Every finding on record at Edgerton Care Center, Inc

Based on interview and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (Wisconsin Nurse Practice Act N6) for 1 of 6 sampled residents (R9) out of a total sample of 16 Residents.R9 had a change of condition that was not assessed properly, communicated to on-coming shifts, nor reported to the resident's medical provider. R9 was sent to the hospital where they remained for 3 days, receiving IV antibiotics.Evidenced by:The Wisconsin Nurse Practice Act states in part .N 6.04 Standards of practice for licensed practical nurses. (1) Performance of acts in basic patient situations. In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider: (a) Accept only patient care delegated acts which the L.P.N. is competent to perform. (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient. (d) Consult with a provider in cases where an L.P.N. knows or should know a delegated act may harm a patient. (e) Perform the following other acts when applicable:1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. or other provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs.The facility's policy titled Notification of Changes no date states in part .The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-changing conditions, or b. Clinical complications.R9 admitted to the facility on [DATE] with diagnoses that include hypertensive heart disease with heart failure, type 2 diabetes mellitus, chronic respiratory failure with hypoxia, obstructive sleep apnea, and hydrocephalus.R9's most recent Minimum Data Set (MDS) dated [DATE] states that R9 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R9 is cognitively intact. R9's MDS also indicates that they are dependent on staff for most of their Activities of Daily Living (ADLs) including bed mobility, transfers, personal hygiene, toileting, and bathing.Nures note entered on 6/16/26 indicated: 5/24/26 at 5:30 PM: Writer was alerted to the hallway by CNA (Certified Nursing Assistant), CNA stated resident turned blue in DR (Dining Room), at that time resident was sitting in WC (wheelchair) being taken to room, resident alert, no coughing, no SOB (Shortness of Breath), no c/o (complaints), no Blue tinge noted. Writer made observation on resident, lungs diminished, no SOB, VSS (Vital Signs Stable), Afebrile, asked resident if she was ok, resident responded I'm fine, that's normal for me, that's my color, I have rocasea[sic] Resident assisted back to room, went to sleep with BIPAP (a noninvasive ventilatory device that helps patients breathe by delivering two levels of air pressure: higher during inhalation and lower during exhalation) on, no further c/o noted or reported.It is important to note that this note was entered on 6/16/26. Additionally, there were no vital signs documented on 5/24/26, no evidence an RN assessment was completed or that a provider was updated.On 6/17/26 at 10:28 AM, Surveyor interviewed DA V (Dietary Aide). Surveyor asked DA V to explain what they observed on 5/24/26 regarding R9, DA V stated that R9 had started coughing during dinner and got really blue in the face. DA V stated that the CNAs came over and looked at R9 but was unsure if they reported it to the nurse.On 6/17/26 at 11:13 AM, Surveyor interviewed CNA K (Certified Nursing Assistant). Surveyor asked CNA K to explain the aspiration event with R9 on 5/24/26, CNA K reported that last night (6/16/26), the nurse called them and asked if R9 was blue, CNA K stated that R9 reported that they were fine and that they passed it on to another CNA. CNA K stated that they had R9's group and reported to Surveyor that R9 didn't look right that night. CNA K stated that they think the other CNA reported the incident to the nurse but is not sure and that they just left it alone. Surveyor asked CNA K who typically applies R9's BiPAP, CNA K stated that the CNAs put it on. Surveyor asked CNA K what time R9 likes for the BiPAP to be applies, CNA K stated between 8:30 PM-9:00 PM. Surveyor asked CNA K on 5/24/26 was R9's BiPAP put on at 5:30, CNA K stated no, and that they don't think R9 was even in bed at that time, typically R9 goes to bed late.On 6/17/26 at 12:32 PM, Surveyor interviewed CNA P. Surveyor asked CNA P to explain the events on 5/24/26 regarding R9, CNA P stated that they were at the nurse's station and another CNA called and said that R9 was blue so they went to see R9. CNA P stated that when they got to R9, they were blue in the face. CNA P stated that they ran to get the nurse and by the time that the nurse got down there, R9 was not blue anymore. CNA P stated that the nurse asked R9 if they were ok and R9 stated yes. Surveyor asked CNA P if the nurse did an assessment, CNA P stated that they said they were going to and then walked away.On 6/17/26 at 3:15 PM, Surveyor interviewed LPN U (Licensed Practical Nurse) Surveyor asked LPN U to explain the events of 5/24/26 regarding R9, LPN U stated that they were sitting at the nurse's station and the CNAs reported that R9 was turning blue. LPN U reported that they went to see R9 and they were sitting in front of their room, and they asked R9 what was going on. LPN U stated that R9's lungs were diminished, R9 had a cough, took vital signs and R9 was then put to bed. LPN U stated that R9 looked fine when they saw them. LPN U stated that R9 reported that they were that color because they had rosacea. Surveyor asked LPN U if rosacea turns skin blue, LPN U stated no, but R9 was not blue when they saw them. Surveyor asked LPN U if that means that the event did not occur, LPN U stated no. Surveyor asked LPN U if they notified the physician about the event, LPN U stated no because when they saw R9 they were fine and that did not need to be reported to the physician. Surveyor asked what R9's vital signs were at that time, LPN U stated that they did not know because they did not document them. Surveyor asked LPN U if R9's aspiration event was documented on the 24-hour board, LPN U stated no.Nurse note on 5/25/26 at 11:04 AM, indicated: Resident blue/grey to face this morning upon writer walking into room to assist with hoyer transfer. Resident started bobbing head slightly. Resident had no complaints of SOB. No loss of consciousness. Alert and oriented x 4 still. SPO2 (oxygen level) was at 48%. Put her on 4L (liters) via nasal cannula and SPO2 increased to 85%. Writer seen that oxygen was not connected to her bipap machine last night. Lungs diminished posterior and anterior in all lobes. She has developed a wet productive cough. Writer was notified by staff that resident had aspiration event last night during dinner and turned blue to the face. She was afebrile 98.4 and BP (Blood Pressure) 131/70. Pulse 111. RR (Respiratory Rate) 20. Oak medical was updated. Agreed with sending out via 911. 911 was called and EMS (Emergency Medical Service) arrived and resident was put on 8L via non re-breather mask. SPO2 increased to 96%. Resident requesting to be sent to [Hospital name]. Writer asked resident if she wanted writer to call her mother and she said only if she is admitted to the hospital. Resident was transferred to stretcher via hoyer and left via ambulance. Call placed to [Hospital] ER (Emergency Room) and resident will be admitted for aspiration pneumonia and placed on IV ABX (Intravenous Antibiotics). Residents mother arrived to facility just now and was updated on resident. DON notified of residents send out/being admitted .On 6/17/26 at 7:54 AM, Surveyor interviewed LPN G (Licensed Practical Nurse). Surveyor asked LPN G to explain the events that occurred with R6 on 5/25/26, LPN G stated that the CNA that was providing cares for R9 asked for assistance with a transfer and reported that R9 was blue/gray in color and didn't look right. R9 was bobbing their head, pulse ox was 48% and then it jumped to 55%. LPN G stated that R9 was able to answer questions and was talking to them. LPN G stated that they noted that R9's oxygen concentrator was not on and was not connected to their BiPAP machine. LPN G stated they got R9 up into the wheelchair, R9 started coughing with a wet cough, oxygen was applied at 4 liters and they were unable to get R9's sats up higher. LPN G stated they called the physician and EMS for evaluation. LPN G reported that the kitchen staff reported that R9 had turned blue at dinner the night before, and it was reported to the nurse who stated that R9 was fine and walked away. Surveyor asked LPN G how a change of condition is communicated between shifts, LPN G stated that it is usually reported at change of shift, but no one had said anything about R9's aspiration event. Surveyor asked LPN G who is responsible for applying R9's BiPAP, LPN G stated that the CNAs and nurses work together and then the nurse has to check it. LPN G stated that R9 never puts their mask on early, it's usually around 10:00 PM before they are ready. LPN G reported that R9 has orders for the nurse to ensure that the O2 is bled into the BiPAP and that there is water in the reservoir.Hospital documentation states in part:5/25/26 at 11:20 AM: Hospitalist admission History and Physical.Chief Complaint: Hypoxia.History of present illness: Patient is a [R9 age and gender] with a history of Chronic hypercapnic respiratory failure, wears BiPAP at night.who is being admitted with pneumonia (new problem).The patient was recently admitted to [Hospital Name] between April 14 and 23 for hypercapnic respiratory failure requiring intubation.Most recently, the patient has had a cough for several days. Her mom says that yesterday it sounded wet. The patient also says that whenever she eats, she has coughing. This morning when staff at her facility checked her pulse ox it was in the low 80s.She was sent to the ER where she was found to be hypoxic and hypercapnic (excessive carbon dioxide in the blood) with multilobar pneumonia (a type of lung infection that affects more than one lobe of the lungs, often causing more severe illness than pneumonia confined to a single lobe). She was placed on BiPAP.Abnormal lab results dated 5/25/26 at 11:00 AM include:pH Arterial 7.27 (H(High)) (indicates a significant acid-base disturbance)pCO2 Arterial 79 (HH) (indicates hypercapnia - an excess of carbon dioxide in the arterial blood.)HCO3 Arterial 36.3 (H) (indicates a metabolic alkalosis or a condition where the body has retained bicarbonate).O2 Saturation Arterial 99.1 (H)BE (base excess) Arterial 6.5 (H) (the blood is more alkaline than normal).CT Angio Chest Pulm (Pulmonary) Embolism (the most common and effective imaging test for diagnosing pulmonary embolism) results dated 5/25/26 state in part: .2. As before, low lung volumes are noted along with elevated diaphragms, left more than right. 3. As before, significant atelectasis is seen of the both lower lobes, along with moderate size dense pneumonic appearing consolidations with some internal air bronchograms in the both lower lobes. However, there appears to be moderate worsening in the right lower lobe and mild worsening in the left lower lobe. 4. Note is made of low density mucoid contents in the lumen of the main bronchi of both lower lobes, suggestive of either mucus impaction or obstructing lesions causing combination of aspiration and/or postobstructive pneumonia with atelectasis.XR Chest 1Vw Portable (Chest x-ray 1 view) results dated 5/25/26: Personally reviewed and shows very diminished lung volume, suspect bilateral lower lobe pneumonia. Assessment and Plan: .I suspect she has aspiration due to the history and appearance on CT. Continue BiPAP. Recheck VBG (Venous Blood Gases). Continue cefepime and vanco (antibiotics). Follow up with blood and sputum cultures. Consider Pulmonary consult tomorrow if not improved, due to appearance of significant mucus plugging on CT. Speech evaluation for aspiration once stable.Hospitalist note dated 5/26/26 at 2:52 PM states in part Reason for visit: Hypoxic hypercarbic respiratory failure. [R9] was able to come off BiPAP this morning and maintain her sats on 4L to 6L of nasal cannula oxygen.Also of note she has extremely poor inspiratory effort and deep inspiration triggers causing coughing jags are problematic for her. At baseline, her mother reports that she does not have significant cough so this is all likely new related to a recent aspiration event.Assessment and Plan: .I suspect she has aspiration pneumonia nd [sic] bronchitis due to the history and appearance on CT, baseline restrictive ung [sic] disease duet o [sic] [NAME] (Obesity Hypoventilation Syndrome), kyphosis, and atelectasis requiring Bipap at night. Continue BiPAP at night, monitor on cannula vs open mask O2 (oxygen) today. Continue cefepime.follow up blood and sputum cultures. Bronchial hygiene, incentive spirometry. Speech evaluation for silent aspiration with VSS. Dose Lasix 20 IV since held on admission.Hospitalist note dated 5/27/26 at 3:57 PM states in part Reason for visit: Hypoxic hypercarbic respiratory failure. [R9] did well on her video swallow evaluation today. She is not short of breath reportedly but is still requiring 4L of nasal cannula oxygen to maintain her sats over 89%. She is coughing intermittently but producing minimal sputum.It is important to note that R9 received IV antibiotics throughout their hospitalization.R9 returned to the facility on 5/28/26.On 6/17/26 at 9:24 AM, Surveyor interviewed R9. Surveyor asked R9 what time they like to have their BiPAP put on, R9 stated between 8:00 PM- 9:00 PM. Surveyor asked R9 if they have ever had it put on at 5:30 PM, R9 stated no.On 6/17/26 at 1:34 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B when they became aware of R9's aspiration event from 5/24/26, DON B stated that they were not aware of an aspiration event occurring on 5/24/26, because there was no documentation indicating an aspiration event and they were not contacted. DON B stated that they read the nurse's note on 5/25/26 and then became aware of an aspiration event. Surveyor asked DON B if they would expect a change of condition to be documented timely, DON B stated yes. Surveyor asked DON B if the provider was updated on 5/24/26, DON B stated not that they were aware of. Surveyor asked DON B if the provider should have been updated, DON B stated yes. Surveyor and DON B reviewed LPN U's late documentation from 5/24/26. Surveyor asked DON B what R9's vital signs were at that time, DON B stated that there was none documented. Surveyor asked DON B how changes of condition are reported shift-to-shift, DON B stated that they have a 24-hour board that changes are put on. Surveyor asked DON B if this event was put on the 24-hour board, DON B stated they would have to look. Surveyor asked DON B if R9's change of condition should have been passed on to the next shift and respiratory assessments should have been completed, DON B stated yes.It is important to note that DON B did not provide Surveyor with any documentation from the 24-hour board regarding this event.R9 had a change of condition and the facility failed to ensure that a complete assessment was performed, the physician was notified, and ongoing monitoring was facilitated, resulting in R9 having a 3 day hospital stay requiring IV antibiotics.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect 36 of 36 residents. Infection control concerns:The facility's employee line list is not inclusive and does not document and track employee symptom onset, well date, last day worked, and date may return to work.Surveyor observed NS H (Nursing Scheduler) delivering linens to resident rooms with the cart uncovered.Surveyor also observed boxes of gloves on the same linen cart touching towels, washcloths, chux (washable bed pads), and gowns. As evidenced by:The facility policy, Handling Clean Line, undated, documents in part, as follows: It is the policy of this facility to handle, store, process, and transport clean linens in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. Linen includes sheets, blankets, pillows, towels, washcloths, and similar items from departments such as nursing, dietary, rehabilitative services, beauty shops, and environmental services. 2. Linen can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands.5. Guidelines for the storage of clean linen include, but are not limited to, the following.a. Clean linen shall be delivered to resident care units on covered linen carts with covers down. The facility policy, Employee Work Restrictions - Infectious Disease, undated, documents in part, as follows: It is our policy to take appropriate precautions to prevent transmission of infectious agents. Employees with a communicable disease or infected skin lesion will be prohibited from working if direct contact with residents or their food will likely transmit the disease. 3.it is the responsibility of the employee's supervisor, or the supervisor on duty, to make determinations regarding work-restrictions, depending on the circumstances. The designated Infection Preventionist may be consulted to provide guidance in decision-making. 4. In the absence of state and local regulations, CDC (Centers for Disease Control) guidelines will be utilized in determining work restrictions. 5. Employees who are restricted from work shall remain away from work until no longer contagious or cleared by a medical provider as needed. Example 1Surveyor reviewed infection control log from March 2026 to Present (June 2026) and noted the following: Dietary I - Date called off (3/2/26) Symptoms (Vomiting) Date of return: (3/5/26)Dietary J Date called off (3/5/26) Symptoms (Vomiting) Date called off (3/5/26) Date of return (3/10/26)CNA K (Certified Nursing Assistant) Date called off (3/13/26) Symptoms (Headache, scratchy throat) Date of return (3/16/26)Dietary I - Date called off (3/17/26) Symptoms (Diarrhea) Date of Return (3/21/26)NS H (Nursing Scheduler) Date called off (3/30/26) Symptoms (Headache, sneezing) Date of return (3/31/26)Med Tech L (Medication Technician) Date called off (4/6/26) Symptoms (Sore throat, fever) Date of return (4/8/26)Activities M Date called off (4/14/26) Symptoms (Congestion) Date of return (4/16/26) Med Tech N Date called off (5/8/26) Symptoms (Vomiting) Date of return (5/10/26)Front Desk O Date called off (6/2/26) Symptoms (Headache, ear ache, sore throat, sweats) Date of return (6/4/26)CNA P Date called off (6/5/26) Symptoms (Congestion, cough, headache) Date of return (6/8/26)CNA Q Date called off (6/15/26) Symptoms (Vomiting, nausea) Date of return: ----Of note: The facility's employee line list is not inclusive and does not document and track employee symptom onset, well date, last day worked, and date may return to work.On 6/17/25 at 1:40 PM and 2:15 PM, Surveyor spoke with ADON/IP C (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP C how long staff should be off work when ill (e.g. fever). ADON/IP C stated 24 hours without fever reducing medication and 48 hours for GI (vomiting, diarrhea). Surveyor asked ADON/IP C if she tracks employee symptom onset date. ADON/IP C stated, no. Surveyor asked ADON/IP C if she tracks employee well dates. ADON/IP C stated, no. Surveyor asked ADON/IP C if she tracks employee last day worked. ADON/IP C stated, no. Surveyor asked ADON/IP C if she tracks the date an employee may return to work. ADON/IP C stated, no. Surveyor asked ADON/IP C if she should be tracking employee symptom onset, well date, last day worked and date may return to work. ADON/IP C stated, yes. ADON/IP C stated, she recently took over Infection Control and will track these moving forward. ADON/IP C stated she will also be tracking any ill employee physician visit notes and if there is any testing such as influenza or covid. Surveyor asked ADON/IP C, would any other staff member have this information such as HR (Human Resources). ADON/IP C stated, she would check and get back to Surveyor. ADON/IP C stated that HR does not have any additional detail to add to the Infection Control line list information.Example 2:On 6/15/26 at 2:33 PM, Surveyor observed NS H (Nursing Scheduler) delivering linens on 3rd floor with an uncovered two (2) tiered laundry cart. The top shelf contains towels, washcloths, chux pads, and gowns all touching boxes of gloves. The bottoms tier contains chux pads and gowns. Surveyor asked NS H, should the linen cart be covered while delivering linens on the unit. NS H stated, yes. Surveyor asked NS H, is it acceptable to have supplies on the clean linen cart touching the linens. NS H stated, she can find the answer however, this is usually the way it is done. Surveyor asked NS H, why is it important to have the linen cart covered and not having supplies in the clean linen cart touching the clean linen. NS H stated, Infection. On 6/17/25 at 1:40 PM and 2:15 PM, Surveyor spoke with ADON/IP C (Assistant Director of Nursing/Infection Preventionist). Surveyor asked ADON/IP C, should the linen cart be covered when delivering linens on the units. ADON/IP C stated, yes. Surveyor asked ADON/IP C, if it is acceptable to have supplies (e.g. boxes of gloves) on the linen cart in direct contact with clean linens. ADON/IP C stated, no, supplies should not be on the same shelf or touching clean linens.

Based on interview and record review, the facility did not ensure written bed holds were completed for 4 of 6 residents (R1, R2, R4 and R19) reviewed for bed holds out of a sample of 16. R1 was transferred to the hospital. The facility did not provide written bed hold notice to R1 and/or R1's resident representative. R2 was transferred to the hospital. The facility did not provide written bed hold notice to R2 and/or R2's resident representative. R4 did not receive a bed hold notice prior to going to the hospital. R19 was sent to the hospital for a change of condition and the facility failed to provide a bed hold. Findings include: The facility's Bed Hold Notice policy, dated 2025, includes, in part: Policy: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. Policy Explanation and Compliance Guidelines: 1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or the resident representative written information that specifies: a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;. c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. 2. In the event of an emergency transfer of a resident, the facility will provide written notices of the facility's bed-hold polices to the resident and/or the resident representative within 24 hours. 3. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record. Example 1: R1's medical record indicated R1 was sent to the hospital on 5/10/26. R1's medical record did not contain written bed hold notice. On 6/17/26 at 1:29 PM, Surveyor interviewed CNO D (Chief Nursing Officer) who indicated that there were no bed holds for R1 for that date. Example 2: R2's medical record indicated R2 was transferred to the hospital on 2/27/26. R2's medical record did not contain a written bed hold notice. On 6/17/26 at 1:29 PM, Surveyor interviewed CNO D (Chief Nursing Officer) who indicated that there were no bed holds for R2 for that date. Example 3: R4 was hospitalized on [DATE]. A bed hold notification was not found in R4's medical record. On 6/17/2026 at 1:12 PM CNO D (Chief Nursing Officer) approached surveyors and indicated the facility did not have a bed hold for the 3/13/26 hospitalization. Example 4: R19 was hospitalized on [DATE]. A bed hold notification was not for in R19's medical record. On 6/17/26 at 8:18 AM, NHA A (Nursing Home Administrator) reported to Surveyor that R19 did not have a bed hold. On 6/18/26 at 8:45 AM, Surveyor interviewed SW E (Social Worker) about bed hold notices. SW E indicated that the admissions nurse gets the initial bed hold on admission, and that a copy of the bed hold notice should go with each resident when they go out to the hospital. SW E stated that the bed hold notice should be included with the other transfer paperwork and given to the resident in their transfer folder. SW E indicated that the facility should keep a copy of the bed hold notice for the resident's medical record.

Based on record review and interview, the facility did not ensure laboratory services were obtained as ordered by the physician for 1 of 3 residents (R19) reviewed for laboratory services out of 16 sampled Residents. R19's laboratory orders were not carried out as ordered. Evidenced by: R19 was admitted to the facility on [DATE] with diagnoses that include alcohol dependence, history of a stroke, toxic encephalopathy, vascular dementia, and adjustment disorder with anxiety. R19 is being seen by a behavioral health Nurse Practitioner (NP). On 6/9/26, the facility had a Quarterly Psychotropic Review. Documentation states in part: Medication.depakote, olanzapine. Target Behavior: 1. Paranoid Behaviors. 2. Agg-Abuse behave (behavior). Paranoia beh- accusatory of theft etc. at home in past. Depakote lab ordered for levels. Surveyor reviewed R19's electronic health record and did not find documentation of the behavior meeting or orders for labs to be drawn. On 6/16/26 at 2:55 PM, Surveyor interviewed Behavioral Health NP Y (Nurse Practitioner). NP Y reported that they had a behavior meeting with the facility on 6/9/26 and had ordered labs to be drawn prior to increasing R19's medications. Surveyor asked NP Y when the labs were to be drawn, NP Y stated on the facility's next lab day.On 6/16/26 at 3:19 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B when R19's labs that were ordered on 6/9/26 were drawn, DON B stated that they would call the lab. DON B reported that the facility's lab draws are done on Mondays and Thursdays. DON B called the lab with Surveyor present and found that R19 has not had any labs drawn since the behavior meeting on 6/9/26.DON B provided Surveyor with written communication from the facility/ provider Huku app stating in part . 6/9/26 at 1:00 PM We need Depakote, CMP (Complete Metabolic Panel) & CBC (Complete Blood Count) level on resident. [Behavioral Health NP Name] wants to increase resident's Depakote. 6/9/26 at 2:23 PM [Primary NP Name] Noted, please add to 6/11 lab day.On 6/16/26 at 5:45 PM, R19's Nurses note states in part: Labs drawn to left hand x1 stick. CBC, CMP and Depakote level. Resident tolerated fair. No bruising or active bleeding noted.On 6/17/26 at 10:59 AM, Surveyor interviewed DON B. Surveyor asked DON B who participated in R19's behavior meeting on 6/9/26, DON B stated NP Y, the pharmacist, the Social Worker, and that they couldn't remember if they were there or not. Surveyor asked DON B who is responsible for entering the orders that were given during the meeting, DON B stated that NP Y sends the recommendations, the Social Worker gets them and is supposed to pass them to myself. Surveyor asked DON B what happened with R19's labs, DON B reported that they didn't get done but were obtained yesterday (6/16/26). Surveyor asked DON B if the orders were put in prior to yesterday, DON B stated no. Surveyor asked DON B if the provider was made aware that the labs were not obtained as ordered, DON B stated no.

Based on interview, and record review, the facility did not ensure each resident received the necessary respiratory care and services that are in accordance with professional standards of practice for 1 of 1 resident reviewed (R9) out of a total sample of 16.R9 has orders for a BiPAP (a noninvasive ventilatory device that helps patients breathe by delivering two levels of air pressure: higher during inhalation and lower during exhalation) that has not been applied properly and that CNA (Certified Nursing Assistant) staff were not trained to apply, Evidenced by:The facility's policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) no date, states in part .2. The facility will obtain an order for the use of CPAP, BiPAP, AVAPS, or Trilogy device and settings from the practitioner.5. The facility will follow manufacturer's instruction for use of the machine.The manufacturer's manual for R9's BiPAP machine ([NAME] DreamStation) states in part .Personnel qualifications: .The operator should read and understand this entire manual before using the device.Oxygen: When administering fixed-flow supplemental oxygen, the oxygen concentration may not be constant. The inspired oxygen will vary, depending on the pressures, patient flows, and circuit leak. Substantial leaks may reduce the inspired oxygen concentration to less than the expected value. Appropriate patient monitoring should be used. Supplemental oxygen: Oxygen (up to 15 LPM (Liters Per Minute) maybe entrained into the patient circuit provided that a pressure valve us used.R9 admitted to the facility on [DATE] with diagnoses that include hypertensive heart disease with heart failure, type 2 diabetes mellitus, chronic respiratory failure with hypoxia, and obstructive sleep apnea.R9's most recent MDS (Minimum Data Set) dated 6/15/26 states that R9 has a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating that R9 is cognitively intact. R9's MDS also indicates that she is dependent on staff for most of her ADLs (Activities of Daily Living) including bed mobility, transfers, personal hygiene, toileting, and bathing.R9's physician orders state the following:3/31/23: Place BiPAP at settings of S mode 12/5 with 30% FIO2 (the proportion of oxygen in the gas mixture that a person breathes in) which is 3L nc (nasal cannula) connected into BiPAP machine. Verify Distilled water is in resivoir [sic].5/28/26: BIPAP: Apply Bipap per settings with 3L bleed in. Assist resident to apply mask at HS (bedtime). Ensure unit is in working order. At Bedtime. Bleed in 3L, connected to Bi-pap machine. VERIFY DISTILLED WATER IS IN RESIVIOR [sic].R9's April 2026 MAR/TAR (Medication Administration Record/Treatment Administration Record) states that R9's BiPAP was signed out by a Med Tech 5 out of 21 opportunities.R9's May 2026 MAR/TAR states that R9's BiPAP was signed out by a Med Tech 4 out of 28 opportunities.R9's care plan states in part .Problem: Problem Start Date:10/25/2021. Requires Bi-pap at noc (night) r/t (related to) dx (diagnosis): chronic/acute respiratory failure and sleep apnea.Approach: .Approach Start Date: 9/7/2022. Place Bi-pap at settings of S mode 12/5, with 30% FIO2 which is 3/liters nc connected to Bi-pap machine. Observe oxygen precautions.It is important to note that there have not been any updates to R9's BIPAP care plan after their hospitalizations.Surveyor reviewed the facility's competency checklist for RNs (Registered Nurses,) LPNs (Licensed Practical Nurses,) and CNAs (Certified Nursing Assistants) - the facility does not have competency/trainings for staff regarding BiPAP use.On 4/14/2026 at 8:59 AM Nurses note states in part: Resident sent to [Hospital Name] ED (Emergency Department). Reported around 0700 that resident was combative while getting up for breakfast which is abnormal for her. Resident did not eat or drink anything at the breakfast table which is also abnormal. Upon observation at dining table, resident confused, slurred speech and not making sense. Lethargic, arms and neck flaccid. BP (Blood Pressure) 148/108 RR (Respiratory Rate) 16 T (Temperature) 97.7 O2 (Oxygen) 92%ra (room air) P (Pulse) 74. [DON Name], DON (Director of Nursing) aware, [Nurse Practitioner Name], APNP (Nurse Practitioner) aware, awaiting response from [POA Name] POA (Power of Attorney) .On 6/17/26 at 7:54 AM, Surveyor interviewed LPN G (Licensed Practical Nurse.) Surveyor asked LPN G about R9 and what occurred on 4/13/26-4/14/26, LPN G reported that they worked until 6:00 PM on 4/13/26 and they were monitoring R9 for confusion. LPN G stated that R9 had not gone to bed before they left so they passed onto the next shift that R9 would need her BiPAP put on. LPN G stated that when they came in the next morning, R9 did not have her BiPAP on.R9s note on 4/15/26 at 8:25 AM states in part: SW spoke with resident's mother this am regarding hospitalization. [Mother's Name] stated that resident is intubated and in ICU.It is important to note that facility documentation states that the Med Tech signed out R9's BiPAP on the TAR on 4/13/26.Hospital documentation states in part, the following:R9's note on 4/14/26 at 2:58 PM, History and Physical: [R9's Name, age] developmentally disabled [R9's gender].[R9's gender] has a chronic hypercapnic respiratory failure and is on Bipap all noight [sic] but noi [sic] extra O2 and no O2 during the day .I am told that [R9's gender] did not wear her Bipap last night and when staff checked on [R9's gender] the AM (morning), [R9's gender] was not responsive. [R9's gender] was brought to the [Hospital Name] ED and placed on Bipap but had significantly respiratory acidosis but did not awaken. Eventually, after discussion with the family [R9's gender] was intubated with the guidance of Anesthesia.Hospital lab results dated 4/14/26 at 9:46 AM:pH Venous 7.31 (L(Low))- blood is more acidic than average.pCO2 Venous 72 (HH (High))- indicates hypercapnia - an abnormally high level of carbon dioxide in the blood.pO2 Venous 57 (H)Bicarbonate Venous 36 (H)- indicator of the metabolic component of acid-base balanceO2 Saturation Venous 86%BE (Base Excess) Venous 7.2 (H)- indicates a metabolic alkalosisCO2 Total Venous 39 (H)- blood has a higher-than-normal bicarbonate contentHospitalist Discharge summary dated [DATE] at 11:47 AM states in part .Discharge Diagnoses: Acute respiratory failure with hypoxia and hypercapnia, acute hypoxemic respiratory failure.Hospital Course: [R9 Name, Age, Gender] with a history of chronic hypercapnic respiratory failure (BiPAP dependent at night), morbid obesity, sleep apnea, congenital hydrocephalus with VP shunt, myelopathy, and prior neck and back surgeries, who was admitted for acute respiratory failure with hypoxia and hypercapnia after being found unresponsive at [R9's gender] care facility following a missed BiPAP session. On admission, she was noted to have significant respiratory acidosis and altered mental status, prompting initiation of BiPAP in ED, followed by intubation for persistent hypoventilation and lack of improvement.[R9's gender] was managed in the ICU (Intensive Care Unit) with mechanical ventilation, sedation, and empiric antibiotics (used when a patient shows signs of infection, but the specific bacterium, fungus, or other pathogen has not yet been confirmed through laboratory tests or cultures).During her ICU course, she developed acute kidney injury, which is improved with supportive care and diuresis.Ventilator weaning was attempted over several days, with extubation to nasal cannula on 4/18 after successful trials of pressure support and clinical improvement. Post- extubation, she required BiPAP at night and supplemental oxygen during the day.R9 returned to the facility on 4/23/26.It is important to note that there have not been any updates to R9's BIPAP care plan after their hospitalizations.On 5/24/26 at 5:30 PM, Nurses note states in part: Writer was alerted to the hallway by CNA (Certified Nursing Assistant), CNA stated resident turned blue in DR (Dining Room), at that time resident was sitting in WC (wheelchair) being taken to room, resident alert, no coughing, no SOB (Shortness of Breath), no c/o (complaints), no Blue tinge noted. Writer made observation on resident, lungs diminished, no SOB, VSS (Vital Signs Stable), Afebrile, asked resident if she was ok, resident responded I'm fine, that's normal for me, that's my color, I have rocasea [sic] Resident assisted back to room, went to sleep with BIPAP on, no further c/o noted or reported.It is important to note that this note was entered on 6/16/26. Additionally, there were no vital signs documented on 5/24/26.5/25/26 at 11:04 AM: Resident blue/grey to face this morning upon writer walking into room to assist with hoyer transfer. Resident started bobbing head slightly. Resident had no complaints of SOB. No loss of consciousness. Alert and oriented x 4 still. SPO2 (oxygen level) was at 48%. Put her on 4L (liters) via nasal cannula and SPO2 increased to 85%. Writer seen that oxygen was not connected to her bipap machine last night. Lungs diminished posterior and anterior in all lobes. She has developed a wet productive cough. Writer was notified by staff that resident had aspiration event last night during dinner and turned blue to the face. She was afebrile 98.4 and BP (Blood Pressure) 131/70. Pulse 111. RR (Respiratory Rate) 20. Oak medical was updated. Agreed with sending out via 911. 911 was called and EMS (Emergency Medical Service) arrived and resident was put on 8L via non re-breather mask. SPO2 increased to 96%. Resident requesting to be sent to SSM Janesville. Writer asked resident if she wanted writer to call her mother and she said only if she is admitted to the hospital. Resident was transferred to stretcher via hoyer and left via ambulance. Call placed to SSM Janesville ER (Emergency Room) and resident will be admitted for aspiration pneumonia and placed on IV ABX (Intravenous Antibiotics). Residents mother arrived to facility just now and was updated on resident. DON notified of residents send out/being admitted .On 6/17/26 at 3:15 PM, Surveyor interviewed LPN U and asked LPN U to explain the events of 5/24/26 regarding R9. LPN U stated that they were sitting at the nurse's station and the CNAs reported that R9 was turning blue. LPN U reported that they went to see R9 and they were sitting in front of their room, and they asked R9 what was going on. LPN U stated that R9's lungs were diminished, R9 had a cough, took vital signs and R9 was then put to bed. LPN U stated that R9 looked fine when they saw them. LPN U stated that R9 reported that they were that color because they had rosacea. Surveyor asked LPN U if rosacea turns skin blue, LPN U stated no, but R9 was not blue when they saw them. Surveyor asked LPN U if that means that the event did not occur, LPN U stated no. Surveyor asked LPN U if they notified the physician about the event, LPN U stated no because when they saw R9 they were fine and that did not need to be reported to the physician. Surveyor asked what R9's vital signs were at that time, LPN U stated that they did not know because they did not document them. Surveyor asked LPN U if R9's aspiration event was documented on the 24-hour board, LPN U stated no. Surveyor asked LPN U who applies R9's BiPAP at night, LPN U stated that it was either themselves or the CNAs. Surveyor asked LPN U if they knew if the CNAs had been trained on BiPAP, LPN U stated that they did not know. Surveyor LPN U if when they checked on R9 that night, did they have the BiPAP on, LPN U reported that they put it in their note, but are not sure if it was on.Hospital documentation states in part:5/25/26 at 11:20 AM: Hospitalist admission History and Physical.Chief Complaint: Hypoxia.History of present illness: Patient is a [R9 age and gender] with a history of Chronic hypercapnic respiratory failure, wears BiPAP at night.who is being admitted with pneumonia (new problem).The patient was recently admitted to [Hospital Name] between April 14 and 23 for hypercapnic respiratory failure requiring intubation.Most recently, the patient has had a cough for several days. Her mom says that yesterday it sounded wet. The patient also says that whenever she eats, she has coughing. This morning when staff at her facility checked her pulse ox it was in the low 80s.She was sent to the ER where she was found to be hypoxic and hypercapnic (excessive carbon dioxide in the blood) with multilobar pneumonia (a type of lung infection that affects more than one lobe of the lungs, often causing more severe illness than pneumonia confined to a single lobe.) She was placed on BiPAP.Abnormal lab results dated 5/25/26 at 11:00 AM include:pH Arterial 7.27 (H(High)) (indicates a significant acid-base disturbance)pCO2 Arterial 79 (HH) (indicates hypercapnia - an excess of carbon dioxide in the arterial blood.)HCO3 Arterial 36.3 (H) (indicates a metabolic alkalosis or a condition where the body has retained bicarbonate).O2 Saturation Arterial 99.1 (H)BE Arterial 6.5 (H) (the blood is more alkaline than normal).CT Angio Chest Pulm (Pulmonary) Embolism (the most common and effective imaging test for diagnosing pulmonary embolism) results dated 5/25/26 state in part: .2. As before, low lung volumes are noted along with elevated diaphragms, left more than right. 3. As before, significant atelectasis is seen of the both lower lobes, along with moderate size dense pneumonic appearing consolidations with some internal air bronchograms in the both lower lobes. However, there appears to be moderate worsening in the right lower lobe and mild worsening in the left lower lobe. 4. Note is made of low density mucoid contents in the lumen of the main bronchi of both lower lobes, suggestive of either mucus impaction or obstructing lesions causing combination of aspiration and/or postobstructive pneumonia with atelectasis.XR Chest 1Vw Portable (Chest x-ray 1 view) results dated 5/25/26: Personally reviewed and shows very diminished lung volume, suspect bilateral lower lobe pneumonia. Assessment and Plan: .I suspect she has aspiration due to the history and appearance on CT. Continue BiPAP. Recheck VBG (Venous Blood Gases). Continue cefepime and vanco (antibiotics). Follow up with blood and sputum cultures. Consider Pulmonary consult tomorrow if not improved, due to appearance of significant mucus plugging on CT. Speech evaluation for aspiration once stable.Hospitalist note dated 5/26/26 at 2:52 PM states in part Reason for visit: Hypoxic hypercarbic respiratory failure. [R9] was able to come off BiPAP this morning and maintain her sats on 4L to 6L of nasal cannula oxygen.Also of note she has extremely poor inspiratory effort and deep inspiration triggers causing coughing jags are problematic for her. At baseline, her mother reports that she does not have significant cough so this is all likely new related to a recent aspiration event.Assessment and Plan: .I suspect she has aspiration pneumonia nd [sic] bronchitis due to the history and appearance on CT, baseline restrictive ung [sic] disease duet o [sic] [NAME] (Obesity Hypoventilation Syndrome), kyphosis, and atelectasis requiring Bipap at night. Continue BiPAP at night, monitor on cannula vs open mask O2 (oxygen) today. Continue cefepime.follow up blood and sputum cultures. Bronchial hygiene, incentive spirometry. Speech evaluation for silent aspiration with VSS. Dose Lasix 20 IV since held on admission.Hospitalist note dated 5/27/26 at 3:57 PM states in part Reason for visit: Hypoxic hypercarbic respiratory failure. [R9] did well on her video swallow evaluation today. She is not short of breath reportedly but is still requiring 4L of nasal cannula oxygen to maintain her sats over 89%. She is coughing intermittently but producing minimal sputum.It is important to note that R9 received IV antibiotics throughout their hospitalization.R9 returned to the facility on 5/28/26.On 6/17/26 at 7:54 AM, Surveyor interviewed LPN G and asked LPN G to explain the events that occurred with R6 on 5/25/26, LPN G stated the CNA that was providing cares for R9 asked for assistance with a transfer and reported that R9 was blue/gray in color and didn't look right. R9 was bobbing her head, pulse ox was 48% and then it jumped to 55%. LPN G stated R9 was able to answer questions and was talking to them. LPN G stated they noted that R9's oxygen concentrator was not on and was not connected to her BiPAP machine. LPN G stated they got R9 up into the wheelchair, R9 started coughing with a wet cough, oxygen was applied at 4 liters and they were unable to get R9's sats up higher. LPN G stated they called the physician and EMS for evaluation. LPN G reported that the kitchen staff reported that R9 had turned blue at dinner the night before, and it was reported to the nurse who stated that R9 was fine and walked away. Surveyor asked LPN G how a change of condition is communicated between shifts, LPN G stated that it is usually reported at change of shift, but no one had said anything about R9's aspiration event. Surveyor asked LPN G who is responsible for applying R9's BiPAP, LPN G stated that the CNAs and nurses work together and then the nurse has to check it. LPN G stated that R9 never puts her mask on early, it's usually around 10:00 PM before she is ready. LPN G reported that R9 has orders for the nurse to ensure that the O2 is bled into the BiPAP and that there is water in the reservoir.On 6/17/26 at 9:24 AM, Surveyor interviewed R9. Surveyor asked R9 what time she likes to have her BiPAP put on, R9 stated between 8:00 PM- 9:00 PM. Surveyor asked R9 if she's ever had it put on at 5:30 PM, R9 stated no.On 6/17/26 at 11:13 AM, Surveyor interviewed CNA K. Surveyor asked CNA K to explain the aspiration event with R9 on 5/24/26, CNA K reported that last night (6/16/26), the nurse called them and asked if R9 was blue, CNA K stated that R9 reported that she was fine and that they passed it on to another CNA. CNA K stated they had R9's group and reported to Surveyor that R9 didn't look right that night. CNA K stated they think the other CNA reported the incident to the nurse but is not sure and that they just left it alone. Surveyor asked CNA K who typically applies R9's BiPAP, CNA K stated the CNAs put it on. Surveyor asked CNA K what time R9 likes for the BiPAP to be applies, CNA K stated between 8:30 PM-9:00 PM. Surveyor asked CNA K on 5/24/26 was R9's BiPAP put on at 5:30, CNA K stated no, and they don't think R9 was even at bed at that time, typically R9 goes to bed late. Surveyor asked CNA K who typically applies R9's BiPAP at night, CNA K stated the CNAs do. Surveyor asked CNA K if they had been trained on how to apply a BiPAP, CNA K stated no. Surveyor asked CNA K if they connect the oxygen to the BiPAP machine, CNA K stated they assume the machine is already set up and ready to go.On 6/17/26 at 12:32 PM, Surveyor interviewed CNA P and asked CNA P to explain the events on 5/24/26 regarding R9. CNA P stated they were at the nurse's station and another CNA called and said R9 was blue so they went to see R9. CNA P stated when they got to R9, she was blue in the face. CNA P stated they ran to get the nurse and by the time the nurse got down there, R9 was not blue anymore. CNA P stated the nurse asked R9 if she was ok and R9 stated yes. Surveyor asked CNA P if the nurse did an assessment, CNA P stated they said they were going to and then walked away. Surveyor asked CNA P if they have put R9's BiPAP on at night, CNA P stated yes and that they know how to put a C-PAP on. Surveyor asked CNA P if they had training on how to apply R9's BiPAP, CNA P stated they haven't been trained at this facility but have been trained at another and they know how to put a C-PAP on.It is important to note that R9 does not have a C-PAP machine.On 6/17/26 at 1:21 PM, Surveyor interviewed CNA T, who is also a Med Tech. Surveyor asked CNA T if they have been trained on how to apply R9's BiPAP, CNA T stated no. Surveyor asked CNA T if the CNAs and Med Techs typically apply R9's BiPAP at night, CNA T stated 100% of the time.On 6/17/26 at 1:34 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B when they became aware of R9's aspiration event from 5/24/26, DON B stated they were not aware of an aspiration event occurring on 5/24/26, because there was no documentation indicating an aspiration event and they were not contacted. DON B stated they read the nurse's note on 5/25/26 and then became aware of an aspiration event. Surveyor asked DON B if they would expect a change of condition to be documented timely, DON B stated yes. Surveyor asked DON B if the provider was updated on 5/24/26, DON B stated not that they were aware of. Surveyor asked DON B if the provider should have been updated, DON B stated yes. Surveyor and DON B reviewed LPN U's late documentation from 5/24/26. Surveyor asked DON B what R9's vital signs were at that time, DON B stated there were none documented. Surveyor asked DON B how changes of condition are reported shift-to-shift, DON B stated they have a 24-hour board that changes are put on. Surveyor asked DON B if this event was put on the 24-hour board, DON B stated they would have to look. Surveyor asked DON B if R9's change of condition should have been passed on to the next shift and respiratory assessments should have been completed, DON B stated yes. Surveyor asked DON B who is responsible for applying a BiPAP to a resident, DON B stated the nurses. Surveyor asked DON B if the CNAs/Med Techs have had training on how to apply a BiPAP, DON B stated not since they have been at the facility.On 6/18/26 at 8:18 AM, CNO D (Chief Nursing Officer) reported to Surveyor that there are no CNA competencies for BiPAP/C-PAP.On 6/16/26 at 8:25 AM, Surveyor interviewed CNA W and asked if they have ever applied R9's BiPAP, CNA W stated yes. Surveyor asked CNA W to explain the process, CNA W stated there are 3 parts - the mask set up, the CPAP, and the oxygen. CNA W stated they have to make sure that the oxygen is attached but believes that they are waiting for a part. Surveyor asked CNA W if they have received any training from the facility about BiPAPs, CNA W stated no.On 6/18/26 at 8:32 AM, Surveyor interviewed CNA Q and asked if they got R9 up for the day, CNA Q stated yes. Surveyor asked V to explain what R9's BiPAP set up looked like this morning, CNA Q stated it was strapped on her face, and she had the oxygen on underneath it. Surveyor asked CNA Q if the oxygen tube was connected to the BiPAP, CNA Q stated no and that R9 had the nasal cannula on under the mask. Surveyor asked CNA Q if they have received any training on BiPAP machines, CNA Q stated no.On 6/18/26 at 8:43 AM, Surveyor interviewed DON B. Surveyor asked DON B if a resident on BiPAP should have a nasal cannula attached to the oxygen concentrator underneath the BiPAP mask, DON B stated no because there would not be a good seal. Surveyor asked DON B if having the nasal cannula attached to the oxygen concentrator be considered and oxygen bleed to the BiPAP machine, DON B stated no.On 6/18/26 at 9:59 AM, Surveyor interviewed RT X (Respiratory Therapist-from DME (Durable Medical Equipment) provider). Surveyor asked RT X what a BiPAP set up should look like, RT X stated that there should be oxygen to the machine, then a corrugated line with oxygen adapter, then the mask is placed on the resident. RT X stated that there should be an adapter for oxygen, and the oxygen tubing connects the BiPAP to the oxygen concentrator. Surveyor asked RT X if there would ever be a time to use a nasal cannula under the BiPAP mask, RT X stated no because you wouldn't get a good seal.The facility did not ensure that nursing staff had proper training to apply a BiPAP to R9. cross reference F684.

