Every finding on record at Golden Years of Lake Geneva

Based on record review and interviews, the facility failed to ensure one of five residents (Resident (R) 1) reviewed received his pain medications as ordered creating the potential for increased discomfort. Findings include: Review of the facility's 2024 policy titled, Pain Assessment and management revealed The care team will respect and support every patient's right to optimal pain relief through education, initial and ongoing assessment, and effective and appropriate pain management. Review of the Face Sheet located under the Demographics tab in the electronic medical record (EMR) revealed R1 was admitted on [DATE] with diagnoses including unilateral primary osteoarthritis, left knee; open wound of lower back and pelvis without penetration into retroperitoneum; non-pressure chronic ulcer of other part of right foot limited to breakdown of skin. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/06/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact. Review of the October 2024 Physician Orders located under the Orders tab in the EMR noted R1 had an order for pregabalin -Schedule V (controlled substance) capsule; 25 mg (milligram); amt (amount): 25 mg/1capsule; oral Once A Day AM with a Start Date of 10/02/24. Review of the Informed Consent for Medication, form, located in the Documents tab in the EMR, dated 10/01/24, was signed by R1 and a facility nurse. The form identified the medication, for consent, as Pregabalin for pain. Review of the October 2024 Medication Administration Orders (MARS) provided by the Director of Nursing (DON), revealed from 10/03/24 through 10/15/24, that the Pregabalin was not administered with the reason noted as not administered: drug/item unavailable. The MAR did not identify why the medication was not administered on 10/02/24. Review of the Progress Notes located under the Resident tab in the EMR, dated 10/16/24, Script sent for Pregabalin to (Pharmacy). Pharmacy Query completed. The notation was written by the Nurse Practitioner. During an interview on 01/08/25 at 11:45 AM, the family of R1 (F1) said the resident could have been much more comfortable. F1 stated, I was told they ran out of the Pregabalin, for his pain, and didn't get it reordered. During an interview, on 01/09/25 at 3:20 PM, with R1's Nurse Practitioner (NP), also the facility DON, the NP stated, I am in the building Monday-Friday and see the majority of the residents. I saw R1 almost every day because of his care needs. When (F1) asked about the Pregabalin, that he was used to taking at home, I sent a script. I don't know what happened with the escribe (electronic prescription) order. In our state, narcotic prescriptions have to go directly to the pharmacy. The DON/NP said she was not informed by the nurses that the Pregabalin was unavailable. In an interview on 01/09/25 at 5:00 PM, neither the Administrator nor the DON/NP said they had a policy regarding escribes to ensure all medications are ordered as intended.

Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150 B of the Act for 1 (R11) of 1 residents reviewed for an allegation of a crime. R11 alleged facility staff forced her to take a shower and slammed her into the wall. R11's allegation of abuse was not reported timely to local law enforcement. Findings include: R11 was admitted to the facility on [DATE] with diagnosis that included Anxiety disorder. R11's quarterly MDS (minimum data set) dated 1/15/24 indicates R11 was assessed as having a Brief Interview for Mental Status score of 13 which indicates R11 is cognitively intact. On 2/7/24, at 9:37 AM, R11 was interviewed by this Surveyor and reported a few days ago she was forced to take a shower against her will and was slammed into the wall. R11 indicated she would like the allegation reported right away and taken care of. On 2/7/24, at 9:45 AM, this Surveyor reported R11's allegation to Nursing Home Administrator-A and Director of Nurses-B. On 2/6/24, R11's progress notes were reviewed and the following was written by Licensed Practical Nurse (LPN)-F on 2/2/24, at 10:00 PM: Writer called to room tonight due to resident (R11)refusing shower or bed bath. Upon entrance, resident notably soiled the bed and required a full bed strip and shower. Resident (R11) agitated and stated there is no need for a shower and just needed clean sheets. Writer re-educated the importance of clean hygiene and proper peri (perennial) care to prevent infection, and that cleaning of the mattress and new bed sheets were required. Resident (R11) then agreed to transfer to shower chair. Per Certified Nursing Assistant (CNA), resident (R11) stated towards the end of the shower that she will report the CNA due to giving her a shower against her will. After being told that resident (R11) was going to report CNA, writer went to check on resident, but sleeping sound. The facility self report dated 2/6/24 indicates R11 remembered CNA in training-D giving her the shower but did not remember who else was helping. R11 indicated she was not harmed and no other incident like this had ever happened to her before. The Facility interview with R11 did not contain any statements about the shower itself, how she was forced to shower or her refusal to shower. The report indicated the other staff that assisted with the shower was Hospitality Aide (HA)-E. On 2/7/24, Nursing Home Administrator (NHA)-A provided this Surveyor with a copy of the completed facility investigation. The Surveyor asked if the police had been notified of the allegation of abuse. NHA-A indicated the police had not been called because they didn't believe the reported incident happened. NHA-A then notified the police more then 24 hours after the allegation was made to the Surveyor. On 2/7/24, the Facility's Policy titled Resident Protection Policy dated 12/20 was reviewed and read: All alleged violations involving mistreatment, exploitation, neglect or abuse are reported immediately to to the Administrator and Office of Caregiver Quality. Immediately means as soon as possible, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. The local law enforcement entity and adult protective services will be notified in addition when there is a reasonable suspicion of a crime as defined by law. The above findings were shared with the Nursing Home Administrator and DON-B on 2/7/24 at 3:00 PM at the daily exit meeting. Additional information was requested if available. None was provided.

Based on interview & record review, the Facility did not ensure that 1 (R11) of 1 resident alleged incidents of physical abuse was thoroughly investigated, and the results of the investigation reported to the State Agency. R11 alleged staff forced her to take a shower and slammed her into the wall. The allegation was not thoroughly investigated as all staff involved were not interviewed, a physical assessment was not completed for injuries and other residents were not interviewed to see if they had similar concerns. Findings include: R11 was admitted to the facility on [DATE] with diagnosis that included Anxiety disorder. R11's quarterly MDS (minimum data set) dated 1/15/24 indicate R11 was assessed as having a Brief Interview for Mental Status score of 13 which indicates R11 is cognitively intact. On 2/7/24, at 9:37 AM, Surveyor interviewed R11 who indicated a few days ago she was forced to take a shower against her will and was slammed into the wall. R11 indicated she would like the allegation reported right away and taken care of. On 2/7/24 at 9:45 AM the allegation from R11 was reported to the Nursing Home Administrator-A and Director of Nurses-B. On 2/6/24, R11's progress notes were reviewed and the following was written by Licensed Practical Nurse (LPN)-F on 2/2/24, at 10:00 PM, Writer called to room tonight due to resident (R11)refusing shower or bed bath. Upon entrance, resident notably soiled the bed and required a full bed strip and shower. Resident (R11) agitated and stated there is no need for a shower and just needed clean sheets. Writer re-educated the importance of clean hygiene and proper peri (perennial) care to prevent infection, and that cleaning of the mattress and new bed sheets were required. Resident (R11) then agreed to transfer to shower chair. Per Certified Nursing Assistant (CNA), resident (R11) stated towards the end of the shower that she will report the CNA due to giving her a shower against her will. After being told that resident (R11) was going to report CNA, writer went to check on resident, but sleeping sound. The Facility Reported Incident (FRI) investigation dated 2/6/24 indicates R11 remembered CNA in training-D giving her the shower but did not remember who else was helping. R11 indicated she was not harmed and no other incidents like this had ever happened to her before. The interview with R11 did not contain any statement about the shower itself, how she was forced or her refusal. The report indicated the other staff that helped with the shower was Hospitality Aide (HA)-E. No statement from HA-E was completed, a physical assessment of R 11 for injuries was not completed and no other residents were interviewed to see if they had similar concerns. On 2/8/24, at 10:30 AM, Nursing Home Administrator-A was interviewed and indicated HA-E was not interviewed as part of the investigation and he could not provide any evidence that other residents were interviewed and there is no documentation R11 was assessed for potential injuries. The above findings were shared with Nursing Home Administrator-A and Director of Nursing-B on 2/7/24, at 3:00 PM, at the daily exit meeting. Additional information was requested if available. None was provided.

Based on observation, interview, and record review the Facility did not ensure that 1 (R134) of 1 Residents observed during medication pass with a gastronomy tube (G-tube) receives the appropriate treatment and services. R134's G-tube placement was not checked prior to administering medication via the G-tube. Findings include: R134 was admitted to the facility on [DATE] with diagnosis that included Dysphasia. On 2/7/24, at 7:45 AM, Registered Nurse (RN)-C was observed administering medication to R134. RN-C prepared the medication then flushed R134's gastronomy tube with water. RN-C-then administered R134's medication one at a time flushing the tube with water between each medication and after the administration was complete. Immediately after the observation RN-C was interviewed and indicated it is the facility's policy not to check gastronomy tube placement by any means before administration of medication or feeding formula. On 2/7/24, Surveyor reviewed the Facility's policy and procedure titled: Tube Feeding dated 11/22 which read: Auscultation is no longer recommended for checking placement of the feeding tube, Movement of air would likely be heard whether the tube was in the correct or incorrect location. Residual check for tube placement is also not recommended for individuals who are alert and able to report symptoms that indicate feeding is not well tolerated. On 2/7/24, at 11:00 AM, Director of Nurses (DON)- B was interviewed and indicated it is the facility's policy not to check placement of a gastronomy tube by any means, DON-B indicated they would rely on the resident to tell them something was wrong with their gastronomy tube. DON-B was not able to provide the Surveyor with a standard of practice the Facility's policy was based on. The above information was shared with Nursing Home Administrator-A and DON-B on 2/7/24 at 3:00 PM. Additional information was requested if available. None was provided.

Based on interview and record review the facility did not ensure 1 (R11) of 1 residents reviewed for transfers or therapeutic leave received a written bed hold notice with the specific duration of the bed hold and policy information. Findings include: R11 was transferred to the hospital on 10/24/23 and 12/6/23. R11 and their representative was not provided a written bed hold notice. Findings include: R11 was admitted to the facility on [DATE]. On 2/7/24, the Surveyor reviewed R11's medical record and it indicated R11 was transferred to the hospital on 10/24/23 and 12/6/23. The resident's medical record did not include documentation that a bed hold notice had been given to the resident and their representative for the hospitalization s. On 2/8/24, at 10:06 AM, the Surveyor interviewed Director of Nurses (DON)-B who indicated they could not find a bed hold notice for R11's transfers to the hospital on 10/24/23 and 12/6/23. On 2/8/24, this Surveyor reviewed the Facility's policy titled Bed Hold Policy dated 7/17 which read: Residents will be provided with bed-hold policy and reiteration of the duration of bed-hold at time of transfer to the hospital. On 2/8/24 at 11:00 AM the above findings were shared with Nursing Home Administrator-A and Director of Nurses-B. Additional information was requested if available. None was provided.

Based on interview and record review, the facility did not ensure 1 (R11) of 1 sampled residents reviewed for a facility initiated discharge received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. R11 was transferred to the hospital on 10/24/23 and 12/6/23. R11 and their representative was not provided a written notice of transfer. Findings include: R11 was admitted to the facility on [DATE]. On 2/7/24, the Surveyor reviewed R11's medical record which indicated R11 was transferred to the hospital on 10/24/23 and 12/6/23. The resident's medical record did not include documentation that a transfer notice had been given to the resident and/or their representative related to the hospitalization . On 2/8/24, at 10:06 AM, the Surveyor interviewed Director of Nurses (DON)-B who indicated they could not find a written transfer notice for R11's transfers to the hospital on 10/24/23 and 12/6/23. On 2/8/24, the Facility's policy titled Transfer and Discharge from the Facility dated 8/17 was reviewed and read: If the facility initiates transfer the facility will provide the resident and resident's representative with notice of transfer or discharge. On 2/8/24, at 11:00 AM, the above findings were shared with Nursing Home Administrator-A and Director of Nurses-B. Additional information was requested if available. None was provided.

