Every finding on record at Greentree Health and Rehabilitation Center

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or had an associate's or higher level degree in food service management or hospitality. This practice had the potential to affect all 32 residents residing in the facility. Findings include: During an initial kitchen tour on 7/13/26 that began at 8:18 AM, Dietary Manager (DM)-C indicated they had not received their Dietary Manager certification. DM-C stated they were currently enrolled in classes, but had not completed them. DM-C stated the facility's Registered Dietician ((RD)-D) was not a full-time employee and was usually at the facility once every other week. On 7/13/26, Surveyor requested the required certification for DM-C or an applicable waiver. On 7/14/26 at 9:44 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the facility did not have a waiver for their Dietary Manager and did not know they needed one. On 7/14/26 at 2:34 PM, Surveyor interviewed RD-D who confirmed they are not a full-time employee of the facility. RD-D stated they are at the facility in person every other week and attend weekly phone meetings.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect 2 residents (R) (R25 and R7) of 14 sampled residents. R25 was on transmission-based precautions (TBP). Staff did not wear the appropriate personal protective equipment (PPE) during cares. In addition, a TBP sign outside R25's room was not in accordance with their order. R7 was on enhanced barrier precautions (EBP). Staff did not wear the appropriate PPE during cares. Findings include: The facility's IPCP Standard and Transmission Based Precautions policy, revised July 2026, indicates: .Transmission-based precautions (TBP) are the second tier of basic infection control and are used in addition to standard precautions for residents who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission .Enhanced Barrier Precautions (EBP): .a. Personal Protective Equipement (PPE): The use of gowns and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with: i. Wounds and/or indwelling medical devices regardless of multidrug-resistant organism (MDRO) colonization .c. Examples of high-contact resident cares requiring gown and glove use for EBP include: i. Dressing, ii. Bathing/showering, iii. Transferring, iv. Providing hygiene, v. Changing linens, vi. Changing briefs or assisting with toileting, vii. Device care or use: .indwelling urinary ., viii Wound care: any skin opening requiring a dressing .4. Droplet precautions are used for residents known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by coughing, sneezing, or talking .c. Use PPE appropriately. i. [NAME] mask (and eye protection if indicated) upon entry into the resident's room or space. d. Limit transport and movement of residents outside of the room to medically necessary purposes .The facility will implement a system to alert staff, residents, and visitors that a resident is on TBP. i. Post clear signage on the door or wall outside the resident's room indicating the type of precautions and the required PPE . 1. R25 was admitted to the facility on [DATE]. On 7/10/26, R25 returned from the hospital with a suspected pneumonia diagnosis. A Minimum Data Set (MDS) assessment, dated 4/24/26, stated R25 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. R25's Medication Administration Record (MAR) contained an order initiated 7/10/26 that indicated: Isolation: Droplet Precautions-PPE: Gown, mask, and gloves every shift for pneumonia. A care plan indicated R25 was on an antibiotic for pneumonia and droplet precautions which required the use of a gown, mask, and gloves (initiated 7/10/26). On 7/13/26 at 9:51 AM, Surveyor observed the entry to R25's room. A facility-made sign indicated they were on droplet and standard precautions. The sign indicated staff should complete hand hygiene and don a mask before entering the room and should complete hand hygiene and dispose of the mask prior to exiting the room. On 7/13/26 at 10:00 AM, Surveyor observed Activity Director (AD)-E enter R25's room. AD-E then exited the room, donned a mask from a PPE cart across the hall, re-entered the room, and asked if R25 wanted to do group activities. R25 said they could not. AD-E then exited the room. AD-E did not don PPE the first time they entered the room or complete hand hygiene upon entering and exiting the room either time. On 7/13/26 at 10:03 AM, Surveyor interviewed AD-E who stated they should have worn a mask to enter R25's room. AD-E was unsure if they needed to don a gown or gloves. When asked if they were going to take R25 to an activity, AD-E stated they forgot R25 was on precautions. On 7/14/26 at 3:38 PM, Surveyor interviewed Infection Preventionist (IP)-F who stated the droplet precautions sign on R25's door was not clear and staff had questions about what PPE to wear. IP-F stated staff should wear a gown, gloves, and a mask to enter the room and goggles if R25 was coughing. On 7/15/26, Surveyor observed the same sign posted outside R25's room which was not in accordance with the order on R25's MAR or their care plan. On 7/15/26 at 11:53 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the sign outside R25's room was old. DON-B stated the facility follows the Centers for Disease Control and Prevention (CDC) guidelines for TBP. DON-B stated precautions signs should be consistent with orders and PPE needs based on a resident's diagnosis. DON-B stated staff had PPE questions related to R25's sign and TBP requirements. 2. R7 was admitted to the facility on [DATE] and had diagnoses including pressure ulcer of the right hip (stage 4), neuromuscular dysfunction of bladder, and urinary device fitting. R7 had an indwelling catheter and required assistance with personal care. An MDS assessment, dated 6/15/26, stated R7 had a BIMS score of 15 out of 15, indicating intact cognition. On 7/13/26 at 10:09 AM, Surveyor observed the entry to R7's room which contained a CDC EBP sign that indicated: ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean hands, including before entering the room and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting. Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound Care: Any skin opening requiring a dressing. Surveyor also observed a PPE cart near the doorway that contained gowns and gloves. On 7/13/26 at 1:26 PM, Surveyor observed Licensed Practical Nurse (LPN)-G exit R7's room. LPN-G indicated they had provided care for R7. When asked what PPE they wore during cares, LPN-G stated they wore a gown and gloves and disposed of the PPE in the room. On 7/13/26 at 1:27 PM, Surveyor interviewed R7 who stated LPN-G attempted to get a urine sample from their catheter. R7 stated LPN-G wore gloves but not a gown. R7 stated LPN-G disposed of their gloves in the garbage can by their bed. Surveyor observed a pair of gloves in the garbage can but not a gown. Surveyor also observed the garbage in R7's bathroom and gown receptacle which were empty. On 7/13/26 at 1:34 PM, Surveyor again interviewed LPN-G who indicated they did not wear a gown during cares for R7 but should have. On 7/15/26 at 11:53 AM, Surveyor interviewed DON-B who verified LPN-G should have worn a gown while attempting to obtain R7's urine sample.

Based on interview and record review, the facility did not complete a Pre-admission Screening and Resident Review (PASRR) assessment for 1 resident (R) (R37) of 14 sampled residents. R37 was admitted to the facility on [DATE]. A PASRR Level I Screen was not completed at the time of admission. Findings include: The facility's PASRR policy and procedure, revised 4/2026, indicates: .A PASRR shall be completed for every resident upon admission. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to a resident with mental illness/mental retardation (MI/MR). Social Services shall contact the appropriate state agency for referral of specialized care and services the resident may require. Care plans will be updated to reflect any specialized services needed. R37 was admitted to the facility on [DATE] and had diagnoses including mild cognitive impairment and generalized anxiety disorder. R37's medical record contained a PASRR Level I Screen that was dated 11/17/25 and was from a previous stay at the facility. On 7/13/26, Surveyor requested R37's PASRR documentation for the current admission. On 7/13/26 at 4:26 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated R37's PASRR Level I Screen was missed.On 7/14/26, the facility provided R37's PASRR Level I Screen which was completed after Surveyor's initial request. The PASRR indicated R37 had a serious mental illness and a 30-day hospital discharge exemption.

Based on observation, interview, and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 1 resident (R) (R37) of 1 sampled resident from a total sample of 14 residents. The facility did not ensure R37's treatment orders for a removeable boot were clearly defined or followed. Findings include: The facility's Positioning Devices policy, revised 5/2026, indicates: .A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device per provider's orders. Residents will be assessed to ensure positioning devices are properly used per provider's orders and residents are not at an increased risk for complications (e.g., skin breakdown, contractures, breathing problems, pain, etc.) . The facility's Skin/Wound Management policy, revised 6/2026, indicates: .It is the policy of this facility to have a weekly skin/wound assessment completed by a licensed nurse .for those residents admitted with a dressing to a wound or cast/splint to an extremity .When a resident is admitted with or returns to the facility with a dressed wound or a cast/splint that is being managed outside the facility, nursing staff shall assess and evaluate the dressed/casted/splinted area at least weekly to check the status of the skin . R37 was admitted to the facility on [DATE] with a right ankle fracture. A Comprehensive Minimum Data Set (MDS) assessment, dated 6/2/26, stated R37 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Seven Braden Scale assessments (used to determine a resident's risk for developing pressure injuries) between 5/19/26 and 6/30/26 indicated R37 was at risk for developing pressure injuries. Discharge summaries from the following appointments indicated: ~ 5/19/26: Splint to right ankle to remain intact until orthopedic follow-up appointment. ~ 6/2/26: Short leg cast applied. Follow-up in 3 weeks or sooner if needed. ~ 6/23/26: R37 is still in a short leg cast. Follow-up in two weeks. Will likely remove cast and place walking boot. Next follow-up appointment is 7/7/26 at 9:00 AM. A progress note written by orthopedic Physician Assistant (PA)-L on 7/7/26 indicated the cast was removed. There was no redness, induration, or skin breakdown and the surgical incisions were healed. The note indicated: 1) Activity modification - wear the boot 24/7 but can remove for hygiene purposes and twice for gentle range of motion exercises. You are strictly not to bear any weight on your right foot . A progress note on 7/7/26 indicated R37 was seen by ortho on 7/7/26 and returned with the following orders/recommendations: Wear the boot 24/7 but can remove for hygiene purposes and twice for gentle range of motion exercises. You are strictly not to bear any weight on your right foot. R37's July 2026 Treatment Administration Record (TAR) included the following order: Wear the boot 24/7 but can remove for hygiene purposes and twice for gentle range of motion exercises. You are strictly not to bear any weight on your right foot. (Every shift - dated 7/8/26). A shower skin check form on 7/10/26 indicated R37 had a right walking boot and staff washed and applied lotion to their lower legs. A skin assessment on 7/10/26 did not indicate R37 had an external device or boot. On 7/13/26 at 11:03 AM, Surveyor interviewed R37 who stated when they admitted to the facility, they had a hard cast on their right lower leg due to an ankle fracture that required surgery. R37 stated the cast was removed a week ago and they wore a removable boot (with foam and Velcro straps) on their right lower leg. R37 stated staff had only removed the boot once. On 7/14/26 at 11:14 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-H who stated nurses complete a weekly head-to-toe skin assessment on a resident's shower day. LPN-H stated R37 had a wound that required a cream (not the ankle) but did not have other skin issues. LPN-H stated they ensure R37's boot is not too tight but do not remove the boot to assess their skin. On 7/14/26 at 11:19 AM, Surveyor interviewed R37 who stated they received a bed bath that morning, but Certified Nursing Assistant (CNA)-I did not remove their boot. R37 stated Assistant Director of Nursing (ADON)-F was the only one who removed the boot and washed the skin underneath. R37 stated no one had removed the boot to complete range of motion on their right ankle. On 7/14/26 at 11:25 AM, Surveyor interviewed CNA-I who stated nurses take care of R37's boot. CNA-I verified they gave R37 a bed bath that morning but did not remove the boot. CNA-I stated the boot was removed on 7/11/26 because it was bothering R37. CNA-I washed R37's toes and applied lotion. CNA-I stated there was a light bruise on the top of R37's second toe which may have been from surgery and the incision looked healthy. CNA-I did not report the bruise to the nurse. On 7/14/26 at 11:32 AM, Surveyor interviewed CNA-J who stated they gave R37 a partial bed bath which did not include their legs and they did not remove their boot. CNA-J stated a nurse checks a resident's skin during a full bed bath. On 7/14/26 at 3:11 PM, Surveyor interviewed LPN-K who stated R37 should keep the right foot elevated. LPN-K stated they offered ice but R37 refused. LPN-K stated they peek at R37's right leg once per shift and offered to show Surveyor how they assess the leg. At 3:13 PM, LPN-K and Surveyor entered R37's room. LPN-K loosened the boot by undoing the Velcro straps and assessed the top of the leg. LPN-K did not take R37's foot out of the boot. When Surveyor asked how they assess the skin that is in the boot, LPN-K asked R37 to lift their leg and removed the boot. LPN-K assessed R37's right lower leg, ankle, and foot and identified three reddened areas. LPN-K stated they would write a progress note and inform ADON-F. LPN-K stated R37's leg needed to be exfoliated and washed. When LPN-K asked if they had a bed bath that day, R37 stated yes, but staff did not remove the boot and that was only the second time the boot had been removed. Following the observation, LPN-K stated R37's TAR should contain orders for the boot. LPN-K and Surveyor reviewed R37's TAR and noted the following order: Wear the boot 24/7 but can remove for hygiene purposes and twice for gentle range of motion exercises. You are strictly not to bear any weight on your right foot. Every shift. LPN-K stated the order needed clarification and they would talk to ADON-F. A progress note by LPN-K on 7/14/26 at 3:29 AM indicated the boot was removed from R37's right lower extremity and toe sensation was intact. There was a reddened area behind the great toe. The skin was dry and flaky on the entire leg. There was also a pinpoint area on the top of the foot near the little toe. Rubbing was observed on the skin on the back of the calf where the boot met the calf. Clarification was needed for the orders. The note indicated to add to the TAR that staff remove the boot off once per shift, check skin and sensation, and assess for pressure injuries. On 7/14/26 at 3:32 PM, Surveyor interviewed ADON-F who was also a wound nurse. When Surveyor informed ADON-F of the observation with LPN-K and R37, ADON-F stated they removed R37's boot last week and cleaned and applied lotion to the skin underneath. ADON-F agreed the boot should be removed daily for cleaning and inspection. ADON-F stated R37 had a hard cast until last week which is why ADON-F assessed the skin under the boot for dressings and incisions. ADON-F stated the surgical wounds did not contain a dressing and the wounds were well approximated. ADON-F did not document the condition of R37's skin because the surgical wounds appeared healed. ADON-F stated R37's heel was pink but blanchable and there were no concerning areas. ADON-F stated they would assess R37's right leg and contact the physician about removing the boot more while in bed since R37 did not get up and understood the need to be non-weight bearing. A progress note by ADON-F on 7/14/26 at 6:25 PM indicated there was a small scab with serous crust on the dorsolateral aspect of R37's right foot where the plastic portion of the air cast was rubbing (0.7 x 0.6 x 0.1) and an area on the distal portion of the incision on the medial malleolus (0.3 x 0.6 x 0.1) with scant serous drainage. The areas were cleaned with soap and water and bandages were applied. Lotion was applied to the intact skin. There was a recommendation for daily changes to assess for any changes. The remaining incisions were well approximated. There were multiple other areas of pink, blanchable skin and a small bruise on the plantar aspect of the medial arch. The medial aspect of the foot contained purple discoloration and what felt like hardware/a screw fixation/or scar underneath a 0.2 x 0.4 area that was not open or weeping and not blanchable. The cast padding was adjusted before reapplication. The note indicated an order would be added to R37's TAR to remove the air cast every shift to assess the skin and ensure the padding is protecting the skin. Recommendations: Right dorsolateral and medial ankle: Remove bandages and wash foot and lower extremity with soap and water. Apply lotion to intact skin and apply protective bandages. Clean air cast boot Monday, Wednesday, and Friday. Nursing to contact ortho in the AM on 7/15/26 to see if the air cast can be off for longer rest periods while in bed with the lower extremity elevated. On 7/15/26 at 10:54 AM, Surveyor interviewed ADON-F who stated they would create a skin issues form based on their findings. ADON-F stated they repositioned the foam under R37's boot and no pressure injuries were identified. ADON-F agreed the order in R37's TAR should have been clarified.

