains open. No update noted to the care plan related to Resident #15's skin integrity since it was developed on 9/3/10. On 8/17/11 at 1:00 PM Surveyor# reviewed the facility's policy and procedures related to wound care last updated 10/09. The manual indicated that wound are to be assessed and measured weekly and to notify the physician of any changes in status of the wound. On 8/18/11 at 8:00 AM NHA (Nursing Home Administrator) A provided Surveyor # a copy of Resident #15's undated CNA (Certified Nursing Assistant) care plan which had no indication of skin care needs for Resident #15. NHA A also provided Surveyor # a copy of a weekly skin documentation sheet dated 8/16/11 indicating the wound measurements and description of Resident #15's right ischial wound. No prior weekly skin documentation sheets were noted in the medical record. On 8/18/11 at 10:30 AM NHA A was informed of the above review. No additional information was provided. 4.) On 8/17/11 at 11:05 AM Surveyor # observed Resident #16 sitting up in her Broda chair with a blue foam boot and dressing to her right foot. On 8/17/11 at 12:30 PM Surveyor # reviewed Resident #16's medical record which indicated the following: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16 was readmitted to the facility on [DATE]. Nursing data collection tool dated 2/9/11 indicates that Resident #16 has no wounds or other skin conditions. The area related to foot problems indicates she has one or more foot problems-e.g.. corns, calluses, bunions, hammer toes, overlapping toes, pain, structural problems. No indication of a pressure ulcer. Podiatry exam note dated 2/16/11 indicates that Resident #16 had a large decubitus blister on her right heel. No indication in nursing notes that the area was measured weekly or when it healed. Nurses progress note dated 3/2/11 indicates that Resident #16 has buttocks reddened at times. No indication of the condition of Resident #16's right heel. Resident #16 was admitted to Hospice service on 3/4/11. Significant change in condition MDS (Minimum Data Set) dated 3/14/11 indicates that Resident #16 is at risk of developing pressure ulcers. There is no indication that Resident #16 has a pressure ulcer or healed ulcer. Podiatry note dated 4/20/11 indicates that Resident #16's decubitus blister to the posterior right heel is resolved. Quarterly MDS dated [DATE] indicates that Resident #16 is at risk for developing pressure ulcers but does not indicate current or healed pressure ulcers. Podiatrist note dated 6/21/11 indicates that Resident #16 has no foot ulcers or open [MEDICAL CONDITION] on her feet. A physician's orders [REDACTED].#16's right heel blister daily and wrap foot in abd pad and Kerlix daily and to wear foam boot. No weekly measurements (which would have been expected 7/3, 7/10, 7/17, and 7/24/11) are indicated in the nurses notes. Nurses progress notes dates 7/6 and 7/13/11 indicate that Resident #16 has a blister to the left heel. physician's orders [REDACTED]. physician's orders [REDACTED].#16 should have a venous Doppler study done to rule out a [MEDICAL CONDITION] and to apply a dressing to the right heel eschar daily. Physicians order dated 8/2/11 indicates to apply skin prep to dry all fluid filled blisters. Nurses progress note dated 8/8/11 indicates skin condition as intact. No weekly measurements or wound description indicated of right heel pressure ulcer (expected at least by 7/31 and 8/7/11). On 8/17/11 at 9:00 AM NHA (Nursing Home Administrator) A provided Surveyor # a copy of an admission skin assessment dated [DATE] for Resident #16. The form indicated that Resident #16 had a 2.5 x 2.5 cm pressure ulcer on her right heel. The wound base had blackish yellow slough and was moist with no active drainage. NHA A told Surveyor # that body checks were done on all facility Residents on 8/16/11. On 8/17/11 at 1:00 PM Surveyor# reviewed the facility's policy and procedures related to wound care last updated 10/09. The manual indicated that wound are to be assessed and measured weekly and to notify the physician of any changes in status of the wound. On 8/18/11 at 8:30 AM NHA A provided Surveyor # a wound treatment and progress record dated 8/18/11 which indicated that Resident #16 had a right heel open area. On 8/18/11 at 10:30 AM NHA A was informed of the above review. No additional information was provided. 