Every finding on record at Fond du Lac Lutheran Home

Based on interviews, record review, and policy review, the facility failed to discuss risks versus benefits and obtain informed consent for the use of psychotropic medication for 1 resident (R) (R4) of 3 sampled residents. The deficient practice had the potential to cause a psychosocial decline in R4's mental status. Findings include: Review of the facility's undated Standard Psychoactive Medication Protocol policy revealed: .Individual is prescribed a psychotropic medication .Nursing: .Review and obtain signature for informed consent with individual or responsible party. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, human immunodeficiency virus (HIV), dementia, and type 2 diabetes mellitus. R4 had a Guardian who was R4's Responsible Party (RP). Review of an Order Entry, dated 11/4/25, revealed an order for Depakote Extended Release (ER) (an anticonvulsant and mood stabilizer medication) 250 milligrams (mg) daily for sexually inappropriate behavior. Review of R4's Medication Administration Record (MAR) for November 2025 revealed an order for Depakote ER 250 mg daily with a start date of 11/5/25. The medication was documented as administered on 11/5/25. There was no documentation as to whether the 11/6/25 dose was administered. The medication was held and not administered from 11/7/25 until it was discontinued on 11/10/25. Review of the Miscellaneous tab of R4's electronic medical record (EMR) revealed there was not a signed informed consent form for the Depakote that was administered on 11/5/25. Review of R4's comprehensive record revealed nothing to indicate a discussion was had with R4's RP regarding the Depakote order, risks versus benefits, or informed consent prior to the administration of the medication on 11/5/25. Review of a Nurse's Note, dated 11/7/25, revealed: Depakote: Order in EMAR (electronic MAR) put on hold. POA (Power of Attorney) wants to speak (with) dialysis before she will consent to (medication). Review of an Incident Note, dated 11/10/25 and written by the Director of Nursing (DON), revealed: (R4) was ordered Depakote to help with sexually inappropriate behavior reduction as it does not interact with (R4's) HIV medication effectiveness. The NP (Nurse Practitioner) gave the order after recommendations were given from the pharmacist. Staff did not update (R4's) POA on the new medication and administered a dose after receiving the order. Later, (R4's) POA was informed and wanted the medication to be held until she could talk to dialysis for safety reasons. (R4's) POA asked what medications (R4) had today and it was noted that a dose was missing on (11/5) as given. There (were) no adverse effects noted the day of the dose being given but the order has been discontinued and all appropriate people updated as (R4's) POA does not consent to use of this medication. Review of R4's Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/6/26, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderately impaired cognition. The MDS assessment indicated R4 had no behaviors in the 7-day look-back period and did not receive any psychotropic medication. During an interview on 5/13/26 at 2:35 PM, Registered Nurse (RN)1 stated she spoke with R4's RP regarding the new medication and informed R4's RP the first dose had been administered. RN1 stated R4's RP stated she wanted to talk to the dialysis facility before the next dose was given to ensure it would not have an adverse effect with dialysis. RN1 stated she asked R4's RP to come back or call the facility after she spoke with the dialysis center to relay the information she received. RN1 stated she never heard back from R4's RP. During an interview on 5/14/26 at 11:45 AM, the DON stated R4's medications were reviewed by the pharmacist and the provider for the most effective medication that would not interact with dialysis or any other medications R4 received. The DON stated the order for Depakote was entered in the EMAR, and one dose was given on 11/5/25 before R4's RP was updated and informed consent was obtained. The DON stated she expected nursing staff to obtain consent before entering a new order for a psychotropic medication.

Based on staff interview and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 50 of 51 residents residing in the facility. (One resident received nutritional needs via tube feeding.)Staff did not consistently monitor and document warewasher (dishwasher) wash and rinse cycles temperatures or chemical pH levels for the chlorine sanitizer.Staff did not consistently test and document the parts per million (PPM) and temperature of the sanitizing solution in the 3-compartment sink.Staff did not consistently monitor and document cooked food temperatures or hot/cold holding temperatures.Staff did not consistently maintain kitchen cooler and freezer logs. Findings include:During an initial tour of the kitchen on 9/2/25 at 9:28 AM, Surveyor interviewed Dietary Manager (DM)-C who indicated the facility follows the Wisconsin Food Code.The 2022 Wisconsin Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure that .(G) Employees are properly cooking time/temperature control for safety food, being particularly careful in cooking those foods known to cause severe foodborne illness and death, such as eggs and comminuted meats, through daily oversight of the employees routine monitoring of the cooking temperatures using appropriate temperature measuring devices properly scaled and calibrated as specified under 4-203.11 and 4-502.11 (B) .(I) Employees are properly maintaining the temperatures of time/temperature control for safety foods during hot and cold holding through daily oversight of the employees routine monitoring for food temperatures .(K) Employees are properly sanitizing cleaned multi-use equipment and utensils before they are reused, through routine monitoring of solution temperature and exposure time for hot water sanitizing, and chemical concentration, pH, temperature, and exposure time for chemical sanitizing.Dishwashing Machine Logs:The facility's undated Recording Dish Machine Temperatures policy indicates: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. 1) The Food Service Manager will provide the dishwashing staff with a log to be posted near the dish machine. 2) The Food Service Manager will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. 3) Staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal. 4) Dishwashing staff will be trained to report any problems with the dish machine to the Food Services Manager as soon as they occur.The 2022 Wisconsin Food Code documents at 4-501.110 (B): The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 49 degrees Celsius (C) or 120 degrees Fahrenheit (F).During a follow-up tour of the kitchen on 9/3/25 at 1:38 PM, Surveyor interviewed DM-C who indicated staff complete dish washing after each meal service and should monitor and document dish machine temperatures and chlorine pH levels prior to each use. From 9/2/25 to 9/4/25, Surveyor reviewed the facility's dishwasher machine logs for June 2025 through July 2025. Surveyor noted the logs contained 38 missing dish machine temperatures and pH levels. Surveyor also noted 39 wash temperatures were below the minimum of 120 degrees F.On 9/4/25 at 9:48 AM, Surveyor interviewed DM-C who stated staff are aware that when the dish machine temperature is below the minimum temperature, they should run empty racks through the dish machine until the temperature is above 120 degrees F. DM-C acknowledged the dish machine logs did not indicate staff took corrective measures when the temperatures were low and verified DM-C was aware of the missing temperatures and pH levels. DM-C stated DM-C has new staff who are still learning to complete the logs.Manual Warewashing and Sanitizing Solution Testing:The 2022 Wisconsin Food Code documents at 4-501.19 Manual Warewashing Equipment, Wash Solution Temperature: The temperature of the wash solution in manual warewashing equipment shall be maintained at not less than 43 degrees C (110 degrees F) or the temperature specified on the cleaning agent manufacturer's label instructions.On 9/4/25 at 9:48 AM, Surveyor interviewed DM-C who stated the facility uses Hydrion QT-40 Quaternary test strips to test the PPM levels in the 3-compartment sink. DM-C stated the cooks wash their dishes at the end of each meal service and should test and document the temperature and PPM in the 3-compartment sink prior to washing their dishes. From 9/2/25 to 9/4/25, Surveyor reviewed the facility's 3-compartment sink temperature and PPM logs for June 2025 through August 2025. Surveyor noted the logs were not consistently completed and contained multiple missing temperatures and PPM levels. On 9/4/25 at 9:48 AM, Surveyor interviewed DM-C who was aware of the missing temperatures and PPM levels and stated new staff are still learning to complete the logs.Food Temperature Monitoring:The 2022 Wisconsin Food Code documents at 3-401.11 Raw Animal Foods: .Raw animal foods such as eggs, fish, meat, poultry, and foods containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with one of the following methods based on the food that is being cooked.The facility's undated Temperature and Recording policy indicates: The temperatures of food items will be taken and properly recorded for each meal. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees F. Staff are to take temperatures often to monitor for safe temperature ranges at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods. Cooking temperatures must be reached and maintained according to regulation, law, and standardized recipes while cooking .Temperatures should be taken periodically .during the portioning, transporting, and delivery process.From 9/2/25 to 9/4/25, Surveyor requested the food temperature logs for June 2025 through August 2025. The facility provided Surveyor with 155 meal temperature logs which included cooked temperatures and served (holding) temperatures. Surveyor noted the following:~ There were no cooked temperatures for 32 meals.~ There were no served (holding) temperatures for 30 meals.~ Of the 155 logs reviewed, 147 logs did not contain a date on which the log was completed.On 9/4/25 at 9:48 AM, Surveyor interviewed DM-C who was aware of the missing temperatures and stated new staff are still learning to complete the logs.Refrigerator and Freezer Temperature Monitoring:The 2022 Wisconsin Food Code documents at 3-202.11 Temperature: .Perishable food items must be stored at appropriate temperatures to prevent spoilage and reduce the risk of foodborne illness. Refrigerators should be set below 41 Fahrenheit (F) (5 Celsius (C)) and freezers at or below 0 F (-18 C).From 9/2/25 to 9/4/25, Surveyor reviewed temperature logs for 2 refrigerators and 2 freezers in the main kitchen for June 2025 through August 2025. The logs indicated temperatures should be taken three times daily. Surveyor noted the following:~ The log for the walk-in refrigerator contained missing temperatures on 64 days.~ The log for the walk-in freezer contained missing temperatures on 61 days.~ The baker refrigerator contained missing temperatures on 62 days.~ The baker freezer contained missing temperatures on 62 days.On 9/4/25 at 9:48 AM, Surveyor interviewed DM-C who was aware of the missing temperatures and stated new staff are still learning to complete the logs.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R6 and R7) of 3 residents observed during the provision of cares. R6 had a feeding tube and was on enhanced barrier precautions (EBP). During an observation of care for R6, Registered Nurse (RN)-D did not wear the appropriate personal protective equipment (PPE).Used gloves were observed on a railing outside R7's room following an observation of care for R7. Findings include:The facility's Enhanced Barrier Precautions Policy, dated 2/6/25, indicates: EBP is used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to the donning of a gown and gloves during high-contact resident care activities that provide opportunities for the transfer of multidrug-resistant organisms (MDROs) to staffs' hands and clothing. EBP is indicated for residents with infection or colonization with an MDRO, wounds, or indwelling medical devices. A feeding tube is considered an indwelling medical device.The facility's Personal Protective Equipment Policy, dated 7/22/22, indicates: Clean, disposable gloves are worn when exposure is planned or anticipated during direct contact with stool or other body fluids.1.From 9/2/25 to 9/4/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder, anxiety, chronic respiratory failure, difficulty swallowing, and a history of gastrostomy feeding tube placement. R6's Minimum Data Set (MDS) assessment, dated 7/10/25, indicated R6 had moderate cognitive impairment. R6 had an activated Power of Attorney of Healthcare (POAHC). A care plan, revised 1/25/23, indicated R6 had a potential for altered nutritional status related to nothing by mouth (NPO) status with full reliance on tube feeding for nutrition and hydration support related to aspiration risk. The care plan also indicated R6 was on EBP.On 9/3/25 at 9:00 AM, Surveyor observed RN-D disconnect R6's feeding tube and flush the tube with 100 cubic centimeters (ccs) of water. During the procedure, RN-D wore gloves but did not wear a gown. Surveyor observed a sign outside R6's door that indicated R6 was on EBP and a PPE cart outside R6's room. On 9/3/25 at 9:05 AM, Surveyor interviewed RN-D who verified RN-D wore gloves but not a gown on while providing feeding tube care for R6.2. From 9/2/25 to 9/4/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including seizure disorder, encephalopathy, and congenital hydrocephalus. R7 had a cerebrospinal drainage device. R7's MDS assessment, dated 7/15/25, indicated R7 had severe cognitive impairment. R7 had an activated POAHC.On 9/3/25 at 10:15 AM, Surveyor observed Certified Nursing Assistant (CNA)-G and CNA-H transfer R7 from wheelchair to bed via Hoyer lift with the intention of checking R7 for incontinence and changing R7's brief if necessary. CNA-G and CNA-H wore gloves during the transfer. R7 refused to be checked for incontinence and indicated R7 wanted to remain in bed and rest. CNA-G and CNA-H then removed gloves and exited the room.On 9/3/25 at 10:31 AM, Surveyor observed used gloves on the railing outside R7's room. Surveyor was uncertain who put the gloves on the railing and was unable to interview CNA-G or CNA-H who went to assist another resident. On 9/4/25, Surveyor interviewed Director of Nursing (DON)-B and informed DON-B about the used gloves on the railing outside of R7's room. DON-B indicated leaving used gloves on a railing was not in accordance with the facility's infection control practices.

Based on staff and resident interview and record review, the facility did not ensure the opportunity to participate in quarterly care conferences was provided for 1 resident (R) (R8) of 22 sampled residents.The facility did not include R8 in quarterly care conferences since 11/5/24.Findings include:The facility's Individual Care Plan Conferences policy, dated 2/2024, indicates: .3. An individual care plan review will be held every three months after the initial care plan conference is held. Scheduling will be done by the Minimum Data Set (MDS) Nurse or designee. The Life Coach will invite the individual or responsible party to the care plan review .From 9/2/25 to 9/4/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including surgical amputation of toe, cellulitis of left lower limb, sepsis, and diabetes. R8's MDS assessment, dated 8/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 had intact cognition. R8 was responsible for R8's healthcare decisions. On 9/2/25 at 10:21 AM and on 9/3/25 at 3:00 PM, Surveyor interviewed R8 who indicated care plan conferences should be quarterly, however, R8 had not had a care plan conference since last year. R8 did not recall receiving mail at the facility with notification of care plan conferences. R8 indicated Director of Life Coach Services (DLCS)-E does not tell R8 about dates or times of care conferences. On 9/3/25 at 1:11 PM and 2:15 PM, Surveyor interviewed DLCS-E who indicated care plan conference meeting notifications were sent via mail to R8's home residence. DLCS-E indicated that was an error and the notifications should have been mailed to R8 at the facility. DLCS-E indicated DLCS-E communicates with R8 on a regular basis but does not verbally inform R8 of scheduled care conferences or discuss care conference outcomes. DLCS-E indicated R8's family indicated they were unable to attend the scheduled conferences due to scheduling conflicts. DLCS-E verified the last care conference R8 attended was on 11/5/24 and care conferences beyond that date only included facility staff. DLCS-E verified R8 is responsible for R8's healthcare decisions and should be the primary contact for all communication.On 9/3/25 at 3:26 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated care conferences should be scheduled on a quarterly basis. DON-B indicated DON-B expects staff to provide care conference notifications to R8 who does not have an activated Power of Attorney for Healthcare (POAHC).