Based on interview and record review, the facility did not ensure that a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 2 residents out of a sample of 16 Residents (R40). The facility was not walking R40 in accordance with her plan of care. This is evidenced by: Facility policy titled Restorative Nursing Programs, dated 2025 states, in part: Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practical level. Policy Explanation and Compliance Guidelines: . 3. Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of qualified therapist or licensed nurse oversight. This training may include but is not limited to: . c. Encouraging residents to remain active and assisting with any exercises according to the plan of care. 7. Residents may receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitation therapy. 11. The discharging therapist. will communicate to the appropriate restorative aide, the provisions of the resident's restorative nursing plan. 12. Restorative aides will implement the plan. R40 was admitted to the facility on [DATE] with diagnoses that include, in part: Muscle wasting and atrophy, not elsewhere classified, multiple sites, Muscle weakness, generalized, Unsteadiness on feet, Repeated falls, Adult failure to thrive, and Pain disorder with related psychological factors. R40's most recent Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 4/30/26 documented that R40 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R40 is cognitively intact. R40's Care Plan, initiated on 5/7/24, with last edit date of 4/12/26, includes, in part: Problem: Transfers from another SNF for long term care placement. Assistance is needed with all ADL's (Activities of Daily Living) d/t (due to) increased weakness. Goal: Resident will ambulate to/from room to dining area with 1 assist and walker. Target Date: 7/9/26.Approach: Walking calendar on table in room for staff to sign after ambulating [Resident Name]. Start Date: 7/9/25. Transfers/ambulates with 4WW (wheeled walker) ad lib in room. 1 assist when walking outside of room. Cues for upright posture and slower gait speed for improved control. Start Date: 6/12/25. R40's Basic CNA Care Plan, dated 8/7/24, with last edit date of 4/12/26, includes, in part: .Mobility: Propels W/C (wheelchair) per self. Ambulate in hallways with staff assist and 4 wheeled walker. Cues for upright posture and slower gait speed for improved control. Walking calendar on table in room for staff to sign after ambulating [Resident Name]. R40's Physical Therapy Treatment Encounter Notes, dated 4/29/26, states, in part: . Writer will care plan walking program for pt (patient) to maintain strength and mobility. R40's Rehab Plan of Care Changes for Nursing, dated 4/29/26, states, in part: . to walk 2-3 times a day, distance as tolerated, assist needed: 1. R40's General Administration History indicates, in part: Document how far resident ambulates in halls with staff.-on June 2, 2026, a zero is documented for ambulation-on June 6, 2026, a zero is documented for ambulation-on June 8, 2026, a zero is documented for ambulation R40's Point of Care History indicates, in part: Walk 10 feet-36 shifts marked Not Applicable in May, 2026-18 shifts marked Not Applicable in June, 2026 R40's Walking Calendar, kept in the room, to be signed by the CNAs (Certified Nursing Assistants) after ambulating with R40, indicated:-15 blank days with no ambulation-3 days marked AM/day shift ambulation On 6/15/26 at 9:45 AM, Surveyor interviewed R40 who stated that she's supposed to be walking every day, but that staff don't always do it. R40 indicated that sometimes days go by, and no one walks with her. R40 stated that she has had a fall recently and that she feels better and gets stronger when staff walk with her according to her walking plan. On 6/16/26 at 10:18 AM, Surveyor interviewed CNA Q (Certified Nursing Assistant) about R40's walking program. CNA Q stated that R40 likes to walk daily and that staff sign the calendar in her room after they walk with her, as well as documenting it in the electronic health record. Surveyor asked CNA Q how often staff are to be walking with R40. CNA Q stated that she thought it was every shift. Surveyor asked CNA Q if R40 ever refused to walk with staff. CNA Q stated that R40 had a fall a few months ago and she might have refused a few times then, but now she is very eager to do therapy and get better with walking. CNA Q indicated that R40 is very motivated and is improving in her mobility with consistent walking with one assist of staff. Surveyor asked if there were times when there weren't enough staff scheduled to take R40 for her walks. CNA Q indicated that yes, sometimes staff is unable to get to taking R40 for her walks, especially on days when there is less staff. CNA Q stated that after R40's fall she had been depressed and refusing to get out of bed because of pain, but now she is really active, always on the go, out of her room and wanting to walk. CNA Q indicated that if staff don't go and ask R40 if she wants to walk, she will put on her call light and ask them if they have time to walk with her. On 6/16/26 at 10:25, Surveyor interviewed CNA R about R40's walking program. CNA R stated that R40 was being walked once a day, and it was documented on the room calendar and in the electronic health record. CNA R indicated that R40 never refuses to do her walks, and that she is eager to walk and always ready to go. CNA R stated that R40's mobility has gotten slightly better when staff are consistent with walking with her. On 6/17/26 at 3:07 PM, Surveyor interviewed CNA T about R40's walking program. CNA T indicated that R40 is to be walked with staff 15 minutes once a shift. CNA T indicated that R40 never refused to walk with staff, except when she had a fall and was in pain, but not recently. CNA T stated that R40's mobility has gotten better with her walking consistently. On 6/16/26 at 10:28 AM, Surveyor interviewed LPN S (Licensed Practical Nurse) about R40's walking program. LPN S stated that she thought R40 was to be walked twice a day, although in the computer it noted only once a day. LPN S stated that after R40 had a fall she had some pain and refused to walk a few times but since she has been going to therapy, she has been eager to walk daily. LPN S stated that R40 is now at least back to her baseline or maybe a little better since she has been walking daily. On 6/16/26 at 11:29 AM, Surveyor interviewed PT F (Physical Therapist Manager) about R40's walking program. PT F indicated that R40 was discharged from PT on 4/29/26. PT F stated that the facility does not have a restorative aide, so she wrote a care plan for R40 to walk with the CNAs as a maintenance type program to prevent a decline in mobility. PT F stated that right after R40 fell she was refusing to walk with staff, so they admitted her back into PT and now she is back to baseline from prior to the fall. PT F stated it was her expectation that R40 ambulate in the hallway with staff each day per her walking plan of care. PT F stated she was unsure why her electronic health record stated to walk only once daily, instead of 2-3 times a day as she had ordered. PT F indicated that she had staff using the calendar in R40's room to remind her of when she was walked last, so she wouldn't forget. On 6/17/26 at 2:16 PM, Surveyor interviewed DON B (Director of Nursing) about R40's walking program. DON B indicated that when PT writes a plan of care for a resident's walking, they give a copy to the floor nurse who is responsible for entering them into the electronic health record. DON B indicated that she would expect that R40's electronic health record would have been updated with her current treatment plan, and she would expect the therapy plan of care to be followed.

Based on interview and record review, the facility did not follow through with the appropriate steps of the PASARR (Preadmission Screening and Resident Review) process for 3 of 5 residents (R6, R7, and R27) reviewed for PASARR screening. R6 did not have a level II PASARR screening completed. R7 did not have a level II PASARR screening completed. R27 was admitted with diagnoses that include schizophrenia and anxiety disorder and was prescribed medications to treat the symptoms of schizophrenia and anxiety. No PASARR 1 or PASARR 2 was completed. Evidenced by: The facility policy, Resident Assessment – Coordination with PASARR Program, indicates, in part: Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to the facility will be screened for serious mental disorders (MD) or intellectual disabilities (ID) and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR level I – initial prescreening that is completed prior to admission i. Negative Level I Screen – permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen – necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II – a comprehensive evaluation by the appropriate state-designed authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs.3. A record of the pre-screening shall be maintained in the resident's medical record.4. Exceptions to the preadmission screening program, dependent upon State requirements, include those individuals who: .b.has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. 5. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have had MD, ID, or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. Example 1 R7 was admitted to the facility on [DATE] with diagnoses, that include, in part: Major Depressive Disorder; Anxiety Disorder; and Depression. Surveyors reviewed R7's Level I PASARR screening which indicated the facility answered Yes to Does the person have a major mental disorder. Surveyors requested documentation for a Level II PASARR. On 6/16/26 at 1:28PM NHA A (Nursing Home Administrator) informed surveyors that the previous social worker did not complete a Level II screening for R7 and they ran the Level II today. Example 2: R27 was admitted to the facility on [DATE] with diagnoses that include schizophrenia and anxiety disorder. PASARR Level 1 Screen was completed on 7/11/25 and was marked as .Hospital Discharge Exemption- 30 Day Maximum: YES. Surveyor requested documentation of PASARR completion for R27. On 6/17/26 at 4:49 PM, NHA A (Nursing Home Administrator) reported that R27 had a 30- day exemption filled out, so it did not trigger for them to complete another PASARR. Surveyor asked NHA A if R27 should have had a PASARR completed, NHA A stated yes. Example 3: R6 was admitted to the facility on [DATE] with diagnoses, that include, in part: Adjustment disorder with anxiety, and Generalized anxiety disorder. Surveyors reviewed R6's Level I PASARR screening which indicated the facility answered No to Does the person have a major mental disorder. On 6/18/26 at 9:51 AM, Surveyor interviewed NHA A (Nursing Home Administrator and requested documentation of a Level !! PASARR. NHA A stated that they didn't have one and should have done one. NHA A indicated that she would be re-doing it today.

Based on interview and record review, the facility did not ensure their abuse policy was implemented for 1 of 8 employees reviewed for background checks. The facility did not complete the Background Information Disclosure (BID) form, Integrated Background Information System (IBIS) and Department of Justice (DOJ) upon hire and every 4 years thereafter for LPN G (Licensed Practical Nurse). Findings include:The facility policy entitled Abuse, Neglect and Exploitation, with a review date of 4/1/26. Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. A. Screening: Potential employees will be screened for history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred.During this recertification survey with an exit date of 6/18/26, Surveyor asked for background check information on LPN G. On 2/25/21, LPN G was hired by the facility. The facility did not have LPN G complete the BID (Background Information Disclosure), IBIS (Integrated Background Information System) and DOJ (Department of Justice) upon hire and 4 years thereafter. On 6/15/26 Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A if the facility has a more recent BID, IBIS and DOJ for LPN G. NHA A stated, no, there is no documentation. NHA A stated she just ran LPN G's IBIS and DOJ for Surveyor. NHA A stated LPN G's BID, IBIS and DOJ should have been completed on 2/25/25. NHA A stated that a BID, IBIS and DOJ should be run upon hire and every 4 years thereafter.

Based on interview and record review, the facility failed to provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 1 Residents reviewed (R6) this has the potential to affect 25 full code residents that reside in the facility. R6 indicated he wished his code status to be full code. R6 was found to be pulseless and not breathing. Facility staff failed to utilize life-support equipment while providing CPR on R6. Facility staff indicated the facility does not have easily accessible life-support equipment, including a backboard or Ambu bag to provide effective emergency CPR. The facility failed to have a process and procedure in place to ensure CPR certified staff members have readily available and organized life-support equipment for when a resident is found pulseless and not breathing and there is a need for emergency resuscitation. The facility's failure to provide proper basic life support, including cardiopulmonary resuscitation on a hard surface and rescue breaths, to a resident who wished to be full code created a finding of immediate jeopardy that began on [DATE]. Surveyors notified NHA A (Nursing Home Administrator), DON B (Director of Nursing), and Corporate RN Z (Corporate Registered Nurse) of immediate jeopardy on [DATE] at 3:30 PM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a severity/scope of E (Potential for Harm/Pattern) as the facility continues to implement its action plan. Evidenced by: Facility policy, titled CPR, dated [DATE], includes: It is the policy of this facility to adhere to resident's rights to formulate advanced directives. In accordance to these rights, this facility will implement guidelines regarding CPR. The facility will follow the American Heart Association guidelines regarding CPR. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and in accordance with the resident's advance directives. Highlights of the 2025 American Heart Association's Guidelines for CPR and ECC (emergency cardiovascular care) includes, in part: . For adult cardiac arrest, rescuers should perform chest compressions with the patient on a firm surface and with the patient's torso at approximately the level of the rescuer's knees . R6 admitted to the facility on [DATE] with the following diagnoses; persistent atrial fibrillation (abnormal heartbeat) , Nonrheumatic aortic (valve) stenosis (when the aortic valve of the heart narrows, and blood flow becomes obstructed), encounter for surgical aftercare following surgery on the circulatory system, aero-sclerosis (build up of plaque) of coronary artery bypass grafts with angina pectoris (chest pain), Type 2 Diabetes Mellitus, Obstructive Sleep Apnea, presence of prosthetic heart valve, long term use of anticoagulants, and presence of aortocoronary bypass graft (surgical procedure that creates a new path for blood to flow to the heart by bypassing blocked arteries), cardiac arrest due to underlying cardiac condition. R6's Hospital Discharge Notes, dated [DATE], includes: On [DATE] R6 underwent AVR (aortic valve replacement) with a 27mm (millimeter) biological valve, CABG (Coronary artery bypass surgery) times 3 . he was ambulating in the hall when he became acutely weak, hypotensive (low blood pressure). He had a code blue with loss of pulse, CPR (Cardiopulmonary resuscitation), Vfib (ventricular fibrillation – life threatening hear rhythm) with defibrillation twice and administration of Epi (epinephrine) and amiodarone. Reintubated during the code. Return of spontaneous circulation obtained after about 7 minutes of CPR. He had some delayed cognition after code blue which was much improved at time of discharge. He has intermittent pain on the left side of the chest and has palpable disruption of the sternocostal cartilage in that location, due to CPR. He was not yet at baseline mobility or mental status so discharge to skilled nursing facility for rehabilitation was recommended and agreed to by patient and spouse. R6's Nurse Notes, dated [DATE], includes: Res arrived via WC (wheelchair) van approximately 12:10 PM. Resident status post triple by-pass. Resident is alert and oriented times 4, makes needs known. Per resident wishes, code status is Full Code. R6's Vitals Log, dated [DATE], indicates R6's weight is 268 pounds. R6's Nurse Note, dated [DATE] at 2:07 AM, includes: At approximately 1:10 AM resident activated his call light. CNA (Certified Nursing Assistant) responded and witnessed resident sitting bedside, CNA reported that she asked resident (R6), what can I do for you? Resident reacted with startled body language, and then collapsed backwards in bed, did not bump head. CNA immediately called for nurse and then dialed 9-11. CPR initiated for FULL CODE STATUS. Unable to auscultate (listening to) vital signs, compressions started. Resident pale, ash colored, pupils pinpoint and fixed, unresponsive to sternal rub, tactile stimuli, and verbal stimuli. At 0120 (1:20 AM), EMT (Emergency Medical team) arrived to include [County name] Sheriff, [Name of town] Police Officer, and 7 other emergency staff (total 9 EMS (emergency medical services)). EMT transferred resident from bed to floor, performed CPR for > (greater than) 35 min, administered EPI x3 and BiCarb (sodium bicarbonate) x1 during CPR . Shock not advised during entire event. LUCAS (device that provides automated chest compressions during CPR) compressions continued until 0200 (2:00 AM). EMT then notified [Hospital name] Physician who pronounced resident Time of Death 0200 on [DATE] On [DATE] at 9:05 AM, Surveyor interviewed Agency RN C (Registered Nurse) regarding R6. RN C indicated she was on the floor working with CNA D (Certified Nursing Assistant) and RN C went down to smoke. RN C indicated when she came back up CNA D said she called 911. RN C indicated that CNA D was doing night rounds and R6 had his call light on and that R6 took a huge breath and fell backwards on the bed. RN C indicated CNA D got the nurse from the other floor, who initiated CPR (Cardiopulmonary resuscitation). RN C indicated that R6 had cardiac surgery prior to coming to the facility. RN C indicated again that CPR was started (unable to remember the nurses name) CNA D dialed 911, he was a big guy, we couldn't move him to the floor, started CPR on the bed and the rescue squad came and RN C believes they moved him to the floor. Surveyor asked RN C if they obtained a crash cart or ambu-bag, RN C indicated she believed CNA D got the cart. Surveyor asked about a backboard, RN C indicated she asked about it, and checked the mattress for a CPR cord, which the bed did not have. RN C indicated they initiated CPR on the bed due to the amount of time it would take to get the board. RN C indicated there were three staff, herself, CNA D and the nurse from upstairs. Surveyor asked RN C where the emergency items for CPR were located, RN C indicated there are a number of rooms where the cart and board are, its in a utility room down the hall. RN C indicated that by the time the CNA was to get the board EMT (emergency medical team) arrived. RN C indicated the other nurse put oxygen on him. Surveyor asked RN C about the compressions on the bed, RN C indicated they looked like good recoil and had a mask with oxygen on him. Surveyor asked RN C how many rounds of compressions were delivered before EMT's arrived, RN C was unable to say. Surveyor asked RN C, with three staff could you have rolled R6 over to put a board under, RN C indicated yes, and that she asked the CNA for a board. On [DATE] at 9:33 AM, Surveyor interviewed CNA D (Certified Nursing Assistant) regarding R6. CNA D indicated she was passing linens when R6 put his call light on, CNA D knocked and asked how she could help. CNA D indicated R6 just looked at her and started trembling and fell back on the bed. CNA D indicated her nurse was on break so she called the nurse upstairs. CNA D indicated she told the nurse upstairs that she needed a nurse now, STAT (immediately) and 911 to help. CNA D indicated she went back to the room and tried to get R6 to respond, he had a stare and would not look at her. CNA D indicated the nurse came in and checked his vitals and then started CPR. CNA D indicated the other nurse arrived so she went and called 911. CNA D indicated RN C told her to go downstairs and wait for EMS (emergency medical services). Surveyor asked CNA D if someone got a crash cart or bag, CNA D I don't think we have a jump start, Surveyor asked if CNA D meant and AED, CNA D indicated yes, haven't seen one. Surveyor asked CNA D if they had a crash cart/bag, CNA D indicated don't believe I've seen one. CNA D indicated she met the police officer. CNA D indicated while waiting for the second nurse, the nurse from upstairs started performing CPR on the bed. CNA D indicated she didn't think the bed had a CPR cord and it was a soft surface, which isn't effective based on her training. (Of note: a standard mattress would not have a CPR pull cord) On [DATE] at 12:16 PM, Surveyor interviewed CNA D a second time. Surveyor asked CNA D how she alerts staff that she needs emergency assistance. CNA D indicated they just got walkie talkies back, but that she had to use the phone at the nurses station to call the nurse as the phone for call lights does not function as a phone, it only says what room number. CNA D indicated how she gets help is by finding someone. CNA D indicated it took approximately 1 minute to get from the room to the nurse's station, then maybe 2-3 minutes to get the nurse down here before the nurse got to the resident. CNA D indicated the nurse took the elevator from 3rd floor to 2nd floor. CNA D indicated she was standing in the doorway of the room saying, hurry up, get over here. CNA D indicated R6 was still breathing when she left the room to call for help. CNA D indicated with three people they could have moved him but he was a large man. CNA D indicated she is CPR certified, did not start CPR due to R6 was still breathing while in the room when she went to get help. CNA D indicated R6 was sitting on the bed side of the bed, and fell backwards on his back with his legs still off the bed . Surveyor reviewed the Emergency Medical Services Transport Report, dated [DATE], includes:. Ambulance and Engine 312 responded for a report of pulseless non-breather, Units arrived on scene and made their way to the patient's apartment. Crews found a .male lying on a hospital bed not breathing and without a pulse. A police officer was performing chest compressions and had their AED (automatic external defibrillator, portable device that detects life threatening rhythms during CPR) placed. A rhythm check was indicated by the officer's AED as crew was moving patient to the floor. The officers AED had no shock advised. Compressions were continued until the next rhythm check. Crew began cutting off the patient's sweatshirt and t-shirt to facilitate placing cardiac monitor pads. Once the patient's chest was exposed, the officers AED pads were removed and the cardiac monitors pads were placed. A rhythm check was indicated. Once the monitor was charged, compressions were paused to assess a rhythm. An IV (intravenous- line in a vein) was attempted in the right AC (antecubital, elbow crease) without success. Staff advised that the patient had a triple bypass surgery a month prior. A rhythm check was indicated. Once the compressions were paused to assess rhythm. PEA (Pulseless Electrical Activity- a non-shockable rhythm) was noted during the rhythm check. The charge was dumped and compressions were resumed until next rhythm check. An IO (intraosseous-an emergency procedure used to gain rapid vascular access for fluid and medication administration) was attempted in the left femur but was unsuccessful. An OPA (oropharyngeal airway- a J shaped plastic device inserted into the mouth of an unconscious person who lacks a gag reflex) was placed and crew began ventilating with a BVM (bag valve mask- a handheld, manual resuscitator device used to provide positive pressure ventilation to patients who are non-breathing). An IO was attempted in the right humeral head and was successful. The patient was intubated.Placement was confirmed by end-tidal monitoring, lung sounds, and misting in the tube. A rhythm check was indicated. Once monitor was charged, compressions were paused to assess rhythm. PEA (pulseless electrical activity) was noted during the rhythm check. The charge was dumped and compressions were resumed until the next rhythm check. The LUCAS mechanical CPR device was placed and took over compressions for the duration of the call. Medical Control was called and advised of the encounter so far along with actions taken. The Medical Doctor stayed on the phone with the crew for the next two rhythm checks. The Medical Doctor advised the crew to cease resuscitation efforts. Crew stopped resuscitation efforts and notified staff members of the situation. Crew cleaned up equipment and cleared shortly after. On [DATE] at 3:50 PM CNA P (Certified Nursing Assistant), CNA Q, CNA R, LPN N (Licensed Practical Nurse), and LPN S indicated the facility does not have a crash cart or a crash kit for readily accessible emergency equipment, but it should. LPN N and LPN S indicated if a resident was found to be pulseless and nonbreathing in bed they could get the resident on the floor or put a backboard under the resident to perform CPR. LPN N and LPN S indicated they do not know if the facility has a backboard. LPN N and LPN S indicated they do not know if the facility has a crash cart. On [DATE] at 4:00 PM LPN H and CNA T indicated they were unsure if the facility had a crash cart or crash kit or readily accessible emergency equipment such as a backboard, suction machine, and ambu bag. LPN H and CNA T indicated they are unsure where these things would be located, but the facilities they previously worked at had all of these things on a cart. Surveyor asked LPN H and CNA T if there was a staff member they could ask. LPN H flagged down RN U (Registered Nurse) who indicated the facility does not have a crash cart and it does have a backboard, but it is not where it is supposed to be stored. RN U indicated she would assist Surveyor in looking for the backboard. Surveyor observed RN U use her key to unlock doors and look for a backboard. On [DATE] at 4:11 PM Surveyor and RN U observed the facility's backboard in a locked utility room at the end of the hallway. RN U indicated all staff should know where to find the facility's emergency equipment. RN U indicated the facility should have a process in place for having emergency equipment accessible for when a resident is found to be pulseless and non-breathing. On [DATE] at 8:03 AM during an interview LPN O indicated the facility does not have a crash cart or a kit with easily accessible emergency supplies. On [DATE] at 8:05 AM, Surveyor spoke with RN G. Surveyor asked RN G, if she found a resident pulseless and not breathing what would she do. RN G stated, she would yell for help (call 911) and on NOC (night) shift she would use her walkie talkie in her pocket to notify floor staff and start CPR (Cardiopulmonary Resuscitation). Surveyor asked RN G, if a resident is in bed when you find them pulseless and not breathing what do you do. RN G stated most beds are too soft to perform CPR. RN G stated, she would immediately lower the bed and slide the resident to the floor prior to starting CPR. RN G stated, it is easy to move residents to the floor as the beds at this facility lower all the way to the floor. Surveyor asked RN G, where is the crash cart located. RN G stated, As far as I known we don't have one and if we do, I don't know where it is. On [DATE] at 8:08 AM during an interview, LPN N indicated this facility does not have a crash cart or crash kit. On [DATE] at 8:15 AM, CNA M indicated if staff witness a full code resident code on the bed staff should get the resident on a backboard or onto the floor to administer CPR. CNA M indicated the facility has a board and it usually hangs in the room across from the nurse station, but it is not there now. CNA M and Surveyor observed the area with 2 wall hooks and no backboard. CNA M indicated the facility should have a bag with CPR supplies, but they don't. CNA M indicated the facility does not have a procedure for paging help if a resident codes, but she would use her radio to call the nurse. On [DATE] at 8:21 AM, CNA L indicated CPR supplies and a back board should be by the nurse station, but she has never seen them and is unsure if the facility has a crash cart. On [DATE] at 8:25 AM, CNA K indicated CPR on a soft surface such as a bed is not effective. CNA K indicated she would try to get the resident onto the floor or put a backboard behind them to administer CPR. On [DATE] at 8:30 AM, CNA J indicated she would use her walkie to get the nurse right away if she found a resident pulseless and non-breathing. CNA J indicated she would have to get resident on a hard surface like the floor to administer CPR or use the facility's back board. CNA J indicated CPR bags are in the cupboard of the nurse's station. Surveyor asked CNA J to show her the bags. CNA J and Surveyor observed the cabinet in the nurse station and there were no bags there. CNA J indicated the facility should have a crash kit where everything is easily accessible. On [DATE] at 8:50 AM, Surveyor interviewed Paramedic/Firefighter W, Paramedic/Firefighter X, EMT/Firefighter V, and Lieutenant Y, who indicated they responded to the call on [DATE] and when they arrived R6 was on a soft bed and there was no hard surface underneath R6. Paramedic/Firefighter W, Paramedic/Firefighter X, EMT/Firefighter V, and Lieutenant Y indicated they did not believe the staff had provided R6 any rescue breathing, but they did provide R6 compressions while he was on the soft bed. Paramedic/Firefighter W, Paramedic/Firefighter X, EMT/Firefighter V, and Lieutenant Y indicated compressions are generally not effective on a soft surface and that is why they immediately put R6 on the floor to administer CPR. On [DATE] at 10:17 AM DON B (Director of Nursing), SW BB (Social Worker), and Interim ADON AA (Assistant Director of Nursing) indicated they were not sure if the facility calls a code color overhead or has a procedure for getting as many staff as possible to the area if a resident were found to be pulseless and non-breathing. DON B indicated the facility does not have a crash kit with supplies all in one place for when an emergency arises. DON B indicated the facility does have a back board and she put it where it is supposed to be on one resident floor but is still trying to locate the one for the other resident floor. DON B and Corporate RN Z indicated staff should not have to run around looking for supplies when a resident is found to be non-breathing and pulseless. DON B indicated staff should have everything in one place to grab and go. DON B indicated staff are to provide rescue breaths when performing CPR and they should be getting resident on a hard surface like the floor or placing a backboard under the resident. The failure to ensure R6, a resident who had chosen to be full code, received basic life support according to current standards of practice when he was found pulseless and non-breathing, the failure of not having readily accessible emergency supplies, and the failure of not having a procedure for getting as many staff as possible to the scene when a resident is found in need of life saving efforts created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when the facility completed the following: ~Charts were audited for similar instances going back through [DATE]. No other residents were impacted by this incident nor were other like incidents identified evidenced by review of other resident deaths that occurred in the facility. This review occurred on 4.30.26 by the Chief Nursing Officer. ~All nursing staff are to be educated on expectations to perform CPR in accordance with professional standards of practice, to include placing the resident on a hard surface or using a back board, to provide ventilations or rescue breaths along with compressions. Education began on 4.30.26 and will continue for each nurse before they work their next shift ~All nursing staff are to be educated on the CPR policy and Medical Emergency Response Policy. This includes the provision of CPR in accordance with professional standards of practice to include CPR on a hard surface, with ventilations or rescue breaths. Education began on pm shift 4.30.26 and will continue for each nurse before they work their next shift ~All nursing staff are to be educated on the creation of emergency kits on a cart that contain supplies for medical emergencies including CPR; one for each 2nd and 3rd floor and expectation to restock the cart after each use and to audit the cart each night shift to ensure it contains all needed supplies. Education began on 4.30.26 and will continue for each nurse before they work their next shift. ~All nursing staff are to be educated as to the location of the emergency carts and that they are to be checked every night shift by the charge nurse for required supplies and restocked by the charge nurse after use. ~A quiz will also be administered to all nurses working to validate competency. (All training noted above to be completed by next working shift. Any nurses who do not compete the competency will not be scheduled until they completed. Competencies and education will be conducted by nursing management and/or a nurse who has the competency education and has been designated to give education.) ~CPR policy and Medical Emergency Response policies were reviewed 0n 4.30.26 for the foundation of education. Chief Nursing Officer developed staff education on providing CPR in accordance with professional standards of practice, to include where to find equipment, that CPR must be done on a hard surface such a backboard or the floor, that ventilations and rescue breaths must be completed along with chest compressions and that the process for obtaining help in an emergency, such as CPR includes calling a Code Blue over the walkie talkies and the charge nurse taking charge of assigning duties during the emergency/code. Education also included review of emergency carts, their contents and location. Education began on pm shift on 4.30.26 by DON B and Interim ADON AA. All nurses will continue to be educated prior to the start of their shift until all nurses are educated. ~Additionally, mock code drills were conducted on both 2nd and 3rd floor on 4.30.26, and will be conducted each shift through Monday, 5.4.26. Education will continue on each shift until all nurses are educated. Education will be added to facility new hire orientation and agency staff education. Mock codes assess that employees know where to find equipment, how to call for help in a Code Blue, to ensure CPR is completed on a firm surface and that ventilations are given in addition to compressions. ~IJ Removal Plan, policies and mock code drill provided to medical director for review. ~All nursing staff will receive education on the facility CPR policy and Emergency Procedures Policy. ~A quiz will be administered to all nursing staff to validate competency of their education. Mock code drills will be conducted daily x 5 days, weekly x 4 weeks, monthly x next 3 months. ~Results of mock code drills will be reviewed at facility QAPI meeting for any further recommendations. Facility assessment will be updated related to need to conduct mock CPR drills routinely.

Based on interview and record review, the facility did not provide evidence that MAs (Medication Aide) had 4 hours of medication based in-service training per year for 1 of 1 MA reviewed for in-service training.MA CC did not have documentation of 4 hours of medication based in-service. Evidenced by:The facility's Continuing Education policy, dated 2/9/26, states, in part: . 1. All levels of employees are expected to complete required trainings within designated time frames.MA CC has a hire date of 8/14/13. MA CC education record for 2025 indicates 2.5 hours of medication related in-service, including:*Medication Administration Pass 1 contact hours*Medication Administration: Antibiotics 0.5 contact hours*Medication Administration: Controlled Substances 0.5 contact hours*Medication Assistance for Medication Aides 0.5 contact hoursOn 5/14/26 at 12:43 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked how many hours of medication related in-service are required for MAs. NHA A stated 4 hours every year. Surveyor asked how many hours MA CC had completed for 2025. NHA A stated 2.5 hours; I would expect that MA CC would have 4 hours.

Based on interview and record review, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 out of 3 total sampled Residents (R1).R1 experienced a change of condition following onset of nasal congestion and a productive cough. R1 was not assessed by a RN (Registered Nurse) prior to being hospitalization for 2 weeks. This is evidenced by:The facility's policy, Change of Condition Process, undated, documents in part, as follows: Unit Nurse Expectations: The unit nurse will identify/assess for changes of condition. All nurses will update the provider and POA (Power of Attorney) immediately of change in condition. The nurse will document the assessment, what the interventions are including any new orders. Unit nurses will assess the resident with COC (change of condition) every shift for 48 hours. The unit nurse will notify the Nurse Manager on call.R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, as follows: inclusion body myositis (a rare progressive muscle disease characterized by chronic inflammation and wasting), functional paraparesis (functional movement disorder causing weakness in both legs), and Chronic Obstructive Pulmonary Disease (progressive lung disease causing inflammation, airway damage and mucus blockage). R1's Minimum Data Set (MDS) dated [DATE], indicates R1 scored 15 out of 15 on his Brief Interview for Mental Status (BIMS) indicating R1 is cognitively intact.On 2/11/26 at 3:16 PM, RN I (Registered Nurse) documented a Progress Note for R1 as follows: Due to symptoms explained by floor staff, resident was tested for flu (influenza) and covid. All results were negative.(no evidence was provided to show that RN I assessed R1 at this time)On 2/11/16 at 3:35 PM, an LPN (Licensed Practical Nurse) documented a Progress Note for R1 as follows: Resident reported not feeling his best today. He stated he has some nasal congestion and a moist productive cough. Writer has not observed and [sic] when asked resident to describe (color) he told writer he didn't know because he doesn't look at it and when writer suggested he put tissue aside and call writer to observe he said he doesn't find that process appealing. Lung sounds are coarse throughout. Temp (temperature) 97.3 and O2 sats (saturation) 90% on room air. He reported no nausea and no specific pain-just tired and wore out. He is drinking fluids but reports his appetite is not really there. Writer updated PCP (primary care provider) via hucu; awaiting response. Resident remained in bed for breakfast and got up before lunch. He ate his meals in his room d/t (due to) not feeling well and he fed himself after set up assist using adaptive silverware. Resident transfers with hoyer lift and uses an electric w/c (wheelchair) for mobility.On 2/12/26 at 2:09 PM, an LPN (Licensed Practical Nurse) documented a Progress Note for R1 as follows: Resident continues to feel tired this shift. Tracheal congestion and audio [sic] wheezing present. Resident told writer he doesn't feel like he needs to cough to clear his throat and writer encouraged him to try to cough and he made a soft attempt to do so with no progress. Temp 97.3 O2 sats 89-91% on room air. Lung sounds coarse. He ate 100% of breakfast while in bed and fed himself after set up assist using adaptive silverware. After breakfast he received his scheduled shower. Resident chose to stay in bed after his shower and he has been sleeping soundly off and on. He wakes to verbal stimuli but goes back to sleep. Writer updated PCP (primary care provider) via Hucu on status. Orders received from NP (Nurse Practitioner) for Mucinex 600 mg (milligrams) BID (twice a day) x 14 days and Duo neb every 6 hours PRN (as needed) for SOB (shortness of breath) and/or wheezing. Writer gave PRN Duo neb at 1:14 PM for SOB/wheezing. After neb resident did have a more powerful cough. Resident slept through lunch but woke after his nebulizer and staff warmed tray up for him.On 2/12/26 at 11:24 PM, LPN H (Licensed Practical Nurse) documents a note in Hucu to the provider: T (Temperature) 96.6 pulse is bouncing between 30-40's O2 90% BP (blood pressure) 81/48, audible wheezes. Lungs pleural friction rub through out [sic] . He is super sick. Can I send him out?(No documentation was provided indicating an RN assessed R1 while being super sick)On 2/12/26 at 11:26 PM, LPN H (Licensed Practical Nurse) documented a note in Hucu to the provider: I got report that he was trying to eat the O2 mask when she gave him a breathing treatment on PMs and he's [sic] baseline is a&ox4 (alerted to person, place, time and event).On 2/12/26 at 11:28 PM, a Nurse Practitioner documented a note to the facility in Hucu: Send out to be evaluated.On 2/12/26 at 11:28 PM, LPN H (Licensed Practical Nurse) documented a note in Hucu to the provider: Thank u [sic]On 2/12/26 at 11:39 PM, LPN H (Licensed Practical Nurse) documented a Progress Note for R1 as follows: I went to check R1 after report and he has a very loud audible wheeze and pleural friction rub sounds in his left lung and his vitals are all running low O2 (oxygen saturation)is at 90% and B/P (blood pressure) is 81/48 I have contacted the NP (Nurse Practitioner) and have received an ok to send him out, I have update the POA (Power of Attorney), ambulance called and he is going to the hospital (name) for evaluation.On 2/13/26 at 12:38 AM, DON B (Director of Nursing) documented a Progress Note for R1 as follows: Call from floor nurse, per report. Resident continues to be lethargic as reported earlier in the day and per Hucu notes on provider's page, resident seems more confused, data collected below. T 96.6 pulse is bouncing between 30-40's O2 (oxygen saturation) 90% BP (blood pressure) 81/48, audible wheezes Lungs pleural friction rub through out [sic] . Per floor nurse provider was updated and resident is to be sent out.R1 was hospitalized from 2/13 - 2/27/26 with diagnoses of pneumonia of right lung due to infectious organism unspecified part of lung (an infection in the lungs make causing breathing difficulties), healthcare-associated pneumonia, sepsis (a life-threatening response to an infection) due to undetermined organism, bradycardia (slow heart rate), acute respiratory failure with hypoxemia (life-threatening emergency where the lungs cannot adequately transfer oxygen to the blood), and sepsis associated hypotension (severe infection causing low blood pressure). The hospital documented, Given the severity and the congested nature of his cough, he underwent a CT of the chest without contrast, that was personally reviewed showing fairly significant infiltrates in the right middle and right lower lobes, as well as early infiltrates in left lower lobe. He was ordered Zosyn and Vancomycin as well as DuoNebs in the ER (emergency room).On 4/29/26 at 10:35 AM, Surveyor spoke with R1. R1 recalls being hospitalized however he does not recall the reason for the hospitalization or events leading up to the hospitalization. It is important to note, R1 was not assessed by an RN (Registered Nurse) upon symptom onset and prior to being hospitalized . On 4/30/26 at 11:07 AM, Surveyor spoke with NP E (Nurse Practitioner). NP E reviewed the Hucu notes related to R1's change in condition. Surveyor asked NP E, would you expect an RN (Registered Nurse) to assess R1 when he was first noted with respiratory symptoms and to continue assessing R1's condition. NP E stated, yes, an RN should have assessed R1. On 4/30/26 at 1:05 PM, Surveyor spoke with RN I (Registered Nurse). Surveyor asked RN I, did the previous DON (Director of Nursing) ask you to monitor R1. RN I stated, yes, the previous DON asked her to touch base with R1. RN I stated, she and the previous DON did not think R1 had any serious issues going on. RN I stated, they thought it was allergies. Surveyor asked RN I, did you assess R1. RN I stated from what she recalls she assessed R1. Surveyor asked RN I, what did you assess. RN I stated, I do not recall. Surveyor asked RN I, did you document the assessment. RN I stated, she does not know.It is important to note, RN I did not document any assessment for R1. On 4/30/26 at 2:00 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, from 2/11-2/12/26 should a RN (Registered Nurse) have assessed R1. DON B stated, RN I (Registered Nurse) tested R1 for influenza and Covid - all tests were negative. Surveyor asked DON B, would you expect RN I or another Registered Nurse to assess R1. DON B stated, yes. Surveyor asked DON B, what would you expect RN I or another Registered Nurse to assess. DON B stated, R1's respiratory status and listen to R1's lungs. Surveyor asked DON B, would you expect RN I or another Registered Nurse to document that assessment. DON B stated, yes.

Based on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a change in condition. This occurred for 1 of 5 Residents (R3) reviewed for notification of change in condition.On 4/30/26 R3 had no urine output on the NOC (overnight) shift. The facility did not notify the provider of the change of conditionThis is evidenced by:The facility's policy, titled Change of Condition Process, undated, states in part: Unit Nurse Expectations: The unit nurse will identify/assess for changes of condition. All nurses will update the provider and POA (Power of Attorney) immediately of change in condition.R3 was admitted to the facility on [DATE] with diagnosis that include urinary tract infection, sepsis (extreme response to an infection), infection and inflammatory reaction due to indwelling urethral catheter, neuromuscular dysfunction of bladder (condition where the nervous system disrupts the bladders ability to control its function), retention of urine, and paraplegia (paralysis of the legs and lower body cause by a spinal cord or nerve problem).R3's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/16/26 indicates R3 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R3 is cognitively intact. R3's physician orders include the following:-Catheter Care: Irrigate Foley with 60 ml (milliliters) Normal Saline, using gentle pressure as needed for blockage/occlusion. Special instructions: May irrigate as needed. Start Date: 9/10/25. End date: Open ended.-Catheter Care: Monitor catheter for patency and provide Foley care Q shift (every shift). Start Date: 9/10/25. End date: Open ended.-Catheter Care: Monitor catheter output Q shift and document in ml. Update provider with abnormal output or if s/sx (signs/symptoms) of infection present. Special instructions: Ensure output is monitored and record Q shift of infection present. Special instructions: Ensure output is monitored and recorded Q shift. Start Date: 9/10/25. End date: Open ended.R3's Comprehensive Care Plan states, in part: .Problem: Resident requires an indwelling urinary catheter R/T (related to) neurogenic bladder. Start Date: 9/19/25. Edited: 2/27/26. Goal: Resident will have catheter care managed appropriately as evidence by: not exhibiting signs of urinary tract infection or urethral trauma. Goal Date: 5/18/26. Edited: 2/18/26. Approaches:. Catheter Care: Monitor catheter output Q (every) shift and document in mL. Update provider with abnormal output or if s/sx of infection present. Start Date: 9/19/25. Edited: 9/21/25.On 4/30/26 at 7:58 AM, a nursing progress note entered into R3's medical record states, in part: CNA (Certified Nursing Assistant) staff report that resident did not have any urine output in his bedside drainage bag at the end of NOC (overnight) shift. Resident observed to have clear colored yellow urine in his tubing. PRN (as needed) flush given to foley catheter without any resistance.On 4/30/26 at 11:09 AM, Surveyor interviewed NP E (Nurse Practitioner) about R3's output. NP E stated that it was her expectation to be notified of a resident's change of condition. NP E indicated that normally staff would notify her via a Hucu app message, and if they do not hear a response from her within an hour that they should try calling her. NP E indicated that she had not received any messages this morning about R3's lack of urine output. NP E stated that it was her expectation that staff notify her if a resident has low urine output, anything less than 240 mL in an 8-hour shift. NP E indicated that she had not been notified about R3, and she should have been. On 4/30/26 at 11:33 AM, Surveyor interviewed CNA F (Certified Nursing Assistant) about R3's foley catheter. CNA F stated that she empties and measures R3's urine output 1-2 times per shift and documents the amount in the electronic medical record. CNA F indicated that she would notify the nurse on duty if R3 had little to no urine in his foley bag for the entire shift.On 4/30/26 at 11:38 AM, Surveyor interviewed RN G (Registered Nurse) about R3's urine output and notifying the provider. RN G stated that she would notify the provider immediately if she noticed a change in condition with R3's catheter, including any signs and symptoms of infection, or decreased urine output. RN G stated she would reach out to the provider with a Hucu app message, unless it was urgent, and then she would call the provider immediately.On 4/30/26 at 12:50 PM, Surveyor interviewed DON B (Director of Nursing) about R3's urine output and notifying the provider. DON B confirmed that there was no Hucu app message sent to the provider about R3's lack of urine output on the NOC shift. DON B stated that she would have expected the nurse to contact the provider given R3's past history of UTIs, sepsis and hospitalization.

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 4 residents (R1) reviewed for falls.R1 had a history of falls including one that resulted in multiple rib fractures. The facility did not complete a thorough root cause analysis on the falls or ensure that care planned interventions were in place for R1.As evidenced by:Facility policy, titled Falls - Clinical Protocol, with last revision date of March 2018, states, in part: Assessment and Recognition: 1. The physician will help identify individuals with a history of falls and risk factors for falling. c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. 2. In addition, the nurse shall assess and document/report the following: . c. Musculoskeletal function, observing for change in normal range of motion. g. Frequency and number of falls since last physician visit; h. Precipitating factors, details on how fall occurred. Cause Identification: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. a. Often multiple factors contribute to a falling problem. 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment of the nature or category of falling, until falling reduces or stops. Monitoring and Follow-Up:. 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. 4. If the individual continues to fall, the staff and physician will reevaluate the situation and reconsider possible reasons for the resident's falling. and also reconsider the current interventions.R1 was readmitted to the facility on [DATE] with diagnoses that include, in part: paranoid schizophrenia (mental health illness where paranoia and delusions are prominent), unspecified dementia severe with mood disturbance, unsteadiness on feet, pain in right hip post fall, muscle wasting and atrophy (wasting away as a result of degeneration of cells), delusional disorder, post-traumatic stress disorder, altered mental status, pain in right and left shoulder, chronic kidney disease and Type 2 diabetes mellitus.R1's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/23/26, indicates R1 has a Brief Interview of Mental Status (BIMS) of 2 out of 15, indicating R1 is severely cognitively impaired. Section GG of R1's MDS indicates R1 uses a wheelchair and requires partial/moderate to substantial/maximum assistance for all Activities of Daily Living (ADLs). Section H of R1's MDS indicates that R1 is frequently incontinent of bladder.R1's electronic medical record includes multiple John Hopkins Fall Assessment Tools with scores of 18-21, which indicate R1 is a high fall risk. R1's comprehensive care plan, includes, in part:-Focus: Resident on a scheduled toileting plan every 2-4-hour checks for safety awareness, fall prevention, continued education to resident, and toileting as needed. Date Initiated: 4/20/25.-Approach: Adapt environment to maximize fall prevention with safety awareness, prevention of falls with staff intervention and monitoring, interventions in place with every 2-3-hour toileting checks. Date Initiated: 4/20/25-Focus: Interventions in place to decrease risk of falls. Resident has cognition issues that hinder safety awareness with removal of safety precautions. Date Initiated: 4/14/25.--Approach: Pool noodle on outer side of bed to remind resident where edge of bed is to prevent rolling out of bed. Replace noodle as needed and gently remind resident that noodle is placed for safety. Date Initiated: 4/14/25. Staff to check that resident has cushion in chair and replace when removed. Date Initiated: 4/14/25. Staff to gently remind resident to have grippy socks on feet and assist with placement. Date Initiated: 4/14/25.--Focus: Basic CNA (Certified Nursing Assistant) Care Plan. Date Initiated: 9/13/24.--Approach: Devices: WC (wheelchair) with auto lock brakes.Grip socks on at all times. (Does remove herself and needs monitoring to ensure placement) . May use EZ stand and 2 assist for toileting and weakness. Scoop mattress. Broda chair. Transfers: 2 assist squat pivot transfer. Date Initiated: 9/13/24.--Focus: Resident at risk for falling r/t____________ (blank). Date Initiated: 9/14/17.--Approach: Call, don't fall signage placed in room as reminder to call for assistance. Date Initiated: 2/12/26. Scoop mattress. Date Initiated: 1/26/26. Staff to make bed after resident is up in am. Will try to make on own. Date Initiated: 11/24/25. When assisting resident with pm cares help her into her pajamas. If resident refuses to change clothes, reapproach at a later time to assist her. Date Initiated: 10/7/25. Gripper strips on floor in BRM (bedroom). Gripper strips next to bed on floor. Ensure that gripper strips are changed as needed when frayed or worn down. Date Initiated: 7/17/25. With increased restlessness E/B (evidenced by) wheeling self in hallway, offer distraction activities and bring to nursing area for increased supervision. Date Initiated: 6/16/25. New low WC delivered. Auto lock brakes used for safety. Date Initiated: 5/27/25. Bed in low position when [Resident Name] is in bed, keep at knee level when out of bed for easier transfers. Date Initiated: 5/24/25. Resident tends to remove fall interventions and needs reminders to keep in place and staff to reimplement interventions when resident has removed. Staff to reapproach patient as needed when [Resident Name] is unable to redirect. Date Initiated: 3/31/25. Keep WC (wheelchair) close to bed. Date Initiated: 3/12/25. Frequent rounds with change of shift, am/pm cares, meals, scheduled activities, routine toileting and NOC (overnight) rounds. Ensure that feet have grippy socks in place. Date Initiated: 7/3/24. Resident is to wear gripper socks at all times. Will frequently remove. Staff to monitor and assist with placement. Explain to [Resident Name] that foot covering should be worn for safety to prevent falls. Date Initiated: 7/3/24.On 9/5/25 at 7:10 PM, R1 had an unwitnessed fall in her room. The fall incident report indicates, in part: 5 Whys: Resident found on floor. Stated she slid out of bed. Grippy socks on floor next to her. Getting ready for bed. Was previously laid down without jammies. Combative while providing cares. Care planned to reapproach if combative or agitated with cares. Resident was to be reapproached. Skin check revealed bruising on top of right and right buttock. Intervention: gripper socks, analgesics, low bed and floor mat. Root cause: resident was to be reapproached. No injury noted.On 10/12/25 at 7:51 PM, R1 had an unwitnessed fall in her room. The fall incident report indicates, in part: Patient was heard falling out of bed. This RN was walking past her room [ROOM NUMBER] minutes prior and she was in bed. Patient stated she was trying to get up. Intervention: Maintenance to review resident's wheelchair. No injury noted. No root cause identified.(Of note: this is the 2nd time R1 has fallen out of bed.) On 10/22/25 at 7:03 PM, R1 had an unwitnessed fall in a peer's room. The fall incident report indicates, in part: Writer heard resident say 'help me' and observed to be sitting on floor with left leg bent inward, in door frame of bathroom, in front of her w/c (wheelchair) at the end of [Resident Room Number] bed. Wearing non-skid tennis shoes. Resident had paper towel in her hand and urine observed on the floor. When asked what happened she stated 'I don't know' and 'I went down'. abrasion to inner right thigh observed from left shoe rubbing inner right thigh.Intervention: gripper socks, rest, and low bed. No injury noted. No root cause identified.On 10/27/25 at 9:20 AM, R1 had an unwitnessed fall in her room. The fall incident report indicates, in part: Resident found on floor next to her bed. Last time she was seen at 0800 (8:00 AM) she was laying in bed. W/c was in bathroom doorway when found turned outward. Resident stated she went to the bathroom, fell, and crawled back to bedside. No injury noted.No root cause identified. No new intervention was put in place.(Of note: this is the 3rd time R1 has fallen out of bed/near the bed and the 2nd of R1's falls related to going to the bathroom).On 11/1/25 at 9:30 PM, R1 had an unwitnessed fall in her bathroom. The fall incident report indicates, in part: . Writer was in hallway and heard 'help me someone'. Resident observed to be sitting on buttocks, on floor of bathroom, with knees bent and legs spread out, barefoot. Gripper socks observed on floor next to her. W/c in door frame. When asked what happened she told writer 'I don't know'.No root cause identified. No new intervention was put in place.(Of note: this is the 3rd time R1 has fallen related to going to the bathroom.)On 11/1/25 at 9:40 PM, a nursing progress note was entered into R1's electronic medical record which states, in part: This writer assessed resident after she was found on the floor of the bathroom. This fall was unwitnessed. She states she went to turn around to get onto the toilet when she lost her balance and fell. Bathroom pull cord was activated and one of the wheelchair brakes were locked. No physical injury noted. she complains of moderate left rib and left ankle pain. resident's pj (Pajamas) and entire bedding were soaked with urine. Bedding and clothing changed. Pain appears to subside with rest.(Of note: this is the 4th time R1 has fallen related to going to the bathroom).On 11/2/25 at 9:02 PM, R1 had an unwitnessed fall in her room. The fall incident report indicates, in part: Resident was unable to state what happened. Walked in and resident was sitting with back against bed and butt on floor. Bed was in lowest position. All she stated was 'help me. No injury noted. No root cause identified. Intervention: gripper socks and rest.(Of note: this is the 4th time R1 has fallen out of bed or near the bed).On 11/22/25 at 8:51 AM, R1 had an unwitnessed fall in her room. The fall incident report indicates, in part: Resident was found laying on her right side next to her bet. She admits to falling stating 'I was trying to make my bed'. She notes some right shoulder and hip pain. Grimacing and increased complaints of pain noted with right shoulder and right hip movement. provider notified. POA (power of attorney) notified and requested that resident was evaluated at [Hospital Name] . New intervention added to care plan for staff to make resident bed in the AM when resident is out of bed.(Of note: this is the 5th time R1 has fallen out of bed or near the bed.)R1's ER notes, dated 11/22/25, indicate, in part: . presented to ED (emergency department) via EMS for evaluation of fall and left rib cage pain. She fell from wheelchair this morning. currently she reports right shoulder pain and pain in left rib cage.her fall was unwitnessed. in ED she was found to have multiple anterior (front of body) and anterolateral (anterior and lateral (side)) acute left rib fractures. traumatic/due to trauma from fall. was admitted as observation for pain control.On 11/23/25 at 4:14 PM, Nurse progress note states the following, in part: Res(ident) returned from her 24-hour hospital observation, around 2 pm. Received report prior to discharge. right hip x-ray negative, 5 rib fractures noted on her left side.On 1/23/26 at 8:47 PM. R1 had an unwitnessed fall in her room. The fall incident report indicates, in part: . Resident slid off edge of her bed on to the floor, the bed was in the lowest position, she had nothing on her feet, was dressed in a night gown, no injuries. No root cause identified.(Of note: this is the 6th time R1 fell out of bed/near the bed).On 1/31/26 at 2:25 PM, R1 had an unwitnessed fall in peer's room. The fall incident report indicates, in part: .Resident found sitting on the floor of [Room Number]. Appeared to be organizing blankets/stuffed animals in another resident's room. No injury noted.No root cause identified. No new intervention in place.(Of note: this is the 2nd unwitnessed fall for R1 in another Residents room)On 2/12/26 at 12:30 AM, R1 had an unwitnessed fall in her room. The fall incident report indicates, in part: Resident was found by CNA sitting on the floor next to her bed in low position. W/c a few feet away from bed and locked. Resident attempted to self-transfer from her bed to her w/c. Resident noted to have been incontinent of urine at the time of the fall. Interventions: gripper socks.No root cause identified. New care plan intervention added of a call don't fall sign.(Of note: this is the 7th time R1 had a fall out of bed/near the bed and the 5th fall R1 had while incontinent or relating to going to the bathroom).On 3/12/26 at 1:04 PM, R1 had a witnessed fall in her room. The fall incident report indicates, in part: Responded to resident's room post fall. Resident was found laying face down on the floor. Housekeeper was in the room at the time of the fall. Per housekeeper and resident, resident was attempting to tie her shoes. Redness noted to left knee and small abrasion noted to right knee. some minor complaints of pain but nothing specific. hospice notified of fall and hospice to send nurse out.No root cause identified. No new interventions were put in place.On 3/18/26 at 9:40 AM, Surveyor observed R1 in a wide low wheelchair in the hallway attempting to self-propel herself. Surveyor observed that R1 was wearing gripper socks, and that she had slid down in the wheelchair seat. On 3/18/26 at 9:45 AM, Surveyor observed R1's room and observed that R1's bed was stripped and not made.On 3/18/26 at 10:04 AM, Surveyor interviewed agency LPN I (Licensed Practical Nurse) about R1's fall interventions. LPN I stated that today was her first time working with R1, and she would have to look up her fall interventions on her care plan.On 3/18/26 at 10:07 AM, Surveyor interviewed CNA G (Certified Nursing Assistant) about R1's fall interventions. CNA G stated that R1's fall interventions included to make sure she has shoes on and that they are tied, a fall mat, low bed, Dycem on her wheelchair, keeping her close to the nurse's station. CNA G indicated that everyone keeps an eye on R1, because she is a big fall risk. Surveyor asked CNA G if she had received any recent education on fall interventions. CNA G stated that she couldn't think of anything recent, but that they had a skills fair a year ago that included using the mechanical lifts safely.On 3/18/26 at 10:14, CNA G and CNA H stood R1 up and confirmed that R1 did not have dycem or anything else in her chair. Surveyor observed CNA G and CNA H go to R1's room to look for her Dycem and were unable to locate any. CNA G stated that she would ask therapy for more Dycem to put in R1's wheelchair. CNA H stated that R1 should have Dycem in her wheelchair to keep from sliding down, but that she had not gotten R1 up that morning. On 3/18/26 at 10:19 AM, Surveyor interviewed agency CNA J who indicated that she had gotten R1 up and ready this morning. Surveyor asked CNA J what R1's fall interventions were. CNA J stated R1's fall interventions included bed all the way down and to have her wheelchair nearby, since R1 does try to transfer herself. Surveyor asked if R1 had Dycem for her wheelchair. CNA J stated that no, R1 did not have any dycem that she was aware of. Surveyor asked CNA J where she would find R1's fall interventions. CNA J stated that she would look on the charting system in her care plan. Surveyor asked CNA J if R1 had ever slid out of her wheelchair. CNA J stated that R1 slides down in her wheelchair all the time and they have to boost her up. CNA J stated that 9 times out of 10 that is how R1 has fallen, by sliding out of her wheelchair. CNA J indicated that she had not received any education or training on fall interventions because she was agency.On 3/18/26 at 10:40 AM, Surveyor interviewed DOR K (Director of Rehab) about R1's fall interventions. DOR K stated that R1 has poor cognition and that she can't retain safety information. DOR K stated that they have assessed R1 after several of her falls and will make recommendations for her care plan and get orders as necessary, like for a gel wheelchair cushion, which R1 ripped apart. Surveyor asked if any of R1's falls were a result of sliding out of her wheelchair. DOR K stated that yes, R1 had slid out of her wheelchair, and that she is supposed to have Dycem under her wheelchair cushion so that the cushion doesn't slide out. DOR K stated that R1 will often remove the cushion and the Dycem, and that her Dycem needs to be replaced weekly.On 3/18/26 at 1:54 PM, Surveyor interviewed DON B (Director of Nursing) about R1's multiple falls. DON B stated that she had only been working at the facility since February. Surveyor asked DON B if root cause analysis had been completed for R1's falls. DON B stated that the IDT (interdisciplinary team) does the 5 Whys but that she was not sure when they started doing that. DON B stated that R1 has decreased safety awareness and decreased cognition, and she doesn't remember that she is declining in abilities and mobility. Surveyor asked DON B how often R1's fall interventions were reviewed by the IDT for effectiveness. DON B stated that usually when a resident has a fall the IDT tries to look at them. DON B indicated that she has been going through the care plans to review them, but she hadn't gotten to R1's yet. Surveyor asked DON B if a call don't fall sign would be an effective intervention for R1 given her decreased cognition. DON B stated no, that would not be a good intervention for R1. Surveyor asked DON B if an intervention of Dycem should be on R1's care plan, given her falls out of her wheelchair, so that all staff, even agency would know about it. DON B stated yes, Dycem should be on R1's care plan. Surveyor asked DON B if there had been any staff education recently about fall prevention. DON B stated that she would have to look, and indicated that yes, there should be staff education about fall prevention. Surveyor asked DON B if she would expect R1's care plan to be updated with effective fall interventions, and if she would expect R1's care planned interventions to be followed. DON B stated yes, that was her expectation.The facility failed to identify a true root cause for R1's repeated falls and failed to ensure that the fall interventions on R1's care plan were appropriate and adequately enforced. R1 had multiple falls, including one that resulted in major injury.