5.) Surveyor # conducted a medical record review on Resident #1. Resident #1 was admitted to the facility on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. According the quarterly Minimum Data Set, dated dated [DATE], Resident #1 needs extensive assistance for all activities of daily living, is incontinent of bowel and bladder and is at risk for developing pressure ulcers. At the time of this assessment, Resident #1 did not have any pressure ulcers present. The facility conducted a Braden Scale for predicating pressure sore risk on 5/23/11. The assessment indicated a score of 15, noting that Resident #1 is at risk for developing a pressure ulcer. The individual plan of care, last updated on 6/11/11, stated that Resident #1 has a potential alteration in skin integrity: recent hospitalization , weakness, decreased mobility, intermittent incontinence, end stage [MEDICAL CONDITION] and diabetes. The plan of care noted that Resident #1's skin was intact Surveyor # conducted a review of the nursing notes contained in Resident #1's medical chart. Nursing note dated 6/14/11 at 8:35 p.m. states that Resident #1 has neck cushion intact, Resident #1 has stiff guarded range of motion in neck area, slight deformity noted, no bulging of bones, able to palpate area of neck, right ear darkening skin, peeling noted. (It was noted that there was not further assessment of the area to the ear such as measurement or location on ear.) A physician order [REDACTED]. Nursing note 6/15/11 9:15 p.m. states that Resident #1 has neck- cushion intact, buttock area, surrounding skin intact has intact blisters on left side, Resident #1's neck guarded range of motion, neck deformity noted. Nursing note 6/15/11 at 9:35 p.m. states that the physician had been notified of Resident #1's change of condition and an order was made to send Resident #1 to the emergency room for further evaluation. Nursing note 6/16/11 at 2:00 a.m., states that Resident #1 was readmitted to the facility at 1:30 a.m. after being at the hospital for evaluation of lethargy, neck deformity and pain to left hand. The nursing note also stated that Resident #1 has an open blister noted to neck and left buttock with minimal drainage. ( It was noted that no further assessment of the open areas to the neck and buttock were indicated such as size and location.) A physician order [REDACTED]. Further review of the medical record showed that Resident #1's individual plan of care had not been updated to indicate the new areas of skin impairment on the right ear, neck and left buttock. It was noted that on 6/18/11, Resident #1 was admitted to hospice. A clinical note, written by Heartland Hospice, dated 6/19/11 indicates that Resident # 1 has new open areas to the neck due to positioning, New bed and mattress has been ordered. Physician order [REDACTED]. It was again noted that there was not a comprehensive assessment of Resident #1's skin impairments, indicating how many areas on her neck and jaw line were present, measurements and condition of the areas. Also there was no additional assessment noted of the area to the left buttock or right ear. The individual plan of care was also noted not to be updated to indicate these changes. Surveyor # asked the facility to provide any documentation and assessment on Resident #1's skin impairments. It was noted that the facility has had change in staffing and the wound care nurse was no longer employed at the facility, and the Director of Nursing that was present during the survey was not employed during the above dates mentioned. Surveyor # was provided with the "weekly wound tracking worksheet", dated 6/20/11. Resident #1 was listed on this tracking tool to have a stage 2 pressure ulcer to the sacrum, onset date 6/19/11 and a stage 2 pressure ulcer the right "SC" ( noted that facility staff were unable to determine what the initials " SC" meant as far as location of wound.) The "Resident Wound Assessment", dated 6/20/11 indicates that this is the initial assessment for Resident #1 and these is a stage 2 pressure ulcer to the right "sc" measuring 1.0 by 2.0 centimeters with serious drainage. Also noted was a stage 2 pressure ulcer to the sacrum measuring 5.0 by 5.0 centim

On 8/17/11, the Administrator was notified that an Immediate Jeopardy existed at F314 at Quality of Care-Pressure Ulcers. This was cited at a scope/severity level J (immediate jeopardy/isolated) on Statement of Deficiency issued 8/19/11 (Event ID N9RF11). Based on observation, interviews and record review on 8/22/11, it was determined that the Immediate Jeopardy was removed on 8/22/11, by which time the facility: * Conducted 100 percent in-house Resident skin sweeps. * Re-educated 85 percent of the licensed staff on the facility ' s new Wound Care Program, which consisted of conducting weekly skin assessments and monitoring tools. * Residents at risk for skin breakdown and those residents with current wounds needs were re-assessed and addressed in their current care plan. * Identified treatments for pressure ulcers have been reviewed and are monitored daily by the unit nurses, and are documented in the Treatment Administration Record, as well as