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 1 resident received adequate supervision to prevent elopement. On 2/23/25, R1 was assessed to be at risk for elopement after R1 attempted to elope fromv the facility. Staff placed a WanderGuard bracelet on R1. On 2/24/25, R1 expressed a desire to leave the facility and go to a local store. On 2/26/25, R1 cut off R1's WanderGuard and a new WanderGuard was applied. On 2/28/25 at 8:35 AM, R1 left the facility without staffs' knowledge and was redirected back into the facility. On 2/28/25 at 3:30 PM, staff found R1 outside walking back from a local store that was approximately 0.3 miles from the facility. R1 had eloped from the facility without staffs' knowledge. The facility's failure to supervise a resident who was assessed as an elopement risk and had a history of elopement attempts and cutting off a WanderGuard led to a finding of Immediate Jeopardy that began on 2/28/25. Surveyor notified Nursing Home Administrator (NHA)-A of the Immediate Jeopardy on 3/25/25 at 4:22 PM. The Immediate Jeopardy was removed and corrected on 3/26/25; however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Elopement Prevention policy, dated 8/10/23, indicates interventions for individuals at risk for elopement will be identified and implemented. Procedure: A) At the time of screening and/or upon admission, gather data regarding history of wandering or elopement. B) A licensed nurse will complete the Elopement Risk Evaluation upon admission to the facility, quarterly, and change of condition .An interim plan of care for minimizing the risk for elopement will be initiated upon high-risk determination .D) The Interdisciplinary Team (IDT) will initiate a plan of care for any individual determined at high risk for elopement. Facility-specific measures as well as individual-specific measures will be included in each high-risk individual's plan of care to minimize risk factors .F) Interventions to decrease risk of wandering such as devices and monitoring will be initiated as deemed appropriate by the IDT and documented in the individual's plan of care. On 3/25/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including hepatic encephalopathy, alcoholic cirrhosis of liver, delirium due to known physiological condition, anxiety disorder, depression, and history of falling. R1 was ambulatory and used a front-wheeled walker and wheelchair for mobility. R1 was semi-independent and required minimal assistance and cueing with activities of daily living (ADLs). An Admission Minimum Data Set (MDS) assessment, dated 1/29/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R1 had moderate cognitive impairment. A Discharge MDS assessment, dated 3/10/25, had a BIMS score of 11 out of 15 which indicated R1 had moderate cognitive impairment. R1 had an activated Power of Attorney for Healthcare (POAHC) who was responsible for R1's healthcare decisions. R1 discharged from the facility on 3/10/25. An Elopement Risk Assessment, dated 1/22/25, indicated R1 was at low risk for elopement and was non-ambulatory. On 2/2/25, R1 was hospitalized with a diagnosis of hepatic encephalopathy and increased confusion. R1 was readmitted to the facility on [DATE]. An Elopement Risk Assessment, dated 2/12/25, indicated R1 was at low risk for elopement. A progress note, dated 2/15/25 at 9:56 PM, indicated R1 was forgetful and had difficulty finding words to express R1's self. There was a noted increase in wandering the halls after supper. By 9:00 PM, R1 had changed clothes 3 times, wandered into another resident's room, and went to the elevator. Staff redirected R1 back to R1's room. Staff talked with R1 and indicated R1's behavior could be due to an increased ammonia level. Staff offered an additional dose of lactulose but R1 refused. The night nurse was updated. A progress note, dated 2/16/25 at 1:14 AM, indicated R1 wandered quite a bit and went into other residents' rooms. R1 was easily redirected, however as soon as staff left R1's room, R1 started to wander again. A progress note, dated 2/16/25 at 4:09 AM, indicated R1 asked to leave the facility and went to the emergency room (ER) via ambulance at approximately 4:05 AM due to increased confusion, restlessness, wandering, and decreased urination. A progress note, dated 2/21/25 at 4:48 PM, indicated R1 was alert and oriented and was readmitted from the hospital in a wheelchair with a diagnosis of hepatic encephalopathy. An Elopement Risk Assessment, dated 2/21/25, indicated R1 was at high risk for elopement. The assessment indicated R1's risk could be related to confusion and the hospital's statement that R1 was sundowning. A progress note, dated 2/23/25 at 8:05 PM, indicated R1 attempted to elope twice on the AM shift. R1 attempted to use the door at the stairwell but staff intervened. When family arrived later in the day, R1 was in the lobby signing R1's self out in the visitor log. Family was concerned that R1 may try to leave again and requested a WanderGuard be placed. A progress note, dated 2/23/25 at 11:26 PM, indicated R1 was up ad lib (as desired) and wandered in and out of rooms and hallways frequently from 9:00 PM to 10:00 PM. An Elopement Risk Assessment, dated 2/23/25, indicated R1 was at high risk for elopement. The assessment indicated R1 attempted to elope twice on the AM shift. Family was concerned R1 may try to leave again and requested a WanderGuard. A progress note, dated 2/24/25 at 2:14 AM, indicated R1 walked the hallways with and without a walker, repeatedly changed clothes, and moved items around R1's room. R1 did not use a call light or ask for assistance and was put back to bed several times. R1 thanked staff and closed R1's eyes but was up again in the hallway a few minutes later. R1 declined to sit in a recliner in the sunroom. Lorazepam (an anxiety medication) was ineffective. There was a WanderGuard on R1's right ankle. A progress note, dated 2/24/25 at 7:23 AM, indicated staff spoke with R1's POAHC about moving R1 to a room closer to the nurses' station on the first floor or a room on the second floor for better WanderGuard monitoring. R1's POAHC asked to consult with other family members and R1's physician before making a decision. A progress note, dated 2/24/25 at 4:17 PM, indicated staff notified R1's family that R1 wanted to walk to a local store. R1's family was in agreement with a WanderGuard. The Nurse Practitioner was notified and a WanderGuard was placed on R1. An Elopement Risk Care Plan, initiated 2/24/25, indicated R1 attempted to leave the facility unattended. The care plan contained the following interventions: Distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. R1 prefers gardening, floral design, word games, socializing with others (initiated 2/24/25); Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes (initiated 2/24/25); Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate (initiated 2/24/25); Wander alert bracelet placed. Staff to check placement every shift and functioning every day (initiated 2/24/25); Monitor location of R1 via frequent checks. 1:1 if available and needed. Family to assist with 1:1 visits as able (initiated 3/4/25). On 3/25/25 at 1:00 PM, Surveyor interviewed Director of Nursing (DON)-B who clarified WanderGuard placement was initiated on 2/23/25 following R1's elopement assessment. The WanderGuard was placed on R1 early on 2/24/25 after review with family. DON-B indicated the note from later in the day on 2/24/25 is when WanderGuard monitoring was placed on R1's medication administration record (MAR). DON-B indicated R1 cut off R1's WanderGuard prior to the elopement on 2/28/25. DON-B stated the first time R1 cut off the WanderGuard was either 2/24/25 or 2/25/25. DON-B stated after R1's request to leave and go to a local store on 2/24/25, it was recommended to R1's family to move R1 to the second floor for closer monitoring. DON-B stated R1 initially did not want to move but was moved to the second floor on 2/26/25. DON-B indicated no other interventions were put in place. On 3/25/25 at 2:02 PM, Surveyor followed-up with DON-B who reported a correction to DON-B's original statement that on 2/25/25, DON-B checked the placement of R1's WanderGuard and noted the WanderGuard was intact. DON-B stated housekeeping staff alerted DON-B on 2/26/25 that R1's WanderGuard was found in the garbage. DON-B stated 2/26/25 was the first time R1 had cut off the WanderGuard. A progress note, dated 2/27/25 at 9:17 PM, indicated R1 cut the WanderGuard off again. A WanderGuard was placed on R1's wheelchair. A progress note, dated 2/28/25 at 8:35 AM, indicated R1 continued to exit seek and left the building without staffs' knowledge. R1 was educated on the risk of leaving the building. R1 did not understand and stated R1 would go out if R1 wanted. Family was aware that R1 needed supervision at all times when awake and R1 should not have any items that could be used to cut off the WanderGuard. A progress note, dated 2/28/25 at 3:58 PM, indicated R1 disappeared from the unit and was found walking back from a local store after buying wine and other items. New WanderGuards were placed on R1's left wrist and 2-wheeled walker. R1 was placed on 1:1 supervision. The note indicated if there were not enough Certified Nursing Assistants (CNAs) for 1:1 supervision, R1 needed to follow the nurse during medication pass. Family agreed to help with 1:1 supervision. On 3/25/25 at 1:58 PM, Surveyor interviewed DON-B who stated R1 cut off R1's WanderGuard on 2/28/25 and used the elevator to get to the ground floor and leave the facility via the front door. DON-B stated R1 may have been cognizant enough to use the stairwell door code to get down the stairs, however, R1 had a walker at the time and DON-B did not feel R1 was able to maneuver the stairs with a walker. On 3/25/25 at 2:33 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who worked the PM shift on 2/28/25. LPN-F stated R1 was not on 1:1 supervision but was on frequent checks and staff left R1's door open for monitoring. LPN-F stated R1 was quick and fast. A progress note, dated 3/1/25 at 1:39 PM, indicated R1 attempted to leave the unit multiple times during the shift and asked for scissors all shift. Staff were unable to locate R1 at one point. R1 was found fully dressed in a bathtub with the water running and stated, I need my hair washed. R1 was assisted out of the bathtub by staff. R1 self- propelled a wheelchair in the hallway and asked to go downstairs. An Elopement Risk Assessment, dated 3/4/25, indicated R1 was at high risk for elopement. The assessment indicated a WanderGuard was in place, however, R1 removed several WanderGuards from R1's body and mobility devices. Staff continued to replace the WanderGuards and attempted to put them in places R1 was not aware of. 1:1 supervision was in place when available. If 1:1 supervision was not available, frequent checks were in place. On 3/25/25 at 2:37 PM, Surveyor interviewed Registered Nurse (RN)-E who was R1's nurse on 3/1/25. RN-E confirmed staff found R1 in the bathtub fully clothed. RN-E stated R1 was not missing for long. RN-E could not recall if R1 was on 1:1 supervision prior to 3/1/25 or after. RN-E confirmed R1 was not on 1:1 supervision on 3/1/25 when R1 went missing. On 3/25/25 at 2:47 PM, Surveyor interviewed DON-B who stated R1 was started on 1:1 supervision immediately after R1's 2/28/25 elopement. DON-B confirmed R1 should have been on 1:1 supervision on 3/1/25 unless family was there or hourly checks were completed. DON-B stated hourly checks should have been documented in R1's MAR or treatment administration record (TAR). Surveyor reviewed R1's MAR and TAR and noted a nursing order, dated 3/6/25, to check on R1's location and WanderGuard placement (walker, wheelchair, purse and left ankle to ensure still on) hourly. Surveyor could not locate any hourly checks prior to 3/6/25. On 3/25/25 at 2:21 PM, Surveyor observed the second floor stairwell doors. The doors were secured with an electronic door pad that required a code to open. Surveyor observed a permanent sign on each of the stairwell doors that contained the code to open the door and deactivate the alarm. The failure to supervise a resident with a history of elopement attempts and who eloped from the facility without staffs' knowledge created a reasonable likelihood for serious harm thus leading to a finding of Immediate Jeopardy. The facility removed the jeopardy on 3/26/25 when it completed the following: 1. Reviewed the facility's Elopement Prevention Policy and updated elopement protocol. 2. Provided all staff education upon next working shift regarding supervision for residents at risk for elopement and steps to take if a resident cuts off a WanderGuard, requests a tool to cut off a WanderGuard, and/or continues to express a desire to leave the unit. 3. Removed plaques at each stairwell doorway that contained a code to enter and exit the unit and placed a small label with the door code at the top of the door frame. 4. Conducted a thorough sweep of all residents for elopement risk and exit-seeking behavior on 3/26/25 and ensured care plans were updated with interventions to address exit-seeking/unsafe behavior and/or statements to ensure safety. 5. Initiated audits of residents with exit-seeking behavior for proper documentation, effectiveness of interventions, and elopement events. Audits will be completed weekly for 4 weeks. Audit results will be brought to the monthly Quality Assurance Performance Improvement committee for review.

Based on staff interview and record review, the facility did not ensure required nurse aid training was completed for 1 of 5 sampled Certified Nursing Assistants (CNAs). CNA-D was hired on 8/23/23. CNA-D did not have 12 hours of in-service training during CNA-D's most recent anniversary hire year. Findings include: According to the Wisconsin Department of Health Services' Webpage titled Nurse Aide Program: Maintaining Registry Status, when an individual is placed on the Wisconsin Nurse Aid Registry, they are given two eligibilities: federal and state. Federal eligibility is mandated by federal law for individuals who work in federally licensed nursing homes. (https://www.dhs.wisconsin.gov/caregiver/nurse-aide/maintain-status.htm) The facility's Quality Assurance and Performance Improvement (QAPI) Plan policy indicates all staff will participate in ongoing annual QAPI training which includes quality improvement principles and practices, how to identify areas for improvement, updates on current performance improvement projects, and how staff can be involved in performance improvement projects. On 3/27/25, Nursing Home Administrator (NHA)-A indicated the facility follows Wisconsin state laws to maintain nurse aid registration requirements. On 3/27/25 at 12:30 PM, Surveyor reviewed CNA-D's in-service training during the most recent anniversary hire year. Surveyor reviewed electronic training hours for CNA-D and noted CNA-D had only completed 2.25 hours of training over the last anniversary hire year. Surveyor noted CNA-D attended 5 meetings between 8/23/23 and 8/23/24. The 2.25 hours CNA-D completed did not cover any of the required education on resident rights, abuse and reporting requirements, dementia training, QAPI process, infection control, compliance and ethics, or resident behavioral health; however, the 5 meetings CNA-D attended covered all the aforementioned education requirements except QAPI. On 3/27/25 at 1:43 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff meetings are usually an hour long depending on the material covered. DON-B verified CNA-D had attended 5 staff meetings and completed 2.25 hours in the facility's electronic training system which indicated CNA-D had completed 7.25 hours of the 12 required hours. DON-B indicated NHA-A sent emails containing meeting content and questions about the content to staff that did not attend meetings. DON-B contacted NHA-A to ascertain if NHA-A had emails from CNA-D. On 3/27/25 at 2:02 PM, Surveyor interviewed NHA-A who indicated it had been difficult to ensure CNA-D completed the required education. NHA-A indicated since CNA-D was hired on 8/23/23, CNA-D failed to complete online training by the due date and was expected to complete the required training by 1/5/25. NHA-A provided a copy of an email NHA-A sent to CNA-D on 3/16/25 that indicated CNA-D had overdue electronic trainings that were due on 4/1/25. The content of the email was a list of 5 trainings from the facility's electronic training system. NHA-A did not provide a response from CNA-D from the email sent on 3/16/25.

Based on observation and staff and resident interview, the facility did not provide a safe, sanitary, or home-like environment for 1 resident (R) (R5) of six sampled residents. On 3/25/25, bowel movement (BM) soiled cloths were observed on R5's bathroom sink. Findings include: The facility provided an undated Standard Activities of Daily Living (ADL) Protocol that did not mention where staff should place soiled items during the provision of care. On 3/25/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and post-polio syndrome. R5's Minimum Data Set (MDS) assessment, dated 1/17/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had no cognitive impairment. R5 was responsible for R5's healthcare decisions. On 3/25/25 at 11:56 AM, Surveyor interviewed R5 who was in bed. When asked about the cleanliness of the facility R5 stated, It could be better. I think the bathroom should be cleaned better. Surveyor observed R5's bathroom and noted BM soiled cloths on the rim of R5's sink. At 12:01 PM, Medication Technician (MT)-C entered the room and administered medication to R5. Surveyor interviewed MT-C who verified the cloths on the rim of the sink were soiled with BM. MT-C indicated soiled linens should not be placed on the sink during cares and should be put in a bag to be taken to the utility room. MT-C indicated MT-C had assisted with R5's cares earlier that day. MT-C indicated the BM soiled cloths were not on the sink at that time. R5 indicated R5 was incontinent of BM and other staff assisted R5 with care at approximately 11:20 AM. On 3/25/25 at 1:48 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff usually put soiled linens directly in a bag to take to the utility room. DON-B verified BM soiled cloths should not have been placed on R5's sink. On 3/25/25 at 2:15 PM, Surveyor interviewed DON-B who indicated the facility does not have a policy that addresses what staff should do with soiled items and provided Surveyor with the above mentioned policy.

Based on staff interview, the facility did not have policies and procedures in place to use in the case of a facility closure. This had the potential to affect all 56 residents residing in the facility. The facility did not have policies and procedures to address a facility closure. Findings include: On 3/27/25 at 12:53 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility would follow state regulations in the event of a closure. NHA-A indicated the facility does not have a written policy to address a facility closure.

Based on staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 1 of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure a thorough and timely background check was completed for Certified Nursing Assistant (CNA)-D. Findings include: The facility's Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program policy, with a review date of 11/8/23, indicates: The object of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention .Screening: .It is the policy of this facility to screen employees .prior to working with residents. Screening components include verification of references, certification and verification of license, and criminal background check. Procedure: 1. Employee Screening and Training - a. Before new employees are permitted to work with residents, references provided by the prospective employee will be verified as well as appropriate board registrations and certifications regarding the prospective employee's background .d. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. A significant finding on the background check will result in denial accordance with state and federal regulations . On 12/19/24, Surveyor reviewed background check information for 8 facility and contracted staff, including CNA-D. CNA-D's hire dates were listed as 3/19/13 and 6/3/24 (rehired). The facility provided a BID form that was not dated. The facility did not provide proof that a BID form was completed for CNA-D prior to or on the date CNA-D was rehired. On 12/19/24 at 2:42 PM, Surveyor interviewed Assistant Nursing Home Administrator (ANHA)-E who indicated BID forms are completed before new staff can start working. ANHA-E verified CNA-D's BID form was not dated and was unsure why. ANHA-E indicated BID forms should be dated. On 12/19/24 at 2:49 PM, Surveyor left a message for Human Resources (HR)-I. Surveyor did not receive a return call as of this writing.

Based on staff and resident interview and record review, the facility did not ensure care and treatment were provided for 1 resident (R) (R1) of 3 sampled residents with a pacemaker (a device placed in the body to support the electrical system in the heart). Staff did not assist R1 in scheduling appointments with a cardiologist to check R1's cardiac health or ensure R1's pacemaker worked properly. On [DATE], R1 was admitted to the hospital after R1's pacemaker battery died and R1's heart rate was in the 30s. (A typical resting heart rate for adults is between 60 and 100 beats per minute.) Findings include: On [DATE], Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and readmitted on [DATE] following hospitalization for pacemaker failure. R1 had diagnoses including acute congestive heart failure (CHF), dyspnea (shortness of breath) and respiratory abnormalities, symptomatic bradycardia (a low heart rate), and sick sinus syndrome (a group of abnormal heart rhythms usually caused by a malfunction of the sinus node, the heart's primary pacemaker). R1's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R1 had moderate cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decisions. R1's care plan did not contain a focus, goal, or interventions for pacemaker use. An office visit progress note, dated [DATE], indicated R1's pacemaker was checked on [DATE] and was functioning appropriately. The remaining battery life was estimated at 23 months. (R1 was admitted to the facility on [DATE] which was approximately 12 months after the [DATE] pacemaker check which allowed for 11 months of battery life after R1's admission.) A hospital discharge summary, dated [DATE], indicated R1 was diagnosed with tachy-[NAME] syndrome (a heart rhythm disorder) and had a pacemaker. A progress note, dated [DATE], indicated R1 had a dual chamber pacemaker. An emergency medicine provider note, dated [DATE], indicated R1 had a pacemaker for tachybradycardia syndrome. Per Emergency Medical Services (EMS), R1's heart rate was bradycardic in the low 30s with no syncope (fainting). The note indicated staff were unable to obtain a report for the pacemaker because they could not get it to read. The clinic sent a nurse to read the pacemaker. The nurse was unable to get a signal and suspected device failure. Heart block or significant bradycardia required an urgent transfer to the cath lab for a pacemaker. A hospital initial encounter note, dated [DATE], indicated R1's pacemaker's battery life had expired. Because R1's heart rate was in the 30s and the pacemaker was not functioning, R1 was admitted to the hospital for acute on chronic heart failure with preserved ejection fraction. A progress note, dated [DATE] at 11:56 PM, indicated R1 was readmitted to the facility at 5:00 PM with a diagnosis of CHF exacerbation. R1 was alert and oriented x 4 and denied pain or shortness of breath (SOB). R1's pacemaker was replaced at the hospital (upper left upper chest) and the site was covered with gauze. On [DATE] at 11:00 AM, Surveyor interviewed Registered Nurse (RN)-G who stated there were 3 residents on RN-G's unit with a pacemaker. RN-G stated each resident with a pacemaker had a transmission box in their room and the pacemaker clinic contacted nursing staff with any concerns and to schedule appointments to check the pacemakers. On [DATE] at 11:15 AM, Surveyor interviewed RN-F who stated there was one resident (R4) on RN-F's unit with a pacemaker who was seen yearly at the pacemaker clinic. RN-F indicated pacemaker checks were completed by the clinic who contacted the facility with any updates or concerns. RN-F was able to locate the transmission device in R4's room. On [DATE] at 1:24 PM, Surveyor interviewed R1 who indicated R1 had a pacemaker for [AGE] years and resided at the facility for 2 years. R1 indicated to the best of R1's knowledge, a pacemaker check was not done at the facility until September of 2024. On [DATE] at 3:30 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C regarding the facility's expectation when a resident is admitted with a pacemaker. Assistant Nursing Home Administrator (ANHA)-D and Social Worker (SW)-E were present during the interview. ADON-C indicated it was the facility's expectation that residents with pacemakers were followed by cardiology and/or the pacemaker clinic. When asked if the facility was aware of R1's pacemaker, ADON-C indicated nothing tipped them off because R1 had stable vital signs. ADON-C indicated R1's doctor was aware that R1 had a pacemaker. SW-E indicated the facility did not have a process in place for residents admitted with pacemakers. On [DATE] at 5:00 PM, Surveyor interviewed Medical Doctor (MD)-H via telephone. MD-H indicated R1 had increasing heart failure problems, but R1's vitals signs had been stable. MD-H indicated MD-H was aware R1 had a pacemaker but was not sure why there was no follow-up care related to the pacemaker since R1 had a number of cardiologists. MD-H indicated MD-H did not check R1's room for a pacemaker transmitter. MD-H stated R1's pacemaker worked until it didn't which resulted in R1's admission to the hospital where it was determined R1's pacemaker was not functioning and had not been checked. MD-H stated MD-H was not sure who was responsible for checking R1's pacemaker and indicated R1 and R1's family bore some responsibility because there would have been a transmitter at R1's home which should have been brought to the facility when R1 was admitted .

