Every finding on record at Lake Country Health Services

Based on observation, interview and record review the facility did not ensure its medication error rate was below 5%. The facility error rate was 7.69% affecting 2 residents (R12 and R67) observed during medication pass. Findings include:The facility policy titled Medication Administration dated 5/7/25 documents (in part) .Staff will ensure each medication is safely administered per practitioner's orders.24. Staff will administer all medications following the Six Rights of Medication Administration: Right resident, right medication, right dose, right time, right route, right documentation. On 8/25/25, at 7:15 AM, Surveyor observed Registered Nurse (RN)-C prepare medications for R67. The following medications were prepared: Amlodipine Besylate 10 MG (milligram) 1 tablet, Baclofen 10 MG 1 tablet, Cetirizine HCL (Hydrochloride) 10 MG 1 tablet, Apixaban (Eliquis) 5 MG 1 tablet, Ferrous Sulfate 325 MG 1 tablet, Furosemide 40 MG 1 tablet, Lisinopril 10 MG 1 tablet, Oxybutynin Chloride 5 MG 1 tablet, Pantoprazole 40 MG Delayed Release 1 tablet, Polyethylene Glycol 3350 Powder for Oral Solution (Miralax)17 grams, Sertraline 50 MG 1 tablet, Tizanidine 2 MG 1/2 tablet, Tizanidine 2 MG 1 tablet, Fluticasone nasal spray 1 puff each nostril, Timolol Maleate 0.5 % 1 drop each eye.Surveyor verified the number of tablets with RN-C and the medications were administered to R67 whole with water.Surveyor reconciled the medications administered with R67's current (August 2025) MAR. R67's MAR documents: Cetirizine HCl Tablet 10 MG give 0.5 tablet by mouth one time a day for Allergy symptoms - start date 8/23/25. Surveyor noted R67 was administered a whole 10 MG tablet versus the 1/2 tablet as ordered. On 8/25/25, at 8:38 AM, Surveyor spoke with RN-C and asked to view the bottle of Cetirizine together. Surveyor advised RN-C that R67's MAR documents an order for 0.5 tablet (5 MG) but a whole tablet of 10 MG was given. RN-C looked at the bottle and stated, Your right she's supposed to get half a tablet. I'll call pharmacy and make sure we can break this in half; the tablet is scored. On 8/25/25, at 7:25 AM, Surveyor observed Registered Nurse (RN)-C prepare medications for R12. The following medications were prepared: Baclofen 20 MG (milligrams) 1 tablet, Gabapentin 100 MG 1 tablet, Metformin Hydrochloride 500 MG 1 tablet, Metoprolol Tartrate 25 MG 1/2 tablet, Amiodarone Hydrochloride 200 MG 1 tablet, Furosemide 20 MG 1 tablet, Citalopram 10 MG 1 tablet, Lisinopril 5 MG 1 tablet, Senna plus 1 tablet, Oxycodone Hydrochloride 5 MG 1 tablet, Insulin Glargine (Lantus) 100 unit/ml (milliliter) 20 units. RN-C prepared all medications, placed the tablets in a plastic medication cup and Surveyor verified number of tablets with RN-C. RN-C added applesauce to the tablets in the cup. RN-C then said she had to do them over because R12 likes his meds crushed. RN-C prepared all the above medications again, placing them in a plastic medication cup, except for Metoprolol Tartrate. Surveyor noted Metoprolol was not added to the medication cup. Surveyor verified number of tablets with RN-C, noting the number of tablets did not match the previous number, it was less the 1 tablet of Metoprolol. Surveyor advised RN-C that during the second observation, Metoprolol was not added to the medication cup, and the number of tablets was 1 less than previously observed. Surveyor and RN-C viewed R12's medication cards and MAR (Medication Administration Record) together. RN-C stated she must've forgot to punch out the Metoprolol and added it to the medication cup. The medications were then crushed and administered to R12 with applesauce. On 8/25/25, at 2:58 PM, Nursing Home Administrator (NHA)-A was advised of the above concerns and medication error rate. No additional information was provided.

Based on observation and interview the facility did not provide routine and emergency drugs and biologicals to meet the needs of each resident for 3 of 4 medications carts observed. Findings include:The facility policy titled Administration of Insulin with Insulin Pen dated [DATE] documents (in part) .Trained staff working under registered nurse delegation will safely and effectively administer insulin. It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge.3. Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date.10. Insulin pens should be disposed of after 28 days or according to the manufacturer's recommendations. The facility policy titled Administration of Eye Drops and Ointment dated [DATE] documents (in part) .Eye medications are administered as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions.d. Label new bottle with date opened and follow facility policy or manufacturer's instructions for when to discard and replace. On [DATE], 8:56 AM, Surveyor observed the Unit 400 medication cart. In the top drawer of the medication cart, Surveyor located the following: Two Lantus insulin pens belonging to R20, both were dated opened 7/5. Latanoprost 0.005% eye drops belonging to R5. The bottle was open and used but not dated when opened. Ketorolac Tromethamine 0.5% eye drops belonging to R5. The bottle was open and used but not dated when opened. Olopatadine HCL (Hydrochloride) 0.2% eye drops belonging to R49. The bottle was open and used but not dated when opened.Surveyor asked Registered Nurse (RN)-D how long insulin was good for once opened. RN-D reported she was not sure. Surveyor advised RN-D of the Lantus insulin pens dated opened 7/5. RN-C stated, We currently don't have anyone on insulin on this unit, so they probably should have been thrown out. Surveyor advised RN-D of the above eye drops not dated when opened. RN-D reported she was not sure how long eye drops are good for before expiring, but eye drops should be dated when opened. On [DATE], 2:28 PM, Surveyor observed the Unit 200 medication cart. In the top drawer of the medication cart, Surveyor located the following: Olopatadine HCL 0.1% eye drops belonging to R75. The bottle was open and used but not dated when opened. On [DATE], at 7:10 AM, during observation of medication pass with RN-C on the Unit 300 medication cart, Surveyor observed RN-C administer Timolol Maleate eye drops to R67. Surveyor noted the eye drops were not dated when opened. RN-C reported eye drops should be dated when opened and are good for 28 days.On [DATE], at 2:59 PM, Nursing Home Administrator (NHA)-A was advised of concerns regarding the expired insulin dated 7/5 and eye drops not dated when opened. No additional information was provided

Based on record review and interviews, the facility failed to honor a resident's advanced directive of do not resuscitate for 1 (R1) of 4 residents reviewed for advanced directives and resident's rights. R1 has a State Do Not Resuscitate (DNR) form signed by R1's Power of Attorney (POA), and an active Medical Doctor (MD) order documenting DNR. On [DATE], R1 became unresponsive and was pulseless. Facility staff did not check R1's advanced directives before performing Cardiopulmonary Resuscitation (CPR) compressions on R1. R1's pulse returned. After receiving compressions, R1 complained of pain as high as 10 out of 10 and required an added MD order for Morphine to control R1's pain. The facility's failure to honor R1's DNR wishes led to facility staff completing chest compressions through the act of cardiopulmonary resuscitation (CPR) that caused R1 to be resuscitated, despite the formulation of an advanced directive to decline such measures and which led to R1 experiencing extreme pain post resuscitation. This situation created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Nurse Consultant-C, and [NAME] President of Success (VP)-D were notified of the immediate jeopardy on [DATE] at 2:36 PM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity (s/s) of an E (potential for harm/pattern) as the facility continues to implement their action plan. Findings include: The facility policy titled, Cardiopulmonary Resuscitation (CPR) with a review date of [DATE], documents, in part: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR) . The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order; and c. If the resident does not show obvious signs of clinical death . CPR certified staff will be available at all times. R1 was admitted to the facility on [DATE] with diagnoses that include Cerebrovascular disease, Dementia, Hypertension, Atrial Fibrillation, Pacemaker, and Type 2 Diabetes. R1's Significant change Minimum Data Set (MDS) assessment dated [DATE] documents that R1 is severely cognitively impaired and requires partial to moderate assist for toileting, mobility, and transfer. R1 has an activated Power of Attorney. Surveyor located multiple signed State DNR forms in R1's electronic medical record. The most recent State DNR form, signed by R1's POA, is dated [DATE]. R1's active MD order dated [DATE], documents: DNR. R1's Advanced Directive Care plan initiated [DATE] documents: Resident's advanced directive is: DNR. Goal: Resident's wishes will be honored. Pertinent Interventions include: Follow advanced directive per MD orders. Refer to MD orders for code status. Follow facility protocol for identification of code status . On [DATE] at 9:15 AM, R1's Physician Assistant (PA) documents in a progress note, in part: Updated by staff that patient was woken up early this morning to receive a shower. However following shower reported by staff that she has had significant increased fatigue and weakness from baseline including knocking over her utensils at breakfast and inability to feed herself, as well as slurred speech . Cares are discussed with POA regarding change in condition who is requesting no workup or ED evaluation, however request for hospice consult instead for comfort measures . goal of care remaining comfort only. R1's progress note dated [DATE] at 11:49 AM, documents in part: [R1] appeared to be weakened and coordination off. [R1] speech slightly slurred and not able to smile. [R1] able to move all extremities. Writer and PA . spoke with . POA who wants [R1] to be kept comfortable . POA agreed for hospice to evaluate for services. R1's Initial plan of care completed by the Hospice company, dated [DATE] documents, in part: Advanced Directives: Do Not Resuscitate . Surveyor noted R1 was started on hospice services on [DATE] with the goal of comfort measures. R1's Hospice Care plan dated [DATE], documents the following intervention: Honor advanced directives. R1's progress note dated [DATE] at 1:22 PM, documents in part: [R1] . coughing while eating and drinking. Appetite poor . Respiratory panel results are back and [R1 is] positive with Influenza A. Hospice nurse aware and new order to start Mucinex . R1's progress note dated [DATE] entered by R1's PA at 11:15 AM documents in part: [R1] has completed isolation precautions for recent influenza with resolution in symptoms noted. [R1] denies any further [upper respiratory symptoms], fevers/chills, shortness of breath or uncontrolled pain . On [DATE] at 11:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E. LPN-E stated that LPN-E worked on [DATE]. LPN-E stated that LPN-E was very familiar with R1. LPN-E stated that R1 had returned to R1's baseline after the diagnosis of Influenza A and LPN-E did not have any concerns regarding R1 on [DATE]. Surveyor asked what R1's advanced directive status was. LPN-E stated that R1 was a DNR. LPN-E stated that LPN-E knew all her residents' code status. LPN-E stated that R1 wore a DNR bracelet on R1's left wrist all the time. Surveyor asked where a staff member would look for advanced directives/code status. LPN-E stated that LPN-E would look in the electronic medical record. LPN-E stated that code status is seen when you open a resident's chart. On [DATE] at 1:14 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-I. CNA-I stated that CNA-I cared for R1 on [DATE] starting at 6 AM. CNA-I stated that R1 was acting normal and per R1's usual. R1 ate normally and followed R1's normal routine. R1's progress note entered by Registered Nurse (RN)-F, dated [DATE] at 6:45 PM documents in part: Nurse called to resident's room by CNA who stated, Resident is not responding. CNA reports that [R1] was providing [bedtime] care when the resident became unresponsive. Upon entering the room and assessment, resident is slumped and limp in the wheelchair; unresponsive to verbal stimulation. Skin noted as cold and pale. Lips are blue-tinged and labored mouth breathing is noted. A weak pulse of 40 is noted to the internal carotid artery. Breathing is labored at 8 per minute. Vigorous sternal chest rub applied; ineffective. Jaw-chin [lift] applied; ineffective. CNA sent to get oxygen line and tank. Resident's condition declining quickly. Chest rise and fall is absent. Intermittent shallow breaths noted. Resident assessed for pulse to radial and the carotid artery - pulse is absent. This nurse is unable to ascertain the resident's code status at this time and situation. Resident lowered to the floor. Upon assessment, pulse is still absent - CPR initiated. CPR effective. Oxygen at 2 [liters per minute] provided for support. [Vital signs] [temperature] 97.3, [pulse] 79, [blood pressure] ,d+[DATE], [respiratory rate] 20, [Oxygen saturation] 98%, [Blood sugar] 331 . The express decision of [R1's POA] as follows: The resident to remain in the facility and NOT be sent out [for] evaluation and treatment. [Hospice staff] to see the resident tonight. Surveyor noted, RN-F initiated CPR without checking for R1's code status. R1's Hospice nurse note with a visit date of [DATE], documents, in part: Call received through triage that patient had become unresponsive, become pulseless, and CPR was initiated despite DNR status . [Patient] was experiencing a significant change in [R1's] level of pain. [R1] was rating pain at 7 out of 10 to R1's chest wall and ribs. [R1] stated that it was painful to take a deep breath . Morphine (a narcotic pain medication) and Lorazepam (an anti-anxiety medication) orders obtained . Surveyor noted R1 had a pain rating of 7 out of 10 and is now requiring a narcotic pain medication to control pain. R1's MD orders entered on [DATE] include the following: -Morphine Sulfate oral solution 100 milligrams(mg)/5 milliliters(ml). Give 0.25 ml by mouth every 2 hours as needed for pain; pain-moderate; pain-severe. -Lorazepam oral tablet 0.5mg by mouth every 4 hours as needed for anxiety, agitation or restlessness. -Complete and document a skin assessment every shift for 3 days. Every shift check skin for bruising injury. R1's progress note dated [DATE] at 12:03 AM documents in part: . CPR was done to [R1] on prior shift, [R1] [complains of] pain to chest/ribs 10 [out of] 10. R1's progress note dated [DATE] at 1:50 AM documents in part: . The current status is resident [complains of] pain ,d+[DATE] to [R1's] chest. [As needed] Morphine . given . Surveyor noted R1 had two pain assessments completed after R1 received compressions and in both assessments, R1 rated pain 10 out of 10. R1's progress note dated [DATE] at 3:18 AM documents, in part: . Resident [complains of] pain to chest/ribs. R1's progress note dated [DATE] at 5:03 AM documents, in part: [R1] continues to [complain of] pain to [R1's] chest/ribs, sleeping with hands folded on her breasts. Noted increased pain with movement. [As needed medications] utilized and effective. R1's progress note dated [DATE] at 10:15 AM, R1's PA documents in part: . Updated by staff that . [R1] was found to be unresponsive with no pulse and deterioration in respirations. CPR was initiated and [R1] received 16 compressions, which [R1] was revived following . Code status confirmed as DNR and Director of Nursing reports education will be carried out to staff as well as continued close monitoring of [R1] ongoing. [R1] currently states that [R1] has a headache and [R1's] back is sore. [R1] is requesting medication for pain . R1's progress note dated [DATE] at 11:55 AM, documents in part: . [R1] complaining of pain and discomfort, given [as needed] Morphine . R1's progress note dated [DATE] at 3:11 PM, documents in part: The current status is [R1] complained of pain of back and chest . R1's progress note dated [DATE] at 1:40 AM, documents in part: . Denies pain at rest. Facial grimacing and moaning out present with repositioning. [As needed Morphine] given prior to cares . R1's progress note dated [DATE] at 9:27 AM, documents in part: Resident is on follow up for chest compressions performed causing some pain and discomfort. R1's progress note dated [DATE] at 11:09 AM, documents in part: Writer reached to [Nurse Practitioner] and hospice for new orders for STAT [chest x-ray] post injury per family request and possible scheduled pain meds for pain medication. Resident has received [as needed Morphine every 2] hours since ,d+[DATE]. Resident in extreme pain and mobility has decreased . Surveyor noted the facility documented that R1 is in extreme pain. R1's progress note dated [DATE] at 4:12 PM documents in part: X-ray results negative for fracture. R1's progress note dated [DATE] at 5:58 AM documents: Pain to chest/ribs. R1's progress note dated [DATE] at 11:15 AM, R1's PA documents in part: . Updated by staff that family requested chest x-ray following recent compressions due to resulting pain. Chest x-ray results are reported as negative. Continues on hospice for comfort measures. R1's MD order entered on [DATE] documents: Morphine Sulfate oral solution 20mg/5ml. Give 0.5ml by mouth every 2 hours for pain. Surveyor noted that R1's Morphine was changed to a scheduled medication to be given every 2 hours instead of every 2 hours as needed. R1's progress note dated [DATE] at 1:42 AM documents in part: Resident is on follow up for monitoring [status post] CPR done on [DATE] PM shift. The current status is [vital signs stable]. Scheduled Morphine given as ordered. Noted [positive] pain indicators continue . Surveyor noted that R1's scheduled medications were discontinued on [DATE] at 9:38 PM. R1 continued to receive scheduled Morphine. Surveyor noted R1's health continued to decline. R1's progress note dated [DATE] at 8:18 AM documents: resident is actively dying. Surveyor reviewed R1's Resident Controlled Substance records for Morphine Sulfate (Concentrate) Oral Solution. On [DATE], Licensed Practical Nurse (LPN)-M documented: Date: [DATE], Time: 1600, Amount Given: 0.25 . On [DATE], LPN-M documented: Date: [DATE], Time: 1800, Amount Given: 0.25 . On [DATE], LPN-M documented: Date: [DATE], Time: 2000, Amount Given: 0.25 . On [DATE], LPN-M documented: Date: [DATE], Time: 2200, Amount Given: 0.25 . Surveyor noted on [DATE], on the evening shift, that R1 did not receive the correct dosage of scheduled morphine for 4 consecutive doses. Surveyor noted R1 was given 0.25ml instead of 0.5ml of Morphine for these 4 doses. Facility staff administered half of the prescribed dosage. (Cross-reference F760). On [DATE] at 12:00 PM, Surveyor requested to speak with LPN-M to conduct an interview. Director of Nursing (DON)-B informed Surveyor that LPN-M was no longer employed at facility. R1's progress note dated [DATE] at 6:40 documents in part: [R1] passed away at approximately 6:30 AM . On [DATE] at 12:32 PM, Surveyor interviewed RN-F who gave R1 compressions on [DATE]. RN-F stated that RN-F was alerted by a CNA that R1 was unresponsive. RN-F stated that when RN-F entered R1's room, RN-F noticed that R1 was in distress. RN-F stated that R1 had a pulse at that time. RN-F sent the CNA to retrieve oxygen. RN-F stated that RN-F did not have a phone or any other help, so RN-F had to determine if R1 was a DNR or not. RN-F stated in order to find that information, RN-F would need to leave the room and go to a computer. RN-F stated that R1 was experiencing a rapid decline and RN-F had to decide to follow protocol or stay with R1 and work with the information that RN-F had at hand. RN-F stated RN-F could not establish DNR status, so RN-F used RN-F's nursing judgement and decided to start CPR. RN-F stated that R1 was eased to the floor and R1 did not have a pulse. RN-F stated RN-F completed between 12 and 15 compressions with a good response. Surveyor asked if R1 was wearing a DNR bracelet. RN-F stated that RN-F did not notice a bracelet before administering compressions but was alerted to the bracelet after the fact. RN-F stated that it was unfortunate that RN-F did not see the bracelet prior to administering compressions. Surveyor asked if RN-F had received training on codes, CPR, or how to get help in determining code status. RN-F stated that RN-F is CPR certified but does not recall receiving training from the facility on codes. RN-F stated that there is not a process for calling a code. RN-F stated that there is not a portable phone that you can call other nurses. RN-F stated that the only way to determine code status is to leave the resident alone and RN-F did not feel comfortable leaving R1 since R1 was experiencing a rapid change of condition. Surveyor asked if R1 was in pain after the incident. RN-F stated that R1 complained of chest pain with movement after the compressions were given. On [DATE] at 1:14 PM, Surveyor interviewed CNA-I. CNA-I stated that CNA-I stated that CNA-I was doing rounds on [DATE] when CNA-I passed R1's room. CNA-I stated that CNA-I saw R1 on the floor and the nurse (RN-F) was assessing R1. CNA-I stated that RN-F told CNA-I to get a sling to help get R1 off the floor. CNA-I indicated that CNA-I did not see RN-F giving compressions to R1. CNA-I stated that R1 was responsive by the time CNA-I passed R1's room. Surveyor asked if R1 complained of any pain after the incident on [DATE]. CNA-I stated that R1 complained of chest pain. Surveyor asked how long the pain lasted. CNA-I stated that the pain lasted until R1 passed away. CNA-I stated that R1 would say that it hurts with any cares. On [DATE] at 1:25 PM, Surveyor interviewed Anonymous staff-G. Anonymous staff-G stated that Anonymous staff-G was working on a different unit the night of [DATE]. Anonymous staff-G stated that another staff member alerted Anonymous staff-G that a resident was unresponsive. Anonymous staff-G rushed to R1's room and noted that R1 was on the floor and RN-F was with R1. Anonymous staff-G stated that Anonymous staff-G saw R1's DNR bracelet on R1's wrist. Anonymous staff-G stated that Anonymous staff-G helped with whatever was needed and then returned to Anonymous staff-G's unit. Surveyor asked if R1 complained of pain. Anonymous staff-G stated that R1 was complaining of pain in R1's chest and back. Surveyor asked where a staff member would find code/DNR status. Anonymous staff-G stated that it is in the electronic medical record and R1 had it on R1's wrist. Anonymous staff stated R1 was only to have comfort measures in place and should not have received compressions. Anonymous staff-G stated, The whole thing was crazy. On [DATE] at 2:04 PM, Surveyor interviewed NHA-A and DON-B. NHA-A stated that the facility identified the concerns that RN-F gave compressions to R1 against R1's wishes. NHA-A stated the facility has educated current staff members on checking for code status before starting CPR, the CPR policy, and the Change of Condition policy. The facility completed audits on all residents' code status to ensure the correct documents are in place, the orders are in the medical record, and the code status appears in the ribbon within the electronic medical record. In addition, NHA-A stated that the facility did a care plan audit that was completed today to assure that advanced directives were correct in all residents' care plans. The facility has been completing Code drills because of this incident. DON-B stated that they are completing one minute management, where management will interview random staff to assure, they are aware of the process and retaining the education that is being completed. NHA-A stated that RN-F was pulled from the floor and suspended after the incident. Before returning to work RN-F will receive further education. Surveyor asked if wearing a DNR bracelet is part of a facility policy. DON-B stated that they do not require residents to wear a DNR bracelet. DON-B stated that a resident can choose to wear a bracelet, and the facility will add an intervention to the resident's care plan. Surveyor asked if R1 was wearing a DNR bracelet. DON-B stated that DON-B saw the DNR bracelet on R1 on [DATE]. Surveyor asked if the bracelet was an intervention on R1's care plan. DON-B stated that DON-B would look to see if the DNR bracelet was in R1's care plan. On [DATE] at 2:55 PM, NHA-A returned to Surveyor with a past non-compliance folder. NHA-A indicated again that the facility identified the concern of CPR being completed on a resident who is a DNR. NHA-A stated that the facility recognized that no resident would want CPR if it were not following their wishes. The facility wanted to focus on the concern so that it does not happen again. On [DATE] at 9:45 AM, Surveyor interviewed NHA-A and DON-B. Surveyor asked if RN-F received training on the code process. NHA-A and DON-B stated that RN-F is CPR certified. NHA-A stated that the topic is covered in new hire orientation and is briefly gone over during nurse-to-nurse training in orientation. NHA-A stated that the Maintenance Director will take new employees on a facility tour to ensure that new staff know where the code carts and AEDs are located. NHA-A confirmed that RN-F did complete new hire orientation. Surveyor asked what the expectation is for staff who are alone, and a resident goes unresponsive. DON-B stated that staff should yell for help, if unable to get help, the staff member should go to computer to check for code status. DON-B stated that code status is also covered in nurse-to-nurse report at the beginning of the staff's shift. Surveyor asked if the DNR bracelet being worn by R1 was in R1's care plan. DON-B stated that it is not in the care plan. (Cross-reference F678). NHA-A provided a power point slide from the new hire orientation presentation. Surveyor reviewed the facility's new hire orientation slide titled, CPR. The slide contains the following bullet points: Licensed staff must maintain current CPR certification through CPR training that includes hands-on practice and in-person skills assessment . Center clinicians are certified in [Basic life support]-[CPR] through programs approved . Each center requires the placement and use of an [AED]. Discuss and show where AED is located. Center staff must participate in Code Drills throughout the year. Surveyor noted the specifics and step by step instructions of a code are not included on the CPR slide presented at new-hire orientation. Surveyor noted that where to find advanced directives/DNR status is not included on the CPR slide. On [DATE] at 10:09 AM, Surveyor informed NHA-A, DON-B, Regional Nurse Consultant-C, and VP-D of the following serious concerns: R1's wishes were not followed and despite multiple areas of DNR documentation, R1 was still administered CPR compressions. R1 complained of ,d+[DATE] pain and the facility documented R1's pain as extreme. R1 was wearing a DNR bracelet that was not included in R1's care plan. RN-F indicated that RN-F did not receive training for codes and stated that there is not a facility process for calling a code. According to Five Possible Side Effects of CPR, You Should Know, The methods used in Cardiopulmonary Resuscitation can have adverse effects such as the following: 1. Aspiration & Vomiting: The most frequent occurrence during CPR, vomiting can present a danger to the cardiac arrest victim. Since the cardiac arrest victim is unconscious, he cannot clear the vomit from his mouth. If not cleared, the victim is likely to aspirate (inhale) it into his lungs, blocking the airway and leading to possible infection. 2. Broken Ribs Bone: A rib fracture is the most common complication of CPR because the force of chest compressions is likely to break ribs. Other chest injury related to chest compressions are sternal fracture and other uncommon complication like lung contusion, pneumothorax, and haemothorax. In the elderly, this is significantly more common due to the brittleness and weakness of their bones. Broken ribs present danger because a broken rib could puncture or lacerate (cut) a lung, the spleen, or the liver. They are also very painful. The frequency of rib fractures associated with out of hospital cardiopulmonary resuscitation is underestimated by conventional chest x-ray. 3. Internal Brain Injuries: Since CPR leaves the brain receiving 5% less oxygen than normal, brain damage is possible. Brain damage occurs within 4 to 6 minutes from the time the brain is deprived of oxygen, and after 10 minutes, it definitely occurs. This can lead to long-term health complications. 4. Abdominal Distension: As a result of air being forced into the lungs, the abdomen of the cardiac arrest patient usually becomes distended (bloated) and full of air during CPR, leading to compression of the lungs (making ventilation more difficult) and an increased chance of vomiting. 5. Aspiration Pneumonia: The result of vomit and foreign objects (like a person's own teeth) being inhaled into the lungs can lead to aspiration pneumonia. This can be very dangerous to a victim's health and could complicate recovery, or even be fatal, even if the cardiac arrest victim does survive CPR. Overall, all of these side effects mean that if a person survives CPR, their long-term health could suffer and be alive. But their overall health and quality of life may be significantly affected. Additionally, the psychological ramifications of a near-death experience can substantially affect a survivor, leading to anxiety, stress, and depression, among other psychological conditions. https://www.mycprcertificationonline.com/blog/five-possible-cpr-side-effects-you-should-know/ The facility's failure to honor R1's DNR wishes which led to facility staff completing chest compressions that caused R1 extreme pain, created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on [DATE]. The immediate jeopardy was removed on [DATE] when the facility implemented the following action plan: Action Plan to prevent Recurrence: [Primary Care Physician], Hospice MD, and POA notified. Hospice in person visit. Skin eval. Pain eval. [Change of Condition] evaluation with [vital signs], Nursing evaluation. Morphine as needed ordered. Identification of other potentially affected residents and action: Current facility residents have the potential to be affected. Current residents will be reviewed for code status orders/documentation. Code status verified on PCC ribbon banner. CP plans are updated appropriately. Systemic measures to prevent reoccurrence: Reeducation to licensed nurses on need to verify code status prior to initiating CPR. If DNR-do not initiate CPR. If full code, initiate CPR and activate 911. Performance effectiveness and monitoring: DON/designee will conduct Code drills. Will be completed on each shift weekly for 4 weeks. Interviews of 5 nurses per week will be conducted x 4 weeks on various shift using case studies and what if scenarios to validate understanding and expectations required during a code situation. Scenarios will include situations where [resident] is a DNR, and others will be scenario where resident is a full code. Results of the above audits will be brought to the [Quality Assurance and Performance Improvement (QAPI)] . QAPI committee met on [DATE] to review above plan. Dated ,d+[DATE]-Ongoing.

Based on observations, interview and record review, the facility failed to have a policy and procedure in place to ensure the code status of residents, as indicated in their advanced directives, was followed. This affected 1 (R1) of 1 residents reviewed for Cardiopulmonary Resuscitation. The facility's phone paging system, which is used to alert all staff of a code blue, was observed not working during survey. The facility's portable phones, which can also be used to alert all staff of a code blue, were not functional on all the units within the facility. The facility's overhead speaker system has not been functional for years. This deficient practice has the potential to effect 27 out of 82 residents who have designated to have full code status (designated to receive cardiopulmonary resuscitation [CPR]) in the facility. *The facility does not have a Code Blue policy and procedure. *R1 has a signed State DNR form, and an active MD order documenting DNR. On [DATE], R1 became unresponsive and was pulseless. Facility staff did not check R1's advanced directives prior to starting Cardiopulmonary Resuscitation (CPR) compressions on R1. R1 received compressions against R1's wishes. *The facility has a phone paging system which is used to call a code blue. Surveyor observed the phone paging system not working while on Survey. *The facility has portable phones that are to be always carried by nursing staff on each of the 4 units at the facility. These phones can also be used to call a code blue if the nurse is in a resident's room alone. While on survey, 2 units (100-unit and 300-unit) had a functional portable phone that could be used to alert and send a code blue page. The 400-unit's phone was just replaced and charging at the time of survey. The 200-unit's phone was missing. Staff expressed concern that reception for the portable phones is poor and unreliable. *The facility's overhead paging system has not been functional for years. Findings include: *On [DATE] at 7:20 AM, Director of Nursing (DON)-B informed Surveyor that the facility does not have a code blue policy. DON-B provided Surveyor with the facility CPR policy and CPR Drill document that is used to direct staff on code procedure. Surveyor was also provided a document used to help aid staff during a CPR drill. This document is titled, Code Blue response and responsibilities. Facility Policy & Procedure: The facility policy titled, Cardiopulmonary Resuscitation (CPR) with a review date of [DATE], documents, in part: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR) . The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order; and c. If the resident does not show obvious signs of clinical death . CPR certified staff will be available at all times. The undated facility document titled, CPR DRILL documents, in part: Initial Responder: Non-nurse: check for responsiveness. Call for help, or I need a nurse STAT. Nurse: Verify that the scene is safe . Check responsiveness. Check for breathing/pulse for 10 seconds . Check airway . Was the chart checked for code status . Did the first responder call a code blue with location or delegate this task? (This should be an overhead page, may use phone in room if applicable.) Was the emergency response system activated immediately/911 called? . (If alone-discussion [regarding]: how to call 911 (use room phone, cell phone, provide initial 2 rounds of CPR then run to call for help, etc). Was the crash cart and [Automated External Defibrillator (AED)] brought to the scene . Was CPR initiated per code status? (Did the chart read full code or DNR) . The undated facility document titled, Code Blue Response and Responsibilities documents, in part: You are the staff member that enters the room and finds a resident unresponsive: What do you do? -As a CNA or non-nursing staff . Call for help and alert nurse immediately. -As the nurse . 1. Check safety of the scene. 2. Check resident responsiveness, pulse, breathing for 10 seconds. 3. Open airway if necessary. If no pulse or respirations: Initiate emergency response system: Yell for help from staff, may pull call light, call out CODE BLUE loudly. When other staff respond, start to delegate. You are in charge of the code. Delegate to confirm code status, bring crash cart and AED immediately, activate emergency response 911 immediately, overhead page CODE BLUE (if phone in room may use phone to page and call 911). (If no response from staff/alone, may leave resident and call 911, check code status, call code, retrieve AED) . Surveyor noted the CPR Drill document, and the Code Blue Response and Responsibilities document indicates that code status should be checked before compressions are started. Surveyor noted the documents state that an overhead page should be used to call a code blue. Surveyor noted that in the CPR Drill document, if a staff member is alone, the staff member should call 911 from the room phone/cell phone, provide initial 2 rounds of CPR then run to call for help. Surveyor noted that in the Code Blue Response and Responsibilities document, if a staff member is alone, the staff member may leave the resident and call 911, check code status, call code and retrieve AED. Surveyor noted a discrepancy in the facility documents as to what staff should do if they are alone when a resident is unresponsive. On [DATE] at 1:38 PM, NHA-A wanted to provide clarity to the Surveyor regarding the facility document titled, Code Blue Response and Responsibilities. NHA-A indicated that education was recently completed regarding codes and code status. The facility CPR policy and Change of Condition Policy were used as the official education. The Code Blue Response and Responsibilities document was not used to educate staff, it was an education piece. NHA-A stated that the document is used as a guideline and helps to ask the probing questions. NHA-A confirmed that the facility does not have a policy regarding code blue. R1 example: *R1 was admitted to the facility on [DATE] with diagnosis that include Cerebrovascular disease, Dementia, Hypertension, Atrial Fibrillation, Pacemaker, and Type 2 Diabetes. R1's Significant change Minimum Data Set (MDS) assessment dated [DATE] documents that R1 severely cognitively impaired and requires partial to moderate assist for toileting, mobility and transfer. R1's has an activated Power of Attorney (POA). Surveyor located multiple signed State DNR forms in R1's electronic medical record. The most recent State DNR form, signed by R1's POA is dated [DATE]. R1's active MD order dated [DATE] documents: DNR. R1's Advanced Directive Care plan initiated [DATE] documents: Resident's advanced directive is: DNR. Goal: Resident's wishes will be honored. Pertinent Interventions include: Follow advanced directive per MD orders. Refer to Md orders for code status. Follow facility protocol for identification of code status . Surveyor noted R1 was started on hospice services on [DATE] with the goal of comfort measures. R1's Hospice Care plan dated [DATE], documents the following intervention: Honor advanced directives. R1's progress note entered by Registered Nurse (RN)- F, dated [DATE] at 6:45 PM documents, in part: : Nurse called to resident's room by CNA who stated, Resident is not responding. CNA reports that [R1] was providing [bedtime] care when the resident became unresponsive. Upon entering the room and assessment, resident is slumped and limp in the wheelchair; unresponsive to verbal stimulation. Skin noted as cold and pale. Lips are blue-tinged and labored mouth breathing is noted. A weak pulse of 40 is noted to the internal carotid artery. Breathing is labored at 8 per minute. Vigorous sternal chest rub applied; ineffective. Jaw-chin [lift] applied; ineffective. CNA sent to get oxygen line and tank. Resident's condition declining quickly. Chest rise and fall is absent. Intermittent shallow breaths noted. Resident assessed for pulse to radial and the carotid artery - pulse is absent. This nurse is unable to ascertain the resident's code status at this time and situation. Resident lowered to the floor. Upon assessment, pulse is still absent - CPR initiated. CPR effective. Oxygen at 2 [liters per minute] provided for support. [Vital signs] [temperature] 97.3, [pulse] 79, [blood pressure] ,d+[DATE], [respiratory rate] 20, [Oxygen saturation] 98%, [Blood sugar] 331. Surveyor noted, RN-F initiated CPR without checking for R1's code status. On [DATE] at 12:32 PM, Surveyor interviewed RN-F who gave R1 compressions on [DATE]. RN-F stated that RN-F was alerted by a CNA that R1 was unresponsive. RN-F stated that when RN-F entered R1's room, RN-F noticed that R1 was in distress. RN-F stated that R1 had a pulse at that time. RN-F sent the CNA to retrieve oxygen. RN-F stated that RN-F did not have a phone or any other help, so RN-F had to determine if R1 was a DNR or not. RN-F stated in order to find that information, RN-F would need to leave the room and go to a computer. RN-F stated that R1 was experiencing a rapid decline and RN-F had to decide to follow protocol or stay with R1 and work with the information that RN-F had at hand. RN-F stated RN-F could not establish DNR status, so RN-F used RN-F's nursing judgement and decided to start CPR. RN-F stated that R1 was eased to the floor and R1 did not have a pulse. RN-F stated RN-F completed between 12 and 15 compressions with a good response. Surveyor asked if R1 was wearing a DNR bracelet. RN-F stated that RN-F did not notice a bracelet before administering compressions but was alerted to the bracelet after the fact. RN-F stated that it was unfortunate that RN-F did not see the bracelet prior to administering compressions. Surveyor asked if RN-F had received training on codes, CPR or how to get help in determining code status. RN-F stated that RN-F is CPR certified but does not recall receiving training from the facility on codes. RN-F stated that there is not a process for calling a code. RN-F stated that there is not a portable phone that you can call other nurses. RN-F stated that the only way to determine code status is to leave the resident alone and RN-F did not feel comfortable leaving R1 since R1 was experiencing a rapid change of condition. Surveyor asked if R1 was in pain after the incident. RN-F stated that R1 complained of chest pain with movement after the compressions were given. On [DATE] at 11:40 AM, Surveyor interviewed LPN-E. LPN-E stated that LPN-E knew R1 very well. Surveyor asked what R1's advanced directive status was. LPN-E stated that R1 was a DNR. LPN-E stated that LPN-E knew all her resident's code status. LPN-E stated that R1 wore a DNR bracelet on R1's left wrist all the time. Surveyor asked where a staff member would look for advanced directives/code status. LPN-E stated that LPN-E would look in the electronic medical record. LPN-E stated that code status is seen when you open a resident's chart. On [DATE] at 2:04 PM, Surveyor interviewed NHA-A and DON-B. NHA-A stated that the facility identified the concerns that RN-F gave compressions to R1 against R1's wishes. NHA-A stated the facility has educated current staff members on checking for code status before starting CPR, the CPR policy and the Change of condition policy. The facility completed audits on all resident's code status to ensure the correct documents are in place, the orders are in the medical record and the code status appears in the ribbon within the electronic medical record. In addition, NHA-A stated that the facility did a care plan audit that was completed today to assure that advanced directives were correct in all resident's care plans. The facility has been completing Code drills because of this incident. DON-B stated that they are completing one minute management, where management will interview random staff to assure, they are aware of the process and retain the education that is being completed. Surveyor asked if wearing a DNR bracelet is part of a facility policy. DON-B stated that they do not require residents to wear a DNR bracelet. DON-B stated that a resident can choose to wear a bracelet, and the facility will add an intervention to the resident's care plan. Surveyor asked if R1 was wearing a DNR bracelet. DON-B stated that DON-B saw the DNR bracelet on R1 on [DATE]. Surveyor asked if the bracelet was an intervention on R1's care plan. DON-B stated that DON-B would look to see if the DNR bracelet was in R1's care plan. On [DATE] at 9:45 AM, Surveyor interviewed NHA-A and DON-B. Surveyor asked if RN-F received training on the code process. NHA-A and DON-B stated that RN-F is CPR certified. NHA-A stated that the topic is covered in new hire orientation and is briefly gone over during nurse-to-nurse training in orientation. NHA-A stated that the Maintenance Director will take new employees on a facility tour to ensure that new staff know where the code carts and AEDs are located. NHA-A confirmed that RN-F did complete new hire orientation. Surveyor asked what the expectation is for staff who are alone, and a resident goes unresponsive. DON-B stated that staff should yell for help, if unable to get help, the staff member should go to a computer to check for code status. DON-B stated that code status is also covered in nurse-to-nurse report at the beginning of the staff's shift. Surveyor asked if the DNR bracelet being worn by R1 was in R1's care plan. DON-B stated that it is not in the care plan. *PHONE PAGING system and PORTABLE PHONE interviews and observations: On [DATE] at 9:45 AM, Surveyor interviewed NHA-A and DON-B. Surveyor asked how the phone paging system works. NHA-a and DON-B indicated that a staff member can go to phone at the nurse's station or on a portable phone, dial 5000 and say CODE BLUE. The page will be transmitted to all 4 of the nurse's station phones within the facility. NHA-A stated that this is not an overhead page, that this page only goes to the nurse's station phones. NHA-A and DON-B stated that the page can be heard by any staff on the unit. NHA-A stated that the portable phones available on each unit and are kept on the nurse's medication cart. NHA-A stated that the phones are available for staff to carry, and they should be carrying them. NHA-A stated that it is expected that nurses carry the portable phones especially on the weekends. Surveyor asked if there was a reason that the portable phones are not mentioned on any of the documents provided (CPR policy, CODE Drill document and the Code blue response and responsibilities). NHA-A stated it is not on the Code blue response and responsibilities, but staff should be aware of the expectation to carry the portable phone. DON-B stated that education had recently been completed to direct staff to clarify the expectations that staff should make sure that the portable phones are always carried. On [DATE] at 10:15 AM, Surveyor interviewed LPN-E. Surveyor asked LPN-E if each unit has a portable phone for nursing staff usage. LPN-E responded that they are aware of a portable phone on the 300 unit but that they do not utilize the portable phone. LPN-E elaborated that the portable phone on the 300 unit doesn't work well and that the portable phone reception is poor and unreliable. LPN-E told Surveyor that they rely on the telephone at the 300-nursing station desk to communicate with staff, doctors or resident family members. LPN-E added that they keep their medication cart close to the 300-nursing station desk so that they can hear the phone and readily access it. On [DATE] at 12:25 PM, Surveyor asked NHA-A and DON-B if they were aware of staff stating that reception is poor and unreliable. NHA-A and DON-B stated that they had never heard that. On [DATE] at 12:30 PM, Surveyor asked for a demonstration of the phone paging system. DON-B walked Surveyor to the 400 unit. DON-B walked down the hallway to the 300-unit nurse's station to test the paging system. Surveyor did not hear a page come through the phone system on the 400-unit. DON-B returned to Surveyor at 12:32 PM. Surveyor informed DON-B that a page was not heard. DON-B stated that DON-B did not think that DON-B was doing it right. DON-B walked back down the hallway to the 300-unit nurse's station. Surveyor did not hear a page come through on the 400-unit. DON-B returned to the 400-unit at 12:34 PM. Surveyor informed DON-B a page was not heard. DON-B stated that everyone could hear throughout the 3 other units and DON-B did not know why the page was not coming through to the 400-unit. DON-B adjusted the volume on the 400-unit phone and turned the volume up. DON-B walked back down the hallway to the 300-unit at 12:35 PM. Surveyor did not hear a page come through on the 400-unit. At, 12:36 PM, DON-B returned to the 400-unit. DON-B asked if the page was effective. Surveyor informed DON-B that a page was not heard. DON-B informed Surveyor that DON-B was going to send a page through the 400-unit phone. DON-B picked up the 400-unit phone, dialed 5000 and stated, test ., test ., test . DON-B and Surveyor walked down the hallway to the 300-unit. Surveyor noted 2 staff members sitting at the nurse's station. At 12:37 PM, DON-B asked the two staff members at the desk if the page that was just sent was heard. Both staff members stated, No. At 12:38 PM, DON-B stated that the staff member at the front desk was going to send a test page to all unit phones. Surveyor did not hear a page come through the 300-unit. NHA-A walked toward the 300-unit and asked if a page was heard. DON-B stated No. DON-B spoke to the front desk staff by telephone and asked if a page was sent. Surveyor heard that a page was sent from the front desk staff. DON-B stated that a code drill was conducted yesterday, and the phone paging system was working fine. DON-B indicated that DON-B was confident that this would be easy to demonstrate. DON-B mentioned that there could be a do not disturb function on the phone and could contribute to not hearing the testing page. DON-B examined the 300-unit nurse's station phone to see if the do not disturb function was on. At 12:42, Maintenance director (MD)-L arrived on the 300-unit to help trouble shoot. DON-B restarted the 300-unit phone. DON-B stated that DON-B was going to go to a different unit to see if the page is going through. Surveyor stayed in the 300-unit waiting for a test page to come through. At 12:53 PM, Surveyor heard the test page come through the 300-unit phone. Surveyor noted that the observation of the phone paging system was started at 12:30 PM and the first page that Surveyor heard was at 12:53 PM, 23 minutes later. Surveyor noted that volume was adjusted on phones. Surveyor noted that a phone was restarted. Surveyor noted that DON-B mentioned a do not disturb function on the phones. Surveyor noted that multiple things could play a part in a page going through or not going through the phone system. On [DATE] at 12:55 PM, Surveyor asked that DON-B demonstrate how a portable phone page will come through to the nurse's unit phones. DON-B borrowed LPN-E's portable phone and sent a test page. Surveyor heard test ., test ., test Come through the unit phone on the 300-unit. Surveyor asked that DON-B go to the end of the hallway and send a page. At 12:56 PM, DON-B went to the end of the hallway. Surveyor heard DON-B's voice stating test ., test ., test but did not hear the page come through to the unit phone. Assistant Director of Nursing (ADON)-K was standing at the 300-unit nurse's station and stated, check the signal. DON-B returned to Surveyor and stated I think I did it wrong. DON-B then went back down the hallway and sent another test page which was heard by Surveyor. Surveyor noted that either there was a signal problem or DON-B did not send the page the same way DON-B had sent a page to be heard at the 300-unit nurse's station a minute prior. On [DATE] at 12:50 PM, ADON-B provided the portable phone education that was completed with staff. ADON-B stated that education was completed on [DATE] through [DATE] and covered that portable phones are to be carried by the nurses. Surveyor asked if every unit had a portable phone. ADON-B stated that the 100-unit and the 300-unit have phones. The 400-unit just got a portable phone today and it is being charged. ADON-B stated the 200-unit does not have a portable phone. ADON-B indicated that the 100-unit and 200-unit were sharing a phone at this time. Surveyor noted that if a code were to take place on the 200 or 400 unit at this moment, the nurse would not have the option of a portable phone to call a code. Surveyor reviewed the education provided about portable phones. The training log/In-service sheet is titled, lunch and learn dated [DATE]. The education documents, in part: . Phone use: Portable phones are 100 and 300 unit. Nurses, please carry the phone and respond to calls to ensure we are responding to [Nurse Practitioner/Primary Care Physician] and family calls. No personal phones are to be used . Surveyor noted that the education does not mention that these portable phones could be used to call a code. On [DATE] at 1:38 PM, Surveyor interviewed NHA-A. NHA-A informed Surveyor that the facility completed a factory reset on the phone system and it is up and running now. Surveyor asked about the portable phones not being available on all units. NHA-A stated the facility now has 3 phones that are working. NHA-A stated that the 200-unit had a phone once upon a time. NHA-A stated that they are looking for the 200-unit phone. NHA-A indicated that the 200-unit is a short hallway and is close enough to the 100-unit in the case of an emergency. *OVERHEAD paging system interviews: On [DATE] at 12:42 PM, Surveyor was informed by MD-L that the facility's main overhead paging system is not working. On [DATE] at 1:00 PM, Surveyor interviewed MD-L. Surveyor asked how long the overhead paging system has not worked. MD-L stated, I don't know. Surveyor asked if it had been down days, weeks, months, or years. MD-L stated months. MD-L stated that a while ago MD-L was conducting a fire drill and that is when MD-L noted that the overhead paging system no longer worked. MD-L stated that MD-L arranged for someone to come look at the overhead paging system on Friday of this week. On [DATE] at 1:38 PM, NHA-A informed Surveyor that the old system for overhead paging has not worked for a long time. NHA-A stated it was an intercom system, but it is not functional and is not part of the process for calling a code. NHA-A indicated that the phone system is to be used for calling a code. NHA-A stated that the overhead intercom system is not part of the code blue process outlined by the facility. On [DATE] at 2:36 PM, NHA-A stated that the overhead paging system has not worked for years. Surveyor noted that the facility has an additional method of an overhead page that could be heard from all areas of the building, but the overhead intercom paging system does not currently work. Surveyor noted that an overhead intercom paging system would not require volume adjustments and would not have a do not disturb function like the phone paging system. On [DATE] at 2:36 PM, NHA-A, DON-B, Regional Nurse Consultant-C and [NAME] President of Success-D were informed of the following concerns: The facility does not have a Code Blue policy to direct staff step-by-step in the case of a resident going unresponsive. R1 was given CPR compressions against R1's wishes. The phone paging system, which is used to call a code, was observed to not be working properly. Surveyor started observation at 12:30 PM and the first test page was not heard until 12:53 PM. The portable phones, which can also be used to call a code, were not available on all 4 units of the facility. Staff member reported the portable phone reception is poor and unreliable. The overhead paging system is not functional and has not been functional for years.