Based on interview, observation and record review, the facility did not ensure that a resident with a deep tissue injury receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new deep tissue injuries from developing for 1 (R6) of 4 residents reviewed for pressure injuries. R6 developed a deep tissue injury and the facility did not implement an intervention put in place to promote healing. Findings include: The facility policy, entitled Pressure Ulcer Treatment, dated 2020, states: A. To promote tissue healing. B. To prevent further tissue breakdown by relieving pressure, reducing friction and shear, correcting or containing incontinence, improving nutritional status, and educating resident and/or significant other. C. Follow established treatment program focused on assessment of resident and pressure ulcer. Section B: Plan: 1. Reduce or eliminate causative factors: pressure, shear, friction, moisture, circulatory impairment, and neuropathy. Section C: Interventions: 1. Management of tissue loads (pressure relief, friction, shear, and moisture) d). Use devices such as pillows and foam wedge to prevent direct contact between bony prominence's. R6 was admitted to the facility on [DATE] with the following diagnoses: Dementia, Non-Hodgkin lymphoma, Malignant neoplasm of unspecified site of right female breast, Arthritis, Parkinson's disease and Neuralgia and neuritis, unspecified of bilateral feet. R6's Significant Change in Status MDS (Minimum Data Set) dated 10/21/22, indicated that R6 has a BIMS (Brief Inventory of Mental Status) score of 2 indicating severe cognitive impairment. MDS also indicated R6 requires extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. MDS indicated R6 is at risk for developing pressure ulcers/injuries and currently has one unhealed unstageable pressure injury presenting as deep tissue injury. Skin treatment indicated are: pressure reducing device for chair, pressure reducing device for bed, pressure ulcer/injury care and applications of ointments/medications other than to feet. On 10/14/22 the Norton Scale was completed. The assessment indicated a score of 13 which indicates R6 is at risk for skin breakdown. On 10/19/22, at 16:00, the facility documented the following progress note for R6: Resident has new deep tissue injury to the distal end of her right great toe (1 x 1 cm). Likely caused by pushing toes into the bar on her wheelchair footrest. Pillow placed on footrest and toe padded with gauze and secured with hipafix tape. Hospice and daughter notified. Will continue to monitor. The facility documented the following physician orders for R6: 10/19/2022, Measure pressure wound to right great toe: Document weekly assessment in Wound Management Tool. Notify MD (Medical Doctor) if decline, and update Care Plan if necessary. 10/19/22, Treatment to pressure wound to right great toe: Flush w/NS (normal saline), apply skin prep and cover with gauze, secure with Hipafix tape. Change Tues/Thurs/Sat and PRN (as needed). 10/19/22, Pressure wound to right great toe: Monitor injury q (each) shift for s/s (signs/symptoms) of infection or worsening condition. Notify MD if decline. R6's Care Plan titled, I know that my skin is at higher risk for breakdown, dated 10/20/22 included interventions: Make sure I have a pillow on the footrest of my Brota (sic) chair to prevent pressure to my toes R6's Care Plan titled, Resident has a pressure injury to right great toe, dated 11/6/22 included interventions: Make sure I have a pillow on the foot of my Brota (sic) chair so that I cannot press my toes into the bar at the front, make sure the blankets are tented over my toes when I am in bed, assess and record the condition of the skin surrounding the pressure ulcer, assess the pressure ulcer for location, stage, size, presence/absence of granulation tissue and epithelization weekly. Review of the Individual Care Plan Worksheet documents the following supportive device: pillows on footrest. Weekly wound rounds were completed on 10/19/22, 10/25/22, 11/1/11, and 11/8/22 by the ADON-D (Assistant Director of Nursing). On 10/19/22 the unstageable deep tissue injury measures 1x1 with a comment documenting the following: The DTI (Deep Tissue Injury) likely caused by resident pressing toes of her feet into the bar on her Brota (sic) chair footrest. A pillow will be kept in place at all times to prevent this from happening, and to allow for healing. On 11/09/22, at 08:06 AM, Surveyor observed R6 sitting upright in a Broda chair by the front desk wearing an enclosed gray tennis shoes with pink laces. R6's feet were dangling with no supportive footrest in place below the feet. No observation of pillow present. On 11/09/22, at 8:44 AM, Surveyor observed R6 in the dining room eating breakfast. Staff is present and assisting R6 with breakfast. R6 is wearing enclosed gray tennis shoes with pink laces and feet are resting directly on footrest of Broda chair. No observation of pillow present. On 11/09/22, at 11:10 AM, Surveyor observed R6 sitting in Broda chair by the front desk. R6 is asleep with her feet slightly elevated. R6 is wearing enclosed gray tennis shoes with pink laces. No observation of pillow present. On 11/09/22, at 11:14 AM, Surveyor interviewed CNA-E (Certified Nursing Assistant) and asked what interventions were in place for R6 for the deep tissue injury. CNA-E informed Surveyor that they are not putting shoes on because they are bandaging the toe. When asked what type of shoe R6 should be wearing CNA-E stated, open toe sandals are okay to wear. Surveyor asked CNA-E if a pillow should be utilized. CNA-E informed Surveyor that they remove the pillow when R6 is eating meals but use the pillow when R6 is laying down. On 11/09/22, at 11:22 AM, Surveyor interviewed RN-F (Registered Nurse) about the current treatments for R6 and the DTI. RN-F informed Surveyor that they are flushing the injury with saline, applying a skin prep and then gauze. Surveyor asked what type of footwear R6 should be wearing. RN-F stated R6 should be wearing sock and no shoes. R6 is not mobile and does not need shoes. R6 should have a pillow under feet and feet should not be touching the footrest. On 11/09/22, at 11:27 AM, Surveyor interviewed RN-G and asked about current treatments for R6 and the DTI. RN-G informed Surveyor that R6 should be wearing slippers and socks and no shoes. They are changing and cleansing the injury with saline, skin prep and gauze. When Surveyor asked if a closed toe tennis shoe should be worn RN-G stated, No a sneaker would put pressure on the toes. RN-G informed Surveyor that slippers or socks should be worn and pillows used anytime R6 is in the Broda chair to float feet off bottom of leg rest. On 11/09/22, at 11:41 AM, Surveyor interviewed ADON-D. Surveyor asked ADON-D what interventions are in place for R6 and the DTI. ADON-D explained that the main issues with R6 is her atrial fibrillation which cause R6 to have a lot of tension during the episodes. What they think happened is that when R6 is tense, R6 shoves her toes into the bar on the footrest of the Broda chair. That is why we have the pillow on R6's footrest. R6 wear sandals during the day and when in bed they tent foot area. Surveyor clarified if a pillow should be used when R6 is in the Broda chair. ADON-D stated yes. Surveyor asked ADON-D what type of footwear R6 should be wearing. ADON-D informed Surveyor that there is gauze over the toe therefore R6 is just wearing sandals. Surveyor asked ADON-D if staff are aware that R6 should be wearing sandals and how that would be communicated. ADON-D informed Surveyor that she did not have it care planned. ADON-D stated that the information would have only been verbally communicated to the CNAs. On 11/09/22, at 12:32 PM, the DON-B (Director of Nursing) and ADON-D came and provided documentation requested. DON-B pointed out that in the wound care note 10/19/22 documents that a pillow will be used when in Broda chair. Use of pillow is also care planned. Surveyor asked how they were addressing pressure to the toes and ADON-D stated that R6 should be wearing sandals however she did just check and there is one pair of gym shoe that appear large enough that it should not cause additional pressure to the toes. Surveyor asked if the tennis shoes were assessed prior to now and ADON-D stated no. On 11/10/22, at 12:08 PM, Surveyor informed DON-B of the above findings. No additional information presented at the time.

Based on observation, interview, and record review the Facility did not ensure that 1 (R19) of 1 Residents observed during medication pass with a gastrostomy tube (G-tube) receives the appropriate treatment and services. R19's G-tube placement was not checked prior to administering medication via the G-tube. Findings include: R19 was admitted to the facility on [DATE] with diagnosis that included Cancer of the tonsils and thyroid gland as well as Dysphasia On 11/10/22 the facilities policy and procedure titled Tube Feeding dated 2018 was reviewed and read: Assess tube placement by aspirating stomach contents. The policy does not say how often placement should be checked. On 11/9/22 at 11:37 AM the surveyor observed Registered Nurse (RN)-G administer medication to R19's G-tube. RN-G flushed R19's G-Tube to which no tube feeding was running prior and then administered 50 milligrams of liquid Vancomycin via R19's G-tube. RN-G then flushed R19's G-Tube with more water and hooked her up to her feeding pump. RN-G did not check placement of R19's G-tube at any time during the observation. On 11/10/22 at 9:30 AM Director of Nurses (DON)-B was interviewed and indicated she was unaware when a G-tube's placement should be checked. The surveyor made her aware that the facility's policy did not indicate how often a G-tube placement check should be done but simply indicated it should be done. DON-B indicated she would look into it but had no knowledge of frequency at that time. On 11/10/22 R19's medical record was reviewed and no information on how often placement of her G-tube should be checked could be found. The above information was shared with the Administrator and DON on 11/10/22 at 10:30 AM. Additional information was requested if available. None was provided.

Based on observation, record review and staff interview, the facility did not ensure residents received their medications. This was discovered with 2 (R3 and R16) of 4 residents that did not receive their medication as ordered. R3 and R4 had medications that were not administered to them as ordered. Findings include: The facility's policy and procedure for Medications, dated 1/2018, was reviewed by Surveyor. The procedure includes: Identify resident by name before administration and observe that all medications are taken. 1.) R3's medical record was reviewed. The Progress Note on 11/01/2022 at 5:40 AM indicates the Writer found a cup of medications in resident medication cabinet containing the following: - one acetaminophen 325 mg(milligram) tablet - two Seroquel 25 mg tabs - one 2 mg loperamide tab - one 5-325 mg Norco The DON-B (Director of Nurses) was notified. R3 takes these medications twice a day and therefore hard to determine which shift the error occurred on. R3 was admitted on Hospice care on 5/8/22 for Dementia. R3 has an activated POA (Power of Attorney). R3 had a Quarterly Minimum Data Set (MDS) assessment on 9/2/22 which indicates severe cognitive impairment. R3 has no self-administer of medication assessment. The MD was notified via fax on 11/3/22 regarding the missed medication. There was no new orders. The POA was notified on 11/3/22 of the missed medications. On 11/09/22 at 9:40 AM Surveyor spoke with the DON-B (Director of Nurses). The DON-B talked to Nurses that were working that day the medications were found. DON-B emailed all the Nurses and informed them not to not leave the medications in the rooms. R3 had no effects from not having medication. The MD (Medical Doctor) and POA were notified on 11/3/22 of the missed medication and there were no new orders or effects. On 11/8/22 at 3:00 PM at the facility Exit Meeting Surveyor shared the concerns with R3's medications. 22692 2.) R16 was admitted to the facility on [DATE] with diagnosis that included Congestive Heart Failure. R16's most recent Quarterly Minimum Data Set (MDS) dated [DATE] indicated R16 and a Brief Score for Metal Status of a 9 indicating moderate cognitive impairment. On 11/9/22 at 8:39 AM the surveyor observed Registered Nurse (RN)-G administer medication to R16. RN-G placed Sertraline 200 milligrams (MG), Myrbetriq 25mg, Miododrine 2.5 mg, Loratadine 10mg, Gabapentin 300mg, aspirin 81mg, and Acyclovir 400mg into a medication cup and placed them next to R16's plate in the dining room. RN-G then left the dining room indicating R16 will take them by herself. On 11/9/22 R16's medical record was reviewed and no assessment indicating she could safely administer her own medication was found. On 11/10/22 at 10:00 AM Director of Nurses-B was interviewed and indicated that R16 should be observed to take her medication and it should not be left to take on her own. The above findings were shared with the Administrator and DON on 11/10/22 at 10:30 AM. Additional information was requested if available. None was provided.

Based on record review and staff interview, the facility did not ensure psychotropic PRN (as needed) medication had indications for long term use. This was discovered with 2 (R3 and R2) of 4 residents reviewed for medication. R3 and R2 have received PRN Ativan beyond 14 days without indications for use to continue. Findings include: The facility's policy and procedure for Use of Psychotropic Medications/Psychotropic Medication Reviews, dated 1/2018, was reviewed by Surveyor. The policy indicates: The goal of the facility is to make every effort to practice according to current medical guidelines and best practices related to the use of psychopharmacological medications in the long term care facility, to include regular reviews, continued need, appropriate dosage, side effects and risks and benefits. 1.) R3's medical record was reviewed by Surveyor. R3 was admitted on Hospice care on 5/8/22 for Dementia. R3 has an activated POA (Power of Attorney). R3 had a Quarterly MDS (minimum data set) assessment on 9/2/22 which indicates severe cognitive impairment. The MAR (Medication Record Administration) was reviewed by Surveyor. The PRN (as needed) Ativan was ordered on 5/27/22. R3's physician order date of 5/27/22 indicates: Ativan 0.5 mg 1-2 tabs every 2 hours as needed for anxiety. There is no stop date. The May MAR indicates R3 received Ativan on 5/29/22. The June MAR had no administrations. The July MAR indicates the Ativan was administered on the 16th and twice on the 17th. The August MAR indicates no administration. The September MAR indicates Ativan was administrated on the 2nd. The October MAR indicates Ativan was administered the 21st, 25th and 31st. The November MAR indicates the Ativan PRN order was discontinued on 11/9/22. There is a new order that started on 11/9/22 with a stop date of 1/20/23. On 11/09/22 at 9:40 AM Surveyor spoke with DON-B (Director of Nurses) and requested additional information related to R3 Ativan PRN medication. DON-B indicated they will look into it. On 11/9/22 at 3:00 PM at the facility Exit Meeting Surveyor shared the concerns with R3's Ativan order. On 11/10/22 08:44 AM Surveyor spoke with DON-B. They contacted R3's Hospice Nurse and they obtained a new Ativan order with a stop date. There was not a physician or practitioner that assessed R3 with this new order. 2). R2 was admitted to the facility on [DATE] with diagnoses that include, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2 started hospice on 7/25/22. R2's Quarterly MDS (Minimum Data Set) dated 10/21/22 documents a BIMS (Brief Inventory of Mental Status) of 4 which indicates that R2 is severely cognitively impaired. Review of R2's medical record documents a physician order dated 7/25/22 that reads, Ativan/Lorazepam Tablet 0.5mg (milligrams) Give 0.5mg (1 tablet) every 2 hours as needed for anxiety or terminal restlessness with a start date of 7/25/22 and end date, open ended. R2's MAR (Medication Administration Record) dated 8/1/22 - 8/31/22 documents that R2 received Ativan/Lorazepam Tablet 0.5mg (milligrams) Give 0.5mg (1 tablet) every 2 hours as needed for anxiety or terminal restlessness, on 8/8/22, 8/17/22, 8/18/22 and 8/22/22. R2's MAR dated 9/1/22 - 9/30/22 documents that R2 received Ativan/Lorazepam Tablet 0.5mg (milligrams) Give 0.5mg (1 tablet) every 2 hours as needed for anxiety or terminal restlessness, on 9/9/22. On 11/09/22, at 9:40 AM, Surveyor spoke with DON-B (Director of Nurses) and requested additional information related to R2's Ativan PRN medication. DON-B indicated they will look into it. On 11/9/22 R2's new physician order dated 11/9/22 reads, Ativan/Lorazepam Tablet 0.5mg (milligrams) Give 0.5mg (1 tablet) every 2 hours as needed for anxiety or terminal restlessness with a start date of 11/9/22 and end date, 1/13/23. On 11/10/22, at 08:44 AM, Surveyor spoke with DON-B. They contacted R2's Hospice Nurse and they obtained a new Ativan order with a stop date. There was not a physician or practitioner that assessed R2 with this new order. On 11/10/22, at 12:08 PM, Surveyor informed facility DON-B (Director of Nursing) of the above findings. No additional information was provided.

Based on observation, interview and record review the facility did not ensure that it maintained a medication error rate below 5 percent during observations of medication administration affecting 1 (R18) of 5 residents observed. Two medication errors were observed out of thirty-one opportunities, for a total error rate of 6.45%. * R18 was administered Potassium Chloride Extended Release 10 Millequivalents (MEQ) extended release and Sublingual (under the tongue) Vitamin B12 1,000 milligrams (MG) crushed when they should not have been. Findings include: On 11/10/22 the website Drugs.com was reviewed for instructions on how to take Potassium Chloride extended release and read: Do not crush, chew, break, or suck on an extended-release tablet or capsule. Swallow the pill whole. Breaking or crushing the pill may cause too much of the drug to be released at one time. On 11/10/22 the website Drugs.com was reviewed for instructions on how to take sublingual vitamin B12 and read: Place under tongue and let dissolve all the way. Do not chew, suck or swallow tablet. R18 was admitted to the facility on [DATE] with diagnoses that included heart failure and anemia On 11/9/22 at 8:50 a.m. the surveyor observed Registered Nurse (RN)-G administer medication to R18. RN-G prepared R18's medications including Potassium Chloride extended release and Sublingual Vitamin B12 which she crushed and placed separate cups and mixed them with applesauce. RN- G then administered R18's medication to him in the dining room. On 11/9/22 at 9:30 a.m. RN-G was interviewed and asked to look at the medication card for R18's sublingual vitamin B-12. RN-G indicated the medication should have been given sublingual but that she crushed it. The above findings were shared with the Administrator and Director of Nurses on 11/10/22 at 1:00 p.m. Additional information was requested if available. None was provided.