Based on staff and resident interview and record review, the facility did not thoroughly investigate allegations of abuse and misappropriation for 2 residents (R) (R2 and R3) of 2 sampled residents. The facility did not thoroughly investigate an allegation of abuse for R2. The facility did not thoroughly investigate an allegation of misappropriation for R3. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation policy, with a review date of 11/8/23, indicates: It is the policy of the facility that everyone will be free from abuse .Verbal abuse involves the use of speech, sound, writing, or gestures when communicating with residents or their families or when within their hearing or sight regardless of their age, ability to comprehend or disability .Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .E. Investigation: .It is the policy of this facility that reports of abuse are promptly and thoroughly investigated .Investigation regarding misappropriation: Complete an active search for missing items including documentation of the investigation: The investigation will consist of at least the following: A review of the completed complaint report, an interview with the person or persons reporting the incident, interviews with any witness to the incident, a review of the resident's medical record if indicated, a search of the resident's room, an interview with staff members having contact with the resident during relevant periods or shifts of the alleged incident, interviews with the resident's roommate, family members, and visitors, a root-cause analysis of all circumstances surrounding the incident .Immediately upon receiving a report of alleged abuse, the Executive Director and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable resident are of utmost priority. Safety, security and support of the resident, their roommate, if applicable and other residents with the potential to be affected will be provided. This should include .iv. Examine, assess, and interview the resident and other residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary .Internal reporting: Employees must always report any abuse or suspicion of abuse immediately to the Executive Director. On 9/24/24, Surveyor received a staff list from Assistant Nursing Home Administrator(ANHA)-D. Surveyor noted 67 employees were listed on the form, including 29 Certified Nursing Assistants (CNAs), 1 Director of Nursing(DON), 1 Assistant Director of Nursing (ADON), 8 Registered Nurses (RNs), and 6 Licensed Practical Nurses(LPNs). 1. On 9/24/24, Surveyor reviewed R2's medical record. R2 had diagnoses including type 2 diabetes, chronic kidney disease (CKD), placement of colostomy, and major depressive disorder. R2's Minimum Data Set (MDS) assessment, dated 8/7/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. On 9/24/24, Surveyor reviewed a facility-reported incident (FRI) regarding an allegation of verbal abuse involving R2 and CNA-I. The incident was reported on 9/7/24 and the investigation concluded on 9/12/24. Surveyor noted staff education on abuse, neglect, and misappropriation was not included in the FRI. Surveyor requested the information from ANHA-D on 9/24/24 at 12:15 PM. ANHA-D indicated staff education and training were provided and ANHA-D would provide the information to Surveyor. On 9/24/24 at 2:19 PM, Surveyor received the staff education documentation from ANHA-D who indicated the documents were education sign-off sheets from the facility's All Staff meeting where abuse and neglect education was provided to all staff. ANHA-D indicated the education was provided a few days ago and was still ongoing. ANHA-D indicated the information covered at the meeting was attached to the employee sign-off sheet. Surveyor reviewed the facility's All Staff document, dated 9/19, that contained staff signatures. Surveyor noted the following nursing staff received abuse, neglect, and misappropriation training during the meeting: 18 out of 67 total employees, including 13 CNAs, 3 RNs, and 1 LPN. The training materials included Reporting Abuse/Neglect/Misappropriation: Who is the Abuse Coordinator, what do you do if you have a suspicion of abuse/neglect/misappropriation, when do you report concerns? An additional form contained the answers to the questions. Surveyor noted there were no additional sign-off sheets for training provided to employees after the All Staff meeting. On 9/24/24 at 3:15 PM, Surveyor interviewed ANHA-D and requested any additional information regarding the number of staff that were trained. ANHA-D confirmed the education was ongoing and ANHA-D was under the assumption the education could be provided after the investigation concluded. ANHA-D indicated ANHA-D was unaware that an allegation of abuse (which was substantiated by the facility's investigation and resulted in the employee being terminated) warranted education on abuse, neglect, and misappropriation as soon as possible to prevent any further incidents. 2. On 9/24/24, Surveyor reviewed R3's medical record. R3 had diagnoses including type 2 diabetes, CKD, presence of pacemaker, anxiety, and depression. R3's MDS assessment, dated 8/15/24, had a BIMS score of 12 out of 15 which indicated R3 had moderately impaired cognition. On 9/24/24, Surveyor reviewed a FRI regarding an allegation of misappropriation involving R3 who reported to nursing staff on 8/10/24 that $12 was missing from R3's dresser drawer. R3 was unsure when the money was taken. The investigation concluded on 8/16/24. Surveyor noted the investigation did not include documentation of follow-up with R3 regarding psychosocial/emotional needs following the incident. The investigation indicated R3 was not interviewed regarding the incident until 8/16/24 and like residents were not interviewed until 8/16/24. In addition, staff interviews were not dated. Surveyor noted an interview with a nursing staff indicated the staff was informed by R3's daughter that R3's money was missing and reported the allegation to administration. The interview indicated another RN was informed of the missing money by R3 and R3's daughter a few days before but nothing was done. The investigation indicated 25 nursing staff were interviewed. An interview with CNA-J indicated CNA-J was informed of the missing money by R3 last week. The investigation did not contain staff education on abuse, neglect, or misappropriation or reporting of allegations. The investigation also did not contain findings, results, resolution, root cause analysis, or follow-up with R3. There were also no interventions put in place to safeguard R3's belongings. On 9/24/24 at 12:15 PM, Surveyor interviewed ANHA-D regarding missing documentation in the investigation for R3's allegation of misappropriation. ANHA-D indicated ANHA-D did not complete the report and wasn't part of the investigation but would find the education documentation. ANHA-D also indicated ANHA-D would attempt to find any additional documentation including why the resident interviews were delayed. On 9/24/24 at 12:50 PM, Surveyor interviewed R3 who indicated R3 did not know what was concluded regarding R3's missing money. R3 indicated someone was supposed to follow-up with R3. R3 stated R3 felt bad because the money was from R3's birthday and R3 didn't have much money. On 9/24/24 at 2:24 PM, Surveyor received staff education documentation from ANHA-D who indicated the documents were education sign-off sheets from the facility's All Staff meeting where staff education on abuse and neglect was provided to all staff. ANHA-D indicated the facility did not have a good reason for the delay of resident interviews and believed employee interviews were completed between 8/12/24 and 8/16/24. ANHA-D acknowledged follow-up for emotional needs was not provided to R3. ANHA-D also indicated follow-up and resolution was not provided to R3 because R3 did not indicate R3 was upset about the missing money, the facility did not find evidence of theft, and the money was not replaced. Surveyor reviewed an All Staff document, dated 8/15, that contained staff signatures. Surveyor noted 43 of 67 total employees received abuse, neglect, and misappropriation training, including 17 CNAs, 4 RNs, and 2 LPNs. The training materials included Reporting Abuse/Neglect/Misappropriation: Who is the Abuse Coordinator, what do you do if you have a suspicion of abuse/neglect/misappropriation, when do you report concerns? An additional form provided answers to the questions. Surveyor noted CNA-J did not receive abuse, neglect, or misappropriation training on 8/15 or 9/19.

Based on observation, staff and resident interview, and record review, the facility did not ensure sufficient staffing to meet residents' care needs. This had the potential to affect multiple residents residing in the facility. Fifteen of 30 staffing shifts reviewed did not meet Certified Nursing Assistant (CNA)-to-resident staffing ratios outlined in the the Facility Assessment which was last updated in April of 2024. Observations indicated call lights were not answered timely and resident care was not provided timely. Resident and staff interviews identified concerns with the provision and receipt of timely and complete care. Findings include: The Facility Assessment, dated April 2024, contained the following information: Staffing Plan: There are 2 Registered Nurses (RNs) and 1 Licensed Practical Nurse (LPN) scheduled for the AM/PM shift and 1 RN for the night (NOC) shift. One Medication Administration Assistant (MAA) is scheduled for the AM/PM shift if an LPN is not available. The following ratios are scheduled for CNAs in response to daily census numbers: 1:11 on AMs, 1:13 on PMs, and 1:22 on NOCs. Between 7/8/24 through 7/10/24, Surveyor reviewed daily nurse staffing postings and schedules for CNA staffing from 6/30/24 through 7/9/24. The following CNA staffing ratios were not met per the Facility Assessment for the shifts outlined below: ~ On 6/30/24, the facility's census was 56. The AM shift listed 4 CNAs for a ratio of 1:14. The NOC shift listed 2 CNAs for a ratio of 1:28. ~ On 7/1/24, the facility's census was 55. The PM shift listed 4 CNAs for a ratio of 1:14. ~ On 7/2/24, the facility's census was 55. The AM shift listed 5 CNAs with 4 CNAs for half of the shift for a ratio of 1:14. The PM shift listed 4 CNAs for a ratio of 1:14. ~ On 7/3/24, the facility's census was 56. The AM shift listed 4.5 CNAs for a ratio of 1:12. ~ On 7/4/24, the facility's census was 56. The NOC shift listed 2 CNAs for a ratio of 1:28. ~ On 7/5/24, the facility's census was 56. The PM shift listed 4 CNAs for a ratio of 1:14. The NOC shift listed 2 CNAs for a ratio of 1:28. ~ On 7/6/24, the facility's census was 57. The NOC shift listed 2 CNAs for a ratio of 1:29. ~ On 7/7/27, the facility's census was 57. The PM shift listed 4 CNAs for a ratio of 1:14 with 2 CNAs after 8:00 PM for a ratio of 1:29. The NOC shift listed 2 CNAs for a ratio of 1:29. ~ On 7/8/24 the facility's census was 57. The PM shift listed 3.8 CNAs for a ratio of 1:15. The NOC shift listed 2 CNAs for a ratio of 1:29. ~ On 7/9/24 the facility's census was 57. The NOC shift listed 2 CNAs for a ratio of 1:29. In summary, 15 of 30 shifts reviewed did not meet the CNA staffing ratio outlined in the Facility Assessment. Observations: 1. On 78/24, Surveyor reviewed R2's medical record. R2 had a urinary catheter and a diagnosis of neurogenic bladder. R2's Minimum Data Set (MDS) assessment, dated 5/17/23, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. On 7/8/24 at 10:27 AM, Surveyor interviewed R2. Surveyor noted that R2's call light was previously activated, but was off at the time of the interview. R2 stated R2 activated the call light because R2 wanted to get up. R2 stated staff entered the room and turned the call light off after R2 told staff what R2 wanted. R2 stated R2 had a cell phone that R2 has used to call staff due to long call light wait times. On 7/9/24 at 10:34 AM, Surveyor noted R2's call light was activated. On 7/9/24 at 10:43 AM, Surveyor observed Nurse Extern (NE)-O enter R2's room, turn off R2's call light, and exit the room. On 7/9/24 at 10:51 AM, Surveyor entered R2's room and asked if R2 was provided the service R2 requested. R2 stated R2 activated the call light because R2 wanted to be changed. R2 stated NE-O told R2 that CNA-N was on break and would help R2 when CNA-N returned. On 7/9/24 at 11:05 AM, Surveyor observed CNA-N enter R2's room. On 7/9/24 at 11:11 AM, Surveyor observed CNA-N exit R2's room with a bag. Surveyor interviewed CNA-N who stated R2 wanted R2's brief changed which CNA-N did. On 7/9/24 at 3:18 PM, Surveyor informed Director of Nursing (DON)-B that R2 waited 31 minutes for care to be provided and that NE-O turned R2's call light off and stated CNA-N would change R2 when CNA-N returned from break. DON-B stated DON-B expects staff to leave a resident's call light on until care is provided and verified 31 minutes is a longer than expected call light response time. 2. On 7/10/24 at 10:31 AM, Surveyor observed R21 activate R21's call light. At 11:08 AM, a CNA entered the room and turned the call light off. R21's call light was activated for a total of 37 minutes. Surveyor observed a CNA assist residents in 2 other rooms before the CNA assisted R21. Resident Interviews: On 7/8/24 at 10:02 AM, Surveyor interviewed R28 who stated the facility is short staffed and it can take 30-45 minutes for staff to answer R28's call light. R28 also stated residents are supposed to receive a shower at least once per week which does not always happen. R28 stated staff cannot always complete all cares and will sometimes change R28's brief without washing R28. On 7/8/24 at 10:32 AM, Surveyor interview R45 who stated the facility is understaffed and it can take awhile for staff to answer R45's call light. R45 stated the CNAs are busy and R45 does not want to make a fuss. On 7/8/24 at 1:14 PM, Surveyor interviewed R12 who stated weekend staffing is poor and call light response time on the weekends is slow. R12 also stated R12's ostomy is not emptied timely and has overfilled and leaked. R12 stated R12 had sat in stool for several hours overnight. On 7/8/24 at 12:10 PM, Surveyor interviewed R20 who expressed difficulty with getting help in the morning and at night. R20 stated call light response times can be 20-30 minutes. R20 stated R20 soiled R20's self several times because staff did not answer R20's call light timely. Staff Interviews: On 7/10/24 at 10:46 AM, Surveyor interviewed CNA-S who stated CNA-S does not feel like CNA-S has enough time to complete tasks, especially with only 2 CNAs which occurs frequently. CNA-S stated there have been days when there is only one CNA on the PM shift. CNA-S stated staff are asked daily to work over or pick up hours. CNA-S stated residents' nail care, oral care, and hygiene suffers because there is not enough staff and there are times when residents don't get washed up. CNA-S stated the facility stopped using agency CNAs a couple of months ago. On 7/10/24 at 10:47 AM, Surveyor interviewed CNA-Q who stated 70% of the time the facility does not have enough CNAs to provide adequate care. CNA-Q stated 2 CNAs are not enough when the census is full. CNA-Q stated the facility stopped using agency CNAs several months ago and the facility has not had enough staff since. CNA-Q also stated CNA-Q gets mandated to stay past CNA-Q's scheduled shift due to staff call-ins and feels pressured to rush through resident care. CNA-Q stated residents complain about call light response times which are longer when the census is higher. On 7/10/24 at 10:54 AM, Surveyor interviewed CNA-R who stated CNA-R does not think there are enough staff. CNA-R stated call lights can be on for 30-60 minutes before staff can respond. CNA-R stated CNA-R feels rushed with resident care and feels pressured to use a Hoyer lift with one 1 person because there is not always enough staff to use 2 staff. CNA-R stated the facility loses staff because of call-ins and poor staffing levels. CNA-R verified residents have complained about call light response times. CNA-R stated it is not uncommon for CNA-R to find residents soaked in urine at the start of the morning shift. CNA-R stated CNA-R feels the NOC shift does not have enough staff to change residents timely. On 7/10/24 at 11:01 AM, Surveyor interviewed CNA-T who stated staffing is an issue and makes it difficult to get tasks done timely. On 7/10/24 at 11:56 AM, Surveyor interviewed CNA-U who stated the facility is short staffed approximately 50% of the time. CNA-U stated residents are often either not washed up or washed up quickly as a result. On 7/10/24 at 1:08 PM, Surveyor interviewed Scheduler (SC)-W who stated on the AM and PM shifts, the facility prefers to have 5 CNAs, but the minimum is 4. SC-W stated Nursing Home Administrator (NHA)-A could answer Surveyor's questions better because SC-W was only employed by the facility for a short time. SC-W stated when SC-W started at the facility, SC-W was told the preferences and minimums for staffing but did not know what the Facility Assessment was or where to find it. On 7/10/24 at 1:19 PM, Surveyor interviewed NHA-A who acknowledged the facility does not always have the staff they need. NHA-A stated there are often 4 CNAs when they hope for 5 and verified the facility is low in meeting the Facility Assessment ratios. When Surveyor asked NHA-A about PM shift staffing on 7/1/24 when the census was 55, NHA-A stated the facility's goal was to have 5 CNAs for a 1:11 ratio and acknowledged the staffing was low because the facility did not have 5 CNAs. NHA-A stated the facility tries to meet the Facility Assessment ratios but staffing is tough.

Based on observation and staff and resident interview, the facility did not ensure dignity was maintained for 3 residents (R) (R305, R45, and R12) of 19 sampled residents who were served meals on disposable dishware. On 7/8/24, breakfast was served in Styrofoam containers because the kitchen was short staffed. During lunch service, staff were observed serving milk and coffee in Styrofoam cups. In addition, resident interviews indicated residents were provided with disposable utensils which made it difficult to cut food. Findings include: During the breakfast meal on 7/8/24, Surveyor observed staff serve breakfast in Styrofoam containers. On 7/8/24 at 10:11 AM, Surveyor noted R305's Cream of Wheat was served in a Styrofoam bowl with plastic cutlery. R305 stated the Cream of Wheat was cold On 7/8/24 at 10:32 AM, Surveyor observed several Styrofoam cups and plastic utensils in R45's garbage can. R45 stated sometimes R45 received plasticware with meals and staff served R45's coffee in a Styrofoam cup. R45 stated it was difficult to cut meat with plastic utensils. In a follow up interview, R45 stated R45 did not have much of an issue with the Styrofoam cups, however, the plastic utensils were frustrating, flimsy, and irritating to cut with. On 7/8/24 at 11:57 AM, Surveyor observed Administrative Assistant (AA)-V at a beverage station on the unit assist with preparing residents' lunch trays by pouring coffee and milk. Surveyor observed AA-V pour milk into a large Styrofoam cup and put the cup on a resident's meal tray. Surveyor interviewed AA-V who stated if a resident's meal ticket indicates the resident wants extra milk or coffee, staff use large Styrofoam cups to serve the resident's beverage because the facility does not have large enough cups to accommodate the resident's request. Surveyor observed a number of small plastic drink cups and regular size plastic coffee cups on the unit. On 7/8/24 at 12:57 PM, Surveyor interviewed R12 who stated sometimes R12's food was served on Styrofoam which R12 did not like and made R12 feel like something was wrong with the kitchen. R12 stated R12 preferred to use a regular plate and regular silverware because it was [NAME] when R12's meal was served on Styrofoam. R12 stated R12 had mobility issues that made it difficult to use Styrofoam and plasticware. R12 stated R12 kept silverware in R12's room so R12 had something to use if R12 received plasticware. On 7/9/24 at 11:44 AM, Surveyor interviewed Dietary Manager (DM)-P who stated the kitchen was short staffed on 7/8/24 so breakfast was served on Styrofoam. When asked about plasticware, DM-P stated residents receive regular silverware unless all meals are served on Styrofoam or a resident is on precautions. DM-P stated if a resident is on any type of precautions, the meal tray is covered in plastic and everything is served on disposable ware. DM-P stated there were 3 residents in the facility who were on precautions and received all meals on Styrofoam. DM-P was not sure why some residents received plasticware On 7/10/24 at 9:15 AM, Surveyor interviewed DM-P regarding the use of Styrofoam DM-P confirmed kitchen staff used Styrofoam containers for the 7/8/24 breakfast meal because there were not enough staff in the kitchen. DM-P acknowledged Styrofoam was not a home-like option for residents. When Surveyor informed DM-P that Styrofoam cups are used to serve residents that want or need extra fluids with meals, DM-P stated nursing staff pass drinks and DM-P was unsure why nursing staff used Styrofoam cups. DM-P stated the kitchen sends plenty of plastic drink cups and coffee cups to the units. DM-P agreed staff can pour 2 plastic cups of milk or coffee if residents want extra. DM-P stated Styrofoam cups should only be used for water pass.

Based on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R43) of 2 residents reviewed for guardianship. R43 had a legal guardian. The facility did not ensure R43 had court-ordered protective placement in the least restrictive environment at the facility. Findings include: Statute Chapter 55.03(4) states the law requires court-ordered protective placement for any resident admitted to a nursing home who has a legal guardian and whose nursing home stay exceeds ninety days. Between 7/8/24 and 7/10/24, Surveyor reviewed R43's medical record. R43 was admitted to the facility on [DATE] with diagnoses including unspecified intellectual disability, senile degeneration of brain, bipolar disorder, and dementia with behavioral disturbance. R43's Minimum Data Set (MDS) assessment, dated 6/5/24, indicated R43 was severely cognitively impaired. R43 had a guardian as a decision maker. R43's medical record contained R43's Letters of Guardianship for a Successor, dated 1/3/1994. Surveyor requested R43's protective placement paperwork. On 7/10/24 at 10:45 AM, Surveyor interviewed Social Worker (SW)-C who stated R43 did not have protective placement paperwork. SW-C stated R43 had previously resided at a group home and came to the facility with a guardianship that was in place for a long time. SW-C was not aware that R43 did not have protective placement or that the facility needed to ensure protective placement was obtained. SW-C stated SW-C had other residents who had protective placement, however, those residents were admitted with protective placement already in place. SW-C stated SW-C had contacted the Aging and Disability Resource Center (ADRC) to ask about protective placement for R43.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R45) of 1 sampled resident had a self-administration of medication assessment or a physician's order to self-administer medication. R45 did not have a self-administration of medication assessment that indicated R45 could safely and accurately self-administer medication. In addition, R45 did not have a physician's order to self-administer medication. Findings include: The facility's Policies and Procedures: Pharmacy Services Section II Medication Administration Policy (effective date: May 2018) Preparation and General Guidelines Section B. Administration 14 indicates: Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medication. On 7/9/24, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and dementia. R45's Minimum Data Set (MDS) assessment, dated 5/15/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R45 had intact cognition. On 7/10/24 at 12:20 PM, Surveyor observed Nurse Extern (NE)-O draw up 17 units of insulin Lispro 100 units/ml (milliliter) (9 units in addition to 8 units per sliding scale) in a syringe and hand the syringe to R45. R45 wiped R45's abdomen with an alcohol swab and self-injected the insulin into the right lower quadrant of R45's abdomen. Prior to entering R45's room, NE-O told Surveyor not to be surprised if R45 self-injected the insulin which was R45's norm. Surveyor noted R45's medical record did not contain a self-administration of medication assessment or a physician's order to self-administer insulin. On 7/9/24 at 2:18 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R45 did not have a self-administration of medication assessment or a physician's order to self-administer insulin. DON-B stated DON-B expects staff to obtain a physician's order and complete a self-administration of medication assessment prior to allowing a resident to self-administer insulin.