Based on observation, interview, and record review, the facility did not ensure a motorized scooter battery was charged in a safe location for 1 resident (R) (R12) of 1 sampled resident. R12 had a motorized scooter. The facility chaged the battery in R12's room. Findings include: The facility's Motorized Assistive Device Policy, revised 4/2026, indicates: .Charging: When in need of charging, a device must be charged in a designated approved location. The following must be adhered to: i. The area is free from combustible materials; ii. Charging is not allowed in resident rooms, exits, and egress pathways; iii. Charging must occur on a stable, non-combustible surface away from flammable items. R12 was admitted to the facility on [DATE] and had a progressive neurological condition. An admission Minimum Data Set (MDS) assessment, dated 7/12/21, indicated R12 used a motorized scooter. A Quarterly MDS assessment, dated 4/20/26, also indicated R12 used a motorized scooter. On 7/13/26 at 11:35 AM, Surveyor observed R12's room which contained a battery charger for a motorized scooter that plugged into a wall outlet. R12 was in the scooter. The battery charger was also observed in the room on 7/14/26 and 7/15/26. On 7/15/26 at 1:22 PM, Surveyor interviewed Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-F who stated R12 prefers to charge their scooter in their room at night. DON-B expressed understanding of the potential safety concern and stated they will find a safe space to charge the scooter.

Based on staff interview, record review, and policy review, the facility failed to timely report an allegation of physical abuse for 2 residents (R) (R1 and R2) of 3 sampled residents. On 7/24/25 at approximately 6:30 AM, R1 put R1's arms around R2's neck, pulled R2 toward R1, and pinched R2's ear. Staff stated R2 appeared upset and did not want the interaction to occur. Staff did not report the abuse until another incident occurred that afternoon. Findings include:Review of the facility's Abuse Prevention policy, dated 7/2024, indicated it is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. All alleged violations will be reported via phone or in writing within two hours to the State LicensingAgency.Review of R1's Face Sheet indicated R1 was readmitted to the facility on [DATE] with diagnoses including mental disorder, schizophrenia, major depressive disorder, and cognitive communication deficit.Review of R2's Face Sheet indicated R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, and chronic kidney disease. Review of a Misconduct Incident Report provided by the facility, dated 7/30/25 at 2:36 AM, indicated that while investigating an incident between R1 and R2 on 7/24/25 at approximately 3:55 PM, the facility discovered another incident that occurred that morning at approximately 6:30 AM. The incident was witnessed by staff but not reported. During an interview on 10/9/25 at 11:28 AM, Licensed Practical Nurse (LPN)1 stated on the morning of 7/24/25 at approximately 6:30 AM, R2 was tearful when another staff informed LPN1 they saw R1 pinch R2's ear. LPN1 said R1 put R1's arms around R2's neck and pulled R2 toward R1. When R2 became upset about the interaction, R1 pinched R2's ear. LPN1 stated LPN1 observed R2 who appeared upset and did not want the interaction to occur. LPN1 stated the residents were separated, however, LPN1 did not report the abuse it until it happened again that afternoon. LPN1 agreed LPN1 should have reported the first occurrence which may have prevented the second occurrence. During an interview on 10/9/25 at 1:13 PM, the Director of Nursing (DON) stated staff should have reported the incident that occurred on the morning of 7/24/25.

Based on staff interview, record review, and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II referral was completed after a significant change in mental status for 1 resident (R) (R1) of 1 resident reviewed. A psychiatric evaluation on 7/23/25 indicated R1 had self-injurious behaviors and hit/pinched others. The evaluation contained recommendations to increase R1's divalproex (anticonvulsant medication) and quetiapine (antipsychotic medication). A PASARR Level II referral was not completed.Findings include:Review of the facility's Resident Assessment - Coordination with PASARR Program policy, dated 7/24, revealed the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Any Level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. Examples include: a. A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms. A resident whose condition or treatment is or will be significantly different from that described in the resident's most recent PASARR Level II evaluation and determination.Review of R1's Face Sheet indicated R1 was readmitted to the facility on [DATE] with diagnoses including mental disorder, schizophrenia, major depressive disorder, and cognitive communication deficit.Review of R1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 9/2/25, indicated R1 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R1 had severe cognitive impairment. Review of R1's State of Wisconsin Department of Human Services Pre-admission Screening and Resident Review (PASARR) Level I Screen, dated 3/24/24, indicated R1 did not meet the criteria for Level II because R1 did not meet the criteria for sections two and three.Review of R1's Psychiatric Evaluation, dated 7/23/25, indicated R1 was evaluated due to behaviors including self-injurious behavior and hitting and pinching others. The evaluation contained recommendations to increase divalproex (anticonvulsant medication) and quetiapine (antipsychotic medication) and evaluate the appropriateness of R1's current level of care. Review of Progress Notes between May 2025 and October 2025 indicated R1 had 16 documented incidents of self-harm, 11 incidents of aggression toward staff, 4 incidents involving other residents, and 9 incidents of different behaviors. During an interview on 10/9/25 at 2:09 PM, the Social Services Director (SSD) was aware of R1's increase in behaviors, however, it did not occur to her to check if R1 needed a PASARR Level II referral. During an interview on 10/9/25 at 1:13 PM, the Director of Nursing (DON) stated she attended R1's July psych meeting. The DON stated the facility was aware of R1's behaviors, had been trying to address them, and was in the process of finding alternate placement for R1. The DON was unsure of the PASARR process.

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R86) of 1 sampled resident was transferred appropriately and in accordance with the facility's policy. On 4/5/25, Certified Nursing Assistant (CNA)-K transferred R86 without a gait belt. R86 fell during the transfer and sustained a head injury that required 3 staples. Findings include: The facility's Safe Resident Handling/Transfers Policy, revised 12/2024, indicates: It is the policy of this facility to ensure residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping employees safe in accordance with current standards and guidelines .All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them .Compliance Guidelines: 1. The Interdisciplinary Team (IDT) or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well as weight and cognitive status .5. Handling aids may include gait belts .and other devices .11. Staff will be educated on the use of safe handling/transfer practices .upon hire, annually, and as the need arises or changes in equipment occur .13. Staff are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. 14. Resident lifting and transferring will be performed according to the resident's individual plan of care . The facility's Fall Prevention Program policy, revised 12/2024, indicates: .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. On 4/21/25, Surveyor reviewed R86's medical record. R86 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (stroke) affecting the right dominant side and long-term use of anticoagulant (blood thinning) medication. R86's Minimum Data Set (MDS) assessment, dated 4/4/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R86 was not cognitively impaired. The MDS assessment indicated R86 transferred with substantial/maximal assistance from staff. An admission activities of daily living (ADL) self-care performance deficit care plan (initiated 1/3/25) indicated R86 required substantial/maximal assistance with transfers with a hemi-walker for wheelchair to bed, bed to wheelchair, wheelchair to recliner, recliner to wheelchair with hemi-walker, minimal assistance and 1 person. The care plan indicated staff should use a 2-wheeled walker for safety with clothing and hygiene for toileting. A therapy communication sheet on transferring for Certified Nursing Assistants (CNAs), dated 3/13/25, indicated: Please resume transferring (R86) (to/from) wheelchair and bed, (to/from) wheelchair and recliner, and (to/from) wheelchair and toilet with hemi-walker and (minimal) (assistance) of one; For toileting, use 2 (wheeled-walker) for safety with clothing and hygiene. On 4/21/25 at 10:07 AM, Surveyor interviewed R86 who indicated R86 fell when getting into bed. R86 indicated R86 hit R86's head and received staples at the hospital. Surveyor observed several scabs on the right side of R86's head. R86's medical record indicated R86's provider was notified of the fall on 4/5/25 and gave an order to send R86 to the Emergency Department (ED) due to a laceration on the right side of the head. An ED discharge summary, dated 4/5/25, indicated R86 stated R86 was trying to stand without a gait belt and fell which caused a laceration on the right side of R86's head. R86 was on anticoagulant medication and sustained a 1.5 centimeter (cm) right temporal laceration with active bleeding. A computed tomography (CT) scan of the head and neck indicated R86 incurred a right frontal scalp hematoma (abnormal pooling of blood in the body under the skin)/laceration. An office visit note, dated 4/7/25, indicated R86 was seen in the ED for a head laceration on 4/5/25. R86 received staples that were to be removed in 10 to 14 days. On 4/22/25, Surveyor reviewed a summary of R86's fall, dated 4/7/25, and noted verbal education on using a gait belt during transfers was provided to CNA-K via phone. On 4/22/25, Surveyor reviewed CNA-K's witness statement, dated 4/5/25, that indicated CNA-K assisted R86 by pivot/walking with a walker next to R86's bed. R86 fell forward and hit R86's head on the bed frame. CNA-K was behind R86 and thought if R86 fell , R86 would fall backward. CNA-K tried to catch R86. A therapy communication sheet on transferring for CNAs, dated 4/8/25, indicated: Please complete transfers only to/from wheelchair and bed, to/from wheelchair and recliner, to/from wheelchair and toilet with use of hemi-walker, minimal assistance (of) 1 and gait belt - no walking, transfers only. On 4/22/25 at 11:48 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R86's care plan which did not indicate a gait belt should be used during transfers. DON-B indicated the general guideline is to use a gait belt for pivot transfers. DON-B reviewed R86's care plan and confirmed the care plan was not updated after R86's fall. On 4/22/25 at 3:50 PM, Surveyor interviewed CNA-K who indicated the fall occurred during CNA-K's first time pivot transferring R86. CNA-K indicated the gait belt was next to the hemi-walker. CNA-K verified CNA-K knew that using a gait belt was the standard of practice when transferring residents. CNA-K indicated CNA-K was nervous to transfer R86 and forgot to use the gait belt. CNA-K knew CNA-K should have used the gait belt as soon as R86 fell . CNA-K held onto R86's clothing and hip during the transfer. CNA-K indicated CNA-K understood the transfer verbiage in R86's care plan prior to therapy staff changing the verbiage following the fall. On 4/22/25 at 4:08 PM, Surveyor interviewed DON-B and Nursing Home Administrator (NHA)-A. DON-B indicated the root cause of R86's fall was an unsafe transfer without a gait belt. DON-B indicated R86's knees buckled and R86 fell forward when R86 was transferred from wheelchair to bed without a gait belt. DON-B indicated DON-B verbally educated CNA-K regarding the use of a gait belt. DON-B indicated the therapy verbiage stated to transfer R86 from wheelchair to bed, toilet, and chair but did not state how to transfer R86. Therapy was asked to clarify the transfer verbiage. DON-B indicated R86's laceration required 3 staples which DON-B did not feel was not a serious bodily injury. DON-B indicated the nurse applied pressure right away but the bleeding would not stop and R86 was sent to the ED. On 4/23/25 at 8:19 AM, Surveyor interviewed Occupational Therapist (OT)-O who confirmed R86 was a 1 assist pivot transfer with a hemi-walker. OT-O indicated a gait belt should always be used which therapy clarified in R86's transfer verbiage following the fall. OT-O indicated nursing staff should only complete transfers and not ambulation and indicated therapy staff wanted to make sure nursing staff used a gait belt and walker for transfers. On 4/23/25 at 8:44 AM, Surveyor received an education sign-in sheet, dated 4/10/25, that referenced using a gait belt during pivot transfers. Surveyor noted 14 nursing staff signed the education and 13 staff were verbally educated via phone. On 4/23/25 at 9:53 AM, Surveyor interviewed CNA-I regarding gait belt with pivot transfer education. CNA-I indicated CNA-I received education on 4/22/25. On 4/23/25 at 9:55 AM, Surveyor interviewed DON-B in NHA-A's office. When Surveyor indicated the education form was dated 4/10/25, however, CNA-I indicated CNA-I was educated on 4/22/25, DON-B indicated some staff on the education form were educated on 4/22/25. DON-B highlighted their names. On 4/23/25 at 11:07 AM, Surveyor interviewed DON-B who indicated education forms are located at the nurses' station for staff to read and sign. When Surveyor asked if staff who were educated verbally signed the education form, DON-B indicated DON-B was unable to find the education form for a period of time but found the form last evening (4/22/25). DON-B indicated staff who received verbal education were not in the building to sign. On 4/23/25 at 11:26 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-M via phone. LPN-M's name was highlighted on the education form which indicated LPN-M was verbally educated via phone on 4/22/25. LPN-M verified DON-B educated LPN-M on gait belt use with pivot transfers via phone on 4/22/25. On 4/23/25 at 11:29 AM, Surveyor interviewed LPN-L via phone. LPN-L's name was not highlighted on the education sheet which indicated LPN-L was verbally educated via phone on 4/10/25. LPN-L indicated LPN-L received education on gait belt use with pivot transfers yesterday evening (4/22/25) via phone. On 4/23/25 at 11:42 AM, Surveyor interviewed CNA-N whose name was not highlighted on the education sheet which indicated CNA-N was verbally educated via phone on 4/10/25. CNA-N indicated CNA-N worked at the facility for 4 years and the facility emphasized the use of gait belts during pivot transfers at meetings. CNA-N indicated CNA-N received education on gait belt use with pivot transfers via phone on 4/22/25. On 4/23/25 at 4:58 PM, Surveyor interviewed NHA-A and asked if nursing staff should have been educated on the need to use a gait belt with a pivot transfer prior to 4/22/25. NHA-A indicated nursing staff should have been educated prior to 4/22/25.

