Every finding on record at Evansville Manor Nursing and Rehab, LLC

Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse for 1 of 5 residents reviewed (R1). R2 has a history of making inappropriate comments and inappropriately touching female residents and staff. R2 is care planned to be kept out of arms reach of female residents and to be monitored when out in common areas. On 2/27/26, R2 was left unsupervised and inappropriately touched R1.The facility's failure to provide adequate supervision and protect residents from sexual abuse created a reasonable likelihood for serious psychosocial harm, thus resulting in a finding of immediate jeopardy (IJ) that began on 2/27/26. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 3/12/26 at 12:00 PM. The immediacy was removed and corrected on 2/28/26. The deficient practice is being cited as past noncompliance. Evidenced by:The facility policy, Vulnerable Adult, Abuse and Neglect Prevention, dated 3/25/25, states: .It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations.All residents are susceptible to maltreatment and exploitation due to their need for nursing home care .Additionally, residents and staff will be protected from abuse, neglect, and harm while they are residing at the facility. There is zero tolerance for abuse or harm of any type. Residents and staff will be monitored for protection. The facility will strive to educate all participants in techniques to protect all parties.R2 was admitted to the facility on [DATE] with diagnoses including stroke, diabetes, kidney disease, impulse disorder, unspecified symptoms and signs involving cognitive functions and awareness, mood disorder, other subjective visual disturbances, and mild cognitive impairment.R2's most recent Minimum Data Set (MDS) indicates R2 has a Brief Interview for Mental Status (BIMS) score of 14 indicating R2 is cognitively intact. R2 has an activated power of attorney.R2's Comprehensive Care Plan states: .When R2 goes to activities he must be escorted to and from and placed at least arms distance away from any/all female residents 7/23/24.R2 exhibits behavior symptoms related to impulse disorder.hits/kicks during cares at times. Taking food items off of other residents trays or snack carts that are not within his diet orders. R2 tends to make sexual comments or attempt to touch staff's behinds. Resident is very honest when he is guilty of making comments and actions.10/2/23 Patient grabbed a female resident chest. 10/20/23 Resident using vulgar language/comments in dining area towards staff and residents, resident is not to have any contact with female resident .1/24/23 room change. 5/3/23 resident concern. 12/4/23 no contact with resident .2/25/24 inappropriate comment to resident .5/15/25 inappropriate behaviors towards females. 9/3/25 Resident has increased negative behaviors with certain staff. 2/27/26 inappropriate behavior toward female resident.R2 will have fewer episodes of making sexual comments or touching staff and other residents private areas/bottoms inappropriately, by the review date.12/4/23 Keep out of arms reach from female residents.Monitoring R2 when he is in a common area.R1 was admitted to the facility on [DATE] with diagnoses including autistic disorder and metabolic encephalopathy (acute confusion, altered mental status.)R1's most recent MDS indicates R1 has a BIMS score of 00 indicating R1 is severely cognitively impaired. R1 has an activated power of attorney.R1's most recent Comprehensive Care Plan states in part:.Vulnerability: Limited speech due to Autism Spectrum Disorder, nonverbal. Resident is unable to call out for help or remove self from a situation she feels unsafe in.Provide safe environment.The facility completed a self-report/investigation which states: .2/27/26 6:30PM, RN E (Registered Nurse) notified NHA A (Nursing Home Administrator) that at approximately 6:30PM R2 was observed with R1 in the lounge, with his hand on her, and it appeared he was touching her private area.no negative effects on resident noted at time of assessment.staff separated residents immediately, ensured R1 was safe, implemented 1:1 for R2, reported to NHA, DON (Director of Nursing), DQA (Division of Quality Assurance), Police Department notified, Guardians updated.The facility's brief statement to state agency states: At approximately 6:45PM, RN E notified NHA A that R2 was found with R1 in the hallway lounge with his hand on her, and it appeared he was touching her private area. The facility initiated an investigation, separated the residents, and placed R2 on 1:1 monitoring. RN E performed a full head to toe assessment on the resident, noting no concerns. The resident did not show any psychological distress from the incident, according to RN E. The police, POA, and provider were notified. Accused CNA was sent home. A detailed summary of investigation along with supporting documentation will be submitted.Facility interviewed residents and staff. Facility completed a timeline of events and ensured safety and placed accused CNA G (Certified Nursing Assistant) on administrative leave pending investigation. R1 went to ER for evaluation and returned with no new orders. Accused CNA G reported she did not know R2 was on 1:1 in the lounge and thought he was supervised only during meals. The facility provided CNA G 1:1 education and provided all nursing staff education regarding sexual abuse, following Kardex, what 1:1 means, and specific behavior training for R2.Facility conclusion states: .The facility concluded that R2 should not have been touching R1 as she is unable to consent. It was identified that some staff required additional clarity regarding supervision protocols for certain residents. To prevent such incidents in the future, the facility provided training to nursing staff on supervision requirements for residents and the specific sexual behaviors necessitating close monitoring, especially when in proximity to other vulnerable individuals. Additionally, the facility is actively pursuing alternative placement for R2 and psychosocial support with geri-psych (geriatric psychiatric unit). Resident has been accepted .and will be transferred on 3/5/26. Resident will remain on 1:1 always until this time. Prior to returning to facility, IDT (Interdisciplinary Team) will ensure a safe and proper plan is implemented for residents. Also, actively working with MCO (Managed Care Organization) to seek placement in a smaller setting/male group home. Facility will ensure through education that all staff assigned on R2's hallway have documented education on proper 1:1 with residents assigned to it. Close monitoring and collaboration with the local law enforcement will continue. Follow up with all residents that were at risk prior in the facility occurred with no further concerns. Staff education will continue. Care plan was updated for R2. R1 had a planned discharge for 3/1/26 and has since been discharged from facility. Follow up occurred with R1's guardian on 3/2/26 and 3/4/26.Surveyor confirmed R1 was discharged on 3/1/26 to her group home and R2 was discharged on 3/5/26 to a geriatric psychiatric facility.On 3/11/26 at 1:50 PM, Surveyor interviewed CNA C, who indicated she has received education recently on sexual abuse, 1:1 supervision, and specific behaviors for R2. CNA C indicated she is aware of the incident from 2/27/26 and after R2 was placed on 1:1. CNA C indicated before the incident, R2 needed to be in staff line of sight at all times when out of his bedroom and at arm's length from all female residents. CNA C indicated R2 is very quick and has touched CNA C and said inappropriate things to her as well.On 3/11/26 at 2:06 PM, Surveyor interviewed CNA D, who indicated she is always down R2's hallway, but was not working on 2/27/26. CNA D indicated prior to the incident on 2/27/26, R2 needed to be in line of sight when out of room and at arm's length from all female residents. After the incident, R2 was 1:1 at all times. CNA D indicated she received education after the incident. CNA D indicated R2 talked about the incident when she came back to work the following Monday and that R2 laughed about the incident.On 3/11/26 at 2:30 PM, Surveyor interviewed RN E, who indicated she was the nurse that was working on 2/27/26. RN E indicated around 6:30 PM, CNA G reported to her that CNA G was returning trays to the cart, came back and saw R2 touching R1 in her abdomen area. CNA G immediately separated the two residents and reported the incident. RN E completed a full head to toe skin check on R1, R2 was put on 1:1 staffing, and all notifications were made. RN E indicated before this incident, R2 was care planned to be in line of sight if out of room, not be left around female residents, and staff had to escort him to and from activities. RN E indicated he needed extra supervision when out of his room. RN E indicated CNA G was agency staff and she was under the impression that the extra supervision was just for mealtimes. RN E indicated everyone received education after the incident.On 3/11/26 at 2:12 PM, Surveyor interviewed FM F (Family Member), who indicated she is R1's activated power of attorney. FM F indicated R1 is not able to use words to communicate. FM F indicated she came to the facility after the incident and R1 was not acting like herself. FM F indicated R1 did not make eye contact. FM F indicated she went with R1 to the emergency room. FM F indicated she has no concerns with how the facility investigated and handled the incident.On 3/12/26 at 11:30 AM, Surveyor interviewed DA H (Dietary Aide), who indicated she is aware of the incident that occurred on 2/27/26 between R2 and R1. DA H indicated she received education after the incident. DA H indicated R2 cannot be left alone, never can be alone. DA H indicated if she ever saw R2 without staff by R2's side she would stay with him until she got a nursing staff to assist him. DA H indicated if she ever witnessed any issues between R2 and another resident she would intervene and report the incident immediately.On 3/12/26 at 11:45 AM, Surveyor interviewed AA I (Activity Aide), who indicated she received education after the incident on 2/27/26. AA I indicated R2 is a 1:1 at all times. AA I indicated if she witnessed R2 being inappropriate with another resident she would separate the two residents and report immediately.On 3/11/26 at 3:02 PM, Surveyor interviewed NHA A. NHA A indicated the incident took place on 2/27/26 around 6:30 PM. NHA A indicated RN E called and reported the incident. NHA A indicated both residents were separated, R2 was placed on 1:1, and R1 was assessed and went to the emergency room. NHA A indicated CNA G was placed on administrative leave and all notifications were made. NHA A indicated care plans were updated, audits completed, staff and residents interviewed, and education was provided to all nursing staff. NHA A indicated they identified a break in communication between the nurse/aide, care plan and supervision were not followed, and they began working on past noncompliance. The facility implemented that only the facility CNAs could work down R2's hallway and if agency had to, then there would be documentation of the training with that agency staff. The facility completed audits to ensure this was being followed. The facility also completed audits on ensuring the 1:1 was in place, 1:1 documentation was completed, and this matched the schedule for the day. The facility also made the decision to not have residents who are unable to verbally communicate be admitted down R2's hallway and Admissions received training on this. NHA A indicated before this incident R2 needed to stay arm's length from all female residents and supervision when out of bedroom.The facility's failure to provide adequate supervision and protect residents from sexual abuse by R2 created a reasonable likelihood for serious psychosocial harm, thus leading to a finding of immediate jeopardy which began on 2/27/26. The facility removed and corrected the immediate jeopardy on 2/28/26 when it completed the following:R2 and R1 immediately separated. R2 placed on 1:1 staffing. A full head to toe assessment completed for R1.CNA G Nursing Assistant placed on administrative leave.Ensured all residents in facility were safe and expressed no concerns regarding safety.Police guardians, state agency, and Medical Director notified.Behavioral Care was sought for R2 to review medications and increased sexual behavior.emergency room evaluation was provided to R1 with no new orders.The facility provided training to the nursing staff on supervision requirements and the specific sexual behaviors necessitation close monitoring, especially when in proximity to other vulnerable individuals and ensuring Kardex is utilized every shift and CNAs review binder for any additional changes to resident care.Agency staff will not be assigned to R2's hallway. Education completed with staffing coordinator, nursing leadership, Human Resources, and NHA to ensure staffing expectations are followed.Documentation 1:1 supervision is being documented every shift.Education for IDT to ensure non-verbal residents will not be placed on R2's hallway.Daily audits to ensure 1:1 is being done and documented.Daily audits to ensure that R2's hallway does not have agency staff scheduled to work on the hall, if no other staff available, documentation that agency employee was educated.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 61 residents. Kitchen staff were not testing the parts per million (PPM) of the chemical sanitizing solution in the low temperature dishwasher during a Norovirus (a contagious virus which causes nausea, vomiting and diarrhea) outbreak.In addition, on 2/4/26 DA I (Dietary Aide) was out with GI (gastrointestinal) illness symptoms. According to CDC (Center for Disease Control and Prevention) DA I should have been removed from work until 48 hours after DA I's last symptom/episode. DA I was allowed to return to work too early after the onset of GI symptoms and prepare food. Failure to ensure a system was in place to test ensure dishes were properly sanitized, and that staff with GI symptoms remained off of work for the appropriate amount of time created a finding of Immediate Jeopardy (IJ). The immediate jeopardy began on 2/6/26. Surveyor notified NHA A (Nursing Home Administrator) and RDO JJ (Regional Director of Operations) of the immediate jeopardy on 2/25/26 at 2:34 PM.The immediate jeopardy was removed on 2/26/26, however the deficient practice continues at a scope and severity of F (potential for harm/widespread) as the facility implements its action plan and due to the following examples:Surveyor observed packages of food on the floor and a dented can on the shelf in the dry storage room.Surveyor observed meat sitting on the kitchen counter to thaw.Surveyor observed food in circulation that was open and undated.Surveyor observed open staff food in a refrigerator and a freezer that contained resident food.Surveyor observed staff taking temperatures of food during lunch meal. Staff did not take temperatures of all foods and the foods were not placed in a steam table to hold temperature.Surveyor observed food brought in by visitors that was open, undated, and moldy.Surveyor observed mighty shake to be thawed and without a thaw or use by date. Findings include:1.) The facility uses the US Food Code as their kitchen's operational standards of practice.2017 Food and Drug Administration (FDA) Food Code states:4-302.14 Sanitizing Solutions, Testing Devices:A test kit or other device that accurately measures the concentration in MG/L of sanitizing solutions shall be provided.4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration:Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration:The effectiveness of chemical sanitizers is determined primarily by the concentration and pH (scale of acidity) of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the concentration of the chemical sanitizer solution.4-701.10 Food-Contact Surfaces and Utensils:Utensils shall be sanitized.4-302.14 Sanitizing Solutions, Testing Devices:Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons:1. The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and2. Too much sanitizer in the final rinse water could be toxic. The facility's Dishwashing Temperature Log policy, undated, states, in part: Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization.The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 degrees C (Celsius) (160 degrees Fahrenheit). (2017 FDA (United States Food and Drug Administration) Food Code). Scope: The policy is pertinent to all kitchen staff and has the potential to affect all residents. Purpose The purpose of this policy is to ensure that dish machine temperatures and concentration of sanitizer, if applicable, are documented for each meal and are within applicable guidelines and regulations to prevent the spread of food borne illness. For hot water sanitizing machines, plate surface temperature must also be documented on a regular basis. Procedure 1. Wash and rinse temperatures shall be documented for each meal on the Dish Machine Temperature Log specific to the type of dish machine in operation (e.g. hot water sanitizing or chemical sanitizing).4. The following guidelines shall be used: .b. Chemical sanitizing machine: i. 120 degree wash + 50-100 ppm hypochlorite (or according to manufacturer's specifications) on dish surface in final rinse. 5. Wash and rinse temperatures and/or sanitizer levels must reach target guidelines before any racks or dishes or utensils are run through the machine. 6. If dish machine temperatures are below guidelines, Dietary Manager and Maintenance Director shall be notified immediately and dishes/utensils shall be sanitized by chemical method.Definitions .Chemical Sanitizing dish machine: A dish machine that uses one of a number of approved sanitizers to sanitize wares.The Dish machines Owner's Manual Revision 1.01A, undated, states in part: .Follow the directions precisely that are on the litmus paper vial and test the water on the surface of the bottom of the glasses. Concentration should be 50 PPM minimum to 100 PPM maximum. If concentration is incorrect contact your chemical supplier.The facility's Dishmachine Temperature Log (high temp machine) dated February 2026, shows the facility documented the dishwasher wash and rinse temperatures three times per day; along with a surface temperature once daily. The log incorrectly identifies the dish machine as being high temperature, when it was actually low temperature. There is no space on the log for documentation of PPM despite facility policy. There is a hand written note at the bottom of the log which states: *wash-120+ * Rinse-140+ *PPM-50-100 * Surface Temp-160(of note: the facility has a low temperature dish machine, however they were utilizing a high-temp log.) The facility's GI Norovirus Outbreak summary indicates outbreak started on 2/9/26 and continued through 2/20/26. On 2/20/26 and 2/21/26, the Employee Call In log indicates that a staff member called in for nausea and vomiting on each date. Important to note: these staff members were not included in the outbreak summary.On 2/24/26 at 9:34 AM, Surveyor observed DA DD (Dining Assistant) and DA EE performing dishwashing of breakfast dishes. DA DD put dishes into the machine and DA EE removed dishes from the machine. Surveyor asked DA DD about the machine and checks that needed to be done to ensure sanitizing of dishes. DA DD indicated it is a high temp machine; we check the gauge for wash and rinse temperatures. The first cycle is the wash; we check the gauge. The second cycle is the rinse; we check the gauge. Surveyor asked if there are any further checks. DA DD stated no, we check the temperatures and mark them on the log. Surveyor reviewed the February 2026 log and asked about PPM and surface temperature. DA DD stated we check the surface temperature on a plate by the gun (thermometer gun). Surveyor asked if PPM is done. DA DD stated no. DA EE stated I checked the plate temperature; it came out right at 160.On 2/24/26 at 11:55 AM, Surveyor interviewed DM BB (Dietary Manager) and asked about dishwashing. DM BB stated it is a low temperature machine; they test the chemical with the test strip. Surveyor asked where the PPM is documented. DM BB reviewed the logs for January 2026 and February 2026 and stated they used the wrong form. This form is for a high temperature machine. They are putting the PPM in the surface temperature column. Surveyor asked DM BB to perform the check for PPM. DM BB took a test strip and dipped it into the well in the outer front of the machine, then held it to the control paper. DM BB stated it shows 100. Surveyor asked what readings the control paper can indicate. DM BB verified that the control paper had indicator for readings of 10, 25, 50, 100, and 200. Surveyor asked if there is an indication on the control paper for 160. DM BB stated no. Surveyor asked if the staff were checking PPM and marking it, in the surface temperature column of the log, as 160; is this an appropriate value? DM BB stated no. Surveyor asked what happens if PPM is out of range. DM BB stated they'd need to tell me; they are marking the surface temperature and not PPM. Surveyor asked, without documentation of PPM, how do you know that PPM was done / was correct. DM BB stated unable to confirm; it should be done with each meal. 2) The facility's Food Safety Requirements Use, Storage, and Food Procurement policy, dated 12/23/25, states, in part: . FACTORS IMPLICATED IN FOODBORNE ILLNESSES Many factors contribute to foodborne outbreaks in facilities. These factors apply not only to center team members, but family and visitors as well. Several factors that cause pathogen growth include, but are not limited to: *Poor Personal Hygiene-Personal health and hygiene are significant factors in preventing foodborne illness. This has been demonstrated in the population at large, commercial food service establishments, and in nursing facilities. Foodborne illness in nursing homes has been associated with Norovirus. Because infectious individuals (persons capable of transmitting an infection or communicable disease whether they are colonized or infected) are a source of Norovirus. Proper handwashing techniques and exclusion of infectious workers from handling food are critical for prevention of foodborne illness. The facility's Infection Control - Employee Health policy, dated 5/8/24, states, in part: POLICY STATEMENT It is the Policy of this company that all facilities provide safe and sanitary storage, handling, and consumption of all foods including those brought to residents by family and other visitors.It is also the policy of this facility to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, including safe food handling by all dietary personnel and any other staff handling food, from the point of receiving through the preparation and service of the meal. Purpose: To ensure and maintain a health standard required of all employees to perform their duties. Policy:. 1a. No employee with a communicable disease shall be allowed to work in the facility until the period of communicability has been determined to have terminated. Procedure: 2. CDC guidance and recommendations will be followed to determine when an employee may return to work after a possibly infectious illness such as Influenza, COVID, GI Flu, etc.The CDC website, https://www.cdc.gov/norovirus/communication-resources/facts-for-food-workers.html, dated 5/8/24, states, in part: . Food workers should stay home when sick and for at least 48 hours after symptoms stop.The Wisconsin Department of Health Services publication titled Recommendations for Prevention and Control of Acute Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities, dated 12/2017, states, in part: .Staff should exclude themselves from resident care and food service duties at the onset of symptoms, including nausea, vomiting, abdominal pain, and/or diarrhea. Such exclusions shall remain in effect until the employee is asymptomatic (free of symptoms) and free of diarrhea and vomiting for 48 hours. On 2/4/26, DA I (Dietary Aide) was listed on the Employee Call-In log as having diarrhea. No well date or return-to-work date was listed. DA I's employee timecard log indicates that DA I returned to work on 2/6/26.On 2/25/26 at 11:44 AM, Surveyor interviewed DA I, who stated he had Chinese food for dinner on 2/4/26 and then started experiencing diarrhea in the night, about 5 hours after consuming the Chinese food. DA I indicated he had diarrhea a couple of times in the night, then started to feel better the next day, after about 24 to 35 hours. DA I confirmed that he returned to work on 2/6/26 for the PM shift. DA I stated his kitchen duties include washing dishes, setting up food trays, putting trays on the food cart, helping with drinks, assembling the trays and taking the food cart down to the halls. DA I stated that after the meal, he cleans the dining room, breaks down the food carts, puts the condiments and drinks away, and washes the meal dishes. On 2/24/26 at 2:53 PM, Surveyor interviewed DM BB (Dietary Manager) and asked about kitchen staff illness. DM BB stated when they call in, staff will tell me about their symptoms and I update ADON/IP C (Assistant Director of Nursing / Infection Preventionist). No matter what, we play it safe and they are out at least 48-72 hours. I am in contact with them while they are out and know the status of their symptoms.On 2/25/26 at 12:42 PM, Surveyor interviewed ADON/IP C (Assistant Director of Nursing/Infection Preventionist) about DA I's symptoms and return-to-work date. ADON/IP C stated that DA I actually called in with an episode of diarrhea on 2/3/26 and then came back on the 2/6/26. ADON/IP C stated that DA I called in at 5:00 AM on 2/4/26 saying he wasn't going to be in and that he had diarrhea the day before. ADON/IP C stated that DA I called again at noon on 2/4/26 stating that he was feeling better hadn't had another episode of diarrhea since that morning.Of note: The facility surveillance line list did not include DA I, the employee call-in log did not include a well date or time for DA I, and when DA I was interviewed by Surveyor, DA I stated that he had episodes of diarrhea in the night of 2/4/26. The failure to check PPM prior to dishwashing and ensure that staff who are ill with GI illness remain off work for the appropriate length of time created a reasonable likelihood for serious harm which created a finding of Immediate Jeopardy. The facility removed the jeopardy on 2/26/26. However, the deficient practice continues at a scope and severity of F (potential for harm/widespread) as the facility continues to implement the following action plan and as evidenced by examples 3 thru 9.On February 23, 2026, Dietary Manager immediately tested the low-temperature dishwasher to verify PPM and logged to ensure ongoing compliance and a new dishwasher temperature and sanitation log was implemented, requiring staff to document the PPM daily.1) Dietary Manager/designee completed education with all dietary staff at time of their next working shift regarding proper temperature and PPM monitoring of dish machine. Return demonstration completed post education. (Summary of education below). Approved Standards Wash temperature: 120-140 F Sanitizer concentration: Minimum 50 PPM Sanitizing method: Chemical sanitizer When to Check PPMPPM must be checked and documented: At the start of each meal period (Breakfast, Lunch, Supper) Any time the machine is refilled, serviced, or adjusted If there is concern the machine is not sanitizing properly How to Check PPM1. Run the dish machine so sanitizer is being dispensed.2. Dip the approved test strip into the solution. (dip test strip into drain well when filled)3. Read the strip according to the manufacturer's color chart.4. Confirm the reading is at least 50 PPM.5. Record wash temperature, PPM, and initials on the Dish Machine Log. If PPM Is Out of Range Stop using the dish machine immediately. Do not send dishes to service. Notify the Dietary Manager and Maintenance. Use an approved alternate sanitizing method as directed 2) DON/Designee to complete education regarding Noro-virus symptoms, monitoring, return to work policy and expectations for their department during next working shift. (Education summary below). Staff who are ill and work in the dietary department while ill, may spread their illness to the residents. The residents in the LTC facility have many risk factors that make them more susceptible to or easier to get sick.It is important if you are not well, to not return to work. Norovirus per the CDC:Norovirus is a very contagious virus that causes vomiting and diarrhea.It is sometimes called the stomach flu or the stomach bug. However, norovirus illness is not related to the flu. The flu is caused by the influenza virus. Norovirus causes acute gastroenteritis, an inflammation of the stomach or intestines.Most people with norovirus illness get better within 1 to 3 days; but they can still spread the virus for a few days after. NOROVIRUS OR GI ILNESS RETURN TO WORK: EMPLOYEE MUST BE OFF WORK FOR 48 HOURS AFTER LAST EPISODE OF WATERY STOOL AND/OR VOMITING AND FEVER RESOLVES (TEMP LESS THAN 100.0 WITHOUT TYLENOL OR ADVIL) EMPLOYEE WILL VERIFY WITH THE IP/DON THEIR RETURN TO WORK DATE AND TIME. Facility's existing Dishwashing Temperature Log policy was reviewed by the Administrator and Dietary Manager; current policies were found to be sufficient and meet regulatory standards 1) Dietary Manager/designee will complete audits to ensure the proper low temperature dishwasher logs daily are completed and temps/chemical levels are within range daily x2 weeks, twice a week x2 weeks and weekly x4 weeks to ensure compliance.2) IP/Designee to audit and monitor proper infection control policy is followed for Dietary staff return to work along with the other facility staff. Audits will be completed daily x30 days and ongoing.All audits will be brought to the Quality Improvement Committee for review and recommendations The deficient practice continues at a scope/severity of F (potential for no more than minimal harm that is not immediate jeopardy/widespread) as evidenced by:3.) The facility's Food Safety Requirements Use, Storage, and Food Procurement policy, dated 12/23/25, states, in part: .SCOPE This policy applies to all facilities to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors. This includes the storage, preparations, distribution, and serving food in accordance with professional standards of food service safety. PURPOSE The purpose of this policy is to ensure that the center: .2. Follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the center's food handling processes. Nursing home residents risk serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure for residents. Sanitary conditions must be present in health care food service settings to promote safe food handling. CMS (Centers for Medicare and Medicaid Services) recognizes the U.S. Food and Drug Administration's (FDA) Food Code and the Center for Disease Control and Prevention's (CDC) food safety guidance as national standards to procure, store, prepare, distribute, and serve food in long term care facilities in a safe and sanitary manner. Effective food safety systems involve identifying hazards at specific points during food handling and preparation, and identifying how hazards can be prevented, reduced, or eliminated. It is important to focus attention on the risks that are associated with foodborne illness by identifying critical control points (CCPs) in the food preparation processes that, if not controlled, might result in food safety hazards are thawing, cooking, cooling, holding, and reheating foods, and employee hygienic practices. On 2/22/26 at 9:03 AM, during the initial kitchen tour with LC AA (Lead Cook,) Surveyor observed an open box of canisters of rolled oats and a box of fig bars sitting on the floor in the dry storage room. LC AA stated nothing should be on the floor. Surveyor observed a dented can of tuna sitting on the shelf. LC AA stated dented cans should not be in the storage room.On 2/24/26 at 2:53 PM, Surveyor interviewed DM BB (Dietary Manager) who stated there are to be no boxes on the floor and no dented cans in the dry storage area. 4.) On 2/22/26 at 9:16 AM, during the initial tour of the kitchen with LC AA (Lead Cook,) Surveyor observed 2 packages of sliced turkey breast sitting on the counter. LC AA stated, those are for supper tonight, they were taken out before serving breakfast this morning. Surveyor asked about process for thawing. LC AA stated they should be on the bottom shelf in the refrigerator.On 2/24/26 at 2:53 PM, Surveyor interviewed DM BB (Dietary Manager) who stated we have a prep schedule that I print, it lets them know when to take things out of the freezer and put them in the refrigerator. Everything should be thawed in refrigerator.5.) On 2/22/26 at approximately 9:20 AM, during the initial tour of the kitchen with LC AA (Lead Cook,) Surveyor observed the following items unlabeled in the Cook's refrigerator: a tray of potatoes, 5 bowls of pureed fruit, a container of chicken patties, and a jar of chicken stock base. LC AA stated that all of the items should be labeled.On 2/24/2026 at 2:53 PM, Surveyor interviewed DM BB (Dietary Manager) who stated all containers are to be labeled and dated.6.) On 2/22/26 at approximately 9:25 AM, during the initial tour of the kitchen with LC AA (Lead Cook,) Surveyor observed an unlabeled Culver's container of frozen custard, with a spoon in it, in the vegetable freezer and an unlabeled sandwich in the vegetable refrigerator. LC AA stated these were staff items and they were not allowed to be in the kitchen storage and should be in the staff refrigerator/freezer in the break room.On 2/24/2026 at 2:53 PM, Surveyor interviewed DM BB (Dietary Manager) who stated no personal items are allowed in the kitchen refrigerator/freezer.7.) The facility's Food Safety Requirements Use, Storage, and Food Procurement policy, dated 12/23/25, states, in part: . FACTORS IMPLICATED IN FOODBORNE ILLNESSES . *Inadequate Cooking and Improper Holding Temperatures-Poorly cooked food promotes the growth of pathogens that may cause foodborne illness. The PHF/TCS (Potentially Hazardous Food / Time/Temperature Control for Safety) foods require adequate cooking and proper holding temperatures to reduce the rapid and progressive growth of illness producing microorganisms, such as Salmonellae and Clostridium botulinum.On 2/22/26 at 12:05 PM, Surveyor observed LA CC (Laundry Aide) remove a tray of liver and onions from the oven and set it on a metal utility cart. LA CC took a kettle of mashed potatoes and a kettle of corn from the stove and set them on the metal utility cart with the liver. LA CC took a thermometer, which had just been used and cleansed by LC AA (Lead Cook), to the sink, rinsed the thermometer, then dried it with paper towel. LA CC used the thermometer to check the liver and onions. (Important to note that LA CC did not check the temperature of the potatoes or corn.) LA CC dished up a plate of liver and onions, potatoes, and corn and handed it to a volunteer assisting in the kitchen, stating it was ready to be served. Surveyor asked about the temperature of the potatoes and corn. LA CC stated, I didn't check them, do you want me to? Surveyor asked LA CC what would normally be done. LA CC went to DM BB (Dining Manager) and asked about how to clean the thermometer. LA CC took an alcohol wipe and cleaned the thermometer. LA CC stated that DM BB told LA CC that the temperatures needed to be 160 or greater. LA CC checked the potatoes, which registered 141 degrees, and the corn, which registered 133 degrees, and stated they would need to be rewarmed. LA CC returned the potatoes and corn to the stove, leaving the liver and onions on the utility cart. LA CC moved the potatoes and corn back to the utility cart after bringing them up to greater than 160 degrees. Surveyor asked if the utility cart helped to hold the temperature for the liver and onions that had remained on the cart. LA CC stated, no, it is not a warmer. Surveyor asked if the liver was the right temperature for safe service. LA CC stated, I don't know. DM BB stated the items will need to be re-temped.On 2/22/26 at 1:13 PM, DM BB stated LA CC is not part of dining staff. I will be talking with LA CC about the temperature checks. The temperatures are all posted in the kitchen. Surveyor asked if the dietary rules/regulations apply if staff from other departments are cooking/serving resident meals. DM BB stated yes, of course.On 2/24/26 at 2:49 PM, Surveyor interviewed LA CC who stated DM BB asked if I was available to cook liver and onions for a resident requested special meal on 2/22/26, as the kitchen doesn't cook liver. Surveyor asked if the facility had provided any education on temperature testing and the process. LA CC stated no, I think the last special meal that I made was about 5 or 6 years ago.On 2/24/26 at 2:53 PM, Surveyor interviewed DM BB and asked about temperature testing of food. DM BB stated that staff is to check when food is coming out of the oven to be placed in the steam table and before meal service. I also have them check temps throughout the meal service. My preference is for food to be held between 150-165. I thought the timing of the special meal would be different and LA CC would have had access to the warmer. I did education with LA CC after lunch on 2/22/26. 8.) The facility's Food Safety Requirements Use, Storage, and Food Procurement policy, dated 12/23/25, states, in part: PROCEDURE .C. Food and Beverage Brought In For Residents .b. Educate and inform .ii. Education on safe food handling will be provided to all team members, family, residents, resident council, visitors, and community groups who may provide food or fluids to residents of the center. This education will include at a minimum: 1. Proper food handling to prevent foodborne illness . 3. Requirements for covered containers or secure wrapping. 4. Proper labeling and dating of each item. 5. Handling of Leftover foods: Leftovers will be used within 7 days (or according to State regulations and ServSafe guideline, whichever is more stringent) or discarded.8. Method for checking proper food temperature. c. Monitor i. Employees will be appointed to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items per center specific schedule.e. Team members will examine food for quality (smell, packaging, appearance) to identify potential concerns.The facility's Information Sheet-Resident Food Brought in by Family or Visitors, undated, states, in part: It is the goal of this facility to maintain safe food practices in accordance with professional standards for food service safety.If bringing food into the facility for a resident, please contact the Kitchen or the Dietary Manger to ensure that food will be: *Covered, labeled, dated and stored in a way that maintains safe storage temperatures.Leftover foods will be used within 7 days.On 2/24/26 at 9:58 AM, Surveyor interviewed LC AA (Lead Cook) about resident snacks. LC AA stated that snacks are stocked in a resident refrigerator in the staff break room. Surveyor and LC AA went to the resident refrigerator and observed a resealable plastic bag, labeled R17, that contained a partial stick of summer sausage wrapped in paper towel and 2 packages of cheese slices. One of the packages of cheese was open with slices of cheese sticking out. The edges of the cheese slices had a green/gray substance on them. Surveyor asked about the substance. LC AA stated it is mold. Surveyor asked about the label on the bag. LC AA stated it belongs to R17, but it should be labeled with a date on the bag and due to the mold, it needs to be thrown away. On 2/24/26 at 2:53 PM, Surveyor interviewed DM BB (Dietary Manager) who stated that when visitors bring in food, if it is going to be stored, rather than eaten right away, staff puts it into a container and labels with product, date, expiration date, and initials. The food in the resident refrigerator should be labeled with date. 9.) The facility's Med Pass Supplement policy, undated, states, in part: .5. Frozen supplements should be stored in freezer until use and pulled to thaw one day before using. Once pulled, supplement should be dated with an expiration date that is 14 days past the current date. Any product that is past expiration date must be discarded.On 2/24/26 at approximately 9:58 AM, Surveyor observed 1 thawed chocolate mighty shake with no use-by date in the resident refrigerator and asked LC AA (Lead Cook) how long a mighty shake is good once thawed. LC AA stated it is good for 2 days. Surveyor asked how long this shake had been thawed. LC AA stated that normally there would be a use-by date; in this case, with no label, did not know.On 2/24/26 at 2:53 PM, Surveyor interviewed DM BB (Dietary Manager) about thawed Mighty Shakes/Supplements. DM BB stated we only allow it for 7 days. In the kitchen we only date things for 3 days. It should be labeled with use by date once in refrigerator.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infections. This has the potential to affect all 61 residents.The facility failed to follow infection control standards of practice and procedures.The facility failed to maintain accurate and up to date outbreak line listings for staff and residents. Staff were allowed to return to work early after the onset of GI (Gastrointestinal Illness) symptoms.The facility failed to ensure residents experiencing GI symptoms were put into precautions timely. Observations were made of staff inappropriately handling soiled linens.Observation were made of staff failing to wear PPE (Personal Protective Equipment) as required.These failures resulted in 17 residents and 13 staff either testing positive for norovirus or exhibiting symptoms of GI illness during a Norovirus outbreak. The facility failed to ensure adequate infection control processes were followed to ensure containment of norovirus during a facility outbreak. This failure created the potential for all residents, staff, and visitors of the facility to become infected with norovirus, potentially leading to serious illness, hospitalization, and or/death, and created a finding of immediate jeopardy (IJ) that began on 2/3/26. Surveyor notified NHA A (Nursing Home Administrator) and RDO JJ (Regional Director of Operations) of the immediate jeopardy on 2/25/26 at 2:31 PM. The immediate Jeopardy was removed on 2/26/26, however, the deficient practice continues at a scope and severity of F (potential for harm/widespread) as the facility implements its action plan. Findings include:The CDC (Center for Disease Control and Prevention) recommends:. When patients with norovirus gastroenteritis cannot be accommodated in single occupancy rooms, efforts should be made to separate them from asymptomatic patients. During outbreaks, place patients with norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients. Consider minimizing patient movements within a ward or unit during norovirus gastroenteritis outbreaks. Consider restricting symptomatic and recovering patients from leaving the patient-care area unless it is for essential care or treatment to reduce the likelihood of environmental contamination and transmission of norovirus in unaffected clinical areas. Consider suspending group activities (e.g., dining events) for the duration of a norovirus outbreak.Personnel who work with, prepare or distribute food must be excluded from duty if they develop symptoms of acute gastroenteritis. Personnel should not return to these activities until a minimum of 48 hours after the resolution of symptoms or longer as required by local health regulations.If norovirus infection is suspected, adherence to PPE use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry) to reduce the likelihood of exposure to infectious vomitus or fecal material. Use Standard Precautions for handling soiled patient-service items or linens, including the use of appropriate PPE. Handle soiled linens carefully, without agitating them, to avoid dispersal of virus. Use Standard Precautions, including the use of appropriate PPE (e.g., gloves and gowns), to minimize the likelihood of cross-contamination.Develop and adhere to sick leave policies for healthcare personnel who have symptoms consistent with norovirus infection. Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Once personnel return to work, the importance of performing frequent hand hygiene should be reinforced, especially before and after each patient contact.Begin active case-finding when a cluster of acute gastroenteritis cases is detected in the healthcare facility. Use a specified case definition and implement line lists to track both exposed and symptomatic patients and staff. Collect relevant epidemiological, clinical, and demographic data as well as information on patient location and outcomes. The Wisconsin Department of Health Services (DHS), Recommendations for Prevention and Control of Acute Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities, dated December 2017, was provided by the facility to the survey team as the standard of practice they used to guide their GI outbreak. This Wisconsin DHS guidance indicates, in part: . A specific case definition for norovirus could be: Acute onset of vomiting and/or diarrhea (three or more loose stools in a 24-hour period) in a resident or staff member and whose symptoms have no other apparent cause. A log should be maintained to record ill staff symptoms, date when they became ill, date they became well, and date they returned to work. Laundry: Ensure laundry personnel are made aware of the potentially infected linen and are provided with appropriate PPE. Line List Instructions: A line list is a log of ill staff and residents with similar signs and symptoms. It should be used as a tool to track illnesses within a facility when an outbreak is suspected and while an outbreak is occurring in real time. A line list is a resource for those managing an outbreak and can help identify when restrictions can be lifted, when ill staff can return to work and when the outbreak is over. When completing the line lists it is important that: . The line list is maintained in real time so it can be used as a management tool. All fields be filled out completely so the outbreak can be fully assessed. Facility policy titled, Infection Control Program, dated 3/7/17, with last revision date of 5/8/24, states, in part: Purpose: The infection control program exists to assure a safe, sanitary, and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of disease and infection. The facility establishes a program under which it: Investigates, controls, and prevents infections in the facility; Decides what procedures such as isolation, should be applied to an individual resident; and maintains a record of incidents and corrective actions related to infections. Preventing spread of infection: When the infection control program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident; The facility must prohibit employees with a communicable disease. from direct contact with residents or their food. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. This is accomplished by maintaining effective methods for investigating the incidence of infection, controlling transmission, and preventing infection. Intent: The intent of this policy is to assure, through the infection control program a system is in place to: Provide surveillance, investigation and monitoring to prevent, to the extent possible, the onset and the spread of infection; Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions; Minimize chance of outbreaks by clustering or cohorting of residents to reduce spread of infection. Determine nursing home precautions (e.g. isolation) as a means of preventing cross-contamination. Demonstrate proper storage, handling, processing, and transport of linens to minimize contamination. Elements of the program include: Program oversight including planning, organizing, implementing, operating, monitoring, and maintaining all of the elements of the program and ensuring that the facility's interdisciplinary team is involved in infection prevention and control; Surveillance, including process and outcome surveillance, monitoring, data analysis, documentation. Surveillance based on systemic data collection to identify infections in residents; A system for detection, investigation, and control of outbreaks of infectious diseases; An isolation and precaution system to reduce the risk of transmission of infectious agents; Infection Control policies, procedures, and practices which promote consistent adherence to evidence-based infection control practices; Process to evaluate and enforce proper environmental controls; Process to evaluate and enforce proper infection control practices by personnel; An employee health program. Facility policy titled, Infection Control - Employee Health, dated 1/10/19, with last revision date of 5/8/24, states, in part: Purpose: To ensure and maintain a health standard required of all employees to perform their duties. Policy: . 1a. No employee with a communicable disease shall be allowed to work in the facility until the period of communicability has been determined to have terminated. Procedure: 2. CDC guidance and recommendations will be followed to determine when an employee may return to work after a possibly infectious illness such as Influenza, COVID, GI Flu, etc. Facility policy titled, Personal Protective Equipment, dated 8/1/15, with last revision date of 6/14/24, states, in part: Policy: To provide guidance for the use and selection of appropriate personal protective equipment (PPE) based on risk of exposure to blood or body fluids, in accordance with state and federal regulations. Procedure: 1. Personal protective equipment (PPE) includes gloves, masks, protective gowns, eyewear, and face shields. 2. PPE will be utilized when an employee is at risk to exposure to blood or body fluids through absorption, inhalation, and/or physical contact. 4. PPE is required for entry into isolation rooms and removal is required prior to leaving isolation rooms. Gloves: 1. Gloves are readily available and should be worn when coming into contact with blood, body fluids, secretions, excretions, mucous membranes and/or intact skin. a. Providing direct resident care involving contact with blood or body fluids. c. When handling soiled linen or items that may be contaminated. f. When entering isolation areas. Gowns: 1. Gowns should be worn when performing tasks that will likely soil the employee's clothing with blood or body fluids. 2. Gowns will be applied prior to entering treatment area. Facility OutbreakDocuments provided by the facility stated that they were in GI/Norovirus Outbreak from 2/9/26 - 2/20/26. A review of the facility's February 2026 Monthly Infection Surveillance log, GI Outbreak Summary, and Employee Call-In Log, provided by the facility, indicated the following: On 2/4/26:DA I (Dietary Aide) listed on the Employee Call-In log as having diarrhea. No well date or return-to-work date listed. DA I's employee timecard log indicates that DA I returned to work on 2/6/26.On 2/25/26 at 11:44 AM, Surveyor interviewed DA I, who stated he had Chinese food for dinner on 2/4/26 and then started experiencing diarrhea in the night, about 5 hours after consuming the Chinese food. DA I indicated he had diarrhea a couple of times in the night, then started to feel better the next day, after about 24 to 35 hours. DA I confirmed that he returned to work on 2/6/26 for the PM shift. DA I stated his kitchen duties include washing dishes, setting up food trays, putting trays on the food cart, helping with drinks, assembling the trays and taking the food cart down to the halls. DA I stated that after the meal, he cleans the dining room, breaks down the food carts, puts the condiments and drinks away and washes the meal dishes.On 2/25/26 at 12:42 PM, Surveyor interviewed ADON/IP C (Assistant Director of Nursing/Infection Preventionist) about DA I's symptoms and return-to-work date. ADON/IP C stated that DA I called in with an episode of diarrhea on 2/3/26 and then came back on the 2/6/26. ADON/IP C stated that DA I called in at 5:00 AM on 2/4/26 saying he wasn't going to be in and that he had diarrhea the day before. ADON/IP C stated that DA I called again at noon on 2/4/26 stating that he was feeling better hadn't had another episode of diarrhea since that morning.The facility surveillance list did not include DA I, the employee call-in log indicated DA I called in on 2/4/26, the log did not include a well date or time for DA I. The facility had no way to verify that DA I was excluded from work for 48 hours after symptoms resolved. On 2/6/26:R10 on 400 hall with nausea, vomiting, and diarrhea. Date of onset 2/6/26. Notes: . [Resident Name] reported nausea, vomiting and diarrhea this morning. feeling better this afternoon and up walking in his room and was down to sunroom for activity. Date resolved: 2/9/26.The facility did not restrict the movement of R10 through the facility for 48 hours after symptoms resolved in order to limit the exposure to well residents. On 2/7/26:R70 on 300 hall with nausea, vomiting and diarrhea. Date of onset 2/7/26. Notes: . Resident reported having diarrhea for two days. Writer got report on the 7th that issue was resolved. At 2230 (10:30 PM) it was reported that resident has been having bouts of watery stools throughout the day. Writer was called into resident's room for vomiting. Upon entering room emesis was puddled by head in bed. Resident also presented more watery stools. On-call [Dr. Name] notified. stated give PRN medication if tolerated. If resident can't tolerate (medication) send to ER. Resident was given medication 0045 (12:45 AM). Writer monitoring for effectiveness. 2/9/26: positive for norovirus. hospitalized . Returning 2/17/26. Last watery stool on 2/14/26. No isolation/monitoring needed upon return. Date resolved: 2/17/26.Of note: The facility stated the GI/Norovirus outbreak began on 2/9/26, despite a staff member with diarrhea on 2/4/26 and two residents reporting nausea, vomiting, and diarrhea on 2/6/26 and 2/7/26. On 2/23/26 at 4:25 PM, Surveyor interviewed ADON/IP C and asked what the criteria is for a norovirus outbreak. ADON/IP C stated that the requirements for a GI outbreak are when a staff or resident had 3 or more episodes of signs and symptoms. On 2/9/26:R49 on 300 hall exposure to nausea and vomiting. Date of onset 2/9/26. Notes: 2/10/26: Resident is being monitored for exposure to roommate with norovirus. Contact precautions in place. 2/11/26: Resident in dining room this AM for breakfast. noted to previously be on isolation for exposure to norovirus. Writer met with resident to assess. [Resident] remains without S&S (signs and symptoms) for > (greater than) 24 hours and reports feeling fine. 2/12/26: Per nursing note on 2/11/26 emesis x2 (times two) on PM shift. Isolation reinstated. Date resolved: 2/15/26. R54 on 200 hall with watery stool, nausea, vomiting. Date of onset: 2/9/26. Notes: 2/9/26: Watery stools noted, 1 watery stool documented. 2/11/26: Resident feeling ill. reports vomiting x3 in the bathroom this AM. Continued with loose stool. Resident placed on Contact precautions. 2/12/26: positive for norovirus. Date resolved: 2/15/26. R33 on 300 hall with multiple loose/watery stools, emesis x1. Date of onset 2/9/26. Notes: 2/10/26: is being monitored for loose/watery stools. Contact isolation. watery stools noted 2/9/26 x1 and 2/10/26 x2. 2/12/26: Emesis x1 on last PM shift. Date resolved: 2/15/26.The facility provided GI/Norovirus Outbreak summary states, in part: S&S (signs and symptoms) started with resident [Resident Initials], (R70), on 2/7/26 per her report of starting with diarrhea '2 days ago'. Reports of more residents displaying GI S&S throughout the day Monday (2/9/26). Those displaying GI S&S were immediately placed on system monitoring and contact/enteral precautions.Of note: Nothing in the facility GI/Norovirus Outbreak summary is mentioned about R10's nausea, vomiting and diarrhea 2 days ago. R70 was admitted to the facility on [DATE] , a review of R70's nursing progress notes, provided by the facility, include the following:--2/2/26: Watery stools noted. No loose stools on this shift.--2/3/26: an episode of watery stools twice on the shift.--2/5/26: Watery stools noted; intermittent stools noted.--2/9/26: Resident reported having diarrhea for two days. Writer got report on the 7th that issue was resolved. At 2230 (10:30 PM) it was reported that resident has been having bouts of watery stools throughout the day. Writer was called into resident's room for vomiting. Upon entering room emesis was puddled by head in bed. Resident also presented more watery stools.--2/9/26: CNA (certified nursing assistant) notified this writer resident had another incontinent loose BM (bowel movement) and would like writer to assess. Writer in to see resident. Resident states she couldn't make it to the commode in time and BM (bowel movement) keeps coming out.--2/9/26: Resident alert and up in chair with no change to baseline mentation. Resident reports ongoing diarrhea. Resident continues to have diarrhea at this time. Writer awaiting results of C-diff testing.On 2/9/26, R70 was seen by the facility APNP (Advanced Practice Nurse Practitioner), whose nursing note states . seen today for chief complaint of abdominal pain, diarrhea, nausea and vomiting. reports she had emesis X2 so far today, last time was after her clear liquid breakfast tray. Symptoms of n/v/d (nausea, vomiting, diarrhea) started yesterday, and she feels they are worsening as the day has progressed. she is having almost constant loose stools. negative c-diff and enteric panel is pending. concern about her abdominal pain as well as ongoing n/v/d. [Resident Name] agreeable to transfer to ER.A 2/9/26 ER note indicates the following, in part: . presented from nursing home with complaint of diarrhea, loose stool > 4-5 BM (bowel movement) a day for 2 days. her stool test today is positive for norovirus. patient is very sick. admit as inpatient. IV hydration given.R70 was admitted to the hospital from [DATE] to 2/17/26. Hospital discharge summary indicates the following, in part: principal diagnosis of acute kidney injury due to diarrhea and norovirus. strongly encouraged patient to vastly improve her oral fluid intake.Of note: R70's care plan was updated on 2/9/26 to include, Resident is being monitored for GI S&S. vomiting and loose/watery stool. Contact/droplet precautions in place. Interventions include, in part: monitoring pain and vital signs, assisting resident with hand washing, provide increased rest periods, notify MD/NP (Medical Director/Nurse Practitioner) of any change in condition.However, there is no intervention to monitor for dehydration or increase fluids with the resident experiencing multiple bouts of watery stools and vomiting. On 2/25/26 at 12:02 PM, Surveyor interviewed ADON/IP C about R70 having several watery stools prior to being placed on isolation precautions. ADON/IP C stated that R70 had one watery stool on 2/1/26 and another on 2/4/26, then nothing until 2/9/26 with two more watery stools. ADON/IP C stated she got that date of 2/7/26 from nursing notes that stated R70 reported to staff having loose stools for 2 days. ADON/IP C stated that R70 probably didn't get put on isolation precautions until the morning of 2/9/26 when she followed up with the NP and got the orders. ADON/IP stated that the norovirus outbreak wasn't confirmed yet because R70 hadn't had 3 loose stools in 24 hours.Of note: A review of R70's nursing notes indicates that R70 had one watery stool on 2/2/26 and two more watery stools on 2/3/26, which would have met the criteria of 3 watery stools within 24 hours. On 2/11/26:R38 on 300 hall with nausea, decreased appetite, decreased PO (by mouth) intake. Date of onset: 2/11/26. Notes: 2/11/26: Resident is being monitored for GI S&S, nausea, decreased appetite, decreased PO intake. Contact precautions in place. Date resolved: 2/14/26.R21 on 300 hall with nausea, vomiting, decreased appetite, decreased PO intake. Date of onset: 2/11/26. Notes: 2/11/26:. Resident experienced sudden onset of nausea and vomiting.2/12/26: one emesis at 0600 (6:00 AM) this AM shift. Date resolved: 2/15/26.R31 on 300 hall with nausea, frequent loose stools, decreased appetite, decreased PO intake. Date of onset: 2/11/26. Notes 2/11/26: Resident woke not feeling well. Reports GI S&S (frequent loose stools, nausea and wants to vomit, reports spitting up. Placed on Contact precautions. 2/12/26: continues with watery stools. positive for norovirus. Date resolved: 2/17/26.HK G (Housekeeper) called off today for continuous diarrhea. is aware she can return 48 hours after last episode. Well date: 2/15/26. No return-to-work date.CNA H sent home for dizziness, nausea, fatigue. worked the 300 hall during the start of GI outbreak. She worked the AM shift and started to develop S&S at the start of PM shift. Sent home due to feeling ill. Returned to work 2/16/26 free of GI S&S.On 2/12/26:R27 on 100 hall with mild nausea. Date of onset 2/12/26. Notes: 2/12/26: . resident having mild nausea this AM. resolved after breakfast. participating in therapy. No isolation required at this time. Date resolved: 2/15/26.R18 on 300 hall with nausea and body aches. Date of onset 2/12/26. Notes: . Resident states not feeling good, upset stomach and body aches. Already in contact precautions due to roommate with GI S&S. Date resolved: 2/15/26.(of note: R18 sits at the same dining table as R70 who first had watery stools on 2/2/26)R30 on 200 hall with body aches and nausea. Date of onset: 2/12/26. Notes: 2/12/26 Resident refused medications. stated does not feel good, body aches and upset stomach. Date resolved: 2/15/26.R44 on 200 hall with diarrhea, abdominal pain and confusion. Date of onset: 2/12/26. Notes: 2/12/26 Resident had two episodes of diarrhea. resident complaints of abdominal pain. Sent to ER for increased confusion. GI panel was positive for norovirus. resident admitted to hospital. 2/16/26 returned from hospitalization S&S free. Date resolved: 2/16/26.R62 on 100 hall with weakness, decreased appetite, loose stools, congestion, cough, fatigue. Notes: Resident admitted . positive for Influenza A. Droplet/contact precautions upon admit. has had 1-2 episodes of loose stools for the past few days. Date resolved: 2/14/26.(Of note: the 300, 200, and 100 hallway have residents experiencing GI symptoms and a second resident was sent to the hospital.)On 2/13/26:R6 on 200 hall with emesis, loose watery stools. Date of onset: 2/13/26. Notes: Resident reports not feeling well on 2/13/26. monitoring for emesis and loose stools. noted meal intake is decreased. two watery stools noted on 2/13/26 . continues with loose/mushy stool today. 2/16/26 continues with watery stool this past NOC (overnight) shift. remain on isolation at this time. Date resolved: 2/19/26.R43 on 100 hall with nausea, chills, and body aches. Date of onset: 2/13/26. Notes: Reported feeling ill on 2/13/26, nausea, chills, body aches, placed on contact precautions due to GI outbreak. 2/15/26: per nurse took off isolation due to no S&S since Thursday. Date resolved: 2/15/26.On 2/15/26:LPN R (Licensed Practical Nurse) Started with GI S&S this AM: Vomiting, diarrhea. Next scheduled shift 2/19/26, returned with no further GI S&S. Onset date: 2/15/26. Well date: 2/19/26.RN S (Registered Nurse) Started with GI S&S today: emesis x2. Next scheduled shift 2/19/26, returned with no further GI S&S. Onset date: 2/15/26. Well date: 2/19/26.On 2/16/26:R39 on 100 hall with nausea, vomiting, loose stools, poor appetite and fatigue. Date of onset: 2/16/26. Notes: 2/16/26 resident had vomited in the dining area, large emesis noted while eating breakfast. states he was nauseous this AM, however, did not report to staff. 2nd emesis after lunch. 2/17/26: . not eating breakfast, reports poor appetite and fatigue. Date resolved: 2/18/26.Of note: the noted resolved date is only 2 days after the resident experienced 2 episodes of nausea and vomiting.CNA E Started with GI S&S today: Loose stools x2, nausea, sweats. Left shift early. Next assigned shift 2/18/26. No further GI S&S. Onset date: 2/16/26. Well date: 2/18/26.R44 was admitted to the hospital on [DATE] with acute onset of nausea, vomiting, diarrhea, altered mental status, and a witnessed seizure-like episode in the emergency department. she had several days of nausea, vomiting, and diarrhea with stool studies positive for norovirus and negative for c-difficile/parasites.A review of R44's physician orders indicate that R44 had fluid monitoring in place with a start date of 11/5/25.Of note: R44's care plan was updated on 2/12/26 to include, Resident is being monitored for GI S&S. vomiting and loose/watery stool. Contact/droplet precautions in place. Interventions include, in part: monitoring pain and vital signs, assisting resident with hand washing, provide increased rest periods, notify MD/NP (Medical Director/Nurse Practitioner) of any change in condition., etc. However, there are no person-centered interventions regarding R44's symptoms or infection. On 2/17/26:R62 with nausea and loose stools. Date of onset: 2/17/26. Notes 2/17/26. reports nausea. states has been having loose stools in her briefs last night and today. Contact precautions initiated due to S&S consistent with GI outbreak. 2/18/26 reports nausea. Date resolved: 2/20/26.R27 with GI S&S. Date of onset: 2/17/26. Notes: 2/17/26 reports new onset of GI S&S. Placed on contact precautions due to GI outbreak. 2/18/26 resident has been without nausea/spitting up for >24 hours. isolation and monitoring for GI S&S discontinued. Date resolved: 2/18/26.(of note: R27 was removed from precautions too early. Symptoms resolved on 2/18/26, which would indicate R27 should have remained on precautions until 2/20/26R39 with recent nausea, vomiting, and cough. Notes: . recent nausea/vomiting episodes. no isolation needed as treating as aspiration pneumonia vs. infectious. Date resolved: 2/24/26.On 2/18/26:DA T Called in today for GI S&S: diarrhea. Onset date: 2/18/26. Well date: 2/22/26.On 2/19/26:R66 with loose stools. Notes: . resident starting with loose stools today. BM (bowel movement) meds held. Continue to monitor. No further stools. Not added to outbreak. Date resolved: 2/19/26.On 2/20/26:CNA U called in with nausea and vomiting. Onset date: 2/20/26. Well date: 2/22/26. Of note: facility declares end of GI Outbreak in their documentation, despite several staff still reporting norovirus symptoms of nausea, vomiting, diarrhea, and low-grade fever as follows: On 2/21/26:CNA V called in with nausea and vomiting. Onset date: 2/21/26. Well date: 2/24/26.CNA W called in with a fever of 100 degrees. Onset date: 2/21/26. Well date: 2/22/26.On 2/23/26:CNA X reported vomiting. Onset date: 2/23/26. Well date: 2/24/26.(of note, CNA X's well date is less than 48 hours from onset)On 2/24/26:MT Y (Maintenance) reported diarrhea. Date onset: 2/24/26. Well date: 2/24/26.On 2/25/26:AD Z (Activities Director) report vomiting. Onset date: 2/25/26. Well date: not listed. 2.) Not wearing PPEOn 2/22/26 at 11:26 AM, Surveyor observed LPN D (Licensed Practical Nurse) and CNA E (Certified Nursing Assistant) enter the room of R1 without wearing PPE. Surveyor observed that R1 had signage on the door that indicated R1 was on contact precautions.On 2/22/26 at 11:28 AM, Surveyor observed LPN D come out of R1's room and asked her about the nature of R1's precautions. LPN D stated that she thought R1 was on precautions for the GI (gastrointestinal) outbreak that the facility had. Surveyor asked LPN D what types of PPE should be worn for someone on contact precautions. LPN D indicated that contact precautions include wearing a gown, gloves, and masks. Surveyor asked LPN D if she had worn PPE while in R1's room. LPN D stated that she had not, because she was only assisting with the Hoyer transfer and not providing cares.On 2/22/26 at 11:31 AM, LPN D approached Surveyor in the hallway and stated that she wanted to clarify that R1 was not on precautions for GI but for pink eye, and that because she was not around R1's eye area she was not required to wear PPE in her room.On 2/22/26 at 11:35 AM, Surveyor observed CNA E come out of R1's room and asked her if R1 was on contact precautions. CNA E stated, not that I know of. Surveyor asked CNA E if she had worn PPE in R1's room. CNA E stated that she had worn gloves to help get R1 ready for the day. 3.) Laundry TourOn 2/23/26 at 7:30 AM, Surveyor completed the facility laundry tour with HS F (Housekeeping Supervisor). Surveyor observed HK G (housekeeper) in the sorting room without wearing PPE. HK G stated that she wears a gown and gloves to sort the laundry, but that she had just taken it off prior to Surveyor entering the room. Surveyor observed HK G donning gown and gloves in the sorting room and begin to sort the soiled laundry. HS F stated that HK G would take off the soiled gown but keep her gloves on when taking soiled linens from the sorting room to the washing machine. HS F stated that HK G would not wear a gown when putting the soiled linens into the washing machine, because the washing room was considered a clean area and there may be risk of rubbing the soiled gown on the laundry cart or clean clothes. 4.) Handling soiled linensOn 2/24/26 at 11:33 AM, Surveyor observed CNA H wheeling an open, overflowing laundry cart down the hallway without wearing any PPE. While Surveyor was observing, CNA H stopped and donned gloves, then continued down the hall, tied up the laundry bag, and placed it in the soiled linen closet. CNA H then returned the empty linen cart back to the clean linen closet and added a new bag to the cart without changing gloves or performing hand hygiene.On 2/24/26 at 1:38 PM, Surveyor interviewed CNA H about the observation with the soiled linens. CNA H stated that when handling soiled linens, they usually wear a gown and gloves. Surveyor asked CNA H if she had worn a gown or gloves when she transferred the soiled linens before lunch. CNA H stated no, that she had forgotten to wear the appropriate PPE. On 2/24/26 at 3:05 PM, Surveyor interviewed ADON/IP C about the facility's infection control program and the recent GI outbreak. ADON/IP C stated that with the GI outbreak she learned that the staff need more supervision and education. ADON/IP C indicated that she would like to do hand washing audits with staff, but that she hadn't had time to start them yet. Surveyor asked if any audits had been completed, such as the use of appropriate PPE. ADON/IP C stated that she did not believe any audits had been done yet.ADON/IP C indicated that as soon as the leadership team found out about residents with GI signs and symptoms, she met with HS F (housekeeping supervisor) to ensure that bleach was used for cleaning to control the spread of infection. ADON/IP C stated she also educated staff on handwashing, and she notified public health about the outbreak. Surveyor asked ADON/IP C about the staff education, and ADON/IP C clarified that the education was verbal only in regards to hand washing.ADON/IP C stated that residents that were in double rooms were left with their roommates as they didn't want to move residents around. ADON/IP C stated affected residents with signs and symptoms stayed in their rooms for the duration of their symptoms until they were clear of symptoms. ADON/IP C stated she believed the dietary manager used disposable tableware for those residents, and they could come out of their rooms for therapy, but that therapy staff were instructed to bleach whatever area they were at. ADON/IP C indicated that individual activities were provided for the residents isolated to their rooms. Surveyor asked ADON/IP C to provide a facility map of the GI outbreak. ADON/IP C stated that she had not completed an outbreak map

