Every finding on record at Heritage Lakeside

Based on observation, interview, and record review, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 12 residents (R) reviewed (R46.) Beginning 03/03/26, R46 presented with a change of condition including shortness of breath, difficulty breathing, and continuous use of a Continuous Positive Airway Pressure (CPAP) machine. The facility failed to assess R46 with the change in condition, failed to notify the provider of R46's change in condition, failed to complete respiratory assessments as per provider order, and failed to implement new care plan interventions. These failures resulted in R46 being transferred to a higher level of care and being diagnosed with a Pulmonary Embolism (PE) requiring a pulmonary artery thrombectomy (an invasive or surgical procedure to remove blood clots from the pulmonary arteries.) The facility's failure to provide care consistent with standards of practice for R46 by not performing comprehensive assessments when R46 had a change in condition with shortness of breath, difficulty breathing, and continuous all-day use of the CPAP machine created a finding of immediate jeopardy that began on 03/03/26. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were informed of the immediate jeopardy on 04/06/26 at 3:57 PM. The immediate jeopardy was removed on 04/07/26, 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:According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. Website on AskMayoExpert. Pulmonary embolism (adult). Mayo Clinic; 2022. https://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/symptoms-causes/syc-20354647) that states, . A pulmonary embolism is a blood clot that blocks and stops blood flow to an artery in the lung. In most cases, the blood clot starts in a deep vein in the leg and travels to the lung. Rarely, the clot forms in a vein in another part of the body. When a blood clot forms in one or more of the deep veins in the body, it's called a deep vein thrombosis (DVT).Because one or more clots block blood flow to the lungs, pulmonary embolism can be life-threatening. However, prompt treatment greatly reduces the risk of death. Common symptoms include:Shortness of breath. This symptom usually appears suddenly. Trouble catching your breath happens even when resting and worsens with physical activity.Chest pain. You may feel like you're having a heart attack. The pain is often sharp and felt when you breathe in deeply. The pain can stop you from being able to take a deep breath. You also may feel it when you cough, bend or lean over.Fainting. You may pass out if your heart rate or blood pressure drops suddenly. This is called syncope.Other symptoms that can occur with pulmonary embolism include:A cough that may include bloody or blood-streaked mucusRapid or irregular heartbeatLightheadedness or dizzinessExcessive sweatingFeverLeg pain or swelling, or both, usually in the back of the lower legClammy or discolored skin, called cyanosisWhen to see a doctorA pulmonary embolism can be life-threatening. Seek urgent medical attention if you experience unexplained shortness of breath, chest pain or fainting.) Facility policy titled, Notification of Changes, reviewed 10/5/25 and revised on 04/06/26 states: .#2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.This may include:a. Life-threatening conditions, or b. Clinical complications.#3. Circumstances that require a need to alter treatment.This may include:a. New treatment. b. Discontinuation of current treatment due to i. Adverse consequences. ii. Acute conditions. iii. Exacerbation of a chronic condition.#7. Change in Condition: Any new symptoms, abnormal findings, or adverse reactions must be documented immediately. A comprehensive assessment, including completion of the eINTERACT Change in Condition assessment, will be initiated to identify, evaluate and communicate the resident's status. Provider notification must follow the established escalation process below:Primary Provider: [on-call service] system1st contact: [xxx-xxx-xxx]2nd contact: [xxx-xxx-xxx]If no provider is reached and the concern is urgent or time sensitive, staff must contact:[on-call service] system NP direct line [xxx-xxx-xxx]If the conditions remain urgent or time sensitive and provider contact cannot be established, staff must contact:[local hospital] - [xxx-xxx-xxx]Manager On Call to collaboratively establish a plan of careFamily or resident representative notification must occur as indicated, and all assessments, notifications, interventions, and follow up actions must be clearly documented in the medical record. R46 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, obstructive sleep apnea, morbidly obese due to excess calories, cardiomegaly, atherosclerotic heart disease with atherosclerosis of arteries of extremities with intermittent claudication of bilateral legs, essential hypertension, stage 3 kidney disease, type 2 diabetes mellitus, and fracture of the lower end of right femur. R46's Minimum Data Set (MDS) assessment, dated 10/15/25, identified R46 had impairment on one lower side and was dependent on assistance for bed mobility, taking on and off footwear, rolling left to right, sitting to lying, chair to bed, toileting, and for transfers. MDS documented R46's Brief Interview for Mental Status (BIMS) score was 13/15, which indicated R46 had intact cognition. Surveyor reviewed R46's ADL (Activities of Daily Living) care plan which indicated:-Bed Mobility: The resident is extensive assistance of 2.-Transfer: The resident requires mechanical Hoyer lift with 2 staff assist for transfers.-PT/OT evaluation and treatment as per provider orders. Surveyor reviewed R46's care plan which included:R46 has altered cardiovascular status related to hypertension, myocardial infarction, and hypokalemia initiated on 04/23/25:-Monitor/document/report as needed any changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight. -Monitor/document/report as needed any signs/symptoms of coronary artery disease (CAD): chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refill, color/warmth of extremities. R46's coronary artery disease care plan related to atherosclerosis, hypertension, myocardial infarction, hyperlipidemia, and stroke initiated on 04/23/25 states:-Encourage routine physical exercise. May need physical therapy (PT) consultation to set up individualized programs. Encourage walking daily. -Monitor/document/report as needed any signs/symptoms of CAD: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, and excessive sweating. R46's Peripheral Vascular Disease (PVD) care plan related to diabetes, lower extremity edema, lymphedema, and on diuretics initiated on 04/23/25 states:- Encourage residents to change position frequently, not sitting in one position for long periods of time. -Give medications for improved blood flow or anticoagulants as ordered. R46's chronic obstructive Pulmonary Disorder (COPD) and use of continuous positive air pressure (CPAP) machine care plan, initiated on 08/05/25, states:-Monitor for difficulty breathing (Dyspnea) on exertion. Remind resident [R46] not to push beyond endurance. -Monitor/document/report as needed any signs and symptoms of respiratory infection: Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (dyspnea), increased coughing and wheezing. -Head of bed elevated to alleviate shortness of breath when lying flat to decrease episodes of difficulty breathing. R46's physician order with a start date of 01/25/26:Complete Respiratory Assessment in the evening, Document under Assessment. Surveyor reviewed R46's last hospitalization history and physical (H&P) discharge note from 02/17/26-02/23/26 which states: .She presented to the emergency room with severe left quadrant pain. CT [computerized tomography-diagnostic imaging procedure using rotating x-rays and computer software to create detailed 3D cross-sectional images of soft tissues, bones, and blood vessels] imaging without abdominal pathology but with incidental right femoral vein filling defect. There was concern for possible DVT [blood clot in a deep vein] and lower extremity venous doppler ultrasound later confirmed extensive new DVT despite ongoing Pradaxa therapy. She was admitted for evaluation of UTI [urinary tract infection,] renal involvement, correction of electrolyte abnormalities, and evaluation of anticoagulation need. She eventually started on a heparin drip for anticoagulation given new acute on chronic extensive DVT. Vascular surgery/cardiology were consulted for guidance on long-term anticoagulation since she developed a new DVT on Pradaxa [blood thinning medication]. It was recommended to continue dabigatran [Pradaxa] 75 mg twice daily. She was medically cleared to discharge back to facility on 02/23/26. Respiratory: normal respirations, unlabored breathing, lungs are clear to auscultation bilaterally with no crackles, wheezes, or rhonchi. Labs/Diagnostics: Imaging: CT of abdomen and pelvis with contrast only. Findings: Limited exam due to motion artifacts. Questionable filling defect of the right common femoral vein cannot exclude underlying thrombus. Recommend venous doppler [non-invasive painless imaging test used to visualize veins and evaluate blood flow] study of the bilateral lower extremities. R46's progress notes include: .On 03/02/26 at 9:00 AM, Resident complained of abdominal pain, inability to have bowel movement, and shortness of breath. Resident continued to yell out. Writer went in. Bowel sounds present x4. Oxygen saturation is 95% on room air. Respirations even and unlabored, no signs of acute respiratory distress observed, Will continue to monitor.-On 3/3/26 at 10:09 AM, Change of Condition-Note Text: Resident complains of Shortness of Breath (SOB) and experienced coughing episode. Oxygen was 82% on room air. Resident placed on 2L oxygen via nasal cannula. Oxygen improved to 90%. VS: BP 135/68, respirations 20, Pulse 106, temp 98.0. Resident appeared anxious during episode but remained responsive. Writer remained with resident and assisted with slow, deep breathing exercises. Resident gradually calmed, coughing subsided, and breathing became more controlled. Resident resting comfortably. No further concerns at this time. Will continue to monitor respiratory status closely and report any changes. -On 3/3/26 at 11:11 AM, Communication - with Resident Note Text: Writer went to resident's room to assist her with insurance claim documents. Resident stated she wasn't feeling well and does not want assistance right now. Writer offered assistance tomorrow, and the resident stated she may not be feeling better tomorrow. On 04/06/26 at 9:37 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G and asked how R46 presented on 03/03/26. LPN G reported on 03/03/26, R46 was complaining of shortness of breath (SOB) and having hard time catching breath. LPN G assessed vitals which showed R46's oxygen saturation was in the 80s on room air, LPN G quickly applied O2 at 2L to increase resident's oxygen intake. LPN G was following a standing order which states, Apply oxygen at 2L [liters] NC [nasal cannula] and if ineffective, notify the provider on call. Surveyor asked LPN G if LPN G notified a physician on call with R46's oxygen changes and complaint of SOB. LPN G reported that LPN G did not notify provider as LPN G thought the standing orders were enough. Surveyor asked LPN G to review the October 2025 staff meeting notes where LPN G was educated on Change in Condition which include: Any new symptoms, abnormal findings, or adverse reactions must be documented immediately, with physician and family notification and follow-up clearly documented. LPN G reported to Surveyor LPN G should have notified provider on call with changes. After 03/03/26, LPN G went on vacation, so LPN G did not know any other information pertaining to R46's care. Surveyor reviewed R46's Treatment Administration Record (TAR), which was missing the 03/03/26 respiratory assessment. Surveyor could not find a comprehensive assessment performed for R46 with the new onset of shortness of breath and complaints of not being able to breathe. Progress note review continued:-On 03/05/26 at 3:11 PM, Administration notes: Resident complaints of SOB and refusing to take CPAP off. O2 is 98% with 2L via CPAP.-On 03/05/26 at 6:30 PM, Resident has been getting aggressive with staff. She begins to yell when things are not done exactly her way. The nurse attempted to administer an as needed medication, and resident started screaming because the CPAP machine was asked to be taken off to avoid aspiration. The nurse left the room and attempted to administer the medication again and she refused to listen to any reason.-On 3/5/2026 at 11:23 PM, Weekly Progress Note: Note Text: Resident has been obsessed with having CPAP with O2 2L on continuously since 3/4/26 in the AM. Resident frequently yelling at staff for all and any needs. Resident demands that her door be left open at all times d/t [due to] possible choking hazards. Resident states this is a rule which is in place. Resident complained of a dry sore mouth this shift, possibly due to wearing CPAP 24/7. Mouthwash and toothettes offered. Will continue to monitor resident. On 04/06/26 at 11:45 AM, Surveyor interviewed LPN F and asked LPN F to review the 03/05/26 progress notes and explain how R46 presented to LPN F. LPN F reported R46 was complaining of SOB and having a hard time breathing. Surveyor asked LPN F if this was out of the ordinary for R46. LPN F reported typically yes but had been going on since 03/03/26. Surveyor asked LPN F if LPN F needed to contact provider to notify of R46's increase in difficulty breathing and using CPAP all day. LPN F stated, Since resident was having hard time breathing since 03/03/26, I thought we were just monitoring until further notice or further decline. On 04/06/26 at 12:50 PM, Surveyor interviewed Registered Nurse (RN) AA and asked RN AA to review progress note with Surveyor. Surveyor read off the progress note and asked RN AA if RN AA should have notified physician, who was on call, of R46's new onset use of CPAP machine all day instead of just at night and the anxiousness pertaining to R46 not being able to breathe without CPAP. RN AA reported R46 is always anxious about something daily. RN AA stated, Yes, the new onset use of the CPAP is not typically [R46's] baseline and only uses the CPAP at night but that RN AA felt R46's new anxiousness was a behavior thing as RN AA completed a respiratory assessment of R46 that night and O2 was fine. Surveyor asked RN AA what R46's physician orders were pertaining to O2 usage. RN AA reported R46 did not have a physician order for the O2, but RN AA knows R46's oxygen level should be above 91% on room air and if not, then facility can use standing orders to adjust oxygen as needed. RN AA felt R46's anxiousness did not appear to be in relation to R46's respiratory status. Progress note review continued:-On 3/6/26 at 10:59 AM, Behavior Note: Resident was asked if she would like to get up and attend church services. Resident declined, stating she could not remove her CPAP because she would not be able to breathe without it. Staff assessed resident while on room air; resident showed no signs or symptoms of shortness of breath. Respirations were even and unlabored, and lung sounds were clear bilaterally. Resident continued to insist she needed to keep the CPAP on and declined removing it. No respiratory distress noted during assessment. Resident remained calm and comfortable. No further concerns at this time.-On 03/07/26 at 12:58 PM, Resident refused to get out of bed today.-On 03/08/26 at 4:13 PM, Resident refused to get out of bed today. Surveyor could not find evidence of any comprehensive assessments being completed for R46 and her refusals of getting out of bed. On 03/24/26 at 2:20 PM, Surveyor interviewed Certified Nursing Assistant (CNA) Q and asked if R46 was receiving PT services before going to the hospital. CNA Q reported to Surveyor R46 received PT services but also has some home exercises R46 is supposed to complete on own in room. R46 can be non-compliant and refuse to get out of bed or do exercises PT asks of R46. R46 becomes fixated on certain things and refuses if R46 does not want to do something. Progress note review continued:-On 03/09/26 at 6:31 AM, Respiratory assessment note: CPAP assessed. No SOB noted. Pulse 80, respirations 18, 96% on room air, lung sounds clear, CPAP cleaned and inspected. No acute respiratory concerns noted. Time spent 15 minutes.-On 3/9/26 at 11:56 AM, Alert Note-Resident has a cough with no secretions noted. Resident is currently using her CPAP machine during the day. She says she is having SOB without the CPAP being used. Otherwise, resident is at 97% on room air and 100% with the CPAP machine on. No fever noted this shift. Resident prefers to eat meals in her room. -On 3/9/26 at 11:12 PM, Behavior Note: Writer started shift at 6:00 PM. Resident has been yelling/screaming out from room all pm shift. Resident yelling for nurse, yelling for some aides by name, yelling for help, and CNAs in room frequently. Resident does not want her door closed; other residents and visitors verbalize that they are annoyed with this behavior due to being able to hear everything clearly. Writer attempted to rationalize with resident but was unsuccessful. Resident is not a good listener; resident just yells and is anxious and extremely excited. Staff and writers will continue to redirect. Staff continue to attempt to meet resident's needs to the best of their ability.-On 03/10/26 at 7:35 AM, Administration notes: Resident insists on wearing CPAP at all times.-On 03/10/26 at 1:10 PM, Resident has refused to get up for meals and only take liquids. Resident is refusing to take CPAP off this day. Resident refusing to get up from bed. Refusing solid foods and only taking liquids.-On 3/10/26 at 6:42 PM, Alert Note: 10 min trial on room air. Resident sats from 98 to 92%. Resident is very anxious and able to be calmed with 1:1 by staff. Resident immediately demanded to have C-pap replaced after trial.-On 03/11/26 at 11:44 AM, Resident refused to get up out of bed to have completed weight.-On 3/11/26 at 3:33 PM, General Note: NP visit with resident related to SOB. NP orders: schedule CTA as soon as possible for SOB related to DVT. R46's physician order 03/11/26:Please schedule CTA of chest as soon as able for shortness of breath, DVT, bed bound at this time, 1 view chest x-ray. The fax cover sheet to Radiology Scheduling states, Please call STAT to schedule. The order summary states, CTA of chest STAT to r/o DVT with experienced SOB. STAT for rule out DVT. A progress note on 03/11/26 at 4:15 PM states, Late entry: Called to schedule chest CTA ASAP. Radiology stated to send order and they would call to schedule. She said to write STAT on it so they could schedule for ASAP. Per nursing, it does not have to be today, so order was sent to radiology. On 04/06/26 at 9:17 AM, Surveyor interviewed Nurse Practitioner (NP) BB and asked when the first time NP BB was notified about R46's shortness of breath. NP BB reported to Surveyor NP BB was on vacation between 03/2/26-03/6/26. Facility was to notify the on-call provider covering for NP BB until NP BB was back from vacation. NP BB reported NP BB then came to facility Monday 03/09/26 or 03/10/26 but thinks it was on Monday 03/09/26. NP BB entered resident room and completed assessment. NP BB had concerns with possible PE so ordered computed tomography angiography [CTA] [non-invasive, quick imaging test (often 5-30 minutes) combining CT scans with iodine contrast dye to create detailed 3D images of blood vessels] as soon as possible. Surveyor asked NP BB to clarify what As soon as possible means versus STAT order. NP BB reported resident R46 was assessed as stable, didn't need ER, and the order could go through the clinic. While NP BB was assessing R46, oxygen was removed so we could communicate and O2 was off for a total of 10-15 mins where resident R46 was assessed to be ok at that time, but NP BB had concerns for potential PE, so NP BB ordered CTA to be completed as soon as possible. Surveyor asked NP BB if NP BB's expectation was the nursing staff should have reported the SOB, with new oxygen use, and continuous use of the CPAP machine throughout the days of R46's complaints prior to NP BB being able to assess resident when back from vacation. NP BB reported staff should have notified provider of this new onset of SOB right away on 03/03/26. Surveyor asked NP BB if NP BB thought staff should have considered this to be potential PE with resident's history of DVT and anti-coagulation therapy. NP BB stated, I guess. My thought was potential PE due to resident being on anticoagulant therapy and history of PE and DVTs. Progress note review continued:-On 3/12/26 at 2:05 PM, Appointment: Resident has an appt for chest CTA today at 3 pm.-On 03/12/26 at 2:41 PM, Resident had chest x-ray at facility.-On 03/12/26 at 2:42 PM, Resident out to hospital to have a CTA at this time.-On 3/12/26 at 4:09 PM, General Note: Radiology calls to report preliminary CTA report shows what appears to be a significant Pulmonary Embolism (PE). Resident will be transferred to the emergency room (ER) for evaluation and treatment. Surveyor reviewed resident's chest x-ray dated 03/12/26 which states: chest x-ray 1 view, short of breath, patient had difficult time taking breath due to her shortness of breath. Impression: Mild cardiomegaly with increased interstitial lung markings which may reflect pulmonary vascular congestion. Mild bibasilar atelectasis [partial collapse or deflation of the small sacs (alveoli) in the lower sections of both lungs]. Progress note review continued:-On 3/13/26 at 7:26 AM, General Note: Writer spoke with ER RN. Resident was transferred to main hospital at 7:00 AM, this morning related to large PE upper and lower left lung fields. Plan is for removal of PE. Resident was transferred on a heparin drip and left with personal CPAP machine.-On 03/14/26-03/17/26, Resident hospitalized .-On 03/17/26, Discharge notes from hospital reported resident initially was started on heparin infusion and evaluated by interventional radiology. Lower extremity duplex ultrasound demonstrated DVT in the right lower extremity. The patient subsequently underwent successful pulmonary artery thrombectomy but no lower extremity venous thrombectomy at this time on 03/13/26. She remained hemodynamically stable during the remainder of the hospitalization. She was transitioned to apixaban (anticoagulation) therapy (10mg twice a day for 7 days followed by 5mg twice a day) for treatment of DVT/PE.-On 03/17/26 at 11:24 AM, admission notes: Reason for Hospital stay: Pulmonary EmbolismFull set of vitals: BP 147/68, O2 96% on 2L NC, R 20, HR 75, Temp 97.5. Resident was readmitted to the facility on [DATE] after extensive care in hospital with new diagnoses including in part, Acute respiratory failure, unspecified with hypoxia or hypercapnia, embolism and thrombosis of arteries of lower extremities, and acute embolism and thrombosis of unspecified deep veins of right lower extremity. R46's physician order 03/18/26: O2 at 1LPM continuous for pulmonary embolism, wean oxygen to keep stats 90% and above Surveyor reviewed R46's respiratory assessments and found in resident's medical record that on 03/03/26, 03/08/26, 03/11/26, 03/20/26-03/22/26, 03/25/26, 03/29/26-03/31/26, and 04/04/26-04/05/26 R46 did not receive respiratory assessments as per physician orders. Facility did not perform comprehensive assessments for R46 after every episode of complaints of difficulty breathing and shortness of breath. On 04/06/26 at 1:36 PM, Surveyor interviewed DON B and asked to review resident's respiratory assessments from 03/02/26- present taking particular attention to 03/03/26, 03/08/26, 03/11/26, 03/20/26, 03/21/26, 03/22/26, 03/25/26, 03/29/26, 03/30/26, 03/31/26, 04/04/26, and 04/05/26. Surveyor asked DON B if R46 received respiratory assessment on those dates. DON B reported R46 did not. DON B stated, My expectation is staff follows physician orders and completes respiratory assessments. On 03/23/2026 at 8:52 AM, Surveyor interviewed R46. R46 reported she has been at facility a while and recently went to hospital but likes the facility. R46 reported R46 is upset with facility for not getting R46 up and out of bed, then R46 developed blood clots. On 03/25/26 at 10:26 AM, Surveyor interviewed R46 again as R46 wanted to divulge more information with R46's recent hospitalization. R46 reported one day about 3 weeks ago, R46 started to have SOB and couldn't breathe. R46 yelled out to any staff who could hear and eventually staff came in and applied oxygen as R46's oxygen had dropped low. R46 reported that it was super hard to breathe for a while. R46 reported that R46 could not even eat food without feeling like R46 could not breathe. R46 took it upon herself to only drink liquids as it was too hard for R46 to eat and have fullness when R46 could not breathe. R46 reported R46 laid in bed for 3 weeks before facility tried figuring out what was going on. One day an x-ray tech came in and they found a clot in R46's leg and immediately within the next hour sent R46 out to the hospital where the surgeon was waiting for R46, so they could remove the clots which had busted loose and went to R46's lungs. R46 reported R46 has been on a blood thinner for a long time. On 03/25/26 at 12:58 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B about R46's hospitalization on 03/12/26 and the events leading up to R46 having clots and a PE as Surveyor noticed in progress notes that R46 was starting to have trouble with SOB on 03/02/26. On 03/03/26, R46 became SOB, and the nurse applied oxygen via nasal cannula. DON B reported DON B was unaware R46 started having breathing concerns on 03/02/26. DON B reported R46 is a difficult resident who has a lot of co-morbidities. DON B reported DON B did not know that the nurse had applied oxygen on 03/03/26 until now. Surveyor asked DON B if it was her expectation for nursing staff to notify the doctor once R46 became SOB and received oxygen supplementation. DON B reported the facility has standing orders which allow nursing staff to apply oxygen at 2L NC and if ineffective, notify the provider on call. Surveyor asked DON B if staff are to follow R46's individualized care plan stating if R46 develops SOB and/or cough notify the provider right away per R46's care plan for R46's diagnosis of altered cardiovascular status. DON B reported expectation is the nurse should have notified provider on call of the SOB concern, O2 change, and the constant use of the CPAP Machine. DON B reported that respiratory assessments were being done by the Respiratory Therapist for the use of CPAP but not for the new oxygen needed via nasal cannula. Surveyor requested provider notification on 03/03/26 with R46's condition change in needing oxygen supplementation while complaining of SOB. DON B reported to Surveyor that DON B would gather provider notification. On 03/25/26 at 1:10 PM, Surveyor spoke with DON B again. DON B reported to Surveyor the provider was not notified on 03/03/26 with the condition change. Surveyor asked DON B why R46 was not assessed more thoroughly or provider notified between 03/03/26-03/11/26. DON B reported expectation would have been nursing to report the continual usage of CPAP and oxygen 2 L NC with the complaint of SOB. Surveyor reported to DON B that Surveyor was reviewing R46's progress notes and reviewed R46 did not receive the chest x-ray as ordered by provider to complete STAT (as soon as possible.) DON B reported DON B did not realize it was delayed. Surveyor reviewed the progress note from 03/11/26 with DON B, and DON B confirmed that nursing should have never stated, Per nursing, it does not have to be today, so order was sent to radiology. DON B reported when provider ordered STAT, which meant provider needed it completed as soon as possible. On 04/06/26 at 11:58 AM, Surveyor interviewed DON B and asked DON B about why LPN G did not notify physicians on call. DON B reported to Surveyor LPN G did in fact try to notify on call provider but could not get through on the service line. DON B reported Nurse Manager C had sent an overall general email to the on-call provider service that the facility was unable to reach a provider on call for residents with significant change in condition. Surveyor requested email documentation. DON B reported that DON B will print the documentation right away. On 04/06/26 at 12:36 PM, Surveyor interviewed DON B again and asked DON B about the on-call provider notification process. DON B reported LPN G did in fact try to call provider on call on 03/03/26 but LPN G could not get hold of anyone, and LPN G did not document in R46's medical record LPN G attempted to contact provider. Surveyor asked DON B what the process is in case a provider on-call does not answer. DON B reported DON B is unsure. Clinical Coordinator M was also present and stated, personally I feel like staff should call the local emergency room (ER) for further direction. Surveyor asked DON B and Clinical Coordinator M if there is a more detailed process or policy in place to replace the on-call provider with someone else to notify such as the Medical Director. DON B reported the Medical Director is also with the [on-call service] system. Nurse Manager C reported to Surveyor that Clinical Coordinator M will revamp the policy on when and how to call the on-call with a backup option such as the local ER. DON B reported to Surveyor nursing staff was having issues with other provider notification concerns for the whole week of 03/02/26-03/06/26. DON B reported Nurse Manager C has an email to verify Nurse Manager C reached out to the [on-call service] system to try to fix the concern of not receiving answers from on-call providers. Surveyor asked what the facility did in the meantime to report changes in condition to a provider. DON B reported there were no other interventions put into place for any residents' change of conditions until NP BB came back from vacation. On 04/06/26 at 1:26 PM, Surveyor interviewed DON B again and asked DON B what standards of practice are used as a resource in providing care in the facility. DON B reported DON B is unsure exactly what Standards of Practice is used but will find out right away. Surveyor asked DON B if there was any education to all the nursing staff on notification to provider with change of condition, process in place for actions to be taken if unable to contact provider, care plan updates as new issues arise, processes and interventions for change in [TRUN

Based on observation, interview, and record review, the facility failed to prepare and distribute food under sanitary conditions. This has the ability to affect all 38 of the facility's residents.Staff were observed to not complete hand hygiene during food preparation and service or maintain sanitary storage.Food was not labeled with identifying information. Open food is not labeled with open or use by dates and no manufacturer's label with use by date. Food was not stored in refrigerator with a cover. A scoop was found in food container, increasing food's risk for contamination.Safe food temperatures for food service were not ensured.Food was not cooled in a way to prevent contamination.Staff washing dishes contaminated their uniform with dirty water sprayed off dishes and then returned to the duty of food preparation and service with the same uniform, no barrier.This is evidenced by:Example 1 The facility policy, titled Hand Washing, dated 1/26/26, states: Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures. Procedure:Clean hands and exposed portions of arms (or surrogate prosthetic devices) immediately begore engaging in food preparation including working with exposed food.During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing task.Before donning (putting on) on gloves to work.The facility policy, titled Food Preparation and Service, dated 2001, states: Food Service Distribution4. Food and nutrition services staff. wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays.The Wisconsin Food Code, dated 2024, states: .food workers must wash their hands thoroughly before putting on gloves and each time gloves are changed. Gloves are not a replacement for handwashing; they are a barrier, and hands must be clean to prevent contamination when gloves fail or are replaced.Gloves should be changed when switching tasks to prevent cross contamination.On 3/23/26 at 8:54 AM, Surveyor observed Dietary Aide (DA) N leave the kitchen. DA N came back into the kitchen and started putting juice trays back into the refrigerator. DA N did not wash hands when she entered the kitchen or before handling the juice.On 3/23/26 at 11:31AM, Surveyor observed DA N getting buckets of ice and placing them on the tray by steamer table. DA N then went to walk-in cooler and took already prepared juices and milks and placed them on same cart. DA N then took a thermometer to take temperatures of the beverages. No hand hygiene prior to taking temperatures.On 3/23/26 at 11:56 AM, Surveyor observed Dietary Manager (DM) I entered kitchen and walked around to observe all staff. DM I did not wash hands upon entering kitchen.On 3/23/26 at 11:58 AM, Surveyor observed DM I observe the steam tray still in oven and asked about it. [NAME] L stated what it was. DM I, with her contaminated hands, took potholders and took meat out of the oven and handed it to [NAME] L to put on the steam table. On 3/23/26 at 12:09PM, Surveyor observed DA K wash hands and set up in front of the steam table preparing to set up trays, while DA N and [NAME] O stood behind waiting for the task to carry trays out to dining room. DA N and [NAME] O did not wash hands prior to starting task. Surveyor was standing right next to the hand washing sink and could easily identify when it was used, even when concentrating on steam table and task in front of Surveyor. On 3/23/26 at 12:36 PM, Surveyor observed DA N return to the kitchen after lunch service to start cleaning. DA N did not wash hands entering the kitchen or before starting task. DA N took leftover beverages back to the cooler, put empty containers in the dish room, and covered leftover desserts with saran wrap with her contaminated hands.On 3/23/26 at 12:36 PM, Surveyor observed DM I also enter the kitchen and go straight to the rack with food storage containers. DM I did not wash her hands when she entered the kitchen, resulting in a contaminated storage container left out by food.On 3/23/26 at 1:21 PM, Surveyor observed DA N with gloves on cleaning and sanitizing tables in dining room. At 1:23 PM, DA N brought her detergent bucket back into the kitchen, did not take off her gloves or wash her hands. With same contaminated gloves she went to clean side of the dish room, picked up a tray of glasses, and brought them out of the clean dish room into the kitchen storage rack On 3/23/26 at 1:25 PM, Surveyor observed Registered Dietician (RD) J come into the kitchen and stop DA N from taking any more clean dishes and instructed DA N to take off her gloves and wash her hands. RD J stated RD J saw what DA N did and just went over to reeducate her. RD J stated she told DA N that hands were to be washed when you start a new task, take gloves off and anytime you touch something dirty. The gloves are a barrier not replacement for washing hands, take off gloves and wash your hands. Example 2 Facility did not provider a policy related to food storage.On 3/23/26 at 8:18 AM, Surveyor completed initial tour inspection with DM I. During tour the following was found:-4 Large bags of classic noodles, rotini noodles, corkscrew noodles, elbow noodles were open, twisted shut without a manufacturer's label, open date, or use by date. Surveyor provided DM I an opportunity to show Surveyor where the date and label were.-A scoop was found in the large flour bin.-An open gallon of milk in cooler without open date, expiration date unreadable. DM I dated the cap with today's date (3/23/26) while Surveyor was standing there, stating DA N opened it. -2 of 3 bottles of BBQ sauce were undated. One bottle was labeled 2/3/26. DM I looked at bottle for visible manufacturer's dates. DM I was unable to find a date. The unlabeled sauces were in the front. DM I wrote the date 2/3/26 on the other two bottles. Surveyor told DM I she was not expected to label the items immediately just because Surveyor found they were undated, especially if she wasn't sure of date.-3 large bottles of syrup were undated. DM I stated they just came in last Friday. This time DM I did not label the product in front of Surveyor. On 3/23/26 at 1:25 PM, Registered Dietician (RD) J came to surveyor with the [NAME] Brother invoices and stated the syrup came in on 2/3/26 and the BBQ sauce came in 2/27/26. On 3/23/26 at 2:56 PM, Surveyor observed a stainless-steel bowl with 7 peeled English cucumbers. Cucumbers were not covered.On 3/23/26 at 8:22 AM, Surveyor interviewed DM I, who stated all things are supposed to be labeled when received, when opened, and clearly marked. On 3/23/26 at 2:57 PM, Surveyor interviewed RD J who stated all food should be stored and handled to prevent food contamination. Surveyor asked what that meant. RD J stated at the right temperature, in a clean, labeled container with a cover.Example 3 The facility policy, titled Food Preparation and Service, dated 2001, states: Food Preparation, cooking, and Holding Time/Temperatures1. The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness.3. The longer food remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, [PHF] (potentially hazardous food) must be maintained below 41 F or above 135 F.Rapid Cooling1. Potentially hazardous foods are cooled rapidly. This is defined as cooling from 135 to 70 within 2 hours and then to a temperature of 41 F within the next 4 hour. The total cooling time between 135 F and 41 F is not to exceed 6 hours.The facility policy titled, Use of Leftovers, dated 1/16/26, states: Excess leftovers should be avoided. Leftovers will be properly handled and used or discarded as appropriate. Leftover foods will not be used for pureed diets.2. Leftovers will be covered, labeled and dated; then stored appropriately (refrigerated or frozen if necessary) immediately after the end of the meal service. 3. Leftovers must be cooled to 70 F within 2 hours and then to 41 F within another 4 hours.4. Leftovers that have not been properly stored will be discarded. (When in doubt, throw it out.)5. Food that is leftover will be handled as noted above and may be used as follows.a. Leftovers should be held for a maximum of 7 days at 41 degrees or less or discarded. Day 1 is the original preparation day. Day 7 is the use by date. (According to the 2022 Federal Food Code.)On 3/23/26 at 8:18 AM, Surveyor observed open browning lettuce in the cooler, dated 3/13/26. Per policy, leftover food dated 3/17/26 reaches day 7 on 3/23/26, and food dated prior to 3/17/26 should be discarded.On 3/23/26 at 12:36 PM, Surveyor observed DM I also enter the kitchen and go straight to the rack to pull a 2-quart tall food storage container with a green lid and place it by steam table. DM I did not wash her hands when she entered the kitchen, resulting in a contaminated storage container left out by food.On 3/23/26 at 12:53 PM, Surveyor observed [NAME] L take food off the steamer tray. [NAME] L stated I am going to throw most of it away; there is not enough to keep. [NAME] L stated she will keep the gravy. Gravy was pulled and placed on the counter in same steamer pan. [NAME] L did not take temperature of gravy but left it sitting on table.On 3/23/26 at 12:58 PM, Surveyor observed [NAME] L place leftover gravy in the contaminated tall 2-quart food storage container, placed by steam table at 12:36 PM by DM I. Container was more than 1/2 full and cover was left off.On 3/23/26 at 2:48 PM, Surveyor interviewed [NAME] L who stated [NAME] L takes food off the steamer and lets it sit out for 1/2 hr.- 1 hr., to cool, checking them within the hour. [NAME] L stated if it is still warm, I leave them out. [NAME] L stated I don't know what temp they are supposed to be at for sure, just want them cooler. Surveyor asked [NAME] L if there was a log where they recorded temperatures of cooling foods. [NAME] L stated there is no log that [NAME] L is aware of. [NAME] L stated [NAME] L does not recheck once it is in the refrigerator.On 3/23/26 at 2:56 PM, Survey observed DM I check the temperature of the gravy container placed in the refrigerator. DM I was uncertain the time the gravy was put in the cooler. Surveyor observed it taken off the steam table and placed in food storage container at 12:58 PM, 1 hour and 58 minutes ago. DM I took cover off thermometer, wiped it with alcohol pad, and waved it in the air for a few minutes. When thermometer read 55 F it was placed in the gravy and read 120 F. DM I stirred the gravy with thermometer. The gravy temperature went down but came back up to 120 F. DM I stated DM I knows it is supposed to cool down to a certain temperature in a certain timeframe, but I will need to look.On 3/23/26 at 3:42 PM, Surveyor interviewed RD J and DM I regarding process on cooling down. RD J stated food is put in a container and put in the fridge. Surveyor asked if there was a time frame and goal temperature. DM I stated the temperature should be between 70-135 in 2hrs. Surveyor asked if they monitor the temperatures while it cools. DM I stated yeah we go back. RD J stated we don't have a log to track. It is something we will be fixing. On 3/24/26 at 10:42 AM, Surveyor observed with RD J, the chicken gravy from 3/23/26 still in the cooler. RD J did not make any comment, took container and threw it away.Example 4The facility policy, titled Food Preparation and Service, dated 2001, states:Food Service Distribution1. Proper hot and cold temperatures are maintained during food service. Foods that are held in the temperature danger zone are discarded after 4 hours. 2. The temperatures of food held in steam tables are monitored throughout the meal by food and nutrition staff.4. Food and nutrition services staff. wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays.On 3/23/26 at 11:30 AM, Surveyor entered the kitchen for follow up. [NAME] L was putting the steamer tray in place; no food placed on tray yet. Once together, [NAME] L started putting steam pans in place. DA N was setting up the condiment/beverage cart. Trays of covered coffee cups and juice cups were already on the tray. DA N was pouring milk. On 3/23/26 at 11:34 AM, Surveyor observed DA N take temperatures of the juices. On 3/23/26 at 11:42 AM, Surveyor observed [NAME] L start taking temperatures of food in steamer tray. [NAME] L had temperature log on table on right, and pile of alcohol pads. Surveyor observed no temperatures recorded for lunch yet. The following food items' temperatures were taken by [NAME] L. While Surveyor observed, [NAME] L vocalized the temperatures. The outcome was: Chicken strips in gravy (182 F), mashed potatoes (190 F), cauliflower (192 F), and ground meat (177 F). All were within range. Gravy temperature was 170 F. Log stated gravy should be >175 F; this was not reheated. Cut up chicken's temperature was 156 F. [NAME] L took steamer pan of meat and placed it back in oven. Surveyor observed two brown bowls with cover and no label in a pan, sitting in the steamer. [NAME] L did not take temperature of food in brown bowls or pan of liquid with hamburgers floating. [NAME] L stated the hamburgers are for a couple residents that don't like chicken.On 3/23/26 at 11:48 AM, Surveyor observed DA N writing temperatures down in the log. Coffee was 70 and juice was 57 F. Per the log coffee should be 170 F and juice should be <41 F. Surveyor interviewed DA N who stated I write down temperatures for juice, all the time. Surveyor asked what do you do if it is out of range. DA N stated I don't know the range.On 3/23/26 at 11:58 AM, Surveyor observed DM I ask what the meat in the oven was for. [NAME] L stated that it is my cut meat, it wasn't to temperature. Surveyor observed DM I take meat out of oven and ask [NAME] L if she had room for it and DM I handed it to [NAME] L. [NAME] L placed on steamer tray and did not take a temperature.On 3/23/26 at 12:00 PM, Surveyor observed [NAME] L serve the two bowls. [NAME] L stated this is pureed meat and vegetable. [NAME] L did not take temperature of pureed food at beginning or just before serving.On 3/23/26 at 12:29 PM, Surveyor observed the lunch food service was completed. Surveyor observed entire process. Gravy that was not within temperature log requirements was used on most of the resident's plates. Between 11:42 AM and 12:53 PM, Surveyor did not observe food temperatures were taken again, not during service, nor when taken off the steamer table. Surveyor interviewed DM I and asked how they ensure the temperatures hold. CM I stated the cooks write the temperature down and place it on the steamer table right away.On 3/23/26 at 12:39 PM, Surveyor interviewed DA K who stated juice and milk should be approximately 40 F and coffee should be 170 F. Surveyor asked DA K what you do when out of range. DA K stated I don't know that has never happened. DA K stated he would have to ask the manager.On 3/23/26 at 1:00 PM, Surveyor reviewed the food service temperature log. There were no temperatures documented for substitute meat (hamburger), ground meat, pureed meat, or pureed vegetable.On 3/26/26 at 1:01 PM, Surveyor interviewed [NAME] L about temperature taking and log. [NAME] L stated she takes the temperature just before serving only and it goes in the log. [NAME] L noted that substitute meat, ground meat, pureed meat and pureed vegetable were blank. [NAME] L stated, Oh I didn't do that. I was in a hurry. [NAME] L looked at ceiling for a minute and then wrote 170 for both substitute and ground meat. Note: above ground meat was 177 F and substitute meat (hamburgers) did not have a temperature taken by [NAME] L during this food service event.On 3/23/26 at 3:42 PM, Surveyor interviewed DM I and RD J about food temperatures. DM I stated they go back and check temperatures. RD J stated we do not have a log to track. RD J stated it is something we will be fixing. Surveyor told RD about observation with temperature log. RD J stated expectation is that everything is temped prior to service, stays on the steamer table until lunch is over, and temperatures are written down in the log when the food temperature is taken.Example 5On 3/23/26 at 12:36 PM, Surveyor observed DA K doing dishes. DA K separated and sprayed dirty dishes, getting water and debris on the front of DA K's scrubs. DA K did not wear an apron. Dirty water was spraying and contaminating his scrubs.On 3/23/26 at 1:16 PM, Surveyor interviewed DA K who stated they do not have or need to wear aprons while doing dishes. DA K stated he could feel the water spraying up when doing dishes but if he held it just right it was not a lot. DA K stated he was not done for the day after he did dishes. Surveyor asked what other tasks DA K has to do today. DA K stated DA K will get the snack cart ready, go on the floor, and serve snack to residents.On 3/23/26 at 2:20 PM, Surveyor observed DA K delivering snacks to residents on unit, wearing same contaminated scrubs, no cover up or apron. On 3/24/25 at 11:02 AM, Surveyor interviewed RD J who stated, aprons, I hadn't thought of that. I suppose if they are getting wet. I'll have to look into that.

Based on observation, interview and record review, the facility did not provide care consistent with professional standards of practice to promote the healing of existing pressure injuries (including prevention of infection to the extent possible) and prevent development of additional pressure injuries for 1 resident (R26) of 5 residents reviewed for pressure injuries in a sample of 12 residentsThe facility did not provide repositioning at a minimum of every 2 hours for R26, or document refusals by R26 to be repositioned at a minimum of every 2 hours, which potentially led to development and exacerbation of a pressure injury to R26's coccyx/sacral (lower back/tailbone) area. Findings include:The facility policy, titled Policy and Procedure for The Prevention and Treatment of Skin Breakdown, not dated, states in part: It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure injuries; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care.for a resident to exercise his or her right to appropriately make informed decisions about care and treatment or to refuse treatment, the facility and the resident will discuss the resident's condition, treatment options, expected outcomes, and consequences of refusing treatment. The facility .will offer relevant alternatives.this will be documented in the resident's medical record.a Refusal of Skin Care Interventions Risk and Benefit Form can be utilized for refusal of care. The facility policy, titled Repositioning, not dated, states in part: Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing.a turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated. R26 was admitted to the facility on [DATE] with diagnoses which include metabolic encephalopathy, nondisplaced fracture of right ulna with routine healing, muscle weakness, cognitive communication deficit and protein-calorie malnutrition. R26 has a Brief Interview for Mental Status (BIMS) score of 12/15, moderately impaired cognition. R26 makes own health care decisions. R26's care plan, dated 01/21/2026, with a target date of 04/28/2026, states in part: The resident has an ADL (activities of daily living) self-care performance deficit related to gait difficulty, generalized weakness. Interventions include.Bed Mobility: extensive assist of one.R26's care plan, dated 01/21/2026, with a target date of 04/28/2026, states in part: Skin: The resident has potential for impairment to skin integrity related to gait difficulty, history of falls, radius and ulna fracture, refusal of repositioning/offloading out of bed. Interventions include alternating air mattress, daily skin inspection and report abnormalities to nurse, repositioning every 2 hours and PRN (as needed), wound care as ordered.R26's care plan, dated 03/20/2026, with a target date of 04/28/2026, states: The resident has stage 3 pressure ulcer to coccyx. Interventions include.follow facility policies/protocols for the prevention/treatment of skin breakdown.the resident needs to turn/reposition at least every 2 hours, more often as needed.On 01/21/2026, R26 had a BRADEN Scale (tool used for predicting pressure sore risk) score of 16, which indicated R26 was mildly at risk of developing a pressure injury. On 03/05/2026, R26's BRADEN score was 14, which indicated moderate risk of developing a pressure injury. Note: R26 was already identified as having a stage III pressure ulcer on coccyx on hospital Discharge summary dated [DATE]. Nursing documentation dated 01/26/2026 states, Resident [R26] noted to have an open area to the coccyx measuring 3cm x 1cm, located between the buttocks directly over the tailbone.resident placed on offloading schedule every 2 hours. Coccyx wound was unstageable (purple or maroon localized area of discoloration with intact skin). R26's care plan included intervention for repositioning every 2 hours. Nursing documentation dated 01/27/2026 states, Resident [R26] continue refusing to get out of bed and offloading her buttocks and has a poor appetite. Nursing documentation dated 02/01/2026 states, Resident [R26] declining getting out of bed for breakfast. Nursing note included R26 was educated on risk/benefit of mobility versus prolonged bedrest. R26's care plan did not include interventions for alternative options to promote offloading for R26. Weekly wound care assessments by wound care providers indicate R26 had wound progression on coccyx with measurements of 1.8cm (length) x 2.1cm (width) x 0.2cm (depth) on 02/13/2026, to 2.5cm (length) x 4.0cm (width) x 1.0cm (depth) on 03/20/2026. Physician orders dated 02/04/2026 states, Wound care to coccyx: apply calcium alginate plain to wound bed. On 02/27/2026, wound care provider was unable to debride R26's coccyx wound at facility. R26 was transferred to local emergency department (ED) for evaluation by a general surgeon for wound debridement. While in the ED, it was discovered R26 had a fever of 38 degrees Celsius (100.4 degrees Fahrenheit) and was subsequently admitted to the hospital to rule out sepsis of wound and receive intravenous antibiotic treatment. On 03/04/2026, R26 had further wound debridement by general surgeon. Wound cultures done were negative for infection. MRI (magnetic resonance imaging) done had findings compatible with ulcer and sinus tract extending into the underlying subcutaneous fat just right of midline. No indication of osteomyelitis noted per MRI. R26 was discharged back to facility on 03/04/2026 with new orders for wound care. No further antibiotics were recommended by the discharging physician. R26's discharge diagnosis included Stage 3 (full thickness tissue loss which may include tunneling and undermining) sacral ulcer with uncomplicated wound infection. R26's care plan dated 03/20/2026 includes interventions for wound care and repositioning every 2 hours, and as needed. There are no interventions for alternative options if R26 refuses to be repositioned, or to document refusals of repositioning. On 03/20/2026, physician ordered indwelling urinary catheter to be placed due to incontinence of urine impeding wound healing. To note: R26 is incontinent of both urine and bowel. On 03/23/2026 at 9:15 AM, Surveyor observed R26 sitting in wheelchair in room. Wheelchair had a pressure reducing mattress in place. R26 did not answer Surveyor's questions other than yes, in my back when asked if having discomfort due to her coccyx wound. On 03/23/2026 at 1:10 PM, R26 was in bed in supine (on back) position, head of bed in low fowlers (slight elevation). No offloading of coccyx area observed. Air circulating mattress on bed. On 03/24/2026 at 7:04 AM, Surveyor observed R26 lying supine in bed, low fowlers. No offloading of coccyx wound observed. Surveyor unable to find documentation of staff repositioning R26 in medical record. No documentation of R26 refusing repositioning noted in medical record since nursing notation on 02/04/2026. No paper record of CNA repositioning times in R26's room. On 03/24/2026 at 7:35 AM, Surveyor interviewed certified nursing assistant (CNA) D and CNA E and asked if R26 was able to reposition self in bed and both stated R26 could not. CNA D and CNA E were asked how often R26 is repositioned when in bed and both stated approximately every 2 hours, but R26 refused to be repositioned at times. Surveyor asked CNA D and CNA E how it is recorded and kept track of when R26 needs to be repositioned next. Both stated there is no record, it is offered to R26, no time frame indicated. CNA E stated R26 prefers to lie on her back while in bed. Surveyor asked CNA D and CNA E what is done when R26 refuses to change positioning, and they stated they respect R26's decision to remain in one position. CNA D and CNA E are not aware of alternatives to offload pressure on coccyx to offer R26. On 03/24/2026 at 7:04 AM, Surveyor interviewed licensed practical nurse (LPN) F, who was performing wound cares on R26 that day, and asked what interventions were in place for R26's wound. LPN F stated, Offloading, pain meds and wound care. LPN F stated R26 acquired wound while residing at facility.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R6) of 5 residents reviewed had documentation the resident and/or legal representative had been informed in advance of the risks and benefits of prescribed psychotropic medications.R6 was prescribed Escitalopram Oxalate (a psychotropic medication). The facility did not obtain written consent from R6 or R6's legal representative.Findings include:R6 was admitted on [DATE] with diagnoses including in part, hypertensive chronic kidney disease, gangrene of left leg, atherosclerosis of arteries of extremities, multiple fracture ribs, type 2 diabetes mellitus, acute pulmonary edema, and major depressive disorder, and anxiety. Surveyor reviewed R6's physician orders, which state in part, -Escitalopram Oxalate Oral Tablet 5 MG (Escitalopram Oxalate), Give 5 mg by mouth one time a day for depression. Surveyor reviewed R6's medical record and did not find an informed consent filled out for R6's depression medication Lexapro. On 03/24/26 at 12:30 PM, Surveyor interviewed Director of Nursing (DON) B and asked if facility had informed consent for R6's Escitalopram Oxalate for depression that was started on 02/19/26. DON B reported that DON B would look for informed consent. On 03/24/26 at 1:10 PM, DON B came into conference room and provided Surveyor with R6's monthly pharmacy reviews but could not provide Surveyor with informed consent for R6's Escitalopram Oxalate.On 03/24/26 at 1:22 PM, Surveyor reviewed R6's medical record and observed an informed consent completed today on 03/24/26 for R6's Escitalopram Oxalate and scanned into R6's medical record. Surveyor reviewed R6's progress notes, which stated, On 03/24/26 at 12:50 PM, Note text: Obtained verbal consent from POA, for Escitalopram. Asked him to stop in to sign forms also. Left at front desk.On 03/25/26 at 9:09 AM, Surveyor interviewed Regional DON P since DON B was not available and asked Regional DON P the process for informed consents when starting psychotropic medications and why R6's informed consent was missed for Escitalopram Oxalate. Regional DON P reported to Surveyor that DON B has a good process in place. Regional DON P reported DON B will usually complete informed consent the day of starting and gives to medical records to scan into the computer. Regional DON P reported that somehow R6's was missing and that this is audited daily but somehow was missing.

