Every finding on record at Hamilton Health Services

Based on observation, staff and resident interview, and record review, the facility did not ensure food was palatable and served at an appetizing temperature for 1 resident (R) (R6) of 5 sampled residents.During observations of meal service, food held in the steam table and reheated food served to residents did not reach or maintain palatable temperatures.Findings include: The 2022 Food and Drug Administration (FDA) Food Code documents at 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S 3-501.19, and except as specified under (B) and in (C) of this section, Potentially Hazardous Food (Time/Temperature Control for Safety Food) shall be maintained: (1) At 57 Celsius (C) (135 Fahrenheit (F)) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11 (B) or reheated as specified in 3-403.11 (E) may be held at a temperature of 54 C (130 F) or above; or (2) At 5 C (41 F) or less. (B) Eggs that have not been treated to destroy all viable Salmonella shall be stored in refrigerated equipment that maintains an ambient air temperature of 5 C (41 F) or less. (C) Potentially Hazardous Food (Time/Temperature Control for Safety Food) in a homogenous liquid form may be maintained outside of the temperature control requirements, as specified under (A) of this section, while contained within specially designed equipment that complies with the design and construction requirements as specified under 4-204.13 (E).The 2022 FDA Food Code documents at 3-403.11 Reheating for Hot Holding: (A) Except as specified under (B) and (C) and in (E) of this section, time/temperature control for safety food that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds.The 2022 FDA Food Code documents at Chapter 3. Food Chapter 3-25: (B) Except as specified under (C) of this section, time/temperature control for safety food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. (C) Ready to eat time/temperature control for safety food that has been commercially processed and packaged in a food processing plant that is inspected by the regulatory authority that has jurisdiction over the plant, shall be heated to a temperature of at least 57 degrees C (135 degrees F) when being reheated for hot holding. (D) Reheating for hot holding as specified under (A)-(C) of this section shall be done rapidly and the time the food is between 5 degrees C (41 degrees F) and the temperatures specified under (A)-(C) of this section may not exceed 2 hours. (E) Remaining unsliced portions of meat roasts that are cooked as specified under 3-401.11(B) may be reheated for hot holding using the oven parameters and minimum time and temperature conditions specified under 3-401.11(B).On 1/26/26 at 9:47 AM, Surveyor interviewed R6 who stated food is not served hot. R6 stated the concern was previously discussed during a Resident Council meeting; however, the food is still served at an unappetizing temperature which causes R6 to not eat meals at times. R6 stated nursing staff are busy and if R6 asks for food to be reheated, the reheated food is not served hot or at an appetizing, palatable temperature.On 1/27/26, Surveyor reviewed Resident Council meeting minutes, dated 12/7/25, that indicated food served to residents was cold and at an unappetizing temperature.On 1/26/26 beginning at 11:40 AM, Surveyor observed lunch service at the steam table in the main dining area kitchenette. Surveyor noted there was no steam rising from food in the steam table and food temperatures were not obtained. Surveyor also noted a thermal plate (a metal plate kept warm and placed under plates to keep food warm during service) was removed from an insulated food cart. The doors to the cart were open during meal service. Dietary Manager (DM)-C stated plate warmers are heated in the downstairs kitchen oven at 200 degrees F and brought up in the cart for service.On 1/27/26 beginning at 7:50 AM, Surveyor observed breakfast service at the steam table in the main dining area kitchenette. Surveyor noted there was no steam rising from food in the steam table. Surveyor observed as breakfast trays were plated and served to residents. DM-C stated the steam table does not reach an appropriate temperature in the morning to heat food and maintain food at appropriate holding temperatures and food frequently needs to be reheated prior to service. DM-C also stated the far-left side well of the steam table did not work. DM-C reheated the remaining plates in the kitchenette microwave. Surveyor observed DM-C heat a plate of scrambled eggs, waffles, and sausage links for 1 minute and 30 seconds. DM-C removed the plate and obtained the following food temperatures:~ Scrambled eggs - 145 degrees F~ Waffles -150 degrees F ~ Sausage links - 108 degrees [NAME] 1/27/26 beginning at 11:52 AM, Surveyor observed Regional Dietary Manager (RDM)-D during lunch service at the steam table. RDM-D confirmed the steam table did not heat to an appropriate temperature in the morning and confirmed the left-hand side well did not work. RDM-D stated a a plate warmer was obtained after breakfast on 1/27/26 and maintenance staff looked at the steam table to determine why food temperatures were cold. RDM-D indicated the facility was in the process of determing how to keep food warm and at an appetizing temperature. RDM-D verified the facility was aware that food was not served at palatable temperatures during meal service. RDM-D verified food temperatures were a concern discussed by residents during food and Resident Council meetings.

Based on staff interview and record review, the facility did not report an allegation of exploitation to the State Agency (SA) for 1 resident (R) (R14) of 2 sampled residents.The facility was informed on 1/7/26 that Licensed Practical Nurse (LPN)-F accepted money from R14. The facility did not report the allegation of exploitation to the SA.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion .Reporting/Response: Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies(e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than twenty-four hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .The Administrator will follow up with government agencies to report the results of the investigation when final within five working days of the incident, as required by state agencies .On 1/27/26, Surveyor reviewed R14's medical record. R14 had diagnoses including anxiety, depression, kidney failure, chronic obstructive pulmonary disease, and type 2 diabetes. R14's Minimum Data Set (MDS) assessment, dated 12/9/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R14 had intact cognition. R14 was R14's own decision maker.On 1/27/26 at 10:15 AM, Surveyor interviewed R14 who stated LPN-F told R14 that LPN-F could not get home from work (on 1/7/26) becaue LPN-F did not have any gas money. R14 stated R14 gave LPN-F eight dollars for gas but the money was returned a short while later. R14 stated R14 knew LPN-F from another facility and LPN-F had previously cared for R14. R14 stated Assistant Director of Nursing (ADON)-E spoke to R14 the following day about the incident and R14 had not seen LPN-F since that night.On 1/27/26 at 11:17 AM, Surveyor interviewed ADON-E who stated a nurse called ADON-E on 1/7/26 and reported that LPN-F had accepted money from R14 because LPN-F did not have gas money to get home from work. ADON-E stated the nurse instructed LPN-F to return the money because it was unacceptable to accept money from a resident. ADON-E reported the incident to Nursing Home Administrator (NHA)-A. ADON-E spoke to R14 on 1/8/26 who verified R14 gave gas money to LPN-F and it was returned. ADON-E stated LPN-F was an agency nurse and R14 knew LPN-F from a facility where R14 had previously resided. ADON-E stated R14 felt R14 and LPN-F had a relationship which made it acceptable for R14 to give LPN-F money.On 1/27/26 at 12:18 PM, Surveyor interviewed NHA-A who stated the incident occurred on 1/7/26 and was reported to NHA-A on 1/8/26. NHA-A stated an e-mail was sent to LPN-F's agency and LPN-F was not allowed to return to the facility. NHA-A stated after ADON-E spoke with R14, NHA-A did not think the incident was an allegation of exploitation or needed to be reported to the State Agency since the money was returned.On 1/28/26 at 9:42 AM, Surveyor again interviewed NHA-A who stated NHA-A thought LPN-F knew it was not acceptable to accept money from a resident. NHA-A indicated LPN-F initially took the money because of a friendly relationship with R14 from a previous facility but gave the money back when instructed to do so.

Based on staff interview and record review, the facility did not thoroughly investigate an allegation of exploitation for 1 resident (R) (R14) of 2 sampled residents.The facility was informed on 1/7/26 that Licensed Practical Nurse (LPN)-F accepted money from R14. The facility did not thoroughly investigate the allegation of exploitation.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion .Investigation of Alleged Abuse, Neglect and Exploitation: .An immediate investigation is warranted when allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur .Written procedures for investigations include: .Investigating different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) .Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause, and providing complete and thorough documentation of the investigation .On 1/27/26, Surveyor reviewed R14's medical record. R14 had diagnoses including anxiety, depression, kidney failure, chronic obstructive pulmonary disease, and type 2 diabetes. R14's Minimum Data Set (MDS) assessment, dated 12/9/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R14 had intact cognition. R14 was R14's own decision maker.On 1/27/26 at 10:15 AM, Surveyor interviewed R14 who stated LPN-F told R14 that LPN-F could not get home from work (on 1/7/26) because LPN-F did not have any gas money, R14 stated R14 gave LPN-F eight dollars for gas which was returned a short while later. R14 stated R14 knew LPN-F from a facility where LPN-F had previously resided and LPN-F had cared for R14. R14 stated Assistant Director of Nursing (ADON)-E spoke to R14 the following day about the incident and R14 had not seen LPN-F since that night.On 1/27/26 at 11:17 AM, Surveyor interviewed ADON-E who stated a nurse informed ADON-E on 1/7/26 that LPN-F had accepted money from R14 because LPN-F did not have gas money to get home from work. ADON-E stated the nurse instructed LPN-F to return the money because it was unacceptable to accept money from a resident. ADON-E reported the incident to Nursing Home Administrator (NHA)-A. ADON-E stated ADON-E spoke to R14 on 1/8/26. R14 confirmed R14 gave LPN-F gas money and the money was returned. ADON-E stated LPN-F was an agency nurse and R14 knew LPN-F from a facility where R14 previously resided. ADON-E stated R14 felt R14 and LPN-F had a relationship so it was acceptable for R14 to give LPN-F money. ADON-E confirmed ADON-E did not do any further investigation after interviewing R14 and reporting the incident to NHA-A.On 1/27/26 at 12:18 PM and 3:25 PM, Surveyor interviewed NHA-A who confirmed the incident occurred on 1/7/26 and was reported to NHA-A on 1/8/26. NHA-A stated an e-mail was sent to LPN-F's agency on 1/8/26 and LPN-F was not allowed to return to the facility. NHA-A stated after ADON-E spoke with R14, NHA-A did not think the incident was an allegation of exploitation. NHA-A stated R14 did not have any adverse psychosocial effects from the incident and NHA-A did not feel the allegation of exploitation required further investigation since the money was returned. NHA-A confirmed the facility did not interview other residents or staff to determine if there were other like concerns. NHA-A stated NHA-A would obtain documentation, interviews, and staff education related to the incident and provide the information to Surveyor. On 1/28/26 at 9:42 AM, Surveyor again interviewed NHA-A who stated NHA-A thought LPN-F knew it was not okay to accept money from a resident. NHA-A indicated LPN-F initially accepted the money due to a friendly relationship from a previous facility where LPN-F cared for R14 but gave the money back when instructed to do so. NHA-A stated the money was a gift and confirmed staff are not allowed to accept gifts from residents. NHA-A gave Surveyor the facility's investigation and stated NHA-A thought the incident between R14 and LPN-F was isolated and no other residents were affected. NHA-A confirmed the facility's investigation did not contain additional resident or staff interviews to ensure no other residents were affected or had similar experiences.