Based on interview and record review the Facility did not ensure 1 (R1) of 4 residents were free from significant medication errors. *On [DATE], R1 was prescribed scheduled morphine due to severe chest and back pain. On [DATE], R1 was not administered the full dosage of their scheduled morphine for four consecutive opportunities. Findings include: R1 was admitted to the facility on [DATE] with diagnoses that include Cerebrovascular disease, Dementia, Hypertension, Atrial Fibrillation, Pacemaker, and Type 2 Diabetes. R1's Significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documents that R1 is severely cognitively impaired and requires partial to moderate assist for toileting, mobility and transfer. Surveyor reviewed R1's closed medical record including progress notes, Electronic Medication Administration Record (EMAR), physicians orders and comprehensive care plans. Surveyor noted R1 was started on hospice services on [DATE] with the goal of comfort measures due to multiple non-responsive episodes and overall decline. R1's Advanced Directive Care plan initiated [DATE] documents: Resident's advanced directive is: DNR. Goal: Resident's wishes will be honored. Pertinent Interventions include: Follow advanced directive per MD orders. Refer to Md orders for code status. Follow facility protocol for identification of code status . R1's Hospice Care plan dated [DATE], documented: Honor advanced directives. R1's progress note entered by Registered Nurse (RN)- F, dated [DATE] at 6:45 PM documents: .Nurse called to resident's room by CNA who stated, Resident is not responding. CNA reports that [R1] was providing [bedtime] care when the resident became unresponsive. Upon entering the room and assessment, resident is slumped and limp in the wheelchair; unresponsive to verbal stimulation. Skin noted as cold and pale. Lips are blue-tinged and labored mouth breathing is noted. A weak pulse of 40 is noted to the internal carotid artery. Breathing is labored at 8 per minute. Vigorous sternal chest rub applied; ineffective. Jaw-chin [lift] applied; ineffective. CNA sent to get oxygen line and tank. Resident's condition declining quickly. Chest rise and fall is absent. Intermittent shallow breaths noted. Resident assessed for pulse to radial and the carotid artery - pulse is absent. This nurse is unable to ascertain the resident's code status at this time and situation. Resident lowered to the floor. Upon assessment, pulse is still absent - CPR (cardiopulmonary resuscitation) initiated. CPR effective. Oxygen at 2 [liters per minute] provided for support. [Vital signs] [temperature] 97.3, [pulse] 79, [blood pressure] ,d+[DATE], [respiratory rate] 20, [Oxygen saturation] 98%, [Blood sugar] 331. Surveyor noted, RN-F initiated CPR without checking for R1's code status. R1 was not to receive any life saving measures due to DNR status and wish for no hospitalization s. (Cross-reference F578). Surveyor reviewed R1's Pain level scale scorings from [DATE]-[DATE]. On [DATE] Evening shift, Surveyor noted R1's Pain level score to be ,d+[DATE]. On [DATE] Night shift, Surveyor noted R1's Pain level score to be ,d+[DATE]. On [DATE] Evening shift, Surveyor noted R1's Pain level score to be ,d+[DATE]. On [DATE] Night shift, Surveyor noted R1's Pain level score to be ,d+[DATE]. On [DATE] day shift, Surveyor noted R1's Pain level score to be ,d+[DATE]. On [DATE] Evening shift, Surveyor noted R1's Pain level score to be ,d+[DATE]. On [DATE] Night shift, Surveyor noted R1's Pain level score to be ,d+[DATE]. On [DATE] day shift, Surveyor noted R1's Pain level score to be ,d+[DATE]. On [DATE] Night shift, Surveyor noted R1's Pain level score to be ,d+[DATE]. Surveyor reviewed R1's Physician orders. On [DATE] an order was obtained for Morphine Sulfate (Concentrate) Oral Solution, 100 mg/5 mL (mililiters), give 0.25 mL by mouth every 2 hours as needed for Pain: Pain-moderate: Pain-severe, Shortness of Breath. On [DATE] an order was obtained for Morphine Sulfate (Concentrate) Oral Solution, 100 mg/5 mL (mililiters), give 0.5 mL by mouth every 2 hours for Pain. Surveyor reviewed R1's Resident Controlled Substance records for Morphine Sulfate (Concentrate) Oral Solution. On [DATE] Licensed Practical Nurse (LPN)-M documented: Date: [DATE], Time: 1600, Amount Given: 0.25 . On [DATE] LPN-M documented: Date: [DATE], Time: 1800, Amount Given: 0.25 . On [DATE] LPN-M documented: Date: [DATE], Time: 2000, Amount Given: 0.25 . On [DATE] LPN-M documented: Date: [DATE], Time: 2200, Amount Given: 0.25 . On [DATE] at 12:00 PM, Surveyor requested to speak with LPN-M to conduct an interview. Director of Nursing (DON)-B informed Surveyor that LPN-M was no longer employed at facility. On [DATE] at 1:45 PM, Surveyor Conducted interview with DON-B. DON-B provided Surveyor with a Summary regarding a medication variance for R1 on [DATE]. DON-B told Surveyor that on [DATE] they had looked at R1's Morphine Sulfate orders, Resident Controlled Substance records, and assessed the opened Morphine Sulfate bottle. DON-B told Surveyor that it was discovered on [DATE] Evening shift that LPN-M had administered Morphine Sulfate 0.25 mL four times on [DATE]. DON-B told Surveyor that this was an medication variance due to R1 not receiving the correct dosage of scheduled Morphine Sulfate 0.5 mL every 2 hours as scheduled. On [DATE] at 2:30 PM, Surveyor met with Nursing Home Administrator (NHA), DON-B, Regional Nurse Consultant-C and VP of Success-D. Surveyor shared concerns related to LPN-M not providing the correct dosage of R1's scheduled Morphine Sulfate to R1 for 4 consecutive doses on [DATE] in which LPN-M administered only half of the prescribed dosage for each administration. The facility did not provide any additional information to Surveyor at this time.

Based on record review and interviews, the facility did not ensure that 1 out of 1 resident (R1) reviewed for abuse allegations was free from exploitation, abuse of power, and mental abuse. A facility Certified Nursing Assistant (CNA-C) and R1 exchanged phone numbers and began a friendship which included several text messages between the two individuals over several months. CNA-C and R1 continued with the relationship to the point that R1 believed CNA-C was his girlfriend and that he would eventually leave the facility and they would live together. CNA-C often visited R1 in his room while she was working and assigned to other units. CNA-C and R1 did become intimate, often talking sexually in text messages, sharing several kisses, laying under covers with one another, and touching in a sexual manner. CNA-C purchased gifts for R1 and would visit even when she was not working. Ultimately the relationship ended, and CNA-C became very adamant the relationship was never real and she wanted no further contact. CNA-C texted R1 comments that were humiliating, degrading, and ridiculing. R1 expressed experiencing disappointment, sadness, and loneliness because of the relationship ending. Facility staff were aware R1 and the alleged perpetrator had been texting and that she would often visit R1 in his room when not assigned to care for him. Facility staff knew R1 received gifts from CNA-C and staff even witnessed love notes being left in R1's room from CNA-C. When Administration became aware R1 and CNA-C had exchanged phone numbers, they did not further investigate the possibility that exploitation and/or possible sexual abuse may be occurring. The facility failed to prevent abuse and exploitation by staff failure to report the relationship between CNA-C and R1 to administration timely and by the failure of administration to intervene and complete a thorough investigation into the relationship, which allowed CNA-C ongoing access to R1. This created a finding of immediate jeopardy that began on 7/7/24. Surveyor notified Nursing Home Administrator-A, Director of Nursing-B, and VP of Success-G of the immediate jeopardy on 10/23/24 at 3:02 p.m. The immediate jeopardy was removed on 10/24/24, however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: Policy Review: Abuse, Neglect and Exploitation. Date implemented 3/2018. Date Reviewed/revised 7/15/2022. 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: Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s). VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. F. Providing emotional support and counseling to the resident during and after the investigation, as needed. R1 was originally admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, chronic kidney disease Stage #3, retention of urine, speech and language deficits, depression, and alcohol use. R1 is responsible for himself in all decision making. A review of the most recent quarterly MDS (Minimum Data Set) dated 7/20/24 shows R1 has a BIMS (Brief Interview for Mental Status) score of 13 indicating intact cognition for daily decision making. Surveyor became aware R1 was in a relationship with Certified Nursing Assistant (CNA)-C was employed at the facility until 9/4/2024 and worked various shifts on various units throughout the facility. On 10/21/24, at 9:30 a.m., Surveyor began a review of the facility's self-reported incident which documents there was an allegation of an inappropriate relationship between a former staff member (CNA-C) and a resident (R1) with the staff member overstepping boundaries and the allegation may or may not involve exploitation (taking advantage of a resident for personal gain). The date discovered is documented as 10/2/24. Date occurred is 10/2/24, at 2:15 p.m. The occurred date and time are estimated. The timeline included in the facility's investigation stated on 10/1/24, an employee made Nursing Home Administrator-A aware of text messages between R1 and CNA-C. On 10/1/24, Nursing Home Administrator-A spoke to R1 and asked about R1's relationship with CNA-C and the employee using his (R1's) credit card. R1 denied the employee used his card. R1 stated the relationship was not an intimate relationship, they were just friends. R1 denied any text messages and did not want to be questioned about the incident. On 10/2/24, Nursing Home Administrator-A interviewed R1 again and asked if she could read their (CNA-C and R1) text messages. R1 allowed Nursing Home Administrator-A to read through the text messages on his (R1's) cell phone. The text messages date back to 7/6/24. Text messages include, I love you, I cant [sic] wait for us to be together, I miss you, I want to kiss you from head to toe, I cant [sic] wait to lay with you, lets be alone, I only belong to you. The text messages also included jealous statements about other caregivers and there were text messages that talked about R1's penis and being inappropriate. R1 stated to NHA-A that he always denied the relationship because he loved her (CNA-C) and did not want to get her in trouble. R1 thought they were going to be together. R1 apologized for not telling the truth earlier. Surveyor conducted a review of the actual text messages that were sent between R1 and CNA-C between 7/7/24 and 9/29/24. The messages establish a relationship building between R1 and CNA-C with each calling each other pet names like crush, love,. boyfriend, and girlfriend. The text messages reveal that R1 and CNA-C thought of each other throughout the day and night and sometimes in a sexually explicit manner. The text messages show CNA-C would visit R1 while at work and assigned to different units. The text messages show R1 was in belief that CNA-C was his girlfriend and hoped that the two of them would be together forever and he would be able to leave the nursing home. On 9/13/24 CNA-C texted R1 saying: What part of LEAVE ME ALONE do you not understand? YOU GOT MY ASS FIRED !!!! I am grateful to be working elsewhere the drama and bullshit at [name of facility] is crazy ! DO NOT CALL TEXT ME AGAIN WE WERE NEVER GOING TO BE ANYTHING YOU WILL BE STUCK IN A NURSING HOME THE REST OF YOUR LIFE! I DON'T WANT TO BE WITH SOMEONE WHO IS STUCK IN A WHEELCHAIR AT A NURSING HOME. [NAME] I GOOD! LEAVE ME ALONE IM NOT KIDDING OTHERWISE I WILL MAKE A PHONE CALL AND IT WONT TURN OUT SO GOOD FOR YOU . On 9/29/24 CNA-C texted R1 for the last time .I HOPE YOUR ASS GETS KICKED OUT! GO LIVE WITH YOUR [NAME]! DON'T THINK I WAS SERIOUS ABOUT YOU I WAS PLAYING YOU. YOU REALLY DON'T THINK SOMEONE LIKE ME WOULD WANT TO BE WITH A MAN WHO HAS TO PISS IN A BAG AND SIT IN A WHEELCHAIR AND SHITS HIMSELF. LOL . BEING NICE TO SOMEONE DOESN'T EQUAL ROMANCE LOL LATER GATOR. Surveyor continued to review the facility's investigation and noted on 10/2/24 the facility did notify the local Police Department. Surveyor was able to review the police report. The report includes details included in the text messages as well as R1 stating he touched CNA-C's breasts under her shirt and the two of them kissed on multiple occasions. The facility's investigation included statements from staff members. The following was noted: On 10/5/24, CNA-H answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-H wrote, No, I have not first person, but I have heard about it from several residents. Question #2-are you aware of staff giving residents gifts? CNA-H wrote yes. On 10/4/24, CNA-I answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-I wrote, I haven't witnessed any myself, but I did hear rumors about something from residents and a CNA about a month or two ago. On 10/4/24, CNA-J answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-J wrote, No I have not witnessed any inappropriate relationships between staff and residents, I've only heard about something of the sort through whispers. On 10/4/24, CNA-K answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-K wrote, I've heard about it threw staff and I have seen sweet/sexual notes from staff to resident. Question #2-are you aware of staff giving residents gifts? CNA-K wrote yes. On 10/7/24, CNA-L wrote a witness statement that documented the following: I witnessed an inappropriate relationship between a resident and a coworker. I am aware of the coworker giving the resident new clothes such as T-shirts. My resident showed me text messages between them. I then reported it to Social Services and Human Resources. My resident had confided in me and told me they were dating, which I reported. A note from the coworker was left pinned up to the resident's bulletin board. It was found in the morning after she was scheduled as a CNA for night shift on unit 200. On 10/21/24 at 12:50 p.m., Surveyor interviewed CNA-D regarding R1. CNA-D stated she was aware of the situation involving R1 and CNA-C and had heard other staff talk about inappropriate texts and letters and that the staff member bought things for R1. CNA-D stated she didn't report it because it was all hearsay. CNA-D stated that talk started bussing around April/May about R1 and CNA-C and then in July it was an everyday topic between staff. Staff would see CNA-C make her way around the facility and out of her way to go see R1. All the staff just wondered why. CNA-D stated she was aware several people reported it to their supervisors. CNA-D stated it wasn't until R1 brought it to upper management that an investigation was really done. On 10/22/24 at 8:10 a.m., Surveyor interviewed Registered Nurse (RN)-E regarding R1 and CNA-C. RN-E stated that sometime between August 5-9th 2024 a night CNA came to her and reported she felt there was some inappropriate contact between R1 and CNA-C. RN-E stated she reported it to the Director of Nursing (previous) and Administrator (previous). RN-E then stated that sometime between August 20-23rd, 2024, while at the 200 Unit nursing station, she heard a CNA talking about the relationship between R1 and CNA-C and that she had bought items for R1. RN-E stated that she then reported this to former Administrator/VP of Success-G and he said he would take it from there. RN-E stated that R1 would make comments about text messages and other staff would see CNA-C going into R1's room when she would be assigned to work on a different unit. RN-E stated that even R1's roommate would say that R1's girlfriend was here again last night. On 10/22/24 at 11:20 a.m., Surveyor interviewed Social Services Coordinator (SSC)-F. SSC-F stated that he was not aware of the relationship between R1 and CNA-C until he was asked to go interview R1 with the other Social Services Coordinator. SSC-F was unable to give a date of the interview, but it was about 2 months ago. R1 was asked about text messages between himself and a staff member. R1 stated why, am I going to get this person in trouble. R1 didn't want to answer questions so SSC-F stated they left the room and were not involved with R1 after that. SSC-F stated that he was told by VP of Success (VPS)-G to just leave it be and wait for further instructions. No follow-up was ever done by SSC-F after that. SSC-F stated he had never heard anything about R1 and a staff person in a relationship prior to that. SSC-F stated in the beginning of October 2024 he was asked to write a care plan for R1 regarding trauma informed care. Social Service progress note dated 10/3/24 at 12:29 p.m., documents; Late Entry: Writer spoke with R1 regarding incident that had happened. R1 stated he was fine and that he had no hard feelings. Writer asked if he felt it would be beneficial for him to see someone for talk therapy. R1 stated no he did not feel it was necessary and that he has a good friend who he visits with on a regular basis who he confides in without judgement. After our talk resident went back to spending time outside with peers. Surveyor reviewed R1's individual plan of care that documents R1 is at risk for retraumatization of past event or experience where reminders/triggers of event or experience may cause behavioral changes and/or emotional distress. Date initiated: 10/4/24. Interventions included to provide a safe environment, monitor for increased withdrawal, anger or depressive behaviors and explore opportunities to avoid. R1 was offered a referral to Psychology as an additional intervention but declined. On 10/22/24 at 12:50 p.m., Surveyor interviewed VPS-G regarding R1. VPS-G stated he was the interim Nursing Home Administrator from 8/9/24 to 9/23/24. VPS-G stated all he was initially aware of is that R1 and CNA-C had exchanged phone numbers. He stated that going forward a whole different picture has been painted. VPS-G stated staff had started to talk about CNA-C having R1's phone number and they were texting one another. VPS-G said he went to talk with R1 and R1 denied anything was going on. CNA-C was also asked about having R1's phone number and she denied it as well. CNA-C stated she felt bad for R1 and just wanted to be there for him. Other facility staff did not say anything moving forward and I just thought there was nothing out of the ordinary going on. VPS-G stated then there was a text that came through to R1 and CNA-C was breaking things off. It was then brought to our attention again and we asked R1 about their relationship. R1 then became cooperative and shared all of the text messages between himself and CNA-C. VPS- G stated once we started to ask CNA-C questions about her having R1's phone number she was educated on this not being appropriate. CNA-C then resigned 9/4/24. Surveyor asked why VPS-G didn't start an investigation when he was made aware that R1 and CNA-C were texting one another. VPS-G stated he didn't think anything was going on and no one else came forward with any information. VPS-G stated he did not go and ask staff if they knew anything about R1 and CNA-C and that he did not ask R1 to see the text messages. VPS-G stated he did not interview R1's roommate nor did he ask any other residents about relationships with staff. VPS-G stated he was not aware R1 received gifts from CNA-C and looking back he should have asked more about the situation. On 10/22/24 at 2:10 p.m., Surveyor interviewed Nursing Home Administrator-A regarding the facility's investigation into the relationship between R1 and CNA-C. Nursing Home Administrator-A stated that on 10/2/24, a staff member had come to her and had a concern about a text message she saw on R1's phone from CNA-C about calling the police on R1. Nursing Home Administrator-A stated she then went to talk with R1, and he denied it at first and said he was just friends with CNA-C. Nursing Home Administrator-A stated after talking with R1 a bit longer he agreed to share the text messages with her. Nursing Home Administrator-A stated she read through all of the messages, and they went back to July. R1 then let Nursing Home Administrator-A take pictures, with a facility cell phone, of the text messages. Nursing Home Administrator-A then said she had asked VPS-G if he had any knowledge of R1 and CNA-C being in a relationship. VPS-G stated he was aware they had exchanged phone numbers but they both stated they were just friends. Nursing Home Administrator-A stated on 9/4/24, she wanted to bring in CNA-C to talk about her about exchanging phone numbers with R1 and the purchase of t-shirts for him. CNA-C then resigned her position before we could get any further statement from her. Nursing Home Administrator-A stated there were a lot of rumors floating around about the relationship, but nobody actually said they saw anything. Nursing Home Administrator-A stated she would have expected staff to report rumors as suspected allegations. Nursing Home Administrator-A stated R1 initially denied anything was going on with CNA-C because he didn't want her to get into trouble. Nursing note dated 10/4/24 at 1:01 p.m., is documented by Nursing Home Administrator-A; Writer spoke to R1 about incident that occurred with former staff member. Writer encouraged resident to monitor his banking information. R1 stated he has had no discrepancies in his bank statements. He stated he will not be canceling his bank card. Writer educated R1 about proper relationships with staff members. R1 understands the expectations of relationships with staff members. On 10/23/24 at 9:05 a.m., Surveyor interviewed R1 in the privacy of his room. Surveyor explained that she had reviewed the facility's investigation regarding the relationship with CNA-C. Surveyor also stated that she was able to review the police report from the Police Department from when they came to speak with R1. Surveyor stated to R1 that she is aware that it must be a sensitive and difficult situation to talk about and that the purpose of the interview is to gain an understanding of how this situation affected R1. R1 stated CNA-C initially asked R1 for his phone number which he stated he gladly gave to her. R1 stated CNA-C was his caregiver and they had developed a friendship. R1 stated he was very comfortable with CNA-C. R1 said he really misses the relationship because he is just a lonely old guy. R1 said CNA-C would often visit him and he was always ok with that. R1 said he had given CNA-C a Visa debit card to purchase some items for him at Kwik Trip. CNA-C did accept it but didn't feel comfortable using it so she returned it to him. R1 said CNA-C did buy him t-shirts with her own money. R1 said CNA-C did want to stop the relationship and said that her job was more important. R1 said he always told CNA-C to not get in trouble because of him. R1 said then he felt like CNA-C knew something wasn't kosher and she told me I got her fired. R1 said CNA-C wouldn't talk to him after that. R1 said he felt really sad about this and asked Nursing Home Administrator-A if it was true that he got her fired. R1 said he never felt threatened by CNA-C only disappointed and sad. Surveyor asked R1 if he could talk a bit more about that. R1 said all I wanted to do is get out of this place and be with her. I don't want to be in a nursing home anymore. I thought we were going to be together forever. R1 said then CNA-C said that I was harassing her because I did text her a few times after she left. I was worried about her. R1 said CNA-C was going to call the police on him and that she and her husband would be filing the report. R1 said the whole situation has made him upset, the kind of upset you feel when you experience a bad break-up. R1 said some of the things CNA-C said to him in the end really broke his heart in two. R1 said he has been able to move on and has a few good friends at the facility he can talk to.R1 said he was offered to talk to a counselor, but he declined. R1 said he didn't think other staff members knew about him and CNA-C, but somehow things got around and there were a lot of rumors that they had sex. R1 said that was not true and, I always knew this place had ears. According to rightuseofpower.org, There is a power inequality whenever you take on a role that gives you authority over another or creates a perception that you have authority. Because of this inequality, residents can be manipulated, exploited, and/or abused by a caregiver who is allowed to begin a relationship with a resident. Therefore, the failure of facility staff to report the relationship between CNA-C and R1 to administration timely and the failure of administration to intervene and complete a thorough investigation into the relationship created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy. The facility removed the jeopardy on 10/23/24 when it completed the following: * Facility completed interviews of residents and staff on 10/9/24 by Executive Director or designee to determine any further concerns of actual or suspected abuse. * Facility staff reeducated by Executive Director or designee on Abuse, Neglect, and Exploitation policy starting 10/23/24 and will be completed prior to next scheduled shift. This reeducation included information on types of abuse, obligation to report abuse, abuse of power, and need to safeguard residents. This education included how abuse can affect a staff members licensure or ability to be employed in facility. * On 10/23/24 Director of Nursing Executive Director and [NAME] President of Success reviewed established Abuse, Neglect and Exploitation policy. No changes were necessary to this policy. * Executive Director or Designee will interview a sampling of no less than 3 staff and 3 residents daily including review of grievances to ensure proper recognition, reporting, and notification of suspected/potential or actual abuse. These audits will be completed daily for 2 weeks, then 5 days per week for 10 weeks or until substantial compliance is maintained. Results of these audits will be brought to QAPI (quality assurance performance improvement) for review and recommendation. * ADHOC QAPI review of this plan was completed 10/23/24 with Medical Director, VP (Vice President) of Success, Director of Nursing, and Executive Director.

Based on interview and record review, the facility did not ensure residents received treatment and care consistent with the N6 Wisconsin Nurse Practice Act for 3 (R2, R16, and R5) of 16 residents reviewed. During the night shift on [DATE], R2 was yelling help me, help me, and couldn't breathe. Certified Nursing Assistant (CNA)-QQ notified Registered Nurse (RN)-PP. RN-PP observed R2 sitting on the edge of the bed, leaning over the half side rail, and not responding. RN-PP laid R2 down in bed, placed the pulse ox on R2's finger but was unable to obtain a reading, checked the oxygen tubing, and observed R2 had agonal breathing. RN-PP noted R2 was a DNR (Do Not Resuscitate) and called R2's daughter who is the 2nd Power of Attorney (POA) to inquire what she would like the facility to do. RN-PP did not complete any further assessments, did not attempt to contact the doctor, and did not call 911. RN-PP contacted the nurse on the short term unit, 100 to 200 units, and asked RN-HH to come to R2's room. Upon RN-HH's assessment, R2 was pulseless and was not breathing. The facility's failure to comprehensively assess R2, contact R2's physician, or call 911 created a finding of Immediate Jeopardy (IJ) which began on [DATE]. NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, VP (Vice President) of Success-G, and VP of Clinical-GG were notified of the immediate jeopardy on [DATE] at 3:02 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of D (potential for harm/isolated) related to the examples involving R16 & R5 and as the facility continues to implement its action plan. * Weekly skin assessments did not address R16's weeping blisters on R16's arms. * R5 was transferred via a Hoyer lift on [DATE]. A bar from the Hoyer lift hit R5's head causing pain. An initial neurological check (neuro-check) evaluation was not documented by the facility staff. R5 was sent to the emergency room (ER) for evaluation. R5 returned to the facility with a diagnosis of a mild concussion. R5 was not placed on the facility's 24-hour board for close monitoring. R5 did not have any documented neuro-checks completed after R5 returned from the ER. Findings include: The facility's policy titled, Change in Condition of the Resident and reviewed/revised [DATE] under Policy documents: A facility should immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Policy Explanation and Compliance Guidelines documents: When a resident presents with a possible change of condition, after a fall or other possible injury, trauma, or noted changes in mental or physical functioning: 1. Assess the resident's need for immediate care/medical condition. Provide emergency care as needed. 2. Assess/evaluate the resident . 3. Notify resident's physician - Use INTERACT Change in Condition: when to report to the MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician Assistant) as a guideline. a. Immediate notification: Immediate notification for any symptom, sign or apparent discomfort that is: 1. Acute or sudden in onset, and: ii. A marked change (i.e. more severe) in relation to usual symptoms and signs, or iii. Unrelieved by measures already prescribed requires a phone call to the provider. Do not fax for issues requiring immediate notification. If no response from provider and condition warrants, call the center medical director. If no response from the center medical director, contact the DON (Director of Nursing) for further guidance. According to the State of Wisconsin Nurse Practice Act: N 6.03 - Standards of practice for registered nurses. (1)? General nursing procedures. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. 1.) R2 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease (receives hemodialysis three times a week), COPD (chronic obstructive pulmonary disease), DM (diabetes mellitus), dementia, anxiety disorder, and obstructive sleep apnea. R2 has an order for CPAP (Continuous Positive Airway Pressure) with 2 liters of oxygen. R2 has an activated Power of Attorney for Health Care (POAHC) and advance directives for DNR (do not resuscitate). R2 was not receiving hospice services. The annual MDS (minimum data set) with an assessment reference date of [DATE] shows R2 has a BIMS (Brief Interview for Mental Status) score of 8 which indicates moderate cognitive impairment. R2 is assessed as having verbal behaviors 1 to 3 days during the assessment period and is not assessed as refusing care. R2 is independent in eating, roll left & right, sit to stand, chair/bed to chair transfers, and toilet transfers. R2 is occasionally incontinent of urine and continent of bowel. R2 was transferred to the hospital on two occasions, [DATE] and [DATE], prior to R2's change of condition. R2 was not hospitalized during either of these transfers. The nurses note dated [DATE] at 12:15 p.m. documents: Resident c/o (complained of) feeling lightheaded and upon standing she vomited. She also stated that she felt her heart beating very fast and felt like she was going to die. Writer took vitals and pulse was 101. Resident stated she still did not feel well. Writer called on call provider which [Name] NP indicated to have her sent out to be checked over. This nurses note was written by LPN (Licensed Practical Nurse)-FF. The nurses note dated [DATE] at 1625 (4:25 p.m.) documents: Resident has come back from ER (emergency room ) via stretcher. She was helped into her wheelchair and is eating dinner now. She came back with new order for Zofran 4 mg (milligram) Q (every) 8 hours PRN (as needed) for nausea. At the ER they did a cardiac monitor along with other labs which showed nothing concerning. Writer updated POA on resident before and after resident was sent out and returned. This nurses note was written by LPN (Licensed Practical Nurse)-FF. The nurses note dated [DATE] at 1751 (5:51 p.m.) documents: Writer received a call from [Name] RN (Registered Nurse) from [hospital] ER that urine test results came back post d/c (discharge) and resident has a UTI (urinary tract infection). New orders received Keflex BID (twice daily) 500 mg for 7 days. This nurses note was written by LPN (Licensed Practical Nurse)-FF. The nurses note dated [DATE] at 2123 (9:23 p.m.) documents: Resident was sent to ER from dialysis to have a new port inserted. Resident had some minor bleeding from site after returning. Call ER to report bleed per summary instructions. An order to place a compression dressing to site. If bleeding does not stop resident is to go to ER. After several minutes bleed has stopped and compression dressing is still intact. Resident is to be woke at 0500 (5:00 a.m.) on [DATE] to return to dialysis for a 0600 (6:00 a.m.) chair time. Family arranged transportation to arrive at 0540 (5:40 a.m.). This nurses note was written by LPN-Z. The progress note dated [DATE] at 11:45 a.m. under Subjective documents: Patient is seen in her room during visit currently resting in bed. She has now completed antibiotics for UTI (urinary tract infection) without any further urinary concerns reported. Recently updated by nursing staff that patient had worsening behaviors with confusion that had been noted upon starting Dilaudid. Pain clinic was updated and gave order to discontinue Dilaudid and start Norco instead, which patient has been tolerating without adverse effect. She does note ongoing back pain at baseline and is reminded to let nursing staff know when she has pain, with goal to optimize her pain control. Patient has no other complaints today. No shortness of breath or chest pain. Mentation appears at baseline currently. Nursing staff to continue to monitor pain control as well with no other new concerns reported today. The nurses note dated [DATE] at 03:26 (3:26 a.m.) documents: Resident summary: Resident A/O (alert/orientated) x (times) ,d+[DATE], able to make needs know, Denies pain and discomfort other than her base line. Resident has dialysis appoint three times a week. Resident independently hydrates and nourishes adequately. Resident independently propels her wheelchair in the facility. Needs assistance with ADL (activities of daily living). On a breathing treatment and pain meds (medication). Resident is continent of bowel and bladder. This nurses note was written by RN-OO. The nurses note dated [DATE] at 05:42 (5:42 a.m.) documents: Pt (patient) put call light on and informed staff she could not breathe. Pt sat at edge of bed. CPAP on. CNA (Certified Nursing Assistant) notified writer and writer went to room. Pt sitting at edge of bed and leaning over the side rail. Lips are blue. Pt is not responding verbally. Writer unable to get pulse ox. Fingers are cyanotic. Agonal breathing present. Pt is a DNR. Writer placed call to daughter [Name] and informed of information. [Name] stated she wanted to call her brother to see if they wanted her to go to the ER. [Name] will call facility back. This nurses note was written by RN-PP. The nurses note dated [DATE] at 05:47 (5:47 a.m.) documents: Pt has no pulse or respirations. Writer placed call to daughter [Name] and updated on death. [Name] is still trying to call her brother. [Name] unsure when they will be coming to the facility. Writer did ask [Name] about funeral home (burial or cremation). [Name] states she has the information and will update facility on funeral home information when they get her [sic] (here). This nurses note was written by RN-PP. The nurses note dated [DATE] at 05:52 (5:52 a.m.) documents: Call placed to [Name] Medical answering service and informed of death with need for call back. This nurses note was written by RN-PP. The nurses note dated [DATE] at 05:55 (5:55 a.m.) documents: Call received from [Name] Medical; [Name] NP informed of death. Permission given to release body to funeral home. This nurses note was written by RN-PP. On [DATE] at 9:34 a.m., Surveyor asked LPN-FF how R2 was during the evening shift on [DATE]. LPN-FF informed Surveyor R2 was completely normal, there were no concerns, nothing with R2's vital signs, behavior or anything. Surveyor asked LPN-FF if R2 complained of not feeling well. LPN-FF informed Surveyor she was stating she was not feeling good for two weeks and they did send her out. LPN-FF informed Surveyor R2 was not admitted and they did not find anything. (See nurses note dated [DATE] On [DATE] at 4:18 p.m., Surveyor spoke with CNA-RR who worked the evening shift on [DATE] and night shift into [DATE]. CNA-RR informed Surveyor she was in training and got to the facility about 6:00 p.m. Surveyor asked CNA-RR if she was in R2's room between 6:00 p.m. & 10:00 p.m. (evening shift). CNA-RR informed Surveyor she went into R2's room one time with the CNA she was training with and R2's call light went off she thought sometime between 8:00 p.m. & 9:00 p.m. CNA-RR explained R2 was on the toilet getting ready for bed and needed her hair put up in a bun. CNA-RR informed Surveyor she did exactly what R2 wanted. The next time R2's call light went off was around shift change and she wanted ice. CNA-RR informed Surveyor she worked the 300 unit during the night shift. CNA-RR informed Surveyor the last time she heard about R2 was between 5:00 a.m. & 6:00 a.m. when RN-PP told her you have to give me a second I have a code & took off running, want to say she passed away. On [DATE] at 11:17 a.m., Surveyor spoke with CNA-QQ on the telephone. Surveyor asked CNA-QQ to explain what occurred on [DATE] with R2. CNA-QQ informed Surveyor it was an average night. R2 got up at 4:00 a.m. and asked for water & ice for a flavor packet she had and then laid back down. CNA-QQ informed Surveyor an hour or hour and a half later R2 was yelling help me help me and she couldn't breathe. CNA-QQ informed Surveyor R2 had a mask on her face. CNA-QQ informed Surveyor she was on the 400 hall with R2 and the nurse was on the 300 hall. CNA-QQ informed Surveyor she yelled for the nurse, who was not a regular nurse, that R2 couldn't breathe. CNA-QQ informed Surveyor the nurse came in then said she needs to see if R2 is a DNR as doesn't look good. CNA-QQ informed Surveyor she went back in a few minutes later and the nurse and another nurse were in the room. She, (referring to RN-PP,) must have called the charge nurse. CNA-QQ informed Surveyor she was told to get another aide as R2 had passed. On [DATE] at 6:35 a.m., Surveyor interviewed RN-PP regarding R2. Surveyor asked RN-PP if she was the nurse assigned to R2. RN-PP informed Surveyor she was the nurse on the 300 & 400 wings. Surveyor asked RN-PP if she had taken care of R2 prior to R2 having a change of condition and expiring. RN-PP informed Surveyor this was the first night with R2 alone explaining she had taken care of her one time prior when she was training with [first name], LPN. Surveyor asked RN-PP if she received report of any concerns involving R2. RN-PP informed Surveyor there were no concerns voiced to her from the PM (evening) shift. RN-PP informed Surveyor since there was COVID in the facility she had checked R2's temperature & oxygen sats and changed the nebulizer equipment. RN-PP indicated R2 was alert & verbal and aroused easily. Surveyor asked RN-PP if she remembers what time R2's change of condition was. RN-PP replied no, it's in the charting. RN-PP informed Surveyor she also administered R2 her morning medication. Surveyor asked what time these medications were given. RN-PP informed Surveyor she can give morning medication any time after 3:00 a.m. and couldn't tell Surveyor what time. RN-PP informed Surveyor she thinks there was an agency CNA working this night and the CNA sits at the 400 nurses' station and she was at the 300 nurses' station. RN-PP informed Surveyor she doesn't know what interactions the CNA had with R2 and Surveyor would have to ask the CNA what her interactions with R2 were. RN-PP informed Surveyor the CNA shouted she's not able to breathe and then said R2's first name. RN-PP informed Surveyor she went down to R2's room, R2 was sitting on the edge of the bed and was leaning over the half side rail. RN-PP indicated she could see that R2 had agonal breathing (abnormal breath that occurs when someone is not getting enough oxygen. Agonal breathing is a sign that someone is in a severe medical emergency and requires immediate action). RN-PP informed Surveyor she moved R2 into bed so she was laying down to see if there was any response. RN-PP indicated R2 was not verbal and her lips & fingers were cyanotic. RN-PP informed Surveyor she could not get a reading from the pulse ox. RN-PP informed Surveyor she placed a call to [name], who is R2's second POA. RN-PP explained to R2's daughter R2 was DNR, confirmed DNR status, and asked what their wishes were. R2's daughter informed RN-PP she was going to call her brother and would get back to the facility. Surveyor asked RN-PP after she spoke with R2's daughter what did she do. RN-PP informed Surveyor she called the nurse from the rehab side, indicating she couldn't remember if she called RN-HH first or the family, and told her she needed help in room [R2's room number]. RN-PP informed Surveyor she ran back to R2's room, RN-HH was in the room, and R2 had passed. Surveyor asked RN-PP if R2 was using her CPAP. RN-PP informed Surveyor R2 was using it with oxygen. Surveyor asked RN-PP if she remembered what the oxygen was set at. RN-PP informed Surveyor she would have to look at the orders. Surveyor asked RN-PP if she increased R2's oxygen. RN-PP replied with agonal breathing it would not have done anything so I left it the way it was. Surveyor asked RN-PP if she called the doctor. RN-PP replied yes. Surveyor asked when she contacted the doctor. RN-PP replied after she passed. RN-PP informed Surveyor she made the NP aware of R2's death and the NP was going to call the doctor. RN-PP informed Surveyor if she had called the doctor prior you get the answering service and when the doctor called back it would have been telling the doctor R2 was dead. Surveyor asked RN-PP why she didn't call 911. RN-PP replied, with her being DNR I needed to know what the family's wishes were, she's a DNR. If she had been dead they (EMS) wouldn't have transported or done CPR (Cardiopulmonary Resuscitation). RN-PP stated, I'm told we can't call 911 unless there is an MD order. Surveyor asked, you can't call 911 first? RN-PP then walked back what she said stating the DON (Director of Nursing) never told her she couldn't call 911 first. RN-PP stated, If I felt she would have made it with transport I would have sent her out. There was agonal breathing. Surveyor asked RN-PP if there is a change of condition what is she supposed to do. RN-PP informed Surveyor there is an E interact in PCC (point click care) assessment to complete, update MD, call family, and ascertain what the family's wishes. If want to go to hospital, call 911, update DON and Administrator. RN-PP informed Surveyor she hasn't had this yet. On [DATE] at 6:25 a.m., Surveyor asked RN-PP what assessments she did for R2 on [DATE]. RN-PP informed Surveyor R2 was not responding verbally. She placed a pulse ox on her finger, couldn't get any reading. That's when she made sure the oxygen was flowing and then went to go speak with [Name], (R2's daughter, 2nd POA). On [DATE] at 1:46 p.m., Surveyor spoke with RN-HH on the telephone regarding R2. RN-HH informed Surveyor she was on the ,d+[DATE] unit and the nurse the other side called her to come over. RN-HH informed Surveyor she assessed R2 and she had already expired, explaining she was pulseless and not breathing. RN-HH informed Surveyor she removed R2's CPAP so she could hear and listen for heart sounds and respirations. Surveyor asked RN-HH after R2 passed what she did. RN-HH informed Surveyor she contacted the doctor while RN-PP was on the phone with the family and made a note the doctor was called and could release the body to the funeral home. On [DATE] at 8:31 a.m., Surveyor asked DON (Director of Nursing)-B if a resident has a change in condition what is the expectation of the nurse. DON-B informed Surveyor observe or assess and follow up appropriately. Surveyor asked what is appropriately. DON-B informed Surveyor depending on concern. Use the interact change of condition guide, notification to MD and family. Surveyor asked DON-B if a resident is a DNR what does this mean. DON-B replied do not resuscitate; what to do for code status, this is in the event the heart stops. Surveyor asked DON-B if a resident is a DNR and has a change in condition what happens. DON-B informed Surveyor if a resident is a DNR or full code does not change how they respond to assessing or observing. They absolutely treat the resident the same. DON-B informed Surveyor her expectation is the MD would be notified of a change in condition. DON-B informed Surveyor with some situations with critical thinking of the nurse 911 may be called prior to the MD being notified. DON-B informed Surveyor the MD should be updated first but there are cases when we don't want to cause harm. The facility's failure to ensure R2 received appropriate care and treatment consistent with profestional standards of practice when R2 experienced a change in condition including shortness of breath and later agonal breathing created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when the facility implemented the following action plan: * Director of Nursing/designee completed an audit on [DATE] of residents requiring transfer from facility to higher level of care within the last 14 days, to verify appropriate assessment and notification, including Emergency Medical Services Activation. * Facility Licensed Nursing staff to be reeducated prior to the next working shift by Director of Nursing or designee on Change of Condition of the Resident policy. This reeducation includes information on assessment/evaluation (regardless of code status), provider notification of findings, and documentation requirements. Reeducation includes use of the INTERACT 4.5 Change in Condition Guidelines for when to immediately notify the physician/provider and activate emergency medical services. * On [DATE], Director of Nursing, Executive Director, and [NAME] President of Success reviewed established Change in Condition of the Resident policy. No changes were necessary to this policy. * Director of Nursing or Designee will review facility charting daily to identify resident change in condition to ensure proper documentation of assessment/evaluation and timely provider notification. These audits will be completed daily for 2 weeks, then with morning clinical 5 days per week for 10 more weeks or until substantial compliance is maintained. Results of these audits will be brought to QAPI (quality assurance performance improvement) for review and recommendation. * ADHOC QAPI review of this plan was completed [DATE] with Medical Director, VP (Vice President) of Success, Director of Nursing, and Executive Director. The deficient practice continues at a scope/severity of D (harm/isolated) as evidenced by the following examples. 38829 2) R16 was admitted to the facility on [DATE] with diagnoses of Other Specified Diseases of Liver, Muscle Weakness, Hypertensive Heart Disease with Heart Failure, Unspecified Asthma, Arthropathic Psoriasis, Immunodeficiency, Type 2 Diabetes Mellitus, and Adjustment Disorder with Muscle Weakness. R16 discharged from the facility on [DATE]. R16's Admission Minimum Data Set (MDS) completed on [DATE] documents R16 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R16 was cognitively intact for daily decision making. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating, required substantial/maximum assistance for shower/bathing, lower dressing, personal hygiene, rolling left to right, and sit to lying. R16 required partial/moderate assistance for upper dressing. R16 was dependent for sit to stand, transferring from chair to bed, and toileting transfers. R16 was occasionally incontinent of bladder and always continent of bowel. R16 is at risk for developing pressure ulcers but has none currently. R16's MDS documents R16 desired to discharge to the community and required active discharge planning. R16's quarterly MDS completed on [DATE] documents R16's BIMS score to be 11, indicating R16 was demonstrating moderately impaired skills for daily decision making. R16's MDS also documents R16 is receiving ointments to areas other than feet. R16's Discharge MDS completed on [DATE] does not assess R16's cognitive skills. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for lower dressing, personal hygiene. Shower/bathing was not attempted due to medical condition. R16 required partial/moderate assistance for upper dressing, sit to lying and lying to sitting, sit to stand, chair to bed transfer, and toilet transfer. Transferring to to tub/shower was not attempted due to medical condition. R16 was supervision for rolling left to right. R16 was frequently incontinent of bladder and always incontinent of bowel. R16's Care Area Assessment (CAA) for Pressure Ulcer/Injury documents: .Care plan will be initiated or reviewed to improve or maintain current ADL (Activities of Daily Living) status and functional ability, maintain continence status, prevent pain, and decrease pressure ulcer/fluid deficit risk. Resident has increased risk for skin impairment related to increased need for help with ADL such as bed mobility which can decrease flood flow and increase pressure leading to wounds . Surveyor notes R16 was assessed to have shearing which was documented on R16's admission evaluation dated [DATE]. R16 also had blisters on bilateral arms and legs that at times would be documented to be weeping. R16's skin focused care plan problem initiated [DATE] states the following: -Actual at (specify location) due to . -Administer treatment per MD (Medical Doctor) orders [DATE] -Encourage and assist as needed to turn and reposition; use assistive devices as needed [DATE] -Float heels as able [DATE] -Report evidence of infection such purulent drainage, [NAME], localized heat, increased pain, notify MD PRN [DATE] Surveyor notes R16's skin care plan was not revised to include person centered interventions to identify the potential for skin breakdown including pressure relieving mattress, pressure relieving cushion for wheelchair, and interventions to address R16's blisters on bilateral arms and legs. R16's Kardex documents R16 is receiving ointments for skin issues. R16's physician orders documents: -Weekly skin review every evening shift every Monday if new skin area is identified follow protocol for SBAR (Situation, Background, Assessment and Recommendation), MD update and risk management. -May have kerlix bedside for wound drainage from bilateral arms and legs as needed for drainage. -Clobetasol Pripionate External Cream 0.05%, apply to affect area topically as needed for psoriasis. -Triamcinolone Acetonide External Cream 0.1%, apply to buttock topically one time a day for dermatitis. R16's Admission Evaluation dated [DATE] documents a score of ,d+[DATE] which means R16 is at risk for skin issues. It is documented by Registered Nurse (RN)-N that R16 has shearing on left buttock and a skin tear on right forearm with no other description for the areas. On [DATE], R16's Braden Scale for Predicting Pressure Sore Risk documents a score of 14, indicating R16 was at moderate risk. On [DATE], Physician (DR)-TT documented that R16 had fragile skin, scattered ecchymosis, weeping and blisters. Continues to have peripheral edema mostly 3rd spacing. Does have very fragile skin with multiple bruises and blistering lesions. 1 to 2 pretibial pitting bilateral lower extremity edema. Bilateral upper extremities puffy. Weeping. Surveyor notes R16's facility weekly head to toe skin checks does not document any of the skin areas identified by DR-TT including addressing interventions on R16's care plan. R16's EMR does not have documentation from nursing addressing areas that are identified as blisters and are weeping. On [DATE], at 2:14 PM, Surveyor interviewed Registered Nurse (RN)-N regarding R16's skin issues. RN-N stated R16 consistently scratched their arms. R16 also had an issue with edema. R16 would have areas that looked like they were open. RN-N stated R16 had multiple blisters with small holes with fluid that would come out. RN-N recalls the shearing area on R16's buttocks not being open but had new skin present. On [DATE], at 10:01 AM, Director of Nursing (DON)-B stated the expectation would licensed professionals should complete skin evaluations and assessments on any area that that has bruising, blisters, or is open. DON-B agreed R16's blisters would require additional assessments to be completed. On [DATE], at 3:22 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R16's skin issues were not further evaluated with comprehensive assessments and person-centered interventions identified and documented in R16's comprehensive care plan. No further information was provided by the facility at this time. 49435 3) On [DATE] at 9:10 AM, Surveyor asked Director of Nursing (DON)-B for the faciliy's neuro-check policy. Nursing Home Administrator (NHA)-A returned to surveyor and informed surveyor that the incident involving the Hoyer lift bar hitting R5's head would be addressed in the fall policy under the neuro-checks section. NHA-A stated the facility does not have a separate neuro-check policy. The facility policy entitled, Fall Prevention and Management Guidelines with a review date of [DATE], documents, in part: . Neuro checks for any unwitnessed fall or witnessed fall, where resident hits their head: Initially, then hourly x 3, then continue neuro checks every 4 hours x 6, then continue neuro checks every 8 hours x 6 or as indicated by the physician. Alert MD (Medical Doctor) of any abnormal findings from neuro checks- do not wait until series is complete to notify MD of abnormal findings. In a document entitled, Post-Fall Assessments dated, August of 2021, The American Association of Post-Acute Care Nursing (AAPACN) documents the following about neuro checks : An assessment of neurological status, often called a neuro check, should be done when a resident hits his or her head or if it is unknown if they hit their head (unwitnessed fall). R5 was admitted to the facility on [DATE] with diagnosis that include Hemiplegia and hemiparesis following stroke, Contracture of left knee, Heart failure, Emphysema, Morbid obesity, Atrial-fibrillation, and Depression. R5's Annual Minimum Data Set Assessment (MDS) dated [DATE] documents R5 is cognitively intact. R5 is dependent on staff for bathing, toileting, lower body dressing, mobility, and transfers. R5's Care Area Assessment (CAA) for Functional Abilities dated [DATE], documents, Resident requires assistance [with] most Activities of Daily Living (ADLs) d/t (due to) impaired mobility. Goal is to ensure resident is safe and needs are met. Nursing staff will continue to offer and assist [with] ADLs and ensure to meet resident's daily needs. On [DATE], at 10:03 AM, Surveyor interviewed R5. R5 informed Surveyor that during a Hoyer lift transfer a few weeks ago, R5 was hit on the top of the head. R5 stated 2 Certified Nursing Assistants (CNAs) were helping R5 get into her wheelchair. R5 stated one CNA was behind her and another one was in front of her. R5 stated the CNA's were talking back and forth to each other about the transfer. R5 stated R5 was lowered into the chair and the top bar of the Hoyer lift hit R5's head very hard. R5 stated she began to cry because the hit was hard and hurt a lot. R5 stated R5 was sent to the hospital for evaluation in the ER (emergency room ). R5 stated the emergency room doctor told R5 that R5 had a mild concussion. R5 returned to the facility. R5 stated the pain lasted a few days and then resolved. R5's incident report entered by Licensed Practical Nurse (LPN)-Z, dated [DATE], at 11:35 AM, documents, [CNA-CC] informed writer [TRUNCATED]