Based on interview and record review, the facility failed to protect the resident's (R) R20) right to be free from verbal abuse by staff for 1 out of 2 residents reviewed.R20 reported Registered Nurse (RN) V grabbed R20's arm. RN V yelled at R20 and stood in front of R20's wheelchair stopping him, as he attempted to get away from RN V. Findings include:The facility's policy titled, Resident Safety Abuse Policy reviewed October 2023 states, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting I harm, pain, or mental anguish. It includes verbal abuse. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents. Mistreatment means inappropriate treatment or exploitation of a resident.R20 was admitted to the facility on [DATE] with diagnoses that included orthopedic after care following surgical amputation of the lower extremity, acute osteomyelitis of the right tibia and fibula (forearm), mild cognitive impairment, and anxiety disorder.[NAME] Data Set (MDS) quarterly assessment completed on 3/17/26 indicated that R20 had no behaviors, required some assistance with activities of daily living, can independently use a wheelchair for mobility, and has a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated intact cognition, R20's care plan initiated 12/17/25 states: Resident presents with and/or family/resident reports trauma related symptoms as related to a history of traumatic event or repeated events- acts of violence with a goal that resident safety will be maintained and resident will continue to verbalize preferences in care plan goals and approaches. Interventions included in part. encourage to tell staff when an event makes him feel uncomfortable. allow resident time to understand and ask questions.R20's care plan initiated 2/25/26 states: . Resident demonstrates a pattern of misinterpreting staff communication.This may lead to distress, conflict with staff, or inaccurate reporting of care interactions with a goal that included, staff interactions with resident will remain consistent, calm, and clear, minimizing opportunities for misunderstanding. R20's care plan interventions include in part, .remain calm, neutral, and supportive if resident becomes accusatory or misinterprets comments.On 3/23/26 at approximately 9:30 AM, Surveyor observed R20 was in bed and his breakfast tray on bedside table was covered and appeared untouched.On 3/23/26 at 10:45 AM, Surveyor requested to interview R20. R20 stated R20 wanted to go and have a cigarette but agreed to meet later, stating R20 had a lot to say.On 3/23/26 at 11:44 PM, Surveyor interviewed R20. R20 reported he was treated badly by a nurse, Registered Nurse (RN V), yesterday (3/22/26). RN V told him he had to wear a mask, and he couldn't leave his room without a mask. R20 reported RN V put a sign up on his bathroom door, said he could not use the shared bathroom and brought a commode into his room, all because his girlfriend had a cough.R20 reported R20's girlfriend (GF) CC came into facility on 3/22/26 to drop R20 off after he had spent the day with her. GF CC was wearing a mask because she had symptoms of being sick. During the interview R20's lunch was brought to R20's room, and Surveyor offered to continue interview after his lunch. R20 stated I'm not really even hungry, I'm just so traumatized by what happened last night with that nurse [RN V].On 3/23/2026 at 1:40 PM, Surveyor continued interview with R20, who reported RN V yelled at him last night, told him he had to wear a mask, and that he would have to stay in his room and couldn't use shared bathroom if he refused to wear a mask. R20 stated when he was downstairs trying to go outside and get away from her, She stood in front of my chair yelling at me to wear a mask and wouldn't let me leave alone. When I tried to leave, she grabbed my bad arm. I just can't stop thinking about it and it makes me mad. She had no right to do what she did.On 3/23/2026 at 1:56 PM, another Surveyor reported that Nursing Home Administrator (NHA) A was made aware of R20's report of RN V holding R20's arm down so the facility has started an investigation. The Surveyor's report is as follows:On 03/23/26 at 12:10 PM, Surveyor entered NHA A's office and NHA A divulged information about a recent accusation of physical abuse concerning R20 and a nurse. Surveyor asked NHA A to explain the details of the incident. NHA A reported to Surveyor that NHA A received an incident report via email right away this morning on 03/23/26 from R20's significant other of a concern that a nurse had not let R20 out of his room and grabbed his wheelchair to prevent him from leaving room. NHA A reported that NHA A is going to start the investigation process and report this incident to the state officials right away. Surveyor asked NHA A why nurse would not let resident out of resident's room. NHA A reported that R20's significant other had come to visit wearing a mask. NHA A reported that the nurse advised R20 that he needed to wear a mask since he may have been exposed and the nurse brought commode in and educated R20 on staying in room. Surveyor asked NHA A if that is normal process to quarantine residents when they are exposed to a potential infected person. NHA A stated to Surveyor, I thought that was ok, as we really don't want Norovirus going through the whole facility since we just got over respiratory issues in the facility. I will have to reach out to infection control about the guidelines for quarantine with potentially exposed residents. NHA A reported that NHA A is starting the investigation process and completing interviews. Surveyor reported to NHA A that Surveyor would update the other Surveyor with this information and let Surveyor communicate with NHA A going forward on this matter.Record review indicated RN V's documentation as follows on 3/22/2026 at 5:32 PM, Behavior Note- Note Text: earlier today this nurse was notified that resident's girlfriend possibly had a virus. She had been here for short time and yesterday with a mask on. Resident had been out with her for a few hours. Girlfriend called later and she stated to this nurse that she went to the MD who said he wanted to test her. She did not have the results at this time and was waiting for the MD [Medical Doctor] to call her with the results. This nurse thanked her and went to talk with resident about masking to help prevent any other residents from coming down with the virus. Resident went out to smoke. This nurse went to find resident and found him wheeling down the hallway very fast with his 12 pack of pop on his lap. Nurse asked to speak to resident, and he yelled 'get away from me you fat b****, I don't want to talk with you' This nurse again attempted to talk to him saying 'I just want to talk to you about wearing a mask. He attempted to wheel into nurse and said 'I told you I don't want to talk to you b****, I'm leaving. Nurse stopped resident's wheelchair to prevent chair from running into her. Residents pop on his lap slipped and he grabbed it with his Lt hand. Nurse removed self from resident's path. Resident wheeled to front door yelling 'I'm leaving' Nurse called nurse manager to update her on what happened at that time. Then resident came back into facility to his room to eat his supper. At that time call received from resident's girlfriend who stated she just got a call from the MD, and she just has a bad spring cold. This nurse then went to resident's room to talk with him. Nurse stood in doorway and said his girlfriend just called and said she does not have the virus, just a very bad cold and left. Nurse attempted to talk to resident later. Went to his room and he said, 'I don't want to talk to you, but you can talk to my girlfriend' and handed me his phone. Nurse put phone on speaker so resident could hear us speak but resident left. I talked with his girlfriend who said she told resident she only has a cold, but he said you grabbed his bad arm when pop slid from his lap. Nurse explained what happened earlier where she attempted to talk with resident, but he attempted to run into writer with his w/c, so I stopped the w/c, and he grabbed his 12 pack of pop with his bad arm to keep it from falling off his lap. There was no physical interaction with resident other than touching the w/c. I thanked her for the update and found resident sitting in the TV room, so I gave him back his phone and told him she wanted to talk with him again. At 1800 this nurse gave report to both night nurses and asked if they could talk with resident who continued to be upset with the situation related to his girlfriend's illness.Further record review indicated a progress note on 3/23/2026 at 1:24 PM, states, COMMUNICATION - with Physician/Res/Family/HPOA/Guardian. Resident complained of pain in the left upper shoulder and requested an X-ray. Nurse Practitioner was notified and with verbal order for X-ray to left upper shoulder. Order placed with Biotech.On 3/24/2026 at 8:28 AM, Surveyor spoke with R20 who reported he spoke with the police yesterday. R20 reported he is very traumatized by the incident, and he stated he often gets his dates mixed up, so he hopes he didn't mix anything up with interviews. R20 stated he is concerned the facility will retaliate.On 3/24/2026 at 9:33 AM, Surveyor interviewed NHA A regarding incident that occurred on 3/22/26 at approximately 5:30 PM between R20 and RN V. NHA A reported that R20's GF CC had emailed the Director of Rehabilitation (Rehab) on 3/22/26 at 5:28 PM with report of RN V grabbing R20's arm. Rehab Director didn't get email until 3/23/26 at 9:06 AM and forwarded it to NHA A, who then received it and sent it to the Social Worker (SW) designee Z to interview R20. Surveyor was provided with a copy of SW Designee Z's documentation R20's statement of the event. No further documentation for an assessment was provided at that time. On 3/24/26 at 10 AM, Surveyor interviewed Director of Nursing (DON) B, who reported RN V suggested R20 wear a mask. DON B stated, We obviously can't make him. DON B also stated R20 was not isolated to his room. We can't make him stay in his room; he goes outside to smoke. DON B stated RN V did report she brought the commode in his room because R20 has a shared bathroom. DON B was not aware if a sign was put on R20's bathroom door. DON D stated RN V had reported the event on 3/22/26 to Nurse Manager (NM) C.On 3/24/2026 at 10:49 AM, Surveyor interviewed NM C, who reported she received a text from RN V that R20's GF CC had suspected she had Norovirus. NM C stated, I told her to have him wear mask, told her to put him on droplet isolation. NM C reported they put a commode in his room and had him wear a mask. A Clinical Coordinator who was in the office during the interview with NM C, interjected stating, Suggested he wear a mask. NM C then stated, I mean I suggested he use it.Surveyor asked NM C if RN V reported GF CC stating anything about RN V grabbing R20's bad arm. Nurse Manager C read through her text messages and read from her phone that RN V texted, Just an FYI [for your information], he [R20] is claiming I grabbed his arm. NM C replied to RN V that she (NM C) would investigate it in the morning. NM C told Surveyor that she gets to the facility early. When Surveyor asked for the investigation notes, NM C stated R20 was asleep, so she didn't get to talk to him and then found out SW Z had already spoken with R20, so NM C just did R20's skin assessment around 9 AM. Surveyor asked for NM C's documentation of assessment. Surveyor asked NM C for the time and a copy of the text. NM C stated she no longer had the texts saved on her phone. NM C reported she has no documentation of her conversation with RN V from 3/22/26. Surveyor reviewed record written by NM C dated 3/23/2026 at 1:37 General Note- Data: Skin assessment done with resident, not any bruising or skin discoloration noted to left arm.Further record review indicated R20 complained of pain after the incident occurred. Note dated 3/24/2026 at 22:29 [10:29 PM] reads in part, When asked about pain resident states his pain is 9/10, radiating from L [left] shoulder down to forearm area. Resident c/o [complains of] LUE [left upper extremity] pain daily, states he has had a past injury to L shoulder and has had trouble with it for years. Scheduled morphine and PRN [as needed] pain med administered during shift.On 3/24/2026 at 2:36 PM, Surveyor interviewed Certified Nurse Assistant (CNA) DD, who stated he was in the facility dining room when incident occurred on 3/22/26. CNA DD reported he did not notice R20 was acting any different nor did R20 mention the incident to him.On 3/24/2026 at 2:40 PM, Surveyor interviewed Licensed Practical Nurse (LPN) G, she did not work at the time of the incident on 3/22/26 but does work with RN V occasionally and has had no concerns with RN V's treatment of the facility residents. On 3/24/2026 at 2:45 PM, Surveyor interviewed CNA D, who reported she went in R20's room the morning of 3/23/26 and R20 said to her that he had a bad day on 3/22/26. CNA D stated R20 was not feeling good and looked drowsy groggy. R20 did not eat breakfast and said he wasn't feeling good. CNA D stated that is not his usual behavior. R20 is usually up and goes outside to have a cigarette before breakfast. CNA D stated that morning when she brought in his breakfast tray, R20 sat at edge of his bed with eyes closed and she was concerned about him sitting at edge as tired as he appeared so suggested he lay back down, and he went back to sleep.On 3/24/26 at 2:57 PM, Surveyor interviewed GF CC with R20 present, who stated she had brought R20 back to the facility around super time, and he had spent the day with her at her house. GF CC stated she wore a mask in the facility because she hadn't been feeling good earlier that day. She had some gastrointestinal symptoms and, I didn't want to spread my germs. Later that evening between 6 and 7 PM, R20 had called her almost in tears and said RN V had pulled his bad arm. While on the phone with R20, RN V came into his room. R20 stated he didn't want to talk to her, and he ended up handing his phone to RN V stating she could talk to GF CC. GF CC stated she asked RN V if she grabbed R20's bad arm. GF CC reported RN V said she grabbed the back of his chair. GF CC stated RN V said R20 has to wear a mask, and she (GF CC) could not come back into facility until she got the results of her illness. GF CC stated RN V had no business yelling and screaming and demanding he wear a mask. GF CC reported she came back to the facility about 7- 7:30 PM on 3/22/26 to take R20 for a ride and to the store to help him calm down and feel better. He wanted to go home and was so upset about what happened.R20 stated the incident happened about 5-5:30 PM on 3/22/26 in the hallway on the 1st floor when he was going outside to have a cigarette. Prior to that RN V had come into his room demanding R20 wear a mask because of his girlfriend's suspected illness. When R20 refused and left, RN V chased him downstairs yelling at him to wear a mask. R20 stated RN V stood in front of my wheelchair yelling at me to wear the mask she had in her hand, when I tried to go around her, she grabbed my bad arm, and it hurt. I was finally able to get around her. R20 stated, Yes, I swore at her. I was mad at her for not letting me leave.The facility called law enforcement on 3/23/26; officers conducted interviews at the time of survey. That report was not yet available.Surveyor was provided with RN V's handwritten statement which states, March 22, 2026, at 15:44 [3:55P PM] I was told that a staff member heard resident and girlfriend talking and she said she had the virus. I texted my Nurse Manager on duty to ask her if she had heard about the above. At 1600 [4 PM] I called name of GF [GF CC] who stated she was sick yesterday, . I texted NM [NM C] and updated her and asked her what we should do at the facility. I also told NM resident did not have any symptoms [GF CC] at this time. She said to mask and glove at this time when working with resident, and have resident stay in his room. I went to his room to talk with him, but he was not in the room. I went to look for him and found him wheeling himself fast through the downstairs hallway with both hands and a 12 pack of pop on his lap. I asked to speak with him and he yelled back get away from me you fat b**** Nurse again in a calm and normal voice said, I just want to talk to you about wearing a mask until [GF CC] calls back with the results before nurse could finish the sentence he yelled and swung his arms saying why do I have to wear a mask he then shouted and wheeled toward nurse, I stopped wheelchair with my hand. He said, I told you I don't want to talk to you, you b****, I'm leaving He again started to move, and I also moved away from him. I saw his 12 pack of pop started to slide off his lap, but he caught it with his left hand and positioned it back on his lap and kept going toward the front door. I followed from a distance then stopped at front desk to talk to door staff. I then texted NM to tell her what happened. I then called her to talk. I went back to work charting, assisting on the floor, checking on other residents. I got another text telling me to put a commode in [R20's] room. I just got the commode in his room when [GF CC] called to tell me her test results were in and she doesn't have the virus. I went down to his [R20's] room to let him know. He said I don't want to talk to you, but you can talk to my girlfriend. so I put it on speaker so he could hear both of us talking but he just left the room. She started talking saying resident said to her I had grabbed his bad arm when the pop slid from his lap. I told [GF CC] what happened, and that there was no physical interaction from either of us other than me touching his wheelchair.Facility interview with CNA U during the facility investigation reads in part: [R20] was upset, said he [R20] was leaving. Nurse was telling him that masks were needed, [R20] was already high strung. Nurse [RN V] went after him after he went off on her, both yelling at each other, both in the wrong.Facility interview with Receptionist R during the facility investigation reads in part:[RN V] said he [R20] needed to be quarantined and masked, and his girlfriend can't come back and that I needed to let [R20] know.Facility interview with Receptionist S during the facility investigation reads in part: [RN V] said he is quarantined and he needed a mask.On 3/25/26, Surveyor was provided a document written by NM C that reads in part, March 22, 2026. At around 6PM, writer received another message from [RN V] that resident was accusing him of grabbing his sore arm. Writer instructed [RN V] to write a progress note and I will talk to him in the morning.On 3/25/2026 at 8:13 AM, Surveyor interviewed NHA A, who stated the expectation is the Nurse Manager should have called her (NHA) immediately after being told that the resident alleged that the RN grabbed his arm on 3/22/26. NHA A stated she was not made aware of the incident until Monday morning. Surveyor stated R20's, GF CC's, and the interviews obtained by the facility from staff witness noted that RN V was yelling at the resident. NHA A stated, yes, that's verbal abuse. The resident stated RN grabbed his arm and would not let him move past her by standing in front of his wheelchair. NHA A agreed this behavior by RN V toward R20 was considered abuse. Surveyor reported to NHA A of the interviews conducted and documentation reviewed, indicated R20 was upset by the incident, did not get out of bed or eat his breakfast the morning after the incident and staff stated this was not R20's normal routine, thus indicating RN V's behavior did cause R20 mental anguish and pain.

Based on record review and interviews, the facility did not ensure that an alleged violation involving abuse by a resident (R20) was reported immediately to the Nursing Home Administrator (NHA) and to the State Survey and Certification Agency. An incident which R20 reported Registered Nurse (RN) V grabbed R20's arm, yelled at R20, and stood in front of R20's wheelchair stopping him as he attempted to get away from RN V, was reported to on call Nurse Manager, who did not report it to the NHA and thus the facility did not report the abuse to the State Survey and Certification Agency.Findings include:The facility's policy titled, Resident Safety Abuse Policy reviewed October 2023 states, Reporting suspected violations: a. The supervisor on duty shall immediately safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of residents property to the facility administrator. The Administrator will notify the DON and/or others as appropriate. c. The Administrator shall report immediately, but no later than 2 hours after forming the suspicion, if the events that caused the suspicion result in serious bodily injury. (see table 1). Table 1 indicates Alleged Violations- All alleged violations of abuse. R20 was admitted to the facility on [DATE] with diagnoses that included orthopedic after care following surgical amputation of the lower extremity, acute osteomyelitis of the right tibia and fibula (forearm), mild cognitive impairment, and anxiety disorder.Most recent [NAME] Data Set (MDS) assessment completed on 3/17/26 indicated that R20 had no behaviors, required some assistance with activities of daily living, can independently use a wheelchair for mobility, and has a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated intact cognition.On 3/23/26 at 11:44 PM, Surveyor interviewed R20. R20 reported he was treated badly by a nurse, Registered Nurse (RN V), yesterday (3/22/26). RN V told him he had to wear a mask, and he couldn't leave his room without a mask on. This interview was interrupted by R20's lunch.On 3/23/2026 at 1:40 PM, Surveyor continued interview with R20, who reported RN V yelled at him last night, told him he had to wear a mask, and that he would have to stay in his room and couldn't use shared bathroom if he refused to wear a mask. R20 stated when he was downstairs trying to go outside and get away from her she stood in front of my chair yelling at me to wear a mask and wouldn't let me leave alone. When I tried to leave, she grabbed my bad arm. I just can't stop thinking about it and it makes me mad. She had no right to do what she did.Record review indicated RN V's documentation as follows on 3/22/2026 at 5:32 PM, Behavior Note- Note Text: earlier today this nurse was notified that resident's girlfriend possibly had a virus. She had been here for short time and yesterday with a mask on. This nurse went to find resident and found him wheeling down the hallway very fast with his 12 pack of pop on his lap. Nurse asked to speak to resident and he yelled 'get away from me you fat b****, I don't want to talk with you' This nurse again attempted to talk to him saying 'I just want to talk to you about wearing a mask. He attempted to wheel into nurse and said 'I told you I don't want to talk to you b****, I'm leaving. Nurse stopped residents wheelchair to prevent chair from running into her. Residents pop on his lap slipped and he grabbed it with his Lt hand. Nurse removed self from residents path. Resident wheeled to front door yelling 'I'm leaving' Nurse called nurse manager to update her on what happened at that time. Nurse attempted to talk to resident later. Went to his room and he said 'I don't want to talk to you but you can talk to my girlfriend' and handed me his phone. Nurse put phone on speaker so resident could hear us speak but resident left. I talked with his girlfriend who said she told resident she only has a cold but he said you grabbed his bad arm when pop slid from his lap. Nurse explained what happened earlier where she attempted to talk with resident but he attempted to run into writer with his w/c so I stopped the w/c and he grabbed his 12 pack of pop with his bad arm to keep it from falling off his lap. There was no physical interaction with resident other than touching the w/c. I thanked her for the update and found resident sitting in the TV room so I gave him back his phone and told him she wanted to talk with him again. At 1800 this nurse gave report to both night nurses and asked if they could talk with resident who continued to be upset with the situation related to his girlfriend's illness.On 03/23/26 at 12:10 PM, Surveyor entered NHA A's office and NHA A divulged information about a recent accusation of physical abuse concerning R20 and a nurse. Surveyor asked NHA A to explain the details of the incident. NHA A reported to Surveyor that NHA A received an incident report via email right away this morning on 03/23/26 from R20's significant other of a concern that a nurse had not let R20 out of his room and grabbed his wheelchair to prevent him from leaving room. NHA A reported that NHA A is going to start the investigation process and report this incident to the state officials right away. Surveyor asked NHA A why nurse would not let resident out of resident's room. NHA A reported that R20's significant other had come to visit wearing a mask. NHA A reported that the nurse advised R20 that he needed to wear a mask since he may have been exposed and the nurse brought commode in and educated R20 on staying in room. Surveyor asked NHA A if that is normal process to quarantine residents when they are exposed to a potential infected person. NHA A stated to Surveyor, I thought that was ok, as we really don't want Norovirus going through the whole facility since we just got over respiratory issues in the facility. I will have to reach out to infection control about the guidelines for quarantine with potentially exposed residents. NHA A reported that NHA A is starting the investigation process and completing interviews.On 3/24/2026 at 10:49 AM, Surveyor interviewed Nurse Manager (NM) C, who reported she received a text from RN V that R20's GF CC had suspected she had Norovirus. Surveyor asked NM C if RN V reported GF CC stating anything about RN V grabbing R20's bad arm. Nurse Manager C read through her text messages and read from her phone that RN V texted, Just an FYI [for your information], he [R20] is claiming I grabbed his arm. NM C replied to RN V that she (NM C) would investigate it in the morning. NM C told Surveyor that she gets to the facility early. When Surveyor asked for the investigation notes, NM C stated R20 was asleep so she didn't get to talk to him and then found out Social Worker (SW) Z had already spoken with R20 so NM C just did R20's skin assessment around 9 AM. Surveyor asked for NM C's documentation of assessment. Surveyor asked NM C for the time and a copy of the text. NM C stated she no longer had the texts saved on her phone. NM C reported she has no documentation of her conversation with RN V from 3/22/26.On 3/25/26, Surveyor was provided a document written by NM C that reads in part, March 22, 2026. At around 6PM, writer received another message from [RN V] that resident was accusing him of grabbing his sore arm. Writer instructed [RN V] to write a progress note and I will talk to him in the morning.On 3/25/2026 at 8:13 AM, Surveyor interviewed NHA A, who stated the expectation is that the Nurse Manager should have called her (NHA) immediately after being told that the resident made the allegation that the RN grabbed his arm on 3/22/26. NHA A stated would have reported this allegation of abuse to the state agency. NHA A was not made aware of the incident until Monday morning.

Based on interview and record review, the facility did not ensure the prevention of further potential abuse from occurring while an investigation was in progress for 1 out of 2 residents (R) investigated for abuse (R20).Facility did not protect R20 when allowing Registered Nurse (RN) V to continue to work with R20 when accused of verbal and physical abuse.Findings include:The facility's policy titled, Resident Safety Abuse Policy reviewed October 2023 states, Procedure for investigation: . d. The Supervisor will ensure that the resident(s) is/are protected from further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. R20 was admitted to the facility on [DATE] with diagnoses that included orthopedic after care following surgical amputation of the lower extremity, acute osteomyelitis of the right tibia and fibula (forearm), mild cognitive impairment, and anxiety disorder.Most recent [NAME] Data Set (MDS) assessment completed on 3/17/26 indicated that R20 had no behaviors, required some assistance with activities of daily living, can independently use a wheelchair for mobility, and has a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated intact cognition.On 3/23/26 at 11:44 PM, Surveyor interviewed R20. R20 reported he was treated badly by a nurse, Registered Nurse (RN V), yesterday (3/22/26). RN V told him he had to wear a mask, and he couldn't leave his room without a mask on.On 3/23/2026 at 1:40 PM, Surveyor continued interview with R20, who reported RN V yelled at him last night, told him he had to wear a mask, and that he would have to stay in his room and couldn't use shared bathroom if he refused to wear a mask. R20 stated when he was downstairs trying to go outside and get away from her she stood in front of my chair yelling at me to wear a mask and wouldn't let me leave alone. When I tried to leave, she grabbed my bad arm. I just can't stop thinking about it and it makes me mad. She had no right to do what she did.Record review indicated RN V's documentation as follows on 3/22/2026 at 5:32 PM, Behavior Note- Note states in part: . Nurse attempted to talk to resident later. Went to his room and he said 'I don't want to talk to you but you can talk to my girlfriend' and handed me his phone. Nurse put phone on speaker so resident could hear us speak but resident left. I talked with his girlfriend who said she told resident she only has a cold but he said you grabbed his bad arm when pop slid from his lap.On 3/24/2026 at 10:49 AM, Surveyor interviewed Nurse Manager (NM) C, who reported she received a text from RN V that R20's GF CC had suspected she had Norovirus. Surveyor asked NM C if RN V reported GF CC stating anything about RN V grabbing R20's bad arm. Nurse Manager C then read through her text messages and from her phone read that RN V texted, Just an FYI [for your information], he [R20] is claiming I grabbed his arm. NM C replied to RN V that she (NM C) would investigate it in the morning. NM C told Surveyor that she gets to the facility early.When Surveyor requested a copy of this communication, NM C stated she no longer had the texts saved on her phone. NM C reported she has no documentation of her conversation with RN V from 3/22/26.On 3/25/26, Surveyor was provided a document written by NM C that reads in part, March 22, 2026. At around 6PM, writer received another message from [RN V] that resident was accusing him of grabbing his sore arm. Writer instructed [RN V] to write a progress note and I will talk to him in the morning.RN V continued to work as R20's nurse after allegation of abuse was made. Record review indicated RN V's documentation on 3/22/26 reads in part, At 1800 [6PM] this nurse gave report to both night nurses and asked if they could talk with resident who continued to be upset with the situation related to his girlfriend's illness.On 3/25/2026 at 8:13 AM, Surveyor interviewed NHA A, who stated the expectation is that the Nurse Manager should have called her (NHA) immediately after being told that the resident made the allegation that the RN grabbed his arm on 3/22/26 so that a complete investigation could have been done ensuring R20's safety and not have RN V continue to care for R20. Surveyor reported to NHA A of the interviews conducted and documentation reviewed, indicated R20 was upset by the incident, did not get out of bed or eat his breakfast the morning after the incident and staff stated this was not R20's normal routine, thus indicating RN V's behavior did cause R20 mental anguish and pain. On 3/25/2026 at 9:48 AM, Surveyor interviewed NHA A, who stated her expectation would be that the harm be removed. Surveyor clarified that she meant the RN V should have immediately been removed from working with residents.On 03/25/2026 at 10:02 AM, Surveyor interviewed NHA A, who reported RN does not have any reports of abuse or mistreatment in her personnel file. NHA A provided dates of training provided to RN V on abuse prevention, recognizing, and reporting.

Based on interview and record review, the facility did not ensure 3 residents/resident representative (R) (R6, R46, and R48) of 5 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, and bed hold notice.-Facility did not have a specific reason on the transfer notice for R6, R46, and R48.-Facility did not provide R6 and R46 a bed hold notice.-Facility did not notify the ombudsman of R6 and R46's transfers to the hospital.Per the Long-Term Care State Operations Manual (SOM), dated 7-23-25, regulation 483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. 483.15(c)(5) Content of Notice. The facility's notice must include all the following at the time notice is provided: -The specific reason for the transfer or discharge. Surveyor reviewed facility policy titled, Transfer and Discharge policy, dated 11/23 last reviewed, which states, 5, When residents are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, not discharges, because the resident's return is generally expected. 7. Before the facility transfers or discharges a resident, the facility will notify the residents and the resident's representative of the transfer and reasons for the move in writing and in a language the resident understands. A copy of the notice will be sent to representative of the office of the state long-term care ombudsman by social services. 9. The notice of transfer or discharge will include all the following: a. specific reason for the transfer or discharge. 11. The facility shall retain a copy of the notice of transfer and discharge and bed-hold acknowledgement in the medical record. Example 1 R6 was admitted on [DATE] with diagnoses including in part, hypertensive chronic kidney disease, gangrene of left leg, atherosclerosis of arteries of extremities, multiple fracture ribs, type 2 diabetes mellitus, acute pulmonary edema, and major depressive disorder, and anxiety. R6's record review indicated that R6 was sent out to the emergency room on [DATE] and 02/15/26. On 03/24/26 at 8:33 AM, Surveyor reviewed notice of transfers for R6's hospitalization on 02/06/26 and 02/15/26, which showed no specific reason for transfer to a higher level of care. On 03/24/26 at 3:05 PM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B could provide Surveyor with documentation in R6's medical record for bed hold, transfer notice, and notification to Ombudsman for R6 being transferred to hospital on [DATE] and 02/15/26. On 03/25/26 at 6:58 AM, Surveyor observed a pile of papers on table in conference room addressed to this Surveyor. Surveyor reviewed documents that state in part, On 02/15/26 in progress note, [R6's] POA verbally gave consent for bed hold. Surveyor did not find a physical bed hold form filled out for R6's hospitalization on 02/15/26. Surveyor also did not find a bed hold form filled out for R6's hospitalization on 02/06/26. Surveyor did not find a notice of transfer for R6's transfer to hospital on [DATE]. Surveyor reviewed notice of transfer documents that stated in part, On 02/15/26, [R6] notice of transfer form: An immediate transfer or discharge is required by the residents' urgent medical needs. Surveyor did not find a specific reason for R6 being transferred to hospital on [DATE]. Surveyor did not find documentation that Ombudsman was notified of R6's hospitalizations on 02/06/26 and 02/15/26. On 03/25/26 at 7:08 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked about papers left in conference room. Surveyor asked NHA A if ombudsman was notified of R6's hospitalizations in February. NHA A reported that since Interim Social Services Designee Y was covering for Social Services Designee Z who had been on leave at the time, DON B and NHA A tried looking for the ombudsman notification and found that Interim Social Services Designee Y did not notify ombudsman and that Social Services Designee Z will complete this today in notifying ombudsman of hospitalizations for the month of February and March. Example 2 R46 was admitted on [DATE] with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, obstructive sleep apnea, morbidly obese due to excess calories, cardiomegaly, atherosclerotic heart disease with atherosclerosis of arteries of extremities with intermittent claudication of bilateral legs, essential hypertension, stage 3 kidney disease, type 2 diabetes mellitus, and fracture of the lower end of right femur. R46 was re-admitted to the facility on [DATE] after extensive care in hospital with new diagnoses including in part, acute respiratory failure, unspecified with hypoxia or hypercapnia, embolism and thrombosis of arteries of lower extremities, and acute embolism and thrombosis of unspecified deep veins of right lower extremity. On 03/24/26 at 3:05 PM, Surveyor interviewed DON B and asked if DON B could provide Surveyor with documentation in R46's medical record for bed hold, transfer notice, and notification to Ombudsman for R46 being transferred to hospital on [DATE] and 03/12/26. On 03/25/26 at 6:58 AM, Surveyor observed a pile of papers on table in conference room addressed to this Surveyor. Surveyor reviewed documents that state in part, On 03/12/26 Notice of transfer form: An immediate transfer or discharge is required by the resident's urgent medical needs. Surveyor did not find a specific reason R46 was being transferred to hospital on [DATE]. Surveyor did not find a notice of transfer for R46's transfer to hospital on [DATE]. Surveyor did not find documentation that Ombudsman was notified of R46's hospitalizations. Surveyor did not find a physical bed hold form filled out for R46's hospitalization on 02/16/26 or 03/12/26. On 03/25/26 at 7:08 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked about papers left in conference room. Surveyor asked NHA A if ombudsman was notified of R46's hospitalizations in February and March. NHA A reported that since Interim Social Services Designee Y was covering for Social Services Designee Z who had been on medical leave at the time, DON B and NHA A tried looking for the ombudsman notification and found that Interim Social Services Designee Y did not notify ombudsman and that Social Services Designee Z will complete this today in notifying ombudsman of hospitalizations for the month of February and March. Example 3 R48 was admitted to the facility on [DATE], with diagnoses including in part, chronic respiratory failure, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes, muscle weakness, essential hypertension, chronic systolic congestive heart failure and chronic ischemic heart disease. R48's Minimum Data Set (MDS) assessment, dated 1/22/26, identified R48 required substantial maximal assistance for toileting and toilet transfer, personal cares and activities of daily living. R48, with a little set up help, could eat and complete his own oral hygiene. R48 was able to independently roll in bed, but dependent for all other position changes with assist of staff and an EZ Stander. R48's Brief Interview for Mental Status (BIMS), dated 1/22/26, was 15/15. A 15 indicates R48 was cognitively intact. R48 understands others but has a cognitive communication deficit. R48's record review indicated that R48 was sent to the emergency room on 2/28/26 in respiratory distress. On 03/24/26 at 8:02 AM, Surveyor reviewed notice of transfers for R48's hospitalization on 2/28/26 which showed no specific reason for transfer to a higher level of care.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Licensed Practical Nurse (LPN) F, LPN G and Registered Nurse (RN) H did not perform hand hygiene prior to administering medication. This affected 5 out of 5 residents (R) (R6, R34, R20, R19, R2).LPN F did not wipe off blood pressure cuff and machine prior to RN H taking and using with another resident (R33). This was evidenced by:On 3/24/26, Nursing Home Administrator (NHA) A stated that Surveyor had all the policies related to hand hygiene. Policy received is specifically related to food preparation. NHA did provide Surveyor with a copy of the orientation plan that shows Director of Nursing (DON) B covers Hand Washing: how, when, why, during her portion of orientation.The Center for Disease Control (CDC) guidelines titled, Clinical Safety: Hand Hygiene for Health Care Workers, dated 2/27/24, states: Healthcare personnel must perform hand hygiene to prevent infection transmission:Before touching a patient,Before clean/aseptic procedures (e.g. obtaining a blood pressure, blood sugar), .Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning (putting on) gloves,Before and after removing gloves,Before and after leaving a resident's room. If visibly dirty, healthcare staff should wash their hands.Example 1On 3/23/26 at 9:32 AM, Surveyor observed LPN F administer medications to R6. LPN F performed no hand hygiene prior to preparing medication. While preparing R6's medication, LPN F realized there was no normal saline spray in the cart. LPN F stated maybe it is in his room and continued medication prep. At 9:47 AM, LPN F minimized computer and locked cart. No hand hygiene at cart or prior to entering R6's room. LPN F administered R6's medication with contaminated hands. LPN F looked for normal saline and asked R6 if he had normal saline. It was not in his room. LPN F completed hand hygiene on way out of R6's room. LPN F went to medication room on [NAME] unit and then over to East unit to find normal saline spray. At 10:01 AM, LPN F came back with normal saline spray and took it to R6's room. LPN F did not complete hand hygiene upon entering room. LPN F, with contaminated hands, handed R6 the new bottle of normal saline spray.On 3/23/26 at 10:04 AM, Surveyor observed RN H prepare medications for R34. RN H completed hand hygiene before preparing R34's medication. RN H started preparing medication and identified missing medication. RN H put medication back in cart and went to medication room on East side. At 10:26 AM, RN H came back with the medication to med cart. RN H did not perform hand hygiene. With contaminated hands, RN H continued with the medication preparation. At 10:26 AM, RN H took medication to R34; no hand hygiene performed when leaving the cart or upon entering the room. With contaminated hands, RN H administered medication to R34.On 3/24/26 at 7:25 AM, Surveyor observed LPN G prepare medication for R19. No hand hygiene observed prior to prepping medication, upon leaving cart, or upon entering room. LPN G administered medication with contaminated hands. On 3/24/26 at 7:42 AM, R20 came out of his room that was right next to medication cart. Surveyor observed that LPN G asked R20 if LPN G could get R20's blood sugar before R20 went downstairs. R20 agreed. LPN G stopped preparing medications for R30 and pulled R20's glucometer kit from bottom drawer, set it up, and put on gloves. No hand hygiene before putting on gloves. With contaminated hands, LPN G obtained R20's blood sugar. On 3/24/26 at 9:28 AM, Surveyor observed LPN G prepare medication for R2. LPN G completed hand hygiene before she started. LPN G prepared medication and used the crusher to crush medication. LPN G did not perform hand hygiene at the med cart or before entering room. Surveyor observed that LPN G put gloves on contaminated hands, checked placement of g-tube, and administered medication. On 3/23/26 at 10:33 AM, LPN F stated hand hygiene is before and after everything. Surveyor asked if he had more specifics related to medication administration. LPN F stated before prepping medications, anytime taking off gloves, before you enter a room and after you leave a room. LPN F stated LPN F completed hand hygiene prior to preparing medication. Surveyor asked what about before entering the room. LPN F stated, no I didn't. Yes, I should have.On 3/23/26 at 10:33 AM, RN H stated hand hygiene is before and after everything. Surveyor asked if RN H had more specifics related to medication administration. RN H stated before prepping medications, anytime taking off gloves, before you enter a room and after you leave a room. RN H stated RN H completed hand hygiene prior to preparing medication. Surveyor asked what about before entering the room. RN H stated, no I didn't. Yes, I should have.On 3/23/26 at 9:32 AM, LPN G stated hand hygiene is always before and after working with patients. After a pause, LPN G stated preparing medication, putting on gloves, taking off gloves, going in a room, leaving a room, always.Example 2Surveyor requested a policy related to wiping down blood pressure equipment. NHA A stated they do not have a specific policy. On 3/23/26 during the 9:47 AM med pass event, Surveyor observed LPN F obtain the blood pressure and pulse of R6 via the blood pressure machine. LPN F took blood pressure cuff out of R6's room and parked it by wall just past nurses' station. LPN F did not wipe off blood pressure machine or cuff. Surveyor consistently monitored blood pressure cuff until its next use. BP cuff was not wiped down.On 3/23/26 at 9:56 AM, Surveyor observed RN H take the contaminated blood pressure cuff to use with R33. Surveyor confirmed blood pressure cuff was used. On 3/23/26 at 10:34 AM, Surveyor interviewed LPN F who stated blood pressure cuffs should be wiped down between use. Surveyor asked if that happened after LPN F used it with R6. LPN F stated no I didn't. Surveyor asked if LPN F should have wiped it down. LPN F stated yes. On 3/23/26 at 10:34 AM, RN H overheard questioning of RN F, and RN H stated she thought it was already wiped down when RN H took it to use with R33. On 3/24/26 at 2:31 PM, Surveyor interviewed Director of Nursing (DON) B who stated DON B expects staff to perform hand hygiene when passing medication, before and after preparing, upon entering and leaving a room, and before they put on gloves and after they take them off. DON B also stated that a blood pressure cuff should be wiped down between residents and glucometers are used on only one patient, they are not shared.

Based on interview, record review, and facility document and policy review, the facility failed to complete a thorough investigation for 1 (Resident #1) of 4 residents sampled for allegations of misappropriation. Specifically, the facility failed to conduct interviews and/or obtain statements from staff regarding Resident #1's missing wallet and identification cards.Findings included:A facility policy titled, Abuse Prevention Policy, revised 11/04/2024, indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The policy revealed, Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: e. The development of investigative protocols governing resident abuse, theft/misappropriation of resident property, resident-to-resident abuse and resident-to-staff abuse; f. Timely and thorough investigations of all reports and allegations of abuse.An admission Record revealed the facility admitted Resident #1 on 04/09/2024. According to the admission Record, Resident #1 had a medical history that included diagnoses of Alzheimer's disease, unspecified psychosis, and hallucinations.An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderately impaired cognition.An email dated 09/02/2025 at 3:12 PM from Resident #1's Responsible Party (RP) to the Social Services Director (SSD) indicated that Resident #1's wallet and social security card were missing. The email revealed that the RP asked the SSD if these items were given to her. The email indicated Resident #1 had reported to family that people were going into rooms and taking stuff over the weekend. The email indicated that these documents were needed to complete insurance paperwork.A Monthly Grievance Log dated 09/2025 indicated a formal grievance was filed on behalf of Resident#1 on 09/03/2025 with a resolution for items to be replaced. The Monthly Grievance Log revealed the complainant was notified of the resolution on 09/11/2025.A Complaint/Grievance Report dated 09/11/2025 indicated the wallet had not been located. The report indicated Resident #1 had been interviewed and denied having a wallet at the facility stating an alternate family member had the wallet. The report indicated Resident #1's RP was notified during a care conference on 09/11/2025 that the wallet had not been located and the facility offered to assist with replacement of the resident's social security card and provided Resident #1's RP the needed social security number. An untitled handwritten document dated 09/03/2025 written by the SSD revealed an interview completed with Resident #1 on 09/03/2025 which Resident #1 denied having the wallet at the facility and indicated the resident identified a specific family member had the wallet and checkbook.An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report was submitted to the state survey agency on 09/12/2025 at 5:25 PM by the Administrator (ADM). The report indicated that a family member had reported that Resident #1's wallet was missing. The report revealed the resident's family member had indicated there was no cash in the wallet, but there was a state identification card and social security card in the wallet.A Misconduct Incident Report submitted to the state survey agency on 09/19/2025 at 10:33 AM indicated the facility was notified that Resident #1 was missing a wallet on that included a state identification card and a social security card. The report and investigation indicated that facility staff had searched for the wallet but had not located the wallet. The investigation included interviewing Resident #1, searching for the wallet, and interviews with additional residents. Further review revealed no interviews with staff who cared for Resident #1 were included in the investigation report.During an interview on 10/20/2025 at 10:46 AM, Licensed Practical Nurse (LPN) E confirmed that she had worked with Resident #1. LPN E stated she was not aware of Resident #1 having a missing wallet. LPN E stated Resident #1 had not reported a missing wallet to her, and no one had asked her about a missing wallet.During an interview on 10/20/2025 at 11:00 AM, Certified Nurse Aide (CNA) A confirmed she had worked with Resident #1. CNA A stated she was not aware that Resident #1 had a missing wallet. CNA A stated that no one had asked her about a missing wallet.During an interview on 10/20/2025 at 11:03 AM, CNA B confirmed she had worked with Resident #1. CNA B stated she had never seen Resident #1 with a wallet, and Resident #1 had not reported a missing wallet to her. CNA B stated that no one had asked her about a missing wallet.During an interview on 10/20/2025 at 11:10 AM, CNA C confirmed that she had worked with Resident #1. CNA C stated Resident #1 had never complained about missing wallet. CNA C stated no one ever interviewed her about a missing wallet.During an interview on 10/20/2025 at 11:14 AM, Trained Medication Aide (TMA) D confirmed she had worked with Resident #1. TMA D stated Resident #1 had not reported anything missing to her. TMA D stated that no one had interviewed her about a missing wallet.During an interview on 10/20/2025 at 1:43 PM, CNA F confirmed that she had worked with Resident #1. CNA F stated Resident #1 had not reported anything missing to her. CNA F stated that no one had interviewed her about a missing wallet.During an interview on 10/20/2025 at 1:58 PM, the SSD stated investigating allegations of abuse, neglect, or misappropriation was a group effort. The SSD stated she worked with the Administrator to determine who to interview and what questions to ask.During an interview on 10/20/2025 at 3:16 PM, the Administrator stated she expected the facility investigation to include interviews with other residents and staff.

Based on interview, record review, and facility document review and policy review, the facility failed to submit an initial report of an allegation of misappropriation to the state survey agency within 24 hours and failed to notify law enforcement for 1 (Resident #1) of 4 residents reviewed for misappropriation. Specifically, the facility failed to report an allegation of a missing wallet and identification cards for Resident #1 to the state agency within the required time for reporting and failed to notify the law enforcement of the allegation.Findings included:A facility policy titled, Abuse Prevention Policy, revised 11/04/2024, indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The policy also specified, 6. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported 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 not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in in serious bodily injury, to the state agency. All reports will be investigated after reporting and finalized, then submitted to the State Agency within 5 working days.An admission Record revealed the facility admitted Resident #1 on 04/09/2024. According to the admission Record, Resident #1 had a medical history that included diagnoses of Alzheimer's disease, unspecified psychosis, and hallucinations.An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderately impaired cognition. An email dated 09/02/2025 at 3:12 PM from Resident #1's Responsible Party (RP) to the Social Services Director (SSD) indicated that Resident #1's wallet and social security card were missing. The email revealed that the RP asked the SSD if these items were given to her. The email indicated Resident #1 had reported to family that people were going into rooms and taking stuff over the weekend. The email indicated that these documents were needed to complete insurance paperwork.A Monthly Grievance Log dated 09/2025 indicated a formal grievance was filed on behalf of Resident#1 on 09/03/2025 with a resolution for items to be replaced. The Monthly Grievance Log revealed the complainant was notified of the resolution on 09/11/2025.A Complaint/Grievance Report dated 09/11/2025 indicated the wallet had not been located. The report indicated Resident #1 had been interviewed and denied having a wallet at the facility stating an alternate family member had the wallet. The report indicated Resident #1's RP was notified during a care conference on 09/11/2025 that the wallet had not been located and the facility offered to assist with replacement of the resident's social security card and provided Resident #1's RP the needed social security number.An untitled handwritten document dated 09/03/2025 written by the SSD revealed an interview completed with Resident #1 on 09/03/2025 which Resident #1 denied having the wallet at the facility and indicated the resident identified a specific family member had the wallet and checkbook. An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report was submitted to the state survey agency on 09/12/2025 at 5:25 PM by the Administrator (ADM). The report indicated that a family member had reported that Resident #1's wallet was missing. The report revealed the resident's family member had indicated there was no cash in the wallet, but there was a state identification card and social security card in the wallet.A Misconduct Incident Report submitted to the state survey agency on 9/19/2025 at 10:33 AM indicated the facility was notified that Resident #1 was missing a wallet that included a state identification card and a social security card. The report and investigation indicated that facility staff had searched for the wallet but had not located the wallet. The report indicated that law enforcement had not been contacted or involved.During an interview on 10/20/2025 at 1:58 PM, the SSD stated investigating allegations of abuse, neglect, or misappropriation was a group effort. The SSD stated that anything that could be reportable should be reported to the ADM and Director of Nursing (DON).During a follow-up interview on 10/20/2025 at 3:05 PM, the SSD stated if someone reported missing money she would report it as an allegation of misappropriation, but missing money is managed differently than other missing items that were not necessarily reportable. The SSD stated it was the ADM who determined if something was reportable. The SSD stated that Resident #1 was sometimes cognitively aware but became confused later in the day.During an interview on 10/20/2025 at 3:16 PM, the ADM confirmed that she was the Abuse Coordinator for the facility. The ADM stated that the SSD notified her of missing items. The ADM stated if it was clothing or candy or something that was easily replaceable, she replaced these types of items. The ADM stated that if money was missing, she reported it as misappropriation and contacted the police. The ADM stated that initially, since there was no money in the wallet, she did not feel it rose to the level of misappropriation. The ADM stated that during a care conference on 09/11/2025, the family had voiced additional concerns related to the missing identification (The concern about the missing social security card was mentioned in the RP's email dated 09/02/2025), so the ADM decided it should be reported and further investigated.During a follow-up interview with the ADM on 10/20/2025 at 4:25 PM, the ADM stated that the allegation had not been reported to the police because there was no specific person or suspect to report.

Based on observation, interview and record review, the facility did not ensure resident's environment was free from accidental hazards to prevent accidents for 1 of 3 residents reviewed.R1 was sitting on multiple items in a wheelchair, which contributed to R1 falling off the wheelchair seat during transport.Findings:According to Nemt Insurance article, dated 05/01/21, It is perfectly acceptable that additional cushioning may be an integral component to a wheelchair user's level of comfort. However, the cushion should be specifically designed by the manufacturer and integrated into the original design of the wheelchair by that manufacturer. If it isn't, then it should be removed from the wheelchair prior to transport in an effort to reduce the likelihood of severe injury if an accident were to occur. While a passenger's personal comfort is important; ultimately their safety, and the safety of those around them is more important.R1 was admitted to the facility on [DATE], with diagnoses that include a stroke affecting the right side of body and morbidly obese. R1's Minimum Data Set (MDS) dated [DATE] indicated R1 has no cognitive impairment, understands, and is understood. R1 requires maximum assistance with bed mobility and is dependent on staff for transfers, toileting, and mobility once in a wheelchair.Surveyor reviewed the incident report that notes on 09/16/25, R1 was being transported to an appointment in wheelchair via van service. Certified Nursing Assistant (CNA) C accompanied R1. During the transport, driver applied brakes to avoid hitting a deer, which led to R1 falling off the seat of the wheelchair and onto the foot pedals. On 10/07/25 at 10:06 AM, Surveyor interviewed CNA C. CNA C stated R1 was sitting on a dycem, cushion, and bath blanket to the best of her knowledge. When the driver applied the brakes, R1 slid under the safety belts and landed on the wheelchair foot pedals. R1's right foot got pinned between the wheelchair wheel and the seat belt device on the floor of the transportation van. CNA C and the van driver attempted to assist R1 but was unable. Van driver called 911. Paramedics arrived and lifted R1 up as another moved the wheelchair out from under R1 and lowered to the floor. From there the paramedics used a sheet to place R1 on a stretcher and transported to the hospital via ambulance.Surveyor reviewed R1's hospital records, dated 09/16/25, which identified R1 acquired a right ankle fracture. R1 was treated and sent back to the facility with follow up orders.On 10/07/25, Surveyor interviewed Director of Nursing (DON) B and asked if having R1 sit on multiple items in the wheelchair during transport contributed to a hazard. DON B said it could have been a possibility, or the driver could have also strapped the belt over the top of the abdomen instead of under it.

Based on observation, interview and record review, the facility did not ensure care plans met medical needs and included preferences for 1 of 3 residents (R) reviewed.R1 had a fall out of wheelchair and there was no intervention added.R1 was sitting on multiple items in the wheelchair per preference that was not noted in the care plan.CAM boot was ordered from the doctor on 09/26/25 and was not added to the care plan.Findings:The facility policy titled, Fall Protocol, states, All licensed personnel are responsible for the initiation and completion of the Risk Management when a fall occurs and the Post Fall Evaluation. Licensed Personnel will implement interventions to prevent further falls. 10. The fall and interventions should be addressed in the care plan. 17. All falls will be addressed and interventions applied. Fall Assessment: . 11. Reassess resident's environment and risk of falling. 13. Implement Immediate Intervention to prevent another fall and add Risk Management report.R1 was admitted to the facility on [DATE] with diagnoses that include a stroke affecting the right side of body and is morbidly obese. R1's Minimum Data Set (MDS) dated [DATE] indicated R1 has no cognitive impairment, understands, and is understood. R1 requires maximum assistance with bed mobility and is dependent on staff for transfers, toileting, and mobility once in a wheelchair.Surveyor reviewed the incident report that notes on 09/16/25, R1 was being transported to an appointment in wheelchair via van service. Certified Nursing Assistant (CNA) C accompanied R1. During the transport, driver applied brakes to avoid hitting a deer which led to R1 falling off the seat of the wheelchair and onto the foot pedals. Example 1On 10/07/25 at 10:06 AM, Surveyor interviewed CNA C. CNA C stated R1 was sitting on a dycem, cushion, and bath blanket to the best of her knowledge. When the driver applied the brakes, R1 slid under the safety belts and landed on the wheelchair foot pedals.On 10/07/25 at 1:15 PM, Surveyor asked for the fall incident report for R1. Director of Nursing (DON) B stated there is not one because it was only looked at as a motor vehicle accident and did not think of it as a fall, but now looking at it, it should have been looked at as a fall. Because it was not looked at as a fall, no intervention was added to R1's care plan.Example 2On 10/07/25 at 10:06 AM, Surveyor interviewed CNA C who was in the van at the time of the incident. CNA C stated R1 was sitting on a dycem, cushion, and bath blanket to the best of her knowledge. On 10/07/25 at 10:32 AM Surveyor contacted Van Service Representative (VR) D by phone and was informed that R1 used cushions under butt and behind back in the wheelchair.On 10/07/25 at 11:10 AM, Surveyor observed R1 in bed and wheelchair was in the room. R1's wheelchair seat contained a dycem, a sit steady cushion, a 2-inch cushion, sheep skin, and a bath blanket. In addition, there was a lumbar back support cushion on the wheelchair. Surveyor asked R1 if all items were used during the deer incident. R1 stated it was and prefers it that way or it would cause tailbone issues.On 10/07/25 at 1:22 PM, Director of Rehab (DR) E informed Surveyor and DON B that R1 has been and is currently using a dycem, sit steady cushion, another cushion, sheep skin, and a bath blanket in the wheelchair for fear R1 will soil the cushion.Surveyor reviewed the care plan and there was no mention of R1's preference to sit on multiple items in the wheelchair, and no mention of the lumbar back support that was used.Example 3Surveyor reviewed R1's physicians orders. Order was received on 09/26/25 that reads, in part, Patient may bear weight on right foot in CAM boot.Surveyor reviewed R1's chart and found no mention of the use of a CAM boot in R1's care plan nor on the CNA Kardex.

The facility did not ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, which had the potential to affect all 42 residents. -Licensed Practical Nurse (LPN) G performed a venous blood draw from R1's foot without evidence of training. -The facility did not have a system in place to evaluate licensed nurse competencies. Findings: R1, an [AGE] year-old male, admitted to the facility on [DATE] for rehab following complications from exploratory abdominal surgery. On 04/29/25, progress notes read in part, Nurse unable to obtain IV access or blood draw for labs. 2 sticks have been attempted. Nurse will pass off to oncoming shift to attempt for stat labs. On 04/30/25, progress notes read in part, Labs drawn from right foot X1 attempt. Resident tolerated well .and given to lab at 0805 am. On 04/30/25 at 9:59 AM, order entered, NP [Nurse Practitioner]-ok to obtain blood sample from foot if able. On 07/01/25 at 1:42 PM, Surveyor requested training and competency evaluations for LPN G, Registered Nurse (RN) D, and RN E. Surveyor reviewed LPN G's, Yearly Staff Education, dated 10/15/24, which included infection control and prevention. LPN G scored 05/10. LPN G's training did not include venipuncture. Surveyor reviewed RN D's training, RN/LPN Nursing Skills Competency Check List, and noted training was dated for 07/01/25. Surveyor reviewed RN E's training, RN/LPN Nursing Skills Competency Check List, and noted training was dated for 07/01/25. On 07/01/25 at 2:53 PM, Surveyor interviewed RN D. RN D stated she was working on the date of the incident, and it was either the first or second day of her orientation. RN D was shadowing LPN G. RN D stated she observed LPN G make at least one attempt to obtain a blood sample from R1's arm but was unsuccessful. RN D reported LPN G stated, Oh I'm just going to try his feet. RN D reported she informed LPN G that RN D was never trained to draw blood from feet. RN D told Surveyor she was not aware of any policy or procedure on using veins in feet for obtaining blood samples, as she was still in orientation at that time. RN D stated one of the nurse managers at the facility told her later that day that procedure is not in their policy and staff should never take blood from the foot. RN D stated during the incident, she stood back and observed and did not take part physically in any part of it. RN D reported all RNs and LPNs that have had training are ok to draw labs. RN D not sure of who has had training. RN D stated hypothetically if she was unable to obtain a sample, she would ask the other nurses or there is a number they can call for an outside qualified person who can come in to help. RN D stated she starts with the hand and works her way up the arm. RN D stated she believes a special order would be needed for any other locations for lab draws. RN D stated she believes the facility held training for venipuncture years ago and possibly a couple years ago while she was working at another facility. On 07/01/25 at 3:31 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated receptionist completes onboarding with new staff. Starting with that, and moving forward, there is a check off sheet of skills staff must complete. NHA A stated she checks in with new staff after orientation and if they staff feel they need more time they accommodate. NHA A said in Relias there is a certain percent, which she believes is 75-80%, they must score in order to have it marked complete. With the classroom or paper education, the nurse managers would go over it with them. NHA A reported LPN G was to receive a notice of discipline, final warning, on 05/12/25, due to LPN G not documenting a change in condition or reporting the change to the RN. On 05/12/25, LPN G gave her notice of resignation prior to the facility giving LPN G her notice of discipline. On 07/02/25 at 9:17 AM, Surveyor interviewed RN E. RN E stated the RNs or those who are educated can perform lab draws. RN E stated if they are unable to obtain a sample after two attempts, they would inform the supervisor or nurse managers and one of those individuals would try. RN E stated arms and hands are the only locations on the body she would obtain a blood sample from and if special orders were needed for other locations, she would ask someone else to perform the task. RN E stated she had previous training for lab draws prior to being hired by this facility. RN E stated she believed there was a paper she had to sign upon hiring. On 07/02/25 at 9:31 AM, Surveyor interviewed RN F. RN F stated the charge nurse, LPNs with training, and RNs can perform lab draws. RN F stated they make two attempts and if they cannot get blood, they let the provider know and the unit manager takes care of it, if it is urgent. RN F stated the locations for lab draws include hand to antecubital area as she believes that is what is in the scope of practice. RN F stated she believes special orders would be required for lab draws to other areas of the body and that special training would be required. RN F stated she believes staff are not allowed to draw blood from feet. On 07/02/25 at 12:36 PM, Surveyor requested the facility's policy and procedure regarding training requirements, including training upon hire, routine training, and specialized training. The facility did not provide the requested information. Surveyor interviewed Director of Nursing (DON) B. DON B stated the facility did not have evidence of licensed nurse training or competency upon hire, since February of this year. DON B stated moving forward all new hires will be trained and/or evaluated for competency upon hire and annually. DON B reported if staff do not meet the criteria for passing the competency training, they would be provided additional education. Surveyor reviewed the facility's licensed nurse staff list with hire date and noted 8 current nursing staff hired since 02/01/25; Clinical Coordinator (CC) K, Nurse Manager M, RN E, RN X, RN Y, RN D, RN W, and LPN Z did not have training nor were evaluated for competency. On 07/02/25 at 1:23 PM, Surveyor interviewed DON B. DON B stated she did not believe they had a standard policy and procedure in relation to venipuncture. DON B reported typically the charge nurse would perform lab draws but nurse managers, the DON, RNs, and LPNs with training could also perform lab draws. DON B reported in the past there was an online training course with a test-out regarding lab draws. Those that completed this course would then receive certification. DON B stated if a nurse was unable to obtain a blood sample, one of the nurse managers, DON, or other floor nurse with training would try. DON B stated the arms, hands, and antecubital areas are the only locations on the body that are used for lab draws. DON B stated they have an outside resource that can be contacted to come in for difficult cases of venipuncture. DON B stated her expectations from staff would be to attempt one of the standard locations for lab draws and ask other staff for assistance if unable to obtain blood, before deciding to try from another location on the body. Regional DON C was present during this interview. Regional DON C stated LPN G, who was involved in the incident, did complete training, but Regional DON C was unable to provide Surveyor with documentation.

Based on interview and record review, the facility did not develop and implement a person-centered care plan for each resident consistent with resident rights including services to attain or maintain the resident's highest or practicable physical, mental or psychosocial needs for 2 of 4 residents reviewed (R3 and R4). R3 and R4 did not have a care plan for an anticoagulant or risk for bleeding. Findings include: Facility policy titled, Care Plans-Comprehensive, last reviewed 06/2022, states in part . The comprehensive care plan is based on a thorough assessment Each resident's comprehensive care plan is designed to incorporate identified problem areas .Incorporate risk factors. Facility policy titled, Anticoagulation-Clinical Protocol, last reviewed 06/2022, states in part . The staff and physician will monitor for possible complications in individuals who are being anticoagulated signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding . Example 1 R3, a [AGE] year-old-female, was admitted to the facility on [DATE], after hospitalization for post-surgical left knee sepsis. R3's diagnoses included atrial fibrillation (a-fib) and anemia. On 03/13/25, R3 was prescribed Xarelto for A-fib. On 05/21/25, R3 was admitted to the hospital. Hospital discharge summary indicated R3 was positive for occult stool. The summary confirmed R3 had arteriovenous malformations in the colon due to anticoagulant use. On 05/30/25, R3 was discharged from the hospital, and re-admitted to the facility, with a diagnosis of acute on chronic anemia, 02/13/25-present. R3 discharged with orders to discontinue Xarelto. On 06/25/25, R3 was prescribed Pradaxa for A-fib. On 07/02/25, Surveyor reviewed R3's care plan and was unable to find current or historical care plan related to anticoagulant use or risk for bleeding. Example 2 R4 was admitted to the facility on [DATE], with diagnoses including stroke, peripheral vascular disease, and history of blood clots in the lungs. R4 was admitted with an order for Pradaxa due to stroke, peripheral vascular disease, and history of blood clots in R4's lungs. R4's Minimum Data Set (MDS), completed on 05/20/25, confirmed R4 scored 15/15 during a Brief Interview for Mental Status (BIMS), indicating intact cognitive function. On 07/02/25, Surveyor reviewed R4's medical record and noted there was no current or historical care plan related to anticoagulant use or risk for bleeding. On 07/02/25, at 9:17 AM, Surveyor interviewed Registered Nurse (RN) E. RN E stated nurses update care plans daily as needed and weekly by the boss. RN E states if there are changes to resident status, nurses discuss it with the CNAs or therapy will fill out forms for staff to read. On 07/02/25, at 9:31 AM, Surveyor interviewed RN F. RN F stated the Certified Nursing Assistants (CNAs) are updated with all changes to a resident's care plan by verbal report or by updating the care plan and Kardex. RN F stated when the Kardex is updated, it populates in the CNA charting. RN F stated the nurses and office staff are responsible for updating the care plans. On 07/02/25, at 9:47 AM, Surveyor interviewed CNA H. CNA H stated therapy will fill out a form for them to review if changes are made to resident status or change in condition. CNA H stated they have a Kardex on the unit and in the computer. CNA H was not sure where the Kardex was at the nurse's station but believes it is updated daily. After a couple minutes, CNA H was able to locate and show Surveyor the Kardex binder. On 07/02/25, at 12:48 PM, Surveyors interviewed Director of Nursing (DON) B. DON B stated the care plans are started by the MDS Coordinator and then each department does their own sections. DON B stated each care plan is personalized depending on each resident's care areas. DON B reported DON B and Nurse Manager (NM) M, will update the care plan and Kardex and notify the nurses. The nurses will update the CNAs in report. DON B reported the Kardex is available at the nurse's station for the CNAs to review, but there is no set routine for them to check it. They just know it's there. Surveyors informed DON B that R3 and R4 did not have a care plan for anticoagulation use and risk of bleeding. DON B could not explain why there was no care plan. On 07/02/25, at 1:45 PM, Surveyor interviewed CNA I. CNA I stated they ask the nurses, or the nurses will tell them in report if a resident is at a higher risk for bleeding in relation to taking blood thinners. CNA I stated there is nothing related to monitoring for this in the CNA charting. CNA I believes there may be some kind of training in Relias. CNA I stated in relation to general changes, CNAs are updated through either report, a black book at the nurses' station, or they have a Kardex in Point Click Care (PCC), which is the facility's electronic medical record system. On 07/02/25, at 1:55 PM, Surveyor interviewed Regional DON C. Regional DON C stated she is very particular in what she includes in the CNA Kardex. Regional DON C stated she believed things related to anticoagulation were more for nurses due to need for assessment. Surveyor addressed the absence of an anticoagulant care plan for either. Regional DON C stated she would make changes moving forward.

Based on observations, interviews and record review, the facility failed to protect the residents' right to be free from sexual abuse. The facility did not implement interventions to protect other residents (R) from exposure of R3's genital area. This affected 2 of 3 residents reviewed for sexual abuse. (R1 and R2) On 03/21/25, R3 exposed his penis in proximity to R1 and R2 in the west dining room. No new interventions were implemented and the previous intervention of placing a blanket on R3's lap was not effective. Findings include: The facility's Abuse policy, with a revision date of 10/2023, indicates: It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrences of harassment, abuse (verbal, physical, mental, or sexual), neglect corporal punishment, involuntary seclusion, physical or chemical restrains not required to treat the residents' medical symptoms, exploitation and misappropriate of resident property. Immediate interventions will be initiated to attempt to eliminate the likelihood that the situation could recur. If a resident's detrimental behavior persists, the IDT will care plan the resident again and determine which corrective actions will need to be taken. On 04/08/25, Surveyor requested and reviewed a facility reported incident that addressed and verified the allegations that R3 exposed himself in an area that R1 and R2 could have seen R1's penis. The investigation included a plan to educate staff and update the policy to improve the facility practice. Staff signatures were noted that they received education on 03/26/25. Surveyor reviewed R1's medical records. R1 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's dementia. R1's most recent Minimum Data Set (MDS) dated [DATE] identifies a Brief Interview for Mental Status (BIMS) score of 1/15, which indicates severe cognitive impairment. R1 was discharged from the facility 03/25/25. Surveyor reviewed R2's medical records. R2 was admitted to the facility on [DATE] with diagnoses that include anxiety and dementia. R2's most recent MDS dated [DATE] identifies R2 has severe cognitive impairment. On 04/08/25, Surveyor observed R2 moving self around the unit in a wheelchair chanting, No, repeatedly. R2 was not able to answer questions appropriately. Surveyor reviewed R3's medical records. R3 was admitted to the facility on [DATE] with diagnoses that include enlarged prostate, stroke, overactive bladder, urinary retention, cognitive communication deficit, and Alzheimer's dementia. R3's care plan with a review date of 04/24/25 indicates R2 requires 2 assist using a mechanical lift for transfers, extensive assist of 2 for toileting and is able to pull pants up and down by self. R3's care plan identifies inappropriate display of nudity and comments to others began on 07/18/23. The latest care planned modification was on 11/18/24. Surveyor reviewed other resident interviews, having no concerns regarding seeing anything inappropriate or feeling uncomfortable. On 04/08/25 at 10:42 AM, Surveyor interviewed Personal Care Assistant (PCA) C who reported is aware of R3's tendencies of exposing himself and is not a Certified Nursing Assistant (CNA) so just reports it. When asked, PCA C stated R3's blanket does not always stay up past his waist. At 12:00 PM, Surveyor interviewed CNA D who reported awareness of R3's behavior of exposing his penis and making sexual comments, but has not seen it personally. When asked what staff is doing to prevent the occurrence, CNA D said staff is to cover R3 up and bring to room for privacy. CNA D added that they do place a blanket on his lap also, but it does not always stay on. At 12:20 PM, Surveyor interviewed Registered Nurse (RN) E. During the interview, RN E stated R3 can drop his blanket at times. At 12:22 PM, Surveyor observed R3 in R3's room, facing the hallway in eyesight of passersby, with the blanket down and his hand in his pants. At 12:30 PM, Surveyor interviewed Director of Nursing (DON) B and together went to R3's room where R3's position was the same. Surveyor asked what could be done differently to avoid exposure to the passersby. DON B stated, We could move his TV and room around to avoid him facing the hallway, and we are trying to change his medication to liquid. At 2:00 PM, Surveyor interviewed CNA F, who verified their presence during the incident, and Surveyor asked what prevention interventions are in place to help prevent R3 from exposing himself to others. CNA F stated they cover R3 up with a blanket and PCA C will do 1:1 if needed. Surveyor asked if the blanket stays on R3's lap and she stated, Not all the time. Surveyor asked if R3 may just need to use the bathroom. CNA F stated does not think so because R3 can and will ask to use the bathroom if needed, and he will laugh and make comments asking staff to play with it (penis) or to sit on it. On 04/08/25 at 2:15 PM, Surveyor interviewed Nursing Home Administrator (NHA) A, and asked what interventions were put into place to avoid the recurrence. NHA A reported it is discussed at morning meetings and the facility is implementing things today.