Based on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 6 residents (R) (R23, R20, R12, R11, R24, and R13) of 12 sampled residents. R23 had a tracheostomy. R23's MDS assessments, dated 1/23/24, 4/24/24, 7/25/25, 8/27/24, and 9/16/24, did not indicate R23 received tracheostomy care. R12 was discharged from Hospice services on 5/12/24. R12's MDS assessments, dated 5/24/24 and 8/24/24, indicated R12 still received Hospice services. R20 was prescribed antiplatelet medication. R20's MDS assessments, dated 9/25/23, 12/26/23, 3/26/24, 6/26/24, and 8/27/24 did not indicate R20 received antiplatelet medication. In addition, R20 had a Preadmission Screening and Resident Review (PASRR) Level II Screen completed on 10/26/23. R20's MDS assessment, dated 8/27/24, indicated a PASRR Level II Screen was not completed. R11 was prescribed antianxiety medication. R11's MDS assessment, dated 8/14/24, did not indicate R11 received antianxiety medication. R24 had a witnessed fall that resulted in a major injury. R24's MDS assessment, dated 5/15/24, did not indicate R11 had any falls since admission or the prior assessment. In addition, R24 was prescribed antipsychotic and antidepressant medication. R24's MDS assessments, dated 2/13/24, 5/15/24, and 8/15/24, did not indicate R24 received antipsychotic or antidepressant medication. R13 was prescribed antianxiety medication. R13's MDS assessment, dated 7/31/24, did not indicate R13 received antianxiety medication. Findings include: 1. Between 9/9/24 and 9/1/24, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] and had diagnoses including encounter for attention to tracheostomy and quadriplegia. R23's medical record contained order for tracheostomy care. On 9/9/24 at 11:36 AM, Surveyor interviewed R23 and noted R23 had a tracheostomy and tracheostomy supplies next to R23's bed. R23 indicated staff suctioned R23 as needed. R23's MDS assessments, dated 1/23/24, 4/24/24, 7/25/25, 8/27/24, and 9/16/24, indicated R23 did not receive tracheostomy care. On 9/10/24 at 11:13 AM, Surveyor interviewed Registered Nurse (RN)-E who completed MDS assessments for the facility. RN-E confirmed R23's MDS assessments should have been coded to indicate R23 received tracheostomy care. 2. Between 9/9/24 and 9/11/24, Surveyor reviewed R12's medical record. R12 was admitted to the facility on Hospice services on 11/16/23 with diagnoses including diffuse large B-cell lymphoma and encounter for palliative care. R12 was discharged from Hospice services on 5/12/24. R12's MDS assessments, dated 5/24/24 and 8/24/24, indicated R12 still received Hospice services. On 9/10/24 at 11:13 AM, Surveyor interviewed RN-E who confirmed R12's MDS assessments, dated 5/24/24 and 8/24/24, should have been coded to indicate R12 no longer received Hospice services 3. Between 9/9/24 and 9/11/24, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, bipolar disorder, anxiety disorder, and venous insufficiency. R20's medical record indicated: ~ R20 was prescribed antipsychotic and antidepressant medication for bipolar disorder and had a Level II PASRR Screen completed on 10/26/23. ~ R20 was prescribed clopidogrel bisulfate (an antiplatelet medication) for peripheral vascular angioplasty status with implants and grafts. R20's MDS assessment, dated 8/27/24, indicated R20 was not evaluated by a Level II PASRR Screen and determined to have a serious mental illness and/or mental retardation or a related condition. R20's MDS assessments, dated 9/25/23, 12/26/23, 3/26/24, 6/26/24, and 8/27/24 indicated R20 received anticoagulant medication instead of antiplatelet medication. On 9/10/24 at 11:13 AM, Surveyor interviewed RN-E who confirmed R20's MDS assessments should have been coded to indicate a PASRR Level II screen was completed and R20 received antiplatelet medication. On 9/11/24 at 12:34 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility followed the MDS manual for coding and NHA-A expected MDS assessments to be coded correctly. 48794 4. Between 9/9/24 and 9/11/24. Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease without dyskinesia, schizoaffective disorder, bipolar disorder, insomnia, anxiety disorder, and epilepsy. R11's medical record contained a physician order for lorazepam (an antianxiety medication). R11's MDS assessment, dated 8/14/24, did not indicate R11 received antianxiety medication. On 9/11/24 at 12:40 PM, Surveyor interviewed RN-E who confirmed R11's MDS assessment should have been coded to indicate R11 received antianxiety medication. 5. Between 9/9/24 and 9/11/24, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and has diagnoses including dementia, Parkinson's disease, metabolic encephalopathy, neuroleptic induced parkinsonism, adverse effect of antipsychotic medication, and bipolar disorder. R24 had an activated Power of Attorney for Healthcare (POAHC). On 9/9/24 at 11:15 AM, Surveyor interviewed R24 and R24's POAHC who indicated R24 had a fall in the facility and sustained a fractured nose. R24's medical record indicated R24 had a witnessed fall on 2/27/24 and was transferred to the hospital. R24 was diagnosed with a closed fracture of the nasal bone, nose laceration, and scalp contusion. R24's MDS assessment, dated 5/15/24, indicated R24 did not have any falls since admission or the prior assessment. On 9/11/24 at 12:40 PM, Surveyor interviewed RN-E who confirmed R24's MDS assessment should have been coded to indicate R24 had a fall with major injury. R24's medical record contained physician orders for duloxetine (an antidepressant medication) and lithium carbonate (an antipsychotic medication) with start dates of 2/7/24. Surveyor reviewed R24's MDS assessments, dated 2/13/24, 5/15/24, and 8/15/24 and noted the following: ~ R24's MDS assessment, dated 2/13/24, did not indicate R24 was prescribed antipsychotic medication. ~ R24's MDS assessment, dated 5/15/24, did not indicate R24 was prescribed antidepressant medication. ~ R24's MDS assessment, dated 8/15/24, did not indicate R24 was prescribed antipsychotic medication. On 9/11/24 at 12:47 PM, Surveyor interviewed RN-E who confirmed R24's MDS assessments should have been coded to indicate R24 received antipsychotic and antidepressant medication. 38793 6. Between 9/9/24 and 9/11/24, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including post-traumatic stress disorder (PTSD) and anxiety. R13's medical record contained physician orders for clonazepam 1 mg (milligram) daily for anxiety (beginning 6/13/24) and buspirone HCl (hydrochloride) 5 mg three times daily for anxiety (beginning 5/21/24). R13's MDS assessment, dated 7/31/24, did not indicate R13 received antianxiety medication. On 9/11/24 at 11:34 AM, Surveyor interviewed RN-E who confirmed R13's MDS assessment should have been coded to indicate R13 received antianxiety medication.

Based on staff interview and record review, the facility did not ensure pharmacy recommendation reports were acknowledge by a physician for 4 residents (R) (R20, R13, R17, and R11) of 5 sampled residents. Three of 6 pharmacy recommendations for R20 were not acknowledged by a physician. Three of 9 pharmacy recommendations for R13 were not acknowledged by a physician. Three of 6 pharmacy recommendations for R17 were not acknowledged by a physician. R11's monthly pharmacy reviews were not consistently completed for the last 7 months. Findings include: 1. Between 9/9/24 and 9/11/24, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease and bipolar disorder. R20 was prescribed the following medications: ~ Ziprasidone 80 milligrams (mg) (an antipsychotic medication) 2 capsules once daily for bipolar disorder ~ Olanzapine 15 mg (an antipsychotic medication) 2 tablets by mouth once daily for bipolar disorder ~ Duloxetine 60 mg (an antidepressant medication) 2 capsules once daily for depression related to bipolar disorder ~ Lamotrigine 100 mg (an anticonvulsant medication) once daily for bipolar disorder ~ Ropinirole for Parkinson's disease Between 4/1/24 and 4/30/24, R20's medications were reviewed by pharmacy. The pharmacy recommendations noted in R20's progress notes were: olanzapine and ziprasidone use, olanzapine dose, ropinirole dose, ropinirole and olanzapine use, Lamictal (lamotrigrine) and ziprasidone and olanzapine and duloxetine monitoring On 6/20/24, a pharmacy recommendation for R20 indicated: duloxetine HCL (hydrochloride) delayed release particles 60 mg give 2 capsules by mouth one time a day for depression related to bipolar disorder. Compliance with the requirement to perform a gradual dose reduction (GDR) may be met, if within the first year in which a resident is admitted on a psychotropic drug or after the prescribing practitioner has initiated a psychotropic drug, a facility attempts a GDR in two separate quarters (with greater than one month between the attempts), unless contraindicated. Recommendation: Trial gradual dose reduction or the continued use is in accordance with relevant current standards of practice. Please document resident specific clinical rationale for why an attempted dose reduction would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder: Between 7/1/24 and 7/30/24, R20's medications were reviewed by pharmacy. The pharmacy noted: duloxetine HCL delayed release particles 60 mg give 2 capsules by mouth one time a day for depression related to bipolar disorder. Compliance with the requirement to perform a GDR may be met, if within the first year in which a resident is admitted on a psychotropic drug or after the prescribing practitioner has initiated a psychotropic drug, a facility attempts a GDR in two separate quarters (with greater than one month between the attempts), unless contraindicated. Recommendation: Trial gradual dose reduction or the continued use is in accordance with relevant current standards of practice. Please document resident specific clinical rationale for why an attempted dose reduction would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder: On 9/11/24 at 9:58 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who provided a paper that indicated R20 had a pharmacy review in April and there were no recommendations. When Surveyor showed NHA-A the progress note in which pharmacy stated there were recommendations, NHA-A indicated NHA-A was not aware of the note and did not have proof of follow-up for the recommendations. NHA-A also indicated there was no follow-up for R20's June and July 2024 pharmacy recommendations and indicated the facility did not have a good process in place with the changeover in administration. 38793 2. Between 9/9/24 and 9/11/24, Surveyor reviewed R13's medial record. R13 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, hypertension, dementia, post-traumatic stress disorder (PTSD), depression, and anxiety. Surveyor reviewed R13's monthly pharmacy recommendations from October 2023 to the present. A monthly pharmacy review, dated 11/22/23, indicated the pharmacist made a recommendation to address R13's chlorhexidine administration, warfarin monitoring, Levemir and metformin monitoring, and Zoloft and trazodone monitoring. The facility was unable to provide a physician's response to the recommendation. A monthly pharmacy review, dated 12/29/23, indicated the pharmacist made a recommendation to address R13's as needed (PRN) diazepam use. The facility was unable to provide a physician's response to the recommendation. A monthly pharmacy review, dated 2/27/24, indicated the pharmacist made a recommendation to address R13's sucralfate use. The facility was unable to provide a physician's response to the recommendation. On 9/11/24 at 10:14 AM, Surveyor interviewed NHA-A regarding R13's pharmacy recommendations. NHA-A was unable to provide proof of follow-up for the recommendations. 3. Between 9/9/24 and 9/11/24, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, hypertension, dementia, atrial fibrillation, and congestive heart failure (CHF). Surveyor reviewed R17's monthly pharmacy recommendations from October 2023 to the present. A monthly pharmacy review, dated 12/29/23, indicated the pharmacist made a recommendation to complete a dose reduction for sertraline (an antidepressant medication). The facility was unable to provide a physician's response to the recommendation. In addition. R17's medical record indicated a dose reduction for sertraline was not completed until 3/1/24. A monthly pharmacy review, dated 1/24/24, indicated the pharmacist made a recommendation to discontinue lovastatin due to no appropriate diagnosis. The facility was unable to provide a physician's response to the recommendation. A monthly pharmacy review, dated 6/17/24, indicated the pharmacist made a recommendation to see the Consultant Pharmacy Report. The facility was unable to provide the Consultant Pharmacy Report and was unsure what recommendation was made by the pharmacist on 6/17/24. A monthly pharmacy review, dated 7/29/24, indicated the pharmacist made a recommendation to decrease pantoprazole to every other day for two weeks and then discontinue the medication due to the risk of side effects. A Nurse Practitioner (NP) responded, Agree 8/2/24, monitor for symptoms. R17's medical record indicated R17 still received pantoprazole twice daily as of 9/10/24. On 9/11/24 at 10:14 AM, Surveyor interviewed NHA-A regarding R17's pharmacy recommendations. NHA-A was unable to provide proof of follow-up R17's recommendations. NHA-A verified R17 still received pantoprazole despite the pharmacy recommendation and NP's response to discontinue the medication. 48794 4. Between 9/9/24 and 9/11/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease without dyskinesia, schizoaffective disorder, bipolar disorder, insomnia, anxiety disorder, and epilepsy. R11's medical record indicated R11 was prescribed the following medications: ~ Prochlorperazine 10 mg (an antipsychotic medication) as needed for nausea ~ Seroquel (an antipsychotic medication) for schizoaffective disorder ~ Cariprazine 3 mg (an antipsychotic medication) for schizoaffective disorder ~ Abilify 15 mg (an antipsychotic medication) for schizoaffective disorder ~ Lorazepam 0.5 mg (an antianxiety medication) as needed for anxiety related to bipolar disorder ~ Sertraline 50 mg for bipolar disorder Surveyor requested R11's pharmacy medication reviews from February 2024 to the present. The facility was only able to provide pharmacy recommendation reviews for February 2024 and June 2024. On 9/11/24 at 10:02 AM, Surveyor interviewed [NAME] President of Success (VPS)-C who acknowledged the facility did not have a process in place for pharmacy reviews, physician reviews of pharmacy recommendations, gradual dose reductions, or behavior management. VPS-C indicated R11 should have had monthly pharmacy reviews for the 7 months R11 resided in the facility.