Based on observation, interview and record review, the facility did not ensure residents with pressure injuries were comprehensively assessed to determine appropriate treatment and interventions. This was observed with 2 (R7 and R24) of 3 residents reviewed with pressure injuries. - R7 developed multiple pressure injures that were not comprehensively assessed to determine changes in treatment and interventions. R7's care plan interventions were not revised and R7's physician was not notified when there was a deterioration to the right posterior heel pressure injury. R7 was observed on 9/22/21 and 9/27/21 sitting up in her recliner. R7 was not wearing her prevalon boots as indicated in R7's care planned intervention dated 7/15/21. On 7/8/21, R7 developed a stage 3 pressure injury to the right posterior calf. On 7/22/21 and 7/27/21 the area was identified as a stage 3. On 8/5/21 the area was described as unstageable. On 9/7/21 the area was identified as a stage 3 and remains at a stage 3. RN-C informed surveyor she had not realized the pressure injury had been staged differently. On 7/8/21, R7 developed an unstageable right posterior heel pressure injury. On 7/16/21 it was identified as a stage 2. On 7/22/21 it was identified as unstageable, and then on 9/14/21 and on 9/22/21 the pressure injury was described as having epibole edges. This indicated a decline in the wound healing. There was no physician notification of this decline, nor revision to the care plan. The area is currently unstagable. On 7/15/21 R7 developed an unstageable pressure injury to the left superior heel. On 7/27/21 the left heel was identified as a stage 3. On 8/5/21 the pressure injury to the left heel was unstageable. There was no staging of the pressure injury until 9/14/21 when it was identified as a stage 3. On 7/27/21 R7 developed an unstageable pressure injury to the right posterior ankle. There was no comprehensive assessment from 8/3 to 8/31/21 (27 days). On 8/19/21 a progress note indicates R7 went to a wound clinic however, there are no assessments from the wound clinic. On 8/24/21 the Pressure injury is documented as a stage 3. On 9/10/21, R7 developed a stage 2 pressure injury to his left buttock. The left buttock wound was not comprehensively assessed to determine appropriate treatment and interventions. According to RN-C a second stage 2 pressure injury developed to the left buttock on 9/27/21. Only 1 assessment of the buttock area could be located. -On 9/4/21, R24 developed a stage 2 coccyx pressure injury. On 9/10/21, the area was described as a stage 3 pressure injury. There was no physician notification at the time of this wound decline and R24's care plan was not updated. Additionally there was no comprehensive assessment conducted of this wound from 9/11 to 9/21/21. Findings include: The facility's policy and procedure for Pressure Ulcer Treatment dated 2020 was reviewed by Surveyor. The procedures indicate to assess the wound weekly and document in the electronic record. The policy includes to promote healing of wound and determine the need for and implement appropriate skin care treatment. 1. On 09/22/21 at 08:50 AM Surveyor observed and spoke to R7 in their room. R7 was sitting in a recliner with their feet resting on the base of the over bed table. R7's right foot was wrapped. R7 indicated they got a wound from the hospital. R7 indicated the dressing is done daily. R7 indicated they have no wounds anywhere else. On 09/22/21 at 03:01 PM Surveyor observed R7 sitting in a recliner in their room. R7 was wearing gripper socks and their feet resting on the base of the over bed table. R7 was not wearing prevalon boots as indicated in R7's care plan intervention dated 7/15/21. Surveyor reviewed R7's medical record. R7 was admitted into the facility on [DATE]. The MDS assessment upon admission completed on 6/13/21 indicates 1 stage 2 PI with risk of pressure injury. R7 was hospitalized from 7/5 to 7/8/21 and was readmitted into the facility on [DATE]. The MDS (Minimum Data Set) assessment 5-day re-entry completed 7/13/21 indicates 4 PI (pressure injury): 1 stage 1 1 stage 2 present on admission; 1 Unstageable and Present on admission; 1 Unstageable/Deep Tissue Injury present on admission; R7 has a plan of care started 6/8/21 for high risk for skin breakdown. The interventions include: -6/8/21 cushion in my wheelchair; skin inspection weekly with bath; keep skin clean and dry; let nurse know about any skin breakdown; avoid shearing; use pillows to float heels. R7 has a plan of care started 7/8/21 for wounds to their heels and risk for skin breakdown. The interventions include: -7/15/21 wear prevalon boots in bed and recliner. -7/15/21 alternating air mattress -7/15/21 teach me to alternate my position every few hours while awake -7/27/21 check frequently during the night and adjust prevalon boots so my heels are protected. A progress note on 09/15/2021 at 11:04 indicates, R7 had a video visit with NP (Nurse Practitioner) at .Wound Clinic. BLE (bilateral lower extremity) wounds are improving. Continue current treatment. Plan is for resident to follow up in 2 weeks for debridement. NP encouraged resident to wear Prevalon Boot to RLE (right lower extremity) while in bed. Resident said she is willing to try wearing it again. There is not a plan of care that identifies actual pressure injuries with revised interventions as R7 continued to develop multiple pressure injuries and/or as the pressure injures continued to deteriorate. A progress note on 9/10/21: Resident noted to have stage II to left upper buttock during toileting, wound measures 1.2 x 1.0cm, states is somewhat tender only with palpitation, other wise doesn't notice or feel it, area cleansed and will apply [MEDICATION(S)] dressing for protection. MD updated. (documented by a Licensed Practical Nurse) A progress note by an RN on 9/10/21 Was called to bathroom by CNA(Certified Nursing Assistant). Resident was noted to have a slightly open reddened area on Left buttock measuring 0.5W x 1.0L. Cleaned and lotion applied. Continue to monitor. The buttock wound was not comprehensively assessed to determine appropriate treatment and interventions. On 09/27/21 at 08:24 AM R7 is sitting on a pressure reduction cushion device in recliner in room. R7 has gripper socks on. R7 does not know how they got their wounds, except they use pillows in bed for their feet. R7 also has an air mattress. R7 was not wearing Prevalon boots as per 7/15/21 care planned intervention. On 09/27/21 at 10:33 AM Surveyor observed R7 wound treatments by RN-D (Registered Nurse) and RN-C. They indicated there are wounds to both heels and had them post hip recovery. On Thursday will be having an angiogram to promote circulation in the right leg. R7 had gripper socks on feet. They will be doing measurements of the wounds tomorrow. The left heel dressing was not dated. There was an open are to the left heel that appeared white/wet appearing wound bed. Area macerated. Will call the physician to get a different treatment. The right leg has 2 wounds and the right heel had a wound. The heel had eschar and slough. The 2 areas on the calf had almost complete slough in the wound beds. The same treatment was completed for all 4 wounds. The buttock wound was not observed at this time. Wound Assessments: Surveyor reviewed the following wound assessments (located in both the progress notes and in the wound assessment section of the electronic record) with RN-C who had completed the wound assessments. 1. Right posterior calf pressure injury started on 07/08/2021 as a stage 2, then became unstageable on 7/22/21, then stage 3 on 7/27/21, then unstageable on 8/5/21, then 9/7/21 stage 3 and has remained at a stage 3 pressure injury. The 09/07/21 Wound assessment in Progress Note documents -R posterior calf: 2.9 x 3 cm, 50% scattered slough/50% granulated. The 09/14/21 Wound assessment in Progress Note documents -R posterior calf: 2.8 x 3.5 x 0.1 cm, 40% scattered slough/60% granulated. The 09/21/21 Wound assessment in Progress note documents -R posterior calf: 3 x 4.5 x cm, slough to base. (no staging noted) On 09/27/21 at 02:04 PM RN-C indicated to Surveyor they didn't realize they were staged differently. 2. Right posterior heel started as an unstageable pressure injury on 7/08/2021, then on 7/16/21 stage 2, then 7/22/21 unstageable, then on 9/14/21 epibole edges, and 9/22/21 epibole edges. This indicated a decline in wound healing. There was no physician notification, or intervention revision, and is currently unstageable. On 9/14/21 when the wound was assessed to have epibole the physician was not contacted. The 09/07/21 Wound assessment in Progress Note documents -R heel: 3.8 x 3 cm, 50% eschar/50% slough The 09/14/21 Wound assessment Progress Note documents -R heel: 3.4 x 2.5 cm, rolled edge at 11-3:00, 70% eschar/10% slough/20% granulation The 09/21/21 Wound assessment in Progress Note documents-R heel: 3.7 x 2.6 cm, 60% eschar/10% slough/30% granulation (at inferior end of wound - no staging was noted) On 09/27/21 at 02:07 PM Surveyor spoke with RN-C. RN-C recognized the wound edge changes being epiboled. They did not update physician with this wound decline and does not currently have wound clinic assessments. 3. Left superior heel started as an unstageable pressure injury on 07/15/2021, then on 7/27/21 was a stage 3, then on 8/5/21 the area was unstageable, then no staging of the pressure injury until 9/14/21 when it is staged as a stage 3 pressure injury. The 09/7/21 Wound assessment in Progress note documents-L heel: 1 x 2.2 cm, slough -L heel (stage III): healed The 09/14/21 Wound assessment in Progress Note documents -L heel: 0.7 x 2 cm, 50% slough/50% eschar. Wounds cleansed, soaked and dressings applied per orders. The 09/21/21 Wound assessment in Progress note documents- L Heel: 0.6 x 1.6 x 0.1 cm, 50% granulated/50% eschar. (no staging noted) On 09/27/21 at 02:02 PM Surveyor reviewed staging concerns with RN-C. RN-C indicated they don't look at the previous assessment. 4. Right posterior ankle pressure injury started 07/27/2021 as unstageable, there was no comprehensive wound assessments from 8/3/21 - 8/31/21 (27 days). The pressure injury remained unstageable. The progress note on 8/24/21 says pressure injury is a stage 3 and progress note on 8/19/21 indicates R7 went out to .wound clinic. There are no assessments from the clinic. The 09/07/21 Wound assessment in Progress note documents-R posterior ankle: 1 x 1 cm, slough to base. Wounds cleansed, soaked and dressings applied per orders. The 09/14/21 Wound assessment in Progress note documents-R posterior ankle: 1 x 0.8 cm, slough to base. The 09/21/21 Wound assessment in Progress Note documents -R posterior ankle: 1 x 1.2 cm, slough to base. (no staging noted) On 09/27/21 at 02:00 PM Surveyor spoke with RN-C. Surveyor indicated the wound staging is not consistent and there is no assessment from the wound clinic on 8/19/21. There are no consistent assessments of the wound. The wound was not staged per standards of practice. RN-C indicated they didn't look back at previous assessment note for staging comparison 5. The left buttock pressure injury started on 09/27/2021 stage 2 measuring 0.8 cm X 0.4 cm. however, previous documented progress notes which indicated; A progress note on 09/10/2021 at 15:33 (3:55 PM) indicated resident was noted to have stage II to left upper buttock during toileting, wound measures 1.2 x 1.0cm, states is somewhat tender only with palpitation, otherwise doesn't notice or feel it, area cleansed and will apply [MEDICATION(S)] dressing for protection. A Progress note on 09/10/2021 10:01 by RN indicated R7 was noted to have a slightly open reddened area on L buttock measuring 0.5W x 1.0 L. Cleaned and lotion applied. Continue to monitor. A 09/21/21 Wound assessment in the Progress note documents-Pressure wound to L upper buttock: 0.4 x 0.5 cm, base epithelized. (no staging noted) On 09/27/21 at 01:56 PM Surveyor spoke with RN-C. RN-C noted a left lateral area (left buttock) today and still has one from 9/10/21. RN-C did not know where the 2nd buttock wound assessment was located. RN-C indicated they told R7 they need to change positions more frequently. On 09/27/21 02:10 PM RN-C stated when she (R7) came back from the hospital on 7/8/21, R7 had the pressure injury on the calf and both heels and the right ankle. A 2nd pressure injury to the left heel developed on 7/8/21 and resolved on 9/7/21. R7 had a Coccyx pressure injury upon admission on 6/12/21 and resolved 6/18/21. RN-C just finished a wound course and hasn't taken the exam yet. The nurses and RN-C do the plan of care. RN-C did not know why the plan of care did not reflect R7's actual pressure injuries or include revised interventions as the areas developed and/or deteriorated. RN-C did not indicate there has been any changes in the plan of care besides more frequent positioning. On 9/26/21 at 3:00 PM at the facility exit meeting Surveyor shared the PI concerns with Administrator-A and DON-B. No further information was provided. 2. R24 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's Norton Scale completed on 8/13/21 by the facility indicates a final evaluation score of 13 which indicates at risk for skin breakdown. R24's Care Plan created on 8/15/21, with no revision dates noted, states I know that my skin is at a higher risk for breakdown. My skin will remain intact while I am here at (facility). The following interventions have approach start dates of 8/15/21: -I know you are using the Standard Care Plan Protocol for Skin Care to help me with this issue. -I like the cushion that is in my wheelchair. I know it can help reduce the chance of me getting a sore from sitting. -Please conduct a systematic skin inspection weekly on my first bath day of the week. Pay particular attention to my bony prominences and heels. -Please keep my skin as clean and dry as possible. If I have an accident, please clean me up quickly so my skin stays intact. -Please let my nurse know if you see any signs of skin breakdown (sore, tender, red, or broken areas). I want them to be treated as soon as possible so they don't get worse. -Please try to avoid shearing my skin during positioning, turning and transfers. -Please use pillows to float my ankles to relieve pressure on my heels. R24's Admission MDS (Minimum Data Set), dated 8/17/21, documents a BIMS (Brief Interview Mental Status) Score of 8 which indicates moderate impairment to daily decision making. The MDS indicates R24 was at risk of developing a pressure ulcer and had no pressure ulcers at admission. R24 requires extensive assistance with support of 2 persons for transfers, bed mobility and toileting. R24's MDS indicates skin and ulcer treatments include pressure reducing devices for the chair and bed. R24's Care Area Assessment (CAA), dated 8/17/21, for pressure ulcer was completed. The CAA Analysis of Findings states R24 triggered for this CAAs area due to being at risk for pressure injury related to being incontinent of bladder and needing assistance with all ADLs (Activities of Daily Living). R24 is working with therapy to improve function with the goal of returning home. Surveyor noted a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . buttocks: measure weekly until healed. Notify MD if decline. Surveyor noted there was no care plan that identifies actual pressure injury with revised interventions for the pressure injury of 9/4/21 when a new pressure injury to the coccyx was identified. The facility's Wound Management Report reviews R24's pressure ulcer as follows: *Wound Information: Pressure Ulcer, coccyx, center, identified 9/4/21 at 10:59 AM, not present on admission created by RN-C on 9/10/21 at 10:59 AM. *On 9/4/21 at 10:59 AM, wound report created by RN-C, states: length 1 cm, width 1 cm, no depth, light exudate, serosanguineous (pale red to pink, thin and watery) exudate, no odor, Stage II, no undermining, no tunneling, epithelial tissue, 100% epithelialization tissue, well defined wound edges, [CONDITION(S)] (redness)/blanchable skin surrounding wound. *On 9/10/21 at 11:00 AM, wound report created by RN-C, states: length 0.9cm, width 0.6 cm, depth 0.1cm, light exudate, serosanguineous (pale red to pink, thin and watery) exudate, no odor, Stage III, no undermining, no tunneling, granulation tissue, 100% granulation tissue, edge not attached to the base, [CONDITION(S)] (redness)/blanchable skin surrounding wound, wound healing status declining. Comments: wound is reduced in size but has now 0.1cm depth. Surveyor noted there was no physician notification documented at the time of wound decline or when the wound was changed from a Stage 2 to a Stage 3 per the wound management report on 9/10/21. Surveyor noted R24's care plan was not updated to reflect R24's decline in coccyx pressure injury such as identifying a repositioning schedule, amount of time up in a chair, provision of incontinence care, etc. Surveyor reviewed the facility's Electronic Health Record (EHR). Surveyor noted there were no further comprehensive wound assessments between the dates 9/11/21 and 9/21/21 (1 week). *On 9/22/21 at 10:53 AM, a wound report created by RN-C states: length 0.4cm, width 0.4cm, no depth, no exudate, no odor, Stage III, no undermining, no tunneling, slough, 10% granulation tissue, 90% slough, well defined wound edges, [CONDITION(S)] (redness)/blanchable skin surrounding wound, declining status. Comments: slough to base. Santyl requested. *On 9/22/21 at 8:14 PM, a wound report created by RN-C states: length 0.4cm, width 0.2cm, no depth, no exudate, no odor, no undermining, no tunneling, slough, 10% granulation tissue, 90% slough tissue, edge not attached to base, well defined wound edges, [CONDITION(S)] (redness)/blanchable skin surrounding wound, stable wound healing status. *On 9/24/21 at 2:05 PM, a wound report created by RN-C states: length 0.3cm, width 0.3cm, no depth, light exudate, serosanguineous exudate, no wound, no undermining, no tunneling, slough tissue, 50% granulation, 50% slough, well defined wound edges, [CONDITION(S)](redness)/blanchable skin surrounding wound, improving healing status. Comments: New order for santyl applied. On 9/27/21 at 1:48 PM, Surveyor interviewed RN-C. RN-C confirmed RN-C was completing weekly wound assessments for R24. When asked if there was any comprehensive assessment completed between 9/11 to 9/21/21, RN-C could not find anything, but would continue to check. RN-C stated it was the expectation that there is a weekly wound assessment and report for R24. RN-C was asked who was responsible to then update the Care Plan for R24 with the new pressure ulcer and RN-C indicated it would be RN-C. RN-C confirmed there was no update to R24's care plan with the pressure ulcer identified on 9/4/21 and the expectation is it would be completed at the time of identification of the new wound. On 9/28/21 at 10:15 AM, Registered Nurse (RN)-C handed surveyor an updated Care Plan for R24, dated 9/27/21, with the following details: I obtained a pressure injury to my coccyx. My wound will show improvement with each assessment. -Monitor my wound and change the dressing per MD orders. -Teach me techniques to change position while seated throughout the day. On 9/28/21 at 12:50 PM, Surveyor interviewed RN-C. RN-C confirmed there was no physician notification completed for R24's declining wound status on 9/10/21. RN-C stated RN-F did complete a late entry progress note for R24 on 9/28/21 at 12:18 AM to add detail regarding R24's wound during the missed wound assessment timeframe of 9/11-9/21/21. RN-C provided a progress note from RN-F that was added as a late entry for 9/17/21 at 9:46 PM stating Measured resident's wound. Base was pink with no drainage noted. Edges were smooth. RN-C stated there was no comprehensive wound report completed, just a progress note. Surveyor noted RN-F's late entry on 9/28/21 does not include any comprehensive assessment documentation such as tissue type or percentages, wound status, odor, tunneling, undermining, or changes to wound. On 9/28/21 at 12:28 PM, Surveyor met with Director of Nursing (DON) - B. DON-B was informed of the missing comprehensive wound assessment, updated care plan, as well as the lack of physician notification of the declining pressure ulcer per order and policy. No further documentation was provided.