Based on interview and record review, the facility did not ensure 2 of 2 residents (R14 & R5) received adequate supervision and assistance devices to prevent accidents. * R14 was admitted to the facility on [DATE] with a fracture of right pubis and history of falls. The facility did not develop a person centered falls care plan and this care plan did not address R14 self transferring. On 7/17/24, R14 attempted to self transfer, fell , and was transferred to the hospital. The hospital ED (emergency department) notes document a new sacral fracture. * R5 was transferred by 2 Certified Nursing Assistants (CNAs), CNA-CC and CNA-DD, via a Hoyer lift on 9/6/24. During the transfer, the bar from the Hoyer lift hit R5's head causing pain. R5 was sent to the emergency room (ER) for evaluation. R5 returned to the facility with a diagnosis of a mild concussion. CNA-CC stated that CNA-CC did not receive formal training on Hoyer lift transfers prior to transferring R5 on 9/6/24. Findings include: The facility's policy titled, Fall Prevention and Management Guidelines last reviewed/revised 7/18/22 under Policy documents: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. 1.) R14's diagnoses includes fracture of right pubis, hypertensive heart disease with heart failure, and anxiety disorder. The at risk for falls due to: recent fall with fracture, history of falls care plan initiated 7/9/24 has the following interventions: * Assess for orthostatic hypotension. Initiated 7/9/24. * Encourage to transfer and change positions slowly. Initiated 7/9/24. * Fall Risk (FYI) (for your information). Initiated 7/9/24. * Have commonly used articles within easy reach. Initiated 7/9/24. * Provide assist to transfer and ambulate as needed. Initiated 7/9/24. * Reinforce w/c (wheelchair) safety as needed such as locking brakes. Initiated 7/9/24. * Report development of pain, bruises, change in mental status, ADL (activities daily living) function, appetite, or neurological status post fall. Initiated 7/9/24. * Therapy eval and treat as ordered. Initiated 7/9/24. The ADL self care deficit care plan initiated 7/9/24 includes interventions of: TOILETING: Assist of 2. Initiated 7/9/24 and TRANSFER: Assist of 2. Initiated 7/9/24. The admission evaluation dated 7/9/24 under section L Mobility/Fall Risk is checked yes for resident is at risk for falls. The nurses note dated 7/10/24 at 02:49 (2:49 a.m.) documents: Resident is on follow up for: F/U (follow up) new admission. The current status is PAC (post acute care) #2 after recent hospitalization with pubic fx (fracture) r/t (related to) fall. Resident is alert and orientated with pleasant affect. No complaints of pain or discomfort noted. Lungs clear, no sob (shortness of breath) or cough noted. Abdomen soft and non=tender, bowel sounds + (positive) times 4. No edema noted to BLEs (bilateral lower extremities). Resident up to bathroom with assist of 1, incontinent of urine. Peri care completed and barrier cream applied. Safety reminders given, call light in reach. Will continue to monitor. This nurses note was written by RN (Registered Nurse)-HH. The Admission MDS (minimum data set) with an assessment reference date of 7/16/24 has a BIMS (Brief Interview for Mental Status) score of 10 which indicates moderate cognitive impairment. R14 is assessed as not having any behaviors. R14 is assessed as requiring partial/moderate assistance for toileting hygiene, rolling left & right, chair/bed to chair transfer, and toilet transfer. R14 is assessed as occasionally incontinent of urine and always continent of bowel. Yes is answered for fell in the last month prior to admission and fracture related to fall in 6 months prior to admission. R14 has not fallen since admission. The fall CAA (care area assessment) dated 7/17/24 under analysis of findings is blank. Under care plan considerations documents, here for rehab s/p (status post) hospitalization d/t (due to) fall severe right hip, knee, and shoulder pain, a comminuted right pubic bone fracture, DJD (degenerative joint disease), WBAT (weight bearing as tolerated); has hx (history) of falling, no falls since admn (admission); proceed to POC (plan of care). The nurses note dated 7/17/24 at 09:28 (9:28 a.m.) documents: The current status is resident sent to hospital for evaluation. Resident sent to hospital for evaluation. This nurses note was written by RN-II. APNP (Advance Practice Nurse Prescriber)-JJ note dated 7/17/24 under subjective documents: Patient seen sitting up in wheelchair. She stated that her pain is much better today. No nausea or vomiting after taking food with her pain medication. She feels like she is having sciatica pain on her left side, and is doing gentle stretching. Looking forward to therapy today. She stated that she does not feel feverish today or any further URI (upper respiratory infection) sx (symptoms). Denies fevers, chills, chest pain, shortness of breath, dizziness, constipation diarrhea, nausea or vomiting. Care discussed with nursing. No other concerns today. Notified by nursing later that patient had fallen and had head trauma - sent to ED (emergency department) for eval (evaluation). Under Assessment and Plan includes Fall *: 7/17 notified by nursing [R14's first name] fell today and hit her head. Nursing noticed a hematoma on her head. She is currently on Plavix. Sent to ED for further assessment. The fall risk assessment dated [DATE] documents a score of 8 which is low risk. The nurses note dated 7/18/24 at 09:44 (9:44 a.m.) documents: Writer called to Resident's room by med tech who heard a loud noise from Resident's room. Upon entry to Resident's room, Resident was sitting on buttocks in front of TV area, Resident sated she hit the back of her head and her right hip-there was a golf ball sized bump to the back of her head. Call light was not on. Resident was wearing gripper socks. All personal items and table were within reach. Resident transferred via [Fire Department initials] to [Hospital initials]; report given to [first name], RN in ED. The nurses note dated 7/23/24 at 11:35 a.m. documents: IDT (interdisciplinary team) review of unwitnessed fall 07/17/2024: Resident was found by medication tech. Resident was found sitting on her buttocks in front of her television area. Resident reported that she hit her head and her right hip. Upon inspection, the resident had a bump noted to the back of her head. Resident reported she stood up by herself and used the wheelchair as support to stand. She then reached for a blanket and fell . Call light was not on at the time of the fall. Gripper socks were in place and her personal items were within reach. Wheelchair brakes were locked. Resident was seen five minutes prior to the fall and she was resting comfortably in her wheelchair at the time. Provider was notified of the fall. Resident is her own person. Resident admitted status post fall at home with pubic fracture. Resident was an assist of one with transfers and ambulation. Due to complaints of pain post fall and head injury, resident was sent to the hospital for further evaluation and treatment. Resident was taken to the hospital by EMS (emergency medical services). Resident did not return at this time. Root Cause: Resident stood unassisted, using her assistive device improperly, and fell while reaching for a blanket. Intervention: Resident was sent out to the hospital for further evaluation and treatment. She has not returned at this time. This nurses note was written by RN-KK. On 10/22/24, Surveyor received and reviewed R14's emergency department hospital records dated 7/17/24. HPI (history of present illness) documents [R14's name] is a 87 y.o. (year old) female with a past medical history of COPD (chronic obstructive pulmonary disease), coronary disease on Plavix, hypertension, complete heart block with pacer in place, with recent fall on 7/5 with right pubic rami fracture who presents from Lake Country rehab with a chief complaint of sacral pain/fall. Per the patient she has been intermittently having left leg numbness since her fracture. She notes that her roommate spent several hours in the bathroom this morning and she could not get in there so she accidentally several other close. She notes that no one answered when she pushed her call bell so she went up getting to the bathroom on her own. She notes when she got over there she did get help getting dressed and changed but later was uncomfortable and started having numbness in her leg again which tends to happen to her when she tried to adjust a pillow and blanket and she fell forward hitting her head and her body in the ground. Since that time she has had increased pain to her sacrum as well as some slight pain to her head. She notes that she did get a Norco prior to coming in but did not take her blood pressure medication. She notes no additional complaints. Under ED course documents: Patient here for mechanical fall. CT head and cervical spine are unremarkable. CT abdomen pelvis showing new sacral fractures . On 10/23/24 at 7:26 a.m., Surveyor interviewed ADON (Assistant Director of Nursing)-X. Surveyor inquired, after a resident is admitted what is the care planning process? ADON-X explained the baseline care plan is developed by the admitting nurse then the social worker and dietitian put in their care plans. ADON-X indicated she goes through all the admission paperwork and updates the care plans. ADON-X informed Surveyor she also believes MDS does some of them and stated there are a lot of people that update and develop the care plan. Surveyor asked ADON-X if she remembers R14. ADON-X replied vaguely. ADON-X informed Surveyor the only thing she can remember about R14 is her fall. ADON-X explained she was working the floor at this time and was not the ADON. ADON-X informed Surveyor she was not working at the time but was told R14 fell and went to the hospital. Surveyor inquired what is the process after a resident has a fall? ADON-X explained the nurse would assess the resident for any injury or if something is not at their baseline. They will update the doctor, sometimes the doctor will send them to the hospital other times they will say to monitor the resident. If the resident is not sent out they will complete neuro checks if the fall is unwitnessed or they hit their head. A post event assessment is completed and fall is documented. ADON-X informed Surveyor the IDT meets to review the assessments and tries to find the root cause of the fall. ADON-X informed Surveyor the IDT meets twice daily and they will update the care plan with interventions as well as the floor nurse is also responsible for interventions. Surveyor inquired if she was involved with developing R14's care plan. ADON-X replied not that I'm aware of; I know RN-II was the nurse and she is no longer employed. Surveyor asked if there was anyone else Surveyor should speak with regarding R14's fall and care plan. ADON-X informed Surveyor [first name] MDS nurse but she no longer works here. Surveyor informed ADON-X R14's care plan interventions were not resident centered and were generic which could be interventions for any resident. Surveyor also informed ADON-X one of R14's interventions was to encourage to transfer slowly but R14 required assistance & should not be self-transferring. On 10/23/24 at 7:49 a.m., Surveyor asked RN-E if she remembers R14. RN-E informed Surveyor R14 came in with a hip fracture, fell , they sent her out, and R14 didn't come back. Surveyor asked RN-E if she was involved in the fall investigation. RN-E replied just IDT. RN-E informed Surveyor R14 got up by herself, didn't use the call light, and was trying to get a blanket. RN-E informed Surveyor R14 didn't want to go out but she hit her head and needed a scan. Surveyor asked if R14 had a history of self-transferring. RN-E replied, I didn't know her that well so don't know the ins and outs. On 10/23/24 at 8:00 a.m., Surveyor asked CNA (Certified Nursing Assistant)-LL if she remembered R14. CNA-LL informed Surveyor she doesn't remember her a lot. Surveyor asked CNA-LL if R14 would self-transfer herself. CNA-LL replied yes. On 10/23/24 at 8:12 a.m., Surveyor asked CNA-D if she remembered R14. CNA-D informed Surveyor she kind of remembers R14. CNA-D informed Surveyor she kind of remembers R14's fall. CNA-D informed Surveyor either RN-II or RN-E told her to give R14 her breakfast tray which she did. CNA-D informed Surveyor she was not there when R14 fell but R14 stood up and hit her head on the dresser. Surveyor asked CNA-D if R14 would self-transfer. CNA-D informed Surveyor R14 was not supposed to but would. CNA-D informed Surveyor she talked to R14 about not self transferring and using her call light. CNA-D informed Surveyor she continually had to tell R14 not to self transfer & use her call light and she wasn't sure if R14 was all there mentally. CNA-D informed Surveyor she would report to the nurse when R14 would self transfer. On 10/23/24 at 8:21 a.m., Surveyor spoke to DON (Director of Nursing)-B about R14. R14 was discharged prior to DON-B working at the facility. Surveyor informed DON-B R14 was admitted to the facility with a fracture and history of falls. R14's care plan was not resident centered. R14 would frequently self transfer herself but there is no documentation of this in her record nor does the care plan address R14's self transferring. Surveyor informed DON-B the facility was aware of R14 self transferring but there is nothing in the record as to what they were doing to prevent R14 from self transferring. Surveyor informed DON-B Surveyor reviewed the hospital ED records dated 7/17/24 the date of the fall which indicate R14 sustained a new sacral fracture. On 10/23/24 at 8:56 a.m., Surveyor informed NHA-A. R14 was admitted to the facility with a fracture and history of falls. R14 would frequently self transfer at the facility. R14's care plan was not resident centered and did not address R14 self transferring. R14 was transferred to the hospital following the fall and hospital ED records indicate R14 sustained a new sacral fracture. No additional information was provided to Surveyor regarding R14's fall. 49435 2.) The facility policy titled Safe Resident Handling and Transfers dated 8/5/22, documents in part: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines . The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly . Two staff members must be utilized when transferring residents with a mechanical lift. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire. The staff must demonstrate competency in the use of mechanical lifts prior to use. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. Resident lifting and transferring will be performed according to the resident's individual plan of care. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device . R5 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia and hemiparesis following stroke, Contracture of left knee, Heart failure, Emphysema, Morbid obesity, Atrial-fibrillation, and Depression. R5's Annual Minimum Data Set Assessment (MDS) dated [DATE] documents R5 is cognitively intact. R5 is dependent on staff for bathing, toileting, lower body dressing, mobility, and transfers. R5's Care Area Assessment (CAA) for Functional Abilities dated 8/3/24, documents, Resident requires assistance [with] most Activities of Daily Living (ADLs) [due to] impaired mobility. Goal is to ensure resident is safe and needs are met. Nursing staff will continue to offer and assist [with] ADLs and ensure to meet resident's daily needs. On 10/21/24 at 10:03 AM, Surveyor interviewed R5. R5 informed Surveyor that during a Hoyer lift transfer a few weeks ago, R5 was hit on the top of the head. R5 stated that 2 Certified Nursing Assistants (CNAs) were helping R5 get into her wheelchair. R5 stated one CNA was behind her and another one was in front of her. R5 stated that the CNAs were talking back and forth to each other about the transfer. R5 stated that R5 was lowered into the chair and the top bar of the Hoyer lift hit R5's head very hard. R5 stated that she began to cry because the hit was hard and hurt a lot. R5 stated she was sent to the hospital for evaluation in the ER. R5 stated the emergency room doctor told her that she had a mild concussion. R5 returned to the facility. R5 stated the pain lasted a few days and then resolved. R5's incident report entered by Licensed Practical Nurse (LPN)-Z, dated 9/6/24 at 11:35 documents: [CNA-CC] informed writer that resident had a hit to the head from the Hoyer and is in pain. Upon entering room, writer observed resident holding her head crying in the wheelchair. [CNA-DD and CNA-CC] explained to writer how the bar fell on to resident's head with a good amount of blunt force. No bleeding or obvious bump noted upon immediate inspection. Resident stated that the Hoyer lift bar hit her on top of her head and that it is throbbing. Immediate Action taken: neuro checks, vitals, [Nurse Practitioner (NP)] notified, DON notified, family notified, 911 to [hospital] per NP. R5's progress note dated 9/6/24 at 1:55 PM documents: Resident came back from [Name of local hospital] ER with a closed head injury, mild concussion, and scalp contusion. Resident states it feels like she got hit in the head with a baseball bat and that her head is just pounding. Tylenol was given prior to her departure and will be given when needed. On 10/22/24 at 9:46 AM, Surveyor interviewed CNA-DD via telephone. Surveyor asked CNA-DD to explain what occurred on 9/6/24 during the Hoyer lift transfer of R5. CNA-DD stated that CNA-CC asked CNA-DD for help getting R5 into R5's wheelchair. CNA-CC stated that CNA-DD had the remote for the Hoyer and was controlling the Hoyer movements. CNA-DD was behind the resident guiding the resident into the chair. CNA-CC was lowering the Hoyer lift bar so resident would be in the chair. CNA-DD stated that CNA-CC let R5 down without supporting the top bar of the Hoyer lift and the bar hit R5's head. CNA-DD indicated it was an accident. CNA-DD stated that CNA-DD put her hand in between R5's head and the bar of the Hoyer until it was lifted. CNA-DD stated R5 was crying and CNA-CC went to get the nurse. Surveyor asked what kind of training is provided for Hoyer lift transfers. CNA-DD stated that CNA-CC was new to working in nursing homes and CNA-DD did not think that CNA-CC was comfortable working with the Hoyer lift. CNA-DD stated she thought training happens when you first start working at the facility during orientation. On 10/22/24 at 1:30 PM, Surveyor interviewed CNA-CC via telephone. Surveyor asked CNA-CC to explain what occurred on 9/6/24 during the Hoyer lift transfer of R5. CNA-CC started by stating that CNA-CC did not have a ton of experience with the Hoyer lift. CNA-CC stated that CNA-DD came to help CNA-CC transfer R5 from R5's bed to the wheelchair. CNA-CC stated that CNA-DD was behind the resident and CNA-CC was directing the Hoyer movements. CNA-CC stated they were lowering R5 into the chair, when R5's weight weighed down the Hoyer and caused R5 to land in the chair and the Hoyer lift bar to come down on R5's head. CNA-CC stated one of us got the nurse and one of us stayed with R5. CNA-CC stated that CNA-CC checked on R5 at the end of CNA-CC's shift to make sure that R5 was ok. Surveyor asked what training CNA-CC received on Hoyer lift transfers. CNA-CC stated she did not get any formal training. CNA-CC stated some other aides showed CNA-CC the basics but again CNA-CC she did not get any formal training. On 10/23/24 at 7:09 AM, Surveyor reviewed CNA-CC's employee file. Surveyor noted a completed hand hygiene competency for CNA-CC. Surveyor noted trainings completed in the following categories: Reporting, HIPPA, Resident Rights, Abuse, Neglect and Exploitation, Infection control, and Falls. Surveyor did not locate a competency related to safe patient handling or Hoyer lift education. On 10/23/24 at 8:57 AM, Surveyor interviewed DON-B. DON-B indicated that the incident was reenacted by the 2 CNAs and DON-B to determine what happened. DON-B indicated that the resident's weight shifted when lowering R5 to the chair and it caused the bar to hit R5's head. DON-B indicated that after this incident, DON-B watched CNAs complete Hoyer lift transfers to make sure that CNAs were completing them correctly. Surveyor asked what training is completed before a CNA can assist in Hoyer transfers. DON-B stated that Hoyer training is part of the orientation process for new hires. Surveyor asked for CNA-CC's training record for the Hoyer lift. DON-B stated that competencies should have been done on hire. Surveyor informed DON-B that Surveyor did not locate CNA-CC's competency for Hoyer lifts in CNA-CC's employee file. DON-B stated that DON-B will get CNA-CC's competencies. On 10/23/24 at 12:25 PM, Nursing Home Administrator (NHA)-A informed Surveyor that NHA-A could not find training competencies regarding safe patient handling or Hoyer lift transfers for CNA-CC. On 10/23/24 at 3:50 PM, NHA-A and DON-B were informed of the concern that R5 was transferred via a Hoyer lift and the bar hit R5's head causing pain. CNA-CC informed Surveyor that CNA-CC did not receive any formal training for the Hoyer lift and the facility did not locate CNA-CC's competencies regarding safe patient handling or Hoyer lift transfers. No additional information was provided.

Based on record review and staff interviews, the facility did not always ensure that they reported allegations of sexual abuse and exploitation to Nursing Home Administrator (NHA)-A and to the State Survey Agency. This occurred for 1 of 1 resident reviewed (R1). Facility staff became aware of a relationship between R1 and CNA (Certified Nursing Assistant)-C that included months of communication via phone calls, text messages, and in-person visits to the resident's room. CNA-C would often visit R1 while working at the facility when she was not assigned to his unit. By the staff not reporting to Administration what they had heard and observed, it allowed the alleged perpetrator (CNA-C) continued access to R1. In addition, the facility failed to submit to the State Survey Agency within the required timeframes, the allegation of sexual abuse and exploitation when they were finally made aware in August 2024. CNA-C worked various shifts, on multiple units of the facility. This had the potential to effect the entire census of 69 residents. Findings include: The facility's policy dated as reviewed 7/15/2022 and titled, Abuse, Neglect and Exploitation documents: 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: Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. VII. Reporting/ Responses 1. Reporting of alleged violations to the NHA, 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 harm. 1.) Surveyor became aware that R1 was in a relationship with Certified Nursing Assistant (CNA)-C which began in July 2024. CNA-C was employed at the facility until 9/4/2024 and worked various shifts on various units throughout the facility. On 10/21/24 at 9:30 a.m., Surveyor began a review of the facility's reported incident which documents there was an allegation of an inappropriate relationship with former staff member (CNA-C) overstepping boundaries and may or may not involve exploitation (taking advantage of a resident for personal gain.) The date discovered is documented as 10/2/24. The date of occurrence is 10/2/24 at 2:15 p.m. The occurred date and time are estimated. The timeline included in the facility's investigation states that on 10/1/24, an employee made NHA-A aware of text messages between R1 and CNA-C. On 10/1/24, NHA-A spoke to R1 and asked about R1's relationship with CNA-C and the employee using his credit card. R1 denied the employee used his card. R1 stated that the relationship was not an intimate relationship, they were just friends. R1 denied any text messages and did not want to be questioned about the incident. On 10/2/24, NHA-A interviewed R1 again and asked if she can read their (CNA-C and R1) text messages. R1 allowed NHA-A to read through the text messages on his cell phone. The text messages date back to 7/6/24. Text messages include, I love you, I cant wait for us to be together, I miss you, I want to kiss you from head to toe, I can't wait to lay with you, let's be alone, I only belong to you, jealous statements about other caregivers; there were text messages that talked about R1's penis and being inappropriate with R1. Surveyor continued to review the facility's investigation and noted that on 10/2/24, the facility notified the Summit Police Department. Surveyor was able to review the police report. The report includes details included in the text messages as well as R1 stating he touched CNA-C's breasts under her shirt and the two of them kissed on multiple occasions. The facility's investigation included statements from staff members. The statements are documented below. On 10/5/24, CNA-H answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-H wrote, No, I have not first person, but I have heard about it from several residents. Question #2-are you aware of staff giving residents gifts? CNA-H wrote yes. On 10/4/24, CNA-I answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-I wrote, I haven't witnessed any myself, but I did hear rumors about something from residents and a CNA about a month or two ago. On 10/4/24, CNA-J answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-J wrote, No I have not witnessed any inappropriate relationships between staff and residents, I've only heard about something of the sort through whispers. On 10/4/24, CNA-K answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-K wrote, I've heard about it through staff and I have seen sweet/sexual notes from staff to resident. Question #2-are you aware of staff giving residents gifts? CNA-K wrote yes. On 10/7/24, CNA-L wrote a witness statement that documented the following: I witnessed an inappropriate relationship between a resident and a coworker. I am aware of the coworker giving the resident new clothes such as T-shirts. My resident showed me text messages between them. I then reported it to Social Services and Human Resources. My resident had confided in me and told me they were dating, which I reported. A note from the coworker was left pinned up to the resident's bulletin board. It was found in the morning after she was scheduled as a CNA for night shift on unit 200. On 10/21/24 at 12:50 p.m., Surveyor interviewed CNA-D regarding R1. CNA-D stated she was aware of the situation involving R1 and CNA-C and had heard other staff talk about inappropriate texts and letters and that the staff member bought things for R1. CNA-D stated that she didn't report it because it was all hearsay. CNA-D stated that talk started buzzing around April/May about R1 and CNA-C and then in July it was an everyday topic between staff. Staff would see CNA-C make her way around the facility and out of her way to go see R1. All the staff just wondered why. CNA-D stated that she was aware several people reported it to their supervisors. CNA-D stated that it wasn't until R1 brought it to upper management that an investigation was really done. On 10/22/24 at 8:10 a.m., Surveyor interviewed Registered Nurse (RN)-E regarding R1 and CNA-C. RN-E stated that sometime between August 5-9th 2024 a night CNA came to her and reported that she felt there was some inappropriate contact between R1 and CNA-C. RN-E stated that she reported it to the Director of Nursing (previous) and NHA (previous). RN-E then stated that sometime between August 20-23rd, 2024, while at the 200 Unit nursing station, she heard a CNA talking about the relationship between R1 and CNA-C and that she had bought items for R1. RN-E stated that she then reported this to former NHA/VP of Success-G and he said he would take it from there. RN-E stated that R1 would make comments about text messages and other staff would see CNA-C going into R1's room when she would be assigned to work on a different unit. RN-E stated that even R1's roommate would say that R1's girlfriend was here again last night. On 10/22/24 at 12:50 p.m., Surveyor interviewed VPS-G regarding R1. VPS-G stated that he was the interim NHA from 8/9/24 to 9/23/24. VPS-G stated that all he was initially aware of is that R1 and CNA-C had exchanged phone numbers. He stated that going forward a whole different picture has been painted. VPS-G stated that staff had started to talk about CNA-C having R1's phone number and they were texting one another. VPS-G said he went to talk with R1 and R1 denied anything was going on. CNA-C was also asked about having R1's phone number and she denied it as well. CNA-C stated that she felt bad for R1 and just wanted to be there for him. Other facility staff did not say anything moving forward and I just thought there was nothing out of the ordinary going on. VPS-G stated that then there was a text that came through to R1 and CNA-C was breaking things off. It was then brought to our attention again and we asked R1 about their relationship. R1 then became cooperative and shared all of the text messages between himself and CNA-C. VPS-G stated that once we started to ask CNA-C questions about her having R1's phone number she was educated on this not being appropriate. CNA-C then resigned 9/4/24. Surveyor asked why VPS-G didn't start an investigation when he was made aware that R1 and CNA-C were texting one another. VPS-G stated that he didn't think anything was going on and no one else came forward with any information. VPS-G stated he did not go and ask staff if they knew anything about R1 and CNA-C and that he did not ask R1 to see the text messages. VPS-G stated he did not interview R1's roommate nor did he ask any other residents about relationships with staff. VPS-G stated he was not aware that R1 received gifts from CNA-C and that looking back he should have asked more about the situation. VPS-G also did not report to the state survey agency within the required timeframe, as an investigation was not conducted until 10/2/24. On 10/22/24 at 2:10 p.m., Surveyor interviewed NHA-A regarding the facility's investigation into the relationship between R1 and CNA-C. NHA-A stated that on 10/2/24, a staff member had come to her and had a concern about a text message she saw on R1's phone from CNA-C about calling the police on R1. NHA-A stated that she then went to talk with R1, and he denied it at first and said he was just friends with CNA-C. NHA-A stated that after talking with R1 a bit longer he agreed to share the text messages with her. NHA-A stated she read through all of the messages, and they went back to July. R1 then let NHA-A take pictures of the text messages with a facility cell phone. NHA-A then said she had asked VPS-G if he had any knowledge of R1 and CNA-C being in a relationship. VPS-G stated that he was aware they had exchanged phone numbers but they both stated they were just friends. NHA-A stated that on 9/4/24 she wanted to bring in CNA-C to talk about her about exchanging phone numbers with R1 and the purchase of T-shirts for him. CNA-C then resigned her position before we could get any further statement from her. NHA-A stated that there were a lot of rumors floating around about the relationship, but nobody actually said they saw anything. NHA-A stated that she would have expected staff to report rumors as suspected allegations. As of the time of survey exit on 10/23/24, the facility did not provide any additional information as to why facility staff did not report suspected abuse/exploitation happening between R1 and CNA-C immediately and also why the facility Administration did not report the allegation to the state survey agency.

Based on record review and staff interviews, the facility did not always ensure allegations of abuse/exploitation were thoroughly investigated for 2 out of 2 residents reviewed (R1, R6). * Facility staff became aware of a relationship between R1 and CNA (Certified Nursing Assistant)-C that included months of communication via phone calls, text messages, and in-person visits to the resident's room. CNA-C would often visit R1 while working at the facility when she was not assigned to his unit. By the staff not reporting to Nursing Home Administrator (NHA) what they had heard and observed, it allowed the alleged perpetrator (CNA-C) continued access to R1. When NHA did become aware that R1 and CNA-C had exchanged phone numbers, they failed to thoroughly investigate the situation by talking with staff who may have knowledge of the incident. CNA-C worked various shifts on multiple units of the facility. This had the potential to effect the entire census of 69 residents. *R6's family member expressed a concern to the facility regarding R6 expressing a Certified Nursing Assistant (CNA) was rough with cares. The facility did not investigate the allegation of abuse/mistreatment and the facility has no documentation of this incident. Findings include: The facility's policy dated as reviewed 7/15/2022 and titled, Abuse, Neglect and Exploitation documents: 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: Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s). VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. F. Providing emotional support and counseling to the resident during and after the investigation, as needed. Surveyor became aware that R1 was in a relationship with Certified Nursing Assistant (CNA)-C which began in July 2024. CNA-C was employed at the facility until 9/4/2024 and worked various shifts on various units throughout the facility. On 10/21/24 at 9:30 a.m., Surveyor began a review of the facility's reported incident which documents there was an allegation of an inappropriate relationship with former staff member (CNA-C) overstepping boundaries and may or may not involve exploitation (taking advantage of a resident for personal gain). The date discovered is documented as 10/2/24. The date of occurrence is 10/2/24 at 2:15 p.m. The occurred date and time are estimated. The timeline included in the facility's investigation stated that on 10/1/24 an employee made Administrator-A aware of text messages between R1 and CNA-C. On 10/1/24, Administrator-A spoke to R1 and asked about R1's relationship with CNA-C and the employee using his credit card. R1 denied the employee used his card; R1 stated the relationship was not an intimate relationship, they were just friends. R1 denied any text messages and did not want to be questioned about the incident. On 10/2/24, Administrator-A interviewed R1 again and asked if she can read their (CNA-C and R1) text messages. R1 allowed Administrator-A to read through the text messages on his cell phone. The text messages date back to 7/6/24. Text messages include, I love you, I cant wait for us to be together, I miss you, I want to kiss you from head to toe, I can't wait to lay with you, let's be alone, I only belong to you, and jealous statements about other caregivers; there were text messages that talked about R1's penis and being inappropriate. The facility's investigation included statements from staff members. The following statements documented: On 10/5/24, CNA-H answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-H wrote, No, I have not first person, but I have heard about it from several residents. Question #2-are you aware of staff giving residents gifts? CNA-H wrote yes. On 10/4/24, CNA-I answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-I wrote, I haven't witnessed any myself, but I did hear rumors about something from residents and a CNA about a month or two ago. On 10/4/24, CNA-J answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-J wrote, No I have not witnessed any inappropriate relationships between staff and residents, I've only heard about something of the sort through whispers. On 10/4/24, CNA-K answered the following question: Have you ever witnessed any inappropriate relationships between staff and residents? CNA-K wrote, I've heard about it through staff and I have seen sweet/sexual notes from staff to resident. Question #2-are you aware of staff giving residents gifts? CNA-K wrote yes. On 10/7/24, CNA-L wrote a witness statement that documented the following: I witnessed an inappropriate relationship between a resident and a coworker. I am aware of the coworker giving the resident new clothes such as T-shirts. My resident showed me text messages between them. I then reported it to Social Services and Human Resources. My resident had confided in me and told me they were dating, which I reported. A note from the coworker was left pinned up to the resident's bulletin board. It was found in the morning after she was scheduled as a CNA for night shift on unit 200. On 10/21/24 at 12:50 p.m., Surveyor interviewed CNA-D regarding R1. CNA-D stated she was aware of the situation involving R1 and CNA-C and had heard other staff talk about inappropriate texts and letters and that the staff member bought things for R1. CNA-D stated that she didn't report it because it was all hearsay. CNA-D stated that talk started buzzing around April/May about R1 and CNA-C and then in July it was an everyday topic between staff. Staff would see CNA-C make her way around the facility and out of her way to go see R1. All the staff just wondered why. CNA-D stated that she was aware several people reported it to their supervisors. CNA-D stated that it wasn't until R1 brought it to upper management that an investigation was really done. On 10/22/24 at 8:10 a.m., Surveyor interviewed Registered Nurse (RN)-E regarding R1 and CNA-C. RN-E stated that sometime between August 5-9th 2024 a night CNA came to her and reported that she felt there was some inappropriate contact between R1 and CNA-C. RN-E stated that she reported it to the Director of Nursing (previous) and Administrator (previous). RN-E then stated that sometime between August 20-23rd, 2024, while at the 200 Unit nursing station, she heard a CNA talking about the relationship between R1 and CNA-C and that she had bought items for R1. RN-E stated that she then reported this to former Administrator/VP of Success-G and he said he would take it from there. RN-E stated that R1 would make comments about text messages and other staff would see CNA-C going into R1's room when she would be assigned to work on a different unit. RN-E stated that even R1's roommate would say that R1's girlfriend was here again last night. On 10/22/24 at 12:50 p.m., Surveyor interviewed VPS-G regarding R1. VPS-G stated that he was the interim Administrator from 8/9/24 to 9/23/24. VPS-G stated that all he was initially aware of is that R1 and CNA-C had exchanged phone numbers. He stated that going forward a whole different picture has been painted. VPS-G stated that staff had started to talk about CNA-C having R1's phone number and they were texting one another. VPS-G said he went to talk with R1 and R1 denied anything was going on. CNA-C was also asked about having R1's phone number and she denied it as well. CNA-C stated that she felt bad for R1 and just wanted to be there for him. Other facility staff did not say anything moving forward and I just thought there was nothing out of the ordinary going on. VPS-G stated that then there was a text that came through to R1 and CNA-C was breaking things off. It was then brought to our attention again and we asked R1 about their relationship. R1 then became cooperative and shared all of the text messages between himself and CNA-C. VPS-G stated that once we started to ask CNA-C questions about her having R1's phone number, she was educated on this not being appropriate. CNA-C then resigned 9/4/24. Surveyor asked why VPS-G didn't start an investigation when he was made aware that R1 and CNA-C were texting one another. VPS-G stated that he didn't think anything was going on and no one else came forward with any information. VPS-G stated he did not go and ask staff if they knew anything about R1 and CNA-C and that he did not ask R1 to see the text messages. VPS-G stated he did not interview R1's roommate nor did he ask any other residents about relationships with staff. VPS-G stated he was not aware that R1 received gifts from CNA-C and that looking back he should have asked more about the situation. VPS-G also did not report to the state survey agency within the required timeframes, as an investigation was not conducted until 10/2/24. Facility staff stated to Surveyor that she had notified the previous Administrator sometime between August 5th and 9th that she felt there was some inappropriate contact between R1 and CNA-C. CNA-C worked 20 additional times, on various shifts and on various units from August 9th until she resigned on 9/4/24. As of the time of survey exit on 10/23/24, the facility did not provide any additional information as to why facility staff did not conduct a thorough investigation when they became aware that R1 and CNA-C had shared telephone numbers and were texting one another and staff reported they felt as though there was inappropriate contact between the 2 of them. 2.) R6 was admitted to the facility on [DATE] with diagnoses that include multiple rib fractures, dysphasia, malnutrition, weakness, and lack of coordination. R6's Admission Minimum Data Set (MDS), dated [DATE], documents R6 has a Brief Interview for Mental Status (BIMS) of 11, indicating R6 has moderately impaired cognition, and requires partial/moderate assistance with personal hygiene and dressing. On 10/21/2024 at 01:25 PM, Surveyor interviewed R6 and R6's family member. R6's family member informed Surveyor that R6 expressed concerns to family member in August 2024 about a CNA being rough with R6 during cares. R6's family member informed Surveyor that R6's family member brought the concern to ADON-X's attention. R6 was unable to recall the situation at time of survey. Surveyor reviewed the facility's Grievance log but did not locate a grievance for R6 regarding rough cares. On 10/22/2024 at 08:40 AM, Surveyor interviewed ADON-X. ADON-X informed Surveyor that she recalls the situation with R6 and the concern R6's family brought to ADON-X's attention. ADON-X indicated R6's family member informed ADON-X that R6 expressed to R6's family member a CNA was rough with R6. ADON-X informed Surveyor that R6 told the CNA they were being too rough, and the CNA continued to be rough. ADON-X informed Surveyor that ADON-X spoke to the CNA. ADON-X informed Surveyor that training and education were provided to the CNA and a grievance form was filed. ADON-X informed Surveyor that No male CNAs was put on R6's report sheet for staff. ADON-X informed Surveyor that R6 did not give a good description of what rough meant. ADON-X informed Surveyor the complaint was investigated, although ADON-X was unsure if other residents were interviewed. ADON-X informed Surveyor education and training were provided to third shift staff on being more gentle with R6 and R6 prefers a gentle touch. Surveyor requested the grievance form and investigation documentation from ADON-X. ADON-X informed Surveyor she would get back to Surveyor with that information. On 10/22/2024 at 09:35 AM, NHA-A informed Surveyor there are no grievances for R6 in August. NHA-A informed Surveyor that NHA-A is currently the grievance official and informed Surveyor that VP of Success-G was the Administrator and grievance official in August 2024. NHA-A informed Surveyor no documentation could be found regarding R6's concern of rough cares in August 2024. On 10/23/2024 at 07:40 AM, Surveyor interviewed VP of Success-G. VP of Success-G informed Surveyor he does not recall the situation with R6. Surveyor notes the facility did not complete a thorough investigation of the alleged abuse/mistreatment of R6 by a CNA that occurred in August 2024. Surveyor informed NHA-A of the above concerns. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. There were observations of call lights not being answered for an extended period of time, Director of Nursing (DON)-B expressed concern regarding nurse staffing levels, record review and residents expressing concerns regarding lack of sufficient staff. The facility had low staffing on night shift on 10/1/24 and 10/4/24, while having a census of 74 and 75 residents. R2 did not receive a scheduled shower on 9/26/24 due to short staffing. Findings include: 1.) Surveyor reviewed the facility's night shift schedule for 10/1/24 which documents 1 nurse and 1 CNA for the 100 and 200 units, and 1 nurse and 2 CNAs (with one CNA marked as late) on the 300 and 400 units. Surveyor noted there are 5 staff members (with one CNA coming in late) that are present in the facility on night shift with a census of 75 residents. Surveyor reviewed the facility's night shift schedule for 10/4/24 which documents 1 nurse and 1 CNA for the 100 and 200 units, and 1 nurse and 1 CNA on the 300 and 400 units. Surveyor noted there are 4 staff members present in the facility on night shift with a census of 74 residents. Surveyor interviewed Business Office Assistant (BOA)-Q on 10/22/24 at 10:37 am. BOA-Q stated she works closely with the Director of Nursing (DON)-B when making the schedule. BOA-Q starts with a master schedule by placing facility staff in blocks for their scheduled hours. BOA-Q will then ask agency staff or facility staff to pick up hours if there are open shifts. BOA-Q stated daily staffing is based on census and acuity. BOA-Q stated she will schedule 1 nurse that oversees the 100 and 200 units on night shift, 1 nurse on the 300 unit and 1 nurse on the 400 unit. BOA-Q stated she will schedule 1-2 CNAs that will oversee the 100 and 200 units, 1 CNA for the 300 unit, and 1 CNA for the 400 unit. Surveyor asked BOA-Q about night shift staffing on 10/1/24 and 10/4/24. BOA-Q stated on 10/4 she had planned for the evening shift nurse to stay and help with nursing and CNA cares on night shift; however, this nurse had left the facility due to another nurse being present on the 100-200 units. BOA-Q stated she will investigate the 10/1/24 night shift staffing and get back to Surveyor with additional information. On 10/22/24 at 1:16 pm, Nursing Home Administrator (NHA)-A notified Surveyor the CNA marked as late on the 10/1/24 night shift schedule started working at 11:00 pm, and an evening staff member stayed late until 11:00 pm to cover. Surveyor notified NHA-A of concerns with low staffing on night shift on 10/1/24 and 10/4/24 with having a census of 74 and 75 residents. Surveyor requested additional information if available. On 10/21/24 at 9:29 am, Surveyor observed a call light activated on the 100 unit. Surveyor observed 7 staff members walking the halls, sitting in the nursing station, and not responding to the call light. Surveyor observed the call light being answered by staff at 9:43 am. On 10/21/24 at 1:29 pm, Surveyor interviewed Certified Nursing Assistant (CNA)-D who stated CNAs within the facility have an average of 12 residents per shift. CNA-D reported the facility is assigning CNAs 13-15 residents per shift due to not having a full census. CNA-D indicated staff help each other out when they are short staffed. CNA-D stated there have been times when she has worked by herself, and a nurse may not have time or have helped with CNA tasks. Surveyor reviewed R7's medical records which documents a progress note dated 10/9/24 at 9:55 pm, which states R7 has complaints of her call light being on for an hour and no one is coming to answer her call light. R7 states she has been having to call her brother-in-law to call the facility to get someone to come to her room for help. R7 stated she is worried that long call light times will continue. Surveyor reviewed the facility's grievance log which includes two grievances with long call light times dated 10/5/24 and 10/9/24. Surveyor noted the grievance dated 10/5/24 for long call light times was resolved on 10/8/24. Surveyor noted the grievance dated 10/9/24 for long call light times was resolved on 10/9/24. On 10/22/24 at 11:24 am, Surveyor interviewed DON-B, who stated call light concerns are related to staffing. DON-B indicated the facility has been doing a lot to improve staffing. The facility has been conducting call light audits, discussing call light concerns at QAPI, discussing call light concerns at management rounds, and discussing call light concerns at staff meetings. On 10/22/24 at 3:15 pm, Surveyor notified NHA-A and DON-B of concerns with low staffing on night shift for 10/1/24 and 10/4/24, long call light times, grievances discussing long call lights, and observations of long call light times. 20483 2.) R2's diagnoses includes chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and dementia. The annual MDS (minimum data set) with an assessment reference date of 7/29/24 indicates R2 has a BIMS (Brief Interview for Mental Status) score of 8 which indicates moderate cognitive impairment. R2 is assessed as being dependent for showers/bathing. R2's physician orders with an order date of 8/13/24 include: Resident has shower scheduled Monday PM (evening) shift and Thursday AM (morning) shift every day shift every Thur (Thursday). An order date of 8/13/24 documents: Resident has shower scheduled Monday PM shift and Thursday AM shift every evening shift every Mon (Monday). The order administration note dated 9/23/24 at 21:26 (9:26 p.m.), documents: Note Text: Resident has shower scheduled Monday PM (evening) shift and Thursday AM (morning) shift every evening shift every Mon. Did not occur due to low staff. This nurses note was written by LPN (Licensed Practical Nurse)-FF. The order administration note dated 9/26/24 at 14:34 (2:34 p.m.), documents: Note Text: Resident has shower scheduled Monday PM (evening) shift and Thursday AM (morning) shift every day shift every Thu (Thursday). Did not occur short staffed. This note was written by LPN-FF. On 10/23/24 at 10:38 a.m., Surveyor informed ADON (Assistant Director of Nursing)-X R2 did not receive her scheduled showers due to low staffing. Surveyor informed ADON-X of R2's order administration notes dated 9/23/24 & 9/26/24 which document R2 did not receive her scheduled shower due to low/short staffing. ADON-X replied, We're not supposed to write anything like that, let me look to see if she had one another date. ADON-X then informed Surveyor R2 had a shower on the 23rd but did not have one on the 26th. On 10/23/24 at 3:56 p.m., Surveyor informed NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, [NAME] President of Success-G, and [NAME] President of Clinical-GG of R2 not receiving a shower on 9/26/24 due to short staffing. No additional information was provided to Surveyor. 3.) On 08/10/2024 and 08/24/2024, during night shift, the facility did not have sufficient staff to meet the needs of residents, per the facility's Assessment. Surveyor reviewed the facility's document titled, Daily Attendance Sheet, dated 08/10/2024, which documents 2 Nurses and 2 Certified Nursing Assistants worked the night shift. The census on 08/10/2024 was 80, per the facility's document titled, Today's Staffing. Surveyor reviewed the facility's document titled, Daily Attendance Sheet, dated 08/24/2024, which documents 2 Nurses and 2 CNAs worked the night shift. The census on 08/24/2024 was 78, per the facility's document titled, Today's Staffing. On 10/21/2024 at 11:43 AM, Surveyor interviewed CNA-SS. CNA-SS expressed to Surveyor that when the facility is not fully staffed, due to call-ins or no shows, residents are not able to receive the care needed. CNA-SS explained to Surveyor that there have been shifts with 1 CNA for 20 residents. CNA-SS informed Surveyor, with only 1 CNA to a unit, with 20 residents, staff are unable to complete baths/showers, and residents are not being toileted. On 10/21/2024 at 11:54 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-FF. LPN-FF informed Surveyor that low staffing has been an issue for a while. LPN-FF informed Surveyor that call light wait times are over an hour when there is low staffing, causing residents to become upset. LPN-FF informed Surveyor that she has verbally communicated concerns to Director of Nursing (DON)-B. LPN-FF informed Surveyor that LPN-FF was not confident on how the grievance/concern process works, but states LPN-FF will either fill out the grievance form and give to DON-B or the concern is communicated verbally. LPN-FF informed Surveyor that LPN-FF is not sure what happens in the grievance process once information is given to DON-B. On 10/22/2024 at 10:37 AM, Surveyor interviewed Business Office Assistant-Q. Business Office Assistant-Q informed Surveyor that Business Office Assistant-Q oversees the schedule with DON-B. Business Office Assistant-Q indicated to Surveyor that on night shift, Business Office Assistant-Q scheduled 1 Nurse on for the 100 and 200 units and 1 Nurse for 300 and 400 units. Business Office Assistant-Q informed Surveyor that Business Office Assistant-Q schedules 1 CNA for the 300 unit, 1 CNA for the 400 unit, and will schedule 1-2 CNAs for the 100 and 200 units. On 10/23/2024 at 07:44 AM, Surveyor interviewed DON (Director of Nursing)-B. DON-B informed Surveyor that the facility does not schedule low staffing and if call ins occur on the shift nurses will help with call lights. DON-B informed Surveyor the facility is working on staffing and that low staff happens due to call ins or unexpected changes. DON-B indicated to Surveyor that if nurses are unable to meet the needs of residents, the nurses or CNA call DON-B and DON-B will come in to help. DON-B also informed Surveyor that the charge nurse would be responsible for reaching out to agency staff or asking other staff to stay late or come in early, if short staffed. On 10/23/2024 at about 03:40 PM, Surveyor notified NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, [NAME] President of Success-G, and [NAME] President of Clinical-GG of above concerns. No additional information was provided.

Based on interview and record review the facility did not ensure 1 (R2) of 1 resident's resident representative was notified when there was a need to alter medical treatment. R2's POA (Power of Attorney) was not notified when there was a change in R2's pain medication. Findings include: The facility's policy titled, Change in Condition of the Resident and reviewed/revised 9/20/2022 under Policy documents A facility should immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 1.) R2 was admitted to the facility with a diagnoses includes chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and dementia. R2's POA (power of attorney) for healthcare was activated on 11/12/21. On 10/21/24, at 2:15 p.m., Surveyor spoke with R2's POA on the telephone. During this conversation R2's POA informed Surveyor they were not informed when R2's pain medication was changed. R2's POA informed Surveyor it's in R2's record if there are any medication changes they are to be notified. R2's nurses note dated 9/25/24, at 13:17 (1:17 p.m.), documents Spoke with [Name] at pain clinic regarding noticeable behavior and confusion issues with resident since recent med (medication) change to Hydromorphone. Waiting on call back from clinic for update on how to proceed forward. This nurses note was written by LPN (Licensed Practical Nurse)-Z. The progress note dated 9/30/24, at 11:45 a.m., under Subjective documents Patient is seen in her room during visit currently resting in bed. She has now completed antibiotics for UTI (urinary tract infection) without any further urinary concerns reported. Recently updated by nursing staff that patient had worsening behaviors with confusion that had been noted upon starting Dilaudid. Pain clinic was updated and gave order to discontinue Dilaudid and start Norco instead, which patient has been tolerating without adverse effect. She does note ongoing back pain at baseline and is reminded to let nursing staff know when she has pain, with goal to optimize her pain control. Patient has no other complaints today. No shortness of breath or chest pain. Mentation appears at baseline currently. Nursing staff to continue to monitor pain control as well with no other new concerns reported today. Under Assessment and Plan documents M54.50 - Low back pain, unspecified*: Chronic R (right) sided; w/ (with) lumbar radiculopathy. Per outpt (outpatient) specialist [Physician's name] - Dilaudid dc'ed (discontinued), Norco resumed instead given concern of worsening behaviors/confusion on Dilaudid. Tolerating Norco so far w/o (without) AE (adverse event), and appreciate ongoing specialists recs (recommendations). This progress note was written by PA (Physician Assistant)-AA. R2's physician orders with an order date 9/8/24 documents Hydromorphone HCL (Diaudid) oral tablet 2 mg (milligram). Give 1 tablet by mouth one time a day every Mon (Monday) for pain after dialysis and Give 1 tablet by mouth one time a day every Wed (Wednesday) for pain after dialysis and Give 1 tablet by mouth one time a day every Fri (Friday) for pain after dialysis and give 1 tablet by mouth every 8 hours as needed for severe pain. This order was discontinued on 9/26/24. R2's physician orders with an order & start date 9/26/24 documents Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligram) (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain. R2's physician orders with an order date of 9/26/24 & start date of 9/27/24 documents Hydrocodone-acetaminophen Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) for pain post dialysis. During R2's record review, Surveyor was unable to locate R2's POA was notified of the change in pain medication. On 10/23/24, at 10:30 a.m., Surveyor asked ADON (Assistant Director of Nursing)-X if a resident is on a pain medication and changed to another pain medication would you notify the resident's representative of this change. ADON-X replied yes. Surveyor informed ADON-X on 9/26/24 R2's Diaudid 2 mg was discontinued and Hydrocodone-acetaminophen 5-325 mg was ordered. Surveyor informed ADON-X Surveyor was unable to locate R2's POA was notified of this change. ADON-X reviewed R2's electronic medical record and stated to Surveyor I do not see anything either. On 10/23/24, at 11:12 a.m., Surveyor informed DON (Director of Nursing)-B R2's POA was not notified when there was a change in pain medication on 9/26/24. No information was provided to Surveyor as to why R2's POA was not notified of the change of pain medication on 9/26/24.