Based on interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 3 sampled residents (R1). On 1/9/26, R1 voiced having increased abdomen and low back pain and was crying while voicing pain rated 10 out of 10. There is no documentation of a RN (Registered Nurse) assessment being completed. There is no documentation of nursing staff continuing to monitor R1's change in condition. R1 was sent to the emergency room on 1/10/26 and diagnosed with pneumonia, acute on chronic respiratory failure, sepsis (life-threatening condition due to the bodies response to an infection) with acute hypoxic respiratory failure (life-threatening condition characterized by severely low blood oxygen levels without an carbon dioxide level elevation, caused by lung injury or impaired oxygen exchange) and septic shock (most sever stage of sepsis occurring when an infection leads to low blood pressure and organ failure which require immediate medical intervention.). Evidenced by: According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. The facility's policy, Change of Condition, dated 8/1/15 with last revision date of 11/13/24, states, in part: Purpose: To ensure prompt notification of the resident, the attending physician. of changes in the resident's physical, psychosocial and/or mental condition and/or status. Procedure: . 2. Specific information that requires prompt notification include, but is not limited to: . c. Uncontrolled pain. o. A need to transfer the resident to a hospital/treatment center. 3. Nurse will complete assessment and document findings in resident record including but not limited to vital signs, pain.R1 was admitted to the facility on [DATE] with diagnoses that include, in part: bipolar disorder (mental health condition characterized by significant mood swings), other chronic pain, low back pain, fibromyalgia (long-term condition that causes widespread body pain and fatigue), schizoaffective disorder (mental health condition consisting of a mix of schizophrenia symptoms such as hallucinations and delusions), generalized anxiety disorder, psychophysiologic insomnia (chronic sleep disorder resulting in persistent difficulty falling asleep or staying asleep triggered by stress and anxiety), and adjustment disorder (excessive emotional or behavior response to stressors).R1's most recent MDS (Minimum Data Set) dated 2/2/26, indicates, in part: a BIMS (Brief Interview of Mental Status) score of 15 out of 15, indicating R1 is cognitively intact. R1's Comprehensive Care Plan states, in part: . Focus: The resident has altered respiratory status/difficulty breathing r/t (related to) chronic respiratory failure, RLD (Restrictive Lung Disease, a category of lung conditions that prevent lungs from fully expanding, leading to decreased lung volume), and OSA (Obstructive Sleep Apnea, a common and potentially serious sleep disorder where breathing repeatedly stops and starts during sleep). Requests/needs HOB (head of bead) elevated and on pillows to prevent from becoming SOB (short of breath), pacing activities, and repositioning. Date initiated: 12/28/23. Revision on: 9/21/24.Interventions: CPAP settings per MD orders. Elevate head of bed. Monitor/document changes in orientation, increased restlessness, anxiety, and/or air hunger. Monitor for s/sx (signs and symptoms) of respiratory distress and reported to MD PRN (as needed): Increased respirations, decreased pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headache, lethargy, confusion, hemoptysis, cough, pleuritic pain, accessory muscle usage. R1's Progress notes indicated: 1/9/26 at 1:47 PM: Resident was complaining of increased abdomen and low back pain. Resident was crying voiced pain 10/10. Writer called NP (Nurse Practitioner). NP gave order to send resident to hospital when writer informed resident. Resident became upset she could not get more meds resident declined to go. 1/10/26 at 2:20 PM: Writer called to resident's room by CNA (Certified Nursing Assistant) at approximately 0700 (7:00 AM). Resident unable to sit at edge of bed unassisted, rapid respirations, increased pain, altered mental status. Writer confirmed with resident that she wished to be transferred to ER, resident stated yes. 911 called, arrived approximately 0730 (7:30 AM), resident left facility via ambulance, nurse to nurse report given. DON (Director of Nursing) and NP [Name] updated. Resident admitted into [Hospital Name] ICU for sepsis and hypotension. Of note: There is no evidence in the medical record that R1 had been assessed by a nurse on 1/9/26, had adequate monitoring from 1/9/26 to 1/10/26, or had been assessed by a nurse prior to being sent to the ER on [DATE]. R1's hospital notes, dated 1/10/26, states, in part: . Chief Complaint: Breathing Problem (Patient states yesterday she felt like she was having difficulty breathing.History of Present Illness: [Resident Name] . presenting with dyspnea (shortness of breath) and respiratory distress. States that she is chronically dyspneic, has been getting worse for the past 24 hours or so.ED (Emergency Department) Course, Decision Making, and Medical Complexity: . [Resident Name] . presenting with respiratory distress. On initial assessment patient is noted to be in mild to moderate respiratory distress with increased work of breathing and speaking short sentences. She is noted to have low-grade fever and mild tachycardia (rapid heart rate). was also initially hemodynamically stable (normal stable vital signs)but progressively became more hypotensive (low blood pressure). received a sepsis fluid bolus (single dose given all at once). Ultimately she was stable but critically ill here in the emergency department. She will be admitted to the ICU for septic shock due to bacterial pneumonia with respiratory failure on BiPAP. Possible UTI as well.Procedure: . Critical Care Documentation. The patient has a critical illness or injury that acutely impairs one or more vital organs systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. Critical Care Condition(s): . Hypercarbia (abnormally low carbon dioxide)/respiratory failure requiring non-invasive ventilation. Shock/Hypotension: Hypotension required blood pressure monitoring and IV fluids and IV pressors (potent medication given to treat life-threatening sepsis and shock in the ICU) and Severe sepsis requiring IV fluids and antibiotics. 1/15/26 at 3:42 PM, discharged from the hospital to return to the facility. On 2/25/26 at 3:41 PM, Surveyor interviewed R1 about her hospitalization. R1 stated that she had been telling them for a while that she wasn't feeling well. R1 stated, when I tell them I don't feel good, or something is wrong they don't listen. R1 indicated that she had told staff every day for about a week, multiple times, that she wasn't feeling well and thought that she had a urinary infection. R1 stated that by the time it was discovered it was really bad, and she had to be sent to the ER and was in the ICU for 5 days. Surveyor asked R1 if the staff had been monitoring or assessing her condition. R1 stated there no assessment or monitoring on 1/9/26 and then on 1/10/26 she was out of it and couldn't even sit up. R1 stated there was no assessment before she was sent to the ER, just that the nurse came and said she didn't look good. R1 indicated that the nurse took her temperature, but no other vital signs were obtained. R1 stated that she was pissed off because no one listens to her concerns. On 2/25/26 at 7:49 AM, Surveyor interviewed RN S (Registered Nurse) about R1's change of condition. RN S stated she worked on 1/9/26 and R1 refused to be sent to the ER. RN S stated that she did not work on 1/10/26 but that she heard she was sent out to the ER on that day. Surveyor asked RN S if she completed any assessment on R1 on 1/9/26 when she worked. RN S stated that she thought she did an abdominal assessment, but she couldn't really remember. Surveyor asked RN S if she had documented the abdominal assessment in R1's electronic medical record. RN S stated that she really couldn't recall what she did back in January. On 2/25/26 at 9:15 AM, Surveyor interviewed DON B (Director of Nursing) if there were any assessments or monitoring of R1's condition on 1/9/26 and 1/10/26. DON B stated she would check in R1's medical record and report back to Surveyor. On 2/25/26 at 11:31 AM, DON B stated that no, she couldn't find anything in R1's medical record that she was further assessed or monitored. Surveyor asked DON B if R1 had a change of condition that would require monitoring and nurse assessments. DON B stated yes that she would have expected the nurse on duty to have taken vital signs and completed an assessment at least every shift, and to enter a progress note into the electronic medical record. Staff noted R1 was crying and endorsed 10/10 abdominal and lower back pain on 1/9/26. Despite R1's refusal to be sent to the ER on [DATE], staff completed no assessments and did no further monitoring of R1's change of condition. The following day, 1/10/26, R1 was confused, lethargic, and unable to sit up. R1 was transferred to the ER and spent 5 days in the ICU with a life-threatening condition.

Based on observation and interview, the facility did not ensure that garbage and refuse were properly disposed of in outside garbage storage receptacles. This practice has the potential to affect all 61 residents. Surveyor observed the facility's outside garbage receptacle to be full to the top and the lid wide open. Evidenced by:On 2/22/26 at approximately 9:30 AM, during the initial kitchen tour with LC AA (Lead Cook), Surveyor observed the outside garbage storage receptables. One of the receptacles had the cover wide open and there were garbage bags up to and over the top of the sides. Surveyor asked LC AA about the lid. LC AA stated, that shouldn't be open, it could cause problems.On 2/24/26 at 2:53 PM, Surveyor interviewed DM BB (Dietary Manager) who stated the lid should be closed for pest control.

:Based on interview and record review, the facility's Quality Assessment and Assurance committee failed to develop and implement appropriate plans of action to correct deficient practices related to food safety requirements and infection control. This has the potential to affect all 61 residents.The facility failed to follow infection control standards of practice and proper sanitation of dishware during a Gastrointestinal illness outbreak. Evidenced by: The facility's Quality Assurance/Assessment and Performance Improvement (QAPI) Plan policy, dated 9/4/24, states, in part: Purpose: The QAPI Program is to utilize an on-going, data driven, pro-active approach to advance to the quality of life and quality of care for all residents at the facility. QAPI principles will drive our facilities decision making to promote excellence in all resident and staff related areas. All facility staff, families, and residents will be encouraged to be involved in identifying opportunities for improvement. Feedback, Data Systems, and Monitoring: The facility will monitor multiple data sources and performance indicators in determining areas of concern, gaps and opportunities and also to determine effectiveness of system modifications and other interventions. Performance Improvement Projects (PIPs) The facility will review the designated sources of data; identify areas where gaps in performance may negatively affect resident or staff outcomes. Where opportunities for improvement are detected, the QAPI Committee with input from the Leadership team will prioritize focus areas for PIP development. Documents provided to Surveyors by the facility, during the recertification survey from 2/22/26-2/25/26, stated that they were in GI/Norovirus Outbreak from 2/9/26 - 2/20/26. The facility did not ensure a resident with norovirus symptoms (R70) was immediately placed on isolation precautions, failed to monitor residents for hydration status resulting in a resident's hospitalization (R70), failed handle soiled linens appropriately or ensure that staff wore personal protective equipment. The facility did not maintain an accurate outbreak line list and facility staff failed to understand return-to-work criteria. These findings created a situation of Immediate Jeopardy. Cross reference F880. Observation, record review and interview during the recertification survey from 2/22/26-2/25/26, showed that the facility was not checking the PPM (parts per million) for the chemical dishwasher and therefore not ensuring that dishes were properly sanitized during the GI/Norovirus outbreak. Cross reference F812. On 2/25/26 at 3:21 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing) regarding QAPI. NHA A and DON B indicated that concerns for QAPI are identified through quality measures, audits, falls, wounds, trends noted. Sometimes we start working on things prior to the meeting and then we review at the meeting. Surveyor asked if there is discussion of infection control at QAPI. NHA A and DON B stated that it is discussed every month and includes outbreaks. Surveyor asked if concerns regarding the gastrointestinal illness outbreak had been discussed with QAPI; timing of placement of residents on isolation, accuracy of outbreak line list, timing of staff return to work. Surveyor asked if sanitation in the kitchen, proper chemical testing, was discussed with QAPI. NHA A stated uncertainty if the specific items had been reviewed; would review notes and update. On 2/25/26 at 4:09 PM, NHA A stated, no, we did not identify the concerns and discuss with QAPI prior to this survey.When adverse resident events are identified, the facility must analyze the cause of the error/event, implement corrective actions to prevent future events, and conduct monitoring to ensure desired outcomes are achieved and sustained, this was not initiated or completed by the facility for infection control despite having a gastrointestinal illness outbreak affecting 17 residents and 13 staff.

Based on observation, interview, and record review, the facility did not ensure that each resident has a safe, clean, comfortable and homelike environment for daily living for 3 of 61 Residents (R3, R21, and R34). R3's room was not clean.R21's room was not clean.R34's room was not clean.R21 and R34 share a bathroom. The shared bathroom was not clean.This is evidenced by:The facility's Cleaning Checklist for Elderly Home, undated, includes: Introduction Maintaining a clean and sanitary environment is essential in elderly care facilities to ensure the health and well-being of residents, staff, and visitors. This checklist provides guidance for cleaning areas where residents are present. Resident Rooms (Occupied) *Dust surfaces gently, avoiding disturbance to residents *Disinfect frequently touched surfaces: bed rails, tables, door handles, light switches *Sweep and mop floors, taking care around personal belongings *Clean bathroom area (if en-suite): toilet, sink, mirrors, grab bars.The facility utilizes a Daily Cleaning Checklist. There is a place for the housekeeper's signature and date. The Daily Cleaning Checklist includes a grid. The grid columns are labeled: Cleaning Task and each room number for the hallway across the top row. Under the Cleaning task column are the task to be completed, which includes: Empty trash, wipe surfaces, disinfect high touch points, sweep/vacuum floor, mop floor, check hand sanitizer, remove debris/clutter, clean & sanitize bathroom, restock paper produces, change curtain (if dirty), double check the room to make sure it's clean.On 2/22/26 at 4:19 PM, Surveyor interviewed R3. When surveyor asked R3 about the cleanliness of her room, R3 stated ugh, made a face of disgust, and gestured her hand around her room. R3 indicated that her room was not clean. Surveyor observed dark, dried spots of food on the floor. There were splatters of red/brown dried substances under R3's bedside table. There was thick string, approximately 6 inches long on the floor under the chair on the far side of the room. There was half of a wrapper for an alcohol prep pad on the floor near the sink.On 2/22/26 at 2:30 PM, Surveyor interviewed R21. R21 stated the facility is not kept clean. R21 stated her room is filthy. R21 stated her room is dusty and no one dusts it. R21 stated staff do not clean the sink counter. R21 stated no one moves the caddies on the counter to clean under them. R21 stated I don't live like this. It's disgusting. This isn't the way I want to live. I have to look at it every day. Surveyor observed R21's room. R21's room over bed light was dusty. There was a granola bar wrapper on the floor under the bed. There were dirty shoe prints on the floor near the bed. There was crushed, white powder on the floor in front of the nightstand near the head of the bed. The wall heater was pulling away from the wall approximately 1 inch, causing the paint to rip from the wall. The sink counter was full of clutter and not kept tidy.On 2/22/26 at 4:08 PM, Surveyor observed R34's room. R34's room had dirty shoe prints on the floor. R34's tube feeding pole had brown liquid splatters (tube feeding liquid) on the pole. R34's wall heater had fallen approximately 1.5 inches down the wall, causing the paint to rip from the wall. There was paper debris under the head of the bed.On 2/22/26 at 4:08 PM, Surveyor observed R21 and R34's shared bathroom. There was feces in the toilet bowl. There were drips of brown liquid dried on the toilet seat. On the back of the toilet, there was a graduated cylinder (container used to empty urine from a foley catheter) sitting upside down on a disposable cloth, discolored and dried with urine. Sitting on the disposable cloth, there was also pair of tubigrip stockings (compression stockings).On 2/23/26 at 8:00 AM, Surveyor observed R3, R21, and R34's rooms. R3 and R34's rooms were the same and still not cleaned. R21's room was observed. R21's granola wrapper that was under the bed had been picked up, otherwise R21's room was the same. R21 and R34's shared bathroom was still not cleaned.On 2/23/26 at 2:33 PM, Surveyor interviewed CNA H (Certified Nursing Assistant) and CNA O. Both CNAs indicated resident rooms are not clean. CNA H indicated the residents have a lot of personal belongings, so it is hard for staff to clean around that. CNA O indicated the floors are dirty and should be mopped more often.On 2/24/26 at 8:31 AM, Surveyor observed a cleaning cart down the hallway where R3, R21, and R34 reside. Surveyor observed R3's room had been cleaned. R21 and R34's rooms and shared bathroom were still not cleaned.On 2/24/26 at 1:57 PM, Surveyor interviewed HS F (Housekeeping Supervisor) regarding resident room cleaning. HS F stated resident rooms should be cleaned daily. HS F stated housekeeping staff does not move resident belongings, so if residents have personal belongings on the sink counter, that area does not get cleaned by housekeeping. HS F stated there is a Daily Cleaning Checklist that gets completed daily and she keeps 3 months of logs in her binder.On 2/24/26, Surveyor requested the Daily Cleaning Checklist for the past 2 weeks for the hall R3, R21, and R34 reside on. The facility provided five days of Daily Cleaning Checklist, 2/10/26, 2/11/26, 2/12/26, 2/18/26, and 2/22/26.2/10/26 Daily Cleaning Checklist has blanks for the following: R3 did not receive sweep/vacuum floor or change curtain (if dirty). R21 did not receive any cleaning. R34 did not receive any cleaning.2/11/26 Daily Cleaning Checklist has blanks for the following: R3 did not have disinfect high touch points or change curtain (if dirty). R21 did not receive cleaning. R34 did not receive disinfect high touch points, clean & sanitize bathroom, and change curtain (if dirty).2/12/26 Daily Cleaning Checklist has blanks for the following: R3 did not receive cleaning. R21 did not receive sweep/vacuum floor, restock paper products, change curtain (if dirty). R34 did not receive sweep/vacuum floor, restock paper products, change curtain (if dirty).2/18/26 Daily Cleaning Checklist has blanks for the following: R3 did not receive mop floor and change curtain (if dirty). R21 did not receive sweep/vacuum floor, restock paper products, change curtain (if dirty). R34 did not receive sweep/vacuum floor, restock paper products, change curtain (if dirty).2/22/26 Daily Cleaning Checklist only has check hand sanitizer marked for R3, R21, and R34. The rest is blank. On 2/24/26 at 3:16 PM, Surveyor interviewed MT P (Maintenance) regarding the cleanliness of resident rooms. MT P indicated he oversees housekeeping, but HS F is the housekeeping supervisor. MT P indicated he was not aware resident rooms were not being cleaned. MT P indicated he was unaware the wall heater units in R21 and R34's room were falling off the walls. MT P indicated rooms are audited when a resident is discharged from the room. MT P indicated staff should put in a work order if there is maintenance required for a resident's room. MT P indicated staff should have reported the wall heater units were falling off the walls.

Number of residents sampled: 61Number of residents cited: 5Based 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) for 5 of 61 residents reviewed (R1, R3, R19, R21, R34). R3 stated she has to wait up to 45 minutes for her call light to be answered and staff leave her room without meeting her needs. R21 states she does not get the care she is supposed to get per her care plan because the staff do not have enough time to complete the task because of lack of staffing. R21 states staff will turn off her call light and leave the room without meeting her needs. R34 did not get repositioned per her care plan because the CNAs stated they were too busy and do not have enough staff. Observation of long call light wait times. R1 does not receive care per her care plan. This is evidenced by: The facility's policy Sufficient Staffing, dated 10/19/23, includes: The facility will have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population. 3. Nursing direct care staffing ratios will be recalculated based on census and level of care needs. 2. Daily reviews of staffing patterns will be reviewed by the Scheduler, HR, administrator, and DON. Changes will be made to staffing hours with administrator approval, based on census and resident level of care. Example 1 On 2/22/2026 at 4:19 PM, Surveyor interviewed R3. R3 indicated there are not enough staff in the facility. R3 stated she gets frustrated with the call light wait times. R3 indicated it can take up to 45 minutes before staff answer her light. R3 indicated there are times when staff are too busy and will leave before meeting all her needs. R3 indicated staff will answer the call light, say they will come back, but it can be more than an hour before they do. Example 2 R21 admitted to the facility on [DATE] with diagnoses including quadriplegia C5-C7 incomplete (partial paralysis of limbs). R21's BIMS (Brief Interview for Mental Status), dated 2/4/26, has a score of 15, indicating R21 is cognitively intact. R21's physician order, dated 1/27/26, includes Physical Therapy Eval (Evaluation) and treat for ROM (Range of Motion) and pain/spasticity to BLE (Bilateral Lower Extremities). R21's comprehensive care plan, last reviewed 2/12/26, includes: Focus: The resident has limited physical mobility.Interventions: Active Assisted Range of Motion Program daily to BLE (see signs hanging in room). R21's CNA (Certified Nursing Assistant) Kardex, printed 2/24/26, includes: Active Assisted Range of Motion Program daily to BLE (see signs hanging in room) and Active Assisted Range of motion to BLE (see signs hanging in room). R21's Passive Rage of Movement Exercises for the Leg and Foot signs include: Perform the exercises a minimum of 5 repetitions, once daily. Hip Bending Movement. Leg Movement In and Out. Hip Turning Movement. Hamstring Stretch. Bending Foot Down Movement. Bending Foot Up Stretch. Moving Foot In and Out. Toe Bending Movement. On 2/22/26 at 2:30 PM, Surveyor interviewed R21. R21 stated the facility does not have enough CNAs. R21 stated she does not receive the ROM exercised to her legs daily as she is supposed to because the staff say they are too busy to complete the task. R21 states staff will come to turn off the call light and then will forget to come back. On 2/23/2026 at 10:46 AM, R21's call light came on. At 10:49 AM, facility staff entered R21's room. R21's call light turned off and staff exited the room. At 10:52 Surveyor entered R21's room and asked if R21's needs were met. R21 indicated she needed incontinent care and the staff member that came in turned off her light and informed R21 she would let a CNA know. At 11:13 AM, a CNA entered R21's room and provided cares for R21. On 2/23/26 at 1:55 PM, Surveyor interviewed CNA O (Certified Nursing Assistant) regarding R21's ROM exercises. CNA O indicated she did not perform R21's ROM exercises today because she was too busy. On 2/23/26 at 2:33 PM, Surveyor interviewed CNA H regarding R21's ROM program. CNA H indicated she and CNA H provided cares for R21. CNA H stated they did not assist R21 with her ROM exercises today because they were too busy. Example 3 R34 admitted to the facility on [DATE] with diagnoses of multiple sclerosis (autoimmune disease of the central nervous system, causing communication issues between the brain and bod), paraplegia (loss of motor and sensory function in the lower extremities), and pressure injury of sacral region stage 4 (a severe wound extending through the skin and subcutaneous fat to expose muscle, tendon, or bone). R34's Brief Interview for Mental Status, dated 12/9/25, has a score of 9, indicating R34 has moderately impaired cognition. R34's comprehensive care plan, last reviewed 12/4/25, includes: Focus: The resident has limited physical mobility.Interventions: bed mobility assist - two Focus: I am at risk for alteration in skin integrityInterventions: Updated 8/15----Turn and reposition me at least every 1-2 hours. On 2/23/26 at 8:00 AM, Surveyor observed R34 lying on her back in bed. R34's head of bed was elevated to approximately 45 degrees. Surveyor made observations of R34 in the same position at 9:33 AM, 10:29 AM, 11:32 AM, 12:53 PM, and 1:14 PM. On 2/23/26 at 1:55 PM, Surveyor interviewed CNA O regarding cares for R34. CNA O indicated she was working with CNA H for the day shift. CNA O indicated she and CNA O had not yet provided cares for R34. CNA O indicated therapy had been in with R34 earlier. CNA O indicated R34 has a wound to her sacrum and should be repositioned at least every 2 hours. CNA O indicated she had not repositioned R34 this shift. On 2/23/26 at 1:56 PM, Surveyor interviewed OT Q (Occupational Therapy) about the care she provided to R34. OT Q indicated she provided oral care and washed R34's hands. On 2/23/26 at 2:33 PM, Surveyor interviewed CNA H regarding cares for R34. CNA H indicated she had just finished providing cares for R34. CNA H indicated that R34 should be repositioned every 2 hours. CNA H indicated she did not reposition R34 today until she provided cares at 2:00 PM. CNA H stated she tries to get to R34 to reposition her but does not always have time to get it done. Example 4 On 2/22/26 at 11:09 AM, Surveyor interviewed R19. R19 reported that the facility has 1 CNA for 20 residents, and they have had to wait up to 1.5 hours to go to the bathroom. Surveyor asked R19 if they had an accident, R19 stated yes and that it made them feel terrible, humiliated, and disrespected. Surveyor asked R19 if they could remember when this incident occurred, R19 stated no, but it was when they were first admitted . On 2/23/26 at 10:05 AM, Surveyor observed call lights. The facility has a call light system that tells how long the call light has been on for. This system is located at the desk in the center of the facility. At 10:05 AM, Surveyor noted that R19's call light had been on for 15 minutes, according to the system. No staff were observed on the hall. At 10:06 AM, NM K (Nurse Manager) went into the room next door to R19. NM K did not answer R19's call light. At 10:07 AM, R19 was noted sitting in the hallway. At 10:09 AM, R19's call light was answered. Total wait time was 19 minutes. At 10:10 AM, Surveyor noted that room [ROOM NUMBER]'s call light had been on for 8 minutes; the floor nurse and NM K were at the nurse's station talking. At 10:10 AM room [ROOM NUMBER]'s call light was turned off. Total wait time was 10 minutes. At 10:30 AM room [ROOM NUMBER]'s call light had been on for 11.5 minutes. At 10:45 AM room [ROOM NUMBER]'s call light was turned off. Total wait time was 26 minutes. At 10:38 AM room [ROOM NUMBER]'s call light had been on for 13 minutes. At 10:49 AM, room [ROOM NUMBER]'s call light was turned off. Total wait time was 32 minutes. Example 5: R1 was admitted to the facility on [DATE]. R1's most recent MDS (Minimum Data Set) dated 2/2/26, indicates, in part: a BIMS (Brief Interview of Mental Status) score of 15 out of 15, indicating R1 is cognitively intact. R1's Care Plan, dated 12/15/23, states, in part: Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) lymphedema, fibromyalgia, chronic pain and morbid obesity. Interventions: 2 staff in room for all cares for staff safety d/t (due to) allegations when able. bathing/shower assist – one. dressing assist – one. personal hygiene/oral care assist – one. toilet use: Hoyer to/from commode with mesh Hoyer sling with commode cut out. On 2/22/26 at 11:48 AM, Surveyor interviewed R1 in her room. Surveyor observed R1 sitting in her recliner with her feet up and the Hoyer sling under her in her chair. R1 stated that the facility does not have enough staff, especially on the PM and overnight shifts. R1 indicated that she had to wait up to an hour for staff to answer her call light or to assist her in getting off the commode. R1 stated that the staff have to use a Hoyer lift to assist her, which requires 2 staff members to get her in and out of bed and on and off the commode. R1 stated that when she has to wait that long on the commode, her right hip and leg go numb, and the back of her legs turn purple. R1 indicated that sitting on the Hoyer sling all day causes her to get indentations on her bottom which hurt like hell. R1 stated she had told staff that she shouldn't be sitting on the Hoyer sling all day, but the more she complains, the more sarcastic staff become, so she stopped saying anything. R1 stated that it makes her very angry and that her concerns are not being taken seriously by staff. On 2/23/26 at 1:55 PM, Surveyor interviewed CNA O regarding staffing. CNA O indicated there are not enough staff to complete everything the residents need. CNA O indicated things like repositioning, range of motion, and oral care does not get done because there is just too much to do. CNA O indicated she was unable to take lunch or break because she was too busy trying to meet the needs of the residents. On 2/23/26 at 2:33 PM, Surveyor interviewed CNA H regarding staffing. CNA H indicated things would be better and she would be able to complete her task if there was more help. CNA H stated she did not get a break today because there is too much to do. CNA H stated she is not able to get everything done. CNA H stated she has to tell residents that she does not have time to complete things or will tell the residents she will have to do things later, but it doesn't get done. CNA H stated she gets the residents clean, changed, and fed and doesn't have time to do much else.

Based on interview and record review, the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications (R1). R1 takes a medication used for anxiety PRN (as needed). The facility failed to recognize that all PRN psychotropic medications or medications used off-label as psychotropic medications should be limited to 14 days unless deemed appropriate by the provider. Evidenced by:The facility policy, Psychotropic Medication, dated 8/1/15 with a last revision date of 5/1/25, states, in part: . Procedure: . 11. PRN orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. R1 was admitted to the facility on [DATE] with diagnoses that include, in part: bipolar disorder (mental health condition characterized by significant mood swings), other chronic pain, low back pain, fibromyalgia (long-term condition that causes widespread body pain and fatigue), schizoaffective disorder (mental health condition consisting of a mix of schizophrenia symptoms such as hallucinations and delusions), generalized anxiety disorder, psychophysiologic insomnia (chronic sleep disorder resulting in persistent difficulty falling asleep or staying asleep triggered by stress and anxiety), and adjustment disorder (excessive emotional or behavior response to stressors). R1's orders state, in part.hydroxyzine HCL (hydrochloride) oral tablet 25 mg (milligrams). Give 1 tablet by mouth at bedtime for anxiety AND Give 0.5 tablet by mouth in the morning for anxiety AND Give 1 tablet by mouth as needed for anxiety once daily. Start date 1/15/26. End date: Indefinite.No evidence was provided to Surveyor that R1's PRN Hydroxyzine was renewed after 14 days. On 2/25/26 at 3:37 PM, Surveyor interviewed DON B (Director of Nursing) who indicated that if a resident has a PRN psychotropic medication or a medication used off-label as a psychotropic medication PRN, the resident should have a new order from the physician every 14 days. DON B stated she did not have a more recent order for R1's hydroxyzine.

Number of residents sampled: 4Number of residents cited: 2Based on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 2 of 4 residents reviewed for grievances (R2 and R40). R2 voiced a grievance to the facility. Staff did not write their concerns up as a grievance, complete an investigation, or follow-up with the complainant. R40's APOA (Activated Power of Attorney) voiced a grievance to the facility. Staff did not write their concerns up as a grievance, complete an investigation, or follow-up with the complainant. Evidenced by: The facility's policy titled Grievance/Concerns last revised on 10/29/24 states in part .Procedure: 1. Facility will make prompt efforts to resolve all grievances.4. Residents have the right to file grievances orally or in writing; and they have the right to file grievances anonymously. 5. At any time, comments, suggestions, or complaints by the residents and/or their representatives are encouraged to direct their concerns to; The Administrator, Social Services Director, Director of Nursing or designee, or any appropriate manager.9. The grievance form includes the date the grievance was received, a summary statement of the resident's grievance, the steps being taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents' concerns, whether the grievance was confirmed or not confirmed, corrective action taken, or to be taken, and the date the written decision was issued. Resolution of the grievance and reporters [sic] satisfaction with the resolution. Example 1 R40 was admitted to the facility on [DATE] with diagnoses that include heart disease, chronic pain, type 2 diabetes mellitus, and other symptoms and signs involving cognitive functions and awareness (memory loss, confusion, concentration, language difficulties, and poor judgement). R40's most recent MDS (Minimum Data Set) dated 12/5/25 states that R40 has a BIMS (Brief Interview of Mental Status) of 6 out of 15, indicating that R40 has severe cognitive impairment. R40's MDS section GG states that R40 requires partial/moderate assistance for bathing, personal hygiene, and upper body dressing, and is dependent on staff for lower body dressing. R40 has an APOA. R40's care plan initiated on 9/6/24 states in part .FOCUS: The resident has an ADL (Activities of Daily Living) self- care performance deficit r/t (related to) weakness, and deconditioning. Resident frequently refuses assistance with ADLs.Interventions: Assist to change brief and get into pajamas every bedtime (date initiated 2/18/26). Bathing/Showering Assist- One.Dressing Assist- One. Personal Hygiene/Oral Care Assist- One. R40's CNA (Certified Nursing Assistant) task interventions history states: 6/4/25 Assist res (resident) nightly w (with)/ pajamas. Resident to have poise pad in underwear. 11/14/25 Assist res nightly w/ pajamas 2/23/26 Assist res nightly w/ pajamas On 2/22/26 at 12:18 PM, Surveyor interviewed APOA J. APOA J stated that R40 was wearing the same clothes that they had on the day before and that staff don't always change them into their pajamas at night. APOA J stated that they lay R40's pajamas on the bed for the night and that they were still there today. Surveyor asked APOA J if they have spoken to facility staff regarding this concern, APOA J stated that they have spoken to NM K (Nurse Manager). On 2/23/26 at 3:27 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if APOA J's concerns regarding R40 not being changed into their pajamas was written up as a grievance, DON B stated that they would have to check. Surveyor asked DON B if they would expect R40 to be changed into their pajamas at night, DON B stated yes. On 2/23/26 at 3:37 PM, Surveyor interviewed NM K. Surveyor asked NM K if they had any conversations with APOA J regarding R40 being changed into their pajamas at night, NM K stated that they have had several conversations and that they updated R40's care plan and talked to the staff and provided education. Surveyor asked NM K if they wrote APOA J's concerns up as a grievance, NM K stated no, and they just handled it. Surveyor asked NM K if they audited R40's cares to ensure that the task was being completed and that the education was effective, NM K stated no. On 2/25/26 at 9:40 AM, NHA A (Nursing Home Administrator) provided Surveyor with a copy of a grievance for R40 and APOA J. The Grievance Form states: Date/ Time of Report: 2/22/26 Origin of Report: Voiced by Individual/Family Resident: [R40 Name] .Reported by: [APOA J name] . Grievance (include Approximate Date/Time): [APOA J name] complained that she felt the caregivers are not changing her mother's brief and putting her in pajamas before bed each night. I lay out a brief, her pajamas, and clothes and she's wearing the same clothes she had on yesterday She stated I'm mostly concerned about getting the brief changed, for obvious reasons citing [sic] odor and skin irritation if left in a wet brief. It is important to note that the Grievance Form does not include and investigation notes or resolution documentation. Surveyor asked NHA A when the grievance was filed, NHA A stated that they had NM K write is yesterday. Surveyor asked NHA A if they would expect grievances to be written up on the day that they occur or when staff is made aware of a concern, NHA A reported that they discuss concerns in the morning meeting. Surveyor asked NHA A if NM K brought APOA J's concerns to the morning meeting, NHA A stated that NM K was not at the morning meeting on Monday. Example 2 R2 voiced a grievance to the facility. Staff did not write up the concern as a grievance or complete an investigation. On 2/22/26 at 3:00 PM, Surveyor interviewed RR FF (Resident Representative) during initial screening of residents. RR FF stated that R2 had a concern regarding a staff member who didn't speak English and R2 wasn't able to properly communicate with the staff member. RR FF stated that the facility was aware as R2 had spoken with NP GG (Nurse Practitioner) about the concern not wanting the staff member to return to care for R2. Surveyor reviewed the facility's February Grievance log. There was no documentation for R2. On 2/23/26 at 2:02 PM, Surveyor interviewed NP GG who stated that R2 had called and left a message about the concern. NP GG stated the information was forwarded to DON B (Director of Nursing) and ADON C (Assistant Director of Nursing) in an email on 2/16/26. On 2/23/26 at 2:12 PM, Surveyor interviewed DON B and asked about R2's concern. DON B reviewed email from 2/16/26 and stated I have a voicemail attachment that I guess I didn't listen to; the email is marked unread. On 2/23/26 at 4:30 PM, DON B stated NS HH (Nursing Scheduler) had been aware of the concern and took care of it. On 2/24/26 at 7:14 AM, a Grievance form and an updated grievance log was provided. The updated log included a line that stated, in part: Date received 2.16.26 Resident Identifier R2 complaint type 'other' Person filing report: DON Date of grievance 2/26 The Grievance form, dated 2/23/26, states, in part; Date/Time of Report: 2/16/26.Date Investigation Completed: 2/23/26. On 2/24/26 at 11:09 AM, Surveyor interviewed NS HH who stated I was told R2 didn't want CNA II (Certified Nursing Assistant) working with R2 due to a language barrier. I talked with CNA II and the float CNA and made arrangements for the float to work with R2. Surveyor asked if administration was made aware of the resident concern. NS HH stated it was someone from administration who told me; I don't recall who, but it was one of them. On 2/25/2026 at 9:59 AM, Surveyor interviewed DON B about the new Grievance log and the Grievance Form. DON B stated my email was marked as unread, I filled out the grievance form and discussed with NS HH on 2/23/26. The situation was handled by NS HH at time of concern. Surveyor asked when the Grievance Form was completed. DON B stated after the discussion with Surveyor on 2/23/26. Surveyor asked if the facility is able to track and trend concerns if grievances are not written up and entered on the log. DON B stated no, I would expect it to be written up, added to log, the process followed through. On 2/25/2026 at 10:24 AM, Surveyor interviewed NHA A, who stated I would expect that all grievances would be reviewed and logged for tracking/trending and ensured follow through.

Based on interview and record review, the facility did not ensure to develop and implement written policies and procedures that: S483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 3 of 8 staff reviewed for background checks. RN LL (Registered Nurse) did not have a background check completed every 4 years.LPN MM (Licensed Practical Nurse) did not have a background check completed every 4 years.CNA X (Certified Nursing Assistant) did not have a universal background check completed despite indicating that she lived out of state last year. This is evidenced by:The facility policy, Policy and Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 11/17/17 with last revision date of 2/25/25, states, in part: Purpose: To provide residents a safe environment that is free from harm. Resident Protection Program Policy and Procedure: The seven elements of the prevention and investigation include: Screening. 1. Screening and Training of New Employees and Volunteers: a. Employees: i. Screen potential employees for a history of abuse, neglect, exploitation, or mistreatment. This includes. checking with the appropriate licensing boards and registries. iv. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks, using the state-specified criminal background system. RN LL (Registered Nurse) was hired by the facility on 10/15/19. RN LL's last completed background check was completed on 10/17/19. RN LL should have had a background check completed by 10/17/23.LPN MM (Licensed Practical Nurse) was hired by the facility on 11/2/20. LPN MM's last background check was completed on 11/2/20. LPN MM should have had a background check completed by 11/2/24.CNA X (Certified Nursing Assistant) was hired by the facility on 2/6/26. CNA X's Background Information Disclosure Form (BID) indicated that she lived in Mississippi from 2/1/18 to 2/19/25. CNA X should have had a background check completed for Mississippi or a universal background check completed. On 2/23/26 at 1:47 PM, Surveyor interviewed HR KK (HR Director) and asked how often background checks should be completed for employees. HR KK stated that background checks are supposed to be completed every 4 years or sooner if they feel like they need to run another one. Surveyor asked about RN LL and LPN MM's background checks. HR KK stated that they were ran yesterday, but that they hadn't been run on time within the last 4 years. Surveyor asked HR KK what they do if an employee indicates that they have lived outside of the state. HR KK stated that they run universal background checks if the employee has lived out of state within the last 5 years. Surveyor asked if a universal or background check had been run on CNA X. HR KK stated that she apparently had overlooked running a universal background check for CNA X. HR KK indicated that she didn't know why it didn't get done, and it should have. HR KK stated that she started her role in November and had an audit in place, but it hadn't been completed yet. On 2/23/26 at 3:24 PM, Surveyor interviewed NHA A (Nursing Home Administrator) about RN LL, LPN MM, and CNA X's background checks. NHA A stated that HR KK started her role in either November or December and that her predecessor had gotten behind on completing the background checks, so corporate had suggested they complete an audit. Surveyor asked NHA A how often she expected the employee background checks to be completed. NHA A indicated that employee background checks should be completed every 4 years. Surveyor asked NHA A what kind of background check should be completed if an employee had lived outside of the state. NHA A stated that employees who have lived outside of the state within the last 7 years should have a national background check completed. Surveyor asked NHA A if it was her expectation that all employee background checks be completed every 4 years and that employees that had lived outside of the state have a universal/national background check completed prior to the start of working in the facility. NHA A stated yes, she would expect those things to be done to keep the residents safe.