Based on observation, staff and resident interview, and record review, the facility did not ensure an environment that was free from abuse for 1 resident (R) (R305) of 1 sampled resident. The facility did not protect R305's right to be free from verbal and mental abuse by R14. Findings include: The facility's Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, dated 11/8/24, indicates: It is the policy of the facility that each resident will be free from abuse .Abuse is the willful infliction of .intimidation .or mental anguish .Abuse includes verbal abuse .Verbal abuse involves the use of speech, sound, writing, or gestures when communicating with residents or their families or within their hearing or sight, regardless of their age, ability to comprehensive, or disability .Mental abuse is the use of verbal or nonverbal conduct which causes, or has the potential to cause, the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .It is the policy of this facility that all staff monitor residents and know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse will be investigated .The facility will ensure that all alleged violations involving abuse .mistreatment .are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse .to the Executive Director of the facility .Employees must always report any abuse or suspicion of abuse immediately to the Executive Director. On 7/8/24, Surveyor reviewed R305's medical record. R305 was admitted to the facility on [DATE] with diagnoses including short-bowel syndrome (a condition that has symptoms of diarrhea, malnutrition, weight loss, and foul-smelling stool), depression, and anxiety disorder. R305's Minimum Data Set (MDS) assessment, dated 7/5/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R305 had intact cognition. On 7/8/24 at 10:08 AM, Surveyor interviewed R305 who was visibly upset and intermittently crying throughout the interview and stated R305 had conflict with R14. R305 described an incident when R305 exited R305's room and R14 told R305 to get the f*** out of my way. R305 indicated the incident was distressing and stated R305 also witnessed R14 mock other residents for being fat and retarded. R305 stated R14's language was offensive and R305 experienced emotional distress due to interactions with R14. Surveyor noted R14's room was across the hall from R305's room. On 7/8/24, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] with diagnoses including anxiety and major depressive disorder. R14's MDS assessment, dated 5/29/24, had a BIMS score of 13 out of 15 which indicated R14 had intact cognition. R14's medical record contained a behavior note, dated 7/6/24 at 2:33 PM, that indicated: R14 became agitated when R305 approached the desk and asked for R305's medications because R305 was leaving the facility for a couple of hours. R14 stated R305 skipped R14 which R305 always does and next time R14 would show (R305) because R14 was done with (R305's) f****** shit and (R305) needed to take (R305's) shitting upstairs. R14 referred to R305 as shitzilla several times throughout the rest of the evening. On 7/9/24 at 12:43 PM, Surveyor interviewed Registered Nurse (RN)-D who stated R14 often cussed and complained about other residents to staff. RN-D indicated R14 habitually complained about other residents getting in R14's way and made vague threats such as I wanna kick 'em in the butt. On 7/9/24 at 3:24 PM, Surveyor interviewed RN-E who stated R14 was recently upset with R305 and cussed about R305 at RN-E's medication cart. RN-E stated R14 used foul language with staff and other residents and spoke badly about other residents within earshot. RN-E stated R14 told RN-E that R14 and R305 had a verbal confrontation in the front lobby. R14 cussed at R305, told R305 to get off the lobby phone, and stated R305 shouldn't touch anything in the common areas because of R305's diarrhea. On 7/9/24 at 3:33 PM, Surveyor interviewed Medication Technician (MT)-F who stated R14 often swore and talked negatively about other residents. MT-F said R14 was known to complain about other residents within earshot and without concern for offending them. On 7/9/24 at 3:43 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A was aware that R14 spoke poorly about other residents to staff. NHA-A reviewed a report on 7/8/24 that informed NHA-A of the altercation between R14 and R305 on 7/6/24. NHA-A stated NHA-A did not consider the altercation between R14 and R305 to be willful abuse. On 7/10/24 at 9:11 AM, Surveyor interviewed R14 who stated R305 should not have been admitted to the facility and called R305 nutzo and a pig. R14 indicated R14 was bothered by R305's diarrhea and stated (R305) belongs in a zoo because (R305) shits all over the place. R14 described an incident when R305 pointed a finger at R14. In response, R14 told R305 that R14 was sick of (R305's) shit. On 7/10/24 at 10:42 AM, Surveyor interviewed RN-G who stated RN-G was aware that R14 had a problem with R305 and stated R14 spoke poorly about R305 to RN-G. In response, RN-G advised R14 to avoid R305.

Based on observation, staff and resident interview, and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R305) of 1 sampled resident. The facility did not report an allegation of verbal abuse to the SA for R305. Findings include: The facility's Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property program, dated 11/8/24, indicates: It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse will be investigated .The facility will ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse .to the Executive Director of the facility .Employees must always report any abuse or suspicion of abuse immediately to the Executive Director .If an incident or allegation is considered reportable, the Executive Director or designee will make an initial (immediate or within 24 hours) report to the State Agency. On 7/8/24, Surveyor reviewed R305's medical record. R305 was admitted to the facility on [DATE] with diagnoses including short-bowel syndrome (a condition that has symptoms of diarrhea, malnutrition, weight loss, and foul-smelling stool), depression, and anxiety disorder. R305's Minimum Data Set (MDS) assessment, dated 7/5/2024, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R305 had intact cognition. On 7/8/24 at 10:08 AM, Surveyor interviewed R305 who was visibly upset and intermittently crying throughout the interview. R305 stated R305 had a conflict with R14 and described an incident when R305 exited R305's room and R14 told R305 to get the f*** out of my way. R305 stated the incident was distressing to R305 and R305 had also witnessed R14 mock other residents for being fat and retarded. R305 stated R14's language was offensive and R305 experienced emotional distress from interactions with R14. Surveyor noted R14's room was across the hall from R305's room. On 7/8/24, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] with diagnoses including anxiety and major depressive disorder. R14's MDS assessment, dated 5/29/24, had a BIMS score of 13 out of 15 which indicated R14 had intact cognition. A behavior assessment indicated R14 had physical behavior directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) which occurred from 1-3 days. R14's functional ability assessment indicated R14 used a wheelchair independently. R14's medical record contained a behavior note, dated 7/6/24 at 2:33 PM, that indicated: R14 became agitated when R305 approached the desk and asked for R305's medications because R305 was leaving the facility for a couple of hours. R14 stated R305 skipped R14 which R305 always does and next time R14 would show (R305) because R14 was done with (R305's) f***** shit and (R305) needed to take (R305's) shitting upstairs. R14 referred to R305 as shitzilla several times throughout the rest of the evening. On 7/9/2024 at 3:43 PM Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A was not notified of the altercation between R14 and R305 on 7/6/24. NHA-A stated NHA-A reviewed a report on 7/8/24 that informed NHA-A of the altercation between R14 and R305. NHA-A stated, We (NHA-A and DON-B) haven't observed R14's behavior ourselves. NHA-A concluded the altercation between R14 and R305 did not rise to the level of willful abuse and wasn't reported to the SA.

Based on observation, staff interview, and record review, the facility did not ensure the comprehensive care plan was implemented for 1 resident (R) (R50) of 19 sampled residents. R50's comprehensive care plan indicated R50 was at risk for developing pressure injuries. The facility did not implement R50's care plan intervention to ensure the prevention of skin breakdown. Findings include: The Facility Assessment, titled Bowel and Bladder Management, dated 8/10/23, indicates: The facility will put prevention measure in place to promote bowel and bladder health. Staff will adopt a person-centered interdisciplinary care plan and implement interventions/approaches to bowel and bladder management to meet the goals of the individual. Per Nursing Home Administrator (NHA)-A, the facility does not have a specific policy for repositioning. Between 7/8/24 through 7/10/24, Surveyor reviewed R50's medical record. R50 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, severe with agitation, violent behavior, history of falling, and muscle weakness. R50's Minimum Data Set (MDS) assessment, dated 5/21/24, indicated R50 was severely cognitively impaired. R50 had a guardianship in place. R50's care plan, dated 5/21/24, indicated R50 had the potential for pressure injury development related to R50's disease process of dementia and immobility. The care plan also stated R50 was incontinent of bowel and bladder and included the following interventions: ~ Follow facility policy/protocols for the prevention/treatment of skin breakdown ~ Assist with routine toileting and skincare for incontinence ~ Assist with turning and repositioning at least every 2-3 hours, more often and as needed or requested ~ Pressure reducing device on bed and chair ~ Change when wet every 2-3 hours and as needed ~ Assist to toilet every 2-3 hours and as needed if incontinent. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes ~ Toilet Use: The resident is able to: ambulate to the toilet with 1 assist, needs 1 assist for toileting ~ Transfers: The resident requires assistance of 1 staff to move between surfaces every 2-3 hours and as needed R50's care plan also indicated R50 had a communication problem related to unclear speech and could not always communicate needs. Between 7/8/24 through 7/10/24, Surveyor observed the following: On 7/8/24 at 9:33 AM and 12:33 PM, Surveyor observed R50 in a recliner in the TV room with the back rest reclined and R50's legs extended. On 7/9/24 at 9:46 AM, 1:24 PM, and 2:05 PM, Surveyor observed R50 asleep in a recliner in the TV room with the back rest reclined and R50's legs extended. On 7/10/24 at 10:43 AM, Surveyor observed R50 asleep in a recliner in the TV room with the back rest reclined and R50's legs extended. On 7/9/24 at 1:24 PM, Surveyor interviewed Nurse Extern (NE)-O who stated R50 used to require 1 staff for transfers but lately required several staff to get R50 up. NE-O confirmed R50 was unable to put the leg rest down or get up by R50's self. NE-O stated staff do not reposition R50 as often as they should and was unsure how often R50 should be repositioned. NE-O indicated R50 is usually in the recliner all day and stated staff get R50 up before breakfast and assist R50 back to bed after dinner. NE-O also stated staff assist R50 with meals in the recliner. On 7/9/24 at 2:06 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-X who stated R50 requires the assistance of 1 staff for transfers on a good day, and the assistance of 2 staff on a bad day. CNA-X was unsure how often R50 is repositioned and stated CNA-X knows there are days when R50 is left there all day. CNA-X stated there are times when R50 can get up from the recliner by R50's self, but R50 is not able to put the footrest down and works around it. On 7/9/24 at 2:18 PM, Surveyor interview Director of Nursing (DON)-B who confirmed staff should assist R50 to the bathroom, and change and/or reposition R50 every 2-3 hours.

Based on observation and staff and resident interview, the facility did not ensure assistance with activities of daily living (ADLs) was provided care in a timely and consistent manner for 1 resident (R) (R2) of 19 sampled residents. R2 waited 31 minutes for staff to provide care. In addition, staff turned R2's call light off prior to providing care. Findings include: 1. On 7/8/24, Surveyor reviewed R2's medical record. R2 had a urinary catheter and was admitted to the facility on [DATE] with a diagnosis of neurogenic bladder. R2's Minimum Data Set (MDS) assessment, dated 5/17/23, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. On 7/8/24 at 10:27 AM, Surveyor interviewed R2. Surveyor noted R2's call light had previously been activated, but was off during the interview. R2 stated R2 had activated the call light because R2 wanted to get up. R2 stated staff had come in and R2 told staff what R2 wanted, but staff turned the call light off. R2 stated R2 has used R2's cell phone to call staff because of long call light wait times. On 7/9/24 at 10:34 AM, Surveyor noted R2's call light was activated. On 7/9/24 at 10:43 AM, Surveyor observed Nurse Extern (NE-O) enter R2's room, turn off R2's call light, and exit the room. On 7/9/24 at 10:51 AM, Surveyor entered R2's room and asked if R2 received the care that R2 requested. R2 stated R2 activated R2's call light because R2 wanted to be changed. R2 stated NE-O told R2 that Certified Nursing Assistant (CNA)-N was on break and would help R2 when CNA-N returned. On 7/9/24 at 11:05 AM, Surveyor observed CNA-N enter R2's room. On 7/9/24 at 11:11 AM, Surveyor observed CNA-N exit R2's room with a bag. Surveyor interviewed CNA-N who stated R2 wanted R2's brief changed which CNA-N did. On 7/9/24 at 1:29 PM, Surveyor interviewed NE-O who verified NE-O turned R2's call light off but confirmed NE-O should have left the call light on until care was provided. NE-O stated NE-O told CNA-N that R2 wanted to be changed when CNA-N returned from break. On 7/9/24 at 3:18 PM, Surveyor informed Director of Nursing (DON)-B that R2 had waited 31 minutes for care to be provided and that NE-O turned off R2's call light and told R2 that CNA-N would change R2 when CNA-N returned from break. DON-B stated DON-B expects staff to leave call lights on until care is provided and confirmed 31 minutes is a longer than expected call light response time.

Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained free of accident hazards for 1 resident (R) (R14) of sampled 19 residents. An unsecured oxygen cylinder was stored in R14's room. Findings include: The facility's Safe Use of Oxygen policy, dated 11/8/23, indicates: .ii. If oxygen cylinders are in use, oxygen cylinders shall be secured in an upright position. If stored up upright, cylinders must be secured. On 7/8/24, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had a diagnosis of chronic obstructive pulmonary disease (COPD). On 7/8/24 at 9:29 AM, Surveyor observed an unsecured oxygen cylinder with an oxygen regulator that was connected stored upright in R14's closet. On 7/9/24 at 12:43 PM, Surveyor interviewed RN-D who verified there was an unsecured oxygen tank in R14's closet and indicated the oxygen cylinder should be in a secured holder or secured in the closet. On 7/9/24 at 12:50 PM, Surveyor interviewed Facility Manager (FM)-I who confirmed the oxygen cylinder was unsecured in R14's room and stated oxygen cylinders should be secured in appropriate holders. On 7/9/24 at 1:00 PM, Surveyor notified Director of Nursing (DON)-B who stated DON-B expects oxygen cylinders to be properly secured. On 7/10/24 at 9:11 AM, Surveyor again observed an unsecured oxygen tank in R14's room closet.

Based on record review, resident interview and staff interview, the facility did not provide adequate pain relief for 1 Resident (R) (R2) of 2 residents reviewed. R2 had shearing to the right and left gluteal folds. R2 was observed during cleansing and treatment of [REDACTED]. After R2 complained of pain and was crying out in pain, the cleansing and treatment of [REDACTED]. R2 was not administered pain medication until approximately an hour after the cleansing and treatment were completed. Findings include: On 8/19/19, the Surveyor reviewed R2's medical record. R2 was admitted to the facility with [DIAGNOSES REDACTED]. R2's significant change MDS (Minimum Data Set) assessment, dated 6/24/19, indicated R2's cognition was intact with a score of 15 out of 15 (the higher the score, the more cognizant), and R2 was administered scheduled and prn (as needed) pain medication. R2's plan of care related to pain with an edited date of 7/23/19, indicated R2 would have decreased signs and symptoms of pain or discomfort. An approach with a start start of 9/14/18 indicated any complaints of pain from R2 were to be addressed promptly with medications/non-pharmacological interventions. R2's physician orders, dated 8/12/19, indicated R2 had an order to administer Tylenol 325 mg (milligrams) two tablets every four (4) hours prn for pain. On 8/19/19 at 12:35 PM, the Surveyor interviewed R2. R2 stated there were open areas on the creases of the buttocks (gluteal folds) that were painful. CNA (Certified Nursing Assistant)-A then entered R2's room to cleanse R2's buttocks/gluteal folds. As CNA-A was cleansing R2's gluteal folds, R2 was crying out in pain and stated, My butt is getting worse. CNA-A left R2's room to get the nurse to advise of pain while cleansing R2's gluteal folds. CNA-A then returned to R2's room. On 8/19/19 at 12:49 PM, the Surveyor observed RN (Registered Nurse)-B enter R2's room to look at R2's gluteal folds. RN-B observed the gluteal wounds and stated to R2, the wounds are getting better. RN-B advised CNA-A to continue to gently wash the powder off of R2's buttocks and gluteal fold areas. R2 stated to RN-B, Why are the sores are so painful now if they are getting better? Seems like they got worse. It hurts. RN-B left the room to look at physician orders. CNA-A was patting the areas gently with a washcloth and R2 was crying in pain. CNA-A then stated to R2, I'm sorry as CNA-A continued to gently cleanse the area. R2 then stated to CNA-A, If it looks better, why is it hurting so bad? At 12:58 PM, RN-B returned to R2's room. CNA-A stated to RN-B, there was so much powder and cream. I got it the best I could. (R2) is in a lot of pain. R2 was on left side in bed, crying in pain. At 12:59 PM, RN-B placed stoma adhesive on R2's gluteal folds. Again, R2 asked RN-B why the gluteal folds are so painful if they are getting better. RN-B stated to R2, Maybe it's the way you have been laying on them. R2 cried out in pain. RN-B then placed barrier ointment on R2's gluteal folds over the stoma adhesive. R2 stated the gluteal folds were burning, stinging now. RN-B stated the treatment has a cooling effect. R2 then stated, It is not cooling, it is stinging and cried out in pain. RN-B did not stop cleansing/treatment of [REDACTED]. On 8/19/19 at 1:07 PM while CNA-A and the Surveyor were still in R2's room, CNA-A stated to the Surveyor, R2 is in pain and requested Tylenol for pain. R2 stated,It hurts so bad. Still stings. CNA-A left R2's room to advise RN-B of R2's continued pain. On 8/19/19 at 1:10 PM, RN-C entered R2's room to complete an assessment of the gluteal folds. RN-C wiped some of the barrier ointment away. R2 was crying in pain when R2 wiped away the ointment. RN-C assessed the gluteal folds and verified there was shearing to both gluteal folds. R2 continued to wait for pain medication. On 8/19/19 at 1:27 PM, the Surveyor interviewed RN-B regarding R2's pain during cleansing and assessment of gluteal folds. RN-B verified cleansing/treatment was not stopped and R2 was not offered a pain pill during cleansing/assessment of the gluteal folds even though R2 was crying out in pain. RN-B stated RN-B wanted to see if the pain would go away once R2 was up in chair. R2 is usually not in this much pain. Have all of R2's pills to give once R2 is up. Don't want to give pain pills if pain doesn't continue. RN-B then stated RN-B was, not aware R2 had requested Tylenol for pain. On 8/19/19 at 1:33 PM, the Surveyor interviewed CNA-[NAME] CNA-A verified CNA-A had advised RN-B that R2 needed a pain pill when CNA-A left R2's room. CNA-A then stated, I just sent another CNA to tell RN-B again that (R2) wanted a pain pill. (R2) is still in pain. On 8/19/19 at 1:35 PM, RN-B came to R2's room to ask R2 what R2 needed. R2 requested [MEDICATION NAME] (a narcotic pain medication) for the pain. R2 then stated, It hurts. When asked by RN-B what the pain level was on a scale of 1 to 10, R2 responded, 10. RN-B verified R2 stated R2's pain level on a scale of 1 to 10 with 10 being the worst pain, was a 10. On 8/19/19 at 1:38 PM, the Surveyor interviewed RN-B regarding the administration of medications to R2. RN-B confirmed R2's pills were just administered, which included 650 mg of Tylenol for pain. RN-B verified R2 did not have an order for [REDACTED]. Once the pain medication was effective, the cleansing/treatment could resume. On 8/19/19 at 1:40 PM, the Surveyor interviewed CNA-E. CNA-E confirmed CNA-A had asked CNA-E to advise RN-B that R2 needed a pain pill. CNA-E verified CNA-E was going to tell RN-B that R2 needed a pain pill, but the Surveyor was talking to RN-B, and a call light went on. CNA-E stated, will tell (RN-B) now. On 8/20/19 at 2:12 PM, the Surveyor interviewed DON (Director of Nursing)-D regarding R2's pain during cleansing/treatment of [REDACTED]. Pain medications should have been offered, and if accepted, administered. Once the pain medication was effective, cleansing/treatment could resume.