Based on interview and record review, the facility did not ensure that 4 of 5 residents reviewed for falls (R4, R22, R24, and R9) received adequate supervision and assistance devices to prevent accidents. R4 had a fall on 8/1/21. The facility did not implement recommended changes following the fall. On 9/2/21 R4 had a fall and was sent to the hospital for evaluation. R4 returned to the facility with a with a large hematoma above her right eye that was bleeding and R4 was unable to see out of her right eye. The facility did not identify interventions, implement interventions, and update the care plan to prevent further falls for R4. R22 had a fall. The facility did not complete a root cause analysis to identify interventions, implement interventions, and update the care plan to prevent further falls for R22. R24 had a fall. The facility did not complete a root cause analysis to identify interventions, implement interventions, and update the care plan to prevent further falls for R24. R9 had a fall. After the fall, the facility did not identify interventions, implement interventions, and update the care plan to prevent further falls for R9. Findings include: The facility's Fall Prevention and Management Policy was dated 10/2018, 2019, 2020 and provided the following information. 2.1 All Residents will be assessed for their fall risk upon admission, quarterly, annually, and with any significant change of condition, and after experiencing a fall. Based upon the results of the fall risk, interventions to manage/prevent future falls may be implemented as well as manipulation of the environment to prevent falls. 3.5 Once the fall risk has been determined and the interventions implemented, proceed to developing the Resident's care plan. Update plan of care on an ongoing basis. 3.11 As soon as possible (15-20 minutes after fall) gather all staff on duty at time of fall, as well as the Resident if possible, and complete the questions found on the post fall huddle. This should help in determining the root cause of the fall. When complete, place original in designee box and one copy in communication book. 1. R4 is [AGE] years old and was admitted to the facility on [DATE]. The progress notes indicate that R4 is alert and oriented x 3, but forgetful. The 1/5/21 annual Minimum Data Set indicated that R4's balance was unsteady during transfers and walking. The 1/20/21 Fall Care Area Assessment indicated that R4 was at risk for falls. R4 already had a fall care plan with a start date of 9/16/18 and a revision date of 9/2/21. The interventions were as follows. Please help remind me to wait for staff. I know I need the sarasteady right now for transfers into bed. I fell because I forgot to wait for assistance. Start Date 05/13/2021 Please remind me to use my call light and ask for assistance when needed. Start Date 04/18/2019 Encourage me to use a w/c when I am feeling weak and to ask for assistance. Start Date 04/18/2019 Please help to remind me not to ambulate/transfer without assistance. I know that Physical Therapy recommends that I use two people to assist me with transfers and ambulation; however, I prefer to have one person help me and to follow me with a wheelchair when I walk using my walker. I do not like to use the stand-up lift for transfers. Start Date 09/16/2018 I know you are using the Standard Care Plan Protocol for Altered Mobility/Falls to help care for me. Start Date 09/16/2018 Please keep my environment free of clutter. Start Date 09/16/2018 I don't mind if you keep my bed in the lowest position with the brakes locked, with my head at top of head of bed. Start Date 09/16/2018 Please keep my personal items and frequently used items within reach. Start Date 09/16/2018 Please keep my call light in reach. Start Date 09/16/2018 FALL 8/1/21 - CARE PLAN NOT UPDATED The progress notes documented the following information; At 8:09 PM, R4 was found in her room sitting on the floor next to the recliner chair. Her wheelchair was behind her. R4 stated that she was transferring from the recliner to the wheelchair and landed on the wheelchair arm rest and slid to the floor. No injuries were noted and R4 denied hitting her head. At 11:52 PM, the facility had completed an Event Report related to R4's fall. Part of the Event Report included a neuro check. The facility's Fall Policy, as noted above, indicated that neuro checks should be completed every shift for 72 hours after a resident has fallen. The facility should have completed neuro checks on all three shifts beginning on the 8/1/21 PM shift and ending on the 8/4/21 Day shift. Although some neuro checks were completed and documented in R4's progress notes; neuro checks were not completed on all three shifts for 72 hours. The following neuro checks were missing. 8/1/21 Night shift (into 8/2/21 Day shift) 8/2/21 Day shift 8/4/21 Day shift On 8/1/21 the facility completed an inter-disciplinary Post Fall Huddle Report. The facility's policy, as noted above, indicated that the purpose of the Post Fall Huddle was to determine the root cause of the fall. The following intervention was recommended to prevent R4 from falling again. R4 was to wear only gripper socks or shoes with traction. This intervention was not added to the care plan as noted above. FALL 9/2/21 - NO NEW INTERVENTIONS TO PREVENT FURTHER FALLS The progress notes documented the following information; At 3:59 PM, R4 was found in her room lying on her right side with her face down. She had a large bump over her right eye with bleeding and bruising. R4 stated that she was picking up a piece of popcorn off of the floor. Emergency Medical Services were called because of the head injury. At approximately 4:15 PM, R4 was transported to the hospital for further evaluation. R4 returned to the facility that same day at 6:00 PM. The emergency department at the hospital had determined that R4 had no broken bones and there were no new orders. Upon her return, R4 was noted to have a large hematoma to her right forehead and eye. The hematoma was bleeding when R4 arrived back at the facility and R4 was unable to see out of her right eye. On 9/2/21 the facility completed an inter-disciplinary Post Fall Huddle Report. The facility's policy, as noted above, indicated that the purpose of the Post Fall Huddle was to determine the root cause of the fall. The following intervention was recommended to prevent R4 from falling again. R4 was supposed to be moved to a room closer to the CNA station. A review of R4's medical record indicated that R4 lived in room # . on 9/2/21 and continued to live in room # . as of 9/27/21; with no room changes in between that time. R1's care plan, as referenced above, documented no new interventions to prevent falls after R4 had fallen on 9/2/21. 5/13/21 was the last time a new intervention was added to the fall care plan; even though a revision date of 9/2/21 was documented. On 9/27/21 at 3 PM, the preceding information was shared with Nursing Home Administrator (NHA) - A and Director of Nursing (DON) - B. DON - B said that R4 had been offered a room change and had chosen not to move. When asked if the facility had considered other interventions, the DON said that the fall committee had not met since R4's fall on 9/2/21 and that is when new interventions would be discussed. DON - B said that the fall committee meets monthly. DON - B was unable to explain why the neuro checks had not been completed after R4's falls on 8/1/21 and 9/2/21. CONTINUED INJURY The progress notes provided the following information; On 9/15/21 R4's attending physician, MD - E, assessed R4's hematoma. MD - E referred R4 to a general surgeon for evaluation of her large facial hematoma. R4 had an appointment scheduled with the general surgeon on 9/29/21. On 9/23/21 Assistant Director of Nursing (ADON) - C documented the following information in the progress notes. R4's hematoma was 3.5 cm high. A skin tear over the wound was scabbed with scant bleeding when the dressing was removed. R4 had a gauze dressing that was secured with tape. 2. R22 was admitted to the facility on [DATE] with diagnoses including: [CONDITION(S)], hypertensive heart disease, heart failure, [CONDITION(S)], peripheral autonomic [CONDITION(S)], anxiety disorder, gout, neuromuscular dysfunction of bladder and stage 4 chronic kidney disease. R22's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R22 has a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. R22 requires extensive assistance with support of 2 people for transfers, bed mobility and toileting. R22's MDS also indicates R22's balance is not steady during transfer, walking and transition. R22's MDS states there were no falls since the prior assessment. R22's Care Area Assessment (CAA) for falls has an assessment date of 1/11/21 with start date of 1/20/21. The CAA analysis of findings state Resident is here for LTC (long term care). (R22) triggered for this CAAs area due to being at risk for falls due to having problems with balance and having a history of falls. Surveyor reviewed R22's initial care plan with the category of falls was dated 12/6/19. The care plan states the following: I know I am at risk for falls. I have many falls at home. Fall on 8/17/21 (Edited 8/29/21). Resident will remain free from falls. Approaches with date of 12/2019: - Please do not leave me unattended in the recliner with legs up, I cannot use the recliner remote to bring my legs down -I don't mind if you keep my bed in the lowest position with the brakes locked -Please help to remind me not to ambulate/transfer without assistance -Please keep my call light in reach -Please keep my environment free of clutter -Please keep my personal items and frequently used items within reach Approaches with date of 9/20/20: -Provide proper, well-maintained footwear. Approaches with date of 4/12/21: -I don't mind if you place pillows in my bed to help remind me where the edge of the bed is. -I know you are going to keep a closer eye on me while I'm completing ADLs (activities of daily living), especially when I'm brushing my teeth -I don't mind that you place my call light on my door handle to my bathroom. I know I'm not the best at asking for help -I appreciate you encouraging me to ask for assistance -I appreciate you moving my bed so I don't fall out of bed -Please toilet me frequently after you give me [MEDICATION(S)] R22's Fall Risk Assessment, dated 8/14/21, indicates a score of 9 or a high risk of falls and to continue with current plan of care. Surveyor reviewed R22's progress notes that indicated on 8/17/21 at 11:24 AM, Resident had an unobserved fall in R22's room. The progress note indicated: (R22) was getting up to go. Lying on R (right) side on top of bottom of rolling table. Recently readmitted with bacteremia and [CONDITION(S)] (urinary tract infection). Large injury to head with moderate to large amount of blood. Blood to RUE (right upper extremity), unable to determine location of injury due to positioning on the floor. 911 called, resident picked up at 1125 and sent to (hospital) for evaluation. POA (Power of Attorney) called. DON (Director of Nursing) notified. MD notified. According to the facility's Fall Prevention and Management Policy, dated 10/2020, indicates the post fall huddle SBAR (situation, background, assessment and recommendation) should be completed as soon as possible to determine the root cause of the fall. Surveyor could not locate the facility post fall huddle SBAR form for this fall. On 9/27/21 at 2:08 PM, Surveyor interviewed DON (Director of Nursing)-B. Surveyor asked if there was a post fall huddle after R22's fall. DON-B thought there was and would look for the form. On 09/27/21 at 02:59 PM, Surveyor interviewed DON-B and NHA (Nursing Home Administrator) - A. DON-B stated the post fall huddle form could not be found which would be the trigger for the fall analysis, care plan and new interventions. No further documentation or information was provided. Surveyor noted R22's progress note dated 8/17/21 at 6:07 PM, indicates R22 returned from hospital around 1330 (1:30PM). Laceration to top of head measuring 4cm, 6 sutures in place. Skin tear next to laceration on top of head measuring 3.5cm x 0.5 cm. Areas cleansed with normal saline. Any bandages unable to stay in place due to hair. While sitting up minimal to no bleeding. Will sleep with head of bed elevated. Skin tear to lower upper extremity crescent shaped 5cm. Cleansed with normal saline, applied steristrips, nonadherent with adhesive and soft roll gauze. Abrasion to upper lip. Cleansed with normal saline, applied triple antibiotic ointment. After visit summary from R22's emergency room visit due to fall and head injury; 1) CT head and neck done showing no acute abnormality. 2) OK to shower briefly and then apply topical antibiotics to skin tear as well as head laceration. 3) Watch for signs of infection such as redness, drainage, or fever. 4) Follow up with (hospital) in 10 days to remove sutures. 5) Follow up with MD in 1 week. Surveyor noted there was no root cause analysis conducted for R22's fall on 8/17/21. Surveyor noted no new interventions to the fall care plan based on a root cause analysis after R22's fall on 8/17/21 except for adding the date of the fall. 3. R24 was admitted to the facility on [DATE] with diagnoses including: closed fracture with routine healing, fracture of right femur, anxiety disorder, hypertension, [CONDITION(S)] heart disease, heart failure and fracture of humerus, right arm with routine healing. R24's Admission Minimum Data Set (MDS), dated [DATE], indicated R24 has a Brief Interview for Mental Status (BIMS) of 8 indicating moderate cognitive impairment. R24 requires extensive assistance with support of 2 people for transfers, bed mobility and toileting. R24's MDS also indicates R24's balance was not steady during transfer, walking and transition. R24's MDS states R24 had a fall with a fracture in the 6 months prior to admission. R24's Care Area Assessment (CAA) for falls has an assessment date of 8/17/21 with worksheet start date of 8/27/21. The CAA worksheet's analysis of findings state Resident triggered for this CAAs area due to having a history of falls and having problems with balance. (R24) is working with therapy to improve function with the goal of returning home. R24's care plan, dated 8/15/21, includes a problem for risk of falls. The care plan reads as follows: I know I am at risk for falls. Fall on 8/15/21. I will remain free from injury throughout the next review. -I don't mind if you keep my bed in the lowest position with the brakes locked. -I know you are using the Standard Care Plan Protocol for Altered Mobility/Falls to help care for me. -Please help to remind me not to ambulate/transfer without assistance. -Please keep my call light in reach. -Please keep my environment free of clutter. - Please keep my personal items and frequently used items within reach. Surveyor reviewed R24's progress notes that indicated on 8/15/21 at 5:57 PM, R24 had unobserved fall in room. Staff entered to find R24 lying flat on R24's back next to R24's broda chair. Brakes on broda chair. Gripper socks on. Soft touch call light on the floor with R24 but did not go off. Writer checked to see that the call light was functioning appropriately when pressed, and it is. ROM WNL (Range of Motion Within Normal Limits). States that pain is what already had, no worse no better. Staff assist x2 with Hoyer to get R24 off the floor. Room rearranged for space/safety. Will monitor vital signs every shift. On-call RN (Registered nurse) notified, POA (Power of Attorney) notified, MD notified. According to the facility's Fall Prevention and Management Policy, dated 10/2020, indicates the post fall huddle SBAR (situation, background, assessment and recommendation) should be completed as soon as possible to determine the root cause of the fall. Surveyor noted in the electronic health record for R24, on 8/15/21, a facility post fall huddle SBAR form was completed and the description of the fall states Staff found resident lying on R24's back on the floor next to broda chair .soft touch did not signal, but is functioning. Unable to determine what resident was doing at the time of fall. In reviewing this post fall report, Surveyor notes there is no indication of a complete root cause analysis as information was not included in the post fall report such as: whether resident was able to use the soft touch call light and why it didn't work, when was R24 was last seen, when was R24 last toileted, if the resident and staff were interviewed to determine what happened, and if the broda chair was properly positioned according to manufacturing instructions. 4. R9 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Malignant Neoplasm of Unspecified Site of Right Female Breast, Non-[CONDITION(S)], and Dementia. R9 has an activated Health Care Power of Attorney(HCPOA). R9's Quarterly Minimum Data Set (MDS) documents R9 to have short and long term memory impairment and demonstrates moderately impaired skills for daily decision making. The MDS also documents R9 requires extensive assistance with bed mobility, transfers, dressing, eating, and toileting. The MDS documents that R9 had 1 fall with injury since the last assessment. R9's Care Area Assessment (CAA) completed on 11/17/20 states that R9 is at higher risk for falls related to weakness and gait/balance instability. R9 has intermittent confusion with impulsivity and attempts to self transfer. A care plan will include interventions to prevent injury related to a fall. Surveyor reviewed R9's Fall comprehensive care plan which reads as follows: Problem: I know I am at a risk for falls because I try often to self transfer. Fall on 10/26, 11/1, 12/23, 12/28, 3/3/2021. 4/22/21, 5/16/21, 8/8/21, 8/31/21 Start Date: 11/13/2018 Last Reviewed/Revised: 08/31/2021 Category: Falls Target Date: 01/21/2020 (Short Term Goal) GOAL: I will remain free from injury throughout the next review. Last reviewed: 10/21/19 Start Date: 12/23/2021 (sic) APPROACH: I know you are going to encourage me to move in different positions with help. Start Date: 05/16/2021 APPROACH: I fell this last time because I was watching a movie with the other residents I tried to get up by myself. Start Date: 04/22/2021 APPROACH: Please allow me time to use the bathroom. I know you have to sit with me, but I will go if given the chance. Start Date: 03/25/2021 APPROACH: I know you will provide me with activities to do before bedtime. I can get a little more restless around that time. Start Date: 03/25/2021 APPROACH: Observe frequently and place in supervised area when out of bed. Start Date: 03/19/2021 APPROACH: I appreciate that you moved my recliner closer to the nurses station so I can be monitored a little closer on PM shift. Start Date: 03/19/2021 APPROACH: I know my family brought in some activities for me to do to occupy my time. Start Date: 03/13/2021 APPROACH: I appreciate that you are going to monitor me for signs and symptoms of urinary tract infection. I get more impulsive when I have a [CONDITION(S)]. Also, push fluids. Start Date: 03/13/2021 APPROACH: Resident to be placed in recliner in front of fireplace in Welcome Center for increased visibility and monitoring. Start Date: 03/03/2021 APPROACH: I know sometimes you need to place my call light more towards my hip, so that it gets pushed when I am trying to get up. Start Date: 07/21/2020 APPROACH: Please keep my personal items and frequently used items within reach, especially when I am getting myself ready for bed sitting at the sink. Start Date: 05/08/2020 APPROACH: Please take me for a walk prior to having me rest in the recliner. Start Date: 02/24/2020 APPROACH: Please assist me back to my room or in the common area after activities. Start Date: 12/08/2019 APPROACH: Provide toileting assistance AC PC et @ HS. NOteably before setting res in day area to watch TV Start Date: 10/02/2019 APPROACH: Please have staff follow me with a w/c when I ambulate with my daughter in the evenings. Start Date: 09/16/2019 APPROACH: I don't mind offering me snack before going to bed. Start Date: 04/03/2019 APPROACH: Daughter will bring resident out to TV area when leaving so resident may be monitor more closely. Start Date: 01/30/2019 APPROACH: I don't mind if you put a chair by the sink so I can brush my teeth safely. Start Date: 01/02/2019 APPROACH: I don't mind if you place a chair on both sides of my bed. That way if I want to get out of bed I have somewhere to sit besides the floor. Start Date: 11/30/2018 APPROACH: Give resident verbal reminders not to ambulate/transfer without assistance. Start Date: 11/21/2018 APPROACH: Golden Years staff will provide more frequent room checks. Start Date: 11/13/2018 (Care Needs Sign-off in POC) APPROACH: I don't mind if you keep my bed in the lowest position with the brakes locked and W/C next to my bed at night time. Start Date: 11/13/2018 APPROACH: Please help to remind me not to ambulate/transfer without assistance. Start Date: 11/13/2018 (Care Needs Sign-off in POC) APPROACH: Please keep my call light pinned on me when in my room. Start Date: 11/13/2018 APPROACH: Please keep my environment free of clutter. Documentation on R9's comprehensive care plan reflects that R9's goal of remaining free from injury had not been reviewed by the interdisciplinary( IDT) since 10/21/19. On 8/31/21, R9's fall risk assessment documents that R9 is high risk for falls. Surveyor reviewed R9's most recent 4 fall incident reports along with the post huddle fall report and progress notes which are outlined below for each fall. 1. 8/8/21 R9 was found sitting on R9's bottom in front of wheelchair at 11:20 AM in west side living room. R9 denies pain has no injury. Both physician (MD) and HCPOA updated. Vitals and neuro checks initiated and per documentation, completed for each shift for 72hrs. Per Post Fall Huddle, interventions were to continue with the fall plan, which included frequent checks. The only root cause analysis was that the facility was short staffed at the time. No new intervention was added to R9's care plan. 2. 8/31/21 R9 was found sitting on R9's bottom several feet away from the recliner R9 had been sitting in at 2:30 PM in the living room. R9 denies pain has no injury. Both physician (MD) and HCPOA updated. Vitals and neuro checks initiated and per documentation, completed for each shift for 72hrs. Per Post Fall Huddle, no root cause analysis was completed. The only intervention documented is to continue frequent checks. No new intervention was added to R9's care plan. 3. 9/4/21 R9 was in the bathroom with a certified nursing assistant (CNA). R9 turned the wrong way from the wheelchair to the toilet and the CNA lowered R9 to the floor at 12:50 PM. R9 had no injury. Both physician (MD) and HCPOA updated. Per Post Fall Huddle-the intervention put into place was to cue R9 for turning, however, the intervention was not added to R9's care plan. 4. 9/18/21 R9 was found sitting on the floor of the west living room at 11:45 AM next to R9's wheelchair. R9 denies pain has no injury. Both physician (MD) and HCPOA updated. Vitals and neuro checks initiated and per documentation, completed for each shift for 72hrs. Per Post Fall Huddle, no root cause analysis was completed. The only intervention documented is to continue frequent checks. No new intervention was added to R9's care plan. Surveyor notes that 3 of R9's falls occurred in the west living room, was trying to ambulate, and the intervention put into place was to continue frequent checks. No new interventions put into place or added to R9's care plan. Surveyor notes that R9's 9/4/21 and 9/18/21 fall did not get added to R9's care plan. Surveyor also notes that the intervention of observing frequently and place in supervised area was added on 3/25/21, however, 3 of R9's falls occurred in area where there was no supervision with frequent checks. Surveyor made observations of R9 during the survey process. On 9/22/21 at 8:34 AM, R9 was in R9's high back chair, sleeping. R9 was in front of the TV in the west living room. Surveyor observed R9's wheelchair is not locked and no staff are in the vicinity. On 9/22/21 at 10:25 AM, R9 is sitting in the recliner chair in the west living room. On 9/22/21 at 2:45 PM, R9 is sitting in R9's high back chair, slightly reclined located in the west living room. Wheelchair brakes are not locked and no staff are in the vicinity. On 9/23/21 at 7:47 AM, R9 is located in the west living room, sitting in R9's high back chair, brakes are not locked, and no staff are in the vicinity. On 9/27/21 at 9:56 AM, R9 is sitting in R9's high back wheelchair, in the upright position,and is sleeping. Wheelchair is unlocked, R9 is sitting in front of the TV in the west living room and no staff are in the vicinity. On 9/27/21 at 11:31 AM, Surveyor spoke to Director of Nursing (DON-B) in regards to R9's falls. DON-B confirmed that the expectation would be that R9's comprehensive care plan should have been updated with R9's falls including updating with new interventions. On 9/27/21 at 3:04 PM, Surveyor shared concern with NHA-A and DON-B that a root cause analysis was not always done after R9's falls and care plan interventions were not established to reduce the potential for further falls. No further information was provided at this time. Surveyor notes per the facility's Policy on Fall Prevention and Management last reviewed 2020, R9 should have been assessed after each fall and based upon the results of the fall risk, interventions to manage/prevent future falls may be implemented as well as manipulation of the environment to prevent falls. The purpose is to systematically assess R9's falls risk factors and provide fall and repeat fall preventive interventions, and outline procedures for documentation and communication procedures. As outlined in the policy, R9's fall risk was not determined with new interventions implemented and did not proceed to updating R9's plan of care on an ongoing basis. Surveyor notes the facility completed a post fall huddle per policy, however, did not determine the root cause of R9's falls.