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 3 sampled Residents (R40).R40's APOA (Activated Power of Attorney) reported that R40 was not being changed into their pajamas at night,Evidenced by:The facility's policy titled Activities of Daily Living with a revision date of 2/25/25 states in part Policy: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrates that such diminution was unavoidable.R40 was admitted to the facility on [DATE] with diagnoses that include heart disease, chronic pain, type 2 diabetes mellitus, and other symptoms and signs involving cognitive functions and awareness (memory loss, confusion, concentration, language difficulties, and poor judgement). R40's most recent MDS (Minimum Data Set) dated 12/5/25 states that R40 has a BIMS (Brief Interview of Mental Status) of 6 out of 15, indicating that R40 has severe cognitive impairment. R40's MDS section GG states that R40 requires partial/moderate assistance for bathing, personal hygiene, and upper body dressing, and is dependent on staff for lower body dressing. R40 has an APOA. R40's care plan initiated on 9/6/24 states in part .FOCUS: The resident has an ADL (Activities of Daily Living) self- care performance deficit r/t (related to) weakness, and deconditioning. Resident frequently refuses assistance with ADLs.Interventions: Assist to change brief and get into pajamas every bedtime (date initiated 2/18/26). Bathing/Showering Assist- One.Dressing Assist- One. Personal Hygiene/Oral Care Assist- One. R40's CNA (Certified Nursing Assistant) task interventions history states:6/4/25 Assist res (resident) nightly w (with)/ pajamas. Resident to have poise pad in underwear.11/14/25 Assist res nightly w/ pajamas2/23/26 Assist res nightly w/ pajamas The task documentation screen states: Question 1: Dressing- Level of Staff Support Provided- CNAs primarily mark 1-person physical help. Question 2: *Activity Did Not Occur- CNAs primarily marked Not Applicable. On 2/22/26 at 12:18 PM, Surveyor interviewed APOA J. APOA J stated that R40 was wearing the same clothes that they had on the day before and that staff don't always change them into their pajamas at night. APOA J stated that they lay R40's pajamas on the bed for the night and that they were still there today. Surveyor asked APOA J if they have spoken to facility staff regarding this concern, APOA J stated that they have spoken to NM K (Nurse Manager). On 2/23/26 at 3:21 PM, Surveyor interviewed CNA L. Surveyor asked CNA L to explain the assistance that R40 requires for getting ready for bed, CNA L stated that R40 needs physical help and reminders, otherwise they will sleep in their clothes. CNA L reported that they know that it has been a problem with R40 not getting into their pajamas and that some staff don't help R40 get changed into their pajamas. On 2/23/26 at 3:27 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if they would expect R40 to be changed into their pajamas nightly, DON B stated yes. Surveyor reviewed R40's CNA task documentation with DON B. Surveyor asked DON B what their interpretation of the task was, DON B stated that R40 requires assistance. Surveyor asked DON B by looking at the documentation, does it appear that R40 has been assisted with getting into their pajamas nightly, DON B stated no. Surveyor asked DON B who is responsible for monitoring CNA documentation, DON B stated that nursing management should be monitoring the task documentation. Surveyor asked DON B if the task stating Activity did not occur would make sense in this instance and if staff should be reporting tasks that don't make sense, DON B stated yes, staff should be reporting a task that doesn't make sense. On 2/23/26 at 3:37 PM, Surveyor interviewed NM K. Surveyor asked NM K if they had any conversations with APOA J regarding R40 being changed into their pajamas at night, NM K stated that they have had several conversations and that they updated R40's care plan and talked to the staff and provided verbal education, but could not remember to who the education was provided to. Surveyor asked NM K if they feel that the education was effective, NM K stated no, because the caregivers are not getting R40 into their pajamas. Surveyor asked NM K if they monitor or audit whether or not tasks are being completed, NM K stated no. Surveyor reviewed R40's task documentation with NM K. Surveyor asked NM K, based on the documentation, does it appear that R40 is never being changed into their pajamas, NM K stated that's what it looks like.

Number of residents sampled: 2Number of residents cited: 2Based on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure injuries (PI) for 2 of 2 Residents (R8 and R34) reviewed for pressure injuries. R34 has a PI and was not repositioned per her care plan. R8 has a stage 4 pressure injury and was observed lying in bed without prevlon boots on. This is evidenced by: The facility's policy Pressure Injury Prevention and Wound Care Management, dated 8/25/25, includes: The purpose of the policy is to provide healthcare staff with the standards of care, and processes to be followed for all residents: *To identify factors that places the residents at risk for the development of pressure injuries and to implement appropriate interventions to prevent the development of clinically avoidable wounds. *To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. *To promote healing of existing pressure injuries and wounds. It is the policy of this facility that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing, in accordance with eh comprehensive assessment and plan of care. The facility will ensure that a resident who is admitted without a pressure injury does not develop a pressure injury, unless clinically unavoidable. A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers. The skin care program will be utilized following the guidelines of the agency for Healthcare Research and Quality (AHRQ), the National Pressure Ulcer/Injuries Advisory Panel (NPIAP) and current standards of Clinical Practice. 2. Repositioning frequency is individualized based on skin/tissue tolerance, support surface, risk, and clinical condition. Example 1 R34 admitted to the facility on [DATE] with diagnoses of multiple sclerosis (autoimmune disease of the central nervous system, causing communication issues between the brain and bod), paraplegia (loss of motor and sensory function in the lower extremities), and pressure injury of sacral region stage 4 (a severe wound extending through the skin and subcutaneous fat to expose muscle, tendon, or bone). R34's Brief Interview for Mental Status, dated 12/9/25, has a score of 9, indicating R34 has moderately impaired cognition. R34's comprehensive care plan, last reviewed 12/4/25, includes: Focus: The resident has limited physical mobility.Interventions: bed mobility assist - two Focus: I am at risk for alteration in skin integrityInterventions: Updated 8/15----Turn and reposition me at least every 1-2 hours. On 2/23/26 at 8:00 AM, Surveyor observed R34 lying on her back in bed. R34's head of bed was elevated at approximately 45 degrees. Surveyor made observations of R34 in the same position at 9:33 AM, 10:29 AM, 11:32 AM, 12:53 PM, and 1:14 PM. On 2/23/26 at 1:55 PM, Surveyor interviewed CNA O (Certified Nursing Assistant) regarding cares for R34. CNA O indicated she was working with CNA H for the day shift. CNA O indicated she and CNA H had not yet provided cares for R34. CNA O indicated therapy had been in with R34 earlier. CNA O indicated R34 has a wound to her sacrum and should be repositioned at least every 2 hours. CNA O indicated she had not repositioned R34 this shift. On 2/23/26 at 1:56 PM, Surveyor interviewed OT Q (Occupational Therapy) about the care she provided to R34. OT Q indicated she provided oral care and washed R34's hands. On 2/23/26 at 2:33 PM, Surveyor interviewed CNA H regarding cares for R34. CNA H indicated she had just finished providing cares for R34. CNA H indicated R34 should be repositioned every 2 hours. CNA H indicated she did not reposition R34 today until she provided cares at 2:00 PM. On 2/23/26 at 3:51 PM, Surveyor interviewed LPN M (Licensed Practical Nurse) regarding residents with pressure injuries and repositioning. LPN M indicated staff should follow the resident's care plan for repositioning. LPN M indicated repositioning should be done every 1-2 hours if a resident has a pressure injury. On 2/23/26 at 3:58 PM, Surveyor interviewed ADON C (Assistant Director of Nursing) regarding residents with pressure injuries. ADON C indicated a resident with a pressure injury should be repositioned every 2 hours unless their care plan states differently. On 2/23/26 at 4:13 PM, Surveyor interviewed DON B (Director of Nursing) regarding residents with pressure injuries. DON B indicated a resident with a pressure injury should be repositioned every 1-2 hours. DON B indicated R34 should have been repositioned per her care plan. Example 2 R8 was admitted to the facility on `12/21/22 with diagnoses that include congestive heart failure ( a condition where the heart muscles cannot pump blood efficiently enough to meet the body's needs, causing blood and fluids to back up into the lungs, legs, and abdomen), peripheral vascular disease ( poor circulation to legs and feet), vascular dementia, and protein- calorie malnutrition. R8's most recent MDS (Minimum Data Set) dated 12/1/25 states that R8 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R8 is cognitively intact. R8's MDS states that they are dependent on staff for toilet hygiene, transfers, and dressing, and require substantial/ maximal assistance for personal hygiene and bed mobility. R8's care plan states in part: .Focus: I am at risk for alteration in skin integrity- decreased mobility, hemiplegia, GI (Gastrointestinal)/colitis.9/15/25 #7 stage 4- l great toe.Interventions: Foot cradle placed on bed. I use pressure reducing mattress/ air mattress.Manage my clinical conditions and contributing factors to reduce my risk of skin breakdown.Prevlon boots to feet while in bed. Provide my treatments as ordered by my physician or wound care team. Turn and reposition me every 2-3 hours. Wound Care physician's most recent note dated 2/19/26 states in part: .Stage 4 Pressure Wound of the left, first toe full thickness.Etiology: Pressure MDS 3.0 stage: 4.Approach: close monitoring, off- loading.wound size (L (length) x W (width) x D (depth): 0.21 x 0.23 x 0.1 cm (centimeters).granulation tissue: 100% . On 2/22/26 at 10:52 AM, Surveyor interviewed R8. Surveyor asked R8 where their pressure injury was located, R8 reported that it was on their foot and that staff has them wear boots during the day and off at night. Surveyor noted that R8 was laying in bed with an air mattress, foot cradle was on bed – keeping the blankets off of R8's feet, and the pressure relieving boots were on the floor. On 2/25/26 at 8:54 AM, Surveyor interviewed DON B. Surveyor asked DON B what the facility has determined the root cause to be for R8's pressure injury, DON B stated that it was due to the blankets causing pressure. Surveyor asked DON B what interventions were implemented, DON B stated they initiated a foot cradle to off- load the blankets. Surveyor shared the observation of R8 not wearing the pressure relieving boots and asked DON B if R8 should be wearing the boots when in bed, DON B stated yes.

Based on observation, interview, and record review the facility did not ensure residents with limited range of motion, received appropriate treatment and services to increase range of motion/mobility and/or to prevent further decrease in range of motion/mobility for 1 of 2 residents (R21) reviewed for range of motion (ROM).R21 did not receive active assisted range of motion to her bilateral lower extremities (BLE) per R21's provider orders and comprehensive care plan.This is evidenced by:The facility's policy Activities of Daily Living (ADLs), dated 2/25/25, includes: Policy: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. A resident will be given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Based on the assessments, a personalized care plan is created. ADLs will be individualized. ADL cares will be provided based on the resident preferences. Resident ADL care needs will be communicated to staff via the care plan and Kardex (a care plan for the CNAs (Certified Nursing Assistants)).R21 admitted to the facility on [DATE] with diagnoses including quadriplegia C5-C7 incomplete (partial paralysis of limbs affecting cervical vertebrae 5 thru 7).R21's BIMS (Brief Interview for Mental Status), dated 2/4/26, has a score of 15, indicating R21 is cognitively intact.R21's physician order, dated 1/27/26, includes Physical Therapy Eval (Evaluation) and treat for ROM (Range of Motion) and pain/spasticity to BLE (Bilateral Lower Extremities).R21's Physical Therapy Treatment Encounter Note(s), dated 2/17/26, states: ROM to BLE targeting hip, knee and ankle. Pt (patient) (R21) tolerates well reporting improve comfort following. Pt (R21) d/c (discharged ) this visit. Hung up ROM program in room. Staff given updated recommendation for ROM program. Pt (R21) d/c due to reaching max level of independence.R21's comprehensive care plan, last reviewed 2/12/26, includes: Focus: The resident has limited physical mobility.Interventions: Active Assisted Range of Motion Program daily to BLE (see signs hanging in room).R21's CNA (Certified Nursing Assistant) Kardex, printed 2/24/26, includes: Active Assisted Range of Motion Program daily to BLE (see signs hanging in room) and Active Assisted Range of motion to BLE (see signs hanging in room). R21's Passive Rage of Movement Exercise signs for the Leg and Foot include: Perform the exercises a minimum of 5 repetitions, once daily. Hip Bending Movement. Leg Movement In and Out. Hip Turning Movement. Hamstring Stretch. Bending Foot Down Movement. Bending Foot Up Stretch. Moving Foot In and Out. Toe Bending Movement.On 2/22/26 at 2:30 PM, Surveyor interviewed R21. R21 stated she does not receive the ROM exercises to her legs daily as she is supposed to. R21 indicated the ROM exercises decreases her edema and pain.On 2/23/26 at 1:55 PM, Surveyor interviewed CNA O (Certified Nursing Assistant) regarding R21's ROM program. CNA O indicated staff use the CNA Kardex to know what assistance a resident needs. CNA O stated R21 has a ROM program with exercises to be done while R21 is in bed. CNA O indicated she assisted CNA H with R21's cares today (2/23/26). CNA O stated they did not perform R21's ROM exercises.On 2/23/26 at 2:33 PM, Surveyor interviewed CNA H regarding R21's ROM program. CNA H indicated she and CNA O provided cares for R21. CNA H indicated the CNAs assist R21 with her ROM exercises. CNA H stated they did not assist R21 with her ROM exercises today (2/23/26). On 2/23/26 at 4:13 PM, Surveyor interviewed DON B (Director of Nursing) regarding care plans. DON B indicated staff should follow residents' care plans.

Based on interview and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 residents (R34) reviewed for medications.R34 had a medication error due to not receiving her medications timely. This is evidenced by:The facility's policy Administering Medications, dated 1/22/24, includes: Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. 4. Medications shall be administered per provider's (MD (Medical Doctor), NP (Nurse Practitioner), PA (Physician Assistant)) written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. 7. Medications should be administered within one (1) hour of the prescribed times. 10. The individual administering the medication shall sign the resident's Medication Administration Record (MAR) for the specific time and day the medication was administered.The facility's policy Medication Error and Drug Interactions, dated 2/12/24, includes: Definition: Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: 1. The prescriber's order.R34 admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder (loss of normal bladder control due to nerve damage), central pain syndrome (chronic neurological condition leading to constant, moderate-to-severe pain), and calculus of kidney (hard mineral and salt deposits forming inside the kidneys, kidney stones).R34's physician orders for February 2026 include: Potassium Citrate-Citric Acid Oral Solution 1100-334 MG/5ML Give 5 ml via G-Tube (Gastrostomy tube, a medical device inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly bypassing the mouth) four times a day for kidney stones. Oxybutynin Chloride Oral Solution 5 MG/5ML Give 5 ml via G-Tube three times a day for urinary leakage.Gabapentin Oral Solution 250 MG/5ML Give 2 ml via G-Tube three times a day for pain.R34's Medication Admin Audit Report includes:Potassium Citrate-Citric Acid Oral Solution 1100-334 MG/5ML Give 5 ml via G-Tube four times a day for kidney stones. Schedule Date 02/23/2026 8:00 AM. Administration Time 02/23/26 9:18 AM. Oxybutynin Chloride Oral Solution 5 MG/5ML Give 5 ml via G-Tube three times a day for urinary leakage. Schedule Date 02/23/2026 8:00 AM. Administration Time 02/23/26 9:18 AM. Gabapentin Oral Solution 250 MG/5ML Give 2 ml via G-Tube three times a day for pain. Schedule Date 02/23/2026 8:00 AM. Administration Time 02/23/26 9:18 AM.On 2/23/26 at 4:28 PM, Surveyor interviewed LPN N (Licensed Practical Nurse). LPN N indicated if a medication is scheduled at 8:00, the medication can be given between 7:00 AM and 9:00 AM. LPN N indicated if the medication is not given in that time frame, it would be a medication error.On 2/23/26 at 4:13 PM, Surveyor interviewed DON B (Director of Nursing. DON B indicated if a medication is scheduled at 8:00 AM, then the nurse can administer the medications between 7:00 AM and 9:00 AM. DON B indicated giving medications outside of the scheduled times would be considered a medication error.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 3 residents (R1) reviewed for abuse. Facility became aware of an abuse allegation on 9/26/25 at 10:15 PM and did not report to the State Agency until 9/27/25 at 12:12 PM. Evidenced by: The facility policy entitled, Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 3/25/25, states, in part: . Purpose: To provide residents a safe environment that is free from harm. Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. The guidelines include compliance with the seven (7) federal components of prevention and investigation. Procedure: . The facility will strive to educate all participants in techniques to protect all parties. 8. Alleged Abuse: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated. Resident Protection Program Policy & Procedure:The seven elements of the prevention and investigation include: *Screening *Training *Prevention *Identification *Investigation *Protection *Reporting/Response. 3. Identification:a. In the event of suspected maltreatment, the needs of the resident will be immediately assessed, and the safety of the resident will be ensured. The safety and health of the resident(s) will be attended to before any other action is taken. Immediate steps should be taken to ensure that no resident remains in danger of maltreatment. 4 Investigation:a. Upon receiving a complaint of alleged maltreatment, the Administrator must be notified immediately and they, the Director of Nursing, or assigned designee, will coordinate an investigation, which will include completion of witness statements.b. When a specific staff member is implicated in the alleged event, the person will be removed from the residents' care area immediately, interviewed by the supervisor assigned, asked to provide a written statement and suspended until the investigation is completed. MUST BE SUSPENDED IMMEDIATELY PENDING INVESTIGATION.h. Education will be provided as needed to all parties involved. 6. Reporting of Incidents:a. All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's designee.b. The facility must report to the State agency immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. R1 admitted to the facility on [DATE] and has diagnoses that include Type 2 Diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R1's MDS (Minimum Data Set) admission Assessment, dated 9/22/25, shows that R1 has a BIMS (Brief Interview of Mental Status) score of 14 indicating R1 is cognitively intact. Note: R1 was out of facility during survey. Surveyor was unable to interview R1. The facility's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 9/27/25, states, in part: . Allegation Type: Abuse: Hitting, slapping, threats of harm, assault, humiliation.Is the date and time when occurred known? YesDate occurred: 9/27/25Time Occurred: 12:00AMIs occurred date and time estimated? YesDate discovered? 9/27/25 Brief Summary of Incident: R1 and CNA C (certified nursing assistant) were witnessed yelling at each other. R1 and CNA C were immediately separated. Ensured R1 felt safe in facility. CNA C suspended pending investigation. Nurse manager, DON (Director of Nursing) and NHA (Nursing Home Administrator) were notified. [City name] Police Department notified.Report Submitted Date: 12:12:46PM . The facility's Risk Management Assessment/Incident, dated 9/26/25, at 10:15PM, states, in part: . Verbal Aggression InitiatedResident: R1Incident Location: Reception/LobbyPerson Preparing Report LPN D (Licensed Practical Nurse) . Agencies/People Notified:LPN E 9/27/25 9:21PM On 10/8/25 at 11:18 AM, Surveyor interviewed LPN D who indicated on 9/26/25 at the beginning of her shift (third) she had been in the nursing office and overheard CNA C and R1 going back and forth yelling at each other. CNA C was antagonizing R1. R1 was yelling CNA C was lazy and smelled like marijuana, and CNA C was yelling at R1 that she was not lazy and what she did in her spare time was her business. LPN D indicated both R1 and CNA C kept yelling at each other. LPN D stepped out of the nurse office and told both R1 and CNA C to stop. R1 went to his room. LPN C told CNA C she is not to talk to a resident that way, that is retaliation when you confront R1 on a complaint he made. LPN D informed CNA C if she has a problem with a resident to go to the DON or NHA. CNA C continued to work the shift on R1's hallway but did not take care of R1. LPN D took care of R1 that night. LPN D indicated she phoned LPN E, who was the nurse on call that night to report the incident. Surveyor asked LPN D what time the incident occurred. LPN D indicated she could not remember exactly but she documented the incident with the time in the Risk Management in PCC (Point Click Care). Surveyor asked what time LPN E was informed and LPN C indicated she had started to phone LPN E and R1 came up to the nurse station and wanted his stuff and informed LPN D he was leaving the facility. LPN D talked with R1 and calmed him down and R1 agreed to stay at facility. LPN D then called LPN E. Surveyor asked what direction was received from LPN E regarding the incident. LPN D indicated LPN E took the information from LPN D and informed LPN D to tell R1 if he chose to leave the facility his insurance would not cover his stay at the facility. LPN D indicated she was uncomfortable with CNA C working the rest of the shift because every time she passed R1's room CNA C would look in his room and give R1 looks. On 10/8/25 at 11:50 AM, Surveyor interviewed LPN E who indicated she was the nurse on call the night of 9/26/25 into 9/27/25. LPN E received a call from LPN D around midnight; LPN E was not certain on time. LPN D reported R1 and CNA C were yelling at each other in the hallway. R1 accused CNA C of smelling like marijuana, and both got into a verbal altercation and had to be separated. Surveyor asked what direction did LPN E relay to LPN D regarding the incident. LPN E indicated she gave no direction. LPN E indicated she should have had CNA C sent home upon hearing of incident. Surveyor asked when LPN E reported the incident to the DON or NHA. LPN E indicated she had not reported the incident that night; it was reported the following Monday morning on 9/29/25 during the morning stand up. Surveyor asked LPN E if the verbal altercation was considered an allegation of abuse and LPN E indicated technically yes. Surveyor asked LPN E when an allegation of abuse should be reported to State and LPN E indicated within an hour of incident. On 10/8/25 at 12:55 PM, Surveyor interviewed NHA A. Surveyor asked when NHA A became aware of the verbal altercation between R1 and CNA C. NHA A indicated the morning of 9/27/25 from DON B who had received a message in the middle of the night on 9/27/25 but did not receive until that morning on 9/27/25. Surveyor asked if the verbal altercation is an allegation of abuse and NHA A indicated yes. NHA A indicated the verbal altercation should have been reported within two hours of incident, and it had not been.

Based on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by a CNA (certified nursing assistant) for 1 of 3 Residents (R1) reviewed for abuse. R1 and CNA C (certified nursing assistant) had a verbal altercation. The facility did not implement appropriate actions to protect R1. CNA C continued to provide direct care to residents. The facility did not educate all staff on abuse during the abuse investigation. Evidenced by: The facility policy entitled, Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 3/25/25, states, in part: . Purpose: To provide residents a safe environment that is free from harm. Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. The guidelines include compliance with the seven (7) federal components of prevention and investigation. Procedure: . The facility will strive to educate all participants in techniques to protect all parties. 8. Alleged Abuse: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated. Resident Protection Program Policy & Procedure:The seven elements of the prevention and investigation include: *Screening *Training *Prevention *Identification *Investigation *Protection *Reporting/Response. 3. Identification:a. In the event of suspected maltreatment, the needs of the resident will be immediately assessed, and the safety of the resident will be ensured. The safety and health of the resident(s) will be attended to before any other action is taken. Immediate steps should be taken to ensure that no resident remains in danger of maltreatment. 4 Investigation:a. Upon receiving a complaint of alleged maltreatment, the Administrator must be notified immediately and they, the Director of Nursing, or assigned designee, will coordinate an investigation, which will include completion of witness statements.b. When a specific staff member is implicated in the alleged event, the person will be removed from the residents' care area immediately, interviewed by the supervisor assigned, asked to provide a written statement and suspended until the investigation is completed. MUST BE SUSPENDED IMMEDIATELY PENDING INVESTIGATION.h. Education will be provided as needed to all parties involved. 6. Reporting of Incidents:a. All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's designee.b. The facility must report to the State agency immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. R1 admitted to the facility on [DATE] and has diagnoses that include Type 2 Diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R1's MDS (Minimum Data Set) admission Assessment, dated 9/22/25, shows that R1 has a BIMS (Brief Interview of Mental Status) score of 14 indicating R1 is cognitively intact. Note: R1 was out of facility during survey. Surveyor was unable to interview R1. The facility's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 9/27/25, states, in part: . Allegation Type: Abuse: Hitting, slapping, threats of harm, assault, humiliation.Is the date and time when occurred known? YesDate occurred: 9/27/25Time Occurred: 12:00AMIs occurred date and time estimated? YesDate discovered? 9/27/25 Brief Summary of Incident: R1 and CNA C (certified nursing assistant) were witnessed yelling at each other. R1 and CNA C were immediately separated. Ensured R1 felt safe in facility. CNA C suspended pending investigation. Nurse manager, DON (Director of Nursing) and NHA (Nursing Home Administrator) were notified. [City name] Police Department notified.Report Submitted Date: 12:12:46PM . The facility provided education on Reporting Allegations of Abuse, Neglect and Misappropriation, on 9/29/25 to LPN E (Licensed Practical Nurse). The facility provided education on Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, on 9/29/25 to LPN E. The facility did not provide abuse education to all facility staff. On 10/8/25 at 11:18 AM, Surveyor interviewed LPN D who indicated on 9/26/25 at the beginning of her shift (third) she had been in the nursing office and overheard CNA C and R1 going back and forth yelling at each other. CNA C was antagonizing R1. R1 was yelling CNA C was lazy and smelled like marijuana, and CNA C was yelling at R1 that she was not lazy and what she did in her spare time was her business. LPN D indicated both R1 and CNA C kept yelling at each other. LPN D stepped out of the nurse office and told both R1 and CNA C to stop. R1 went to his room. LPN C told CNA C she is not to talk to a resident that way, that is retaliation when you confront R1 on a complaint he made. LPN D informed CNA C if she has a problem with a resident to go to the DON or NHA. CNA C continued to work the shift on R1's hallway but did not take care of R1. LPN D took care of R1 that night. LPN D indicated she phoned LPN E, who was the nurse on call that night to report the incident. Surveyor asked LPN D what time the incident occurred. LPN D indicated she could not remember exactly but she documented the incident with the time in the Risk Management in PCC (Point Click Care). Surveyor asked what time LPN E was informed and LPN C indicated she had started to phone LPN E and R1 came up to the nurse station and wanted his stuff and informed LPN D he was leaving the facility. LPN D talked with R1 and calmed him down and R1 agreed to stay at facility. LPN D then called LPN E. Surveyor asked what direction was received from LPN E regarding the incident. LPN D indicated LPN E took the information from LPN D and informed LPN D to tell R1 if he chose to leave the facility his insurance would not cover his stay at the facility. LPN D indicated she was uncomfortable with CNA C working the rest of the shift because every time she passed R1's room CNA C would look in his room and give R1 looks. Surveyor asked LPN D if she had received any abuse education regarding the abuse allegation from 9/26/25 and LPN D indicated no. On 10/8/25 at 11:50 AM, Surveyor interviewed LPN E who indicated she was the nurse on call the night of 9/26/25 into 9/27/25. LPN E received a call from LPN D around midnight; LPN E was not certain on time. LPN D reported R1 and CNA C were yelling at each other in the hallway. R1 accused CNA C of smelling like marijuana, and both got into a verbal altercation and had to be separated. Surveyor asked what direction did LPN E relay to LPN D regarding the incident. LPN E indicated she gave no direction. LPN E indicated she should have had CNA C sent home upon hearing of incident. Surveyor asked when LPN E reported the incident to the DON or NHA. LPN E indicated she had not reported the incident that night; it was reported the following Monday morning on 9/29/25 during the morning stand up. Surveyor asked LPN E if the verbal altercation was considered an allegation of abuse and LPN E indicated technically yes. Surveyor asked LPN E when an allegation of abuse should be reported to State and LPN E indicated within an hour of incident. LPN E indicated she had received education on abuse after this incident. On 10/8/25 at 12:55 PM, Surveyor interviewed NHA A. Surveyor asked when NHA A became aware of the verbal altercation between R1 and CNA C. NHA A indicated the morning of 9/27/25 from DON B. Surveyor asked if the verbal altercation is an allegation of abuse and NHA A indicated yes. NHA A indicated the verbal altercation should have been reported within two hours of incident, and it had not been. Surveyor asked what protection was put into place for R1 and other residents at the time of the incident. NHA A indicated R1 and CNA C were separated, and CNA C did not have contact with R1 that night. Surveyor asked NHA A what the facility policy says regarding investigating an allegation of abuse. NHA A indicated CNA C should not have continued to provide cares that night and should have been suspended immediately pending investigation per facility policy. Surveyor asked NHA A per facility policy who should have received education on abuse. NHA A indicated the two nurses for sure, ideally all staff.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that all alleged violations are thoroughly investigated, and that steps were taken to prevent further abuse for 1 or 3 residents reviewed (R1). On 9/27/25, the facility became aware of an abuse allegation regarding R1. The facility failed to provide evidence to prevent further abuse to R1 and other residents. The facility allowed the staff member identified in the abuse allegation to continue working with residents. Evidenced by: The facility policy entitled, Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 3/25/25, states, in part: . Purpose: To provide residents a safe environment that is free from harm. Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. The guidelines include compliance with the seven (7) federal components of prevention and investigation. Procedure: . The facility will strive to educate all participants in techniques to protect all parties. 8. Alleged Abuse: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated. Resident Protection Program Policy & Procedure:The seven elements of the prevention and investigation include: *Screening *Training *Prevention *Identification *Investigation *Protection *Reporting/Response. 3. Identification:a. In the event of suspected maltreatment, the needs of the resident will be immediately assessed, and the safety of the resident will be ensured. The safety and health of the resident(s) will be attended to before any other action is taken. Immediate steps should be taken to ensure that no resident remains in danger of maltreatment. 4 Investigation:a. Upon receiving a complaint of alleged maltreatment, the Administrator must be notified immediately and they, the Director of Nursing, or assigned designee, will coordinate an investigation, which will include completion of witness statements.b. When a specific staff member is implicated in the alleged event, the person will be removed from the residents' care area immediately, interviewed by the supervisor assigned, asked to provide a written statement and suspended until the investigation is completed. MUST BE SUSPENDED IMMEDIATELY PENDING INVESTIGATION.h. Education will be provided as needed to all parties involved. 6. Reporting of Incidents:a. All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's designee.b. The facility must report to the State agency immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. R1 admitted to the facility on [DATE] and has diagnoses that include Type 2 Diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R1's MDS (Minimum Data Set) admission Assessment, dated 9/22/25, shows that R1 has a BIMS (Brief Interview of Mental Status) score of 14 indicating R1 is cognitively intact. The facility's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 9/27/25, states, in part: . Allegation Type: Abuse: Hitting, slapping, threats of harm, assault, humiliation.Is the date and time when occurred known? YesDate occurred: 9/27/25Time Occurred: 12:00AMIs occurred date and time estimated? YesDate discovered? 9/27/25 Brief Summary of Incident: R1 and CNA C (certified nursing assistant) were witnessed yelling at each other. R1 and CNA C were immediately separated. Ensured R1 felt safe in facility. CNA C suspended pending investigation. Nurse manager, DON (Director of Nursing) and NHA (Nursing Home Administrator) were notified. [City name] Police Department notified.Report Submitted Date: 12:12:46PM . On 9/27/25, at 12:12:46 PM, the facility submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the state. The facility's investigation did not include providing protection to R1 and residents in the facility. CNA C continued to provide direct care to residents after the abuse incident occurred. The facility provided education on Reporting Allegations of Abuse, Neglect and Misappropriation, on 9/29/25 to LPN E. The facility provided education on Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, on 9/29/25 to LPN E. The facility did not provide education to all staff on abuse. On 10/8/25, at 11:18AM, Surveyor interviewed LPN D who indicated on 9/26/25 at the beginning of her shift (third) she had been in the nursing office and overheard CNA C and R1 going back and forth yelling at each other. CNA C was antagonizing R1. R1 was yelling CNA C was lazy and smelled like marijuana, and CNA C was yelling at R1 that she was not lazy and what she did in her spare time was her business. LPN D indicated both R1 and CNA C kept yelling at each other. LPN D stepped out of the nurse office and told both R1 and CNA C to stop. R1 went to his room. LPN C told CNA C she is not to talk to a resident that way, that is retaliation when you confront R1 on a complaint he made. LPN D informed CNA C if she has a problem with a resident to go to the DON or NHA. CNA C continued to work the shift on R1's hallway but did not take care of R1. LPN D took care of R1 that night. LPN D indicated she phoned LPN E, who was the nurse on call that night to report the incident. Surveyor asked LPN D what time the incident occurred. LPN D indicated she could not remember exactly but she documented the incident with the time in the Risk Management in PCC (Point Click Care). Surveyor asked what time LPN E was informed and LPN C indicated she had started to phone LPN E and R1 came up to the nurse station and wanted his stuff and informed LPN D he was leaving the facility. LPN D talked with R1 and calmed him down and R1 agreed to stay at facility. LPN D then called LPN E. Surveyor asked what direction was received from LPN E regarding the incident. LPN D indicated LPN E took the information from LPN D and informed LPN D to tell R1 if he chose to leave the facility his insurance would not cover his stay at the facility. LPN D indicated she was uncomfortable with CNA C working the rest of the shift because every time she passed R1's room CNA C would look in his room and give R1 looks. Surveyor asked LPN D if she had received any abuse education regarding the abuse allegation from 9/26/25 and LPN D indicated no. On 10/8/25, at 11:50AM, Surveyor interviewed LPN E who indicated she was the nurse on call the night of 9/26/25 into 9/27/25. LPN E received a call from LPN D around midnight, LPN E was not certain on time. LPN D reported R1 and CNA C were yelling at each other in the hallway. R1 accused CNA C of smelling like marijuana, and both got into a verbal altercation and had to be separated. Surveyor asked what direction did LPN E relay to LPN D regarding the incident. LPN E indicated she gave no direction. LPN E indicated she should have had CNA C sent home upon hearing of incident. Surveyor asked when LPN E reported the incident to the DON or NHA. LPN E indicated she had not reported the incident that night; it was reported the following Monday morning on 9/29/25 during the morning stand up. Surveyor asked LPN E if the verbal altercation was considered an allegation of abuse and LPN E indicated technically yes. Surveyor asked LPN E when an allegation of abuse should be reported to State and LPN E indicated within an hour of incident. LPN E indicated she had received education on abuse after this incident. On 10/8/25, at 12:55PM, Surveyor interviewed NHA A. Surveyor asked when NHA A became aware of the verbal altercation between R1 and CNA C. NHA A indicated the morning of 9/27/25 from DON B. Surveyor asked if the verbal altercation is an allegation of abuse and NHA A indicated yes. Surveyor asked what protection was put into place for R1 and other residents at the time of the incident. NHA A indicated R1 and CNA C were separated, and CNA C did not have contact with R1 that night. Surveyor asked NHA A what the facility policy says regarding investigating an allegation of abuse. NHA A indicated CNA C should not have continued to provide cares that night and should have been suspended immediately pending investigation per facility policy. Surveyor asked NHA A per facility policy who should have received education on abuse. NHA A indicated the two nurses for sure, ideally all staff.

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 residents (R2) reviewed for medication errors.R2 received the wrong dose of a medication, and the facility failed to increase registered nurse (RN) assessments and update the provider timely when R2 had a change in condition.Evidenced by:The facility's policy titled Change in Condition last revised on 11/13/24, states in part .Procedure: 1. The physician and Durable Power of Attorney/responsible party will be notified when there has been a change that is sudden in onset, change that is a marked difference in usual sign/symptoms and/or the signs/symptoms are unrelieved by measures already prescribed: 2. Specific information that requires prompt notification include, but is not limited to: a. Significant change or instability of vital signs; .g. Change in level of consciousness; .k. A medication error or adverse reaction to medication; l. A significant change in the resident's physical/psychosocial/mental condition; .o. A need to transfer the resident to a hospital or treatment center; .3. Nurse will complete assessment and document findings in resident record including but not limited to vital signs, pain, respiratory status as applicable, cardiac status as applicable, etc. Notification of medical professional and resident representative will be documented in medical record. 4. If the physician cannot be reached, the Medical Director will be notified to report the change in condition until the physician can be reached.According to Drugs.com, .The most commonly reported signs and symptoms associated with clozapine overdose are: sedation, delirium, coma, tachycardia, hypotension, respiratory depression or failure; and hypersalivation. There are reports of aspiration pneumonia, cardiac arrhythmias, and seizure. Clozaril: Package Insert / Prescribing Information.According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.R2 admitted to the facility on [DATE] with diagnoses that include urinary tract infection, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), schizoaffective disorder (a mental health condition that includes schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and mood disorder symptoms), and chronic pain syndrome.R2's most recent Minimum Data Set (MDS) stated that R2 has a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating that R2 is cognitively intact.R2's hospital discharge orders dated 8/25/25 included:Clozapine 100mg oral tablet 1 tab(s) oral once a day (in the morning).Clozapine 200mg oral tablet 1 tab(s) oral once a day (at bedtime).8/25/25 at 4:31 PM nurse's note: NP (Nurse Practitioner) questioning clozapine dose due to hospital notes stating it wasn't in their formulary. Admissions director clarified with hospital that resident was not taking in the hospital. Writer called residents outside social worker to discuss. She gave writer [Nurse Name] who works with [Physician Name] who manages her psychotropic medications. Writer then spoke with [Nurse Name] who will send orders to [Pharmacy Name] to titrate dose of clozapine back up to home dose. This will start on 8/27.R2's new orders for clozapine (entered on 8/26/25 at 12:53 PM) is as follows: Clozapine oral tablet 25mg. Give 12.5 mg by mouth in the morning related to schizoaffective disorder for 2 days. Use pre- dosed pill packs supplied by resident psych MD (Medical Doctor), then give 25mg by mouth in the morning related to schizoaffective disorder for 2 days. Use pre- dosed pill packs supplied by resident psych MD. Then give 50mg by mouth in the morning related to schizoaffective disorder for 2 days. Use pre- dosed pill packs supplied by resident psych MD. Then give 75mg by mouth in the morning related to schizoaffective disorder for 2 days. Use pre- dosed pill packs supplied by resident psych MD. Then give 100mg by mouth in the morning related to schizoaffective disorder for 5 days. Use pre- dosed pill packs supplied by resident psych MD.Clozapine oral tablet 25mg. Give 12.5mg by mouth at bedtime related to schizoaffective disorder for 1 day. Use pre- dosed pill packs supplied by resident psych MD. Then give 25mg by mouth at bedtime related to schizoaffective disorder for 2 days. Use pre- dosed pill packs supplied by resident psych MD. Then give 50mg at bedtime related to schizoaffective disorder for 2 days. Use pre- dosed pill packs supplied by resident psych MD. Then give 75mg at bedtime related to schizoaffective disorder for 2 days. Use pre- dosed pill packs supplied by resident psych MD. Then give 100mg at bedtime related to schizoaffective disorder for 2 days. Use pre- dosed pill packs supplied by resident psych MD. Then give 125mg at bedtime related to schizoaffective disorder for 1 day. Use pre- dosed pill packs supplied by resident psych MD.8/26/25 at 9:47 AM nurse's note: Patient was up this am, had shower and medication that included Clozapine 100mg. Patient was in dining room asleep and was assessed and laid back down after eating some cream of wheat as she was unable to stay awake. Staff was informed of situation as well as the nurse for psychiatry and the case worker and they stated they would call back.Of note, despite the medication error the facility did not complete a comprehensive assessment of R2 despite R2 showing signs of sleepiness. The note indicates R2 was assessed but the medical record does not specify findings for R2 and what staff assessed.8/26/25 at 10:47 AM, NP C note states: SNF (Skilled Nursing Facility) nurse reports med error this am (morning) regarding clozapine. Nurse reports she gave dose of 100mg this am. Unsure of what order from community psychiatry team is as it was held in the hospital, and they were issuing new titration orders. Nurse reports [resident's name] was up and had a shower, she ate breakfast but is sleeping now. VSS (vital signs stable). She is sleeping comfortably but easily arouses per nurse. I req (requested) [sic] nursing alert her psychiatry team who rx (prescribe) and manages the clozapine for directions as I am unable to see what dose they rx for her (prior to hospital stay it sounds like it was 100mg in morning and 200mg at hs (bedtime). Nurse reports she did not get a dose yesterday at SNF (skilled nursing facility) from what she can see. Nursing to closely monitor and alert the psychiatry/ prescribing provider for directions on clozapine and following dose given this am. Nurse verbalizes understanding and reports she will closely monitor and update if any changes or new orders from psychiatry team.Of note, NP C directed close monitoring of R2.8/26/25 at 11:31 AM nurse's note: Resident here after fall at home and stay in hospital. The resident took a shower and got dressed well. Resident has stable vital signs and took medications whole with water. The resident had 100mg of Clozapine and staff was informed as well as her psych team. Resident continues to rest comfortably has 0ml (milliliters) of fluid with bladder scan and has had a large incontinent episode.There is no indication of RN assessment of R2 despite R2 displaying a change in level of alertness.Medication Administration note:8/26/25 at 1:27 PM: Combivent Respimat Inhalation Aerosol Solution 20-100mcg (micrograms)/ACT. 1 puff inhale orally 4 times a day for related to chronic obstructive pulmonary disease, unspecified- Patient resting comfortably can be aroused but not enough to take inhaler.Despite R2's inability to use the inhaler and decreased level of alertness the facility did not complete a comprehensive assessment or contact R2's MD.8/26/25 at 9:17 PM nurse's note: Resident continues to sleep this shift, hard to wake drowsy. Resident would say a few words but return back to sleep. Declined dinner and just wanted to sleep. Vitals done BP (Blood Pressure) 166/89 HR (Heart Rate) 116, Temp 97.5, SPO2 (Oxygen level) 88 on RA (Room Air), Resp (Respirations) 18. Writer was able to wake resident at about 21 (9 PM) for med pass with snacks.It is important to note despite R2's change of condition there was no physician notification when resident had an elevated blood pressure and heart rate, and decreased oxygen saturation level.8/27/25 at 5:22 AM nurse's note: Writer was called to resident room, upon arrival, resident was found on the floor in front of her bed face down. Resident had socks on, call light was off. Resident's brief was soaked at the time of fall. Resident stated that she was trying to get up, and the rest of her speech was confused. Writer immediately called DON B (Director of Nursing), and she completed an over the phone assessment. Head to toe assessment completed, no injuries noted, no sign of head injury, no hematomas (bruise), resident unable to effectively communicate her pain, some facial grimacing laying on the floor but looked more comfortable when transferred to bed using Hoyer. Message left for on call [MD name]. Neuro checks (neurological checks) initiated, and vitals checked. Cares completed on resident. Resident was reminded to use call light and wait for help.Of note, Surveyor was unable to locate and did not receive any documented vital signs since 8/26/25 at 9:17 PM.Documentation from answering service for MD dated 8/27/25 at 5:30 AM states: Nursing home personnel updating a non- injury fall for this patient. Nursing home staff informed this will be documented in the patient chart.It is important to note that there is no documentation indicating that facility staff reported R2's increased BP and heart rate, and decreased oxygen saturation levels from earlier, confusion and confused speech noted at the time of the fall. Additionally, there was no follow up with the MD after staff did not receive a return call back from the on-call doctor.8/27/25 at 3:58 PM, SW (Social Worker) note states: Another attempt was made to review baseline care plan with resident. Upon waking around 10am, she had a difficult time eating her food. She appeared very lethargic and had difficulty staying awake. It was then determined that resident should be sent to the hospital.8/27/25 at 12:31 PM nurse's note: Resident lethargic staff notified writer of low blood pressure and resident speech was garbled. This writer went down to assess resident, and she was asleep. I went ahead and reassessed blood pressure to find that her blood pressure was lower than staff reported. I attempted to wake resident but was unable to wake her up. Call placed to [NP name] updated her on resident's change of condition. New order received to send to send [sic] resident out via 911 due to altered mental status, hypotension, and fall. As resident had fell previously around 0400 (4:00 AM). After 911 was called writer went in to monitor resident and yet again attempt to awaken resident. This time I was able to arouse resident and she was talking and stated, I am just tired I am okay. Resident transferred to [Hospital Name] for evaluation.8/27/25 at 12:34 PM NP C's note: Call to voicemail 12:15 to report [R2's name] has been sleeping all morning, she was up for breakfast but at this time she is lethargic, BP 77/44 p (pulse) 89 R 19 po2 (oxygen level) 91%. I returned call and spoke with her nurse who reports speech was reported by another staff as garbled, but she is not waking up or speaking for nurse now. Nurse advised to send [R2's name] to ER (Emergency Room) via 911 for AMS (Altered Mental Status), garbled speech, fall, and hotn (hypotension/ low blood pressure). Order given to and read back by [Nurse's name] at [Facility's name]. Of note [R2's name] had a fall from bed this am, per telephone encounter non injury fall at 5:30 am. SNF chart shows she had confused speech at time and later req (required) Tylenol for headache shortly before 7 am.R2's History and Physical (H&P) dated 8/27/25 states in part: .History limited from patient due to incoherent speech. Patient concerns limited to headache and butt pain. When asked why she is here she reports that she fell. Discussed with RN (Registered Nurse) at [Facility Name] who reports an unwitnessed fall the day prior without hitting her head or loss of consciousness. RN expressed concern for hypotension to 83/40, incoherent speech, lethargy, holding food in mouth, liquid coming out of mouth while chin was positioned to chest. Onset was sudden and occurred this afternoon prior to arrival. Baseline presentation of patient is limited to RN due to admission to [Facility's name] the day prior upon discharge from [Hospital Name]. RN does report medication changes upon discharge including instructions to gradually titrate dose of clozapine. However, due to medication administration error, the patient was given clozapine 100mg instead of 12.5mg.ED (Emergency Department) Course: Vitals: BP 108/54, RR 18, Temp 98.2, SpO2 95%, HR 88 thirty minutes after arrival.Treatment: Aspirin 324mg, Tylenol 650mg, NS (Normal Saline) 1L(liter), Zosyn 4.5g. R2's Physician Discharge Summary dated 8/29/25 states in part .Principal/ Final Diagnoses: Accidental overdose of clozapine.Patient Course & Care: [R2's name] was admitted to [Hospital Team Name] for further evaluation and treatment of Accidental overdose of clozapine.Patient altered on arrival. Discussed with RN (Registered Nurse) at [Facility Name] who reports unwitnessed fall the day prior without hitting her head or loss of consciousness. RN expressed concern for hypotension 83/40, incoherent speech, lethargy, holding food in mouth, liquid coming out of mouth while chin was positioned to chest. Reported administration error of clozapine by [Facility Name] staff of a dose of 100mg that should have been 12.5mg at the start of a gradual titration regimen.On 9/17/25 at 1:19 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B to explain the medication error that occurred with R2. DON B explained that herself and NP C were reviewing R2's admission orders and NP C requested staff to get clarification of R2's clozapine order. DON B stated that the facility reached out to R2's psych team and obtained new orders to start on 8/27/25, and that the new orders were passed on to the next shift. DON B reported that the next morning, R2 was noted to be very sleepy, and it was discovered that she was given 100mg of clozapine. Surveyor asked DON B if on 8/26/25 when R2 had increased blood pressure and heart rate, decreased oxygen level, and was hard to wake would be considered a change in condition, DON B stated yes. Surveyor asked if the provider should have been updated, DON B stated yes. Surveyor asked DON B if staff should have spoken with a provider, as opposed to leaving a message, after R2's fall when notes stated that she had confused speech, DON B stated staff left a message with the answering service. Surveyor asked DON B what type of increased monitoring/assessment was implemented for R2 after the medication error, DON B stated that she was unable to find anything in R2's EHR (electronic health record).On 9/17/25 at 1:42 PM, Surveyor interviewed NP C. Surveyor asked NP C regarding R2's clozapine orders, NP C stated that on 8/25/25, she had instructed facility staff to clarify orders with R2's outside psychiatric provider because she does not prescribe clozapine. Surveyor asked NP C if she was made aware of R2's medication error, NP C stated yes and that she instructed staff to reach out to R2's psychiatric team with any changes in mentation and vital signs. Surveyor asked NP C if she would expect facility staff to update the provider when R2 had a change in condition on 8/26/25 including increased blood pressure and heart rate, decreased oxygen level, and was hard to wake, NP C stated that she had no idea that situation had occurred and she would have expected facility staff to report it, and that she would have sent her to the ER.R2 had a change of condition after receiving the incorrect dose of Clozapine. NP C requested close monitoring the facility failed to do complete ongoing comprehensive assessments of R2 despite changes in level of alertness and vital signs. R2 was sent to the hospital due to accidental overdose of Clozapine.

Based on observation, interview, and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (R5) reviewed for medications.R5 has medications that should not be crushed prior to administration. R5 received those medications crushed. R5 received an enteric coated medication when the medication should have been in a chewable form. This is evidenced by: The facility's policy Medication Error, dated 5/14/21, includes: All medication errors and drug reactions will be reported promptly to the licensed nurse, the attending physician, and will be documented according to established procedures. Medication error is defined as the preparation or administration of medications or biological that is not in accordance with the prescriber's orders, manufacturer specifications regarding the preparation and administration of the medication or biological and/or accepted professional standards for medication or biological administration. A detailed account of the error will be recorded on an incident report. Such documentation must include, but is not limited to: a. Time and date of the incident b. Name, strength, and dosage of medication administrated c. Resident's reaction to the medication d. Condition of the resident e. Any treatment administered f. Date and time the physician was notified and what instructions were given. The facility's Medications Not To Be Crushed form, dated 2002, includes: Aspirin enteric coated, Guaifenesin extended release, Bupropion extended release, Finasteride, Tamsulosin, and Omeprazole.Example 1On 10/30/25 at 8:30 AM, Surveyor observed LPN D (Licensed Practical Nurse) prepare R5's medications. Surveyor observed LPN D take an Aspirin enteric coated 81 mg tab out of the stock container and place it in the medication cup. LPN D placed Bupropion HCL ER (XL) 300 mg tablet, Finasteride 5 mg tablet, and Guaifenesin ER 600 mg tablet into the medication cup. LPN D proceeded to crush these medications. LPN D placed Omeprazole 20 mg capsule and Tamsulosin 0.4 mg capsule into another medication cup. LPN D opened both capsules and placed the medication inside the capsules into the medication cup with the other crushed medications. LPN D administered these medications to R5. Surveyor interviewed LPN D regarding the crushed medications. LPN D indicated she can crush and administer these medications because R5 has an order for crushed medications.Of note, R5 does not have a physician order to crush medications. R5's physician orders, printed 10/30/25, include:Aspirin Low Dose Oral Tablet Chewable 81 mg (milligrams) Bupropion HCL ER (extended release) (XL) Oral tablet extended release 24 hour 300 mg. DO NOT CRUSHFinasteride oral tablet 5 mg.DO NOT CRUSHGuaifenesin ER oral tablet extended release 12 hour 600 MGOmeprazole oral capsule delayed release 20 mg.DO NOT CRUSHTamsulosin GCL (Glyceryl trinitrate ) oral capsule 0.4 mg.CAPSULES SHOULD BE SWALLOWED WHOLE-DO NOT CRUSH, CHEW OR OPENOn 10/30/25 at 9:56 AM, Surveyor interviewed LPN E regarding medication errors. LPN E indicated crushing a medication that should not be crushed is a medication error. LPN E indicated given a medication that is enteric coated when the order is for a chewable is a medication error.On 10/30/25 at 10:03 AM, Surveyor interviewed RN F (Registered Nurse) regarding medication errors. RN F indicated crushing extended-release medications is a medication error. RN F indicated opening capsules that should not be opened and dispensing the medication from inside is considered a medication error.On 10/30/25 at 11:39 AM, Surveyor interviewed DON B (Director of Nursing) regarding medication errors. DON B indicated crushing medications that are extended release is a medication error. DON B indicated extended-release medications should not be crushed. DON B indicated capsules should not be opened unless there is an order to open them.