Based on record review, staff and resident interviews, the facility did not ensure 2 (R (Resident) 2 and R7) of 5 sampled residents received care, consistent with professional standards of practice, to prevent the development of pressure injuries unless the individual's clinical condition demonstrates they were unavoidable. The facility had assessed R2 to be at risk for the development of pressure injuries due to multiple medical comorbidities and immobility. The resident's plan of care intervention included turning and repositioning every two hours. The resident had been placed on a fracture type bed pan at approximately 9:30 PM on 9/4/18 and staff did not remove the bed pan until approximately 10:00 AM on the morning of 9/5/18. Staff had not routinely repositioned the resident per the plan of care during the night. Subsequently, the resident developed a large stage I pressure injury to the buttocks and three stage II pressure injuries to the area of the skin that had been in direct contact with the bed pan. Additionally, staff did not report the pressure injuries to the wound nurse until the morning of 9/6/18, for evaluation and physician contact to obtain complete assessment of the wounds, appropriate treatment modality initiation and timely changes in the resident's plan of care interventions. R7 was at high risk for skin impairment. During an observation, R7's buttocks had been dragged across a mattress during a transfer. In addition, R7's heels were placed in full contact with a pillow and the resident was not repositioned every 2 hours per the resident's plan of care. Findings include: 1. R2 had [DIAGNOSES REDACTED]. The resident was assessed to be at risk for the development of pressure related injuries due to multiple medical comorbidities and immobility. The resident required the use of a full body lift to accomplish transfers; did not ambulate; required extensive assistance from staff to perform bed mobility; had range of motion deficits of both lower extremities; and scored a 12 of 15 on the cognitive screen (the higher the score, the more cognizant) and had notable periods of forgetfulness. R2's plan of care interventions for a problem listed as Resident at risk for skin breakdown related to impaired mobility and [DIAGNOSES REDACTED]. R2's medical record included a nursing entry dated 9/5/18 at 10:37 PM, that documented, Patient has an area 22 cm(centimeters) by 0.3 cm reddened ring around buttocks. Non-blanchable. 3 clear fluid filled blisters noted along ring, minimal complaints of pain. Cleansed, skin prep applied and [MEDICATION NAME] applied. Will continue to monitor. A macerated area to right gluteal fold measuring 1.5 cm by 1.0 cm. [MEDICATION NAME] applied to area. On 10/8/18 at 8:45 AM, the Surveyor interviewed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B. NHA-A verified R2 had been placed on a fracture style bed pan by an agency CNA (Certified Nursing Assistant) at approximately 9:30 PM, on 9/4/18 per the resident's request. NHA-A indicated the agency CNA did not know the resident well and assumed the resident would activate call light when done using the bed pan. NHA-A stated the agency CNA exited the building at 10:00 PM on 9/4/18 and did not report to the oncoming night shift that R2 had been placed on the bed pan, and approximately 8:00 AM the morning of 9/5/18, staff discovered R2 still on the bed pan at which time it was noted the resident had pressure related injuries to the area of the skin on the buttocks that had been in contact with the bed pan for 11 hours. DON-B stated, (R2) needs to be repositioned at night due to bed mobility issues and cannot move self enough to adequately relieve pressure. We looked at the call light report and (R2) had not activated the call light at any time during the night on 9/4/18 to 9/5/18. We educated the agency staff, had the wound nurse evaluate the wound and changed the resident's care plan interventions for pressure injury. On 10/8/18 at 9:30 AM, the Surveyor interviewed R2, who stated, The staff left me on the bed pan. I kept pushing the call light for someone to come, but no one did. I didn't call out. It made an impression on my butt and it was sore for a while (could not elaborate how severe the pain was on a scale of 1-10). I have MS ([MEDICAL CONDITION]) and diabetes. I am [AGE] years old. They are still checking my butt daily and sometimes they put a dressing on it. The Surveyor noted the resident's correct age was 74 per the medical record. On 10/8/18 at approximately 10:00 AM, the Surveyor interviewed RN (Registered Nurse)-C, who functions as the facility's wound nurse. RN-C stated, (R2) was put on a bed pan the evening of 9/4/18 and was not taken off the bed pan until the following morning. The resident developed a stage I pressure injury and three stage II pressure injuries due to pressure from the bed pan. The resident did not call out that evening and did not activate the call light. Staff had not repositioned the resident at all during the night because the resident was sleeping soundly and sometimes when repositioned, the resident has painful spasms from the [MEDICAL CONDITION]. The resident did have some discomfort at the pressure injury sites. I saw the area last Friday and the wounds are no longer open. The resident still has a macerated area on the left gluteal fold which was due to moisture from lying on the bed pan. The stage I pressure injury is still non blanchable. I did educate the agency CNA involved in the incident, but did no further education of any other staff. I believe I was first informed of the wounds on 9/6/18 and evaluated them on that date. I called the doctor and got treatment orders and changed the resident's pressure injury interventions on the plan of care on 9/6/18. R2's medical record included a nursing entry dated 9/6/18 at 7:59 AM which was documented by RN-C. The entry noted, Macerated area on left gluteal fold measuring 2.0 x (by) 0.4 x 0.1. Primary care physician faxed, requested [MEDICATION NAME] to area covered by [MEDICATION NAME] and change daily and as needed. Care plan updated, bariatric bed pan to be used moving forward and CNA to check every 2 hours that (R2) not on the bedpan while in bed. A further nursing entry dated 9/6/18 at 11:38 AM, documented by RN-C noted, Area on buttocks assessed. Stage I ring on buttocks measures 22 x 0.3. Has 3 small clear fluid filled blisters on the ring measuring 1) top right buttock 0.5 x 0.5. 2) Top left buttocks 0.5 x 0.5. 3) bottom left buttock 1.5 x 0.3. R2's medical record included a nursing entry dated 9/8/18 at 7:15 AM, Blisters to buttocks are no longer intact. Are blanchable and fading and a nursing entry dated 9/11/18 at 9:02 PM, Received new air mattress. A fax dated 9/6/18 at 9:35 AM, to R2's primary care physician indicated, This morning found a 22 x 0.3 cm ring on buttocks with 3 clear filled blisters measuring 0.5 x 0.5; 0.5 x 0.5; and 1.5 x 0.3. Also noted a macerated area 2.0 x 0.4 x 0.1 in left gluteal fold. (MONTH) we have [MEDICATION NAME] for the ring and blister every shift and [MEDICATION NAME] covered with [MEDICATION NAME] daily and as needed for the macerated area? The physician approved the order at 10:57 AM on 9/6/18. On 10/8/18 at 12:20 PM, the Surveyor interviewed NHA-A and DON-B. NHA-A stated, (R2) received the pressure injuries on the evening of 9/4/18 into the morning of 9/5/18. I was not updated on the incident until 9/6/18. The nurse on call was to be notified per facility policy and was not until 9/6/18. (R2's) plan of care was not updated until 9/6/18. We did an investigation and noted the root cause of the pressure injury to be lack of communication by staff and not following the care plan to reposition every two hours. DON-B stated, I told the nurse managers to talk with their staff regarding repositioning and reporting skin breakdown in their monthly meeting. I don't have a staff sign in sheet for that meeting. I remember talking about skin and repositioning with the CNA's but it was not in a formal meeting but I have no sign in sheet and probably didn't talk with everyone. We did not do any audits regarding repositioning and reporting skin breakdown after 9/6/18. In addition, NHA-A added, I did talk to staff on 9/26/18 (prior to R2's incident) about general incident reporting. 2. On 10/8/18, the Surveyor reviewed R7's medical record which included a Braden Scale dated 8/15/18, used for prediction of pressure injury risk with a score of 11, high risk. R7's CNA care plan card dated 10/8/18 indicated the resident was to have a change in position every 2 hours and heels were to be free floated. On 10/8/18 at 10:17 AM, the Surveyor noted that R7 complained of buttock pain and agreed to be transferred from chair to bed to relieve pressure and at 10:19 AM, CNA-M and CNA-L arrived in R7's room with a full body mechanical lift to transfer R7. During the observation of the transfer, the full body lift moved vertically (up and down) slowly and CNA-L commented the mechanical lift having a low battery. The Surveyor observed R7's bed was positioned as low as possible over the legs of the mechanical lift and CNA-M and CNA-L physically positioned R7 over the mattress by pulling the sling horizontally, causing R7's buttocks to drag along the twin size mattress from the edge of the mattress to the center of the bed (approximately 19 inches). R7 was positioned on the resident's back in bed with both heels in full contact with a pillow that had been placed under the resident's legs and covered with a blanket. The Surveyor and CNA-L then observed R7's heel positioning after removing the blanket and CNA-L verified the resident's heels were not free-floated, then readjusted the pillow to free float R7's heels. On 10/8/18 at 10:34 AM, the Surveyor interviewed CNA-M and CNA-L regarding the observation of R7's buttock being dragged across the mattress during the observed transfer. CNA-L indicated the transfer could have been halted while a new battery was obtained. CNA-M verified the bed was as low as possible over the legs of the mechanical lift. On 10/8/18 at 12:24 PM, the Surveyor observed R7 in bed, positioned on the resident's back. On 10/8/18 at 1:18 PM, the Surveyor observed Hospice CNA (HCNA)-N in R7's room, who indicated had just completed transferring R7's out of bed. HCNA-N verified R7 was positioned on the resident's back in bed prior to the transfer. (2 hours and 59 minutes since transferred to bed on back.)