Based on observation, interviews, and record review the facility did not address and resolve grievances conveyed on behalf of 2 (R9 and R12) of 5 residents reviewed for grievances. * On 10/18/2024, a grievance was initiated for R9 related to R9 having concerns with not being checked on night and being double briefed on night shift. Surveyor noted the grievance form documented the grievance was resolved, but R9 continued to express concern to Surveyor of on-going issue and Surveyor observed R9 saturated in urine in the morning on 10/23/2024. * R12 informed Surveyor of concerns that R12 is not getting up before 06:00 AM, as care planned, and has not been updated on a concern R12 voiced regarding a room change discussed with the Facility. Findings include: The Facility's policy, titled Grievance Policy, with a last reviewed date of 07/2022, documents in part, POLICY the facility will seek to resolve concerns, complaints or grievances and provide residents, reasonable parties, staff and others feedback and resolution in a timely manner . . Residents, residents' families and responsible parties, facility staff and facility contractors will be in-serviced on the Grievance procedure, how to initiate a grievance, who the Grievance Officer is and how resolutions will be communicated. The Department Head that is assigned the concern form is responsible for investigating the issue and following up to provide a resolution to the issue within 72 hours of being assigned the grievance. The Grievance Officer will ensure that: . Written grievance resolution decisions include the date when the original concern was received, a summary statement of the concern, steps taken to investigate, a summary or findings or conclusions regarding the concern, whether the concern was confirmed or not, any corrective action taken and the date the written decision was issued. 1.) R9 was admitted to the facility on [DATE] with diagnoses which includes, muscle weakness, heart failure, morbid obesity, and muscle wasting. R9's Quarterly Minimum Data Set (MDS), dated [DATE], documents R9 has a Brief Interview of Mental Status (BIMS) of 15, indicating R9 is cognitively intact. R9's Quarterly MDS, dated [DATE], is the most recent MDS indicating R9's self-care performance, and documents, R9 requires substantial/maximal assistance with toileting hygiene and rolling left and right. On 10/21/2024 at 09:25 AM, Surveyor interviewed R9. R9 informed surveyor of concerns R9 has with third shift staff not changing or check on R9, double briefing R9 and R9 wakes up in the morning in a puddle of urine. R9 informed Surveyor that R9 has voiced concerns of these issues to Nurses and Certified Nursing Assistants (CNA) on first shift. R9 informed Surveyor that R9 has told staff R9 does not want to be double briefed. R9 informed Surveyor that R9 was not double briefed last night, but woke up this morning and urine leaked through R9's brief but was changed this morning. On 10/22/2024 at 7:05 AM, Surveyor observed R9 in bed, and smelled of urine. R9 informed Surveyor that the CNA came in a little bit ago and said they would change R9 after breakfast. On 10/22/2024 at 09:35 AM, Surveyor interviewed NHA-A. NHA-A informed Surveyor that NHA-A is the Grievance Official. NHA-A indicated NHA-A follows up on grievances and talk about the grievances in daily stand-up meetings. NHA-A informed Surveyor that any staff member can fill out a grievance form and put in under NHA-A's door. NHA-A informed Surveyor that Department Heads will round daily with residents. NHA-A informed Surveyor they will ask residents if they want to file a formal complaint or not, but all abuse is to be reported. NHA-A indicated that if a resident voices concerns, the resident should be asked if they would like to file a formal complaint, if family voices concerns, then it should be a formal grievance. On 10/22/2024 at 10:13 AM, Surveyor observed that R9 was clean and changed. On 10/22/2024 at 12:46 PM, Surveyor interviewed CNA-D regarding grievance procedure. CNA-D informed Surveyor that and concerns should be brought to a supervisor, or the DON and they would follow up with it. On 10/22/2024 at 12:47 PM, Surveyor interviewed RN-E regarding the grievance process. RN-E informed Surveyor that RN-E would fill out a grievance form and give to the Executive Director or DON, and if the concern was involving abuse RN-E would call right away. RN-E informed Surveyor that not everything is written on a grievance form, most things are verbally relayed to Executive Director or DON and they will determine if a grievance form is filled out or not. On 10/23/2024 at 08:05 AM, Surveyor observed CNA-MM providing cares for R9. Surveyor observed R9 to have saturated urine in R9's brief, as well as bed sheets. Surveyor noted a strong smell of urine. R9 indicated R9 had not been checked or changed through the night. Surveyor reviewed the Facility's Grievance Log but did not locate a grievance for R9. On 10/23/2024 at 07:44 AM, Surveyor interviewed DON-B. DON-B informed Surveyor that the expectation for grievances is staff should see if the concern can be immediately resolved, and if not, a grievance form should be completed and resolved within 7 days. DON-B informed Surveyor that if concerns were brought to staff, staff would report to the Nurse or DON and rule out abuse and/or address the problem. DON-B indicated that any staff member can fill out a grievance form. Surveyor asked DON-B about R9's concerns, DON-B indicated DON-B addressed R9's grievance on Monday 10/21/2024 and indicated DON-B is still working to resolve the concern but does have the grievance form and would provide that to Surveyor. Surveyor reviewed the document titled, GRIEVANCE/COMPLAINT REPORT, with a received date of 10/18/2024 and documents in part, . Describe grievance/complaint using factual terms: Resident was Double briefed on night shift and not checked on . DOCUMENTATION OF FACILITY FOLLOW UP, Surveyor noted DON-B name is documented as the individual designated to this concern. Date assigned: 10/18/24 Time: 12:56 Date to resolved by: 10/21/2024 Was a group meeting held?, Surveyor noted Yes is marked, identify all individuals in attendance: Surveyor noted this section is blank. What other actions(s) was/were taken to resolve grievance/complaint (be specific)? Surveyor noted CNA was spoken with to ensure no double briefings. RESOLUTION OF GRIEVANCE/COMPLAINT Was grievance/complaint resolved? Surveyor noted, Yes, describe resolution is marked, but no description is given. Surveyor noted document was signed by DON-B on 10/18/2024. No additional information was provided. 2.) R12 was admitted to the facility on [DATE] with diagnoses that includes Multiple Sclerosis, dysphagia, and neuromuscular dysfunction of bladder. R12's most recent Quarterly MDS, dated [DATE], documents R9 BIMS score of 09, indicating R9 has moderately impaired cognition. On 10/21/2024 at 09:35 AM, Surveyor interviewed R12. R12 informed Surveyor that she does not currently like the room she is in and has requested to change rooms but has not heard anything back. R12 informed Surveyor that R12 has been getting self out of bed the last 4 days and indicated R12 has brought self to the bathroom and dressed self. R12 informed Surveyor that R12 likes to get up early in the morning and staff is aware of this. R12 informed Surveyor that staff will come in to empty her catheter bag, but R12 waits about an hour for call light to be answered. Surveyor reviewed R12's care plan and noted under ADL self-care deficit f/t: MS, physical limitations, documents, Resident's preference is to get up before 0600 am daily On Sunday please assist her in getting the church service on television, with an initiation date of 10/16/2023. Transfer: 1 assist w/2ww for transfers, with an initiation date of 03/13/2024. Surveyor noted a progress note, dated 09/16/2024 indicating R12 had a fall trying to self-transfer from bed to wheelchair, no injuries noted. On 10/22/2024 at 07:34 AM, Surveyor observed CNA (Certified Nursing Assistant)-K assisting R12 out of bed. On 10/22/2024 at 10:15 AM, R12 informed Surveyor that R12 feels that Social Services Coordinator-F is avoiding R12 regarding the room change. On 10/22/2024 at 01:08 PM, Surveyor spoke with Social Services Coordinator-F. Social Services Coordinator-F informed Surveyor Social Services Coordinator-F is aware of R12 requesting a room change, and Social Services Coordinator-F informed R12 that they would discuss it when a room became available. Social Services Coordinator-F informed Surveyor that Social Services Coordinator-F and R12 only had a verbal discussion about 1.5 months ago regarding the room change and there is no formal documentation regarding the room change request. On 10/23/2024 at 07:14 AM, Surveyor observed R12 in bed, R12 informed Surveyor R12 has been up just laying in bed for hours and would like to get out of bed. R12 informed Surveyor that R12 does not want to fall, so R12 was waiting for someone to come help R12 out of bed. R12 informed Surveyor that Social Services Coordinator-F came this morning to talk with R12 regarding room change. On 10/23/2024 at 08:05 AM, Surveyor interviewed CNA-MM. CNA-MM informed Surveyor that R12 like to get out of bed around 06:30-06:45 AM and that information regarding specifics on resident preferences can be found in Point Click Care. On 10/23/2024 at 08:54 AM, Surveyor interviewed DON-B. DON-B informed Surveyor that R12 is up for breakfast and has never voiced concerns regarding the time R12 gets out of bed. Surveyor informed DON-B that the time R12 likes to get out of bed is already documented in R12's care plan. Surveyor informed NHA-A and DON-B of above findings. No additional information was provided as to why the facility did not address and resolve grievances conveyed on behalf of R12.

Based on interview and record review, the facility did not ensure their admissions policy was followed for 1 resident (R16) of 1 residents reviewed. * R16 was admitted on [DATE] and did not sign the admission agreement within 48 hours which includes but not limited to: consent to treat, financial agreement, and resident rights. Findings Include: The facility's Admission Policy implemented 10/1/18 and last revised on 11/1/23 documents: Policy : All facilities must follow the policy and procedures for all admissions to mitigate bad debt risk. The admission process sets the precedent for all the billing and collection process. The Executive Director will delegate the admission process to the appropriate individual(based on staffing pattern of the facility). This individual must ensure that both clinical and financial assessments are completed before any admission decision. Policy Explanation and Compliance Guidelines Admission Agreement The Admissions Designee, will ensure the admission agreement and Alternative Dispute Resolution(ADR) is completed in Carefeed on day of admission, with proper signatures in place. The entire admission packet should be completed in Carefeed within 48 hours of admission. Note, the patient/family is NOT required to sign in agreement of the ADR. A new admission agreement is required in the following circumstances: -All first time admissions -Any admission that was discharged with no intent to return, regardless of time between discharge and return A properly signed admission agreement should include the following: -Patient's signature, unless deemed legally incompetent. In this case, the Medical Director needs to document the reason in the medical chart. In addition, two facility signatures are required. OR -Patient's x mark, if unable to sign. In this situation, two facility signatures are required as witness. -Legal representative, if applicable -Facility representative -If signed by a Legal representative, a copy of the applicable legal documents must be provided to the facility and maintained with admission documents Financial Agreement The financial Agreement must be completed in Carefeed by the business office manager, or designee, on all admissions except short term stays that have confirmed a pay source for the entire stay. The admitting pay source should have already been confirmed prior to admission. This agreement serves as a validation of that pay source, as well as a determination of next or secondary pay source. Information should be obtained prior to admission if possible. If necessary, the agreement is to be completed on day of admission. The information is needed to ensure they receive any and all benefits that they are entitled to receive. Potential available benefits include, but are not limited to: -Insurance-Must follow specific insurance requirements regarding authorizations, documentation, etc. -Insurance may cover part of a stay based on level of care needs A business office associate should also meet with the patient/family to discuss the following: -Payment terms and expectations -Format of monthly statement -Benefits of Direct Deposit, if not signed upon admission -All other benefits available for the patient Admission File After all Signers have completed their session in Carefeed and the documents move to Completed Status, the admission agreements, along with supporting documents, are automatically, uploaded to the patient's PCC Misc tab by Carefeed. The admission file documents are maintained in PCC Misc tab. 1.) R16 was admitted to the facility on [DATE] with diagnoses of Other Specified Diseases of Liver, Muscle Weakness, Hypertensive Heart Disease with Heart Failure, Unspecified Asthma, Arthropathic Psoriasis, Immunodeficiency, Type 2 Diabetes Mellitus, and Adjustment Disorder with Muscle Weakness. R16 discharged from the facility on 10/17/24. R16's Admission Minimum Data Set(MDS) completed on 9/23/24 documents R16 has a Brief Interview for Mental Status(BIMS) score of 15, indicating R16 was cognitively intact for daily decision making at time of assessment. On 10/22/24 at 11:24 AM, Surveyor interviewed Admission Director (AD-M) in regards to the admission process. AD-M explained that all admission paperwork should be explained to the Resident and/or representative including insurance benefits. The admission paperwork should be completed timely of admission to the facility. The admission paperwork is completed electronically and AD-M always offers to provide the Resident and/or representative with a 'hard copy'. AD-M informed Surveyor that AD-M was out on medical leave during the time R16 was admitted to the facility and that Social Services Coordinator (SSC-F) was completing the admission paperwork for new Residents admitted to the facility. On 10/22/24 at 12:42 PM, Surveyor spoke to SSC-F in regards to R16 and the admission process. SSC-F confirmed that SSC-F was covering for admissions and completing the required paperwork when R16 was admitted to the facility. SSC-F believes SSC-F had R16 sign electronically on the facility's I-Pad. Surveyor requested a copy of R16's signed admission agreement including notification of R16's financial agreement. Surveyor explained to SSC-F that Surveyor is unable to locate the Admission File in R16's electronic medical record(EMR). On 10/22/24 at 2:18 PM, SSC-F informed Surveyor that R16's admission paperwork somehow got deleted and the facility is working on getting it retrieved. On 10/22/24 at 3:15 PM, Surveyor shared the above findings with Nursing Home Administrator (NHA-A) and Director of Nursing (DON-B) regarding that R16's signed admission paperwork is not available. On 10/23/24 at 9:04 AM, NHA-A informed Surveyor that R16's admission paperwork including but not limited to: consent to treat and financial agreement was not reviewed with R16 and/or representative and acknowledged with signature of understanding by R16 and/or representative. NHA-A stated the expectation is that it should have been completed with R16 and/or representative and several things fell through the cracks during that period of time. NHA-A stated he understood the concern that R16's admission paperwork was not reviewed and acknowledged by R16 and/or representative. No additional information was provided by the facility at this time.

Based on interview and record review the facility did not ensure 1 (R16) of 16 Residents reviewed had a comprehensive care plan that was reviewed and revised by the interdisciplinary team as determined by the Resident's assessed needs. R16's care plan was not revised to accurately identify R16's at risk for pressure areas/skin impairments, the need for a toileting plan, and discharge planning interventions. Findings Include: 1.) R16's Admission Minimum Data Set(MDS) completed on 9/23/24 documents R16 has a Brief Interview for Mental Status(BIMS) score of 15, indicating R16 was cognitively intact for daily decision making. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for shower/bathing, lower dressing, personal hygiene, rolling left to right, and sit to lying. R16 required partial/moderate assistance for upper dressing. R16 was dependent for sit to stand, transferring from chair to bed, and toileting transfers. R16 was occasionally incontinent of bladder and always continent of bowel on the admission MDS. R16's MDS documents R16 desired to discharge to the community and required active discharge planning. R16's quarterly MDS completed on 10/9/24 documents R16's BIMS score to be 11, indicating R16 was demonstrating moderately impaired skills for daily decision making. R16's MDS also documents at this time that R16 is frequently incontinent of bowel and bladder. R16's Discharge MDS completed on 10/17/24 does not assess R16's cognitive skills. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for lower dressing, personal hygiene. Shower/bathing was not attempted due to medical condition. R16 required partial/moderate assistance for upper dressing, sit to lying and lying to sitting, sit to stand, chair to bed transfer, and toilet transfer. Transferring to to tub/shower was not attempted due to medical condition. R16 was supervision for rolling left to right. R16 was frequently incontinent of bladder and always incontinent of bowel. R16's comprehensive care plan documents R16 shows potential for discharge initiated 9/17/24. Goal was to discharge home when clinical and rehabilitation goals are met. Interventions included: -Arrange transportation-9/17/24 -Complete a post discharge plan. Provide copy and review with Resident and/or representative 9/17/24 -Investigate need for special equipment, home health services, lifeline, outpatient therapy, physical follow up, resources. Make referrals as needed. 9/17/24 -Review progress toward discharge during scheduled meetings 9/20/24 Surveyor notes that R16's discharge focused problem was not revised during R16's stay at the facility to incorporate a person-centered approaches, knowing R16 potentially having only 30 days of stay at the facility. R16's comprehensive care plan documents R16 has urinary incontinence due to impaired mobility initiated 10/1/24. Interventions included: -Administer medication per MD orders 10/1/24 -Apply skin moistures/barrier creams as needed 10/1/24 -Place urinal/bedpan within Residents reach 10/1/24 -Provide assistance with toileting 10/1/24 -Provide incontinent care as needed 10/1/24 On 9/20/24 a grievance was filed by R16 in regards to incontinence care. A toileting plan was to be implemented at night. R16 was occasionally incontinent of bladder, always continent of bowel at admission and was frequently incontinent of bladder and always incontinent of bowel at time of discharge. R16's care plan was not revised to include person centered interventions for a toileting plan or interventions to address R16's continence decline. Surveyor notes that R16 has shearing documented on R16's admission evaluation dated 10/17/24. R16 also had blisters on bilateral arms and legs that at times would be described as weeping. R16's skin focused problem initiated 9/17/24 states the following: Actual at(specify location) due to -Administer treatment per MD orders 9/17/24 -Encourage and assist as needed to turn and reposition; use assuasive devices as needed 9/17/24 -Float heels as able 9/17/24 -Report evidence of infection such purulent drainage, [NAME], localized heat, increased pain, notify MD PRN 9/17/24 Surveyor notes that R16's skin care plan was not revised to include person centered interventions to identify the potential for skin breakdown including pressure relieving mattress, pressure relieving cushion for wheelchair, person centered intervention to float heels, and interventions to address R16's blisters on bilateral arms and legs. On 10/22/24 at 11:07 AM, Surveyor interviewed Director of Nursing (DON-B). DON-B agreed that R16's comprehensive care plan was not person centered and the care plan was lacking for person centered interventions. DON-B understands that R16 did not participate in the revision of R16's care plan and R16's care plan was not revised to incorporate appropriate goals and needs of R16. DON-B understands the concern and the facility had no additional information to provide.

Based on interview and record review, the facility did not develop and implement an effective discharge planning process focusing on resident discharge goal, preparation for transition and reduction in factors leading to preventable readmission for 1 resident (R16) of 1 residents reviewed for discharge planning. * The facility did not complete the admission process for R16 and/or representative including explaining R16's available benefits at time of admission detailing that R16 would either need to private pay as of 10/18/24, or the facility would need to assist R16 with an effective discharge plan for 10/18/24. R16 was notified at 8:45 AM on 10/17/24 the option of private pay or discharge home effective 10/18/24. R16 chose to discharge home on 10/18/24. Findings Include: The facility's Transfer and Discharge Policy implemented June 2017 and last revised on 7/15/22 documents: Anticipated Transfers or Discharges-initiated by the Resident a. Obtain physicians' orders for transfer or discharge and instructions or precautions for ongoing care. b. A member of the interdisciplinary (IDT) team completes relevant sections of the Discharge Summary. The nurse caring for the Resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the Resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results. ii. A final summary of the Resident's status. iii. Reconciliation of all pre-discharge medications with the Resident's post-discharge medications. iv. A post discharge plan of care that is developed with the participation of the Resident, and the Resident's representative(s) which will assist the Resident to adjust to his or her new living environment. c. Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the Resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. e. The comprehensive, person-centered care plan shall contain the Resident's goals for admission and desired outcomes and shall be in alignment with the discharge. 1.) R16 was admitted to the facility on [DATE] with diagnoses of Other Specified Diseases of Liver, Muscle Weakness, Hypertensive Heart Disease with Heart Failure, Unspecified Asthma, Arthropathic Psoriasis, Immunodeficiency, Type 2 Diabetes Mellitus, and Adjustment Disorder with Muscle Weakness. R16 discharged from the facility on 10/17/24. R16's Admission Minimum Data Set(MDS) completed on 9/23/24 documents R16 has a Brief Interview for Mental Status(BIMS) score of 15, indicating R16 was cognitively intact for daily decision making. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for shower/bathing, lower dressing, personal hygiene, rolling left to right, and sit to lying. R16 required partial/moderate assistance for upper dressing. R16 was dependent for sit to stand, transferring from chair to bed, and toileting transfers. R16 was occasionally incontinent of bladder and always continent of bowel on the admission MDS. R16's MDS documents R16 desired to discharge to the community and required active discharge planning. R16's quarterly MDS completed on 10/9/24 documents R16's BIMS score to be 11, indicating R16 was demonstrating moderately impaired skills for daily decision making. R16's Discharge MDS completed on 10/17/24 does not assess R16's cognitive skills. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for lower dressing, personal hygiene. Shower/bathing was not attempted due to medical condition. R16 required partial/moderate assistance for upper dressing, sit to lying and lying to sitting, sit to stand, chair to bed transfer, and toilet transfer. Transferring to to tub/shower was not attempted due to medical condition. R16 was supervision for rolling left to right. R16 was frequently incontinent of bladder and always incontinent of bowel. R16's comprehensive care plan documents R16 shows potential for discharge initiated 9/17/24. Goal was to discharge home when clinical and rehabilitation goals are met. Interventions included: -Arrange transportation-9/17/24 -Complete a post discharge plan. Provide copy and review with Resident and/or representative 9/17/24 -Investigate need for special equipment, home health services, lifeline, outpatient therapy, physical follow up, resources. Make referrals as needed. 9/17/24 -Review progress toward discharge during scheduled meetings 9/20/24 Surveyor notes R16's discharge care plan is not person-centered and was not updated during R16's stay at the facility. On 9/18/24, a care conference was held with Resident and family in attendance. It is documented that there may be a need for more care services in the home. If necessary upon discharge, may need electric lift. R16 is currently still very weak and requiring a lot of assistance with transfers and activities of daily living(ADLS). R16 and family concerned about how to address R16's needs at home if unable to build up a lot of strength. On 9/27/24, R16 was diagnosed with COVID, requiring isolation. R16's Occupational Therapy(OT) Discharge Summary dated 10/17/24 documents R16 had a setback during that period of time and both OT and Physical Therapy (PT) could be provided at bedside. Surveyor notes with every visit of R16, Doctor of Osteopathic Medicine (DO)-BB documents that discharge planning including discussion with therapy team, family and social worker is the goal. DO-BB also documents with every visit that durable medical equipment(DME) needs will be determined and ordered based on R16's needs at time of discharge. Discharge planning did not occur for R16 until the day before discharge and ordering of DME did not occur during R16's stay at the facility. On 10/17/24 at 8:45 AM, Social Services Coordinator (SCC)-F documents that Director of Nursing (DON)-B and SSC-F went to R16's room to discuss that R16's insurance days had been exhausted with a last covered day being 10-16-24. SSC-F and DON-B were not aware of the insurance policy of only having 30 days at the facility. SSC-F informed R16 that the options were to either discharge home or privately pay at the facility. R16 did not want to pay privately at the facility and requested discharge home. SSC-C does not document any attempts to order DME. SSC-F documents that SSC-F was informed by MDS Reimbursement (MDS)-T that R16 could not appeal. On 10/17/24 at 8:48 AM, DON-B documents that DON-B called family of R16 and informed that R16's insurance was ending and R16 wanted to proceed with discharge. On 10/17/24 at 11:51 AM, DON-B documents that R16 receives PT and OT. R16 transfers with 2 assist stand pivot in therapy, and with a sit to stand on the floor, toilets with sit to stand and dependent on peri-care, upper body dressing minimum assist, lower body dressing moderate assist, unable to ambulate and bed mobility is minimum to moderate assist. R16 will need diabetic teaching in preparation for discharge. Surveyor notes the facility obtained a discharge order from the physician including home health, PT and OT. A Recapitulation of Stay was completed, 30 day medication supply sent to R16's pharmacy of choice and a referral was made to a home health agency. No documentation that needed DME was obtained. R16 did sign the Discharge Instructions. Surveyor notes there is a diabetic teaching in preparation for discharge, document what was taught and response every shift with a start date of 10/17/24. There is no documentation in R16's electronic medical record(EMR) of diabetic teaching On 10/22/24 at 9:28 AM, Surveyor spoke with Intake Home Health (IHH)-EE who confirmed that a referral was sent on 10/17/24 by the facility. IHH-E stated that R16 was admitted back to the hospital on 10/18/24. Documentation in the system stated that R16 was unsafe at home and will need a skilled nursing facility. On 10/22/24 at 9:37 AM, Surveyor spoke with Registered Nurse Home Health (RNHH)-R who stated that RNHH-R was notified by R16's primary physician's office on 10/18/24 that the office called an ambulance for R16. RNHH-R was informed it took 5 people to get R16 into the home and RNHH-R had conflicting information that either R16 wanted to go home or that R16's insurance benefits had run out. On 10/22/24 at 10:22 AM, Surveyor spoke with Registered Nurse (RN)-S from R16's primary physician's office. RN-S stated the office received a very frantic phone call from R16's family about 8:30 AM on 10/18/24. RN-S stated the family could not take care of R16 and that R16 needed a sit to stand or hoyer lift but there was neither in the home. RN-S confirmed the office called an ambulance for R16. R16 was admitted back in the hospital on 10/18/24 with diagnoses of sepsis and urinary tract infection(UTI). RN-S stated that R16 had a raging UTI and a narly wound on R16's buttocks. RN-S did not receive any discharge paperwork for R16 from the facility. On 10/22/24 at 11:15 AM, Surveyor interviewed MDS-T in regards to R16's insurance benefits. MDS-T explained that R16's insurance was not medicare and R16 only had 30 days coverage. MDS-T stated that R16 could have appealed directly to the insurance company, stayed at the facility pending the results and possibly would have had to pay out of pocket if decision was not to continue coverage at the facility. The initial verification of 30 day benefit would have been circulated to the rest of the interdisciplinary team(IDT). On 10/22/24 at 11:24 AM, Surveyor interviewed Admissions Director (AD)-M in regards to R16. AD-M stated that exact insurance coverage/benefits should be explained to the Resident and/or representative at time of admission as well as explained to the IDT. AD-M informed Surveyor that AD-M was on medical leave when R16 was admitted and SSC-F was covering. On 10/22/24 at 12:42 PM, Surveyor interviewed SSC-F. SSC-F confirmed SSC-F was completing the admission process during the time R16 was admitted to the facility. SSC-F stated that Central Intake (CI)-U confirms a Resident's verification of insurance benefits and informs the facility. SSC-F denies being aware that R16 only had 30 days for rehabilitation. SSC-F stated that insurance updates did not indicate that R16 only had 30 days of benefits. SSC-F stated that therapy does a home evaluation. SSC-F stated that R16 was not offered the option to appeal directly to the insurance company. SSC-F stated that R16 was given the option to private pay for continued rehabilitation or discharge home and R16 chose to discharge home. SSC-F stated that R16's family indicated they would order a sit to stand for R16. SSC-F confirmed that R16 would have benefited from more time at the facility. On 10/22/24 at 1:42 PM, Director of Rehabilitation (DOR)-W stated that R16 was a sit to stand with assistance of 2 and all ADLS was an assist of 1. DOR-W informed Surveyor that the therapy department did not know R16 only had 30 days of benefits. DOR-W confirmed that therapy completes home evaluations. DOR-W stated that therapy did not do a home evaluation prior to discharge because it was not recommended by therapy that R16 return home. DOR-W confirmed that R16 was making minimal improvements slowly and was slowed down when R16 got COVID. DOR-W stated that R16 was not at baseline at time of discharge and that there was no sit to stand currently at home for R16. On 10/22/24 at 2:01 PM, Surveyor confirmed with MDS-T that R16 could have with the assistance of SSC-F appeal directly to the insurance company. On 10/23/24 at 9:11 AM, Surveyor interviewed Corporate Level CI-U. CI-U confirmed referrals for skilled nursing facility is handled by CI-U. CI-U verify's financials through electronic medical record which gives a quick summary. CI-U states that each facility is responsible for confirming verification of benefits of each Resident which is done by the business office. CI-U denies verifying R16's insurance benefits. On 10/23/24, at 9:37 AM, Surveyor interviewed Business Office Assistant (BOM)-Q. BOM-Q stated that verification of benefits for a Resident is completed at the Corporate Level (CI-U) and that SSC-F was covering the admission process when R16 was admitted to the facility. On 10/23/24, at 10:01 AM, DON-B does not recall what was discussed with family when DON-B made the phone call to discuss R16's discharge. On 10/23/24, at 10:13 AM, SSC-F confirmed that CI-U was helping with verification of benefits when SSC-F was helping with the admission process. SSC-F stated that CI-U would print off the verification of benefits and send with the referral for each Resident. Surveyor notes that on 9/16/24, 1 day prior to R16's admission to the facility on [DATE], the facility was notified per documentation on the verification of benefits for R16, that R16 only had 30 days of coverage at the facility. The facility did not initiate discharge planning with the intent to discharge R16 after the 30 days. The facility did not review the insurance benefits of coverage with R16 and/or representative at time of admission as the facility as no documentation that R16 and/or representative signed acknowledgement of financial benefits during the admission process. The facility did not provide R16 with the option to appeal directly to the insurance company. R16 discharged late afternoon on 10/17/24. IDT confirm R16 was not safe to discharge home and could have benefited from more skilled nursing care, which resulted in R16 being admitted to the hospital less than 24 hours from discharge. On 10/23/24 at 11:21 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the concern that the facility waited until the last covered day to inform R16 of the issue with the 30 day insurance benefits, despite documentation that the facility knew of the R16's 30 day insurance coverage 1 day prior to R16's admission to the facility. NHA-A agreed that discharge planning was inadequate for R16 and communication with IDT hampered the discharge process for R16. No additional information was provided by the facility at this time.

Based on observation, interview, and record review the facility did not provide the necessary ADL (Activities of Daily Living) services for 3 (R7, R11, and R13) of 17 residents who were dependent on staff to provide ADL care. R7 is dependent for bathing and R7 did not receive showers on 9/8/24 and 9/15/24. R11 is dependent for bathing and R11 received 2 showers for the month of September 2024. R13 is dependent for continence care and did not receive continence care multiple times in July 2024. Findings include: 1.) R7 was admitted to the facility on [DATE] with a diagnosis that includes hemiplegia, anxiety, neuromuscular dysfunction of the bladder, dementia, reduced mobility, and speech deficits following cerebral infarction. R7 is dependent on staff for bathing, transferring, and toileting. Surveyor reviewed R7's medical record which documents R7 did not receive a shower on 9/8/24 and 9/15/24. Surveyor could not locate any not documentation of R7 declining a shower on 9/8/24 or 9/15/24. R11 was admitted to the facility on [DATE], with a diagnosis that includes multiple sclerosis, chronic respiratory failure, and morbid obesity. R11 is dependent on staff for bathing and toileting. Surveyor reviewed R11's medical record which documents R11 received 2 showers for the month of September 2024. Surveyor notes R11 received a shower on 9/20/24 and 9/24/24. Surveyor does not see documentation of R11 declining a shower on 9/3/24, 9/6/24, 9/10/24, 9/13/24, 9/17/24, and 9/27/24. On 10/22/24 at 10:07 am, Surveyor interviewed Director of Nursing (DON)- B who states Certified Nursing Assistant (CNA)'s provide showers to residents. CNA's are to notify the nurse if a resident declines a shower and document in the computer. Surveyor notified DON- B of shower concerns with R7 and R11. DON- B indicates R11 receives bed baths which may not be documented, but then states she is new to the facility and still learning residents. DON- B states R7 gets a lot of visitors on Sundays and staff may have offered baths on a different day. On 10/22/24 at 11:20 am, DON- B notified Surveyor she looked into R7's and R11's medical record and did not find showers documented for R7 on 9/8/24 and 9/15/24 which are Sundays and reminded Surveyor that R7 typically has many visitors on Sundays. On 10/22/24 at 12:39 pm, DON- B provided Surveyor skin assessments for R7 and R11 for the month of September and October 2024. Surveyor notes the skin assessments for R7 and R11 however, Surveyor notified DON- B that skin assessments are not documentation of showers and requested additional information on showers if available. On 10/22/24 at 3:13 pm, Surveyor notified Nursing Home Administrator (NHA)- A and DON- B of shower concerns for R7 and R11. Surveyor requested additional information if available. No additional information was provided. 20483 2.) R13 was admitted to the facility on [DATE] with diagnoses includes multiple sclerosis, hypertension and age related osteoporosis. The urinary incontinence care plan initiated 6/3/24 & revised 6/4/24 documents the following interventions: * Adjust toileting times to meet resident's needs. Initiated 6/4/24. * Administer medication per MD (medical doctor) orders. Initiated 6/4/24. * Apply skin moisturizers/barrier creams as needed. Initiated 6/4/24. * Identify voiding pattern and establish toileting program. Initiated 6/4/24. * Provide assistance with toileting. Initiated 6/4/24. * Provide incontinent care as needed. Initiated 6/4/24. * Report changes in amount, frequency, color or odor of urine. Initiated 6/4/24. * Report changes in skin integrity found during daily care. Initiated 6/4/24. * TOILETING PLAN: offer and assist with toileting q (every) 2-3 hrs (hours) while awake pending patterning. Initiated 6/4/24. * Use absorbent products as needed. Initiated 6/4/24. The functional abilities (self care & mobility) CAA (care area assessment) dated 6/13/24 under nature of problem/condition documents CAA triggered due to the resident needing a lot of assistance with ADL's (activities daily living) in the look back period. The resident was a total lift upon admission. Under care plan considerations documents The resident needs assistance with ADL's in the look back period. The staff will continue to assist the resident with ADL's. The resident is able to make their basic needs known. The staff will monitor the resident for changes in physical functioning and notify the provider for further evaluation and treatment as needed. The resident is active in the plan of care and any questions or concerns will be addressed on an on going basis. No referrals are needed at this time but will make referrals as needed in the future. The residents care plan will address the need for assistance with ADL's. The quarterly MDS (minimum data set) with an assessment reference date of 9/12/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R13 is assessed as not having any behavior. R13 is assessed as being dependent for toileting hygiene, chair/bed to chair transfer, and toilet transfer. R13 requires partial/moderate assistance to roll left and right. R13 is assessed as being frequently incontinent of urine and bowel. On 10/21/24 at 9:33 a.m., Surveyor observed R13 dressed for the day sitting in an electric wheelchair in the room. Surveyor asked R13 back in July were there times when staff did not provide continence cares for her. R13 replied yes. R13 explained there was a time when she was on the bedpan for two hours. Surveyor asked if she reported this. R13 replied she complained to the administrator but now that administrator isn't here anymore and there is a different lady. Surveyor asked if there was a time in July when she wasn't provided continence cares from 9:00 a.m. to 4:00 p.m. R13 replied yes. R13 informed Surveyor that some times at night she isn't checked the whole night or some times just once depending who is working. R13 informed Surveyor it has been better since she moved to her current room which is on the other side of the building. On 10/22/24, from 7:35 a.m. to 7:50 a.m., Surveyor observed morning cares for R13 with CNA (Certified Nursing Assistant)-MM. No concerns were identified during this observation. On 10/22/24 Surveyor reviewed R13's bowel and bladder elimination records for July 2024 under the task tab. Surveyor noted there is no documentation R13 received continence cares on 7/2/24 during the night shift, 7/3/24 during the day & night shifts, 7/9/24 during the evening shift, 7/12/24 during the night shift, 7/14/24 during the evening shift, 7/15/24 during the day shift, 7/21/24 & 7/23/24 during the night shift, and 7/25/24 during the day shift. On 10/22/24 at 9:14 a.m., Surveyor asked CNA-NN if she took care of R13. CNA-NN replied yes actually she was recently moved. Surveyor asked CNA-NN what did they have to do for R13. CNA-NN informed Surveyor they did her cares and she was a Hoyer transfer with 2 people to get out of bed into the chair. When R13 was in the chair she would try to do a portion of getting herself dressed. Surveyor inquired when R13 was provided with incontinence cares. CNA-NN replied she would let us know if she was wet. CNA-NN explained they would change her and put her back in the chair. Surveyor asked if incontinence cares are documented. CNA-NN informed Surveyor they are suppose to document this and will stay late complete her charting. On 10/23/24 at 7:18 a.m., Surveyor again asked R13 if during July was there ever a time when staff did not change her. R13 replied yes, all the time. R13 then informed Surveyor during the 4th of July weekend there was no one here stating, who wants to be cleaning old ladies. On 10/23/24 at 8:27 a.m., Surveyor asked DON (Director of Nursing)-B what is the expectation for staff providing continence care to residents. DON-B informed Surveyor they should be following what is on the care card and care plan, there are no odors and kept clean & dry. Surveyor inquired if the CNA's document continence care. DON-B informed Surveyor if the task is activated. Surveyor informed DON-B R13 informed Surveyor there were multiple times in July when R13 did not receive continence care and there are multiple times in the task documentation for bowel and bladder when continence care is not documented. On 10/23/24 at 8:56 a.m., Surveyor informed NHA (Nursing Home Administrator)-A there were multiple times in July when R13 was not provided continence care and documentation doesn't show R13 received continence care. No additional information was provided for R13.

Based on interview and record review, the facility did not ensure residents with urinary incontinence were comprehensively assessed to receive appropriate treatment and services to prevent complications and restore continence to the extent possible for 1 (R16) of 1 Resident reviewed for incontinence. * A bladder assessment and care plan with person centered interventions was not implemented when R16's urinary continence declined from occasionally incontinent to frequently incontinent. Findings Include: 1.) R16's Admission Minimum Data Set (MDS) completed on 9/23/24 documents R16 has a Brief Interview for Mental Status(BIMS) score of 15, indicating R16 was cognitively intact for daily decision making. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for shower/bathing, lower dressing, personal hygiene, rolling left to right, and sit to lying. R16 required partial/moderate assistance for upper dressing. R16 was dependent for sit to stand, transferring from chair to bed, and toileting transfers. R16 was occasionally incontinent of bladder and always continent of bowel on the admission MDS. R16's MDS documents R16 desired to discharge to the community and required active discharge planning. R16's quarterly MDS completed on 10/9/24 documents R16's BIMS score to be 11, indicating R16 was demonstrating moderately impaired skills for daily decision making. R16's MDS also documents at this time that R16 is frequently incontinent of bowel and bladder. R16's Discharge MDS completed on 10/17/24 does not assess R16's cognitive skills. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for lower dressing, personal hygiene. Shower/bathing was not attempted due to medical condition. R16 required partial/moderate assistance for upper dressing, sit to lying and lying to sitting, sit to stand, chair to bed transfer, and toilet transfer. Transferring to to tub/shower was not attempted due to medical condition. R16 was supervision for rolling left to right. R16 was frequently incontinent of bladder and always incontinent of bowel. R16's completed Care Area Assessment(CAA) dated 9/23/24 documents: .Urinary incontinence CAA triggered secondary to the level of assistance needed with toileting needs and actual incontinence episodes. Contributing factors include weakness, impaired mobility, and cognitive loss. Risk factors include skin breakdown, falls and recurrent UTI's. Care plan will be initiated/reviewed to improve/maintain current toileting skills and ability to transfer to the commode, continence status, decrease fall and pressure ulcer risk, and decrease risk for UTI. Resident at decreased level of adls which requires staff assist with toileting which can impact residents level of continence, increase risk for skin impairment, proceed to careplan. R16's comprehensive care plan documents R16 has urinary incontinence due to impaired mobility initiated 10/1/24. The following interventions are listed for R16: -Administer medication per MD orders 10/1/24 -Apply skin moistures/barrier creams as needed 10/1/24 -Place urinal/bedpan within Residents reach 10/1/24 -Provide assistance with toileting 10/1/24 -Provide incontinent care as needed 10/1/24 On 9/20/24 a grievance was filed by R16 in regards to incontinence care. A toileting plan was to be implemented at night. R16 was occasionally incontinent of bladder, always continent of bowel at admission and was frequently incontinent of bladder and always incontinent of bowel at time of discharge. R16's care plan was not revised to include person centered interventions for a toileting plan or interventions to address R16's continence decline. On 10/22/24 at 10:01 AM, Surveyor interviewed Director of Nursing (DON-B). DON-B agreed that R16's comprehensive care plan was not person centered and the care plan was lacking for person centered interventions. DON-B stated that R16's toileting plan was every 2-3 hours and upon call light. DON-B acknowledges this toileting plan was not documented on R16's care plan. On 10/23/24 at 10:21 AM, Certified Nursing Assistant (CNA)-P informed Surveyor that R16 was always incontinent and was not aware of any toileting plan. On 10/23/24 at 12:18 PM, Surveyor shared with Nursing Home Administrator (NHA)-A that R16's toileting program was not documented on R16's care plan. R16 had a decline in continence from occasionally incontinent of bladder to frequently incontinent of bladder. A toileting program was not implemented for R16. On 10/23/24 at 12:57 PM, DON-B stated that the facility does not complete a formal bladder assessment on all residents. Assessing continence is done at admission only. DON-B confirmed that R16's continence status changed during R16's stay and was not addressed. DON-B understands Surveyor's concern of R16's continence declined, was not addressed, and R16's care plan was not updated to include interventions to improve R16's continence status. On 10/23/24 at 2:50 AM, Registered Nurse (RN)-N was interviewed by Surveyor. RN-N was not aware of R16 having a toileting plan. RN-N stated that R16's continence status did change during R16's stay and required the sit to stand to transfer to the toilet. On 10/23/24 at 3:22 PM, NHA-A informed Surveyor the facility does not have a policy and procedure for a bowel/bladder program. Per [NAME] President of Clinical (VP)-GG, bladder training should be incorporated into a Resident care plan. No additional information was provided as to why the facility did not ensure R16 was comprehensively assessed to receive appropriate treatment and services to receive appropriate treatment and services to prevent complications and restore continence to the extent possible.

Based on interview and record review, the facility did not ensure therapy services were provided in a timely manner for 2 (R4 and R16) of 2 residents reviewed for therapy services. *R4 returned to the facility on [DATE] after receiving Cortisone (a steroid medication that can help with pain and inflammation) injections to both knees. R4's orthopedic doctor advised that R4 should start Physical Therapy (PT). R4 did not start PT until 9/5/24. *R16 did not receive a home evaluation before discharge. Findings include: 1.) On 10/23/24 at 10:40 AM, Surveyor was informed by Nursing Home Administrator (NHA)-A that the facility does not have a policy for the communication process between staff and the therapy department, for the timing of therapy services, or for the process of home evaluations. R4 was admitted to the facility on [DATE] with diagnosis that includes Stroke, Type 2 Diabetes and Osteoarthritis of the left knee and Bilateral (both sides) knee arthritis. R4's Annual Minimum Data Set Assessment (MDS) dated [DATE], documents R4's cognition is moderately impaired. R4 is independent with toileting, dressing, mobility, and transfers. R4 requires partial to moderate assistance with bathing. R4 started physical therapy on 9/5/24. R4's Functional Abilities Care Area Assessment (CAA) dated 9/12/24 documents: Activities of daily living (ADL) function CAA triggered secondary to assistance required in ADLs. Impaired balance and transition during transfers and functional impairment in activity. R4's Care plan with a start date of 10/31/23 documents: Pain/potential for pain [related to] impaired mobility. Interventions include: Therapy eval and treat as ordered. On 10/21/24 at 9:55 AM, Surveyor interviewed R4. R4 stated that R4 received injections in R4's knees to help with pain a few months ago. R4 indicated that R4 was supposed to receive therapy after the injections but that therapy did not start right away. R4 stated that R4 complained to a staff member that R4 was not getting therapy and therapy started after that. R4 indicated that after the injections, physical therapy, and scheduled medications, R4's knee pain is controlled. R4's orthopedic doctor note dated 7/25/24 documents: [Bilateral] knee arthritis. Provided [bilateral] knee cortisone injections. Therapy 2-3 [times per] week for leg strengthening simple balance. [Follow up] as needed for [increased] pain. R4's MD order dated 7/25/24 documents, PT therapy 2-3 [times per] week for leg strengthening and simple balance. Surveyor reviewed R4's PT notes provided by the facility and noted that PT started on 9/5/24. This was 42 days after R4's orthopedic doctor ordered PT to be done 2 to 3 times per week. R4's progress note entered by Physician Assistant (PA-AA) dated 7/29/24 at 9:06 AM, documents, in part: . [status post] cortisone injections to knees on 7/25. Therapy 2-3 [times per] week ordered for strengthening, balance. [Follow up] [as needed] for increased pain. [R4] reports pain has improved at this time. Surveyor noted that the facility PA, PA-AA, also acknowledged that therapy was ordered to start on 7/25/24. On 10/21/24 at 3:44 PM, Surveyor interviewed PT Director (PT)-W. Surveyor asked when R4 started physical therapy. PT-W stated that therapy started after R4 received knee injections. PT-W indicated that there was a delay because the PT order was not brought to their attention until one of the doctors spoke to the therapy department. Surveyor informed PT-W that R4's order for PT was placed on 7/25/24 and PT was not started until 9/5/24. PT-W indicated that the over a month delay was a big delay and not typical for the facility. PT-W stated, we should have been on that. On 10/21/24 at 3:59 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-Y. Surveyor asked what the process is when a resident returns from an outside doctor appointment with therapy orders. LPN-Y stated LPN-Y would enter a progress noted, notify the provider, and enter the order. LPN-Y stated a copy of the therapy order would be printed off and either handed to the therapy department or placed in their mailbox. On 10/21/24 at 4:05 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-X. ADON-X stated that if PT is ordered for a resident, a copy of the order is given to the therapy department. If no one is available to take the order, it is placed in the therapy mailbox. Surveyor informed ADON-X of the delay in R4's therapy after knee injections. Surveyor asked if that type of a delay is typical or expected. ADON-X stated, not at all. On 10/22/24 at 1:44 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor informed DON-B of the delay in PT for R4. Surveyor asked if a delay is expected when PT is ordered by an outside MD. DON-B stated that PT is typically started immediately after an order is received. On 10/23/24 at 8:25 AM, Surveyor interviewed PA-AA about R4's therapy delay. PA-AA indicated that the PT orders should have been followed. PA-AA stated that there have been issues in the past with communication between staff and PT. PA-AA stated that PA-AA has personally gone to the PT departed and communicated the need for PT in the past. PA-AA stated that communication has improved with new management. Surveyor noted that the facility procedure of getting orders to the PT department was not followed and was missed, causing R4's delay in therapy treatment. On 10/22/24 at 3:20 PM, Surveyor informed Nursing Home Administrator (NHA)-A, DON-B, and [NAME] President of Success (VP)-G of the concern that R4 had a MD order for PT that was entered on 7/25/24 and PT did not start until 9/5/24. No further information was provided as to why the facility did not ensure therapy services were provided in a timely manner for R4. 38829 2) R16 was admitted to the facility on [DATE] with diagnoses of Other Specified Diseases of Liver, Muscle Weakness, Hypertensive Heart Disease with Heart Failure, Unspecified Asthma, Arthropathic Psoriasis, Immunodeficiency, Type 2 Diabetes Mellitus, and Adjustment Disorder with Muscle Weakness. R16 discharged from the facility on 10/17/24. R16's Admission Minimum Data Set (MDS) completed on 9/23/24 documents R16 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R16 was cognitively intact for daily decision making. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for shower/bathing, lower dressing, personal hygiene, rolling left to right, and sit to lying. R16 required partial/moderate assistance for upper dressing. R16 was dependent for sit to stand, transferring from chair to bed, and toileting transfers. R16 was occasionally incontinent of bladder and always continent of bowel on the admission MDS. R16's MDS documents R16 desired to discharge to the community and required active discharge planning. R16's quarterly MDS completed on 10/9/24 documents R16's BIMS score to be 11, indicating R16 was demonstrating moderately impaired skills for daily decision making. R16's Discharge MDS completed on 10/17/24 does not assess R16's cognitive skills. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for lower dressing, personal hygiene. Shower/bathing was not attempted due to medical condition. R16 required partial/moderate assistance for upper dressing, sit to lying and lying to sitting, sit to stand, chair to bed transfer, and toilet transfer. Transferring to to tub/shower was not attempted due to medical condition. R16 was supervision for rolling left to right. R16 was frequently incontinent of bladder and always incontinent of bowel. R16's verification of benefits documented on 9/16/24, 1 day prior to R16's admission to the facility documents that R16 only had 30 days of benefits at the facility. The facility did not acknowledge this documentation and did not prepare R16 for discharge to occur on 10/17/24, 30 days later. On 10/22/24 at 1:42 PM, Director of Rehabilitation (DOR)-W stated that R16 was a sit to stand with assistance of 2 and all ADLS was an assist of 1. DOR-W informed Surveyor that the therapy department did not know R16 only had 30 days of benefits. DOR-W confirmed that therapy completes home evaluations. DOR-W stated that therapy did not do a home evaluation prior to discharge because it was not recommended by therapy that R16 return home. DOR-W confirmed that R16 was making minimal improvements slowly and was slowed down when R16 got COVID. DOR-W stated that R16 was not at baseline at time of discharge and that there was no sit to stand currently at home for R16. Surveyor notes that therapy did not recognize that R16 only had 30 days of benefits at the facility. Therapy did not monitor insurance updates and complete a home evaluation. If a home evaluation had been completed, recommendations and safety issues could have been identified in order to help R16's discharge to the community successful. R16 ended back up in the hospital less than 24 hours from discharge from the facility. On 10/23/24 at 11:21 AM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A the concern that R16 did not receive rehabilitation services in order for R16 to reach baseline and/or improve in physical ability to ensure safety upon discharge from the facility. The therapy staff did not complete a home evaluation prior to R16 being discharged to determine the need for durable medical equipment and safety status resulting in R16 not having a safe discharge and the need for re-admission to the hospital. NHA-A agreed this is a concern. Surveyor requested from NHA-A documentation of R16's re-admission to the hospital on 10/18/24. On 10/23/24 at 3:22 PM, NHA-A confirmed hospital documentation refers to R16 not being able to be cared for at home and required placement in a skilled nursing facility. Surveyor requested multiple times for the hospital documentation which NHA-A stated would be provided. NHA-A stated the hospital documentation would be forwarded to Surveyor. At the time, the facility provided no additional information. No additional information was provided as to why the facility did not ensure that R16 received therapy services in a timely manner.