Based on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 39 residents residing in the facility. Enhanced Barrier precautions (EBP) were not implemented for R187 who had an indwelling urinary catheter. Staff did not complete appropriate hand hygiene after providing care for R6. Residents were not offered hand hygiene prior to the lunch meal on 4/22/25. Finding includes: The facility's ICPC Standard and Transmission-Based Precautions (TBP) policy, dated 2/2025, indicates: .Enhanced Barrier Precautions (EBP): Expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of multidrug-resistant organisms (MDROs) to staffs' hands and clothing then indirectly transferred to residents or from resident to resident (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs.) A. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with: i. Wounds and/or indwelling medical devices regardless of MDRO colonization; ii. MDRO infection or colonization .C. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include: i. dressing; ii. bathing/showering; iii. transferring; iv. providing hygiene; v. changing linens; vi. changing briefs or assisting with toileting; vii. device care or use: central vascular line (including hemodialysis catheters) indwelling urinary catheter, feeding tube, tracheostomy/ventilator .vii. wound care: any skin opening requiring a dressing . The facility's Infection Control Policy/Procedure for Laundry Services, dated 3/2025, indicates: It is the policy of this facility to ensure a clean supply of linens and to protect employees who handle and process the laundry. 1. Routine handling of soiled linens: A. Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and of persons handling the linen. B. All soiled linen should be bagged or put into carts at the location where used . The facility's Hand Washing policy, dated 3/2025, indicates: It is the policy of this facility to cleanse hands and prevent transmission of possible infectious material and provide a clean, healthy environment for residents and staff .For specific hand washing and waterless hand hygiene procedures, the facility refers to the Centers for Disease Control and Prevention (CDC) and the World Health Organization current guidelines. The Centers for Disease Control and Prevention (CDC) About Handwashing information from CDC.gov, dated 2/16/24, indicates: Many diseases and conditions are spread by not washing hands with soap and clean, running water. Hand washing with soap is one of the best ways to stay healthy. If soap and water are not readily available, use a hand sanitizer with at least 60% alcohol to clean your hands. Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surface to person when you: Touch your eyes, nose, and mouth with unwashed hands; Prepare or eat food and drinks with unwashed hands; Touch surfaces or objects that have germs on them; Blow your nose, cough, or sneeze into your hands and then touch other peoples' hands or common objects. You can keep yourself and your loved ones healthy by washing your hands often, especially during key times when you are likely to get and spread germs: Before, during, after preparing food; Before and after eating food . The facility's Meal, Preparing Resident for policy, dated 5/2024, indicates: .9. Encourage and assist residents to wash his/her hands and face before receiving the meal or to use wipes available in the dining areas . 1. From 4/21/25 to 4/23/25, Surveyor reviewed R187's medical record. R187 was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, vascular dementia, urinary retention, and urinary device. R187 had an indwelling urinary catheter. R187's Minimum Data Set (MDS) assessment, dated 4/4/25, had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated R187 was not cognitively impaired. On 4/21/25 at 1:01 PM, Surveyor interviewed R187 and noted there was not an EBP sign or a PPE cart near the entrance to R187's room. R187 indicated staff complete catheter care for R187 approximately 4 to 5 times per day. Surveyor also noted there was not a PPE cart inside the room. On 4/23/25 at 10:08 AM, Surveyor interviewed R187 and observed an EBP sign on the wall near the entrance to R187's room and a PPE cart near the foot of R187's bed. R187 was unsure why the cart was place there and indicated staff recently put it there. When asked if staff wear gowns and gloves during catheter care, R187 stated staff wear gloves but do not wear gowns. R187's medical record contained a physician order, dated 3/27/25, for a 16 French Foley catheter and Foley catheter care per facility policy. R187's plan of care contained an intervention for catheter care beginning 4/2/25. R187's plan of care also indicated R187 should be on EBP (initiated 4/2/25). On 4/23/25 at 10:52 AM, Surveyor interviewed Director of Nursing (DON)-B who was also the facility's Infection Preventionist (IP). DON-B indicated DON-B put an EBP sign near R187's door on the evening of 4/21/25. DON-B verified R187 should have been on EBP prior to 4/21/25 since R187 returned from the hospital with a catheter. When asked why R187 was not on EBP from 3/27/25 to 4/21/25, DON-B indicated it was missed. 2. On 4/21/25 at 12:20 PM, Surveyor observed Certified Nursing Assistant (CNA)-F exit R6's room with a clear plastic bag of unknown items in one hand and a Hoyer sling in the other hand. Surveyor noted CNA-F was not wearing gloves. CNA-F walked down the hall to two covered receptacles. CNA-F unsnapped the lid of one receptacle, placed the plastic bag inside, and snapped the lid in place. CNA-F then unsnapped the lid of the second receptacle, put the Hoyer sling and another item in the receptacle, and snapped the lid in place. Without completing hand hygiene, CNA-F then walked down the hall and into the dining room to assist residents. On 4/21/25 at 12:22 PM, Surveyor attempted to interview CNA-F who indicated CNA-F was in the middle of getting residents out of the dining room and did not have time to talk to Surveyor. On 4/21/25 at 1:25 PM, Surveyor interviewed CNA-F who became agitated when Surveyor asked what was in the clear plastic bag that Surveyor observed CNA-F carrying at 12:20 PM. CNA-F indicated the bag contained a poopy diaper. CNA-F indicated CNA-F also carried a soiled Hoyer sling and a resident's pants and put them in the laundry receptacle. CNA-F verified CNA-F should have completed hand hygiene after placing the items in the receptacles but indicated CNA-F only lifted the garbage lids and did not put CNA-F's whole hand inside. CNA-F then unsnapped the lid of a nearby garbage receptacle with bare hands, lifted the lid, waved a hand over the garbage, and snapped the lid back in place. CNA-F did not complete hand hygiene after touching the garbage can lid. Surveyor then observed CNA-F use a touch screen on the wall with a bare hand directly after opening the garbage can. When Surveyor asked if CNA-F should have completed hand hygiene after touching the garbage can, CNA-F forcefully put CNA-F's hand under a hand sanitizer dispenser causing hand sanitizer to get on the touch screen and Surveyor. CNA-F completed hand hygiene and yelled, There are you happy now? CNA-F then left the area. On 4/23/25 at 1:14 PM, Surveyor interviewed DON-B who indicated the proper procedure to remove soiled linens and clothing from a resident's room is to bag the items for transport and complete hand hygiene immediately after placing the items in the soiled linen receptacle. DON-B indicated staff should complete hand hygiene after depositing garbage in the garbage receptacle before doing anything else. 3. On 4/22/25 at 11:30 AM, Surveyor observed the noon meal and noted there were 20 residents in the dining room. Surveyor noted there were no sanitizing hand wipes on the tables. At 11:39 AM, the lunch meal was served to the residents. At 11:45 AM, Surveyor observed R5 arrive in the dining room. R5 was served drinks and a meal but was not offered hand hygiene prior to eating. At 12:04 PM, R26 entered the dining room. At 12:06 PM, R26 was served drinks and a meal but was not offered hand hygiene prior to eating. On 4/22/25 at 11:59 AM, Surveyor interviewed R188 who indicated R188 was not offered hand hygiene prior to the meal. On 4/22/25 at 12:28 PM, Surveyor interviewed R26 who indicated R26 was not offered hand hygiene before the meal and was not usually offered hand hygiene before meals. On 4/22/25 at 12:34 PM, Surveyor interviewed Lead [NAME] (LC)-H who indicated CNAs should offer residents hand hygiene before meals. LC-H indicated there are hand wipes available for residents and showed Surveyor the hand wipes in the dining room. LC-H indicated the CNAs in the dining room for lunch were CNA-F and CNA-I. On 4/22/25 at 1:04 PM, Surveyor interviewed DON-B who indicated residents should be offered hand hygiene prior to meals. DON-B indicated residents should be offered hand sanitizing wipes or a pump of hand sanitizer gel to sanitize hands before eating. On 4/22/25 at 1:24 PM, Surveyor interviewed CNA-F who indicated CNA-F did not offer residents hand hygiene during the lunch meal. When Surveyor asked why hand hygiene was not offered, CNA-F replied, I don't know. I couldn't tell you. On 4/23/25 at 2:44 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff have been trained and should follow the facility's infection control and hand hygiene policies.

Based on observation, staff and resident interview, and record, review, the facility did not maintain dignity for 3 residents (R) (R20, R11, and R6) of 23 sampled residents. R20 required feeding assistance. On 4/22/25, R20 watched other residents eat in the dining room and waited 16 minutes for assistance. In addition, staff in the dining room did not address or speak to R20. R11 and R6 required feeding assistance. On 4/22/25, staff in the dining room did not speak to R11 and R6 while feeding them. Findings include: The facility's Meal, Preparing Resident for policy, dated 5/2024, indicates: It is the policy of this facility that the primary purpose of preparing the resident for a meal is to serve the meal in a pleasant environment and to make the mealtime a pleasant event. Encourage residents to eat in the dining area. This provides each resident with an opportunity to socialize and make new friends . The facility's Dietary Support Personnel, Sufficient policy, dated 1/2022, indicates: .Sufficient support personnel means having enough dietary and food nutrition staff to safely carry out all the functions of the food and nutrition services. This does not include staff, such as licensed nurses, nurse aides, or paid feeding assistants involved in assisting residents with eating . 1. On 4/22/25 at 11:30 AM, Surveyor observed the noon meal in the dining room and noted 23 residents were in the dining room during the meal. At 11:39 AM, Surveyor observed Lead [NAME] (LC)-H begin to serve residents. At 11:48 AM, Surveyor noted all residents had been served except R20. On 4/22/25 at 11:45 AM, Surveyor observed Certified Nursing Assistant (CNA)-I assist R11 and CNA-F assist R6. Surveyor noted neither CNA-I or CNA-F addressed or talked to R11 or R6 while assisting them with eating. At 11:57 AM, Surveyor observed CNA-I begin to talk and interact with R11. CNA-I continued to converse with R11 and offer choices throughout the end of the meal. CNA-F still had not spoken to R6. On 4/22/25 at 11:53 AM, Surveyor noted R20 was watching residents eat in the dining room. Staff had not yet provided R20 with a meal or drink. Surveyor also noted none of the staff in the dining room (CNA-I, CNA-F, and LC-H) had addressed R20. On 4/22/25 at 11:53 AM, Surveyor interviewed LC-H who indicated R20 requires feeding assistance and it is common for R20 to wait to eat. LC-H indicated there are three residents who require feeding assistance and usually two staff to assist with feeding. LC-H indicated one resident has to wait until the other residents eat before that resident receives assistance. On 4/22/25 at 11:55 AM, Surveyor observed CNA-F stand up and walk away from R6 who had finished eating. CNA-F did not say anything to R6 before leaving the table. Surveyor observed CNA-F walk to R20's table and sit down to assist R20. LC-H brought a plate of food to R20 and R20 was provided with a drink. CNA-F began to feed R20 but did not speak to or address R20. CNA-F did not introduce CNA-F's self to R20, did not describe the food on R20's plate, did not apologize for R20 having to wait 16 minutes to eat, and did not engage in any small talk or conversation. On 4/22/25 at 11:58 AM, Surveyor observed CNA-F stand up from feeding R20 and assist another resident who was exiting the dining room. CNA-F did not say anything to R20 and left the dining area. R20 was left sitting at the table with R20's food and drink. On 4/22/25 at 12:03 PM, Surveyor observed CNA-F walk into the dining room, turn around, and walk back out. R20 was still sitting at the table watching other residents finish their meals. R20's food and drink was still in front of R20. On 4/22/25 at 12:05 PM, Surveyor observed CNA-F walk into the dining room and sit by R20. CNA-F sat down and resumed feeding R20 but did not speak to R20. CNA-F did not ask if R20's food was cold, apologize for leaving R20 in the middle of the meal, or explain where CNA-F had gone for 7 minutes and why R20 had to wait. Surveyor observed CNA-F laugh and talk with staff in the dining room while feeding R20. On 4/22/25 at 12:08 PM, Surveyor observed CNA-I wheel R11 out of the dining room. CNA-I did not speak to R11 while CNA-I wheeled R11 out of the room. On 4/22/25 at 12:33 PM, Surveyor observed CNA-F stand up and use R20's clothing protector to wipe R20's face. CNA-F then pushed R20's wheelchair out of the dining room. CNA-F did not speak to R20 during meal service or when exiting the dining room. On 4/22/25 at 12:34 PM, Surveyor interviewed LC-H who indicated some CNAs talk to residents and some do not. LC-H indicated sometimes staff do not talk to R20 because R20 can not always respond. On 4/22/25 at 1:04 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff who assist a resident with eating should talk and interact with the resident, even if the resident is nonverbal or unable to understand what is said to them. DON-B indicated staff should offer bites of food and ensure the resident is satisfied with their food and its temperature. DON-B indicated staff should engage in small talk and ongoing communication with residents as appropriate. DON-B indicated there should be enough staff to feed residents who need assistance with eating. DON-B indicated it is not acceptable for a resident to watch other residents eat for 16 minutes before they receive food and assistance. DON-B indicated staff should not leave a resident for 7 minutes in the middle of feeding them. DON-B indicated it is not acceptable for staff to ignore residents and not speak to them while feeding them. On 4/22/25 at 1:24 PM, Surveyor interviewed CNA-F who verified CNA-F did not talk to R20 or R6 when CNA-F fed R20 and R6 lunch. CNA-F indicated CNA-F was not taught that during CNA training. CNA-F indicated it is typical for R20 or another resident to wait 20 to 30 minutes to be fed while the rest of the residents are eating or being assisted. CNA-F indicated CNA-F left the dining room while feeding R20 to assist another resident out of the dining room. After CNA-F assisted the resident to their room, CNA-F toileted the resident and helped another staff transfer a resident before CNA-F returned to the dining room to resume assisting R20. When asked if it is typical to leave the room while feeding a resident, CNA-F indicated it happens sometimes and depends on the day. When asked why CNA-F did not talk to R20 or R6 while assisting them, CNA-F indicated CNA-F does not have much to say to them. On 4/23/25 at 2:44 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should communicate and interact with residents in the dining room while assisting them. NHA-A indicated it is not acceptable for a resident to wait up to 16 minutes to eat while other residents are being fed. NHA-A indicated it is not acceptable for a CNA to leave a resident while feeding them to provide care for another resident.

Based on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R9) of 2 sampled residents. R9 was under Guardianship. The facility did not ensure court-ordered protective placement in the least restrictive environment was obtained after R9's nursing home stay exceeded 60 days. Findings include: From 4/21/25 to 4/23/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, epilepsy, and major depressive disorder. R9's Minimum Data Set (MDS) assessment, dated 1/15/25, had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R9 was unable to complete the interview. R9 had a Guardianship that was activated on 9/29/21. R9's medical record contained a petition for protective placement that was dated 8/22/24. On 4/23/25 at 9:12 AM, Surveyor reviewed R9's medical record with Social Worker (SW)-P who confirmed the petition for protective placement was not the final order. SW-P indicated SW-P would look for the final order. On 4/23/25 at 2:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A was not aware of protective placement for R9 and would inform SW-P. On 4/23/25 at 3:00 PM, Surveyor interviewed SW-P who indicated the facility usually received protective placement paperwork from the Guardian and the court usually sent paperwork to the facility upon a resident's admission. SW-P indicated the facility should have obtained protective placement for R9 in September or October of 2024 after the final protective placement hearing.

Based on staff interview and record review, the facility did not make a prompt effort to investigate and resolve a grievance for 1 resident (R) (R5) of 1 sampled resident. R5 voiced a concern to staff and the Grievance Official that another resident repeatedly woke R5 up in the early morning hours. R5's grievance was not documented, thoroughly investigated, or resolved. Findings include: The facility's Resident and Family Grievances Policy, revised 12/2024, indicates: It is the policy of this facility to support each resident's .right to voice grievances without discrimination or fear of reprisal .Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of the complaint/grievance .1. The Social Worker has been designated as the Grievance Official. 2. The Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, issuing written grievance decisions to the resident, and coordinating with state and federal agencies as necessary in light of specific allegations .4. A resident may voice grievances with respect to .the behavior of staff and other residents, and other concerns regarding their long term care stay .8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or the Grievance Official .10. Procedure: .b. The staff member receiving the grievance will record the nature and specifics of the grievances on the designated grievance form or assist the resident .to complete the form .12. The facility will make prompt efforts to resolve grievances. From 4/21/25 to 4/23/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis and anxiety disorder. R5's Minimum Data Set (MDS) assessment, dated 1/15/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 was not cognitively impaired. R5 was responsible for R5's healthcare decisions. On 4/21/25 at 10:24 AM, Surveyor interviewed R5 who indicated R5 is woken up at 5:30 AM due to another resident yelling and screaming down the hall. R5 indicated R5 has informed management, however, R5 does not think they can do anything. On 4/22/25 at 3:58 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-K and asked if CNA-K received any complaints from R5. CNA-K indicated R5 complained about another resident who wakes R5 up with noises in the early morning hours. CNA-K indicated CNA-K has not informed anyone or filed a grievance. CNA-K indicated CNA-K does not work a lot and thought other staff were aware of R5's complaint. On 4/23/25 at 9:10 AM, Surveyor interviewed Social Worker (SW)-P who confirmed SW-P is the facility's Grievance Official. SW-P indicated R5 voiced the same complaint to SW-P. R5 was offered a room change but declined. SW-P indicated SW-P's conversation with R5 and the room change offer were not documented. When Surveyor asked if a grievance should have been filed on R5's behalf, SW-P indicated it was a toss-up if a grievance should have been filed. SW-P indicated since R5 appeared to be upset and brought the issue to Surveyor's attention, SW-P should have filed a grievance. On 4/23/25 at 11:45 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated filing a grievance depended on how upset R5 still was. NHA-A indicated the facility offered R5 options which R5 declined. NHA-A indicated if a resident has a concern, they can start a grievance form. NHA-A indicated NHA-A and SW-P can start a grievance form also. NHA-A indicated the process involves talking with the person who voiced the grievance to see if they want to file a formal grievance. NHA-A does not know if R5 was offered the chance to file a formal grievance and indicated NHA-A did not recently talk to R5 regarding the issue. When Surveyor asked if NHA-A would consider R5 to be still upset if R5 brought the issue to Surveyor's attention, NHA-A indicated it is different for R5 and stated the facility can not do much because they cannot send the other resident away.