Based on interview and record review, the facility did not always ensure that they implemented written procedures for screening agency staff prior to working with residents at the facility. This has the potential to affect all 51 residents residing with in the facility.On 3/4/26, the facility became aware that an agency Certified Nursing Assistant (CNA S), who had worked 12 previous shifts on various units/floors was working under a false identification as CNA T. The facility did not put new processes in place related to verifying identification of the agency staff prior to orientation and their first scheduled shift. This gave CNA S the continued ability to obtain work while posing as CNA T. This has the potential to affect the safety of all 51 residents of the facility. This is evidenced by:Policy Review: Compliance with Reporting Allegations of Abuse/Neglect/Exploitation (date implemented, revised, and reviewed is blank.)Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes.Compliance Guidelines: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to ensure that the facility is doing all that is within its control to prevent occurrences.1.) Screening: The facility will screen employees for a history of abuse, neglect, or mistreating residents by attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries. Policy: Abuse, Neglect and Exploitation (date implemented, revised, and reviewed is blank.): It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 1). Screening a. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.1.) Background reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants. 2.) Screenings may be conducted by the facility itself, third-party agency or academic institution.3.) The facility will maintain documentation of proof that the screening occurred. On 3/17/26, Surveyor initiated a complaint investigation which addressed a concern that the facility had an Agency CNA who was working under an [NAME] name (an assumed, false, or additional name used to conceal a person's true identity.) The CNA was originally identified as CNA T. According to the review of the Police Department report, on 3/3/26, a food order was delivered to the facility at approximately 7:46 PM. The [NAME] Police became aware that this food was ordered and then paid for fraudulently and began an investigation. The [NAME] Police were able to narrow down 2 females who had ordered and received the food on the evening of 3/3/26. The individual who was said to have paid for the food was CNA T, who was an agency CNA who works at multiple different facilities. CNA T was working at the facility on 3/3/26 on the third floor.On 3/4/26, [Town Name] Police returned to the facility, as they were made aware by facility management that CNA T was scheduled to start her shift at 2:00 PM. Facility Management provided the police officer with a photocopy of CNA T's (out of state) driver's license that was provided to the facility by the staffing agency. At approximately 2:00 PM on 3/4/26, the [Town name] Police made contact with CNA T at the front entrance of the facility. The police officer asked the female if she was CNA T, in which she stated she was and agreed to further speak with the police officer.The [Town name] Police continued to gather information regarding the food order and delivery from the evening of 3/3/26. The [Town name] Police established probable cause to arrest CNA T. The police officer asked CNA T for her identification so they could confirm her identity, she stated she did not have her identification with her. The police officer, after further conversation, proceeded to get the photocopy of the driver's license of CNA T that was provided by the facility. The police officer noticed similarities in their facial features but did not believe the female that the officer had contact with was the same female in the driver's license photo. The police officer asked the female if she knew who the female was in the driver's license photo and asked if that was her. The female responded no. The police officer asked her if she was working for [Care Center] under a fake name, she said no.The police officer made contact with [Care Center] and asked the staff member if she knew an employee by the name of CNA T. The staff member stated she did know CNA T and was able to identify her as the female who was in the police officer's squad car. The female was transported to the [town name] Police Station where further questioning led to the female identifying herself as CNA S. CNA S informed the police officer that she is a travel nurse for a staffing agency and worked at [Care center.] The police officer asked CNA S why people at [Care center] think her name is CNA T, she responded she didn't know. Further discussion lead the police officer to believe that CNA T is CNA S's mother and that CNA S has been using her mother's identity to work at [Care Center.CNA S informed the police officer that she is a licensed CNA in multiple states, including Wisconsin. CNA S stated that her mother (CNA T) is also a licensed CNA but is no longer in the medical field. CNA S stated that she use [sic] to be employed with the staffing agency and is currently suspended for a year due to attendance issues. CNA S created her mother (CNA T) an account with the staffing agency, got hired with them, and has been working under her mother's identity. CNA S claims that she has only been working under a false identity for a couple weeks. On 3/18/26 at 10:10 AM, Surveyor conducted an interview with NHA A (Nursing Home Administrator) regarding the use of agency staff and her knowledge of CNA T not being who she identified herself as. NHA A stated she became aware of the situation when the Police arrived at the facility on 3/4/26 to arrest CNA T for potential credit card fraud. NHA A stated she tried to call the staffing agency on 2 separate occasions to report the incident and that CNA T was no longer welcome to work at the facility. NHA A stated then the situation of the false identity came about and that CNA S was posing as CNA T while working at the facility. All the staff and residents knew her as CNA T, and no one had any idea she was not who she said she was. NHA A stated that the staffing agency finally returned her phone call and told them that CNA S had previously worked for the staffing agency, but she got blocked from working there due to attendance issues. CNA S stated she needed the money so she applied under her mother's name and then could continue to work through the agency. Surveyor asked NHA A what the screening process is for new/first time agency staff who report to the facility for a shift. NHA A explained that the staffing agency obtains all of the required background information and upon hire, this information is uploaded to a shared portal that she has access to. NHA A is provided with all the information for each agency employee that is hired by the facility through this online portal. NHA A stated that upon orientation, the facility never asked her to provide identification because they never had a reason to believe that the person showing up to work was not who they said they were. NHA A stated that the facility has a contract with the staffing agency and they do all of the hiring. Once the person is hired, they put themselves out on this portal to pick up various shifts at various facilities who need to fill open shifts. Surveyor asked NHA A if she had reported this incident to the state survey agency. NHA A stated she did not because it was an active police investigation and she was charged for credit card fraud, not working at the facility under a false identification. NHA A stated CNA S has a current/valid Certified Nursing Assistant license through the state of Wisconsin and no findings on the caregiver misconduct registry. It was noted that CNA T also had a valid Wisconsin license and no misconduct findings. NHA A stated the facility continues to use the staffing agency and at this point, no changes had been made to the process when new agency personnel show up for a shift and how they verify their identity. (Of note: the facility did not report a suspicion of a crime to the state agency)On 3/18/26, Surveyor conducted a review of the contract between [Care Center] and the staffing agency. Under Agency's Responsibilities the following is documented:b. Professional Credential Verification. For each type of professional listed in section C of the Order Form, the agency will verify the credential(s) and/or document(s), if any, that have been selected ( Credential Verification Services). The agency will only permit Professionals that satisfy the applicable credential requirements of Section C of the order form to accept shifts posted by the client [Facility name]. Notwithstanding the foregoing, Client acknowledges and agrees that Agency's Credential Verification Services will not substitute for or relieve Client of its own statutory, regulatory, and/or contractual obligations, if any, to independently verify credentials, documents, and/or information pertaining Professionals. Section C-Credentials to be Verified (includes) photo identification, criminal background check, license verification.On 3/18/26, Surveyor obtained a copy of the background information that was submitted by the staffing agency for their employee identified as CNA T. All credentials were verified and valid. CNA S also had valid credentials provided to the facility from her previous employment with the agency.CNA T (identified as CNA S) worked the following total 12 shifts at the facility:On 2/8/26, CNA S worked as CNA T on AM shift on the 3rd floor.On 2/9/26, CNA S worked as CNA T on the AM and part of the PM shift on the 3rd floor.On 2/10/26, CNA S worked as CNA T on the AM and PM shift on the 3rd floor.On 2/11/26, CNA S worked as CNA T on the NOC shift on the 2nd floor.On 2/24/26, CNA S worked as CNA T on the NOC shift on the 3rd floor.On 2/27/26, CNA S worked as CNA T on the AM shift on the 3rd floor.On 2/28/26, CNA S worked as CNA T on the NOC shift on the 3rd floor.On 3/1/26, CNA S worked as CNA T on the AM shift on the 3rd floor.On 3/2/26, CNA S worked as CNA T on the PM shift and NOC shift of the 3rd floor.On 3/3/26, CNA S worked as CNA T on the PM shift on the 3rd floor. During the investigation, Surveyor conducted a review of the facility's grievance file. It was noted that resident R2 submitted a grievance on 3/1/26. The grievance stated that on 2/27/26, a Certified Nursing Assistant left her wet and did not check and change her per the plan of care. The facility's investigation included looking over the schedules and the staff member, in question, was new. The resolution was that the Certified Nursing Assistant was educated regarding check/change of briefs and the importance of peri care. More training for check-off. It was noted that this grievance was filed against CNA T. The education provided to CNA T documents that she is new to her occupation of CNA and has been noted to be a phenomenal worker by staff and is always answering call lights and does not complain about doing anything that is asked of her. Due to the facility not implementing their policy on Abuse/Neglect and Misappropriation of property, they failed to confirm the proper identity of an agency CNA (CNA S) upon hire to work at their facility. CNA S was able to work as CNA T for a total of 12 shifts at the facility, on various units, without proper screening by both the staffing agency and the facility. Although CNA T was later identified as CNA S, Once the facility became aware that CNA T was really CNA S, they did not change their process to ensure that all employees were properly screened, including verification of identity, prior to working with the residents of the facility. This had the potential to affect all residents, as the practice remained unchanged and agency staff continued to be used to meet the facility's scheduling demands.

Based on observation and interview, the facility did not dispose of garbage and refuse properly. This has the potential to affect all 54 residents. The facility did not ensure that lids on the dumpster were shut and secured to prevent pests.This is evidenced by: The facility policy titled, Sanitization, states in part: . 14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters with lids. On 3/26/26 at 10:25 AM Surveyor observed one lid open on recycling dumpster, and one lid open on regular trash dumpster.On 3/26/26 at 11:10 AM Surveyor interviewed DM V (Dietary Manager). Surveyor asked DM V if she knew why the dumpster lids would be open. DM V stated that sometimes the wind will catch them or when the truck comes to dump the trash the lid will remain open. Surveyor asked DM V what days they pick up trash. DM V stated Monday, Wednesday, and Friday for regular trash, and only Fridays for recycling dumpster. DM V stated that her staff tries to remember to shut the lids when the trash is taken out. Surveyor asked DM V how often her staff takes the trash out. DMV stated that each position in the kitchen is responsible for different stations, trash cans and everything is emptied daily. Surveyor asked would you expect one of your staff to see the trash lid open and close it, DM V stated yes.

Based on observation, interview and record review, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 6 (R6, R7, R8, R9, R10, R11) of 12 residents reviewed for Activities of Daily Living (ADLs). R6, R7, R8, R9, R10, and R11 expressed long call light wait times. Facility documentation shows residents waited an hour or more for ADL care when prompted with their call lights. Findings includeThe facility uses a call light system that alarms mini mobile devices on each of the facility's 2 resident floors (2nd floor and 3rd floor). When a resident uses their call light to notify staff of a need, the devices for that floor sound an alarm. The devices are meant to be carried so that nursing staff can hear the alarms while they are on the floor providing cares and services on behalf of the residents. There is no central hub that alarms, nor are their any indicators outside of each room (light above door, sound near door, etc.). On 3/18/26 at 9:20 AM, Surveyor interviewed CNA G (Certified Nursing Assistant) who stated that there are supposed to be 4 mobile devices on each floor for each of the scheduled CNAs, but some have gone missing so there are currently only 2 on the third floor. CNA G stated that staff usually leave one in the central nursing area and check on it when they have time in passing. CNA G stated that she believes many call lights do not get answered timely or at all due to not hearing the tone because there are not enough mobile devices and often CNAs are too busy to stop by the central nursing station to check the devices for alerts. CNA G showed Surveyor the mobile device that was laying on the table in a closed off room at the nursing station. The device showed active alarms and resolved alarms and the length of time that each took to be resolved. On 3/18/26 at 9:34 AM, Surveyor interviewed CNA H who stated that she gets complaints daily of long call light wait times from residents. When asked if she believed the lack of mobile devices has anything to do with these complaints, CNA H stated, Absolutely.Example 1R6 was admitted to the facility on [DATE]. His most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 13, indicating R6 is cognitively intact.On 3/18/26 at 3:40 PM, R6 indicated that he has waited, at times, for up to 45 minutes for care when using his call light.The call light log that was presented to Surveyor by CNA G indicated that on 3/18/26, R6 waited 1 hour and 32 minutes (time stamped at 8:51 AM) for cares to be given. Example 2R7 was admitted to the facility on [DATE]. Her most recent MDS, dated [DATE], shows a BIMS score of 15, indicating R7 is cognitively intact.On 3/17/26 at 10:25 AM, R7 indicated to Surveyors that she has waited, at times, for up to 45 minutes for care when using his call light.Example 3R8 was admitted to the facility on [DATE]. His most recent MDS, dated [DATE], shows a BIMS score of 15, indicating R8 is cognitively intact.On 3/18/26 at 2:27 PM, R8 indicated that he has waited, at times, for over an hour and a half for care when using his call light.The call light log that was presented to Surveyor by CNA G indicated that on 3/18/26, R8 waited 1 hour and 34 minutes (time stamped at 7:47 AM) for cares to given. Example 4R9 was admitted to the facility on [DATE]. His most recent MDS, dated [DATE], shows a BIMS score of 15, indicating R9 is cognitively intact.On 3/18/26 at 2:31 PM, R9 indicated that he has waited, at times, for up to 4 hours for care when using his call light and, on multiple occasions, has not gotten a response at all. R9 stated the response time is, Horrible.The call light log that was presented to Surveyor by CNA G indicated that on 3/18/26, R9 waited 1 hour and 10 minutes (time stamped at 5:11 AM) for cares to given. Example 5R10 stated to Surveyors on 3/18/26 at 1:19 PM that she frequently waits over an hour when using her call light.The call light log that was presented to Surveyor by CNA G indicated that on 3/18/26, R10 waited 2 hours and 36 minutes (time stamped at 7:37 AM) for cares to given. Example 6R11 was admitted to the facility on [DATE]. Her most recent MDS, dated [DATE], shows a BIMS score of 15, indicating R11 is cognitively intact.On 3/18/26 at 2:15 PM, R11 indicated that she was waited over 2 hours lately for care when using her call light.The call light log that was presented to Surveyor by CNA G indicated that on 3/18/26, R11 waited 50 minutes (time stamped at 9:40 AM) for cares to given. On 3/18/26 at 10:57 AM, Surveyor interviewed NHA A (Nursing Home Administrator) who stated that the facility has had some trouble with their call light system, which is new to the facility. NHA A stated that there have been some problems with the wireless internet in the building, which is a requirement for the mobile devices to work properly. NHA A stated that this is now fixed. When asked if each of the 4 CNAs scheduled on each floor should have a device to answer call lights, NHA A stated yes. Surveyor asked NHA A if she was aware that some of the mobile devices were missing, NHA A indicated she was unaware. NHA A indicated that call lights could possibly go unanswered if CNAs are not properly notified.

Based on interview and record review, the facility did not complete a performance review of every nurse aide at least once every 12 months for 2 of 5 Certified Nursing Assistants (CNA) reviewed.CNA U did not have an annual performance review.CNA H did not have an annual performance review.Evidenced by:The facility's Performance Evaluations policy, dated 9/2020, states, in part: The job performance of each employee shall be reviewed and evaluated at least annually. 1. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter.CNA U was hired 1/28/15. CNA U did not have an annual performance evaluation completed for 2025.CNA H was hired 8/21/19. CNA H did not have an annual performance evaluation completed for 2025.On 3/26/26 at 2:31 PM, Surveyor interviewed CNA H about performance evaluations. CNA H stated I don't recall having one. I have received paperwork about whether or not there was a raise, but no information about my performance.On 3/26/26 at 2:16 PM, Surveyor interviewed HRM W (Human Resources Manager) about performance evaluations. HRM W stated the evaluations for 2025 for CNA U and CNA H had been started by the past DON (Director of Nursing) but were not completed. HRM W stated that an annual evaluation is required.On 3/26/26 at 2:18 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who stated she would expect staff to have an annual performance evaluation.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that all alleged violations are thoroughly investigated, and that steps were taken to prevent further abuse for 2 of 3 residents (R1) reviewed. The facility became aware of a resident-to-resident altercation between R1 and R5 on 2/16/26. The facility failed to do a thorough investigation and put interventions into place to prevent future occurrences. Evidenced by:The facility policy entitled Abuse, Neglect and Exploitation, dated 2025, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.The components of the facility abuse prohibition plan are discussed herein: . The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: .B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified. staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; .D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect;E. Ensuring the health and safety of each resident.V. Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B Written procedures for investigations include: .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protecting of ResidentThe facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:A. Responding immediately to protect the alleged victim and integrity of the investigation;B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;C. Increased supervision of the alleged victim and residents.F. Providing emotional support and counseling to the resident during and after the investigation, as needed;G. Revision of the resident's care plan. R1 was admitted to the facility on [DATE] and has diagnoses that include paranoid schizophrenia (chronic mental disorder defined by intense, irrational delusions and auditory hallucinations, often involving persecution or conspiracy) and unspecified dementia severe with mood disturbance (significant cognitive decline coupled with behavioral symptoms like agitation, depression, apathy, or aggression. It results from brain damage, making communication difficult and causing emotional instability).R1's Minimum Data Set (MDS) Significant Change Assessment, dated 2/23/26, shows that R1 has a Brief Interview of Mental Status (BIMS) score of 02 indicating R1 has severe cognitive impairment.On 3/17/26 at 11:54 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) who indicated on 2/16/26 CNA D (Certified Nursing Assistant) reported to her that R1 had slapped R5 across the face. LPN C indicated the two residents were separated immediately. LPN C indicated she assessed R5 for any red marks and then reported the incident to the ADON (Assistant Director of Nursing), who is no longer employed at the facility. LPN C indicated the ADON directed LPN C to keep the two residents separated and keep an eye on them. Surveyor asked if vital signs or further follow up were completed with R5 and R1. LPN C indicated she had not completed any further assessing. LPN C indicated she had informed FM F (Family Member) of the incident as she was just arriving at that time to visit R5. LPN C indicated she then reported the incident to NHA A (Nursing Home Administrator). Surveyor asked LPN C if she documented the incident. LPN C indicated no. Surveyor asked LPN C if there were interventions put into place following this incident to prevent it from happening again. LPN C indicated she was not aware. LPN C indicated there was nothing put on the nurses 24-hour board or passed through in report when she worked her next shift. Surveyor asked LPN C if R1 has behaviors. LPN C indicated yes, paranoia, delusions, and aggressiveness with staff and residents. Surveyor asked what is meant by aggressiveness and LPN C indicated verbal aggressiveness that has been happening for a long time. Surveyor asked LPN C if she is aware of any other incidents regarding R1 and other residents. LPN C indicated yes, there was an altercation awhile back with R1 and R12. Surveyor asked LPN C what the facility's process is for a resident-to-resident altercation. LPN C indicated the staff are to separate the residents, make sure they are safe, and report it. LPN C indicated the facility would have to investigate and report it to the state.On 3/17/26 at 12:25 PM, Surveyor interviewed CNA D and asked if she was aware of an altercation between R1 and R5. CNA D indicated she had been charting in the conference room by the nurse station when R12 informed her R1 had just slapped R5's face. CNA D indicated R12 was right outside the conference room in the hallway and R1 and R5 were in front of R12. CNA D indicated she did not witness the slap. CNA D separated R1 and R5 immediately by taking R5 down the hallway. CNA D informed LPN C right away once CNA D separated the two residents and both residents were safe. Surveyor asked CNA D if R1 had ever struck another resident and CNA D indicated yes, R12. CNA D indicated R1 had slapped R12 on her face a year or so ago. Surveyor asked if R1 has behaviors. CNA D indicated yes, R1 gets combative with staff and gets verbally aggressive with staff and residents. Surveyor asked CNA D, after the incident between R1 and R5 were new interventions passed on to staff on how to prevent this from happening again. CNA D indicated no, the incident was passed on in report.On 3/18/26 at 9:25 AM, Surveyor interviewed CNA E. Surveyor asked if R1 has behaviors and CNA E indicated yes, R1 is verbally and physically aggressive with staff and residents. CNA E indicated a while back R1 hit R12. CNA E indicated she recently heard R1 had hit R5. Surveyor asked if CNA E was aware of any new interventions put into place after the incident with R1 and R5. CNA E indicated no and explained CNA E would know because she is responsible for updating the CNA cheat sheets. The cheat sheets direct the CNAs how to care for the residents. CNA E indicated if there were new interventions she would have known to add them onto those sheets. CNA E indicated she is to update the cheat sheets every week. Surveyor asked CNA E what R1's typical day is like. CNA E indicated when R1 is not sleeping, R1 tootles around the unit independently. Surveyor asked CNA E if R1 participates in activities. CNA E indicated we try but R1 will not stay in the activities. On 3/18/26 at 11:00 AM, Surveyor interviewed NHA A and asked what the facility's process is for a resident-to-resident altercation. NHA A indicated that staff report the incident to her. NHA A then reports it to the state, investigates it and provides education. Surveyor asked NHA A if she was aware of an incident between R1 and R5 on 2/16/26. NHA A indicated she does not recall. Surveyor asked NHA A if staff had informed her of R1 slapping R5 on 2/16/26. NHA A indicated on 2/16/26 LPN C or ADON at that time did report that R12 witnessed R1 slapping R5. Surveyor asked NHA A who had reported the incident to the ADON. NHA A could not recall. Surveyor asked whom R12 reported the incident. NHA A indicated she could not recall. Surveyor asked if there was any documentation on this incident. NHA A indicated no it was just conversation. Surveyor asked NHA A if there should be documentation; NHA A indicated yes. Surveyor asked what NHA A had done with the information she received from staff. NHA A indicated she talked to R12. R12 indicated that R1 did not slap R5. R12 indicated to NHA A that R1 was tapping R5 on the face. NHA A indicated R1 and R5's wheelchairs had somehow hung up together. NHA A indicated there were no words exchanged between R1 and R5. NHA A indicated nothing more was done with the incident or documented; she had no concerns after talking with R12 about the incident. Surveyor asked if there was any follow up with R1 and R5 after the conversation with staff and R12. NHA A indicated no. Surveyor asked if NHA A interviewed the CNA and nurse that had reported it. NHA A indicated no. Surveyor asked if the facility interviewed other residents to see if there were concerns regarding R1 and their safety in the facility. NHA A indicated no. Surveyor asked NHA A how it was determined not to investigate this resident-to-resident altercation. NHA A indicated R12 stated R1 lightly tapped R5 on the face. Surveyor asked NHA A should a resident-to-resident altercation be investigated? NHA A indicated yes. Surveyor asked NHA A if this incident could have been potentially reportable to state. NHA A indicated yes. Surveyor asked if there should have been documentation on this incident; NHA A indicated yes.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 3 of 3 incidents involving 3 residents (R1, R5 & R6) reviewed for abuse. The facility became aware of a resident-to-resident altercation between R1 and R5 on 2/16/26. The facility failed to do an investigation and report to the state if indicated. Facility did not report a suspicion of a crime when they became aware of a staffing agency CNA (Certified Nursing Assistant) working under false identification. A staff member was alleged to have abused R6, and the facility did not report it to the State Agency. Evidenced by: The facility policy entitled Abuse, Neglect and Exploitation, dated 2025, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The components of the facility abuse prohibition plan are discussed herein: . V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B Written procedures for investigations include: . 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Example 1: R1 was admitted to the facility on [DATE] and has diagnoses that include paranoid schizophrenia (chronic mental disorder defined by intense, irrational delusions and auditory hallucinations, often involving persecution or conspiracy) and unspecified dementia severe with mood disturbance (significant cognitive decline coupled with behavioral symptoms like agitation, depression, apathy, or aggression. It results from brain damage, making communication difficult and causing emotional instability). R1's Minimum Data Set (MDS) Significant Change Assessment, dated 2/23/26, shows that R1 has a Brief Interview of Mental Status (BIMS) score of 02 indicating R1 has severe cognitive impairment. R5 was admitted to the facility on [DATE] and has diagnoses that include unspecified dementia (Cognitive decline with the specific cause unknown. It involves progressive memory loss and cognitive impairment that interferes with daily life.) and down syndrome (a genetic condition caused by an extra copy of chromosome 21, resulting in physical growth delays, mild to moderate intellectual disabilities, and characteristic facial features). R5's Minimum Dats Set (MDS) Quarterly Assessment, dated 1/23/26, shows that R5 has a Brief Interview of Mental Status (BIMS) score of 00, indicating R5 has severe cognitive impairment. On 3/17/26 at 11:54 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) who indicated on 2/16/26 CNA D (certified nursing assistant) reported to her that R1 had slapped R5 across the face. LPN C indicated the two residents were separated immediately. LPN C indicated she assessed R5 for any red marks and then reported the incident to the ADON (Assistant Director of Nursing), who is no longer employed at the facility. LPN C indicated the ADON directed LPN C to keep the two residents separated and keep an eye on them. Surveyor asked if vital signs or further follow up was completed with R5 and R1. LPN C indicated she had not completed any further assessing. LPN C indicated she had informed FM F (family member) of the incident as she was just arriving at that time to visit R5. LPN C indicated she then reported the incident to NHA A (Nursing Home Administrator). Surveyor asked LPN C if she documented the incident. LPN C indicated no. On 3/17/26 at 12:25 PM, Surveyor interviewed CNA D and asked if she was aware of an altercation between R1 and R5. CNA D indicated she had been charting in the conference room by the nurse station when R12 informed her R1 had just slapped R5's face. CNA D indicated R12 was right outside the conference room in the hallway and R1 and R5 were in front of R12. CNA D indicated she did not witness the slap. CNA D separated R1 and R5 immediately by taking R5 down the hallway. CNA D informed LPN C right away once CNA D separated the two residents and both residents were safe. Surveyor asked CNA D if R1 had ever struck another resident and CNA D indicated yes, R12. CNA D indicated R1 had slapped R12 on her face a year or so ago. On 3/17/26 at 3:00 PM, Surveyor interviewed R12. Surveyor asked R12 if she had witnessed a resident altercation between R1 and R5. R12 indicated yes. R12 indicated R1 and R5 were both in their wheelchairs going in opposite directions and somehow the wheelchairs got hung up together in the passing. R1 then slapped R5 on the shoulder. R12 indicated there were no words exchanged. R12 indicated she informed a cna right away and that cna separated R1 and R5. On 3/18/26 at 11:00 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked what the facility's process is for a resident-to-resident altercation. NHA A indicated that staff report the incident to her. NHA A then reports it to the state, investigates it and provides education. Surveyor asked NHA A if she was aware of an incident between R1 and R5 on 2/16/26. NHA A indicated she does not recall. Surveyor asked NHA A if staff had informed her of R1 slapping R5 on 2/16/26. NHA A indicated on 2/16/26 LPN C or ADON at that time did report that R12 witnessed R1 slapping R5. Surveyor asked NHA A who had reported the incident to the ADON. NHA A could not recall. Surveyor asked whom R12 reported the incident. NHA A indicated she could not recall. Surveyor asked if there was any documentation on this incident. NHA A indicated no it was just conversation. Surveyor asked NHA A if there should be documentation; NHA A indicated yes. Surveyor asked what NHA A had done with the information she received from staff. NHA A indicated she talked to R12. R12 indicated that R1 did not slap R5. R12 indicated to NHA A that R1 was tapping R5 on the face. NHA A indicated R1 and R5's wheelchairs had somehow hung up together. NHA A indicated there were no words exchanged between R1 and R5. NHA A indicated she had no concerns after talking with R12 about the incident. Surveyor asked if there was any follow up with R1 and R5 after the conversation with staff and R12. NHA A indicated no. Surveyor asked if NHA A interviewed the cna and nurse that had reported it. NHA A indicated no. Surveyor asked if the facility interviewed other residents to see if there were concerns regarding R1 and their safety in the facility. NHA A indicated no. Surveyor asked NHA A how it was determined not to investigate this resident-to-resident altercation. NHA A indicated R12 stated R1 lightly tapped R5 on the face. Surveyor asked NHA A should a resident-to-resident altercation be investigated? NHA A indicated yes. Surveyor asked NHA A if this incident could have been potentially reportable to state. NHA A indicated yes. Surveyor asked if there should have been documentation on this incident; NHA A indicated yes. Example 2: Surveyor initiated a complaint investigation which addressed a concern that the facility had an Agency CNA (Certified Nursing Assistant) who was working under an [NAME] name (an assumed, false or additional name used to conceal a person's true identity). The CNA was originally identified as CNA T. On 3/18/26 at 10:10 Am, Surveyor conducted an interview with NHA A (Nursing Home Administrator) regarding the use of agency staff and her knowledge of CNA T, not being who she identified herself as. NHA A stated she became aware of the situation when the Police arrived at the facility on 3/4/26 to arrest CNA- T for potential credit card fraud. NHA A stated she tried to call the staffing agency, on 2 separate occasions, to report the incident and that CNA T was no longer welcome to work at the facility. NHA A stated that then the situation of the false identity came about and that CNA S was posing to be CNA T while working at the facility. All the staff and residents knew her as CNA T, and no one had any idea she was not who she said she was. NHA A stated that the staffing agency finally returned her phone call and told them that CNA S had previously worked for the staffing agency, but she got blocked from working there due to attendance issues. CNA S stated she needed the money so she applied under her mother's name (CNA T) and then could continue to work through the agency. Surveyor asked NHA A what the screening process is for new /first time agency staff who report to the facility for a shift. NHA A explained that the staffing agency obtains all the required background information and upon hire, this information is uploaded to a shared portal that she has access to. NHA A is provided with all the information for each agency employee that is hired by the facility through this online portal. NHA A stated that upon orientation, the facility never asked the agency personnel to provide identification because they never had a reason to believe that the person showing up to work was not who they said they were. NHA A stated that the facility has a contract with the staffing agency and they do all the hiring. Once the person is hired, they put themselves out on this portal to pick up various shifts at various facilities who need to fill open shifts. Surveyor asked NHA A if she had reported this incident to the state survey agency. NHA A stated she did not because it was an active police investigation and she was charged for credit card fraud, not working at the facility under a false identification. NHA A stated the facility continues to use the staffing agency and at this point, no changes had been made to the process when new agency personnel show up for a shift how they verify their identity. As of exit, the facility was unable to provide additional information as to why they did not report the suspicion of a crime when they became aware that a staffing agency CNA (CNA S) was working under false identification. Example 3: R6 was admitted to the facility on [DATE]. On 2/21/26, CNA Q (Certified Nursing Assistant) alleged that another staff member had forced R6 out of his bed, despite R6 stating he did not want to get up. In an interview with Surveyors on 3/18/26, CNA Q stated that R6 stated to her in the morning of 2/21/26 that he did not want to get up for breakfast because he was in so much pain and wanted to wait for the nurse to deliver his morning medications before getting out of bed. CNA Q stated that she communicated this to another CNA who then indicated that R6 could not do that and went into R6's room and started yelling at R6 and forced R6 out of bed, while calling him racist. CNA Q stated to Surveyors that she felt this was abusive and reported it to the nurse, who then reported it to NHA A (Nursing Home Administrator). The facility conducted a thorough investigation into the allegation; however, the State Agency has no record of this being reported. On 3/18/26 at 10:57 AM, Surveyor interviewed NHA A who stated that she believed the allegation to sound of abuse and NHA A should have reported the incident to the state agency. NHA A stated that by the time she realized that the incident should have been reported to the facility, it was past due and then decided to not report it at all.

Based on interview and record review, the facility did not ensure that each resident was free from abuse from another Resident for 1 of 11 residents (R5) reviewed for abuse. R12 had witnessed R1 slap R5 when both R1 and R5's wheelchairs got hung up on each other. R12 reported the incident to staff immediately. R1 has a history of aggressive behaviors towards staff and other residents. R1 has had another known altercation with R12 in the past. Evidenced by:The facility policy entitled Abuse, Neglect and Exploitation, dated 2025, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.III. Prevention of Abuse, Neglect and ExploitationThe facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: .B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified. staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; .D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect;E. Ensuring the health and safety of each resident.V. Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.VI. Protection of the ResidentThe facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. R1 admitted to the facility on [DATE] and has diagnoses that include paranoid schizophrenia (chronic mental disorder defined by intense, irrational delusions and auditory hallucinations, often involving persecution or conspiracy) and unspecified dementia severe with mood disturbance (significant cognitive decline coupled with behavioral symptoms like agitation, depression, apathy, or aggression. It results from brain damage, making communication difficult and causing emotional instability).R1's Minimum Data Set (MDS) Significant Change Assessment, dated 2/23/26, shows that R1 has a Brief Interview of Mental Status (BIMS) score of 02 indicating R1 has severe cognitive impairment.R1's Care Plan, dated 12/06/2019, with a target date of 5/24/2026, states, in part: . Problem: Problem Start Date: 12/06/2019. Category: Cognitive Loss/Dementia. Resident has impaired decision-making R/T (related to) her diagnoses of paranoid schizophrenia, dementia, delusional disorder. BIMS score is less than 13. Resident is not her own person.Approach: .-Approach Start Date: 12/06/2019. Allow resident to make decisions although ensuring her safety and safety of others. R5 admitted to the facility on [DATE] and has diagnoses that include unspecified dementia (Cognitive decline with the specific cause unknown. It involves progressive memory loss and cognitive impairment that interferes with daily life.), major depressive disorder (a serious mental health condition characterized by persistent, intense feelings of sadness, hopelessness, and a loss of interest in activities), and down syndrome (a genetic condition caused by an extra copy of chromosome 21, resulting in physical growth delays, mild to moderate intellectual disabilities, and characteristic facial features).R5's Minimum Dats Set (MDS) Quarterly Assessment, dated 1/23/26, shows that R5 has a Brief Interview of Mental Status (BIMS) score of 00, indicating R5 has severe cognitive impairment. On 3/17/26 at 11:54 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) who indicated on 2/16/26 CNA D (Certified Nursing Assistant) reported to her that R1 had slapped R5 across the face. LPN C indicated the two residents were separated immediately. LPN C indicated she assessed R5 for any red marks and then reported the incident to the ADON (Assistant Director of Nursing), who is no longer employed at the facility. LPN C indicated the ADON directed LPN C to keep the two residents separated and keep an eye on them. Surveyor asked if vital signs or further follow up were completed with R5 and R1. LPN C indicated she had not completed any further assessing. LPN C indicated she had informed FM F (Family Member) of the incident as she was just arriving at that time to visit R5. LPN C indicated she then reported the incident to NHA A (Nursing Home Administrator). Surveyor asked LPN C if she documented the incident. LPN C indicated no. Surveyor asked LPN C if there were interventions put into place following this incident to prevent it from happening again. LPN C indicated she was not aware. LPN C indicated there was nothing put on the nurses 24-hour board or passed through in report when she worked her next shift. Surveyor asked LPN C if R1 has behaviors. LPN C indicated yes, paranoia, delusions, and aggressiveness with staff and residents. Surveyor asked what is meant by aggressiveness and LPN C indicated verbal aggressiveness that has been happening for a long time. Surveyor asked LPN C if she is aware of any other incidents regarding R1 and other residents. LPN C indicated yes, there was an altercation awhile back with R1 and R12. Surveyor asked LPN C what the facility's process is for a resident-to-resident altercation. LPN C indicated the staff are to separate the residents, make sure they are safe, and report it. LPN C indicated the facility would have to investigate and report it to the state.On 3/17/26 at 12:25 PM, Surveyor interviewed CNA D and asked if she was aware of an altercation between R1 and R5. CNA D indicated she had been charting in the conference room by the nurse station when R12 informed her R1 had just slapped R5's face. CNA D indicated R12 was right outside the conference room in the hallway and R1 and R5 were in front of R12. CNA D indicated she did not witness the slap. CNA D separated R1 and R5 immediately by taking R5 down the hallway. CNA D informed LPN C right away once CNA D separated the two residents and both residents were safe. Surveyor asked CNA D if R1 had ever struck another resident and CNA D indicated yes, R12. CNA D indicated R1 had slapped R12 on her face a year or so ago. Surveyor asked if R1 has behaviors. CNA D indicated yes, R1 gets combative with staff and gets verbally aggressive with staff and residents. Surveyor asked CNA D, after the incident between R1 and R5 were new interventions passed on to staff on how to prevent this from happening again. CNA D indicated no, the incident was passed on in report.On 3/17/26 at 1:30 PM, Surveyor interviewed FM F who indicated on 2/16/26 LPN C informed her that R1 had slapped R5. R1 and R5's wheelchairs somehow got hung up together and R1 got frustrated and slapped R5. FM F indicated the facility has not reached out to her regarding the incident and what has been put into place to prevent future occurrences. FM F expressed concerns with R1. R1 goes into R5's room and other resident rooms and takes things. On 3/17/26 at 3:00 PM, Surveyor interviewed R12. Surveyor asked R12 if she had witnessed a resident altercation between R1 and R5. R12 indicated yes. R12 indicated R1 and R5 were both in their wheelchairs going in opposite directions and somehow the wheelchairs got caught together. R1 then slapped R5 on the shoulder. R12 indicated there were no words exchanged. R12 indicated she informed a CNA right away and that CNA separated R1 and R5. Surveyor asked R12 if she had ever been involved in an altercation with R1. R12 indicated yes, R1 grabbed her arm a few times and pulled her. R12 indicated she has told the staff, and the staff have advised R12 to not say anything to R1 anymore. R12 indicated she has observed R1 screaming and hitting at staff.On 3/18/26 at 9:25 AM, Surveyor interviewed CNA E. Surveyor asked if R1 has behaviors and CNA E indicated yes, R1 is verbally and physically aggressive with staff and residents. CNA E indicated a while back R1 hit R12. CNA E indicated she recently heard R1 had hit R5. Surveyor asked if CNA E was aware of any new interventions put into place after the incident with R1 and R5. CNA E indicated no and explained CNA E would know because she is responsible for updating the CNA cheat sheets. The cheat sheets direct the CNAs how to care for the residents. CNA E indicated if there were new interventions she would have known to add them onto those sheets. CNA E indicated she is to update the cheat sheets every week. Surveyor asked CNA E what R1's typical day is like. CNA E indicated when R1 is not sleeping, R1 tootles around the unit independently. Surveyor asked CNA E if R1 participates in activities. CNA E indicated we try but R1 will not stay in the activities. On 3/18/26 at 11:00 AM, Surveyor interviewed NHA A and asked what the facility's process is for a resident-to-resident altercation. NHA A indicated that staff report the incident to her. NHA A then reports it to the state, investigates it and provides education. Surveyor asked NHA A if she was aware of an incident between R1 and R5 on 2/16/26. NHA A indicated she does not recall. Surveyor asked NHA A if staff had informed her of R1 slapping R5 on 2/16/26. NHA A indicated on 2/16/26 LPN C or ADON at that time did report that R12 witnessed R1 slapping R5. Surveyor asked NHA A who had reported the incident to the ADON. NHA A could not recall. Surveyor asked whom R12 reported the incident. NHA A indicated she could not recall. Surveyor asked if there was any documentation on this incident. NHA A indicated no it was just conversation. Surveyor asked NHA A if there should be documentation; NHA A indicated yes. Surveyor asked what NHA A had done with the information she received from staff. NHA A indicated she talked to R12. R12 indicated that R1 did not slap R5. R12 indicated to NHA A that R1 was tapping R5 on the face. NHA A indicated R1 and R5's wheelchairs had somehow hung up together. NHA A indicated there were no words exchanged between R1 and R5. NHA A indicated she had no concerns after talking with R12 about the incident. Surveyor asked if there was any follow up with R1 and R5 after the conversation with staff and R12. NHA A indicated no. Surveyor asked if NHA A interviewed the CNA and nurse that had reported it. NHA A indicated no. Surveyor asked if the facility interviewed other residents to see if there were concerns regarding R1 and their safety in the facility. NHA A indicated no. Surveyor asked NHA A how it was determined not to investigate this resident-to-resident altercation. NHA A indicated R12 stated R1 lightly tapped R5 on the face. Surveyor asked NHA A should a resident-to-resident altercation be investigated? NHA A indicated yes. Surveyor asked NHA A if this incident could have been potentially reportable to state. NHA A indicated yes. Surveyor asked if there should have been documentation on this incident; NHA A indicated yes.

Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 4 of 17 sampled residents (R6, R2, R24, and R16). R6 and R16 are being cited at severity level 3 (actual harm). R2 and R24 are being cited at severity level 2 (potential for more than minimal harm). R6 has diagnoses of neurogenic bowel (loss of normal bowel function) and constipation. The facility failed to accurately assess and monitor R6 for constipation, decreased fluid intake and output as well as changes in R6's mental status, resulting in frequent visits to the emergency department. The facility failed to notify R6's primary care physician of his level of inadequate fluid intake and significant increases in urine output. Between 1/1/25 and 3/31/25, R6 has been send to the hospital several times requiring IV (intravenous) fluid administration. R16 experienced sudden onset of four (4) projectile coffee ground emesis (forceful vomiting of dark digested blood). The facility waited 2+ hours to send R16 to the ED (emergency department). R24 had a change of condition and focused assessments were not completed for continued monitoring of changes. R2 had a changes in her physical condition that were not addressed by the facility as a change in condition. This is evidenced by: The facility policy entitled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, dated 9/2017, states, in part: . 1. As part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. This should include a review of gastrointestinal problems during any recent hospitalization s . 2. Examples of lower gastrointestinal tract conditions and symptoms include: . f. alteration in bowel movements; . h. Residents taking antidiarrheal medications or medications related to bowel mobility . 3. In addition, the nurse shall assess and document/report the following: . c. change in mental status or level of consciousness; . e. Signs of dehydration (altered level of consciousness, lethargy, dizziness, recent change in mental status, dry mucous membranes, decreased urine output); f. Abdominal assessment; . Treatment/Management . 3. The staff and physician will address significant complications due to bowel dysfunction . Monitoring and Follow-Up . 2. The physician will adjust interventions based on identification of causes, resident responses to treatment, and other relevant factors. 3. Before prescribing additional courses of medications, the physician should carefully evaluate and examine directly an individual who has not responded as expected to an initial course of treatment such as antidiarrheal medication, changes in the bowel regimen, etc. The facility policy entitled, Bowel Management Protocol, undated, states, in part: 1) NOC (Night Shift) Nurse will run the Resident Bowel Management Report in [Name of Electronic Medical Record] each NOC shift . 2) Identify all residents who have not had a bowel movement in the last 2 or more days and add them to the Nurse's Daily Bowel Report. 3) Provide Dietary department a copy of the Nurse Daily Bowel Report by 6 AM . 4) Follow this procedure for residents with 2 or more days since last bowel movement. Day #2 No Bowel Movement -Dietary will provide a natural remedy (i.e. power pudding, prune juice, prunes, fiber cookie) with the AM (morning) meal. Day #3 No Bowel Movement - Dietary will provide a natural remedy (i.e. power pudding, prune juice, prunes, fiber cookie) with the AM meal. -AM Nurse will complete a full bowel assessment and document a progress note in [Name of Electronic Medical Record]. - If resident has not had a bowel movement by 12:00 PM, AM Nurse to administer 30 mL of Milk of Magnesia (Laxative that pulls water into the bowel) per Standing Orders. Day #4 No Bowel Movement -NOC Nurse will complete a full bowel assessment and administer Bisacodyl (Laxative that increases movement in the intestines) 10 mg (milligrams) suppository per Standing Orders on last rounds . then document a progress note in [Name of Electronic Medical Record]. -If a resident has not had a bowel movement by 11 AM: -Dietary will provide a natural remedy (i.e. power pudding, prune juice, prunes, fiber cookie) with the meal. -AM Nurse will complete a full bowel assessment and document a progress note in [Name of Electronic Medical Record] and update MD (Medical Doctor) as well as resident responsible party. The facility policy entitled, Resident Hydration and Prevention of Dehydration, dated 10/2017, states, in part: Policy Statement: This facility will strive to provide adequate hydration and to prevent and treat dehydration. Policy Interpretation and Implementation 1. The dietitian will assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need. 2. Minimum fluid needs will be calculated and document on initial, annual, and significant change assessments, using current standards of practice .4. The dietitian and nursing staff will educate the resident and family regarding hyderation [sic] and preventing dehydration. 5. Nurses will assess for signs and symptoms of dehydration during daily care. 6. Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily routine bases as part of daily care. a. Intake will be document in the medical records. b. Aides will report intake of less than 1200 ml (milliliters)/day to nursing staff . 8. Orders may be written for extra fluids to be encouraged between meals and/or with medication passes. a. A specific minimum amount should be included in the order . 9. The dietitian, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake . 12. Nursing will monitor and document fluid intake and the dietitian will be kept informed of status. The interdisciplinary team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved. According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. Example 1: R6 was admitted to the facility on [DATE], with diagnosis that include, in part: heart failure, epilepsy (seizure disorder), generalized anxiety disorder, cerebral infarction (stroke), hypertension (high blood pressure), history of cardiac arrest (heart stops beating), presence of other cardiac implants and grafts. hereditary spastic paraplegia (group of hereditary disorders causing progressive, spinal, spastic leg muscle weakness), MELAS syndrome (genetic disorder causing muscle weakness, seizures and stroke-like episodes), neurogenic bowel (loss of normal bowel function due to a nerve problem), and constipation. R6's Minimum Data Set (MDS), with Assessment Reference Date of 3/12/25, states that R6 has a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating that R6 is cognitively intact. Section GG indicates R6 utilizes a manual wheelchair and mechanical lift for mobility. GG0115 indicates R6 has impairment on both his right and left lower extremities. GG0130 indicates he is independent for eating, and dependent on staff for toileting hygiene, showering and bathing, and lower body dressing. GG0170 indicates R6 is dependent on staff for rolling left and right, transferring between a chair and a bed, and transferring to a toilet is marked not applicable. Section H indicates R6 has an indwelling catheter. H0400 indicates R6 is always incontinent of bowel. H0500 indicates that a toileting program is currently being used to manage R6's bowel continence. H0600, which asks if there is constipation present is not complete. Section K indicates R6 has no signs or symptoms of a swallowing disorder. R6's Comprehensive Care Plan states, in part: Problem: Potential for dehydration r/t (related to) frequent episodes of N/V (nausea/vomiting), recurrent UTI's (urinary tract infections), periods of lethargy with refusals of meals/fluids. Problem Start Date: 12/10/24. Approach: Frequent oral cares d/t (due to) emesis (vomiting) and dehydration. Approach Start Date: 1/23/25. Approach: Assess for dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance). Approach Start Date: 12/10/24. Approach: Document any and all refusals for this resident. Approach Start Date: 12/10/24. Approach: Encourage fluids of choice. Keep iced water cup filled at bedside. Approach Start Date: 12/10/24. Approach: Record intake and output every shift. Approach Start Date: 12/10/24. Approach: Update wife every shift if resident has any nausea or vomiting, poor intake and any other changes. Approach Start Date: 12/10/24. (Of note: This problem was created on 12/10/24, with all approaches starting the same day except for frequent oral cares which started 1/23/25. No additional approaches or interventions were put in place to improve R6's fluid intake, even with multiple hospitalization s.) Problem: Resident has potential for constipation R/T (related to) decreased mobility. Problem Start Date: 11/18/16. Problem End Date: 7/11/23. Edited: 2/25/25. Goal: Resident will have a regular, soft-formed bowel movement at least every 3rd day. Long Term Goal Date: 5/25/25. Approach: Follow bowel protocol as needed. Approach Start Date: 3/1/23. Approach: Monitor unbilical for any changes in hernia type protruding area, pain or change in bowel movements. Update MD if changes. Approach Start Date: 6/28/18. Approach: Administer medications per MD order. Monitor effectiveness and side effects. Approach Start Date: 11/18/16. Approach: Document frequency and character of bowel movements. Approach Start Date: 11/18/16. Approach: Encourage fluids of choice. Approach Start Date: 11/18/16. Approach: Monitor for signs of constipation such as decreased bowel sounds/abdominal pain/distension/decreased appetite/fever, etc. Approach Start Date: 11/18/16. (Of note: This problem start date is indicated to be 11/18/16 and no approaches or interventions were put in place after 3/1/23. Also of note, this problem is indicated to have an end date of 7/11/23.) Problem: Resident requires supra pubic catheter R/T DX (Diagnosis): neurogenic bladder (bladder control is affect due to nerve damage). HX (History): chronic, frequent UTI's. Approach: Encourage fluids of choice. Water mug within reach and encouraged to drink every 2 hours. Family supplies [Brand Name] packages to flavor water. Approach Start Date: 3/12/25. Approach: Record catheter output amount. Change catheter per [Doctor's Name] orders only. Approach Start Date: 9/21/21 . Problem: Basic CNA (Certified Nurse Assistant) Care Plan. Problem Start Date: 9/13/24. Approach: . Transfers: Hoyer and assist of 2 . Grooming/Dressing/Toileting: . Extensive assist with hygiene and dressing. Supra pubic catheter. Incontinent of bowel. Provide incontinence care after each incontinence episode . Behavior and Cognition: Pleasant and cooperative . Approach Start Date: 9/13/24. (Of note, this care plan does not indicate Water mug within reach and encouraged to drink every 2 hours.) R6's Physician Orders state, in part: Benefiber (Fiber Supplement, Supports Digestive System) Clear SF (dextrin) (wheat dextrin) powder in packet; 3 gram/3.5 gram; amt (amount): 2 tsp (teaspoons); oral, Once a day, 12:00 PM. Start Date: 11/14/24. End Date: 1/30/25. Start Date: 1/30/25. End date: 3/24/25. Bisacodyl (Laxative that increases movement in the intestines) [OTC] (Over the Counter) suppository; 10 mg (milligrams); amt: 1 suppository (solid dosage form inserted into the rectum where it dissolves or melts to deliver medication); rectal. Special Instructions: Give at 8 pm and 5 am daily. Twice a day. 20:00 (8:00 PM), 04:00 (4:00 AM). Start Date: 11/16/24. End Date: 1/10/25. Bisacodyl [OTC] (Over the Counter) suppository; 10 mg (milligrams); amt: 1 suppository; rectal. Special Instructions: Give at 8 pm and 4 am daily (may be given at 3A (3:00 AM) if awake). Twice a day. 20:00 (8:00 PM), 04:00 (4:00 AM). Start Date: 1/10/25. End Date: 1/30/25. Bisacodyl [OTC] (Over the Counter) suppository; 10 mg (milligrams); amt: 1 suppository; rectal. Special Instructions: Insert 1 suppository to equal 10 mg per rectum BID (twice a day) at[sic] 8 pm and 4 am daily (may be given at 3A if awake). [NAME] a day. 20:00, 04:00. Start Date: 1/30/25. End Date: 3/24/25. Bisacodyl [OTC] tablet, delayed release (DR/EC); 5 mg; amt: 1 tab daily; oral. Special Instructions: Take one tablet daily. Once a day. 06:30-10:00. Start Date: 9/19/24. End Date: 1/30/25. Bisacodyl [OTC] tablet, delayed release (DR/EC); 5 mg; amt: 1 tab daily; oral. Special Instructions: Take one tablet to equal 5 mg daily X 360 doses. Once a day. 06:30 - 10:00. Start Date: 1/30/25. End Date: 1/25/26. Docusate sodium (stool softener that increases the amount of water the stool absorbs in the gut to treat constipation) [OTC] tablet; 100 mg; amt: 200 mg; oral. Special Instructions: Give Docusate Sodium 200 mg BID (twice a day). Twice a day. 06:30 - 10:00, 18:30 - 22:30 (6:30 PM - 10:30 PM). Start Date: 12/5/24. End Date: 1/30/25. Start Date: 1/30/25. End Date: 3/24/25. Electrolyte (Electrolyte Supplement) Fast Chew tablet; 0.5 (3.3g); amt: 1; oral. Once a day. 06:30-10:30. Start Date: 6/22/24. End Date: 1/30/25. Electrolyte Fast Chew tablet; 0.5 (3.3g); amt: 1; oral. Special Instructions: Take 1 tab to equal 3.3 g daily. Once a day. 06:30-10:30. Start Date: 1/30/25. End Date: 3/24/25. Fleet Enema (sodium phosphates) (draws water into colon and rapidly produces a bowel movement) [OTC] enema (introduction of liquid through rectum into the large intestine to treat constipation); 19-7 gram/118 mL (milliliters); amt: 133 mL; rectal. Special Instructions: Insert 133 mL into rectum daily PRN (as needed) for constipation. As needed. PRN 1 (as needed once per day). Start Date: 1/30/25. End Date: 3/24/25. Milk of Magnesia (Laxative that pulls water into the bowel) (magnesium hydroxide) [OTC] suspension; 400 mg/5 mL; amt: 30 ml; oral. Special Instructions: daily prn for constipation. As needed. PRN 1. Start Date: 6/22/24. End Date: 1/30/25. Milk of Magnesia (Laxative that pulls water into the bowel) (magnesium hydroxide) [OTC] suspension; 400 mg/5 mL; amt: 30 ml; oral. Special Instructions: Take 30 mL daily PRN for constipation. As needed. PRN 1. Start Date: 1/30/25. End Date: 3/24/25. Miralax (Laxative that draws water into the bowels) (polyethylene glycol 3350) [OTC] powder; 17 gram/dose; amt: 17 grams; oral. Special Instructions: MIX IN ORANGE JUICE PER RESIDENT REQUEST. Once a Day on Mon (Monday). 11:00 - 13:00 (1:00 PM). Start Date: 6/22/24. End Date: 1/30/25. Miralax (polyethylene glycol 3350) [OTC] powder; 17 gram/dose; amt: 17 grams; oral. Special Instructions: RESIDENT WOULD LIKE MIRALAX MIXED WITH ORANGE JUICE. MIX WITH METAMUCIL AS WELL AND TELL RESIDENT WHAT HE IS RECEIVING PER FAMILY. Hold if having loose stools. Twice a day. 06:30 - 10:30, 18:00 - 22:30. Start Date: 6/22/24. End Date: 1/30/25. Start Date: 1/30/25. End Date: 3/24/25. Start Date: 3/25/25. Senna Plus (Keeps water in the intestines which increases movement in the intestines and treats constipation) (sennosides-docusate sodium) [OTC] tablet; 8.6-50 mg; amt: 17.2 - 100 mg; oral. Special Instructions: Give Senna Plus 2 tablets daily. Hold if having loose stools. Twice a day. 06:30 - 14:00 (2:00 PM), 18:30 - 22:00. Start Date: 6/22/24. End Date: 1/30/25. Senna Plus (sennosides-docusate sodium) [OTC] tablet; 8.6-50 mg; amt: 17.2 - 100 mg; oral. Special Instructions: Take 2 tabs to equal 17.2 - 100 mg daily. Hold for loose stools. Once a day. 06:30 - 14:00 (2:00 PM). Start Date: 1/30/25. End Date: 3/24/25. Soap suds enema (Irritates the lining of the colon which stimulates bowel contractions and encourages person to release contents of their bowel) enema; warm soap suds; at least 500 ml; rectal. Special Instructions: if no results from scheduled bisacodyl suppositories given at HS (bedtime) and 0400 (4:00 AM), sign out and give warm soap suds enema if no results from suppositories. As needed. PRN 1. Start Date: 1/12/25. End Date: 2/3/25. Soap suds enema, enema; warm soap suds; amt: at least 500 ml; rectal. Once a day. 10:00 (10:00 AM). Start Date: 2/4/25. End Date: 2/10/25. Sodium chloride 0.9% (IV Fluid Replacement) parenteral (intravenous) solution - ; amt: 125 ml/hr (milliliters/hour) over 16 hours; intravenous. Special Instructions: Order updated since resident had a liter of fluids while at the ER (emergency room ). Now run 0.9% sodium chloride at 125 ml/hr over 24 hours; intravenous. Once - One Time. 22:00 (10:00 PM). Start Date: 1/22/25. End Date: 1/22/25. Encourage fluids every shift. Every Shift; day, pm, noc. Start Date: 1/18/23. End Date: Open Ended. UPDATE WIFE EVERY SHIFT IF RESIDENT HAS ANY NAUSEA OR VOMITING, POOR INTAKE, AND ANY OTHER CHANGES. Special Instructions: call if output less than 3000 ml in 24 hrs, call if input is less than 64 oz. Every Shift; day, pm, noc. Start Date: 11/4/24. End Date: Open Ended. (Of note: This list contains 5 different medications that either draw water into the colon or prevent the body from absorbing water from the colon. On 12/10/24 at 21:57 (9:57 PM), a Progress Note is written that states, in part: Notes from [Physician's Name] visit today: Make sure he has 64 oz (ounces) (1,893 milliliters) of fluid daily . please keep track of urine output daily . chronic constipation, continue with current bowel regimen and fluid intake . On 12/11/24 at 14:39 (2:39 PM), a Progress Note is written by LPN S (Licensed practical Nurse), that states, in part: .He did not have a BM (bowel movement) from scheduled Bisacodyl suppository given on noc (night) shift. PM (Evening) nurse aware. Resident drank 480 ml at both meals and drank 360 ml water with med passes. He was drinking his flavored ice water in his personal water bottle. He drank approximately 16 oz (473 ml) by the end of this shift . (Of note, no bowel assessment is indicated as being done) On 12/27/24 at 12:32 PM, a Telephone Note is written by a clinic RN, that states, in part: .Note from 12/10/24 visit: 1. Constipation -Return to previous bowel regimen: bisacodyl suppository twice daily (morning and night) . -Encourage fluid intake goal of 64 ounces daily (two 32[sic]-ounce containers) . R6's Fluid Intake is care planned to be documented every shift. From 1/1/25 to 3/25/25, R6 had no fluid intake documented for 15 different days. In a physician's note to the facility, the physician reports R6 requires 64 oz (1,893 mL) every day to maintain hydration. From 1/1/25 to 3/25/25 R6 never reaches his fluid intake goal. The most fluid intake that R6 had in a single day, according to facility documentation, was 1,360 mL. On 1/1/25 at 13:43 (1:43 PM), a Progress Note is written by LPN S, that states, in part: Resident had large BM as a result of scheduled Bisacodyl suppository given by noc nurse . Resident offered no c/o pain, SOB (shortness of breath) or feeling ill . On 1/1/25, R6 consumed 480 mL of fluid, according to the fluid intake record. The resident is documented to have a large bowel movement at 14:43 (2:43 PM). On 1/2/25 at 13:34 (1:34 PM), a Progress Note is written that states: Resident was lethargic and hard to arouse all morning, writer entered room on 3 separate occasions to evaluate VS (vital signs) wnl (within normal limits), resident would raise head, open and close eyes, lower head, no response to questions, after the third time, I s/w (spoke with) his wife who agreed that we should send him to the hospital, about an hour later (at which point we were waiting for transport,), resident awoke and claimed to feel fine. (Of note: No bowel assessment documented prior to transport) On 1/2/25 at 15:43 (3:43 PM), a Progress Note is written by RN AA (Registered Nurse), that states, in part: Resident left facility at this time via [EMS Agency Name] EMS . On 1/2/25 at 23:15 (11:15 PM), R6 is documented to have a large bowel movement. On 1/2/25 at 23:23 (11:23 PM), a Progress Note is written by RN Z, that states, in part: Resident returned from ER (emergency room ) visit at PM/NOC (Evening/Night) cross shift. Resident recorded not to have had a bowel movement since 1/1/25. Resident given a prn warm water soap suds enema of 750 ml which produced an x (extra) large liquid and soft formed stool bowel movement. After getting cleaned up, resident was given his scheduled PM shift bisacodyl suppository. On 1/4/25, R6 consumed 240 mL of fluid, according to the fluid intake record. The resident did not have a bowel movement. On 1/5/25, R6 consumed 480 mL of fluid, according to the fluid intake record. The resident is documented to have a large bowel movement at 14:00 (2:00 PM). On 1/6/25, no fluid intake is documented for R6. The resident is documented to have a small bowel movement at 20:56 (8:56 PM) and a large bowel movement at 23:03 (11:03 PM). On 1/6/25 at 23:08 (11:08 PM), a Progress Note is written by RN Z, that states, in part: Called to resident's room by CNA (Certified Nursing Assistant) stating that resident had a large emesis. Resident observed to have a large projectile emesis that was liquid brown in color with some small amounts of brown colored sediment that was highly suspicious of stool. Staff had been in resident's room to clean him up after him having a large liquid brown stool from his late PM shift scheduled bisacodyl suppository . Resident was alert and able to answer simple questions, but appeared worn out and very tired . Resident stated he drank very little for fluids . Phone call to [Physician Name] who was on call for [Physician Name] and permission to send resident to [Hospital Name] ER for evaluation . (Of note: No lung or bowel assessment documented prior to transport). On 1/7/25 at 03:46 AM, a Progress Note is written by RN Z, that states, in part: Phone call from [Hospital Name] ER and spoke with nurse caring for resident. Resident is being admitted for some more labs and possible ABX (antibiotic) TX (treatment) On 1/9/25 at 14:18, a Progress Note is written by RN BB that states, in part: Resident returned via stretcher from hospitalization [Hospital Name] discharge dx (diagnosis): Pneumonia . On 1/19/25 at 15:33 (3:33 PM), a Progress Note is written by RN BB that states, in part: 600 ml warm water/[NAME] soap enema given at 1530 (3:30 PM) producing large bowel movement-soft, formed . Resident's fluid intake has been only fluids at meals and with meds (medications) . On 1/20/25, R6's fluid intake was not recorded. Total urine output was 950 mL. The resident is not documented to have a bowel movement on this day. On 1/20/25 at 13:04 AM (1:04 PM), a Progress Note is written by LPN R that states, in part: Small emesis of yellow bile after enema this am . Denies pain. Drank 240 this am and 720 this afternoon. Working on water bottle in room at this time. On 1/21/25, R6's fluid intake was not recorded. Total urine output was 1,600 mL. The resident is not documented to have a bowel movement on this day. On 1/21/25 at 10:35 AM, a Progress Note is written by LPN R that states, in part: Resident lethargic this am (morning). Responds appropriately to verbal stimuli. Opens eyes to commands but falls back to sleep. Decline breakfast stating he is sick to stomach at this time. PRN (as needed) Zofran (anti-nausea medication) administered. Up in recliner at this time . On 1/21/25 at 13:56 (1:56 PM), a Progress Note is written that states, in part: Called [Physician Name]'s office regarding resident vomiting for 2-3 days, has not held anything down today, including morning meds and has been unable to stay awake. Writer concerned about dehydration . (of note, there is no indication if this author was an LPN or an RN) (Of note: There is only one prior note in the past 2-3 days referencing vomiting. No abdominal assessments were conducted during the past 2-3 days. R6 did not have a bowel movement on 1/20 or 1/21 per charting above.) On 1/22/25 at 10:04 AM, an After Visit Summary was printed that lists the diagnosis as: Nausea and Vomiting, unspecified vomiting type. On 1/21/25 at 23:13 (11:13 PM), a Progress Note is written that states, in part: Res returned from the hospital around 1900 (7:00 PM) via EMS on a stretcher. EMS reported that res had emesis coming up the elevator . BP (Blood Pressure) 98/46 . p (pulse): 56 . RR (Respiratory Rate) 22 . Res BP was rechecked later in the shift, with a BP reading of 100/57. Res was encouraged to increased fluid intake . (Of note: No abdominal assessment or bowel sounds recorded.) On 1/22/25, R6's fluid intake was documented as 30 mL. Total urine output was 900 mL, indicating a fluid loss of 870 mL. The resident is not documented to have a bowel movement on this day. (Of note: R6 did not have a BM on 1/20, 1/21 or 1/22 per charting) On 1/22/25 at 06:31 AM, a Progress Note is written by RN Z that states, in part: Resident lethargic this morning and minimally responsive to verbal commands to where it was unsafe for him to take his early morning meds. Resident[sic] has not had any results from his bisacodyl suppository administered at 0400am (4:00 AM) or on the PM shift. Resident vitals all within normal limits with exception of a pulse that seems slower than his usual . Order given to send to resident in to [Hospital Name] ER for evaluation again. Note resident has not had a reported or recorded BM since 1/19/25. When paramedics arrived to transport, resident responded enough to try and drink a small amount of water which almost immediately came [sic] back up. Resident had 200 ml emesis . On 1/22/25 at 10:04 AM, an After Visit Summary was printed from R6's ER visit that lists the diagnosis as nausea and vomiting, unspecified vomiting type. On 1/22/25 at 15:09 (3:09 PM), a Progress Note is written by LPN S that states, in part: Writer learned of resident's return to facility via [EMS Agency Name] service as he arrived to unit . He opened his eyes here and there but did not keep them open for any length of time . He opened his eyes to verbal stimuli but did not keep them open for too long. He did take noon med crushed in pudding but needed verbal cues to swallow the pudding once it was in his mouth. His mouth was so dry upon return that he was unable to suck on a straw so writer used the straw to put water in the side of his cheek which he was able to swallow w/o difficulty. Resident declined lunch . Just before the end of shift he drank 180 ml water that writer offered. He has had no emesis since . (Of note: No abdominal assessment was recorded over this time period. Additionally, the LPN notes signs of dehydration at this time, however Surveyor was unable to locate an RN assessment in reference to these concerns.) On 1/22/25 a Physician's Order is placed that states, in part: Send to [Hospital Name] ER for IV placement so resident can have his ordered IV fluids x 24 hrs. STAT - Immediately. STAT. Start Date: 1/22/25. End Date: 1/22/25. (Of note: an RN is licensed and trained to place IV's as part of the licensure process.) On 1/23/25 at 00:29 (12:29 AM), a Progress Note is written by RN Z that states, in part: [EMS Agency Name] arrived to transport resident to [Hospital Name] ER[sic] for IV placement. Resident had a medium emesis of yellow thin fluid . On 1/23/25 at 02:30 (2:30 PM), a Progress Note is written by RN Z that states, in part: . Resident had IV (intravenous) placed and they gave him a liter of fluid in the hospital. Will continue to administer the remainder of the fluids (2 liters) upon resident's return. On 1/23/25 at 04:16 (4:16 AM), a Progress Note is written by RN Z that states, in part: Resident has not had a recorded bowel movement since 1/19/25. PRN 750 ml warm soap suds enema was given in lieu[sic] of scheduled bisacodyl suppository. Resident did not appear to have any results immediately from the enema only expelling stool colored water. (Of note: Facility continues to acknowledge resident has not had a bowel movement, and it has now been 4 days since R6's previous bowel movement. Additionally, no bowel assessment has been conducted.) On 1/23/25 at 04:49 (4:49 AM), a Progress Note is written by RN Z that states, in part: Resident returned from [Hospital Name] ER . Resident has IV placed in left hand and reported to have received a liter[sic] of fluids while in the ER . had IV fluid order updated to infuse at 125ml/hr (milliters/hour) for sixteen hours. On 1/23/25 a Physician Order is placed that states, in part: Frequent oral cares d/t emesis and dehydration. Every shift. day, pm, noc. Start Date: 1/23/25. End Date: 1/25/25. On 1/23/25 at 12:20 PM, a Progress Note is written by LPN R that states, in part: Called to resident room at 1130 (11:30 AM). Resident with moderate amount of[sic] bile emesis present . [EMS Agency Name] picked resident up at 1200 (12:00 PM) for transport to [Hospital Name] . (of note: no evidence of an RN assessment being completed) On 1/23/25 at 16:38 (4:38 PM), a Progress Note is written that states, in part: [Hospital Name] RN called to request the medication record to be faxed to [phone number] . RN stated patient is admitted as admitting diagnosis was Altered Mental Status with S&S (Signs and Symptoms) of Confusion, Cough, and Nausea . On 1/27/25 at 11:50 AM, a Progress Note is written by RN BB that states, in part: Discharge diagnosis listed emesis and constipation . (no evidence of continued monitoring or assessments being completed on R6 after returning from the hospital other than documenting if R6 had N/V or not.) On 1/29/25 at 14:01 (2:01 PM), a Progress Note is written by LPN S that states, in part: . He received prn Soap Suds Enema from [LP[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure a resident (R291) did not abuse 2 out of 18 sampled Residents (R290 and R33.) R291 has a history of exhibiting socially inappropriate/disruptive behavior towards staff and other residents. The facility was aware of R291's behavior and this behavior was noted in R291's care plan. R291's care plan indicates R291 is one on one supervision while resident awake, door alarm, and 15-minute checks while resident is sleeping. Despite knowing these behaviors, the facility did not ensure R291 had adequate supervision which led to R291 entering R290's room, physically grabbing R290's head while R290 was in bed, and screaming and swearing at R290 to Get the fuck out of my bed. On the annual survey, R291 entered R33's room and Surveyor observed R291 hit R33 on the head. Surveyor observed R291 agitated, difficult to redirect, and going in to R33's room twice, the second time R291 hit R33 on the head. Surveyor observed R291 attempting several times to enter R290's room. Surveyor observed a staff attempting to support R291 but was not successful. No other staff or management came to support R291 during this time. The facility previously had an immediate jeopardy that began on 9/8/22 and was removed on 10/21/22 due to abuse and not supervising R291. The facility's Plan of Correction (POC) states, in part, 1:1 supervision of resident when outside of the resident's room Ongoing 15-minute checks completed by floor nurse or assigned CNA (Certified Nursing Assistant) door alarm present . The facility's failure to ensure adequate supervision to prevent abuse created a finding of immediate jeopardy that began on 1/6/23. Surveyor notified the Director of Operations and Director of Nursing of the immediate jeopardy on 1/11/23 at 12:30 PM. The immediate jeopardy was removed on 1/10/23; however, the deficient practice continues at a scope/severity of D as the facility continues to implement its action plan. Evidenced by: The facility policy titled Abuse Prevention Program with a revision date of December 2016, states in part; Policy Statement our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 5. Implement measures to address factors that may lead to abusive situations, for example: a. Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; b. Instruct staff regarding appropriate ways to address interpersonal conflicts; and c. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements; 8. Protect residents during abuse investigations; 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and 10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. In Sexual Abuse of Older Nursing Home Residents: A Literature Review, the authors note the statement by the World Health Organization, Regardless of the type of abuse psychological, physical, sexual, financial, and neglect, it will certainly result in unnecessary suffering, injury or pain, the loss or violation of human rights, and a decreased quality of life for the older person https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4302365/ R291 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's Disease with late onset, Anxiety Disorder, Insomnia, Restlessness and agitation, Depression, and Alcohol abuse. R291's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/13/22, indicates R291 has a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. R291 has an Activated Health Care Power of Attorney (APOAHC). R291's Comprehensive Care Plan, indicates, in part: Problem start date: 10/27/22, Behavioral Symptoms - Resident has expressed sexual behaviors towards others and based on assessment is unable to consensually participate in this type of behavior. Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by sexually inappropriate behaviors and foul language towards staff and other residents. Long Term Goal Target Date 3/16/23: Resident will accept redirection when exhibiting socially inappropriate/disruptive behavior toward staff or other residents. Approach: Start Date 10/27/22, administer medications per physician orders, assess resident as needed using the sexuality and intimacy worksheet, remind resident he is married and provide education related to appropriate interactions with others, avoid over-stimulation, identify and report possible triggers for suggestive or sexual language, maintain a calm, slow, understandable approach and environment for and with resident. Observe and report socially inappropriate/disruptive behaviors when around others. Provide snack (ice cream), provide meaningful engagement or activities to resident, remove resident from group activities when behavior is unacceptable, remove resident from other resident's rooms and unsafe situations. Staff should watch their body language staff wear appropriate attire. Staff should be aware of their own body language and conversations they are having with coworkers, visitors and residents. Staff should explain their role upon entering room. Address the resident formally and maintain their professionalism. When available, have male caregivers and nurses provide care for resident. One on one supervision while resident awake. Door alarm and 15-minute checks while resident sleeping. Problem start date: 10/19/22, Behavioral Symptoms - Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Long Term Goal Target Date 3/16/23 Resident will wander safely within specified boundaries. Approach 10/20/22 Door sensor alarm to resident's doorway to be turned on when in his room. Resident to have one on one supervision when awake. Maintain a calm environment and approach to the resident. Redirect resident if wandering into another room; offer resident to stay by nurses' station to be in line of sight of staff. When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). Problem start date: 10/4/22, Behavioral Symptoms - Resident uses inappropriate language towards others. Longer Term Goal Target Date 3/16/23 Resident will accept redirection from staff when using inappropriate language towards others. Approach 10/4/22 gently but firmly inform resident that inappropriate language are not welcome. Do not engage in discussion. Maintain a calm, slow, understandable approach . Problem start date: 9/13/22, Potential for elopement r/t cognitive status, unaware of safety concerns. Long Term Goal Target Date 3/16/23 Pt. will make no attempts of elopement E/B no sounding of code alert. Approach 9/13/22 check function weekly. Check placement every shift per nursing. Code alert bracelet to left ankle. #10. Gently redirect from stairwells and/or elevators. Picture of resident in all identified locations. Problem start date: 8/24/22 Behavioral Symptoms- Resident has been known to make sexually inappropriate comments towards staff and grabbing at staff. Long Term Goal Target Date 3/16/23 Resident will accept assistance from staff, if resident is not redirectable, staff will ensure resident is safe, leave resident's room and reapproach. Approach 10/20/22 door sensor alarm in resident's doorway to be turned on when resident is in his room. Resident to have one on one supervision. Approach start date 10/4/22 gently but firmly inform resident that inappropriate touching and/or sexual remarks are not welcome. Do not engage in discussion. If continues, ensure resident safety and reapproach with second staff person to complete cares. Approach start date 9/8/22 resident to have supervision when around female residents. Staff to ensure no inappropriate interactions . Problem start date: 5/6/22 Behavioral Symptoms - APOAHC stated resident has a history of grabbing other residents aggressively and becoming physically aggressive with staff. APOAHC indicated resident has not made any sense when he talks; resident is able to form words, but the words together do not make sense. Resident has used swear words often. Approach start date 5/6/22 Staff can attempt to redirect resident. Staff should have a calm approach when interacting with resident. Ask simple yes, no questions. Staff can meet with resident 1:1 if needed/able. If resident becomes agitated staff can reapproach after giving resident time to calm down. During periods of increased agitation, remove resident away from other residents and take to safe area to calm down. Approach start date 8/2/22 Approaches to redirect resident to his own room. Sign placed outside of resident's room to direct him to his own room. Surveyor asked for R291's Certified Nursing Assistant (CNA) Care Card. Facility provided a document titled, Profile Care Plan Approaches which states, in part: Nutritional Status 6/9/22, .1:1 supervision at meals .If you have to leave resident, move all food and inedible items out of his reach. Behavioral Symptoms 10/4/22, Gently but firmly inform R291 that inappropriate touching and/or sexual remarks are not welcome. Do not engage in discussion. If continues, ensure resident safety and reapproach with second staff person to complete cares. Behavioral Symptoms 10/27/22, Resident should be placed in a calm and quiet environment at least an arms length away from other residents to ensure resident's safety. Surveyor reviewed Physician Order Report 1/1/23-1/31/23 which states, in part: Start date, 8/29/22 May be seen by behavioral health, start date 8/29/22 Target Behavior: (sexual inappropriateness, increased resident distress, dangerous to self or others) At the end of each shift mark frequency - how often behavior occurred and intensity - how resident responded to redirection, intensity code: 0=did not occur, 1=easily altered, 2=difficult to redirect. Special instructions staff note: add frequency and intensity med notes to order for tracking. Every shift; day, pm, noc. Start date, 9/13/22 Check placement of wander guard every shift. Start date, 9/20/22 check wander guard function weekly. Start date, 11/24/22 Update POA with any instances of combative behavior (call daughter). Start date, 11/28/22 Check function of door alarm sensor Qshift. Every shift; day, pm, noc. Surveyor reviewed behavior tracking from 12/1/22-1/10/23 .target behavior sexual inappropriateness, increase resident distress, dangerous to self or others .out of the 41 days reviewed there is see note documented for 20 of the days. The behavior documentation is not consistently tracking intensity or frequency. Progress notes reviewed, 12/11/22 13:47 (1:47 PM) .talking and swearing very loudly at the lunch table. He did not become aggressive physically but continued to be very vocal and curse .12/16/22 14:23 (2:23 PM), He swung at CNA and connected with her left shoulder-did not cause injury. 12/17/22 21:24 (9:24 PM), CNA needed assistance with toileting resident, while nurse and CNA were toileting resident, he hit CNA in her face causing her to bite the inside of her lip. Nurse and CNA redirected and educated resident. After toileting resident, staff was able to place resident in bed 12/18/22 22:13 (10:13 PM), Resident looking for the bathroom; was redirected back to his room Writer entered room to find CNAs in bedroom with resident in bathroom pacing. Writer offered assist to resident. Resident stated, I gotta take a piss and they told me I had to come in here.Resident proceeded to pull out his penis and pee in the corner .CNAs attempted to intervene which agitated resident more. Writer instructed CNAs to step back as to not overwhelm resident resident did make comments with washing of his penis and tried to grab writer's hand to move back to location, was easily redirected 12/24/22 23:48 (11:48 PM), Staff reported that during shift change resident slapped the evening shift care giver. Care giver was trying to assist resident and resident slapped her. 1/1/23 0:00 (12:00 AM), Resident trying to visit with a female resident this PM, resident was hard to redirect .1/9/23 9:41 AM, .he punched first CNA in the face. 1/9/23 18:24 (6:24 PM), .resident combative with staff, hitting at staff member. 1/10/23 16:09 (4:09 PM), .resident struck another resident .1/11/23 23:36 (11:36 PM), .CNA stated that resident had been sleeping in recliner and became restless and got up. CNA was assisting with incontinence cares when resident punched her in the eye. RT (right) eye with green/purple bruising and swelling to upper eyelid . Surveyor reviewed notes from Behavioral Care Solutions (BCS) from time of admission with BCS, 9/16/22, states, in part: Patient referred for BCS services for vulgar language and aggressive behavior towards staff .9/29/22, Can get anxious and agitated at times. It is reported he did have a physical altercation with peer. Confused with poor memory 10/21/22, Note: writer received phone call from SW and nursing staff, report patient with recent increased aggression toward peers and staff, now has been wandering. Now has 1:1 sitting when out of his room and a door alarm to alert staff when he is leaving his room .Per staff, he has increased behaviors of aggression and agitation in the PM hours .11/1/22, Assessment & Plan .Encourage structured activities during the day. Provide 1:1, redirection, distraction 12/21/22, Today behavioral documentation was reviewed and reported the following symptoms: Resident yelling get the fuck out of here! Go back to your room! and continued yelling despite redirection (11/17). Cursing at others (10/23), some false beliefs expressed at times. Staff able to easily redirect, left alone to settle and re-approach. Spoke to nursing staff, it is reported that patient hit CNA during toileting assistance on 12/17/22. It is reported that at times he will wander to find the bathroom. He becomes agitated during this time and irritated staff believe it is due to his worsening Dementia and memory. Some increased confusion reported in the evening hours Assessment & Plan .Encourage structured activities during the day. Provide 1:1, redirection, distraction R290 was admitted to the facility on [DATE] with diagnoses including Hydronephrosis with Renal and Ureteral Calculous Obstruction, Nausea, Anxiety Disorder, and Pain. R290's most recent MDS with ARD of 10/23/22, indicates R290 has a BIMS score of 10, indicating R290 is moderately impaired. R290 is own person. Care plan Problem start date 10/26/22 mobility: WC for mobility. Able to propel per self. Staff to assist as needed .GROOMING/DRESSING/TOILETING: Own teeth. Set up for oral cares, UB (upper body) hygiene/grooming. Assist as needed to complete UB cares. 1 assist for LB (lower body) dressing, peri-care and showers. Scheduled toileting/check and change every 2-3 hours and PRN to decrease incontinence, promote skin integrity and dignity BEHAVIOR AND COGNITION: A&O x4. Pleasant and cooperative .STOP sign on room door to deter unwanted visitors. Surveyor reviewed Grievance/Concern Form; Date the concern occurred: 1/6/23. Summary of concern: R290 stated to me that on Friday night resident (R291) entered her room, and started moving her blinds back and forth. He also approached her and said get the hell out of my bed Resident states she had her call light on. Also states this has happened before. She was very upset. Emotional support given. RN J (Registered Nurse) completed grievance form. R33 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Anxiety Disorder, Sensorineural hearing loss, Difficulty in walking, and Cognitive communication deficit. R33's most recent MDS with ARD of 1/3/23, indicates R33 has a BIMS score of 6 out of 15 indicating R33 is severely impaired. R33 has an Activated Health Care Power of Attorney. R33's Care Plan states, in part, Problem start date 10/21/22 Resident expresses sadness/anger when she recalls having to take her daughter and leave her abusive husband previously in her life. There are no known triggers for resident. Long Term Goal Target Date: 4/10/23 Resident will demonstrate a healthy acceptance of her outcome with that situation. Approach start date 10/21/22 allow resident to express feelings. Assess for mood/behavior problems. Identify positive relationships that resident could draw on for support. Resident does not like to discuss her past physical abuse as this is how she copes with this. Staff will redirect and reassure resident if resident becomes triggered by the past event. On 1/9/23 at 4:00 PM, Surveyor introduced self to R291. R291 was in room, sitting in recliner with feet up, hands behind head, and watching TV. R291 was appropriately dressed and looked up at Surveyor and smiled. R291 started talking about trucking and was repeatedly swearing using the F word. At first R291 was smiling but he started pointing and talking about an issue with trucking. He had tears in his eyes, began frowning, started swearing louder with more aggression. R291's door alarm was activated when Surveyor walked through room door. CNA Z (Certified Nursing Assistant) approached Surveyor after alarm was sounded. CNA Z indicated R291 has a door alarm for safety reasons. R291 wanders into other resident's bedrooms. CNA Z indicated R291 is on 15-minute checks and has the door alarm when he is in his room. CNA Z indicated R291 is supposed to be one on one supervision when he is out in the common areas of the facility. CNA Z indicated there are times staff will forget to turn the alarm on and R291 will wander to the completely opposite side of the nursing home. CNA Z indicated other residents are frustrated and scared when R291 goes into their rooms. Surveyor asked if there were rooms that R291 was more likely to go in. CNA Z pointed at the two rooms (R290 and R33) next to R291. CNA Z indicated R33 doesn't seem bothered by R291 going into R33's room, but R33 forgets things right after they happen. CNA Z indicated R290 does not like when R291 goes into her room and that she is scared of R291. On 1/9/23 at 4:30 PM, Surveyor observed R291 sitting near the nurses' station. Surveyor observed the staff at the nurses' station leave the area and R291 was left with no staff near or with R291. No one on one support provided. On 1/10/23 at 8:00AM-8:20AM, Surveyor observed R291 sitting at the edge of his bed. No staff were present inside or outside of room. Door alarm was turned on. On 1/10/23 at 8:27AM-9:15AM, Surveyor observed R291 sitting in the dining room eating breakfast. R291 was sitting at a table by himself with his back turned to others and looking out the window. Staff were present assisting other residents with their meal trays and coming in and out of the dining room area. No one on one support provided. On 1/10/23 at 9:30 AM, Surveyor observed R291 sitting in wheelchair near the nurses' station. Two staff were near the computers and were talking. No one on one support provided. On 1/10/23 at 10:24 AM-12:20 PM, Surveyor observed R291 in bedroom sitting in recliner with feet up, awake and watching TV. On 1/10/23 at 9:22 AM, Surveyor introduced self to R290. Surveyor observed R290's room door shut with a small sign on door. The sign was in a shape of a hexagon, with a hand on it, light red in color, and said STOP. R290 indicated she was doing okay and that she had been at the facility since October 2022. R290 indicated she has concerns with her neighbor, R291. R290 indicated R291 is not a safe person to be around and that the stop sign on her door does not work at all. R290 indicated R291 walks into her room and will use her bathroom and that this has happened at least three different times. R290 indicated she has voiced concerns about this and the only thing that was put in place was the stop sign on the door. R290 indicated she does not understand why R291 can't be moved, that she is terrified of him, and that all the staff in the facility know this. R290 indicated that on 1/6/23 at 9:09 PM, R291 came into her room. R290 indicated this time was different than the other three times R291 entered her room. R290 indicated on 1/6/23 she was in bed, door shut, and her lights off. Surveyor observed R290's bed and noted that the head of the bed is in a direction where if someone enters the room, you would not be able to see who entered. R290 indicated she heard her bedroom door open, and her lights came on. R290 stated, The guy next door came right next to my bed and screamed, Get the fuck out of my bed. He uses the F word all the time. R290 indicated R291 was naked except for an adult brief on. R290 indicated R291 grabbed her head and continued yelling and swearing. R290 indicated she put her call light on and was repeatedly pressing the call light. R290 indicated R291 went to her blinds and was messing around with them and then took a chair and threw it. R290 indicated R291 is very strong, he's not big, but rough and very strong. R290 indicated she kept pressing the call light and that she didn't know what to do. R290 indicated she thought R291 was going to crawl into bed with her. R290 indicated, I was frightened to death. As R290 replayed the incident Surveyor observed tears in her eyes, she was holding her hands tightly and shaking. R290 indicated she did not hear R291's door alarm go off that night. R290 indicated there are times she hears the alarm, so she knows he is out and there are times that she doesn't hear the alarm and he is in her room. R290 indicated she listens for the alarm, but that it is not always reliable. R290 indicated R291 then left her room and a few minutes later a staff answered her call light. R290 indicated she told the staff what had just happened, and the staff kept saying, I'm so sorry, I'm so sorry. R290 indicated she did not know the name of the staff that answered the call light but knew that it was one of the CNAs that were working that evening. R290 indicated someone must have reported the incident because AC W (Admissions Coordinator) came and talked to her twice about it on Monday. R290 indicated there were three staff in her bathroom talking to her about the incident on Monday evening. R290 indicated one staff said, Oh, he (R291) has hit her many times. R290 indicated R291 has never physically harmed her before, but everyone knows she is scared to death of him and disgusted by him. R290 indicated she can't even stand to look at him. R290 stated, People know, everyone knows I have problems with him, nothing got done, and then the incident on that Friday happened. I can't handle this. Surveyor observed R290's voice raising and becoming louder with more panic. R290 stated, DM K (Dietary Manager) told me last week that I don't have to worry, he won't be sitting next to me [during meals]. She knows! Everyone knows. I don't want that guy next door. On 1/10/23 at 11:55 AM, CNA U indicated there is a list of people with their pictures of who wanders. CNA U indicated she knows who is at risk for wandering because she is a regular staff. CNA U indicated R291 wanders into other people's rooms. Surveyor asked what supervision is provided to R291. CNA U indicated that he is basically a one on one support when he's not in his room. CNA U indicated they had a document they were signing off for 15-minute checks for R291 as well. CNA U indicated she can not find the sheet and does not know if the 15-minute checks still need to be completed. CNA U indicated R291 needs to have eyes on him, and that staff will have him sit at the nurses' station so everyone can keep an eye on him. CNA U indicated the door alarm that is used doesn't always go off when it should. CNA U indicated she heard that R291 touched another resident, R290, and now they don't sit near each other during meals. CNA U indicated that when R291 is difficult to redirect having a different staff step in and assist works well. Sometimes that different face is all that is needed for a reset. Surveyor observed CNA U ask coworker if 15-minute checks are still in place. Coworker stated, I can't find the documentation, so I don't know. On 1/10/23 at 2:45 PM, AA KK (Activity Aide) indicated R290 is terrified of R291. AA KK indicated that R291 went into R290's room the other night and was throwing things around and cursing at R290. AA KK indicated she witnessed R290 tell another staff about the incident last night (1/9/23). AA KK indicated R290 was afraid to go to bed last night. AA KK indicated that AC W had a conversation with R290 about the incident as well. AA KK indicated staff struggle with R291 and that he is known to grab others so he has to sit at his own table. AA KK indicated R291 went into another resident's room recently and she struggled to get him out of the room and that he was swearing at staff. AA KK indicated that she has had to take R291 from room to room while she is assisting other residents. AA KK indicated she will have him sit outside the room with the bedroom door closed. AA KK indicated she wouldn't know if R291 has an activity care plan. AA KK indicated that the nurse tells her if she needs to know something regarding a resident. On 1/10/23 at 2:45PM, CNA I indicated she has worked with R291 when he was on the 2nd floor as well as him being on the 3rd floor. CNA I indicated R291 has some behaviors, and some are more sexual. CNA I indicated R291 is a retired truck driver and that he likes motorcycles. CNA I indicated that he will wander into other resident rooms. CNA I indicated for interventions they will walk with R291 and give him something else to do. CNA I indicated R291 will sit by the nurses' station and sometimes they have to take him room to room to ensure everyone's safety. CNA I indicated the approach is very important with R291, you have to ask him if he wants to do something. CNA I indicated he goes into R290's room quite often. Just recently R291 was saying inappropriate things to R290 and now R290 does not want to sit near R291 at mealtimes. There was something they had to sign so everyone knows they don't sit next to each other. R290 is afraid of R291. R291 will go into R33's room, but she doesn't even know he is in there. CNA I indicated the door alarm takes a while to come on and it's not that loud. CNA I indicated R291 is both one on one supervision and line of sight. CNA I indicated they usually do 15-minute checks or like a half an hour check. CNA I indicated R291 can get combative when trying to redirect, and approach is so important. CNA I indicated that sometimes the staff attitude is more of the issue. On 1/10/23 at 3:00 PM, Surveyor observed R291 sitting in the recliner in his room with his back to the door. On 1/10/23 at 3:06 PM, Surveyor observed R291's sensor alarm on the door frame sounding. Surveyor observed R291 ambulating independently in the hall while wearing socks, 1 shoe on the wrong foot, jeans, and no shirt. Surveyor observed R33 sitting in the hall outside her room as R291 walked by R33 to get to the TV area across from the dining room before sitting down. On 1/10/23 at 3:07 PM, Surveyor observed RA D (Resident Assistant) assist R291 with putting his shirt on and escorted him back to his room. On 1/10/23 at 3:10 PM, CNA V indicated when R291 is in his bedroom he can be alone. CNA V indicated that the door alarm needs to be on. CNA V indicated there are times that staff forget to turn on the alarm, if R291 walks past the elevator then the wander guard alarm goes off. CNA V indicated there are times the door alarm goes off and R291 is sitting in his recliner and there are times it doesn't go off and he's out of his room. CNA V indicated they were doing 15-minute checks, but that they haven't been lately and that she (CNA V) doesn't know where the sign off sheet went. CNA V indicated the timeframe of the checks had changed quite a bit and that management lets them know. CNA V indicated that when R291 is out of his room he needs to always have staff around him and that he will sit near the nurses' station. CNA V indicated that R291 cycles and that there are times that he is up all night long. CNA V indicated that R291 doesn't like to wear or keep clothes on, and that staff try their best to encourage him to have something on. CNA V indicated R291 gets agitated and wants to be up and walking around more on the PM shifts. CNA V indicated that during the day R291 is always in his room, it's like he's trapped in there. CNA V is not aware if the activities department does any activities with R291. CNA V indicated the approach is incredibly important with R291. Regular staff that know R291 will say, Come sit in your truck seat! when trying to assist him in sitting in wheelchair. CNA V indicated R291 also loves motorcycles. CNA V indicated the facility does provide dementia care training, but that this CNA has never worked with someone so aggressive before and they have not had training that's more specific. CNA V indicated it takes a different approach when working with someone that is this aggressive. CNA V indicated she knows that R290 is scared of R291. R290's room door is always shut. CNA V indicated that if R291's alarm goes off and staff are in someone else's room they can't get to him right away. CNA V indicated that R291 has been able to get to R290's bedroom because staff can't get there in time. CNA V indicated she knows that R290 doesn't want to sit next to R291 during meals because they all had to recently sign a sheet that explained that. CNA V indicated R291 will wander into other people's bedrooms, and this upsets them as well. On 1/10/23 at 3:17 PM, Surveyor observed R291's sensor alarm sounding as he walked from his room directly across the hall into R33's bathroom carrying a chux (incontinence pad.) Surveyor observed there were no staff present as R291 entered R33's bathroom. Surveyor alerted RA D (Resident Assistant) that R291 was in R33's room. RA D entered R33's room and escorted R291 out of R33's room. On 1/10/23 at 3:19 PM, Surveyor asked RA D if R291 should be in other residents' rooms? RA D replied, No. Surveyor asked RA D, has R291 entered R33's room prior to today? RA D stated, Yes. RA D added, If I'm being honest, he should be in a dementia unit. RA D added, R291 has a thing about going in two (2) resident (R33 and R290) rooms. Surveyor asked RA D, does it bother either R33 or R290 when R291 enters their rooms? RA D stated, R33 doesn't mind, she will talk with R291. It is important to note, R33 has a history of being abused by a family member in the home prior to being admitted to the facility. R33 is moderately cognitively impaired and is unable to recall the abuse. Surveyor asked, how does R290 feel when R291 enters her room? RA D added, She's scared shitless of him - terrified! On 1/10/23 at 3:20 PM, Surveyor observed R291's sensor alarm sounding again. RA D approached R291 attempting to assist [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to ensure safety and prevent accidents for 1 of 2 residents (R291) reviewed for wandering and resident to resident altercations, and residents' environment is free of accident hazards for 3 of 3 sampled residents (R34, R8, and R28) reviewed for falls, 2 of 2 units with unsecured chemicals, and 2 of 2 residents (R5 and R7) with medication left at bedside. Example 1 R291 is at high risk for wandering and has a known history of aggressive behaviors toward other residents and staff. The facility failed to implement appropriate interventions, failed to follow resident care plans, and failed to put adequate supervision in place. R291 was not being supervised and had a physical altercation with R290 and R33. The facility's failure to provide adequate supervision for a resident known to wander and with a known history of aggressive behaviors toward others created a finding of immediate jeopardy (IJ) that began on 1/1/23. Surveyor notified the Director of Operations and Director of Nursing of the immediate jeopardy on 1/11/23 at 12:30 PM. The immediate jeopardy was removed on 1/10/23, however the deficient practice continues at a scope/severity of G as the facility continues to implement its action plan. Evidenced by: The facility policy titled Wandering and Elopement with a revision date of March 2019, states in part; Policy Statement The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. R291 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with late onset, Anxiety Disorder, Insomnia, Restlessness and agitation, Depression, and Alcohol abuse. R291's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/13/22, indicates R291 has a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. R291 has an Activated Health Care Power of Attorney. R291's Comprehensive Care Plan, indicates, in part: Problem start date: 10/27/22, Behavioral Symptoms- Resident has expressed sexual behaviors towards others and based on assessment is unable to consensually participate in this type of behavior. Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by sexually inappropriate behaviors and foul language towards staff and other residents. Long Term Goal Target Date 3/16/23: Resident will accept redirection when exhibiting socially inappropriate/disruptive behavior toward staff or other residents. Approach: Start Date 10/27/22, administer medications per physician orders, assess resident as needed using the sexuality and intimacy worksheet, remind resident he is married and provide education related to appropriate interactions with others, avoid over-stimulation, identify and report possible triggers for suggestive or sexual language, maintain a calm, slow, understandable approach and environment for and with resident. Observe and report socially inappropriate/disruptive behaviors when around others. Provide snack (ice cream), provide meaningful engagement or activities to resident, remove resident from group activities when behavior is unacceptable, remove resident from other resident's rooms and unsafe situations. Staff should watch their body language staff wear appropriate attire. Staff should be aware of their own body language and conversations they are having with coworkers, visitors and residents. Staff should explain their role upon entering room. Address the resident formally and maintain their professionalism. When available, have male caregivers and nurses provide care for resident. One on one supervision while resident awake. Door alarm and 15-minute checks while resident sleeping. Problem start date: 10/19/22, Behavioral Symptoms- Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Long Term Goal Target Date 3/16/23 Resident will wander safely within specified boundaries. Approach 10/20/22 Door sensor alarm to resident's doorway to be turned on when in his room. Resident to have one on one supervision when awake. Maintain a calm environment and approach to the resident. Redirect resident if wandering into another room; offer resident to stay by nurses' station to be in line of sight of staff. When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). Problem start date: 10/4/22, Behavioral Symptoms- Resident uses inappropriate language towards others. Longer Term Goal Target Date 3/16/23 Resident will accept redirection from staff when using inappropriate language towards others. Approach 10/4/22 gently but firmly informed resident that inappropriate language are not welcome. Do not engage in discussion. Maintain a calm, slow, understandable approach . Problem start date: 9/13/22, Potential for elopement r/t cognitive status, unaware of safety concerns. Long Term Goal Target Date 3/16/23 Pt. will make no attempts of elopement E/B no sounding of code alert. Approach 9/13/22 check function weekly. Check placement every shift per nursing. Code alert bracelet to left ankle. #10. Gently redirect from stairwells and/or elevators. Picture of resident in all identified locations. Problem start date: 8/24/22 Behavioral Symptoms- Resident has been known to make sexually inappropriate comments towards staff and grabbing at staff. Long Term Goal Target Date 3/16/23 Resident will accept assistance from staff, if resident is not redirectable, staff will ensure resident is safe, leave resident's room and reapproach. Approach 10/20/22 door sensor alarm in resident's doorway to be turned on when resident is in his room. Resident to have one on one supervision. Approach start date 10/4/22 gently but firmly inform resident that inappropriate touching and/or sexual remarks are not welcome. Do not engage in discussion. If continues, ensure resident safety and reapproach with second staff person to complete cares. Approach start date 9/8/22 resident to have supervision when around female residents. Staff to ensure no inappropriate interactions . Problem start date: 5/6/22 Behavioral Symptoms- APOAHC (Activated Power of Attorney for Health Care) stated resident has a history of grabbing other residents aggressively and becoming physically aggressive with staff. APOAHC indicated resident has not made any sense when he talks; resident is able to form words, but the words together do not make sense. Resident has used swear words often. Approach start date 5/6/22 Staff can attempt to redirect resident. Staff should have a calm approach when interacting with resident. Ask simple yes, no questions. Staff can meet with resident 1:1 if needed/able. If resident becomes agitated staff can reapproach after giving resident time to calm down. During periods of increased agitation, remove resident away from other residents and take to safe area to calm down. Approach start date 8/2/22 Approaches to redirect resident to his own room. Sign placed outside of resident's room to direct him to his own room. Surveyor asked for R291's Certified Nursing Assistant (CNA) Care Card. Facility provided a document titled, Profile Care Plan Approaches, which states in part: Nutritional Status 6/9/22, .1:1 supervision at meals .If you have to leave resident, move all food and inedible items out of his reach. Behavioral Symptoms 10/4/22, Gently but firmly inform R291 that inappropriate touching and/or sexual remarks are not welcome. Do not engage in discussion. If continues, ensure resident safety and reapproach with second staff person to complete cares. Behavioral Symptoms 10/27/22, Resident should be placed in a calm and quiet environment at least an arms length away from other residents to ensure resident's safety. Surveyor reviewed Physician Order Report 1/1/23-1/31/23 which states in part: Start date, 8/29/22 May be seen by behavioral health, start date 8/29/22 Target Behavior: (sexual inappropriateness, increase resident distress, dangerous to self or others) At the end of each shift mark frequency- how often behavior occurred and intensity- how resident responded to redirection, intensity code: 0=did not occur, 1=easily altered, 2=difficult to redirect. Special instructions staff note: add frequency and intensity med notes to order for tracking. Every shift; day, pm, noc. Start date, 9/13/22 Check placement of wander guard every shift. Start date, 9/20/22 check wander guard function weekly. Start date, 11/24/22 Update POA with any instances of combative behavior (call daughter). Start date, 11/28/22 Check function of door alarm sensor Qshift. Every shift; day, pm, noc. Surveyor reviewed behavior tracking from 12/1/22-1/10/23 .target behavior sexual inappropriateness, increase resident distress, dangerous to self or others .out of the 41 days reviewed there is see note documented for 20 of the days. The behavior documentation is not consistently tracking intensity or frequency. Progress notes reviewed, 12/11/22 13:47 .talking and swearing very loudly at the lunch table. He did not become aggressive physically but continued to be very vocal and curse .12/16/22 14:23, He swung at CNA and connected with her left shoulder-did not cause injury. 12/17/22 21:24, CNA needed assistance with toileting resident, while nurse and CNA were toileting resident, he hit CNA in her face causing her to bite the inside of her lip. Nurse and CNA redirected and educated resident. after toileting resident, staff was able to place resident in bed 12/18/22 22:13 (10:13 PM), Resident looking for the bathroom; was redirected back to his room Writer entered room to find CNA's in bedroom with resident in bathroom pacing. Writer offered assist to resident. Resident stated, I gotta take a piss and they told me I had to come in here.Resident proceeded to pull out his penis and pee in the corner .CNAs attempted to intervene which agitated resident more. Writer instructed CNAs to step back as to not overwhelm resident resident did make comments with washing of his penis and tried to grab writer's hand to move back to location, was easily redirected 12/24/22 23:48 (11:48 PM), Staff reported that during shift change resident slapped the evening shift care giver. Care giver was trying to assist resident and resident slapped her. 1/1/23 0:00 (12:00 AM), Resident trying to visit with a female resident this PM, resident was hard to redirect .1/9/23 9:41 AM, .he punched first CNA in the face. 1/9/23 18:24 (6:24 PM), .resident combative with staff, hitting at staff member. 1/10/23 16:09 (4:09 PM), .resident struck another resident .1/11/23 23:36 (11:36 PM), .CNA stated that resident had been sleeping in recliner and became restless and got up. CNA was assisting with incontinence cares when resident punched her in the eye. RT (right)eye with green/purpe bruising and swelling to upper eyelid . Surveyor reviewed notes from Behavioral Care Solutions (BCS) from time of admission with BCS. On 9/16/22, states, in part: Patient referred for BCS services for vulgar language and aggressive behavior towards staff .9/29/22, Can get anxious and agitated at times. It is reported he did have a physical altercation with peer. Confused with poor memory 10/21/22, Note: writer received phone call from SW (Social Worker) and nursing staff, report patient with recent increased aggression toward peers and staff, now has been wandering. Now has 1:1 sitting when out of his room and a door alarm to alert staff when he is leaving his room .Per staff, he has increased behaviors of aggression and agitation in the PM hours .11/1/22, Assessment & Plan .Encourage structured activities during the day. Provide 1:1, redirection, distraction 12/21/22,Today behavioral documentation was reviewed and reported the following symptoms: Resident yelling get the fuck out of here! Go back to your room! and continued yelling despite redirection (11/17). Cursing at others (10/23), some false beliefs expressed at times. Staff able to easily redirect, left alone to settle and re-approach. Spoke to nursing staff, it is reported that patient hit CNA during toileting assistance on 12/17/22. It is reported that at times he will wander to find the bathroom. He becomes agitated during this time and irritated staff believe it is due to his worsening Dementia and memory. Some increased confusion reported in the evening hours Assessment & Plan .Encourage structured activities during the day. Provide 1:1, redirection, distraction On 1/9/23 at 4:00 PM, R291 was in his bedroom, sitting in recliner with feet up, hands behind head, and watching TV. R291's door alarm was activated when Surveyor walked through bedroom door. CNA Z (Certified Nursing Assistant) approached Surveyor after alarm sounded. CNA Z indicated R291 has a door alarm for safety reasons. R291 wanders into other residents' bedrooms. CNA Z indicated R291 is on 15-minute checks and has the door alarm when he is in his room. CNA Z indicated R291 is supposed to be one on one supervision when he is out in the common areas of the facility. CNA Z indicated there are times staff will forget to turn the alarm on and R291 will wander to the completely opposite side of the nursing home. CNA Z indicated other residents are frustrated and scared when R291 goes into their bedrooms. On 1/9/23 at 4:30 PM, Surveyor observed R291 sitting near the nurses' station. Surveyor observed the staff at the nurses' station leave the area and R291 was left with no staff near or with R291. No one on one support provided. On 1/10/23 at 8:00 AM-8:20 AM, Surveyor observed R291 sitting at the edge of his bed. No staff were present inside or outside of room. Door alarm was turned on. On 1/10/23 at 8:27 AM-9:15 AM, Surveyor observed R291 sitting in the dining room eating breakfast. R291 was sitting at a table by himself with his back turned to others and looking out the window. Staff were present assisting other residents with their meal trays and coming in and out of the dining room area. No one on one support provided. On 1/10/23 at 9:30 AM, Surveyor observed R291 sitting in a wheelchair near the nurses' station. Two staff were near the computers and were talking. No one on one support provided. On 1/10/23 at 10:24 AM-12:20PM, Surveyor observed R291 in bedroom sitting in recliner with feet up, awake and watching TV. On 1/10/23 at 11:55 AM, CNA U indicated there is a list of people with their pictures of who wanders. CNA U indicated she knows who is at risk for wandering because she is a regular staff. CNA U indicated R291 wanders into other people's rooms. Surveyor asked what supervision is provided to R291? CNA U indicated that he is basically a one on one support when he's not in room. CNA U indicated they had a document they were signing off for 15-minute checks for R291 as well. CNA U indicated she can not find the sheet and does not know if the 15-minute checks still need to be completed. CNA U indicated R291 needs to have eyes on him, and that staff will have him sit at the nurses' station so everyone can keep an eye on him. Surveyor observed CNA U asked coworker if 15-minute checks are still in place? Coworker stated, I can't find the documentation, so I don't know. On 1/10/23 at 2:45 PM, AA KK (Activity Aide) indicated R290 is terrified of R291. AA KK indicated that R291 went into R290's bedroom the other night and was throwing things around and cursing at R290. AA KK indicated R291 went into another resident's room recently and she struggled to get him out of the room and that he was swearing at staff. On 1/10/23 at 2:45 PM, CNA I indicated R291 will sit by the nurses' station and sometimes they have to take him room to room to ensure everyone's safety. CNA I indicated the door alarm takes a while to come on and it's not that loud. CNA I indicated R921 is both one on one supervision and line of sight. CNA I indicated they usually do 15-minute checks or like a half an hour check. On 1/10/23 at 3:00 PM, LPN G (Licensed Practical Nurse) indicated R291's door alarm should be on when he is in his bedroom. LPN G indicated she is not sure if he's still on 15-minute checks right now. LPN G indicated she is not sure if R291 is on one to one supports right now, but that she doesn't think he is. LPN G indicated they try to keep an eye on him. On 1/10/23 at 3:06 PM, Surveyor observed R291's sensor alarm on the door frame alarming. Surveyor observed R291 ambulating independently in the hall while wearing socks, 1 shoe on the wrong foot, jeans, and no shirt. Surveyor observed R33 sitting in the hall outside her room as R291 walked by R33 to get to the TV area across from the dining room before sitting down. On 1/10/23 at 3:07 PM, Surveyor observed RA D (Resident Assistant) assist R291 with putting his shirt on and escorted him back to his room. On 1/10/23 at 3:10PM, CNA V indicated when R291 is in his room he can be alone. CNA V indicated that the door alarm needs to be on. CNA V indicated there are times that staff forget to turn on the alarm, if R291 walks past the elevator then the wander guard alarm goes off. CNA V indicated there are times the door alarm goes off and R291 is sitting in his recliner and there are times it doesn't go off and he's out of his room. CNA V indicated they were doing 15-minute checks, but that they haven't been lately and that she (CNA V) doesn't know where the sign off sheet went. CNA V indicated the timeframe of the checks had changed quite a bit and that management lets them know. CNA V indicated that when R291 is out of his room he needs to always have staff around him and that he will sit near the nurses' station. CNA V indicated that if R291's alarm goes off and staff are in someone else's room they can't get to him right away. CNA V indicated R291 will wander into other people's rooms, and this upsets them. On 1/10/23 at 3:17 PM, Surveyor observed R291's sensor alarm sounding as he walked from his room directly across the hall into R33's bathroom carrying a chux (incontinence pad). Surveyor observed there were no staff present as R291 entered R33's bathroom. Surveyor alerted RA D (Resident Assistant) that R291 was in R33's room. RA D entered R33's room and escorted R291 out of R33's room. On 1/10/23 at 3:19 PM, Surveyor asked RA D if R291 should be in other residents' rooms? RA D replied, No. Surveyor asked RA D, has R291 entered R33's room prior to today? RA D stated, Yes. RA D added, If I'm being honest, he should be in a dementia unit. RA D added, R291 has a thing about going in two (2) resident (R33 and R290) rooms. Surveyor asked RA D, does it bother either R33 or R290 when R291 enters their rooms? RA D stated, R33 doesn't mind, she will talk with R291. It is important to note, R33 has a history of being abused by a family member in the home prior to being admitted to the facility. R33 is moderately cognitively impaired and is unable to recall the abuse. Surveyor asked, how does R290 feel when R291 enters her room? RA D added, She's scared shitless of him - terrified! On 1/10/23 at 3:20 PM, Surveyor observed R291's sensor alarm sounding again. RA D approached R291 attempting to assist him. On 1/10/23 at 3:23 PM, Surveyor observed R291's sensor alarm going off again. RA D stated to R291, have a seat, as R291 is still standing. R291 stated, all I have to do is sit in the chair? R291 stated, waki [NAME]. Surveyor observed R33 wearing a Santa hat while sitting inside the entry way of her room drinking a soda. Surveyor observed RA D standing in between R33 and R291. R291 looked at R33 and stated, Hey pee wee I'm Santa [NAME] as he reached out and hit R33 on the top of her head. R33 exclaimed, Ouch! Surveyor observed RA D telling R291 to sit right here (in his wheelchair). R291 refused to sit down and continued to ambulate. Surveyor observed R291 attempted to repeatedly enter R290's room. RA D held the doorknob to prevent R291 from opening R290's door. RA D stated, Hey R291, we can't go that way, as R291 is walking toward the elevators setting off the WanderGuard alarm. R291 turned around and was looking in R33's room. On 1/10/23 at 3:25 PM, Surveyor spoke with RA D. RA D stated nobody likes to help her with R291 and he is a 2 assist. RA D stated, R291 is not allowed to be within arm's reach of another resident. RA D stated, R291 sundowns (A symptom that often occurs in people with dementia. Sundowning or sundown syndrome, is common in dementia patients and refers to the onset of of hard-to-manage behaviors toward the end of the day.) RA D stated, R291 gets aggressive and has been known to swing and pull other residents' hair. Surveyor asked RA D, whose hair did R291 pull? RA D stated, R291 has pulled R290's hair. Surveyor asked RA D did you observe R291 make contact with R33's head. RA D stated, Yes. RA D stated, R290 told me about R291 pulling her hair last night. RA D clarified she was not working when the hair pulling incident occurred last week. RA D stated, R291 is not to be within arm's reach of other residents. Surveyor asked RA D, when was arm's reach put in place? RA D stated, I have no idea. RA D stated, if R291 is in his room I can walk away (leave him) as his motion sensor is on at all times. Surveyor asked RA D, is R291 on 1:1? RA D stated, I don't know. Surveyor asked RA D, what interventions are effective with R291? RA D stated, if R291 is more agitated we redirect him with Cheetos or ice cream. RA D stated, this works most of the time, however, some days it's like this and never ending. Surveyor asked RA D is it acceptable for a resident to hit another resident? RA D stated, no. Surveyor asked RA D, what will you do with this information? RA D stated, she will report this to the nurse immediately. Note, while Surveyor was speaking with RA D, we stayed in proximity of R291's room at all times. On 1/10/23 at 3:39 PM, Surveyor spoke with R33. Surveyor asked R33, do you feel safe? R33 replied, Oh yes. Surveyor asked R33 do any residents bother you? R33 stated, No. Surveyor asked R33 do any residents come into your room uninvited? R33 stated, No. Surveyor asked R33, has another resident ever hit you? R33 stated, No. Surveyor asked R33, has anybody hit you today? R33 stated, No. Note, the facility failed to keep their most vulnerable residents safe. Using the concept of a reasonable person, women don't want to be touched by strangers and would feel threatened, unsafe, and vulnerable if unable to defend themselves from unwanted physical violence. On 1/10/23 at 4:04 PM, ADON C (Assistant Director of Nursing) indicated she was aware of the incident that occurred on 1/6/23 between R290 and R291. Surveyor asked ADON C what one on one means? ADON C indicated that it means one staff with resident. On 1/11/23 at 8:28 AM, DON B (Director of Nursing) provided Surveyor documentation for R291's 15-minute checks. DON B provided no documentation for 15-minute checks after 1/1/23. On the 15-minute check documentation for 1/1/23 it states, 1-1, No checks done - no staff to do checks 2-10pm. DON B indicated ADON C was looking into why that was written because there were staff working that evening. DON B indicated she cannot speak about the past, but moving forward, education is now being provided on what one on one supports mean. Surveyor asked DON B what does one on one supports mean? DON B indicated it means one staff assigned to resident. DON B indicated she would provide more documentation on the 15-minute checks if she finds the documentation. Note, no further documentation was provided to Surveyor. On 1/12/23 at 2:48 PM, RN J (Registered Nurse) indicated R291 will go into other people's bathrooms, and he has peed on other people's bathroom floors before. RN J indicated R291 is supposed to be a one on one when he is out of his bedroom, but that he still sneaks out of his room. RN J indicated she is glad R291 is a one on one now on the second floor. RN J indicated R291's door alarm doesn't always work correctly, sometimes it goes off and he's sitting in his recliner and sometimes staff forget to put on the alarm before they leave the room. RN J indicated he (R291) really has to be one on one supports because of his falls as well. The moment you leave him he could fall, his gait is off. He really should be in a Dementia Care unit. It's like he doesn't have any control . The facility's failure to provide adequate supervision to prevent resident to resident altercations created a finding of immediate jeopardy. The facility removed the jeopardy on 1/10/23 when the following was implemented: R291's care plan was updated on 1/10/23 with new interventions developed and initiated to support safety and location awareness to protect him and other residents from harm. Interventions include one on one supervision at all times, his room has been moved to the 2nd floor to decrease stimulation. On 1/12 new approach techniques put in place in the form of hand in hand techniques when walking with resident. A schedule created on 1/10 indicates by timeframe what staff member is responsible for providing one on one supervision 24 hours per day. 2 staff members will be present on unit at all times with one providing one on one supervision to R291 at all times. Staff have walkie talkie and access to phone to contact other staff or to dial 911 in the event of an emergency. R290 and R33's care plans were evaluated on 1/12 for need for increased supervision or other safety interventions. IDT did not feel R290 or R33 required increased supervision as R291 has been moved off unit and neither of the female residents were agressors. R290 and R33 will be observed daily for any psychosocial impacts such as increased behaviors, change in routine, or self isolation that may relate to incidents that involved R291. Staff education provided by Director of Operations and Director of Nursing started on 1/10/23 and includes new care plan interventions for R291 including definition of one on one, sensor alarm use, hand in hand approach techniques, what to do in the event of an emergency, how to protect residents from abuse or negative incidents and putting interventions in place to support resident centered care and safety. Education will also be provided on R291 and R33's observation needs. Group in-services will be held 1/13. Any staff who has not already been educated will be educated by the start of their next shift. Consultation with MD, DPOA, and IDT on 1/9, 1/10, 1/11, and 1/12 to evaluate and develop care interventions to support R291. Referral started 1/12 to [NAME] Gero Psych unit. R291 was seen by Behavioral Health Services on 1/12. Ongoing collaboration and evaluation will occur with MD, IDT, and DPOA to support R291 and to support effectiveness and response of current interventions and treatments, development or modification of interventions as needed to support individualized comprehensive care and safety for R291 and other residents. All other residents care plans were reviewed by 1/12 to ensure appropriate interventions are in place to ensure individualized care interventions in place to support the highest level of safety and quality of life. Resident Safety Policy will be reviewed at the Quality Assurance Meeting 1/13. A Quality Assurance Meeting will take place on 1/13/2023. Director of Nursing and or designee will do daily spot checks on various shifts at least 5 times per week for 2 weeks and then 3 times per week for 2 weeks and then 3 times per week ongoing - to ensure one on one supervision is in place for R291, sensor alarm in place and functioning. 3 random residents care plans will be audited per week by Director of Nursing or designee to validate care interventions and ensure safety and other interventions are implemented and followed. All findings will be brought to the Quality Improvement Committee for review. Example 2 R291 has had multiple falls since his admission to the facility. The facility failed to implement appropriate fall interventions and identify and explore possible root causes for R291's falls. R291 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with late onset, Anxiety Disorder, Insomnia, Restlessness and agitation, Depression, Pain in left hip, Pain in right knee, Muscle wasting and atrophy, Alcohol abuse, Unspecified hearing loss, and Repeated Falls. R291's most recent MDS with ARD of 12/13/22, indicates R291 has a BIMS score of 00 indicating severe cognitive impairment. R291 has an Activated Health Care Power of Attorney. R291's Comprehensive Care Plan, indicates, in part: Approach Start Date 5/11/22 DEVICES: Hoyer lift PRN, WC, Bilateral transfer bars, 2WW. TRANSFERS: When resident is alert, awake and willing to participate he transfers with 2 WW and 2 assist and ambulates with 2 assist and 2 WW. Needs extra time to process information. Encourage with ice cream. Keep your voice upbeat and cheerful. May use Hoyer and 2 assist if not awake and alert. MOBILITY: See transfer info for info regarding ambulation ability. WC for mobility. Staff to assist. GROOMING/DRESSING/TOILETING: Own teeth. Staff to assist with oral cares. Dependent on staff for 2 assist with ADLs. Check and change/offer toileting every 2-3 hours and PRN during day, every 4 hours at noc with use of family provided extra absorbent briefs. Trial tuck brief at night to keep open to air. Problem Start Date 5/6/22 Category Falls DX: left hip fracture with IM nailing. DX: Alzheimer disease with decreased safety awareness. Long Term Goal Target Date 3/16/23 Will have decreased risk of injuries r/t fall events. Approach Start Date: 12/6/22 Gripper strips on floor at bedside. Approach Start Date: 9/21/22 Toilet after meals. Approach Start Date: 9/10/22 Pharmacist med review. Approach Start Date: 7/12/22 Resident is capable of sitting/kneeling on floor in front of WC and then raising self back into WC. Not a true fall if witnessed as movement is purposeful. Approach Start Date: 6/21/22 Low bed. Approach Start Date: 5/12/22 Frequent rounds. Unable to comprehend use of call light. Approach Start Date: 5/12/22 Keep frequently used items within reach. Resident enjoys being in recliner near nursing station for comfort and socialization with staff. Approach Start Date: 5/12/22 OT/PT as ordered. Approach Start Date: 5/12/22 Pain management. Approach Start Date: 5/6/22 Bed against wall. Surveyor reviewed R291's Fall Event Reports. Fall Event Reports indicate in part: Event Date: 6/18/22 14:28 (2:28PM) . Location of fall: Day Room, Describe: Resident observed lying on floor on left side. Resident was previously seen in wheelchair by nurse station. MAE (Moves all Extremities). Neuro checks WNL (Within Normal Limitis). VSS (Vital Signs Stable). No injury noted. Resident assisted back into wheelchair with 2 staff assist. Denies pain. DON notified. Message left with POA to return call for update. Was fall witnessed: No. No injury, no pain. Interventions: None of the Above . Event Date: 6/19/22 21:44 (9:44PM) . Location of fall: Resident Room, Describe: Heard someone say goddammit and hear a noise. This writer and CNA went and looked to see where it came from and CNA found resident on floor in front of table with lamp on it. Resident can't say what he was doing. No injury noted. VSS/Neuro's WNL. Was fall witnessed: No. No injury, no pain. Interventions: Other-scoop mattress if available Event Date: 7/11/22 21:00 (9:00PM) . Description: Resident on bilateral knees earlier this pm. At 21:00 found sitting on floor by his bed. Stated cooler down here. Location of fall: Blank. Was fall witnessed: Blank. Pain, Injury: Blank. Interventions: Blank. Notifications: .Place w/c