in the nurses ' notes until the wound is healed. * Licensed staff completes skin checks at bathing times and report findings to the charge nurse for appropriate follow up. Assessments continue to be completed upon admission, readmission, quarterly, and with significant changes in condition. * Weekly wound rounds are conducted with the Director of Nursing and the current Wound Nurse, who are assigned to stage the wounds. A Clinical Consultant Registered Nurse, who is familiar with wound care, will oversee that processes are in place in regards to the facility ' s Wound Care Program. * The facility is actively seeking a certified wound care specialist. * The facility will continue to address resident ' s wound care needs during weekly Quality of Care meetings between the clinical IDT (interdisciplinary team) members. The facility will continue to address any immediate related needs, including reportable events but not limited to, during the daily morning clinical meeting. All findings will be presented at monthly Performance Improvement (Quality Assurance) meetings. The deficient practice continues at a scope/severity level of an E (No actual harm that is not immediate jeopardy/pattern as the facility must continue to ensure all staff consistently implement proper assessment, monitoring and treatment of [REDACTED].

Based upon staff interview and record review, the facility did ensure that a Resident physician was notified and consulted with when there was a change in the status of a Resident pressure ulcer. This was observed in 1 (Resident #5) of 17 sampled Residents with pressure ulcers. Resident #5 was admitted to the facility with no pressure ulcers and was assessed by the facility to be considered at low risk for the development of pressure ulcers. Resident #5 developed a stage 4 pressure ulcer on the buttocks and the physician was not notified or consulted with regarding changes in this pressure ulcer. Resident #5 had an air/walking boot on the left leg which was identified as not fitting correctly and when removed Resident #5 had a pressure ulcer, which on 8/4/11 was assessed as a stage 3 pressure ulcer. Findings include: 1. On 8/15/11 through 8/18/11 Surveyor # reviewed Resident #5's medical record. Resident #5 is a [AGE] year old individual who was admitted to the facility on [DATE] for rehabilitation. Resident #5's [DIAGNOSES REDACTED]. and incontinence. Resident #5 did not have pressure ulcers at the time of admission. The Admission MDS (minimum data set) for Resident #5 with a reference date of 2/14/11 indicates Resident #5 is at risk for pressure ulcers and does not currently have pressure ulcers. The interventions checked are pressure reduction in the bed and chair. It also indicates Resident #5 requires staff assist with ADL's (activities of daily living) and is non-ambulatory. The Admission CAAs (care area assessment) for pressure ulcers identifies risk factors of diabetes, immobility, incontinence and obesity and a plan of care was developed. The most recent MDS is a Significant Change in Condition with an assessment reference date of 6/25/11. This MDS indicates that Resident #5 requires staff assist with ADL's and is non-ambulatory. This MDS indicates Resident #5 has 3 stage 2 pressure ulcers with an onset date of 6/13/11. The interventions checked are pressure reduction in bed and chair, nutrition and ulcer care. The Significant Change in Condition CAAs for pressure ulcers indicate Resident #5 is up in the Broda chair for short periods, has a Braden scale score of "15", which indicates that Resident #5 is at risk for pressure ulcers and remains a risk for skin breakdown. On 8/15/11 a complaint investigation was initiated for Resident #5 due to a concern with a stage 4 pressure ulcer. On 8/15/11 at the initiation of the survey, Surveyor # requested a list of current facility Residents that have pressure ulcers from the facility Administrator. Facility 8/12/11 Wound List Information: On 8/15/11 at 10:15 a.m. Surveyor # received the facility pressure ulcer list from the Administrator. This list dated 8/12/11 includes all of Resident #5 wound measurements since admission. Resident #5 is listed as having the following; arterial ulcers on the left and right heel and the left medial ankle; and a stage 3 pressure ulcer on the right buttock. According to the 8/12/11 facility wound list the earliest wound assessment tracking form for Resident #5 is dated 5/27/11 and indicates Resident #5 sustained shearing on the right and left buttock and required treatment with Vitamin A&D ointment to the area. The next wound tracking is dated 6/3/11 and indicates the initial areas of Resident #5's buttocks caused by sheering have grown larger. The treatment remains the same (Vitamin A&D). Upon further