Based on observation, interview and policy review, the facility did not ensure they stored, prepared, distributed, and served food in accordance with professional standards for food policy safety. The facility failed to label and date perishable items found in the refrigerator. This has the potential to affect all 33 of 33 residents residing in the facility. Findings include: The facility policy, titled Food Storage, dated 09/23/24, states, 12. Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and stated before being refrigerated. Leftover food is sued within 7 days or discarded as per the 2022 Federal food code. On 01/12/25 at 8:53 AM, during initial brief tour of the kitchen, Surveyor observed food items in the refrigerator were not labeled correctly. Surveyor observed an open bag of cherry jam dated December 2nd as the open date. Surveyor observed chopped onions in the refrigerator that were in a container not labeled. Surveyor observed an open milk jug that was half empty not labeled with an open date. Surveyor observed a V8 100% Vegetable juice that was half drank and noticeably separated, with the only date on the juice being July 8th. Lastly, Surveyor observed a tub of leftover pulled pork that had not been labeled or dated on the container. On 01/12/25 at 9:15 AM, Surveyor interviewed interim Kitchen Supervisor (KS) L regarding food labeling in the refrigerator. KS L admitted the food should have been labeled if it was not and if the food was past the seven days date it should have been thrown out. KS L believed the V8 juice probably had the received date on it, but without a clear open date they had no way to confirm the open date of the V8 juice. KS L confirmed that staff should be labeling all leftovers and items that are opened in the refrigerator with open dates and throwing away if not used in seven days. On 01/14/25 at 9:10 AM, Surveyor interviewed Registered Dietitian (RD) M regarding leftover policy. RDM stated they had switched to the seven day plan as per their policy and the federal food code; however, they agree that milk and other items needed to be labeled with open dates. They did education already and made sure everyone has their black sharpie ready. RD M would expect the food be labeled appropriately and if it is past the seven days thrown out.

Based on observations and record review, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional practice. This had the potential to affect 7 out of 7 residents (R) (R2, R14, R17, R20, R32, R33, R136) for proper storage and 1 of 1 resident (R) (R18) for proper labeling. 16 new unopened insulin pens and one bottle of Humalog were found in an out of temperature range refrigerator. R18 did not have an accurate label for insulin. Findings include: Example 1 The facility policy, titled Storage of Medications, dated November 2020, states: . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 3. The nursing staff is responsible for maintaining medication storage and preparations areas in a clean, safe, and sanitary manner. 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured locations . The facility policy, titled Refrigerators and Freezers, dated December 2014, states: Policy Statement- This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Acceptable temperature ranges are 35 F to 40 F for refrigerators and less than 0 F for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. The Wisconsin Department of Health Services document titled, Insulin Storage Guide, dated June 2023, states: Insulin is available from drug manufacturers in two basic packages- vials and pens. General insulin storage requirements are as follows: 1. Never freeze; frozen insulin should be thrown away. 6. Unopened, not-in-use insulin should be stored in a refrigerator at a temperature of 36 F-46 F. On 01/15/2025 at 7:35 AM, Surveyor observed the east wing medication refrigerator thermometer reading 28 F. There was ice buildup around freezer tray and a container with 16 insulin pens and one vial on the top shelf just underneath the ice. On 01/15/2025 at 7:35 AM, Surveyor observed the east wing medication refrigerator temperature logs were half completed for November 2024, no log for December 2024, and January 2025 log to date missed two dates. According to the January 2025 refrigerator log, it was out of range 5 days out of 12 entries (the two dates missed not counted), and was below freezing on 1/7/2025 - 30 F, 1/8/2025-28 F, and 1/9/2025- 30 F. On 01/15/2025 at 7:55 AM, Surveyor interviewed Director of Nursing (DON) B, who stated her expectation is that the nursing staff maintain the refrigerators, temperature logs, and storage of medication. 49353 Example 2 Facility policy titled, Storage of Medications, with no date states in part: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Current Wisconsin State pharmacy labeling requirements effective December 2020 state all prescription medications must include in part: .patient name, date of birth, name and strength of medication, dosage, route . R18 was admitted to the facility on [DATE] with pertinent diagnosis of diabetes mellitus II. R18's physician orders include: -06/29/24 Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 25 unit subcutaneously at bedtime for blood sugar control -08/13/24 Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 25 unit subcutaneously in the morning for diabetes On 01/13/25 at 9:50 AM, Surveyor observed Registered Nurse (RN) C complete medication administration of insulin for R18. Surveyor observed lantus insulin injection pen with a pharmacy label that stated, Inject 25 units subcutaneously at bedtime for blood sugar control. The opened date stated 01/07 and expiration date of 02/07. Surveyor had RN C verify order prior to administration of insulin. Surveyor verified two orders for lantus to be administered daily. On 01/13/25 at 9:53 AM, Surveyor interviewed RN C who stated the label hadn't been updated after an additional order for lantus had been added by the provider. Surveyor asked RN C what the facility policy is regarding pharmacy label not matching the physician order. RN C stated the medication should be sent back to pharmacy to be correctly labeled. On 01/15/25 at 1:50 PM, Surveyor interviewed Director of Nursing (DON) B regarding labeling of medications. DON B stated when a medication label does not match the order the expectation is for the nurse to send it back to pharmacy to be correctly labeled. DON B stated recognition that this had the potential to cause harm if the wrong medication had been administered and would re-educate staff on facility policy for correct medication labeling.

Based on observation, record review and interview, the facility did not ensure 1 resident (R) of 12 sampled residents (R21) was reasonably accommodated for personal needs. R21's room is set up so that he cannot access or use his sink. This is evidenced by: R21 was admitted to the facility on [DATE] and has diagnoses that include but are not limited to: Parkinson's disease with dyskinesia, with fluctuations; difficulty in walking, not elsewhere classified. R21's Minimum Data Set (MDS) assessment, dated 11/19/24, indicated that R21 uses a wheelchair and a 4 wheel walker for mobility. R21's care plan, dated 11/26/24, states: ADL: The resident has an ADL self-care performance deficit r/t Parkinson's disease, weakness, encephalopathy. Ambulation: Ambulate assist of two 250', follow with w/c and use personal 4ww (leave walker in hallway after use so resident does not attempt to use on is own) or distance as tolerate by resident and safe gait pattern. On 01/12/2025 at 1:01 PM, Surveyor interviewed R21 and his Family Member (FM) K who stated there is an issue getting to R21's sink. Surveyor observed it was in the corner while asking for clarification. FM K stated R21 cannot get his wheelchair in the space in front of the sink, nor can he use his walker. R21 stated he can't turn his walker around. R21 stated he doesn't wash his hands, and they don't offer me a wipe either. On 01/13/25 at 9:21 AM, Surveyor observed R21 brushing his teeth in his room; no staff were around to assist him. Surveyor observed R21 propelling his wheelchair towards the sink. R21 was unable to get his chair into the space in front of sink. R21 tried to reach out and put kidney basin in sink. R21 was unable to reach the sink and attempted to stand. R21 was unsuccessful two times before he grabbed foot board of extra bed in front of sink and dresser to attempt to stand. There were still no staff around. Surveyor told R21 to sit and she would get him help. Surveyor got staff to assist resident. On 1/14/25 at 11:38 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J about hand hygiene for residents. When asked if the resident should have washed his hands, CNA J indicated she knew R21 couldn't get to the sink. On 01/14/25 at 11:50 AM, Surveyor interviewed Director of Nursing (DON) B. DON B was not aware that R21 could not reach his sink.

Based on observation, interview and record review, the facility did not ensure that a resident who is unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain safety and personal hygiene (hand hygiene) for 1 out 4 residents (R). R21 does not receive hand hygiene services after toileting or when in his room. This is evidenced by: The policy, titled Handwashing/Hand Hygiene, dated August 2019, states, This facility considers hand hygiene the primary means to prevent the spread of infections. R21 was admitted to the facility on [DATE] and has diagnoses that include but are not limited to: Parkinson's disease with dyskinesia, with fluctuations; non-Alzheimer's dementia; needs assistance with personal care; weakness; difficulty in walking, not elsewhere classified. R21's Minimum Data Set (MDS) assessment, dated 11/19/24, indicated that R21 needs assist with his personal hygiene and activities of daily living. For example, he has been assessed as needing substantial/maximum assist with toilet hygiene and personal hygiene, while oral hygiene is rated - supervision or touching assistance. R21's care plan, dated 11/26/24, states: ADL: The resident has an ADL self-care performance deficit r/t Parkinson's disease, weakness, encephalopathy. Nail care weekly on bath day . Personal Hygiene: extensive assist of 1 On 01/13/2025 at 7:42 AM, Surveyor observed morning cares of R21. Certified Nursing Assistant (CNA) I assisted R21 to the bathroom. At end of cares R21's wheelchair was turned towards the door, and R21 started to self-propel to the dining room. R21 was not offered a washcloth, hand sanitizer, or opportunity to wash his hands after using bathroom or as part of his cares. On 01/13/2025 at 9:21 AM, Surveyor observed R21 brushing his teeth in his room. R21 was holding his kidney basin on his lap with his left hand and toothbrush in right. No staff in room to assist him. On 01/14/2025, at 11:27 AM, Surveyor observed CNA J assist R21 to the bathroom. CNA J used appropriate hand hygiene during intervention for self. No hand hygiene offered to R21 after toileting. On 01/12/2025 at 1:01 PM, Surveyor interviewed R21 and Family Member (FM) K. FM K reported there is an issue getting to R21's sink. Surveyor observed it was in the corner and asked R21 if he could get to his sink. R21 indicated his wheelchair does not fit in space in front of his sink, and he cannot manipulate his walker into the space either. R21 stated he cannot use his sink, and they do not help me wash my hands. They don't offer me a wipe either. On 01/14/2025 at 11:38 AM, Surveyor interviewed CNA J about hand hygiene for residents. When asked if the resident should wash hands after using the bathroom, CNA J stated yes. CNA J also indicated she knew R21 couldn't get to the sink. CNA J proceeded to conclude on her own that she should have offered to assist R21 with hand hygiene. On 01/14/2025 at 11:50 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated her expectations are that hand hygiene be used before entering a patient room and all those times. DON B expects that staff would encourage and assist residents with hand hygiene after toileting.

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice (N6 Wisconsin Nurse Practice Act), the comprehensive person-centered care plan, and the resident's choice for 1 of 13 sampled residents (R1). R1 had a change in condition; staff did not complete comprehensive neurological assessments or have a Registered Nurse assess R1 as the change of condition continued. R1 was sent to the emergency room several hours later and had suffered a stroke, and as a result was put on hospice services. The facility's failure to assess R1 and provide appropriate treatment for stroke symptoms created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator of the immediate jeopardy on [DATE] at 11:55 a.m. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: Facility policy titled, Neurological assessment dated ,d+[DATE], states in part, - .General guidelines: -1. Neurological assessments are indicated: d. When indicated by resident's condition. -2. When assessing neurological status, always include frequent vital signs. -3. Any change in vital signs or neurological status in a previously stable resident should be reported to the physician immediately. -Steps in the Procedure: -4. Determine residents' orientation to time, place, and person. -5. Observe residents' patterns of speech and speech clarity. -6. Take temperature, pulse, respirations, and blood pressure. -7. Check pupil reaction a. Darken room, b. Open eyelid with your fingers, c. Turn on flashlight and observe size and reaction of pupil, d. Repeat the other eye. -8. Determine motor ability: a. Have resident move all extremities, b. Ask resident to squeeze fingers. Note strength bilaterally, c. Have resident plantar and dorsiflex. Note strength bilaterally. Ask resident if/she has any numbness or tingling in legs/feet/toes and document accordingly. -9. Determine sensation in extremities. Rub residents' arms at the same time to if resident has decreased sensation in either arm. Check sensation in lower extremities also and document accordingly. -10. Check gag reflex with tongue depressor, if safe for resident. -11. Have resident smile to determine if there is any facial drooping and document accordingly. -12. Check eye opening, verbal, and motor responses using the Glasgow Coma Scale. Record observations. *Documentation should be recorded in resident's medical record: 1. Date and time procedure was performed. 3. All assessment data obtained during the procedure. *Reporting: 1. Notify the physician of any change in a resident's neurological status . According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. R1 was readmitted to the facility on [DATE] with diagnoses which included in part: Alzheimer's disease, atrial fibrillation, nonrheumatic mitral valve insufficiency, and atherosclerotic heart disease. R1's Minimum Data Set (MDS) assessment, dated [DATE], identified R1 scored 3 during a Brief Interview for Mental Status (BIMS), indicating impaired cognition. R1 had no impairment to upper or lower extremities. R1 was independent with eating, supervision for oral hygiene, partial assistance rolling from left to right in bed, and dependent on toileting, upper/lower body dressing, and personal hygiene. MDS dated [DATE] indicated significant change in status, and MDS was not completed to show R1's current physical functionality. Surveyor observed resident functionality as totally dependent on staff for all cares. Surveyor reviewed R1's care plan. Surveyor observed no updated care plan since 2021. Surveyor reviewed R1's progress notes: -Late entry entered on [DATE] by Registered Nurse (RN) K referring to [DATE] at 9:30 AM, .During am med pass resident was a little sleepy than usual. Assessment done, resident responding to name by opening eyes and sayings yes in a low voice. Resident had her shower a few minutes ago and shower aide reported resident was fully awake. Pupils equal and reactive to light. Bilateral hands with equal grab, squeeze and strength, bilateral lower resident able to push on my hand. Face equal symmetry, no facial droop noted. No s/s [signs/symptoms] of pain noted. Lung CTA. No signs of respiratory distress noted. VS ,d+[DATE], P83, res 16, O2 sats 94 at r/a. HOB at 30 degrees. Charge nurse and clinical manager following on resident`s condition . Surveyor did not observe a complete neurological assessment performed at this time. RN K did not assess orientation to time, place, and person. RN K did not assess full motor ability by assessing resident's movements of all extremities, asking resident if resident had any numbness or tingling in legs/feet/toes and document accordingly. -Late entry entered on [DATE] by Licensed Practical Nurse (LPN) C referring to [DATE] at 11:08 AM, . this writer went to give resident noon medication, resident still responding to name by opening eyes and going to sleep. No signs of TIA 3/stroke noted. Neuro assessment remains WNL [within normal limits]. B/P ,d+[DATE], P 81, R 17, O2 97 AT R/A. Lab done and results pending at this time . Surveyor did not find a comprehensive neurological assessment completed by a Registered Nurse for the entry above. A Licensed Practical Nurse cannot assess. -Late entry entered on [DATE] by LPN D referring to [DATE] at 11:15 AM, .this Writer was notified by an employee that they wanted me to go down and evaluate resident as she seemed very sleepy. Writer went down to the resident's room. Resident was rousable and did talk to me. I did a check on her vitals which were all WNL. I had the resident squeeze hands and both L and R upper extremities were able to move and squeeze my fingers. Had resident move BLE [bilateral extremities] and resident had movement on both sides. I touched her toes and feet and resident was able to move those as well. Resident was sleeping when writer left the room. Writer went to the desk and asked the nurses to please monitor her frequently and to notify the doctor of any changes . Surveyor did not find a comprehensive neurological assessment completed by a Registered Nurse for the note above. A Licensed Practical Nurse cannot assess. -Late entry entered on [DATE] by LPN C referring to [DATE] at 11:30 AM, .Completed a skin assessment on resident and patient was asleep. Checked resident VS: BP:,d+[DATE], P: 89, RR:16, Temp: 97.8, SPO2: 97% RA WNL. Patient was able to respond to stimuli and grasped my hand when checking pulse and blood pressure. Patient responded to name but was drowsy. Notified Physician and was told to monitor. Notified house clinical nurse, and evening nurse. Labs were ordered CBC & CMP . Surveyor did not find an accurate neurological assessment completed by a Registered Nurse for the 11:30 a.m., late entry note. A Licensed Practical Nurse cannot assess. - Late entry entered on [DATE] by LPN D referring to [DATE] at 12:10 PM, .Writer spoke to Nurse at the cart and discusses ordering some lab work to ensure that we are not dealing with something that we do not know about as resident is still sleepy but still responding to stimuli. Writer put call into NP to get orders for CBC and CMP. - Late entry entered on [DATE] by LPN D referring to [DATE] at 12:10 PM, .NP was notified of Change of condition and labs were ordered. STAT Labs placed in 4-[NAME], printed, and drawn by nurse. Sent to lab asap . - Late entry entered by Medical Doctor (MD) P on [DATE] referring to [DATE] at 6:20 PM, .On-Call Telemedicine Visit: Nurse called FNP in follow up stating the patient is really lethargic. She is not really letting us really wake her up. Chart was reviewed. Nurse called FNP [family nurse practitioner] in follow up stating the facility staff said that she did not get up today because she was too sleepy but he just went in and checked her. She is lying in bed. Her left arm is flaccid. She is responding but just barely, just mumbling verbally. Chart was reviewed. Nurse called in MD stating this elderly patient is CPR status. The facility staff said that she was sleeping so they did not want to get her out of bed. MD just went in and checked on resident on robot. She is still sleeping. He tried to arouse her and she does open her eyes. She kind of mumbles and that is the extent of it. She is able to move her right side but her left arm is flaccid. She is not moving it. She is moving her right leg but her left leg she is not moving that well at all. It does move some though but he cannot get her to move the left arm at all. He cannot get her to respond. She has not been out of bed today. Chart was reviewed. A/P: Flaccid hemiplegia affecting left dominant side Slowness and poor responsiveness Unspecified speech disturbances Contusion of left thigh, subsequent encounter; Other abnormalities of gait and mobility; Pain in left knee; Pain in right knee; Low back pain, unspecified; Essential (primary) hypertension; Hyperlipidemia, unspecified; Morbid (severe) obesity due to excess calories - CBC and CMP. - To consider to send patient out. - IV F NS 1 liter bolus. - Follow up to assess at bedside. - Continue to monitor. - Continue with other plan of care . -On [DATE] at 11:44 PM, a change of condition for R1 was entered by RN M, .At approx. 1715 I went into resident's room to administer medications. Report received from dayshift nurse stated that resident was sleepy, so they hadn't gotten her up; she was still lying in bed. Attempted to rouse resident; she opened her eyes but was only able to mumble incoherently. Noted that she had movement in her RUE and RLE but only limited movement in her LLE, and her left arm was completely flaccid. Requested assist from East wing RN, who verified assessment findings and checked V/S: ,d+[DATE], pulse = 119/irreg, O2 sat = 95%, Temp = 97.2. Called MD and attempted to describe resident's status but he insisted that I call him back on an on-call number. Called MD again and described resident's status; advised him that I wanted to send resident to ER for eval and he stated that he wanted to assess resident via mobile computer portal first. Notified DON at 1740 and informed her that it was my desire to have resident evaluated in the ER immediately, and she said she would call MD. Notified (resident's daughter and POA for healthcare) at 1745 and informed her of resident's condition; she stated that she wanted her mother to be sent to ER immediately, and she would go to the hospital to meet her. MD had re-appeared on the computer screen robot at that point and I notified him of POA's decision to have resident evaluated in the ER. East nurse contacted 911 and paramedics arrived to transport resident at 1755, left facility with resident at 1805. East nurse called hospital at 2245 and was informed that resident did in fact have a CVA and would be kept in the hospital overnight, further updates to follow tomorrow . -On [DATE], discharge hospital note indicated, .On [DATE], [AGE] year female chronic atrial fibrillation not on anticoagulation secondary to falls and history of hematoma following anticoagulation. Patient was brought to the emergency department from nursing home with concerns of facial droop and sleepiness. Patient was noted to have facial droop around 8am today, and during the day was noted to be sleepy, and did not communicate much. She is generally talkative at baseline. In view of left-sided facial droop and likely weakness of left upper and lower extremity, patient was seen in the emergency room . In the emergency room patient was lethargic and evaluated. Hospital course: Patient underwent an MRI which showed right MCA [Middle Cerebral Artery] distribution infarcts involving temporal parietal and frontal lobes. Patient remained drowsy and lethargic and evaluated by speech and due to significant impairment with swallowing it was not safe to proceed with swallow evaluation. Alternative forms were discussed with family and family did not want to pursue these avenues. Patient continued to have left hemiplegia and was drowsy and lethargic not following any commands. Family ultimately decided they did not want to pursue any more medical care and wanted to pursue hospice placement. Patient was discharge to SNF today [DATE] for enrollment in hospice . Progress note: -On [DATE] at 11:43 AM, .eighty-seven-year-old female readmitted from hospital to NH with new diagnosis of Acute right MCA stroke with left hemiplegia. Alert but does not verbalize. NPO and now admitted to hospice . On [DATE] at 8:40 AM, Surveyor interviewed Family Member (FM) R and asked FM R about R1's condition before [DATE] and then about the stroke event that occurred on [DATE]. FM R indicated that R1's normal condition before [DATE] was that R1 was very active and would be up early every morning in wheelchair. FM R indicated that facility staff usually would get R1 up in the mornings into R1's wheelchair and R1 would [NAME] around the facility in wheelchair, rummaging through dresser drawers and visiting staff. FM R indicated that R1 loved to see what was going on in hallways and stayed busy with organizing R1's room. On [DATE], FM R received a phone call from RN M who sounded frantic. RN M indicated to FM R that R1 was not responding like normal and couldn't move left side at all. RN M indicated to FM R that R1 was not responding to staff starting this morning on [DATE]. RN M indicated to FM R that RN M wanted to send R1 to the emergency room . FM R requested to RN M that RN M send R1 to the emergency room now. FM R indicated that when FM R arrived at the emergency room , the provider indicated that R1 most likely suffered a stroke. On [DATE] at 12:09 PM, Surveyor interviewed Hospitalist Y and asked Hospitalist Y if Hospitalist Y could walk Surveyor through the events that occurred when R1 was transferred to the hospital from the facility on [DATE]. Hospitalist Y indicated that R1 was transferred from the facility and appeared not responsive, lethargic, and had complete paralysis on the left side upper and lower extremity. Surveyor asked Hospitalist Y if R1 was brought in earlier in the day could the hospital do anything further for R1. Hospitalist Y indicated that R1 had underlying AFIB that was not being treated due to family request of not being on a blood thinner due to recent falls with hematomas. Hospitalist Y indicated if R1 would have been brought to hospital earlier the hospital could have started R1 on some Tissue Plasminogen Activator (TPA) medications to bust up the clot that occurred. Hospitalist Y indicated that if any other interventions were to be placed then R1 would have had to be transferred to a higher level for further care as hospital had limited resources. On [DATE] at 2:31 PM, Surveyor interviewed LPN C and asked about the events on [DATE] that led to R1's transfer to the emergency department. LPN C indicated that LPN C was only involved with completing the treatments for R1 such as the skin assessment and that LPN C was not the primary nurse for R1. LPN C indicated that when LPN C went into R1's room around 11:30 AM, R1 was extra sleepy which was unusual as R1 is very active and tootles around in R1's wheelchair. LPN C indicated that she let charge nurse LPN D know. On [DATE] at 3:25 PM, Surveyor interviewed RN L and asked RN L about the events that led to R1 transferring to the emergency department on [DATE]. RN L indicated that RN L came on shift on [DATE] at 2:00 PM. RN L was called from east wing to assist RN M in R1's room around 5:15 PM. RN L indicated that RN M sounded very alarmed. RN L indicated that when RN L entered R1's room RN L could clearly see that something was very wrong with R1. RN L indicated that R1 was not responding and lethargic. RN L could see that R1 could not move left side at all. RN L indicated that RN L immediately told RN M to call the provider. RN L indicated that RN M called the provider, and the provider came in with telehealth robot and ordered RN M to start IV and infuse saline 250ml. RN L indicated the provider refused to send R1 to the hospital at RN M's request. RN L indicated that RN M immediately called R1's family which then FM R indicated to send R1 to the emergency room immediately. RN L indicated to Surveyor that no one reported to nursing staff at shift change that anything was wrong with R1 all day other than R1 being extremely sleepy. RN L indicated that R1 being extremely tired was not R1's normal for R1's day to day status. On [DATE] at 3:31 PM, Surveyor interviewed LPN D and asked about the events that led to R1 transferring to the emergency department on [DATE]. LPN D indicated that R1 was sleepy in the morning of [DATE] but that LPN D assessed R1 around 11:00 AM. LPN D indicated that R1 had equal hand grasps and vitals were stable. LPN D indicated that LPN D was still slightly concerned so LPN D contacted Nurse Practitioner (NP) X on call. NP X did not answer at first. LPN D called again about 30 minutes later. NP X ordered labs and to continue to monitor. LPN D indicated that R1's vitals were good throughout the day. LPN D indicated that staff did not notify R1's family timely about the sleepiness. Surveyor asked LPN D what monitor for changes meant from NP X's order. LPN D indicated that staff was to just keep checking on R1 and monitor vitals. Surveyor asked LPN D why did documentation show that LPN D did not notify NP until 12:15 PM even though LPN D felt there was something wrong around 11:15 AM. LPN D indicated that LPN D didn't get a chance to call NP until around 12:15PM, then NP did not answer right away. NP called back around 12:45 PM and ordered labs to be drawn for R1 and continue to monitor. Surveyor asked LPN D exactly what time labs were ordered. LPN D indicated that after receiving the order at 12:45 PM staff drew blood and sent immediately to lab. Surveyor asked LPN D when labs were resulted. LPN D indicated that LPN D was done with shift and left at 2:30 PM, and at that time labs were not back yet. LPN D looked on computer and indicated that labs were resulted at 3:14 PM. LPN D indicated LPN D did not know what the results were as LPN D left facility when shift was over. On [DATE] at 4:55 PM, Surveyor interviewed RN K and asked about the events that led to R1 transferring to the emergency department on [DATE]. RN K indicated that R1 was the medication nurse that day for R1. RN K indicated that Certified Nurse Assistant (CNA) O reported to RN K in the morning time that R1 was not feeling well. RN K indicated that RN K went into R1's room around 9:30 AM and R1 was sleepy but vitals were stable. RN K indicated that R1 usually fights the nebulizer machine when administering, and this time R1 did not resist nebulizer. RN K indicated that R1 was extra sleepy and thought at that point there was a change of condition and so RN K let LPN D know of vitals and extra sleepiness. RN K indicated that RN K thought the charge nurse and supervisor would take over caring for R1 to figure out what was going on so RN K did not do anything further. LPN D indicated to RN K that LPN D would assess R1 and then call provider. RN K continued passing medications throughout the day. RN K left shift at 2:00 PM and saw that complete blood count and a comprehensive metabolic panel were ordered for labs but no results were in at that time. RN K admitted to not documenting until the next day as RN K is contracted and only has set hours to work. RN K completed documentation the next day on [DATE]. RN K indicated there was a huddle that took place on [DATE] that involved Director of Nursing (DON) B, LPN C, LPN D, and CNA O reviewing the events that transpired on [DATE]. RN K indicated that staff were told to go back into chart and document on R1 pertaining to neurological assessment completion. RN K indicated there was a lot of pointing fingers and about who CNA O informed about R1's condition early morning on [DATE], when CNA O gave R1 a bath. RN K indicated to Surveyor that CNA O did not report to RN K until around 9 AM. RN K indicated that CNA O did not report the elevated blood pressure to RN K at all. On [DATE] at 5:15 PM, Surveyor interviewed RN M and asked about the events that led to R1 transferring to the emergency department on [DATE]. RN M indicated that on [DATE], RN M arrived at work and finished report around 3:00 PM. RN M had 1 nurse to 25 residents so RN M likes to get RN M's bearings, make to do list and treatments. RN M did a quick walk down the hallway around 3:30 PM and peeked into R1's room where R1 appeared to be sleeping. RN M started medication pass and around 5:15 PM noticed that R1 was not up in the dining room for dinner. RN M asked CNA W on that evening where R1 was and CNA W indicated to RN M that during report staff told CNA W that R1 was not getting up all day due to being extra sleepy. RN M decided to go check on R1 in room. When RN M entered R1's room, RN M noticed that R1 wasn't responding like normal, and RN M assessed facial drooping and left side flaccid. RN M indicated that adrenaline kicked in and knew the situation was an emergency. RN M quickly called east wing RN L for a second opinion. RN M indicated that RN L said call the provider quickly and transfer R1 out to the emergency room . RN M contacted NP X right away and NP X indicated that since it's an emergency NP X cannot give orders to send to the ED and to call MD P. RN M quickly called MD P and tried to explain it was an emergency. MD P quickly became aggravated and told RN M to call back on the correct number as the number RN M called wasn't the correct one. RN M then found the other cell number for MD P and called MD P. RN M indicated to MD P that R1 had been extra sleepy all day and now has facial drooping with left side paralysis. RN M asked MD P if RN M could send R1 to the emergency department as it is severe. RN M indicated that MD P wanted to jump on the telehealth robot first to assess R1. RN M indicated that MD P remoted into the telehealth robot and wheeled down the hallway with the computer into R1's room. RN M indicated that MD P indicated to start IV fluids bolus 250ml and keep monitoring. RN M indicated to MD P the importance of needing to send her into the emergency room . MD P indicated monitor R1 and infuse the normal saline fluids. RN M immediately called FM R and informed FM R what occurred and R1's condition. FM R insisted that RN M send R1 into the emergency room right away. RN M indicated that RN M called DON B and explained the situation and that RN M would be sending R1 out to the emergency room . DON B indicated to RN M that DON B would call MD P and speak with MD P about the situation. RN M indicated to RN L to call 911 now. RN L called 911 and stated that EMS would be arriving shortly. RN M indicated to Surveyor that MD P never did call back and give the order to transfer R1 out to the hospital nor did RN M hear from DON B again that night. RN M indicated that when EMS arrived, EMS stated that it was good facility called them in for R1. Surveyor asked RN M if RN M observed anyone go in and check on R1 between the time RN M started shift at 2:30PM until 5:15 PM. RN M indicated that RN M did not observe anyone go into R1's room. RN M indicated that CNA W who was on shift was pulling a double shift that day, and CNA W indicated to RN M at dinner time that day shift reported they did not get R1 up at all today due to R1 being extremely sleepy. On [DATE] at 7:59 AM, Surveyor interviewed CNA O and asked about the events that led to R1 transferring to the emergency department on [DATE]. CNA O indicated that CNA O was R1's bath aide on [DATE]. CNA O indicated that R1 wasn't R1's self. CNA O stated that R1 usually resists baths and will swing arms at CNA O but R1 did not do this, this time. CNA O indicated that CNA O completed vitals and reported to RN K that R1's blood pressure was ,d+[DATE] which was not R1's norm. CNA O indicated that once RN K did not go check on R1, CNA O went to Social Services Director AA and Activities Director Z. Then Social Services Director AA and Activities Director Z went to LPN D. On [DATE] at 8:09 AM, Surveyor interviewed LPN C again and asked for clarification on when LPN C went into R1's room to complete skin assessment. LPN C indicated that LPN C was not R1's primary nurse and went into R1's room to perform skin assessment which would be the time indicated on her late entry of around 11:30 AM. LPN C noticed R1 was extra sleepy and could only mumble softly to LPN C. LPN C reported R1's sleepiness and minimal responsiveness to RN K who was R1's primary nurse. On [DATE] at 8:15 AM, Surveyor interviewed LPN D and asked for clarification on events that led to R1's event on [DATE]. LPN D indicated that LPN D was notified by Activities Director Z at 11:00 AM that CNA O reported to RN K that R1 was extra sleepy and off. LPN D entered R1's room around 11:00 AM, but unsure of exact time and started assessing R1. LPN D indicated that LPN D rubbed R1's arms and chest vigorously. LPN D indicated that R1 opened eyes and when LPN D asked R1 was R1 ok, R1 responded in a low voice yes. LPN D indicated that LPN D grabbed R1's hands and R1 grasped equal. LPN D indicated that LPN D felt around on both feet and pushed a little and then gathered a set of vitals. LPN D indicated that R1 seemed very sleepy but ok. LPN D indicated that LPN D indicated to RN K to monitor closely for any changes. LPN D asked RN K around noon if there were any changes for R1. RN K indicated there was not a change in R1 so LPN D contacted NP and had to leave a message. Surveyor asked LPN D what monitoring closely meant. LPN D indicated that RN K was to follow the change of condition and neurological assessment policy. Surveyor asked LPN D what expectation is for documenting events in the Electronic Health Record (EHR). LPN D indicated that expectation is everything is documented shortly after the event or the same day. LPN D indicated that [DATE] was so busy that LPN D charted in the EHR the next day. Surveyor asked LPN D was LPN D sure of time frames since documentation was the next day on [DATE]. LPN D indicated that LPN D did best at remembering time frames. Surveyor asked LPN D who was the primary nurse for R1 on [DATE]. LPN D indicated the shifts are split into sections. LPN D indicated the treatment nurse is the primary nurse, then there is a nurse who does the medication portion at the cart, and there is a charge nurse, and then a clinical manager which is I LPN D. LPN D indicated that LPN C was the primary nurse for R1 on [DATE]. On [DATE] at 8:27 AM, Surveyor interviewed LPN C again for clarification on who was the primary nurse for R1 on [DATE] as LPN D indicated that LPN C was primary nurse for R1 on [DATE]. LPN C immediately became defensive and explained to Surveyor there are some fishy things going on with R1's situation on [DATE]. LPN C indicated that LPN C was the treatment nurse but was never told by anyone of R1's condition. When LPN C went into complete skin assessment, R1 did not seem like R1's self and LPN C reported this to LPN D, the clinical manager. LPN C indicated that LPN C never saw LPN D set foot into R1's room and that LPN D's documentation is fake. LPN C indicated that the next day on [DATE] there was a huddle meeting and DON B and LPN D indicated that everyone needed to back document neuro assessments on R1 from [DATE]. LPN C indicated that LPN C didn't do a neuro assessment but only performed a skin assessment. LPN C indicated that during the huddle there was a lot of pointing fingers on who CNA O reported to. LPN C indicated at first CNA O stated she reported to a different RN then reported to LPN C. LPN C indicated that CNA O never reported R1's condition to LPN C. On [DATE] at 10:20 AM, Surveyor interviewed DON B and asked for the timeline on events that led to R1's event on [DATE]. DON B indicated that DON B didn't know all the details of the event on [DATE] but that staff did their best at trying to make sure there were no obvious changes during the day shift that led up to R1 being transferred out to the emergency department. Surveyor asked what DON B's expectation was for assessing R1 for possible stroke. DON B indicated that staff were to follow the facility's neurological assessment if staff were suspicious that R1 was having a stroke. DON B indicated that all staff that were involved documented their interactions with R1 on [DATE]. Surveyor indicated to DON B that progress notes were reviewed and noted that all entries were documented the next day, and the documentation did not follow the facility's neurological assessment protocol. Surveyor asked DON B why entries were documented late. DON B indicated that DON B didn't realize that no one documented that day on [DATE] so DON B asked staff to document the next day on [DATE]. DON B indicated that documentation is something the facility is working on with staff. DON B's expectation is that documentation is completed the day of or shortly after the event. DON B indicated that next day charting is not acceptable. Surveyor asked DON B what DON B did when RN M notified DON B of R1 having a possible stroke. DON B indicated that DON B called provider to see about transferring R1 out. DON B indicated that around 3:30 PM DON B checked on R1 before leaving for the day and didn't seem to have any obvious concerns other than being extra tired. Surveyor asked where that documentation was, and DON B indicated that DON B did not document that. The failure to assess and provide appropriate interventions for R1 led to serious harm for R1, which created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when it completed the following: *All nursing staff to be educated on change of condition policy and when to notify MD. *Facility will do a house sweep to identify any other residents with a change of condition, with appropriate MD notification. *Nursing staff will be educated on symptoms of a stroke by using the FAST (face, arms, speech, time) assessment. Nursing staff will be educated on proper neurological assessment. * On [DATE], facility reviewed policies and

Based on observation, record review, and interview, the facility failed to ensure residents received adequate fluid and food intake to maintain acceptable parameters of hydration and nutrition for 3 of 3 residents (R) (R2, R1, R19). R2 was admitted to the facility on [DATE]. R2 was sent to hospital on 03/16/24 and returned on 03/23/24 with diagnosis of failure to thrive and laboratory results of elevated blood urea nitrogen (BUN) and creatinine indicating dehydration. R2 was hospitalized on [DATE] with elevated BUN, creatinine, and albumin levels, resulting in R2 being transferred to another critical care hospital and expiring on 05/27/24. The facility failed to ensure R2 received adequate fluid intakes to maintain acceptable parameters of hydration to include the following: * failure to assess daily fluid intake; * failure to accurately assess and complete assessments for signs and symptoms of dehydration (e.g., sunken eyes, cool/clammy skin, dry tongue, dark colored urine, and sticky saliva); * failure to develop a plan of care to encourage fluid intake and prevent dehydration; * failure to recognize dehydration and put interventions in place to prevent further dehydration; * failure to communicate R2 not meeting the recommended daily fluid intake with the physician. The facility's failure to assess R2's hydration and develop a plan of care for hydration created a finding of immediate jeopardy that began on 05/20/24. Surveyor notified Nursing Home Administrator of the immediate jeopardy on 09/18/24 at 11:55 a.m. The immediate jeopardy was removed on 09/19/24; however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan and as evidenced by: R1 was readmitted after having a stroke with no nutritional assessment or updates to the nutritional care plan to maintain nutritional and hydration status. R19 is at risk for dehydraton and has no care plan for hydration interventions. This is evidenced by: The facility's Resident Hydration and Prevention of Dehydration policy with the revised date of October 2017, reads in part: 1. The dietitian will assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need. 2. Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments, using current standards of practice. 5. Nurses will assess for signs and symptoms of dehydration during daily care. 6. Nurses; aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. A. intake will be documented in the medical records. B. Aides will report intake of less than 1200ml/day to nursing staff. 7. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. A. ADL status, diagnosis, individual preferences, habits, and cognitive and medical status will be considered in all interventions. B. The physician will be notified. 11. If laboratory results are consistent with actual dehydration, the physician may initiate IV hydration. hospitalization will be recommended, as necessary. 12. Nursing will monitor, and document fluid intake and the dietitian will be kept informed of status. The interdisciplinary team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved. R2 was admitted on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage in brain stem, type 2 diabetes with diabetic neuropathy, morbid obesity, muscle weakness, anxiety disorder, hemiplegia left dominant side, chronic pain, cerebral infarction, chronic embolism and thrombosis right femoral vein, lobar pneumonia, chronic kidney disease stage 2, and edema. Minimum Data Set (MDS) 5 day admission assessment, dated 02/12/24, documented a Brief Interview for Mental Status (BIMS) score of 10, indicating R2 had moderate cognitive impairment. R2 had impairment to one side of the upper extremity. R2 requires staff to provide set-up assistance with meals. MDS quarterly assessment, dated 05/14/24, documents a BIMS score of 8, indicating R2 had moderate cognitive impairment. R2 had impairment to one side of the upper extremity and impairment to both sides of the lower extremities. R2 was independent eating meals. Care plan: dated 02/06/24 with revision date of 02/13/24 Focus: The resident has nutritional problem or potential nutritional problem r/t (related to) Bilateral Lower Extremity Edema, Chronic GERD, CKD State 2, Chronic Pain, Decreased mobility & endurance, Hypertension, Super Obesity, CMT2 w/ diabetic neuropathy MNA screening score 9. Goal: The resident will maintain adequate nutritional status as evidenced by maintaining weight within +/- 5% of 345#, no s/sx (signs and symptoms) of malnutrition, and consuming at least 75% of at least 3 meals daily through review date. Revised 02/13/24 Intervention: 02/06/24 Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 02/06/26 RD to evaluate and make diet change recommendations PRN, 2/13/24 Resident status monitored by nutrition at risk team. 04/25/24: Provide and serve supplements as ordered: LPS BID Ensure Plus with meals Gelatein Plus with PM & HS Snack Pass High Protein Orange Juice TID with meals, Provide, serve diet as ordered. Monitor intake and record q (every) meal. CCHO diet, IDDSI 5-Minced & Moist texture (No Bread) with thin liquids. Note the care plan does not address dehydration with interventions. Dehydration risk observation/assessment on 02/06/24 was not completed to identify a score or determination if R2 was at risk for dehydration. The assessment documented R2 having no weight loss, having bladder incontinence, having a history of dehydration, and having 3 or more predisposing factors. The facility did not complete further dehydration risk assessments. Nutrition Evaluation Comprehensive assessment dated [DATE] was completed by the Registered Dietician. The assessment documented fluid needs of 2,400 ml, and meals calories 1,728 would be 75% of meal intake to meet the required calories. Nutrition Evaluation Comprehensive assessment dated [DATE] documented fluid needs of 2,400 ml, Resident is at high nutritional risk related to dx, MNA screening score of 9, intakes less than 75%, wounds continue to be healing. Refuses to roll. The assessment did not address R2's low fluid intakes or risk of dehydration. Review of the Nutrition at Risk (NAR) assessments for wound care show they document R2's meal intakes and do not address fluid intakes or risk for dehydration. The assessments document meal intakes for 02/15/24 - 68%, 02/22/24 - 62%, 02/29/24 - 48% with the addition of a mighty shake, 03/23/24 no meal intake, 04/04/24 - 58% with change of mighty shake to ensure plus. 04/11/24 - 56%, 04/18/24 - 56%, 04/25/24 - 51% encourage healthy snacks, 05/02/24 - 49%, 05/09/24 - 47%. There are no further assessments. Review of prior fluid intakes for the month of February: R2 refused fluids seven shifts and staff did not document fluid intakes for six shifts. Of the documented daily fluid intakes, R2 had an approximate daily fluid intake of 449 ml. In March, R2 refused fluids nine shifts and staff did not document fluid intakes for 18 shifts. Of the documented daily fluid intakes, R2 had an approximate daily fluid intake of 416 ml. In April, R2 refused fluids five time and staff did not document fluid intake for 12 shifts. Of the documented daily fluid intakes, R2 had an approximate daily fluid intake of 625 ml. Documentation of fluid intakes: 5/1/24 & 5/2/24: 240 ml 5/3/24: 480 ml 5/4/24: 480 ml 5/5/24: 840 ml 5/6/24: 540 ml 5/7/24: 320 ml 5/8/24: 320 ml 5/9/24: 480 ml 5/10/24: 340 ml 5/11/24: 240 ml - resident refused fluids AM and PM shift 5/12/24: 240 ml - resident refused fluids AM 5/13/24: No documentation of fluids 5/14/24: 510 ml 5/15/24: 420 ml 5/16/24: 520 ml 5/17/24: 370 ml 5/18/24: 480 ml 5/19/24: 440 ml 5/20/24: 400 ml on the afternoon shift. Resident refused fluids during AM shift. Documentation of Foley catheter urine output: 5/1/24: 575 ml 5/2/24: 500 ml 5/3/24: 600 ml 5/4/24: 500 ml 5/5/24: 500 ml 5/6/24: 475 ml 5/7/24: 600 ml 5/8/24: 550 ml 5/9/24: 75 ml - no documentation of output for the night shift 5/10/24: 300 ml - no documentation of output for the PM shift 5/11/24: 450 ml 5/12/24: 650 ml 5/13/24: 525 ml 5/14/24: 800 ml 5/15/24: 600 ml 5/16/24: 250 ml 5/17/24: 200 ml 5/18/24: 700 ml 5/19/24: 150 ml - no output for PM shift 5/20/24: 30 ml Note on 05/19/24: foley catheter urine output was 100 ml during AM shift, no urine output for PM shift, and 50 ml during night shift. The facility did not consult with a physician regarding R2 having no output on the PM shift on 05/19/24. Surveyor's review of R2's medical record did not identify completed laboratory tests. Surveyor asked Director of Nursing (DON) B to provide any laboratory results for R2 and no documentation was provided. Review of nurse's note documents on 05/09/24 3:54 PM, communication with physician. Pt with low urine output of 25 ml for day shift. Medical Doctor (MD) P updated, he orders as follows: Flush foley catheter with 500 ml NS every shift. Note R2's vital signs on 05/09/24: 103/49 blood pressure, 16 Respirations, 97.4 temperature, 99% oxygen saturations on room air. Total fluid intake from 05/08/24 was 320 ml with urine output on 05/09/24 AM shift of 25 ml and PM shift of 50 ml and no documentation of urine output for night shift. No further nurse's notes were documented in R2's chart until 05/20/24. Nurse's notes on 05/20/24 at 1:51 AM, documented in part: PM shift reported res had little to no output on their shift and very little on the AM shift. Urine in tubing of res catheter is very dark amber color, not cloudy but only approx 100mL. Woke res and enc her to drink. Res initially refuses but is unable to tell writer why she does not want to drink anything. Res normally eats ice chips and freq c/o nausea or states she is going to vomit. Note res does develop hiccups shortly after taking a few sips of water. VSS except res is a little tachycardic at 111 and O2 sats are 90% on RA. Res was lying flat at this time and was also expressing her dislike for being roused from her sleep. Res appears dehydrated with sunken eyes and dry skin and lips. CNAs performed cares on res and also noted that she did not appear as she normally does and is not as verbally responsive as she was and seems to have a staring, unblinking gaze at times until she is interrupted and then is able to focus again. Res offers no complaints and in fact when asked how she was feeling stated everything feels fine. Nurse will cont to push fluids with res and monitor output and vitals. Nurse will call NP [nurse practitioner] in early AM to obtain orders for labs this AM. Res is currently resting in bed with her eyes closed and in no acute distress. On 05/20/24 at 4:49 AM, Change of Condition Note Text: Assessed res this AM. Vitals stable though BP trending down. Res cont to state she feels fine. Res has taken approx. 100mL of fluid from writer and small sips from other staff but is mostly refusing to drink. Call placed to NP and he gave orders for CMP and CBC this AM and to give res duoneb and recheck oxygen saturations. Discussed res continuing to be her own person and continuing to make detrimental choices regarding her health. NP states they will get labs and then go from there. Note of vital signs: 05/20/2024 1:34 AM, blood pressure (b/p) 106/48, temperature (T) 97.4 F Temporal Artery, pulse (P) 111 bpm, respirations 18 breaths/min, and oxygen saturations (O2) 90.0% Room Air. 05/20/2024 4:47 AM, b/p 99/42, T97.4 F Temporal Artery, P101 bpm, respirations 20 breaths/min, and O2 88.0% Room Air. 05/20/2024 6:10 AM, O2 88.0% Room Air. 05/20/2024 10:26 AM, b/p 105/42, T97.4 F Forehead (non-contact), P90 bpm Regular, respirations 16 Breaths/min, and O2 91.0% Room Air. Progress notes on 05/20/24 read in part: Late Entry: Note Text: DOS 05/20/24. On-Call Telemedicine Visit: S: Nurse called in stating patient has not been eating or drinking anything and nursing staff told nurse yesterday that she had only 50 CC of output on day shift and thenonly [sic] 50 cc on p.m. shift too. There is about 100 cc of dark urine. Nurse has been pushing fluids with her all night. She drank 120 cc and that was after encouraging her. She does not give the nurse any indication of why she does not want to drink. Nurse asked her if it makes her nauseous. She did say a couple of times she wanted to throw up but she did not throw up. It is very common that she says that. She refused her meds yesterday including her Reglan which could be helping her but she is not taking them, so nurse was wondering if nursing staff could do labs on her this morning. Monday .She has had sporadic intake. Her wounds are not healing .Lung sounds are absent on the right side and very hard to hear on the left side .A/P (Assessment and Plan): Hypoxemia, Other specified symptoms and signs involving the circulatory and respiratory systems, Dehydration, Anuria and oliguria, Anorexia, Other signs and symptoms involving food and fluid intake, Morbid (severe) obesity due to excess calories; Muscle weakness (generalized); Essential (primary) hypertension; Chronic kidney disease, stage 2 (mild). CBC (complete blood count), CMP (complete metabolic panel). Continue to monitor . On 05/20/24 at 4:50 PM, Change of Condition, Note Test: Resident was transferred to [hospital] via ambulance due to a change of mental status, increased nausea, increased edema in upper and lower extremities, and decreased urine output . On 05/20/24 at 9:54 PM, Communication - Note Text: Writer spoke with [Name] RN (Registered Nurse) at [Hospital Name] ED, RN stated that resident will be transferred to a higher level of care due to critically high labs, CR of 3.5, dehydration, elevated WBC requiring Levaquin, the need for norepi due to blood pressure issues, and wound care . On 05/23/24, the facility called the second hospital and found resident was in the intensive care unit and was on palliative care and would not be returning to the facility. Review of the emergency room (ER) report dated 05/20/24, which read in part: .while in route EMS noted that she had a b/p in the mid 80's .full sepsis workup had been ordered .Patient on exam does have stage III pressure ulcers on her buttocks as well as her left thigh. Patient became hypotensive, started lab Levophed (Norepinephrine is a vasoconstrictor, similar to adrenaline, used to treat life-threatening low blood pressure.) .laboratory studies were obtained, patient is meeting sepsis criteria. Elevated liver enzymes from an unknown source. Pro-cal is elevated to 6.7. Patient started on levofloxacin therapy we have replaced albumin as well as the calcium . National Library of Medicine documented 05/08/23: Untreated hypotension can be a significant cause of morbidity and mortality. Norepinephrine is a first-line agent for hypotension that does not respond to fluid therapy and can be a powerful adjunct in managing a critically ill patient. Review of ER laboratory results: Creatinine: 3.5 is high with normal range of 0.40 -1.00. BUN: 42 is high with normal range of 6-24. Albumin: 1.8 is low with normal range of 3.7 - 5.2. AST: 238 is high with normal range of 13-39. ALT: 170 is high with normal range of 7-38. Procalcitonin 6.7 is high with normal range of 0.00 -0.07. Interpretation: Significant bacterial infection likely: patient is at increased risk for bacterial sepsis and/or septic shock. WBC: 20.7 is high with normal range of 4.1 - 10.9. Blood culture and urinalysis were negative. CT of chest identified a fatty liver, small left pleural effusion, and opacity right middle lobe suggesting probable atelectasis. On 05/20/24, R2 was transferred from the hospital emergency room by helicopter to another critical care hospital and admitted until passing on 05/27/24. On 09/17/24 at 2:53 PM, Surveyor interviewed RN L asking about R2's condition and intakes prior to transfer. RN L indicated R2 was having continued decline with intakes and the physician was not doing anything. On 05/20/24, the resident was declining and when MD P was updated, MD P would not transfer resident to the ER and said for us to monitor. RN L went to resident and said if she wanted to go to the ER and we will send her, and resident agreed. Surveyor asked about R2's status between 05/09/24 and 05/20/24 since there were no notes in the chart. RN L indicated there should be notes daily on R2 and she was declining. On 09/18/24 at 9:47 AM, Surveyor interviewed Certified Nursing Assistant (CNA) Q about monitoring of resident's fluid intake and reporting of low intakes. CNA Q indicated the CNAs are to document in the computer and should notify the charge nurse when there is low intake. The charge nurse should notify the Director of Nursing and dietician. Surveyor asked how R2's fluid intakes were during the entire stay at the facility. CNA Q indicated R2 had low fluid intake and only liked ginger ale and apple juice and did not like water. R2 continued to decline during her entire stay at the facility. On 09/18/24 at 9:55 AM, Surveyor interviewed DON B about R2's fluid intakes. DON B indicated she could not speak to what occurred with R2 as she was not the DON at that time. DON B indicated her expectations are for the nurses to document if the resident is on fluid restrictions and that would be documented in the treatment record. Offers of free fluids would not be documented only if specific reason. The dietician would be tracking fluid intakes and reviewing. If the resident was at nutritional risk they would be reviewed weekly and otherwise monthly. DON B indicated she believes R2 was looked at weekly for nutrition at risk. Surveyor reviewed with DON B the nutrition at risk documentation reviewed only meal intakes and did not address fluid intakes. On 09/19/24 at 8:35 AM, Surveyor interviewed MD P and asked when MD P would expect staff to notify MD P when a resident is not taking in the recommended number of fluids that registered dietician has recommended for the individual. Surveyor stated, For example someone who has ordered to intake 2400mls but only intakes 200-480 mls a day. MD P indicated that staff would need to notify nurse practitioner following the facility's protocols for eating and drinking. MD P indicated that every situation is different such as residents refusing or not feeling good for the day but if a resident has not eaten or drank in over 24 hours, MD P expects staff to follow protocol, figure out the cause of resident not eating, follow up with dietician to seek preferences, and notify provider right away. The failure to assess and provide appropriate hydration interventions for R2 led to serious harm and death for R2, which created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 09/19/24 when it completed the following: All nursing staff educated on facility policy for tracking fluids/hydration at the facility, including reviewing hydration, notifying MD, and new hydration assessments. Facility completed a house sweep for all residents at risk for dehydration, using a dehydration assessment to determine who is at risk. All at risk residents with less than 1500ml daily intake will be reviewed weekly at Resident at Risk Meetings. All residents at risk for dehydration will have updated care plans. On 9/19/2024, facility reviewed the dehydration procedures in coordination with Nursing, IDT, and Dietitian, including how the facility tracks hydration, reviews dehydration, and follows up on residents at risk. Facility updated the hydration assessment and follows residents who scored an 8 or higher. All residents at risk who consume less than 1500ml will be reviewed and physician will be notified. Hydration policy updated related to required components on dehydration being available for nurses to use/follow. Facility will review dehydration assessments/update care plans on admission, quarterly, and as needed. 46693 Example 3 R19 was admitted to the facility on [DATE] with diagnoses which included: paranoid schizophrenia, stroke, malnutrition, heart failure, altered mental status, dysphagia, and hemiplegia. R19's Minimum Data Set (MDS) assessment, dated 07/05/24, identified R19 scored 9 during a Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R19 is paralyzed on one side of body. R19 was independent with eating, max assist for oral hygiene, max assist for rolling from left to right in bed, and dependent on toileting, upper/lower body dressing, and personal hygiene. Surveyor reviewed R19's dehydration assessment, dated 09/18/24, that indicates R19 scored an 8 meaning R19 is at high risk for dehydration. Surveyor reviewed R19's care plan that had no mention of the risk for dehydration except for one sentence that was added the day of survey, 09/23/24. The sentence under goal section reads, Resident will have no s/sx of dehydration. On 09/23/24, Surveyor reviewed the Registered Dietitian (RD) assessment dated [DATE] that notes R19's daily fluid requirement should be 2700ml. Fluids were not met on 09/20/24 and 09/22/24, therefore the facility placed R19 on the Nutrition at Risk list that is looked at weekly. Surveyor reviewed weights and labs and found them to be within normal limits. Labs dated 08/19/24 are as follows: Sodium 138, BUN 10, and Creatinine 0.67. On 09/23/24 at 2:00 PM, Surveyor interviewed Director of Nursing (DON) B and RD V. Surveyor asked both to identify where on R19's care plan that shows R19's risk for dehydration, the causes, and interventions/revisions to address it. DON B stated the care plan was not revised yet because the team has not met yet for the week. They are also in the process of placing collection hats in the toilets for measuring intake and output. DON B stated that R19 is on the list for monitoring, but it is still a work in progress. On 09/23/24 at 2:53 PM, Surveyor interviewed DON B and asked about R19's nutrition, hydration, and output status. DON B indicated that R19 can feed self after set up. DON B stated that she thought that once the hydration assessment was completed, it would pull to the care plan and automatically create it like the other areas, but it did not. Surveyor asked DON B how staff are monitoring that R19 is not becoming dehydrated. DON B indicated that staff should record intakes and outputs. Surveyor asked DON B if anyone has addressed R19's hydration status. DON B stated, Not completely at this time. Surveyor did not find an updated care plan in place to address R19's risk for dehydration, the causes, and interventions/revisions to address it. 48793 Example 2: R1 was readmitted on [DATE] with diagnoses which included in part: Alzheimer's disease, atrial fibrillation, nonrheumatic mitral valve insufficiency, and atherosclerotic heart disease. R1's Minimum Data Set (MDS) assessment, dated 07/23/24, identified R1 scored 3 during a Brief Interview for Mental Status (BIMS), indicating impaired cognition. R1 had no impairment to upper or lower extremities. R1 was independent with eating, supervision for oral hygiene, partial assistance rolling from left to right in bed, and dependent on toileting, upper/lower body dressing, and personal hygiene. MDS dated on 09/19/24 indicated significant change in status, and MDS was not completed to show R1's current physical functionality. Surveyor observed resident functionality as totally dependent on staff for all cares. Surveyor reviewed R1's care plan. Surveyor observed no updated care plan since 2021. On 09/17/24 at 8:40 AM, Surveyor interviewed Family Member (FM) R and asked FM R about R1's condition and R1's NPO (nothing by mouth) status. FM R indicated to Surveyor that FM R has been requesting to the facility staff to offer pleasurable foods as R1 has become more aware of surroundings and responding to yes and no questions. FM R indicated to Surveyor that FM R doesn't understand why R1 is not being offered some kind of foods and fluids now that FM R is back to the facility. FM R indicated that FM R is aware that while R1 was in the hospital FM R denied wanting tube feeding placement, but FM R now wants that to be changed for R1 as R1 is coming around more after the stroke. On 09/18/24 at 1:50 PM, Surveyor observed FM R feeding R1 pudding and requested to LPN C that R1 start being offered pleasurable foods as FM R keeps asking staff and no one will provide R1 with food. LPN C indicated that R1 is NPO and has not been assessed to eat yet. On 09/18/24 at 1:53 PM, Surveyor interviewed Director of Nursing (DON) B and asked about R1's nutrition, hydration, and output status. DON B indicated that R1 is NPO. Surveyor asked DON B how staff are monitoring that R1 is not becoming dehydrated as Surveyor has not observed any intake or urine output for R1 in the 3 days being on survey. DON B indicated that staff should be using swabs for R1's mouth to moisten R1's lips but staff should be also monitoring intakes and outputs. Surveyor asked DON B if anyone has addressed R1's hydration status. DON B stated, I guess not. On 09/18/24 at 3:11 PM, Surveyor interviewed Dietician V and asked if Dietician V has addressed R1's hydration and intake since R1 has been readmitted to facility 09/13/24. Dietician V indicated no, Dietician V has not addressed, but Dietician V knows that R1's intake needs to be addressed. Dietician V indicated that a meeting was supposed to take place soon but it has not been scheduled yet to address. Surveyor did not find an updated nutritional care plan in place to address R1's intake. Surveyor did not find a speech therapy assessment to address safe nutritional intake for R1.