Based on observation, interview, and record review, the facility did not ensure all alleged violations were thoroughly investigated for 2 of 5 allegations of abuse reviewed involving four Residents (R291, R290, R23, and R7). R290 reported an allegation of abuse on 1/6/23. The allegation of abuse was reported to management on 1/7/23 and documented as a grievance. The facility began investigating the allegation on 1/9/23. No interventions were put in to place to ensure safety until 1/10/23 after Surveyors brought a concern to the attention of the facility. On 12/15/22 R23 wandered into R7's bedroom and R7 pinched R23's right hand. The facility initiated an investigation and submitted a self-report to state agency. The facility interviewed the residents and the one staff that was involved in the incident. No other Residents were interviewed to determine if they had any concerns of abuse or neglect. No other staff were interviewed during the investigation to determine if there was additional information. Evidenced by: The facility policy titled Abuse Investigation and Reporting with a revised date July 2017, states in part, Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. 6. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical conditions; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 2. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location. b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process. c. Should a person disclose information that may be self-incriminating, that individual will be informed of his/her rights to terminate the interview until such time as his/her rights are protected (e.g., representation by legal counsel). d. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. 3. The investigator will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process. a. If the ombudsman declines the invitation to participate in the investigation, that information will be noted in the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken. 4. The investigator will consult daily with the Administrator concerning the progress/findings of the investigation. 5. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator . The facility policy titled Abuse and Neglect-Clinical Protocol with a revised date March 2018, states, in part, 1. Abuse .the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility policy titled Grievance Policy with no date, states, in part, .Response Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Official. Upon receipt of a grievance or concern, the Grievance Official will review the grievance, determine immediately if the grievance meets a reportable complaint. Consistent with the facility's Abuse Prevention Policy the facility Administrator and Grievance Official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law. The Grievance Official will initiate the appropriate notification and investigation processes per individual circumstance and facility policies. The investigation will consist of at least the following: A review of the completed complaint report. An interview with the person or persons reporting the incident if applicable. Interviews with any witnesses to the incident or concern. A review of the resident medical record if indicated. A search of resident room (with resident permission). An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident. Interviews with the resident's roommate, family members, and visitors. A root-cause analysis of all circumstances surrounding the incident. As necessary, the Grievance Official and facility leadership will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. R291 was admitted to the facility on [DATE] with diagnoses including, Alzheimer's Disease with late onset, Anxiety Disorder, Insomnia, restlessness and agitation, depression, repeated falls, hearing loss, alcohol abuse, and Dementia. R291's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/13/22, indicates R291 has a BIMS (Brief Interview for Mental Status) score of 00 indicating severe cognitive impairment. R291 has an Activated Health Care Power of Attorney. R291 has a history of exhibiting socially inappropriate/disruptive behavior towards staff and other residents. The facility previously had an immediate jeopardy in October 2022 in regard to R291 and supervision. The facility was aware of R291's behavior and care planned the behavior. R291's care plan indicates R291 is one on one supervision while resident is awake, a door alarm and 15-minute checks while resident is sleeping. Despite knowing these behaviors, the facility did not ensure R291 had adequate supervision which led to R291 entering R290's bedroom and R290 physically grabbing R290's head while R290 was in bed. R291 was screaming and swearing at R290 to Get the fuck out of my bed. The incident caused psychosocial distress for R290 as she was unable to fall asleep and experienced extreme anger over the situation. R290 was admitted to the facility on [DATE] with diagnoses including, Hydronephrosis with Renal and Ureteral Calculous Obstruction, Anxiety Disorder, and Pain. R290's most recent MDS with ARD of 10/23/22, indicates R290 has a BIMS score of 10 indicating R290 is moderately impaired. R290 is her own person. R290's Comprehensive Care Plan, indicates, in part: Care plan Problem start date 10/26/22 .BEHAVIOR AND COGNITION: A&O x4. Pleasant and cooperative. Surveyor reviewed R290's Grievance/Concern Form, Date the concern occurred: 1/6/23. Summary of concern: (R290) stated to me that on Friday night resident (R291) entered her room and started moving her blinds back and forth. He also approached her and said, get the hell out of my bed Resident states she had her call light on. Also states this has happened before. She was very upset. Emotional support given. RN J (Registered Nurse) completed grievance form. On 1/9/23 at 4:00 PM, Surveyor saw R291 in his room, watching TV. R291's door alarm was activated when Surveyor walked through room door. CNA Z (Certified Nursing Assistant) approached Surveyor after alarm was sounded. CNA Z indicated R291 has a door alarm for safety reasons. R291 wanders into other resident's bedrooms. CNA Z indicated R291 is on 15-minute checks and has the door alarm when he is in his bedroom. CNA Z indicated R291 is supposed to be one on one supervision when he is out in the common areas of the facility. CNA Z indicated there are times staff will forget to turn the alarm on and R291 will wander to the completely opposite side of the nursing home. CNA Z indicated other residents are frustrated and scared when R291 goes into their bedrooms. Surveyor asked if there were bedrooms that R291 was more likely to go in. CNA Z pointed at the two bedrooms (R290 and R33) next to R291. CNA Z indicated R290 does not like when R291 goes into her room and that she is scared of R291. On 1/10/23 at 9:22AM, Surveyor introduced self to R290. Surveyor observed R290's room door shut with a small sign on door. The sign was in a shape of a hexagon, with a hand on it, light red in color, and said STOP. R290 indicated she has concerns with her neighbor, R291. R290 indicated R291 is not a safe person to be around and that the stop sign on her door does not work at all. R290 indicated R291 walks into her room and will use her bathroom and that this has happened at least three different times. R290 indicated she has voiced concerns about this and the only thing that was put in place was the stop sign on the door. R290 indicated she does not understand why R291 can't be moved, that she is terrified of him, and that all the staff in the facility know this. R290 indicated that on 1/6/23 at 9:09 PM R291 came into her bedroom. R290 indicated this time was different than the other three times R291 entered her room. R290 indicated on 1/6/23 she was in bed, door shut, and her lights off. Surveyor observed R290's bed and noted that the head of the bed is in a direction where if someone enters the room, you would not be able to see who entered. R290 indicated she heard her bedroom door open, and her lights came on. R290 stated, The guy next door came right next to my bed and screamed, Get the fuck out of my bed. He uses the F word all the time. R290 indicated R291 was naked except for an adult brief on. R290 indicated R291 grabbed her head and continued yelling and swearing. R290 indicated she put her call light on and was repeatedly pressing the call light. R290 indicated R291 went to her blinds and was messing around with them and then took a chair and threw it. R290 indicated R291 is very strong, he's not big, but rough and very strong. R290 indicated she kept pressing the call light and that she didn't know what to do. R290 indicated she thought R291 was going to crawl into bed with her. R290 indicated, I was frightened to death. As R290 replayed the incident Surveyor observed tears in her eyes, holding her hands tightly and shaking. R290 indicated she did not hear R291's door alarm go off that night. R290 indicated there are times she hears the alarm, so she knows he is out and there are times that she doesn't hear the alarm and he is in her room. R290 indicated she listens for the alarm, but that it is not always reliable. R290 indicated R291 then left her bedroom and a few minutes later a staff answered her call light. R290 indicated she told the staff what had just happened, and the staff kept saying, I'm so sorry, I'm so sorry. R290 indicated she did not know the name of the staff that answered the call light but knew that it was one of the CNA's that were working that evening. R290 indicated someone must have reported the incident because AC W (Admissions Coordinator) came and talked to her twice on Monday. R290 indicated there were three staff in her bathroom talking to her about the incident on Monday evening. R290 indicated one staff said, Oh, he (R291) has hit her many times. R290 indicated R291 has never physically harmed her before, but everyone knows she is scared to death of him and disgusted by him. R290 indicated she can't even stand to look at him. R290 stated, People know, everyone knows I have problems with him, nothing got done, and then the incident on that Friday happened. I can't handle this. Surveyor observed R290's voice raising and becoming louder with more panic in her tone. R290 stated, DM K (Dietary Manager) told me last week that I don't have to worry, he won't be sitting next to me (during meals). She knows! Everyone knows. I don't want that guy next door. Please note per R290's interview, at least one staff member was aware this incident occurred on 1/6/23. R290 indicated staff are aware she is afraid of R291. R290 continued to express fear on 1/10/23 days after the incident occurred. On 1/10/23 at 11:55AM, CNA U (Certified Nursing Assistant) indicated R291 wanders into other people's bedrooms. Surveyor asked what supervision is provided to R291. CNA U indicated that he is basically a one-on-one support when he's not in his room. CNA U indicated they had a document they were signing off for 15-minute checks for R291 as well. CNA U indicated she heard that R291 touched another resident, R290, and now they don't sit near each other during meals. On 1/10/23 at 2:45 PM, AA KK (Activity Aide) indicated R290 is terrified of R291. AA KK indicated that R291 went into R290's bedroom the other night and was throwing things around and cursing at R290. AA KK indicated she witnessed R290 tell another staff about the incident last night (1/9/23). AA KK indicated R290 was afraid to go to bed last night. AA KK indicated that AC W had a conversation with R290 about the incident as well. AA KK indicated staff struggle with R291 and that he is known to grab others, so he must sit at his own table. On 1/10/23 at 2:45 PM, CNA I indicated she has worked with R291 when he was on the 2nd floor as well as him being on the 3rd floor. CNA I indicated that he will wander into other resident rooms. CNA I indicated he goes into R290's bedroom quite often. Just recently R291 was saying inappropriate things to R290 and now R290 does not want to sit near R291 at mealtimes. R290 is afraid of R291. CNA I indicated the door alarm takes a while to come on and it's not that loud. CNA I indicated R921 is both one on one supervision and line of sight. CNA I indicated they usually do 15-minute checks or like a half an hour check. On 1/10/23 at 3:10 PM, CNA V indicated she knows that R290 is scared of R291. R290's room door is always shut. CNA V indicated that if R291's alarm goes off and staff are in someone else's room they can't get to him right away. CNA V indicated that R291 has been able to get to R290's bedroom because staff can't get there in time. CNA V indicated she knows that R290 doesn't want to sit next to R291 during meals because they all had to recently sign a sheet that explained that. CNA V indicated R291 will wander into other people's rooms, and this upsets them as well. On 1/10/23 at 4:04 PM, ADON C (Assistant Director of Nursing) indicated she was aware of the incident that occurred on 1/6/23 between R290 and R291. ADON C indicated that a grievance was filled out on 1/7/23 because that is when it got reported to ADON C. ADON C indicated that RN J (Registered Nurse) called and reported the incident on 1/7/23 during her PM shift. ADON C indicated that AC W (Admissions Coordinator) was working on the grievance now. Surveyor asked ADON C why it wasn't started as an investigation. ADON C indicated there was no injury and no intent to cause harm. Surveyor asked ADON C what one on one means. ADON C indicated that it means one staff with a resident. On 1/10/23 at 4:15PM, AC W indicated that she just got the grievance that R290 filed. AC W indicated that R290 does not like R291 going into her room. AC W indicated that R290 told her that the door alarm doesn't always go off fast enough and that the stop sign isn't working. Surveyor asked AC W what intervention was put in place immediately to ensure everyone's safety. AC W indicated that they are going to put a black mat outside of R290's bedroom, it looks like a black hole and then R291 won't go in her bedroom. AC W indicated the mat and tape are on her desk currently. AC W indicated that she found out about the incident yesterday, 1/9/23 because it had been the weekend. AC W indicated that she talked to R290 and that now the story sounds more serious. AC W indicated that she still had to talk to the staff that worked that evening. AC W indicated that R291 is at the nurse station until bedtime. AC W indicated they try to keep R290's bedroom door shut; she is very scared. Surveyor asked why the incident wasn't reported on Friday evening. AC W indicated that she was looking into that as well. Surveyor asked AC W for a copy of the grievance that was filed and what was started for the investigation. AC W indicated she didn't have much to show because she just started the investigation, Surveyor asked for what she had started. Note, Surveyor did not receive any additional information or documentation regarding the facility's investigation. On 1/10/23 R291 was moved to another floor and placed on strict 1 on 1 observations. On 1/11/23 at 9:30AM, DOO O (Director of Operations) indicated the facility filed the incident as a grievance and that the description of events looks different now. Surveyor asked for RN J's (Registered Nurse) phone number and asked if the facility discovered what CNA answered R290's call light on 1/6/23. The facility did not provide the name of the CNA who answered R290's call light on 1/6/23. On 1/11/23 at 12:20PM, AC W indicated she has calls out to the staff that worked on 1/6/23. Surveyor asked if AC W called them today. AC W indicated Yes, this morning. Please Note, this is several days after the incident occurred. On 1/12/23 at 2:48PM, RN J indicated that she was the staff that assisted R290 with completing the grievance that was filed on 1/7/2023. RN J indicated she worked PM shift on 1/6/23 and 1/7/23. Surveyor asked if anyone had reported the incident between R291 and R290 on 1/6/23, RN J indicated the evening of 1/6/23 was a terrible night. RN J indicated there were four staff, two agency staff and two regular staff working. RN J indicated she doesn't remember anything being reported to her, but someone could have told her something and she blocked it out. RN J indicated on 1/7/23 she went to check on R290 and that is when R290 told her that R291 was in her bedroom on 1/6/23. RN J indicated that R290 reported to her that R291 was messing around with her blinds and told her to get the hell out of my bed. R290 was upset and told RN J that R291 has been in her room before and that she needed to tell her daughter. RN J indicated that on 1/7/23 she was instructed to write up the concern as a grievance, so she did that. RN J indicated she was glad R291 was a one on one now on the second floor. On 1/17/23 at 1:21PM, DON B (Director of Nursing) indicated for resident-to-resident altercations the first thing that staff must do is ensure resident is out of immediate danger and then consult with administration and go from there. R290 experienced psychosocial harm from the incident on 1/6/23. R290 expressed extreme fear and anxiety. R290 couldn't sleep and shared these feelings with facility staff. Through interviews it was determined that staff in multiple departments knew of R290's concerns and fears of R291. There were reoccurring incidents and attempts from R291 to enter R290's bedroom, despite knowing this history, the facility did not start an investigation until several days later. This resulted in no immediate intervention being put into place to ensure R290's safety from R291 until 1/10/23. The failure to implement an intervention and conduct a thorough investigation resulted in R290 experiencing and expressing ongoing psychosocial harm in the form of recurrent and ongoing fear since 1/6/23. (Cross reference F600, F609 & F689.) Example 2: R23 was admitted to the facility on [DATE] with diagnoses that include, Alzheimer's disease, other abnormalities of gait and mobility, weakness, depression, Adult failure to thrive, cognitive communication deficit, Muscle wasting and atrophy, and repeated falls. R23 most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/7/22, indicates R23 has a BIMS (Brief interview of Mental status) score of 00 indicating severe cognitive impairment. R23 has an Activated Health Care Power of Attorney. R7 was admitted to the facility on [DATE] with diagnoses that include, Type 2 diabetes mellitus with diabetic chronic kidney disease, other abnormalities of gait and mobility, and depression. R7's most recent MDS with ARD of 9/10/22, indicates R7 has a BIMS score of 3 indicating severe cognitive impairment. R7 has an Activated Health Care Power of Attorney. The facility Self-Report to the State Agency states, in part, Date occurred 12/15/22 Time occurred 6:00 PM. Briefly Describe the incident CNA (Certified Nursing Assistant) heard yelling from R7's room. CNA responded to it immediately and found R23 in R7's room. R7 was upset and telling CNA to get R23 out of his room. CNA started to redirect R23 out of R7's room and at that moment R7 grabbed R23's right hand and started to squeeze it. CNA intervened and redirected R23 out of the room and took R23 to the nurse for evaluation. Describe the effect Immediately after the incident R23 had redness noted on her right hand. There did not appear to be any effect on R23 and she went to bed shortly after the incident and was resting peacefully on her side with her right hand under her. The rest of her alert charting noted no residual effects of the incident both physically or emotionally. Explain .The facility placed both residents on 15 min. check to ensure R7's privacy and R23's safety. R23 was redirected back to her room where she was surrounded by familiar objects and got ready for bed. On 1/12/23 at 5:44 PM, ADON C (Assistant Director of Nursing) indicated that NHA A (Nursing Home Administrator) with the assistance of corporate staff completed the investigation for the Self-Report that was submitted to the state agency on 12/23/22. ADON C indicated that she asked NHA A the Surveyors questions via text message (NHA A is on vacation out of the country). ADON C indicated that NHA A did not interview all residents during the investigation because the incident happened in R7's room and he did not go to other resident rooms or in common area. ADON C indicated the only staff that was interviewed was the staff that witnessed the incident, no other staff were interviewed. ADON C indicated that typically for resident-to-resident allegations of abuse the Social Worker completes the interviews. No additional information was provided to surveyor. Please note that there is no evidence of a thorough investigation due to other staff working were not interviewed related to the incident, to know if other staff had witnessed similar events or if it's occurred before. No other residents were interviewed to show that others, have not been affected by a similar incident.