Based on interview and record review the facility did not provide a written notice of transfer, including the reason for transfer and appeal rights to the resident, and their representatives, at the time of transfer from the facility. This was observed with 7 (R49, R51, R58, R3, R4, R55, R75) of 7 residents reviewed for transfers. * R49 was transferred to the hospital on 2/3/24 and was not provided a written notice of the transfer including reason for the transfer and appeal rights. * R51 was transferred to the hospital on 4/5/24 and was not provided a written notice of transfer including reason for the transfer and appeal rights. * R58 was transferred to the hospital on 6/15/24 and was not provided a written notice of transfer including reason for the transfer and appeal rights. * R3 was transferred to the hospital on 5/16/24 and was not provided a written notice of transfer including reason for the transfer and appeal rights. * R4 was transferred to the hospital on 5/7/24 and was not provided a written notice of transfer including reason for the transfer and appeal rights. * R55 was transferred to the hospital on 5/4/24 and was not provided a written notice of transfer including reason for the transfer and appeal rights. * R75 was transferred to the hospital on 4/21/24 and was not provided a written notice of transfer including reason for the transfer and appeal rights. Findings include: On 6/18/24, at 2:09 PM, Surveyor spoke with (Director of Nurses) DON-B. DON-B indicated the facility does not have a policy and procedure for written transfer requirements. The transfer requirements would be on the bed-hold form itself. This information is not sent with the resident at the time of transfer. 1.) R49 was transferred to the hospital on 2/3/24 due to a change in condition. R49 returned to the facility on [DATE]. R49 has an activated Power of Attorney for Healthcare (POA-HC) . R49's medical record did not contain evidence the required transfer notice information was provided to R49 or their POA-HC at the time of transfer. On 6/19/24, at 10:37 AM, DON-B indicated R49 went out to the hospital on 2/3/24, came back to the facility, then went out to the hospital again. R49 returned to the facility on [DATE]. DON-B stated she did not have any documentation regarding the transfer notice requirements for either transfer. On 6/19/24, at 3:00 PM, during the daily exit meeting, Surveyor notified the (Nursing Home Administrator) NHA-A of R49's transfer notice requirements not being provided with either transfer. 2.) R51 was transferred to the hospital on 4/15/24 due to a change in condition. R51 returned to the facility on [DATE]. R51 currently has an activated Power of Attorney for Healthcare. R51's medical record did not contain evidence the required transfer notice information was provided to R1 or their responsible party at the time of transfer. On 6/19/24, at 9:26 AM, Surveyor spoke with the Director of Nursing (DON)-B. DON-B shared the facility had contacted R51's family about a room change that day. DON-B does not have documentation the required transfer notice was provided to R51 or their responsible party. On 6/19/24, at 3:00 PM, during the daily exit meeting, Surveyor notified the (Nursing Home Administrator) NHA-A of R51's transfer notice requirements not being provided with transfer. 3.) R58 was transferred to the hospital on 6/15/24 for a change in condition. R58 had not returned to the facility at the time of survey. R58's medical record did not contain evidence the required transfer notice information was provided. On 6/18/24, at 01:38 PM, Surveyor spoke with (Admission Director) AD-G. AD-G documented on 6/19/24 they verbally reviewed the Bed-Hold form with R58's Power of Attorney for Healthcare. The Bed-Hold form contains portions of the required transfer notice information. AD-G shared they try to connect with the resident, or Power of Attorney for Healthcare, the next day (day after transfer). They only go over the bed-hold information and not the transfer notice information. AD-G shared the Bed-Hold form does not go out with the resident at the time of transfer. On 6/19/24, at 3:00 PM, during the daily exit meeting, Surveyor notified the (Nursing Home Administrator) NHA-A of R58's transfer notice requirements not being provided with transfer. 38146 4) R55 admitted to the facility on [DATE] and has diagnoses that include acute and subacute infective endocarditis, infection and inflammatory reaction due to cardiac and vascular devices, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Epilepsy, Chronic Atrial Fibrillation, Anemia, and Congestive Heart Failure. R55 is assessed to be cognitively intact and his medical record documents: Responsible party - self. R55 was hospitalized on [DATE] and readmitted to the facility on [DATE]. Surveyor was unable to locate evidence a transfer notice was provided in R55's medical record and asked Director of Nursing (DON)-B to provide. On 6/18/24, at 3:10 PM, DON-B reported the nurses should be completing a change in condition (CIC) form under assessments. R55 did not have a CIC form in his medical record. On 6/19/24, at 9:41 AM, Surveyor again asked DON-B for information regarding R55's hospitalization and the transfer notice provided. Surveyor was advised by DON-B the facility does not have evidence a transfer notice was completed or provided to R55. 49011 5.) R3 was transferred to the hospital on 5/16/24 due to a change in condition. R3 returned to the facility on [DATE]. R3 is responsible for self and does not have an activated Power of Attorney for Healthcare (POA-HC). R3's medical record did not contain evidence the required written transfer notice information was provided to R3 or their representative at the time of transfer. Surveyor reviewed R3's electronic medical record and discovered R3 had been sent to the emergency roiagnom on [DATE] and found documentation that Admission Director-G gave notice via voicemail as signed on the Bed Hold Policy and Notice of Transfer paperwork on 5/19/24 at 2:44pm to R3's representative however there was no evidence a written notice of the reason for transfer, and appeal rights were provided to R3 or their representative. On 6/19/24, at 3:00 PM, during the daily exit meeting, Surveyor notified the Facility of R3's written transfer notice requirements not being provided. 6.) R4 was transferred to the hospital on 3/28/24 due to a change in condition. R4 returned to the facility on [DATE]. R4 is responsible for self and does not have an activated Power of Attorney for Healthcare (POA-HC). R4's medical record did not contain evidence the required written transfer notice information was provided to R4 or their representative at the time of transfer. Surveyor reviewed R4's electronic medical record and discovered R4 had been sent to the emergency roiagnom on [DATE] and found documentation that Admission Director-G gave notice via phone related to the Bed Hold Policy and Notice of Transfer paperwork on 3/29/24 at 9:40 am to R4's representative however there was no evidence written notice of the reason for transfer, and appeal rights were provided to R4. On 5/7/24 R4 was again transferred to the hospital due to a change in condition. R4 returned to the facility on [DATE]. R4's medical record did not contain evidence the required written transfer notice information was provided to R4 or their representative at the time of this transfer. Surveyor reviewed R4's electronic medical record and discovered R4 had been sent to the emergency roiagnom on [DATE] and found a progress note that was created on 5/13/24, at 8:39am, effective 5/8/2024, Resident has a 15-day bed hold with his Medicaid benefit and resident confirmed he does want to return to facility once medically ready. Per Director of Nursing (DON)-B there is no additional paperwork for this hospital stay indicating written notice of the reason for transfer and appeal rights was provided to R4. On 6/19/24, at 3:00 PM, during the daily exit meeting, Surveyor notified the Facility of R4's written transfer notice requirements not being provided. 36161 7.) R75 was admitted to the facility on [DATE] with a diagnosis that included malignant neoplasm of lower lobe, gastroenteropathy, atrial fibrillation and chronic obstructive pulmonary disease. R75's nursing note dated 4/21/24 documents, General Note Text: Writer spoke with daughter on phone in am and misunderstood what daughter was asking, thought she was asking of the BUN (Blood Urea Nitrogen-blood test that measures the amount of nitrogen found in the blood) result, but it was for the BNP (Brain Natriuretic Peptide) which is elevated. I updated NP (nurse practitioner) which she ordered a one-time order of Lasik 20 mg (milligrams) which the resident did not take .Daughter asked resident if she wanted to go to the hospital and she stated yes. Writer called EMS (emergency medical services) for transport to ER (emergency room ). Surveyor was unable to locate any written notice of transfer including appeal rights in R75's medical record. On 6/18/24, at 2:45 PM, Surveyor informed Nursing Home Administration (NHA)-A and Director of Nursing (DON)-B of the above findings. Surveyor asked NHA-A if R75 was provided with a transfer notice when R75 was sent to the emergency roiagnom on [DATE]. NHA-A informed Surveyor he would review R75's medical record and let Surveyor know. On 6/20/24, at 10:56 AM, DON-B informed Surveyor the facility did not provide a transfer notice to R75 or R75's representative after R75 was transferred to the emergency roiagnom on [DATE]. No additional information was provided as to why the facility did not provide R75 with a notice of transfer when R75 was transferred to the hospital on 4/21/24.

Based on interview, observation and record review, the facility did not ensure 4 (R8, R11, R12 and R13) of 4 residents reviewed for pressure injuries (PI) receive care, consistent with professional standards of practice, to prevent the development of pressure injuries and residents with pressure injuries receive necessary treatment and services to promote healing, prevent infection and prevent new injuries from developing. ~ R12 was admitted to the facility with intact skin. R12 developed a Stage 2 Pressure Injury to right knee. R12 had a care plan for refusals but it did not address how to provide care to the resident to prevent skin breakdown. R12's treatment to right knee was not transcribed to MD orders and was not completed every 3 days as ordered resulting deterioration of the wound to a stage 3 pressure injury. ~ R8 was admitted to the facility on [DATE] with comorbidities that put resident at high risk for PI's and with redness noted to skin. No interventions, MD orders, or care plan was in place for R8 until after an unstageable sacral PI was found on 8/16/20. On 8/18/20 the PI was noted to have 100% slough and needed chemical debridement. Care plan and interventions were not put in place until 8/19/20. ~ R11 was admitted to the facility with intact skin. R11 had a care plan in place for Open [CONDITION(S)] to buttocks that were not assessed or measured. R11 continued to have open areas to buttocks that were not assessed properly. R11 was at risk for skin breakdown and no preventative measures were in place to prevent heel breakdown. A Deep Tissue Injury was identified to R11's left heel. It was not assessed timely. Interventions were put in place for left heel but right heel interventions were not put in place. R11's right heel was observed resting on his mattress while NP (Nurse Practitioner) had ordered Prevalon boots to both feet. ~ R13 was admitted to the facility on [DATE] with wounds including pressure injuries to the right and left heel, coccyx, and a wound to the right great toe. The facility did not complete an assessment of R13's wounds that included measurements, staging or a description of the heel wounds and coccyx wounds until 9/30/20. R13 was hospitalized from 11/14/20-11/22/20. Upon return to the facility there is no documented assessment of the heel wounds and coccyx wounds until 12/2/20. There is no documentation of assessment to the right great toe wound since R13's admission to the facility on [DATE]. Findings include: The AMDA (American Medical Directors Association) clinical practice guideline entitled 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer [Injury] is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear. Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management. Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications. Step 2. Examine the patient's skin thoroughly to identify existing pressure ulcers. Examine the patient's skin upon admission or readmission. Step 3. Assess the patient's overall physical and psychosocial health and characterize the pressure ulcers. A pressure ulcer should be assessed along with the patient's overall clinical, functional, and cognitive status weekly reassessment and documentation of ulcer characteristics is recommended. More frequent assessment may be necessary for ulcers that are not responding to treatment or are worsening despite treatment. Step 4. Identify factors that can influence ulcer treatment and healing.functional status. Functional factors, including impaired mobility, a self-care deficit, and incontinence (especially fecal incontinence), may influence the severity, duration, and healing of a pressure ulcer. Step 5.Documentation should cover all pertinent characteristics of existing pressure ulcers, including location; size; depth; maceration; color of the ulcer and surrounding tissues; a description of any drainage, eschar, necrosis, odor, tunneling, or undermining; tissue types covering the wound bed; .and a description of the peri-wound skin .including type and amount of drainage. Step 6. Identifying priorities in managing the ulcer and the patient .Pain control related to the ulcer and any comorbid conditions.The same factors that increase a patient's susceptibility to developing pressure ulcers .may also impair the healing of an existing pressure ulcer . Surveyor reviewed the facility's Pressure Ulcer/Injury, Prevention of policy with an Original Effective Date of June 2017. Documented was: PURPOSE To prevent skin breakdown and development of pressure ulcers/injuries. POLICY PROCEDURE 1. Assess for risk of pressure ulcer/injury development. a. Identify high and low risk residents. 2. Assess and identify complicating conditions that may contribute to pressure ulcer/injury development. 3. Develop care plan to eliminate or minimize risk factors including: a. Diet. b. Nutritional supplementation. c. Hydration. d. Pressure relief measures. e. Resistance or refusal of care. * Explain care plan approaches to resident. 4. Apply moisture barrier gently to dry skin as well as the perineum (if incontinent of urine/involuntary of stool). 5. Change bed linen whenever wet or soiled. 6. Keep sheets dry and free of wrinkles and debris. 7. Use appropriate support surface in the resident's bed and chair. 8. Use pressure reducing or relieving devices in resident's bed and chair. 9. Use foot cradle as necessary. 10. Establish a turning and positioning schedule in bed and chair to meet the resident's needs. 11. Position with appropriate surfaces to protect body prominences . ASSESSMENT GUIDELINES May include, but not limited to: * Comorbid conditions. * General condition of skin. * Impaired circulation including presence or absence of sensation of pain. * Medications that affect wound healing. * Cognitive impairment. * Nutritional status. * Urinary and/or fecal incontinence. * Hydration/fluid balance. * Weight (over/under ideal or usual body weight). * Bedfast. * Mobility status, including bed mobility. * Limited range of motion and deformities. * Refusing or resisting care. * History of pressure ulcers/injuries. * Behavior. * Indwelling Catheter. * Pressure ulcer/injury risk assessment tools per facility policy. These assessment tools may be in the facility electronic medical record (EMR/EHR) . DOCUMENTATION GUIDELINES: Documentation may include: * Date, time, approaches to prevent pressure ulcer/injury development. * Preventative equipment used. * Condition of the resident's skin. * Physician notification when change in condition is observed. * If a pressure ulcer/injury is present, the Licensed Nurse is responsible to record condition of the skin, including stage, size, site, depth, color, drainage and odor as well as the treatment provided. Notification of the physician is required when a new pressure ulcer/injury is identified as well as when treatment is not effective. * Signature and title. CARE PLAN DOCUMENTATION GUIDELINES: Problem: * Identify the appropriate problem under which to list the pressure ulcer/injury care as an approach. * Identify and treat the underlying cause of the pressure ulcer/injury. * Consider listing complicating conditions, as well as possible risks and complications. Goal: * List measurable goal(s) to be accomplished. If a pressure ulcer/injury is present this may be resolution of the cause of the pressure ulcer/injury as well as healing of the pressure ulcer/injury. * Identify target date. Approaches: * Identify responsible discipline for each approach. * Record instructions unique to this resident. * Identify approaches to optimal nutrition and nutritional support. * Monitoring of weight. * Appropriate diagnostic tests. * Record approached to promote adequate hydration. * Monitoring of appropriate diagnostic tests. * Identify necessary monitoring and observation of the underlying condition. * Record treatment as ordered. * Record all pressure reducing or relieving surfaces. * Identify frequency of positioning. * Record behavior management if appropriate. NOTE: Inspect skin upon admission and once a shift, particularly over bony prominences. Heels and sacrum are most common areas for skin breakdown. Use Braden or Norton scale for assessment of risk for development of pressure ulcers/injuries. Either scale should be completed weekly x4 then at least quarterly or upon clinical change in resident status. Document assessment findings . Surveyor reviewed the facility's Care Plans - Comprehensive policy with a date of 12/2016. Documented was: Policy Statement An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation 1. The facility's Care Planning/Interdisciplinary Team (IDT), in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the [Minimum Data Set (MDS)]. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems . 4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools before interventions are added to the care plan . 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly and whenever necessary . 1.) R12 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set, dated dated dated [DATE] section G documented R12 as non-ambulatory, extensive 2 person assist for bed mobility and total dependence for transfers. Section M documented the resident as having a stage 1 pressure injury and was identified to be at risk of developing pressure injuries. R12's BIMS (Brief Interview for Mental Status) on 2/13/21 indicated a score of 11 - moderately impaired. R12's care plan focus area initiated 11/25/20 documented: ADL (Activity of Daily Living) self-care deficit related to weakness. Interventions: Encourage and/or assist to reposition frequently. R12's care plan focus area initiated 12/8/20 documented: Resident is at risk for skin integrity condition or pressure sores related to history of pressure sores, impaired mobility, incontinence and obesity. Interventions: - Avoid friction/shearing while repositioning: If resident is unable to assist, use at least two staff members, use lift sheet, bed should be as flat as possible with lifting. - Assist to reposition every 2-3 hours and as needed. - Head to toe assessment by Licensed Nurse performed weekly at minimum. - Keep resident clean and dry. Use barrier cream after good peri-care. Apply proper incontinent products as indicated. - Pillows between legs for repositioning - initiated 1/19/21 - Ensure draw sheet is flat prior to repositioning in bed - initiated 1/20/21. - Left Prevalon boot, Encourage repositioning, allowing dressing changes, and applying Prevalon boot. Resident can be resistive to cares, and complying with current wound orders as well as assistive devices for pressure relief. These interventions were initiated 2/18/21 after the start of survey. On 12/11/20 the facility identified a stage 2 pressure injury on R12's coccyx measuring 1.5 x 0.5 x 0.3 cm (centimeters) which subsequently progressed to a stage 3 with presence of slough. Measurements on 2/17/21 were 1.5 x 1.0 x 0.7 cm. Appropriate treatments were implemented and completed. On 1/18/21 the facility identified a wound to R12's right knee. Documentation indicated: Upon doing cares, Certified Nursing Assistant noted a 2 cm x 1 cm area - abrasion on lateral right knee area - patient unable to straighten legs out while in bed - and area is rubbing upon mattress causing friction. Area cleansed with normal saline and foam padded border gauze applied. Surveyor spoke with Registered Nurse (RN)-C who reported he does wound rounds weekly. During wound rounds, he assesses and measures the wounds in centimeters and completes the wound treatment. RN-C reported he documents the information on paper (Pressure Ulcer System Evaluation Tool) and had not transferred the information into R12's electronic record yet. Review of (RN)-C's documentation regarding the right knee wound: 1/20/21 - Pressure ulcer stage 2. 1.5 x 1.0 x 0.1. Pressure from staying on right side. Surveyor noted there was no description of the wound appearance documented. 1/27/21 - Pressure ulcer stage 3. 1.5 x 1.0 x 0.2. Painful. 50/50 slough. There was no other description of the wound appearance documented. 2/3/21 - Pressure ulcer unstageable. 1.5 x 1.0 x 0.3. Going to wound care on 2/10. 75/25 slough/granulation. Scant drainage. Very painful. Surveyor noted there was no other description of the wound appearance documented. There was no description of the drainage to include color, clarity or odor if present. 2/10/21 - Pressure ulcer unstageable. 1.5 x 1.0 x 0.3. 100% slough. Out to wound care. New orders received from doctor. 2/17/21 - Pressure ulcer unstageable. 1.5 x 1.0 x 0.2. Lays on right side majority of day. 100% slough. Painful to resident. No drainage. There was no other description of the wound appearance documented. Physician Report of Consultation dated 2/10/21 documented: Patient presents with a right knee injury, question pressure versus trauma. Exposed tendon. Recommend [MEDICATION(S)] in wound every Monday, Wednesday and Friday. Fill any remaining dead space with Silver Alginate. I may consider a wound vac for knee due to concern of prosthetic health. Wound 1.5 x 1 x 1 cm deep. Review of R12's January, 2021 Treatment Administration Record (TAR) revealed no treatment was transcribed onto the TAR for her right knee pressure injury when the wound was identified on 1/18/21, nor for the remaining days of the month. Review of R12's February, 2021 TAR revealed no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the TAR the resident did not have a treatment in place to be completed for her right knee pressure injury from 1/18/21 to 2/12/21. On 2/18/21 at 12:47 PM Surveyor spoke with RN-C and asked how nurses would know if a treatment needed to be done. RN-C reported nurses would look at the TAR. Surveyor asked RN-C if R12 had a treatment in place for her right knee pressure injury. Surveyor and RN-C reviewed R12's January, 2021 TAR together and noted there was no treatment in place for the right knee pressure injury. Surveyor and RN-C reviewed R12's February, 2021 TAR together and noted there was no treatment in place for the right knee pressure injury until 2/12/21. RN-C stated: I realize now I must not have transcribed it. Surveyor asked RN-C how often the treatment was supposed to be done to R12's right knee pressure injury. RN-C reported the initial treatment was for a foam dressing change every 3 days. This order was not transcribed onto the TAR, therefore the dressing was not changed every 3 days as ordered. On 1/27/21 R12's right knee pressure injury showed a decline with the presence of slough. The treatment was changed to include [MEDICATION(S)] and the dressing was to be changed every 3 days. This order was not transcribed onto the TAR, therefore the treatment was not completed every 3 days as ordered. RN-C reported he was doing the treatment weekly with wound rounds. Surveyor asked RN-C if anyone else was doing the treatment, to which he replied No. On 2/10/21 R12 was seen by the wound doctor and the treatment was changed to [MEDICATION(S)] and Silver Alginate every Monday, Wednesday and Friday. Surveyor verified with RN-C the treatment orders for R12's right knee were to be completed every 3 days starting 1/18/21, but due to the orders having not been transcribed onto the TAR until 2/12/21, the dressing had only been changed weekly, when RN-C completed wound rounds. Surveyor asked RN-C if he thought the lack of transcription of the treatment onto the TAR (which was to be completed every 3 days) contributed to the wound decline. RN-C stated: Probably. On 2/22/21 at 11:30 AM Surveyor observed wound care to R12's right knee performed by RN-C. No concerns with wound care or infection control were identified. Surveyor observation of the wound revealed dark shadowing on the old dressing. The dressing was removed and Surveyor observed no active drainage. RN-C reported there was no odor. Surveyor observation of wound: Edges of the wound were pink. There was no signs or symptoms of infection noted. Slough observed to 75% of wound bed. Pink granulation tissue to 25% of wound bed (RN-C reported the area was previously slough). RN-C measured the wound and Surveyor verified the measurements in centimeters to be 1.8 x 1.7 x 0.3 with 0.5 undermining at 9 o'clock. Surveyor observed the wound closely, no tendon was visible to Surveyor. Surveyor asked RN-C to which area the doctor was referring when he documented visible tendon. RN-C stated I have no idea. I never agreed with that. I see the wound every week and do treatment and have seen no tendon. It's had slough 100% at one point, but now that's getting better. Review of R12's medical record revealed the facility was not consistently completing weekly skin checks or head to toe assessments by Licensed Nurse (weekly at minimum) as indicated on the care plan. Surveyor interview with R12 on 2/18/21 at 9:00 AM revealed the resident admitted to be resistive to change of position and treatment at times, including removing the pillow between her knees and removing the boots on her feet. Facility progress notes documented numerous entries of R12's refusal to reposition and allow dressing changes, however the facility did not investigate reasons for her refusals. In addition, the facility did not create a personalized comprehensive care plan to address the resident's refusal of care and develop an approach to provide appropriate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/22/21 at 2:45 PM Director of Nursing (DON)-B was notified of the above. No additional information was provided. 2.) R8 was admitted to the facility on [DATE]. R8's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R8's Admission/Readmission Evaluation with a date of 7/30/20. Documented under Skin Integrity/Braden Scale was Braden Scale Total Score: 21 which indicated not at risk for pressure injuries. Documented under Integrity was Site: Other (specify): Skin folds. Type: Other (specify): Reddened. The Braden scale result contradicted the Integrity section because R8 already had breakdown of skin. Surveyor reviewed R8's Baseline Care Plan with a date of 7/30/20. Documented was Bowel/Bladder Needs: Incontinent of bladder. Incontinent of bowel. Documented under Skin Care Needs was Other skin concerns: red abdominal folds. Skin treatments - see [Treatment Administration Record (TAR.)] There were no other interventions or preventative measures noted including no turn and reposition schedule or at risk for skin breakdown interventions. Surveyor reviewed R8's Skin Review - Weekly assessment with a date of 8/1/20. Documented was Skin Condition: . 9. Other: redness under breasts and in groin area per [unit staff] and unit nurse. The rest of the assessment form was blank. Surveyor reviewed R8's Skin Review - Weekly assessment with a date of 8/4/20. Documented was Skin Condition: . 1. Skin Intact . 9. Other: per unit staff skin check sheet. The rest of the assessment form was blank. This contradicted the 8/1/20 Skin Review that noted redness to breast area and groin. Surveyor reviewed R8's Braden Scale for Predicting Pressure Sore Risks with an effective date of 8/6/20. Documented was a score of 16 which indicated at risk. Surveyor reviewed R8's MDS admission assessment with an assessment reference date of 8/6/20. Documented under Cognition was a BIMS (brief interview mental status) score of 14 which indicated cognitively intact. Documented under Functional Status for Bed Mobility was 3/3 which indicated Extensive Assistance - resident involved in activity, staff provide weight-bearing support; Two plus persons physical assist. Documented under Functional Status for Transfer was 3/3 which indicated Extensive assistance - resident involved in activity, staff provide weight-bearing support; Two plus persons physical assist. Documented under Bowel and Bladder was Urinary Incontinence 2. Frequently incontinent and Bowel Incontinence 3. Always incontinent. Documented under Skin Conditions was Is this resident at risk of developing pressure ulcers/injuries? 1. Yes. Surveyor reviewed R8's Care Area Assessment (CAA) related to Pressure Ulcer/Injury with an assessment date of 8/12/20. Documented under Nature of the Problem/Condition was No pressure areas. Does have [Moisture Associated Skin Damage (MASD)] in abdominal folds and has medicated [MEDICATION(S)] ordered for this. Risk factors is incontinent of bowel and bladder and needs assist with mobility. Surveyor reviewed R8's Skin Review - Weekly assessment with a date of 8/15/20. Documented was Skin Condition: . 4a. Redness. a. Pre-existing . 9. Other: per unit staff skin check sheet, surgical incisions breasts. The rest of the assessment form was blank. On 8/15/20 an MD order for Apply barrier cream to buttocks [every] shift and [as needed (PRN)] for protection was added to R8's MD orders. There was no order for barrier cream prior to 8/15/20. On 8/17/20 a Wound Evaluation Tracker was opened for R8. Documented was Date of wound data collection: 8/16/20. Site: Sacrum. Type: Pressure. Length: 4 cm. Width: 2 cm. Depth: ?. Stage: Unstageable. Additional descriptions: Had day surgery on 8/14. Pressure injury not noted on 8/15 weekly skin check. The wound bed assessment was blank. Documented under Current Preventative Interventions was Pressure redistribution mattress. [Wheelchair] cushion. There was no turning or repositioning program in place. Surveyor reviewed R8's Wound Evaluation Tracker for sacral PI with an assessment date of 8/18/20. Documented was Length: 4 cm. Width: 2 cm. Depth: blank . Wound Bed: Slough 100%. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R8's MD orders. On 8/19/20 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no air mattress or turning and repositioning in place prior to 8/19/20. Surveyor reviewed R8's Comprehensive Care Plan with initiation date of 8/19/20. Documented was Focus: Pressure ulcer actual or at risk due to: Assistance required in bed mobility, pressure ulcer present. Goal: Pressure Ulcer will heal without complication. Interventions: - Air mattress. - Complete Braden Scale per Living Center Policy. - Conduct weekly skin inspection. - Float heels. - Provide pressure reducing wheelchair cushion. - Provide pressure reducing mattress. - Skin assessment to be completed per Living Center Policy. On 10/2/20 the following interventions were added: - Limit time up in [wheelchair] to no more than 1 hour for meals. - Reposition every 2 hours as needed. The resident was found to be at risk for pressure injuries due to comorbidities, incontinence, and redness and skin breakdown found on admission. There were no interventions in place prior to the Unstageable pressure injury being found on 8/16/20 and no care plan in place until 8/19/20 when PI was noted to be 100% slough and needed debridement. On 2/17/21 at 11:18 AM, Surveyor interviewed Registered Nurse (RN)-C who assessed wounds at the facility. Surveyor asked when he started as wound nurse in the facility. RN-C stated early August. Surveyor asked about preventative measure for R8. RN-C stated he was not sure what was in place. Surveyor asked if RN-C assessed the wound in August. RN-C noted the previous wound nurse that no longer works at the facility did the initial assessment but he did assess it as well. RN-C stated, It was already unstageable when we found it. On 2/22/21 at 2:25 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what is done when a wound is found. DON-B stated the wound is assessed, they measure and describe the wound and update the MD and family if needed. Surveyor asked what preventative measures should have been in place for R8 due to mobility issues and obesity. DON-B stated air mattress and repositioning. Surveyor asked why the air mattress and repositioning were not in place until after the wound was found. DON-B was unsure. Surveyor asked if someone at high risk should have a care plan and preventative measures in place. DON-B stated yes. DON-B was updated on concerns with R8. 3.) R11 was admitted to the facility on [DATE]. R11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R11's Admission/Readmission Evaluation with a date of 8/11/20. The Skin Integrity/Braden Scale section was blank with no documentation. Surveyor reviewed R11's Baseline Care Plan with a date of 8/11/20. The care plan was blank with no documentation. Surveyor reviewed R11's Comprehensive Care Plan with initiation date of 8/17/20. Documented was Focus: Altered skin integrity non pressure related to: Open [CONDITION(S)] related to moisture and incontinence. Goal: Affected area will heal without complication. Interventions: - Barrier Cream to Buttocks with incontinence episodes and PRN. - Complete Braden Scale per Living Center Policy. - Conduct weekly skin inspection. - Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor, notify physician of significant findings. - Nutritional and Hydration support. - Provide thorough skin care after incontinence episodes and apply barrier cream. - Referral to Therapy. - Skin assessment to be completed per Living Center Policy. - Treatments as ordered. - Turning and repositioning schedule per assessment. - Weekly Wound assessment. Surveyor reviewed R11's Braden Scale for Predicting Pressure Sore Risks with an effective date of 8/18/20. Documented was a score of 16 which indicated at risk. Surveyor reviewed R11's MDS admission assessment with an assessment reference date of 8/18/20. Documented under Cognition was a BIMS (brief interview mental status) score of 11 which indicated moderately impaired. Documented under Functional Status for Bed Mobility was 3/3 which indicated Extensive Assistance - resident involved in activity, staff provide weight-bearing support; Two plus persons physical assist. Documented under Functional Status for Transfer was 4/3 which indicated Total dependence - full staff performance every time during entire 7-day period; Two plus persons physical assist. Documented under Bowel and Bladder was Appliances: Indwelling catheter and Bowel Incontinence 2. Frequently incontinent. Documented under Skin Conditions was Is this resident at risk of developing pressure ulcers/injuries? 1. Yes. Surveyor reviewed R11's Care Area Assessment (CAA) related to Pressure Ulcer/Injury with an assessment date of 8/18/20. Documented under Care Plan Considerations was: The staff will continue to assist the resident with bed mobility and toileting. Staff will continue to monitor the resident's skin for alterations. The resident does not have a pressure ulcer at this time. If a pressure ulcer develops the IDT (interdisciplinary team) will put interventions into place to assist in wound healing. Staff will notify the provider of any changes in skin integrity. There was no documentation of the open [CONDITION(S)] related to moisture and incontinence. Surveyor reviewed R11's Skin Review - Weekly assessments and weekly skin checks for 8/22/20, 8/26/20, 8/29/20, 9/2/20, 9/9/20, 9/16/20, 9/17/20 and 9/24/20. Documented was skin intact or negative for any changes in skin integrity. Buttock wounds Surveyor reviewed R11's Progress Notes. Documented on 9/30/20 at 10:04 AM was IDT reviewed injury of known cause. Resident has moisture associated breakdown to bilateral buttocks, 3 small open areas 1cm in diameter. Resident has frequent incontinent episodes, refuses to reposition often in bed on his back/buttocks. Root cause: Incontinence and refusal to reposition while in bed. Intervention: Barrier cream [three times daily (TID)] and PRN (as needed) with incontinence of cares. Care plan reviewed and updated as indicated . Surveyor noted barrier cream to buttocks was already an intervention in place as of 8/17/20 on care plan. No other interventions were added. A Pressure Ulcer System Evaluation Tool was started on 9/30/20 for R11's buttocks. Documented on 9/30/20 was 3 small 1 cm diameter moisture associated abrasions. Barrier cream with cares. Wounds were not assessed correctly to include location, color, odor, drainage or peri-wound characteristics. Documented on 10/7/20 was 3 small openings continue. Surrounding tissue reddened. Wounds were not assessed correctly to include location, size, color, odor, or drainage. Documented on 10/14/20 was Excoriation throughout, incontinence continues, small 1 cm openings with no change. Wounds were not assessed correctly to include location, color, odor, or drainage. Documented on 10/21/20 was Excoriated, red, painful. 1 opening closed. 2 others remain. Encouraged to reposition. Wounds were not assessed correctly to include location, size, odor, drainage or peri-wound characteristics. Documented on 10/28/20 was 2 x 1 cm openings, reddened and irritated surrounding tissue. Refuses to reposition. Wounds were not assessed correctly to include location, odor, or drainage. Left and right buttocks wounds were assessed correctly each week from 11/4/20 through 12/16/20. There were no assessments completed to buttock wounds the week of 1 [TRUNCATED]

Based on observation, interview, and record review the Facility did not provide the necessary treatment and services to prevent pressure injuries and promote healing of pressure injuries for 4 (R42, R9, R10, & R26) of 8 Residents reviewed for pressure injuries and/or are at risk of developing pressure injuries. * R42 has multiple stage 4 pressure injuries which developed/declined prior to the last recertification and complaint surveys. R42's physician orders signed on 9/5/18 documented multiple different treatment for [REDACTED]. R42 goes out monthly to a wound clinic with the last visit being on 9/13/18. During this visit the wound doctor documented an unstageable pressure injury on R42's right ankle with treatment orders for the pressure injuries including the right ankle. These orders were not transcribed and there was no assessment of R42's right ankle pressure injury. During treatment observation, the correct treatment was not done including applying [MEDICATION NAME] 0.1% cream on the pressure injuries, when there was no physician's order to apply this cream onto R42's pressure injuries. * R9 has a [DIAGNOSES REDACTED]. The Facility was not assessing R9's feet prior to R9 developing a Stage 3 pressure injury on her right heel which was identified on 5/24/18. R9's legal representative was not notified of the pressure injury until 6/1/18 approximately 8 days later. The weekly wound evaluations were completed by a LPN (Licensed Practical Nurse) without an RN (Registered Nurse) assessment until 8/10/18 and did not always include an assessment just measurements of R9's pressure injury. * R10 who is at risk for pressure injuries was observed without her heels being offloaded and without any padding for the tubing around R10's ears. * R26's heels were observed not being floated and R26 was observed not wearing the pressure relieving boots according to the plan. R42 & R9 are being cited at a scope/severity of G (harm/isolated). Findings include: 1) R42's [DIAGNOSES REDACTED]. The actual skin integrity break and/or pressure sore(s) care plan initiated 10/25/17 & revised 9/14/18 documents for interventions; Assess and measure all skin integrity areas per policy initiated 10/25/17, Encourage to float heels while in bed initiated 4/26/18, Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote healing and prevent complications initiated 10/25/17, Initiate treatment per Physician order initiated 10/25/17, Monitor and report any new open areas, drainage, increased drainage or pain to nurse immediately initiated 10/25/17, Monitor for c/o (complaint of) pain. Medicate PRN (as needed) and offer pain medication prior to treatment. Update Physician regarding effectiveness and increased need for pain medications initiated 10/25/17, Patient chooses to lay on flat on back and not turn side to side initiated 3/23/18, Provide treatment to wound(s) per current treatment order. Assess wound(s) for s/s (signs/symptoms) of infection with each dressing change/treatment. Report findings of redness, warmth, swelling, increased drainage or increased pain to physician initiated 10/25/17 & revised 12/1/17, Resident chooses not to wear hard soled shoes when out of the building initiated 10/25/17 & revised 1/16/18. Resident has order to be followed by outside wound treatment center initiated 6/20/18, Resident should wear protective boots when she goes oop (out on pass) for protection initiated 3/20/18, Use towel rolls in hands for joint protection initiated 3/14/18 and Will continue to educate resident on the use of proper footwear while out of bed initiated 1/15/18. The quarterly MDS (Minimum Data Set) with an assessment reference date of 7/12/18 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R42 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, is dependent with two person physical assist for transfer and does not ambulate. R42 is checked for having an indwelling catheter and is always incontinent of bowel. R42 is at risk of pressure ulcers and is coded as having three Stage 4 pressure injuries and one unstageable pressure injury. The monthly physician orders for 9/18 and signed by the physician on 9/5/18 documents pressure injury treatments of: [MEDICATION NAME] & [MEDICATION NAME] AG to right & left post calf & coccyx every day - cover w/(with) allevyn border, [MEDICATION NAME] therabond every 72hrs (hours) - moisten with tap water; cut to cover wound and 2-3 mm (milliliter) of surrounding skin - cover w/allevyn border, may use foam border dressings with wound treatments, Soap & water wash to legs/feet/ankle - dry, apply natural shield or eq. (equivalent) barrier cream - cover with abd. (abdominal) & kling daily, cleanse coccyx w/ns (with normal saline) f/b (followed by) Alginate AG f/b non adherent foam border dressing every qd (every day). On 9/17/18 at 10:03 a.m., Surveyor observed R42 in bed on her right side wearing bilateral boots. Surveyor asked R42 how she was doing. R42 informed Surveyor she felt nauseated and didn't feel like talking. On 9/18/18 at 8:45 a.m., Surveyor observed R42 in bed on her back with the head of the bed elevated. R42 had pillows under hands with a wash cloth in R42's left hand and is wearing bilateral blue boots. Surveyor noted R42's tube feeding is running at 60cc (cubic centimeters). On 9/18/18 at 9:30 a.m., R42 informed Surveyor the staff doesn't always change the dressings on her feet and legs. R42 informed Surveyor on the buttocks the nurse changes the outer dressing every day and the inside dressing every 72 hours. R42 informed Surveyor the nurse was going to change her dressings at 1:00 p.m. Surveyor asked permission to observe the dressing change which R42 gave. On 9/18/18 at 9:41 a.m., during medication administration Surveyor heard R42 inform RN-E she doesn't want her dressings changed at 1:00 p.m. today because she has a shower. RN-E explained to R42 she is only working until 2:30 p.m. and will inform the evening shift. On 9/18/18 at 2:50 p.m., Surveyor asked R42 how she initially received the pressure injuries. R42 replied, from laying in bed. Surveyor asked R42 if she allows staff to reposition her. R42 replied I usually say yes. R42 informed Surveyor the CNA (Certified Nursing Assistant) noted there aren't any dates on her dressings on her legs and she thinks the CNA told RN (Registered Nurse)/UM (Unit Manager)-F. R42 informed Surveyor she doesn't remember the last time the dressings on her legs were done and they haven't been done in the last three days. On 9/18/18 at 3:23 p.m., Surveyor observed CNA (Certified Nursing Assistant)-X & CNA-Y entered R42's room. CNA-X informed R42 they were going to shower her now. The bedding & the bilateral prevalon boots were removed from R42 and Surveyor noted none of the dressings on R42's lower extremities are dated. R42's incontinence product was unfastened, CNA-Y positioned R42 on her side and CNA-X using disposable wipes provided care to remove the stool from R42's rectal area and buttocks. After all the stool was removed, CNA-X taped a plastic bag over R42's coccyx pressure injury, and a sling was placed under R42. The nurse disconnected R42's tube feeding, the sling was attached to the Hoyer lift, and R42 was transferred into the shower chair. On 9/19/18 at 9:10 a.m., Surveyor observed R42 in bed on her back with pillows under her hands, a rolled up wash cloth in R42's left hand and wearing bilateral prevalon boots. Surveyor asked R42 permission again to observe her treatments which R42 gave. Coccyx Treatment: On 9/19/18 at 11:31 a.m., Surveyor entered R42's room with RN (Registered Nurse)-T and RN/UM (Unit Manager)-F to observed R42's treatment. R42's treatment supplies were placed on top of a towel on the over bed table. RN-T & RN/UM-F washed their hands and placed gloves on. RN-T asked R42 how her pain was which R42 replied good. RN-T removed the blanket from R42, the pillow between her legs, right arm, and under R42's left side. RN-T unfastened the incontinence product, and R42 was positioned on her right side with RN/UM-T holding onto R42. RN-T removed the dressing from R42's coccyx, placed the dressing in a plastic bag, removed her gloves, cleansed her hands and placed gloves on. RN-T and RN/UM-F switched places so RN-T was now holding onto R42. RN/UM-F removed her gloves, cleansed her hands, placed gloves on and measured R42's coccyx pressure injury which was 8.2 cm (centimeter) x 5.6 cm by 0.2 cm with .5 tunneling at 11 o'clock. RN/UM-F and RN-T removed their gloves, cleansed their hands, placed gloves on and then switched places so RN/UM-F was holding onto R42. At 11:44 a.m., RN-T wet [MEDICATION NAME] with normal saline, squirted normal saline on the coccyx wound bed, dabbed the wound bed with a four by four gauze, removed her gloves and placed new gloves on. RN-T did not wash or cleanse her hands. RN-T placed [MEDICATION NAME] 0.1% on a cotton tip applicator, placed this cream on R42's wound bed removed her gloves and placed gloves on. RN-T placed the [MEDICATION NAME] on the wound bed, removed her gloves and placed new gloves on. RN-T opened a package of derma cel AG removed her right glove, placed a new glove on and removed scissors from her pocket. RN-T cut a piece of dermacel and placed the dermacel on the wound bed, applied skin prep around the wound, removed her gloves and placed new gloves on. RN-T placed a comfort foam dressing over R42's coccyx pressure injury, removed her gloves and cleansed her hands. RN-T placed gloves on, dated the dressing and fastened the incontinence product. RN/UM-F informed R42 she was going to place her on her back and R42 was placed on her back. RN-T and RN/UM-F removed their gloves, cleansed their hands and placed gloves on. Surveyor noted there were multiple physician's orders for the pressure injury treatment. There was no physician's order for [MEDICATION NAME] for pressure injury treatment, and it was unclear which order the nurse was to follow. Left calf, Left heel, Left ankle: On 9/19/18 at 11:54 a.m., RN/UM-F held up R42's left leg, RN-T removed the border foam dressing from R42's lower left calf, removed her gloves and placed new gloves on. RN-T wet a wash cloth and placed the wet wash cloths on R42's lower left calf to help loosen the dressing which was under the border foam dressing. RN-T squirted the dressings with normal saline, asked R42 how she was doing, removed two dressings, removed her gloves and cleansed her hands. On 9/19/18 at 11:58 a.m. RN/UM-F removed the dressing from R42's left heel, stated she was going to measure, removed her gloves, cleansed her hands and placed gloves on. RN-T held onto R42's left leg while RN/UM-F measured R42's left calf which measured 0.8 cm by 1.4 cm, left heel which measured 1.6 cm by 1 cm and R42's left ankle which measured 0.8 cm by 1 cm. After measuring, RN/UM-F removed her gloves and cleansed her hands. At 12:01 p.m. RN-T removed her gloves, washed her hands and went to the treatment cart located outside R42's room. At 12:04 p.m., RN-T reentered R42's room with supplies, cleansed her hands and placed gloves on. RN/UM-F held onto R42's left leg while RN-T squirted normal saline on R42's left calf open area and dabbed the wound bed with four by four gauze. RN-T removed her gloves, placed gloves on and opened a package of dermaginate ag. RN-T placed [MEDICATION NAME] 0.1% cream on cotton applicators and applied this cream on the wound bed of R42's left calf. RN-T removed her gloves, cleansed her hands, and placed gloves on. RN-T squirted normal saline on dermaginate and placed the dressing over R42's left calf open area. RN-T removed her gloves, dated the comfort border dressing, cleansed her hands and placed gloves on. RN-T applied skin prep around the open area, covered the left calf open area with foam dressing, removed her gloves and washed her hands. Surveyor noted there were multiple physician's orders for the pressure injury treatment. There was no physician's order for [MEDICATION NAME] for pressure injury treatment, and it was unclear which order the nurse was to follow. On 9/19/18 at 12:13 p.m., RN-T placed gloves on, wiped the left heel pressure injury with soapy water on a paper towel, removed her gloves and placed gloves on. RN-T placed [MEDICATION NAME] 0.1% cream on a cotton applicator and placed this cream on R42 left heel pressure injury. RN-T placed skin prep around the pressure injury and covered the left heel pressure injury with foam dressing. Surveyor noted there were multiple physician's orders for the pressure injury treatment. There was no physician's order for [MEDICATION NAME] for pressure injury treatment, and it was unclear which order the nurse was to follow. At 12:15 p.m. RN-T removed her gloves, cleansed her hands, and placed gloves on. RN-T applied skin prep around R42 left ankle open area but did not place any dressing over the area. RN/UM-F placed a gripper sock and prevalon boot on R42's left foot. RN/UM-F and RN-T removed their gloves and washed their hands. Surveyor noted the 9/5/18 physician's order for the ankle is soap and water wash to legs/feet/ankle-dry, apply natural shield or eq. (equivalent) barrier cream-cover with abd and kling daily. The 9/5/18 physician's order does not include skin prep to be applied to the left ankle open area. Right calf: On 9/19/18 at 12:18 p.m., RN-T & RN/UM-F placed gloves on, RN-T placed a pillow under R42's right leg and RN-T removed the dressing from R42's right calf. RN/UM-F measured the right calf which measured 15 cm by 1 cm. RN-T & RN-UM-F removed their gloves and washed their hands. At 12:22 p.m. after washing her hands, RN/UM-F left R42's room. RN-T placed gloves on, wet a wash cloth which RN-T and placed the wash cloth over R42's right calf pressure injury. Surveyor noted R42's right calf pressure injury was bleeding with the blood dripping onto the sheet. RN-T removed her gloves, cleansed her hands, and cut a piece of dermaginate ag. RN-T placed [MEDICATION NAME] 0.1% cream on a cotton applicator and then applied the cream on R42's right calf pressure injury. RN-T placed the dermaginate ag dressing on the pressure injury and covered the pressure injury with a foam dressing. RN-T removed her gloves. Right Ankle: At 12:28 p.m., Surveyor asked RN-T about R42's right ankle which had a foam dressing on. Surveyor noted the dressing was not dated. Surveyor also noted RN/UM-F did not measure or assess the right ankle. RN-T placed gloves on, attempted to remove the foam dressing, removed her gloves, cleansed her hands and went to the treatment cart. At 12:32 p.m. RN-T reentered R42's room, cleansed her hands and placed gloves on. RN-T placed paper towels on the bed and squirted normal saline on to help remove the foam dressing. RN-T removed the foam & dermagel dressing from R42's right outer ankle removed her gloves and placed new gloves on. RN-T informed Surveyor she didn't see a treatment for [REDACTED]. RN-T cut the dermagel ag & wet this dressing, placed the dressing over R42's right ankle pressure injury and covered the pressure injury with a coversite cover dressing. RN-T removed her gloves, cleansed her hands, placed a gripper sock and blue prevalon boot on R42's right foot. RN-T covered R42 with blanket, placed the call light tube by R42's mouth, gathered her supplies and left R42's room. Surveyor noted there was no physician's order for the treatment of [REDACTED]. On 9/19/18 at 2:55 p.m., Surveyor asked IDON (Interim Director of Nursing)-B what the treatment should be for R42's coccyx. IDON-B informed Surveyor cover with allevyn border every day, [MEDICATION NAME] therabond every 72 hours, moisten with tap water, cut to cover wound and 2-3mm of surrounding skin. Surveyor asked if there was is any ointment/cream that should be applied. IDON-B informed Surveyor it just says moisten with tap water. Surveyor asked about R42's right & left calf. IDON-B informed Surveyor [MEDICATION NAME] and [MEDICATION NAME] ag to right and left posterior calf and cover with allevyn dressing. Surveyor asked about the left heel treatment. IDON-B informed Surveyor she needs to clarify the orders from the wound doctor. On 9/19/18 at 3:38 p.m., Surveyor met with IDON-B & RN Consultant-C regarding R42's pressure injuries. Surveyor informed IDON-B & RN Consultant-C Surveyor is having a hard time determining when R42 developed the Stage 4 pressure injuries. Surveyor also informed IDON-B & RN Consultant-C there are multiple treatments on the physician orders signed 9/5/18 and inquired what is suppose to be the correct treatment for [REDACTED]. Surveyor informed IDON-B and RN Consultant-C during R42's treatment observation Surveyor observed RN-T apply [MEDICATION NAME] 0.1% cream which is not on any of R42's pressure injury treatment orders. Surveyor informed IDON-B & RN Consultant-C during R42's treatment observation RN/UM-F did not measure or assess R42's right ankle pressure injury, the Surveyor was unable to locate any information regarding the right ankle pressure injury in R42's medical record and asked for information. The nurses note dated 9/19/18 at 7:16 p.m. documents, Complete head to toe skin assessment completed by two RNs. New areas of concern noted on Weekly Skin assessment dated today. MD updated on new areas. The weekly skin review dated 9/19/18 documents for the right ankle under description Addendum 9/20/18 Right ankle skin impairment measuring 1.3 x 1.0. Surveyor noted there is no assessment of the wound bed and there is no stage documented. On 9/20/18 at 1:42 p.m., IDON-B provided Surveyor with R42's wound consult dated 9/13/18. Under findings documents, Current dressings dated 9/8/18 5 days wear time. Multiple pressure injuries. Under findings also includes, Right lateral ankle 1 x (times) 1 cm (centimeter) eschar. Unstageable. Under recommendations documents, *NEEDS PREVALON BOOTS WASHED OR REPLACED* 1.) Silveral & Allevyn border to legs & left heel ulcer q (every) 48 hours. 2.) Allevyn border alone to right lateral ankle q 48 hours. 3) New: Hydrafera Blue moisten to coccyx. Replace blue q 72 hours. Change outer dressing daily. F/u (follow up) 3 weeks. Wound Doctor-Z progress note dated 9/13/18 under medical decision making documents, Multiple pressure injures in a patient who is bed bound due to NMO (neuro[DIAGNOSES REDACTED] optica). No sign of infection. Dressings are not being changed as ordered. On 9/20/18 at 1:42 p.m., IDON-B also provided Surveyor with R42's treatment orders dated 9/19/18 which documents, Treatment order clarification to coccyx: Apply calazine to wound perimeter f/b (followed by) [MEDICATION NAME] blue f/b ABD pad & secure change (triangle) ABD pad daily Change (triangle) [MEDICATION NAME] blue Q (every) 72 hours. and Treatment order clarification to (L) (left) heel, (R) (right) lateral ankle, (L) & (R) calves: Cleanse with gentle soap & water f/b Pat dry f/b [MEDICATION NAME] f/b Allevyn border change (triangle) Q (every) 48 hours. Surveyor noted the clarification orders does not include to moisten the Hydrafera Blue as indicated in the wound consult dated 9/13/18. On 9/20/18 at 1:42 p.m., Surveyor met with IDON-B to discuss the information IDON-B had collected regarding R42's pressure injuries. IDON-B provided Surveyor with information about R42's pressure injuries which included the coccyx, L and R calf and left heel. These injuries developed prior to the last recertification and complaint surveys and which had been reviewed. Surveyor inquired about the wound consult dated 9/13/18 addressing all of R42's wounds and asked where the orders from this consultation are. IDON-B informed Surveyor she doesn't have these orders. Surveyor inquired what happens when a Resident returns with orders from a consult. IDON-B explained the orders are reviewed by the nurse and are suppose to be transcribed as an order. IDON-B indicated the nurse would write a telephone order after calling the doctor and reviewing the recommendations with the doctor. IDON-B informed Surveyor the nurse would also transcribe the orders on the TAR (treatment administration record). IDON-B informed Surveyor R42 goes out to the wound clinic monthly and the last time prior to the (MONTH) visit was 8/13/18. Surveyor inquired if these orders were transcribed. IDON-B informed Surveyor the recommendations from the 8/13/18 wound consult are not on the orders as the last wound order IDON-B sees is 7/17/18. Surveyor asked why the orders from the 9/13/18 wound consult were not transcribed. IDON-B explained when R42 returned the consultation form was in a brown envelope which was placed in the appointment slot and not opened. Surveyor inquired why there wasn't an assessment for the right ankle pressure injury as there was a dressing over the area. IDON-B informed Surveyor she can't answer that and wasn't aware of anything on R42's right ankle. IDON-B informed Surveyor there is a treatment order now and a head to toe assessment was completed. Surveyor asked what should happen if a pressure injury is discovered. IDON-B informed Surveyor if a nurse discovers an area they should measure & assess the area, call the doctor, get a treatment order, notify the family, complete a progress note and write the treatment on the TAR. On 9/20/18 at 4:22 p.m., IDON-B informed Surveyor she has nothing further to provide Surveyor regarding R42's pressure injuries. 2. R9 has a [DIAGNOSES REDACTED]. R9's POA (Power of Attorney) was activated on 10/31/14. The quarterly MDS (Minimum Data Set) with an assessment reference date of 4/5/18 documents a BIMS (brief interview mental status) score of 6 which indicates severe impairment. R9 requires supervision with one person physical assist for bed mobility & transfers and does not ambulate. R9 is at risk for pressure injuries and is coded as not having any pressure injuries. The at risk for alteration in skin integrity care plan initiated 4/11/18 documents interventions of; Barrier cream to peri area/buttocks as needed initiated 4/11/18, Encourage fluids initiated 4/11/18, Encourage to float heels while in bed initiated 4/11/18 & revised 4/26/18, Encourage to reposition as needed initiated 4/11/18 & revised 5/24/18, and Observe skin condition with ADL (activity daily living) care daily; report abnormalities initiate 4/11/18. During review of R9's medical record including the (MONTH) (YEAR) TAR (Treatment Administration Record) Surveyor was unable to locate staff were checking R9's feet. R9 has a [DIAGNOSES REDACTED]. The nurses note dated 5/24/2018 documents, CNA (Certified Nursing Assistant) notified writer that resident c/o (complained of) right heel pain, noted wet area on bed where right foot had been lying. RN (Registered Nurse) observed what appears to be a non-intact blister. The first layer of skin of the proximal portion peeled back from second layer of skin but is soft and pliable. Exposed skin is pink, tender to touch. The skin of the distal portion is intact. Two pea sized dark bruises can be visualized through the opaque skin. Area cleansed with normal saline. Skin edges approximated. Covered with soft, border dressing. Heels floated. Physician-U's office notified. Message left for Physician-U's nurse. Will return call if further orders. The nurses note dated 5/24/2018 documents, Dressing to blister to R heel CDI (clean dry intact), Physician-U's nurse returned call, treatment orders written. The nurses note dated 5/24/2018 documents, Resident is on follow up for: increased pain, decline in ADLs (activity daily living). The current status is Non-intact blister. The first layer of skin of the proximal portion peeled back from second layer of skin but is soft and pliable. Exposed skin is pink, tender to touch. The skin of the distal portion is intact. Two pea sized dark bruises can be visualized through the opaque skin. Area cleansed with normal saline. Skin edges approximated . Heels floated. New order for soft border dressing. Will review with wound rounds by Wound Nurse on 5/25. Surveyor did not note R9's POA was notified of R9's pressure injury. The nurses note dated 5/24/2018 documents, Resident continues to be monitored on 24 hr board for R (right) heel blister. Resident received meds and requested ice for her R heel to decrease pain. Resident is resting in room with call light within reach. The pressure ulcer care plan initiated 5/24/18 & revised on 6/25/18 documents interventions of Float heels when in bed initiated 5/24/18 with a revised and resolved date of 5/25/18, Complete Braden Scale per facility policy initiated 5/24/18 & revised 6/25/18, Conduct weekly skin inspection initiated 5/24/18, Do not massage over bony prominence initiated 5/24/18, Nutritional and Hydration support initiated 5/24/18, Per resident request use both towels to elevate heels off of bed. Resident chooses not to use heelz up device in bed initiated 6/6/18, Provide wound treatment per MD order until healed initiated 8/7/18, Skin assessment to be completed per facility policy initiated 5/24/18 & revised 6/25/18, Treatment as ordered initiated 5/24/18, and Weekly wound assessment initiated 5/24/18. The nurses note dated 5/25/2018 documents, Patient denies discomfort with blister on foot. New orders placed. Patient is not to wear any shoes at all until after the blister heels. The wound evaluation tracker dated 5/25/18 documents for site right heel for type blister length 4.1, Width 5.3, depth 0.1 and stage Unstageable. When was the wound identified documents 5/24/2018. Under wound type Pressure ulcer (in-house acquired) is identified. Under the section wound bed Granulation % (percentage) is documented as 100. This evaluation was signed on 6/4/2018 by LPN (Licensed Practical Nurse)/WN (Wound Nurse)-V. Surveyor noted this pressure injury was not assessed by a RN (Registered Nurse) and was staged incorrectly. The National Pressure Ulcer Advisory Panel redefined the definitions of pressure injuries during the National Pressure Ulcer Advisory Panel (YEAR) staging consensus conference which documents an Unstageable pressure injury as a Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Stage 3 Pressure injury is defined as Full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The late entry nurses note dated 6/1/18 documents, Resident seen by wound specialist today for open blister of R heel. Area measures 3.8 x 3.4 x 0.1cm (centimeter), 75% granulation and 25% slough. Discolored area mid wound. Peri wound with mild [MEDICAL CONDITION]. Moderate amt (amount) of serous drainage. Will continue current order to R heel. Educated on the need to keep pressure off heels and no shoes (to wear non-skid socks). Resident shows clear understanding. Family udated (sic) on wound condition. Surveyor noted this is the first notation of R9's legal representative being updated. The significant change MDS with an assessment reference date of 6/4/18 has a BIMS score of 7 which indicates severe impairment. R9 requires extensive assistance with two plus person for bed mobility & transfer, walk in room is coded as activity occurred only once or twice with one person physical assist, and did not ambulate in corridor. R9 is at risk for developing pressure injuries and is coded as having one Unstageable slough and/or eschar pressure injury. The wound evaluation dated 6/8/18 documents for staging unstageable and the wound bed as 50% granulation and 50% slough. This wound evaluation was signed by LPN/WN-V. Surveyor noted there is no RN assessment. The wound evaluation dated 6/15/18 documents for staging, unstageable and the wound bed as 50% granulation and 50% necrotic. Surveyor noted there is no RN assessment. The wound evaluation dated 6/22/18 documents for staging unstageable and the wound bed as 50% granulation and 50% slough. Surveyor noted there is no RN assessment. The wound evaluation dated 6/29/18 documents for stage as Suspected Deep Tissue Injury and the wound bed as 50% granulation and 50% slough. Surveyor noted there is no RN assessment and has been incorrectly staged. According to the National Pressure Ulcer Advisory Panel a deep tissue pressure injury is Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Surveyor reviewed R9's (MONTH) (YEAR) TAR and noted diabetic foot checks were being completed at hour of sleep from 6/1 to 6/5 and then the foot checks have been crossed out. The wound evaluation dated 7/6/18 documents for staging unstageable and the wound bed as 50% granulation and 50% slough. Surveyor noted there is no RN assessment. The wound evaluation dated 7/20/18 documents for staging III (Stage 3) and the wound bed as 50% granulation and 50% slough. Surveyor noted R9's right heel pressure injury is now differently staged despite same 50% granulation and 50% slough description and there is no RN assessment. Surveyor noted since development this wound has been called unstageable, a deep tissue injury and now a stage 3. Surveyor reviewed R9's (MONTH) (YEAR) TAR and noted diabetic foot checks completed at hs (hour sleep) except on 7/5, 7/10, 7/19 7/20, 7/28 & 7/31. The wound evaluation dated 8/3/18 documents for staging III (Stage 3) and the wound bed as 75% granulation and 25% slough. Surveyor noted there is no RN assessment for R9's right heel pressure injury. The wound evaluation dated 8/10/18 documents for staging III. There is no description of the wound bed documented. This assessment was completed by Interim DON (Director of Nursing)-B. The wound evaluations dated 8/24/18 & 8/30/18 completed by RN/UM (Registered Nurse/Unit Manager)-F documents staging III. There is no assessment of the wound bed documented. Surveyor reviewed R9's (MONTH) (YEAR) TAR and noted the diabetic foot check daily at bedtime yellowed out which indicates they have been discontinued. The quarterly MDS with an assessment reference date of 9/4/18 documents a BIMS score of 6 which indicates severe impairment. R9 requires limited assistance with one person physical assist for bed mobility & transfers, and does not ambulate. R9 is at risk for developing pressure injuries and is coded as not having a pressure injury which is an error. The skin grid dated 9/5/18 only includes drainage and measurements for R9's right heel pressure injury. There is no Stage documented or any assessment of the wound bed. The wound evaluation dated 9/13/18 & 9/19/18 documents for stage II (Stage 2). According to current standards of practice pressure injuries should not be backstaged. There is no assessment of the wound bed documented. On 9/17/18 at 11:25 a.m., Surveyor observed R9 sitting in a wheelchair in her room. There is a cushion in R9's wheelchair with a towel on top of the cushion. Surveyor observed R (TRUNCATED)