Based on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 3 errors occurred during 25 opportunities which resulted in a 12% medication error rate that affected 1 resident (R) (R14) of 4 residents observed during medication administration. On 9/9/24, R14 was administered three medications in the wrong form per the manufacturer's instructions. Findings include: The facility's Medication Administration policy, revised January 2024, indicates: If it is safe to do so, medication tablets may be crushed or capsules emptied using the following guidelines and with a specific order from the prescriber: Long acting, extended release, or enteric coated dosage forms should generally not be crushed; an alternative should be sought. On 9/9/24, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] with diagnoses including cancer, hypertension, chronic kidney disease, dementia, and asthma. R14's most recent Minimum Data Set (MDS) assessment, dated 8/20/24, stated R14's Brief Interview for Mental Status (BIMS) score was 13 out of 15 which indicated R14 had intact cognition. On 9/9/24 at 9:04 AM, Surveyor observed Licensed Practical Nurse (LPN)-F prepare and administer R14's AM medication. On 9/9/24 at 9:07 AM, Surveyor observed LPN-F crush all of R14's medications, including a 600 mg (milligram) guaifenesin extended release (ER) tablet, a 20 mEq (milliequivalents) potassium chloride extended release tablet, and a 20 mg omeprazole delayed release (DR) capsule. On 9/9/24 at 9:08 AM, Surveyor observed a bubble pack that contained R14's potassium chloride ER. The bubble pack contained a sticker that stated Do Not Crush/Chew. On 9/9/24 at 9:09 AM, Surveyor interviewed LPN-F who verified LPN-F crushed all of R14's medications and mixed them in applesauce. LPN-F was not aware of any of R14's medications that could not be crushed. On 9/9/24 at 9:43 AM, Surveyor observed the manufacturer's package that contained R14's omeprazole DR. The manufacturer's instructions indicated not to crush or chew the medication. On 9/9/24 at 9:51 AM, Surveyor observed the manufacturer's instructions for guaifenesin ER which stated not to crush or chew the medication. Surveyor noted a physician order for R14, dated 2/22/24, that stated, May crush all medications permissible by manufacturer. On 9/9/24 at 11:13 AM, Surveyor interviewed Director of Nursing (DON)-B who verified extended and delayed release medications should not be crushed.

Based on staff interview and record review, the facility did not monitor for adverse reactions of a high-risk medication for 1 resident (R) (R20) of 5 residents reviewed for unnecessary medications. R20 was prescribed lamotrigine (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 for lamotrigrine 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, seizures, stiff neck, sensitivity to light, unusual bleeding or bruising, rash, swollen lymph nodes, yellowing of the skin or eyes, painful or bloody urination, trouble walking, racing heartbeat, skipped or slow heartbeat, or shortness of breath. On 9/10/24, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had a diagnosis of bipolar disorder. R20's medical record indicated R20 was prescribed 100 milligrams of lamotrigrine once daily for bipolar disorder. R20's medical record did not indicate R20 was monitored for adverse reactions of side effects of lamotrigine. On 9/10/24, Surveyor requested to see monitoring for R20's lamotrigine. On 9/11/24 at 8:49 AM, Surveyor noted monitoring for adverse reactions/side effects of lamotrigine was added to R20's plan of care. On 9/11/24 at 12:34 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed there was no prior monitoring in place for R20's anticonvulsant medication. NHA-A indicated the facility was not aware adverse reaction/side effect monitoring should be completed for anticonvulsant medication if the medication was prescribed for off-label use.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R13) of 5 sampled residents was offered a pneumococcal vaccine. R13's medical record did not contain documentation that R13 was offered a pneumococcal vaccine. Findings include: The facility's Pneumococcal Vaccine (Series) policy, dated 1/11/24, indicates: It is the policy of the facility to offer residents immunization against pneumococcal disease in accordance with current Centers for Disease Control and Prevention (CDC) guidelines and recommendations .1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented including efforts to determine date of immunization or type of vaccine received .2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized .4. The resident/representative retains the right to refuse the immunization. Refusals should be documented in the medical record along with what education was provided and a risk versus benefit discussion. The CDC publication found at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate indicates: The CDC recommends pneumococcal vaccination for adults 19 through [AGE] years old who have certain chronic medical conditions or other risk factors .chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma . On 9/9/24, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including dementia, diabetes mellitus, and chronic obstructive pulmonary disease (COPD). R13's Minimum Data Set (MDS) assessment, dated 7/31/24, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R13 had intact cognition. R13's medical record did not indicate a pneumococcal vaccination was offered or declined by R13 or R13's representative. On 9/11/24 at 1:04 PM, Surveyor interviewed [NAME] President of Success (VPS)-C who confirmed R13's medical record did not contain documentation that a pneumococcal immunization was offered or refused. VPS-C stated R13 should have been offered the immunization.

Based on staff interview and record review, the facility did not ensure a Significant Change Minimum Data Set (MDS) assessment was completed for 1 resident (R) (R12) of 12 sampled residents. The facility did not complete a Significant Change MDS assessment when R12 discharged from Hospice services. Findings include: Between 9/9/24 and 9/11/24, Surveyor reviewed R12's medical record. R12 was admitted to the facility on Hospice services on 11/16/23 with diagnoses including diffuse large B-cell lymphoma and encounter for palliative care. R12's medical record indicated: ~ R12 discharged from Hospice services on 5/12/24. ~ The facility completed Quarterly MDS assessments for R12 on 5/24/24 and 8/24/24. On 9/10/24 at 11:13 AM, Surveyor interviewed Registered Nurse (RN)-E who completed the facility's MDS assessments. RN-E confirmed a Significant Change MDS assessment should have been completed when R12 discharged from Hospice services. RN-E indicated RN-E was able to see that R12 discharged from Hospice services on R12's medical record dashboard and also indicated R12's discharge from Hospice services would have been discussed in a stand-up meeting. On 9/11/24 at 12:34 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility followed the MDS manual for coding. NHA-A indicated R12's MDS assessment should have been coded as a Significant Change MDS assessment after R12 discharged from Hospice services.

Based on staff interview and record review, the facility did not ensure written notification of coverage change and the financial liability for continued stay at the facility was provided when Medicare Part A benefits ended for 2 residents (R) (R26 and R10) of 5 sampled residents. The facility did not provide R26 with an Advanced Beneficiary Notice (ABN) form that contained the daily rate for which R26 was liable if R26 chose to remain in the facility after R26's Medicare Part A benefits ended. The facility did not provide a Notice of Medicare Non-Coverage (NOMNC) form (used to inform Medicare beneficiaries when their covered services are ending and their appeal rights) to R10 when R10's Medicare Part A benefits ended. Findings include: The Centers for Medicare and Medicaid Services (CMS)-10123 form indicates a Notice of Medicare Non-Coverage (NOMNC) form must be delivered at least two calendar days before Medicare-covered services end or the second to last day of service if care is not being provided daily. Note: The two-day advance requirement is not a 48-hour requirement .The provider must ensure the beneficiary or representative signs and dates the NOMNC form to demonstrate the beneficiary or representative received the notice and understands the termination decision can be disputed. The CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (ABN) form indicates: The ABN provides information to the beneficiary so the beneficiary can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility .The ABN is only issued if the beneficiary intends to continue services and the skilled nursing facility believes the services may not be covered under Medicare. 1. Between 9/9/24 and 9/11/24, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] with a diagnosis of status post reverse arthroplasty of left shoulder. R26 was R26's own person. R26's medical record indicated the following: ~ R26 signed a NOMNC form on 7/10/24 that indicated R26's Medicare Part A benefits were ending on 7/12/24. ~ R26 remained in the facility after R26's Medicare Part A benefits ended on 7/12/24. ~ R26 discharged from the facility on 8/16/24. R26's medical record did not indicate R26 was provided with an ABN form. On 9/11/24 at 1:36 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who could not locate an ABN form for R26. NHA-A indicated R26 should have received an ABN form since R26 remained in the facility after R26's Medicare Part A benefits ended on 7/12/24. 48794 2. Between 9/9/24 and 9/11/24, Surveyor reviewed R10's medical record. A Recapitulation of Stay, dated 9/3/24, and a progress note, dated 9/3/24, indicated R10 returned from an appointment with Infectious Disease with an order to discontinue R10's intravenous (IV) antibiotics on 9/4/24. A review of the facility's documentation indicated R10's last covered day of Medicare Part A benefits was 9/4/24. R10 discharged from the facility on 9/5/24. The review indicated the end of R10's Medicare Part A benefits was resident-initiated and a NOMNC form was not required. R10's medical record did not indicate termination of R10's Medicare Part A benefits was resident-initiated. On 9/10/24 at 12:21 PM, Surveyor interviewed Director of Rehab (DOR)-D who confirmed DOR-D provided therapy services for R10. DOR-D stated R10 had met all goals for therapy and no longer required Medicare Part A skilled therapy. DOR-D stated IV medication was the only service that prevented R10 from returning home. DOR-D stated when R10's IV antibiotics were discontinued on 9/4/24, R10's Medicare Part A coverage ended and R10 discharged home. On 9/11/24 at 1:10 PM, Surveyor interviewed [NAME] President of Success (VPS)-C who acknowledged termination of R10's Medicare Part A benefits was facility-initiated and R10 should have received a NOMNC form prior to R10's last covered day.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R11 and R24) of 5 sampled residents were monitored for adverse consequences of an antipsychotic medication. R11 was prescribed aripiprazole (an antipsychotic medication) for schizoaffective disorder. The facility did not complete an Abnormal Involuntary Movement Scale (AIMS) (a rating scale that helps identify and monitor side effects of antipsychotic medications) when R11 admitted to the facility on antipsychotic medication. R24 was prescribed lithium carbonate (an antipsychotic medication) for bipolar disorder. The facility did not complete an AIMS or implement monitoring for adverse reactions to the antipsychotic medication. Findings include: The facility's Psychotropic Medications policy, dated 10/24/22, indicates: Residents should not receive psychotropic drugs unless the medication is necessary to treat specific conditions as diagnosed and documented in the clinical record and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication .8. Residents who receive an antipsychotic medication will have an AIMS test performed on admission, at least every 6 months, when the antipsychotic medication is changed, and as necessary .12. The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as .b. During the pharmacist's monthly medication regimen review .d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive care plan. 1. On 9/10/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease without dyskinesia, schizoaffective disorder, bipolar disorder, insomnia, anxiety disorder, and epilepsy. R11's Minimum Data Set (MDS) assessment, dated 8/27/24, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R11 had intact cognition. R11 had an activated Power of Attorney for Healthcare (POAHC). R11's medical record contained physician orders for the following antipsychotic medications: ~ Prochlorperazine maleate oral tablet 10 mg (milligrams) as needed for nausea ~ Quetiapine fumarate oral tablet 25 mg daily for schizoaffective disorder ~ Quetiapine fumarate oral tablet 100 gm give 1.5 tablet by mouth once daily for schizoaffective disorder ~ Quetiapine fumarate oral tablet 300 mg give 150 mg by mouth once daily for schizoaffective disorder ~ Cariprazine HCl (hydrochloride) oral capsule 3 mg give 3 daily for schizoaffective disorder and bipolar disorder ~ Aripiprazole oral tablet 15 mg daily for schizoaffective disorder R11's quetiapine order had an original start date of 2/8/24. R11's aripiprazole order had an original start date of 5/31/24. R11's medical record contained an AIMS completed on 6/24/24. R11's medical record did not indicate an AIMS was completed upon R11's admission to the facility, when changes were made to R11's antipsychotic medication, or when R11 was prescribed an additional antipsychotic medication. On 9/11/24 at 1:10 PM, Surveyor interviewed [NAME] President of Success (VPS)-C who confirmed an AIMS was not completed upon R11's admission to the facility or with changes or additions to R11's antipsychotic medication. VSP-C stated the facility identified concerns with their process and confirmed corrections had not yet been implemented. 2. On 9/10/24, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including dementia, Parkinson's disease, neuroleptic induced parkinsonism, adverse effect of antipsychotic medication, metabolic encephalopathy, and bipolar disorder. R24's MDS assessment, dated 8/15/24, had a BIMS score of 7 out of 15 which indicated R24 had severe cognitive impairment. R24 had an activated POAHC. R24's medical record contained a physician order for lithium carbonate 600 mg daily for bipolar disorder with a start date of 2/7/24. R24's medical record did not contain an AIMS or adverse side effect monitoring for antipsychotic medication. On 9/11/24 at 9:25 AM, Surveyor interviewed VPS-C who confirmed the facility did not complete an AIMS for R24 or implement adverse side effect monitoring for antipsychotic medication which should have been initiated upon admission.