Based on staff interview and record review, the facility did not ensure an injury of unknown origin was reported to the State Agency (SA) for 1 resident (R) (R32) of 4 sampled residents. On 4/2/25, staff discovered a hematoma on R32's left forearm. Facility staff and Hospice staff were unsure how the injury occurred. The facility did not report the injury of unknown origin to the SA. Findings include: The facility's Abuse Prevention policy and procedure, updated 7/2024, indicates: Identification of abuse - Identify events, such as but not limited to suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. All alleged violations will be reported via phone or in writing within 2 hours to the State Licensing Agency. The facility shall follow up with the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days . From 4/21/25 to 4/23/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including dementia, adult failure to thrive, and palliative care. R32's Admission Minimum Data Set (MDS) assessment, dated 2/5/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R32 had severely impaired cognition. R32 had an activated Power of Attorney for Healthcare (POAHC). A progress note, dated 4/2/25 at 3:14 PM, indicated the writer was informed by staff that R32 had discoloration on the bilateral wrists. Upon assessment, the writer noted R32's wrists contained purplish, red/brown discoloration. R32 denied pain to the areas. The writer was informed by a Hospice Certified Nursing Assistant (CNA) that the discoloration had come and gone over the past few weeks and the Hospice nurse was aware. The Hospice nurse also verified the discoloration had come and gone over the past few weeks and and indicated the discoloration was senile purpura. R32 was interviewed and stated R32 felt safe. The note indicated staff would continue to monitor R32's arms due to R32 having increased negative behavior toward staff with cares. A progress note, dated 4/3/25 at 2:30 PM, indicated Hospice staff were in R32's room doing AM cares when the writer was called into the room and shown R32's left arm that had previous bruising. A raised hematoma that measured 9 centimeters (cm) x 10 cm was noted on the left side of R32's outer forearm. R32 had no complaints of pain or discomfort. R32 refused ice and was combative with staff. The Director of Nursing (DON) was notified. The note indicated staff would notify R32's POAHC and physician. On 4/21/25, Surveyor reviewed a facility investigation for R32's injury of unknown origin. The facility contacted R32's Power POAHC who indicated R32 was combative during a visit on 4/2/25 and hit R32's arms on the bed. The investigation determined the injury occurred when R32 hit R32's arms on the bed during the visit. The injury of unknown origin was not reported to the SA. On 4/21/25 at 2:25 PM, Surveyor interviewed DON-B who indicated the facility completed an investigation for R32's injury of unknown origin. DON-B verified the facility did not report the injury of unknown origin to the SA.

Based on staff interview and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 resident (R) (R32) of 4 sampled residents. R32 had an injury of unknown origin that was discovered on 4/2/25. The facility did not interview other residents to rule out abuse during the investigation. Findings include: The facility's Abuse Prevention policy and procedure, updated 7/2024, indicates: Identification of abuse - Identify events, such as but not limited to suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. The investigation shall consist of: .6. Interviews with other residents to whom the accused employee provides care or services. From 4/21/25 to 4/23/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including dementia, adult failure to thrive, and palliative care. R32's Admission Minimum Data Set (MDS) assessment, dated 2/5/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R32 had severely impaired cognition. R32 had an activated Power of Attorney for Healthcare (POAHC). A progress note, dated 4/2/25 at 3:14 PM, indicated the writer was informed by staff that R32 had discoloration on the bilateral wrists. Upon assessment, the writer noted R32's wrists contained purplish, red/brown discoloration. R32 denied pain to the areas. The writer was informed by a Hospice Certified Nursing Assistant (CNA) that the discoloration had come and gone over the past few weeks and the Hospice nurse was aware. The Hospice nurse also verified the discoloration had come and gone over the past few weeks and indicated the discoloration was senile purpura. R32 was interviewed and stated R32 felt safe. The note indicated staff would continue to monitor R32's arms due to R32 having increased negative behavior toward staff with cares. A progress note, dated 4/3/25 at 2:30 PM, indicated Hospice staff were in R32's room doing AM cares when the writer was called into the room and shown R32's left arm which had previous bruising. A raised hematoma that measured 9 centimeters (cm) x 10 cm was noted on the left side of R32's outer forearm. R32 had no complaints of pain or discomfort. R32 refused ice and was combative with staff. The Director of Nursing (DON) was notified. On 4/3/25, the facility began an investigation for R32's injury of unknown origin. The facility interviewed R32 and all staff who worked with R32 on 4/2/25 and 4/3/25. The facility also contacted R32's POAHC who indicated R32 was combative during a visit on 4/2/25 and hit R32's arms on the bed. The facility contacted Hospice and discontinued R32's anticoagulant therapy (which can increase bruising). In addition, R32 was wearing geri-sleeves on each arm to protect R32's arms/skin. The investigation did not include interviews with other residents to rule out abuse. On 4/21/25 at 2:25 PM, Surveyor interviewed DON-B who indicated the facility completed an internal investigation for R32's injury of unknown origin. DON-B verified the facility did not interview other residents to rule out abuse.

Based on staff interview and record review, the facility did not revise a care plans in accordance with current care needs for 1 resident (R) (R32) of 15 sampled residents. R32's care plan was not updated to include calling R32 by R32's preferred names. R32's care plan was also not updated when R32 incurred an injury of unknown origin and geri-sleeves were implemented to protect R32's skin. Findings include: From 4/21/25 to 4/23/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including dementia, adult failure to thrive, and palliative care. R32's Admission Minimum Data Set (MDS) assessment, dated 2/5/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R32 had severely impaired cognition. R32 had an activated Power of Attorney for Healthcare (POAHC). On 4/21/25 at 1:15 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who indicated when R32 was first admitted , staff called R32 by a shortened version of R32's name. CNA-C indicated R32 also told staff to call R32 grandma which staff sometimes did. CNA-C indicated R32 could be behavioral during cares and sometimes calling R32 grandma helped calm R32. CNA-C indicated one of R32's family members heard CNA-C call R32 grandma when they visited. CNA-C indicated R32's family member stated staff should not call R32 grandma because R32 was not their grandma and R32 did not like that. CNA-C told Assistant Director of Nursing (ADON)-D and the Social Worker (SW) who were going to talk to R32's POAHC. CNA-C was not sure of the outcome of the conversation and indicated CNA-C no longer calls R32 grandma. On 4/21/25 at 2:23 PM, Surveyor interviewed ADON-D who indicated ADON-D was working on the evening that CNA-C called R32 grandma and R32's family member got upset. ADON-D indicated the facility contacted R32's POAHC to explain what happened and that it sometimes helps if staff call R32 grandma when R32 is having difficulty with cares. R32's POAHC gave approval for staff to call R32 grandma if it helped. R32's medial record indicated R32 had an injury of unknown origin that was discovered on 4/3/25. The facility completed an investigation for R32's injury. R32 was known to be combative at times. The investigation indicated R32 was combative, swung R32's arms, and hit R32's arms on the bed during a visit with R32's POAHC. The facility, in conjunction with Hospice staff, initiated geri-sleeves (sleeves worn to protect skin) to protect and prevent injury to R32's skin. On 4/21/25, Surveyor reviewed R32's plan of care and noted there were no care plan updates related to the preferred names staff should call R32 or that R32 should wear geri-sleeves on the bilateral upper extremities. On 4/21/25 at 2:23 PM, ADON-D indicated the facility had not yet care planned the information. On 4/21/25 at 2:25 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R32's care plan was not updated to include the preferred names staff should call R32 or that R32 should wear geri-sleeves on both arms to protect R32's skin. DON-B confirmed R32's care plan should have been updated.

Based on observation, staff interview, and record review, the facility did not ensure 3 residents (R) (R7, R12, and R186) of 17 sampled residents received assistance as needed to complete activities of daily living (ADLs). R7 did not receive assistance with positioning, toileting, and breakfast. R12 did not receive weekly showers. In addition, the facility did not address R12's request for more showers. R186 did not receive a shower while at the facility. Findings include: The facility's Activities of Daily Living (ADLs) policy, dated 12/2024, indicates: Care and services will be provided for the following ADLs: 1. Bathing, dressing, grooming, and oral care; 2. Transfer and ambulation; 3. Toileting; 4. Eating to include meals and snacks .3. A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .5. The facility will maintain individual objectives of the care plan. The facility's Resident Showers policy, dated 12/2024, indicates: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice .1. Residents will be provided showers per request or the facility's schedule protocol and based upon resident safety . 1. From 4/21/25 to 4/23/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, diabetes, moderate protein calorie malnutrition, and dysphagia. R7 received Hospice services. R7's Minimum Data Set (MDS) assessment, dated 3/5/25, indicated R7 required staff assistance with eating set up, substantial/maximal assistance with rolling left and right, and substantial/maximal assistance with toileting. The MDS assessment also indicated R7 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R7 had severe cognitive impairment. R7 had a Guardian for healthcare decisions. A care plan (initiated 5/5/22) indicated R7 had an ADL self care performance deficit related to immobility, overall decline, and decreased motivation. The care plan contained the following interventions: Bed mobility: Requires substantial/maximal assistance with lying to sitting on end of bed, sitting to lying, and rolling left and right; Eating: May have meals/snacks/drinks independently in room with frequent visual checks at mealtime to ensure safety; and Toilet use: Requires two-person assistance .and is dependent for toileting hygiene. A care plan (initiated 8/9/24) indicated R7 had the potential for pressure ulcer development related to incontinence and spending a lot of time in bed. The care plan contained an intervention for R7 to be repositioned every two hours while in bed as tolerated. A care plan (initiated 5/5/22) indicated R7 was at high nutritional risk secondary to protein calorie malnutrition, Hospice care, Alzheimer's disease, kidney disease, and diabetes. The care plan contained an intervention to monitor/document/report to MD as needed for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and if appears concerned during meals. On 4/21/25 at 10:27 AM, Surveyor observed R7 in bed. Surveyor noted R7 was leaning to the right side and had slid to the bottom of the bed. R7 indicated R7 was not comfortable. On 4/23/25 at 8:30 AM, Surveyor observed R7 in bed with the head of the bed elevated 45 degrees. R7 was leaning to the right side. Surveyor noted R7's breakfast tray was not set up and was in front of R7 untouched. The tray contained a plate of food that was uncovered, however, R7's milk, orange juice, and cereal were still covered. On 4/23/25 at 9:31 AM, Surveyor observed R7 in bed with the head of the bed elevated 45 degrees. R7 was leaning to the right side with R7's head touching the right bed rail. R7's breakfast tray was still untouched and not set up for breakfast. On 4/23/25 at 9:36 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who stated breakfast trays are usually delivered around 8:00 AM. CNA-C indicated dietary staff were supposed to bring in the tray and remove covers from the plate, liquids, and cereal. CNA-C indicated R7 liked to sleep in and usually did not touch R7's breakfast tray until between 9:30 and 10:00 AM. CNA-C also indicated R7 was repositioned every two hours by CNAs or Hospice staff. CNA-C was assigned to R7 that shift and indicated the AM shift started at 6:00 AM. CNA-C stated CNA-C had not yet turned, repositioned, or checked and changed R7 or checked to see if R7 was eating. On 4/23/25 at 9:43 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who indicated ADON-D observed dietary staff pass by with trays approximately 30 minutes ago. ADON-D indicated dietary staff typically set up R7's tray. ADON-D indicated R7 had a history of non-compliance with eating in an upright position and a history of aspiration and recent pneumonia. ADON-D indicated R7 should be repositioned by facility CNAs or the Hospice aide. ADON-D had not observed Hospice with R7 yet that day. ADON-D reviewed orders (dated 9/26/24) that indicated R7 could eat meals and snacks in R7's room unsupervised (discussed with Guardian) and staff should frequently check on R7 during meals and snacks. ADON-D stated CNAs should have offered and/or done repositioning by that time. On 4/23/25 at 10:15 AM, Surveyor interviewed CNA-C who stated R7 was just repositioned and changed for the first time that shift. CNA-C indicated R7 was having difficult eating cereal so another staff was assisting R7 with eating. On 4/23/25 at 3:14 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should check, change, and reposition R7 every 2-3 hours. DON-B indicated most residents are checked, changed, and repositioned before and after meals and before shift change on the AM and PM shifts unless care planned for every 2 hours like R7. DON-B verified the AM shift starts at 6:00 AM and confirmed staff should have checked, changed, and repositioned R7 before 9:36 AM and set up R7's tray before 10:15 AM. DON-B indicated meal set up includes removing covers. On 4/23/25 at 3:24 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated LPN-E heard R7 call out at approximately 9:36 AM and checked on R7. With the assistance of Clinical Market Leader (CML)-G, LPN-E checked, changed, and repositioned R7 who was incontinent of a medium amount of urine and a smear of stool. LPN-E indicated R7's condom catheter was not in place. LPN-E reheated R7's plate of food and removed covers from R7's oatmeal and liquids. CML-G assisted R7 with eating oatmeal. LPN-E indicated R7 required assistance with eating at times due to confusion and a history of swallowing issues. R7's Guardian had signed a diet non-compliance form to liberalize R7's diet for comfort when R7 started Hospice services. LPN-E agreed with DON-B that R7 should have been checked, changed, repositioned, and set up, assisted, or frequently checked on during eating. 49010 2. From 4/21/25 to 4/23/25, Surveyor reviewed R12's medical record. R12 was readmitted to the facility on [DATE] and readmitted again on 4/2/25 after a three-day discharge. R12 had diagnoses including traumatic brain injury, urinary incontinence, urinary catheter, morbid obesity with alveolar hypoventilation, and urinary tract infection (UTI). R12's MDS assessment, dated 4/4/25, had a BIMS score of 15 out of 15 which indicated R12 was not cognitively impaired. The MDS assessment also indicated R12 required substantial/maximal assistance with showering/bathing, upper and lower body dressing, and putting on/taking off footwear. On 4/21/25 at 12:15 PM, Surveyor interviewed R12 who indicated R12 did not receive weekly showers and R12's scalp and hair were greasy. R12 indicated R12 would like to shower more than once weekly. R12 indicated R12 told staff that R12 needed to shower more than once per week but still did not receive regular showers. R12 indicated R12 was told staff have a lot of other residents to shower and were not able to give R12 a shower. On 4/22/25, Surveyor observed a grievance from R12, dated 1/6/25. The grievance indicated R12 wanted to shower two times per week. The grievance also indicated R12 wanted staff to wake R12 up and get R12 ready for breakfast daily. The action taken was listed as discussed with resident and staff. The summary of pertinent findings stated resident would like to be up for breakfast daily. The summary of the grievance did not mention R12's shower request. The corrective action taken was listed as Care plan and Kardex (an abbreviated care plan used by nursing staff) updated. Staff aware/updated. R12's plan of care (initiated 10/31/22) indicated R12 had an ADL self care performance deficit related to muscle weakness and fracture to right distal femur that was surgically repaired. The goal indicated R12 will maintain current level of function or improve in: bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene. The plan of care contained the following intervention: Bathing: R12 requires substantial/maximal assistance with shower transfer and requires substantial/maximal assistance with showering and bathing (initiated 1/10/23). Surveyor noted there was not an update to R12's care plan following the grievance request to shower twice per week. R12's Kardex also did not indicate R12 would like to shower twice weekly. On 4/23/25, Surveyor reviewed the facility's shower schedule which indicated R12 was scheduled for a shower on the Monday AM shift. The shower schedule was not updated for twice weekly showers. On 4/23/25 at 10:17 AM, Surveyor interviewed LPN-J who indicated LPN-J fills out a shower sheet for every resident shower. LPN-J indicated shower sheets need to be completed even if the resident refuses the shower and a nurse must still complete a skin check for the resident (which is documented on the shower sheet). LPN-J indicated shower sheets are given to DON-B. On 4/23/25 at 11:15 AM, Surveyor reviewed R12's shower sheets for 1/1/25 through 4/23/25. Surveyor noted 6 shower sheets dated 1/6/25, 1/13/25, 1/20/25, 3/10/25, 4/7/25, and 4/21/25. On 4/23/25 at 11:15 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the 6 shower sheets received for R12 were the only shower sheets the facility had for R12 in 2025. On 4/23/25 at 1:14 PM, Surveyor interviewed DON-B who indicated residents should be offered showers at least once weekly. DON-B indicated staff need to fill out a shower sheet or a refusal sheet and a nurse needs to complete a skin check even if the resident did not receive a shower. DON-B indicated if a resident files a grievance indicating they would like two showers per week, the resident should be offered two showers per week. DON-B also indicated the shower schedule, care plan, and Kardex should be updated with the twice weekly schedule. Surveyor and DON-B discussed R12's shower request, grievance, and the 6 shower sheets for R12. When asked why there were only 6 showers for R12 and why R12's care plan and Kardex and shower schedule were not updated after R12 filed a grievance, DON-B indicated there was a break in the system. On 4/23/25 at 2:44 PM, Surveyor interviewed NHA-A who indicated residents should be offered weekly showers. NHA-A indicated R12's shower grievance should have been completed and R12 should have been offered twice weekly showers. NHA-A indicated R12's care plan, Kardex, and shower schedule should have been updated to twice weekly showers. NHA-A also indicated there should have been audits to ensure the grievance was addressed and R12's expectations were met. 3. From 4/21/25 to 4/23/25, Surveyor reviewed R186's medical record. R186 was readmitted to the facility on [DATE] and had diagnoses including methicillin-resistant Staphylococcus aureus (MRSA) infection, epilepsy, morbid obesity, above knee right leg amputation, urinary retention, and urinary tract infection. R186's MDS assessment, dated 4/10/25, indicated R186 required substantial/maximal assistance with showering/bathing, upper and lower body dressing, and putting on/taking off footwear. The MDS assessment had a BIMS score of 10 out of 15 which indicated R186 had moderately impaired cognition. On 4/21/25 at 12:53 PM, Surveyor interviewed R186 who indicated R186 would like a shower. R186 indicated R186 had not been offered a shower since R186 was admitted to the facility two weeks prior. R186's plan of care indicated R186 had an ADL self care performance deficit related to weakness, physical deconditioning, pain, and right above the knee amputation (initiated 4/8/25). The plan of care contained a goal that R186 will safely perform ADLs through the review date. The plan of care contained the following intervention: Bathing (Shower/Bath Self): The resident ranges from being independent to requiring partial/moderate assistance with personal hygiene (initiated 4/8/25). Surveyor noted R186's MDS assessment and plan of care contained conflicting information on the level of assistance R186 needed for showers/bathing. On 4/23/25, Surveyor reviewed the facility's shower schedule which indicated R186 was scheduled for a shower on the Monday PM shift. On 4/23/25 at 10:17 AM, Surveyor interviewed LPN-J who indicated LPN-J fills out a shower sheet for every resident shower. LPN-J indicated shower sheets need to be completed even if the resident refuses the shower and a nurse must still complete a skin check for the resident (which is documented on the shower sheet). LPN-J indicated shower sheets are given to DON-B. On 4/23/25, Surveyor requested shower sheets for R186 since R186's admission on 4/8/25. On 4/23/25 at 11:15 AM, NHA-A indicated there were no shower sheets, refusals, or skin check sheets for R186. On 4/23/25 at 1:14 PM, Surveyor interviewed DON-B who indicated residents should be offered showers at least once weekly. DON-B indicated staff need to fill out a shower sheet or a refusal sheet and a nurse needs to complete a skin check even if the resident did not receive a shower. DON-B indicated a resident should be assigned a shower day upon admission. DON-B reviewed R186's medical record and confirmed there were no skin checks completed. DON-B indicated it was not acceptable that R186 had not received a shower since admission. On 4/23/25 at 2:44 PM, Surveyor interviewed NHA-A who indicated residents should be offered weekly showers.