Based on observation, record review and staff interview, the facility did not ensure that each resident receives adequate supervision to prevent accidents for 1 (resident #1) of 12 sampled residents. Thirty-seven residents, all who have some degree of cognitive deficits, reside on the third floor of the facility. Eighteen residents are independent with mobility with the use of assistive devices. This has the potential to affect the eighteen residents who are independent with mobility. Resident #1 had a history of [REDACTED]. Resident #1 self propelled her w/c (wheelchair) on the unit, exited a door and fell down nine concrete stairs. The exit door had an alarm system, and was sounding to alert staff. Resident #1 was through the door and fell down the stairs prior to any staff arrival. Although staff had a wandering and falls plan of care in place, the facility did not ensure resident #1 had an adequate supervision plan in place to ensure resident #1's safety. Resident #1 continues to self propel her w/c on the unit without supervision and also continues to open exit doors to the stairwell. As a result of the facility's actions to not ensure adequate supervision for resident #1, after she had exited a door and fell down concrete stairs, this posed an Immediate Jeopardy situation which began on 1/23/13. The NHA (Nursing Home Administrator) was officially notified of the Immediate Jeopardy situation on 2/07/13 by the state agency. The facility NHA was made aware of the identified concern during meeting on 2/5/13 with surveyor and took action. Actions included updating the care plan for this resident as well as any other resident that may display similar wandering behavior; actions also included updating internal procedure including the use of 1:1 (one to one) staff with specific residents as needed. These actions removed the immediate jeopardy on 2/6/13. Findings include: The facility had a policy and procedure for "Wanderer Interventions", dated 1/29/13. The policy and procedure indicated the following: Objective: To identify the role and responsibility of staff with a wandering resident who is attempting to leave. Procedure: 1. If a resident is agitated and voicing desire to leave, unit nurse is to assess the resident's behavior and determine appropriate intervention to keep resident safe. 2. Interventions may include assigning a staff person to conduct frequent checks on the resident, providing 1:1 care for as long as needed, and/or attempting to engage resident in an alternate activity. 3. Listen to what the resident is saying and feeling. Repeat back feelings. If they say they are going home, ask where home is and could they tell you about it. Respond with things such as "You must really like your house, how many years did you live there?" etc. Tell them it may take awhile to get there, wouldn't they like to come with you to get a drink first or a sweater in case it gets cool, etc. Do not directly deny facts they are telling you. Resident must sense your understanding of how they feel. 4. If a resident is attempting to leave, face the resident making eye contact, if this does not appear threatening. Talk in a soothing, unhurried voice. 5. If physical redirection is necessary, use a gentle touch on the resident's arm, shoulder, back, or waist if he/she will let you. 6. If resident exits floor or facility, staff person will accompany resident. Try to encourage resident to return with you back to the nursing home or unit. (Stay with resident to ensure his/her safety. 7. Inform a co-worker that you are leaving with the resident. 8. Co-worker is to notify Charge Nurse immediately. 9. Charge Nurse will direct a second staff person to provide additional assistance to the resident and accompany the staff person. 10. If resident continues to be adamant about not returning to the facility, utilize local police department by calling 911. 11. Upon return to the facility, a full nursing assessment is to be performed. 12. An incident report is to be completed including weather conditions at time of elopement. 13. Contact the resident's physician regarding details of the incident. 14. Contact the resident's power of attorney/family regarding details of the incident. 15. Immediate interventions are to be determined and implemented for resident's safety. 16. The Director of Clinical Services, Chief Operations Office, and Social Worker are to be notified at the time of the incident. Notification is to include resident leaving floor or leaving facility. 17. The care plan is to be reviewed and updated by interdisciplinary team. On 2/6/13, surveyor # calculated the distance and layout of the third floor by the use of the 2 foot ceiling tiles. Surveyor # observed upon exiting the main elevator there is the main corridor that is approximately 182 feet from each end (where a nurses' station is located) The main corridor houses 16 residents. When turning to the right, after exiting the elevator, and at the end of the corridor there is a 90 degree right turn and a corridor which houses 4 residents. This corridor is approximately 76 feet from the main corridor. Turning to the right from the main elevator, and at the end of the main corridor, you can also turn left to a corridor that houses 5 residents. This corridor is approximately 98 feet in length. At both ends of these corridors there is an exit door, that when opened will alarm. From the corridor that turns to the left, approximately 2/3 of the distance down the corridor, there is another corridor that leads to the beauty shop and dining area. There is an unalarmed elevator that staff indicated is used for maintenance and kitchen staff. (This is approximately 20 feet from the corridor that houses five residents). When turning left at the main elevator, and at the end of the corridor, there is another corridor with a 90 degree turn to the left. This corridor is approximately 100 feet long. This corridor houses 12 residents. Approximately 10 feet from the end of the corridor there is an exit door which alarms when opened. There is also a double metal door approximately 1/3 the distance down the corridor from the nurses' station that is not locked. Behind the doors is an elevator, that does not have an alarm system to notify staff if a resident would be entering. The metal doors also do not have an alarm notification when the doors are opened. On 2/6/13 at 9:15 AM, DON-A (Director of Nursing) indicated to surveyor # that staff utilize this elevator on Sundays when they take residents downstairs to church. On 2/6/13, surveyor # observed there were a total of 6 exit doors that lead to a stairwell on the third floor that sound an alarm when opened. All exit doors had a stop sign mesh across doorway, which is attached to the doorframe by a velcro strip. Two of the six doors had a sign which said "church closed today". All six doors had a key pad next to the door frame that if # and 1 are pressed simultaneously, the door will not alarm when opened. Also when the door was opened and the alarm sounded, 1,3,7,9, can be depressed individually and in order and the alarm will silence. On 2/6/13 at 8:10 AM, RN-B (Registered Nurse- Unit Manager) indicated to surveyor # that the main elevator has a wanderguard system installed. RN-B stated all first floor exit doors that lead to the outside have the wanderguard system. RN-B indicated no other doors or elevators have the wanderguard system installed. RN-B stated resident #1 utilized a wanderguard. RN-B indicated when residents that wore a wanderguard bracelet comes within a certain number of feet to the doors on 1st floor or the main elevator, an alarm will sound. On 2/5/13 surveyor # reviewed resident #1's medical record. According to the face sheet, dated 5/1/12, resident #1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The facility developed a plan of care for "Behaviors", dated 4/13/12. The plan of care indicated the problem area is that resident does wander at times and has wandered into other residents rooms. Resident has a history of agitation and can become resistive to cares however, this does appear well controlled by medication at this time. Resident can appear delusional and can be paranoid as well.....The following interventions were implemented: * If resident does attempt to leave the building staff should follow her out of building and the police should be called as she is at the facility under protective placement. * If resident is being abusive towards staff, staff should make sure resident is safe, leave her room and reproach later. * Analyze behavior for possible cause and effect relationship. * Apply and maintain wanderguard alarm bracelet. * Assist back to bed when up at night. * Discuss reasons for safety measures with resident and family. * Encourage family to ventilate feelings. * Encourage participation in self care. * Give choices in daily care. * If causal factor is identified attempt to reduce. * Meet quarterly with pharmacy consultant to review psychotropic medications. * Monitor prescribed medication for desired effects and update physician/psychiatrist as needed. * Provide a non-threatening atmosphere. * Provide consistent daily routine. * Provide frequent and consistent supervision. * Recognize stressors which may precipitate problem behavior. * Remove unsafe objects from resident's immediate environment. * Staff interventions to redirect when wandering is observed. * Talk during care. * Use calm approach when inappropriate behavior is exhibited. * Added 6/12/12- Risperdal is discontinued. Will continue to monitor behaviors. No other changes were implemented on the plan of care regarding resident #1's supervision plan. The facility also developed a plan of care for "At Risk for Falls", dated 6/13/12. The following interventions were implemented: * Low bed, clip alarm, motion sensor alarm when in bed, floor mat, gripper socks/non-skid shoes, two posey grip to w/c....... * Added on 1-23-13- 1:1 supervision while awake for 24 hours. * Added on 1/25/13- therapy screen, 3 day behavior tracking and on 1/28/13 to continue behavior tracking for additional week. No other changes were implemented on the plan of care regarding resident #1's supervision plan. The MDS (minimum data set), dated 11/29/12, indicated resident #1 had moderately impaired cognitive skills and wandered 4 -6 days, but less than daily. Resident #1's nurses' notes indicated the following: * 11/6/12-wheeling chair up and down hall, trying to open stairway doors. States my mother just had a baby and I wanna see my baby sister ..... * 1/23/13-at some point after lunch at approximately 1305 (1:05 PM) writer heard the atrium stairwell alarm sounding. Ran to atrium stairwell, opened door to stairwell and saw a w/c about halfway down the stairs moving down with a person in the w/c. I ran down the steps and when w/c was about 2/3rd down the stairwell writer saw the person moving forward and out of the w/c. I then heard resident land onto the floor ....... (Resident sent to the emergency room and returned later that day without any injuries except achiness). * 2/3/13- tried to open the atrium door after removing the stop sign from the doorway. Staff redirected her ..... On 2/6/13 at 9:15 AM, surveyor # interviewed DON-A regarding what the facility had done to prevent further accidents after resident #1 had fallen down the stairs on 1/23/13. The following was indicated: * Post an information sheet at the nurses' stations regarding resident #1's likes and dislikes, and indicated when anxious give some time to spend with her, she just wants a little attention. * Placed on 1:1 supervision for 24 hours. * Re-educated staff on the importance of answering alarms. * Had the local fire department assess exit doors. Suggested possible delayed doors. (Facility looking into this option but has not committed to changing to delayed doors). * Conducted a medication review. * Completed an hourly behavior monitoring for 10 days. Hourly documentation included sleeping, calm, agitated, yelling and other to be documented. (1 time documented on 1/25 at 1:30 PM, resident #1 opened atrium exit door). * Therapy screen (recommend changing sign at the doorways to saying "store closed for the day" rather than stop signs. (Facility did not follow therapy recommendations, but added a sign to some of the exit doors that stated "church closed today". * Interviewed nursing staff who worked all three floors. Discovered there were 4 CNA's on the floor and 2 licensed staff on the floor at the time the alarm sounded. One nurse was doing her medication pass and did not clearly hear the alarm. 2 CNA's were assisting a resident and initially did not hear the alarm clearly, and when recognized, one CNA responded. The other 2 CNA's did not hear the alarm. * Interviewed 8 other nursing personnel that worked on 1st and 2nd floor, 7 staff did not hear the door alarm and one staff heard the alarm but was on break. The facility indicated they turned the intercom sound louder. When an exit door sounds, there is also a statement over the intercom which indicates which exit door is sounding. The intercom sounds in public areas, but not in residents' rooms. On 2/5/13 at 9:38 AM, surveyor opened the atrium exit door (the door resident #1 had exited on 1/23/13). The alarm immediately sounded and there was not any staff in sight in the hall. 45 seconds had passed before staff arrived at the door. All staff came from another hall. There was an irregular shaped platform and nine painted concrete steps that led to another concrete landing, where resident was discovered by staff on 1/23/13. On 2/6/13 at 8:38 AM, surveyor overheard resident #2's motion sensor sound in his room. There were not any staff in immediate sight. After 2 minutes and 20 seconds a laundry staff came by and turned the alarm off. There was not any nursing staff that responded at any time. On 2/5/13 at 10:05 AM, surveyor # interviewed CNA-C regarding resident #1 and facility practice for responding to alarms. CNA-C stated resident is very confused, and she sundowns, sometimes as early as 2:00 PM. CNA-C indicated that resident #1 self propels w/c all over the unit, prior to the incident of 1/23/13 and continued to self propel on the unit without staff supervision at times. CNA-C indicated that she only works part time on 3rd floor, but staff probably have to remove resident #1 from the stairwell door at least one time weekly. CNA-C stated she has never observed resident #1 get all the way through the door, but has observed her to get part way through the doorway before staff could arrive. CNA-C indicated that staff can't always respond immediately to alarms, if they are assisting other residents. CNA-C stated that usually third floor staffs with five CNA's and 2 nurses, but today only have four CNA's, but there is suppose to be one CNA coming at 10:00 AM according to the schedule. On 2/5/13 at 10:15 AM, surveyor # interviewed CNA-D regarding resident #1 and facility practice regarding responding to alarms. CNA-D stated resident #1 is confused and can "key up" after lunch. CNA-D indicated that resident #1 self propels her w/c on the third floor. CNA-D stated resident #1 will attempt to exit through the stairwell doors at times, but not sure specifically how often. CNA-D stated resident #1 "keys up" frequently after family leaves and then states she wants to go home. CNA-D indicated when any alarm sounds, staff are to immediately respond, and the intercom states which exit door is alarming. CNA-D stated the problem is when staff are in a resident's room with the door closed, they can hear someone talking on the intercom, but cannot always hear what is being said. CNA-D indicated since resident #1 fell down the stairs, staff are on high alert to the intercom. CNA-D stated resident #1 is very quick when self propelling her w/c. CNA-D indicated that staff try to keep resident #1 involved in activities, but there are times she just likes to self propel her w/c in the halls. CNA-D verified there has been no changes in resident #1's supervision plan after she had fallen down the stairs. CNA-D stated that staff try to keep an eye on her, but is not always possible as they are busy with other residents. CNA-D indicated there is always a concern with staffing levels when chair/bed or door alarms sound, due to the layout of the unit and also if staff are in rooms the alarms can't always be heard. On 2/5/13 at 10:50 AM surveyor # interviewed LPN-K (Licensed Practical Nurse) regarding resident #1 and facility practice of responding to alarms. LPN-K verified she was the first to respond to the atrium door alarm that sounded on 1/23. LPN-K indicated she was at team 2 nurses' station (approximately 262 feet away from alarming door, also the door was down another hall and unable to be visualized from where LPN-K was when she first heard the alarm). Surveyor # questioned LPN-K where the other staff were at the time the door was alarming, LPN-K responded, "I would like to know where all the staff were". LPN-K stated she was aware there was a staff person following her. LPN-K indicated the mesh stops signs have been across exit doorways "forever". LPN-K stated resident #1 is in a totally delusional state of mind, but does self propel her w/c about the third floor, and can be very quick. LPN-K indicated on occasion, resident #1 will voice that she wants to go home, but not with determination. LPN-K stated she was aware exit doors open at times, but can not recall who specifically has opened the exit doors. LPN-K indicated she was also aware resident #1 had been redirected away from an exit door once, other than the incident that occurred on 1/23/13. LPN-K stated CNA's are trained to close resident doors when they are with them in their room, but staff can not hear alarms that sound (bed/chair/door) and the intercom that also states which door has been opened, has lowered sound levels and difficult to hear. LPN-K indicated staff should have resident doors opened a "crack", so staff can hear. LPN-K stated "I had to run a long way to get to the door" and "would like to know where everyone was". LPN-K indicated a note was posted, after the 1/23 incident, in the nurses station (could not locate note at 3-2 nurses station) about diversional activities for resident #1, but doesn't think it indicated when to implement. LPN-K stated today there are 2 nurses and 2 CNA's on the third floor and there will be another CNA that comes in at 10:00 AM. LPN-K indicated there were usually staffed with five CNA's and sometimes four. LPN-K stated there is always a concern that a resident could exit a door leading to the stairwell before staff can arrive. LPN-K indicated if staff are with residents in their rooms they can not immediately respond to an alarm, and also concerns due to the floor plan on the third floor, as all the halls cannot be supervised all the time. LPN-K indicated when she hears an exit door alarm, she always hopes someone can get there quick, as a resident has more of a chance for injury from falling down the stairs, than falling out of a w/c or bed. LPN-K verified there has been no changes in resident #1's supervision plan to prevent accidents. On 2/5/13 at 12:55 PM, surveyor # interviewed CNA-E regarding resident #1 and facility practice regarding responding to alarms. CNA-E stated on the day shift resident #1 is pleasantly confused, but on PM's she is very different. CNA-E indicated that resident #1 becomes angry, yells and hits. CNA-E stated resident #1 self propels her w/c on the unit, and is very quick in the w/c. CNA-E indicated resident #1 likes to escape through the exit doors, but varies per night, and minimally a few times a week is opening the exit doors to the stairwell. CNA-E stated resident #1 can be calm and demeanor changes quickly without notice. CNA-E indicated when resident #1 is agitated, staff usually stays with her, but sometimes staff are not aware of resident #1's agitation immediately. CNA-E stated resident #1 is very "crafty". CNA-E indicated there was also a time, about a month ago, when she showed CNA-E how to silence the alarm by pushing 1,3,7,9 on the keypad next to the door. CNA-E stated resident #1 stood up out of her w/c and showed CNA-E how to disengage the alarm and told CNA-E the code. CNA-E stated the nurses are aware that resident #1 could do that. CNA-E indicated she thought alarms can be heard in resident rooms, but if staff are with a resident, staff can not always respond to a sounding alarm immediately. CNA-E stated she thought if staff are busy, resident #1 could easily silence the alarm and be through the door without anyone knowing. CNA-E stated all of the residents on the third floor have dementia. On 2/5/13 at 2:30 PM, surveyor # interviewed CNA-F regarding resident #1 and facility practice for responding to alarms. CNA-F stated she is aware resident fell down stairs by exiting through a door. CNA-F indicated she was also aware that resident #1 has opened exit doors a few times, but staff always redirected. CNA-F stated at times, resident #1 is calm and then suddenly becomes agitated and speaks of needing to leave. CNA-F indicated resident #1 was very confused and self propels her w/c on the third floor. CNA-F verified there had not been any changes to resident #1's supervision plan. CNA-F stated staff try to monitor resident #1 closely, but resident #1 can not always be directly supervised. On 2/5/13 at 2:40 PM, surveyor # interviewed CNA-G regarding resident #1 and facility practice regarding responding to alarms. CNA-G stated resident #1 "sundowns" and randomly displays mostly anger at everyone. CNA-G indicated on a bad day resident #1 can try to exit the doors to the stairwell about 3 times, mostly around supper. CNA-G indicated resident #1's bad days can be as much as 3-4 days a week. CNA-G stated staff hear the door alarms and respond and remove the resident from the exit door. CNA-G indicated she has concerns since the incident on 1/23/13, that resident #1 could get through the exit door before staff arrive. CNA-G indicated staff try to respond to the alarms immediately but not always able if staff are with another resident. CNA-G verified that resident #1 continues to self propel her w/c on the floor, and is very quick. On 2/5/13 at 2:50 PM, surveyor # interviewed CNA-H regarding resident #1. CNA-H indicated that resident #1 has intermittent confusion and has good and bad days. CNA-H stated when resident #1 has her bad days she is restless and verbalizes she is upset. CNA-H indicated resident #1 self propels her w/c on the unit and when upset will verbalize she wants to go home, school etc. CNA-H indicated if staff see her by an exit door she is redirected. CNA-H stated she has responded to a exit door alarm and had redirected resident #1 away from the door. On 2/6/13 at 7:30 AM, surveyor # interviewed RN-I regarding resident #1 and facility practice. RN-I stated she works part time on the third floor, and has worked at facility since 08/2012. RN-I indicated she was not aware of any incident of resident #1 opening exit doors prior to the incident on 1/23. RN-I verified that resident #1 self propels her w/c on the floor. RN-I indicated that resident #1 can be calm and behavior can change suddenly. RN-I stated when resident #1 became agitated, staff try to do 1:1 supervision, but most of the time is redirected. RN-I indicated sometimes when family leaves resident #1 says she needs to leave. RN-I stated resident #1 usually only uses her feet to self propel, but when she wants to move quickly she uses her feet and her hands and can move very quickly. RN-I stated she was not aware of any specific place that CNA's document the number of times resident opens the exit doors. RN-I indicated the nurses will document in the MAR (medication administration record), regarding resident #1's wandering, but opening of the exit doors is not monitored, but could be added if the behavior happened frequently. RN-I stated resident #1 spends most of her time in activities but resident #1's behavior changes quickly. RN-I indicated the facility did do 1:1 supervision for a few days after the incident on 1/23, and did complete behavior charting for a while. RN-I indicated she was not aware of any time that resident #1 had tried to open an exit door, since the incident on 1/23. RN-I verified there is not any changes in resident #1's supervision plan. RN-I indicated she has had concerns about the number of staff working on the unit, on occasion, but that would depend on the day. RN-I stated if there were 4 or 5 lights on at once, staff need to prioritize. RN-I indicated if staff are busy with residents, they cannot always hear the alarms, but exit door alarms need to be a priority. RN-I stated there were usually 5 CNA's on the floor, rarely 6 and at times there are only 4 CNA's and 2 nurses. RN-I indicated each CNA takes a 20 minute break and a half hour break and only allowed to go individually. RN-I indicated the nurses take their breaks separately and when they have time. RN-I indicated she never had enough concern regarding staffing to speak to the unit manager. On 2/6/13 at 8:45 AM, surveyor # interviewed CNA-J regarding resident #1 and facility practices. CNA-J stated she was aware there were a few times that resident #1 opened an exit door, a few weeks to a month, prior to 1/23. CNA-J indicated staff try to involve resident #1 with activities but there are times she just wants to self propel her w/c in the hall. CNA-J stated if staff do respond to a resident that opened an exit door, the nurse should be notified. CNA-J indicated the CNA's do not document residents that have opened the exit door. CNA-J stated there are blind halls on the unit at times because of the layout of the unit, and if staff are busy in other areas of the unit. CNA-J indicated residents can not always be supervised when in a hall. CNA-J stated all residents on the third floor have some cognitive impairments. CNA-J verified there was not any changes in resident #1's supervision plan. CNA-J indicated the 3rd floor usually staffs with five CNA's and two nurses, but lately there have been four CNA's frequently. CNA-J stated she has concerns there are not enough staff to respond to alarms immediately, partly because of the floor plan of the unit, and if staff are busy with another resident in their room, staff cannot leave immediately, and at times staff can't hear alarms sounding. CNA-J indicated when the nurses are at each of the nurses station they can monitor the all hallways, but they are not always at the nurses station. On 2/5/13 at 10:45 AM, 12:40 PM and at 3:05 PM and on 2/6/13 at 8:10 AM, surveyor # interviewed RN-B Unit Manager regarding resident #1 and facility practices for alarms. RN-B stated resident #1 self propels her w/c on the unit. RN-B indicated she was aware the 1/23 incident was the first time resident #1 opened an exit door that lead to a stairwell. RN-B indicated since the incident, the facility did post information material about resident #1 at the nurses' station and added the church sign to the door, but there are no other changes in resident #1's supervision plan. RN-B stated all exit doors has an alarm system that sounds when the door is opened, and there is a keypad next to the door that can disengage the alarm prior to opening (# and 1 simultaneously) and to press 1379 to silence the alarm after it has activated. RN-B stated she did respond to the door alarm on 1/23 and stated resident #1 was saying she needed to go shopping. RN-B indicated prior to resident #1 exiting the atrium door on 1/23, resident #1 was just self propelling around the unit and not making any statements that she wanted to leave, and her behavior was calm. RN-B verified the wandering plan of care was not specific to attempts to open or exit doors into stairwells, and didn't think the care plan needed to be specific. RN-B indicated she wasn't aware how far away the first person was prior to arriving at the stairwell, when resident #1 had fallen down the stairs on 1/23. On 2/6/13 at 9:15 AM, surveyor # interviewed DON-A. DON-A stated she had also responded to the exit door alarm on 1/23. DON-A indicated upon her arrival to the stairwell, resident #1 was lying on the cement landing at the bottom of the steps. DON-A indicated resident #1 sustained a small bump to her head and complained of leg pain/tingling. DON-A indicated when she arrived on scene, resident #1 stated she needed to go shopping. DON-A stated resident #1 was transferred to the hospital and returned 3 hours later without injuries. DON-A indicated resident #1 had no memory of the incident after it had occurred. DON-A stated resident #1 never attempted to open an exit door prior to the incident on 1/23, but not sure if had after, and would have to look at the medical record. DON-A indicated resident #1 does have many delusional behaviors. DON-A stated there is an elevator on the hall, near the atrium exit door is located, and staff utilize that elevator on Sundays when taking residents downstairs to church. DON-A verified the above listed interventions that was completed. DON-A stated resident #1 doesn't give warning of her thought process. DON-A indicated the facility completed behavior tracking for 10 days following the incident, but the tracking did not provide triggers to the incident. DON-A verified resident #1 continues to self propel w/c about the unit and there could be times when resident #1 and other residents are without direct supervision. DON-A verified resident #1 can move quickly while self propelling her w/c. DON-A stated staff try to know where resident's #1's whereabouts are, but was not always possible as they could be busy with other residents, and resident #1 was independent with mobility. DON-A verified there were no changes in resident #1's plan of care ensure adequate supervision to prevent further accidents. On 2/6/13 at 10:05 AM, surveyor # interviewed CNA-L regarding resident #1 and facility practice. CNA-L stated prior to the incident of 1/23, CNA-L had just happened to come across resident #1 removing the stop sign mesh over the doorway of a different exit door on the third floor. CNA-L indicated resident #1 hadn't opened the door yet and was re-directed. CNA-L stated resident #1 knows how to remove the mesh stop signs. CNA-L indicated there are concerns with the number of staff on the unit due to the layout of the floor and difficulty with hearing alarms when staff are in resident rooms. CNA-L stated staff do try to involve resident #1 in activities, but there are times she just wants to self propel her w/c on the unit. CNA-L indicated resident #1 can not always be supervised when she is self propelling her w/c.

Based on record review, staff and family interviews, the facility did not ensure that 1 (resident #1) of 9 sampled residents received adequate supervision and assistance devices to prevent accidents. Resident #1 was assessed to be at high risk for falls and had a care plan intervention in place to include the use of an alarm while up in a chair. On 11/27/12, resident #1 fell out of the wheel chair and sustained a laceration that required sutures, and an acute subarachnoid hemorrhage. The Neurosurgeon consultation indicated that resident #1 was not a surgical candidate. An alarm had not been placed on resident #1 while seated in a wheel chair at the time of the fall, per the resident's care plan. After resident #1 sustained the fall, resident #1 experienced an increase in difficulty of upper body control with leaning forward and to one side and required therapy services for an evaluation of her seating. At the time of survey, resident #1 required the use of a lap buddy in the wheel chair to ensure no further falls occurred, due to extremely poor upper body control. Findings include: Resident #1's admission face sheet dated 2/10/12 indicated the resident had [DIAGNOSES REDACTED]. Resident #1's falls risk assessment dated [DATE] indicated the resident had scored an 8 (total score of above 10 represents high risk for falls), the falls risk assessment completed for the resident on 5/19/12 indicated a score of 9, and a falls risk assessment completed on the resident on 10/22/12 indicated a score of 11. According to the 10/22/12 falls assessment, the resident's risk of falls had increased since the admission falls assessment had been completed. A corresponding falls CAA (Care Area Assessment) for resident #1 dated 2/17/12 indicated, "Resident is currently a total lift for transfers with a two assist. Resident is a moderate risk for falls. Resident needs assistance with all ADL's (activities of daily living). Resident is at risk for falls that could cause injury". Resident #1's risk for falls care plan was reviewed last on 9/12/12 and included a goal that the resident would remain safe in her environment. Care plan interventions included the use of a low bed, body pillow for positioning (dated 6/1/12), clip alarm (dated 2/18/12), motion sensor alarm (dated 2/18/12), floor mat (dated 2/18/12), two assist with standing lift if not bearing weight well (no date included) and lay resident down for 1 hour in a.m. and p.m. (dated 8/13/12). A corresponding group sheet care guidelines developed for resident #1 dated 11/27/12 and utilized by direct care staff indicated low bed, sensor, alarm in bed and wheel chair, motion sensor at bedside, floor mat and grab bars. Review of a nursing entry in resident #1's medical record dated 6/1/12 indicated the resident had sustained a fall without injury. A care plan intervention for the use of a lipped mattress was initiated, but discontinued on 10/5/12. A nursing entry dated 8/8/12 indicated resident #1 was noted to be sloughing to the left. From 8/8/12, there was no documented indication that the resident had issues with upper body control. Additional documentation from 10/23/12 through 11/4/12 indicated that resident #1 was treated with an antibiotic for a diagnosed urinary tract infection and on 11/6/12, resident #1 had an episode of a near syncopal episode but did not lose consciousness. Review of an additional nursing entry in resident #1's medical record dated 11/27/12 at 5:45 p.m. indicated the resident had been, "observed lying on floor in front of wheel chair in small pool of blood by head. Has laceration by right eye". The documentation suggested that neurological checks and vitals were within normal limits. The physician was notified relating to the laceration including the eye becoming bruised and swollen. In addition, resident #1 sustained a small skin tear and was sent to the emergency room . The emergency room documentation dated 11/27/12 indicated, "at nursing home, in wheel chair, unwitnessed fall, found patient face down on floor, facial injury, abrasions to right wrist. The patient presents today following fall and concern for injury. Patient was sitting in her wheel chair with staff and when staff directed their attention elsewhere and then looked back at the patient she was face down on the floor. Acquired a right eye abrasion/bruising as well as an abrasion to right knee. The character of symptoms is pain. The degree at present is minimal." A CT (Computerized Tomography) of the head and cervical spine without contrast was performed which indicated, "there is a small amount of high attenuation material seen extending along the frontal sulci in the right parafalcine region as well as the left anterior frontal region and along the left Sylvian fissure. This is consistent with acute posttraumatic subarachnoid hemorrhage. There is prominent soft tissue swelling over the right lateral orbit with a small amount of soft tissue gas, probably related to laceration. Impression: 1. Acute subarachnoid hemorrhage without significant mass effect. These critical results were phoned to the ER physician. 2. Prominent pre-orbital soft tissue hematoma." A Neurosurgeon was consulted. He recommended that no acute neurosurgical intervention is indicated and the patient would not be a surgical candidate even if bleeding worsened. The resident received sutures to a 3 cm (centimeter) laceration on the right forehead/eyebrow area and was discharged back to the facility. Review of the fall incident report completed on 11/27/12 for resident #1 did not indicate any check marks in the alarms column on the form. The interventions listed that were in place at the time of the fall indicated, "has low bed only with mat next to floor." The report also indicated the resident's injuries consisted of a laceration to right eye area and large bruise right temple. The report was completed by RN (Registered Nurse)- G. An interdisciplinary screen/referral therapy request was initiated for resident #1 on 11/28/12 that indicated a request for a therapy screen for wheel chair positioning and posture alignment due to a fall from the wheel chair. The problem was described as, "resident fell from wheel chair p.m. shift on 11/27/12. Multiple CNA's report that resident leans forward in wheel chair and likely that is how fall occurred." A therapy evaluation was completed for the resident on 11/28/12. A nursing entry in resident #1's medical record dated 12/2/12 indicated, "resident very much leaning to the left side today. Repositioned several times with pillow for support." On 12/14/12 at 8:00 a.m., surveyor # interviewed RN-L regarding resident #1. RN-L is the Unit Coordinator for resident #1's unit. RN-L stated, her (resident #1) leaning in the wheel chair has been recent and more notable within the last week." On 12/14/12 at 8:35 a.m., surveyor # interviewed OT (Occupational Therapist)-C regarding resident #1. OT-C stated, "She (resident #1) was leaning to one side in her wheel chair and has had poor posture leaning at times for a while, but it has been worse and more uncontrolled since the fall (on 11/27/12). We just tried a different chair with contoured built in laterals on both sides, but she is still displaying forward lean per the nurses, so yesterday we tried a different chair which did not make a difference. I added a half lap tray yesterday to try to see if the resident liked it and to see if it will prevent leaning. We are in the process of trying different interventions for her and monitoring them over time." On 12/14/12 at 9:00 a.m., surveyor # interviewed resident #1's ADPOAHC (Activated Durable Power of Attorney for Health Care) via the telephone. ADPOAHC-D stated, "They (the facility) told me the alarm wasn't on when she (resident #1) fell on [DATE] and she is supposed to have a clip alarm on when in the wheel chair. They said they didn't want to have her unattended due to her always wanting to get back into bed, so they put her at the nurses station after dinner, but she wasn't being attended because staff were busy bringing residents back from the dining room when she fell . They also told me it was an unwitnessed fall." On 12/14/12 at 9:15 a.m., surveyor # reviewed the facility's self report for resident #1's fall, which was reported to the state survey and certification agency on 11/28/12. The self report document indicated upon further investigation by the facility, that resident #1 did not have a wheel chair clip alarm on at the time of the fall. RN-G, who completed the fall incident report, reported that she did not think resident #1's plan of care included a clip alarm while up in a wheel chair. The self report indicated that CSW (Certified Social Worker)-H conducted resident #1's fall investigation and had informed RN-G that according to resident #1's current care plan and group sheet, the resident was supposed to have a wheel chair alarm. CSW-H completed that following interviews as part of the investigation: ~ LPN (Licensed Practical Nurse)-I indicated when resident #1 was discovered on the floor, no alarms had been sounding. ~ CNA (Certified Nursing Assistant)-J verified that resident #1 did not have an alarm on her chair at the time of the fall. ~ CNA-K indicated she was the CNA that had assisted resident #1 from the dining room to the nursing station area on the day of the incident, just before resident #1 had fallen. CNA-K was asked if resident #1 had an alarm on her wheel chair at the time of the incident and CNA-K stated, "We took her (resident #1's) alarms off a while ago" and stated that resident #1 did not have an alarm on at the time she fell . ~ CNA-B stated she had gotten resident #1 out of bed and placed her in a wheel chair for dinner on 11/27/12 and verified that resident #1 did not have an alarm on her wheel chair at the time of the incident, stating "They discontinued that a while ago." CSW-H reviewed resident #1's group sheet with CNA-B which indicated that resident #1 was to have alarms on while in bed and up in a wheel chair. CNA-B stated "I must have missed that part" and indicated that during her shift she felt rushed and that she normally reads the whole group sheet, but didn't that night. On 12/14/12 at 9:20 a.m. surveyor # interviewed CNA-E and CNA-F regarding resident #1. Both staff verified to the surveyor that resident #1 had issues with leaning to one side prior to the fall on 11/27/12, and that therapy had issued a wedge to place under one side to prevent leaning, sometime (date unknown) before the fall had occurred. On 12/14/12 at 1:15 p.m., surveyor # interviewed CNA-B regarding resident #1. CNA-B verified to the surveyor that she had assisted resident #1 out of bed and into a wheel chair just before the supper hour on 11/27/12. CNA-B stated, "I didn't place an alarm on her (resident #1) in the wheel chair. I didn't look at her care guidelines and didn't see and alarm on her chair. I didn't place an alarm on her wheel chair that evening per her plan of care". On 12/14/12, surveyor # observed the dining room on resident #1's unit and noted that the dining room was approximately 50 yards and around the corner from the nursing station. The facility conducted audits of all residents who were currently utilizing fall intervention devices on 11/28/12 to ensure that the devices were current and the devices utilized were listed on both the plan of care and the resident care guidelines. Additionally, the facility inserviced staff on utilizing correct resident fall interventions on 11/15/12 and again on 12/11/12-12/12/12, and inserviced all staff on 11/28/12 on using and following resident care group sheet guidelines.