Based on observation, interview and record review, the facility did not implement outbreak prevention measures to help prevent the development and transmission of communicable diseases and infections such as COVID-19. This deficient practice was observed with 1 (R325) of 1 residents who was on a 14 day quarentine and requiring contact and droplet precautions/isolation (gloves, gown, eye protection, and N95.) * R325 was admitted from the hospital, unvaccinated and met the CDC (Centers for Disease Control) criteria for droplet isolation for 14 days. R325 had no sign on the door indicating the need to wear Personal Protective Equipment (PPE) or to indicate R325 was on any type of isolation. There was no PPE cart located outside or F325's room. Surveyor was allowed to enter R325's room without wearing the appropriate PPE for an unvaccinated Resident who was recently admitted into the faciltiy from the hospital. RN-D was observed not wearing appropriate PPE (an N95) when administering medication to R325. R325's room door remained open and they were not observed in their room. Findings include: The facility policy and procedure COVID Isolation admitted d 8/2021 was reviewed. The procedure indicates the following: - All unvaccinated residents who are new admissions and readmissions will be placed in a 14-day quarantine, even if they have a negative test upon admission. - Unvaccinated new residents that have had no known contact with someone with COVID, have had a negative COVID test, and show no signs/symptoms of COVID, will be put in soft isolation meaning staff must wear gowns, facemask's, and eye protection when entering the room. Resident should receive therapy and meals in their room unless contraindicated due to health concerns. - Unvaccinated new residents with suspected contact with someone with COVID, a positive COVID test, or showing signs/symptoms of COVID will be put in isolation. Staff must wear gowns, N95 masks, gloves, and eye protection in their room. Residents must receive therapy, meals, and any treatments in their room. The CDC guidelines for Long Term Care Facilities, revised 2/23/21 indicates the following: HCP (Healthcare Personnel) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. The PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: Respirator Put on an N95 respirator (or equivalent or higher-level respirator) before entry into the patient room or care area, if not already wearing one as part of extended use strategies to optimize PPE supply. Other respirators include other disposable filtering facepiece respirators, powered air purifying respirators (PAPRs), or elastomeric respirators. N95 respirators or respirators that offer a higher level of protection should be used when performing or present for an aerosol generating procedure. See appendix for respirator definition. Disposable respirators should be removed and discarded after exiting the patient room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask. If reusable respirators (e.g., powered air-purifying respirators [PAPRs] or elastomeric respirators) are used, they should also be removed after exiting the patient room or care area. They must be cleaned and disinfected according to manufacturer reprocessing instructions prior to re-use. Eye Protection Put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply. Protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes and sprays. Ensure that eye protection is compatible with the respirator so there is not interference with proper positioning of the eye protection or with the fit or seal of the respirator. Remove eye protection after leaving the patient room or care area, unless implementing extended use. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse. Gloves Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. Double gloving is not recommended when providing care to patients with suspected or confirmed [CONDITION(S)]-CoV-2 infection. Gowns Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Reusable (i.e., washable or cloth) gowns should be laundered after each use. In general, HCP caring for patients with suspected or confirmed [CONDITION(S)]-CoV-2 infection should not wear more than one isolation gown at a time. On 09/22/21 at 10:57 AM Surveyor conducted the Entrance Conference with Administrator-A and DON-B (Director of Nurses). There was no COVID residents in building, no TBP (transmission based precautions) and no type of resident isolation. On 9/22/21 during the survey screening process a Surveyor went into R325's room for an interview. There was no signs on the door to indicate any isolation in process, or if PPE was necessary. Additionally there was no PPE cart outside the room door. Surveyor asked staff prior to entering the room if it was OK to enter as the door to the room was closed. Staff informed surveyor that is was permissable to enter R325's room, wearing a surgical mask and eye protection. Staff were not aware of the required PPE that should be worn upon entering R325's room. On 9/22/21 at 10:22 AM a Surveyor went into (R325) room without appropriate PPE due to there was no indications this resident was on droplet, or any type, of isolation. There was no signs on the door to indicate a quarantine. On 09/27/21 at 08:20 AM Surveyor observed RN-D (Registered Nurse) during medication observation. RN-D prepared medication and went into R325's room. RN-D indicated R325 is on soft isolation because they are not fully vaccinated. RN-D had donned a surgical mask, gloves, eye protection and a gown hanging in the room. Surveyor did not observe any sign to indicate isolation or type of isolation. RN-D should have been wearing an N95. Surveyor observed RN-D administering medications to two additional residents after RN-D administered medication to R325. This was not a quarantine unit. On 9/27/21 around 9:00 AM Surveyor reviewed the facility's Infection Control with DON-B who is also the facility Infection Preventist. DON-B indicated R325 is on soft (contact) isolation for 2 weeks period for unvaccinated and staff would wear a gown. There are signs on the door of the resident's room. There would be a red sign on the inside of the door with an admitted and date of clearance. The staff would wear gowns for 14 days for an unvaccinated resident with no symptoms, along with respiratory assessments every shift. The facility is using contact isolation, which is the soft isolation for unvaccinated asymptotic residents for 14 days. The facility does not have a shortage of PPE and staff are fit tested for N95's. They do schedule vaccinated staff to care for the resident with suspected COVID exposures from the hospital. On admission residents vaccine status is obtained. The facility does a rapid COVID test on residents upon admission and every shift a respiratory assessment. The facility follows CDC, CMS (Center for Medicare and Medicaid Services) and DHS (Department of Health Services) recommendations. There is no further information regarding R325's droplet isolation implementation. On 09/27/21 at 10:58 AM Surveyor observed R325's room. There was no sign anywhere to indicate quarantine measures. The door was open and R325 was not in their room. Surveyor spoke to DON-B at this time and DON-B indicated R325 was admitted on [DATE] and today would be the last day in quarantine. DON-B indicated Staff were educated regarding a new Admission who is unvaccinated should be in a 14 day isolation. R325 was admitted to the facility from a hospital setting. On 09/27/21 at 02:58 PM at the facility exit meeting with Administration Surveyor shared the infection control concerns. There was no additional information provided.

