Every finding on record at Elroy Health Services

Based on interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 4 out of 4 residents (R1, R3, R7, and R8) reviewed of a total sample of 8 residents. R1 was observed by staff to ingest three cups of undetermined pills that were sitting on his bedside table and by his chair. R1 was not adequately monitored after taking all of these medications, nor was the provider notified timely. R3 did not have his physician orders transcribed to hold an anticoagulant medication prior to a medical procedure. R3 continued to receive his anticoagulant medication for 4 days. R8 received his medication from another resident's bubble pack of medications. R8's narcotic counts were incorrect. R7 received a double dose of tramadol on 8/2/26 that wasn't reported and on 8/5/26 received a dose of tramadol too soon, according to the physician's order. Evidenced by: The facility policy titled, Medication Error Reporting and Adverse Drug Reaction Prevention and Detection, dated 2007, states, in part: Policy: The facility utilizes a system to assure that medication usage is evaluated on an ongoing basis. Medication errors and adverse drug reactions are assessed, documented, and reported as appropriate to the resident's attending physician and/or prescribers. Guidelines and Definitions: 1. Medication Error/Variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional. Such events may be related to prescribing, order communication. administration. monitoring and use. Procedures: 3. Facility staff monitor the resident for possible medication-related adverse consequences. Example 1: R1 was admitted to the facility on [DATE] and has diagnoses that include, in part: Interstitial Pulmonary Disease unspecified, Chronic Diastolic Heart Failure, Chronic Kidney Disease stage 3 unspecified, Unspecified Atrial Fibrillation, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Osteoarthritis, and Displaced Trimalleolar Fracture of Right lower leg. R1's Physician Orders include, in part: --Oxycodone HCl Oral Tablet 5 mg *Controlled Drug* Give 2.5 mg by mouth every 8 hours as needed for Pain. Start Date: 6/1/26 --Metoprolol Tartrate Oral Tablet. Give 25 mg by mouth two times a day for Ventricular rate control in A Fib (Atrial Fibrillation). Start Date: 6/1/26 --Duloxetine HCl Oral Capsule Delayed Release Particles. Give 30 mg by mouth one time a day for Chronic muscle or bone pain. Start Date: 6/2/26 --Methocarbamol Oral Tablet. Give 500 mg by mouth three times a day for Pain. Start Date: 6/1/26 R1's Progress Note, dated 6/11/26 at 2:11 PM, indicated the following: CNA yesterday reported that resident had 2 cups of medications on chair and one cup on meal tray and liquid protein in glass on meal tray. Resident took all medications. Upon entering room, noted that one cup containing TUMS and liquid protein in glass still on the med tray. There were two empty medication cups in the garbage can. This writer asked medication nurse if she gave resident his medications and she stated that she watched him take all of his medications. Unsure if resident had taken his early morning medication at 0500 (5:00 AM). When giving resident his medications, he would have had one medicine cup at 0500, one for his 13 pills, one for his TUMS and his glass for his liquid protein. Vitals were taken and b/p (blood pressure) 96/63; 96% (oxygen) on room air and HR (heart rate) was 99 and irregular as resident does have A-fib. This writer did speak with the PM nurse from the night before and asked if she noticed any extra medications at bedside when she gave him his HS (bedtime) medications and she stated No and she did give him his medications. Resident noted to be alert and oriented x 4. Vital signs today at this time: 115/64 (blood pressure); 97.8 (temperature); 83IR (heart rate irregular); 18 (respirations; 96% (oxygen) on room air. He is alert and oriented x 4 and able to make his needs known. Resident joking with staff stating that his vital signs are too good. PA G was informed of the above. Her response is to make sure that staff watch resident take his medications at ordered times. R1's Incident reporting documentation indicates the following: On 6/11/26 at 10:30 AM, DON B (Director of Nursing) was notified of the medication error. On 6/11/26 at 1:45 PM, PA G (Physician Assistant) was notified of the medication error. Of note, there is a delay in notifying the DON and the doctor. R1's Post Event Observation and Progress Notes indicate the following: On 6/11/26 at 10:30 PM, The current status is Resident has been sleeping per his norm this shift and has had no c/o (complaints). No vital signs were recorded. On 6/12/26 at 11:10 AM, The current status is resident is alert with no distress noted. VSS (vital signs stable). Vital signs were recorded as 133/83 (blood pressure); 97 (temperature); 97 (heart rate); 20 (respirations) Of note, this is the first set of vital signs recorded after the event, approximately 24 hours later. On 6/12/26 at 9:49 PM, The current status is Resident is alert with no complaints this shift. Currently resting in bed. Vital signs were recorded as 102/73 (blood pressure); 97.5 (temperature); 84 (heart rate); 20 (respirations) On 6/13/26 at 6:07 AM, The current status is. sleeping at this time. will continue to monitor. Vital signs were recorded as 94/63 (blood pressure); 97.5 (te9perature); 80 (heart rate); 18 (respirations) On 6/13/26 at 2:07 PM, The current status is Resident alert with no complaints this shift. Currently resting in bed. Continue to monitor Vital signs were recorded as 104/64 (blood pressure); 98.1 (temperature); 78 (heart rate); 16 (respirations) On 6/13/26 at 10:07 PM, The current statis is Resident is alert with no complaints this shift. Currently resting in bed. Vital signs were recorded at 104/64 (blood pressure); 98.1 (temperature); 78 (heart rate); 16 (respirations) Of note, these are exact duplicate vital signs from the ones recorded earlier in the day. On 6/14/26 at 3:53 AM, The current status is Resident is alert with no complaints this shift. Currently resting in bed. Vital signs were recorded at 104/64 (blood pressure); 98.1 (temperature); 78 (heart rate); 16 (respirations) Of note, these are exact duplicate vital signs from the ones recorded twice on 6/13/26. On 6/14/26 at 12:03 PM, The current status is Resident is A&O (alert & oriented). Continue to monitor. Vital signs were recorded as 102/68 (blood pressure); 98 (temperature); 90 (heart rate); 20 (respirations) On 6/14/26 at 8:03 PM, The current status is Resident is A&O. Continue to monitor. Vital signs were recorded as 107/61 (blood pressure); 98.2 (temperature); 74 (heart rate); 18 (respirations) On 8/26/26, Surveyor requested documentation of education provided to staff for R1's medication error regarding self-administration of medications. VPS I provided documentation of the nurses meeting agenda and attendance. On 6/17/26 the facility held a nurse's meeting that included, Medication Administration: do not leave medications at bedside. observe residents taking medications. ensure medications are swallowed before leaving room. Of note, only 9 of the facility's 21 nurses attended the meeting. On 8/25/26 at 1:20 PM, Surveyor interviewed RN C (Registered Nurse) and asked what kind of monitoring was completed for someone who had a medication error. RN C stated that there was a risk management that they would be assessing the resident every 8 hours per facility protocol. Surveyor asked RN C if vital signs would be completed as part of the monitoring. RN C stated they would monitor whatever the doctor told them to monitor. Surveyor asked RN C if there had been a medication error with R1. RN C stated she didn't remember but she would look it up. On 8/25/26 at 1:40 PM, RN C approached Surveyor and stated that she looked up R1's medication error and that the CNA (Certified Nursing Assistant) stated that the resident told her that he took several cups of medication. The CNA couldn't see what was in the cups, but R1 normally gets 3 cups of medications in the morning, and he took all of them. RN C stated that they considered it a medication error because the nurse said she watched him take the medications, but she didn't. On 8/25/26 at 1:35 PM, Surveyor interviewed LPN D (Licensed Practical Nurse) and asked what kind of monitoring was completed for someone who had a medication error. LPN D stated that she would take their vital signs and fill out the risk assessment. LPN D stated that vital signs should be checked every 15 minutes for the first hour. Surveyor asked if there was a medication error with R1. LPN D stated that she couldn't recall if she was working that day, but that she had been told that whoever was working the PM shift had left medications in R1's room and he took them all in the morning. On 8/25/26 at 1:59 PM, Surveyor interviewed MT E (Medication Technician) and what kind of monitoring was completed for someone who had a medication error. MT E indicated that they would do vital signs frequently and reach out to the doctor. Surveyor asked MT E if there was a medication error with R1. MT E stated that she did not see any cups of medication in R1's room, and that she watched him take the medications she gave him. MT E stated that she distinctly remembers handing R1 his medications one at a time, because previously he had tried to take all the medications at once and spilled them down his front. MT E indicated that RN C had been taking R1's vital signs after the incident, but she did not know of any other follow-up protocols that were put in place after R1's medication error. On 8/25/26 at 2:20 PM, Surveyor interviewed CNA F (Certified Nursing Assistant) about R1's medication error. CNA F indicated that she saw the medication cups sitting in R1's room with medications in them. When she entered R1's room that morning. CNA F stated there was one cup that was on R1's bedside table that had 3 pills in it, and 2 med cups next to chair that had 7 or 8 pills in them. CNA stated that R1 asked her what all the pills were for. CNA F stated that she didn't know, but she would get the nurse. CNA F stated that by the time the nurse came into R1's room, R1 had already taken all the pills. On 8/26/26 at 7:46 AM, Surveyor interviewed RN J and asked what kind of monitoring was completed for someone who had a medication error. RN J stated that it would depend on their symptoms and what the medication was but generally monitoring them and taking vital signs every shift at least. RN J stated that she would also monitor whatever parameters the doctor gave us to monitor. Surveyor asked RN J if there was a medication error with R1. RN J indicated that she was not working at that time but that she had been told that there were meds found at bedside. RN J stated that luckily R1 was in a room by himself, as they didn't know where the medications were from. On 8/26/26 at 12:20 PM, Surveyor interviewed MD H (Medical Director) about R1's medication error. Surveyor asked MD H what kind of monitoring she would expect after a resident had a medication error. MD H stated that she would expect vital signs to be monitored at least hourly for the first 4 hours and then continue to monitor symptoms and vital signs for the next 24 hours. MD H indicated that ideally R1's medication error would not have occurred, as the facility has a protocol to watch the residents take all of their medications. MD H stated that in this incidence of not being sure what were in R1's medication cups that he ingested, she would have expected the facility to do an inventory of his medications to determine what they could possibly be. MD H indicated that she would expect that the facility do some investigating as well as use professional judgment. MD H stated that the facility could have also reached out to the pharmacy to get insight and direction from them. On 8/26/26 at 1:19 PM, Surveyor interviewed VPS I (Vice President of Success) and asked if there were any self-administer assessments or physician orders for R1. VPS I stated there was not. Surveyor asked VPS I if R1 should have medications left at his bedside. VPS I indicated no, the nurses are supposed to ensure that R1 takes his medications before leaving the room. Surveyor asked VPS I what her expectation would be for monitoring a resident who had a medication error. VPS I stated that she would expect that vital signs be taken and a progress note entered at least every shift. VPS I stated that DON B had a nurses meeting on medication administration recently. VPS I provided documentation of the nurses meeting agenda and attendance. On 6/17/26 the facility held a nurse's meeting that included, Medication Administration: do not leave medications at bedside. observe residents taking medications. ensure medications are swallowed before leaving room. Of note, only 9 of the facility's 21 nurses attended the meeting. Example 2: R3 was admitted to the facility on [DATE] and has diagnoses that include, in part: Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Type 2 Diabetes Mellitus with Chronic Kidney Disease, End Stage Renal Disease, Long term (current) use of anticoagulants, and Dependence on Renal Dialysis. R3's Physician Orders include, in part: --Apixaban (Eliquis) Oral Tablet 5 mg. Give 5 mg by mouth two times a day for anticoagulation. Start Date: 6/29/26. R3's Progress Note, dated 8/4/26 at 12:55 PM, indicated the following: A fax was received on 7/31/26 at 12:05 PM from [Hospital Name] with instructions for upcoming procedure on 8/5/26. Medication instructions stated to hold Eliquis for 2 days prior to procedure. Orders were not placed in the MAR (Medication Administration Record) to hold Eliquis which resulted in resident receiving this medication on 8/3/26 at 8:20 AM and 4:22 PM and on 8/4/26 at 3:16 AM. This medication was put on hold for today's PM and tomorrow morning AM doses. This writer called [Hospital Name]. and inquired if the procedure would need to be rescheduled. the Surgeon said they could still do the procedure but to also only give 1/2 of his insulin doses tonight and hold the remaining Eliquis doses prior to the procedure tomorrow. R3's MAR (Medication Administration Record) indicates the following for Apixaban (Eliquis) 5 mg: On 8/1/26 PM dose – resident refused medication. On 8/2/26 AM dose – resident refused medication. On 8/2/26 PM dose – resident given medication. On 8/3/26 AM dose - resident given medication. On 8/3/26 PM dose – resident given medication. On 8/4/26 AM dose – resident given medication. On 8/4/26 PM dose – medication held. Of note, the resident received 4 doses of a medication that had physician orders to be held. On 8/4/26 at 11:55 AM, the IDT (interdisciplinary team) Progress Note indicated, in part: RCA (Root Cause Analysis): Procedure instructions were received by fax but were not transcribed and entered into the resident's MAR. There was no follow-through or verification process to ensure the pre-procedure medication instructions had been implemented, resulting in Eliquis being administered during the ordered hold period. [Hospital Name] confirmed that the procedure could proceed as scheduled. Continue to hold Eliquis as directed and follow the updated insulin instructions. Monitor the resident for signs or symptoms of abnormal bleeding or other complications. R3's Post Event Observation and Progress Notes indicate the following: On 8/4/26 at 1:03 PM, The current status is Resident is stable, resting in bed. Resident received Apixaban on 8/3/26 at 8:20 AM and 4:22 PM and on 8/4/26 at 3:16 AM. These doses should have been held pending upcoming procedure on 8/5/26. Orders were not placed in the MAR to hold these doses. No adverse effects noted since this is a regularly scheduled medication for this resident. On 8/4/26 at 7:55 PM, The current status is Resident continues to have his medications held and halved until procedure is over. Has had no c/o (complaints) at this time. Of note, no other progress notes or vital signs were obtained after this event. On 8/26/26, Surveyor requested documentation of education provided to staff after R3's medication transcription error. VPS I (Vice President of Success) provided Surveyor with a Training Inservice Sign in Sheet that indicated Hold orders. Provider orders who to assign to. were discussed at the meeting. Of note, only 10 of the facility's 21 nurses attended the meeting. On 8/26/26 at 12:59 PM, Surveyor interviewed RN C (Registered Nurse) and VPS I about R3's medication error. RN C indicated that she had been off, but she noted that there were upcoming appointments on the clipboard in the nurse's station. RN C stated that she doesn't work that hallway, so she wasn't aware that the hold orders hadn't been put on the MAR (Medication Administration Record). RN C stated that R3 had refused a couple doses of the medication, so he only received 2 out of 4 doses that should have been on hold. RN C indicated that they immediately called the surgical team and they gave instructions to continue to hold the medication and proceed with the procedure. Surveyor asked whose responsibility it was to ensure that physician's orders were transcribed correctly into the resident's MAR. VPS I indicated that it is the floor nurse who takes the order is expected to enter it into the MAR. Example 3: R8 was admitted to the facility on [DATE] and has diagnoses that include, in part: Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Neuralgia and Neuritis unspecified, Generalized Anxiety Disorder, Presence of Left artificial knee joint, Migraine unspecified, and Complete Rotator Cuff tear or rupture of left shoulder. R8's Physician Orders include, in part: --Pregabalin Oral Capsule 150 mg. Give 150 mg by mouth three times a day for chronic pain. Start Date: 6/29/26 --Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give 1 tablet by mouth every 8 hours as needed for moderate to severe pain for 3 months. Start Date: 6/29/26. Discontinue Date: 8/25/26. R8's Progress Note Communication with Physician, dated 8/20/26 at 10:26 AM, indicated the following: Writer noted in controlled substance log that resident did not receive HS (bedtime) dose of pregabalin 150 mg capsule. Resident has pregabalin 150 mg capsule scheduled twice daily. Resident is A&O (alert & oriented) x4, able to make needs known and participate in assessment. at baseline. Writer notified DON B (Director of Nursing) and resident was placed on PA G's (Physician Assistant) list. for medication error. On 8/26/26 at 8:10 AM, Surveyor attempted to contact PA G and left a message but did not receive a call back. A review of R8's MAR (Medication Administration Record) indicates that both the pregabalin 150 mg and hydrocodone-acetaminophen 5-325 mg have errors in the narcotic count. Multiple times the documentation for these medications are not listed appropriately, in descending order, each time the medication is administered. On 8/26/26, Surveyor requested documentation of the education provided to the nurse regarding R8's medication error on 8/20/26. The document received states in part . Type/Nature of Incident: Medication Error. Date of Incident: 8/20/26 at 8:57 AM.Effective Date: 8/20/26.Note: education completed with the nurse. Of note, the document provided does not specify what type of education was completed, nor to which staff member the education was completed with. On 8/26/26 at 12:59 PM, Surveyor interviewed RN C (Registered Nurse) and VPS I about R8's medication error. RN C stated that there are two residents on that hall that receive the medication pregabalin, and that the medication cards are placed right next to each other in the narcotics drawer. RN C indicated that while R8 has physician orders for 150 mg of pregabalin, the other resident's order is only for 50 mg of pregabalin. RN C stated that the nurse on duty gave 3 of the other resident's 50 mg pregabalin pills to R8 to make up the 150 mg capsule. RN C indicated that R8 actually received the right amount of medication, but that they filled out an incident report because it was taken from the wrong resident's medication card. Surveyor asked VPS I if she would expect the nurses to complete the 5 Rights of Medication Administration, including ensuring that the medication administered was from the right resident's medication card. VPS I stated yes, and that she recognizes that the facility needs to do more education on med errors. Surveyor also pointed out the discrepancies in R8's narc counts for both pregabalin and hydrocodone-acetaminophen. VPS I indicated that there had been some confusion because not every resident's narcotics counts had been listed on the MAR. VPS I indicated they would be doing a house-wide sweep of the narc count documentation. Example 4 R7 was admitted to the facility on [DATE] with diagnosis that include bipolar disorder, congestive heart failure, anxiety disorder, and chronic obstructive pulmonary disease. R7's physician's order dated 5/7/26 states: Tramadol HCl Oral Tablet 50mg (milligram). Give 50mg by mouth every 8 hours as needed for moderate to severe pain. On 8/2/26 at 10:12 AM, R7's Resident Controlled Substance Record states that R7 received 2 tablets of tramadol. This administration was not signed out on R7's MAR (Medication Administration Record). On 8/5/26 at 7:05 PM, R7's Resident Controlled Substance Record states that R7 received 1 tablet of tramadol. On 8/5/26 at 11:15 PM, R7's Resident Controlled Substance Record states that R7 received 1 tablet of tramadol. This administration was not signed out on R7's MAR until 8/6/26 at 11:07 PM. It is important to note that R7's order is for every 8 hours as needed, and these two doses are only 4 hours apart. On 8/7/26 at 9:47 AM Progress note states in part . IDT (Interdisciplinary Team) Clinical Review.Reason for Review: Medication documentation discrepancy involving PRN (as needed) tramadol was administered on 8/5/36 at 2315 (11:15 PM). The administration was not documented in [Electronic Health Record system]/eMAR. Background: Resident has an order for tramadol 50mg every 8 hours as needed. On 8/6/26, while preparing to administer tramadol, nursing reviewed the controlled substance record and notes a dose signed out on 8/5/26 at 2315 (11:15 PM) with the narcotic count documented as correct at 23 tablets remaining. The last tramadol administration documented in [Electronic Health Record system]/eMAR was 8/5/26 at 1905 (7:05 PM). Resident was assessed and remained alert with no symptoms or adverse effects noted.Intervention: 1. Education provided to the nurse that controlled medication must be documented consistently in both the controlled substance record and [Electronic Health Record system]/eMAR at the time of administration. It is important to note that there is no documentation of education provided regarding the medication being administered too soon on 8/5/26, nor was there documentation of the medication error on 8/2/26. On 8/26/26, Surveyor requested documentation of the education provided to the nurse regarding R7's medication error on 8/5/26. The document received states in part . Type/Nature of Incident: Medication Error. Date of Incident: 8/6/26 10:21 AM.Effective Date: 8/20/26 Note: nurse education completed. On 8/26/26 at 10:42 AM, Surveyor interviewed VPS I (Vice President of Success). Surveyor and VPS I reviewed R7's MAR and Resident Controlled Substance Record and noted the medication errors on 8/2/26 and8/5/26. Surveyor asked VPS I if there was a medication error report for the error on 8/2/26, VPS I stated that they were not aware of the error until now. Surveyor asked VPS I if education should have been provided to the nurse prior to 8/20/26, VPS I stated that education should have been completed immediately. The facility did not ensure that physician orders were followed due to transcription errors, self-administration of medication errors, narcotics count errors, timely notification to provider of medication errors and inadequate monitoring after med errors occurred.

Based on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 sampled residents (R1) reviewed for self- administration of medications out of a total sample of 8 residents.R1 was observed by staff to ingest three cups of undetermined pills that were sitting on his bedside table. R1 did not have an order to self-administer medications, nor did they have an assessment completed to determine their competency for self-administering medications. This is evidenced by:The facility policy titled, Self-Administration by Resident, dated 2007, states, in part: Policy: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. Procedures: 1. An assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process. The facility policy titled, Medication Administration: General Guidelines, dated 2007, states, in part: Policy: Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices. Procedures: . 20. The resident is always observed after administration to ensure that the dose was completely ingested. R1 was admitted to the facility on [DATE] and has diagnoses that include, in part: Interstitial Pulmonary Disease unspecified, Chronic Diastolic Heart Failure, Chronic Kidney Disease stage 3 unspecified, Unspecified Atrial Fibrillation, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Osteoarthritis, and Displaced Trimalleolar Fracture of Right lower leg. R1's Care Plan, dated 6/1/26, states in part: Focus: .Anticoagulant therapy treatment (A-Fib): At risk for adverse effects. Interventions: Administer per MD orders. Focus: Diuretic therapy to treat (CHF, HTN): At risk for adverse effects. Interventions: Administer medications per MD orders. Opioid use r/t (related to) right ankle fracture, knee wound, osteoarthritis. Interventions: Administer medications as ordered. R1's Physician Orders include, in part:--Oxycodone HCl Oral Tablet 5 mg *Controlled Drug* Give 2.5 mg by mouth every 8 hours as needed for Pain. Start Date: 6/1/26--Metoprolol Tartrate Oral Tablet. Give 25 mg by mouth two times a day for Ventricular rate control in A Fib (Atrial Fibrillation). Start Date: 6/1/26--Duloxetine HCl Oral Capsule Delayed Release Particles. Give 30 mg by mouth one time a day for Chronic muscle or bone pain. Start Date: 6/2/26--Methocarbamol Oral Tablet. Give 500 mg by mouth three times a day for Pain. Start Date: 6/1/26 Of note, R1 does not have a physician's order to self-administer medications, nor was there a competency assessment anywhere in R1's medical record for self-administering of medications. R1's Progress Note, dated 6/11/26 at 2:11 PM, indicated the following: CNA yesterday reported that resident had 2 cups of medications on chair and one cup on meal tray and liquid protein in glass on meal tray. Resident took all medications. Upon entering room, noted that one cup containing TUMS and liquid protein in glass still on the med tray. There were two empty medication cups in the garbage can. This writer asked medication nurse if she gave resident his medications and she stated that she watched him take all of his medications. Unsure if resident had taken his early morning medication at 0500 (5:00 AM). When giving resident his medications, he would have had one medicine cup at 0500, one for his 13 pills, one for his TUMS and his glass for his liquid protein. Vitals were taken and b/p (blood pressure) 96/63; 96% (oxygen) on room air and HR (heart rate) was 99 and irregular as resident does have A-fib. This writer did speak with the PM nurse from the night before and asked if she noticed any extra medications at bedside when she gave him his HS (bedtime) medications and she stated No and she did give him his medications. Resident noted to be alert and oriented x 4. Vital signs today at this time: 115/64 (blood pressure); 97.8 (temperature); 83IR (heart rate irregular); 18 (respirations; 96% (oxygen) on room air. He is alert and oriented x 4 and able to make his needs known. Resident joking with staff stating that his vital signs are too good. PA G was informed of the above. Her response is to make sure that staff watch resident take his medications at ordered times. On 6/15/26 at 9:40 AM, the IDT (interdisciplinary team) Progress Note indicated, in part: RCA (Root Cause Analysis): Medications left at bedside. Resident does not have a self-administration for him to make [sic] medication without being monitored and medication should [sic] be left at bedside. Interventions: Re-education provided to staff on leaving medication at bedside without self-administration orders. On 8/25/26 at 1:20 PM, Surveyor interviewed RN C (Registered Nurse) and asked what kind of assessments were completed for someone to self-administer their own medications. RN C stated that there was a self-admin assessment they do. RN C stated she would also ask their doctor if they felt it was safe and have them write an order. RN C indicated that if a resident did have a self-administer assessment, it would be rechecked quarterly. Surveyor asked RN C if R1 had a self-administer order or assessment. RN C stated that R1 did not. Surveyor asked RN C if it was okay to leave medications at R1's bedside. RN C stated no, it was not, that the nurses are supposed to make sure that the residents take all of the medications before they leave the room. On 8/25/26 at 1:35 PM, Surveyor interviewed LPN D (Licensed Practical Nurse) and asked what kind of assessments were completed for someone to self-administer their own medications. LPN D stated that there was nobody currently in the facility who had an order or assessment to self-administer their medications. LPN D indicated that if someone wanted to self-administer their own medications, they would have to sign a risk versus benefits document, but she had never known of anyone to do that. Surveyor asked LPN D if it was okay to leave medications at R1's bedside. LPN D stated no that they have to watch them take their medications. LPN D indicated that if a resident doesn't want to take their medications right away, she will take them back and lock them in the medication cart. On 8/25/26 at 1:59 PM, Surveyor interviewed MT E (Medication Technician) and asked what kind of assessments were completed for someone to self-administer their own medications. MT E stated that the doctor, the DON (Director of Nursing), and the NHA (Nursing Home Administrator) would have to assess them. Surveyor asked MT E if it was okay to leave medications at R1's bedside. MT E indicated no, if R1 did not have a self-administer medication assessment, they were supposed to stay with them and watch them take all of their medications. On 8/26/26 at 7:46 AM, Surveyor interviewed RN J and asked what kind of assessments were completed for someone to self-administer their own medications. RN J stated there was only one resident in the facility that was care planned to take their own medications, and that they would have to do an assessment to determine if the resident was able to understand what medications they were taking, if they had the manual dexterity to be able to take them, and their health history. Surveyor asked RN J if it was okay to leave medications at R1's bedside. RN J stated no. On 8/26/26 at 1:19 PM, Surveyor interviewed VPS I (Vice President of Success) and asked if there were any self-administer assessments or physician orders for R1. VPS I stated there was not. Surveyor asked VPS I if R1 should have medications left at his bedside. VPS I indicated no, the nurses are supposed to ensure that R1 takes his medications before leaving the room. VPS I stated that DON B had a nurses meeting on medication administration recently. VPS I provided documentation of the nurses meeting agenda and attendance. On 6/17/26 the facility held a nurse's meeting that included, Medication Administration: do not leave medications at bedside. observe residents taking medications. ensure medications are swallowed before leaving room.Of note, only 9 of the facility's 21 nurses attended the meeting. The facility did not ensure that R1 was adequately assessed and supervised for self-medication administration.