Based on observations, record review and staff interviews, the facility did not provide services in accordance with each resident's written plan of care for 2 (resident #1 and #3) of 8 sampled residents. Resident #1 was assessed to be at high risk for falls and had a care plan intervention in place to include the use of an alarm while up in a chair. On 11/27/12, resident #1 fell out of the wheel chair and sustained a laceration that required sutures, and an acute subarachnoid hemorrhage. The Neurosurgeon consultation indicated that resident #1 was not a surgical candidate. An alarm had not been placed on resident #1 while seated in a wheel chair at the time of the fall, per the resident's care plan. After resident #1 sustained the fall, resident #1 experienced an increase in difficulty of upper body control with leaning forward and to one side and required therapy services for an evaluation of her seating. At the time of survey, resident #1 required the use of a lap buddy in the wheel chair to ensure no further falls occurred, due to extremely poor upper body control. Resident #3 was assessed to be at high risk for falls and had an intervention in place for the use of a sensor pad alarm while up in the wheel chair. On the day of survey, resident #3 was observed to have both a tabs alarm and a sensor pad activated while seated in a wheel chair. Resident #3's care plan had not been followed as directed. Findings include: 1. Resident #1's admission face sheet dated 2/10/12 indicated the resident had [DIAGNOSES REDACTED]. Resident #1's falls risk assessment dated [DATE] indicated the resident had scored an 8 (total score of above 10 represents high risk for falls), the falls risk assessment completed for the resident on 5/19/12 indicated a score of 9, and a falls risk assessment completed on the resident on 10/22/12 indicated a score of 11. According to the 10/22/12 falls assessment, the resident's risk of falls had increased since the admission falls assessment had been completed. A corresponding falls CAA (Care Area Assessment) for resident #1 dated 2/17/12 indicated, "Resident is currently a total lift for transfers with a two assist. Resident is a moderate risk for falls. Resident needs assistance with all ADL's (activities of daily living). Resident is at risk for falls that could cause injury". Resident #1's risk for falls care plan was reviewed last on 9/12/12 and included a goal that the resident would remain safe in her environment. Care plan interventions included the use of a low bed, body pillow for positioning (dated 6/1/12), clip alarm (dated 2/18/12), motion sensor alarm (dated 2/18/12), floor mat (dated 2/18/12), two assist with standing lift if not bearing weight well (no date included) and lay resident down for 1 hour in a.m. and p.m. (dated 8/13/12). A corresponding group sheet care guidelines developed for resident #1 dated 11/27/12 and utilized by direct care staff indicated low bed, sensor, alarm in bed and wheel chair, motion sensor at bedside, floor mat and grab bars. Review of a nursing entry in resident #1's medical record dated 6/1/12 indicated resident #1 had sustained a fall without injury. A care plan intervention for the use of a lipped mattress was initiated, but discontinued on 10/5/12. A nursing entry dated 8/8/12 indicated resident #1 was noted to be sloughing to the left. From 8/8/12, there was no documented indication that resident #1 had issues with upper body control. Review of an additional nursing entry in resident #1's medical record dated 11/27/12 at 5:45 p.m. indicated the resident had been, "observed lying on floor in front of wheel chair in small pool of blood by head. Has laceration by right eye". The documentation suggested that neurological checks and vitals were within normal limits. The physician was notified relating to the laceration including the eye becoming bruised and swollen. In addition, resident #1 sustained a small skin tear and was sent to the emergency room . The emergency room documentation dated 11/27/12 indicated, "at nursing home, in wheel chair, unwitnessed fall, found patient face down on floor, facial injury, abrasions to right wrist. The patient presents today following fall and concern for injury. Patient was sitting in her wheel chair with staff and when staff directed their attention elsewhere and then looked back at the patient she was face down on the floor. Acquired a right eye abrasion/bruising as well as an abrasion to right knee. The character of symptoms is pain. The degree at present is minimal". A CT (Computerized Tomography) of the head and cervical spine without contrast was performed which indicated, "there is a small amount of high attenuation material seen extending along the frontal sulci in the right parafalcine region as well as the left anterior frontal region and along the left Sylvian fissure. This is consistent with acute posttraumatic subarachnoid hemorrhage. There is prominent soft tissue swelling over the right lateral orbit with a small amount of soft tissue gas, probably related to laceration. Impression: 1. Acute subarachnoid hemorrhage without significant mass effect. These critical results were phoned to the ER physician. 2. Prominent pre-orbital soft tissue hematoma". A Neurosurgeon was consulted and recommended that no acute neurosurgical intervention is indicated and the patient would not be a surgical candidate even if bleeding worsened. Resident #1 received sutures to a 3 cm (centimeter) laceration on the right forehead/eyebrow area and was discharged back to the facility. Review of the fall incident report completed on 11/27/12 for resident #1 did not indicate any check marks in the alarms column on the form. The interventions listed that were in place at the time of the fall indicated, "has low bed only with mat next to floor". An interdisciplinary screen/referral therapy request was initiated for resident #1 on 11/28/12 that indicated a request for a therapy screen for wheel chair positioning and posture alignment due to a fall from the wheel chair. The problem was described as, "resident fell from wheel chair p.m. shift on 11/27/12. Multiple CNA's report that resident leans forward in wheel chair and likely that is how fall occurred". A nursing entry in resident #1's medical record dated 12/2/12 indicated "resident very much leaning to the left side today. Repositioned several times with pillow for support". On 12/14/12 at 8:35 a.m., surveyor # interviewed OT (Occupational Therapist)-C regarding resident #1. OT-C stated "she (resident #1) was leaning to one side in her wheel chair and has had poor posture leaning at times for a while, but it has been worse and more uncontrolled since the fall (on 11/27/12). We just tried a different chair with contoured built in laterals on both sides, but she is still displaying forward lean per the nurses, so yesterday we tried a different chair which did not make a difference. I added a half lap tray yesterday to try to see if the resident liked it and to see if it will prevent leaning. We are in the process of trying different interventions for her and monitoring them over time". On 12/14/12 at 8:00 a.m., surveyor # interviewed RN-L regarding resident #1. RN-L is the Unit Coordinator for resident #1's unit. RN-L stated, her (resident #1) leaning in the wheel chair has been recent and more notable within the last week". On 12/14/12 at 9:15 a.m. surveyor # interviewed CNA-E and CNA-F regarding resident #1. Both staff verified to the surveyor that resident #1 had issues with leaning to one side prior to the fall on 11/27/12, and that therapy had issued a wedge to place under one side to prevent leaning, sometime (date unknown) before the fall had occurred. On 12/14/12 at 1:15 p.m., surveyor # interviewed CNA-B regarding resident #1. CNA-B verified to the surveyor that she had assisted resident #1 out of bed and into a wheel chair just before the supper hour on 11/27/12. CNA-B stated, "I didn't place an alarm on her (resident #1) in the wheel chair. I didn't look at her care guidelines and didn't see and alarm on her chair. I didn't place an alarm on her wheel chair that evening per her plan of care". Refer to the citation F323 for additional information relating to resident #1. 2. The facility conducted audits of all resident's who were currently utilizing fall intervention devices on 11/28/12 to ensure that the devices used for residents were current and these devices utilized were listed on both the resident's care plan and the resident's care guidelines, which are used by direct care staff to determine a resident's care needs. This audit indicated that resident #3 was to have a motion detector at bedside and a wheel chair seat alarm in place. The audit indicated resident #3's devices were working and that the resident's care plan and group care guidelines indicated the same directives for use of these devices for safety interventions. The facility inserviced staff on utilizing correct resident fall interventions on 11/15/12 and again on 12/11/12-12/12/12, and inserviced all staff on 11/28/12 on using and following resident care group sheet guidelines. Resident #3's fall risk assessment dated [DATE] indicated the resident had scored a 15 on the assessment which represented that the resident was at high risk for falls. Review of a fall incident report dated 11/30/12 indicated that resident #3 had sustained a fall without injury. Resident #3's falls care plan with a review date of 10/29/12 indicated that the resident was at risk for falls due to confusion, increased weakness, impaired mobility and recurrent falls. The goal of this care plan indicated resident #3 would remain safe in his environment. Care plan interventions were listed as motion sensor alarm at bedside, sensor pad alarm in wheel chair and gripper socks/non skid shoes. On 12/14/12 at 7:15 a.m. and again at 9:15 a.m., surveyor # observed resident #3, seated in a wheel chair with a tabs alarm on and a sensor alarm on and activated. On 12/14/12 at 9:20 a.m., surveyor # interviewed MT (Medication Technician)-N regarding resident #3. MT-N verified to the surveyor that resident #3's wheel chair had a tabs alarm and a sensor alarm on and both were activated. MT-N stated, "His (resident #3) plan of care states he is to only have a sensor alarm on his wheel chair and he has both a tabs and a sensor on. I know they were going through and revamping everything on the care cards to match the care guidelines". Resident #3's group sheet care guidelines dated 12/11/12 indicated the same interventions as listed on the resident's fall care plan. On 12/14/12 at approximately 9:30 a.m., CNA-M verified to the surveyor that the group sheet care guidelines dated 12/11/12 for resident #3 was current and the resident did not have a care plan intervention to include the use of a tabs alarm on his wheel chair. On 12/14/12 at 9:25 a.m., surveyor # interviewed DON (Director of Nursing)-A regarding resident #3. DON-A stated, "after resident #1's fall on 11/27/12, we went into each resident's chart and room to ensure they had the right fall prevention devices, and that the care guidelines and plan of care were identical. We made sure the plan of care, the care guidelines, and the fall prevention devices matched during an audit done on 11/28/12". After resident #1 sustained a fall with a significant injury and did not have an alarm on per her plan of care, the facility reviewed all safety devices, care plans and care guidelines to ensure they matched. Additionally, the facility had completed inservice training for staff to utilize the care guidelines to determine resident's care needs. On the day of survey, and after the facility had completed an audit and training of staff, resident #3 was noted to have a safety device in place that was not an intervention on his care plan.