Based on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 2 residents (R) (R23 and R189) of 3 sampled residents. On 4/22/25, staff administered R23's AM and noon medications more than an hour after the scheduled times. On 4/22/25, staff left R189's medications at the bedside for R189 to self-administer. R189 did not have a physician order to self-administer medication or a self-administration of medication assessment that indicated R189 could safely and accurately self-administer medication. Findings include: The facility's undated Medication Administration-General Guidelines policy indicates: Medications are administered as prescribed in accordance with good nursing principles and practices .Administration: .k. Medications are administered in accordance with written orders of the attending physician .o. Medications are only administered after the 5 rights have been reviewed .4) right time; .r. Medications are administered within 60 minutes of scheduled time .Residents are allowed to self-administer medication when specifically authorized by the attending physician and in accordance with procedures for self-administration of medication . The facility's Self-Administration of Medication policy, dated 4/2025, indicates: Purpose: To determine the ability of alert residents to participate in self-administration of medication. To maintain the safety and accuracy of medication administration .2. If a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on changes in the resident's status .4. If the resident is a candidate for self-administration of medication, this will be indicated in the medical record .9. Resident's care plan will be updated to reflect self-administration when applicable. 1. On 4/22/25, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, major depressive disorder, and history of urinary tract infections (UTIs). R23's Minimum Data Set (MDS) assessment, dated 3/21/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R23 was not cognitively impaired. R23 had a Guardian. On 4/22/25 at 2:01 PM, Surveyor observed Assisted Director of Nursing (ADON)-D prepare R23's noon medications. Per ADON-D, R23's noon medications should be administered during lunch time which was 11:00 AM to 1:00 PM. ADON-D verified R23's noon medications were late. ADON-D indicated R23's AM medications were administered at 10:30 AM and 11:00 AM which is why R23's noon medications were being administered at that time. R23's noon medications were administered at 2:14 PM. R23's Medication Administration Record (MAR) contained the following orders: ~ Buspirone 10 milligram (mg) tablet Give 10 mg three times daily at AM 06 (6:00 AM), Lunch, PM 15 (3:00 PM) ~ Baclofen 20 mg tablet Give 20 mg three times daily at AM 06 (6:00 AM), Lunch, PM 15 (3:00 PM) On 4/22/25 at 2:15 PM, Surveyor interviewed Director of Nursing (DON)-B who verified medication times are an hour before to an hour after the medication is scheduled. DON-B indicated a resident's MAR turns red if the resident's medications are more than an hour past the scheduled time. Surveyor informed DON-B of what Surveyor observed for R23. DON-B verified R23's medications were considered late. 2. On 4/22/25, Surveyor reviewed R189's medical record. R189 was admitted to the facility on [DATE] and had diagnoses including peripheral vascular disease (PVD) and cellulitis. R189's MDS assessment, dated 4/4/25, had a BIMS score of 15 out of 15 which indicated R189 was not cognitively impaired. R189 made R189's own medical decisions. On 4/22/25 at 7:34 AM, Surveyor observed ADON-D prepare R189's AM medication. R189's MAR contained the following orders: ~ Acetaminophen 500 mg Give 1000 mg three times daily ~ Acyclovir 400 mg tab Give 1 tablet twice daily ~ Multivitamin 1 tab Give 1 tablet once daily ~ Vitamin C 1000 mg Give 1000 mg by mouth once daily ~ Vitamin D 1000 international units (IU) Give 1000 units by mouth once daily ~ Prednisolone AC 1%, 1 drop to left eye once daily every other day On 4/22/25 at 7:40 AM, Surveyor observed ADON-D leave a cup with R189's AM medication on R189's bedside table. ADON-D then left R189's room, shut the door, and retrieved Arginaid (wound healing medication) from the medication storage room. R189's medical record did not contain a physician order to self-administer medication or a self-administration of medication assessment that indicated R189 could self-administer medication. On 4/22/25 at 7:47 AM and 8:15 AM, Surveyor interviewed ADON-D who verified ADON-D left R189's AM medication on the bedside table. ADON-D verified R189 did not have a physician order to self-administer medication. ADON-D indicated R189 was going to wait to take the medication. ADON-D indicated ADON-D usually stored prepared medication in a locked medication cart and usually did not leave medication with residents to self-administer without supervision.

Based on staff interview and record review, the facility did not monitor for adverse reactions of a high-risk medication for 1 resident (R) (R86) of 5 sampled residents. R86 was prescribed gabapentin (an anticonvulsant medication). The facility did not monitor for adverse reactions or side effects of the high-risk medication. Findings include: Per medlineplus.gov, potential side effects of gabapentin include: Loss of balance or coordination, double vision, blurred vision, uncontrollable movements of the eyes, difficulty thinking or concentrating, difficulty speaking, headache, drowsiness, dizziness, diarrhea, constipation, loss of appetite, weight loss, nausea, vomiting, and uncontrollable shaking of a part of the body. Some side effects can be serious such as swelling of the face, throat, tongue, lips, and eyes, difficulty swallowing or breathing, hoarseness and seizures . On 4/21/25, Surveyor reviewed R86's medical record. R86 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the right dominant side and long-term use of anticoagulants (blood thinning medication). R86's Minimum Data Set (MDS) assessment, dated 4/4/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R86 was not cognitively impaired. R86's medical record contained the following order: ~ Gabapentin capsule 400 milligrams (mg). Give 1 capsule by mouth once daily for neuropathic pain. Give 1 capsule by mouth in the afternoon for neuropathic pain. Give 1 capsule by mouth at bedtime for restless leg syndrome. R86's medical record did not indicate R86 was monitored for adverse reactions/side effects of gabapentin. On 4/23/25 at 3:05 PM, Surveyor interviewed Director of Nursing (DON)-B who reviewed R86's medical record and confirmed R86's medical record did not contain monitoring interventions for adverse reactions/side effects of gabapentin.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R187) of 5 sampled residents was monitored for adverse reactions to psychotropic medication. R187 had an order for paliperidone (an antipsychotic medication). R187's medical record did not contain an Abnormal Involuntary Movement Scale (AIMS) assessment (a rating scale designed to measure involuntary movements known as tardive dyskinesia which is a disorder that can develop as a side-effect of long-term treatment with antipsychotic medication) for the use of paliperidone. Findings include: The facility's Use of Psychotropic Medication(s) policy, dated 12/2024, indicates: .1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, antianxiety, and hypnotics .13. Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, as needed (PRN), or per facility policy . On 4/23/25, Surveyor reviewed R187s medical record. R187 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, paranoid schizophrenia, portal vein thrombosis, and atrial fibrillation. R187's Minimum Data Set (MDS) assessment, dated 4/4/25, had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated R187 was not cognitively impaired. R187 had an order for paliperidone (an antipsychotic medication used to treat mental disorders including schizophrenia). R187's medical record did not contain an AIMS assessment. On 4/23/25, Surveyor asked to review R187's AIMS assessment. On 4/23/25 at 3:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated that facility did not have an AIMS assessment for R187. On 4/23/25 at 4:07 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who indicated an initial AIMS assessment should have been completed on the day of admission.

Based on staff interview and record review, the facility did not ensure an allegation of neglect was reported to the State Agency (SA) for 1 resident (R) (R1) of 3 sampled residents. On 7/18/24, R1 had a fall with major injury. R1's care plan contained an intervention for a sensor alarm on R1's bed. The facility's fall investigation indicated a sensor alarm was not on R1's bed at the time of the fall. The facility did not report the potential neglect to the SA. Findings include: The facility's Abuse Prevention policy, with a revision date of July 2024, indicates: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .Identification of Abuse - Identify events, such as but not limited to, suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. 1. Bruises, skin tears and injuries of unknown source will be investigated to rule out abuse .Investigation - All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigated .The investigation shall consist of: .5. An interview with staff members (on all shifts) having contact with the resident(s) during the period of the alleged incident; .Reporting/Response - All alleged violations will be reported via phone or in writing within 2 hours to the State Licensing Agency. The facility shall follow-up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days .Definitions - Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . On 9/11/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including dementia, left humerus fracture, and hypertension. R1's Minimum Data Set (MDS) assessment, dated 6/14/24, stated R1's Brief Interview for Mental Status (BIMS) score was 2 out of 15 which indicated R1 had severe cognitive impairment. R1's medical record indicated R1 had an activated Power of Attorney for Healthcare (POAHC). A fall investigation indicated R1 had an unwitnessed fall in R1's room on 7/18/24 at approximately 3:45 AM. R1 was found on R1's back on the floor. R1's bed was in the lowest position and a floor mat was in place. When asked what happened, R1 stated, I was trying to walk. An assessment indicated R1's vital signs, neurological checks, and range of motion to left upper and lower extremities were at baseline. R1 complained of right upper extremity and right hip/lower extremity pain with movement. A Hoyer lift was used to assist R1 into bed. A Hospice nurse arrived to assess R1 and discussed R1's condition with R1's POAHC. The Hospice nurse and R1's POAHC decided to have staff monitor R1 throughout the day to determine if further measures should be taken. Pain medication was administered to ensure comfort for any complaints or signs of pain. Due to R1 guarding R1's right hip and upper right thigh, an order was received at approximately 3:00 PM to obtain an X-ray of R1's right hip. An X-ray was obtained at the facility on 7/18/24 at approximately 5:20 PM. Per the guidance of the Hospice nurse and R1's POAHC, the facility continued previously ordered Hospice comfort medication and repositioning to ensure comfort. The X-ray report, dated 7/19/24, indicated R1 had an acute basil cervical right femoral neck fracture. Following Hospice, Medical Doctor (MD), and POAHC notification, a decision was made to keep R1 comfortable with appropriate pain management in the facility. On 7/19/24 at 10:10 AM, R1 passed away. The fall investigation indicated 20 staff were interviewed regarding the use of a sensor alarm on R1's bed. Approximately half of the staff remembered a bed alarm in use for R1 and the other half did not remember ever seeing a bed alarm in use for R1. On 9/11/24 at 12:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-D via telephone. CNA-D indicated CNA-D observed R1 lying sideways on the floor following R1's fall on 7/18/24. R1's bed was in a low position and a fall mat was on the floor. CNA-D indicated there was not a sensor alarm on R1's bed. On 9/11/24 at 2:30 PM, Surveyor interviewed Regional Administrator (RA)-C who indicated the facility initiated an investigation on 7/19/24 and did not have a clear picture of the circumstances surrounding the fall at that time. RA-C indicated the facility identified on 7/22/24 that staffs' use of R1's bed alarm was inconsistent with R1's care plan. RA-C verified R1's fall with injury was not reported to the SA. RA-C indicated the facility didn't think the fall would be considered or classified as neglect.