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R11) of 1 resident received the necessary care and services to prevent and monitor weight loss or gain. Staff did not notify R11's physician of a significant weight gain and did not follow the physician's order for weight monitoring. Findings include: The facility's Weight Monitoring policy, dated 12/21/22, indicates: The Interdisciplinary Team (IDT) will strive to prevent, monitor, and intervene for undesirable weight changes for residents .1. The nursing staff will measure a resident's weight on admission, the next 2 days, and weekly for 3 additional weeks thereafter .3. Weights will be recorded in the resident's electronic health record .6. Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation .8. The threshold for significant weight change will be based on the following criteria, a. 1 month - 5% weight change is significant; greater than 5% is severe; b. 3 months - 7.5% weight change is significant; greater than 7.5% is severe; c. 6 months - 10% weight change is significant; greater than 10% is severe .10. The nursing staff will notify the individual or responsible party, physician, and Registered Dietitian (RD) or designee of any individual with an unintended significant weight change. On 9/11/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease without dyskinesia, schizoaffective disorder, bipolar disorder, insomnia, anxiety disorder, and epilepsy. R11's Minimum Data Set (MDS) assessment, dated 8/27/24, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R11 had intact cognition. R11 had an activated Power of Attorney for Healthcare (POAHC). Surveyor reviewed R11's weights and noted the following: ~ On 8/22/24, R11 weighed 342.6 pounds (lbs) ~ On 8/21/24, R11 weighed 348.0 lbs ~ On 8/10/24, R11 weighed 344.0 lbs ~ On 8/2/24, R11 weighed 343.2 lbs ~ On 7/26/24, R11 weighed 346.8 lbs ~ On 7/24/24, R11 weighed 327.5 lbs ~ On 7/8/24, R11 weighed 317.9 lbs ~ On 6/15/24, R11 weighed 309.5 lbs ~ On 6/10/24, R11 weighed 309.5 lbs ~ On 6/8/24, R11 weighed 307.3 lbs ~ On 5/25/24, R11 weighed 289.9 lbs ~ On 5/18/24, R11 weighed 289.9 lbs ~ On 5/11/24, R11 weighed 289.9 lbs ~ On 5/7/24, R11 weighed 290.0 lbs ~ On 4/15/24, R11 weighed 287.9 lbs ~ On 4/11/24, R11 weighed 289.2 lbs ~ On 3/2/24, R11 weighed 255.3 lbs ~ On 2/22/24, R11 weighed 281.2 lbs ~ On 2/20/24, R11 weighed 277.0 lbs ~ On 2/19/24, R11 weighed 278.2 lbs ~ On 2/14/24, R11 weighed 287.0 lbs ~ On 2/10/24, R11 weighed 253.0 lbs ~ On 2/8/24, R11 weighed 253.3 lbs ~ On 2/7/24, R11 weighed 246.6 lbs Per the facility's policy, the above weights indicated R11 had a severe weight change of 38.93% from 2/7/24 to 8/22/24. A progress note, dated 2/23/24, indicated R11 gained 34 pounds since admission. The progress note indicated R11 had diagnoses including schizoaffective disorder, Parkinson's disease, and bipolar disorder and was prescribed antipsychotic medication which may affect R11's appetite and ability to make sound decisions. R11's physician was updated. No new orders were received. On 2/24/24, R11's physician was notified of R11's weight gain. No new orders were received. A nutrition and dietary progress note, dated 4/30/24, indicated R11's weight was up 41 pounds (16%) in 3 months. The progress note indicated R11 received antidepressant and antipsychotic medication which affected R11's appetite and weight status. A Nutritional Assessment, dated 5/14/24, indicated R11 had a significant weight gain of 13% due to excessive intake and schizoaffective disorder. No new recommendations were made by the RD. A weight note, dated 6/14/24, indicated R11 had a 6% weight gain in 1 month and a 7.5% weight gain in 3 months. No new nutrition interventions were noted. On 6/24/24, R11's Advance Practice Nurse Practitioner (APNP) was notified. No new orders were received. A weight note, dated 7/15/24, indicated R11 had a weight gain of 9% in 3 months. The note indicated R11's mood stabilizer medication may affect R11's appetite and meal intake. No new nutritional interventions were noted. An RD weight review, dated 8/8/24, indicated R11 gained 96 pounds (a 38% weight gain) in 6 months. R11 was on a mood stabilizer medication known to increase appetite and lead to weight gain. No new nutritional interventions were noted. A nutrition note, dated 8/8/24, indicated R11's medication side effects were reviewed by the IDT and R11 was scheduled for a neurology appointment the following week. On 8/14/24, R11 was admitted to the hospital due to a change in condition. R11 returned to the facility on [DATE]. R11's medical record did not contain any additional weights after R11's readmission weight on 8/22/24. A physician order stated to obtain R11's weight on admission, daily x 2, weekly x 3, and then monthly and obtain a re-weight if R11's weight changed 5 pounds since the last weight. On 9/11/24 at 1:10 PM, Surveyor interviewed [NAME] President of Success (VPS)-C who acknowledged the facility did not have documentation that indicated R11's physician was aware of R11's significant weight gain. VPS-C stated due to R11's hospitalization , R11's neurology appointment was canceled and staff were not able to reschedule the appointment until October. VPS-C acknowledged further notification to R11's physician should be noted in R11's medical record. VPS-C indicated staff should have followed R11's physician order for weights following R11's return from the hospital.

Based on observation, staff and resident interview, and record review, the facility did not provide adequate supervision for 1 resident (R) (R1) of 4 sampled residents. The failure to supervise R1 led to R1 being able to verbally and physically abuse another resident, R2. On 5/23/24, staff observed R1 exit R2's room and state, I'm going to kick your ass. R2 reported to staff that R1 had thrown a Styrofoam cup of coffee creamers at R2. Following the incident, the facility did not implement any interventions to ensure the safety of R1, R2, or other residents. On 5/24/24, Licensed Practical Nurse (LPN)-D observed R1 in the hallway outside R2's room. R1 appeared agitated and was repeatedly stating, Shut the f*** up. LPN-D did not attempt to redirect R1 or implement any interventions to supervise R1 before LPN-D left the area. R1 then entered R2's room, threw a basket full of items which hit R2 in the forehead, and stated, That's what you get you f****** bitch. R2 was tearful and incurred redness and swelling on R2's forehead. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, states the facility will ensure the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; B. Possible indicators of abuse include .Verbal abuse of a resident overheard or inappropriate verbal conduct overheard; Physical abuse of a resident observed .Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include .Increased supervision of the alleged victim and residents and room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. On 6/24/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, epilepsy, schizoaffective disorder, bipolar disorder, insomnia, and anxiety. R1's most recent Minimum Data Set (MDS) assessment, dated 5/20/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 had minimal cognitive impairment. On 6/24/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including diffuse large B-cell lymphoma, lymphedema, and encounter for palliative care. R2's Quarterly MDS assessment, dated 5/24/24, had a BIMS score of 15 out of 15 which indicated R2 had intact cognition. R1's admission care plan indicated R1 was at risk for behaviors related to schizoaffective disorder and bipolar mental illness. R1's behaviors included refusing medications and inappropriate physical and verbal behaviors. R1's care plan contained interventions to call family members, administer medications as ordered, provide supervision in social gatherings/recreation programs, and remain calm and avoid angry reactions if behaviors are exhibited. R1's admission documentation contained a physician order, dated 8/24/23, from R1's previous facility that stated to monitor R1 for behaviors including biting, hitting, kicking, spitting, cussing, racial slurs, and aggression. R1's medical record indicated the following: ~ On 2/7/24, R1 was agitated, displayed behaviors toward staff, and refused medications. ~ On 3/10/24, R1 struck out at a Certified Nursing Assistant (CNA) during cares. ~ On 3/27/24, R1 yelled in the hallway I'm going to beat someone's ass one day! and threatened a CNA because R1's lunch tray was late. ~ During an activity on 4/1/24, R1 told other residents to shut up and used foul language toward staff and residents. ~ On 4/7/24, R1 called a CNA names and swore at them. ~ On 4/14/24, R1 threw a cup at a CNA and swore at them. ~ When Director of Nursing (DON)-B entered R1's room on 4/14/24 and asked if R1 threw items at a CNA, R1 threw items at DON-B ~ On 4/28/24, R1 threw snacks in the hallway and swore at staff. ~ On 5/9/24, R1 swore at staff and made racist comments. R1's care plan was not updated to reflect R1's increased behaviors toward residents and staff. ~ On 5/23/24, staff observed R1 swear and complain in the dining room. R1 was redirected to R1's room while staff prepared R1's meal tray. When staff brought the meal tray to R1's room, staff observed R1 leave R2's room and say, I'm going to kick your ass. R2 stated R1 entered R2's room, picked up a Styrofoam cup full of coffee creamers from R2's bedside table, and threw the cup at R2. R2 asked, Why would (R1) do that? I don't even know (R1). The facility did not implement increased supervision or any interventions for R1 or R2 following the incident. ~ On 5/24/24 at 4:30 PM, LPN-D observed R1 in the hallway outside of R1 and R2's rooms. R1 repeatedly stated, Shut the f*** up. When LPN-D asked if R1 was okay, R1 told LPN-D to shut the f*** up and stop talking to me like that. LPN-D then exited the area and left R1 and R2 unsupervised. ~ On 5/24/24 at 4:45 PM, staff heard yelling from R2's room and observed R1 in R2's room. R2 stated R1 entered R2's room, picked up a wicker basket full of remote controls and personal items from R2's bedside table, threw the basket at R2's head, and yelled, That's what you get you f******* bitch. R2 was crying and had redness and swelling on R2's forehead. R1 was removed from R2's room and immediately placed on 1:1 supervision. ~ On 5/24/24, the police interviewed R1 and R2 regarding the incident. Per the police report, R1 was charged with battery (willful and unlawful use of force or violence upon the person of another). R2 told the police that was not the first time R1 had done something like this. ~ On 5/30/24, R1 was seen by a psychiatric Nurse Practitioner (NP) who indicated R1's 1:1 supervision could be discontinued. ~ On 6/4/24, R1 made inappropriate loud comments about another resident's weight. ~ On 6/5/24, R1 yelled and swore at staff about the mess in R1's bed. On 6/24/24 at 11:45 A.M., Surveyor interviewed R2 regarding the incident with R1. R2 reports that R2 was unsure why R1 did that. R2 stated that R2 was not afraid to leave R2's room and was continuing to participate in activities in the facility. On 6/24/24 at 1:30 PM, Surveyor interviewed LPN-D regarding R1's current supervision. LPN-D verified R1 was not on increased supervision when R1 was out of R1's room. LPN-D stated it was best to leave (R1) alone until (R1) calms down. On 6/24/24 at 1:45 PM, Surveyor interviewed CNA-E regarding R1's current supervision. CNA-E verified R1 was not on increased supervision when R1 was out of R1's room. CNA-E stated the interventions in R1's care plan to redirect R1 when aggravated were sometimes effective. On 6/24/24 at 2:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R1's current supervision. NHA-A verified R1 was not on increased supervision related to behaviors.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 2 residents (R) (R1 and R2) of 4 sampled residents. On 5/23/24, R1 entered R2's room and threw a Styrofoam cup full of creamers at R2. The incident was not thoroughly investigated to ensure further abuse was prevented and resulted in another allegation of abuse involving R1 and R2 on 5/24/24. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, states the facility will initiate an investigation for allegations or suspicions of abuse, including: 1. Identify staff responsible for the investigation; 2. Exercise caution in handling evidence that could be used in a criminal investigation (e.g., not destroying evidence); 3. Investigate different types of alleged violations; 4. Identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s); 5. Focus the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Provide complete and thorough documentation of the investigation. On 6/24/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, epilepsy, schizoaffective disorder, bipolar disorder, insomnia, and anxiety. R1's Minimum Data Set (MDS) assessment, dated 5/20/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 had intact cognition. R1's admission care plan indicated R1 was at risk for behavior related to schizoaffective disorder and bipolar mental illness. R1 refused medications and had inappropriate physical and verbal behavior. The care plan contained interventions to call family members, administer medications as ordered, provide supervision in social gatherings/recreation programs, and remain calm and avoid angry reactions if behaviors were exhibited. On 6/24/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including diffuse large B-cell lymphoma, lymphedema, and encounter for palliative care. R2's MDS assessment, dated 5/24/24, had a BIMS score of 15 out of 15 which indicated R2 had intact cognition. Surveyor reviewed R2's medical record related to an incident that occurred between R2 and R1 on 5/24/24. A progress note, dated 5/23/23 at 12:15 PM, indicated R1 was aggressive and threatening toward staff. Registered Nurse (RN)-F observed R1 leave R2's room and state, I'm going to kick your ass. R2 reported to RN-F that R1 entered R2's room and threw a Styrofoam cup full of coffee creamers at R2. On 6/24/24 at 12:14 PM, Surveyor interviewed R2 who verified R1 had thrown a Styrofoam cup full of coffee creamers at R2 on 5/23/24 for no apparent reason. R2 stated R2 did not know R1 and wondered why R1 would do something like that. On 6/24/24 at 12:23 PM, Surveyor interviewed NHA-A regarding the resident-to-resident altercation between R1 and R2 on 5/23/24. NHA-A verified the incident between R1 and R2 on 5/23/24 was not reported to administration or the SA and was not thoroughly investigated to prevent further abuse from occurring.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was reported to Nursing Home Administrator (NHA)-A and the State Agency (SA) for 2 residents (R1 and R2) of 4 sampled residents. On 5/23/24, R1 entered R2's room, threw a Styrofoam cup full of coffee creamers at R2, and verbally threatened R2. Staff did not report the allegation of abuse to NHA-A and the facility did not report the allegation of abuse to the SA. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, states the facility will report all alleged violations to the Administrator, State Agency, Adult Protective Services and all other required agencies (e.g., law enforcement when applicable) within a specified timeframe: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. On 6/24/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, epilepsy, schizoaffective disorder, bipolar disorder, insomnia, and anxiety. R1's Minimum Data Set (MDS) assessment, dated 5/20/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 had intact cognition. R1's admission care plan stated R1 was at risk for behaviors related to schizoaffective disorder and bipolar mental illness. R1 refused medications and had inappropriate physical and verbal behaviors. The care plan contained interventions to call family members, administer medications as ordered, provide supervision in social gatherings/recreation programs, and remain calm and avoid angry reactions if behaviors were exhibited. On 6/24/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including diffuse large B-cell lymphoma, lymphedema, and encounter for palliative care. R2's MDS assessment, dated 5/24/24, had a BIMS score of 15 out of 15 which indicated R2 had intact cognition. Surveyor reviewed R2's medical record related to an incident that occurred between R1 and R2 on 5/24/24. A progress note, dated 5/23/23 at 12:15 PM, indicated R1 was aggressive and threatening toward staff. Registered Nurse (RN)-F observed R1 leave R2's room and state, I'm going to kick your ass. R2 reported to RN-F that R1 entered R2's room and threw a Styrofoam cup full of coffee creamers at R2. On 6/24/24 at 12:14 PM, Surveyor interviewed R2 who verified R1 threw a Styrofoam cup full of coffee creamers at R2 on 5/23/24 for no apparent reason. R2 stated R2 did not know R1 and wondered why R1 would do something like that. On 6/24/24 at 12:23 PM, Surveyor interviewed NHA-A who verified the resident-to-resident altercation between R1 and R2 was not reported to NHA-A or Director of Nursing (DON)-B until the morning of 5/24/24. NHA-A also verified the incident was not reported to the SA.

