Every finding on record at Lafayette Manor

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 3 of 3 residents (R8, R42, and R44) reviewed for falls. R8 had a history of falls including one that resulted in a rib fracture. The facility did not complete a fall investigation, a thorough root cause analysis, or ensure that care planned interventions were appropriate and in place for R8.R42 had a fall that was not thoroughly investigated for a root cause and an intervention was not put in place to prevent further falls. The facility did not complete ongoing monitoring for R42 after his fall.R44 had a fall that was not thoroughly investigated for a root cause and an intervention was not put in place to prevent further falls.This is evidenced by:The facility policy Accidents and Supervision, dated 1/6/26, includes: The resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff . are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff d. Documenting interventions (e.g., .care plans for the individual resident) e. Ensuring that the interventions are put into action f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks. i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new interventionsThe facility policy Fall Procedure, dated 1/26, includes: Staff shall assess for risk, provide preventative measures, and address falls in a safe and professional manner. Fall risk assessment: 2) Upon assessment, staff will provide needed intervention to prevent fall. Intervention is added to care plan. Fall incident: 1) When a fall is discovered, floor nurse will complete an immediate initial evaluation of resident. Evaluation is to include: a. Head to toe check for injury b. Vital signs c. ROM (Range of Motion) of all extremities: note any deformities or changes from baseline. d. Pain check 2) All unwitnessed falls and noted head injuries on witnessed falls are to include neuro checks including: a. LOC (Level of Consciousness): note any change from baseline b. Pupil response c. Hand grasp: note change from baseline 3) Neuro checks and follow up is to be completed. 4) Fall is to be reported immediately to the charge nurse. Additionally, any changes in neuro checks should also be reported to charge nurse immediately. 7) Notify DON (Director of Nursing) and NHA (Nursing Home Administrator) 8) Documentation: a Fall note b. Neuro check (if applicable) c. Pain assessment d. Fall risk assessment e. Update fall care plan of immediate interventionExample 1:R8 admitted to the facility on [DATE] with diagnoses including dementia and need for assistance with personal care.R8's Brief Interview for Mental Status (BIMS) on 8/22/25 has a score of 10, indicating R8 has moderate cognitive impairment.R8's Fall Risk Evaluation, dated 8/19/25, has a score of 24, indicating R8 is at risk for falls.R8's comprehensive care plan includes:Focus: Potential for falls r/t (Related To) dementia, self care deficit, weakness, balance deficit, recent h/o (History Of) falls, incontinence, intermittent pain, medications received. Last revised on 5/26/24. Goals: resident will have tab and/or cushion alarm for safety r/t wandering and new fall. Last revised on 11/4/25. Interventions: Ensure bed is kept in lowest position (Initiated 6/12/24). Ensure call light is available to Resident (Initiated 6/12/24). If fall occurs, alert provider (Initiated 5/21/24). If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol (Initiated 5/21/24). Utilize devices as appropriate to ensure safety (i.e. bed mats, sensor alarms, etc.) Tab and/or pressure alarms and floor mat while in bed (Initiated and revised on 6/12/24). Assistive devices: Walker, manual wheelchair, and gait belt (Initiated and revised on 5/21/24)R8's nurse progress notes, dated 9/5/25 at 10:51 AM, written by RN G (Registered Nurse), states: Late entry for 9-4-25 at 0900 (9:00 AM) resident was headed to thpy (Therapy) session with thpy staff and had informed them earlier that he had missed sitting back down in w/c (Wheelchair) after going to the BR (Bathroom) and sat on the floor during the night around 0400 (4:00 AM). He stated night shift staff had assisted him and that he was not hurt and did not hit his head. Resident had vitals checked and WNL (Within Normal Limits). Will monitor for changes updated residents wife and Admin staff, and provider updated.Of note, R8's medical record does not have a fall report for R8's reported fall on 9/4/25. R8 did not have neuro checks completed. R8's reported fall was not thoroughly investigated to find a root cause and no interventions were put in place to prevent future falls.On 3/24/26 at 11:28 AM, Surveyor interviewed RN G regarding falls. RN G indicated if a resident falls there is a process to follow that includes assessing for injury, obtaining vital signs and neuro checks, and notification to DON, the provider and POA (Power of Attorney). RN G indicated if a fall is unwitnessed or a resident hits their head, neuro checks should be completed for 3 days along with monitoring for injuries every shift for 3 days. RN G indicated all the information should be documented in the resident's medical chart. Surveyor asked RN G what is the process if a resident reports a fall but staff did not observe it or assist the resident getting back up. RN G indicated if a resident reports a fall, staff should treat the report as an actual fall and follow the facility policy. Surveyor asked RN G about R8's 9/4/25 fall. RN G stated she thought it was hearsay and did not complete a fall investigation, neuro checks, or implement a new intervention. RN G indicated she did not treat R8's 9/4/25 report of falling as an unwitnessed fall but should have.On 3/25/26 at 11:22 AM, Surveyor interviewed DON B (Director of Nursing) about falls. DON B indicated if a resident reports a fall, the facility should treat that report as an actual fall and follow the facility's fall process. DON B indicated R8's reported fall on 9/4/25 should have been treated as an actual fall and was not. DON B indicated R8's fall was not thoroughly investigated, a root cause was not completed and no new interventions were put into place to prevent further falls. DON B indicated continued monitoring after R8's fall was not completed.R8's 9/9/25 fall report includes the following: Unwitnessed fall Date 9/9/25 13:15 (1:15 PM)Incident Location: Resident's roomIncident Description: Resident was found on the floor at the end of bed propted [sic] up on his hand and knees and was alert. Housekeeper was staff person that saw resident as she was passing by the room door. Resident was able to be assisted back into w/c (Wheelchair) and nurse was informed of resident being on the floor and was then assessed. Neuro checks were initiated as fall was unwitnessed. BP (Blood Pressure) was elevated the first 3 of 15 min (Minute) checks. Resident has hypertension as diag (Diagnosis). Will relay this to provider. Resident Description: Resident told the staff housekeeper he was looking for his hat and then said he was trying to put on a jacket and looking for it. Immediate Action Taken: Neuro checks initiated and everything WNL (Within Normal Limits) except his BP was elevated x 3. BP now within parameters. A skin check was done and he had red abrasion areas on lower right posterior rib cage. Area palpated and he denied increased pain at any specific area with palpation but had general soreness of lower right rib. Offered to get a x-ray set up for rib but he declined and stated he wanted to wait until tomorrow to see how he feels. He doesn't think its fractured. Wife has been informed of same and she stated it is ok to wait on any x-ray and see how he feels later. Resident was given prn (As Needed) Tylenol for pain around 1415 (2:15 PM). Predisposing Environmental Factors: Other (Describe)Other Info: w/c has anti- roll brakes but one side wasn't fitting tight per resident. Maint (Maintenance) was informed to check for a repair.R8's nurse progress notes include:9/9/25 4:49 PM, Resident has been transported to the ER (Emergency Room) for eval (Evaluation) of right rib pain.9/9/25 9:53 PM, 1932 (7:32 PM) phone call from [Name] at the ER; she states that resident does have a right rib fracture. 2000 (8:00 PM)-resident returned to the nursing home.9/10/25 7:40 AM, Received the response from provider to continue to monitor resident s/p (Status Post) fall.9/10/25 2:53 PM, Resident has been participating in thpy sessions today and was able to propel self about in his w/c with some assist at times to use the bathroom and transfer in and out of bed. Had taken a prn pain med this morning with relief and was offered again but declined. Appetite was good for breakfast as he slept in until aprox [sic] 0900 (9:00 AM). He has been taking naps per his usual routine. 9/11/25 10:48 AM, Resident was up at usual time this morning and had c/o (Complaint Of) soreness/stiffness in right side but had a prn pain med at night that helped. He took prn Tylenol at breakfast and then went to thpy session. Mood is cheerful and he is more talkative today. 9/11/25 2:43 PM, Residents [sic] wife here to visit this afternoon and he is now out of room and socializing with staff. Given cup of coffee per request.On 3/23/26 at 8:20 AM, Surveyor observed R8 in his room, laying in bed. R8's bed height was not in the lowest position. R8 did not have floor mat in his room. R8 did not have a tab or pressure alarm in his room.On 3/24/26 at 10:08 AM, Surveyor observed R8's room and R8's Certified Nursing Assistant (CNA) Kardex. R8's CNA Kardex includes the fall interventions of ensure bed is kept in lowest position and tab and/or pressure alarms and floor mat while in bed. R8 did not have a floor mat in his room. R8's bed was not in the lowest position. R8 did not have a tab or pressure alarm.On 3/24/26 at 11:45 AM, Surveyor interviewed CNA H (Certified Nursing Assistant). CNA H indicated CNAs look at residents' CNA Kardex to determine interventions for fall prevention. Surveyor and CNA H observed R8's room. CNA H indicated R8's fall interventions were not in place. Surveyor and CNA H observed R8's bed was not in the lowest position, there was no floor mat and no alarms.On 3/25/26 at 10:47 AM, Surveyor interviewed DON B (Director of Nursing) about falls. DON B indicated if a resident falls, the staff should follow the facility's fall procedure which includes neuro checks for unwitnessed falls, assessing for injury, notifying the provider and POA. DON B indicated the IDT (Interdisciplinary Team) reviews the falls, looks at current interventions, implement new interventions and update the care plans with the changes. DON B indicated ongoing monitoring should be completed every shift for 3 days after a resident has a fall. DON B indicated if R8's fall on 9/4/25 would have been thoroughly investigated to find a root cause and interventions put in place, it may have prevented R8 from falling on 9/9/25.Example 2:R42 admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia, and mild cognitive impairment.R42's Brief Interview for Mental Status (BIMS), dated 2/24/26, has a score of 12, indicating R42 has moderate cognitive impairment.R42's Fall Risk Evaluation, dated 11/28/25, has a score of 15, indicating R42 is at risk for falls.R42's comprehensive care plan includes:Focus: Potential for falls r/t (Related To) dementia, TBI (Traumatic Brain Injury), weakness, balance deficit.(Initiated and revised 2/17/24)Interventions: Anticipate and meet the resident's needs (Initiated 2/17/24). Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (Interdisciplinary Team) as to causes (Initiated 2/17/24). Follow facility fall protocol (Initiated 2/17/24). Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.(Initiated 2/17/24).R42's nurse progress note include:12/2/25 7:09 PM, Resident was found sitting on his buttocks on the floor propped against the bed. Resident stated he was trying to get in the bed. Denies hitting head, stated all I hit was the floor. Resident denies any pain at this time. No skin tears or bruises noted. Resident vitals 134/80, 90, 97.3, 18, 97% room air. Resident was educated on the importance of using the call light and voiced understanding. At 1839 (6:39 PM) administrator [Name] notified, 1850 (6:50 PM) residents POA [Name] notified. 12/3/25 3:23 PM, Resident was up at usual times today and able to propel self about unit in w/c (Wheelchair) with no new c/o (Complaint Of) pain. Vitals and neuro checks stable.Of note, continued monitoring of R42 after his fall was not documented. R42's assessments include Neurologic Focused Evaluation, dated 12/2/25 6:58 PM. Of note, the Neurologic Focused Evaluation contains one set of neuro checks.On 3/24/26 at 11:28 AM, Surveyor interviewed RN G regarding falls. RN G indicated if a resident falls there is a process to follow that includes assessing for injury, obtaining vital signs and neuro checks, and notification to DON, the provider and POA (Power of Attorney). RN G indicated if a fall is unwitnessed or a resident hits their head, neuro checks should be completed for 3 days along with monitoring for injuries every shift for 3 days. RN G indicated all the information should be documented in the resident's medical chart.On 3/25/26 at 10:47 AM, Surveyor interviewed DON B (Director of Nursing) about falls. DON B indicated if a resident falls, the staff should follow the facility's fall procedure which includes neuro checks for unwitnessed falls, assessing for injury, notifying the provider and POA. DON B indicated the IDT (Interdisciplinary Team) reviews the falls, looks at current interventions, implement new interventions and update the care plans with the changes. DON B indicated ongoing monitoring should be completed every shift for 3 days after a resident has a fall. DON B indicated R42's fall was not thoroughly investigated, a root cause was not completed and no new interventions were put into place to prevent further falls. DON B indicated continued monitoring after R42's fall was not completed.Example 3:R44 admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and fracture of left and right femur.R44's Brief Interview for Mental Status (BIMS), dated 1/16/26, has a score of 0, indicating R44 is severely cognitively impaired.R44's Fall Risk Evaluation, dated 10/26/25, has a score of 10, indicating R44 is at risk for falls.R44's comprehensive care plan includes:Focus: Risk for falls (Initiated 7/16/25)Goal: Resident will be free of falls (Initiated 7/16/25)Interventions: Determine Residents ability to transfer (Initiated 7/16/25). If fall occurs, alter provider (Initiated 7/16/25).R44's Fall report includes:Un-witnessed fall Date 1/13/26 18:10 (6:10 PM)Incident Location: Dining RoomIncident Description: CNA (Certified Nursing Assistant) came and got nurse and resident was noted to be on the floor lying on her left side holding her head. Resident broda chair back wheels were off the ground and the resident calves were on the foot rest of chair. Resident is noted to have an egg size knot to the left upper forehead. When resident was asked if she was hurt she would reply with my head. Admin [Name], [Name] hospice and residents POA (Power of Attorney) [Name] notified. EMS (Emergency Medical Services) was called and report called into [Name] ER (Emergency Room). Immediate Action Taken: Description: Resident was assisted off the floor and into her chair, vitals were taken . Resident was taken to her room to be cleaned up. Predisposing Environmental Factors: NonePredisposing Physiological Factors: NonePredisposing Situation Factors: None(Of note: R44 had a fall that was not thoroughly investigated for a root cause, and an intervention was not put in place to prevent further falls.)On 3/25/26 at 10:47 AM, Surveyor interviewed DON B (Director of Nursing) about falls. DON B indicated if a resident falls, the staff should follow the facility's fall procedure which includes neuro checks for unwitnessed falls, assessing for injury, notifying the provider and POA. DON B indicated the IDT (Interdisciplinary Team) reviews the falls, looks at current interventions, implement new interventions and update the care plans with the changes. DON B indicated ongoing monitoring should be completed every shift for 3 days after a resident has a fall. DON B indicated R44's fall was not thoroughly investigated, a root cause was not completed and no new interventions were put into place to prevent further falls.

Based on interview and record review, the facility did not establish and 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 infection. This has the potential to affect the census (42).The facility staff line lists do not monitor specific symptoms.Evidenced by:The facility policy entitled Infection Surveillance, dated 1/05/26, states, in part: . Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections.Definitions: Infection surveillance refers to an ongoing systemic collection, analysis, interpretation, and dissemination of infection-related data.Policy Explanation and Compliance Guidelines: .6. The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: . i. signs and symptoms.13. Data to be used in the surveillance activities may include, but are not limited to: . i. Documentation of signs and symptoms in clinical record.The facility provided staff surveillance line lists for January 2026, February 2026, and March 2026. The line lists include vague symptoms.The January 2026 staff line lists show there were four staff call ins. The recorded symptoms on the line list includes: not feeling well, sick, and not feeling good.Of note: These are not specific symptoms for the facility to track and be able to determine return to work dates correctly.The February 2026 staff line list shows three staff called in with symptoms recorded as not feeling well and sick.Of note: These are not specific symptoms for the facility to track and be able to determine return to work dates correctly.The March 2026 staff surveillance list shows three staff called in with vague symptoms recorded as feeling sick, sick, don't feel well, and flu-like symptoms.Of note: These are not specific symptoms for the facility to track and be able to determine return to work dates correctly.On 3/25/26 at 9:54 AM, Surveyor interviewed IP I (Infection Preventionist) and asked should the facility be tracking specific symptoms on the staff and resident surveillance lists? IP I indicated yes. Surveyor reviewed the vague symptoms sick, not feeling well, and flu-like symptoms with IP I and asked if the symptoms were specific to illness. IP I indicated no. Surveyor asked if the facility would need specific symptoms to track illnesses and determine return to work dates. IP I indicated yes.On 3/25/26 at 10:49 AM, Surveyor informed NHA A (Nursing Home Administrator) of concerns with infection control. Surveyor reviewed the symptoms recorded on the staff line lists with NHA A. NHA A agreeable with needing specific symptoms to track illnesses and determine return to work dates for staff.

Based on observation, interview, and record review, the facility did not ensure other alternatives were tried prior to installing/utilizing bed rails, failed to accurately assess the risk of possible entrapment, failed to obtain informed consent for bed rails, failed to obtain physician orders for bed rails, failed to care plan the need and use of bed rails, failed to obtain risk versus benefits for bed rails, failed to measure the gap between the mattress and bed rails for entrapment, and failed to ensure the bed dimensions were appropriate for the resident's size and weight for 9 of 14 residents (R30, R17, R6, R5, R2, R27, R8, R42, R44) reviewed for bed rails. R30 did not have physician order's for bed rails, did not have measurements for gaps with the mattress and bed rails, did not have a bed rail assessment for entrapment, did not have proof of risk vs. benefits for bed rails, did not have ongoing monitoring or audits of bed rails, did not have alternatives tried prior to installing bed rails, there was no evidence that bed dimensions were based on resident's size and weight, no adherence to manufacturer's guidelines, and bed [NAME] were not included on R30's care plan. R2 did not have physician order's for bed rails, did not have measurements for gaps with the mattress and bed rails, did not have a bed rail assessment for entrapment, did not have proof of risk vs. benefits for bed rails, no ongoing monitoring or audits of bed rails, no alternatives tried prior to installing bed rails, no evidence that bed dimensions were based on resident's size and weight, no adherence to manufacturer's guidelines, and bed [NAME] were not included on R2's care plan. R27 did not have physician order's for bed rails, did not have measurements for gaps with the mattress and bed rails, did not have proof of risk vs. benefits for bed rails, no ongoing monitoring or audits of bed rails, no alternatives tried prior to installing bed rails, no evidence that bed dimensions were based on resident's size and weight, no adherence to manufacturer's guidelines, and bed [NAME] were not included on R27's care plan. R6 has grab bars on her bed. The facility did not attempt alternatives to the grab bar, assess for entrapment or risk versus benefits, or obtain consent for the use of grab bars. R8 has grab bars on his bed. The facility did not attempt alternatives to the grab bar, assess for entrapment or risk versus benefits, or obtain consent for the use of grab bars. R42 has grab bars on his bed. The facility did not attempt alternatives to the grab bar, assess for entrapment or risk versus benefits, or obtain consent for the use of grab bars. R44 has grab bars on her bed. The facility did not attempt alternatives to the grab bar, assess for entrapment or risk versus benefits, or obtain consent for the use of grab bars. R17 has grab bars on the bed. The facility did not have evidence of a safety assessment and the grab bars were not care planned. R5 has grab bars on the bed. The facility did not have evidence of an assessment, risk versus benefits and the grab bars were not care planned. Example 1: Facility policy, titled, Proper Use of Bed Rails, dated 1/5/22 with last review date of 1/6/26, states, in part: Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Policy Explanation and Compliance Guidelines: Resident Assessment: 1. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: . b. Size and weight. h. Ability to toilet self safely; i. Cognition. k. Mobility (in and out of bed); l. Risk of falling. 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails. Examples of the potential risks with the use of bed rails include: a. Accident hazards (e.g. falls, entrapment). 4. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. Informed Consent: 6. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily. 7. The information that the facility should provide to the resident, or resident representative includes, but is not limited to: a. What assessed medical needs would be addressed by the use of bed rails; b. The resident's benefits from the use of bed rails and the likelihood of these benefits; c. The resident's risk from the use of bed rails and how these risks will be mitigated. 8. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail. Appropriate Alternatives: 9. The facility will attempt to use appropriate alternatives prior to installing or using bed rails. 10. Alternatives that are attempted should be appropriate for the resident. 11. If no appropriate alternatives are identified, the medical record should include evidence of the following: a. Purpose for which the bed rail was intended and evidence that alternatives were tried and were not successful. b. Assessment of the resident, the bed, the mattress, and rail for entrapment risk (which would include ensuring bed dimensions are appropriate for resident size/weight), and c. Risks and benefits were reviewed with the resident or resident representative, and informed consent was given before installation or use. Installation and Maintenance of Bed Rails: 12. The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes: a. Checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible. b. Ensuring that the bed's dimensions are appropriate for the resident by: i. Confirming that the bed rails are appropriate for the size and weight of the resident using the bed; ii. Installing bed rails using the manufacturer's instructions and specifications to ensure a proper fit; iii. Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment; iv. Ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident's head or body. v. Checking bed rails regularly to make sure they are still installed correctly, and have not shifted or loosened over time. c. Observing ongoing precautions. and increasing resident supervision, especially with the use of air-filled mattresses or therapeutic air-filled beds that may present a different entrapment risk than rail entrapments. D. Conducting routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. Ongoing Monitoring and Supervision: 15. The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan, including, but not limited to, the following information: a. The type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation and monitoring. c. Ongoing assessment to assure that the bed rail is used to meet the resident's needs; d. Ongoing evaluation of risks. 16. Responsibilities of ongoing monitoring and supervision are specified as follows: b. A nurse assigned to the resident' will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly. d. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails. R30 was admitted to the facility on [DATE] with a diagnosis of Huntington's Disease (genetic disorder that causes the nerve cells in the brain to decay). R30's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/6/26 indicates R30 has a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating, R30 has severe cognitive impairment. Section GG of R30's MDS indicates that R30 is totally dependent on staff for all Activities of Daily Living (ADLs) including eating, toileting hygiene, bathing, dressing, transferring, and rolling in bed from side to side. R30 was assessed on 2/4/25 to be at risk for falls. Surveyor conducted record review and noted R30 did not have a physician order's for bed rails, did not have measurements for gaps with the mattress and bed rails, did not have a bed rail assessment for entrapment, did not have proof of risk vs. benefits for bed rails, did not have ongoing monitoring or audits of bed rails, did not have alternatives tried prior to installing bed rails, there was no evidence that bed dimensions were based on resident's size and weight, no adherence to manufacturer's guidelines, and bed [NAME] were not included on R30's care plan. A review of R30's nursing progress notes, includes the following: On 7/15/25: Resident was noted to be very restless early this morning per the night shift and then around 0645 (6:45 AM) staff were in to check on her and she had both legs over the edge of the bed on side closest to the hall door. Resident's torso was on bed yet so she was repositioned and this was reported to the hospice staff today when here and they have updated hospice staffing looking into continued use of the air mattress on bed. Was passed on to the oncoming shift to monitor for safety. On 8/11/25: This writer noted tonight that resident's rail was off her bed tonight when this writer went in to give resident her meds. A form was filled out for the maintenance department on resident's bed rail. On 3/24/26 at 8:26 AM, Surveyor observed R30 in bed with side rails and an air mattress. R30 was unable to answer any questions about her side rails. On 3/25/26 at 9:00 AM, Surveyor interviewed LG J (Legal Guardian) about R30's bed rails. LG J stated that he thought he had given verbal consent to the hospice provider, but nothing in writing. LG J indicated that he had not been educated on the risks vs. benefits of side rails. On 3/24/26 at 9:43 AM, Surveyor interviewed EVS C (Environmental Services Supervisor) about the facility's bed rail process. EVS C stated that his department will get a slip from nursing or physical therapy that a resident needs bed rails installed, and then they will go and install them when the resident is not in their bed. EVS C stated that he does not determine who qualifies to have a bed rail, and he was unsure if there were any alternatives tried prior to installing bed rails. EVS C stated that he had been working at the facility for a year and a half, and some of the bed rails had been on the beds since before he started working there. EVS C was unsure if any consents were obtained from the resident or resident representative before installing bed rails. EVS C stated that he doesn't do any measurements of the bed or mattress, and that the appropriate bed size would be determined by physical therapy. EVS C indicated that he just eyeballs the gap between the mattress and the bed rail, but does not take any measurements, and he had never been informed that was something that he needed to do. EVS C stated that when a resident moves out, he checks the bed and cleans the wheels but that he doesn't do any ongoing maintenance on the beds or bed rails EVS C stated that the nursing staff use the beds every day, so they will send him a maintenance request if the bed needs to be looked at. EVS C indicated that when a resident moves out of the facility, he removes the bed rails because a resident should only have bed rails if there is a physician or PT (physical therapy) order. Surveyor asked EVS C if he had manufacturer's guidelines for R30's bed, and EVS C stated that he would look. On 3/24/26 at 10:18 AM, EVS C came to Surveyor and stated that he did not have any manufacturer's guidelines for R30's bed because it was a bed that was provided to R30 from hospice. EVS C stated that because it is a hospice bed and hospice rails, they don't do anything with that bed. EVS C indicated that if he did get a maintenance request for that bed, he would deny it because its hands off due to it not being their bed or their equipment. EVS C stated that if anything goes wrong with R30's bed, the staff will call hospice. EVS C indicated that he didn't have any specifications for R30's bed or bed rails at all. On 3/24/26 at 11:31 AM, Surveyor interviewed COTA D (Certified Occupational Therapy Assistant) and asked her about their bed rail process. COTA D stated that if a resident had bed rails it would be in their care plan, and they should have a physician's orders prior to placing the bed rails. COTA D indicated that they would do a bed rail assessment and a risk versus benefits for the bed rails to ensure that the resident was safe to use bed rails. On 3/24/26 at 11:43 AM, Surveyor accompanied EVS C to R30's room to measure the gap between the mattress and the bed rails. EVS C measured the gap to be 2 1/4 inches on the right side and no gap on the left side. EVS C confirmed that R30 was using a bariatric bed, and that the gap between the mattress on the right side was large enough to get an arm between the mattress and the bed rail. Surveyor asked EVS C if there was possibility that R30 could become entrapped in that gap between the mattress and the bed rail. EVS C stated yes, R30 could get her arm stuck in there and could become entrapped. On 3/24/26 at 12:13 PM, Surveyor interviewed CNA E (Certified Nursing Assistant) and asked her if there was a possibility that R30 could become entrapped between her mattress and bed rail. CNA E stated definitely there was a possibility that R30 could become entrapped. On 3/24/26 at 12:15 PM, Surveyor interviewed CNA F and asked her if there was a possibility that R30 could become entrapped between her mattress and bed rail. CNA F stated yes, there was a possibility that R30 could become entrapped. On 3/24/26 at 12:34 PM, Surveyor interviewed DON B (Director of Nursing) about the facility's bed rail process. Surveyor asked DON B if R30 had a bed rail assessment completed prior to installing the bed rails. DON B stated that she was not seeing one in the electronic health record, and she would have to look further into that. Surveyor asked DON B if they had ensured that R30's bed was appropriate for her size and weight. DON B stated that R30 had a bariatric bed, but she would have to look further into that. Surveyor asked DON B if R30 should have been assessed for safety prior to installing the bed rails. DON B stated yes, but that R30's bed and bed rails had been provided by hospice, so she could not speak on their process. Surveyor asked DON B if a risk versus benefits for possible entrapment should have been completed with R30 prior to installing the bed rails. DON B stated yes, there should have been a risk vs. benefits completed. Surveyor asked DON B if R30 had a potential risk for entrapment with a gap between the mattress and bed rails. DON B indicated that there was a potential risk for entrapment. On 3/24/26 at 12:44 PM, Surveyor interviewed NHA A (Nursing Home Administrator) about the facility's bed rail process. NHA A indicated that if the resident or family request bed rails they would assess them for that. NHA A stated that if they are a hospice resident, hospice will sometimes bring in a hospice bed and siderails that fit that bed. R30 stated that R30's bed rails are a comfort thing for her because she is able to roll over and grab them with assistance, that she can pull up and stay up with the bed rails. Surveyor asked NHA A if any alternatives had been tried with R30 prior to installation of the bed rails. NHA A stated that she could not remember because R30 had that same bed and bed rails at her previous facility. NHA A indicated that maintenance does not measure the bed for appropriate dimensions based on the resident's weight and size. Surveyor asked NHA A if the maintenance staff does routine maintenance on the beds or bed rails. NHA A stated that she didn't think that was something that the maintenance department did, because if staff notice something wrong with them, they would put a lock out tag on it and complete a maintenance request slip. Surveyor asked NHA A if there had been a bed rail assessment completed with R30 prior to installing the bed rails. NHA A accessed R30's electronic health record, and stated no, that she did not see one. NHA A indicated that everyone who has bed rails should have a bed rail assessment, and that it was her expectation that R30 would have one completed. Surveyor asked NHA A if R30 should have a signed consent and physician's orders for bed rails. NHA A stated yes, R30 should have those things for bed rails. Surveyor asked NHA A if R30 should have bed rails included on her care plan. NHA A indicated that it was her expectation that R30 would have bed rails included on her care plan. Surveyor asked NHA A if a risk versus benefits should have been completed with R30 prior to installation of the bed rails. NHA A indicated that If it was deemed to be a risk to her then yes, she should have a risk vs benefits completed. Surveyor asked NHA A if the gap between R30's mattress and side rail could be a potential risk for entrapment. NHA A answered yes, it could be a potential risk for entrapment. Example 2: R2 was admitted to the facility on [DATE] with diagnoses that include, in part, Hemiplegia (complete paralysis) and Hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side, Dysphagia (difficulty swallowing), Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, Morbid Obesity, Schizoaffective Disorder Bipolar type, Anxiety Disorder, Epilepsy unspecified, Other Muscle Spasm, and Insomnia. R2's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/31/26 indicates R2 has a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating, R2 has moderate cognitive impairment. Section GG of R2's MDS indicates that R2 is totally dependent on staff for all Activities of Daily Living (ADLs) including toileting hygiene, bathing, dressing, transferring and rolling in bed from side to side. R2 was assessed on 10/31/25 to be at risk for falls. R2 did not have physician order's for bed rails, did not have measurements for gaps with the mattress and bed rails, did not have a bed rail assessment for entrapment, did not have proof of risk vs. benefits for bed rails, no ongoing monitoring or audits of bed rails, no alternatives tried prior to installing bed rails, no evidence that bed dimensions were based on resident's size and weight, no adherence to manufacturer's guidelines, and bed [NAME] were not included on R2's care plan. On 3/23/26 at 7:53 AM, Surveyor observed R2 in her bed sleeping with side rails on her bed. On 2/23/26 at 12:33 PM, Surveyor attempted to interview R2 but R2 was unable to answer any questions about her bed rails. Example 3: R27 was admitted to the facility on [DATE] with diagnoses that include, in part Type 2 Diabetes Mellitus, Kidney transplant, Epilepsy unspecified, and Anxiety disorder. R27's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/6/26 indicates R27 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating, R27 is cognitively intact. Section GG of R27's MDS indicates that R27 is partially dependent on staff for all Activities of Daily Living (ADLs) including toileting hygiene, bathing, dressing, transferring, but is independent with rolling in bed from side to side. R27 was assessed on 3/7/26 to be at risk for falls. R27's bed rail assessment, dated 11/21/25, indicates that R27 has a history of falls, and that R27 displays poor bed mobility or difficulty moving to a sitting position on the side of the bed. Side rails/assist bar was indicated as enabler to promote independence. R27 did not have physician order's for bed rails, did not have measurements for gaps with the mattress and bed rails, did not have proof of risk vs. benefits for bed rails, no ongoing monitoring or audits of bed rails, no alternatives tried prior to installing bed rails, no evidence that bed dimensions were based on resident's size and weight, no adherence to manufacturer's guidelines, and bed [NAME] were not included on R27's care plan. On 3/23/26 at 11:13 AM, Surveyor observed R27 in her room with bed rails on her bed. R27 stated that she never signed a consent or been provided education on the risks and benefits of the use of side rails. Example 4: R6 was admitted to the facility on [DATE] and has diagnoses that include metabolic encephalopathy (an acute or subacute brain dysfunction caused by systemic illness, toxins, or organ failure rather than structural damage), abnormal posture, and unspecified dementia (when symptoms of cognitive decline- such as memory loss, impaired reasoning, and personality changes- are present, but the specific underlying cause has not been determined). R6's Progress Note, dated 1/02/26 12:36 PM, states, in part: .Resident had a witnessed fall. Jumped out of wheelchair while cna (certified nursing assistant) was wheeling her to the table in the dining room. R6's Progress Notes, dated 1/02/26 02:55 AM, states, in part: .Resident had an unwitnessed fall. Resident's bed alarm went off only three beeps and when staff got to her room she was on the floor mat crawling; bed in low position, bed alarm on, and floor mat in place. On 3/23/26 at 11:00 AM, Surveyor observed grab bars on R6's bed. The facility was unable to find any risk and benefits for the grab bars. The facility did not have any documentation showing these grab bars were care planned or how they would be monitored to ensure safe and proper fit. Example 5 R8 admitted to the facility on [DATE] with diagnoses including dementia and need for assistance with personal care. R8's Brief Interview for Mental Status (BIMS) on 8/22/25 has a score of 10, indicating R8 has moderate cognitive impairment. On 3/23/26 at 8:20 AM, Surveyor observed R8's bed. R8 had grab bars on his bed. R8's medical record does not contain information on alternatives attempted prior to installing grab bars. R8 does not have an assessment for the grab bars. R8 does not have a risk versus benefits for the use of grab bars. R8 does not have consent for the use of grab bars. R8's comprehensive care plan does not include the use of grab bars. On 3/24/26, Surveyor asked NHA A (Nursing Home Administrator) for documentation regarding R8's grab bars. NHA A was unable to provide any documentation regarding R8's grab bars. Example 6 R42 admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia, and mild cognitive impairment. R42's Brief Interview for Mental Status (BIMS), dated 2/24/26, has a score of 12, indicating R42 has moderate cognitive impairment. On 3/23/26 at 11:49 AM, Surveyor observed R42's bed. R42 had grab bars on his bed. R42's medical record does not contain information on alternatives attempted prior to installing grab bars. R42 does not have an assessment for the grab bars. R42 does not have a risk versus benefits for the use of grab bars. R42 does not have consent for the use of grab bars. R42's comprehensive care plan does not include the use of grab bars. On 3/24/26, Surveyor asked NHA A (Nursing Home Administrator) for documentation regarding R42's grab bars. NHA A was unable to provide any documentation regarding R42's grab bars. Example 7 R44 admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and fracture of left and right femur. R44's Brief Interview for Mental Status (BIMS), dated 1/16/26, has a score of 0, indicating R44 is severely cognitively impaired. On 3/23/26 at 11:57 AM, Surveyor observed R44's bed. R44 had grab bars on her bed. R44's medical record does not contain information on alternatives attempted prior to installing grab bars. R44 does not have an assessment for the grab bars. R44 does not have a risk versus benefits for the use of grab bars. R44 does not have consent for the use of grab bars. R44's comprehensive care plan does not include the use of grab bars. On 3/24/26, Surveyor asked NHA A (Nursing Home Administrator) for documentation regarding R44's grab bars. NHA A was unable to provide any documentation regarding R44's grab bars. Example 8 R17 was admitted to the facility on [DATE] and has diagnoses of hemiparesis and hemiplegia. R17 is also blind. On 3/23/26 at 11:26 AM, Surveyor observed grab bars affixed to the bed in R17's room. Facility documentation, dated 6/8/22, indicates R17 signed a risks and benefits for the bedrails. The facility was unable to find an assessment for the grab bars. Additionally, the facility did not have any documentation showing these grab bars were care planned or how they would be monitored to ensure safe and proper fit. Example 9 R5 admitted to the facility on [DATE] and has diagnoses that include malignant neoplasm of colon (Cancer). R5 is on hospice. On 3/23/26 at 10:16 AM, Surveyor observed grab bars affixed to the bed in R5's room while she was in it. The facility was unable to find an assessment or any risk and benefits for the grab bars. Additionally, the facility did not have any documentation showing these grab bars were care planned or how they would be monitored to ensure safe and proper fit. On 3/24/26 at 12:34 PM, Surveyor interviewed DON B (Director of Nursing) about the facility's bed rail process. DON B indicated that therapy will let them know that the resident might benefit from bed rails and then an order is requested from the physician. DON B stated that they also complete a bed rail assessment that is included in their chart. DON B indicated that once the order is received and assessment completed, then they let maintenance know to install the bed rails. Surveyor asked DON B if a risk versus benefits was discussed with the resident about bed rail entrapment. DON B stated that she had never done a risk versus benefits for bed rails. Surveyor asked DON B if an air mattress with bed [NAME] would increase a resident's risk for entrapment. DON B stated that she couldn't say if that was a potential risk and that she would have to look further into that. The facility did not ensure other alternatives were tried prior to installing/utilizing bed rails, failed to accurately assess the risk of possible entrapment, failed to obtain informed consent for bed rails, failed to obtain physician orders for bed rails, failed to care plan the need and use of bed rails, failed to obtain risk versus benefits for bed rails, failed to measure the gap between the mattress and bed rails for entrapment, and failed to ensure the bed dimensions were appropriate for the resident's size and weight for R30, R17, R6, R5, R2, R27, R8, R42, and R44.

Based on interview and record review, the facility did not provide the proper discharge documentation for 1 of 1 resident reviewed for discharge (R4).The facility sent R4 to the emergency room (ER) on 10/28/25 and 11/19/25. The hospital admitted R4 to the hospital both times. R4 did not receive bed hold notices either time.Evidenced by:The facility policy entitled Bed Hold Policy, dated 1/06/26, states, in part: . Policy: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave.Policy Explanation and Compliance Guidelines:1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or the resident representative written information that specifies:a. The duration of the State bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; b. The reserve bed payment policy in the state plan policy, if any.c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed.2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours.3. The facility will keep a signed and dated copy of the bed hold notice information given to the resident and/or resident representative in the resident's file and/or medical records. R4 admitted to the facility on [DATE] and has diagnoses that include Type 2 Diabetes Mellitus (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugars) and epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain).R4's Quarterly Minimum Data Set (MDS) Assessment, dated 1/10/26, shows that R4 has a Brief Interview of Mental Status (BIMS) score of 12 indicating R4 has moderate cognitive impairment. R4's Hospital Discharge summary, dated [DATE], states, in part: . admission: [DATE] D/C (discharge): 10/29/25. R4 presenting to the emergency room with confusion and difficulty swallowing.Surveyor conducted a review of R4's medical record. Surveyor could not locate any evidence that the facility provided R4 or their representative with the required bed hold notice information in writing at the time of the hospitalization transfer.Surveyor requested a bed hold notice for the hospitalization. NHA A (Nursing Home Administrator) returned to Surveyor and indicated the facility did not have the bed hold notice.R4's Hospital Discharge summary, dated [DATE], states, in part: . admission: [DATE]. History of Present Illness: . R4 was sent to the emergency room from nursing home with complaints of confusion, slurred speech and difficulty with swallowing that he noticed this morning.Surveyor conducted a review of R4's medical record. Surveyor could not locate any evidence that the facility provided R4 or their representative with the required bed hold notice information in writing at the time of the hospitalization transfer.Surveyor requested a bed hold notice for the hospitalization. NHA A (Nursing Home Administrator) returned to Surveyor and indicated the facility did not have the bed hold notice.On 3/25/26 at 11:25 AM, Surveyor interviewed NHA A who confirmed the facility did not provide the bed hold notice to R4 on 10/28/25 or 11/19/25 at the time of hospital transfer or after. Surveyor asked NHA A who is responsible for providing the bed hold notices to the residents or to the residents' representatives. NHA A indicated the nurses on the floor are responsible for providing the bed hold notices at the time of transfers. Surveyor asked NHA A if the facility should have provided the bed hold notices to R4 at each time of transfer. NHA A indicated yes.

Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan to meet personal preferences and goals, or address the resident's medical, physical, mental and psychosocial needs for 1 of 14 residents (R30) reviewed for care plans.R30's care plan does not include a focus, goal, or interventions for fall risk.Evidenced by:The facility policy titled, Comprehensive Care Plans states, in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. 2. The comprehensive care plan will be developed with 14 days after the completion of the comprehensive MDS (Minimum Data Set) assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.Example:R30 was admitted to the facility on [DATE] with diagnoses that include, in part, Huntington's Disease, Major Depressive Disorder, Anxiety Disorder, and Insomnia.R30's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/6/26 indicates R30 has a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating, R30 has severe cognitive impairment. Section GG of R30's MDS indicates that R30 is totally dependent on staff for all Activities of Daily Living (ADLs) including eating, toileting hygiene, bathing, dressing, transferring and rolling in bed from side to side.R30 was assessed on 2/4/25 to be at risk for falls.A review of R30's nursing progress notes, includes the following:On 7/15/25: Resident was noted to be very restless early this morning per the night shift and then around 0645 (6:45 AM) staff were in to check on her and she had both legs over the edge of the bed on side closest to the hall door. Resident's torso was on bed yet so she was repositioned and this was reported to the hospice staff today when here and they have updated hospice staffing looking into continued use of the air mattress on bed. Was passed on to the oncoming shift to monitor for safety.Of note, nowhere in R30's comprehensive care plan does it include that R30 is at risk for falls or include any person-centered interventions to keep R30 safe from falling.On 3/25/26 at 12:17 PM, Surveyor interviewed CNA E (Certified Nursing Assistant) who stated that they are made aware of a resident's care by management telling them verbally or posting something in the report room. Surveyor asked CNA E if someone was a fall risk, should it be on their care plan. CNA E stated yes, falls should be on their care plan along with interventions for that resident.On 3/25/26 at 12:16 PM, Surveyor interviewed CNA K who stated that they are made aware of a resident's care through shift-to-shift report, or by the nurses, or by the care plans that are in the resident's rooms and in their online chart. Surveyor asked CNA K if someone was a fall risk, should it be on their care plan. CNA K stated yes, falls should be on their care plan.On 3/25/26 at 12:30 PM, Surveyor interviewed IP I (Infection Prevention Nurse) and asked about the facility's care plan process. IP I stated that the IDT (interdisciplinary team) are the ones who normally update a resident's care plan. Surveyor asked IP I if a resident was assessed to be a fall risk, should that be included on their care plan. IP I stated yes, if someone was a fall risk it should be on their care plan.On 3/25/26 at 1:18 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about the facility's care plan process. NHA A indicated that the head of each department would be responsible for updating their part of the care plan. Surveyor asked NHA A if the resident's care plan should reflect their goals, preferences and needs. NHA A stated yes. Surveyor asked NHA A if the resident's care plan should include person centered interventions. NHA A stated yes. Surveyor asked NHA A if a resident who was assessed to be at risk for falls should have a fall risk care plan. NHA A stated yes, anyone who was considered a fall risk should have a section for falls on their care plan.