Based on record review and staff interview, the facility did not ensure a physician was notified in a timely manner when 1 Resident (R) (R1) of 1 residents had a sudden onset of acute pain that was not controlled with pharmacological or non-pharmacological interventions. R1 received anticoagulant (medication used to thin the blood and prevent clots) and antibiotic therapy following hip surgery and a wound infection. On 11/02/19, R1 experienced an acute onset of head, neck and shoulder pain. Staff faxed MD (Medical Doctor)-C, but did not receive a response. Staff did not follow-up with MD-C until 11/04/19 when R1's INR (international normalized ratio) (a blood test used to determine how much time it takes blood to clot) was above normal which increased R1's risk for bleeding. On 11/04/19, R1 was hospitalized with a brain and spinal bleed which hospital documentation indicated began three days prior. As a result of the facility's failure to ensure the physician was notified timely of R1's acute onset of head, neck and shoulder pain, R1 waited over 48 hours before being sent to the ED (emergency department) on 11/04/19 for treatment of [REDACTED]. This created a finding of Immediate Jeopardy that began on 11/02/19. NHA (Nursing Home Administrator)-A was notified of the immediate jeopardy on 9/23/20 at 12:30 pm. The jeopardy was verified to be removed 9/23/20; however, the deficient practice continues at a scope/severity level D (Potential For More Than Minimal Harm/Isolated) as the facility continues to implement its action plan. Findings include: The facility's Change of Condition Reporting policy, dated 9/2020, states: It is the policy of this facility that all changes in resident condition will be communicated to the physician. Acute Medical Change 1. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for a physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician. 2. If unable to contact the attending physician or alternate physician timely, notify the Medical Director for follow-up to a change in resident condition. The package insert for [MEDICATION NAME] ([MEDICATION NAME]) (an anticoagulant medication used to thin the blood and prevent clots) states: [MEDICATION NAME] can cause major or fatal bleeding. Perform regular monitoring of INR in all treated patients. Instruct patients about prevention measures to minimize risk of bleeding and to report signs and symptoms of bleeding. The most common adverse reactions to [MEDICATION NAME] are fatal and nonfatal hemorrhage from any tissue or organ. Drug interactions: More frequent INR monitoring should be performed when starting or stopping other drugs or when changing dosages of other drugs, including drugs intended for short-term use (e.g., antibiotics .). On 9/22/20, the Surveyor reviewed a complaint filed with the State Agency. The complaint alleged R1 complained of severe shoulder pain on 11/03/19, could not get out of bed and expressed a desire to die. The complaint indicated nursing staff attributed R1's behavior to dementia. The Surveyor reviewed R1's medical record. R1 was admitted to the facility for short-term rehab following surgery for [REDACTED]. R1's Admission MDS (Minimum Data Set), dated 10/21/19, indicated R1 was cognitively impaired and required extensive assistance of staff for transfers and ADLs (activities of daily living). R1's goal upon discharge was to return home where R1 lived independently prior to hospitalization . R1 had a physician's orders [REDACTED]. R1's Anticoagulant Therapy care plan, dated 10/15/19, contained an intervention to monitor/document and report to the MD any signs and symptoms of anticoagulant complications including sudden severe headaches, muscle/joint pain and sudden changes in mental status. R1's INR was 2.5 (within normal limits) on 10/28/19 and scheduled to be rechecked on 11/04/19. R1 also had a physician's orders [REDACTED]. R1 finished the course of Keflex on 10/31/19. In addition, R1 received [MEDICATION NAME] (an [MEDICATION NAME] used to treat pain and fever) three times daily for pain relief. Progress notes, dated 10/31/19 and 10/29/19, indicated R1 ambulated with less pain and was expected to discharge in two to three weeks. A progress note, written by LPN (Licensed Practical Nurse)-D on 11/02/19 at 4:18 PM, stated, .Lots of pain today in (R1's) neck and shoulders. Given ([MEDICATION NAME]) and ([MEDICATION NAME]) (a narcotic use to treat moderate to severe pain). Some relief yet resident still is not comfortable, please monitor. A progress note, written by LPN-E on 11/03/19 at 2:19 AM, stated, .(R1) has been unable to stand or walk since PM shift. (R1) has been yelling at the top of (R1's) lungs and waking up the whole hallway tonight several times .Increased confusion noted. Report to day shift. The note also indicated R1 repeatedly yelled help me to specific family members. A progress note, written by LPN-E on 11/03/19 at 2:48 AM, indicated MD-C was faxed on the day shift (11/02/19) regarding R1's increased neck and shoulder pain with left arm and hand weakness. The note stated a mini neuro check was performed. R1's hand grips were the same and there was no tongue deviation, but R1's smile was asymmetrical. The note indicated R1 displayed no signs or symptoms of a stroke. It was noted R1 could move R1's left leg, but would not stand on the leg. The note also indicated R1 was increasingly more confused. A progress note, written by LPN-E on 11/04/19 at 6:42 AM, stated, (R1) up yelling all night about being in pain .(R1) still (complains) of neck, left shoulder, left arm and left leg pain. (R1) is unable to stand on own power today .(R1) has been on antibiotics and [MEDICATION NAME] 4 mg daily. The note indicated LPN-E called the on-call MD three times that morning and was awaiting a reply due to R1's INR level of 5.7. A progress note, dated 11/04/19 at 10:48 AM, stated, Seen by (MD-C) today with new orders for CT (computerized tomography) scan (used to visualize cross-sectional images of the body including the soft tissues, blood vessels and bones) without contrast (dye) for stroke . A progress note, dated 11/04/19 at 5:03 PM, stated Call received from (MD-C) today with orders to have (R1) be seen in ED due to CT scan results indicating a brain and spinal bleed. A hospital admission note, dated 11/04/19, stated, .(Three) days ago patient developed a headache followed by severe neck pain and generalized weakness. Patient was sent in for a noncontrast head CT and found to have blood in the 4th ventricle (the most inferiorly located ventricle that drains directly into the central canal of the spinal cord) extending down into the cervical spine area. Patient states (patient's) headache has improved, but (patient) has developed significant neck pain. The ED Summary and Plan stated, Based on history, it is likely that (patient's) hemorrhage occurred three days ago. The ED Clinical Impression stated R1 suffered an acute spontaneous intraventricular hemorrhage (bleeding inside or around the ventricles of the brain) associated with [MEDICATION NAME] coagulopathy (associated with life-threatening bleeding). R1 was discharged to a different skilled nursing facility on palliative care with possible hospice in the near future. According to the complaint, R1 passed away on 2/15/20. On 9/22/20 at 2:00 PM, DON (Director of Nursing)-B and NHA (Nursing Home Administrator)-A (who were not employed by the facility at the time of the incident) verified LPN-D sent MD-C a fax on 11/02/19 regarding R1's acute onset of pain. DON-B verified MD-C did not respond to the fax until 11/04/19. DON-B stated with an acute onset of severe pain, staff should call instead of fax the MD. DON-B verified staff should have followed up with MD-C when they did not receive a response in a timely manner. On 9/23/20 at 5:56 AM, the Surveyor interviewed LPN-E via telephone. LPN-E stated R1 had a lot of increased shoulder and neck pain and didn't want to stand on the left leg. LPN-E stated a mini neuro check was performed on R1 after LPN-E noted R1 had increased confusion from the day before (11/02/19). LPN-E could not recall if LPN-E attempted to contact the on-call MD or MD-C on the 11/03/19 or 11/04/19 NOC (night) shifts. LPN-E also stated the 11/03/19 progress note that indicated R1's smile was asymmetrical was incorrect. LPN-E stated R1's smile was symmetrical and R1 displayed no signs or symptoms of a stroke. On 9/23/20 at 2:29 PM, the Surveyor interviewed LPN-D via telephone. LPN-D verified R1 experienced a sudden onset of increased head, neck and shoulder pain that was not relieved by medication on 11/02/19 and stated staff attempted to reposition R1 for comfort. LPN-D also worked on 11/03/19, but could not recall details of R1's condition. LPN-D stated if an MD didn't respond to a fax for a resident with a change in condition within a few hours, LPN-D typically called the MD's nurse and requested the MD be paged. LPN-D could not recall if that occurred on 11/02/19. LPN-D also stated if contact was not made with the MD before the end of the shift, the oncoming shift was asked to follow-up. LPN-D stated LPN-D did not believe R1's condition warranted a call to MD-C on 11/02/19 and stated it was acceptable to send a fax first.

Based on record review and staff interview, the facility did not provide the necessary care and services to maintain the highest practical well being in accordance with a comprehensive assessment and plan of care related to pain management for 1 Resident (R) (R1) of 3 residents. On 11/02/19, R1 experienced an acute onset of head, neck and shoulder pain. Staff faxed MD (Medical Doctor)-C, but did not receive a response. Despite R1's repeated complaints of head, neck and shoulder pain with left arm, left left hand and left leg weakness, staff did not follow-up with MD-C until 11/04/19. On 11/04/19, R1 was hospitalized with a brain and spinal bleed which hospital documentation indicated began three days prior. As a result of the facility's failure to ensure the physician was notified timely of R1's acute onset of head, neck and shoulder pain, R1 waited over 48 hours before being sent to the ED (emergency department) on 11/04/19 for treatment of [REDACTED]. This created a finding of Immediate Jeopardy that began on 11/02/19. NHA (Nursing Home Administrator)-A was notified of the immediate jeopardy on 9/23/20 at 12:30 pm. The jeopardy was verified to be removed 9/23/20; however, the deficient practice continues at a scope/severity level D (Potential For More Than Minimal Harm/Isolated) as the facility continues to implement its action plan. Findings include: The facility's Pain Management policy, dated 9/2020, states: It is the policy of this facility to provide an environment and program that assists each resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well being .Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. Assessment: 1. The resident will be assessed for pain . B. Upon development of new symptoms of acute or chronic pain that has not been previously addressed. Management: 2. Medication(s) received, refused and response to medication will be documented on the MAR (medication administration record). Monitoring: 1. Monitor pain status and treatment effects every shift. 2. Consult physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures. On 9/22/20, the Surveyor reviewed a complaint filed with the State Agency. The complaint alleged R1 complained of severe shoulder pain on 11/03/19, could not get out of bed and expressed a desire to die. The complaint indicated nursing staff attributed R1's behavior to dementia. The Surveyor reviewed R1's medical record. R1 was admitted to the facility for short-term rehab following surgery for [REDACTED]. R1's Admission MDS (Minimum Data Set), dated 10/21/19, indicated R1 was cognitively impaired, required extensive assistance of staff for transfers and ADLs (activities of daily living), had frequent pain and received PRN (as needed) narcotic pain medication. R1's goal upon discharge was to return home where R1 lived independently prior to hospitalization . R1 had a physician's orders [REDACTED]. R1 also received 1000 mg of [MEDICATION NAME] (an [MEDICATION NAME] medication used to treat minor aches and pains and fever) three times daily. R1's Acute/Chronic Pain care plan, dated 10/15/19, stated R1 was able to communicate with staff regarding pain. R1's care plan contained interventions to complete a pain assessment every shift, monitor/document for probable cause of each pain episode, remove/limit causes where possible and monitor/report to the nurse any signs and symptoms of non-verbal pain including yelling out, irritability, restlessness and agitation. R1 had a physician's orders [REDACTED]. R1's Anticoagulant Therapy care plan, dated 10/15/19, contained an intervention to monitor/document and report to the MD any signs and symptoms of anticoagulant complications including sudden severe headaches, muscle/joint pain and sudden changes in mental status. Progress notes, dated 10/31/19 and 10/29/19, indicated R1 ambulated with less pain and was expected to discharge in two to three weeks. A medication administration note, dated 11/02/19 at 12:02 AM, indicated R1 requested and received 5 mg of [MEDICATION NAME] for left hip pain and a headache. The mediation was documented as effective. A progress note, written by LPN (Licensed Practical Nurse)-D on 11/02/19 at 4:18 PM, stated, .Lots of pain today in (R1's) neck and shoulders. Given ([MEDICATION NAME]) and ([MEDICATION NAME]) .some relief yet resident still is not comfortable, please monitor. A narcotic count sheet indicated 2.5 mg of [MEDICATION NAME] was administered at 9:00 AM. A follow-up pain assessment was not completed. R1 did not receive [MEDICATION NAME] during the AM shift. A fax to MD-C, dated 11/02/19, stated, Neck, shoulder pain, (left) arm/hand weakness - no (signs/symptom) of stroke. Please advise. A progress note, written by LPN-E on 11/03/19 at 2:19 AM, stated, .(R1) has been unable to stand or walk since PM shift. (R1) has been yelling at the top of (R1's) lungs and waking up the whole hallway tonight several times .Increased confusion noted. Report to day shift. The note also indicated R1 repeatedly yelled help me to specific family members. R1's MAR indicated R1 received 5 mg of [MEDICATION NAME] at 6:12 PM. The medication was documented as ineffective. The assessment stated R1 continues to complain of pain with no change in strength. R1's MAR also indicated R1 received 0.5 mg of [MEDICATION NAME] (an anti-anxiety medication) at 7:41 PM for increased agitation and an inability to be redirected. The medication was documented as effective. R1's medical record did not contain documentation to indicate a physician was notified or that R1 received any additional pain medication during the shift. A progress note, written by LPN-E on 11/03/19 at 2:48 AM, indicated MD-C was faxed on the day shift (11/02/19) regarding R1's increased neck and shoulder pain with left arm and hand weakness. The note stated a mini neuro check was performed and R1 displayed no signs or symptoms of a stroke. It was noted R1 could move R1's left leg, but would not stand on the leg. The note also indicated R1 was increasingly more confused. A narcotic count sheet indicated R1 received 5 mg of [MEDICATION NAME] at 1:30 AM. A follow up pain assessment was not completed. R1's MAR indicated R1 received 5 mg of [MEDICATION NAME] at 10:14 AM for left shoulder and neck pain. The medication was documented as effective. A progress note, written by LPN-E on 11/04/19 at 6:42 AM, stated, (R1) up yelling all night about being in pain .(R1) still (complains) of neck, left shoulder, left arm and left leg pain. (R1) is unable to stand on own power today .(R1) has been on antibiotics and [MEDICATION NAME] 4 mg daily. The note indicated LPN-E called the on-call MD three times that morning and was awaiting a reply due to R1's INR (international normalized ratio) (used to determine how long it takes blood to form a clot) level of 5.7 (2.0 to 3.0 is the effective therapeutic range for a person taking [MEDICATION NAME]). A progress note, dated 11/04/19 at 10:48 AM, stated, Seen by (MD-C) today with new orders for CT (computerized tomography) scan (used to visualize cross-sectional images of the body including the soft tissues, blood vessels and bones) . A progress note, dated 11/04/19 at 5:03 PM, stated Call received from (MD-C) today with orders to have (R1) be seen in ED due to CT scan results indicating a brain and spinal bleed. A hospital admission note, dated 11/04/19, stated, .(Three) days ago patient developed a headache followed by severe neck pain and generalized weakness. Patient was sent in for a noncontrast (without dye) head CT and found to have blood in the 4th ventricle (the most inferiorly located ventricle that drains directly into the central canal of the spinal cord) extending down into the cervical spine area. Patient states (patient's) headache has improved, but (patient) has developed significant neck pain. The ED Summary and Plan stated, Based on history, it is likely that (patient's) hemorrhage occurred three days ago. The ED Clinical Impression stated R1 suffered an acute spontaneous intraventricular hemorrhage (bleeding inside or around the ventricles of the brain) associated with [MEDICATION NAME] coagulopathy (associated with life-threatening bleeding). R1 was discharged to a different skilled nursing facility on palliative care with possible hospice in the near future. According to the complaint, R1 passed away on 2/15/20. On 9/22/20 at 2:00 PM, DON (Director of Nursing)-B and NHA (Nursing Home Administrator)-A (who were not employed by the facility at the time of the incident) verified LPN-D sent MD-C a fax on 11/02/19 regarding R1's acute onset of pain. DON-B verified MD-C did not respond to the fax until 11/04/19. DON-B stated with an acute onset of severe pain, staff should call instead of fax the MD. DON-B verified staff should have followed up with MD-C when they did not receive a response in a timely manner. DON-B also stated staff should have completed a comprehensive pain assessment. On 9/23/20 at 5:56 AM, the Surveyor interviewed LPN-E via telephone. LPN-E stated R1 had a lot of increased shoulder and neck pain and didn't want to stand on the left leg. LPN-E stated a mini neuro check was performed after LPN-E noted R1 had increased confusion from the day before (11/02/19). LPN-E could not recall if LPN-E attempted to contact an on-call MD or MD-C on the 11/03/19 or 11/04/19 NOC (night) shifts. On 9/23/20 at 2:29 PM, the Surveyor interviewed LPN-D via telephone. LPN-D verified R1 experienced a sudden onset of increased head, neck and shoulder pain that was not relieved by medication on 11/02/19 and stated staff attempted to reposition R1 for comfort. LPN-D also worked on 11/03/19, but could not recall details of R1's condition. LPN-D stated if an MD didn't respond to a fax for a resident with a change in condition within a few hours, LPN-D typically called the MD's nurse and requested the MD be paged. LPN-D could not recall if that occurred on 11/02/19. LPN-D also stated if contact was not made with the MD before the end of the shift, the oncoming shift was asked to follow-up. LPN-D stated LPN-D did not believe R1's condition warranted a call to MD-C on 11/02/19 and stated it was acceptable to send a fax first.