Based on observation, interviews, and record review the facility did not ensure that care and services were provided to prevent pressure injuries from occurring or worsening for 5 (R7, R1, R2, R10, and R3) of 15 sampled residents reviewed who were identified as at risk for the development of pressure injuries. *R7 was admitted to the facility without pressure injuries to his gluteal area. On 1/19/17, when R7 was noted to have unblanchable redness to his bilateral buttocks, no new interventions were put into place to prevent the area from worsening. On 1/20/17 an incident report documents a stage 2 pressure injury. There is no documentation in R7's medical record that new interventions were put into place to prevent the area from worsening until 1/23/17 when R7 was noted to have two unstageable pressure injuries to his ischial tuberosities. The wound was not comprehensively assessed to include measurements until 1/25/17, at which time the wound was incorrectly staged as a stage 2. The wound continued to be staged incorrectly as an unstageable pressure injury when the wound bed was visible to stage. R7 was also observed to have her wound cleansed with Dakin's without orders specifying what solution strength should be used. R7's development of 2 avoidable pressure injuries, which remain unhealed, caused actual harm to the resident. *R1, R2, and R10 were observed with their heels not offloaded of pressure per their plan of care. *R3's pressure injury was not comprehensively assessed for 5 days after being admitted to the facility with a wound. Example 1 involving R7 rises to a scope and severity level of G (harm/isolated). Findings include: 1. R7 has [DIAGNOSES REDACTED]. R7 was admitted to the facility on [DATE] without a pressure injury. R7's Minimum Data Set, with an assessment reference date of 1/10/17, documents that R7 is at risk for the development of pressure injuries, has no pressure injuries, and requires extensive assistance of 2 plus staff for bed mobility. Rejection of care behavior was not observed. Progress notes on 1/19/17 at 10 p.m. document Bilateral buttocks red, non-blanchable, appears to be beginning to shear, message left for MD/NP to initiate treatment. There is no documented update to R7's plan of care on 1/19/17 when he was first noted to have skin breakdown. There are no measurements or staging of the wound completed. On 7/24/17 at 8:49 a.m. the surveyor interviewed DON-B. The surveyor asked if a new skin impairment is noted are staff expected to measure the area. DON-B stated, Yes. There is no documentation that a physician was notified. The surveyor shared the concern that there is no documented size of the area noted on 1/19/17. On 7/24/17 at 8:49 a.m. the Surveyor interviewed DON (Director of Nursing)-B. The Surveyor asked DON-B what is the expectation for staff to contact the physician regarding a new skin impairment. DON-B informed the Surveyor on the shift that it occurred on. The Surveyor asked if staff should contact a physician for unblanchable redness. DON-B stated if they suspect it is a pressure injury they should. The Surveyor asked what is the expectation for the time frame to hear back from a physician. DON-B stated it should be within a reasonable amount of time. If don't hear back should page again, and if still don't hear back should contact medical director. An occurrence report dated 1/20/17 at 3 p.m. documents a pressure ulcer to the coccyx measuring 0 x 0 x 0, stage 2 to the coccyx and left hip with serous drainage. Tissue type is documented as [MEDICATION NAME] tissue. Immediate actions taken include air mattress. Delivery ticket documentation from Dynamic Medical Systems LLC, provided by the facility, documents that an air mattress was not ordered or received until 1/23/17. Other immediate action documented as taken are MD notified with no new orders received. There is no documentation in R7's medical record that an MD was notified. Other immediate actions documented as taken include area cleansed, skin assessment completed, employee education, and dressing applied. There is no order for a dressing. Review of R7's medical record, including progress notes and treatment administration record, do not document that a dressing was applied, what type of dressing was applied, or when the dressing should be changed/monitored. Immediate interventions also include wheelchair pressure reduction cushion. On 1/24/17 at 9:04 a.m. the Surveyor interviewed DON-B. The Surveyor asked about the wheelchair pressure reduction cushion being an immediate intervention. DON-B informed the Surveyor that R7 should have already had this in place, and that he rarely goes into to his wheelchair per his choice. The Surveyor asked for any additional information of interventions put into place on 1/20/17 to prevent the pressure injuries from worsening. On 7/24/17 at 1:45 p.m. DON-B informed the Surveyor that the dressing applied on 1/20/17 was an intervention, that it was not put in the TAR, but that it is documented in the incident report. There are no new interventions documented to prevent pressure injuries in R7's medical record, including his care plan, physician orders, progress notes, and treatment administration record until 1/23/17. NP (nurse practitioner)-S progress notes on 1/23/17 document an encounter visit with a chief complaint of wound. The progress note documents Nursing staff report they noted redness to (R7)'s bilateral ischial tuberosities on Saturday and Allevyn foam border dressing was applied for protection. They note he refuses to reposition, and is constantly sitting in the bed with HOB (head of bed) elevated at nearly 90 degrees. The section Physical Examination documents Unstageable pressure ulcer to bilateral ischial tuberosities approximately 2 round with significant depression. Central area covered in eschar, moderate serosanguineous drainage. Non-blanchable [DIAGNOSES REDACTED]/purple discoloration surrounding open area. New orders placed on 1/23/17 include to cleanse the wounds with normal saline, hydrogel, cover with Allevyn foam border and change every 3 days, refer to healogics visiting wound NP, refer to skilled nursing facility wound LPN/wound rounds for treatments/monitoring of wound, start alternating air pressure relief mattress, start bed rest at least three time per day-side lying with off pressure loading of buttocks, wheelchair cushion in place-PT (physical therapy) eval for proper cushion for wounds, start vitamin C 500 mg daily, and consult dietician for nutritional evaluation. NP-S documents that she discussed with the R7 at length of need to off load pressure and changing position at least every 2 hours. There are no documented wound measurements on 1/23/17 for the facility to assess/monitor if the wound is progressing towards healing or deteriorating. On 1/25/17 LPN (licensed practical nurse)-W documents a 7 x 7 x unknown stage 2 pressure injury to R7's left trochanter. A picture from the assessment shows a wound to R7's left tuberosity. There is no documentation of the wound bed. On 1/25/17 LPN-W documents a 6 x 3 x unknown stage 2 pressure injury to R7's coccyx. A picture from the assessment shows a wound to R7's right tuberosity. There is no documentation of the wound bed. On 1/28/17 progress notes from LPN-X, who is wound care certified, documents, Previously documented Stage II PU (pressure ulcer) to coccyx and left greater trochanter, are actually unstageable PU to bilateral isch (ischial) tuberosities. Both with distinct and attached edges and uneven margins. Both with scant amount of serosanguineous drainage observed. Both with firm and intact periwounds, free from maceration and indurations, some blanchable [DIAGNOSES REDACTED] observed. Right measures 7.4 x 5 x 0.1 with 90% tightly adhered yellow slough and 10% granulation tissue. Left measures 10 x 7.6 x 0.1 with 10% granulation tissue, 20% tightly adhered yellow slough, and 70% tightly adhered soft eschar. Both cleansed with NS (normal saline), covered with Hydrogel, AG fiber, and foam dsg (dressing). NP/RP (responsible party) notified On 7/24/17 at 1 p.m. the Surveyor interviewed LPN-X. The Surveyor asked LPN-X how she came up with the determination that the wound was not staged correctly. LPN-X informed the Surveyor through the documentation, which includes pictures of the wound, and interview with the nurse she was able to determine it was mis-staged. R7's wounds continued to deteriorate. On 2/7/17 the left ischial tuberosity is documented to measure 9.9 x 6.1 x 2.3 with 100% loosely adherent slough. The right ischial tuberosity, on 2/7/17, is documented to measure 6.5 x 3.9 x 3 with 50% loosely adherent slough and 50% bright beefy red tissue. On 2/7/17 R7 was seen by a wound physician. A skin/subcutaneous tissue/muscle/fascia level excisional debridement was performed to the left ischial. Adipose, dermis, epidermis, fascia, muscle and subcutaneous tissue were removed along with devitalized tissue: exudate, necrotic/eschar, and slough. On 2/10/17 R7 started receiving hospice care. Progress notes on 3/1/17 document Unstageable PI's (pressure injuries) observed to bilateral ischial tuberosities. Both with even margins. Both with moderate amounts of serosanguineous drainage observed .right measures 5.2 x 2 x 3 with 2 cm of undermining from 12:00 to 3:00, with 10% slightly adhered yellow slough and 90% granulation tissue. Left measures 8.8 x 3.7 x 2, with 1.5 cm of undermining from 12:00 to 5:00 and a 4 cm tunnel at 11:00, with 70%granulation tissue and 30% loosely adhered yellow slough. Tx (treatment) orders changed .NP notified, discussed with pt (patient), he is his own RP (responsible party). R7's pressure injury to his right ischial tuberosity remained staged as unstageable despite 90% of the wound bed being visible (not mostly obscured with slough or eschar). On 3/8/17 R7's wound to the right ischial tuberosity is documented as measuring 5.5 x 2 x 3 with 100% bright beefy red tissue. The wound remained staged as unstageable despite 100% of the wound bed being visible. On 3/15/17 R7's wound to the right ischial tuberosity is documented as measuring 5.7 x 2.5 x 2.8 with 100% bright beefy red tissue. The wound remained staged as unstageable despite 100% of the wound bed being visible. The wound to the left ischial tuberosity is documented as 7.8 x 4 x 1 with 90% bright beefy red tissue and 10% loosely adherent slough. The pressure injury is documented as unstageable despite 90% of the wound bed being visible. On 3/22/17 R7's wound to the right ischial tuberosity is documented as measuring 5 x 2 x 2.8 with 100% bright beefy red tissue. The wound to the left ischial tuberosity is documented as 7.3 x 4 x 1 with 100% bright beefy red tissue. The wounds remained staged as unstageable despite 100% of the wound bed being visible. On 3/27/17 R7's wound to the right ischial tuberosity is documented as measuring 5 x 2 x 1 with 100% bright beefy red tissue. The wound to the left ischial tuberosity is documented as 7.2 x 4 x 1 with 100% bright beefy red tissue. The wounds remained staged as unstageable despite 100% of the wound bed being visible. On 7/24/17 at 11 a.m. the Surveyor interviewed LPN-X, who no longer works at the facility, over the phone. LPN-X informed the Surveyor while at the facility she would follow wounds, and coordinate wound cares along with an RN. The Surveyor read LPN-X documentation of the wounds from 3/8/17-3/22/17 and questioned why they were staged as unstageable. LPN-X stated that was an error, should have been staged as a stage 4. LPN-X informed the Surveyor that the stage 4 was based on the depth of the wound was to the muscle. On 4/7/17 R7's wound to the right ischial tuberosity is documented as measuring 5 x 1.8 x 1 with 100% bright beefy red tissue. The wound is staged as a healing stage 4. The wound to the left ischial tuberosity is documented as 7.2 x 4 x 1. The wound is staged as a healing stage 4. On 7/14/17 R7's wound to the right ischial tuberosity is documented as a stage 4 measuring 2.1 x 1.1 x 0.8. The wound to left ischial tuberosity is documented as a stage 4 measuring 4.5 x 3 x 0.21. On 7/19/17 at 10:06 a.m. the Surveyor observed RN Manager-C perform a treatment to R7's wounds. The Surveyor observed RN Manager-C clean both wounds with Dakin's 0.5%. Following the treatment the Surveyor reviewed R7's medical record and noted an order dated 5/30/17 that stated to cleanse the bilateral ischial pressure ulcers with Dakin's. The Surveyor noted that the order did not specify the percentage of the solution. The Surveyor then reviewed the treatment administration record and noted that it did not contain a solution percentage. On 7/20/17, during the daily exit meeting with the facility, the Surveyor informed DON-B that she had been unable to find an order that specified what strength of Dakin's solution to use. On 7/24/17 at 1:45 p.m. the Surveyor asked DON-B if there was any additional information related to no order specifying what strength Dakin's to use. DON-B stated the order was clarified with the physician and was ordered for 0.50%. 2.) Surveyor reviewed R1's medical record on 7/18/17 to 7/24/17. R1 is receiving hospice care. The skin integrity care plan initiated 2/3/17 & revised on 6/12/17 includes an intervention dated 2/3/17 of Float heels while in bed, with use of heelzup device as tolerated by patient. The quarterly MDS with an assessment reference date of 7/2/17 and signed as complete on 7/14/17 documents R1 requires extensive assistance with two plus person physical assist for bed mobility & transfers, does not ambulate, is continent of bowel and frequently incontinent of bladder. R1 is at risk for pressure injury development and is coded not having any pressure injuries. On 7/19/17 at 6:46 a.m. Surveyor observed R1 in bed on her back. Surveyor observed there is a foot cradle on the bed, there is a heel lift pad under R1's calves but her heels are resting directly on the mattress. On 7/19/17 at 7:23 a.m. Surveyor observed R continues to be in bed on her back with her heels resting directly on the mattress and are not being offloaded. On 7/19/17 at 8:03 a.m. Surveyor observed R continues to be in bed on her back with her heels resting directly on the mattress and are not being offloaded. On 7/19/17 at 9:11 a.m. Surveyor observed R1 in bed on her back with her eyes closed, the head of the bed is elevated and there is an over bed table across the bed with R1's breakfast. Surveyor observed R1 has not eaten any of her breakfast, the silverware is still wrapped, and R1's coffee has been spilled. Surveyor observed R1's heels continue to be on the mattress and are not being offloaded. On 7/20/17 at 7:11 a.m. Surveyor observed R1 in bed on her back with the foot cradle at the end of the bed. Surveyor observed there is a pillow under R1's calves but her heels are resting directly on the pillow and are not being offloaded. On 7/20/17 at 7:45 a.m. Surveyor observed R1 continues to be in bed on her back. Surveyor observed there is a pillow under R1's calves but her heels are resting directly on the pillow and are not being offloaded. On 7/24/17 at 2:17 p.m. Surveyor informed ADON (Assistant Director of Nursing)-J during R1's record review Surveyor had noted R1 heels should floated. Surveyor informed ADON-J of the observations of R1's heels not being offloaded. ADON-J verified R1's heels should be floated. 3.) Surveyor reviewed R2's medical record on 7/18/17 to 7/24/17. The quarterly MDS (minimum data set) with an assessment reference date of 6/5/17 and signed as complete on 6/16/17 has a BIMS (brief interview mental status score of 6 which indicates severe impairment. R2 is dependent on staff with two plus person physical assist for transfer & bed mobility, does not ambulate, and is occasionally incontinent of bowel and bladder. R2 is at risk for pressure injuries and is coded as not having any pressure injuries. The Braden assessment dated [DATE] has a score of 12 which is high risk. The ADL (activities daily living) care sheets dated 7/17/17 documents under the section turns and positioning 2 assist, reg (regular) w/c (wheelchair) for all meals and place pillow behind back during meals; Yellow dot, float heels. On 7/18/17 at 1:59 p.m. Surveyor observed R2 in bed on her left side. Surveyor asked R2 if Surveyor could look at her feet. After receiving permission Surveyor observed there is a heel lift pad under R2's calves. Surveyor observed R2's left heel is floated but right heel is resting directly on the mattress. On 7/19/17 at 6:49 a.m. Surveyor observed R2 in bed on her back. Surveyor observed R2's heels are resting directly on the mattress and are not being offloaded. On 7/19/17 at 7:35 a.m. Surveyor observed R2 continues to be in bed on her back with her heels resting directly on the mattress. Surveyor observed the heels up pad is on the chair with towels on top of the heels up pad. On 7/19/17 at 8:33 a.m. Surveyor observed CNA (Certified Nursing Assistant)-AA and CNA-Y place gloves on, CNA-Y removed the pillow from R2's right side and removed the bedding off R2. Surveyor observed R2 heels are resting directly on the mattress and are not being off loaded. The incontinence product was unfastened, R2 was positioned on her right side and a bed pan was placed under R2. R2 was positioned on her back, the call light was placed in reach and CNA-AA told R2 to call when she was ready. Staff removed their gloves and washed their hands. On 7/19/17 at 8:53 a.m. Surveyor observed CNA-AA and CNA-Y enter R2's room and place gloves on. R2 was positioned on her right side and the bed pan was removed. CNA-AA washed R2's frontal peri area, R2 was positioned on her right side and CNA-AA washed R2's buttocks. An incontinence product was placed on R2 and staff positioned R2 up in bed. CNA-AA placed a pillow under R2's calves but R2's heels were resting directly on the mattress. CNA-AA informed R2 she was going to wash her hands and then get her set up for breakfast. On 7/20/17 at 7:16 a.m. Surveyor observed R2 in bed on her back. Surveyor observed R2's heels are resting directly on the mattress and are not being offloaded. Surveyor observed the heel lift pad is on R2's wheelchair. On 7/20/17 at 7:43 a.m. Surveyor observed R2 in bed on her back, there is a pillow under her calves and R2's heels are resting directly on the mattress. Surveyor observed the heel lift pad continues to be on R2's wheelchair. On 7/24/17 at 2:17 p.m. Surveyor informed ADON (Assistant Director of Nursing)-J of the observations of R2's heels not being offloaded according to her plan of care. 4.) R3 was re-admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of R3's Medical Record revealed no wound assessment or measurements were obtained for R3's pressure ulcer on his right buttock upon admission. Wound was present when R3 discharged to the hospital on [DATE]. Review of R3's Wound Summary sheets documented wound measurements of the right buttock pressure ulcer were not completed until 6/26/17 (5 days after admission). Review of R3's Progress Notes revealed no documentation of an assessment or measurements of R3's right buttock pressure ulcer prior to 6/26/17. On 7/19/17 at 11:30 am Surveyor interviewed ADON-M. Surveyor asked ADON-M why the Wound Summary site documented R3's buttock wound as 3 different locations (Right Ischial Tuberosity, Coccyx and Sacrum). ADON-M brought a computer to review the wound measurements with Surveyor. ADON-M reported it is a computer problem, and confirmed the measurements provided to Surveyor were for the pressure ulcer on R3's right buttock. On 7/19/17 at 1:50 pm DON-B provided Surveyor with a report dated 6/22/17 regarding the RN who did not assess or measure R3's right buttock wound upon admission. DON-B provided Surveyor with Nurses Meeting June 2017 paper which documented: Upon any admission or re-admission, the nurse must remove any dressing on the resident and if a wound is present, you must measure the wound, assess tissue type and drainage and enter with picture into the wound rounds program on that day. On 7/24/17 at 1:20 pm Surveyor interviewed DON-B. DON-B confirmed the facility was aware on 6/22/17 that R3's right buttock pressure ulcer was not assessed or measured. Surveyor asked why measurements were not completed until 6/26/17, DON-B stated I don't have an answer for that. DON-B reported she will ask ADON-M and will provide information to the Surveyor as needed. No additional information was provided to Surveyor. 5.) Surveyor reviewed R10's medical record from 7/18/17 to 7/25/17. R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Hypertension, [MEDICAL CONDITION], Pneumonia and Weight Loss. R10's quarterly MDS (Minimum Data Set) dated 6/6/17 documents a BIMS (brief interview for mental status) score of 07, indicating that R10 is severely cognitively impaired. Section G (Functional Status) documents that R10 requires extensive assist and a two person physical assist for her bed mobility and transferring needs. Section M (Skin Conditions) documents that R10 is at risk for the development of pressure ulcers and has no current pressure injuries. R10's Pressure Ulcer CAA (Care Area Assessment) with a reference date of 3/6/17 documents under the Analysis of Findings section, R10 has a history of [MEDICAL CONDITION], depression, Hypertension and recently diagnosed with [REDACTED]. Under the Care Plan Considerations section it documents, Staff will continue to monitor, support and care plan. She will have no red or open areas. R10's Skin Integrity care plan with an initiated date of 3/1/17 documents under the Interventions section, Follow facility policies/protocol for the prevention/treatment of [REDACTED]. R10's CNA (Certified Nursing Assistant) care card dated 7/17/17 documents under the Turns and positions section, Heelz up device when in bed as tolerated. R10's Braden Scale for Predicting Pressure Sore Risk on 6/3/17 documents a score of 17, indicating that R10 is at lower risk for the development of pressure ulcers. On 7/18/17 at 11:19 a.m., Surveyor observed CNA-FF in R10's room. R10 requested a wet wash cloth from R10 and declined to go to lunch, instead requesting lunch in her room. Surveyor observed R10 to be laying supine in bed with her Heelz up device below R10's calves. Surveyor observed R10's heels resting directly on the mattress and not offloaded to relieve pressure as documented in R10's plan of care. Surveyor noted that CNA-FF did not reposition R10's Heelz up device and that R10's heels remained resting directly on the mattress. On 7/18/17 at 12:35 p.m., Surveyor observed R10 laying supine in bed. Surveyor observed R10's Heelz up device below R10's knees and R10's heels resting directly on the mattress and not offloaded to relieve pressure as documented in R10's plan of care. On 7/20/17 at 10:13 a.m., Surveyor observed R10 to be laying on her right side in bed. Surveyor observed R10's right heel resting directly on the mattress and R10's left heel resting directly on R10's Heelz up pad. Surveyor noted that R10's heels were not offloaded to relived pressure as documented in R10's plan of care. On 7/20/17 at 1:57 p.m., Surveyor observed R10 laying supine in bed with R10's Heelz up pad beneath R10's calves. Surveyor observed R10's heels resting directly on the mattress and not offloaded to relieve pressure as documented in R10's plan of care. On 7/24/17 at 11:03 a.m., Surveyor informed RN (Registered Nurse) Manager-C of the above findings. Surveyor asked RN Manager-C if R10's heels should be offloaded to relieve pressure on R10's heels as documented in R10's plan of care. RN Manager-C informed Surveyor that R10's heels should be offloaded to relieve pressure on R10's heels as documented in R10's plan of care. On 7/24/17 at 3:14 p.m., during the daily exit conference, Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not provide R10 the necessary services, consistent with professional standards of practice, to the development of new pressure injuries from developing.

Based on a complaint received at the Southeastern Regional office, Facility self report, observation, staff interview, and record review the Facility did not have identified safety interventions in place for preventing falls for 3 (R2, R1, & R12) of 6 sampled Residents reviewed for falls. * On 7/3/17 CNA-T did not follow R2's care plan when she removed R2 off the bed pan by herself in bed. R2 kicked her left leg over her right causing R6 to fall out of bed. R2 was transferred to the hospital where she was [DIAGNOSES REDACTED]. R2 was readmitted to the facility on [DATE]. On 7/18/17 R2 was observed being transferred with the wrong size hoyer sling. * R1 has a safety intervention which includes not to be left alone in the bathroom. R1 was left alone on the toilet with the bathroom door closed. * R12 care plan documents R12 should be toileted. R12 was checked and changed and then placed in her wheelchair. R12 attempted to self transfer onto the toilet and fell . Example 1 involving R2 rises to a scope of severity of G (isolated/harm). Findings include: 1. Surveyor reviewed R2's medical record on 7/18/17 to 7/24/17. The ADL (activity of daily living) care plan initiated on 12/2/16 and revised on 1/23/17 includes an intervention dated & initiated on 1/23/17 & revised on 2/27/17 of BED MOBILITY: Requires 2A (two assist) to reposition and turn in bed. The fall risk assessment dated [DATE] is checked for at risk for falls/injury related to gait/balance problems, history of falls, osteoarthritis and pain. The quarterly MDS (Minimum Data Set) with an assessment reference date of 6/5/17 and signed as complete on 6/16/17 has a BIMS (brief interview mental status score of 6 which indicates severe impairment. R2 is dependent on staff with two plus person physical assist for transfer & bed mobility, does not ambulate, and is occasionally incontinent of bowel and bladder. The ADL (activity daily living) care sheet dated 7/3/17 documents under the section turns and positioning 2 assist, reg (regular) w/c wheelchair for all meals and place pillow behind back during meals; Yellow dot, float heels. Under toileting documents, Toilet ppr (per patient request), prompt upon rising, before/after meals, prior to HS (hour sleep) & ppr bladder, & ppr for bowel. The nurses note dated 7/3/17 documents, 0800 (8:00 a.m.) pt (patient) was sent to hospital due to a fall, pt VSS (vital signs stable), Neuro assessment completed pt responds meaningful, Dr. (doctor) NP (nurse practitioner) ADON (assistant director of nursing) and Son all updated, education given to staff. The occurrence report dated 7/3/17 under section notes for nurses note documents PT (patient) being turned to the rt (right) side for cleaning after using the bed pan, pt through (sic) left leg over right and went over bedside. Under Resident statement documents pt (patient) stated I was helping CNA (Certified Nursing Assistant)-T turn by putting my lt (left) leg over towards the window and I fell to the ground. Under conclusion documents, IDT (interdisciplinary team) meet and review r/t (related to) fall out bed while staff was providing care for resident, POC (plan of care) was not being followed and resident obtained pelvic fracture. Staff education immediately provided, staff member was suspended for noncompliance with resident POC. CNA-T's statement which was written by HR (Human Resource)-U dated 7/3/17 documents, About 7-7:15 am, was taking R2 off of bedpan. CNA-T had care delivery guide in pocket, turn & positioning states two assist with bed mobility. R2 kicked left leg over right leg, rolling towards the window. R2 kicked pretty hard, CNA-T states that she just kept rolling and she couldn't stop her. CNA-T stated that she tried to catch R2 by the waist but couldn't catch her. The bed was at hip level on CNA-T. CNA-T did not move her, nurse paged for fall response team and 911 was called. Surveyor was unable to interview CNA-T as CNA-T is no longer employed at the Facility. The nurses note dated 7/5/17 documents, IDT (interdisciplinary team) meet and reviewed fall out bed, resident fall out of bed while care was being provided, resident obtained pelvic fx (fracture) and transferred to OMH (Oconomowoc Memorial Hospital) via 911. Resident was admitted for elevated creat. (creatinine) level and right sided pelvic fx. The hospital discharge summary dated 7/10/17 under discharge [DIAGNOSES REDACTED]. The nurses note dated 7/10/17 documents, Status: resident arrives via ambulance 1500 (3:00 p.m.) from pro health with R (right) pelvic fx and UTI (urinary tract infection), cont (continue) on ABT (antibiotic) oral for 2 more days, has skin tear on L (left) arm and stage 1 ulcer on coccyx, resident c/o (complained of) pain to R (right) leg 10/10 percocet eff (effective), pleasant with staff, needs assistance with eating, good appetite and requests lots of fluids, signs DNR (do not resuscitate) form with witnesses dressing changed to skin tear and allevyn applied to coccyx for prevention Physician-V updated with meds (medication) and arrival. The significant change MDS with an assessment reference date of 7/17/17 and signed as complete on 7/21/17 documents a BIMS (brief interview mental status score of 6 which indicates severe impairment. R2 requires extensive assistance with two plus person physical assist for transfer & bed mobility, and is occasionally incontinent of bowel and bladder. The falls CAA (care area assessment) dated 7/21/17 documents under analysis of findings, R2 has a history of degenerative spine disease, cervical [DIAGNOSES REDACTED], edema, polymyalgia rheumatica, obesity, Gerd (gastroesophageal reflux disease) and depression. Staff monitor q (every) 2-3 hours and prn (as needed), offering toileting opportunities, encouraging fluids and assisting with repositioning. They make sure call light is with in reach and room is well lit and clutter free. All needs are anticipated and me (sic) by staff. She fell out of bed while being cared for by staff and fractured pelvis. No other falls have been recorded. The ADL care sheets dated 7/17/17 under transfers documents, 2 assist, total dependent lift (green/large) sling WITHOUT leg strap. On 7/18/17 at 11:51 a.m., Surveyor observed R2 sitting in a wheelchair in her room. Surveyor observed R2's legs are extended with a pillow under her legs, there is a pillow behind her back and a sling under R2. Surveyor observed the sling has purple binding. On 7/18/17 at 12:41 p.m., Surveyor observed CNA (Certified Nursing Assistant)-X and CNA-Y in R2's room with gloves on. CNA-X informed R2 they were going to lay her down. CNA-X and CNA-Y hooked the sling with purple binding to the Hoyer lift and R2 was transferred from the wheelchair onto the bed. CNA-X & CNA-Y unhooked the sling from the Hoyer lift and positioned R2 from side to side to remove the sling. On 7/19/17 from 9:35 a.m. to 9:57 a.m., Surveyor observed morning cares for R2 with CNA-AA and CNA-Y. Upon completion of cares, CNA-AA removed a sling from the wheelchair. CNA-Y informed CNA-AA that is not the right sling for R2 and informed CNA-AA the sling should have a green binding. CNA-Y stated that she would get one and left R2's room. CNA-Y returned to R2's room with a sling with green binding. At 10:00 a.m., Surveyor asked CNA-Y how she knows the correct Hoyer sling for R2. CNA-Y informed Surveyor it's on the care plan what size sling it is. On 7/24/17 at 11:51 a.m., Surveyor asked ADON (Assistant Director of Nursing)-J what should staff do if the wrong size sling is in a Resident's room. ADON-J replied, change it out immediately. Surveyor asked ADON-J if staff should transfer a Resident with the wrong size sling. ADON-J replied, No, did you see this? Surveyor informed ADON-J of the observation of staff transferring R2 with the wrong size sling on 7/18/17. 2. Surveyor reviewed R1's medical record on 7/18/17 to 7/24/17. The falls care plan initiated on 12/19/16 and revised on 5/26/17 includes an intervention dated 12/19/16 of Do not leave alone in BR (bathroom). On 7/18/17 at 3:25 p.m., Surveyor observed CNA (Certified Nursing Assistant)-CC and CNA-DD enter R1's room with a sit to stand lift. CNA-CC & CNA-DD washed their hands, placed gloves on, placed a sling around R1 and connected the sling to the sit to stand lift. CNA-CC asked R1 if she was ready, R1 was raised off the broda chair and wheeled into the bathroom. CNA-DD lowered R1's pants and incontinence product and R1 was lowered onto the toilet. CNA-CC placed a towel over R1's upper thighs and CNA-DD removed the sling. CNA-CC moved the sling out of the bathroom, staff removed their gloves, and washed their hands. At 3:31 p.m. CNA-CC left R1's room and CNA-DD was in the bathroom speaking with R1. At 3:34 p.m. CNA-DD informed R1 she would give her privacy, stepped outside the bathroom and closed the bathroom door. At 3:38 p.m. CNA-DD opened the bathroom door and asked R1 if she was all done. R1 replied, yes. CNA-CC returned to R1's room. CNA-CC washed her hands and placed gloves on. CNA-DD cleansed her hands and placed gloves on. CNA-CC placed the sling around R1 and R1 was raised off the toilet. CNA-DD provided peri care, the incontinence product was changed, and R1's pants were pulled up. CNA-CC wheeled R1 out of the bathroom and lowered into the broda chair. Surveyor noted during this observation R1 was left alone in the bathroom. On 7/20/17 at 1:38 p.m. Surveyor asked ADON (Assistant Director of Nursing)-J if the falls intervention not to leave R1 alone in the bathroom current. ADON-J replied, I believe so. Surveyor informed ADON-J of the observation of R1 being left alone in the bathroom on 7/18/17. ADON-J informed Surveyor he will look into this and get back to Surveyor. On 7/20/17 at 2:40 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above. On 7/20/17 at 4:10 p.m. ADON-J informed Surveyor not leaving R1 alone in the bathroom is still an intervention. 3. Surveyor reviewed R12's medical record on 7/20/17 to 7/24/17. R12 [DIAGNOSES REDACTED]. R12 has an activated power of attorney and receives hospice care. The bladder incontinence care plan revised 2/27/17 includes intervention dated 1/4/17 of SCHEDULED TOILETING: Provide assistance at specific intervals based on voiding habits (SPECIFY: when). 0700 (7:00 a.m.) q (every) 2 hrs (hours), and PPR (per patient request) and last NOC (night) round. Do not leave on toilet alone. The quarterly MDS (minimum data set) with an assessment reference date of 4/3/17 and signed as complete on 4/13/17 has a BIMS (brief interview mental status) score of 9 which indicates moderately impaired. R12 requires extensive assistance with one person physical assist for bed mobility & toilet use, extensive assistance with with two plus person physical assist for transfers, does not ambulate and is frequently incontinent of bowel & bladder. R12 is coded as having one fall with no injury since the previous assessment. The nurses note dated 5/31/17 documents, Patient had another fall onto floor trying to get to bathroom. No injuries. MD (medical doctor) updated. Family updated. Neuro checks negative. The falls details report dated 5/31/17 under the section notes documents Patient was placed in front of nurses station in wheelchair. Patient was just toileted and got dressed for the day. When CNA (Certified Nursing Assistant) went back down the hallway to check on another resident she found R12 on the floor sitting up trying to scoot butt across floor to the bathroom. Under resident statement documents Unable to provide accurate account of incident. Patient is pleasantly confused. The fall scene investigation report dated 5/31/17 under the falls team meeting notes section documents CNA-BB reinterviewed stated she did change resident in bed around 0345-0400 (3:45 a.m.-4:00 a.m.) then Resident attempted to transfer self to go into bathroom. CNA-BB educated on phone that we need to assist resident to toilet & not just check & change at night. Resident cannot always express need to use toilet accurately. CNA verbalized understanding. The nurses note dated 6/1/17 documents Focus: Unwitnessed fall from Broda chair. Status: Sleeping, no discomfort, respirations even, non-labored. no complaints of pain, no nonverbal indicators present. No self transfer attempts. Neurocheck monitoring via flow sheet. The nurses note dated 6/1/17 documents IDT (interdisciplinary team) note post fall on 5/31/17 -Resident was assesses and changed per plan of care, however the aide changed her in bed and IDT recommends taking resident to the toilet as after check and change resident does not feel she has used the toilet. The CNA-BB was educated via phone call with DON (Director of Nursing)-B on 6/1/17 at 12:30 and verbalized understanding. On 7/24/17 at 11:31 a.m. Surveyor asked DON (Director of Nursing)-B should CNA-BB have toileted R12 instead of checking and changing which may have prevented R12's fall on 5/31/17. DON-B informed Surveyor she wants to look at the care delivery guide the day before R12's fall and will get back to Surveyor. On 7/24/17 at 11:39 a.m. DON-B informed Surveyor R12 should have been toileted and not checked & changed. On 7/24/17 at 3:38 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above.