review of Resident #5's medical record Surveyor # noted that there is no documentation to indicate that there was physician notification on these areas becoming larger. Surveyor # noted that there is not a weekly wound tracking form again until 6/20/11, which indicates that Resident #5 has stage 2 pressure ulcers on the left buttock and 2 stage 2 pressure ulcers on the right buttock. A different treatment is noted to the pressure ulcer areas. The next weekly wound tracking form is dated 6/27/11 and indicates the same pressure ulcers and treatments as documented on 6/20/11. The next wound tracking is on 7/10/11 (13 days later). This document indicates that Resident #5's right buttock has tunneling that is 6.2 cm deep and is a full thickness wound. The treatment has changed for this particular wound. This is the last date of pressure ulcer staging and tracking using this form. On 8/4/11 the facility documented on Resident #5's pressure ulcers utilizing a form different from the form used for previous pressure ulcer documentation. This form now includes a description of Resident #5's pressure ulcers. On 7/27/11 Resident #5 went out to a wound clinic for a consultation. This consultation indicates that Resident #5 has a stage 4 pressure ulcer and recommends that Resident #5 utilize a low air mattress due having a stage 4 sacral ulcer. Resident #5's leg pressure ulcers On 8/15/11 Surveyor # during review of resident #5's medical record Surveyor #2155 noted that on 5/12/11 Resident #5 sustained a right ankle fracture. An orthopedic consult dated 6/7/11 indicates that an air/walker boot was placed on the left lower extremity; although Resident #5 is non-ambulatory. Within Resident #5's medical record there is a note from Resident #5's podiatrist dated 6/21/11 which indicates that the boot Resident #5 is wearing does not fit properly and that Resident #5 needs a wheelchair that supports the left leg better. On 7/26/11 Resident #5's nurse's notes indicate that the walking boot was removed on 7/26/11 and that an open area was present right above the ankle, measuring 4.3 cm by 3.3 cm with scant amount of bleeding and that the area is consistent with the boot applying pressure on area. The documentation does not indicate why the boot was removed. Following this discovery, there is no documentation that indicates the orthopedic doctor was called regarding the determination that the boot was causing pressure. The air/walking boot was not discontinued until 8/15/11 at an orthopedic appointment despite the determination that the air/walking boot caused a pressure ulcer back on 7/26/11. Review of Resident #5's weekly wound assessment tracking form dated 8/4/11 indicates that Resident #5 has a right and left heel pressure ulcer that is unstageable; Resident #5's left medial ankle has a stage 3 pressure ulcer (where the air/walking boot caused pressure) and right ischial stage 4 pressure ulcer. On 8/16/11 at 10:38 a.m. Surveyor # observed LPN-G(Licensed Practical Nurse) change Resident #5 pressure ulcer dressings. Resident #5 is on contact isolation due to Resident #5 having an infection in an ankle pressure ulcer. LPN-G indicated that Resident #5 had the air boot on up to yesterday and that they padded the boot to ease pressure to her ankle/leg. LPN-G indicated the boot was on at all times. Review of the 2/20/11 Plan of Care (POC) for Alteration in skin integrity does not address the fact that Resident #5 has pressure ulcers on her legs nor does it address that Resident #5 wears a boot that caused pressure. On 8/17/11 at 1:20 p.m. Surveyor # spoke with the Interim Director of Rehabilitation-E as the current director was on leave from the facility. Rehab staff-E indicated that they were aware of Resident #5's boot not fitting correctly from the Podiatrist note (dated 6/21/11). Staff-E indicated that Nursing Staff was responsible for calling the Orthopedic doctor to get a new boot due to this was a boot that rehab could not replace. Resident #5's medical record did not reveal that the boot was ever changed or that the orthopedic physician was called. On 8/16/11 at 10:30 a.m. Surveyor # spoke with Resident #5's physician. Physician-I indicated he was not aware of the air walking boot not fitting properly and indicated that the physician that ordered it should have been updated. Physician-I indicated he did not know specifics or details on Resident #5 pressure ulcers. Physician-I indicated that Resident #5 goes to the wound clinic now and that was initiated by the facility. Physician -I did identify that Resident #5 is at high-risk of developing pressure ulcers due to diabetes and obesity. On 8/16/11 at 3:33 p.m. Surveyor # shared Resident #5 pressure ulcer concerns at the daily exit meeting with the Administrator.