Based on interview, and record review, the facility did not ensure that the comprehensive care plan is reviewed and revised for 3 of 14 residents (R1, R8, R42). R8's care plan did not have safety interventions in place, had fall interventions in place that were no longer appropriate, and did not have fall interventions revised after a fall. R42's care plan did not have safety interventions in place and did not have fall interventions revised after a fall. R1 has an order for Prevalon boots to always be on. The facility did not add the order to R1's Care Plan. R1's Care Plan indicates R1 requires assistance with ambulation. R1 does not ambulate. This is evidenced by: The facility policy. entitled, Comprehensive Care Plans, dated 1/5/22, includes It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The comprehensive care plan will describe, at a minimum, the following: f. Resident specific interventions that reflect the resident's needs and preferences. The facility policy, entitled, Accidents and Supervision, dated 1/6/26, includes: Monitoring for effectiveness and modifying interventions when necessary. a. All staff . are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff d. Documenting interventions (e.g., .care plans for the individual resident) e. Ensuring that the interventions are put into action f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks. i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new interventions The facility policy, entitled, Fall Procedure, dated 1/26, includes: Staff shall assess for risk, provide preventative measures, and address falls in a safe and professional manner. e. Update fall care plan of immediate intervention. The facility policy Abuse, Neglect and Exploitation, dated 3/18/26, includes: VI. Protection of Resident G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Example 1 R8 admitted to the facility on [DATE] with diagnoses including dementia and need for assistance with personal care. R8's Brief Interview for Mental Status (BIMS) on 8/22/25 has a score of 10, indicating R8 has moderate cognitive impairment. R8's comprehensive care plan includes the following interventions: Ensure bed is kept in lowest position (Initiated 6/12/24). Utilize devices as appropriate to ensure safety (i.e. bed mats, sensor alarms, etc.) Tab and/or pressure alarms and floor mat while in bed (Initiated and revised on 6/12/24).Assistive devices: Walker, manual wheelchair, and gait belt (Initiated and revised on 5/21/24).Chair/bed-to-chair transfer: Independent (Initiated 6/20/25). R8 has antiroll back brakes applied to his wheelchair as a fall prevention intervention. R8's care plan did not reflect this. R8 has interventions for a floor mat, bed in low position, and tab and/or pressure alarms. R8's care plan did not reflect this. On 3/24/26 at 11:45 AM, Surveyor interviewed CNA H (Certified Nursing Assistant) regarding care plans. CNA H indicated CNAs use the CNA Kardex to see what interventions a resident has in place. Surveyor asked CNA H about R8's care plan interventions. CNA H indicated R8 does not utilize these interventions. CNA H indicated R8 transfers independently. CNA H indicated if the floor mat was in place or if the bed was in a low position, it would increase the falling risk for R8. R8 had a fall on 9/4/25 and 9/9/25. R8's fall care plan was not revised with new interventions. On 3/25/26 at 10:40 AM, Surveyor interviewed DON B (Director of Nursing) regarding care plans. DON B indicated the IDT (Interdisciplinary Team) reviews and revises care plans as needed. DON B indicated the care plan should be accurate and reflect the resident's needs. DON B indicated R8's care plan was not revised as it should have been, and it is not accurate. Example 2: R42 admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia, and mild cognitive impairment. R42's Brief Interview for Mental Status (BIMS), dated 2/24/26, has a score of 12, indicating R42 has moderate cognitive impairment. On 3/13/26 the facility initiated an investigation of an allegation of abuse. As a result of the investigation, the facility implemented interventions for R42. The facility placed a motion sensor at R42's bedroom door. The facility also educated the staff that R42 was not to be placed next to female residents when he is out of his room. On 3/24/26 at 10:02 AM, Surveyor interviewed CNA F (Certified Nursing Assistant) regarding interventions for R42. CNA F indicated R42 has a door motion alarm and is not to be placed by female residents when he is out of his room. On 3/24/26 at 10:27 AM, Surveyor interviewed RN G (Registered Nurse) regarding interventions for R42. RN G indicated when R42 is out of his room, he is kept at a distance from female residents. RN G indicated they do not sit R42 next to females in the dining room or lounge. R42's comprehensive care plan does not include these interventions. On 3/25/26 at 10:40 AM, Surveyor interviewed DON B (Director of Nursing) regarding R42. DON B indicated these safety interventions should be on R42's care plan but are not. R42 had a fall on 12/2/25. R42's fall care plan was not revised with new interventions. On 3/25/26 at 10:54 AM, Surveyor interviewed DON B regarding R42's fall care plan. DON B indicated R42's fall care plan was not revised with new interventions after his fall and the care plan should have been updated. Example 3: R1 was admitted to the facility on [DATE] and has diagnoses that include central spinal cord syndrome (incomplete spinal cord injury, characterized by disproportionately greater motor weakness in the upper extremities (arms/hands) compared to the lower extremities (legs)) and muscle weakness. R1's admission Orders, dated 9/5/24, states, in part: .Pressure Ulcer/Injury: Risk of Pressure Ulcers/Injuries- Yes.Prevelon boots at all times for pressure relief. *Note: R1's comprehensive care plan or CNA Kardex do not list R1's Prevalon boots to be on always as ordered. R1's Comprehensive Care Plan, dated 9/11/24, states, in part: . Focus: Risk for falls r/t (related to) central cord syndrome with significant physical limitations. Medications received, intermittent pain. Date Initiated: 9/11/24. Revision on: 9/28/24. Interventions: *Assist Resident with ambulation and transfers, utilizing therapy recommendations. Date Initiated: 9/11/24. R1's Physical Therapy (PT) Discharge summary, dated [DATE]- 12/24/25, states, in part: .Ambulation: Walk 10 Feet- not applicable. On 3/25/26, at 1:00 PM, Surveyor interviewed TD P (Therapy Director) and asked if R1 was ever able to ambulate. TD P indicated no. Surveyor read R1's Care Plan intervention: Assist Resident with ambulation and transfers, utilizing therapy recommendations. Date Initiated: 9/11/24 to TD P. TD P indicated therapy never made recommendations for R1 to ambulate. TD P indicated therapy never attempted to ambulate R1 due to safety concerns and medical diagnosis. TD P indicated therapy had tried to stand R1 but that was never successful. TD P indicated R1 wants to walk but R1 cannot. On 3/25/26 at 1:29 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked when R1 is to have Prevalon boots on and if there was an order for the Prevalon boots. DON B brought Surveyor R1's admission orders to the facility. In the admission orders was the order for Prevalon boots to always be on. DON B indicated the staff had missed that order. Surveyor asked if the Prevalon boots should be on the care plan. DON B indicated yes. Surveyor asked DON B who is responsible for updating the care plans with new interventions and revising the interventions. DON B indicated everyone is. Surveyor asked if the intervention on R1's care plan indicating R1 requires assistance to ambulate per therapy recommendation is current. DON B indicated no, R1 cannot ambulate due to his legs/knees. DON B indicated the facility did not revise that intervention.

Based on record review and interview, the facility did not ensure 1 of 1 resident (R7) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. R7 has a diagnosis of Post Traumatic Stress Disorder (PTSD) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions.Evidenced by:The facility policy entitled Comprehensive Care Plans, dated 1/06/26, states, in part: . Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Definitions: . Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization.Policy Explanation and Compliance Guidelines: .3. The comprehensive care plan will describe, at a minimum, the following: . g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. R7 admitted to the facility on [DATE] and has diagnoses that include PTSD (a mental health condition triggered by experiencing or witnessing terrifying events, causing symptoms like flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event). R7's Social History Information form, dated 3/23/25, states, in part: . Additional Information: About 15 years ago she fell over a second story banister while on a ladder painting. Shattered her whole mid-section, several 20 hours + surgeries, 6 month stay at UW. Had to learn how to walk again.History of Trauma/Traumatic events: About 10 years ago she suffered a terrible seizure letting us know she had a large brain tumor. Since then, she has had 3 to 4 major brain operations, three sets of chemo and radiation. Potential Triggers: Bright and blinking lights can set off seizures for her. Surveyor reviewed R7's medical record and could not locate a trauma informed care assessment.Surveyor reviewed R7's Care Plan and the Certified Nursing Assistant (CNA) Kardex and found no focus areas regarding PTSD or PTSD interventions for R7's triggers.On 3/24/26 at 2:53 PM, Surveyor interviewed CNA L and asked if CNA L was aware of R7 having PTSD. CNA L indicated no. Surveyor asked CNA L if CNA L was aware of R7 having any triggers for PTSD. CNA L indicated no.On 3/24/26 at 2:55 PM, Surveyor interviewed CNA M and asked if CNA M was aware of R7 having PTSD. CNA M indicated no. Surveyor asked CNA M if CNA M was aware of R7 having any triggers for PTSD. CNA M indicated R7 just gets anxious and worries easily.On 3/24/26 at 2:58 PM, Surveyor interviewed LPN N (Licensed Practical Nurse) and asked LPN N if she was aware of R7 having PTSD. LPN N indicated no. Surveyor asked LPN N if LPN N was aware of R7 having triggers for PTSD. LPN N indicated no.On 3/24/26 at 3:03 PM, Surveyor interviewed SW O (Social Worker) and asked if SW O was aware of R7's diagnosis of PTSD. SW O indicated she was not aware. Surveyor asked SW O if she recalled completing a Trauma Informed Care Assessment on R7 on admission. SW O indicated no. Surveyor asked SW O what the facility process is for a resident admitted with a history of PTSD. SW O indicated at admission the facility completes a social history and PTSD is captured in there. SW O indicated with R7 being less vocal SW O worked with the family on the social history. SW O pulled up R7's Social History and reviewed the Traumatic event section with Surveyor. Surveyor asked SW O for a resident with a history of PTSD should there be a Trauma Informed Care Assessment completed on admission. SW O indicated the facility typically does not complete Trauma Informed Care Assessments. Surveyor asked SW O if the facility should be aware of PTSD triggers. SW O indicated if the triggers are related to the facility somehow yes. Surveyor asked SW O with a Trauma Informed Care Assessment not completed, how would the facility know what the triggers are. SW O indicated the facility does the triggers in the social history. Surveyor asked SW O if PTSD and triggers should be care planned. SW O indicated if triggers were something here like anxiety, depression, for veterans for loud noises. Surveyor asked SW O how staff would be aware of a resident with PTSD and the triggers. SW O said the social history is in the residents' medical records. Surveyor asked if staff on the floor would be looking through a resident's medical record. SW O indicated PTSD, and triggers should be on the CNA Kardex and on the care plans for CNAs and nurses to see. Surveyor asked if there was something on R7's care plan or CNA Kardex regarding PTSD and triggers and SW O indicated no.

Based on interview and record review, the facility did not establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 3 of 5 residents (R50, R6, R27) reviewed for antibiotic stewardship.R50 was treated prophylactically with an antibiotic for prevention of urinary tract infections (UTI). The facility did not have an antibiotic stewardship conversation with the Provider regarding R50.R6 was treated with an antibiotic without a sensitivity completed to be able to identify what antibiotics would be susceptible to the bacteria.R27 was treated with an antibiotic that was not susceptible to the bacteria identified. Evidenced by:The facility policy entitled Antibiotic Stewardship Program, dated 1/05/26, states, in part: . Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: .ii. Laboratory testing shall be in accordance with current standards of practice. b. Monitoring antibiotic use: .ii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. Example 1:R50 is on the January 2026 line list for a prophylactic antibiotic for UTI.R50's Physician Order, dated 12/15/25, states: Cephalexin (Keflex) 250 mg (milligrams) two times daily. Take BID (two times a day) for Uti prophylaxis (prevention).R50's December 2025 Medication Administration Record (MAR) shows R50 received Cephalexin 250 mg BID from 12/15/25- 12/18/25. Cephalexin was stopped while R50 was treated with Ciprofloxacin for a wound infection.R50's January 2026 MAR shows R50 received Cephalexin 250 mg BID from 1/9/26-1/31/26.R50's February 2026 MAR shows R50 received Cephalexin 250 mg BID from 2/1/26-2/3/26.On 3/25/26 at 9:54 AM, Surveyor interviewed IP I (Infection Preventionist) and asked if it is appropriate to treat prophylactically with antibiotics. IP I indicated no. Surveyor asked IP I if there was a conversation with the physician regarding antibiotic stewardship. IP I looked and found no documentation. Surveyor asked IP I, if a physician chooses to treat prophylactically with an antibiotic should there be documentation showing the facility had a conversation regarding antibiotic stewardship. IP I indicated yes.Example 2:R6 is on the February 2026 line list for UTI. A positive urinalysis (UA) was collected on 2/09/26. A urine culture, dated 2/11/26, identifies bacteria >100,000 CFU (colony forming unit) per mL (milliliter) Aerococcus Urinae. There was no sensitivity (lab test to determine the most effective antibiotic for treatment). R4 was treated with Nitrofurantoin and Levaquin antibiotics.R6's February 2026 MAR shows R6 received Nitrofurantoin 100 mg (milligrams) BID (twice a day) from 2/5/26-2/17/26. R6 received Levaquin 500 mg daily from 2/18/26-2/27/26.On 3/25/26, at 9:54 AM, Surveyor interviewed IP I and asked if there was a sensitivity completed with R6's culture. IP I indicated she had called Health Information at the hospital on 2/23/26 and the Health Information informed IP I the sensitivity was not completed. IP I indicated R6 was treated with Nitrofurantoin, starting on 2/10/26 for four days. R6 was not improving. The physician then started her on Levaquin for 10 days. Surveyor asked IP I if R6 should have been treated with the Nitrofurantoin and Levaquin without having a sensitivity to show what antibiotics would treat the Aerococcus Urinae. IP I indicated no, there should have been a sensitivity completed prior to initiation of antibiotics.Example 3:R27 is on the March 2026 line list for a uti. R27's urine culture, dated 3/12/26, shows >100,000 CFU/mL (colony forming unit per milliliter). Enterococcus faecuim Vancomycin-Resistant and >100,000 CFU/mL Aerococcus urinae. R27 was treated with Ciprofloxacin for 7 days for uti. R27's sensitivity shows the following antibiotics are susceptible:-Daptomycin, Linezoid, Nitrofurantoin, and Tigecycline.*Note this does not include ciprofloxacin or antibiotics from Ciprofloxacin's class. Therefore, Ciprofloxacin would not be appropriate to treat the bacteria.R27's March 2026 MAR shows R27 received Ciprofloxacin 500 mg (milligrams) BID (twice a day) from 3/15/26- 2/21/26.On 3/25/26 at 9:54 AM, Surveyor interviewed IP I and asked if Ciprofloxacin was sensitive to the bacteria identified in R27's culture. IP I looked at the sensitivity list and indicated no. IP I indicated R27 should not have been treated with the Ciprofloxacin.

Based on observation, interview, document review, and policy review, the facility failed to ensure unauthorized staff, two of two Certified Medication Aides ((CMA)1 and CMA2), did not have the keys to the locked narcotic box on the medication cart and to the medication storage room. Findings include: Review of the facility's Medication Technician/Aide job description provided by the Administrator dated 2023 indicated, Major Duties and Responsibilities.no narcotic pass allowed. Review of CMA1's Medication Technician/Aide job description provided by the Administrator was signed 11/02/23 and CMA2's Medication Technician/Aide job description was signed 10/15/25. Review of the facility's undated policy titled, Handling of Controlled Substances provided by the Administrator indicated, .Recommended Procedures, Schedule II Narcotic Medications: 5. The Nurse is responsible to keep the key.to the Schedule II medication storage areas. Review of the facility's undated policy titled, Administration of Medications by Staff provided by the Administrator indicated, 11. All drugs will be stored in a locked cabinet or cart. C-11 controlled substances must be stored under double lock.Keys.are limited to those who require them. Observation on 10/15/25 at 5:26 AM, CMA1 unlocked the medication cart and, with the key on the key ring, unlocked the locked narcotic box. CMA1 verified at this time the number of narcotics available in the narcotic box matched the quantity listed in the narcotic binder for each resident. During an interview on 10/15/25 at 5:26 AM, CMA1 confirmed that she is not allowed to distribute narcotic medications to residents at this facility. If a resident required a narcotic medication, she would have to contact the nurse on the other floor or the Director of Nursing (DON) to dispense the narcotic to the resident. During an interview on 10/15/25 at 5:37 AM, Licensed Practical Nurse (LPN)1 stated that CMAs at this facility are not allowed to dispense narcotic medications to the residents. She stated CMA1 would have to call her, and she would go up to her floor and give the resident's narcotic medication. During an interview on 10/15/25 at 6:44 AM, Registered Nurse (RN)1 stated that only nurses can dispense narcotic medications to the residents. During an interview on 10/15/25 at 2:41 PM, CMA2 stated that during her shift she has the keys to the medication cart and the key to the locked narcotic box. CMA2 stated that at the change of shift she does the verifying of the narcotics in the locked box with the narcotic binder with the oncoming nurse or CMA. CMA2 confirmed that she cannot give residents their narcotic medications. During an interview on 10/15/25 at 3:30PM, the Administrator and DON confirmed that the facility has only two CMAs and that although they use agency staff, they never accept an agency CMA for an assignment at this facility. After reviewing the facility's policies, the Administrator confirmed that the CMAs should not have the key to the locked narcotic box as indicated in the facility's policy.

Based on interview and record review the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 5 residents reviewed for abuse (R4 and R5). Staff documented a resident-to-resident altercation, involving R4 on 8/5/25, which was not reported to the State Agency.Staff documented a resident-to-resident altercation, involving R5 on 8/5/25, which was not reported to the Administrator or State Agency.Evidenced by:The facility policy titled, Abuse, Neglect and Exploitation, revised 6/24/25, includes in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.The components of the facility abuse prohibition plan are discussed herein: .VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. On 8/13/25 Surveyors reviewed a progress note for R2, dated and timed 8/5/25 9:09 PM, Author: LPN C (Licensed Practical Nurse). The note contained the following information, in part:.Once supper was over, resident was taken out by staff for a cigarette, upon return her behaviors worsened. She began yelling at R4 to Shut the fuck up. Writer was at med cart when she heard an item fall, resident threw her wander guard in R4's direction, it is unknown if she had the intention to hit him with the object.When resident R5 walked by, she slammed her walker into the chair in front of her and said, I'll kill you.On 8/13/25 at 4:02PM Surveyors interviewed LPN C (Licensed Practical Nurse) via telephone regarding the events she documented on 8/5/25 involving, R2, R4, and R5. During the interview LPN C indicated she recalled the events documented in her note. LPN C indicated that she reported the events between R2 and R4 to NHA A (Nursing Home Administrator) but was only about certain she reported the events between R2 and R5 to NHA A. Surveyor asked LPN C if she should report a potential verbal abuse or threat to the NHA when a resident says, I'll kill you, to another resident. LPN C indicated, it makes sense to report it as abuse, but with R2 it's hard because it's part of her disease.On 8/13/25 at 2:06PM Surveyors interviewed NHA A. Surveyors reviewed the information from the 8/5/25 progress note above with NHA A. During the interview NHA A indicated that LPN C reported to her the events between R2 and R4 and that she did not recall the events between R2 and R5 being reported to her. Surveyor asked NHA A if these events should have been reported to her and to the State Agency as allegations of abuse. NHA A indicated they should have.

Based on interview and record review, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for 2 of 5 residents reviewed for abuse (R4 and R5). Staff documented an observation of a resident-to-resident altercation, involving R4 on 8/5/25, which was not investigated by the facility. Staff documented an observation of a resident-to-resident altercation, involving R5 on 8/5/25, which was not investigated by the facility. Evidenced by:The facility policy titled, Abuse, Neglect and Exploitation, revised 6/24/25, includes in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.The components of the facility abuse prohibition plan are discussed herein: .V. Investigation of Alleged Abuse, Neglect, and Exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur.On 8/13/25 Surveyors reviewed a progress note for R2, dated and timed 8/5/25 9:09PM, Author: LPN C (Licensed Practical Nurse). The note contained the following information, in part:.Once supper was over, resident was taken out by staff for a cigarette, upon return her behaviors worsened. She began yelling at R4 to Shut the fuck up. Writer was at med cart when she heard an item fall, resident threw her wander guard in R4's direction, it is unknown if she had the intention to hit him with the object.When R5 walked by, she slammed her walker into the chair in front of her and said, I'll kill you.On 8/13/25 at 2:06PM Surveyors interviewed NHA A and reviewed the information from the 8/5/25 progress note above with NHA A. Surveyors asked if the events documented between R2 and R4 and R2 and R5 should have been investigated as allegations of abuse. NHA A indicated they should have.

Based on interview and record review, the facility did not ensure that residents were free from abuse, perpertrated by a Certified Nusing Assistant (CNA) for 1 of 17 sampled residents (R40). R40 had voiced to a CNA to stop during cares as the CNA was hurting him. The CNA continued providing care despite the residents request and voicing discomfort. Addtionally, staff who overheard the interaction did not intervene to protect R40. Evidenced by: The facility policy entitled, Abuse, Neglect and Exploitation, dated [DATE], states, in part: . Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse . III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff . E. Ensuring the health and safety of each resident . R40 was admitted to the facility on [DATE] and has diagnoses that include, malignant neoplasm of unspecified part of left bronchus or lung (a cancerous tumor that has developed in the left bronchus, one of the large airways in the lungs) and nontraumatic intracranial hemorrhage (bleeding in the brain that occurs without trauma or surgery). R40 admitted to hospice [DATE] and expired [DATE]. A Facility Self Report dated [DATE], at 11:14:22 AM, states, in part: . Summary of Incident: Allegation Type: Abuse: Hitting, slapping, threats of harm, assault, humiliation. Name-Affected Person: R40 Name-Accused Person: CNA D . Date occurred: [DATE]. Time occurred: 06:15 AM . Date discovered: [DATE] . Briefly describe the incident . R40 recently admitted to the facility. It was reported that resident was reporting pain during cares when CNA D was assisting. CNA D continued cares after resident stated to stop . Explain what steps the entity took upon learning of the incident to protect the affected person and others from further potential misconduct: Upon learning of the incident, investigation was started; CNA D was put on leave. Residents interviewed to determine if they feel their rights are being upheld by CNA D and other staff . R40's progress note written by LPN E (Licensed Practical Nurse) dated [DATE], 6:15 AM, states: Went in to give R40 pain med and Ativan which R40 refused. R40 also refused to have brief changed and lidocaine patch applied. I told the two CNAs that were trying to change his brief to just leave him alone because R40 was getting irate and was verbally abusive to CNAs and I. CNA D came up to this floor went down to R40's room and told him he was going to be changed, he did not have a choice in the matter. CNA D told R40 to suck it up buttercup. R40 screamed the whole time CNA D was in there . Resident Interviews conducted by SW G (Social Worker) during investigation, dated [DATE], shows 3 residents voiced CNA D does not respect their wishes and 3 residents indicate CNA D has disregarded their wishes. 2 of those 3 residents voiced they do not feel safe when CNA D works with them. Written statement by LPN E, dated [DATE], states, in part: . CNA C, CNA F, and I went in R40's room to check him and administer his medications- I attempted to give R40 his meds and he refused. So, I was going to wait for CNA C and CNA F to give R40's cares and try again. R40 started grabbing at CNA F and CNA C at which time R40 was told that he was not to do that because it was unacceptable behavior. CNA C and CNA F started to try and check R40 again and he would not stop screaming saying Leave me alone! R40 said he wanted a male to care for him. I told CNA C and CNA F R40 is screaming and saying no so just leave him alone and we would come back later, Then I saw CNA D go past the nursing station door. I got up to see what CNA D was doing, and she was going into his room. R40 started screaming and I heard CNA D say, Suck it up buttercup because we are fixing to change you. I walked down to the room because R40 was continually screaming, I said just leave him alone and check back later. CNA D said just send me some help in here and a pad. CNA C took a pad to her, she cleaned him up, came by the office and said he had a large BM (bowel movement) tell CNA C to mark it. CNA D then went back downstairs R40 screamed during the whole process. CNA C's statement, dated [DATE], at 1:41 PM, states: CNA C was on 3rd floor and CNA D was on 2nd floor. CNA F was a float between the two floors. CNA C heard resident say, Stop you are hurting me and CNA D asked CNA C to get a Chux and wipes and said, Some help would be nice. CNA D stated,Yelling isn't doing you justice at all CNA D replied. CNA D asked R40 if he thinks it is. R40 responded Obviously not. CNA D was yelling at R40, and CNA D was being mean and rough to R40. R40 continued to tell CNA D to stop, and she continued to keep going. CNA D did not give R40 the option to not get changed and CNA C and CNA F offered to change R40 and educated him on having a wet brief on and R40 still said no he did not want to be changed. CNA C and CNA F told him okay and that they would have day shift try to change him. CNA D came upstairs after CNA F went back down to 2nd floor. CNA D asked what the resident's name was and what room he was in. CNA C told CNA D the room number and R40's name. SW G's interview with R40, dated [DATE], states, in part: . Spoke with R40 regarding situation where nursing staff reported hearing CNA speaking harshly to R40 and allegedly completing cares against his will. R40 stated in his interview that he sort of remembered the situation, but his pain was bad . Education on Resident Rights, Professionalism- Customer Service, and Abuse, Neglect and Exploitation are dated [DATE] by CNA D. It should be noted CNA D has received previous disciplinary action regarding resident rights/self-determination, dignity/respect and insubordination as listed below: Action Plan for Incident [DATE] CNA D and R40 shows: Care Plan for R40 updated to address pain management: -Breathing - Stress Balls during Care - Medications for Pain scheduled instead of PRN (as needed) Discussion between CNA D and Interim NHA A (Nursing Home Administrator) related to resident rights and customer service. Inservice for all staff -Resident rights/self-determination Continue touch bases with R40 to determine if needs are being met. CNA D's Disciplinary Action Report dated [DATE], states, in part: . Rules Violated: Resident dignity- respectful treatment of residents . Nature of Incident: A resident felt threatened and demeaned . CNA D's Disciplinary Action Report dated [DATE], states, in part: . Rules Violated: 1. Insubordination . 3. Departmental policies of safety rules and regulations. Nature of Incident: 1. CNA does not follow directions given by nurse on duty and must be reminded multiple times of required tasks of job description . 3. It has been reported on [DATE] that a resident was calling out from their room, and it was noted that CNA was standing at the medication cart conversing with the nurse and not responding to resident . On [DATE], at 7:30 AM, Surveyor interviewed CNA C and asked CNA C to talk about the incident that occurred on [DATE] with R40. CNA C indicated her and CNA F were in R40's room with LPN E between 5:00 AM and 6:00 AM and asked R40 if we could check to see if he was incontinent which he was. R40 said Please don't touch me, so we left him alone and stated we would come back later to try again. CNA C stated we went back to try again and R40 stated, No, leave me alone. We left the room. When CNA F and CNA C went back downstairs, CNA D yelled at CNA F stating Where the hell have you been? We explained we were in with R40, and he was refusing to be changed. CNA D asked what the resident's name was and room number. CNA C indicated she told CNA D and CNA D went upstairs to R40's room. CNA C indicated she followed CNA D upstairs and as CNA C was walking toward R40's room she heard R40 saying to CNA D, Please leave me alone. Please stop, you are hurting me! CNA C indicated she heard CNA D yell at R40 Screaming isn't doing you justice; it isn't doing you no good! When CNA C reached the room, CNA D asked CNA C to go get a blue chux and stated, some help would be nice. CNA C indicated LPN E was standing outside the room. CNA C went in R40's room and handed CNA D the items requested and suggested with R40 screaming, we should leave R40 alone and come back later. CNA D continued with cares even though R40 was screaming. Surveyor asked CNA C if R40 was screaming due to pain and CNA C indicated yes. CNA C indicated by the sounds R40 was making, R40 was in a lot of pain. CNA D would not listen to me and kept going with providing the cares. I reported it to NHA A (Nursing Home Administrator) that morning. Surveyor asked when the incident happened, and CNA C indicated between 5:00 AM and 6:00 AM. On [DATE] at 7:45 AM, Surveyor interviewed CNA F and asked her to tell Surveyor about the incident on [DATE] with R40. CNA F indicated she was floating that night and had gone upstairs to assist CNA C. Between 5 and 5:30 AM, we went in by R40. R40 was refusing to be changed. LPN E was in room with us. CNA F indicated it took all three of us to convince R40 to take his AM medications. R40 indicated he wanted a male caregiver because us women were ganging up on him. CNA F indicated they left the room. CNA F went back downstairs, and CNA D asked what took so long and CNA F informed CNA D that R40 was refusing to be changed. CNA D offered to go up and attempt, so CNA F indicated she gave CNA D the room number and resident name. CNA F indicated she was not up in R40's room when incident occurred, but CNA D came back downstairs and indicated she had completed care for R40 with no problems. CNA F indicated she was informed by CNA C and LPN E that CNA D went in R40's room by herself and R40 refused, and CNA D rolled him anyway. CNA F indicated she had told CNA D residents have the right to refuse and CNA D indicated that staff can't leave a resident soiled because they will break down. On [DATE] at 7:55 AM, Surveyor interviewed CNA D and asked her to tell Surveyor about the incident on [DATE] with R40. CNA D indicated she was scheduled on the lower floor. CNA F indicated they had a hard time with R40, and he was refusing to be changed. CNA D offered to attempt cares with R40 and went upstairs to R40's room. CNA D indicated telling R40 he needed to be cleaned up because he was full of BM (bowel movement). R40 didn't say anything but made a few noises AH, AH. CNA D indicated R40 was full of BM and staff could not leave a resident like that because they will break down. CNA D indicated she was trying to break the ice and told R40 to suck it up buttercup, we are going for a ride. Surveyor asked CNA D how R40 replied to that, and CNA D indicated R40 did not say a whole lot but did not say what R40 said specifically. CNA D told R40 he was going to roll on his side towards the wall and CNA D began cleaning R40 up with wipes. R40 was pushing up against the wall with his hands trying to roll back over as CNA D was cleaning him. CNA D indicated R40 was bracing himself. Surveyor asked if R40 was in pain and CNA D indicated R40 might have said Ow! Surveyor asked CNA D if R40 was scared. CNA D stated he could have been because I was rolling him towards the wall. CNA D indicated she was not aware R40 had brain cancer. Surveyor asked CNA D if R40 ever told CNA D to stop and CNA D indicated R40 might have said Stop. CNA D indicated she was aware R40 did not want his bottom cleaned. Surveyor asked if R40 told her that and CNA D indicated no R40 was just fidgety. On [DATE] at 3:16 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A regarding the Facility Self Report dated [DATE] regarding R40 and CNA D. Surveyor asked NHA A if CNA D is still employed at facility. NHA A indicated yes. Surveyor asked what education CNA D has received and NHA A indicated resident rights, customer service and abuse. NHA A provided copies to Surveyor. Surveyor asked NHA A if this incident would be considered abuse and NHA A indicated yes, that is why we did a self-report on it. Surveyor asked NHA A to help Surveyor understand why CNA D was educated but not all of nursing staff. NHA A indicated the nursing staff was educated on resident rights at the inservice. Surveyor asked if nursing staff was educated on abuse and NHA A indicated no. NHA A indicated no explanation to why the facility did not educate all nursing staff on abuse after the incident. Surveyor asked if all staff should have been educated on abuse and NHA A indicated yes. Surveyor asked NHA A what facility has put into place to ensure residents safety from CNA D and NHA A indicated the Social Worker does touch base meetings with residents that had concerns regarding CNA D. Surveyor asked NHA A how often these touch base meeting occured and requested documentation. NHA A indicated she would check with the Social Worker. Surveyor asked NHA A how CNA D is monitored and how CNA D's interactions with residents are monitored and NHA A indicated through charting and touch base with residents for new concerns and following up if new concerns are brought forward. Surveyor asked if any new concerns regarding CNA D have come forward and NHA A indicated not to her knowledge. On [DATE] at 3:30 PM, Surveyor interviewed NHA A and SW G. Surveyor asked SW G if she did touch bases with residents and SW G indicated yes and she would look for them and get them to Surveyor. Surveyor asked what facility did to ensure residents safety when CNA D returned to work. SW G indicated the touch bases with residents and CNA D had someone with her the first night she returned to work on [DATE]. SW G indicated she interviewed all residents and followed up with the residents that had voiced concerns regarding CNA D. SW G indicated she also would ask residents in normal conversations during the day but did not document these conversations. SW G indicated she does walk bys and asks residents how they are doing but has not charted those. SW G indicated she asks residents if they feel safe and asks if they have any concerns when she completes BIMS (Brief Interview of Mental Status) and PHQ (Patient Health Questionnaire) quarterly and when needed for mood change. On [DATE] at 9:16 AM, Surveyor interviewed NHA A. Surveyor asked NHA A to help me understand if the facility considered the incident abuse should all staff have been educated on abuse. NHA A indicated she has no answer. With resident interviews, residents didn't voice concerns with other staff. It was handled as an isolated incident. Surveyor asked NHA A what her expectation is for staff if they observe abuse by another staff member towards a resident. NHA A indicated she would expect them to take over and ask that staff to leave. Surveyor asked with that being said, was that the case in this incident and NHA A indicated no, all staff should have been educated. Surveyor asked NHA A what time the incident was reported to the NHA, and NHA A indicated it should have been between 7:00 AM and 7:30 AM. NHA A indicated LPN E reported it to her, but NHA A did not have the time documented. Surveyor showed NHA A the Facility Self Report time with a reported time of 6:15 AM and it shows it was reported to the State Agency at 11:14 AM. Surveyor asked when it should be reported to the State and NHA A indicated within 2 hours. Surveyor asked if it was reported within the 2 hours, NHA A indicated no. Surveyor asked when should staff report abuse to the facility and NHA A indicated immediately. Surveyor asked NHA A how the facility ensured safety to all nonverbal residents and NHA A indicated by monitoring for bruises and injuries of unknown origin, watch for more agitation. Surveyor asked NHA A if skin assessments had been completed at the time of the investigation and NHA A indicated not at the time, but they are completed weekly. NHA A indicated the facility should have completed additional skin assessments with nonverbal residents at the time of the investigation. Surveyor asked NHA A if this was a complete investigation and NHA A indicated no, it should have included all staff education on abuse and skin assessments on nonverbal residents.

Based on observation, interview, and record review, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure injuries (R8). R8 developed a pressure injury, and the facility did not transcribe orders, did not ensure orders were being carried out, and did not put interventions in place to help improve and heal R8's pressure injury. Findings include. The facility's policy, Pressure Injury Prevention and Management, states: *After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. *Interventions will be based on specific factors identified in their risk assessment, skin assessment, and any pressure injury assessment (e.ge., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). *Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present period basic or routine care interventions could include comma but are not limited to: i.) Redistribute pressure such as repositioning, protecting and/or offloading heels, etc.); ii.) Minimize exposure to moisture and keep skin clean; iii.) Provide appropriate, pressure-redistributing, support surfaces, iv.) Provide non-irritating surfaces; and v.) Maintain or improve nutrition and hydration status, where feasible. *Interventions will be documented in the care plan and communicated to all relevant staff. R8 was admitted to the facility on [DATE] and has diagnoses that include dementia and hemiplegia (paralysis of one side of the body) affecting left non-dominant side. Her most recent Minimum Data Set (MDS), dated [DATE] includes a Brief Interview for Mental Status (BIMS) score 00, indicating R8 is severely cognitively impaired. R8 was admitted with a stage 2 pressure injury on her left elbow. R8's 9/21/24 Braden (scale for predicting pressure ulcer risk), reveals a score of 12, indicating R8 is at high risk for pressure ulcer development. R8's care plan states, Focus: Alteration in skin integrity with potential for additional areas of skin breakdown related to dementia, left hemiparesis, weakness, functional urinary and bowel incontinence (date initiated: 11/7/23) .Goal: Management of pressure ulcer (date initiated 11/7/23), prevention of future pressure ulcers (date initiated 11/7/23). The interventions for R8's skin integrity focus, all dated 11/7/23, are: *Evaluate skin for areas of blanching or redness *Evaluate ulcer characteristics *Keep skin clean and well lubricated *Monitor bony prominences for redness *Monitor ulcer for signs of progression or declination *Notify family of new onset finding *Provide wound care per treatment order R8's Kardex (Certified Nursing Assistant care plan) does not address any guidance for CNAs on how to address and manage R8's pressure injuries (positioning, cares, etc.) R8's nutritional orders include Magic Cup (protein supplement) one time a day (ordered 3/24/24), Liquacel (protein supplement) at supper for wound healing (ordered 12/28/23), and Breeze (protein supplement) three times a day with all meals (ordered 12/21/23). The facility documented the following progress note on 11/8/24 at 2:31 PM: CNA reported that resident had a hole in her L foot. Upon assessment this writer noted a round open area measuring 15mm x 10mm x 2mm with slough tissue to the wound bed. Some necrotic tissue noted to wound bed as well. No drainage noted at this time. Peri wound skin red and blanchable. No tunneling noted. Wound edges red and moist in appearance. Dry flakey skin noted beyond peri wound area. Cleaned with NS (normal saline) and bordered foam dressing applied. DON (Director of Nursing) updated. Doctor updated via fax. R8's physician directed staff to continue to monitor and continue with the border foam dressing. The facility's weekly wound observation, dated 11/11/24, states that R8's pressure injury to the left heel measures 10 mm x 10 mm x 2 mm (length x width x depth) with 100% slough, no drainage or odor, with a peri-wound description of red and blanchable and wound edges described as red and moist. Additionally, this observation documents border foam as the current treatment plan. No documentation was provided showing that R8's border foam dressing was being completed, nor the details of the order (frequency, timing, etc.). On 11/13/24 at 2:11 PM, LPN I (Licensed Practical Nurse) documented the following progress note for R8 Resident's left foot wound looks infected at this time and has an odor to it. Inside of wound does appear to be tunneling and yellow drainage is present. LPN I notified R8's physician, who then requested the NP (Nurse Practitioner) see R8 quickly, as he (R8's physician) was unable to get to the facility until 11/25/24. The 11/19/24 weekly wound observation noted the left heel to be worsening with measurements of 7mm x 9mm x 5 mm, tunneling all around the perimeter of the wound, deepest at 6:00 at 0.4 cm. The wound was also described as red and blanchable, with non-attached wound edges. The wound was noted to be unstageable at this point. The NP's note from her wound visit with R8 dated 11/19/24 states, Having pain upon assessment of wound today. Pulling her foot away from provider and kicking with the right foot .patient is severely contracted .swelling of soft tissues .pressure ulcer of left leg, unspecified pressure ulcer stage. The NP's post visit summary states, The optimal goal for wound care will be to relieve pressure, keep the wound clean, and attempt to prevent infection. Cleanse wound with wound cleanser. Patient to have plain packing gauze impregnated with Santyl and lightly fluffed into wound bed. Cover with small nonstick pad and Band-Aid or Tegaderm. Change daily. This order was placed on 11/19/24 with a start date of 11/19/24. The NP order for Santyl external ointment 250 unit/gram applied daily to left heel was not started until 11/22/24. Additionally, according to R8's Medication Administration Record (MAR), R8's Santyl treatment was not done on 11/24/24 and 11/25/24. Of note, the facility experienced an environmental emergency beginning 11/27/24 which required transfer of all residents to other local facilities. The facility sent its own staff to these neighboring facilities and continued caring for their own residents. Residents returned to the facility on [DATE]. During this hiatus from the facility, R8's MAR indicates all her medications and treatments were conducted with exception of the Santyl treatment to her left heel. From 11/28/24 up to and including 12/6/24, no documentation was made that these treatments were carried out at the temporary facility. Subsequent weekly wound observations on 11/28/24 and 12/5/24 indicate the wound was unchanged with measurements and description of the wound matching that of the 11/19/24 assessment. On 12/12/24 at 10:11 AM, Surveyor observed RN H (Registered Nurse) conduct R8's daily Santyl treatment. R8 was lying in bed on her right side. Of note, R8 does not have an air mattress. When RN H lifted the blanket off R8, her left foot was observed directly on the mattress. The wound, which had been described as left heel was observed to be on the ball of R8's large toe. This area appeared to be directly on the mattress as R8's foot appeared to naturally turn down to the mattress. R8 was lying on her right side with her knees together and the left foot draped over her right so that the underside of her left foot's large toe presses directly on the mattress. After the treatment, RN H put a fleece blanket between R8's knees. When asked if R8's foot should have been offloaded from the mattress prior to the treatment, RN H stated, Yes, and indicated that R8 had blue boots (a boot to offload pressure) in the past but would kick them off. RN H indicated that R8 can be repositioned on her left side, although she (R8) prefers to lay on her right side. On 12/12/24 at 1:52 PM, Surveyor interviewed LPN I who stated that on 11/13/24 she was told by the night shift nurse that she had smelled an odor coming from R8's left foot wound. LPN I stated that this night nurse did not contact the doctor and indicated that this night nurse had been aware of this odor from R8's foot for a few days. LPN I stated that she went and looked at the wound and it had an odor and it was tunneling. LPN I stated that she then contacted the doctor. LPN I stated that she was unaware of any pressure relieving devices for R8 and had not seen anything specifically care planned for her and staff to follow for pressure relief. Additionally, on 12/12/24, Surveyor interviewed CNA O (2:24 PM) and CNA P (2:29 PM), both of whom stated that they did not know of any interventions to prevent pressure and/or offload R8's foot nor were they doing anything specific as there was nothing care planned. CNA O indicated that she doesn't position R8 on her left side as that is her weak side and prefers not to lie on that side. It should be noted that R8 does not have a specialty pressure-relieving/reducing mattress, but rather the standard mattress that all residents use. The facility was unable to provide any information on the standard mattress and its pressure relieving capabilities. On 12/12/24 at 5:25 PM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A is the interim NHA at the facility and was DON before her interim NHA status. When asked to review R8's MAR from 12/1-12/6, NHA A indicated she would expect it to be signed out and to have been completed for those dates. NHA A is unable to say it was completed based on MAR not being signed out. Surveyor asked if this would be documented any other place as completed, NHA A indicated she would look. Additionally, NHA A indicated there was an order for border foam for the initial treatment of R8's left foot wound, but the order was never put into the system. NHA A indicated she was unaware how many times it was done or if the treatment was conducted regularly. NHA A was unable to find any historical or current interventions for R8 to offload and/or relieve pressure from her left foot wound. The facility became aware of R8's left foot wound on 11/8/24, which was assessed to be a stage 2 pressure injury, and had orders to apply border foam, however, this order was not put into the facility's system. It is unknown the extent of its application. Additionally, on 11/13/24, R8's wound was noted to have worsened, having become odiferous with draining and tunneling observed. The wound was assessed at this time and noted to be unstageable. R8 was seen by the NP on 11/19/24, who confirmed the wound to be unstageable, with orders changed to Santyl daily, which was not started until 11/22/24 with treatments on 11/24/24 and 11/26/24 not documented. Additional treatments were not documented to have been done between 11/28/24 to 12/6/24 when R8 was at a neighboring facility due to the facility having an environmental emergency. On 12/12/24, Surveyor observed R8's foot directly on her mattress. The facility did not put any interventions in place at any time on or after 11/8/24 to offload and/or reduce pressure on R8's foot.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 39 residents. Nutritional supplements and food items were observed with improper dates. An employee walked through the kitchen with no hairnet. A scoop was observed inside a container of sugar. Findings include Example 1 On 12/10/24 at 8:48 AM, Surveyor, along with DM Q (Dietary Manager), observed the following in the kitchen's dry storage: *3 bags of unopened pasta with no use by date *28-6 lb. cans of various vegetables and pie fillings with no received or use-by dates At 9:00 AM, Surveyor and DM Q observed the following in the kitchen's main refrigerator: *A container of sunflower seeds with an open/prepared date of 5/17/24 and a use by 10/17/24 *4 thawed nutritional supplements with no thaw dates (manufacturer label states the supplement must be used within 14 days of thawing). At 9:07 AM, DM Q stated that the nutritional supplements need to be thrown away as there is no thaw date and the container of sunflower seeds is past its use-by date and needed to be discarded. Example 2 On 12/10/24 at 9:08 AM, Surveyor, along with DM Q, observed CM R (County Maintenance) walk into the main kitchen without a hairnet. CM R walked through food preparation areas. CM R acknowledged Surveyor at this time indicating that he was not wearing a hairnet and needed one. Example 3 On 12/10/24 at 9:08 AM, Surveyor, along with DM Q, observed a large container of sugar in the facility's main kitchen. Inside the container of sugar a scoop could be seen. At this time, DM Q stated the scoop should not be in there due to potential cross-contamination and infection control standards.