Based on interview and record review the facility did not immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there was a significant change in the resident's physical condition for 7 residents out of 19 reviewed (Resident 10, 15, 6, 3, 7, 8 and Resident 9). Resident 10 experienced a change in condition including left sided weakness and lethargy. The facility did not complete a thorough assessment and did not report all findings to the Nurse Practitioner. Resident 10's family was not notified timely of the change in condition The failure to provide all findings to the physician and notify the family created a finding of immediate jeopardy. The immediate jeopardy began on 6/2/16. The Nursing Home Administrator was notified of the immediate jeopardy on 6/8/16 at 11:56 AM. The facility removed the immediacy on 6/7/16, however the deficient practice continues at a severity/scope level of E (potential for more than minimal harm that is not immediate jeopardy/pattern) as the facility continues to implement its removal plan and as evidenced by the following. The facility had no evidence that the physician or family was immediately notified when Resident 15's left lower leg venous stasis ulcer increased in size and amount of drainage. The facility had no evidence that Resident 6's physician was notified when Resident 6 presented with a documented weight gain of 13.05%. Resident 3's Nursing Note (NN) documented that Resident 3 Responds appropriately but seems to have problems putting words, sentences together .will continue to monitor and assess. Resident 3's Medical Doctor (MD) was not immediately consulted for the change of condition. Resident 3's Activated Power of Attorney for Healthcare (APOAHC - spouse and daughter) were not immediately contacted regarding this change of condition. Resident 3's Nursing Note (NN) document for Resident 3, Pt (patient) given one time dose of antibiotics and tolerated without adverse reaction. Resident 3's Activated Power of Attorney for Healthcare (APOAHC - spouse and daughter) were also not immediately contacted regarding the antibiotic ordered and given. Resident 7 has a pressure injury (PI) to her coccyx. Resident 7's PI worsened to a Stage IV with bone exposure. The facility failed to notify Resident 7's Guardian with this change of condition. The facility had no evidence that Resident 8's physician was notified when Resident 8 presented with a documented weight change of greater than 5%. The facility had no evidence that Resident 9's physician was notified when Resident 9 presented with a documented weight change of greater than 5%. Evidenced by: The facility's SBAR (Situation, Background, Appearance, Review and Notify) Communication tool and Progress Note procedure, dated July 2015, states in part: POLICY: The center supports the use of the SBAR to: Communicate effectively with the Medical Doctor (MD), Nurse Practitioner (NP) . when the resident has had an acute change in condition, Document communication with the Medical Doctor (MD), Nurse Practitioner (NP) . PROCEDURE: 1. Initiate the SBAR . after having contact with the resident to obtain and accurate history prior to contacting the provider when the resident has a change of condition. a. Review the resident's medical record. Diagnosis, Medication, Recent Progress notes from MD/NP, Recent Nurses Notes .4. Notify the MD, NP . with the information on the SBAR . 5. Document notification of family or health care proxy on the SBAR . 7. Place the SBAR in the Nurse's Notes section of the resident's medical record. According to the American Medical Directors Association, Stroke Management in the Long-Term Care Setting Clinical Practice Guideline, Columbia, MD: AMDA 2011. Early identification and treatment can help to decrease stroke-related disability and death for appropriately selected patients. For this reason, the signs of acute stroke must be recognized and addressed promptly. Common presentations of an acute stroke include: Sudden confusion, difficulty speaking, or difficulty understanding speech. Sudden difficulty walking, severe dizziness or loss of balance or coordination. Sudden numbness or weakness of the face or in and arm or leg, especially if confined to one side of the body. Sudden severe headache with no other readily identifiable cause. If at any time a patient displays any of these acute neurological symptoms go to step four. Step four: Confirm that the patient is suffering an acute stroke. Clarify and describe the patient's signs and symptoms. Summary: Patients who have a stroke should be assessed promptly. It is up to the facility and interdisciplinary team leaders to ensure that mechanisms are in place to rapidly identify the patient who is experiencing an acute stroke and to determine-taking into consideration factors, including the patient's preferences-whether to treat the patient in the facility or transfer him or he to an acute care setting. According to a Scientific statement from the American Heart Association in 2006 in an article entitled, Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke, More than 50% of the 1.2 million people who suffer an acute [MEDICAL CONDITION] infarction (AMI) or coronary death each year in the United States die in an emergency department (ED) or before reaching a hospital within an hour of symptom onset. About 700 000 individuals will have a stroke each year, 167 000 of those who have [MEDICAL CONDITION] will die, and more will suffer a major disability. Of the stroke deaths that occur each year, almost half occur before the patient reaches the hospital. Many of these deaths and significant disability could be prevented if patients received earlier treatment. Although the benefits of early treatment of [REDACTED].Delay to treatment for [REDACTED]. The disability associated with stroke and with heart failure after AMI is largely a consequence of infarct size, and lack of timely treatment is a major determinant of increased infarct size in both AMI and stroke. Unfortunately, most individuals who experience symptoms delay substantially before seeking treatment . Stroke trials demonstrated that treatment within 3 hours of symptom onset is beneficial for patients with acute ischemic stroke. Even within the 3-hour window, benefit from [MEDICATION NAME] decreases as time from symptom onset increases. An analysis of 6 large, randomized, controlled trials of intravenous [MEDICATION NAME] corroborated these findings and indicated that the optimal administration time is within 90 minutes of symptom onset. <http://circ.ahajournals.org/content/114/2/168.full> Example 1 Resident 10's [DIAGNOSES REDACTED]. Resident 10 fell at the facility on 4/7/16 and suffered a subdural hematoma. Resident 10's [MEDICATION NAME] (blood thinner) was discontinued in the hospital due to the subdural hematoma and the plan was to reconsider re-starting the medication in 3-6 months if there are no further falls. Resident 10's care plan for Cardiovascular/Circulatory, dated 4/19/16, indicates the potential for alteration in circulation related to [MEDICAL CONDITION] Fibrillation, Hypertension, [MEDICAL CONDITIONS], [DIAGNOSES REDACTED] and Heart Murmur. Interventions include: Medications/treatments as ordered, update physician/family as needed, labs as ordered, vital signs per protocol and as needed, monitor neurological state, monitor for sign/symptoms of [MEDICAL CONDITION], lung sounds as needed, provide resident education as needed, consults as needed, and encourage rest periods as needed. Resident 10's NP (Nurse Practitioner) visit note, dated 4/15/16, indicates DNR (Do Not Resuscitate), IVs (intravenous): undecided, hospitalization s: no, discuss any changes in condition with patient and her daughters. hospitalization s only for major injury such as open fracture per daughter/POA (Power of Attorney). Will discuss future hospitalization s on a case-by-case basis. Resident 10's NP visit note, dated 5/24/16, treatment plan: [REDACTED]. When fully resolved, 2-3 months post injury, consider resumption of [MEDICATION NAME]. Resident 10's vital signs log indicates the following: 5/19/16 AM: Blood pressure 136/71, pulse 88, respirations 16, temperature 97. 5/21/16 NOC: Blood pressure 138/70, pulse 69, respirations 18, temperature 96.6, oxygen 96%. 5/22/16 AM: Blood pressure 126/68, pulse 83, respirations 18, temperature 97.8, and oxygen 96%. Resident 10's Resident Summary, dated 5/30/16, indicates her speech is clear and she is on 15 minute checks. LPN II (Licensed Practical Nurse) completed a SBAR (Situation, Background, Appearance, Review and notify) Communication form on 6/2/16 which indicates: -Change in condition, symptoms or signs are: Lethargy -This started on: 6/2/16, since this started it had gotten: Stayed the same. -This condition, symptom has occurred before: No -Primary Diagnoses: [REDACTED].>-Other pertinent history: Subdural hemorrhage -Vital signs: blood pressure 143/100, pulse 73, respirations 18, temperature 96.7 pulse oximetry 92% on room air. -Decreased level of consciousness, Decreased mobility, unable to move left arm, cloudy urine, and pain head left side, abnormal speech slurring her words, DNR. -Summarize your observations and evaluation: Slumped over to the left side of her wheelchair, drool running out of her mouth. -Notified: NP MM on 6/2/16 at 5:30 AM. -Recommendations: Hold her until family is notified then later transport to hospital. -Name of Family notified: Family Member NN on 6/2/16 at 8:45 AM. Please note Resident 10 is part of a managed care organization. The on call Nurse Practitioner may not be familiar with the resident staff are calling about and may not be in the same area. NP MM is from another state and is not familiar with Resident 10. The NP MM's call log for NP MM for Resident 10 indicates the following call for 6/2/16: -4:54 AM, from LPN (Licensed Practical Nurse) II -Resident 10 acting funny this am. VSS (vital signs stable), Afebrile, (pulse) 73-(respirations) 20- (blood pressure) 154/90, (oxygen) 92%. Alert, oriented, talking. Some drooling noted. Moving extremities. Neuro status WNL (within normal limits). Lung assessment not done. Asked nurse to get lung assessment and BS (blood sugar) while I hold. Lungs CTA (clear to auscultation), BS-122. DNR. Intervention-Stat CBC (Complete Blood Count), BMP (Basic Metabolic Panel), U/A (urinalysis), CS (culture and sensitivity). May straight catheter if needed. Vital signs every shift for 3 days. Return call if any further change in condition. I will update daughter. Will ask primary NP to follow up. (Of Note: LPN II did not complete a thorough neurological assessment, nor did he inform NP MM that Resident 10 left had grasp was weak. Resident 10's vitals were in limits however not typical for Resident 10. NP MM did not contact or discuss the change of condition with Resident 10's POA to determine treatment plan or possible hospitalization .) -5:36 AM, from LPN II-Nurse now stated Resident 10's speech is slurred. Resident 10 not moving left arm but moving both legs. PERRLA (pupils equal, round, reactive to light, accommodation). Urine is cloudy. Intervention-I will call daughter with update in change in condition and discuss if want any further interventions. -5:39 AM-from NP MM, call to Family Member NN. Left voice mail message to return call as soon as possible. On call number provided. (Of note, this was the first time someone attempted to call family to discuss change of condition and how they should treat Resident 10.) -5:48 AM, from NP MM, call to facility to see if any other contact number. Four contact numbers listed in chart. Will attempt to call. -6:01 AM, from NP MM, call to Family Member OO. Left voice mail regarding change in condition. Requested return call back as soon as possible. On call number provided. -6:03 AM, from NP MM, call to Family Member PP no answer. -6:05 AM, from NP MM, call to Family Member QQ. Updated on change in condition. Stroke verse infection. Family Member QQ will have Family Member NN/POA contact NP MM. On call number provided. (Note: this is the first contact with Resident 10's family to update and consult on the change in condition.) -6:17 AM, from Family Member OO, Family Member OO returns call. She is unable to reach Family Member NN. Updated on change in condition and Plan of Care so far. Discussed possible causes of change in condition, infection verses stroke. Intervention-Family Member OO will go see her mother now and return call to NP MM with update and wishes for any further interventions. -6:23 AM, from Family Member PP, Family Member PP has talked with her sisters and they are all going to see their mother. -6:58 AM, from LPN KK, Day shift nurse calling stating family at bedside and would like Resident 10 sent to emergency room . LPN KK has contacted primary care physician. On 6/2/16, the facility obtained a telephone order for 911 transport to emergency room for evaluation and treatment. There is no time on the telephone order. Resident 10's nursing note 6/2/16 at 6:55 AM by LPN II, Was called to Resident 10's room by CNA (Certified Nursing Assistant) stating resident was acting strange. Found resident slumped over in wheelchair. Resident 10 was able to converse, vital signs within normal limits. Resident 10 had slurred speech, inability to use her left arm, eyes were equal and reactive, and she was able to move both lower extremities. NP was called she ordered CBC, BMP and UA/CS. She stated she would contact family to make a decision, later she ordered transport to hospital. Vital signs log: 6/2/16 night shift (no actual time documented) blood pressure: 143/100, pulse 73, respirations 18, temperature 96.7, oxygen 92% on room air. By LPN II. Resident 10's nursing note, 6/2/16 at 10:41 AM by LPN KK: Resident 10 lying in bed head of bed up 30 degrees. Noted left facial (illegible) drooping. Lethargic, unable to follow simple command. Forceful one word answers. States Throw, up. Unable to utilize left arm. Unable to smile or stick out tongue. No left hand strength, denies pain. Vital signs blood pressure 191/118, Pulse 87, temperature 97, oxygen 93% on room air, respirations 20. Skin dry and warm pallor. Charge nurse called for assessment. DON (Director of Nursing) called and updated. 911 called for transport with POA present, consent. Managed Care organization and physician updated. 911 arrived and transported Resident 10 to emergency room . Resident 10 noted to have built up saliva/foam at mouth. Resident 10 admitted to hospital [DIAGNOSES REDACTED]. Resident 10's hospital notes, dated 6/2/16: Resident 10 sent to emergency department with reports of altered mental state and left-sided weakness that began sometime early this morning. We heard varying reports of onset of symptoms between 3 and 4:30 this morning. She apparently initially was altered and then noted to have left-sided facial droop and weakness. She has a history of an unwitnessed fall on April 7 resulting in a subdural hematoma. After discharge from that event family had told the neurosurgeon that they would not want any type of surgical intervention due to her advanced age and medical condition. Also important in her history is that blood thinners were recently discontinued because of her fall and subdural hematoma. Emergency Department vitals at 8:00 AM: Blood pressure 224/140, pulse 84, respirations 13. Physical exam: -Constitutional: She appears well-developed and well-nourished. She appears lethargic. Her eyes are generally closed and she appears to be sleeping. Sonorous (deep sound) respirations with some drooling and bubbles forming at the mouth with left facial droop. -Eyes: Right eye exhibits abnormal extraocular motion. Persistent gaze to the right. Pupils are small and minimally reactive. Extraocular movements cannot be assessed. -Neurological: She appears lethargic. There is some spontaneous movement of the right upper extremity and lower extremities bilateral. The left upper extremity is flaccid. Left facial droop is present with some drooling and bubbles forming at the mouth. She is occasionally able to follow commends with her right upper extremity. Computed tomography (CT) results: Findings consistent with interval development of right parietal infarct, acute/subacute, without hemorrhagic component. Physician spoke at length with Resident 10's daughters and reviewed her CT scan findings. The daughter stated that she had been able to speak and eat but was not walking much due to complaints of hip pain prior to onset of symptoms this morning. The daughters feel that if she is eligible they would like her to receive [MEDICAL CONDITION] therapy to try to regain some functional status. Her recent head trauma is a contraindication. Spoke with neurologist and unfortunately this patient does not meet criteria for [MEDICAL CONDITION] therapy. She had recent head injury with subdural hematoma less than 2 months prior to onset of stroke. The exact time of onset of her stroke in not known and the fact that it is already showing up on non-contrast CT scan at the time of arrival suggests the stroke may have been present for a longer period of time. Her age greater than [AGE] years is also a relative contraindication. He recommends aspirin and only modest blood pressure control though we would like to keep her hypertensive to obtain perfusion. The family including four daughters was notified that this has potential for deterioration and potentially life ending event. Resident 10 was discharged on [DATE] with overall prognosis is poor with terminal [DIAGNOSES REDACTED]. Estimated life expectancy weeks possible 6-8 weeks. Transfer Resident 10 to inpatient hospice. On 6/7/16, at 9:32 AM, Surveyor interviewed CNA HH. CNA HH stated she worked with Resident 10 on 6/1/16 and she was acting like her typical self. Resident 10 was able to transfer with 1 staff assist which was more like supervision only as she was able to transfer without physical help. Then CNA HH worked with Resident 10 on 6/2/16. CNA HH stated her shift began at 2:00 AM and she first saw Resident 10 at 3:30 AM when she went in to toilet her. CNA HH stated Resident 10 was not acting like herself and she had difficulty transferring Resident 10 into the wheelchair. CNA H stated Resident 10 was not responding per her normal self and what she said was noncoherant. CNA HH tried to get Resident 10 to sit up in her wheelchair and she was not able to and so CNA HH went to get LPN II and CNA JJ to help with Resident 10. CNA HH reported to LPN II that Resident 10 was not acting like herself. CNA HH and CNA JJ needed to use the full body mechanical lift to transfer Resident 10 back to bed as she was not able to stand up on her own (this was a major change of condition). LPN II took Resident 10's vital signs. During this time Resident 10 stated she was nauseous and CNA HH obtained a basin for her. CNA HH stated at around 4:00 AM RN (Registered Nurse) LL came over to assess Resident 10 and LPN II stated he was going to call Resident 10 family and doctor. At that time CNA HH went to help other residents and she checked on Resident 10 every 15 minutes to ensure she was comfortable. CNA HH stated when you looked at Resident 10's eyes it looked like there was nothing there. At 6:00 AM the day shift started and LPN KK started her shift. CNA HH stated that LPN II told LPN KK that this all started at 6:00 AM which it did not and CNA HH was so frustrated that nothing had been done she documented this and gave it to LPN KK. CNA HH stated that LPN KK called Resident 10's doctor and family and had her sent out to the hospital around 7:00-7:30 AM. Surveyor asked CNA HH how she was so certain about the time she first saw the change in Resident 10 and CNA HH stated because she had looked at her watch. Resident 10 was on 15 minute checks so she needed to know. CNA HH confirmed she regularly worked with Resident 10 and told LPN II this was not Resident 10's normal behavior. On 6/7/16, at 1:56 PM, Surveyor interviewed CNA JJ. CNA JJ confirms she assisted CNA HH with Resident 10 on 6/2/16. CNA JJ stated she could not recall the exact time but was doing her last rounds which she typically starts around 4:00 AM. CNA JJ stated when she arrived at Resident 10's room Resident 10 was sitting in her wheelchair in the bathroom and she was slumped over in the chair and could not sit up. We got the mechanical lift and transferred Resident 10 back to bed. LPN II came in to check her out and CNA JJ went back to her unit to continue her rounds. On 6/7/16, at 11:35 AM, Surveyor interviewed LPN II. LPN II stated on 6/2/16 around 5:00 AM a CNA came to him and stated Resident 10 was behaving funny. LPN II stated he was not sure of the exact time but it was at the end of the shift. LPN II stated when he arrived at the room Resident 10 was in the wheelchair in the bathroom slumped over to the left side, was able to communicate with him and was tracking with her eyes. LPN II stated Resident 10 was not able to grasp with her left hand but he was not familiar with her so he did not know if that was normal. Resident 10 was able to move both of her feet. The CNAs got Resident 10 into bed then he obtained her vitals which were in normal limits and he called the Nurse Practitioner on call (NP MM) and reported what happened. LPN II stated NP MM ordered labs and a urinalysis and that NP MM would contact the family. LPN II called the night shift supervisor, RN LL, to have her check Resident 10 again more thoroughly. Resident 10's eyes were equal and brisk, she was not able to use her left hand and it was cold, she was losing her ability to move her feet and her speech was slurred. LPN II called NP MM again to update her on the changes and NP MM requested additional family member names and numbers. When LPN KK came in for the morning shift she said she could tell what was going on with Resident 10 and she called and had her transported out to the hospital. Nursing Home Administrator (NHA) A and DON B interviewed LPN II on 6/8/16 regarding the events on 6/2/16 with Resident 10. LPN II stated she started his medication pass on the 400 unit at 3:00 AM and that the medication pass takes him 1 hour. Once he finished the 400 medication pass he began the 300 unit medication pass around 4:00 AM. LPN II stated he was about halfway through his medication pass when CNA HH approached him regarding Resident 10 having a change of condition. LPN II stated this occurred at roughly 4:45-5:00 AM. NHA A asked if it could have occurred closer to 3:30 AM and LPN II stated it was not possible because he had already finished the 400 unit medication pass and was half way through the 300 unit medication pass. LPN II stated once he was approached by CNA HH he immediately went to Resident 10's room where Resident 10 was in her wheelchair in the bathroom and CNA HH and JJ were beginning to take Resident 10 back to bed. LPN II left the room and contacted the Nurse Practitioner and gave her report regarding her change of condition. LPN II also contacted the RN Supervisor to assist him with assessing Resident 10. On 6/7/16, at 12:00 PM, Surveyor interviewed RN LL. RN LL stated it was close to the end of her shift on 6/2/16 when LPN II came over to her unit and said something was wrong with a patient. RN LL went to the unit Resident 10 was on and LPN II stated he had called the physician and received orders and needed help getting a urine sample. RN LL stated when she walked in Resident 10's room she was lying in bed on her left side facing the wall and RN LL asked LPN II to help reposition Resident 10 so they could get a urine sample. LPN II stated he thought Resident 10 had a stroke and asked RN LL if she knew Resident 10. RN LL stated she did not work with Resident 10 thus did not know her and so she was not sure and that LPN II should call the physician to find out what to do. RN LL stated Resident 10 was moaning and not able to use her left arm. LPN II left the room to call the NP while RN LL stayed in the room. LPN II returned and stated they were going to call the family to decide what measures to take and what the family wanted to do. RN LL asked if LPN II needed anything else then returned to her side of the building. NHA A and DON B interviewed RN LL on 6/8/16 (please note this is after the survey) regarding the events on 6/2/16 with Resident 10. RN LL stated she was contacted by LPN II between 4:00-5:00 AM on 6/2/16. RN LL stated she knew it was that time as she stated that she was starting her medication pass and she always starts it around 4:00 AM. RN LL immediately went to the wing to assist LPN II. LPN II had already contacted the NP and LPN II noticed Resident 10 had left sided weakness and wanted RN LL's assistance evaluating her and assistance with new orders. LPN II received direction from the NP to continue to monitor as the NP was contacting family, due to age noting could be done per NP. On 6/7/16, at 1:03 PM, Surveyor interviewed LPN KK who worked the morning shift. LPN KK stated when she came in on 6/2/16 LPN II reported Resident 10 was not feeling well. LPN KK stated she went into Resident 10's room and noted left sided weakness and that Resident 10 was not able to talk very well but said she was going to throw up. LPN KK attempted to call Resident 10's NP but was unable to reach her. At that time Resident 10's daughters were coming into the building and went straight to Resident 10's room. Resident 10's family stated they wanted her sent out and LPN KK stated she was working on it and called 911 to send Resident 10 to the hospital. LPN KK stated that CNA HH had approached her and stated that LPN II was not telling the truth about the timeframe when this started. LPN KK instructed CNA HH to document this in a letter which CNA HH did and LPN KK put the letter in DON B's box. On 6/7/16, at 2:32 PM, Surveyor interviewed NP MM who was on call on 6/2/16. NP MM stated when she was contacted she was told that Resident 10 was drooling and appeared weak but her vital signs were stable, she was alert, moving her legs and neurological checks were normal. NP MM requested that LPN II obtain a blood sugar check while she waited on the phone. NP MM stated LPN II did not state how long this had been going on. NP MM stated she ordered some labs and told LPN II to call back if there were any changes. LPN II called back stating Resident 10 was not able to move her arm and her speech was slurred. NP MM stated she then attempted to call Resident 10's family because Resident 10 was a DNR and she wanted to know how aggressive to be. NP MM stated she does not send a resident out to the hospital who is a DNR without talking with the family first. NP MM stated she did not recall being informed on the initial call that Resident 10's left hand grasp was weak but she would not have done anything different before ruling out an infection. NP MM stated she could not recall being told Resident 10 recently had a fall with a subdural hematoma and was recently taken off [MEDICATION NAME]. NP MM stated the initial signs of a stroke can mimic an infection and when the facility called back and reported the slurred speech then she began calling the family to make a decision. NP MM stated when she did speak with the family they stated they wanted to go to the facility and see Resident 10 before making a decision. Then another nurse called back stating this situation has been occurring since 4:00 AM and NP MM ordered to send to ER per family wishes. On 6/7/16, at 8:56 AM, Surveyor interviewed Family Member NN, Resident 10's POA, with the other family members on the line. Family Member NN stated she first received a message at 5:40 AM from NP MM stating there was a change in Resident 10's condition and she suspected she had a stroke and to return the call to NP MM. The other daughters also received a call from NP MM stating she suspected Resident 10 had a stroke and she was waiting to her from family what to do next. The daughters went to the facility and straight to Resident 10's room. On arrival there was no one in the room with Resident 10. Resident 10 was lying in bed with just a tank top on and was drooling and blowing bubbles. Family Member NN stated she could tell that Resident 10 had a stroke. Family Member NN went to the nursing station and told LPN KK they wanted Resident 10 sent out to the hospital. Family Member NN stated that they were given conflicting information and was told it started around 6:00 AM then the CNA said it started between 3:00-3:30 AM. They were also told her vital signs were normal. Family Member NN stated no one from the facility attempted to call them. When the ambulance arrived Resident 10's blood pressure was very high. Family Member NN stated if the facility suspected Resident 10 had a stroke they should have acted on it. On 6/13/16 Resident 10's physician, Physician RR wrote a statement: The [MEDICATION NAME] was discontinued during her hospitalization . After addressing Resident 10's risk verse benefit profile by attending hospital physician and myself, it was advised by all that further use of any anti-platelet or anticoagulant of any kind following her frequent falls with [DIAGNOSES REDACTED]. On 6/21/16 per request of Surveyor and Advanced Directive Care plan for Resident 10 was sent from the Optum office. Please note this Advanced Care Plan was not in Resident 10's medical record at the time of the survey. Resident 10's Advanced Care Plan dated 12/28/15 indicates the following, inpart: -Member Goal of Care: Function and comfort. Waiting return call from---at this time. Discuss need for diagnostic testing and treatments on a case-by-case basis with---/HcPOA. No aggressive workup or treatment for [REDACTED]. -Pt is a DNR -Care and Treatment NOT to be initiated: Intubation, tube feeding, blood [MEDICAL CONDITION], hospitalization s other than for critical symptom management. Pacemaker insertion. -Care and treatment that is undecided: IV's for hydration. Antibiotics oral, IM, and IV, Lab studies, Diagnostic testing, major surgery other than for critical symptom management. hospitalization Comments: Discuss any changes in condition with patient and her daughters. hospitalization s only for major injury such as an open fracture per---HcPOA. Will discuss further hospitalization s on a case by case basis. Please note that Resident 10's signs and symptoms of a stroke are considered critical symptoms and she should have been sent to the hospital as soon as the symptoms presented themselves. The facility did not consult with Resident 10's physician as not all the pertinent information was provided and the facility did not contact and update the family on Resident 10's change of condition timely so a decision for care could be made timely. The facility removed the immediacy on 6/7/16 when they began re-education of nurses on the timely notification to physicians with regards to resident's change of condition: The need to give the resident's Physician or Nurse Practitioner full and complete information regarding a change in resident's condition. Current residents with a change in condition were given a full clinical assessment and education with licensed staff regarding the need to complet

Based on record review and interview the facility did not ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 19 residents (Resident 10). The facility did not develop a plan to monitor Resident 10 after the [MEDICATION NAME] was discontinued. Resident 10 experienced a change in condition including left sided weakness and lethargy, indications of signs of a possible stroke. The facility did not complete a thorough assessment and did not report all findings to the Nurse Practitioner. The failure to provide the necessary care including a thorough and complete assessment created a finding of immediate jeopardy. The immediate jeopardy began on 6/2/16. The Nursing Home Administrator was notified of the immediate jeopardy on 6/8/16 at 11:56 AM. The facility removed the immediacy on 6/7/16, however the deficient practice continues at a severity/scope level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan. This is evidenced by the following: According to The Long Term Care Nursing Desk Reference by Barbara Acello: Neurologic assessment Purpose of neurological assessment The neurological assessment is performed on residents with suspected neurological conditions or disorders. The most common problems are head injury and stroke. If a resident experiences a change in mental status or neurological signs, reassess and notify the physician immediately. Resident evaluation The resident's level of consciousness and mental orientation are important indicators of neurological status. A change in level of conscious is the most important sign of neurologic deterioration. To assess level of consciousness and orientation: 1. Ask the resident his or her name. If he or she responds correctly, evaluate response to date/time, place, and situation. If response is appropriate, ask about season and year. 2. Disorientation commonly affects the resident's knowledge of date first, followed by time, place, caregiver, and self. 3. Assess the quality of the verbal response. Evaluate the clarity of the resident's speech. Assess the resident's ability to make him or herself understood. Rambling responses suggest the resident is having problems with thought processes and organization. 4. Assess the resident's ability to follow directions. Determine whether he or she can follow a simple command. Evaluate the resident's ability to remain focused on the task. 5. If the resident does not respond to verbal stimuli, try painful stimuli. Assess for a response on both sides of the body to rule out monoplegia (paralysis of one limb). To evaluate motor function: 1. Test the resident's grip strength using both hands simultaneously. Instruct the resident to squeeze your fingers as hard as possible. Compare the grip strength in both hands. The dominant hand may be slightly stronger. 2. Instruct the resident to close his or her eyes and extend the arms forward. Position the palms facing upward. Determine whether either arm falls downward or pronates, indicating muscle weakness. 3. Apply gentle downward pressure to the resident's leg. Instruct the resident to raise the leg while you press gently downward. Press gently on the mid-thigh to evaluate muscle strength. 4. To assess an unconscious resident, apply painful stimulus. With a pencil or pen, press on the fingernail bed. If the resident withdraws, compare the strength of each arm. 5. Manually flex and extend the extremities to evaluate muscle tone. 6. Stroke the lateral foot with your thumbnail to evaluate the plantar reflex. The toes should flex. Observe for a positive Babinski sign, suggesting an upper motor neuron lesion. (A positive Babinski sign is extension of the great toe and abduction of the other toes instead of the normal flexion reflex). 7. Complete the neurological assessment by checking vital signs, pupils, and completing the Glasgow Coma Scale. Neurological checks Neurological (neuro) checks are performed when a neurological disorder or injury is suspected. Neuro checks are normally documented on a flow sheet. The following points are essential to a thorough assessment. Avoid documenting, neuro's negative. List each component of the assessment individually and note the results. Level of consciousness The level of consciousness is always the most important indicator of cerebral injury or other neurological problem. Apply the following definitions consistently when describing the resident: Memory is the ability to recall what is experienced, learned or retained. Evaluate the resident's ability to remember: Speech The resident's ability to speak at will is described as: -[MEDICAL CONDITION]: inability to speak, Dysphasia: difficulty speaking, Articulate: speaks fluently, Appropriate/inappropriate. Pain The response to pain is a measure of the resident's response to external stimulation. -Reaction to stimulation: note the reaction to verbal stimuli, touch, smell, or other stimuli -Reaction to painful stimulation: the resident's reaction to painful stimuli, such as a sternal rub or pressing on the nailbed with a pen. Pupil assessment Early assessment of pupil size and response to light is critical to establish a baseline measurement. Continue to monitor and compare the pupil response during subsequent neurologic checks. Increased intracranial pressure or temporal lobe herniation will cause pupil dilation. This almost always develops on the side of the raised pressure. Initially, the pupil is reactive to light. It subsequently becomes sluggish, and then fails to respond to light at all. As the intracranial pressure increases, the pupil on the opposite side is similarly affected. Determine if pupils are equal, reactive/nonreactive, Sluggish According to a Scientific statement from the American Heart Association in 2006 in an article entitled, Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke, More than 50% of the 1.2 million people who suffer an acute [MEDICAL CONDITION] infarction (AMI) or coronary death each year in the United States die in an emergency department (ED) or before reaching a hospital within an hour of symptom onset. About 700 000 individuals will have a stroke each year, 167 000 of those who have [MEDICAL CONDITION] will die, and more will suffer a major disability. Of the stroke deaths that occur each year, almost half occur before the patient reaches the hospital. Many of these deaths and significant disability could be prevented if patients received earlier treatment. Although the benefits of early treatment of [REDACTED].Delay to treatment for [REDACTED]. The disability associated with stroke and with heart failure after AMI is largely a consequence of infarct size, and lack of timely treatment is a major determinant of increased infarct size in both AMI and stroke. Unfortunately, most individuals who experience symptoms delay substantially before seeking treatment . Stroke trials demonstrated that treatment within 3 hours of symptom onset is beneficial for patients with acute ischemic stroke. Even within the 3-hour window, benefit from [MEDICATION NAME] decreases as time from symptom onset increases. An analysis of 6 large, randomized, controlled trials of intravenous [MEDICATION NAME] corroborated these findings and indicated that the optimal administration time is within 90 minutes of symptom onset. <http://circ.ahajournals.org/content/114/2/168.full> Resident 10's [DIAGNOSES REDACTED]. Resident 10 fell at the facility on 4/7/16 and suffered a subdural hematoma. Resident 10's [MEDICATION NAME] (blood thinner) was discontinued in the hospital due to the subdural hematoma and to reconsider this in 3-6 months if there are no further falls. Resident 10's care plan for Cardiovascular/Circulatory, dated 4/19/16, indicates the potential for alteration in circulation related to [MEDICAL CONDITION] Fibrillation, Hypertension, [MEDICAL CONDITIONS], [DIAGNOSES REDACTED] and Heart Murmur. Interventions include: Medications/treatments as ordered, update physician/family as needed, labs as ordered, vital signs per protocol and as needed, monitor neurological state, monitor for sign/symptoms of [MEDICAL CONDITION], lung sounds as needed, provide resident education as needed, consults as needed, and encourage rest periods as needed. The care plan does not identify the recent discontinuation of [MEDICATION NAME] or to monitor for signs of a stroke. Resident 10's care plan for Fall/Injury indicates Resident 10 transfers with 1 staff assist and the use of a walker and was updated on 4/20/16 to include 15 minute checks for safety. Resident 10's care plan for Urinary Continence care plan includes to prompt to toilet every 2 hours at night and at 2:00 AM and 11:00 PM. Resident 10's NP (Nurse Practitioner) visit note, dated 4/15/16, indicates DNR (Do Not Resuscitate), IVs (intravenous): undecided, hospitalization s: no, discuss any changes in condition with patient and her daughters. hospitalization s only for major injury such as open fracture per daughter/POA (Power of Attorney). Will discuss future hospitalization s on a case-by-case basis. Resident 10's NP visit note, dated 5/24/16, treatment plan: [REDACTED]. When fully resolved, 2-3 months post injury, consider resumption of [MEDICATION NAME]. On 6/21/16 per request of Surveyor and Advanced Directive Care plan for Resident 10 was sent from the Optum office. Please note this Advanced Care Plan was not in Resident 10's medical record at the time of the survey. Resident 10's Advanced Care Plan dated 12/28/15 indicates the following, inpart: -Member Goal of Care: Function and comfort. Waiting return call from---at this time. Discuss need for diagnostic testing and treatments on a case-by-case basis with---/HcPOA. No aggressive workup or treatment for [REDACTED]. -Pt is a DNR -Care and Treatment NOT to be initiated: Intubation, tube feeding, blood [MEDICAL CONDITION], hospitalization s other than for critical symptom management. Pacemaker insertion. -Care and treatment that is undecided: IV's for hydration. Antibiotics oral, IM, and IV, Lab studies, Diagnostic testing, major surgery other than for critical symptom management. hospitalization Comments: Discuss any changes in condition with patient and her daughters. hospitalization s only for major injury such as an open fracture per---HcPOA. Will discuss further hospitalization s on a case by case basis. Please note that Resident 10's signs and symptoms of a stroke are considered critical symptoms and she should have been sent to the hospital as soon as the symptoms presented themselves. Resident 10's vital signs log indicates the following: 5/19/16 AM: Blood pressure 136/71, pulse 88, respirations 16, temperature 97. 5/21/16 NOC: Blood pressure 138/70, pulse 69, respirations 18, temperature 96.6, oxygen 96%. 5/22/16 AM: Blood pressure 126/68, pulse 83, respirations 18, temperature 97.8, oxygen 96%. Resident 10's Resident Summary, dated 5/30/16, indicates her speech is clear and she is on 15 minute checks. LPN II (Licensed Practical Nurse) completed a SBAR (Situation, Background, Appearance, Review and notify) Communication form on 6/2/16 which indicates: -Change in condition, symptoms or signs are: Lethargy -This started on: 6/2/16, since this started it had gotten: Stayed the same. -This condition, symptom has occurred before: No -Primary Diagnoses: [REDACTED].>-Other pertinent history: Subdural hemorrhage -Vital signs: blood pressure 143/100, pulse 73, respirations 18, temperature 96.7 pulse oximetry 92% on room air. -Decreased level of consciousness, Decreased mobility, unable to move left arm, cloudy urine, pain head left side, abnormal speech slurring her words, DNR. -Summarize your observations and evaluation: Slumped over to the left side of her wheelchair, drool running out of her mouth. -Notified: NP MM on 6/2/16 at 5:30 AM. -Recommendations: Hold her until family is notified then later transport to hospital. -Name of Family notified: Family Member NN on 6/2/16 at 8:45 AM. Resident 10 is part of a managed care organization. The on call Nurse Practitioner (NP) may not be familiar with the resident staff are calling about and may not be in the same area. NP MM is from another state and is not familiar with Resident 10. The NP MM's call log for NP MM for Resident 10 indicates the following call for 6/2/16: -4:54 AM, from LPN (Licensed Practical Nurse) II -Resident 10 acting funny this am. VSS (vital signs stable), Afebrile, (pulse) 73-(respirations) 20- (blood pressure) 154/90, (oxygen) 92%. Alert, oriented, talking. Some drooling noted. Moving extremities. Neuro status WNL (within normal limits). Lung assessment not done. Asked nurse to get lung assessment and BS (blood sugar) while I hold. Lungs CTA (clear to auscultation), BS-122. DNR. Intervention-Stat CBC (Complete Blood Count), BMP (Basic Metabolic Panel), U/A (urinalysis), CS (culture and sensitivity). May straight catheter if needed. Vital signs every shift for 3 days. Return call if any further change in condition. I will update daughter. Will ask primary NP to follow up. Note: NP MM did not contact or discuss the change of condition with POA. LPN II did not complete a thorough neurological assessment, nor did he inform NP MM that Resident 10's left hand grasp was weak. Resident 10's vitals were in limits however not typical for Resident 10. -5:36 AM, from LPN II-Nurse now stated Resident 10's speech is slurred. Resident 10 not moving left arm but moving both legs. PERRLA (pupils equal, round, reactive to light, accommodation). Urine is cloudy. Intervention-I will call daughter with update in change in condition and discuss if want any further interventions. -5:39 AM-from NP MM, call to Family Member NN. Left voice mail message to return call as soon as possible. On call number provided. This was the first time someone attempted to call family to discuss change of condition. -5:48 AM, from NP MM, call to facility to see if any other contact number. Four contact numbers listed in chart. Will attempt to call. -6:01 AM, from NP MM, call to Family Member OO. Left voice mail regarding change in condition. Requested return call back as soon as possible. On call number provided. -6:03 AM, from NP MM, call to Family Member PP no answer. -6:05 AM, from NP MM, call to Family Member QQ. Updated on change in condition. Stroke verse infection. Family Member QQ will have Family Member NN/POA contact NP MM. On call number provided. -6:17 AM, from Family Member OO, Family Member OO returns call. She is unable to reach Family Member NN. Updated on change in condition and Plan of Care so far. Discussed possible causes of change in condition, infection verse stroke. Intervention-Family Member OO will go see her mother now and return call to NP MM with update and wishes for any further interventions. -6:23 AM, from Family Member PP, Family Member PP has talked with her sisters and they are all going to see their mother. -6:58 AM, from LPN KK, Day shift nurse calling stating family at bedside and would like Resident 10 sent to emergency room . LPN KK has contacted primary care physician. On 6/2/16, the facility obtained a telephone order for 911 transport to emergency room for evaluation and treatment. There is no time on the telephone order. Resident 10's nursing note 6/2/16 at 6:55 AM by LPN II, Was called to Resident 10's room by CNA (Certified Nursing Assistant) stating resident was acting strange. Found resident slumped over in wheelchair. Resident 10 was able to converse, vital signs within normal limits. Resident 10 had slurred speech, inability to use her left arm, eyes were equal and reactive, she was able to move both lower extremities. NP was called she ordered CBC, BMP and UA/CS. She stated she would contact family to make a decision, later she ordered transport to hospital. Vital signs log: 6/2/16 night shift (no actual time documented) blood pressure: 143/100, pulse 73, respirations 18, temperature 96.7, oxygen 92% on room air. By LPN II. Resident 10's nursing note, 6/2/16 at 10:41 AM by LPN KK: Resident 10 lying in bed head of bed up 30 degrees. Noted left facial (illegible) drooping. Lethargic, unable to follow simple command. Forceful one word answers. States Throw, up. Unable to utilize left arm. Unable to smile or stick out tongue. No left hand strength, denies pain. Vital signs blood pressure 191/118, Pulse 87, temperature 97, oxygen 93% on room air, respirations 20. Skin dry and warm pallor. Charge nurse called for assessment. DON (Director of Nursing) called and updated. 911 called for transport with POA present, consent. Managed Care organization and physician updated. 911 arrived and transported Resident 10 to emergency room . Resident 10 noted to have built up saliva/foam at mouth. Resident 10 admitted to hospital [DIAGNOSES REDACTED]. Resident 10's hospital notes, dated 6/2/16: Resident 10 sent to emergency department with reports of altered mental state and left-sided weakness that began sometime early this morning. We heard varying reports of onset of symptoms between 3 and 4:30 this morning. She apparently initially was altered and then noted to have left-sided facial droop and weakness. She has a history of an unwitnessed fall on April 7 resulting in a subdural hematoma. After discharge from that event family had told the neurosurgeon that they would not want any type of surgical intervention due to her advanced age and medical condition. Also important in her history is that blood thinners were recently discontinued because of her fall and subdural hematoma. Emergency Department vitals at 8:00 AM: Blood pressure 224/140, pulse 84, respirations 13. Physical exam: -Constitutional: She appears well-developed and well-nourished. She appears lethargic. Her eyes are generally closed and she appears to be sleeping. Sonorous (deep sound) respirations with some drooling and bubbles forming at the mouth with left facial droop. -Eyes: Right eye exhibits abnormal extraocular motion. Persistent gaze to the right. Pupils are small and minimally reactive. Extraocular movements cannot be assessed. -Neurological: She appears lethargic. There is some spontaneous movement of the right upper extremity and lower extremities bilateral. The left upper extremity is flaccid. Left facial droop is present with some drooling and bubbles forming at the mouth. She is occasionally able to follow commends with her right upper extremity. CT (computed tomography) results: Findings consistent with interval development of right parietal infarct, acute/subacute, without hemorrhagic component. Physician spoke at length with Resident 10's daughters and reviewed her CT scan findings. The daughter stated that she had been able to speak and eat but was not walking much due to complaints of hip pain prior to onset of symptoms this morning. The daughters feel that if she is eligible they would like her to receive [MEDICAL CONDITION] therapy to try to regain some functional status. Her recent head trauma is a contraindication. Spoke with neurologist and unfortunately this patient does not meet criteria for [MEDICAL CONDITION] therapy. She had recent head injury with subdural hematoma less than 2 months prior to onset of stroke. The exact time of onset of her stroke in not known and the fact that it is already showing up on non-contrast CT scan at the time of arrival suggests the stroke may have been present for a longer period of time. Her age greater than [AGE] years is also a relative contraindication. He recommends aspirin and only modest blood pressure control though we would like to keep her hypertensive to obtain perfusion. The family including four daughters were notified that this has potential for deterioration and potentially life ending event. Resident 10 was discharged on [DATE] with overall prognosis is poor with terminal [DIAGNOSES REDACTED]. Estimated life expectancy weeks possible 6-8 weeks. Transfer Resident 10 to inpatient hospice. On 6/7/16, at 9:32 AM, Surveyor interviewed CNA HH. CNA HH stated she worked with Resident 10 on 6/1/16 and she was acting like her typical self. Resident 10 was able to transfer with 1 staff assist which was more like supervision only as she was able to transfer without physical help. Then CNA HH worked with Resident 10 on 6/2/16. CNA HH stated her shift began at 2:00 AM and she first saw Resident 10 at 3:30 AM when she went in to toilet her. CNA HH stated Resident 10 was not acting like herself and she had difficulty transferring Resident 10 into the wheelchair. CNA H stated Resident 10 was not responding per her normal self and what she said was noncoherant. CNA HH tried to get Resident 10 to sit up in her wheelchair and she was not able to and so CNA HH went to get LPN II and CNA JJ to help with Resident 10. CNA HH reported to LPN II that Resident 10 was not acting like herself. CNA HH and CNA JJ needed to use the full body mechanical lift to transfer Resident 10 back to bed as she was not able to stand up on her own. LPN II took Resident 10's vital signs. During this time Resident 10 stated she was nauseous and CNA HH obtained a basin for her. CNA HH stated at around 4:00 AM RN (Registered Nurse) LL came over to assess Resident 10 and LPN II stated he was going to call Resident 10's family and doctor. At that time CNA HH went to help other residents and she checked on Resident 10 every 15 minutes to ensure she was comfortable. CNA HH stated when you looked at Resident 10's eyes it looked like there was nothing there. At 6:00 AM the day shift started and LPN KK started her shift. CNA HH stated that LPN II told LPN KK that this all started at 6:00 AM which it did not and CNA HH was so frustrated that nothing had been done she documented this and gave it to LPN KK. CNA HH stated that LPN KK called Resident 10's doctor and family and had her sent out to the hospital around 7:00-7:30 AM. Surveyor asked CNA HH how she was so certain about the time she first saw the change in Resident 10 and CNA HH stated because she had looked at her watch. Resident 10 was on 15 minute checks so she needed to know. CNA HH confirmed she regularly worked with Resident 10 and told LPN II this was not Resident 10's normal behavior. On 6/7/16, at 1:56 PM, Surveyor interviewed CNA JJ. CNA JJ confirms she assisted CNA HH with Resident 10 on 6/2/16. CNA JJ stated she could not recall the exact time but was doing her last rounds which she typically starts around 4:00 AM. CNA JJ stated when she arrived at Resident 10's room Resident 10 was sitting in her wheelchair in the bathroom and she was slumped over in the chair and could not sit up. We got the mechanical lift and transferred Resident 10 back to bed. LPN II came in to check her out and CNA JJ went back to her unit to continue her rounds. On 6/7/16, at 11:35 AM, Surveyor interviewed LPN II. LPN II stated on 6/2/16 around 5:00 AM a CNA came to him and stated Resident 10 was behaving funny. LPN II stated he was not sure of the exact time but it was at the end of the shift. LPN II stated when he arrived at the room Resident 10 was in the wheelchair in the bathroom slumped over to the left side, was able to communicate with him and was tracking with her eyes. LPN II stated Resident 10 was not able to grasp with her left hand but he was not familiar with her so he did not know if that was normal. Resident 10 was able to move both of her feet. The CNAs got Resident 10 into bed then he obtained her vitals which were in normal limits and he called the Nurse Practitioner on call (NP MM) and reported what happened. LPN II stated NP MM ordered labs and a urinalysis and that NP MM would contact the family. LPN II called the night shift supervisor, RN LL, to have her check Resident 10 again more thoroughly. Resident 10's eyes were equal and brisk, she was not able to use her left hand and it was cold, she was losing her ability to move her feet and her speech was slurred. LPN II called NP MM again to update her on the changes and NP MM requested additional family member names and numbers. When LPN KK came in for the morning shift she said she could tell what was going on with Resident 10 and she called and had her transported out to the hospital. NHA A and DON B interviewed LPN II on 6/8/16 regarding the events on 6/2/16 with Resident 10. LPN II stated she started his medication pass on the 400 unit at 3:00 AM and that the medication pass takes him 1 hour. Once he finished the 400 medication pass he began the 300 unit medication pass around 4:00 AM. LPN II stated he was about halfway through his medication pass when CNA HH approached him regarding Resident 10 having a change of condition. LPN II stated this occurred at roughly 4:45-5:00 AM. NHA A asked if it could have occurred closer to 3:30 AM and LPN II stated it was not possible because he had already finished the 400 unit medication pass and was half way through the 300 unit medication pass. LPN II stated once he was approached by CNA HH he immediately went to Resident 10's room where Resident 10 was in her wheelchair in the bathroom and CNA HH and JJ were beginning to take Resident 10 back to bed. LPN II left the room and contacted the Nurse Practitioner and gave her report regarding her change of condition. LPN II also contacted the RN Supervisor to assist him with assessing Resident 10. On 6/7/16, at 12:00 PM, Surveyor interviewed RN LL. RN LL stated it was close to the end of her shift on 6/2/16 when LPN II came over to her unit and said something was wrong with a patient. RN LL went to the unit Resident 10 was on and LPN II stated he had called the physician and received orders and needed help getting a urine sample. RN LL stated when she walked in Resident 10's room she was lying in bed on her left side facing the wall and RN LL asked LPN II to help reposition Resident 10 so they could get a urine sample. LPN II stated he thought Resident 10 had a stroke and asked RN LL if she knew Resident 10. RN LL stated she did not work with Resident 10 thus did not know her and so she was not sure and that LPN II should call the physician to find out what to do. RN LL stated Resident 10 was moaning and not able to use her left arm. LPN II left the room to call the NP while RN LL stayed in the room. LPN II returned and stated they were going to call the family to decide what measures to take and what the family wanted to do. RN LL asked if LPN II needed anything else then returned to her side of the building. NHA A and DON B interviewed RN LL on 6/8/16 regarding the events on 6/2/16 with Resident 10. RN LL stated she was contacted by LPN II between 4:00-5:00 AM on 6/2/16. RN LL stated she knew it was that time as she stated that she was starting her medication pass and she always starts it around 4:00 AM. RN LL immediately went to the wing to assist LPN II. LPN II had already contacted the NP and LPN II noticed Resident 10 had left sided weakness and wanted RN LL's assistance evaluating her and assistance with new orders. LPN II received direction from the NP to continue to monitor as the NP was contacting family, due to age nothing could be done per NP. On 6/7/16, at 1:03 PM, Surveyor interviewed LPN KK who worked the morning shift. LPN KK stated when she came in on 6/2/16 LPN II reported Resident 10 was not feeling well. LPN KK stated she went into Resident 10's room and noted left sided weakness and that Resident 10 was not able to talk very well but said she was going to throw up. LPN KK attempted to call Resident 10's NP but was unable to reach her. At that time Resident 10's daughters were coming into the building and went straight to Resident 10's room. Resident 10's family stated they wanted her sent out and LPN KK stated she was working on it and called 911 to send Resident 10 to the hospital. LPN KK stated that CNA HH had approached her and stated that LPN II was not telling the truth about the timeframe when this started. LPN KK instructed CNA HH to document this in a letter which CNA HH did and LPN KK put the letter in DON B's box. On 6/7/16, at 2:32 PM, Surveyor interviewed NP MM who was on call on 6/2/16. NP MM stated when she was contacted she was told that Resident 10 was drooling and appeared weak but her vital signs were stable, she was alert, moving her legs and neurological checks were normal. NP MM requested that LPN II obtain a blood sugar check while she waited on the phone. NP MM stated LPN II did not state how long this had been going on. NP MM stated she ordered some labs and told LPN II to call back if there were any changes. LPN II called back stating Resident 10 was not able to move her arm and her speech was slurred. NP MM stated she then attempted to call Resident 10's family because Resident 10 was a DNR and she wanted to know how aggressive to be. NP MM stated she does not send a resident out to the hospital who is a DNR without talking with the family first. NP MM stated she did not recall being informed on the initial call that Resident 10's left hand grasp was weak but she would not have done anything different;y before ruling out an infection. NP MM stated she could not recall being told Resident 10 recently had a fall with a subdural hematoma and was recently taken off [MEDICATION NAME]. NP MM stated the initial signs of a stroke can mimic an infection and when the facility called back and reported the slurred speech then she began calling the family to make a decision. NP MM stated when she did speak with the family they stated they wanted to go to the facility and see Resident 10 before making a decision. Then another nurse called back stating this situation has been occurring since 4:00 AM and NP MM ordered to send to ER per family wishes. On 6/7/16, at 8:56 AM, Surveyor interviewed Family Member NN, Resident 10's POA, with the other family members on the line. Family Member NN stated she first received a message at 5:40 AM from NP MM stating there was a change in Resident 10's condition and she suspected she had a stroke and to return the call to NP MM. The other daughters also received a call from NP MM stating she suspected Resident 10 had a stroke and she was waiting to her from family what to do next. The daughters went to the facility and straight to Resident 10's room. On arrival there was no one in the room with Resident 10. Resident 10 was lying in bed with just a tank top on and was drooling and blowing bubbles. Family Member NN stated she could tell that Resident 10 had a stroke. Family Member NN went to the nursing station and told LPN KK they wanted Resident 10 sent out to the hospital. Family Member NN stated that they were given conflicting information and was told it started around 6:00 AM then the CNA said it started between 3:00-3:30 AM. They were also told her vital signs were normal. Family Member NN stated no one from the facility attempted to call them. When the ambulance arrived Resident 10's blood pressure was very high. Family Member NN stated if the facility suspected Resident 10 had a stroke they should have acted on it. On 6/13/16 Resident 10's physician, Physician RR, wrote a statement: The [MEDICATION NAME] was discontinued during her hospitalization . After addressing Resident 10's risk verse benefit profile by attending hospital physician and myself, it was advised by all that further use of any anti-platelet or anticoagulan