Based on interview and record review, the facility did not ensure each resident receives adequate supervision and safety to prevent accidents and hazards for 1 of 1 Residents reviewed for smoking (R51).On 4/5/26, R51 was observed by staff to be smoking an illegal substance in his room. R51 had a history of illicit drug use, however, this was not addressed upon R51's admission. No monitoring was put in place for R51 regarding the use of illegal substances. R51 has a roommate, and residents in rooms near R51 use oxygen.The facility's failure to provide adequate supervision and protect residents from smoking in the facility and illegal substance use created a finding of immediate jeopardy (IJ) that began on 4/5/26. Surveyor notified NHA A (Nursing Home Administrator) and VPS E (Vice President of Success) of the immediate jeopardy on 5/7/26 at 1:50 PM. The immediate jeopardy was removed on 5/7/26. 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.Evidenced by:The facility policy, Safety for Residents with Substance Use Disorder, dated 10/18/22, states, in part: . Policy Explanation and Compliance Guidelines: 1. Residents with a history of SUD (substance use disorder) will be assessed for risks including the potential to leave the facility without notification and use of illegal/prescription drugs. Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors. 6. Residents with SUD may try to continue using substances during their stay in the nursing home. Facility staff will assess the resident for the risk for substance use in the facility and have knowledge of signs and symptoms of possible substance(s) that include, but are not limited to: a. Frequent leaves of absence with or without facility knowledge.The facility policy, Smoking Policy, dated 5/2019, with last review date of 9/10/24, states, in part: Policy: It is the policy of this facility to provide a safe and healthy environment for residents. including safety related to smoking. Safety protections apply to smoking and non-smoking residents. Policy Explanation and Compliance Guidelines: 1. Smoking is prohibited in all areas except the designated smoking area.R51 was admitted to the facility on [DATE] with diagnoses that include, in part: Parkinson's Disease, Cognitive Communication Deficit, Cardiac Arrhythmia, Dizziness and Giddiness, Syncope and Collapse, and Other Psychoactive Substance Dependence uncomplicated (added to diagnosis list on 4/7/26).R51's most recent Minimum Data Set (MDS) indicates R51 has a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R51 is moderately cognitively impaired.R51's most recent Comprehensive Care Plan states, in part:Focus: History of smoking in community r/t (related to): Smokes occasionally both on and off premises. Date Initiated: 1/20/26. Goal: Will remain compliant with facility non-smoking policy. Date Initiated: 1/20/26. Revision on: 4/9/26. Will smoke safely in designated areas. Date Initiated: 1/20/26. Revision on: 4/9/26. Interventions: Allow to smoke independently in designated areas. Date Initiated: 1/20/26. Complete smoking eval per facility guidelines. Date Initiated: 1/20/26. Resident is aware of no smoking in room. Date Initiated: 4/6/26. Secure smoking materials at nurses station or other designated area for storage. Date Initiated: 1/20/26.R51's Nicotine Assessment, dated 9/17/25, indicates a Category of: Independent, that resident smokes cigars daily but understands and adheres to the smoking policy.R51's Nicotine Assessment, dated 4/7/26, indicates a Category of: At Risk, requiring staff supervision.On 7/7/25 an History of Present Illness (HPI) document states, in part: . Social History: Non-prescribed substance use: marijuana (any form); Non-prescribed substance use details: 4 times after 6 pm - last time used about 3 weeks ago.On 7/17/25: an office visit document for new admission follow-up states, in part: .Falls: Cannabis Abuse (Resolved).On 4/3/26 at 9:29 PM, R51's progress note states in part: Resident out to bank when writer here. Back approximately 7:00 PM. States had Chinese for supper.On 4/5/26 at 5:48 PM, R51's progress note states in part: Resident went out to dinner with Nephew to the Dalles (sic). Forgot to sign out of the facility.On 4/5/26 at 10:00 PM, R51's telehealth visit note states in part: Resident was out with family today had fallen and has an abrasion on his right knee but, resident returned with crack and was smoking it in his room.On 4/6/26 at 5:56 AM, R51's telehealth visit note states in part: . The patient had been smoking crack cocaine in his room. Social History: Substance Use: Recent crack cocaine use (smoking crack in his room) . called about. elevated blood pressure of 203/89 after recent crack cocaine use. They hypertensive episode appears to be related to recent recreational crack cocaine use.On 4/6/26 at 1:26 PM, NHA A sent an email to VPS E that states in part: .so (DON B's first name) and I just spoke with CNA (CNA H's Name) who was present yesterday. She states the following - (R51) left with his family and when he got back he said they took him to get Chinese food. He then told (CNA I's name) (another CNA ) and myself that we had to come down to his room. We went down to see what he needed and he opened his glasses case and had a baggie with like white crystals or something in it. He asked if we wanted to smoke crack. We told him no and said he shouldn't be doing that either. He I don't care, then he picked it up and started to smoke. We told him you cant smoke inside but he wouldn't listen so I went and got (LPN J's name) and she handled it from there. I believe she took all the stuff out of his room.(CNA I's name) - I gave him a shower no problems and then he went back in his room I wanted to check on him around 340 and he was out with his nephew at Chinese in the dells with his nephew. He came back and had a scrape on his knee and told us he fell with his family. When he got back he pulled (CNA H's name) aside and showed her the stuff and he was being inappropriate towards her. (CNA H) then told the nurse and the nurse went down to address it and take his stuff, she then told us if he was going to go outside he needed to be supervised at all times. He did not show it to me at all. But I did see like little white specks on his table and the case he had. (CNA H) told me that he was smoking and I went into the room and told him if he wants to smoke anything he has to go outside. After I told him to stop he put it back on his table. It didn't look like it was still going when he put it on his table. Then (LPN J) came and took away his lighter and anything he had.(LPN J's name) - I spoke to LPN J this morning and she said that the girls came to get her and she went down when she got down to his room she took everything she could find. She did not see him smoking anything in the room, she also instructed him that if he is going to smoke he cannot do it in the building and that staff would assist with supervision if he was to go outside at all.On 4/6/26 at 2:07 PM, R51's provider notification states in part: . Situation: consumption of recreational drug use and hypertension. Background: . Resident participates in recreational drug activities. Assessment: . Resident has an elevated blood pressure after use of recreational drugs.On 4/6/26 at 2:34 PM, R51's progress notes states in part: Resident expressed signs of depression and recent use of recreational drug to help resolve his depression, behavioral health consult reviewed with resident.On 4/7/26 a Skilled Nursing Facility (SNF) Acute visit states, in part: . Incident: patient left the facility, he did not sign out, returned with knee abrasion and crack cocaine. Reportedly, patient flushed cocaine before it could be confiscated. Patient admits to use of recreational use of cocaine and marijuana/THC over many years. He notes he last did cocaine several years ago, before he moved into. SNF. Patient meets criteria for substance use disorder in that he continues to use marijuana/cocaine in situations that are physically hazardous (leaving the facility with family and acquiring the substance) and he continues to use marijuana/cocaine despite knowing that it has a negative effect on his physical health.Focus: History of substance use disorder as evidenced by : Use of illegal drugs. Date Initiated: 4/6/26. Goals: Will not harm self or others due to use of unauthorized substances. Date Initiated: 4/6/26. Revision on: 4/9/26. Will eliminate unauthorized use/consumption of illegal drugs (THC or crack). Date Initiated: 4/6/26. Revision on: 4/9/26. Resident will demonstrate understanding that substance use is not permitted in the facility through the next review date. Date Initiated: 4/6/26. Revision on: 4/9/26. Interventions: Contact emergency services for signs of overdose and administer opioid reversal agents as indicated. Date Initiated: 4/6/26. Discuss coping strategies. Date Initiated: 4/6/26. Educate on risks of leaving the facility to seek out substances and/or early, unplanned discharge. Date Initiated: 4/6/26. Encourage frequent contact with family and friends that are supportive of resident's recovery and do not encourage substance use, as desired by resident. Date Initiated: 4/6/26. Revision on: 5/7/26. If appears under the influence of unauthorized substance, notify MD and observe for safety/changes in condition. Date Initiated: 4/6/26. Increase monitoring and supervision of resident and their visitors. Date Initiated: 4/6/26. Instruct resident and visitors that alcohol/drugs may not be brought onto the premises. Date Initiated: 4/6/26. Monitor for signs and symptoms of a potential drug overdose. Administer Narcan per facility protocol. Date Initiated: 4/6/26. Revision on: 5/7/26. Offer resident a behavioral contract if cognitively able to consent, and only if will encourage resident to follow plan of care. Date Initiated: 4/6/26. Psychological or psychiatric services as indicated/ordered. Date Initiated: 4/6/26. Report changes in mood and suspected use of substance use to physician. Date Initiated: 4/6/26. Revision on: 5/7/26. Support resident's strengths and provide positive affirmations. Date Initiated: 4/6/26. Revision on: 5/7/26. Upon discharge, provide appropriate referrals and discharge instructions. Date Initiated: 4/6/26.Focus: Opioid use - risk of. Date Initiated: 4/7/26. Goals: Resident will not experience prolonged constipation, ileus, or impaction while taking opioids throughout the review period. Date Initiated: 4/7/26. Revision on: 4/9/26. Resident will not experience signs/symptoms of overdose or adverse drug event through review date. Date Initiated: 4/7/26. Revision on: 4/9/26. Interventions: Monitor for side effects. Date Initiated: 4/7/26. Monitor for signs and symptoms of a potential drug overdose. Administer Narcan per facility protocol. Date Initiated: 4/7/26.(of note: R51 is not receiving opioid medications)Focus: At risk for smoking related injury r/t (related to) disability. Date Initiated: 4/7/26. Revision on: 4/27/26. Goals: Resident will maintain safety while smoking independently. Date Initiated: 4/7/26. Revision on: 4/9/26. Resident will have no smoking relating injuries. Date Initiated: 4/7/26. Revision on: 4/9/26. Resident will remain compliant with facility smoking policy and procedure. Date Initiated: 4/7/26. Revision on: 4/9/26. Interventions: Allow resident to smoke independently in designated area. Date Initiated: 4/7/26. Assure smoking material is extinguished prior to resident leaving smoking area. Date Initiated: 4/7/26. Complete nicotine assessment per facility policy. Date Initiated: 4/7/26. Observe resident for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management of concerns. Date Initiated: 4/7/26. Resident not to have cigarettes or smoking material on person. Date Initiated: 4/7/26. Review smoking policy with resident and/or family. Date Initiated: 4/7/26. Storage of smoking materials per facility policy. Date Initiated: 4/7/26.(Of note: this care plan was added after the incident on 4/5/26 where R51 was found smoking crack cocaine in his room.)R51's physician orders include the following, in part: Opioid Medication Side Effects: Resident has no scheduled opioids. Due to risk/history of substance use, monitor for signs of possible opioid exposure or overdose. Monitor for: abdominal pain/distention, confusion, disorientation, hallucinations/delusions, dizziness/light-headedness, lethargy/increased sedation, agitation/anxiety, decreased responsiveness/unresponsiveness, decreased respirations. Notify: Nurse immediately; notify provider for any new or worsening symptoms or signs of overdose. Start Date: 4/7/26. This order is being signed out on R51's Treatment Administration Record (TAR) each shift.Of note: Cocaine is a stimulant drug and would require different monitoring for side effects and overdose than an opioid medication.R51's Certified Nursing Assistant (CNA) Care Plan/Kardex, as of 5/7/26, indicates the following, in part: . Resident Care: . Encourage frequent contact with family and friends that are supportive of resident's recovery and do not encourage substance use, as desired by the resident. Monitor for signs and symptoms of a potential drug overdose. Administer Narcan per facility protocol. Safety: . Allow resident to smoke independently in designated areas. Increase monitoring and supervision of resident and their visitors. Resident not to have cigarettes or smoking material on person.(Of note: despite R51 having a history of THC use, this is the first time the facility has addressed R51's substance use. R51's care plan indicates Increase monitoring and supervision of resident and their visitors, but it does not indicate what type of increased monitoring or supervision such as what staff are to be doing or what this is to consist of.)On 4/8/26 at 9:53 AM, R51's Interdisciplinary Team (IDT) review states in part: Reason for Review: Unwitnessed fall outside of building. Resident is known to use substance abuse (sic).On 4/13/26 at 4:56 PM, R51's physician communication note indicates: Response: Patient meets criteria for substance use disorder.On 5/3/16 at 1:36 PM, R51's progress note states in part: . Still goes out with family at least once a month to go to bank. Staff to ask/monitor if he did any smoking or other meds/drugs while out.Of note, a review of the Resident Sign In/Sign Out sheets located at the front desk of the facility, indicated that R51 signs himself out of the facility approximately 1-2 times per month.On 5/6/26 at 8:42 AM, Surveyor interviewed R51 about his smoking. R51 stated that he quit smoking cigarettes years ago but that he smokes the occasional cigar. Surveyor asked R51 if he ever smoked in his room. R51 stated that a couple of weeks ago he was smoking an illegal substance in his room. R51 did not indicate what the illegal substance was but stated that he smoked it in a pipe and that he got the materials while he was out with family.On 5/6/26 at 10:11 AM, Surveyor interviewed CNA F (Certified Nursing Assistant) and asked what monitoring was being done for R51. CNA F stated she wasn't sure, since she usually works night shift. Surveyor asked CNA F if she had received any education recently on smoking and illegal substance use. CNA F stated yes that she did some online training a month or two ago.On 5/6/26 at 10:13 AM, Surveyor interviewed CNA G and asked what monitoring was being done for R51. CNA G stated that she makes sure he has proper footwear, and his call light is within reach. Surveyor asked CNA G if she had received any education recently on smoking and illegal substance use. CNA G stated yes that she had received training within the last 30 days.On 5/6/26 at 10:15 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) and asked what monitoring was being done for R51. LPN C stated that when R51 is out of his room, she makes sure that he is using his cane. LPN C stated that when R51 leaves she is also making sure that he doesn't bring any illegal substances back to the facility with him. Surveyor asked LPN C if she had any knowledge of R51 smoking in his room. LPN C stated she saw the pipe on his table on PM shift the day he was out, but she didn't know what it was, otherwise she would have done something about it.On 5/6/26 at 1:35 PM, Surveyor interviewed MD T (Medical Director) about the incident of R51 smoking an illegal substance in his room. MD T stated that the facility had informed her that R51 came back from visiting family on Easter and the nurses reported that he had smoked crack while out with family. MD T indicated that she had never been informed that R51 was smoking in his room. MD T stated that the opioid monitoring was not something that she ordered, but that it was something initiated by the nursing staff. MD T stated that the facility might have put the opioid monitoring in place just for R51's safety, however they should be monitoring for signs of cocaine use. MD T indicated that administering Narcan for a cocaine overdose would not be appropriate.On 5/6/26 at 2:07 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked what they are doing to keep R51 and the other residents safe. NHA A stated that they have updated R51's care plan while being respectful of his resident rights. NHA A indicated that when R51 returns from being out of the facility they ask him if he needs to turn in anything on his person. NHA A stated that he had R51 re-sign the smoking policy and that materials need to be turned in and stored appropriately. NHA A indicated that he discussed with R51 that illicit substances are not allowed in the building.On 5/6/26 at 3:00 PM, Surveyor interviewed CNA H (Certified Nursing Assistant) via telephone. CNA H said she walked into R51's room at around 7:30 PM because his call light was on and she saw him with a pipe in his hand. CNA H stated she asked R51 what it was, and he told her he was smoking crack from it. CNA H stated that she went and told LPN J (Licensed Practical Nurse). CNA H stated that LPN J went to R51's room and supposedly took all of his crack material. However, at about 8:00 PM, CNA H said that her and CNA I went to R51's room again to get his roommate ready for bed, and the resident must have had more stuff, because he was smoking the pipe again. CNA H stated that R51 asked her and CNA I if they wanted to smoke crack with him. CNA H stated they both said no and again she went and told LPN J. Surveyor asked CNA H what monitoring was being done for R51. CNA stated that she wasn't sure, as she had not worked on R51's hall since the incident. Surveyor asked CNA H if she had received any education on smoking and illegal substance use. CNA H stated yes, they had a whole folder of education they had to read on that.On 5/6/26 at 3:07 PM, Surveyor interviewed CNA I via telephone. CNA I stated that she went to R51's room with CNA H to get his roommate ready for bed, and while in the room she saw a grey silverish container with white crumbs on it. R51 told her it was coke but she has never seen coke so she couldn't say if it was or not. CNA I stated that she did not see R51 actually smoking the pipe. CNA I indicated that R51 ask CNA H if she wanted to smoke crack with him, but that R51 did not ask her that question. CNA I stated R51 was looking directly at CNA H when he said that, so she assumed he was asking CNA H. Surveyor asked CNA I what monitoring was being done for R51. CNA I stated that they are to tell the charge nurse if they see R51 smoking in his room again. Surveyor asked CNA I if she had received any education on smoking and illegal substance use. CNA I stated yes, they had been given a paper to read and sign.On 5/6/26 at 3:11 PM, Surveyor interviewed LPN J (Licensed Practical Nurse) via telephone. LPN J stated that R51 had came back from somewhere with his family and he was sitting in his room when the two CNAs went in to get his roommate ready for bed and R51 told them he was smoking his crack pipe. LPN J said it was CNA H who came and told her that R51 was smoking crack in his room. LPN J stated that she saw R51 had a little black tin that was full of little white chunks that looked like crystals and he had a beaker looking thing and a hard glasses case that he kept the beaker thing in. LPN J stated that she asked R51 what he was doing, and he said, Apparently you already know. LPN J stated she left the room and immediately called DON B (Director of Nursing). LPN J stated that DON B told her to go to R51's room and confiscate all the stuff. LPN J stated that when she went back into R51's room, the black tin was empty and everything magically disappeared. LPN J indicated that she saw R51 shoving things in his shoes and in his pants. LPN J was unsure if those were the crystals and the beaker. LPN J stated the only thing that R51 gave her was a little cleaning tool like a tiny ice pick and some tobacco rolling papers, which had nothing to do with what she actually saw earlier. LPN J stated she didn't know what happened to the tin, pipe or crystals. LPN J stated she then called DON B back and told her that R51 had made everything disappear. LPN J stated that DON B told her that she needed to go back and find everything. LPN J stated she then took an agency nurse with her back to R51's room, but that they couldn't find anything. LPN J could not recall the agency nurse's name. LPN J stated that she couldn't remember if R51 was smoking in his room once or twice that night. LPN J stated that DON B didn't call the police until the next day because she couldn't find anything. Surveyor asked LPN J how she ensured R51's and the other resident's safety. LPN J stated that she confiscated what she could that could be considered dangerous. Surveyor asked LPN J what monitoring was being done with R51 since this incident. LPN J stated that she thought they added something to R51's care plan, but she wasn't sure what. Surveyor asked LPN J if she had received any education on smoking and illegal substance use. LPN J stated she had received education, but it was mostly just related to smoking.On 5/6/26 at 4:06 PM, Surveyor interviewed RN K (Registered Nurse) and asked her what monitoring was being done for R51. RN K checked R51's TAR and stated that R51 has diabetic foot checks, pain checks, and monitoring for opioid side effects. Surveyor asked RN K if opioid monitoring would be the same as monitoring someone for crack cocaine use. RN K stated no, that if someone was using crack she would check for changes in behavior, restlessness, dilated pupils and slurred speech. Surveyor asked RN K if she had received any education on smoking and illegal substance use. RN K stated yes, they had recently gone over that.On 5/6/26 at 4:17 PM, Surveyor interviewed CNA L and asked her what monitoring was being done for R51. CNA L stated that she monitors R51 when he is up and walking and asks him hourly if he needs anything. Surveyor asked CNA L if she had received any education on smoking and illegal substance use. CNA L stated no, she had not received any education on that recently.On 5/6/26 at 4:19 PM, Surveyor interviewed CNA M and asked her what monitoring was being done for R51. CNA M stated she was monitoring every hour to make sure R51 was not self-transferring. Surveyor asked CNA M if she had received any education on smoking and illegal substance use. CNA M stated no, she had not received any education recently. On 5/6/26 at 4:21 PM, Surveyor interviewed CNA N and asked her what monitoring was being done for R51. CNA N stated that R51 is not supposed to be ambulating by himself, so she makes sure to check on him every hour. Surveyor asked CNA N if she had received any education on smoking and illegal substance use. CNA N stated yes, on smoking a couple weeks ago.On 5/6/26 at 5:03 PM, Surveyor interviewed RN K and asked her if Narcan would be effective for someone using cocaine. RN K stated it couldn't hurt, as it could save someone's life who needed it and only make them feel crappy if they received it and didn't need it. Surveyor asked RN K how often R51 left the facility with family. RN K stated that R51 left the facility with family frequently, at least weekly. RN K indicated that sometimes R51 leaves the facility and forgets to sign out the book at the front desk.On 5/6/26 at 5:05 PM, Surveyor interviewed CNA N and asked her how often R51 left the facility with family. CNA N stated she would say it was at least once per week. On 5/7/26 at 7:44 AM, Surveyor interviewed NHA A and asked him if he was aware that R51 had admitted to the facility with prior use of illegal substances. NHA A stated he did not believe that staff were aware of that.On 5/7/26 at 8:41 AM, Surveyor interviewed NHA A and asked him why R51 had been ordered Narcan. NHA A stated that Narcan was ordered for R51 due to his substance use and to be proactive because he may use other substances that Narcan would be effective for.On 5/7/26 at 8:45 AM, Surveyor interviewed LPN C and asked her how often R51 left the facility with family. LPN C stated that R51 goes out with family at least twice per month, sometimes more often.On 5/7/26 at 8:49 AM, Surveyor interviewed RN O and asked her what she would be monitoring for someone who was using cocaine. RN O stated she would look for pinpoint pupils, euphoria, lethargy, hallucinating or delusions. Surveyor asked RN O if she would use Narcan for someone using cocaine. RN O stated yes, she would use Narcan if she suspected a resident had used drugs. Surveyor asked RN O if Narcan would be effective for someone using cocaine. RN O stated she had never administered Narcan, so she couldn't really tell whether it would be effective or not. Surveyor asked RN O if she had received education on smoking and illegal substance use. RN O stated yes, she had received training on both of these recently.On 5/7/26 at 8:54 AM, Surveyor interviewed CNA P and asked her how often R51 leaves the facility with family. CNA P stated that R51 leaves the facility at least once a week for sure. Surveyor asked CNA P what monitoring was being done for R51. CNA P stated that they check on him every hour to see if he needs anything and to make sure he is not getting up by himself. Surveyor asked CNA P if she had received any education on smoking and illegal substance use. CNA P stated yes, she had received education on smoking.On 5/7/26 at 10:30 AM, Surveyor interviewed R51 about smoking in the building. R51 confirmed that he had smoked crack cocaine once in his bathroom at the facility, and then the rest he went outside to smoke later on that same night in the smoking area on the facility premises. R51 stated that the police came the next day, but he couldn't remember what the officer said to him.A police report dated 4/6/26 at 12:30 PM was provided to Surveyor by the [NAME] County Police Department, which states, in part: A resident reported he was smoking crack cocaine. Said he got it while he was out with his nephew. PD Q (Police Deputy) responded to the call on 4/6/26 at 12:52 PM. [Resident Name] went to [location] in [town] with his nephew. [Resident Name] paid $50 for a bag of crack cocaine. [Resident Name] said he smoked some yesterday and flushed the rest this morning. When I told [Resident Name] not to buy more crack, [Resident Name] said, 'I probably will'.On 5/7/26 at 11:05 AM, Surveyor interviewed PD Q who stated that he was called to the facility and made contact with R51 on 4/6/26. PD Q stated that R51 told him he said he paid $50 for a bag of crack cocaine while out with family. PD Q indicated that R51 claimed to have smoked some of it and flushed the rest of it down the toilet that morning. PD Q stated there was no illegal substance or paraphernalia when he came to the building. PD Q stated that R51 told him that he smokes crack pretty often while out with family and that he was very clear that he would do it again. PD Q stated that he didn't file a report because he didn't find any evidence of drugs at that point. PD Q stated that there were other substances found in his room including weed wax melt and a THC wafer that was confiscated by nursing home staff and disposed of. PD Q stated that he spoke with SS R (Social Services) who said that he confiscated those materials and had already destroyed them before PD Q arrived at the facility.(Of note: Weed wax melts can be highly concentrated form of cannabis (THC) used for dabbing and vaporization and a THC wafer is a wafer tablet that's fast-disintegrating and contains cannabis extract.)On 5/7/26 at 11:20 AM, Surveyor interviewed SS R about R51's possession of illegal substances and smoking in his room. SS R stated that he helped create the education that was provided to all staff, and that he was the one who contacted law enforcement. SS R indicated that when PD Q arrived at the facility, he escorted him to R51's room, where PD Q interviewed R51 privately. SS R stated that he was not present when PD Q searched R51's room, but PD Q told him that he did not find anything. Surveyor asked SS R about finding a weed wax melt and THC wafer in R51's room. SS R stated that he was not involved with the search of R51's room, and that he was under the understanding that everything had been turned into the nurse the night before. SS R stated that it was NHA A (Nursing Home Administrator) who searched R51's room. On 5/7/26 at 11:24 AM, Surveyor interviewed NHA A (Nursing Home Administrator) about the incident involving R51's possession of illegal substances and smoking in his room. NHA A stated that he went to R51's room and found an Altoids container and a glove, and that the Altoids container was empty but that it was wet and looked like it had been washed out. NHA A stated that he gave those materials to PD Q. NHA A stated that PD Q went down to R51's room, but that he was not present when PD Q searched R51's room. Surveyor asked NHA A why the police hadn't been contacted sooner. NHA A stated that he couldn't speak to that but, that [Town name] does not have their own police department and that [NAME] County is only in [Town name] on certain days. Surveyor asked NHA A about the weed wax melt and THC wafer. NHA A stated that he didn't confiscate anything else from R51's room but the Altoid's container and glove and had no knowledge of a weed wax melt and TCH wafer being found in R51's room. The failure to provide adequate supervision and protect residents from R51 smoking an illegal substance in the facility created a reasonable likelihood for serious harm, which created a finding of immediate jeopardy. The facility removed the jeopardy on 5/7/26 when it completed the following:Identified Resident continues to reside at the facility. Identified Resident. had his smoking materials removed from the room, Sound Physicians on call service updated, PCP (primary care provider) updated, CP (care plan) reviewed, behavioral contract completed, COC completed, Psychosocial evaluation recompleted, nicotine assessment completed, smoking acknowledgement form recompleted, Police contacted, recent behaviors reviewed for changes, recent progress notes reviewed for changes, monitoring orders placed, opioid care plan and hx/o substance use CP with interventions and monitoring, Dx updated. Started on 4/6/26.Current residents who have a hx/o (history of) substance use disorder and residents that smoke have the potential to be affected. Residents identified to smoke had new smoking acknowledgement forms completed which include re-education on not smoking in their rooms and a Nicotine assessment recompleted to ensure safe smoking. An ongoing audit was initiated on 4/7/26 to observe for safe smoking practices and no smoking materials in rooms. Residents identified to have a hx/o substance use disorder had their care plan revised to include monitor for s/sx of opioid overdose and stimulant use.Education/Training:Residents identified to smoke were re-educated on not smoking in their rooms and safe smoking practices, and storage of materials. This was completed on 4/6/26 with

Based on interview and record review, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 2 residents (R43) reviewed for transportation for medical appointments. R43 had a medical appointment scheduled for 5/4/26 and the facility failed to arrange transportation. Evidenced by: The facility does not have a transportation policy. R43 was admitted to the facility on [DATE] with diagnoses that include cognitive communication deficit (a condition where cognitive impairments disrupt a person's ability to communicate effectively, despite intact language or speech abilities), cirrhosis of liver (a complication of long-term inflammation of the liver. It results in the replacement of healthy liver tissue with scar tissue, called fibrosis), alcohol abuse, and hepatitis C (a liver disease caused by the hepatitis C virus).R43's most recent MDS (Minimum Data Set) dated 4/30/36 states that R43 has a BIMS (Brief Interview of Mental Status) of 14 out of 15, indicating that R43 is cognitively intact.On 5/5/26 at 10:23 AM, Surveyor interviewed R43. R43 reported that they were supposed to have a medical appointment yesterday (5/4/26) and their ride never showed up. Surveyor observed a sticky note on R43's bedside table that stated 5/4 at 10:45 [Facility Name] general surgery consult [City Name, Physician's Name]. R43 reported to Surveyor that they threatened to leave the facility after they failed to set up transportation to their appointment.Surveyor requested a list of all appointments from 5/1/26-5/6/26. The list provided stated that R43 had an appointment on 5/4/26 at 10:45 AM and states was missed due to not having transportation, [Transportation Company's Name] was contacted and did not respond.On 5/6/26 at 4:24 PM, Surveyor interviewed Scheduler V. Surveyor asked Scheduler V what the process is for scheduling transportation for appointments, Scheduler V stated that depending on their insurance, they call different transportation companies to arrange transportation. Surveyor asked Scheduler V what type of transportation had been arranged for R43's appointment on 5/4/26, Scheduler V stated they had gotten ahold of [Transportation Company Name] and they were unable to do it, and the other transportation company cannot provide transportation on Mondays. Surveyor asked Scheduler V if the facility has a transportation van, Scheduler V stated yes but if a resident does not have Medicaid, the facility will not get reimbursed for the ride. Surveyor asked Scheduler V what type of insurance R43 had, Scheduler V stated R43 had Medicaid pending. Surveyor asked Scheduler V when they were made aware that R43 did not have transportation to their appointment, Scheduler V stated Monday morning. Surveyor asked Scheduler V if they had tried to schedule R43 with another transportation company, Scheduler V stated no. Scheduler V reported to Surveyor that the facility's transportation van was recently in the shop for repairs.On 5/7/26 at 9:00 AM, Surveyor interviewed BOM W (Business Office Manager). Surveyor asked BOM W what R43's payor source was on admission, BOM W stated that it was Medicaid pending. Surveyor asked BOM W if Medicaid will back date and cover costs incurred, BOM W stated yes. Surveyor asked BOM W if Medicaid would cover the cost of transportation to appointments, BOM W stated yes. Surveyor asked BOM W what happens when a resident needs transportation to an appointment and doesn't have a payor source, BOM W stated that the facility will set the resident up with transportation and the facility will absorb the cost or the resident will pay privately, and then when Medicaid is approved, the facility can bill for the transportation. On 5/7/26 at 9:32 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A what the expectation is for scheduling transportation for residents' appointments, NHA A stated that they should be scheduled timely and that the facility should be following up with the transportation company. Surveyor asked NHA A when the facility's transportation van had gotten out of the shop, NHA A reported that they weren't sure but would look into it. Surveyor asked if R43 should have been taken to their appointment using the facility's transportation van, NHA A stated that they were not sure when R43's payor source was approved.It is important to note that NHA A provided surveyor with an email stating that the facility's transportation van was in the shop from 4/16/26- 4/30/26.

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 2 of 5 Residents (R68 & R6) reviewed for notification of change in condition. On 10/26/25, R68 had a BP (Blood Pressure) of 68/52, was feeling dizzy and lightheaded. Throughout the night R68 had BPs readings of 80/40, 89/56, and 94/58. The next morning on 10/27/25 at 9:15 AM, R68 had a fall. The facility did not notify physician of change in condition throughout the night. On 3/5/26, the facility sent an e-Interact communication to the provider of R6's change of condition. The facility did not follow up with the provider regarding the change of condition to get any new orders or monitoring recommendations for R6 for several hours, after the change of condition was noted. This is evidenced by: The facility's policy, entitled Change in Condition of the Resident, dated 9/20/22, states, in part: . Policy: A facility should immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Policy Explanation and Compliance Guidelines: When a resident presents with a possible change of condition, after a fall or other possible injury, trauma, or noted changes in mental or physical functioning: . 3. Notify resident's physician- Use INTERACT Change in Condition: When to report to the MD (medical doctor)/NP (nurse practitioner)/PA (physician assistant) as a guideline. a. Immediate notification: Immediate notification for any symptom, sign or apparent discomfort that is: i. Acute or sudden in onset, and: ii. A marked change (i.e., more severe) in relation to usual symptoms and signs, or iii. Unrelieved by measures already prescribed requires a phone call to the provider. Do not fax for issues requiring immediate notification. DOCUMENTATION: Documentation needs to include, but is not limited to the following: 1. Description of change in condition noted and assessment or observation of findings. 3. Notification of provider- include date, time, what was conveyed, any orders received. INTERACT: VITAL SIGNS BP (blood pressure): Report Immediately: Systolic BP>200mmHg (milliliters of mercury high column of mercury) or <90 mmHg. Example 1: R68 admitted to the facility on [DATE] and has diagnoses that include displaced trimalleolar fracture of right lower leg (fracture of lower leg sections that form your ankle joint), hypertensive heart disease with heart failure (occurs when long term unmanaged high blood pressure forces the heart to work too hard causing the muscle to thicken and eventually become weak) and chronic atrial fibrillation (heart arrhythmia characterized by an irregular, often rapid heart caused by chaotic electrical signals in the heart's upper chambers). R68's Physicians Orders, dated for 10/01/25- 10/31/25 includes: *Blood Pressure parameter: update MD if systolic BP >160 or diastolic BP<60. 10/28/25. *Diuretics- Observe for the following: . hypotension. If any symptoms observed, document in progress note and notify physician. *Furosemide. 80 mg. two times a day. for systolic heart failure. *Lisinopril 20 mg twice a day. for hypertension. *Metoprolol Succinate ER. 12.5mg daily for rate control in atrial fibrillation *Ramipril 10 mg two times a day for hypertension R68's BP readings are as follows: 10/26/25 8:21 PM BP - 68/52 10/26/25 9:00 PM BP - 80/40 10/26/25 10:00 PM BP - 89/56 10/26/25 11:00 PM BP - 94/58 10/27/25 12:05 AM BP - 104/64 10/27/25 9:15 AM BP - 68/40 Of Note- There are 4 BPs obtained with the systolic under 90. According to INTERACT (facility standard of practice) the physician should have been notified immediately and not by fax. R68's Progress Notes include: On 10/24/25 at 1:43 PM, Note Text- R68 returned from an ortho (orthopedic) appointment yesterday. Weight bearing as tolerated in cast. had a syncopal episode while being casted. A medical emergency was called. R68 was evaluated by code team and found to be hypotensive. On 10/26/25 at 8:40 PM, Note Text: Resident feeling dizzy and lightheaded. Says he saw black. Nurse took BP 68/52. RN notified and she will assess. On 10/26/25 at 9:04 PM, Note Text: LPN (licensed practical nurse) reports BP of 68/52 pulse 67. Resident had been up in wheelchair since 4:00 PM with visitors. He states that this is longer time than he is used to being out of bed. While waiting to be put back in bed he complained of feeling lightheaded and started seeing black. He said that when put back into bed he instantly felt better, and LPN took his BP. He states that he did not lose consciousness. Resident is alert and oriented x 4. He answers questions appropriately. HOB (head of bed) is elevated. Skin is warm, dry, pink. Respirations are 18, regular with no accessory muscle use. O2 94% on room air. Manual BP at 9:00PM 80/40 with heart rate 70 and irregular. (History of A-fib). Resident states that he has been drinking fluids (including soda) throughout the day. (chart shows 720 mLs (milliliters) as of noon) . His medications include Lasix 80 mg (milligrams) twice a day, lisinopril, metoprolol succinate. Will continue to monitor. On 10/27/25 at 4:06 AM, Note Text: Resident was checked on by staff and vital signs taken 10:00 PM and 11:00 PM. Vital signs taken at 12:00 AM after resident used the bedpan were 104/64 heart rate 72 and irregular. Notes faxed to PCP (primary care physician). On 10/27/25 at 9:15 AM, SBAR (Situation, Background, Assessment and Response)-Change of Condition. Called to R68's room by CNA (certified nursing assistant) stating that R68 is on the floor. Assessment.: .R68 was sitting on his buttock with legs straight out in front of him. CNA and PT (Physical Therapy) stated they attempted to stand R68 with gait belt and walker from a sitting position on his bed and when he started to stand, his right leg (casted) started sliding and R68 was lowered to the floor. R68 stated that he felt dizzy and lightheaded while sitting on the floor. BP noted to be very weak and low at 70/46. Recommendations: Send R68 via ambulance to ER (emergency room) for evaluation. Surveyor asked NHA A (Nursing Home Administrator) for documentation of the actual time fax was sent to PCP regarding R68's low BPs on 10/26/25 and 10/27/25. NHA A provided the following documentation from clinic: Encounter Date: 10/27/25. Received a fax from [NAME] Health Services: On 10/27/25 at 4:06 AM, Resident was checked on by staff and vital signs taken 10:00 PM and 11:00 PM. Vital signs taken at 12:00 AM after resident used the bedpan were 104/64 heart rate 72 and irregular. Notes faxed to PCP (primary care physician). On 10/26/25 at 9:04 PM, LPN reports BP of 66/52 pulse 67. Resident had been up in wheelchair since 4:00 PM with visitors. He states that this is longer time than he is used to being out of bed. While waiting to be put back in bed he complained of feeling lightheaded and started seeing black. He said that when put back into bed he instantly felt better, and LPN took his BP. He states that he did not lose consciousness. Resident is alert and oriented x 4. He answers questions appropriately. HOB (head of bed) is elevated. Skin is warm, dry, pink. Respirations are 18, regular with no accessory muscle use. O2 94% on room air. Manual BP at 9:00PM 80/40 with heart rate 70 and irregular. (History of A-fib). Resident states that he has been drinking fluids (including soda) throughout the day. (chart shows 720mLs (milliliters) as of noon) . His medications include Lasix 80 mg (milligrams) twice a day, lisinopril, metoprolol succinate. Will continue to monitor. Fax from NP, dated 10/27/25 at 9:15 AM, states, in part: . Reduce furosemide from 80 mg twice a day to 40 mg twice a day due to hypotension. On 5/6/26 at 11:21 AM, Surveyor interviewed ADON U (Assistant Director of Nursing) and asked if ADON U could recall back in November working with R68. Surveyor reviewed R68's progress notes with ADON U. Surveyor asked if ADON U had notified the physician on R68's BP of 68/52, lightheadedness, and seeing black on 10/26/25. ADON U indicated no. ADON U indicated she had informed the charge RN and that RN assessed R68. ADON U indicated she is unable to see a progress note indicating the physician was notified. Surveyor asked ADON U if a BP of 68/52 would be considered a change of condition that would need to be reported to the physician. ADON U indicated yes, it is reportable. ADON U indicated the facility uses eINTERACT for standards of practice and follows the parameters for vital signs in eINTERACT. Surveyor asked ADON U if R68's BP of 68/52 should have been reported to the physician. ADON U indicated yes, the nursing staff have been taught on off hours and weekends for a change of condition, the nursing staff are to use the Sound Physician, which is a tele visit where we interact with the physician by video. ADON U informed Surveyor to check with NHA A as he is able to run a Sounds Report for physician updates. On 5/6/26 at 12:04 PM, Surveyor asked NHA A for documentation to verify actual time physician notification occurred for R68's low BP. NHA A did provide the documentation. NHA A indicated the facility would have expected the MD to be notified immediately of R68's BP of 68/52, lightheadedness, and seeing black. NHA A indicated he would have expected a face-to-face notification over the Sounds iPad not by fax. On 5/6/26, at 1:24 PM, Surveyor interviewed MD T (Medical Doctor). Surveyor reviewed R68's change of condition with MD T starting with R68's ortho visit on 10/23/25 where he had a syncopal episode, and then a BP of 68/52, feeling lightheadedness, dizzy, and seeing black on 10/26/25 at 8:40 PM. On 10/26/25, at 9:00 PM R68 had a BP of 80/40. On 10/26/25, at 10:00 PM, R68 had a BP of 89/56. On 10/26/25, at 11:00 PM, R68 had a BP of 94/58. On 10/27/25, at 9:15 AM, R68 had a BP of 70/46 and a fall. MD T indicated with the event that had occurred during the ortho visit, MD T would think the facility would have been monitoring R68's BP. MD T indicated with a BP of 68/52 and the symptoms R68 was having, MD T would have expected a sounds physician notification. MD T indicated she would have expected some change to be made. MD T indicated the low BPs from the syncopal episode to the BP checks up to the fall would have warranted a call and a change to be made or sent to the ER. On 5/7/26, at 3:01 PM, Surveyor interviewed VPS E (Vice President of Success) who indicated she would have expected a physician notification immediately with a BP of 68/52, lightheadedness, dizzy and seeing black. VPS E indicated the facility uses INTERACT for standards of practice. VPS E indicated a fax at 4:06 AM is unacceptable. Example 2: R6 was admitted to the facility on [DATE] with diagnosis that include, in part: Chronic Obstructive Pulmonary Disease (COPD), Acute and Chronic Respiratory Failure with Hypoxia (a medical condition where tissues or organs in the body do not receive enough oxygen to function properly), Acute and Chronic Respiratory Failure with Hypercapnia (a medical condition defined by abnormally elevated levels of carbon dioxide in the bloodstream), Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Dependence on Supplemental Oxygen, Weakness, Other Diseases of Bronchus not elsewhere classified, and Personal History of Covid-19. R6's most recent Minimum Data Set (MDS) indicates R6 has a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R6 is cognitively intact. R6's Comprehensive Care Plan states, in part: .Focus: Has/At risk for respiratory impairment related to COPD. Date Initiated: 3/2/21. Goal: Will have no acute respiratory distress. Date Initiated: 3/2/21. Revision on: 2/12/26. Interventions: Administer oxygen per MD orders: Oxygen 1-4 Liters per nc (nasal canula) to keep O2 sats > than 88%. Currently on 2L/min (2 liters per minute) continuous (oxygen) via nasal canula. Date Initiated: 6/1/23. Revision on: 3/19/26. Obtain pulse oximetry and report abnormal findings. Date Initiated: 3/2/21. A review of R6's EHR (electronic health record) include the following progress notes: On 3/5/26 at 6:40 AM, The Change in Condition reported on this CIC Evaluation are: Altered Mental Status, unresponsiveness, tired, weak, confused or drowsy. Nursing observations, evaluation, and recommendations are: She was sleeping harder than usual and only arousable by this writer. Lung sounds were clear earlier in my shift vs (versus) what is being reported now by AM shift. She was a no void on NOC's (overnight) which was not reported to this writer on the shift. No coughing noted, very dry mouth observed. Recommendations: fax was sent per DON (Director of Nursing) notification. On 3/5/26 at 9:24 AM, Patient is hard to arouse, unable to take pills. Charge nurse is aware and monitoring patient. On 3/5/26 at 10:35 AM, Patient is hard to arouse, unable to take pills. Charge nurse is aware and monitoring patient. On 3/5/26 at 10:48 AM, Spoke with PA X (Physician Assistant) regarding resident's condition and she gave the order: CBC (Complete Blood Count lab that measures the cells in a person's blood) and CMP (Complete Metabolic Panel lab test used to determine overall health) today if no clinical improvement by noon. Labs have been drawn and will be sent to lab for processing. Awaiting results. On 3/5/26 at 1:05 PM, PA X in house to see resident with this writer and upon her assessment and her reviewing lab results gave the verbal order to send resident via ambulance to hospital. Resident was changed to a nonrebreather (mask) on 5 liters and oxygen did finally come up to 87%. Resident still very slow to respond without physical manipulation. Ambulance was called, ER called and son [Name] updated and he will be going to meet her at the hospital. On 3/5/26 at 1:35 PM, Resident left via ambulance at this time. R6's hospital Discharge summary, dated [DATE], states the following, in part: . Principal Diagnosis: Acute on chronic respiratory failure with hypoxia.Active Hospital Problems: Acute on chronic respiratory failure with hypoxia, Hypercapnic respiratory failure, Acute kidney injury, COPD, Chronic diastolic heart failure, metabolic encephalopathy, Stage 3b Chronic kidney disease. Summary of admission: . Patient is somnolent, awakens to voice and denies pain but otherwise doesn't participate in history. Per report pt (patient) was less alert last night and then worse this morning. Minimal intake this morning and no urine output overnight or this morning. Her oxygen levels were noted to be 80% on 4 L (liters) and was started on a nonrebreather, subsequently put on BiPAP for a few hours which was removed prior to transport. Hospital Course: [Resident Name] was admitted with acute on chronic hypercapnic respiratory failure, metabolic encephalopathy and AKI (Acute Kidney Injury). CXR (chest x-ray) and BNP (B-type natriuretic peptide test to determine heart failure) suggested fluid overload. She was placed on BIPAP (Bilevel Positive Airway Pressure machines - noninvasive ventilators used to treat breathing difficulties) and given IV diuretics. IV antibiotics were started for concern of possible CAP (community acquired pneumonia). It was felt that her confusion was likely multifactorial including the hypercapnia, high dosed Seroquel, and AKI. On 5/7/26 at 2:39 PM, Surveyor interviewed RN Y (Registered Nurse) about resident changes in condition. RN Y stated a change in condition would include if a resident was not eating, restless, a change in vital signs, a fever, or changes in behavior. Surveyor asked RN Y how she would notify the physician of a change in condition. RN Y stated that she was instructed to use the Sounds communication system on the computer, but personally she would try to call the physician. On 5/7/26 at 2:42 PM, Surveyor interviewed RN Z about resident changes in condition. RN Z stated that a change of condition would be fatigue, changes in mentation, and vital signs out of parameter. Surveyor asked RN Z how she would notify the physician of a change in condition. RN Z stated she would call the physician and also contact her supervisor. On 5/7/26 at 2:47 PM, Surveyor interviewed LPN AA (Licensed Practical Nurse) about resident changes in condition. LPN AA stated that a change of condition would be anything out of the normal. Surveyor asked LPN AA how she would notify the physician of a change in condition. LPN AA stated she would call them if she felt like it was a situation that couldn't be waited on. On 5/7/26 at 2:51 PM, Surveyor interviewed RN O about R6's change in condition. RN O stated that the CNA (Certified Nursing Assistant) had called her to R6's room and when she went in to assess her, she noted that R6 was difficult to rouse and had taken her oxygen tubing off. RN O stated that she replaced the oxygen on R6 and took her pulse oximetry, noting that R6's O2 sats were in the mid to low 80's range. RN O stated that PA X (Physician Assistant) was in the facility that day and told her to increase R6's oxygen liters to 4, which she did. RN O stated she gave R6 her nebulizer treatment which didn't help any, so PA X told her to get a nonrebreather mask for R6. RN O stated that R6's oxygen levels continued to go down, so PA X told her to send R6 out to the hospital. Surveyor asked RN O about physician notification for changes in condition. RN O stated that she used the e-Interact tool because that would give them a paper trail of notifying the provider. RN O indicated that if she felt it was an emergency, she would use her nursing judgment and send someone out before contacting the physician. On 5/7/26 at 2:52 PM, Surveyor interviewed LPN C about R6's change in condition. LPN C stated that R6 tends to take her oxygen off, and on that day, they couldn't get her oxygen level up and she was kind of out of it. LPN C stated that they increased R6's liters of oxygen, but PA X was in the facility and made the decision to send her out. On 5/7/26 at 2:57 PM, Surveyor interviewed PA X (Physician Assistant) and asked what her expectation for notification was if a resident has a change of condition. PA X stated that it would depend on the timeline, and if it was outside of office hours of 8:00 AM to 4:30 PM they would have had to use the Sounds (telehealth on call doc service). PA X stated that during office hours they could either contact the clinic or use Sounds. PA X indicated, however, that if someone was critical, she would expect the staff to use their nursing judgment to send them to the hospital without contacting the physician first. On 5/7/25 at 3:11 PM, Surveyor interviewed VPS E (Vice President of Success) about physician notification and R6's change in condition. VPS E stated that sending a fax to the physician would not be appropriate in that situation, and that the staff should have called the doctor to follow up.