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 2 of 3 residents (R6 and R15) reviewed for falls and 4 of 5 residents (R12, R18, R19, and R20) reviewed for Hoyer transfers. R6 is being cited at severity level 3 (actual harm). R15, R12, R18, R19, and R20 are being cited at severity level 2 (potential for more than minimal harm). R6 was left in her bed with the bed in the high position. R6 fell out of bed landing face down resulting in a nasal fracture and lacerations to her forehead and lip that required sutures. R12, R18, R19, and R20 were being transferred with a Hoyer lift and only one staff present, resulting in R12 sustaining a skin tear to his toe. R15's care planned interventions were not being followed, resulting in a possible hand fracture. This is evidenced by: Facility policy titled, Fall Reduction Policy dated 8/1/15 with last revision date of 10/13/23, states in part: Purpose: To provide an environment that remains as free of accident hazards as possible .To promote a systematic approach and monitoring process for the care of residents who have fallen and/or those who are determined to be at risk . Risk Identification and Assessment: 1. A systematic approach data collection to evaluate and identify the presence if risk factors, related causes, and complications . Prevention and Treatment Guidelines: 1. These risk factors include, but are not limited to: a. Mental status . c. Ambulation and elimination status . Example 1: R6 was admitted to the facility on [DATE] with diagnoses that include Anxiety Disorder, unspecified, Posttraumatic Stress Disorder, unspecified, Unspecified Symptoms and Signs Involving Cognitive Function and Awareness, Unspecified Intellectual Disabilities, Mild Cognitive Impairment of Uncertain or Unknown Etiology, Bipolar Disorder, and Unspecified Dementia. R6's most recent Minimum Data Set (MDS) dated [DATE] states that R6 has a Brief Interview of Mental Status (BIMS) of 8 out of 15, indicating that R6 has moderate cognitive impairment. Section GG of the MDS, states that R6 requires total dependence on staff for all Activities of Daily Living (ADLs) including toileting, hygiene, dressing, showering, transfers, and bed mobility. R6's Comprehensive Care Plan states, in part: -Focus: The resident is at risk for falls R/T (related to) immobility, use of psychotropic medications- 1/19/23-Fall with injury - sent to ER 2/20/25 UWF (Unwitnessed Fall) Date Initiated: 01/13/23 Revision on: 02/20/25. -Goals: Resident will be free from further serious injury related to falls through the next review date. Date Initiated: 01/21/24 Revision on: 02/28/25 Target Date: 05/29/25. Interventions: 2/20/25 Ensure Resident's bed is lowered when leaving room. Date Initiated: 02/24/25 . 2/20/25 UWF Fall mat by bed and soft touch call light. Date Initiated: 02/20/25 Revision on: 02/24/25 . 2/21/25 Bari bed with a Bari air mattress. Date Initiated: 02/24/25 . CANCELLED: For fall on 1/19/23 - Ensure that she is positioned in middle of bed (air mattress) Resolved: 1/23/24. -Focus: The resident has limited physical mobility R/T (related to) low back pain, poor balance and gait -GG task items removed from POC (Point of Care) charting for walking: Resident not ambulatory, Sitting edge of bed: Resident not able to sit at edge of bed, Toileting: resident does not use toilet or commode, Wheelchair: Resident does not use standard w/c (wheelchair)- uses a Broda. Date Initiated: 01/13/23 Revision on: 02/18/24. -Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Date Initiated: 07/05/23 Revision on: 02/17/25 Target Date: 05/29/25. -Interventions: Ambulation/Locomotion- Broda Chair - Manual -one assist-use pedals. Date Initiated: 01/13/23 Revision on: 12/22/23 . Bed Mobility Assist - One. Date Initiated: 01/23/23 . Resolved: Bed mobility assist of two. Resolved: 1/23/23 . Transfer Assist - Full body lift - Assist Two -Hoyer. Date Initiated: 01/13/23 Revision on: 01/13/23. R6's Certified Nursing Assistant (CNA) Kardex states, in part: Bed Mobility: *2/20/25 Ensure Resident's bed is lowered when leaving room * Bed Mobility Assist - One Mobility/Transfer: *Ambulation/Locomotion - Broda Chair - Manual * Transfer Assist - Full Body Assist - Assist Two -Hoyer Safety/Monitor: * 1/19/24 slightly recline Broda chair for comfort and positioning * 2/20/25 UWF Fall mat by bed and soft touch call light * 2/21/25 Bari bed with a Bari air mattress R6's Fall Report dated 2/20/25 at 7:30 AM, states, Writer called to resident's room by NOC (overnight) shift nurse. 200 LPN (Licensed Practical Nurse) in with resident. Resident lying face down on floor perpendicular to bed. Substantial amount of blood on floor, laceration noted to right forehead and upper lip, nose bleeding. 911 had been called. An addendum to this fall incident entered by DON B (Director of Nursing), States, IDT met to review fall from 2/20. Staff were in room a few minutes prior getting resident cleaned up for the day. Resident was found laying face down on the floor. Resident was assessed by the nurse and was decided to send out due to lacerations and bloody nose. Provider, hospice, and POA (Power of Attorney) updated. Resident provided a soft touch call light and fall mat next to bed. R6's emergency room (ER) After Visit Summary, dated 4/20/25, states, in part: Dx (Diagnosis): Fall, initial encounter, Facial laceration, initial encounter, Bilateral hand pain, Closed fracture of nasal bone, initial encounter, Hospice care patient, Epistaxis (nosebleed). Chief Complaint: Fall. Pt (patient) was reaching for call light when she fell out of bed unwitnessed. Pt is on C-Collar (cervical collar to support and stabilize the neck). Pt has a bloody nose and hematoma (a pool of mostly clotted blood that forms in the tissues) to forehead . Procedure: Laceration Repair to Forehead (2.6 cm X 7.5 cm X 3 cm). One layer suture closure. 6 sutures placed. Procedure: Lip Laceration (less than 2.5 cm X 3.5 cm). One layer suture closure. 7 sutures placed Progress Note: Resident presented after fall out of bed. Noted to have a large lip laceration as well as a laceration above her right eye which are bleeding. Significant blood in bilateral nostrils and nasal bridge swelling. Also question a laceration to the nasal septum on the right side. She is in a cervical collar and will maintain C-spine precautions Laceration repair needed to her face. Will place Afrin and cotton into her nostrils in order to try to obtain hemostasis (cessation of bleeding) . On 5/12/25 at 10:25 AM, Surveyor interviewed CNA I (Certified Nursing Assistant) and asked her what R6's current fall interventions were. CNA I stated that R6's bed was to be all the way to the ground, a fall mat in place next to the bed, don't leave her unattended when the bed is in high position, make sure call light is within reach, and make sure she has everything she needs before you leave the room. Surveyor asked CNA I if R6 ever attempted to self-transfer or get out of bed on her own. CNA I stated that R6 does not self-transfer or attempt to get out of bed on her own. Surveyor asked CNA I to accompany her to R6's room. Surveyor asked CNA I where R6's call light was. CNA I retrieved the call light from behind R6's bed and placed it next to her on the bed. On 5/13/25 at 10:30 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) and asked her what time the incident involving R6. LPN E stated the incident happened at approximately 7:00 AM. LPN E stated that it had to have happened pretty early, since NOC (overnight) shift was still there. LPN E stated she was in the process of preparing her medication cart when RN H (Registered Nurse) told her that R6 had fallen. LPN E said she went to R6's room and saw that she was laying on the floor facedown. LPN E stated that she didn't want to move her. LPN E stated that she thought that LPN G was the one that called 911. LPN E stated that she asked R6 what happened and R6 indicated that she had been reaching for her call light. LPN E stated that R6 was crying but consolable. LPN E stated that she noted that the bed was up at waist high level and that she was able to lean her hip into it when she bent down to get closer to R6. On 5/13/25 at 12:49 PM, Surveyor interviewed CNA F about the incident involving R6. CNA F stated that she got R6 dressed and put the Hoyer sling under her, then went to another room to get clothes for someone else when she heard R6 yelling for help. CNA F indicated that when she returned to R6's room she was on the floor face down and bleeding. CNA F stated that she ran and got the nurses for help, and they helped her roll R6 onto her back. CNA F indicated that they all stayed with R6 until the ambulance arrived. Surveyor asked CNA F what time the fall took place. CNA F stated that it happened around 7:10 AM. CNA F stated that R6 was crying and in a lot of pain. CNA F stated that R6 doesn't even roll by herself, so it was a freak accident, and she wasn't even sure how it happened. (Of note, R6's bed was at waist height per LPN E's interview, CNA F indicated she left R6 to attend to another resident.) On 5/13/25 at 1:03 PM, Surveyor interviewed RN H about the incident involving R6. RN H stated that he thought it happened around the change of shift, sometime between 6:30 AM and 7:00 AM. RN H stated that he worked the NOC shift and was giving report to the nurse who had come in that morning. RN H stated that he saw CNA F come down the hall saying that R6 had fallen out of bed. RN H stated he went to R6's room and noted her on the floor laying on her back with a gash in her face. On 5/14/25 at 7:59 AM, Surveyor interviewed LPN M and asked her if R6 was able to roll over by herself. LPN M stated no, she had never seen R6 roll over by herself. On 5/14/25 at 8:38 AM, Surveyor interviewed CNA L and asked her if R6 was able to roll over by herself. CNA L stated no, she had never seen R6 roll over by herself. On 5/14/25 at 8:40 AM, Surveyor interviewed CNA J and asked if R6 was able to roll over by herself. CNA J stated no, that R6 was a full heavy assist. CNA J stated that maybe if R6 were propped up on her side then maybe she could roll over the rest of the way, but she could not completely roll over by herself. On 5/14/25 at 8:47 AM, Surveyor interviewed CNA K and asked if R6 was able to roll over by herself. CNA K stated no, that R6 was a full assist for transfers and turning in bed. On 5/14/25 at 8:52 AM, Surveyor interviewed MD N (Maintenance Director). Surveyor asked MD N to measure a bed which was at waist high position. MD N measured this to be approximately 35 inches from the floor. MD N stated that beds should only be that high for the staff to perform cares on the residents and they should not be left in that position. On 5/14/25 at 9:56 AM, Surveyor interviewed RN C and asked her if R6 was able to roll over by herself. RN C stated no, she had never seen R6 roll over by herself. On 5/14/25 at 10:01 AM, Surveyor interviewed LPN G about the incident involving R6. LPN G stated that she heard CNA F yelling for assistance. LPN G indicated that when she entered R6's room she saw she had fallen and was lying face down. LPN G stated that with the assistance of two other nurses, they stabilized R6's neck, holding her head in place, and log rolled her over onto her back to see where the blood was coming from. LPN G stated that she applied pressure to R6's forehead and lip and tried to wipe her nose to clear the clots that were coming out of her nose. LPN G stated that she couldn't remember the exact time of the incident, but that it was early and around shift change. Surveyor asked LPN G if R6 was able to roll over by herself. LPN G replied no, that R6 cannot roll by herself. On 5/14/25 at 12:11 PM, Surveyor interviewed DON B (Director of Nursing) about the incident involving R6. DON B stated that CNA F had been doing cares with her and she's a Hoyer, so CNA F left the room to start cares on another two-assist person and heard R6 yelling for help. CNA F went into R6's room and she was laying on her face. CNA F called the nurses to the room for help. The nurses called 911 because R6 was bleeding from her face. Surveyor asked DON B if she would expect that the CNAs would not leave residents unattended with the bed in high position. DON B stated yes, that was her expectation. R6 was left in bed in the high position resulting in a fall with a nasal fracture and laceration(s) requiring sutures. Example 2: Facility policy titled, Total Mechanical Transfer dated 8/1/15 with a revision date of 8/22/23, states, in part: Purpose: To safely transfer residents who have been assessed per the Safe Patient Handling program to require the use of a total mechanical lift . Procedure: . 2. The total mechanical lift must have two staff members present. Staff members include nurses, aides, PT (Physical Therapy) and OT (Occupational Therapy) . R12 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia (paralysis that affects one side of the body) and Hemiparesis (one sided muscle weakness) following Cerebral Infarction (a stroke resulting from disrupted blood flow to the brain) affecting Right Dominant side and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (malfunction of many peripheral nerves throughout the body). R12's most recent BIMS dated 5/7/25 states that R12 has a BIMS of 15 out of 15, indicating that R12 is cognitively intact. R12's Comprehensive Care Plan states, in part: -Focus: [Resident Name] is at risk for falls R/T (related to) DM (Diabetes Mellitus), non-ambulatory status. Date Initiated: 05/09/22 Revision on: 12/18/23. Goal: [Resident Name] will be free from incident/ falls though the review date. Date Initiated: 05/09/22 Revision on: 04/21/25 Target Date: 07/29/25. Interventions: Assist of 2 with Hoyer (For incident on 6/9/22) Date Initiated: 06/10/22. -Focus: I am at risk for alteration in skin integrity R/T decreased mobility due to right sided weakness after a Stroke; risk for fluid volume overload due to CHF (Congestive Heart Failure) . history of previous skin integrity issues . structural foot changes . 12/16 Skin abrasion noted to left superior first toe and third toe. Date Initiated: 05/09/22 Revision on: 12/17/24 Goal: I will be free from further skin breakdown through the review date. Date Initiated: 05/09/22 Revision on: 04/21/25 Target Date: 07/29/25 Interventions: 12/16 Skin abrasion noted to left superior first toe and third toe. Intervention: Ensure proper foot positioning when transferring patient. Date Initiated: 12/17/24. R12's CNA Kardex states, in part: Mobility/Transfer: *Resident is non ambulatory and unable to transfer without a Hoyer and 2 assist. Walking will be removed from POC charting as this is not applicable. He is a right hemi from a previous CVA (Cerebral Vascular Accident). * Transfer Assist - Assist of 2 with Hoyer Watch placement of feet with transfers and when sitting in the recliner Safety/Monitor: *Assist of 2 with Hoyer (For incident on 6/9/22) * 12/16 Skin abrasion noted to left superior first toe and third toe. Intervention: Ensure proper foot positioning when transferring patient. R12's Clinical Progress Notes, state, in part: On 12/16/24 at 4:14 PM, CNA reports while transferring resident from bed to shower chair clipped resident's toes/feet on Hoyer lift. On 12/16/24 at 4:35 PM, Skin abrasion noted to left superior first toe and third toe less than 1 CM in length and width not actively bleeding at this time. Res. (Resident) reports abrasion occurred during transfer. Res. states he feels safe at this time, and it was an accident. Education reinforced on transfer safety to assisting CNA. NP (Nurse Practitioner), POA (Power of Attorney) and ADON (Assisted Director of Nursing) updated. NP instructed to cont. (continue) to monitor update with any changes. On 5/12/24 at 10:31 AM, Surveyor interviewed R12 who stated that usually the staff are pretty good about getting two staff members to use the Hoyer lift and that he thought that the CNA did not mean any harm when she transferred him alone. On 5/13/25 at 12:09 PM, Surveyor interviewed DON B and asked her if she expected the staff to follow the safe mechanical transfer policy. DON B stated yes, she expected the staff to follow the facility policy for safe transfers using the Hoyer with two staff members. On 5/14/25 at 4:42 PM, Surveyor interviewed CNA Q about the incident with R12. CNA Q stated that it was a PM shift, before dinner, and she was planning on giving R12 a shower. CNA Q stated that she radioed for help three times in the span of 20 minutes and did not receive any reply. CNA Q stated she then went out into the hallway looking for someone to help her transfer R12 but couldn't find anyone. CNA Q stated that with the stress of trying to get R12's shower done before dinner, she took it upon herself to transfer R12 by herself and he sustained a cut on his toe. On 5/14/25 at 3:00 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked her if she expected staff to follow facility policies regarding safe transfers. NHA A stated yes, she expected the policy to be followed for Hoyer transfers and that they would always have two staff members to assist when using the Hoyer. Example 3: R18 was admitted to the facility on [DATE] with diagnoses that include Hereditary Spastic Paraplegia (weakness, stiffness, and paralysis in the leg muscles), Generalized Anxiety Disorder, Depression, unspecified, and Cognitive Communication Deficit. R18's most recent MDS dated [DATE] states that R18 has a BIMS of 8 out of 15, indicating that R18 is moderately impaired. R6's Comprehensive Care Plan states, in part: -Focus: The resident has limited physical mobility R/T paraplegia . Sit to stand, toilet transfer, steps, stairs, ambulation and picking up objects not applicable and will be removed from POC (Point of Care) charting. Date Initiated: 9/6/24. Revision on 3/23/25. -Goal: The resident will improve current level of mobility through next review date. Date Initiated: 9/6/24 Revision on: 9/12/24 Target Date: 6/5/25. -Intervention: Ambulation: The resident is non-ambulatory. Date Initiated: 9/6/24. Bed Mobility Assist - Two. Date Initiated: 9/6/24 . Transfer Assist - Full Body Lift - Assist Two. Date Initiated: 9/6/24. On 5/14/25 at 8:15 AM, Surveyor interviewed R18 who stated that they use the lift to hoist me out of bed. R18 stated there is usually two people using the Hoyer lift to transfer him, but occasionally they will only have one staff. Example 4: R19 was admitted to the facility on [DATE] with diagnoses that include Depression, unspecified, Permanent Atrial Fibrillation (an irregular and chaotic heartbeat), Chronic Respiratory Failure with Hypoxia (insufficient oxygen to the tissues), and Chronic Kidney Disease. R19 had not had a BIMS completed yet at time of survey. R19's Comprehensive Care Plan states, in part: -Focus The resident has limited physical mobility R/T obesity, metatarsal fxs (foot fractures). Date Initiated: 5/12/25. Revision on 5/12/25. -Goal: The resident will improve current level of function in transferring through next review date. Date Initiated: 5/12/25 Target Date: 8/7/25. -Intervention: Ambulation/Locomotion - Wheelchair - manual. Date Initiated: 5/12/25. Bed Mobility Assist - Two. Date Initiated: 5/12/25 . Transfer Assist - Full Body Lift - Assist Two. Date Initiated: 5/12/25. Revision on 5/13 /25. On 5/14/25 at 8:39 AM, Surveyor interviewed R19 who stated that the facility is using the Hoyer lift to transfer her. R19 stated that they use one to two staff members to assist her when using the Hoyer lift. Example 5: R20 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis following Cerebral Infarction affection left non-dominant side, Unspecified Dementia without behavioral disturbance, Depression, unspecified, and Other Symptoms and Signs involving Cognitive Functions and Awareness. R20's most recent MDS dated [DATE] states that R20 has a BIMS of 10 out of 15, indicating that R20 is moderately impaired. R20's Comprehensive Care Plan states, in part: -Focus The resident has limited physical mobility R/T (related to) weakness/deconditioning, personal hx (history) of CVA (Cereberal Vascular Accident) with left sided weakness. Date Initiated: 11/1/24. Revision on 11/15/24. -Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through next review date. Date Initiated: 4/17/25 Target Date: 7/2/25. -Intervention: Ambulation/Locomotion - Wheelchair - manual one assist as needed. Date Initiated: 11/1/24. Bed Mobility Assist - Two. Date Initiated: 1/3/25. Transfer Assist - Full Body Lift - Assist Two. Date Initiated: 11/1/24. Revision on: 1/3/25. On 5/14/25 at 8:34 AM, Surveyor interviewed R20 who stated that they put me on this machine and lift me up. R20 indicated that mainly they use two staff members when using the Hoyer but that they don't always have enough workers so sometimes they just use one. On 5/14/25 at 3:00 PM, Surveyor interviewed NHA about her expectation for staff using the Hoyer lift for resident transfers. NHA stated that it was her expectation that staff would always have two people assisting when using the Hoyer lift. Example 6: R15 was admitted to the facility on [DATE] with diagnoses that include, in part: Type 2 Diabetes Mellitus, Peripheral Vascular Disease (a progressive circulation disorder caused by narrowing and blockage in the blood vessels), Congestive Heart Failure, Chronic Pain, Uncomplicated Anxiety disorder, Acquired Absence of Right Leg Below Knee amputation, Gangrene Left Leg, Chronic Kidney Disease, and Adult Failure to Thrive. R15's most recent MDS dated [DATE] states that R15 has a BIMS of 3 out of 15, indicating that R15 has severe cognitive impairment. Section GG of R15's MDS indicates that R15 is totally dependent upon staff for bed mobility, toileting, and transfers. R15's Comprehensive Care Plan states, in part: -Focus: The resident is low risk for falls 4/26/25 Unwitnessed fall Date Initiated: 03/18/25 Revision on: 04/28/25. -Goal: I will be free from further incident/ falls though the review date. Date Initiated: 03/18/25 Target Date: 06/15/25 -Interventions: 4/26/25 Unwitnessed fall--Lay resident down after all meals. Date Initiated: 04/28/25. -Focus: The resident has limited physical mobility r/t Atherosclerosis of Native Arteries of Extremities with Gangrene, Left Leg. Date Initiated: 03/18/25 Revision on: 03/18/25 -Goal: The resident will improve current level of function in transferring through next review date. Date Initiated: 03/18/25 Target Date: 06/15/25. -Interventions: Ambulation/Locomotion - Wheelchair - Manual -dependent Date Initiated: 03/18/25. Bed Mobility Assist - Two. Date Initiated: 03/18/25. Transfer Assist - Full Body Lift - Assist Two. Date Initiated: 03/18/25. R20's CNA Kardex, states, in part: Bed Mobility: *Bed Mobility Assist - Two Mobility/Transfer: *Ambulation/Locomotion - Wheelchair- Manual -dependent *Transfer Assist - Full Body Lift - Assist Two Safety/Monitor: * 4/26/25 Unwitnessed fall--Lay resident down after all meals. *Assist resident to meet needs and maintain safety: keep call light within reach. keep personal effects in easy reach, remind to avoid sudden position changes that may cause increased pain. R15's Incident Report for Unwitnessed Fall states the following: On 4/26/25 at 7:00 PM, At about 1900 hrs. (7:00 PM), writer was called to resident's room by CNA stating that resident was on the floor. Upon arrival, writer found resident on the floor on her left side. resident did not appear to be in pain. resident was conversing with staff in her normal tone, moving both upper extremities. Resident was on the floor left side facing bed, wheelchair behind her. Call light was not on at this moment. Resident stated that she might have been sleeping and declined having pain at this moment No injuries sustained from this fall; resident declined having pain. Full ROM (Range of Motion) noted to all extremities . R15's Incident Report for Injury of Unknown Origin states the following: On 4/29/25 at 12:00 PM, Res (resident) right hand swollen placed call to primary at UW [NAME] left message called POA . update given decision made to send to Mertier for eval (evaluation) transported via stretcher van .Sent to ER for x-ray. Results have conflicting information about chronic or new fracture in hand. DON and NHA (Nursing Home Administrator) notified . R15's ER Note dated 4/28/25 states, in part: Chief complaint: Hand pain History: Presents to the ER for right wrist pain and swelling. Here by private ambulance from SNF. Patient states that on Friday, she tripped and fell in doorway. Since then she has had some pain in the dorsum of her right hand. Staff only noted the swelling today. X-ray imaging results: 3 view Findings: No displaced fracture or dislocation. Alignment anatomic. Joint spaces maintained. Findings of remoted healed fracture of the base of the 5th metacarpal. Diagnosis: Fall from standing, initial encounter. Closed displaced fracture of shaft of fifth metacarpal bone of right hand, initial encounter. Likely acute or chronic fracture. Splint application. Refer to orthopedics. Please note, there is disagreement in the ER encounter, with the radiologist stating that there was no new fracture to the hand, while the ER doctor was undecided if it was an acute or chronic fracture. On 5/1/25 the Interdisciplinary Team (IDT) review states: Unwitnessed fall. Root cause: Asleep in w/c (wheelchair). Intervention: Lay dawn after meals. Intervention is effective. Signed by NHA on 5/1/25 On 5/12/25 at 10:40 AM, Surveyor observed R15 in her room asleep in her wheelchair. On 5/15/25 at 9:16 AM, Surveyor observed R15 in her room asleep in her wheelchair. On 5/15/25 at 9:33 AM, Surveyor interviewed CNA Y and asked her about laying R15 down after meals. CNA Y stated that she asked R15 that morning and that she refused. Surveyor asked CNA Y where she documents R15's refusals. CNA Y indicated that there was no place to document refusals. CNA Y stated that she didn't think that R15 had much of a fall plan because she has only had the one fall, during which she was grabbing for something, and they gave her a grabber. CNA Y stated that she had asked R15 twice to lay down after breakfast and she had refused. CNA Y indicated that she had reported the refusal to RN C. On 5/15/25 at 9:36 AM, Surveyor interviewed RN C about laying R15 down after meals. RN C stated that R15 does refuse to lay down about 50% of the time, but that CNA Y had not reported any refusals to her that morning. Surveyor asked RN C where the refusals are documented. RN C stated that she would normally enter a progress note. On 5/15/25 at 9:40 AM, Surveyor interviewed CNA Z about laying R15 down after meals. CNA Z stated that R15 will refuse to lay down after breakfast a lot, so she really encourages R15 to lay down after lunch because there is such a long time between lunch and dinner. Surveyor asked what she would do if R15 refuses to lay down. CNA Z stated that she would tell the floor nurse and the DON. On 5/15/25 at 9:45 AM, Surveyor interviewed R15 who was sitting in her room in her wheelchair. R15 stated that the staff do ask her to lie down and sometimes she does, and sometimes she doesn't. R15 indicated that staff had talked to her about the importance of laying down and that she shouldn't spend so much time sleeping in her wheelchair, but that she doesn't want to spend all day in bed. On 5/15/25 at 11:03 AM, Surveyor reviewed the Treatment Administration Record (TAR) with RN C and asked her how she knew that R15 refused to lay down 50% of the time, since it was not being documented as such. RN C stated it was just what she had heard. RN C indicated that today was the first time that the CNAs told her that R15 had refused to lay down after breakfast. Surveyor asked how she would find out if R15 refused. RN C indicated that she would rely on the CNAs to report that information to her. On 5/15/25 at 11:21 AM, Surveyor interviewed RN X about laying down R15 after meals. RN X stated that R15 will refuse to lay down about 50% of the time, especially after breakfast. Surveyor asked RN X if those refusals are documented anywhere. RN X stated that she was not sure she had ever documented a refusal. Surveyor asked RN X if refusals should be documented. RN X stated that yes, refusals should be documented either in the MAR (Medication Administration Record) or TAR or put in a progress note. On 5/15/25 at 2:22 PM, Surveyor interviewed DON B about laying down R15 after meals. DON B stated it should be on her care plan. DON B indicated that she didn't think that they triggered it for the CNAs to be able to chart on it, so she would expect the nurses to enter a progress note into the electronic health record. DON B stated that she would expect the nurse and CNA to collaborate, either the nurse to check or the CNA to tell the nurse that she refused to lay down. DON B stated that she did complete a risk versus benefits with R15 today about her being up in her chair more than an hour at a time, but that she was unaware that she was refusing to lay down after meals. Surveyor asked DON B if repeated refusals was something that she would expect the staff to communicate to her. DON B stated yes, she would have expected the staff to communicate that with her before today. Surveyor asked DON B how they are keeping R15 safe if she is asleep in her wheelchair. DON B stated that the CNAs do rounds and are checking on her throughout the day. Surveyor asked DON B if laying down after meals was an effective intervention for falling asleep in the wheelchair if she continues to refuse. DON B indicated no, that would not be an effective intervention and that they would have to talk to the staff and meet as an IDT team to revise the intervention. The facility failed to protect Residents from being transferred unsafely, failed to ensure staff are following care planned interventions or reviewing and revising the care plan to ensure interventions are appropriate.

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 1 resident (R56) reviewed for wandering and elopement potential. R56 has dementia and mild intellectual disabilities and has an Activated Power of Attorney for Health Care (APOAHC). R56 eloped from the facility on 8/5/24. The facility did not have adequate supervision to ensure they were aware of R56's whereabouts and did not have security measures and monitoring in place to ensure R56 could not access various locations in the building. R56 exited a door at the rear of the facility; the door alarm was disengaged allowing R56 to exit a door into a fenced-in courtyard and out through a gate without sounding an alarm and alerting staff R56 had exited the facility. The facility's failure to provide adequate supervision for R56 and to ensure R56 did not have a means of exiting the facility created a finding of immediate jeopardy that began on 8/5/24. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 9/25/24 at 10:55 PM. The immediate jeopardy was removed on 8/5/24, however, the deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility implements its removal plan. Findings include: The facility's policy titled, Policy & Procedure Elopement Risk and Prevention, last revised 7/15/23, states in part . Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual care plan. Procedure: 1. Residents who have been assessed at risk for elopement shall have interventions in place in their plan of care. 2. As part of the facility's Preventative Maintenance Program, all secured doors and elevator keypads (if applicable) will be checked for proper function on a weekly basis by the Maintenance department. These checks will be documented with date and time completed. 3. The Administrator and Director of Nursing will be notified immediately of any concerns with secured doors or keypads. 4. Resident's arm/leg monitor bracelet will be checked every shift for placement and daily to ensure device is functioning properly. 5. At no time shall a door alarm be turned off, without the continual supervision of the exit. In the event that the door locks/alarms of a secure unit become disabled (ex. (example) Power failure/fire alarm) the facility must ensure a temporary protective system is in place (ex. Battery activated alarm; staff monitored exits, etc.). Routine Procedure for Wandering Residents and Prevention of Missing Residents/Elopement: 1. All residents shall be reviewed for safety awareness, cognitive impairment (i.e. Dementia diagnosis, BIMS <7 (less than), and history or current risk of elopement/wandering/exit seeking upon admission, readmission, quarterly and as needed. 3. Residents who are at risk for possible elopement shall be accompanied by staff, or responsible party, when outside of the facility this would include on and off facility grounds. The facility employs a Wanderguard system attached to approximately 3 doors within the facility. The Wanderguard system will alarm when a resident with a Wanderguard tab (either on their person or wheelchair) passes through a doorway with a compatible installed alarm system. The facility uses a model of Wanderguard that is good for 1 year once activated. At the end of 1 year, a new Wanderguard tab must be placed on the resident. The Wanderguard tab has an activation date printed on it, much like an expiration date, that the Wanderguard must be activated to start the 1-year clock. Residents in the facility that are deemed elopement risks have Wanderguards. All other doors leading outside are armed with a tab alarm (a string with a magnet is attached to the door frame and a box that the magnet attaches to is connected to the door itself). When a door is opened, the magnet releases from the box causing it to alarm. R56 was originally admitted to the facility on [DATE] and has diagnoses that include dementia, alcohol abuse, mild intellectual disabilities, unspecified symptoms, and signs involving cognitive functions and awareness, unspecified fall, muscle wasting and atrophy, unsteadiness on feet, congestive heart failure (CHF), cardiomyopathy, and paroxysmal atrial fibrillation. R56's most recent Minimum Data Set (MDS), dated [DATE], indicates that R56 has a Brief Interview for Mental Status (BIMS) of 13. R56 has an activated power of attorney for healthcare. R56's MDS indicates he has no behaviors and does not wander. R56 is independent with oral hygiene, toileting hygiene, upper and lower body dressing, personal hygiene, roll left to right, sit to lying, lying to sitting, sit to stand, chair to bed transfers, toilet transfers, and walking. R56 requires setup or clean up assistance with personal hygiene and is occasionally incontinent of bowel and bladder. R56's care plan states in part . Care Plan Focus: The resident has limited physical mobility r/t (related to) CHF and deconditioning. Interventions: Ambulation/Locomotion Assist - Independent, may ambulate with no AD (assistive device) distances to tolerance WBAT (weight bear as tolerated). Date Initiated: 7/21/24. R56's Elopement Risk Assessments are documented as follows . 6/12/2024 Elopement Risk - 1 Month Low Risk 4.0 6/15/2024 Elopement Risk - Admission Low Risk 2.0 6/20/2024 Elopement Risk - Quarterly Low Risk 6.0 Progress Note from 6/18/2024 at 16:30 (4:30 PM) states, Health Status Note. Note Text: Nursing updated this writer that resident is trying to leave. Writer found resident sitting in his room in his recliner. Two adults present in res (resident) room who were introduced to this writer as old friends. The male friend explained res has been living next to them, renting from them for [AGE] years. Writer asked resident if we could talk. He agreed. Writer reiterated with resident the concern of him wanting to leave the SNF (Skilled Nursing Facility) today. He shook his head yes. Writer explained that if he were to leave today, it would be against medical advice which could follow up w/negative outcome financially and for his health. His friends agreed with this writer and also attempted to explain negative effects of leaving AMA (Against Medical Advice). Writer suggested a care conference to discuss with his care team the future plans for him. Writer explained he would be able to voice his thoughts and concerns and the team could collaborate to get him a safe and correct discharge. Resident shook his head in agreement the entire conversation as writer empathized with him regarding his current SNF stay. Writer assured him that follow-up with the social worker regarding a care conference would be done, and that writer will update him with further information when able. Writer contacted SNF SW (Social Worker) to update and request care conference. SW replied stating she would see resident tomorrow a.m. and get it scheduled. Writer updated nursing on conversation and instructed to continue to monitor. Progress Note from 6/19/2024 at 20:23 (8:23 PM). Health Status Note. Note Text: Resident more confused this shift. Calling the bar and requesting pizzas and cases of beer to be delivered. Thinks leaving tomorrow and wants to have party. Family came in and did bring small pizza and sodas. Resident relaxing in room with family. Progress Note from 6/20/2024 at 11:06 (11:06 AM). Health Status Note. Note Text: Nursing called this writer this a.m. (morning) to report resident increased agitation. Nursing reports resident has belongings packed in a bag and with him as he is demanding to leave facility. Writer instructed nursing to attempt to redirect resident and distract resident until IDT (Interdisciplinary Team) arrives. Writer instructed nursing to call resident sister as she is involved in his care. Writer arrived at facility and resident brother and sister present speaking with NP (Nurse Practitioner). DON (Director of Nursing) reported to this writer that brother and sister are requesting to have a care conference. Writer updated SW (Social Worker). SW, this writer, res (resident), his brother, and his sister present w/ (with) Physical Therapist met to discuss resident's mood, concerns, and possible activation of POA (Power of Attorney). Conversation included resident not making safe decisions and not understanding his medical conditions and his increased confusion/irritability/agitation. Sister suggested PO (by mouth) Lorazepam for increased agitation and states she believes he took this medication some time back. Sister also requested to have UA (urinalysis) done as she believes his behaviors are exacerbated. Brother and sister are in agreement that resident is not making safe decisions as far as wanting to leave. Sister is POA listed and is agreeable to activation. Therapy discussed home visit planned to happen next week and determined Wednesday would be the day that worked for everyone. Staff to make resident a calendar with dates listed of upcoming appointments, therapies, and home visit so he can see plan himself. Resident appeared calmer and more cooperative after meeting. SW asked resident if he'd be willing to have a medication as needed for anxiety and he was agreeable. Writer contacted NP and rec'd (received) new orders: 1) Lorazepam 1mg tab PO q (every) 6H (hours) PRN (as needed), anxiety; 2) UA clean catch for increased agitation and anxiety; 3) CBC w/diff (complete blood count), CMP (complete metabolic panel), Lipase, Amylase, TIBC (total iron binding capacity), B12, & TSH (thyroid-stimulating hormone), orders noted. Progress Note from 6/20/2024 at 21:21 (9:21 PM). Health Status Note. Note Text: Resident kept wanting to go outside. Writer spoke with NP and obtained order for Wanderguard. Wanderguard placed on resident left wrist. Progress Note from 6/21/2024 at 22:24 (10:24 PM). Daily Skilled Charting. Note Text: resident wandering in the hallways frequently, no exit seeking at this time, WG (Wanderguard) on arm, orient to self, seeks nurse out for tums for complains of (c/o) gas with relief, vss (vital signs stable). Progress Note from 6/22/2024 at 22:19 (10:19 PM.) Daily Skilled Charting. Note Text: Wanders halls in wheel chair [sic], calls [name of bar] nightly to order beer and pizza. Delusional, thinks he has billions of dollars coming on Friday. Receiving skilled nursing care for CHF and fluid volume overload. A&Ox3-4 (Alert and Oriented) with mild confusion r/t (Related to) hx (history) of ETOH (alcohol) use. Denies SOB (shortness of breath), trace edema to BLEs (bilateral lower extremities), no change in mental status. 1 A (assist) ADLs (activities of daily living) and transfers, no acute change in condition noted, cont (continue) plan of care. Progress Note from 6/26/2024 at 16:37 (4:37 PM). Health Status Note. Note Text: MD (medical doctor) in facility this afternoon and provided signature to POA activation form. This writer called sister [sister's name] who is listed as POA in his paperwork. Writer informed her resident is now activated. She asked, So what does this mean now? Writer informed her that resident is no longer able to make his final decisions regarding his healthcare. Writer explained that moving forward, staff will be calling her with updates and anything medically involving resident. She stated understanding and call was ended. Writer updated NP that MD was in and signed form in agreeance of activation. Progress Note from 6/30/2024 at 23:28 (11:28 PM). Incident Note. Note Text: RN [initials] witnessed resident exiting second set of doors in the front of the facility. RN [initials] immediately and quickly went out to speak with the resident. Resident stood up, RN [initials] asked resident to sit down and redirected. RN [initials] wheeled resident back into facility. A facility document titled, Elopement, dated 6/30/24 at 23:09 (11:09 PM), states in part . Incident Description: Nursing Description: RN witnessed resident outside 2nd set of front doors. Resident was in his wheelchair. Resident stood up. RN asked resident to sit and walked him in. Resident was compliant. Immediate Action Taken: RN redirected and brought resident back inside. Injuries Observed at Time of Incident: No injuries observed at time of incident. Mental Status: Oriented to Place and Oriented to Person. Predisposing Physiological Factors: Confused. Other Info: Resident unaware of situation. Habitual bar person. Talks about beer often. Plans on returning to bar ASAP (as soon as possible). Statements: RN witnessed resident outside 2nd set of front doors. RN went outside and brought resident back in. Notes: IDT (Interdisciplinary Team) reviewed event from 6/30. Resident does have activated POA however is able to make decisions. He wanted to go sit outside. This event would not be considered an elopement. Resident was in WC (wheelchair) and exited the front door, staff followed him outside with no time unsupervised. No concerns noted and was easily redirected back into the building. Resident able to state he just wanted some fresh air. Note: Facility did not complete an Elopement Risk Assessment following R56 leaving the building without staff knowledge on 6/30/24. Progress Note from 7/2/2024 at 01:15 (1:15 AM). Health Status Note. Note Text: Up wandering about the facility searching for food and soda, asks visitors, residents, and staff for beer. States waiting for the bar to fax over papers to order beer. Redirected from resident refrigerator several times. Sleeping in bed without behaviors noted since 10pm. Progress Note from 7/4/2024 at 23:20 (11:20 PM). Daily Skilled Charting. Note Text: Noted with inappropriate behavior redirected. Resident has not had any behaviors this shift. Progress Note from 7/10/2024 at 12:43 (12:43 PM). Health Status Note. Note Text: Patient discharged home this AM shift. Transported by POA/sister. Note: R56 discharged home on 7/10/24 and returned to the facility on [DATE] due to increased dementia symptoms and poor medication/health management. R56's Elopement Risk Assessment was documented as follows . 7/19/2024 Elopement Risk - Readmission Low Risk 4.0 Progress Note from 7/23/2024 at 22:53 (10:53 PM). Daily Skilled Charting. Note Text: Resident admitted to facility on 7/19/24 from home d/t an increase in dementia symptoms & poor medication/health mgmt. He is A/Ox3 with periods of confusion/agitation. Not always pleasant or cooperative. Can be non-compliant at times. Sees therapy as scheduled. Transfers 1A. WC (wheelchair) for mobility & can self-propel but is often found standing or walking. 1A w/bathing, drsg (dressing), bed mobility, PO (oral)/hygiene cares, & toileting. Continent of b&b (bowel and bladder). Skid resistant shoes on when up. Wanderguard present to L. (left) wrist. Care Plan Focus: Wander Risk Assessment per facility policy. Reassess risk periodically according to policy, initiated 7/19/24. Wanderguard placement and checks per facility policy: LEFT ANKLE, revised 7/29/24. WANDER/ ELOPEMENT RISK- Add to at risk books and lists, initiated 7/19/24. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, initiated 7/19/24. Progress Note from 8/5/2024 at 20:01 (8:01 PM). Health Status Note. Note Text: Received call from resident's family stating that resident made it back home, Writer asked if family is able to return resident to facility and family agreed, Resident was brought back to facility in 20 minutes. Resident walked back in facility, had confused speech, refers to staff members using made up names and sticks to them. Resident has Wanderguard to left wrist. Front door alarm sounded when resident returned into facility. No alarm sounded when resident left, and no staff noticed him leave. According to DON (Director of Nursing) some residents saw the resident leave the premises from the back. Resident gets comfortable walking around the facility wandering all hallways usually during the day. Resident stated that the Judge told him that he could go out of the building . The facility document titled, Elopement, dated, 8/5/24 at 15:00 (3:00 PM), states in part . Incident Description: Nursing Description: Received call from resident's family stating that resident made it back home. Writer asked if family is able to return resident to facility, and family agreed. Resident was brought back to facility in 20 mins (minutes). Resident walked back in the facility. Had confused speech. Refers to staff members using made up names and stick [sic] to them. Resident had wonder [sic] guard to left right [sic]. Front door alarm sounded when resident returned into the facility. No alarms sounded when resident left, and no staff noticed him leave. According to the DON, some residents saw resident leaving the premises from the back. Resident gets comfortable walking around in the facility wandering all hallways usually during the day. Resident stated that the judge had told him that he can go out the building. Immediate Action Taken: DON and ADON (Assistant Director of Nursing) notified immediately. NP notified as well. POA called, no answer but voicemail left. Injuries Observed at Time of Incident: No injuries observed at time of incident. Mental Status: Oriented to person. Statements: No statements found. Notes: 8/6/24, IDT team met to discuss resident elopement yesterday. He walked to his nephew's house here in town with the intent to get snacks and return. SW met with resident upon his return to facility and reeducated him that he cannot leave facility. Intervention is to have Activities offer resident to join monthly shopping trip to buy more snacks. 8/9/24, Current alarm system and Wanderguard system being reviewed. Audits in place to ensure resident informs staff if he would like to go on a leave or have family bring snacks. Investigation to root cause initiated and audits/education implemented. 8/13/24, Self-report submitted. Conclusion is that magnet on 300 door, a secondary magnet was engaged by another resident. Other resident [resident initials] admitted to using the magnet to disengage alarm. Resident [resident initials] was educated on not tampering with any alarms or security systems. Resident had an updated elopement assessment which indicated high risk. R56 Wanderguard still in place. Audits are continuing at least daily to ensure that alarms are engaged and working on all doors. Will continue to review at QAPI (Quality Assurance and Performance Improvement) to see if additional audits are needed. A new Wanderguard system is being pursued. The facility documented and reported to the state agency the incident that occurred on 8/5/24, stating, On August 5th, 2024, resident's nephew called facility and told staff that resident was at his house to visit and was wanting snacks. Resident was interviewed as to why he left. He stated that the judge (this is what he calls the Social Worker at the facility) told him he could leave facility and he went to get snacks from his family member's house. Social Services reeducated resident that he cannot leave the facility without someone accompanying him and that he must tell nursing staff where he is going and sign out. Upon investigation it was discovered that resident had exited the 300-wing lounge door into the courtyard. The alarm that was on the door was disengaged and a separate magnet was placed on the alarm so it would not sound. The magnet was taken away so it could not be used to shut off the alarm moving forward. The alarm is now re-engaged so it cannot be shut off without intervention. Separate magnet was taken away on 300 wing door so the alarm cannot be shut off without alarming and intervention. Additional details included in the report: * Skin assessment was conducted, and resident sustained no injuries and had no skin alterations. *Police were not notified due to resident being safe in facility and no evidence of a crime being committed. *Facility is continuing to investigate to ensure no other processes or protocols were violated. *Resident's last elopement assessment on 7/19/24 was low risk. *An updated elopement assessment will be conducted. *R56 had updated SLUMS (St. Louis University Mental Status), MOCA (Montreal Cognitive Assessment), and MMSE (Mini-Mental State Examination) (Cognitive tests) and overall, functionally, a moderate cognitive-linguistic impairment is identified. Specific difficulties are noted in executive functioning and reasoning/judgement, problem solving, attention, and delayed recall/memory. *Staff educated on not disengaging alarm. *Daily audits are being conducted to ensure all the exit door Wanderguard and alarm systems are working properly. Note: R56 left the facility and went to his brother's home which is approximately 0.7 miles from the facility in a residential area. The facility was unaware that R56 was not in the building until R56's brother called to report that he was at his home. R56's Elopement Risk Assessment was documented as follows . 8/12/2024 Elopement Risk - Significant Change High Risk 11.0 The care plan for R56 was updated. Care Plan Focus: The resident is an elopement risk/wanderer/at risk to leave facility without notice. 8/5/24 Purposefully left building to walk to nephews' home to get snacks and return. Date Initiated: 8/12/24. Interventions: 8/5/24 Purposefully left building to walk to nephews' home to get snacks and return. SW (Social Worker) met with resident upon his return to facility and reeducated him that he cannot leave facility. Intervention is to have Activities offer resident to join monthly shopping trip to buy more snacks, initiated 8/6/24. Monitor for exit seeking and document episodes. Interventions for exit seeking behaviors: 1) provide 1:1 and reassurance, 2) offer distraction such as activity or snack, revised 7/22/24. On 9/24/24 at 1:05 PM, Surveyor interviewed SW C (Social Worker). Surveyor asked SW C if she could tell Surveyor what she knows about R56's elopement on 8/5/24. SW C stated, I was made aware of the elopement when R56 returned. When R56 came back I did tell him he needed to let someone know if he was going to leave and sign out at the front. Surveyor asked SW C if R56 was able to leave the facility unsupervised. SW C stated, R1 does have POA - I don't believe when he left, he was able to leave on his own. Surveyor asked SW C what R56 told her during her interview with him. SW C stated, R56 and I took a walk, and he showed me how he left. He left through the courtyard. Surveyor asked SW C if there was always an alarm on the door going out to the courtyard. SW C stated, at that time don't know if there was an alarm on that door or not. There was a gate that he was able to open. Gate is locked now but was not at that time. Surveyor asked SW C if R56 had a Wanderguard at the time of his elopement. SW C stated, R56 had Wanderguard I believe at the time. Surveyor asked SW C what doors leading outside of the facility have Wanderguard alarms. SW C stated, Wanderguard doors are by the kitchen, front and lounge/TV/common area, those are the ones that I can think of. Surveyor asked SW C if she ever witnessed the 300-wing door alarm disengaged. SW C stated, they used to put a magnet up on the door to silence the alarm. Education was done after R56 eloped with staff to no longer use a magnet to disarm the alarm. Surveyor asked SW C if she knew what R56 was wearing the day he eloped. SW C stated, I am unsure what resident was wearing. On 9/23/24 at 5:40 PM, Surveyor spoke with R24 and asked if he ever used a magnet to get out the door on the 300 wing. R24 stated he had a magnet for a while that he could put on the outside door alarm to disarm it. R48 had one as well. We were trustworthy to go outside unattended. The magnets were taken away after R56 got outside into the courtyard and through the gate. On 9/24/24 at 3:10 PM, Surveyor interviewed R48. Surveyor asked R48 if he remembers an incident where he saw another resident leave the facility. R48 stated, I remember it. I was out in gazebo with a friend. They had a red magnet attached to the doorframe so if you wanted to go in or out you could use it to silence the alarm. We were on the honor system. Anyone who went out the door knew it was there to use. It was hot that day. Surveyor asked R48 if he remembers what time this occurred. R48 stated, my friend comes at 1:00 PM and leaves around 3:00 PM. We had been out there a half hour to an hour before R56 came out. I have seen him out there multiple times. R56 used to be in wheelchair, would wheel over to the gate, stand up take his shirt off and wave it over his head, sit back down and come back in. R48 stated, this day, R56 went to the gate let himself out, walked along the edge of the property along the fence till out of view. Then 45 minutes to an hour later the DON came out looking for him and asked if we had seen him. R56 had a Wanderguard placed because he would exit the building frequently and we were short staffed then. R56 would be at the end of the lot before someone got out there to bring him back. We are all being penalized now. We can't go out without setting the alarm off and before we could go out on our own recognizance. On 9/24/24 at 11:50 AM, Surveyor interviewed Activity Aide K. Surveyor asked Activity Aide K if she uses or has seen anyone use the magnet on the 300-wing door. Activity Aide K stated, I use a red magnet when I take residents out to the gazebo area for organized activities. This makes it so I can open the door from outside and inside without the alarm going off. The magnet is now kept in the front office. It was on the door frame before. On 9/24/24 at 11:55 AM, Activity Aide K came back to speak with Surveyor stating, I was wrong, we no longer use the red magnet. On 9/24/24 at 1:32 PM, DON B (Director of Nursing) and NHA A came into the conference room to report to Surveyor that they believe that R56 returned about 3:00 PM. R56 was last seen by R48 and his family. R48 saw the resident leave but they did not report this to anyone, but they saw R56 leave through the courtyard gate. Surveyor asked DON B if the gate was open or closed. NHA A states, we were unable to establish if the gate was open but normally it is closed so we assumed R56 opened it. We also have a new Wanderguard system being installed as we speak, they started working on it yesterday. All doors will have Wanderguard alarms. Surveyor asked NHA A if there were any other doors that she was aware of that had magnets on them to silence the alarm. NHA A stated, that was the only door with a magnet. The gate on the fenced in area is now locked and we will also be getting, at some point, new fencing that I believe will also be alarmed if someone tries to exit it. Additional Progress Notes for R56: Progress Note from 8/10/2024 at 10:14. Daily Skilled Note. Note Text: Resident has been pleasant this shift, has confused speech. Resident wanders the hallways. Progress Note from 8/10/2024 at 19:38 (7:38 PM). Health Status Note. Note Text: Resident attempted to get out of the building a few times. Was redirected by staff and resident was able to turn his focus on something else and behavior stopped. Wanderguard on left wrist. Progress Note from 8/27/2024 at 12:37. Daily Skilled Note. Note Text: Patient at baseline able to make needs known. Minimal wandering this shift redirectable. On 9/23/24 at 2:15 PM, Surveyor observed R56 in his room, lying in bed. R56 sat up independently. R56 is noted to have a Wanderguard on his left wrist. On 9/23/24 at 7:15 PM, Surveyor interviewed FM/POA F (Family Member/Power of Attorney). FM/POA F stated, R56 is a bachelor and always lived alone with his dog. R56 has lived in the community all his life and has a history of walking all over town with his dog. R56 has some intellectual deficits and sometimes needs help, has been this way his entire life. R56 had been at the facility in June and discharged early July, he lives in an upper apartment, 21 steps, and he did not do well at home by himself; he did not take his meds and ended up back at the hospital. R56 then readmitted to the facility from the hospital due to weakness and needing more therapy. R56 was in a wheelchair when he first returned to the facility. R56 would go throughout the facility, sometimes he sat out front of the building and the staff would bring R56 back in. In August R56 left the facility and walked to his brother's home, it is about 3 - 4 blocks from the facility. I think he probably cut through yards to get there. He showed up at the house looking for snacks and his brother called the facility to say he was there and were taking him to get snacks and would bring him back. On 9/24/24 at 8:35 AM, Surveyor interviewed LPN G (Licensed Practical Nurse). Surveyor asked LPN G if R56 was known to wander. LPN G stated, initially there was no wandering then once R56 cleared and became clearer he attempted to elope and a Wanderguard was placed as an intervention. During his first stay R56 would sit out front. He went home then and then came back as he did not do well at home. R56 was readmitted to the 400 unit. R56 absolutely has cognitive issues. Prior to admission was very active in the community, would walk around town with his dog all day long. On 9/24/24 at 8:45 AM, Surveyor interviewed CNA H (Certified Nursing Assistant). Surveyor asked CNA H if R56 wanders in the facility or attempts to leave the facility. CNA H stated, in the morning R56 is usually out walking around. R56 spends a decent amount of time in his room. I have never heard that he was at risk for elopement. I am also not aware of R56 ever eloping from the facility. Surveyor asked CNA H where she would locate the information that a resident was at risk for wandering. CNA H stated, I would look for that information on the CNA sheets. It should say the resident has a Wanderguard or that they are a wanderer. On 9/24/24 at 1:32 PM, Surveyor asked NHA A if facility has a way for monitoring Wanderguard expiration dates. NHA A stated, it is not in MAR/TAR (Medication Administration record/Treatment Administration Record) to check the Wanderguard expiration date but would expect that to be done. Surveyor asked NHA A if the facility completed any education with staff on the gate. NHA A stated, no, not specifically the gate. Surveyor asked NHA A if any education was completed with residents on the magnet or exit doors. NHA A stated, no, we did not specifically educate residents on magnet or door, at least nothing formally. NHA brought in copies of audits completed on doors, audits started 8/9/24 and continue. On 9/24/24 at 2:30 PM, Surveyor went into front office to ask NHA A to check doors with Surveyor. RDC D (Regional Director of Clinical Services) stated, we are now adding the Wanderguard expiration dates to the MAR/TAR as an extra check. Medical Records has been keeping track of the expiration dates as she is the one that orders them. Wanderguards used are good for 1 year. On 9/24/24 at 2:45PM, NHA A and Surveyor checked all doors. All alarms in place and functioning. Surveyor notes gate is secured with chain and padlock. On 9/24/24 at 3:00 PM, Surveyor reviewed the facility elopement binder. All residents listed by the facility as being at risk for elopement were identified in the binder. The facility was aware that R56 was at risk for elopement and had gotten outside the building on 6/30/24. The facility documented this event and placed a Wanderguard on R56 but did not consider it an elopement and reassess R56 at that time. R56 continued to exhibit wandering behavior, including stating to staff that he was leaving. The facility did not put measures into pl [TRUNCATED]