Based on record review and staff interviews, the facility did not ensure the physician was immediately consulted with a significant change in 1 of 6 (R1) sampled resident's physical, mental, and/or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly to determine a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). R1 had a history of [REDACTED]. The resident was assessed to have low oxygen saturation levels with tachypnea (rapid breathing rate) on [DATE] and on the morning of [DATE], was assessed to have a significantly low blood pressure reading and fever. Staff did not address the abnormal vital signs and did not notify R1's physician of these changes in the resident's condition. Ultimately, the resident received a dose of [MEDICATION NAME] (antihypertensive medication) at 8:00 PM on [DATE] and was found pulseless and not breathing at 12:30 AM on [DATE]. The facility's failure to notify the physician regarding resident R1's change in condition created a finding of immediate jeopardy that began on [DATE]. The facility was notified of the immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a harm level of D (potential for harm/isolated). Findings include: The facility's current Change in Condition Alert (no date included) indicated if staff notice any signs or symptoms of change in condition to include any change from baseline vital signs, the physician should be notified. Example: Review of R1's closed medical record included documentation the resident was admitted to the facility on [DATE] after sustaining a fall at home with resultant sacral fracture. The resident had [DIAGNOSES REDACTED]. ([MEDICAL CONDITION] placed the resident at risk for cardiac arrhythmia). R1 was on a free water restriction and encouraged to consume foods higher in sodium. Documentation indicated R1's right elbow wound vac was discontinued earlier than ordered due to maceration. Orders for Santyl ointment and dressing changes once daily were initiated. R1's sodium level was obtained at the hospital just prior to discharge with results of 129. Normal sodium levels are ,[DATE]. R1's medication regime included nightly dosing of the antihypertensive medication [MEDICATION NAME]. admission orders [REDACTED]. Review of R1's current (MONTH) (YEAR) MAR (Medication Administration Record) was incorrectly documented as Blood Pressure per policy. No directions specified for order and Temperature per policy. No directions specified for order. R1's MAR indicated [REDACTED]. This discrepancy was verified to the Surveyor by RN (Registered Nurse)-J on [DATE] at approximately 11:30 AM. On [DATE], the results of R1's sodium level was 124 and white blood count was within normal limits. A repeat sodium level ordered was completed on [DATE] which indicated no improvement in R1's sodium level. As a result of R1's low sodium level, 1 gram sodium tablet was ordered daily to be initiated into the resident's medication regime. Documentation from [DATE] to [DATE] indicated R1 presented with a low grade fever; all other vital signs were within normal limits during that time frame. R1's documented vital signs from time of admission until [DATE] indicated blood pressure readings ranged from ,[DATE]-,[DATE]; pulse rates ranged from ,[DATE]; breaths per minute ranged from ,[DATE] and oxygen saturation readings ranged from ,[DATE]%. On [DATE], R1's temperature was documented as 100.3 degree F (Fahrenheit). All other vital signs were within normal limits at that time. R1's medical record did not include documentation that additional vital signs were obtained until [DATE]. At that time, R1's oxygen saturation level was low at 87% with a respiratory rate of 24 breaths per minute and the resident's blood pressure and temperature reading were within normal limits. On [DATE] at 7:00 a.m., LPN (Licensed Practical Nurse)-A documented the following vital signs for R1: Blood pressure- ,[DATE] Pulse- 87 and regular Temperature- 100.3 degrees F Oxygen saturation- 95% on room air Respiratory rate- 18 breaths per minute On [DATE] at 7:00 AM, the Surveyor interviewed LPN-A regarding R1. LPN-A indicated she had worked R1's unit on [DATE] until 11:00 AM and had reported R1's blood pressure was a bit low to LPN-G, who then worked R1's unit until 10:00 PM. LPN-A verified not rechecking R1's vital signs before leaving R1's unit on [DATE] stating, I was too busy. LPN-A indicated she completed a head to toe physical evaluation of R1 at 7:00 AM on [DATE] but did not look at the resident's right elbow wound because, it was covered by a dressing. LPN-A indicated she had not observed R1's elbow wound the prior ,[DATE] weeks and thought the higher than normal temperature was due to R1 having several blankets on at the time the temperature reading was obtained. LPN-A indicated she did not inform an RN or physician of the abnormal vitals obtained on R1. LPN-A verified to the Surveyor that she was aware [MEDICAL CONDITION] placed R1 at higher risk for cardiac arrhythmia and verified the facility had not initiated staff education regarding the procedure for action when a resident has abnormal vital signs. LPN-A stated she did not document R1's vital signs obtained on [DATE] at 7:00 AM into the resident's medical record until 10:00 AM that day due to a computer glitch. On [DATE] at 8:50 AM, the Surveyor interviewed MD (Medical Doctor)-F via the telephone, who was R1's primary care physician. MD-F indicated R1's [MEDICAL CONDITION] was most likely caused by severe digestive problems. When informed of the resident's change in condition beginning [DATE], MD-F indicated would have been expected to have been notified to determine if changes in the resident's treatment plan were necessary, to potentially include bolus of fluids or holding medications. MD-F stated, I would think it was the standard of practice to let me know when a resident was showing abnormal vital signs so I could evaluate and determine need for changes in course of treatment. R1's medical record included documentation dated [DATE] at 10:16 AM, Res (resident) found unresponsive at 00:35 (12:30 AM) by RN .RN started CPR (Cardiopulmonary Resuscitation). Writer called 911. R1 ultimately expired that morning. The facility has a 24 hour report change in condition document that all licensed staff are to review at start of their shift. The facility's 24 hour reports did not include R1's name or documentation regarding the resident's condition for the duration of R1's stay. During interviews with the Surveyor on [DATE] at 7:55 AM and 9:40 AM, NHA (Nursing Home Administrator)-C verified the 24 hour reports did not include any documentation regarding R1. In addition, NHA-C indicated DON (Director of Nursing)-E informed him R1 had an unexpected death and was to be discharged home on [DATE]. NHA-C stated, I was unaware of the resident's change in condition and abnormal vital signs without follow up. On [DATE] at 11:50 AM, the Surveyor interviewed RN-E. RN-E stated, I was mistaken when I told (DC (Deputy Coroner)-H) that after R1 had presented with a low blood pressure and fever the morning of [DATE], that the vitals had been retaken. Staff are taught that if a temperature is above 100 degrees F and if the blood pressure is low, repeat vitals should be obtained within the hour and if they are still abnormal, this information is to be relayed to the physician and passed along to the next shift. After (R1's) death, I interviewed both (LPN-G) and (LPN-B) and neither of them knew that (R1) had a change in condition. On [DATE] at 12:30 PM, the Surveyor interviewed C (Coroner)-I via the telephone regarding R1. C-I indicated he had been made aware of R1's condition by the ambulance squad who answered the 911 call on [DATE] for R1, stating the ambulance personnel were concerned with R1's abnormal vital signs obtained early morning of [DATE] and lack of follow up vitals, then the resident was found pulseless and not breathing at 12:30 AM on [DATE]. C-I indicated ordered an investigation be conducted by DC-H regarding R1 which was completed on [DATE]. C-I indicated DC-H was concerned of the lack of facility responses during the investigation. The narrative note documented by the ambulance service that attempted resuscitation for R1 on [DATE] indicated, It came to the crews attention that the patient's vitals were last checked at 10:00 AM on [DATE]. The patient's blood pressure was ,[DATE] as charted by nursing home records. The patient also had a temperature of 100.3. These were the last vitals obtained with no one reporting them to anyone. This is a great concern because these are not normal numbers and action should have been taken. The ambulance was not called until the nursing staff found the patient unresponsive and no pulse or breathing at 12:46 AM on [DATE]. Although R1 presented with abnormal vital signs on [DATE] and again on [DATE] at 7:00 AM, R1's vital signs were deteriorating, staff did not monitor additional vital signs for R1 and did not promptly consult with the physician; staff subsequently administered R1's dose of [MEDICATION NAME] that evening. Ultimately, R1 coded and expired. The facility's failure to promptly consult the physician with R1's significant change in condition created a situation of immediate jeopardy that was removed on [DATE] when the facility implemented the following action plan: On [DATE]: 1. Notified MD of immediate jeopardy at 3:00 PM 2. Facility initiated Quality Improvement plan for physician notification. 3. Reviewed and revised policy and procedures as necessary for physician notification 4. Review of additional resident progress notes was completed regarding the need for potential change of condition follow up and physician notification 5. Director of Nurses and designee began in-servicing nursing staff on policy and procedures for physician notification. Staff on current shift were in-serviced and oncoming to be in-serviced prior to shift 6. Administrator and Director of Nursing are responsible for implementation of the above plan Additional action taken: 1. Policies for Physician Notification will be reviewed through the QAPI Process 2. Director of Nursing or designee will review daily progress notes for change of condition and physician notification. Results of the progress note reviews will be reviewed through the QAPI process At the time of this complaint investigation survey, staff were being educated as per the facility's plan of correction from a previous survey conducted on [DATE] on change in condition alert. Documentation indicated only 3 staff had received this education to date. LPN-A did not receive this education as per the documented educational sign in sheet.

Based on record review and staff interviews the facility did not ensure 1 of 6 sampled residents (R1)received treatment and care in accordance with professional standards of practice, the comprehensive assessment and person-centered care plan. R1 had a history of [REDACTED]. The resident was assessed to have low oxygen saturation levels with tachypnea (rapid breathing rate) on [DATE] and on the morning of [DATE], was assessed to have a significantly low blood pressure reading with fever. Staff did not address the abnormal vital signs, did not place the resident on a 24 hour significant change report/list, did not recheck the resident's vital signs during the entire day of [DATE], and did not communicate the abnormal vital signs to the oncoming shift nurse. Ultimately, R 1 received a dose of [MEDICATION NAME] (antihypertensive medication) at 8:00 PM on [DATE] and was found pulseless and not breathing at 12:30 AM on [DATE]. The facility's failure to recheck R1's abnormal vital signs, communicate these abnormal findings to other nursing staff and act upon R1's change in condition created a finding of immediate jeopardy that began on [DATE]. The facility was notified of the immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a harm level of D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy/procedure entitled Shift to Shift Report dated ,[DATE] indicated that person to person report will be done at 5:30 AM, 2:00 PM and 10:30 PM. The off-going nurse will report on each resident with the oncoming nurse from the 24 hour log form. The nurse will also record report privately for other oncoming nurses to listen to. The following information will be given regarding each resident: ~ Current condition (stable, serious, no change etc.) ~ Any follow up that needs to be done regarding any noted resident changes (MD still not called back, family not home, care plan updating). ~ Any other issues which may affect the resident's care. Concerns regarding resident care will be noted by the oncoming nurse. The oncoming nurse will address the concerns to the appropriate staff/department and follow up as indicated when he/she does routine rounds (or before if necessary). Example: Review of R1's closed medical record indicated the resident was admitted to the facility on [DATE] after sustaining a fall at home with resultant sacral fracture. The resident had [DIAGNOSES REDACTED]. [MEDICAL CONDITION] placed the resident at risk for cardiac arrhythmia. The resident was on a free water restriction and encouraged to consume foods higher in sodium. Documentation indicated R1's right elbow wound vac was discontinued earlier than ordered due to maceration. Orders for Santyl ointment and dressing changes once daily were initiated. R1's sodium level was obtained at the hospital just prior to discharge with results of 129. Normal sodium levels are ,[DATE]. R1's medication regime included nightly dosing of the antihypertensive medication [MEDICATION NAME]. admission orders [REDACTED]. Review of R1's current (MONTH) (YEAR) MAR (Medication Administration Record) incorrectly included documentation Blood Pressure per policy. No directions specified for order and Temperature per policy. No directions specified for order. R1's MAR indicated [REDACTED]. This discrepancy was verified to the Surveyor by RN (Registered Nurse)-J on [DATE] at approximately 11:30 AM. Documentation from [DATE] to [DATE] indicated R1 presented with a low grade fever, all other vital signs were within normal limits during that time frame. R1's documented vital signs from time of admission until [DATE] indicated blood pressure readings ranged from ,[DATE]-,[DATE]; pulse rates ranged from ,[DATE]; breaths per minute ranged from ,[DATE] and oxygen saturation readings ranged from ,[DATE]%. On [DATE], the results of R1's sodium level was 124 and white blood count was within normal limits. A repeat sodium level ordered was completed on [DATE] which indicated no improvement in R1's sodium level. As a result of R1's low sodium level, 1 gram sodium tablet was ordered daily to be initiated into the resident's medication regime. On [DATE], R1's temperature was documented as 100.3 degree F (Fahrenheit). All other vital signs were within normal limits at that time. R1's medical record did not include documentation that additional vital signs were obtained until [DATE]. At that time, R1's oxygen saturation level was low at 87% with a respiratory rate of 24 breaths per minute and the resident's blood pressure and temperature reading were within normal limits. On [DATE] at 7:00 AM, LPN (Licensed Practical Nurse)-A documented the following vital signs for R1: Blood pressure- ,[DATE] Pulse- 87 and regular Temperature- 100.3 degrees F Oxygen saturation- 95% on room air Respiratory rate- 18 breaths per minute On [DATE] at 7:00 AM, the Surveyor interviewed LPN-A regarding R1. LPN-A indicated she had worked R1's unit on [DATE] until 11:00 AM and had reported R1's blood pressure was a bit low to LPN-G, who then worked R1's unit until 10:00 PM. LPN-A verified not rechecking R1's vital signs before leaving R1's unit on [DATE] stating, I was too busy. LPN-A indicated she completed a head to toe physical evaluation of R1 at 7:00 AM on [DATE] but did not look at the resident's right elbow wound because, it was covered by a dressing. LPN-A indicated she had not observed R1's elbow wound the prior ,[DATE] weeks and thought the higher than normal temperature was due to R1 having several blankets on at the time the temperature reading was obtained. LPN-A indicated she did not inform an RN or physician of the abnormal vitals obtained on R1. LPN-A verified to the Surveyor that she was aware [MEDICAL CONDITION] placed R1 at higher risk for cardiac arrhythmia and verified the facility had not initiated staff education regarding the procedure for action when a resident has abnormal vital signs. LPN-A stated had not documented R1's vital signs obtained on [DATE] at 7:00 AM into the resident's medical record until 10:00 AM that day due to a computer glitch. On [DATE] at 7:35 AM, the Surveyor interviewed LPN-B via the telephone regarding R1. LPN-B verified she worked the night shift on [DATE] and had not received any report concerning R1's change in condition. LPN-B stated, I was really upset. If I knew the issues (with R1's abnormal vital signs) I would have rechecked the vitals and notified someone. (R1) should have been on the 24 hour change in condition report which we are to check before the start of each shift but was not. I had not seen the elbow wound since the treatment is not usually done on the shifts I work. I told the DON (Director of Nursing) about my concerns. We have not received any training since this happened with (R1) regarding what to do when abnormal vital signs in a resident are noted. On [DATE] at 9:10 AM, the Surveyor interviewed LPN-G via the telephone regarding R1. LPN-G indicated LPN-A never reported any concerns regarding R1 to her, so at 8:00 PM, on [DATE], the resident was administered the antihypertensive ([MEDICATION NAME]) as ordered. LPN-G stated, At the time I gave (R1) night meds, the resident was lethargic which was not her normal. I didn't think much of it because the resident was very active that day and was tired because was to be discharged from the facility to home on [DATE]. If I would have known about the low blood pressure and fever, I would have monitored them and updated the physician. I probably would have checked the elbow wound and held the night time dose of [MEDICATION NAME]. We have not received any training since this happened with (R1) regarding what to do when abnormal vital signs in a resident are noted. R1's medical record included documentation dated [DATE] at 10:16 AM, Res (resident) found unresponsive at 00:35 (12:30 AM) by RN .RN started CPR (Cardiopulmonary Resuscitation). Writer called 911. R1 ultimately expired that morning. The facility has a 24 hour report change in condition document that all licensed staff are to review at start of their shift. The facility's 24 hour reports did not include R1's name or documentation regarding the resident's condition for the duration of R1's stay. During interviews with the Surveyor on [DATE] at 7:55 AM and 9:40 AM, NHA (Nursing Home Administrator)-C verified the 24 hour reports did not include any documentation regarding R1. In addition, NHA-C indicated DON (Director of Nursing)-E informed him R1 had an unexpected death and was to be discharged home on [DATE]. NHA-C stated, I was unaware of the resident's change in condition and abnormal vital signs without follow up. On [DATE] at 11:50 AM, the Surveyor interviewed RN-E. RN-E stated, I was mistaken when I told (DC (Deputy Coroner)-H) that after R1 had presented with a low blood pressure and fever the morning of [DATE], that the vitals had been retaken. Staff are taught that if a temperature is above 100 degrees F and if the blood pressure is low, repeat vitals should be obtained within the hour and if they are still abnormal, this information is to be relayed to the physician and passed along to the next shift. After (R1's) death, I interviewed both (LPN-G) and (LPN-B) and neither of them knew that (R1) had a change in condition. On [DATE] at 12:30 PM, the Surveyor interviewed C (Coroner)-I via the telephone regarding R1. C-I indicated he had been made aware of R1's condition by the ambulance squad who answered the 911 call on [DATE] for R1, stating the ambulance personnel were concerned with R1's abnormal vital signs obtained early morning of [DATE] and lack of follow up vitals, then the resident was found pulseless and not breathing at 12:30 AM on [DATE]. C-I indicated ordered an investigation be conducted by DC-H regarding R1 which was completed on [DATE]. C-I indicated DC-H was concerned of the lack of facility responses during the investigation. The narrative note documented by the ambulance service that attempted resuscitation for R1 on [DATE] indicated, It came to the crews attention that the patient's vitals were last checked at 10:00 AM on [DATE]. The patient's blood pressure was ,[DATE] as charted by nursing home records. The patient also had a temperature of 100.3. These were the last vitals obtained with no one reporting them to anyone. This is a great concern because these are not normal numbers and action should have been taken. The ambulance was not called until the nursing staff found the patient unresponsive and no pulse or breathing at 12:46 AM on [DATE]. Although R1 presented with abnormal vital signs on [DATE] and again on [DATE] at 7:00 AM, R1's vital signs were deteriorating, staff did not monitor additional vital signs for R1 and did not report the abnormal vital signs to oncoming staff or to the RN on duty; staff subsequently administered R1's blood pressure medication ([MEDICATION NAME]) that evening and was not aware R1's blood pressure had been low earlier in the day. Ultimately, R1 coded and expired. At the time of this complaint investigation survey, staff had not been educated regarding the procedure what to do when a resident presents with abnormal vital signs. The facility's failure to recheck R1's abnormal vital signs, communicate these abnormal findings to other nursing staff and act upon R1's change in condition created a finding of immediate jeopardy that was removed on [DATE] when the facility implemented the following action plan: On [DATE]: 1. MD was notified of the IJ at 3:00 PM 2. Review of residents on antihypertensive medications to verify if a physician has ordered parameters and they are transcribed to the EAR (electronic medical record) as ordered 3. Facility initiated Quality Improvement plan for identification of change of condition, shift to shift reporting of change of condition, CPR and reviewed with the medical director. 4. Reviewed and revised policy and procedures as necessary for shift to shift reporting, comprehensive assessment and CPR 5. Review of Resident progress notes was completed for residents to monitor for need for potential change of condition follow up 6. Director of Nurses and Designee began in-servicing nursing and therapy staff related to policy and procedures for shift to shift report, comprehensive assessment and CPR policy. Staff on current shift were in-serviced and oncoming staff in-serviced prior to shift 7. Facility Crash cart was audited for appropriate equipment 8. All employee files were audited for CPR certification cards 9. The facility staffing schedule was reviewed to ensure a CPR Certified staff member will be present in facility for all shifts 10. Administrator and Director of Nursing are responsible for implementation of the above plan On [DATE]: 1. Facility contacted physicians for residents on Antihypertensive medications that did not have ordered parameters and asked for parameters Additional action taken: 1. Director of Nursing or designee will review daily progress notes for change of condition. Results of the progress note reviews will be reviewed through the QAPI process 2. Director of Nursing or Designee will review charts of residents admitted to monitor that orders transcribed match the admission orders [REDACTED]. Results of the review will be reviewed through the QAPI process