Based on record review and interview the facility did not provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC); thus, did not provide the notice of Medicare services ending and the accurate potential financial liability to residents whose Medicare coverage was ending for 1 of 3 residents reviewed (R48).R48 was receiving Medicare A benefits. R48 was not provided with the NOMNC and SNFABN form thus not being provided with the accurate financial liability. Evidenced by:The facility's policy titled Advance Beneficiary Notice dated 5/12/25 states in part .5. To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The notices must nit be provided while the resident/ representative is under duress or in an emergency situation.R48's Medicare coverage ended on 4/22/26. R48 or their representative was not provided with a NOMNC or SNF ABN form. R48 was not informed of his entire potential liability and reason for ending of benefits prior to the benefits ending. Notice was provided to R48's representative on 4/27/26.On 5/5/26 at 3:51 PM, Surveyor interviewed MDS (Minimum Data Set) Coordinator D . Surveyor asked MDS Coordinator D what the process is for handing out beneficiary notices, MDS Coordinator D stated that they are provided to the resident or their representative two days prior to their last covered day. Surveyor asked MDS Coordinator D about R48's notices being late, MDS Coordinator D stated that R48's notices got missed and were not provided prior to their last covered day. Surveyor asked MDS Coordinator D if the notices should have been provided to R48's representative prior to 4/22/26, MDS Coordinator D 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 (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 16 sampled Residents (R7).R7 reported that facility staff do not assist with shaving, despite R7 having their own shaver. R7 noted to have approximately 1/4 facial hair on their chin.Evidenced by:The facility's policy titled Activities of Daily Living (ADLS) dated 7/26/22 states in part .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.R7 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder (a mental health condition characterized by significant mood swings, including manic (or hypomanic) episodes and depressive episodes), dementia, polyneuropathy (nerve disease caused by damage to many nerves, often due to conditions like diabetes or alcohol overuse), and radiculopathy (condition caused by the compression of a spinal nerve root, leading to symptoms such as pain, numbness, and tingling along the affected nerve).R7's most recent MDS (Minimum Data Set) dated 5/5/26 states that R7 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R7 is cognitively intact. R7's MDS also states that R7 is dependent on staff for showering/bathing and personal hygiene.R7's care plan dated 2/5/19 states in part .Focus: ADL self care deficit as evidenced by: related to: physical limitations, bipolar disorder, osteoarthritis, chronic pain to BLE (Bilateral Lower Extremities). Goal: Will be clean, dressed, and well groomed daily to promote dignity and psychosocial wellbeing. Interventions/Tasks: .Encourage and assist to shower or bathe as desired and as needed.It is important to note that neither R7's care plan nor R7's CNA (Certified Nursing Assistant) Kardex addresses R7's personal hygiene/grooming.On 5/7/26 at 12:39 AM, Surveyor interviewed R7. Surveyor noted that R7 had facial hair on their chin that was approximately 1/4 long. Surveyor asked R7 how they feel about having the whiskers on their chin, R7 stated that they don't like them and that they even have their own shaver on the dresser. Surveyor observed an electric shaver on R7's dresser. Surveyor asked R7 if they ask the staff to shave them, R7 stated yes, but if they forget to ask, staff doesn't do it.On 5/7/26 at 12:46 PM, Surveyor interviewed CNA S. Surveyor asked CNA S if they provided cares for R7 this morning, CNA S stated yes. Surveyor asked CNA S how often they shave R7, CNA S stated that they forget about it. Surveyor asked CNA S if they noticed R7's whiskers on their chin this morning, CNA S stated no and asked Surveyor if they are long. Surveyor reported that R7's facial hair is approximately 1/4 long.On 5/7/26 at 2:11 PM, Surveyor interviewed VPS E (Vice President of Success). Surveyor asked VPS E how often they would expect resident to be shaved, VPS E stated that for female residents, they want to consider their dignity and appearance and should shave residents accordingly. Surveyor asked VPS E if a resident asks to be shaved, should staff be completing that request, VPS E stated yes.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 39 opportunities that affected 2 out of 5 residents (R54 & R46) included in the medication pass task, which resulted in an error rate of 5.13%.R54's orders include levothyroxine daily at 5:30 AM. Staff administered R54's levothyroxine at 8:09 AM. Staff administered R54's levothyroxine and calcium at the same. Staff administered R54's levothyroxine at the wrong time and against manufacturer's directions not to administer with Calcium.Staff administered R46's levothyroxine at 7:46 AM. The order is to administer levothyroxine at 6:00 AM. Staff administered this medication late.Evidenced by:The facility policy entitled Medication Administration, dated 1/26, states, in part: . POLICY: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so.PROCEDURES: Medication Preparation: .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR (Medication Administration Record) with the medication label.Medication Administration:1. Medications are administered in accordance with written orders of the prescriber.3. The timing of medication administration must align with manufacturer specifications.14. routine medications are administered according to the established medication administration schedule for the nursing care center.Example 1:R54 was admitted to the facility on [DATE] and has diagnoses that include hypothyroidism (where an underactive thyroid gland fails to produce enough hormones, causing bodily functions to slow down) and age-related osteoporosis (a condition where bones lose density and strength causing fragile bones and a high fracture rate).R54's Comprehensive Minimum Data Set (MDS) Assessment, dated 5/5/26 shows R54 has a Brief Interview of Mental Status (BIMS) score of 12, indicating R54 has moderate cognitive impairment.R54's Physicians Orders, dated 5/06/26, states, in part: . Calcium 600 + D3 Oral Tablet 600-400 MG (Milligrams)- Unit (Calcium Carbonate-Cholecalciferol). Give 1 tablet by mouth in the morning for supplement. Start Date: 4/23/25.Levothyroxine Sodium Tablet 150 MCG (Micrograms). Give 1 tablet by mouth one time a day for low thyroid hormone. Start Date: 4/23/25.R54's May 2026 MAR, states, in part: . Calcium 600 +D3 Oral Tablet 600-400 MG-UNIT. Give 1 tablet by mouth in the morning for supplement at AM 7. Start Date: 4/23/25.Levothyroxine Sodium Tablet 150 MCG. Give 1 tablet by mouth one time a day for low thyroid hormone at 5:30AM. Start Date: 4/23/25.According to Mayo Clinic, https://www.mayoclinic.org, administering levothyroxine with calcium carbonate may cause an increased risk of certain side effects.According to drugs.com, https://www.drugs.com, levothyroxine and calcium carbonate should be administered 4 hours apart. Taking levothyroxine and calcium carbonate together can affect your thyroid level and make levothyroxine less effective.On 5/06/26 at 7:59 AM, Surveyor observed LPN C (Licensed Practical Nurse) administer R54's Levothyroxine 150 mcg and Calcium 600 +D3 600mg/400unit at the same time.On 5/16/26 at 10:10 AM, Surveyor interviewed LPN C. Surveyor asked when R54's levothyroxine should be given. LPN C indicated at 6:00 AM. Surveyor reviewed with LPN C that LPN C administered R54's levothyroxine and calcium at 8:09 AM. Surveyor asked if levothyroxine and calcium should be administered together. LPN C indicated no. Surveyor asked LPN C if R54 received her levothyroxine late. LPN C indicated yes, and LPN C indicated she did not get to R54 when she was supposed to. Example 2:R46 was admitted to the facility on [DATE] and has diagnoses that include hypothyroidism (where an underactive thyroid gland fails to produce enough hormones, causing bodily functions to slow down).R46's Quarterly Minimum Data Set (MDS) Assessment, dated 3/30/26 shows R46 has a Brief Interview of Mental Status (BIMS) score of 03, indicating R46 has severe cognitive impairment.R46's Physicians Orders, dated 5/06/26, states, in part: . Levothyroxine Sodium Tablet 75 MCG (micrograms). Give 1 tablet by mouth one time a day related to HYPOTHYROIDISM. Start Date: 7/22/20.R46's May 2026 MAR (Medication Administration Record) states, in part: . Levothyroxine Sodium Tablet 75 MCG. Give 1 tablet by mouth one time a day related to HYPOTHYROIDISM. at 06:00. Start Date: 7/22/20.On 5/6/26 at 7:46 AM, Surveyor observed LPN C administer R46's Levothyroxine 75 mcg.On 5/06/26 at 10:10 AM, Surveyor interviewed LPN C and asked what time R46's Levothyroxine is ordered to be administered. LPN C indicated 6:00 AM. LPN C indicated she administered R46's levothyroxine late. LPN C indicated there is an hour before and an hour after the ordered time that the medication can be administered. LPN C indicated if a medication is ordered on the MAR for AM, the nurse has from 6:00 AM until 10:00 AM to administer the medication. LPN C indicated she administered R46's levothyroxine late due to so much going on this morning.On 5/6/26 at 4:19 PM, Surveyor interviewed VPS E (Vice President of Success). Surveyor informed VPS E of observation of LPN C administering R54's levothyroxine with calcium at 8:09 AM. VPS E indicated levothyroxine, and calcium should not be administered together. VPS E indicated the levothyroxine administered late and with calcium would be a medication error. Surveyor informed VPS E of observation of LPN C administering R46's levothyroxine at 7:46 AM. VPS E indicated the medication was administered late and considered a medication error.

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents (R2). R2 had a fall on 5/29/25. PA D (Physician Assistant) ordered x-rays STAT (right away) due to complaints of pain to right wrist and right hip. X-rays did not get completed as ordered. R2 was shaking due to severe pain the next morning and was sent to the hospital. R2 was diagnosed with a fracture to the right hip and pelvis as well as avulsion (a small piece of bone pulled off the wrist bone, causing a small fracture) to right wrist. The facility's failure to get the x-rays completed STAT as ordered resulted in a delay in treatment for R2. Evidenced by: The facility policy entitled Change in Condition, dated 9/20/22, states, in part: . A facility should immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident's representative when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Policy Explanation and Compliance Guidelines: When a resident presents with a possible change in condition, after a fall or other possible injury, trauma, or noted changes in mental or physical functioning: 1. Assess the resident's need for immediate care/medical attention. Provide emergency care as needed . 2. Notify resident's physician-Use INTERACT Change in Condition: When to report to the MD (medical doctor), NP (nurse practitioner), PA as a guideline . R2 admitted to the facility on [DATE] and has diagnoses that include unilateral, primary osteoarthritis, left hip (type of arthritis that occurs when flexible tissue at the ends of bones wears down), personal history of (healed) traumatic fracture, and unspecified dementia. R2's Quarterly Minimum Data Set (MDS) Assessment, dated 5/10/25, shows R2 has a Brief Interview for Mental Status (BIMS) score of 8 indicating R2 has moderate cognitive impairment. R2's Care Plan, dated 7/10/23, states in part: . Focus: ADL (activities of daily living) self-care deficit as evidenced by need for staff assist r/t (related to) dementia. Date Initiated: 7/10/23. Revision on: 5/13/25 . Interventions/Tasks: *Ambulation/Locomotion: non-ambulatory at this time may stand/pivot transfer. Requires extensive assist of 1 staff for locomotion with w/c (wheelchair) at this time with wrist and hip fracture. Date Initiated: 7/10/23 Revision: 6/03/25 . *Transfer: Assist of 1-2 staff with CGA (contact guard assistance) to stand/pivot at this time. Date Initiated: 7/10/23 Revision on: 6/03/25 . At risk for complications due to musculosketal problems r/t fracture (R) wrist, (R) hip and T12 compression fracture. Date Initiated: 6/03/25 . *Provide assist of (specify level of assist) to transfer and reposition in bed. Date Initiated: 6/03/25 . R2's Un-Witnessed Fall Report, dated 5/29/25, at 3:40PM, states, in part: .Incident Description: . Resident found in hallway on floor, resident walked down hall holding onto side railing on wall with wheelchair down hallway in front of resident's room. Resident was seen by CNA (certified nursing assistant) fall forward hitting hand on side of railing onto floor with right arm under herself on her right side, resident fell onto right shoulder and placed right side of face on floor. Resident denied pain to right shoulder of [sic] face, c/o (complained of) pain to right wrist and right hip. PA D present during assessment. VS (vital signs) stable .ROM (range of motion) intact with some mild pain to right upper and lower extremities . Immediate Action Taken: Description: Resident assessed, VS stable, DON (director of nursing) aware of fall, PA D ordered X-ray images of Right wrist, pelvic and hip . Statements: CNA H. Relation: Ancillary Staff Date: 5/29/25 Statement: Seen resident walking down the hall holding on to side railing, went to get wheelchair (less than 50 feet away) and turned around, seen resident falling forward, hitting hand on side rail falling forward onto right shoulder and gently placing face on floor with fall . R2's Progress Notes are as follows: 5/29/25 3:40 PM Type: Clinical Follow Up Note Text: The current status is Fall due to resident self-transferring down hallway holding onto side railings. VS stable. ROM intact, mild pain with right wrist and right hip . PA D assessed resident at this time with orders for STAT x-ray of right wrist and pelvic and hip imaging . 5/29/25 3:59 PM Type: Communication-with Physician/Resident/Family/HPOA (healthcare power of attorney)/Guardian Note Text: Resident suffered from a fall. PA D here and gives orders as follows: -X-ray right wrist 3 views-STAT -X-ray pelvis and unilateral right hip-STAT Dx (diagnosis): Fall. 5/29/25 5:00 PM Type: Communication-with Physician/Resident/Family/HPOA/Guardian Note Text: This writer discussed with PA D in regard to STAT x-ray order. The company that provides the services may not be here till the next day. PA D hoped they would be here later in the evening but if not, monitor resident for signs of pain and send to hospital if needed. Important to note: Surveyor spoke with PA D and DON B and found DON B did not notify PA D that STAT X-rays were not completed until 5/30/25 when R2 was sent to ER (emergency room). 5/30/25 7:36 AM Type: SBAR (Situation, Background, Assessment and Response)-Change in Condition Situation: Called to R2's room by therapist stating that resident trying to get out of bed and in severe pain on right hip area and moderate to maximum assist for transfer. Background: S/p (status post) fall yesterday afternoon with MD order for x-rays of hip/pelvis and right wrist. Has not been done yet and probably not until after lunch. Assessment (RN: Registered Nurse)/Appearance (LPN: Licensed Practical Nurse): Resident shaking in pain, moderate to maximum assist of 2 for transfer. Resident c/o severe pain to right hip with some shortening of RLE (right lower extremity). Bruising noted to right wrist . Response: Call placed to PA D and son informing of change and that resident needs to be seen in ER. Recommendations: Send to ER via ambulance. Son will meet at the hospital. 5/30/25 7:40 AM Type: Clinical Follow Up Note Text: The current status is Resident c/o severe right hip/pelvic pain 10/10 and requiring moderate/maximum assist of 2 for transfer as she was attempting to get out of bed. Resident also c/o severe pain while sitting in w/c. Resident was scheduled to have mobile x-ray today but due to severe pain, sending to ER for evaluation at this time with son, POA meeting at the hospital . 5/30/25 11:14 AM Type: Communication- with Physician/Resident/Family/HPOA/Guardian Note Text: This writer placed a call to ER with them reporting that resident indeed has fracture to right hip and pelvis as well as evulsion to right wrist. Resident is going to be transferred [Hospital name] for surgery . R2's Hospital Discharge summary, dated [DATE], at 1:12 PM, states, in part: .Date of Admission 5/30/25. Date of discharge: [DATE] .Principal Diagnosis: Closed displaced fracture of right femoral neck .Major Procedures: right hip hemiarthroplasty 5/30/35 . Summary of admission Chief Complaint, History of Present Illness, Pertinent Exam, Lab & Radiology Studies: .The patient lives at a nursing home. Yesterday, she was ambulating and had a fall. There are limited details available regarding the fall itself. She was brought to the emergency department today due to worsening pain . She endorses pain, and points to her right hip when I ask if she has any pain .Hospital course: . She underwent surgical fixation of her right hip fracture with orthopedic surgery . A cock-up wrist splint was placed for her right triquetral avulsion fracture . On 7/1/25 at 11:15 AM, Surveyor interviewed PA D. PA D indicated to Surveyor she was in the facility at the time of R2's fall on 5/29/25. PA D indicated she assessed R2 with the facility staff. PA D had concerns about the right hip with the way R2 had fallen on her right side and complained of pain to right wrist. PA D indicated she had ordered x-rays to be completed STAT on the right hip, wrist, and pelvis. Surveyor asked if PA D was notified the x-rays were not completed 5/29/25 and PA D indicated she was not notified the x-rays were not completed until R2 was sent to the ER on [DATE]. PA D indicated she expected the x-rays to be completed that day on 5/29/25 since she ordered them STAT. Surveyor asked PA D if she would expect to be notified if the x-rays were not able to be completed that day and PA D indicated yes, she probably would have sent R2 to the ER if they were not able to be completed. PA D indicated she would expect all orders to be followed especially STAT orders. On 7/1/25 at 12:20 PM, Surveyor interviewed RN C (Registered Nurse) who indicated on the morning of 5/30/25, approximately 6:30 AM, RN C was called to R2's room. Therapy had been passing by R2's room and heard R2 screaming in pain and trying to get out of her bed. RN C indicated she had found out in that morning's report R2 had a fall the day before on 5/29/25 and was to get x-rays on that day (5/30/25). RN C indicated she was not going to wait for the x-rays that day, so RN C sent R2 to the ER. RN C indicated R2 was in so much pain. RN C indicated R2 had received Tylenol around 5:30AM due to so much pain that AM. Surveyor asked RN C if a STAT order for an x-ray is received and cannot be completed that day due to mobile imaging what is the process to follow. RN C indicated the facility would notify the MD and see if s/he wants the resident sent to ER or what s/he would like to do. On 7/1/25 at 3:11 PM, Surveyor interviewed CNA H who indicated she was working with R2 the day R2 had fallen. CNA H indicated at the time of the fall R2 complained of pain to her right wrist and hip. Surveyor asked CNA H if R2 was experiencing pain the rest of that evening after she had fallen. CNA H indicated R2 would not get out of her wheelchair the rest of that evening which was a big change for R2. CNA H indicated she had noticed R2 was shaking around 7:30-8:00 PM. CNA H asked R2 if she was in pain at that time but R2 just mumbled. CNA H indicated she reported it to the nurse. CNA H indicated at 9:00 PM R2 was really shaking more. Surveyor asked CNA H if R2 was in pain and CNA H indicated R2 was not getting out of wheelchair, R2 was not walking that evening, and R2 was shaking, she felt R2 was in pain. CNA H indicated R2 was not acting her baseline, and it was reported to the nurse. On 7/1/25 at 3:25 PM, Surveyor interviewed DON B and asked what the facility's process is for receiving and completing STAT imaging orders. DON B indicated they go through a mobile imaging service. Once we receive orders for imaging we notify the company's dispatch service and notify them of the order being routine or a STAT order. If it is a routine order, the company will come 1 to 2 days after we notify them. If it is a STAT order we hope the company arrives within 4 hours of us notifying them. With STAT orders the dispatch service reaches out to the technicians that come to the facility to complete the imaging. The technicians are then to call us back with an estimated time frame. If we do not hear back within 2 - 4 hours it is expected we call them back. If the company is not able to make it to the facility the day the order is expected to be completed as STAT, it is expected the provider be notified and see if the provider wants the resident sent to ER for the imaging or if he wants the facility to monitor the resident. DON B indicated he found out the next morning around 7:00-7:30 AM when he arrived at the facility the x-rays had not been completed. It was reported R2 was in pain, and they sent her out to the ER. Surveyor asked DON B if the provider had been notified on 5/29/25 that the imaging STAT orders would not be completed. DON B indicated he had gone over to the clinic the afternoon of 5/30/25 and informed PA D that the x-rays were not completed as ordered on 5/29/25 and R2 was sent to the ER that morning due to pain. Surveyor asked DON B what PA D's expectation was for the STAT imaging orders and DON B indicated PA D felt the STAT orders should have been completed within 4 hours of receiving the order. DON B indicated his expectations were the STAT imaging orders should have been completed the evening of 5/29/25. DON B indicated the MD and his self should have been notified the evening of 5/29/25 that the orders would not be completed by the charge nurse. Surveyor asked DON B with R2 not wanting to get up out of wheelchair or ambulating that evening and shaking episodes, would that be considered a change in condition for R2. DON B indicated yes, and the MD should have been notified and R2 should have been sent to ER that evening. Surveyor asked if MD was notified that evening and DON B indicated no. On 7/1/25 at 3:55 PM, Surveyor interviewed LPN J who indicated on 5/29/25 she had come in to work at 6pm. LPN J had received in report that R2 had a fall that afternoon and the facility was monitoring R2, and imaging was coming that evening. Surveyor asked if she received a call from the imaging company saying they were coming or not coming. LPN J indicated it would be in her progress notes. LPN J looked and said there is no note, so no call was received. LPN indicated that by 8 or 9 pm if no call is received from the imaging company, it generally means the company will not be coming until the next day. Surveyor asked LPN J if the order is for STAT and at 8-9pm the company still has not shown up what is the expectation. LPN J indicated if she was at another facility she would send resident to ER, but this facility does not do it that way. We go through the imaging company. Surveyor asked LPN J if MD should have been notified and LPN J indicated we were monitoring R2 and if change in condition we would send her out. Surveyor asked if R2 not getting up out of wheelchair or wanting to ambulate would that be a change for R2. LPN J indicated a change in level, and she would put that on the 24-hour report. R2 experienced a delay in treatment due to STAT X-rays not getting completed as ordered and this was not communicated to R2's provider. R2 was shaking due to severe pain the next morning and was sent to the hospital. R2 was diagnosed with a fracture to the right hip and pelvis as well as evulsion to right wrist.