Based on observation, interview and record review the facility failed to ensure a resident (R2) did not abuse 3 out of 6 sampled Residents (R6, R1, and R3). R2 has a history of making inappropriate sexual statements toward staff, trying to grab and touch staff's breasts or other private areas. The facility was aware of R2's behavior and care planned this behavior. Despite knowing these behaviors, the facility did not ensure R2 had adequate supervision which led to R2 sexually touching a female resident. R2 also entered other residents' rooms uninvited and struck or frightened them. The facility's failure to ensure adequate supervision to prevent abuse created a finding of immediate jeopardy that began on 9/8/22. Surveyor notified the NHA A (Nursing Home Administrator) of the immediate jeopardy on 9/8/22 at 4:30 PM. The immediate jeopardy was removed on 10/21/22, however the deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Evidenced by: The facility policy titled, Abuse Prohibition undated, indicates, in part; Policy Statement: Facility Care Center has a zero-tolerance policy for abuse, neglect or exploitation, social media posts or misappropriation of property. As such, all employees are required to maintain a work and living environment that is professional and free from threat of and/or occurrence of harassment, abuse (verbal, physical, mental, psychological, or sexual), neglect, exploitation, corporal punishment, involuntary seclusion, social media posts or misappropriation of property for all residents . Purpose: 1. To protect resident from abuse, neglect, or exploitation by anyone, including but not limited to staff, other residents, consultants, volunteers, staff, or other agencies serving the resident, family members or legal guardian, friends, or other individuals. 2. To provide a safe, comfortable, and homelike environment . B. Training of Staff 1. All staff shall be trained on abuse, neglect, and misappropriation of property at the following intervals a. Upon hire b. Semi-annually c. Staff will be re-trained on the importance of ensuring resident safety immediately upon any observation or report of alleged abuse 2. Training shall include the following: a. Definitions of abuse, neglect, and misappropriation of property b. Reporting requirements c. Signs of potential abuse d. Signs of caregiver stress, burnout and frustration which may led to abuse e. Caring for residents with verbal and physical behavior concerns f. Investigation policy g. Appropriate interventions to deal with combative, aggressive and/or catastrophic reactions of residents. C. Prevention of Abuse . d. The administrator or designee shall ensure enough staff on each shift to meet the needs of the residents and ensure that the staff assigned has knowledge of the individual resident care needs. e. Background checks for all current staff shall be completed at least every 4 years. f. Care Conferences with residents and families to include conversations about how they have been treated or cared for, concerns with any staff, visitors or family members. According to the article written by a member of the [NAME] University Law School, Grandparent Molesting: Sexual Abuse of Elderly Nursing Home Residents and its Prevention, Emotional signs and symptoms [of sexual assault in a nursing home] include denial, humiliation, flashbacks, intense fear, guilt, anxiety, depression, feelings of hopelessness and helplessness, phobias, and rage. These conditions are symptomatic of post-traumatic stress disorder or rape trauma syndrome. Because victims of sexual abuse are likely to be cognitively impaired, practitioners must consider additional effects of abuse. Often cognitively impaired individuals are unable to describe the assault event, the fears, or the feelings of helplessness. This makes it more difficult to provide these victims with necessary services because they are unable to express their needs. In addition, victims suffering from dementia, including Alzheimer's disease, often display post-rape emotional distress, including disorganized or agitated behaviors, sleep disturbance, and extreme avoidance of certain staff members. Research shows that sexual abuse may increase the victim's mortality. Injuries, but more significantly stress, from the assault may exacerbate other health conditions of the victim, such as hypertension and diabetes. http://scholarship.law.[NAME].edu/cgi/viewcontent.cgi?article=1066&context=elders In Sexual Abuse of Older Nursing Home Residents: A Literature Review, the authors note the statement by the World Health Organization, Regardless of the type of abuse [psychological, physical, sexual, financial, and neglect], it will certainly result in unnecessary suffering, injury or pain, the loss or violation of human rights, and a decreased quality of life for the older person https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 65/ The National Centers for Victims of Crimes website http://www.[NAME].org defines sexual assault as: Sexual assault takes many forms including attacks such as rape or attempted rape, as well as any unwanted sexual contact or threats. Usually, a sexual assault occurs when someone touches any part of another person's body in a sexual way, even though clothes, without that person's consent. Some types of sexual acts which fall under the category of sexual assault include fondling and attempted rape. Sexual assault in any form is often a devastating crime. Whatever the circumstances, no one asks or deserves to be sexually assaulted. R2 admitted on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's quarterly MDS (Minimum Data Set) assessment on 9/12/22 indicates R2 had a BIMS (Brief Interview for Mental Status) score of 99 indicating severe cognitive impairment. R2's Comprehensive Care Plan, indicates, in part: Problem start date: 10/19/22, Behavioral Symptoms- Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety) . Approach start date: 10/19/22, Maintain a calm environment and approach to the resident. Redirect resident if wandering into another room; offer resident to stay by nurses' station to be in line of sight of staff. Approach start date 10/19/22, When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). Problem start date: 10/4/22, Behavioral Symptoms- Resident uses inappropriate language towards others. Approach start date: 10/4/22, Gently but firmly informed resident that inappropriate language is note [sic] welcome. Do not engage in discussion. Maintain a calm, slow, understandable approach. Provided 1:1 with resident as needed/able. Problem start date: 8/24/22, Behavioral Symptoms- Resident has been known to make sexually inappropriate comments towards staff and grabbing at staff. Approach Date 10/4/22, Gently but firmly inform R2 that inappropriate touching and/or sexual remarks are not welcome. Do not engage in discussion. If continues, ensure resident safety, and reapproach with second staff person to complete cares. Approach Date 9/8/22, Resident to have supervision when around female residents. Staff to ensure no inappropriate interactions . Approach Date 8/24/22, Provide 1:1 session with resident as needed/able. Problem start date: 5/6/22, Behavioral Symptoms- APOAHC (Activated Power of Attorney for Health Care) stated resident has a history of grabbing other residents aggressively and becoming physically aggressive with staff. APOAHC indicated resident has not made any sense when he talks; resident is able to form words, but the words together do not make sense. Resident has used swear words often. Approach Date 5/6/22, Staff can attempt to redirect resident. Staff should have a calm approach when interacting with resident. Ask simple yes, no questions. Staff can meet with resident 1:1 if needed/able. If resident becomes agitated staff can reapproach after giving resident time to calm down. Approach Date 5/6/22, During periods of increased agitation, remove resident away from other residents and take to safe area to calm down. Approach Date 8/2/22, Approaches to redirect resident to his own room. Sign placed outside of resident's room to direct him to his own room. R2's Treatment Administration History indicates a Start Date on 8/29/22, Target Behavior: (sexual inappropriateness, increase resident distress, dangerous to self or others). At the end of each shift mark Frequency- how often behavior occurred and Intensity- how resident responded to redirection. (Note: 8/29/22 Sexual monitoring began, APOAHC (Activated Power of Attorney for Health Care) advised on 5/6/22 of history of grabbing other residents aggressively and becoming physically aggressive, this monitoring was after numerous documented occurrences of aggressiveness towards residents and staff). R6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's MDS measures her cognitive ability at 4, severely impaired. Review of R6's progress notes document on 9/8/22 at 8:15 PM, a CNA (Certified Nurse Assistant) observed a male resident touching R6's breast. The CNA separated the residents and took R6 to her room to listen to music. Administration was notified. On 10/20/22 at 1:23 PM, Surveyor asked Activity Staff G to describe the Resident-to-Resident behavior with R2 and R6. Activity Staff G replied, DON B (Director of Nursing) placed both residents in front of the television, provided ice cream and soda to share. Activity Staff G further explained that she asked DON B if this was appropriate, DON B replied, she thought it would be cute and was putting them on a date. Activity Staff G stated to the Surveyor that she felt this was inappropriate as R2 is married and R6 has a boyfriend. On 9/8/22, Activity Staff G reported to Surveyor that she heard R6 screaming, so she went to the dining room to find R2 grabbing R6's crotch and her breasts. R6 had her clothes on. Activity Staff G stated to the Surveyor that she heard R2 talking about getting a blow job and R6 was replying yes. Activity Staff G reported to the Surveyor that she informed LPN D (Licensed Practical Nurse) who was doing medication pass at the time. Activity Staff G reported to Surveyor that R2 continue to ask R6 for a blow job for a few days. Surveyor asked Activity Staff G if she had documented this behavior, Activity Staff G replied that she may have put it on a piece of paper and gave it to DON B. On 10/20/22 at 1:57 PM, Surveyor interviewed ADON H (Assistant Director of Nursing). Surveyor asked ADON H the procedure for sexual contact, ADON H replied she would separate, ensure resident safety, take steps to ensure future safety, notify POA (Power of Attorney) and physician. ADON H further stated she would create a care plan, document in progress notes, obtain staff statements, gathering resident statements, and complete a skin assessment. Surveyor asked if ADON H was aware of the sexual contact on 9/8/22 between R2 and R6, ADON H replied that she was on call that night and when she was notified, she instructed the nurse what to do and did a care plan from home. Surveyor asked ADON H what the nurse was instructed to do, ADON H replied to separate the resident, do a skin assessment, ask R6 if she felt safe, provide meals in a separate dining room, keep an eye on R2 and notify NHA A (Nursing Home Administrator). Surveyor asked ADON H if there was any monitoring or follow up with R6, ADON H replied that she did not do a follow up, the SW (Social Worker) went and talked with R6 and said that R6 was not bothered by it and stated that R6 wanted it. Surveyor asked ADON H if R2 was in a line of sight at the time of the incident, ADON H replied that R2 was in the dining room when this happened, and they would need to be in the hallway to be in the line of sight. Surveyor asked ADON H if there should be monitoring after a sexual contact, ADON H replied yes and this is put in the task for every shift for inappropriate behavior, ADON H reports she reads the notes of the whole building every day and did not see anything else. Surveyor asked ADON H if R6 was monitored, ADON H replied, we didn't have a task to monitor R6, it was more of us to talk with her. Surveyor asked ADON H who sees the tasks when they are entered, ADON H replied just the nurses the CNAs do not see the tasks as I don't know how to enter that in the system. Surveyor asked ADON H if the incident should be reported and was there a report done, ADON H replied, that's tricky, if unwanted, yes, she verbalized she liked it and wanted it. Surveyor asked ADON H if the facility completed sexual consent assessment for R6 ADON H replied, I don't know. Surveyor asked ADON H if there were any sexual consent assessments done on R2, ADON H replied, I don't think so. Surveyor asked ADON H if the police should have been called, ADON H replied, if R6 would have been bothered by it or felt assaulted, yes. On 10/20/22 at 2:21 PM, Surveyor interviewed DON B. Surveyor asked DON B the process of a Resident-to-Resident sexual altercation. DON B replied that's abuse and administration needs to be informed immediately, keep residents safe, get statements from residents and staff, notify DON, physician, family and administration and document in the progress notes. Surveyor asked DON B if she is aware of the sexual altercation between R2 and R6, DON B replied, I wasn't working so I can't describe. DON B further reported to Surveyor that she was not the DON at the that time but was a staff nurse. Surveyor asked DON B if she put R2 and R6 in front of the television, DON B reported that she was not working that day. DON B further reported to the Surveyor that R2's care plan is to keep R2 at the nurse's station. R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff did not ensure R2 was adequately supervised to protect R6 from sexual abuse. R1 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly MDS (Minimum Data Set) assessment on 9/9/22 indicates R1 had a BIMS (Brief Interview for Mental Status) score of 13 indicating cognitively intact. R1's cognitive impairment is that he understands and is understood. R1's Comprehensive Care Plan, indicates, in part. .Problem start Date: 8/23/22, R1 can become frustrated towards confused residents who enter his room mistakenly. Has history of throwing water from his glass at others. Goal: Resident will remain calm and use call light to alert staff of need for assistance. Approach Start Date: 8/23/22 . Door alarm used per resident request for his personal privacy. Stop sign on door to remind other resident to not enter . Maintain a calm environment and approach when R1 becomes frustrated. Gently reassure him that he has his rights to privacy and who enter his room. (Note: 7/29/22 R2 hit R1 on the chin, 8/23/22 care plan added interventions. 9/26/22 R2 walked into R1's room and R2 hit R1 on the head twice. Current interventions were not modified.) Problem Start Date: 10/4/22, Resident has a black cloth placed on the floor outside of his room . Problem Start Date: 1/14/20, At times, when resident is upset, he becomes inpatient with staff, and he will make unsubstantiated negative claim, statement towards staff. At times, resident will become upset and perseverates on issues that have already been resolved and addressed . Approach Start Date: 10/4/22, Gently redirect and remind resident that past issues have been resolved when he perseverates on them. R1's record review progress notes indicate in part: On 9/26/22 at 8:54 PM, Resident threw water on another resident (R2) who was standing in his doorway. When nursing asked why he did that he stated, That man called me an[OBSCENITY] , and was standing in my doorway and I thought he was going to come into my room, it's the only thing I could find to throw at him, Nurse educated resident that we cannot throw water or anything at another resident or staff. Resident stated that he understood. R2's record review documents, in part: On 9/27/22 at 7:14 AM, R2's medical record documents in part, Resident very agitated this am, being aggressive [aggressive] with staff, and very hard to redirect, PRN (as needed) [MEDICATION(S)] 2.5mg, will monitor. Resident sitting at nursing station in/standing up from wheelchair, keeps standing up and unable to redirect to stay seated. Will monitor . Facility Self Report incident on 9/26/22, submitted on 9/27/22. On 9/27/22 at 5:20 PM, Resident offered room move and showed other rooms in the facility. Resident declined. SW (Social Worker) and NHA (Nursing Home Administrator) met with resident and daughter and discussed options of keeping him and other residents safe. Agreed for intervention to keep door shut starting at suppertime to provide resident with privacy during nighttime hours. On 9/27/22 at 8:39 PM, The nurse called by administrator to do full skin observation on resident due to allegations of resident. Nurse and CNA (Certified Nursing Assistant) went into resident room. Told resident that I had to do a full skin assessment and resident stated, what for, this nurse told him, it was facility protocol to do skin observation when said allegations are made. Resident agreed to observation. During observation of resident skin, this nurse asked why he didn't tell me about other resident hitting him last night when he was asked about the situation, and resident stated I just remembered today what happened This nurse asked what happened resident stated I was sitting in my chair eating dinner with my back to the wall, my tray was in front of me and then he (R2) walked into my room, and got behind me and bop, bop, bopped me [sic] on the head I asked if he could show me where so I could look for marks, and resident pointed to top of forehead in the center (no marks noted at said area). While continuing with the observation resident stated He was standing in my doorway, and calling me an[OBSCENITY] , and so I took my cup here (pointed to his blue cup of water) and then went like this (threw his arm in a upward motion) and [NAME] [sic] my water on him (laughing while saying it), then he turned around walked back some and took his shirt off, I got him good with that cold water too, I know because he hollered at me . On 10/4/22, R2 was moved from 3rd floor to 2nd floor. On 10/19/22 at 9:43 AM, Surveyor interviewed Med-tech F and asked Med-tech F the process of a resident in another resident's room, she replied she would go in, redirect and intervene. Surveyor asked Med-tech F, if there are any concerns with residents wandering into other residents' rooms or touching other residents. Med-Tech F replied to the Surveyor, upstairs there is an issue (referring to the third floor), there are a couple of residents, so R2 was moved to the second floor. Surveyor asked Med-Tech F what interventions were put into place with wandering residents, Med-tech F replied, we have tried a black mat on the floor and keeping the doors shut. Surveyor asked Med-Tech F if there are any stop signs on the doors, she replied she did not know and would have to check. R3 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Entry Tracking Record dated 10/7/22, does not indicate a MDS (Minimum Data Set) assessment, and no other assessments. R3's Comprehensive Care Plan indicates, in part: Problem Start Date: 10/10/22, Resident stated she has been in a car accident in the past, had cancer three times, was physically and sexually assaulted. Resident is currently bothered by events listed. Resident is triggered by being pinned down and having people grab at her clothes. Approach Start Date: 10/10/22, Staff will attempt to redirect resident if triggered by past events. Staff will remind resident of her location and that resident is in a safe place . Problem Start Date: 10/7/22, Resident indicated she is bothered by little interest or pleasure in doing things, feeling down, depressed, or hopeless, feeling tired and having little energy, trouble sleeping, poor appetite and trouble concentrating. Resident recently admitted to SNF (Skilled Nursing Facility) for rehabilitative services (new environment). Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approach Date: 10/18/22, Acknowledge to the resident that the current situation must be difficult. Meet with resident 1:1 as needed/able. Encourage resident to verbalize feelings, concerns, fears, etc. Clarify misconceptions. Meet with resident 1:1 as able/needed . On 10/17/22 at 9:47 AM, R3's record documents in part, Writer met with resident regarding another resident wandering into resident's room over the weekend. Resident indicated is okay after the event occurring. Resident indicated she wants to leave her door closed most of the time. Resident in agreement with having black cloth outside door to deter other resident's from entering her room as resident does like to leave her door open at times. Writer to place black cloth outside resident's door. Social services will remain available as needed. Of note there is documentation of the exact incident that occurred in R3's medical record. (Note: R3's care plan does not indicate this intervention of a black cloth at the time of exit on 10/20/22). On 10/20/22 at 12:55 PM, Surveyor interviewed R3. Surveyor asked R3 if anyone has come to talk with her or follow up about R2 entering her room. R3 replied to the Surveyor, nobody has talked to me yesterday except the Surveyor and nobody has yet talked to me today. Surveyor asked R3 how she feels and if she feels safe, R3 replied, it triggered survival mode, I hung on for dear life when he (R2) was trying to pull the walker away, I didn't know what he wanted. R3 further explained that she did not know how strong R2 was and if she would be able to outdo him. (Note: R3 has an intervention regarding triggers related to past incident in her care plan.) On 10/19/22 at 1:13 PM, Surveyor interviewed SW C (Social Worker). Surveyor asked SW C the process of a Resident-to-Resident altercation. SW C replied to the Surveyor, make sure residents are safe, if there is no altercation, I will follow up the next day; if there is an altercation like physical, I will talk with the NHA A right away and bounce off interventions. Surveyor asked SW C regarding documenting the incidents. SW C replied, staff document in the progress notes. Surveyor asked if SW C is responsible for the self-reports. SW C stated she does not do the self-report but will complete a grievance if one needs to be filed. Surveyor asked SW C how she learned of the incident with R2 entering R3's room. SW C replied to the Surveyor, I believe at stand up. Surveyor asked if SW C if NHA A was present at stand up, she replied NHA A is always there, but would need to check the schedule. Surveyor asked SW C if R2 had known behaviors of going into other residents' rooms, SW C replied yes. Surveyor asked SW C if R2 has interventions in place, SW C replied, our interventions previously were not working, R2 has interventions of redirecting and making sure all other residents are safe. Surveyor asked SW C how other residents are ensured they are safe, SW C replied, we do check ins and make sure R2 stays by the nurse's station. Surveyor asked SW C if there is documentation of check ins, SW C replied they would be in the nurse's documentation, we do have eyes on him, but we don't log in or anything. Surveyor asked SW C if R2 is in the line of sight, SW C replied, yes, his room is across from my office. Surveyor asked SW C if R2 has been in any other residents' rooms, SW C replied, one other resident that I am aware of. Surveyor asked SW C to share the information that was exchanged at stand up regarding R3, SW C replied that R3 was shook up over it with a man walking into her room, she has a history of abuse and we talked about interventions, we offered for her to move her room and she declined, she said she likes to keep her door open and would keep it shut and use a black cloth in front of the door. On 10/19/22 at 4:24 PM, Surveyor continued interview with SW C. Surveyor asked SW C if there was any monitoring for R3 or following up on her emotional status, SW C replied that she always checks in with R3 daily and anyone who is here for short term rehab. On 10/20/22 at 5:39 PM, Surveyor interviewed NHA A. Surveyor asked NHA A of each if she would expect monitoring to done after each incident and NHA A replied yes. Surveyor asked NHA A if there was any monitoring done with these incidents, she replied not to my knowledge. Surveyor asked NHA A if a sexual consent assessment was completed for R2 and R6, she replied not to my knowledge. Surveyor asked NHA A if she was aware of the incident with R2 and R3, she replied no. Surveyor asked NHA A if the facility had adequate supervision to prevent abuse. NHA A stated yes. The facility's failure to provide adequate supervision and prevent abuse created a finding of immediate jeopardy. The facility removed the jeopardy on 10/21/22 when the following was completed: I. Resident Who Have Suffered, or are Likely to Suffer, a Serious Adverse Outcome as a Result of the Non-Compliance: Residents were not able to consent to sexual activity. Resident 1 had known sexual behavior toward staff during care. Resident 1 touched Resident 2 in the groin and breast. Resident 1 had a known history of aggressive behaviors and wandering. Resident 1 entered other residents' room and hit or scared a resident. The facility failed to have adequate supervision or care plan interventions to prevent resident to resident incident. All resident in the facility are at risk for potential unwanted contact with Resident1. II. Actions the Facility will Take: Resident 1. has the potential for sexual and or aggressive behaviors: Immediate interventions include During waking hours facility will provide one on one supervision. Door sensor alarm and 15 minutes security checks while sleeping. Abuse training to include types of abuse, reporting abuse and stopping abuse including education on notification of the police for suspicion of abuse will be initiated and will be provided prior to next working shift for all employees. Training will be conducted by the Administrator and or Social Worker. Education on care plans, timely interventions, and re-assessment of interventions will be completed. Education in Sexual consent worksheet and sexual consent definition will be completed for all staff prior to their next working shift. Sexual Intimacy Worksheet will be completed with residents Resident 1 and Resident 2. Residents 1, 2 and 3 will have Trauma Informed Assessments completed. Residents 1, 2, and 3 will be checked in with by staff on each shift to ensure resident feels safe and does not have any concerns. Interviews will be completed with all other residents to identify any other incidents. Residents with cognitive impairment will be assessed for any new psychosocial signs or symptoms of distress. Care plans updated to reflect results of assessments, behaviors, and interventions. Sexual Intimacy worksheets will be completed on any residents that display sexual or intimate behavior. An audit of trauma informed care assessments will be completed and residents needing an assessment will be completed by end of day. Care plans will be updated as needed. Incidents have been reported using the MIR system Law enforcement notified of sexual event. Medical Director, Primary MD, Behavioral Solutions - psych provider, residents and or their representatives notified of incidents and modifications in care plan. The Ombudsman will be notified of incidents. Systems, Policies and Procedures: Abuse policy has been reviewed. A Sexual Intimacy Policy has been developed as well as an Intimacy Assessment Worksheet utilizing resources from the State Ombudsman Program. Monitoring, Audits, QAPI, and Facility Assessment: Administrator, Social Services Director, or designee will audit progress notes 5 times per week for 4 weeks, weekly for 3 weeks and monthly for 3 months. Intentional rounds to include checking in with resident and/or observing resident throughout the facility on each shift for 30 days. Audits of care plans and interventions will be completed 5x per week for 3 weeks, weekly for 4 weeks and monthly for 3 months. Quality Improvement committee will be notified of audit findings.

Based on observation, interview and record review the facility did not ensure that residents receive care consistent with professional standards of practice, to prevent pressure injuries and do not develop pressure injuries for 3 of 6 sampled residents (R) (R1, R4 and R6). R1 was at risk for pressure injury. The facility failed to ensure the pressure injury was assessed and measured weekly. R1's pressure injury deteriorated to a stage IV pressure injury which became infected. The facility's failure to ensure residents at risk for pressure injuries receive the care and services to prevent pressure injury deterioration created a finding of immediate jeopardy that began on 7/12/22. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 9/15/22 at 3:45 PM. The immediate jeopardy was removed on 9/16/22, 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. R4 was admitted to the facility with two pressure injuries. The facility did not complete the following timely: * Document wound descriptions or staging. * Complete a RN (Registered Nurse) Assessment of the wounds. * Complete initial wound care based on hospital discharge orders and last wound care treatment in the hospital. * Notify R4's provider. * Obtain Signed Physician Orders. R6 was admitted with a pressure injury (PI); this PI was not assessed upon admission. This is evidenced by: Example 1 The facility's policy of Pressure Ulcers/Skin Breakdown-Clinical Protocol dated April 2018 Includes: 2.the nurse shall describe and document/report the following: a. full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. b. pain assessment . 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) measured her cognitive ability as moderately impaired. R1 required extensive assist with bed mobility and was totally dependent with transfers. R1 developed a pressure injury on 2/7/22. R1's Braden Score (a measurement device used to estimate resident at risk for development of pressure injury): 3/18/22 was 13-14 at moderate risk. 6/17/22 was 13-14 at moderate risk. R1's Care Plan includes: -6/29/21 Weekly skin observation with shower. -9/7/22-At risk for alteration in skin integrity r/t (related to) decreased mobility and incontinence of bowel and bladder .current pressure area to right gluteal fold. -8/31/22 Low loss air mattress. -12/21/21 Boost supplement 4 ounces twice a day. -2/17/22 Arlinda supplement as ordered twice a day. -6/17/22 [MEDICATION(S)] supplement 1 scoop three times a day. -9/7/22 Assess and record the condition of the skin surrounding pressure ulcer. -9/7/22 Assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization with dressing changes. -9/7/22 Repositioning every 2 hours. Physicians wound care orders include: -2/7/22 barrier cream to coccyx/buttock twice a day until healed-DC (discontinue) 2/16/22. -6/14/22 and 6/15/22- treatment to right posterior thigh: clean right posterior thigh with wound cleanser; apply skin prep and foam for protection. Change every three days and PRN (as needed) if soiled-DC 7/5/22. -6/25/22 Up in wheelchair for no more than 2-hour intervals-Open ended DC date. -7/5/22 wash wound on lateral thigh with wound wash, apply collagen to wound bed, skin prep peri-wound, cover with foam dressing. Change every day and prn DC date 7/30/22. -7/26/22 Wound solution soak wound to right gluteal fold for 15 minutes twice a day-Open ended DC date. -7/26/22 Wound care: right gluteal fold. After wound solution soak: apply silver alginate and bordered foam-complete twice a day and prn-DC date 9/7/22 Nursing/Progress notes review includes: -2/2/22 R1 has reddened area to inner left buttocks approximately 2 cm (centimeters) in diameter, barrier cream applied -2/7/22 R1 noted to have a 1 x 1 cm open area, stage 2 secondary to shearing to right buttock, midline. NP (Nurse Practitioner) notified barrier cream applied. -2/26/22 in Wound Management notes-right gluteal fold wound measures 2 cm x 1.5 cm x .01 cm. -3/15/22 treatment done to left inner buttocks, wound bed yellow . Of note, R1's pressure injury on 2/7/22 was noted to be a stage 2. On 9/15/22 at 2:50 PM, Surveyor spoke to LPN F (Licensed Practical Nurse) about her documentation on 2/2/22 and 3/15/22. LPN F said she was mistaken in her documentation about the pressure injury being on the left inner buttocks, that the pressure injury was on the right buttock. The employee that documented on 2/7/22 no longer works at the facility. Nursing/Progress notes continue: -6/28/22 wound care done right upper thigh worsening, area is 2.5cm x 3.0 cm with a raised .8 cm ridge reddened around yellow slough and gray peri bed. Wound nurse updated. Of note, R1s the facility has no evidence of R1s pressure injury being assessed or measured from 2/7/22 to 6/28/22. On 6/28/22 R1s pressure injury was noted to have deteriorated from a stage 2 on 2/7/22 to a stage 3 or unstageable, it is difficult to know without accurate assessment of how much of the wound bed contained slough, on 6/28/22. -7/3/22 periwound measures 3.0 cm x 2.8 cm x UKD (unknown depth). Unable to measure depth to would bed with hardened red raised Epiboly ridge surrounding entire wound bed-wound bed is 20% slough and 75% eschar-wound nurse and NP updated. -7/9/22 dressing to right gluteal fold 25% shadowing noted with dark brown drainage-foul necrotic odor noted-wound remains 3.0 cm x 2.8 cm-no epiboly noted-resident did not display signs of pain with treatment. -7/12/22 Resident complained of increased pain right upper thigh wound area-scheduled medications given prior to whirlpool bath-grey and new pink blanchable area surrounding entire wound bed-wound measures 3.5 cm x 3.5 cm x unknown depth-wound is unstageable and true depth not visualized-peri wound bed is 90% necrotic with strong odor, moderate green-tan exudate on previous foam dressing noted-A small opening/hole noted .3 cm x .3 cm at approximately at 5:00 on wound bed-message left for LPN C wound nurse .; Of note, the pressure injury is now documented as unstageable. -7/25/22 discussion with NP G (Nurse Practioner) today related to declining wound-wound solution soak for 15 minutes twice a day-then apply silver alginate and dressing. Of note there is no evidence the facility assessed or measured the wound for 13 days between 7/12/22 and 7/25/22. On 7/25/22 the facility documents the pressure injury is deteriorated. -7/26/22 treatment to right gluteal wound 5.5 cm x 3.7 cm x 1.7 cm-minimal drainage with moderate odor with 70% yellow slough, 30% grey slough-resident has pain at site -8/6/22 treatment performed to right gluteal fold-still emits foul odor-gray slough present to wound bed .appears to be a small hole in right base of wound-message left on wound nurses' voicemail as she is out of office until 8/8/22. Of note, the pressure injury is not assessed or measured from 7/26/22 -8/6/22 this is 11 days between assessments there are no measurements on 8/6/22. -8/8/22 wound bed continues to be 50-75% covered in slough/loosening eschar. 8/9/22 communication to NP G regarding facility visit tomorrow-resident's wound seems to be stalling-would like input from NP on alternative treatments. Of note, NP G did not see R1 on 8/10/22 and there was no change in wound care orders. -8/23/22 treatment completed to right gluteal wound-continued strong odor moderate tan exudate with large amount of loose grey slough interior deep wound bed-resident state has pain with dressing changes and would like to be medicated prior to wound care-resident has flat affect and does not always express her pain needs. -8/27/22 resident medicated prior to treatment-wound bed is worsening in depth with large amount of grey slough and odor. Message left for LPN C wound care nurse. On 9/15/22 at 2:10 PM, Surveyor spoke with IDON B (Interim Director of Nursing). Surveyor asked IDON B about her documentation on R1's wound on 7/12/22 and 8/27/22. Surveyor asked IDON B regarding R1's worsening wound. Surveyor interviewed IDON B regarding the deterioration of R1's wound. Surveyor asked IDON B to explain what the facility did when R1s wound was deteriorating. IDON B said if a wound has a change or is worsening, then LPN C is notified because she is the wound nurse, and she calls the physician or NP if it is needed. -8/30/22 resident seen by physician today-low air loss mattress ordered. It's important to note R1's physician did not observe R1's wound during his visit on 8/30/22 or at any time while R1 had a wound. -8/31/22 wound is oval shape-drainage from wound is severe-foul odor noted as soon as writer entered room-wound measured 3.2 cmx 2.9 cm - depth at the deepest area which would be at 0300 if you visualize the wound as a clock, measures 3.4 cm-the shallowest part at the 0900-point measures 2.5.cm in depth-R1 was medicated prior to wound care. Of note, this is the first measurement of R1's pressure injury since 7/26/22. The pressure injury has significantly deteriorated now with foul odor and increased in size. -9/6/22 spoke with NP G regarding wound care and wound progression-NP G will be at facility 9/7/22 to assess and plan will be discussed tomorrow for future treatments. -9/8/22 12:18 AM, received call from NP G concerning resident wound-new verbal orders 1. Antibiotic twice a day for 10 days related to wound 2. Collect wound culture 3. Resident to be up only for meals for one week-turn every 2 hours 4. Continue wound solution soak for 15 minutes then apply honey dressing then foam dressing. -9/8/22 2:51 PM, .called nurse to room because resident appeared unwell-resident respiration at 35, breathing very noisy, resident was shaking profusely, arms and hands were cold, unable to take vital signs due to shaking, temperature 102. 0, oxygen saturation 73% on room air-oxygen placed at 4 liters per nasal cannula-EMS called and resident sent to hospital. NP G called and updated on resident status. Surveyor reviewed R1's hospital admission wound, and wound measurement records documented 9/8/22. The hospital admitted R1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The emergency room physician documented R1's wound as right ischial tuberosity-wound bed assessment black, deep pink, brown, slough, granulation tissue-exudate description moderate purulent brown-length 5 cm width 3cm depth 7.5 cm-tunneling 7.5 cm (around 2 o'clock-could be wound bed destruction or tunnel as it is difficult to visualize)-stage IV. On 9/15/22 at 11:00 AM, Surveyor spoke to NP G. NP G said the facility updated her appropriately and she was working with the wound nurse on R1's wound care. Surveyor asked NP G if she saw or assessed R1's wound prior to 9/7/22. NP G said no. Surveyor asked NP G if she saw R1's wound on 9/7/22. NP G said yes, it was upsetting, I ordered antibiotics because I thought it was infected. On 9/15/22 at 1:00 PM, Surveyor spoke to LPN C. Surveyor asked LPN C if NP G visited the facility to see residents. LPN C said NP G visits the facility on Monday and Wednesday each week. Surveyor asked LPN C why NP G did not see R1's wound until 9/7/22. LPN C said she does not do rounds with NP G. Surveyor asked LPN C if R1 had a pressure relief mattress on her bed prior to the low air loss mattress that was in place on 8/31/22. LPN C said R1 had an air mattress overlay prior to the low air loss mattress, but she did not know what kind it was or when it was placed on R1's bed. Surveyor asked LPN C what the procedure was if a nurse doing wound care assessed the wound as getting worse. LPN C said she expected the nurse to call NP G if the wound looked worse. Surveyor asked LPN C why R1's wound was not measured, assessed, or documented from 3/15/22 to 6/28/22. LPN C said she was working the floor and going to school and when she had time to do wound measurements, the wound measurements were documented in the progress notes. The facility's failure to consistently assess and measure R1s pressure injury and implement aggressive pressure injury prevention measures to prevent the pressure injury from deteriorating created a finding of immediate jeopardy. The facility removed the jeopardy on 9/16/22 when the following was completed the following: All current residents with pressure injuries (2) and any resident identified as at risk will have an RN assessment completed which will include measurements, assessment including a Braden, documentation to include progress notes, orders, and plan of care. MD will be updated on all findings on every wound. All residents and or their representatives will be updated on their current wound status. Skin Prevalence rounds - complete skin assessments on all current residents regardless of risk will be completed with the goal of identifying any new or unidentified skin issues. Braden scale assessments will be completed on all residents to identify risk and needed interventions to maintain or promote healing with all identified skin/wound issues. New interventions will be implemented immediately. Care plans will be updated to reflect all current interventions. Medical Director will be notified of all pressure injuries or other skin conditions. RNs and LPNs will be educated on ensuring physician notification of any changes in wounds at the time of discovery and in the event the wound deteriorates. 9/15/2022 RNs and LPNs will be educated on the facility skin care policy and procedure for wounds. 9/15/2022. RNs and LPNs will be educated on the requirement of RN assessment of wounds within 24 hours of discovery. 9/15/2022 RNs, LPNs, and CNAs will be educated on immediately implementing aggressive Pressure Injury prevention measures for all residents at risk at admission, change of notification or at time of noting risk. 9/15/2022 LPNs and RNs will be educated on completing a weekly assessment of wounds to include measurements. 9/15/2022 CNAs will be educated on alerting any changes of skin condition immediately to the nurse while immediately implementing interventions for the resident to include robust turning and repositioning. 9/16/2022 All training noted above will be completed by the next working shift. Education will be provided by nursing management or a nurse who has been previously educated and designated to give the education. Root Cause Analysis will be scheduled and completed. RCA findings and action plan will be implemented. Scheduled for 9am 9/16/2022. Skin care Policy and Procedure will be operationalized supporting weekly prevalence, assessment, documentation, appropriate treatment, precaution measures and reporting. Medical Director will be involved in any modifications or training. DON, Nursing Manager, or nursing designee will conduct audits weekly indefinitely with the Medical Director or NP regarding residents with pressure injuries. DON, Nursing Manager, or Nursing Designee will conduct audits 5 times per week for 2 weeks, weekly for 4 weeks, and monthly for 3 months to ensure physician notification of residents with risk of pressure injuries. DON, Nursing manager, or designee will complete audits 3x per week for 3 weeks, weekly for 3 weeks and 3 times month for 3 months to ensure interventions are in place for each resident identified as at risk. DON, Nursing Manager, or designee will complete audits on anyone with a PI to ensure weekly documentation is noted in the medical record. MDS Coordinator, DON, Nursing Manager, or Designee will complete audits 3x per week for 3 weeks, weekly for 3 weeks, and 3x per month for 3 months, to ensure there is a robust care plan in place for Pressure Injuries. Random audits of the medical record will be completed by the MDS coordinator, DON, or Designee to ensure provider notification, care plan revision with updated interventions, and documentation of skin concerns. All audits listed above will be reviewed at QA meeting for further recommendations. Example 2 The facility policy titled, Admission Assessment and Follow-up: Role of the Nurse, indicates, in part: Purpose The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS .8. Conduct a physical assessment, including the following systems. Skin .12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Documentation The following information should be recorded in the resident's medical record:3. All relevant assessment data obtained during the procedure .5. Orders obtained from the physician . R4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's admission nurses note on 9/8/22 at 3:56PM, documented by LPN E (Licensed Practical Nurse), indicates, in part: Resident admitted .today .Skin assessment completed areas of concern noted. Open areas to coccyx x2. Right buttock is 6cm x 8cm left buttock is 5cm x 7cm . R4's Admission Observation note dated 9/8/22 was completed by LPN E. The Skin section notes, in part, the following: .Alterations in skin? Yes Comments: Open areas to coccyx x 2. right buttocks is 6cm x 8cm left buttock is 5cm x 7cm . The wound section notes the following: *Location: coccyx *Length - head to toe direction (centimeters) 6 *Width - hip to hip direction (centimeters) 8 * Can depth be measured? No * Proceed with wound care observation? No Of note, there is no description of the wound bed, surrounding tissue, or staging of the wound. On 9/15/22 at 10:26 AM, Surveyor interviewed LPN E and asked what her responsibilities include when she finds a wound on a resident regardless of if it is on admission or facility acquired. LPN E indicated, report to the ADON (Assistant Director of Nursing); DON (Director of Nursing); write-up a communication to the doctor and that goes in their box. Surveyor asked LPN E if the physician is contacted by phone as well or just the communication form. LPN E indicated, call as well. Surveyor asked LPN E if this is documented. LPN E indicated, it depends on the nurse, usually if I find it, I put in a progress note and if you got new orders, you would put those in too. Surveyor asked LPN E if she would stage the wound. LPN E indicated, I'm an LPN and so cannot stage wounds, I just describe what I see, what the wound bed looks like, drainage, pain, eschar, slough. I personally also take measurements. Surveyor referenced LPN E's documentation for R4 on 9/8/22 and asked if she completed wound care on that date. LPN E indicated; the wound care order did not start until 9/11/22. Surveyor asked LPN E if she recalls if she completed wound care on 9/8/22. LPN E indicated, if I took the bandage off and looked at it, I would have done the wound care. Surveyor asked LPN E if there should have been a description of the wound in the documentation when it was found. LPN E indicated, yes. Surveyor reviewed LPN E's documentation of the wound measurements with her. Surveyor asked if she recalled if the wounds were truly right buttock 6cm x 8cm and left buttock 5cm x 7cm as the measurements from 9/14/22 were documented as RT buttock 0.6 cm x 0.8 cm x 0.2 cm and LT buttock 0.5 cm x 0.7 cm x 0.2 cm. LPN E indicated the measurements she took were accurate as documented and that it was a large area of redness. There is no documentation indicating the R4's wound was assessed by a RN (Registered Nurse) prior to the survey team entering the facility. R4's ED (Emergency Department) to Hosp-Admission paperwork, indicates, in part: Wound 8/25/22 .Left gluteal pressure injury Stage 3 .8/26/22 Right medial gluteal pressure injury Stage 3 . Of note, the documentation shows the last date wound care was performed on the left gluteal pressure injury was 9/7/22 and 9/6/22 on the right gluteal pressure injury. R4's Hospital After Visit Summary, dated 8/25/22 - 9/8/22, indicates in part: .Discharge Instructions .Incision/Wound Care: Gluteal dressing: Change every 3 days and PRN (as needed): Cleanse with NS (normal saline), apply sensi-care to wound bed, cover with foam dressing, secure with transparent film . R4's TAR (Treatment Administration Record) for 9/1/22 to 9/15/22, indicates the first time the gluteal wound care was signed out as completed was 9/11/22. R4's nurses notes indicate, in part, the following: 9/14/22 3:05 PM WOUND NOTE: DRSG CDI (dressing clean dry intact) to buttocks. Resident admitted to facility with stage II pressure injuries to bilateral buttocks. No drainage or odor noted; wound beds pink with peeling white skin to peri wound. RT buttock 0.6 cm x 0.8 cm x 0.2 cm (parameters consistent with admission note). LT buttock 0.5 cm x 0.7 cm x 0.2 cm (parameters consistent with admission note). The note was e-signed by LPN C, who is also wound care certified. There is no documentation indicating that the physician was updated regarding R4's PI's (Pressure Injury). 9/15/22 11:31 AM Writer assessed open area to bilateral buttocks. Appears to be macerated on both sides, small amount of drainage noted on dressing, serosang, no odor noted . The note was e-signed by RN H (Registered Nurse). 9/15/22 11:31AM Observation of bilateral buttock wound with RN H. Small amount of serosanguinous drainage to wound that was not present yesterday. Proximal peri area presents macerated, which was not present yesterday .Also will request venelex BID (twice daily) from PCP (Primary Care Provider). This note was e-signed by LPN C. On 9/14/22 at 2:55 PM, Surveyor interviewed LPN C and asked if a new resident is admitted to the facility with a wound, is it the expectation that the nurse admitting the resident and looking at wound be able to describe and stage the wound. LPN C indicated, yes. Surveyor asked if there is documentation of a wound description or staging for R4. LPN C indicated, she had been out of the building and would be documenting on the wound today. On 9/15/22 at 12:28 PM, Surveyor received unsigned orders for R4 from NHA A (Nursing Home Administrator). NHA A indicated the orders had been verified and they were awaiting a fax back from the provider. NHA A also indicated there were no physician communication sheets for R4. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There are no specific orders for R4's wounds noted on the physician orders. On 9/15/22 at 1:45 PM, Surveyor interviewed LPN C, who is also the facility wound care certified nurse, and asked if a resident is admitted with a wound and the hospital discharge orders indicate wound care is to be done every three days, when would you expect the first dressing change to be done? LPN C indicated; it depends on when it was last done in the hospital. Surveyor asked LPN C who is responsible for checking when the dressing was last changed in the hospital. LPN C indicated, usually we are told by the hospital nurse in report. If not, we could use the date on the dressing itself, if no date on dressing, then just change it and start fresh on admission. Surveyor reviewed with LPN C hospital documentation noting wound care on 9/7 and asked when the initial dressing change should have been completed in the facility. LPN C indicated on 9/10. (Of note, the first documentation of a dressing change being completed is noted on 9/11/22.) Surveyor asked LPN C at what point, when a wound is identified, is the provider supposed to be notified of and examine the wound. LPN C indicated; they typically have not physically looked at it unless we have a problem. Notification should be done within 24 hours, if it is something like redness then it can be faxed. Surveyor asked if a resident has a stage II wound how should the provider be notified. LPN C indicated, a phone call, anything that requires more than skin prep should be a phone call. Surveyor asked LPN C if the wound is found by an LPN, should an RN assess the wound. LPN C indicated that an RN should assess the wound in addition to the LPN observation within 24 hours and that it should be documented in the progress note. Surveyor asked LPN C if there is a RN assessment for R4's wounds. LPN C indicated, today RN H looked at the wounds. Surveyor asked LPN C if this should have been done before today. LPN C indicated, yes. Surveyor asked LPN C if the first time the wound was staged was in her note on 9/14/22. LPN C indicated, yes. Surveyor asked LPN C if this should have been done before 9/14/22. LPN C indicated, yes. Surveyor read number 3 from the section Assessment and Recognition, from the facility policy, Pressure Ulcers/Skin Breakdown - Clinical Protocol, to LPN C, which indicates: The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Surveyor asked LPN C if this was completed with R4. LPN C indicated, we don't do this now, we will have to get a process in place. Surveyor reviewed the unsigned physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked LPN C if it should be a RN that is making treatment recommendations. LPN C indicated; we had more RN's when that was written so we should change it to wound care nurse. Surveyor asked LPN C, once the recommendation is made, do you send the order to be signed by the provider. LPN C indicated I will do a telephone order or fax a physician communication and I can't change the order until we get that ok. Surveyor asked LPN C if the wound care orders from the hospital discharge, currently being used, should be listed on the orders waiting to be signed. LPN C indicated, yes, and she is not sure why they are not. Surveyor asked LPN C, how long the discharge orders from the hospital can be used before the facility gets a new order from the resident's or facility provider. LPN C indicated, 24 hours. Surveyor noted to LPN C that R4's orders are 7 days out from hospital discharge. LPN C indicated, right, so I called our medical director because I was not getting a response from R4's provider. On 9/15/22 at approximately 2:25 PM, Surveyor interviewed IDON B (Interim Director of Nursing) and asked what the expectation is for a staff member that finds a wound on a resident regardless of if it is on admission or facility acquired. IDON B indicated, they should document the appearance; assessments; size; update LPN C; if treatment is needed, other than skin prep, call NP (Nurse Practitioner) at that time and get orders. Surveyor asked IDON B if she would expect things like odor, pain, appearance of wound bed, and staging to be documented. IDON B indicated, yes, with staging though, LPNs cannot stage the wounds, some RNs are comfortable, and some aren't, so documenting a description is best. Surveyor asked IDON B when and how the provider should be notified of the wound. IDON B indicated, after it is assessed and staged. Surveyor asked IDON B if a wound is found by a LPN, should it be assessed by a RN and how soon. IDON B indicated it should be assessed by a RN within 24 hours. Surveyor asked IDON B when the hospital discharge orders should be replaced with orders from the facility provider. IDON B indicated, that is not my area. NHA A was present and indicated she would follow-up. No additional information was provided. Example 3 R6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Admission Observation note dated 9/12/22 was completed by an Licensed Practical Nurse (LPN)- wound section states: wound: 0.5 cm (centimeters) x 0.3 cm x 0.1cm; there is no description of wound, wound bed, or whether or not there is any drainage. R6's baseline care plan does not indicate that R6 has a pressure injury. R6's hospital discharge instructions state: Heel suspension boot while in bed; this intervention is not listed on R6's care plan. Additionally, R6 has wound care orders for his PI that are not listed on the care plan. On 9/14/22 R6 was seen by LPN C (Licensed Practical Nurse), who is also wound care certified. LPN C's wound note indicates that R6 has a stage 2 PI (Pressure Injury) to his right heel, no drainage, no odor, pink wound bed with thick white edges. Measurements: 0.3 cm x 0.3 cm x 0.2 cm. There is no documentation indicating that the physician was updated regarding R6's PI by either nurse. Additionally, there is no documentation indicating the R6's wound was assessed by a Registered Nurse (RN) prior to the survey team entering the facility. On 9/15/22 at 1:56 PM, Surveyor interviewed LPN C. Surveyor asked LPN C if PIs should be assessed by a RN on admission, LPN C stated that in addition to the LPN's observation, a RN should assess a resident with a PI within 24 hours of admission, and that the assessment should be documented in the nurse's notes. Surveyor asked LPN C if R6's PI was assessed by a RN within 24 hours of admission, LPN C stated no. Surveyor asked LPN C if a resident is admitted with a PI, should the physician be updated, LPN C stated that if the wound requires more than skin barrier then the physician should be updated within 24 hours of admission. Surveyor asked LPN C if R6's physician was updated, LPN C stated no. Surveyor asked LPN C if assessments and physician notification should be documented in the nurse's notes, LPN C stated that there should be a note. On 9/15/22 at 2:59 PM, Surveyor interviewed LPN D (Licensed Practical Nurse). Surveyor asked LPN D what the process was for baseline care plans, LPN D stated that when the admissions nurse does the assessment, she fills out the baseline care plan form, has the resident or POA (Power of Attorney) sign the bottom of the form, hangs a copy in the resident's bathroom, and puts a copy in the resident's EHR (Electronic Health Record). Surveyor asked LPN D if a resident is admitted with a PI, should the baseline care plan indicate that the resident has a wound, LPN D stated yes, it should go under the skin section, it should say where the PI is and should list the interventions.