Based on observation, interview, and record review, the facility did not ensure residents with pressure injuries received necessary treatment and services to promote healing and prevent infection, and did not ensure residents received care and treatment to prevent development of pressure injuries. This occurred for 2 of 5 residents (R) reviewed for pressure injuries. (R1 and R11). R1 did not have a care plan with interventions in place to prevent a pressure injury and developed a deep tissue injury on the left heel, causing actual harm. R1 was not repositioned to prevent the development of pressure injuries. R11 did not have weekly assessments documented for a stage 4 pressure injury. Example 1: According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019: Staff should assess and document the physical characteristics of the wound bed and the surrounding skin and soft tissue at least weekly. Weekly wound assessment and documentation should include, in part: Anatomical location, category/stage, size and surface area, tissue type, color, periwound condition, wound edges, exudate, and odor. NPIAP guidance also recommends repositioning all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved. According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019: Deep Tissue Injury (DTI) is purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. R1 was readmitted to the facility on [DATE] with diagnoses which included in part: Alzheimer's disease, atrial fibrillation, nonrheumatic mitral valve insufficiency, and atherosclerotic heart disease. R1's Minimum Data Set (MDS) assessment, dated 07/23/24, identified R1 scored 3 during a Brief Interview for Mental Status (BIMS), indicating impaired cognition. R1 had no impairment to upper or lower extremities. R1 was independent with eating, supervision for oral hygiene, partial assistance rolling from left to right in bed, and dependent for toileting, upper/lower body dressing, and personal hygiene. MDS dated [DATE] indicated significant change in status, after R1 suffered a stroke. The MDS was not completed to show R1's current physical function. During the survey, Surveyor observed resident being totally dependent on staff for all cares. Surveyor reviewed R1's care plan. Surveyor observed no care plan for pressure injuries (PIs) or skin integrity. Surveyor reviewed Braden scale completed on 09/13/24 indicating that R1 scored 12 and was at high risk for pressure injuries. Surveyor reviewed R1's skin assessments: -On 09/13/24, R1 had a turning and repositioning program in place and no pressure injuries noted. -On 09/16/24, R1 had pressure injury device on bed and a turning and repositioning program in place with no pressure injuries noted. -On 09/17/24, indicated R1 had a new stage 1 pressure injury to the left heel. Skin prep heels and pad and protect interventions were put into place. On 09/16/24 at 10:33 AM, Surveyor observed R1 lying in bed supine with heels directly lying on bed with no elevation or pillow placed underneath R1's heels for off-loading measures. On 09/16/24 at 12:20 PM, Surveyor observed R1 lying supine in same position sleeping in bed. R1's heels were directly lying on bed with no elevation or pillow placed underneath R1's heels to prevent skin breakdown from occurring. On 09/16/24 at 12:29 PM, Surveyor observed Licensed Practical Nurse (LPN) C enter R1's room and apply a nebulizer mask. Surveyor did not observe LPN C reposition R1. Surveyor observed R1 lying supine looking around in bed. R1's heels were directly lying on bed with no elevation or pillow placed underneath R1's heels to prevent skin breakdown from occurring. On 09/16/24 at 12:41 PM, Surveyor observed LPN C and Certified Nursing Assistant (CNA) I reposition R1 to R1's partial right side. LPN C placed a pillow behind R1. Surveyor observed R1's heels lying directly on the mattress. Surveyor did not observe LPN C or CNA I off load R1's heels to prevent further breakdown. On 09/17/24 at 7:32 AM, Surveyor observed R1 lying in bed supine with heels directly lying on uncovered mattress on bed with no elevation or pillow placed underneath R1's heels. Surveyor observed the fitted sheet to be bunched up to R1's bottom/back and not under R1's lower extremities. On 09/17/24 at 9:12 AM, Surveyor observed Family Member (FM) R upset and request CNA I and CNA N come in and reposition R1. On 09/17/24 at 9:16 AM, Surveyor observed CNA I and CNA N enter R1's room. CNA I rolled R1 back to the right side facing the window. Surveyor observed a red purplish spot the size of a golf ball on the bottom and lateral side of R1's left heel. Surveyor asked CNA I and CNA N if they have seen that on the bottom of R1's heel and CNA I and CNA N indicated they have not. Surveyor asked CNA I and CNA N if there are any protective measures in place to prevent skin breakdown. CNA I and CNA N indicated that there is not but would let the nurse know that is on duty. Surveyor did not observe CNA I and CNA N reposition R1's heels to off-load. Surveyor observed R1's heels directly lying on R1's bed. On 09/17/24 at 1:20 PM, Surveyor brought LPN D into R1's room to discuss R1's left heel. LPN D uncovered R1's left heel. LPN D looked at R1's left heel and indicated that R1's left heel is starting to breakdown. LPN D indicated that R1's left heel is slightly boggy and is red/purple in color about the size of a golf ball. LPN D indicated that R1's left heel is the start of a deep tissue injury due to R1's heels being directly on the mattress without off-loading and R1 should have some kind of protection on R1's heels to prevent further breakdown. Surveyor asked LPN D what measures are in place for R1 to prevent skin breakdown since R1 was readmitted on [DATE] after a stroke that impaired R1's mobility. LPN D indicated that at this time there are no measures, but LPN D would get an order and podus boots in place to prevent further breakdown. Surveyor asked LPN D how often staff are to reposition R1 and if R1 should have heels elevated to off load. LPN D indicated that staff should be repositioning every 2 hours and off-loading heels. Surveyor observed LPN D roll a blanket up and try to place under R1's heels, but Surveyor observed R1's left heel still touching the mattress. On 09/17/24 at 1:38 PM, Surveyor interviewed LPN C and asked about a skin assessment completed on 09/16/24 at 9:34 AM. LPN C indicated that LPN C did not see anything wrong with R1's left heel. Surveyor asked LPN C if anyone had reported to LPN C that R1's left heel was starting to break down. LPN C indicated that on 09/16/24 whenever hospice staff were at facility, hospice staff reported to LPN C that R1's left heel was red/purple in color. Surveyor asked LPN C if LPN C assessed R1's left heel after it was reported from staff of the discoloration of R1's left heel. LPN C indicated that LPN C did not assess R1's left heel. Surveyor asked LPN C if LPN C placed any interventions to prevent further breakdown from occurring. LPN C indicated no, LPN C did not do anything different, but LPN C will go off load R1's heels now. Surveyor did not observe LPN C enter R1's room. On 09/18/24 at 7:45 AM, Surveyor observed R1 lying in bed supine with podus boots up to knees not covering R1's heels. R1's heels were lying directly on the mattress with no off-loading in place. On 09/18/24 at 9:00 AM, Surveyor observed FM R in room visiting with R1. Surveyor observed podus boots to be up to knees not providing off-loading measures and R1 still lying supine in bed. On 09/18/24 at 12:35 PM, Surveyor observed FM R in room visiting with R1. Surveyor observed R1 still lying supine in bed. Surveyor interviewed FM R and asked if staff have been in to reposition R1. FM R indicated that R1 has not been repositioned, but FM R requested to staff that staff assist with repositioning for R1. On 09/18/24 at 1:30 PM, Surveyor interviewed CNA U who was on R1's hall. CNA U indicated that CNA U and the other CNA have not been in R1's room since earlier this morning around 7:30 AM. CNA U did not reposition since this morning. CNA U asked Surveyor isn't R1's family in R1's room. Surveyor asked CNA U does that mean that family provides repositioning. CNA U indicated well sometimes they help but that CNA U should have probably been in R1's room earlier to reposition. On 09/18/24 at 1:44 PM, Surveyor observed family reposition R1 onto left side and placed podus boots on R1's feet to off-load R1's heels. Surveyor interviewed FM R and asked if staff came in to reposition R1 and FM R stated, No, my daughter and I had to reposition mom and provide oral cares. FM R indicated that FM R repositioned R1 so R1 was comfortable. On 09/18/24 at 1:53 PM, Surveyor interviewed Director of Nursing (DON) B and asked about repositioning residents who are dependent on total staff care. DON B indicated that totally dependent residents and who are at risk for a PI should be repositioned every 2 hours and as needed. Surveyor did not observe a pressure injury device on R1's bed or repositioning every 2 hours through all observations from 09/16/24-09/18/24. Surveyor observed podus boots placed on R1's heels 09/18/24 after Surveyor's interview with the wound nurse. 40181 Example 2 Record review identified R11 was admitted to the facility on [DATE]. R11 had the following diagnoses, in part, encephalopathy, type 2 diabetes mellitus, and unspecified dementia. R11 did not have any pressure injuries present at the time of admission. During R11's stay in the facility, R11 developed a pressure injury on the spine. Record review identified R11 was hospitalized from 06/21/24 through 06/27/24 for surgical intervention of the stage 4 pressure injury of the lumbar spine. Hospital records identified R11 had osteomyelytis of L1 vertebra. R11 returned to the facility with a wound vac to the wound and IV antibiotic therapy. The wound vac treatment was discontinued on 06/30/24 and IV antibiotic treatment was completed on 08/03/24. Record review identified the most recent Weekly Wound Observation Tool documentation for the stage 4 pressure injury on the lumbar spine was dated 08/22/24. The document labeled the wound as a surgical wound. The comments section of the document noted, Skin area located on the low back that is leaking clear fluid. No infection present, healed otherwise from back surgery. The documents listed measurements of 0.75 centimeters (cm) by 0.4 cm by 0.01 cm. Surveyor was unable to find any other weekly assessment documentation of the lumbar spine pressure injury with measurements and description of wound condition or drainage after that date. Surveyor did find skin/wound notes that documented the lumbar spine pressure injury continued to have drainage from the area, but there was no description of the wound, surrounding tissue, or measurements. Surveyor identified a progress note titled Infection Note, dated 09/16/24, which stated in part, Resident has orders to begin antibiotic treatment for an infected wound on his back . On 09/17/24 at 5:54 AM, Surveyor observed wound care on R11's left heel pressure injury and lumbar spine injury provided by LPN D and LPN J. The dressing removed from the lumbar spine stage 4 pressure injury showed evidence of drainage from the wound. On 09/18/24 at 12:33 PM, Surveyor interviewed LPN D, who stated they were the certified wound nurse for the facility. Surveyor asked why they were not documenting a weekly wound assessment with description of the wound, measurements, and description of drainage for the stage 4 pressure injury to R11's lumbar spine. LPN D stated they were not aware the wound was a pressure injury and was told by previous wound nurse the wound was a surgical wound. LPN D stated they were not aware they should continue to document on the wound because they considered it healed because it had no measurable size. Surveyor asked LPN D if the wound was healed if it continued to have drainage. LPN D stated no, there was probably something still present. LPN D confirmed the NP from the wound clinic cultured the lumbar spine wound last week and identified an infection and ordered antibiotics. LPN D stated they would resume weekly assessments with documentation of the lumbar spine pressure injury.

Based on observation, interviews, and record review, the facility did not ensure 1 of 1 resident (R3) at high risk for pressure ulcer development received the necessary treatment and services needed to prevent the development of a pressure injury (PI) or to prevent worsening of an existing PI. -R3 developed a facility acquired unstageable PI to right foot on 07/10/24 which became larger with a macerated center on 07/16/24 resulting in actual harm. The facility did not complete weekly comprehensive assessments of R3's PI. The facility did not ensure preventative pressure relieving measures were implemented. The PI of the right foot is cited at actual harm. -R3 acquired a PI to right buttock stage II, due to shearing on 06/12/24. Interventions to prevent friction and shearing were not put into place. The facility did not complete weekly comprehensive assessments of R3's PI. Findings include: The facility policy titled Prevention of Pressure Injuries, reads in part . Assess the resident on admission (within twenty-four hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors. During the assessment, inspect: a. Presence of erythema. b. Temperature of skin. c. Edema. Inspect the skin on a daily basis when performing or assisting with personal cares or ADLs. a. Identify any signs of developing pressure injuries (i.e. non-blanchable, erythema). b. Inspect pressure points. Evaluate, report, and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. According to the National Pressure Injury Advisory Panel/European Pressure Ulcer Advisory Panel (NPIAP/EPUAP), Weekly assessments provide an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan. The NPIAP directs that the professional should reevaluate the pressure injury assessment plan if the pressure injury does not show signs of healing within two weeks and adjust the treatment accordingly. The NPIAP states a comprehensive wound assessment should be completed weekly and should consist of the following information: -location of the wound; -category/stage of the wound; -size of the wound; -tissue type(s); -description of the wound bed and periwound; -description of the wound edges; -presence of any sinus tracts, undermining, or tunneling; -presence of exudate or drainage; -presence of necrotic tissue or slough; -presence of odor; -presence/absence of granulation tissue and/or epithelialization; and -the current treatment being utilized. R3 was admitted to the facility on [DATE]. Diagnoses (dx) included osteomyelitis of ankle and foot, type 2 diabetes mellitus, venous insufficiency, and heel fracture. R3's Minimum Data Set (MDS) assessment, completed on 06/18/24, indicated R3 had no skin concerns or PIs and was at risk for PIs. R3's skin care plan: -06/12/24, has right buttock open areas possibly due to shearing. (Surveyor noted no interventions related to right buttock wound). -06/14/24, The resident is at risk for skin breakdown/pressure areas related to dx of diabetes, does not like to get out of bed at times, incontinent of bowel and bladder at times. (Surveyor noted no interventions related to risk for skin breakdown). -07/11/24, unstageable pressure area to bottom of right foot. -07/16/24, resident has pressure area to left coccyx-new-facility acquired. R3's skin interventions: -06/14/24, Diabetes medication as ordered. -06/14/24, Fasting serum blood sugar. -06/14/24, Monitor and document blood sugars. -06/14/24, Monitor and document signs of hypoglycemia. -06/14/24, Dietary consult. -06/14/24, Monitor and report compliance with diet. (Note, interventions listed above do not address R3's right buttock PI, shearing, and potential for skin breakdown). -07/03/24, Check heels and feet twice daily for any skin issues. -07/05/24, Check air mattress and let maintenance know of any concerns. -07/11/24, Heel riser to be used when resident is in bed. (Note, Surveyor did not observe this intervention during the survey period.) -07/16/24, Resident has pool noodle at end of bed to help prevent foot from touching footboard. Place pillow under heels to be sure heels/feet are not touching bed/footboard (Note, Surveyor observed pool noodle on R3's floor during the survey period. R3's heels/feet were not elevated on pillows. Surveyor observed R3's right foot and heel to be resting against the footboard). R3's physician orders included: -07/10/24, right foot, cleanse area with ns, pat dry, cover with mepilex, two times a day for wound care. -07/18/24, weekly skin assessments. (Surveyor noted orders on 07/22/24, were obtained after Surveyor interviewed staff related to R3's PIs.) -07/22/24, 4.2 cm x 6.0 cm unstageable pressure wound to bottom of right foot. Cleanse with normal saline, pat dry, apply telfa, followed by gauze, two times daily. (Note, order for 4.2 cm x 6.0 cm is not accurate based on measurements from 07/16/24 of 8.0 cm x 6.2 cm). -07/22/24, Stat referral to wound care to right posterior foot. (Note, no physician orders related to right buttock wound). R3's skin assessments: -06/12/24, admission progress note, right buttock has an open area. (Note, a comprehensive skin assessment was not completed.) -06/20/24, a comprehensive weekly skin assessment was not completed. -06/27/24, RIGHT BUTTOCK, pressure: 4 x 4 x 0, suspected deep tissue injury, (Note, a comprehensive skin assessment was not completed.) -07/04/24, RIGHT BUTTOCK, pressure: 4 x 4 x 0, suspected deep tissue injury, (Note, a comprehensive skin assessment was not completed.) -07/10/24, progress note reads: unstageable pressure area on bottom of RIGHT FOOT. Measures approx. 4.2 x 6.0 cm. (Note, a comprehensive skin assessment was not completed.) -07/16/24, RIGHT BUTTOCK, stage 2 pressure area, facility acquired on 06/12/24, possibly from friction and shearing. 1.0 x 0.8 cm. (Note, 07/16/24 is the first comprehensive skin assessment, 34 days after acquiring PI.) RIGHT GREAT TOE/RIGHT FOOT, 8 cm x 6.2 cm. Scant drainage. Area is red and rolled edges with macerated center. No redness/swelling around site, no greenish drainage, (Note, 07/16/24, is the first comprehensive skin assessment, 6 days after acquiring PI.) LEFT GLUTEAL FOLD, 2.5 cm x 0.8 cm, stage 2 pressure area, facility acquired, new. During interview with Director of Nursing (DON) B, it was noted Quality Nurse M completed skin assessment of R3's buttocks on 07/16/24; she noted the dressing was dated 12 days prior on 07/04/24. Surveyor noted there are no physician orders for buttock treatment. On 07/22/24 at 10:15 AM, Surveyor interviewed R3. R3 was lying in bed. Surveyor observed R3's right foot was wrapped with clean, dry gauze dressing. Surveyor observed R3's right foot was resting on the surface of the bed, and on the footboard of the bed. R3 stated, My right foot was okay when I admitted , now I have a sore on it, maybe from rubbing on the footboard. R3 reports receiving showers twice weekly. R3 confirmed he does not like to reposition often, and he is most comfortable on his back. On 07/22/24 at 10:36 AM, Surveyor interviewed Registered Nurse (RN) K. RN K reported she requested a stat order wound consult today, as R3's right foot is odorous. RN K confirmed R3 has a follow-up appointment scheduled with orthopedics on 07/31/24. On 07/22/24 at 10:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G. LPN G reported weekly wound progress was completed by an employee who no longer works at the facility. LPN G was not aware of the staff person responsible for completing weekly wound assessments now. On 07/22/24 at 2:29 PM, Surveyor observed R3's feet were resting on the surface of the bed. Surveyor did not observe heel risers or a pool noodle per R3's care plan. On 07/23/24 at 6:37 AM, Surveyor observed R3 in bed, blue pool noodle was lying on the floor. R3's feet were resting on the surface of the bed and against the footboard of the bed. On 07/23/24 at 9:08 AM, Surveyor observed R3 in bed, blue pool noodle was lying on the floor. R3's feet were resting on the surface of the bed and against the footboard of the bed. On 07/23/24 at 9:16 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D. CNA D stated staff are to keep R3's feet off the footboard of the bed and to elevate his feet on pillows. On 07/23/24 at 9:18 AM, Surveyor observed LPN L complete wound treatment to R3's right foot. Surveyor observed R3's bottom great right toe and pad of bottom right foot were black covered eschar and unstageable. R3 denied pain in the foot during treatment. There were no concerns related to wound treatment completed by LPN L. R3 declined to allow Surveyor to observe wounds to his buttocks. On 07/23/24 at 9:48 AM, Surveyor interviewed DON B. DON B reported the employee who was completing weekly wound care assessments no longer works at the facility. DON B stated she was aware weekly wound assessments and documentation were not completed for a week after the employee left, but stated assessments had been completed by Quality Nurse M last week on 07/16/24. Surveyor noted staff education had not been completed with all staff on PI prevention prior to start of this survey. Current noncompliance was observed during the survey.

Based on observations, interviews and record review, the facility did not ensure 3 of 3 residents (R7, R5, and R1) reviewed with pressure injuries (PI) and at high risk of pressure injury development received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. R7 developed a stage 2 PI to the right gluteus on 03/27/24, a stage 2 PI to spine on 05/01/24, and a stage 3 PI to the left heel on 05/13/24 which became unstageable on 5/29/24 resulting in actual harm. The facility did not initiate preventative pressure relieving measures, complete weekly comprehensive assessments of the PI, and no treatment changes or physician notification for increasing size of the PIs. This example is cited at actual harm. R1 was readmitted to the facility on [DATE] with 4 PIs (left heel, right heel, right ischial tuberosity and penis). R1 developed a stage 2 PI to the right heel in the facility on 4/24/24. R1 did not have weekly comprehensive assessments of the PIs to determine staging, no updated treatment orders or physician notification, or updated interventions on the care plan for pressure relief for the heels to promote healing. R5 had a facility acquired PI from friction and shearing, to the left lower extremity. A comprehensive assessment of the PI was not completed. Interventions to prevent friction and shearing were not put in place until after the PI developed. This is evidenced by: Facility policy titled Wound Care with no date of review/revision states the following: Documentation: The type of wound care given, date and time the wound care was given, position in which the resident was placed, name and title of the individual performing the wound care, any change in the resident's condition, all assessment data (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound, and how the resident tolerated the procedure. Reporting: Report other information in accordance with facility policy and professional standards of practice. *According to the National Pressure Injury Advisory Panel/European Pressure Ulcer Advisory Panel (NPIAP/EPUAP), Weekly assessments provide an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan. The NPIAP also directs that the professional should reevaluate the pressure injury assessment plan if the pressure injury does not show signs of healing within two weeks and adjust the treatment accordingly. The NPIAP also states that a comprehensive wound assessment should be completed weekly and should consist of the following information: - location of the wound; - category/stage of the wound; - size of the wound; - tissue type(s); - description of the wound bed and periwound; - a description of the wound edges; - the presence of any sinus tracts, undermining, or tunneling; - the presence of exudate or drainage; - the presence of necrotic tissue or slough; - the presence of odor; - the presence/absence of granulation tissue and/or epithelialization; and - the current treatment being utilized. The NPIAP 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . Example 1 R7 was admitted to facility on 11/09/23 with pertinent diagnoses of encephalopathy, type II diabetes mellitus with foot ulcer, dysphagia, cognitive communication deficit, acquired absence of left toe, cellulitis of left lower limb, stage 3 pressure injury, diabetic foot ulcer, dementia, diabetic neuropathy, and left femur fracture. R7's admission Minimum Data Set (MDS) assessment completed on 11/14/23 stated no skin conditions were present and R7 was at risk for PI. R7's most recent MDS assessment, which was a quarterly, dated 05/16/24 states R7 had two stage 2 PIs and one stage 3 PI. R7's Brief Interview for Mental Status (BIMS) score is 9 out of 15 indicating moderate cognitive impairment. Surveyor reviewed R7's comprehensive care plan and noted the following: ADL: The resident has an ADL self-care performance deficit (initiated 11/9/23) Interventions: -Reposition every 2 hours (initiated: 6/14/24) -Self cares: Max assist for all bathing and dressing (4/19/24) -Transfers: hoyer (4/19/24) -W/C MOBILITY: Use leg rests only for transportation then remove. Encourage w/c mobility to/from his room in resident's hallway. (1/23/24) -BED MOBILITY: extensive assist (11/29/23) SKIN: Resident has pressure area to left heel. (facility acquired). Resident has diagnosis of dementia, type II diabetes, is assist of II and the hoyer for transfers, and repositioning. (Initiated 11/29/23; last revised 6/12/24) INTERVENTIONS: -Apply PRAFO boot to left foot to be worn all day and then protective boots in bed. Check skin over for redness/skin breakdown from brace before and after putting on and off. (6/12/24) This intervention started one month after the PI on the heel was identified. -Avoid friction and shear. Keep linen and clothing wrinkle free to avoid undue pressure points to skin, avoid sliding and pulling (11/10/23) -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. (11/10/23) -Be sure heels are not touching the bed or the backs of the wheelchair. (6/12/24) -Check right heel BID and report any redness, black area/skin concerns. (initiated: 11/10/23) (revised: 06/12/24) This intervention started one month after the PI on the heel was identified. -Complete Braden scale per facility policy (11/10/23) -Do skin care BID- 1.) rinse with saline, pat dry, 2.) Silvadene 1% topical cream on plain aquacel over ulcer. 3.) Cover with ABD pad and roll gauze. (initiated: 11/10/23) (revised: 6/12/24) -Encourage repositioning every 2-3 hours to offload on pressure areas and to promote healing. (initiated: 5/10/24, revised: 6/12/24 change to repositioning every 1-2 hours) -Inform the resident/resident representative/MD/dietary of any new skin breakdown promptly. (11/10/23) -Resident goes to wound care at least weekly. See documentation on measurements. (initiated: 5/10/24, revised: 6/12/24) Review of dietary orders did not address nutritional, and protein needs to promote healing of wounds. R7's weight on 03/18/24 was 228.8 lbs. and on 06/17/24 weight was 209 lbs. resulting in a weight loss of 8.65% in 3 months. Surveyor reviewed R7's PI documentation: Right gluteus stage 2 PI: in-house acquired on 03/27/24. New open area identified right buttock. Area cleansed well. Border foam applied. MD and Power of Attorney (POA) updated. No physician orders for treatment documented. 03/27/24: 2cm x 1.4cm 04/03/24: 1.45cm x 1cm 04/24/24: 5.5cm x 3.27cm - MD/POA not notified of change. 05/01/24: 5.31cm x 2.23cm 05/08/24: 5.38cm x 2.13cm No assessment of wound bed, characteristics, drainage, or depth for the above measurements. No new interventions to promote healing for the above measurements. 05/15/24: 2.87cm x 1.21cm 05/21/24: 4.85cm x 1.64cm - No physician notification of increase in size of wound. 06/05/24: 2.57cm x 0.81cm 06/12/24: 1.62cm x 0.5cm No assessment of wound bed, characteristics, drainage, or depth for the above measurements. No new interventions to promote healing for above measurements. Spine stage 2 PI: in-house acquired on 05/01/24. 05/01/24: 1.36cm x 0.49cm - MD or POA not notified. 05/03/24: Daily and as needed for soiled dressing. To coccyx remove soiled dressing, cleanse with NS (normal saline) pat dry and cover with bordered foam. one time a day. Of note, this is not the coccyx, but the lower spine PI. 05/08/24: 1.27cm x 0.61cm No assessment of wound bed, characteristics, drainage or depth for the above measurements. No new interventions for the above measurements. On 05/10/24, care plan was updated to encourage repositioning every 2-3 hours. 05/10/24: Treatment Administration Record documented wound care to coccyx, cleanse with ns (normal saline), pat dry and cover with bordered foam dressing. every day shift every 3 day(s) for coccyx wound change if soiled, saturated or coming loose, until healed. Of note, this is not the coccyx, but the lower spine PI. 05/15/24: 1.49cm x 0.86cm - No physician notification of increase in size. 05/21/24: 1.43cm x 0.53cm 06/05/24: 1.24cm x 0.22cm 06/10/2024: Appointment scheduled for 06/12/24. R7 seen by provider and requested a wound care referral for wound on his back. 06/12/24: 1.29cm x 0.78cm No assessment of wound bed, characteristics, drainage or depth for the above measurements. No new interventions for the above measurements. 06/13/2024 Received new order for Mid thoracic spine dressing change daily, clean wound with saline wound wash, pat dry, SSD (put on like frosting/thick), cover with mepilex/one time a day for wound care. On 06/17/24 at 1:36 PM, Surveyor observed foam dressing in place mid-back with no date. Surveyor observed during wound care moderate amount of greenish-yellow drainage on dressing with no odor. Surveyor observed nickel-size opening. Peri wound area dry, intact, reddened, purple, and white. Surveyor observed to be non-blanchable. Left Heel 05/13/24: 4.22cm x 3.51cm - No assessment of wound bed, characteristics, or depth. New order to cleanse with NS, pat dry, apply border foam daily every day and every evening for stage 3 pressure ulcer to left heel. 05/14/24: Received wound care orders for PRAFO boot to be worn all day and then protective boots in bed to offload the heel and Augmentin 875/125 1 tab BID x10 days. Left heel stage 3 PI: in-house acquired on 05/13/24. Received orders for wound care clinic with first visit 05/14/24. No comprehensive assessment including wound bed, depth, characteristics documented. Surveyor did not observe prior to 05/13/24 any skin assessments of the left heel or interventions to relieve pressure from heels to prevent injury. On 5/14/24 Signs of wound infection noted and treated promptly with antibiotics started the same day. 05/15/24: 2.74cm x 1.79cm - No assessment of wound bed, characteristics, or depth. 05/16/24 - final lab on wound culture from 05/14/24 wound clinic visit - two morphologic types of Coryneform bacilli present and light Staphylococcus aureus. No new orders or interventions for the left heel. 05/21/24: 2.58cm x 0.44cm - No assessment of wound bed, characteristics, or depth. 05/29/24 -wound clinic assessment: 75% necrotic tissue and 25% red tissue in the periphery. The necrotic area measures 1.8cm x 1.1cm inside the wound. Measurement of wound is 2.0cm x 2.5cm x 0.1cm. Dull redness surrounding the wound with exfoliation at the edge. The dull redness measures 8x6cm. New wound orders received - left heel unstageable pressure injury wound care: Do daily 1. Rinse with saline. Pat dry. 2. SSD on plain aquacel. 3. Cover with ABD pad and gauze roll. Left heel ulcer infection: Doxycycline 100mg 2x/day x14 days. (wound culture done). Prafo boot LLE on at all times. May wear soft protective boot at night. Follow-up in 2 weeks. Noted documentation in the wound clinic notes that the wound clinic spoke with facility who states wound has been present for at least 2 months. Of note, Surveyor did not find wound culture results in medical record so cannot verify if PI was infected. 06/05/24: 4.26cm x 3.12cm - No assessment of wound bed, characteristics, or depth. 06/12/24: 5.56cm x 3.35cm -No assessment of wound bed or depth. 06/13/24: New order for left heel pressure 1) clean with saline wound wash, pat dry. 2) Silvadene 1% cream (apply like frosting/thick) on plain aquacel, place over ulcer. 3) cover with ABD and rolled gauze. PRAFO boot day and night. 4) heel protector to RLE. On 06/17/24 at 8:08 AM, Surveyor observed R7 in wheelchair in hallway near elevator nursing station. Unable to determine if pressure reducing cushion in place. On 06/17/24 at 11:40 AM, Surveyor observed R7 sitting in wheelchair in same position, near nursing station. Surveyor asked RN E when wound care would be completed for R7 for observation. RN E stated after lunch R7 likes to lie down. On 06/17/24 at 1:36 PM, R7 was put in bed. R7 was in wheelchair for 5 hours and 28 minutes without repositioning. Surveyor observed roll gauze dressing in place on left heel dated 6/14. No drainage on outside dressing. During wound care, Surveyor observed left heel to have a large, blackened area with some open areas of heel with red discoloration of skin. Surveyor observed scant serosanguinous drainage present with no odor. On 06/17/24 at 1:36 PM, Surveyor observed foam dressing in place on right buttock with date 6/13. During wound care, Surveyor observed no drainage present. Surveyor observed wound bed intact, darkened discoloration. Surveyor did not observe Registered Nurse (RN) check for blanching. Surveyor observed peri wound area is darkened with 2 areas of bright red noted at 5 o'clock and 11 o'clock position. On 06/17/24 at 1:36 PM, Surveyor observed R7 lying on back in bed, podus boots (heel-protecting boots) on. R7 was on a concave mattress with higher edges to prevent rolling out of bed. No additional pillows or offloading devices observed in place for pressure points. R7 received wound cares and returned to same position of lying on back when cares completed at 2:06 PM. On 06/17/24 at 4:40 PM, Surveyor observed R7 lying on back in same position. R7 was in same position of lying on back in bed for 2 hours and 34 minutes without repositioning. On 06/17/24 at 2:06 PM, Surveyor interviewed Registered Nurse (RN) E about what kind of mattress was in place under R7. RN E stated it was a curved edge mattress to prevent R7 from rolling out of bed. Surveyor asked if it was also a pressure relieving mattress. RN E stated no, she didn't think so. On 06/17/24 at 3:40 PM, Surveyor interviewed Director of Nursing (DON) B and Nursing Home Administrator (NHA) A regarding wound care policy and expectations. Surveyor asked what the expectation is for completing wound care assessment and documentation. DON B stated that wound assessment is completed weekly by the Wound Nurse (WN) and documented with pictures in resident's Electronic Medical Record (EMR). Surveyor asked if any documentation is expected to be completed by RN doing dressing change. DON B stated that the RN would only document the care being completed. Surveyor asked expectations regarding observing changes in wound during cares to be communicated to provider. DON B stated that the provider should be notified immediately. Surveyor asked if pressure reducing mattresses are used in facility. NHA A stated yes. Surveyor asked what is considered a pressure relieving mattress. NHA A stated they are mattresses using air - either a pump or air mattress. Surveyor requested manufacturer's guide for the mattress observed being used by R7 as pressure relieving. NHA A unable to provide documentation by survey exit. Example 2 R1 was admitted to the facility on [DATE] with diagnoses including orthopedic surgery, type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema-bilateral, anemia in chronic kidney disease, type 2 diabetes mellitus with diabetic neuropathy-unspecified, chronic kidney disease stage 5, venous insufficient (chronic) (peripheral), and arteriovenous fistula-acquired. R1 has a surgical history of arterialization of deep vein of the left lower extremity with further surgical amputation that was complicated by infection in January 2024. R1's MDS assessment dated [DATE] states R1 requires substantial/maximum assistance with toileting hygiene, shower/bath, lower body dressing, putting on/taking off footwear, personal hygiene, mobility with rolling left and right, lying to sitting, sitting to lying, sit to stand, chair/bed-to-chair transfers, toilet transfers, tub/shower transfers, partial/moderate assistance with upper body dressing, and is independent with eating. R1's BIMS score is 15 out of 15, which indicates intact cognition. R1's MDS Section M states R1 has a PI, is at risk for pressure injury, has more than one pressure injury. MDS states R1 has one stage 2 PI, and one stage 2 PI was present on admission. MDS states no pressure reducing device for chair, has a pressure reducing device for bed, no turning/repositioning program, no pressure ulcer/injury care, and has a surgical wound. R1 was hospitalized on [DATE] until 04/19/24. R1's readmission MDS dated [DATE] states in section M that R1 is at risk for developing PIs, current number of unhealed PIs listed; two stage 2 PIs with one being present upon admission/entry or entry, one stage 3 PI and was present upon admission/entry or reentry. One unstageable pressure injury due to coverage of wound bed by slough and or eschar and this was present upon admission/entry or reentry. R1's care plan: Resident has potential for impairment to skin integrity related to diabetes, peripheral artery disease, gangrene, surgical amputation of all toes on the left foot. Resident has the following wounds: PI to left heel, PI to right heel, surgical amputation of all toes to left foot-wound vac in place, and PI to tip of penis. Date initiated 04/05/24. Goals: Resident's (R1) skin will show signs of healing by review date. Date initiated 04/05/24 and target date 07/04/24. Interventions: Administer treatments and monitor for effectiveness, be sure to pack tunneling when completing wound care, complete Braden scale per facility protocol, encourage good nutrition and hydration to promote healthier skin, inform resident/representative/physician/dietary of any new skin breakdown promptly, monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration, etc. to physician, no tub bathing or submerging wound until healed. Pressure reduction mattress to bed, pressure reduction cushion in chair. Repositioning every 2-3 hours and prn. Date initiated 04/05/24. Avoid friction and sheer. Keep linen and clothing wrinkle free to avoid undue pressure points to the skin, avoid sliding and pulling. Date initiated 05/02/24. On 04/05/24 at 6:12 p.m., R1's nursing progress note states R1 arrived at facility at 4:20 p.m., via transport van from hospital. R1 at facility for therapy, wound care, and dialysis services. R1 had surgical amputation to his left great toe, left 2nd toe and left 3rd toe. R1 has a stage 2 pressure ulcer to his coccyx. No measurements or assessment was completed of the coccyx. Surveyor reviewed left heel PI wound documentation: On 04/24/24, wound assessment documented left heel PI was a stage 3 measuring 4.3cm length x 3.9 cm width. No documentation of pressure relieving device for heels, no updates to care plan, and no physician notification for treatment to promote healing. 05/02/24 at 12:39 p.m., progress note stating Medi honey every other day to left heel. Cover with a dry dressing one time a day every other day. No other documentation in nursing progress notes about left heel PI. Surveyor reviewed first right heel PI wound documentation: On 04/24/24, wound assessment documented right heel stage 2 in house acquired with measurements 1.02 cm length x 0.83 cm width. No documentation indicating: exact date present, no documentation if wound has tunneling or undermining, no description of wound bed, if wound had exudate, no description of peri-wound, no indication if R1 had pain, and no treatment orders documented. On 05/01/24 at 5:47 a.m., R1's weekly wound assessment states, right heel stage 2 PI house acquired, present 1 week. PI measures 0.7cm length, x 0.7cm width, and depth not applicable. Documentation states wound is improving. No documentation indicating: exact date present, no documentation if wound has tunneling or undermining, no description of wound bed, if wound had exudate, no description of peri-wound, no indication if R1 had pain, and no treatment orders documented. Surveyor reviewed second right heel PI documentation: 05/01/24 at 5:49 a.m., R1's weekly wound assessment states, right heel stage 2 PI present on admission for 2 weeks. PI measures 3.4cm length x 1.5cm width, and depth not applicable. Documentation states PI is a new wound and physician, resident/responsible party, dietician, and therapy were notified. No documentation indicating: exact date present, no documentation if wound has tunneling or undermining, no description of wound bed, if wound had exudate, no description of peri-wound, no indication if R1 had pain, and no treatment orders documented. Surveyor reviewed third right heel DTI PI documentation: 05/01/24 at 5:50 a.m., R1's weekly wound assessment states, right heel PI present on admission staged as DTI (deep tissue injury), which has been present for 2 weeks. PI Measures 4.1cm length x 1.7cm width, and depth not applicable. Documentation indicated progress as new and physician, resident/responsible party, dietician, and therapy were notified. No documentation indicating: exact date present, no description of wound bed, if wound had exudate, no description of peri-wound, no indication if R1 had pain, and no treatment orders documented. Documentation of three PIs on the right heel lacks clarification because of different staging and measurements with no indications as to when each wound developed. Surveyor reviewed right ischial tuberosity PI wound documentation, unknown when acquired since no documentation: On 04/24/24, the wound assessment documented states right ischial tuberosity PI stage 3 measuring 1.85 cm length x 1.39 width, and depth not noted. Surveyor could not find documentation indicating: how it was acquired, how long wound has been present, exact date present, no documentation if wound has tunneling or undermining, no description of wound bed, if wound had exudate, no description of peri-wound, no indication if R1 had pain, and no treatment orders documented. Surveyor unable to determine if PI was facility acquired. On 05/01/24 at 6:44 a.m., the weekly wound assessment documentation states right ischial tuberosity PI stage 3 measuring 1.2cm length x 1.1cm width, and depth not applicable. Documentation states wound staged by in-house nursing and wound is improving. No documentation indicating: how it was acquired, how long wound has been present, exact date present, no documentation if wound has tunneling or undermining, no description of wound bed, if wound had exudate, no description of peri-wound, no indication if R1 had pain, and no treatment orders documented. Surveyor reviewed penis PI wound documentation: R1's skin care plan initiated on 04/05/24 documented a PI on the tip of the penis. R1 had an indwelling Foley catheter upon admission to the facility. On 04/08/24, R1 was transported to the hospital via ambulance. At the hospital, R1's Foley catheter was changed and no documentation about a PI to tip of penis. On 04/09/24 when physician saw R1 in the facility, physician ordered removal of the indwelling Foley. R1 did not voice any concerns or complaints to the physician about any pain or PI of the penis. On 04/10/24, R1's indwelling Foley catheter was removed. No documentation indicating a PI to the tip of the penis. On 04/30/24, wound assessment completed stating stage 2 PI to tip of penis with measurements of 1.1 cm length x 1.0 cm width and being present on admission. No other documentation of wound. On 05/02/24, physician progress note for facility visit with R1 stated nursing had reported R1 has a scab on the penis near the urethral opening. R1 told physician that the wound/scab has been present since R1 had an indwelling Foley catheter. No drainage noted, and R1 did not report fever or chills. Physician noted area of the urethral opening is intact, without surrounding erythema, edema, warmth, tenderness, or drainage. Physician ordered for facility to apply bacitracin to area. No other documentation noted in R1's medical record regarding PI of the tip of the penis. Resident was hospitalized on [DATE] for hypoglycemia and did not return to the facility. Surveyor unable to visualize wounds to assess accurate staging. On 06/17/24 at 1:30 p.m., Surveyor requested additional information on R1's wounds, treatments, and outcomes. On 06/17/24 at 2:00 p.m., Surveyor interviewed R1 and R1's sister about wound care and treatment while R1 was a resident at the facility. R1 stated care and treatment of R1's wounds was not good. R1 stated the staff did not pay attention to the wounds as they should have. R1 stated R1's heels were not kept off the bed and R1 did not receive boots for R1's feet until transferred to the hospital from dialysis. (This occurred on 05/06/24). R1 stated R1 wound have been in worse shape if not winding up at the hospital. R1 stated R1's condition was worsening while R1 was a resident at the facility. On 06/17/24 at 5:30 p.m., Surveyor interviewed DON B and asked what the expectation is for the wound care documentation and treatments. DON B stated part of the reason DON B came to the facility was to implement a wound care program for the facility. Surveyor asked for clarification on when the right ischial tuberosity PI started. Surveyor asked if it was present on readmission from the hospital on 4/19/24. DON B reviwed documentation and could not answer the question. Surveyor asked if DON B is aware that the weekly documentation only includes length and width of wounds. No descriptions are documented, no depths are measured, resident pain not documented, and no treatment orders documented on the weekly wound care rounds. Surveyor informed DON B that the photographs taken of the wounds are to enhance the documentation of the wounds, but not to replace the documentation. Some of the photographs are blurry and the markings the nurse puts on the photographs to mark where the wound is, covers the wound, or blocks clear view of the wound. DON B states facility is working on a program. On 06/18/24 at 3:49 p.m., Surveyor interviewed infection preventionist/wound care nurse (IP/WC) I. Surveyor asked IP/WC I what the facility policy is on wound care and documentation. IP/WC I stated wounds are measured and photographed every week and the information is documented on the skin and wound form. Surveyor asked about R1's wound care and lack of documentation for treatments being completed, lack of documentation indicating what the treatment is, what the wound is, the description of the wound, date wound identified, and no documentation of treatments of PI/wounds of the left gluteus or the ischial tuberosity. R1's weekly wound/skin forms only had scant information and none of the assessments were comprehensive. IP/WC I did not have an answer. Surveyor asked why R1 did not have any orders to prevent PIs or interventions to relieve heel pressure. IP/WC I stated R1 was in and out of the hospital frequently during R1's stay at the facility. IP/WC I did not offer any further explanation of wound care or prevention. 41945 Example 3 R5 was admitted to facility on 5/28/24 with metabolic encephalopathy, COPD, peripheral vascular disease, generalized edema, congestive heart failure, mild cognitive impairment, reduced mobility, and unspecified stage pressure ulcer of buttock. R5's MDS assessment at admitted d 06/03/24 states R5 is at risk for PI and admitted with three stage 2 PIs on right lateral leg and two stage 2 PIs on coccyx/buttock. R5's BIMS score is 14 out of 15 indicating cognition is intact. R5's BRADEN score for predicting pressure sore risk is 18 indicating R5 is at risk. Surveyor reviewed the comprehensive care plan completed for R5 on admission and noted the following (Initiated 5/29/24): ADL: The resident has an ADL self-care performance deficit r/t weakness, decreased mobility. The resident will improve current level of function in ADLs through the review date. (5/29/24) -BED MOBILITY: extensive assist of 1 (5/29/24) -TOILET USE: extensive assist of 1 (5/29/24) -TRANSFER: assist of 1 with four wheeled walker (5/29/24) -Encourage the resident to participate to the fullest extent possible with each interaction. (5/29/24) The resident has Peripheral Vascular Disease (PVD). The resident will remain free of complications related to PVD through review date. (5/29/24) -Elevate legs when sitting or sleeping. (5/29/24) -Encourage good nutrition and hydration. (5/29/24) -Encourage resident to change position frequently, not sitting in one position for long periods of time. (05/29/24) -Monitor/document/report PRN any s/sx of complications of extremities: coldness of extremity, pallor, rubor, cyanosis and pain. (05/29/24) SKIN: The resident has potential for impairment to skin integrity r/t decreased mobility. The resident's Skin injuries will show signs of healing by review date. (5/29/24) -Administer treatments and monitor for effectiveness (5/29/24) -Complete Braden scale per facility protocol (5/29/24) -Encourage good nutrition and hydration in order to promote healthier skin. (5/29/24) -Follow facility protocols for treatment of injury. (5/29/24) -Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. (5/29/24) -PRESSURE REDUCTION: Pressure reduction mattress to bed, pressure reduction cushion in chair. (5/29/24) -REPOSITIONING: Every 2-3 hours and PRN (5/29/24) -TOILETING: Q 2-3 hours while awake and PRN during NOC (5/29/24) On 06/17/24, Surveyor completed review of R5's wound care treatment and assessment and noted the following: Right gluteus stage 2 PI admitted with PI on 05/29/24: 05/29/24: Gluteal cleft/buttock wound; Cleanse with NS, dry, apply Medi honey gel or hydrogel to open areas, then place calcium alginate or hydrofiber, secure with a large sacral foam dressing. Change daily and PRN soiling Once it's healed, use barrier cream bid one time daily for wound care. 06/05/24: 0.81cm x 0.73cm. - No depth, characteristics, wound bed description, or drainage documented. Only documentation of wound assessment. Picture in record obscuring center of wound. On 06/17/24 at 10:01 AM, Surveyor observed foam dressing in place on right buttock with a date of 6/14 written on it. Surveyor observed during care wound bed is intact with slight white area of new skin growth and no drainage. Peri wound area is clean, dry, intact, blanchable, and no redness. On 06/17/24, Surveyor observed wound dressing dated 6/14. Wound care order states to change dressing daily and PRN. Intergluteal cleft stage 2 PI admitted with PI on 05/29/24: 05/29/24: Gluteal cleft/buttock wound; Cleanse with NS, dry, apply Medi honey gel or hydrogel to open areas, then place calcium alginate or hydrofiber, secure with a large sacral foam dressing. Change daily and PRN soiling Once it's healed, use barrier cream bid one time daily for wound care. No wound assessment of measurements. 06/05/24: 0.11cm x 1.07cm x 0.19cm 06/12/24: 0.43cm x 1.2cm x 0.5cm No characteristics of wound bed, description, or drainage documented for above measurements. Right lateral thigh distal stage 2 PI admitted with PI on 05/29/24: 05/29/24: wound order for right lateral leg; keep clean and dry. Paint with betadine daily one time a day for wound care. No wound assessment of measurements. 06/05/24: 2.72cm x 2.37cm 06/12/24: 3.22cm x 2.35cm No characteristics of wound bed, drainage, or depth documented for above measurements. No physician notification of increase in woun

Based on observation, interview and record review, the facility did not establish and implement an ongoing infection prevention and control program to prevent, recognize and control the onset and spread of infection to the extent possible as evidenced by the cumulative failures of the following. This had the potential to affect all 35 residents in the facility. The facility did not immediately implement precautions and resident isolation with a new onset Gastrointestinal illness (GI). The facility did not maintain ongoing, real-time surveillance within the facility to identify a GI outbreak or to identify other outbreaks. The facility did not post signage to inform staff and visitors of the new onset GI outbreak. The facility did not implement enhanced cleaning to control and prevent additional spread of the GI illness until approximately 2:00 PM 2/28/23, over 14 hours after the first resident developed symptoms. The facility's failure to implement infection prevention and control measures to prevent the spread of GI illness created a finding of immediate jeopardy that began on 2/27/23 at 11:45 PM when Licensed Practical Nurse (LPN) I did not implement isolation precautions and the use of PPE for staff when two or more residents became ill with sudden onset GI symptoms. Surveyor informed Nursing Home Administrator (NHA) A of the immediate jeopardy on 03/02/23 at 1:00 p.m. The immediate jeopardy was not removed at the time of the facility exit on 03/02/23. In addition to the immediate jeopardy, the following deficient practices, which do not constitute immediate jeopardy, were also identified: Did not ensure the containment of potentially infectious materials when the PPE (Personal Protective Equipment) bins were left in the hallway of the Covid-19 unit, uncovered. Did not ensure staff practiced good hand hygiene upon providing services to Covid positive individuals and before providing additional services to other residents. Did not ensure staff wore appropriate PPE upon entering the rooms of, or providing care to, Covid-19 positive residents (R). Did not ensure staff practiced good hand hygiene with the provision of incontinence care to R3. Surveyor requested surveillance from 10/26/22 (last Recertification Survey) to present day. The facility was only able to provide surveillance for one day in December 2022 (12/12/22), as the Infection Control Preventionist (ICP) was a Corporate staff member and had taken the surveillance home to work on. A snow storm prevented the ICP from bringing the surveillance to the facility the next day, and currently, the ICP is on vacation. The ICP has not yet returned the surveillance to the facility to give staff knowledge of current data and no other staff person was updating the surveillance. There was no other staff person designated to take over this task while the ICP was away from her duties. The 12/12/22 data indicated 10 residents ill with Covid-19 with onset on that date. There is no way of knowing until the additional surveillance is received, how many residents and staff became ill, if any hospitalization s or deaths occurred, the onset date and the wellness date of each, or if the outbreak is ongoing. This is evidenced by: The facility policy states under Covid-19 Surveillance and Reporting, . All surveillance findings are collected daily and reviewed daily by the infection preventionist . The facility Policy continues, . Symptomatic residents . are cared for by staff using a NIOSH - approved N95 or equivalent or higher level respirator, eye protection (goggles or a face shield that covers the front and sides of the face) gloves, and a gown . Under the section titled Coronavirus Disease- Using Personal protective Equipment, the policy directs staff on the following: . When caring for a resident with suspected or confirmed SARS-CoV-2 infection the following infection prevention and control practices are followed: a. Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection adhere to standard precautions and the use of a NIOSH-approved N95 or equivalent or higher level respirator, gown, glove and eye protection. 1. An N95 respirator . is donned before entry into the resident room or care area . 4. Disposable respirators are removed and discarded after exiting the resident's room or care area .Hand hygiene is performed after removing the respirator or facemask . The facility policy for Norovirus Prevention and Control states, .Avoid exposure to vomitus or diarrhea. Place residents on contact precautions . when symptoms are consistent with norovirus gastroenteritis . During outbreaks, residents with norovirus gastroenteritis will be placed on contact precautions for a minimum of 48 hours after the resolution of symptoms. For the policy titled Outbreak of Communicable Diseases, the following was noted: 1. An outbreak of a communicable disease can be defined as one of the following: - One case of an infection that is highly communicable; - Trends that are ten percent of more above the historical rate of infection for the facility; or - Occurrence of three or more cases of the same infection over a specific period of time and in a defined area. An outbreak of food poisoning is defined as two or more cases in persons who shared the same meal or one case of botulism. An outbreak of influenza is defined as anything exceeding the endemic rate, or a single case if unusual for the facility . Centers for Disease Control and Prevention (CDC) Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings (2011) includes the following directives: - During outbreaks, place patients with norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients - Actively promote adherence to hand hygiene among healthcare personnel, patients, and visitors in patient care areas affected by outbreaks of norovirus gastroenteritis. On the morning of 2/28/23 at 8:03 AM, Surveyors learned the Main Dining Room was closed for the day related to resident illness. Surveyor entered the West/Middle Units and learned there were two residents that initially became ill during the night shift (2/27/23 at 11:45 PM) with Gastrointestinal (GI) symptoms of diarrhea and abdominal pain, and by the morning of 2/28/23 at 8:00 AM, there were 6 additional residents ill, making the total at that time to 8 residents with variable symptoms of diarrhea, abdominal pain, nausea and/or vomiting. Surveyors noted that there was no precaution signage posted upon entrance to the facility or the units of residents living areas of a current potential GI outbreak. There also were no signage posted on ill resident rooms. There were no PPE bins or hampers outside any of the rooms and staff were entering resident rooms with only the source control used the day before, which included surgical masks and goggles. Licensed Practical Nurse (LPN) I was the night shift nurse on duty the night of 2/27/23 and had left for the day. A phone call was placed to LPN I by Surveyor, and no response was initially received. At 9:52 AM, Surveyor noted RN G (Registered Nurse and Unit Manager) was donned in an isolation gown, gloves, surgical mask and goggles. RN G was setting up PPE bin outside the double doors to the entrance of the East Unit. Surveyor asked RN G how many residents were ill with GI symptoms. RN G handed the Surveyor the list of residents and stated, All the residents marked with a dot by their name are now sick with GI symptoms. I contacted the doctors and they ordered fecal panel testing to determine the cause. We don't know if it is Norovirus or a foodborne illness right now. The doctors ordered the fecal panels to rule out foodborne. Surveyor reviewed the list and noted there were 8 residents with dots by their names. RN G further stated, It started with [R34] and [R31] on the night shift. Now we have 6 more residents ill. Night shift nurse did not put precautions into place because she thought it was food related. I am going around now and putting out the PPE bins and trying to get stool samples. Upon review, Surveyor noted that at the time of speaking with RN G there were 6 additional residents ill with GI symptoms. These were two residents residing on the active Covid-19 Unit (East), R40 and R14 and 4 residents living on the Middle Unit (R39, R32, R38 and R36). At 12:59 PM, Surveyor first noticed the Main Entrance Elevator, which escorts individuals directly to the East unit (active Covid-19 unit) contained signage to direct individuals to the West elevator, as this elevator accesses the Covid-19 unit. On 2/28/23 at 1:00 PM, Surveyor interviewed LPN F. LPN F stated the GI illness . started just before the night shift came on duty. [R34] came walking down the hall and said she just threw up. I was getting my coat on. [LPN I] was taking over. I had already clocked out and was done. I then left . At 1:09 PM, a phone call was placed to LPN I with no answer. A message was left for LPN I to call Surveyor back to learn details of the GI outbreak onset. At 1:40 PM, Surveyor noted HK L (Housekeeping) was on the West unit with her cart cleaning. Surveyor interviewed HK L and learned that she was unaware there was an outbreak of GI illness and stated that she was not informed to provide enhanced cleaning of the units and rooms. HK L did state that she cleans all the time with a bleach solution but enhanced cleaning means I do all touchable surfaces. At 1:46 PM, Surveyor again approached RN G. There were now 14 residents ill with GI symptoms. Added to the list were R20, R28, R22, R33, R17 and R18. RN G also stated there were 4 staff out with GI symptoms. RN G stated the resident physicians felt the illness was foodborne and did not order Norovirus testing only fecal panels to rule out food related cause. At 3:30 PM, Surveyor spoke with MD R who entered the facility for rounds. MD R stated he was informed of the new onset GI illness this morning by RN G. MD R stated that he felt the illness was . Foodborne related due to the number of residents ill with such a rapid onset and no clustered living arrangements, it's all over the building. A viral illness is rapid but not this rapid . MD R went on to state that he ordered enhanced viral testing on his residents. At 3:54 PM, Surveyor telephoned MD S, who is the primary physician in the facility as well as the Medical Director. MD S stated that she consulted with RN G and her Nurse Practitioner this morning regarding the new onset GI illness. She also stated that she ordered stool specimens on her residents to determine commonality. MD S further stated, I am thinking the cause is something other than Norovirus. I know Norovirus can spread very rapidly but I have not heard of this instance in Wisconsin yet this year, but there is always a first case. It goes very rapidly. I am thinking a higher probability of foodborne because it's so rapid and all over, there is no clusters of living arrangements of the residents . Surveyor asked MD S if precautions should have been put into place with the first two cases. MD S stated, Yes, most definitely should have implemented precautions because it is yet unknown what is causing this illness. On 3/1/23 at 6:30 AM, Surveyor interviewed LPN I, who had just completed her Night Shift assignment. LPN I stated, It all started with [R34] who was walking down the hall with a basin containing emesis/vomit and said 'I am sick. I threw up.' I immediately took her back to her room and did a set of vital signs and no fever. I was getting report from [LPN F] when [R34] came down the hall. Then [R31] got sick . By this morning, we had two residents on East Unit and 5 or 6 down here on Middle Unit that were sick . Surveyor asked LPN I why she did not initiate precautions and educate staff on PPE wear with the first two cases. LPN I stated, To be honest, the first thing I thought of was the food. I didn't even think viral . [R34] stated to me that the meatloaf tasted off. So no, I did not start precautions. I should have because I guess, we really didn't know for sure . By 3/1/23 at 8:30 AM, there were another three new cases (R24, R35 and R7). R35 lived on Middle Hall between R39 and R36, both who became ill 2/28/23. R24 lived on West Hall across the hall and kitty-corner from R18 who became ill on the afternoon of 2/28/23 and finally, R7 who shares a room with R17, who became ill the afternoon of 2/28/23. This was now a total of 17 residents ill with the addition of two more staff ill (6 total). Of concern is, Surveyor reviewed the illness onset and compared this with the map of the facility and noted, the first two cases started on the Middle Unit, three rooms down and across the hall from each other. The Middle and West units share the same staff. The second set of cases were two rooms across the hall from each other on East Unit and the other new four cases were all on the same hall of each other (Middle Hall). The third set of cases were all on the West unit. There was noted commonality between onset of each other (within 24 hours) and room locations. Whether the illness was foodborne related or viral related, it was not yet known at the time of illness onset, and precautions should have been implemented when the first two cases of resident GI illness appeared. The failure to put measures in place to identify a GI outbreak and to put interventions in place to prevent the spread of the infection created an immediate jeopardy that began 02/27/23. The immediate jeopardy was not removed at the time of exit. The deficient practice continues at a level F for the identified reasons below: Covid 19 Upon entrance to the facility on [DATE] at 9:15 AM, Surveyors noted signage posted on the entrance door that the facility was currently in a Covid-19 outbreak and that masks were required for all upon entrance. Arriving on the Covid-19 unit, Surveyor noted staff to be wearing surgical masks and all resident doors with the exception of one (R6) were open to the hallway. There were 6 residents (R6, R14, R16, R40, R41 and R42) living on the East Hall, which was the Covid-19 unit. All these residents tested positive for Covid-19. There was one resident in the hospital. Surveyor noted there were a total of 15 soiled hampers throughout the hall for staff to dispose of used PPE. Of these 15 hampers, only two red bins had covers on them. The other 12 had soiled or used PPE within and were uncovered, potentially transmitting airborne bacteria and pathogens throughout the hall. An interview with the Interim Director of Nursing, DON B was completed on 2/27/23 at 3:35 PM. DON B stated, All the PPE bins on East unit had covers. I don't know why the covers were removed. I will do education right now. DON B also stated that doors to the resident rooms were to be closed if the resident allowed. DON B stated that there are some residents that prefer the door to remain open, or other residents need close monitoring related to fall risk. In these cases, the doors are to be left open. When asked the potential effects of not having covers on the used PPE hampers, DON B stated, Well you can potentially transmit the virus on to others. Of note: All residents live on the second floor of the facility. There are two elevators that provide escort to staff/residents/visitors from the main entrance to the residential living area. The East and the West elevators. The East elevator goes directly to the East Unit, which was currently locked down related to the Covid-19 outbreak. There was no signage on this elevator to direct staff and visitors to use the West Hall elevator versus the East Hall elevator. Staff and visitors were frequently observed using this East elevator and then walking through the East Unit and through the double doors to the Middle and West Units. Improper PPE use The noon meal service was observed on the East/Covid-19 Unit on 2/27/23. The following was observed: - The meals arrived on the unit at 12:00 PM via the East elevator on a cart with no staff. Dietary placed the cart of meals into the elevator and sent the elevator to the unit. All meals were served on disposable plates with disposable cups and plastic utensils. CNA H (Certified Nursing Assistant) began to pass meal trays to each resident on the unit and the following was noted: - CNA H already was wearing a surgical mask and goggles. She then donned a gown and gloves and entered the room of Resident (R) 6. Once R6 was served, CNA H left the room, removed her gown and gloves, then donned a new gown and pair of gloves and entered the room of R40. - Once R40 was served, CNA H left the room, removed the gown and gloves and donned another new gown and pair of gloves and entered the room of R14. - CNA H then left R14's room, removed the gown and gloves and donned a new gown and pair of gloves and entered the room of R41. - CNA H then left the room of R41, removed the gown and gloves and obtained packages of ketchup. She then donned a gown and gloves and re-entered the room of R14 with the ketchup, exited the room and removed the gown and gloves, donned a new gown and pair of gloves and entered the room of R6 to respond to the call light. - CNA H then left the room of R6 and removed her gown and gloves, donned a new gown and pair of gloves and entered the room of R42, who was in a private area of the unit, past the double firedoors. CNA H served R42 her meal and upon leaving, removed the gown and pair of gloves. CNA H informed Surveyor that R16 did not sleep well through the night and was allowing her to sleep. There was no hand washing or sanitizing between each resident served. There was no changing over of the mask with each exit and prior to the entrance to another resident room. At 12: 42 PM, Surveyor interviewed CNA H regarding her knowledge and training of hand hygiene. CNA H stated that she received training often on hand hygiene. When asked why she did not sanitize or wash her hands with the service of each resident and the removal of PPE, CNA H stated, I usually do sanitize each time I take my gloves off. I don't know, it's just so much when entering all these rooms each time. I know I'm supposed to sanitize each time I take off the gloves, I guess I didn't. On 2/28/23 at 7:15 AM, CNA H entered the room of R16, who was positive for Covid-19 during this observation. CNA H entered the room with a surgical mask and eye goggles that were resting on top of her head and not protecting her eyes. She did not don a gown or a pair of gloves. CNA H wheeled a shower chair and a stack of towels into the room and closed the door to the hallway. Surveyor then approached RN G (Registered Nurse and Unit Manager) and asked if any residents were removed from precautions during the night. RN G stated that all residents on the unit remain active Covid and there have been none that were discontinued from Transmission Based Precautions (TBPs). Surveyor then explained the observation made with CNA H entering R16's room with no PPE. RN G immediately went to the room, knocked on the door and ordered CNA H out of the room. CNA H stated that the resident was on the shower chair, so RN G donned a gown and gloves and entered the room and sent CNA H out of the room to don the appropriate PPE. While CNA H was donning the PPE, Surveyor asked her why she did not put on the proper PPE prior to entering the room. CNA H stated, I don't know why. She was falling. I had to go get the shower chair and help her. Surveyor then asked why she went to get the shower chair first, rather than assisting R16 to a safe position first. CNA H stated, I don't know, I just did. 46693 On 02/27/2023 at 10:45 AM, Surveyor was in R6's room who was currently on COVID precautions. During the interview with R6, Activity Aide J opened the door to R6's room, stepped in with both feet wearing only a surgical mask and reached out while Activity Aide J handed R6 a booklet. Surveyor finished the interview with R6. Afterwards, Surveyor interviewed Activity Aide J and asked if she received training on correct Personal Protective Equipment (PPE) to wear in COVID rooms. Activity Aide J stated that she does not go in there, she just hands things through the door and then walked away. 30570 Hand Hygiene On 2/27/23 at 1:15 PM, Surveyor observed CNA C and D enter R3's room with R3. CNA C and D donned gloves without performing hand hygiene. CNA C and D transferred R3 via a mechanical lift to bed. CNA C and D rolled R3 side to side in bed as CNA C removed a urine soiled brief from R3. CNA C washed R3 and proceeded to apply barrier cream. CNA C did not remove her gloves and perform hand hygiene prior to applying the cream. CNA C proceeded to place a clean brief and redress R3 without first removing her gloves and performing hand hygiene. Following the observation Surveyor spoke with CNA C and D about the observation. CNA C expressed she should have removed her gloves and performed hand hygiene before putting on the cream and clean brief on. On 2/28/23 at 11:39 am, Surveyor spoke with Director of Nursing (DON) B about the observation. DON B explained she would expect staff to perform hand hygiene when entering the resident room before donning gloves. She would also expect staff to remove their gloves, perform hand hygiene and don clean gloves whenever going from a dirty task to clean. Surveyor requested and received the facility policy titled Handwashing/Hand Hygiene which is not dated. the policy in part reads: ~This facility considers hand hygiene the primary means to prevent the spread of infections. ~Use alcohol based hand rub or soap and water for the following situations: before and after direct contact with residents, before donning sterile gloves, before moving from a contaminated body site to clean body site during resident care .