Based on observation, interview, and record review, the facility did not ensure a resident's environment remained free of accidents and hazards for 1 of 3 residents (R3) reviewed for falls. R3's family provided information related to R3's familiar routine and preferences. The facility failed to get this information on R3's baseline care plan, on R3's comprehensive care plan, or get it to the front line staff to use for fall prevention. R3's alarm did not sound when she self transferred. R3 fell and sustained a hip fracture. The facility's management staff reported to Surveyor that R3 has behaviors of deactivating her alarm system. R3's medical record does not contain goals, monitoring, or interventions related to this behavior in regard to fall prevention. Facility staff used education with R3 as an intervention for fall prevention when R3 was only oriented to self, noted to be confused at baseline, was assessed to have severe cognitive impairment, and have a diagnosis of Alzheimer's. Evidenced by: Facility policy, titled Fall Prevention and Management Guidelines, revised 7/18/24, includes: Policy-Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury . upon admission the nurse will complete a fall risk assessment . the nurse will initiate interventions to help prevent falls on the resident's baseline care plan. Suggested standard interventions may include: implement universal environmental interventions that decrease the risk of resident falling . suggested interventions for residents determined to be at higher risk for falls may include: provide interventions that address unique risk factors measured by the risk assessment tool, medications, psychological, cognitive status, or recent changes in functional status. Provide additional interventions as directed by the resident's assessment and based on input from the resident or family members . Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care . the plan of care will be revised as needed and should be communicated to the staff, the resident, and the residents family are responsible party . R3 admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease, dysphagia, unsteady on feet, weakness, long term use of anticoagulants, edema, and urinary tract infection. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/19/25 indicates R3's cognition is severely impaired with a BIMS (Brief Interview for Mental Status) score of 3 out of 15. R3's Hospital Discharge, dated 6/13/25, includes: . female with history of Alzheimer's disease with significant cognitive deficits, chronic kidney disease, hypothyroidism, hypertension, chronic lower extremity edema who presents to hospital with recurrent falls, generalized weakness, worsening, lower extremity edema, and worsening confusion. The patient has had progressive memory issues and has been cared for in her home with family members and other caregivers in the past several years, but does continue to have some time at home alone. Family has noted her to be more confused and has had several falls over the past week or more. It is difficult to get a coherent history from the patient . She has been ambulating sometimes with the walker and sometimes without . In the emergency room, she was noted to be generally weak and confused with some agitation. Work up, including left neck, knee x-ray without acute findings, but underlying degenerative arthritis. Chest x-ray and rib films without acute fracture or acute process. Lab work significant for urine analysis consistent with Urinary Tract Infection. Lactate and white blood cell count normal . D [NAME] elevated with lower extremity ultrasound negative for DVT . The patient was treated with a dose of rosechin [sic] and intravenous fluids. She was monitored in the emergency room with the hope that she would be able to discharge to a skilled nursing facility, however, she had significant agitation which required one on one monitoring . Discharge diagnoses: primary-late onset Alzheimer's disease without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety . Discharge to a skilled nursing home . R3's Fall Risk Assessment, dated 6/13/25, indicates R3 is at risk for falls with a score of 17. R3's Fall Risk Assessment includes: walk in room-limited assist of 1 staff . walk in corridor-limited assistance of 1 staff . locomotion on unit-limited assist of 1 staff . mobility device-wheelchair . ambulation/locomotion-wheelchair/ambulation with gait belt and assist of 1 . Balance-postural hypotensive, impulsivity or poor safety awareness . Fall history- 1 month- 1 to 2 falls . 2 months- 1 to 2 falls . 6 months- 1 to 2 falls . Additional risk factors: diuretics, antihypertensive, cathartics/laxatives . Continence in last 14 days- occasional incontinence . Resident is at risk for falls . R3's Nurse Notes, dated 6/13/25 at 2:54 PM, includes: . admitted from (hospital) . with the following diagnoses: urinary tract infection .late onset Alzheimer's dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety . Resident vitals- weight:170.6 pounds, height: 60 inches, temperature: 97.7 degrees F, pulse: 78, respirations: 18, blood pressure: 89/38, oxygen saturation: 98% on room air . Resident is assist of 1 with personal hygiene, transfers, dressing, toileting, and ambulation. Resident does ambulate with gait belt. Resident is at risk for falls due to impulsive and poor safety awareness and so has bed and wheelchair sensor alarms on. Resident is both continent and incontinent of bowel and bladder and does wear a pull up. Resident likes to sleep in recliner in her clothes. R3's Nurse Notes, dated 6/13/25 at 10:50 PM, includes: Resident is a . admitted from hospital . Resident is alert to self only. She is confused and wants to call her parents. She was given a house phone to use. Lungs clear and oxygen saturation is 94% on room air. Bowel sounds active . Resident is hard of hearing with no hearing aids. She is both continent and incontinent of urine and is wearing a pull up. She is in her recliner with her regular clothes on. Per family this is how she sleeps. Her favorite TV station is on the TV and she is watching it. She is a risk for falls due to confusion and willfulness. Many sticky notes from family are on wall directing staff to familiar [sic] cares for R3. She requires one assist with transfers, dressing, toileting, ambulation, personal hygiene. Recliner has pressure alarm in place, and it is working. Will continue to monitor safety of resident. R3's Baseline Care Plan and Comprehensive Care Plan, dated 6/13/25, includes: At risk for falls due to: increased confusion, Urinary Tract Infection, Alzheimer's disease . Encourage to transfer and change positions slowly. Have commonly used articles within easy reach . Effective date 6/13/25 . (It is important to note the person centered interventions noted in R3's Nurse Note dated 6/13/25, were not added to R3's Baseline Care Plan or R3's Comprehensive Care Plan.) R3's Nurse Note, dated 6/14/25 at 6:50 AM, includes: .Resident is alert to self only. She is confused and wants to call her parents. She was given a house phone to use . Resident sleeps in her recliner with her regular clothes on per family this is how she sleeps. Residents has a favorite TV station, will have on at all times. Risk for falls due to confusion and willfulness. Many sticky notes from family are on wall directing staff to familiar cares for (R3). Resident requires one assist with transfers, dressing, toileting, ambulation, personal hygiene. Recliner has pressure alarm in place, and it is working. Will continue to monitor safety of resident . (It is important to note the person-centered interventions noted of keeping R3's television on at all times, sleeping in her recliner, use of alarms, and sleeping with regular clothes on are noted in a nurses note, but were not put on R3's care plan.) R3's Nurse Note, dated 6/14/25 at 9:48 AM, includes: . Resident will not remain seated in her wheelchair. We have alarm on the seat of chair. She wants to stand and to go home. We explain that she could have a fall if not careful. Resident still wants to leave her wheelchair, Notified Director of Nursing, informed to call physician as needed. (It is important to note R3 has an alarm on her chair. R3's BIMS score of 3 out of 15 indicating severe cognitive impairment, her diagnosis of Alzheimer's disease, and staff are educating her as an intervention for fall prevention.) R3's Nurse Note, dated 6/14/25, at 12:51 PM, includes: Resident will not remain seated in her wheelchair. We have alarm on the seat of chair. She wants to stand and to go home. We explain that she could have a fall if not careful. Resident still wants to leave her wheelchair. (It is important to note R3's BIMS score of 3 out of 15 indicating severe cognitive impairment, her diagnosis of Alzheimer's disease, and staff are educating her as an intervention for fall prevention.) R3's Physician Communication Note, dated 6/14/25 at 2:01 PM, includes: Notified . physician of resident continued restlessness and unable to stop her from self-transferring, chair alarm intact and functioning, offered her activities and have her sitting with staff as much as possible but once left alone she continues to get up out of chair and is high fall risk, request for an order for as needed lorazepam for restlessness. R3's Physician Communication Note, dated 6/14/25 at 2:09 PM, includes: Medical Doctor ordered Lorazepam 0.5mg (milligrams) as needed twice daily for restlessness. R3's Nurse Note, dated 6/14/25 at 2:17 PM, includes: informed power of attorney of new medication ordered, okay with lorazepam ordered for resident. R3's Nurse Note, dated 6/14/25 at 2:50 PM, includes: . Resident is alert to self only. She is confused and wants to call her parents; she has been very restless, continues to try and self transfer or walker [sic] hallways, had staff sit one-on-one with her and still continues, notified (named) physician who ordered PRN lorazepam 0.5mg for 2x day awaiting E-script to be sent to pharmacy. Power of Attorney consented to medication . Resident sleeps in her recliner with her regular clothes on per family this is how she sleeps. Resident has a favorite TV station, will have on at all times. Risk for falls due to confusion and willfulness. Many sticky notes from family are on wall directing staff to familiar cares for resident. Resident requires one assist with transfers, dressing, toileting, ambulation, personal hygiene. Recliner has pressure alarm in place, and it is working. Daughter visited her today and sat with her outside for awhile. Chair alarm intact and functioning while in wheelchair, does not stop resident from standing up and transferring self. Will continue to monitor safety of resident. R3's Nurse Note, dated 6/14/25 at 8:57 PM, includes: . Resident at this time is in wheelchair going up and down hallways. She is very quiet. R3's Nurse Note, dated 6/14/25 at 10:50 PM, includes: . Resident is alert to self only. She is confused and very impulsive. Resident is hard of hearing with no hearing aids. She is both continent and incontinent of urine and is wearing a pull up. Resident sleeps in her recliner with her regular clothes on per family this is how she sleeps. Residents has a favorite TV station, will have on at all times. Risk for falls due to confusion and willfulness. Many sticky notes from family are on wall directing staff to familiar cares for (R3). Resident requires one assist with transfers, dressing, toileting, ambulation, personal hygiene. Recliner has pressure alarm in place, and it is working. Staff is doing frequent checks and 1:1 with her as needed. Will continue to monitor safety of resident . R3's Nurse Note, dated 6/15/25 at 6:50 AM, includes: . Resident is alert to self only. She is confused and restless . Resident sleeps in her recliner with her regular clothes on per family this is how she sleeps. Residents has a favorite TV station, will have on at all times. High risk for falls due to confusion and willfullness, chair alarm intact and functioning. Many sticky notes from family are on wall directing staff to familiar cares for R3. Recliner has pressure alarm in place, and it is working . Will continue to monitor for safety of resident. R3's Nurse Note, dated 6/15/25 at 10:50 PM, includes: . Resident is alert to self only. She is confused at baseline. Resident has slept most of the day in the recliner chair . resident sleeps in her recliner with her regular clothes on per family this is how she sleeps. Resident has a favorite TV station will have on at all times. High risk for falls due to confusion and willfulness, chair alarm intact and functioning. Many sticky notes from family are on wall directing staff to familiar cares for R3 . recliner has pressure alarm in place and it is working. No pain or discomfort noted. Will continue to monitor safety of resident. R3's SBAR Change of Condition Form, dated 6/20/25 at 7:23 PM, includes: Called to resident's room by Licensed Practical Nursing (LPN) and another resident who saw resident sit on the floor in her room and then scooting on her buttock out into the hallway. Other resident states that she did not hit her head. Resident herself unable to tell staff what she was trying to do. Resident was assisted into her w/c (wheelchair) and allowed to propel in hallway with staff observing her whereabouts. Vitals: temperature- 98.4; pulse- 93; respirations- 20; blood pressure- 139/45; oxygen saturation level- 96% on room air. Background: Alzheimer's dementia with sundowning. Assessment (Registered Nurse)/Appearance (Licensed Practical Nurse): Resident was found to have no internal/external rotation or shortening of lower extremity. No new skin issues noted. Vitals stable. No complaints of pain. Resident was placed in her wheelchair with sensor alarm in wheelchair and allowed to roam to help tire her out. Assessment: Recommendations: Allow resident to roam to help tire her out, offer her snacks and see if will watch TV. Response: Power of Attorney updated, Nurse on call notified. Physician updated . who saw resident and stated neuros not needed. Monitor per facility protocol. R3's Fall Report, dated 6/20/25, includes: witnessed fall . Incident Description: Called to resident's room by Licensed Practical Nursing and another resident who saw resident sit on the floor in her room and then scooting on her buttock out into the hallway. Other resident states that she did not hit her head. Resident herself unable to tell staff what she was trying to do. Resident was assisted into her w/c and allowed to propel in hallway with staff observing her whereabouts. Vitals: temperature- 98.4; pulse- 93; respirations- 20; blood pressure- 139/45; oxygen saturation level- 96% on room air . Alzheimer's dementia with sundowning . Resident Description: Resident unable to give description . Immediate Action Taken: Try to keep resident in line of sight when up wandering . Mental status- oriented to person . Predisposing Environmental Factors: Fall alarm sounding, fall alarm on and properly positioned . Predisposing Physiological Factors: confused, gait imbalance, impaired memory . Predisposing Situation Factors: ambulating without assistance . Other resident interview/witness to fall: I saw resident walking in room, then lost balance and sat down on the floor and then started scooting on her buttock towards the hallway. She did not hit her head. R3's Comprehensive Care Plan, updated 6/20/25 with the following: Pressure alarm on at all times to be transferred from bed to wheelchair to recliner. R3's Nurse Note, dated 6/21/25 at 4:23 AM, includes: No new complaints of pain. No signs or symptoms of any new injury from fall. Will continue to monitor resident more closely when more restless and maybe even try one on one (if able). Otherwise monitor resident safety. R3's Therapy Note, dated 6/21/25 at 12:23 PM, includes: Cognitive status: Never/rarely made decisions . confused . Resident has been alert but confused, is occasionally participating in therapy. Resident and staff educated to elevate her lower extremities when sitting in her recliner. Resident requires assist of one with transfers with gait belt, assist of one for personal hygiene, dressing and tray set up for meals. Pain is monitored every shift and resident given prn Tylenol. Resident taking her medications as ordered. Nursing monitoring oral intake and encourage. Nursing monitoring for any signs of anxiety/restlessness . Resident displayed the following: Wandering Exit seek behaviors. Resident exit seeking, wandering and confused. Chair alarm intact and functioning, wanderguard intact . R3's Nurse Note, dated 6/21/25 at 8:30 PM, includes: The current status is no new complaints of pain. No signs of any new injury from fall. Will continue to monitor resident closely. Chair alarm intact and functioning. Continue to educate resident to transfer with staff assistance. (It is important to note R3's BIMS score is 3 out of 15 indicating her cognition is severely impaired, R3's assessments and nurse notes indicate R3 is only oriented to herself, R3's diagnosis of Alzheimer's disease, and nurse notes indicating R3 is confused at baseline. It is also important to note the intervention being used is educating R3 to transfer with staff assistance.) R3's Interdisciplinary Team Meeting Note, dated 6/23/25, includes: Resident had a witnessed fall Resident is a new admit within the last week and a half, resident has an Alzheimer's diagnosis, resident is an assist of 1, resident is alert to self only. Care Plan review/update: Resident has Alzheimer's diagnosis, resident is difficult to direct, resident has had poor intake, resident is not aware of safety hazards, resident is impulsive, resident was sitting in recliner, resident had just spilled her med plus 2.0, resident to ambulate when resident is showing signs of restlessness . R3's Comprehensive Care Plan, updated 6/23/25 with the following: When noted to be restless offer to ambulate in hallway with contact gait assistance of 1 staff and walker . Tab alarm on when up in wheelchair. R3's SBAR Change of Condition Form, dated 6/24/25 at 10:55 PM, includes: Unwitnessed fall with pain to left leg and external rotation . CNA (Certified Nursing Assistant) responded to resident yelling for help. Resident was sitting in recliner prior to fall in gown. Assessment (RN)/Appearance (LPN): Resident was found on the floor with head against bathroom door lying curled on left side. Complained of pain to left leg. Vitals: Blood Pressure: 162/75 Pulse: 8 [sic] Respirations:18 Oxygen saturation: 94% on room air. Temperature: 97.7degrees F . Assessment: Resident noted to have old scabbed abrasion to left knee and raised red area to knee. Lift to bed via hoyer and noted that resident was unable to lift leg without using hands. Resident stated that pain was in left groin area. Recommendations: (blank) Response: Assistant Director of Nursing informed of fall and agreed that resident should be sent to emergency room stat. Daughter informed of transfer to hospital report called to emergency room nurse and ambulance called. R3's Fall Report, dated 6/24/25 at 11:45 PM, including: Unwitnessed fall . in resident's room . Nursing description: CNA responded to resident yelling for help. Resident was sitting in recliner prior to fall in gown. Resident description: Resident unable to give description. Immediate action taken: Resident was found on the floor with head against bathroom door lying curled on left side. Complained of pain to left leg. Brief was pulled down and floor in front of chair was wet. Resident noted to have old scabbed abrasion to left knee and raised red area to knee. Lift to bed via hoyer and noted that resident was unable to lift leg without using hands. Resident stated pain was in left groin area. Taken to hospital: yes. Level of pain: occasional labored breathing. Short periods of hyperventilation. Negative vocalization: occasional moan or groan. Low level of speech with negative quality. Facial Expression: facial grimacing. Body language: rigid, fists clenched, knees pulled up, pulling or pushing away. Striking out. Consolability: distracted or reassured by voice or touch . Oriented to person . Predisposing Environmental Factors: Fall alarm improperly placed/not functioning. Predisposing Physiological Factors: Confused, impaired memory, incontinent. Predisposing Situation Factors: Ambulating without assist. Other info: Alarm was in chair not alarming, floor wet, and brief down . Statements: CNA F: I am not sure if it was water or urine on the floor. I last toileted her at 9:00 PM, she voided quite a bit and had some on the toilet seat. I had toileted her a couple times throughout PM shift, she had a medium bowel movement and was incontinent as well during the shift earlier. CNA G said he saw her last at 10:30 PM and she was asleep in her chair. CNA I: The last time I can confirm the alarm working was at the end of PM shift, so I guess 10:00 PM. Not sure the last time she was toileted, she was sleeping in her recliner the last time I saw her, I could not tell you the exact time. The floor was wet from water, but that was in front of her recliner, not where she fell, where she fell was dry. The alarm was in place in the chair, when I entered the room after the fall it was turned off. I checked it and it worked at that time. CNA F says it was on prior to the fall but when I entered after I turned it on and it worked fine. Resident had some agitation as she did not like the night gown and wanted to be in regular clothes. When I walked in after the fall she was incontinent of bladder. CNA G: I believe she was getting up to go look for clothes to go home. Last time I saw her was 10:30 PM. She was sitting on her alarm pad and it appeared to be on. I didn't get her up to check if it would sound or anything but she was sleeping and seemed to be all good. Last time I know of that she was toileted was 9:00 PM by CNA F. I am not sure what the liquid was but when she fell her brief was by her knees and I didn't see any water in sight so I am guessing it was urine. The alarm was on but it wasn't beeping. CNA I turned it off and back on after the fall and it worked fine. I can't think of anything else at this time. R3's Nurse Note, dated 6/24/25 at 11:57 PM, includes: Emergency Services arrived and transferred to hospital emergency room . Bones: . impacted fracture left proximal femur . Impression: Subcapital (fracture extends through the head and neck of the femur) fracture left hip. R3's emergency room Note, dated 6/25/25 at 12:21 AM, includes: Disposition: transfer to other facility . History of present illness: . presenting with left hip pain after an unwitnessed fall this evening at the nursing home where the patient resides . While at the nursing home this evening, the patient had an unwitnessed fall with left hip pain after the fall. Uncertain whether the patient hit her head. No loss of consciousness was witnessed. The patient is not anticoagulated. The patient herself is unable to give a history due to dementia. Physical exam: In pain with any hip movement. Suspect posterior cervical spine tenderness, without obvious step-off . Dentition appears unaffected from the fall, though patient's dentition is poor. Pelvis appears stable with left hip tenderness at the pelvis. No obvious distal left femur or distal extremity deformity, nor obvious deformity of joints . No tenderness with right leg motion at hip . R3's Interdisciplinary Team Meeting Note, dated 6/25/25 at 9:14 AM, includes: Reason for Review: Resident had an unwitnessed . Resident is impulsive, resident has Alzheimer's dx, resident will sundown, resident can be difficult to redirect, resident recent admission comes independent from home, resident wanders throughout facility in wheelchair. Resident is not aware of safety hazards. Care Plan Review/Updates: RCA (Root cause analysis)- Resident was sleeping in recliner, resident was in gown and brief, resident attempted to self-transfer and ambulate without assistance to the bathroom, resident did not call for assistance, resident is not aware of safety hazards, resident took brief off on way to bathroom, resident lost balance and fell to the floor. Resident cannot always verbalize her needs. Intervention - Staff to offer assist with routine toileting at routine times for example upon arising, and before and after meals, therapy, activates and at bed time. Resident to be checked on noc shift rounds. R3's Comprehensive Care Plan, updated 6/25/25, to include: Offer toileting more frequently as does not alert staff to needs and check on rounds at night for toileting needs. (Of note: R3 was placed in a gown instead of her own clothes (per family R3 prefers to sleep in her clothes). R3's alarm did not function properly when R3 was attempting to self transfer as it was noted to be turned off.) R3's Orthopedic Pre-operative Note, dated 6/25/25 at 10:00 AM, includes: R3 arrives to surgery from emergency room with left hip fracture. Patient is disoriented to person, place, time, situation, and at baseline . presents with left hip fracture following an unwitnessed fall at her skilled nursing facility. Chief complaint: left hip fracture. History: . Per chart review, patient recently hospitalized [DATE]-[DATE] . for recurrent falls, worsening confusion and generalized weakness. Given Rocephin and Fosfomycin for urinary tract infection with urine culture growing pan sensitive E.Coli. Appears family was interested in more of a comfort care approach . She was started on Zyprexa and ultimately discharged to skilled nursing facility. Last night she was brought to the emergency room from her facility for left hip pain after an unwitnessed fall. She arrived afebrile, vitally stable, non-hypoxic on room air . CT pelvis showed subcapital fracture of the left hip . On interview with the patient, she reports being in pain, but otherwise not oriented to situation and unable to provide further meaningful history. (It is important to note R3's fall resulted in harm when she was diagnosed with a fracture of the left hip.) R3's Orthopedic Consultation, dated 6/25/25 at 10:22 AM, includes: reason for consult: left hip fracture . Plan to take patient to operating room for left hip hemiarthroplasty . R3's Orthopedic Pre-operative Note, dated 6/25/25 at 1:40 PM, includes: pre-operative diagnosis: left femoral neck fracture, pathological due to osteoporosis with minimal trauma . Procedure: cemented hemiarthroplasty of the hip . Findings: displaced fracture of the femoral neck with general poor bone quality . R3's X-ray, dated 6/25/25 at 2:29 PM, includes: X-ray pelvis and lateral hip: final result . closed fracture of left hip, initial . Narrative and Impression: x-ray of pelvis and lateral hip obtained on 6/25/25 at 2:29 PM . Reason for exam: post op . Impression: Left hip hemiarthroplasty without immediate postoperative complication. The sacroiliac joints, right hip joint and symphysis pubis remain grossly aligned. Soft tissue gas overlies the operative site. R3's Kardex, dated 7/1/25, includes: bed mobility- assist of 1, at times able to reposition self . dressing- assist of 1 set up and encourage her to do what she is able, assist with lower body dressing . Safety- alert bracelet to left ankle for safety, FYI (for your information) Fall Risk, Pressure alarm on at all times to be transferred from bed to recliner. Have commonly used articles within easy reach, offer toileting more frequently as does not alert staff to needs and check on rounds at night for toileting needs, provide assistance in locating own room, tab alarm on when up in wheelchair, when noted to be restless offer to ambulate in hallway with . assist of one staff and walker . On 7/1/25 at 12:39 PM, DON B (Director of Nursing) indicated at the time of R3's unwitnessed fall her alarm was turned off. DON B stated, We concluded that we think she shut it off herself, before transferring. DON B and Surveyor reviewed R3's current Comprehensive Care Plan and Kardex. DON B indicated R3's comprehensive care plan and Kardex do not contain goals or interventions related to R3's behavior of shutting off her own pressure alarm. On 7/1/25 at 12:56 PM, LPN E (Licensed Practical Nurse) indicated R3's family leaves sticky notes on the wall behind her bed with information related to R3's preferences and familiar routine. LPN E indicated family reported to the facility staff that R3 prefers to sleep in her recliner wearing her street clothes. LPN E indicated the night of R3's fall she was dressed in a hospital gown. LPN E and Surveyor reviewed R3's Baseline Care Plan/Comprehensive Care Plan and Kardex. LPN E indicated R3's preferences should be on the Kardex and Comprehensive Care Plan, but they aren't. LPN E indicated she was unaware R3 likes to have a certain channel on her TV and her TV on at all times. On 7/1/25 at 1:13 PM, RN C (Registered Nurse) stated, She liked to sleep in her recliner fully dressed. I did her admission. I put it in a nurses note. RN C indicated Certified Nursing Assistants who dress R3 do not look at nurse notes often, because they get their information from the Kardex. Surveyor and RN C reviewed R3's Comprehensive Care Plan and Kardex. RN C indicated she did not add this entry on R3's care plan, but she did get a recliner for R3's room. RN C and Surveyor reviewed R3's fall from 6/24/25 noting R3 was wearing a hospital gown. On 7/1/25 at 2:46 PM, CNA F (Certified Nursing Assistant) indicated she was working on 6/24/25 when CNA G heard a scream and when she went to look she found R3 on the floor. CNA F indicated R3's alarm was placed, but it was not sounding when R3 fell. CNA F indicated R3 does not shut her own alarm off. CNA F stated, I helped her last. I put alarm on. I think it did not function properly. CNA F indicated she was not aware of R3's preference to sleep in street clothes and that is why she put a hospital gown on R3. CNA F stated, I didn't know she liked personal clothes on. It was my fault. I apologize about that. I just did what I know and put her in our gowns. I would find that information in the care plan or the Kardex. CNA F indicated the family writes on Sticky notes and posts them on wall behind her bed with information related to R3's familiar routine and preferences. CNA F indicated that one of the sticky notes stated R3 likes to sleep in recliner. CNA F stated, That was not in the care plan. Surveyor asked about her personal clothing preference, CNA F stated, I do not see this on her care plan. We have different nurses too at times and they wouldn't maybe know her clothing preference or her preference of sleeping in a recliner. It should be in the care plan. CNA F indicated the alarm has since been exchanged for one that is functioning all the time. On 7/1/25 at 2:50 PM, DON B, CNA F, and Surveyor observed sticky notes on wall behind R3's bed. DON B indicated sticky notes are not part of R3's medical record or care plan. DON B indicated it is his expectation that CNAs would use the residents' Kardex and Care Plan for information on how to care for residents. On 7/1/25 at 3:14 PM, DON B indicated if family provides information about preferences it should be added to the resident's care plan. DON B stated, We found out now she likes to be in a gown with a sweatshirt and pants on. Surveyor and DON B reviewed R3's care plan. DON B stated, It could be added in there. DON B indicated person-centered care information should get to front

Based on interview and record review, the facility did not ensure that 1 of 3 residents (R3) reviewed for receiving a psychotropic medication were free from unnecessary drugs. R3 receives Olanzapine, an antipsychotic medication, for Alzheimer's disease with late onset. This is evidenced by: The facility policy titled, Use of Psychotropic Medications, reviewed 4/27/25, includes: it is the intent of this policy to ensure that residents only receive psychotropic medications when other non-pharmacological interventions are clinically contradicted. Additionally these medications should only be used to treat residents medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Adequate indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contradicted. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indication for use means that the medication administered is consistent with manufacturers recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence based review of articles that are published in medical and/or pharmacy journals . chemical restraint refers to any drug used for discipline or that makes it more convenient for staff to care for a resident, and not required to treat medical symptoms. This includes instances when a psychotropic medication may be approved to treat certain symptoms, however, non-pharmacological interventions should be used or attempted, unless clinically contraindicated, because they are less dangerous to the residents health and safety . A psychotropic drug is any drug that affects brain activity is associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Psychotropic medications are to be used only when a practitioner determines that the medication is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication . R3 admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease, dysphagia, unsteady on feet, weakness, long term use of anticoagulants, edema, and urinary tract infection. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/19/25 indicates R3's cognition is severely impaired with a BIMS (Brief Interview for Mental Status) score of 3 out of 15. R3's physician orders, June 2025 and July 2025, states in part: . Olanzapine Oral tablet 2.5 MG (milligrams) . Give one tablet by mouth at bedtime related to Alzheimer's disease with late onset. (It is important to note Alzheimer's disease with late onset is not an appropriate indication of use for an antipsychotic.) On 7/1/25 at 3:50 PM PA D (Physician Assistant) indicated she prescribed R3 Olanzapine due to her late onset Alzheimer's disease with behavioral disturbance. Surveyor asked PA D if R3 had behaviors that were persistent and harmful to herself or others. PA D indicated R3 is someone who has severe psychosis in her mental state, she is impulsive, and she lacks safety awareness. Surveyor asked PA D to describe R3's psychosis. PA D indicated R3 tries to stand without help, wanders, and at times thinks she needs to be somewhere else. On 7/1/25 at 5:10 PM NHA A (Nursing Home Administrator) indicated wandering, lacking safety awareness, and self-transferring are common symptoms in a person with Alzheimer's disease and does not necessarily warrant the use of an antipsychotic medication. NHA A indicated the facility has done some education with area providers on unnecessary medication use and they will continue to educate them. The facility failed to ensure residents receiving antipsychotic medications have appropriate diagnoses for medication use.