Based on interview and record review, the facility did not identify issues to which quality assessment and assurance activities are necessary or make a concentrated effort to improve facility quality. This has the potential to affect all 39 residents. The facility does not have a Quality Assurance and Performance Improvement (QAPI) system in place and has failed to identify areas needing improvement to develop, implement, monitor, and evaluate action plans to achieve specific goals to improve quality of care. This is evidenced by the following: The facility policy, entitled Quality Assurance and Performance Improvement (QAPI) and dated 1/1/24, states, in part, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to: . Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . Governing oversight responsibilities include but are not limited to: . Ensuring the program is sustained during transitions in leadership and staffing . The facility conducts at least one distinct performance improvement project (PIP) annually that focuses on high risk or problem prone areas. Additional projects may be conducted as needed, and may be clinical or non-clinical in nature . The facility policy, entitled, QAPI Change Process, dated 1/1/24, states, in part: The facility has established and utilizes a systemic approach to performance improvement activities to ensure changes are effective and improvements are sustained . The facility must conduct distinct performance improvement projects, based on the scope and complexity of facility services and available resources, identified in the facility assessment . The facility must conduct at least one improvement project annually that focuses on high-risk or problem-prone areas, identified by the facility through data collection and analysis .: On 12/11/24 at 2:22 PM, Surveyor reviewed the facility QAPI binder. There was no evidence of the facility having a PIP in place to improve quality of care for the residents. On 12/12/24 at 2:06 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding the QAPI process and plan. Surveyor asked NHA A how the facility tracked QAPI initiatives. NHA A stated she didn't have an answer for that as she has only conducted one QAPI meeting herself since assuming the role of NHA in October. Surveyor asked NHA A if the facility was currently working on any PIPs. NHA A replied no, they were currently not working on any PIPs. Surveyor asked NHA A if they should be working on a PIP at least annually to ensure quality of care to the residents. NHA A replied yes, they should have a PIP, but with the changes in facility leadership it has been difficult to prioritize the QAPI plan and initiatives. The facility did not follow their QAPI plan to identify at least one improvement project that focused on problem areas to ensure quality of care for their residents.

Based on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff one of whom must be the administrator, owner, a board member or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 39 Residents residing within the facility. Quality Assurance and Performance Improvement (QAPI) meetings did not consist of the required attendees/members for any of the quarterly meetings in the past year. This is evidenced by: The facility policy, entitled Quality Assurance and Performance Improvement (QAPI) and dated 1/1/24, states, in part, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . The QAA (Quality Assessment and Assurance) Committee shall be interdisciplinary and shall consist of a minimum of: i. The Director of Nursing Services ii. The Medical Director or his/her designee; iii. At least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member, or other Individual in a leadership role; and iv. The Infection Preventionist . On 12/11/24 at 2:22 PM, Surveyor reviewed the facility's QAPI Committee meeting sign in sheets and noted the following: The QAPI meeting attendance sheet dated 11/6/23 did not include the Infection Preventionist (IP). The QAPI meeting attendance sheet dated 1/31/24 did not include the IP. The QAPI meeting attendance sheet dated 4/29/24 did not include the Administrator or IP. The QAPI meeting attendance sheet dated 7/29/24 did not include the IP. The QAPI meeting attendance sheet dated 10/28/24 did not include the IP. On 12/12/24 at 2:06 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding the facility's QAPI process and QAA meetings. Surveyor asked NHA A who should be in attendance for the QAPI meetings. NHA A replied the NHA, DON (Director of Nursing), MD (Medical Director), Social Services, Dietary, Activities, Pharmacy, and the MDS (Minimum Data Set) Coordinator. Surveyor asked NHA A if the IP should be in attendance at the meetings. NHA A indicated she was not aware the IP needed to attend the meetings, as infection control is presented by the DON at the meetings. Surveyor reviewed the facility QAPI policy with NHA A. Surveyor asked if, per their policy, the IP should be included in the QAPI meetings. NHA A replied yes, the IP should attend the meetings.

Based on interview and record review, the facility has not established 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. The facility does not have a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This has the potential to affect all 39 residents (R) in the facility. Surveyors observed missing ceiling tiles with water actively dripping from a pipe into a container near residents during the lunch meal. The facility does not have mechanism for tracking Multi-Drug Resistant Organisms (MDRO). The facility's monthly infection control rates were not segregated for specific infection types. The facility could not provide evidence their water management program included: 1) Descriptions of the building water system using text and flow diagrams. 2) Identification of areas where Legionella and other opportunistic waterborne pathogens can grow and spread. 3) Description of where control measures should be applied and how to monitor them. Findings include: The facility policy titled, Infection Surveillance, date reviewed, 10/23/24, indicates, in part: Policy: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections . Policy Explanation and Compliance Guidelines: .7. The facility will communicate via (specify how, e.g. written reports, staff meetings, etc.) to staff and/or prescribing practitioners information related to infection rates and outcomes in order to revise interventions/approaches and/or re-evaluate medical interventions as indicated. 8. Monthly time periods will be used to capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. 9. All resident and infections will be tracked. Separate, site-specific measures may be tracked as prioritized from the infection control risk assessment . The facility policy titled, Infection Prevention and Control Program, date reviewed, 10/23/24, indicates, in part: Policy: The facility has established and maintains 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 as per accepted standards and guidelines .3. Surveillance: .b. The infection preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee . The facility policy titled, Water Management Program, date reviewed, 10/23/24, indicates, in part: Policy: It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens .in the facility's water systems based on nationally accepted standards (e.g., ASHRAE, CDC, EPA). Policy Explanation and Compliance Guidelines: .3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems .4. Data to be used for completing the risk assessment may include but are not limited to: a. Water system schematic/description. b. Legionella environmental assessment .5. Based on the risk assessment, control points will be identified. The list of identified points shall be kept in the water management program binder . The CDC Legionella Toolkit-Version 1.1 - June 24, 2021, Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings. A Practical Guide to Implementing Industry Standards, indicates, in part: Page 4 - Where can Legionella grow and/or spread? . *Water heaters . *Electronic and manual faucets . *Showerheads and hoses . *Ice Machines . Page 8 - Describe Your Building Water Systems Using Text .You will need to write a simple description of your building water system and devices .This description should include details like where the building connects to the municipal water supply, how water is distributed, and where pools, hot tubs, cooling towers, and water heaters or boilers are located . Page 10 - Describe Your Building Water Systems Using a Flow Diagram .In addition to developing a written description of your building water system, you should develop a process flow diagram . Page 11 - Identify Areas Where Legionella Could Grow & Spread .Once you have developed your process flow diagram, identify where potentially hazardous conditions could occur in your building water system . Example 1 On 12/10/24 at 11:18 AM, surveyors observed resident dining at the lunch mealtime in the first-floor dining area. Surveyors observed 5 ceiling tiles missing with exposed pipes, a ladder, a container, and towels placed under the open ceiling with water dripping into the container and debris on the floor. The container the water was dripping into was less than 2 feet from 2 residents sitting at a dining table. There were an additional 5 residents seated at another table near the open ceiling and container collecting the dripping water. On 12/10/24 at 11:30 AM, Surveyors interviewed NHA A (Nursing Home Administrator) in the first-floor dining area. NHA A indicated a pipe started leaking yesterday from a resident room above the dining room that maintenance was currently trying to repair. Surveyor asked NHA A how she would feel if she was one of the residents dining next to this. NHA A indicated not well. Surveyor asked if this could be an infection control issue in a dining area. NHA A indicated it could be and that the residents should have been seated somewhere else. On 12/10/24 at 11:36 AM, staff moved a total of 7 residents to an area away from the open ceiling and dripping water. Example 2 On 12/11/24 and 12/12/24 Surveyor reviewed the infection control program documentation provided by the facility. On 12/12/24 at 10:07 AM, Surveyor met to review the infection control program with LPN I, (Licenses Practical Nurse) who is also the Infection Preventionist (IP) for the facility, and NHA A. NHA A is the interim NHA at the facility and was DON (Director of Nursing) before her interim NHA status. Surveyor asked if the facility has a tracking mechanism for residents who have MDRO's (Multi-Drug Resistant Organisms). LPN I and NHA A indicated with the size of the building they know which residents have MDRO's and were able to list these residents for Surveyor. LPN I and NHA A indicated they do not have an actual mechanism to track these MDROs that others would be able to access. Example 3 On 12/11/24 and 12/12/24 Surveyor reviewed the infection control program documentation provided by the facility. On 12/12/24 at 10:07 AM, Surveyor met to review the infection control program with LPN I, who is also the Infection Preventionist (IP) for the facility, and NHA A. NHA A is the interim NHA at the facility and was DON (Director of Nursing) before her interim NHA status. Surveyor reviewed the monthly IC (Infection Control) rates that were provided by the facility with LPN I and NHA A. The monthly rates provided are for overall infection rates and not segregated for specific infection type. NHA A indicated that she completes the monthly infection rates and only completes overall rates and does not have them by specific infection type. Surveyor asked how they can ascertain an increase in a certain infection type without segregated rates. NHA A indicated they cannot. Example 4 On 12/12/24, Surveyor reviewed the water management documentation provided by the facility. On 12/12/24 at 5:18 PM, Surveyor interviewed NHA A regarding the facility water management program information that had been provided. Surveyor was unable to locate: 1) Descriptions of the building water system using text and flow diagrams. 2) Identification of areas where Legionella and other opportunistic waterborne pathogens can grow and spread. 3) Description of where control measures should be applied and how to monitor them. Surveyor asked NHA A if maintenance was available to speak with as the water management policy indicates the Maintenance Director maintains documentation that describes the facility's water system. NHA A indicated that maintenance was not available at that time. Surveyor reviewed the above items that could not be located in the water management documents provided. NHA A indicated that these things should have been included in the water program and that she will check maintenance to see if she can locate the binder referenced in the policy. Of note, no further documentation related to the water management program was provided to the Surveyor.

Based on observation, interview, and record review, the facility did not ensure drugs and biological's are labeled in accordance with currently accepted professional standards for 2 of 2 Medication carts reviewed and 2 of 2 medication rooms for medication storage. The 2nd floor medication cart had an undated open insulin pen for R34, and expired morphine tablets for R25. The 3rd floor medication cart had a cough syrup for R1 with no open date or expiration date. The 2nd and 3rd floor medication storage rooms had expired stock meds. Evidenced by: The Facility's Policy, entitled Labeling of Medications and Biologicals, dated 1/5/2022 with last revision date of 11/2024 states, in part: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications . 1. All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices . 9. Labels for medications designed for multiple administration (such as inhalers, eye drops), the label will identify the specific resident for whom it was prescribed . The Facility Policy, entitled, Medication Storage, dated 1/5/2024 with last revision date of 11/2024, states, in part: .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms according to the manufacturer's recommendations . 9. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed . The Facility Policy, entitled, Medication Administration, dated 1/5/2022 with last revision date of 11/2024, states, in part: Medications are administered . in accordance with professional standards of practice . 12. Compare medication source (bubble pack, vial, etc.) with MAR (Medication Administration Record) to verify resident's name, medication name, form, dose, route, and time . 13. Identify expiration date. If expired, notify nurse manager . Example 1 On 12/12/24 at 8:28 AM, Surveyor observed the 2nd floor medication storage room with LPN I (Licensed Practical Nurse). Surveyor found two bottles of Thiamin Vitamin B1 100 mg (milligrams) with an expiration date of 11/2024, one bottle of Super View Healthy Eyes eye vitamins with expiration date of 7/2/24 and a bottle of Paxlovid 300 mg with an expiration date of 11/2024. Surveyor asked LPN I how long medications were good for after the open date. LPN I answered the medications were good for 30 days after opening. Example 2 On 12/12/24 at 8:49 AM, Surveyor observed the 3rd floor medication storage room with LPN I. Surveyor found a box of acetaminophen 650 mg suppositories with an expiration date of 2/2024. LPN I indicated that the last resident to use this medication was over a year ago. Surveyor found a bottle of Vitamin D 10 mcg (micrograms) with an expiration date of 11/2024. Surveyor asked LPN I who was responsible for checking the medication storage rooms for expired medications. LPN I replied that typically the night nurses go through the storage rooms and dispose of expired medications. Example 3 On 12/12/24 at 9:11 AM, Surveyor observed the 2nd floor medication cart with DON B (Director of Nursing). Surveyor noted two bottles of GenTeal eye drops not properly dated with an open date, a box of Hydrocort (hydrocortisone) 25 mg suppositories with an expiration date of 11/2024, a bottle of fish oil capsules not properly dated with an open date, a blister pack of Muccinex removed from the original packaging with no expiration date, a used Lantus insulin pen for R34 with no open date and no expiration date, and morphine sulfate 15 mg tablets for R25 with an expiration date of 9/25/24. DON B indicated that the insulin pens are normally dated when they are first used. Surveyor asked DON B if the nurses administering the medications should be checking the expiration dates. DON B replied yes, but that hospice was responsible for checking the medication cart for expired medications for their patients. Example 4 On 12/12/24 at 9:31 AM, Surveyor observed the 3rd floor medication cart with RN H (Registered Nurse). Surveyor found a bottle of Delsym cough syrup for R1 with no expiration date and not properly dated with an open date. Surveyor asked RN H how long medications were good for after the open date. RN H answered the medications were good for 28 days after opening. On 12/12/24 at 1:47 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding medication storage and expiration dates. Surveyor asked NHA A who was responsible for checking medication carts and medication storage rooms for expired medications. NHA A replied that the nurses are responsible for checking for expired medications, and also that the pharmacy comes every three months and does an audit looking for expired medications. Surveyor asked NHA what her expectation was for dating over the counter medications and insulin pens. NHA A stated the nurses were expected to date the bottles when they open them and also date eye drops and insulin. Surveyor asked NHA A how long medications were good for after the open date. NHA A indicated the medications were good until the manufacturer's expiration date. Surveyor asked NHA A if she expected that the medications administered to the residents would be before the expiration date. NHA A replied yes, that would be her expectation.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 1 of 17 abuse investigations reviewed involving (R40). Facility became aware of an abuse allegation on [DATE] at 6:15 AM and did not report it to the State Agency until [DATE] at 11:14 AM. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated [DATE], states, in part: . Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . V1I. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . R40 was admitted to the facility on [DATE] and has diagnoses that include, malignant neoplasm of unspecified part of left bronchus or lung (a cancerous tumor that has developed in the left bronchus, one of the large airways in the lungs) and nontraumatic intracranial hemorrhage (bleeding in the brain that occurs without trauma or surgery). R40 admitted to hospice [DATE] and expired [DATE]. Facility Self Report dated [DATE], at 11:14:22 AM, states, in part: . Summary of Incident: Allegation Type: Abuse: Hitting, slapping, threats of harm, assault, humiliation. Name-Affected Person: R40 Name-Accused Person: CNA D (Certified Nursing Assistant) . Date occurred: [DATE]. Time occurred: 06:15 AM . Date discovered: [DATE] . Briefly Describe the incident . R40 recently admitted to the facility. It was reported that resident was reporting pain during cares when CNA D was assisting. CNA D continued cares after resident stated to stop . Explain what steps the entity took upon learning of the incident to protect the affected person and others from further potential misconduct: Upon learning of the incident, investigation was started; CNA D was put on leave. Residents interviewed to determine if they feel their rights are being upheld by CNA D and other staff . On [DATE] at 9:16 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A what time the incident was reported to you, and NHA A indicated it should have been between 7:00 AM and 7:30 AM. NHA A indicated LPN E (Licensed Practical Nurse) reported it to her, but NHA A did not have the time documented. Surveyor showed NHA A the Facility Self Report time reported was 6:15 AM and it shows it was reported to the State Agency at 11:14 AM. Surveyor asked when the self-report should have been reported to the State Agency and NHA A indicated within 2 hours. Surveyor asked if it was reported to the State Agency within 2 hours and NHA A indicated no. Surveyor asked the NHA A when should staff report abuse to the facility, NHA A indicated immediately.

Based on interview and record review, the facility failed to thoroughly investigate an accusation of physical abuse for 1 of 17 residents (R40) reviewed for abuse. Facility became aware of an abuse allegation on [DATE] and did not complete a thorough investigation. Evidenced by: The facility policy, entitled Abuse, Neglect and Exploitation, dated [DATE], states, in part: . Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse . V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g. not tampering or destroying evidence). 3. Investigating different types of alleged violations. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: . A. Responding immediately to protect the alleged victim and integrity of the investigation; . C. Increased supervision of the alleged victim and residents . VII. Reporting/Response . 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences. b. Defining how care provisions will be changed and/or improved to protect residents receiving services. c. Training of staff on changes made and demonstration of staff competency after training is implemented. d. Identification of staff responsible for implementation of corrective actions. e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan . R40 was admitted to the facility on [DATE] and has diagnoses that include, malignant neoplasm of unspecified part of left bronchus or lung (a cancerous tumor that has developed in the left bronchus, one of the large airways in the lungs) and nontraumatic intracranial hemorrhage (bleeding in the brain that occurs without trauma or surgery). R40 admitted to hospice [DATE] and expired [DATE]. Facility Self Report dated [DATE], at 11:14:22 AM, states, in part: . Summary of Incident: Allegation Type: Abuse: Hitting, slapping, threats of harm, assault, humiliation. Name-Affected Person: R40 Name-Accused Person: CNA D (Certified Nursing Assistant) . Date occurred: [DATE]. Time occurred: 06:15 AM . Date discovered: [DATE] . Briefly Describe the incident . R40 recently admitted to the facility. It was reported that resident was reporting pain during cares when CNA D was assisting. CNA D continued cares after resident stated to stop . Explain what steps the entity took upon learning of the incident to protect the affected person and others from further potential misconduct: Upon learning of the incident, investigation was started; CNA D was put on leave. Residents interviewed to determine if they feel their rights are being upheld by CNA D and other staff . Resident Interviews conducted by SW G (Social Worker) during investigation, dated [DATE], shows 3 residents voiced CNA D does not respect their wishes and 3 indicate CNA D has disregarded their wishes. 2 of those 3 residents voiced they do not feel safe when CNA D works with them. On [DATE] at 3:30 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and SW G (Social Worker). Surveyor asked SW G if she did touch bases with residents and SW G indicated yes and she would look for them and get them to Surveyor. Surveyor asked what facility has done to ensure residents safety when CNA D returned to work, and SW G indicated the touch bases with residents and CNA D had someone with her the first night she returned to work on [DATE]. SW G indicated she interviewed all residents and followed up with the residents that had voiced concerns regarding CNA D. SW G indicated she also would ask residents in normal conversations during the day but did not document these conversations. SW G indicated she walks by a resident room and asks residents how they are doing but has not charted those. SW G indicates she asks residents if they feel safe and ask if they have any concerns when she completes BIMS (Brief Interview of Mental Status) and PHQ (Patient Health Questionnaire) quarterly and when needed for mood changes. On [DATE] at 9:16 AM, Surveyor interviewed NHA A. Surveyor asked NHA A how the facility ensured safety to all nonverbal residents and NHA A indicated by monitoring for bruises and injuries of unknown origin, watch for more agitation. Surveyor asked NHA A if skin assessments had been completed at time of investigation and NHA A indicated not at time, but they are completed weekly. NHA A indicated the facility should have completed additional skin assessments with nonverbal residents at the time of investigation. Surveyor asked NHA A if this was a complete investigation and NHA A indicated no, it should have included all staff education on abuse and skin assessments on nonverbal residents.

Based on observation, interview, and record review, the facility did not ensure adequate supervision or fall interventions were in place for residents who required increased supervision to prevent accidents/hazards from occurring for 2 of 3 sampled residents (R3 and R1). R3 was to have an alarm on for a fall intervention according to her Plan of Care. R3 had a fall on 1/15/24 resulting in a right hip fracture. The facility did not have an alarm placed on R3 at the time of the fall. Evidenced by: The facility policy, entitled Fall Policy and Procedure, undated, states, in part: Policy: Staff shall assess for risk, provide preventative measures, and address falls in a safe and professional manner. Procedure: Fall risk assessment: 1) Upon admission, a fall risk assessment completed. Risk will be assessed quarterly and PRN (as needed). 2) Upon assessment, staff will provide needed intervention to prevent fall. Intervention is added to the care plan . Fall team meeting: 3) Staff education will be distributed as applicable within 24 hours of meeting . The facility policy, entitled Fall Risk Assessment, with a revision date of 1/15/23, states, in part: Policy: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Policy Explanation and Compliance Guidelines: 1) The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified. 2) The risk assessment will contain the following components: a. Identify environmental hazards and individual risks, including the need for supervision. b. Evaluate and analyze hazards and risks. 3) An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. 4) The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident . The facility policy, entitled Resident Alarms, with a revision date of 1/15/24, states, in part: Policy: It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being . Policy Explanation and Compliance Guidelines: 2) The facility shall establish and utilize a systemic approach for the safe and appropriate use of resident alarms, including efforts to identify risk; evaluate and analyze risk; implement interventions to reduce risk; and monitor for effectiveness of the interventions and modifying interventions when necessary . 5) Implementation of interventions d. Interventions shall be communicated to all relevant staff, including frequency/time frames and responsibility. 6) Monitoring and modification . b. When alarms are utilized, additional monitoring shall be provided, including but not limited to: i. Verifying alarms are used in accordance with the resident's care plan . Example 1: R3 was admitted to the facility on [DATE] and has diagnoses that include: unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking. Unspecified dementia is a dementia without specific diagnosis,) repeated falls, muscle weakness, and unsteadiness on feet. R3's Minimum Data Set (MDS) Admission Assessment, dated 3/17/23, shows R3 has a Brief Interview of Mental Status (BIMS) score of 10 indicating R3 has moderate cognitive impairment. Section GG shows R3 is dependent (Helper does ALL of the effort. resident does none of the effort to complete the activity) for Sit to Stand, Chair/bed to chair, and Toileting. R3's Fall Risk Evaluation, dated 12/7/23, states, in part: Score - 17 At Risk History of Falls (past 3 months) - 3 or more falls in past 3 months . 5. Gait/balance - Balance problem while standing, Balance problem while walking . R3's baseline care plan, dated and signed by R3 on 12/8/23, states, in part: H. Safety Risks 1. Does resident have a history of falls? Yes 2. Did resident have a fall any time in the last month prior to admission/entry or reentry? Yes 21a. Specify fall during the last month prior to admission. Self-Transfer . *Of Note - there are no fall interventions in place even though R3 is identified as a fall risk. R3's Physician Orders, dated 1/18/24, state, in part: Pressure alarms are in place and functioning properly . Order Date: 1/7/24 Start Date: 1/7/24 . R3's Treatment Administration Record (TAR) for January 2024 shows: Pressure alarms are in place and functioning properly. Every shift Start Date: 1/7/24 6:30 AM for 11/7/23 through time of fall on 1/15/24. R3's Care Plan, dated 1/12/24, with a target date of 4/1/24, states, in part: Focus: Risk for Falls Goal: Resident will be free of falls Interventions/Tasks: *Assist Resident with ambulation and transfers, utilizing therapy recommendations. Date Initiated: 1/14/24 . *If Resident is a fall risk, initiate fall risk precautions. Date Initiated: 1/14/24 . *Of note - Does not mention R3 is to have an alarm in place. Focus: Safety Date Initiated: 1/14/24 Goal: Resident will remain safe Date Initiated: 1/14/24 Target Date: 4/1/24 Interventions/Tasks: *Perform safety risk evaluation(s) on admission, as needed and upon changes in condition Date Initiated: 1/15/24 *Safety measures- including strategies to reduce the risk of infection, falls, injury initiated as appropriate Date Initiated: 1/15/24 . *Of note - Does not mention R3 is to have an alarm in place. Focus: The resident has limited physical mobility r/t (related to) UTI (Urinary Tract Infection), dementia, weakness, balance deficit. Date Initiated: 12/18/23 . Interventions/Tasks: *Chair/bed-to-chair transfer:1 assist Date Initiated: 1/14/24 *Sit to Stand: 1-2 assist Date Initiated: 1/14/24 * Walk 19 feet: Dependent 1 assist with walker and wheelchair to follow Date Initiated: 1/14/24 *Ambulation: The resident is totally dependent on (1) staff for walking. Date Initiated: 1/14/24. Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t UTI, dementia, weakness, balance deficit. Date Initiated: 12/18/23 . Interventions/Tasks: Date Initiated: 1/14/24 . *Transfer: The resident is totally dependent on (x) staff for transferring. Date Initiated: 1/14/24. *Transfer: The resident requires Mechanical Lift (SPECIFY) with (x) staff assistance for transfers. Date Initiated: 1/14/24 . R3's Certified Nursing Assistant (CNA) Kardex, dated 1/18/24, states, in part: Safety: *Be sure the Resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. *Ensure that the Resident is wearing appropriate footwear shoes or non-skid socks when ambulating or mobilizing in w/c (wheelchair). *Follow facility fall protocol. *Of note - there is no mention of R3 to have alarms placed. R3's Incident/Fall Report documents the following: Nursing Description: Resident was lying in hallway about 20 feet from door on her right side with her head against the wall. She had her nonslip shoes on. Her wheelchair/walker was in her room. She had been sitting in her recliner, which was still in the reclined position. No alarms were activated. Fall was unwitnessed. Resident Description: Resident stated that she was trying to walk and that she would never walk on this floor again. She c/o (complained of) right hip pain that increased with movement. Immediate Action Taken: Description: CNAs alerted writer and vitals were taken while resident was in position she was found in on the floor. Neuro assessment performed and was WNL (within normal limits). DON (Director of Nursing) alerted, order received from (MD Name) and EMS (emergency medical services) alerted for transport to ER (emergency room ). Resident was not moved except to lie flat on back with support of head and under R (right) knee to help relieve pressure on R hip. Resident Taken to Hospital: Y Level of Pain: PAINAD (Pain Assessment in Advanced Dementia Scale - 1-3=mild pain, 4-6=moderate pain, 7-10=severe pain) - 7 Level of Consciousness: Alert Mobility: Ambulatory with assistance Mental Status: Oriented to Person, Oriented to Situation, Oriented to Place, Oriented to Time Predisposing Environmental Factors: None Predisposing Physiological Factors: Gait Imbalance, Recent Illness, Weakness/Fainted Predisposing Situation Factors: Ambulating without Assist Other Info: Hx. (history) of falls Witnesses: No witnesses found . R3's progress note dated 1/15/24, at 2:34 PM, states: Resident was lying in hallway about 20 feet from door on her right side with her head against the wall. She had her nonslip shoes on. Her wheelchair/walker was in her room. She had been sitting in her recliner, which was still in the reclined position. No alarms were activated. Fall was unwitnessed. Order received from (MD Name) to send resident to ER for evaluation as resident was c/o (complained of) R hip pain. Facility's Incident Audit Report, dated 1/15/24 at 2:10PM, states, in part: I took (resident name) to her room from lunch there was not an alarm on the resident. Then transferred her to her recliner took her shoes off gave her the call light and left the room. Then about an hour and a half the other CNA and I heard a loud noise and down the hallway and seen (resident name) on the floor. I then went left the aide and resident and went to get nurse. R3's History and Physical (H&P), dated 1/15/24, states, in part: Patient admitted to hospital 1/15/24 at 11:50PM . Chief Complaint: Transfer from outside hospital for fall with right-sided intertrochanteric hip fracture and C7 compression fracture . History of Present Illness: .female with a history of . osteoporosis and gait instability with history of frequent falls . who presents as a transfer from outside hospital for fall with right-sided intertrochanteric hip fracture and C7 compression fracture. The patient initially presented to (Hospital Name) after a fall at her skilled nursing facility . Physical Examination: . Extremities: Right lower extremity shortened and externally rotated, distal neurovascular bundle intact with 2+ dorsalis is pulse . Imaging: . CT Abdomen and Pelvis with contrast . Impression: 1. Acute impacted intertrochanteric right femoral neck fracture with adjacent soft tissue contusion . CT Cervical Spine without contrast: . Impression: 1. Acute anterior wedge compression deformity of C7 . XR Femur Min 2 Views R . Findings: Intertrochanteric right hip fracture noted. Active Hospital Problems: Diagnosis: -Fall -Closed fracture of right hip with nonunion -Compression fracture of C7 vertebra with nonunion -Closed wedge compression fracture of T8 vertebra with nonunion -Skin tear of elbow without complication, right, subsequent encounter . Operation Date: 1/16/24 Preoperative Diagnosis: 1. Right closed intertrochanteric femur fracture Postoperative Diagnosis: 1. Right closed intertrochanteric femur fracture On 1/18/24 at 2:57 PM, Surveyor asked DON B (Director of Nursing) to describe R3's fall on 1/15/24. DON B indicated prior to lunch R3 had been working with OT (occupational therapy). OT had positioned R3 at dining room table for lunch in R3's wheelchair and did not connect R3's clip alarm. DON B indicated the clip alarm was hanging on R3's wheelchair but not connected to R3. A CNA had taken R3 from the dining room table back to R3's room and transferred R3 into her recliner. DON B indicated the CNA could not recall hooking the clip alarm to R3. R3 self-transferred out of the recliner and attempted walking down hall about 20 feet and fell . DON B indicated right after the fall she went into R3's room and found the clip alarm still hanging on the wheelchair indicating it had not been attached to R3 and found the recliner's footrest still up indicating R3 climbed out of the recliner. Surveyor asked DON B if R3 should have had a clip alarm on at time the time of the fall and DON B indicated yes. Surveyor asked DON B if she would expect the clip alarm to be care planned if it was part of R3's plan of care and DON B indicated yes. Surveyor asked DON B if she would expect R3's plan of care to be followed and DON B indicated yes. Surveyor asked DON B how many residents were care planned for alarms and DON B indicated 6. Surveyor asked DON B if education was provided to staff. DON B indicated the facility will be doing education to staff as they are working on it. Surveyor asked if education should have been completed immediately after the fall seeing there were 6 residents care planned for alarms and DON B indicated yes. Surveyor asked DON B if there was a reason education had not been started and DON B indicated having no explanation for that. 36253 This example regarding R1 rises to a scope and severity level of D (potential for harm/isolated). Example 2: R1 was admitted to the facility on [DATE] and has diagnoses that include dementia with agitation. His most recent Minimum Data Set (MDS), dated [DATE], shows a score of 0 which means R1 has severe cognitive impairment. R1 is ambulatory and his care plan, dated 11/1/23, states he is to be 1:1 with staff at all times due to wandering and elopement. Since R1's admission, he has eloped from the building multiple times and has gotten into physical altercations with staff and other residents. R2 was admitted to the facility on [DATE] and has diagnoses that include intracranial injury and dementia. His most recent MDS, dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 13, indicating R2 is cognitively intact. R4 was admitted to the facility on [DATE] and has diagnoses that include dementia. His most recent MDS dated [DATE], shows a BIMS score of 0 which means R4 has severe cognitive impairment. His care plan, dated 11/21/23, states he is to be 1:1 with staff at all times due to wandering. R4 has gotten into physical altercations with staff and other residents on multiple occasions. The facility has submitted 3 self-reports to the state agency since 9/11/23 due to R4 hitting other residents. R1, R2, and R4 reside on the same floor. The facility submitted a self-report to the state agency regarding an incident which occurred on 12/29/23 at approximately 5:00 PM. In the incident, the facility describes how R1 hit R2 when R2 tried to sit near R1 at the dining room table. Staff were able to separate R1 and R2. R2 did not sustain any injuries. Surveyors interviewed R2 on 1/18/24 and he did not recall the incident and had no concerns with any other residents. The schedule for 12/29/23 indicates there were 2 Certified Nursing Assistants (CNAs) and 1 Registered Nurse (RN) to provide 2 residents with 1:1 and provide cares and services to the other 15 residents (17 total residents). On 1/18/24 at 2:40 PM, Surveyor interviewed CNA C who stated that she was wheeling the food cart into the dining room when she witnessed R1 and R2 hitting each other. CNA C stated that when arriving into the dining room, R1, R2, and R4 were at the same table and CNA D was the only staff member in the dining room and had turned her back to R1's table to assist another resident at another table. On 1/18/24 at 3:10 PM, Surveyor interviewed RN E, who was the nurse at the time of the incident on 12/29. RN E stated that there were only 2 CNAs and her to work the floor and provide 1:1 for both R1 and R4. RN E stated that she started the PM shift doing 1:1 with R1 but had to then do her nursing tasks so the CNAs took over and got R1 and R4, as well as other residents, into the dining room for dinner. RN E stated there was only 1 staff in the dining room for 1:1 with 2 separate residents. RN E stated that there was supposed to be a CNA in addition to CNA C and CNA D, but that CNA was unable to arrive to the facility until 5:00 PM and did so right after the incident occurred. RN E stated that it has happened on multiple occasions where there not enough staff to provide 1:1 on both R1 and R4, so she will try to sit with them both but R1 tends to get up and walk around so she must pick a resident to go with and leave the other, which means she must go with R1 due to his frequent attempts to wander and leave the building. On 1/18/24, Surveyor interviewed NHA A (Nursing Home Administrator) who stated that staffing has been an issue with providing 1:1 with two residents on the same floor, but it is absolutely her expectation that R1 and R4 always have their own staff. RN E and CNA C both stated that they did not receive any education on the 1:1 process, nor did they receive any additional information or education on how to protect other residents from R1 or R4. CNA D was unable to be reached. The facility was aware they had two potential volatile residents (R1 and R4) and had care planned them to be 1:1 to protect other residents and did not ensure these care plans were carried out and R2 was struck by R1.

Based on interview and record review, the facility did not monitor antibiotic use for 1 of 2 residents (R2) reviewed for antibiotic use of a total sample of 15 residents. R2 began receiving prophylactic antibiotics for reoccurring Urinary Tract Infections (UTIs) in January of 2022. In August of 2023, R2's prophylactic antibiotic was changed to a different antibiotic without laboratory confirmation of its effectiveness and continued to receive this antibiotic prophylactically. R2 was prescribed an antibiotic to treat a UTI despite a sensitivity report indicating R2 had developed resistance to the antibiotic. The facility did not thoroughly review R2's urine cultures and sensitivity results, did not recognize bacterial strain had become resistant and continued to provide R2 with an antibiotic in two separate orders that was documented as ineffective/resistant. The facility did not follow Standards of Practice (SOP) for Antibiotic Stewardship for antibiotic use for R2. This is evidenced by: The facility's antibiotic prescribing practices policy states the following: 1. Antibiotics will be administered only as prescribed by the physician or other authorized practitioner. 2. The decision to prescribe an antibiotic will be guided by medical knowledge, best practices, and professional guidelines. 3. Data from the facility's most recent antibiogram will be used to establish facility protocols/preferred drugs for antibiotic prescribing. 4. The facility, in collaboration with the pharmacy, will ensure availability of preferred drugs. 5. The facility will utilize a 5D's approach to antibiotic prescribing: a. Diagnosis: each prescription will include the reason for the antibiotic, rationale (prophylaxis versus therapeutic) and treatment site. b. Drug: the prescribed medication will be appropriate for the treatment site and identified Organism. Narrow spectrum antibiotics will be prescribed whenever possible. c. Dose: the dose and route of administration will be clearly identified in the antibiotic prescription. the dose will be appropriate to the site of infection comma resident characteristics (i.e. renal function, weight), and established guidelines. d. Duration: documentation shall include start date, end date, and planned days of therapy. The length of therapy shall be in accordance with evidence-based treatment guidelines. e. De-escalation: Reassessment of empiric precautions will be conducted after 2-3 days for appropriateness and necessity, factoring and results of diagnostic tests, laboratory results, and/or changes in the clinical status of the resident. 6. Random audits of antibiotic prescription shall be performed to verify completeness and appropriateness. R2 was admitted to the facility on [DATE]. R2's Minimum Data Set (MDS) dated [DATE] indicated R2 has a Brief Interview of Mental Status (BIMS) score of 9 out of 15 indicating cognitive impairment. R2 has an indwelling catheter and is always incontinent of bowel. Section N does not indicate that R2 is taking an antibiotic. On 1/10/22, R2 began taking Fosfomycin 3 gm one time every 10 days as a prophylactic antibiotic for reoccurring UTIs. A 3/21/23 Urine Culture and Sensitivity Report indicates the following: Klebsiella Pneumoniae greater than 100,000 colonies Proteus Mirabilis greater than 100,000 colonies Both organisms were sensitive to Ciprofloxacin, which was ordered and administered twice daily for 7 days. It should be noted both of these organisms were also sensitive to Bactrim DS. (generic: Trimethoprim / Sulfamethoxazole). Per the Center for Disease Control and Prevention (CDC), Klebsiella [kleb-see-[NAME]-uh] is a type of gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis. Increasingly, Klebsiella bacteria have developed antimicrobial resistance.in healthcare settings, Klebsiella infections commonly occur among sick patients who are receiving treatment for other conditions . patients who are taking long courses of certain antibiotics are most at risk for Klebsiella infections. On 8/18/23, R2's prophylactic Fosfomycin (antibiotic used to treat bladder infections ) was changed to Bactrim DS (double strength) 800-160 mg twice daily every 10 days. No documentation was provided or available that shows R2 was sensitive to Bactrim DS at this time. Facility Medication Administration Records (MAR) indicate R2 took the prophylactic dose of Bactrim DS on August 18th and 28th; September 7th, 17th, and 27th; October 7th, 16th, and 27th; and November 6th. On 10/25/23 the facility ordered a urinalysis for R2 which returned the following analysis and sensitivity results on 10/27/23 at 8:26 AM: Klebsiella Pneumoniae greater than 100,000 colonies At this time, this organism was sensitive to Cipro, but was resistant to Bactrim. On 10/27/23 at 8:54 AM, the Nurse Practitioner (NP) placed an order for Bactrim DS 800-160 mg twice daily for 7 days. R2's October MAR indicates he received Bactrim once on 10/27/23 and twice on 10/28/23, 10/29/23, and 10/30/23. At this time, R2 was taking 2 different Bactrim orders, one prophylactically, and one for his current UTI. R2's physician, MD D (Medical Director), reviewed the 10/27/23 sensitivity report on 10/30/23 at 3:14 PM and ordered R2's Bactrim to be discontinued due to the organism having resistance. MD D then switched R2's Bactrim to Cipro twice daily for 7 days, starting 10/30/23. It should be noted that MD D discontinued R2's Bactrim order for his UTI, but did not cancel the prophylactic Bactrim order, which R2 took again on 11/6/23 as evidenced by the MAR and the following progress note dated 11/6/23 at 7:30 PM: *This writer gave resident his eye drops tonight and his routine meds tonight whole with extra pudding as resident had both his Bactrim DS and his Cipro tonight. Resident took his antibiotics well whole in pudding. On 11/9/23 at 9:22 AM, Surveyor interviewed MD D who confirmed that R2 had been taking Fosfomycin since January of 2022 and was switched to Bactrim DS in August due to cost. Additionally, MD D stated that he reviewed R2's record and R2 had not seen a urologist since January of 2022. Additionally, MD D stated that the NP that ordered the Bactrim for R2's October UTI did so in error. MD D stated R2 should not be on the prophylactic Bactrim any longer and that any use of an antibiotic long term can create resistance. On 11/9/23 at 10:45 AM, Surveyor interviewed DON B (Director of Nursing). Although DON B is not the facility's designated infection preventionist, she oversees the infection control program. DON B stated that she was unaware that R2 was taking an antibiotic that was not sensitive to R2's current organism. DON B stated that R2 should not be taking either of his current Bactrim orders, given the resistance to it. Additionally, DON B stated she was unable to find any culture and sensitivity reports between 3/21/23 and 10/25/23. Between 3/21/23 and 10/25/23, R2 became resistant to Bactrim DS. R2 was taking Bactrim prophylactically as of 8/18/23, despite no laboratory indication as to whether this was appropriate. R2 continued to take the prophylactic Bactrim in August, September, and October. An additional order of Bactrim was placed for R2 on 10/27/23 despite sensitivity reports that he had become resistant, which he took 7 times between 10/27 and 10/30. This excludes the 2 additional doses of the prophylactic Bactrim he took on 10/27/23. Additionally, R2 was administered the prophylactic Bactrim on 11/6/23 along with his new order of Cipro, depsite being resistant.