Based on observation, interview and record review, the facility did not ensure that residents were free from physical, emotional and mental abuse for 6 (R11, R12, R13, R14, R15, and R16) of 9 residents reviewed for abuse. *On 7/29/22, R7 attempted to climb into R11's bed. R11 pushed her table towards R7 and yelled for assistance. Staff came in and removed R7 from R11's room. *On 7/8/22, R7 entered R15's room. R7 punched R15 in the nose and face. R15 received a scratch on his nose due to the interaction. *On 6/28/22, R7 entered R16's room. R7 tried to grab R16's wheelchair and was grabbing at R16. R16 reported that R7 hit her in the head. *R14 stated R7 had entered her room on multiple occasions. R7 sat on R14 while R14 was in bed. R7 hit R14 on multiple occasions. R14 has observed R7 walking around with no pants on. R14 is afraid of R7. R7 was observed touching the back of R14's wheelchair, R14 was saying get away to R7 and R14 was cowering. Staff were in the area and did not interfere with the interaction. *R7 entered R13's room. R7 hit R13 on his arm. *R12 stated R7 continually comes into R12's room. R12 has observed R7 walking around with only a brief on. R12 is afraid of R7. Evidenced by: Surveyor made several attempts to acquire the facility abuse policy, the facility was unable to provide the abuse policy other than the abuse reporting and investigating policy. R7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's Comprehensive MDS (Minimum Data Set), dated 8/09/22, indicates R7 has severe cognitive impairment. Behavior Symptoms (E0200): Physical behavior symptoms directed towards others, occurred 1-3 days. Verbal behavior symptoms directed towards others, occurred 1-3 days. Wandering (E0900), occurred 1-3 days. R7 requires extensive assistance of two staff members for dressing, bed mobility, toileting, and hygiene. R7 requires supervision of 1 staff member for transfers. R7 is always incontinent of bowel and bladder. Staff assessment of pain - nonverbal, verbal, facial; frequency of 1-2 days. Example 1 R11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's Comprehensive MDS (Minimum Data Set) Assessment, dated 7/15/22, indicates R11 is cognitively intact and is understood and understands. R11 needs total dependence of two assist to transfer. The facility Verification of Investigation, dated 7/29/22, includes, in part, the following: Provide Detailed Description of Event/Allegation: Resident (R11) alleged that resident (R7) had tried to climb into her bed. Casual/Contributing Factors and Observations: . On 7/29/22 (R7) wandered into (R11) room. She stated he attempted to climb into the bed, she states she grabbed the overbed table and placed in front of her bed, as if to block it and prevent him. He walked to the end of the bed and attempted to crawl in that way. She states he had his knee on her bed at the foot. She stated on 7/9/22 and again on 8/1/22 to DON (Director of Nursing) that he did not make any physical contact with her personally. She stated she yelled out to get out and put her call light on. When this writer asked her if help arrived, she stated yes (CNA XXX (Certified Nursing Assistant) and another girl came right away. Provide Summary and Outcome of Investigative Findings: . States she is afraid it may happen again. Offered to close her door at night which she has agreed to. Nursing will monitor her for any changes to behavior for her/anxiety of fear. Care plan developed. R7's Progress Notes includes in part: On 7/29/22 at 22:45 (10:45 PM), Nurses Note states, During shift report, this writer was advised that resident was having a bad day. Per other staff yesterday was worse with behaviors to keep a close eye on resident. Resident had wandered into a female resident's room and attempted to climb into bed with her which greatly upset the female resident. Resident has been wandering, entering other resident's rooms, touching and moving items at and around the nurse's station and removing items from the med cart all afternoon. Resident kept trying to take the laptop every time nurse stepped away from the cart during med pass. Staff attempted multiple times to redirect resident which was doable at times and impossible other times. At one point resident attempted to go into the storage room off the dining area and use it as a restroom. Attempted to redirect to his room, however, was extremely difficult. When finally, did get him to his room it took 3 staff members to keep him in there, all the while resident was attempting to leave the room. Resident needed to be changed due to smelling of urine and bowel. Took 3 staff member to attempt to clean up. The entire time resident was attempting to punch, kick, and bite at staff members. At one point made contact with a hard kick to CNA's chest. DON updated. Call made to on-call doctor who ordered [MEDICATION(S)] 2mg PO (by mouth) now. 8/24/22 at 5:10 PM Surveyor interviewed R11 about the incident that occurred on 7/29/22 with R7. R11 stated R7 had wandered into her room prior to 7/29/22. R11 had requested staff keep R7 out of her room. R11 stated she would block her doorway with her wheelchair to keep R7 out of her room. R11 stated on 7/29/22 around 10:30 PM R7 wandered into R11's room. R7 put his knee on R11's bed and R11 pushed her over bed table towards R7 and yelled for help. Two staff came into R11's room to get R7 out of R11's room. Staff told R11 they would try to keep a closer eye on R7. R11 stated she was afraid of R7 and R7 is a big man and scares her. R7 continues to come into R11's room uninvited. 8/30/22 at 2:45 PM Surveyor spoke with R11 via telephone. R11 stated R7 has continued to enter her room multiple times a day uninvited; staff are not with R7 and do not keep R7 from entering R11's room uninvited. Example 2 R15 was admitted to the facility 1/28/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's Comprehensive MDS (Minimum Data Set) Assessment, dated 8/6/22, indicates R15 is cognitively intact and is understood and understands. R15 needs extensive assist of two to transfer. The facility Misconduct Incident Report, dated 7/8/22, includes, in part, the following: Briefly Describe the Incident: (R7) went into (R15's) room without permission. (R15) asked (R7) to leave and (R7) walked over to the [NAME] (sp). (R15) sternly told (R7) to leave and (R7) walked over to (R15) and as (R15) stated He sucker punched me. When (R15) was asked to show how (R7) did it, (R15) said that (R7's) hand pushed (R15's) side of face by eyes which then moved his glasses and put a scrape on (R15's) nose. On 8/25/22 at 10:58 AM, Surveyor interviewed R15. R15 stated he was sitting in his room watching television when R7 entered R15's room uninvited and punched R15 in the nose and face. The bridge of R15's nose bled. R15 stated R7 continues to come into his room uninvited. R15 stated staff have a hard time handling R7, and R15 would have to keep his room door shut to keep R7 out of the room and R15 likes to keep the room door open. R15 stated he is not afraid of R7 because he uses his reacher to hit R7. R7 also goes into R15's closet trying to take things and when R15 told R7 to stop R7 came at R15 so R15 hit R7 with his reacher 3 or 4 times and R7 stopped and left. Example 3 R16 was admitted to the facility 4/18/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's Comprehensive MDS (Minimum Data Set) Assessment, dated 6/22/22, indicated R16 has severe cognitive impairment and is understood and understands. R16 needs extensive assistance of one to transfer. R7's Progress Notes includes, in part, the following: 6/28/22, 4:53 PM, . (R7) then entered room of (R16) and was trying to grab her wheelchair. (R7) was also grabbing at resident and (R16) was telling (R7) to exit the room at which time CNA (Certified Nursing Assistant) H went into resident's room to assist in prevention of any injuries to resident. (R16) reported that (R7) had struck her in the head. CNA H got in between (R16) and (R7) at which time (R7) punched CNA in the right upper lip which resulted in a swollen lip, loose tooth and pain of mouth. Example 4 R14 was admitted to the facility 6/22/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's Comprehensive MDS (Minimum Data Set) Assessment, dated 6/22/22, indicated R14 has moderate cognitive impairment and is understood and understands. R14 needs limited assist of one to transfer. On 8/24/22 at 6:05 PM, Surveyor interviewed R14. R14 stated R7 had entered her room on multiple occasions uninvited. R7 sat on R14 while R14 was in bed. R7 hit R14 on multiple occasions. R14 has observed R7 walking around with no pants on. R14 is afraid of R7. On 8/24/22 at 6:40 PM, Surveyor observed R14 sitting next to the nurse's station speaking on the telephone. R7 went up to R14 and placed his hand on the back of R14's wheelchair. R14 was cowering and saying get away to R7. Staff were in the area and did not interfere with the interaction. R7's Progress Notes include in part: On 7/30/22 at 00:08 (12:08 AM), Nurses Note states, Resident wandered into Rm [number] (R14) and was moving items around on the nightstand just inside the door. Took a few tries to redirect and at first resident made a move like he was going to punch writer. Example 5 R13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's Comprehensive MDS (Minimum Data Set) Assessment, dated 8/4/22, indicated R13 is cognitively intact and is understood and understands. R13 needs limited assist of one to transfer. On 8/24/22 at 5:57 PM, Surveyor interviewed R13. R13 stated that R7 comes into R13's room uninvited. R13 stated R7 raised a fist to hit R13, R13 blocked the punch with his arm and R7 hit R13's arm. R13 stated he does not want R7 in his room and has informed staff of this; however, R7 continues to come into R13's room. R13 stated he has observed R7 lying in a bed in the room next to R13's room, which is a storage room. Staff have left R7 in this room to sleep. Example 6 R12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's Comprehensive MDS (Minimum Data Set) Assessment, dated 6/27/22, indicated R12 has severe cognitive impairment and is understood and understands. R12 needs supervision when transferring. On 8/24/22 at 5:38 PM, Surveyor interviewed R12. R12 stated R7 comes into R12's room continually. R12 has asked R7 to leave; however, R7 has sat down or goes through R12's things. R12 has observed R7 in her room with no pants on, just a brief. R12 stated she does not feel safe with R7 in her room, R12 is afraid of R7. R12 stated she has asked staff to keep R7 out of her room, but staff are too busy to keep an eye on R7. R7's Progress Notes include, in part, the following: On 6/28/22 at 16:53 (4:53 PM), Nurses Note states, Resident was wandering, exit seeking and becoming increasingly agitated and aggressive this afternoon. At 1500 (3:00 PM) hrs (hours) resident has taken a bottle off the nurse's station counter and when CNA, went to take the bottle back, he punched her in the stomach. CNA reported no injury. Resident was provided with PRN [MEDICATION(S)] at 1530 (3:30 PM) hrs. At 1600 hrs (4:00 PM) resident entered room of female resident and proceeded to lay down on her bed. CNA was able to persuade resident to get out of other resident's bed, however he continued to wander the hallways. Resident then entered room of resident and was trying to grab her wheelchair. R7 was also grabbing at resident and resident was telling R7 to exit the room at which time CNA went into resident's room to assist in prevention of any injuries to resident. Resident reported R7 had struck her in the head. CNA got between resident and R7 at which time R7 punched CNA in the right upper lip which resulted in a swollen lip, lose tooth and pain of mouth. On 6/30/22 at 13:01 (1:01 PM), Nurses Note states, R7 has wandering the halls since 0230 (2:30 AM) this morning. We have attempted multiple times to have him sit in the dining room or lay in bed. He will sit or lay down for a few minutes, however, is back up and pacing. Has complained a few times of his feet hurting and he was given PRN Acetaminophen. Going into other resident's rooms. When activities aide attempted to stop him from entering Rm [number], he became combative and trapped aide against the wall. Writer attempted to assist, and he was also verbally abusive with nurse. Had gestured like he was going to punch nurse, however, did not follow through. Telehealth visit this morning has resulted in some medication changes. Administration was asked if there was someone to assist as resident needs 1:1 attention as staff is unable to perform their job duties due to resident's behaviors. On 6/30/22 at 15:53 (3:53 PM), Nurses Note states, Writer spoke with NP (Nurse Practitioner) r/t increase behaviors, difficult to redirect. With telephone order to give [MEDICATION(S)] 0.5mg now as one time order. On 7/01/22 at 9:17 AM, Nurses Note states, Resident was up all-night wandering at hallway, following other staff and going into other resident's rooms. Difficult to redirect On 7/14/22 at 16:25 (4:25 PM), Nurses Note states, Provided 1:1 with resident. He would alternate between sitting down for awhile and then pacing the halls. Several attempts to enter other's rooms but was able to redirect. One resident started yelling at him when he went towards her room. Resident will sit calmly when someone sit next to him. On 7/15/22 at 11:23 AM, Nurses Note states, Resident around 1115 (11:15 AM) pacing the hallways, grabbing stuff off the med cart, punching staff during cares. Encouraged to sit down, ask if he was having pain, he said no then yes. Tylenol given. Reports of him having a lg (large) BM (bowel movement) today, clean dry pad on. Called and updated POA (power of attorney), fax sent to request increase in antianxiety medication. On 7/18/22 at 21:097 (9:09 PM), Nurses Note states, At 1600 (4:00 PM) resident was wandering about, grabbing papers off counter, handling objects on med cart, entering other resident's rooms. At times would become angry with re-direction. [MEDICATION(S)] prn given at 1730 (5:30 PM); medication finally took affect and resident is in bed at this time. On 7/23/22 at 19:52 (7:52 PM), Nurses Note states, Resident has been up pacing, entering other rooms, hitting staff and cursing at them, grabbing items off desk, pushing wheelchairs around. Has attempted twice to leave through West exit. Has tried twice to go down the stairs but was unable to get the door open. [MEDICATION(S)] prn given at 2115 (9:15 PM), ineffective. He laid down about half an hour ago and so far is still there; will continue to monitor. On 7/25/22 at 00:22 (12:22 AM), Nurses Note states, Resident is back up wandering and continues to attempt to enter other resident's rooms. On 7/25/22 at 02:02 (2:02 AM), Nurses Note states, Resident is still up and wandering around at this time, requiring one on one to keep him out of other resident's rooms. On 7/27/22 at 09:51 (9:51 AM), Nurses Note states, Resident's behavior has improved. Although he does continue to pace, strike out at staff at time. He is calmer. Has been sleeping more. Appetite has improved as well. On 7/28/22 at 23:07 (11:07 PM), Nurses Note states, The resident has had medication changes with [MEDICATION(S)] discontinued and [MEDICATION(S)] started. Behavior this evening was agitation and restlessness from the beginning of my shift at 1600 (4:00 PM) until he fell asleep around 2100 (9:00 PM). The resident was going into other resident's rooms, wandering around the facility, and pulling care carts down the hallway, PRN [MEDICATION(S)] was given and improvement to his behavior was seen. Medication administration is charted in his EMAR (electronic medication administration record). On 7/31/22 at 15:42 (3:42 PM), Nurses Note states, Resident has been having one on one staff buddy to keep resident from going into resident's rooms, grabbing on to equipment. Resident has been nice to staff, and then would turn on staff and be pushing them away from things that he wanted to grab. Continuous pacing the floor and touching everything he could get his hands onto. On 8/02/22 at 10:22 (10:22 AM), Nurses Note states, I called [doctors name] to report aggressive behavior exhibited by the resident since the discontinuation of [MEDICATION(S)]. The resident has been hitting staff this week, including during change of shift today at 1430 (2:30 PM) the resident punched a CNA in the shoulder, he then pulled wound care cart down the hall, and tried to leave the building multiple times in the next hour. I called [doctors name] and was asked to send SBAR and list of medications, which I faxed. No response yet. My recommendation was for a re-evaluation of medication. After observing the resident's behavior listed above for the next several hours when all PRN medications given, my new recommendation would be a change of facility to support his late set Alzheimer's diagnosis. On 8/03/22 at 10:55 (10:55 PM), Nurses Note states, Resident continues to need redirection. Writer found resident was walking on east. Writer spoke to resident and redirected to other direction. Resident hugged writer and said thank you. Resident then said he didn't know what to do so writer directed back towards west dining. Resident sat down and closed eyes. Writer left resident with nursing staff. On 8/03/22 at 16:54 (4:54 PM), Nurses Note states, Client was calm in the morning between 6am and 8am and then he became agitated. He was given all his scheduled meds but still he could not calm down. [MEDICATION(S)] was given to him and he calmed down and slept for about 45 minutes but when he got up his agitation had increased. He took his afternoon meds and an order to increase [MEDICATION(S)] sprinkles from 125 to 250 was implemented and the client became calm. On 8/03/22 at 21:34 (9:34 PM), Nurses Note states, The resident was exhibiting aggressive behavior slapping two staff members on the shoulder. He was confused starting around 1900 (7:00 PM) until he fell asleep at 2100 (9:00 PM). The resident was walking into various rooms of residents on the unit when he was unwelcomed and was guided away by staff to common areas or his room. He continued to wander the hallways asking for help, he had wide eyes, was not responding to questions, oriented 0/4, and was not speaking in coherent sentences. I administered his PRN [MEDICATION(S)] as per verbal orders from the on-call physician at 2007 (8:07 PM). The resident fell asleep within an hour of being administered the medication. On 8/04/22 at 21:05 (9:05 PM), Nurses Note states, Client has been restless, agitated and anxious the entire afternoon. The client took his scheduled medications, and he still could not calm down. The client started pushing other clients and he even tried punching two of the residents. The nurse intervened the client and tried to convince the client to stay in his room where the client stayed only for about 5 minutes and came out. The client kept pacing up and down trying to enter other resident's rooms. One of the CNAs assigned to stay with the client until the client calmed down. The client calmed down around 2115 (9:15 PM). On 8/04/22 at 21:23 (9:23 PM), Nurses Note states, Client tried to hit one of the dietary aid and shouted at two of the clients and tried to punch them. The nurse had to intervene and redirected the client to go to his room. On 8/05/22 at 15:02 (3:02 PM), Nurses Note states, Resident reported of being up all night. Finally went to sleep at 0830 (8:30 AM) slept until noon when lunch was being served. He at 75% of his meal with encouragement of staff. He appears to have flat affect. Looks tired. Took his afternoon medications. Back to bed around 1400 (2:00 PM), sleeping. On 8/05/22 at 20:10 (8:10 PM), Nurses Note states, The resident woke up from a late nap at 2000 (8:00 PM). He walked out of his room confused and covered in urine from wetting himself during his sleep. A CNA guided him back to his room to try to help him get changed. Once in his room she grabbed a pair or pants for him and he socked her in the arm before she could change him. I administered the resident PRN medication but he has been administered all of his scheduled medication at this point. On 8/06/22 at 14:50 (2:50 PM), Nurses Note states, Reported to have slept since 2200 (10:00 PM) until 0830 (8:30 AM) this am. Ate 75% of breakfast. Took medication and fell back to sleep until lunch. Woke up, at [sic] 25% of meal. Wander, looks dazed. Some complaints of pain to stomach. He is constipated. Tried toileting him several times today. MOM (milk of magnesia) and prune juice given. 1 small bm (bowel movement). He is still constipated. Wandering going into other resident's rooms. [Residents in three rooms] all yelling at him to get out. Staff have intervened several times. 1:1 needed at 1500 (3:00 PM). On 8/10/22 at 22:38 (10:38 PM), Nurses Note states, Current medication regimen appears to be effective; resident is resting in bed at this time. Will continue to monitor. On 8/12/22 at 14:16 (2:16 PM), Nurses Note states, Discussed with doctor concerns with changes in behavior with resident. [MEDICATION(S)] appeared to be working but in the the [sic] last two weeks noted increase in behavior despite redirection. Increased [MEDICATION(S)] to 50mg BID (twice a day) to continue with [MEDICATION(S)] and will discuss [MEDICATION(S)] d/c (discontinue) with follow-up. Reviewed use of [MEDICATION(S)] and continued need to keep. Resident not using on a regular basis. Will update resident representative on above. On 8/20/22 at 23:53 (11:53 PM), Nurses Note states, R7 has been up wandering the halls, and handling things on the desk. Has made several attempts to enter other rooms. Earlier he was swearing at the PM CNA when she was attempting to provide cares, and cocked his fist at her. PRN [MEDICATION(S)] at 1630 (4:30 PM) was ineffective. He is now sitting in a chair by the nurse's station. On 8/25/22 at 11:51 AM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A stated R7's family did not want R7 to relocate to a different facility. NHA A stated she knew that R7 wandered into other residents' rooms and that other residents were complaining of R7 wandering into their rooms. NHA A stated after R7 had an interaction with R15 on 7/8/22 a Misconduct Incident Report was filed with the State Agency due to R7 cutting R15's nose when R7 struck R15 and an Investigation was completed when R11 stated that R7 attempted to crawl into bed with R11. No other incidents between R7 and other residents were formally investigated. R7 was placed on hour or half hour checks, but R7 was still allowed to ambulate throughout the facility unsupervised. R7 continued to enter other resident's rooms, a rope was put across the South Hall with a stop sign, however residents who lived down the South Hall stated that it restricted their movement up and down the hall so it was removed. NHA A stated interviews were sporadically completed with other residents regarding R7, but no interventions were put in place to assure R7 would stay out of other residents' rooms except medication changes, however the medication changes were not working. On 8/25/22 at 4:33 PM, Surveyor interviewed NHA A. NHA A stated the facility should keep other residents safe from R7's interactions. NHA A stated she does not feel that R7 is acting willfully, does nothing purposefully, however R7 does get aggressive intentionally. The facility failed to ensure all residents were kept safe from abuse by allowing R7 to continue to ambulate throughout the entire facility independently unsupervised, entering other resident rooms uninvited and having interactions with other residents, including hitting and trying to crawl into bed with other residents.

Based on observation, interview and record review, the facility did not ensure a resident who needs [MEDICAL CONDITION] care was provided such care consistent with professional standards of practice, the comprehensive care plan, and the resident's goals. This occurred for one of one resident (Resident (R) 59) with a [MEDICAL CONDITION] (trach). Displacement or obstruction of a [MEDICAL CONDITION] may result in loss of the airway and respiratory obstruction, which can lead to respiratory arrest and death. The facility did not have emergency equipment readily available for accidental extubation. The facility's failure to ensure emergency equipment for accidental extubation, displacement or obstruction, created a finding of Immediate Jeopardy (IJ), beginning on [DATE]. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed of the IJ finding on [DATE] at approximately 11:00 a.m. The facility removed the jeopardy on [DATE]; however, the deficient practice continue at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. This is evidenced by: According to the University of Pittsburgh Medical Center's guide for [MEDICAL CONDITION] care, If your [MEDICAL CONDITION] comes out or becomes blocked, you need to have a plan to deal with the emergency situation quickly. If you are unable to solve the problem quickly, call 911 . According to this standard of practice, It is good to make an emergency kit. It should include all of the supplies needed for a [MEDICAL CONDITION] change. These supplies are: -a clean [MEDICAL CONDITION] set with obturator -water soluble lubricant, such as [MEDICATION NAME] -suction catheter -syringe, if you have a cuffed [MEDICAL CONDITION] -sterile saline bullets -gloves -[MEDICAL CONDITION] ties -a smaller size [MEDICAL CONDITION] set with obturator .Remember to make an emergency plan. On [DATE], Surveyor received and reviewed two facility policies. One policy entitled, Tracheotomy Care, last revised on [DATE], states the following, in part, POLICY .Tracheotomy is performed per physician orders by a licensed professional or by the resident if they are found to be competent in their skills to do so . This policy does not identify what equipment is needed [MEDICAL CONDITION]. The second policy entitled, Tracheotomy Suctioning, dated [DATE], does not identify what suctioning equipment is needed or where it is located. On [DATE], Surveyor reviewed the Facility Assessment Tool. The date the assessment was updated is [DATE], and the date the assessment was reviewed with .QAPI (Quality Assurance Performance Improvement) committee, is (MONTH) (YEAR). The Facility Assessment states, in part: .3. Part 2: Services and Care We Offer Based on our Residents' Needs .Other special care needs .[MEDICAL CONDITION] cares .Policies and procedures for provision of cares 3.5 .Annually we review policies and as needed in QAPI .If a referral presents with a new [DIAGNOSES REDACTED]. Nurse using the policies make recommendations to the DON for revisions . On [DATE], Surveyor reviewed R29's medical record. The resident has [DIAGNOSES REDACTED]. The resident was admitted for long term care in (MONTH) (YEAR). According to the medical record, the resident requests Cardio [MEDICAL CONDITION] Resuscitation (CPR) if R59's heart stops beating or if the resident stops breathing. The resident's Brief Interview for Mental Status (BIMS) score, dated [DATE], was a 15 out of 15 possible points. According to the BIMS assessment, a score of 15 indicates R59 has intact cognitive function. The resident makes her own health care decisions. The resident has a physician's order, dated [DATE], which states,[MEDICAL CONDITION] every day and evening shift. There are no specific orders as to what [MEDICAL CONDITION] consists of. There are no physician's orders [MEDICAL CONDITION] size and how often to change it, how frequently to change the trach, how frequently to check oxygen saturation levels, or orders for oxygen if the resident's oxygen saturation level falls below a given point. The facility has a basic standing order for suctioning that states, Oral/Nasal Suctioning in Emergency. Surveyor reviewed R59's oxygen saturation documented in the medical record from [DATE] to [DATE]. The following dates are when the facility documented the resident's oxygen saturations: -[DATE] to [DATE] -[DATE] to [DATE] -[DATE] to [DATE] -[DATE] -[DATE] -[DATE] to [DATE] -[DATE] -[DATE] to [DATE] -[DATE] There is no noted routine when the facility checks and documents R59's oxygen saturation. Surveyor reviewed R59's comprehensive care plan. The care plan states the following, in part: Focus: [MEDICAL CONDITION]/RESPIRATORY/SELF ADMINISTRATION OF NEB (Nebulizer or medicated breathing treatment): The resident has a [MEDICAL CONDITION] .and dx (diagnosis) of [MEDICAL CONDITION] .Date Initiated: [DATE] . Goal: The resident will have no abnormal drainage [MEDICAL CONDITION] through the review date. Date Initiated: [DATE] .Target Date: [DATE] . Interventions .Ensure [MEDICAL CONDITION] are secured at all times. Date Initiated: [DATE] .HOB (Head of Bed) elevated at all times to facilitate adequate/optimal breathing .Date Initiated: [DATE] .Suction as necessary (refer to standing order) Date Initiated: [DATE] . The care plan does not identify how to complete R59'[MEDICAL CONDITION] or what to do if the resident'[MEDICAL CONDITION] obstructed, dislodged or extubated. The care plan does not identify when to administer oxygen therapy, how often or when to check R59's O2 sats, how to clean the resident's inner and outer cannulas. The care plan does not identify how often or when to suction the resident's trach, and the care plan does not indicate the size of the outer and inner cannulas, or the location of the obturator. The care plan does not identify the need to have an inner [MEDICAL CONDITION] that is one size smaller in case the resident becomes decannulized (where [MEDICAL CONDITION] is removed) and [MEDICAL CONDITION] to be replaced. Surveyor reviewed R59's nurses' notes, from [DATE] to [DATE]. The notes state the following, in part: -[DATE]: Resident states that she usually coughs in the morning after her neb tx. (treatment) and clears the secretions in her throat. She then changes her cannulas which has cloudy sputum and occasionally a scant amount of blood noted as resident throat gets irritated with clearing coughs EARLY PNEUMONIA .is expectorating (coughing) yellow brownish phlegm via trach. She changes her own inner cannula and nurses clean them for her. Denies SOB (Shortness of Breath) but states she does get momentary feeling of SOB when she 'coughs up a (mucous) plug.' . -[DATE]: RN (Registered Nurse) called to resident's room staff stating that resident was having difficulty breathing. When RN arrived in resident's room, Resident was coughing and stating that she couldn't breathe. O2 sat. 95% on RA (Room Air)/trache. RN asked resident if she wanted to go to the ER (emergency room ) to be evaluated and resident stated yes. When paramedics arrived they suctioned resident's trache, having to insert the suction tubing into the canula (sic) approximately ,[DATE] inches to retrieve a mucus plug that was blood tinged. the plug was approximately 1.5 cm (centimeters) in diameter. Resident was suctioned several times after the plug was removed just to get any additional mucus present. Resident then felt much better and decided that she did not need to be transported (to ER), MD (Doctor of Medicine) and resident's son was updated. -[DATE]: .at (7:30 a.m.) .into residents room to give her the neb tx .Resident took out her inner canula and gave it to nurse to clean. Nurse noted thick green/brown phylem (sic) in canula. Resident did her neb tx then started her coughing to clear out her trach. She continued to cough large amounts of thick phylem with blood. Resident stated she wanted to go to the ER to be seen by MD .Nurse called residents Son .and left message to call facility then called 911. Report given to EMTs (Emergency Medical Technicians) who took resident to .hospital .Resident back from ER at this time. Staff and EMTs assisted resident back into bed .Resident stated had a blood vessel that broke. Nurse read (hospital) paperwork which talks about suctioning resident, given IV fluids and doing labs/x-ray to rule out pneumonia since wheezing was heard in all fields upon admit to ER. After review of labs and x-ray (normal) resident stated she felt better and asked to go back to facility . There is no documentation in the nurses' notes in which the resident was suctioned by nursing staff, from [DATE] to [DATE]. On [DATE] at 10:17 a.m., Surveyor interviewed R59. The resident has a trach, and has a raspy voice as if phlegm is located in the resident's throat. The resident stated she has had [MEDICAL CONDITION] approximately eight years, and lived at home prior to living at the facility for long term care. R59 stated she has been admitted to the facility previously, for short term rehab, several times within the past year. During the continued interview, R59 stated her son changes the outer cannula (or trach) for her, and the resident is able to complete her own nebulizer treatments and change the inner cannula. R59 indicated the nurses clean the inner cannula tube with Dawn dish soap, which is how the resident cleaned the inner cannula at home. R59 indicated the facility has not ordered the inner cannula replacements for the resident since the resident has been admitted to the facility. The resident further stated, The one I have now is getting plugged .It will get plugged and I'll have to cough it (the phlegm) out .They (staff) can't suction it out (because) it's hard. R59 further indicated the facility does not have the outer cannula supplies to be changed. During the continued interview, R59 stated a few months ago the resident had a difficult time breathing and needed to be suctioned. The resident stated the facility did not have the tubes on the suction machine in order to suction the resident's trach. R59 explained the facility called the ambulance in order to suction the resident. The resident stated the paramedics suctioned the resident at the facility and left the tubes for the facility to keep for the suction machine. Surveyor observed several inner cannulas in a basin on the resident's bedside table in the resident's room. Surveyor did not observe an Ambu bag (a manual resuscitator bag used on residents who are not breathing or not breathing adequately) in the resident's room. Surveyor was not able to find an obturator in the resident's room. On [DATE] at 12:20 p.m., Surveyor interviewed RN F. The RN indicated she cleans R59's inner cannula with Dawn dish soap when the resident removes this cannula. RN F stated she is not sure what [MEDICAL CONDITION] the resident requires and is unsure if the resident has an obturator in the resident's room. During the continued interview, Surveyor asked how often staff are to check R59's O2 sats. RN F replied the physician does not currently require the resident's O2 sats to be checked, but the RN checks the resident's oxygen sats when the resident has trouble breathing or is short of breath. During the interview, Surveyor noted R59 has orders for [MEDICAL CONDITION] and asked RN F what this entailed. RN F replied R59 completes all [MEDICAL CONDITION] and RN cleans the inner cannulas. At 4:29 p.m., Surveyor interviewed the DON. The DON confirmed R59 completes the majority of [MEDICAL CONDITION], and facility nurses clean the cannulas with special Dawn dish soap. The DON stated the facility has no physician's orders for the cleaning of [MEDICAL CONDITION], need for oxygen, when and how often the O2 sats should be checked and there are no orders as to when to suction the resident. The DON stated there are no physician's orders for the sizes of the outer and inner cannulas. At 4:49 p.m., the DON informed Surveyor there is not an obturator and an inner tube one size smaller in the resident's room During the continued interview, Surveyor asked about the orders [MEDICAL CONDITION], dated [DATE]. The DON indicated the Minimum Data Set (MDS) Coordinator completed R59's Minimum Data Set and realized the resident did not have orders [MEDICAL CONDITION]. As a result, these orders were obtained on [DATE]. The DON stated the facility does not have a standard of practice to follow when [MEDICAL CONDITION], or for having emergency equipment or procedures. On [DATE] at approximately 4:30 p.m., Surveyor asked how long R59 can breathe without [MEDICAL CONDITION] place. The DON stated she was unsure at this time. The facility's failure to be prepared in case of an emergency per professional standards of practice created a finding of immediate jeopardy beginning [DATE] when R59 suffered her first respiratory event. The facility removed the immediate jeopardy on [DATE]. On [DATE] the facility submitted a plan of removal which included updating facility policy and procedures for tracheotomy care. The facility also obtained the necessary supplies, comprehensive physician orders, emergency equipment for resident and educated and trained licensed staff on tracheotomy care based on current standards of practice. The resident care plan was revised and updated to include resident preferences and tracheotomy care information per professional standards of practice.

Based on interview and record review, the facility did not ensure licensed nurses have specific competencies and skills necessary to care for residents with a [MEDICAL CONDITION]. This occurred for one of one resident (Resident (R) 59) with a [MEDICAL CONDITION] (trach). Displacement or obstruction of a [MEDICAL CONDITION] may result in loss of the airway and respiratory obstruction, which can lead to respiratory arrest and death. The facility's failure to ensure staff had the training and/or competency to provide care in an emergency extubation, displacement or obstruction situation, created a finding of Immediate Jeopardy (IJ), beginning on [DATE]. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed of the IJ finding on [DATE] at approximately 11:00 a.m. The facility removed the jeopardy on [DATE]; however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated as evidenced by: The facility did not ensure the proficiency of nurse aides. The facility did not have 2 of 5 sampled Certified Nursing Assistants (CNA) demonstrate competency in skills and techniques necessary to care for residents' needs. Demonstration of competency to have the skills and techniques to care for residents was not completed for two CNAs. This is evidenced by: On [DATE], Surveyor received and reviewed two facility policies. One policy entitled, Tracheotomy Care, last revised on [DATE], states the following, in part, POLICY .Tracheotomy is performed per physician orders [REDACTED]. This policy does not identify what staff training is required [MEDICAL CONDITION]. The second policy entitled, Tracheotomy Suctioning, dated [DATE], does not identify what staff training is required for suctioning care. 1. On [DATE], Surveyor reviewed R29's medical record. The resident has [DIAGNOSES REDACTED]. According to the medical record, the resident requests Cardio [MEDICAL CONDITION] Resuscitation (CPR) if R59's heart stops beating or if the resident stops breathing. The resident's Brief Interview for Mental Status (BIMS) score, dated [DATE], was a 15 out of 15 possible points. According to the BIMS assessment, a score of 15 indicates R59 has intact cognitive function. The resident makes her own health care decisions. Surveyor reviewed R59's nurses' notes, from [DATE] to [DATE]. The notes state the following, in part: -[DATE]: Resident states that she usually coughs in the morning after her neb tx. (treatment) and clears the secretions in her throat. She then changes her cannulas which has cloudy sputum and occasionally a scant amount of blood noted as resident throat gets irritated with clearing coughs EARLY PNEUMONIA .is expectorating (coughing) yellow brownish phlegm via trach. She changes her own inner cannula and nurses clean them for her. Denies SOB (Shortness of Breath) but states she does get momentary feeling of SOB when she 'coughs up a (mucous) plug.' . -[DATE]: RN (Registered Nurse) called to resident's room staff stating that resident was having difficulty breathing. When RN arrived in resident's room, Resident was coughing and stating that she couldn't breath. O2 sat. 95% on RA (Room Air)/trache. RN asked resident if she wanted to go to the ER (emergency room ) to be evaluated and resident stated yes. When paramedics arrived they suctioned resident's trache, having to insert the suction tubing into the canula (sic) approximately ,[DATE] inches to retrieve a mucus plug that was blood tinged. the plug was approximately 1.5 cm (centimeters) in diameter. Resident was suctioned several times after the plug was removed just to get any additional mucus present. Resident then felt much better and decided that she did not need to be transported (to ER), MD (Doctor of Medicine) and resident's son was updated. -[DATE]: .at (7:30 a.m.) .into residents room to give her the neb tx .Resident took out her inner canula and gave it to nurse to clean. Nurse noted thick green/brown phylem (sic) in canula. Resident did her neb tx then started her coughing to clear out her trach. She continued to cough large amounts of thick phylem with blood. Resident stated she wanted to go to the ER to be seen by MD .Nurse called residents Son .and left message to call facility then called 911. Report given to EMTs (Emergency Medical Technicians) who took resident to .hospital .Resident back from ER at this time. Staff and EMTs assisted resident back into bed .Resident stated had a blood vessel that broke. Nurse read (hospital) paperwork which talks about suctioning resident, given IV fluids and doing labs/x-ray to rule out pneumonia since wheezing was heard in all fields upon admit to ER. After review of labs and x-ray (normal) resident stated she felt better and asked to go back to facility . On [DATE] at 10:17 a.m., Surveyor interviewed R59. The resident has a trach, and has a raspy voice as if phlegm is located in the resident's throat. The resident stated she has had [MEDICAL CONDITION] approximately eight years. R59 indicated the facility has not ordered the inner cannula replacements for the resident since the resident has been admitted to the facility. The resident further stated, The one I have now is getting plugged .It will get plugged and I'll have to cough it (the phlegm) out .They (staff) can't suction it out (because) it's hard. R59 further indicated the facility does not have the outer cannula supplies to be changed. During the continued interview, R59 stated a few months ago the resident had a difficult time breathing and needed to be suctioned. R59 explained the facility called the ambulance in order to suction the resident, and the paramedics were able to suction the resident at the facility. On [DATE] at 12:20 p.m., Surveyor interviewed RN F. Surveyor asked what RN F would do in case R59 had an emergency with the trach. The RN replied a couple of weeks ago, the resident had thick phlegm and blood in the resident sputum. RN F explained at that time she asked the resident if she wanted to be suctioned which the resident declined, so RN F called 911. During the interview, Surveyor noted R59 has orders for [MEDICAL CONDITION] and asked RN F what this entailed. RN F replied R59 completes all [MEDICAL CONDITION] and RN cleans the inner cannulas. Surveyor asked if RN F has had [MEDICAL CONDITION] training from the facility, to which the RN indicated she has not had any training [MEDICAL CONDITION] since graduating nursing school in 1995. Surveyor asked RN F what would the RN do if R59 became decannulized (where [MEDICAL CONDITION] is removed). RN F asked if Surveyor meant if R59 was unable to breathe. The RN then stated she would loosen R59's phlegm with normal saline, suction the resident to open the airway and call the EMTs. RN F did not indicate using oxygen. Further, suctioning without the cannula in place could damage the airway. RN F stated she is not sure what [MEDICAL CONDITION] the resident requires and is unsure if the resident has an obturator in the resident's room. At 4:29 p.m. on [DATE], Surveyor interviewed the DON. The DON stated the facility does not have a standard of practice to follow when [MEDICAL CONDITION], or for having emergency equipment or procedures. Surveyor asked the DON if nurses have been trained by the facility for [MEDICAL CONDITION] care. The DON replied nursing staff have competencies, such as suctioning, [MEDICAL CONDITION] is not one of the competencies. The DON further stated the facility does not admit many residents with trachs. On [DATE], Surveyor reviewed the Facility Assessment Tool. The date the assessment was updated is [DATE], and the date the assessment was reviewed with the Quality Assurance Performance Improvement Committee, is (MONTH) (YEAR). The Facility Assessment states, in part, .3. Part 2: Services and Care We Offer Based on our Residents' Needs .Staff training/education and competencies 3.4 .Competencies .Resident assessment and examinations .trach care . As identified at F695 (cross reference F695), the facility did not have an emergency plan and did not have emergency equipment readily available in R59's room. Staff did not have the training to recognize that emergency equipment is needed in the resident's room. The failure to ensure that staff were trained [MEDICAL CONDITION] created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when the facility submitted a plan of removal which included revised policy and procedures for tracheotomy care. The faclity also provided education and training to licensed staff with return demonstration for tracheotomy care consistent with current standards of practice and educated all staff on identifying potential emergent situations for a tracheotomy resident and the protocols to follow. All staff were educated on emergency procedures and placement of emergency equipment. Schedule for routine care complete with comprehensive detailed information for tracheotomy for resident established and all licensed staff trained on how to provide those cares. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by: 2. On [DATE] during the extended survey, Surveyor requested the annual training and competency evaluations for 5 random sampled CNAs. The facility was not able to provide any evidence of competency in skills for CNA R and CNA S. Surveyor reviewed the dates of hire for the CNAs. CNA R has been employed at the facility since [DATE]. CNA S has been employed at the facility since [DATE]. On [DATE] at 9:20 a.m., Surveyor interviewed the Director of Nursing and Nurse Consultant (NC) W. They acknowledged the competencies had not been evaluated for these two CNAs in quite some time.

Based on record review and interview, the facility did not provide adequate supervision and assistance devices to prevent 1 of 5 residents who wear a wander guard alert safety bracelet (R1) from eloping. R1 is to wear a code alert (wander guard) on her ankle as she is known to ambulate independently. Her wandering behavior had increased following a recent medication change and on [DATE] during the day R1 set off the alarms when she attempted to leave the facility. The facility did not implement a plan to know the whereabouts or to increase supervision of R1 when her wandering behaviors increased. During the overnight of [DATE] and [DATE] R1 was able to exit the building without staff knowledge due to the door alarms or wander guard alarm not sounding. R1 was last observed by facility staff at approximately 10:45 p.m. On [DATE] at 2:50 a.m. facility staff noted R1 was missing but did not call police until 3:34 a.m. R1 was found dead by police on [DATE] at 4:08 a.m. outside on the west side of the facility's building. The temperature at the time of finding R1 was 30 degrees with a wind chill factor of 20 degrees. The failure to ensure adequate supervision when R1 began wandering more frequently and was known to have exited the facility on [DATE] at 3:15 p.m. created a finding of immediate jeopardy that began on [DATE]. NHA (Nursing Home Administrator) was notified of the immediate jeopardy on [DATE] at 10:10 a.m. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. This is evidenced by the following: Review of the facility's policy titled: Wandering Resident Code Alert/Wander Guard dated ,[DATE], read in part: Policy: In an effort to prevent residents from wandering away from the facility; Rice Lake Convalescent Center has developed procedures to be taken when a resident leaves the facility unsupervised or without reporting to the facility staff their time of departure and expected time of return. Primary goal of the facility, related to the wandering resident, is to ensure resident safety utilizing the least restrictive means available. Therefore, door alarms activated 24 hours a day and the Code Alert (Wander Guard commonly used as generic term) system will be utilized. Personalized, ,[DATE] minute checks by specifically assigned staff or physical restraints will be used only in cases of extreme circumstances. Antipsychotic and other psychoactive drugs will not be used unless the need is clearly indicated Review of the facility's policy titled: Wandering Resident ,[DATE] Minute Location Check dated ,[DATE], read in part: .Procedure: Charge Nurse, Social Worker, and/or Administrator, Director of Nursing will make the decision to initiate the ,[DATE] minute check list of a resident who is at increased risk of wandering out/away from facility. Documentation will be charted in the medical record of the initiation of ,[DATE] minute checks and at the discontinuance of the ,[DATE] minute checks Delegation of every ,[DATE] minute checks: 1. The charge nurse at report each shift will verbally delegate the responsibility for the ,[DATE] minute checks on the wandering resident's whereabouts to their assigned nursing assistant. Other nursing assistants and staff members will also be responsible for noting location of resident throughout their shift R1 was admitted to the facility on [DATE] and has the current [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documents the Brief Interview for Mental Status score of a 2 identifying R1 is severely cognitively impaired. Transfer and ambulation is documented as requiring supervision, oversight, encouragement or cueing with the support of set up help from staff. Review of the Cardiopulmonary resuscitation (CPR) information sheet documented for no CPR to be completed and was signed by R1's legal representative on [DATE]. Review of R1's care plan document: BEHAVIOR: The resident tends to wander r/t (related to) Dementia. R1 has a hx of entering other resident rooms without consent. Interventions: Distract resident form wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (Created on [DATE]). Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes (Created on [DATE]). Resident has Wanderguard (Created on [DATE]). The facility did not change or initiate new care plans after R1 was found in the stairway. Review of nurse's notes read in part: [DATE] 21:42, Type: Behavior Note, Note Text: Resident noted to be wandering more this shift. Resident had opened one of the emergency exits on east end, was going into resident rooms uninvited [DATE] 12:28 Type: Order Note, Note Text: Seen by (Dr.Name) MD M on monthly rounds, Medications and vital signs reviewed. Discussed recent evening behaviors. Order received for Risperdal 7.5mg every HS. Dictation to follow. [DATE]:52 Type: COMMUNICATION - with Physician. Note Text: Situation: Per phone call from (Dr.Name) MD M, new orders received to DC Risperdal, Give Mirtazapine 7.5mg every HS [DATE] 13:02, Type: Orders - Administration Note, Note Text: Monitor behaviors/sleep pattern related to Mirtazapine use. every (sic) day and evening shift for Monitoring for 21 Days Resident noted to be up and wandering hallway this AM at approximately 4 am, resident was walking up and down hall and closing the doors to every other resident's room. Resident was redirected and shown back to her room and resident was noted to be back up and wandering hallways again at approximately 5 am [DATE] 00:17 (a.m.), Type: Behavior Note, Note Text: Increased behaviors noted this shift. Res observed wandering before et (and) immediately after PM meal, wandering into other resident's rooms et through their belongings. Writer responded to loud noises c/ (with) this res et res across the hall - this res had taken her purse et believed it was her own. Writer attempted to redirect et to provide reality orientation, res unaffected. 1 to 1 c/ staff provided when res attempted to go out an alarmed door to the stairwell . [DATE] 00:00, Type: Behavior Note, Note Text: Res was observed c/ increased behaviors/wandering this shift before et after PM meal. Res was wandering the halls et into resident's rooms, with occasion of attempting to either take other resident's items or put her items into other resident rooms, looking for her husband who was supposed to come et get her tonight. Res was not easily directed, denies pain/discomfort. At one point, this res had wandered to the West part of the building et attempted to exit through the dbl doors, however, staff was able to successfully intercept, 1 on 1 then provided until res decided to go to bed. Still awaiting MD response . Review of the Certified Nursing Assistant (CNA) behavior charting documented wandering behaviors occurred on: ,[DATE] charted at 3:35 a.m., ,[DATE] charted at 1:38 a.m., ,[DATE] charted at 9:56 p.m., ,[DATE] charted at 2:47 a.m., 2:07 p.m., and [DATE] charted at 1:46 a.m. Review of additional behavior monitoring flow sheet documented wandering behaviors occurred on: Day shift: ,[DATE] one time, ,[DATE] one time, ,[DATE] one time, ,[DATE] one time and ,[DATE] one time. Afternoon shift: ,[DATE] one time, ,[DATE] one time, ,[DATE] three times, ,[DATE] three times, ,[DATE] three times, ,[DATE] three times and ,[DATE] three times. Night shift: ,[DATE] one time, ,[DATE] four times. Review of the R1's Treatment Administration Record (TAR) documented: Check Wanderguard placement 2x/day. every day and evening shift for monitoring - start date [DATE] 0700. This was checked as completed and the TAR did not document if functionality of the wander guard was ever completed. Review of police report read in part: Occurred Between: Sat [DATE] 3:34 a.m., Arrival time: 3:35 a.m. INITIAL INFORMATION - Reporting Officer C .LPN (License Practical Nurse) A (staff member) had contacted Barron County Dispatch advising resident, R1 . was not in her room and could not be located in the building. LPN A (Licensed Practical Nurse) did not have a clothing description or know the last time R1 had been observed Staff member, LPN A stated she noticed R1 missing from her room at approximately 2:50 AM and that they had checked the entire building three times prior to contacting law enforcement. They also stated staff members walked the exterior of the building and drove around the area of the facility attempting to locate R1. She was not located inside or outside of the building by them. I was advised that R1 had attempted to leave the building through the west door on the second floor at approximately 3:00 PM. This was reported to me by RN (Register Nurse) B. Officer D and Sergeant E began looking outside while I spoke with staff. Moment later, Officer D advised they had located R1 outside near the west second floor exit and that she was possibly deceased . STAFF INTERVIEWS After R1 was located, I began interviewing staff members. I was told that it was determined that the last time R1 had been observed was 10:00 PM by nurse, LPN F, whose shift ended at approximately 12:45 AM. I was told at that time that no one had checked on R1 or observed her since that time. I asked every staff member if they were required to conduct checks on the residents at certain intervals and was informed by all that they had no required checks and that each resident had different needs so there was no procedure related to interval checks. I was informed that every door accessible to the exterior was alarmed and that the doors automatically set to alarm starting at 7:00 PM. the doors to all the stairwells are alarmed as well. The alarms were reported to have been functioning properly and every alarmed door I exited sounded the alarm. Any time an alarm sounds it has to be manually silenced by staff by entering a code on a keypad near that specific door. I was also advised that R1 wears a Wanderguard bracelet which sets of a separate alarm if she is near an exit when the door is opened. I was informed that R1 had been wandering a lot more recently after a medication change which occurred on [DATE]. Staff stated R1 was often up wandering the halls recently and not sleeping as well LPN A STATEMENT: I spoke with LPN A who state she began work at 2:40 AM and started checking rooms. She stated she checked R1's room and did not observe her in her room. This occurred at 2:50 AM. LPN A began checking the building for R1 after notifying other staff. R1 (sic) LPN A stated she checked in the parking lot, Indian mound Park, along Lakeshore Drive, both sides of the building and north to the Medical Arts building which is approximately 120 feet from the north end of the building and did not locate R1. She then contacted the Director of Nursing (DON), and administrator, (Nursing Home Administrator (NHA) and informed them of the incident. She then contacted Barron County dispatch to report the incident Certified Nursing Assistant (CNA) G STATEMENT: I spoke with CNA G who advised when she began work she was informed by nurse, LPN F, that R1 was asleep and to not disturb her. Several employees stated R1 had been wandering a lot recently and not sleeping as well at night. CNA G stated she was advised by LPN F that R1 was finally sleeping soundly and she was under the impression from LPN F that she was not supposed to disturb her. CNA G stated she did not check on R1 the remainder of the evening. She stated she did not have to complete mandatory checks on R1 . Register Nurse (RN) B STATEMENT: I spoke with RN B who advised she arrived for work at 3:00 PM and around that time, the west second floor door alarm as well as a Wanderguard alarm began sounding. RN B stated she went to that location and observed R1 standing in between the two sets of doors. She stated she got R1 back into the building with no concerns. She stated R1 was walking the halls throughout her shift and that she last saw R1 between 7:00 PM and 8:00 PM. She state she never observed R1 in the west hall and that LPN F was working on the east side of the building. RN B said when LPN F was leaving around midnight, she stated everyone was fine and in bed. RN B stated shortly after that, a resident passed away so she was with that residents family. RN B stated around 3:00 AM she was advised that R1 was missing and began searching the building for her as well as outside and did not locate her. RN B stated during her shift she did not hear any unexplainable alarms sounding and the only Wanderguard alarm she heard was when R1 attempted to leave around 3:15 PM. RN B state she looked out every window of the building and did not observe R1 outside. Environmental Services (ES) H INFORMATION: .ES H stated none of the cameras were operational . LPN F STATEMENT: .She stated she observed R1 asleep soundly at 10:00 PM in her bed. I asked LPN F about telling CNA G not to disturb R1 the rest of the night and she stated she did not tell . CNA G not to check on R1. She stated she only meant not to wake her by bringing her to the restroom, etc . CNA I STATEMENT: I was able to obtain a written statement that nurse, CNA I, completed for the administrative investigation. In this statement, CNA I reports that LPN F had gotten R1 in her room at around 9:00 PM and that she completed 15 minute checks on R1 with the last check being at 10:45 PM . ADDITIONAL INFORMATION .Vice President of Operations (VPO) J informed me that they do not subscribe to the security service so they get limited record information. He stated the system only stores a small amount of data at a time. Every time an alarm is set off, the system records that alarm and deletes the oldest information in the system, therefore, he stated all the alarm information during the time in question had already been erased as they were testing the alarms all day . I spoke with the Administrator, NHA, who stated he spoke with a family that was present last night with a hospice resident who passed away prior to or around the time of this incident .NHA state he spoke with this family who state they never observed R1 . Officer D's report read in part: .Sergeant E and I exited the northwest doors and noticed that it was very dark on the patio area .I walked down the ramp and shined my flashlight in the yard to the south and when I moved it across the yard to the west I observed a body, later verified to be R1, laying face down on the grass. Sergeant E and I went up to R1 and Sergeant E checked for a pulse by wasn't able to fine one. At 4:08 AM I radioed to dispatch that I had located R1 and to page an ambulance. R1 was laying more on her left side with her arms underneath her body. R1's lips were turning blue in color and she appeared to be deceased EMS personnel had rolled R1 onto her back in order to attach equipment leads and later confirmed R1 was deceased as they had no heart rhythm .In R1's left hand was a pink colored pajama top and a white bra appeared to be hooked around her left forearm. On R1's lower left leg near her ankle was the Wander Guard monitor .Her socks were white and appeared to have little to no grass or dirt stains . I paced off the approximate distance from the northwest entrance to where R1 was located to roughly 102 feet. I paced off the approximate distance from R1's room, #216, to the northwest door to be approximately 390 feet Once Medical Examiner (ME) K arrived she informed me I could remove the alert bracelet on R1's leg .returned to the northwest door to see if the alarm would sound. When I passed through the sensors along the door the audible alarm sounded. I should be noted that the audible alarm for the Wander Guard was significantly louder that then general alarm that sounds when a door is opened . Sergeant E's report read in part: .R1 was wearing blue jean type pants and short sleeve shirt. It was approximately 31 degrees outside at that time and was windy . Investigator L's report read in part: .VPO J told me that only four exterior doors have the Wonder (sic) Guard on them. However; all the doors are audibly alarmed. VPO J said that they tested the Wonder Guard and it worked on all the doors except the west door. When they put it down by the floor, which is where it would have been on R1, it did not always trip the alarm. However, the regular door alarm would have tripped once the door was pushed open . Review of the facility's investigation the staff statements concur with the police report statements. Surveyor toured the facility and upon entering the west wing it was noted to have no residents residing on this hall. As Surveyor entered the hall a motion sensor began to sound, with staff attending to the alarm immediately. Surveyor was able to hear the west door alarm sounding as Surveyor was down the middle hall. On [DATE] at 8:40 a.m., Surveyor interviewed the NHA of the events of the incident. NHA indicated upon the facility's investigation it appears R1 may have left the facility between [DATE] 10:45 p.m. and [DATE] 2:45 a.m. R1 would walk the halls and was able to be redirected when she tried to get to the double doors. The facility had no previous concerns of R1 opening doors or behaviors of pursuing to exit the building. NHA indicated it appears R1 had exited the west door on the second floor and there is no log of when the alarm went off and no staff has knowledge of the alarm sounding. Interviews of staff and family members of the other resident that had passed that evening, all indicated no knowledge of the alarm sounding and someone turning the alarm off. NHA indicated all doors have wander guard alarms and have alarms. The NHA indicated he was notified at 3:29 a.m. and the DON indicated she was notified around 3:20 a.m. The NHA indicated staff should be doing a midnight census count and was not sure if it was done at midnight or at 3:00 a.m. NHA indicated that staff, visitor or family would not use the west entrance. NHA and Surveyor went to the west entrance and doors are unable to be opened from the outside, the door did alarm as we exited the building. NHA indicated he was not sure R1 was on 15 minute checks and would have expected R1 to be on 15 minute checks. NHA indicated maintenance checks the alarm systems monthly and each alarm system has a different key pad to re-set the alarms. The alarms continue to alarm until someone re-sets the alarm at that location. NHA indicated during the staff interviews LPN F indicated around 10:00 - 10:15 p.m. she saw R1 in the door way and redirected R1 to bed and watched R1 go back to bed and shut the door. At 10:45 p.m. CNA I indicated R1 was sleeping in bed. NHA indicated during the family interviews the family used the main east entrance and no residents exited the building with the family. On [DATE] at 8:15 a.m., Surveyor interviewed ME (Medical Examiner) K about R1's death. ME K indicated she arrived to the facility on [DATE] at 4:46 a.m. and it was extremely cold outside the temperature reading from her car read 30 degrees and there was a dusting of snow on the ground. Rice Lake Airport weather report recorded a 20 degree wind chill. EMS (Emergency Medical Services) had assessed R1 and confirmed there was no EKG activity. ME K indicated she did not take a body temperature as R1 was being sent for forensic autopsy in Minnesota. R1 was in the yard where there is a slope and R1's head was down the slope. R1 was wet from the waist to ankle and her socks were wet. The socks were not that soiled and had no shoes on. R1 was wearing a light weight shirt that was nylon and cotton blend, bra, panties, blue jeans and was holding in her hand a pajama top, bra and socks. Clothes were not soiled from attempts of crawling. The ground was soft and there were no abrasions or bruising noted. R1's tissue was still soft with slight rigor to the arms and legs and could break the rigor easily. Lividity was noted in pressure areas to appear bright red and is typical of hypothermia. ME K indicated she did not have the cause of death and is waiting for the autopsy results from Minnesota, as this could take up to two months. The failure to monitor and provide increased supervision for R1 to prevent accidents and death and waiting 44 minutes before calling police created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when it implemented the following: 1. All residents have been re-evaluated for wandering risk. 2. Reviewed documentation for all current residents for any indication of wandering. 3. Care plans have been reviewed and revised for all residents who have been identified as exit seekers. 4. Developed door code policy and going forward door codes will be changed monthly 5. Wandering Resident/Code Alert/Wander Guard policy reviewed and revised. Enviromental will now be checking weekly. Checking for Wanderguard placement and functionality have been placed on the TAR to be done twice a day on those residents with wander guards. 6. Wandering/Missing resident procedure reviewed and revised. 7. Education for all staff on the following: Door alarms, wandering/missing residents, changing door alarms, 15 minute location check 8. Maintenance checked all exterior doors for the functionality of the wanderguard system. Confirmed that all wander guards are operational. All exit doors were checked for functionality of access security alarm. All exit doors were checked for proper latching. Door alarms are being checked daily x 1 week and then weekly. 9. Missing resident audits will be completed 2x's daily on different shifts x 1 week, then 1 x per day x's 1 week, then weekly x 1 month, then monthly. 10. New policies will be added to new employee orientation and agency orientation 11. Midnight census will be completed daily by the charge nurse on duty at midnight. 12. ,[DATE] minute check list will be initiated for a resident who is at increased risk of exiting out/away from facility.