Based on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services to promote healing and prevent new injuries from developing for 2 of 5 residents (R35 and R44) reviewed for pressure injuries. R35 was at risk for PI development. R35 developed two stage 3 facility acquired PIs that deteriorated. Observations were made of multiple layers between R35 and the air mattress. The facility failed to provide education and/or risks vs benefits when R35 declined repositioning. Staff did not ensure consistent documentation of repositioning or incontinence care, which were noted contributors to R35's PIs. Staff did not protect R35's periwound when applying the prescribed treatment. The facility's failures to implement preventive interventions for residents at risk for PIs, failure to provide education and/or risks vs. benefits when a resident declined repositioning, and failure to correctly apply a prescribed treatment created a finding of immediate jeopardy that began on 1/15/25. Surveyor notified Nursing Home Administrator A (NHA) of the immediate jeopardy on 2/28/25 at 10:05 AM. The immediate jeopardy was removed on 2/28/25; however, the deficient practice continues at a scope/severity of G (actual harm/isolated) as the facility continues to implement their action plan as evidenced by: R44 was admitted with a pressure injury. The facility failed to complete weekly pressure injury assessments per standards of practice. Observations were made of multiple layers between R44 and the air mattress. R44's PI deteriorated as evidenced by undermining and tunneling. Evidenced by: The AMDA (American Medical Directors Association) clinical practice guideline titled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer, and identify related causes and complications. The National Pressure Injury Advisory Panel (NPIAP) at www.NPIAP.com defines PIs in the following categories: Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister. Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Wound Source article titled Pressure Injury and Microclimate: How Linen Layers May Contribute dated 2/14/24 states in part, . Pressure Injury Risk: How Linen Layers May Contribute: Linen layers have the potential to impact skin microclimate in the following ways: Reduce airflow Affect pressure redistribution Increase friction coefficient Dry or macerate skin Increase skin temperature Clinicians should select the correct type and amount of layers between the patient and support surface. Evidence suggests this selection is a high-value, low-cost, intervention. Regarding linen type, the NPIAP 2019 guidelines specifically recommend the use of silk or silk-like sheets versus cotton and cotton blend sheets . Regarding linen number, experts have found that incontinence pads, transfer sheets, or a combination of linens can significantly increase the mean peak sacral pressure when compared to a single flat sheet. Even on both a low-air-loss surface and foam surface, regardless of head-of-bed angle, pressure may be increased. This occurrence was confirmed by an in vitro study by [NAME] et al which examined the effect on interface pressures with the use of wet and dry incontinence pads against the gluteal and sacral areas of mannequins with soft, tissue-like qualities. In a 2018 retrospective review using International Pressure Ulcer Prevalence data from 216,626 participants, additional linen layers were found as a risk factor for both superficial and severe pressure injuries . Pressure Injury and Microclimate: How Linen Layers May Contribute | WoundSource The facility's policy titled Pressure Injuries and Non pressure Injuries last reviewed on 7/20/2022, states in part, .Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present .Additional Skin Impairment Definitions: Moisture Associated Skin Damage: inflammation of the skin and erosion from prolonged exposure to moisture and its [sic] contents. Common sources of moisture include urine and stool, perspiration, wound exudate, and effluent from an ostomy .2. Weekly: a. Complete a head-to-toe skin check and document findings on the Skin Review .If new areas are present: i. notify MD (Medical Doctor) ii. Notify resident/ responsible party iii. Initiate treatment per order .b. Assess current wounds at least every 7 days, or more frequently as needed (e.g., decline in wound, presence of infection, wound healed) . Example 1: R35 was admitted to the facility on [DATE], and was readmitted to the facility after a hospitalization on [DATE] with diagnoses that included osteomyelitis of vertebra (infection in the spine), type 2 diabetes mellitus, morbid obesity, and radiculopathy of lumbar region (a condition where nerve roots on the lower back are compressed or irritated, causing pain and other symptoms that radiate down the leg-numbness, tingling, burning, weakness or muscle spasms, difficulty walking or standing, loss of reflexes in the leg). R35's most recent MDS (Minimum Data Set) dated 1/6/25 states that R35 has a BIMS (Brief Interview for Mental Status) of 13 out of 15, indicating that R35 is cognitively intact. The MDS also indicates that R35 is dependent on staff for toileting, bathing, transfers, and bed mobility. R35 is always incontinent of bowel and bladder and has paralysis of her lower extremities. R35's care plan dated 11/21/24 and revised on 1/30/25 states in part: Interventions: *Administer treatments as ordered and monitor for effectiveness (initiated 11/21/24). *Monitor dressing to ensure it is intact and adhering. Report lose [sic] dressing to treatment nurse (revised 12/10/24). *Monitor nutritional status. Serve diet as ordered, monitor intake and record (initiated 12/10/24). *Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size ., stage (initiated 11/21/24). *Resident is to be turned and repositioned in even hours using a wedge and may be on back for meals only, more often as needed or requested (initiated 1/30/25). *The resident requires the bed to be as flat as possible to reduce shear. The resident prefers to be repositioned with 2 people (revised 12/10/24). The resident requires air flotation mattress on bed (initiated 12/10/24). Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort (initiated 12/10/24). Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate (initiated 12/10/24) . It is important to note that R35's care plan was not updated to reflect current wounds and locations. R35's repositioning intervention was added 22 days after the development of the PI. R35's Braden Scale (for predicting pressure sore risk) scores are as follows: 11/27/24: 16-at risk 12/6/24: 16-at risk 12/13/24: 15-at risk 1/10/25: 16-at risk 1/17/25: 14-moderate risk 1/24/25: 14-moderate risk R35's weekly skin checks since readmission, indicate the following: 1/9/25: dry skin 1/16/25: pressure injury to coccyx 1/23/25: coccyx stage 2, left gluteal fold (boundary between the buttocks and posterior (back) of thigh) 1/30/25: coccyx stage 2, left gluteal fold 2/6/25: coccyx wound 2/13/25: PI - buttock R35's Non-Pressure Weekly Tracker documentation is as follows: 1/8/25: .2. Wound acquired: b. In house. 2a. Date acquired: 1/8/25. 3. Type: h) Open area. 4. Location: Lower gluteal cleft buttock .5a. Length 4.8 cm (centimeters) 5b. Width 2.7cm. 5c. Depth 0.1cm .7. Drainage e. purulent. 8. Amount of drainage b. light .23. Comments: MASD (Moisture Associated Skin Damage) .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Zinc ointment apply Q (every) shift 3xday (3 times a day) for 30 days Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; off- load wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able . 1/15/25: . 4. Location: Coccyx. Description: Wound area previously documented as MASD has now progressed to stage 3 pressure injury .5a. Length 3.4 cm 5b. Width 1.9cm. 5c. Depth 0.1cm .Tissue Type .6c. Granulation 30% 6d. Slough 70% .7. Drainage b. Serous. 8. Amount of drainage c. moderate .23. Comments: MASD- Wound area previously documented as MASD has now progressed to stage 3 pressure injury of coccyx as of 1/15/25. This tracker to be closed and completed, new tracker will be opened .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Leptospermum honey to wound bed followed by duoderm (adhesive dressing) 3x/week (3 times per week) Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; off- load wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. [Wound Care Doctor] here to eval and treat resident. Surgical excisional debridement procedure completed at bedside. Resident tolerated well . It is important to note despite the MASD deteriorating to a stage 3 pressure injury (PI) the facility continued to document this PI on the facility's non-pressure wound tracker. 1/22/25: .5a. Length 14.7 cm 5b. Width 2cm. 5c. Depth 0.4cm .Tissue Type .6c. Granulation 30% 6d. Slough 70% .7. Drainage b. Serous. 8. Amount of drainage d. heavy .23. Comments: MASD- Wound area previously documented as MASD has now progressed to stage 3 pressure injury of coccyx as of 1/15/25. This tracker to be closed and completed, new tracker will be opened. Exacerbated due to increased drainage and noncompliant with offloading .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Santyl apply once daily followed by calcium alginate. Skin prep peri wound. Cover with foam with border daily. Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; offload wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. [Wound Care Doctor] here to eval and treat resident. Surgical excisional debridement procedure completed at bedside. Resident tolerated well . Of note: on 1/22/25 the PI deteriorated by increasing in size, heavy drainage. Despite staff noting R35 was noncompliant with offloading, there is no evidence of education or risks vs benefits being provided. R35's MAR (Medication Administration Record) has the following order: * Ensure resident is being repositioned every 2 hours. Every shift. Start date: 1/30/25. The following dates and shifts are marked no: 2/1/25 PM (evening) shift, 2/5/25 PM shift, and 2/14/25 PM and NOC (night) shifts. Of note: R35's order to be repositioned was not added to the MAR until 1/30/25. 1/29/25: . stage 3 pressure injury .5a. Length 18.2 cm 5b. Width 3.2cm. 5c. Depth 0.2cm .Tissue Type .6c. Granulation 70% 6d. Slough 10% 6e. Necrotic 20% .7. Drainage b. Serous. 8. Amount of drainage c. moderate .23. Comments: MASD- Wound area previously documented as MASD has now progressed to stage 3 pressure injury of coccyx as of 1/15/25. This tracker to be closed and completed, new tracker will be opened. Exacerbated due to increased drainage and incontinence .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Sodium hypochlorite (dakins) apply once daily and as needed for 30 days: 0.125% dakins Secondary dressing(s) ABD pad apply once daily for 30 days. Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; offload wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. [Wound Care Doctor] here to eval and treat resident. Surgical excisional debridement procedure completed at bedside. Resident tolerated well . 2/5/25: . stage 3 pressure injury .5a. Length 14.1 cm 5b. Width 10.1cm. 5c. Depth 0.3cm .Tissue Type .6a. Skin 10% 6d. Slough 85% 6e. Necrotic 5% .7. Drainage b. Serous. 8. Amount of drainage c. moderate .23. Comments: MASD- Wound area previously documented as MASD has now progressed to stage 3 pressure injury of coccyx as of 1/15/25. This tracker to be closed and completed, new tracker will be opened. Exacerbated due to increased drainage and incontinence .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Sodium hypochlorite (dakins) apply once daily and as needed for 30 days: 0.125% dakins Secondary dressing(s) ABD pad apply once daily for 30 days. Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; offload wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. [Wound Care Doctor] here to eval and treat resident. Surgical excisional debridement procedure completed at bedside. Resident tolerated well . Of note: R35's PI now has 85% slough in the wound bed when on 1/29/25 R35's wound bed had 70% granulation and only 20% necrotic tissue, which would indicate a deterioration in the wound. 2/12/25: . stage 3 pressure injury .5a. Length 12.5 cm 5b. Width 3.6cm. 5c. Depth 0.4cm .Tissue Type .6a. Skin 10% 6c. Granulation 50% 6e. Necrotic 50% .7. Drainage b. Serous. 8. Amount of drainage c. moderate .23. Comments: MASD- Wound area previously documented as MASD has now progressed to stage 3 pressure injury of coccyx as of 1/15/25. This tracker to be closed and completed, new tracker will be opened. Improved evidenced by decreased surface area .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Sodium hypochlorite (dakins) apply once daily and as needed for 30 days: 0.125% dakins Secondary dressing(s) ABD pad apply once daily for 30 days. Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; offload wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. [Wound Care Doctor] here to eval and treat resident. Surgical excisional debridement procedure completed at bedside. Resident tolerated well . (Of note: the PI assessment indicates 110% as evidenced by Skin 10% 6c. Granulation 50% 6e. Necrotic 50%. Assessments should never account for more than 100%. Facility staff did not clarify the characteristics of the wound bed or that the percentage was over 100%) The following documentation is regarding R35's second pressure injury that developed that was found as an unstageable. 1/15/25: . 2. Pressure injury acquired b. In house. 2a. Date acquired 1/15/25. 3. Location: Right thigh (rear) type: pressure. Length 0.5cm Width 1.1cm Depth 0.1cm Stage 3 .5. Tissue Type .5d. Slough 100% .6. Drainage: b. Serous. 7. Amount of drainage: b. light .6. Additional interventions/plans: [Wound Care MD] here to eval and treat. Treatment plan as follows: Cleanse with wound cleanser at time of dressing change, apply silver sulfadizine 3x/week and PRN for 30 days. Surgical excisional debridement completed at bedside via [MD name]. Removal of necrotic tissue and established margins of viable tissue. Resident tolerated procedure well . (Of note: R35's left thigh wound was found as a stage 3, on 1/15/25 which is the same day that R35's MASD deteriorated to a stage 3 pressure injury. The wound has 100% slough which would indicate the wound is an unstageable Pressure injury.) 1/22/25: . 3. Location: Left thigh (front) type: pressure. Length 6.5cm Width 6.3cm Depth 0.1cm Stage 3 .5. Tissue Type .5a. Skin 60% 5c. Granulation 40% 5d. Slough 20% .6. Drainage: b. Serous. 7. Amount of drainage: d. heavy .20. Comments: .Previously documented as right posterior thigh in error. Area is LEFT posterior thigh/buttock .6. Additional interventions/plans: [Wound Care MD] here to eval and treat. Treatment plan as follows: Cleanse with wound cleanser at time of dressing change, apply silver sulfadizine 3x/week and PRN for 30 days. Surgical excisional debridement completed at bedside via [MD name]. Removal of necrotic tissue and established margins of viable tissue. Resident tolerated procedure well . (Of note: Of note: the PI assessment indicates 120% as evidenced by Skin 60% 5c. Granulation 40% 5d. Slough 20%. Facility staff did not clarify the characteristics of the wound bed or that the percentage was over 100%.) 1/29/25: . 3. Location: Left thigh (rear) type: pressure. Length 2.5cm Width 2.2cm Depth 0.1cm Stage 3 .5. Tissue Type .5c. Granulation 30% .5e. Necrotic 70% .6. Drainage: b. Serous. 7. Amount of drainage: c. moderate .20. Comments: .Previously documented as right posterior thigh in error. Area is LEFT posterior thigh/buttock. Improved as evidenced by decrease in surface area .6. Additional interventions/plans: [Wound Care MD] here to eval and treat resident. Treatment plan as follows: Dressing Treatment Plan Primary Dressing(s) Sodium hypochlorite solution (dakins) apply once daily and as needed for 30 days: 0.125% dakins Secondary Dressing(s) ABD pad apply once daily for 30 days. Peri wound treatment Zinc ointment apply once daily and as needed for 30 days. Surgical excisional debridement completed at bedside via [MD name]. Removal of necrotic tissue and established margins of viable tissue. Resident tolerated procedure well . 2/5/25: . 3. Location: Left thigh (rear) type: pressure. Length 0.4cm Width 1.7cm Depth 0.1cm Stage 3 .5. Tissue Type .5d. Slough 100% .6. Drainage: b. Serous. 7. Amount of drainage: b. Light .20. Comments: .Previously documented as right posterior thigh in error. Area is LEFT posterior thigh/ buttock. Improved as evidenced by decrease in surface area .6. Additional interventions/plans: [Wound Care MD] here to eval and treat resident. Treatment plan as follows: Dressing Treatment Plan Primary Dressing(s) Sodium hypochlorite solution (dakins) apply once daily and as needed for 30 days: 0.125% dakins Secondary Dressing(s) ABD pad apply once daily for 30 days. Peri wound treatment Zinc ointment apply once daily and as needed for 30 days. Surgical excisional debridement completed at bedside via [MD name]. Removal of necrotic tissue and established margins of viable tissue. Resident tolerated procedure well . 2/12/25: 3. Location: Left thigh (rear) type: pressure. Length 1.4cm Width 1.6cm Depth 0.1cm Stage 3 .5. Tissue Type .5c. Granulation 100% .6. Drainage: b. Serous. 7. Amount of drainage: b. Light .20. Comments: .Previously documented as right posterior thigh in error. Area is LEFT posterior thigh/buttock. Improved as evidenced by decrease in surface area .6. Additional interventions/plans: [Wound Care MD] here to eval and treat resident. Treatment plan as follows: Dressing Treatment Plan Primary Dressing(s) Sodium hypochlorite solution (dakins) apply once daily and as needed for 30 days: 0.125% dakins Secondary Dressing(s) ABD pad apply once daily for 30 days. Peri wound treatment Zinc ointment apply once daily and as needed for 30 days. Surgical excisional debridement completed at bedside via [MD name]. Removal of necrotic tissue and established margins of viable tissue. Resident tolerated procedure well . R35's CNA (Certified Nursing Assistant) documentation from 1/1/25-2/17/25 is as follows: Task: Did you turn and reposition? Response: Yes-58 answers out of 144 opportunities. It is important to note that the facility failed to document on 86 repositioning opportunities. B&B: Bowel and Bladder Elimination: January and February-bowel movements tracked and documented daily on most shifts. Urination is not tracked at all. On 2/18/25 at 9:30 AM, Surveyor observed wound care with DON B (Director of Nursing) and LPN EE (Licensed Practical Nurse). Surveyor observed R35 lying in bed with a low air loss mattress. R35 had several layers underneath her; the bed had a fitted sheet, a lift sheet, a cloth chux pad, an incontinence brief, and a purple incontinence liner that was saturated with urine. Wound care was completed by LPN EE, and a new incontinence brief and purple incontinence liner was reapplied. On 2/19/25 at 9:48 AM, Surveyor interviewed LPN EE. Surveyor asked LPN EE how she can ensure that the Dakin solution isn't touching the healthy skin after changing R35's dressing, LPN EE stated that she tries to form it to the wound. Surveyor asked how they know that it stays in place when being changed or repositioned, LPN EE stated that staff have to make sure it is in place, but she is not sure. It is important to note, that during wound care, the Dakin-soaked gauze was lying flat on the wound bed, not tucked into the wound, and was coming in contact with healthy skin. According to the National Library of Medicine< https://www.ncbi.nlm.nih.gov/books/NBK507916/> Due to its properties as an acid-based compound, Dakin solution can be corrosive to healthy tissue, especially at higher concentrations. An oil-based ointment such as petroleum jelly can be applied to surrounding healthy tissue to reduce skin irritation and prevent the debridement of viable tissue. Dakin solution also loses its antiseptic properties rapidly after application due to the instability of the compound. Therefore, gauze sponges soaked with Dakin used to pack necrotic wounds must be frequently changed. It is usually applied twice daily to lightly to moderately exudative wounds and twice daily for highly exudative or contaminated wounds. On 2/19/25 at 8:58 AM, Surveyor interviewed CNA E. Surveyor asked CNA E how often R35 is checked and changed, CNA E stated every 2 hours and is repositioned every 2 hours from side to side. Surveyor asked CNA E if they document repositioning and toileting, CNA E stated that they don't. Surveyor asked how many layers should be under a resident on an air mattress, CNA E reported that there should be a fitted sheet, a draw sheet, and a brief. Surveyor asked if she has ever noticed R35 to have a fitted sheet, draw sheet, cloth chux pad, purple liner, and an incontinence brief on, CNA E yes. Surveyor asked if she reported it to anyone, CNA E stated no and that she just removes it. On 2/18/25 at 3:23 PM, Surveyor interviewed CNA MM. Surveyor asked how many layers are under R35, CNA MM reported a sheet, a draw sheet, a cloth chux pad, and a purple incontinence liner. Surveyor asked how often is R35 repositioned, CNA MM stated every 2 hours and that they document it and they used to have a paper they filled out, but now it's added to her tasks. On 2/18/25 at 1:48 PM, Surveyor interviewed DON B. Surveyor asked DON B how many layers should be under a resident that is on an air mattress, DON B stated that it should be just the sheet. Surveyor asked DON B if he observed all of the layers under R35, DON B stated yes. Surveyor asked DON B if they have identified the root cause of R35's coccyx wound worsening. DON B provided documentation from the wound MD indicating it was due to R35 refusing offloading and due to incontinence. DON B reported that they obtained an order for a wedge cushion on 1/24/25 and implemented that, as well as adding turn every 2 hours to R35's CNA tasks. DON B also stated that he added Bowel and Bladder documentation to the CNA task list. Surveyor reviewed CNA documentation with DON B. Surveyor asked DON B how he knows that R35 is being repositioned every 2 hours, if the task only asks if she was repositioned, DON B stated he wasn't sure. Surveyor also reviewed R35's bowel and bladder documentation and pointed out that the CNAs were not documenting R35's incontinence episodes. R35 was at risk for PI development and developed two stage 3 facility acquired PIs. The facility failed to follow standards of practice as evidenced by observations of multiple layers between R35 and the air mattress, failed to provide education and/or risks vs benefits when R35 declined repositioning, did not ensure consistent documentation of repositioning, and failed to ensure treatments were applied to only the pressure injury wound bed. The facility's failure to implement preventive interventions for residents at risk for PIs, failure to provide education and/or risks vs. benefits when a resident declined repositioning, failure to complete weekly assessment per standard of practice, and failure to correctly apply prescribed treatments created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on 2/28/25, when it completed the following: *Both residents remains at the center and care plan regarding pressure injury reviewed and updated. In house residents with pressure injuries have the potential to be affected. Skin sweep completed 2/28/2025. On 2/28/2025 Director of nursing or designee implemented re-education with nursing staff (CNAs and licensed nurses) on Pressure Injury and Non-Pressure Injury policy and Use of Support Surface policy. This education included: o the need to ensure care plan is followed including managing moisture and incontinence including not using multiple layers with air mattresses o If cares/treatments are refused to notify licensed nurse/DON/designee and education provided on risks and benefits to resident or responsible party, notify MD and update care plan o obtaining Periwound treatment in order from MDs o Wound assessments including measurements and ensuring surface area adds up to 100% of assess Identified education will occur prior to start of next scheduled shift. On 2/28/2025, facility reviewed their Pressure Injury and Non-Pressure Injury and Use of Support Surface policies. No changes were required to policies. On 2/28/25, DON/designee also verified that residents with pressure injuries have accurate assessment of pressure injuries, including physician orders for treatment and dressing changes that are completed per MD order. Interdisciplinary review completed of care plans for residents with pressure injuries and a visual audit was completed by Director of Nursing or designee to ensure care planned interventions for pressure injury healing and prevention are in place. DON/designee to complete random observation (audit) of dressing changes per MD order with periwound treatment, if warranted, and cares/treatment to ensure dressing changes completed per MD order, interventions to promote healing including no multiple layers on air mattresses, and ensure proper documentation of refusal of skin care and treatment. Audits will also include Pressure injury weekly documentation to ensure accurate and complete, and CNA task documentation on if cares accepted and documented per care plan. Audits will be completed daily x 7 days. These audits will then continue on varying shifts three times per week for 4 additional weeks then 2 times per week for 4 additional weeks. Results of audits will be presented to facility QAPI committee for review and any recommendations. Ad hoc QAPI meeting held on 2/28/2025 to review this plan Example 2: R44 was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus, pressure ulcer of sacral region, stage 2, anxiety disorder, and panic disorder. R44's most recent MDS dated [DATE] states that R44 has a BIMS of 15 out of 15, indicating that R44 is cognitively intact. The MDS also indicates that R44 is dependent on staff for bed mobility, transfers, bathing, and dressing her lower body. R44's care plan initiated on 12/17/24 states: .Focus: The resident has a stage 2 pressure ulcer to coccyx or potential for pressure ulcer development r/t Hx (history) of ulcers, decreased mobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: *Monitor dressing to ensure it is intact and adhering. Report lose [sic] dressing to treatment nurse. *Monitor nutritional status. Serve diet as ordered, monitor intake and record. *Monitor/ document/ report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size .* The resident requires air flotation pressure redistribution device. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate . R44's documentation on facility's Pressure Injury (PI) Weekly Tracker is as follows: 12/16/24: .Location: Coccyx Type: Pressure. Length 0.9cm Width 0.8cm Depth 0.3cm stage 2. 5. Tissue type: 5c. Granulation 50% 5d. Slough 50%. 6. Drainage b. Serous 7. Amount of drainage b. Light .B. Plan/ Treatment .6. Turn and reposition every 2 hours . R44 was admitted with a PI that was 50% slough, which would indicate it's at least a stage 3. 12/18/24: . Length 1.1cm Width 0.8cm Depth 0.3cm stage 3. 5. Tissue type: 5c. Granulation 20% 5d. Slough 80%. 6. Drainage b. Serous 7. Amount of drainage c. moderate .B. Plan/ Treatment .6. Turn and reposition every 2 hours- Cleanse with wound cleanse [sic], apply medihoney to wound bed, cover with bordered foam dressing. Skin prep to periwound daily x 30 days. Surgical excisional debridement performed to remove necrotic tissue and establish viable tissue . It is important to note that there were no wound measurements from 12/18/24-1/8/25, during which time R44's PI increased in size. 1/8/25: .Length 4.1cm Width 0.5cm Depth 0.1cm stage 3. 5. Tissue type: 5a. Skin 50% 5c. Granulation 10% 5d. Slough 40%. 6. Drainage b. Serous 7. Amount of drainage c. moderate .B. Plan/Treatment .6. Turn and reposition every 2 hours- Cleanse with wound cleanse [sic], apply medihoney to wound bed, cover with bordered foam dressing. Skin prep to periwound daily x 30 days. Surgical excisional debridement performed to remove necrotic tissue and establish viable tissue . 1/15/25: 1/8/24: . Length 3.5cm Width 1.8cm Depth 0.6cm stage 3 . 5. Tissue type: 5a. Skin 80% .5d. Slough 10%. 6. Drainage b. Serous 7. Amount of drainage b. moderate .B. Plan/Treatment .6. Turn and reposition every 2 hours- Cleanse with wound cleanser. Skin prep periwound apply 3x/weekly. Lightly pack wound using iodoform 1/4 3x/week (leaving a tail) and cover with duoderm. Surgical excisional debridement performed to remove necrotic [TRUNCATED]

Based on observations, interview, and record review the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 68 residents (R) residing in the facility. The facility's outbreak that started in October 2024 was resolved too early. Facility staff were unaware of their current outbreak and were not following proper source control during the outbreak. Staff surveillance was not complete for staff illnesses and staff returned to work too early from illnesses. This is evidenced by: The facility's policy titled Infection Prevention and Control Program, dated 7/23/24, states in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. The designated Infection Preventionist is responsible for oversight of the program and serves as a leader to our staff on infectious disease, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all resident, staff .based upon a facility assessment and accepted national standards. The infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings and any corrective actions made by the facility . All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. The facility's policy titled Infection Outbreak Response and Investigation, dated 2/26/23, states in part: Definitions: Outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. If a condition is rare or has serious health implications, an outbreak may involve only one case. The following triggers shall prompt an investigation as to whether an outbreak exists: .A single case of a rare or serious infection (i.e. COVID-19). Implementation of infection control measures: .Symptomatic employees will be screened by the Infection Preventionist, or designee . Transmission-based precautions will be implemented as indicated for the particular organism. Staff should be educated on the mode of transmission of the organism, symptoms of infection and isolation or other special procedures. This includes special environmental infection control measures that are warranted based on the organism and current CDC guidelines. The incubation period, period of contagiousness, and date of most recent case will be used in making the determination that the outbreak is resolved. Example 1 Facility document titled Covid Outbreak Time Log 10/1/24 to 11/17/24, states in part: On 10/2/24, the facility initiated a COVID outbreak. On 11/2/24, R1 tested positive for COVID. On 11/17/24, the facility ended their outbreak status and discontinued universal masking. According to dhs.wisconsin.gov, respiratory outbreaks can be closed after two incubation periods have passed with no new cases being identified. For COVID-19 outbreaks, this is 28 days . Of note, the facility ended their outbreak on day 15. Example 2 On 2/16/24 at 9:20 AM, Surveyors entered the facility. Posted on the front entrance door was a sign titled Attention Visitors. The sign states in part: Attention Visitors We are currently experiencing a COVID outbreak . If you choose to visit during this outbreak, please review the following: .Facemasks should be worn at all times during your visit. On 2/16/25 at 9:30 AM, Surveyor observed DA L (Dietary Aide) delivering a drink cart on the hallway without a mask on. On 2/16/25 at 12:54 PM, Surveyor interviewed DA L regarding the COVID outbreak. During the interview, Surveyor observed DA L did have a mask on. DA L was not wearing the mask appropriately as the mask was below his nose during the interview. DA L indicated he was not aware the facility was in outbreak and that is why he had not been wearing a mask earlier. Surveyor asked DA L if he had education on the correct way to wear a mask and DA L indicated he was aware of the correct way to wear a mask. Surveyor asked DA L if he was wearing the mask correctly and DA L indicated he was not wearing the mask correctly. On 2/16/25 at 9:32 AM, Surveyor observed CNA O (Certified Nursing Assistant) sitting in the center hub of the facility without a mask on. On 2/16/25 at 12:54 PM, Surveyor interviewed CNA O regarding the COVID outbreak. CNA O indicated she should have been wearing a mask earlier but was not. Surveyor observed CNA O during the interview wearing her mask correctly. On 2/16/25 at 11:10 AM, Surveyor interviewed LPN N (Licensed Practical Nurse) regarding COVID outbreak. LPN N indicated the facility was not in outbreak and staff were wearing mask as a precaution. On 2/17/25 at 12:55 PM, Surveyor observed RN P (Registered Nurse) standing in the hallway wearing her mask below her chin while talking to visitors. Surveyor interviewed RN P regarding the correct way to wear a mask. RN P indicated she was not wearing the mask correctly. RN P indicated she believed there had only been one staff member who tested positive for COVID, and it was past 10 days so she is unsure if the facility was still in outbreak. On 2/16/25 at 12:51 PM, DON B (Director of Nursing) indicated the facility had been in COVID outbreak status since 2/4/25. On 2/17/25 at 8:23 AM, Surveyor observed DA Q walk into the dining room from an outside entrance and walk into the kitchen not wearing a mask. When surveyor went to interview DA Q, she had already left the facility. On 2/17/25 at 8:25 AM, Surveyor observed PC R (Pest Control Contractor) walk out of the kitchen, through the dining room where residents were eating breakfast and to the center hub of the facility. PC R was not wearing a mask. Surveyor observed PC R speaking with NHA A (Nursing Home Administrator). Surveyor interviewed PC R regarding not wearing a mask. PC R indicated he was not aware there was a mask mandate in the facility. PC R indicated he did not notice the sign on the front door indicating the facility was in a COVID outbreak. PC R indicated no staff member told him the facility was in outbreak. PC R indicated no staff member asked him to put on a mask. On 2/17/25 at 8:25 AM, Surveyor interviewed NHA A regarding contractors wearing a mask while in the facility. NHA A indicated the facility recommends contractors wear a mask. NHA A indicated there is a sign at the front door stating the facility is in a COVID outbreak. On 2/18/25 at 12:30 PM, Surveyor interviewed DON B regarding the COVID outbreak. DON B indicated staff should be aware of the outbreak and should wear their mask correctly. Example 3 Surveyor reviewed the facility's staff line list for November 2024, December 2024, and January 2025. November 2024 staff line list states in part: 11/19/24 LPN EE (licensed practical nurse) called in with symptoms of fatigue, nausea, emesis, and diarrhea. Return to work date of 11/22/24. Of note, there is no date symptoms resolved. December 2024 staff line list states in part: 12/7/24 HA FF (Hospitality Aide) called in with symptoms of headache, nausea, and emesis. Return to work date of 12/8/24. Of note, there is no date symptoms resolved, and the return-to-work date is 24 hours after GI (gastrointestinal) symptoms. 12/10/24 CNA GG called in with symptoms of nausea, emesis, and diarrhea. Return to work date of 12/11/24. Of note, there is no date symptoms resolved, and the return-to-work date is 24 hours after GI symptoms. 12/16/24 UC J (Unit Clerk) called in with symptoms of myalgia (muscle pain), headache, and sore throat. Of note, there are no testing results listed, and no date symptoms resolved. 12/20/24 HA FF called in with symptoms of emesis. Return to work date of 12/21/24. Of note, there is no date symptoms resolved, and the return-to-work date is 24 hours after GI symptoms. 12/23/24 HA HH called in with symptoms of nausea and emesis. Of note, there is no date symptoms resolved. January 2025 staff line list states in part: 1/2/25 HA FF called in with symptoms of fever, emesis, and diarrhea. Of note, there is no date symptoms resolved. 1/2/25 RN I called in with symptoms of myalgia, headache, sore throat, cough and diarrhea. Of note, there is not testing results listed, and no date symptoms resolved. 1/5/25 CNA DD called in with symptoms of emesis and diarrhea. Of note, there is no date symptoms resolved. 1/7/25 MN II (Maintenance) called in. Return to work date of 1/8/25. Of note, there are no symptoms listed. 1/21/25 HO JJ (Housekeeper) called in with symptoms of fever, headache, sore throat, rhinorrhea (runny nose), and itching. Testing results listed Influenza. Comments section states return to work 1/25/25 if fever free without medication and symptoms improve. Of note, there is no date symptoms resolved. 1/28/25 CNA KK call in with symptom of sore throat. Return to work date 1/7/25 [sic]. Of note, there is no date symptoms resolved. 1/28/25 CNA LL called in with symptoms of nausea, emesis, and diarrhea. Of note, there is no date symptoms resolved. On 2/18/25 at 12:30 PM, Surveyor interviewed IP S (Infection Preventionist) regarding staff surveillance. DON B was also present for the interview. IP S indicated staff should remain out of the facility if they have GI symptoms for 48 hours after symptoms have resolved. IP S indicated without completing the section of when symptoms resolved it is hard to determine if staff returned to work too early. IP S indicated HA FF and CNA GG returned to work too early. IP S indicated COVID testing should be completed if staff have symptoms of COVID and it should be documented on the line listing. IP S indicated RN I and UC J should have had testing completed. IP S indicated MN II should have had documented symptoms when he called in. IP S indicated the staff line listing should be filled out completely and was not.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 68 residents who reside at the facility. Surveyor observed dietary aide without a beard restraint in the kitchen. Surveyor observed garbage cans near the food prep area without lids. Surveyor observed spilled food or drink in the walk-in fridge. Evidenced by: The facility policy, Employee Sanitary Practices- Food and Nutrition Services, dated, 7/27/22, states, in part; .All food and nutrition services employees will practice good personal hygiene and safe food handling procedures .1. Wear hair restraints (hairnet, beard restraint) to prevent hair from contacting exposed food . On 2/16/25 at 9:45 AM, Dietary Manager K (DM) and Surveyor toured the kitchen. Surveyor observed Dietary Aide L (DA) in the kitchen not wearing a beard restraint. Surveyor observed garbage cans near the food prep area without lids. Surveyor observed yellow substance spilled in the walk-in refrigerator. DM K indicated she will ask staff to clean up the spill and it most likely was eggs. On 2/19/25 at 1:20 PM, Nursing Home Administrator A (NHA) indicated he would expect staff to wear a beard restraint when in the kitchen and when handling food. NHA A indicated understanding with the spilled food and need for lids on garbage cans near food and food prep area. The facility failed to maintain a safe and sanitary environment in which food is prepared, stored, and distributed.

Based on observation, interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R). This has the potential to affect all 68 residents residing at the facility. Surveyors entered on the weekend due to the facility triggering for low weekend staffing. NHA A (Nursing Home Administrator) indicated the schedule is based on the census and hours per patient day (HPPD), which does not take into consideration the acuity of the facility's resident population. Residents in Resident Council voiced concerns that staff take too long to answer call lights and meal trays on the halls are not passed timely due to staff not being available. R56 voiced concerns about long wait times when wanting to get up. Staff stated there are care items they cannot complete for residents due to having low staffing. This is evidenced by: The Facility Assessment Tool, date 1/3/25, states in part: Staffing plan: RN/LPN/LVN (Registered Nurse / Licensed Practical Nurse / Licensed Vocational Nurse) 1.5:40 RN/LPN Days, 1.5:40 RN/LPN Evenings. Direct care staff 1:13 ratio CNA (Certified Nursing Assistant) Days, 1:13 ratio CNA Evenings, 1:26 ration CNA Nights. Staff Hours on Average: RN Hours: .5, CNA Hours: 1.6, Total Nursing Staff Hours: 3.0 HPPD (Hours per patient day) is used to measure the amount of time for care each resident receives in a 24 hour period. HPPD is calculated using the following equation: total nursing hours divided by the number of residents. Example 1 On Sunday, February 16, 2025, surveyors entered the building for the facility's annual recertification survey. Surveyors entered on a weekend due to the facility triggering for low weekend staffing. Example 2 On 2/19/25 at 8:39 AM, Surveyor interviewed NHA A regarding the facility staffing. NHA A indicated he actively participates in the scheduling of the facility. NHA A stated the facility staffs according to the census, if the census goes up then the facility staffs more CNAs and if the census goes down then the facility will schedule less CNAs. NHA A stated the ideal schedule would be 3.0 HPPD. NHA A indicated during the all-staff monthly meetings, the staff have voiced it would be beneficial to have more staff scheduled. NHA indicated during resident council, residents have voiced concerns about low staffing levels. The facility census postings were reviewed for the dates 2/2/25 through 2/19/25 for HPPD, as follows: 2/2/25 was 2.6 HPPD (Sunday) 2/3/25 was 2.6 HPPD 2/4/25 was 2.5 HPPD 2/5/25 was 2.8 HPPD 2/6/25 was 2.6 HPPD 2/7/25 was 2.7 HPPD 2/8/25 was 2.9 HPPD (Saturday) 2/9/25 was 2.9 HPPD (Sunday) 2/10/25 was 2.5 HPPD 2/11/25 was 2.5 HPPD 2/12/25 was 3.2 HPPD 2/13/25 was 2.7 HPPD 2/14/25 was 2.3 HPPD 2/15/25 was 2.4 HPPD (Saturday) 2/16/25 was 2.7 HPPD (Sunday) 2/17/25 was 2.7 HPPD 2/18/25 was 2.6 HPPD 2/19/25 was 2.8 HPPD Of note, only one day (2/12/25) was at or above 3.0 HPPD. Example 3 Resident council minutes were reviewed. November 2024 resident council minutes state in part: 2nd shift can sometimes take too long to answer a call light . December 2024 resident council minute state in part: Residents voiced concerns for Hall trays not being passed timely, resulting in food that isn't as warm as they'd like. Resident stated that they understand that sometimes someone needs assistance when trays come but that someone should help to avoid food temps. On 2/19/25 at 12:30 PM, Surveyor interviewed NHA A regarding resident council concerns about staffing. NHA A stated residents in resident council have mentioned concerns with staffing but it is not a continual common theme. Example 4 R56 admitted to the facility on [DATE] with diagnoses including arthritis (joint inflammation). R56's comprehensive assessment, dated 1/5/25, indicates R56 is dependent on staff for toileting, personal hygiene, and requires 2 staff for transferring between surfaces. On 2/16/25 at 12:13 PM, Surveyor interviewed R56 about call light response time. R56 stated when he turns on his call light, staff will come in and turn it off and tell him they need to get a second person. R56 states it will take them 20 minutes or longer before they come back. R56 states he will sometimes turn his light back on if it takes too long for them to return. On 2/19/25 at 9:34 AM, Surveyor interviewed CNA E (certified nursing assistant) regarding call light response times. CNA E indicated call lights will be on for longer than 20 minutes at times. CNA E indicated she will go into a resident's room, turn off the call light without meeting the resident's needs and tell the resident she will be back. Example 5 On 2/19/25 at 9:20 AM, Surveyor interviewed LPN N (Licensed Practical Nurse) regarding staffing. LPN N indicated she does not perform any CNA duties when working because she does not have time to help. On 2/19/25 at 9:23 AM, Surveyor interviewed MT M (Med Tech, a CNA that can administer medications) regarding staffing. MT M indicated she does not perform any CNA duties when she is working as a med tech but will occasionally answer a resident's call light if she has time. On 2/19/25 at 9:24 AM, Surveyor interviewed CNA E regarding staffing. CNA E is employed full time at the facility. Surveyor asked CNA E to think about the last 2 weeks she has worked and to recall a time when she received help from ancillary staff or the nurses. CNA E indicated she has not received help from other staff or the nurses when completing her CNA duties. CNA E indicated she cannot complete all the resident's care, due to low staffing. CNA E indicated she cannot always get to things like resident's oral care. CNA E indicated resident call light response time can be longer than 20 minutes at times due to low staffing. On 2/19/25 at 9:38 AM, Surveyor interviewed CNA CC regarding staffing. CNA CC indicated he can't get it all done when questioned about completing resident care. CNA CC indicated he cannot complete things like range of motion or oral care for residents. CNA CC states he must prioritize things like changing incontinent residents over providing oral care. On 2/19/25 at 12:30 PM, Surveyor interviewed NHA A regarding low staffing. NHA A indicated multiple department heads are [NAME] certified and can work as a CNA but it is rarely required. 44552 Example 6 On 2/16/25 Surveyor observed lunch starting down D hallway at 12:10 PM. Most residents down D hallway eat in the common/living room area down D hallway. Surveyor observed no staff in common area on two separate times during lunch time. Surveyor observed no staff from 12:20PM-12:32PM and again at 12:40PM-12:51PM. Multiple residents require supervision and assistance during meals. Surveyor observed R38 struggling with her meal. Surveyor observed R38 attempting to raise her spoon up five times and was unable to get her spoon all the way up to her mouth. R38 asked Surveyor if Surveyor could help her eat her meal. Example 7 On 2/16/25 at 12:30 PM, CNA Z (certified nursing assistant) indicated it is usually just one staff down D hall on the weekends. CNA Z indicated it depends on the weekend if there is an activity aid at the facility. CNA Z indicated there are times she can not get all the tasks done due to the staffing ratio. CNA Z indicated there is supposed to be a float CNA that works all hallways. CNA Z indicated staff is not quick to respond when asking for help over the walkie talkie. CNA Z indicated there are times that the float CNA is helping someone else, on break, or the position didn't get filled that day. Example 8 R38 was admitted to the facility on [DATE]. R38's Minimum Data Set, dated dated dated [DATE] indicates R38 has a brief interview of mental status score of 08 out of 15, indicating R38 is moderately cognitively impaired. On 2/16/25 at 2:18 PM, R38 indicated she needs assistance with eating meals. Surveyor asked R38 if the CNA often got pulled to answer call lights or help others during mealtime? R38 stated yes. Surveyor asked if R38 often waits for assistance to eat? R38 indicated yes. R38 indicated staffing is a concern and there is often not enough staff down R38's hallway. Example 9 On 2/16/25 at 2:45 PM, CNA AA indicated it is common that there is only one CNA down D hallway. CNA AA indicated staffing is a concern. Example 10: On 2/17/25 at 2:18 PM, CNA BB (certified nursing assistant) indicated staffing is a concern. CNA BB indicated there is often one CNA down D hallway and with the population they serve down D hallway it gets very chaotic. There are not activity aides or any activities during the weekends. CNA BB indicated the activities are not geared for residents with dementia. CNA BB indicated she has voiced these concerns, and nothing changed. CNA BB indicated more activities would benefit everyone down D hallway. CNA BB indicated there are times she can't get to everyone at the end of the shift to assist with repositioning and going to the bathroom. CNA BB indicated the float is not usually down D hallway and recently two minors were working on A hallway alone and neither of them can use the Hoyer lift. CNA BB indicated she is often very rushed, and the residents can feel that. 50285 Example 11: R12 was admitted to the facility on [DATE] with diagnoses that include, in part: Muscle Weakness, Type 2 Diabetes Mellitus, Emphysema Unspecified (a chronic lung disease that makes it difficult to breathe), Major Depressive Disorder, and Chronic Pain. R12's MDS (Minimum Data Set) with a target date of 2/10/25, indicates, in part: BIMS (Brief Interview of Mental Status) score of 14 out of 15, indicating R12 is cognitively intact. R12's Care Plan, dated 1/16/25, states, in part: Focus: ADL (Activities of Daily Living) self-care deficit as evidenced by: total assist related to: progressive generalized weakness, severe . Goal: Will receive assistance to meet ADL needs . Interventions: Bed Mobility: Assist of 2 for bed mobility able to reposition self slightly . Dressing: Requires extensive assist of 1 staff to dress . Locomotion: requires total assist with locomotion . Personal Hygiene: Assist of 1 to wash own face and hands . Toileting: Assist of 2 using bedside commode and use of shower sling for transfers. Generally continent of bowel, occasionally incontinent of bladder . Transfer: Assist of 2 staff and use of mechanical lift . On 2/16/25 at 10:18 AM, Surveyor interviewed R12, who stated, the people work very hard here, but they don't have enough staff. R12 indicated that he has had to wait a long time for staff assistance. R12 stated that last night he waited a half hour to use the commode, but that sometimes it is over an hour. R12 indicated that the staff have to use the Hoyer lift to get him to the commode, and that sometimes they can't find anyone to help, so that he has to wait longer. R12 stated that it was very difficult to wait that long to go to the bathroom, and that he felt, like I'm not very important. Example 12: R1 was admitted to the facility on [DATE] with diagnoses that include, in part: Alzheimer's Disease with late onset, Dementia in other diseases classified elsewhere, moderate, and Major Depressive Disorder. R1's admission MDS with a date of 11/25/24, indicates, in part: a BIMS score of 9 out of 15, indicating R1 has moderate cognitive impairment. R1's Care Plan, dated 2/15/21, states, in part: Focus: ADL self-care deficit related to: physical limitation, dementia with behaviors . Goal: Will be clean, dressed and well groomed daily to promote dignity and psychosocial wellbeing . Interventions: Ambulation: [Resident Name] is non ambulatory at this time . Bathing: [Resident Name] requires extensive to near total assist with showering . Bed Mobility: [Resident Name] requires extensive assist of 1 staff with repositioning . Dressing: [Resident Name] requires extensive assist of 1 staff for dressing . Eating: [Resident Name] requires set up assist with meals . Locomotion: [Resident Name] requires extensive assist of 1 staff for locomotion in wheelchair . Personal Hygiene: [Resident Name] requires extensive assist with personal hygiene . Toileting: [Resident Name] requires extensive assist of one staff with toileting and is frequently incontinent of bladder and bowel . Transfers: [Resident Name] requires extensive assist with transfers with 2 staff and use of EZ-stand . On 2/16/25 at 10:52 AM, Surveyor interviewed R1, who stated that sometimes she has to wait an hour for her call light to be answered. R1 stated that it makes her feel anxious to wait that long to have to use the bathroom, as she is unable to do it by herself. Example 13: R316 was admitted to the facility on [DATE] with diagnoses that include, in part: Weakness, Hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body), Hemiparesis (one-sided muscle weakness), and Personal History of Urinary Tract Infections. R316's Care Plan, dated 2/12/25, states, in part: Focus: ADL self-care deficit as evidenced by: right sided deficit/weakness related to: stroke . Goal: Will improve current level of function in ADLs (activities of daily living) through the review date . Interventions: Ambulation/Locomotion: with device wheelchair . Bathing/Showering: Assist of 1 staff . Personal Hygiene: Assist of 1 staff . Toileting: Assist of 1 staff . Transfer: Assist of 2. Transfer with EZ-stand for all transfers with 2 staff . On 2/16/25 at 10:28 AM, Surveyor interviewed R316, who indicated that usually he has to wait a long time for his call light to be answered. R316 stated that he requires assistance from staff to get up and then to lay back down, and that he had to wait a half hour this morning. R316 stated he felt extremely frustrated having to just sit and wait, and that at times they are so short staffed he has to wait an hour. Example 14: R15 was admitted to the facility on [DATE] with diagnosis that include, in part: Seizures, Contracture of Muscles, multiple sites, Weakness, and Unspecified Atrial Fibrillation (a common heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly). R15's admission MDS with a date of 1/21/25, indicates, in part: a BIMS score of 13 out of 15, indicating R15 is cognitively intact. R15's Care Plan, dated 7/15/24, states, in part: Focus: ADL self-care deficit as evidenced by: need for staff assist . Goal: Will improve current level of function in ADLs through the review date . Interventions: Ambulation/Locomotion: [Resident Name] is non-ambulatory at this time. Requires extensive assist with locomotion . Bathing/Showering: Assist of 1 to shower or bathe . Bed Mobility: Requires assist of 1 for bed mobility . Dressing: Assist of 1 for dressing . Personal Hygiene: Assist of 1 to set up and encourage her to wash her own face and hands . Toileting: Assist of 1 for toileting. Continent of both bowel and bladder with occasional episodes of bladder incontinence . Transfer: Transfer with 1 staff, walker and gait belt . On 2/16/25 at 10:36 AM, Surveyor interviewed R15, who indicated that call lights are not answered right away, sometimes she has to wait because the staff are busy. R15 indicated she did not know how long she has to wait, but at times it can be quite long. R15 stated she is angry when she has to wait to go to the bathroom and she sometimes has accidents if she has to wait too long due to their not being enough staff. Example 15: On 2/16/25 at 2:13 PM, Surveyor interviewed Staff Member F, who wished to remain anonymous. Staff Member F told Surveyor that she does not feel like there is enough staff to meet the residents needs. Staff Member F stated that sometimes she is scheduled to work A wing by herself with over 20 residents to care for, and that she doesn't feel like that is safe. Staff Member F indicated that when they are short staffed, they are not able to get resident's showers completed, do oral cares, or toilet and reposition every two hours. Staff Member F stated that this happens frequently. Example 16: On 2/18/25 at 10:57 AM, Surveyor interviewed CNA E who stated that they are short staffed a couple times a week, mostly on PM shift. CNA E stated that when they don't have enough staff they can't get to toileting or repositioning the residents frequently enough. Cross Reference: F686