Based on staff interview and record review, the facility did not ensure physician visits were completed timely for 2 residents (R) (R2 and R4) of 5 sampled residents. R2 was admitted to the facility on [DATE]. R2 was not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. R4 was admitted to the facility on [DATE]. R4 was not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Findings include: The facility's Leadership Policies and Procedures indicates: VI: Medical Services: .2. The physician visits the patient/resident according to the following guidelines: Every months for three months and every 60 days thereafter, or more often as clinically driven. 1. On 7/8/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including large cell lymphoma, lymphedema, and encounter for palliative care. R2's Minimum Data Set (MDS) assessment, dated 5/24/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. R2 did not have an activated power of attorney for healthcare (POAHC). R2's medical record indicated R2 was seen by the facility's physician for medical care and oversight in conjunction with palliative care providers. R2 was seen by the physician for an initial visit on 11/17/23 and monthly visits on 12/8/23, and 1/4/24. R2 was not seen again by a physician or Nurse Practitioner (NP) until 3/27/24. 2. On 7/8/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, chronic pain syndrome, chronic vascular disorders of intestines, type 2 diabetes with diabetic peripheral angiopathy, pressure ulcer of left heal unstageable, peripheral vascular angioplasty status with implants and grafts, chronic obstructive pulmonary disorder (COPD), and bipolar disorder. R4's MDS assessment, dated 6/26/24, had a BIMS score of 10 out of 15 which indicated R4 had moderate cognitive impairment. R4 did not have an activated POAHC. R4's medical record indicated R4 was seen by the facility's physician for an initial visit on 9/27/23. R4 was seen by an NP in October of 2023 and December of 2023. R4's medical record did not indicate R4 was seen by a physician every 30 days for the first 90 days after admission. On 7/8/24, Surveyor requested any additional physician visits for R2 and R4 from [NAME] President of Success (VPS)-C. On 7/8/24 at 12:35 PM, Surveyor interviewed VPS-C who stated the information Surveyor obtained through R2 and R4's medical records was correct regarding physician visits for both residents. VPS-C stated VPS-C contacted the physician's group and requested any additional documentation for visits conducted for R2 in February of 2024 and for R4 in October, November and December of 2023. VPS-C verified R4's visits in October and December of 2023 were completed by an NP. On 7/8/24 at 1:15 PM, VPS-C approached Surveyor and stated R2's physician's group stated a visit for R2 was on the schedule in February of 2024, but there was no documentation to confirm the visit occurred. VPS-C stated the physician would enter a note in R2's medical record shortly. VPS-C confirmed R4 was not seen by a physician in October, November or December of 2023 and was unsure why it was overlooked by the facility and the physician's group. VPS-C also confirmed R4 was not seen by a physician every 30 days for the first 90 days after admission.

Based on staff interview and record review, the facility did not ensure laboratory services were provided timely for 1 Resident (R) R2) of 5 sampled residents. The facility did not have a process in place to audit for expired lab supplies which caused a delay in obtaining a Respiratory Panel for R2. Findings include: On [DATE], Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and cerebral infarction (also known as stroke). R2's Minimum Data Set (MDS) assessment, dated [DATE], contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 had little cognitive impairment. R2 was responsible for R2's healthcare decisions. In a note entered at 3:45 AM on [DATE], R2's medical record indicated R2's Nurse Practitioner (NP) ordered a Respiratory Panel for symptoms of upper respiratory illness. A nursing progress note, dated [DATE] at 12:51 PM, indicated: (R2) is complaining of having congestion. Per NP, recommended (R2) be swabbed for Respiratory Panel. Swabs expired in house. Called (named lab service). Currently, they are only testing for COVID-19 and influenza, no RSV (respiratory syncytial virus). Swabs are being sent which adds an extra day to testing. Updated NP that R2 will be tested for COVID-19 and influenza only when the swabs arrive. R2's medical record indicated a courier picked up R2's Respiratory Panel sample on [DATE] at 8:33 AM. On [DATE] at 11:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who showed Surveyor the lab supply room. LPN-C indicated LPN-C would check for an expiration date if LPN-C needed to use a supply item, but was not sure if the facility had a process to pull items nearing their expiration dates in advance. On [DATE] at 11:54 AM, Surveyor interviewed Lab Team Lead (LTL)-D (an employee of the facility's contracted lab services company) via phone who indicated the facility was responsible for checking expiration dates on lab supplies and ordering new supplies to keep in stock. On [DATE] at 12:08 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should check for expiration dates on lab supply items prior to use. DON-B indicated the facility did not have a staff specifically assigned to audit and pull items nearing expiration dates. DON-B indicated the former Assistant DON (ADON) completed that task, but left employment around Christmas time in 2023. DON-B indicated no one was reassigned the task and stated, I didn't think of it until right now. DON-B indicated the facility hired a new ADON who started [DATE] and indicated the new ADON will take over the task. DON-B verified lab supply expiration dates were not checked/audited since the former ADON left employment. DON-B verified there was a delay in obtaining R2's Respiratory Panel due to expired swabs. DON-B indicated a lab courier picked up labs whenever the facility called during normal business hours. DON-B verified the swabs needed for R2's Respiratory Panel were expired on [DATE] and stated the contracted lab sent new supplies on the evening run. DON -B indicated the facility obtained a swab and sent the swab for testing first thing on [DATE]. On [DATE], Surveyor reviewed the facility's Critical Event Analysis and Action Plan Worksheet, with date of discovery [DATE], that indicated: Summary of critical event .Labs-being followed up on timely and documented on the line list for new admits and current residents-supplies available and valid .The Action Plan(s) to Prevent Recurrence section of the document did not indicate what action the facility took to address the concern regarding expired lab supplies. The document was signed by DON-B on [DATE].

Based on staff interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection. The facility did not implement a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This had the potential to affect all 26 residents in the facility. The facility did not identify where Legionella and other opportunistic waterborne pathogens can grow and spread. The facility did not document flushing or other measures to prevent the growth of opportunistic waterborne pathogens such as Legionella in identified areas where such pathogens may grow. Findings include: The facility's Legionella Surveillance Policy, dated 10/24/22, contained the following information: It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections .Physical Controls: i. Cooling towers and potable water systems shall be routinely maintained .iii. Non-potable water systems shall be routinely cleaned and disinfected . On 7/12/23 at 2:42 PM, Surveyor interviewed Maintenance Director (MD)-I who stated the facility's water management plan did not indicate how water flowed throughout the facility. A clipboard provided by MD-I included water temperature logs and the facility's Legionella Surveillance Policy, but did not include a water management plan. MD-I stated MD-I did not currently work in the facility full time, but when MD-I was full time, MD-I went through unused units weekly, flushed toilets, and ran sinks and showers. MD-I stated the TELS system (electronic system for maintenance) had a weekly reminder for Friday, but was not documented as complete in TELS. MD-I could not provide documentation that Maintenance Supervisor (MS)-J performed weekly flushing and could not provide additional information related to the facility's water management plan. MD-I stated MS-J was employed by the facility for approximately one month and was currently off. On 7/13/23 at 8:52 AM, Surveyor received a phone call from Nursing Home Administrator (NHA)-A and MS-J. MS-J stated unused water fixtures were flushed weekly, but specific areas of the facility were flushed every Monday and Tuesday to ensure all were being flushed. MS-J stated this was conducted in conjunction with the weekly Monday water temperature monitoring, but the facility did not document the flushing.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 26 residents residing in the facility. The facility did not consistently monitor and document warewasher (dishwasher) wash and rinse cycles. Findings include: During an initial tour of the kitchen beginning on 7/10/23 at 8:30 AM, Dietary Manager (DM)-D indicated the facility followed the Wisconsin Food Code. DM-D confirmed the facility's dishwashing machine was a single tank, conveyor, dual temperature machine and indicated the wash cycle temperature should reach at least 160 degrees Fahrenheit (F) and the rinse cycle temperature should reach at least 180 degrees F. The Wisconsin Food Code 2022 documents at 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than .(3) For a single tank, conveyor, dual temperature machine, 71 Celsius/160 Fahrenheit. The facility's Dish Machine Temperature Log, dated 7/27/22, contained the following information: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. 1. Staff will monitor dish machine temperatures throughout the dishwashing process. 2. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. A. The director of food and nutrition services/dietary manager will spot check this log to endure temperatures are appropriate and staff are correctly monitoring dish machine temperatures . During an initial tour of the kitchen beginning on 7/10/23 at 8:30 AM, Surveyor and DM-D confirmed the facility's Dish Machine Temperature and Sanitizer Log, dated 6/25/23 through 7/9/23, did not contain documentation of dish machine temperatures for the dinner meal. On 7/10/23 at 11:30 AM, Surveyor interviewed Cook (CK)-G who indicated dish machine temperatures should be monitored and recorded after each meal. Surveyor and CK-G confirmed dish machine temperatures for the dinner meal were not documented from 6/25/23 through 7/9/23. CK-G also verified that on 7/10/23, the log contained dish machine temperatures for breakfast, lunch, and dinner despite the fact dinner did not yet occur. CK-G indicated the documented dinner temperature was most likely a mistake. On 7/12/23 at 8:27 AM, Surveyor requested the Dish Machine Temperature and Sanitizer Logs for June and July of 2023. Surveyor reviewed the logs with DM-D who confirmed only two dinner meal dish machine temperatures were documented from 5/30/23 through 7/11/23. DM-D verified the facility's policy instructed staff to record dish machine temperatures for each meal.