Based on observation, interview and record review the facility did not ensure that residents admitted without a pressure injury (PI) did not develop pressure injuries unless clinically unavoidable and did not ensure residents are provided cares and services consistent with professional standards of practice to prevent the development of PI for 1 of 5 residents (R14) reviewed for pressure injuries. R14 developed a stage 3 PI behind his left ear. The facility failed to implement pressure relieving interventions prior to R14 developing a PI. Evidenced by: The AMDA (American Medical Directors Association) clinical practice guideline entitled, '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 serosanguinous 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. Category/Stage IV: Full thickness tissue loss - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. 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. Suspected Deep Tissue Injury (DTI) - depth unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The facility's policy titled Pressure Injury Prevention and Wound Care Management last revised on 3/4/24 states in part, .A complete assessment is essential to an effective pressure injury preventions and treatment program. A comprehensive assessment helps the facility to identify residents at risk of developing pressure ulcers, as well as the level and nature of their risks .4. The clinicians responsible for the residents' care will review risk factors and identify whether and to what extent those risks can be modified, stabilized, or removed .9. Daily, the clinicians responsible for caring for the Resident will assess the status of the dressing if present (intact, soiled, leaking) and evaluate for complications such as infection and/ or uncontrolled pain . It is important to note that the facility's policy does not address device related pressure injuries. R14 was admitted to the facility on [DATE] with diagnoses that include acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF). R14's most recent MDS (Minimum Data Set) dated 9/11/24 states that R14 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R14 is cognitively intact. R14's physician orders for left ear wound care are as follows: 9/14/24: Apply skin prep to affected area on left ear q (every) shift and padding to oxygen tubbing until healed. Every shift for skin sore. 9/19/24: Wound care L ear: cleanse with wound cleanser, pat dry, apply hydrocolloid sheet (thin) every day shift every 3 day(s) for skin sore. (a hydrocolloid sheet is a thin dressing that is waterproof and provides a moist environment to promote wound healing.) R14's care plan initiated on 7/28/22 and revised on 9/22/24 states in part: .I am at risk for alteration in skin integrity related to: hx (history) of previous amputation, immobility secondary to spina bifida, obesity, and CHF, risk for altered gas exchange due to COPD, risk for loss of sensation in lower extremity due to DM, bladder incontinence, refusals to reposition, risk for bleeding due to chronic anticoagulant medication use, lower extremity edema due to lymphedema, risk for MASD (Moisture Associated Skin Damage) due to colostomy, risk for pressure injury due to oxygen tubing, sedentary lifestyle .Goal: I will be free from skin breakdown through the next review date .Interventions: * 9/14/24 padding to oxygen tubing. * 9/14/24 tx (treatment) as ordered . It is important to note that prior to 9/14/24, R14's care plan did not include any interventions to prevent a device related pressure injury due to R14's continuous oxygen use. Nurse's notes state the following: 9/14/24 at 2:15 PM: New skin concern noted behind pt. (patient) left ear. Pt. reports from oxygen tubing. On-call MD (Medical Doctor) notified. New orders obtained, apply skin prep & oxygen tube padding until healed. On-call RN (Registered Nurse) updated, risk management completed. Risk Management documentation is as follows: 9/14/24 at 2:18 PM: Incident description: Nursing description: CNA (Certified Nursing Assistant) reported sore behind pt. left ear. This writer evaluated pt ears and noticed breakdown present behind left ear. Resident description: Pt. reports sore is from oxygen tubing .Immediate Action Taken: Description: Applied barrier between oxygen tubing and pt. left ear, notified on-call MD [MD name], obtained order for skin prep q (each) shift and padding to oxygen tube . It is important to note that there was no documentation of wound characteristics, measurements, or drainage consistency/ amount in neither the nurse's notes nor the Risk Management documentation. Additionally, there was no documentation on the wound from 9/14/24 when it was discovered, until 9/16/24. Skin and Wound Evaluation documentation is as follows: 9/16/24: A. Describe 1. Type: 15. Pressure 15a. Stage: 3. Stage 3: Full- thickness skin loss. 22. Location: Rear Left Ear 23. Acquired: 1. In- House Acquired. 24. How long has the wound been present .24a. Exact Date: 9/14/24 .Wound Measurements: 1. Area: 0.3 cm2 (centimeters) 2. Length: 1.6 cm 3. Width: 0.3 cm 4. Depth: 0.1 cm .C. Wound Bed: .2. Granulation 2a. % of granulation: 1. 100% of wound filled .D. Exudate (drainage): 1. Amount: 2. Light .H. Treatment: .2. Cleansing Solution: 11. Generic wound cleanser .4. Primary Dressing: 8. Film/ Membrane . 9/19/24: A. Describe 1. Type: 15. Pressure 15a. Stage: 3. Stage 3: Full- thickness skin loss. 22. Location: Rear Left Ear 23. Acquired: 1. In- House Acquired. 24. How long has the wound been present .24a. Exact Date: 9/14/24 .Wound Measurements: 1. Area: < 0.1 cm2 (centimeters) 2. Length: 0.5 cm 3. Width: 0.1 cm 4. Depth: 0.1 cm .C. Wound Bed: .2. Granulation 2a. % of granulation: 1. 100% of wound filled .D. Exudate (drainage): 1. Amount: 2. Light 2. Type: Serosanguineous (both blood and serum drainage) .H. Treatment: .2. Cleansing Solution: 11. Generic wound cleanser .4. Primary Dressing: 8. Hydrocolloid . On 9/23/24 at 11:20 AM, Surveyor observed R14 without padding to his oxygen tubing. On 9/24/24 at 2:10 PM, Surveyor observed R14 without padding to his oxygen tubing. On 9/25/24 at 8:41 AM, Surveyor observed R14 without padding to his oxygen tubing. On 9/24/24 at 2:10 PM, Surveyor observed wound care with DON B (Director of Nursing). Wound care was completed as ordered, but no padding was noted on R14's oxygen tubing. After wound care was completed, Surveyor asked DON B if she would have expected nurses to documents assessments of the area once it was identified, DON B stated yes. Surveyor asked DON B if she was able to find any documentation or assessments, DON B stated no. Surveyor asked DON B when the wound was identified as a stage 3, DON B stated that when she looked at it on 9/16/24, it was a stage 3. Surveyor asked DON B if R14 should have padding on his oxygen tubing, DON B stated yes and that there was not any on there currently. On 9/25/24 at 8:41 AM, Surveyor interviewed R14. Surveyor asked R14 when he started to have pain behind his ear, R14 stated that his ear started hurting months ago. Surveyor asked R14 if he currently has padding on his oxygen tubing, R14 stated no and reported that the padding does not stay on very well. Surveyor asked R14 if nurses check his skin on shower days, R14 stated yes, but they don't always check behind my ears. On 9/26/24 at 9:19 AM, Surveyor interviewed LPN N (Licensed Practical Nurse). Surveyor asked LPN N how she was made aware of the wound behind R14's ear, LPN N stated that she didn't remember. Surveyor asked LPN N what the wound looked like and if the area was open, LPN N stated that it was pressure from the oxygen tubing but was unable to recall if the area was open. Surveyor asked LPN N what the wound area looked like; LPN N stated that there was an indentation from where the tubing was. Surveyor asked LPN N if she documented any characteristics of the wound, LPN N stated that she did not think so. Surveyor asked LPN N what color the area was, LPN N stated that she would not give a definite color. Surveyor asked LPN N if she measured the wound, LPN N stated that she couldn't remember. The facility failed to implement interventions to prevent device related pressure injuries and failed to implement interventions once R14 acquired a pressure injury. Additionally, the facility failed to gather data according to standards of practice when a resident obtains a new pressure injury.

Based on interview and record review, the facility did not ensure that each staff implemented proper safety interventions as directed by a resident's plan of care and did not ensure residents were free from accidents and hazards for 1 of 3 residents (R1) reviewed for falls. On [DATE], a Certified Nursing Assistant (CNA) attempted to provide care to R1 without maintaining the proper safety interventions as directed in R1's care plan. R1 rolled off the bed, falling approximately 2 feet and hitting his head. Facility staff picked up R1 off the floor and placed him in bed before the Registered Nurse (RN) could arrive on the scene to assess R1 for possible injuries. R1 was sent to the hospital where he was found to have suffered a fractured neck, resulting in his death. This created a finding of immediate jeopardy that began on [DATE]. The facility's failure to ensure staff follow proper safety interventions to prevent accidents created a finding of Immediate Jeopardy that began on [DATE]. Surveyor notified INHA C (Interim Nursing Home Administrator) of the Immediate Jeopardy on [DATE] at 3:20 PM. The Immediate Jeopardy was removed on [DATE]; however, the deficient practice continues at a scope/severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. R1 was admitted to the facility with diagnoses that include: hemiplegia and hemiparesis following cerebral infarction, aphasia, convulsions, dysphagia, right ankle and foot contractures, and tremors. R1 is not ambulatory, is nothing per oral (NPO), and is nonverbal. R1's care plan states he is dependent on two staff for dressing (dated [DATE]), toilet use (dated [DATE]), personal and oral hygiene (dated [DATE]), and transfers (dated [DATE]). R1's comprehensive care plan and Kardex (CNA care plan), dated [DATE], state, Bed mobility/Assist-Dependent on 2 staff. Bed to be positioned in lowest possible position with fall mat in place when resident in bed. Ensure resident is positioned in the middle of the bed for comfort and safety. Additionally, R1's care plan states, Is at risk for falls .Bed to be positioned in lowest possible position with fall mat in place when resident in bed ([DATE]) .body pillows and/or support device (pillow wedges) bilaterally in place when resident is in bed to assist with proper body position and comfort. ([DATE]) The facility uses the Morse fall scale to determine if a resident is at risk for falls. A [DATE] Morse fall scale assessment for R1 shows a score of 30, indicating R1 is at moderate risk for falling. On [DATE] at approximately 4:00 PM, R1 experienced a fall from his bed. The fall report, documented by LPN D (Licensed Practical Nurse), states, 2 CNAs were putting resident to bed using the Hoyer lift, after he was in bed the second CNA had left. The first CNA (CNA E) turned to get the fall mat and resident crossed his legs quickly and rolled out of the bed to the floor . The facility contacted EMS (Emergency Management Services) emergently. According to EMS records, EMS arrived at the facility at 4:12 PM, then arrived at the hospital at 5:17 PM. Of note, the EMS report for the transfer states that R1's bed was at a height of approximately 2 feet off the ground when they arrived to R1's room. At the hospital, R1 was found to have a fractured C7 lamina (cervical, base of the neck). Hospital notes indicate R1 had a witnessed aspiration event (at the hospital) with significant respiratory compromise. According to hospital records, R1 expired on [DATE] due to hypoxemic respiratory failure due to 1) massive aspiration with complete left lung opacification 2) septic shock and 3) right C7 lamina/facet fracture from fall at skilled nursing facility prior to transfer (which required rigid c-spine collar). Following the fall, the facility's interdisciplinary team (IDT) met and documented the following dated [DATE]: IDT team met to review the witnessed fall that occurred on [DATE] when resident rolled himself out of bed when the CNA turned his back to reach for the fall mat. Resident's bed was low, call light clipped near him on the bed, two CNAs had gotten him into bed when the second CNA left, the first CNA turned to reach for the fall mat and resident crossed his legs and flipped himself to the floor. The CNA called for the nurse and then 911 and was left on the floor for the EMT to assess and get onto the gurney. Root cause of the fall was the inability to stop the motion once started when he crossed his legs his body followed. Intervention both CNAs to complete all cares together. The facility did not provide any other investigation notes, statements, vitals, or assessments of R1 regarding the fall. Surveyors conducted the following interviews on [DATE]: *At 11:40 AM, LPN D stated that on [DATE] she was called to the room by CNA E and then saw R1 on the floor on his stomach. LPN D then called RN F. LPN D stated she, CNA E, and CNA G lifted R1 off the floor before RN F arrived because he was moving in a way that she had never seen before and that he appeared to be in pain. *At 1:40 PM, CNA G stated that on [DATE], CNA E came out into the hall and requested help. When she got to R1's room she saw R1 on the floor on his stomach and then LPN D came to the room. CNA G stated she, LPN D, and CNA E then picked R1 up and put him back into bed. CNA G stated she and CNA E held the shoulders and LPN D held the legs and they lifted him into bed. According to CNA G, shortly after R1 was put back into bed, RN F came into the room and stated that they should not have gotten R1 off the floor until an appropriate assessment was made. CNA G stated that when they rolled R1 over, there was blood gushing from his head. Additionally, CNA G stated the bed was at about knee height when she got to the room and was not all the way to the floor and R1's wedges were not positioned in his bed. CNA G stated the wedges may have been on his chair or at the foot of the bed, but were not in place. CNA G also stated that she would normally provide cares for R1 by herself. The only time she needed help is with transfers. *At 2:39 PM, CNA H stated she had worked with R1 in the past and he frequently kicks his one leg over the other, so he could fall off the bed if left unattended. CNA H also stated that she has provided cares to R1 by herself in the past but would ask for assistance if R1 would clench his legs or be swinging them. *At 3:37 PM, CNA I stated that R1 would frequently lean toward 1 side of the bed and the wedges helped position him correctly and that the wedges were to go under his bed sheet. Surveyors conducted the following interviews on [DATE]: *At 3:00 PM, CNA J stated that 4 wedges were used for R1's positioning to keep him in the middle of the bed. Additionally, CNA J stated R1 would frequently [NAME] one leg over the other and she was concerned he would fall out of bed. *At 3:04 PM, RN F stated that on [DATE] when she responded to R1's room, he was already in bed and she was concerned that staff had moved him. RN F stated that she got there as quick as she could and they hurried before she could respond. RN F stated that she did do vitals and an assessment and usually puts those into the computer, but did not do so on this night. Surveyors interviewed all nursing staff who worked during the time of the incident - LPN D, RN F, LPN K, CNA G, CNA H, CNA I, and CNA J. All stated they had not assisted CNA E with transferring R1 into bed before he had fallen out, nor were any of these staff aware of who assisted CNA E. Surveyor was unable to speak with CNA E. None of the staff who were interviewed by Surveyor had been questioned by the facility about the incident or provided statements and did not receive any education regarding the event. CNA G, CNA H, CNA I, and CNA J all stated that the wedges for R1 were used to help keep him positioned in the middle of the bed. On [DATE] at 8:34 AM, DON B (Director of Nursing) and INHA C (Interim Nursing Home Administrator) stated to surveyors that they had spoken to CNA E late the previous day ([DATE]) and CNA E stated that he was sticking to his story that he had turned his back briefly to R1 and that is when R1 rolled out of bed. Additionally, CNA E had told DON B and INHA C that he does not recall who it was that assisted him with initially getting R1 into bed, nor what the person looked like. INHA C stated that the incident should have been reported as potential abuse as it is unknown how R1 got to the floor and CNA E was the only one in the room. DON B stated that she did not gather any statements other than CNA E's because she considered it a witnessed event. DON B stated that she did not know the details of the fall, such as what the height of the bed was at the time, if other interventions were in place, such as R1's wedges, but an investigation probably would have revealed such information. DON B stated that it is her expectation that if there is an RN in the building, residents should not be moved off the floor until they are assessed by the RN for any signs of injuries. DON B stated that the new intervention of both CNAs to complete all cares together was different than R1's care plan for two (2) staff needed for bed mobility and assist. When asked if she considered bed mobility and the placement of the wedges for proper positioning as cares, DON B stated, Yes. The failure to ensure staff follow proper safety interventions to prevent accidents created a finding of Immediate Jeopardy that began on [DATE]. The facility removed the immediate jeopardy on [DATE] when it had completed the following: ~The facility initiated an investigation and submitted to the state agency. The local police department was notified of suspected neglect and/or abuse. ~A house sweep was conducted to ensure all fall interventions, as indicated on the written plan of care, were in place. Any adverse findings were immediately addressed. ~Risk Management was reviewed to identify residents that had experienced a fall between [DATE] and [DATE] to ensure a thorough investigation was completed to determine root cause and implement new interventions appropriate to prevent reoccurrence. Any adverse findings were immediately addressed. ~On [DATE], education began each shift with nursing personnel regarding Risk Management (Falls) Policies and Procedures; this education included, but was not limited to review of the following: *Not turning ones back to a resident until resident has all care planned interventions in place. *Following residents written plan of care; ensuring interventions established to reduce risk for fall and/or significant injury are in place as indicated on written plan of care. *Per Post Fall Policy, a resident should not be moved from current position, post fall, until licensed nurse collects necessary data to ensure resident is safe to move. *Residents who are deemed safe to move post fall, per a licensed nurse, should be transferred via Hoyer Lift. Staff should not arm/leg lift a resident into bed. *Residents are to be transferred per their written plan of care. *The Interdisciplinary Team was educated on Risk Management (Falls); specifically, as it pertains to the expectation for the team to complete thorough investigations post fall. The purpose of this investigation is to determine root cause and implement new interventions appropriate to prevent reoccurrence. ~ Administrator and/or designee will audit the compliance of this plan via random staff/resident interviews, environmental observation(s), and examination of Risk Management Reports. Findings and trends will be reported to QAPI Committee and Corporate Compliance for further review and consideration.

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 3 (R3) sampled residents. R3 had a diagnosis of CHF (Congestive Heart Failure). The facility failed to complete comprehensive assessments for R3 including daily weights and monitoring edema, resulting in repeated hospitalization s. Evidenced by: According to an article from The National Library of Medicine titled Congestive Heart Failure (Nursing) last updated 11/5/23, .Monitoring: Patients with HF require frequent monitoring of vital signs, including oxygen saturation .Frequent assessment and monitoring for symptoms is also indicated. All patients with HF require daily weight monitoring . Congestive Heart Failure (Nursing) - StatPearls - NCBI Bookshelf (nih.gov) According to the article by 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 The facility's policy Resident Height and Weight last reviewed on 7/7/23 states in part: .6. Weekly or daily weights are recommended if any of the following are present: .e. Unstable CHF or significant edema . Example 1: R3 was initially admitted to the facility on [DATE] with diagnoses that included acute on chronic respiratory failure with hypoxia, anxiety, depression, COPD (Chronic Obstructive Pulmonary Disease), and CHF. R3's physician orders included Bumetanide (a diuretic) 2mg (milligrams) Give one tablet by mouth daily. Start date: 6/13/23, End date: 6/21/23. R3's physician orders for weights are as follows: ~7/17/23: Weight daily in the morning after going to the bathroom and before breakfast - if you gain 3 or more pounds in one day or 5 pounds in a week, call Heart Failure Clinic. One time a day. ~8/17/23- Admission weight procedure - weigh upon admission and for 2 days after admission, then weekly for 3 weeks, then monthly unless otherwise ordered. Update dietician and MD (Medical Doctor)/ NP (Nurse Practitioner) with any significant weight changes. R3's care plan dated 8/29/23 states in part: Focus: The resident has Congestive Heart Failure, HTN (hypertension), A-Fib (Atrial Fibrillation), anemia. Interventions: .Monitor/document/report PRN (as needed) and s/sx (signs/symptoms) of Congestive Heart Failure: dependent edema of legs and feet, periorbital edema, SOB (Shortness of Breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to nutrition, crackles and wheezes upon auscultation of the lungs, Orthopnea (shortness of breath when laying flat), weakness and/or fatigue, increased heart rate (Tachycardia), lethargy and disorientation . On 6/27/23 and 7/14/23, R3 had a visit with the Cardiology NP. R3's After Visit Summary included the following orders: .1. Weigh yourself daily in the morning after going to the bathroom and before breakfast - if you gain 3 or more pounds in one day or 5 pounds in a week, call Heart Failure Clinic. 2. Check for swelling in your feet, legs, and abdomen. Call Heart Failure Clinic if you notice increase in swelling. 3. Are you experiencing shortness in breath? Call Heart Failure Clinic if you notice worsening shortness of breath with activity or shortness of breath when you are lying down . Additionally written on R3's After Visit Summary on 7/14/23 was a handwritten note indicating that R3's next appointment was scheduled for 8/8/23 at 1:30 PM. On 8/11/23, R3 was sent to the hospital and was diagnosed with acute on chronic respiratory failure with hypoxia, dyspnea, fatigue, and rhinovirus. R3 was discharged from the hospital on 8/17/23 and returned to the facility. It is important to note that the facility did not reinstate R3's daily weights when readmitted to the facility. R3's weights are as follows: 8/17/23: 167 lbs. (pounds) 8/18/23: 165 lbs. 8/19/23: no weight 8/20/23: no weight 8/21/23: 166 lbs. 8/22/23: 166 lbs. 9/1/23: 165.5 lbs. On 9/1/23, R3 was sent to the hospital. The hospital H&P (History and Physical) states in part: .He reports about 1-2 days ago he developed worsening productive cough, SOB (shortness of breath), and chest pain with coughing .R3 was noted to have a BNP (Brain natriuretic peptide (blood test that measures heart failure) of 2778 (Reference Range for BNP is <=450 pg/mland); 1+ edema in BLE (Bilateral Lower Extremities) and his weight was 170 lbs. During this hospitalization , R3 was diagnosed with COPD exacerbation and was additionally treated for chronic HFpEF (Heart Failure with preserved Ejection Fraction; the hospital was treating R3 with Bumex 2 mg daily, Potassium 20mEq (milliequivalents), Dapagliflozin 10 mg daily, I&Os (Intake and Outputs) and daily weights. R3 returned to the facility on [DATE]. The facility had not obtained R3's weight upon readmission on 9/3/23 or 9/4/23. R3's weight were as follows: 9/5/23: 165 lbs. 9/12/23: 169.5 lbs. 10/1/23: 168.2 lbs. 11/1/23: 173 lbs. 12/1/23: 171 lbs. 1/11/24: 175 lbs. There is no documentation indicating that the physician, nurse practitioner and/or the Heart Failure clinic were updated that R3 had a 4.5 lb. weight gain between 9/5/23 and 9/12/23, a 4.8 lb. weight gain between 10/1/23 and 11/1/23, and a 4 lb. weight gain between 12/1/23 and 1/11/24. On 11/29/23, R3 had a fall and was found sitting on the floor next to his bed. Nurse's notes indicate that R3 had removed his oxygen and his oxygen level was at 77%, blood pressure 117/64, respiratory rate 20, temperature 97.7, and pulse was 118. On 11/30/23, Nurse's note states .Resident has edema noted. Resident has diminished pedal pulses . On 12/7/23, Nurse's note states .Resident has edema noted. Resident has peripheral edema . On 12/10/23, Nurse's note states pt (patient) up in w/c (wheelchair), in no acute distress, c/o (complaining of) sudden sub-sternal non-specific CP (chest pain) described as sharp, no radiation. Pain increases with deep breathing no significant SOB, increased anxiety noted, 101/63, HR (heart rate) 86, sat 94%, RR (respiratory rate) 22, O2 (oxygen) at 3L (liters), neb (nebulizer) treatment given along with scheduled loraz (lorazepam) and digoxin. Lung sounds clear throughout, continue to closely monitor pt at this time for any increase/change in pain or other symptoms. Pts primary nurse for this shift will follow up as needed. There is no documentation indicating R3's physician or nurse practitioner were updated on R3's condition, nor is there any follow up documentation until 12/14/23. Additionally, there is no documentation on R3's edema status or a weight being taken since 12/1/23. On 12/14/23, Nurse's note states .Resident has edema noted . The vital signs listed in this same note were not obtained as follows: Temperature 97.0 dated 12/12/23, Pulse 104 dated 12/13/23, Respirations 18 dated 12/12/23 Blood Pressure 122/82 dated 12/7/23, O2 91% dated 12/12/23. On 12/29/23, Nurse's note states .resident c/o no [sic] feeling well by the therapy department. Resident complaint of headache. Writer noted resident had increased fatigue and SP2 [sic] (oxygen level) 89 on 2.5 L O2. Writer increased O2 to 3.5 L with good effect. Rapid COVID test administered and resident positive for COVID . There was no respiratory or cardiovascular assessment completed. On 12/31/23, COVID-19 note states Vital signs: BP: 120/78 (dated 12/29/23), Temp 97.9 Pulse: 60 bpm (beats per minute), Weight 171 lbs. (dated 12/1/23), Resp: 18, BS (blood sugar) 102mg/dl (dated 11/12/23), O2: 96% .Active COVID Symptoms .cough. Current interventions and effectiveness: Slept in recliner through NOC (night), denies SOB or pain, cough remains, Isolation maintained. It is important to note that in the initial COVID note on 12/29/23, it is not documented that R3 had a cough. On 1/1/24, COVID-19 note states, Vital signs: BP: 132/70, Temp: 98.2, Pulse: 90, Resp: 18, O2: 93% .Active COVID symptoms .cough, agitation . On 1/2/24, COVID-19 note states, Vital Signs: VSS (Vital Signs Stable) .Active COVID Symptoms .none .Current interventions and effectiveness: vss monitoring and isolation precautions. On 1/2/24 at 2:42 PM, Health Status note states, Resident called writer to room with complaints of not being able to breathe. Writer checked O2 sat - 71%. Writer gave resident nebulizer treatment and 2 puff albuterol. Rechecked O2 sat - 76%. Spoke with [NP] and decided to send resident to hospital. Sent resident 911 . There is no documentation indicating that facility staff assessed R3's respiratory status or cardiovascular status since being diagnosed with COVID-19. R3's weight had not been obtained since 12/1/23. R3's hospital notes dated 1/2/24 state in part: [R3] presents to the emergency department for evaluation of shortness of breath. The patient reports that his symptoms have been present for the past week. Currently lives at a nursing facility. Was recently diagnosed with COVID-19. Sent to emergency department for evaluation of shortness of breath. No chest pain. Does have intermittent cough. Also notes lower extremity edema .BNP 4,536 R3 returned from the hospital on 1/2/23 with diagnosis of acute on chronic congestive heart failure. There is no documentation indicating that the facility performed an assessment on R3 when he returned from the hospital. No weight was obtained. On 1/3/24, COVID-19 note states, .VSS, afebrile. Active COVID Symptoms .Lungs clear, diminished in bases. SOB. In [sic] 3L O2, O2 sats 96% .Current interventions and effectiveness: Monitor VS and lung sounds. Maintain isolation precautions. On 1/3/24, COVID-19 note states, Vital Signs: 98/60 (dated 1/2/24), Temp: 97.5, Pulse: 75 bpm, Weight: 171 lbs. (dated 12/1/23) Resp: 18 .O2: 99% .Active COVID Symptoms .asymptomatic . On 1/4/24, Health Status note states, At about 9:30 AM, writer was called to resident's room by another nurse and notified that resident just had a fall and was still on the floor. Writer rushed to resident's room, found resident on the floor with DON (Director of Nursing) right next to resident. Pt was actively bleeding as he was lying on his left side on the floor. Vitals taken .Resident was transported to the hospital. VS taken; resident is on 2L nasal cannula . It is important to note that between R3's hospitalization on [DATE] and 1/4/24, facility staff did not assess R3's edema, obtain a weight, or complete a comprehensive assessment of R3's respiratory or cardiovascular status. R3's ED (Emergency Department) note dated 1/4/24, states in part: .Medical Decision-Making/ED Course/Plan .[R3] with acute hypoxic respiratory failure with hypercarbia (increase in carbon dioxide in the bloodstream). Decision to put patient on BiPAP (a machine used to help push air into your lungs) to help with gas exchange. COVID negative which is contrary to triage note .Chest x-ray does show some degree of vascular congestion as well as left-sided pleural effusion and patient does have a BNP greater than 500. Suspect some degree of slight volume overload. Gentle diuresis .Should improve with BiPAP . In addition to being placed on BiPAP, R3 received Lasix (diuretic) 20mg IV (intravenously) in the ED. R3's hospital discharge summary dated 1/11/24 states in part: .Principal Diagnosis: 1. Acute exacerbation of HFpEF (Heart Failure with Preserved Ejection Fraction) 2. Acute on chronic (2L) Chronic Hypoxic Respiratory Failure 3. Aspiration Pneumonia 4. AECOPD (Acute Exacerbation of Chronic Obstructive Pulmonary Disease) .in the ED, [R3] O2 sat was 84% and improved to 98% on 4L O2. Labs were notable for a BUN (measures the amount of urea nitrogen found in your blood) 29, Cr (creatinine) 1.5 (baseline 0.8), BNP 593, and lactic acid 3 .Repeat COVID test was negative. [R3] CXR (Chest x-ray) revealed cardiomegaly (enlarged heart) with moderate pulmonary vascular congestion and a left lung base opacity .[R3] was given IV Lasix 20mg . On 1/11/24, Health Status note states, Resident returned via ambulance from [hospital] after being treated for hypoxia and asp. (aspiration) pneumonia and post covid; vss; O2 on at 2L per n/c (nasal canula), able to make needs known, eating snacks at nurses desk. R3 returned to the facility on [DATE]. Documentation provided to Surveyor by the facility indicates that there was no comprehensive assessment completed on R3 upon his return. Additionally, the Health Status note does not identify that R3 was in the hospital for an exacerbation of HFpEF. On 1/12/24, nurse's note states, .VSS, LSC (lung sounds clear) with occasional productive cough .Cont. (Continue) o2 at 2 liters, SPO2 stable, no SOB observed . On 1/13/24, nurse's note states, Resident with sob and fatigue at times when o2 tank depleted, desats to 68% and then sats increase to 88% on 2L per n/c; often resident takes o2 off and propels down the hallway needing frequent redirection from staff. VSS. On 1/14/24, nurse's note states in part, A&O (alert and orientated) x 2-3 with periods of confusion and forgetfulness, able to make needs known .VSS, LSCTA (lung sounds clear to auscultation) after cough and deep breathe . On 1/15/24, R3 had another fall after tripping on his oxygen tubing and was sent to the ED for further evaluation of the hematoma on the top of his head. R3 did not return to the facility. It is important to note that there is no documentation indicating that facility staff assessed R3's edema after his return from the hospital on 1/11/24 and had not obtained a weight since 1/11/24. On 1/30/24 at 11:59 AM, Surveyor interviewed CNA M (Certified Nursing Assistant). Surveyor asked CNA M how she knows what weights are due for the day? CNA M stated that the nurses print out a list for them, or they will tell them. On 1/30/24 at 12:00 PM, Surveyor interviewed LPN D (Licensed Practical Nurse). Surveyor asked LPN D how the nurses know what weights are due for the day? LPN D stated that the night shift typically puts together the list. Surveyor asked LPN D if the weights show up on the MAR (Medication Administration Record) or the TAR (Treatment Administration Record), LPN D stated yes. Surveyor asked LPN D if the system flags the staff when there is a weight discrepancy, LPN D stated yes. On 1/30/24 at 1:51 PM, Surveyor interviewed DON B (Director of Nursing) and ADON L (Assistant Director of Nursing). Surveyor asked what the facility's policy was for weighing new admissions, DON B stated they are weighed on admission for 2 days, then weekly for 3 weeks, and then monthly. Surveyor asked if the policy changes for residents with CHF. DON B stated that it depends on what the order says. Surveyor asked DON B to look at R3's order for weights. DON B stated that R3 was to be weighed monthly. Surveyor asked DON B to review R3's notes from the Cardiology NP (Nurse Practitioner) from 6/27/23 and 7/14/23. After reviewing the notes, Surveyor asked if R3 should have been receiving daily weights? ADON L and DON B stated yes. Surveyor asked when R3's daily weight orders were discontinued. DON B stated that when a resident is admitted to the hospital, all of their orders are discontinued, and we start with all new orders. Surveyor asked if anyone consulted with R3's cardiologist to see if the daily weights should be reinstated? DON B stated that they do not consult the cardiologist unless the resident has an appointment and comes back with new orders. Surveyor asked if R3 went to his scheduled cardiology appointment on 8/8/23. ADON L reported that R3's daughter had canceled the appointment, was going to change providers, and would reschedule the appointment. Surveyor asked ADON L if R3's daughter ever rescheduled the appointment. ADON L stated that she didn't know. Surveyor asked if anyone from the facility followed up with R3's daughter about the appointment? ADON L stated no. Surveyor asked DON B if she would expect the nurses to increase their monitoring of R3's edema, cardiovascular/respiratory assessments, and obtaining weights after being diagnosed with acute on chronic congestive heart failure on 1/2/24. DON B stated yes. Surveyor asked DON B if there was documentation that the nurses assessed those areas. DON B stated no. Surveyor asked DON B if the nurses assessed those areas on 1/3/24, DON B stated no. Surveyor asked DON B if any of the above assessments were completed prior to R3 going to the hospital on 1/4/24, DON B stated no. Surveyor asked DON B if the nurses increased monitoring of R3 after he returned from the hospital on 1/11/24, DON B stated they were doing daily skilled charting. Surveyor asked if the daily skilled charting included an assessment of R3's edema or cardiovascular assessment, DON B stated no. On 1/30/24 at 3:24 PM, Surveyor spoke with MD P (Medical Doctor). Surveyor asked MD P if he would expect the facility to obtain daily weights for R3 after his recent hospitalization s and exacerbations of CHF. MD P stated that it would certainly have been reasonable to obtain daily weights and it could have been beneficial. Surveyor asked MD P if he would expect facility staff to be completing cardiovascular and respiratory assessments on R3; MD P stated yes.

Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 1 residents (R10). R10 had complained to the facility's nurse that she was having a skin concern that was causing R10 pain. The nurse failed to assess R10's pain and failed to complete a skin assessment. R10 developed a non-pressure wound which required surgical debridement. Facility staff failed to implement treatment orders for multiple days. Evidenced by: The facility's policy titled Pressure Injury Prevention and Wound Care Management, last revised on 2/24/23, states in part: .Policy: It is the policy of this facility that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care .5. Resident's skin will be monitored daily during cares by nursing assistant and skin check will be completed weekly by licensed nurse .9. Daily, the clinicians responsible for caring for the Resident will assess the status of the dressing if present, (intact, soiled, leaking), and evaluate for complications such as infection and/or uncontrolled pain . R10 was admitted to the facility on [DATE] with diagnoses that include: venous insufficiency, type 2 diabetes mellitus, chronic pain syndrome, atrial fibrillation, and hypertension. R10's most recent Minimum Data Set (MDS) dated [DATE] states that R10 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R10 is cognitively intact. R10's MDS also indicates that R10 requires extensive assistance from staff with bed mobility, transfers, and toilet use. Nurse's note dated 4/23/23 at 1:31 AM: Resident yelling out, Resident stated that she was having pain between her thighs. Nurse went to look at the site of pain, resident started cussing at nurse and continued to be belligerent. Nurse told cnas [sic] (Certified Nursing Assistant) to continue with cream on the site. Will continue to monitor. Surveyor reviewed R10's Medication Administration Record (MAR) and there is no documentation indicating that R10 received pain medication at that time. Additionally, there is no documentation of a pain assessment, or a skin assessment having been completed. R10's MAR indicates that R10 received Hydrocodone-Acetaminophen 5/325mg (narcotic pain medication) on 4/23 at 8:01 PM with a pain rating of 7/10, on 4/25 at 5:19 PM with a pain rating of 6/10, and 4/26 at 9:19 PM with a pain rating of 5/10; Surveyor requested documentation indicating where R10 was having pain, none was provided. R10 was seen by the wound doctor on 4/27/23. Wound documentation is as follows: Focused Wound Exam (Site 9) Non-Pressure Wound of the Left Ischium Full Thickness Wound size (L x W x D): 8.5 x 4.5 x 0.1 cm (centimeters) Surface area: 38.25 cm^2 .Exudate: Moderate Serosanguinous [sic] (thin watery fluid, pink in color) Slough (yellow/ white material in wound bed): 20% Granulation tissue: 60% Skin 20%. Additional wound detail believed to be 2/2 (secondary to) brief shearing skin .Dressing Treatment plan Primary dressing(s) Leptospermum honey apply once daily for 30 days Secondary dressing(s) Foam silicone border apply once daily for 30 days .Site 9: Surgical Excisional Debridement Procedure Indication for procedure: Remove necrotic tissue and establish the margins of viable tissue .Procedure note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgical excise 7.65 cm^2 of devitalized tissue including slough, biofilm, and non-viable subcutaneous level tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 20 percent to 0 percent . Surveyor reviewed R10's MAR and Treatment Administration Record (TAR) for April and May 2023. No order was put into R10's Electronic Health Record (EHR) for the orders that the wound doctor wrote on 4/27/23, Treatment plan Primary dressing(s) Leptospermum honey apply once daily for 30 days Secondary dressing(s) Foam silicone border apply once daily for 30 days, until 5/8/23. MD orders: Wound care to left ischium: cleanse wound with soap and water, pat dry, apply Medi-honey to wound bed and cover with silicone foam border gauze QD (every day). One time a day for non-pressure wound to left ischium. Order date: 5/8/23 Start date: 5/8/23. It is important to note that this treatment was ordered on 4/27/23. Location: R (right) posterior thigh. Cleanse with wound cleanser and pat dry. Apply calazime lotion to area with incontinence care. Every 2 hours as needed for incontinence care. Order date: 5/8/23 Start date: 5/8/23 On 5/4/23 at 8:20 AM, Surveyor interviewed R10. R10 reported to Surveyor that 2 weeks ago on a Saturday night, she was complaining of pain; R10 states that she was calling out ow, ow, ow. R10 reported that 2 CNAs and a nurse came into her room; per R10, the nurse stated, I don't like your attitude, I'm going to write you up in your chart. R10 also reported that the nurse said, There is an open area there, but I'm not going to help you, and then left the room. Surveyor asked R10 if she reported the interaction to anyone? R10 stated that she told DON B (Director of Nursing.) Surveyor asked R10 how having the nurse walk out on her made her feel? R10 stated that she was surprised because she didn't know that a nurse could refuse treatment, and it also made her angry. On 5/4/23 at 2:38 PM, Surveyor interviewed CNA L. Surveyor asked CNA L if he could recall the events that took place between R10 and the nurse? CNA L stated that during the overnight shift, R10 was screaming and crying, which is unusual for her. CNA L reported that the nurse caught an attitude, R10 flipped her off, and then the nurse walked out of the room. Surveyor asked CNA L if the nurse assessed R10's pain or skin? CNA L stated no, she documented her behavior and hasn't been in there since. Surveyor asked CNA L if R10 had any open areas? CNA L stated that R10 had 2 open areas, one on each thigh. Surveyor asked CNA L what type of cream they put on R10? CNA L reported that they applied a barrier cream. Surveyor asked CNA L if there were any other nurses working that night? CNA L stated yes. Surveyor asked CNA L if the other nurse was asked to assess R10? CNA L stated not that he was aware. On 5/4/23 at 3:03 PM, Surveyor interviewed DON B. Surveyor asked DON B if she would have expected the nurse to complete a pain assessment? DON B stated that she would expect that the nurse would have talked to R10 about her pain. Surveyor asked DON B if she would have expected the nurse to complete a skin assessment? DON B stated that the nurse should have looked at it. Surveyor asked DON B if CNAs should put cream on open areas? DON B stated no, the nurse should have assessed it to determine what cream to put on. On 5/8/23 at 9:30 AM, Surveyor met with LPN P (Licensed Practical Nurse). Surveyor requested to observe wound care. R10 declined wound care until after she was cleaned up, but agreed to allow Surveyor to observe her wound. LPN P assisted R10 to roll onto her left side. Surveyor observed a foam dressing on R10's posterior thigh. Surveyor asked LPN P how often they change R10's dressing? LPN P reported that it is changed usually every other day. It is important to note that at the time of the observation and interview, there were no orders in the computer for wound care to R10's left ischium/posterior thigh area. Surveyor reviewed R10's Weekly Skin Check dated 4/26/23, completed by LPN O. The document states that there were no new skin alterations identified. On 5/8/23 at 2:06 PM, Surveyor interviewed LPN O. Surveyor asked LPN O what her process was for completing R10's weekly skin check? LPN O stated that she asks the aides if there are any changes in condition and asks the resident if there are any changes in condition. They said there weren't any new changes. Surveyor asked LPN O if she physically looked at R10's skin? LPN O stated that she looked at it when she was sitting in her chair. Surveyor asked LPN O if she looked at R10's bottom? LPN O stated that she was sitting in her chair before she went to bed, and that she looked at her skin before she went to bed. On 5/8/23 at 2:08 PM, Surveyor interviewed RN M (Registered Nurse,) who is also the wound nurse. Surveyor asked RN M who is responsible for reviewing the notes from the wound doctor? RN M stated that herself and another nurse are responsible for reviewing the notes. Surveyor asked RN M if she would expect that the orders given by the wound MD (Medical Doctor) would be put into the computer? RN M stated yes. Surveyor asked RN M if wound care should have been provided to R10 from 4/27-5/8? RN M stated yes. RN M stated she accompanied the wound MD on 5/3/23 and completed wound care. Surveyor asked RN M how the floor nurses would know what R10's wound care orders would be if they weren't in the computer? RN M stated that they wouldn't. On 5/9/23 at 8:50 AM, Surveyor asked LPN H to observe wound care on R10; LPN H stated that she did not have any orders for wound care. On 5/9/23 at 9:24 AM, Surveyor met with R10. Surveyor observed that R10 was not using an air mattress. Surveyor asked R10 if she had ever had an air mattress on her bed? R10 reported that she did have an air mattress when she was first admitted to the facility, but it would not stay inflated. Surveyor asked R10 if the facility had tried a different air mattress? R10 stated that she was not sure. Surveyor asked R10 if the facility discussed risks vs. benefits of not using an air mattress with her, R10 stated no. On 5/9/23 at 9:29 AM, Surveyor observed R10's left posterior thigh and ischium area with the assistance of CNA F. Surveyor observed the wound area that still had some open areas with what appeared to be yellow slough. On 5/9/23 at 9:49 AM, Surveyor interviewed RN M. Surveyor asked RN M what they determined the etiology of R10's wound was? RN M stated that R10 reported that her brief was scratching her. RN M stated that the area is healed over now, so she obtained new orders. Surveyor asked RN M if the new order was to be scheduled or PRN (as needed?) RN M stated that it should be applied with incontinence cares and as needed. Surveyor discussed the order with RN M as it was entered into the computer. Order entered states: Location: R (right) posterior thigh. Cleanse with wound cleanser and pat dry. Apply calazime lotion to area with incontinence care. Every 2 hours as needed for incontinence care. Surveyor asked RN M if the order was meant for the left posterior thigh or the right posterior thigh? RN M stated that she must have put the order in wrong. Surveyor asked RN M if the order should have been scheduled vs. PRN? RN M stated that it should be completed with incontinence cares. Surveyor asked RN M how nurses would know to do the treatment if it was not scheduled? RN M stated that she would have to change it. Surveyor asked RN M what the expectation is for staff when completing the weekly skin assessment? RN M stated that if they find anything, it should be reported to the MD, POA (Power of Attorney,) ADON (Assistant Director of Nursing,) and for them to do an evaluation. Surveyor asked RN M if she would expect the nurse to look at all of the resident's skin? RN M stated yes, it should be done once a week or if something comes up or if they report that something hurts. Surveyor asked RN M if she would expect that the nurse looks at the entire body? RN M stated yes. Surveyor asked RN M if the facility had discussed risks vs. benefits of not using an air mattress with R10? RN M stated yes and that she would provide Surveyor with the documentation. It is important to note that Surveyor was not provided any documentation regarding risks vs. benefits of not using an air mattress. On 5/9/23 at 1:44 PM, Surveyor interviewed MD N. Surveyor asked MD N once he was alerted about R10's ischial wound, if he could determine how long she had the wound? MD N stated that it was hard to tell how long it had been there, but that R10 reported that it was there for a while, she had mentioned it in passing while we were working on her legs. Surveyor asked MD N if he would expect that when he writes orders, the facility implements them? MD N stated yes. Surveyor told MD N that the facility staff never entered the orders into the computer from 4/27/23 - 5/8/23 and asked if he would expect to have been updated that the treatment was not being completed; MD N stated yes. The facility failed to properly address R10's pain and provide an accurate and complete skin assessment resulting in a non-pressure wound that required surgical debridement to facilitate healing.

Based on interview and record review, the facility did not ensure that the resident environment remains free of accident hazards as is possible for 1 resident (R1) of 3 residents reviewed for falls out of 4 sampled residents. R1 has a care plan fall intervention which states bed in lowest position while R1 is in bed. R1 fell out of bed when the bed was in an elevated position and sustained a subdural hematoma as a result of the fall. Of note, per WebMD a subdural hematoma is a pool of blood between the brain and its outermost covering. Subdural hematoma can be a medical emergency. It's usually caused by a head injury strong enough to burst blood vessels. This can cause pooled blood to push on the brain. This is evidenced by: The facility's Policy and Procedure entitled Fall Reduction Policy dated 12/4/18, includes, in part: .7. Document in the clinical record a summary of the fall including, but not limited to, assessment, intervention and resident response.11. The fall interventions in the residents care plan must be followed. R1 was admitted to the facility 6/22/18 with diagnoses which include stroke, right side flaccidity and difficulty swallowing and speaking. R1's care plan for fall risk includes: Date initiated 6/25/21- Bed to be positioned in lowest possible position with fall matt in place when resident in bed. On 8/8/21 at 4:00 AM, RN E (Registered Nurse) documents: Was heading to resident room to change tube feeding, upon entering the room resident was found on the floor face down. Bed was in high position, bumper pillows in place and fall mat in place. Tube feeding line was stretched taut. The facility's incident description dated 8/8/21 at 4:00 AM states in part; Nursing Description: Was heading to resident room to change tube feeding, upon entering the room resident was found on the floor face down. Bed was in high position, bumper pillows in place and fall mat in place. Tube feeding line was stretched taught {sic}. Description: .reassessed, checked vitals and contacted ambulance, MD, (DON) Director of Nursing, and family. Root Cause Analysis: bed remote control within resident reach and bed placed in high position. Intervention: Bed Control to be place under mattress when not in use by staff. Changed to Velcro control to back side of head of bed. Witness: Found resident laying of floor, face down on floor mat. Bed in high position and body pillows were still in place. Bed control hanging off bed. Bed was in lowest position when checked on recently. On 8/24/21 at 4:30 PM, Surveyor spoke to RN E. RN E said R1's bed was always to be in the low position. RN E said she had seen R1 in his bed about an hour earlier and his bed was in the lowest position. RN E said she had not seen R1 ever manipulate the bed controls. Surveyor contacted the CNA (Certified Nurse Assistant) that worked with R1 on 8/8/21. Surveyor left a message and has not received a return call. On 8/24/21 at 1:00 PM, Surveyor spoke to CNA C. CNA C said she has worked with R1 and his bed must be in the lowest position, because he flails his legs around and it's easy for him to fall. CNA C said she has not seen R1 work the bed controls. On 8/24/21 at 1:25 PM, Surveyor spoke to CNA D. CNA D said she has worked with R1 and his bed must be in low position at all times because he moves his left leg a lot. R1's hospital documentation dated 8/8/21 includes: Presents from his nursing home-subdural hematoma after an unwitnessed fall out to bed. On 8/24/21 at 2:00 PM, Surveyor spoke with DON B. DON B said R1's bed is to be in the lowest possible position at all times and should not have been left in the high position. R1 fell when the bed was left in the high position there is no evidence R1 was capable of manipulating the bed controls. Staff interviewed stated they have not witnessed R1 attempt to manipulate the bed controls. R1 fell sustaining a subdural hematoma, a medical emergency, related to the fall.