Based on interview and record review, the facility did not develop a plan of care related to a resident assessment. This was observed with 2 (R5 and R24) of 12 resident reviewed. * R5 was admitted with a Foley catheter and then bladder incontinence. R5 did not have a plan of care developed for their bladder status. * R24 was admitted with mood and behavior medications and no plan of care was developed regarding these health concerns. Findings include: The facility's policy and procedures for Care Plan dated 2020 was reviewed by Surveyor. The policy indicates the facility will develop and implement a person centered care plan for each resident admitted to the facility. This includes measurable objectives and timeframe's to meet a resident's medical and psychosocial needs. 1. On 09/22/21 at 10:16 AM Surveyor spoke with R5 in their room. R5 indicated they do not have a catheter for their bladder anymore. They indicated it was because of an infection. R5 indicated staff assist them to the bathroom. R5's medical record was reviewed. R5 was readmitted from the hospital on 7/14/21 for [CONDITION(S)] (urinary tract infection) with [CONDITION(S)]. The Hospital Discharge Summary on 7/14/21 indicates a Foley catheter was placed for urinary retention. The Admission MDS (Minimum Data Set) assessment completed on 7/12/21 indicates a Foley catheter is used for bladder. The PN (progress note) on 7/20/21 indicates the Foley catheter was removed and R5 expressed relief. The PN on 07/20/2021 at 8:42 AM indicates a telephone order from the physician to remove the Foley catheter, monitor urine output and If no output by 3 p.m., insert straight cath. If bladder output is less then 150 mL(milliliters) reinsert catheter and consult Urology. The only Bladder assessment in R5 medical record was completed on 7/12/21. The Bladder assessment completed on 7/12/21 indicates R5 is currently incontinent of bladder, however no incontinence type or pattern. R5's Bladder charting daily output indicates R5 had a Foley catheter at this time. The Bladder assessment conducted on 7/12/21 is not accurate or comprehensive. There is no plan of care for the Foley catheter, nor bladder status. On 09/23/21 at 09:53 AM Surveyor spoke with DON-B (Director of Nurses). DON-B indicated they would look into R5 bladder plan of care. On 09/28/21 at 09:24 AM Surveyor spoke with DON-B. DON-B indicated the admission nurse would start the plan of care and any changes the nurse would revise it. On 9/26/21 at 3:00 PM at the exit meeting with Administrator-A and DON-B Surveyor shared the concerns with R5 bladder plan of care. There was no additional information provided. 2. R24 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R24 has a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor noted on the Treatment Administration Record (TAR) for R24 there is an order, dated 8/12/21, to monitor and document target behavior, intervention and side effects on every shift due to the [MEDICATION(S)] order. R24's Admission Minimum Data Set (MDS) assessment completed on 8/17/21 documents: A Brief Interview of Mental Health Status (BIMS) score of 8, indicating moderate impairment for daily decision making; a Resident Mood Interview score of 9, indicating mild depression; Delusions were indicated and verbal behavioral symptoms directed towards others occurring 1-3 days which significantly interferes with resident's care. R24's MDS also indicates R24 received an antidepressant 5 of the last 7 days since admission. R24's Care Area Assessment (CAA), dated 8/17/21, for psychosocial well-being states under the care plan considerations A care plan will include interventions to promote the best psychosocial well-being. R24's CAA dated 8/17/21 for [CONDITION(S)] medication use indicates A care plan will observe for adverse consequences of taking the antidepressant medication. R24's CAA dated 8/17/21 for mood states under Analysis of Findings, R24 triggered for this CAA area due to Resident Mood Interview 'Thoughts that you would be better off dead, or hurting yourself in some way' is indicated. A care plan will include interventions to help resident adjust to current situation. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor reviewed R24's Care Plan and Surveyor noted R24's Care Plan does not include any goals or interventions for mood, behaviors and antidepressant medication use or adverse consequences as indicated in the CAA. On 9/28/21 at 9:30 AM, Surveyor interviewed RN (Registered Nurse)-D. RN-D confirmed RN-D completed the CAA assessments for R24. RN-D stated RN-D was also responsible for adding the recommendations for the care plans that were in the CAA's to the actual care plan document. RN-D reviewed the care plan and noted there were no care plan goals or interventions for mood, behaviors or antidepressant medication use or consequences. RN-D stated there was an expectation R24 would have those care plan interventions based on the CAA and MDS assessments, but forgot to add them. On 9/28/21 at 10:45 AM, Surveyor interviewed DON (Director of Nursing)-B and NHA (Nursing Home Administrator)-A. Surveyor shared the concern of no care plan goals or interventions for R24 specific to mood, behaviors or antidepressant medication use. DON-B confirmed that R24 should have corresponding care plan's based off the MDS and CAA assessment. No further documentation was provided.