Based on observation, staff and resident interview, and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being in accordance with the comprehensive plan of care for 1 Resident (R) (R11) of 1 resident. The facility did not apply R11's Tubigrips (compression stockings) per R11's physician order and plan of care. Findings include: The facility's Comprehensive Care Plan policy, revised 9/23/22, contained the following information: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 7/10/23 Surveyor reviewed R11's medical record. R11 had diagnoses that included diabetes type 2, venous insufficiency (chronic, peripheral), and chronic redness to bilateral lower extremities. R11's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R11 had intact cognition. R11's plan of care indicated R11 required the assistance of one staff for activities of daily living (ADLs). A wound note, dated 6/7/23, indicated Medical Doctor (MD)-E and Assistant Director of Nursing (ADON)-C assessed R11's left lower extremity and new orders were entered on R11's Treatment Administration Record (TAR). Surveyor reviewed R11's plan of care and TAR and noted the following order: Tubigrips on AM, off hour of sleep (HS); R11 to only wear right Tubigrip to right leg and left Tubigrip not to be worn; waiting for arterial doppler results; MD-E or MD (unnamed) will reinstate left Tubigrip contingent upon results two times a day for venous stasis with a start date of 6/8/23. A progress note, dated 7/4/23, indicated MD-E noted the wounds to R11's bilateral lower extremities were improving; however, the edema was more pronounced. The note indicated the plan was for a vascular surgery consult and continue no compression to the left lower leg. On 7/10/23, Surveyor interviewed R11 and noted R11's legs were wrapped in gauze. R11 indicated R11 had open sores on both legs which were improving. In the unwrapped areas, Surveyor noted R11's legs were deep red and swollen from below both knees to the top of the gauze wrap as well as both ankles. Surveyor observed Tubigrip compression stockings in R11's bathroom. R11 confirmed R11's legs and feet were swollen and remained swollen throughout the day. R11 stated R11 previously wore Tubigrips daily and was not sure why the Tubigrips weren't applied. On 7/11/23 at 11:17 AM, Surveyor noted R11 did not have a Tubigrip stocking on R11's right leg. On 7/11/23, Surveyor reviewed R11's TAR and noted the TAR indicated R11's Tubigrip was applied in the AM and removed at HS from 7/1/23-7/10/23. Surveyor also noted the TAR indicated R11's Tubigrip was applied in the AM on 7/11/23. On 7/11/23 at 2:26 PM, Surveyor observed MD-E and ADON-C provide wound care for R11 who did not have a Tubigrip stocking on the right leg. When MD-E unwrapped the gauze bandages on R11's legs, Surveyor noted an open area on R11's right outer shin, and scabbed scratches on R11's left lower leg. Surveyor noted both of R11's lower legs were deep red and purple in color. Surveyor observed MD-E assess both lower legs and provide wound care for a blister and open area on the right shin. MD-E indicated the open area was 4.1 centimeters (cm) by 2.5 cm and caused by a blister due to swelling. MD-E indicated Tubigrip stockings were ordered to manage edema (swelling). Surveyor observed MD-E cleanse and debride the open area and ask ADON-C if R11 had compression stockings or Tubigrips applied for edema. ADON-C denied Tubigrips or compression stockings were applied to R11's bilateral lower extremities. When Surveyor asked ADON-C if R11 had an order for Tubigrip stockings, ADON-C indicated no. Surveyor then observed ADON-C enter R11's bathroom and perform hand hygiene. ADON-C exited the bathroom with Tubigrip stockings and asked R11 if the Tubigrips were applied to R11's arms. R11 indicated the Tubigrips were for R11's legs and stated staff didn't apply the Tubigrips. Surveyor observed ADON-C dress R11's wounds, hand R11 the Tubigrip stockings and ask if R11 could apply the Tubigrips to R11's lower extremities. R11 attempted to apply the Tubigrips, but was not able to do so. ADON-C then applied the Tubigrips to R11's lower extremities. On 7/12/23 at 8:00 AM, Surveyor interviewed Nursing Home Administrator(NHA)-A who indicated the staff initials for 7/10/23 on R11's TAR under section tubi-grips applied in AM were those of ADON-C. NHA-A indicated the staff initials for 7/10/23 on R11's TAR under the section tubi-grips off in HS were those of Registered Nurse (RN)-F. NHA-A confirmed orders on a resident's TAR and in the their medical record should be followed as ordered.

Based on staff interview and record review, the facility did not consult with the physician for 1 Resident (R) (R1) of 1 residents sampled when the resident experienced a change in condition in R1's right second toe. R1's physician was not consulted in a timely manner on 5/18, 5/21, and 5/24/2021 when the wound on R1's right second toe deteriorated and presented the potential need to alter treatment. R1's second toe subsequently became infected and gangrenous and required amputation. The facility's failure to provide timely updates and consultation with R1's physician related to R1's wound condition and treatment created a finding of Immediate Jeopardy (IJ), which began on 5/18/2021. Surveyor notified Nursing Home Administrator (NHA)-A of the IJ on 8/19/2021 at 1:00 PM. The IJ was removed on 8/19/2021. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: On 8/18/2021, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) R1's most recent Minimum Data Set (MDS), dated [DATE], documented R1 had long and short term memory problems, required supervision for eating, extensive assist for bed mobility and was dependent on staff for transfers. R1's MDS further documented R1 had a diabetic foot ulcer and was at risk for skin breakdown. On 8/18/2021, Surveyor reviewed R1's Wound Clinic Notes dated 4/28/21,in which the physician documented the following regarding the diabetic ulcer of toe of the right foot. Medical Decision Making: With respect to the second toe ulcer, I did message the wound clinic recommending we just treat this patient conservatively with [MEDICATION(S)] swabs every day. It does not look grossly infected amputating the toe probably would heal, but there is a chance that it would not and that would create a whole host of other more major problems that would lead to arteriography (radiography of an artery) in this likely high risk patient among other things if the second toe gets grossly infected that would push us to more aggressive treatment such as initially amputation seeing if it would heal and if it would not arteriography. On 5/18/2021 the facility's Non-Pressure Skin Assessment of the right second toe wound documented the wound measures 1.0 cm X 1.0 cm with purulent (sign of infection) drainage noted to the area, further documenting the wound clinic will be updated with the assessing nurse's findings. R1's medical record lacks documentation indicating the physician received and/or responded to the nurse's wound assessment update or that the facility tried contacting the physician again when it did not get a response R1's progress notes documented the following: - 5/21/2021 at 4:06 PM, Nursing Note, wound clinic called and message left about change in wound on toe -await reply- - 5/21/2021 at 4:10 PM, Nursing note, message left with wound clinic about change in toe. - 5/23/2021 at 11:42 PM, Type: Skin/Wound Note Text: Right second toe: toe continues to leak thick, purulent, cloudy white/yellow drainage. No odor noted. Skin to entire foot is sloughing off. Wound to the right second toe bleeds when gently being cleaned. Entire foot is very swollen and feels to be full of fluid, fragile skin covers entire dorsal side of the foot. When cleansing and touching foot, resident does not show any signs/symptoms of pain. Wound care appointment scheduled for this upcoming Friday (5/28). - 5/24/2021 at 2:54 AM, Type: Skin/Wound Note Text: Sent nurse practitioner and physician at wound clinic to update on right second toe infection and multiple pressure injuries to bottom. - 5/24/21 at 11:17 PM, Type: Skin/Wound Note text: MD noted new pressure injuries found on resident. No new orders. Resident has wound clinic appointment 5/28/21. On 8/18/2021 at 2:27 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor questioned the NHA-A regarding the lack of the physician's response to updates provided on 5/18/21, 5/21/21 and 5/24/21. NHA-A indicated that due to NHA-A not being a medical clinician, NHA-A did not wish to respond to the Surveyor's question. On 8/18/2021 at 3:13 PM, Surveyor interviewed Registered Nurse (RN)-F. RN-F indicated RN-F is employed at the wound clinic and is familiar with R1. RN-F indicated the following after reviewing R1's electronic chart: R1's electronic health record does not include documentation that the physician was updated during the month of May with any wound concerns. For a change in condition of a wound the clinic would expect a phone call and not a fax. Phone calls would receive more immediate attention and a fax may not get immediate attention. If a facility is concerned regarding the condition of a wound, an appointment can be made for the patient to be seen. If a nurse reports thick, purulent drainage to the office, typically an appointment is scheduled or if the resident already has a scheduled appointment the office will try to get the resident in sooner. From 4/28/2021 - 6/2/2021 there were no documented updates to the physician regarding R1's wound care. On 5/28/2021, R1 was transported to the wound clinic but returned to the facility without being seen as the clinic indicated R1 did not have an appointment scheduled. R1 was seen at the wound clinic on 6/2/2021. The clinic note documented the following: Assessment/Plan: 1. gangrene of toe of right foot, we will proceed with amputation of the right second toe possibly the metatarsal head. 2. [CONDITION(S)] ([CONDITION(S)]-resistant Staphylococcus aureus) infection. (Note: [CONDITION(S)] is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) Medical decision-making: The patient unfortunately has an [CONDITION(S)] and [CONDITION(S)] infection of the right second toe. I was hoping that by painting this with [MEDICATION(S)] we could keep it in check but it has gotten much worse. Physical exam: The second toe has an open wound with exposed proximal interphalangeal joint anteriorly. On 8/18/2021, Surveyor reviewed Wound Clinic nurse's documentation dated 6/2/21, which documented the following regarding the wound #2 located right second toe. Plan: Physician evaluated R1's toe today .The wound was dressed with [MEDICATION(S)] swab stick and covered with a nonadherent dressing (Oil [MEDICATION(S)]) and covered with a lightly wrapped kerlix roll gauze, over the foot and ankle to secure. Change the dressing once a day. Surgery to amputate the second toe and metatarsal of the right foot will be scheduled. R1's second toe was amputated on 6/8/2021. Surveyor reviewed the Patient Discharge Instructions dated 6/8/2021, which documents: Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge orders include: 1.5 gram IV (intravenous) [MEDICATION(S)] (antibiotic) daily for 3 days. Discharge Wound Care: Place 4 by 4 on amputation site right #2 toe daily. On 8/19/2021 at 9:47 AM, Surveyor interviewed Wound and Ostomy (CWON) RN-G. RN CWON- G indicated R1 is seen at the wound clinic. RN CWON-G indicated there were no documented updates to the clinic from 4/28/21 - 6/2/21. CWON-G indicated when the facility does not receive a prompt response to a patient's change condition the facility is able to send the resident to the emergency room for assessment and this would trigger a call from the ER to the wound clinic and the physician involved in the patient's wound care. CWON-G indicated the facility Director of Nursing may want to contact the wound clinic to share any concerns and become involved when the nursing staff does not receive a response from the clinic. On 8/18/2021 at 3:13 PM, Surveyor interviewed Registered Nurse (RN)-F. RN-F indicated RN-F is employed at the wound clinic and is familiar with R1. Surveyor asked RN-F if the amputation of R1's second toe could have been prevented had the staff updated the physician on the changes seen on 5/18/21, 5/21/21 and 5/24/21. RN-F indicated RN- F cannot categorically say the amputation could have been prevented or if it was an evolving wound due to R1's comorbidities but it was possible amputation could be the result if the facility was not following good wound care practices. Cross reference F684. The failure to consult with the physician in a timely manner related to R1's wounds prevented timely medical intervention and created a finding of IJ. The facility removed the jeopardy on 8/19/21 when it had completed the following: All licensed staff educated on the Change of Condition Of The Resident (Observing Recording and Reporting) Policy This policy includes the following education: Change of condition refers to a deviation from the patient/resident's baseline in physical, cognitive, behavioral or functional domains. The change of condition may be short lived or extend for a period of time and presents as a shift from the norm for that patient/resident. When a resident presents with a change in condition - Example- to a wound - deteriorating wound condition- the nurse will asses the resident and notify the attending practitioner of the resident's condition. Documentation needs to include: Date and Time of incident (if applicable), time condition change - wound deterioration - was observed Observation of assessment findings Notification/Consultation of practitioner; consistent with the expectation found in INTERACT guidelines - include date, time, what was conveyed, and any orders received (each time notified) On 8-19-2021 the Change Of Condition Of The Resident (Observing Recording and Reporting) was reviewed by the Sr. DCS and NHA. Policy addresses guidance related to communication and documentation. Center will review and revise shift to shift reporting process which includes communicating to the on-coming shift, any communication to the MD that has not yet received a response. This includes oral and faxed communication. All progress notes for the last 72 hours will be reviewed to identify any potential communication to the MD without a documented response by the Sr. DCS - completed 8-19-2021. DON and/or designee will review all progress notes through the morning stand-up meeting held Mondays - Fridays x 8 weeks, then weekly x 4 weeks, then monthly x 3 months. Results of the audits will be reviewed by the QAPI committee for further recommendations.