Based on observation and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 10 residents (Resident #5) reviewed for nursing care and pain. Resident #5 had a significant change in condition and the nursing staff did not ensure appropriate assessments were completed, did not document within the medical record, did not obtain vital signs as needed, did not assess the resident's hydration status and did not assess for underlying causes to the increase in the resident's behaviors including not conducting pain assessments. The failure to provide the care needed for Resident #5 created a finding of Immediate Jeopardy situation that began on 03/31/16. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the Immediate Jeopardy at 11:00 a.m. on 04/21/16. Immediate Jeopardy was removed on 04/20/16. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan. As evidenced by: On 04/20/16 at 11:00 a.m., Surveyor reviewed the medical record for Resident #5 and noted the following: - Minimum Data Set (MDS), dated [DATE], states Resident #5 was severely cognitively impaired, had physical behaviors directed towards others, and required extensive assistance with all personal cares. MDS states Resident #5 is on a scheduled pain management program. - Current physician orders, received 04/20/16, state Resident #5 received [MEDICATION NAME] 325 mg. Give 2 tablets by mouth every 4 hours as needed for pain, fever. - Resident #5 has [DIAGNOSES REDACTED]. - Resident #5 was a DNR (do not resuscitate) and requested hospitalization and treatment to treat infections and pain. On 04/20/16 at 10:00 a.m., Surveyor reviewed nursing notes and fluid intake records for Resident #5 from 02/17/16 - 04/11/16 and noted the following: - 02/17/16: (Date of admission) Temperature 97.7. Hydration assessment completed and within normal limits. - 03/03/16: UA (urine analysis) results received - faxed to (MD N). call out to clinic. Stated that they are waiting for culture to prescribe antibiotic. - 03/0716: (MD N) here for rounds. This writer spoke with (MD N), stated that resident has history of UTI's and family is requesting order for cranberry pill for UTI [MEDICATION NAME]. Surveyor identified no physician order for [REDACTED]. - 03/16/16: physician order: Cranberry capsule. Give 1 capsule by mouth every day shift for UTI [MEDICATION NAME]. Medication unavailable. -03/30/16 This is the second day in a row and the third day in the last four days that the intake record indicates no fluid intake. There was no hydration assessment of the resident. - 04/01/16 at 2:41 a.m.: Resident did have a moderate amount of greenish/yellow drainage from her vaginal area when toileting this shift. Area cleaned up and checked later and no drainage present. Peri area not red/swollen. Temperature 97.3. Will update MD during regular business hours. There were no other vial signs documented and no evidence that a nurse assessed Resident #5. - 04/01/16 at 12:01 p.m.: Writer noted progress note stating Resident noted to have green vaginal discharge during the noc shift. Writer followed with floor nurse taking care of resident, who stated she had not had any further discharge and that an FYI fax had been sent to the MD. Staff to continue to monitor for the weekend. Despite the note to monitor for the weekend there were no documented vital signs and no documented assessments of the resident over the weekend (04/02 and 04/03/16). - 04/04/16: This writer spoke with (MD N) regarding urinary concerns. Requested order for ua/uc. (MD N) here for rounds. New orders: Cranberry pill 500 mg daily, urine culture and push fluids. - 04/05/16 at 10:42 a.m.: Urinalysis results faxed to (MD N) and call placed for medication options as resident frequently spits out meds. - 04/05/16 at 12:00 p.m.: Call returned from (MD N's) office. Requested fax be sent regarding concerns of oral treatment and not being effective for UTI treatment due to resident spitting out medications at times. Fax sent to (MD N) regarding these concerns. - 04/05/16 at 12:05 p.m.: Writer discussed UA results with (RN P). RN placed call and fax to MD requesting ABN IM as resident often would spit out pills and liquids. Resident would only take offered fluids at times. Resident often refused and would push away foods and fluids. - 04/05/16 at 12:06 p.m.: Writer notified by (LPN J) that Resident's UA had come back very abnormal and that they had calls out to get antibiotics, were also requesting IM route if possible as resident refuses meds at times and has increased agitation the last few days. Depsite abnormal lab results, there was no documented assessment of the resident and no documented vital signs. - 04/05/16 at 4:03 p.m.: Fax returned from (MD N) regarding UTI treatment options. Urine culture was ordered 04/05/16. Recommendations pending culture results. - 04/06/16: UA/UC results received. Faxed to (MD N). - 04/06/16 at 7:45 p.m.: UA/UC results faxed to (MD N) x 3. Awaiting response to address results. Staff have ben offered/encouraged resident to drink fluids. Resident will often push staff away, refusing fluids. Will continue to offer/encourage resident to drink. There was no documented assessment of Resident #5 despite abnormal lab results from the previous day and despite the resident's poor intake (4oz on 4/5/16 and 3 oz this day). - 04/07/16 at 2:50 a.m.: Residents urine continues to be green in color and thick. MD updated and awaiting orders. - 04/07/16 at 9:12 a.m.: Writer noted resident would not swallow medications that were give. Writer took all medications out of her mouth and cleaned. Resident would not close mouth. Tongue was dry but oral cares had appeared to be done. Resident would not close mouth to drink fluids for writer. Resident was not following direction at that time. Writer discussed decline in health status with RN who placed calls to see if family wanted resident to go for evaluation and treatment. - 04/07/16 at 11:04 a.m.: Resident not closing mouth to swallow. - 04/07/16 at 12:00 p.m.: LPN reported to this writer that resident would not close her mouth and would not swallow liquid medication. Resident would not close lips around a cup or straw to drink. Resident was becoming agitated and pushing staff away/striking out at staff when they tried to encourage fluids or provide cares. This writer attempted to get vitals, but was unsuccessful due to resident's agitation level. - 04/07/16 at 2:09 p.m.; Writer notified that resident had been sent to the ER because she had significant increase in agitation, they were having difficulty providing cares as resident was becoming combative when staff would attempt. Resident was refusing and/or not comprehending how to eat/drink, yelling at staff to get away when attempting to help. Staff reports multiple faxes and phone calls to MD regarding UTI concerns with no response so they sent her to ER to obtained treatment for [REDACTED]. - 04/07/16 at 4:00 p.m.: Received call from (MD N's) office. Stated that (MD N) wanted staff at RLCC to know that urine culture grew strep viridians and treating with antibiotics would not help. Orders to push fluids. Nurse updated that resident was being seen in ER. - 04/07/16 at 5:10 p.m.: Report from ER called to this writer. Stated that resident would be coming back to facility with hospice referral, [MEDICAL CONDITIONS]. Returned with following orders: [MEDICATION NAME] 250 mg/5ml oral liquid, give 5 ml oral every 48 hours for 7 days for UTI. [MEDICATION NAME] 10 mg every 3-4 hours as needed for pain. [MEDICATION NAME] 0.25 mg every 6 hours for agitation. Call and fax placed to (MD N) to update on current status. - 04/08/16: Received hospice standing orders. - 04/10/16: At 1945 (7:45 p.m.) CNA was completing rounds and alerted writer that resident had passed. Writer went down and checked for pulse and no pulse or heart rate noted. Son, POA and hospice was called. On 04/25/16 at approximately 10:00 a.m., Surveyor reviewed behavior monitoring for Resident #5 from 03/23/16 - 04/10/16 and noted the following; - 03/23/16: No behaviors noted - 03/24/16: No charting on this date noted. - 03/35/16: Kicking/hitting noted at 2:32 p.m. - 03/26/16: No behaviors noted - 03/27/16: No behaviors noted - 03/28/16: Kicking/hitting noted at 2:59 p.m. - 03/29/16: No charting on this date noted. - 03/30/16: No behaviors noted - 03/31/16: Kicking/hitting/biting and wandering noted. - 04/01/16: Wandering - 04/02/16: Kicking/hitting/pinching/scratching/spitting - 04/03/16: Kicking/hitting/grabbing - 04/04/16: Kicking/hitting/yelling/screaming/grabbing/ - 04/05/16: Kicking/hitting - 04/06/16: Kicking/hitting/grabbing - 04/07/16: No behaviors noted. - 04/08/16: No behaviors noted. - 04/09/16: No behaviors noted - 04/10/16: No behaviors noted. Resident passed away on this date. Despite the fact that the resident's behaviors increased, there was no documented assessment of the resident or attempt to determine what was the underlying cause to these behaviors. Pain might have been one underlying cause. On 04/21/16, Surveyor requested a copy of all pain assessments for the time frame noted above and no pain assessment was provided. The only pain assessment conducted is with above noted MDS, dated [DATE]. On 04/20/16 at 11:35 a.m., Surveyor interviewed Registered Nurse (RN) B in regard to the above noted nursing notes. Surveyor discussed concerns with RN B in regard to lack of nursing assessments documented within Resident #5's medical record. RN B stated the facility did provide education to the nursing staff on 01/19/16 stating it is a requirement of their license to ensure documentation is completed for all residents. RN B stated she went through Resident #5's nursing notes and felt the charting was not very good and felt the nursing notes needed to be improved. RN B stated the nursing staff were not monitoring the fluid intake amounts for Resident #5. Surveyor requested all hydration assessments for Resident #5 during the above noted time frame and RN B stated the only hydration assessments completed for Resident #5 during the above noted nursing note time frame was on 02/17/16 and 04/07/16. RN B stated the nursing staff should have been doing more hydration assessments and should have been monitoring her fluid intake needs. On 04/21/16 at 9:50 a.m., Surveyor interviewed RN B in regard to the nursing staff not assessing and documenting their findings within the medical record for Resident #5. RN B stated on 01/19/16 she had provided education to the nursing staff on the facility's documentation policy. RN B provided Surveyor a copy of the education, dated 01/19/16, which stated, I (employee name) have received re-instruction on RLCC's documentation policy. I am aware that to hold a license in the State of Wisconsin I am obligated under my license to document any and all interventions related to patient care, and this documentation can be used in the Court of Law, therefore, I understand that documentation must be done timely accurately and completely. I will adhere to this regulation and entirely complete all documentation related to my nursing care. I will sign and/or initial all documents that pertain to the nursing care I deliver during my work shift. I will contact the Director of Nursing/designee whenever I encounter an issue that requires additional interventions when the current treatment is not working. RN B stated the nursing staff should have called the on-call physician instead of faxing and should have sent the resident out to the ER immediately when they were concerned about the abnormal labs and not getting a response from the physician. On 04/21/16 at 1:35 p.m., Surveyor interviewed Medical Records (MR) R in regard to dietary assessments and notes within the medical record. MR R stated all dietary assessments and notes would be in the nursing notes and if they are not there then no assessment and no dietary note was completed. Surveyor reviewed above noted nursing notes with MR R and no dietary assessments were noted. On 04/21/16 at 1:30 p.m., Surveyor interviewed the NHA and DON in regard to the above noted information for Resident #5. Surveyor addressed concerns in regard to very little nursing assessments and charting being completed for Resident #5, no daily hydration assessments being completed, no pain assessments being completed and no vital signs being taken when needed and then charted. The DON stated she had reviewed the medical record for Resident #5 and agreed. The NHA stated she, along with the DON, on 04/20/16, had a meeting with the nursing staff to discuss assessments and charting. Cross reference F157 and F327. The failure to monitor Resident #5's vital signs and to provide ongoing assessment of the resident's condition as her condition changed created a finding of immediate jeopardy. The facility removed the jeopardy on 04/20/16. On 04/21/16 at 8:00 a.m., Surveyor interviewed the DON, NHA and RN D in regard to Resident #5's medical care. RN D stated the facility immediately educated nursing staff in regard to hydration and completed a sweep of the building assessing all current residents for dehydration. RN D stated they had identified residents who were at risk for dehydration and were not appropriately monitoring them. RN D stated the hydration education provided to the nursing staff included providing hydration assessments, documenting the assessment, notifying the dietary department if changes should occur and as needed, monitoring the intake and output logs and ensuring appropriate interventions were implemented. No nursing staff was to begin work until having completed the training.

Based on record review and interview, the facility did not provide fluid intakes to maintain proper hydration and health for 10 of 10 residents reviewed for hydration (Resident #5, #1, #2, #4, #9, #10, #3, #6, #7 and #8). Depsite an order on 03/07/16 to push fluids Resident #5 consumed 12% of required fluids from 03/22/16 to 04/06/16. The failure to ensure sufficient fluid intake for Resident #5, who was admitted to the hospital on [DATE] with dehydration, a urinary tract infection, [MEDICAL CONDITION] created a finding of Immediate Jeopardy situation that began on 03/07/16. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the Immediate Jeopardy at 11:00 a.m. on 04/21/16. The Immediate Jeopardy was removed on 04/20/16; however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm that is not immediate jeopardy/pattern) as evidenced by: Residents #1, #2, #4, #9, #10, #3, #6, #7 and #8 had low fluid intakes and the facility did not ensure a hydration assessment was completed or that the residents were consuming adequate fluids. As evidenced by: Facility policy titled, Hydration Assessment Policy, dated 04/20/16, states hydration assessments are to be done upon admission, during quartery review and as needed, Scores of 10 or higher indicate resident is at risk for dehydration and further assessment should be conducted to review residents fluid needs. The nurse will notify the charge nurse/DON and begin interventions as appropriate, Give the resident the amount of fluid ordered by the nurse or physician, if ordered or indicated, record fluids on I&O every shift for a minimum of 48 hours, All residents must be encouraged to maintain adequate fluid intake, Adequatecy is determined by many factors, but in general, residents who are confused and are unable to help themselves should be offered fluids with each staff interaction. 1. On 04/20/16 at 11:00 a.m., Surveyor reviewed the medical record for Resident #5 and noted the following: - Minimum Data Set (MDS), dated [DATE], states Resident #5 was severely cognitively impaired, had physical behaviors directed towards others, and required extensive assistance with all personal cares. - Resident #5 has [DIAGNOSES REDACTED]. - Resident #5 was a DNR (do not resuscitate) and had requested hospitalization and treatment for [REDACTED]. Surveyor reviewed nursing notes for Resident #5 from 02/17/16 - 04/11/16 and noted the following nursing entries: - 02/17/16: Date of admission. Temperature 97.7. Hydration assessment completed and within normal limits. There was no calculation of the resident's fluid needs, despite the resident being a high risk for dehydration. When the resident's fluid needs were calculated in April 2016, it was determined that Resident #5 needed 85 oz. of fluids each day. - 03/07/16: During routine rounds, the physician noted that this resident had a history of [REDACTED]. There is no evidence this was done. On 04/20/16 at 11:50 a.m., Surveyor was provided with fluid intakes for Resident #5 from 03/22/16 - 04/11/16 and noted the following total daily fluid intakes: - 03/22/16: 12 ounces - 03/23/16: 6 ounces - 03/24/16: 0 ounces - 03/25/16: 24 ounces - 03/26/16: 6 ounces - 03/27/16: 0 ounces - 03/28/16: 12 ounces - 03/29/16: 0 ounces - 03/30/16: 0 ounces - 03/31/16: 24 ounces - 04/01/16: 0 ounces - 04/02/16: 22 ounces - 04/03/16: 29 ounces - 04/04/16: 16 ounces - 04/05/16: 4 ounces Nursing notes: 12:05 p.m.: Resident often refused and would push away foods and fluids. - 04/06/16: 3 ounces. Nursing notes at 7:45 p.m. Staff have been offered/encouraged resident to drink fluids. Resident will often push staff away, refusing fluids. Will continue to offer/encourage resident to drink. Documented intake over the 16 days from 03/22/16 to 04/06/16 was 158 ounces, which was less than 12% of what the resident required (1360 ounces). - 04/07/16: 2 ounces Resident #5's nursing notes for 04/07/16 indicate: - 04/07/16 at 2:50 a.m.: Residents urine continues to be green in color and thick. Medical Doctor (MD) updated and awaiting orders. - 04/07/16 at 9:12 a.m.: Writer noted resident would not swallow medications that were given. Writer took all medications out of her mouth and cleaned. Resident would not close mouth. Tongue was dry but oral cares had appeared to be done. Resident would not close mouth to drink fluids for writer. Resident was not following direction at that time. Writer discussed decline in health status with RN who placed calls to see if family wanted resident to go for evaluation and treatment. - 04/07/16 at 11:04 a.m.: Resident not closing mouth to swallow. - 04/07/16 at 12:00 p.m.: Licensed Practical Nurse (LPN) reported to this writer that resident would not close her mouth and would not swallow liquid medication. Resident would not close lips around a cup or straw to drink. Resident was becoming agitated and pushing staff away/striking out at staff when they tried to encourage fluids or provide cares. This writer attempted to get vitals, but was unsuccessful due to resident's agitation level. - 04/07/16 at 2:09 p.m.: Writer notified that resident had been sent to the emergency room (ER) because she had significant increase in agitation, they were having difficulty providing cares as resident was becoming combative when staff would attempt. Resident was refusing and/or not comprehending how to eat/drink, yelling at staff to get away when attempting to help. Staff reports multiple faxes and phone calls to MD regarding UTI concerns with no response so they sent her to ER to obtained treatment for [REDACTED]. - 04/07/16 at 4:00 p.m.: Received call from (MD N's) office. Stated that (MD N) wanted staff at RLCC to know that urine culture grew strep viridians and treating with antibiotics would not help. Orders to push fluids. Nurse updated that resident was being seen in ER. - 04/07/16 at 5:10 p.m.: Report from ER called to this writer. Stated that resident would be coming back to facility with hospice referral, [MEDICAL CONDITIONS]. Returned with following orders: [MEDICATION NAME] 250 mg/5ml oral liquid, give 5 ml oral every 48 hours for 7 days for UTI. [MEDICATION NAME] 10 mg every 3-4 hours as needed for pain. [MEDICATION NAME] 0.25 mg every 6 hours for agitation. Call and fax placed to (MD N) to update on current status. - 04/08/16: Received hospice standing orders. - 04/10/16: At 7:45 p.m., Certified Nursing Assistant (CNA) was completing rounds and alerted writer that resident had passed. Writer went down and checked for pulse and no pulse or heart rate noted. Son, POA and hospice was called. On 04/21/16, Surveyor reviewed the ER department admission note for Resident #5, dated 04/07/16, and noted the following: Resident #5 was admitted to emergency department on 04/07/16 and was diagnosed with [REDACTED]. Surveyor reviewed ER lab results and noted the following: - Peripheral Pulse Rate: 115 (high) - Respiratory rate: 22/minute (high) - Systolic blood pressure: 145 mmHg (high) - White blood cells: 24.9 (high) - HCT: 47.5% (high) - Neut Number: 20.3 (high) - Potassium level: 7.4 mmol/L (high) - CO2: 16 mmol/l (low) - BUN: 185 mg/dl (high) - Creatinine: 8/8 mg/dl (high) - [MEDICATION NAME] Lvl: 3.2 GM/dl (low) - Lactic Acid Lvl: 3.2 mmol/L (high) - Glomerular filtration rate: 4.3 (low) - UA Appear: 3+ (abnormal) - UA WBC: >100 (abnormal) - UA RBC: 51-100 (abnormal) - UA Bacteria: 4+ (abnormal) - Sodium Lvl: 139 (high) - Blood Culture Report: Pseudomonas Aeruginosa and [DIAGNOSES REDACTED] pneumoniae. - UA Color: Brown - UA Specific Gravity: 1.028 On 04/20/16 at 12:15 p.m., Surveyor interviewed Dietary Manager (DM) A in regard to Resident #5's dietary/fluid needs. DM A stated the dietary department or the Dietician was not notified that Resident #5's fluid intakes were low during the above noted time frame. Surveyor and DM A reviewed the comprehensive dietary care plan for Resident #5 and noted the care plan to state Resident #5 was at risk for malnutrition. Surveyor asked DM A if the dietary department calculated recommended daily fluid intake needs on the care plan and DM A stated no. DM A calculated the recommended fluid intakes for Resident #5 and stated Resident #5's daily fluid intake needs was 85 ounces per day. DM A and Surveyor reviewed the daily intakes logged in the medical record by nursing staff for the above noted time frame. DM A stated the dietary department and the dietician should have been notified immediately so interventions could be implemented. DM A stated the dietary department and the Dietician are to monitor the fluid intake needs. DM A stated she was not made aware of Resident #5 not taking enough fluids until she was put on Hospice on 04/08/16. DM A stated the last Dietician assessment in the medical record was on 02/25/16. DM A stated if the Dietician was told of low intakes she would have immediately done an assessment, and because there was no assessment, she can assume the Dietician was not made aware of the low fluid intakes during the above noted time frame for either Resident #5 or any other resident within the facility. On 04/20/16 at 2:15 p.m., Surveyor interviewed Registered Nurse (RN) P in regard to the cares being provided to Resident #5, RN P stated she was the nurse in charge of taking care of Resident #5 during the day shift on 04/04/16, 04/05/16, 04/06/16 and 04/07/16. RN P stated she was not aware of the facility having hydration assessments to do and therefore did not do a hydration assessment until 04/07/16 when signs and symptoms of dehydration were noted. RN P stated she was not aware of Resident #5 not getting enough fluids. RN P stated the CNAs told her that Resident #5 would push away any fluids being offered. On 04/20/16 at 11:35 a.m., Surveyor interviewed RN B in regard to the above noted nursing notes. Surveyor discussed concerns with RN B in regard to lack of nursing assessments documented within Resident #5's medical record. RN B stated the nursing staff were not monitoring the fluid intake amounts for Resident #5. RN B stated the only hydration assessments completed for Resident #5 during the above noted nursing note time frame was on 02/17/16 and 04/07/16. RN B stated the nursing staff should have been doing more hydration assessments and should have been monitoring her fluid intake needs. RN B stated she did not know why IV fluid treatment was not initiated. Surveyor requested all hydration assessments for Resident #5 during the above noted time frame and RN B stated other than in the nursing note on 04/07/16, the facility had only completed one hydration assessment on 02/17/16. On 04/21/16 at 3:40 p.m., Surveyor interviewed Medical Director (MD) O in regard to the cares for Resident #5 as noted above and the facility's quality assurance (QA) program. MD O stated he was contacted today by the NHA and was informed of the immediate jeopardy situation (reference F157, F309 and F327). MD O stated he is part of the facility's QA committee and attends the meetings almost monthly. Surveyor asked MD O if the facility had discussed with him that they had identified a concern with the facility nursing staff not monitoring fluid intakes, not completing an assessment on Resident #5 and then not documenting their findings within the medical record. MD O stated he did not believe it had ever been brought up to him before and was not aware of any hydration concerns within the facility. MD O stated he was not sure if the education provided to nursing staff on 01/16/16 (as noted above) was brought to his attention and he would have to review the monthly QA notes to be sure. MD O stated he is aware that the facility continuously tries to do better at documentation and this has been an ongoing issue. MD O stated he would expect the nursing staff to complete a thorough assessment on all residents and then document their assessment within the medical record. On 04/21/16 at 1:30 p.m., Surveyor interviewed the NHA and DON in regard to the above noted information for Resident #5. Surveyor addressed concerns in regard to very little nursing assessments and charting being completed for Resident #5, no daily hydration assessments being completed, dietary staff not monitoring fluid intake needs and nursing staff not updated dietary when low fluid intakes were being charted, no new interventions implemented when low fluid intakes were noted, and no dietary assessments. Failure to ensure adequate fluid intake for Resident #5 created a finding of immediate jeopardy. According to a study published by the National Institute of Health (http://www.ncbi.nlm.nih.gov/pubmed/ 084), An overall mortality rate of 29.8% was found in elderly persons who were hosptialized with dehydrations. The facility removed the jeopardy on 04/20/16. On 04/21/16 at 8:00 a.m., Surveyor interviewed the DON, NHA and RN D in regard to Resident #5's medical care. RN D stated the facility immediately educated nursing staff on 04/20/16 in regard to hydration and completed a sweep of the building assessing all current residents for dehydration. RN D stated they had identified residents who were at risk for dehydration and were now appropriately monitoring them. RN D stated the hydration education provided to the nursing staff included providing hydration assessments, documenting the assessment, notifying the dietary department if changes should occur and as needed, monitoring the intake and output logs and ensuring appropriate interventions were implemented. Cross reference F157 and F309. The deficient practice continues at a scope/severity of E (potential for more than minimal harm that is not immediate jeopardy/pattern) as evidenced by the following: 2. On 04/25/16, Surveyor reviewed the daily fluid intakes for Resident #1 along with the estimated daily fluid intake needs and noted the following: - Calculated Daily Fluid intake needs provided to this surveyor by DM A on 04/25/16: 115 ounces/day - Total daily fluid intakes for Resident #1 for 04/18/16: no charting; 04/19/16: no charting; 04/20/16: no charting; 04/21/16: 28 ounces. - No hydration assessments noted within the medical record. 3. Resident #2's calculated Daily Fluid intake needs provided to this surveyor by DM A on 04/25/16: 77.04 ounces/day - Total daily fluid intakes for Resident #2 for 04/18/16: 32 ounces; 04/19/16: 34 ounces; 04/20/16: 32 ounces; 04/21/16: 36 ounces. - No hydration assessments noted within the medical record. 4. Resident #4's calculated Daily Fluid intake needs provided to this surveyor by DM A on 04/25/16: 154.6 ounces/day - Total daily fluid intakes for Resident #4 for 04/18/16: 48 ounces; 04/19/16: 6 ounces; 04/20/16: no charting; 04/21/16: no charting. - No hydration assessments noted within the medical record. 5. Resident #9's calculated Daily Fluid intake needs provided to this surveyor by DM A on 04/25/16: 67.51 ounces/day - Total daily fluid intakes for Resident #9 for 04/18/16: 30 ounces; 04/19/16: 46 ounces; 04/20/16: 12 ounces; 04/21/16: 14 ounces. - No hydration assessments noted within the medical record. 6. Resident #10's calculated Daily Fluid intake needs provided to this surveyor by DM A on 04/25/16: 51.46 ounces/day - Total daily fluid intakes for Resident #10 for 04/18/16: 22 ounces; 04/19/16: 16 ounces; 04/20/16: 64 ounces; 04/21/16: 30 ounces. - No hydration assessments noted within the medical record. 7. Resident #3 has potential risk factors for dehydration due to [DIAGNOSES REDACTED]. Review of Resident #3's initial Nutrition/Dietary assessment of 03/08/16, by Registered Dietician (RD) M included diagnoses, height, weight, diet, intakes being 76-100%, [MEDICATION NAME] level of 2.3, he is independent with eating ability, his MNA (Mini Nutritional Assessment) score was 12, which is within normal limits (WNL), indicating normal nutrition and an estimate of kilo calorie (kcal) needs per day. There was no assessment of fluid intake or daily fluid needs. On 03/09/16, DM A met with Resident #3 to discuss his diet, likes and dislikes. This note included Resident #3 would like to have coffee, milk and juice with his meals. This note did not include review of his fluid intake or identify his estimated fluid needs. Resident #3's urinary care plan includes an intervention of Monitor and document intake and output per facility policy. Resident #3's skin care plan includes an intervention of Encourage good nutrition and hydration to promote healthy skin. Resident #3's nutritional care plan does not address fluid needs and there is not a care plan for hydration. On 04/25/16, DM A calculated Resident #3's daily fluid intake needs at Surveyor 's request and determined Resident #3's daily fluid needs to be 118.5 ounces. Review of Resident #3's intake records starting 03/30/16, Surveyor identified the following intake examples: 03/30/16 at 4:43 p.m.-16 ounces, 03/31/16 at 5:20 p.m.-12 ounces, 04/01/16 at 9:03 p.m.-16 ounces, 04/02/16 at 5:12 p.m.-12 ounces, 04/03/16 at 11:54 a.m.-24 ounces and 1:49 p.m.-20 ounces, 04/05/16 at 10:19 a.m.-4 ounces and at 8:41 p.m.-8 ounces. The intake documentation for Resident #3 is incomplete; it does not include all shifts or all meals. Based on these intake records, it would be impossible to determine Resident #3's total daily fluid intake and to assess his risk for dehydration. Resident #3 had not been assessed for being at risk for dehydration until 04/20/16, after Surveyor had brought up the concern of residents not being assessed for dehydration risk. 8. Resident #6 has [DIAGNOSES REDACTED]. Resident #6 had not been assessed for daily fluid needs or for potential dehydration. Resident #6's initial Nutrition/Dietary assessment, dated 03/31/16 by RD M, included Resident #6's daily kcal needs and that Resident #6's MNA was within normal limits. This dietary assessment did not address Resident #6's daily fluid needs. Resident #6's care plan included, The resident has nutritional problem or potential nutritional problem. Resident is on a diabetic diet r/t (related to) Diet restrictions. Resident #6's care plan did not include hydration needs or interventions related to fluid intake. On 04/25/16, DM A calculated Resident #6's daily fluid intake needs at Surveyor 's request and determined Resident #6's daily fluid needs to be 93.32 ounces. Review of Resident #6's intake records starting 03/26/16, Surveyor identified the following intake examples: 03/26/16 at 5:30 p.m.-16 ounces, 03/29/16 at 9:43 p.m.-16 ounces, 04/01/16 at 9:15 p.m.-16 ounces, 04/02/16 at 5:12 p.m.-12 ounces, 04/05/16 at 10:19 a.m.-4 ounces and 8:38 p.m.-16 ounces and 04/11/16 at 8:44 p.m.-14 ounces. The intake documentation for Resident #6 in incomplete, it does not include all shifts or all meals. Based on these intake records, it would not be possible to determine Resident #6's total daily fluid intake and to assess his risk of dehydration. No dehydration risk assessment had been done for Resident #6 until 04/20/16. 9. Resident #7 has [DIAGNOSES REDACTED]. Resident #7's quarterly Nutrition/Dietary assessment, dated 03/08/16, RD M identified Resident #7's weights and his MNA score places Resident #7 at risk for malnutrition. RD M's note does not address Resident #7's fluid needs or an overview of his fluid intakes. Resident #7's care plan included a problem for nutrition; it did not address fluid needs. Resident #7's care plan for potential skin impairment identified he has a suprapubic catheter and intervention read, Encourage good nutrition and hydration in order to promote healthier skin. On 04/25/16, DM A calculated Resident #7's daily fluid intake needs at Surveyor 's request and determined Resident #7's daily fluid needs are 78.58 ounces. Review of Resident #7's intake records beginning 03/26/16, Surveyor identified the following intake examples: 03/26/16 at 12:00-14 ounces and 5:30 p.m.-8 ounces, 03/29/16 at 10:15 a.m.-24 ounces and at 1:31 p.m.-20 ounces, 04/01/16 at 1:32 p.m.-16 ounces, 04/05/16 at 1:54 p.m.-10 ounces and at 2:11 p.m.-24 ounces, 04/09/16 at 9:32 a.m.-20 ounces and 04/19/16 at 10:18 a.m.-20 ounces. The intake documentation for Resident #7 is incomplete; it does not include intake for all shifts or all meals. Based on these intake records, it would not be possible to determine Resident #7's total daily fluid intake and to assess his risk of dehydration. Resident #7 did not have a dehydration risk assessment completed until 04/20/16. 10. Resident #8 has [DIAGNOSES REDACTED]. Resident #8 is at risk for dehydration due to being on diuretic medication. Resident #8's annual Nutrition/Dietary assessment of 10/27/15, RD M addressed Resident #8's weight and appetites; it does not include fluid intake needs. Resident #8's care plan includes a focus area of Resident #8 being on a diuretic. Interventions include Monitor for side effects and effectiveness Q (every) - SHIFT. And Report pertinent lab results to MD (medical doctor) (Especially HCT (hematacrit), Na+ (sodium), K+ (potassium). Resident #10's nutrition care plan addresses beverage preferences but not other measures to promote fluid intake. Resident #8 was assessed by DM A, at Surveyor 's request on 04/25/16, to have daily fluid intake needs of 75.53 ounces. Surveyor was not provided with Resident #8's intake records. Resident #8 also did not have a dehydration risk assessment completed until 04/20/16.

Based on interview and record review, the facility did not ensure the physician was consulted regarding a significant change in condition for 2 of 10 residents (Resident #5 and #3) reviewed for change in condition. Resident #5 had signs and symptoms of a urinary tract infection which were worsening and the facility did not consult with the physician, thus delaying treatment. The resident was eventually diagnosed at the hospital with a urinary tract infection, dehydration, [MEDICAL CONDITION]. The failure to consult with the physician with a significant change in condition for Resident #5 created a finding of Immediate Jeopardy situation that began on 04/05/16. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the Immediate Jeopardy at 11:00 a.m. on 04/21/16. Immediate Jeopardy was removed on 04/21/16. The deficient practice continues at scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as evidenced by the following: Resident #3 was noted to have redness on the dorsum of his right foot on 03/24/16 and redness and bogginess on his right heel on 03/26/16. No physician consultation or notification was made of these changes until 04/07/16, when the dorsum of Resident #3's right foot was found to have dark brown eschar present with significant redness and his right heel had black eschar tissue and redness present. As evidenced by: 1, On 04/20/16 at 11:00 a.m., Surveyor reviewed the medical record for Resident #5 and noted the following: - Minimum Data Set (MDS), dated [DATE], states Resident #5 was severely cognitively impaired, had physical behaviors directed towards others, and required extensive assistance with all personal cares. - Resident #5 has [DIAGNOSES REDACTED]. - Resident #5 was a DNR (do not resuscitate) and had requested hospitalization and treatment to treat infections and pain. On 04/20/16 at 10:00 a.m., Surveyor reviewed nursing notes for Resident #5 from 02/17/16 - 04/11/16 and noted the following nursing entries: -03/30/16. Fluid intake records indicate that Resident #5 had no fluid intake three of the last four days, with the only intake from 03/27 - 03/30/16 being 12 ounces on 03/28/16. There was no consultation with the physician regarding this lack of fluid intake. - 04/01/16 at 2:41 a.m.: Resident did have a moderate amount of greenish/yellow drainage from her vaginal area when toileting this shift. Area cleaned up and checked later and no drainage present. Peri area not red/swollen. Temperature 97.3. Will update MD during regular business hours. Despite this significant change, the facility did not immediately consult with the physician. - 04/01/16 at 12:01 p.m.: Writer noted progress note stating Resident noted to have green vaginal discharge during the noc shift. Writer followed with floor nurse taking care of resident, who stated she had not had any further discharge and that an FYI fax had been sent to the MD. Staff to continue to monitor for the weekend. Although the facility had sent a fax to the physician, there is no evidence that nursing consulted with the physician regarding this condition change. - 04/04/16: This writer spoke with (MD N) regarding urinary concerns. Requested order for ua/uc. (MD N) here for rounds. New orders: Cranberry pill 500 mg daily, urine culture and push fluids. - 04/05/16 at 10:42 a.m.: Urinalysis results faxed to (MD N) and call placed for medication options as resident frequently spits out meds. - 04/05/16 at 12:00 p.m.: Call returned from (MD N's) office. Requested fax be sent regarding concerns of oral treatment and not being effective for UTI treatment due to resident spitting out medications at times. Fax sent to (MD N) regarding these concerns. - 04/05/16 at 12:05 p.m.: Writer discussed UA results with (RN P). RN placed call and fax to MD requesting ABN IM as resident often would spit out pills and liquids. Resident would only take offered fluids at times. Resident often refused and would push away foods and fluids. - 04/05/16 at 12:06 p.m.: Writer notified by (LPN J) that Resident's UA had come back very abnormal and that they had calls out to get antibiotics, were also requesting IM route if possible as resident refuses meds at times and has increased agitation the last few days. - 04/05/16 at 4:03 p.m.: Fax returned from (MD N) regarding UTI treatment options. Urine culture was ordered 04/05/16. Recommendations pending culture results. - 04/06/16: UA/UC results received. Faxed to (MD N). - 04/06/16 at 7:45 p.m.: UA/UC results faxed to (MD N) x 3. Awaiting response to address results. Staff have been offered/encouraged resident to drink fluids. Resident will often push staff away, refusing fluids. Will continue to offer/encourage resident to drink. The facility did not promptly consult with the physician and continued to wait for a return call even after there had been no response to the faxes that had been sent, thus delaying treatment. - 04/07/16 at 2:50 a.m.: Resident's urine continues to be green in color and thick. MD updated and awaiting orders. There was no assessment of the resident and no prompt consultation with the physician regarding the resident's condition. - 04/07/16 at 9:12 a.m.: Writer noted resident would not swallow medications that were given. Writer took all medications out of her mouth and cleaned. Resident would not close mouth. Tongue was dry but oral cares had appeared to be done. Resident would not close mouth to drink fluids for writer. Resident was not following direction at that time. Writer discussed decline in health status with RN who placed calls to see if family wanted resident to go for evaluation and treatment. - 04/07/16 at 11:04 a.m.: Resident not closing mouth to swallow. - 04/07/16 at 12:00 p.m.: LPN reported to this writer that resident would not close her mouth and would not swallow liquid medication. Resident would not close lips around a cup or straw to drink. Resident was becoming agitated and pushing staff away/striking out at staff when they tried to encourage fluids or provide cares. This writer attempted to get vitals, but was unsuccessful due to resident's agitation level. - 04/07/16 at 2:09 p.m.; Writer notified that resident had been sent to the ER because she had significant increase in agitation, they were having difficulty providing cares as resident was becoming combative when staff would attempt. Resident was refusing and/or not comprehending how to eat/drink, yelling at staff to get away when attempting to help. Staff reports multiple faxes and phone calls to MD regarding UTI concerns with no response so they sent her to ER to obtained treatment for [REDACTED]. ER admission note for 04/07/16 indicates Resident #5 was diagnosed with [REDACTED]. - 04/07/16 at 4:00 p.m.: Received call from (MD N's) office. Stated that (MD N) wanted staff at facility to know that urine culture grew strep viridians and treating with antibiotics would not help. Orders to push fluids. Nurse updated that resident was being seen in ER. Note: This is the first time facility staff has spoken with the physician since getting the culture results on 04/06/16. During this time there were no treatment changes and no new orders. - 04/07/16 at 5:10 p.m., Report from emergency room (ER) called to this writer. Stated that resident would be coming back to facility with hospice referral, [MEDICAL CONDITIONS]. Returned with following orders: [MEDICATION NAME] 250 mg/5ml oral liquid, give 5 ml oral every 48 hours for 7 days for UTI. [MEDICATION NAME] 10 mg every 3-4 hours as needed for pain. [MEDICATION NAME] 0.25 mg every 6 hours for agitation. Call and fax placed to (MD N) to update on current status. - 04/08/16: Received hospice standing orders. - 04/10/16: 7:45 p.m. Certified Nursing Assistant (CNA) was completing rounds and alerted writer that resident had passed. Writer went down and checked for pulse and no pulse or heart rate noted. Son, POA and hospice were called. On 04/20/16 at 2:15 p.m., Surveyor interviewed Registered Nurse (RN) P in regard to the cares being provided to Resident #5. RN P stated she was the nurse in charge of taking care of Resident #5 during the day shift on 04/04/16, 04/05/16, 04/06/16 and 04/07/16. RN P stated that on 04/06/16 they had attempted to call and fax the physician multiple times due to increased worsening of signs and symptoms but did not get a call back or a returned fax from the physician. RN P stated she did not know why she did not call an on-call physician and just send her out on 04/06/16 but feels she should have stating, I don't know why I didn't .should have. On 04/20/16 at 11:35 a.m., Surveyor interviewed RN B in regard to the above noted nursing notes. Surveyor discussed concerns with RN B in regard to lack of nursing assessments documented within Resident #5's medical record and no physician was notified on 04/06/16 when signs and symptoms of infection were worsening. RN B stated the nursing staff was attempting to contact MD N but was not getting a response. RN B stated the nursing staff should have called an on-call and Resident #5 should have been sent out to the ER. On 04/21/16 at 9:50 a.m., Surveyor interviewed RN B in regard to the nursing staff not assessing and documenting their findings within the medical record for Resident #5. RN B stated the nursing staff should have called the on-call physician instead of faxing and should have sent the resident out to the ER immediately when they were concerned about the abnormal labs and not getting a response from the physician. On 04/21/16 at 8:00 a.m., Surveyor interviewed the DON, NHA and RN D in regard to Resident #5's medical care. The DON and the NHA stated the nursing staff should have contacted the physician or an on-call physician on 04/06/16 when worsening signs and symptoms developed and Resident #5 should have been sent to the ER. The NHA stated she felt this was a concern and ensured that education on physician notification would start immediately. On 04/21/16 at 3:40 p.m., Surveyor interviewed Medical Director (MD) O in regard to the cares for Resident #5 as noted above and the facility' quality assurance (QA) program. MD O stated he was contacted today by the NHA and was informed of the immediate jeopardy (reference F157, F309 and F327). MD O stated he is part of the facility's QA committee and attends the meetings almost monthly. Surveyor asked MD O if the facility had discussed with him that they had identified a concern with the facility nursing staff not contacting the physician with significant changes in condition other than by faxing. MD O stated there is always an on-call physician available and the nursing staff should be picking up the phone and consulting with a physician rather than sending a fax, especially if there is a change in condition. On 04/25/16, Surveyor received a copy of all faxes sent to the physician in regard to Resident #5 during the above noted time frame. Surveyor noted no faxes sent to physician from 03/31/16 - 04/10/16 were in the medical record. On 04/21/16 at 9:32 a.m., Surveyor interviewed MD N's nurse, RN Q, via telephone. RN Q stated MD N had visited Resident #5 at the facility on 04/04/16 and received notice on 04/07/16 that Resident had been sent to the ER. RN Q stated MD N's office has no record of faxes being received to her office from 04/04/16 - 04/10/16 and if communication would have been received, it would be in the medical record. RN Q stated the facility's way of communicating to MD N is only through faxing. RN Q stated if the office sees a fax they will then put it on MD N's desk for him to review when available. On 04/21/16 at 1:30 p.m., Surveyor interviewed the NHA and DON in regard to the above noted information for Resident #5. Surveyor addressed concerns in regard to no physician notification was completed and Resident #5 should have been sent to the ER per her advanced directives. Both the NHA and the DON agreed with this surveyor. Cross reference F309 and F327. Staff failure to immediately consult with the physician, thus delaying [DIAGNOSES REDACTED]. The jeopardy was removed on 04/21/16 when the facility implemented the following: Facility reviewed and revised the physician notification policy, reviewed the new protocol with all staff prior to working next shift, all residents were reviewed for acute change of condition to ensure proper notification occurred. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as evidenced below. The 11/22/11 facility policy Pressure Ulcer Care read in part: 1. If skin breakdown should occur or is identified upon admission, document in the resident medical record. 2. Consult with the attending physician/Wound Nurse Practitioner and physical therapy to obtain an appropriate treatment and document in the medical record. 2. On 04/21/16, Surveyor began review of Resident #3's medical record and facility documentation and identified Resident #3 was admitted to the facility on [DATE]. Resident #3 has [DIAGNOSES REDACTED]. Resident #3 had a right femoral tibial arterial bypass also in 09/2014. Resident #3 was assessed by the facility as being at risk for pressure ulcer development. Resident #3 was receiving treatment by Occupational Therapy (OT) that included [MEDICAL CONDITION] wraps of both lower extremities. The wraps covered Resident #3's feet and lower legs from just above his toes to just below his knees. A 03/24/16 progress note by Certified Occupational Therapy Assistant (COTA) F, read in part: Padded over right distal knee and right dorsum of foot due to redness from previous wrapping . A 03/26/16 progress note by Occupational Therapist (OT) E read in part: Skin check with no sores noted, heels reddened - consulted with nursing and informed they are now floating heels in bed . A Podiatric Assessment completed 03/26/16 by RN G, identified Resident #3 had areas of redness related to pressure. Resident does have a red boggy area on the right heel that does blanch. (No mention of left heel or the dorsum or Resident #3's right foot). Foam pillow placed under heels while in bed to prevent skin breakdown. There were no measurements of the red area on Resident #3's right heel. A section of this assessment form asks Referral for medical intervention? No was answered. Surveyor reviewed OT progress notes for Resident #3 of 03/28/16, 03/29/16 and 03/31/16, the dates LE [MEDICAL CONDITION] treatment was done, these notes do not include what the skin of his heels or the dorsum of his right foot looked like on these dates. The next note addressing Resident #3's right heel was written on 04/02/16 by OT E. This progress note included: Removed wrap, skin check completed with Moderate redness to R (right) heal (sic) (nursing aware and has been floating heel in bed . Resident #3's nursing progress notes and skin/wound assessment notes from 03/24/16-04/06/16 do not include any documentation of Resident #3's heels or the dorsum of his right foot, or that a physician was consulted. An 04/06/16, OT progress note by COTA F read in part: Patient's shower rescheduled for tomorrow vs today, therefore LE (lower extremity) wraps will be changed tomorrow. A nursing progress note of 04/07/16 at 11:25 a.m., by RN C read in part: Wraps removed by CNA and noted black and discolored areas. CNA immediately notified nursing and nursing notified management. The right heel measures 5 x 7 cm. (centimeter) and is black in color with surrounding skin red. There is a purple irregular shaped spot on the right inner ankle area measuring 4.5 x 4.7 cm which is surrounder (sic) by redness. The entire area measures 9 x 8 cm He has an appt. (appointment) with (Nurse Practitioner I's name) at 1330 (1:30 p.m.) with Heartland transporting. A call was placed to (Resident #3's primary physician) to inform. Awaiting call back. On 04/21/16 at appoximately 1:30 p.m., Surveyor asked RN D if she knew if a physician was informed of Resident #3's red areas on his heels and the dorsum of his right foot prior to 04/07/16. RN D said she would need to check. No evidence of physician consultation was provided to Surveyor . On 04/25/16 beginning at 11:00 a.m., Surveyor interviewed OT E and COTA F. Surveyor asked COTA F if she had told nursing about the redness noted on the dorsum of Resident #3's right foot on 03/24/16. COTA F could not recall. Surveyor provided COTA F a copy of her progress note for 03/24/16 to review. COTA F looked at her note and commented the note does not indicate that she had. Surveyor then asked OT E if she had measured the red areas on Resident #3's heels or the red area on the dorsum of Resident #3's right foot. OT E said she had not done measurements of the areas. OT E was asked if she had told nursing on 04/02/16, that Resident #3's right heel had moderate redness. OT E said she was not sure. OT E reviewed her progress note of 04/02/16, and said, My note says nursing was aware. Surveyor pointed out that did not specify if they had been made aware of the moderate redness on 04/02/16. OT E acknowledged understanding of Surveyor 's statement. Communication by phone and email was completed on 04/26/16 with the NHA and RN B, regarding physician consultation regarding the pressure areas on Resident #3's heels, especially the right heel and dorsum of his foot. This resulted in the following email from RN B at 1:52 p.m. on 04/26/16, Regarding (Resident #3's initials) and doctor notification, I have calls out to pool nurses to call me. I have talked with RLCC (Rice Lake Convalescent Center) facility nurses and reviewed documentation. There are not aware of the doctor being notified nor is it charted. (RN G's first name) from pool is who documented finding the red heel, I need to speak to her before I can say with certainty that MD (medical doctor) was not notified, but as of right now that is how it appears.