Based on observation, interview, and record review, the facility failed to provide an ongoing program to support resident choice of activities, based on the comprehensive assessment and care plan and the preferences of each resident for 2 (R38 and R58) of 20 total sampled Residents and 2 (R33 and R25) of 12 supplemental residents who reside on D Hallway. Surveyor observed R38, R58, R33 and R25 from 2/16/25-2/18/25. The facility did not provide residents with meaningful activities. Evidenced by: The facility policy, Activities, dated 7/11/22, states, in part; .2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Promote or enhance physical activity. c. Promote or enhance cognition. d. Promote or enhance emotional health. e. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence. f. Reflect resident's interests and age. g. Reflect cultural and religious interests of the residents. h. Reflect choices of the residents .9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs . Example 1 R38 was admitted to the facility on [DATE] with a diagnoses including Alzheimer's disease, Dementia with psychotic disturbance, restless leg syndrome, essential tremor, and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). R38's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 1/21/25, indicates R38 has a BIMS (Brief Interview for Mental Status) score of 08 indicating R38 is moderately cognitively impaired. R38 has an activated power of attorney. R38's Comprehensive Care Plan, states, in part; .While in the facility, R38 states that it's important that she engage in activities that are meaningful to her preferences/interest 10/22/24 .I am catholic faith and would like to participate in religious services/practices such as attending in-house services and self-directing my own prayer. I enjoy socializing with others, spending time with family/friends, keeping up with the morning news, country music, baking/cooking, being around children, balloon ball, and watching TV/movies. I also like to sit/relax and socialize outdoors; I prefer warm weather. I used to enjoy making cards, coloring, and parties/socials. It is important for me to engage in my favorite activities .I would benefit from accommodations from physical limitations by having assistance to/from programs. I would benefit from accommodations from visual limitations by having large print materials. I would like pet visits, if available, and I enjoy dogs .I would like to vote, if able . Surveyor reviewed R38's activity participation documentation from December 2024 and January 2025. There are 21 days with no activity participation documentation. Surveyor observed R38 on 2/16/25. R38 was not offered and did not participate in any activities. R38's activity documentation for 2/16/25 was blank. On 2/16/25 at 2:18 PM, R38 indicated the facility is short staffed and this concerns R38. R38 indicated she would like to be offered different things to do. Surveyor observed R38 on 2/17/25. Surveyor did not observe R38 participating in any activities. Surveyor reviewed R38's activity documentation for 2/17/25, R38 participated in watching a movie for the entire day. Surveyor observed R38 on 2/18/25. At 10:35 AM, R38 went and got her nails done and returned to D hallway shortly after. R38 did not participate in any other activities. Example 2 R33 was admitted to the facility on [DATE] with a diagnoses including Alzheimer's disease, adjustment disorder with depressed mood, unspecified hearing loss, and dementia with anxiety. R33 most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/4/24, indicates R33 has a BIMS (Brief Interview for Mental Status) score of 00 indicating R33 is severely cognitively impaired. R33 has an activated power of attorney. R33's Comprehensive Care Plan, states, in part; .it is important that she engage in activities that are meaningful to her preferences/interest .I enjoy looking through magazines/the newspaper, baking/cooking, observing programs, attending social/special events, watching TV/movies, socializing with others, doing word search puzzles, and playing cards-dirty clubs. I use to enjoy the news, working in my flower garden, walking to my son's house, and traveling. I also like to sit/relax in nature and outdoors when the weather is nice. I prefer hot/warm and sunny weather. It is important for me to engage in my favorite activities 9/7/21 . Surveyor reviewed R33's activity documentation from December 2024 and January 2025. There are 22 days with no activity participation documented. Surveyor observed R33 on 2/16/25. R33 was not offered and did not participate in any activities. R33's activity documentation for 2/16/25 was blank. Surveyor observed R33 on 2/17/25. Surveyor did not observe R33 participating in any activities. Surveyor reviewed R38's activity documentation for 2/17/25, R33 participated in watching a movie for the entire day. Surveyor observed R33 on 2/18/25. R33 did not participate in any activities in the morning. At 1:55 PM, activity staff assisted R33 in attending the baking activity in the activity room until 3 PM. R33 did not participate in any other activities. Example 3 R25 was admitted to the facility on [DATE] with a diagnoses including dementia. R25's most recent MDS (Minimum Data Set) with ARD (Assessment Reference date) of 12/12/24, indicates R25 has a BIMS (Brief Interview for Mental Status) score of 03 indicating R25 is severely cognitively impaired. R25 has an activated power of attorney. R25's Comprehensive Care Plan, states, in part; .it is important that she engages in activities that are meaningful to her .I prefer to keep to myself. I do enjoy reading the newspaper and magazines, resting/laying down, listening to all kinds of music, socializing with others, doing word search puzzles and watching TV/movies. I also like to sit/relax, socials, and nature watch outdoors when the weather is nice; I prefer warm/cool weather. I use to enjoy bingo, sewing/knitting, and having a vegetable garden. It is important for me to engage in my favorite activities .12/13/23 .I would benefit from accommodations from cognitive limitations by having reminders for programs, verbal/physical prompts, single step direction, and assistance to/from programs .I would benefit from accommodations from hearing limitations by having placement near the speaker/leader of the program .I would benefit from accommodations from physical limitations by having assistance to/from program . Surveyor reviewed R25's activity participation documentation for December 2024 and January 2025. There are 22 days with no activity participation documented. Surveyor observed R25 on 2/16/25. R25 was not offered and did not participate in any activities. R25's activity documentation for 2/16/25 was blank. Surveyor observed R25 on 2/17/25 and 2/18/25. Surveyor did not observe R25 participate in any activities. Surveyor reviewed R25's activity participation documentation. R25 listened to the radio. Example 4 R58 was admitted to the facility on [DATE] with a diagnoses including cognitive communication deficit, weakness, anxiety disorder, major depressive disorder, and mild cognitive impairment. R58's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 1/6/25, indicates R58 has a BIMS (Brief Interview for Mental Status) score of 08 indicating R58 is moderately cognitively impaired. R58 has an activated power of attorney. R58's Comprehensive Care Plan, states, in part; .it's important that she engage in activities that are meaningful to her preferences/interest .I am of the catholic faith and would like to participate in religious services such as self-directing my own prayer and possibly attending in-house services. I enjoy socializing with others, coloring, keeping up with the local news, listening to classic country music, reading all kinds of materials, car rides and watching TV. I use to enjoy gardening/plants. I also like to sit/relax outdoors, and I prefer warm weather. It is important for me to engage in my favorite activities 1/6/25 . Surveyor observed R58 on 2/16/25. R58 was not offered and did not participate in any activities. R58's activity documentation for 2/16/25 was blank. On 2/16/25 at 2:57 PM, R58 asked what there was to do. Staff indicated R58 could go to the bathroom. R58 indicated that's something to do and she could go to the bathroom. Surveyor asked R58 if she would like some activities and things to do. R58 indicated she would like that. On 2/17/25 at 2:18 PM, CNA BB (Certified Nursing Assistant) indicated there is often one CNA down D hallway and with the population they serve down D hallway it gets very chaotic. There are not activity aides or any activities during the weekends. CNA BB indicated the activities are not geared for residents with dementia. CNA BB indicated she has voiced these concerns, and nothing had changed. CNA BB indicated more activities and activities that are tailored for residents with dementia would benefit everyone down D hallway. On 2/18/25 at 9:45 AM, CNA KK indicated there are not a lot of activities offered for residents on D hallway. CNA KK indicated the activities are not for residents with dementia. On 2/18/25 at 10:43 AM, Surveyor asked LPN X (Licensed Practical Nurse) about activities for the residents on D hallway. Surveyor asked about activities specifically for residents with dementia. LPN X indicated she was unsure what was offered for the residents on D hallway. LPN X indicated, They all look so bored. On 2/19/25 at 9:13 AM, LES NN (Life Enrichment Specialist) indicated she always encourages her staff to include the residents on D hallway for all activities. LES NN indicated she will stress more to her staff about encouraging all residents to attend activities. LES NN indicated she will follow up with her staff regarding weekend activities as well. LES NN indicated she has some good staff on the team now and there has been improvements. LES NN indicated she tries to keep the bigger activities scheduled on the same days and there are items down D hallway so the residents can use items such as coloring pages, books, and puzzles. Surveyor asked LES NN how do you ensure residents that are not independent with activities still have meaningful activities and are included? LES NN indicated she always asks residents at resident council about activities and what they would like to see on the calendar. LES NN indicated they will pair up residents and try to bring as many residents as possible down to activities. LES NN indicated the resident might prefer to watch and observe an activity and it is important for them to still be invited and included in that activity. LES NN indicated staff will reapproach the resident as well if they at first decline joining the activity. LES NN indicated they do the best they can for including the residents that have dementia and may need more support. LES NN indicated R38, R58, and R33 can be independent with activities. LES NN indicated R25 is more difficult in finding activities that she may enjoy participating in. Surveyor shared with LES NN observations regarding residents down D hallway and activities. LES NN indicated CNA's can assist with activities as well and assist in setting up residents with activities. Surveyor indicated if there is one CNA down D hallway there might not be a lot of time to do activities. LES NN stated yes that is true. LES NN indicated she will provide education to her weekend staff and that Wednesday and Thursday are better down D hallway. On 2/19/25 at 12:30 PM CNA M indicated R38, R58, R33, and R25 are not independent with their activities. CNA M indicated the residents need assistance and support from staff for activities. On 2/19/25 at 12:36 PM, CNA Z indicated R38, R58, R33, and R25 need assistance with activities. CNA Z indicated they are not independent or able to structure their own activities. On 2/19/25 at 1:20 PM, NHA A (Nursing Home Administrator) indicated understanding regarding the concern with the lack of activities for the residents on D hallway. The facility failed to provide an on going program to support resident choice of activities, based on the comprehensive assessment and care plan and the preferences of each resident who resides at the facility.

Based on observation, interview and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment for 1 of 20 sampled residents (R316) and 6 of 12 supplemental residents ((R15, R11, R30, R18, R26, R42). R316, R42, R15, R11, R30, R18, and R26 indicated that the dining room was very cold, and they were wearing jackets or wrapped in blankets to stay warm. Resident Council meeting minutes dated 1/23/25, indicated the facility was aware that residents had concerns of it being too cold in the dining room. Evidenced by: Facility policy, entitled Safe and Homelike Environment Policy, dated 6/16/22, includes in part . Definitions: Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents . Policy Explanation and Compliance Guidelines . 7. The facility will maintain comfortable and safe temperature levels. a. The facility will strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit . Example 1 R316 admitted to the facility on [DATE]. R316's Minimum Data Set (MDS) dated [DATE] indicates, in part: a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating R316 is cognitively intact. On 2/16/25 at 12:26 PM, Surveyor observed R316 dressed in only a hospital gown and gripper socks in the dining room. R316 had a blanket wrapped around his shoulders. R316 was seated at the dining room table eating lunch. On 2/17/25 at 12:42 PM, Surveyor observed R316 dressed only in a hospital gown and gripper socks in the dining room. R316 had a blanket wrapped around his head, another blanket wrapped around his shoulders, and a third blanket on his lap. R316 was seated at the dining room table eating lunch. On 2/18/25 at 8:18 AM, Surveyor observed R316 again dressed only in a hospital gown and gripper socks and huddled in blankets in the dining room. Resident stated, it is definitely cold in here today. Example 2 R11 was admitted to the facility on [DATE]. R11's MDS dated [DATE] indicates, in part: a BIMS score of 15 out of 15, indicating R11 is cognitively intact. On 2/18/25 at 8:19 AM, Surveyor observed R11 with a blanket around her shoulders in the dining room. R11 answered yes when asked if she was cold. Example 3 R42 admitted to the facility on [DATE]. R42's MDS dated [DATE] indicates, in part: a BIMS score of 11 out of 15, indicating mild cognitive impairment. On 2/18/25 at 8:20 AM, Surveyor observed R42 sitting at the dining room table wearing a jacket. R42 told Surveyor he was wearing the jacket because he was trying to keep warm. Example 4 R30 was admitted to the facility on [DATE]. R30's MDS dated [DATE] indicates, in part: a BIMS score of 10 out of 15, indicating a moderate cognitive impairment. On 2/18/25 at 8:21 AM, Surveyor observed R30 sitting at the dining room table wearing a jacket. Surveyor asked R30 if he was cold. R30 stated you bet I'm cold. Example 5 R18 was admitted to the facility on [DATE]. R18's MDS dated [DATE] indicates, in part: a BIMS score of 10 out of 15, indicating a moderate cognitive impairment. On 2/18/25 at 8:22 AM, Surveyor observed R18 sitting at the dining room table wearing a jacket. Surveyor asked R18 if he was cold. R18 stated yes I am cold, especially since I just got out of the shower. Example 6 R26 admitted to the facility on [DATE]. R26's MDS dated [DATE] indicates, in part: a BIMS score of 9 out of 15, indicating a moderate cognitive impairment. On 2/18/25 at 8:24 AM, Surveyor observed R26 wrapped in a blanket while sitting at a table in the dining room. Surveyor asked R26 if she was cold. R26 replied, oh yes, it is cold in here. On 2/18/25 at 8:25 AM, Surveyor observed PTA C (Physical Therapy Assistant) enter the dining room and visibly shudder. PTA C said, brr its cold in here. On 2/18/25 at 8:25 AM, Surveyor took a reading of the air temperature in the dining room, which read 56.8 degrees Fahrenheit. On 2/18/25 at 8:26 AM, Surveyor interviewed NHA A (Nursing Home Administrator) in the dining room and showed him the temperature reading. NHA A stated he would check the thermostats and get the boilers going to get it warmer in here. NHA A stated it would take about an hour to kick in. On 2/18/25 at 10:12 AM, Surveyor took a reading of the air temperature in the dining room, which read 62.2 degrees Fahrenheit. On 2/18/25 at 12:32 PM, Surveyor interviewed PTA C about the temperature in the dining room this morning. PTA C stated that she thought it was too cold in the dining room for the residents to be in there this morning, and that sometimes when it is really cold, they would keep the residents in their rooms to eat. On 2/18/25 at 12:36 PM, Surveyor took a reading of the air temperature in the dining room, which read 64.4 degrees Fahrenheit. On 2/18/25 at 12:37 PM, Surveyor interviewed NHA A, and asked how long the temperature in the dining room had been an issue. NHA A indicated that there is only a concern when the temperature reaches below zero, in which case they take additional measures such as closing the blinds to keep the heat in. Surveyor pointed out that many of the blinds in the dining room were up on this day and throughout the survey period. NHA A stated that they also will provide the residents with blankets and sweaters if they ask. Surveyor shared with NHA A that this was a concern that was brought up at resident council in January and asked why it had not been corrected. NHA A indicated that the facility is in need of two brand new boilers, and they needed an opportunity for the weather to get warmer in order to install them. NHA A stated that they had contracted with a company to come out and repack the ceiling with more insulation to maintain the heat. This was originally scheduled for 2/14/25 but was canceled and rescheduled for 2/21/25. NHA A stated that they had shut the dining room in January when it was very cold, but that they like to respect the resident's choice to eat in the dining room. Surveyor pointed out to NHA A that 56.8 degrees Fahrenheit was well below the acceptable air temperature range for the facility, and asked if he would consider that to be a homelike environment. NHA A stated that he believes they do everything they can to maintain a homelike environment in the facility, but they respect the resident's choice above all else. On 2/18/25 at 1:45 PM, Surveyor interviewed Maintenance G. Surveyor asked if he monitors the ambient temperature in the dining room. Maintenance G stated that he did not. Surveyor asked Maintenance G if 56.8 degrees Fahrenheit was an acceptable dining room temperature. Maintenance G stated no it was not.

Based on observation and interview and record review, the facility did not ensure that residents were ensured a dignified existence and self-determination for 1 of 20 sampled residents (R316). R316 voiced concerns that he had no clothes to wear and was forced to wear a hospital gown all the time, including to the dining room for meals. As evidenced by: The Facility policy titled, Resident Rights, dated 9/2017, states, in part: Purpose: To ensure that resident rights are respected, protected, and promoted . Procedure: Residents will be treated with respect and dignity and care for each resident will be given in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality . 38. All facility staff are to encourage residents to exercise their rights by providing choices . R316 admitted to the facility on [DATE]. R316's Minimum Data Set (MDS) dated [DATE] indicates, in part: a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating R316 is cognitively intact. On 2/16/25 at 12:26 PM, Surveyor observed R316 dressed in only a hospital gown and gripper socks in the dining room. R316 had a blanket wrapped around his shoulders. R316 was seated at the dining room table eating lunch. On 2/17/25 at 12:42 PM, Surveyor observed R316 dressed only in a hospital gown and gripper socks in the dining room. R316 had a blanket wrapped around his head, another blanket wrapped around his shoulders, and a third blanket on his lap. R316 was seated at the dining room table eating lunch. On 2/17/25 at 4:34 PM, Surveyor interviewed R316 who indicated that he prefers not to go to the dining room in a hospital gown. R316 stated that he also has an assisted living apartment, where all of his clothes are, and that he only has one pair of clothes with him. R316 stated that he tries to keep his one set of clothes for when he has to go out to appointments. R316 indicated that he does not have anyone in the area who can bring his clothes to him from his assisted living apartment. Surveyor asked R316 if anyone in the community had offered for him to wear extra clothes from the lost and found. R316 stated they had not. Surveyor asked R316 if he would be willing to wear some extra clothes from the community until he could get his own from his apartment. R316 stated yes, he would really appreciate not having to wear a hospital gown. R316 stated he was not here to win a beauty contest, but that he feels exposed in the hospital gown, and they are not very warm. On 2/18/25 at 9:29 AM, Surveyor interviewed SW D (Social Worker) about R316 not having any clothes to wear. SW D indicated that R316's family lives in another state, and he didn't have anyone to bring him clothes from his apartment. SW D stated he had contacted R316's assisted living manager, and a staff member from the assisted living would be bringing R316 some of his clothes and other belongings, hopefully by the end of the week. Surveyor asked SW D if the community laundry had some extra clothes in the lost and found that could be offered to R316. SW D indicated that they do have extra clothes and he would try to get him some today. On 2/18/25 at 10:16 AM, Surveyor observed R316 in his room in a t-shirt and sweat pants. R316 stated that it felt good to be wearing regular clothes, even if they were not his own. Surveyor asked R316 if staff had ever offered him clothes before today. R316 stated no, today was the first time they had ever offered him clothes to wear.

Based on observation, interview, and record review the facility did not promote and facilitate resident self-determination through support of resident choices and preferences for 1 (R44) of 20 sampled residents and 1 (R15) of 12 supplemental residents reviewed. R44 and R15 voiced concerns with receiving eggs almost every day for breakfast. R44 and R15 indicated they shared this concern, and it has not been corrected. Evidenced by: The facility policy, Resident Rights, dated 7/22, states, in part; .17. The resident has the right and this facility promotes and support the right to make choices about aspects of his/her life in the facility that are significant to the resident . Example 1 R44 was admitted to the facility on [DATE]. R44's most recent MDS dated [DATE] states that R44 has a BIMS of 15 out of 15, indicating that R44 is cognitively intact. R44's most recent Nutritional Assessment, states, in part; .preferences: see tray card . On 2/19/25 at 8:33 AM, R44 indicated most mornings she receives scrambled eggs. R44 indicated she has voiced her preferences and concern with the kitchen. R44 indicated she continues to receive scrambled eggs. Surveyor reviewed meal ticket. R44's meal ticket does not include any preferences or not wanting scrambled eggs. 50285 Example 2: R15 was admitted to the facility on [DATE]. R15's Minimum Data Set (MDS) with a date of 1/21/25, indicates, in part: a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicating R15 is cognitively intact. R15's Care Plan, dated 7/15/24, states in part: Focus: At risk for nutritional status change related to history of unintended weight loss . Intervention: Honor food preferences .: On 2/16/25 at 10:36 AM, Surveyor interviewed R15, who indicated that the food was sometimes good, and sometimes not so good, but that she hates scrambled eggs and gets them every morning. On 2/17/25 at 8:34 AM, Surveyor observed R15 in the dining room. R15 was served scrambled eggs for breakfast by BOM H (Business Office Manger). Surveyor overheard R15 saying I hate scrambled eggs. R15 was not offered a substitution. Surveyor observed R15 eating the toast and oatmeal, then returning to her room, leaving the scrambled eggs untouched. On 2/17/25 at 9:52 AM, Surveyor interviewed BOM H and asked her if the residents could get a substitution if they didn't like something that was served. BOM H stated that they do accommodate substitutions. Surveyor asked BOM H if she had offered R15 a substitution when she stated that she hated scrambled eggs. BOM H stated that she did not hear R15 say that. Surveyor asked BOM H what the process was to have a resident's dietary preferences printed on their meal ticket. BOM H stated that the dietary manager meets with the residents when they first move in to the community and then periodically after that. On 2/18/25 and again on 2/19/25, Surveyor reviewed R15's meal ticket in the dining room. R15's meal ticket stated both times: Regular cut meat into bite size, large portions, built up fork, built up knife, built up spoon. No amendment was made to indicated that R15 did not like scrambled eggs. On 2/19/25 at 10:57 AM, [NAME] OO indicated the kitchen will add resident preferences to their meal tickets at admission and as needed. [NAME] OO indicated she will let DM (Dietary Manager) know about the need to update R44 and R15's meal tickets. On 2/19/25 at 1:20 PM Nursing Home Administrator A (NHA) indicated understanding regarding the need to update R44 and R15's meal tickets to include preferences. The facility did not promote and facilitate resident self-determination through support of resident choices and preferences.

Based on interview and record review, the facility did not ensure that all incidents involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the incident, if the events involve abuse to the appropriate agencies for 2 of 2 resident-to-resident abuse allegations (R50 and R53). R50 has a history of being verbally aggressive towards others. R50 was verbally aggressive towards R53 and made him cry on 2/10/25. The UC J (Unit clerk), NHA A (Nursing Home Administrator), DON B (Director of Nursing), and RN I (Registered Nurse), were aware of this incident, but it was not reported to the state agency. Evidenced by: Facility policy, titled Abuse, Neglect and Exploitation dated 2/2018 with a revision date of 7/15/22, 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 . Definitions: Verbal Abuse means the use of oral, written or gestured communications or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . 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 to all other required agencies . within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or 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 . B. The Administrator will follow up with government agencies to report the results of the investigation when final within 5 working days of the incident, as required by state agencies . R50 was admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R50's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/28/24, indicates R50 has a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R50 is cognitively intact. (Of note, R50's comprehensive care plan does not include her Dementia diagnosis or include anything about aggressive behaviors, triggers, or interventions.) R50's Progress Notes include, in part, the following: On 2/10/25 at 8:55 AM, Type: Behavior Note: Resident came into Bird Room while another resident was actively enjoying a tv program. [Resident Name] went to the tv and changed the channel, without regard for the other resident. The other resident politely went to the unit clerk and requested for the channel to be put back to what he was watching. As the Unit Clerk was changing the channel, [Resident Name] started yelling at the unit clerk and the other resident. She stated I don't need anybody else in here disturbing me while I do my work! I don't watch tv to watch tv! and I can't have games on the tv in here because they are distracting! You can go somewhere else to watch tv! BUT NOT HERE in MY workspace! Unit clerk reminded [Resident Name] that the bird room is a public space. [Resident Name] stated they could go somewhere else other than the Bird Room . [Resident Name] continued to argue over the unit clerk and the other resident got very upset and said he would just leave and go elsewhere and was crying. This writer reminded [Resident Name] that the Bird room is for all residents and that she should be respectful to others. [Resident Name] ignored this writer as if she wasn't there. Note: yesterday, this same resident was in the bird room and [Resident Name] came to the room and started blaring music from her cell phone to force him to leave the area. When asked to turn the music down, [Resident Name] pretended she wasn't being talked to . [Resident Name] was again reminded that she had other tv options and other places she could choose to do her work but could not control the tv when someone else was already watching it and that it's everyone's room, not just for her. This note will be given to ED (Executive Director). On 2/19/25 at 10:26 AM, Surveyor interviewed RN I (Registered Nurse) about the verbal altercation between R50 and R53. (RN I is the author of above progress note). RN I stated that R53 was sitting in the bird room watching TV when R50 came in and changed the channel. RN I stated that R53 politely asked R50 to change it back, but R50 ignored him, so R53 left the room and talked to UC J (Unit Clerk) to have the channel changed back. R53 told UC J that R50 was giving him a hard time. UC J went to the bird room with R53 and attempted to change the channel. R50 started screaming saying we don't have the right to disrupt her in her workspace during her work time. R50 said she was not to be disturbed and there are plenty of other places for people to watch TV. UC J politely told R50 that was a space for everyone to use. R50 started screaming louder and repeating this is my workspace. At this point, R53 became emotional, stating I was not trying to hurt anyone or upset anyone I was just trying to watch TV, and then R53 left the room in tears. RN I indicated both her and UC J have told R50 that she needs to be more respectful of others, but she ignores them. RN I indicated that the previous day, R50 blasted her music on her cell phone in order to get R53 to leave. R50 again ignored them. RN I stated that R53 will still go in the bird room to enjoy the birds and watch TV, but only if R50 is not in there. RN I indicated that R53 is afraid to go in there now, as is several other residents and family members. Surveyor asked RN I if this would be considered resident-to-resident verbal abuse. RN I stated that yes she would consider it verbal abuse, because R50 just kept screaming at R53 until he started crying. Surveyor asked who she reports abuse allegations to. RN I stated she reported this incident to NHA A and that she printed out her progress behavior note for him to review. On 2/19/25 at 12:37 PM, Surveyor interviewed UC J via telephone. Surveyor asked UC J about R50's behaviors. UC J indicated that there have been several incidents in the bird room with other residents. UC J stated that a few days prior, she noticed R50 and another resident sitting in the bird room with the lights off. When UC J went to turn the lights on for the other resident, R50 started screaming at them. UC J indicated it has been an ongoing issue. Surveyor asked UC J about the event that happened between R50 and R53 on 2/10/25. UC J stated R53 was in the bird room watching the game channel when R50 came in and changed the channel. R53 began screaming profanity at R53 and told him he could go somewhere else to watch TV. UC J indicated R53 became very upset when he came out and told her what had happened, that he was crying and visibly upset. Surveyor asked UC J if she would consider this resident-to-resident verbal abuse. UC J stated yes, she would. Surveyor asked UC J who she reports allegations of abuse to. UC J stated she reported this incident to NHA A. On 2/19/25 at 1:06 PM, Surveyor interviewed DON B (Director of Nursing) and discussed the incident between R50 and R53. Surveyor asked DON B if this incident would be considered resident-to-resident verbal abuse. DON B stated no, he did not consider it to be verbal abuse. Surveyor reviewed the progress note with DON B and asked if one resident screaming at another resident and making them cry would be verbal abuse. DON B stated it was his understanding that R50 was not yelling at R53 directly but was just yelling in general. On 2/19/25 at 1:39 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about the incident that occurred between R50 and R53 on 2/10/25. Surveyor asked NHA A if this incident could be considered resident-to resident verbal abuse. NHA A indicated no because it was his understanding that her outbursts are more directed at staff members and not at other residents. Surveyor pointed out that the incident progress note as well as several staff interviews indicated that R53 was visibly upset and crying after the incident. Surveyor asked NHA A what the process was for determining if a resident-to-resident altercation was reportable. NHA A replied he would follow the CMS resident-to-resident diagram, and did not feel that it rose to the level of a reportable incident. Of note, the Resident-to-Resident Altercation Flowchart states in part: resident to resident altercation occurs - did resident act willfully? Willful means the individual's act was deliberate- not inadvertent or accidental regardless of whether or not the individual intended to inflict injury or harm. (A resident whose involuntary movements cause him/her to accidentally strike another has not committed a willful act.) if the no option is selected, do not report. Document an immediate assessment and lack of willful intent. Assess-care plan- intervene. Goal: Prevent reoccurrence and keep other residents safe. Also, the flowchart states Use of this flowchart must provide for immediate reporting (see F609) or the facility must clearly document the rationale for not reporting. The facility failed to recognize and report a resident-to-resident altercation, despite several staff members having knowledge of the incident. The facility failed to recognize a resident's verbally aggressive behaviors and negative interactions with other residents as abuse and failed to report this incident to the state agency within the appropriate timeframes. Cross Reference: F609 & F744