Based on observation, staff and family interviews, and record review, the facility did not ensure 1 Resident (R) (R12) of 14 sampled residents received the appropriate care and services necessary to attain the highest practicable well-being. Staff were observed transferring R12 using a mechanical lift that caused the resident to complain of pain during the transfer. R12's plan of care was revised on 9/18/17, instructing staff to transfer R12 via a full body lift with 2 person physical assist. R12 was noted to have reoccurring bruises to the resident's breast area with multiple stages of healing thought to be caused by the use of the mechanical lift. Findings include: According to the electronic medical record for R12, the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R12's most recent MDS (Minimum Data Set) assessment dated [DATE], documented R12 was somewhat cognitively intact, scoring 11 out of 15, with 15 being the most cognitively intact. R12's physical mobility care plan initiated 7/12/17 and revised on 9/18/17, indicated R12 required the full body lift with 2 person physical assist. The care plan indicated the resident was at risk for falls, incontinent of bowel and bladder, and had pain to the knees and both shoulders. The care plan instructed staff to allow R12 to rest and provide ice for the resident's knee and shoulder pain as needed. Additionally, R12 had scheduled [MEDICATION NAME] for pain and biofreeze (a pain relieving gel) and [MEDICATION NAME] as needed for pain. R12's room had a quick reference care card available for Certified Nursing Assistants) CNAs to reference regarding how to care for R12. R12's care card was dated 7/23/17 and directed staff to use the stand up mechanical lift with 2 staff present for transfers for R12. On 9/21/17 at 9:30 a.m., the Surveyor observed CNA (Certified Nursing Assistant)-C and CNA-D transfer R12 from the wheelchair to the toilet using a stand up mechanical lift. The CNAs left the resident attached to the lift, left the bathroom, closed the bathroom door and exited the resident's room. On 9/21/17 at 9:41 a.m., R12 began calling out for help. The Surveyor observed LPN (Licensed Practical Nurse)-B walk past R12's room twice while the resident was calling out for help, before entering the room and checking on R12. CNA-C had been passing water to residents and did not stop to check on R12 while the resident was calling out for help. On 9/21/17 at 9:47 a.m., the Surveyor noted LPN-B asking CNA-C and CNA-D to assist R12. The CNAs entered R12's room and performed hand hygiene. Using the stand up mechanical lift, which R12 was already strapped into, the CNAs assisted R12 to a standing position while they cleaned the resident's urethral and buttocks areas. R12 repeatedly said, Oh it hurts! Oh .I'm gonna fall. R12 winced and continued to complain of pain during the observation. It was noted that the lift had a strap that wrapped around R12's chest, a footrest and handles for the resident to grasp. During this time R12's knees were bent and the resident was supported largely by the chest strap. R12's hands were on the handles as the resident's arms were outstretched. The entire transfer observation took approximately five minutes and R12 was again seated in the wheelchair. FM (Family Member)-E arrived and entered R12 the resident's room, asking the CNAs why they continued to use that lift for R12, when they know they are not supposed to do so. The CNAs commented that R12's care plan still directed them to use this lift before leaving R12's room. Immediately following this observation, at 9:52 a.m., the Surveyor interviewed FM-E and R12. FM-E stated multiple staff were talked to about using this lift and how it was not appropriate for R12. FM-E stated R12 does not have the leg strength to stand up, has arthritis and pain to the shoulders, and it (the stand up lift) was leaving bruises R12's left breast. R12 and FM-E showed the Surveyor the large bruised area to the resident's left breast. R12's left breast area was noted to be deep purple and red surrounding the areola, with yellow and green areas extending above the areola, below the breast, and out towards the resident's left armpit. R12 commented the bruised areas on her breast were painful and FM-E indicated the bruising started a while ago. On 9/21/17 at 10:10 a.m., the Surveyor interviewed CNA-C, who verified R12's bruising has been present for a week or two and R12 usually complains of pain during transfers. On 9/21/17 at 10:12 a.m., the Surveyor interviewed CNA-D, who verified she was aware of R12's complaints of pain during transfers. CNA-D indicated not reporting R12's complaints of pain to the nurse. On 9/21/17 at 10:15 a.m., the Surveyor interviewed LPN-B, who verified she was the nurse caring for R12 and no one reported to her that R12 was having any pain or bruising in the left breast area. On 9/21/17 at 10:17 a.m., the Surveyor interviewed LPN-G, who verified knowing R12 had a bruise to her breast that started a month or two ago. LPN-G indicated R12's bruise was thought to be caused from the stand up lift and was fading. LPN-G verified the CNAs were supposed to use a full body lift to transfer R12. R12's 9/2017 TAR (Treatment Administration Record) included documentation that R12 was found to have a bruise on 8/23/17, under left arm and under breast (not on the breast). The TAR did not include documentation regarding size, color, or extent of R12's bruising. The TAR instructed staff to monitor the area once daily until healed. The TAR included monitoring documentation by LPN-B of the area for seven days during the month of September 2017, including the day of this observation 9/21/17. On 9/21/17 at 1:00 p.m., the Surveyor interviewed LPN-B regarding R12's 9/2017 TAR documentation. LPN-B stated she must have looked at it a while ago and must have forgot because she looks at so many bruises. LPN-B verified she did not look at R12's left breast area this day, even though she already documented having looked at it. LPN-B then indicated she would be sure to look at the bruise when she had an opportunity. The facility provided Non-Pressure Skin Condition observation documentation for R12. The initial skin observation was dated 8/22/17 and indicated, Bruise under left arm to under left breast was purple, blue under the heading characteristics. No additional information was documented, to include measurements of the bruised area, other than LPN-G's opinion that the bruise was caused from the stand up lift sling. On 9/18/17 the Non-Pressure Skin Condition observation documentation completed by LPN-G indicated, bruise to left breast and under arm, improving .bruise is now faded to light yellow. On 9/21/17 at 2:00 p.m., the Surveyor interviewed DON (Director of Nursing)-A, who indicated R12's bruising to the left breast was not from a known, isolated incident. DON-A stated the bruising was discovered and staff assumed it was from the stand up lift chest strap and the nurse should have been notified R12 was in pain. DON-A indicated therapy staff evaluated R12 for safety while transferring with the stand up lift and recommended the stand up lift for R12's transfers. DON-A stated on 9/18/17, R12's physician was contacted by staff and an order for [REDACTED].>On 9/21/17 at 3:00 p.m., the bruising to R12's breast was observed by DON-A and the Surveyor. DON-A described the bruise as surrounding the resident's areola and bottom half of the breast extending over toward the resident's armpit. DON-A verified R12's bruise included the colors of purple, red, yellow, and green present. DON-A verified the last documented observation was 9/18/17, and just indicated the color was yellow. DON-A verified the left breast injury must have been reoccurring, as the bruise had different stages of healing and staff should have documented the size, characteristics and extent of R12's bruising.