Based on observation, interview and medical record review, the facility did not provide care and services to prevent the development of pressure ulcers, nor provide treatment to prevent worsening of pressure ulcers, for 1 of 10 residents reviewed for pressure ulcers. Resident #3 was admitted without pressure ulcers. Resident #3 had multiple risk factors and was assessed by the facility as being at risk for pressure ulcer development. Resident #3 developed stage I and II pressure ulcers to his coccyx and buttocks, deep tissue injury to the dorsum of his right foot and an unstageable pressure ulcer to his right heel. The facility did not implement adequate measures to prevent pressure ulcers from occurring and after development of pressure ulcers of Resident #3's right lower extremity, there was lack of assessment and treatment to prevent worsening of pressure ulcers. This is evidenced by: On 04/21/16, Surveyor began review of Resident #3's medical record and facility documentation and identified Resident #3 was admitted to the facility on [DATE]. Resident #3 has [DIAGNOSES REDACTED]. During an interview with Registered Nurse (RN) D on 04/21/16 at 1:33 p.m., Surveyor asked RN D if Resident #3 was at risk for pressure ulcers on admission. RN D looked in the computer and told Surveyor that Resident #3's Braden scale on 03/04/16 assessed Resident #3 as being at moderate risk for pressure ulcers. Resident #3's Minimum Data Set (MDS) assessments completed 03/11/16, 03/18/16 and 04/01/16 also identified Resident #3 was at risk for pressure ulcer development. Resident #3's initial MDS, completed 03/11/16, identified Resident #3 as needing extensive assistance of one staff for bed mobility. Resident #3 continues to need extensive assistance for bed mobility. Coccyx/Buttocks A 03/19/16, 6:41 p.m., Skin Observation Tool for Resident #3 read in part: Open areas to buttocks, covered with bordered foam . (Through review of nursing progress notes, skin observation tools, skin/wound notes and wound care flow sheets, Surveyor was unable to determine when the first open area to Resident #3's buttocks was initially discovered. Resident #3's 03/18/16 MDS identified Resident #3 had one stage II pressure ulcer with the date of oldest stage II pressure ulcer being 03/17/16). Resident #3's 03/04/16 initial care plan included interventions of repositioning every two hours and a wheelchair cushion. Resident #3 used an E-Maxx memory foam redistribution mattress. Resident #3 developed open areas on his buttocks on 03/17/16. Resident #3's plan of care was not changed to include the use of the low air loss mattress until 03/23/16. A 03/26/16, 3:12 a.m., Skin Observation Tool for Resident #3 read: Site Right buttock Type Pressure .5 x 1 cm (centimeter) Depth (blank) Stage N/A Site Right buttock Type Pressure 2 cm x 1 mm (millimeter) Depth .1 mm Stage I Site Left buttock Type Pressure 1 cm x 1 mm Other L (left) butt red area Type Pressure 6 cm x 3 cm R (right) butt red area Type Pressure 8 cm x 2 cm. Red areas to buttocks, covered with barrier cream, being followed by wound RN . Bilateral lower extremities unwrapped skin assessed and rewrapped . Skin Observation Tool documentation for 04/01/16 and 04/09/16, for Resident #3 did not include information about Resident #3's coccyx or buttocks pressure ulcers. A 04/15/16, 8:21 p.m., Skin Observation Tool for Resident #3 read in part: Open and purple areas noted on coccyx that are being treated with a 6 x 6 [MEDICATION NAME]. Continuing to monitor. Resident #3's Wound Care Flow Sheets included the following: 03/31/16-Wound Type Pressure Location coccyx, L buttock Measurements (Length, Width, Depth) 2 areas; (upper) 5 x 0.5 x 1 cm & 4.7 x 2.5 x 0.1 cm /c (with) islands of [MEDICATION NAME] tissue, yellow 60%, pink 40%. Odor No. (Drng (drainage) bloody). Wound Margins pink, Surrounding Tissue pink. There was no staging identified on this flow sheet. A Skin/Wound Notes for Resident #3 read in part: 03/31/16 - He has 2 open areas on his coccyx/left buttock. The coccyx wound also involved the left buttock, measuring 5 x 0.5 x 0.1 cm., and the left buttock area is 4.7 x 2.5 x 0.1 cm. with islands of [MEDICATION NAME] tissue. The wound base is approximately 60% yellow and 40% pink. Both areas were cleansed with normal saline and adhesive foam applied. Low air loss mattress requested and Dr. (Resident #3's physician) was informed. This note was written by RN C. (On 04/25/16, Surveyor attempted to interview RN C about her note requesting the low air loss mattress as Surveyor had been told the low air loss mattress was put in place on 03/23/16. RN C did not speak with Surveyor on 04/25/16 prior to leaving her shift. During a phone call on 04/26/16 with the Nursing Home Administrator (NHA), RN B and Environmental Manager (EM) K, Surveyor was informed by EM K the special mattress had been put on Resident #3's bed on 03/23/16 and a few days later, RN C was told Resident #3 was already on a low air loss mattress). 04/07/16 - Wound Care Flow Sheet: Wound Type Pressure Location coccyx/ L buttock Measurements 3 areas; (^ upper) 3.5 x 0.3 x 0.1 cm, 0.4 x 2 x 0.1 cm & 0.4 x 1 x 0.1 cm Drainage Scant serosang drng Wound Bed pink gran (granulation)/epith ([MEDICATION NAME]) Wound Margins pink, Surrounding Tissue pink. There was no staging identified on this flow sheet. A Skin/Wound Note for Resident #3 on 04/07/16 at 9:55 a.m., read in part: Coccyx/left buttock significantly improved. The upper area on the coccyx measures 3.5 x 0.3 x 0.1 cm. with 2 small open areas on the left buttock, the upper one measuring 0.4 x 2 x 0.1 cm and the lower one 0.4 x 1 x 0.1 cm. All 3 areas have a pink wound base. We continue with adhesive foam . 04/14/16 - Wound Care Flow Sheet: Wound Type Pressure Location coccyx/L buttock Measurements coccyx healed; L buttock 0.2 x 0.2 cm Drainage scant serosang Wound Bed pink gran/epith Wound Margins pink, Surrounding Tissue pink. There was no staging identified on this flow sheet. A Skin/Wound Note for Resident #3 on 04/14/16 at 4:36 p.m., read in part: The area on his coccyx is healed. The open area on the left buttock measures 0.2 x 0.2 cm . No depth or staging of the left buttock area was addressed. From review of Resident #3's medical record and interviews, Surveyor identified Resident #3 had one stage II pressure ulcer beginning 03/17/16, according to Resident #3's 03/18/16 MDS. On 03/19/16, documentation identified open areas to buttocks. The low air loss mattress was not implemented until 03/23/16. During a discussion with RN B on the morning of 04/25/16, about Resident #3's mattresses, RN B said the low air loss mattress was started on 03/23/16 because that was the first day one was available. They had requested one to come, but a resident discharged that was on one, so Resident #3 was given that one on 03/23/16. Despite Resident #3 receiving the low air loss mattress on 03/23/16, he continued to develop further pressure ulcers on his coccyx and buttocks. Refer to the above 03/26/16 and 03/31/16 skin documentation. No additional changes to the care plan were made. Right Foot/Heel Resident #3 was receiving treatment by Occupational Therapy (OT) that included [MEDICAL CONDITION] wraps that covered his feet and lower legs from just above his toes to just below his knees. A 03/24/16, progress note by Certified Occupational Therapy Assistant (COTA) F read in part: Padded over right distal knee and right dorsum of foot due to redness from previous wrapping . On 03/26/16, a progress note by Occupational Therapist (OT) E read in part: Skin check with no sores noted, heels reddened - consulted with nursing and informed they are now floating heels in bed . A Podiatric Assessment completed 03/26/16, by RN G, identified Resident #3 had areas of redness related to pressure. Resident does have a red boggy area on the right heel that does blanch. (No mention of left heel). Foam pillow placed under heels while in bed to prevent skin breakdown. There were no measurements of the red area on Resident #3's right heel. Surveyor referenced Resident #3's nursing progress notes and found no documentation regarding Resident #3's right heel. Resident #3's initial care plan, dated 03/04/16, did not include interventions of heel suspension boots or to float/elevate heels. The facility implemented the heel lift cushion and the Prevalon boot to his right foot on 03/26/16, after the red, boggy area was found. Prevention measures had not been in place prior, despite Resident #3's significant risk factors. Surveyor reviewed the following OT progress notes for Resident #3: 03/28/16 - .[MEDICAL CONDITION] on B LE's improving. [MEDICAL CONDITION] mgmt (management) completed today as well. 03/29/16 - Patient participated in [MEDICAL CONDITION] mgmt and measurements (of the [MEDICAL CONDITION]) today with lymph massage completed. Patient continues to make progress with decreasing amount of [MEDICAL CONDITION] in Le's . 03/30/16 - This note pertained only to upper extremity treatment. 03/31/16 - Completed Lymph mgmt to B LE's 04/01/16 - This note did not include LE treatment this date. The OT progress notes of 03/28/16, 03/29/16 and 03/31/16, the date LE [MEDICAL CONDITION] treatment was done, do not include what the skin of his right foot and heel looked like. Resident #3's Skin/Wound assessment notes from 03/24/16-04/05/16 do not include any documentation of Resident #3's heels or the dorsum of his right foot. Nursing progress notes from 03/24/16-04/06/16 do not include documentation of Resident #3's skin assessments of his heels or the dorsum of his right foot. The 03/26/16 Podiatric Assessment identified Resident #3 had an area of redness related to pressure, the red, boggy area on the right heel that does blanch. No staging or measurements were included. The next note addressing Resident #3's heel was written on 04/02/16 by OT E. This progress note included: Removed wrap, skin check completed with Moderate redness to R (right) heal (sic) (nursing aware and has been floating heel in bed. And applied 2 short stretch compression bandages with artiflex protection to R dorsum foot. No measurements were obtained of the red area on Resident #3's right heel. Surveyor reviewed nursing progress notes and did not find documentation of nursing assessing Resident #3's skin on his feet, despite the known red areas. OT E included in her progress note for 04/04/16, B (bilateral) LE (lower extremity) stretch compression bandaging was completed. There was no mention of Resident #3's heels or the dorsum of his right foot that had been identified as being red previously. A 04/06/16, OT progress note by COTA F read in part: Patient's shower rescheduled for tomorrow vs today, therefore LE (lower extremity) wraps will be changed tomorrow. On 04/07/16, Certified Nursing Assistant (CNA) H removed Resident #3's lower extremity wraps and gave Resident #3 a shower. CNA H's statement read in part: I noticed the top of his left foot (it was the right foot) and the heel of the right foot. Then I got him in bed and dressed. That is when he asked for a P.T. (Physical Therapy) girl to come look at his foot. I thought that the nurse's knew about his feet and the condition because they were already being wrapped. So I called therapy and (COTA) F asked me questions in which I did answer them. A Skin/Wound nursing progress note of 04/07/16 at 11:25 a.m., by RN C read in part: Resident scheduled to have [MEDICAL CONDITION] wraps changed by therapy today. Resident also scheduled for shower. Wraps removed by CNA and noted black and discolored areas. CNA immediately notified nursing and nursing notified management. The right heel measures 5 x 7 cm. (centimeter) and is black in color with surrounding skin red. There is a purple irregular shaped spot on the right inner ankle area measuring 4.5 x 4.7 cm which is surrounder (sic) by redness. The entire area measures 9 x 8 cm He has an appt. (appointment) with (Nurse Practitioner (NP) I's name) at 1330 (1:30 p.m.) with Heartland transporting. A call was placed to (Resident #3's primary physician) to inform. Awaiting call back. Wound care flow sheets that identified skin impairment of Resident #3's right heel and right dorsum were first dated 04/07/16, the day the areas were found to have eschar and significant redness. 04/07/16 - Wound Type pressure, Location right heel, Measurements (Length, Width, Depth) 5 x 7 cm, Drainage None, Wound Bed Color Black, Tissue eschar, Wound Margins intact, Surrounding Tissue red. 04/14/16 - Wound Type pressure, Location right heel, Measurements (Length, Width, Depth) 5.3 x 6.5 cm, Drainage None, Wound Bed Color Black, Tissue eschar, Wound Margins intact, Surrounding Tissue pink. 04/07/16 - Wound Type pressure, Location right top, inner aspect of foot. Measurements (Length, Width, Depth) 9 x 8 cm total area, 4.5 x 4.7 cm irregular shaped purple area surrounded /c redness, not open. Surrounding Tissue Red. Treatment Protect /c foam, prevalon boot. 04/14/16 - Wound Type pressure, Location right foot, top/inner aspect, Measurements (Length, Width, Depth) 3 purple areas top to bottom: 1 x 1, 4 x 4.3 & 1 x 1 cm. The center one is slightly fluid filled. Wound Margins intact, Surrounding Tissue red/pink. Treatment ADB, cast padding & spandage. Skin Observation tool: A 04/01/16, 10:44 a.m., Skin Observation Tool for Resident #3 read in part: No new skin issues noted at this time. Unable to assess feet and lower extremities due to [MEDICAL CONDITION] wraps being wrapped by therapy only per therapy order. A 04/09/16, 1:39 a.m., Skin Observation Tool for Resident #3 read, Resident had two areas of necrotic tissue to Right foot. Continuing to monitor. A 04/15/16, 8:21 p.m., Skin Observation Tool for Resident #3 read: Resident had two areas of necrotic tissue to Right foot. During Surveyor 's observation of wound care by RN C, on 04/21/16 beginning at 10:02 a.m., Surveyor asked Resident #3 if he has any pain in his feet. Resident #3 said no, the nerves in my feet and legs are shot. Resident #3 also told Surveyor that he is supposed to be getting a new boot for his right foot but hasn't got it yet and he isn't sure what the hold up is. Surveyor visualized the dorsum of Resident #3's right foot and his right heel and noted the dark brownish eschar on the dorsum of his foot and the black eschar on his right heel. During the observation of Resident #3's treatments by RN C, Surveyor noticed Resident #3 had the heel lift cushion under his lower legs, yet his left heel was touching the mattress. Resident #3 does not have a preventive boot in use for his left foot. When RN C completed the treatments, Surveyor pointed this out to RN C and RN C adjusted the heel lift cushion. On 04/21/16 beginning at 12:40 p.m., Surveyor interviewed the Senior Program Director of Rehab Care (SPDRC) L and discussed the concerns of Resident #3 developing the pressure ulcers on his right foot. SPDRC L was shown some of Resident #3's OT progress notes and asked if Resident #3's red areas on his right foot would have been measured by therapy, would they be documented anywhere other than the notes Surveyor had for Resident #3. SPDRC L said no, if measurements were done they would be in the notes. During an interview with RN B on 04/25/16 at 8:25 a.m., Surveyor asked RN B if Resident #3 used foot pedals on his wheelchair. RN B said Resident #3 did use foot pedals. Surveyor asked if the foot pedals on Resident #3's wheelchair were padded prior to the development of the right heel pressure ulcer. RN B said Resident #3 had dycem on his foot pedals but they were not padded. RN B said Resident #3 is very rarely up in his wheelchair. RN B said they padded the calf area on his wheelchair on 04/07/16 and they were using the boot on Resident #3's right heel since 03/26/16. RN B was asked if Resident #3 is cooperative with turning and repositioning. RN B said he is. On 04/25/16 beginning at 11:00 a.m., Surveyor interviewed OT E and COTA F. Surveyor asked COTA F if she had told nursing about the redness noted on the dorsum of Resident #3's right foot on 03/24/16. COTA F could not recall. Surveyor provided COTA F a copy of her progress note for 03/24/16 to review. COTA F looked at her note and commented the note does not indicate she had. Surveyor then asked OT E if she had measured the red areas on Resident #3's heels or the red area on the dorsum of Resident #3's right foot. OT E said she had not done measurements of the areas. OT E was asked if she had told nursing on 04/02/16, that Resident #3's right heel had moderate redness. OT E said she was not sure. OT E reviewed her progress note of 04/02/16, and said, My note says nursing was aware. Surveyor pointed out that did not specify if nursing had actually been made aware of the moderate redness on 04/02/16. OT E acknowledged understanding of Surveyor 's statement. OT E said the wrapping had very little compression over the heels, she was more concerned with the top of the foot. During the above interview with OT E and COTA F, Surveyor asked if they had seen Resident #3's foot pedals padded. COTA F said no. Surveyor asked what Resident #3 wore on his feet when he was up in his wheelchair prior to the Prevalon boot starting 03/26/16. COTA F said he had gripper socks on over the ace wraps. Resident #3 did not wear shoes or slippers due to the [MEDICAL CONDITION]. Surveyor had viewed photos of Resident #3's lower extremities taken in therapy on 03/09/16 and observed Resident #3's feet resting on a blue cushion. Surveyor asked if that cushion was used just in therapy and OT E said it was. On 04/25/16, Surveyor read Resident #3's progress note from his appointment with NP I, at the wound clinic on 04/07/16. This note read in part: Pulse(s) Right dorsalis pedis pulse: 0 - Absent, not palpable, monophasic with Doppler. Right posterior tibial pulse: 0 - -Absent, not palpable, no Doppler pulse. Left dorsalis pedis pulse: 0 -Absent, not palpable, biphasic with Doppler. Left posterior tibial pulse: 0 - -Absent, not palpable. Both lower extremities when elevated have no blanching. No rubor noted with dependence. The right heel has black eschar 6 cm x 6.3 cm that is firm thick and cool. The right dorsum of the foot has an area 8 x 7 cm. The center 4 x 4.3 cm is a light tan-purple color and then the rest of the peri-area is nonblanchable red, irregular edge . NP I dictated she had consulted with Resident #3's primary physician and they had considered these areas as possibly related to [MEDICATION NAME] induced necrosis, yet the area did not begin as a bullae or in a soft fatty tissue area commonly occurring with the [MEDICATION NAME] induced necrosis. And .he may have had a change in his arterial blood flow due to being off the [MEDICATION NAME] for almost a month's period of time, and then having increased compression of the lower extremity or increased pressures at the heel site or foot causing pressure ulcers in an arterial compromised leg . And .we will treat the patient as arterial compromise with deep tissue injury and pressure ulcer of the right heel . And Will have Rice Lake Convalescent Center order a PRAFO boot to offload the heel at all times. As of the morning of 04/21/16, Resident #3 had not received the PRAFO boot that was discussed on 04/07/16.

Based on record review and interview, the facility did not ensure that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 5 of 6 residents reviewed (Resident #1, #6, #2, #3, and #5). Resident #1 had a decline in wounds and was hospitalized . The facility did not ensure appropriate interventions were implemented and did not follow physician orders [REDACTED]. This first example is cited at a level G. The following examples are at a lower level. The facility did not ensure that wound care had been completed for Residents #6, #2, #3 and #5. This is evidenced by: Facility policy titled, Pressure ulcer prevention and treatment interventions guidelines, dated 2010, states, 2. If a pressure ulcer or lower extremity ulcer is present initiate the Weekly Wound Documentation Progress Sheet .Signs of healing (i.e. decreased size and depth of the ulcer, decreased drainage) should be evident after 2-4 weeks of treatment. Notify Physician/NP and family/designee if any evidence of deterioration is noted and/or if the wound is not showing progress in 2-4 weeks .The Care Plan is to be evaluated and revised based on the response, outcomes, and needs of the resident .Provide treatment as ordered. As evidenced by: 1. On 01/19/16 at 10:21 a.m., Surveyor reviewed the medical chart for Resident #1 and noted the following: - Resident #1 has a [DIAGNOSES REDACTED]. Resident's Power of Attorney for Health Care (POAHC) is currently activated. - Minimum Data Set (MDS), dated [DATE], states Resident #1 was at high risk for pressure ulcers and had three venous/arterial ulcers currently present. Resident #1 noted to have dementia with cognitive impairment and short term memory loss. - Certified Nursing Assistant (CNA) care plan, received 01/19/16, stated Resident #1 was to have a ROHO cushion to her wheelchair, cannot sleep in her wheelchair at night, and is to lay down in her bed or her recliner. The care plan did not indicate Resident #1 had wounds. No repositioning scheduled noted on care plan. No two hour elevation of feet noted on care plan as directed by physician. - Comprehensive Nursing care plan, received 01/19/16, stated, Avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short. Encourage resident to keep legs elevated as much as possible to reduce [MEDICAL CONDITION], keep skin clean and dry. Monitor/document location, size and treatment of [REDACTED]. to MD., pressure reducing cushion to protect skin while in bed, pressure reducing cushion in chair, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudates and any other notable changes or observations and treatment of [REDACTED]. Facility Weekly Wound Documentation On 01/19/16, Surveyor reviewed wound care documentation completed by the facility nursing staff and noted the following: -WOUND #1 - RIGHT LOWER LATERAL LEG - VENOUS ULCER - 10/25/15: Wound measures 0.7 cm x 2 cm x 0.1 depth. Red granulation present. Treatment: [MEDICATION NAME], ABD, [MEDICATION NAME] and [MEDICATION NAME]. Treatment to be changed daily. - 10/29/15: Wound measures 0.9 cm x 0.9 cm x superficial. Skin pink. Same treatment and noted above. - 11/05/15: Wound healed. -WOUND #2 - RIGHT POSTERIOR CALF - VENOUS ULCER - 10/25/15: Wound measures 4 cm x 10 cm x 0.1 depth. Skin pink, granulation present. No s/x of infection. Current treatment: [MEDICATION NAME], ABD, [MEDICATION NAME]. Treatment to be done twice daily (BID). - 10/29/15: No visible open area - unmeasurable. Large amounts of clear drainage noted. Continue current treatment noted above. - 11/05/15: No visible open area - unmeasurable. Large amounts of clear drainage noted. Continue current treatment noted above. - 11/15/15: No visible open area - unmeasurable. Small amount of clear drainage noted. Continue current treatment noted above. - 11/17/15: Wound opened into 3 separate wounds. Wound #1: 1.8 cm x 1.0 cm x 0.1 cm. Skin pink with granulation present. Wound #2: 1.3 cm x 1.5 cm x 0.1 cm. Skin pink with granulation present. Wound #3: 2.2 cm x 1.2 cm x 0.1 cm. Skin pink with granulation present. treatment for [REDACTED]. Treatment to be changed every 3 days and as needed. - 11/25/15: Wound #1: 2.7 x 3 cm x 0.1 cm. Skin pink and granulation present. Continue treatment as noted above. Surveyor noted no change in treatment was provided with increase in wound size. No new interventions implemented were noted within the medical record for increased size of wound. Wound #2: 1.5 cm x 1.5 cm x 0.1 cm. Skin pink and granulation noted. Continue treatment as noted above. Surveyor noted no change in treatment was provided with increase in wound size. No new interventions implemented were noted within the medical record for increased size of wound. Wound #3: 4.0 cm x 1.6 cm x 0.1 cm. Skin pink with granulation noted. Continue treatment as noted above. Surveyor noted no change in treatment was provided with increase in wound size. No new interventions implemented were noted within the medical record for increased size of wound. - 12/03/15: Wound #1: 2.5 cm x 3.0 cm x 0.1 cm. Skin pink with granulation present. Same treatment as noted above. Continue treatment as noted above. Surveyor noted no change in treatment; no new interventions implemented were noted. Wound #2: 2.0 cm. x 2.0 cm. x 0.1 cm. Skin pink with granulation present. Same treatment as noted above. Continue treatment as noted above. Surveyor noted no change in treatment was provided with increase in wound size. No new interventions implemented were noted within the medical record for increased size of wound. Wound #3: 3.8 cm x 2.0 cm. x 0.1 cm. Skin pink with granulation noted. Continue treatment as noted above. Surveyor noted no change in treatment. No new interventions implemented were noted. On 01/19/16 at 2:00 p.m., Surveyor interviewed Registered Nurse (RN) A in regard to the noted increase in wound size. RN A stated no new interventions or treatments were implemented at this time. RN A stated the facility should have implemented an intervention to promote the wounds from increasing in size and getting worse. - 12/06-12/15: No documented skin assessment within the medical record was noted by Surveyor and was not provided upon request. - 12/13-19/15: No documented skin assessment within the medical record was noted by Surveyor and was not provided upon request. - 12/23/15: Nurse's Note: Area on right mid calf measures 4 cm x 1.6 cm x 0.2 cm. Moderate amount of serosang drainage noted on old dressing. Wound bed and surrounding tissue white and macerated. Area cleansed with N.S. [MEDICATION NAME] AG applied to wound bed and covered with [MEDICATION NAME], plain foam, and [MEDICATION NAME]. Area on right lower calf measures 5cm x 2cm x 0.2 cm. Wound bed and surrounding tissue white and macerated. Area cleansed with N.S. [MEDICATION NAME] AG applied to wound bed and covered with [MEDICATION NAME], plain foam, and [MEDICATION NAME]. A&D ointment applied to leg also. A&D ointment also applied to dry, chapped, red skin on arms and buttocks. -WOUND #3 - LEFT CALF - VENOUS ULCER - 10/25/15: Wound measures 13.2 cm x 12.5 cm with black eschar. Treatment: [MEDICATION NAME], 4x4, [MEDICATION NAME]. Treatment to be changed daily. - 10/29/15: Wound measures 2 cm x 2 cm with unknown depth. White and green slough present. Continue current treatment noted above. - 11/05/15: Wound measures 1.8 cm x 1.9 cm x 0.1 cm. Tissue red with granulation present. Continue current treatment noted above. - 11/06/15 - 12/22/15: Surveyor was unable to identify wound assessment documentation within the medical record and not provided upon request. - 12/23/15: Wound measures 3 cm x 2 cm x 0.2 cm. Tissue pink with granulation present. Treatment: [MEDICATION NAME] AG, [MEDICATION NAME], foam, [MEDICATION NAME]. Treatment to be changed daily. - 12/29/15: Wound measures 1.5 cm x 1.2 cm x 0.2 cm. Skin pink with [MEDICATION NAME] tissue present. Treatment: [MEDICATION NAME] AG, [MEDICATION NAME], foam and [MEDICATION NAME]. Treatment to be changed daily. -WOUND #4 - LEFT UPPER SHIN - 11/17/15: Dressing changed. Area on left upper shin is a skin tear from removal of old dressing. Area measures 3.0cm x 3.0cm x superficial. Small amount of blood noted on old dressing. Wound bed is red granulation tissue. Wound margins are clean and intact and surrounding tissue is pink. Area cleansed with N.S. [MEDICATION NAME] AG applied to wound bed and covered with bordered foam [MEDICATION NAME]. No comprehensive assessment within the medical record for this wound was identified and not provided upon request. -BUTTOCKS AND UPPER THIGH AREA - 12/21/15: Nurses' Notes: Resident buttock remain very red. No comprehensive nursing assessment was identified within the medical record for this area. - 12/22/15 - 12/28/15: No documentation with the medical record was identified for this wound during this time frame. - 12/29/15: Nurses' Notes: Dressings changed. Buttocks and upper thigh skin is peeling, with open areas noted, and bleeding. Area is very foul smelling. Attempted to contact POA and #2 contact. Unable to reach either. Call placed to (MD C)'s nurse. She talked with (on-call MD). She would like resident to be seen in ED (emergency department) for eval (evaluation). Call to 911 to request ambulance at 1520 (3:20 p.m.). Report called to triage RN at Mayo hospital-Barron. Ambulance left facility with resident at 15:45 (3:45 p.m.) All appropriate paperwork sent along. On 01/19/15 at approximately 1:30 p.m., Surveyor reviewed the physician's orders [REDACTED].#1 for December 2015 and January 2016. -physician progress notes [REDACTED]. - 10/26/15: physician progress notes [REDACTED].#1) was having weeping legs and some confusion.1. Lower extremity [MEDICAL CONDITION] and weeping legs. The Nursing home has been changing bandages nearly every hour with soaked gauze. No information given on how she obtained wounds on her legs. (Resident #1) is frail appearing, with scoliotic curve which causes her left ear to be touching her left shoulder. Able to transfer to procedure room table with help of nursing staff. She had several non stick dressings wrapped with kurlex around both legs. The right leg was completely soaked. No compression stockings. WOUNDS- LEFT LEG: #1) posterior: 1.5 cm W x 1.8 cm L x 0.3 cm dry circumscribed. #2) Multiple anterior black eschar measured as an area/cluster 13.2 cm w x 12.5 cm L x 0.1 cm D. RIGHT LEG: #3) lateral 0.7 cm W x 2 cm L x 01 cm D watery skin tear dripping clear fluid. #4) Posterior 4 cm W x 10 cm L x 0.2 D watery skin tear dripping clear fluid. Both legs were redressed using the detailed instructions listed below. E tubi grips may be substitutied for F/G if needed for comfort. LEFT LEG DRESSING: #1) cover with [MEDICATION NAME] border change every 3 days unless soiled or wet. #2) Cover with petrolium infused gauze and cover with ABD pad for protection. Wrap with [MEDICATION NAME] and cover leg with size E Tubi-grip. RIGHT LEG DRESSING: #3) cover with [MEDICATION NAME] border change every 3 days unless soiled or wet. Add ABD for drainage and change when wet or soiled. Wrap with [MEDICATION NAME] and cover leg with size E tubi grip. #4) cover with petrolium infused gauze and cover with ABD pad for protection. Wrap with [MEDICATION NAME] and cover leg with size E tubi-grip. - 10/27/15: physician progress notes [REDACTED]. Reviewed current facility medication list and chart. SPECIFIC CONCERNS: 1. Lower extremity venous ulcers. The RN (from the facility) apologized that she had not had time to change dressings today or evaluate wounds .The nursing home has also had trouble getting the size E tubi grips as ordered . EXAM: . (Resident #1) has [MEDICATION NAME] wrap with underlying [MEDICATION NAME] and infused gauze placed incorrectly, not over wounds. No tubi grip in place . Discussed how to do the dressing changes with RN and she observe me re-dress patient wounds. RN says that she is trying to order the correct tubi grips. I suggested that they could use ACE wraps if not able to get the tubi grips soon . - 11/10/15: physician progress notes [REDACTED].#1) has [MEDICATION NAME] wrap with no [MEDICATION NAME] or compression in place. I did not unwrap her today. Dressings are dry and no breakthrough drainage. Per RN there is no [MEDICATION NAME] or [MEDICATION NAME] only infused gauze over wounds. Poor compliance with wound care instructions and comprehesion/elevation. Discussed the dressing changes with RN, I again - 11/17/15: physician progress notes [REDACTED]. Lower extremity venous ulcers: The (facility) RN apologized that she had not had time to change dressing today or evaluate the wounds .The nursing home has also had trouble getting the size E tubi grips as ordered. EXAM: .(Resident #1) has [MEDICATION NAME] wrap without underlying [MEDICATION NAME] and infused gauze placed only on the back of her legs. No [MEDICATION NAME] or foam dressing. No tubi grip or compression in place. I complete unwrapped her, swelling is mostly stable, little more in the right leg than previously. When I was removing [MEDICATION NAME] there was a new wound below her medial left knee, which was stuck to the [MEDICATION NAME] and peeled of skin 3x3 cm area. Bright red bleeding at the surface, but did not require hemostasis pressure. Lower legs are more purple hue than last time and no longer dripping serous fluid. The upper [MEDICAL CONDITION] are dry and with scabs and excoriation from scratching is apparent. The back of her right leg has some granulation tissue forming and has become a cluster of three wounds. Back of her left leg has soft granulation tissue. No blistering skin, no sign of [MEDICAL CONDITION]. Red skin with exforiation from scratching on her arms and legs bilaterally. IMPRESSION: Venous stasis with bilateral venous ulcers. Also suspect arterial disease as well but she did not want any further studies . I redressed the wounds with [MEDICATION NAME], foam dressing and [MEDICATION NAME]. I spoke to the RN again about the importance of compression .May need debridement of ulcers in the future, I may need to see her in clinic to perform debridement next week. I am concerned about the poor compliance from nursing staff with dressing changes as ordered. Each time I have done the dressings there is something different, sometimes based on what supplies are available and the generic products are not preferred. I will plan on speaking with nursing administration about my concerns. - 12/08/15: physician progress notes [REDACTED]. EXAM: (Resident #1's) lower extremities with dependent [MEDICAL CONDITION], no weeping or blisters. Venous stasis discoloration, cool to touch. Ulcer on the back of left leg measures 2.0 x 1.5 and right leg with cluster of ulcers measing 7 cm x 2 cm. Granulation tissue is present. There is a foul odor present. No drainage. Legs are very dry and flaking. Covered the legs with A&D ointment. Used [MEDICATION NAME] in the wound base, covered with [MEDICATION NAME] and foam dressing and wrapped lower legs in kurlex and covered with tubi-grip. IMPRESSION: .2. Wound care done today, slow progress. I would like to do a debridement in clinic .Continue wound dressings as noted in NH chart. The wounds are dry and only need once daily changes. I starter her on Barctrim for the foul odor, suspecting either her foley or skin infection. 3. A&D ointment to her skin, legs, arms, groin 1-2 times per day. Ok for [MEDICATION NAME] to groin. On 01/19/16 at approximately 1:30 p.m., Surveyor reviewed the physician's orders [REDACTED].#1. physician's orders [REDACTED].>- 11/06/15: [MEDICATION NAME] cream to be applied to buttocks topically as needed for rash. Order discontinued on 01/04/16. - 11/18/15: Bilateral leg dressing change every day shift every 3 days for wound care. Cleanse wounds with N.S, cover with [MEDICATION NAME] AG, [MEDICATION NAME], and [MEDICATION NAME]. Change every 3 days. Order discontinued on 12/09/15. - December 2015: 1) physician's orders [REDACTED]. Apply [MEDICATION NAME] to wound bed, cover with [MEDICATION NAME] with small squire of foam, wrap with [MEDICATION NAME] every day shift for wound care. Order was discontinued on 12/11/15. Surveyor noted this not to be completed for a total of 1 out of 3 days. 2) physician's orders [REDACTED]. Apply [MEDICATION NAME] to wound bed, cover with [MEDICATION NAME] with small square of foam, wrap with [MEDICATION NAME]. Change daily. Every day shift for wound care. Order was discontinued on 01/04/16. Surveyor noted this treatment not be completed for a total of 7 out of 17 wound care treatments. 3) physician's orders [REDACTED]. This order was discontinued on 01/04/16. Surveyor noted this was not done for a total of 6 out of 31 times. This was not on the resident's care plan. 4) physician's orders [REDACTED]. Apply [MEDICATION NAME] to wounds, cover whole area with [MEDICATION NAME] and cut large piece (15x15 cut in half), foam, wrap with [MEDICATION NAME]. Change daily every day shift for wound care. Order discontinued on 01/04/16 Surveyor noted this not to have been completed for a total of 7 out of 19 days. 5) physician's orders [REDACTED]. [MEDICATION NAME] size E/F from ankles to knees. On in mornings and off at night. Order discontinued on 01/04/16. Surveyor noted this was not completed for 4 of 62 times 6) physician's orders [REDACTED]. Order discontinued on 01/04/16. Surveyor noted this was not completed for a total of 12 times out of 46 opportunities. 7) physician's orders [REDACTED]. Order discontinued on 01/04/16. Surveyor noted this was not completed for a total of 9 times out of 42 times. - January 2016: 1) Resident #1 was to have wound care to the left extremity wound which was to change [MEDICATION NAME] and apply [MEDICATION NAME] every day shift related to local infection of the skin and subcutaneous tissue. This order was started on 01/11/16 and discontinued on 01/16/16. Surveyor noted that during this time frame this treatment was not completed for a total of 3 out of 6 times. On 01/19/16 at approximately 11:00 a.m., Surveyor interviewed RN A in regard to the above noted missing treatments for Resident #1. RN A stated if the TARs are left blank then the nurses did not do the treatment. RN A stated she would have to educate her staff to ensure that all treatments were being completed per physician order. -Refusal of Cares/Education to Resident: Nurses' Notes, (10/19/15 - 01/19/15) - 12/21/15: Resident has been picking at skin on arms and legs this evening. Resident buttock remain very red. Tried to have resident lay down in bed for a while to relieve pressure from buttocks. Resident refuses. Remains on antibiotic for skin infection. No adverse effects. Surveyor was unable to identify an intervention implemented to prevent further breakdown of skin to the buttock region. Surveyor was unable to identify a comprehensive nursing assessment of the skin to the buttock region. - 12/24/15: Resident encouraged repeatedly to off load to recliner as she will not sleep/lay in a bed. Resident refuses request and chooses to sit in her w/c all day and good portion of the night. - 12/25/15: Back of resident's thighs are dry and leathery with raw open areas and drainage. Cleansed with normal saline, [MEDICATION NAME] and ABD applied and secured with [MEDICATION NAME]. Placed call to MD (Medical Doctor) and received order. Informed of non-compliance with off loading and MD states to inform family on Monday that non-compliance may result in [MEDICAL CONDITIONS] and possible death. - 12/25/15: Resident refused PM applications of her A&D ointment stating I do not like to feel greasy and I am not itching and have not been itching for a while. She was educated to continue with the applications as instructed to prevent the itching from occurring but she still refused. - 12/26/15: Declined to reposition out of wheelchair or out of recliner. - 12/28/15: Message left for POA to return call to give update on skin issues and non compliance of off-loading. Surveyor noted, per nursing documentation, Resident #1 was admitted to hospital on [DATE] and was then discharged back to the facility on [DATE]. -Hospital Discharge Summary - 01/07/16 On 01/19/16 at approximately 10:00 a.m., Surveyor reviewed the hospital discharge summary report, dated 01/07/15, and noted the following: - Principal Discharge Diagnoses: [REDACTED].Physical Examination: SKIN: Shows excoriated [MEDICAL CONDITION] in the upper extremities bilaterally with some thickening of the skin. Lower extremities are significantly worse with her legs from the waist down being characterized by multiple excoriations, thickening of the skin in the distal shins and over the base of her feet, and [DIAGNOSES REDACTED] extending over the entire buttocks up to the ileal wings and down the proximal thighs with nonblanching [DIAGNOSES REDACTED]. In addition to this, the patient has the outline of old and persistent skin ulceration measuring approximately 3 cm by over 15 cm in length with some mild eschar in places. This goes down to the layer of dermis. There is no undermining. It is nontender and there is no discharge. The patient has several small ulcerations in the distal lower extremities, right worse than left, all of 4 cm or less in diameter, again without discharge. These have reportedly been cultured in the emergency room IMPRESSION/REPORT/PLAN: 1. History of frequent [MEDICAL CONDITION] with recurrent skin ulceration most prominent in the right posterior thigh with early nonblanching [DIAGNOSES REDACTED] across her entire buttock complicated by patient noncompliance with positioning, frequent scratching with pruritus, memory deficits and noncompliance with topical therapy. Patient will need at least 2 midnights to address her issues. Because of her history [MEDICAL CONDITION] and her allergy to [MEDICATION NAME] I started her on intravenous Bactrim as I want to get high serum levels of the antibiotic to address the likelihood of recurrent skin infections. The patient will be positioned and will try and enforce this as appropriately as possible. Wound care nurse will be consulted for management of her multiple lower extremity wounds .I had a frank discussion with her son, who is present in the emergency room , he realizes that she is likely failing, consideration may be given for hospice care if no easily correctable solution is found. Physician and Hospital Staff Interviews -MD B: On 01/19/16 at 10:48 a.m., Surveyor interviewed MD B in regard to Resident #1's wounds via telephone. MD B stated Resident #1 first came to the Emergency Department on 12/29/15 due to worsening of wounds. MD B stated he had read MD C's clinic notes and felt MD C had extensive knowledge on the resident's wounds. MD B stated MD C was very concerned with Resident #1 scratching at wounds and felt some wound cares were not being completed by the facility nursing staff. MD B stated when he first saw Resident #1 in the hospital, she had extensive wounds to the buttock area and a lot of [DIAGNOSES REDACTED]. MD B stated he felt something was obviously irritating the skin. MD B stated some of the notes from the nursing home stated Resident #1 was refusing cares but while Resident #1 was hospitalized from [DATE] - 01/07/16, there was never any concern with Resident #1 refusing wound care treatment. MD B stated Resident #1 was very easy to work with and this made him wonder if this was a case of possible neglect on the part of the facility. MD B stated the hospital did not alter the treatment of [REDACTED]. MD B stated the only thing the hospital did different was alter a change in a medication which he believed was causing her to scratch due to itching and this helped in decreasing the itching. MD B stated the hospital nursing staff and wound care nurses did not have to struggle to get Resident #1 to be compliant with wound care. MD B felt the facility nursing staff were not aggressive enough in attempting to ensure treatment to all the wounds were being done. MD B stated if the facility nursing staff had been applying the wound care treatment correctly, Resident #1 would not have been able to touch the wounds to scratch them with her fingernails. -MD C On 01/19/16 at 2:55 p.m., Surveyor interviewed MD C via telephone. MD C stated she was Resident #1's primary physician and visits the resident often. MD C stated she first saw Resident #1 on 10/26/15 due to an exacerbation of [MEDICAL CONDITIONS] and she was very [MEDICAL CONDITION] in the lower extremities, which developed weeping. MD C stated at this time Resident #1 had four [MEDICAL CONDITION] to lower extremities, which consisted of superficial blisters, and these [MEDICAL CONDITION] were covered and wrapped to ensure the areas remained dry. MD C stated she visited the resident at the facility on 10/27/15, 11/10/15, 11/17/15 and 12/08/15 and noted the following: - 10/27/15: MD C stated she entered the facility to find the resident in her room with her old dressing on. The facility nursing staff were noted to be running around attempting to find wound care supplies. MD C stated she had told the facility nursing staff that she would be at the facility to look at the wounds and to please have the resident prepped and ready for her. MD C stated this was not done. MD C stated she noted the resident not to have the correct size [MEDICATION NAME]. MD C stated the tupigrip prevents swelling and prevents the wounds from getting bigger. MD C stating by using a different size increases the risk of the wounds to become worse. MD C stated after assessing the resident it did appear that the swelling had improved. MD C stated she spoke with the nursing staff and educated them on the importance of providing the correct size [MEDICATION NAME]. - 11/10/15: MD C stated she entered the facility to find the resident in her room with her old dressing on. MD C noted Resident #1 not to have the correct size [MEDICATION NAME] on. MD C stated the facility did not have treatment supplies ready for her. MD C stated the resident was doing well at this time. - 11/17/15: MD C stated she entered the facility to find the resident in her room with her old dressing on. MD C stated she interviewed the floor nurse who told her, I haven't had time to change the dressing today. MD C stated she would do it. MD C stated Resident #1 still did not have the same size [MEDICATION NAME] and her legs were now wrapped with an ace wrapping. MD C stated as she started removing the ace wrapping and [MEDICATION NAME], she noted resident to have either a scratch like area to the skin right below her knee which appeared to have dried blood. MD C stated as she slowly removed the [MEDICATION NAME] from this area, to which the blood had dried and caused the [MEDICATION NAME] to adhere to the skin area, it peeled away the resident's skin, exposing an open area which measured 3cm x 3cm. MD C stated she felt there was poor compliance with wound care from the facility and again educated the nursing staff on the importance of following the physician's wound treatment orders. MD C stated she felt very concerned and started calling the facility daily in attempt to speak to the facility's nursing supervisor. MD C stated each time she contacted the facility she was either directed right to voicemail or was told by the facility staff that the nursing supervisor was unavailable. MD C stated she was finally able to speak with the facility's nurse supervisor and expressed concern to her that she felt the resident was suffering due to poor compliance to wound care by the facility nursing staff. MD C stated she was told by the nursing supervisor that she would make sure that she spoke to the nursing staff and would follow up to make sure that treatments were being done and also being done properly. MD C stated the supervisor also told her that supplies would be made available to her immediately when she was there to assess the resident. MD C stated she felt very concerned and also addressed her concerns with the resident's son. - 12/08/15: MD C stated she came to the facility to assess the resident's wounds and noted Resident #1 to have a foul odor coming from the wounds on her legs bilaterally and also from her groin area which was red. MD C stated she covered all the skin with A&D, [MEDICATION NAME] and then a wrap. MD C noted the facility was not using [MEDICATION NAME], which had originally ordered but were using some weird foam which was very harsh and damaging to the resident's skin. MD C stated she asked the nurse why the nursing staff were not using [MEDICATION NAME] per the MD order and the nurse told her, That's just what they give us to use. MD C stated she told the nursing staff they could not use this type of foam and educated them on the importance of using [MEDICATION NAME] to assist with wound healing. MD C stated she started Resident #1 immediately on an antibiotic for a possible infection and applied A&D to her whole skin area which had some strange elephant like appearance. MD C stated it was shortly after that she had heard the resident was hospitalized due to worsening of her wounds. MD C stated she felt Resident #1's hospitalization was due to the nursing staff not following her directions in regard to appropriate wound care. MD C stated that since her hospitalization , Resident #1's wound care is being done by her and the resident's wounds have healed 30%. MD C stated she was also concerned because the facility had never attempted to contact her in regard to any changes of condition with her wounds in regard to an increase in size. MD C stated she was unaware of Resident #1's wound increasing in size (as noted above) and strongly felt the facility should have immediately notified her. MD C stated if the facility would have contacted an on-call physician, there would have been a note placed within her medical record and no documentation of an on-call physician was entered. MD C felt Resident #1 has dementia and is not a very reliable source for information and felt if she did refuse treatment, the nursing staff should have been more aggressive at attempting to ensure all treatments were being completed, and if unable to do so, they should have contacted her immediately. FACILITY INTERVIEW: On 01/19/16 at 2:45 p.m., Surveyor interviewed RN A in regard to Resident #1's wounds. RN A stated Resident #1's wounds to her right leg went from one wound into three separate wounds due to non-compliance with lying down. RN A stated Resident #1 does not like to lie in bed due to her having scoliosis which is very uncomfortable. RN A stated Resident #1 does not like to elevate her legs and doesn't want to offload. RN A stated Resident #1 would complain that her [MEDICATION NAME] were too tight and would take them off, stating they hurt. RN A stated MD C would refuse to address these concerns even when Resident #1 would scratch so hard that it would cause her skin to bleed. RN A stated MD C

Based on interview, record review and policy review, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the resident wishes and plan of care for 1 of 23 residents (Resident #2) as it relates to receiving CPR (Cardiopulmonary Resuscitation). Resident #2 was his own person and made his own decisions. Resident #2 signed a document on [DATE] indicating that Resident #2 is to be a Full Code for Cardiopulmonary Resuscitation. On [DATE], Resident #2 was found unresponsive with no breath sounds and no heart rhythm. No one initiated CPR as directed by Resident #2's code status. No one called 911. Subsequent to this event, the facility provided training to all nursing personnel beginning [DATE] on when CPR should be initiated. Two of four staff interviewed on [DATE] continued to state that if the arrest was unwitnessed, they would perform CPR based on professional judgment and medical efficacy, rather than on the guidelines indicated by the American Heart Association and regulatory guidance by CMS. This could affect 23 of 49 residents who have indicated they want CPR if found pulseless and non-breathing. The failure to provide the care needed by Resident #2 negated Resident #2's only chance for survival. This created a finding of Immediate Jeopardy situation that began on [DATE]. The nursing Home Administrator (NHA) was notified of the Immediate Jeopardy at 4:35 p.m. on [DATE]. Immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for harm that is not Immediate Jeopardy/pattern) as the facility fully implements its CPR policies. This is evidenced by: Review of the facility's undated policy entitled Intensity of Care, which was in effect on [DATE], states: "It is the policy of this nursing home to adhere to the resident wishes in regards to their own desired level of care in the event of a critical or terminal illness. Should the resident be so stricken and become unable to communicate their current level of care choices, RLCC staff will honor the desired level of care choices indentified on this form... CPR - I am expressing a desire to have CPR be done in the event of a [MEDICAL CONDITION]. I understand that in the event of an observed [MEDICAL CONDITION], CPR will be initiated by staff and emergency medical personnel will be called. I understand that in the event of an unobserved [MEDICAL CONDITION], an assessment will be made for apparent signs of life. CPR will instituted based upon the professional judgment and its medical efficacy." The facility policy did not follow CMS S&C Memo ,[DATE], dated [DATE], or the guidelines outlined by the American Heart Association, which indicate that CPR should be started for those who have requested it unless: (1) the resident has a do not resuscitate (DNR) order; (2) the resident has obvious signs of clinical death (e.g., rigor mortis, dependent lividity (pooling of the blood that occurs after death and may look blue, purple or black and is similar to bruising), decapitation, transection, or decomposition) or (3) the initiation of CPR could cause injury or peril to the rescuer. A review of Resident #2's medical record was completed on [DATE]. According to the medical record when Resident #2, who was [AGE] years old, admitted to the facility on [DATE], he signed a document indicating that he wished to be a Full Code for Cardiopulmonary Resuscitation. This document was signed by Resident #2, his spouse, and the Social Worker. The nurse charting, Registered Nurse (RN) F, on [DATE] at 5:20 p.m. states, "Resident appears to more sleepy this am, SPO2 96%, but is sleeping more during the day. Lung sounds are diminished and wet." The nurse charting by RN A on [DATE] at 11:47 p.m. states, "At 7:55 p.m., Certified Nursing Assistant (CNA) alerted License Practical Nurse (LPN) G that resident was on the floor in his room. Writer returning from supper proceeded to resident's room shortly behind LPN G. Resident was on the floor, on his left side with blood from mouth and nose. Resident was unresponsive with no vital signs noted. At 8:00 p.m., LPN G notified Administrator (Nursing Home Administrator -NHA). Due to fall writer notified Coroner's office at 8:00 p.m. and spoke with Assistance Coroner (AC) H. Writer called, on call M.D (Medical Doctor) I and obtained order to remove body at 8:10 p.m. Writer reached spouse a, at 8:30 p.m.. Spouse accompanied with family arrived at 9:20 p.m. and spent time with resident before arrival of Coroner. AC H arrived at RLCC and made pronouncement at 9:30 p.m. Family requested clergy, Father Jim arrived to administer rites to resident, No belongings were sent with resident." The nurse charting on [DATE] at 4:58 p.m., states, "Intensity of Care Per resident's chart regarding CPR: I (resident) am expressing a desire to have CPR be done in the event of a [MEDICAL CONDITION]. I (resident) understand that in the event of an observed [MEDICAL CONDITION], CPR will be initiated by staff and emergency medical personnel will be called. I (resident) understand that in the event of an unobserved [MEDICAL CONDITION], an assessment will be made for apparent signs of life. CPR will be instituted based upon the professional judgment and its medical efficacy. This writer's assessment included finding resident lying on the floor, with blood pooled on floor from nose and mouth. No active bleeding noted. Resident was found to be unresponsive, vital signs ceased, and face was purple (sic). This writer's professional judgment was CPR would have no medical efficacy, CPR was not initiated." On [DATE] at 4:00 p.m., Surveyor interviewed RN A regarding Resident #2. RN A indicated the bleeding had stopped from his face and the blood on the floor was fresh, not bright red and not black, it was red. His face was blue in color and checked all vitals and he was cold and unresponsive. RN A indicated his stethoscope is amplified so he is able to hear if there was any breath or heart sounds. RN A indicated he did not attempt CPR; it was up to his discretion if an unwitnessed event. It is up to him to make the call. RN A indicated 911 was not called. Following surveyor's exit from the facility a statement was faxed to DQA office. The statement was written by RN A. The statement was written, signed and dated [DATE]. RN A's statement reads in part, "Resident has no signs of life ie no vital signs, was cold to the touch and face was a dark blue /purple. eyes were unresponsive...I checked residents code in the chart. CPR was checked with the following CPR will be instituted based upon the professional judgement and medical efficacy. I felt that in my judgement CPR would not be effective." On [DATE], Surveyor interviewed Barron County Coroner (BCC C) over the phone. Surveyor read the statement by RN A to BCC C. BBC C stated that "cold to the touch" depends on several factors such as room temperature, circulation, size of the resident. The coroner stated that in a cardiac event (which is what the preliminary autopsy indicates) a person's face would turn blue/purple immediately. Subsequent to this event, the facility provided training for all nursing personnel beginning [DATE] on when CPR should be initiated. Surveyor asked RN A if he was trained on the new CPR policy. RN A indicated they are to check the code status, green is full code, and the sticker on the chart and on the name plate on door. This means to start CPR and call for help and continue until EMTs are to take over. RN A indicated he had recently been trained on this. RN A was able to identify his signature on the Charge Nurse Guidelines & CPR training sheet on [DATE]. Surveyor asked RN A if the same situation occurred today what he would do. RN A indicated he would do the same thing today; it depends on the situation and the resident. RN A indicated he would have to think about it now with the new training, but it is up to his professional judgment. Surveyor interviewed LPN B regarding CPR policy. LPN B indicated she was trained on CPR. LPN B identified her name was not on the Charge Nurse Guidelines & CPR training sheet from [DATE]. LPN B indicated she has to check the code status, red meaning no CPR and green means CPR. Surveyor asked if CPR would be performed on a resident that was a full code and found on the floor, unresponsive, no vitals and a bluish color to the face. LPN B indicated she would assess and check the body if warm and assess if CPR would be of any benefit and call 911. If the body was cold and if signs of unobserved fall on the floor, may call the death, it would depend on the resident. Surveyor interviewed LPN J and RN K regarding CPR. LPN J and RN K indicated they were just trained and the green dots mean go - do CPR and red means stop - do not resuscitate. LPN J and RN K indicated this is for every resident and do CPR on a full code no matter what until EMS arrives. LPN J was able to identify her signature on the Charge Nurse Guidelines & CPR training sheet from [DATE]. RN K was able to identify her signature on the Charge Nurse Guidelines & CPR training sheet from [DATE]. Review of the current resident census, 23 of the 49 residents are requesting CPR. Surveyor interviewed the Director of Nursing (DON) regarding CPR. The DON indicated this event, policy change and training occurred before she took the position of Director of Nursing. The DON provided Surveyor the new Intensity of Care form, undated. This is the form that newly admitted residents sign if they wish to have CPR. The form reads in part: "It is the policy of Rice Lake Convalescent Center (RLCC) to adhere to the wishes of any one reside in this nursing home regarding their desired level of care in the event of critical or terminal illness. In the event that a resident becomes ill and is unable to communicate their level of care choices, RLCC staff will honor the desired level of care indicated on this form...CPR I am expressing my desire to receive CPR in the event of [MEDICAL CONDITION]. I understand that in the event of a [MEDICAL CONDITION], CPR will be initiated by RLCC staff and emergency medical personnel will be called. I understand that in the event of a [MEDICAL CONDITION], an assessment will be made for any apparent signs of life. CPR will be instituted based upon professional judgment and medical efficacy." The failure to provide CPR created a finding of immediate jeopardy. Although it is not certain that CPR would have been effective in reviving Resident #2, the failure to honor his wishes and to provide the care he wanted denied him the only opportunity he had for living. Immediate action was needed to try to revive him and this was not forthcoming. Immediate jeopardy was removed on [DATE] when the facility revised the facility CPR policy to accurately reflect CMS guidelines and educated all nursing staff prior to working their next shift.