Based on observation, interview, and record review, the facility did not ensure a safe environment that was free from abuse for 1 Resident (R1) of 4 residents sampled for abuse. R2 has a history of agitation and abuse. R2 struck R1 in the face, causing a bloody lip. Evidenced by: The facility's policy titled, Abuse, Neglect, and Exploitation no date, states in part: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .III. Prevention of Abuse, Neglect and Exploitation .B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents. And assure that the staff assigned have the knowledge of the individual residents' care needs and behavioral symptoms .D. The identification, ongoing assessments, and care planning for appropriate interventions, and monitoring of residents with needs and behaviors that might lead to conflict or neglect . R1 was admitted to the facility on [DATE] with diagnoses that include: Bipolar Disorder, Anxiety Disorder, Depression, and malignant neoplasm of the right breast. R1's most recent Minimum Data Set (MDS) dated [DATE], states that R1 has a Brief Interview of Mental Status (BIMS) score of 4 out of 15, indicating that R1 has severe cognitive impairment. R2 was admitted to the facility on [DATE] with diagnoses that include: unspecified Dementia moderate, with behavioral disturbances and agitation, pain, and a history of alcohol dependence. R2's most recent completed MDS dated [DATE], states that R2 has a BIMS of 00 out of 15, indicating that R2 has severe cognitive impairment. R2 has a documented history of physical abuse towards staff and other residents. The facility submitted a self-report to the State Agency (SA) indicating that on 8/31/23, R2 had struck R1 in the face, resulting in a bloody lip. The report indicates that R1 and R2 were both in the common area/dining room, along with other residents. R2 was in a recliner and R1 was at a table. The report indicates that the nurse was in the hallway, near the nurse report room. SW F (Social Worker) provided R2 with a snack and then returned to her office. SW F left her office approximately 18 minutes later, and R1 stated that R2 had hit her and was noted to have blood on her lip. R2 was noted to have blood on his hand. R2's care plan states in part: Basic Care Needs: 6/30/23 I need: some assistance with walking with bathroom use, with bathing Because I: have poor balance, muscle weakness, get confused, dementia, behavioral issues. I show this by falling frequently, having trouble making decisions, not understanding instructions, not being able to tell you what I want or need, being forgetful, being combative at times, losing my balance. Approach: .I move about the unit: with supervision, please know where I am at all times. When I am out of my room, I need to be 1:1 supervision with staff all shift Wander Guard: .I have a motion alarm on my door that will sound when I leave my room. I need to be 1:1 with staff at all times when I am out of my room . On R2's Treatment Administration Record (TAR), there is an entry that states I ensure that this resident was 1:1 supervision with staff all shift. Every shift start date of 8/1/23. For the month of August, there are 11 blank shifts, and 12 shifts that are marked with a 9 which means other/see progress notes. For the month of September, there were 12 blank shifts, 4 shifts marked 9. Surveyor reviewed R2's progress notes for August and September and the explanations for the 9 vary between resident refused, n/a (not applicable,) and no explanation documented. On R2's TAR there is an entry that states, Motion alarm on door is functioning properly. Every shift start date 8/1/23. For the month of August, there are 4 blank shifts documented. For the month of September, there are 5 blank shifts documented. On 9/12/23 at 9:37 AM, Surveyor observed R1 sitting in the dining area at a table. R2 was sitting at another table with another resident. There were no staff members present. On 9/12/23 at 10:20 AM, Surveyor observed R1 and R2 in the dining area, there were no staff present. On 9/12/23 at 10:25, Surveyor observed 2 staff members in the report room with the door partially closed that is next to the dining area. The staff members were not within eyesight of the residents in the dining area. On 9/12/23 at 10:45 AM, Surveyor observed R2 in the dining area with 4 other residents, there were no staff present. On 9/12/23 at 12:10 PM, Surveyor observed R2 in the dining area with 2 other residents, there were no staff present. On 9/12/23 at 1:00 PM, Surveyor observed R2 in bed sleeping. R2's door was open approximately 1/3 of the way, the door alarm was not engaged. R2's door alarm is positioned with 1 piece at the top of his door and the other piece connected to the top of the door jam. On 9/13/23 at 7:12 AM, Surveyor observed R2 in bed sleeping. R2's door was wide open, and the door alarm was not engaged. On 9/13/23 at 7:36 AM, Surveyor observed staff bring R2 to the dining area and placed him at a table with another resident. There were several other residents in the dining area as well. Staff left the dining area to pass meal trays to other resident rooms, and the nurse was in the hallway speaking with a visitor. There was no supervision in the dining area. On 9/12/23 at 10:20 AM, Surveyor interviewed R1. Surveyor asked R1 if she feels safe at the facility, R1 stated no. Surveyor asked R1 if she would explain why she doesn't feel safe, R1 stated that there is a guy named [NAME] and he punched me in the face. R1 stated that she was talking with another resident when it happened. R1 then states, the trouble is that he has a room down by mine, where I go to sleep at night. It is important to note that despite R1's severe cognitive impairment, she was able to recall the assault committed by R2. Using the reasonable person concept, a reasonable person would not expect to be struck in the face in their home. A reasonable person would expect to feel safe in their home and not fearful of others residing in their home. Using the reasonable person concept R1 not only was physically harmed but verbalizes fear and not feeling safe as an outcome of the incident. Additionally, R2's Certified Nursing Assistant (CNA) behavior monitoring task indicates that he likes to be called Grandpa. On 9/13/23 at 7:52 AM, Surveyor interviewed CNA C. Surveyor asked CNA C what interventions are in place to keep other residents safe from R2? CNA C stated that they have an alarm on his door so they can hear him and alarms on other resident's doors, so they know if he goes into their rooms. CNA C stated that they always keep an eye on him and that she checks on him when she walks by his room. Surveyor asked CNA C how she knows if R2's door alarm is going off? CNA C stated that there is a light that flashes in the report room. Surveyor asked CNA C how she would know the alarm is going off if she wasn't in the report room? CNA C stated that she wouldn't. Surveyor asked CNA C to test R2's door alarm; CNA C walked into R2's room, Surveyor stayed in the report room and the alarm did not go off. On 9/13/23 at 8:09 AM, Surveyor interviewed CNA D. Surveyor asked CNA D what interventions are in place to keep other residents safe from R2? CNA D stated she redirects him, and that R2 sleeps a lot so if she sees him getting agitated, she will take him to bed or put him in the recliner. CNA D also stated that she would play music for R2. On 9/13/23 at 9:07 AM, Surveyor interviewed RN E (Registered Nurse). Surveyor asked RN E what interventions are in place to keep other residents safe from R2? RN E stated that it's hard because he snaps out of nowhere. RN E reported that they are watching him and keeping an eye on him and that R2 has had some medication changes recently. Surveyor asked RN E if R2 is supposed to have 1:1 supervision? RN E stated yes, if it's possible, but they don't have an extra staff person to provide 1:1. On 9/13/23 at 9:44 AM, Surveyor interviewed SW F (Social Worker). Surveyor asked SW F to describe the incident that occurred between R1 and R2. SW F stated that she had seen R2 in the dining area and got him a soda and a cookie; she returned to her office for approximately 10 minutes and then was walking through the dining area when R1 stated that R2 hit her. SW F stated that she noted that R1 had blood on her lip, she separated the residents, and went to get the DON (Director of Nursing) and the NHA (Nursing Home Administrator) once the nurse arrived in the dining area. Surveyor asked SW F if R2 is supposed to be 1:1? SW F stated that she thought he was only 1:1 when he escalated. Surveyor asked SW F to review R2's care plan. Surveyor asked SW F if according to the care plan, should R2 have been 1:1 at the time of the incident? SW F stated that based on the care plan, R2 should have had 1:1 supervision. On 9/13/23 at 10:49 AM, Surveyor interviewed NHA A and DON B. Surveyor asked what interventions are in place to keep other residents safe from R2? NHA A stated that she can't call him an official 1:1 because they don't always have the staff to provide it. NHA A stated that they make sure that they know where he is, they have changed his medications, and they have educated staff on approaches with him. Surveyor asked DON B and NHA A if R2 should have 1:1 supervision according to his care plan and his TAR? NHA A stated yes, especially when he is escalated; 1 staff stays with him, and another staff member removes the other residents from the area. Surveyor asked how his door alarm works; DON B stated that when his door is completely shut and he opens it, the alarm will go off. Surveyor asked DON B to test the door alarm. DON B went to R2's room while Surveyor stayed in the report room. Surveyor noted that when the alarm was set off, it made a ding-[NAME] sound and had a flashing light. Surveyor asked DON B if R2's door must be completely closed for the alarm to sound? DON B stated yes. Surveyor asked DON B what happens when there are no staff in the report room and R2's alarm goes off? DON B stated that she doesn't really know, but that someone is usually in the area. Surveyor discussed the blank areas in R2's TAR under 1:1 and the motion alarm with DON B. Surveyor asked DON B if she would expect that nursing staff fill out the TAR? DON B stated yes. The facility did not consistently implement care planned interventions to ensure that other residents were kept safe from R2's abuse. Using the reasonable person concept R1 not only was physically harmed but verbalizes fear and not feeling safe as an outcome of the incident.

Based on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 resident (R1) of 3 sampled residents reviewed. R1 received prophylactic antibiotics for a vesicointestinal fistula (a channel like formation between the bladder and the bowel) from August 10, 2020 to January 29, 2021. R1 developed a [CONDITION(S)] ([CONDITION(S)]) and continued to receive this antibiotic despite resistance from October 2020 to January 2021. R1 was placed on broad spectrum antibiotics for [CONDITION(S)]'s (Urinary Tract Infections) without documentation for indication of use of a broad spectrum antibiotic, or evidence the facility reviewed if a narrower spectrum antibiotic would have been effective, as indicated in resident's culture and sensitivity reports. The facility did not thoroughly review R1's pathogen results from urine cultures and sensitivities. The facility did not recognize R1 had an [CONDITION(S)] with [CONDITION(S)] (Multi Drug Resistant Organism) and was likely colonized with the [CONDITION(S)]. The facility did not follow Standards of Practice (SOP) for Antibiotic Stewardship for antibiotic use for R1. This is evidenced by: The facility's policy, dated Infection Control Manual 2017, titled Infection Prevention and Control Manual, Antibiotic Stewardship & MDROs, states in part: Antibiotic stewardship refers to systemic efforts to optimize the use of antibiotics - not just reduce the total volume used - to maximize their benefits to patients, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy .Stewardship involves identifying the microbe responsible for disease, utilizing evidence based definitions when indicated; selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed . Leadership Commitment: A well-defined leadership commitment to include: -Policies and Procedures including evidence based standards of practice promoting a judicious process for antibiotic use in the organization . -A solid communication system including nursing staff and prescribing practitioners including the organization system (policies, procedures and protocols) for the use of antibiotics. This communication includes a system to identify any potential prescribing concerns to the Infection Preventionist, DON, Pharmacy Consultant and Medical Director for appropriate follow up timely . Tracking and Reporting: Tracking and reporting of antibiotic use and outcomes will be completed in the facility to identify adherence to the facility policy and procedures, use and outcomes. Tracking will allow the facility to identify patterns, prevalence of antibiotic use as well as specific ordering data. Outcomes (i.e. adverse drug events, antibiotic resistant organisms, C. difficile infections, etc.) will be tracked by the infection Preventionist and discussed with the Quality Assurance Committee for action planning . Education: Education on antibiotic stewardship will be provided to facility staff, practitioners, residents and families/responsible parties . POLICY: This facility's antibiotic stewardship program promotes the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Antibiotics will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes . PROCEDURE: 1. When the nurse suspects that the resident has an infection, the nurse will perform an evaluation of the resident . 2. The Nurse will utilize the (insert facility/approved tools: i.e. Loeb Minimum Criteria, McGeer Contitutional [sic] Criteria, AHRQ-[CONDITION(S)] SBAR, etc.) infection criteria protocol to determine if it is necessary to treat with antibiotics or if adjustments in therapy need to be made. (Of note, per NHA A (Nursing Home Administrator) and IP H (Infection Preventionist), the facility utilized the Loeb Criteria for surveillance and treatment). 3. Notify physician/practitioner of resident change of condition and evaluation information. The nurse to communicate to physician of infection criteria protocol to treat the respective infection. 4. When diagnostics are ordered by the practitioner, the nurse will contact the lab/radiology to notify of physician order. a. Physician will be notified of results of diagnostics to ensure resident is taking the appropriate antibiotic or if antibiotic needs to be discontinued or changed. 5. If indicated, based upon (identified) criteria, an antibiotic is ordered, the practitioner will identify the diagnosis/indication, the appropriate antibiotic, proper dose, duration and route. a. In the event that the prescribing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director will be contacted for further direction . 10. The Infection Preventionist will track antibiotic use and monitor adherence to evidence-based criteria, including: a. Documentation related to antibiotic selection and use b. Tracking antibiotics used to review patterns of use and determination of the impact of the antibiotic stewardship interventions . f. Provide reports related to monitoring antibiotic usage and resistance data to the QAA committee 11. During the quarterly QAA Committee Meeting, The Pharmacist, Medical Director, Infection Preventionist and IDT (Interdisciplinary Team) will analyze the antibiotic use in the facility to collaborate with nursing and clinical leaders for identification of potential QAPI (Quality Assurance and Performance Improvement) process action plan related to analysis of the tracking and trending of data for quality outcomes. Findings: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Care plan 7/18/21 includes, in part: -I NEED: support for symptoms of a urinary tract infection -I need my nurses to -- offer me fluids, offer me medications for pain and fever as needed, check if I'm having side effects while I'm taking antibiotics -I need my aides to - let my nurse know about changes to the color or odor of my urine, offer me fluids -MY GOAL IS TO: to be free from symptoms of a urinary tract infection -GOAL TIME: two weeks On 4/13/21, R1's quarterly MDS (minimum data set) notes BIMS (Brief Interview for Mental Status Score) of 9, indicating R1 is moderately impaired. MDS indicates R1 is dependent on staff for toileting hygiene and is incontinent of bowel and bladder. Review of R1's Nurses Notes; Physician Communication Faxes; Culture/Sensitivity Reports; Physician Orders; and overall MARs (Medication Administration Records); notes the following: On 7/15/20 3:08PM -- .painful urination, mucous in urine and on incontinent pad. C/o (complained of) retention over past day or so. Order obtained for U/A (Urinalysis) and cultures if needed. Start [MEDICATION(S)] 250mg twice daily until culture complete . 7/17/20 Urine Culture and Sensitivity Report: Escherichia Coli greater than 100,000 colonies (No resistance to antibiotics noted) Citrobacter Koseri (Diversus) 10,000 to 49,000 colonies (Resistant to 1 antibiotic and Intermediate to 1 antibiotic) Both of these organisms were sensitive to [MEDICATION(S)], which was ordered. Two other organisms were reported on the culture without sensitivity reports. Streptococcus Gallolyticus 50,000 to 100,000 colonies Aerococcus Viridans 10,000 to 49,000 colonies A fax transmission to Dr. (MD name) on 8/9/20 notes: Concern: R1 has had multiple [CONDITION(S)]'s over the last few months. It has been noticed these have increased since d/c (discontinuation) of prophylactic antibiotic. R1 now realized this and he wants the antibiotic back for his fistula. Can we get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? A response from Dr. (MD name) on 8/10/20, through the provider's electronic health system communication, notes: Yes [MEDICATION(S)] 250mg oral daily. The following handwritten order dated 8/10/20 is noted on the August 2020 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Of note, R1 was started on a prophylactic broad spectrum antibiotic: [MEDICATION(S)]. On 8/10/20 nurses notes include, in part: Resident was given the first dose of [MEDICATION(S)] 250mg at noon for prophylactic Tx. of his vesicointestinal fistula . On 10/15/20 nurses notes include, in part: .Resident given 650mg APAP (acetaminophen) for generalized pain@0110. F/U (follow up) @ 0305 resident said pain was unrelieved. Upon further inquiry, resident described pain as [CONDITION(S)] Physician/NP Contact: sent fax to PCP (Primary Care Provider) to update them on resident freq c/o (complaints of) bladder spasm like pain. Resident has been having this at times and was restarted on the antibiotic and it seems it has been starting to get more freq bouts of this. Resident often has H.A. (headache) or bladder area pain and the prn Tylenol seems to help but wanted the PCP to be aware. On 10/15/20 a fax transmission to Dr. (MD name) notes R1 has been having c/o bladder spasm like pain and is recurring more frequently. He is awakened at night by it and sometimes pain is during the day. Tylenol 650mg is given with some relief. Happens daily. He continues on his [MEDICATION(S)] 250mg daily for fistula prophylaxis. A response from the provider's electronic health system notes: Have the (facility name) do a urine culture. On 10/16/20 .A fax was received from Dr. (MD name) today at the clinic. MD gave orders for staff to obtain a urine specimen for C & S (Culture and Sensitivity) r/t (related to) resident having bladder spasms and increased pelvic pain . On 10/18/20 nursing notes state in part; received the preliminary culture report today showing greater than 100,000 gram neg bacteria. C & S pending yet . On 10/19/20 nursing notes state in part; .received the C & S report of recent urine. Faxed the report to the clinic for PCP to address. Shows resident has proteus mirabilis. Resident has had some mild bladder pain today and has requested Tylenol at noon . On 10/20/20 Urine Culture and Sensitivity Report: Proteus mirabilis greater than 100,000 colonies (Resistant to 7 antibiotics and Intermediate to 1) This organism was sensitive to [MEDICATION(S)] which was ordered [CONDITION(S)] Resistant Staphylococcus Aureus 10,000 to 49,000 colonies (Resistant to 4 antibiotics) (Of note, R1's Discharge/Transfer Form from 10/1/18 notes a history of [CONDITION(S)] in his urine) This organism was not tested for sensitivity to [MEDICATION(S)] Both of these organisms were Resistant to [MEDICATION(S)]. On 10/20/20 nurses notes include, in part: Physician/NP Contact: spoke with (name), nurse at (name) hospital at 8/10[sic] REGARDING: new ABX (antibiotic) order as culture shows resistant to current ABX [MEDICATION(S)]. She stated Dr. [name] will address once final culture received .new medication order received for this resident [MEDICATION(S)] 500mg three times daily for 10 days . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . For bladder spasms, pelvic pain in (illegible). Dx: [CONDITION(S)]. This order is also noted on provider response through their electronic health system. R1 remained on [MEDICATION(S)] prophylactically, despite being resistant to [MEDICATION(S)]. November POS states in part; [MEDICATION(S)] HCL 250 mg tab give one 1 tablet by mouth daily for vesicointestional fistula for prophylaxis. December POS dated 11/18/20 states in part; [MEDICATION(S)] HCL 250 mg tab give one 1 tablet by mouth daily for vesicointestional fistula for prophylaxis. January POS states in part; [MEDICATION(S)] HCL 250 mg tab give one 1 tablet by mouth daily for vesicointestional fistula for prophylaxis. February POS states in part; [MEDICATION(S)] HCL 250 mg tab give one 1 tablet by mouth daily for vesicointestional fistula for prophylaxis. (Of note, this order is crossed out and a handwritten note states discontinue (d/c) 1/29/21). Of note, although both organisms on urine culture and sensitivity dated 10/20/20 showed resistance to [MEDICATION(S)], R1 continued to receive [MEDICATION(S)] as a prophylactic antibiotic between the months of October 2020 and January 2021. On 1/25/21: Physician's Telephone order form notes: Urine C & S, UA. On 1/26/21: Fax transmission sheet to Dr. (MD name) notes: Have received order to obtain urine specimen for UA & C/S. Please provide dx (diagnosis) to complete lab order .A same day reply through the provider electronic health system notes: [CONDITION(S)]. On 1/27/21: Telephone order form notes the following: Obtain a UA with C & S if indicated. Secondary to c/o suprapubic pain, urinary frequency, concentrated urine, and increased negative behaviors. On 1/27/21 R1's nurses notes include, in part: resident had a straight cath UA obtained and was sent to the lab at (Hospital name) hospital to be processed. Resident had scant amount of blood urine return at end of procedure. On 1/28/21 R1's nurses notes include, in part: resident had c/o pain and moaning tonight .Received preliminary results of U.A. obtained yesterday. Faxed these to (Hospital name) hospital primary clinic for M.D. to review. Shows large amounts of blood, positive nitrates and leukocytes, and 3+ bacteria . On 1/29/21 Urine Culture and Sensitivity Results: Proteus mirabilis greater than 100,000 colonies (Resistant to 7 antibiotics and Intermediate to 1) This organism was resistant to [MEDICATION(S)]. [MEDICATION(S)] was discontinued and [MEDICATION(S)] was started which this organism was sensitive to. Of note, this is the second time R1 has shown greater than 100,000 of Proteus mirabilis on C&S and noted to be resistant to [MEDICATION(S)]. R1 received [MEDICATION(S)] as a prohpylatic antibiotic from October 2020 to January 2021. On 1/29/21 R1's nurses notes include, in part: Physician/NP Contact: attending physician received the results of resident's urinalysis and the PCP has written a new order for resident to stop the [MEDICATION(S)] and to start on [MEDICATION(S)] 250mg PO x 10 days for a [CONDITION(S)]. Resident has greater than 100,000 CFU (colony forming unit) of proteus mirabilis bacteria . On 1/29/21: Orders noted on culture results transmitted through provider electronic health system note: Discontinue [MEDICATION(S)]. [MEDICATION(S)] 250mg twice daily for 10 days. On 1/29/21: A Physician's Telephone Order form notes: 1/29/21 Discontinue [MEDICATION(S)]. Start [MEDICATION(S)] 250mg tablet by mouth twice daily x 10 days for [CONDITION(S)]. On 2/24/21 R1's nurses notes indicate, in part: Physician/NP Contact: attending physician PCP has addressed the Pharmacy Report and has declined the recommendation to evaluate the long term use of Ciprofloxin [sic] for treating fistula .Progress note: resident c/o supra pubic pain, prn (as needed) Tylenol given @ 1600, resident resting, later started yelling has pain, straight cath done to relieve the bladder pressure as he has a PRN order for cath for bladder pain .resident said no he doesn't want to go to the hospital . On 2/25/21 R1's nurses notes indicate, in part: Follow-up: Resident had awakened during the night at 0400 and had c/o supra pubic area pain. Was given prn Tylenol for pain which was effective .during breakfast he was calling out as bladder area pain returned .Resident was spoken to about going for an eval either at the clinic or the ER and he seems to be agreeable. The PCP was sent update and will ask for either ER, clinic, or possible urology appt for resident .nurse practitioner responded to updates sent to clinic today .discussed recommendations with Admin staff and the legal guardian and the decision was made to send resident to the ER for eval as his pain episodes are getting intense and causing resident great distress .transfer to ER for eval of supra pubic pain .Resident has returned from the ER with new order to start oral antibiotic tomorrow for [CONDITION(S)]. Resident had been given IV [MEDICATION(S)] at the ER .PCP was sent an update on today's orders and referral request for urology . On 2/25/21: A fax transmission form to Dr. (MD name) notes the following: Resident having increased pain in bladder and c/o pain in left knee. Calls out freq during the night and gets little hours of sleep. He has completed the antibiotic for [CONDITION(S)] and the routine [MEDICATION(S)] was D/c'd on 1/29/21 when the order was given to (illegible) start the [MEDICATION(S)] 250mg bid x 10 days - [CONDITION(S)]. Urine is pink tinged at x's the last 24 hours. Would a urology appt be in order to eval the cause of pain in bladder area as pain is getting worse. Or Clinic, ER eval today . On 2/25/21: A Physician's Telephone order form notes the following: Send to ER at (Hospital name) to have evaluated for increased s/s (signs/symptoms) of suprapubic pain possibly r/t vesicointestinal fistula. 2/25/21: A handwritten order indicates - start [MEDICATION(S)] 250mg by mouth twice a day on 2/26/21 and give x 10 days (for [CONDITION(S)]) 2/25/21: A Physician's Telephone order form notes: Set up appt for a urology referral. R/T suprapubic pain and vesicointestinal fistula. On 2/25/21 Urine Culture and Sensitivity Report: Proteus mirabilis greater than 100,000 colonies (Resistant to 8 antibiotics) This organism was sensitive to [MEDICATION(S)], which was prescribed. Enterococcus Faecalis 50,000 to 100,000 colonies (Resistant to 3 antibiotics) This organism was not tested for sensitivity to [MEDICATION(S)] Of note, this is the third time R1 has shown greater than 100,000 of Proteus mirabilis on C&S with now noted resistance to 8 antibiotics. On 3/5/21 R1's nurses notes include, in part: Dr. (MD name) urology visit - new orders drink at least 2 L of fluid per day. [MEDICATION(S)] 250mg once a day for 4 more doses [MEDICATION(S)] 500mg by mouth twice a day for full 2 weeks for [CONDITION(S)] On 3/29/21 R1's nurses notes include, in part: Physician/Consult Visit: 3/29/21 attending physician spoke to/with resident examined resident Result/Actions: .Dr. (MD name) was here at the manor today and seen [sic] resident .Dr.(MD name) wrote a T.O. for the following: UA, urine C & S . On 3/31/21 .Have approached resident x 2 and he is not willing to have a straight cath collection for the U.A. ordered as he c/o it causing too much pain. Resident was asked about allowing the CNA's to place a urinal between his legs when he is in bed and he was swearing and said he couldn't [sic] pee in a bottle. Was explained that the urinal could be placed during his sleep or towards morning and urine collection possibly be obtained that way. He was more receptive to this and will be tried tonight . On 3/29/21: A physician's Telephone Order form notes the following: U/A, urine C/S for dysuria. On 4/5/21 Urine Culture and Sensitivity Report: Proteus mirabilis 50,000 to 100,000 colonies (Resistant to 7 antibiotics and Intermediate to 1) This organisms was susceptible to [MEDICATION(S)] which was prescribed. Enterococcus Faecalis 50,000 to 100,000 (Resistant to 3 antibiotics) This organism was not tested for sensitivity to [MEDICATION(S)] [CONDITION(S)] Pneumoniae 50,000 to 100,000 (Resistant to 1 antibiotic and Intermediate to 1) This organisms was susceptible to [MEDICATION(S)] which was prescribed. On 4/1/21: Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Of note, R1 continues to show resistance to Proteus mirabilis on culture. On 5/30/21 Urine Culture and Sensitivity Results: Escherichia Coli greater than 100,000 colonies (Not resistant to any antibiotics tested ) This organism is sensitive to [MEDICATION(S)] which was prescribed. Proteus mirabilis 50,000 to 100,000 colonies (Resistant to 8 antibiotics) This organism is resistant to [MEDICATION(S)] which was prescribed [CONDITION(S)] Pneumoniae greater than 100,000 colonies (Resistant to 1 antibiotic) This organism is sensitive to [MEDICATION(S)] which was prescribed. On 5/30/21: A physician's Telephone Order form notes the following: Start [MEDICATION(S)] D.S. one tab by mouth twice daily x 7 days for [CONDITION(S)]. On 6/2/21: A handwritten order indicates - [MEDICATION(S)] 500mg three times a day x 7 days ([CONDITION(S)]). A Physician's telephone order form for this same date, notes: [MEDICATION(S)] 500mg 3 x daily for 7 days for [CONDITION(S)]. D/C [MEDICATION(S)]. Of note, R1 was put on [MEDICATION(S)], however, culture results showed Proteus mirabilis and [CONDITION(S)] Pneumoniae were resistant to this antibiotic. R1 received [MEDICATION(S)] which was resistant to the bacteria for 2 days prior to new prescription. This is the second antibiotic R1 is showing [CONDITION(S)] resistance to. On 7/12/21: A fax transmission sheet to Dr. (MD name) notes the following: Resident having c/o pain describes as a (burning pain) in penis. He is voiding per usual incontinence and urine is yellow with some concentrated color at times .He refuses to come to clinic or ER for evaluation. Could you see him at (facility name) sometime for this? On 7/16/21 R1's nurses notes include, in part: attending physician spoke to/with resident examined resident .new orders received and noted .UA C & S-abdominal pain, ok to use condom cath to obtain specimen .nurse placed condom catheter on resident at 1915 to obtain a urine sample for UA .urine was obtained and sent to (Hospital name) hospital . 7/17/21 .Physician/NP Contact: physician on call Dr. (MD name) regarding: lab results UA positive for bacteria, Nitrites .new order for [MEDICATION(S)] 250mg twice a day times 3 days .Resident did c/o pain when urinating, that resolved quickly once he is done urinating . 7/18/21 .Resident is continuing to show signs of bladder pain, guarding, grimacing, clenching fist, yelling . 7/19/21 .Urinary symptoms have subsided today. Resident did refuse his [MEDICATION(S)] this AM .Resident took scheduled dose of [MEDICATION(S)] tonight. Continues with occasional periods of urinary pain . 7/20/21 Urine Culture and Sensitivity Report: Proteus mirabilis greater than 100,000 colonies (Resistant to 8 antibiotics) Enterococcus Faecalis 50,000 to 100,000 colonies (Resistant to 3 antibiotics) Both organisms are resistant to [MEDICATION(S)] which was initially prescribed on 7/17/21. Of note, the facility did not recognize R1 had a series of resistance to [MEDICATION(S)] and did not relay this to the prescribing physician. The Facility faxed a copy of the results with a handwritten note on the results indicating R1 was started on [MEDICATION(S)] 250mg by mouth twice daily for 3 days on 7/17/21. R1 is resistant. Did you want him to have something else .? The electronic record system used by the provider this was faxed to notes a receipt scan of 7/19/21 at 3:50pm. Notes attached to the culture report from the physician's office indicate on 7/20/21 at 8:22AM the physician noted to switch antibiotic to [MEDICATION(S)] 250mg twice daily for 10 days. Then [MEDICATION(S)] 500mg daily long term for prevention of future infection. 7/20/21: Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Give one tab every day starting on 7/30/21 for long term prevention of [CONDITION(S)]. A physician's telephone order form for the same date notes this order as well. 7/21/21: Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Stop 7/30/21. A physician's telephone order form for the same date notes this order as well. R1's August MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Start on 7/30/21. Of note, despite R1's history of [CONDITION(S)]'s R1 was prescribed yet a second antibiotic. It is likely R1 is colonized with bacteria and repeated use of prophylactic antibiotic use will only increase R1's resistance to antibiotic therapy. On 8/5/21 at 2:44PM, Surveyor interviewed IDON B (Interim Director of Nursing) and asked for clarification from the EPIC (provider electronic health communication record) telephone encounter regarding R1's urine culture results that were provided. There is a hand written note on the culture results not dated or timed that notes: Resident was started on [MEDICATION(S)] 250mg by mouth twice daily x 3 days on 7/17/21. Resident is resistant. Did you want him to have something else . IDON B was able to access the telephone encounter through the electronic system and show that the facility received the results on 7/19/21 and that it was faxed to the clinic. The encounter notes a fax from the facility to the provider on 7/19/21 at 3:50PM. (Of note, a response was not received by the provider until 7/20/20) Surveyor asked IDON B if this information should have been called to a provider instead of faxing, so that the resident could have had the resistant medication stopped and new order given. IDON stated, yes, they should have called. (Of note, R1 received [MEDICATION(S)] on 7/19 PM and 7/20 AM per the Medication Administration Record.) On 8/5/21 at 3:13PM, Surveyor interviewed IP H (Infection Preventionist) and NHA A (Nursing Home Administrator). Surveyor reviewed R1's culture and sensitivity reports and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? NHA A indicated they should have. Surveyor asked if there was any documentation that this had occurred. NHA A stated, she was not sure and that should would check as that was the previous Infection Control Nurse who is no longer employed with the facility. Of note, no further documentation was provided. Surveyor asked, with the January 2021 culture results, should someone have spoken with the doctor regarding [MEDICATION(S)] resistance. NHA A stated, yes, and it was stopped. Surveyor asked, in reviewing the culture reports would you consider is it possible that R1 is now colonized with Proteus mirabilis and potentially Enterococus Faecalis and [CONDITION(S)] pneumonia as well? NHA A stated, possibly. The facility did not ensure Antibiotic Stewardship was implemented for R1 by: 1) Not following standards of practice for use of broad spectrum antibiotics; 2) Not thoroughly reviewing R1's urine culture results; 3) Not noting that R1 had a [CONDITION(S)] Proteus Miraibilis (most likely colonized) which urine cultures and sensitivities showed was resistant to the prophylactic antibiotic he continued to received October 2020 through 1/29/21. 4) Not providing R1 with risks and benefits of continuing prophylactic antibiotic therapy, including the risk of multi drug resistance.

Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R51) reviewed for fall concerns. R51 attempted to self-transfer and fell out of bed on 2/6/18 dislocating his left hip (which had previously fractured during a fall at the facility on 1/27/18). The facility did not ensure that R51's care plan interventions were implemented, and did not complete a thorough fall investigation after each fall. This is evidenced by: The facility's Resident Falls policy and procedure, dated 3/3/11, states, in part: . it is the facility's policy to act in a proactive manner to identify and assist those residents at potential risk for fall, plan for preventative strategies, and facilitate as safe an environment as possible . An Injury/Incident Investigation Report Form must be completed with each fall. Information related to the fall must be gathered by any witnesses. All sections must be filled out, including a description of the incident, internal review, and findings documented with approaches taken. A probable cause of the incident must be determined, otherwise an investigation must be done .All resident falls must be written on the resident's Fall Care Plan in their chart, including any interventions that are put in place after the fall. This information must also be included on the Care Plan in the resident's room . R51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R51 was readmitted to the facility on [DATE] with a new [DIAGNOSES REDACTED]. R51's quarterly MDS on 12/26/17 noted a BIMS (Brief interview for Mental Status) score of 11, indicating moderate cognitive impairment. Before R51's fall on 1/27/18 he walked short distances in his room independently with a cane and was his own decision maker. R51's Fall Risk Assessment on 1/31/18 notes a total score of 18. This document notes that if the total score is 10 or greater, the resident should be considered at HIGH RISK (emphasis included) for potential falls. R51's Comprehensive Care Plan, dated 9/28/17, includes, in part: Problem: Potential for Injury Falls: Prior to admit, related to weakness, unsteady gait, poor judgement . Goal: (R51) will be free of injury; (R51) will be free of falls. Approaches: . Entry dated 1/29/18: Encourage (R51) to wear gripper socks when not wearing shoes and in bed. Entries to care plan dated 1/31/18: Clip alarm in bed and chairs s/p (status [REDACTED]. Review of R51's Nurses Notes include, in part: R51 had 3 falls without injury due to self-transfer on 10/7/17, 10/17/17, and 1/22/18. The facility evaluated R51 and updated R51's care plan with new interventions for these falls. On 1/27/18 at 6:16 AM, R51 had an unwitnessed fall out of bed due to self-transferring out of bed. R51 had left hip pain and was sent to the hospital, where it was determined that R51 had sustained a left femur fracture which was surgically repaired. On 1/31/18 R51 returned to the facility from the hospital at 2:20 PM. R51 was found on the floor next to his bed at 5:55 PM due to self-transfer. R51 was sent to the hospital for evaluation and no injury was sustained. On 2/6/18 at 9:25 PM, R51 had an unwitnessed fall from bed and was complaining of left hip pain. R51 was sent to the hospital. R51's Emergency Department Notes from 2/6/18, include, in part: (R51) status [REDACTED]. (R51) presents with left hip pain, internal rotation . rates pain 9/10 with movement of the hip . X-ray to left hip showed: Superior dislocation of the (left hip) prosthesis . Treatment: . Deep sedation .Hip reduction method: Traction and counter traction, reduction successful . R51's fall at the facility on 2/6/18, resulted in dislocation of his recent surgically repaired left hip, which had to be reduced with conscious sedation at the emergency department. Review of R51's 15 minute checks show that the checks were being completed from 1/31/18 through 2400 (midnight) on 2/2/18. 15 minute checks were then started again on 2/7/18 at 12:45 AM. (It is important to note that there is no evidence that 15 minute checks were being completed for R51 from 2/3/18-2/7/18.) Review of the facility's Resident Injury/Incident/Accident Report investigation of R51's fall on 2/6/18 is incomplete with blanks noted on the document. On the form, under the heading Internal Review, the document was not complete, areas left blank on the form included: -Fall was witnessed or not witnessed -Gait belt Used (Yes/No) -ICP (Interdisciplinary Care Plan) Followed (Yes/No) - Probable Cause Identified? (Yes/No) If No-then proceed with investigation -Injuries: Probable Cause Identified? (Yes/No) If No-then proceed with investigation. On 4/12/18 at 2:16 PM, Surveyor interviewed DON B (Director of Nursing) and ADON E (Assistant Director of Nursing) about R51's fall on 2/6/18. Surveyor reviewed R51's 15 minute check observation documentation (from 1/31/18-2/2/18 and 2/7/18), asking if there was any other documentation. None was found. ADON E stated that she had put out a stack of 15 minute check sheets for R51 on 1/31/18 for staff to complete. DON B stated that 15 minute checks sheets should have been in place from 2/2/18 to 2/7/18 and were not. Surveyor also reviewed the facility's Resident Injury/Incident/Accident Report, dated 2/6/18 for R51 with DON B and ADON E. Surveyor asked if the investigation should have been completed for R51's fall on 2/6/18, and DON B stated yes it should have been. Surveyor asked if the facility determined if R51's care plan for 15 minute checks and clip alarm in bed was being followed at the time of the fall on 2/6/18. DON B stated that she was not sure, as there had been a time when alarms were not being used for R51. On 4/12/18 at 2:20 PM, Survey interviewed LPN M (Licensed Practical Nurse) on the phone about R51's fall on 2/6/18. LPN M stated that she recalled being in the report room that evening and heard something, then heard R51 hollering and she went to his room and found him on the floor. Surveyor asked if LPN M noticed if a bed alarm was in place or going off, LPN M stated that she did not recall. On 4/12/18 at 2:46 PM, Surveyor interviewed CNA N (Certified Nursing Assistant) who had worked on 2/6/18 when R51 fell . CNA N stated that R51 did get restless and that she was the only CNA on the unit after 8:30 PM. CNA N stated, We weren't doing 15 minute checks on him at that time, they didn't have the sheets out for him, but I was still checking on him, I went out to wipe tables then the nurse came and told me he was on the floor. We had a sheet (for 15 minutes checks) then we didn't, but I was still checking him. Surveyor asked if R51 had a clip alarm in place that night. CNA N stated that she did not recall if the alarm was placed and did not recall hearing it going off. R51 had multiple falls while at the facility. The facility did re-assess R51 and update R51's care plan after the falls occurred. The facility did not ensure that R51's care plan interventions for safety and supervision where consistently being followed and did not thoroughly investigate the fall that occurred on 2/6/18, which resulted in R51 going to the Emergency department for treatment of [REDACTED].