Based on interview and record review, the facility did not ensure residents have an environment free of hazards and did not provide adequate supervision and assistive devices for 2 of 3 sampled residents (R1 and R3). R1's care plan intervention of 1A (one-person assist) with walker for transfers and ambulation was not implemented. R1 fell while standing up next to her bed when CNA C (Certified Nursing Assistant) let go of R1 for between 30-35 seconds while R1 was moving her feet and getting them situated in her shoes. Subsequently, R1 lost her balance and sustained a fall that resulted in a right femoral neck (hip) fracture, scalp hematoma and large hematoma to right proximal forearm. CNA C stated to Surveyor she let go of R1, leaving her standing independently. When she heard 2 clicks and a loud noise, she turned around to find R1 on the floor. R3 fell on [DATE] when a CNA attempted to transfer R3 by self, rather than with the assist of a second person as indicated in R3's care plan. The CNA thought R3 needed only the assist of 1, and she let go of R3's gait belt when she attempted to pull up R3's pants. R3, who is on a blood thinner, was sent to the emergency room for evaluation. Evidenced by: Facility policy entitled Fall and Fall Risk, Managing, dated March 2018, states, in part: Policy: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Definition: According to the MDS (Minimum Data Set), a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level . Fall Risk Factors 1.d. Obstacles in footpath 2. Resident conditions that may contribute to the risk of falls include: e. lower extremity weakness, medication side effects, [CONDITION(S)], functional impairments, and visual deficits. Resident -Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-center fall prevention plan (e.g. care plan) to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of [CONDITION(S)], as applicable) to try to minimize serious consequences of falling. 5. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exit that continue to present a risk for falling or injury due to falls. R1 was admitted to the facility on [DATE] with diagnoses that include history of falls, dizziness, rhabdomyolysis (this can cause muscle pain and weakness), muscle wasting and atrophy, moderate cardiomegaly with [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] stage 3. On 6/7/21 at 11:40 AM, prior to her admission to the facility, R1's hospital H&P (History and Physical) documents the following: R1 has a PMH [past medical history] sig [significant] for [CONDITION(S)], [CONDITION(S)] [hypertension], and combined systolic and diastolic heart failure who presents reporting a fall. The patient reports for the past 2 days she has been suffering from [CONDITION(S)] when raising from bed. Yesterday she was able to sit up for 20 min [minutes] and the lightheadedness normalized, and she was able to go about her day normally. Despite this she fell and hit her head on a bookcase, but was able to move over to a couch to help herself back up . On 6/8/21 R1's hospital report form indicates the following: The patient (R1) had borderline [CONDITION(S)] and [CONDITION(S)] overnight. R1 is her own person. R1's Admission MDS (Minimum Data Set), dated 6/17/21, indicates the following: R1 is moderately cognitively impaired, Section B shows that R1's Speech Clarity indicates R1 has clear speech - distinct intelligible words; Makes Self Understood indicates R1 is understood. Ability to Understand Others indicates R1 understands - clear comprehension. Section G shows that R1 Balance During Transitions and Walking Moving from seated to standing position R1 is Not steady, only able to stabilize with human assistance. Surface-to-surface transfer (transfer between bed and chair or wheelchair) indicates R1 is Not steady, only able to stabilize with human assistance. Section J shows that R1 had a fall in the last month (note: this contributed to her admission to the facility on [DATE]), R1 also fell within the last 2-6 months prior to admission. R1's CAA (Care Area Assessment) for Falls with an Assessment Date of 6/17/21 indicates R1 had a recent fall at home r/t [related to] hypotensive episode with c/o [complaint of] dizziness. Remains at risk for further falls r/t advanced age, impaired balance, increased weakness and decreased functional mobility. Impaired safety awareness. R1's Basic CNA Care Plan dated 6/18/21 states, in part: Devices: Glasses, 2 wheeled walker, bilateral transfers bars, TRANSFERS: 1 assist and walker, MOBILITY: 1 assist and 2 WW [wheeled walker] in room. BEHAVIOR and COGNITION: A&O x4 [alert to person, place, time, and situation]. Pleasant and cooperative. R1's comprehensive care plan indicates Problem Start Date: 6/18/21, R1 remains at risk for falls r/t (related to) advanced age of 90, impaired balance, increased weakness, decreased functional mobility. Impaired safety awareness. Goal: Will put interventions in place to decrease potential for injuries with fall events. Approach: Keep call light and frequently used items within reach, OT/PT (Occupational Therapy/Physical Therapy) as ordered, Pain management. Following R1's fall on 7/4/21, the facility added the following two (2) interventions to R1's care plan on 7/4/21: Keep pathways clear when transferring/walking, Resident (R1) to have 1 staff member assist resident with gait belt and walker with each transfer/walk-continuous. R1's comprehensive care plan indicates R1 was hospitalized after fall at home during which she hit her head on bookcase. Reports that she had been experiencing hypotensive episodes when getting up from bed with c/o's [complaints of] dizziness for a few days prior to fall. Dx [diagnosis]: A-fib, [CONDITION(S)] [hypertension], and heart failure. Pt's [Patient's] goal is to improve balance, strength and function. R1's Goals include: R1 will ambulate 150 feet with SBA [Stand by assist] using 2WW [wheeled walker] to demonstrate increased activity tolerance. PT/OT for strengthening/endurance Set up for UB [upper body] hygiene/grooming and dressing. Assist of 1 to complete cares. On 7/4/21 at 4:45 AM, R1's Progress Notes state as follows: LPN D (Licensed Practical Nurse) called this DON (Director of Nursing) regarding fall. LPN D stated resident (R1) was being assisted by CNA C when resident fell and hit her head. This DON started to call on call MD (Medical Doctor) to get orders and notify. On 7/4/21 at 4:53 AM, R1's Progress Notes state as follows: LPN D called this DON back stating resident cannot move one of her legs and on call MD told her to send resident to the ER [emergency room ]. This DON was updated on status. LPN D stated resident has not been moved and ambulance is on their way to pick her up and take her to hospital. On 7/4/21 at 5:09 AM, LPN D documented a Safety Event - Fall Report Description: Witnessed fall in room at 4:18 AM Location of Fall: Resident Room Describe exactly what happened; why it happened; what the causes were. If any injury, state part of body injured. If property or equipment damaged, describe damage: While prepping medication for another resident, I heard CNA C call out, Are you there, R1 has fall [sic]. I quickly went to assess R1. R1 had fallen near her bed with her head towards the entry door of her room. I asked what happened. She stated that she was trying to go to the restroom. She lost her balance fall [sic] and hit her head on the door. I completed an assessment. [Note: LPN's cannot assess as it is out of their scope of practice.] Vitals and neurochecks on R1 prior to CNA C and LPN D assisting her back to bed. R1 stated she felt dizzy prior to falling and her foot felt funny like she was off balance. She also stated that she could not move her right leg. She was able to demonstrate movement of left leg and upper extremities. After the assessment LPN D called DON B, called the Physician who was on call and contacted R1's next of kin. I (LPN D) also phoned the ambulance to transport R1 to hospital. I (LPN D) stay [sic] with R1 for comfort and to assess in changed in her condition until the ambulance arrived. Pain Observation: Does resident exhibit or complain of pain related to the fall? Yes, 4-Moderate Pain - Distressing, Miserable Body Observation: Abrasion, Bruising, Swelling, Bump Range of Motion: ROM (Range of Motion) painful/limited in lower extremity Positioning of Extremities: Rotation/Deformity/Shortening of Right Lower Extremity Lower Right Extremity Movement: Absent Speech: Clear - Distinct, intelligible words Does the resident respond to the following: Name, Pain, Environment? Does the resident exhibit or complain of any of the following since the fall? Note the options are Dizziness/Lightheadedness, Headache, Nausea/Vomiting, [CONDITION(S)] Note: None of these are selected Possible Contributing Factors: Current safety devices/interventions in place at time of fall - She was using a walker; Resident incontinent or voiced need to use the bathroom. Add time resident last used bathroom or received incontinent care - She had requested assistance the [sic] bathroom; Placement of assistive device (Where located?) - The walker was placed to Right side of her (R1); Environment (describe) Clean and clear of clutter; Footwear (describe): Nonskid socks and walking shoes were on; Clothing (describe) thin pajama bottoms and top. Did resident complain of or experience any of the following PRIOR to the fall? Dizziness/lightheadedness Updated PCP (Primary Care Provider) and Bedside Approach Sheet: 7/5/21 On 7/4/21 at 7:06 AM, R1's ED (emergency department) provider note indicates, in part, as follows: Patient presents with: Fall - fell while walking to bathroom this AM at SNF [skilled nursing facility]. Reports her feet were not flat on the floor so she fell backwards and hit her head, R [right] elbow and R hip. Reporting right hip and knee pain. Large visible hematoma R elbow. ED course: Patient reexamined at 7:10 AM, pelvis x-ray showing a right femoral neck fracture. Patient updated in regards to x-ray findings and need for admission. Right lower extremity with normal sensation. Able to move all toes. Bilateral pedal pulses normal and symmetric. Hematoma to right proximal forearm . X-ray pelvis with right hip - 7/4/21 Impression: Right femoral neck fracture On 7/4/21 at 7:23 AM, R1's Progress Notes state as follows: LPN D documented Resident is safe, vitals are stable, she has reported the inability to flex right leg at the hip. There is a hematoma on right forearm with some abrasions. There are two bruises in the inner antecubital space. On 7/4/21 at 4:18 PM, R1's Progress Notes state as follows: Call placed to ER. Resident admitted for right femur FX [fracture] with scheduled surgery tomorrow. 7/5/21 at 10:07 AM, R1's Progress Notes state as follows: Resident needs to have pathways clear prior to attempting to transfer. Remind resident to stay seated until pathways clear, gait belt on, and walker in front of resident. Updated Care Plan CNA C completed an Incident Report that is not signed nor dated that states, in part: Employee statement: Writer was with resident and just stood by assist to stand. Writer let her get [unable to read writing], tell her to get balance. Writer moved tray table out of way to make more room (clear better path for writer standing near resident) writer heard two clicks and whoops. Writer couldn't catch her in time. Resident was falling forward when writer turned slightly to move table. Note: R1 was standing and CNA C was not holding onto R1 to help stabilize her. Subsequently, R1 fell and fractured her hip. R1's care plan intervention of 1A (assist) with walker for transfers and ambulation was not implemented. LPN D completed an Incident Report that is signed and undated that states, in part: Did you ask resident what happened? What was the response? Yes, lost balance while standing, dizzy - fell and hit head on door . Employee statement: I was prepping meds for another resident when the CNA (CNA C) asked, Are you out there? R1 just falled [sic]. I went to R1's room and saw R1 on the floor. I asked what happened and assessed her. R1 appeared alert and oriented but stated that she lost her balance. After assessing R1 and gathering vital signs I called the DON about having R1 evaluated at the hospital. She informed me to call the doctor on call. I spoke with the doctor and family about the incident. I called the ambulance and had R1 sent to the hospital for further evaluation. Vital checks, neuro checks and incident report were completed. NHA A documented an Investigation Summary, which states in part .On 7/4/21, R1 had a fall that resulted in her being sent out to the emergency room for further evaluation. Prior to being sent out, R1 was with CNA C, needing assistance going to the bathroom. CNA C was moving the tray table away from R1's path when R1 lost her balance resulting in a fall. CNA C was unable to catch her in time to prevent her from falling .Prior to the resident's departure from the facility, LPN D asked the resident what happened. R1 reported to LPN D, she lost her balance while standing, was dizzy and fell and hit her head. (It is important to note that CNA C could not catch R1 in time as she had her back turned to R1 and was not holding onto R1 or her gait belt as she was standing up. R1's care plan intervention of 1A with walker for transfers was not implemented, resulting in R1's fall with a right femoral neck fracture.) The NHA's Investigation Summary continues: Upon Medical Record Review, R1 was a one assist with a gait belt and walker . Care Plan was being followed at the time of the fall. R1 was actively working with therapy for rehabilitation services and was making progress and working on discharging to a Memory Care Assisted Living Facility in to be closer to her family. On 7/14/21 at 8:20 AM, Surveyor spoke with CNA C. Surveyor asked CNA C how many people were in R1's room when she fell . CNA C stated only 1 person, herself. Surveyor asked CNA to describe R1's fall the morning of 7/4/21. CNA C stated she was helping R1 get up and let her get steady. CNA C stated R1 said, I can't get steady. CNA C stated, when R1 is standing up and has just put shoes on her feet, she always takes some steps to get her feet situated. CNA C stated maybe her shoes are too big or the or don't fit properly. CNA C stated R1 dances (clarified this is tapping and moving her feet around in the shoe) to get her feet situated in her shoes. CNA C stated the nurse mentioned that R1 has a left sided gait which contributes to her risk of falls. CNA C stated R1 always makes statements about her shoes and needing to get her feet situated before transferring and ambulating. Surveyor asked CNA C did you ever tell anybody about concerns with R1's footwear. CNA C stated, no. CNA C stated before R1's fall, I didn't have the tray table moved out far enough. CNA C stated, usually she'll (R1) stand and she does this thing with her feet; R1 taps and moves her feet around to get her feet situated in her shoes. CNA C stated, before the fall R1 always made statements about her footwear and needing to get her feet situated in her shoes. CNA C stated R1 has had these shoes since admission and they are the only pair she wore while at the facility. CNA C stated, R1 would stick her feet out further and tap on the floor. CNA C stated, R1's foot tapping before walking may be her way of mentally preparing before she ambulates. CNA C stated R1 liked to wear gripper socks inside her shoes. (Note: this may have contributed to her need to adjust her feet within her shoes before ambulating.) CNA C stated she doesn't know if the shoes feel funny on her feet; CNA C stated there are no laces or Velcro on the shoes and they are soft and not structured or stiff. CNA C stated, she let go of R1 because, I didn't have the table moved out far enough. CNA C stated she let go of R1, leaving her standing independently when she heard 2 clicks, a loud noise, and turned around to find R1 on the floor. Surveyor asked CNA C how long did you leave R1 standing independently before she fell . CNA C stated, 35 seconds. Surveyor repeated, you left R1 standing independently without your hands on her for 35 seconds before she fell ? CNA C stated yes, she was not holding onto R1 for 30-35 seconds before R1 fell and fractured. Surveyor asked CNA C how is R1 care planned to transfer and ambulate. CNA C stated, 1 person assist. CNA C stated, I should have my hand on her gait belt I realized. CNA C stated, R1 started moving by herself and that's when she fell . (Note: CNA C had her back turned and does not know if R1 lost her balance or started moving independently as the fall was not witnessed. In addition, all fall reports indicate that R1 lost her balance and fell . Irregardless, R1 is care planned for 1 assist with transfers and CNA C did not have her hands on R1 when she was standing independently attempting to get her feet situated in her shoes.) Surveyor asked CNA C has the facility provided training to you or any staff regarding falls since 7/4/21. CNA C stated, no. Surveyor asked CNA C, if you could change anything about what occurred on this day what would you do differently. CNA C stated, I'd make darn sure I had the tray table away . On 7/14/21 at 10:05 AM, Surveyor spoke with CNA Trainer J. Surveyor asked CNA Trainer J if she and/or other staff have received training on falls over the past few months. CNA Trainer J stated, No. On 7/14/21 at 10:10 AM, Surveyor spoke with CNA/Med Tech K (Certified Nursing Assistant/Medication Technician). Surveyor asked CNA/Med Tech K if she or other staff has received training regarding falls. CNA/Med Tech K stated she was not at the most recent training and does not know. CNA/Med Tech K stated she thinks there was a packet of information possibly in June. On 7/14/21 at 3:10 PM, Surveyor spoke with LPN D. Surveyor asked LPN D to talk about R1's fall the morning of 7/4/21. LPN D stated she heard CNA C say, Are you out there R1 just fell . LPN D stated she immediately went to R1's room. R1's feet were facing the bed and her head was facing the door. LPN D stated CNA C told her she was taking R1 to the bathroom and the table was by CNA C. LPN D stated CNA C moved the table and R1 fell . LPN D stated R1 was wearing gripper socks, shoes. LPN D stated R1 stated she was dizzy and lost her balance. LPN D obtained vitals and looked R1 over. LPN D stated minutes after the fall R1 stayed she was unable to move her right leg stating, I can't, I can't. LPN D contacted the on call Physician and family. LPN D called 911 to have R1 sent to the hospital. Surveyor asked LPN D did CNA C mention how long she did not have her hands on R1 while R1 was standing. LPN D stated, She didn't specify how long. On 7/14/21 at 4:56 PM, Surveyor spoke with NHA A and DON B. Surveyor asked DON B do you expect staff to follow resident care plans? DON B stated, Yes. Surveyor asked DON B if a resident is care planned to have a 1 assist with transfers and ambulation should staff follow the care plan? DON B stated, Yes. Surveyor asked DON B if a resident is a 1 assist should staff have their hands on the resident/gait belt at all times when they are standing preparing to ambulate? DON B stated, Yes. DON B added, CNA C was moving something out of the way and R1 stood up. (Note: based on CNA's written statement and interview with Surveyor, R1 was standing when CNA C let go of R1 and left her standing independently for 30-35 seconds before she fell .) Surveyor asked DON B during the fall investigation did you find any areas of concern? DON B stated, no. Surveyor asked DON B and NHA A, are you aware R1 was left standing independently for 35 seconds before she fell ? Both NHA A and DON B stated, no. NHA A added, she would like to know how CNA C calculated 35 seconds and she is going to call her as she does not believe it could have been that length of time. Surveyor asked DON B would you expect staff to be holding onto a resident if they are standing up and require a 1 assist. DON B stated, Yes. NHA A stated, I need to understand from CNA C because that's a different story than was painted previously. On 7/15/21 approximately 7:30 AM, NHA A provided Surveyor with a ROC (Record of Conversation) Report with CNA C on 7/14/21. Review of conversation: Conversation held via phone: CNA C went over R1's fall with NHA A (Nursing Home Administrator) and DCO H (Director of Clinical Operations). Education provided to CNA C regarding following care plan if resident needs assistance with transfers/ambulation not to let go of the gait belt. CNA C verbalized understanding. On 7/15/21 at approximately 8:30 AM, NHA A provided Surveyor with an email from CNA C to NHA A on 7/14/21 at 5:35 PM states as follows: In regards to the time frame of 30 seconds it was used again only as an estimate time when asked to estimate the amount of time while on the phone with the Surveyor. All the while interrupted by my 7 yr. (year) old. It all happened so fast! It was less than that as after standing and repeating my motions did not take me that long. Note: Ultimately, CNA C assisted R1 to a standing position and when R1 was attempting to get her balance, CNA A took her hands of R1's gait belt, leaving R1 standing independently before she fell sustaining a right femoral neck (hip) fracture, scalp hematoma and large hematoma to right proximal forearm. R1's care plan intervention of 1A (assist) with walker for transfers and ambulation was not implemented. On 7/15/21 at 10:10 AM, Surveyor spoke with DON B and DCO H (Director of Clinical Operations). DON B stated CNA C informed her after R1's fall with injury on 7/4/21 that R1 had been ambulating independently prior to her fall. Note, there is no indication R1 ambulated independently in her medical record. DON B stated CNA C told her it was a recent occurrence before her fall with fracture on 7/4/21. CNA C did not share this information with anybody until after R1 fell and fractured. DON B stated she first heard of R1 ambulating independently after R1 was sent to the hospital on 7/4/21. Surveyor asked DON B, at any point did you provide risks and benefits to R1 related to self-transferring. DON B stated, Nope. Surveyor asked DON B did you educate staff following R1's fall. DON B stated, no. DON B added, since Surveyor provided new information to her that CNA C didn't have her hands on the resident/resident's gait belt when Surveyor spoke with facility yesterday afternoon, DON B stated NHA A educated CNA C over the phone yesterday (see above) after we heard of her statement from you yesterday. Surveyor asked DON B should all staff be educated following this fall with injury. DON B stated, Yes. Surveyor asked DON B if you were aware that CNA C did not have her hands on R1 before she fell would you have educated all staff? DON B stated, Yes. The facility did not conduct a thorough investigation regarding R1's fall with fracture. CNA C failed to follow R1's care plan intervention of 1A with walker for transfers and ambulation, resulting in R1 sustaining a right femoral neck (hip) fracture, scalp hematoma and large hematoma to right proximal forearm serious injuries. R1 required surgical intervention to repair her fractured hip. Example 2 R3 (resident) was admitted to the facility on [DATE] with diagnoses that include [CONDITION(S)] and [CONDITION(S)] following a cerebral infarction affecting left non-dominant side, Muscle Wasting and Atrophy, Difficulty Walking, and Acute on Chronic Systolic [CONDITION(S)]. R3's quarterly MDS (Minimum Data Set), dated 6/7/21, gives a BIMS (Brief Interview of Mental Status) of 11 indicating R3 has moderate cognitive impairment. R3's care plan, dated 5/28/21, states, in part: .Problem: .increased SOB [shortness of breath] with exertion and increased generalized weakness. Approach: .Transfers with hemi-walker, gait belt, and assist of two . R3's Basic CNA (Certified Nurse Assistant) Care Plan, dated 5/28/21, states, in part: .Transfers with hemi-walker, gait belt and assist of two . John Hopkins Fall Assessment, dated 5/19/21, has a score of 15 indicating R3 is a high risk for falls. On 6/2/21 at 4:00 PM, Incident Report states, in part: .Description: .CNA states he lost balance and slipped down to the floor on his left side this writer noticed 2.5 cm(centimeter) skin tear to left elbow . On 6/21/21 at 6:40 PM, Incident Report states, in part: .Additional Information: @ 6:40 PM this writer called into resident room to assess resident's left arm at this time area below left elbow protruded out resident arm warm to touch and painful .new orders received to send to ER [emergency room ] for eval due to resident being on anticoagulation med (Eliquis). Of note, R3 received a hematoma to his arm but no other injury was noted post fall. On 7/14/21, at 9:05 AM, Surveyor interviewed R3. R3 indicated at the time the fall occurred one CNA was transferring him out of bed. R3 indicated CNA had let go of him to pull his pants up and he lost his balance and fell on to left side hitting left arm on his night stand. R3 indicated the CNA had not put his shoes, leg brace or gait belt on him. R3 indicated he was to be transferred with assist of two at the time of the fall. On 7/14/21, at 2:20 PM, Surveyor interviewed CNA E. CNA E indicated she had transferred R3 out of bed by herself using R3's three pronged cane with a gait belt, leg brace and shoes on. CNA E indicated she let go of the gait belt around R3's waste and bent down to pull R3's pants up. R3 lost his balance and fell down to floor on his left side. CNA E indicated R3 was to transfer with assist of one, shoes on with leg brace, gait belt, and three pronged cane at the time of the fall. On 7/14/21, at 2:20 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated during time of the fall R3 was transferred with assist of one. DON B indicated the care plan at the time of the fall stated R3 was to transfer with assist of two. Surveyor asked DON B if she would expect CNAs to follow the residents' care plans. DON B indicated she would expect the CNAs to follow the residents' care plans. Surveyor asked DON B if any education was provided to staff post fall. No education was provided to this Surveyor. The facility did not ensure R3's care plan was being followed to prevent R3's fall with injury.

Based on interview and record review the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (R9) reviewed for falls. R9 had two falls after admission, R9 began having increased complaints of hip and back pain after the fall. The facility failed to assess the reason for increased pain and failed to notify the MD of the increased pain. R9 was found to have a displaced hip in x-rays ordered 12 days after the second fall. This is evidenced by: The Facility's Policy and Procedure entitled Falls- Clinical Protocol revised March 2018, documents in part: .2. In addition, the nurse shall assess and document/report the following: .c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; .g. frequency and number of falls since last physician visit; .1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall . The Board of Nursing Chapter N 6 Standards of Practice for Registered Nurses and Licensed Practical Nurses, dated December 2018, outlines the standards as follows: N 6.03 Standards of practice for registered nurses. (1) GENERAL NURSING PROCEDURES. An RN (Registered Nurse) 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 . N 6.04 Standards of practice for licensed practical nurses. (1) PERFORMANCE OF ACTS IN BASIC PATIENT SITUATIONS. In the performance of acts in basic patient situations, the LPN (Licensed Practical Nurse) shall, under the general supervision of an R.N. or the direction of a physician, podiatrist, dentist or optometrist: (a) Accept only patient care assignments which the LPN is competent to perform; (b) Provide basic nursing care; (c) Record nursing care given and report to the appropriate person changes in the condition of a patient; (d) Consult with an RN, physician, podiatrist, dentist or optometrist in cases where an LPN knows or should know a delegated nursing or medical act may harm a patient; and, (e) Perform the following other acts when applicable: 1. Assist with the collection of data; 2. Assist with the development and revision of a nursing care plan; 3. Reinforce the teaching provided by an RN, physician, podiatrist, dentist or optometrist and provide basic health care instruction; or, 4. Participate with other health team members in meeting basic patient needs. As noted above, assessment falls under the Registered Nurse's scope of practice, and is not within the scope of practice for Licensed Practical Nurses. R9 admitted to the facility on [DATE] after having a surgical repair of displaced fracture to the base of the neck of the right femur on 3/17/21. R9 admitted with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 admitted to the facility with the following orders: [MEDICATION(S)] 50 mg (milligrams) 1/2 tablet by mouth every 4 hours as needed, [MEDICATION(S)] 100 mg take 1 capsule by mouth two times daily as needed (moderate or severe pain) and Follow up with Orthopedic PA (Physician Assistant) 2-3 week postop (after surgery). R9's Alteration in comfort Care Plan dated 4/8/21, documents in part: Alteration in comfort r/t (related to) S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . End stage dementia and is a Hospice patient. Cognitive loss does not allow for patient to verbalize needs/pain consistently or accurately. Physical indicators of discomfort E/B (evidenced by) increased restless, agitation and calling out. Long Term Goal Target Date: 7/8/2021, Resident will have decrease risk of any non-verbal signs of pain (e.g. crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc.) . It is important to note all approach dates for this care plan are documented as 4/8/21 not 3/23/21 when R9 admitted . R9's Basic CNA (Certified Nursing Assistant) Care Plan dated 4/8/21, documents in part: .DEVICES: Hoyer transfer, Geri-chair .TRANSFERS: Hoyer transfer with assist of 2 . R9's Fall Care Plan dated 3/23/21, documents in part: My initial safety plan, Reduction in change of falls . R9 had 2 falls after admitting to the facility: 3/23/21- While performing a routine round found resident on floor on her bottom asking for help i assessed the patient and took some vitals which where all stable she had no visible injuries or any cries of pain after i assessed her i assisted her to the wheel chair i faxed the occurrence to the md (Medical Doctor) and attempted to call guardian but had no answer [SIC] This note is documented by an Agency LPN. It is important to note there is no RN assessment or consultation prior to moving R9 and no evidence the Physician received update in relation to fall. 3/24/21- Writer heard resident yelling help me I'm scared at 1530 (3:30 PM) and found her on the mat next to her bed in a sitting position. No injuries noted. VSS (vital signs stable) and neuro wnl (within normal limits). She was assisted via EZ stand to the bathroom and then to her w/c (wheelchair). She kept saying help me. When writer asked her if she was in pain she said yes terrible pain. She was given [MEDICATION(S)] and lorazepam (antianxiety medication) at 1545 (3:45 PM). She continued to be extremely anxious and was having a hard time sitting still. She was being wheeled around the unit and spoken to continuously but she continued to try and get out of her chair and asked to go to bed. Once in bed she continued to say her back hurt and to help her. Writer called hospice at 1630 (4:30 PM) and they said they would send out a nurse to assess. Hospice arrived at approximately 1800 (6:00 PM). After assessing resident, [MEDICATION(S)] 15 mg IR (immediate release) was changed from half tab (tablet) to whole tab every 3 hours and lorazepam increased from 0.5 mg to 1 mg every 3 hours. She received this at 1845 (6:45 PM). She continued to be restless until about 2030 (8:30 PM) when she fell asleep and has been sleeping since. She said she enjoys music so a radio was put in her room for her to enjoy. [SIC] This note is documented by a LPN also. It is important to note there was no RN assessment or consultation prior to moving R9 and no evidence the Physician was made aware R9 had a second fall and then complained of terrible pain. R9's Progress Notes dated 3/23/21 at 2:58 PM- Resident admit to facility around 1400 (2 PM) . It is important to note that there is no mention of pain in this admission note. R9's Pain Scale dated 3/23/21 PM- 4 (on a 0-10 pain scale) R9's Progress Notes dated 3/23/21 at 5:50 PM- .Resident fell at other facility and Dx (diagnosis) displaced neck fx (fracture) to the Rt hip, was fixed on 3/17/21. Resident is very restless and has a sitter at the hospital attempts to get up by herself several times. Rcd (received) [MEDICATION(S)] (anti-[CONDITION(S)] pain medication) at 7am for pain, has Tylenol, [MEDICATION(S)] .2 assist and stand up lift for transfers. [SIC] R9's Progress Notes dated 3/23/21 at 6:07 PM- .Resident seems to be in pain. Alerted nurse . R9's Pain Scale dated 3/24/21 PM see note, comment= unable to rate R9's Pain Scale dated 3/25/21 AM s/sx (signs symptoms) pain, comment= yelling out rcd (received) PRN (as needed) [MEDICATION(S)] (opioid, analgesic); PM see note; NOC see NN (Nurses Note) R9's Progress Notes dated 3/25/21 at 2:14 PM- Resident in bed yelling out Help me Help me Went into room resident moaning out, with facial grimacing, [MEDICATION(S)] 15mg and [MEDICATION(S)] (anti-anxiety medication) 0.5mg po (by mouth) crushed and given in pudding . R9's Progress Notes dated 3/25/21 3:17 PM- Hospice here to see resident, order written for resident to get [MEDICATION(S)] scheduled instead of prn. R9's Progress Notes dated 3/25/21 at 3:45- Resident slept until approx (approximately) 10am this morning, s/sx of pain, yelling out, voiced pain to hip and back, rcd [MEDICATION(S)] with some effectiveness, and rcd PRN Lorazepam for s/sx of anxiety, yelling outhelp me .Resident 2 assist and SUL (stand up lift) for transfers, resident did yell out it pain .Hospice her at 3pm will be changing medications to assist with pain management and anxiety. [SIC] Of note there is no indication of an RN assessment with increased complaints of pain to hip and back s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Progress Notes dated 3/26/21 at 12:25 AM- Resident is awake and calling out loudly for help. She tells writer that her hip hurts . R9's Pain Scale dated 3/26/21 AM 5/10?, comment= unable to express a number; PM unable to express number. R9's Pain Scale dated 3/27/21 AM s/sx pain, comment= voiced pain to Rt (right) hip/[MEDICATION(S)] scheduled; PM unable to express number, comment= only expressed facial saddness when repositioned; NOC c/o (complains of) pain with reposition [SIC] R9's Progress Notes dated 3/27/21 at 2:11 PM- .S/Sx of pain with transfers and movement, after transfers no further c/o offered when not moving . Of note R9 continues to complain of pain especially with movement there is no indication of an RN assessment with increased complaints of pain after two known falls. R9's Pain Scale dated 3/28/21 AM c/o (complains of) pain; PM only expressed facial sa [SIC] R9's Progress Notes dated 3/28/21 at 2:28 PM- .awoke approx 0535 (5:35 AM) calling out, help me, help me. Resident rcd scheduled [MEDICATION(S)] 7.5mg at that time .Approx 0700 (7 AM) resident continued to yell out help me, help me, after repositioning, resident inc (incontinent) of urine, peri care done .Rcd PRN Lorazepam x2 (two times) for s/sx of anxiety appeared not effective, resident would appear to calm down for approx. 10 min (minute) and then continue yelling out help me. C/O pain to hip/ and buttocks, rcd scheduled [MEDICATION(S)] and PRN [MEDICATION(S)] which at 12pm appeared not to be effective . Of note R9 continues to complain of pain especially with movement there is no indication of an RN assessment with increased complaints of pain after two known falls. R9's Pain Scale dated 3/29/21 AM c/o pain; PM see notes; NOC 5/10 R9's Progress Notes dated 3/29/21 at 3:23 PM- Resident slept until approx. 0830 (8:30 AM) then started to call out help me, help me. Rcd scheduled [MEDICATION(S)] and rcd PRN due to s/sx of pain. PRN slight effective. R9's Pain Scale dated 3/30/21 AM yes, comment yelling out, help; PM yelling out R9's Progress Notes dated 3/30/21 at 3:05 AM- CNA reported resident was moaning when being turned/re positioned . R9's Progress Notes dated 3/30/21 at 5:25 AM- Resident is awake but calm. When asked if she was having pain she stated Yes. R9's Progress Notes dated 3/30/21 at 6:21 AM- Resident has been calling out loudly Help me! Staff assisted her to get up into her chair. She has continued to yell loudly . Of note R9 continues to have pain despite pain medication offered and pain medication only being slightly effective. There is no assessment of the reason for R9's increased complaints of pain and no update to R9's primary physician despite increased compliant of pain. R9's Pain Scale dated 3/31/21 AM s/sx pain; PM see NN R9's Progress Notes dated 3/31/21 at 2:59 PM- .approx. 1050 (10:50 AM) to give resident her medications and resident spit out medications crushed in pudding and was combative .resident yelling and screaming help me, help me. R9's Pain Scale dated 4/1/21 AM s/sx pain; PM s and sx of pain R9's Pain Scale dated 4/2/21 PM sad face R9's Progress Notes dated 4/4/21 at 10:18 PM- Resident has been up in the geri-chair a lot of the evening . R9's Progress Notes dated 4/5/21 at 2:17 PM- .Imaging came and did x ray to Rt knee and pelvis per order . Of note this imaging was scheduled upon admission as part of routine x-ray orders. R9's X-ray result dated 4/5/21 documents: .Findings: 3 views of the right hip including pelvis shows prior total right hip replacement with evidence of dislocation of the femoral head prosthesis with respect to the acetabulum .Impressions: Prior total right hip replacement with evidence of dislocation . It is important to note that the facility received this x-ray report on 5/19/21. R9's Pain Scale dated 4/5/21 NOC 5/10 R9's Progress Notes dated 4/6/21 at 3:35 PM- .only yelled out once with transferring then when transferred resident was calm . Physician Assistant Progress Notes dated 4/8/21- .She is currently sitting in her wheelchair and appears comfortable. She denies pain . R9's Pain Scale dated 4/9/21 PM 3/10 R9's Pain Scale dated 4/12/21 AM c/o pain, comment= voiced pain rcd scheduled and prn [MEDICATION(S)] R9's Progress Notes dated 4/12/21 at 3:49 PM- .c/o pain . R9's Pain Scale dated 4/13/21 AM yes, comment= crying, moaning; NOC 5/10 R9's Progress Notes dated 4/14/21 at 12:40 AM- .She transfers with use of the easy stand and one to two assist . Physician Assistant Progress Notes dated 4/14/21- .She does note some pain . Physician Assistant Progress Notes dated 4/15/21- .Nursing notes that patient's pain has improved, but her anxiety fluctuates . R9's Pain Scale dated 4/17/21 NOC 4/10 R9's Pain Scale dated 4/19/21 NOC 4/10 R9's Pain Scale dated 4/26/21 NOC 5/10 general discomfort Physician Assistant Progress Notes dated 4/26/21- She is currently lying in bed and appears comfortable .Discussed with social worker, who received a call from orthopedics. Ortho has reviewed post-op x-ray and patient's hip is dislocated. Ortho note reviewed and surgery is recommended if patient is not near end of life. Discussed with Hospice who will contact patient's guardian regarding surgery. R9's Progress Notes dated 4/27/21 at 1:36 PM- .X-ray results from 4/5/21 that were mailed to resident ortho MD as ordered. Per hospice nurse, X-ray shows a dislocation of the hip. Resident does not appear to be in any increased pain or discomfort. No shortening noted at this time . Of note, R9 had routine x-rays performed on 4/5/21 however the facility was not aware of these results until 4/28/21 almost 23 days later. R9's x-rays revealed a dislocation of the hip as the causative factor for R9's increase pain. Physician Assistant Progress Notes dated 4/22/21- .She appears comfortable . R9's Progress Notes dated 4/27/21 at 1:31 PM- .Dr. (Doctor) present and reports that since pain is controlled-further surgical intervention may not be in resident best interest . Physician Assistant Progress Notes dated 4/28/21- She is currently sitting in her wheelchair and appears comfortable. At this time she denies pain .Hospice spoke with Guardian, and at this point she would like to decline surgery. If pain is worse in the future this could be revisited. Hospice discussed with Previous DON on ways to prevent this from happening in the future. R9's Pain Scale dated 5/3/21 NOC 5/10 R9's Progress Notes dated 5/4/21 at 3:18 PM- .transferred with 2 assist and Hoyer lift . R9's Pain Scale dated 5/5/21 NOC 5/10 R9's Pain Scale dated 5/6/21 NOC 5/10 R9's Progress Notes dated 5/7/21 at 3:52 AM- .She has had some discomfort with being re positioned . R9's Pain Scale dated 5/8/21 AM c/o pain R9's Progress Notes dated 5/9/21 at 2:33 PM- .Hoyer lift and 2 assist for transfers, tolerated. R9's Pain Scale dated 5/12/21 AM s/sx pain R9's Pain Scale dated 5/13/21 NOC 5/10 general discomfort R9's Progress Notes dated 5/13/21 at 11:29 PM- .She previously had a hip fracture with repair. However the hip is dislocated .She is transferred per two assist with use of Hoyer lift . R9's Pain Scale dated 5/14/21 AM s/sx pain, comment= yelling out rcd PRN [MEDICATION(S)]; PM comment= yells out when staff repositions R9's Progress Notes dated 5/14/21 at 11:25 PM- .Resident only yelled out in pain when being repositioned . R9's Pain Scale dated 5/15/21 NOC 5/10 R9's Progress Notes dated 5/16/21 at 12:13 AM- .Resident has been resting quietly unless being repositioned, then she yells out in pain but settles down quickly . On 5/18/21 at 2:46 PM, Surveyor interviewed LPN/CM H (Clinical Manager). Surveyor asked LPN/CM H as a LPN when a resident falls, what you do; LPN/CM H said radio for RN, take VS, neuro check if applicable. Surveyor asked LPN/CM H when a RN is in the facility and they come to assess, do they make their own progress note; LPN/CM H said yes. Surveyor asked LPN/CM H who should be contacted when a resident falls, LPN/CM H said a RN if not here in the building, MD and Family if resident wishes. Surveyor asked LPN/CM H how a Physician should be updated regarding a fall, LPN/CM H said if there's no injury via fax, if there's an injury then call. Surveyor asked LPN/CM H for a resident that is admitted with a hip fracture, has a couple falls and is complaining of pain, is there anything else you would do; LPN/CM H stated call the Physician to update and request an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/18/21 at 4:27 PM, Surveyor interviewed CNA J (Certified Nursing Assistant). Surveyor asked CNA J if R9 ever expresses pain, CNA J said sometimes when we roll her. Surveyor asked CNA J how she expresses pain, CNA J stated she'll yell ow! What are you doing? On 5/18/21 at 4:30 PM, Surveyor interviewed CNA K. Surveyor asked CNA K if R9 ever expresses pain, CNA K said when we move her or roll her. Surveyor asked CNA K how she expresses pain, CNA K stated she yells out Ouch! and asks Hey, what are you doing? On 5/18/21 at 4:33 PM, Surveyor interviewed HRN I (Hospice RN). Surveyor asked HRN I where R9's x-ray orders came from, HRN I said on admission she had orders for a follow up appointment and seen as she admitted to Hospice, the facility requested to complete the x-ray and remove staples at the facility instead of going to the Orthopedic Clinic office. Surveyor asked HRN I when the x-ray was done, HRN I said I believe it was 3/31/21. Surveyor asked HRN I how were they informed of the x-ray results, HRN I explained the order for x-ray indicated the imaging company was to send the radiograph via disc to the Orthopedic office (this was done on 4/20/21), the imaging company did not update the facility on the x-ray results; the Orthopedic office called Hospice to report the results on 4/26/21, we then in turn called the facility and spoke to the Previous DON (Director of Nursing) and gave her the results on 4/28/21; we began an investigation into what happened with this at that time. Surveyor asked HRN I if she would have expected the facility do an investigation into this matter as well, HRN I said yes, I would. Surveyor asked HRN I if she felt R9's pain was well controlled, HRN I replied that she felt her yelling out could be pain or could be multi-factorial; HRN I explained they were in contact with the Hospice often and changing medication orders to best manage her pain. Surveyor asked HRN I if she would expect the facility to use the PAINAD (Pain Assessment in Advanced Dementia Scale) scale for a resident with Dementia, HRN I said yes. Surveyor asked HRN I if she could point out when R9's pain seemed less, HRN I stated in the beginning she was having a lot of pain, but we were making changes and adjustments to aide that but it really seemed to be when we got her the broda chair and they started using the tilt and space in that. Surveyor asked HRN I when the broda chair was put into place, HRN I said 4/8/21. On 5/18/21 at 5:28 PM, Surveyor interviewed IDON B (Interim Director of Nursing). Surveyor asked IDON B when R9 had the x-ray, IDON B said 4/5/21. Surveyor asked IDON B if she could explain why the facility did not get the x-ray results, IDON B stated my understanding is that the results were to be sent to the orthopedic office. Surveyor asked IDON B if she would expect the facility to follow up on why they didn't have the results from the x-ray, IDON B said yes. Surveyor asked IDON B if the staff have access to the PAINAD scale in the facility, IDON B stated yes. Surveyor asked IDON B if pain medication is not effective, what you would expect to happen; IDON B said I'd expect non-pharmacological interventions to be tried too. Surveyor asked IDON B if there should be a RN assessment when a resident has an unwitnessed fall, IDON B replied yes; if there is one in the facility they would radio for them, if there isn't one in the facility, they would call them, there is always a RN on call. Surveyor asked IDON B if she could tell what date R9's transfer status changed from the stand up lift to the Hoyer lift, IDON B said per R9's care plan it was 4/8/21. Surveyor asked IDON B if there was any indication why it was changed on 4/8/21, IDON B said no. Surveyor asked IDON B if the facility would have been aware of R9's dislocation sooner, would her transfer status have changed at that time; IDON B said that would depend on what the MD decided, the MD didn't want any intervention. On 5/18/21 at 7:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if she was aware of R9's x-ray results on 4/27/21 that showed her surgically repaired hip was dislocated, NHA A said no, that information was not brought to my attention. Surveyor asked NHA A if she had been aware of the results, would she have conducted an investigation; NHA A said yes, of course. R9 admitted to facility on 3/23/21 with a surgical repair of a displaced right femur fracture. R9 fell on [DATE] and 3/24/21; after the falls R9 began complaining of increased pain with the need for pain medication adjustments. There was no RN assessment as to why R9 had increased pain despite complaints of hip and back pain. R9's physician was not consulted regarding the increased pain. On 4/5/21 R9 had an x-ray of right hip ordered, instead of an Orthopedic Clinic visit, since R9 had admitted to Hospice. R9's x-ray results showed her right hip was dislocated. The facility did not learn of these results until 4/26/21 per PA notes. The Facility failed to investigate the dislocation of R9's hip and why they did not have R9's x-ray results until 21 days after she had the x-ray.