Based on observation, interview and record review the facility failed to ensure each Resident received adequate supervision to prevent accidents for 3 of 4 Residents (R1, R2, and R4) reviewed for accidents out of a total sample of 4 Residents. R1 is severely cognitively impaired and has an APOAHC (Activated Power of Attorney for Health Care). R1 had eloped from the facility previously on 9/10/20. The facility did not update R1's care plan timely. On approximately 2/15/21, staff did not transfer R1's Wander Guard bracelet from his Broda chair to his wheelchair (the facility's first line of defense) after discontinuing his Broda chair. From approximately 2/15 - 2/19/21, staff falsely documented that the Wander Guard bracelet was in place on R1's new wheelchair. Staff did not attach the Wander Guard bracelet when they became aware, on 2/17/21, that R1 did not have the Wander Guard bracelet. Staff did not increase supervision of R1 when he appeared upset and made an earlier attempt to leave the building in the afternoon of 2/19/21. R1 eloped from the building on 2/19/21. The temperature was 16 degrees and he was wearing 2 T-shirts and pants when a passerby happened to see him. When found, his wheelchair was stuck in the snow and ice. Staff was unaware he was gone. After his return, staff attached the bracelet to a metal portion of the wheelchair, contrary to manufacturer directions. The Facility's failure to move R1's Wander Guard bracelet to R1's wheelchair (the facility's first line of defense), its failure to ensure staff was checking placement of the bracelet and not falsifying checks, its failure to implement other lines of defense, such as close monitoring, and its failure to ensure placement of the bracelet on the wheelchair met manufacturer approval created a finding of Immediate Jeopardy which began on 2/19/21. The NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on 3/4/21 at 3:00 PM. The immediate jeopardy was removed on 3/4/21, 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 and as evidenced by the fact that two other residents (R2 and R4) had wander guard bracelets placed on metal without first calling the manufacturer to verify approval since this was contrary to written manufacturer instructions. This is evidenced by: Senior Technical Support Specialist (STS) L at [NAME] Healthcare, the manufacturer of the Wander Guard, provided Surveyor the following Wander Guard User Manual for the Wander Guard E series departure alert system that states, in part, as follows: Wander Guard signaling device (Model or ) should be placed on the resident's dominant wrist, the resident's ankle or a wheelchair in such a way so that the metal from the wheelchair is away from the signaling device. The metal in a wheelchair frame (or any other metal items) may interfere with the signaling device's signal to the door modules. Note, the facility uses Model . The Wander Guard Departure Alert System User and Installation Manual guidelines state, in part, as follows: Bracelet Placement: Wander Guard bracelets (Model series) should be placed on the resident's dominant wrist. The metal in a wheelchair frame (or any other metal items) may interfere with the bracelet's signal to the door modules. Before proceeding with alternate placement, you must contact Technical Services for further instructions. Your bracelet placement protocol needs to define the standard placement for bracelets and any special procedure required before using an alternate placement. Call Technical Service at [PHONE NUMBER] before using any alternate placement. Warning: The Wander Guard E series departure alert system is designed to assist staff, not replace them. The responsibility for maintaining the security of wanderers remains with a conscientious, alert staff. (Emphasis intended) Wander Guard E signaling devices are designed for wrist and ankle placement .Do not place the signaling device on or next to metal, such as wheelchair frames, jewelry, watches, etc. or allow it to come in contact with a door or associated hardware such as crash-bars, push-bars, etc. Metal could interfere with the signal sent to the door module. The Wander Guard E series .as with any electronic equipment is not foolproof. Electronic magnetic interference (EMI) may occur, in fact, EMI is common in most environments and can be generated by other electronic equipment in the facility. Sometimes EMI noise is high enough that the operation of the Wander Guard system and any other devices using radio frequencies - could be affected. Introduction to the Wander Guard E departure alert system: Staff vigilance is the most important element of an effective wanderer management program. Wandering Signaling devices: Do not place the signaling device on or next to metal, such as wheelchair frames, jewelry, watches, etc. or allow it to come in contact with a door or associated hardware such as crash-bars, push-bars, etc. Metal could interfere with the signal sent to the door module. The facility policy, Elopement Risk and Prevention, revised 7/28/20, states, in part, as follows: It is the policy of this facility all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or condition that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual care plan. Procedure: 1. Residents who have been assessed at risk for elopement shall have interventions in place in their plan of care. 2. As part of the facility's Preventative Maintenance Program, all secured doors and elevator keypads (if applicable) will be checked for proper function on a weekly basis by the Maintenance department. These checks will be documented with date and time done. 3. The Administrator and Director of Nursing will be notified immediately of any concerns with secured doors or keypads. 4. Residents arm/leg monitor bracelet will be checked daily for placement and weekly to ensure device is functioning properly. 5. At no time shall a door alarm be turned off, without the continual supervision of the exit. In the event that the door locks/alarms of a secure unit become disabled (ex. Power failure / fire alarm) the facility must ensure a temporary protective system is in place (ex. battery activated alarm', staff monitored exits, etc.). 6. Facility shall conduct elopement drills. Routine Procedure for Wandering Residents and Prevention of Missing Residents/Elopement: 1. All residents shall be reviewed for safety awareness impairment and elopement concerns upon admission, readmission, and quarterly and as needed. 2. Residents identified as a risk for elopement will have interventions put in place. 3. All residents who are at risk for possible elopement shall be accompanied by staff, or responsible party, when leaving the facility grounds. 4. Residents at risk for elopement shall be identified on Elopement Book. This book will have the list of all residents assessed to be at risk for elopement with their name, room number and photo. This book will be located in a central location in the facility such as the receptionist area. 5. Staff will be communicated to whenever the book/name plate by the door of their room is updated. 6. When a door alarm sounds, staff shall immediately respond to determine the cause of the alarm. a. The staff person responding to the alarm will check the outside of the building/vicinity of the area to determine if a resident has exited the building.] b. If upon investigation no reason can be found for the sounding of the alarm, the Administrator/D.O.N. (Director of Nursing)/designee must be notified and a head count will be initiated on all the units and completed accounting of the residents will be given to the Administrator/D.O.N. or designee. Example 1: R1 was admitted to the facility on [DATE] with diagnoses that include [CONDITION(S)], bilateral below the knee amputations, type 2 diabetes with diabetic [CONDITION(S)] and muscle wasting and atrophy. R1 has an APOAHC (Activated Power of Attorney for Health Care). R1's Annual MDS (Minimum Data Set) dated 2/9/21 indicates R1 has a BIMS (Brief Interview of Mental Status) of a 4 out of 15, which indicates he is severely cognitively impaired. Section B indicates that R1 has clear speech, is able to make himself understood and can understand others. Section G indicates that R1 requires extensive assistance of 2 staff for bed mobility, transferring, dressing, and ambulating. R1's Wandering Risk Scale assessments were as follows using the following scoring tool: 0-8 = Low Risk to Wander 9-10 = At Risk 11 and above = High Risk 6/3/20: 7 6/6/20: 7 7/6/20: 2 7/23/20: 7 9/29/20: 7 10/2/20: 7 10/12/20: 9 11/18/20: 0 1/13/21: 0 1/17/21: 0 R1's most recent Wandering Risk assessment, dated 1/17/21, scored a 0 (low risk) despite the fact that he had eloped from the facility on 9/10/20 when staff found him in the back parking lot looking for his car. On 9/10/20 at 7:08 AM, R1's Behavior NN (Nurses Note) indicates the following: Patient had wandered outside in his wheel chair to the back parking lot looking for his car. Patient was confused and thought he had a doctor appointment today. Patient was easily redirected and brought back into facility. The director of nursing was notified of the incident. Staff will continue to monitor patient. On 9/10/20 at 5:25 PM, R1's Health Status NN indicates the following: Writer spoke with R1's APOAHC earlier this date. R1's APOAHC wondered if R1 leaving the building is r/t (related to) dementia progressing or if it's a new behavior. R1's APOAHC stated R1 can be manipulative and kind of sneaky. During IDT (Interdisciplinary Team) this AM, resident has demonstrated this type of behavior before and has cut off Wander Guard bracelets including wheelchair and body. R1's APOAHC confirmed this. Writer told R1's APOAHC we would be attaching Wander Guard underneath WC (wheelchair) seat where he couldn't see it. R1's APOAHC agreed with this. Writer and staff member from Medical Records placed bracelet. Functionality confirmed and orders entered. Elopement binder to be updated with resident's picture. Resident asleep. On 10/6/20 R1 was hospitalized for COVID-19 as well as other comorbidities. On 10/12/20 R1 was readmitted to the facility. On 10/31/20 R1's NN states R1 has moderate impairment (decisions poor, needs supervision) On 12/19/20 R1's NN state as follows: R1 stated he was going to walk out of the facility, Whether you like it or not. R1's Elopement Care Plan states, in part, Wander Guard placement and checks per facility policy (Date Initiated 10/2/20). Wander/Elopement Risk - Add to at risk books and lists (Date Initiated 10/2/20). Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the needs for more exercise? Intervene as appropriate (Date Initiated 10/2/20). Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book (Date Initiated 11/18/20). Monitor for fatigue and weight loss (Date Initiated 10/2/20). Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes (Date Initiated 10/2/20). Of note, the wandering care plan was not implemented timely, as it was not developed until 10/2/20 which is 22 days after R1's Wander Guard was placed on 9/10/20. R1's TAR (Treatment Administration Record) documents the follows: Wander Guard function test to be completed daily. Refer to product user manual for proper functioning. If Wander Guard not functioning replace device - every night shift. Order Date: 9/10/20 Check placement of Wander Guard every shift: Device is located on Resident's wheelchair - underneath (out of sight) - every shift. Order Date: 9/10/20 R1's Broda chair was changed to a regular wheelchair the week on 2/15/21. R1's Wander Guard bracelet, which had been attached to his Broda chair, was not moved to the new wheelchair. It is important to note that staff, from 2/15/21 to 2/19/21 continued documenting that the bracelet was in place and functioning even though R1 did not have a Wander Guard on him or his wheelchair. On 2/19/21 around 2:20 PM, CNA E (Certified Nursing Assistant) notes in her statement, below, that R1 Was trying to escape down 200 hallway. On 2/19/21 (at approximately 3:35 PM), CNA I (Certified Nursing Assistant) notes in her statement, below, that R1 was Rolling around core and hallways, was in front room two hours before (elopement) Note, the front room is next to the main doors where R1 exited the facility. There is no evidence staff increased supervision of R1 despite his attempt to escape and his movement down the hallways. On 2/19/21 at 7:12 PM, RN D (Registered Nurse) documented the following NN for R1: Resident returned to facility by neighbors walking by as resident was in w/c just outside of facility parking lot; He is in street clothes, 2 short sleeved shirts and pants; he did not have a jacket or gloves on. He is alert, vss (Vital signs stable); declined to have blood sugar checked; provided meal to resident and is in his room; resident declined blankets, hands are cool to touch, DON (Director of Nursing), Administrator (Nursing Home Administrator), POA (Power of Attorney), and NP (Nurse Practitioner) updated; will place resident on 15 minute checks for 24 hours for safety. On 2/19/21 at 10:36 PM, LPN G (Licensed Practical Nurse) documented the following NN: elopement: res was outside the facility at the entrance of the parking lot a neighbor alerted staff approximately 6:00 PM vitals obtained, head to toe assessment performed no signs of injury, res refuse accu ck (check to monitor blood sugar level) .res ref (refused) supper adequate fluids received NP, DON, Administrator, POA all notified .15 minute cks initiated staff completed witness statements functioning wander guard in place located underneath w/c # EXP (expiration) 10/18/2021. On 2/20/21 at 6:40 AM, RN K (Registered Nurse) documented the following NN: Monitored resident temp (temperature) throughout the night to make sure he was not hypothermic. 97.7 and 98.1 On 3/4/21 at 8:53 AM, Surveyor spoke with the Community Member who found R1 and asked her to describe the situation that she witnessed on 2/19/21. Community Member stated she was driving down the street where the facility is located. As she approached the stop sign at the corner of (Name of Street and Name of Intersection Street) she saw R1 outside by himself in his wheelchair. Community Member stated she stopped, rolled down her passenger window, and asked R1 if he needed help. R1 responded, I could use a push. Community Member stated she pulled her car over, turned on her hazards and got out of her vehicle. A second passerby stopped to assist R1 to get back to the facility. Community Member stated R1, Was not lucid where he was or where he was going. R1 stated to Community Member that he needed dessert after beef stew (Note, R1 refused his dinner prior to eloping from the facility) and stated he came from church and pointed to the main entrance of the facility where he had exited. Community Member stated R1 was in his wheelchair and was stuck in the gutter on chunks of ice and snow. Community Member added there was a lot of ice and snow at the time this occurred. Community Member stated R1 was in the gutter and was definitely not on the sidewalk. The Community Member, who had noticed R1's lips were blue, put a jacket over R1 and she and the passerby brought R1 back to the facility. Community Member stated R1 was wearing short sleeves, pants that were cut short because he has no legs, and was not wearing a coat, hat or gloves. Community Member stated it was 14 degrees without the wind chill. (https://www.timeanddate.com/weather/usa/madison/historic). Community Member stated she and passerby pulled R1 out of the ice and snow where he was stuck and returned him to the facility. Community Member stated she rang the doorbell multiple times before a staff member, presumably a CNA, answered the door. The staff member stated, Oh my God R1, how did you get out? R1 did not reply. The staff member stated that R1 had a Wander Guard on and the alarms should have gone off. The staff member stated no one knew R1 was missing and there were only 3 staff members in the facility and they couldn't keep track of everyone. Community Member stated she this situation made her furious and what was most concerning is that staff didn't even know R1 was outside unattended. The facility completed an investigation regarding R1's elopement. Type of Incident: Elopement Date: 2/19/21 Time 6:10 PM Description of the Incident: Resident found outside by a neighbor by the facility driveway entrance. Resident was last seen by staff at 5:30 PM. Resident return to facility at 6:10 PM. Temperature outside was approximately 16 degrees. Resident was wearing 2 short sleeve t-shirts, pants. Resident is a BLE [CONDITION(S)]. Effect of the incident on the resident at their reaction. Resident's exposed skin on arms and hands were cool to cold to touch. Skin under clothing was warm. Resident stated he was fine. There were no s/s hypothermia. No injuries noted. Resident was offered warm fluids and was given a blanket to cover himself with. Vital signs taken and were WNL (within normal limits). What action was taken immediately to protect the resident and any other residents at risk? Wander Guard applied to underside of w/c seat to prevent resident from cutting or breaking it off. Resident will not allow Wander Guard to be placed on his wrist. Date and time reported and to whom. NHA A (Nursing Home Administrator) at 7:07 PM, DON B at 6:38 PM. Results of Investigation Age: 7/29/48 When admitted and where - 6/3/20 from local hospital Dx: PVD (peripheral vascular disease), DM (diabetes mellitus), CAD (Coronary Artery Disease), [CONDITION(S)], BLE [CONDITION(S)], [CONDITION(S)] (hypertension), muscle wasting/atrophy, diabetic [CONDITION(S)] Cognition and decision maker - BIMS is 4. Resident has APOA. Any additional facts about the residents condition or actions that are pertinent to this investigation - none Documentation relevant to allegation: Documentation of event completed in PCC (PointClickCare) progress note and Risk Management report. Care plan updated with intervention. Contact with resident, family or legal decision maker to assure obtain their information and assure them it is being resolved and resident is safe. Stay in contact during the investigation and provide them with the results and document those discussions. Daughter, APOA, updated on elopement by staff nurse. NHA (A) and DON (B) had discussion with daughter. Will follow up with daughter once investigation has been completed. Update will be documented in progress notes in PCC. Additional Findings: RCA (Root Cause Analysis) completed and found that resident was previously in a Broda chair with a Wander Guard applied to the underside of the seat, as resident will find ways to remove the Wander Guard if on his wrist/ankle. Resident was changed to a regular w/c but the Wander Guard did not get transferred from the Broda Chair to the w/c. In addition, nurses were not consistently checking the Wander Guard placement and function per policy. There is only 1 Wander Guard checker for the building which is shared between nursing and maintenance. The Wander Guard alarm is not loud enough for staff to hear when they are in the back half of each resident hallway and not able to be heard when staff is in resident rooms with doors closed. Review of elopement risk UDAs (User-defined assessments) completed. There were 2 additional residents at high risk for wandering/elopement. Facility had only 1 additional Wander Guard. The facility's staff statements regarding R1's elopement RN D's statement, dated 2/19/21, indicates the following: I did not see the resident prior to incident. Contributing Factors: No Wander Guard in place. I informed ADON (C) of need for Wander Guard on PM shift 2/17/21. I also informed Therapy (Dir of Therapy) F of need for Wander Guard from old Broda chair on 2/18/21 PM shift. CNA H (Certified Nursing Assistant) statement, dated 2/19/21, indicates the following: Describe the life of the resident for three hours before he left: Rolling around, wandering in wheelchair What time was the Resident last observed and what were they doing at that time? 5:00 at the core (nurses station) What were you doing at the time? Different hall Time last rounded: 5:30 PM Time last toileted or catheter/urinal emptied? Refused Results of last toileting: (urine, BM, changed, refused): Refused Were there any alarms in use and were they sounding at the time of the fall? No Contributing Factors What is the Resident's mental status, mood and behavior status at the time of fall? Wandering How does this compare to their usual? Normal Other than having extra staffing what do YOU think contributed to or caused this fall (elopement) and what do YOU think would be a good intervention to prevent a fall (elopement)? New Wander Guard CNA E's statement, dated 2/19/21, indicates the following: Describe the life of the resident for three hours before he left: Upset, wanted to leave. What time was the Resident last observed and what were they doing at that time? 2:20 PM something was trying to escape down 200 What were you doing at the time? Was taking a different resident out to smoke. Time last rounded: 5:15'ish (PM) Time last toileted or catheter/urinal emptied? IDK (I don't know) Results of last toileting: (urine, BM, changed, refused): Blank Were there any alarms in use and were they sounding at the time of the fall? No Contributing Factors What is the Resident's mental status, mood and behavior status at the time of fall? Upset How does this compare to their usual? Depends on day What is the Resident's physical status at the time of the fall? Okay How does this compare to their usual? Normal Other than having extra staffing what do YOU think contributed to or caused this fall (elopement) and what do YOU think would be a good intervention to prevent a fall (elopement)? Wander Guard being on him. LPN G (Licensed Practical Nurse) statement, dated 2/19/21, indicates the following: Describe the life of the resident for three hours before he left: Elopement What time was the Resident last observed and what were they doing at that time? 5:15 PM What were you doing at the time of the elopement? Passing meds (medication) Time last rounded: Blank Time last toileted or catheter/urinal emptied? Blank Results of last toileting: (urine, BM, changed, refused): Blank Were there any alarms in use and were they sounding at the time of the fall? Blank Contributing Factors What is the Resident's mental status, mood and behavior status at the time of fall? Res more confused, non-compliant with meds How does this compare to their usual? Blank What is the Resident's physical status at the time of the fall? Blank How does this compare to their usual? Blank Other than having extra staffing what do YOU think contributed to or caused this fall (elopement) and what do YOU think would be a good intervention to prevent a fall (elopement)? Functioning Wander Guard CNA I's statement dated 2/19/21, indicates the following: Describe the life of the resident for three hours before he left: Rolling around core and hallways, was in front room two hours before (elopement) Note, the front room is next to the main doors where R1 exited the facility. What time was the Resident last observed and what were they doing at that time? 5:35 PM at core, refused supper, brief change and bed What were you doing at the time? Passing trays Time last rounded: 5:35 PM Time last toileted or catheter/urinal emptied? 4:45 PM Results of last toileting: (urine, BM, changed, refused): Urine Were there any alarms in use and were they sounding at the time of the fall (elopement)? No-Wander Guard not in place when he's required to have one. Contributing Factors What is the Resident's mental status, mood and behavior status at the time of fall? Irritable refusing cares and supper How does this compare to their usual? Usually irritated or angry when care are involved. What is the Resident's physical status at the time of the fall? Not applicable How does this compare to their usual? Blank Other than having extra staffing what do YOU think contributed to or caused this fall (elopement) and what do YOU think would be a good intervention to prevent a fall (elopement)? A new Wander Guard in place because it would help alert us better to be told if he had tried before. On 3/3/21 at 11:20 AM, Surveyor observed R1's Wander Guard hanging on a strap that is held together with approximately 20 staples. The Wander Guard is hanging from the metal push-bar that runs across the entire back of R1's wheelchair. Note, the manufacturer guidelines state specifically, Do not place the signaling device on or next to metal, such as wheelchair frames, jewelry, watches, etc. or allow it to come in contact with a door or associated hardware such as crash-bars, push-bars, etc. Metal could interfere with the signal sent to the door module. On 3/3/21 at 1:14 PM, DON B (Director of Nursing) entered the following order in the MAR (Medication Administration System): Resident (R1) has dx (diagnoses) of [CONDITION(S)] as evidenced by confusion, as evidenced by wandering, exit seeking, and attempts to elope. Document the # (number) of times the resident exit seeks/attempts to elope each shift. (Note, the facility was not systematically documenting R1's wandering or attempts to elope prior to 3/3/21 at 1:14 PM. CNA E (Certified Nursing Assistant) indicates that R1's elopement attempts, Fluctuate a lot. CNA E stated that some days R1 does not make any attempts to elope and other days he will make multiple attempts in a day.) On 3/3/21 at 2:15 PM, Surveyor spoke with RN D (Registered Nurse). Surveyor asked RN D if she is familiar with R1. RN D stated, Yes, I am. RN D stated, I can tell you that R1 was last seen in the front lounge, he refused dinner, and CNAs prompted him to come back to his room. RN D added, a neighbor brought him to the door. RN D stated she was on her supper break at the time. RN D stated she immediately returned from break and found R1 to be wearing 2 short sleeve shirts, no coat and no prosthetic legs. RN D stated she tried to get R1 warmed up, checked vitals and he refused a blood sugar check. R1 decided to eat when we got him inside the facility. RN D stated R1 told her he was, Trying to catch a ride. RN D contacted NHA A and DON B, discussed the plan of action, 15 minute checks until Wander Guard is placed. Surveyor asked RN D do you know why the Wander Guard was not on R1. RN D stated R1 had previously been in a Broda chair, was switched to a regular wheelchair, and the Wander Guard was not switched over to his new wheelchair. RN D stated she noted the Wander Guard was not on him on 2/17/21. RN D stated she looked for the R1's previous Broda chair/Wander Guard in storage, the therapy room, and lounge on the 300. RN D was unable to locate the Broda/Wander Guard. RN D stated on 2/17/21 she left a note for ADON C in the DON's (Director of Nursing) mailbox. Note, ADON C was previously the Interim DON prior to the new DON starting on 2/15/21. RN D stated on 2/18/21 she spoke with Dir of Therapy F (Director of Therapy) notifying her the Wander Guard was not switched over from his Broda chair and asked Dir of Therapy F if she could locate R1's previous Broda chair and the Wander Guard underneath it. RN D stated this was a verbal conversation with Dir of Therapy F. Dir of Therapy F was unable to locate the Broda/Wander Guard. RN D stated on 2/19/21 after R1 eloped from the facility, she was able to locate 1 extra Wander Guard locked in Medical Records. RN D stated within 1 hour of R1 eloping from the facility she placed a new Wander Guard on R1's wheelchair. RN D stated, I think he (R1) may have been out there 10 minutes or less. R1's hands were cool. Surveyor asked RN D what door R1 went out. RN D stated the front door. Surveyor asked RN D if the door was propped open. RN D stated, No. Surveyor asked RN D if staff take R1 outside. RN D stated, Not that I'm aware of. RN stated, a Risk Management Assessment was completed for the elopement. On 3/4/21 at 8:30 AM, Surveyor spoke with Dir of Therapy F (Director of Therapy). Surveyor asked if any staff members spoke with her regarding R1's missing Wander Guard. Dir of Therapy F stated RN D asked her if R1's Wander Guard was still on the Broda chair (that was changed out). Dir of Therapy F stated she immediately checked the storage room and the Broda/Wander Guard was not in there. Dir of Therapy F stated she went back to RN D and told RN D, I don't know where the Broda chair is. Dir of Therapy F stated, RN D confirmed to me, Okay so I know she heard me. Surveyor asked Dir of Therapy F if she knows when RN D asked her to check for the Broda/Wander Guard. Dir of Therapy F stated, It would have been before he (R1) decided to take a little stroll downtown. Surveyor asked, do you mean before R1 eloped on 2/19/21. Dir of Therapy F stated, Yes. On 3/3/21 at 2:48 PM, Surveyor spoke with CNA E (Certified Nursing Assistant). Surveyor asked CNA E if she is familiar with R1. CNA E stated, Yes ma'am. Surveyor asked CNA E when the last time was she had seen R1. CNA E stated she was working on a different unit that day and last saw R1 around 2:30 PM. CNA E stated she did not see R1 again until after he eloped and was back in the facility. CNA E stated she was shifted over to the 400 unit around 5:30 - 5:45 PM after R1 eloped. CNA E added she was feeding another resident down the 200 unit prior to that. CNA E stated she thought R1 was brought back earlier than 6:10 PM but didn't look at the clock and it may have been after 6:10 PM. Surveyor asked CNA E if R1 tries to get out of the facility. CNA E stated, He gets pretty confused and upset at times. CNA E added, he was a farmer and a truck driver, sometimes he thinks he's in a hotel and tries to come and go. CNA E added, we're still trying to work with him, I think. Surveyor asked CNA E how often she works with R1. CNA E stated, pretty regularly because when he gets upset I'm one that can get him calmed down. I'm a farmer as well, we talk about that, it calms him down. Surveyor asked CNA E how frequently does R1 attempt to elope. CNA E stated, Every once in a while it depends on his mood that day, he seems to fluctuate a lot. Surveyor asked CNA E are there any signs or triggers that you have noticed with R1 and attempting to elope. CNA E stated the biggest sign is when R1 says, It's ridiculous. I can take care of myself! CNA E added that R1 does not know why he is here (at the facility). CNA E added one trigger is when he asks for ice water and we tell him he's on thickened liquids. He doesn't like that. CNA E added he really likes thickened apple juice and the nurses will give him chocolate shakes. On 3/4/21 at 7:58 AM and 11:55 AM, Surveyor spoke with DON B. Surveyor asked DON B to describe what happened with R1 on 2/19/21. DON B stated she started working at the facility on 2/15/21. DON B stated on 2/19/21 she received a call from RN D that R1 got out of the building and a neighbor had brought him back. DON B stated R1 was brought back to the facility on [DATE] around 6:10 PM. Surveyor asked DON B do you know how long R1 was outside. DON B stated, No. DON B stated, R1's arms

Based on observation, interview, medical record review and facility policy and procedure review, the facility did not implement professional standards of practice to prevent PI's (pressure injuries) from developing or worsening, or to promote healing of PI's. Assessments of PIs are not consistently being completed by a RN (Registered Nurse) for 3 of 5 residents reviewed for PIs out of a sample of 16 residents (R23, R14, and R4). R23 developed an avoidable facility-acquired unstageable PI to her right heel. The facility identified this PI on 12/1/20 when it was unstageable with 100% eschar. Surveyor observed R23 lying on her back with her heels directly on the mattress. The facility did not measure the wound weekly and did not notify and consult with R23's Physician when the wound worsened. R14 has [DIAGNOSES REDACTED]. R14 developed an avoidable facility-acquired unstageable PI to her left lateral heel. The PI was initially identified as a closed blister to R14's left lateral heel on 2/6/21, which progressed to an unstageable PI on 2/11/21. The facility did not measure the blister or report the blister to RN E (Registered Nurse) or IDON B (Interim Director of Nursing), who are in charge of wound care, until it progressed to to an unstageable PI on 2/11/21. The facility did not determine the root cause of R14's PI. Subsequently, the facility did not take action to remove the source of the pressure to prevent the PI from worsening. R4 developed a deep tissue injury (DTI). Nursing staff did not assess, measure, document, or update the MD (Medical Doctor) or NP (Nurse Practitioner). This is evidenced by: According to the National Pressure Ulcer Advisory Panel (NPUAP) - now known as National Pressure Injury Advisory Panel (NPIAP) standard of practice, .Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that heels are free of the surface of the bed Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf . (NPUAP Heel Pressure Ulcer: 2014 International Pressure Ulcer Prevention & Treatment Guidelines, 2014). According to AMDA (American Medical Doctors Association)-The Society for Post-Acute and Long-Term Care Medicine. Pressure Ulcers. Clinical Practice Guideline. http:// wwv.r.amda.com/ tools/ guideline!'l.cfm#pressureulcer. Accessed 12/9/14. DIABETES MANAGEMENT IN THE POST-ACUTE AND LONG-TERM CARE SETTING II. treatment of [REDACTED]. Foot Care Treatment Plans: At risk foot (patients who smoke; have vascular insufficiency, [MEDICAL CONDITION], retinopathy, [MEDICAL CONDITION], history of ulcers or amputations, structural deformities, infections, skin/nail abnormality; are on anticoagulation therapy; cannot see, feel, or reach their feet.) treatment plan: [REDACTED]. To the extent feasible, train patients to perform. daily foot care and inspection. The facility's Pressure Injury Prevention and Wound Care Management, Policy, revised 6/30/20, states, in part: Purpose: The purpose of the policy is to provide healthcare staff with the standards of care, and processes to be followed for all residents. To identify factors that place the residents at risk for the development of pressure injuries and to implement appropriate interventions to prevent the development of clinically avoidable wounds. To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. Policy: It is the policy of this facility that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care. The facility will ensure that a resident who is admitted without a pressure injury does not develop a pressure injury, unless clinically unavoidable. A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers. Risk Identification and Assessment: A complete assessment is essential to an effective pressure injury prevention and treatment program. A comprehensive assessment helps the facility to identify residents at risk of developing pressure ulcers, as well as the level and nature of their risks. 1. A Braden Scale should be completed for all residents upon admission/readmission for a total of four consecutive weeks, quarterly with each MDS (Minimum Data Set) assessment and when a significant change of condition occurs. 2. Residents with a Braden Scale score of 12 or less should be considered at high risk for pressure injury development. 3. Risk factors identified by the Braden Scale, MDS, or other assessment should be reviewed and addressed as determined appropriate through the RAI (Resident Assessment Instrument) process, including the resident's care plan. These risk factors include, but are not limited to; .b. Impaired or decreased mobility and functional ability, c. Under nutrition, malnutrition, and hydration deficits, d. comorbid conditions (e.g. diabetes mellitus, [MEDICAL CONDITIONS] disease), .h. increase in friction or shear, J. Resident refusal of some aspects of care and treatment 4. The clinicians responsible for the residents' care will review risk factors and identify whether and to what extent those risk can be modified, stabilized or removed. 5. Resident's skin will be monitored daily during cares by nursing assistant and skin check will be completed weekly by licensed nurse. Prevention and Treatment Guidelines: The skin care program will be utilized following the guidelines of the Agency for Healthcare Research and Quality (AHRQ), the National Pressure Ulcer Advisory Panel (NPUAP) and current standards of clinical Practice. 2. Wounds will be treated based on the etiology of the wound. 3. The goals of wound treatment are to: a. Keep the ulcer bed moist and the surrounding skin dry, b. Protect the ulcer from contamination, and c. Promote healing The facility's policy entitled Pressure Injury Prevention and Wound Care Management, with a revision date of 6/30/20, states in part .the facility will ensure that a resident who is admitted without a pressure injury does not develop a pressure injury, unless clinically unavoidable. Example 1 R23 was admitted to the facility 8/31/16 with [DIAGNOSES REDACTED]. R23 curently was diagnosed with [REDACTED]. On 11/12/20 R23 was diagnosed with [REDACTED]. During this time R23 experienced confusion and lack of appetite and had a significant change of condition. This change of condition placed R23 at higher risk for PI (Pressure Injury) development. R23's Significant Change MDS (Minimum Data Set) assessment, on 11/20/20, Section C indicates that R23's BIMS (Brief Interview of Mental Status) is 10, indicating she is moderately cognitively impaired. (Note, R23's BIMS is usually 15, however, she developed temporary confusion as a result of COVID-19). Section G, notes that R23 is dependent on staff for bed mobility, Section M notes that R23 is at risk for PI development. R23's Braden Score (Risk factor for PI development) on 11/8/20 = 21 not at risk. R23's Braden Score on 12/8/20 = 12 (High Risk) indicating high risk for skin breakdown. R23's Comprehensive Care Plan, dated 1/4/21, addresses open areas on R23's right heel and left foot-1st digit arterial wound (hallux). Goal: I will be free of complications and minimized pain related to my skin alteration through the review date: 3/10/21. Interventions: Administer my treatments as ordered, Assess /monitor the alteration in my skin integrity and document status weekly, Lay down in bed for 1-2 hours after breakfast and lunch to facilitate wound healing, low air loss mattress on bed, prevent trauma and ensure I have proper fitting footwear. Of note, this is after R23 developed an in house PI. R23's Kardex Care Plan, dated 2/10/21, notes, in part, under Bed Mobility: 1 assist. The section under Mobility/Transfer notes, Administer [MEDICATION NAME] as ordered by MD (Medical Doctor), Locomotion-wheelchair one assist, No ambulating at this time, Transfer: 1 assist with FWW (front wheeled walker) and gait belt. Right Heel 12/1/20: 5.05 cm x 2.64 x 2.49 - 100% eschar - Unstageable *12/9/20: 6.27 x 2.95 x 2.82 - 90% eschar - Unstageable (8 days in between measurements, PI is slightly larger) 12/18/20: 5.76 x 2.52 x 2.89 - 100% epithelium - Unstageable 12/23/20: 6.84 x 2.89 x 2.8 - 100% epithelium -Unstageable 1/8/21: 5.19 x 2.39 x 2.9 - 100% epithelium - Unstageable (16 days in between measurements) 1/23/21: 6.79 x 3.21 x 2.58 - 100% epithelium - Unstageable 2/2/21: 4.47 x 2.49 x 2.45 - 100% eschar - Unstageable (16 days in between measurements) 2/4/21: 2.77 x 1.23 x 2.81 - 100% eschar -Unstageable On 2/5/21 R23's Physician documented the following information related to R23's PI. Site 1: Unstageable DTI (Deep Tissue Injury) of the Right Heel: Etiology: Pressure; MDS (Minimum Data Set) 3.0 Stage: Unstageable DTI with intact skin; Duration: Greater than 54 days; Objective: Healing; Wound Size (L x W x D) 3.0 cm x 3.5 cm x not measurable cm; Surface Area: 10.50 cm2; Exudate: None; Dressing treatment plan: [REDACTED]. On 2/10/21 at 2:10 PM, Surveyor observed R23 lying in bed. RN E (Registered Nurse) lifted R23's covers off R23's lower legs and feet in preparation to change R23's dressing to her right heel. Surveyor observed R23's heels directly on the mattress and not floated. Surveyor asked RN E if R23's heels are floated. Surveyor observed RN E slide her hand under R23's heels and stated, Nope. Surveyor asked RN E and IDON B (Interim Director of Nursing) what stage the PI is. IDON B stated the heel is unstageable because of the eschar. RN E added that the eschar is adhered and there is no drainage. On 2/10/21 at 2:56 PM, Surveyor asked RN E if R23's heels should have been floated. RN E stated, Yes. RN E stated, she will be providing education to staff regarding floating heels. On 2/11/21 at 3:37 PM, Surveyor spoke with RN E. Surveyor asked RN E how often are wounds to be measured. RN E stated, Weekly. Surveyor asked RN E what stage was R23's right heel pressure injury when it was first discovered. RN E stated, Unstageable. Surveyor asked RN E if staff do daily foot checks. RN E stated CNAs (Certified Nursing Assistants) check R23's feet two times per day. Surveyor requested R23's daily documented skin checks. The facility did not provide any documentation. Surveyor asked RN E if R23's PI worsened. RN E stated, Yes. Surveyor asked RN E what caused R23's PI to worsen. RN E stated she is unsure. Surveyor asked RN E if the facility determined the root cause analysis of R23's right heel PI. RN E stated, I do not have a root cause analysis identified. Surveyor asked RN E should you have determined the root cause of R23's pressure injury. RN E stated, Yes. Surveyor asked RN E why is it important to determine the root cause of a PI. RN E stated, How do you know how to make it better if you don't know what caused it, right? Surveyor asked RN E do you have any concerns related to the stage of R23's PI's at the time it was identified. RN E stated, she wasn't working at this facility when it was found. Surveyor asked RN E does it concern you that R23's PI was unstageable at the time it was first discovered. RN E stated, Yes, because there's a skin injury. If they (residents) come without one, they're not supposed to get one, it's upon us to do everything we can to prevent it. Surveyor stated R23's right heel PI was measured 12/1/20 and was measured again 12/9/20, eight (8) days later. R23's right heel PI increased in size. Surveyor asked RN E did the facility notify R23's Physician. RN E stated, no. Surveyor asked RN E would you expect the facility to notify R23's Physician when her PI increased in size on 12/9/20. RN E stated, Yes. Example 2 R14 was admitted to the facility 2/20/18 and currently has [DIAGNOSES REDACTED]. R14's Quarterly MDS (Minimum Data Set) assessment, dated 12/9/20, Section C indicates that R14's BIMS (Brief Interview of Mental Status) is 14, indicating she is cognitively intact. Section G, indicates that R14 is dependent on staff for bed mobility, Section M indicates that R14 is at risk for PI development. R14's Braden Score (Risk factor for PI development) on 2/4/21 = 15, indicating R14 is at risk of skin breakdown. R14's Comprehensive Care Plan, dated 2/5/21, addresses a stage 3 PI to R14's lateral right foot/ankle. Goal: My pressure ulcer will show signs of healing, without associated complications (infection), by /through the review date. Interventions: .Float heels as I allow. Manage my co-morbidities and health conditions that can contribute to skin and wound healing. R14's Kardex Care Plan, dated 2/10/21, notes, in part:, under Bed Mobility: Independent. Note, R1's care plan indicates R14 requires 1 assist for bed mobility. R14's Left Lateral Heel - Skin & Wound Evaluation, dated 2/11/21, indicates the following: Type: 4. Blister; Location: Left Heel; Acquired: In-house Acquired; How Long has the Wound Been Present: 1. New; Wound Measurements: 2/11/21: 15.9 cm 2 x 4.6 cm x 4.2 cm; Depth/Undermining/Tunneling: Not applicable; Wound Bed: Slough-20%; Evidence of Infection: None;. R14's Physician notified of open blister to left lateral heel. New orders received for xeroform and border foam to left heel. R14's Skin Checks do not indicate any impairment. There is no documentation in R14's record of daily diabetic foot checks. R14 would be considered at risk for foot ulcer according to AMDA Diabetes Management in the post-acute and long-term care setting. On 2/6/21 the following treatment order was entered. On 2/8/21 R14's Physician signed the treatment order: Wound Care: Left lateral heel. Apply skin prep to large blister nightly. It is important to note there is no measurement or detail regarding this blister when it was identified. Surveyor requested all documentation related to the R14's PI from 2/6/21. No additional documentation was received. On 2/7/21 at 9:56 AM, RN K documented the following Progress Note: Wound Care: Cleanse foot with soap and water. Apply xeroform gauze and cover with a silicon foam border one time a day for wound healing. On 2/9/21 at 9:30 PM, an agency nurse documented the following Progress Note: Large blister to left lateral heel popped, skin prep not applied. New treatment initiated daily until healed. It is important to note that neither IDON B or RN E were informed of this PI until 2/11/21, after it had progressed to an extensive unstageable PI. On 2/11/21 at 2:50 PM, Surveyor entered R14's room with RN K (Registered Nurse) to observe dressing changes. Surveyor observed R14 laying on her left side across the foot of her bed with her feet on the floor, specifically her left lateral foot and heel were directly on the floor. Surveyor observed RN K perform R14's PI treatments. RN K performed the dressing change to R14's left lateral heel. RN K stated this was a blister that opened. Surveyor asked RN K to describe the PI. RN K stated the wound contains 25% slough. RN K stated the blister was first noted on 2/7/21 (note, it was first noted on 2/6/21). Surveyor asked R14 if staff float her heels and explained what that meant. R14 stated when she lays in bed she pushes her feet against the footboard. R14 stated, I'll show you. Surveyor observed R14 lying on her left side, she lifted her right leg and placed the plantar (bottom) surface of her right foot on on the footboard of her bed. R14 demonstrated to Surveyor how she bends her right leg and pushes her right foot against her footboard. Surveyor observed this motion put pressure on her right foot and left lateral foot and heel as it rubbed against the bed creating pressure, shear and friction to the heel. Of note these are key components to PI development. Surveyor asked RN K if it is acceptable for R14 to have her feet directly on the floor. Note, R14 was wearing only gripper socks. RN K stated R14 is able to reposition in bed and will transfer to her wheelchair independently at times. There is no evidence the facility educated R14 regarding the risks and benefits of pushing her feet against her footboard, laying her feet on the floor when she lays across the foot of her bed, or placing pressure on her feet in the presence of a PI. Of note, R14 has [DIAGNOSES REDACTED].) These [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. On 2/11/21 at 3:37 PM, Surveyor spoke with RN E and IDON B (Interim Director of Nursing). Surveyor asked RN E when did you identify the PI on R14's heel. RN E stated, I learned about it today. When would you have expected to be notified. RN E stated, I would have expected to be notified on 2/6/21 (when the blister was identified). Surveyor asked what stage is the PI to R14's left lateral heel. IDON B stated, It's unstageable. Surveyor asked RN E and IDON B have you determined the root cause of R14's PI to her heel. RN E stated, We are in the process of determining the root cause analysis. Note, the facility identified the blister to R14's heel 5 days prior, however, they have not attempted to determine the root cause analysis. Without determining the cause the facility cannot develop an appropriate intervention to prevent PI's or worsening of the PI. RN E added, R14 goes out to [MEDICAL TREATMENT] and we need to determine what kind of chair R14 sits in (most are reclining to elevate feet), look at the foot pedals on wheelchair, re-evaluate the fit of her slippers, evaluate how she self-propels in her wheelchair, and evaluate her mattress. Surveyor shared R14's statement regarding putting her feet on her footboard as well as Surveyor's observation of R14 pushing her right foot against her footboard, which put pressure on her plantar surface of her right foot, in addition to her left left lateral foot and heel as it rubbed against the bed creating pressure, shear and friction to the heel. Surveyor asked RN E and IDON B if they provided risk and benefits to to R14 related to putting her feet on her footboard. IDON B stated, I don't think we knew she was putting her heels on her footboard. RN E added, We're going to be doing that investigation today. Note, the facility has not provided any risks/benefits to R14's related to R14 putting her feet on he footboard of her bed. Surveyor requested daily diabetic foot checks. Note, no documentation was provided. Example 3 - This is example is at a Level 2 R4 was admitted to the facility on [DATE], and re-admitted on [DATE] with the following Diagnosis: [REDACTED]. R4's MDS (Minimum Data Set) dated 11/12/20 shows that R4 has a BIMS of 2, which indicates severe cognitive impairment. Section G shows that R4 requires extensive assist with bed mobility and toilet use, and is completely dependent on staff for transfers and eating. Section M0150 shows that R4 is at risk for developing pressure injuries and section M0210 indicates that R4 does not have any PI. R4's Comprehensive Care Plan dated 12/21/18 and revised on 9/16/20 states .is at risk for alteration in skin integrity related to Braden Score assessment shows risk, Cognitive Impairment, Impaired mobility, Urinary incontinence. Interventions include, in part: I use a pressure relieving mattress on my bed, routinely turn and reposition every 2 hours as tolerated by patient, use a pressure relieving cushion in my wheelchair. On 2/10/21 at 12:56 PM, Surveyor observed R4's skin with CNA J (Certified Nursing Assistant). R4 was observed with an excoriated buttocks and a dime sized area on his coccyx that appeared to be a DTI (Deep Tissue Injury). Surveyor asked CNA J if she knew how long R4's buttocks had looked like this way, CNA J reported 1-2 weeks. On 2/10/21 at 1:25 PM, Surveyor interviewed LPN D (Licensed Practical Nurse) and asked if she was going to be working with R4. LPN D stated she was looking at R4's treatments because the CNA was wondering if R4 had treatments to his buttocks. LPN D stated she looked at R4's bottom and stated he had a small spot/bruise on his left upper buttock and a red area on his left hip. On 2/10/21 at 3:30 PM, Surveyor reviewed R4's nurse's notes, LPN D did not chart any skin irregularities for R4. Surveyor reviewed the Weekly Skin Check dated 2/5/20 completed by RN C that indicated R4 had a pressure injury to his sacrum. There was no wound assessment or documentation in the nurse's notes, MD was not updated, APOA (Activated Power of Attorney) was not updated, and treatment orders were not obtained. On 2/10/21 at 3:16 PM, Surveyor interviewed RN C. Surveyor asked RN C what is the facility's process when you discover a new PI, RN C stated they update the NP and DON, put in a progress note, update family, and get a treatment order. Surveyor asked RN C about the Weekly Skin Check she completed on 2/5/20, for R4. RN C stated the PI was not new and R4 had a dressing on the area previously. It is important to note R4 did not have any documentation or treatment orders for a PI previously. On 2/10/21 at 3:24 PM, Surveyor interviewed RN E. Surveyor asked RN E about the PI to R4's sacrum, RN E stated she was unaware of a PI for R4 and he is not currently on the weekly wound rounds. Surveyor discussed the Weekly Skin Check with RN E. Surveyor asked RN E if she would expect RN C to document the wound and update the NP, RN E stated yes. Surveyor asked RN E if she would expect LPN D would document a bruise, RN E stated yes. On 2/11/21, Surveyor reviewed nurse's notes and wound assessment for R4. The wound assessment identified a DTI, treatment orders were obtained and APOA updated. Care plan interventions were updated to include air mattress to bed. On 2/11/21 at 10:00, Surveyor observed an Air Element air mattress on R4's bed. R4 was sitting in the recliner without a pressure relieving cushion under him. On 2/11/21 at 10:14 AM, Surveyor interviewed RN E. Surveyor asked RN E if a resident has a care plan intervention for a pressure relieving cushion in their chair, would you expect the cushion to be in the chair, RN E stated yes.