Based on record review and interview the facility did not ensure 1 of 5 residents (Resident 3) received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility did not follow Resident 3's plan of care regarding constipation. Resident 3 is on a narcotic, which may cause constipation. The facility failed to offer extra fiber or stool softener or preventative laxatives. Resident 3 was eventually hospitalized with a bowel obstruction. Evidenced by: The facility's "Preventing Bowel Constipation or Obstruction" policy, dated 10/2012, includes the following: Policy: To assure adequate bowel movements for residents in order to prevent discomfort or complications from constipation or bowel obstruction. Procedure: 3. All bowel movements will be documented on the appropriate flow sheet. 5. The bowel movement flow sheet will be reviewed each night by the night shift CNA (Certified Nursing Assistant) assigned to that household. 6. Any resident who has not had a bowel movement the previous day will be added to the dietary Intervention List. That list, with the name of the household on the top, will be taken to the first floor and placed on the table outside of the kitchen. If there are no residents who need to be added to the list, a note will be sent down that says "none". Residents on these lists will be given dietary interventions as those residents are able to have, according to dietary orders, ie. (id est (that is) prune juice, prunes, etc. 7. Any residents who have not had a bowel movement for two days will be added to the dietary Intervention List and sent to the kitchen. A duplicate list also given to the day nurse on the household so that they can follow-up with suppositories, laxatives or enemas as needed and according to physician's orders [REDACTED]. A duplicate list will be given to the day nurse on the household for assessment and follow-up with the physician. The "Pain Management in the Long-Term Care Setting Clinical Practice Guidelines", undated, includes the following: Managing Constipation in Patients Starting Opioid treatment for [REDACTED]. Caregivers should: Encourage the patient to drink ample fluids, including fruit juices. Use regular small doses of stimulant laxative plus stool softeners. Increase daily fiber as tolerated along with adequate hydration to prevent fiber from hardening stool. Help the patient to remain as mobile as possible. Assist the patient to sitting position during a bowel movement. Provide the patient with comfort and privacy. Physicians should: Support the caregiver actions recommended above. Prescribe a regular dose of a stimulant laxative plus a stool softener in combination with [MEDICATION NAME] or [MEDICATION NAME] as indicated, increasing the dose until the desired effect is achieved. If no bowel movement occurs within 2-3 days, prescribe a laxative such as milk of magnesia, a [MEDICATION NAME] suppository, or an enema. Reduce the [MEDICATION NAME] dosage if feasible or reduce the dosages of other medications that affect bowel motility, such as calcium channel blockers and drugs with significant [MEDICATION NAME] properties. Example Resident 3 was admitted to the facility on [DATE] following hospitalization for a surgical repair of a fractured distal femur. Resident 3's [DIAGNOSES REDACTED]. Resident 3 has an activated health care power of attorney that was activated on 10/4/13. On 11/22/13 at 10:45 AM Surveyor reviewed the following information in Resident 3's medical record. Resident 3's Resident Data Collection, Admission, dated 9/9/13, included the following: Bowel and Bladder Evaluation, Bowel Habits: Continent: No. Constipated: Yes, at times. Laxative used: Yes. Enemas used: Yes, at home. Resident 3's MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 9/16/13, included the following information: Section C, Cognitive Patterns, BIMS (Brief Interview for Mental Status) summary score was a 10, indicating moderate cognitive impairment. Section G, Functional Status, indicated:Transfer status: Total dependence, with physical assist of two or more persons. Toilet use status: Extensive assistance, with physical assist of two or more persons. Section H, Bladder and Bowel, indicated: Bowel Continence, occasionally incontinent. Bowel Toileting Program: No. Bowel Patterns: Constipation present? No. Section J, Health Conditions, indicated: Pain Management: Been on a scheduled pain medication regimen? Yes. Received PRN (as needed) pain medications or was offered and declined? Yes. Received non-medication intervention for pain? No. Resident 3's Constipation Plan of Care, dated 9/9/13, includes the following approaches: Dietary interventions as follows: (ie. Prunes, juice, power pudding, etc.) as res (resident) allows. Monitor and record frequency and size of BM (bowel movement) on personal care flow sheet. If no BM for 3 days, administer per current MD (Medical Doctor) order. Resident 3's admission physician's orders [REDACTED]. * [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) 10-325 mg (milligram) per tab (tablet), take 1 tab by mouth every 4 hours as needed for pain. This medication was administered 50 times from 9/9/13 thru 9/30/13. * [MEDICATION NAME] 10 mg suppository, insert 1 suppository into rectum daily as needed for constipation. This medication was administered 9/13/13 with no effect, 9/18 with medium BM results, 9/22/13, the MAR indicated effective, however no size of BM was documented, 9/26/13 with no effect. * Milk of Magnesia (MOM) suspension, give 30 ml (milliliters) by mouth once daily as needed for constipation. This medication was administered 9/13/13, the MAR indicated effective, however no size of BM was documented, 9/17/13 with nothing documented on the MAR as to effectiveness, and 9/22/13 indicating BM, but no size was documented on the MAR. * Polyethylene [MEDICATION NAME] ([MEDICATION NAME]) 3350 bottle, take 17 g (grams) by mouth daily as needed for constipation. This medication was administered 9/26/13, the MAR indicated small BM. * Sennosides (Senna tablet) 8.6 mg tablet, take 8.6 mg by mouth 2 times daily as needed for constipation. This medication was not administered to Resident 3. Resident 3's physician telephone orders included the following: 9/28/13, 11:00 AM, Tap water enema prn (as needed) for abdominal distention. (Resident 3's MAR indicated this treatment was administered 9/28/13, results documented was decompression, no BM was indicated as a result. 10/1/13, 2:00 AM, admitted to (name of hospital) for bowel obstruction ... Resident 3's progress notes included the following entries: 9/9/13, 4:15 PM, ... bowel sounds active in all 4 quads (quadrants). Family states she is incontinent of bowel and bladder @ (at) times. She does prefer to use a bedside commode and is afraid/anxious to use toilet. Family stated she has been using commode @ home at this time is unable to bear weight d/t (due to) fracture. She asked to use commode during the assessment, when told she needed to use bed pan, she got anxious, had to redirect and reassure (with) family's help. She has a brace on Rt (right) leg (with) a rod surgically implanted. ... 9/13/13, 10:50 AM, ... Skin turgor < (less than) 3 sec (seconds). BS (bowel sounds) + (positive) x (times) 4 quadsrants, abd (abdomen) soft, round, non-tender with palpation, PRN bisoc (bisocodyl) suppository given early AM (without) results. Res then requested MOM given (with) effectiveness. ... 9/18/13, 12:50 PM, ... Res given prn MOM (without) results then bisocodyl (suppository) (with) medium results, ... 9/22/13, 4:30 AM, [MEDICATION NAME] supp (suppository) for (no) BM x 4 days. 9/22/13, 10:30 AM, .... Was given PRN MOM for constipation results obtained. 9/26/13, 9:50 AM, ... Res given suppository due to (no) BM x 4 days, (no) eff (effect) at this time, BS + x 4 quadrants, (no) abd distention or pain (with) palpation. Res is having flatulence (gas). ... (Resident 3's physician) in to see Res, ... 9/26/13, 2:00 PM, Res given [MEDICATION NAME] this AM (with) small loose results. Res states she usually goes q (every) 3-4 days and her husband verified this (with) writer. BS + x 4, abd soft non-tender (with) palpation, res passing flatulence, 9/28/13, 2:30 PM, Res c/o (complained of) abd pain this am "cramping", BS + x 4 quadrants, abd round hard on LUQ (left upper quadrant), ... Res states at home she frequently required enemas, husband (Resident 3's husband's name) here and confirmed, call placed to (Resident 3's physician) and updated on entry. MD gave order for tap water enema prn for abdominal distension. Enema administered (with) XL (extra large) amts (amounts) of flatulence, mucous clear, yellow in color. Res stated she felt much relief, distention relieved, abd non-tender (with) palpation after tx (treatment). .... 10/1/13, 8:00 PM, SBAR (situation, background, assessment, recommendation) 7:30 PM, this writer and (Registered Nurse) assessed resident. Bowel sounds hypoactive. Abdominal distention present. Pain rated at a 7 out of 10. Poor appetite and fluid intake. Has had no bowel movement for several days. Multiple tap water enema and suppositories attempted to help the constipation. Flatulence present. ... Resident agrees to go to ER (emergency room ) to have abdominal distention and pain evalutated. 7:45 PM, (Physican's Assistant) called and updated on change of condition, gave order to send to ER. 8:40 PM, Called ER and gave verbal report to nurse. Resident being sent out by ambulance, non-emergent. 9:00 PM, This writer called (Resident 3's husband) and updated about resident's condition. Thankful that she was sent for evaluation. Stated he always gave MOM everyday to resident. Also called (Director of Nursing) to update about resident's condition change. Resident 3's Transfer Form, 10/1/13, 8:40 PM, Abdominal pain. Left upper quadrant pain. Noted 7 out of 10. Nausea. Poor appetite and fluid intake. Currently on abx (antibiotic) for UTI (urinary tract infection). Multiple suppositories and tap water enemas given over the course of few days. Yellow, clear mucous, flatulence present. Bowel sounds hyporeactive. Abdomen distended. Increasing pain. Physician documentation from the hospital included the following: 10/1/13, 10:15 AM, The patient presents with abdominal distention in the upper abdomen, in the left upper quadrant. Onset: The symptoms/episode began/occurred gradually 2 week(s) ago. The symptoms do not radiate. Associated signs and symptoms: Pertinent positives: constipation, nausea. ... The symptoms are described as pressure. Modifying factors: The symptoms are alleviated by nothing. The symptoms are aggravated by movement. At its worst the pain was a 7/10. In the emergency department the pain is unchanged. Per Nursing home staff, no bowel movement for 9 days, had a suppository 3-4 days ago, tap water enemas and more suppositories. Only had a small amount of yellow-clear mucus out and some flatulence. Has a UTI,[MEDICAL CONDITION] + (Methacillin Resistant Staphalococcus Aureus positive), on an antibiotic. 10/1/13, 10:26 PM, Exam, Abdomen/GI (gastrointestinal): Inspection: distension, that is severe, in the [MEDICAL CONDITION] area and left upper quadrant. Bowel sounds: diminished. Palpation: moderate abdominal tenderness, in the left upper quadrant. 10/1/13, 11:28 PM, Disposition: Admit ordered for (Physician's Assistant). Preliminary [DIAGNOSES REDACTED]. Xray, Abdomen, 10/1/13, Impression: massive volume of stool throughout the ascending [MEDICATION NAME], and proximal descending colon. There is opacity of gas and stool within the rectum and distal colon. Proximal to the colon, there is diffuse mild distention of the small bowel. The findings could indicate developing obstruction as result of the massive volume of inspissated stool. The dilated small bowel could also be the result of adynamic ileus. Xray, Abdomen, 10/2/13, Reason for Exam: Small bowel obstruction, [MEDICAL CONDITION] tube placement. Impression: ... Massive volume of stool throughout the proximal to mid colon. There is now [MEDICATION NAME] distention of the rectum with air indicating that a colonic obstruction is not likely present. Mild diffuse distention of the small bowel most likely indicating an adynamic ileus. The possiblility of developing obstruction proximal to the massive volume of colonic stool cannot be excluded. On 11/22/13 at 12:55 PM Surveyor interviewed Registered Nurse (RN) C. RN C stated the CNA (Certified Nursing Assistant) will document each resident's bowel movement on the "Lax and BM Record". RN C stated a nurse will review the documentation and then shred the "Lax and BM Record" after reviewing. RN C stated the BMs are not documented elsewhere unless a medication is given for the BM, such as an enema, Milk of Magnesia, suppository, etc. On 11/22/13 at 1:00 PM Surveyor interviewed Director of Nursing (DON) B. DON B stated the weekly BM sheets (Lax and BM Record) are destroyed and BMs are not documented anywhere else. DON B stated there was no record of Resident 3's BMs except what was documented in Resident 3's progress notes. DON B stated "I guess we should keep the BM sheets." DON B stated she would expect staff to monitor and document BMs for Resident 3, especially since she was on a narcotic. On 11/22/13 at 2:50 PM Surveyor interviewed Resident 3's Family Member (FM) D. FM D stated he informed the facility that Resident 3 has always had a problem with constipation, would receive Milk of Magnesia at home on a daily basis and would receive enemas as well. FM D stated Resident 3 would complain of stomach pain and had told the nursing staff her abdomen hurt before she went to the hospital. FM D stated he believed Resident 3 was in pain. The facility was informed by Resident 3's family that she had a history of [REDACTED]. The facility did not provide Resident 3 with preventative bowel regime to prevent constipation. Resident 3 was hospitalized with a bowel obstruction.

Based in interview and record review, the facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) for 1 of 1 incidents reviewed. The facility did not have evidence that all alleged violations were thoroughly investigated, and that steps were taken to prevent further potential abuse while the investigation was in progress for 1 of 1 incident reviewed. The facility did not ensure that if the alleged violation was verified appropriate corrective action was taken for 1 of 1 incident reviewed. Resident 2 was observed to have Resident 1 pinned between the wall and Resident 2's wheelchair and was noted to be massaging the genitalia of Resident 1. The facility did not implement appropriate interventions to prevent reoccurrence. The facility did not immediately initiate an investigation and did not report the incident to the administrator of the facility, the state agency or the police department. The facility did not conduct an analysis to determine the cause of facility system breakdown in reporting and did not provide education to staff regarding the initiating corrective action timely. Two days after the incident, staff observed Resident 2 again heading towards Resident 1. Since the incident Resident 1 has been noted to have an increase in behaviors which required intervention from a psychologist. His behaviors include yelling at staff to " not touch him there " when providing peri-care. He is more anxious and wants to spend more time in bed. The medication record shows an increase in the use of [MEDICATION NAME] since the incident. Lack of immediate action to prevent further abuse and immediate and thorough investigation created an Immediate Jeopardy which began on 11/19/12 and was discovered on 12/11/12. The Nursing Home Administrator was informed of this finding on 12/11/12 and the jeopardy was removed on 12/11/12. The deficient practice continues at a D level as all portions of the corrective actions have not been fully implemented. This is evidenced by the following: Resident 1 has [DIAGNOSES REDACTED]. The facility completed a quarterly Minimum Data Set (MDS) assessment for Resident 1 on 9/18/12. This assessment indicates that Resident 1 usually makes himself understood and understands others. Resident 1 scored 7 points on the Brief Interview for Mental Status (BIMS), denoting severe cognitive impairment. Section D, "Mood", of this assessment notes that Resident 1 has felt down, depressed or hopeless for several days during the assessment period. Section E, "Behavior" of this assessment indicates that Resident 1 did not have behaviors during the assessment period. "Functional Status" indicates that Resident 1 needs extensive assistance and physical assist to move between locations in his room and about the unit and uses a walker and wheelchair or mobility devices. According to the "[DIAGNOSES REDACTED]. The "Face Sheet" notes that Resident 2 is [AGE] years old and was admitted to the facility on [DATE] and is his own decision-maker. The facility completed a quarterly MDS assessment on 10/9/12 for Resident 2. This assessment notes that Resident 2 is understood by others and understands others and scored 12 points on the BIMS assessment. A score of 12 points indicates that Resident 2 has moderate cognitive impairment. Section D, "Mood", notes that Resident 2 has trouble with sleep, feels tired/little energy and has trouble with concentration. Section E, "Behavior" notes that Resident 2 did not exhibit behaviors during the assessment period. "Functional Status" states that Resident 2 is able to move about the unit with supervision (oversight, encouragement) and set-up assist only and uses a walker, wheelchair and prosthesis. Resident 1's "Nurse's Notes" dated 11/21/12 state, "11:30-Late entry for 11/19/12 2:50 PM. This writer was told by CNA (Certified Nursing Assistant) that this resident was found c (with) another peer (resident-male) and the other peer had his hand on private genital area on top of pants. CNA immediately separated residents; resident did not voice any complaints of being hurt, nor any negative behavior noted. Resident's POC (plan of care) updated to include being arms-length aware from peer resident." It is important to note that there is no additional documentation dated 11/19/12 nor 11/20/12 regarding this incident. Social worker ' s interview of the CNA (CNA E) on 11/26/12 10:24 AM revealed that she eye witnessed (Resident 2) rubbing (Resident 1's) crotch and that (Resident 1's) wheelchair was 'pinned' between the partition near the elevator and (Resident 2's) wheelchair. She contacted the nurse (RN G) and reported the situation. There is no mention of the incident that occurred on 11/19/12 in Resident 2's medical record until 11/21/12 when the following was written: "11/21/12, 1130 (11:30 AM): Late entry for 11/19/12 2:50 PM. This writer was told by CNA that resident was found touching peer (male) on top of pants in genital area. CNA immediately separated the two residents and redirected them. Peer did not appear been in distraught; nor any negative behaviors noted. Resident's POC updated to include keeping resident arm's length from peer. Will cont (continue) to monitor." CNA E, after separating the residents, immediately reported the incident to RN G. Surveyor spoke with RN G on 12/11/12 at 10:11 AM. RN G stated she was in the report room when she was approached by CNA E who reported that she caught (Resident 2) touching (Resident 1) inappropriately in the groin area and that CNA E stated that she separated the two residents. RN G stated that she repeated this information to the Director of Nurses (DON B). Surveyor asked RN G what she told DON B. RN G stated that she told DON B exactly what CNA E stated. Surveyor asked RN G what her response was to the incident. RN G stated that she documented on an incident report on 11/21/12 and that 15 minute checks were started. RN G stated that she was not exactly sure on what she needed to do. Surveyor asked RN G what DON B stated to do about the situation. RN G stated that she does not remember. RN G then stated that DON B stated to keep an eye on them. Surveyor asked RN G when the last time she was educated on abuse. RN G stated that she was educated on abuse at the last nurses meeting which was before this incident occurred. RN G stated that there was a discussion after the incident about what steps to take like contacting the doctor and filling out the incident report. Surveyor spoke with DON B on 12/11/12 at 10:20 AM. Surveyor asked DON B about what happened on 11/19/12 between Resident 1 and Resident 2. DON B stated that she was in the report room and a CNA came in and told what happened. Surveyor asked what exactly the CNA stated. DON B stated that CNA E stated that (Resident 2) was trying to touch (Resident 1) inappropriately. DON B stated that she asked if it occurred on top of clothes. Surveyor asked DON B if this was exactly what was reported or if there was more specific information. DON B stated that CNA E stated that it looked like Resident 2 was trying to be sexual with Resident 1 and that Resident 2's hand was on that area and this made CNA E realize and separate the two residents. DON B stated that these CNAs are "seasoned" girls and they have seen this kind of stuff before. DON B stated that she did not know if (Resident 1) knew what was going on but she knows that (Resident 2) knew. DON B stated that next she implemented that Resident 2 be an arm's length away from Resident 1. Surveyor asked DON B why an investigation was not initiated. DON B stated that she felt it was an isolated event, they were monitoring the residents and that this was the first time she had heard of this. Surveyor asked DON B if the observation of Resident 2 inappropriately touching Resident 1 met the definition of sexual abuse. DON B stated, "I guess it does." Surveyor asked DON B when NHA A was informed of the incident. DON B stated that she did not talk to NHA A about the incident on 11/19/12. Surveyor asked DON B if the police were called and DON B questioned Surveyor if the police should have been called. Surveyor asked DON B if staff should be educated related to the incident. DON B stated that all staff should have been educated. The Director of Nurses did not immediately report the incident to the administrator. The facility did not immediately investigate the incident and did not put effective measures in place, did not communicate to all staff the directive to keep the residents arms-length apart when not supervised, and did not implement actions that would keep residents safe and prevent further possible abuse. Subsequently, on 11/21/12, a second incident almost occurred. Surveyor spoke with DON B and SW C on 12/11/12 at 11:55 AM about "another possible occurrence witnessed" documented in the 11/21/12 incident report. DON B stated that it was on the 21st, when Resident 2 appeared to be going toward Resident 1. Surveyor asked DON B who told her this. DON B stated that LPN D told her about this. SW C stated that she was pretty sure that CNA F told LPN D about the incident. SW C stated that Resident 2 never got to Resident 1. Surveyor asked if there was any documentation regarding this second incident. SW C stated that there was no documentation related to this particular incident on 11/21/12 and stated, "That's when I was like, I need to do something about this." SW C added that there was also a problem that CNA E had told CNA F about the 11/19/12 incident, so 2 CNAs knew about the incident. DON B added that Resident 2 was not placed on 15 minute checks until 11/21/12. On 12/11/12 at 1:17 PM, Surveyor spoke with LPN D about the incident between Resident 1 and Resident 2. LPN D stated that she was off on Monday, 11/19/12 and did work on 11/21/12. LPN D stated she was in the hallway when she was summoned by (CNA F) who was assisting another resident into a common bathroom. LPN D stated that she went over to Resident 1 and Resident 2. Surveyor asked LPN D how far apart Resident 1 was from Resident 2. LPN D stated that they were a little more than 1 arm's length apart. LPN D stated that at that time, CNA F stated that Resident 1 and Resident 2 could not be next to each other and CNA F told LPN D about the incident that had occurred on Monday. LPN D stated that next she called SW C and that SW C was not aware of the 11/19/12 incident. LPN D stated that she believed that this was when the investigation was started. Surveyor asked why she called SW C. LPN D stated that she wanted to make sure SW C was aware of the incident. Surveyor asked if there were other residents around. LPN D stated that there were other residents around but she was not sure who or how many. Surveyor asked LPN D about the intervention that was placed for protection. LPN D stated that it was to keep (Resident 2) an arm's length away from Resident 1 if he was unsupervised. Surveyor asked LPN D how this is implemented. LPN D stated, "I see what you're saying." Surveyor asked LPN D how CNA F knew about the incident. LPN D stated that CNA F was told by CNA E on Monday (11/19/12). LPN D stated that she had not received education regarding abuse since the incident. It was not until a second incident almost occurred on 11/21/12 that the facility initiated an investigation and recognized that the incident constituted sexual abuse. The facility completed an "Alleged Nursing Home Resident Mistreatment Report" via the online reported system on 11/21/12 at 8:29 AM. This document states the following: " ...Date Occurred: 11/19/12; Time occurred: unknown as of yet; Allegation type: abuse; Resident's Name: (Resident 1); Name of accused: (Resident 2); Title of accused: resident; Summary of incident: This worker was informed at 8:39 AM on 11/21/12 from LPN (Licensed Practical Nurse) (LPN D) that (Resident 2) was found massaging (Resident 1's) penis on top of his pants on 11/19/12. (LPN D) stated she had just received this report from CNA (CNA F) a few minutes earlier (on 11/21/12); Person preparing report (Social Worker (SW) C)." The facility began an investigation into the incident on 11/21/12 and reported the results of the investigation to the State Agency on 11/26/12. The investigative notes and summary are as follows: "Misconduct Incident Report" (11/26/12): " ...Date Occurred: 11/19/12; Time occurred: 2:00 PM; Date Discovered: 11/21/12; Briefly describe the incident: On 11/19/12, (Resident 2) was found 'massaging' (Resident 1's) penis/genitalia region on the 2nd floor dining room. Both individuals were clothed. (Resident 2) was said to be rubbing (Resident 1) on top of his clothing, between his legs, when CNA (CNA E) noticed and intervened, removing (Resident 1) from the situation. (For more information please see attached interviews); Describe the effect that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident. The affected person (Resident 1) appears to be more agitated and paranoid since the incident. When staff member attempted to change (Resident 1's) incontinence pad (Resident 1) became agitated and yelled, 'Don't touch me!' Staff members report (Resident 1) has repeatedly requested to go back to his room during daytime hours, which is out of character for (Resident 1). The agitation and paranoia could be a result of the inappropriate touching, or as a result of a visit from a private investigator a few days prior, or even as a result of this Alzheimer's or dementia. The cause of the aforementioned behaviors could be result of the events that have occurred with (Resident 1) recently. It is difficult to pinpoint where the behaviors stem from as (Resident 1) is unable to voice his concerns due to his diagnoses. Explain the steps the entity took upon learning of the incident to protect the affected person(s) and others from potential misconduct: Lafayette Manor has taken the following steps to ensure safety: 1) Provide (Resident 2) with his own private room; 2. Complete 15 minute checks; 3) Ensure resident is arm's length away from other residents when unsupervised by staff ...Law enforcement contacted or involved? No (checked) ..." "Aggressive Resident to Resident Incident Form" (signed 11/26/12) by CNA E (the witness), Director of Nursing (DON) B, and Registered Nurse (RN) G: "Briefly describe the incident: CNA reported to RN on duty in this witness's presence that resident (Resident 2) was touching (Resident 1) in private genital area on top of clothing. CNA reported residents and redirected and came and told RN staff. Has this resident had any injury? No; Who witnessed the incident? CNA; How were residents and others protected? Residents were separated and (Resident 2) had no closer than arm's length to other peers. What changes were implemented to prevent this from occurring in the future? Care plan updated to keep within arm's length of other peers, monitor resident as this has never happened before & event may be isolated. Contact Administrator with voice contact: 11/21/12; Time: 10:00; If no injury leave message for MD: Date: 11/21/12. Time: 8:00 AM; Message left for Social Worker: 11/21/12; Time: 8:00 AM as another possible occurrence was witnessed. Behavior listed on behavior tracking form: No (checked); Added aggressive incident and date of incident on Care Plan: Yes (checked) ..." Investigation Notes, written by SW C on 11/26/12: " ...8:55 AM Interview with (Resident 1): This worker approached (Resident 1) who was sitting outside the kitchenette at a table by the television on second floor near the Willow Lane hallway/ This worker asked (Resident 1) if she could talk with him. (Resident 1) stated, 'yes,' then added 'I would like to go to bed soon.' This worker responded with, 'Wouldn't you like to stay up and watch some television? It would be lunch time in a few hours.' (Resident 1) stated "No, I am tired. I didn't sleep last night.' This worker asked if it would be ok to talk a little before (Resident 1) went to bed. (Resident 1) stated, 'Yes.' This worker asked (Resident 1) how he was doing and (Resident 1) responded, 'Fine.' This worker asked (Resident 1) how everything was going, (Resident 1) responded, 'Good.' This worker continued on with small talk. This worker informed (Resident 1) that she (this worker) was the social worker and liked to check in with residents to see how things were going. (This worker paused.) (Resident 1) did not speak. This worker further explained if there was ever anything (Resident 1) needed hour could contact his worker. This worker also explained she was available to discuss any type of questions, comments or concerns. Throughout conversation (Resident 1) appeared agitated and continually tapped his left hand on his leg. (Resident 1) continually looked to the floor when speaking with this worker. Before and after the interview, (Resident 1) stated he wanted to go to bed several times. This worker told (Resident 1) she would talk to the nurse (LPN D) (Resident 1) wanted to go back to bed. (LPN C) stated this was atypical behavior and added that she had noticed (Resident 1) has been more agitated that usual today, she wonders if this agitation is a result of the aforementioned incident. 9:10 AM-Interview with (Resident 2): This worker met with (Resident 2) in her office, (Resident 2) was awake and orientated. This worker began conversation with (Resident 2), asking him how everything was going. (Resident 2) stated he has a bad cough and pneumonia. This worker stated she was sorry to hear that ...This worker informed (Resident 2) that she wanted to talk with him regarding a situation that occurred between him (Resident 2) and another resident on Monday of this week. (Resident 2) stated, 'ok.' This worker asked (Resident 2) if he could remember anything from Monday. (Resident 2) looked around the room, and the responded, 'No.' This worker told (Resident 2) that she had been informed that (Resident 2) had touched another resident on their private part (this worker signaled to the area reported). This worker explained that touching others in such a way is no ok because it makes the other person feel uncomfortable and unsafe. (Resident 2) agreed, shaking his head yes and stating, 'I know. That shouldn't happen.' This worked asked (Resident 2) what should be done so that everyone at Lafayette Manor can be safe. (Resident 2) responded, 'I won't do it again.' This worker explained that touching others in private parts could be considered abuse. This worker further explained by law this incident would need to be reported to the state. (Resident 2) stammered, "Why, why can't we just keep this quiet?' This worker explained by law any incident of abuse must be reported. (Resident 2) stated, 'I don't remember anything ...I, I would like to be told if I'm doing something wrong so I can stop ...This writer kindly referenced a previous conversation with (Resident 2) regarding an incident that occurred in the past re: privacy of his room-mate and inappropriate comments made towards staff while assisting with cream to his genitals. This worker informed (Resident 2) that all of these incidents could be viewed as unsafe and make others feel uncomfortable ...9:45 AM-This worker interviewed (CNA F) about the aforementioned incident. (CNA F) confirmed that she had heard from another CNA (CNA E) that (CNA E) had saw (Resident 2) touch (Resident 1) ...(CNA F) added that she was informed she should keep (Resident 2) away from (Resident 1) and watch (Resident 2) to ensure he wasn't touching other residents. 10:24 AM-This worker contacted (CNA E) via phone. (CNA E) informed this worker that on 11/19/12, she eye witnessed (Resident 2) 'rubbing (Resident 1's) crotch ...she contacted the nurse and reported the situation. This worker asked (CNA E) when she had reported she stated it was the same day following the incident. This worker asked (CNA E) which nurse she reported it to and (CNA E) stated (RN G) whom then reported it to (DON B). For further clarification/detail (CNA E) was just returning from her lunch break (around 2:00 PM) and going to enter the kitchenette, when she noticed that (Resident 1's) wheelchair was 'pinned' between the partition near the elevator and (Resident 2's) wheelchair ...10:30 AM: This worker spoke with (DON B) and (Nurse Consultant H) re: this situation. Through conversation it appears (DON B) did hear about the incident, but was not aware of the severity. There apparently was a miscommunication between staff members and details of the incident were incomplete. Staff members will be completing essential paperwork and will continue to monitor the safety of all residents. It was decided that (Resident 2) be further than arms reach away from residents when unsupervised. (Resident 2) will need to have a private room to ensure safety as his roommate is a male resident and has complained of privacy issues in the recent past. Staff will also be completing 15 minute checks on (Resident 2). Around 2:00 PM this worker received a call from (LPN D) who was updated on safety precautions. During the phone conversation (LPN D) reported that (CNA I) had informed her that when attempting to provide cares for (Resident 1), (Resident 1) began yelling for her not to touch him 'down there' ((Resident 1) did not want the CNA near his gentile (genital) area) ...When speaking with (Resident 2), this worked reiterated safety and educated (Resident 2) on explaining what inappropriate touch was. (Resident 2) stated, 'There must be a misunderstanding. Me and that gentleman were just monkey-ing around ...(Resident 2) stated he just 'touched' him 'there' as a 'joke.' 5:00 PM-This worker spoke with (CNA I) who clarified when attempting to change his incontinence pad last evening (Resident 1) yelled, 'Get out of there! Don't touch me.' (CNA I) stated she thought this was weird because (Resident 1) never acted like that before. It should be noted that ...(Resident 1) has appeared more agitated since the aforementioned incident. (Resident 1) has voiced not wanting to be touched by CNAs during cares ...(Resident 2) does not have a medical [DIAGNOSES REDACTED]. In talking with him and staff (Resident 2) is said to be oriented X's (times) three. He knows staff members and several residents by name and can recall past and present events ..." Resident 1's Nurse's Progress Note, dated 12/5/12, states the following: * Mood: (BLANK) * Behavior: Problem Behavior: Yelling out at NOC (night), Swearing, Effective Measure: Redirect, Reposition, Get up *Mood/Behavior Status: "Deteriorated, Increase in talking to self and swearing." *Occasionally noted to be agitated with staff, has conversations with self and swears at self. New order to see SBS (Southwest Behavioral Science) professionals due to increased behaviors will continue to monitor." Review of Resident 1's Alteration in Mood Care plan dated 9/25/12 with a goal that Resident 1 will verbalize what is making Resident 1 feel sad, directs staff to monitor Resident 1 for negative statements about Resident 1's family. Note: there were no interventions put into place for Resident 1 after the 11/19/12 resident-to-resident altercation to keep him safe or for monitoring and assessing his psychosocial functioning. Review of Resident 1's Alteration in Thought Process care plan dated 9/25/12 with a goal that Resident 1 will continue to function at highest practicable level directs staff to track Resident 1's behaviors of, yelling out for help at night, negative statements about family, feelings of sadness, thinking bad things will happen to Resident 1, and swearing at staff during cares. Note: there were no new interventions put into place for Resident 1 after the 11/19/12 resident to resident sexual contact. Review of Resident 1's physician orders [REDACTED]. Review of Resident 1's MAR(Medication Administration Record) for November 2012 indicates that Resident 1 received [MEDICATION NAME] .25 mg by mouth on 11/26,11/28, and 11/30/2012.( Please note that 11/26/12 was the first time in November that Resident 1 was administered the as needed [MEDICATION NAME], and this was 6 days after the altercation.) Review of Resident 1's MAR for December 2012 indicates that Resident 1 received [MEDICATION NAME] .25 mg by mouth on 12/2,12/6,12/9 and 12/10/2012. (Please note: since the resident to resident altercation on 11/19/12 Resident 1 has been administered the as needed [MEDICATION NAME] for an overall total of 7 times.) Resident 1 has exhibited new and worsening behaviors which required medical intervention and increased use of anti-anxiety medications after the incident. Surveyor spoke with Nurse Consultant (NC) H on 12/11/12 at 9:27 AM. NC H stated that SW C was going to do the education piece regarding the incident. NC H stated that there was nothing documented regarding education. NC H stated that the facility was "lacking" in education. NC H stated that if you didn't document it, you didn't do it. Surveyor spoke with SW C on 12/11/12 at 9:45 AM. Surveyor asked SW C about any history of inappropriate behaviors exhibited by Resident 2. SW C stated that there was a privacy issue in the past that she was informed of by former employees of the facility. SW C stated that she was informed that Resident 2 was peeking in over on his roommate during the night. SW C stated that she was also told that when staff place cream on Resident 2's genitalia, he would moan. Surveyor asked SW C if Resident 2's roommate was affected by the situation. SW C stated that there seemed to be no affect. Surveyor asked SW C if there was ever any behavior monitoring completed related to this incident with Resident 1 and Resident 2. SW C stated that this was the only time she had heard of this incident and the behavior documenting would be important and this this was a good idea. Surveyor asked SW C about the intervention to keep Resident 2 an "arm's length away when unsupervised" and how staff implement this. SW C stated that at night, Resident 2 has a glass of brandy with some other residents so CNAs monitor during this time. Surveyor asked SW C about the education the facility has provided to the staffs regarding the "miscommunication" and failure to place appropriate interventions and initiate and investigation. SW C stated that when she did her interviews with staff involved she spoke to each of them about reporting incidents. SW C stated that it is planned that she, DON B and Nursing Home Administrator (NHA A) will do in-services. Surveyor asked SW C if she spoke to DON B about the incident and what was reported to DON B. SW C stated that DON B said that "(Resident 2) touched (Resident 1)." Surveyor asked SW C if she educated DON B on reporting incidents so that investigation could begin. SW C stated that she did do so, but there was no documentation regarding any education for staffs. Surveyor asked if any other staffs were educated. SW C stated that there was no education completed. Surveyor asked why the police were not called regarding the incident. SW C stated that she had asked (NHA A) if the police should be called and that NHA A stated it was "resident-to-resident, so don't have to call the police." Surveyor asked if Resident 2 knew what he was doing when he touched Resident 1's genital area. SW C stated that Resident 2 knew what he was doing. Failure to immediately report the incident on 11/19/12, to initiate an investigation, and to implement a plan that was communicated to all staff to keep residents (particularly Resident 1) safe from Resident 2 created a finding of immediate jeopardy. The facility removed the jeopardy on 12/11/12, by which time the facility had: *Ensured that Resident 2 was moved to a different floor of the nursing home, ensured 15 minute checks would be performed and that Resident 2 was to always be more than arm's length away from other residents and that Resident 2 will be in line of sight of a staff member unless in his room. A motion sensor with audible alarms was placed on the door of his room to ensure that staff is aware of Resident 2 leaving his room * All staff has been reeducated on resident abuse/neglect focusing on resident to resident incidents before the start of their next shift. *Law enforcement was notified of the incident between Residents' 1 and 2. *A psychiatric consult was scheduled for both Residents' 1 and 2.

Based on interview and record review, the facility did not develop or implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for 1 of 1 incident reviewed. The facility ' s policy for abuse addresses acts by a caregiver or a non-client resident. It does not specifically address resident-to-resident abuse. In regard to caregiver or non-client resident abuse, the policy and procedure notes that staff will immediately inform their supervisor or management staff, who will immediately notify the administrator/acting administrator in person or with direct telephone contact ... Documentation will include, but is not limited to...approaches taken to protect during the investigation and to prevent recurrence. The facility did not implement its policies and procedures after Resident 2 was observed to have Resident 1 pinned between the wall and Resident 2's wheelchair and was noted to be massaging the genitalia of Resident 1. The facility did not immediately report this incident of sexual assault to the administrator of the facility, the state agency or the police department and did not immediately investigate what had occurred. The facility did not place appropriate interventions to prevent reoccurrence. It was not until two days later, when Resident 2 was again approaching Resident 1, that staff notified the administrator, began an investigation, and put measures in place to prevent further potential abuse. Since the incident, Resident 1 has been noted to have an increase in behaviors which has required evaluation from a psychologist. His behaviors include yelling at staff to " not touch him there " when providing peri-care. He is more anxious and wants to spend more time in bed. The medication record shows an increase in the use of [MEDICATION NAME] since the incident. Failure to implement its policies and procedures following the incident of sexual abuse created an Immediate Jeopardy, which began on 11/19/12 and was discovered on 12/11/12. The Nursing Home Administrator was informed of this finding on 12/11/12 and the jeopardy was removed on 12/11/12. The deficient practice continues at a D level as all portions of the corrective actions have not been fully implemented. This is evidenced by the following: The facility's policy titled "Resident Abuse, Neglect Mistreatment, Misappropriation of Property, and Injuries to a Resident of Unknown Source" (Reviewed 10/5/12) states, "Abuse: Means any of the following-1. An act or repeated acts by a caregiver or non-client resident (note: this does not address acts by a resident), including but not limited to restraint, isolation or confinement, that when contrary to the entity's policies and procedures, not a part of the client's treatment plan, and done intentionally to cause harm, does any of the following: a. Causes or could reasonably be expected to cause pain or injury to a client or the death of a client, and the act does not constitute self-defense as defined in s.939.48, Stats; b. Substantially disregards a client's rights under ch. 50 or 51, Stats. or a caregivers duties and obligations to a client; c. Causes of could reasonably be expected to cause mental or emotional damage to a client, including harm to the client's psychosocial or intellectual functioning that is exhibited by anxiety, depression, withdrawal, regression, outward aggressive behavior, agitation or a fear of harm or death, or a combination of these behaviors ...Procedure: 1. Any person may report an allegation or potential caregiver misconduct to any entity employee at any time. Upon receiving such a report, either verbal or written, the entity employee shall immediately inform their supervisor or management staff, who will immediately notify the administrator/acting administrator in person or with direct telephone contact. 2. Any facility employee having either direct or indirect knowledge of potential misconduct involving a facility client shall immediately follow the reporting procedures. 3. The supervisor receiving verbal or written information shall take prompt measures to assess and ensure the safety and welfare of the client(s) involved, immediately notify the administrator/acting administrator of the allegation along with any other appropriate individuals. Following notification of the Administrator, the Supervisor/Administrator reporting will complete the employee incident form if appropriate, and will within 24 hours completed the 'Alleged Nursing Home Mistreatment, Neglect and Abuse Report' ...5. All investigations and assessments will be recorded in the nursing notes. Documentation will include, but is not limited to resident/client's condition including date, time and place of the incident, approaches taken to protect during the investigation and to prevent recurrence, administrator called, guardian updated and follow up care ..." The facility ' s policy does not address reporting to the police. According to CMS (Centers for Medicare and Medicaid Services) memo(S&C: 11-30-NH) Reporting Reasonable Suspicion of a Crime in a Long-Term Care Facility (LTC), "Memorandum Summary: Reporting Suspicion of a Crime: Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility. Reporting to State Survey Agencies (SAs) and Law Enforcement: Reports must be submitted to at least one law enforcement agency of jurisdiction and the SA (in fulfillment of the statutory directive to report to the Secretary) ..." Cross reference F225 for further details of the following. According to nurse ' s notes for Resident 1 (11/21/12, 11:50 AM, late entry for 11/19/12 at 2:50 PM), Social Worker (SW) C ' s, CNA E observed Resident 1 trapped between the wall and Resident 2 ' s wheelchair. Resident 2 was massaging/rubbing the genital area of Resident 1, who has severe cognitive impairment. CNA E separated the residents, and then reported what she had observed to RN G, who was in the same room as Director of Nurses (DON B). RN G immediately reported the incident to DON B. Surveyor spoke with DON B on 12/11/12 at 10:20 AM. Surveyor asked DON B about what happened on 11/19/12 between Resident 1 and Resident 2. DON B stated that she was in the report room and a CNA came in and told what happened. Surveyor asked what exactly the CNA stated. DON B stated that CNA E stated that (Resident 2) was trying to touch (Resident 1) inappropriately. DON B stated that she asked if it occurred on top of clothes. Surveyor asked DON B if this was exactly what was reported or if there was more specific information. DON B stated that CNA E stated that it looked like Resident 2 was trying to be sexual with Resident 1 and that Resident 2's hand was on that area and this made CNA E realize and separate the two residents. DON B stated that these CNAs are "seasoned" girls and they have seen this kind of stuff before. DON B stated that she did not know if (Resident 1) knew what was going on but she knows that (Resident 2) knew. DON B stated that next she implemented that Resident 2 be an arm's length away from Resident 1. Surveyor asked DON B why an investigation was not initiated. DON B stated that she felt it was an isolated event, they were monitoring the residents and that this was the first time she had heard of this. Surveyor asked DON B if the observation of Resident 2 inappropriately touching Resident 1 met the definition of sexual abuse. DON B stated, "I guess it does." Surveyor asked DON B when NHA A was informed of the incident. DON B stated that she did not talk to NHA A about the incident on 11/19/12. Surveyor asked DON B if the police were called and DON B questioned Surveyor if the police should have been called. Surveyor asked DON B if staff should be educated related to the incident. DON B stated that all staff should have been educated. Contrary to it policies and procedures - which were developed for caregiver and non-client resident abuse - the Director of Nurses did not: 1. immediately report the sexual assault to the administrator; 2. begin an immediate investigation to determine if other residents had been abused; 3. develop a plan (other than monitoring the residents and keeping the resident ' s arm-length apart when not supervised) to keep Resident 1 and other residents safe and did not communicate a plan to all staff; 4. document in either resident ' s record on 11/19 or 11/20/12 the details of what had occurred or the steps being taken to prevent further possible abuse, in Resident 1 or Resident 2 ' s record; 5. call the police. (This step was missing from the facility ' s policies and procedures.) Failure to take these measures created an opportunity for further potential abuse to occur. Subsequently, on 11/21/12, a second incident almost did occur. Surveyor spoke with DON B and SW C on 12/11/12 at 11:55 AM about "another possible occurrence witnessed" documented in the 11/21/12 incident report. DON B stated that it was on the 21st, as reported by LPN D, that Resident 2 appeared to be going toward Resident 1. SW C stated that Resident 2 never got to Resident 1. Surveyor asked if there was any documentation regarding this second incident. SW C stated that there was no documentation related to this particular incident on 11/21/12 and stated, "That's when I was like, I need to do something about this." On 12/11/12 at 1:17 PM, Surveyor spoke with LPN D about the incident between Resident 1 and Resident 2. LPN D stated that she was off on Monday, 11/19/12 and did work on 11/21/12. LPN D stated she was in the hallway when she was summoned by (CNA F) who was assisting another resident into a common bathroom. LPN D stated that she went over to Resident 1 and Resident 2. Surveyor asked LPN D how far apart Resident 1 was from Resident 2. LPN D stated that they were a little more than 1 arm's length apart. LPN D stated that at that time, CNA F told LPN D that Resident 1 and Resident 2 could not be next to each other and CNA F told LPN D about the incident that had occurred on Monday. LPN D stated that next she called SW C and that SW C was not aware of the 11/19/12 incident. LPN D stated that she believed that this was when the investigation was started. Surveyor asked why she called SW C. LPN D stated that she wanted to make sure SW C was aware of the incident. Surveyor asked if there were other residents around. LPN D stated that there were other residents around but she was not sure who or how many. Surveyor asked LPN D about the intervention that was placed for protection. LPN D stated that it was to keep (Resident 2) an arm's length away from Resident 1 if he was unsupervised. Surveyor asked LPN D how this is implemented. LPN D stated, "I see what you're saying." Surveyor asked LPN D how CNA F knew about the incident. LPN D stated that CNA F was told by CNA E on Monday (11/19/12). LPN D stated that she had not received education regarding abuse since the incident. It was not until a second incident almost occurred on 11/21/12 that the facility initiated an investigation and recognized that the incident constituted sexual abuse. The facility completed an "Alleged Nursing Home Resident Mistreatment Report" via the online reported system on 11/21/12 at 8:29 AM. This document states the following: " ...Date Occurred: 11/19/12; Time occurred: unknown as of yet; Allegation type: abuse; Resident's Name: (Resident 1); Name of accused: (Resident 2); Title of accused: resident; Summary of incident: This worker was informed at 8:39 AM on 11/21/12 from LPN (Licensed Practical Nurse) (LPN D) that (Resident 2) was found massaging (Resident 1's) penis on top of his pants on 11/19/12. (LPN D) stated she had just received this report from CNA (CNA F) a few minutes earlier (on 11/21/12); Person preparing report (Social Worker (SW) C)." The facility began an investigation into the incident on 11/21/12 and reported the results of the investigation to the State Agency on 11/26/12. The investigative notes and summary are documented in F225. (Cross reference F225.) According to the facility ' s Misconduct Incident Report" (11/26/12): " The affected person (Resident 1) appears to be more agitated and paranoid since the incident. When staff member attempted to change (Resident 1's) incontinence pad (Resident 1) became agitated and yelled, 'Don't touch me!' Staff members report (Resident 1) has repeatedly requested to go back to his room during daytime hours, which is out of character for (Resident 1). The agitation and paranoia could be a result of the inappropriate touching, or as a result of a visit from a private investigator a few days prior, or even as a result of this Alzheimer's or dementia. The cause of the aforementioned behaviors could be result of the events that have occurred with (Resident 1) recently. It is difficult to pinpoint where the behaviors stem from as (Resident 1) is unable to voice his concerns due to his diagnoses. When SW C interviewed Resident 1 at 8:55 AM on 11/26/12, she noted: " Throughout conversation (Resident 1) appeared agitated and continually tapped his left hand on his leg. (Resident 1) continually looked to the floor when speaking with this worker. Before and after the interview, (Resident 1) stated he wanted to go to bed several times. This worker told (Resident 1) she would talk to the nurse (LPN D) (Resident 1) wanted to go back to bed. (LPN C) stated this was atypical behavior and added that she had noticed (Resident 1) has been more agitated that usual today, she wonders if this agitation is a result of the aforementioned incident. " SW C also wrote during her investigation, " Around 2:00 PM this worker received a call from (LPN D) who was updated on safety precautions. During the phone conversation (LPN D) reported that (CNA I) had informed her that when attempting to provide cares for (Resident 1), (Resident 1) began yelling for her not to touch him 'down there' ((Resident 1) did not want the CNA near his gentile (genital) area). Review of Resident 1's physician orders [REDACTED]. Review of Resident 1's MAR(Medication Administration Record) for November 2012 indicates that Resident 1 received [MEDICATION NAME] .25 mg by mouth on 11/26,11/28, and 11/30/2012.( Please note that 11/26/12 was the first time in November that Resident 1 was administered the as needed [MEDICATION NAME], and this was 6 days after the altercation.) Review of Resident 1's MAR for December 2012 indicates that Resident 1 received [MEDICATION NAME] .25 mg by mouth on 12/2,12/6,12/9 and 12/10/2012. (Please note: since the resident to resident altercation on 11/19/12 Resident 1 has been administered the as needed [MEDICATION NAME] for an overall total of 7 times.) Resident 1 has exhibited new and worsening behaviors which required medical intervention and increased use of anti-anxiety medications after the incident. Failure to develop and implement appropriate policies and procedures on 11/19/12 to report, investigate, and to implement a plan that was communicated to all staff to keep residents (particularly Resident 1) safe from Resident 2 created a finding of immediate jeopardy. The facility removed the jeopardy on 12/11/12, by which time the facility had: *Ensured that Resident 2 was moved to a different floor of the nursing home, ensured 15 minute checks would be performed and that Resident 2 was to always be more than arm's length away from other residents and that Resident 2 will be in line of sight of a staff member unless in his room. A motion sensor with audible alarms was placed on the door of his room to ensure that staff is aware of Resident 2 leaving his room * All staff has been reeducated on resident abuse/neglect focusing on resident to resident incidents before the start of their next shift. *Law enforcement was notified of the incident between Residents' 1 and 2. *A psychiatric consult was scheduled for both Residents' 1 and 2.