Based on interview and record review, the facility did not ensure all residents receive treatment and care in accordance with professional standards of practice for 1 of 10 sampled residents (R1). R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not weigh R1 as frequently as indicated in facility policy and did not measure abdominal girth when staff identified [CONDITION(S)]. When R1 experienced a change of condition, including a 9 pound weight gain, the facility did not reweigh the resident or update the provider despite R1's diagnoses. R1 was noted to have an increase in [CONDITION(S)] and complained of shortness of breath. Despite these findings the facility did not complete further weights or update the physician. This is evidenced by: According to an article by the Harvard Medical School, Fluid buildup indicates worsening heart failure .The buildup of excess fluid in your body can take a variety of forms from belly bloating and swollen ankles to nausea, persistent coughing and fatigue. You may be tempted initially to dismiss this hodgepodge of problems as having little to do with your heart. However, they all signal water retention, which can mean trouble for people with a history of heart failure. Fluid buildup can quickly escalate into a life-threatening situation . https://www.health.harvard.edu/heart-health/fluid-retention-what-it-can-mean-for-your-heart According to WebMD's Heart Failure Health Center, Sometimes your symptoms may get worse very quickly. This is called sudden heart failure. It causes fluid to build up in your lungs, causing congestion. (This is why the problem is often called [CONDITION(S)].) .Sudden heart failure is an emergency. You need care right away. http://www.webmd.com/heart-disease/heart-failure/tc/heart-failure-symptoms The facility policy, Weight Assessment and Intervention, last reviewed [DATE], indicates, Policy: The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents. Procedure: Weight Assessment: 1. The nursing staff will measure resident weights on admission, the next 2 days, and weekly for 3 additional weeks thereafter. 2. If no weight concern are noted after the initial 3 days and 3 weeks after, routine weights will be measured monthly thereafter, unless ordered more frequently by the physician. 6. Any weight change of five (5) pounds or more since the last weight assessment will be retaken for confirmation. 8. The threshold for significant weight change will be based on the following criteria [where percentage of body weight change = (usual weight - actual weight) / (usual weight) x 100]: a. 1 month - 5% weight change is significant; greater than 5% is severe. 10. The nursing staff will notify the individual or responsible party, physician and RDN or designee of any individual with an unintended significant weight change. The facility policy, Condition Change of the Resident, effective [DATE], indicates in part . Purpose: To observe, record and report any condition change to the physician so proper treatment can be implemented. Procedure: 4. Assessment and monitoring include, but are not limited to the following: b. Swelling and discoloration. If present, document size, site, amount and color. o. Abdominal spasms or pain. r. Dyspnea or variations in respirations (irregular). The facility policy, Change in Condition of the Resident (Observing, recording, and Reporting) Policy, last reviewed [DATE], states in part . The facility should immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission MDS (Minimum Data Set) dated [DATE] indicates the following in part . BIMS (Brief Interview of Mental Status) 10, indicating moderate cognitive impairment. R1 requires limited assistance of two staff for bed mobility, extensive assistance of two for transfers, extensive assistance of one for dressing and toileting, and limited assistance of one for personal hygiene. R1 is a Full Code. R1's Baseline Care Plan, dated [DATE], includes in part . Social Service's Needs: Depression Screening: Other: Anxiety. Special Treatments/Procedures: Oxygen, Route: NC (nasal cannula), LPM (liters per minute): 1. Pain: Pain Present: Location: back and left side. Characteristics: achy. R1's Comprehensive Care Plan, dated [DATE], includes in part . Focus: At risk for nutritional status change r/t (related to) T1DM (Type 1 Diabetes Mellitus), [CONDITION(S)] of the liver, dysphagia, and heart disease. Interventions: Review weights and notify RD (Registered Dietician), MD (Medical Doctor), and responsible party of significant weight changes. Note: R1's Comprehensive Care Plan does not include any focused nursing care plans to address R1's medical concerns. On [DATE] at 15:27 (3:27 PM), Facility Admission Notes states in part, Alert and oriented times 4, able to make needs known. Lungs are clear throughout, O2 sat (saturation) 92% on 1 LPM via NC (nasal cannula). Bowel sounds are active times 4, abdomen firm, tender, and round from [CONDITION(S)], is continent of bowel and bladder. Has 1+ non pitting [CONDITION(S)] to right side of body as resident lays on that side. Will continue to monitor. On [DATE] at 23:47 (11:47 PM), Facility Daily Skilled Note, states in part . Skin Turgor: Dry - resolved with lotion ,d+[DATE] sec (seconds). Most recent pain level: Pnl (pain) 0 - [DATE] at 23:43 (11:43 PM). [CONDITION(S)] present: No. Summary: Resident A&OX4 (alert and oriented times 4). Lungs CTA (clear to auscultation). Resident's oxygen saturation 95% on 2L (liters) O2 per NC (nasal cannula). She c/o (complains of) anxiety and feels SOB (short of breath) at times. She has multiple areas of skin breakdown. She uses call light appropriately and calls to use bed pan. No c/o pain, call light within reach. Note: Initial facility assessment indicates R1 has no [CONDITION(S)] present or pain. On [DATE] at 11:53 AM, Facility Daily Skilled Note, states in part . Skin Turgor: Dry - resolved with lotion ,d+[DATE] sec. Most recent pain level: Pnl 1 - [DATE] at 8:58 AM. Pain scale: Numerical. Abdomen especially on the left side and is on a pain management. [CONDITION(S)] Present: Yes, describe below . extremities and abdomen. Respiratory: Regular/unlabored, dyspnea on exertion. Summary: Resident A&OX4, Lungs CTA. Resident's oxygen saturation 96% on 3L O2 per NC. No c/o pain. Note: This is the first mention of [CONDITION(S)] since admission. Increase in weight/weight gain, [CONDITION(S)], and SOB are all characteristic signs of CHF exacerbation. Abdominal [CONDITION(S)] in a resident with a history of ascites should alert the nurse to complete measurements on abdominal girth, monitor, and update the physician accordingly. On [DATE] at 11:53 AM, Facility Daily Skilled Note, states in part . Skin Turgor: Dry - resolved with lotion ,d+[DATE] sec. Most recent pain level: Pnl 2 - [DATE] 11:51. Pain scale: Numerical. Regular Heart Rhythm: [CONDITION(S)] Present. No. Respiratory: Regular/unlabored. Summary: Resident is working with therapies. Nursing will continue to monitor. On [DATE] at 15:14 (3:14 PM), Facility Nutritional Assessment Note, states in part . Current weight is 138 - [DATE]. Weight remains stable without significant variances. Note: Facility policy indicates weight to be done from admission daily times 3 days then weekly times 3 weeks. The weight used for the Nutritional Assessment was from [DATE]. No other weights were documented for R1 at this time. On [DATE] at 09:57 (9:57 AM), Facility Daily Skilled Note, states in part . Skin Turgor: Dry - resolved with lotion ,d+[DATE] sec. Most recent pain level: Pnl 0 - [DATE] at 09:57 (9:57 AM). Pain Scale: Numerical. [CONDITION(S)] Present: Yes, describe below . LLE (left lower extremity), RUE (right upper extremity), abdomen. Respiratory: Regular/unlabored, Orthopnea. Dyspnea when lying flat and on exertion. Summary: Resident A&OX4. Lungs CTA. Resident's oxygen saturation 96% on 3L O2 per NC. No c/o pain. Note: The facility again is documenting [CONDITION(S)], and dyspnea (difficulty breathing) however the facility did not update the MD or complete a weight or abdominal girth. On [DATE] at 10:20 AM, Facility documentation of a Telephone Encounter with Physician states in part . Regarding labs today. Hemoglobin has come up slightly. Kidney function remains poor but no worse than prior. Her BUN (Blood Urea Nitrogen - a lab to test kidney function) continues to climb. Please limit her oral protein intake, encourage fluids and recheck these labs Tuesday depending on outcome of palliative care appointment that she has tomorrow. On [DATE] at 10:09 AM, Facility Daily Skilled Note, states in part . Skin Turgor: Dry - resolved with lotion ,d+[DATE] sec. Most recent pain level: Pnl 3 - [DATE] 10:09. Pain scale: Numerical. Abdomen and LLE and is now on pain management. [CONDITION(S)] present: Yes, describe below . right thigh, LLE, abdomen. Respiratory: Regular/unlabored Orthopnea. Dyspnea when lying flat and on exertion. Summary: Resident A&OX4. Lungs CTA. Resident's oxygen saturation 96% on 3L O2 per NC. No c/o pain. Note: The facility is documenting [CONDITION(S)], and dyspnea (difficulty breathing) however the facility did not update the MD or complete a weight or abdominal girth. On [DATE] at 10:53 AM, Psychosocial Note states in part . R1's Palliative Care Nurse, came today to visit and see how R1 is doing. She said she looks rough. We told her that R1 has been taking her meds (medications) normally and that she doesn't ask for Acetaminophen very often. We told her that R1 often does not want to do therapy due to her swelling and pain. Is going to schedule her pain meds for 3 times a day instead of doing them as needed. Nurse stated, that R1 does qualify for hospice and that she spoke with R1 about it but that R1 was not accepting of that yet. On [DATE] at 12:37 PM, Facility Note titled, COMMUNICATION, states in part . Physician/Res/Family/HPOA/Guardian Note Text: Doctor responded to labs done yesterday stating: Hemoglobin has come up slightly. Kidney function remains poor but no worse than prior. [CONDITION(S)] is no longer a concern. Her BUN continues to climb. Please limit her oral protein intake, encourage fluids and recheck these labs Tuesday depending on outcome of palliative care appointment that she has tomorrow. On [DATE] at 10:10 AM, Facility Daily Skilled Note, states in part . Skin Turgor: Dry - resolved with lotion ,d+[DATE] sec. Most recent pain level: Pnl 3 - [DATE] 10:09 Pain scale: Numerical. abdomen and left side and is on pain management. Regular Heart Rhythm: Yes. Peripheral pulses present. Capillary refill less than 3 seconds. [CONDITION(S)] present: Yes, describe below . LLE, RUE, abdomen. Respiratory: Regular/unlabored Orthopnea (shortness of breath in a lying position.) Dyspnea when lying flat and on exertion. Summary: Resident A&OX4. Lungs CTA. Resident's oxygen saturation 96% on 3L O2 per NC. No c/o pain. Note: The facility is documenting [CONDITION(S)] now in additional areas RUE (right upper extremity) and dyspnea (difficulty breathing) however the facility did not update the MD or complete a weight or abdominal girth. On [DATE] at 10:39 AM, Facility Daily Skilled Note, states in part . Skin Turgor: Dry - resolved with lotion ,d+[DATE] sec. Most recent pain level: Pnl 2 - [DATE] 07:44 Pain scale: Numerical. BLE and back and abdomen and is on pain management. Regular Heart Rhythm: Yes. [CONDITION(S)] present: Yes, describe below LLE, RUE, abdomen and arms. Respiratory: Regular/unlabored Orthopnea. Dyspnea when lying flat and on exertion. Summary: Resident A&OX4. Lungs CTA. Resident's oxygen saturation 96% on 3L O2 per NC. No c/o pain. Resident has been drinking more soda and not eating regular food. Needs more education on proper nutrition. Note: R1 now showing more [CONDITION(S)]. Staff continued to fail to weigh R1, measure abdominal girth, update the physician on changes. This is especially important in patients with CHF and ascites. Increase in weight/weight gain, [CONDITION(S)], and SOB are all characteristic signs of CHF exacerbation On [DATE] at 10:00 AM, Facility Daily Skilled Note, states in part . Skin Turgor: Dry - resolved with lotion ,d+[DATE] sec. Most recent pain level: Pnl 3 - [DATE] 08:45 Pain scale: Numerical. On scheduled Tylenol for pain management/resident states not effective. Regular Heart Rhythm: Yes. Peripheral pulses present: Respiratory: Regular/unlabored. Summary: Resident is working with therapies resident very anxious, vital signs are stable, nursing will continue to monitor. On [DATE] at 12:28 AM, Facility Daily Skilled Note, states in part . Skin turgor: Dry - resolved with lotion ,d+[DATE] sec. Most recent pain level: Pnl 3 - [DATE] 08:45 Pain scale: Numerical. LLE and RUE; abdomen; back and is on pain management. Regular heart rhythm: Yes. Capillary refill less than 3 seconds. [CONDITION(S)]: Yes, describe below. BLE; abdomen. Respiratory: Regular/unlabored shallow orthopnea - dyspnea when lying flat, dyspnea on exertion. Respiratory treatments: Oxygen continuous. On [DATE] at 10:25 AM, Facility Note, SBAR - Change of Condition Situation: Resident is c/o not being able to breathe and very restless and can't get comfortable and has restless leg. Very anxious. Background: Assessment (RN)/Appearance (LPN): VS: 97.8; 78; 20; ,d+[DATE]; 99% on 3 liters/nasal cannula. Resident is very anxious and states that she is not sleeping and has been up all night long thinking about lots of things. Resident worried about her breathing, her blood sugar, snacking on several items throughout the night. Response: PA-C (Physician Assistant - Certified) is here today and will have him talk with her and review her medications to see if there is something he can do for her. Resident made aware and is ok with this. Director of Nursing (DON) also aware. On [DATE] at 11:24 AM, Facility Daily Skilled Note, states in part . Skin Turgor: Extremely dry - tenting - 4+ (4 plus) sec. Most recent pain level: Pnl 4 - [DATE] 11:24. Pain scale: Numerical. Abdomen and left side and is on a pain management. Regular Heart Rhythm: Yes. [CONDITION(S)] Present: Yes, describe below . abdomen and lower extremities. Summary: Resident A&OX4. Lungs CTA. Resident's oxygen saturation 96% on 3L O2 per NC. No c/o pain. Resident has been drinking more soda and not eating regular food. Needs more education and proper nutrition. On [DATE], Progress Note from Physician Assistant Certified (PA-C) states in part . Patient seen today during nursing home rounds, nursing reporting anxiety ongoing since hospital. Discussed with patient she describes feelings of shortness of breath, restlessness, difficulty sleeping. These have been ongoing since prior to hospitalization , somewhat worsened recently. Notes that symptoms are worst at night, better once sun comes up, however they do not change based on position i.e. lying down versus sitting up. States that her lower extremity [CONDITION(S)] has massively improved recently, she continues to output a large amount of urine status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Objective: AOX3 appears anxious 1+ bilateral lower [CONDITION(S)]. No abdominal tenderness, there is some ascites present. Assessment: 1. Anxiety associated with dying process. No medication or new orders. Plan: VS reviewed and stable. Her fluid status seems to be improving nicely. She has longstanding anxiety which she admits has increased since news of her terminal diagnosis. She is currently on an SNRI, SSRI, and [MEDICATION(S)] (antidepressant medications). Therefore, will trial [MEDICATION(S)] 0.125 mg tid (three times daily) prn (as needed), adjust dose as needed. Nursing Home Social Worker is communicating with palliative care/hospice staff. Patient is appropriate for hospice, seems more willing to consider this moving forward. This would be advantageous as it may open up better mental health counseling options for her. On [DATE] at 11:24 AM, Facility Note titled, Communication- with Physician/Res/Family/HPOA (Healthcare Power of Attorney/Guardian, states in part . Text: Resident was seen by PA-C regarding her complaints today and after talking with her and reviewing her orders, he wrote a script for [MEDICATION(S)] 0.25 mg (milligrams) give ½ tab (0.125 mg) TID (three times a day) as needed for anxiety r/t (related to) SOB. Resident aware of above and script faxed to pharmacy. On [DATE] at 20:35 (8:35 PM), Facility Note titled, Acute Condition/Change of Condition Note, states, Called to resident room for resident c/o RUQ (right upper quadrant) abdominal pain, states It isn't a little pin prick it is stabbing Resident stomach is rigid, tender, firm, has hypoactive bowel sounds in upper quadrant, has not had a BM since [DATE], given prn bowel meds and [MEDICATION(S)] (medication for Nausea) to see if that helps. Will continue to monitor. Note: R1 is now complaining of stabbing upper quadrant pain which should be considered a medical emergency, along with update to the Physician. On [DATE] at 11:24 AM, Facility Daily Skilled Note, states in part . Skin Turgor: Dry - resolved with lotion ,d+[DATE] sec. Most recent pain level: Pnl 0 - [DATE] 10:23 PM. Pain scale: PAINAD. Regular Heart Rhythm: Yes. [CONDITION(S)] Present: No. Summary: Nursing will continue to monitor. On [DATE] at 8:38 AM, Weight obtained and documented as, Weight 147 (+3.0% change from last week. Comparison weight [DATE], 138.0, +6.5%, +9.0 lbs. (pounds). R1's weights were charted by the facility as follows: [DATE] - 138.0 pounds [DATE] - 147.0 pounds (increase of 6.52% or 9 pounds in 16 days) Note: The facility policy states that weights are to be done daily times 3 days, then weekly times 3 weeks, and then monthly. R1 only had 2 weights in 16 days. This is a significant weight gain of 9 lbs in 16 days a crucial medical finding in a resident with known CHF and ascites warranting physician notification. Note: R1 signed DNR form on [DATE]. On [DATE] at 12:45 PM, Facility Daily Skilled Note, states in part . Skin Turgor: Dry - resolved with lotion, ,d+[DATE] sec. Fragile-tissue thin. Most recent pain level: Pnl 4 - [DATE] at 12:45 PM. Pain scale: Numerical. Abdomen and LE and is on pain management. Regular heart rhythm: Yes. [CONDITION(S)] present: Yes, Describe below . LLE, RUE, abdomen. Summary: Resident A&oX4. Lungs CTA. Resident's oxygen saturation 96% on 3L O2 per NC. No c/o pain. Resident has been drinking more soda and not eating regular food. Needs some education about proper nutrition. Encouraging resident to take the prn [MEDICATION(S)] for her anxiety due to SOB. On [DATE] at 02:25 (2:25 AM), Facility Note titled, SBAR - Change of condition Situation: Resident had call light on and also yelling out; she is on floor on left side of bed sitting on butt hanging on to BSC (bedside commode) frame. Background: Resident said, 'I just rolled over and I fell on the floor.' Hx of: DM 1 with diabetic chronic kidney disease, alcoholic [CONDITION(S)] of liver with ascites, muscle weakness, CHF, anxiety disorder, cardiac pacemaker, [CONDITION(S)]. Assessment (RN)/Appearance (LPN): Resident is very anxious. Assessment: VS (vital signs): ,d+[DATE] 73 87.8 16 oxygen saturation 93% on 3L O2. Neuros WNLs (within normal limits). VSS (vital signs stable). Resident has no inward/outward rotation or shortening of BLE. So skin issues noted from fall. Response: Resident assessed for injury, lifted into bed and VS taken. Fax will be sent to PCP on fall, DON will be notified in am (morning). Recommendation: Continue to monitor. On [DATE] at 03:17 (3:17 AM) Facility Note titled, SBAR - Change of Condition, states in part . Situation: at 0145 (1:45 AM) Resident demanding to go to hospital because I hurt all over and I can't breathe Resident asked for O2 to be turned up and it was increased to 4L for comfort. Background: DM 1 with diabetic chronic kidney disease, Alcoholic [CONDITION(S)] of liver with ascites, muscle weakness, CHF, anxiety disorder, cardiac pacemaker, [CONDITION(S)]. Resident did have earlier fall at 2215 but is not c/o pain from fall nor expressed desire to go to hospital for fall. She denies hitting head. Assessment (RN)/Appearance (LPN): resident very anxious, pale and tired looking. Assessment: VS: ,d+[DATE] 73 98.7 18 Oxygen saturation of 93% on 3L O2 per NC. Response: offered her [MEDICATION(S)], repositioning Recommendations: complete paperwork to go to hospital. Note: R1 is her own person and had requested to go to the hospital at 1:45 AM. The Nurse documented R1 was pale, tired looking demanding to go to the hospital yet the facility failed to send R1 per her wishes. On [DATE] at 03:43 (3:43 AM), Facility Note titled, COMMUNICATION - with Physician/Res/Family/HPOA/Guardian, states in part . Note Text: Palliative care nurse returned call about fall. I also made her aware of resident demand to go to hospital at 0145 and that resident was sleeping at this time but I would complete paperwork for transfer in case she still wanted to go. On [DATE] at 04:28 (4:28 AM), Facility Note titled, SBAR - Change of Condition, states in part . Response: Resident aware at this time (0430) O2 sat 94% on 4L per NC, RR (respiratory rate) 18. She is lying on right side and c/o SOB. No mention of going to hospital. Lungs are clear with diminished bases. She is eating ice cream and wanting barrier cream on her peri are for itch. On [DATE] at 05:27 (5:27 AM), Facility Note titled, Acute Condition/Change of Condition, sates in part . Note Text: Resident again found on the floor next to her bed calling out for help, assisted back into bed and stating that she can't breathe, wanting to go to the hospital. Ambulance called, (Managed Care Organization Name) called as well as Palliative called. ER updated. On [DATE] at 05:52 (5:52 AM), Facility Note titled, Communication - with Physician/Res/Family/HPOA/Guardian, states in part . Note Text: Friend called and providers called as well as ER. Ambulance here and staff assisted onto cot. Left at this time. On [DATE] at 7:07 AM, Hospital Note, states in part . History of Present Illness: Per RN, patient has been ringing the bell all night for [CONDITION(S)], anxiety, sensation of SOB and pain all over. As soon as the RN was in the room, she was comfortable. The night RN told the day time RN that she had it with her. She also refused [MEDICATION(S)] because she told the nurse that it made it worse. She is currently on palliative care but will transition to hospice on Monday (in two days). Respiratory: Positive for shortness of breath. Psych/Behavioral: Positive for sleep disturbance. The patient is nervous/anxious. Physical exam: Constitutional: General: She is not in acute distress. She is currently sleeping without any distress. Cardiovascular: Rate and Rhythm: Normal rate. Pulmonary: Effort: Normal. No tachypnea, accessory muscle usage or respiratory distress. Condition at discharge: Improved. On [DATE] at 8:19 AM, Emergency Department/Urgent Care Note, states in part . At 8:19 AM writer received phone call from Emergency Medical Services (EMS), regarding pt (patient) code status. Pt coded (absence of heartbeat and breathing) in ambulance, and pt did not have DNR bracelet on. Writer verbally told pt was DNR, but no paperwork with pt. EMS started CPR and writer called facility to update. RN at facility stated pt was DNR. Paperwork faxed to ER documenting DNR status. Attempted to call EMS to update status. EMS arrived in ER, CPR stopped, and pt pronounced dead at 0830. On [DATE] facility note at 08:19 (8:19 AM) states in part . Note Text: Received a call back from the ER (emergency room ) nurse stating that resident on the way back to us, she coded in the ambulance. This writer told them that she was just made a DNR (do not resuscitate) yesterday. DNR POST form was faxed to the ER immediately. On [DATE] at 08:32 (8:32 AM), Facility Note titled, Communication - with Physician/Res/Family/HPOA/Guardian, states in part . Note Text: Received a call back from Hospital ER that resident passed away in the ER. They were informed that the friend was indeed the boyfriend and had been notified of her transfer to hospital. Also that palliative care was also contacted and aware of the above. On [DATE] at 8:48 AM, Hospital Note, states in part . History of Present Illness: Call from EMS, asking for clarification on code status as patient has coded enroute back to the facility. She was not wearing a band and ACP status in her chart was full code. She was known from earlier encounter to be a palliative care so facility was called and clarified she is DNR. They faxed completed form. EMS did CPR from 08:19 (8:19 AM) to 08:28 (8:28 AM) when they arrived at Hospital. All resuscitation efforts were held. She was pulseless and non-breathing. She was pronounced dead at 08:30 (8:30 AM). On [DATE] at 12:38 PM, Surveyor interviewed PA-C F. Surveyor asked PA-C F if R1 had significant weight change and [CONDITION(S)] would he expect to be updated. PA-C F stated, If there is any change or change in clinical status I would expect to be notified. The primary purpose of my visit with R1 on [DATE] was to discuss hospice. There were no obvious signs of an acute change when I saw her on the [DATE]. I would expect notification on any of these changes. On [DATE] at 1:17 PM, Surveyor interviewed (Doctor of Osteopathy) DO G. Surveyor asked DO G if she would be expect to be notified of any changes in weight or [CONDITION(S)] for R1. DO G stated, I would expect notification for any changes in status. I rely heavily on the nursing assessments, especially in this case when I had not seen the resident. If their assessments are not accurate or included old/inaccurate information I wouldn't know that. R1's weights should have been taken according to the facility policy and I believe that is daily for 3 days, then weekly times 3 weeks, and then monthly. If that was done I should have been updated according to their policy. I should also have received communication regarding changes in R1's [CONDITION(S)]. Any new changes should have been communicated. On [DATE] at 2:27 PM, Surveyor interviewed (Registered Nurse) RN H and (Licensed Practical Nurse) LPN I. Surveyor asked RN H and LPN I regarding the process for staff obtaining weights. RN H stated, Weights come up in the MAR and TAR but we try to do them on bath days. We then write on the (Certified Nursing Assistant) CNA sheets who needs a weight done, LPN I stated, If weight is off we would update the MD. Staff do struggle to get weights done. With staffing issues and current outbreak staff struggle to get them all done. Agency staff is not always sure what to do. Surveyor asked RN H and LPN I if a resident has changes in [CONDITION(S)] for a resident with CHF and ascites what the process is. RN H stated, I would assess lung sounds, measure the girth of belly, review labs and update the MD with findings. On [DATE] at 2:38 PM, Surveyor interviewed CNA J. Surveyor asked CNA J what the facility process is for obtaining weights. CNA J stated, The nurses tell us which weights we need to get. Surveyor asked CNA J what is done if the weight is off. CNA J stated, Depends on if the weight is way off. If the weight is way off I would get a reweight to ensure is was an accurate weight. I would also report any weights that are way off to the charge nurse. On [DATE] at 3:03 PM, Surveyor interviewed IDON B. Surveyor asked IDON B if she would expect staff to notify the physician of an increase of 9 pounds in 16 days on a resident with CHF and ascites. IDON B stated, 'Yes. Weights should be done according to the facility policy and any significant changes should be reported to the physician. Surveyor asked IDON B if that same patient had an increase or change in [CONDITION(S)] would that also be expected to be reported to the physician. IDON B stated, Yes. The facility failed to update R1's PCP in a timely manner when R1 experienced a significant weight gain on [DATE], failed to complete a reweight despite significant weight gain and failed to notify the physician with increased [CONDITION(S)] and SOB. The facility failed to recognize a change of condition in a resident presenting with signs and symptoms of CHF exacerbation and ascites in a patient who was a severely compromised cardiac patient.

Based on interview and record review, the facility did not ensure each resident's environment remains as free of accident hazards as is possible for 1 of 2 sampled residents (R36) reviewed for accidents. The facility did not follow fall interventions for R36, resulting in a fall with fracture. Findings include The facility's policy titled Fall Prevention and Management Guidelines states, Evaluation: Complete a post fall evaluation and complete required notifications after every fall, near miss fall, or assisted fall. Upon initial review, investigation, and assessment, nurse to update the care plan as to (i) any new interventions put in place to try to prevent additional falls, and (ii) removal of any interventions determined to be no longer appropriate. The policy also states the interdisciplinary team (IDT) will review each fall/fall investigation during the next morning meeting. R36 was admitted to the facility on [DATE] and has diagnoses including Alzheimer's Disease. His most recent MDS (Minimum Data Set), dated 6/7/21, shows a BIMS (Brief Interview for Mental Status) score of zero, which indicates R36 is severely cognitively impaired. R36 experienced 2 falls on 5/14/21, the first at 3:20 PM and the second at 7:20 PM. Both of these falls occurred while R36 was trying to get up from a recliner in the dining room. Neither resulted in injury. After the second fall, a post-fall assessment was completed with the immediate intervention for R36 to not be in the recliner. On 5/21/21 at 9:45 AM, R36 fell again from the recliner in the dining room while trying to stand up. CNA U (Certified Nursing Assistant) was charting at the computer in the dining room at the time of the fall. A facility incident report states, CNA was sitting on opposite side of solarium and heard loud thump, looked over and saw resident laying on floor. Resident was lying on his right side. Resident had been sitting in recliner. Baseball size hematoma posterior aspect of head. Intact. Bilateral hips palpitated, resident moaned when right hip palpitated. R36 was sent to the ED (Emergency Department) within an hour where a CT scan revealed R36 had a fracture of the inferior pubic ramus (pelvis). A facility progress note, dated 5/31/21, shows IDT met to discuss the 5/21/21 fall. The note states, The computer charting table was moved into the corner to face the solarium to monitor residents while charting as an intervention for the 5/21/21 fall. R36's care plan was updated on 5/31/21 to read Do not put in a recliner. On 8/18/21 at 1:32 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated the nurse that was working during the falls on 5/14/21, and completed post-fall assessments for both falls, did not update R36's care plan to keep him off of recliners, but she should have. DON B stated the nurse has had trouble with updating care plans in the past and no longer works at the facility. DON B stated she was not sure why it did not get on the care plan until 5/31/21, but someone on the IDT should have made sure it was on the care plan. DON B stated, We said he shouldn't have been in the recliner, then he should not have been in the recliner when referring to R36's 5/21/21 fall. On 8/19/21, DON B presented Surveyor with additional information regarding follow up from the 5/21/21 fall. The information shows that on 5/31/21, the facility identified R36's care plan was not being followed and put together an action plan that states the facility would: *Educate staff and nursing on updating care plans. *Ensure care plans are updated immediately after initiating an intervention *All falls are reviewed at every morning meeting, MDS Coordinator and DON will ensure interventions are in the care plan. The facility provided Surveyor with sign-in sheets for an in-service training that occurred on 6/2/21 and 6/3/21 titled General Info. On 8/19/21 at 10:18 AM, Surveyor interviewed RN D (Registered Nurse) and RN E. Both RN D and RN E serve as charge nurses and stated after each fall, a post-fall assessment is to be completed and any interventions listed on the assessment should be added to the care plan immediately until they can be reviewed by the IDT. If a fall happens on a weekend (Friday evening, Saturday or Sunday), interventions are still to be put into place and added to the care plan until the IDT meets on Monday morning to review. At 10:30 AM, Surveyor interviewed RCMD P (Resident Care Management Director), who also serves as the MDS Coordinator. RCMD P stated interventions are to be placed on the care plan immediately until they can be reviewed the following morning, or Monday if it is a weekend, by the IDT. On 8/18/21 at 12:10 PM, Surveyor interviewed CNA T who stated she was working when R36's fall occurred on 5/21/21. CNA T stated she vaguely remembered the fall and did not hear any details about the fall. CNA T stated she was neither debriefed on the fall nor did she receive any education regarding the fall or care plans. On 8/18/21 at 11:15 AM, Surveyor interviewed CNA U who was the lone staff member in the dining room when R36 fell . CNA U stated nobody talked to her after the fall and she did not receive any education on falls or care plans. On 8/18/21, Surveyor interviewed CNA L (11:15 AM) and RN F (10:30 AM). CNA L was assigned to R36's wing on 5/21/21 and RN F completed the post-fall assessment after R36 fell . Both stated nobody had talked to them after the fall and hadn't received any education on falls or care plans. Additionally, on 8/19/21 at 2:20 PM, Surveyor interviewed CNA W who had been observed working on R36's hall and has been working at the facility since December of 2020. CNA W stated she did not have access to residents' care plans, did not have a paper copy on her person, and did not have access to the facility's computer system to view resident care plans. CNA W stated if she has questions on a resident's care, she asks another staff member. On Saturday, 6/26/21 at 7:10 PM, R36 experienced another fall, this time from his wheelchair. RN V filled out a post-fall assessment, listing the new immediate intervention as a wheelchair alarm. It was not added to the care plan and the IDT team, which met on 6/28/21, did not mention or review the need for a wheelchair alarm. Neither RN F nor RN V attended the in-service education on 6/2/21 or 6/3/21, according to facility records. Additionally, neither CNA U nor CNA W attended the in-service training. On 8/19/21 at 1:45 PM, Surveyor again interviewed DON B, who acknowledged that RN F did not attend the in-service training on 6/2/21 or 6/3/21. DON B stated she was pretty sure she had spoken with RN V regarding the in-service. DON B also stated she felt R36 did not need a wheelchair alarm and was never given a wheelchair alarm, but stated their process is for nurses to put interventions onto the care plan until IDT can review. The facility was aware R36 was falling frequently and created interventions but did not add those interventions to the care plan and subsequently did not follow those interventions, resulting in an additional fall with fracture. The facility did not provide the education to all staff and nurses as stated in their corrective plan and subsequent falls revealed additional interventions were not added to care plans.