Based on observation, record review and staff interview, the facility did not ensure 5 residents (Resident (R)3, R4, R5, R2, and R8 ) of 8 residents reviewed for pressure injuries and pressure injury risk received appropriate treatment and services to promote healing and/or prevent pressure injuries from developing. Example 1 (R3) is being cited at Severity Level 3. R3 was assessed to have a reddened stage 1 pressure injury to the right buttock upon admission. The physician was not notified, a treatment order was not obtained and monitoring was not initiated. R3 frequently refused cares and interventions and the area worsened. Approximately two weeks later, R3 was assessed to have an unstageable pressure injury to the right buttock. In addition, R3 was observed with heels in contact with the mattress, an incontinence pad in bed and was positioned by staff with an incontinence pad instead of a slide sheet. R4 was admitted with an unstageable pressure injury to the right heel. R4 required an off-loading boot to be worn on the right foot and lower leg. R4 developed a Stage 2 pressure injury to the right calf due to the boot strap rubbing on the skin. The facility did not have a system in place to direct staff to monitor the right foot and lower leg to prevent pressure injuries from the medical device. R5, who was at risk for the development of pressures injuries, was observed to have a coccyx dressing during an observation of cares. R5 did not have a physician's orders [REDACTED]. In addition, R5 was observed in a recliner without a foam cushion, in bed without heels free floated and was positioned without a slide sheet during cares. R2 had a healing stage 4 pressure ulcer to the left buttock fold, a history of a deep tissue injury to the bottom of the left lateral foot and a treatment order for skin prep to the posterior left heel twice daily. During an observation of cares, staff positioned R2 with an incontinence pad instead of a slide sheet. R8 was assessed to be at risk for the development of pressure injuries. The written plan of care and CNA (Certified Nursing Assistant) Kardex directed staff to utilize a slide sheet when re-positioning R8. An observation was made whereby a slide sheet was not used. When interviewed, staff indicated they did not use a slide sheet for R8. Findings include: The facility's Pressure Ulcer Prevention & Treatment policy, dated 4/4/16, states: 1.1 Based on the comprehensive assessment of a resident/patient, the center must ensure that: 1. A resident/patient who enters the center without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident/patient having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. 2.1 The intent of this policy is that the resident/patient does not develop pressure ulcers unless clinically unavoidable and that the center provides care and services to: Promote the prevention of pressure ulcer development; Promote the healing of pressure ulcers that are present; and Prevent development of additional pressure ulcers. 3.4 PUSH (Pressure Ulcer Scale for Healing) Tool will be completed weekly by WCC (Wound Care Certified) (or designated wound round nurse with WCC consultation as needed) when pressure ulcers(s) identified, to continue until 2 weeks after resolution date. 3.6 Treatments and interventions (including but not limited to repositioning per individualized needs) will be utilized based on current standards of practice, provider orders will be obtained as required, and treatment changes will be considered if no improvement is seen after approximately two (2) weeks. 4.1 Documentation will be maintained in resident/patient's electronic medical record. 1. On 1/30/17 Surveyor reviewed the medical record of R3. The resident was admitted to the facility with [DIAGNOSES REDACTED]. R3's most recent MDS (Minimum Data Set), dated 1/11/17, documented R3 was cognitively intact, required extensive to full assistance of staff for bed mobility, transfers and ADLs (activities of daily living) and had an unhealed stage 1 pressure injury. R3's skin integrity plan of care, dated 1/17/17, indicated R3 had an unstageable pressure injury to the right buttock. An admission skin assessment, dated 1/04/17, indicated R3 had a 1 cm (centimeter) (length) x 2 cm (width) stage 1 right buttock pressure injury to which barrier cream was applied. The assessment indicated staff were to monitor the area in the TAR (treatment administration record), apply a treatment or dressing, notify the wound care nurse and observe the wound weekly. As of 1/05/17, interventions in R3's skin integrity plan of care included a cushion in wheelchair and recliner, encourage good nutrition and hydration, follow facility protocols for treatment of [REDACTED]. A Skin Observation Tool, dated 1/11/17, contained a section entitled Known Skin Impairments. Under Section 2. List of Skin Impairments Already Being Addressed/Monitored, the assessment stated, coccyx-barrier cream. There was no further description or assessment of the area. The assessment also indicated staff were to apply a treatment or dressing and continue weekly observations. A Focus Note, dated 1/12/17, stated, Buttocks have mottled appearance/no open areas .barrier cream applied. A PUSH Tool, dated 1/17/17, indicated R3 had an in-house acquired 3.0 cm x 3.5 cm x 0.1 cm (depth) unstageable pressure injury with necrotic (dead) tissue to the right buttock. The wound assessment stated, red tissue with thin lay (sic) of black tissue, irregular. Wound seems to be a combination of pressure, moistness and shearing. The PUSH Tool indicated R3 was to have a specialty mattress, a pressure reduction device for chair and a turning/repositioning program. In addition, R3 was to lie down after meals and staff were to free float R3's heels. The PUSH Tool further indicated staff were documenting every 2 hours related to R3's refusal of cares, including toileting and time out of the recliner. The PUSH Tool stated, Specialty mattress ordered on admission, but did not wish to lie down, states (R3) always slept in recliner. Request Santyl/allevyn tx (treatment) to buttock. Increased repositioning schedule to q1h (every one hour) with documentation .Has cushion in wheelchair and recliner. CP (careplan) updated. Interventions added to R3's care plan included: measure wound to right buttock weekly; tx as ordered (1/17/17), encourage to lie in bed more often to relieve back pain and get off buttocks (1/19/17), ROHO w/c (wheelchair) cushion (1/19/17), specialty mattress (1/20/17) and lie down AM (morning) and PM (evening) as resident allows (1/20/17). A nursing note, dated 1/17/17, stated, (R3) had (sic) a pressure ulcer - acquired in-house incident on 1/17/17 at 6:00 a.m. Noted during cares, toileting .Area cleansed, allevyn applied. Immediate care plan intervention: Resident agreed to lie down, positioned off buttock. A physician's orders [REDACTED]. One time a day every other day for wound care. A physician's orders [REDACTED]. A PUSH Tool, dated 1/25/17, indicated R3's unstageable right buttock pressure injury included the coccyx area and had spread to the left buttock. The wound measured 5.6 cm x 15.2 cm x 0.1 cm and contained necrotic tissue. The PUSH Tool stated, Q1h positioning, refuses at times. Refuses toileting but has been allowing peri-cares. Lying in bed more frequently now, using specialty mattress. CP updated to not use incontinent pad .Continue ROHO cushion w/c; refuses any cushion in recliner . Interventions to R3's care plan included: encourage side to side assist with positioning (1/25/17); no incont (incontinence) pads in bed (1/25/17) and slide sheet for positioning (1/25/17). Nursing and dietary notes, dated 1/11, 1/12, 1/18 and 1/19, indicated R3 refused cares, interventions and dietary supplements. On 1/30/17, Surveyor reviewed R3's January 2017 TAR. The TAR did not contain treatment or monitoring schedules for R3's pressure injury prior to 1/18. On 1/31/17 at 2:30 p.m., Surveyor interviewed DON (Director of Nursing)-A regarding R3's pressure injury. DON-A indicated staff charted a stage 1 pressure injury with an open area upon admission. DON-A stated the wound should have been charted as a stage 2 upon admission and had gotten worse. DON-A stated barrier cream was placed on the wound upon admission; however, the physician was not notified and a treatment order was not obtained. DON-A verified the pressure area should have been monitored on the TAR and a treatment should have been obtained to prevent the area from getting worse. On 1/31/17 at 3:15 p.m., Surveyor interviewed RN (Registered Nurse)-D, who performed R3's admission assessment. RN-D indicated the area was not open upon admission and stated, I thought I left a voicemail for (MDSRN (Minimum Data Set Registered Nurse)-G), the wound care nurse. RN-D indicated (RN-D) didn't remember if wound monitoring was initiated or if the physician was notified. On 1/31/17 at 4:25 p.m., Surveyor interviewed R3 regarding R3's pressure injury. R3 indicated (R3) brought a pressure reducing cushion from home but was unable to use it in the facility's recliner. R3 stated, It makes me feel like I'm going to fall out. R3 indicated (R3) was not offered a dycem or non-skid surface for the cushion. On 2/01/17 at 7:45 a.m., Surveyor interviewed MDSRN-G regarding R3's pressure injury. MDSRN-G indicated (MDSRN-G) wasn't notified of R3's reddened area upon admission. When asked what interventions the facility would have implemented, MDSRN-G stated, We would do barrier cream, get (R3) off the area, get a better cushion for the recliner and wheelchair and do weekly charting. MDSRN-G further stated the pressure area should have been on the TAR or somewhere so the nurses would know to monitor. MDSRN-G indicated a specialty mattress was ordered upon admission, but was given to someone else when R3 slept in the recliner. On 2/01/17 at 8:15 a.m., Surveyor observed R3 in bed with both heels in contact with the mattress. R3 stated, My wound is getting better. The left side is almost healed. The right side is getting better. On 2/01/17 at 8:58 a.m., Surveyor asked MDSRN-G for the 1/31/17 wound clinic note. MDSRN-G stated, The wound clinic sent a treatment order, but they don't send a note. They don't measure the wound or describe it. A physician's orders [REDACTED]. On 2/01/17 at 9:00 a.m., Surveyor entered R3's room with LPN (Licensed Practical Nurse)-L. Upon observing R3's heels on the mattress, LPN-L verified R3's heels should be free floated. On 2/01/17 at 9:57 a.m., Surveyor observed R3 in bed with a thin pillow under both shins and both heels in contact with the mattress. On 2/01/17 at 10:00 a.m., Surveyor observed MDSRN-G and CNA (Certified Nursing Assistant)-J provide wound and perineal care for R3. During cares, Surveyor observed an incontinence pad underneath R3. MDSRN-G indicated R3 should have a draw (slide) sheet in bed instead of an incontinence pad. During cares, MDSRN-G and CNA-J used the incontinence pad to slide R3 in bed. The incontinence pad was pulled across the bed with R3's buttocks in contact with the pad and heels in contact with the mattress. Following wound care, MDSRN-G retrieved a slide sheet and placed it under R3. A PUSH Tool, dated 2/01/17, indicated R3's unstageable right buttock wound measured 5.3 cm x 4.6 cm x 0.1 cm. The assessment stated, Soft black tissue to right buttock measures 1.5 x 1.3. Rest of area pink or beefy red. Left buttock and coccyx are healed, pink intact tissue. Much improved this past week; more compliant with amount of time in bed and using bed during noc (night); specialty mattress in place. Resident stated that MD told (resident) at the wound clinic yesterday that (resident) was on the right track. 2. On 1/31/17 Surveyor reviewed R4's medical record. R4 was admitted on [DATE] with [DIAGNOSES REDACTED]. R4's MDS (Minimum Data Set) dated 1/11/17 indicates R4 had one unstageable pressure injury upon admission to the facility. On 8/4/16 R4 was prescribed an off-loading boot to the right foot and lower leg, and continues to use the boot. The TAR (Treatment Administration Record) dated for 8/4/2016-9/14/2016 directs nursing staff to check skin integrity and foot q (every) shift, three times a day for prevent pressure on heel. After 9/14/16, there is no further direction to nursing staff to monitor R4's skin integrity. The PUSH (Pressure Ulcer Scale for Healing) Tool completed on 11/8/16 states R4 developed a pressure injury which was acquired in house on 11/8/16. The pressure injury is located on the right lower calf and measures 1.8 cm(centimeters) x 2.0 cm x 0.1 cm. It is classified as a Stage 2 pressure injury. Progress Record dated 11/9/16 from APNP (Advanced Practice Nurse Prescriber) states, posterior right calf with new open area, secondary rubbing of off-loading boot, too tight. On 1/31/17 at approximately 9:10 a.m., Surveyor interviewed DON-A regarding monitoring of skin integrity when using a medical device. DON-A verified the monitoring on the TAR started 8/4/2016 and was discontinued on 9/14/2016. DON-A was unsure why it was discontinued and stated her expectation would have been it would have been kept on the TAR for as long as R4 was using it. DON-A was unable to provide any information showing nursing staff was monitoring R4's skin integrity from 9/14/16-11/8/16 to prevent a pressure injury from occurring due to a medical device. 3. On 1/30/17, Surveyor reviewed the medical record of R5. The resident was admitted to the facility with [DIAGNOSES REDACTED]. R5's most recent MDS, dated [DATE], documented R5 was cognitively intact, required extensive to full assistance of staff for transfers, bed mobility and ADLs (activities of daily living) and was at risk for the development of pressure injuries. R5 had a recent decline in condition following a hospital stay for [MEDICAL CONDITION] and shortness of breath. R5's physical mobility care plan, dated 7/24/16, contained interventions for a foam cushion in recliner and a slide sheet for positioning. R5's skin integrity plan of care, dated 7/31/15, contained an intervention for heels off mattress. R5's Kardex (a modified care plan contained in residents' rooms for staff use), dated 1/30/17, contained the same interventions. On 1/30/17 at 11:15 a.m., Surveyor observed R5 in a recliner in R5's room. On 1/30/17 at 1:27 p.m., Surveyor observed CNA-J and CNA-P transfer R5 from recliner to bed. During the transfer, Surveyor did not observe a foam cushion in R5's recliner. When asked how long R5 was in the recliner, CNA-P stated, (R5) got up around 8:30 a.m., went in the chair and ate breakfast. CNA-P indicated R5 remained in the recliner all morning and stated, We repositioned (R5) .lifted (R5) up and let (R5) stretch .made sure (R5's) bottom was off there (recliner) for awhile and put (R5) back in the chair. While CNA-J and CNA-P positioned R5 in bed, Surveyor observed a dressing on R5's coccyx. CNA-J stated the dressing needed to be changed and notified LPN (Licensed Practical Nurse)-M. LPN-M entered the room, donned gloves and used a draw sheet to pull R5 across the bed. R5's buttocks were in contact with the draw sheet and heels (in socks) were in contact with the mattress. LPN-M then removed R5's dressing, applied skin prep to the area and applied a clean dressing. When Surveyor inquired about the dressing, LPN-M stated, The nurse practitioner will come and look at it. The family wanted the dressing on. Following wound care, LPN-M lifted R5's legs and CNA-P placed a pillow under R5's shins. R5 was positioned with both heels resting on the pillow. When Surveyor inquired about R5's foam cushion, LPN-M indicated LPN-M was unfamiliar with the foam cushion and did not know R5 was to have the cushion in the recliner. When Surveyor inquired about R5's heels, LPN-M checked R5's Kardex and indicated R5's heels were to be off the mattress. When Surveyor indicated both heels were in contact with the pillow, LPN-M indicated that was okay. R5's medical record indicated R5 was sent to the ER (emergency room ) during the PM (evening) shift on 1/30 for a decline in condition. On 1/31/17, Surveyor reviewed R5's TAR and did not observe an order for [REDACTED]. On 1/31/17 at 3:30 p.m., Surveyor interviewed DON-A regarding R5's coccyx dressing and foam cushion. DON-A stated, (R5) had a surgical area on the buttocks/rectal area. (R5) should have a cushion in the recliner. I'm not sure of any area that is developing. On 2/01/17 at 7:45 a.m., Surveyor interviewed LPN-L regarding R5's coccyx dressing. LPN-L stated, It was on report that family put a dressing on (R5) when they took (R5) home over the weekend. I'm not sure when it was placed, but (R5's spouse) asked a CNA to tell me to change the dressing on Sunday (1/29). There was allevyn on the coccyx and (R5's spouse) stated R5 got the wound from the hospital. The area looked like a scratch with the first phase of skin break down. I couldn't get ahold of (MDSRN-G) on the weekend. LPN-L indicated LPN-L charted the situation and an assessment of the area in handwritten notes, but not in R5's medical record. On 2/01/17 at 7:55 a.m., Surveyor interviewed MDSRN-G, the facility's wound care nurse, regarding R5's coccyx dressing. MDSRN-G stated, I didn't look at (R5) before (R5) left (for the hospital). I think (R5's) daughter, who is a nurse practitioner, placed a dressing on (R5). (LPN-L) called me on Sunday after being asked to change the dressing by family. I'm not sure if there's any charting on the area or why the dressing was placed. 4. On 1/31/17, Surveyor reviewed the medical record of R2. The resident was admitted to the facility with [DIAGNOSES REDACTED]. R2's most recent MDS, dated [DATE], documented R2 required extensive to full assistance of staff for transfers, bed mobility and ADLs (activities of daily living). R2's medical record indicated R2 had a healing stage 4 pressure injury that measured 1.0 cm x 1.0 cm x 0.5 cm on 1/27. R2 had a history of [REDACTED]. R2's Kardex, dated 1/30/17, contained the same intervention. On 2/1/17 at 9:25 a.m., Surveyor observed CNA-J and CNA-K provide perineal care for R2. During the provision of cares, CNA-J and CNA-K used an incontinence pad to position and pull R2 across the bed. R2's buttocks were in contact with the incontinence pad and R2's heels (in socks) were in contact with the mattress. Immediately following the observation, Surveyor interviewed CNA-K who verified a slide sheet was not used for positioning. 5. On 1/31/17 Surveyor reviewed the medical record of R8. The undated facesheet contained within the medical record indicated R8 was admitted with [DIAGNOSES REDACTED]. The most recent 12/7/16 quarterly MDS (Minimum Data Set) assessment indicated R8 was at risk for the development of pressure injury. Additionally, the BIMS (Brief Interview for Mental Status) documented R8 scored a 4/15 which indicated severe cognitive impairment. The 12/7/16 Braden assessment indicated R8 scored a 13 placing the resident at moderate risk for the development of pressure injury. R8's current written plan of care presented by the facility, most recently updated 1/16/17, directed staff to use a slide sheet in bed. The CNA Kardex (a plan of care used by CNA staff) also directed staff to use a slide sheet in bed. On 2/1/17 at 9:06 a.m., Surveyor observed toileting and perineal care provided to R8 by CNA-B and CNA-C. After the resident was toileted, the CNAs transferred R8 to bed for perineal care. A slide sheet was not used before, during or after the cleansing, to roll, shift or adjust the resident in bed. When the cleansing was complete and staff re-positioned R8 for sleep, the resident was boosted in bed using a sheering motion as buttocks was dragged across the incontinence pad. On 2/1/17 at 9:30 a.m., Surveyor interviewed CNA-B who verified a slide sheet was not used for R8. We have them available but we don't use them for (R8).