Based on observation, record review and interview the facility did not ensure that medically related social services were provided to assist 1 resident (Resident 1) from a sample of 4 residents to maintain the highest practicable physical, mental, and psychosocial well-being and to ensure that the facility was meeting the resident ' s physical and emotional needs. Resident 1 was sexually assaulted by another male resident on 11/19/12. Documentation and interviews confirm that he has had an increase in behaviors since that time (increased anxiousness, increased use of Lorazepam, yelling out and demanding that staff " not touch him there " when providing peri-care, increased requests to go to bed early) The facility has not assessed these behaviors or implemented adequate monitoring, supervision, and behavioral management plans. This is evidenced by: The facility's policy titled "Resident Abuse, Neglect Mistreatment, Misappropriation of Property, and Injuries to a Resident of Unknown Source" (Reviewed 10/5/12) states, "...3. The supervisor receiving verbal or written information shall take prompt measures to assess and ensure the safety and welfare of the client(s) involved ..." (Emphasis added.) Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's quarterly MDS (Minimum data Set) with an ARD (Assessment Reference Date) of 9/18/12 and a completion date of 9/21/12 indicates that Resident 1's speech is clear, usually makes self understood and understands others. Section C (Cognitive Patterns) of the MDS indicates that Resident 1 scores a 7 out of 15 on the BIMS (Brief Interview for Mental Status),and had no delirium. Section D, Mood, indicates that Resident 1 had feelings of being down, depressed or hopeless. Resident 1's total Mood Severity Score was 1 indicating that the feelings occurred several days. Section E, Behaviors, indicates that Resident 1 exhibited no behavioral symptoms. Review of Resident 1's Alteration in Mood Care plan dated 9/25/12 with a goal that Resident 1 will verbalize what is making Resident 1 feel sad, directs staff to monitor Resident 1 for negative statements about Resident 1's family. Review of Resident 1's Alteration in Thought Process care plan dated 9/25/12 with a goal that Resident 1 will continue to function at Highest Practicable Level directs staff to track Resident 1's behaviors of, yelling out for help at night, negative statements about family, feelings of sadness, thinking bad things will happen to Resident 1, and swearing at staff during cares. Neither plan has been updated since 9/25/12. "Misconduct Incident Report" (11/26/12): " ...Date Occurred: 11/19/12; Time occurred: 2:00 PM; Date Discovered: 11/21/12; Briefly describe the incident: On 11/19/12, (Resident 2) was found 'massaging' (Resident 1's) penis/genitalia region on the 2nd floor dining room. Both individuals were clothed. (Resident 2) was said to be rubbing (Resident 1) on top of his clothing, between his legs, when CNA (CNA E) noticed and intervened, removing (Resident 1) from the situation. (For more information please see attached interviews); Describe the effect that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident. The affected person (Resident 1) appears to be more agitated and paranoid since the incident. When staff member attempted to change (Resident 1's) incontinence pad (Resident 1) became agitated and yelled, 'Don't touch me!' Staff members report (Resident 1) has repeatedly requested to go back to him room during daytime hours, which is out of character for (Resident 1). The agitation and paranoia could be a result of the inappropriate touching, or as a result of a visit from a private investigator a few days prior, or even as a result of this Alzheimer's or dementia. The cause of the aforementioned behaviors could be result of the events that have occurred with (Resident 1) recently. It is difficult to pinpoint where the behaviors stem from as (Resident 1) is unable to voice his concerns due to his diagnoses." Investigation Notes, written by SW C on 11/26/12: " ...8:55 AM Interview with (Resident 1): This worker approached (Resident 1) who was sitting outside the kitchenette at a table by the television on second floor near the Willow Lane hallway/ This worker asked (Resident 1) if she could talk with him. (Resident 1) stated, 'yes,' then added 'I would like to go to bed soon.' This worker responded with, 'Wouldn't you like to stay up and watch some television? It would be lunch time in a few hours.' (Resident 1) stated "No, I am tired. I didn't sleep last night.' This worker asked if it would be ok to talk a little before (Resident 1) went to bed. (Resident 1) stated, 'Yes.' This worker asked (Resident 1) how he was doing and (Resident 1) responded, 'Fine.' This worker asked (Resident 1) how everything was going, (Resident 1) responded, 'Good.' This worker continued on with small talk. This worker informed (Resident 1) that she (this worker) was the social worker and liked to check in with residents to see how things were going. (This worker paused.) (Resident 1) did not speak. This worker further explained if there was ever anything (Resident 1) needed hour could contact his worker. This worker also explained she was available to discuss any type of questions, comments or concerns. Throughout conversation (Resident 1) appeared agitated and continually tapped his left hand on his leg. (Resident 1) continually looked to the floor when speaking with this worker. Before and after the interview, (Resident 1) stated he wanted to go to bed several times. This worker told (Resident 1) she would talk to the nurse (LPN D) (Resident 1) wanted to go back to bed. (LPN C) stated this was atypical behavior and added that she had noticed (Resident 1) has been more agitated that usual today, she wonders if this agitation is a result of the aforementioned incident. It is important to note that there are no additional social service notes in Resident 1's medical record since the 11/26/12 entry. Review of Resident 1's physician orders [REDACTED]. Review of Resident 1's MAR (Medication Administration Record) for November 2012 indicates that Resident 1 received Lorazepam .25 mg by mouth on 11/26,11/28, and 11/30/2012. (Please note that 11/26/12 was the first time in November that Resident 1 was administered the as needed Lorazepam, and this was 6 days after the altercation.) Review of Resident 1's MAR for December 2012 indicates that Resident 1 received Lorazepam .25 mg by mouth on 12/2, 12/6, 12/9 and 12/10/2012. (Please note: since the resident to resident altercation on 11/19/12 Resident 1 has been administered the as needed Lorazepam for an overall total of 7 times.) Review of Resident 1's nurses ' progress note dated 12/5/12 stated the following: * Mood : BLANK (This is the same as 11/5/12 progress note.) * Behavior: Problem Behavior: Yelling out at NOC (night), Swearing, Effective Measure: Redirect, Reposition, Get up (same as 11/5/12) *Mood/Behavior Status: "Deteriorated, Increase in talking to self and swearing." * Occasionally noted to be agitated with staff, has conversations with self and swears at self. New order to see SBS (Southwest Behavioral Science) professionals due to increased behaviors, will continue to monitor." On 12/11/12 at 11:00 AM, Surveyor asked DON B when the psych consult was scheduled for Resident 1. DON B stated,"I think it is today." On 12/11/12 at 3:15 PM, Surveyor asked DON B why Resident 1's care plan was not updated after the incident on 11/19/12 and what the facility did to monitor/treat Resident 1. DON B stated, "When Resident 1's behaviors resurfaced we thought that the increase was just a reoccurrence from Resident 1's Dementia, we did not put two and two together to think that the increase in behaviors could have been from the incident on 11/19/12. " On 12/11/12 at 3:20 PM, Surveyor asked SW (Social Worker) C what the facility did for Resident 1 after the occurrence on 11/19/12 and if SW C met with/assessed Resident 1 for changes in Resident 1's well-being following the incident. SW C stated, "I did go in and talk with Resident 1 but did not chart anything." Surveyor then asked SW C why Resident 1's plan of care was not updated to reflect how the facility was going to keep Resident 1 safe following the incident, SW C did not respond. Surveyor then asked SW C why the facility waited 16 days to get any type of professional assistance for Resident 1, SW C stated, "I guess we should have consulted with someone sooner, but it was hard to tell what was going on with Resident 1. We didn't know if it was from Resident 1's Alzheimer's/Dementia getting worse." Cross reference F 225

Based on observation, interview and record review the facility did not ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 residents out of 11 reviewed (Resident 10, and 8) Resident 10 was admitted to the facility with [DIAGNOSES REDACTED].>100 per minute 13 of the last 15 times documented without physician notification. Also, the facility used oxygen at higher levels than prescribed routinely during her stay, which, in a person with [MEDICAL CONDITION], can cause carbon [MEDICATION NAME] retention and lead to acidosis, [MEDICAL CONDITION](rapid heart rate), [MEDICAL CONDITION], coma, respiratory arrest and death. These failures created an immediate jeopardy beginning on 7/2/12; the administrator was notified of the immediate jeopardy at 1:45 pm on 8/29/12. The immediate jeopardy was removed on 8/29/12 but continues at a D level as not all components of the plan of correction have been implemented and, as evidenced by the following example. Resident 8 was admitted to the facility with an ulcer on her left ankle. The facility determined it to be a venous stasis ulcer and did not properly assess, care plan, and treat the ulcer. This is evidenced by: Example 1 Resident 10 was admitted to the facility on [DATE]. Resident 10's diagnoses, per the discharge summary dated 6/26/12, include acute [MEDICAL CONDITIONS] hypertension, hypoxemia, hypercapnic acidosis, demand ischemia, hypercarbia, and staph pneumonia. Additionally the document indicates, "The day prior to discharge she desaturated into the 70's on her [MEDICAL CONDITION]. This was thought to be due to narcotics but concern was raised for possible pneumonia. She was started on broad spectrum antibiotics. A sputum culture was obtained. It was positive for staph aureus." Surveyor reviewed the closed record for Resident 10 on 8/29/12 and noted 3 sets of admission documents from the transferring hospital. Document 1, Hospital Encounter form, a 4 page document, includes a history and physical electronically signed on 6/20/12 at 0039 (12:39 am). Document 2, a 6 page document, indicates discharge summaries dated 6/26/12 at 1148 (11:48 am) and includes an order for [REDACTED]. Document 3, a 5 page document, indicates discharge orders and instructions facesheet - patient copy, also includes the Moxifloxacin order, the form indicates it was electronically signed by the MD on 6/26/12 at 12:30pm). Upon questioning Director of Nursing (DON) B regarding a concern that Resident 10 did not receive Moxifloxacin as ordered during her stay at the facility, DON B provided Surveyor with a 4th admission document, a 5 page document, which is identical to Document 3 except that it does not contain the Moxifloxacin order. Even though the facility had 4 documents that had inconsistencies, nurses did not clarify the orders with the MD. Instead, DON B indicates that Document 4 is the document the facility used to prepare the medication administration records and send to pharmacy to get the medications filled. As a result, Resident 10 did not receive Moxifloxacin, an antibiotic intended to treat Resident 10's pneumonia during her stay at the facility. The medical record also contained an X-ray Chest AP view now stat bedside, performed on 6/24/12, findings indicate, "There is increased consolidation in the left lung base as well as new consolidation in the medial right lung base." This document indicates it was faxed to the facility on [DATE] at 4:48 pm as part of a 27 page document. Resident 10 was noted to have orders for home oxygen at 3 liters at rest and 4 liters with activity. Also using [MEDICAL CONDITION] at HS with IPAP 16 EPAP 6 RR 16 as of 6/26/12. Resident 10's care plan, potential for altered respiratory function, related to [MEDICAL CONDITIONS], dated 6/26/12, indicates a goal of Resident will be free of shortness of breath/congestion, and, indicates approaches to include Oxygen 3 L via nasal cannula / mask as ordered, for at rest, 4 L with activity routinely. Assess vitals and breath sounds as ordered & prn. Surveyor interviewed DON B and RN C on 8/29/12 at 1:45 pm. DON B and RN C indicated that Resident 10 had [MEDICAL CONDITION] and their expectation would be that Resident 10 should have had a lung assessment each shift. DON B indicated that 3 L at rest would mean when Resident 10 was in bed and 4 L when she was out of bed. DON B indicated she would not expect the nursing staff to use oxygen above the ordered parameters without consultation with the physician because excessive oxygen use in a [MEDICAL CONDITION] resident could cause complications. It should be noted that persons with [MEDICAL CONDITION] who receive excessive supplemental oxygen can develop CO2 retention, and subsequent hypercapnia. This can lead to acidosis, [MEDICAL CONDITION](rapid heart rate), [MEDICAL CONDITION], coma, respiratory arrest and death. A nursing note dated 6/26/12 at 10:30 pm states in part, lung sounds clear to auscultation, uses 3 - 4 L of oxygen at rest and 5 L with activity. It should be noted that the oxygen levels are not as ordered by the physician. A nursing note dated 6/27/12 at 6:45 am states in part lungs with bilateral diminished bases otherwise clear. The nursing note also reiterates the oxygen rates from the 6/26/12 10:30 pm note, again, these do not follow the physician orders [REDACTED]. A nursing note dated 6/28/12 at 6:45 am states in part oxygen at 4 L while in bed and 5 L when up to the bathroom. These oxygen levels do not follow the physician orders [REDACTED]. This nursing note also indicates that Resident 10's lungs are clear to auscultation. A nursing note dated 6/29/12 at 6:00 am states in part that oxygen is at 4 L while in bed and 5 L when up to the bathroom. These oxygen levels do not follow the physician orders [REDACTED]. This nursing note also indicates that Resident 10's lungs with diminished breath sounds at bases and throughout and with faint wheezes throughout. This is a change from the previous clear to auscultation with no increase in monitoring or call to the physician. A nursing note dated 7/2/12 at 2:20 am states in part that Resident has a pulse rate of 117, a respiratory rate of 22 and an oxygen saturation rate of 77 % on 4 L. The note continues that the oxygen rate was turned up to 4.5 L and indicates that the staff will recheck in 15 minutes. There is no additional notation on the change in the resident after 15 minutes and there was no lung assessment completed with this change in condition or call to the physician. It should be noted that Resident 10 was noted in bed at 2:20 am and the oxygen rate should have been at 3 L per physician orders. A nursing note dated 7/2/12 at 10:15 am states in part that Resident 10 has a pulse rate of 106 and a respiratory rate of 20 with an oxygen saturation rate of 88 % on 4.5 L of oxygen. Again it appears that Resident 10 was in bed and the oxygen level should have been at 3 L per physician orders. A nursing note dated 7/3/12 at 6:45 am states in part that Resident 10 has a pulse rate of 88 and a respiratory rate of 22 with an oxygen saturation rate of 92 % on 4.5 L of oxygen. Again it appears that Resident 10 was in bed and the oxygen level should have been at 3 L per physician orders. A nursing note dated 7/6/12 indicates that Resident 10 has oxygen saturation rates at 84 -86% on 5 L of oxygen and is lethargic and unable to answer questions. Resident 10 was sent to the emergency room for treatment. It should be noted that Resident 10's pulse was documented almost every shift and from 6/30/12 through discharge Resident 10's pulse rate was >100 13 of the 17 times documented. Although Resident 10's respiratory rate was documented the nursing staff did not ever indicate the quality of the respiratory rate/effort or use of accessory muscles. [MEDICAL CONDITION] be a symptom of carbon [MEDICATION NAME] retention, yet nursing didn't immediately consult with the physician about the resident ' s elevated pulse rate. Resident 10 was seen in the local hospital emergency room and noted to have a blood carbon [MEDICATION NAME] level of >130 with a normal of 35 - 45, and a blood oxygen level of 56 with a normal of 80 - 100. Resident 10 was also noted to be lethargic, in obvious distress with wheezing, lung sounds scattered, decreased breath sounds with almost no air movement. Resident 10's respiratory rate on admission was noted to be 54. Resident 10 was intubated and sent via medflight to a higher level of care hospital. Resident 10 was sent to the hospital she was in before admission to the nursing home, who upon admission, wrongly assumed Resident 10 had received the Moxifloxacin that had been ordered prior to discharge. The hospital noted the impression is [MEDICAL CONDITION] exacerbation is likely due to pneumonia. Surveyor interviewed Physician's Assistant (PA) L on 8/29/12 at 2:09 pm. PA L indicated that Resident 10 was noted as a carbon [MEDICATION NAME] retainer and the oxygen use should be monitored closely and should always follow the physician's orders [REDACTED]. PA L indicated that she did contact the DON at that time. PA L indicated that it was imperative, given Resident 10's comorbidities, that she receives her antibiotics as ordered for the pneumonia. Resident 10 was admitted to the facility with a [DIAGNOSES REDACTED].>100 per minute 13 of the last 15 times documented, and the facility used oxygen at higher levels than prescribed routinely during her stay. These failures created an immediate jeopardy beginning on 7/2/12. The immediate jeopardy was removed on 8/29/12 when the facility ensured that all nurses received inservice training prior to the start of their next shift on [MEDICAL CONDITION] clinical manifestations, the use of oxygen with a [MEDICAL CONDITION] diagnosis, the risk of carbon [MEDICATION NAME] retention in resident's with a [MEDICAL CONDITION] diagnosis, monitoring oxygen saturation levels, lung sounds, vital signs and oxygen parameters and any changes in condition. Example 2 Resident 8 was admitted to the facility on [DATE] with an open area on her left lateral malleolous. The information sent from the hospital to the nursing home only indicates that Resident 8 has an ulcer on her left ankle but does not indicate the type of ulcer. The "Nurses' Progress Note, time period July 2012, states under skin condition "condition treated open area L lateral malleolus." The "Nurses' Progress Note, time period August 2012, states under skin condition "stasis ulcer, L lateral malleolus, keep pressure off wound, tx (treat) per wound nurse/MD." The Minimum Data Set (MDS), assessment reference date 7/30/12, indicates that Resident 8 is at risk for developing pressure ulcers but has no current pressure ulcers. The MDS indicates that Resident 8 has 1 venous or arterial ulcer present. The Care Area Assessment for Pressure Ulcers states in part, no pressure ulcers, Resident has a venous ulcer on left ankle present at admission to the manor. Requires staff assistance to move sufficiently to relieve pressure over any one site. Decreased mobility, requires staff assist for transfers, ambulation and repositioning. Is at risk for pressure ulcers and will proceed to care plan. A Wound Report form, dated 7/25/12, states under comments: Area on ankle appears healed. Recommend keeping covered with foam dressing for protection. Moisturize with Vaseline change every 3 days. Discontinue Unna boot. Ace wrap for 24 hours after Unna boot removed. The "type of wound" is not completed. A Wound Report form, dated 8/1/12 states wound is .3 by .3 by .1 cm with a wound bed that is yellow and has slough. The edges are pink and the surrounding skin is healthy with no pain. The comments sections states, "ulcer appears open. No drng (drainage) noted. Slough in wound bed. Recommend daily Vaseline to area and keep covered with bordered foam. No [MEDICAL CONDITION] in lower legs noted." A Wound Report form, dated 8/15/12 states wound is .3 by .4 by .2 cm with a wound bed that yellow with purulent exudate. The edges remain pink but the surrounding skin is now [MEDICAL CONDITION] and the progress is noted as deteriorated. The recommendations include "Increase in [MEDICAL CONDITION] of LLE (left lower extremity) noted. Recommend [MEDICATION NAME] around wound, small amt (amount) [MEDICATION NAME] to wound, cover with bordered form or gauze dressing. Moderate Compression either with [MEDICATION NAME] or [MEDICATION NAME] lite wrap (or comparable product) from base of toes to 1 inch below knee. Change 2 times a week. The type of wound was noted to be venous stasis ulcer. A Wound Report dated 8/20/12 states wound is .2 by .3 by .2 cm with scant purulent exudate the wound bed is yellow and the edges pink with health surrounding skin with the progress noted as improved. The recommendations indicate [MEDICAL CONDITION] improved over last week. Recommend Calmoseptime around wound and small amt [MEDICATION NAME] to ulcer. Cover with bordered foam or gauze. Change 3 times a week. Recommend [MEDICATION NAME] - mod compression, start with 1 layer, from base of toes to 1 inch below knee. Leg elevateion when sitting except for meal times. Surveyor observed Resident 8 on 8/21/12 at 3:00 PM. Resident 8 was observed up in her wheelchair in her room. Resident 8 had her legs dependent with grippy socks on. [MEDICAL CONDITION] was noted in the left lower extremity from approximately the knee down. Registered Nurse (RN) I was observed to provide a treatment to Resident 8's ankle. RN I removed the previous dressing and the ulcer was noted to be approximately pea sized and circular in appearance, clean and dry. Resident 8's left leg was pale and the same coloration from her thigh to her toes with no hemosideran staining noted. It should be noted that the leg was not wrapped and [MEDICATION NAME] was not used as the treatment as recommended above. The type of wound is again noted as venous stasis ulcer. A Wound Report dated 8/29/12 states wound is .3 by .4 by .2 cm with a small amount of purulent exudate with a yellow wound bed and pink edges with WNL (within normal limits) surround skin and no change in progress. Recommendations indicate [MEDICAL CONDITION] improved from a couple weeks ago. Recommendation: [MEDICATION NAME] to periwound. [MEDICATION NAME] to ulcer. Cover with Allevyn Gentle or [MEDICATION NAME] border dressing. Change 3 times a week. [MEDICATION NAME] for mod compression. Legs elevated when sitting except at meal times. The wound type states venous stasis ulcer and has a question mark under arterial ulcer. The care plan for Resident 8 only indicates potential for impaired skin integrity and does not indicate the treatments as recommended and does not indicate to elevate the legs as recommended. Surveyor interviewed the facility wound care consultant (WWC) K on 8/29/12 at 12:05 pm. Surveyor asked WWC K how she determined the type of ulcer Resident 8 had. WWC K indicated that she determined by looking at the wound. Surveyor asked what the characteristics of a venous stasis ulcer are. WWC K responded, irregular shape, drainage, usually above the ankle and the hemosideran staining. Surveyor asked if WWC K thought that Resident 8's ulcer appeared to meet these characteristics. WWC K stated she did not think so and added that today, 8/29/12, she had also considered a potential for an arterial ulcer, with characteristics of punched out and dry looking. Surveyor asked what clinical testing would be needed to determine arterial/venous ulcers. WWC K indicated an ABI (Ankle Brachial Index). Surveyor asked if WWC K had completed this test. WWC K stated she had not. Surveyor questioned the recommendation of compression and if an ABI should be performed before recommending compression. WWC K stated that an ABI is the standard of practice to perform prior to the initiation of compression. Surveyor asked if WWC K had considered pressure as the cause of Resident 8's ulcer. WWC K stated she did not consider this. Surveyor questioned how WWC K ensured that the facility was implementing her recommendations. WWC K stated she did not do anything to ensure that the facility had implemented the recommendations.

Based on interview and record review the facility did not ensure that the facility immediately consulted with the resident's physician; when there is a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 1 resident out of 11 reviewed (Resident 3). Resident 3's suprapubic catheter was removed by staff due to urine leakage and bleeding. The catheter could not be placed back in. The staff did not call Resident 3's physician to report that the catheter could not be replaced. Resident 3 was sent to the hospital after several more failed attempts to re-insert the catheter. Resident 3's tract was closed and inaccessible. Resident 3's suprapubic catheter could not be placed at the hospital and Resident 3 was sent to another hospital and a procedure initiated to dilate his penis was completed, and a Foley catheter was inserted in order for his bladder to empty. Resident 3 had physician ordered parameters for his blood sugars. Resident 3's blood sugars were above the parameters 5 times since 8/11/12 and the facility did not inform Resident 3's physician. Findings as follows: Resident 3 was readmitted to the nursing home on 8/4/12 with [DIAGNOSES REDACTED]. Resident 3's most current physician's orders [REDACTED]. A nursing note on 8/12/12 at 2:30 AM states, "Resident found with bed soaked in urine. SP (suprapubic) catheter with bloody drainage surrounding opening. Notified RN, decided to change catheter d/t drainage and urine. This nurse attempts failed. RN attempts failed." A nursing note on 8/12/12 at 3:00 AM states. "Call placed to DON. Explained situation. Told to wait until AM so others could try their hand at inserting catheter." A nursing note on 8/12/12 at 9:30 AM states, "Attempted to replace sp cath, unable to advance into bladder-increased resistance. Call placed to MD (MD name) order to send to ER for eval..." A nursing note on 8/12/12 at 2:00 PM indicates that Resident 3 will be admitted to the hospital for observation then sending to (another hospital name) for placement of catheter... Resident 3's emergency room note dated 8/12/12 at 10:58 AM states, "Exam negative for abscess, [MEDICAL CONDITIONS] swelling, however there is some inflamed subcutaneus tissue in the cystotomy port..." Procedures indicate, "Suprapubic catheter inserted by myself, without success. Tract appears to be closed and inaccessible. Minimal blood drainage. Urine leaking from site before attempt. Attempt first with 24 French then 16 French without success. Coude (special type of catheter with a firmer tip) via urethra (opening in the penis) was attempted as will without success... Resident 3's hospital History and Physical dated 8/12/12 indicates that his suprapubic port identified midline with subcutaneous tissues seen with inflammation and some urine drainage noted. No surrounding [DIAGNOSES REDACTED] or discharge. Penis demonstrates [DIAGNOSES REDACTED] (an abnormal congenital opening of the male urethra upon the undersurface of the penis). The assessment indicates: This [AGE] year old gentleman has a history of [MEDICAL CONDITION] for which he is given a suprapubic catheter. The patient since pulled out his catheter and was not able to be replaced non surgically. Currently the patient is incontinent and has had low volumes on the bladder scan every 3 hours through the night. He has been voiding through both the port and the urethra. Plan to send to (another hospital name) so see urologist tomorrow. On 8/13/12 Resident 3's Doctors Orders/Progress Notes (Notes from urologist assessment) indicates, "Dilated urethra and placed 8 F pediatric Foley (in penis). Will need primary urologist to place S/P at later date. The plan is to return to nursing home and schedule an appt with previous urologist this week. A Physician Visit Record dated 8/15/12 indicates that a #14 Coude 5 cc balloon Foley inserted and to return to urologist on 9/19/12. On 8/21/12 at 11:00 AM Surveyor interviewed DON B (Director of Nurses) regarding the standard of practice when a suprapubic catheter comes out and cannot be replaced. DON B stated, "Attempt to get it back in right away and if you cannot call the MD. This situation was my fault. The nurse did not tell me that there was trauma; she just told me that she couldn't get it back in. I told her that I would be in at 6:30 and would try then. I got busy and I tried at around 9:00. The site did not have active bleeding and did not look swollen. I tried and couldn't, it started to bleed. Then we sent him to the hospital." Surveyor asked for the facility policy and DON B stated that they did not have one. No follow up was done regarding what to do when a Suprapubic catheter comes out and cannot be replaced. On 8/24/12 at 9:30 AM, Surveyor interviewed MD F regarding Suprapubic catheter care. MD F stated that it is practice that when a suprapubic catheter comes out the ideal would be to reinsert the Foley into the tract so it does not close. When a suprapubic catheter comes out in the middle of the night the MD may just state to wait until the AM but it still would warrant a call to the MD. MD F continued on to state that if there was trauma to the area as in active bleeding it at least warrants a phone call to the physician so that a treatment plan can be established, because trauma to the area can lead to swelling and difficulty re-inserting the tube. MD F stated that Resident 1's situation ended up being a big deal because no one could get the suprapubic re-inserted, so Resident 3 had to spend the night at the hospital and be sent to another hospital to have his penis dilated and a catheter placed. Resident 3 had his supra pubic catheter removed and the facility was unable to replace his catheter. The facility did not call a physician or provide the necessary care and services timely. They could not replace the catheter until approx 7 hours later. At that time the hospital could not get a suprapubic catheter in so they sent him to another hospital where they could not place the supra pubic catheter either. A catheter was placed in his penis after a procedure was performed to dilate his urethra. Example 2 Resident 3 was readmitted to the nursing home on 8/4/12 with [DIAGNOSES REDACTED]. A Physician's Telephone order dated 8/4/12 at 1:45 PM states to continue with same sliding scale and accuchecks QID call if sugars less than 60 and greater than 250... A review of Resident 3's Blood Sugar Flow sheet for July and August 2012 indicates that following blood sugars above his ordered parameters: 8/11/12 at 8:00 PM BS was 253, 8/14/12 at 11:00 BS was 258, 8/16/12 at 8:00 PM BS was 254, 8/19/12 at 4:00 PM BS 286 and at 8:00 PM BS was 284. A review of Resident 3's medical record indicates that a physician was not called when Resident 3's blood sugars were over 250 on 8/11, 8/14, 8/16, and 8/19. The facility did not call Resident 1's physician when his blood sugars were out of his physician ordered parameters. On 8/21/12 at 1:00 PM Surveyor interviewed DON B regarding Physician ordered blood sugar parameters. DON B stated that on the Blood Sugar Flow sheet for July and August it is written on the form that Resident 3's blood sugar parameters are less than 60 and over 350 to call MD. Surveyor showed DON B the most current order in which the parameters are to call the MD if blood sugars are lower than 60 and over 250. DON B stated that the current order is what is to be followed and the staff should have called the sugars that were above 250. DON B stated that she would change the current Blood Sugar Flowsheet to reflect Resident 3's current blood sugar orders.

Based on interview and record review it was noted that 1 of 11 residents reviewed (Resident 10) was not free of significant medication errors. Resident 10 was admitted to the facility with [DIAGNOSES REDACTED]. This is evidenced by: Resident 10 was admitted to the facility on [DATE]. Resident 10's diagnoses, per the discharge summary dated 6/26/12 indicate acute [MEDICAL CONDITIONS] hypertension, hypoxemia, hypercapnic acidosis, demand ischemia, hypercarbia, and staph pneumonia. Additionally the document indicates, "The day prior to discharge she desaturated into the 70's on her [MEDICAL CONDITION]. This was thought to be due to narcotics but concern was raised for possible pneumonia. She was started on broad spectrum antibiotics. A sputum culture was obtained. It was positive for staph aureus." Surveyor reviewed the closed record for Resident 10 on 8/29/12 and noted 3 sets of admission documents from the transferring hospital. Document 1, Hospital Encounter form, a 4 page document, includes a history and physical electronically signed on 6/20/12 at 0039 (12:39 am). Document 2, a 6 page document, indicates discharge summaries dated 6/26/12 at 1148 (11:48 am) and includes an order for [REDACTED]. Document 3, a 5 page document, indicates discharge orders and instructions facesheet - patient copy, also includes the Moxifloxacin order, the form indicates it was electronically signed by the MD on 6/26/12 at 12:30pm). Upon questioning Director of Nursing (DON) B regarding a concern that Resident 10 did not receive Moxifloxacin as ordered during her stay at the facility, DON B provided Surveyor with a 4th admission document, a 5 page document, which is identical to Document 3 except that it does not contain the Moxifloxacin order. Even though the facility had 4 documents that had inconsistencies, nurses did not clarify the orders with the MD. Instead, DON B indicates that Document 4 is the document the facility used to prepare the medication administration records and send to pharmacy to get the medications filled. As a result, Resident 10 did not receive Moxifloxacin, an antibiotic intended to treat Resident 10's pneumonia during her stay at the facility. The medical record also contained an X-ray Chest AP view now stat bedside, performed on 6/24/12. Findings indicate, "There is increased consolidation in the left lung base as well as new consolidation in the medial right lung base." This document indicates it was faxed to the facility on [DATE] at 4:48 pm as part of a 27 page document. Resident 10 was seen in the local hospital emergency room noted to have a blood carbon [MEDICATION NAME] level of >130 with a normal of 35 - 45, and a blood oxygen level of 56 with a normal of 80 - 100. Resident 10 was also noted to be lethargic, in obvious distress with wheezing, lung sounds scattered, decreased breath sounds with almost no air movement. Resident 10's respiratory rate on admission was noted to be 54. Resident 10 was intubated and sent via medflight to a higher level of care hospital. Resident 10 was sent to the hospital she was in before admission to the nursing home, who upon admission, wrongly assumed Resident 10 had received the Moxifloxacin that had been ordered prior to discharge. The hospital noted the impression is [MEDICAL CONDITION] exacerbation likely due to pneumonia. Surveyor interviewed Physician's Assistant (PA) L on 8/29/12 at 2:09 pm. PA L indicated that Resident 10 was noted as a carbon [MEDICATION NAME] retainer and the oxygen use should be monitored closely and should always follow the physician's orders [REDACTED]. PA L indicated that she did contact the DON at that time. PA L indicated that it was imperative, given Resident 10's comorbidities, that she receive her antibiotics as ordered for the pneumonia. Resident 10 was admitted to the facility with a [DIAGNOSES REDACTED].