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer for 1 of 4 residents (Resident 5). Resident 5 was admitted to the facility without a pressure ulcer (PU) and was identified to be at risk for PU development. Interventions were not put into place to prevent Resident 5 from developing a PU. Resident 5 developed an avoidable, unstageable PU to the right heel while in the facility. In addition, Resident 5 has a [DIAGNOSES REDACTED]. The facility had no evidence that the facility mattresses are pressure redistributing and failed to re-educate staff regarding PU prevention once a facility acquired PU was identified. This is evidenced by the following: The Quick Reference Guide entitled "Pressure Ulcer Prevention" published by the National Pressure Ulcer Advisory Panel (NPUAP) in 2009 indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Ensure the heels are free of the surface of the bed. Using a pillow under the calves so the heels are elevated (i.e., "floating") will accomplish reduction of pressure on heels. The facility's Policy and Procedure for Skin Care revised 2/10, states in part; the facility will promote the prevention of PU development with assessment and prevention measures, this process begins at the very first contact with an admit. A complete head to toe assessment is completed other focus areas include mobility. The facility will make every attempt to assure PU does not develop unless clinically unavoidable. Types of Ulcerations: A pressure ulcer is defined as any lesion caused by unrelieved pressure that result in damage to the underlying tissue. Unstageable: Full thickness tissue loss-depth unknown. Depth of the ulcer is completely obscured by slough and or eschar in the wound bed. Risk Factors: impaired/decreased mobility and decreased functional ability, co-morbid conditions such as diabetes. Objective: Protect area including use of egg crate mattress and pressure relieving boots. The facility uses either a Panacea or Medline mattress as their standard mattress. The facility had no evidence that the mattress used in the facility is rated for pressure redistribution. The facility's Preventative Skin Care Protocol dated 10/15/14 states in part; Interventions: repositioning schedule, air mattress, specialized mattress, air flotation mattress, elbow and heel protectors and floating of heels or Zero protective boots. Be proactive with residents who may not feel pressure or the need to reposition. The facility's policy on Diabetic Nail Care dated 4/11 states in part; the Registered Nurse (RN) or Licensed Practical Nurse (LPN) is responsible for providing nail care for all diabetics on a weekly basis. Nurses are responsible for checking the resident's feet for any changes in skin condition. Examination of the feet daily is done by the Certified Nursing Assistants (CNA's). On a weekly basis during nail care, nurses are to inspect the diabetic's foot for any change. On 12/16/14, at 3:15 PM Surveyor interviewed DON B regarding the facility skin care policy. DON B stated she is wound care certified along with another night shift nurse. DON B stated a skin risk assessment is completed on admission then weekly times 4 weeks. DON B stated that when the facility identifies a resident to be at risk for skin impairment the facility puts something in place on the care plan to prevent the skin impairment. DON B stated the Certified Nursing Assistants (CNA's) complete skin checks twice daily with cares and the bath CNA reports skin issues to the nurse if skin issues are noted on bath days. DON B stated the facility does complete weekly foot checks on residents with diabetes. If a wound is identified DON B and the physician is notified to provide treatment orders. Director of Nursing (DON) B indicates the facility mattresses have a built in egg crate. Example Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's admission Braden assessment, dated 10/28/14, indicates Resident 5 scored an 18 indicating Resident 5 was at risk for PU development. The facility's Braden risk score indications are as follows: At Risk: 15 -18, Moderate Risk: 13-14, High Risk: 10-12, Very High Risk: 9 or below. The Braden assessment was again completed on 11/4/14 with a score of 18 at risk, 11/11/14 with a score of 17 at risk and 11/18/14 with a score of 20. Resident 5's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/4/14, indicates A Brief Interview for Mental Status (BIMS) was completed with Resident 5 scoring a 10 indicating moderate cognitive impairment. Section M0150 of the MDS indicates Resident 5 is at risk for developing a PU. Section G0110, Activities of Daily Living (ADL's) indicates Resident 5 requires 2 staff and extensive assistance for bed mobility and transfers. A Care Area Assessment (CAA) worksheet states in part; at mild risk for pressure ulcer with a Braden of 18 on 11/4/14. Requires extensive assistance for bed mobility and staff assist with repositioning as needed and requested. Able to make slight changes in position, admitted [MEDICAL CONDITION] left sided weakness putting her at greater risk for PU. Skin remains intact at this time. Resident 5's comprehensive care plan potential for PU development related to (r/t) decreased mobility due to (d/t) stroke with left sided weakness dated 11/17/14 states in part; needs reminding with some assistance at times to turn/reposition at least every 2 hours, more often as need and requested. Nursing notes dated 11/22/14 at 10:59 AM state in part; remains alert, forgetful able to make needs known, complained of (c/o) pain in right hip. Nursing notes dated 11/23/14 at 10:16 AM states in part; remains alert, forgetful able to make needs known, c/o pain in right hip. Nursing notes dated11/24/14 at 7:29 AM states in part; fax sent to physician requesting treatment for [REDACTED]. Nursing notes dated 11/24/14 at 10:09 AM states in part; resident has order for treatment to right heel and reposition often. Weekly PU Record dated 11/24/14 states in part; stage: unstageable, 3 centimeter (cm) x 3 cm wound bed dark purple. Scored 20 on Braden, extensive assist with bed mobility, MDS stated yes at risk for PU, care plan states able to reposition side to side, c/o pain to heel. Pressure relieving interventions: float, avoid pressure. Physician telephone order dated 11/24/14 states, Wound care certified nurse at facility to evaluate and oversee course of treatment for [REDACTED]. An update to the PU comprehensive care plan dated 11/24/14 states in part; unstageable PU to right heel. Float heels, no pressure heel boot to right foot at all times, weekly wound documentation. Physician orders [REDACTED]. Nursing notes dated 11/25/14 at 1:10 AM states in part; left foot in blue boot and heals (sic) are floated of (sic) bed. Nursing notes dated 11/25/14 at 6:45 AM states in part; alert but can be forgetful at times, to have blue boots on and be repositioned often. Weekly PU Record dated 12/1/14 states in part; stage: unstageable, 3 centimeter (cm) x 3 cm wound bed dark purple. Area remains intact non-blanchable no c/o pain, blue boot on at all times. Preventative measures: avoid pressure to heel, elevate when possible, wear blue boot as ordered. Weekly PU Record dated 12/8/14 states in part; states in part; stage: unstageable, 3cm x 3 cm wound bed dark purple. Weekly PU Record dated 12/15/14 states in part; unstageable, 3 centimeter (cm) x 3 cm wound bed dark purple. Preventative measures: elevate feet and monitor every shift. On 12/16/14 at 9:45 AM Surveyor observed Resdient 5's right heel PU. Licensed Practical Nurse (LPN) AA lifted Resident 5's right heel, the heel had a 50 cent sized black eschar cap. Per LPN AA there is no treatment to the area just daily monitoring and the zero pressure relieving boot on at all times. On 12/16/14, at 3:15 PM, Surveyor interviewed DON B regarding Resident 5's pressure ulcer. DON B stated that on the morning of 11/24/14/ CNA V noticed the PU and notified DON B. DON B assessed the right heel and determined that the heel was an unstageable PU. Surveyor asked DON B if the facility completes weekly foot checks for residents with diabetes. DON B confirmed the facility does complete weekly foot checks, Surveyor asked where the foot checks were documented for Resident 5. DON B looked at Resident 5's treatment administration record and stated there was no documentation of weekly foot checks for Resident 5, DON B confirmed weekly foot checks should have been completed for Resident 5. Surveyor asked DON B if Resident 5 was at risk for PU development upon admission. DON B stated she reviewed the MDS and agreed that Resident 5 was at risk for PU development. Surveyor asked DON B what the facility had in place to prevent Resident 5 from developing a PU. DON B stated Resident 5 was to be repositioned every 2 hours and she has a built in egg crate mattress on her bed. Surveyor asked DON B if the facility has a standard of practice for PU prevention if a resident is at risk, including floating of resident heels. DON B stated the facility does not have a standard of practice to float resident heels if the resident is at risk. On 12/17/14 at 8:30 AM Surveyor interviewed CNA V regarding PU education she has received. CNA V stated the facility has inservices at least yearly. Surveyor asked CNA V if she received PU education within the last month. CNA V stated she has not received education regarding PU prevention in the past 30 days. Surveyor asked CNA V if she was aware of any care plan changes for Resident 5, CNA V stated only that she is to have the boot on her right foot at all times. On 12/17/14 at 8:35 AM Surveyor interviewed CNA W regarding PU education she has received. CNA W stated that facility has inservices at least yearly. Surveyor asked CNA W if she has received PU education within the last month CNA W stated she has not received education regarding PU prevention in the past month. CNA W stated staff checks pressure points such as heels, elbows buttocks every time they complete cares and to report red areas to the nurse. If staff notices red areas on their skin we are to reposition residents more frequently. On 12/17/14 at 8:45 AM Surveyor interviewed CNA X regarding PU education she has received. CNA X stated that the facility provides annual PU education. Surveyor asked CNA X if she has received PU education within the past month CNA X stated she has not received education regarding PU prevention in the past month. CNA X stated CNA's check resident's skin daily with cares looking at the resident's buttocks, heels, and feet. If a red area is noticed the CNA is to report to the nurse. CNA X stated she was informed by the nurse within the last month that Resident 5 has a PU on her right heel and she is to wear her boot at all times. On 12/17/14 at 12:25 PM Surveyor interviewed DON B regarding education provided to staff regarding PU's. DON B stated she had spoken to the Interdisciplinary team at team meeting about how the PU happened and what we could do differently. We put the zero protective boot on right away. DON B stated she did not think the PU was there very long. Resident 5 developed an avoidable, unstageable PU to the right heel. Resident 5 was identified as at risk for PU development upon admit, however the facility failed to implement interventions to prevent PU development and failed to re-educate frontline staff regarding PU prevention strategies to prevent additional facility acquired PU's.

Based on observation, interview, and record review, the facility did not ensure that 3 of 6 residents sampled for pressure ulcers received the necessary care and treatment to promote healing and prevent further pressure ulcers from developing. Resident #12 was admitted to the facility on [DATE] with stage II pressure ulcers on both the right and left buttock. The pressure ulcers have healed and reopened 3 additional times. The facility made no changes to Resident #12's plan of care to prevent the reoccurrence of the pressure ulcers. Additionally, during observations of Resident #12's right ischial pressure ulcers, the surrounding tissue presented as a deep tissue injury (DTI). This had not been identified by the facility. Resident #1 developed a pressure ulcer to his coccyx upon return from the hospital. Assessments for Resident #1 did not reflect accurate staging and was missing a full weekly assessment, which is a standard of practice for pressure ulcers. The care plans reflected only potential for the development of pressure ulcers, not actual wounds. Furthermore, the Dietary Manager was not aware of the worsening pressure ulcer and thus did not incorporate a high protein food/fluid item in his diet to enhance healing. Resident #2 developed a pressure ulcer to her left calf and to her right middle to lower gluteal crease. Assessments do not indicate the size of the pressures ulcers nor do they give you a clear picture of the pressure ulcers. The care plans indicate the potential for skin breakdown and that resident's skin will remain intact. There is no indication of the actual stage 2 to stage 4 pressure ulcers. This is evidenced by: According to the National Pressure Ulcer Advisory Panel (NPUAP) skin care and treatment of [REDACTED]. ~ Development and implementation of individualized programs of skin care; ~ Built-in mechanisms to evaluate programs to ensure they are effective; ~ Use of supportive offloading surfaces; ~ Use of moisturizers and skin protectants; ~ Proper positioning, transfer, and turning techniques to minimize skin injury due to friction and sheer; ~ Reposition chair bound residents every hour utilizing a written repositioning schedule; and ~ Accurately document skin risk assessment, prevention strategies as well as resident response. The NPUAP also indicates that a suspected DTI is a "...Purple or maroon localized area of discolored intact skin....due to damage of underlying soft tissue from pressure and/or sheer..." Example #1: Resident #12 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #12's most current Minimum Data Set (MDS) was dated 1/16/13. and indicated the following: ~ Cognition was moderately impaired; ~ Required extensive assistance for bathing, dressing, grooming, walking, and using the bathroom; ~ Required extensive assistance to move while in bed; ~ Had a Foley catheter; ~ Was occasionally incontinent of bowels; ~ Weighed 224 pounds; ~ Was at risk for the development of pressure ulcers; ~ Had a pressure reducing device for the chair; and ~ Was on a turning and repositioning program. Resident #12's skin care plan was dated 1/23/13 and indicated, "...Potential for skin breakdown..." The approaches included to observe skin daily with cares and weekly during Resident #12's bath, and to reposition every 2 hours and as needed. Resident #12's Certified Nursing Assistant (CNA) care plan dated 1/23/13, directed staff to reposition Resident #12 every 2 hours and as needed, and indicated Resident #12 had a "...regular cushion..." in the wheelchair. Surveyor # completed a review of the facility's skin risk assessments dated 5/30/12, 6/6/12, 6/13/12, and 2/4/13. All assessments had a cumulative score of 17. According to the risk assessment, a cumulative score of 15 to 18 represented mild risk for the development of pressure ulcers. The accuracy of the risk assessment would be in question as Resident #12 had already developed stage II pressure ulcers 3 separate times as well and has a suspected DTI. The facility utilized a form titled "Weekly Pressure Ulcer Record." Surveyor # completed a review of Resident #12's "Weekly Pressure Ulcer Records" since admission and noted the following: ~ 5/30/12, on admission, "...Rt (right) buttock... .5 x .9 (0.5 centimeters by 0.9 centimeters)...Surrounding Skin Color [MEDICATION NAME]" ~ 5/30/12, on admission, "...Left buttock.. .3 x 0.6 (3.0 centimeters by 0.6 centimeters)..." The right buttock was noted as healed on 6/3/12. The left buttock was noted as healed on 6/20/12. "Weekly Pressure Ulcer Records" continue, ~ 6/20/12, "...L (left) upper inner gluteal crease...Stage 2.. .0.6 x 0.2...Depth 0.2...Surrounding Skin Color [MEDICATION NAME] already ordered for other now healed ulcer sites on both buttocks. Will use for this also..." The pressure ulcer on the left gluteal crease was noted as healed on 6/26/12. Resident #12 developed another pressure ulcer at the same time the previous ones were noted as healed. * There were no changes made to Resident #12's plan of care in attempts to prevent toprevent further pressure ulcers from developing. "Weekly Pressure Ulcer Records" continue: ~ 9/28/12, "...Recurring (sic)...L buttock/upper...Stage 2...0.5 x 0.5 Depth 0.1...Surrounding Skin Color Pink...Area where previous Pressure Ulcer was, reopened. [MEDICATION NAME] applied..." The left buttock pressure ulcer was noted as healed on 10/10/12. * Despite the reoccurrence of the pressure ulcer, there were no changes made to Resident #12's plan of care. On 2/4/13 a nursing note indicated, "...stage II pressure ulcers 1 cm (centimeter) apart R (right) upper inner posterior thigh near gluteal crease 0.1 x 0.3 x 0.1...inferior to that the 2nd (one) measuring 0.1 x 0.5 x 0.1 for which [MEDICATION NAME] probable old ulcer site..." * Again, there were no changes made to Resident #12's plan of care to prevent the reoccurrence of pressure ulcers. On 2/7/13 at 10:55 a.m., Surveyor # observed RN-I (Registered Nurse) with the assistance of CNA-A and CNA-S complete a dressing change on Resident #12's pressure ulcers. CNA-A and CNA-S assisted Resident #12 to turn onto his right side at which point it was noted that Resident #12 had been incontinent of stool. CNA-A expressed that Resident #12 was rarely incontinent of stool. Once CNA-A and CNA-S completed incontinence cares, RN-I removed the old [MEDICATION NAME] from Resident #12's right ischial area. Surveyor # noted that where Resident #12's left and right buttock met was significantly reddened. Surveyor # also noted both the right and left ischial areas were reddened. The right ischium had approximately a 10.0 cm in diameter area of purple-red discoloration. RN-I visualized the right ischial area and indicated the pressure ulcers were healed. RN-I then applied a new [MEDICATION NAME] to the area and indicated she was applying it for protection. RN-I also directed CNA-A to apply a barrier cream to Resident #12's buttocks. On 2/7/13 at 11:05 a.m., Surveyor # spoke with RN-I about Resident #12's pressure ulcers. RN-I indicated the ischial areas have been "more problematic." RN-I also indicated she was not certain why Resident #12's pressure ulcers kept reoccurring. On 2/7/13 at 1:30 p.m., Surveyor # spoke with RN-I again about the facility's practices for wound management. RN-I indicated when wounds re-open, they would send a note to the physician and re-institute the same orders which had been used previously to treat the wound. RN-I also stated RN-N was the wound nurse. On 2/8/13 at 7:50 a.m., Surveyor # spoke with RN-N. RN-N indicated he worked full time, however didn't consider himself the wound nurse. RN-N indicated he had little training on wounds and wound management. RN-N also stated the Director of Nursing (DON) was wound certified and was the person who "keeps the pulse" on significant wounds. RN-N stated there were three RNs, including himself, who filled the role of the treatment nurse. RN-N stated the treatment nurse that day was the one who completed the wound assessment and wound documentation independently. RN-N also stated the facility does not have a wound team. RN-N stated he was the treatment nurse about 50% of the time. RN-N stated the treatment nurses were responsible for managing all wounds. Surveyor # asked RN-N what they did when a pressure ulcer was not responding to a treatment. RN-N indicated they would contact the physician and initiate some other type of treatment. Surveyor # asked RN-N about Resident #12's pressure ulcers. RN-N indicated they had opened and closed several times. RN-N stated [MEDICATION NAME] had previously worked to treat the wounds, therefore he would re-institute the [MEDICATION NAME] when Resident #12 again had a pressure ulcer. Surveyor # asked RN-N why he thought Resident #12 kept developing pressure ulcers. RN-N stated he was not certain. RN-N stated Resident #12 generally sat straight in his wheelchair so he didn't feel positioning was a factor. Surveyor # asked RN-N if the facility had ever changed Resident #12's mattress or wheelchair cushion. RN-N indicated they had not. Surveyor # also asked RN-N what the facility used for barrier creams. RN-N indicated there were several different kinds. RN-N indicated the use of barrier creams was by exception, and not automatically used. RN-N indicated the CNAs were directed to use a barrier cream on those residents who required it via the CNA care plans. RN-N stated the use of the barrier creams would be documented in the CNA charting books. Surveyor # reviewed both Resident #12's CNA care plan and the CNA charting books. There were no directives to the CNA to apply a barrier cream to Resident #12's reddened skin on the buttocks. On 2/7/13 at 1:45 p.m., Surveyor # spoke with CNA-A about the use of barrier creams. CNA-A indicated barrier creams were used by exception for any resident with redness on the buttock area, per the direction of the treatment nurse, and if a resident requested it. CNA-A stated most residents had some type of barrier cream but they don't automatically put the barrier creams on. Surveyor # asked CNA-A about Resident #12. CNA-A stated she puts barrier creams on Resident #12 when directed to do so by the treatment nurse. Surveyor # requested RN-N and the DON to observe Resident #12's pressure areas with Surveyor # . On 2/8/13 at 9:05 a.m., Surveyor # observed Resident #12's pressure ulcers with RN-N and the DON. RN-N removed the [MEDICATION NAME] covering the right ischial area. Surveyor # asked both RN-N and the DON about the purple-red area on Resident #12's right ischium. The area again measured approximately 10.0 cm in diameter. RN-N stated he had never seen the discolored area before. The DON indicated that it looked like it could be the start of a DTI. Example #2: According to the NPUAP (National Pressure Ulcer Advisory Panel), a pressure ulcer is considered unstageable if there is, "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." According to the standards of practice outlined by the NPUAP (National Pressure Ulcer Advisory Panel), the US Department of Public Health's Agency for Health Care Policy and Research, and the "Nurses Clinical Guide to Wound Care" published in 1995, the assessment and documentation of a wound is to include: ~Location of the wound using the correct anatomical descriptors. ~Shape of the wound. ~Documentation of the anatomical position of the person during measuring as this can alter measurements. ~Measurements as Length x Width x Depth in centimeters. ~Measurements using the clock system with 12:00 the person's head and 6:00 the person's feet. ~Note any undermining. ~Note any tunneling. ~Asses and record the wound base and record the types of tissue using percentages. ~Drainage type and odor if applicable. ~The wound edges. ~The surrounding tissue at least 4 centimeter out. ~Presence of pain. The NPUAP also recommends that this documentation take place at least weekly and whenever the wound is visible as with a dressing change. Resident #1 was originally admitted to the facility on [DATE]. Current medical [DIAGNOSES REDACTED]. On 7/6/12, Resident #1 was admitted to the hospital for the treatment of [REDACTED]. This Significant Change in Status (SCIS) MDS dated [DATE], correctly identified the pressure ulcer as unstageable. Note: Surveyor # did not receive the Weekly Pressure Ulcer Record for this time period. Slough is a layer or mass of dead tissue separated from surrounding living tissue. It indicates the presence of bacteria (bioburdan or biofilm) on the wound. In order for healthy healing to occur, this slough needs to be removed. It presents as whitish, yellow, green, or gray stringy or a slimy coating over the wound or over a section of the wound, and it grows rapidly. 1. In reviewing the MDS assessments completed for Resident #1 (6/27/12 quarterly, 7/27/12 SCIS, 10/17/12 SCIS, and 1/9/13 quarterly), regarding the need for staff assistance with Activities of Daily Living, all four assessments indicate Resident #1 is dependent on staff for daily tasks of bathing, personal hygiene, dressing, transfers, mobility, and toileting. The facility SCIS MDS dated [DATE]'s CAA for Pressure Ulcer Team Assessment and Analysis states, "...(Resident #1) returned from the hospital with an open blister to his coccyx that is now covered with slough..." Note: This is the same verbiage from the previous assessment of 7/27/12. 2. The most recent Care Plan written for Resident #1 was dated 1/17/13 and includes the following care concerns: - "Potential for skin breakdown." According to this plan of care, Resident #1 has a history of stasis ulcers to the lower bilateral extremities. - "At risk for elimination dysfunction." This plan of care indicates Resident #1's skin is intact. Observations made during the survey indicate Resident #1 was up in his Broda chair for meals only, then placed in bed lying on his sides. This was written on Resident #1's plan of care. Note: There is no indication of Resident #1's actual Stage 2 to Stage 3 pressure ulcer on his coccyx. 3. The facility documents wounds on a form titled Weekly Pressure Ulcer Record. This is the only area in which wound documentation takes place. There is no in depth narrative in the nursing notes or wound notes. However, if completed correctly, this form can be a thorough assessment of each wound. According to the Weekly Pressure Ulcer Record, the following was noted in the coccyxgeal wound of Resident #1: Date of Onset 9/16/12. Note: The date of opening gives suspicion that tissue damage was occurring under the skin surface, as it was a blister in July when he returned from the hospital and two months later, this progressed to an open area. Excerpts from the documentation in the Weekly Pressure Ulcer Record, which each time included stage, size, odor, exudate, wound bed, surrounding tissue/wound edges, surrounding skin color, and narrative include: - 9/16/12: Coccyx, Stage 2 Size- 2 cm (centimeters) with 0.1 depth Odor- none Exudate (drainage) - none Wound Bed- pink Surrounding Tissue/Wound Edges- red Surrounding Skin Color- pink Narrative- There is a narrative from the nurse that states there is a note to the doctor to change the treatment to a Hydrogel. Note: A healthy wound bed would be described as red, which indicates good blood flow to the area. The measurement above does not indicate length by width using the correct anatomical descriptors or the presence or absence of undermining or tunneling. A good assessment would also evaluate the skin temperature surrounding the wound and also the temperature of adjacent tissues, and also the skin texture surrounding the wound (mushy, boggy, firm, etc.). With this assessment, one can determine if tunneling or undermining may be occurring under the skin surface. Also of importance, a healthy wound should not be dry, as no drainage present. A moist wound bed is preferred. Note: The treatment order dated 9/19/12 states "Hypergel to the right gluteal ulcer until debrided, then use Hydrogel..." If [MEDICATION NAME] was required since 9/16/12, then the wound should have been documented as Stage 3 or higher since that time, as Stage 2 wounds do not require [MEDICATION NAME]. The above wound documentation does not mention the presence or absence of slough or eschar. - 9/24/12: Coccyx, Stage 2 Size- 1.5 cm with 0.1 depth The measurement does not indicate length by width using the correct anatomical descriptors or the presence or absence of undermining or tunneling. Also important to note, the standard of practice is to not reverse-stage a pressure ulcer because the damage to underlying tissues (muscle, tendons, subcutaneous fat, dermis, etc.) has already occurred and cannot be replaced. One would need to document the wound as a healing Stage 3, but since there was an inaccurate staging of the ulcer, one would not be aware of this. Once healed over, granulation tissue becomes scar tissue, and is only 80% as strong as the skin was prior to the wound development, and may be easily re-opened. - 9/30/12: Coccyx, Stage 2 Size 1.5 cm circular with 0.1 cm depth - 10/10/12: Coccyx, Stage 2 Size- 2 x 3.5 with 0.2 depth (compared to 1.5 cm. circular with 0.1 cm. depth from 9/30/12) Exudate- Serosanguinous (a mixture of a clear fluid and blood) Wound Bed - yellow and red This assessment also does not indicate how much exudate is present. This assessment also indicates a substantial size increase to the wound. Yellowing of the wound bed gives rise to suspicion of slough development. - 10/14/12: Coccyx, Stage 2 Size- 1.5 cm with 0.1 depth The measurement does not indicate length by width using the correct anatomical descriptors or the presence or absence of undermining or tunneling. - 10/15/12: Coccyx, Stage 2 Size- 4 x 3 with 0.1 depth Exudate- Serosanguineous Wound Bed- red and white One also does not know if the white tissue is slough and how much exudate is present. Once again, this increase in size is substantial. One does not know if the physician has been notified, as this is not documented. - 10/24/12: Coccyx, Stage 2 Size- 2.5 x 3 with 0.1 depth Exudate- Serosanguineous Wound Bed - red and white Once again, one does not know if the white tissue is slough and how much exudate is present. The MDS assessment for 10/27/12 indicates Resident #1 had one Stage 2 pressure ulcers that developed 9/16/12, and the most severe tissue type was coded as granulation tissue (pink or red tissue with shiny, moist, granular appearance). Note: If a wound has slough, the standard of practice is to document the wound as a Stage 3, 4, or unstageable, as the nurse is unable to identify the wound bed with the slough covering the wound. The Weekly Pressure Ulcer Record continues: - 10/28/12: Coccyx- Stage 2 Size- 0.3 cm circular with 0.5 depth There was no measurement in the section for tunneling or undermining. The size documented is conflicting with the previous measurements. A wound will not heal this rapidly over this short period of time. - 11/5/12: Coccyx, Stage 2 Size- 0.3 cm circular with 0.3 depth Once again, the measurement of the wound is conflicting. - 11/12/12: Coccyx, Stage 2 Size- 2 x 3 with 0.2 depth, Exudate- Serosanguineous Wound Bed - red and yellow Once again, one does not know if the yellow is slough and how much exudate is present. - 11/18/12: Coccyx, Stage 2 Size- 2 x 3 with 0.2 depth Exudate- Serosanguinous Wound Bed- red and yellow There is no knowledge if the yellow in the wound bed is slough and how much exudate is present. - 11/25/12: Coccyx, Stage 2 Size- 2.5 circular with 0.2 depth Exudate- serous (clear fluid) Wound Bed- yellow and red granulation There is no knowledge if the yellow in the wound bed is slough and how much exudate is present. - 12/5/12: Coccyx, Stage 2 Size- 2.5 cm circular with 0.1 depth Exudate- serous There was no measurement in the section for tunneling or undermining, nor is there a noted mention of the amount of serous exudate present. - 12/12/12: Coccyx Stage 2 Size- 2 cm oval with 0.1 depth - 12/14/12: Coccyx Stage 2 Size- 2.5 cm circular with 0.1 depth Exudate- serous Odor- "yes" Wound Bed- granulation tissue Surrounding Skin Color- flesh Surrounding Tissue/Wound Edges- flesh Narrative- The nursing narrative states, "Hypergel daily to debride." In reviewing the medical record, the Hypergel was ordered 11/29/12. Hypergel is a water-based wound treatment used to soften and debride moist and dry eschar, or dead tissue. There was no mention of the new order on the documentation of the wound prior to this. This indicates the wound is farther advanced than a Stage 2. This is also the first time that odor is present. - 12/26/12: Coccyx Stage 2 Size- 1.5 x 2.5 with 0.2 depth - 1/2/13: Coccyx, Stage 2 Size- 2.5 x 1.5 with 0.1 depth (compares to 1.5 x 2.5 with 0.2 depth on 12/26/12) Exudate- moderate Odor- none Wound Bed- "sluff and red" The size indicated here is conflicting with the previous entry of 12/26/12, as one does not know which measurement is length and which is width. The current standard of practice is to always measure length (head to toe direction of the body) x width (right to left sides of the body) so that documentation is consistent in order for the assessment to be accurate. Also the presence of slough indicates a Stage 3 or higher or unstageable. - 1/9/13: Coccyx Stage 2 Size- 2.5 x 3.0 with 0.3 depth Exudate- yellow slough Odor- none Wound Bed- yellow and red Surrounding Skin Color- pink Surrounding Tissue/Wound Edges- pale purple Narrative -The nursing narrative states, "Area worse as in larger in size." This wound has clearly advanced in size and the wound characteristics. The nurses still continue to document this wound as a Stage 2 even though there is a presence of slough and now the edges have deepened in color. There is still no mention on the presence or absence of tunneling or undermining. The pale purple coloring creates a suspicion of tunneling. However, this area was left blank on the assessment form. - 1/16/13: All documentation is the same as above except the nursing narrative states, "Size stabilized. Wound still occupied with large area of necrotic slough. Hypergel continues." - 1/22/13: Coccyx Stage 2 Size- 2.5 x 2.5 with 0.4 depth - 1/29/13: Coccyx Stage 2 Size- 2.5 x 2.5 with 0.6 depth Exudate- purulent drainage (indicates pus), Odor- " +" (positive) Wound Bed- dark red Surrounding Skin Color- red Surrounding Tissue/Wound Edges- red Narrative- "Area now tunneling. Will request [MEDICATION NAME] gauze packing." The order for the [MEDICATION NAME] packing was received on 1/29/13. This remains the current treatment for [REDACTED]. - 2/4/13: Coccyx Stage 2, Size- 2.5 x 2.5 with 0.6 depth Exudate- Serosanguineous Odor-none Wound Bed - dark red Surrounding Skin Color- flesh Surrounding Tissue/Wound Edges- flesh Narrative- The nursing narrative states, "[MEDICATION NAME] gauze in use." On 2/7/13 at 10:35 a.m., Surveyor # observed the treatment to Resident #1's coccyx wound by RN-I (Registered Nurse). The wound itself was over the upper right sacrum, not the coccyx, and measured approximately 2.5 cm length x 2.5 cm width. The depth was deep and tunneling at 5:o'clock to 7:o'clock. The surrounding skin was dark pink and the wound edges were light pink to white maceration. There was no odor evident to the wound and it appeared clean. There were no measurements taken during this dressing change by RN-I. RN-I stated measurements are taken once weekly and that the measurements were done on Monday, which was 2/4/13. On 2/8/13 at 8:20 a.m., Surveyor # interviewed the DON (Director of Nursing) on various topics, including Resident #1 and his pressure ulcer and how Dietary is involved with skin interventions. The DON stated that when a resident has an open area, Dietary is notified through nursing. Dietary then implements a number of interventions for wound healing. The DON admitted the facility "dropped the ball" on Resident #1 and did not get Dietary involved when he developed the pressure ulcer. On 2/8/13, at 9:18 a.m., Surveyor # questioned DM-K (Dietary Manager) regarding her involvement with Resident #1 regarding weight loss and the worsening of the pressure ulcer. DM-K stated she was aware of the pressure ulcer in August 2012, but was unaware that it worsened. When asked what her plan was now that the ulcer worsened, DM-K stated, "I'll be adding something hi-protein (jello, pudding, supplements, etc. between meals) to his diet." Of note is this: without proper education regarding wounds, nursing staff were unaware of the correct staging of Resident #1's wound and the measurements taken were conflicting. There was no updating to his plan of care when the wound developed seven months ago, and documentation of the wound does not meet the current standards of practice regarding accuracy and consistency. Furthermore, the facility did not involve the dietary department to allow for high protein interventions crucial to the healing of wounds. Example #3: Resident #2 was originally admitted to the facility 12/7/10 and readmitted [DATE]. Her current medical [DIAGNOSES REDACTED]. On 11/7/12, Resident #2 developed a blister to her left calf as a result of the leg brace she wore. On 11/12/12, Resident #2 developed a Stage 2 pressure ulcer to her right middle to lower gluteal crease. This pressure ulcer progressed to a Stage 4, then was later documented as a Stage 3. The facility developed a comprehensive care plan for Resident #2 dated 11/30/12. Included in the areas of concern is the following: - "Potential for skin breakdown"- Included in the goals for this plan was "Resident's skin will remain intact." Note: There is no indication of Resident #2's actual Stage 2 to Stage 4 pressure ulcer on her calf or gluteal crease. The facility documents wounds on a form titled Weekly Pressure Ulcer Record. This is the only area in which wound documentation takes place. There is no in-depth narrative in the nursing notes or wound notes. However, if completed correctly, this form can be a thorough assessment of each wound. According to the Weekly Pressure Ulcer Record, the following was noted in the left calf wound for Resident #2. Excerpts from the documentation in the Weekly Pressure Ulcer Record, which each time included stage, size, odor, exudate, wound bed, surrounding tissue/wound edges, surrounding skin color, and narrative include: - 11/7/12: LEFT CALF Stage: 1, presented as a blister Size: 2.8 x 5 cm (centimeters) with no depth Exudate: none present Odor: none present Wound bed: none Surrounding skin color: [DIAGNOSES REDACTED]tous (indicates redness) but blanchable Surrounding tissue/wound edges: charting is left blank Nursing narrative: none written. The measurement above does not indicate length by width using the correct anatomical descriptors or the presence or absence of undermining or tunneling. A good assessment would also evaluate the skin temperature surrounding the wound, the temperature of adjacent tissues, and the skin texture surrounding the wound (mushy, boggy, firm, etc.). With this assessment, one can determine if tunneling or undermining may be occurring under the skin surface. - 11/19/12: (12 days later) Stage: 2 Size: 6.8 x 2 with 0.1 depth (this measurement does not indicate which size is length or which is width) Exudate: moist (this does not indicate the color of the drainage or the amount) Nursing narrative: There is no nursing narrative other than "Hydrogel," which provide absorption, desloughing and [MEDICATION NAME] of necrotic and fibrotic tissue. This was the treatment ordered at the time. If slough has been present, then the pressure ulcer should have been at least a stage 3. This assessment also indicates a substantial size increase to the wound; however, there was no change to the plan of care. - 11/26/12: Stage: none documented Size: 6.5 x 2 with 0.2 depth (This measurement does not indicate which size is length or which is width) Exudate: "Serosanguineous lower 2/3" (this does not indicate the amount of drainage, nor is the location documented according to the clock method, which is the standard of practice). Wound bed: "yellow upper 1/3 light red below that" Slough is a layer or mass of dead tissue separated from surrounding living tissue. It indicates the presence of bacteria (bioburdan or biofilm) on the wound. In order for healthy healing to occur, this slough needs to be removed. It presents as whitish, yellow, green, or gray stringy or a slimy coating over the wound or over a section of the wound, and it grows rapidly. Resident #2's medical record indicated Hypergel was ordered on [DATE] to remove slough and debride the calf wound. Once the slough was debrided, the facility was to return to Hydrogel daily as the treatment. If slough is present, the wound would be classified as Stage 3, 4, or unstageable, depending on the amount present. Serosanguineous drainage is watery and bloody drainage. - 12/5/12: Stage: 2 Size: 4cm x 2 cm with 0.2 depth (this measurement does not indicate which size is length or which is width) Exudate: serous (this does not indicate the amount of drainage present) Wound bed: "eschar in middle yellow around" (This indicates necrotic tissue which requires [MEDICATION NAME]. The wound should now have been documented as unstageable.) Nursing narrative: "Monitor area pillows between legs when Res (Resident) on her side may be helpful." This entry does not clearly evaluate the wound. Serous exudate represents a clear, watery drainage, and is considered healthy. - 12/11/12: Stage: 2 Size: 4 x 1 with 0.2 depth (This measurement does not indicate which size is length or which is width.) Exudate: serous (This does not indicate the amount of the drainage.) Wound bed: white (One does not know if the color indicates the presence of slough.) Note: The standard of practice is to not reverse-stage a pressure ulcer, as the damage to underlying tissues (muscle, tendons, subcutaneous fat, dermis, etc.) has already occurred and cannot be replaced. One would need to document the wound as a healing Stage 3 or 4, but since there was an inaccurate staging of the ulcer, one would not be aware of this. Once healed over, granulation tissue becomes scar tissue, and is only 80% as strong as the skin was prior to the wound development, and may be easily re-opened. - 12/12/12: Stage: 2 Size: 4 x 1 with 0.2 depth (This measurement does not indicate which size is length or which is width.) Exudate: serous (This does not indicate the amount of the drainage.) Wound bed: white - 12/19/12: Stage: 3 Size: 3 x 0.8 with 0.4 depth (This measurement does not indicate which size is length or which is width.) Exudate: purulent (This indicates pus is present and does not indicate the amount of the drainage.) Odor: yes Wound bed: eschar and yellow - 12/26/12: Stage: 2 (Once again, with the presence of slough, one should document the wound as unstageable and not reverse-stage.) Size: 3.2 x 1.0 with 0.2 depth (This measurement does not indicate which size is length or which is width.) Exudate: slough (This does not indicate the color of the drainage or the amount.) Wound bed: yellow Note: Slough is not exudate; it is bioburdan or biofilm and represents bacter