Based on interview and record review, the facility did not provide the necessary care and services to promote healing of a pressure ulcer resulting in deterioration and development of infection in pressure ulcers for 1 of 1 sampled resident. Resident #3 was admitted to the facility on [DATE] following surgical repair of a [MEDICAL CONDITION]. Resident #3 had additional [DIAGNOSES REDACTED]. Upon admission, Resident #3 was assessed as having deep tissue injury (DTI) to both heels. The immediate jeopardy began on 10/31/12 when: ~The facility did not implement immediate interventions to promote healing and prevent deterioration of the pressure ulcers; ~The facility's wound nurse was a Licensed Practical Nurse, who, by virtue of her license, is unable to complete a comprehensive assessment of wounds. There was no Registered Nurse assessment; ~The wound nurse incorrectly documented wounds as "stable" or "improved" where there were obvious signs of deterioration; ~Interventions that were implemented were not consistent with accepted standards of practice for treatment of [REDACTED]. ~Resident #3's pressure ulcers have deteriorated. She reported pain in both heels and has declined in her ability to walk due to the pain. ~Additionally, she has been diagnosed with [REDACTED]. The facility's failure to adequately assess and address Resident #3's risk factors on admission, its failure to implement appropriate interventions to relieve pressure, and its failure to revise the care plan when the heel wounds were noted to have deteriorated, created a finding of immediate jeopardy. The immediate jeopardy was identified on 1/17/13. The NHA (Nursing Home Administrator) was notified on the immediate jeopardy on 1/17/13. The immediate jeopardy was removed on 1/18/13, but noncompliance remained at the lower scope and severity level of D (potential for harm that is not immediate jeopardy/isolated) as the facility has yet to fully implement its plan for ongoing monitoring and assessment of residents' pressure ulcers. This is evidenced by: According to the National Pressure Ulcer Advisory Panel (NPUAP), a deep tissue injury is a "...Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or sheer..." The NPUAP also indicates, "...Use devices that totally relieve pressure on the heel..." (This was not done until around 12/29/12, two months after admission. The quilted booties that were used prior to approximately 11/7/12, did not meet professional standards of practice for relieving pressure and the Prevalon boots did not always stay on the resident's feet at night.) According to "Pressure Ulcers in Adults: Prediction and Prevention," skin care and treatment should have specific interventions which are documented and monitored. "...specific details are needed on who should provide the care, how often, and the supplies and equipment needed. How the care is to be undertaken should be individualized, written, and readily available. Furthermore, results of the interventions and the care being rendered, and adjustment in the interventions, as indicated by the outcomes should be documented. To ensure continuity, documentation of the plan of care must be clear, concise, and assessable to every caregiver..." (This was not done as the "Checklist of Skin Risk Factors and Interventions" dated 10/21/12 was not specific. Further, ongoing revisions to the care plan were not developed and implemented when weekly rounds showed the heels had deteriorated, e.g., 11/7/12, 11/13/12, 11/22/12, and 12/5/12.) According to Braden, B. (2001) Risk Assessment in Pressure Ulcer Prevention, a standardized risk assessment tool should be completed on admission and weekly for the first four weeks after admission, and then quarterly or with a change in condition. (Weekly "assessments" were completed by an LPN, who is not trained to assess and who repeatedly incorrectly identified the heels as " stable," e.g., 11/7/12, 11/13/12, 11/22/12, 12/5/12, and 12/12/12 when, in fact, the ulcers had changed in size or color.) The NPUAP and European Pressure Ulcer Advisory Panel (EPUAP) indicate that with each dressing change or at least weekly, an evaluation of a pressure ulcer should be documented including at a minimum, the location and stage, the size, exudate, any pain, a description on the wound bed, and a description of the wound edges. The NPUAP and EPUAP indicate the documentation should be completed more frequently with wound complications. The NPUAP and EPUAP also indicate that with any signs of deterioration of a pressure ulcer, it should be addressed immediately. (There was no weekly assessment or measurement of the wounds between 11/22 and 12/5/12 and between 12/19/12 and 12/28/12.) According to the NPUAP, pressure ulcers on the heels need immediate interventions to off-load the heels. The NPUAP also indicates pressure ulcers to the heels should never be debrided. (The nurse practitioner debrided the heels on 12/19/12 and the resident has experienced heel pain since then.) According to the American Family Physician, "The risk of lower extremity amputation is 15 to 46 times higher in diabetics than in persons who do not have diabetes mellitus ...The vast majority of diabetic foot complications resulting in amputation begin with the formation of skin ulcers. " Resident #3 was admitted to the facility on [DATE] following surgical repair of a [MEDICAL CONDITION]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #3: ~Had no cognitive impairments; ~Required extensive assistance of 2 staff persons for bed mobility, transfers, and walking; ~Required extensive assistance of 1 staff person for bathing, dressing, grooming, and toileting; ~Had an impairment of functional range of motion on 1 side of the lower extremities; ~Was at risk for the development of pressure ulcers; and ~Had 2 unstageable suspected deep tissue injury pressure ulcers. Resident #3's Care Area Assessment (CAA) Summary dated 11/7/12 indicated, "...admitted with multiple skin issues. Healing impacted by diabetes, [MEDICAL CONDITIONS] and now mobility...limited by [MEDICAL CONDITION] develop care plan..." Resident #3's "Initial Care Plan" was dated 10/31/12. This was the care plan noted in Resident #3's clinical record. The skin care plan interventions included: ~11/14/12, an air mattress; ~A foam dressing to the heels, heel protectors, Podus boots, and [MEDICATION NAME] (all undated). Surveyor # requested Resident #3's care plan developed after the completion of Resident #3's MDS dated [DATE]. Surveyor # received a care plan dated 1/16/13. All approaches under the skin care plan were dated 1/16/13. There was no evidence that approaches were implemented immediately despite Resident #3's current pressure ulcers and comorbidities. Resident #3's Certified Nursing Assistant (CNA) care plan was noted as "updated" on 1/16/13. The approaches included protector boots and a heel riser when Resident #3 was in bed. These approaches were noted to be in bold lettering. On 1/16/13 at 4:25 p.m., Surveyor # spoke with the Director of Nursing (DON) regarding the bold lettering. The DON indicated that anything on the CNA care plan in bold lettering was an indicator to staff that an approach was new. Surveyor # asked the DON when the approaches of the protector boots and heel riser were added to Resident #3's care plan. The DON indicated she was unsure exactly when, but it would have been sometime in the past 1 to 2 weeks. Resident #3's most current skin risk assessment was dated 10/31/12. It indicated Resident #3 had a cumulative score of 18. According to the scoring of the risk assessment, a score of 12 or less indicated high risk for the development of pressure ulcers. Surveyor # completed a review of a facility form titled "Checklist Of Skin Risk Factors and Interventions" for Resident #3 dated 10/31/12. Under the column titled "Interventions," were multiple skin interventions including positioning with supportive devices, pressure reduction devices for bed and wheelchair, elevating heels allowing the practitioner to check which interventions are most appropriate. Despite Resident #3's risk factors (diabetes, immobility, and existed deep tissue injury to both heels), the only interventions listed for Resident #3 were to turn and reposition (timing intervals were left blank), encourage Resident #3 to walk, dietary supplements, and to use assistive devices to reduce friction. The approach to " turn and reposition " was not specific and did not indicate how often this should be done. Surveyor # completed a review of Resident #3's admission assessment dated [DATE]. It indicated Resident #3 had a 3.0 centimeter (cm) in diameter blister on the left heel and a 3.0 by (x) 4.0 blister to the right heel. Surveyor # completed a review of Resident #3's nursing notes and noted the following: 10/31/12, "...has blisters that are purple in color...left heel...3 cm (3.0 centimeters) in diameter...right heel is 3x4 cm (3.0 cm by 4.0 cm)..." The facility identified that Resident #3 had 1 unstageable deep tissue injury (DTI) on each heel. Despite this knowledge, there were no interventions added to Resident #3's plan of care which allowed for total off-loading of Resident #3's heels. Between 10/31/12 and 11/7/12 there was no documentation of the status of Resident #3's heel ulcers. Nursing notes continue: ~11/7/12, "...right heel, DTI, 4x4.2xm (cm) (4.0 cm x 4.2 cm),mushy, white color, not open...foam to protect...left heel, DTI, 3.5x4 m, mushy and purple in color...foam to protect...Fax Sent: Dr...regarding bilateral heels. Udating that they are being monitored and heel protectors on when in bed..." Surveyor # reviewed the fax dated 11/7/12. It indicated Resident #3 had DTI to both heels and staff were covering the heels with a foam dressing as well as applying heel protectors while in bed. This was the first indication that Resident #3's physician had been contacted regarding the DTIs to both heels. In addition to documenting wound measurements in the nursing notes, the facility also utilized a form titled, "Weekly Wound Documentation Progress Sheet." Surveyor # completed a review of Resident #3's wound progress sheet dated 11/7/12. It indicated the same measurements as noted in the nursing notes. Under the column titled "Wound Progress/Pain," it indicated the wounds were stable. By 11/7/12, the DTIs on both heels were not stable but had deteriorated and increased in size. There were no changes made to Resident #3's plan of care in attempts to completely off-load Resident #3's heels. On 11/8/12, Resident #3 was seen by NP-H (Nurse Practitioner). NP-H's progress note indicated, "...cannot palpate dorsalis pedal pulses or posttibial pulses but they are very easily found with a Doppler, strong and biphasic. The left heel has a hemorrhagic blister on the lateral side measuring 3 cm x 3 cm and the right heel has a hemorrhagic blister on the right lateral side that measures 3 cm x 4 cm...They are not [DIAGNOSES REDACTED]tous..." Nursing notes continue: ~11/13/12, "...c/o (complains of) pain to L (left) foot the am (morning) stating it was aching and burning...blister to heel still intact foam in place for protection..." ~11/14/12, "...right heel, 5x5.5 cm, DTI, mushy purple in color...left heel DTI, 3x6.5 cm, mushy purple in color, where (sic) boots at all times..." Surveyor # reviewed Resident #3's "Weekly Wound Documentation Progress sheet" dated 11/14/12. It reiterated the same measurement as noted in the nursing notes of 11/14/12. It also indicated the wounds were stable. Resident #3's pressure ulcers were not stable and continued to deteriorate and increase in size. There were no changes made to Resident #3's plan of care to ensure total off-loading of Resident #3's heels. On 11/14/12, Resident #3 was seen by NP-H. The NP-H's progress notes dated 11/14/12 indicated, "...They are concerned about her bilateral heels. They may have increased in size...Left hemorrhagic blister on the lateral heel now measures 3 cm x 5.5 cm and on the right heel 2.5 cm x 5.0 cm. They are not draining. There is a stage I pressure ulcer redness around them...Right heel...increased in size...Left heel...increased in size...Plan...add a low-air-loss mattress to her bed...continue with protective boots to offload these heels...will add [MEDICATION NAME] the bilateral lower extremities to help with the [MEDICAL CONDITION]" The low air loss mattress was added to Resident #3's care plan on 11/14/12. There were no further nursing notes or wound progress notes regarding the status of Resident #3's bilateral heel pressures ulcers until 11/22/12. Nursing notes continue: ~11/22/12, "...right heel, 5x8 cm DTI, blister, mushy and purple, skin intact around with purple [MEDICAL CONDITION] skin surrounding...foam pad to protect...left heel, 3.4x7.5 cm, DTI, blister, mushy and purple, skin intact around with purple [MEDICAL CONDITION] skin surrounding...foam pad to protect..." Surveyor # reviewed Resident #3's "Weekly Wound Documentation Progress Sheet" for 11/22/12. The pressure ulcers were again noted as measured in the nursing notes of 11/22/12. The wound progress note again indicated the wounds were stable. There is again a noted increase in the size of the pressure ulcers indicating they have deteriorated. Despite this, the wounds were still noted as stable. There were no changes made to Resident #3's plan of care. There were no further nursing notes or wound progress notes regarding Resident #3's bilateral heel pressure ulcers until 12/5/12. This was 13 days after the last observations were documented. Nursing notes continue: ~ 12/5/12, "...right heel, DTI, 4.5 x 3.5cm, calloused over, hard purple area. Surrounding tissue calloused and intact...foam pad to protect daily...left heel, DTI, 3.5 x 7cm, calloused over, hard purple area. Surrounding tissue calloused and intact...Foam pad to protect daily. Note: Resident wears boots on her feet at all times to protect her heels..." Surveyor # reviewed a "Weekly Wound Documentation Progress Sheet" dated 12/5/12. It again reiterated the measurements as noted in the nursing notes of 12/5/12. The progress note also indicated the wounds had improved. There was no other documentation of the status of Resident #3's bilateral heel pressure ulcers until 12/12/12. Nursing notes continue: ~12/12/12, "...right heel, 4.5 x 5 cm, dry, calloused purple area, calloused surrounding skin...Treatment - foam pad and kerlix and protect with a Podus boot...left heel, 4 x 8 cm, DTI, dark calloused purple area, calloused surrounding skin...Treatment - foam pad and kerlix and protect with a Podus boot..." Resident #3's bilateral heel ulcers again show an increase in size. The facility identified that a Podus boot was now being utilized. The wound progress notes indicated the wounds were stable. There was no further documentation regarding Resident #3's bilateral heel pressure ulcers until 12/19/12. Nursing notes continue: ~12/19/12, "...right heel DTI 5 x 5 cm, dried purple and calloused over, not open...left heel, DTI, 3.5 x 4 cm, dried purple calloused, not open..." The "Weekly Wound Documentation Progress Sheet" dated 12/19/12, indicated the wounds were stable. On 12/19/12, Resident #3 was again seen by NP-H. Surveyor # reviewed the progress note dated 12/19/12. It indicated, "...bilateral heel hemorrhagic blisters that became black eschar. The wound care nurse...states they have become quite loose and she would like me to debride them away...The left hemorrhagic blister on the lateral heel now measures 2.5 cm x 2.4 cm after debridement of the loose black edges. The right heel measures 1.5 cm x 3.0 cm with a small black area proximal to larger ulcer measuring 1 x 0.5 cm...the surrounding skin is intact..." This was the first noted documentation that Resident #3 had developed a second unstageable pressure ulcer to the right heel. There was no further documentation of the status of Resident #3's bilateral heel ulcers until 12/28/12. This was 9 days after the last noted nursing note and "Weekly Wound Documentation Progress Sheet" note. Nursing notes continue: 12/28/12, "...right heel, 5 x 5 cm DTI, 100% eschar with calloused edges...podus boots when she is in bed along with an air mattress...left heel, DTI 3 x 3 cm, 100% eschar with calloused edges...Podus boots when in bed and an air mattress..." 12/29/12, "...wears protective boots to feet at all times and heels are bridged off bed for comfort..." This was the first indication that Resident #3's heels were bridged or suspended off the mattress. There was no further documentation regarding the condition of Resident #3's bilateral heel pressure ulcers until 1/2/13. Nursing notes continue: 1/2/13, "...right heel, DTI, 4.6 x 5 cm, 100% eschar with callused (sic) dry edges...left heel, 3.2 x 2.6 cm, 100% eschar with callused (sic) dry edges..." 1/3/13, "...Complaints of heel pain on previous shift..." 1/4/13, "...complained of some pain while the dressings were changed to her heels...complained of burning pain 8/10 (8 out of 10) in her heels..." 1/5/13, "...c/o (complains of) pain to bilateral heels rating 7/10..." 1/9/13, "...Right heel: The dark colored area measured 4.8 x 3.7 cm...Left heel: The dark area measured 3.3 x 2.5 cm...continues to complain on (sic) increased pain in heels..." 1/10/13, "...> (greater) pain in bilateral heel ulcer areas, decline in ability to stand and/or walk since last visit to...NP...Since ulcer debridement, patient has complained of > severe pain SX (symptoms) in bilateral heel ulcers..." On 1/10/13, Resident #3 was seen by NP-H. Surveyor # completed a review of NP's progress notes. The progress notes indicated, "...call to tell me she had some significant changes in her feet...she has increased pain in her heels so she no longer has been walking or doing physical therapy...Dr...did increase her pain medication which she states has helped some but as long as she does not walk on them or touch them they feel okay...states the pain in her heels has been developing over the last month. She notes now that it is constant...she wears protective boot at night. She does not wear them during the day...pulses...easily found with Doppler of both feet. The left hemorrhagic blisters on the lateral heel now measure 3 cm x 2.1 cm and on the right heel 3.5.cm x 5.0 cm. There is 4 cm tender [DIAGNOSES REDACTED] around the left heel ulcer and 2.5 cm tender [DIAGNOSES REDACTED] around the right heel ulcer...Assessment...Right heel blister...increased size...Left heel....blister, increased [MEDICAL CONDITION] bilateral heels...Plan...treat the [MEDICAL CONDITION] to the ulcerated eschar...to wear her protective boots 24 hours a day..." The facility did not document the condition of Resident #3's bilateral heel pressure ulcers again until 1/15/13. Nursing notes continue: 1/15/13, "...Right heel...unable to stage...measures approx (approximately) 5.0 cm x 4.0 cm and is 100% eschar...Wound has fleshy smell...Left heel...unable to stage; area currently measures approx. 2.8 cm x 4.0 cm and is 100% eschar...wound has fleshy smell..." The DTIs to Resident #3's bilateral heels were now infected as well as larger in size. Surveyor # completed a review of Resident #3's Treatment Administration Record (TAR) for November 2012. The TAR indicated that beginning 11/7/12 Resident #3 had "...heel protectors on when in bed..." According to the TAR, on 11/9/12, heel protectors when in bed were discontinued and the TAR indicated, "...heel protectors on at all times 11/9/12..." On 1/16/13 at 4:30 p.m., Surveyor # observed Resident #3 seated in the west wing day room playing cards. Surveyor # noted Resident #3 had light blue boots on both feet which extended from Resident #3's toes to just below her knees. Surveyor # requested the DON to assess Resident #3's boots to determine if Resident #3's heels were suspended in the boots. The DON escorted Resident #3 to her room and completed the assessment in the presence of Surveyor # . The DON indicated Resident #3's heels were suspended and not resting on the foot rests of Resident #3's wheelchair. Surveyor # noted the boots were Prevalon boots. During this time, Resident #3 expressed to the DON that the Prevalon boots do not stay on at night as the velcro did not stay adhered. The DON indicated she would be getting Resident #3 new boots. On 1/16/13 at 11:20 a.m., Surveyor # spoke with CNA-C (Certified Nursing Assistant). CNA-C indicated she worked full time and usually worked the wing in which Resident #3 resided. Surveyor # asked CNA-C about Resident #3. CNA-C indicated when Resident #3 was first admitted to the facility, she wore short quilted heel protectors with 1 Velcro strap located at the ankle that attached each side to the other. CNA-C was unaware of any other type of device used to position Resident #3's feet. CNA-C indicated the facility discontinued these and applied the boots in which Resident #3 currently had on. CNA-C was uncertain of when the change occurred. On 1/16/13 at 11:00 a.m., Surveyor # spoke with RN-A (Registered Nurse). RN-A was noted to be working on the floor where Resident #3 resided. RN-A indicated she worked full time and was the charge nurse. RN-A stated she usually did not work the floor, but assisted the nurses on each wing as well as complete tasks as assigned by the Director of Nursing (DON). Surveyor # asked RN-A, who was the full time nurse on the wing in which Resident #3 resided. RN-A stated there was no full time nurse as most of the nurses worked part time. Surveyor # asked RN-A about the facility's Wound Management Program. RN-A indicated LPN-B (Licensed Practical Nurse) was the facility's wound nurse. RN-A stated LPN-B completed all wound measurements as well as weekly documentation. Surveyor # also asked RN-A about the facility's practice for physician notification. RN-A indicated she would contact a physician immediately if she noted a DTI. RN-A also stated she would contact a physician with any noted deterioration of a pressure ulcer. On 1/16/13 at 1:40 p.m., Surveyor # again spoke with RN-A about Resident #3. RN-A indicated Resident #3 had blisters on both heels when first admitted to the facility. RN-A indicated the blisters "opened up at some point." RN-A stated she had not seen the blisters as the nurses on the floor were the ones who completed the treatment, and the wound nurse did the weekly measurements. RN-A indicated she was unsure why Resident #3's bilateral DTIs got worse. On 1/16/13 at 4:40 p.m., Surveyor # spoke with Resident #3 about the pressure ulcers on her heels. Surveyor # asked Resident #3 how long she had had the Prevalon boots. Resident #3 stated the facility put the boots on when she starting complaining of pain in her heels. Resident #3 also stated when she was first admitted , the only thing she had on her feet were gripper socks. Surveyor # also noted a heel riser on Resident #3's bed. Surveyor # asked Resident #3 how long she had had the heel riser. Resident #3 indicated it was about the same time the facility gave her the Prevalon boots. Resident #3 also expressed to Surveyor # that she is no longer able to walk due to the pain she experiences in her heels when she does. On 1/16/13 at 1:00 p.m. and 2:50 p.m., Surveyor # spoke with the DON about the facility's Wound Management Program. The DON stated that the facility did not have a wound team. The DON stated the facility has a wound nurse who was an LPN. The LPN independently completes all the wound rounds including the measurements and condition of all pressure ulcers. The DON indicated the LPN was not wound certified. The DON stated the wound nurse would then give her the "Weekly Wound Documentation Progress Sheet" and she would review them. The DON stated she would always look to see if the wounds were declining and if so would pursue it right away. The DON also stated the facility utilized a NP to assist them with wound care. Surveyor # requested to talk with LPN-B. The DON indicated she was not available and was off work for an extended period of time. On 1/24/13 at 12:19 p.m., Surveyor # spoke with NP-H. NP-H indicated she was a certified wound nurse and saw patients with wounds only by referral. Surveyor # asked NP-H about Resident #3. NP-H indicated Resident #3's physician had made a referral for her to see Resident #3. NP-H indicated her first appointment with Resident #3 was on 11/8/12 in the clinic. NP-H indicated Resident #3's bilateral pressure ulcers appeared as intact blood blisters. Surveyor # asked NP-H if the blood blisters were considered DTIs. NP-H stated yes. NP-H indicated she saw Resident #3 again at the facility on 11/14/12. NP-H stated that because there was increased redness around the eschar, she wanted to make sure Resident #3's heels were in fact being off-loaded so she ordered an air mattress. NP-H indicated the facility told her Resident #3 was wearing protective boots. NP-H also indicated that as far as she knew there was no type of specialized mattress on Resident #3 bed at the time she ordered the air mattress. NP-H indicated that when she saw Resident #3 on 12/19/12, she considered Resident #3's bilateral DTIs to be stable. NP-H stated at the time she debrided away only the area of dead loose skin around the edges of the pressure ulcers as the eschar on heels should not be removed. NP-H stated she did see Resident #3 again in the clinic on 1/10/13 at the request of the facility, and at that time she diagnosed Resident #3 with [MEDICAL CONDITION] in both heels. NP-H stated that she has since seen Resident #3 and Resident #3's heels were improving. Surveyor # asked NP-H about Resident #3's protective boots. NP-H indicated the facility told her that Resident #3 was wearing protective boots, however she did not recall what type of device Resident #3 initially had on. NP-H stated she did recall that on 12/19/12 and 1/10/13, Resident #3 had on the large blue puffy boots as she had to remove them. Surveyor # attempted to contact the physician several times without success. The facility's failure to adequately assess and address Resident #3's risk factors on admission, its failure to implement appropriate interventions to relieve pressure, and its failure to revise the care plan when the heel wounds were noted to have deteriorated, created a finding of immediate jeopardy. The immediate jeopardy that began on 10/31/12 was removed on 1/18/13 when the facility: 1. Completed a skin sweep of the facility with the LPN and an RN to determine if other residents had pressure ulcers or were at risk for development of pressure ulcers; 2. Reviewed care plans and implemented appropriate interventions as needed; 3. Began weekly skin rounds by both the LPN and an RN.

Based on interview and record review, the facility did not ensure that 2 of 3 sampled residents' physicians were consulted when a significant change in condition occurred. On [DATE], Resident #1 had a significant change condition including vital signs. The physician was not immediately notified. On [DATE], Resident #2 had a fall which resulted in a head injury. There was no evidence that the physician had been contacted. This is evidenced by: The AMDA (American Medical Directors Association) Protocols for Physician Notification indicate: ~Immediate physician notification is required for residents with a low pressure of less than ,[DATE] or 20 points below the resident's usual blood pressure, or a low blood pressure associated with an altered level of consciousness, or diaphoresis; ~Immediate physician notification is required for residents with a pulse greater than 120 or new onset associated with other symptoms; ~Immediate physician notification of a fall with suspected injuries, and non-immediate with a fall with insignificant injury. Example #1: Resident #1 was admitted to the facility on [DATE] from the hospital. Admitting [DIAGNOSES REDACTED]. The admission assessment dated [DATE], indicated Resident #1: ~Was alert and oriented; ~Was easily distracted; ~Speech was clear and unclear; ~Usually understands; ~Was independent in bed mobility and eating; ~Required supervision for toileting, hygiene and bathing; and ~Limited assistance with transfers, ambulation, and dressing. Surveyor # completed a review of Resident #1's nursing notes and noted the following: [DATE], "...Pulse: 82...BP (blood pressure): ,[DATE]...strong equal grasps. Pupils are equally responsive to light..." [DATE], "...Pulse: 67...BP: ,[DATE]...Pulse: 72...BP: ,[DATE]...usually confused and disoriented. She does have long term memory but her short term memory appears poor..." [DATE], "...Pulse: 84...BP: ,[DATE]... anxious and restless at times...Pulse: 110...BP: ,[DATE]...Communication: answers simple questions-Resident has some communication defecits from dementia...disoriented x (times) 4..." [DATE], "...Pulse: 80 BP: ,[DATE]...very confused, anxious and restless...weakness at times..." [DATE], "..XXX,[DATE]...78 (pulse)..." [DATE], "...poor appetite...coughing during meals...13:13 (1:13 p.m.)...pulse 120...BP: ,[DATE]..." At 1:13 p.m., when nurses documented an increase in Resident #1's pulse and a decrease in her blood pressure, there was no evidence of a comprehensive assessment being completed. There was no physician consultation. Nursing notes continue: [DATE], "...17:58 (5:58 p.m.) Telephone Call Placed: To...hospital. Nurse stated she was being admitted for a stroke...20:47 (8:47 p.m.) late entry resident family request for resident to be sent to the ER (emergency room )...left via ambulance at 1520 (3:20 p.m.)..." There were no nursing notes depicting the circumstances surrounding Resident #1 being transported to the hospital. On [DATE] at 4:12 p.m., Surveyor # spoke with Family-G. Family-G indicated she was the person who requested Resident #1 be sent to the hospital after observing Resident #1's status on [DATE]. Family-G indicated that when she arrived at the facility on [DATE] at approximately 2:45 p.m., she observed Resident #1 sitting by the nurses' station with her head bent backwards, mouth wide open, and non-responsive. Family-G indicated she spoke with the nurses who were seated at the nurses' station about her concerns. She was told nothing wrong with Resident #1 as she was just sleepy from the [MEDICATION NAME] she had just received. Family-G stated she demanded the facility call 911 and have Resident #1 sent to the hospital. Family-G stated at that point a nurse did call. Family-G indicated Resident #1 had a significant decline in her status. Family-G stated when Resident #1 was admitted to the facility 5 days prior, she was walking and talking. Family-G stated Resident #1 was to be at the facility for a matter of days for rehab and then return home. Family-G indicated she felt the facility was negligent in identifying and responding to Resident #1's change in condition. Surveyor # completed a review of Resident #1's hospital Discharge Summary dated [DATE]. This indicated Resident #1 was admitted to the hospital on [DATE]. It also indicated Resident #1 had an extensive stroke and expired on the morning of [DATE]. The cause of death was noted [MEDICAL CONDITION] or stroke. Resident #1's Minimum Data Set (MDS) was dated [DATE] and indicated Resident #1: ~Sometimes understood, sometimes understands; ~Short term memory was intact but had long term-memory problems; ~Cognitive skills were moderately impaired; ~Was inattentive at all times; ~Had no behaviors; ~Required extensive assistance of 2 staff persons for bed mobility, transfers, and toileting; ~Required extensive assistance of 1 staff person for walking, dressing, grooming, and eating; ~Was totally dependent for bathing; and ~Indicators of daily pain. The picture of Resident #1 on admission was clearly different than that of Resident #1's MDS dated [DATE]. According to the MDS dated [DATE], Resident #1 had had a significant decline in functioning since admission. On [DATE] at 1:40 p.m., Surveyor # spoke with RN-A (Registered Nurse). RN-A indicated she was the charge nurse. RN-A indicated she generally did not work the floor, but assisted the nurses on each station as well as complete tasks as assigned by the Director of Nursing (DON). RN-A indicated she was not on duty the day Resident #1 was transported to the hospital. RN-A indicated she was aware of the situation and indicated Resident #1's daughter came into the facility and felt there was a change in Resident #1's condition. RN-A indicated the staff on duty did not see the changes in Resident #1's status. RN-A stated Resident #1 was transported to the hospital due to the expressed wishes of the daughter. RN-A stated Resident #1 did not return to the facility and she was unaware of why. RN-A indicated that if any resident had a significant change in condition, she would notify the physician immediately. On [DATE] at 2:50 p.m., Surveyor # spoke with the DON. Surveyor # asked the DON what had occurred on [DATE] in regard to Resident #1. The DON recalled that she was on the wing where Resident #1 resided on [DATE]. The DON indicated Resident #1's daughter came into the facility on [DATE] and indicated Resident #1 did not look right and requested she be sent to the emergency room . The DON stated the Speech Therapist (ST) was also on the floor at the same time and indicated to the DON that Resident #1 had a change in her condition since the noon meal when she had assisted her to eat. The DON also stated the ST told her Resident #1 was diaphoretic and something was not right. The DON stated she then called 911. Example #2: Surveyor # completed a review of Resident #2's clinical record and noted the following: Resident #2 was admitted to the facility on [DATE] from the hospital. Admitting [DIAGNOSES REDACTED]. Surveyor # completed a review of Resident #2's nursing notes and noted the following: [DATE], "...alert & (and) awake, oriented time/place/person, somewhat forgetful...firm hand grip, and equal. Speech: is normal..." [DATE], "...fall...alert & oriented, hand grasps strong equal, pupils are unequal per usual...small bruise immediately noted to back of resident's head....physician notified...via fax..." On [DATE], Surveyor # requested the fax for Resident #2 as noted in the nursing note of [DATE]. None was received. On [DATE] at 2:50 p.m., Surveyor # spoke with Director of Nursing. Surveyor # asked the DON about the fax for Resident #2 on [DATE]. The DON stated she was not able to find it. There was no evidence that the physician had been immediately consulted of Resident #2's fall in which she sustained a head injury. Nursing notes continue: [DATE], "...17:57 (5:57 p.m.)...Late Entry: from 0830 (8:30 a.m.) this am (morning)...Cna (Certified Nursing Assistant) came to writer stating res (resident) did not seem right. writer went...to res room. Res's eyes were open but did not respond to writer verbally...Res did not squeeze writer's hand...VS (vital signs) 96.2 (temperature) 18 (respirations) 42 (pulse) irregular and faint b/p (blood pressure) ,[DATE]. Res then had emesis...Res sent to ER (emergency room )...was admitted . Surveyor # reviewed a fax dated [DATE]. The fax indicated Resident #2 was unresponsive, not following commands, and not using her right arm. The fax also reiterated the vital signs as noted in the nursing note of [DATE]. Resident #2 had a significant change in condition which was emergent. Despite this, the facility sent the physician a fax. Resident #2 returned to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 expired on [DATE]. On [DATE] at 1:40 p.m., Surveyor # spoke with RN-A. RN-A stated she faxes all information to residents' physicians unless a resident had a significant change in condition. RN-A indicated she would then call the physician. RN-A stated it was the facility's practice to notify physicians via fax. RN-A indicated the fax becomes a permanent part of the medical record. On [DATE] at 2:50 p.m., Surveyor # spoke with DON. The DON indicated it was the facility's practice to fax physicians unless there was a significant change in condition which warranted a call to the physician. The DON also stated faxes were a permanent record in residents' clinical records.

Based on interview and record review, the facility did not ensure that 4 of 11 sampled residents received the necessary care and treatment to maintain or improve the highest practicable physical, mental, and psychosocial well-being. Resident #1 was admitted to the facility from the hospital for short-term rehabilitation. Resident #1 was a full code. It was Resident #1's intent to return home. On [DATE], Resident #1 had a significant change in condition which was not identified by the facility. A family member present at the facility noted the change in Resident #1's condition and requested Resident #1 be transported to the hospital. Resident #1 was diagnosed with [REDACTED]. Resident #3 had [DIAGNOSES REDACTED]. The physician ordered an 1800 cc (cubic centimeter) fluid restriction as well as to monitor Resident #3's urinary output. While the facility identified the fluid restriction, there was no consistent intake completed nor was intake tallied to determine if Resident #3 was exceeding the fluid restriction. There was no consistent output completed to determine Resident #3's urinary output. Resident #30 had physician ordered lab work which was not completed timely by the facility. Resident #32 had physician ordered lab work which was never completed by the facility. This is evidenced by: According to the American Medical Directors Association (AMDA) Protocols for Physician Notification: ~Any resident with an abnormal pulse or blood pressure should have vital signs taken specifically noting the rate and rhythm of the pulse and blood pressure, heart, lung, and neurological assessment, and to assess for chest pain, diaphoresis, dyspnea, fever, and blood loss. ~Any resident with speech or swallowing difficulties should have vital signs taken and a neurological assessment completed. Example #1: Resident #1 was admitted to the facility on [DATE] from the hospital. Admitting [DIAGNOSES REDACTED]. The admission assessment dated [DATE], indicated Resident #1: ~Was alert and oriented; ~Was easily distracted; ~Speech was clear and unclear; ~Usually understands; ~Was independent in bed mobility and eating; ~Required supervision for toileting, hygiene and bathing; and ~Limited assistance with transfers, ambulation, and dressing. Surveyor # completed a review of Resident #1's nursing notes and noted the following: -[DATE], "...Pulse: 82...BP (blood pressure): ,[DATE]...strong equal grasps. Pupils are equally responsive to light..." -[DATE], "...Pulse: 67...BP: ,[DATE]...Pulse: 72...BP: ,[DATE]...usually confused and disoriented. She does have long term memory but her short term memory appears poor..." -[DATE], "...Pulse: 84...BP: ,[DATE]... anxious and restless at times...Pulse: 110...BP: ,[DATE]...Communication: answers simple questions-Resident has some communication deficits from dementia...disoriented x (times) 4..." Resident #1's care plan was dated [DATE]. It identified as problems: adjustment to the nursing home, falls, and pain. The care plan contained no directives to staff on assistance required for all care areas including bathing, dressing, eating, going to the bathroom. Nursing notes continue: [DATE], "...Pulse: 80 BP: ,[DATE]...very confused, anxious and restless...weakness at times..." [DATE], "..XXX,[DATE]...78 (pulse)..." [DATE], "...poor appetite...coughing during meals...13:13 (1:13 p.m.)...pulse 120...BP: ,[DATE]..." At 1:13 p.m., when nurses documented an increase in Resident #1's pulse and a decrease in her blood pressure, there was no evidence of a comprehensive assessment being completed. There was no physician consultation. Nursing notes continue: [DATE], "...17:58 (5:58 p.m.) Telephone Call Placed: To...hospital. Nurse stated she was being admitted for a stroke...20:47 (8:47 p.m.) late entry resident family request for resident to be sent to the ER (emergency room )...left via ambulance at 1520 (3:20 p.m.)..." There were no nursing notes depicting the circumstances surrounding Resident #1 being transported to the hospital. On [DATE] at 4:12 p.m., Surveyor # spoke with Family-G. Family-G indicated she was the person who requested Resident #1 be sent to the hospital after observing Resident #1's status on [DATE]. Family-G indicated when she arrived to the facility on [DATE] at approximately 2:45 p.m., she observed Resident #1 sitting by the nurses' station with her head bent backwards, mouth wide open, and non-responsive. Family-G indicated she spoke with the nurses who were seated at the nurses' station about her concerns and she was told nothing wrong with Resident #1 as she was just sleepy from the [MEDICATION NAME] she had just received. Family-G stated she demanded the facility call 911 and have Resident #1 sent to the hospital. Family-G stated at that point a nurse did call. Family-G indicated Resident #1 had a significant decline in her status. Family-G stated when Resident #1 was admitted to the facility 5 days prior, she was walking and talking. Family-G stated Resident #1 was to be at the facility for a matter of days for rehab and then return home. Family-G indicated she felt the facility was negligent in identifying and responding to Resident #1's change in condition. Surveyor # completed a review of Resident #1's hospital Discharge Summary dated [DATE]. This indicated Resident #1 was admitted to the hospital on [DATE]. It also indicated Resident #1 had an extensive stroke and expired on the morning of [DATE]. The cause of death was noted [MEDICAL CONDITION] or stroke. Resident #1's Minimum Data Set (MDS) was dated [DATE] and indicated Resident #1: ~Sometimes understood, sometimes understands; ~Short term memory was intact but had long term-memory problems; ~Cognitive skills were moderately impaired; ~Was inattentive at all times; ~Had no behaviors; ~Required extensive assistance of 2 staff persons for bed mobility, transfers, and toileting; ~Required extensive assistance of 1 staff person for walking, dressing, grooming, and eating; ~Was totally dependent for bathing; and ~Indicators of daily pain. The picture of Resident #1 on admission was clearly different than that of Resident #1's MDS dated [DATE]. According to the MDS dated [DATE], Resident #1 had had a significant decline in functioning since admission. On [DATE] at 1:40 p.m., Surveyor # spoke with RN-A (Registered Nurse). RN-A indicated she was the charge nurse. RN-A indicated that she generally did not work the floor, but assisted the nurses on each station as well as complete tasks as assigned by the Director of Nursing (DON). RN-A indicated she was not on duty the day Resident #1 was transported to the hospital. RN-A indicated she was aware of the situation and indicated that Resident #1's daughter came into the facility and felt there was a change in Resident #1's condition. RN-A indicated the staff on duty did not see the changes in Resident #1's status. RN-A stated Resident #1 was transported to the hospital due to the expressed wishes of the daughter. RN-A stated Resident #1 did not return to the facility and she was unaware of why. RN-A indicated if any resident had a significant change in condition she would notify the physician immediately. On [DATE] at 2:50 p.m., Surveyor # spoke with the DON. Surveyor # asked the DON what had occurred on [DATE] in regard to Resident #1. The DON recalled that she was on the wing where Resident #1 resided on [DATE]. The DON indicated Resident #1's daughter came into the facility on [DATE] and indicated Resident #1 did not look right and requested she be sent to the emergency room . The DON stated the Speech Therapist (ST) was also on the floor at the same time and indicated to the DON that Resident #1 had a change in her condition since the noon meal when she had assisted her to eat. The DON also stated the ST told her Resident #1 was diaphoretic and that something was not right. The DON stated she then called 911. Example #2: Resident #3 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current MDS assessment dated [DATE] indicated Resident #3: ~Had no cognitive impairments; ~Required extensive assistance of 2 staff persons for bed mobility, transfers, and walking; and ~Required extensive assistance of 1 staff person for bathing, dressing, grooming, and toileting. Surveyor # completed a review of Resident #3's physician orders. On [DATE], the physician ordered an 1800 cc (cubic centimeter) fluid restriction and to monitor urine output daily for 1 week. Surveyor # completed a review of Resident #3's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"...enter what you gave..." Surveyor # noted that beginning [DATE] through [DATE], the day shift had no documentation of intake for 17 days, the evening shift had no documentation of intake for 3 days. None of the intakes were totaled to determine if Resident #3 was exceeding the 1800 cc fluid restriction on a daily basis. The [DATE] MAR indicated [REDACTED]. Surveyor # noted the following urinary output beginning on [DATE] through [DATE]: ~Night shift, no output documented; ~Day shift, 1 entry documented during the 7 days which indicated no urinary output; ~Evening shift, 4 entries indicating no output, 1 day indicating 50 cc, and 2 days with no documentation. Surveyor # completed a review of Resident #3's [DATE] MAR. 10 shifts during the month of December had no documentation of intake. None of the intakes were tallied to determine if Resident #3 was exceeding the 1800 cc fluid restriction. On [DATE] at 11:00 a.m., Surveyor # spoke with RN-A about the facility's practice for documenting intake and output (I&O). RN-A indicated the CNAs (Certified Nursing Assistants) document fluid intake when recording the percentage of a meal eaten and output would be documented in the CNA charting. Surveyor # asked RN-A how I&O was tallied. RN-A indicated in order to determine I&O she would need to pull up the CNAs charting. Surveyor # completed a review of Resident #3's food and fluid intake from [DATE] through [DATE]. The documentation indicated the amount of fluid intake for each meal, however it was not tallied. Surveyor # also completed a review of Resident #3's urinary output documented in the CNA charting from [DATE] through [DATE] and noted the following: [DATE], night shift 1 continent void with no cc's noted, day shift no documentation, evening shift 1 incontinent void; [DATE], night shift no output, day shift 900 cc's, evening shift no documentation; [DATE], night shift no documentation, day shift 100 cc's evening shift, no output; [DATE], night shift no documentation, day shift no documentation, evening shift continent 3 times with no cc's indicated; [DATE], night shift no documentation, day shift no documentation, evening shift no output; [DATE], night shift no documentation, day shift no documentation, evening shift no output; [DATE], night shift continent 1 time with no cc's indicated, day shift no output, evening shift no output; and [DATE], night shift no documentation, day shift no documentation, evening shift no output. The outputs were not totaled to provide a practitioner with a clear picture of the resident's status. On [DATE] at 12:15 p.m., Surveyor # spoke with the DON. Surveyor # and the DON reviewed the documentation for Resident #3's I&O and acknowledged the lack of documentation. The DON indicated the facility did not have a good tracking system for I&O since becoming computerized. Example #3: Resident #30 was admitted to the facility on [DATE]. On [DATE], Resident #3's physician ordered laboratory work including an ammonia level and an INR (International Normalized Ratio). INR is a laboratory test completed to measure the time it takes for blood to clot and compares it to an average. Surveyor # was unable to locate the laboratory report in Resident #30's clinical record. On [DATE] at 2:00 p.m., Surveyor spoke to the DON and requested the laboratory reports for Resident #30's lab work ordered on [DATE]. On [DATE] at 4:00 p.m., the DON indicated she was unable to find the laboratory reports for Resident #30. The DON indicated the lab work had not been completed as ordered. The DON stated she was unsure why. On [DATE], the physician re-ordered the laboratory tests at which point they were obtained. Resident #30's INR of [DATE] was noted to be within normal limits. Example #4: Resident #32 was admitted to the facility on [DATE]. Surveyor # completed a review of Resident #32's laboratory reports and noted on [DATE], Resident #32's uric acid level was 8.5 mg/dL (milligrams per deciliter). The report notes this level as being "H" or high with the normal range being 2.3 -6.4 mg/dL. A uric acid level is a test to check the level of uric acid in the blood. High blood levels of uric acid could lead to gout. Uric acid is associated with diabetes as well as the development of kidney stones. On [DATE], Resident #32's physician ordered a uric acid level. Surveyor # was unable to locate the laboratory report in Resident #32's clinical record. On [DATE] at 2:00 p.m., Surveyor # spoke to the DON and requested the laboratory report for Resident #32. On [DATE] at 4:00 p.m., the DON indicated she was unable to find the laboratory report for Resident #32. The DON indicated the lab work had not been completed as ordered. The DON stated she was unsure why.

Based on observation, interview, and medical record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical and mental well-being for 1 of 7 residents reviewed for pain control. Resident #3 was admitted to the facility following surgery for [REDACTED]. Facility staff did not: -Properly treat her pain following this surgery. -Assess pain while Resident #3 was being rolled in bed. -Premedicate her before movement, despite the pain assessment indicating that she has pain with movement. -Stop cares when she was demonstrating and verbalizing significant pain during cares. -Consult with the physician regarding pain control before the Surveyor brought it to the facility's attention. -Mention that Resident #3 wore an immobilizer on her left leg (which reduced her pain level when turning in bed) on the CNA care plan, or the pain assessment. This is evidenced by: Resident #3's medical record states that she fell at home on 07/03/12 and sustained a left distal femur (near her knee) fracture, with "significant displacement and angulation" requiring the surgical placement of a rod. She was air-lifted to a larger hospital on [DATE], when she developed acute [MEDICAL CONDITION] due to septic shock secondary to ,[MEDICAL CONDITION].-difficile [MEDICAL CONDITION] (which causes frequent loose stools). She has a history of [DIAGNOSES REDACTED] in her legs, requiring a wheelchair for mobilization, and was on an [MEDICATION NAME] medication, [MEDICATION NAME], at home to treat her [DIAGNOSES REDACTED]. She is alert and oriented. A pain assessment completed on the day of her admission to the facility (07/11/12 at 5:30 p.m.) states that Resident #3 has acute sharp pain in her left leg, and that it hurts worse "when being moved - stationary is fine" and that medication makes her pain feel better. On 07/19/12, the Director of Nursing (DON) told Surveyor that the nurse who completed the assessment no longer works at the facility. The pain assessment did not mention that Resident #3 wears an immobilizer on her left leg. A facility nurse initiated an initial care plan on 07/12/12, and checked a box by the words "PAIN - ALTERED COMFORT" AEB (as evidenced by) recent L hip fx (left [MEDICAL CONDITION]). The numbers 1, 2, and 3 were circled as a pain level goal out of a range of 1 - 10, with 10 being excruciating. There were also check marks in front of the following areas: -Assess/document on pain assessment form -Use pain scale + establish pain level goal -Monitor for non-verbal s/s (signs/symptoms) of pain: groan, grimace, guarding of area, sleeplessness, etc. -Evaluate non-medication pain relief: rest, massage, heat/cold, position/pillows, Other: -Attempt to distract: TV/ music/prayer/relaxation tape/techniques, etc. Other: Resident #3 is in isolation precautions because of the [MEDICAL CONDITIONS], and is incontinent of frequent loose stools, requiring staff to turn her often while in bed. A Physical Therapy evaluation dated 07/12/12 states that while Resident #3 was wearing her immobilizer, she reported 0 out of 10 for left knee pain with movement, and her left knee pain was 10 out of 10 with movement by staff (without the immobilizer). Nurses notes regarding Resident #3's pain state: 07/12/12: (written by the night nurse) "Resident has c/o (a complaint of) pain in her left knee during movement of left leg." There was no plan put into place to pre-medicate Resident #3 before moving her although the physician was contacted to clarify other orders. Resident #3 was given 650 milligrams of [MEDICATION NAME] for a head ache on the night shift. 07/13/12: (written by the night nurse) "@0140 (at 1:40 a.m.) res. (Resident) c/o L (left) leg pain & body pain stating the bed was too hard & she hurt & couldn't get comfortable. Rated pain #8/10, repositioned & given Tylenol (aka [MEDICATION NAME] or APAP), this along with the TV sounds (TV started) & res. was able to fall asleep. Res. states she always has the TV on at noc (night) so she can sleep." Despite her rating her pain an 8/10, the physician was not consulted regarding pain control. 07/14/12: "Resident had c/o restless legs and pain in her left leg during the night. She was given prn APAP 650 mg (milligrams) and [MEDICATION NAME] 10 mg at 2350 (11:50 p.m.) which was "very effective". Resident slept well afterwards and awoke this morning stating that she felt "great". The facility did try putting an air mattress on Resident #3's bed, but she preferred to not have it so it was removed on 07/15/12. She also complained of restless legs on 07/15/12 and [MEDICATION NAME] was administered at 6:15 p.m., which was effective. The facility's annual survey began on 07/17/12. Resident #3 had not received any Tylenol or [MEDICATION NAME] since the above dose on 07/15/12. Nurse's notes on 07/16/12 stated that Resident #3 "refused to have cares done on lower torso this shift, no reason, she just stated no." On 07/17/12 the night shift nurse charted that Resident #3's groin is reddened and zinc protective ointment was applied. "Res. had a pair of orange shorts with a draw string waist line on when had involuntary stool she requested the staff cut them off her repeatedly "don't try to take them off just cut them off" so shorts were cut off & thrown/res. request." There was no further information documented that her refusing lower torso cares were because of pain, or that pain medication was offered. Resident #3 had not had any pain medication for 2 days prior. Resident #3's Admission Medication and Treatment sheet dated 07/11/12 states that she had an order for [REDACTED]. Surveyor reviewed Resident #3's MAR indicated [REDACTED]. Surveyor had expressed a concern about Resident #3's pain regime to the facility on [DATE] while meeting with the DON after the daily exit, noting that Resident #3 had only had [MEDICATION NAME] twice since her admission. Surveyor interviewed the Director of Nursing (DON) by telephone on 07/23/12 at 10:23 a.m. to confirm that resident #3's physician's orders [REDACTED]. The DON stated she would see if there was a new order obtained. The DON telephoned Surveyor back at 11:09 a.m. on 07/23/12, saying that on the original order from the hospital, the physician added "PRN" so that the MAR indicated [REDACTED]. She also agreed that Resident #3's pain was not controlled well, and stated, "I didn't want you to think it was a med error." Surveyor interviewed Resident #3 on 07/17/12 at 12:45 p.m. and again at 5:35 p.m. Surveyor explained that surveyors observe the staff taking care of residents as part of the tasks of the survey, and asked if it would be alright to observe Resident #3 receive her cares. Resident #3 stated that it would be fine, but also stated, "I hope I don't make too much noise for you." Surveyor asked Resident #3 what she meant, and she said that she wished it didn't hurt so much when the staff rolls her in bed. Surveyor asked Resident #3 how her pain control was generally, and she stated, "That's one place where they could improve. I wish I had a special call light. When I put my light on because I didn't get a tea bag, and it's not answered for a half an hour, that's not so bad, but I wish I could have a special call light to let them know that I'm in pain - that would be wonderful." Resident #3's CNA care plan does not mention that she is to wear her immobilizer. The care plan also instructs the CNAs to "report pain to nurse." Surveyor observed Resident #3's personal cares provided by Certified Nursing Assistant (CNA) A, beginning at 7:30 a.m. on 07/18/12. CNA A rolled Resident #3 to her right side. Her immobilizer was not on. She quietly said "ow" when she was turned, and grimaced. CNA A had to roll Resident #3 several times, as she had loose stools each time she was rolled. Resident #3's groin areas, labia, and her buttocks were red and raw from the loose stools, and she had an open area on her left buttock. CNA A stated that he told Licensed Practical Nurse (LPN) D about the raw areas and the open area, and was given Zinc Oxide to apply to these areas. While CNA A turned Resident #3, she continued to say, "oh, that hurts", "ow, ow, hi-hi-hi-hi", "you're twisting my knee". Resident #3 also stated that CNA A is the most gentle of the CNAs, and that "when some of the girls turn me it's excruciating." Resident #3 then said that Tylenol doesn't always work. CNA A continued to roll Resident #3 back and forth to get her clean and to apply the Zinc Oxide, and a clean brief. CNA A did not elicit the help of another caregiver to stabilize the leg during rolling. At times Resident #3 clenched the side rails and clenched her eyes closed, moaning and whimpering quietly. Once while on her left side, Resident #3 called out loudly, yelling, "The knee, the knee, the knee!" CNA A told Resident #3, "You're OK" as he held her on her side. Resident #3 asked him, "Is my foot straight?" and CNA A stated, "It will be shortly." Resident #3 said, "I can feel it's not straight. Put the immobilizer on! It's bad! Ow! Ow! Ow!" When CNA A placed Resident #3's left leg back in the immobilizer, the resident whimpered and grimaced, and said, "It's pulling on my knee - Ow - it's my foot - straighten my foot! It still hurts big time!" Surveyor asked CNA A if Resident #3 could have some pain medication. CNA A responded, "I have no idea; I'm not a nurse." And proceeded with his cares. Once CNA A put pillows under Resident #3's legs she stated, "Oh that feels better" but Resident #3 continued to clench her eyes shut and hold onto the side rails. Surveyor asked Resident #3 if she would be willing to be premedicated before her cares, and she said, "Oh that would be so nice. Do you think they could do that?" Following the above observation, Surveyor asked LPN D if Resident #3 could have something for pain. She stated, "I don't know - I'm not passing pills today. I'll see if the other nurse can give her something." LPN D had worked a double shift the previous day, and had not given any Tylenol or [MEDICATION NAME] to Resident #3. Surveyor informed LPN D that Resident #3 has significant pain with turning, and asked if the nurses do their pain assessments while residents are being moved. LPN D responded, "Honestly, in the real world, when I have med pass to do besides treatments, I don't have time to watch cares." Surveyor asked if the CNAs know that they should report to the nurses when residents are having pain. LPN D stated, "They all know that." LPN D told Surveyor at 9:15 a.m. that Resident #3 had refused Tylenol when it was offered, and that she had a call out to Resident #3's physician, and said, "I think they'll tell me the [MEDICATION NAME] is doing it (treating the pain)." (Note that Resident #3 had only 2 doses of [MEDICATION NAME] since admission.) LPN D later told Surveyor that she heard back from the physician, who "did not want to schedule anything for pain" for Resident #3. Surveyor asked LPN D if she advocated for the resident, and if she described the level of her pain to the physician, and LPN D stated that the physician said that Resident #3 just "doesn't like to move." The physician did order [MEDICATION NAME], 50 mg, three times a day, as needed, of which Resident #3 received a dose at 11:00 a.m. on 07/18/12. Surveyor asked CNA A at 8:10 a.m. on 07/18/12 if Resident #3 usually hurts like that during cares, and CNA A responded, "Always!" After the daily exit on 07/18/12, Surveyor met with the DON and Dietary Manager I, and explained the above observations and the concerns with the facility's lack of pain control for Resident #3. The DON stated that she was unaware that Resident #3 had been having pain. Also, Surveyor asked the DON if she has recently looked at Resident #3's raw peri area, and the DON stated that she had not. The DON stated she knew how important it is to prevent pain. The facility's Resident Roster Matrix which was updated on 07/17/12, does not indicate that Resident #3 has any issues with pain/comfort.

Based on observation, interview and record review the facility failed to assure each resident received adequate supervision and assistive devices to prevent accidents for 4 of 5 residents reviewed who had a history of [REDACTED]. Resident #2, who had a recent history of falling which resulted in hospitalization for a traumatic brain injury, was not provided with appropriate supervision and or assistive devices to prevent accidents. Either Resident #2's pressure alarm had not been turned on and Resident #2 was able to get up and ambulate without staff knowledge or Resident #2 was escorted to the bathroom without a gait belt and made to wait by the doorway while a CNA cleaned the toilet. One of these two scenarios resulted in a fall which caused a head injury requiring staples to close the wound. Resident #10 who is at risk for falls, was observed with his pressure alarm pad not connected to the alarm box as he returned from breakfast. Resident #1 has a history of falls. Resident #1 fell on [DATE] and 05/13/12; no root cause analysis was assessed and no new interventions were added to prevent further falls. Resident #6 had a history of [REDACTED]. This is evidenced by: The facility's policy, "High Risk for Falls Program" states in part, "Implementation Steps: 1. Identify residents with potential for repeat falls... 4. The interdisciplinary team or established Fall Prevention Team will review the resident assessment and Care Plan and document fall prevention approaches and interventions monthly and as needed... 6. If a fall occurs, assessment and updated interventions will be discussed and documented by the interdisciplinary team or fall prevention team." 1. Resident #2 was admitted to the facility on [DATE] following a closed head injury, intracerebral bleed that occurred when Resident #2 fell from a ladder at home. Resident #2's [DIAGNOSES REDACTED]. Resident #2 is alert and oriented and able to make independent decisions. Surveyor interviewed Resident #2 on 07/17/12 at 1 p.m. Resident #2 stated that he had a fall that sent him back to the hospital. Resident #2 stated, "They kinda blamed me for the fall, but I don't agree." When asked to elaborate Resident #2 continued, "When I fell , the girl told me I could do it, and that I needed to do more on my own now. She took me to the bathroom and didn't have me wear a gait belt. She walked with me to the bathroom and when she opened the door to the bathroom, the toilet it was dirty, it had poop on it, and she didn't want me to sit in that. She had me just wait, standing by the bathroom door, as she cleaned the toilet. She said I needed to wait till she got it cleaned up before I could sit down. As she was cleaning, my legs got weak. I asked her if I could just use it anyway but she didn't want me to and then my legs gave out and I fell . I don't remember anything after I fell . When I got back here, they said I should have waited for her to help me, but I did. I wonder if she would have just let me sit down, use the toilet or if she had a gait belt on me if I would have fallen. I don't think she did everything right." Surveyor reviewed Resident #2's medical record on 07/17-19/12. Upon admission Resident #2 was identified as being at risk for falls. Resident #2's care plan states under problems "impaired physical mobility, increased risk for injury." Facility staff implemented a pressure alarm in bed and chair, and a mat on the floor at bedside in order to help prevent injuries. At the time of the fall Resident #2's care plan directed him to transfer with assistance of 1 staff. According to nurses notes on 07/12/12 at 6:10 a.m. "was in bed resting, apparently got up out of bed and began walking to the bathroom unassisted then fell " under the heading Alarms is "Resident had a pressure alarm on his bed but per CNA it did not sound and was found to be turned off. Resident had a mat on the floor but it had been moved by the CNA just minutes prior to the event."... "EFFECTS: resident struck back of his head on the floor resulting in significant bleeding. He c/o pain to his head." ... Under the heading Describe event: "CNA reported: CNA (CNA's First name) reported that she went to resident's room in response to his call light and that she was going to assist him to the bathroom so moved his floor mat, then opened the bathroom door. Upon opening the bathroom door she noticed that it required some cleaning. As she was cleaning in the bathroom she heard a noise and when she turned she saw the resident walking towards the bathroom then start falling, but she was unable to reach him in time to catch him." Under type of injury, "noted blood pooling around resident's head as he was laying on his back on the floor, The back of his head was not observed by RN but it is reasonable to expect that there was a laceration and hematoma present. Resident was sent to ER via ambulance." Interventions: "Current pressure alarm had an on/off switch requiring it to be manually turned on. This alarm was removed and replaced with a pressure alarm which reactivates automatically when the resident sits on the pressure pad part of the alarm system." A post fall investigation includes a statement from the CNA L that states "I went to "Resident #2's first name" room to take him to the bathroom as his light was on. I turned off his light and he sat up I moved the floor mat, and opened the bathroom door. The toilet was covered in dried on BM(bowel movement). I told "Resident #2's first name" to wait while I cleaned it off, I figured the bed alarm would go off if he got up. As I finished the toilet seat I heard "Resident #2's first name" walking into the bathroom by himself, no gait belt or shoes. Right as I turned and saw him, he was already falling. I went to catch him, but it was too late, he fell straight over. (Another CNA's name) heard and got the nurse, (Nurse's first name) immediately. "By then I was wondering how he had gotten up w/o (without) my knowledge. His bed alarm was turned "off ". He for sure hit his head, as it was bleeding. He stayed conscious the entire time and was talking to us saying he hurt all over." A note from RN M on the post fall investigation report indicates under resident's response to "why do you think you fell ?" I did not ask him at the time. I heard later that while at the ER(emergency room ) he told his wife that an aid was taking him to the BR(bathroom) and he was standing in the doorway waiting for her to clean in the BR and that he just couldn't stand any longer." Surveyor interviewed RN M at 7 a.m. on 07/19/12 related to the fall. RN M was the nurse on duty at the time of Resident #2's fall. RN M showed Surveyor the position Resident #2 was in when she first observed him the floor. RN M stated Resident #2's feet were in the bathroom and his body protruded from the bathroom at an angle into the room. The position Resident #2's feet were at least 6 inches into the bathroom. RN M stated his head was laying in a pool of blood when she arrived to the room. RN M stated with his previous traumatic brain injury she knew it could be very serious and so she called 911 right away. RN M stated she did not move Resident #2 at all. When asked if Resident #2 was reliably interviewable RN M said yes, when asked if she had ever known Resident #2 to tell stories that were not true, RN M stated "No." Based on CNA L's initial statement, the facility gave the night CNA who had last toileted Resident #2 a written warning for not turning back on Resident #2's pressure alarm. As a result of the fall. Resident #2 was seen in the emergency room and then hospitalized . Resident #2 was readmitted to the facility on [DATE] with staples at the back of his head, which are to be removed on 07/19/12. Resident #2 has complained of pain related to the staples and has had increased dizziness and nausea. Resident #2 now requires the assistance of 2 for transfer and ambulation. Surveyor was given a statement from the NHA on 07/19/12 which indicates that as a result of conflicting information between the resident and staff statements CNA L will be suspended, and required to meet with administration prior to reporting for duty. Surveyor was unable to find conclusive evidence to determine weather the night CNA forgot to turn on the alarm as CNA L claimed, or weather CNA L walked Resident #2 to the bathroom without a gait belt and made him wait to use the toilet as Resident #2 reported, but either of the actions resulted in the fall. 2. Resident #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] stated the resident needs extensive assistance with activities of daily living. The fall risk assessment dated [DATE] scored the resident at a 10 and on 05/13/12 the resident was scored as a 8. A total score of 10 or above represents high risk. A restraint/device assessment was completed on 02/15/12 and 05/13/12 documenting the resident uses a pressure alarm in bed/chair. A review of Resident #10 nursing notes indicate a potential for falls. Notes indicate that resident #10 has a pressure alarm in bed and chair. He transfers with assist of 1 person and EZ stand and ambulates with gait belt, wheeled walker and assist of 2. The care plan indicates a problem dated 3/6/2012 of a potential for injury/falls. The goals box has hand written in "pressure alarm bed and chair". The CNA care plan with an "update 7/18/2012" states resident #10 is to have a pressure alarm in bed and chair. On 07/19/12 at 8:54 a.m. Surveyor observed Resident #10, in his wheelchair, being transported out of the elevator and down the hall towards his room. The cord from Resident #10's pressure alarm pad was dangling over the handlebar on the back of his wheelchair. No alarm box was present on the wheelchair. Surveyor followed Resident #10 as he was transported by CNA S down the hall to his room. Surveyor interviewed CNA S who entered the bedroom with Resident #10. Surveyor explained that Resident #10 was observed going down the hall without his alarm box attached, and CNA S stated she just retrieved the alarm box and applied it to the alarm pad. The DON was also present for this interview. At 9:55 a.m. Surveyor spoke with the DON about the above observation, she stated she had followed up with the staff who had gotten Resident #10 up this a.m and that the she stated she had just forgotten to put it on this morning. 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the Minimum Data Set ((MDS) dated [DATE] Resident #1 was cognitively impaired, required extensive assistance with all activities of daily living. On 07/18/12 Surveyor observed Resident #1 transferred via hoyer lift and assistance of two staff. On 11/06/11 a pull tab alarm in bed and chair were added to the resident's care plan. On 12/16/11 a self release seat belt in the wheelchair was added and a pressure alarm was added to the wheelchair and the bed. The nurses notes dated 04/17/12 stated Resident #1 fell from bed and was found on floor with alarms sounding at 1:00 a.m. The resident received no injuries from the fall. The fall investigation report did not include any new interventions to prevent further falls. No new interventions were added to the resident's care plan or the Certified Nursing Assistant's (CNA) sheets. The nurses notes dated 05/08/12 at 4:00 a.m. stated Resident #1 fell from bed and was found on the floor sitting between the bed and the wheelchair. The resident had pain in the buttocks and was transferred to the emergency room . The resident was examined and found to have no fractures. The resident's care plan was updated with the use of a scoop mattress and a mat on the floor next to the bed. The nurses notes dated 05/13/12 stated Resident #1 fell from bed with the pull tab alarm sounding. The resident had no injuries. No new interventions were added to the resident's care plan or to the CNA sheets to prevent further falls. The nurses note dated 06/06/12 at 4:50 p.m. resident fell out of bed onto the fall mat. The investigation report stated the pull tab alarm did not alarm as the string was not pulled to activate and the pressure alarm was connected but not turned on. The resident was not injured. The care plan was updated to check alarms for functioning every shift and a grab bar was added to the bed. On 07/19/12 at 9:05 a.m. Surveyor discussed the falls with the Director of Nursing (DON). Surveyor questioned the DON as to what corrective actions were taken after the falls on 04/17/12 and 05/13/12 and where was the documentation of the root cause analysis of the falls. The DON reviewed the resident's chart and fall investigation reports and could find no documentation. The DON stated nurses should update the care plan with new interventions after a fall. The DON stated in the morning department head meeting, the facility reviews falls. No further information was provided to the surveyor. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. failure, anxiety, dementia with agitation and chronic obstructive pulmonary disease. Resident #6 has a history of falls one dated 06/21/2012 for a fall from bed with no injury and the facility added a new intervention of a pressure alarm in bed. On 07/07/2012 fall from bed with injury and the facility did not add new interventions to prevent future falls. Surveyor on 07/19/2012 reviewed facility policy for High Risk for Falls Program. In the section of Implementation Steps: 6. If a fall occurs, assessment and updated intervention will be discussed and documented by the interdisciplinary team or fall prevention team. Surveyor on 07/18/2012 reviewed Resident #6 ' s medical record. Nurse ' s notes dated 06/21/2012 at 10:57 p.m. Resident #6 sustained a fall from his bed at 5:00 p.m. with no apparent injury. Review of Resident #6 ' s care plan Potential for injury/falls indicated a new intervention hand written in dated 06/21/2012 of a pressure alarm and pull tab and motion alarm in bed; seat belt alarm in w/c (wheelchair). Mat on floor when in bed. Resident #6's medical record indicated a fall assessment dated [DATE] was rated at 15 for high risk for falls. Resident #6 nurse's note dated 07/07/2012 at 8:55 p.m. indicated Resident #6 sustained a fall from his bed at 5:30 p.m. with injury to his chin. Physician was notified. Interventions: continue to observe Care Plan reviewed/update. On 07/09/2012 at 1:37 p.m. physician fax order received to monitor until area on chin is healed. On 07/09/2012 at 1:46 p.m. physician fax order received to monitor bruise on her cheek until healed. Surveyor on 07/18/2012 reviewed Resident #6's care plan for Potential for injury/Falls. No new interventions or new approaches where indicated related to the fall from 07/07/2012. Surveyor 0n 07/19/2012 reviewed post fall investigation report for Resident #6's fall on 07/07/2012, did not indicate new interventions. Interview with Director of Nurses (DON) on 07/19/2012 asking for any additional information or interventions that may have been added relate to Resident #6's 07/07/2012 fall. On 07/19/2012 at 2:40 p.m. DON indicated no new interventions were put into place on 07/07/2012 for falls. DON indicated that she and the Nursing Home Administrator (NHA) added intervention for prevention of falls to the care plan today for Resident #6.