Based on interview and record review, the facility did not immediately consult with the resident's physician and did not notify the resident's legal representative of a significant change in the resident's physical status or need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 1 resident out of 5 reviewed (Resident 1). Resident 1 was on antibiotics for [MEDICAL CONDITION] in a gangrenous foot. Orders for the antibiotic ran through 6/26/12. It was reported to the Director of Nursing (DON), in error, on 6/26/12 that Resident 1's POA had wanted treatments and antibiotics stopped, a decision that the facility did not agree with. The DON went to the ethics committee for interventions. The DON did not contact Resident 1's POA to discuss the alleged request or change of condition or need to alter treatment of [REDACTED]. The lack of follow through led to Resident 1 not receiving the antibiotic for 11 days. Resident 1's foot became more swollen and red with increased drainage after the antibiotic was stopped. Although the physician was called to report that the gangrene was worse, nurses did not inform the physician that redness and drainage had increased (common symptoms of an infection) or that the antibiotics had been discontinued. It wasn't until 7/5/12 when the POA insisted that nursing staff call the physician due to the condition of Resident 1's foot that the physician was aware the antibiotics had been discontinued. On 7/5/12 the physician told the nursing staff to find out from Resident 1's POA if she wanted the antibiotic restarted as it had lapsed and the family/physician were not aware of the lapse. The physician indicated that If the POA wanted them to be restarted then orders were to be written. This did not get completed on 7/5/12. Resident 1 was restarted on antibiotics on 7/7/12 at Resident 1's POA's insistence. Resident 1 received an order for [REDACTED]. The facility took off the patch but did not notify Resident 1's physician until 6/25/12 and received an order to discontinue the patch. Findings as follows: Resident 1 had been hospitalized for [REDACTED]. Resident 1's discharge summary dated 6/5/12 indicated that Resident 1 was evaluated by vascular surgery and palliative care. A determination was made to stop the IV antibiotics and continue with the PO (by mouth) antibiotics. They (family) understood that the antibiotics will not be curative and are being used for palliation. Resident 1's discharge summary dated 6/5/12 indicates an order for [REDACTED]. Although an appointment was made by the hospital for 6/13/12, Resident 1 was not sent for this appointment. A nursing note on 6/15/12 at 10:45 AM states that an on-call physician was called about antibiotic and [MEDICAL CONDITION] and the on-call physician ordered [MEDICATION NAME] 875 mg BID until 6/19/12 until Resident 1's primary care physician can evaluate Resident 1. (Resident 1 presented with a rash on his peri area and back). Resident 1's right foot was still red swollen and painful with 2 plus [MEDICAL CONDITION]. A nursing note on 6/16/12 at 4:00 PM states that primary care physician was at the facility for routine visit. MD ordered to discontinue (DC) Agumentin and re-[MEDICATION NAME] as it was felt that Resident 1's redness on his right leg had increased. The 2 antibiotics were reordered to be given through 6/26/12, with an "automatic" stop date order. A physician's orders [REDACTED]. A nursing note on 6/20/12 at 10:30 AM documented by the wound care nurse indicates, "Per wound assessment this am, new ulcers noted in right great toe and in spaces between 2nd, 3rd, 4th and 5th toes. Small amount purulent drainage. Wound beds 100% yellow slough, edges and periwound macerated. Phone call to primary MD update given...this week the redness has resolved." The following are nursing notes describing Resident 1's wound: 6/21/12 at 10:45 PM: has wound to right foot toes they are blackened and blackened under part of foot. Odor coming from foot...Resident has 3 plus [MEDICAL CONDITION] to right foot. 6/22/12, at 4:45 PM: took off [MEDICATION NAME] per POA's request says he "is like a zombie" and was fine before they started him on the patch. The RN put it on paper to have the physician address it. No phone call to Resident 1's physician regarding his lethargy after starting the [MEDICATION NAME] Patch. 6/25/12 9:15 PM: 3rd and 4th toes remain black and 2nd toe is partially black and is slightly blue/purple in color. Sight drainage noted with odor. Black started under foot. Left message for DON...Right foot swollen and slightly red. 2 plus [MEDICAL CONDITION] The facility's 24 hour report sheet dated 6/25/12 indicates that [MEDICATION NAME] off, POA does not want it or ATB (antibiotic)... The Daily Physician's Log dated 6/25/12 indicates an entry FYI: 2nd toe blue/purple. No other description of right foot/toes. The entry also indicates to update MD on discontinuation of [MEDICATION NAME]. A Nursing Documentation Log dated 6/25/12 states, "...POA not wanting [MEDICATION NAME] on or other pain meds given. Doesn't want antibiotic given. ?need court interventions? It is documented by nursing staff that 2 MD's were updated (although in the nursing notes it was just updated regarding the [MEDICATION NAME] discontinuing). Added onto the form indicates (Primary MD) notified 6/28/12." A nursing note on 6/26/12 at 5:30 AM states Right foot remains red and [MEDICAL CONDITION]. Toes and underneath remains black...3:00 PM (On-call MD) of Resident's pain patch discontinued also notified about 2nd toe being blue and purple and also have a call in to (Primary physician name). 6/27/12 7:30 PM-Resident completed antibiotic course...No change in right foot. A nursing note on 6/28/12 at 3:00 AM states Right foot remains slightly red and [MEDICAL CONDITION]. A nursing note on 6/29/12 at 2:00 PM states Right foot remains to have blackened toes...foot red and slightly [MEDICAL CONDITION]. The Daily Physician Log dated 6/29/12 states FYI: Black continues to spread to other toes and under foot. (Response section of the form states "ok" on 7/2/12 by an on-call physician and to update primary Tuesday). A nursing note on 6/30/12 at 4:30 AM states Right foot slightly red and [MEDICAL CONDITION]. Toes remain black. A nursing note on 7/1/12 at 3:45 PM states right foot still swollen and red with black toes. A nursing note on 7/2/12 at 3:30 AM states right foot [MEDICAL CONDITION] and red 3rd and 4th toes remain black. Blackened area continues to spread to other toes and foot. A nursing note on 7/2/12 at 10:00 AM states spoke with (on-call physician) and was updated that res right foot continues to be swollen with all toes and under feet blackened and spreading. Will update (primary physician) also will continue to monitor. The Daily Physician's Log dated 7/3/12 states, "FYI: black area continues to spread to other toes and under foot with 3 plus [MEDICAL CONDITION]." The physician's response indicates to elevate (right foot) as much as possible. The note does not indicate that the physician was notified that Resident 1's foot was reddened and [MEDICAL CONDITION] and possibly infected. A nursing note on 7/3/12 at 10:00 AM states, (Primary MD name) updated on progression of gangrene area to other toes and underneath foot on part of foot and 3 plus [MEDICAL CONDITION] to right foot. MD stated to elevate right foot as much as possible. The primary physician was not informed that the antibiotics had been discontinued. A nursing note on 7/5/12 at 3:00 AM states, Right foot red and [MEDICAL CONDITION] continues to spread from toes to underneath of foot. A nursing note on 7/5/12 at 5:00 PM states, "Right foot is very swollen and red. I looked at the sole of his foot to check the gangrene and there was a serous/serosanguineous drainage. I updated the RN and called (Primary physician) Dr said to wrap foot with loose gauze and change BID. The DR also said to speak with the wound care nurse to have her look at it and since she has been taking care of the foot. Daughter was in and I updated her and she was okay with the dressing and monitor." On 7/5/12 8:00 PM-Wound care nurse was in says his gangrene is now wet on plantar surface of his foot. The drainage has a foul smell to it and is a moderate amount. The swelling has moved up to mid-calf and is red...I called the RN and left message for DON and NHA. A Wound Report dated 7/5/12 completed by the wound nurse indicates that Resident 1 has necrotic tissue on the plantar surface 2 x 4.5 cm with purulent, foul odor, moderate amount of drainage. The wound was necrotic black [MEDICAL CONDITION], [DIAGNOSES REDACTED] and deteriorated. Pt. very restless, difficult to assess. Eschar on plantar surface fluctuant. Maceration noted between 1 and 2nd 4th and 5th toes. 3rd and 4th toes remain dry. [MEDICAL CONDITION] noted to med calf. Recommendations outline [DIAGNOSES REDACTED]... Spoke with daughter and had a lengthy discussion re: comfort care. A nursing note on 7/6/12 at 2:00 PM states right foot and ankle are [MEDICAL CONDITION] up to calf of leg and there is a foul odor from the foot. 7/7/12-2:00 AM-Right foot red and [MEDICAL CONDITION] up to med calf. Toes and plantar portion of foot black due to gangrene. Resident very agitated while applying lamb's wool. Moderate amount of serosangenous drainage between toes with strong foul smell. A nursing note on 7/7/12 at 4:30 PM states, "POA here and asked about antibiotics this nurse looked and is not on any (antibiotic). Stated she wants him [MEDICATION NAME] like he was before...(On call MD) called and ordered until Monday when Primary MD can evaluate...POA seemed upset when she left and while talking with this writer." A nursing note on 7/11/12 at 6:50 AM Primary MD called order to send Resident 1 to ER for right foot wound eval. The above nursing notes do not indicate that the nursing staff reported to the MD that Resident 1's foot was also red along with swelling to indicate that an infection/[MEDICAL CONDITION] could be occurring. In addition, the facility did not indicate that Resident 1 was not currently on antibiotics when reporting physical symptoms to the MD. Resident 1's emergency room note dated 7/11/12 states, "The affected area is on the lateral aspect of right toes, medial aspect of right toes, plantar aspect of right first toe, right second toe, right third toe and fourth toe, ball of foot right first toe right second toe right third toe, right fourth toe. Right first, second, third and fourth toenail. The patient reports increased drainage fever pain redness swelling. History obtained from daughter. [MEDICAL CONDITION] that is moderate blackened toes 1st to medial aspect 5 toe with drainage and draining inferior to the 1st to 3rd digit." Resident 1's Hospital History and Physical dated 7/11/12 states, "He is noted to have an ulceration extending through the entire skin layer measuring approximately 0.5 cm at the sacrum. This is surrounded by an area approximately 3 1/2 x 5 cm ... the base of the ulcer remains to be pink. Extremities-...The right foot shows black dry desiccated toes from the great toe including the 2nd, 3rd, and 4th toes and medial aspect of the 5th toe. There is also a semicircular area of hard black eschar extending on the plantar surface from the base of the 4th through 2nd toes and measuring approximately 2-1/2 to 3 cm proximally on the plantar aspect of the foot. Surrounding this is an area of general [DIAGNOSES REDACTED] and bogginess. There is milky foul smelling, thin discharge emanating from the distal aspect of the black eschar on the plantar surface of the foot. The dorsal aspect of the foot shows diffuse [DIAGNOSES REDACTED] and bogginess, although no specific crepitus over the entire dorsal aspect and extending proximally up the lower leg. The plantar aspect of the foot shows [DIAGNOSES REDACTED] extending approximately 3-4 cm proximal to the black eschar with a very pale non blanchable area of skin measuring approximately 2 by 4 cm and then more [DIAGNOSES REDACTED] over the med heel and extending up the posterior aspect of the ankle into the lower leg. He has no palpable pulses in the lower extremity..." The history and physical continues on to state that on 6/5/12 Resident 1's family declined surgical intervention and a decision was made to return to the facility on oral antibiotics knowing that eventually the gangrene would continue to slowly progress. At the facility he initially completed a 10 day course of [MEDICATION NAME]. A second 10 course was ordered. At the end of that time the antibiotic lapsed and I was not aware of the lapse date. They (antibiotics) were there-fore not re-started. ...Over the course of the next 10 days or so the [DIAGNOSES REDACTED] of the foot was noted to get somewhat worse and on the 5th of July he was noted to have drainage from the plantar aspect of the foot. The facility contacted the physician at that time with request for direction regarding the dressing of the foot. I had asked the nurse to check with the family and POA regarding their wish on whether or not to re-start the antibiotics at this time. Apparently that conversation was never held with the family and the antibiotics were not restarted until the daughter inquired if things were improving on the antibiotics. On the 7th of July it was discovered he actually had not been started on the antibiotics on the 5th. (on-call physician) called and antibiotics were restarted on the 7th, Resident 1 continued to have drainage and the POA requested to have further evaluation of his leg. Resident 1 was started on IV antibiotics for recurrent [MEDICAL CONDITION]. On 7/11/12 at 2:20 PM Surveyor interviewed Family Member D regarding her concerns regarding Resident 1's condition of his foot. Family Member D stated that she was very concerned when she came into the facility on [DATE] and noted that he (Resident 1) was sitting in the lobby of the facility with no covering to his foot and a puddle of drainage under his foot. Family Member described Resident 1's foot as very red swollen and draining. Family member D stated to the nurse that the antibiotic is not working and maybe the MD should be called. Family Member stated that the nurse came back and stated that they were going to put a new dressing on it and consult with the wound nurse. Family Member D stated that on Saturday (7/7/12) when she came in inquired again if the antibiotic is not working as it looked worse and the nurse told FM D that he was not on an antibiotic and it was noted that things were just supposed to take their course. FM D stated that she was very upset by Resident 1 not being on an antibiotic as that was the plan to keep him on it to keep the infection at bay for comfort. The facility nurse told me that they said it was me who wanted the antibiotic stopped and I have never had a conversation about that, as the antibiotic was keeping him comfortable. I insisted that the nurse call the physician and have the 2 antibiotics restarted immediately. On 7/17/12 at 3:52 PM Surveyor interviewed MD E regarding Resident 1's plan for care of his foot. MD E stated that the plan from the hospital discharge on 6/5/12 was to keep him on oral antibiotics as he was not a surgical candidate. The plan was to keep him on and evaluate his foot when the antibiotics stop date ended. He had a course and the facility felt he may have been allergic to it so we switched it, then a couple days later the family felt that his foot looked worse and his rash was not related to the antibiotic but the new medication [MEDICATION NAME]. So we restarted [MEDICATION NAME] and I put a stop date through 6/26/12. I did not put re-evaluate on the order but I assumed that the nurses would let me know if his foot showed signs of infection. That is what I expect from the staff if his foot is changing in appearance. I was informed on the 3rd of July that his gangrene was spreading but no indication of any issues with infection or increased redness. The next thing I heard was on July 5th that the daughter was mad because Resident 1 had drainage all over the floor and the nurse said "what do you want us to do about it." I was taken "aback" by the nurse stating that. I had to ask about the appearance I assumed he was on the antibiotics and not sure why he wasn't so I told the nurse to check with the family and if they don't want them restarted then continue with current plan but if yes resume antibiotic orders as before, then I have a call from the POA on 7/10/12 (next office day) angry that his antibiotics were stopped. They should have not been stopped if he had any indication of redness or signs of infection. On 7/17/12 at 9:30 AM Surveyor interviewed CWN C (certified wound nurse) regarding her contact with Resident 1. CWN C stated that she had no contact with him before he came back to the facility on [DATE]. CWN C stated that she had seen Resident 1's foot on 7/5/12 and it was worse than the previous time she observed it. CWN C stated that it was very swollen and red with increased drainage and odor. On 7/18/12 at 10:30 AM Surveyor along with Surveyor met with DON B regarding the events regarding Resident 1. Surveyor asked DON B if someone has a [MEDICATION NAME] and the family wants it discontinued what is the process. DON B stated, "The nurse finds out why and calls the physician and gets an order to get it discontinued. The nurse should have received an order on the day the family wanted it discontinued not placing it on the doctor board." Surveyor asked DON B if she was aware of any concerns with Resident 1. DON B stated, "Yes, she is very upset that her father's antibiotic was discontinued and now is back in the hospital with [MEDICAL CONDITION]. I was made aware by a nurse that she wanted the antibiotics discontinued and also pain meds. The nurse felt that this was not in the resident's best interest so I called to the ethics committee to get intervention. I called them but they did not call me back before this was over. I realized now that this was not accurate information, Resident 1's POA did want them continued and we should have called her first to find out more information and this could have been resolved then. The nurse documented that Resident 1's POA didn't want the antibiotics restarted and the nurse left me a voice mail that FM D did want them restarted." Surveyor asked if FM D's concerns were documented as grievances and followed up. DON B stated, "No there is no documentation of a grievance or concern." Surveyor asked DON B if she had reviewed Resident 1's medical record and she stated, "Yes we had a board meeting last evening to resolve some of the issues. I feel that we could have done better, the antibiotics were discontinued due to a stop order on the antibiotic which was appropriate, but if the foot was getting worse then the nurses should have called the MD to report the findings and let he know that Resident 1 was not on an antibiotic. The nurses should be telling the MD the big picture. An appointment was missed that should not have been and we should have had a plan of care that everyone was familiar with for continuity of care then everyone would have known what the POA wanted and what the plan for his foot was."

Based on observation, interview and record review the facility did not ensure that 1 of 6 residents reviewed (Resident 1) received the necessary care and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care *Resident 1 was found with open wounds to his right foot between his toes. The documentation does not describe the wounds or surrounding tissue. Subsequent to discovering the wound, there is no evidence that the facility monitored his wounds or assessed the wounds on a daily basis or even weekly. *The physician was notified and ordered a podiatry consult. Four days later the physician saw Resident 1's foot wounds and found them macerated, swollen, and red and again ordered Resident 1 to see a Podiatrist and ordered it ASAP. The facility did not schedule a podiatry visit for Resident 1 and the facility did not assist in arranging transport for an outside podiatry appointment for Resident 1. *Resident 1 was seen by a physician and placed on an antibiotic, but the facility continued to not assess the wounds and document the findings. The wound nurse consultant was to see Resident 1 and there is no evidence that the consultant saw Resident 1. * Resident 1 experienced pain during treatment of [REDACTED]. Even after returning from the hospital, as observed during survey, Resident 1 continues to experience significant pain during treatment with ineffective procedures to reduce the amount of pain. *Resident 1 was sent to an on call physician on 6/29/12 per family insistence and was sent to a hospital for a direct admit due to the infection on vascular issues where he received IV antibiotics. Resident 1's toes became darker and he was sent to another hospital for a surgical consult for possible surgical intervention. Resident 1 was diagnosed with [REDACTED]. ~Wet or Moist Gangrene develops as a complication of an untreated infected wound. Swelling resulting from the bacterial infection causes a sudden stoppage of blood flow. Cessation of blood flow facilitates invasion of the muscles by the bacteria and multiplication of the bacteria because disease-fighting cells (white blood cells) cannot reach the affected part. The failure to provide Resident 1 with the care necessary to prevent the development of an infected wound and to prevent pain during treatment created a finding of immediate jeopardy beginning 5/21/12. The NHA (administrator) was formally notified on 6/13/12 of the immediate jeopardy. The immediate jeopardy was removed on 6/13/12, however, the deficient practice continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) because the facility still has to fully implement its action plan. Findings as follows: The facility's Policy and Procedure manual for Wound Care and Pressure ulcers last updated 5/2012 includes the following information for wounds: Purpose: To be consistent with treating and assessing all wounds. To promote healing and/or prevention. All nursing staff to follow the same procedure and protocol. Procedure: ...For a new open area, staff is to complete the Checklist for Ulcer treatment and forward this form to the wound care nurse upon completion Wound Care Guidelines 6. For any bruises/skin tears/skin ulcerations, an incident report and investigation will be completed. 7. Acute care plans will be completed for each skin alteration. 8. Family and physician must be notified of all skin alterations (...Ulcerations) and documented in their chart. 10. All pressure/vascular ulcerations will be followed on wound rounds on a weekly basis followed by the wound care team. 12. Wound rounds will be completed on a weekly basis. 13. The wound care nurse will be in charge of completing all skin sheets every Wednesday for all skin ulcerations (pressure/Vascular/blisters) and will provide a weekly report for the DON, ADON, Dietary, and PT. This report is to be typed with measurements, assessments of the wound and treatment. If any treatment is ineffective and the wound is not showing improvement after 2 week period, the MD will be notified and a change in treatment plan must be decided. 14. The wound care nurse will have weekly documentation of all skin issues in the progress notes. Weekly documentation must be finished by Friday of that week. Weekly documentation must have updated measurements, treatments, [DIAGNOSES REDACTED]. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 is not his own legal decision maker. Resident 1's nursing notes dated 5/16/12 at 8:00 PM state, "Noted open area between 2nd-3rd-4th rt. toes. Area cleansed. Gauze placed between toes. Message left for DON and NHA. Noted in MD book for (primary physician name)." Please note that there is no order for a dressing to Resident 1's toes, nor was Resident 1's POA informed of Resident 1's newly open area between toes and the need to alter treatment. A Resident Injury/Incident/Accident Report form dated 5/16/12 indicates that a new open area between Resident 1's toes was found in the shower room at 9:30 PM and the probable cause was "pressure areas." The back of the form states, "Immediate contacts if injury occurred..Physician contacted 5/17/12 at 4:00 PM." The NHA and DON were contacted and informed at 11:00 PM on 5/16/12. NHA A and DON B both signed off on the form on 6/4/12, so they were aware of the open areas. On 5/17/12 at 4:00 PM a Resident 1's nursing note states, "Spoke with (Primary physician name) and informed of open areas on toes. May see (DR Name-Podiatrist)." The facility did not contact the podiatrist or assist the family in making arrangements to see the podiatrist. On 5/20/12 a nursing note at 4:30 PM states, "(Primary Physician name) here to see res. new orders received to give [MEDICATION NAME] 500 mg po TID x 10 days-foot [MEDICAL CONDITION]. Sched. (schedule) with Podiatry ASAP, non-weight bearing to right foot. Use Hoyer for transfers no brace or shoe to right foot, sock only (with dressing to toes) until healed." A note at 8:20 PM states that a call was placed to POA to update on new orders received. physician progress notes [REDACTED]. Have been dressing with gauze and abx. (antibiotic) oint. (ointment). C/O pain in toes otherwise staff report appetite still ok and no other problems noted...Right foot with macerated, raw open areas in web space of 1/2 and 2/3 toes. No odor or purulence. Gauze saturated with serous fluid. + (positive) [DIAGNOSES REDACTED] of dorsum of mid foot, no bullae or vesicles (blisters). A/P: 1. [MEDICAL CONDITION] of right foot, skin break web spaces.-Dicloxicillin 500 mg TID x 10 days-Podiatry consult-NWB (non-weight bearing) to right foot-leave shoe and brace off until healed..." On 5/20/12 a care plan problem was added which states, "[MEDICAL CONDITION] Right foot...no goal was listed and the one and only approach listed states, "Antibiotic started: Dicloxicillin 500 mg po TID for 10 days." There are no other interventions listed regarding monitoring, assessing or any other interventions needed for wound healing. A nursing note on 5/21/12 at 9:30 AM states, "Spoke with POA on MD visit yesterday and new orders. POA also questioned on what she would like done with resident seeing a podiatrist as she was offered (in house podiatrist that comes) or seeing (podiatrist name) in outpatient at nearby hospital. POA will speak with resident's wife and return call." A note at 1:40 PM states that the nurse spoke with on-call physician and gave orders to apply gauze with triple antibiotic ointment to and between toes d/t sores, change BID...res to see wound specialist for eval here at manor for right toes. Will update MD (on call book). No further call from POA yet." Please note that there is no documentation in Resident 1's medical record as to the measurements of the wound, an assessment of the wound, nor progress or lack of progress of the wounds. The following nursing notes reveal what was documented regarding Resident 1's wounds, and pain levels (other than that the dressing was changed as ordered): 5/21/12 at 3:00 PM-...C/O sore right lower legs, feet. Lower leg red and warm to touch, leg elevated throughout shift... 5/22/12 at 5:45 AM-...No evidence of pain or discomfort... 5/23/12 at 8:00 PM-Open areas between toes cleansed. Dressing applied to area. Resident c/o discomfort with treatment... 5/24/12 at 10:40 AM-...no pain or discomfort noted... 5/25/12 at 3:30 AM...No evidence of pain or discomfort noted... Complaints of pain subsequently became more common with no physician intervention until four days later. 5/25/12 at 8:00 PM-...c/o pain in right toes when writer was doing treatment to toes. 5/26/12 at 2:40 PM-Resident complained of leg pain. PRN Tylenol administered. 5/27/12 at 4:35 AM-...C/O pain in right foot during cares... 5/27/12 at 1:30 PM-...complained of foot pain due to [MEDICAL CONDITION]. PRN Tylenol administered. 2x2's in between affected toes without triple antibiotic ointment. (Please note the current order states TAO) 5/28/12 at 5:00 AM-...dry gauze noted between toes. 5/28/12 at 7:00 AM-Tylenol grains 10 given for pain in rt foot. Had bloody serous drainage between 3rd and 4th toes. Small amount. New gauze applied. Put on call sheet that foot is still red and [MEDICAL CONDITION]. 5/28/12 at 3:00 PM-Called (POA name) his daughter and informed her of condition of father's foot and that we will notify DR in AM about resident foot not improving. 5/28/12 at 8:00 PM-...C/O pain during treatment to right toes. Tylenol 650 mg given at 7:00 PM prior to treatment... 5/29/12 at 1:00 PM-MD updated on condition of resident's foot. MD updated of wound care nurse to see resident on 5/30/12. MD ordered [MEDICATION NAME] 5/325 PO one hour before wound treatment one time only, then to continue [MEDICATION NAME] 5/325 PO PRN. MD updated of appt with (on call MD name) at (Clinic name) this afternoon. Daughter called and updated on appt this afternoon. (Please note that Resident 1's daughter came into the facility after receiving a phone call the eve prior about her father's toes. Resident 1's daughter saw that Resident 1's toes were very swollen and fiery red with darkened skin on toes and she insisted at this time that her father be be seen by a physician for his toes. 5/29/12 at 2:30 PM- 2x2 drsg saturated with drainage-serosanguinous. Toes cleansed 2 x2 dressing applied between toes. A Physician clinic note dated 5/29/12 states that the chief complaint of Resident 1 is discolored toes right foot with sores between 2nd and 3rd digits and [MEDICAL CONDITION]. The provider comment was "Admit to hospital". The hospital History and Physical dated 5/29/12 states,"..XXX[AGE] year old man who presents with right leg swelling, in fact he had a crack that started in his foot about a week ago and it has seemed to progress where his whole foot has become red. He was placed on [MEDICATION NAME] for his [MEDICAL CONDITION] but it has seemed to worsen over the past couple of days, where this morning it was found by his POA to be red. Extremities: His left leg does have redness over his foot. He does have sores and cracks in between his 2nd, 3rd, and 4th toes and 3 of his toes do have peripheral markings on the tips of them. Assessment: Diabetic foot [MEDICAL CONDITION] with poor circulation to his feet. Resident 1's toes turned black and cold and were transferred to a different hospital for peripheral vascular evaluation for possible surgical intervention and management of the infection. Resident 1 was diagnosed with [REDACTED]. According to medicinenet.com, "Wet ... gangrene is the most dangerous type of gangrene because if it is left untreated, the patient usually [MEDICAL CONDITION] and dies within a few hours or days. Wet gangrene results from an untreated (or inadequately treated) infection in the body where the local blood supply has been reduced or stopped by tissue swelling, gas production in tissue, bacterial toxins, or all of these factors in combination. Additionally, conditions that compromise the blood flow such as or vascular trauma (for example, a knife wound that cuts off arterial flow) can occur first. Then the locally compromised area becomes infected, which can result in wet gangrene ...Wet gangrene is a medical emergency and needs immediate treatment. Treatment is usually done in a hospital, and a surgeon needs to be involved because the local area needs debridement (surgical removal of the dead and dying tissue). In some patients, debridement will not be adequate therapy, and amputation of a limb may be needed ... " According to emedicinehealth.com, "Wet or moist gangrene develops as a complication of an untreated infected wound. Swelling resulting from the bacterial infection causes a sudden stoppage of blood flow. Cessation of blood flow facilitates invasion of the muscles by the bacteria and multiplication of the bacteria because disease-fighting cells (white blood cells) cannot reach the affected part. The wet gangrene can be extremely painful..." Resident 1 was readmitted to the facility on [DATE] with 2 antibiotics and a palliative care order. The antibiotics would not be curative. On 6/7/12 at 1;00 PM Surveyor 1 interviewed FM I (Family Member) regarding Resident 1. FM I stated that the facility did not call her the day they found the open areas until the next day. The facility did tell FM I that they have a podiatrist that comes to the facility and can make that arrangement. FM I stated that 4 days later they got another call the the MD came to see Resident 1 and ordered the podiatry appt again. The facility stated to FM I that she would have to make her own arrangements for transport if he was not going to be seen here. FM I stated that she had no way to get him there. FM I also stated that she was not told the seriousness of the condition of his foot and the podiatrist was ordered ASAP on 5/20/12. FM I continued on to state that on the 28th the facility called her to say that they would be calling the MD in the AM as the foot was not better. FM I stated that she went to the facility in the AM and looked at Resident 1's foot and was shocked to see it bright red, swollen and weeping. The toes were also dark too. FM I then insisted that he be seen right away and then the facility offered to make arrangement to the appt, got him pain pills and said the Wound care specialist would see him soon. FM I stated that when she got to the MD appt the MD stated that this went on too long and wanted him in the hospital right away. On 6/13/12 at approximately 9:10 AM RN D stated that she was pre-medicating Resident 1 and would be ready to do his treatment at 10:00 AM. On 6/13/12 at 10:00 AM Surveyor observed RN D complete dressing changes to Resident 1's toes. RN E came into the room to assist with Resident 1 in distracting him due to his dementia. RN D began the treatment to Resident 1's toes. Resident 1 pulled his foot away from RN D when she attempted to do the dressing changes. RN E was encouraging Resident 1 to sing a song with her. Resident 3rd and 4th toes were dark purple/black in color. Resident 1 yelled out in pain during his treatment, and several times pulled his foot up to his chest and said "no, no don't it hurts. Resident 1 stated don't do that it hurts, don't do that Goddammit or I'm not gonna sing anymore if you keep that up." RN E kept encouraging Resident 1 to sing for distraction but when RN D was actually touching and holding Resident 1's foot he stopped singing and called out in pain. RN D continued the treatment until it was completed but tried to hurry. (The treatment for [REDACTED]. Surveyor asked RN D what Resident 1 had for pain before the treatment. RN D stated that Resident 1 had [MEDICATION NAME] 50 mg for pain but he really didn't take much - he refused and he didn't "take enough to help with the pain." Resident 1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident 1 had complained of pain during cares/treatment to his foot on 5/21/12, 5/23/12, 5/25/12 at 8:00 PM and 5/27/12 at 4:30 AM with no interventions listed for pain control and no PRN pain medication given for Resident 1's complaints of pain. On 6/13/12 at 10:30 AM surveyor interviewed the clinical care coordinator (CCC) C and RN E regarding what to do when an open area is found on a resident. RN E stated that we would notify the MD and explain what is seen, assess the wound, take vital signs and explain dressings to MD. Place the Resident name on the 24 hour board and the reason they are on the board. CCC C stated that a treatment sheet is filled out to monitor the wound and the wound care nurse is notified. CCC C stated that she did not see that the wound was added to the treatment sheet for monitoring or that the wound care nurse saw Resident 1. On 6/13/12 at 12:15 PM Surveyor interviewed NHA A. (DON B was not at the facility at this time). Surveyor asked NHA A if she or DON B had looked at Resident 1's chart after he was sent to the hospital. NHA A stated, "I've been in the record several times trying to do damage control due to the podiatry appt that was not scheduled. The family member came in here angry and wondering why we didn't get him to the podiatrist sooner and why he wasn't seen when his foot became worse sooner, now his toes are black. I reviewed the notes and did not note any issues with orders for a dressing, no issues noted." Surveyor stated to NHA A that there was not monitoring, or assessment of wounds daily or weekly as her policy states (even though the facility was just in a plan of correction for skin issues) Surveyor asked how this resident's skin issues were missed and NHA A stated, "You can't be everywhere all the time, I guess." On 6/13/12 at 11:30 AM Surveyor interviewed NHA regarding appointment scheduling. NHA A stated that it is the facility policy that if a person needs to be seen the family is asked to transport if they can't we make arrangements for them to be seen. The facility has a company that comes for dental and podiatry. We will help with the transportation if the family cannot transport. Surveyor asked for a policy and procedure for transportation to appointments. A letter was given to Surveyor dated 3/4/11 and is directed to the residents and responsible parties which states, "We are trying to eliminate the cost of transporting the residents to outside appointments since the 25.00 did not cover the cost of an escort had to be sent along. The facility as you know remains financially challenged and we must cut costs where ever we can. Therefore if we are offering a service in-house to residents, we will no longer be able to transport them to that appointment. Residents electing to stay with their dentist, optometrist, and audiologist will need to make arrangements for their own transportation." On 6/13/12 at 3:10 PM Surveyor interviewed RN D regarding pain during the treatment to Resident 1. RN D stated that she usually didn't work with him and when he didn't take his medication she got someone to distract him. RN D stated that she could have waited until she got pain meds in him (Resident 1) but she did not want to wait to do his toes. Surveyor asked RN D what else could be done if he was having pain during his treatment and not taking his meds due to his confusion. RN D did not have an answer but Surveyor suggested to call the MD and RN D stated, "We could." On 6/18/12 at 9:00 AM Surveyor interviewed MD H regarding Resident 1's condition of his toes. MD H stated that when she saw the toes there were crevices between the toes with drainage, redness and [MEDICAL CONDITION] so an antibiotic was ordered. MD H also stated that she re-ordered the podiatrist as he (Resident 1) needed some sort of device to keep his toes apart or a referral to see what was going on with between his toes. MD H stated that if his toes were wet then she would have not ordered triple antibiotic ointment (which they were) and and would have ordered only a dry gauze. The failure to assure that Resident 1's wounds were assessed monitored and treated according to standards of practice and facility policy, and the failure to consult with the doctor and family when significant changes occurred, created an immediate jeopardy situation. Immediate jeopardy was removed on 6/13/12 when the facility completed the following: The facility initiated re-inservice education as follows: -This plan will begin on 6/13/12 PM shift and continue with nurses prior to starting their next shift until all the nurses are re-educated and to continue to June 15th to capture part time employees. -The residents in the facility with wounds will have a skin check performed by a licensed nurse beginning 6/13/12. -On June 14th a Wound Care Certified Nurse will evaluate all wounds found in the facility and develop treatment plans for the wounds in conjunction with the resident's physician. -All appropriate and necessary physician orders [REDACTED]. -Nurses will be inserviced on each individual wound treatment plan and assess wounds properly documenting progress or lack of progress. It will also review physician notification and pain assessments. -At each shift to shift report individualized care plans for skin breakdown and breakdown prevention will be reviewed. This will begin today 6/13/12 and continuing forever. -Care plans for residents with wounds will be updated to reflect interventions in place. -The facility will be sending a nurse to wound certification. -The facility will complete a new pain assessment (for Resident 1) on 6/13/12 by the Clinical Care Coordinator.