Based on observation, interview and record reviews, the facility staff failed to adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 (R246) of 16 residents reviewed for pain. R246 was observed reporting pain on 8/14/18 to staff without response. R246 rated pain at 10 out of 10. The facility did not adequately assess and treat R246's pain, did not identify a pain level goal according to R246's goals and preferences, did not address pain in baseline care plan, did not offer non-pharmacological interventions for pain management, did not update plan of care when interventions were found to relieve R246's pain, did not obtain a Physician order for [REDACTED]. This is evidenced by: According to the Journal of the American Medical Directors Association, It is essential that physicians and mid-level practitioners, who care for residents in long-term care facilities, be proficient in the recognition, assessment, and treatment of [REDACTED]. pain. (Winn, Peter A. S., Dentino Andrew N. (2004) Effective Pain Management in the Long-Term Care Setting. Volume 5 (Issue 5), pp. 342-352.) Facility's policy entitled Pain Management, undated, includes, in part: .each resident at risk for pain, regardless of the level of cognition, be screened for pain on admission, readmission, and with change of condition .residents experiencing pain will be treated promptly using pharmacological and/or non-pharmacological interventions to maximize function and promote quality of life . the goal is to develop and implement a safe and comprehensive plan that maximizes improvement in function and quality of life . Purpose: To provide consistent assessment, management, monitoring, and evaluation guidelines for the implementation of individualized pain management in order to facilitate optimal comfort, dignity, and quality of life for all residents regardless of their level of functioning . Pain Screening: Licensed staff will screen for pain using an appropriate tool considering factors such as age and level of cognition under the following circumstances: .admission, readmission, change of condition with onset of pain, post-accident/incident, report from resident/family/staff/visitor of pain . 1 CNA (Certified Nursing Assistant) . Recognize and report discomfort, verbalization, and behaviors indicative of pain . report changes to nurse in ADL (Activities of Daily Living) function related to pain . Licensed Nursing Staff: Facilitate and implement pain management procedures for each resident . conduct and document pain assessments: admission, readmission, upon [DIAGNOSES REDACTED].Initiate pain tracking when pain management is not effective .Administer, observe, document, and report all of the following: . complaints of unmanaged pain . Communicate with physician regarding assessment and pain management. Evaluate plan of care. Facility's policy entitled Notification Of Changes Policy, includes, in part: The facility shall promptly notify the resident and/or resident representative and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences .The nurse will immediately notify the resident, resident's physician, and the resident representative for the following: .A significant change in the resident's physical, mental, or psychosocial status . A need to alter treatment . The nurse will notify the resident, resident's physician, and the resident representative for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician . R246 is a [AGE] year old male and was admitted on [DATE] with [DIAGNOSES REDACTED]. R246's most recent Minimum Data Set (MDS), with a target date of 8/10/18, indicates R246's cognitive function to be moderately impaired with a Brief Interview for Mental Status (BIMS) score of 9. R246's MDS also indicates that he has not had any pain the past five days, was not on a scheduled pain medication regimen, has not received any PRN (as needed) pain medications, or received non-medication intervention for pain. R246's MDS indicates that a Pain Assessment interview was conducted and pain was present, frequency was occasionally, pain did not make it hard for R246 to sleep or limit his day-to-day activities, pain intensity is moderate, and that staff assessment for pain was not conducted. R246's Baseline Care Plan, dated 7/27/18, does not include goals or interventions related to pain. R246's Comprehensive Care Plan, dated 8/8/18, includes, in part: Goal: Resident will state relief of pain . Approach: . Administer medications as ordered. Evaluate/ record/ report effectiveness/ adverse side effects . Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge . Monitor and record any complaints of pain (location, duration, quantity, quality, alleviating factors, aggravating factors). Monitor for presence of pain/tolerance during movement. *It is important to note that R246's care plan does not include specific non-pharmacological interventions including pillow intervention from PT (Physical Therapy) evaluation (7/27/18), cushion intervention from OT (Occupational Therapy) Treatment Encounter (7/30/18), other non-pharmacological interventions, or a pain level goal/acceptable level of pain for R246. R246's Hospital Discharge Summary, dated 7/27/18, includes, in part: Discharge Diagnoses: [REDACTED]. Location of pain: Right hip . Onset: sudden . Characteristics: aching . Intermittent or Constant Intensity: constant .Relieving Factors: Pain killer . Major Neurocognitive Disorder: Saint Louis University Mental Status (SLUMS) examination completed with a score of 3 out of 30 (1-20 dementia ) . Health Care Power of Attorney (HCPOA) was activated this admission . 7/23/18 Subject: .(R246) .now 16 days status [REDACTED].currently taking occasional Tylenol or [MEDICATION NAME] for pain control . General appearance: alert, cooperative, no distress, oriented to self only . R246's Physician Order, dated 7/16/2018- 8/16/2018, include the following medications prescribed for pain: -[MEDICATION NAME], 500 MG (milligrams), take one tab by mouth every 6 hours PRN pain, max 4 grams/24 hours -[MEDICATION NAME] 50 MG, take 0.5 tab by mouth every 6 hours PRN pain -[MEDICATION NAME], 325 MG, two tabs, by mouth every 6 hours PRN pain or temperature * It is important to note R246 does not have any scheduled medications for his pain. R246's Medication Administration Record [REDACTED] * Important to note all days 7/27-8/16/18 are blank in all fields including pain scale except for the following: R246 received PRN [MEDICATION NAME], half of a 50 MG tab (dose=25 MG) as follows: 8/2/18 at 12:52 AM, reason - pain, pain scale - hurts like hell, result-effective; comment: right hip pain 8/3/18 at 11:36 PM, reason - pain, pain scale - 6/10, result - effective; comment: pain/general discomfort 8/14/18 at 1:25 PM, reason - pain, pain scale - 9/10, result - somewhat effective; comment: pain/lower back, radiates to abdomen, received at 1100 8/14/18 at 5:45 PM, reason - pain, pain scale - 8/10, result - effective; comment: pain/back 8/16/18 at 10:47 AM, reason - pain, pain scale - 10/10, result (blank) R246 received PRN [MEDICATION NAME] 325 MG, two tabs (dose =650 MG) as follows: 8/15/18: at 12:27 PM, Reason - Pain, Pain Scale - 10/10, Result: somewhat effective *It is important to note facility provided no evidence of R246's pain being assessed, monitored, and recorded regularly on MAR, including times when R246 had little or no pain. On 8/14/18 at 11:37 AM, Surveyor interviewed R246. R246 indicated that he fell in the kitchen at his home and hurt his hip, but as of the past couple days he has pain in and around his lower back/ ribs area that isn't being controlled. R246 indicated that the pain gets worse when he coughs or shifts positions. Surveyor observed R246 grimace and wince in pain while shifting positions in his easy chair. R246 stated, Oooooh. It hurts, and Ooooh. Ouch, when he shifted in chair and coughed throughout interview. When asked how he would rate his pain on a scale of 1-10, R246 stated, 10. When asked if he has told staff members about his pain, he indicated that he has told all of the staff members that he had talked to this morning about his pain. On 8/14/18 at 12:16 PM, Surveyor observed R246 in the dining room. R246 motioned for CNA H, with his arm, for her to come towards him and stated, My back is real sore. CNA H replied, I will let the nurse know. R246 grabbed his left side by his waist, closed his eyes, moaned, and grimaced. CNA H did not leave the dining area. Three staff were in the dining area at this time including CNA N, CNA M, and CNA H. On 8/14/18 at 12:18 PM, Surveyor observed R246 state, My back hurts, to CNA H. CNA H replied, I will let the nurse know. CNA H did not leave the dining area. On 8/14/18 at 12:19 PM, Surveyor observed R246 holding his left side, again state, My back is real sore. CNA H stated to R246, I will make sure to tell the nurse after you eat. CNA H did not leave the dining area. On 8/14/18 at 12:22 PM, Surveyor observed R246 talking to SLP T (Speech Language Pathologist). R246 stated, My back hurts. It hurts bad. CNA H entered the conversation stating, As soon as lunch is over, I will go tell the nurse. R246 continued to have his hand on his left side, sighed, and closed his eyes. CNA H did not leave the dining area. On 8/14/18 at 12:23 PM, R246 shifted in his chair and stated, I am sorry. My back is sore. CNA H replied, It's ok. After everyone is done I will go tell the nurse. Two staff were in the dining area at this time including CNA M and CNA H. CNA H did not leave the dining area. On 8/14/18 at 12:26 PM, Surveyor observed Housekeeper O talking with R246. R246 stated, Oh, my back hurts. I don't know what the hell caused it. Housekeeper O replied, I will tell the nurse. R246 readjusted himself in chair, let out a moan, and stated again, I am sorry. Four staff were in the dining area at this time including Housekeeper O, CNA N, CNA M, and CNA H. On 8/14/18 at 12:32 PM, Surveyor observed R246 motion to CNA N to come closer, by waving his arm. R246 stated, My back hurts when I cough. CNA N replied, Looks like you had a pain pill. We will walk to your recliner. R246 added, It just started hurting today when I got up. Two staff members were in the dining area at this time including CNA N and CNA H. On 8/14/18 at 12:35 PM, Surveyor observed CNA H tell LPN U that she promised R246 that she would tell LPN U that his back hurt on the left side. On 8/14/18 at 12:40 PM, Surveyor interviewed LPN U who indicated that she gave R246 a [MEDICATION NAME] at 11:00 AM. *It is important to note facility provided no evidence that LPN U assessed R246 at this time, asked him about his pain level, or offered him Tylenol as physician ordered (every six hours for pain PRN) or attempted a non-pharm to reduce R246's pain. Assessments: R246's Admission Assessment, dated 7/27/18, includes, in part: Observation date: 7/27/18 2:57 PM . Pain: Resident expresses experiencing pain or hurting: No . Complete PAINAID? No . Comments: [MEDICATION NAME] at noon prior to transport, pain well controlled . *It is important to note R246 was given [MEDICATION NAME] approximately 3 hours prior to this assessment being completed. R246's Physical Therapy Evaluation and Plan of Treatment/Initial Assessment, dated 7/27/18, includes, in part: Pain Assessment: Method = Patient communicated pain using faces pain rating scale At rest: Pain at rest = 0/10 With Movement: Pain with movement = 4/10, Frequency = Intermittent; Location: right hip, back; Pain Description/Type: Aching Limitations: Pain limits following functional activities: all mobility Management: What relieves pain? Over the counter remedies, change in body position Causes: What exacerbates pain? Prolonged activity, other = right hip movement. Back pain when leaning against wheelchair back rest - relieved with pillow Cognitive - Communicative Assessment: Instructions: Follows Directions = one step without assistance Cognition: Oriented to = person, place, temporal concepts; Safety Awareness = Impaired; New Learning Capacity = Impaired Other: Other cognitive Functioning: Did not recall hip precautions. *It is important to note that pain relief intervention of using a pillow while in wheelchair was not added to R246's Comprehensive Care Plan or Baseline Care Plan and this assessment does not contain pain goals or an acceptable level of pain for R246. R246's Occupational Therapy Evaluation and Plan of Treatment, dated 7/29/18, includes, in part: . (R246) was diagnosed with [REDACTED]. He also injured his left elbow (scratch and contusion; no fracture) . Pain = present, assessment indicated . Clinical Impressions: Patient currently presents with posterior hip precautions, increased pain, .all impacting his safety and independence with ADLs, transfers, and functional mobility .Reason for therapy: .provision of pain management techniques in order to enhance patient's quality of life by improving ability to be able to return to prior level of living . *It is important to note that this evaluation does not specify what pain management techniques are to be used or establish pain goal or acceptable level of pain of R246. Review of R246's Assessments, Nurse Notes (NN), and Occupational Therapy (OT) Notes and Physical Therapy Notes (PT) include, in part: NN: 7/27/18 2:47 PM: (R246) is a [AGE] year old male patient . whom fell at home .had right hip pain, sent to hospital and found to have right [MEDICAL CONDITION]. Surgical repair done . Pain controlled with [MEDICATION NAME] and prescription faxed to pharmacy. 7/28/18 1:16 PM: .Resident denies pain . 7/29/18 12:55 PM: .No complaints of pain . OT Note: R246's Occupational Therapy Treatment and Encounter Note, dated 7/29/18, includes, in part: .Patient felt like he would fall if he did not sit due to pain and feeling off balance .Patient unable to recall precautions .Pain = present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient; Behaviors exhibited: Minimal pain when at rest and increase in pain when standing; Does pain limit patient's functional activities? Yes; Pain limits the following functional activities: functional transfer, mobility and ADLs; What relieves pain? Remaining still; What exacerbates pain? Standing *There is no indication that OT reported R246's pain to nursing NN: 7/30/18 5:12 AM . No complaints of pain or discomfort at this time . 7/30/18 9:56 AM . No complaints of pain . 7/30/18 10:01 PM . Denies pain. States that he has pain only if he is in one position too long . * It is important to note that there is no additional information provided as to location or severity of R246's pain in this note. OT Note: 7/30/18, includes, in part: .Patient complained of pain caused by chair alarm digging into back, patient provided with cushion for back and unit staff educated on importance of cushion placement for patient comfort .Pain = No pain present per patient verbal and nonverbal communication . *It is important to note this intervention of using a cushion for comfort was not added to the Baseline Care Plan and was not on R246's Comprehensive Care Plan as of 8/16/18. NN: 7/31/18 12:04 AM .No discomfort voiced at this time related to his right hip/surgical incision. 7/31/18 10:11 AM . Resident denied increased pain this morning and after therapy when asked. PT Note: R246's Physical Therapy Treatment Encounter Note, dated 7/31/18, includes, in part: Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient: Behaviors Exhibited: grimacing; Does pain limit patient's functional activities? Yes; Pain limits the following functional activities; weight bearing, right lower extremity movement; What relieves pain? Change in body position; What exacerbates pain? Standing, Prolonged Activity . *It is important to note facility provided no evidence of this pain being reported to unit nurse. OT Note: 7/31/18, includes, in part: .Patient did offer complaint of pain mid-back bilateral hip pain prior to standing . When asked patient if he was having any pain, patient reports no pain . Pain = Patient unable to communicate pain; lack of pain determined based upon patient behavior (patient presents with no signs/symptoms of pain) . NN: *It is important to note that R246's 8/1/18 Nurse Notes do not include pain in the entries. No evidence was provided of R246 being asked if he was in pain. 8/2/18 2:09 AM .Resident complained of pain with processes in his right hip stating, It hurts like hell. PRN [MEDICATION NAME] administered as ordered. Resident placed back to bed and has been sleeping sound since. 8/3/18 5:48 AM .Denied pain when asked . PT Note: 8/3/18, includes, in part: Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient: Behaviors Exhibited: grimacing, repositioning to increase knee and hip flexion in supine; Does pain limit patient's functional activities? No; What relieves pain? Change in body position; What exacerbates pain? Other (stretching to promote hip and knee extension) OT Note: 8/3/18, includes, in part: .Pain = unable to determine at this time (Unable to say exactly where and what) . NN: 8/4/18 11:56 AM .Resident states his right lower extremity feels better when he is self-propelling wheelchair than when he is resting in recliner with bilateral lower extremities elevated. 8/5/18 1:38 PM .Resident denied pain this shift . 8/6/18 12:51 PM . No complaint of pain . 8/6/18 9:36 PM .Denies pain . *It is important to note that 8/7/18 Nurse Notes do not include pain in entries. No evidence was provided of R246 was asked about his pain level this day. 8/8/18 1:45 AM .Resident denied pain to areas. 8/8/18 1:09 PM . No complaint of pain . *It is important to note R246's pain was being assessed approximately one time daily. R246's Admission Pain Management Assessment, dated 8/8/18, includes, in part: Cognitive status - moderately impaired - decisions poor; cues/supervision required Is resident currently expressing pain? No Resident Pain Interview: Presence Ask resident, Have you been in pain or hurting at any time in the last five days? - Yes Location of pain - right hip Manner of expressing pain - verbalization Resident Pain Interview: frequency Ask resident How much of the time have you experienced pain or hurting over the last 5 days? - Occasionally Resident Pain Interview: Made it hard to sleep . No . Resident Pain Interview: Limited daily activities .No . Verbal Descriptor Scale: .rate intensity of your worst pain over last 5 days .Moderate Character of Pain . - aching Duration of pain . - pain comes and goes What brings pain or increases pain? Movement and Weight Bearing Interventions? [MEDICATION NAME] and rest . see MAR for [MEDICATION NAME] ordered, dose, frequency . Effectiveness of [MEDICATION NAME] used - always effective Plan of Care - Initiate Plan of Care . NN: 8/9/18 10:52 PM .Denies pain . PT Note: 8/9/18, includes, in part: Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient: Behaviors Exhibited: facial grimacing; Does pain limit patient's functional activities? No; What relieves pain? Sitting down, remaining still; What exacerbates pain? Standing, bending NN: 8/10/18 10:57 PM .Has denied pain when asked . PT Note: 8/10/18, includes, in part: Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient: Behaviors Exhibited: facial grimacing, protective behaviors to area of pain and reflexive responses (e.g., ouch, and stop); Does pain limit patient's functional activities? No; What relieves pain? Sitting down, remaining still; What exacerbates pain? Other (supine stretching in left lower extremity) NN: *It is important to note that R246's Nurse Notes, dated 8/11/18, do not include an entry on R246's pain level. No evidence was provided of R246 being asked about his pain. 8/12/18 2:51 AM .No complaints of pain . 8/13/18 1:00 PM Care Conference held today with Interdisciplinary Team and resident, resident spouse, and resident's daughter . *It is important to note that this note does not indicate R246's pain was discussed at this meeting. No mention of pain in this note. 8/14/18 1:23 PM: .Resident complained of left lower back pain that radiates to abdomen at 1100, requested/received 1/2 [MEDICATION NAME] at that time, was somewhat effective. * It is important to note this is a new area of pain noted. It is also important to note that Surveyor observed CNA H report to LPN U that R246 was having left sided back pain at 12:35 PM. Facility provided no evidence of LPN U assessing R246 at the time pain was reported or offering him his other as needed medication or non-pharms while reporting in this note that the [MEDICATION NAME] was only somewhat effective. 8/14/18 9:36 PM: .Resident stated severe back pain at 1740, given [MEDICATION NAME] that was effective. Stated that back pain increased with cough . *It is important to note that Surveyor observed CNA H report to LPN U that R246 was having pain in his back on the left side at 12:35 PM. R246 was given medication for pain at 17:40, 5 hours and 5 minutes later. Facility provided no evidence of staff assessing R246's pain location or severity between 12:35-17:40 or offering him his PRN Tylenol or other non-pharm's. PT Note: 8/14/18, includes, in part: Pain = Present, assessment indicated; Pain Assessment Method = Patient verbalized pain level; Does pain limit patient's functional activities? No; What relieves pain? Sitting down, remaining still, Other (rubbing back); What exacerbates pain? Standing, prolonged activity . Pain at rest = 0/10 . Pain with movement = 5/10; Frequency: Intermittent; Location: mid-back; Description/Type: Discomforting and Sharp, quick. *It is important to note R246's verbalized pain description as it is recorded that he is not always able to verbalize his pain. NN: 8/15/18 12:27 PM: .Resident complained of pain 10/10 to lower back. Requested/received 650 MG [MEDICATION NAME] at 1000, was somewhat effective. *It is important to note that R246's pain increased to a 10/10 and the facility did not update the physician with this increase in pain. 8/15/18 11:03 AM: .Denied back pain when asked, I'm good honey thank you for asking. PT Note: 8/15/18, includes, in part: Patient refusing ambulation due to mid-back pain, applied Biofreeze to decrease pain, patient reports helped previous day, added back cushion to wheelchair due to redness noticed on back from leaning on wheelchair . Pain = Present, assessment indicated; Pain Assessment Method = Pain level determined based upon behaviors exhibited by patient: Behaviors Exhibited: Defensive to touch, facial grimacing and moaning; Does pain limit patient's functional activities? No; What relieves pain? Sitting down, remaining still, Other (rubbing back); What exacerbates pain? Standing, prolonged activity . *It is important to note that there is no Physician order for [REDACTED]. R246's MAR, dated 7/27/18-8/16/18, includes, in part: Order: [MEDICATION NAME] 325 MG . Frequency: PRN . Special Instructions: every six hours PRN pain or temperature . Diagnosis (blank) . Start/End Date: 7/27/18- open ended . Wednesday, 8/15/18: Time: 12:27, Reason - Pain, Pain Scale - 10/10, Result: somewhat effective *It is important to note that R246's pain increased to a 10/10 and the facility did not update the physician with this increase in pain. NN: 8/16/18 12:16 AM: .No feelings of lower back pain have been voiced . 8/16/18 6:01 AM: .No feelings of discomfort voiced . PT Note: 8/16/18, includes, in part: . Pain = Present, assessment indicated; Pain Assessment Method = Pain communicated via nonverbal method: Does pain limit patient's functional activities? Yes; Pain limits the following functional activities; Standing tolerance; What relieves pain? Change in body position, Other (Biofreeze); What exacerbates pain? Standing, Bending, Reaching, Prolonged Activity . Pain at rest: 3/10; Frequency = Intermittent; Location: lower back, lower abdomen during activity or when coughing; Pain Description/Type: difficulty giving exact description, general discomfort .Pain with movement = 6/10; Frequency = Intermittent; Location: lower back, lower abdomen during activity or when coughing; Pain Description/Type: difficulty giving exact description, general discomfort and stiffness . On 8/16/18 at 10:22 AM, Surveyor interviewed R246. R246 indicated that he was currently in pain, stating, It is in my back and around my belly, when I cough or sneeze it really hurts and I am telling all of them I am in pain. R246 indicated that when he fell he hurt his hip and that area hurts when they help him in and out of bed or go from sit to stand. R246 used his left hand to show Surveyor the area of pain and while doing this R246 winced, closed his eyes, grimaced, and moaned. When asked to rate his pain level on a scale one to ten, R246 immediately responded, Ten (10/10). On 8/16/18 at 10:31 AM, during an interview, MT I (Med Tech) indicated R246 has not complained to him about being in pain this shift. MT I stated, Yesterday he complained of pain. I usually ask him about 10:30 AM, but I don't work every day. MT I indicated that it is his expectations that if a resident complains of pain to staff, the staff is to tell MT I, and MT I will go ask resident about pain level and location. MT I indicated that no staff members have reported R246 to be in pain today. On 8/16/18 at 10:36 AM, Surveyor observed MT I asked R246 about pain. R246 stated, I have bad pain in my back and it started after I broke my hip. MT I asked R246 if he wanted a pain pill? R246 stated, I am in pain. MT I asked R246 to rate his pain 1-10. R246 stated, 10. MT I asked, So the pain is a 10 out of 10? R246, Yes. 10 out of 10. On 8/16/18 at 10:39 AM, during an interview, CNA H indicated that she usually tells the nurse immediately if a resident reports they are in pain, but on Tuesday, when dining, R246 said he was in pain when he coughed and she waited until after the meal to report to the nurse. CNA H indicated that she explained to R246 that he had to wait until everyone was done eating and then she would tell the nurse about his pain. CNA H also indicated that it is ok for to leave the dining area if other staff are around and the area is not left unattended by staff. On 8/16/18 at 10:43 AM, during an interview, CNA J indicated that she assisted R246 with AM cares around 7:00 AM that morning and R246 complained to her about having pain in his back. CNA J stated, I did not tell anyone he was in pain. I should have. On 8/16/18 at 10:48 AM, during an interview, CNA K indicated that she assisted R246 to the toilet around 8:30 AM after breakfast. CNA K indicated that at this time R246 complained of back pain and pain around his waistline. CNA K stated, I did not tell anyone he was in pain. CNA K also indicated that she should have told the nurse on the unit about R246's verbalization of pain. On 8/16/18 at 10:49 AM, during an interview, MT I indicated that one CNA or nurse has to be in the dining room when residents are eating and if more than one are in there, one may leave to give the nurse a message. When asked if R246 reported that he was in pain while dining and three CNAs are in the dining room, may one leave to give nurse the message. MT I stated, Yes. On 8/16/18 at 11:01 AM, during an interview, CNA M indicated that no one staff member is assigned to dining room and a staff member could leave dining room if another aide or nurse was in dining room at that time. CNA M also indicated that R246 complains most mornings of being in pain and she reports this to the nurse on the unit. On 8/16/18 at 12:25 PM, PTA/TDM L (Physical Therapy Assistant /Therapy Department Manager) indicated that R246 occasionally complains about back pain and when this occurs she and her department staff record it in a Progress Note and report it to the nurse on the unit. PTA/TDM L also indicated that they try to get as much information from R246 as possible, such as where the pain is located, how much pain is experiencing, if it is an ache or sharp pain. On 8/16/18 at 12:28 PM, during an interview, PT P (Physical Therapist) indicated that she had worked with R246 around 9:15 - 10:00AM and R246 complained of having lower back pain and abdomen pain and she recalled that this pain started yesterday. R246 stated, I didn't pass it on today or ask about pain meds. Yesterday we talked about his lower back. I should have passed it along to his nurse. PT P also indicated that during this session she didn't ask R246 how much pain he was having. On 8/16/18 at 12:26 PM, during an interview, COTA Q (Certified Occupational Therapy Assistant) indicated that she has worked with R246 and when he reports he is in pain, she usually tells the nurse and inquires about the pain medications that R246 has received. On 8/16/18 at 1:01 PM, during an interview PT P indicated she had worked with R246 on 8/14/18 and he complained of having pain in his back that was sharp and quick and she did not recall if she reported this to R246's Unit Nurse. On 8/16/18 at 2:00 PM, during a phone interview, LPN V indicated that the clinic has not received any updates regarding R246's pain. LPN V indicated that she would expect the facility to notify the MD/clinic if R246 was experiencing pain rated at 8,9,10 out of 10, if current pain treatments were not controlling pain, or if a new area of pain was reported. On 8/16/18 at 2:32 PM, during an interview, NM/LPN S indicated that she expects nurses to ask R246 every time they administer medications if he is in pain and to record it on the MAR under pain scale. NM/LPN S indicated that staff has not been doing this. NM/LPN S also indicated that new onset pain or pain levels of 8/10, 9/10, 10/10 should be reported to R246's Medical Doctor (MD) and MD was not notified. * It is important to note facility provided no evidence of MD notification or pain assessing/ monitoring at every medication pass. On 8/16/18 at 3:10 PM, during an interview, DON B indicated that she expects all staff, including housekeepers, nurse (TRUNCATED)

Based on interview and record review, the facility did not consult with the resident's physician when there was a change in the resident's physical condition or a need to alter treatment for 1 of 4 residents (R) reviewed (R5). On 10/6/17 (Friday) at 5:15 PM, R5 sustained a witnessed fall. The facility faxed the physician. R5 was verbalizing pain, had facial grimacing, loudly groaning, and was constantly moving in bed and could not get comfortable. Staff administered PRN (as needed) [MEDICATION NAME] multiple times and documented that the [MEDICATION NAME] was not very effective. There was no direct physician contact made regarding R5's fall and increase in pain until almost 26 hours after R5's fall. On 10/7/17 at 6:45 PM, R5 was sent to the ER (emergency room ) for evaluation. R5 was found to have a fractured rib. Evidenced by: The facility's Notification of Changes policy, undated, includes, in part, the following: The facility shall promptly notify the resident and/or the resident representative and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences. Procedure: 1. The nurse will immediately notify the resident, resident's physician and the resident representative(s) for the following (list is not all inclusive): a. An accident involving the resident, which results in injury and has the potential for requiring physician intervention. b. A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication. c. A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. d. A decision to transfer or discharge the resident from the facility. R5's [DIAGNOSES REDACTED]. R5's most current MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/6/16 indicates R5 has severe cognitive impairment. R5's Quarterly Fall Risk Assessment with an ARD of 9/4/17 indicates R5 is at high risk for falls and requires extensive assistance of one person for transfers. R5's Event Report, dated 10/6/17 at 5:25 PM, included, in part, the following: Event Date: 10/6/17 5:25 PM. Location of Fall: Resident Room. What was Resident doing just prior to fall? in bed. Pain Observation: No Pain. Range of Motion: ROM X4 without pain/limitations. Positioning of Extremities: No Rotation/Deformity/Shortening Noted. Level of Consciousness: Alert Wakefulness - Perceives the environment clearly and responds appropriately to stimuli. Facial Muscle Movement: Strong. Upper Left Extremity Movement/Grasps: Strong. Upper Right Extremity Movement/Grasps: Strong. Lower Left Extremity Movement: Strong. Lower Right Extremity Movement: Strong R5's medical record included, in part, the following notes: 10/6/17 at 5:17 PM - Witnessed fall in response to alarm sounding. This writer arrived at resident's doorway just as he lost his balance, caught himself on bed and partially sat on edge of bed, then slid to the floor. Did not hit his head. Was incontinent of stool at time of fall and had been incontinent of urine in bed. No injury noted. VSS (Vital Signs Stable). Assisted to bathroom for peri care and then back to bed. 10/6/17 at 5:24 PM - Attempted to call POA (Power of Attorney). No answer and voice mail did not engage. MD (Medical Doctor) notified per fax. 10/6/17 at 7:33 PM - R5's Medication Administration Record [REDACTED]. (1) 5 milligram (mg) tab. Pain rating not documented. 10/6/17 at 9:45 PM - Resident stated general pain at 9:30 PM. Given [MEDICATION NAME] (oxy) and is sleeping at this time. 10/7/17 at 1:06 AM - Resident awoke and is in room loudly groaning and sitting at bedside. Writer asked resident if he is in pain, which resident answered, Yeah and Yeah when asked if it hurts all over. PRN oxy administered. Will continue to monitor. 10/7/17 at 1:06 AM - PM R5's MAR indicated [REDACTED]. (1) 5 mg tab. Pain rating: Unable to express. 10/7/17 5:56 AM - Resident continues to show signs of pain. Facial grimacing, moaning frequently. Has PRN (as needed) oxy 5 mg tabs every 6 hours which resident received early in the night and was not very effective. Resident appears to be confused, not sure what he is doing. Sitting up on edge of bed multiple times adjusting blankets. Frequent incontinence noted. Resident having trouble standing next to bed. Does allow staff to help him with urinal. Will continue to monitor. 10/7/17 at 8:08 AM, R5's MAR indicated [REDACTED]. (2) 5 mg tab. Pain rating not documented. General discomfort-fall. 10/7/17 at 9:44 AM - Resident continues with noted pain this AM. Facial grimacing noted. Having hard time standing. PRN [MEDICATION NAME] given which has helped some. Incontinent today. Angry with staff when they were trying to assist him this AM with ADL's (Activities of Daily Living) such as getting dressed, toileting, etc. Needs ques to eat his meal this morning. Resident looking pale. No SOB (Shortness of Breath) noted. VSS (Vital Signs Stable). Will continue to monitor. 10/7/17 at 1:20 PM - Resident assisted with lunch and ate 100%. Resident continues to have increased confusion. Resident will sit on edge of bed and not say anything when asked what he is doing. Continues to be incontinent of urine. 2 assist to pivot transfer, SUL (Stand Up Lift) to be used if resident can't stand up. Rests in bed throughout the day. PRN [MEDICATION NAME] given for pain. No further injury noted from fall. VSS 10/7/17 at 2:29 PM - R5's MAR indicated [REDACTED]. (2) 5 mg tab. Pain rating 7/10. 10/7/17 at 2:51 PM - Resident constantly moving in bed, can't get comfortable, wanting to set at edge of bed with his head and shoulders forward. Never comfortable when placed back in bed. 10/7/17 at 4:45 PM - Telephone Order - Send out for eval (evaluation) and tx (treatment). (Note, per the ambulance run report, the ambulance was called at 5:23 PM and arrived at the facility at 5:36 PM to transport R5 to the hospital.) 10/7/17 at 6:04 PM - Call placed to resident's POA and she agreed to have the On-Call Dr. (Doctor) called and to have resident sent out if necessary. Dr. contacted and order received to send out for evaluation and treatment. Resident has not spoken, but appeared to understand when asked if he could sit in his wheelchair and lay his head on over table, as he helped and was willing. Resident later was fed and ate about 25% of supper, but would not sit up straight to do this. 10/7/17 at 6:33 PM, the hospital History and Physical indicates: [AGE] year old male presents emergency department today via EMS (Emergency Medical Service). He comes from an extended care facility. Apparently, he had a witnessed, controlled fall yesterday onto his buttock. Today, he was complaining of some pain. Pain medication, which he has not received in some time. Diagnoses: [REDACTED]. [DIAGNOSES REDACTED]. I spoke to the nurse caring for him at the extended care facility and confirm this. I also spoke with his daughter in the room who corroborates that he is at his baseline now and had no subsequent respiratory depression. His laboratory analysis is unremarkable. He is safe to discharge home. I advised them not to give him any more pain medication. He also does have a fractured left seventh rib and I advised the family on incentive spirometer. The portable frontal chest x-ray results: 1. Rib [MEDICAL CONDITION] posterolateral seventh rib noted, possibly acute, correlate with symptoms. This was not seen on 11/20/16 chest x-ray. 2. No [MEDICAL CONDITION] abnormality appreciated. No pneumothorax. 10/7/17 at 6:45 PM - Resident transported by ambulance per stretcher to hospital. Hospital updated on norm of mentation and current concern. 10/7/17 at 11:08 PM - Resident returned to room at around 9:35 PM. Helped to bed by ambulance staff. Hospital report show rib fx (fracture) of left posterial lateral 7th rib. Surveyor reviewed R5's [MEDICATION NAME] usage for the past month (9/8/17 - 10/6/17) prior to R5's fall with rib fracture. It is important to note when R5 received PRN [MEDICATION NAME] over the past month it was for various types of pain. However, there is no documentation of rib pain and forward leaning posture for comfort prior to R5's fall on 10/6/17. It is also important to note that 1 tablet of [MEDICATION NAME] had been effective in managing R5's pain until R5's fall with rib fracture on 10/6/17. The facility started administering 2 tabs of [MEDICATION NAME] to R5 on two occasions on 10/7/17, and it did not relieve R5's pain. R5 received 1 tab, which was effective, as documented below. 9/11 - Received 1 tab of [MEDICATION NAME] for a headache - Results not documented 9/12 - Received 1 tab of [MEDICATION NAME] for general discomfort - PRN Result 0/10 pain (Effective) 9/28 - Received 1 tab of [MEDICATION NAME] for all over pain - Results not documented 9/29. - Received 2 tab of [MEDICATION NAME] for 8/10 (8 out of 10) foot pain - No c/o (complaints of pain) PRN Results: Effective R5 did not receive 2 tabs of [MEDICATION NAME] at any time during the month prior to his fall. On 11/20/17 at 4:05 PM and 6:15 PM, Surveyor spoke with the DON B (Director of Nursing). Surveyor asked DON B when the physician should be notified of a fall. DON B stated it is acceptable to notify the physician via fax regarding a fall if there is no injury. Surveyor asked DON B what prompted staff to send R5 to the ER to be evaluated (approximately 24 hours after he sustained a fall.) DON B replied that R5 was sent to the ER due to increased pain. Surveyor asked DON B to review R5's NN (Nurses Notes) and tell me when she would expect the physician to have been called. DON B stated she would expect the physician to have been called on 10/6/17 at 9:30 PM, when the nurse documented that R5 stated he was having general pain. DON B stated at this point she would have expected the nurse to assess, investigate, and to call the physician with an update. DON B stated the nurses notes do not describe the location or the type of pain that R5 was experiencing but that it should have included this information as well.

Based on observation, interview and record review the facility did not ensure each resident receives that necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 5 residents (Resident 1). Resident 1 had multiple wounds on his leg; the facility did not investigate the possible cause of the wounds, to include the size of his bed, to prevent additional wounds. The facility also did not monitor the wounds to ensure they were healing. Resident 1 was diagnosed with [REDACTED]. This is evidenced by the following: Resident 1's [DIAGNOSES REDACTED]. Resident 1 is 76 inches (6 foot 4 inches) tall and weighs 213.6 pounds. Resident 1 utilizes an Easy Care 7 bed. Maintenance C measured the bed to be 83 inches from headboard to footboard. On 9/28/16, at 8:37 AM, Surveyor observed Resident 1 sleeping in bed. Surveyor noted the head of the bed was up approximately 45 degrees, Resident 1 had multiple pillows behind him. Resident 1's legs were bent at the knees and his feet were pressing against the foot board. Resident 1's progress notes include: -8/14/16, weekly summary, Resident 1 has a small skin abrasion on his right heel from where he may have kicked or rubbed up against a broken foot board on his bed. Spouse pointed it out during a shower; small wound was cleaned and left open to air due to a dry scab present on the foot, no sign of infection and no complaint of pain or discomfort. Entered by Licensed Practical Nurse (LPN) D. Note: There is not an assessment of the abrasion/wound or indication the physician was notified. Per maintenance records Resident 1's broken foot board was reported to Maintenance C on 8/17/16. On 9/28/16, at 1:45 PM, Surveyor interviewed Maintenance C. Maintenance C stated he received a work order to fix Resident 1's foot board from a housekeeper who stated she noted it lying on his floor. Maintenance C stated he immediately went to Resident 1's room and replaced the bolts and put the foot board back on. Resident 1 told Maintenance C that the foot board had been off for days. Resident 1's progress notes include: -8/19/16 Resident 1 is free of skin issues at this time. -9/2/16 Resident 1's skin is intact. -9/3/16 Resident 1's wife reported Resident 1 has several scabs present to right lower extremity. Upon assessment, Resident 1 found to have healing scab present to lateral dorsal aspect of right foot and small dry scab to lateral aspect of right lower leg. Slight non-[MEDICAL CONDITION] to right foot and ankle. No [DIAGNOSES REDACTED], warmth or swelling to the site will continue to monitor. Entered by an LPN. Note: There was no Registered Nurse (RN) assessment of the area. -9/4/16 Scabs to right lower extremity (RLE) intact. -9/4/16 Scabs to RLE are open to air. Applied skin prep to scabs. -9/6/16 skin prep applied to intact scabs on RLE and right foot. -9/7/16 physician faxed back okay for skin prep to sites on RLE and discontinue when healed. -9/11/16 Resident 1 complained of RLE pain. Assessment revealed swelling, redness and warmth on outer calf between ankle and knee. No sign of any drainage. Resident does have two small dried scabs in this area. Will elevate and provide warm compress for this evening. Contact physician in morning. Note: This is the first documentation by a RN regarding Resident 1's scabs. On call notified no antibiotic ordered tonight. Temperature 99.1 Tylenol was given earlier. Scabs intact on lower feet. -9/12/16 Resident 1's clinic called regarding +3 [MEDICAL CONDITION], redness and warmth to RLE. Clinic will call back with orders. -9/12/16 Cleansed scabs to RLE. Scabs are intact, RLE is warm, red and Resident 1 had some complaints of pain related to areas. New order to start [MEDICATION NAME] 20 mg day and [MEDICATION NAME] (antibiotic) 100 milligrams (mg) twice a day for 7 days. -9/14/16 Area of blood noted on pad in wheelchair. It was a moderate amount of blood which had come from the lateral side of his foot as the scab had been probably rubbed off. Area was cleansed and [MEDICATION NAME] applied. The scab on his lateral calf remains intact and skin prep applied. -9/17/16 Resident 1 is on antibiotic for [MEDICAL CONDITION] to RLE, has intact scabs to right shin, outer (lateral) right ankle and top of right foot. -9/25/16 Scabs on lateral right calf remain intact. Dressings on right lateral ankle and foot are intact. There is no assessment including dimensions of Resident 1's scabs. On 9/28/16, at 9:20 AM, Surveyor interviewed Resident 1. Resident 1 stated his foot is better now and he does not have pain. Resident 1 stated his bed is not long enough though and it is not comfortable as his feet hit the foot board. On 9/28/16, at 2:24 PM, Surveyor interviewed Nurse Manager E who stated she did not know Resident 1 had wounds and did not have any additional information except what was in the progress notes. Nurse Manager E also stated she was not aware there were any concerns with Resident 1's bed not fitting him. On 9/28/16, at 3:40 PM, Surveyor and LPN D went to observe Resident 1's RLE. Prior to entering the room LPN D stated You'll notice his bed is too small. LPN D stated he has spoken to Resident 1's wife about it but nobody else. Surveyor noted 3 small dry scabs on Resident 1's right calf, ankle and foot. LPN D stated he thought the one on the foot came from when he kicked the foot board off the bed. On 9/28/16, at 4:45 PM, Surveyor interviewed Director of Nursing (DON) B who stated if a resident has a skin tear, scab or something they are monitoring an event is created in the record. This event is then monitored on the 24 hour daily note sheet. DON B stated the physician should be notified of any new issues and there should be an investigation into the cause so an intervention could be put into place. DON B stated she was not aware of the scabs on Resident 1's RLE. The facility did not have assessments for the wounds on Resident 1's right lower extremity thus they were not able to identify if they were getting better, worse or no change. The facility also did not thoroughly look into the cause of the wounds so that interventions could be put in place to prevent additional wounds. In addition, the facility felt that the wounds could have been from the bed and they didn't take action to correct the situation.

Based on interview and record review the facility did not ensure the each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident 3). Resident 3's interventions to prevent falls, including supervision, were not followed. Resident 3 went through a stairwell door, fell down a flight of 11 stairs in her wheelchair, and sustained a head injury. This is evidenced by the following: The facility has multiple floors. Each floor is a long hallway. At the end of the hall is an elevator and stairwell that has a Code Alert alarm for individuals at risk of wandering with a Code Alert bracelet. If you do not have a bracelet no alarm sounds when opening the door. The nurse's station is located in the middle of the hallway. The dining room is at the other end of the hallway. Resident 3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 3's room is located in the middle of the hallway across from the nurse's station. On 9/8/16 the facility developed a care plan for At risk for falls for Resident 3. Interventions include: reminders not to ambulate/transfer without assistance, fall prevention program and toileting every 2 hours and as needed. Resident 3 was not identified as at risk for elopement and did not have a Code Alert bracelet. Per Resident 3's nursing notes: -9/8/16 Resident 3 fell out of bed. Resident 3 had a large lump on her left forehead and an abrasion below the lump. Resident 3 was sent to the emergency room and received stitches in her forehead. -9/13/16 Resident 3 was found on the floor in her room in front of her recliner. No injuries were noted. -9/18/16 Sensor pad alarm in bed and recliner, tabs alarm in wheelchair. -9/21/16 Slid out of wheelchair. Tab alarm sounding. On 9/21/15 Resident 3's care plan was updated to include keep foot pedals off wheelchair. Resident 3's nursing notes: -9/25/16 Leaning forward and fell out of wheelchair. On 9/30/16 Resident 3's care plan was updated to include: sensor alarm in chair and bed. Resident 3 enjoys rolling balls of yarn offer this activity when restless or bored. Keep in view of staff. On 10/11/16, at 10:42 AM, Surveyor interviewed Minimum Data Set Nurse (MDS Nurse) J who confirmed she updated Resident 3's care plan on 9/30/16 including keeping in view of staff. MDS Nurse J stated staffs were to keep Resident 3 in line of sight when she was agitated. Surveyor asked how staff would know when she was agitated and in need to be in line of sight. MDS Nurse J stated when Resident 3 was restless, trying to stand up or not occupied with something like watching television then she should be in line of sight. MDS Nurse J stated the nurse, based on staff report, would determine if in view was needed or not. Resident 3's nursing notes: -10/1/16 at 1:00 PM, multiple attempts to self-transfer, alarm has sounded each time. Resident 3 is confused and difficult to re-direct, Resident 3 has a hard time following directions. -10/2/16 at 6:26 AM, Resident 3 was awake entire night. Resident 3 made many attempts to self-transfer setting off alarm many time through night. Provided 1:1 many times through night. Resident 3 is currently sitting up in wheelchair at nursing station. -10/2/16 at 9:54 AM, At approximately 9:00 AM Licensed Practical Nurse (LPN) G was walking down the hall and heard a faint alarm sounding from stairwell. LPN G opened the stairwell door to find Resident 3 laying on the bottom of the 11 stairs yelling help. LPN G immediately called for help and alerted staff to call 911 and ran to asses Resident 3. Resident 3 was alert with a head laceration. Both feet were on the bottom stair and Resident 3 was laying on her left side and the wheelchair was by her head. Resident 3's oxygen saturation was 95% and pulse was 77. Small amount of blood noted from Resident 3's mouth. Emergency Medical Service arrived to assist. Blood pressure was 140/80, face color was gray. Resident 3 was transported to the hospital. Her hospital notes indicate Resident 3 was admitted to the hospital and diagnosed with [REDACTED]. Resident 3 had neurological changes from her baseline dementia and sustained right scalp laceration and a left forearm abrasion. Resident 3 was discharged from the hospital on [DATE] on hospice. On 10/12/16, at 2:35 PM, Surveyor interviewed Physician K who stated Resident 3 suffered a closed head injury from the fall on 10/2/16. Physician K stated that hospice care was inevitable for Resident 3 and it is hard to say what effect the fall had in the determination of starting hospice due to Resident 3's underlying dementia. On 10/11/16, at 10:24 AM, Surveyor interviewed Certified Nursing Assistant (CNA) I about Resident 3's fall. CNA I stated on 10/2/16 Resident 3 was in the dining area after breakfast. CNA I left the area to collect trays from resident rooms. When CNA I returned to the dining room Resident 3 was not there and CNA I assumed someone took Resident 3 to her room. CNA I stated she does not work with Resident 3 often but knows that Resident 3 typically spends her day in the area around the nurses station. On 10/11/16, at 9:02 AM, Surveyor interviewed CNA H. CNA H stated she only works every other weekend typically and was working on 10/2/16. CNA H stated after breakfast on 10/2/16, CNA H was assisting residents back to their room and provided cares. Resident 3 did not appear anxious; she propelled herself down the hall. CNA H stated the last time she saw Resident 3 was around 8:30 when she was playing with the cord from the tablet on the wall. CNA H stated she was in another resident's room when she heard a thump sound but did not think anything of it. Upon leaving the room CNA H saw LPN G in the hall. LPN G stated she could hear an alarm, CNA H stated to walk toward LPN G to find where the alarm was. LPN G opened the stairwell door and CNA H could hear the alarm and LPN G yelled to get help. CNA H stated she went to get LPN F and assisted LPN G as directed by getting gloves, blankets and filling Resident 3's oxygen tank. CNA H stated she had not been told to keep Resident 3 in line of sight. On 10/11/16, at 10:53 AM, Surveyor interviewed LPN G. LPN G stated she only works as needed and she was working the morning of 10/2/16. LPN G stated Resident 3 was tooling around in her wheelchair that morning. LPN G stated she was completing her morning medication pass when she heard a faint alarm. LPN G started looking for the alarm and when LPN G opened the stairwell door she found Resident 3 at the bottom of the stairs and LPN G yelled for help. LPN G stated Resident 3 was conscious the entire time. LPN G applied pressure to the laceration on her head and waited for EMS to arrive. LPN G stated Resident 3's oxygen was not in place and LPN G asked CNA H to refill the tank then reapplied the oxygen tubing as Resident 3 was laying on it. LPN G stated following the fall she placed a stop sign on the door and monitored to ensure other residents did not go by the stairwell. On 10/11/16, at 1:47 PM, Surveyor interviewed LPN F. LPN F confirmed she was working the morning of 10/2/16. LPN F stated she started her shift at approximately 6:00 AM and at that time Resident 3 was at the nurse's station because she had been restless all night. Resident 3 frequently tried to get up during the night so staff assisted her into her wheelchair near the nursing station was she continued to be restless. LPN F stated after the CNAs got Resident 3 ready for the day she was pretty calm compared to the night shift. At approximately 8:30 AM LPN F was assisting with residents and Resident 3 was resting in her wheelchair by her room. LPN F stated she last saw Resident 3 at approximately 8:45 AM in her wheelchair by her room. LPN F stated staff tries to keep Resident 3 in line of sight when she is restless. They keep an eye on Resident 3 as much as they can and her room was moved closer to the nurse's station to help keep her in line of sight. LPN F stated Resident 3 does not need to have someone with her all the time, just to keep an eye on her so she does not try to stand up or walk. LPN F stated on 10/2/16 she was assisting with another resident who needed to go to the hospital. LPN F was at the nurse's station when she heard someone yell help. LPN F then saw CNA H come out of the stairwell; LPN F looked down the stairwell and saw Resident 3 with LPN G. LPN F then went to call 911. On 10/11/16, at 10:21 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated Resident 3's should be in line of sight of staff at times of restlessness, and she did not require 1:1 supervision. DON B stated Resident 3's restlessness is determined by who is taking care of her and the CNAs can determine if she is restless and needing to be in line of sight. DON B stated typically restlessness for Resident 3 is moving up and down in her bed or chair, picking at things like clothing and oxygen tubing or fidgeting with things. DON B stated the CNAs know Resident 3 and it's their job to know when she needs to be in line of sight of staff. DON B stated the care plan should have been written more clearly. On 10/11/16, at 1:09 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated following Resident 3's fall on 10/2/16 the nurse put a stop sign on the stairwell door and maintenance set the alarm on the stairwell to sound when anyone opens the door whether they have a Code Alert bracelet or not. The facility did not provide the supervision Resident 3 required to help prevent falls thus Resident 3 was able to open the stairwell door and fell down the stairs without staff knowledge sustaining a head injury.

Based on interview and record review the facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health in 1 of 7 residents reviewed for hydration (Resident 3). Resident 3 did not meet his RD's (Registered Dietitian's) daily fluid intake recommendation in the 26 days prior to his 9/27/15 hospitalization . Resident 3 was admitted to the hospital with [REDACTED]. This is evidenced by the following: Resident 3's [DIAGNOSES REDACTED]. Resident 3 has contractors to his hands. The following documentation was noted in Resident 3's chart prior to this hospitalization : Resident 3's quarterly MDS (Minimum Data Set) with an end observation date of 8/10/15 documents that Resident 3 needs extensive assist with eating, and has limited ROM (range of motion) to both upper extremities. Resident 3's care plan, in place at the time of his 9/27/16 hospitalization , documents a problem dated 2/19/15 which states: Nutritional Status. Resident requires a therapeutic diet: High Fiber, NAS (No added salt), and Resident enjoys eating in room w/ (with) roommate. Interventions to this care plan problem dated 2/19/15 include: 206 supplement TID (three times a day), Monitor intake of supplements . Encourage oral intake of food and fluids . Monitor and record intake of food . A Nutritional Assessment on 6/16/15 documents that Resident 3's total fluids required to meet his needs is 2600 or 25 ml / kg (milliliters / kilogram). This assessment identifies that Resident 3's fluid intake is 1,000 - 1499 cc (cubic centimeters) per day. This assessment documents: Consult for supplement follow up. Intakes remain sporadic. Often refuses meals. He does enjoy the 206 supplement juice. He refuses all other supplement choices. Wt. (weight) stable. Continue with supplement as ordered. A Nutritional Assessment completed on 8/17/15 documents that Resident 3's oral intake meets 26 - 75% of his estimated needs consuming 1500 - 2000 cc per day. Resident 3's oral intakes for 9/2015 are as follows: 9/1/15 720 cc 9/2/15 1140 cc 9/3/15 480 cc 9/4/15 720 cc 9/5/15 920 cc 9/6/15 800 cc 9/7/15 240 cc 9/8/15 720 cc 9/9/15 840 cc 9/10/15 737 cc 9/11/15 460 cc 9/12/15 360 cc 9/13/15 not recorded 9/14/15 100 cc 9/15/15 680 cc 9/16/15 280 cc 9/17/15 180 cc 9/18/15 240 cc 9/19/15 600 cc 9/20/15 240 cc 9/21/15 440 cc 9/22/15 840 cc 9/23/15 840 cc 9/24/15 200 cc 9/25/15 480 cc 9/26/15 360 cc There is no documented evidence Resident 3 met his required fluid needs during 9/2015. Resident 3's MAR (Medication Administration Record) for 9/2015 shows that Resident 3 was to receive [MEDICATION NAME] 10 mg every day, and [MEDICATION NAME] 40 mg twice a day. Resident 3 would frequently refuse his medications. From 9/20/15 - 9/26/15 Resident 3 received [MEDICATION NAME] 10 mg 3 of 7 times, and [MEDICATION NAME] 6 of 14 times. Resident 3's facility progress notes state: 9/18/15 at 9:32 pm: . Awakened and assisted with supper, ate approx. (approximately) 25%. Refused all meds (medications). 9/22/15 at 9:32 pm: C/o (complained of) feeling too warm at 2115 (9:15 pm). Stated HA (head ache) and given Tylenol 1000 mg (milligrams) at 2125 (9:25 pm). Repositioned for comfort. Refused to take medication and refused supper. Alternative offered and declined. 9/23/15 11:03 am: . Resident c/o (complained of) not feeling well and CNA (Certified Nursing Assistant) reports that resident was staring off when cares were completed Writer asked resident to describe how he was feeling, stated crappy. Writer asked resident to elaborate, resident would not use any other descriptive words . 9/24/15 11:23 pm: Resident refused PM & HS meds. He had the hiccups and said he didn't feel good. Writer asked him if he wanted a sprite and he asked for diet cola. He drank a few sips. Later CNA reported that he had thrown up his soda. He was afebrile and he had no other emesis. 9/25/15 2:53 pm: Summary Two: Resident is A & O (alert and oriented) x 3. Is on a high fiber, NAS diet. Has had recent decline in appetite. Is frequently refusing meals and intake is approx. 25% of meals eaten. Has supplement of 206 drink TID. Fluid intake is average of 240 cc with meals. 9/25/15 9:42 pm: . Refused PM and HS medications. Refused supper and 206 supplement. Alternatives of food and fluid offered and resident declined. 9/26/15 9:53 am: Resident refused all medications this AM. Continues with poor intake. Resident only took in his 206 supplement and 2 bites of toast. 9/26/15 10:25 pm: Resident refused to eat any supper. He had some sips of water was all this shift 9/27/15 6:39 am: Resident states he is not feeling right and wants to go to the hospital. Resident has had very poor intake the past few days, refusing meals, fluids, and meds . 9/27/15 9:21 pm: . He was admitted to the hospital for dehydration and acute kidney injury and was given 1500 ml of normal saline . Resident 3's Hospital notes from 9/27/15 state: ED (Emergency Department) Notes: Chief Complaint: Weakness. HPI (History of Present Illness) Comments: The patient is a resident of a local nursing home. According to nursing staff there he has not been eating or drinking for the last 3 days. There has been no vomiting or diarrhea. No fever. No cough . Skin: Positive for pallor (an unhealthy pale appearance) . Skin: skin is warm and dry. There is pallor . Patient appears to be quite dehydrated clinically . ED Course / Medical Decision Making . The patient's blood pressure was about 80 systolic when he arrived here in the emergency room . He was given IV (Intravenous) fluid bolus his pressure came up to about 110 systolic and his color improved quite a bit as well with the IV fluids. After seeing the patient here in the emergency room (Physician) decided to admit him to the hospital. Final Diagnostic Impression: Patient is quite dehydrated. And this is complicated by the fact that he is taking a diuretic on a regular basis. The reason for the poor intake over the past 3 days is not clear. He does have some [MEDICAL CONDITION] at this time but most or all of this is probably prerenal due to his dehydration. Also he has a slightly elevated troponin which is also probably due to renal dysfunction History and Physical: . presents to the ER (emergency room ) with severe dehydration / AKI (Acute Kidney Injury). He notes decreased appetite and po intake associated with some nausea for last several days to 1 week At the time of admission his speech difficulty is worsened by dry mucus membranes, and limited history . Assessment and Plan: AKI Assessment: Due to poor intake and over diuresis. Plan: [MEDICATION NAME] - held, [MEDICATION NAME] - held, Col - benemid - held, IVF (Intravenous fluids) hydration with NS. Dehydration Assessment: Due to poor intake and over diuresis. Plan: as above. [MEDICAL CONDITION]: Assessment: Due to poor intake and over diuresis. Plan: IVF hydration, hold [MEDICATION NAME] - check echocardiogram (? [MEDICAL CONDITIONS]. Hospital Labs 9/27/15 BUN (Blood Urea Nitrogen) - Elevated 105 (Normal 8 - 26) Creatinine - Elevated 3.1 (Normal 0.7 - 1.3) Resident 3 remained in the hospital for 4 days, returning to the facility on [DATE] with Hospice to follow. On 5/9/16 at 12:43 pm Surveyor spoke with DON (Director of Nursing) B regarding Resident 3 and his hospitalized from [DATE] - 10/1/15. Surveyor asked DON B who was responsible for adding up and / or analyzing the fluid intake data that is collected to ensure residents are meeting their recommended fluid intake totals. DON B stated the facility does not have a good system for this and that there is no person or persons assigned to add up the intake totals. Surveyor asked DON B what she would expect to be done if a resident was not meeting their fluid intake totals. DON B stated for Resident 3 she would have expected the physician to be called, the dietician should have done another assessment and updated the goals, and staff should have spoken to Resident 3 about this as well. Surveyor asked DON B to provide any additional information to assist Surveyor in reviewing this dehydration event for Resident 3. DON B stated I don't believe I'm going to be able to find anything. No additional information was provided to Surveyor . On 5/10/16 at 11:00 am Surveyor called Dr. C's (Resident 3's Primary Care Physician's) office and spoke with Nurse K. Dr. C was not in the office. Nurse K informed Surveyor that the clinic had no documented evidence that the facility had called to inform Dr. C of Resident 3's poor fluid intake prior to Resident 3's hospitalization on [DATE]. Nurse K stated there was documentation on 9/18/15 noting Resident 3 had not had a BM (bowel movement) for several days. On 5/11/16 at 11:35 am Surveyor again called Dr C's office in hopes of speaking with Dr. C. A message was left. On 5/11/16 at 1:38 pm Nurse L from Dr C's office returned Surveyor 's call stating Dr C has stated that any discussion with the facility regarding Resident 3's care or condition, including just prior to his hospitalization on [DATE], would be documented in the facility record. The facility had documented information that Resident 3 did not meet his fluid needs every day for almost a month and Resident 3 had complaints of not feeling well. The physician nor the dietitian was informed to add interventions to prevent dehydration. Resident 3 requested to go to the hospital and was diagnosed with [REDACTED].