Based on interview and record review the facility failed to provide basic life support, including CPR (Cardiopulmonary resuscitation), to a resident requiring emergency care and failed to notify emergency medical personnel for 1 of 3 total sampled Residents (R1). R1 was found pulseless and not breathing on [DATE]. R1's Physician order [REDACTED]. Facility failure to begin cardiopulmonary resuscitation and for failing to call 911, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator), DON B (Director of Nursing) CN F (Corporate Nurse) and CN G of the immediate jeopardy on [DATE] at 4:40 PM. The immediate jeopardy was removed on [DATE]. However the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: Per CMS (Centers for Medicare and Medicaid Services) Cardiopulmonary resuscitation (CPR) refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. Per The American Heart Association, all potential rescuers are to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. Per CMS, when addressing full-code residents: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services. Facility Policy entitled 'Cardio-Pulmonary Resuscitation,' revised on [DATE], states, in part: Purpose: To ensure that all Advanced Directives for each and every resident are individualized by/for that resident, documented and effectively implemented at the facility and that for those residents without an advanced directive or DNR order, full CPR is performed unless clinically contraindicated. Policy: .4. If a resident becomes unresponsive (either witnessed or unwitnessed) the resident's advanced directives/POLST (Physicians Order For Life Sustaining Treatment) will be followed. 5. CPR is to be initiated unless: a. obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or b. initiating CPR could cause injury or peril to the rescuer . Procedure: If a resident is a full code status the following applies: 1. Determine unresponsiveness by shouting are you okay and/or gently shaking or tapping resident. 2. If no response, call for help of other staff members. 3. Instruct other staff responding to scent to obtain emergency supplies and notify [DATE] or emergency personnel. Do not leave Resident. 4. If resident is not face-up, re-position to a face-up position while supporting head, neck and back. To perform CPR ensure resident is placed on a backboard or hard surface. 5. Check resident for breathing or gasping breath while simultaneously checking for a pulse. If either or both are absent initiate CPR. 6. Follow CPR instructions as per American Health Association Healthcare Provider steps . 7. When EMS arrives, they become lead in the resuscitation effort. Follow their directives. 8. Contact resident's physician and family. 9. Document events in medical record . R1 was admitted on [DATE] with [DIAGNOSES REDACTED]. R1's Admission MDS (Minimum Data Set) dated [DATE] indicates that R1 has a BIMS (Brief Interview of Mental Status) of a 4 out of 15 indicating severe cognitive impairment. R1 is dependent on staff for assistance with bed mobility, transfers, toileting and eating. R1's February 2020 MAR (Medication Administration Record) states, in part: Advance Directive Full Code. R1's Care Plan, initiated on [DATE], states, in part: The Resident has advance directives/wishes in place full code . interventions: Code Status: Full Code. R1's Physician Orders, signed on [DATE], state, in part: Full code . order status: active. Order date: [DATE]. R1's [DATE] MAR indicated [REDACTED]. R1 was admitted to Hospice on [DATE]. R1's Hospice Comprehensive Assessment and Plan of Care update report, faxed on [DATE], states, in part: Code Status: Full code. R1's Hospice Visit Note Report, dated [DATE], signed by Hospice RN E (Hospice Registered Nurse), states, in part: In home time began [DATE] at 7:35 AM.Patient Passed. Comments related to death: when writer arrived, patient was not breathing and had no pulse. Patient appeared to have passed peacefully.Narrative: Writer arrived for routine visit, upon assessment patient not breathing and no pulse. Auscultated for 2 minutes, pulse and breath sounds absent. Spoke with daughter (name) and son (name) who said it would be best to not perform chest compressions as it was unknown how long patient had not been breathing. Patient appeared peaceful. Daughter (name) arrived and was tearful but coping appropriately. Low bereavement risk . There is no indication of what time this hospice narrative note was created on [DATE]. On [DATE] at 16:45 (4:45 PM) R1's Nurses Note, states, in part: reported from day shift nurse that resident expired at 0752 this am; body removed from facility at 1645 with all family present and offered no questions at this time; procession provided by staff with funeral director. There is no indication in R1's chart regarding what occurred during R1's passing, whether CPR was initiated or 911 was called. On [DATE] at 12:53 PM, Surveyor interviewed Hospice RN E regarding R1. Hospice RN E indicated she went to the facility to do a routine visit. Hospice RN E indicated when she got to the facility on [DATE], R1 did not appear to be breathing. Hospice RN E indicated she tried to call R1's son and could not get a hold of him, and called R1's daughter. Hospice RN E indicated she told R1's daughter it was unknown how long R1 has not been breathing and that her daughter said no to doing CPR. Hospice RN E indicated she was at the facility around 7:30 AM on [DATE]. Surveyor asked Hospice RN E what she would do if finding a full code hospice patient pulseless and not breathing, Hospice RN E stated, We don't do CPR, yes she was a full code. Hospice RN E indicated that if we find someone, we tell the facility or call 911. Surveyor asked if anyone at the facility was notified, Hospice RN E indicated that an aide walked into R1's room after her and that they (facility staff) were fully aware and the nurse went in. Hospice RN E indicated that the facility did not start compressions and did not call 911. On [DATE] at 1:18 PM, Surveyor interviewed Hospice RN E regarding R1. Hospice RN E indicated from what she remembers, she doesn't recall mottling, and R1's skin wasn't super cool, as if she was laying there for a while. Hospice RN E indicated she just saw that she was not breathing. On [DATE] at 12:39 PM, Surveyor interviewed LPN C (Licensed Practical Nurse) regarding R1 on [DATE]. LPN C indicated she started her medication pass per normal and knew R1 would get a nebulizer treatment and that RN D was training with her. LPN C indicated that RN D went into check on R1 and came out and said I don't think she's breathing. LPN C indicated that the CNA indicated that he/she didn't think she was breathing when he/she did cares. (LPN C is unable to say who the CNA was). LPN C indicated she checked R1's vitals before 7:00 AM, and R1 had no blood pressure, no pulse, and no lung sounds. LPN C indicated she told the Hospice personnel who was there (could not remember if it was a nurse or an aide). LPN C indicated that R1 was cool to the touch and did not have mottling or stiffness. LPN C indicated that she assumed R1 was a DNR due to being Hospice. LPN C indicated she was not aware that R1 was a full code as she never double checked on R1's code status. LPN C indicated that RN D found R1 not Hospice. LPN C indicated she asked hospice about R1 and was not able to verify if R1 was alive and breathing when hospice was doing cares. On [DATE] at 1:03 PM, Surveyor interviewed RN D regarding R1 on [DATE]. RN D indicated she went into R1's room and Hospice was in there with R1. RN D indicated she looked at R1 and that R1 looked like she passed away. RN D indicated that Hospice personnel said to her that R1 was a full code, she wasn't breathing and had no heart rate. RN D indicated R1 did not seem to have mottling and that she felt like she hadn't been dead long. Surveyor asked RN D to walk her through what to do if finding a full code resident pulseless and not breathing, RN D indicated, Well the hospice lady was running the show. RN D indicated that she does not know whether CPR should have been initiated on R1 or not. RN D indicated they were unaware of how long she'd been gone. On [DATE] at 12:20 PM, Surveyor interviewed CN G (Corporate Nurse) and CN F regarding R1. CN F indicated the Hospice nurse entered the room and declared her deceased . CN G indicated per Hospice, the nurse talked to our CNA who was in R1's room prior and said she was okay and then when Hospice RN E found obvious signs of death, she determined she was deceased , as Hospice is able to declare death. On [DATE] at 9:54 AM, Surveyor interviewed POA H (Power of Attorney) regarding R1. POA H indicated that the facility would not give her information, and that she is unaware of what went on. POA H indicated that no one from the facility talked to her brother, who is R1's other POA. POA H indicated that R1 was a full code and that she received a call around 7:52 AM on [DATE], telling her they were not sure how long R1 has been without a pulse. POA H indicated the person on the phone asked her if I wanted her revived. POA H indicated she questioned why they would call me and say she doesn't have vitals and then ask if I wanted her revived when she's a full code. On [DATE] at 12:51 PM, Surveyor interviewed POA H a second time related to R1. POA H indicated she told them (staff) not to touch her and asked why they didn't initiate CPR. POA H indicated that staff did not answer that question. R1's Cause of Death form, dated [DATE], indicates Diastolic heart failure, stage 4 [MEDICAL CONDITION] and NSTEMI with years in between onset and death. On [DATE] at 3:49 PM, Surveyor interviewed MD J (Medical Director) regarding R1. Surveyor asked if CPR should be initiated on a Resident who is a full code, MD J stated, Yes, along with dialing 911 for help. MD J indicated that if someone knew she (R1) was a full code, with good communication and knowledge of being a full code, yes they're to initiate CPR and dial 911. The failure to begin cardiopulmonary resuscitation and for failing to call 911, created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: The facility will immediately complete a root cause analysis regarding incident with (R1) and implement immediate interventions as detailed below to prevent future incidents. Root cause determined to be communication issue between Hospice nurse and facility staff. The facility will immediately conduct an in-house chart audit of all patients signed code status to include advance directive forms, physician order [REDACTED]. Completed [DATE]. The facility will audit all RN and LPN CPR certifications to ensure up to date. Completed [DATE]. All Hospice providers contacted and provided education regarding process expectations upon finding a Full Code Resident pulseless or breathless. Hospice provider must immediately alert Facility staff of code and stay with the Resident. Facility staff will initiate CPR. Education started on [DATE] and will continue until all hospice staff educated. All staff, including agency and contracted staff, will be educated prior to their next working shift on the following: 1. Identification of code status: Full code vs. DNR and need to immediately initiate CPR for all residents deemed Full code to include all residents even those on Hospice Services. 2. All Hospice personnel will immediately be educated on the need to follow Residents wishes including providing CPR to those residents requesting CPR and to immediately initiate emergency procedures when a resident is deemed full code. CPR code drill conducted [DATE]. Like Residents: House Audit conducted of all Residents' code status on [DATE]. There are currently no Residents in house on Hospice Services that is also a full code. Validation of CPR certification to be completed upon employment and annually upon license verification on [DATE]; to be completed by HR (Human Resources) or designee. Verified all Residents' current code status accurately reflected in PCC on banner in both POC (Point of Care) and PCC (Point Click Care) on [DATE]. All staff including agency and contracted staff, will be educated prior to their next working shift on the following: 1. Identification of code status: Full code Vs. DNR and need to immediately initiate CPR for all residents deemed full code to include all residents even those on Hospice Services. 2. All Hospice personnel will immediately be educated on the need to follow residents wishes including providing CPR to those residents requesting CPR and to immediately initiate emergency procedures when a resident is deemed full code. All Hospice providers contacted and provided education regarding process expectations upon finding a full code resident pulseless or breathless. Hospice provider must immediately alert facility staff of code and stay with the Resident. Facility staff will initiate CPR. System Correction: Facility will immediately review, update and educate all staff on CPR Policy and Procedure related to current American Heart Association (AHA) recommendations for providing CPR. System correction is focused on education related to following code status. Education will include all nursing staff and will be ongoing until all staff are educated. Staff will receive education prior to their next shift. Hospice Residents that also have a full code status will have this status clearly outlined on their PCC (point click care) and POC (Point of Care) banner. All hospice providers contacted and provided education regarding process expectations upon finding a full code resident pulseless or breathless. Hospice provider must immediately alert facility staff of code and stay with the Resident. Facility staff will initiate CPR. Changes in code status will be discussed in the morning meeting. Unit managers will update licensed status in the event of change of code status after the morning meeting. Care plans and code status demonstration will be updated on resident's records. Mock code blue drills will be immediately conducted on every shift starting [DATE] for 1 week, then weekly x 4 (times four), and monthly thereafter. Results will be reviewed at QAPI. Education - was initiated immediately: Education regarding emergency response and CPR initiation initiated immediately. Education will include all nursing staff and will be on going until all staff are educated. Staff will receive education prior to their next shift. Education is being issued via in-person in-servicing. Phone education is being implemented to target staff members who are not in the facility with validation by signature prior to the start of their next shift. A facility master staff roster is presently utilized to ensure staff members receive education. All Hospice providers contacted and provided education regarding process expectations upon finding a full code resident pulseless or breathless. Hospice provider must immediately alert facility staff of code and stay with the Resident. Facility will initiate CPR. Monitoring: DON or Designee is responsible to complete QA (Quality Assurance) tool on: Code status audits of new admits daily x 1 week, 3 x/week x 3 weeks, and weekly x 1 month. Code status then reviewed with quarterly care plan review and at the time of Hospice Service Admission. Mock code blue drills will be immediately conducted on every shift starting [DATE] for 1 week, then weekly x 4, and monthly thereafter. Results will be reviewed at QAPI. Summation of audit tool presented quarterly to QAPI (Quality Assurance and Performance Improvement) Committee. The Medical Director was updated on this correction and removal-abatement plan as well as occurrences of which this plan pertains. Monitoring will be initiated and completed by the Administrator and/or designee as indicated above. Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI (Quality Assurance Performance Improvement) committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits will be determined at that time. If issues are identified, re-education will be completed. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed and revisions will be made as deemed necessary.

Based on interview and record review the facility failed to ensure Hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 or 2 Hospice residents out of a total sample of 3 Residents (R1). R1's plan of care was not coordinated and communicated adequately between the facility and Hospice. The hospice service agreement did not specify if hospice staff would or would not provide cardiopulmonary resuscitation (CPR). R1 desired to be a full code and CPR was not initiated when the hospice nurse found R1 pulseless and nonbreathing. Facility failure to coordinate care with hospice, for failing to know, and for failing to spell out in the hospice service agreement, what care hospice would and would not provide, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator), DON B (Director of Nursing), CN F (Corporate Nurse) and CN G of the immediate jeopardy on [DATE] at 4:40 PM. The immediate jeopardy was removed on [DATE]. However the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: Facility Policy entitled 'Hospice,' dated [DATE], states, in part: It is the policy of (Name of company) to follow a written procedure for admitting and caring for a resident choosing to be on Hospice and to ensure the facility communicates, establishes, and agrees upon a coordinated plan of care for both providers which reflects the hospice philosophy, and is based on an individualized assessment of the resident's needs. New referral process: . The resident must meet Hospice criteria: life expectancy of 6 months or less, opt for palliative care, and preferably be a DNR (Do not Resuscitate) status . Skilled Nursing: . A completed hospice care plan must be made available for the resident's chart from hospice.Care Plans: The hospice nurse and IDT will develop the hospice portion of the care plan.The skilled nursing facility care plan will be merged with the hospice plan of care so the resident will have an integrated plan of care. The joint care plan will be kept in the care plan section of the resident's chart. Facility Contract/Agreement, for Hospice states, in part: 4. Duties and obligations of facility.4.1 Services. Facility will furnish to Hospice Patients all services needed to meet the personal care and nursing needs that would have been provided by the primary caregiver at home at the same level of care provided before hospice care was elected . 4.11 Staff Qualifications. All Facility staff who render services of any kind to Hospice Patients under this Agreement must be fully qualified, licensed, certified and registered, as applicable in accordance with applicable federal, state and local laws and must act only within the scope of their state license, certification, or registration in their respective disciplines and in compliance with professional standards . 7. Advance Directives. Hospice and Facility will comply with federal Patient Self-Determination Act. Hospice and Facility will inform each Hospice patient about advance directives under applicable state law . The facility's service agreement with hospice does not outline the responsibilities of either the hospice staff or the facility staff when a full-code resident is found pulseless and non-breathing. Hospice Agency's Policy, entitled 'Resuscitative Guidelines,' dated ,[DATE], states in part: 1. (Agency Name) employees are not required to be certified in CPR in order to perform basic life support in an emergency. 2. Hospice patients and families are informed regarding resuscitative guidelines verbally and in writing included in the Admission Supplement. 3. Each agency is responsible to know and adhere to any state specific regulations related to CPR. 4. In the event an employee encounters a patient who is a full code: a. If comfortable performing and or has training in basic life support, call 911 and initiate CPR. b. If no training or uncomfortable with initiating basic life support, call 911. 5. If states require staff to provide resuscitative measures, the agency will be responsible for ensuring staff complete necessary CPR certification courses (online CPR certification is not acceptable). R1 was admitted on [DATE] with [DIAGNOSES REDACTED]. R1 was admitted to Hospice on [DATE]. R1's Hospice Comprehensive Assessment and Plan of Care update report, faxed on [DATE], states, in part: Code Status: Full code. R1's Hospice Visit Note Report, dated [DATE], signed by Hospice RN E (Hospice Registered Nurse), states, in part: In home time began [DATE] at 7:35 AM.Patient Passed. Comments related to death: when writer arrived, patient was not breathing and had no pulse. Patient appeared to have passed peacefully.Narrative: Writer arrived for routine visit, upon assessment patient not breathing and no pulse. Auscultated for 2 minutes, pulse and breath sounds absent. Spoke with daughter (name) and son (name) who said it would be best to not perform chest compressions as it was unknown how long patient had not been breathing. Patient appeared peaceful. Daughter (name) arrived and was tearful but coping appropriately. Low bereavement risk . There is no indication of what time this hospice narrative note was created on [DATE]. On [DATE] at 16:45 (4:45 PM) R1's Nurses Note, states, in part: reported from day shift nurse that resident expired at 0752 this am; body removed from facility at 1645 with all family present and offered no questions at this time; procession provided by staff with funeral director. There is no indication in R1's chart regarding what occurred during R1's passing, whether CPR was initiated or 911 was called. On [DATE] at 12:53 PM, Surveyor interviewed Hospice RN E regarding R1. Hospice RN E indicated she went to the facility to do a routine visit. Hospice RN E indicated when she got to the facility on [DATE], R1 did not appear to be breathing. Hospice RN E indicated she tried to call R1's son and could not get a hold of him, and called R1's daughter. Hospice RN E indicated she told R1's daughter it was unknown how long R1 has not been breathing and that her daughter said no to doing CPR. Hospice RN E indicated she was at the facility around 7:30 AM on [DATE]. Surveyor asked Hospice RN E what she would do if finding a full code hospice patient pulseless and not breathing, Hospice RN E stated, We don't do CPR, yes she was a full code. Hospice RN E indicated that if we find someone, we tell the facility or call 911. Surveyor asked if anyone at the facility was notified, Hospice RN E indicated that an aide walked into R1's room after her and that they (facility staff) were fully aware and the nurse went in. Hospice RN E indicated that the facility did not start compressions and did not call 911. On [DATE] at 1:18 PM, Surveyor interviewed Hospice RN E regarding R1. Hospice RN E indicated from what she remembers, she doesn't recall mottling, and R1's skin wasn't super cool, as if she was laying there for a while. Hospice RN E indicated she just saw that she was not breathing. There is no indication that Hospice RN E told facility staff that R1 was full code, if the facility staff were told to initiate CPR or call 911. There is no indication documented as to why Hospice RN E did not initiate CPR on R1 or call 911 herself. On [DATE] at 11:49 AM, NHA A came to Surveyor and indicated that a CNA had been in there 10 minutes prior. On [DATE] at 12:39 PM, Surveyor interviewed LPN C (Licensed Practical Nurse) regarding R1 on [DATE]. LPN C indicated she started her medication pass per normal and knew R1 would get a nebulizer treatment and that RN D was training with her. LPN C indicated that RN D went into check on R1 and came out and said I don't think she's breathing. LPN C indicated that the CNA indicated that he/she didn't think she was breathing when he/she did cares. (LPN C is unable to say who the CNA was). LPN C indicated she checked R1's vitals before 7:00 AM, and R1 had no blood pressure, no pulse, and no lung sounds. LPN C indicated she told the Hospice personnel who was there (could not remember if it was a nurse or an aide). LPN C indicated that R1 was cool to the touch and did not have mottling or stiffness. LPN C indicated that she assumed R1 was a DNR due to being Hospice. LPN C indicated she was not aware that R1 was a full code as she never double checked on R1's code status. LPN C indicated that RN D found R1 not Hospice. LPN C indicated she asked hospice about R1 and was not able to verify if R1 was alive and breathing when hospice was doing cares. There is no indication that Hospice RN E informed LPN C that R1 was a full code, or instructed LPN C to start CPR or to call 911. On [DATE] at 1:03 PM, Surveyor interviewed RN D regarding R1 on [DATE]. RN D indicated she went into R1's room and Hospice was in there with R1. RN D indicated she looked at R1 and that R1 looked like she passed away. RN D indicated that Hospice personnel said to her that R1 was a full code, she wasn't breathing and had no heart rate. RN D indicated R1 did not seem to have mottling and that she felt like she hadn't been dead long. Surveyor asked RN D to walk her through what to do if finding a full code resident pulseless and not breathing, RN D indicated, Well the hospice lady was running the show. RN D indicated that she does not know whether CPR should have been initiated on R1 or not. RN D indicated they were unaware of how long she'd been gone. On [DATE] at 12:20 PM, Surveyor interviewed CN G (Corporate Nurse) and CN F regarding R1. CN F indicated the Hospice nurse entered the room and declared her deceased . CN G indicated per Hospice, the nurse talked to our CNA who was in R1's room prior and said she was okay and then when Hospice RN E found obvious signs of death, she determined she was deceased , as Hospice is able to declare death. On [DATE] at 9:54 AM, Surveyor interviewed POA H (Power of Attorney) regarding R1. POA H indicated that the facility would not give her information, and that she is unaware of what went on. POA H indicated that no one from the facility talked to her brother, who is R1's other POA. POA H indicated that R1 was a full code and that she received a call around 7:52 AM on [DATE], telling her they were not sure how long R1 has been without a pulse. POA H indicated the person on the phone asked her if I wanted her revived. POA H indicated she questioned why they would call me and say she doesn't have vitals and then ask if I wanted her revived when she's a full code. On [DATE] at 12:51 PM, Surveyor interviewed POA H a second time related to R1. POA H indicated she told them (staff) not to touch her and asked why they didn't initiate CPR. POA H indicated that staff did not answer that question. On [DATE] at 1:52 PM, Surveyor interviewed CN F and CN G regarding R1. CN G indicated for R1 signs of death is absence of breath and no pulse. CN F and CN G both indicated they were unaware that hospice does not do CPR per Hospice RN E. On [DATE] at 2:15 PM, Surveyor interviewed NHA A regarding Hospice initiating CPR. NHA A indicated that she was unaware that Hospice does not initiate CPR. On [DATE] at 4:19 PM, Surveyor interviewed Hospice DPS I (Director of Professional Services) regarding CPR. Hospice DPS I indicated the facility receives a copy of admission paper work, and would have code status on hand. Hospice DPS I indicated if deceased for a while, CPR would not be initiated, would call 911 as it depends on the clinician's comfortability with initiating CPR. Hospice DPS I indicated if the clinician is not comfortable they're to call 911 for a full code. Surveyor asked Hospice DPS I about R1 being a full code, Hospice DPS I indicated, it depends, if they're dead and have been dead whether or not CPR should be started, but our policy states to call 911. Hospice DPS I indicated Hospice policies and procedures are sent over if requested. Hospice DPS I indicated she faxed the policy to the facility. There is no evidence that the facility requested policies and procedures from Hospice for advance directives prior to [DATE]. On [DATE] at 3:49 PM, Surveyor interviewed MD J (Medical Director) regarding R1. MD J indicated that if someone knew she (R1) was a full code, with good communication and knowledge of being a full code, yes they're to initiate CPR and dial 911. The failure to coordinate care with hospice, for failing to know, and for failing to spell out in the hospice service agreement, what care hospice would and would not provide, created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: The facility will immediately completed a root cause analysis regarding incident with (R1) and implement immediate interventions as detailed below to prevent future residents. Root cause determined to be communication issue between Hospice nurse and facility staff. The facility will immediately conduct an in-house chart audit of all patients signed code status to include advance directive forms, physician order [REDACTED]. Completed [DATE]. The facility will audit all RN and LPN CPR certifications to ensure up to date. Completed [DATE]. All Hospice providers contacted and provided education regarding process expectations upon finding a Full Code Resident pulseless or breathless. Hospice provider must immediately alert Facility staff of code and stay with the Resident. Facility staff will initiate CPR. Education started on [DATE] and will continue until all hospice staff educated. All staff, including agency and contracted staff, will be educated prior to their next working shift on the following: 1. Identification of code status: Full code vs. DNR and need to immediately initiate CPR for all residents deemed Full code to include all residents even those on Hospice Services. 2. All Hospice personnel will immediately be educated on the need to follow Residents wishes including providing CPR to those residents requesting CPR and to immediately initiate emergency procedures when a resident is deemed full code. CPR code drill conducted [DATE]. Like Residents: House Audit conducted of all Residents' code status on [DATE]. There are currently no Residents in house on Hospice Services that is also a full code. Validation of CPR certification to be completed upon employment and annually upon license verification on [DATE]; to be completed by HR (Human Resources) or designee. Verified all Residents' current code status accurately reflected in PCC on banner in both POC (Point of Care) and PCC (Point Click Care) on [DATE]. All staff including agency and contracted staff, will be educated prior to their next working shift on the following: 1. Identification of code status: Full code Vs. DNR and need to immediately initiate CPR for all residents deemed full code to include all residents even those on Hospice Services. 2. All Hospice personnel will immediately be educated on the need to follow residents wishes including providing CPR to those residents requesting CPR and to immediately initiate emergency procedures when a resident is deemed full code. All Hospice providers contacted and provided education regarding process expectations upon finding a full code resident pulseless or breathless. Hospice provider must immediately alert facility staff of code and stay with the Resident. Facility staff will initiate CPR. System Correction: Facility will immediately review, update and educate all staff on CPR Policy and Procedure related to current American Heart Association (AHA) recommendations for providing CPR. System correction is focused on education related to following code status. Education will include all nursing staff and will be ongoing until all staff are educated. Staff will receive education prior to their next shift. Hospice Residents that also have a full code status will have this status clearly outlined on their PCC (point click care) and POC (Point of Care) banner. All hospice providers contacted and provided education regarding process expectations upon finding a full code resident pulseless or breathless. Hospice provider must immediately alert facility staff of code and stay with the Resident. Facility staff will initiate CPR. Changes in code status will be discussed in the morning meeting. Unit managers will update licensed status in the event of change of code status after the morning meeting. Care plans and code status demonstration will be updated on resident's records. Mock code blue drills will be immediately conducted on every shift starting [DATE] for 1 week, then weekly x 4 (times four), and monthly thereafter. Results will be reviewed at QAPI. Education - was initiated immediately: Education regarding emergency response and CPR initiation initiated immediately. Education will include all nursing staff and will be on going until all staff are educated. Staff will receive education prior to their next shift. Education is being issued via in-person in-servicing. Phone education is being implemented to target staff members who are not in the facility with validation by signature prior to the start of their next shift. A facility master staff roster is presently utilized to ensure staff members receive education. All Hospice providers contacted and provided education regarding process expectations upon finding a full code resident pulseless or breathless. Hospice provider must immediately alert facility staff of code and stay with the Resident. Facility will initiate CPR. Monitoring: DON or Designee is responsible to complete QA (Quality Assurance) tool on: Code status audits of new admits daily x 1 week, 3 x/week x 3 weeks, and weekly x 1 month. Code status then reviewed with quarterly care plan review and at the time of Hospice Service Admission. Mock code blue drills will be immediately conducted on every shift starting [DATE] for 1 week, then weekly x 4, and monthly thereafter. Results will be reviewed at QAPI. Summation of audit tool presented quarterly to QAPI (Quality Assurance and Performance Improvement) Committee. The Medical Director was updated on this correction and removal-abatement plan as well as occurrences of which this plan pertains. Monitoring will be initiated and completed by the Administrator and/or designee as indicated above. Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI (Quality Assurance Performance Improvement) committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits will be determined at that time. If issues are identified, re-education will be completed. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed and revisions will be made as deemed necessary.

Based on interview and record review the facility did not ensure staff had the proper qualifications to administered medications. This has the potential to affect approximately 36 of 56 residents. CMA C (Certified Medical Assistant) was passing medications in a skilled nursing facility without the appropriate qualifications. On 2/26/20, CMA C administered ten times the prescribed dose of [MEDICATION NAME] to R1. Review of facility schedules finds CMA C routinely passed medications on the 300/400 units and had been doing so since July 2019. The facility's failure to ensure staff had the appropriate credentials to perform the tasks assigned to them created a finding on immediate jeopardy that began on 7/31/19. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 3/3/20 at 10:30 AM. The facility removed the jeopardy on 3/3/20; however, the deficient practice continues at a scope/severity level of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. This is evidenced by: According to Wisconsin Administrative Code for Nursing Homes, DHS 132.60(5)(d)2, `Personnel who may administer medications.' In a nursing home, medication may be administered only by a nurse, a practitioner, as defined in s. 450.01 (17), Stats., or a person who has completed training in a drug administration course approved by the department. The Facility's Policy and Procedure entitled Administering Medications with a revision date of 2/6/17 documents, in part: .1. Only person licensed or permitted by this State may prepare, administer or record the administration of medications. Nursing personnel who are authorized to administer medications include: Registered Nurses and Licensed Practical Nurses .3. Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified and the medication is labeled according to accepted standards . A CMA (Certified Medical Assistant) does not hold the credentials needed to pass medications in a skilled nursing facility. In order to pass medications in a skilled nursing facility, a person must be a Certified Medication Assistant, a licensed nurse, or be currently enrolled in a nursing school and have completed certain courses in pharmacology. Certified nursing assistants who become certified medication aides in Wisconsin must, per DHS 129.24(1), Wis. Administrative Code, complete coursework that includes: (c) Legal and ethical considerations. 1. Federal and state nursing home standards, regulations, statutes, and administrative rules. 2. Standards of Practice for Registered Nurses and Licensed Practical Nurses, ch. N 6 specific to registered nurse delegation. 3. Professional and staff roles and liabilities. 4. Resident rights regarding administration of medications. 5. Confidentiality of information related to residents. 6. Facility policies and procedures for administration of medications. (d) Overview of body systems related to routes of medication administration and the classes of medications. 1. Anatomy of body structures that pertain to medication administration, including structure of the eye, ear, nose, mouth, vagina, rectum, and skin, which are necessary to administer medication correctly via these routes. 2. Functions of these body structures that impact medication administration and effectiveness. 3. Diseases of these body structures that impact medication administration and medication effectiveness. Note: Examples of anatomy, function and diseases are provided in the curriculum development guide. (e) Medication fundamentals, including: 1. Medication orders. 2. Medication mathematics, weights and measures. 3. Dosage forms, including pills, capsules, ointments, patches, and suppositories. 4. Drug effects and actions. 5. Classes or types of commonly used medications in nursing homes. 6. Use of the drug or drug indication. 7. Side effects of the medications. 8. Specific medication administration requirements. Note: [MEDICAL CONDITION] is not part of the basic medication aide course. 9. Medication packaging systems. 10. Medication storage, destruction or return of medication. (f) Medication administration. 1. Techniques and procedures of various routes of medication administration. Note: Injections, and medications administered via a tube, a nebulizer, or an oxygen route will not be evaluated as part of the basic nursing home medication aide curriculum. 2. Six rights of medication administration, including right patient, right drug, right dose, right route, right time, and right documentation. (g) Observations, communication, and reporting. Requirements for timely reporting and documenting the administration of all medication, including the need for PRN medications and the resident's response, refusal to take medication, omission of medications, errors in the administration of medication and drug reactions and any change in the condition of a resident. (h) Medication safety. 1. Prevention of medication errors. 2. Causes and reporting of medication errors. Surveyor requested Policy and Procedure for CMAs from NHA A (Nursing Home Administrator) on 3/2/2020 at 4:50 PM. At 5:27 PM on 3/2/2020 NHA A reported that they do not have a Policy and Procedure for CMA's but they had been utilizing the Medication Aide Responsibility Job Description undated. CMA C has been employed at this facility since 12/11/13 when she was hired as a CNA (Certified Nursing Assistant). CMA C obtained the Medical Assistant certification 6/29/15. She began passing medications sometime in July 2019. Per the Facility's 2020 schedules, CMA C worked in the capacity of passing medications 19.5 shifts in January, 21 shifts in February, and 2 shifts in March. On 2/26/20, CMA C administered [MEDICATION NAME] to R1. R1 was to receive a 5 mg dose. Instead, CMA C administered a 50 mg dose. Part of the Facility's investigation into R1's medication error was a statement from CMA C (Certified Medical Assistant). It documents: On Wednesday 2/26/20 around 10:00 AM. I drew up [MEDICATION NAME] for resident (R1), as instructed by the hospice nurse. The order on the MAR indicated [REDACTED]{sic} I've never given that much [MEDICATION NAME] before, so I questioned it. I asked the nurse I was working with, DON B (Director of Nursing), Is this the right order on the MAR? She stated that it was and I asked again. She was unaware of the change of dose and/or different bottle we had received from the pharmacy. The order should have been changed and confirmed on the MAR indicated [REDACTED]. This did not happen. I thought I was giving the right dose as instructed. I mixed it with applesauce after asking if this was okay. The patient refused the medication. I left it with the hospice nurse so that she could try to re-attempt. She was successful and she informed me of this. I was still questioning this dose after the fact and this is when DON B called NP (Nurse Practitioner) and made interventions. {sic} Per R1's Nurses Note dated 2/26/2020 at 17:00 (5:00 PM), documents: At approximately 1450 (2:50 PM) I (DON B) was alerted by the med tech, she stated that the residents' family had concerns of a possible change in her breathing pattern. While walking to room the med tech alerted me of a possible suspected drug overdose involving [MEDICATION NAME]. As the pharmacy sent two different [MEDICATION NAME] orders with different concentration amounts. This writer immediately went to residents room to assess her heart rhythm, breathing patterns and O2 (oxygen) saturations. Upon arrival resident was lying in bed resting peacefully, no signs of distress or cyanosis, no use of accessory muscles. During entire ordeal the resident never lost consciousness and was alert and responsive to speech, She made eye contact when name was called. Pulse ranged from 60 to 68, respirations 16 to 18 even, non labor, blood pressure 135 / 73, O2 saturation 93 to 95% on Room air. This writer immediately contacted hospice to let them know of the possible overdose, hospice nurse then instructed me to call NP. I received a verbal order to give [MEDICATION NAME] after I had given report of resident condition and vital signs. I administered [MEDICATION NAME] and called 911 per order. Residents family in agreement, Resident transferred out via ambulance to ER (emergency room ). DON B was given an order to administer [MEDICATION NAME] to R1 as a result of this medication error. [MEDICATION NAME] is a narcotic antagonist which is used to counteract the effects of narcotics (it can treat narcotic overdose in an emergency situation). Of note, from 1/1/20 through 3/2/20 there were 3 of 6 residents with orders for [MEDICATION NAME] Solution that resided on the 300/400 units where CMA C was scheduled to work. On 3/2/20 at 4:00 PM, Surveyor interviewed NHA A. Surveyor asked NHA A when CMA C began working in the role of passing medications, NHA A said July of 2019. Surveyor asked NHA A for all CMA C's training records related to medications. NHA A returned with a folder that did not include any training records. Folder did include a job description for a Nurse Technician and a job description for a Certified Medication Assistant. Surveyor asked NHA A if CMA C was in nursing school, NHA A said no. On 3/20/2020 at 4:50 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if CMA C had any training on medications prior to R1's medication error, NHA A said Not that I can find. Surveyor asked NHA A if CMA C was working anywhere else, NHA A stated, No, she is full time here. Surveyor asked NHA A how she is scheduled, NHA A explained that she is scheduled to work in a nurse slot however if a CNA calls in, she may be pulled from that role into working as a CNA. Surveyor asked NHA A when she is scheduled, does she work on a designated unit, NHA A said yes, 300/400 units. Surveyor asked NHA A how many residents that could potentially serve, NHA A said approximately 36 residents. Surveyor asked NHA A if the facility had any other CMAs, NHA A stated not as of today. Surveyor asked NHA A when CMA C last worked passing medications, NHA A said today. Surveyor asked NHA A if CMA C worked the entire shift passing medications, NHA A stated no about noon, she was pulled from that task and put into role of CNA. Surveyor asked NHA A if CMA C had any other medication errors, NHA A explained that she was unsure if she would be able to find that information as they track the medication errors as part of QA (quality assurance) but didn't include staff names involved. Surveyor asked NHA A if she knew what CMA C's jobs were prior to being hired here, NHA A said she would look in her file. NHA A returned with part of CMA C's resume which documents that her previous job history was as event coordinator and marketing manager. The Facility's failure to ensure staff have the appropriate credentials and training created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 3/2/20 when it had completed the following: 1. CMA C was removed from passing medications 2. Audit tool distributed to Human Resources to ensure proper licensure and contents of employee files 3. Administrator, Director of Nursing, and Human Resources educated on scope of CMA's 4. CMA C educated on scope of practice for CMAs 5. Facility policy reviewed and revised for proper utilization of Medication Technicians/Aides 6. Facility reviewed and revised Medication aide Job Description 7. All facility licensed personnel credentials were reviewed and validated as appropriate 8. The HR (Human Resource) Director, Administrator, or Designee will conduct audits of 2 employee files to ensure ongoing and sustained compliance. Adverse findings will be immediately addressed. Findings will be reported to QAPI (quality assurance process improvement) Committee and Corporate Compliance.

Based on interview and record review the facility did not ensure residents were free from significant medication errors for 1 of 6 sampled residents (R1). R1 had an order to receive 5 mg (milligrams) of [MEDICATION NAME] sulfate. On [DATE], CMA-C (Certified Medical Assistant) administered ten times the dose that was ordered. [MEDICATION NAME] had to be administered to reverse the effects of the medication and R1 was sent to the emergency room . The facility's failure to ensure that a resident was free from a significant medication error created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on [DATE] at 10:30 AM. The immediate jeopardy was removed [DATE]; however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The Facility's Policy and Procedure entitled Administering Medications with a revision date of [DATE] documents, in part: .3. Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified and the medication is labeled according to accepted standards . R1 was a long term resident of the facility with [DIAGNOSES REDACTED]. R1 sustained a right femur fracture during a fall on [DATE]. R1 had a steady decline in her health status from then on. R1 was admitted to hospice on [DATE]. R1 had an active physician's orders [REDACTED]. This calculates to a dosage of 5 mg. R1's MAR (Medication Administration Record) had two [MEDICATION NAME] orders: 1) [MEDICATION NAME] Solution 20 mg/ml, give 5 mg by mouth every 2 hours as needed for pain, SOB (shortness of breath). This order was started on [DATE] and was discontinued on [DATE]. 2) [MEDICATION NAME] Solution 2 mg/ml, give 2.5 ml by mouth every 2 hours as needed for pain. This order was started on [DATE]. Pharmacies supply medications as concentrations based on availability, including [MEDICATION NAME]. Oftentimes, these concentrations are different than previously supplied. All bottles look the same but the concentration of its contents may be very different. Manufacturers change the concentration often without notification. It is the responsibility of the professional administering the medication to review the concentrations on the bottle and complete the calculations in order to administer the correct dosage to the patient. According to the facility investigation, there were two bottles of [MEDICATION NAME] in the medication cart: 1) [MEDICATION NAME] Oral Solution 100 mg per 5 ml (20 mg/ml), take 0.25 ml (5 mg) by mouth every 2 hours as needed for pain. 2) [MEDICATION NAME] Solution 10 mg/5 ml 2.5 ml (5 mg) by mouth every 2 hours as needed for pain or SOB. It is important to note that the first order for [MEDICATION NAME] Solution with a concentration of 100 mg per 5 ml (20 mg/ml) was discontinued on [DATE] but remained in the medication cart. Surveyor reviewed the facility's investigation into this medication error. A statement from CMA C (Certified Medical Assistant) states, On Wednesday [DATE] around 10:00 AM. I drew up [MEDICATION NAME] for resident (R1), as instructed by the hospice nurse. The order on the MAR indicated [REDACTED]. I asked the nurse I was working with, DON B (Director of Nursing), 'Is this the right order on the MAR?' She stated it was and I asked again. She was unaware of the change of dose and/or different bottle we had received from the pharmacy. The order should have been changed and confirmed on the MAR indicated [REDACTED]. This did not happen. I thought I was giving the right dose as instructed. I mixed it with applesauce after asking if this was okay. The patient refused the medication. I left it with the hospice nurse so that she could try to re-attempt. She was successful and she informed me of this. I was still questioning this dose after the fact and this is when DON B called NP (Nurse Practitioner) and made interventions. Of note, R1 had two bottles of [MEDICATION NAME] in the medication cart, one with a higher concentration (100 mg/ 5 ml) with instructions to administer 0.25 ml and one with a lower concentration (10 mg/5 ml) with instructions to administer 2.5 ml. CMA A drew up 2.5 ml of the higher concentration bottle which resulted in R1 receiving ten times the dose she should have received. It is important to note that CMAs are unlicensed in the state of Wisconsin and are not allowed to pass medications unless they successfully complete coursework and become certified medication assistants. (Refer to F726.) R1's nurses note dated [DATE] at 5:00 PM, states, At approximately 1450 (2:50 PM) I (DON B) was alerted by the med tech, she stated that the residents' family had concerns of a possible change in her breathing pattern. While walking to room the med tech alerted me of a possible suspected drug overdose involving [MEDICATION NAME]. As the pharmacy sent two different [MEDICATION NAME] orders with different concentration amounts. This writer immediately went to resident's room to assess her heart rhythm, breathing patterns and O2 (oxygen) saturations. Upon arrival resident was lying in bed resting peacefully, no signs of distress or cyanosis, no use of accessory muscles. During entire ordeal the resident never lost consciousness and was alert and responsive to speech, She made eye contact when name was called. Pulse ranged from 60 to 68, respirations 16 to 18 even, non labor, blood pressure ,[DATE], O2 saturation 93 to 95% on room air. This writer immediately contacted hospice to let them know of the possible overdose, hospice nurse then instructed me to call NP. I received a verbal order to give [MEDICATION NAME] after I had given report of resident condition and vital signs. I administered [MEDICATION NAME] and called 911 per order. Residents family in agreement, Resident transferred out via ambulance to ER (emergency room ). DON B was given an order to administer [MEDICATION NAME] to R1 as a result of this medication error. [MEDICATION NAME] is a narcotic antagonist which is used to counteract the effects of narcotics (it can treat narcotic overdose in an emergency situation). While R1 was in the ER she had her vital signs (temperature, pulse, respirations, blood pressure and oxygen saturation) monitored, she had lab work drawn and had an EKG (electrocardiogram which measures electrical activity of the heartbeat) conducted. R1 then returned to the facility. R1 expired on [DATE]. R1's cause of death is not known at this time; the Facility, Hospice nor Physician Office have death certificate as of [DATE]. On [DATE] at 4:50 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if she would expect the staff that passes medication to ensure they are giving the correct dose of medication, NHA A said yes. Surveyor asked NHA A if someone passing medications asks a co-worker who also passes medications to verify an order, would you expect that to happen, NHA A said well, I'm not a nurse, but I would think they would check. Surveyor asked NHA A if she would expect one person to pass off medication to another person to administer, NHA A reiterated, I'm not a nurse so I'm not exactly sure of the protocol but I would feel more comfortable if there were documentation around the situation. The facility's failure to ensure staff administer the correct dose of [MEDICATION NAME] created a finding of immediate jeopardy. The immediate jeopardy was removed [DATE] when the facility completed the following: 1. Report was run to audit and clarify all liquid [MEDICATION NAME] orders in facility 2. All orders reviewed and clarified 3. DON validated transcription of orders is consistent with medication concentration available 4. Carts were audited to ensure liquid medications available are appropriate to active orders only 5. Pharmacy consultants completed med cart audits 6. Pharmacy informed of facility updated practice of providing one consistent formulary, specifically in regards to [MEDICATION NAME]: 100 mg/5 mL (20 mg/ 1 mL) 7. Hospice informed of facility desired practice of providing one consistent formulary, specifically in regards to [MEDICATION NAME]: 100 mg/5 mL (20 mg/ 1 mL) 8. Licensed professionals given education on avoiding common medication errors - Initiated on: [DATE] and ongoing 9. Licensed professionals reviewed dosing calculation, specifically related to liquid medication, including [MEDICATION NAME]; with quiz and re-education 10. Return demonstration competency completed with staff licensed professionals, to include three checks of order to label 11. Licensed professions re-educated specifically pertaining to checks of medication orders to label 12. Regional Nurse Consultant re-educated DON specifically pertaining to checks of medication orders to label 13. QA (quality assurance)/QI (quality improvement) Tools were developed and implemented to ensure ongoing and sustained compliance. Adverse findings will be immediately addressed. compliance and maintenance with this plan. To be completed on-going by DON or designee, using the following increments:

Based on observation, interview and record review the facility did not ensure residents do not develop pressure ulcers/injuries (PU/PI) unless clinically unavoidable and did not ensure residents are provided cares and services consistent with professional standards of practice to prevent the development of PU/PI and to promote the healing of existing PI's for 4 of 4 Residents reviewed for PI's out of a total sample of 10 Residents (R7, R8, R12 and R13). R7 is at risk for developing PI's and developed a PI. R7's PI was not staged appropriately and interventions were not put into place timely to prevent further deterioration of R7's wound. R7 was not repostioned per his Care Plan. R8 did not have the appropriate wound care completed on 3/9/2020 and R8's care plan is not current for his skin impairment. R12 did not have heels floated twice on 3/9/2020. R13 does not have an appropriate treatment in place and when wound worsened there was no consultation with Physician. This is evidenced by: Facility Policy entitled 'Wound/Skin Alteration Care Policy,' dated 10/17/19 states, in part: Purpose: to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. To promotoe healing of existing wounds and/or skin alterations. Procedure: .2. Residents with a Braden Scale score of 12 or less should be considered to be at high risk for pressure ulcer development.5. Resident's skin will be examined at least weekly by a licensed nurse.7. Skin impairments, including pressure ulcers, non-pressure ulcer wounds (venous, arterial, and diabetic), surgical wounds, MASD, burns, blisters, significant skin tears and abrasions, and significiant bruises should be assessed and documented weekly by a licensed nurse, in (computer system) If a skin alteration is present, at least weekly there should be documentation of an assessment or evaluation of the wound characteristics. Documentation should include: the date the wound is observed, location, staging (or description of appears of wound extent) {sic}, size (length, width, depth, tunneling or sinus tract measurements if present), color, odor, approximate amount of exudate if present. Pain if present (nature and frequency, episodic or continuous), wound bed (color and type of tissue, granulation, necrosis, slough). Description of wound edges and surrounding tissue (rolled edges, redness, maceration).13. Wound and skin care interventions will be monitored and evaluated for effectiveness. Care plans will include specific and measurable goals and interventions. The care plan will be reviewed and revised at least quarterly, or with significant change in condition. Per the National Pressure Injury Advisory Panel, Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Per the National Center for Biotechnology Information, Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion (loss of the outerlayer of skin) . Per Merriam Webster Dictionary, the ischial tuberosity is a bony swelling on the posterior part of the superior ramus of the ischium that gives attachment to various muscles and bears the weight of the body in sitting. Drive Manufacturer Mattress information for Med-aire assure, foam base alternating pressure and low air loss mattress system, indicates the mattresses are intended to help reduce the incidence of pressure ulcers while optimizing patient comfort. Active mattress replacement system provides both alternating pressure and low air loss to optimize pressure redistribution, shear/friction reduction, and microclimate control. Designed to prevent, treat and heal pressure ulcers in the home or long term care setting. Broda manufacturer website indicates Broda's unique Comfort Tension Seating® system provides pressure redistribution and airflow for increased sitting comfort and support. Comfort Tension Seating states Broda's proprietary Comfort Tension Seating® conforms to the body, providing enhanced pressure redistribution and long-term seating comfort. Each strap conforms individually to the patients' body, thus suspending the weight of the patient across multiple points. Comfort Tension Seating® works in conjunction with tilt-in-space seating system to provide therapeutic pressure relief, enhance postural support and maintain skin integrity. The seating base used in this system is a heavy gauge [MEDICATION NAME] chloride strapping installed under tension and riveted to the seating frame of the chair. With memory retention, the straps return to their original shape within seconds providing consistent seating comfort and pressure redistribution. The Facility's Policy and Procedure entitled Dressing Change- Clean dated 9/17/18 documents, in part: .1. Adjust bedside stand to wait level. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the bedside stand. Arrange the supplies so they can be easily reached. 3. Tape a biohazard or plastic bag on the bedside stand or open on the bed 5. Adjust the height of the bed to waist level 19. Apply the ordered dressing and secure with tape. 20. Discard disposable items into the designated container . Example 1: R7 was admitted on [DATE] with [DIAGNOSES REDACTED]. R7 previously had an open skin impairment to the Left Ischial Tuberosity from 7/16/19 - 11/22/19, which was indicated as healed on 11/22/19. R7's Care Plan, indicated to be in place in December 2019 states in part: I have an actual impairment to skin integrity of the left medial thigh r/t (related to) continued sitting/pressure/MASD date initiated: 07/25/2019. Revision on: 12/14/2019. Goal: The resident will have no complications r/t pressure ulcer of the left ischial tuberosity through the review date.Revision date: 08/19/2019. The Resident's skin injury of the left ischial tuberosity will be healed . Revision on: 08/19/2019.Interventions: Administer my wound care as ordered (12/14/2019) .Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short .Encourage good nutrition and hydration in order to promote healthier skin . monitor/document location, size and treatment of [REDACTED]. to MD Use caution during transfers and bed mobility to prevent striking arms, legs , and hands against any sharp or hard surface . Wash wound with wound cleanser, pat dry, place honey hydrogel over wound then cover with boarder gauze . weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date initiated: 07/25/2019. (R7) is at risk for alteration in skin integrity related to Braden Score of 15, impaired mobility, and he chooses to sleep in his recliner rather than a bed. His safety awareness is also poor .Revision on: 08/22/2019 . Interventions: .Position my body with pillows/support devices, and protect bony prominences as needed. Date initiated: 04/18/2019 . Re-position me at least every 2 hours. Date initiated 04/18/2019 . Use a pressure relieving cushion for my recliner. Date initiated: 04/18/2019. R7's current 'At Risk for alteration in skin integrity,' Care Plan, indicates the same interventions as the Care Plan above, which was in place in December of 2019. R7's Care Plan revised on 1/29/20 states in part: I have an actual impairment to skin integrity of the MASD to left ischium r/t continued sitting/MASD. Goal: The resident's will have no complications r/t pressure ulcer of the left ischial tuberosity through the review date. Revision on 02/05/2020 . The resident's skin injury of the left ischial tuberosity will be healed by review date .Revision on: 02/05/2020. Target Date: 03/16/2020. Interventions are indicated to be the same as Care Plan initiated on 7/25/2019. R7'S CNA (Certified Nursing Assistant) Care Plan (Kardex) printed on 3/9/20, indicates to reposition R7 at least every 2 hours. To check for incontinence every 2 hours and as needed. R7 needs extensive assist of 1 with bed mobility. R7 is totally dependent on staff for locomotion. R7 transfers with a mechanical lift and assist of 2 (two). R7 is dependent for toileting. R7's Braden Scale for Predicting Pressure Sore Risk, dated 11/24/19 indicates R7 has a score of 15, which indicates R7 is at risk for PI's. The Braden scale indicates that R7's skin is very moist, he's chair fast, mobility is very limited, his nutrition is adequate and there is potential for friction and shearing to be a problem. On 12/2/19, R7's weighed 152.4 pounds. On 12/6/19 R7's Wound Evaluation, indicates an in house acquired Moisture Associated Skin Damage (MASD) to left thigh. Measuring 1.93 cm (Centimeters) by 1.61 cm. Wound bed is indicated as 40% [MEDICATION NAME] tissue and 60% granulation tissue. Progress notes indicate acute full thickness MASD, initial wound encounter measurements are 2cm in length by 2.5cm in width and 0.1cm depth. No slough and no eschar present. The periwound skin moisture is normal and skin color is normal. Treatment section indicates additional care of air flow pad, cushion, incontinence management, moisture control, moisture barrier, and turning/repositioning program. On 12/13/19 R7's Wound Evaluation, indicates MASD to left thigh. Measuring 1.99cm by 2.44cm with a wound bed of 30% [MEDICATION NAME] tissue and 70% granulation tissue. Progress note indicates measurements are 1.5cm by 2.5cm by 0.1cm. No slough and no eschar present, wound is improving. On 12/15/19 R7's Wound Care order indicates left medial thigh, wash wound with wound cleanser, pat dry. Apply Zeroform and cover with border gauze. Perform wound care every other day until healed. (Discontinued (D/c'd) 12/29/19) On 12/19/20, R7's Weekly Skin Check form indicates skin alteration of a left gluteal fold skin tear indicated as being a stage II. It's important to note that the facility interchangeably describes R7's wound location as left gluteal fold, left lower buttock/upper medial thigh, left thigh, and left ischial wound. Based on an interview with DON B, the left gluteal, left thigh and left ischial wound are all the same wound. On 12/20/19 R7's Wound Evaluation, indicates MASD to left thigh. Measuring 2.2cm by 1.36cm with Wound bed of 30% [MEDICATION NAME] and 70% granulation tissue. Progress indicates the wound is stalled. R7's Quarterly MDS (Minimum Data Set) dated 12/21/19, indicates the following: R7 has a BIMS (Brief interview of Mental Status) of a 9 out of 15 indicating moderate cognitive impairment. R7 needs 1 person extensive assistance for bed mobility, transfers and toileting. R7 is indicated as needing 1 person extensive assist to ambulate in his room. R7 needs limited 1 person assistance with locomotion on and off the unit. R7 is indicated as being frequently incontinent of bowel and bladder and is not indicated as being on a toileting program. Section M indicates that R7 is at risk for PI's and does not currently have any unhealed PI's, but has MASD (Moisture Associated Skin Damage). R7's Braden Scale on 12/24/19 indicates R7 has a score of 13, which indicates that R7 is at moderate risk for pressure injuries. On 12/27/19 R7's Wound Evaluation, indicates MASD to left thigh. Measuring 0.69 cm by 0.93 cm with a wound bed of 30% [MEDICATION NAME] and 70% granulation tissue. Wound progress is indicated as stalled. On 12/29/19 R7's Wound Care order indicates left lower buttock/upper medial thigh MASD sore cleanse area with wound cleanser. Pat dry. Apply Zeroform and cover with border gauze. Perform every other day until healed. On 12/30/19, R7's Wound Care order indicates left lower buttock/upper medial thigh MASD sore. Cleanse area with wound cleanser. Pat dry. Mix small amount of cologne and hydrogel and cover sore. Cover with border gauze. Perform on days every other day until healed. (D/c'd 1/6/20) On 1/2/20 R7's weight was 136.4 pounds. This is a 16 pound/10.4% weight loss in 1 month. R7 is receiving supplements. R7's weight loss puts him at a greater risk for pressure injury development. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White paper, Dated 2009, states in part: .general consensus indicates that nutrition is an important aspect of a comprehensive care plan for prevention and treatment of [REDACTED]. Adequate calories, protein, fluids, vitamins, and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown .compromised nutritional status such as unintentional weight loss, undernutrition, protein energy malnutrition (PEM), and dehydration deficits are known risk factors for pressure ulcer development. On 1/3/20 R7's Wound Evaluation, indicates MASD to left thigh. Measuring 0.99cm by 1.92 cm. Wound bed is 100% granulation. Periwound skin texture is normal and periwound skin moisture is normal. There is no change in wound progression. Goal indicates healable. R7's wound appears to Surveyor, based on a photo, to have macerated wound edges and the wound bed appears a pale pink almost white/yellow in color in some areas throughout the wound bed based on the picture attached to R7's Wound Evaluation. On 1/4/20, R7's Wound Care order indicates wound care to left medial thigh. Wash wound with wound cleanser and pat dry. Mix together collagen and hydrogel apply to wound. Cover with a border gauze daily until healed. (D/c'd 1/15/20) On 1/7/20 at 11:09 AM, R7's Nurses Note states, in part: Open wound to upper left thigh/gluteal fold area yellow/radish (SIC) wound bed with scant of serisan (SIC) drainage. Peri wound slightly reddish but no s/sx (signs or symptoms) of infection. Dressing and tx (treatment) applied per order. On 1/10/20 R7's Wound Evaluation, indicates MASD to left thigh. Measurements are 2.57cm by 0.97cm. Wound bed is indicated as being 100% granulation tissue. On 1/17/20, R7's Wound Care orders indicate: wound care for pressure ulcer to left ischium. Clean with saline or wound cleanser. Skin prep to surrounding skin and border of dressing once placed. Cover with foam or [MEDICATION NAME]. Change dressing three times per week. (D/c'd 1/21/20) On 1/17/20 R7's Wound Evaluation indicates MASD to left thigh. Measurements are 1.47cm by 1.76cm. Wound bed is indicated as 100% [MEDICATION NAME] tissue and periwound is blanchable. Treatment indicates [MEDICATION NAME] with additional care of air flow pad, cushion, incontinence maintenance, moisture control, moisture barrier and turning/repositioning program. Goal of care indicates healable. Progress note indicates Resident admitted to Hospice service today. New wound care orders. Wound care performed and weekly assessment and wound picture updated. The picture associated with this measurement per Surveyors review of this photo the area does not look 100% [MEDICATION NAME] as wound bed has an appearance of white/yellow tissue in the wound bed based on photo documentation. On 1/17/20, R7's Hospice Note, states in part: Problem: Skin risk.patient has identified factors that result in the increase in risk for skin breakdown.indwelling urinary catheter. May insert 14-22 French Foley catheter PRN for [MEDICAL CONDITION] or obstruction; to assist healing or perineal and sacral wounds in incontinent patients; or for end-of-life palliative care comfort . Wound Care order: orders wound care for pressure ulcer to left ischium: clean with saline or wound cleanser. Skin prep to surrounding skin and border of dressing once placed. Cover with foam or [MEDICATION NAME] (duoderm). Change dressing 3 times per week.was very kyphosed Has pressure wounds on left hip and back. Has lost 15 pounds in the last 3 months . Hospice is identifying R7's wound as being a pressure injury at this time. R7's Admission MDS dated [DATE], indicates R7 has moderate cognitive impairment. R7 is dependent on two person extensive assist from staff for bed mobility and toileting. R7 requires two person extensive assist with transfers. R7 did not walk in his room during the look back period. R7 is dependent on a one person physical assist for locomotion on the unit and is dependent on a two person physical assist for locomotion off the unit. R7 is at risk for PI's and does not currently have PI's, but is indicated as having MASD. Section H indicates that R7 has a Catheter and is frequently incontinent of stool and is not on a toileting program. On 1/22/20, R7's Wound Care orders indicate: Wound care for pressure ulcer to left ischium, clean with saline or wound cleanser. Skin prep to surrounding skin and border of dressing once placed. Apply xeroform then cover with foam dressing. Change dressing three times a week. (D/c'd 1/27/20) On 1/24/20 R7's Wound Evaluation indicates MASD to left thigh. Measurements are 2.49cm by 1.7cm. Wound bed indicates 50% granulation tissue and 50 % eschar tissue with a normal periwound. Additional care indicates turning/repositioning program. Goal of care states healable. Progress note states in part: .76-100% pink granulation tissue, no slough, no eschar and no epithelization present. There is no change noted in the wound progression. This measurement indicates that R7's wound has changed from 100% [MEDICATION NAME] tissue to 50 % necrotic tissue in a week. MASD areas do not acquire slough or eschar. Once slough or eschar is present the wound is now indicated as being a pressure injury. The facility has not identified R7s wound as being a PI. R7's Braden Scale dated 1/24/20 indicates R7 has a score of 12 which makes R7 at high risk for developing a PI. On 1/27/20, R7's Wound Care orders indicate cleanse wound with wound wash. Apply thera honey gel to wound bed, apply skin prep wipe to peri-skin. Cover with [MEDICATION NAME] gentle dressing. (D/c'd 1/30/20) On 1/31/20, R7's Wound Care orders indicate: Wound care MASD to left ischium cleanse with wound wash, apply santyl to wound bed, apply xeroform, apply skin prep wipe to peri-skin then cover with [MEDICATION NAME] gentle dressing. (D/c'd 2/4/20) On 1/31/20 R7's Wound Evaluation indicates MASD to left thigh. Measurements are 2.61cm by 3.54cm. Wound bed is indicated as 30% granulation and 70% eschar. This is a decline in R7's wound. Goal of care slow to heal and indicates R7's wound is stable. Progress note, states in part: .Moderate amount of serous drainage noted which has no odor.There is no change noted in the wound progression. This measurement indicates that R7's wound went from 50% eschar to 70% eschar which indicates a decline in R7's wound. The picture associated with this measurement per Surveyors review of this photo the area appears greater than 70% eschar and less than 30% granulation tissue. On 2/2/20 R7's weight was 131.5 pounds. On 2/4/20, R7's Wound Care orders indicate wound care to pressure ulcer to left ischium every 5 days and as needed. Cleanse with wound wash. Cover the wound bed with calcium alginate dressing cut fit to size. Apply skin prep to the intact peri-skin, cover with [MEDICATION NAME] gentle dressing. (D/c'd on 2/11/20) On 2/7/20 R7's Wound Evaluation indicates MASD to left thigh. Measurements are 4.07cm by 2.21 cm. Wound bed is indicated as being 10% granulation tissue, 20% slough tissue and 70% eschar tissue. Goal of care is slow to heal. Progress note states left, posterior thigh is an acute full thickness MASD, IAD (incontinence associated [MEDICAL CONDITION]), stable, slight change, hospice to manage treatment orders. The picture associated with this measurement per Surveyors review of this photo the area appears 100% necrotic tissue made up of eschar and slough. On 2/11/20, R7's Wound Care orders indicate left ischial tuberosity wound cleanse daily with soap and water, apply santyl, calcium alginate and foam bordered dressing daily and prn until heals. (D/c'd on 2/13/20) On 2/13/20, R7's Weekly Skin Check form indicates skin alteration of left gluteal fold being an Unstageable ulcer. Form indicates no new skin alterations identified. On 2/13/20, R7's Wound Care orders indicate wound care to pressure ulcers to left ischium daily and prn. Remove old dressing, cleanse with wound wash, pat dry, and apply skin prep to intact skin. Apply mesalt dressing cut to fit the eschar tissue. Apply only to dark black dead tissue. Apply alginate wound dressing to cover open skin for drainage absorption. Cover with bordered gauze. (D/c'd 2/17/20) On 2/14/20 R7's Wound Evaluation indicates Unstageable (slough and/or eschar) to left thigh. Measurements are 2.84 by 3.5cm. Wound bed is 100% slough. Treatment section for additional care indicates a cushion, mattress with pump and a turning/repositioning program. Progress note states superficial and not over a bony area but with the decline of the patient leading to hospice and patient not eating it deteriorated. Pressure wound is Unstageable due to slough, wound was examined and debrided by (MD D) (Medical Doctor), recommendations is to do wet to moist soaked with full strength Dakins solutions. R7's wound has had eschar/slough in it since 1/17 or 1/24/20 and has had turning/repositioning program in place since 4/18/19. R7's wound is now being called an Unstageable PI due to eschar/slough when R7's wound has been at least an Unstageable PI from 1/24/20 to current based on photos associated with R7's wound. Measurements and photos associated with R7's wounds indicated that R7's wound has became larger and has deteriorated since 12/6/19. As of 2/14/20 this is the first time a mattress with a pump has been identified as being in place for R7. Facility staff are unable to say when R7's mattress was placed on his bed. R7 has a history of skin break down in the same area as R7's current wound. R7 had a regular standard mattress in place prior to receiving a mattresss with a pump on it. On 2/14/20 R7's Wound Note from MD G (Medical Doctor) states, in part: Etiology: Pressure.Unstageable necrosis. Wound Size ( L x W x D): .3.5 x 3.5 x not measurable. Slough: .100%. This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of a biofilm. Additional wound details: Wound started as moist as it was superficial and not over boney (SIC) area but with the decline of patient, leading to hospice and patient not eating, it deteriorated. Full strength Dakin's wet to moist to kill and prevent return of black slough. If hospice want to continue their current treatment (Collagen mesalt and alginate), I would remove the collagen for now.surgically excise 12.25cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.1cm and healthy bleeding tissue was observed . My goal for this wound is healing as evidenced by a decrease in surface area of the wound and/or a decrease in percentage of necrotic tissue within the wound bed. On 2/17/20 R7's Wound Care Orders indicate Wound care to pressure ulcer to left ischium daily and as needed. Remove old dressing, cleanse with wound wash, pat dry, apply skin prep to intact skin, apply wet to moist gauze full strength dankins solution. Cover with bordered gauze. It is important to note that prior to 2/17/20, R7's wound care has been changed 11 different times between 12/15/19 and 2/17/20. During that time R7's wound has not been given time to respond to each treatment before being changed to a different treatment. Therefore the staff are unable to evaluate the effectiveness of those treatments. National Pressure Ulcer Advisory Panel, 'Prevention and treatment of [REDACTED].Assessment of Pressure Ulcers and Monitoring of Healing.Assessment of the individual with a Pressure Ulcer.2. Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing as expected despite appropriate local wound care, pressure redistribution, and nutrition.2.1 Expect some signs of pressure ulcer healing within two weeks.If progress toward healing is not seen within two weeks, the individual, the pressure ulcer, and the plan of care should be re-evaluated. On 2/21/20 R7's Wound Evaluation indicates Unstageable to left thigh. Measurements are 3.27cm by 3.46cm by 0.5cm (depth). Wound bed is 100% slough. Progress note states, in part: Wound size . 6 x (by) 4 x 0.5cm .exudate moderate serous. Slough: 100% this wound is in an [MEDICAL CONDITION] stage and is unable to progress to healing phase because of the presence of a biofilm. Wound progress: deteriorated. R7's Braden Scale on 2/24/20, indicates R7 scores an 11 which means R7 is at high risk for PI's. On 2/28/20 R7's Wound Evaluation indicates Unstageable to left thigh. Measurements are 3.59cm by 5.19cm by 1.5cm. Wound base is indicated to be 10% granulation tissue and 90% slough. Goal of care indicates slow to heal and progress of wound indicates improving. On 3/2/20 R7's weight was 130.5 pounds. On 3/6/20 R7's Wound Evaluation indicates Unstageable to left thigh, in house acquired and that it's 3 months old. Measurements are 5.66cm by 6.07cm by 1.5cm. There is no assessment of the wound bed tissue or periwound. The evaluation indicates progress is slow to heal and improving. The picture associated with this measurement per Surveyors review of this photo the area appears significantly larger. The area appears to have at least 75% necrotic tissue with periwound having dark discoloration along with red and pale tissue along the wound edges. On 3/9/20 at 9:20 AM, Surveyor observed R7's room. R7 was not in his room at this time. R7 has an alternating mattress which was set to 150 pounds. R7 was out to an activity at this time. On 3/9/20 at 9:26 AM, Surveyor interviewed LPN F regarding wounds down her hallway. LPN F indicated that she has R1 to do wound care on yet. LPN F indicated that she called hospice over the weekend related to R1's wound as she thought they needed to be cultured. LPN F indicated that R1's wound is deep, I can't believe how deep his wound has gotten. LPN F indicated that she thinks R1's wound is infected because it stinks terribly, and that she was the nurse over the weekend. On 3/9/20 at 10:40 AM, Surveyor observed R7 not to be in his room at this time as he is out in the lounge area. On 3/9/20 at 11:00 AM, Surveyor observed R7 to be in his broda chair in the lounge near bird aviary. R7 has a pillow under his feet and black socks on without shoes on. R7 has a full body sling under him and a thin blue cushion. On 3/9/20 at 12:00PM, Surveyor observed R7 to be in his chair at the dining room table for lunch at this time. On 3/9/20 at 12:15 PM Surveyor interviewed CNA I regarding R7. CNA I indicated that R7 will be laid down after lunch and then gotten back up into his chair. CNA I indicated that she hasn't been back to check R7 since after breakfast. On 3/9/20 at 1:20 PM, Surveyor observed CNA I and CNA C transfer R7 from his broda chair into bed. R7 was sitting in his broda chair with a full body sling under him. R7's broda chair was observed to have a thin light blue cushion filled with air. R7's cushion appears to be a waffle cushion. R7's dressing is intact to Left ischial area with drainage shadowing, showing through on half of the dressing thats dated 3/8. CNA I indicated that R7 was last laid down and checked between 8:45 AM and 9:00AM. CNA I indicated R7 was gotten back up right away as he doesn't like to lay down. CNA C indicated that R7 used to stand up and pivot transfer and now he no longer does. CNA C indicated now that R7 is in his bed or chair all the time it's gotten worse, (refering to R7's wound). CNA C indicated that R7 is now a full body lift for transfers. CNA C indicated that R7's full body lift sling, is always left under him when he is in the chair, but not when he's in the bed. On 3/9/20 at 1:45 PM, Surveyor observed Agency LPN F provide wound care for R7. R7's wound ap (TRUNCATED)

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent PIs (pressure injuries) from worsening, for 1 of 4 resident reviewed for PIs out of a sample of 26 residents (R248). R248 was admitted with a Stage 2 PI, on 2/18/19, which progressed to a stage 3 PI on 3/12/19. The facility did not ensure that the ordered treatment was in place, implement approaches to prevent the PI from worsening and were not thoroughly assessing R248's PI. This is evidenced by: The facility's Pressure Injury Prevention and Management Policy and Procedure, dated 8/26/2018, revised 12/3/2018, states, in part: If a pressure ulcer is present, at least weekly there should be documentation of an assessment or evaluation of the wound characteristics. Documentation should include: - The date the wound was observed - Location - Staging (or description of appearance of wound extent) - Size (length, width, depth, tunneling or sinus tract measurements if present) - Color, odor, approximate amount of exudate if present - Pain if present (nature and frequency, episodic or continuous) - Wound bed (color, and type of tissue, granulation, necrosis, slough) - Description of wound edges and surrounding tissue (rolled edges, redness, maceration) Documentation of the wound characteristics will be completed in PCC (Point Click Care) using the PCC Skin and Wound Assessment. This assessment is started in the mobile application. If a device is not available or in need of service, the documentation will be completed in the web-based version Weekly Wound Assessment. Consent for photography will be obtained in the admission packet. If a pressure ulcer shows no evidence of progress toward healing after 2-4 weeks, a re-evaluation of the current treatment plan may be indicated The Comfort Company Manufacturers User Guide and Manual for chair cushions states, in part: DO NOT place anything in between the user and the product. Additional materials may reduce the effectiveness of the product and increase risk factors for skin breakdown and instability. Findings: R248 was admitted to the facility, on 2/18/19, with diagnosed including: [DIAGNOSES REDACTED]. (Note, there is no [DIAGNOSES REDACTED].) R248's admission MDS (Minimum Data Set), dated 2/25/19, indicates a BIMS (Brief Interview of Mental Status) of 9, indicating R248's cognition is moderately impaired. R248's record indicates that R248 is own person and makes own decisions. R248's admission MDS indicates extensive assist is needed with bed mobility and transfers. R248's Baseline Care Plan, dated 2/18/19, does not indicate any open areas to the buttock or coccyx. R248's Comprehensive Care Plan, with initiation date of 2/27/19, states, in part: The resident has actual impairment (Stage 2 PI) to skin integrity of the coccyx r/t (related to) fragile skin, needs for assist with transfers and positioning, poor nutritional status, infection, recent hospitalization , and history of skin breakdown. Resident prefers to sleep in recliner. Goal: The resident's PI of the coccyx will be healed by review date (revised 3/12/19). Interventions: Monitor/document location, size and treatment of [REDACTED]. to MD (Medical Doctor). Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R248's Physicians Orders, dated 2/27/19, indicate the following order, in part: Pressure with Light/Minimal . Exudate Cleanse with Normal Saline. Apply Hydrogel dressing. Change every 24 hours and PRN (as needed). Reevaluate in 2 weeks in the evening. (It is important to note that this order does not indicate what open area to which this dressing should be applied for R248.) R248's most recent Braden Score (scale for predicting pressure sore risk), completed on 3/11/18, shows a score of 17, indicating that R248 is at mild risk for PI development. R248's Weekly Skin Assessments were documented as follows . 2/18/19 Stage 2 PI to coccyx, measuring 2.6 cm (centimeters) (length) x (by) 2.0 cm (width), with 100% [MEDICATION NAME] tissue to wound bed. Moderate amount of Sanguineous/Bloody, with faint odor. 2/27/19 Stage 2 PI to coccyx, measuring 2.5 cm (length) x 2.1 cm (width), with 60% [MEDICATION NAME] tissue and 40% granulation tissue. Light amount of purulent drainage, with faint odor. 3/6/19 Stage 2 PI to coccyx, with 80% [MEDICATION NAME] tissue and 20% granulation tissue. Light amount of serous drainage, with faint odor. (It is important to note that R248's PI had no measurements on 3/6/19. The facility was documenting that this open area was located on R248's coccyx. However, it was actually located on the right mid-inner buttock. The location of the wound is not documented accurately.) On 3/10/19 at 9:05 AM, Surveyor observed R248 in recliner with feet up. R248 had a cushion in recliner and an incontinent pad between R248 and the cushion. On 3/12/19 at 9:20 AM, Surveyor observed toileting of R248 with CNA [NAME] (Certified Nursing Assistant). R248 was taken into the bathroom, assisted by CNA [NAME] to stand and turn. R248 had been incontinent of urine and CNA [NAME] assisted R248 to change clothing. Surveyor observed area to right mid-inner buttock, approximately 3 cm (length) x 2 cm (width) x 0.2 cm (depth). Surveyor asked if CNA [NAME] was aware of open area. CNA [NAME] stated, I have only been down this hall about a week, but I have reported this area on different occasions to the nurse on duty. Surveyor observed no dressing to open area on the bottom at this time. CNA [NAME] completed peri care on R248 and applied barrier cream to open area on bottom. Surveyor observed cushion in R248's recliner to have incontinent pad covering cushion. (Of note, leaving a wound open to air inhibits wound healing and puts the resident at risk for infection. Of note, CNA [NAME] placed barrier cream, not the treatment ordered, on R248's PI) On 3/12/19 at 12:27 PM, Surveyor observed RN D (Registered Nurse) assist R248 to stand. Upon standing, Surveyor observed R248 to be wearing a pair of sweatpants soaked in urine that were in direct contact with the wound and no incontinent product was in place. Surveyor observed R248's open area to right mid-inner buttock without a dressing. The open area was observed to be covered with approximately 50% white slough. Surveyor and RN D observed PI to R248's buttock. Surveyor asked RN D about the open area to which it was stated, I have never looked at R248's bottom prior to this. Surveyor asked how RN D would stage the open area. RN D indicated, The area on the bottom is a Stage 3. Surveyor observed R248 to have a cushion in wheelchair and in recliner. (Of note, the PI has deteriorated to a Stage 3, was again left open to air which inhibits wound healing and was in direct contact with urine, which increases the potential for infection.) On 3/12/19 at 12:58 PM, Surveyor interviewed LPN F (Licensed Practical Nurse). LPN F stated skin checks are to be completed weekly, if something is abnormal or there is a change, skin checks are to be done every shift. Surveyor asked about R248's skin checks. LPN F stated that skin checks for someone like him, who is diabetic, should be done daily. LPN F had last looked at R248's bottom on 3/8/19. LPN F states, PI on the bottom is more on the butt cheek. Area has not changed, is no better or no worse. On 3/12/19 at 1:04 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked what process the facility follows for wound monitoring. DON B states that she or NHA A (Nursing Home Administrator) would be notified by the CNA or Nurse of any new skin issues. DON B and NHA A would then notify RN H about the area, who would then complete an assessment. Weekly skin check forms are done during showers by the CNA, who gives them to the Nurse to sign off on, and they are then sent to DON B. Surveyor asked for a copy of R248's Weekly Skin Forms done on R248's shower day, the facility was unable to provide this documentation to the Surveyor. DON B states that RN H completes weekly skin and wound rounds. RN H is the PM shift nurse and is also the facilities wound nurse. RN H does not have any formal training at this time, but facility is planning on RN H attending class to become wound certified. DON B reports that, on 3/6/19, along with RN H, wound rounds were completed together. DON B states that she and RN H looked at R248's PI. DON B indicates that the weekly assessment was completed along with pictures and measurements. Weekly Skin and Wound Evaluation was completed on 3/06/19. Surveyor asked to review picture and measurements taken at that time. The facility was unable to provide this to the Surveyor. DON B stated that they were unable to find pictures or measurements from that date. On 3/12/19 at 5:35 PM, Surveyor interviewed MDS C and NHA A. MDS C indicated that the Baseline Care Plan is completed on admission by the floor nurse working. MDS C then completes the Comprehensive Care Plan. Surveyor asked if R248 came in with a PI on the buttocks, should it be included on the Baseline Care Plan. NHA A and MDS C both indicate that Yes, it should be on the Baseline Care Plan, and it was not. On 3/14/19 at 4:52 PM, Surveyor interviewed CCR I (Comfort Care Representative) about cushion being used by R248 in the facility. CCR I states that the documentation indicates that the Comfort Care Vicair Cushion is a high quality cushion used for high risk patients and acceptable to use on Stage 3 and Stage 4 PI's. Surveyor then asked if there was anything that would reduce the effectiveness of the cushion. CCR I stated, Placing any product between the patient and the cushion does reduce the quality of the cushion and the effectiveness. R248 was admitted with a Stage 2 PI. The facility did not monitor or put interventions in place to ensure that R248's PI did not deteriorate. The facility did not ensure that weekly skin assessments, including accurate measurements, and treatments were completed for R248's PI.

Based on interview and record review, the facility did not ensure that a resident who enters the facility without a pressure injury (PI) does not develop a pressure injury unless the resident's condition demonstrates that it was unavoidable and a resident with a PI receives necessary treatment and services to promote healing, prevent infection and prevent new injuries from developing for 1 of 13 residents (R) reviewed with PI's or at risk for PI's (R31). Although Resident 31 was at risk for PI development, the facility failed to implement aggressive PI interventions to prevent the development of PI's. The facility discovered on 8/31/17 that a pressure redistributing cushion was not in the chair and the facility corrected the occurrence. However on 10/10/17 R31's cushion was not in the Broda chair. The facility failed to re-educate all staff on the importance of assuring pressure redistribution interventions are in place per resident's plan of care. Once R31 developed a PI, the facility failed to re-evaluate the Comprehensive Care Plan to prevent deterioration of the PI. R31's PI deteriorated to an unstageable PI, became infected with undermining. R31's wound progressed to an stage III pressure injury on 9/12/17. Resident 31 was not on an appropriate mattress for a stage III pressure injury. R31's PI deteriorated to an unstageable PI on 9/18/17. Findings as follows: The facility policy on PI's lists as treatment and interventions: The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate; Reposition more frequently as needed, based on the condition of the skin and the residents comfort; Select appropriate support surfaces based on the resident's mobility, continence, skin moisture, and perfusion, body size, weight, and overall risk factors. The facility does not have a policy for weekly preventative skin assessments. R31's [DIAGNOSES REDACTED]. R31's Minimum Data Set (MDS), dated [DATE], list her bed mobility and transfer ability as totally dependent on staff, toileting as extensive assistance required from staff and personal hygiene and bathing as totally dependent on staff. R31's MDS Skin Assessment documents her as at risk for a PI and she has bed and chair pressure relief devices and is on a repositioning program. R31's Care Area Assessment (CAA), dated 7/8/17, documents at risk for PI. R31's Braden Score, dated 7/8/17, (measures risk of skin breakdown) was a 13, which is at moderate risk for skin breakdown. R31's care plan, from 4/18/17 to 9/22/17, listed skin care interventions .reposition every two hours when in bed, keep clean and dry, offer fluids with position change, barrier cream to peri area. On 8/31/17, when R31 developed the stage II PI, her bed mattress was a foam mattress, rated for PI's up to stage III but not including a stage III. On 8/31/17, R31 developed a stage II PI - .8 cm by .6 cm - small amount serosanguineous drainage noted. Wound Care Order is to clean with wound cleanser and apply foam bordered dressing and change every three days and as needed (PRN). Nurse Practitioner (NP) updated. On 9/3/17, the wound care documentation indicates, 0.8 by 0.6 cm - no change in Wound Care Orders. On 9/12/17, the wound care documentation indicates - 2 cm by 1 cm - slough tissue in middle of wound - apply wound cleanser; apply Santyl ointment and foam border dressing daily until healed. (Of note: on 9/12/17, R31's stage II PI worsened to a stage III PI. The facility failed to re-evaluate R31's Comprehensive Care Plan and implement additional interventions to prevent deterioration of R31's PI. On 9/18/17, the wound care documentation indicates - NP (wound certified) Initial Assessment: Unstageable - wound bed covered with slough or eschar - deep pink [DIAGNOSES REDACTED] surrounding the wound; Description - becoming larger and covered in eschar this week and the surrounding tissue seems indurated and very fragile - 2 cm by 2.4 cm; R31's PI continued to deteriorate and became infected. Ordered one week of bedrest - side to side positioning; Keflex 500 mg (milligrams) three times a day for ten days to treat wound [MEDICAL CONDITION] (wound was not cultured); [MEDICATION NAME] (protein supplement) - one packet once a day; Florajen ([MEDICATION NAME] supplement) - three teaspoons once daily for 21 days; Multivitamin once daily. The facility failed to recognize R31's current redistribution mattress was only good up to a Stage III but not including a stage III. On 9/22/17, an alternating air mattress rated for stage III and stage IV PI's was placed on R31's bed. The facility failed to implement an appropriate pressure redistribution mattress for 10 days after the PI deteriorated to a stage III and became infected. On 11/29/17 at 10:35 A.M., Surveyor observed R31 laying in bed, covered with a blanket. R31's heels were not floated. A bed cradle was positioned on the foot end of the resident's bed, with no covers over the cradle. On 9/22/17, the care plan was updated with alternating pressure relief mattress overlay placed on R31's bed, reposition every hour when up, for one week 9/20/17 to 9/27/17 - to be up short time for meals and in bed - side to side. On 9/25/17, the wound care documentation indicates - Unstageable with slough or eschar covering wound bed - deep pink tissue - 1.5 cm area surrounding wound bed. 3 cm by 1.8 cm; Wound Care Orders - clean with normal saline, apply Santyl to wound, and foam bordered dressing daily and PRN until healed. On 10/1/17, the wound documentation indicates - wound bed covered by slough/and/or eschar over 95% of wound bed - surrounding tissue light pink 1 cm - 2.2 cm by 1.8 cm - continue same Wound Care Orders. Documentation provided: On 10/9/17 the Hospice aide took the pressure relief cushion from the Broda chair. R31 was not on the pressure relief cushion for lunch and dinner. On 10/10/17, staff noted R31 was not sitting on a pressure relief cushion in the Broda chair. 10/15/17 - wound bed - unstageable covered by slough/ or eschar - approx. 90% base - 3 cm by 2 cm by .2 cm with .3 cm undermining at 4 o'clock to 7 o'clock area. Wound Care Orders - clean with normal saline, apply Santyl ointment to wound bed, then cover with piece of calcium alginate and foam bordered dressing daily and prn. This tx (prescription) is appropriate. 10/21/17 - suspected deep tissue - yellow slough - moderate serosanguineous drainage - [DIAGNOSES REDACTED]tous approx. 1 cm circular of the wound no streaking - more undermining - 2.0 cm by 1.5 cm by .5 cm with .5 cm undermining from 4 o'clock to 8 o'clock of wound. (Of note the facility now changes to PI to a SDTI from an unstageable.) On 10/24/17 - Hospice nurses (2) plus the NP(Wound Certified Nurse), here. In agreement with current Wound Care Order - will continue this treatment for [REDACTED]. 10/29/17 - deep pinkened - approx. 1.8 cm from approx. 5 PM to 12 PM clock face - 60% slough - light exudate - 1.8 cm by 1.8 cm by .4 cm with .5 cm undermining from 4 o'clock to 6 o'clock of wound - same Wound Care Orders. 11/5/17 - suspected deep tissue - yellow slough - light drainage - surrounding tissue light pink - .4 cm about most of wound - 30% slough - 1.8 cm by 1.6 cm by .3 cm - .4 cm undermining from 5 o'clock to 7 o'clock of wound - Wound Care Orders continue to be appropriate . 11/12/17 - suspected deep tissue injury in evolution - wound tissue pink and 30% slough - 1.8 cm by 1.5 cm by .1 cm with .4 cm undermining deep from approx. (approximately) the 7-8 o'clock area. 11/26/17 - suspected deep tissue - wound bed pink and 10% slough - surrounding tissue non-[DIAGNOSES REDACTED]tous - 1.2 cm by .5 cm by .1 cm with .5 cm undermining. On 11/29/17, the care plan was updated with - to be last up and first down - only up for meals. On 11/30/17 at 7:39 AM, Surveyor spoke with CNA D (Certified Nursing Assistant). CNA D said that she turns and repositions R31 every two hours when she is in bed. On 11/30/17 at 9:10 AM, Surveyor spoke with CNA C. CNA C said she turns R31 every two hours. On 11/30/17 at 10:30 AM, Surveyor spoke with RN E (Registered Nurse). RN E said the aides turn all the residents every two hours. 12/1/17 - 1 cm by 1 cm by .2 cm - scant drainage (no documentation of undermining area) On 12/1/17 at 10:00 AM, Surveyor spoke with DON B (Director of Nursing). DON B said the maintenance person was in the process of ordering more alternating pressure mattresses and they had not arrived yet.

Based on observation, interview and record review the facility did not ensure that 2 (Resident 4 and Resident 8) of 7 residents reviewed for pressure ulcers, received the care and services to prevent and promote the healing of pressure ulcers. The facility did not develop a plan of care for prevention of pressure ulcers for Resident 4, who was noted to be at risk for the development of pressure ulcers. Resident 4 then developed pressure ulcers on the gluteal area of the buttocks. When Resident 4's was identified with the pressure ulcers a care plan was not implemented. Resident 4's pressure ulcers increased in size and failed to progress toward healing as evidence by a stage 3 pressure ulcer with 80% slough in the wound bed. Resident 8 is a risk for pressure ulcer development. Resident 8 was admitted to the hospital and returned to the facility with a Suspected Deep Tissue Injury (SDTI) to the right heel. Resident 8's heels were observed not floating. This is evidenced by: The facility's policy dated 2010, titled Policy and Procedure for the Prevention and treatment of [REDACTED]. Update the Care Plan for Skin Integrity and nursing assistant care cards with skin concern, appropriate risk factors, turning intervals and interventions as appropriate. Example 1 Resident 4 was readmitted to the facility on [DATE]. Resident 4 [DIAGNOSES REDACTED]. Resident 4's significant change MDS (Minimum Data Set) assessment on 8/8/15 identified that he was at risk for development of pressure ulcers. Review of Resident 4 comprehensive care plan updated on 8/18/15 does not indicate that Resident 4 is at risk for skin breakdown or has actual loss of skin integrity and does not include any interventions (e.g.: daily skin monitoring, keeping skin clean and dry, toileting program to promote continence of bowels, repositioning, or pressure reduction) to prevent pressure ulcers. Review of Resident 4's nursing notes show that on: 8/6/15 Resident 4 had 2 small pea sized open area underside of penis, treatment was ordered, on 8/18/15 Resident 4 had superficial slit in the posterior gluteal folds, right (side) approx. (approximately) 1.5 x 0.3 cm and the left one is 1 cm x 0.5 cm are to apply Calmoseptane BID until healed. On 8/25/15 at 7:55 AM Surveyor observed CNA (Certified Nursing Assistant) L providing personal care for Resident 4. During cares Surveyor observed 3 small open areas on the head of Resident 4's penis (Resident 4 has an indwelling Foley catheter) a red rash on Resident 4 inner thigh and open areas to Resident 4 right and left ischium. There was a partially intact dressing to Resident 4's left ischium which was contaminated with stool. CNA L applied barrier cream to Resident 4's skin and stated Resident 4 skin looked worse than it has in the past and that she would notify the nurse. Resident 4 was then gotten up for breakfast. On 8/25/15 at 10:12 AM Surveyor observed NP (Nurse Practioner) C measure the open and affected areas of Resident 4's skin. The area on Resident 4's left ischium measured 1.5 cm (centimeters) width by 1 cm length and depth was superficial with 80% slough (indicating at least stage 3) in the wound bed, right ischium open area was 2 cm by 1 cm, superficial and wound bed was red. Surveyor asked NP C what was the cause of these open areas NP C stated that she thought they were moisture associated [MEDICAL CONDITION], but that pressure could be a contributing factor. NP C stated that these areas had been looking better before this day 8/25/15 and that she would be writing new orders for Resident 4. Surveyor also observed a gel foam cushion in Resident 4's wheel chair. Surveyor asked for the manufacturers recommendations for use of this cushion which states recommended use: patients at low risk for pressure ulcers. NP C stated that they would be changing the cushion due to Resident 4's increased risk factors. On 8/27/15 at 1:45 PM Surveyor interviewed RN (Registered Nurse) E to review Resident 4 care plan, RN E stated that there was not a plan of care for Resident 4 for skin or pressure ulcer prevention or treatment and there should have been, RN E stated that she would get this corrected. The facilty failed to ensure that Resident 4 received the proper prevention and treatment of [REDACTED]. No interventions were addressed to prevent Resident 4 from developing pressure ulcers. Resident 4 then developed pressure ulcers on the gluteal area on 8/18/15. On 8/25/15 (7days later) it increased in size and failed to progress toward healing as evidence by Resident 4's pressure ulcer is currently a stage 3 with 80% slough in wound bed. 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. Example 2 Resident 8 has [DIAGNOSES REDACTED]. Resident 8's Braden assessment, dated, 7/30/15, indicates Resident 8 scored a 14 indicating Resident 8 is at moderate risk for PU development. Resident 8's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/3/15, indicates A Brief Interview for Mental Status (BIMS) of 12 indicating Resident 8 has moderate cognitive impairment. Section M0150 of the MDS indicates Resident 8 is at risk for developing a PU. Section G0110, Activities of Daily Living (ADL's) indicates Resident 8 requires 2 staff and total assistance for bed mobility and transfers. Resident 8 has a comprehensive care plan Potential for tissue integrity impairment dated 4/16/09. An approach to this care planned problem states in part; Reposition every 2 hours, minimize pressure on bony prominences. Nursing notes dated 7/30/15, at 12:17 AM state in part, Initial Assessment 7/30/15. Pressure Ulcer: Unstageable; Area: right heel dark pigmented area of the right heel. Approximately 1.5 centimeters (cm) circular. Onset date of discovery: on admission. Wound Tissue: blackish. On 8/24/15 at 1:40 PM Surveyor observed Resident 8 lying in bed. Resident 8's lower extremities were on a pillow however, Resident 8's right heel was not floated off the surface of the bed. On 8/25/15 at 7:00 AM Surveyor observed Resident 8 lying in bed. Resident 8's heels were on a pillow but not floated off the surface of the bed. On 8/26/15 at 7:04 AM Surveyor observed the treatment to Resident 8's right heel. Resident 8's lower extremities were on a pillow but Resident 8's right heel was not floated off the surface of the bed. Surveyor asked Registered Nurse (RN) G if Resident 8's heel was floated off the surface of the bed. RN G was adjusting the pillow and stated yes it is floated and placed her hand under the heel after she had tucked the pillow under Resident 8's lower extremity. Resident 8's heel was not floated off the surface of the bed prior to RN G adjusting the pillow. On 8/26/15 at 7:04 AM Surveyor observed the wound treatment to the right heel. The right heel had a dime-sized area of black discoloration to the right heel which appeared as a suspected deep tissue injury in evolution. Surveyor asked Registered nurse (RN) R if the area on the right heel was hard or appeared leathery RN R stated the heel was soft. On 8/27/15 at 6:55 AM Surveyor observed Resident 8 in bed. Resident 8's lower extremities were on a pillow but not floated off the surface of the bed. Surveyor asked Certified Nursing Assistant (CNA) H to look at Resident 8's heels. Surveyor asked CNA H if Resident 8's heels were touching the mattress. CNA H stated that Resident 8's heels were touching the mattress and should be free floating. On 8/27/15 at 2:15 PM Surveyor interviewed Registered Nurse (RN) E regarding the facility's policy for skin policy for prevention of skin impairment. RN E stated that residents identified at risk for heel ulcers should have their heels floated. Surveyor asked RN E if Resident 8 should have his heels floated off the surface of the bed. RN E stated she would expect Resident 8 to have his heels floated.

Based on interview and record review the facility did not ensure that each resident's drug regimen was free from unnecessary drugs for 1 resident (Resident 6) of 13 residents reviewed for unnecessary drugs. An unnecessary drug is any drug when used without adequate monitoring or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Resident 6 receives [MEDICATION NAME] therapy which increases the risk of potential bleeding including gastrointestinal (GI) bleeding. The facility had increased Resident 6's [MEDICATION NAME] dosage which increases the potential for adverse effects including bleeding. The facility failed to notify Resident 6's physician when Resident 6 presented with black stool a sign of GI bleeding. When Resident 6 presented with a second black stool the facility notified the nurse practitioner (NP) but no labs were ordered to monitor Resident 6's [MEDICATION NAME] therapy. In addition, Resident 6 had signs and symptoms of worsening [MEDICAL CONDITIONS] and the facility failed to recognize the potential for elevated International Normalized Ratio (INR) (lab test to monitor [MEDICATION NAME] level) with [MEDICAL CONDITION] exacerbation. Subsequently, Resident 6 was transferred to the emergency room (ER) where a [MEDICATION NAME] time (PT) and INR were drawn. The INR was elevated at 4.69. An elevated INR increases the risk of bleeding including GI bleeding. Resident 6 was admitted to the hospital with [REDACTED]. This is evidenced by: Division of Quality Assurance Memo 08-002, March 4, 2008 indicates a standard of practice for [MEDICATION NAME] ([MEDICATION NAME]) monitoring. The standard of practice includes the following: A test called INR is the lab test that is routinely performed to monitor [MEDICATION NAME] levels. For most individuals, if stable, safe INR level will be between 2 and 3.5, depending on the reason for the medication. When a [MEDICATION NAME] regime is started, a baseline INR is typically obtained. The initial INR should be performed within two to three days. After the initial INR, follow-up INR's may be done every three to five days. INR's are then continued every three to five days until two consecutive stable therapeutic INR readings are established, usually a level between 2 and 3.5. After the two consecutive INR reading are obtained that are between 2 and 3.5, guidelines support INR's to be drawn weekly for 4 weeks. When a resident is stable after the weekly INR's, then an INR will be performed every four weeks as long as [MEDICATION NAME] is being used. NOTE: The above standards are clinically supported and published by the American College of Chest Physicians. However, as with all standards, physicians or others who are monitoring [MEDICATION NAME] may order INRs to be conducted sooner or later to meet specific or unique resident needs. As a nurse, nurse assistant or caregiver, when you see that the accepted standard is not being followed, you should ascertain if there is a legitimate reason for the deviation. You have a responsibility to make sure there is an adequate reason for providing care that is contrary to the accepted standards of practice. Oftentimes, a resident may be stable while on [MEDICATION NAME]; however, other factors may cause the [MEDICATION NAME] to become toxic or in some cases ineffective. Facility staff need to be aware of those circumstances that may compromise [MEDICATION NAME]'s effect so that they can inform the resident, the resident's family, physician, or pharmacist. Monitoring and additional interventions can then be taken in order to avoid clotting or bleeding. NUTRITION-Nutrition can play a significant role in the response to [MEDICATION NAME]. When residents stop eating, have nausea and vomiting, or start IV therapy, this may significantly affect the response to [MEDICATION NAME]. When patients stop eating, change diet, or add supplements; it is important to notify the physician, pharmacist and others who are monitoring the [MEDICATION NAME] about this change in the resident's routine. In the event of such changes, the INR should be checked within one week and monitored just like a medication interaction. Subsequent INR readings will be dependent on the resident's condition and INR readings . MONITORING-Besides monitoring for INR, facility staff can monitor for signs and symptoms of bleeding. Those symptoms include bruising, bleeding from the gums during teeth brushing, blood in the stool, sudden onset confusion that may indicate bleeding in the brain, or recent changes in breathing patterns or sounds that may indicate bleeding in the lungs. These symptoms need to be reported to the physician and addressed quickly as they may be an indication that [MEDICATION NAME] has become toxic. The facility's Anticoagulation Monitoring Service Policy and Procedures states in part: Anticoagulation Monitoring Service Patient Education Record: 5. Warning Signs: Discoloration of the urine and stool (black tarry) .Managing Excessive Prolongation of the INR: Minor Bleeding: A. Above therapeutic range but <10: hold [MEDICATION NAME] until INR declines to therapeutic range, then restart at a lower dose and institute more frequent monitoring (recommend if INR only mildly elevated). Oral Vitamin K, 1.25 milligram (mg) can be used if high risk of hemorrhage. Serious Bleeding: INR therapeutic or elevated: Vitamin K, 5-10 mg, Intravenous. Fresh-frozen plasma at a dose of at least 15 milliliters/kilogram. Resident 6's [DIAGNOSES REDACTED]. Resident 6 has a care planned problem dated 10/6/14, which states in part: Potential for uncontrolled bleeding related to anticoagulation therapy. An approach to this care planned problem states in part: assess any bleeding, monitor coagulation studies and report to physician as needed. Resident 6's [MEDICATION NAME] Therapy Flow Record states in part: 7/13/15, INR Result: 2.1 [MEDICATION NAME] Order: Continue 2 mg 6 days week Monday- Friday and Sunday; 3 mg Saturday. Of note, a hand written note at the top of this record states (Goal is 2-2.5). Resident 6's [MEDICATION NAME] Therapy Flow Record states in part: 8/3/15, INR Result: 1.8 A telephone order dated 8/3/15, signed by Nurse Practitioner (NP) C which states in part: [MEDICATION NAME] 3 mg 3 times week; 2 mg 4 times week. Start with 3 mg tonight. Next INR Order Date: Check INR in 2 weeks (8/17/15). Of note, this is an increase in [MEDICATION NAME]. Nursing note dated 8/15/15 at 2:20 PM states in part: noisy, congested cough, non-productive, wheezing heard. Notified NP C orders received chest -x-ray (CXR). Blood pressure (BP) 95/59. (Low BP). Of note, Resident 6's baseline BP's: 103-114 (systolic)/51-67 (diastolic). Nursing note dated 8/15/15 at 5:43 PM states in part: BP 90/63. (Low BP) A telephone order dated 8/15/15, signed by NP C, states in part: CXR related to congested cough, crackles, and shortness of breath, lethargic too weak to get out of bed. History of [MEDICAL CONDITIONS]. Resident 6's [MEDICATION NAME] Therapy Flow Record states in part: 8/17/15, INR Result: 1.9. [MEDICATION NAME] Order: 3 mg 4 times week; 2 mg 3 times week. Next INR Order Date: 2 weeks. A telephone order dated 8/17/15 states in part: [MEDICATION NAME] 3 mg 4 times week; 2 mg 3 times week. INR in 2 weeks (8/31/15). Of note, this is an increase in [MEDICATION NAME]. Nursing note dated 8/19/15 at 9:44 AM states in part: BP 97/60 (low BP). Nursing note dated 8/22/15 at 10:25 AM states in part: Stool: black tarry looking this PM. Of note, there is no evidence of an assessment for Resident 6 after the discovery of the black tarry stool. In addition, there is no evidence the physician was notified of Resident 6's change of condition thus there was no monitoring of Resident 6's [MEDICATION NAME] therapy despite evidence of potential GI bleeding. Nursing note dated 8/23/15 at 3:06 PM states in part: Consulted with NP C resident had bowel movement that was black, NP C called and new orders received; hemocult x's 3, labs in AM, to start [MEDICATION NAME] ([MEDICATION NAME]). Hemocult #1 positive. A telephone order dated 8/23/15, signed by NP C, states in part: Hemocult x's 3. Complete blood count (CBC) with differential; Basic Metabolic Panel (BMP); Total Iron Binding Count; Folate and Iron. Hemocult Positive; [MEDICAL CONDITION]. [MEDICATION NAME] 20 mg one daily. Of note, although labs were ordered for Resident 6 there was no lab ordered to monitor Resident 6's [MEDICATION NAME] level which had recently been increased to a higher dose. Lab Values: 8/25/15: CBC: Hemoglobin: 7.0 (Critical low) Hematocrit: 22 (Critical Low). Physician Plan of Care dated 8/25/15 states in part: Positive black stool with positive hemocult x's 1; [MEDICAL CONDITION]; lung sounds with crackles, low BP 93/47. The hospital History and Physical dated 8/25/15 states in part: Chief Complaint: GI bleeding. History of Present Illness: Found to have rectal bleeding this morning and was brought to the ER. Found to be significantly anemic. Evaluation in the ER revealed a very pale-appearing individual, moderately low BP at 91/48. Body temperature was low at 96.7. Repeat blood work in the ER demonstrated hemoglobin of 6.4 and a hematocrit of 20. Type and cross was taken for 2 units with planned transfusion. Reviewed status with the patient's sister who is her healthcare power of attorney; it is the sister's decision that this individual not receives further [MEDICAL CONDITION] and be given comfort measures only. Accordingly, after the current transfusion, further blood [MEDICAL CONDITION] will be discontinued. The sister has discussed this in depth and understands that this is a potentially fatal diagnosis. Impression: Acute GI bleeding; [MEDICAL CONDITION] secondary to GI bleeding. Due to the active GI bleeding, no anticoagulation for [MEDICAL CONDITION] will be administered. ER Laboratory Value dated 8/25/15: INR: 4.69 (high). INR Interpretation: Therapeutic range: 2.0-3.0. Hospital progress note 8/25/15 at 3:16 PM states in part: admitted with acute GI bleeding and severe [MEDICAL CONDITION]. Blood transfusion started in ER. Discussed status with sister health care power of attorney (HCPOA). Advised that this is a critical illness; this is potentially a fatal illness. Resident carries a Do not Resuscitate (DNR). The sister reconfirmed this. The sister has requested palliative care and does not wish further [MEDICAL CONDITION]. Palliative care consult requested. Facility nursing notes dated 8/25/15 at 7:53 PM state in part: sent to ER for evaluation of [MEDICAL CONDITIONS], and possible pneumonia. Spoke to nurse at hospital Resident 6 was admitted to hospital for GI bleed and [MEDICAL CONDITION]. Resident 6 was to get 2 units of packed red blood cells however, removed intravenous needle after one unit and will not receive second unit; has been made comfort care. Nursing note dated 8/26/15 at 7:26 PM states in part: readmitted from hospital was found to have GI bleed. On 8/27/15 at 9:55 AM Surveyor interviewed NP C regarding Resident 6's black stools. Surveyor asked NP C if she was aware that Resident 6 was on [MEDICATION NAME]. NP C states she was aware that Resident C received [MEDICATION NAME] therapy. Surveyor asked NP C why an INR was not completed with the other labs that NP C ordered for Resident 6 on 8/23/15. NP C stated she was not sure why she did not order an INR. NP C stated she wanted to assess Resident 6's CBC. Surveyor asked NP C if a resident presents with black stool and is on [MEDICATION NAME] therapy would it be expected that an INR be completed. NP C stated she typically would complete an INR if a resident was on [MEDICATION NAME] and having bleeding she was not sure why she did not order an INR. On 8/27/15 at 11:55 AM Surveyor spoke with Licensed Practical Nurse (LPN) I regarding Resident 6's black stool on 8/22/15. LPN I stated the Certified Nursing Assistant (CNA) told her that Resident 6 had a black stool and she went to look at it. LPN I stated the stool was in the toilet so she was unable to determine the amount of black stool. LPN I stated the stool was black and tarry. LPN I stated she did not consult with the physician because she did not feel it was a big issue as stools can appear dark due to different foods or iron. Surveyor asked LPN I if Resident 6 received iron LPN I stated no I do not think she does. Surveyor asked LPN I if she was alone in the facility LPN I stated she worked with a Registered Nurse (RN). Surveyor asked LPN I if she mentioned the black stool to the RN or had the RN look at the stool. LPN I stated she did not tell the PM RN but she did report to the night shift RN to watch for black stools because Resident 6 is on [MEDICATION NAME]. LPN I further stated that night must have been the start of it, (GI bleeding) because she is at the hospital now, it happened fast. If I thought it was a big deal we would have held the [MEDICATION NAME]. On 8/27/15 at 1:15 PM Surveyor interviewed RN D regarding Resident 6's black stool on 8/23/15. RN D stated she called NP C to update on black stool on 8/23/15. RN D thought she mentioned to NP C that Resident 6 was on [MEDICATION NAME]. On 8/27/15 at 2:15 PM Surveyor interviewed RN E and Director of Nursing (DON) B regarding Resident 6's GI bleed. Surveyor asked RN E what the facility considers a change of condition (COC) and when the facility should notify the physician of changes. RN E stated that black, tarry stool would be considered a COC and that the facility should have notified the physician or NP with the onset of the first black, tarry stool especially if the resident receives [MEDICATION NAME]. RN E stated she would have expected an INR to be ordered for a resident with black, tarry stools. Surveyor asked DON B if she considered the black stool a change of condition requiring a physician consult DON B stated she would consider it a change and the physician should have been consulted. DON B agreed an INR should have been completed and stated she was surprised it was not completed as NP C always asks the staff if the resident receives [MEDICATION NAME]. The facility failed to consult with the physician when Resident 6 who receives [MEDICATION NAME] therapy presented with black, tarry stools and had a positive hemocult a sign of GI bleeding. In addition, the facility failed to recognize the adverse effects of [MEDICATION NAME], including bleeding, with the recent increases in [MEDICATION NAME] dosage. The facility failed to monitor laboratory values to ensure INR remained in therapeutic range. As a result Resident 6 was transferred to the ER where Resident 6 received a blood transfusion.