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without pressure injuries does not develop pressure injuries and a resident having pressure injuries receives necessary treatment and services to promote healing, prevent infection and prevent new injuries from developing for 2 of 9 residents (Residents 12 and 7). Resident 12 was admitted to the facility and was identified to be at risk for pressure Injury (PI) development as Resident 12 was admitted with a stage 4 PI to his right Ischial area. Resident 12 was initially placed on and continues to use an alternating pressure mattress. Resident 12 was observed to have a right heel lateral suspected deep tissue injury (SDTI) purple area with intact skin and medial stage 2 ulcer, which is documented by the physician as red, and yellow brown slough identified at the wound clinic appointment for the Ischial PI follow up. The facility failed to note the skin breakdown on Resident 12's heel. Resident 12 developed a facility acquired Stage 3 that worsened into a stage 4 PI to his right heel. Consequently, Resident 12 developed [DIAGNOSES REDACTED] in the right heel and required Intravenous (IV) antibiotics. Resident 7 was admitted to the facility without a pressure injury (PI) and was identified to be at high risk for PI development. Resident 7 was placed on a pressure redistribution mattress upon admit despite Resident 7 requiring the head of bed (HOB) to be elevated at 30 degrees at all times placing much of Resident 7's weight on her coccyx region. The facility failed to recognize Resident 7's increased risk and failed to implement additional measures to prevent PI. Resident 7 developed a facility acquired, avoidable PI that worsened to a Stage IV. The PI developed two infections including [MEDICAL CONDITION] (MRSA). Once the PI was identified the facility failed to immediately assess the root cause for the PI development and failed to implement aggressive interventions to prevent the deterioration of the PI. In addition, the facility failed to ensure interventions were appropriately implemented to prevent further PI deterioration, failed to ensure weekly skin assessments were completed as directed per professional standards of practice, failed to appropriately stage the PI, and failed to notify the family with the deterioration of the PI. The facility's failure to put preventative measures i.e. offload heels upon admission with Resident 12's known medical history and risk for PI development, failure to recognize a Stage 3 PI during weekly skin and diabetic foot checks, and the facility's failure to update Resident 12's plan of care to prevent deterioration of the PI once the Stage 3 PI was identified created a finding of immediate jeopardy. The immediate jeopardy began on 1/8/16 when the Stage 3 PI was identified by the wound clinic physician and was noted to contain slough; by definition once a PI contains slough the PI is at least a stage 3. Once identified by the physician the facility did not implement interventions to prevent further skin breakdown to the right heel; i.e. offload the heel. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy on 5/17/16. The immediacy was removed on 5/19/16 and continues at as severity and scope of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan. This is evidenced by: Of note the National Pressure Ulcer Advisory Panel (NPUAP) now refers to pressure ulcers (PU) as pressure injuries (PI). The facility's Wound Care Policy dated 7/15 and entitled Wound Prevention and Management states in part; Pressure Ulcer (PU) Prevention/Treatment: The center recognizes it is difficult to describe a set of protocols that would fit every circumstance. However, Braden recommends that following: manage moisture, manage nutrition, manage friction and shear and manage other general care issues. Select appropriate interventions based on the following: Braden risk assessment score and skin integrity assessment/prevention and treatment care plan. The following interventions are efforts to stabilize, reduce or remove underlying risk factors. At risk (15-18) frequent turning, pressure reduction support surface if bed or chair-bound; Moderate risk (13-14) turning schedule use foam wedges for 30 degree lateral positioning, pressure reduction support surface; reduce pressure to heels, manage moisture, nutrition, friction and shear; High risk (10-12) increase frequency of turning, supplement with small shifts in body position, use foam wedges for 30 degree lateral positioning, pressure reduction support surface reduce pressure to heels, manage moisture, nutrition, friction and shear; Very High Risk (9 or below) All the above. Note: Low air loss beds do not substitute for turning schedule. Procedure: 2. Review assessments and identify individualized interventions using the skin integrity assessment/prevention treatment care plan. Interventions may include but are not limited to: a. Manage Pressure: use support surfaces on bed or wheelchair; turning and repositioning, offload heel pressure. D. elevate head of bed (HOB) no more than 30 degrees unless clinical condition warrants greater elevation; protect elbows and heels if being exposed to friction. 3. Include resident/responsible party goals in development of care plan. 4. Enter all applicable interventions on the skin integrity assessment/prevention and treatment care plan. 5. Present at the next appropriate daily clinical meeting for a new onset or change in condition of wound. 7. Communicate interventions to staff. 8. Provide training to staff as needed. 10. Review and revise skin integrity assessment/prevention and treatment care plan to reflect interventions to heal pressure injuries and stabilize, reduce or remove underlying factors. According to the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Prevention Points: Skin Care: 2. Inspect skin daily for signs of PI; 3. Assess pressure point such as sacrum, coccyx, heels .8. Avoid positioning an individual on an area of [DIAGNOSES REDACTED] or PI; Repositioning and Mobilization: 2. Choose a frequency for turning based on the support surface in use and the tolerance of the skin for pressure; 4. Turn the individual into a 30 degree side lying position, and use your hand to determine if the sacrum is off the bed; 5. avoid positioning the individual on body areas with PI; 6. ensure the heels are free from the bed; 7. consider the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface. Infected Pressure Ulcers in Elderly Individuals notes, Pressure ulcers in elderly individuals can cause significant morbidity and mortality and are a major economic burden to the health care system .They can lead to severe or intolerable pain, are prone to infection, and are associated with high mortality rates . <http://cid.oxfordjournals.org/content/35/11/1390.long> The Mayo Clinic website notes that Complications of pressure ulcers include: Sepsis.[MEDICAL CONDITION] occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It's a rapidly progressing, life-threatening condition that can cause organ failure. [MEDICAL CONDITION]. [MEDICAL CONDITION] is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. [MEDICAL CONDITION] can lead to life-threatening complications. Bone and joint infections. An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteo[DIAGNOSES REDACTED]) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications. <http://www.mayoclinic.org/diseases-conditions/bedsores/basics/complications/con- 848> The facility uses a Panacea mattress as their standard mattress. According to manufacturer's recommendation, the mattress used in the facility is rated for pressure reduction and redistribution and may be appropriate through Stage 2 PI. Example 1 Resident 12 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/5/15 indicated a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident 12 had moderate cognitive impairment. However, Resident 12 is his own person. Resident 12 preferred to be a full code. Section MO150 of the MDS indicates Resident 12 is at risk for PI development. Section GO110, Activities of Daily living (ADL's) indicates Resident 12 required extensive assistance with 2 person physical assist for bed mobility and transfers. A PU Care Area Assessment (CAA) worksheet dated 11/6/15 states in part: Triggers: bed mobility self - performance problem is indicated - extensive assistance is required. Extrinsic risk factors: needs special mattress or seat cushion to reduce to reduce or relieve pressure; requires regular schedule of turning. [MEDICATION NAME] Factors: immobility, incontinence, altered mental state, cognitive loss, and poor nutrition. Analysis of findings: has one stage 4 PI on his Ischial area and is at risk for more, needs assist with turning, transfers and mobility. Care Plan Considerations: CAA triggered due to resident needing assistance with bed mobility, and having an existing stage 4 PI on his right Ischial area. Resident 12's goal is to have no new PI and the one that he has will heal. Of note the quarterly MDS dated [DATE] indicates Resident 12 continues to be at risk for PI development and [MEDICAL CONDITION] is documented for the stage 4 PI on Resident 12's right heel. The Braden Assessment form (PI risk form) was completed on 10/29/15 with a score of 14 indicating Resident 12 is at moderate risk for PI development. The Braden Assessment form was completed on 11/6/15 with a score of 16 indicating Resident 12 is at minimal risk for PI development. The Braden Assessment form was completed on 11/12/15 with a score of 16 indicating Resident 12 is at minimal risk for PI development. The Braden Assessment form was completed on 1/28/16 with a score of 16 indicating Resident 12 is at minimal risk for PI development. Of note Resident 12 has now developed an unstageable PI to his right heel. Resident 12's physician's orders [REDACTED]. Resident 12 has a Comprehensive Care Plan Review Summary dated 10/15 Section Skin/Wound includes: Skin Integrity Assessment Prevention and Treatment Plan of Care received and updated. Weekly Skin Assessment reviewed, Braden Risk Assessment Score 14. Of note there is no documentation to off load heels. Resident 12 has a comprehensive plan of care dated 10/15 entitled Skin Integrity Assessment: Prevention and Treatment Care Plan, at risk (15-18) 1-28-16 score 16. Frequent turning, Maximum Remobilization, Protect heels, Manage Moisture, Nutrition, Friction, and Shear. Pressure reduction support surface if bed or chair-bound. On 1/16 Resident 12's care plan was revised to include the following: Moderate Risk (13-14) turning schedule use of foam wedges for 30 degrees lateral positioning, Protect heels, Manage Moisture, Nutrition, Friction, and Shear. Pressure reduction support surface. Interventions include: Complete Braden scale upon admission and weekly. On 4/16 Resident 12's care plan was revised to include the following interventions: Manage Moisture- use commercial Moisture Barrier, Use absorbent Pads or Diapers that Wick & Hold Moisture. Offer bedpan/ urinal glass of water in conjunction with Turing Schedules. Manage Nutrition: Monitor Weight, and Monitor Meal Intake. Manage Friction and Shear: Elevate HOB (Head of Bed) no more than 30 degrees unless clinical condition precludes. Use Lift Sheet to move Resident. Protect Elbows and Heels if being exposed to Friction. Other General Care Issues: No Massage of Reddened bony Prominences, No Do-Nut Type Devices, Maintain Good Hydration, Avoid Dry Skin. Skin Hygiene and Inspection: Bathe with mild soap, rinse, and dry thoroughly. Moisturize skin with lotion to keep the skin soft and pliable, especially over bony prominences. Keep skin clean, dry, and free of body wastes, perspiration and wound drainage. Inspect the skin for s/s (Signs and symptoms) of breakdown. Activity/ Mobility: Provide ROM (Range of Motion) as applicable. Keep linen dry and wrinkle free. Pressure reduction or pressure relief surface. Specialty mattress - Air mattress in written in. Involve Therapy when indicated. Turn and Reposition Program: Yellow Dot, Blue boots as ordered, no shoes, and elevates legs on foot rest dated 2/23/16. Of note Resident 12's care plan was revised which states in part, Blister (R) Rt (Right) heel dated 3/8/16 and Rt (Right) heel ulcer dated 3/25/16. Interventions listed include: Monitor wound weekly and PRN (When necessary), Provide treatment per MD (Medical Doctor) order, Update MD within 2 weeks if no evidence of healing. Resident 12's Certified Nursing Assistant (CNA) ADL Care Sheet undated, includes yellow dot which indicates: Turning and Repositioning Program dated July 2015. States in part,1. Place a yellow dot on the nameplate of the resident's door and /or wheelchair/gerichair whenever a resident is: unable to turn self, unable to reposition self. 2. Turn and reposition resident s every 1-2 hours when; in bed or in any type of chair. 3. Offer reminders to turn and reposition residents with sensory impairment whenever a resident is; able to turn self and able to reposition self. Of note there is direction to offload heels. Nurse Practitioner (NP) U notes dated 10/30/15 - 11/9/15 without a timestamp includes, Extremities: 1+ [MEDICAL CONDITION] (Swelling), pedal pulses normal, hard brace on bilateral ankles. NP U notes dated 11/11/15 - 11/16/15 without a timestamp includes, Extremities: No [MEDICAL CONDITION], +2 pedal pulses. NP U notes dated 11/18/15 without a timestamp includes, Extremities: No [MEDICAL CONDITION], +2 pedal pulses, ankle braces on. NP U notes dated 11/20/15 without a timestamp includes, Extremities: No [MEDICAL CONDITION], +2 pedal pulses, and multiple scabbed sores on the right foot, likely due to the leg brace. Physician's Telephone Order dated 11/20/15 without a timestamp, states, Please cover right foot with kerlix (Gauze) before putting brace on. NP U notes dated 11/22/15 without a timestamp includes, Extremities: No [MEDICAL CONDITION], +2 pedal pulses, braces left ankle. NP U notes dated 11/23/15 without a timestamp includes, Extremities: No [MEDICAL CONDITION], +2 pedal pulses, and multiple scabbed sores on the right foot, likely due to the leg brace. Physician's Telephone Order dated 12/7/15at 1:00 PM, states, Blue boot on while in bed. Diagnosis: [REDACTED]. Wound Care Consultation Notes dated 1/8/16, states in part, New ulcers R lateral SDTI- purple area intact skin, medial stage 2 ulcer, red , yellow- brown slough. Treatment ordered: 1. Leave AFO off right foot unless patient is standing and walking. 2. Apply Santyl to R heel ulcer daily, gauze or [MEDICATION NAME] to cover. 3. Prevalon boots, but also ensure no direct pressure on post. (Back) of heel. Nurse's notes dated 1/8/16 without a timestamp, indicate that Resident 12 was seen at the Wound clinic and a new ulcer was found to R heel SDTI. Orders received as noted above for treatment. Physician's Telephone Order dated 1/19/16 at 5:30 PM, states,1. Cleanse R heel blister/OA (Open area) with NS (Normal Saline), apply Santyl, F/b (Followed by) gauze and secure with kerlix QD (Every day) until healed. Date identified: 11/22/15. To be noted, there are no measurements between 11/22/15 - 1/19/16. The facility's Wound notes dated 1/19/16 at 5:02 PM include: Type: Other. Classification- Blister. Source- Facility Acquired. Tissue Types: Bright Pink or R= 20%, Slough Loosely adherent = 80%. Size cm (Centimeters) 1.80 x 2.50 x 0.01 L x W x D (Length, Width, Depth). Physician's Telephone Order dated 1/20/16 at 2:00PM, states in part, Vitamin C 500 mg (Milligrams) 1 tab X 2 weeks PO (Oral) Zinc 220 mg 1 tab PO X 2 weeks. Diagnosis: [REDACTED]. The facility's Wound notes dated 1/26/16 at 2:04 PM include: Type: Other. Classification- Blister. Source- Facility Acquired. Tissue Types: Slough Loosely adherent = 20%. Necrotic Soft, Adherent = 80%. Size cm 2.10 x 2.90 x 0.01 Physician's Telephone Order dated 1/29/16 at 11:30 AM, states in part, Right foot brace to only be on while ambulating, may have on to transfer, and then off. Diagnosis: [REDACTED]. Physician's Telephone Order dated 2/1/16 at 11:30AM, states in part, Ok to continue to walk with Brace on at PT (Physical Therapy). If ulcer/wound changes needs to stop ambulation and do another type of strength exercise. The facility's Wound notes dated 2/2/16 at 3:38 PM include: Type: Other. Classification- Blister. Source- Facility Acquired. Tissue Types: Slough Loosely adherent = 20%. Necrotic Soft, Adherent =80%. Size cm 2.10 x 2.90 x 0.01 Wound Care Consultation Notes dated 2/4/16, states in part, Heel ulcer 80% eschar, 20 % slough 3x3x4 cm. Off load heel at all times but may wear shoes for therapy. Physician's Telephone Order dated 2/4/16 at 5:30 PM, states in part, Off load R heel at all times but may wear shoes for therapy. The facility's Wound notes dated 2/9/16 at 1:20 PM include: Type: Other. Classification- Blister. Source- Facility Acquired. Tissue Types: [MEDICATION NAME] (Pale Pink or Red) = 5%, Slough Loosely adherent = 85%, Necrotic Soft, Adherent = 10%. Size cm 2.8 x 3.10 x 0.01. Please note that wound has increased in size and faciltiy did not impliment any new changes to the plan of care. Resident 12's Summary notes dated 2/11/16, states in part, Skin: PM's (Evening shift) reporting foot ulcer 'worsening and odorous'. The facility's Wound notes dated 2/16/16 at 9:51 AM include: Type: Other. Classification- Blister. Source - Facility Acquired. Tissue Types: Necrotic Soft, Adherent = 100%. Size cm 4.0 x 4.5 x 0.01. Please note that wound has increased in size from the previous week and faciltiy did not impliment any new changes to the plan of care. Wound Care Consultation Notes dated 2/18/16, states in part, Right Heel: 4 x 5.4 x unable to measure due to eschar. The facility's Wound notes dated 2/23/16 at 8:32 AM include: Type: Other Classification- Blister. Source- Facility Acquired. Tissue Types: Necrotic Soft, Adherent = 100%. Size cm 4.0 x 5.0 x 0.01. Nursing wound documentation states, Was seen by Wound MD on Monday and wound was debrided. X-rays taken and positive for Osteo. Started on ATB (Antibiotic) therapy Tuesday afternoon. Resident 12's Summary notes dated 2/25/16, states in part, ADL's - held r/t (Related to) inability to wear boots/brace for ambulation. Wound Vac (Vacuum) and foot ulcers; seen in wound clinic. PICC (Peripheral Inserted Central Catheter) line place for IV antibiotics for osteo[DIAGNOSES REDACTED]. The facility's Wound notes dated 3/2/16 at 10:11 AM include: Type: Other. Classification- Blister. Source- Facility Acquired. Tissue Types: Bright Pink or Red=10%, Slough Non Adherent = 10%, Necrotic Soft, Adherent =80%. Size 3.0 x 4.10 x unknown. Nursing wound notes indicate IV therapy as ordered for osteo[DIAGNOSES REDACTED]. Resident 12 wears boots at all times- no shoe. Continuing with hold on ambulation and restorative program. Wound Care Consultation Notes dated 3/7/16, states in part, Stage 4 PU right heel - bone visible. 90% devitalized tissue, sharp debridement, slight odor, Pulses not palpable, foot [MEDICAL CONDITION]. Diagnosis: [REDACTED]. The facility's Wound notes dated 3/8/16 at 10:37 AM include: Type: Other. Classification- Blister. Source- Facility Acquired. Tissue Types: Bright Pink or Red=10%, Slough Non Adherent = 40%, Slough white [MEDICATION NAME]=10%, Necrotic Soft, Adherent = 40%. Size cm 3.9 x 4.9 x 0.20. Wound nursing notes include: New orders received for IV Antibiotic therapy. The facility's Wound notes dated 3/22/16 at 8:03AM include: Type: Vascular. Classification - Diabetic Ulcer. Of note, the facility is now classifying the PU as a diabetic ulcer and changed the type to vascular. Source- Facility Acquired. Tissue Types: Bright Pink or Red=10%, Slough Non Adherent = 40%, Slough white [MEDICATION NAME]=10%, Necrotic Soft, Adherent = 40%. Size cm 3.9 x 4.9 x 0.20. The facility's Wound notes dated 3/29/16 at 5:51 PM include: Type: Vascular. Classification - Diabetic Ulcer. Source- Facility Acquired. Tissue Types: [MEDICATION NAME] (Pale Pink or Red) =20%, Bright Pink or Red= 10% Slough Non Adherent = 20%, Slough white [MEDICATION NAME]=30%, Necrotic Soft, Adherent = 20%. Size cm 4.5 x 4.9 x 2.00 The facility's Wound notes dated 4/5/16 at 9:54 AM include: Type: Vascular. Classification- Diabetic Ulcer. Source- Facility Acquired. Tissue Types: [MEDICATION NAME] (Pale Pink or Red) =10%, Bright Pink or Red= 80%, Slough white [MEDICATION NAME]=10%. Size cm 4.5 x 4.9 x 2.00 The facility's Wound notes dated 4/13/16 at 6:56 AM include: Type: Vascular. Classification - Diabetic Ulcer. Source- Facility Acquired. Tissue Types: [MEDICATION NAME] (Pale Pink or Red) =10%, Pale Pink Non granulating =10%, Bright Pink or Red=40%, Slough white [MEDICATION NAME]=10%, Necrotic Hard, Firm, Adherent =20%. Size cm 4.5 x 4.9 x unknown. Wound Care Consultation Notes dated 4/7/16, states in part, Pressure Ulcer right heel, Osteo Right heel. Measurements: Right heel 4.2 x 5.6 x 1.2. Please note that the wound has increased in size from the previous week with no changes in the care plan. The facility's Wound notes dated 4/19/16 at 2:23 PM include: Type: Vascular. Classification - Diabetic Ulcer. Source- Facility Acquired. Tissue Types: [MEDICATION NAME] (Pale Pink or Red) =10%, Pale Pink Non granulating =10%, Bright Pink or Red=40%, Slough white [MEDICATION NAME]=10%, Necrotic Hard, Firm, Adherent =20%. Size cm 5.3 x 4.9 x unknown. The facility's Wound notes dated 4/26/16 at 7:44 AM include: Type: Vascular. Classification - Diabetic Ulcer. Source- Facility Acquired. Tissue Types: [MEDICATION NAME] (Pale Pink or Red) =10%, Pale Pink Non granulating =10%, Bright Pink or Red=40%, Slough white [MEDICATION NAME]=10%, Necrotic Hard, Firm, Adherent =20%. Size cm 5.3 x 4.9 x unknown. Wound Care Consultation Notes dated 4/28/16, states in part, Right Heel: Tunneling 5.5 cm, bone palpable. New wound dorsal right ankle, white /yellow slough. Family reports that he (Resident 12) now is using a Hoyer (Mechanical lift) for all transfers as he cannot bear weight on the heel. Not walking and in bed or chair all day. Resident 12's physician's orders [REDACTED]. The facility's Wound notes dated 5/3/16 at 4:30 PM include: Type: Vascular. Classification - Diabetic Ulcer. Source- Facility Acquired. Tissue Types: [MEDICATION NAME] (Pale Pink or Red) =10%, Pale Pink Non granulating =10%, Bright Pink or Red=20%, Slough white [MEDICATION NAME]=60% Size cm 5.3 x 4.9 x unknown. Wound nursing notes indicate: Wound Vac being used. The facility's Wound notes dated 5/10/16 at 4:04 PM include: Type: Vascular. Classification - Diabetic Ulcer. Source- Facility Acquired. Tissue Types: Bright Beefy Red =35%, Necrotic Hard, Firm, Adherent=5%, Necrotic Soft, Adherent 60%. Size cm 5.0 x 4.9 x unknown. Wound nursing notes indicate: Increase in slough. The facility's Wound notes dated 5/17/16 at 7:44 AM include: Type: Vascular. Classification - Diabetic Ulcer. Source- Facility Acquired. Tissue Types: Pale Pink Non granulating =50%, Necrotic Hard, Firm, Adherent=5%, Necrotic Soft, Adherent 40%. Size cm 5.0 x 4.9 x unknown. Wound nursing notes state, Granulating pink tissue with yellow slough and small area of eschar. Noted bone showing through since last debridement at clinic. Review of Resident 12's Physical Therapy notes dated 4/28/16, states in part, Pt (Patient) Resident 12 was walking with CNA (Certified Nursing Assistant) staff with bilateral AFO's with bilateral platform 2 ww (Wheeled walker). Brace caused skin issues on right heel leading to a wound. Pt had recent wound vac on right heel, now just using dressings with nursing staff. Pt is cleared to stand on RLE (Right lower extremity), however orders for AFO during gait inhibit gait training currently. Pt has weakened to require use of Hoyer dependent lift for transfers. Review of Resident 12's Treatment Administration Record (TAR) dated 11/23/15 states in part, Cover R foot with (2x2) size kerlix before putting on brace. Of note, the first date this treatment is documented is 11/23/15. Resident 12's Daily Diabetic foot checks: 11/15- 4 days are not signed out. 12/15- 3 days are not signed out. 1/16 - 6 days are not signed out. Yellow Dot and Reposition at least every two hours is recorded as FYI (For your information) and not signed out for the entire month of 11/15. Resident 12's Weekly Skin Assessment: 11/15- initialed on 11/18/15 12/15 - initialed on 12/23/15. On 5/18/16 at 2:10 PM, Surveyor observed Resident 12 sitting in a wheel chair on a cushion with blue boot on and gripper socks on both feet. Resident 12 has a yellow dot on his name plate at the entrance to his room. Resident 12 was noted to have a dressing on his right foot. Surveyor observed a Micro Air alternating pressure mattress on Resident 12's bed that was on and set at 6. Of note, this air mattress was delivered to Resident 12 on 10/29/15 and has been in place since admission. On 5/18/16 at 2:30 Surveyor interviewed Resident 12's Family Member (FM) V with the agreement from Resident 12. Surveyor asked FM V about the dressing on Resident 12's right foot. FM V stated, It is a stage 4 PU (pressure injury) that developed here. They didn't keep the pressure off of his heels and that is why I made these signs and put them on the wall to elevate his heels as much as possible. FM V took her cell phone out of her purse and showed Surveyor the pictures of the PI that developed on Resident 12's right heel. FM V indicated that Resident 12 was admitted with a stage 4 to his backside and his heels were fine. Surveyor noted that the two signs on the wall written by FM V. The first sign states, Braces off during the day. Braces on for transfer only. Slippers only. No braces at all. The second sign states, Elevate legs as much as possible during the day. Please put pillow under calves and blue boots on when in bed. Of note, there are no dates on either sign but the second sign has FM V's name and phone number. On 5/19/16 at 7:25 AM, Surveyor observed Resident 12 lying in bed on his left side. Surveyor asked CNA W to lift the sheets by Resident 12's feet. Surveyor observed bilateral blue heel boots on Resident 12 that were resting on the mattress. CNA W placed a pillow under Resident 12's calves and off loaded his heels. On 5/19/16 at 9:30 AM, Surveyor observed Resident 12 sitting in his wheel chair without blue boots and no foot pedals. Resident 12 did have gripper socks on both feet that appeared to be very tight. Surveyor asked Resident 12 how the wound on his right foot developed. Resident 12 stated, I had braces and they created more problems. Surveyor asked Resident 12 if he has pain in the right foot wound. Resident 12 indicated that the pain was not bad. Surveyor asked Resident 12 if the nursing staff float his heels or elevate his heels off the mattress when he is in bed. Resident 12 indicated that he did not recall that being done. On 5/19/16 at 9:45 AM, Surveyor observed Resident 12's blue boots and foot pedals on top of the dresser. Surveyor observed a stand up walker with bilateral arm braces in Resident 12's room. On 5/19/16 at 9:50 AM, Surveyor interviewed Licensed Practical Nurse (LPN) X regarding Resident 12 and the need for the blue boot. LPN X indicated that she was not sure if Resident 12 should be wearing the blue boot. LPN X indicated that she would have to look at the care plan. On 5/19/16 at 9:55 AM, Surveyor interviewed Registered Nurse (RN) BB regarding Resident 12's PU on his right heel. RN BB indicated that the wound started with the AFO brace rubbing. RN BB did not recall if it was a blister as they use to cushion it with kerlix. On 5/19/16 at 10:05 AM, Surveyor observed Resident 12 sitting in his wheelchair without the blue boots on or foot pedals on the wheel chair. On 5/19/16 at 10:10 AM, Surveyor interviewed Physical Therapy Assistant (PTA) Z regarding Resident 12 and the PU on his right heel. PTA Z indicated that the PTA who used to work with him when he was first admitted no longer works at the facility. PTA Z indicated she was told the PU developed from the AFO that Resident 12 was wearing to assist with transfers and ambulation. On 5/19/16 at 10:13 AM, Surveyor observed Occupational Therapist (OT) AA propelled Resident 12 to therapy. Resident 12 did not have blue boots on or foot pedals on his wheel chair. On 5/19/16 at 10:20 AM, Surveyor observed Resident 12 in therapy. OT AA was working on upper arm strengthening. Resident 12 did not have blue boots on or foot pedals on his wheel chair in the therapy gym. Surveyor observed very tight gripper socks that went over Resident 12's feet and above his heels with the dressing in place on Resident 12's right foot. Surveyor interviewed OT AA regarding the need for foot pedals and blue boots. OT AA indicated that Resident 12 said he did not need the foot plates on today and some days he wears the booties. On 5/19/16 at 10:30 AM, Surveyor interviewed CNA Y regarding Resident 12 and the need for foot pedals and blue boots. CNA Y indicated that Resident 12 always wears gripper socks. CNA Y stated, I usually put boots and foot pedals on after the bathroom. I never went back in after he brushed his teeth. On 5/19/16 at 10:40 AM, Surveyor interviewed Director of Nursing (DON) B regarding Resident 12 and the need to wear the blue boots. DON B indicated that she would have to check the care plan. Surveyor asked DON B to come to Resident 12's room. When Surveyor and DON B arrived at Resident 12's room, OT AA was in the room and placed the foot pedals on the wheel chair and put the blue boots on Resident 12's feet. DON B asked OT AA if she was co treating with P.T. OT AA stated, No. DON B then stated, The foot pedals and blue boots should have been on. On 5/19/16 at 12:30 PM, Surveyor asked Resident 12 if he ever refuses to wear the blue boots. Resident 12 stated, I never have refused to wear the blue boots. Example 2 Resident 7 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/22/16 indicated a Brief Interview of Mental Status (BIMS) score was completed by staff indicating Resident 7 is severely impaired. Section M0150 of the MDS indicates Resident 7 was at risk for developing a PI. Section G0110, Activities of Daily Living (ADL's) indicates Resident 7 requires total assistance of 2 staff for bed mobility and transfers. A PI Care Area Assessment (CAA) worksheet dated 1/25/16 states in part: Triggers: bed mobility self- performance total dep

Based on observation, interview and record review the facility did not ensure each resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 8 residents (Resident 10 and Resident 3) reviewed for falls. Resident 10 had two falls at the facility. Resident 10's care plan upon admission states that Resident 10 is to transfer with 1 assist and to wear non-skid socks/shoes. Resident 10 fell two times at the facility (3/23/16 and 4/7/16). At the time of both falls, Resident 10 was documented as wearing regular socks, not gripper socks or shoes, per her care plan. As a result of the fall on 4/7/16, Resident 10 sustained a scalp hematoma, subdural hemorrhage and right hand fractures. When given the opportunity, the facility did not provide any additional documentation for these falls, including any additional education provided to staff. The first example (Resident 10's fall on 4/7/16) rises to a level of actual harm and the remaining example is no actual harm. Resident 3's comprehensive care plan states that Resident 3 requires a 2 assist for transfers and Supervision: Do not leave alone on toilet. The facility did not follow Resident 3's care plan by leaving her unattended in the bathroom while on the toilet. Resident 3 fell while unattended on the toilet. On 4/5/16 after Resident 3's fall the facility added a new intervention to the care plan that states Do not leave unattended while in bathroom. Essentially, no new care plan intervention was added following this fall. When given the opportunity, the facility did not provide any additional documentation for these falls, including any additional education provided to staff. Evidenced by: The facility policy titled Falls and Injuries with an effective date of July 2015 states: The center strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program, and strives to provide an environment that is free from hazards over which the center has control and provides supervision and assistance devices to each resident to prevent avoidable accidents. Using the Fall/Injury Assessment: Prevention and Management Care Plan, all residents are assessed for fall risk factors and hazards upon admission, quarterly, after a fall and with a change of condition . Risk: Any external factor or characteristic of an individual that influences the likelihood of an accident including, but not limited to, musculoskeletal, cognitive, medical sensory, environmental, pharmacological and neurological factors. Procedure: The Interdisciplinary Team (IDT) works with the resident and family to identify and implement appropriate interventions that reduce the risk of falls or injuries while maximizing dignity and independence. 1. Assess and review risk factors and hazards for falls and injuries using the Fall/Injury Assessment: Prevention and Management Care Plan. Include resident and/or responsible party in determining past history of falls and causative factors. 2. Review/evaluate other IDT assessments. 5. Implement the Fall/Injury Assessment: Prevention and Management Care Plan upon admission based on individual resident's needs. 7. Provide training to staff as needed. Example 1 Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 10's quarterly Brief Interview for Mental Status (BIMS) score for cognition is 15, indicating she is cognitively intact. Resident 10's comprehensive care plan states a Problem: Fall/Injury Assessment: Prevention and Management dated 3/16 (March 2016). The Assessment indicates Fall/Injury Risk related to: Musculoskeletal: Pain, stiffness, unsteady; Medical Factors: Exhaustion, weakness, cardiovascular diagnosis; Cognitive Impairment Factors: Dementia. The Goal indicates No falls/injury. The Interventions indicate: Transfer: 1 assist, Non-skid socks/shoes, call family to purchase different blanket/comforter (added 3/23/16 after the first fall), Do not leave alone in bathroom (added 4/7/16), out to ER (emergency room ) reassess B&B (Bowel and Bladder) upon return (dated 4/7/16). Resident 10's comprehensive care plan states a Problem: ADL (Activities of Daily Living)/Mobility Care Plan dated 3/16 (March 2016). The Problem indicates Potential or Actual ADL/Mobility deficit, poor oral hygiene, oral infection r/t (related to): Cervicalgia, spinal stenosis, PVD (Peripheral Vasular Disease); The Goal indicates Will transfer with A1 (Assist of 1) to bed/chair/toilet . The Interventions indicate Personal Hygiene/Grooming/Dressing/Undressing: Assist/encourage/provide per resident other: Toileting, Provide assistive device as needed for transfer: A1 (Assist of 1) supervision On 3/23/16 Resident 10's Nurses Note (NN) entered at 9:15 PM indicates the following: Had a fall at 4:45 PM. No injuries. DON and family notified. Fall sheet done with computer documentation. Patient to call for transfer and ADLs. No complaint of pain anywhere else; hip pain (left) is normal. Continue to monitor. The FSI - Fall Scene Investigation Report for Resident 10's fall on 3/23/16 at 4:45 PM, indicates the following: 1. Factors observed at time of fall: Resident slipped 2. Draw a picture of area and position in which resident was found. (e.g. face down, on back/R or L side, position of arms and legs, furniture/equipment/devices nearby). The picture indicates Resident 10 in front of her bed with the wheelchair in front of her. The report states, Slid down on butt sitting up when writer came into room 3. Fall Summary: Found of floor (unwitnessed) 4. Fall location: Resident room 5. What was resident doing during or just prior to fall?: Other: putting on pants slid off of bed 6. What time of assistance was resident receiving at time of fall? Alone and unattended 7. What did the resident say they were trying to do just before they fell ? Put on pants 8. Describe the resident's mental status prior to fall: Stable - no confusion 9. Describe resident's psychological status prior to fall: No problem at time *10. Footwear at time of fall: Socks (Regular socks, not gripper socks) *What appears to be the initial root cause(s) of the fall? Pt didn't have slipper (gripper) socks on. Trying to dress herself. May need an aide to help with ADL's. On 4/7/16 a Nurses Note (NN) entered 3:55 AM indicates the following: Called to resident's room. Resident lying on left side with pool of blood under head. Resident alert c/o (complaining of) left hip discomfort, right hand and shoulder pain. Resident unmoved as c/o pain and pool of blood. Ambulance called at 3:40 AM. Nurse Practitioner (NP) notified at 3:45 AM, daughter notified at 3:50 AM and made aware of incident and transfer. 4:00 AM, ambulance here and assessing resident at this time. On 4/7/16 a NN entered at 4:20 AM indicates patient left for emergency room for evaluation and treatment. The FSI - Fall Scene Investigation Report for Resident 10's fall on 4/7/16 at 4:45 PM, indicates the following: 1. Factors observed at time of fall: Wheelchair/bed brakes unlocked (one side unlocked) 2. Draw a picture of area and position in which resident was found. (e.g. face down, on back/R or L side, position of arms and legs, furniture/equipment/devices nearby). The picture indicates Resident 10 underneath the sink and kiddie corner to the toilet. 3. Fall Summary: Found of floor (unwitnessed) 4. Fall location: Bathroom 5. What was resident doing during or just prior to fall?: Other: Sleeping 6. What time of assistance was resident receiving at time of fall? Alone and unattended 7. What did the resident say they were trying to do just before they fell ? This question is left blank 8. Describe the resident's mental status prior to fall: Sleeping 9. Describe resident's psychological status prior to fall: Sleeping *10. Footwear at time of fall: Socks (Regular socks, not gripper socks) *What appears to be the initial root cause(s) of the fall? Resident unable to state due to change in LOC (level of consciousness). Resident 10 was sent out to the hospital emergency room . Resident 10's hospital report states as follows: Patient is a [AGE] year old female who was admitted on [DATE] with fall in bathroom unwitnessed. She was found to have a scalp hematoma, subdural hemorrhage and right hand fractures. Resident 10 was observed in the hospital for 24 hours. Resident 10's right hand x-ray results indicate: Erosive osteoarthritis is evident in the distal and proximal interphalangeal joints of the second through fifth digit. Patient has a non-displaced fracture through the proximal shaft of the proximal phalanx of the fourth digit. In addition there is a small lucency seen through the base of the fourth metacarpal I cannot exclude a undisplaced fracture at this site. The right hand x ray impression indicates: Undisplaced fracture through proximal shaft of the proximal phalanx of fourth digit. 2. I am suspicious of undisplaced fracture through the base of the fourth metacarpal. 3. Erosive osteoarthritis Resident 10's CT of her head and brain indicates a 4 mm (millimeter) right subdural hematoma overlying the frontal lobe. The right hand CT impression indicates: 1. Large left parietal scalp hematoma. 2. No acute intracranial hemorrhage, [DIAGNOSES REDACTED], or CT evidence of acute infarct. Stable severe chronic microvascular ischemic disease. 3. No acute fracture or malalignment of the cervical spine. Multilevel degenerative disc and facet disease. On 5/19/16 at 1:15 PM, Surveyor spoke with Resident 10. Surveyor asked Resident 10 how she feels about wearing gripper socks. Resident 10 stated she likes them and stated, I'm wearing them right now. Surveyor asked Resident 10 if she ever refused or said no to wearing her gripper socks. Resident 10 replied, No. Resident stated she was going to the bathroom when she fell on [DATE]. Resident 10 stated she was knocked unconscious during the fall on 4/7/16. Example 2 Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's admission Brief Interview for Mental Status (BIMS) score for cognition is 12, indicating she is moderately cognitively impaired. Resident 3's comprehensive care plan states a Problem: Fall/Injury Assessment: Prevention and Management dated 3/17/16. The Assessment indicates Fall/Injury Risk related to: History of falls; Musculoskeletal: Pain; Cognitive Impairment Factors: Dementia, Alzheimer's, CVA (stroke). The Goal indicates Will be free of a serious injury if a fall would occur and No falls/injury. Resident 3 was The Interventions indicate: Transfer: 2 assist (3/31/16), Supervision: Do not leave alone on toilet, Call light in reach, Room free of clutter, Room well lit, Do not leave unattended while in bathroom (Dated 4/5/16 after Resident 3's fall), Non-skid socks/shoes. Fall/Injury Assessment: Prevention and Management Care Plan indicates Resident 3 has fall/injury risk related to hearing and visual impairment. The following two NN entries demonstrate that the facility is aware that Resident 3 is impulsive and self-transfers. On 3/18/16 Resident 3's NN entered at a documented time of AM states Pt (patient) is very hard of hearing and impulsive. Noted ambulating unattended in room. Room change received to place closer to nursing station . On 3/20/16 Resident 3's NN entered at 10:15 AM states, Pt stable. Patient attempting to self-transfer. Pt reminded to wait for staff after pushing call light will mentor and support. On 4/5/16 Resident 3's NN entered at 4:00 PM states the following: Resident fell in bathroom at 12:45 PM, after being set on toilet. Husband was in bedroom and CNA (Certified Nursing Assistant) had left pt (patient) in bathroom and told her to use call light when finished. Pt found lying on left side in between toilet and wheelchair. ROM (range of motion) intact to all extremities. No injury noted except abrasion to left thigh. Neuro checks initiated and WNL (within normal limits). Resident reported she did not hit her head but fall was unwitnessed. No complaint of pain at this time. POA (Power of Attorney for Health Care) present at time of fall and aware of situation. Pt was transferred off of floor into bed. MD updated and will continue to monitor and support. The FSI - Fall Scene Investigation Report for Resident 3's fall on 3/23/16 at 4:45 PM, indicates the following: 1. Factors observed at time of fall: Fall unwitnessed 2. Draw a picture of area and position in which resident was found. (E.g. face down, on back/R or L side, position of arms and legs, furniture/equipment/devices nearby). The picture indicates Resident 3 is lying between the toilet and her wheelchair. Fall investigations notes lying on left side. 3. Fall Summary: Found of floor (unwitnessed) 4. Fall location: Resident's bathroom 5. What was resident doing during or just prior to fall?: Attempting to self-transfer 6. What time of assistance was resident receiving at time of fall? Alone and unattended 7. What did the resident say they were trying to do just before they fell ? I was trying to pull up my pants. 8. Describe the resident's mental status prior to fall: Confused - baseline unchanged 9. Describe resident's psychological status prior to fall: Baseline - unchanged *10. Footwear at time of fall: Shoes *What appears to be the initial root cause(s) of the fall? Resident had call light on but did not wait for someone to come before getting off Conclusion: Care plan updated to make sure staff stays with resident while on toilet. It is important to note that the facility did not follow Resident 3's care plan by leaving her unattended in the bathroom on toilet. Resident 3's initial care plans stated, that Resident 3 is 2 assist for transfers (as of 3/31/16), Supervision: Do not leave alone on toilet. On 5/19/16 at 1:50 PM, Surveyor spoke with Director of Nursing (DON) B. Surveyor asked DON B if she expects staff to follow care plans. DON B replied, Yes. Surveyor discussed Resident 10's falls on 3/23/16 and 4/7/16 as well as the injuries sustained as a result of the fall on 4/7/16. Surveyor asked DON B if Resident 10 should have been wearing gripper socks or shoes and had a staff member assisting her to the bathroom. DON B stated, Yes. Surveyor discussed Resident 3's fall and asked DON B if it was acceptable to leave Resident 3 unattended on the toilet. DON B stated, No. Surveyor asked DON B if she had any further information for these falls. DON B stated she would check. DON B did not provide any additional documentation for these falls, including any additional education provided to staff.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was adequately monitored and that the drug regimen was free from adverse consequences for 1 (Resident 19) of 19 residents reviewed for adequate monitoring. Resident 19 was prescribed [MEDICATION NAME], an anticoagulant medication that increases the risk of bleeding. In January 2016 Resident 19 was placed on an antibiotic. Antibiotics can potentiate the effect of [MEDICATION NAME] ([MEDICATION NAME]). The facility did not complete monitoring for symptoms of drug interactions and increased risk of bleeding secondary to the initiation of the antibiotic. Resident 19 was subsequently hospitalized with significant vaginal bleeding, critical low hemoglobin, supra-therapeutic International Normalized Ratio (INR) (lab test to monitor [MEDICATION NAME] level) requiring a blood transfusion. This is evidenced by: The facility's policy entitled [MEDICATION NAME] ([MEDICATION NAME]) and other Anticoagulant Medications dated 7/2015 states in part: the center monitors residents receiving [MEDICATION NAME] ([MEDICATION NAME]) therapy using the PT/INR log. PT/INR lab monitoring is used for residents receiving [MEDICATION NAME] and the frequency of lab monitoring is ordered by the physician. In addition, residents receiving any type of anticoagulant are monitored for signs and symptoms of bleeding to promote the safe and effective use of these medications. The plan of care attached to this policy states, Inform MD that resident is on [MEDICATION NAME] ([MEDICATION NAME]) any time antibiotics are ordered as antibiotics have the potential to affect anticoagulation status. Of note, this is not the care plan Resident 19 has for anticoagulation. According to < <http://packageinserts.bms.com/pi/[MEDICATION NAME].pdf>> Concomitant use of drugs that increase bleeding risk, antibiotics, antifungals, [MEDICATION NAME] (herbal) products. More frequent INR monitoring should be performed when starting or stopping other drugs, including [MEDICATION NAME], or when changing dosages of other drugs, including drugs intended for short-term use (e.g., antibiotics, antifungals, corticosteroids) Example 1 Resident 19 was admitted to the facility on [DATE]. Resident 19 has [DIAGNOSES REDACTED]. Of note, Resident 19 receives hospice services. Resident 19's care plan dated 6/15 states in part: Anticoagulant Therapy Goal: Will be free from signs and symptoms of bleeding. Interventions: monitor for signs and symptoms of bleeding. Resident 19's physician orders [REDACTED]. Resident 19's physician orders [REDACTED]. Give with 1 mg to equal 1.5 mg. physician progress notes [REDACTED]. It has been present for 2 days and there is a small amount of fluid leaking. Plan: obtain culture of left toe; start Keflex (antibiotic) 500 mg three times daily. Anticoagulation: INR stable, on 12/6/15 it was 2.6. Repeat INR in 1 month. Culture results dated 12/24/15 state in part: 2+ staphylococcus aureus. The final culture report dated 12/27/15 states in part: [MEDICAL CONDITION] (MRSA). Sensitive to [MEDICATION NAME]. A telephone order dated 12/27/15 states [MEDICATION NAME] 300 mg three times daily for 10 days. Contact isolation [MEDICAL CONDITION] left great toe. Discontinue Keflex. Nursing notes dated 12/30/15 am state no adverse reactions to antibiotic for left great toe. Nursing notes dated 12/31/15 pm state no adverse reactions to antibiotic for left great toe. Nursing notes dated 1/1/16 (no time) state in part: no adverse reactions to antibiotic for left great toe. Nursing notes dated 1/3/16 at 2:00 PM state in part: no adverse reactions to antibiotic. Nursing notes dated 1/4/16 (no time) state in part: no adverse reactions to antibiotic. Nursing notes date 1/5/16 noc states in part: refused antibiotic due to having small emesis times 1. Of note, there is no evidence the facility monitored Resident 19's INR while Resident 19 was receiving the antibiotic and taking [MEDICATION NAME] simultaneously. Nursing notes dated 1/6/16 at 9:15 AM state in part: emesis times two brown liquid. Patient also having large amounts of vaginal bleeding, brown loose stools, and color is very pale in appearance. Message left for hospice nurse. Nursing notes dated 1/6/16 at 2:00 PM hospice nurse and medical doctor (Dr.) D updated on vaginal bleeding. Dr. D here to assess resident. Nursing notes dated 1/6/16 at 4:40 PM state in part: confirmed order to hold [MEDICATION NAME]. Dr. D saw Resident 19 today new order for PT/INR, complete blood count (CBC), and basic metabolic panel (BMP). A telephone order dated 1/6/16 states in part: CBC, BMP, and INR STAT (immediately). Hold [MEDICATION NAME] for 5 days. Resident 19's labs dated 1/6/16 indicated a critical high INR of 5.8; a critical low hemoglobin of 6.3. A telephone order dated 1/6/16 states in part: give 5 mg vitamin k (aids in clotting) and re-check INR in AM. Nursing notes dated 1/6/16 at 9:00 PM state in part: notified to send Resident 19 to ER per physician due to critical low lab values and increased bleeding. Patient updated and agreed to go to ER. Hospice nurse notified and stated that treatment in the ER could result in revocation of hospice patient notified and stated would like to go to ER. Nursing notes dated 1/6/16 pm state Resident 19 admitted with significant vaginal bleeding. Hospital Admission History and Physical dated 1/6/16 states in part: Assessment: 1. [MEDICAL CONDITION] secondary to acute blood loss from endometrial bleeding and early hypovolemic shock, corrected with fluid resuscitation. 2. [MEDICATION NAME]-induced coagulopathy (blood's ability to clot is impaired) due to [MEDICATION NAME] /[MEDICATION NAME] interaction. Plan: Transfuse 2 units red blood cells (RBC's) and transfuse plasma. Hospital Progress notes dated 1/7/16 state in part: has had some vaginal bleeding however is improved as compared to admission. Assessment and Plan: 1. acute blood loss [MEDICAL CONDITION] secondary to endometrial bleeding. Bleeding has diminished. Hemoglobin 7.5 this morning. 4. [MEDICATION NAME]- induced coagulopathy - INR on admission 5.3. She was given 2 units of fresh frozen plasma (FFP). Patient will likely be in hospital for 48-72 more hours. Hospital progress notes dated 1/8/16 state in part: 1. Acute blood loss [MEDICAL CONDITION] secondary to endometrial bleeding. Bleeding has diminished significantly. She is off the [MEDICATION NAME]. Hemoglobin is stable. She was transfused with 2 units of FFP and 3 units of packed red blood cells (PRBC). 4. [MEDICATION NAME] induced coagulopathy - discussed with patient and husband at this point will remain off of [MEDICATION NAME]. For now believe the risk of bleeding from [MEDICATION NAME] outweighs its benefits. Hospital progress notes dated 1/9/16 state in part: 1. acute blood loss [MEDICAL CONDITION] secondary to endometrial bleeding. Bleeding has slowed down significantly. She has received 2 units of FFP and 3 units of blood . 4. [MEDICATION NAME] induced coagulopathy - [MEDICATION NAME] has been discontinued. At this point risk outweighs benefits. Hospital discharge summary dated 1/12/16 states in part: 1. acute blood loss [MEDICAL CONDITION] secondary to endometrial bleeding. Bleeding has slowed down dramatically. She has been transfused with 2 units of FFP and 3 units of PRBC's during this admission. 4. [MEDICATION NAME] induced coagulopathy - [MEDICATION NAME] has been discontinued. At this point life-threatening endometrial bleeding outweighs the benefit of [MEDICATION NAME] therapy. On 5/19/16 at 2:40 PM Surveyor interviewed Director of Nursing (DON) B regarding the facility's policy on monitoring [MEDICATION NAME] when on antibiotics. It should be noted that DON B started employment with the facility on 5/16/16. DON B stated she would expect and from facility's past practice that [MEDICATION NAME] be monitored more frequently typically every 3 days when on antibiotics. Surveyor reviewed Resident 19's medical record with DON B and DON B replied I would have expected the INR to be monitored more frequently once the antibiotic was initiated. The facility's failure to monitor the INR once Resident 19 was started on antibiotic therapy lead to a supra-therapeutic INR and critically low hemoglobin secondary to [MEDICATION NAME] induced coagulopathy. Resident 19 subsequently required hospitalization secondary to severe endometrial bleeding requiring hospitalization and blood transfusion.