Based on observation and resident and staff interviews, the facility did not ensure that the resident environment remained as free of accident hazards as possible for 3 of the facility's 42 residents (resident #17, #8 and #9) when O2 (Oxygen) was observed in use with a heated electric hair dryer in the hair salon of the facility. Resident #17 was observed in the hair salon seated under a hair dryer. O2 at 2 Liters per nasal cannula was observed in use on resident #17's face. Resident #12 and resident #13 were also seated in the hair salon at this time. Residents #8 and #9 indicated they have also been under the hair dryer while their oxygen was running. The failure of the facility to follow safety policies with regards to use of O2 created a situation of Immediate Jeopardy, which began 4/16/15 when the O2 was observed being used within close proximity of a heated hair dryer. NHA (Nursing Home Administrator)-A was formally notified on 4/16/15 that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed on 4/16/15. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) pending confirmation that the facility has been able to sustain compliance. Findings include: Manufacturer's Safety Instructions for the "Highland Machine Commercial Filtered Hair Dryer," which is utilized in the facility's hair salon, indicated the following, "Warning: to reduce the risk of burns, electrocution, fire or injury to persons... "9. Do not use outdoors or operate where aerosol (spray) products are being used or where O2 is being administered." Lakeshore Respiratory Therapy Care Services, the provider of O2 for the facility, in a 2/19/14 policy entitled, "General O2 Safety Precautions," indicated..."2. Fire Hazard - No smoking, open flames, heat or exposure to other sources of ignition when using O2. O2 will not burn. It does, however, vigorously accelerate burning of any flammable material. 3...Electrical appliances such as...hair dryers (this includes the use of beauty shop hooded hair dryers) may be considered sources of ignition...5. If resident is exposed to smoking, open flames, heat or other sources of ignition, they must be off O2 for at least 20 minutes to allow existing O2 to dissipate from their clothing." DQA notified facilities of the danger of O2 use and hair dryers in the memo "DQA 12-005" (5/4/12): "Using electric hair dryers near oxygen use is potentially dangerous. Sparks can be caused by problems with the hair dryer, the cord or with a loose electrical connection. In addition, electric dryers produce hot air which can be dangerous in an oxygen-enriched environment. The U.S. Consumer Product Safety Commission warns consumers not to operate an electric hair dryer where aerosol or spray products are being used, or where oxygen is being administered. Most manufacturers' product labels for electric hair dryers carry warnings to not use electric hair dryers where oxygen is in use. CMS (Centers for Medicare and Medicaid) Region V refers to the CGA (Compressed Gas Association) publication CGA P-2.7 - 2000 edition, section 5.3, which addresses use of oxygen near a source of ignition. This section states that oxygen use should be at least five feet from hair dryers... " On 4/16/15 at 10:29 a.m., surveyor # observed resident #17 seated under a hair dryer in the hair salon of the facility. The hair dryer was emitting warm air. Resident #17 was observed wearing O2 per nasal cannula via the use of a portable O2 tank that was attached to the wheelchair. The O2 was flowing, as the tank was set at 2 liters. HS (Hair Stylist)-C, resident #12 and resident #13 were also in the hair salon. On 4/16/15 at 10:30 a.m., surveyor # interviewed HS-C regarding the use of O2 and hair dryers. HS-C verified awareness that O2 was hazardous when used around an electric hair dryer. HS-C stated resident #17 was fragile, newly admitted to hospice care and that HS-C was not sure if the resident was stable enough to be taken off O2. HS-C confirmed clarification about the resident's condition without O2 was not sought. Upon examination of the hair salon, it was noted there was no cautionary signs warning staff about the hazards of oxygen use and hair dryers. On 4/16/15 at 10:40 a.m., surveyor # interviewed resident #17 regarding the observation in the hair salon with the O2 in use. When the surveyor asked if the resident could go without O2 in the hair salon, resident #17 stated, "I'm not sure, they haven't tried it." On 4/16/15 at 10:51 a.m., surveyor # interviewed resident #8, who was one of 2 other residents in the facility who utilize O2 therapy. Resident #8 confirmed using O2 per nasal cannula, via a portable tank in the hair salon. Resident #8 indicated no one ever gave instructions to remove the O2 in the salon, while under the hair dryer. On 4/16/15 at 12:20 p.m., surveyor # interviewed resident #9, who is the other resident in the facility who utilizes O2. Resident #9 stated "They cut my hair here, sometimes I sit under the dryer with O2." On 4/16/15 at 1:20 p.m., surveyor # interviewed NHA-A regarding the use of hair dryers with O2 therapy. NHA-A verified the hair dryers in the salon had heating elements which allowed hot air to flow and O2 should not be utilized in the hair salon. NHA-A indicated education would be initiated for all staff. The failure to ensure a safe environment by failing to ensure that oxygen was not in use while residents were under the hair dryer created a finding of immediate jeopardy. The jeopardy was removed on 4/16/15 when NHA-A removed the oxygen from the hair salon, DON (Director of Nursing)-B placed a sign in the hair salon stating "No Oxygen Use in the Beauty Salon) and all staff on duty, and all staff prior to to working their next shift, to include the beautician, were trained on the proper use and policy for oxygen.

Based on record review, staff and resident interviews, the facility did not ensure changes were made to the plan of care to provide adequate supervision and assistive devices to prevent accidents for 1 (resident #1) of 4 sampled residents reviewed for falls. Resident #1 had a history of [REDACTED]. The facility implemented an alarm system to notify staff when resident #1 attempted to stand unassisted. Although the facility initiated physical therapy for strengthening after resident #1 fell , they did not address the resident's independent removal of the alarm and/or turning the alarm off. The facility did not complete a comprehensive assessment regarding the causal factors of resident #1's falls and did not revise the resident's care plan in attempt to prevent further falls. On 6/15/14, resident #1 turned off his alarm and was found by staff lying on the floor. Resident #1 complained of pain and was transferred to the hospital and diagnosed with [REDACTED]. Findings include: On 6/16/14, surveyor # reviewed resident #1's medical record and it indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS (Minimum Data Set) assessment dated [DATE] indicated the resident had severe cognitive impairment, required extensive assistance of 1 with transfers and toilet use. This MDS indicated resident #1 was at risk for falls and had sustained two falls, without injury, since the previous assessment and the resident's balance from a seated to standing position was not steady, and was only able to stabilize with staff assist. Resident #1's care plan dated 12/26/13 included, "I have a history/am at risk for falls r/t (related to): medication, balance, poor safety awareness." The following interventions were included: * Bed and chair alarms * Keep room free of clutter and keep necessary items, such as call light, urinal, bedside table within reach * PT (Physical Therapy)/OT (Occupational Therapy)/Restorative referral as needed * Anti rollbacks on w/c (wheel chair), added 3/3/14 Nurse's notes dated 5/2/14 (no time documented)- "Resident was attempting to self transfer to the commode, chair alarm went off. The CNA (Certified Nursing Assistant) tried to catch resident when he was falling to the floor.......Call Don't Fall sign placed in resident's room. Resident was reminded several times during the day to use the call light." The post fall investigation, dated 5/5/14, indicated the fall had been evaluated/analyzed and interventions require additional input for the following reasons: needs reminders to use call lights and a Call, Don't Fall sign was placed. Nurse's notes dated 5/7/24 at 8:00 p.m.- "Resident put his coat on backwards, and was found attempting to remove his alarm off the wheel chair. Standing up without assist." Resident #1's medical record indicated PT was initiated for strengthening on 5/8/14. Nurse's notes dated 5/20/14 at 6:00 p.m.- "Resident was found on the floor against his bed, has a bruise from right shoulder blade to lower back." The incident report form dated 5/20/14 indicated resident #1 "Self transfer. Had removed the alarm." The post fall investigation dated 5/20/14 indicated the fall had been evaluated/analyzed and interventions require additional input for the following reasons: A motion alarm was considered however determined unrealistic due to resident's mobility in w/c while in room and halls. Social Worker discussed "Call, Don't Fall" risk. Has been participating in physical therapy since 5/8/14 and has gotten stronger. Staff to check frequently. Resident #1's care plan was not updated to include staff completing frequent checks of the resident, nor was a specific description to the meaning of frequent checks. The medical record did not include documentation that "frequent checks" were completed. Nurse's notes dated 5/31/14 at 3:30 p.m.- "Resident self transferred to the toilet and turned off alarm....Encouraged to call for assistance when needs to use the bathroom." Nurse's notes dated 6/15/14 at 3:38 p.m.- "Staff found resident on floor in his private room, sensor alarm was on, but not sounding, resident stated he did not hit his head, resident stated he was trying to walk, staff encouraged resident to call for assistance if he needs to transfer anywhere, resident upset about this." The Incident Report Form dated 6/15/14 at 3:00 p.m. included a "Brief description of incident" "Resident found on floor, stated he was trying to walk. Sensor pad on but not sounding." The post fall investigation dated 6/16/14 indicated the fall had been evaluated/analyzed and interventions require additional input for the following reasons: the alarm was tested (did not indicate if the alarm was functioning appropriately). Nurse's Notes dated 6/15/14 at 9:49 p.m.- At 8:50 p.m., resident was found lying on the floor in his private room, when asked what the resident was doing, (resident) stated "walking," resident had turned off his alarms, resident did c/o (complaint of) pain in his left arm and left leg, once staff got resident back into his wheel chair, resident began to convulse in what appeared to be a seizure, resident's pupils were dilated and fixed, resident was unresponsive, lost all color to face, staff unable to get a BP (blood pressure), this lasted approximately 4 minutes. When resident became responsive again, pupils became equal, round and reactive, and color appeared back to resident's face. BP at this time was able to be heard and was 80/50....Resident now states he has no pain in his left leg, but still has a lot of pain in his left arm. Resident would not allow staff to move him. On call Physician gave order to send to hospital via ambulance to eval (evaluate) and treat. Nurse's Notes dated 6/16/14 at 3:20 a.m.- Returned to the facility at 3:12 a.m. via ambulance. Resident #1 was transferred to bed with assist of 4 staff and a draw sheet. Discomfort noted during transfer. He (resident #1) has an immobilizer in place on the left upper extremity. Diagnoses: [REDACTED]. The x-ray results dated 6/16/14, indicated resident #1 sustained a mildly displaced and impacted left humeral neck fracture and a comminuted (bone is splintered or crushed) fracture of the left superior pubic ramus (pelvic). On 6/16/14 at 3:15 p.m. and 4:50 p.m., surveyor # interviewed NHA (Nursing Home Administrator)-B regarding resident #1. NHA-B verified resident #1 fell during self transfers on 6/15/14 and sustained fractures. NHA-B indicated the alarm, which was implemented to notify staff if resident #1 was attempting to stand unassisted, had not sounded. NHA-B indicated the nurse aides check all alarms when they apply them and verified resident #1 had turned off the alarm. On 6/17/14 at 9:20 a.m., surveyor # interviewed CNA-A in the presence of resident #1. CNA-A indicated she has seen resident #1 attempting to remove his alarms prior to 6/15/14. CNA-A verified the alarms are checked at the beginning of each shift, and as they are applied to make sure the alarms are functioning correctly. CNA-A said she has seen resident #1 turning around in the wheel chair and unhooking the alarm. CNA-A wasn't aware of any changes to resident #1's plan of care in response to the resident turning off the alarm, until after the resident fell on [DATE]. Resident #1 nodded his head "yes" when surveyor # asked if he ever turned off or removed his alarms and if he turned the alarm off on 6/15/14, prior to his falls. On 6/17/14 at 9:36 a.m., surveyor # interviewed NHA-B regarding resident #1. NHA-B indicated the facility's investigation regarding resident #1's falls on 6/15/14 were still in progress. NHA-B indicated she spoke with LPN (Licensed Practical Nurse)-C regarding resident #1's fall on 6/15/14, as LPN-C was the staff that responded to the resident's fall. NHA-B stated, LPN-C indicated resident #1's alarms were functioning correctly when staff assisted resident #1 prior to the falls. On 6/17/14 at 11:30 a.m., surveyor # interviewed NHA-B and IDON (Interim Director of Nursing)-D regarding resident #1's care plan. NHA-B indicated staff did not implement changes to resident #1's care plan to address the resident independently removing the alarm and/or turning the alarm off, prior to the resident's falls that occurred on 6/15/14. IDON-D verified the only changes made to resident #1's care plan was on 5/8/14 when PT was added in attempt to prevent further falls. NHA-B and IDON-D verified the facility had not implemented interventions in attempt to prevent further falls such as adjusting resident #1's toileting schedule, moving resident #1 to a room closer to the nurse's station, increasing resident #1's supervision, or moving the location of resident #1's alarm in an attempt to prevent independent removal or turning the alarm off, until after resident #1 had sustained fractures from the fall that had occurred on 6/15/14.