Based upon interview and record review, the facility did not ensure facility standards of care for providing neurological checks and monitoring of vitals was completed for 3 (R4, R22, and R24) of 4 sampled residents reviewed for post-fall care. R4 had a fall on 8/1/21. The facility did not implement recommended changes following the fall. The facility did not complete neuro checks for R4 after that fall. On 9/2/21 R4 had a fall and was sent to the hospital for evaluation. R4 returned to the facility with a with a large hematoma above her right eye that was bleeding and R4 was unable to see out of her right eye. The facility did not complete neurological (neuro) checks after the fall. R22 had a fall. The facility did not complete neuro checks after R22's fall. R24 had a fall. After the fall, the facility did not complete neuro checks and vital signs for R24. Findings include: The facility's Fall Prevention and Management Policy was dated 10/2018, 2019, 2020 and provided the following information. 2.1 All Residents will be assessed for their fall risk upon admission, quarterly, annually, and with any significant change of condition, and after experiencing a fall. Based upon the results of the fall risk, interventions to manage/prevent future falls may be implemented as well as manipulation of the environment to prevent falls. 3.5 Once the fall risk has been determined and the interventions implemented, proceed to developing the Resident's care plan. Update plan of care on an ongoing basis. 3.10 Each shift will monitor Resident's vital signs, neurochecks, assess for bruising, related to fall, and document findings x 72 hours' post fall. 1. R4 is [AGE] years old and was admitted to the facility on [DATE]. The progress notes indicate that R4 is alert and oriented x 3, but forgetful. The 1/5/21 annual Minimum Data Set indicated that R4's balance was unsteady during transfers and walking. The 1/20/21 Fall Care Area Assessment indicated that R4 was at risk for falls. FALL 8/1/21 - NO NEURO CHECKS The progress notes documented the following information; At 8:09 PM, R4 was found in her room sitting on the floor next to the recliner chair. Her wheelchair was behind her. R4 stated that she was transferring from the recliner to the wheelchair and landed on the wheelchair arm rest and slid to the floor. No injuries were noted and R4 denied hitting her head. At 11:52 PM, the facility had completed an Event Report related to R4's fall. Part of the Event Report included a neuro check. The facility's Fall Policy, as noted above, indicated that neuro checks should be completed every shift for 72 hours after a resident has fallen. The facility should have completed neuro checks on all three shifts beginning on the 8/1/21 PM shift and ending on the 8/4/21 Day shift. Although some neuro checks were completed and documented in R4's progress notes; neuro checks were not completed on all three shifts for 72 hours. The following neuro checks were missing. 8/1/21 Night shift (into 8/2/21 Day shift) 8/2/21 Day shift 8/4/21 Day shift FALL 9/2/21 - NO NEURO CHECKS The progress notes documented the following information; At 3:59 PM, R4 was found in her room lying on her right side with her face down. She had a large bump over her right eye with bleeding and bruising. R4 stated that she was picking up a piece of popcorn off of the floor. Emergency Medical Services were called because of the head injury. At approximately 4:15 PM, R4 was transported to the hospital for further evaluation. According to the facility's fall policy, R4 should have had neuro checks completed on all three shifts; beginning upon her return from the hospital on the 9/2/21 PM shift and ending on the 9/5/21 day shift. There were no documented neuro checks in R4's medical record from 9/2/21 - 9/5/21. On 9/27/21 at 3 PM, the preceding information was shared with Nursing Home Administrator (NHA) - A and Director of Nursing (DON) - B. DON - B was unable to explain why the neuro checks had not been completed after R4's falls on 8/1/21 and 9/2/21. 2. R22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R22 has a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. R22 requires extensive assistance with support of 2 people for transfers, bed mobility and toileting. R22's MDS also indicates R22's balance is not steady during transfer, walking and transition. R22's MDS states there were no falls since the prior assessment. R22's Care Area Assessment (CAA) for falls has an assessment date of 1/11/21 with start date of 1/20/21. The CAA analysis of findings state Resident is here for LTC (long term care). (R22) triggered for this CAAs area due to being at risk for falls due to having problems with balance and having a history of falls. Surveyor reviewed R22's progress notes that indicated on 8/17/21 at 11:24 AM, Resident had an unobserved fall in R22's room. The progress note indicated: (R22) was getting up to go. Lying on R (right) side on top of bottom of rolling table. Recently readmitted with bacteremia and [CONDITION(S)] (urinary tract infection). Large injury to head with moderate to large amount of blood. Blood to RUE (right upper extremity), unable to determine location of injury due to positioning on the floor. 911 called, resident picked up at 1125 and sent to (hospital) for evaluation. POA (Power of Attorney) called. DON (Director of Nursing) notified. MD notified. Surveyor noted R22's progress note dated 8/17/21 at 6:07 PM, indicates R22 returned from hospital around 1330 (1:30PM). Laceration to top of head measuring 4cm, 6 sutures in place. Skin tear next to laceration on top of head measuring 3.5cm x 0.5 cm. Areas cleansed with normal saline. Any bandages unable to stay in place due to hair. While sitting up minimal to no bleeding. Will sleep with head of bed elevated. Skin tear to lower upper extremity crescent shaped 5cm. Cleansed with normal saline, applied steristrips, nonadherent with adhesive and soft roll gauze. Abrasion to upper lip. Cleansed with normal saline, applied triple antibiotic ointment. After visit summary from R22's emergency room visit due to fall and head injury; 1) CT head and neck done showing no acute abnormality. 2) OK to shower briefly and then apply topical antibiotics to skin tear as well as head laceration. 3) Watch for signs of infection such as redness, drainage, or fever. 4) Follow up with (hospital) in 10 days to remove sutures. 5) Follow up with MD in 1 week. The Facility's Fall Prevention and Management Policy, last dated 10/2020, indicates that neuro checks and vitals should be completed and documented every shift for 72 hours after a resident has fallen. Surveyor observed R22's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor vital signs every shift. Surveyor reviewed R22's neuro checks which reflected: -8/17/21 PM Shift, Surveyor found no vitals or neuro checks documented. -8/17/21 NOC Shift, Surveyor found no vitals documented, neuro check in progress note. -8/18/21 at 6:13AM (NOC shift of 8/17 Progress Note), Neuro Check. Resident very alert this am. Denied pain at this time due to recent fall. No drainage to head wounds overnight. Will continue to monitor. -8/18/21 AM Shift, Surveyor found no neuro checks documented. Vitals were documented. -8/18/21 PM Shift, Surveyor found no vitals or neuro checks documented. -8/18/21 NOC Shift, Surveyor found no vitals documented. Neuro checks in progress note. -8/19/21 at 6:20 AM (NOC shift 8/18 Progress Note), Neuro Check. Resident very sleepy this am. Denied pain at this time due to recent fall. No drainage to head wounds overnight. Will continue to monitor. -8/19/21 at 1:28 PM (Progress Note), Neuro Checks intact. No complaints of pain at this time due to recent fall. No drainage noted to head wounds or left arm. Will continue to monitor. -8/19/21 PM Shift, Surveyor found no vitals documented. Neuro checks documented in progress note. -8/19/21 at 11:26 PM (Progress Note), Neuro Check. Resident alert tonight. Red bruising noted around right eye and forehead. Denied pain at this time. No drainage to head wounds noted. Will continue to monitor. -8/19/21 NOC Shift, Surveyor found vitals documented. Neuro check documented in progress note. -8/20/21 at 6:20 AM (NOC shift 8/19 Progress Note), Neuro Check. Resident sleeping comfortably in room. Red bruising noted around right eye and forehead. Denied pain at this time. No drainage to head wounds noted. Vital signs as charted. Will continue to monitor. -8/20/21 at 2:39 PM (Progress Note), Resident alert and orientated at baseline. Denies pain throughout day. Neuro check within normal limits at baseline. Face and head wounds dry, no signs or symptoms of infection. Surveyor noted the facility did not complete neuro checks and vitals for R22 on all three shifts beginning on the 8/17/21 AM shift and ending on the 8/19/21 NOC shift ( no neuro checks on 8/17/21 AM, 8/17/21 PM, 8/17/21 NOC, 8/18/21 AM, 8/18/21 PM, 8/18/21 NOC, 8/19/21 AM, 8/19/21 PM, 8/19/21 NOC). Surveyor also noted some neuro checks and vitals were not completed as required on all three shifts for 72 hours, as well as, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor noted that the facility did not conduct 5 out of 9 opportunities to conduct vital signs post fall according to Facility policy. Surveyor noted the facility did not complete 3 out of 9 opportunities to conduct neuro checks post fall according to Facility policy. On 09/27/21 at 09:22 AM, Surveyor interviewed RN-C. RN-C stated the expectation is for neuro checks to be completed in progress notes for 72 hours post fall every shift and there is no form to complete for the neuro checks. Care plans are completed by nursing staff when there is a new issue. On 9/27/21 at 2:08 PM, Surveyor interviewed DON (Director of Nursing)-B. Surveyor confirmed with DON-B that neuro checks would be in the progress notes. The vitals as well as the neuro checks post fall should be completed for 72 hours after a fall every shift. Surveyor indicated the neuro checks and vitals could not be seen in the Electronic Health Record for R22. DON-B would look for further documentation. On 09/27/21 at 02:59 PM, Surveyor interviewed DON-B and NHA (Nursing Home Administrator) - A. Surveyor shared concern for not having complete neurological or vital sign documentation for R22 post fall on 8/17/21 for the 72 hours per policy. DON-B confirmed it was the expectation. No post fall huddle form could be found which would be the trigger for the fall analysis, care plan and new interventions. No further documentation or information was provided. 3. R24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's Admission Minimum Data Set (MDS), dated [DATE], indicated R24 has a Brief Interview for Mental Status (BIMS) of 8 indicating moderate cognitive impairment. R24 requires extensive assistance with support of 2 people for transfers, bed mobility and toileting. R24's MDS also indicates R24's balance was not steady during transfer, walking and transition. R24's MDS states R24 had a fall with a fracture in the 6 months prior to admission. R24's Care Area Assessment (CAA) for falls has an assessment date of 8/17/21 with worksheet start date of 8/27/21. The CAA worksheet's analysis of findings state Resident triggered for this CAAs area due to having a history of falls and having problems with balance. (R24) is working with therapy to improve function with the goal of returning home. Surveyor reviewed R24's progress notes that indicated on 8/15/21 at 5:57 PM, R24 had unobserved fall in room. Staff entered to find R24 lying flat on R24's back next to R24's broda chair. Brakes on broda chair. Gripper socks on. Soft touch call light on the floor with R24 but did not go off. Writer checked to see that the call light was functioning appropriately when pressed, and it is. ROM WNL (Range of Motion Within Normal Limits). States that pain is what already had, no worse no better. Staff assist x2 with Hoyer to get R24 off the floor. Room rearranged for space/safety. Will monitor vital signs every shift. On-call RN (Registered nurse) notified, POA (Power of Attorney) notified, MD notified. Surveyor noted R24's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor vital signs every shift. Surveyor reviewed R24's neuro checks and vitals in the Electronic Health Record which reflected: -8/15/21 NOC shift, Surveyor noted no documented vitals or neuro checks. -8/16/21 at 12:49 AM (Progress Note) Staff found that resident was fiddling with her call light and pulled the cord from the wall, wires detached from call light box. Facilities notified. -8/16/21 at 1:14 AM (Progress Note) Writer sitting outside of resident room for safety due to call light. She is talking to people who are not there. R24 is having visual hallucinations, seeing a little boy climbing the stairs. R24 also was asking where the baby is. R24 has been restless all night and has not slept. Writer assisted with taking resident to bathroom, noting a few clumps of sediment in the toilet. Hat placed for urine monitoring. -8/16/21 at 2:12 AM (Progress Note) Facilities arrived at 1:45 AM and fixed the call light. -8/16/21 AM Shift, Surveyor noted no vitals or neuro check documented. -8/16/21 at 8:54 PM (Progress Note) Neuro check done. Resident unresponsive to calling name and gently shaking. Would not open eyes or squeeze hand. Unable to sit up for transfer for Sara Steady. POA called to give update on resident's condition. Resident is DNR, so asked family if they would like R24 to go to the hospital for further evaluation. POA did not want resident sent to hospital but requested updates on 8/17. VS taken and were stable. -8/17/21 at 5:12 AM (Progress Note) Neuro check completed for fall 8/15. When writer asked if resident could squeeze my hand, resident was able to complete task x3. When writer asked to open eyes, resident was able to flutter them open. When writer asked if resident was in pain, resident did not respond in any way. VS as charted. Will continue to monitor. -8/17/21 at 9:25 AM (Progress Note) MD aware of resident unresponsiveness on PM shift last night. Continuing to monitor. This morning R24 is lethargic, but responding. Eating breakfast with prompting and assistance. Faxed MD for UA due to dark, foul urine and confusion. Requested to straight cath if unable to clean catch. -8/17/21 at 10:42 AM (Progress Note) Spoke with POA regarding suspected [CONDITION(S)] (Urinary tract infection), POA is in agreement with obtaining urine sample, stating R24 was symptomatic this way when had [CONDITION(S)]'s. POA is asking for her sibling to come visit. Will ask social worker. -8/17/21 at 12:36 PM (Progress Note) Varying alertness and lethargy, mostly lethargic. Responds to name and stimuli. -8/17/21 at 12:42 PM (Progress Note) MD approved straight cath to obtain urine sample. -8/17/21 AM Shift, Surveyor noted no neuro check documentation. Vitals were documented. -8/17/21 PM Shift, Surveyor noted no neuro check and no vitals documentation. -8/17/21 NOC Shift, Surveyor noted no neuro check documentation. Vitals were documented. -8/18/21 AM Shift, Surveyor noted no neuro check documentation. Vitals were documented. The facility did not complete neuro checks and vitals for R24 on all three shifts beginning on the 8/15/21 PM shift and ending on the 8/18/21 AM shift (no neuro checks on 8/15/21 PM, 8/15/21 NOC, 8/16/21 AM, 8/16/21 PM, 8/16/21 NOC, 8/17/21 AM, 8/17/21 PM, 8/17/21 NOC, 8/18/21 AM). Surveyor noted some neuro checks and vitals were not completed as required on all three shifts for 72 hours, as well as, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor noted that the facility did not conduct 3 out of 9 opportunities to conduct vital signs post fall according to Facility policy. Surveyor noted the facility did not complete 6 out of 9 opportunities to conduct neuro checks post fall according to Facility policy. On 09/27/21 at 09:22 AM, Surveyor interviewed RN-C. RN-C stated the expectation is for neuro checks to be completed in progress notes for 72 hours post fall and there is no form to complete for the neuro checks. On 9/27/21 at 2:08 PM, Surveyor interviewed DON (Director of Nursing)-B. Surveyor confirmed with DON-B that neuro checks would be in the progress notes. The vitals as well as the neuro checks post fall should be completed for 72 hours after a fall every shift. Surveyor indicated not all of the neuro checks and vitals could not be seen in the Electronic Health Record for R24. DON-B would look for further documentation. On 09/27/21 at 02:59 PM, Surveyor interviewed DON-B and NHA (Nursing Home Administrator) - A. Surveyor shared concern of the incomplete neurological or vital sign documentation for R24. DON-B confirmed it was the expectation and did not have any further documentation or information to provide.

Based on interview and record review, the facility did not ensure a resident was comprehensively assessed after a bladder catheter removal. This was observed with 1 (R5) of 1 residents with a Foley catheter. * R5 was admitted with a Foley catheter that was removed after a hospital stay for [CONDITION(S)] with a urinary tract infection. There was no bladder assessment after the Foley catheter was removed and R5 has periods of incontinence. Findings include: The facility's policy and procedure for Bladder assessment dated 2020 was reviewed by Surveyor. The policy indicates resident bladder will be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/22/21 at 10:16 AM Surveyor spoke with R5 in their room. R5 indicated they do not have a catheter for their bladder anymore. They indicated it was because of an infection. R5 indicated staff assist them to the bathroom. R5's medical record was reviewed. On 7/14/21, R5 was readmitted from the hospital for a [CONDITION(S)] (urinary tract infection) with [CONDITION(S)]. The Hospital Discharge Summary on 7/14/21 indicates a Foley catheter was placed for urinary retention. The Admission MDS(minimum data set) assessment completed on 7/12/21 indicates a Foley catheter is used for bladder. The progress note on 7/20/21 indicates the Foley catheter was removed and R5 expressed relief. The progress note on 07/20/2021 at 8:42 AM indicates a telephone order from the physician to remove the Foley catheter, monitor urine output and If no output by 3 p.m., insert straight cath. If bladder output is less then 150 mL(milliliters) reinsert catheter and consult Urology. The only Bladder assessment in R5's medical record was completed on 7/12/21. The Bladder assessment completed on 7/12/21 indicates R5 is currently incontinent of bladder, however no incontinence type or pattern. R5's Bladder charting daily output indicates R5 had a Foley catheter at this time. The Bladder assessment conducted on 7/12/21 is not accurate or comprehensive. After the Foley catheter was removed on 7/20/21 there is no comprehensive bladder assessment, nor toileting pattern. The daily bladder output after 7/20/21 and up to 9/27/21 indicates occasional bladder incontinence. On 09/23/21 at 09:53 AM Surveyor spoke with DON-B (Director of Nurses). DON-B indicated they would look into R5's bladder assessment. On 9/26/21 at 3:00 PM at the exit meeting with Administrator-A and DON-B Surveyor shared the concerns with R5 bladder assessment. There was no additional information provided.

Based on observation, interview and record review the facility did not ensure that all medications were labeled and stored in accordance with standard of practice for 1 of 1 medication room with the potential to affect 15 resident's who reside in the building. * 2 bottles of insulin for R18 were observed to be expired * A bottle of partially used insulin unlabeled and undated was observed. * 14 syringes of influenza vaccine were observed to be expired. Findings include: On [DATE] the facility's policy titled Storage and expiration of Medications, Biological's, Syringes and Needles was reviewed dated [DATE] and read: Facility should ensure that medications and biological's that have expired on the label, have been retained longer recommended by manufacturer or supplier guidelines are stored separate from other medications until destroyed or returned to the pharmacy. On [DATE] at 12:42 PM the facility's medication room was observed with Licensed Practical Nurse (LPN)-E. In the medication room refrigerator the following was observed: * R18's bottle of [MEDICATION NAME] with a date open of [DATE] * R18's bottle of [MEDICATION NAME] with a date open of [DATE] * A bottle of [MEDICATION NAME] Regular insulin partially used with no date open and no resident name. * 5 syringes of influenza vaccine with an expiration date of [DATE] * 9 syringes of influenza vaccine with an expiration date of [DATE] Immediately after the above observation LPN-E was interviewed and indicated insulin should be disposed of 30 days after it is opened and expired medication should be disposed of. LPN-E then took the expired medication to dispose of it. The above medications were observed to be commingled with other medications. On [DATE] the web site [MEDICATION NAME].com was reviewed and read: throw away all opened [MEDICATION NAME] vials after 28 days. On [DATE] the web site [MEDICATION NAME].com was reviewed and read: The [MEDICATION NAME] vials you are using should be thrown out after 28 days. The above findings were shared with the Administrator and Director of Nurses on [DATE] at 1:00 PM.