Based on record reviews, observations, and interviews, the facility did not provide the necessary treatment and services to promote healing of pressure ulcers, or prevent the development of pressure ulcers for 3 of 21 residents reviewed (#2, #15 & #6). Resident #2 developed a pressure ulcer at the facility on 12/6/10. An initial assessment was completed on 12/6/10, and treatment was initiated. According to the Treatment Administration Record (TAR)'s, treatments were done from 12/10 through 12/16/10, and the pressure ulcer was to have been evaluated on 12/16/10. There was no evidence the pressure ulcer was reassessed, or that the facility continued to treat the pressure ulcer. Additionally, there was no evidence that the pressure ulcer was reassessed after the initial assessment on 12/6/10. When admitted to the hospital on [DATE], the pressure ulcers were still present. Resident #15 developed pressure ulcers at the facility. Nursing staff did not complete weekly assessments to monitor the pressure ulcer status for all identified pressure ulcers for one week in January 2011 and one week in February 2011. Resident #6 was identified to be at risk for pressure ulcers, and the care plan indicated the resident should be repositioned every 2 hours. Observations revealed that Resident #6 was not repositioned according to her plan of care on 3/30 & 4/4/11. Findings include: 1.) Surveyor # reviewed Resident #2's record on 4/6/11. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2 received all nutrition via a gastrostomy tube. According to the Pressure Ulcer Care Area Assessment (CAA) dated 11/29/10, Resident #2's skin was intact, and the resident was at risk for breakdown due to incontinence. A Braden Skin Risk assessment was completed on 11/17/10, with a score of 8, indicating Resident #2 was at "very high risk" for skin breakdown. The initial Nursing Data Collection Form dated 11/17/10, indicated Resident #2 was comatose. The Admission Skin assessment dated [DATE], identified bilateral scars on the buttocks, and dry skin. According to documentation in the nurses' notes on 12/6/10, Resident #2 was noted to have new open areas. The left buttock measured 4 cm x 1cm, and the right buttock measured 3cm x 0.8cm. There was no subsequent documentation in the nurses' notes related to the pressure ulcers. A review of the pressure ulcer documentation sheets revealed an initial evaluation on 12/6/10, describing a pressure ulcer to the coccyx measuring 2cm x 2.5cm. There were no additional assessments on the pressure ulcer documentation sheets. There was no additional evidence that assessments of the pressure ulcer had been completed. Surveyor # asked the Director of Nursing, if there was any other evidence that Resident #2's pressure ulcer had been evaluated after 12/6/10. The Director of Nursing brought in copies of the 24 hour reports which revealed the assessment of 12/6/10. No further mention of pressure ulcers was found in the 24 hour reports. The Director of Nursing stated she could find no further documentation showing the pressure ulcers had been assessed. The Director of Nursing stated that the nurse manager that had been responsible for wound management when Resident #2 was in the facility was no longer employed by the facility. Surveyor # reviewed the physician's orders [REDACTED]. Resident #2 had a treatment for [REDACTED]. The [MEDICATION NAME] treatment was done on 12/6 and 12/7/10. On 12/10/10, there was a physician's orders [REDACTED]. The order was for 1 week, then re-evaluate. The December 2010 TAR revealed the normal saline wash, [MEDICATION NAME] gel, dry dressing treatment was initialed as done from 12/10/10 through 12/16/10. There was no documentation on the TAR that any treatment was provided for Resident #2's pressure ulcer after 12/16/10. On 12/20/10, Resident #2 was admitted to the hospital after a change in condition. A review of the emergency room documentation indicated the resident had "decubiti to the sacral area, with multiple areas of open tissue, foul smelling clear type of drainage." 2.) Surveyor # reviewed Resident #15's record on 3/30 - 4/6/11. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Pressure Ulcer Care Area Assessment (CAA) completed 1/6/11, indicated Resident #15 had no pressure ulcers on admission, and was at risk for breakdown related to decreased functional status mobility, and intermittent bowel incontinence. A Pressure Ulcer CAA completed 3/4/11, indicated a wound vac was in place. The CAA summary indicated Resident #15 was not using the current electric scooter. The resident bought the scooter used and it was not fitted prior to use, and the resident preferred to stay in scooter despite education risk of pressure ulcer development. A review of the nursing care plan indicated that Resident #15 refused to get out of her scooter, and the pressure ulcer was unavoidable due to use of the electric scooter. Resident #15 was refusing to use a regular wheelchair, and refuses to allow repositioning. On 4/5/11, Surveyor # reviewed the Resident Wound Assessment sheets for Resident #15. The Resident Wound Assessment sheets indicated a pressure ulcer on the coccyx was first noted on 1/11/11. Weekly Resident Wound Assessment documentation was found for 1/14 & 1/21/11. There was no documentation for the week of 1/28/11. According to the Resident Wound Assessment documentation on 2/6/11, an area was noted on the left ischium measuring 4cm x 6.6cm. The cause was related to the use of the scooter that was improperly fitted. An area on the right heel was also noted on this date. Two areas were noted on the coccyx. There was a cover sheet dated 2/12/11, that listed Resident #15 as having pressure ulcers, but there were no corresponding Resident Wound Assessment sheets on that date. Resident Wound Assessment sheets dated 2/17/11, were found and reviewed. The wound documentation sheets included assessments of 2 areas on the coccyx and the left ischial pressure ulcer. There was no assessment of the right heel pressure ulcer. Documentation of pressure ulcer assessments in March 2011, addressed all pressure ulcer areas and occurred each week of the month. 3.) Surveyor # reviewed Resident #6's medical record on 03/28-04/06/11. Resident #6 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Review of Resident #6's Braden Scale for Predicting Pressure Ulcers dated 04/05/11, indicates Resident #6 to be at risk for the development of pressure ulcers. Review of Resident #6's plan of care dated 02/28/11, indicates a problem of potential for skin breakdown, resident is at risk for pressure ulcers due to decreased functional ability, assist with bed mobility, decreased mobility, poor skin integrity, [MEDICAL CONDITION] and failure to thrive. The goal for this problem is resident's skin will remain intact x 90 days, An approach to attain this goal is turn and reposition every 2 hours. Surveyor # made the following observations of Resident #6's positioning while in bed on on 03/30/11. At 8:32am., Resident #6 was in bed positioned on her left side with a pillow behind her back. At 9:13am., Resident #6 was in bed positioned on her left side with a pillow behind her back as at the last observation. At 10:15am., Resident #6 was in bed positioned on her left side with a pillow behind her back as at the previous observations. At 10:56am., Resident #6 was in bed positioned on her left side with a pillow behind her back as at the previous observations. At 11:36am., Resident #6 was in bed positioned on her left side with a pillow behind her back as at the previous observations. At 1:00pm., Resident #6 was in bed positioned on her left side with a pillow behind her back as at the previous observations. At 1:00p.m on 3/30/11, Surveyor # spoke with Resident #6 regarding her positioning. Resident #6 stated she is unable to reposition herself from side to side but can shift her position a little. Resident #6 stated staff only repositions her when she calls for assistance. Surveyor # observed Resident #6's bed positioning on 04/05/11. At 8:30a.m. Resident #6's was in bed positioned on her left side. At 10:35a.m. Resident #6's was in bed positioned on her left side. Surveyor # shared the above observations made on 03/30 and 04/05/11, of Resident #6 not being repositioned as per her plan of care. On 04/06/11 at approximately 9:30a.m. Surveyor # asked the Director of Nursing if she had any further information as to why Resident #6 had not been repositioned every 2 hours on 03/30 and 04/05/11, and she indicated she did not.