Based on observation, interviews and record review, the facility did not ensure 3 (Residents 1, 7 and 10) of 3 residents reviewed for pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Resident 1 was admitted to the facility with no pressure ulcers. Resident 1 developed a facility acquired stage 4 pressure ulcer on the left ileococcyxgeal and did not receive necessary assessments for treatment and care of the pressure ulcers based upon current standards of practice. Skin assessments were not done weekly per standard of practice, care plans were not updated as needed, and interventions to prevent pressure ulcer development or to promote healing were not implemented or were not implemented timely. The facility failed to correctly identify, document, and evaluate the pressure ulcer and did not timely consult with the physician or family concerning appropriate treatments possible treatment changes when the pressure ulcer deteriorated. Resident 1 was observed continuously for greater then 3 hours on 4/18/12, in which no position change attempts or offers to reposition were done by staff. This prevented Resident 1 from attaining or maintaining her highest practicable well-being. The failure to provide Resident 1 with the care necessary to prevent the development of a stage 4 pressure ulcer created a finding of immediate jeopardy beginning 6/28/11. The NHA (administrator) and DON (Director of Nursing) were formally notified on 4/18/12 of the immediate jeopardy. The immediate jeopardy was removed on 4/19/12, when a Quality Performance Improvement Plan was initiated; the deficient practice continues at a scope/severity level of G (actual harm/isolated) as evidenced by the following examples: Resident 7 developed a Stage 2 Pressure Ulcer to her left heel. The facility did not consult Resident 7's physician when changes were noted, develop or implement a plan of care to prevent pressure ulcers development for Resident 7. Resident 10 was admitted to the facility with stage 4 pressure ulcers on his bilateral heels. Resident 10's ulcers have improved in the facility. However, the facility did not float Resident 10's heels or have Resident 10 on an air mattress as directed by his plan of care. This is evidenced by: The National Pressure Ulcer Advisory Panel guidelines found at www.npuap.org <http://www.npuap.org>. The International Guideline Prevention and treatment of [REDACTED]. Repositioning Documentation 5. Record repositioning regimes, specifying frequency and position adopted, and include an evaluation of the outcome of the repositioning regime. Repositioning Education and Training 6. Education about the role of repositioning in pressure ulcer prevention should be offered to all persons involved in the care of individuals at risk of pressure ulcer development, including the individual and significant others (where possible). Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type(s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]. The facility policy titled "Wound Care Guidelines", dated 6/2006, indicates 1. Upon new admission, quarterly and annually assessment period the Assistant Director of Nursing (ADON) will complete a Braden ... Those people (Residents) that score a 14 or below will be placed on weekly skin assessments. Weekly skin assessment documentation will be charted in the nurse's notes in the resident chart ... 5. Certified Nursing Assistant (CNA's) will be responsible for completing the shower / skin sheet for all residents. The shower sheets are to be turned into the charge nurse upon completion ... 7. Acute care plans will be completed for each skin alteration ... 9. A wound care team will consist of a treatment nurse, Director of Nursing (DON), ADON, Minimum Data Set (MDS) coordinator, dietary manager, and physical therapist. All residents on a pressure reduction and/or relief mattress will be monitored weekly. 10. All pressure and/or vascular ulcerations will be followed on wound rounds on a weekly basis followed by the wound team ... 13. The wound care nurse will be in charge of completing all skin sheets every Wednesday for all ulcerations (pressure/vascular ...) and will provide weekly report ... This report will be typed with measurements, assessment of the wound (pressure ulcer) and treatment. If any treatment is ineffective and the wound is not showing improvement after 2 weeks period, the Medical Doctor (MD) will be notified and a change in treatment plan must be decided. 14. The wound care nurse will have weekly documentation of all skin issues ... Weekly documentation must have updated measurements, treatments, diagnoses, and interventions such as: pressure relief mattress, turning and repositioning schedule intervention, dietary interventions ... Example 1 Resident 1's [DIAGNOSES REDACTED]. Resident 1's quarterly Minimum Data Set (MDS), dated [DATE], indicates Resident 1 is able to make self understood to express ideas and wants, and Resident 1 has clear comprehension to understand others. Resident 1's cognitive score is a 15 to indicate Resident 1 is cognitively intact. Resident 1 needs extensive assist of 1 with bed mobility, toilet use, and personal hygiene. Resident 1 is total dependent with assist of 2 with transfers. Resident 1 is frequently incontinent of bowel and bladder. Resident 1 is at risk for developing pressure ulcers. Resident 1 has 1 stage 4 unhealed pressure ulcer. Resident 1's Care Area Assessment (CAAs), dated 1/23/12, indicates Pressure Ulcers: 1. Extrinsic risk factors; pressure; Requires staff assistance to move sufficiently to relieve pressure over any one site, confined to bed or chair most of the time... 3. Treatments / Other factors: newly admitted /readmitted history of healed pressure ulcer. Bedfast or wheel chair bound. Head of bed elevated all or most of the time. 4. Description of problem: Resident 1 has a stage 4 pressure ulcer that is healing. 5. Causes / Contributing factors: see above. 6. Care Plan: Will develop Care Plan revise current plan. The most recent Braden Pressure Ulcer Risk Assessment was completed on 4/3/12 in which the facility scored Resident 1 a 17 (12 or less indicates a high risk for the development of pressure ulcers). Resident 1's score of 17 indicates Resident 1 is at low risk for developing pressure ulcers. However, staff incorrectly assessed Resident 1 ' s risk as evidenced below: The following scores were noted on the above Braden Assessment: 1. Sensory Perception- 4 (No Impairment: Has no sensory deficit which would limit ability to feel or voice pain or discomfort.) However, Resident 1 has [DIAGNOSES REDACTED]. Resident verbalizes inability to feel pain to ischium and to lower extremities. 2. Moisture- 3 (Occasionally moist- Skin is occasionally moist requires extra linen change approximately once a day.) However, Resident 1's most recent MDS, dated [DATE] indicated Resident 1 is frequently incontinent. 3. Activity- 2 (Chairfast- Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.) 4. Mobility- 3 (Slight Limited- Makes frequent slight changes in body or extremity position independently.) However, Resident 1's most recent MDS, dated [DATE] indicated Resident 1's extensive assist with bed positioning.) 5. Nutrition- 4 (Excellent- Eats most of every meal never refuses a meal... Occasionally eats between meals....Does not require a supplement) However, Resident 1 receives [MEDICATION NAME] supplement twice a day. 6. Friction and Shear- 1 (Problem- Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures, or agitation leads to almost constant friction.) By observation, Resident 1 sits on a Roho cushion in her Broda chair and sleeps on a Betabed overlay mattress in bed. On 4/16/12, at 3:30 PM, Surveyor was handed a one page form titled "Betabed alternating air mattress" manufacturer recommendations. The Betabed recommendations indicate:... 2. Clinical application: The system is recommended for patients with low risk of developing pressure ulcers who require preventative measures.... Contraindications: The Betabed system is contraindicated for patients... with medium to high risk of developing pressure ulcers, with pressure ulcers Stage 2 and above... Fax received on 4/18/12, at 9:50 AM, Milwaukee Mattress and furniture: There is no evidence this mattress has pressure redistributing, reducing or relieving qualities. Resident 1's care plan titled "potential for skin impairment", dated 1/24/12 and a second hand written date as 4/10/12, indicates; Problem: Potential for impaired skin integrity: Related to: a. History of chronic diarrhea. b. Immobility. c. Incontinence... Manifested by: a. Inability to position self. b. Stage 4 coccyx wound. c. Alert and oriented. d. Makes needs known. Goal: Resident 1's skin will be free from skin breakdown and infection. Approaches: 1. See Impaired Mobility care plan 2. Reposition every 2 hours... 4. Air mattress on bed. 5. Cushion in chair. 6. Bed Cradle on bed. (Observed not to be in place 4 days of the 4 day survey.) 7. Treatments and creams as ordered. 8. Hoyer transfers to decrease shear with transfers... 10. Encourage highest degree of mobility... 12. Use lift sheet to reposition resident. 13. Inspect areas at risk for ulcers... Resident 1's care plan titled "Impaired Physical Mobility", dated 1/24/12 and a second hand written date as 4/10/12, indicates; Problem: Impaired physical mobility related to: 1. [DIAGNOSES REDACTED]. 2. Right lower leg amputation. Manifested By: 1. Inability to transfer self. 4. Inability to position own body without assist... Approaches; 1. Transfers with a total assist of 2 with Hoyer lift. 2. Reposition every 2 hours. 3. Assist with bed mobility as follows: extensive assist of 1... 8. Ensure proper positioning and repositioning of joints... Resident 1's Resident Plan of Care (Placed for Certified Nursing Assistant (CNA) use) located in Resident 1's room hanging on Resident 1's room wall, updated 4/12/12, indicates:.. 3. Mobility: a. Transfer total assist of 2 and Hoyer lift. b. Bed mobility: extensive assist of 1. c. Non weight bearing. 4. Special Equipment: a. Alternating air mattress. b. Trapeze. c. Roho Cushion in (w/c) wheel chair. d. Above needed due to: Assist with repositioning self in bed... Skin Integrity: a. Preventive care: (The area has no documentation or direction written.) b. Pressure Ulcer: Stage 4 (physician ordered wound treatment is written). No further information is provided under skin integrity. 5. On the bottom of this plan of care is hand written: No slide board transfers, Up in w/c no more than 1 1/2 hour at a time, except for special afternoon activities... (It is important to note the Plan of Care directing the CNAs to care for Resident 1 does not include a turning or repositioning schedule.) On 4/17/12, at 9:00 AM Surveyor reviewed Resident 1's clinical record. Resident 1's clinical record included, inside the front cover of Resident 1's clinical record, a one page hand written document. The one page document indicates "(Resident 1's name) has a habit of becoming extremely ill extremely fast. If he (Resident 1) feels he needs urgent medical attention at (Hospital name) - please listen to him (Resident 1). It is vital. " The one page document is signed by Resident 1's physician. Resident 1's lab results, dated 12/31/11, indicates [MEDICATION NAME] level of 1.7 (Normal [MEDICATION NAME] range is 2.8 to 4.8). On 4/17/12, at 3:00 PM Surveyor requested Resident 1's weekly pressure ulcer review and measurements from DON B. DON B provided Surveyor Resident 1's wound documentation from 7/6/11 through 4/11/12. DON B stated no documentation was completed prior to 7/6/11 as documentation was previously done in the nursing notes. DON B stated she reviewed Resident 1's wound documentation and there was no documentation related Resident 1's Stage 4 pressure ulcer prior to 7/6/11. Resident 1's physician progress notes [REDACTED]. Resident 1's Wound Consultant report, dated 4/22/11, indicates Resident 1 presents with a new wound to left hip (left Ischial). Resident 1 states it has been present for a couple of weeks. Resident 1's left hip in a concave formation of tissue. Opening is the size of a pin hole with macerated tissue surrounding it. After aggressively cleansed with saline macerated tissue was removed to reveal a wound to measure in depth 0.05 centimeters (cm) tissue of wound bed is beefy red and draining small amount of serous drainage (drainage resembles a thin watery and clear yellow substance)... Findings consistent with a wound with the etiology of cause of injury to equal shearing... Return to clinic in 3 to 4 weeks... Standard of practice, as indicated by the NPUAP-EPUAP Treatment Guideline and The NPUAP-EPUAP Treatment Quick Reference Guide note: Assess the pressure ulcer initially and re-assess it at least weekly, document findings... With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications) ... Signs of deterioration should be addressed immediately. Contrary to professional standards of practice and facility policy, facility staff took no measurements of the pressure ulcers from 4/22/11 until 6/28/11, 67 days later. Resident 1's nursing notes, dated 6/28/11, Wound care: Left Ischial ulcer in scar tissue of old wound. Deep in the divet of skin 0.5 centimeters (cm) by 0.6 cm by 0.4 cm deep.... dressed with wound cleanser moistened gauze , dead space of divet filled with gauze an secured with bordered dressing... Resident 1's current care plan indicates Resident 1 has a ROHO cushion in his wheel chair and an overlay air mattress on his bed. Resident 1's nursing notes, dated 6/30/11, call placed to wound clinic regarding left Ischial pressure ulcer agreed Resident 1 did not need clinic visit... will communicate with wound clinic regarding wound. There is no evidence Resident 1's physician ordering the visit was notified of the cancelled hospital wound clinic visit. Resident 1's nursing notes, dated 7/6/11, state left ischial pressure ulcer slightly larger. Instructed nursing to use less gel and to be sure the dressing is secure at all times... wound measurements 1 cm by 1 cm by 0.5 cm, beefy red base... Resident 1 is without feeling at site... (Resident 1's physician was not notified or updated with the increase in the pressure ulcer size. Resident 1's care plan was not updated or revised with the increase in size and the non-healing of Resident 1's pressure ulcer.) Resident 1's nursing note, dated 7/10/11, state dressing to left ischial wound (pressure ulcer) changed. More drainage today and increase in odor... (Resident 1's physician was not updated with pressure ulcer changes. Resident 1's care plan was not updated or revised with pressure ulcer changes.) Resident 1's nursing note, dated 7/12/11, states dressing on buttocks (left ischial) removed. Moderate odor. Brownish serosanguinous drainage. Dressing saturated with drainage. Resident 1's wound care note, dated 7/12/11, Resident 1's wound has increased drainage and increased in size since 7/10/11. Pressure ulcer measurements 1.5 cm by 1.5 cm by 2.2 cm. Instructed on position changes and possible bedrest. Changed to collegen. Message left for wound clinic... (Treatment change did not occur until 2 days after pressure ulcer change was present.) Resident 1 Wound care note, dated 7/29/11, states left Ischial pressure ulcer, beefy red and increased in depth.. Pressure ulcer measurements 1.5 cm by 1 cm by 2 cm (Resident 1's depth measured 1.3 cm on 7/22/11)... Resident 1 again instructed on change in position. (Resident 1's physician was not updated with the change in pressure ulcer measurement, and no change was made to Resident 1's care plan.) Resident 1 Wound care note, dated 7/29/11, states staging clarification. Resident 1's left ischial pressure ulcer is a chronic stage 4 wound as it is recurring in scar tissue of a previous stage 4 pressure ulcer that had surgical repair. Resident 1 nursing note, dated 8/3/11, states Resident 1 seen by physician and discussed wound. Resident 1 requesting to see Wound Clinic to manage wound care. Resident 1's Physician wrote an order to set up visit with wound clinic to co-manage pressure ulcer. Resident 1's nutrition evaluation, dated 8/9/11, states Resident 1 with increased nutrition needs due to Stage 4 pressure ulcer ... [MEDICATION NAME] initiated on 7/27/11 and to end tomorrow. Note wound is healing slowly... serial [MEDICATION NAME] would be recommended if nutrition becomes a concern related to wound healing... weight maintenance is the goal until wound is healed. Diet order is in place to aid in control of weight gain... Do not recommend further protein supplements... will follow up monthly or as needed. Resident 1's wound care note, dated 8/12/11, states Resident 1's pressure ulcer little change overall. Attempted to call Wound clinic consultant, will try again on Monday (August 15th)... Resident 1 will need to go on bed rest... (It is important to note that Resident 1 did not go on bed rest until 10/28/11, approximately 2 1/2 months after this note was written.) Resident 1's wound care note, dated 8/16/11, states Resident 1's pressure ulcer remains clear and granulating but no difference in size... Continue collagen... Will continue to follow. Resident 1's wound care note, dated 8/23/11, states Resident 1's pressure ulcer little change overall. Measurements are 2 cm by 1.6 cm by 1.3 cm. (Although the note indicates "little change" this is an increase in size from the 8/16/11 measurement by 1 cm by 1.6 cm by 1.2 cm) continue same plan of care. (No changes were made to Resident 1's treatment or to Resident 1's care plan.) Resident 1's wound care note, dated 8/29/11, states Resident 1's pressure ulcer with un-measurable undermining... Continue with Collagen and bordered foam. Resident 1's physician progress notes [REDACTED]. Resident 1's wound care nursing note, dated 9/8/11, states Report called to Wound Clinic. Appointment scheduled for 9/30/11. (This appointment would be 58 days after the physician ' s 8/3/11 order was received and is the second call placed to wound clinic since 8/12/11.) Resident 1's wound care nursing note, dated 9/9/11, states Resident 1's left ischial pressure ulcer.. Depth has increased in size again... Roho cushion in wheel chair... Stage 4 pressure ulcer measured 1.7 cm by 1.2 cm by 2 cm depth. Continue collagen until appointment at wound clinic... There is no evidence Resident 1's physician was notified in the change in Resident 1's stage 4 pressure ulcer or that staff implemented a change in care. Resident 1's wound care nursing note, dated 9/20/11, states Resident 1's wound remains unchanged. Resident 1 without feeling to the pressure ulcer. Resident 1's physician was notified and new treatment orders received to discontinue Puracol and change to Mesalt. Resident 1's wound care nursing note, dated 9/29/11, states Resident 1's pressure ulcer slight increase in size 2 cm by 1 cm by 1 cm depth. Wound bed deeper red... Continue Mesalt for now. Wound clinic appointment tomorrow. There is no evidence a physician was notified of the decline in Resident 1's pressure ulcer. Resident 1's Wound Consultant Summary, dated 9/30/11, indicates, Wound noted on right hip (report should indicate left hip) is beefy red, draining moderate amount of serosanguinous drainage. The wound (pressure ulcer) measures 1.7 cm length by 0.5 cm width and 2 cm depth: no tunneling: undermining at 12 o'clock to equal 0.4 cm and at 6 O'clock to equal 0.2 cm... Finding consistent with a wound that has increased a large amount in size... Recommendations: 1. Continue treatment with Mesalt. 2. Continue to offload by tilting every hour for 15 minutes (when in the chair). 3. Continue use of alternating air mattress... 5. Schedule follow up in 3 to 4 weeks... Resident 1 remained on the Betabed mattress. Resident 1's wound care nursing note, dated 10/21/11, states No change in the wound. Margins dusky... measures 1.8 by 1.2 by cm depth... Most serious undermining between 4 and 7 O'clock posterior 0.8 cm... Will switch to alginate and reevaluate in 1 to 2 weeks... Resident 1's physician order, dated 10/21/11, indicates 1. Discontinue Mesalt. 2. Cleanse wound with normal saline. Dress with alginate cover with bordered foam dressing change daily. 3. Nutritional consult. Resident 1's nutrition progress note, dated 10/25/11, states Resident 1 is meeting goals for weight maintenance while wound is healing... Established nutritional needs are increased due to wound... [MEDICATION NAME] twice a day and continue to monitor. Resident 1's physician order, dated 10/26/11, [MEDICATION NAME] (supplemental drink) twice a day for wound care. Resident 1's wound care nursing note, dated 10/28/11, states wounds now tunnel to 4.3 cm at 5 to 6 O' c clock. Base dusky red with minimal drainage... Call placed to Wound clinic consultant early this week for status report, have not received a return call back... Placed on bedrest except for meals... Resident 1's physician order, dated 10/28/11, states discontinue previous wound care to left ischial wound. Cleanse with normal saline. Pack with full package of collagen and cover with bordered foam dressing change daily... Resident 1's physician order, dated 10/28/11, states, bedrest except for meals. Up in wheel chair no more then 1 1/2 hours at a time. Resident 1's physician orders, dated 11/8/11, states Continue bedrest except meals no more then 1 1/2 hour at a time except for special afternoon activities then no more then 2 hour in wheel chair for special activities. [DIAGNOSES REDACTED]. Resident 1's physician order, dated 11/8/11, states 1. Discontinue Collagen. 2. Flush left ischial wound with normal saline. Pack with alginate to full depth of the wound and cover with bordered foam dressing change every other day... Resident 1's wound care nursing note, dated 11/18/11, states spoke with wound clinic consultant on 2 separate occasions. Wound clinic will resume management of pressure ulcer... Appointment scheduled for 12/3/11... Resident 1's Wound Consultant Summary, dated 12/2/11, indicates, Wound check;... Measurement taken Length 0.7 cm by width 0.6 cm by depth 0.8 cm... Wound noted on left ischial area draining moderate serous drainage: small amount of maceration noted around wound bed. Resident 1's wound clinic report, dated 12/30/11, indicates Resident 1 to return to clinic in 4 to 6 weeks. (The time frame would indicate Resident 1 to return to the hospital wound clinic, the first or second week in February 2012. Resident 1 has not seen the wound clinic consultant since 12/30/11.) Resident 1's nursing note, dated 1/13/12, states wound cleansed and redressed. No drainage from the wound... On 4/18/12, at 9:35 AM Surveyor requested Resident 1's weekly skin sheets from Licensed Practical Nurse (LPN) W. LPN W provided Surveyor weekly skin checks, dated 1/31/12, 2/7/12, 2/14/12, 2/21/12-2/24/12 (combined on one form), 3/6/12 and 3/9/12 (combined on one form) and 3/16/12. On 4/18/12, at 9:35 AM Surveyor spoke with LPN W regarding Resident 1's weekly skin checks and requested Resident 1's most current weekly skin check. LPN W stated the last weekly skin check done by the CNAs and Nurses was completed on 3/16/12. LPN W also indicated the facility has changed the weekly skin checks policy several times in the past several months and is not sure what the current policy direction is regarding weekly skin checks. LPN W stated weekly skin checks have not been done on any resident since 3/16/12. No further information was provided to Surveyor . Skin Grid Left Ischium: Left ischium pressure ulcer; Date first observed: Recurrent 1. Dated 1/6/12, Length: 0.5 centimeters (cm). Width 0.4 cm. Depth: 0.4 cm. (No further documentation of the pressure ulcer was described in the weekly pressure ulcer measurement.) Comments: Resident 1 returned from inpatient hospital stay. Resident 1's assessment completed by the hospital staff Registered Nurse (RN) prior to discharge, but this writer (DON B) did measurements. 2. Dated 1/13/12, Length: 0.5 centimeters (cm). Width 0.4 cm. Depth: 0.4 cm. Undermining: Tunneling (No description of location or size is indicated.). Exudate: Serous. Exudate (drainage) Amount: Scant. Odor: Yes. Wound bed: Red. Edges: Macerated (softening of tissue by soaking in fluids). Surrounding Skin: Healthy. Progress: No change. Treatment: Continue same treatment... Resident 1 assessment indicates Resident 1 has scant drainage. Resident 1 continues to receive the calcium alginate dressing indicated for the use of moderate to heavy drainage. 3. Dated 1/27/12, Length: 0.6 centimeters (cm). Width 0.5 cm. Depth: 0.4 cm. Undermining: Tunneling (No description of location or size is indicated.). Exudate: Serous. Exudate Amount: Scant. Odor: Yes. Wound bed: Red. Edges: Macerated. Surrounding Skin: Healthy. Progress: Deteriorated. Treatment: Continue same treatment... (It is important to note the documentation indicates the pressure ulcer is "Deteriorated" and there is no update to Resident 1's physician or to Resident 1's comprehensive care plan.) 4. Dated 2/4/12, Length: 0.5 centimeters (cm). Width 0.7 cm. Depth: 0.6 cm. Undermining: Tunneling (No description of location or size is indicated.). Exudate: Serous. Exudate Amount: Small. Odor: Yes. Wound bed: Red. Edges: Macerated. Surrounding Skin: Healthy. Progress: Improved. (It is important to note the wound size has increased and no other indication of improvement is noted from the measurement of 1/27/12 to indicate an improvement in the pressure ulcer.) Treatment: Continue same treatment... Comments; Wound (pressure ulcer) edges continue with maceration. Some tissue is sloughing off so the pressure ulcer measurements are slightly increased this week. If measurements continue to increase, will update Medical Doctor (MD) and adjust treatment if instructed by MD. (The physician was not updated and there are no changes to the comprehensive care plan.) 5. Dated 2/8/12, Length: 0.5 centimeters (cm). Width 0.4 cm. Depth: 0.4 cm. Undermining: Tunneling (No description of location or size is indicated.). Exudate: Serous. Exudate Amount: Scant. Odor: Yes. Wound bed: Red. Edges: Macerated. Surrounding Skin: Healthy. Progress: Improved. Treatment: Continue same treatment... (It is important to note Resident 1's pressure ulcer has shown no signs of healing in 5 weeks and Resident 1's Physician has not been updated, Resident 1's treatment remains unchanged, and Resident 1's care plan has not been updated or revised. to enhance healing of the Stage 4 pressure ulcer.) Standard of practice, as indicated by the NPUAP-EPUAP Treatment Guideline and The NPUAP-EPUAP Treatment Quick Reference Guide note: Assess the pressure ulcer initially and re-assess it at least weekly, document findings... With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications) ... Signs of deterioration should be addressed immediately. Here, staff took no measurements of the pressure ulcers from 2/8/12 until 3/9/12, 28 days later. 6. Dated 3/9/12, Length: 1 centimeters (cm). Width 1 cm. Depth: 1 cm. Undermining: Tunneling (No description of location or size is indicated.). Exudate: Serous. Exudate Amount: Small. Odor: Yes. Wound bed: Pink. Edges: Macerated. Surrounding Skin: Healthy. Progress: No Change. Treatment: Continue same treatment... Comment: Resident 1 to follow time limit to stay off left side as in previous. (Resident 1's pressure ulcer has increased in size and no indication of Resident 1's Physician notification or an update or revision to Resident 1's care plan to enhance the healing of Resident 1's stage 4 pressure ulcer.) 7. Dated 3/26/12, (2 weeks since Resident 1's last measurement) Length: 0.8 centimeters (cm). Width 0.6 cm. Depth: 0.5 cm. Undermining: Tunneling (No description of location or size is indicated.). Exudate: Serous. Exudate Amount: Small. Odor: No. Wound bed: Pink. Edges: Macerated. Surrounding Skin: Healthy. Progress: Improved. Treatment: Continue same treatment... 8. Dated 3/30/12, Length: 0.8 centimeters (cm). Width 0.4 cm. Depth: 0.3 cm. Undermining: Tunneling (No description of location or size is indicated.). Exudate: None... Odor: No. Wound bed: Pink. Edges: Macerated. Surrounding Skin: Healthy. Progress: Improved. Treatment: Continue same treatment... Resident 1's assessment indicates Resident 1 has no drainage. Resident 1 continues to receive the calcium alginate dressing indicated for the use of moderate to heavy drainage. 9. Dated 4/6/12, Length: 0.8 centimeters (cm). Width 0.5 cm. Depth: 0.3 cm. Undermining: Tunneling (No description of location or size is indicated.). Exudate: Serous. Exudate Amount: Scant Odor: No. Wound bed: Pink. Edges: Macerated. Surrounding Skin: Healthy. Progress: Improved. Treatment: Continue same treatment. 10. Dated 4/11/12, Length: 0.7 centimeters (cm). Width 0.4 cm. Depth: 0.3 cm. Undermining: Tunneling (No description of location or size is indicated.). Exudate: None... Odor: No. Wound bed: Pink. Edges: Macerated. Surrounding Skin: Healthy. Progress: Improved. Note: Resident 1 was observed to with the calcium alginate dressing on 4/17/12 during the pressure ulcer observation. Resident 1's pressure ulcer assessments from 1/13/12 through 4/11/12 indicate Resident 1's had scant to no amount of drainage, and Resident 1's pressure ulcer did not respond to the current treatment. Resident 1's physician and/or Hospital wound clinic Consultant was not consulted with the pressure ulcer treatment changes. Resident 1's nutrition note, dated 2/9/12, states Resident 1 continues with stage 4 pressure ulcer.. Resident 1 continues [MEDICATION NAME] twice a day... Resident 1 currently stable... (The nutrition note does not address Resident 1 [MEDICATION NAME] level of 1.7 or review of previous laboratory findings.) Resident 1's nutrition note, dated 3/8/12, states Resident 1 continual stage 4 pressure ulcer... No change to Nutrition. (The nutrition note does not address Resident 1 [MEDICATION NAME] level of 1.7 or review of previous laboratory findings.) Resident 1's nutrition note, dated 4/12/12, states Resident 1 Stage 4 pressure ulcer continues but healing slow... Continues [MEDICATION NAME] twice a day for wound healing... No change to nutrition plan of care... (The nutrition note does not address Resident 1 [MEDICATION NAME] level of 1.7 or review of previous laboratory findings.) On 4/17/12, at 7:00 AM, Resident 1 was observed by Surveyor in a full upright positioning sitting in his bed. Resident 1 was sitting on a tan colored air overlay on top of a standard mattress with white cord surround

Based on interview and record review the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Resident 2 was assessed to need 2 persons and a gait belt to assist in transfers. On 2/11/11 a nursing assistant had transferred Resident 2 to the toilet with another staff person. The nursing assistant assisted Resident 2 off the toilet by herself and Resident 2 fell while only being assisted with 1 staff. Resident 2 was sent to the emergency room and diagnosed with [REDACTED]. Findings as follows: Resident 2 was admitted to the facility 11/21/07 with a primary [DIAGNOSES REDACTED]. Resident 2's comprehensive care plan for falls last update 1/21/11 states that Resident 2 is assessed to need extensive assistance of 2 and a walker for transfers and toileting. Resident 2's CNA care plan (kept in room closet) dated 11/21/07 states that Resident 2 needs extensive assist of 2 for transfers and toileting. Resident 2's fall assessment risk score dated 1/10/11 is a 10 which indicates a high fall risk. A nursing note on 2/11/11 at 9:35 AM states that Resident 2 was going to the bathroom and stood at the rail so CNA could wipe her bottom and she fell sideways in the bathroom. The facility investigation for Resident 2's fall dated 2/11/11 states that Resident 2 requested to use the bathroom and CNA C went out in hallway to get assist for the transfer. DON B and CNA C used a gait belt and transferred Resident 2 to the bathroom. CNA C stated that she left the bathroom but kept the door open where CNA could see Resident 2. Resident 2 verbally stated that she was finished and ready to get up. CNA C stated that she went into the bathroom and asked Resident 2 if she was able to stand and Resident 2 said yes. CNA C placed a gait belt on Resident 2 and she stood her up in the bathroom by herself to finish peri care and pull up her pants. While doing this Resident 2 fell . Resident 2 complained of left shoulder and left leg pain right away. CNA C knew that Resident 2 was a 2 person assist with transfers and toileting but CNA C stated that she thought that Resident 2 could do it and was trying to get her ready for church on time. CNA C stated that she knows where the care plan is located to find the information and amount of assistance required. The Social Worker verified the closet care plan CNA C stated that she attended the inservice on Abuse and Neglect on 2/3/11 which covered following the care plan. Resident 2 was sent to the emergency room and was diagnosed with [REDACTED]. Resident 2 has a sling on her arm and a splint on her leg and is transferred by a Hoyer lift. A review of Resident's CNA care plan in her closet indicates on 2/14/11 that she is not to bear weight but does not identify how she is to be transferred. Resident 2's comprehensive care plan updated 2/23/11 states that she may not bear weight on left leg and may be out of bed to wheelchair but does not indicate how the staff is supposed to transfer her. On 3/1/11 at 12:45 PM Surveyor interviewed DON B regarding Resident 2's fall. DON B stated that CNA C had just asked for her assistance in transferring Resident 2 to the toilet so she knew she needed 2 people. DON B stated that CNA C was trying to get her to church and not be late and had a lapse in judgment. CNA C was just at our all-staff inservice where it was specifically stated that not following the care plan could be justified as neglect. DON B stated that they terminated CNA C. DON B was asked to review the care plan of Resident 2 and find her transfer status on it. DON B stated that a Hoyer lift transfer should be on the care plan and stated that she would take care of it right away. The inservice held on 2/3/11 that CNA C attended states on the Caregiver Misconduct-Simplified Definitions form that neglect is a careless or negligent act that: failures to follow facility procedure or care plan and causes or could cause pain, injury or death but is not intended to cause harm. The facility did not substantially follow Resident 2's care plan of using 2 assist for a transfer and toileting and Resident 2 fell and received 3 fractures.

Based on record review and interview, the facility did not ensure services provided by the facility met professional standards of quality for 1 of 15 (Resident 1) residents. Resident 1 experienced a fall with loss of consciousness. The physician was not updated with all pertinent information necessary to determine treatment. When a change in Resident 1's condition was noted, the physician was not immediately updated. Failure to ensure services provided met professional standards of quality created a finding of immediate jeopardy. Immediate Jeopardy began on [DATE]. The facility was notified of the immediate jeopardy on [DATE]. The facility removed the immediate jeopardy on [DATE], however the deficient practice continues at a scope/severity level D (potential for harm/isolated) because the facility needs to ensure that the measures that were put in place are being followed. This is evidenced by the following: The AMDA (American Medical Directors Association) guidelines for Acute Change of Condition (ACOC) in the Long-Term Care Setting clinical practice guidelines documented the following: Step 2 Describe and document symptoms and/or condition changes. Patients in long-term care facilities are most likely to report symptoms to a nursing assistant, family member, nurse or other caregiver. It is therefore extremely important that care giving staff describe symptoms as accurately and completely as possible so that practitioners can determine their significance. When assessing the patient with signs or symptoms that may indicate an ACOC, care giving staff should, at a minimum, do the following: -Regardless of the patient's cognitive level, ask the patient how he or she is feeling or how the symptoms developed. -Take vital signs -Assess the patient's overall condition, level of consciousness, and function -Seek information that might help a practitioner identify possible causes (both acute and chronic conditions) of the symptoms to help determine which body symptoms to evaluate further. The AMDA guidelines continue: -Examples of staff roles and responsibilities in monitoring patients with ACOCs included: recognize the change early, assess patient's symptoms and physical function and document detailed descriptions of observations and symptoms, update the charge nurse or supervisor if the patient's condition deteriorates or patient fails to improve within expected time frames, report patient's status to practitioner as appropriate... Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Per Resident 1's care plan, original date [DATE], Resident 1 is alert and oriented. Resident 1's nursing notes indicate that on [DATE], Resident 1 called for assistance. During this time Resident 1 attempted to stand and fell . On [DATE], at various times, Surveyor interviewed Certified Nursing Assistant (CNA) M, CNA N, CNA O, and Licensed Practical Nurse (LPN) H who all state that when they saw Resident 1 on the floor following the fall on [DATE] he was unresponsive. These statements indicated that Resident 1 was " unconscious with his eyes rolled back, " " out of it, " and " unresponsive. " Cross Reference F309 for interviews On [DATE], at 8:21 PM, Surveyor interviewed RN G about the events on [DATE] with Resident 1. RN G stated she was notified by CNA O that Resident 1 had fallen. RN G stated she went to Resident 1's room and noted Resident 1 on the floor with a pillow behind his head and CNA N and CNA M were in the room. RN G state when she entered the room Resident 1 was trying to get up (contrary to the other interviews and LPN H who entered after RN G). RN G stated Resident 1 wanted to get up and denied pain so she instructed staff to assist him up into bed with a gait belt. RN G stated she called the on call physician, via paging system, and was instructed by the physician to put a dressing on Resident 1's elbow and do neurological (neuro) checks every 2 hours. RN G stated she then received a call from DON B and RN G explained to DON B what had occurred. RN G told Surveyor she did not consider sending Resident 1 to the emergency room because "in her judgment" Resident 1 did not need to be sent. RN G stated Resident 1 did not lose consciousness that she saw and no one told her he did. RN G stated if she would have seen Resident 1 unconscious she would have sent him to the hospital. On [DATE], at 3:24 PM, Surveyor spoke with RN G again. RN G stated she spoke with CNA M who saw Resident 1 fall and CNA M did not say Resident 1 was unresponsive. RN G confirmed she did not ask any of the staff who was present, including CNA M, if Resident 1 lost consciousness at any point or to describe what they saw. On [DATE], at 10:33 AM, Surveyor interviewed Medical Doctor (MD) K who was the physician on call on [DATE]. MD K stated he remembered most of the incident from that night. MD K stated when the nurse called she stated Resident 1 had fallen and RN G reviewed Resident 1's vital signs and stated Resident 1 had developed a goose egg on the back of his head. MD K instructed RN G to monitor Resident 1 following the facility's neuro check protocols and call with any changes. MD K stated he was not familiar with the facility's policy for neuro checks but his protocol would be to do neuro checks every 15 minutes four times, then every 30 minutes four times, then hourly... MD K stated he was not informed that Resident 1 was unconscious when RN G called and reported the incident. On [DATE], at 5:09 PM, Surveyor interviewed DON B about the response to Resident 1's fall on [DATE]. DON B stated when she spoke with RN G on [DATE] she asked RN G to reassess Resident 1 at that time. DON B instructed RN G to do neuro checks every hour for her shift and then every 2 hours at night. DON B stated it is the facility policy to do neuro checks every 2 hours but wanted it done more frequently due to LPN H's concern. DON B stated it is her expectation that if a resident loses consciousness, a physician is contacted immediately and if the resident does not respond within 1 minute the nurse is to call 911. DON B stated when she questioned RN G about the incident, RN G stated Resident 1 came around right away and that RN G reported this to the physician. DON B did not know what standard or guideline was used to develop the facility's neuro check policy. Resident 1's "Neurological Assessment Flow Sheet" indicates the vital sign parameters to notify a physician are less than 90 or greater than 160 (systolic) and less than 60 or greater than 90 (diastolic). On [DATE] vital signs are recorded as: 9:00 PM- alert, equal pupil response and blood pressure ,[DATE] (note: out of parameters - requiring physician notification). 10:00 PM-blood pressure ,[DATE] (note: out of parameters - requiring physician notification). [DATE] 4:00 AM-Drowsy, pupil response equal, blood pressure ,[DATE] pulse 94. 6:00 AM-Drowsy, pupil response slow, blood pressure ,[DATE]. Resident 1's nursing notes on [DATE] indicate: - 4:00 AM Resident 1 awoken for neuro checks. "Hand grasps equal but weak..." -6:00 AM Resident 1 "awake and attempting to get out of bed. Resident 1 slow to respond." -7:30 AM Assessment from 7:00 AM showed Resident 1 "awake and looking left (with) both eyes. Resident could not turn eyes to look (at) RN, could (not) follow RN finger either. Pupils very slow to react to light...(Resident 1) also unable to lift arms (without) assistance." On [DATE], at 8:06 AM, Surveyor interviewed RN I about Resident 1 following the fall on [DATE]. RN I stated she worked the night shift and came in on [DATE] at about 10:30 PM. RN I stated RN G stated that Resident 1 had fallen and suffered a head injury. RN I stated that RN G reported that MD K was called and to do neuro checks every 2 hours and update the physician in the morning. RN I stated at 4:00 AM she stated that Resident 1 seemed sluggish but that RN I thought it was related to Resident 1 being tired from being up all night. RN I then stated at 5:00 AM a CNA reported that Resident 1 did not look right and that RN I went in and assessed Resident 1 at about 5:30 AM. RN I stated that Resident 1 did not seem right and was not answering questions. RN I then called the oncoming day RN to come in early and help with the assessment. RN I stated RN J reassessed Resident 1 at about 6:00 AM and noted Resident 1 facing to the left. RN I stated the physician was called and Resident 1 was sent to the hospital in the facility van with a CNA and the maintenance man. The physician was not updated immediately on the change of condition at 4:00 AM or at 6:00 AM when neuro check results changed. Resident 1's emergency room report, dated [DATE], indicates Resident 1 arrived at the hospital at 8:15 AM. Resident 1 was diagnosed with [REDACTED]. (Resident 1) also had a left parietal fracture." Resident 1 was discharged back to the nursing home on comfort measures and expired on [DATE]. The failure of nursing personnel to follow professional standards of practice in the assessment, care, and treatment of [REDACTED]. The facility removed the immediate jeopardy on [DATE], by which time the facility had: Re-educated nurses on assessing residents after a fall with head trauma, updated the facility policy on neurological assessments and updated the assessment form to reflect the changes, updated the policy on transporting residents to the hospital, and updated the facility change of condition policy.

Based on interview 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, in accordance with the comprehensive assessment and plan of care, for 2 of 15 residents (Resident 1 and 22) with a change of condition. A Registered Nurse (RN) did not personally assess Resident 1 after a fall with a head injury and did not report all pertinent information to the physician. When neurological checks may have been abnormal at 4 AM, another Registered Nurse did not assess the resident more frequently, and did not immediately inform the physician of the changes. Failure to ensure the necessary care and services created a finding of immediate jeopardy. Immediate Jeopardy began on [DATE]. The facility was notified of the immediate jeopardy on [DATE]. The facility removed the immediate jeopardy on [DATE], however the deficient practice continues at a scope/severity level D (potential for harm that is not immediate jeopardy/isolated) because the facility needs to ensure that the measures that were put in place are being followed. Resident 22 had increased pain and the physician increased her Fentynal Patch to 50 mcg. Resident 22 had a 25mch on her already and the staff added a new 25 mcg patch around 12 noon. Around 2:00 PM Resident 22 had a condition change to very lethargic and low blood pressure. The nurse called Resident 22's physician but did not notify him that the new patch was placed already on Resident 22. Later in the evening an LPN noted the additional patch and called the MD again and reported that she took the new patch off. Resident 1 was diagnosed with [REDACTED]. This is evidenced by the following: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Per Resident 1's care plan, original date [DATE], Resident 1 needed 1 staff person to assist with transfers and ambulates with 1 assist and a walker. Resident 1's physician's orders [REDACTED]. Resident 1's nursing notes indicate on [DATE], Resident 1 called for assistance. During this time Resident 1 attempted to stand and fell . Surveyor interviewed Certified Nursing Assistant (CNA) M on [DATE], at 4:08 PM. CNA M confirmed she was the staff person in the room when Resident 1 fell on [DATE]. CNA M stated that she went into Resident 1's room to assist him at around 9:30 PM. CNA M turned to get Resident 1's walker; at that time Resident 1 attempted to stand up independently.. Before CNA M could assist Resident 1, Resident 1 fell . CNA M stated Resident 1 was on the floor and was unconscious with his eyes rolling back. CNA M ran out of the room to get help. CNA M saw CNA N and CNA CC in the hall. CNA M stated that CNA N and CNA CC came down to the room then Registered Nurse (RN) G entered the room. RN G then sent CNA CC to get additional help. CNA M stated that CNA N applied gauze to Resident 1's arm as it was bleeding and CNA N put a pillow under Resident 1's head. CNA M stated she and CNA N asked RN G to do something and RN G stated there is "nothing I can do, he is a no code." CNA M stated that then Licensed Practical Nurse (LPN) H entered the room. CNA M was then told to leave and assist another resident. CNA M stated that RN G never asked her what had happened. CNA M stated CNA CC approached her later in the evening to ask what happened but not RN G. CNA M stated the following day Director of Nursing (DON) B approached CNA M and asked her to complete a report. On [DATE], at 3:16 PM, Surveyor interviewed CNA N about the incident with Resident 1 on [DATE]. CNA N stated that CNA M came out of Resident 1's room and stated Resident 1 had fallen. CNA N and CNA O went to Resident 1's room. CNA N stated she saw Resident 1 on the floor, his eyes rolling back and he was not responding to anyone. CNA N stated she put a pillow under Resident 1's head and then RN G entered the room and instructed CNA N to wrap Resident 1's arm with gauze. CNA N stated they had the slide board ready to transfer him but then he "woke up" and wanted to get up off the floor. CNA N stated RN G did not do the vitals and that she did not see RN G do any hands on assessment of Resident 1, RN G "just stood there." CNA N, with help from other CNAs, used a gait belt and assisted Resident 1 off the floor and into bed. CNA N then left Resident 1's room to assist other residents. On [DATE], at 3:47 PM, Surveyor interviewed CNA O about Resident 1's fall on [DATE]. CNA O stated that CNA M came down the hall and told CNA O and CNA N that Resident 1 had fallen. CNA O stated on the way to Resident 1's room she stopped and told RN G. CNA O stated when she got to the room she saw Resident 1 laying flat on his back and his left elbow was bleeding. CNA O stated when she entered the room Resident 1 "was out of it" and non responsive and it was "scary." CNA O stated CNA M, CNA N and she were the first in the room, then RN G entered. CNA O stated she left the room at that time, CNA O then came back to see if additional help was needed. CNA O stated at that time LPN H was taking Resident 1's vitals. CNA O stated the aides did not assist with vitals during the night that the nurses were to take the vitals. On [DATE], at 2:23 PM, Surveyor interviewed LPN H about Resident 1's fall on [DATE]. LPN H stated that a CNA came down to the 2nd floor calling for help upstairs. LPN H responded to Resident 1's room and noted Resident 1 was unconscious, there were about 5 CNAs in the room attending to Resident 1 and cleaning up blood and RN G was leaning up against the wall. LPN H asked RN G about sending Resident 1 to the hospital and RN G stated she was not going to send him anywhere. LPN H stated staff assisted Resident 1 up into bed and then RN G left the room. LPN H stated she was the one who took Resident 1's vitals and they were out of parameters. LPN H could not recall what the vitals were at the time of the interview. LPN H stated she felt RN G had called the physician without getting vitals and she was concerned for Resident 1 so LPN H called DON B at home to explain the situation. LPN H then returned to the 2nd floor to assist residents. On [DATE], at 8:00 PM, Surveyor interviewed CNA CC about Resident 1's fall on [DATE]. CNA CC stated she was sent to get additional staff help from downstairs. CNA CC stated when she entered Resident 1's room she noted a backboard in the room and a CNA wrapping Resident 1's elbow with gauze. CNA CC states she saw LPN H taking Resident 1's vitals and Resident 1 asking to get up off the floor. CNA CC stated she helped assist Resident 1 into bed and stayed with Resident 1. CNA CC stated RN G left to room to call people and later came back in and removed the dressing on his elbow and took measurements. CNA CC also stated that RN G took vital signs at that time. On [DATE], at 8:21 PM, Surveyor interviewed RN G about the events on [DATE] with Resident 1. RN G stated she was notified by CNA O that Resident 1 had fallen. RN G stated she went to Resident 1's room and noted Resident 1 on the floor with a pillow behind his head and CNA N and CNA M were in the room. RN G stated when she entered the room Resident 1 was trying to get up (contrary to the other interviews). RN G stated Resident 1 was bleeding a small amount from his left elbow so she asked CNA N to wrap the area with Kerlix. RN G stated Resident 1 wanted to get up and denied pain so she instructed staff to assist him up into bed with a gait belt. RN G stated once Resident 1 was in bed RN G took his vitals. RN G stated she called the on call physician, via paging system, and was instructed by the physician to put a dressing on Resident 1's elbow and do neurological (neuro) checks every 2 hours. RN G stated she then attempted to call Nursing Home Administrator A as per the policy. RN G stated she then received a call from DON B and RN G explained to DON B what had occurred. RN G told Surveyor she did not consider sending Resident 1 to the emergency room because in her judgment Resident 1 did not need to be sent. RN G stated Resident 1 did not lose consciousness that she saw and no one told her he did. RN G stated if she would have seen Resident 1 unconscious she would have sent him to the hospital. On [DATE], at 3:24 PM, Surveyor spoke with RN G again. RN G stated she spoke with the CNA who saw Resident 1 fall and the CNA did not say Resident 1 was unresponsive. RN G confirmed she did not ask any of the staff who was present if Resident 1 lost consciousness. On [DATE], at 10:33 AM, Surveyor interviewed Medical Doctor (MD) K who was the physician on call on [DATE]. MD K stated he remembered most of the incident from that night. MD K stated when the nurse called she stated Resident 1 had fallen and RN G reviewed Resident 1's vital signs and stated Resident 1 had developed a goose egg on the back of his head. MD K instructed RN G to monitor Resident 1 following the facility's neuro check protocols and call with any changes. MD K stated he was not familiar with the facility's policy for neuro checks but his protocol would be to do neuro checks every 15 minutes four times, then every 30 minutes four times, then hourly etc. MD K stated he was not informed that Resident 1 was unconscious when RN G called and reported the incident. On [DATE], at 5:09 PM, Surveyor interviewed DON B about the response to Resident 1's fall on [DATE]. DON B stated that when she spoke with RN G on [DATE] she asked RN G to reassess Resident 1 at that time. DON B instructed RN G to do neuro checks every hour for her shift and then every 2 hours at night. DON B stated it is the facility policy to do neuro checks every 2 hours. DON B stated it is her expectation that if a resident loses consciousness a physician is contacted immediately and if the resident does not respond within 1 minute the nurse is to call 911. DON B stated when she questioned RN G about the incident, RN G stated Resident 1 came around right away and that RN G reported this to the physician. Resident 1's "Neurological Assessment Flow Sheet" indicates the vital sign parameters to notify a physician are less than 90 or greater than 160 (systolic) and less than 60 or greater than 90 (diastolic). On [DATE] vital signs are recorded as: 9:00 PM- alert, equal pupil response and blood pressure ,[DATE] (note: out of parameters - requiring physician notification). 10:00 PM-blood pressure ,[DATE] (note: out of parameters - requiring physician notification) [DATE] 4:00 AM-Drowsy, pupil response equal, blood pressure ,[DATE] pulse 94. 6:00 AM-Drowsy, pupil response slow, blood pressure ,[DATE]. Resident 1's nursing notes on [DATE] indicate: - 4:00 AM Resident 1 awoken for neuro checks. "Hand grasps equal but weak..." -6:00 AM Resident 1 "awake and attempting to get out of bed. Resident 1 slow to respond." -7:30 AM Assessment from 7:00 AM showed Resident 1 "awake and looking left (with) both eyes. Resident could not turn eyes to look (at) RN, could (not) follow RN finger either. Pupils very slow to react to light...(Resident 1) also unable to lift arms (without) assistance." On [DATE], at 8:06 AM, Surveyor interviewed RN I about Resident 1 following the fall on [DATE]. RN I stated she worked the night shift and came in on [DATE] at about 10:30 PM. RN I stated RN G stated that Resident 1 fell and suffered a head injury. RN I stated that RN G reported that MD K was called and to do neuro checks every 2 hours and update the physician in the morning. RN I stated at 4:00 AM she stated that Resident 1 seemed sluggish but that it was related to Resident 1 being tired from being up all night. RN I then stated at 5:00 AM a CNA reported that Resident 1 did not look right and that RN I went in and assessed Resident 1 at about 5:30 AM. This was her first reassessment since 4 AM when the resident had questionable hand grasps. RN I stated that Resident 1 did not seem right and was not answering questions. RN I then called the on coming day RN to come in early and help with the assessment. RN I stated RN J reassessed Resident 1 at about 6:00 AM and noted Resident 1 facing to the left. RN I stated the physician was called and Resident 1 was sent to the hospital in the facility van with a CNA and the maintenance man. Resident 1's emergency room report, dated [DATE] indicates Resident 1 had "intraparenchymal and subarachnoid bleed, pretty significant in size, although no mass effect. (Resident 1) also had a left parietal fracture." Resident 1 was discharged back to the nursing home on comfort measures and expired on [DATE]. The facility's failure to immediately relay accurate information to the physician and to more closely monitor the resident's neuro signs after obtaining questionable results at 4 AM created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], by which time the facility had: Re-educated nurses on assessing residents after a fall with head trauma, updated the facility policy on neurological assessments, and updated the facility change of condition policy. Example 2 Resident 22 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 22 was on a 25 mcg patch of [MEDICATION NAME] for pain. Nurses notes on ,[DATE] and [DATE] stated that Resident 22 had been complaining of increased back pain. On [DATE], at 9:30 AM the nurse spoke with the MD and notified of increased back and all over pain. The physicians order was to increase the patch strength to 50 mcg. The nurse documents that she will apply another 25 mcg patch. On [DATE] at 12 Noon, a nurses note states that [MEDICATION NAME] Patch 25 mcg was added additionally to other 25 mcg patch. On [DATE] at 2:15 PM a nursing note written by RN DD states, "BP ,[DATE], ...Resident lying on bed-C/O back, arm, and neck pain, C/O inability to raise her arm or head. Moans and yells with any movement, has not eaten breakfast or lunch. Neck slightly hyperextended, very lethargic..." MD was called and order received for lab work. There is no documentation that reiterated that Resident 22 had a new 25 mcg placed around 12 noon. On [DATE] at 2:45 PM Surveyor and interviewed RN DD regarding the phone call to MD on [DATE]. RN DD stated, "I probably just gave him the vital info and he ordered blood work. I probably didn't mention that she had the patch put on already. I didn't think it would take effect yet. Maybe I should have mentioned it but I didn't think twice about it." A nursing note on [DATE] at 4:30 PM written by DON B indicates that no critical lab values from labs drawn earlier today. There is no mention of any indication of the increased [MEDICATION NAME]. On [DATE], at 3:30 PM, Surveyors and interviewed DON B regarding her [MEDICATION NAME] increase on [DATE]. DON B stated, "I was going on to the unit to review another resident's medical record and was asked to look at her (Resident 22). The family was there and they didn't say anything about a patch. RN DD and LPN H were handling the doctor calls. I had no clue the new patch was on, I felt like an idiot when I found that out. I looked at the lab values and reassured the family that we would be checking her every 2 hours and would call with any condition changes. The MD was called and informed of the lab results with no new orders. No one told me that they had already placed the patch on at noon. I would have expected that the nurse tell the MD and take the patch off with her being very lethargic and monitor her closer. I understand that the patch was not taken off until much later in the shift. I did give an inservice regarding change of condition, and pain patches." On [DATE], a nursing note at 8:15 PM states, "Resident unresponsive to any stimuli. BP ,[DATE], p-60, R-8 and O2 80%. Call out to MD and she is on way. I pulled the 25 mcg patch of [MEDICATION NAME] put on today. " On [DATE], at 2:55 PM, Surveyors and interviewed LPN H regarding Resident 22 and her increased [MEDICATION NAME] on [DATE]. LPN H stated, " I received report from RN DD as she took over from LPN EE who left early. I was told the [MEDICATION NAME] was increased and RN DD called the MD and told him that Resident 22 was just being tired. I went and checked on Resident 22 and noted that she did not look right and something was off, I then called the RN to come down. We called the on call MD as she kept getting worse and if I didn't know better it was the effects of the [MEDICATION NAME] I told the RN. The RN reviewed her orders, but the new 25 mg patch was not signed out on the day shift, so the RN did not give me permission to pull the patch. The 24 hour report just indicated that the patch was increased, it did not say it was put on and it wasn't signed out until later. About 8:00 PM I called the PA again and she said she was on the way and I told her about the patch that it was on her and she said to pull it off. On [DATE] at 9:50 PM a nursing note states, "(MD Name) assessed resident stating too much pain med. Ordered to decrease from 50 to 25 mcg stating sensitivity to [MEDICATION NAME] was a possibility. Also ordered O2 nasal cannula to increase to 5 liters to increase low sats...Do vitals every 30 minutes until resident becomes more alert and aware..." Resident 22's Office Note (from the physician's assistant who came to see Resident 22) dated [DATE] states that Resident 22 was reported to be somnolent and later received a phone call that she was too somnolent and there is difficulty arousing her, and the nurse removed the patch. The PA stated that Resident 22 had Somnolence secondary to too much narcotic. A nursing note on [DATE] at 9:20 AM indicates that Resident 22 was sent to the ER for an evaluation. Resident 22's Transfer Form dated [DATE] states, "Resident had a pain patch increased [DATE] resulting in severe respiratory distress. Has been on O2 at 5 lm since that time O2 sat vary from 80% to 93% T-99.5, p-82, R-16, and BP ,[DATE]. Continues to stare at times. Has not voided since yesterday. Fluids pushed. Coughing with rattling-productive this AM. Resident 22's emergency room Report dated [DATE] states that Resident 22 had abdominal pain that had been worsening. She was on 25 mcg of [MEDICATION NAME] and another 25 mg was ordered and she did become somewhat unresponsive with shallow respirations. She was brought to the ER to be evaluated for that. She otherwise, had been doing very well except for this worsening pain and there is some confusion of when her patch was taken off. DON B gave surveyor in inservice that was held on [DATE] which states: Identifying and preventing Drug interactions-Residents who are placed on a new narcotic or who have a dose increase nee to be monitored every hour for the first 8 hours. This will help identify and adverse reactions promptly. The med needs to be added to the 24 hour report. The following needs to be monitored: [MEDICAL CONDITION], clammy skin, decreased respirations, trouble speaking, [MEDICAL CONDITION], confusion, severe sleepiness, and feeling faint. The facility did not give resident 22's physician an accurate assessment by not reporting that the patch was placed on, did not closely monitor her condition, and did not remove the patch when she showed adverse reactions to the increased [MEDICATION NAME].