Based on interview, observation and record review, the facility did not ensure that 5 (R11, R24, R5, R6 and R16) out of 14 residents sampled for care planning had a comprehensive care plan developed that included individualized approaches to care to maintain highest level of functioning and safety. *The facility did not develop a comprehensive care plan for R11 after she developed a facility acquired pressure injury and did not develop a comprehensive care plan for R11's bladder incontinence. *The facility did not develop a comprehensive care plan for R24 that included a discharge plan. *The facility did not develop a comprehensive care plan for R16 for his gastrostomy tube ([DEVICE].) * The facility did not develop a comprehensive care plan for R6 after he developed facility acquired pressure injuries. *The facility did not develop a comprehensive care plan for R5 for monitoring [MEDICAL CONDITION] or to address a [DIAGNOSES REDACTED]. Findings include: Surveyor reviewed facility's Care Plan Policy with a review date of 10/2017. Documented under 2. Comprehensive Care Plan was a. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, and that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plans must describe the following: i. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. ii. Any services that would otherwise be required under Federal guidelines but are not provided due to the resident's right to exercise of their rights including the right to refuse treatment. iii. In consultation with the resident and the resident's representative, 1. The resident's goals for admission and desired outcomes. 2. The resident's preference and potential for future discharge. Facility with document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. 3. Discharge plans in the comprehensive care plan, as appropriate, in accordance with the state requirements. Findings include: 1. R11 was admitted to the facility 6/11/19 with [DIAGNOSES REDACTED]. Surveyor reviewed R11's admission MDS (Minimum Data Set) with an assessment reference date of 6/18/19. Documented under H0300. Urinary Continence was Occasionally incontinent (less than 7 episodes of incontinence). Documented under M0100. Determination of Pressure Ulcer/Injury Risk was [NAME] Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Documented under M0150. Risk of Pressure Ulcers/Injuries was 1. Yes. Surveyor reviewed R11's CAA's (Care Area Assessments) with a reference date of 6/18/19. Documented under Urinary Incontinence and Indwelling Catheter: Analysis of Findings was Resident triggered for this CAA area due to having incontinence and limitations with mobility that cause her to need extensive assistance with ADLs (activities of daily living.) Documented under 16. Pressure Ulcer/Injury was Existing pressure ulcer/injury .right coccyx, 0.3 x 0.5 cm, no drainage, odor, surrounding skin excoriated. Surveyor reviewed R11's Comprehensive Plan of Care with an initiation date of 6/11/19. There is no care plan for bladder incontinence. There is no care plan for a Stage 2 pressure injury. On 8/06/19 at 10:43 AM interviewed Director of Nursing (DON)-B. Surveyor asked if a resident triggers a CAA for incontinence should it be care planned. DON-B stated yes. DON-B was unable to find a care plan for R11's bladder incontinence. On 8/07/19 at 8:11 AM Surveyor interviewed DON-B. Surveyor asked why there was no care plan for R11's Stage 2 pressure injury. DON-B was unable to say why there was not a care plan developed. Don-B stated Yes, there should be a care plan for that. 2. R24 was admitted to the facility 4/12/19 with [DIAGNOSES REDACTED]. R24 was discharged to the community on 5/3/19. Surveyor reviewed R24's admission MDS (Minimum Data Set) with an assessment reference date of 6/18/19. Documented under Q0400. Discharge Plan was Is active discharge planning already occurring for the resident to return to the community? 1. Yes Surveyor reviewed R24's Comprehensive Plan of Care with an initiation date of 4/12/19. There is no care plan for discharge planning. On 8/07/19 at 10:00 AM Surveyor interviewed DON-B. Surveyor asked why there was no care plan for R24's discharge planning. DON-B stated there was one completed on discharge 5/3/19. Surveyor asked why there was not one developed on admission. DON-B stated she was unaware one needed to be developed on admission. 3. R16 was admitted to the facility 6/27/19 with [DIAGNOSES REDACTED]. Surveyor reviewed R16's CAA's (Care Area Assessments) with a reference date of 7/4/19. Documented under 13. Feeding Tubes was The resident is receiving feeding through a PEG tube until his swallowing improves and he is able to eat adequately to support his health. Surveyor reviewed R16's MD orders. Documented on 7/28/19 was flush [DEVICE] with 30 mL of water (every 12 hours) to maintain patency. Surveyor reviewed R16's Comprehensive Plan of Care with an initiation date of 6/27/19. There is no care plan for R16's [DEVICE]. On 8/06/19 at 1:09 PM Surveyor interviewed Licensed Practical Nurse (LPN)-E. Surveyor asked what nursing does with his [DEVICE]. LPN-E stated it gets flushed twice a day and monitored to make sure it is clean and dry. On 8/06/19 at 1:14 PM Surveyor interviewed DON-B. Surveyor asked why there was no care plan for R16's [DEVICE]. DON-B was unable to say why there was not a care plan developed. DON-B stated Yes, there should be a care plan for that. 4. R6 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 8/6/19 R6's initial Minimum (MDS) data set [DATE] indicated R6 had a stage 2 pressure injury that should be addressed in the care plan. On 8/6/19 R6's care plan was reviewed and did not include a comprehensive care plan for care and treatment of [REDACTED]. The only care plan in place was for at risk of pressure injury. On 8/6/19 R6's most recent measurement of his coccyx pressure injury was reviewed and read: 7/30/19 0.6 centimeters long by 0.3 centimeters wide. Stage 2. Date identified 7/1/19. R6 was observed throughout the survey to have measures in place to promote healing of his pressure injury and appeared to be receiving proper care and treatment. On 8/7/19 the facilities policy titled Care Plan Policy dated 10/17 was reviewed and read: The facility will develop a comprehensive care plan that included measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychological needs that are identified in the comprehensive assessment. A comprehensive care plan must be developed within 7 days after completion of the comprehensive assessment. On 8/7/19 at 1:30 PM the Director of Nurses was interviewed and indicated that R6 should have a care plan for care and treatment of [REDACTED]. 5. On 08/07/19, The facility's policy entitled Care Plan Policy was reviewed and read: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, and that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plans must describe the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 08/07/19, Surveyor reviewed R5's Minimum Data Set (MDS) dated on 05/04/19. The MDS indicated that R5 has a brief interview for mental status (BIMS) score of 15, indicating that R5 is cognitively intact. The MDS also indicated that R5 received a diuretic (diuretic medication is the medication which treats a fluid retention ([MEDICAL CONDITION]) and swelling caused by the kidney disease and other medical conditions) seven out of seven days. On 08/05/19 at 10:13 am, Surveyor conducted an interview with R5. R5 indicated that she had a [MEDICAL CONDITION] and that the condition was severe. R5 also indicated that she might require [MEDICAL TREATMENT] in the near future due to her poor kidney function. R5 indicated she had had a [MEDICAL CONDITION] for many years, and indicated that her physician was discussing possible [MEDICAL TREATMENT] treatment ([MEDICAL TREATMENT] is a procedure performed with a machine that removes waste from the body, while keeping a safe level of certain chemicals for people with the severe kidney disease). Surveyor noted bilateral (both) [MEDICAL CONDITION] (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body) to R5's lower legs and lower arms. On 08/06/19, Surveyor reviewed R5's medical record which indicated that R5 was admitted into the facility on [DATE] with the medical [DIAGNOSES REDACTED]. R5's physician order [REDACTED]. Physician orders [REDACTED]. legs. On 08/07/19, Surveyor reviewed the plan of care for R5 which indicated that R5 did not have an active care plan for R5's [MEDICAL CONDITION] nor for the severe kidney disease. R5's urinary incontinence plan of care indicated to encourage R5 to drink a lot of fluids throughout the day. On 08/07/19 at 8:35 am, Director of Nursing (DON)-B indicated that the plan of care has to be initiated for all residents with the [MEDICAL CONDITION]. DON-B also indicated that R5 should be drinking a lot of fluids because R5 had a medical history of [REDACTED]. On 08/07/19 at 10:05 am, Surveyor observed R5 was sitting in the wheelchair and R5's legs were not elevated. R5 continued to have [MEDICAL CONDITION] present to her lower legs. On 08/07/19 at 11:00 am, Administrator-A and DON-B were made aware of the findings above.

Based on observation, interview and record review the facility did not ensure that it maintained a medication error rate below 5 percent during observations of medication administration affecting 3 (R18, R21 and R26) of 4 residents observed. Three medication errors were observed out of twenty-five opportunities, for a total error rate of 16%. * R18 was administered a dose of insulin for a [MEDICATION NAME] pen that was not primed. * R21 was administered an inhaler without waiting at least 30 seconds between inhalations. * R26 was administered tamsulosin ([MEDICATION NAME]) before eating and not 30 minutes after eating per manufacturers instructions. R26 was also almost administered aspirin that expired on ,[DATE]. Findings include: 1. R18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:49 AM Registered Nurse (RN)-C was observed administering [MEDICATION NAME]to R18 via a flex pen. RN-C took R18's blood glucose which measured 300. RN-C then Placed a new needle on R18's [MEDICATION NAME] flex pen and dialed a dose of 14 units. RN-C then administered the insulin to R18. RN-C did not prime the needle using 2 units to expel air from the needle before administering R18 her insulin. On [DATE] R18's current physician orders [REDACTED]. On [DATE] the manufacturers web site novomedlink.com was reviewed and read: priming the [MEDICATION NAME] pen before each use hold the dose selector to 2 units press and hold the button . A drop of insulin should be seen in the needle tip. On [DATE] at 10:00 AM the Director of Nurses was interviewed and indicated R18's [MEDICATION NAME] pen should be primed before each use. 2. R21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 7:50 AM Registered Nurse (RN)-C was observed administering a [MEDICATION NAME] inhaler to R21. RN-C handed R21 the [MEDICATION NAME] inhaler. R21 shook the inhaler, took an inhalation, shook it again and took another inhalation 10 seconds later. RN-C sis not give an instructions to R21 to wait 30 seconds before the second inhalation. On [DATE] R21's current physician orders [REDACTED]. On [DATE] the manufactures web site [MEDICATION NAME].com was reviewed and read: After the initial inhalation wait 30 seconds and repeat the inhalation. 3. R26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 8:08 AM Registered Nurse (RN)-C was observed administering medication to R26. RN-C asked R26 if he had eaten breakfast and R26 indicated not yet. RN-C then pored an [MEDICATION NAME] coated aspirin 81 milligrams (MG) from a stock bottle with an expiration date of ,[DATE]. RN-C then popped a tamsulosin 0.4 MG from a bubble pack that had a sticker that read administer 30 minutes after eating. RN-C then went to hand R26 the medication cup and the surveyor stopped and showed her the expired bottle of aspirin. RN-C then took the aspirin out of R26's medication cup and went to the medication room to get a new bottle of aspirin. RN-C then administered R26's medication. R26 was observed to get his breakfast at 8:20 AM. On [DATE] R26's current physician orders [REDACTED]. On [DATE] the manufactures web site [MEDICATION NAME].com was reviewed and read: take [MEDICATION NAME] one time each day, 30 minutes after the same meal each day. [MEDICATION NAME] is to be taken after meals to reduce cardiovascular side effects as taking it on an empty stomach increases its absorption up to 70%. The above findings were shared with the Administrator and Director of Nurses on [DATE] at 2:45 PM.

Based on observation, interview, and record review, the Facility did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries for 1 (R2) of 3 Residents reviewed for pressure injuries. R2 was observed to have an unstageable pressure injury to his right heel that started as a blister on 3/21/19 (facility acquired) and 2 stage 2 pressure injuries to his coccyx that he was admitted with; R2 was observed not to have pressure relief to his heels while in bed. The air mattress was observed to be deflated and R2's heels rested directly on the mattress on 4/9/19. Furthermore during observation of the treatment to R2's heels and coccyx proper infection control practices were not used and possible contamination of the pressure injuries was observed. R2's pressure injuries were not staged or described with characteristics of the wound other than measurements following initial documentation on 3/21/19. R2's Physician was not notified when his heel pressure injury deteriorated from a stage 2 blister to unstageable. Findings include: R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's Initial Minimum Data Set (MDS) with a reference date of 3/13/19 was reviewed and indicated R2 has 2, stage 2 pressure injuries to his coccyx. The MDS also indicated R2 had a Brief Interview for Mental Status score of 13 (Intact long and short term memory.) R2's pressure injury care plan dated 3/1/19 was reviewed and indicated: Elevate heels on pillows when possible while in bed. R2's event report dated 3/21/19 for his right heel pressure injury indicated: Pressure ulcer right heel intact blister 3 centimeters (cm) X 2.7 cm. Stage 2. Notify Medical Doctor if decline. R2's Physician order [REDACTED]. On 4/10/19 R2's right heel measurements were reviewed and no staging or discription of wound characteristics of R2's right heel pressure injury could be found after 3/21/19. On 4/9/19 at 10:20 AM Surveyor observed R2 in his bed on an air mattress Surveyor observed the air mattress was off and the bed was flat. R2 indicated he was uncomfortable. R2's heels were observed to be in contact with the bed. A pillow was under R2's legs but the pillow was flat allowing R2's heels to come in contact with the bed. Surveyor observed wound care on 4/9/19 at 10:30 AM and noted that proper infection control technique was not employed throughout the treatment. (Cross-reference F880). At the conclusion of the treatment, RN-C placed a pillow under R2's legs but the height of the pillow was not enough to elevate R2's heels off the mattress. RN-C and Licensed Practical Nurse (LPN)-D then left the room. R2's bed was still not inflated and the bed frame could be felt when pressing on the mattress. R2's heels were directly on the mattress. R2 then indicated he was very uncomfortable and could feel the bed wasn't inflated. R2 requested the Surveyor tell someone about the mattress. On 4/9/19 at 10:50 AM the Surveyor brought Director of Nurses (DON)-B into R2's room to show her the deflated mattress. DON-B indicated the bed should be inflated and turned the bed on which immediately inflated. R2 then indicated the bed was much more comfortable. R2's heels still remained in contract with the mattress. On 4/9/19 at 12:35 PM R2 was observed in bed with his heels directly on the mattress. On 4/9/19 at 1:50 PM R2 was observed in bed with his heels directly on the mattress. At 1:53 PM R2 was repositioned and his heels were elevated off the mattress with the use of 2 pillows. On 4/10/19 at 8:50 AM DON-B was interviewed and indicated she assessed R2's right heel pressure injury and indicated it was a stage 2 because the whole wound bed isn't covered by slough (no slough was noted to be in R2's right heel pressure injury on 4/9/19 per observation of the Surveyor it was covered by black necrotic tissue). DON-B indicated if any part of the wound bed is visualized it is a stage 2. DON-B indicated she did not know when the blister opened up but it was some time ago. On 4/10/19 at 9:55 AM Administrator-A was interviewed and indicated he and DON-B called the wound clinic yesterday and the facility is staging R2's pressure injury incorrectly and if it had slough it is a stage 3 (no slough was noted to be in R2's right heel pressure injury on 4/9/19 per observation of the Surveyor it was covered by black necrotic tissue). Administrator-A indicated R2's physician should have been notified when R2's blister opened and was not. (Cross-reference F580). On 4/10/19 R2's current physician's orders [REDACTED]. Notify Medical Doctor if decline. On 4/10/19 at 10:10 AM DON-B and Assistant Director of Nurses-E assessed R2's right heel ulcer which measured 1.5 cm x 0.9 centimeters and were assessed as unstageable by DON-B. The above findings were shared with the Administrator and DON on 4/11/19 at 11:00 AM. Additional information was requested if available.