Based on observation, resident and staff interviews and record review, the facility did not ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable; and a resident having pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 5 (residents #4, #10, #15, #17 and #20) of 8 residents reviewed for pressure ulcers in a total sample of 23 residents. Resident #4 had a history of [REDACTED]. The resident also had multiple medical co-morbidities that put her at risk for the development of pressure related ulcers. The resident was assessed by the facility to be at risk for pressure ulcer development. The facility did not establish a skin integrity plan of care to include interventions to protect the resident's heels from pressure ulcers. Additionally, when staff transferred the resident out of bed, it was accomplished in a manner that did not provide protection from friction and sheer to the resident's bare heels. Resident #10 was admitted to the facility without pressure ulcers. Although resident #10 was at moderate risk for development of pressure ulcers, the facility did not develop a comprehensive plan of care for pressure ulcer prevention. Resident #10 developed a stage II pressure ulcer to the left heel, a deep purple area on the right heel, an unstageable ulcer to the left calf area, and two stage II pressure ulcers to the buttocks area. The facility did not consistently implement measures to prevent further breakdown and promote healing. Resident #15 experienced a decline, which included significant weight loss. The care plan related to skin breakdown was not revised to reflect the decline, and appropriate interventions were not implemented. Resident #17 developed a [MEDICAL CONDITIONS] to the right lower extremity, and subsequently required bed rest for five days beginning on [DATE]. The facility did not evaluate resident #17's risk for pressure ulcer development, and did not modify the plan of care to prevent skin breakdown. Resident #17 developed a stage II pressure ulcer to the right buttock on [DATE]. Other than a treatment to the affected area, the facility did not modify the plan of care to prevent further breakdown. The buttocks ulcer healed on [DATE] and re-occurred on [DATE]. On [DATE] resident #1 developed an unstageable pressure ulcer to the right heel. The facility implemented the use of gel boots and elevation of the heels. During observations on [DATE], those interventions were not consistently implemented. Resident #20 was a very tall gentleman, and his feet pushed against the foot board of his bed. Appropriate interventions related to the resident's feet were not developed and implemented. Findings include: The facility's "Skin Care Protocol", revised on [DATE], directed staff to, "..Assess resident for need of antipressure devices in the wheelchair, bed mattress, elbow or heel protectors, to relive pressure from the area and include this intervention in the care plan...Update the care plan and document on a continual basis...Measure wound every week (Wednesdays) and record the measurements on the wound progress sheet. Be sure to include the exact measurements...wound bed status, stage of the wound...and if it has improved or not...The licensed nurse will complete the Braden Risk Assessment Scale when there is a change in condition involving mobility, continence, nutrition, hydration, or sensory perception putting the resident at increased risk for developing pressure sores...Care plans will be developed according to the risk level recommendations...as well as additionally resident specific information regarding prevention interventions...". Regarding "Mechanical Loading and Support Surfaces", the protocol noted, "...Each resident who cannot or does not freely reposition their self in bed will have an individualized turning clock schedule which will be documented in the resident's care plan...Use positioning devices such as a pillow, body pillow, foot cradle, wedges, blankets, gel boot, etc. to prevent direct contact with skin surfaces...Totally relieve pressure on heels by placing a pillow under the calf muscles allowing the heels to hang freely, and use gel boots...Update care plan for positioning devices...". 1. The facility face sheet, dated [DATE] and contained within the medical record, indicated resident #17 was admitted to the facility on [DATE]. The face sheet documented resident #17 had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set), dated [DATE], documented resident #17 required extensive staff assistance with bed mobility and was at risk for pressure ulcer development. A skin assessment completed on [DATE] documented resident #17's skin was intact. A Braden scale, completed on [DATE], documented a score of 18, indicating low risk. The weekly nursing summary, dated [DATE], indicated resident #17 required every-two-hour positioning. The weekly nursing summary, dated [DATE], documented the use of a comfortex mattress (pressure reducing) and the use of a gel cushion in the wheel chair. The integrated notes, dated [DATE] at 3:40 p.m., documented resident #17 had swelling and pain to her right leg. The right leg was documented as "...swollen & tight & warm to touch." The physician was contacted, and resident #17 was sent to the emergency room for evaluation. The emergency room note dated [DATE] documented a differential [DIAGNOSES REDACTED]. On [DATE] an ultrasound examination verified two acute thrombi in the right popliteal vein and superficial femoral veins. On [DATE] the physician ordered bed rest for a total of five days. Although resident #17's condition changed where she required total bed rest for five days on [DATE] and had increased swelling and pain in the leg, the facility did not re-evaluate or assess resident #17's risk for skin breakdown. No risk assessment or revision of the plan of care was completed. The plan of care did not address the risk for skin breakdown or include any interventions to prevent pressure ulcer development, including to the heels. The integrated notes for resident #17 on [DATE] at 10:45 a.m. indicated, "Open area on Rt. (right) buttocks stage II. Measures 1.5 X 1.3 X 0.1 (centimeters)...Resident is on bed rest d/t (due to) [MEDICAL CONDITION]". Although a treatment was ordered to the area on [DATE], no changes were made to the plan of care, including a repositioning plan, to prevent further breakdown. On [DATE] the weekly wound documentation form indicated resident #17 developed an unstageable pressure ulcer to the right heel, which measured 5.2 cm (centimeter) by 5.4 cm, and was documented as an intact blister. On [DATE] the facility updated the plan of care and treatment record to include "Blue gel boots on feet bilate (bilaterally - pertaining to both sides of the body). Keep heels elevated off bed. Monitor (right) heel BID (twice a day). The facility did not make any further changes to the plan of care, including frequency of repositioning efforts to promote healing and prevent further breakdown of the buttocks/coccyx. On [DATE] the physician orders [REDACTED]. On [DATE] the treatment record and integrated notes documented the stage II ulcer to resident #17's right buttock was healed, and the treatment was discontinued. On [DATE] an order for [REDACTED]. The annual MDS, dated [DATE], indicated resident #17 required extensive staff assistance with bed mobility and transfers. The MDS documented resident #17 had no unhealed pressure ulcers at a stage 1 or higher at section M0210. According to the RAI (Resident Assessment Instrument) manual, section M0210 should be coded to reflect any pressure ulcers in the past seven days. According to the medical record documentation, resident #17 had an unstageable ulcer to the right heel during the seven-day look back period. As a result of the inaccurate coding of the MDS section M0210, section M0300 was not completed to include documentation of the stages of the ulcers. Section M0900 of the MDS documented no healed pressure ulcers since the last assessment. According to the medical record as noted above, resident #17 had a stage II pressure ulcer to the right buttock which was healed on [DATE]. Furthermore, the CAA (Care Area Assessment) summary, dated [DATE], did not include the presence of current pressure ulcers or history of healed ulcers since the last assessment. The CAA did not included an accurate description of the problem, causes and contributing factors, or risk factor analysis of the care area so that an appropriate care plan could be developed for resident #17. During an interview with surveyor # on [DATE] at 12:25 p.m., RN (Registered Nurse)-A verified the MDS section M0210 and M0300 were not accurately completed. RN-A verified resident #17 had an unstageable pressure ulcer during the seven-day look back period; therefore those ulcers should have been coded on the MDS. RN-A verified section M0900 was not accurately coded to include the healed pressure ulcer to resident #17's buttock as documented in the medical record. RN-A verified the CAA for pressure ulcers did not include the current or history of pressure ulcers nor an accurate summary of the problems or risk factors related to the care area. On [DATE] the plan of care for resident #17 was revised to include the use of two staff assistance for transfers with the use of a total lift to avoid pressure and discomfort to the heel during transfers. On [DATE] the facility developed a plan of care for resident #17 for "Low Risk per Braden: Potential for alteration in skin integrity related to deconditioning." The plan did not address the resident's current pressure ulcer or the history of an ulcer to the right buttock. The plan included the following interventions: -adequate fluid and food intake -body/skin audit at least weekly -keep linens dry and wrinkle free -keep skin clean and dry. Wash with soap, rinse & dry -report any red or open areas -teach resident/family to observe for skin changes -maintain good body alignment w (with)/weight distributed evenly -blue gel boots on feet bilaterally, keep heels elevated off bed, monitor right heel twice a day. The plan of care did not address the frequency of repositioning efforts or evaluation of support surfaces. On [DATE] the weekly wound documentation form indicated resident #17 developed a stage II pressure ulcer to the right buttocks measuring 0.5 cm by 0.5 cm, with a depth of 0.1 cm. The physician was contacted, and a treatment order for the area was obtained. No changes were made to the plan of care following the re-occurrence of a stage II pressure ulcer on resident #17's right buttocks. On [DATE] the weekly wound documentation form documented the pressure ulcer to resident #17's right buttocks was healed, and the right heel ulcer remained unstageable and measured 7.6 cm by 6 cm. On [DATE], from 8:25 a.m. to 9:35 a.m., surveyor # observed resident #17 while the resident was in her bed. Resident #17 had a blue gel boot on the right foot only. The pillow was not positioned in a manner that would elevate the resident's heels off the bed's surface. Resident #17's left heel was in full direct contact with the mattress, and the right heel boot was in full direct contact with the mattress. On [DATE] at 8:25 a.m. surveyor # interviewed resident #17. The resident stated she only wore a boot to the right foot and had not been utilizing a boot on the left foot. Resident #17 stated the blue boot was placed on the right foot after she developed a sore on that heel. Resident #17 indicated the facility never provided a boot for the left foot. On [DATE] at 9:45 a.m. LPN (Licensed Practical Nurse)-B and surveyor # observed resident #17 while the resident was in her bed. LPN-B verified to surveyor # resident #17 only had a boot on the right foot and verified the pillow placed under resident #17's legs was not achieving elevation of the heels off the bed's surface. LPN-B stated she was not aware of resident #17 utilizing a blue gel boot to the left heel. LPN-B removed the boot to resident #17's right foot and completed the treatment to the wound. The surveyor observed the resident's right heel had a black, dry eschar cap over the right heel. On [DATE] at 9:50 a.m. surveyor # interviewed CNA (Certified Nursing Assistant)-C regarding resident #17. CNA-C verified resident #17 only had a boot to the right heel, and no boot was present for the left heel. CNA-C checked the CNA reference sheet and verified the reference sheet did not include any direction for use of gel boots or any special repositioning efforts. Surveyor # observed CNA-C provide assistance with morning cares for resident #17. The surveyor observed pink scar tissue present to the resident's right buttock area. On [DATE] at 12:25 p.m. surveyor # interviewed RN-A regarding resident #17. RN-A verified the plan of care directed staff to utilize blue gel boots to both of the resident's feet and to elevate the resident's feet off of the bed's surface. RN-A was not aware resident #17 was not utilizing a boot to the left foot. RN-A checked the CNA reference sheet, which was utilized by the CNAs daily. The RN verified the reference sheet did not include directions for the use of gel boots or any specialized repositioning efforts. RN-A verified resident #17's risk for skin breakdown increased at the time she had a [MEDICAL CONDITION] of the right leg with resulting bed rest for five days. RN-A verified no risk assessment had been completed to reflect the increased risk or revisions to the plan of care for prevention of skin breakdown. RN-A verified the plan of care was revised on [DATE] to include the use of the boots and elevation of the heels. RN-A stated it was the facility's practice to elevate all residents' heels while the residents were in bed. The RN was not able to explain why, if that was the standard already implemented, it was added to the plan of care for resident #17 on [DATE]. RN-A verified the plan did not include any changes following the development and re-occurrence of a stage II pressure ulcer to the right buttock. RN-A verified resident #17's repositioning schedule had not been modified, and the resident remained on the same support surfaces as prior to the breakdown. On [DATE] at 12:55 p.m. surveyor # interviewed CNA-E regarding resident #17. CNA-E stated the resident was only able to make slight changes in position independently and required extensive staff assistance for position changes. CNA-E stated even prior to the [MEDICAL CONDITION], resident #17 required extensive staff assistance. CNA-E stated resident #17 received repositioning every two hours currently and prior to skin breakdown. On [DATE] at 1:00 p.m. surveyor # interviewed CNA-F regarding resident #17. CNA-F stated resident #17 required extensive staff assistance with bed mobility currently and prior to the [MEDICAL CONDITION]. CNA-F stated resident #17 was not physically able to independently reposition herself and would not remember to do so if she were able. CNA-F stated she was not aware of any changes to the plan of care at the time the bed rest was implemented. CNA-F stated resident #17 had always been on a two hour repositioning program and was not aware of any changes. CNA-F verified after the development of the pressure ulcer to the heel, a gel boot was implemented to the right foot and a total lift was utilized. CNA-F was not aware of any other changes. On [DATE] at 1:14 p.m. RN-A informed surveyor # the facility policy was to complete Braden risk assessments quarterly. RN-A verified resident #17 had not had a Braden risk assessment completed since [DATE]. RN-A verified the plan of care for resident #17 did not address the risk for skin breakdown when the resident was placed on bed rest on [DATE]. On [DATE] at 2:20 p.m. surveyor # observed resident #17 while the resident was in her bed. Resident #17 only had a blue gel boot to the right foot, and both feet were not elevated off of the mattress. Although a pillow was in place under the legs, the pillow did not elevate the feet enough to keep the heels off the bed's surface. 2. The face sheet, dated [DATE] and contained within the medical record, indicated resident #10 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The admission skin assessment, dated [DATE], documented no pressure ulcers. Interventions for skin risk listed on the assessment included: -daily skin inspection -w/c (wheelchair) cushion -Comfortex-special mattress -increased fluids -proper fitting shoes -proper fitting chair -wrinkle free bed linens. The interventions did not include the use of gel boots, repositioning program or heel elevation. The comprehensive physical assessment, dated [DATE], documented an absence of the left pedal pulse. The Braden scale, completed on [DATE], documented a score of 14, which indicated moderate risk for the development of pressure ulcers. The undated "Resident Care Requirements" documented resident #10 had abrasions, but did not indicate pressure ulcers on admission or a preventative skin care program. The [DATE] TAR (Treatment Administration Record) for resident #10 included a nursing order, dated [DATE], to monitor an intact blister to the left heel, heels up off mattress, continue until resolved. The integrated notes, dated [DATE] at 3:30 a.m., documented an intact blood blister to resident #10's left heel measuring 1.5 by 0.5 (centimeters). The note indicated the physician was faxed regarding the heel blister. On [DATE] the physician returned the fax regarding the blister to the left heel and documented, "Noted. Keep pressure off heel at rest." On [DATE] at 1:15 p.m. the integrated notes documented the blister to the resident's left heel opened. The note indicated the blister measured 3 cm by 3 cm, no shoes to the left foot, and the physician was faxed. On [DATE] the physician provided treatment orders that included triple antibiotic ointment to the left heel wrapped with gauze. The TAR was updated with the following order: "L (left) heel open area, cleanse, TAO (Triple Antibiotic Ointment), gauze til healed", and the nursing order of [DATE] (as noted above) to elevate the resident's heels off the mattress was discontinued. Although the facility implemented no shoes to the left foot, no other changes were made to the plan of care for resident #10. The intervention of elevating heels off the mattress had been discontinued on the TAR as of [DATE]. The plan of care for resident #10 did not include the intervention of elevating the heels off the mattress. The facility completed an admission MDS with a reference date of [DATE] for resident #10. The MDS documented the resident had severely impaired cognitive skills, required extensive staff assistance of two for bed mobility and transfers, was frequently incontinent of bowel and bladder, was at risk for pressure ulcer development, and had one unhealed stage II pressure ulcer. The CAA was triggered for pressure ulcers. The CAA documentation did not include a thorough assessment of the resident using the care area-specific resources and analysis of the findings in the context of their relationship to the care area. The CAA did not draw conclusions about the causal/contributing factors and description of the problem or risk factors related to the care area. The CAA did not include any documentation whether referral to other disciplines was warranted and did not document whether a care plan would be developed, including the reason why or why not. Section V of the MDS indicated a check mark that pressure ulcers were addressed in the care plan, but no further documentation was present regarding pressure ulcers. The CAA did not further evaluate appropriate risk factors, so that an appropriate care plan could be developed as directed by the RAI manual. On [DATE] at 10:30 a.m. the integrated notes documented, "...(Right) heel has deep purple area on heel...lotion applied...applied slippers...bilateral no shoes...". On [DATE] the facility received a return fax from the physician with orders that included a podiatry consult. The podiatry consult was not completed. During an interview with surveyor # on [DATE] at 1:05 p.m., RN-G stated no podiatry consult was completed for resident #10. RN-G stated the consult was not completed on [DATE] due to an elevated INR (International Normalized Ratio) (bleeding time). Resident #10's medical record noted labs on [DATE], [DATE] and [DATE] indicated the resident had elevated INRs. Subsequent INRs completed on [DATE], [DATE] and [DATE] were noted to be within therapeutic range (,[DATE]). The medical record did not document any further assessment or description of resident #10's right heel from [DATE] to [DATE]. A physician progress notes [REDACTED]. On [DATE] the physician orders [REDACTED]. -cleanse B/L (bilateral) heels daily with saline -[MEDICATION NAME] to the right heel covered with [MEDICATION NAME] and gauze kling MWF (Monday, Wednesday and Friday) -left heel: [MEDICATION NAME] to periphery of ulcer/isosorb gel followed by [MEDICATION NAME] and gauze, and kling wrap, MWF -suspension of B/L heels at bedtime -elevation B/L heels at rest. The TAR was updated to include the orders, and the elevation of the heels was re-implemented on [DATE]. The care plan for resident #10, dated [DATE], documented an alteration in skin integrity related to pressure ulcer of the left heel. Interventions included treatments as ordered, assess wound daily, body/skin audit at least weekly, heels up on pillows when in bed, apply heel guards as necessary, COP (Change of Position) every two hours in bed and as needed, maintain good body alignment with weight distributed evenly, observe for any signs and symptoms of infection, provide pressure relieving equipment: w/c gel cushion, comfortex mattress, report any red or open areas. The plan of care did not address the condition of the right heel. On [DATE] the integrated notes documented a discussion with resident #10's daughter regarding the resident's status and a possible Hospice referral. The note indicated the daughter wanted to speak to her brother before proceeding with the Hospice referral. No evaluation of the left or right heel wounds were completed/documented from [DATE] to [DATE]. On [DATE] the facility received physician orders [REDACTED]. Although treatment changes were obtained, no wound assessments were documented. The new treatment ordered on [DATE] was not documented on the TAR as completed until [DATE]. The weekly wound documentation, dated [DATE], indicted the left heel was a stage II pressure ulcer. The wound measured 3 cm by 2.5 cm and the depth was documented as superficial. The TAR for [DATE] did not contain documentation that the treatments to the left and right heels were completed as ordered from [DATE] to [DATE]. The weekly wound documentation record noted the following assessments of the left heel: [DATE] - not staged - 2.5 cm by 2.3 cm with a depth of 4 mm (millimeters). On [DATE] the integrated notes documented a 1 cm by 1 cm open area on the back of the resident's left lower leg. The weekly wound documentation form indicated the wound was a pressure ulcer that was unstageable. The wound documentation on [DATE] indicated the wound was 2.1 cm by 1.5 cm with a depth of 0.2 cm, and the wound was not staged. Although a treatment to the ulcer was initiated, no changes were made to the plan of care to prevent further breakdown for resident #10. On [DATE] at 7:20 p.m. the integrated notes documented the left heel wound had a foul smell and bloody drainage. The physician was contacted and ordered an antibiotic, and a culture of the would was obtained. The wound culture, dated [DATE], documented heavy growth of gram negative bacilli. On [DATE] the weekly wound documentation form documented two stage II pressure ulcers on the resident's left buttock. The integrated notes, dated [DATE], documented the areas to measure 0.6 by 0.3 cm on the left side and 0.6 by 0.5 cm on the right side. The integrated notes also documented the resident's left heel to have a foul smell with dressing change, was approximately 75% necrotic tissue and measured 3 by 3 by 0.3 cm depth. Although the nurse practitioner was updated regarding resident #10's declining condition, including the two new open areas, no treatment to the area was implemented; and the plan of care was not revised. On [DATE] at 10:35 a.m. surveyor # interviewed NP (Nurse Practitioner)-M regarding resident #10. NP-M verified she was informed of the multiple open areas on [DATE]. NP-M stated at that point she was more concerned with resident #10's overall condition decline, and the family was in the process of considering Hospice services. NP-M stated no specific treatment was ordered to the new open areas. The integrated notes, dated [DATE] at 12:05 p.m., documented the two stage II ulcers to the resident's left upper buttock and just left of the coccyx. The ulcers measured 1.5 by 1.5 cm and 2 by 1.5 cm respectively. The note indicated Hospice had been informed. On [DATE] a chest x-ray was completed, and the physician orders [REDACTED]. Resident #10 signed onto Hospice care as of [DATE]. On [DATE] at 8:52 a.m. surveyor # interviewed LPN-K regarding resident #10. LPN-K indicated if a resident required the use of a prevention device, like gel boots or heel elevation, that intervention should be documented on the care plan. LPN-K could not recall if resident #10 was provided with heel elevation on admission. On [DATE] at 9:00 a.m. surveyor # interviewed LPN-J regarding resident #10. LPN-J verified the admission interventions, dated [DATE], did not include any interventions specific to repositioning or heel protection. LPN-J verified the care plan, dated [DATE], indicated the use of heel guards and heel elevation. LPN-J stated it was usually general practice for the facility to elevate the heels of anyone who required staff assistance for mobility, but the LPN could not verify that had been completed for resident #10. On [DATE] at 9:05 a.m. surveyor # observed CNA-H and CNA-I provide care to resident #10. During the observation, resident #10 had blue gel boots on both feet, and dressings were intact to both heels. Two stage II pressure ulcers were observed to resident #10's left buttock. During the observation, the wounds were cleansed with soap and water, but no further treatment was provided (i.e. barrier cream or other treatment). CNA-H and CNA-I indicated they thought the nurse may provide a treatment. On [DATE] at 10:03 a.m. surveyor # interviewed LPN-J regarding treatment for [REDACTED]. LPN-J stated she thought the CNAs were applying soothe and cool (a barrier cream) to the area, but was not sure. On [DATE] at 12:20 p.m. surveyor # interviewed CNA-L regarding resident #10. CNA-L stated as far as she could recall, resident #10 did not have any specific interventions for protection of his heels on admission. CNA-L indicated resident #10 was provided gel boots and staff were to ensure his heels were elevated off of the mattress after the pressure ulcer developed. On [DATE] at 12:27 p.m. surveyor # interviewed CNA-O regarding resident #10. CNA-O stated it was her practice to elevate the heels of any resident who was dependent on staff for mobility. CNA-O stated the care plan should direct if the heels should be elevated or if the resident required the use of boots. CNA-O was unsure when those interventions were implemented for resident #10, but stated the resident had been on an every-two-hour repositioning program since admission. On [DATE] at 3:05 p.m. surveyor # interviewed CNA-N regarding resident #10. CNA-N verified that, from the time of admission, resident #10 was dependent on staff for mobility, including bed mobility. CNA-N was not aware of any changes to the repositioning plan of care for resident #10. CNA-N indicated he thought resident #10 had been admitted to the facility with the pressure ulcer to the heel and thought the boots had been implemented almost from the time of admission, but the CNA was not completely sure. On [DATE] at 10:55 a.m. surveyor # interviewed RN-G regarding resident #10. RN-G stated the facility TAR is part of the plan of care; therefore, some of the interventions documented on the TAR were not included on the actual plan of care document. RN-G verified the first documented assessment of resident #10's left heel ulcer was noted on [DATE]. RN-G verified the treatment sheet was updated to include elevation of the heels at that time. RN-G verified the treatment sheet noted the intervention of heel elevation was discontinued when new treatment orders were obtained on [DATE]. RN-G stated although discontinued on the treatment sheet, and not noted on the care plan, that did not mean heel elevation was not continued. RN-G verified the record documented a deep purple area to the right heel on [DATE], and subsequent treatments were completed to the area. RN-G verified the medical record did not contain any further assessment or documentation regarding the status of the right heel. RN-G verified she completed the documentation in the integrated notes on [DATE] at 10:45 a.m. The RN indicated if she would have evaluated the right heel at that time, she would have documented her assessment. (Note the integrated notes on [DATE] at 10:45 a.m. did not address any assessment of resident #10's right heel.) RN-G was not able to provide any description of the right heel condition. RN-G stated the area should have been assessed weekly. RN-G verified on [DATE] the intervention of elevating the heels was re-implemented on the TAR. RN-G verified the TAR did not document the physician ordered treatment to resident #10's right and left heels was completed on [DATE] and [DATE], and again from [DATE] to [DATE]. RN-G verified it was the facility policy to assess and document on the status of all wounds weekly. RN-G verified the ulcer on resident #10's left calf area, noted on [DATE], was a pressure ulcer resulting from friction and/or shearing. RN-G verified no changes were made to the plan of care other than a treatment to the ulcer. RN-G stated there were already interventions in place; therefore, no changes were needed. RN-G verified resident #10 continued to have an every-two-hour repositioning plan, despite the continued decline in condition and development of additional ulcers. RN-G verified no treatment orders were obtained for the buttocks ulcers noted on [DATE]. RN-G verified resident #10 elected Hospice services as of [DATE]. The resident expired on [DATE]. On [DATE] at 1:05 p.m. RN-G verified to surveyor # no changes had been made to resident #10's support surface (i.e.. mattress, wheel chair cushion) throughout his stay. 3. Resident #4's admission face sheet, dated [DATE], indicated the resident had [DIAGNOSES REDACTED].